3-1-60... · 5101:3-1-60 Page 1 Appendix DD STATUS CODES: (1) PAY CURRENT PRICE (2) PAY CURRENT...

5101:3-1-60 Page 1

Appendix DD STATUS CODES: (1) PAY CURRENT PRICE (2) PAY CURRENT PRICE ON AND AFTER EFFECTIVE DATE-OTHERWISE PAY

Amended PREVIOUS PRICE (3) NO PAYMENT AFTER EFFECTIVE DATE, PAY PREVIOUS PRICE PRIOR TO EFFECTIVE DATE

LAB & CURR CURR PREV PREV

PROF/ ASC ASC ASC PREV ASC ASC

PA EFFECT STATUSCURRENT PREVIOUS TECH F/U CURRENT EFFECT END ASC EFFECT END

APPR VISIT CODE DESCRIPTION DATE CODE PRICE PRICE INDIC. DAYS GROUP DATE DATE GROUP DATE DATE

09999 Modifier code 01/01/04 3 NC 0.02

10021 Fine needle aspiration,w/o imaging guid 01/01/02 1 62.72 D 0

10022 Fine needle aspiration w imaging guidance 01/01/02 1 64.62 P 0

* 10040 Acne surgery 01/01/04 2 62.13 45.24 10

* 10060 Drainage of skin abscess 01/01/04 2 72.81 46.91 10

10061 Drainage of skin abscess 01/01/00 2 86.89 75.66 0

* 10080 Drainage of pilonidal cyst 01/01/04 2 89.75 51.78 10

10081 Drainage of pilonidal cyst 01/01/00 2 103.02 86.98 0

* 10120 Remove foreign body 01/01/00 2 50.40 40.32 10

10121 Remove foreign body 01/01/00 2 106.80 89.22 0 2 01/01/04 OPEN

* 10140 Drainage of hematoma/fluid 01/01/04 2 84.47 57.57 10

* 10160 Puncture drainage of lesion 01/01/04 2 55.67 46.93 10

10180 Complex drainage, wound 01/01/00 2 90.13 81.32 0 2 2-17-91 OPEN

* 11000 Surgical cleansing of skin 01/01/04 2 34.34 27.20 0

11001 Additional cleansing of skin 01/01/00 2 15.02 17.24 711004 Debride genitalia & perineum 01/01/05 1 415.55 011005 Debride abdom wall 01/01/05 1 565.62 011006 Debride genit/per/abdom wall 01/01/05 1 523.27 011008 Remove mesh from abd wall 01/01/05 1 212.89 0

11010 Debridement w/removal of foreign matter 01/01/00 2 214.12 198.10 10 2 01/01/04 OPEN



11040 Surgical cleansing, abrasion 01/01/00 2 24.25 22.13 1

11041 Surgical cleansing of skin 01/01/00 2 37.34 33.97 7 3 01/01/02 OPEN

11042 Cleansing of skin/tissue 01/01/00 2 48.48 43.73 7 3 01/01/02 OPEN 2 2-17-91 12/31/01

11043 Cleansing of tissue/muscle 01/01/00 2 117.24 93.81 7 2 2-17-91 OPEN

11044 Cleansing tissue/muscle/bone 01/01/00 2 162.07 131.44 7 2 2-17-91 OPEN

* 11050 Trim skin lesion 04/01/98 3 NC 19.52 0

11051 Trim 2 to 4 skin lesions 04/01/98 3 NC 28.51 0

11052 Trim over 4 skin lesions 04/01/98 3 NC 31.01 7

11055 Paring or cutting of benign lesion 01/01/00 2 13.84 11.07 0

11056 Paring or cutting of benign lesions; 2 to 4 01/01/00 2 19.75 15.80 0

11057 Paring or cutting of benign lesions; more than 4 01/01/00 2 21.46 17.30 7

11100 Biopsy of skin lesion 01/01/00 2 39.40 32.08 7

11101 Biopsy, each added lesion 01/01/00 2 20.18 16.96 7

* 11200 Removal of skin tags 01/01/04 2 54.08 34.23 10 2 2-17-91 12-31-95

11201 Removal of added skin tags 01/01/00 2 13.28 10.62 0 1 01/04/88 OPEN

* 11300 Shave skin lesion 01/01/04 2 40.48 30.11 0

ACTION: Final DATE: 01/06/2005 4:21 PMAMENDEDAppendix

5101:3-1-60

APPENDIX p(17616) pa(23012) d(84173) ra(79232) print date: 01/06/2005 9:30 PM

5101:3-1-60 Page 2







11301 Shave skin lesion 01/01/00 2 42.46 37.20 0











11400 Removal of skin lesion 01/01/00 2 42.49 33.99 7


11402 Removal of skin lesion 01/01/00 2 74.30 60.02 7 1 2-17-91 OPEN
















11450 Removal, sweat gland lesion 01/01/00 2 154.33 134.18 21 2 2-17-91 OPEN









5101:3-1-60 Page 3

















11641 Removal of skin lesion 01/01/00 2 123.83 109.57 14 2 10/01/04 OPEN 1 2-17-91 9/30/04





11700 Scraping of 1-5 nails 04/01/97 3 NC 14.11 1

11701 Scraping of additional nails 04/01/97 3 NC 10.20 1

11710 Scraping of 1-5 nails 04/01/97 3 NC 14.11 1

11711 Scraping of additional nails 04/01/97 3 NC 8.68 1

11719 Trimming of nondystrophic nails, any number 01/01/98 1 NC

11720 Debridement of nail, any method, 1 to 5 01/01/00 2 17.56 15.10 1

11721 Debridement of nail, any method, 6 or more 01/01/00 2 28.86 25.46 1

11730 Removal of nail plate 01/01/00 2 43.19 38.40 1

11731 Removal of second nail plate 04/01/99 3 NC 26.09 1

11732 Remove additional nail plate 01/01/00 2 19.16 15.33 1

11740 Drain blood from under nail 01/01/00 2 21.69 18.78 0

11750 Removal of nail bed 01/01/00 2 102.43 92.52 45

11752 Remove nail bed/finger tip 01/01/00 2 143.46 130.29 45

11755 Biopsy, nail unit 01/01/00 2 61.86 57.06 14

11760 Reconstruction of nail bed 01/01/00 2 69.61 60.21 45

11762 Reconstruction of nail bed 01/01/00 2 142.15 132.84 60

11765 Excision of nail fold, toe 01/01/00 2 34.26 28.26 0

11770 Removal of pilonidal lesion 01/01/00 2 144.57 133.47 60 3 2-17-91 OPEN



* 11900 Injection into skin lesions 01/01/04 2 34.24 22.59 0

* 11901 Added skin lesion injections 01/01/04 2 41.35 33.66 0

11920 Correct skin color defects 05/01/94 1 NC

5101:3-1-60 Page 4









11950 Subcutaneous inj. of filling material, 1cc or less 07/01/03 2 52.93 BR 30

11951 Subcutaneous inj. of filling material, 1.1 to 5.0 cc 07/01/03 2 72.38 BR 30

11952 Subcutaneous inj. of filling material, 5.1 to 10.0 cc 07/01/03 2 95.73 BR 30

11954 Subcutaneous inj. of filling material, over 10.0 cc 07/01/03 2 115.45 BR 30

11960 Insert tissue expander(s) 07/01/03 2 522.51 BR 90 2 2-17-91 OPEN

11970 Replace tissue expander 05/20/86 3 NC BR

11971 Remove tissue expander(s) 01/01/00 2 136.86 109.49 7 1 2-17-91 OPEN

11975 Insert contraceptive cap 01/01/00 2 72.50 84.64 0

11976 Removal of contraceptive cap 01/01/00 2 86.83 113.61 0

11977 Remove/reinsert contra cap 01/01/00 2 155.96 159.78 0

11980 Subcutaneous hormone pellet impantation 01/01/00 1 81.56 0

11981 Insert drug delivery implant device 01/01/02 1 83.89 0

11982 Remove drug delivery implant device 01/01/02 1 95.84 0

11983 Remove rein drug deliv implant device 01/01/02 1 155.84 0

12001 Repair superficial wound(s) 01/01/00 2 67.35 53.88 1



12005 Repair superficial wound(s) 01/01/00 2 122.20 104.52 1 2 2-17-91 OPEN










12020 Closure of split wound 01/01/00 2 109.03 93.39 0 1 1-1-96 OPEN

12021 Closure of split wound 01/01/00 2 73.39 59.90 0 1 1-1-96 OPEN

12031 Layer closure of wound(s) 01/01/00 2 85.58 68.61 14


12034 Layer closure of wound(s) 01/01/00 2 123.85 106.21 14 2 2-17-91 OPEN





5101:3-1-60 Page 5



















13100 Repair of wound or lesion 01/01/00 2 123.92 102.99 14 2 2-17-91 OPEN

13101 Repair of wound or lesion 01/01/00 2 166.23 145.65 14 2 10/01/04 OPEN 3 1-1-96 9/30/04

* 13102 Repair of wound or lesion ea additional 5cm or less 01/01/04 1 56.24 54.37 10











13160 Late closure of wound 01/01/00 2 384.60 319.44 30 2 2-17-91 OPEN

13300 Repair of wound or lesion 04/01/00 3 NC 274.63 30 4 2-17-91 OPEN

14000 Skin tissue rearrangement 01/01/00 2 265.34 217.72 30 2 2-17-91 OPEN




14040 Skin tissue rearrangement 01/01/00 2 394.31 343.14 30 3 01/01/02 OPEN 2 01/01/97 12/31/01




14300 Skin tissue rearrangement 01/01/00 2 622.03 562.76 30 4 1-1-96 OPEN 3 2-17-91 12-31-95


15000 Skin graft procedure 01/01/00 2 146.26 117.01 45 2 2-17-91 OPEN

5101:3-1-60 Page 6







15001 Burn wound preparation 01/01/00 2 40.25 45.96 45

15050 Skin pinch graft procedure 01/01/00 2 177.56 142.05 45 2 2-17-91 OPEN

15100 Skin split graft procedure 01/01/00 2 377.77 319.34 45 2 2-17-91 OPEN


15120 Skin split graft procedure 01/01/00 2 438.51 381.18 45 3 01/01/02 OPEN 2 01/01/97 12/31/01


15200 Skin full graft procedure 01/01/00 2 351.64 290.75 45 3 2-17-91 OPEN








15342 Cultured skin graft, 25 cm 01/01/01 1 $99.28 10

15343 Culture skn graft addl 25 cm 01/01/01 1 $17.22 10

15350 Skin homograft procedure 01/01/00 2 191.33 153.06 45 2 2-17-91 OPEN

15351 Allograft Application 01/01/00 2 35.57 40.22 45 2 01/01/04 OPEN

15400 Skin heterograft procedure 01/01/00 2 150.45 146.37 45 2 2-17-91 OPEN

15401 Xenograft Application 01/01/00 2 35.57 40.22 45 2 01/01/04 OPEN

15570 Form skin pedicle flap 01/01/00 2 335.25 268.20 45 3 2-17-91 OPEN




15580 Attach skin pedicle graft 04/01/00 3 NC 210.46 45 3 2-17-91 OPEN




15625 Skin graft procedure 04/01/00 3 NC 118.18 45 3 2-17-91 OPEN


15650 Transfer skin pedicle flap 01/01/00 2 238.74 215.56 45 5 2-17-91 OPEN

15732 Muscle-skin graft, head/neck 01/01/00 2 910.60 731.10 90 3 2-17-91 OPEN

15734 Muscle-skin graft, trunk 01/01/00 2 971.60 912.05 90 3 2-17-91 OPEN

15736 Muscle-skin graft, arm 01/01/00 2 868.45 812.42 90 3 2-17-91 OPEN

15738 Muscle-skin graft, leg 01/01/00 2 773.80 619.04 90 3 2-17-91 OPEN

15740 Island pedicle flap graft 01/01/00 2 552.47 504.76 90 2 2-17-91 OPEN

15750 Neurovascular pedicle graft 01/01/00 2 622.70 578.80 90 2 2-17-91 OPEN

15755 Microvascular flap graft 04/01/97 3 NC 1366.02 90 3 2-17-91 OPEN

5101:3-1-60 Page 7







15756 Free muscle flap 01/01/00 2 1,749.79 1,552.58 90

15757 Free skin flap 01/01/00 2 1,753.10 1,552.58 90 3 1-1-01 12/31/03

15758 Free fascial flap 01/01/00 2 1,749.93 1,552.58 90 3 1-1-01 12/31/03

15760 Composite skin graft 01/01/00 2 441.25 393.09 90 2 2-17-91 OPEN

15770 Derma-fat-fascia graft 01/01/00 2 397.28 358.56 60 3 2-17-91 OPEN

15775 Hair transplant punch grafts 05/01/94 1 NC

15776 Hair transplant punch grafts 05/01/94 1 NC

15780 Abrasion treatment of skin 05/01/94 1 NC




* 15786 Abrasion treatment of lesion 01/01/04 2 104.34 75.09 10

15787 Abrasion, added skin lesions 01/01/00 2 15.00 13.93 90

15788 Chemical peel, face, epiderm 05/01/94 1 NC

15789 Chemical peel, face, dermal 05/01/94 1 NC

15792 Chemical peel, nonfacial 05/01/94 1 NC

15793 Chemical peel, nonfacial 05/01/94 1 NC

15810 Salabrasion 05/01/94 1 NC

15811 Salabrasion 05/01/94 1 NC

15819 Plastic surgery, neck 05/01/94 1 NC

15820 Revision of lower eyelid 05/01/94 1 NC

15821 Revision of lower eyelid 05/01/94 1 NC

15822 Revision of upper eyelid 05/01/94 1 NC

15823 Revision of upper eyelid 05/01/94 1 NC

15824 Removal of forehead wrinkles 05/01/94 1 NC

15825 Removal of neck wrinkles 05/01/94 1 NC

15826 Removal of brow wrinkles 05/01/94 1 NC

15828 Removal of face wrinkles 05/01/94 1 NC

15829 Removal of skin wrinkles 05/01/94 1 NC

15831 Excise excessive skin tissue 05/01/94 1 NC









5101:3-1-60 Page 8







15840 Graft for face nerve palsy 01/01/00 2 737.91 706.31 90 4 2-17-91 OPEN

15841 Graft for face nerve palsy 01/01/00 2 1,081.95 971.41 90 4 2-17-91 OPEN

15842 Graft for face nerve palsy 01/01/00 2 1,737.64 1,592.66 90 4 2-17-91 12/31/03

15845 Skin and muscle repair, face 01/01/00 2 705.27 691.86 90 4 2-17-91 OPEN

15850 Removal of sutures 05/01/94 3 NC 15.00

15851 Removal of sutures 01/01/01 2 35.31 28.25 0 1 05/25/91 OPEN

15852 Dressing change,not for burn 01/01/00 2 40.56 32.45 0

15860 Test for blood flow in graft 01/01/00 2 88.96 83.93 0

15876 Suction assisted lipectomy 05/01/94 1 NC




15920 Removal of tail bone ulcer 01/01/00 2 307.02 260.18 30 3 2-17-91 OPEN

15922 Removal of tail bone ulcer 01/01/00 2 440.00 386.66 30 4 2-17-91 OPEN

15931 Remove sacrum pressure sore 01/01/00 2 338.79 275.94 30 3 2-17-91 OPEN






15940 Removal of pressure sore 01/01/00 2 360.64 296.08 30 3 2-17-91 OPEN




15946 Removal of pressure sore 01/01/00 2 1,030.86 936.39 60 4 2-17-91 OPEN

15950 Remove thigh pressure sore 01/01/00 2 293.31 246.35 30 3 2-17-91 OPEN






15999 Removal of pressure sore 05/01/94 1 BR 0

16000 Initial treatment of burn(s) 01/01/00 2 35.86 30.11 0

16010 Treatment of burn(s) 01/01/00 2 35.29 28.94 0

16015 Treatment of burn(s) 01/01/00 2 117.61 112.56 0 2 2-17-91 OPEN

* 16020 Treatment of burn(s) 01/01/04 2 52.82 34.03 0

* 16025 Treatment of burn(s) 01/01/04 2 103.61 66.80 0

16030 Treatment of burn(s) 01/01/00 2 79.78 63.82 0 1 2-17-91 12/31/03

5101:3-1-60 Page 9







16035 Incision of burn scab 01/01/00 2 186.03 160.24 0 2 2-17-91 12/31/03

16036 Incise burn scab, addl incis 01/01/01 1 65.13 10

16040 Burn wound excision 04/01/99 3 NC 73.50 14



* 17000 Destroy benign/premal lesion 01/01/04 2 44.24 28.93 10

17001 Destruction of add'l lesions 04/01/98 3 NC 9.40 0


17003 Destruction of benign lesions; 2-14, each 01/01/00 2 8.53 6.82 0

17004 Destruction of benign lesions; 15 or more 01/01/00 2 132.38 123.39 0

17010 Destruction skin lesion(s) 04/01/98 3 NC 36.20 0

17100 Destruction of skin lesion 04/01/98 3 NC 21.92 0

17101 Destruction of 2nd lesion 04/01/98 3 NC 7.25 0


17104 Destruction of skin lesions 04/01/98 3 NC 50.11 0

17105 Destruction of skin lesions 04/01/98 3 NC 26.07 0

17106 Destruction of skin lesions 01/01/00 2 181.42 157.56 0



* 17110 Destruction of skin lesions 01/01/04 2 63.31 23.08 10


17200 Electrocautery of skin tags 04/01/98 3 NC 24.52 0

17201 Electrocautery added lesions 04/01/98 3 NC 12.80 0

* 17250 Chemical cautery, tissue 01/01/04 2 46.72 24.13 0

* 17260 Destruction of skin lesions 01/01/04 2 61.55 54.63 10














5101:3-1-60 Page 10











17304 Chemosurgery of skin lesion 01/01/00 2 323.78 281.94 30

17305 2nd stage chemosurgery 01/01/00 2 137.73 124.24 30

17306 3rd stage chemosurgery 01/01/00 2 119.55 103.12 30

17307 Followup skin lesion therapy 01/01/00 2 121.02 104.97 30

17310 Extensive skin chemosurgery 01/01/00 2 32.54 26.03 30

* 17340 Cryotherapy of skin 01/01/04 2 31.67 30.53 10

* 17360 Skin peel therapy 01/01/04 2 81.98 40.28 10

17380 Hair removal by electrolysis 05/01/94 1 NC

17999 Skin tissue procedure 05/01/94 1 BR 0

* 19000 Drainage of breast lesion 01/01/04 2 56.00 38.26 0

19001 Drain added breast lesion 01/01/00 2 21.03 16.82 0

19020 Incision of breast lesion 01/01/00 2 149.91 119.93 14 2 2-17-91 OPEN

19030 Injection for breast x-ray 01/01/00 2 61.15 48.92 0

19100 Biopsy of breast 01/01/00 2 60.48 48.38 0 1 2-17-91 OPEN

19101 Biopsy of breast 01/01/00 2 174.88 139.90 14 2 2-17-91 OPEN

19102 Bx breast percut w/image 01/01/01 1 182.78 0 2 1-01-02 OPEN

19103 Bx breast percut w/device 01/01/01 1 362.11 0 2 1-01-02 OPEN

19110 Nipple exploration 01/01/00 2 210.81 168.65 14 2 2-17-91 OPEN

19112 Excise breast duct fistula 01/01/00 2 183.40 146.72 14 3 2-17-91 OPEN

19120 Removal of breast lesion 01/01/00 2 235.54 197.53 14 3 2-17-91 OPEN

19125 Excision, breast lesion 01/01/00 2 250.45 221.78 14 3 2-17-91 OPEN

19126 Excision,add'l breast lesion 01/01/00 2 118.78 111.27 14 3 2-17-91 OPEN

19140 Removal of breast tissue 01/01/00 2 281.68 238.51 21 4 2-17-91 OPEN

19160 Removal of breast tissue 01/01/00 2 279.20 276.13 21 3 2-17-91 OPEN

19162 Remove breast tissue, nodes 01/01/00 2 623.04 571.08 21 7 2-17-91 OPEN

19180 Removal of breast 01/01/00 2 396.86 353.23 21 4 2-17-91 OPEN

19182 Removal of breast 01/01/00 2 376.12 345.36 21 4 2-17-91 OPEN

19200 Removal of breast 01/01/00 2 701.27 629.14 60



19260 Removal of chest wall lesion 01/01/00 2 589.17 475.48 60 5 2-17-91 12/31/03

19271 Revision of chest wall 01/01/00 2 909.86 798.06 60

19272 Extensive chest wall surgery 01/01/00 2 952.90 819.60 60

19290 Place needle wire, breast 01/01/00 2 52.88 42.30 45 1 1-1-01 OPEN

5101:3-1-60 Page 11







19291 Place needle wire, breast 01/01/00 2 27.30 21.84 45 1 1-1-01 OPEN

19295 Place breast clip, percut 01/01/01 1 70.87 019296 Place po breast cath for rad 01/01/05 1 3456.25 019297 Place breast cath for rad 01/01/05 1 70.77 019298 Place breast rad tube/caths 01/01/05 1 1306.61 0

19316 Suspension of breast 06/30/85 1 NC

19318 Reduction of large breast 07/01/03 2 729.29 BR 60 4 2-17-91 OPEN

19324 Enlarge breast 06/30/85 1 NC

19325 Enlarge breast with implant 06/30/85 1 NC

19328 Removal of breast implant 01/01/00 2 261.67 231.95 30 1 2-17-91 OPEN

19330 Removal of implant material 01/01/00 2 318.27 279.85 30 1 2-17-91 OPEN

19340 Immediate breast prosthesis 07/01/02 2 362.72 366.66 30 2 2-17-91 OPEN

19342 Delayed breast prosthesis 01/01/00 2 591.85 553.32 30 3 2-17-91 OPEN

19350 Breast reconstruction 07/01/03 2 581.66 BR 42 4 2-17-91 OPEN

19355 Correct inverted nipple(s) 05/01/94 1 NC

19357 Breast reconstruction 01/01/00 2 835.41 738.49 60 5 2-17-91 OPEN

19361 Breast reconstruction 01/01/00 2 1,050.74 985.05 60

19364 Breast reconstruction 01/01/00 2 1,417.11 1,133.69 60 5 2-17-91 12/31/03

19366 Breast reconstruction 01/01/00 2 1,011.93 930.80 60 5 2-17-91 OPEN

19367 Breast reconstruction 01/01/00 2 1,237.04 1,150.98 60

19368 Breast reconstruction 01/01/00 2 1,433.47 1,305.14 60

19369 Breast Reconstruction 01/01/00 2 1,360.18 1,245.83 60

19370 Surgery of breast capsule 01/01/00 2 389.54 353.04 30 4 2-17-91 OPEN

19371 Removal of breast capsule 01/01/00 2 470.92 431.59 30 4 2-17-91 OPEN

19380 Revise breast reconstruction 06/30/85 1 NC

19396 Design custom breast implant 06/30/85 1 NC

19499 Breast surgery procedure 05/01/94 1 BR 0

* 20000 Incision of abscess 01/01/04 2 118.53 82.28 10

20005 Incision of deep abscess 01/01/00 2 146.39 121.32 14 2 2-17-91 OPEN

20100 Explore wound, neck 01/01/00 2 415.65 370.81 10

20101 Explore wound, chest 01/01/00 2 135.30 117.20 10

20102 Explore wound, ab/flank/back 01/01/00 2 166.43 143.54 10

20103 Explore wound, extremity 01/01/00 2 223.69 193.11 10

20150 Excision of epiphyseal bar 01/01/00 2 689.26 620.30 90

20200 Muscle biopsy 01/01/00 2 73.06 65.15 14 2 2-17-91 OPEN

20205 Deep muscle biopsy 01/01/00 2 127.37 107.64 14 3 2-17-91 OPEN

* 20206 Needle biopsy, muscle 01/01/04 2 110.61 61.50 0 1 2-17-91 OPEN

20220 Bone biopsy, trocar/needle 01/01/00 2 78.28 62.62 7 1 2-17-91 OPEN

5101:3-1-60 Page 12







20225 Bone biopsy, trocar/needle 01/01/00 2 105.80 106.46 7 2 2-17-91 OPEN

20240 Bone biopsy, excisional 01/01/00 2 143.71 121.12 14 2 2-17-91 OPEN

20245 Bone biopsy, excisional 01/01/00 2 207.07 181.10 14 3 2-17-91 OPEN

20250 Open bone biopsy 01/01/00 2 270.54 245.98 21 3 2-17-91 OPEN

20251 Open bone biopsy 01/01/00 2 307.90 280.31 21 3 2-17-91 OPEN

* 20500 Injection of sinus tract 01/01/04 2 189.57 46.94 10

* 20501 Inject sinus tract for x-ray 01/01/04 2 103.29 25.59 0

* 20520 Removal of foreign body 01/01/04 2 200.76 76.79 10

20525 Removal of foreign body 01/01/00 2 169.81 136.74 14 3 2-17-91 OPEN

20526 Carpal tunnel therapeutic injection 01/01/02 1 44.53 0

* 20550 Inj tendon/ligament/cyst 01/01/04 2 41.82 37.90 0

20551 Injection, tendon origin/insertion 01/01/02 1 44.53 0

20552 Trigger point injection, 1-2 muscle grps 01/01/02 1 44.53 0

20553 Trigger point injection, 3+ muscle grps. 01/01/02 1 44.53 0

* 20600 Drain/inject joint/bursa 01/01/04 2 36.77 33.98 0



20612 Aspirate/inj ganglion cyst 07/01/03 1 38.40 0

20615 Treatment of bone cyst 01/01/00 2 82.80 66.24 0

20650 Insert and remove bone pin 01/01/00 2 97.34 77.87 7 3 2-17-91 OPEN

20660 Apply,remove fixation device 01/01/00 2 108.71 101.14 7 2 2-17-91 12/31/03

20661 Application of head brace 01/01/00 2 249.65 206.07 7 3 2-17-91 12/31/03

20662 Application of pelvis brace 01/01/00 2 338.43 307.70 7 3 2-17-91 12/31/03

20663 Application of thigh brace 01/01/00 2 272.05 242.19 7 3 2-17-91 12/31/03

20664 Application of halo brace 01/01/00 2 341.67 297.28 7

* 20665 Removal of fixation device 01/01/04 2 95.93 54.28 10 1 2-17-91 12/31/03

* 20670 Removal of support implant 01/01/04 2 212.11 75.29 10 1 2-17-91 OPEN

20680 Removal of support implant 01/01/00 2 187.04 166.85 14 3 2-17-91 OPEN

20690 Apply bone fixation device 01/01/00 2 188.18 182.63 30 2 2-17-91 OPEN

20692 Apply bone fixation device 01/01/00 2 316.91 302.05 45 3 01/01/04 OPEN

20693 Adjust bone fixation device 01/01/00 2 246.93 197.54 45 3 01/01/04 OPEN

20694 Remove bone fixation device 01/01/00 2 201.41 161.13 45 1 1-1-96 OPEN

20802 Replantation, arm, complete 01/01/00 2 2,094.16 1,965.95 90

20804 Replantation, arm, partial 04/01/96 3 NC BR 90

20805 Replant forearm, complete 01/01/00 2 2,616.58 2,406.27 90

20806 Replantation,forearm,partial 04/01/96 3 NC BR 90

20808 Replantation, hand, complete 01/01/00 2 3,169.36 2,571.76 90

20812 Replantation, hand, partial 04/01/96 3 NC BR 90

5101:3-1-60 Page 13







20816 Replantation digit, complete 01/01/00 2 1,704.98 1,474.76 90

20820 Replantation, digit, partial 04/01/96 3 NC BR 90

20822 Replantation digit, complete 01/01/00 2 1,433.36 1,219.16 90

20823 Replantation, digit, partial 04/01/96 3 NC BR 90

20824 Replantation thumb, complete 01/01/00 2 1,677.77 1,474.76 90

20826 Replantation, thumb, partial 04/01/96 3 NC BR 90

20827 Replantation thumb, complete 01/01/00 2 1,470.02 1,253.55 90

20828 Replantation, thumb, partial 04/01/96 3 NC BR 90

20832 Replantation, leg, complete 04/01/96 3 NC BR 90

20834 Replantation, leg, partial 04/01/96 3 NC BR 90

20838 Replantation, foot, complete 01/01/00 2 2,142.08 1,965.95 90

20840 Replantation, foot, partial 07/01/03 3 NC BR 90

20900 Removal of bone for graft 01/01/00 2 239.30 196.00 21 3 2-17-91 OPEN

20902 Removal of bone for graft 01/01/00 2 357.07 294.93 21 4 2-17-91 OPEN

20910 Remove cartilage for graft 01/01/00 2 176.34 141.07 45 3 1-1-96 OPEN

20912 Remove cartilage for graft 01/01/00 2 306.28 266.54 45 3 1-1-96 OPEN 4 2-17-91 12-31-95

20920 Removal of fascia for graft 01/01/00 2 254.00 219.17 60 4 2-17-91 OPEN

20922 Removal of fascia for graft 01/01/00 2 315.03 263.08 60 3 2-17-91 OPEN

20924 Removal of tendon for graft 01/01/00 2 329.88 290.78 21 4 2-17-91 OPEN

20926 Removal of tissue for graft 01/01/00 2 233.77 189.69 21 4 2-17-91 OPEN

20930 Spinal bone allograft 01/01/96 1 BR 21

20931 Spinal bone allograft 01/01/00 2 95.02 89.99 21

20936 Spinal bone autograft 01/01/96 1 BR 21

20937 Spinal bone autograft 01/01/00 2 145.48 138.77 21

20938 Spinal bone autograft 01/01/00 2 157.27 150.07 21

20950 Record fluid pressure,muscle 01/01/00 2 67.93 59.40 0

20955 Microvascular fibula graft 01/01/00 2 2021.90 BR 90 4 2-17-91 12/31/03

20956 Microvascular bone graft, iliac crest 01/01/00 2 1,822.62 1,561.15 90 4 01/01/97 OPEN

20957 Microvascular bone graft, metatarsal 01/01/00 2 1,844.51 1,617.36 90 4 01/01/97 OPEN

20960 Microvascular rib graft 04/01/97 3 NC BR 90 4 2-17-91 OPEN

20962 Microvascular bone graft 01/01/00 2 1,900.53 BR 90 4 2-17-91 12/31/03

20969 Bone-skin graft 01/01/00 2 2,249.66 2,091.53 90 4 2-17-91 12/31/03

20970 Bone-skin graft, pelvis 01/01/00 2 2,196.74 2,048.89 45 4 2-17-91 12/31/03

20971 Bone-skin graft, rib 04/01/97 3 NC BR 90 4 2-17-91 OPEN

20972 Bone-skin graft, metatarsal 01/01/00 2 2,160.77 2,064.68 90 4 2-17-91 12/31/03

20973 Bone-skin graft, great toe 01/01/00 2 2,333.22 2,202.01 90 4 2-17-91 12/31/03

20974 Electrical bone stimulation 01/01/00 2 97.54 106.26 30

20975 Electrical bone stimulation 01/01/00 2 144.52 152.52 45 2 2-17-91 OPEN

5101:3-1-60 Page 14







* 20979 Low intensity ultrasound stimulation 01/01/04 1 36.97 11.26 0

20982 Ablate, Bone Tumor(s) Perq 01/01/04 1 2850.06 0

20999 Musculoskeletal surgery 05/01/94 1 BR 0

21010 Incision of jaw joint 01/01/00 2 532.99 474.44 60 2 2-17-91 OPEN

21015 Resection of facial tumor 01/01/00 2 319.48 291.30 45 3 01/01/04 OPEN

21025 Excision of bone, lower jaw 01/01/00 2 280.93 224.74 90 2 2-17-91 OPEN

21026 Excision of facial bone(s) 01/01/00 2 225.46 187.42 90 2 2-17-91 OPEN

21029 Contour of face bone lesion 01/01/00 2 427.22 403.20 45 2 01/01/04 OPEN

21030 Removal of face bone lesion 01/01/00 2 272.33 252.97 90

21031 Remove exostosis, mandible 01/01/00 2 175.28 140.22 45

21032 Remove exostosis, maxilla 01/01/00 2 189.68 199.81 45

21034 Removal of face bone lesion 01/01/00 2 635.74 544.45 90 3 2-17-91 OPEN

21040 Removal of jaw bone lesion 01/01/00 2 134.27 117.23 90 2 2-17-91 OPEN

21041 Removal of jaw bone lesion 07/01/03 3 NC 330.86 90 2 2-17-91 12/31/03

21044 Removal of jaw bone lesion 01/01/00 2 569.59 511.80 90 2 2-17-91 OPEN

21045 Extensive jaw surgery 01/01/00 2 791.67 718.01 90

21046 Remove mandible cyst complex 07/01/03 1 613.58 90 2 01/01/04 OPEN

21047 Excise lwr jaw cyst w/repair 07/01/03 1 760.42 90 2 01/01/04 OPEN

21048 Remove maxilla cyst complex 07/01/03 1 631.48 90

21049 Excis uppr jaw cyst w/repair 07/01/03 1 720.46 90

21050 Removal of jaw joint 01/01/00 2 608.02 550.11 90 3 2-17-91 OPEN

21060 Remove jaw joint cartilage 01/01/00 2 568.62 519.99 90 2 2-17-91 OPEN

21070 Remove coronoid process 01/01/00 2 403.09 359.90 90 3 2-17-91 OPEN

21076 surgical obturator prosthesis 01/01/00 2 726.79 717.42 10

21077 Orbital prosthesis 01/01/00 2 1,827.48 1,804.29 90

21079 Interim obturator prosthesis 07/01/03 2 1025.57 BR 90

21080 Definitive obturator prosthesis 07/01/03 2 1171.37 BR 90

21081 Mandibular resection prosthesis 07/01/03 2 1056.18 BR 90

21082 Palatal augmentation prosthesis 07/01/03 2 932.95 BR 90

21083 Palatal left prosthesis 07/01/03 2 900.52 BR 90

21084 Speech aid prosthesis 07/01/03 2 1032.57 BR 90

21085 Oral surgical splint 07/01/03 2 402.91 BR 90

21086 Auricular prosthesis 07/01/03 2 1146.21 BR 90

21087 Nasal prosthesis 07/01/03 2 1125.71 BR 90

21088 Facial prosthesis 05/01/94 1 BR 90

21089 Unlisted maxillofacial prosthesis 05/01/94 1 BR 90

21100 Maxillofacial fixation 01/01/00 2 154.94 123.95 90 2 2-17-91 OPEN

21110 Interdental fixation 05/01/94 1 NC

5101:3-1-60 Page 15







21116 Injection, jaw joint x-ray 01/01/00 2 47.00 37.60 0

21120 Reconstruction of chin 01/01/00 2 258.14 206.51 90

21121 Reconstruction of chin 01/01/00 2 367.13 324.61 90 7 01/01/04 OPEN



21125 Augmentation lower jaw bone 01/01/00 2 338.25 270.60 90

21127 Augmentation lower jaw bone 01/01/00 2 517.63 454.01 90 9 01/01/04 OPEN

21137 Reduction of forehead 01/01/00 2 458.48 408.77 90



21141 Reconstruct midface, LeFort 01/01/00 2 855.57 775.63 90



21144 Reconstruct midface, lefort 04/01/96 3 NC 673.57 90

21145 Reconstruct midface, lefort 01/01/00 2 912.07 823.66 90



21150 Reconstruct midface, lefort 01/01/00 2 1,177.19 1,061.79 90






21172 Reconstruct orbit/forehead 01/01/00 2 1,282.50 1,167.13 90

21175 Reconstruct orbit/forehead 01/01/00 2 1,548.84 1,400.99 90

21179 Reconstruct entire forehead 01/01/00 2 1,051.34 933.76 90

21180 Reconstruct entire forehead 01/01/00 2 1,176.45 1,061.79 90

21181 Contour cranial bone lesion 01/01/00 2 462.32 408.77 90 7 01/01/04 OPEN

21182 Reconstruct cranial bone 01/01/00 2 1,523.60 1,358.57 90



21188 Reconstruction of midface 01/01/00 2 1,049.24 933.76 90

21193 Reconstruct lower jaw bone 01/01/00 2 788.00 706.72 90





21199 Reconstr lwr jaw w/advance 01/01/01 1 $767.55 90

5101:3-1-60 Page 16







21206 Reconstruct upper jaw bone 01/01/00 2 657.52 582.03 90 5 2-17-91 OPEN

21208 Augmentation of facial bones 01/01/00 2 561.14 513.24 90 7 2-17-91 OPEN

21209 Reduction of facial bones 01/01/00 2 323.23 274.67 90 5 2-17-91 OPEN

21210 Face bone graft 01/01/00 2 565.83 541.15 90 7 2-17-91 OPEN

21215 Lower jaw bone graft 01/01/00 2 594.54 571.51 90 7 2-17-91 OPEN

21230 Rib cartilage graft 01/01/00 2 583.54 520.97 90 7 2-17-91 OPEN

21235 Ear cartilage graft 01/01/00 2 407.18 361.64 90 7 2-17-91 OPEN

21240 Reconstruction of jaw joint 01/01/00 2 782.74 749.67 90 4 2-17-91 OPEN



21244 Reconstruction of lower jaw 01/01/00 2 670.65 638.11 90 7 2-17-91 OPEN

21245 Reconstruction of jaw 01/01/00 2 628.88 560.62 90 7 2-17-91 OPEN


21247 Reconstruct lower jaw bone 01/01/00 2 1,219.56 1,182.39 90


21249 Reconstruction of jaw 01/01/00 2 973.15 1,020.89 0 7 2-17-91 OPEN


21256 Reconstruction of orbit 01/01/00 2 911.51 845.72 90

21260 Revise eye sockets 01/01/00 2 911.10 863.04 90

21261 Revise eye sockets 01/01/00 2 1,318.39 1,153.63 90

21263 Revise eye sockets 01/01/00 2 1,517.61 1,484.91 90

21267 Revise eye sockets 01/01/00 2 959.04 810.99 90 7 2-17-91 OPEN

21268 Revise eye sockets 01/01/00 2 1,131.98 978.61 90

21270 Augmentation cheek bone 01/01/00 2 539.79 545.06 90 5 2-17-91 OPEN

21275 Revision orbitofacial bones 01/01/00 2 582.09 488.02 90 7 2-17-91 OPEN

21280 Revision of eyelid 01/01/00 2 354.46 314.71 30 5 2-17-91 OPEN


21295 Revision of jaw muscle/bone 01/01/00 2 74.39 59.51 30 1 01/01/04 OPEN

21296 Revision of jaw muscle/bone 01/01/00 2 217.39 183.38 30 1 01/01/04 OPEN

21299 Cranio/maxillofacial surgery 05/01/94 1 BR 90

21300 Treatment of skull fracture 01/01/00 2 51.30 41.04 14 2 2-17-91 OPEN

21310 Treatment of nose fracture 01/01/00 2 41.63 33.30 30 2 2-17-91 OPEN



21325 Repair of nose fracture 01/01/00 2 208.36 190.90 30 4 2-17-91 OPEN



21336 Repair nasal septal fracture 01/01/00 2 282.87 234.85 45 4 01/01/04 OPEN

5101:3-1-60 Page 17







21337 Repair nasal septal fracture 01/01/00 2 165.46 134.40 30 2 2-17-91 OPEN

21338 Repair nasoethmoid fracture 01/01/00 2 325.57 275.93 30 4 2-17-91 OPEN

21339 Repair nasoethmoid fracture 01/01/00 2 412.96 360.82 45 5 2-17-91 OPEN


21343 Repair of sinus fracture 01/01/00 2 603.95 526.88 45 5 1-1-96 12/31/03

21344 Repair of sinus fracture 01/01/00 2 805.13 678.88 45

21345 Repair of nose/jaw fracture 01/01/00 2 447.76 383.75 60 7 01/01/04 OPEN

21346 Repair of nose/jaw fracture 01/01/00 2 547.78 478.75 90



21355 Repair cheek bone fracture 01/01/00 2 155.48 124.38 0 3 2-17-91 OPEN

21356 Repair cheek bone fracture 01/01/00 2 253.06 228.77 45

21360 Repair cheek bone fracture 01/01/00 2 375.55 333.48 60 4 2-17-91 12/31/03

21365 Repair cheek bone fracture 01/01/00 2 743.60 658.20 90 5 2-17-91 12/31/03

21366 Repair cheek bone fracture 01/01/00 2 819.55 734.00 60

21385 Repair eye socket fracture 01/01/00 2 502.99 452.71 90 5 2-17-91 12/31/03





21400 Treat eye socket fracture 01/01/00 2 92.28 73.82 60 2 2-17-91 OPEN

21401 Repair eye socket fracture 01/01/00 2 168.17 140.14 60 3 2-17-91 OPEN



21408 Repair eye socket fracture 01/01/00 2 575.12 496.38 60

21421 Treat mouth roof fracture 01/01/00 2 309.04 270.88 60 4 2-17-91 OPEN

21422 Repair mouth roof fracture 01/01/00 2 472.94 440.29 60 5 2-17-91 12/31/03

21423 Repair mouth roof fracture 01/01/00 2 542.72 486.87 60

21431 Treat craniofacial fracture 01/01/00 2 362.70 313.41 60

21432 Repair craniofacial fracture 01/01/00 2 414.65 368.63 90

21433 Repair craniofacial fracture 01/01/00 2 1,174.07 1,031.33 90

21435 Repair craniofacial fracture 01/01/00 2 833.30 736.68 90

21436 Repair craniofacial fracture 01/01/00 2 1,169.23 1,015.94 60

21440 Repair dental ridge fracture 01/01/00 2 167.02 137.56 90 3 2-17-91 OPEN

21445 Repair dental ridge fracture 01/01/00 2 309.61 274.19 90 4 2-17-91 OPEN

21450 Treat lower jaw fracture 01/01/00 2 167.98 138.05 30 3 2-17-91 OPEN



5101:3-1-60 Page 18









21461 Repair lower jaw fracture 01/01/00 2 462.44 434.84 90 4 1-1-96 OPEN



21470 Repair lower jaw fracture 01/01/00 2 835.20 775.15 60 5 2-17-91 12/31/03

21480 Reset dislocated jaw 01/01/00 2 43.38 34.70 7 1 2-17-91 OPEN

21485 Reset dislocated jaw 01/01/00 2 174.82 144.53 21 2 2-17-91 OPEN

21490 Repair dislocated jaw 01/01/00 2 492.08 423.01 90 3 2-17-91 OPEN

21493 Treat hyoid bone fracture 01/01/00 2 68.75 66.50 30 3 1-1-96 OPEN

21494 Repair hyoid bone fracture 01/01/00 2 339.90 328.26 30 4 2-17-91 OPEN

21495 Repair hyoid bone fracture 01/01/00 2 288.66 250.50 30 4 2-17-91 12/31/03

21497 Interdental wiring 05/01/94 1 NC

21499 Head surgery procedure 05/01/94 1 BR 0

21501 Drain neck/chest lesion 01/01/00 2 161.88 132.59 30 2 2-17-91 OPEN

21502 Drain chest lesion 01/01/00 2 337.29 269.83 30 2 2-17-91 OPEN

21510 Drainage of bone lesion 01/01/00 2 275.63 220.50 21 3 2-17-91 12/31/03

21550 Biopsy of neck/chest 01/01/00 2 84.14 70.68 0 1 2-17-91 12/31/03

21555 Remove lesion neck/chest 01/01/00 2 172.38 141.01 14 2 2-17-91 OPEN

21556 Remove lesion neck/chest 01/01/00 2 252.29 229.61 14 2 2-17-91 OPEN

21557 Remove tumor, neck or chest 01/01/00 2 497.64 435.00 30

21600 Partial removal of rib 01/01/00 2 344.29 275.43 30 2 2-17-91 OPEN

21610 Partial removal of rib 01/01/00 2 427.69 342.15 30 2 2-17-91 OPEN

21615 Removal of rib 01/01/00 2 554.53 497.39 30

21616 Removal of rib and nerves 01/01/00 2 558.96 470.28 60

21620 Partial removal of sternum 01/01/00 2 392.56 332.33 90 2 2-17-91 12/31/03

21627 Sternal debridement 01/01/00 2 353.71 282.97 30

21630 Extensive sternum surgery 01/01/00 2 860.84 733.29 90

21632 Extensive sternum surgery 01/01/00 2 829.50 718.38 90

21685 Hyoid Myotomy & Suspension 01/01/04 1 628.98 90

21700 Revision of neck muscle 01/01/00 2 290.15 247.70 60 2 2-17-91 OPEN

21705 Revision of neck muscle/rib 01/01/00 2 439.64 351.71 60



21740 Reconstruction of sternum 01/01/00 2 732.82 616.74 90

21742 Repair stern/nuss w/o scope 07/01/03 1 584.26 90

21743 Repair sternum/nuss w/scope 07/01/03 1 629.92 90

21750 Repair of sternum separation 01/01/00 2 520.40 445.12 60

5101:3-1-60 Page 19







21800 Treatment of rib fracture 01/01/00 2 50.86 41.17 0 1 2-17-91 OPEN

21805 Treatment of rib fracture 01/01/00 2 121.33 97.98 30 2 2-17-91 OPEN

21810 Treatment of rib fracture(s) 01/01/00 2 392.92 342.87 0 2 2-17-91 12/31/03

21820 Treat sternum fracture 01/01/00 2 75.35 64.11 0 1 2-17-91 OPEN

21825 Repair sternum fracture 01/01/00 2 403.74 349.40 45

21899 Neck/chest surgery procedure 05/01/94 1 BR 0

21920 Biopsy soft tissue of back 01/01/00 2 83.28 69.06 14 1 2-17-91 12/31/03

21925 Biopsy soft tissue of back 01/01/00 2 192.66 154.13 14 2 2-17-91 OPEN

21930 Remove lesion, back or flank 01/01/00 2 217.96 231.70 14 2 2-17-91 OPEN

21935 Remove tumor of back 01/01/00 2 692.44 594.25 60 3 2-17-91 OPEN

22100 Remove part of neck vertebra 01/01/00 2 474.72 419.04 90 3 2-17-91 12/31/03

22101 Remove part, thorax vertebra 01/01/00 2 491.53 433.64 90 3 2-17-91 12/31/03

22102 Remove part, lumbar vertebra 01/01/00 2 405.11 335.65 90 3 2-17-91 12/31/03

22103 Remove extra spine segment 01/01/00 2 121.60 116.39 90

22105 Remove part of neck vertebra 04/01/96 3 NC 548.14 90

22106 Remove part, thorax vertebra 04/01/96 3 NC 480.66 90

22107 Remove part, lumbar vertebra 04/01/96 3 NC 375.41 90

22110 Remove part of neck vertebra 01/01/00 2 619.53 541.39 90

22112 Remove part, thorax vertebra 01/01/00 2 625.79 545.24 90

22114 Remove part, lumbar vertebra 01/01/00 2 569.43 473.19 90

22116 Remove extra spine segment 01/01/00 2 120.25 115.20 90

22140 Reconstruct neck spine 04/01/96 3 NC 900.98 90

22141 Reconstruct thorax spine 04/01/96 3 NC 979.54 90

22142 Reconstruct lumbar spine 04/01/96 3 NC 1079.79 90

22145 Reconstruct vertebra(e) 04/01/96 3 NC 314.00 90

22148 Harvesting bone graft 04/01/96 3 NC 183.37 90

22150 Reconstruct neck spine 04/01/96 3 NC 913.79 90

22151 Reconstruct thorax spine 04/01/96 3 NC 925.51 90

22152 Reconstruct lumbar spine 04/01/96 3 NC 940.26 90

22210 Revision of neck spine 01/01/00 2 1,041.72 917.31 90

22212 Revision of thorax spine 01/01/00 2 993.80 901.35 90

22214 Revision of lumbar spine 01/01/00 2 949.67 847.89 90

22216 Revision of extra spine segment 01/01/00 2 296.66 283.14 90

22220 Revision of neck spine 01/01/00 2 1,029.74 929.73 90

22222 Revision of thorax spine 01/01/00 2 924.01 834.03 90

22224 Revision of lumbar spine 01/01/00 2 997.90 885.85 90

22226 Revision of extra spine segment 01/01/00 2 296.91 283.14 90

22230 Additional revision of spine 04/01/96 3 NC 258.01 90

5101:3-1-60 Page 20







22305 Treat spine process fracture 01/01/00 2 120.72 108.28 30 1 2-17-91 OPEN

22310 Treat spine fracture 01/01/00 2 149.50 119.60 60 1 2-17-91 OPEN

22315 Treat spine fracture 01/01/00 2 406.37 348.11 90 2 2-17-91 OPEN

22318 Open treatment and/or reduction of odontoid fracture 01/01/00 1 1073.15 90

22319 Open treatment and/or reduction of odontoid fracture 01/01/00 1 1211.55 90

22325 Repair of spine fracture 01/01/00 2 749.56 636.35 90 3 2-17-91 12/31/03

22326 Repair neck spine fracture 01/01/00 2 971.03 875.05 90 3 2-17-91 12/31/03

22327 Repair thorax spine fracture 01/01/00 2 949.70 844.70 90 3 2-17-91 12/31/03

22328 Repair each add. spine fx 01/01/00 2 237.83 229.22 90

22505 Manipulation of spine 01/01/00 2 94.67 76.66 45 2 2-17-91 OPEN

22520 Percut vertebroplasty thor 01/01/01 1 385.35 10

22521 Percut vertebroplasty lumb 01/01/01 1 361.54 10

22522 Percut vertebroplasty addl 01/01/01 1 126.25 10

22532 Lat Thorax Spine Fusion 01/01/04 1 1107.77 90

22533 Lat Lumbar Spine Fusion 01/01/04 1 1033.99 90

22534 Lat Thor/Lumb, Addæl Seg 01/01/04 1 261.92 0

22548 Neck spine fusion 01/01/00 2 1,308.83 1,193.29 90

22554 Neck spine fusion 01/01/00 2 1,031.75 954.68 90

22556 Thorax spine fusion 01/01/00 2 1,213.18 1,119.58 90

22558 Lumbar spine fusion 01/01/00 2 1,141.40 1,054.89 90

22585 Additional spinal fusion 01/01/00 2 289.24 279.43 90

22590 Spine & skull spinal fusion 01/01/00 2 1,123.08 1,047.00 90

22595 Neck spinal fusion 01/01/00 2 1,093.87 1,046.75 90

22600 Neck spine fusion 01/01/00 2 916.15 879.31 90

22610 Thorax spine fusion 01/01/00 2 899.67 828.00 90

22612 Lumbar spine fusion 01/01/00 2 1,116.73 1,038.68 90

22614 Spine fusion, extra segment 01/01/00 2 320.44 306.72 90

22625 Lumbar spine fusion 04/01/96 3 NC 972.51 90

22630 Lumbar spine fusion 01/01/00 2 1,067.37 981.07 90

22632 Spine fusion, extra segment 01/01/00 2 270.00 260.09 90

22650 Additional spinal fusion 04/01/96 3 NC 279.50 90

22800 Fusion of spine 01/01/00 2 1,031.86 990.66 90

22802 Fusion of spine 01/01/00 2 1,588.56 1,476.38 90

22804 Fusion of spine 01/01/00 2 1,744.38 1,602.69 90

22808 Fusion of spine 01/01/00 2 1,222.44 1,099.73 90

22810 Fusion of spine 01/01/00 2 1,335.69 1,195.78 90

22812 Fusion of spine 01/01/00 2 1,578.59 1,442.80 90

22818 Kyphectomy 01/01/00 2 1,602.69 1,532.60 90

5101:3-1-60 Page 21







22819 Kyphectomy 01/01/00 2 1,734.53 1,643.31 90

22820 Harvesting of bone 04/01/96 3 NC 171.43 90

22830 Exploration of spinal fusion 01/01/00 2 622.38 598.53 30

22840 Insert spine fixation device 01/01/00 2 389.60 311.68 90

22841 Insert spine fixation device 01/01/97 2 BR 90







22848 Insert pelvic fixation device 01/01/00 2 317.36 298.26 90

22849 Reinsert spinal fixation 01/01/00 2 783.43 626.74 90

22850 Remove spine fixation device 01/01/00 2 510.17 462.63 30

22851 Apply prosthetic spine device 01/01/00 2 352.83 333.59 90



22899 Spine surgery procedure 05/01/94 1 BR 0

22900 Remove abdominal wall lesion 01/01/00 2 248.39 241.79 14 4 2-17-91 OPEN

22999 Abdomen surgery procedure 05/01/94 1 BR 0

23000 Removal of calcium deposits 01/01/00 2 224.36 184.68 60 2 2-17-91 OPEN

23020 Release shoulder joint 01/01/00 2 452.56 391.41 21 2 2-17-91 OPEN

23030 Drain shoulder lesion 01/01/00 2 163.76 133.98 15 1 2-17-91 OPEN

23031 Drain shoulder bursa 01/01/00 2 96.56 77.25 21 3 01/01/04 OPEN

23035 Drain shoulder bone lesion 01/01/00 2 444.26 355.41 30 3 2-17-91 OPEN

23040 Exploratory shoulder surgery 01/01/00 2 515.43 449.98 90 3 2-17-91 OPEN

23044 Exploratory shoulder surgery 01/01/00 2 399.28 341.07 45 4 2-17-91 OPEN

23065 Biopsy shoulder tissues 01/01/00 2 87.10 71.11 0 1 2-17-91 12/31/03

23066 Biopsy shoulder tissues 01/01/00 2 157.14 125.71 14 2 2-17-91 OPEN

23075 Removal of shoulder lesion 01/01/00 2 122.86 101.83 7 2 2-17-91 OPEN

23076 Removal of shoulder lesion 01/01/00 2 320.67 268.13 21 2 2-17-91 OPEN

23077 Remove tumor of shoulder 01/01/00 2 663.69 554.97 30 3 2-17-91 OPEN

23100 Biopsy of shoulder joint 01/01/00 2 358.99 330.71 90 2 2-17-91 OPEN

23101 Shoulder joint surgery 01/01/00 2 334.23 308.02 45 7 2-17-91 OPEN

23105 Remove shoulder joint lining 01/01/00 2 481.58 455.56 60 4 2-17-91 OPEN

23106 Incision of collarbone joint 01/01/00 2 307.38 262.04 45 4 2-17-91 OPEN

23107 Explore,treat shoulder joint 01/01/00 2 499.60 454.33 60 4 2-17-91 OPEN

23120 Partial removal, collarbone 01/01/00 2 340.59 283.50 60 5 2-17-91 OPEN

5101:3-1-60 Page 22







23125 Removal of collarbone 01/01/00 2 491.51 439.38 60 5 2-17-91 OPEN

23130 Partial removal,shoulderbone 01/01/00 2 410.87 360.05 60 5 2-17-91 OPEN

23140 Removal of bone lesion 01/01/00 2 315.07 267.71 90 4 2-17-91 OPEN



23150 Removal of humerus lesion 01/01/00 2 422.40 364.22 90 4 2-17-91 OPEN



23170 Remove collarbone lesion 01/01/00 2 337.98 279.95 30 2 2-17-91 OPEN

23172 Remove shoulder blade lesion 01/01/00 2 347.43 285.93 30 2 2-17-91 OPEN

23174 Remove humerus lesion 01/01/00 2 507.12 434.66 30 2 2-17-91 OPEN

23180 Remove collarbone lesion 01/01/00 2 378.45 302.76 90 4 2-17-91 OPEN

23182 Remove shoulderblade lesion 01/01/00 2 442.52 357.03 90 4 2-17-91 OPEN


23190 Partial removal of scapula 01/01/00 2 372.31 325.98 60 4 2-17-91 OPEN

23195 Removal of head of humerus 01/01/00 2 517.33 455.92 90 5 2-17-91 OPEN

23200 Removal of collarbone 01/01/00 2 588.83 506.24 60

23210 Removal of shoulderblade 01/01/00 2 600.15 514.57 60

23220 Partial removal of humerus 01/01/00 2 737.57 645.68 90

23221 Partial removal of humerus 01/01/00 2 922.24 842.30 90

23222 Partial removal of humerus 01/01/00 2 1,000.20 800.16 90

23330 Remove shoulder foreign body 01/01/00 2 71.91 57.53 0 1 2-17-91 OPEN

23331 Remove shoulder foreign body 01/01/00 2 283.24 226.59 90 1 2-17-91 OPEN

23332 Remove shoulder foreign body 01/01/00 2 591.51 515.60 60

23350 Injection for shoulder x-ray 01/01/00 2 46.41 37.13 0

23395 Muscle transfer,shoulder/arm 01/01/00 2 748.15 598.52 90 5 2-17-91 OPEN

23397 Muscle transfers 01/01/00 2 822.56 743.40 90 7 2-17-91 OPEN

23400 Fixation of shoulderblade 01/01/00 2 647.91 578.04 90 7 2-17-91 OPEN

23405 Incision of tendon & muscle 01/01/00 2 433.07 387.15 30 2 2-17-91 OPEN

23406 Incise tendon(s) & muscle(s) 01/01/00 2 559.99 502.55 30 2 2-17-91 OPEN

23410 Repair of tendon(s) 01/01/00 2 643.37 579.42 90 5 2-17-91 OPEN

23412 Repair of tendon(s) 01/01/00 2 726.05 664.16 90 7 2-17-91 OPEN

23415 Release of shoulder ligament 01/01/00 2 431.53 367.45 7 5 2-17-91 OPEN

23420 Repair of shoulder 01/01/00 2 759.12 696.42 90 7 2-17-91 OPEN

23430 Repair biceps tendon rupture 01/01/00 2 487.50 427.00 90 4 2-17-91 OPEN

23440 Removal/transplant tendon 01/01/00 2 499.07 435.11 45 4 2-17-91 OPEN

23450 Repair shoulder capsule 01/01/00 2 712.70 650.83 90 5 2-17-91 OPEN


5101:3-1-60 Page 23











23470 Reconstruct shoulder joint 01/01/00 2 916.11 836.20 90

23472 Reconstruct shoulder joint 01/01/00 2 995.32 979.88 90

23480 Revision of collarbone 01/01/00 2 501.78 429.61 90 4 2-17-91 OPEN

23485 Revision of collarbone 01/01/00 2 684.24 610.54 90 7 2-17-91 OPEN

23490 Reinforce clavicle 01/01/00 2 586.47 519.24 14 3 2-17-91 OPEN

23491 Reinforce shoulder bones 01/01/00 2 736.76 670.20 14 3 2-17-91 OPEN

23500 Treat clavicle fracture 01/01/00 2 108.50 89.75 30 1 2-17-91 OPEN

23505 Treat clavicle fracture 01/01/00 2 182.43 153.20 90 1 2-17-91 OPEN

23515 Repair clavicle fracture 01/01/00 2 395.61 354.65 90 3 2-17-91 OPEN

23520 Treat clavicle dislocation 01/01/00 2 104.72 85.01 30 1 2-17-91 OPEN


23530 Repair clavicle dislocation 01/01/00 2 377.76 341.58 90 3 2-17-91 OPEN






23570 Treat shoulderblade fracture 01/01/00 2 114.53 95.50 30 1 2-17-91 OPEN

23575 Treat shoulderblade fracture 01/01/00 2 197.74 166.74 90 1 2-17-91 OPEN

23585 Repair scapula fracture 01/01/00 2 461.23 410.13 90 3 2-17-91 OPEN

23600 Treat humerus fracture 01/01/00 2 170.86 143.02 30 1 2-17-91 OPEN


23615 Repair humerus fracture 01/01/00 2 537.99 490.65 90 4 2-17-91 OPEN

23616 Repair humerus fracture 01/01/00 2 1,159.96 1,075.75 90 4 1-1-96 OPEN




23650 Treat shoulder dislocation 01/01/00 2 159.63 131.74 7 1 1-1-96 OPEN

23655 Treat shoulder dislocation 01/01/00 2 206.06 180.22 7 1 2-17-91 OPEN

23660 Repair shoulder dislocation 01/01/00 2 427.25 412.43 90 3 2-17-91 OPEN

23665 Treat dislocation/fracture 01/01/00 2 230.72 189.16 90 2 2-17-91 OPEN

23670 Repair dislocation/fracture 01/01/00 2 462.53 442.52 90 3 2-17-91 OPEN

23675 Treat dislocation/fracture 01/01/00 2 289.85 239.49 90 2 2-17-91 OPEN

23680 Repair dislocation/fracture 01/01/00 2 577.83 556.20 90 3 2-17-91 OPEN

5101:3-1-60 Page 24







* 23700 Fixation of shoulder 01/01/04 2 173.00 132.28 10 1 2-17-91 OPEN

23800 Fusion of shoulder joint 01/01/00 2 808.09 759.11 90 4 2-17-91 OPEN

23802 Fusion of shoulder joint 01/01/00 2 839.78 729.69 90 7 2-17-91 OPEN

23900 Amputation of arm & girdle 01/01/00 2 891.83 789.16 90

23920 Amputation at shoulder joint 01/01/00 2 777.13 706.61 90

23921 Amputation follow-up surgery 01/01/00 2 279.37 236.85 14 3 1-1-96 OPEN

23929 Shoulder surgery procedure 05/01/94 1 BR 0

23930 Drainage of arm lesion 01/01/00 2 136.91 109.53 30 1 2-17-91 OPEN

23931 Drainage of arm bursa 01/01/00 2 73.78 59.02 30 2 1-1-96 OPEN

23935 Drain arm/elbow bone lesion 01/01/00 2 325.21 260.17 30 2 2-17-91 OPEN

24000 Exploratory elbow surgery 01/01/00 2 342.28 319.47 60 4 2-17-91 OPEN

24006 Release elbow joint 01/01/00 2 452.33 401.28 60 4 01/01/04 OPEN

24065 Biopsy arm/elbow soft tissue 01/01/00 2 86.60 69.28 10 1 1-1-96 12/31/03

24066 Biopsy arm/elbow soft tissue 01/01/00 2 232.04 191.01 90 2 1-1-96 OPEN

24075 Remove arm/elbow lesion 01/01/00 2 180.55 145.01 90 2 2-17-91 OPEN

24076 Remove arm/elbow lesion 01/01/00 2 284.57 245.17 90 2 2-17-91 OPEN

24077 Remove tumor of arm/elbow 01/01/00 2 602.04 538.99 90 3 1-1-96 OPEN

24100 Biopsy elbow joint lining 01/01/00 2 255.19 226.03 90 1 2-17-91 OPEN

24101 Explore/treat elbow joint 01/01/00 2 357.93 346.22 90 4 2-17-91 OPEN

24102 Remove elbow joint lining 01/01/00 2 463.09 448.27 90 4 2-17-91 OPEN

24105 Removal of elbow bursa 01/01/00 2 206.90 184.25 90 3 2-17-91 OPEN


24115 Remove/graft bone lesion 01/01/00 2 478.07 421.97 90 3 2-17-91 OPEN


24120 Remove elbow lesion 01/01/00 2 347.98 314.75 90 3 2-17-91 OPEN



24130 Removal of head of radius 01/01/00 2 354.12 323.63 90 3 2-17-91 OPEN

24134 Removal of arm bone lesion 01/01/00 2 526.44 445.09 90 2 2-17-91 OPEN

24136 Remove radius bone lesion 01/01/00 2 436.18 399.39 90 2 2-17-91 OPEN

24138 Remove elbow bone lesion 01/01/00 2 400.14 349.23 90 2 2-17-91 OPEN

24140 Partial removal of arm bone 01/01/00 2 525.17 442.17 90 3 2-17-91 OPEN

24145 Partial removal of radius 01/01/00 2 404.21 342.47 90 3 2-17-91 OPEN

24147 Partial removal of elbow 01/01/00 2 407.38 346.10 90 2 2-17-91 OPEN

24149 Radical resection, elbow 01/01/00 2 721.91 632.29 90

24150 Extensive humerus surgery 01/01/00 2 746.75 676.13 90 3 2-17-91 12/31/03

24151 Extensive humerus surgery 01/01/00 2 805.66 720.44 90 4 2-17-91 12/31/03

24152 Extensive radius surgery 01/01/00 2 468.76 412.74 90 3 2-17-91 12/31/03

5101:3-1-60 Page 25







24153 Extensive radius surgery 01/01/00 2 580.90 544.44 90 4 2-17-91 12/31/03

24155 Removal of elbow joint 01/01/00 2 605.47 555.36 90 3 2-17-91 OPEN

24160 Remove elbow joint implant 01/01/00 2 356.83 308.99 60 2 2-17-91 OPEN

24164 Remove radius head implant 01/01/00 2 325.17 287.87 30 3 2-17-91 OPEN

24200 Removal of arm foreign body 01/01/00 2 69.18 55.34 0

24201 Removal of arm foreign body 01/01/00 2 225.02 185.41 14 2 2-17-91 OPEN

24220 Injection for elbow x-ray 01/01/00 2 55.43 44.34 0

24300 Manipulate elbow, under anesthesia 01/01/02 1 254.12 90

24301 Muscle/tendon transfer 01/01/00 2 495.23 446.05 90 4 2-17-91 OPEN

24305 Arm tendon lengthening 01/01/00 2 299.15 249.46 90 4 01/01/04 OPEN

24310 Revision of arm tendon 01/01/00 2 263.72 216.75 90 3 2-17-91 OPEN

24320 Repair of arm tendon 01/01/00 2 540.28 482.71 90 3 2-17-91 OPEN

24330 Revision of arm muscles 01/01/00 2 499.04 455.86 90 3 2-17-91 OPEN

24331 Revision of arm muscles 01/01/00 2 549.74 501.56 90 3 2-17-91 OPEN

24332 Tenolysis of triceps 01/01/02 1 353.76 90

24340 Repair of ruptured tendon 01/01/00 2 408.78 370.18 90 3 2-17-91 OPEN

24341 Repair tendon/muscle, upper arm or elbow 01/01/00 2 407.98 349.60 90 3 01/01/97 OPEN

24342 Repair of ruptured tendon 01/01/00 2 569.00 524.42 90 3 2-17-91 OPEN

24343 Repair, elbow ligament, w. local tissue 01/01/02 1 466.16 90

24344 Repair, elbow ligament, w tendon graft 01/01/02 1 704.80 90

24345 Repair, medial ligament, w local tissue 01/01/02 1 466.16 90 2 01/01/04 OPEN

24346 Reconstruct elbow ligament 01/01/02 1 704.80 90

24350 Repair of tennis elbow 01/01/00 2 265.94 235.15 90 3 2-17-91 OPEN




24356 Revision of tennis elbow 01/01/00 2 379.62 349.26 90 3 2-17-91 OPEN

24360 Reconstruct elbow joint 01/01/00 2 696.07 687.98 90 5 2-17-91 OPEN



24363 Replace elbow joint 01/01/00 2 1,048.67 1,044.05 90 7 2-17-91 OPEN

24365 Reconstruct head of radius 01/01/00 2 433.78 391.96 90 5 2-17-91 OPEN

24366 Reconstruct head of radius 01/01/00 2 518.69 505.64 90 5 2-17-91 OPEN

24400 Revision of humerus 01/01/00 2 547.40 480.17 90 4 2-17-91 OPEN



24430 Repair of humerus 01/01/00 2 730.03 687.80 90 3 2-17-91 OPEN

24435 Repair humerus with graft 01/01/00 2 763.19 720.46 90 4 2-17-91 OPEN

5101:3-1-60 Page 26







24470 Revision of elbow joint 01/01/00 2 444.34 413.23 90 3 2-17-91 OPEN

24495 Decompression of forearm 01/01/00 2 399.05 341.19 90 2 2-17-91 OPEN

24498 Reinforce humerus 01/01/00 2 614.37 548.73 90 3 2-17-91 OPEN


















24586 Repair elbow fracture 01/01/00 2 797.99 740.34 90 4 2-17-91 OPEN


24600 Treat elbow dislocation 01/01/00 2 186.25 149.00 7 1 2-17-91 OPEN

24605 Treat elbow dislocation 01/01/00 2 219.73 183.55 7 2 2-17-91 OPEN

24615 Repair elbow dislocation 01/01/00 2 503.28 459.58 90 3 2-17-91 OPEN

24620 Treat elbow fracture 01/01/00 2 302.48 259.55 90 2 2-17-91 OPEN


* 24640 Treat elbow dislocation 01/01/04 2 127.81 65.81 10 2 2-17-91 9/30/04

24650 Treat radius fracture 01/01/00 2 134.88 107.90 60

24655 Treat radius fracture 01/01/00 2 225.16 180.13 60 1 2-17-91 OPEN

24665 Repair radius fracture 01/01/00 2 424.62 376.04 90 4 2-17-91 OPEN

24666 Repair radius fracture 01/01/00 2 537.20 487.59 90 4 2-17-91 OPEN

24670 Treatment of ulna fracture 01/01/00 2 135.84 108.67 30 1 2-17-91 OPEN

24675 Treatment of ulna fracture 01/01/00 2 252.76 202.21 90 1 2-17-91 OPEN

24685 Repair ulna fracture 01/01/00 2 473.45 425.66 90 3 2-17-91 OPEN

24800 Fusion of elbow joint 01/01/00 2 584.58 538.75 90 4 2-17-91 OPEN

24802 Fusion/graft of elbow joint 01/01/00 2 696.68 635.14 90 5 2-17-91 OPEN

24900 Amputation of upper arm 01/01/00 2 483.46 420.62 90

5101:3-1-60 Page 27







24920 Amputation of upper arm 01/01/00 2 466.12 393.35 90


24930 Amputation follow-up surgery 01/01/00 2 516.56 441.33 90

24931 Amputate upper arm & implant 01/01/00 2 646.48 582.39 90

24935 Revision of amputation 01/01/00 2 792.29 714.06 31

24940 Revision of upper arm 05/01/94 1 BR 90

24999 Upper arm/elbow surgery 05/01/94 1 BR 0

25000 Incision of tendon sheath 01/01/00 2 211.55 182.34 30 3 2-17-91 OPEN

25001 Incision flexor tendon sheath, wrist 01/01/02 1 212.58 90



25024 Decompress fasciotomy, forea/wrist, 01/01/02 1 495.48 90 3 1-1-02 OPEN

25025 Decompress fasciotomy, forea/wrist, w debr 01/01/02 1 801.99 90 3 1-1-02 OPEN

25028 Drainage of forearm lesion 01/01/00 2 216.58 173.26 0 1 2-17-91 OPEN

25031 Drainage of forearm bursa 01/01/00 2 138.71 110.97 0 2 2-17-91 OPEN

25035 Treat forearm bone lesion 01/01/00 2 416.48 333.18 30 2 2-17-91 OPEN

25040 Explore/treat wrist joint 01/01/00 2 367.03 311.21 21 5 2-17-91 OPEN

25065 Biopsy forearm soft tissues 01/01/00 2 80.61 76.76 0 1 2-17-91 12/31/03

25066 Biopsy forearm soft tissues 01/01/00 2 167.00 133.60 14 2 2-17-91 OPEN

25075 Removal of forearm lesion 01/01/00 2 182.46 145.97 7 2 2-17-91 OPEN


25077 Remove tumor, forearm/wrist 01/01/00 2 534.47 457.72 21 3 2-17-91 OPEN

25085 Incision of wrist capsule 01/01/00 2 307.01 246.47 60 3 2-17-91 OPEN

25100 Biopsy of wrist joint 01/01/00 2 240.77 214.79 60 2 2-17-91 OPEN

25101 Explore/treat wrist joint 01/01/00 2 284.54 259.07 60 3 2-17-91 OPEN

25105 Remove wrist joint lining 01/01/00 2 357.88 325.71 90 4 1-1-96 OPEN

25107 Remove wrist joint cartilage 01/01/00 2 346.47 284.32 60 3 2-17-91 OPEN

25110 Remove wrist tendon lesion 01/01/00 2 207.72 166.48 30 3 2-17-91 OPEN

25111 Remove wrist tendon lesion 01/01/00 2 195.27 165.13 30 3 2-17-91 OPEN

25112 Reremove wrist tendon lesion 01/01/00 2 242.29 206.69 30 4 2-17-91 OPEN

25115 Remove wrist/forearm lesion 01/01/00 2 430.28 344.22 60 4 2-17-91 OPEN

25116 Remove wrist/forearm lesion 01/01/00 2 445.57 375.81 30 4 2-17-91 OPEN

25118 Excise wrist tendon sheath 01/01/00 2 270.77 244.43 30 2 2-17-91 OPEN

25119 Partial removal of ulna 01/01/00 2 375.48 333.44 60 3 2-17-91 OPEN


25125 Remove/graft forearm lesion 01/01/00 2 434.71 351.76 60 3 2-17-91 OPEN

25126 Remove/graft forearm lesion 01/01/00 2 443.21 354.57 60 3 2-17-91 OPEN

25130 Removal of wrist lesion 01/01/00 2 276.53 234.91 21 3 2-17-91 OPEN

5101:3-1-60 Page 28







25135 Remove & graft wrist lesion 01/01/00 2 355.54 307.03 21 3 2-17-91 OPEN

25136 Remove & graft wrist lesion 01/01/00 2 306.76 265.96 21 3 2-17-91 OPEN

25145 Remove forearm bone lesion 01/01/00 2 372.44 297.95 30 2 2-17-91 OPEN



25170 Extensive forearm surgery 01/01/00 2 601.21 512.31 45 3 2-17-91 12/31/03

25210 Removal of wrist bone 01/01/00 2 312.75 264.76 90 3 2-17-91 OPEN

25215 Removal of wrist bones 01/01/00 2 471.11 411.50 90 4 2-17-91 OPEN



25246 Injection for wrist x-ray 01/01/00 2 59.35 47.48 0 2 2-17-91 12-31-95

25248 Remove forearm foreign body 01/01/00 2 222.70 178.16 60 2 2-17-91 OPEN

25250 Removal of wrist prosthesis 01/01/00 2 352.23 302.89 60 1 2-17-91 OPEN

25251 Removal of wrist prosthesis 01/01/00 2 515.52 441.28 60 1 2-17-91 OPEN

25259 Manipulate wrist under anesthesia 01/01/02 1 251.13 90

25260 Repair forearm tendon/muscle 01/01/00 2 376.06 300.85 90 4 2-17-91 OPEN






25275 Repair tendon sheath, forearm/wrist 01/01/02 1 449.87 90 4 1-1-02 OPEN

25280 Revise wrist/forearm tendon 01/01/00 2 346.79 277.43 90 4 2-17-91 OPEN

25290 Incise wrist/forearm tendon 01/01/00 2 234.34 187.47 30 3 2-17-91 OPEN

25295 Release wrist/forearm tendon 01/01/00 2 291.26 233.01 60 3 2-17-91 OPEN

25300 Fusion of tendons at wrist 01/01/00 2 460.43 401.04 90 3 2-17-91 OPEN

25301 Fusion of tendons at wrist 01/01/00 2 427.70 378.46 60 3 2-17-91 OPEN

25310 Transplant forearm tendon 01/01/00 2 461.54 376.79 90 3 2-17-91 OPEN

25312 Transplant forearm tendon 01/01/00 2 518.09 425.13 90 4 2-17-91 OPEN

25315 Revise palsy hand tendon(s) 01/01/00 2 542.70 444.57 60 3 2-17-91 OPEN

25316 Revise palsy hand tendon(s) 01/01/00 2 689.93 562.14 60 3 2-17-91 OPEN

25320 Repair/revise wrist joint 01/01/00 2 543.67 470.23 60 3 2-17-91 OPEN

25330 Revise wrist joint 04/01/97 3 NC 463.73 90 5 2-17-91 OPEN

25331 Revise wrist joint 04/01/97 3 NC 634.94 90 5 2-17-91 OPEN

25332 Revise wrist joint 01/01/00 2 592.86 528.30 0 5 2-17-91 OPEN

25335 Realignment of hand 01/01/00 2 670.68 590.34 0 3 2-17-91 OPEN

25337 Reconstruct ulna/radioulnar 01/01/00 2 535.85 460.87 90 5 01/01/04 OPEN

25350 Revision of radius 01/01/00 2 490.15 402.99 90 3 2-17-91 OPEN

5101:3-1-60 Page 29







25355 Revision of radius 01/01/00 2 550.48 474.93 90 3 2-17-91 OPEN

25360 Revision of ulna 01/01/00 2 448.92 360.39 90 3 2-17-91 OPEN

25365 Revise radius & ulna 01/01/00 2 647.82 554.01 90 3 2-17-91 OPEN

25370 Revise radius or ulna 01/01/00 2 687.47 612.99 90 3 2-17-91 OPEN

25375 Revise radius & ulna 01/01/00 2 687.83 621.52 90 4 2-17-91 OPEN

25390 Shorten radius/ulna 01/01/00 2 561.73 475.55 90 3 2-17-91 OPEN

25391 Lengthen radius/ulna 01/01/00 2 709.84 611.47 90 4 2-17-91 OPEN

25392 Shorten radius & ulna 01/01/00 2 739.11 648.57 90 3 2-17-91 OPEN

25393 Lengthen radius & ulna 01/01/00 2 824.20 740.43 90 4 2-17-91 OPEN

25394 Osteoplasty of carpal bone 01/01/02 1 524.80 90

25400 Repair radius or ulna 01/01/00 2 628.19 537.36 90 3 2-17-91 OPEN

25405 Repair/graft radius or ulna 01/01/00 2 766.77 657.94 90 4 2-17-91 OPEN

25415 Repair radius & ulna 01/01/00 2 707.21 612.45 90 3 2-17-91 OPEN

25420 Repair/graft radius & ulna 01/01/00 2 873.89 761.14 90 4 2-17-91 OPEN

25425 Repair/graft radius or ulna 01/01/00 2 775.05 620.04 90 3 2-17-91 OPEN

25426 Repair/graft radius & ulna 01/01/00 2 799.26 679.37 90 4 2-17-91 OPEN

25430 Vascular pedicle graft for carpal bone 01/01/02 1 463.17 90

25431 Repair nonunion carpal bone 01/01/02 1 459.10 90

25440 Repair/graft wrist bone 01/01/00 2 543.07 483.19 30 4 2-17-91 OPEN

25441 Reconstruct wrist joint 01/01/00 2 667.28 601.19 90 5 2-17-91 OPEN





25446 Wrist replacement 01/01/00 2 947.54 913.75 90 7 2-17-91 OPEN

25447 Repair wrist joint(s) 01/01/00 2 555.51 496.22 30 5 2-17-91 OPEN

25449 Remove wrist joint implant 01/01/00 2 641.34 538.96 90 5 2-17-91 OPEN

25450 Revision of wrist joint 01/01/00 2 407.16 380.93 60 3 2-17-91 OPEN

25455 Revision of wrist joint 01/01/00 2 509.31 454.20 60 3 2-17-91 OPEN

25490 Reinforce radius 01/01/00 2 533.47 453.03 7 3 2-17-91 OPEN

25491 Reinforce ulna 01/01/00 2 552.83 474.23 7 3 2-17-91 OPEN

25492 Reinforce radius and ulna 01/01/00 2 675.50 584.03 7 3 2-17-91 OPEN

25500 Treat fracture of radius 01/01/00 2 144.59 115.67 30

25505 Treat fracture of radius 01/01/00 2 266.73 213.38 90 1 2-17-91 OPEN

25515 Repair fracture of radius 01/01/00 2 459.78 412.03 90 3 2-17-91 OPEN




5101:3-1-60 Page 30







25530 Treat fracture of ulna 01/01/00 2 138.83 111.06 90

25535 Treat fracture of ulna 01/01/00 2 263.91 212.95 90 1 2-17-91 OPEN

25545 Repair fracture of ulna 01/01/00 2 456.93 403.66 90 3 2-17-91 OPEN

25560 Treat fracture radius & ulna 01/01/00 2 141.95 113.56 15

25565 Treat fracture radius & ulna 01/01/00 2 305.99 250.96 90 2 2-17-91 OPEN

25574 Treat fracture radius & ulna 01/01/00 2 415.50 364.61 90 3 1-1-96 OPEN

25575 Repair fracture radius/ulna 01/01/00 2 574.96 515.10 90 3 2-17-91 OPEN

25600 Treat fracture radius/ulna 01/01/00 2 168.65 134.92 45

25605 Treat fracture radius/ulna 01/01/00 2 292.74 234.19 60 3 2-17-91 OPEN



25622 Treat wrist bone fracture 01/01/00 2 148.34 118.67 90

25624 Treat wrist bone fracture 01/01/00 2 251.08 200.86 90 2 2-17-91 OPEN

25628 Repair wrist bone fracture 01/01/00 2 433.45 379.43 90 3 2-17-91 OPEN

25630 Treat wrist bone fracture 01/01/00 2 153.83 123.06 90

25635 Treat wrist bone fracture 01/01/00 2 236.43 189.14 90 1 2-17-91 OPEN

25645 Repair wrist bone fracture 01/01/00 2 386.41 340.79 90 3 2-17-91 OPEN

25650 Repair wrist bone fracture 01/01/00 2 173.33 138.66 90 1 2-17-91 9/30/04

25651 Perc skel fixation ulnar styloid fracture 01/01/02 1 275.29 90

25652 Open treatment ulnarstyloid fracture 01/01/02 1 405.88 90

25660 Treat wrist dislocation 01/01/00 2 189.07 156.84 60 1 2-17-91 OPEN

25670 Repair wrist dislocation 01/01/00 2 416.34 370.31 90 3 2-17-91 OPEN

25671 Perc skelet fix dist radioulnar disloca 01/01/02 1 334.75 90 1 1-1-02 OPEN

25675 Clsd trea distal radioulnar disloc w man 01/01/01 2 208.99 167.19 7 1 1-4-88 OPEN


25680 Treat wrist fracture 01/01/00 2 243.02 199.92 14 2 2-17-91 OPEN

25685 Repair wrist fracture 01/01/00 2 510.32 458.46 60 3 2-17-91 OPEN

25690 Treat wrist dislocation 01/01/00 2 290.35 253.84 7 1 2-17-91 OPEN


25800 Fusion of wrist joint 01/01/00 2 563.99 516.10 90 4 2-17-91 OPEN

25805 Fusion/graft of wrist joint 01/01/00 2 648.63 599.63 90 5 2-17-91 OPEN

25810 Fusion/graft of wrist joint 01/01/00 2 611.08 572.85 90 5 2-17-91 OPEN

25820 Fusion of hand bones 01/01/00 2 440.80 412.02 30 4 2-17-91 OPEN

25825 Fusion hand bones with graft 01/01/00 2 545.70 508.10 60 5 2-17-91 OPEN

25830 Fusion radioulnar joint/ulna 01/01/00 2 550.38 460.87 90 5 01/01/04 OPEN

25900 Amputation of forearm 01/01/00 2 472.89 390.27 90



5101:3-1-60 Page 31









25920 Amputate hand at wrist 01/01/00 2 439.82 384.21 90

25922 Amputate hand at wrist 01/01/00 2 370.15 319.47 90 3 2-17-91 OPEN


25927 Amputation of hand 01/01/00 2 447.05 372.87 60



25999 Forearm or wrist surgery 05/01/94 1 BR 0

* 26010 Drainage of finger abscess 01/01/04 2 201.16 59.98 10

* 26011 Drainage of finger abscess 01/01/04 2 195.66 115.71 10 1 2-17-91 OPEN

26020 Drain hand tendon sheath 01/01/00 2 246.30 197.04 30 2 2-17-91 OPEN

26025 Drainage of palm bursa 01/01/00 2 282.23 225.78 30 1 2-17-91 OPEN

26030 Drainage of palm bursa(s) 01/01/00 2 355.16 284.13 30 2 2-17-91 OPEN

26034 Treat hand bone lesion 01/01/00 2 310.79 248.63 30 2 2-17-91 OPEN

26035 Decompress fingers/hand 01/01/00 2 426.06 340.85 45 4 2-17-91 12/31/03

26037 Decompress fingers/hand 01/01/00 2 400.57 332.19 45 4 2-17-91 12/31/03

26040 Release palm contracture 01/01/00 2 189.75 151.80 60 4 2-17-91 OPEN


26055 Incise finger tendon sheath 01/01/00 2 183.68 150.42 30 2 2-17-91 OPEN

26060 Incision of finger tendon 01/01/00 2 118.93 95.14 14 2 2-17-91 OPEN

26070 Explore/treat hand joint 01/01/00 2 192.19 153.75 60 2 2-17-91 OPEN

26075 Explore/treat finger joint 01/01/00 2 230.58 184.46 60 4 2-17-91 OPEN

26080 Explore/treat finger joint 01/01/00 2 219.06 175.25 60 4 2-17-91 OPEN

26100 Biopsy hand joint lining 01/01/00 2 203.80 164.55 60 2 2-17-91 OPEN

26105 Biopsy finger joint lining 01/01/00 2 247.48 197.98 60 1 2-17-91 OPEN

26110 Biopsy finger joint lining 01/01/00 2 201.36 161.09 60 1 2-17-91 OPEN

26115 Removal of hand lesion 01/01/00 2 178.49 142.79 7 2 2-17-91 OPEN

26116 Removal of hand lesion 01/01/00 2 281.11 224.89 7 2 2-17-91 OPEN

26117 Remove tumor, hand/finger 01/01/00 2 413.89 336.48 60 3 2-17-91 OPEN




26130 Remove wrist joint lining 01/01/00 2 323.95 259.16 60 3 2-17-91 OPEN

26135 Revise finger joint, each 01/01/00 2 364.64 291.71 60 4 2-17-91 OPEN

26140 Revise finger joint, each 01/01/00 2 325.60 260.48 45 2 2-17-91 OPEN

26145 Tendon excision, palm/finger 01/01/00 2 340.53 272.42 30 3 2-17-91 OPEN

26160 Remove tendon sheath lesion 01/01/00 2 168.81 135.05 30 3 2-17-91 OPEN

5101:3-1-60 Page 32







26170 Removal of palm tendon, each 01/01/00 2 232.60 186.84 60 3 2-17-91 OPEN

26180 Removal of finger tendon 01/01/00 2 273.20 229.45 60 3 2-17-91 OPEN

26185 Sesamoidectomy, thumb or finger 01/01/00 2 271.38 217.10 90 4 01/01/04 OPEN 3 01/01/97 12/31/03

26200 Remove hand bone lesion 01/01/00 2 308.01 246.41 21 2 2-17-91 OPEN


26210 Removal of finger lesion 01/01/00 2 280.55 224.44 14 2 2-17-91 OPEN

26215 Remove/graft finger lesion 01/01/00 2 383.15 313.84 14 3 2-17-91 OPEN

26230 Partial removal of hand bone 01/01/00 2 322.11 257.69 90 7 2-17-91 OPEN

26235 Partial removal, finger bone 01/01/00 2 315.98 252.78 90 3 2-17-91 OPEN

26236 Partial removal, finger bone 01/01/00 2 279.45 223.56 90 3 2-17-91 OPEN

26250 Extensive hand surgery 01/01/00 2 407.58 338.20 90 3 2-17-91 OPEN

26255 Extensive hand surgery 01/01/00 2 622.62 522.77 90 3 2-17-91 OPEN

26260 Extensive finger surgery 01/01/00 2 395.78 317.02 90 3 2-17-91 OPEN

26261 Extensive finger surgery 01/01/00 2 464.31 413.76 90 3 2-17-91 OPEN

26262 Partial removal of finger 01/01/00 2 321.78 257.42 90 2 2-17-91 OPEN

26320 Removal of implant from hand 01/01/00 2 231.16 184.93 60 2 2-17-91 OPEN

26340 Manipulate finger joint-anesthesia 01/01/02 1 191.40 90

26350 Repair finger/hand tendon 01/01/00 2 367.78 294.22 90 1 2-17-91 OPEN

26352 Repair/graft hand tendon 01/01/00 2 440.79 352.63 90 4 2-17-91 OPEN







26390 Revise hand/finger tendon 01/01/00 2 504.41 421.98 60 4 2-17-91 OPEN


26410 Repair hand tendon 01/01/00 2 241.05 192.84 60 3 2-17-91 OPEN


26415 Excision, hand/finger tendon 01/01/00 2 441.40 369.93 60 4 2-17-91 OPEN

26416 Graft hand or finger tendon 01/01/00 2 531.38 450.20 60 3 1-1-96 OPEN

26418 Repair finger tendon 01/01/00 2 241.34 193.07 60 4 2-17-91 OPEN

26420 Repair/graft finger tendon 01/01/00 2 383.43 306.74 90 4 2-17-91 OPEN






5101:3-1-60 Page 33







26437 Realignment of tendons 01/01/00 2 302.91 242.33 30 3 2-17-91 OPEN

26440 Release palm/finger tendon 01/01/00 2 263.26 210.61 60 3 2-17-91 OPEN

26442 Release palm & finger tendon 01/01/00 2 297.80 238.24 60 3 2-17-91 OPEN

26445 Release hand/finger tendon 01/01/00 2 234.56 187.65 60 3 2-17-91 OPEN

26449 Release forearm/hand tendon 01/01/00 2 380.90 304.72 60 3 2-17-91 OPEN

26450 Incision of palm tendon 01/01/00 2 182.61 146.09 30 3 2-17-91 OPEN

26455 Incision of finger tendon 01/01/00 2 169.65 135.72 30 3 2-17-91 OPEN

26460 Incise hand/finger tendon 01/01/00 2 158.46 126.77 30 3 2-17-91 OPEN

26471 Fusion of finger tendons 01/01/00 2 306.04 244.83 30 2 2-17-91 OPEN

26474 Fusion of finger tendons 01/01/00 2 309.36 247.49 30 2 2-17-91 OPEN

26476 Tendon lengthening 01/01/00 2 240.95 192.76 90 1 2-17-91 OPEN

26477 Tendon shortening 01/01/00 2 285.98 228.78 90 1 2-17-91 OPEN

26478 Lengthening of hand tendon 01/01/00 2 314.00 251.20 30 1 2-17-91 OPEN

26479 Shortening of hand tendon 01/01/00 2 340.31 275.86 30 1 2-17-91 OPEN

26480 Transplant hand tendon 01/01/00 2 416.00 332.80 90 3 2-17-91 OPEN

26483 Transplant/graft hand tendon 01/01/00 2 508.17 418.18 90 3 2-17-91 OPEN

26485 Transplant palm tendon 01/01/00 2 437.90 350.32 90 2 2-17-91 OPEN

26489 Transplant/graft palm tendon 01/01/00 2 383.15 306.52 90 3 2-17-91 OPEN

26490 Revise thumb tendon 01/01/00 2 475.94 402.06 60 3 2-17-91 OPEN

26492 Tendon transfer with graft 01/01/00 2 535.15 450.26 60 3 2-17-91 OPEN

26494 Hand tendon/muscle transfer 01/01/00 2 468.11 390.39 60 3 2-17-91 OPEN

26496 Revise thumb tendon 01/01/00 2 530.74 457.94 60 3 2-17-91 OPEN

26497 Finger tendon transfer 01/01/00 2 528.15 437.47 90 3 2-17-91 OPEN

26498 Finger tendon transfer 01/01/00 2 746.70 645.55 90 4 2-17-91 OPEN

26499 Revision of finger 01/01/00 2 492.52 413.85 60 3 2-17-91 OPEN

26500 Hand tendon reconstruction 01/01/00 2 288.63 230.90 45 4 2-17-91 OPEN



26508 Release thumb contracture 01/01/00 2 309.43 247.54 30 3 2-17-91 OPEN

26510 Thumb tendon transfer 01/01/00 2 290.75 232.60 15 3 2-17-91 OPEN

26516 Fusion of knuckle joint 01/01/00 2 342.34 273.87 30 1 2-17-91 OPEN

26517 Fusion of knuckle joints 01/01/00 2 488.16 392.57 30 3 2-17-91 OPEN

26518 Fusion of knuckle joints 01/01/00 2 465.75 384.12 30 3 2-17-91 OPEN

26520 Release knuckle contracture 01/01/00 2 300.50 240.40 45 3 2-17-91 OPEN

26525 Release finger contracture 01/01/00 2 274.63 219.70 30 3 2-17-91 OPEN

26530 Revise knuckle joint 01/01/00 2 365.43 292.34 45 3 2-17-91 OPEN

26531 Revise knuckle with implant 01/01/00 2 451.83 361.46 90 7 2-17-91 OPEN

26535 Revise finger joint 01/01/00 2 293.50 243.85 90 5 2-17-91 OPEN

5101:3-1-60 Page 34







26536 Revise/implant finger joint 01/01/00 2 414.77 339.99 90 5 2-17-91 OPEN

26540 Repair hand joint 01/01/00 2 392.72 324.51 90 4 2-17-91 OPEN

26541 Repair hand joint with graft 01/01/00 2 512.27 437.90 90 7 2-17-91 OPEN

26542 Repair hand joint with graft 01/01/00 2 379.31 307.01 21 4 2-17-91 OPEN

26545 Reconstruct finger joint 01/01/00 2 375.03 300.02 90 4 2-17-91 OPEN

26546 Repair non-union metacarpal or phalanx 01/01/00 2 502.32 405.70 90 4 01/01/04 OPEN

26548 Reconstruct finger joint 01/01/00 2 420.79 340.04 0 4 2-17-91 OPEN

26550 Construct thumb replacement 01/01/00 2 1,160.06 1,032.33 60 2 2-17-91 OPEN

26551 Microvascular toe-to-hand transfer 01/01/00 2 2,401.82 2,114.17 90 4 01/01/97 12/31/03

26552 Construct thumb replacement 04/01/97 3 NC BR 90 4 2-17-91 OPEN



26555 Positional change of finger 01/01/00 2 898.32 803.11 90 3 2-17-91 OPEN

26556 Microvascular free toe joint transfer 01/01/00 2 2,378.60 2,134.98 90

26557 Construct finger replacement 04/01/97 3 NC BR 90 3 2-17-91 OPEN

26558 Added finger surgery 04/01/97 3 NC BR 90 2 2-17-91 OPEN

26559 Added finger surgery 04/01/97 3 NC BR 90 2 2-17-91 OPEN

26560 Repair of web finger 01/01/00 2 310.35 248.28 60 2 2-17-91 OPEN



26565 Correct metacarpal flaw 01/01/00 2 382.27 309.05 90 5 2-17-91 OPEN

26567 Correct finger deformity 01/01/00 2 339.15 271.32 90 5 2-17-91 OPEN

26568 Lengthen metacarpal/finger 01/01/00 2 508.39 427.37 30 3 2-17-91 OPEN

26580 Repair hand deformity 01/01/00 2 949.66 880.14 0 5 2-17-91 OPEN

26585 Repair hand deformity 04/01/02 3 NC 740.38 60 5 1-1-97 3-31-02

26587 Reconstruct extra finger 07/01/03 2 543.79 BR 60 5 1-1-96 OPEN

26590 Repair finger deformity 01/01/00 2 923.52 866.71 60 5 2-17-91 OPEN

26591 Repair muscles of hand 01/01/00 2 164.64 131.71 45 3 1-1-96 OPEN

26593 Release muscles of hand 01/01/00 2 286.33 229.06 45 3 2-17-91 OPEN

26596 Excision constricting tissue 01/01/00 2 477.78 429.47 30 2 2-17-91 OPEN

26597 Release scar contract 04/01/02 3 NC 524.41 30 3 1-1-97 3-31-02

26600 Treat metacarpal fracture 01/01/00 2 105.16 84.13 0

26605 Treat metacarpal fracture 01/01/00 2 156.79 125.43 90 2 2-17-91 OPEN

26607 Treat metacarpal fracture 01/01/00 2 264.67 218.30 90 2 2-17-91 OPEN

26608 Treat metacarpal fracture 01/01/00 2 262.66 218.30 90 4 01/01/04 OPEN

26615 Repair metacarpal fracture 01/01/00 2 289.97 255.65 90 4 2-17-91 OPEN

26641 Treat thumb dislocation 01/01/00 2 148.31 118.65 0 OPEN

26645 Treat thumb fracture 01/01/00 2 200.09 160.07 0 1 2-17-91 OPEN

5101:3-1-60 Page 35







26650 Repair thumb fracture 01/01/00 2 283.18 239.44 7 2 2-17-91 OPEN

26665 Repair thumb fracture 01/01/00 2 391.97 344.71 14 4 2-17-91 OPEN

26670 Treat hand dislocation 01/01/00 2 136.76 109.41 0

26675 Treat hand dislocation 01/01/00 2 259.93 220.72 0 2 2-17-91 OPEN

26676 Pin hand dislocation 01/01/00 2 296.01 254.76 15 2 2-17-91 OPEN

26685 Repair hand dislocation 01/01/00 2 361.05 311.37 14 3 2-17-91 OPEN

26686 Repair hand dislocation 01/01/00 2 398.51 349.78 0 3 2-17-91 OPEN

26700 Treat knuckle dislocation 01/01/00 2 134.49 107.59 0

26705 Treat knuckle dislocation 01/01/00 2 179.03 143.22 7 2 2-17-91 OPEN

26706 Pin knuckle dislocation 01/01/00 2 271.76 243.81 15 2 2-17-91 OPEN

26715 Repair knuckle dislocation 01/01/00 2 284.32 242.44 14 4 2-17-91 OPEN

26720 Treat finger fracture, each 01/01/00 2 81.82 66.33 7


26727 Treat finger fracture, each 01/01/00 2 229.51 183.61 45 7 2-17-91 OPEN

26735 Repair finger fracture, each 01/01/00 2 280.65 237.82 60 4 2-17-91 OPEN


26742 Treat finger fracture, each 01/01/00 2 177.60 142.08 0 2 2-17-91 OPEN



26755 Treat finger fracture, each 01/01/00 2 124.66 99.73 0 OPEN

26756 Pin finger fracture, each 01/01/00 2 190.35 152.28 7 2 2-17-91 OPEN


26770 Treat finger dislocation 01/01/00 2 110.93 88.74 7

26775 Treat finger dislocation 01/01/00 2 142.94 114.35 7

26776 Pin finger dislocation 01/01/00 2 208.41 166.73 7 2 1-1-96 OPEN

26785 Repair finger dislocation 01/01/00 2 212.15 177.82 75 2 2-17-91 OPEN

26820 Thumb fusion with graft 01/01/00 2 447.16 366.42 30 5 2-17-91 OPEN

26841 Fusion of thumb 01/01/00 2 401.67 329.00 30 4 2-17-91 OPEN

26842 Thumb fusion with graft 01/01/00 2 493.81 416.35 30 4 2-17-91 OPEN

26843 Fusion of hand joint 01/01/00 2 425.46 346.19 30 3 2-17-91 OPEN

26844 Fusion/graft of hand joint 01/01/00 2 482.17 395.53 30 3 2-17-91 OPEN

26850 Fusion of knuckle 01/01/00 2 353.18 282.54 14 4 2-17-91 OPEN

26852 Fusion of knuckle with graft 01/01/00 2 431.26 347.09 30 4 2-17-91 OPEN

26860 Fusion of finger joint 01/01/00 2 278.81 223.05 30 3 2-17-91 OPEN

26861 Fusion of finger joint,added 01/01/00 2 99.69 103.51 30 2 2-17-91 OPEN

26862 Fusion/graft of finger joint 01/01/00 2 384.45 308.67 30 4 2-17-91 OPEN

26863 Fuse/graft added joint 01/01/00 2 194.98 184.90 30 3 2-17-91 OPEN

26910 Amputate metacarpal bone 01/01/00 2 384.69 313.58 60 3 2-17-91 OPEN

5101:3-1-60 Page 36







26951 Amputation of finger/thumb 01/01/00 2 229.65 183.72 45 2 2-17-91 OPEN

26952 Amputation of finger/thumb 01/01/00 2 316.51 253.21 60 4 2-17-91 OPEN

26989 Hand/finger surgery 05/01/94 1 BR BR 0

26990 Drainage of pelvis lesion 01/01/00 2 307.38 245.90 0 1 2-17-91 OPEN

26991 Drainage of pelvis bursa 01/01/00 2 242.35 193.88 0 1 2-17-91 OPEN


27000 Incision of hip tendon 01/01/00 2 218.49 174.79 30 2 2-17-91 OPEN



27005 Incision of hip tendon 01/01/00 2 383.25 306.60 14

27006 Incision of hip tendons 01/01/00 2 413.66 353.38 60

27025 Incision of hip/thigh fascia 01/01/00 2 486.29 409.30 60

27030 Drainage of hip joint 01/01/00 2 670.90 597.71 90 3 2-17-91 12/31/03

27033 Exploration of hip joint 01/01/00 2 681.95 606.70 90 3 2-17-91 OPEN

27035 Denervation of hip joint 01/01/00 2 796.96 703.80 30 4 2-17-91 OPEN

27036 Capsulectomy or capsulotomy of hip 01/01/00 2 670.61 572.35 90

27040 Biopsy of soft tissues 01/01/00 2 116.34 97.48 0 1 2-17-91 OPEN

27041 Biopsy of soft tissues 01/01/00 2 360.01 296.76 0 2 2-17-91 OPEN

27047 Remove hip/pelvis lesion 01/01/00 2 278.67 223.12 7 2 2-17-91 OPEN

27048 Remove hip/pelvis lesion 01/01/00 2 302.11 256.34 30 3 2-17-91 OPEN

27049 Remove tumor, hip/pelvis 01/01/00 2 659.84 579.14 60 3 2-17-91 OPEN

27050 Biopsy of sacroiliac joint 01/01/00 2 261.35 221.32 90 3 2-17-91 OPEN

27052 Biopsy of hip joint 01/01/00 2 376.96 330.04 90 3 2-17-91 OPEN

27054 Removal of hip joint lining 01/01/00 2 511.78 461.34 90

27060 Removal of ischial bursa 01/01/00 2 268.11 220.38 60 5 2-17-91 OPEN

27062 Remove femur lesion/bursa 01/01/00 2 275.01 227.96 90 5 2-17-91 OPEN

27065 Removal of hip bone lesion 01/01/00 2 326.75 269.79 30 5 2-17-91 OPEN

27066 Removal of hip bone lesion 01/01/00 2 516.53 433.19 60 5 2-17-91 OPEN

27067 Remove/graft hip bone lesion 01/01/00 2 708.19 617.48 60 5 01/01/04 OPEN

27070 Partial removal of hip bone 01/01/00 2 536.98 429.58 90

27071 Partial removal of hip bone 01/01/00 2 595.15 476.12 90

27075 Extensive hip surgery 01/01/00 2 848.38 747.98 90

27076 Extensive hip surgery 01/01/00 2 1,060.62 869.76 90

27077 Extensive hip surgery 01/01/00 2 1,147.65 1,025.91 90



27080 Removal of tail bone 01/01/00 2 314.67 266.18 90 2 2-17-91 OPEN

* 27086 Remove hip foreign body 01/01/04 2 189.07 73.36 10 2 01/01/97 OPEN

5101:3-1-60 Page 37







27087 Remove hip foreign body 01/01/00 2 352.07 290.05 14 3 02/17/91 OPEN

27090 Removal of hip prosthesis 01/01/00 2 561.95 532.31 90

27091 Removal of hip prosthesis 01/01/00 2 1,126.25 1,023.33 90

27093 Injection for hip x-ray 01/01/00 2 65.86 52.69 0

27095 Injection for hip x-ray 01/01/00 2 75.64 60.51 0 1 2-17-91 12-31-95

27096 Injection procedure for sacroiliac joint 01/01/00 1 289.43 0

27097 Revision of hip tendon 01/01/00 2 457.65 401.67 60 3 2-17-91 OPEN

27098 Transfer tendon to pelvis 01/01/00 2 459.34 401.67 60 3 2-17-91 OPEN

27100 Transfer of abdominal muscle 01/01/00 2 535.03 464.84 60 4 2-17-91 OPEN

27105 Transfer of spinal muscle 01/01/00 2 513.33 439.12 60 4 2-17-91 OPEN

27110 Transfer of iliopsoas muscle 01/01/00 2 665.37 588.87 60 4 2-17-91 OPEN

27111 Transfer of iliopsoas muscle 01/01/00 2 645.87 581.55 60 4 2-17-91 OPEN

27120 Reconstruction of hip socket 01/01/00 2 969.89 881.79 90

27122 Reconstruction of hip socket 01/01/00 2 856.19 795.76 90

27125 Partial hip replacement 01/01/00 2 841.12 778.89 90

27130 Total hip replacement 01/01/00 2 1,154.31 1,109.59 90

27132 Total hip replacement 01/01/00 2 1,327.74 1,269.23 90

27134 Revise hip joint replacement 01/01/00 2 1,611.93 1,456.21 90



27140 Transplant of femur ridge 01/01/00 2 637.42 569.63 60

27146 Incision of hip bone 01/01/00 2 764.49 611.59 90

27147 Revision of hip bone 01/01/00 2 1,020.23 878.84 90

27151 Incision of hip bones 01/01/00 2 1,098.27 923.26 90

27156 Revision of hip bones 01/01/00 2 1,175.94 979.67 90

27158 Revision of pelvis 01/01/00 2 950.43 830.19 90

27161 Incision of neck of femur 01/01/00 2 849.00 749.66 90

27165 Incision/fixation of femur 01/01/00 2 935.80 837.61 90

27170 Repair/graft femur head/neck 01/01/00 2 877.19 798.93 90

27175 Treat slipped epiphysis 01/01/00 2 256.64 205.31 90

27176 Treat slipped epiphysis 01/01/00 2 607.78 541.37 90

27177 Repair slipped epiphysis 01/01/00 2 744.71 664.74 90


27179 Revise head/neck of femur 01/01/00 2 653.64 581.20 90


27185 Revision of femur epiphysis 01/01/00 2 355.65 284.52 60

27187 Reinforce hip bones 01/01/00 2 777.47 738.49 30

27193 Treat pelvic ring fracture 01/01/00 2 220.29 176.23 45 1 1-1-96 OPEN

5101:3-1-60 Page 38







27194 Treat pelvic ring fracture 01/01/00 2 385.73 311.18 45 2 1-1-96 OPEN

27200 Treat tail bone fracture 01/01/00 2 94.93 80.52 30

27202 Repair tail bone fracture 01/01/00 2 399.09 319.27 60 2 2-17-91 OPEN

27215 Pelvic fracture(s) treatment 01/01/00 2 578.72 558.49 90

27216 Treat pelvic ring fracture 01/01/00 2 569.64 455.71 60



27220 Treat hip socket fracture 01/01/00 2 296.15 239.61 60

27222 Treat hip socket fracture 01/01/00 2 536.37 434.22 90

27226 Treat hip wall fracture 01/01/00 2 797.15 757.98 90

27227 Treat hip fracture(s) 01/01/00 2 1,124.51 899.61 90

27228 Treat hip fracture(s) 01/01/00 2 1,206.98 965.58 90

27230 Treat fracture of thigh 01/01/00 2 253.33 204.45 30 1 2-17-91 OPEN

27232 Treat fracture of thigh 01/01/00 2 542.31 465.45 90

27235 Repair of thigh fracture 01/01/00 2 703.76 651.87 90


27238 Treatment of thigh fracture 01/01/00 2 288.57 251.39 30 1 2-17-91 OPEN

27240 Treatment of thigh fracture 01/01/00 2 613.67 520.61 60





27250 Treat hip dislocation 01/01/00 2 279.95 235.62 30 1 2-17-91 OPEN

27252 Treat hip dislocation 01/01/00 2 414.30 343.54 30 2 2-17-91 OPEN

27253 Repair of hip dislocation 01/01/00 2 701.11 640.60 60


27256 Treatment of hip dislocation 01/01/00 2 170.56 140.03 45

27257 Treatment of hip dislocation 01/01/00 2 265.09 239.53 45 3 01/01/04 OPEN


27259 Repair of hip dislocation 01/01/00 2 1,041.02 896.41 90

27265 Treatment of hip dislocation 01/01/00 2 240.67 226.53 45 1 2-17-91 OPEN

27266 Treatment of hip dislocation 01/01/00 2 337.11 305.03 45 2 2-17-91 OPEN

27275 Manipulation of hip joint 01/01/00 2 120.31 98.47 14 2 2-17-91 OPEN

27280 Fusion of sacroiliac joint 01/01/00 2 662.93 557.73 90

27282 Fusion of pubic bones 01/01/00 2 570.72 502.00 90

27284 Fusion of hip joint 01/01/00 2 859.77 766.36 90

27286 Fusion of hip joint 01/01/00 2 867.25 779.47 90

27290 Amputation of leg at hip 01/01/00 2 1,299.93 1,218.62 90

5101:3-1-60 Page 39







27295 Amputation of leg at hip 01/01/00 2 951.85 867.63 90

27299 Pelvis/hip joint surgery 05/01/94 1 BR 0

27301 Drain thigh/knee lesion 01/01/00 2 261.65 209.32 0 3 2-17-91 OPEN


27305 Incise thigh tendon & fascia 01/01/00 2 286.49 233.99 45 2 2-17-91 OPEN

27306 Incision of thigh tendon 01/01/00 2 195.00 156.00 14 3 2-17-91 OPEN

27307 Incision of thigh tendons 01/01/00 2 259.51 208.03 30 3 2-17-91 OPEN

27310 Exploration of knee joint 01/01/00 2 518.93 455.39 90 4 2-17-91 OPEN

27315 Partial removal, thigh nerve 01/01/00 2 335.44 303.27 30 2 2-17-91 OPEN

27320 Partial removal, thigh nerve 01/01/00 2 306.82 278.22 30 2 2-17-91 OPEN

27323 Biopsy thigh soft tissues 01/01/00 2 103.79 88.15 0 1 2-17-91 OPEN

27324 Biopsy thigh soft tissues 01/01/00 2 220.78 180.12 14 1 2-17-91 OPEN

27327 Removal of thigh lesion 01/01/00 2 203.68 166.06 7 2 2-17-91 OPEN

27328 Removal of thigh lesion 01/01/00 2 274.30 238.77 30 3 2-17-91 OPEN

27329 Remove tumor, thigh/knee 01/01/00 2 715.09 602.58 60 4 01/01/04 OPEN

27330 Biopsy knee joint lining 01/01/00 2 296.17 280.47 90 4 2-17-91 OPEN

27331 Explore/treat knee joint 01/01/00 2 352.77 330.77 90 4 2-17-91 OPEN

27332 Removal of knee cartilage 01/01/00 2 477.78 461.39 90 4 2-17-91 OPEN

27333 Removal of knee cartilage 01/01/00 2 447.60 432.81 90 4 2-17-91 OPEN

27334 Remove knee joint lining 01/01/00 2 505.24 467.77 90 4 2-17-91 OPEN

27335 Remove knee joint lining 01/01/00 2 579.10 540.65 90 4 2-17-91 OPEN

27340 Removal of kneecap bursa 01/01/00 2 228.09 197.58 60 3 2-17-91 OPEN

27345 Removal of knee cyst 01/01/00 2 324.28 287.58 60 4 2-17-91 OPEN

27347 Knee lesion excision 01/01/00 2 184.68 214.14 90 4 01/01/04 OPEN

27350 Removal of kneecap 01/01/00 2 471.18 433.48 90 4 2-17-91 OPEN

27355 Remove femur lesion 01/01/00 2 427.21 373.45 90 3 2-17-91 OPEN

27356 Remove femur lesion/graft 01/01/00 2 496.92 427.35 90 4 2-17-91 OPEN

27357 Remove femur lesion/graft 01/01/00 2 539.16 468.04 90 5 01/01/04 OPEN

27358 Remove femur lesion/fixation 01/01/00 2 245.46 235.76 90 5 01/01/04 OPEN

27360 Partial removal leg bone(s) 01/01/00 2 565.25 452.20 90 5 2-17-91 OPEN

27365 Extensive leg surgery 01/01/00 2 828.25 711.62 45

27370 Injection for knee x-ray 01/01/00 2 47.49 37.99 0

27372 Removal of foreign body 01/01/00 2 246.08 207.13 14 7 2-17-91 OPEN

27380 Repair of kneecap tendon 01/01/00 2 416.16 372.85 60 1 2-17-91 OPEN

27381 Repair/graft kneecap tendon 01/01/00 2 586.74 534.93 60 3 2-17-91 OPEN

27385 Repair of thigh muscle 01/01/00 2 449.84 409.62 60 3 2-17-91 OPEN

27386 Repair/graft of thigh muscle 01/01/00 2 607.78 568.10 90 3 2-17-91 OPEN

27390 Incision of thigh tendon 01/01/00 2 278.72 234.78 45 1 2-17-91 OPEN

5101:3-1-60 Page 40









27393 Lengthening of thigh tendon 01/01/00 2 342.97 295.66 90 2 2-17-91 OPEN

27394 Lengthening of thigh tendons 01/01/00 2 407.76 345.79 90 3 2-17-91 OPEN

27395 Lengthening of thigh tendons 01/01/00 2 616.14 543.83 90 3 2-17-91 OPEN

27396 Transplant of thigh tendon 01/01/00 2 420.33 365.04 90 3 2-17-91 OPEN

27397 Transplants of thigh tendons 01/01/00 2 561.11 463.16 90 3 2-17-91 OPEN

27400 Revise thigh muscles/tendons 01/01/00 2 468.51 414.62 90 3 2-17-91 OPEN

27403 Repair of knee cartilage 01/01/00 2 468.52 424.12 90 4 2-17-91 OPEN

27405 Repair of knee ligament 01/01/00 2 500.28 465.48 90 4 2-17-91 OPEN

27407 Repair of knee ligament 01/01/00 2 527.30 464.81 90 4 2-17-91 OPEN

27409 Repair of knee ligaments 01/01/00 2 736.53 690.33 90 4 2-17-91 OPEN27412 Autochondrocyte implant knee 01/01/05 1 1175.01 9027415 Osteochondral knee allograft 01/01/05 1 980.31 90

27418 Repair degenerated kneecap 01/01/00 2 618.04 561.40 60 3 2-17-91 OPEN

27420 Revision of unstable kneecap 01/01/00 2 560.54 514.27 90 3 2-17-91 OPEN

27422 Revision of unstable kneecap 01/01/00 2 559.80 525.84 90 7 2-17-91 OPEN

27424 Revision/removal of kneecap 01/01/00 2 561.79 533.32 90 3 2-17-91 OPEN

27425 Lateral retinacular release 01/01/00 2 309.82 295.62 30 7 2-17-91 OPEN

27427 Reconstruction, knee 01/01/00 2 545.97 518.91 90 3 2-17-91 OPEN



27430 Revision of thigh muscles 01/01/00 2 520.40 465.52 90 4 2-17-91 OPEN

27435 Incision of knee joint 01/01/00 2 460.26 398.72 60 4 2-17-91 OPEN

27437 Revise kneecap 01/01/00 2 491.54 450.98 60 4 2-17-91 OPEN

27438 Revise kneecap with implant 01/01/00 2 642.01 600.56 90 5 2-17-91 OPEN

27440 Revision of knee joint 01/01/00 2 575.16 550.72 90 5 2-17-91 12/31/03

27441 Revision of knee joint 01/01/00 2 529.67 482.14 90 5 2-17-91 OPEN



27445 Revision of knee joint 01/01/00 2 1,016.99 978.46 90

27446 Revision of knee joint 01/01/00 2 919.16 897.75 90

27447 Total knee replacement 01/01/00 2 1,228.01 1,172.63 90

27448 Incision of thigh 01/01/00 2 637.64 592.40 90

27450 Incision of thigh 01/01/00 2 782.35 712.09 90

27454 Realignment of thigh bone 01/01/00 2 904.61 723.69 90

27455 Realignment of knee 01/01/00 2 681.60 611.52 60

27457 Realignment of knee 01/01/00 2 722.19 659.90 60

5101:3-1-60 Page 41







27465 Shortening of thigh bone 01/01/00 2 717.65 637.96 90

27466 Lengthening of thigh bone 01/01/00 2 824.42 725.72 90

27468 Shorten/lengthen thighs 01/01/00 2 960.88 877.30 90

27470 Repair of thigh 01/01/00 2 888.43 801.66 90

27472 Repair/graft of thigh 01/01/00 2 1,004.25 926.72 90

27475 Surgery to stop leg growth 01/01/00 2 450.77 403.32 90




27486 Revise knee joint replace 01/01/00 2 1,100.94 992.32 90

27487 Revise knee joint replace 01/01/00 2 1,441.87 1,304.89 90

27488 Removal of knee prosthesis 01/01/00 2 862.21 781.37 90

27495 Reinforce thigh 01/01/00 2 886.41 815.67 0

27496 Decompression of thigh/knee 01/01/00 2 295.06 236.05 90 5 01/01/04 OPEN









27507 Treatment of thigh fracture 01/01/00 2 791.08 738.53 90 4 1-1-96 12/31/03







27516 Repair of thigh growth plate 01/01/00 2 302.68 245.98 60 1 2-17-91 OPEN

27517 Repair of thigh growth plate 01/01/00 2 469.64 407.56 60 1 2-17-91 OPEN

27519 Repair of thigh growth plate 01/01/00 2 761.69 672.79 90

27520 Treat kneecap fracture 01/01/00 2 181.30 145.04 30 1 2-17-91 OPEN

27524 Repair of kneecap fracture 01/01/00 2 549.08 502.70 90 3 2-17-91 12/31/03

27530 Treatment of knee fracture 01/01/00 2 209.96 167.97 30 1 2-17-91 OPEN

27532 Treatment of knee fracture 01/01/00 2 360.13 316.04 90 1 2-17-91 OPEN

27535 Treatment of knee fracture 01/01/00 2 638.85 562.83 90 3 1-1-96 12/31/03

27536 Repair of knee fracture 01/01/00 2 745.62 662.48 90

5101:3-1-60 Page 42







27538 Treat knee fracture(s) 01/01/00 2 251.43 201.14 30 1 2-17-91 OPEN

27540 Repair of knee fracture 01/01/00 2 652.02 590.92 90

27550 Treat knee dislocation 01/01/00 2 250.60 200.48 90 1 2-17-91 OPEN

27552 Treat knee dislocation 01/01/00 2 325.33 269.06 90 1 2-17-91 OPEN

27556 Repair of knee dislocation 01/01/00 2 741.99 657.28 90



27560 Treat kneecap dislocation 01/01/00 2 155.06 124.05 7 1 2-17-91 OPEN

27562 Treat kneecap dislocation 01/01/00 2 296.80 268.90 7 1 2-17-91 OPEN

27566 Repair kneecap dislocation 01/01/00 2 619.38 559.10 90 2 2-17-91 OPEN

27570 Fixation of knee joint 01/01/00 2 101.78 86.88 30 1 2-17-91 OPEN

27580 Fusion of knee 01/01/00 2 896.35 717.08 90

27590 Amputate leg at thigh 01/01/00 2 586.69 499.15 90



27594 Amputation follow-up surgery 01/01/00 2 304.33 251.70 60 3 01/01/04 OPEN


27598 Amputate lower leg at knee 01/01/00 2 564.14 503.49 90

27599 Leg surgery procedure 05/01/94 1 BR 0

27600 Decompression of lower leg 01/01/00 2 258.94 214.03 60 3 01/01/04 OPEN



27603 Drain lower leg lesion 01/01/00 2 213.16 170.53 0 2 2-17-91 OPEN

27604 Drain lower leg bursa 01/01/00 2 160.46 128.37 0 2 2-17-91 OPEN

27605 Incision of achilles tendon 01/01/00 2 122.69 98.15 15 1 2-17-91 OPEN

27606 Incision of achilles tendon 01/01/00 2 187.65 150.12 15 1 2-17-91 OPEN

27607 Treat lower leg bone lesion 01/01/00 2 413.86 331.09 30 2 2-17-91 OPEN

27610 Explore/treat ankle joint 01/01/00 2 441.67 372.53 90 2 2-17-91 OPEN

27612 Exploration of ankle joint 01/01/00 2 418.87 364.18 60 3 2-17-91 OPEN

27613 Biopsy lower leg soft tissue 01/01/00 2 85.89 68.71 0 1 2-17-91 12/31/03

27614 Biopsy lower leg soft tissue 01/01/00 2 235.21 188.17 14 2 2-17-91 OPEN

27615 Remove tumor, lower leg 01/01/00 2 594.72 506.67 21 3 2-17-91 OPEN

27618 Remove lower leg lesion 01/01/00 2 218.24 174.59 14 2 2-17-91 OPEN

27619 Remove lower leg lesion 01/01/00 2 371.38 302.73 60 3 1-1-96 OPEN 2 2-17-91 12-31-95

27620 Explore, treat ankle joint 01/01/00 2 335.53 298.38 90 4 2-17-91 OPEN

27625 Remove ankle joint lining 01/01/00 2 464.99 419.90 90 4 2-17-91 OPEN

27626 Remove ankle joint lining 01/01/00 2 505.94 483.01 90 4 2-17-91 OPEN

27630 Removal of tendon lesion 01/01/00 2 242.45 193.96 30 3 2-17-91 OPEN

5101:3-1-60 Page 43







27635 Remove lower leg bone lesion 01/01/00 2 442.72 390.47 90 3 2-17-91 OPEN

27637 Remove/graft leg bone lesion 01/01/00 2 517.21 447.99 90 3 2-17-91 OPEN

27638 Remove/graft leg bone lesion 01/01/00 2 555.24 484.54 90 3 2-17-91 OPEN

27640 Partial removal of tibia 01/01/00 2 611.78 508.53 90 2 2-17-91 OPEN

27641 Partial removal of fibula 01/01/00 2 486.36 393.15 90 2 2-17-91 OPEN

27645 Extensive lower leg surgery 01/01/00 2 728.84 630.99 90

27646 Extensive lower leg surgery 01/01/00 2 652.16 569.04 90

27647 Extensive ankle/heel surgery 01/01/00 2 600.42 530.14 90 3 01/01/04 OPEN

27648 Injection for ankle x-ray 01/01/00 2 45.21 36.17 0

27650 Repair achilles tendon 01/01/00 2 510.09 458.18 90 3 2-17-91 OPEN

27652 Repair/graft achilles tendon 01/01/00 2 558.63 507.77 90 3 2-17-91 OPEN

27654 Repair of achilles tendon 01/01/00 2 564.46 515.18 90 3 2-17-91 OPEN

27656 Repair leg fascia defect 01/01/00 2 237.06 189.65 60 2 2-17-91 OPEN

27658 Repair of leg tendon, each 01/01/00 2 265.52 217.52 90 1 2-17-91 OPEN




27675 Repair lower leg tendons 01/01/00 2 378.12 332.48 60 2 2-17-91 OPEN

27676 Repair lower leg tendons 01/01/00 2 436.55 390.16 75 3 2-17-91 OPEN

27680 Release of lower leg tendon 01/01/00 2 281.92 238.30 60 3 2-17-91 OPEN

27681 Release of lower leg tendons 01/01/00 2 357.34 310.56 60 2 2-17-91 OPEN

27685 Revision of lower leg tendon 01/01/00 2 294.53 243.66 90 3 2-17-91 OPEN

27686 Revise lower leg tendons 01/01/00 2 388.74 338.71 90 3 2-17-91 OPEN

27687 Revision of calf tendon 01/01/00 2 326.57 283.69 60 3 2-17-91 OPEN

27690 Revise lower leg tendon 01/01/00 2 425.84 370.15 90 4 2-17-91 OPEN

27691 Revise lower leg tendon 01/01/00 2 497.85 433.10 90 4 2-17-91 OPEN

27692 Revise additional leg tendon 01/01/00 2 102.48 98.51 90 3 2-17-91 OPEN

27695 Repair of ankle ligament 01/01/00 2 385.22 357.23 90 2 2-17-91 OPEN

27696 Repair of ankle ligaments 01/01/00 2 427.13 375.67 90 2 2-17-91 OPEN

27698 Repair of ankle ligament 01/01/00 2 535.87 518.80 90 2 2-17-91 OPEN

27700 Revision of ankle joint 01/01/00 2 514.73 499.63 90 5 2-17-91 OPEN

27702 Reconstruct ankle joint 01/01/00 2 809.52 773.48 90

27703 Reconstruction, ankle joint 01/01/00 2 795.12 719.92 90

27704 Removal of ankle implant 01/01/00 2 373.86 330.82 45 2 2-17-91 OPEN

27705 Incision of tibia 01/01/00 2 579.32 520.61 90 2 2-17-91 OPEN

27707 Incision of fibula 01/01/00 2 264.26 217.36 90 2 2-17-91 OPEN

27709 Incision of tibia & fibula 01/01/00 2 580.99 540.37 90 2 2-17-91 OPEN

27712 Realignment of lower leg 01/01/00 2 693.63 575.35 90

5101:3-1-60 Page 44







27715 Revision of lower leg 01/01/00 2 742.42 646.46 90 4 2-17-91 12/31/03

27720 Repair of tibia 01/01/00 2 682.02 638.33 90

27722 Repair/graft of tibia 01/01/00 2 619.83 543.07 90

27724 Repair/graft of tibia 01/01/00 2 838.60 716.80 90

27725 Repair of lower leg 01/01/00 2 676.95 541.56 90

27727 Repair of lower leg 01/01/00 2 648.50 569.95 75

27730 Repair of tibia epiphysis 01/01/00 2 335.41 268.33 60 2 2-17-91 OPEN

27732 Repair of fibula epiphysis 01/01/00 2 312.43 251.83 60 2 2-17-91 OPEN

27734 Repair lower leg epiphyses 01/01/00 2 441.71 392.47 75 2 2-17-91 OPEN

27740 Repair of leg epiphyses 01/01/00 2 457.33 435.10 90 2 2-17-91 OPEN

27742 Repair of leg epiphyses 01/01/00 2 556.90 483.65 90 2 2-17-91 OPEN

27745 Reinforce tibia 01/01/00 2 529.03 465.13 90 3 2-17-91 OPEN

27750 Treatment of tibia fracture 01/01/00 2 201.16 160.93 90 1 2-17-91 OPEN

27752 Treatment of tibia fracture 01/01/00 2 323.97 260.43 90 1 2-17-91 OPEN

27756 Repair of tibia fracture 01/01/00 2 413.84 353.82 90 3 2-17-91 OPEN



27760 Treatment of ankle fracture 01/01/00 2 169.56 135.65 90 1 2-17-91 OPEN


27766 Repair of ankle fracture 01/01/00 2 444.71 394.02 90 3 1-1-96 OPEN 2 2-17-91 12-31-95

27780 Treatment of fibula fracture 01/01/00 2 138.49 110.79 14 1 2-17-91 OPEN

27781 Treatment of fibula fracture 01/01/00 2 235.31 188.25 30 1 2-17-91 OPEN

27784 Repair of fibula fracture 01/01/00 2 357.82 304.32 60 3 2-17-91 OPEN



27792 Repair of ankle fracture 01/01/00 2 412.65 366.89 90 3 2-17-91 OPEN








27824 Treat lower leg fracture 01/01/00 2 197.61 158.09 60 1 1-1-96 OPEN





5101:3-1-60 Page 45







27829 Treat lower leg joint 01/01/00 2 367.09 293.67 90 2 1-1-96 OPEN

27830 Treat lower leg dislocation 01/01/00 2 211.40 169.76 30 1 2-17-91 OPEN

27831 Treat lower leg dislocation 01/01/00 2 236.56 208.19 30 1 2-17-91 OPEN

27832 Repair lower leg dislocation 01/01/00 2 342.39 295.57 60 2 2-17-91 OPEN

27840 Treat ankle dislocation 01/01/00 2 182.02 150.47 90 1 2-17-91 OPEN

27842 Treat ankle dislocation 01/01/00 2 238.20 196.56 90 1 2-17-91 OPEN

27846 Repair ankle dislocation 01/01/00 2 503.39 447.56 90 3 2-17-91 OPEN

27848 Repair ankle dislocation 01/01/00 2 593.64 474.91 90 3 2-17-91 OPEN

27860 Fixation of ankle joint 01/01/00 2 109.59 92.50 60 1 2-17-91 OPEN

27870 Fusion of ankle joint 01/01/00 2 746.22 610.50 90 4 2-17-91 OPEN

27871 Fusion of tibiofibular joint 01/01/00 2 473.96 413.50 90 4 2-17-91 OPEN

27880 Amputation of lower leg 01/01/00 2 561.06 487.79 90





27888 Amputation of foot at ankle 01/01/00 2 529.14 467.01 90

27889 Amputation of foot at ankle 01/01/00 2 505.91 443.21 75 3 01/01/04 OPEN

27892 Decompression of leg 01/01/00 2 297.85 238.28 90 3 01/01/04 OPEN



27899 Leg/ankle surgery procedure 05/01/94 1 BR 0

28001 Drainage of bursa of foot 01/01/00 2 96.84 77.47 30

28002 Treatment of foot infection 01/01/00 2 187.41 149.93 30 3 2-17-91 OPEN

28003 Treatment of foot infection 01/01/00 2 343.23 274.58 30 3 2-17-91 OPEN

28005 Treat foot bone lesion 01/01/00 2 365.18 292.14 30 3 2-17-91 OPEN

28008 Incision of foot fascia 01/01/00 2 208.57 169.03 60 3 2-17-91 OPEN

28010 Incision of toe tendon 01/01/00 2 182.63 162.16 30

28011 Incision of toe tendons 01/01/00 2 176.20 140.96 30 3 01/01/04 OPEN

28020 Exploration of a foot joint 01/01/00 2 272.49 228.52 90 2 2-17-91 OPEN

28022 Exploration of a foot joint 01/01/00 2 214.47 176.19 90 2 01/01/04 OPEN

28024 Exploration of a toe joint 01/01/00 2 199.34 159.47 60 2 01/01/04 OPEN

28030 Removal of foot nerve 01/01/00 2 266.22 238.99 30 4 2-17-91 OPEN

28035 Decompression of tibia nerve 01/01/00 2 310.69 279.62 45 4 2-17-91 OPEN

28043 Excision of foot lesion 01/01/00 2 157.96 126.37 7 2 2-17-91 OPEN

28045 Excision of foot lesion 01/01/00 2 245.77 209.67 14 3 2-17-91 OPEN

28046 Resection of tumor, foot 01/01/00 2 440.45 367.90 0 3 2-17-91 OPEN

28050 Biopsy of foot joint lining 01/01/00 2 235.17 196.75 90 2 2-17-91 OPEN

5101:3-1-60 Page 46







28052 Biopsy of foot joint lining 01/01/00 2 219.41 186.79 90 2 01/01/04 OPEN

28054 Biopsy of toe joint lining 01/01/00 2 169.03 135.22 60 2 2-17-91 OPEN

28060 Partial removal foot fascia 01/01/00 2 266.62 230.86 45 2 2-17-91 OPEN

28062 Removal of foot fascia 01/01/00 2 366.97 332.27 60 3 2-17-91 OPEN

28070 Removal of foot joint lining 01/01/00 2 263.90 227.83 45 3 2-17-91 OPEN

28072 Removal of foot joint lining 01/01/00 2 224.32 187.53 30 3 2-17-91 OPEN

28080 Removal of foot lesion 01/01/00 2 215.30 180.50 60 3 2-17-91 OPEN

28086 Excise foot tendon sheath 01/01/00 2 235.95 191.30 30 2 2-17-91 OPEN

28088 Excise foot tendon sheath 01/01/00 2 220.55 179.55 30 2 2-17-91 OPEN


28092 Removal of toe lesions 01/01/00 2 170.50 136.40 30 3 2-17-91 OPEN

28100 Removal of ankle/heel lesion 01/01/00 2 298.49 247.50 90 2 2-17-91 OPEN

28102 Remove/graft foot lesion 01/01/00 2 401.38 352.94 90 3 2-17-91 OPEN





28108 Removal of toe lesions 01/01/00 2 230.20 201.62 90 3 2-17-91 12-31-95

28110 Part removal of metatarsal 01/01/00 2 219.19 180.91 90 3 2-17-91 OPEN




28114 Removal of metatarsal heads 01/01/00 2 521.13 416.90 90 3 2-17-91 OPEN

28116 Revision of foot 01/01/00 2 359.34 287.47 60 3 2-17-91 OPEN

28118 Removal of heel bone 01/01/00 2 320.87 280.35 90 4 2-17-91 OPEN

28119 Removal of heel spur 01/01/00 2 296.14 260.86 90 4 2-17-91 OPEN

28120 Part removal of ankle/heel 01/01/00 2 305.03 247.33 90 7 2-17-91 OPEN

28122 Partial removal of foot bone 01/01/00 2 336.54 274.74 90 3 2-17-91 OPEN

28124 Partial removal of toe 01/01/00 2 253.29 208.44 90 3 2-17-91 12-31-95

28126 Partial removal of toe 01/01/00 2 211.61 181.21 90 3 01/01/04 OPEN 3 2-17-91 12-31-95

28130 Removal of ankle bone 01/01/00 2 415.26 358.51 60 3 2-17-91 OPEN

28140 Removal of metatarsal 01/01/00 2 334.63 282.94 60 3 2-17-91 OPEN

28150 Removal of toe 01/01/00 2 215.80 176.57 30 3 2-17-91 OPEN

28153 Partial removal of toe 01/01/00 2 215.10 181.68 60 3 01/01/04 OPEN 2 2-17-91 12-31-95

28160 Partial removal of toe 01/01/00 2 221.45 189.71 90 3 01/01/04 OPEN

28171 Extensive foot surgery 01/01/00 2 466.15 420.00 60 3 2-17-91 OPEN



5101:3-1-60 Page 47







* 28190 Removal of foot foreign body 01/01/04 2 224.60 73.73 10

28192 Removal of foot foreign body 01/01/00 2 197.93 158.34 14 2 2-17-91 OPEN

28193 Removal of foot foreign body 01/01/00 2 240.59 192.47 14 4 2-17-91 OPEN

28200 Repair of foot tendon 01/01/00 2 264.74 234.82 90 3 2-17-91 OPEN

28202 Repair/graft of foot tendon 01/01/00 2 347.52 305.34 90 3 2-17-91 OPEN

28208 Repair of foot tendon 01/01/00 2 207.82 169.82 60 3 2-17-91 OPEN

28210 Repair/graft of foot tendon 01/01/00 2 327.76 285.68 90 3 2-17-91 OPEN

28220 Release of foot tendon 01/01/00 2 236.83 201.61 60

28222 Release of foot tendons 01/01/00 2 322.27 290.50 60 1 2-17-91 OPEN

28225 Release of foot tendon 01/01/00 2 178.08 142.46 60 1 2-17-91 OPEN

28226 Release of foot tendons 01/01/00 2 227.73 189.69 60 1 2-17-91 OPEN

28230 Incision of foot tendon(s) 01/01/00 2 195.79 156.99 90 1 2-17-91 12-31-95

28232 Incision of toe tendon 01/01/00 2 148.18 118.54 0 4 2-17-91 12-31-95

28234 Incision of foot tendon 01/01/00 2 143.76 115.01 30 2 01/01/04 OPEN 3 2-17-91 12-31-95

28236 Transfer of foot tendon 04/01/96 3 NC 356.75 90 2 2-17-91 OPEN

28238 Revision of foot tendon 01/01/00 2 405.66 360.86 60 3 2-17-91 OPEN

28240 Release of big toe 01/01/00 2 191.63 153.30 7 2 2-17-91 OPEN

28250 Revision of foot fascia 01/01/00 2 289.36 250.21 45 3 2-17-91 OPEN

28260 Release of midfoot joint 01/01/00 2 345.17 293.20 90 3 2-17-91 OPEN

28261 Revision of foot tendon 01/01/00 2 454.44 363.55 90 3 2-17-91 OPEN

28262 Revision of foot and ankle 01/01/00 2 739.10 600.60 90 4 2-17-91 OPEN

28264 Release of midfoot joint 01/01/00 2 532.17 482.82 90 1 2-17-91 OPEN

28270 Release of foot contracture 01/01/00 2 216.39 175.73 90 3 01/01/04 OPEN 2 2-17-91 12-31-95

28272 Release of toe joint, each 01/01/00 2 173.70 139.17 60 3 2-17-91 12-31-95

28280 Fusion of toes 01/01/00 2 220.73 176.58 45 2 2-17-91 OPEN

28285 Repair of hammertoe 01/01/00 2 250.07 215.35 90 3 2-17-91 OPEN

28286 Repair of hammertoe 01/01/00 2 233.00 197.10 90 4 2-17-91 OPEN

28288 Partial removal of foot bone 01/01/00 2 232.39 185.91 90 3 2-17-91 OPEN

28289 Hallux rigidus correction 01/01/00 2 210.30 243.88 90 3 01/01/04 OPEN

28290 Correction of bunion 01/01/00 2 307.22 267.05 60 2 2-17-91 OPEN




28296 Correction of bunion 01/01/00 2 481.29 434.25 90 3 2-17-91 OPEN 4 1-4-88 2-16-91




28300 Incision of heel bone 01/01/00 2 468.21 387.59 90 2 2-17-91 OPEN

5101:3-1-60 Page 48







28302 Incision of ankle bone 01/01/00 2 491.15 450.20 90 2 2-17-91 OPEN

28304 Incision of midfoot bones 01/01/00 2 430.04 372.67 90 2 2-17-91 OPEN

28305 Incise/graft midfoot bones 01/01/00 2 585.06 490.43 90 3 2-17-91 OPEN

28306 Incision of metatarsal 01/01/00 2 289.03 253.15 90 4 2-17-91 OPEN



28309 Incision of metatarsals 01/01/00 2 492.41 393.93 90 4 2-17-91 OPEN

28310 Revision of big toe 01/01/00 2 270.03 227.16 90 3 2-17-91 OPEN

28312 Revision of toe 01/01/00 2 254.26 218.32 90 3 2-17-91 OPEN

28313 Repair deformity of toe 01/01/00 2 225.60 180.48 90 2 2-17-91 OPEN

28315 Removal of sesamoid bone 01/01/00 2 251.99 217.46 60 4 2-17-91 OPEN

28320 Repair of foot bones 01/01/00 2 479.41 434.47 14 4 2-17-91 OPEN

28322 Repair of metatarsals 01/01/00 2 372.57 312.41 45 4 2-17-91 OPEN

28340 Resect enlarged toe tissue 01/01/00 2 364.78 325.55 45 4 1-1-96 OPEN

28341 Resect enlarged toe 01/01/00 2 432.44 387.62 60 4 1-1-96 OPEN

28344 Repair extra toe(s) 01/01/00 2 241.18 192.94 60 4 1-1-96 OPEN

28345 Repair webbed toe(s) 01/01/00 2 313.60 272.74 60 4 1-1-96 OPEN

28360 Reconstruct cleft foot 01/01/00 2 696.60 620.77 90

28400 Treatment of heel fracture 01/01/00 2 146.21 116.97 7 1 2-17-91 OPEN



28415 Repair of heel fracture 01/01/00 2 699.60 559.68 90 3 2-17-91 OPEN

28420 Repair/graft heel fracture 01/01/00 2 836.10 668.88 90 4 2-17-91 OPEN

28430 Treatment of ankle fracture 01/01/00 2 139.71 111.77 14




28450 Treat midfoot fracture, each 01/01/00 2 114.31 91.45 14

28455 Treat midfoot fracture, each 01/01/00 2 168.75 137.10 90

28456 Repair midfoot fracture 01/01/00 2 148.44 118.75 30 2 1-1-96 OPEN

28465 Repair midfoot fracture,each 01/01/00 2 380.08 304.06 90 3 2-17-91 OPEN

28470 Treat metatarsal fracture 01/01/00 2 111.39 89.11 0

28475 Treat metatarsal fracture 01/01/00 2 158.40 126.72 90

28476 Repair metatarsal fracture 01/01/00 2 196.75 163.84 30 2 2-17-91 OPEN

28485 Repair metatarsal fracture 01/01/00 2 311.70 249.36 90 4 2-17-91 OPEN

28490 Treat big toe fracture 01/01/00 2 59.11 47.29 0

28495 Treat big toe fracture 01/01/00 2 78.95 64.35 60

28496 Repair big toe fracture 01/01/00 2 134.23 107.38 15 2 2-17-91 OPEN

5101:3-1-60 Page 49







28505 Repair big toe fracture 01/01/00 2 205.35 164.28 60 3 2-17-91 OPEN

28510 Treatment of toe fracture 01/01/00 2 58.13 46.81 0

28515 Treatment of toe fracture 01/01/00 2 74.11 60.96 60 1 2-17-91 9/30/04

28525 Repair of toe fracture 01/01/00 2 160.31 128.25 60 3 2-17-91 OPEN

28530 Treat sesamoid bone fracture 01/01/00 2 61.96 49.57 45

28531 Treat sesamoid bone fracture 01/01/00 2 124.88 99.90 45 3 01/01/04 OPEN

28540 Treat foot dislocation 01/01/00 2 75.73 60.58 90

28545 Treat foot dislocation 01/01/00 2 107.49 85.99 90 1 2-17-91 OPEN


28555 Repair foot dislocation 01/01/00 2 357.36 285.89 90 2 2-17-91 OPEN









28630 Treat toe dislocation 01/01/00 2 78.34 65.88 45

28635 Treat toe dislocation 01/01/00 2 100.01 82.27 45 1 2-17-91 OPEN


28645 Repair toe dislocation 01/01/00 2 223.19 178.55 60 3 2-17-91 OPEN

28660 Treat toe dislocation 01/01/00 2 55.26 44.21 7



28675 Repair of toe dislocation 01/01/00 2 178.89 143.11 45 3 2-17-91 OPEN

28705 Fusion of foot bones 01/01/00 2 814.89 745.61 90 4 2-17-91 OPEN





28737 Revision of foot bones 01/01/00 2 502.65 444.23 90 5 1-1-96 OPEN


28750 Fusion of big toe joint 01/01/00 2 320.70 256.56 90 4 2-17-91 OPEN



28800 Amputation of midfoot 01/01/00 2 413.48 358.69 90

28805 Amputation thru metatarsal 01/01/00 2 409.33 356.01 90

5101:3-1-60 Page 50







28810 Amputation toe & metatarsal 01/01/00 2 289.23 240.92 90 2 2-17-91 OPEN

28820 Amputation of toe 01/01/00 2 194.93 155.94 45 2 2-17-91 OPEN

28825 Partial amputation of toe 01/01/00 2 175.31 140.25 45 2 2-17-91 OPEN

28899 Foot/toes surgery procedure 05/01/94 1 BR 0

29000 Application of body cast 01/01/00 2 126.89 101.51 2









29049 Application of shoulder cast 01/01/00 2 40.58 32.46 2



29065 Application of long arm cast 01/01/00 2 53.03 42.42 2

29075 Application of forearm cast 01/01/00 2 43.66 34.93 2

29085 Apply hand/wrist cast 01/01/00 2 42.89 34.31 2

29086 Application of finger cast 01/01/02 1 39.10 2

29105 Apply long arm splint 01/01/00 2 42.89 34.31 2

29125 Apply forearm splint 01/01/00 2 29.84 23.87 2

29126 Apply forearm splint 01/01/00 2 36.41 29.13 2

29130 Application of finger splint 01/01/00 2 20.49 16.39 2

29131 Application of finger splint 01/01/00 2 29.53 23.62 2

29200 Strapping of chest 01/01/00 2 28.15 22.52 2

29220 Strapping of low back 01/01/00 2 30.71 25.29 2

29240 Strapping of shoulder 01/01/00 2 29.95 23.96 2

29260 Strapping of elbow or wrist 01/01/00 2 24.01 19.21 2

29280 Strapping of hand or finger 01/01/00 2 21.93 17.54 2

29305 Application of hip cast 01/01/00 2 124.31 99.45 2

29325 Application of hip casts 01/01/00 2 133.78 107.02 2

29345 Application of long leg cast 01/01/00 2 76.15 60.92 2


29358 Apply long leg cast brace 01/01/00 2 105.80 84.64 2


29405 Apply short leg cast 01/01/00 2 52.13 41.70 2


5101:3-1-60 Page 51








29440 Addition of walker to cast 01/01/00 2 24.61 19.69 2

29445 Apply rigid leg cast 01/01/00 2 110.73 88.58 2

29450 Application of leg cast 01/01/00 2 42.99 34.39 2

29505 Application long leg splint 01/01/00 2 39.16 31.33 2

29515 Application lower leg splint 01/01/00 2 37.20 29.76 2

29520 Strapping of hip 01/01/00 2 27.14 21.93 2

29530 Strapping of knee 01/01/00 2 27.80 22.93 2

29540 Strapping of ankle 01/01/00 2 22.52 19.84 2

29550 Strapping of toes 01/01/00 2 20.69 18.43 2

29580 Application of paste boot 01/01/00 2 35.90 32.70 2

29590 Application of foot splint 01/01/00 2 29.51 25.39 2

29700 Removal/revision of cast 01/01/00 2 25.85 29.69 2




29720 Repair of body cast 01/01/00 2 28.23 22.58 2

29730 Windowing of cast 01/01/00 2 30.03 24.95 2

29740 Wedging of cast 01/01/00 2 46.35 37.08 2

29750 Wedging of clubfoot cast 01/01/00 2 54.28 43.42 2

29799 Casting/strapping procedure 05/01/94 1 BR 0

29800 Jaw arthroscopy/surgery 01/01/00 2 287.28 229.82 90 3 01/01/04 OPEN

29804 Jaw arthroscopy/surgery 01/01/00 2 471.73 461.99 90 3 1-1-96 OPEN

29805 Shouder arthroscopy, w/w/o synov biopsy 01/01/02 1 262.26 90 3 1-1-02 OPEN

29806 Shoulder arthroscopy, capsulorrhaphy 01/01/02 1 728.15 90 3 1-1-02 OPEN

29807 Repair of slap lesion 01/01/02 1 708.60 90 3 1-1-02 OPEN

29815 Arthroscopy, shoulder, diag, 04/01/02 3 NC 302.68 60 1-1-97 03-31-02

29819 Shoulder arthroscopy/surgery 01/01/00 2 450.99 433.64 60 3 2-17-91 OPEN





29824 Shoulder arthroscopy, dist claviculect 01/01/02 1 443.08 90 5 1-1-02 OPEN



29827 Arthroscop rotator cuff repr 07/01/03 1 722.80 90 5 01/01/04 OPEN

29830 Elbow arthroscopy 01/01/00 2 304.19 277.47 60 3 2-17-91 OPEN

29834 Elbow arthroscopy/surgery 01/01/00 2 335.38 304.62 60 3 2-17-91 OPEN

5101:3-1-60 Page 52











29840 Wrist arthroscopy 01/01/00 2 263.34 218.09 60 3 2-17-91 OPEN

29843 Wrist arthroscopy/surgery 01/01/00 2 331.21 291.40 60 3 2-17-91 OPEN





29848 Wrist arthroscopy/surgery 01/01/00 2 250.59 200.47 60 9 01/01/04 OPEN

29850 Knee arthroscopy/surgery 01/01/00 2 466.27 467.47 60 4 1-1-96 OPEN


29855 Tibial arthroscopy/surgery 01/01/00 2 603.68 541.70 60 4 1-1-96 OPEN

29856 Tibial arthroscopy/surgery 01/01/00 2 705.16 632.95 60 4 1-1-96 OPEN

29860 Hip arthroscopy, diagnostic 01/01/00 2 361.62 323.11 30 4 01/01/04 OPEN

29861 Hip arthroscopy/surgery 01/01/00 2 507.62 477.89 60 4 01/01/04 OPEN

29862 Hip arthroscopy/surgery 01/01/00 2 556.20 526.80 60 9 01/01/04 OPEN

29863 Hip arthroscopy/surgery 01/01/00 2 518.53 480.87 60 4 01/01/04 OPEN29866 Autgrft implnt, knee w/scope 01/01/05 1 763.16 9029867 Allgrft implnt, knee w/scope 01/01/05 1 912.10 9029868 Meniscal trnspl, knee w/scpe 01/01/05 1 1238.40 90

29870 Knee arthroscopy, diagnostic 01/01/00 2 257.00 226.46 30 3 2-17-91 OPEN

29871 Knee arthroscopy/drainage 01/01/00 2 365.76 329.65 90 3 2-17-91 OPEN

29873 Knee arthroscopy/surgery 07/01/03 1 332.60 90














5101:3-1-60 Page 53









29891 Ankle arthroscopy/surgery 01/01/00 2 478.91 449.07 60 3 01/01/04 OPEN

29892 Ankle arthroscopy/surgery 01/01/00 2 495.85 463.47 60 3 01/01/04 OPEN

29893 Endoscopic plantar fasciotomy 01/01/00 2 276.58 255.63 60 9 01/01/04 OPEN

29894 Ankle arthroscopy/surgery 01/01/00 2 418.61 406.97 60 3 2-17-91 OPEN




29899 Ankle arthroscopy/surgery 07/01/03 1 664.17 90 3 01/01/04 OPEN

29900 Metacarp jt arthroscopy,w synov biop 01/01/02 1 314.12 90 3 1-1-02 OPEN

29901 Metacarp joint arthroscopy w debride 01/01/02 1 346.43 90 3 1-1-02 OPEN

29902 Metacarp jt arthroscopy, w reduc ligam 01/01/02 1 371.95 90 3 1-1-02 OPEN

29909 Unlisted procedure, arthroscopy 04/01/02 3 NC BR 60

29999 Unlisted arthroscopy procedure 01/01/02 1 BR 90

30000 Drainage of nose lesion 01/01/00 2 59.53 47.62 1

30020 Drainage of nose lesion 01/01/00 2 60.41 48.33 1

30100 Intranasal biopsy 01/01/00 2 46.22 40.32 0

30110 Removal of nose polyp(s) 01/01/00 2 84.25 70.88 14

30115 Removal of nose polyp(s) 01/01/00 2 203.37 173.69 30 2 2-17-91 OPEN

30117 Removal of intranasal lesion 01/01/00 2 167.33 146.05 14 3 2-17-91 OPEN

30118 Removal of intranasal lesion 01/01/00 2 479.65 427.47 60 3 2-17-91 OPEN

30120 Revision of nose 01/01/00 2 301.91 298.95 60 1 2-17-91 OPEN

30124 Removal of nose lesion 01/01/00 2 131.52 106.63 7 1 2-17-91 12/31/03

30125 Removal of nose lesion 01/01/00 2 352.36 308.02 14 2 2-17-91 OPEN

30130 Removal of turbinate bones 01/01/00 2 148.10 118.48 90 3 2-17-91 OPEN

30140 Removal of turbinate bones 01/01/00 2 184.86 156.65 90 2 2-17-91 OPEN

30150 Partial removal of nose 01/01/00 2 465.52 411.23 60 3 2-17-91 OPEN

30160 Removal of nose 01/01/00 2 543.72 518.29 0 4 2-17-91 OPEN

* 30200 Injection treatment of nose 01/01/04 2 54.36 34.90 10

* 30210 Nasal sinus therapy 01/01/04 2 87.55 39.28 10

30220 Insert nasal septal button 01/01/00 2 85.91 74.24 45

* 30300 Remove nasal foreign body 01/01/04 2 97.91 44.40 10

30310 Remove nasal foreign body 01/01/00 2 99.34 87.34 0 1 2-17-91 OPEN

30320 Remove nasal foreign body 01/01/00 2 242.20 214.06 0 2 2-17-91 OPEN

30400 Reconstruction of nose 07/01/03 2 487.49 BR 60 4 2-17-91 OPEN



5101:3-1-60 Page 54







30430 Revision of nose 07/01/03 2 375.15 BR 45 3 2-17-91 OPEN



30460 Revision of nose 01/01/00 2 499.98 446.71 90 7 01/01/04 OPEN

30462 Revision of nose 01/01/00 2 969.04 894.16 90 9 01/01/04 OPEN

30465 Repair nasal stenosis 01/01/01 1 600.56 10 9 01/01/04 OPEN

30520 Repair of nasal septum 01/01/00 2 328.19 319.39 60 4 2-17-91 OPEN

30540 Repair nasal defect 01/01/00 2 386.89 347.94 14 5 2-17-91 OPEN

30545 Repair nasal defect 01/01/00 2 584.66 531.82 90 5 01/01/04 OPEN

* 30560 Release of nasal adhesions 01/01/04 2 97.40 53.89 10 2 2-17-91 OPEN

30580 Repair upper jaw fistula 01/01/00 2 335.05 312.46 30 4 2-17-91 OPEN

30600 Repair mouth/nose fistula 01/01/00 2 262.93 235.98 30 4 2-17-91 OPEN

30620 Intranasal reconstruction 01/01/00 2 346.60 322.95 90 7 2-17-91 OPEN

30630 Repair nasal septum defect 01/01/00 2 365.30 324.19 0 7 2-17-91 OPEN

* 30801 Cauterization inner nose 01/01/04 2 98.24 45.59 10 1 2-17-91 OPEN

30802 Cauterization inner nose 01/01/00 2 89.11 71.75 0 1 2-17-91 OPEN

30901 Control of nosebleed 01/01/00 2 54.18 43.34 1

30903 Control of nosebleed 01/01/00 2 71.29 58.37 1 1 2-17-91 OPEN

30905 Control of nosebleed 01/01/00 2 112.78 92.40 1 1 2-17-91 OPEN

30906 Repeat control of nosebleed 01/01/00 2 107.79 86.23 1 1 2-17-91 OPEN

30915 Ligation nasal sinus artery 01/01/00 2 338.03 287.33 14 2 2-17-91 OPEN

30920 Ligation upper jaw artery 01/01/00 2 523.79 429.99 14 3 2-17-91 OPEN

30930 Therapy fracture of nose 01/01/00 2 59.08 47.26 7 4 01/01/04 OPEN

30999 Nasal surgery procedure 05/01/94 1 BR 7

* 31000 Irrigation maxillary sinus 01/01/04 2 96.75 46.85 10

* 31002 Irrigation sphenoid sinus 01/01/04 2 108.63 70.51 10

31020 Exploration maxillary sinus 01/01/00 2 156.73 135.44 90 2 2-17-91 OPEN

31030 Exploration maxillary sinus 01/01/00 2 324.65 319.42 90 3 2-17-91 OPEN

31032 Explore sinus,remove polyps 01/01/00 2 372.64 355.83 90 4 2-17-91 OPEN

31040 Exploration behind upper jaw 01/01/00 2 461.20 415.66 90

31050 Exploration sphenoid sinus 01/01/00 2 297.40 273.77 90 2 2-17-91 OPEN

31051 Sphenoid sinus surgery 01/01/00 2 397.25 371.05 0 4 2-17-91 OPEN

31070 Exploration of frontal sinus 01/01/00 2 245.05 216.55 30 2 2-17-91 OPEN

31075 Exploration of frontal sinus 01/01/00 2 510.32 473.14 90 4 2-17-91 OPEN

31080 Removal of frontal sinus 01/01/00 2 555.95 495.91 90 4 2-17-91 OPEN

31081 Removal of frontal sinus 01/01/00 2 622.48 554.58 90 4 01/01/04 OPEN



5101:3-1-60 Page 55









31090 Exploration of sinuses 01/01/00 2 553.31 519.44 90 5 2-17-91 OPEN

31200 Removal of ethmoid sinus 01/01/00 2 268.62 229.81 90 2 2-17-91 OPEN



31225 Removal of upper jaw 01/01/00 2 1,037.22 867.79 90

31230 Removal of upper jaw 01/01/00 2 1,173.10 1,063.93 90

31231 Nasal endoscopy, dx 01/01/00 2 68.96 61.43 14

31233 Nasal/sinus endoscopy, dx 01/01/00 2 132.28 123.78 14 2 2-17-91 OPEN

31235 Nasal/sinus endoscopy, dx 01/01/00 2 136.66 124.44 14 1 2-17-91 OPEN

31237 Nasal/sinus endoscopy, surg 01/01/00 2 167.21 157.72 14 2 2-17-91 OPEN




31254 Revision of ethmoid sinus 01/01/00 2 256.65 264.72 14 3 1-1-96 OPEN


31256 Exploration of maxillary sinus 01/01/00 2 180.50 175.30 14 3 1-1-96 OPEN

31267 Endoscopy, maxillary sinus 01/01/00 2 284.70 270.83 14 3 1-1-96 OPEN

31276 Sinus surgical endoscopy 01/01/00 2 412.70 384.14 14 3 1-1-96 OPEN



31290 Nasal/sinus endoscopy, surg 01/01/00 2 885.29 729.94 14





31299 Sinus surgery procedure 05/01/94 1 BR 0

31300 Removal of larynx lesion 01/01/00 2 732.93 615.19 60 5 2-17-91 OPEN

31320 Diagnostic incision larynx 01/01/00 2 261.71 209.37 60 2 2-17-91 OPEN

31360 Removal of larynx 01/01/00 2 986.24 861.39 90

31365 Removal of larynx 01/01/00 2 1,369.84 1,221.18 90

31367 Partial removal of larynx 01/01/00 2 1,096.00 895.78 90

31368 Partial removal of larynx 01/01/00 2 1,481.21 1,256.89 90


31375 Partial removal of larynx 01/01/00 2 994.24 821.91 60



5101:3-1-60 Page 56







31390 Removal of larynx & pharynx 01/01/00 2 1,519.46 1,227.63 90

31395 Reconstruct larynx & pharynx 01/01/00 2 1,780.02 1,504.75 90

31400 Revision of larynx 01/01/00 2 523.23 418.58 90 2 01/01/04 OPEN

31420 Removal of epiglottis 01/01/00 2 528.69 422.95 60 2 01/01/04 OPEN

31500 Insert emergency airway 01/01/00 2 90.13 85.48 0

31502 Change of windpipe airway 01/01/00 2 38.25 30.60 0

31505 Diagnostic laryngoscopy 01/01/00 2 32.14 25.71 0 1 2-17-91 9/30/04

31510 Laryngoscopy with biopsy 01/01/00 2 75.51 60.41 0 2 2-17-91 OPEN

31511 Remove foreign body, larynx 01/01/00 2 92.18 76.28 0 2 2-17-91 OPEN


31513 Injection into vocal cord 01/01/00 2 118.25 121.13 0 2 2-17-91 OPEN

31515 Laryngoscopy for aspiration 01/01/00 2 89.79 72.52 0 1 2-17-91 9/30/04

31520 Diagnostic laryngoscopy 01/01/00 2 112.37 103.40 0

31525 Diagnostic laryngoscopy 01/01/00 2 131.99 119.11 0 1 2-17-91 OPEN

31526 Diagnostic laryngoscopy 01/01/00 2 142.42 146.31 30 2 1-1-96 OPEN 1 2-17-91 12-31-95

31527 Laryngoscopy for treatment 01/01/00 2 163.16 154.25 7 1 2-17-91 OPEN

31528 Laryngoscopy and dilatation 01/01/00 2 129.50 125.12 7 2 2-17-91 OPEN

31529 Laryngoscopy and dilatation 01/01/00 2 135.31 126.74 7 2 2-17-91 OPEN

31530 Operative laryngoscopy 01/01/00 2 180.36 174.00 30 2 2-17-91 OPEN





31541 Operative laryngoscopy 01/01/00 2 242.97 208.42 30 4 2-17-91 OPEN31545 Remove vc lesion w/scope 01/01/05 1 281.96 031546 Remove vc lesion scope/graft 01/01/05 1 430.61 0



31570 Laryngoscopy with injection 01/01/00 2 218.98 220.93 30 2 2-17-91 OPEN

31571 Laryngoscopy with injection 01/01/00 2 232.66 204.79 30 2 2-17-91 OPEN


31576 Laryngoscopy with biopsy 01/01/00 2 112.50 113.09 30 2 2-17-91 OPEN

31577 Remove foreign body, larynx 01/01/00 2 139.26 140.69 30 2 2-17-91 OPEN



31580 Revision of larynx 01/01/00 2 732.48 626.75 90 5 2-17-91 OPEN

31582 Revision of larynx 01/01/00 2 1,091.89 930.12 90 5 2-17-91 OPEN

31584 Repair of larynx fracture 01/01/00 2 903.36 768.03 90 4 2-17-91 12/31/03

5101:3-1-60 Page 57







31585 Repair of larynx fracture 01/01/00 2 252.13 201.70 30 1 2-17-91 OPEN

31586 Repair of larynx fracture 01/01/00 2 423.25 341.09 45 2 2-17-91 OPEN

31587 Revision of larynx 01/01/00 2 469.91 375.93 45

31588 Revision of larynx 01/01/00 2 686.22 557.04 30 5 2-17-91 OPEN

31590 Reinnervate larynx 01/01/00 2 480.01 BR 30 5 2-17-91 OPEN

31595 Larynx nerve surgery 01/01/00 2 445.79 356.63 30 2 2-17-91 OPEN

31599 Larynx surgery procedure 05/01/94 1 BR 0

31600 Incision of windpipe 01/01/00 2 200.81 195.47 0 2 2-17-91 12/31/03

31601 Incision of windpipe 01/01/00 2 246.96 238.20 0




31611 Surgery/speech prosthesis 01/01/00 2 358.03 294.14 0 3 2-17-91 OPEN

31612 Puncture/clear windpipe 01/01/00 2 58.03 51.55 0 1 2-17-91 OPEN

31613 Repair windpipe opening 01/01/00 2 199.09 159.27 0 2 2-17-91 OPEN

31614 Repair windpipe opening 01/01/00 2 398.49 318.79 0 2 2-17-91 OPEN

31615 Visualization of windpipe 01/01/00 2 117.91 100.20 0 1 2-17-91 OPEN31620 Endobronchial us add-on 01/01/05 1 193.28 0

31622 Diagnostic bronchoscopy 01/01/00 2 157.12 157.19 0 1 2-17-91 OPEN

31623 Bronchoscopy 01/01/00 2 168.17 156.96 0 2 01/01/04 OPEN

31624 Bronchoscopy 01/01/00 2 169.69 158.38 0 2 01/01/04 OPEN

31625 Bronchoscopy with biopsy 01/01/00 2 189.06 177.06 0 2 2-17-91 OPEN



31630 Bronchoscopy with repair 01/01/00 2 195.76 189.17 0 2 2-17-91 OPEN

31631 Bronchoscopy with dilation 01/01/00 2 214.32 206.88 30 2 2-17-91 OPEN

31632 Bronchoscopy/Lung Bx, Add'L 01/01/04 1 49.80 0

31633 Bronchoscopy/Needle Bx Add'L 01/01/04 1 61.40 0

31635 Remove foreign body, airway 07/01/02 2 196.98 197.67 30 2 2-17-91 OPEN31636 Bronchoscopy, bronch stents 01/01/05 1 177.64 031637 Bronchoscopy, stent add-on 01/01/05 1 63.38 031638 Bronchoscopy, revise stent 01/01/05 1 197.26 0

31640 Bronchoscopy & remove lesion 01/01/00 2 256.90 250.00 30 2 2-17-91 OPEN

31641 Bronchoscopy, treat blockage 07/01/02 2 265.47 271.39 30 2 2-17-91 OPEN

31643 Bronchoscopy, with placement of catheter 01/01/00 2 119.30 140.97 0 2 01/01/04 OPEN

31645 Bronchoscopy, clear airways 07/01/02 2 160.92 165.22 0 1 2-17-91 OPEN

31646 Bronchoscopy,reclear airways 07/01/02 2 139.71 142.73 0 1 2-17-91 OPEN

31656 Bronchoscopy,inject for xray 01/01/00 2 115.87 123.08 7 1 2-17-91 OPEN

5101:3-1-60 Page 58







31700 Insertion of airway catheter 01/01/00 2 80.51 67.93 15 1 2-17-91 OPEN

31708 Instill airway contrast dye 01/01/00 2 58.13 53.68 0 1 2-17-91 9/30/04

31710 Insertion of airway catheter 01/01/00 2 58.42 54.77 0 1 2-17-91 12/31/03

31715 Injection for bronchus x-ray 01/01/00 2 42.79 38.60 0 1 2-17-91 12/31/03

31717 Bronchial brush biopsy 01/01/00 2 86.33 69.06 7 1 2-17-91 OPEN

31720 Clearance of airways 01/01/00 2 55.75 44.60 0 1 2-17-91 OPEN

31725 Clearance of airways 01/01/00 2 87.11 82.99 90

31730 Intro windpipe wire/tube 01/01/00 2 140.05 130.54 0 1 2-17-91 OPEN

31750 Repair of windpipe 01/01/00 2 559.11 447.29 60 5 2-17-91 OPEN

31755 Repair of windpipe 01/01/00 2 824.97 692.29 0 2 2-17-91 OPEN

31760 Repair of windpipe 01/01/00 2 954.60 815.18 60

31766 Reconstruction of windpipe 01/01/00 2 1,301.36 1,139.63 60

31770 Repair/graft of bronchus 01/01/00 2 1,036.22 904.00 90

31775 Reconstruct bronchus 01/01/00 2 1,090.70 953.56 90

31780 Reconstruct windpipe 01/01/00 2 949.63 835.17 60

31781 Reconstruct windpipe 01/01/00 2 1,127.72 967.42 90

31785 Remove windpipe lesion 01/01/00 2 762.73 620.49 60 4 2-17-91 12/31/03

31786 Remove windpipe lesion 01/01/00 2 1,082.44 901.13 90 OPEN

31800 Repair of windpipe injury 01/01/00 2 366.88 293.50 90 2 2-17-91 12/31/03

31805 Repair of windpipe injury 01/01/00 2 640.69 561.84 90

31820 Closure of windpipe lesion 01/01/00 2 239.61 191.69 30 1 2-17-91 OPEN

31825 Repair of windpipe defect 01/01/00 2 347.87 280.15 30 2 2-17-91 OPEN

31830 Revise windpipe scar 01/01/00 2 239.99 196.34 30 2 2-17-91 OPEN

31899 Airways surgical procedure 05/01/94 1 BR 0

* 32000 Drainage of chest 01/01/04 2 124.82 74.39 0 1 2-17-91 OPEN

32001 Total lung lavage 04/01/00 3 NC 192.65 0

32002 Treatment of collapsed lung 01/01/00 2 93.34 88.70 0 2 2-17-91 12/31/03

32005 Treat lung lining chemically 01/01/00 2 87.29 81.23 30 2 2-17-91 12/31/0332019 Insert pleural catheter 01/01/05 1 662.26 0

32020 Insertion of chest tube 01/01/00 2 174.09 166.41 0 2 2-17-91 12/31/03

32035 Exploration of chest 01/01/00 2 428.79 343.03 90


32095 Biopsy through chest wall 01/01/00 2 467.71 395.98 90

32100 Exploration/biopsy of chest 01/01/00 2 641.30 551.21 90

32110 Explore/repair chest 01/01/00 2 708.12 595.65 90

32120 Re-exploration of chest 01/01/00 2 589.93 489.97 90

32124 Explore chest,free adhesions 01/01/00 2 660.83 567.82 90

32140 Removal of lung lesion(s) 01/01/00 2 728.49 634.79 90

5101:3-1-60 Page 59







32141 Remove/treat lung lesions 01/01/00 2 769.75 661.50 90

32150 Removal of lung lesion(s) 01/01/00 2 686.01 584.85 90

32151 Remove lung foreign body 01/01/00 2 650.15 541.48 90

32160 Open chest heart massage 01/01/00 2 514.42 417.81 90

32200 Drainage of lung lesion 01/01/00 2 618.94 495.15 90

32201 Pneumonostomy 01/01/00 2 217.59 174.07 90

32215 Treat chest lining 01/01/00 2 533.02 447.91 90

32220 Release of lung 01/01/00 2 973.48 859.73 90

32225 Partial release of lung 01/01/00 2 733.03 618.20 90

32310 Removal of chest lining 01/01/00 2 704.76 607.87 90

32320 Free/remove chest lining 01/01/00 2 1,062.54 958.54 90

* 32400 Needle biopsy chest lining 01/01/04 2 98.27 86.25 0 1 2-17-91 OPEN

32402 Open biopsy chest lining 01/01/00 2 422.09 364.00 90

32405 Biopsy, lung or mediastinum 01/01/00 2 106.95 99.21 0 1 2-17-91 OPEN

* 32420 Puncture/clear lung 01/01/00 2 94.36 89.82 0 1 2-17-91 OPEN

32440 Removal of lung 01/01/00 2 1,086.65 972.83 90

32442 Sleeve pneumonectomy 01/01/00 2 1,231.03 1,090.23 90

32445 Removal of lung 01/01/00 2 1,253.80 1,125.83 90

32480 Partial removal of lung 01/01/00 2 958.54 877.11 90

32482 Bilobectomy 01/01/00 2 1,005.21 917.94 90

32484 Segmentectomy 01/01/00 2 1,033.60 941.47 90

32485 Partial removal of lung 04/01/96 3 NC 926.16 90

32486 Sleeve lobectomy 01/01/00 2 1,123.56 1,005.14 90

32488 Completion pneumonectomy 01/01/00 2 1,204.30 1,078.18 90

32491 Removal of lung 01/01/97 1 NC 90

32500 Partial removal of lung 01/01/00 2 765.20 686.45 90

32501 Remove lung & repair bronchus 01/01/00 2 232.89 228.58 90

32520 Remove lung & revise chest 01/01/00 2 1,151.84 1,037.04 90



32540 Removal of lung lesion 01/01/00 2 740.89 637.53 90

32601 Thoracoscopy, diagnostic 01/01/00 2 251.11 224.64 14






32650 Thoracoscopy, surgical 01/01/00 2 518.91 447.91 45

5101:3-1-60 Page 60






















32800 Repair lung hernia 01/01/00 2 621.08 519.32 21

32810 Close chest after drainage 01/01/00 2 561.84 456.61 14

32815 Close bronchial fistula 01/01/00 2 1,065.09 926.19 21

32820 Reconstruct injured chest 01/01/00 2 1,108.58 990.33 21

32850 Donor pneumonectomy 05/01/94 1 NC

32851 Lung transplant, single 07/01/03 2 1,606.45 BR 90

32852 Lung transplant w/bypass 07/01/03 2 1,731.24 BR 90

32853 Lung transplant, double 07/01/03 2 1,955.66 BR 90

32854 Lung transplant w/bypass 07/01/03 2 2,059.69 BR 9032855 Prepare donor lung, single 01/01/05 1 BR 032856 Prepare donor lung, double 01/01/05 1 BR 0

32900 Removal of rib(s) 01/01/00 2 813.65 669.95 90

32905 Revise & repair chest wall 01/01/00 2 939.16 816.12 90

32906 Revise & repair chest wall 01/01/00 2 1,176.74 1,029.86 90

32940 Revision of lung 01/01/00 2 846.05 739.06 90

* 32960 Therapeutic pneumothorax 01/01/04 2 109.32 79.97 0

32997 Total lung lavage (unilateral) 01/01/00 1 238.9 0

32999 Chest surgery procedure 05/01/94 1 BR 0

* 33010 Drainage of heart sac 01/01/00 2 97.41 92.43 0 2 2-17-91 OPEN

* 33011 Repeat drainage of heart sac 01/01/04 2 91.06 89.15 0 2 2-17-91 OPEN

33015 Incision of heart sac 01/01/00 2 298.10 248.22 90



5101:3-1-60 Page 61







33030 Partial removal of heart sac 01/01/00 2 1,073.17 977.52 90

33031 Partial removal of heart sac 01/01/00 2 1,007.26 836.96 90

33050 Removal of heart sac lesion 01/01/00 2 657.79 553.02 90

33120 Removal of heart lesion 01/01/00 2 1,436.63 1,331.43 90

33130 Removal of heart lesion 01/01/00 2 969.32 832.90 90

33140 Transmyocardial laser revasculatization 01/01/00 1 958.36 90

33141 Heart tmr w/other procedure 01/01/01 1 $208.03 90

33200 Insertion of heart pacemaker 01/01/00 2 663.03 593.84 90





33210 Insertion of heart electrode 01/01/00 2 166.43 161.27 0

33211 Insertion of heart electrode 01/01/00 2 171.03 163.67 90

33212 Insertion of pulse generator 01/01/00 2 294.35 270.02 30

33213 Insertion of pulse generator 01/01/00 2 319.39 292.59 90

33214 Upgrade of pacemaker system 01/01/00 2 366.04 328.36 45

33215 Reposition pacing-defib lead 07/01/03 1 208.07 90

33216 Revision implanted electrode 01/01/00 2 278.71 250.07 30

33217 Insert/revise electrode 01/01/00 2 291.78 258.71 45

33218 Repair pacemaker electrodes 01/01/00 2 271.10 240.85 30

33220 Repair pacemaker electrode 01/01/00 2 275.42 242.77 45

33222 Pacemaker aicd pocket 01/01/00 2 282.89 265.72 45 2 01/01/04 OPEN

33223 Pacemaker aicd pocket 01/01/00 2 336.12 302.94 45 2 01/01/04 OPEN

33224 Insert pacing lead & connect 07/01/03 1 337.01 90

33225 L ventric pacing lead add-on 07/01/03 1 298.87 90

33226 Reposition l ventric lead 07/01/03 1 324.56 0

33233 Removal of pacemaker system 01/01/00 2 159.40 132.72 45

33234 Removal of pacemaker system 01/01/00 2 296.34 326.30 45

33235 Removal pacemaker electrode 01/01/00 2 349.48 371.10 45

33236 Remove electrode/thoracotomy 01/01/00 2 475.00 387.61 45



33240 Insert/replace pulse gener 01/01/00 2 357.71 317.80 45

33241 Remove pulse generator only 01/01/00 2 158.13 131.45 45

33242 Repair pulse generator/leads 04/01/00 3 NC 350.45 45

33243 Remove generator/thoracotomy 01/01/00 2 876.32 760.16 45

33244 Remove generator 01/01/00 2 482.89 444.87 45

5101:3-1-60 Page 62







33245 Implant heart defibrillator 01/01/00 2 808.58 728.32 30

33246 Implant heart defibrillator 01/01/00 2 1,104.40 1,017.60 45

33247 Insert/replace leads 04/01/00 3 NC 578.84 45

33249 Insert/replace leads/gener 01/01/00 2 760.41 763.18 45

33250 Ablate heart dysrhythm focus 01/01/00 2 942.98 754.38 45

33251 Ablate heart dysrhythm focus 01/01/00 2 1,172.04 997.35 90

33253 Incise & reconstruct atria 01/01/00 2 1,479.22 1,325.45 90

33260 Ablate heart dysrhythm focus 04/01/96 3 NC 611.29 90

33261 Ablate heart dysrhythm focus 01/01/00 2 1,137.90 929.34 90

33282 Implantation of a cardiac event recorder 01/01/00 1 283.39 90

33284 Removal of an implantable cardiac event recorder 01/01/00 1 218.58 90

33300 Repair of heart wound 01/01/00 2 896.76 781.94 90

33305 Repair of heart wound 01/01/00 2 1,087.83 935.89 90

33310 Exploratory heart surgery 01/01/00 2 832.97 717.09 90

33315 Exploratory heart surgery 01/01/00 2 1,042.32 879.01 90

33320 Repair major blood vessel(s) 01/01/00 2 863.33 755.43 90

33321 Repair of major vessel 01/01/00 2 1,117.75 1,037.17 90

33322 Repair major blood vessel(s) 01/01/00 2 1,169.55 1,029.01 90

33330 Insert major vessel graft 01/01/00 2 962.39 797.50 90

33332 Insert major vessel graft 01/01/00 2 1,085.10 944.30 90

33335 Insert major vessel graft 01/01/00 2 1,280.80 1,068.21 90

33350 Repair major blood vessel(s) 04/01/96 3 NC BR 90

33400 Repair of aortic valve 01/01/00 2 1,371.25 1,225.07 90

33401 Valvuloplasty, open 01/01/00 2 1,309.79 1,208.02 45

33403 Valvuloplasty, w/cp bypass 01/01/00 2 1,364.47 1,231.56 45

33404 Prepare heart-aorta conduit 01/01/00 2 1,632.21 1,493.11 90

33405 Replacement of aortic valve 01/01/00 2 1,668.50 1,513.39 90

33406 Replacement, aortic valve 01/01/00 2 1,867.49 1,819.64 45

33410 Replacement, aortic valve w/ stentless tissue valve 01/01/00 1 1,606.70 90



33413 Replacement, aortic valve 01/01/00 2 2,031.01 1,940.22 45

33414 Repair, aortic valve 01/01/00 2 1,767.19 1,772.82 45

33415 Revision, subvalvular tissue 01/01/00 2 1,541.06 1,430.54 90

33416 Revise ventricle muscle 01/01/00 2 1,606.00 1,444.96 90

33417 Repair of aortic valve 01/01/00 2 1,641.65 1,604.21 90

33420 Revision of mitral valve 01/01/00 2 1,124.93 1,010.55 90

33422 Revision of mitral valve 01/01/00 2 1,511.36 1,424.83 90

5101:3-1-60 Page 63







33425 Repair of mitral valve 01/01/00 2 1,551.38 1,464.03 90



33430 Replacement of mitral valve 01/01/00 2 1,800.40 1,655.56 90

33460 Revision of tricuspid valve 01/01/00 2 1,365.18 1,232.72 90

33463 Valvuloplasty, tricuspid 01/01/00 2 1,487.82 1,475.53 45

33464 Valvuloplasty, tricuspid 01/01/00 2 1,577.35 1,516.59 45

33465 Replace tricuspid valve 01/01/00 2 1,652.49 1,533.40 90

33468 Revision of tricuspid valve 01/01/00 2 1,730.27 1,627.91 90

33470 Revision of pulmonary valve 01/01/00 2 1,131.29 982.46 90

33471 Valvotomy, pulmonary valve 01/01/00 2 1,226.31 1,176.33 45

33472 Revision of pulmonary valve 01/01/00 2 1,229.74 1,227.76 90

33474 Revision of pulmonary valve 01/01/00 2 1,274.27 1,227.76 90

33475 Replacement, pulmonary valve 01/01/00 2 1,631.28 1,605.62 45

33476 Revision of heart chamber 01/01/00 2 1,471.87 1,353.95 90


33496 Repair of prosthetic valve clot 01/01/00 2 1,556.79 1,474.38 90

33500 Repair heart vessel fistula 01/01/00 2 1,450.22 1,379.40 90

33501 Repair heart vessel fistula 01/01/00 2 882.38 773.44 90

33502 Coronary artery correction 01/01/00 2 986.75 861.33 90

33503 Coronary artery graft 01/01/00 2 1,262.32 1,289.11 90

33504 Coronary artery graft 01/01/00 2 1,443.60 1,361.39 90

33505 Repair artery w/tunnel 01/01/00 2 1,573.46 1,542.62 45

33506 Repair artery, translocation 01/01/00 2 1,565.34 1,542.62 45

33508 Endoscopic vein harvest 07/01/03 1 11.42 90

33510 Cabg, vein, single 01/01/00 2 1,445.13 1,364.51 90

33511 Cabg, vein, two 01/01/00 2 1,575.28 1,498.05 90

33512 Cabg, vein, three 01/01/00 2 1,704.82 1,631.35 90

33513 Cabg, vein, four 01/01/00 2 1,836.69 1,764.66 90

33514 Cabg, vein, five 07/01/02 2 1,903.61 2,012.47 90

33516 Cabg, vein, six+ 07/01/02 2 2,018.03 2,146.40 90

33517 Cabg, artery-vein, single 07/01/02 2 132.39 146.77 90

33518 Cabg, artery-vein, two 07/01/02 2 249.95 277.27 90

33519 Cabg, artery-vein, three 07/01/02 2 366.81 406.53 90

33521 Cabg, artery-vein, four 07/01/02 2 484.71 536.93 90

33522 Cabg, artery-vein, five 07/01/02 2 602.26 666.95 90

33523 Cabg, artery-vein, six+ 07/01/02 2 718.80 797.11 90

33530 Coronary artery, bypass/reop 07/01/02 2 301.85 427.53 90

5101:3-1-60 Page 64







33533 Cabg, arterial, single 01/01/00 2 1,489.17 1,406.13 90

33534 Cabg, arterial, two 01/01/00 2 1,663.96 1,581.28 90

33535 Cabg, arterial, three 07/01/02 2 1,248.05 1,816.40 90

33536 Cabg, arterial, four+ 01/01/00 2 2,006.40 1,931.35 90

33542 Removal of heart lesion 01/01/00 2 1,640.92 1,478.54 90

33545 Repair of heart damage 01/01/00 2 1,981.75 1,770.50 90

33572 Open coranary endarterectomy 01/01/00 2 206.25 196.44 90

33600 Closure of valve 01/01/00 2 1,667.41 1,628.91 45

33602 Closure of valve 01/01/00 2 1,595.25 1,486.25 45

33606 Anastomosis/artery-aorta 01/01/00 2 1,790.82 1,772.82 90

33608 Repair anomaly w/conduit 01/01/00 2 1,797.28 1,790.59 45

33610 Repair by enlargement 01/01/00 2 1,752.49 1,772.82 45

33611 Repair double ventricle 01/01/00 2 1,851.60 1,819.64 45

33612 Repair double ventricle 01/01/00 2 1,907.66 1,839.57 45

33615 Repair (simple fontan) 01/01/00 2 1,849.01 1,802.11 45

33617 Repair by modified fontan 01/01/00 2 1,949.90 1,843.17 45

33619 Repair single ventricle 01/01/00 2 2,184.18 2,063.22 45

33641 Repair heart septum defect 01/01/00 2 1,242.66 1,183.42 90

33645 Revision of heart veins 01/01/00 2 1,413.42 1,299.69 90

33647 Repair heart septum defects 01/01/00 2 1,655.03 BR 90

33660 Repair of heart defects 01/01/00 2 1,469.15 1,436.18 90


33670 Repair of heart chambers 01/01/00 2 1,867.94 1,819.64 90




33690 Reinforce pulmonary artery 01/01/00 2 1,131.68 1,052.10 90



33696 Repair of heart defects 04/01/96 3 NC 1490.83 90


33698 Repair of heart defects 04/01/96 3 NC 1321.96 90



33720 Repair of heart defect 01/01/00 2 1,508.48 1,439.19 90

33722 Repair of heart defect 01/01/00 2 1,586.82 1,486.25 45

33730 Repair heart-vein defect(s) 01/01/00 2 1,819.21 1,787.46 90

33732 Repair heart-vein defect 01/01/00 2 1,597.80 1,500.53 45

5101:3-1-60 Page 65










33750 Major vessel shunt 01/01/00 2 1,198.12 1,096.29 90



33764 Major vessel shunt & graft 01/01/00 2 1,183.89 1,104.69 90


33767 Atrial septectomy/septostomy 01/01/00 2 1,387.74 1,271.57 45

33770 Repair great vessels defect 01/01/00 2 1,886.54 1,837.17 45






33778 Repair great vessels defect 01/01/00 2 1,935.95 BR 90




33786 Repair arterial trunk 01/01/00 2 1,998.55 1,866.71 90

33788 Revision of pulmonary artery 01/01/00 2 1,519.76 1,414.70 90

33800 Aortic suspension 01/01/00 2 834.72 750.39 90

33802 Repair vessel defect 01/01/00 2 1,016.96 1,011.04 90

33803 Repair vessel defect 01/01/00 2 1,109.74 1,057.63 90

33813 Repair septal defect 01/01/00 2 1,173.65 BR 90


33820 Revise major vessel 01/01/00 2 939.87 987.51 90

33822 Revise major vessel 01/01/00 2 994.01 1,011.04 90

33824 Revise major vessel 01/01/00 2 1,128.28 1,057.63 90

33840 Excise coarctat aorta w/anastomosis 01/01/00 2 1,199.04 1,322.62

33845 Excision aorta coarctation w/ graft 04/01/04 2 934.12 993.89 90

33851 Remove aorta constriction 01/01/00 2 1,288.44 BR 90


33853 Repair septal defect 01/01/00 2 1,845.81 1,796.35 45

33860 Ascending aorta graft 01/01/00 2 1,872.79 1,697.62 90



33870 Transverse aortic arch graft 01/01/00 2 2,289.27 2,119.66 90

5101:3-1-60 Page 66







33875 Thoracic aorta graft 01/01/00 2 1,761.01 1,500.79 90

33877 Thoracoabdominal graft 07/01/02 2 2,381.29 2,382.84 90

33910 Remove lung artery emboli 01/01/00 2 1,123.19 929.02 90

33915 Remove lung artery emboli 01/01/00 2 931.96 782.62 90

33916 Surgery of great vessel 01/01/00 2 1,239.33 1,067.78 90

33917 Repair pulmonary artery 01/01/00 2 1,426.17 1,513.37 45

33918 Repair pulmonary atresia 01/01/00 2 1,490.80 1,414.70 45



33922 Transect pulmonary artery 01/01/00 2 1,320.15 1,208.02 45

33924 Remove pulmonary shunt 01/01/00 2 254.23 243.01 45

33930 Removal of donor heart/lung 05/01/94 1 NC33933 Prepare donor heart/lung 01/01/05 1 BR 0

33935 Transplantation, heart/lung 07/01/03 2 2,448.08 BR 90

33940 Removal of donor heart 05/01/94 1 NC33944 Prepare donor heart 01/01/05 1 BR 0

33945 Transplantation of heart 07/01/03 2 1,747.33 BR 90

33960 External circulation assist 01/01/00 2 551.31 441.05 3

33961 External circulation assist 01/01/00 2 500.26 446.03 1

33967 Perc insertion intra-aortic balloon 01/01/02 1 188.69 0

33968 Removal of intra-aortic balloon assist device 01/01/00 1 31.85 90

33970 Aortic circulation assist 07/01/02 2 346.65 384.29 1

33971 Aortic circulation assist 01/01/00 2 297.09 237.67 7

33973 Insert balloon device 01/01/00 2 451.27 431.53 45

33974 Remove intra-aortic balloon 01/01/00 2 568.13 454.50 45

33975 Implant ventricular device 07/01/02 2 1,051.22 1,077.95 45

33976 Implant ventricular device 07/01/02 2 1,186.14 1,420.09 45

33977 Remove ventricular device 01/01/00 2 901.48 754.58 45

33978 Remove ventricular device 01/01/00 2 1,009.20 862.36 45

33979 Insert intracorp ventric assist device 07/01/03 2 1715.94 BR 90

33980 Remove intracorp ventr assist device 07/01/03 2 2204.20 BR 90

33999 Cardiac surgery procedure 05/01/94 1 BR 90

34001 Removal of artery clot 01/01/00 2 605.95 546.45 60


34101 Removal of artery clot 01/01/00 2 492.23 443.06 60 3 1-1-96 12/31/03

34111 Removal of arm artery clot 01/01/00 2 420.56 385.71 30



5101:3-1-60 Page 67







34203 Removal of leg artery clot 01/01/00 2 565.44 505.87 30

34401 Removal of vein clot 01/01/00 2 567.35 498.66 60





34501 Repair valve, femoral vein 01/01/00 2 490.29 422.44 60

34502 Reconstruct, vena cava 01/01/00 2 1,227.96 1,133.26 90

34510 Transposition of vein valve 01/01/00 2 591.46 511.08 60

34520 Cross-over vein graft 01/01/00 2 615.92 536.30 60

34530 Leg vein fusion 01/01/00 2 787.51 710.04 60

34800 Endovasc abdo repair w/tube 01/01/01 1 894.67 90

34802 Endovasc abdo repr w/device 01/01/01 1 987.63 9034803 Endovas aaa repr w/3-p part 01/01/05 1 1009.59 90

34804 Endovasc abdo repr w/device 01/01/01 1 987.63 90

34805 Endovasc Abdo Repair W/Pros 01/01/04 1 853.49 90

34808 Endovasc abdo occlud device 01/01/01 1 170.15 90

34812 Xpose for endoprosth, aortic 01/01/01 1 278.61 60

34813 Xpose for endoprosth, femorl 01/01/01 1 197.99 60

34820 Xpose for endoprosth, iliac 01/01/01 1 402.28 90

34825 Endovasc extend prosth, init 01/01/01 1 533.70 90

34826 Endovasc exten prosth, addl 01/01/01 1 170.15 90

34830 Open aortic tube prosth repr 01/01/01 1 1,393.07 90

34831 Open aortoiliac prosth repr 01/01/01 1 1,505.84 90

34832 Open aortofemor prosth repr 01/01/01 1 1,505.84 90

34833 Xpose for endoprosth, iliac 07/01/03 1 447.02 0

34834 Xpose, endoprosth, brachial 07/01/03 1 210.15 0

34900 Endovasc iliac repr w/graft 07/01/03 1 658.72 90

35001 Repair defect of artery 01/01/00 2 952.27 878.59 90

35002 Repair artery rupture, neck 01/01/00 2 909.77 815.74 90



35013 Repair artery rupture, arm 01/01/00 2 858.49 795.09 90

35021 Repair defect of artery 01/01/00 2 1,001.40 913.84 90

35022 Repair artery rupture, chest 01/01/00 2 1,031.01 915.70 90

35045 Repair defect of arm artery 01/01/00 2 628.94 584.50 60

35081 Repair defect of artery 01/01/00 2 1,324.95 1,126.71 90

35082 Repair artery rupture, aorta 01/01/00 2 1,597.10 1,330.56 90

5101:3-1-60 Page 68








35092 Repair artery rupture, aorta 01/01/00 2 1,740.77 1,596.70 90


35103 Repair artery rupture, groin 01/01/00 2 1,598.92 1,480.14 90


35112 Repair artery rupture,spleen 01/01/00 2 799.04 711.80 90


35122 Repair artery rupture, belly 01/01/00 2 1,401.66 1,279.17 90


35132 Repair artery rupture, groin 01/01/00 2 1,086.67 1,006.35 90


35142 Repair artery rupture, thigh 01/01/00 2 851.69 800.14 90


35152 Repair artery rupture, knee 01/01/00 2 718.49 631.95 90

35161 Repair defect of artery 01/01/05 3 NC 932.65 90

35162 Repair artery rupture 01/01/05 3 NC 1,026.13 90

35180 Repair blood vessel lesion 01/01/00 2 575.27 497.49 60



35188 Repair blood vessel lesion 01/01/00 2 614.64 539.71 60 4 01/01/04 OPEN





35207 Repair blood vessel lesion 01/01/00 2 573.29 512.61 30 4 01/01/04 OPEN

35211 Repair blood vessel lesion 01/01/00 2 1,021.94 854.46 60













5101:3-1-60 Page 69










35301 Rechanneling of artery 01/01/00 2 891.48 783.80 90

35311 Rechanneling of artery 01/01/00 2 1,229.82 1,162.58 90


35331 Rechanneling of artery 01/01/00 2 1,003.92 903.35 90









35390 Reoperation, carotid 01/01/00 2 133.01 124.55 90

35400 Angioscopy 01/01/00 2 137.05 130.69 30

35450 Repair arterial blockage 07/01/02 2 533.46 542.87 30






35460 Repair venous blockage 01/01/00 2 253.99 235.83 30







35476 Repair venous blockage 01/01/00 2 256.56 235.83 30

35480 Atherectomy, open 07/01/02 2 591.93 593.07 60






35490 Atherectomy, percutaneous 07/01/02 2 580.38 594.85 30

5101:3-1-60 Page 70












35500 Vein harvest 07/01/03 2 231.68 BR 90

35501 Artery bypass graft 01/01/00 2 1,013.60 967.21 90



35508 Artery bypass graft 01/01/00 2 975.35 912.95 90


35510 Artery Bypass Graft 01/01/04 1 902.77 90










35531 Artery bypass graft 01/01/00 2 1,226.21 1,140.77 90















35572 Harvest femoropopliteal vein 07/01/03 1 253.47 90

35582 Vein bypass graft 01/01/05 3 NC 1,361.83 90

5101:3-1-60 Page 71







35583 Vein bypass graft 01/01/00 2 1,148.00 954.04 90

35585 Vein bypass graft 01/01/00 2 1,372.35 1,097.88 90

35587 Vein bypass graft 01/01/00 2 1,070.64 1,004.82 90

35600 Harvest artery for cabg 01/01/01 1 209.75 90






35623 Bypass graft, not vein 01/01/00 2 684.17 601.65 45








35647 Aorotofemoral bypass graft 01/01/02 1 1,135.39 90











35682 Composite bypass graft 01/01/00 2 331.34 309.25 90

35683 Composite bypass graft 01/01/00 2 377.34 352.18 90

35685 Bypass graft patency/ vein patch 01/01/02 1 157.74 90

35686 Bypass graft patency/AV fistula patch 01/01/02 1 130.59 90

35691 Arterial transposition 07/01/02 2 978.33 993.15 45




35697 Reimplant Artery Each 01/01/04 1 113.57 0

35700 Reoperation, bypass graft 01/01/00 2 136.92 120.29 90

5101:3-1-60 Page 72







35701 Exploration, carotid artery 01/01/00 2 311.73 273.36 60

35721 Exploration, femoral artery 01/01/00 2 294.23 263.88 30

35741 Exploration popliteal artery 01/01/00 2 301.98 268.76 30

35761 Exploration of artery/vein 01/01/00 2 303.53 270.33 30

35800 Explore neck vessels 01/01/00 2 333.34 289.96 60

35820 Explore chest vessels 01/01/00 2 581.36 496.26 60

35840 Explore abdominal vessels 01/01/00 2 466.64 408.52 60

35860 Explore limb vessels 01/01/00 2 307.78 270.59 30

35870 Repair vessel graft defect 01/01/00 2 913.91 793.80 90

35875 Removal of clot in graft 01/01/00 2 496.67 446.74 30 9 01/01/04 OPEN

35876 Removal of clot in graft 01/01/00 2 673.69 538.95 45 9 01/01/04 OPEN

35879 Revision, lower extremity arterial bypass 01/01/00 1 711.22 90

35881 Revision, lower extremity arterial bypass 01/01/00 1 780.7 90

35901 Excision, graft, neck 01/01/00 2 421.90 374.75 45

35903 Excision, graft, extremity 01/01/00 2 464.46 407.89 45

35905 Excision, graft, thorax 01/01/00 2 757.79 606.23 45

35907 Excision, graft, abdomen 01/01/00 2 746.42 625.20 45

* 36000 Place needle in vein 01/01/04 2 22.36 12.88 0

36002 Pseudoaneurysm injection 01/01/02 1 130.32 0

36005 Injection, venography 01/01/00 2 43.16 34.53 0

36010 Place catheter in vein 01/01/00 2 120.81 114.29 0



36013 Place catheter in artery 07/01/02 2 116.86 122.27 0


* 36015 Place catheter in artery 01/01/00 2 163.14 153.45 0

36100 Establish access to artery 01/01/00 2 149.14 139.65 0



36145 Artery to vein shunt 07/01/02 2 99.27 116.09 0

36160 Establish access to aorta 07/01/02 2 127.81 129.35 0

36200 Place catheter in aorta 01/01/00 2 143.66 141.82 0







5101:3-1-60 Page 73









36260 Insertion of infusion pump 01/01/00 2 450.01 411.96 60 3 01/01/04 OPEN

36261 Revision of infusion pump 01/01/00 2 216.86 182.50 15 2 2-17-91 OPEN

36262 Removal of infusion pump 01/01/00 2 169.15 142.98 15 1 2-17-91 OPEN

36299 Vessel injection procedure 05/01/94 1 BR 0

* 36400 Drawing blood 01/01/04 2 33.80 8.29 0

36405 Drawing blood 01/01/04 2 17.31 16.39 0

36406 Drawing blood 01/01/00 2 10.24 8.22 0

* 36410 Drawing blood 01/01/04 2 15.33 11.87 0

* 36415 Drawing blood 01/01/00 2 3.63 0

* 36416 Capillary blood draw 07/01/03 1 3.63 0

* 36420 Establish access to vein 01/01/00 2 39.58 37.11 0

* 36425 Establish access to vein 01/01/04 2 27.77 25.41 0

* 36430 Blood transfusion service 01/01/04 2 27.62 26.84 0

* 36440 Blood transfusion service 01/01/00 2 49.36 47.92 0

* 36450 Exchange transfusion service 01/01/00 2 104.29 100.95 0

* 36455 Exchange transfusion service 01/01/00 2 118.17 115.65 0

36460 Transfusion service, fetal 01/01/00 2 302.32 302.32 0

36468 Injection(s);spider veins 05/01/94 1 NC

36469 Injection(s);spider veins 05/01/94 1 NC

* 36470 Injection therapy of vein 01/01/04 2 93.04 39.58 10

* 36471 Injection therapy of veins 01/01/04 2 116.56 57.41 1036475 Endovenous rf, 1st vein 01/01/05 1 1571.23 036476 Endovenous rf, vein add-on 01/01/05 1 311.23 036478 Endovenous laser, 1st vein 01/01/05 1 1448.16 036479 Endovenous laser vein addon 01/01/05 1 314.08 0

36481 Insertion of catheter, vein 01/01/00 2 313.48 304.08 0

* 36488 Insertion of catheter, vein 01/01/04 3 NC 60.46 0

* 36489 Insertion of catheter, vein 01/01/04 3 NC 73.91 0 1 1-1-96 12-31-03

36490 Insertion of catheter, vein 01/01/04 3 NC 78.48 0

36491 Insertion of catheter, vein 01/01/04 3 NC 78.60 0 1 1-1-96 12-31-03

36493 Repositioning of cvc 01/01/04 3 NC 50.80 0

36500 Insertion of catheter, vein 01/01/00 2 104.08 86.60 0

* 36510 Insertion of catheter, vein 01/01/04 2 132.46 39.80 0

36511 Apheresis wbc 07/01/03 1 63.30 0

36512 Apheresis rbc 07/01/03 1 63.30 0

36513 Apheresis platelets 07/01/03 1 63.30 0

5101:3-1-60 Page 74







36514 Apheresis plasma 07/01/03 1 63.30 0

36515 Apheresis, adsorp/reinfuse 07/01/03 1 63.30 0

36516 Apheresis, selective 07/01/03 1 63.30 0

36520 Plasma and/or cell exchange 07/01/03 3 BR 90.74 0

36521 Plasma and/or cell exchange 07/01/03 3 BR 66.73 0

36522 Photopheresis 01/01/00 2 132.49 105.99 0

36530 Insertion of infusion pump 01/01/04 3 NC 299.43 0 3 1-1-96 12-31-03

36531 Revision of infusion pump 01/01/04 3 NC 237.56 0 2 1-1-96 12-31-03

36532 Removal of infusion pump 01/01/04 3 NC 138.71 0 1 1-1-96 12-31-03

36533 Insertion of access port 01/01/04 3 NC 260.71 0 3 1-1-96 12-31-03

36534 Revision of access port 01/01/04 3 NC 147.37 0 2 1-1-96 12-31-03

36535 Removal of access port 01/01/04 3 NC 116.10 0 1 1-1-96 12-31-03

36536 Remove cva device obstruct 01/01/04 3 NC 919.46 0

36537 Remove cva lumen obstruct 01/01/04 3 NC 208.59 0

36540 Collect blood venous device 01/01/01 1 20.00 90

36550 Declotting of implanted vascular access device 01/01/00 1 22.52 0

36555 Insert Non-Tunnel Cv Cath 01/01/04 1 225.03 0 1 1-1-04 OPEN

36556 Insert Non-Tunnel Cv Cath 01/01/04 1 193.15 0 1 1-1-04 OPEN

36557 Insert Tunneled Cv Cath 01/01/04 1 486.43 10 2 1-1-04 OPEN













36578 Replace Tunneled Cv Cath 01/01/04 1 368.64 10 2 1-1-04 OPEN







5101:3-1-60 Page 75







36589 Removal Tunneled Cv Cath 01/01/04 1 118.31 10 1 1-1-04 OPEN

36590 Removal Tunneled Cv Cath 01/01/04 1 253.49 10 1 1-1-04 OPEN

36595 Mech Remov Tunneled Cv Cath 01/01/04 1 571.54 0

36596 Mech Remov Tunneled Cv Cath 01/01/04 1 130.96 0

36597 Reposition Venous Catheter 01/01/04 1 112.25 0

* 36600 Withdrawal of arterial blood 01/01/04 2 19.93 16.15 0

36620 Insertion catheter, artery 01/01/00 2 48.27 46.21 0


36640 Insertion catheter, artery 07/01/02 2 106.97 115.54 0 1 2-17-91 OPEN


36680 Insert needle, bone cavity 01/01/00 2 61.25 59.60 90

36800 Insertion of cannula 01/01/00 2 122.63 116.03 7 3 2-17-91 OPEN

36810 Insertion of cannula 01/01/00 2 220.48 224.61 7 3 2-17-91 OPEN

36815 Insertion of cannula 07/01/02 2 146.45 151.56 60 3 2-17-91 OPEN36818 Av fuse, uppr arm, cephalic 01/01/05 1 540.32 90

36819 Arteriovenous anastomosis, open 01/01/00 1 597.81 90 3 1-1-02 OPEN

36820 Anastomosis forearm vein transpos 01/01/02 1 583.44 90 3 1-1-02 OPEN

36821 Artery-vein fusion 01/01/00 2 436.15 403.49 60 3 2-17-91 OPEN

36822 Insertion of cannula(s) 01/01/00 2 314.81 267.91 45

36823 Insertion of cannula(s) 01/01/99 1 BR 45

36825 Artery-vein graft 01/01/00 2 551.09 536.04 60 4 2-17-91 OPEN

36830 Artery-vein graft 01/01/00 2 592.09 473.67 60 4 2-17-91 OPEN

36831 Artery-vein fistula excision 01/01/00 2 256.95 280.57 90 9 01/01/04 OPEN

36832 Revise artery-vein fistula 01/01/00 2 463.89 371.11 60 4 2-17-91 OPEN

36833 Artery-vein fistula revision 01/01/00 2 371.90 424.49 90 4 10/01/04 OPEN

36834 Repair A-V aneurysm 01/01/00 2 478.64 443.66 90

36835 Artery to vein shunt 01/01/00 2 295.04 255.02 60 4 2-17-91 OPEN

36838 Dist Revas Ligation, Hemo 01/01/04 1 843.74 90

36840 Insert mandril 07/01/03 3 NC BR

36845 Fusion with mandril 07/01/03 3 NC BR

36860 Cannula declotting 01/01/00 2 128.55 117.73 0 2 2-17-91 OPEN

36861 Cannula declotting 07/01/02 2 146.24 152.27 60 3 2-17-91 OPEN

36870 Av fistula revision, open 01/01/01 1 986.20 90 9 01/01/04 OPEN

37140 Revision of circulation 01/01/00 2 1,070.40 987.83 90




37181 Splice spleen/kidney veins 01/01/00 2 1,165.18 1,067.66 90

5101:3-1-60 Page 76







37182 Insert hepatic shunt (tips) 07/01/03 1 628.88 0

37183 Remove hepatic shunt (tips) 07/01/03 1 292.13 0

37195 Thrombolytic therapy for stroke 01/01/00 2 215.74 188.83 0

37200 Transcatheter biopsy 01/01/00 2 172.43 149.02 0

37201 Transcatheter therapy infuse 01/01/00 2 270.18 315.64 0

37202 Transcatheter therapy infuse 01/01/00 2 266.72 247.05 0

37203 Transcatheter retrieval 01/01/00 2 233.19 219.23 0

37204 Transcatheter occlusion 01/01/00 2 821.97 789.68 0

37205 Transcatheter stent 01/01/00 2 353.68 327.04 0




37209 Exchange arterial catheter 01/01/00 2 99.15 89.42 737215 Transcath stent, cca w/eps 01/01/05 1 804.37 9037216 Transcath stent, cca w/o eps 01/01/05 1 774.81 90

37250 Intravascular ultrasound, initial vessel 01/01/00 2 78.15 62.52 C

37251 Intravascular ultrasound, each additional vessel 01/01/00 2 59.60 47.68 K

37500 Endoscopy ligate perf veins 07/01/03 1 504.87 90

37501 Vascular endoscopy procedure 07/01/03 1 500.00 90

37565 Ligation of neck vein 01/01/00 2 223.31 198.79 60

37600 Ligation of neck artery 01/01/00 2 259.18 227.42 30



37607 Ligation of fistula 01/01/00 2 255.61 227.98 45 3 01/01/04 OPEN

37609 Temporal artery procedure 01/01/00 2 142.67 114.73 0 2 2-17-91 OPEN


37616 Ligation of chest artery 01/01/00 2 587.18 469.74 60

37617 Ligation of abdomen artery 01/01/00 2 660.08 562.11 45

37618 Ligation of extremity artery 01/01/00 2 268.32 234.03 30

37620 Revision of major vein 01/01/00 2 515.13 460.17 90

37650 Revision of major vein 01/01/00 2 245.15 210.20 30 2 01/01/04 OPEN

37660 Revision of major vein 01/01/00 2 451.45 389.89 90

37700 Revise leg vein 01/01/00 2 200.50 185.99 30 2 2-17-91 OPEN

37720 Removal of leg vein 01/01/00 2 290.92 268.18 30 3 2-17-91 OPEN

37730 Removal of leg veins 01/01/00 2 384.90 353.10 30 3 2-17-91 OPEN

37735 Removal of leg veins/lesion 01/01/00 2 512.80 470.40 21 3 2-17-91 OPEN

37760 Revision of leg veins 01/01/00 2 492.00 446.74 60 3 2-17-91 OPEN

37765 Phleb Veins - Extrem - To 20 01/01/04 1 NC 90

5101:3-1-60 Page 77







37766 Phleb Veins - Extrem 20+ 01/01/04 1 NC 90

37780 Revision of leg vein 01/01/00 2 160.33 136.47 30 3 2-17-91 OPEN

37785 Revise secondary varicosity 01/01/00 2 140.48 112.38 15 3 2-17-91 OPEN

37788 Revascularization, penis 07/01/03 2 879.24 BR 90

37790 Penile venous occlusion 01/01/00 2 378.81 336.40 45 3 01/01/04 OPEN

37799 Vascular surgery procedure 05/01/94 1 BR 0

38100 Removal of spleen, total 01/01/00 2 585.58 528.67 21

38101 Removal of spleen, partial 01/01/00 2 570.85 499.92 21

38102 Removal of spleen, total 01/01/00 2 198.44 187.18 45

38115 Repair of ruptured spleen 01/01/00 2 593.67 514.22 21

38120 Laparoscopy, splenectomy 07/01/03 2 659.24 BR 90

38129 Unlisted laparoscopy, procedure, spleen 01/01/00 1 BR 14

38200 Injection for spleen x-ray 01/01/00 2 110.02 106.16 0

38204 Bl donor search management 07/01/03 3 NC

38205 Harvest allogenic stem cells 07/01/03 1 54.74 0

38206 Harvest auto stem cells 07/01/03 1 54.74 0

38207 Cryopreserve stem cells 07/01/03 1 NC

38208 Thaw preserved stem cells 07/01/03 1 NC

38209 Wash harvest stem cells 07/01/03 1 NC

38210 T-cell depletion of harvest 07/01/03 1 NC

38211 Tumor cell deplete of harvst 07/01/03 1 NC

38212 Rbc depletion of harvest 07/01/03 1 NC

38213 Platelet deplete of harvest 07/01/03 1 NC

38214 Volume deplete of harvest 07/01/03 1 NC

38215 Harvest stem cell concentrte 07/01/03 1 NC

38220 Bone marrow aspiration 01/01/02 1 148.78 0

38221 Bone marrow biopsy, needle/ trocar 01/01/02 1 159.37 0

* 38230 Bone marrow collection 01/01/04 2 193.38 192.18 10

38231 Stem cell collection 07/01/03 3 NC 71.12 0

* 38240 Bone marrow transplantation 01/01/00 2 111.78 104.72 0

* 38241 Bone marrow transplantation 01/01/00 2 110.34 103.56 0

38242 Lymphocyte infuse transplant 07/01/03 1 62.27 0

* 38300 Drainage lymph node lesion 01/01/04 2 175.67 64.11 10 1 2-17-91 OPEN

38305 Drainage lymph node lesion 01/01/00 2 194.51 155.61 21 2 2-17-91 OPEN

38308 Incision of lymph channels 01/01/00 2 230.39 197.46 90 2 2-17-91 OPEN

38380 Thoracic duct procedure 01/01/00 2 335.10 277.26 90



5101:3-1-60 Page 78







38500 Biopsy/removal,lymph node(s) 01/01/00 2 126.30 112.05 0 2 2-17-91 OPEN

38505 Needle biopsy,lymph node(s) 01/01/00 2 71.25 57.21 0 1 2-17-91 OPEN





38542 Explore deep node(s), neck 01/01/00 2 284.15 241.94 60 2 2-17-91 OPEN

38550 Removal neck/armpit lesion 01/01/00 2 272.81 243.75 30 3 2-17-91 OPEN

38555 Removal neck/armpit lesion 01/01/00 2 599.45 514.04 60 4 2-17-91 OPEN

38562 Removal, pelvic lymph nodes 01/01/00 2 475.19 418.94 30

38564 Removal, abdomen lymph nodes 01/01/00 2 498.37 446.84 60

38570 Laparoscopic lymph node biop 01/01/00 1 397.12 10 9 01/01/04 OPEN

38571 Laparoscopic lymphadenectomy 01/01/00 1 543.18 10 9 01/01/04 OPEN

38572 Laparoscopic lymphadenectomy 01/01/00 1 661.77 10 9 01/01/04 OPEN

38589 Unlisted laparoscopy, procedure, lymphatic system 01/01/00 1 BR 14

38700 Removal of lymph nodes, neck 01/01/00 2 504.09 434.41 60 2 2-17-91 12/31/03

38720 Removal of lymph nodes, neck 01/01/00 2 795.71 705.26 60

38724 Removal of lymph nodes, neck 01/01/00 2 808.37 695.37 60

38740 Remove armpit lymph nodes 01/01/00 2 314.98 283.73 60 2 2-17-91 OPEN

38745 Remove armpits lymph nodes 01/01/00 2 466.59 427.36 60 4 2-17-91 OPEN

38746 Remove thoracic lymph nodes 01/01/00 2 184.48 171.05 45

38747 Remove abdominal lymph nodes 01/01/00 2 203.61 190.73 45

38760 Remove groin lymph nodes 01/01/00 2 418.01 382.00 60 2 2-17-91 OPEN

38765 Remove groin lymph nodes 01/01/00 2 780.54 709.82 60

38770 Remove pelvis lymph nodes 01/01/00 2 714.65 685.30 60

38780 Remove abdomen lymph nodes 01/01/00 2 879.53 809.64 90

38790 Injection for lymphatic xray 01/01/00 2 91.45 73.16 7 1 2-17-91 12/31/03

38792 Injection for identification of sentinal node 07/01/03 2 18.68 BR 7

38794 Access thoracic lymph duct 01/01/00 2 187.60 171.60 7

38999 Blood/lymph system procedure 05/01/94 1 BR 0



39200 Removal chest lesion 01/01/00 2 694.77 615.92 90

39220 Removal chest lesion 01/01/00 2 884.49 800.28 90

39400 Visualization of chest 01/01/00 2 306.38 263.47 7

39499 Chest procedure 05/01/94 1 BR 0

39501 Repair diaphragm laceration 01/01/00 2 652.94 586.74 60

39502 Repair paraesophageal hernia 01/01/00 2 771.90 698.53 60

5101:3-1-60 Page 79







39503 Repair of diaphragm hernia 01/01/00 2 1,561.59 1,445.98 90

39520 Repair of diaphragm hernia 01/01/00 2 783.33 712.45 60





39545 Revision of diaphragm 01/01/00 2 589.85 503.80 60

39560 Resection, diaphragm; with simple repair 01/01/00 1 588.75 90

39561 Resection, diaphragm, with complex repair 01/01/00 1 809.25 90

39599 Diaphragm surgery procedure 05/01/94 1 BR 0

40490 Biopsy of lip 01/01/00 2 55.61 47.93 0

40500 Partial excision of lip 01/01/00 2 251.36 240.99 90 2 2-17-91 OPEN



40525 Reconstruct lip with flap 01/01/00 2 438.59 422.51 30 2 2-17-91 OPEN

40527 Reconstruct lip with flap 01/01/00 2 524.88 505.29 60 2 2-17-91 OPEN

40530 Partial removal of lip 01/01/00 2 286.10 258.40 30 2 2-17-91 OPEN

40650 Repair lip 01/01/00 2 211.48 202.14 30 3 2-17-91 OPEN

40652 Repair lip 01/01/00 2 251.40 237.18 30 3 2-17-91 OPEN

40654 Repair lip 01/01/00 2 309.61 298.25 30 3 2-17-91 OPEN

40700 Repair cleft lip/nasal 01/01/00 2 585.65 514.35 90 7 01/01/04 OPEN


40702 Repair cleft lip/nasal 01/01/00 2 603.04 537.71 90



40799 Lip surgery procedure 05/01/94 1 BR 0

* 40800 Drainage of mouth lesion 01/01/04 2 81.67 55.72 10

40801 Drainage of mouth lesion 01/01/00 2 115.23 102.34 14 2 2-17-91 OPEN

* 40804 Removal foreign body, mouth 01/01/04 2 96.34 54.14 10

40805 Removal foreign body, mouth 01/01/00 2 141.30 127.96 14 2 2-17-91 12/31/03

40806 Incision of lip fold 01/01/00 2 20.11 16.41 14 2 01/01/97 12/31/03

40808 Biopsy of mouth lesion 01/01/00 2 51.26 41.20 14

40810 Excision of mouth lesion 01/01/00 2 72.81 59.93 14

40812 Excise/repair mouth lesion 01/01/00 2 107.10 91.99 14

40814 Excise/repair mouth lesion 01/01/00 2 179.88 160.23 14 2 2-17-91 OPEN

40816 Excision of mouth lesion 01/01/00 2 187.89 166.26 14 2 2-17-91 OPEN

40818 Excise oral mucosa for graft 01/01/00 2 131.08 110.60 14 1 2-17-91 OPEN

40819 Excise lip or cheek fold 01/01/00 2 107.05 85.84 30 1 2-17-91 OPEN

5101:3-1-60 Page 80







40820 Treatment of mouth lesion 01/01/00 2 53.91 43.13 0 1 2-17-91 12/31/03

40830 Repair mouth laceration 01/01/00 2 72.04 58.10 0

40831 Repair mouth laceration 01/01/00 2 120.63 107.40 7 1 2-17-91 OPEN

40840 Reconstruction of mouth 01/01/00 2 399.82 361.15 14 2 2-17-91 OPEN




40845 Reconstruction of mouth 01/01/00 2 988.38 1,026.28 14 5 2-17-91 OPEN

40899 Mouth surgery procedure 05/01/94 1 BR 14

* 41000 Drainage of mouth lesion 01/01/04 2 99.80 61.44 10 1 2-17-91 12/31/03

* 41005 Drainage of mouth lesion 01/01/04 2 95.58 56.20 10 1 2-17-91 OPEN





41010 Incision of tongue fold 01/01/00 2 47.53 38.02 14 1 2-17-91 OPEN





41100 Biopsy of tongue 01/01/00 2 72.58 58.20 15 2 2-17-91 9/30/04

41105 Biopsy of tongue 01/01/00 2 71.67 59.41 15 2 2-17-91 12/31/03

41108 Biopsy of floor of mouth 01/01/00 2 56.98 45.66 0

41110 Excision of tongue lesion 01/01/00 2 83.02 68.48 0 1 2-17-91 12/31/03

41112 Excision of tongue lesion 01/01/00 2 140.50 123.44 7 2 2-17-91 OPEN



41115 Excision of tongue fold 01/01/00 2 97.37 85.45 0 1 2-17-91 12/31/03

41116 Excision of mouth lesion 01/01/00 2 134.90 120.25 0 1 2-17-91 OPEN

41120 Partial removal of tongue 01/01/00 2 468.28 400.22 90 5 2-17-91 OPEN

41130 Partial removal of tongue 01/01/00 2 550.61 481.95 90

41135 Tongue and neck surgery 01/01/00 2 1,033.85 827.08 90

41140 Removal of tongue 01/01/00 2 1,198.92 1,055.89 90

41145 Tongue removal; neck surgery 01/01/00 2 1,431.56 1,256.36 90

41150 Tongue, mouth, jaw surgery 01/01/00 2 1,130.52 959.28 90

41153 Tongue, mouth, neck surgery 01/01/00 2 1,286.74 1,155.05 90

41155 Tongue, jaw, & neck surgery 01/01/00 2 1,518.62 1,339.41 90

41250 Repair tongue laceration 01/01/00 2 86.14 71.83 7 2 2-17-91 OPEN

5101:3-1-60 Page 81









41500 Fixation of tongue 01/01/00 2 187.92 165.59 14 1 2-17-91 OPEN

41510 Tongue to lip surgery 01/01/00 2 174.18 148.79 30 1 2-17-91 OPEN

41520 Reconstruction, tongue fold 01/01/00 2 148.53 135.87 30 2 2-17-91 OPEN

41599 Tongue and mouth surgery 05/01/94 1 BR 14

41800 Drainage of gum lesion 01/01/00 2 54.62 44.39 14 1 2-17-91 OPEN

41805 Removal foreign body, gum 01/01/00 2 59.52 49.74 14 1 2-17-91 12/31/03

41806 Removal foreign body,jawbone 01/01/00 2 118.16 104.56 14 1 2-17-91 12/31/03

41820 Excision, gum, each quadrant 05/01/94 1 NC

41821 Excision of gum flap 05/01/94 1 BR 30

41822 Excision of gum lesion 01/01/00 2 139.22 129.64 30



41826 Excision of gum lesion 01/01/00 2 118.22 105.99 7 2 2-17-91 9/30/04

41827 Excision of gum lesion 01/01/00 2 189.47 174.28 0 2 2-17-91 OPEN

41828 Excision of gum lesion 05/01/94 1 NC

41830 Removal of gum tissue 05/01/94 1 NC

41850 Treatment of gum lesion 05/01/94 1 BR 30

41870 Gum graft 05/01/94 1 NC

41872 Repair gum 05/01/94 1 NC

41874 Repair tooth socket 05/01/94 1 NC

41899 Dental surgery procedure 05/01/94 1 BR 0

42000 Drainage mouth roof lesion 01/01/00 2 54.98 43.98 7 2 2-17-91 OPEN

42100 Biopsy roof of mouth 01/01/00 2 62.85 50.28 7

42104 Excision lesion, mouth roof 01/01/00 2 90.45 79.40 0 2 2-17-91 12/31/03

42106 Excision lesion, mouth roof 01/01/00 2 116.05 119.06 7 2 2-17-91 12/31/03

42107 Excision lesion, mouth roof 01/01/00 2 243.73 225.40 30 2 2-17-91 OPEN

42120 Remove palate/lesion 01/01/00 2 352.68 312.27 90 4 2-17-91 OPEN

42140 Excision of uvula 01/01/00 2 89.43 71.54 30 2 2-17-91 OPEN

42145 Repair,palate,pharynx/uvula 01/01/00 2 460.75 411.13 60 5 2-17-91 OPEN

42160 Treatment mouth roof lesion 01/01/00 2 94.33 80.94 0 1 2-17-91 12/31/03

42180 Repair palate 01/01/00 2 129.87 116.46 30 1 2-17-91 OPEN


42200 Reconstruct cleft palate 01/01/00 2 516.28 413.02 90 5 2-17-91 OPEN




5101:3-1-60 Page 82








42225 Reconstruct cleft palate 01/01/00 2 459.39 402.65 90 5 2-17-91 12/31/03

42226 Lengthening of palate 01/01/00 2 490.05 427.78 90 5 01/01/04 OPEN

42227 Lengthening of palate 01/01/00 2 448.17 391.92 90


42260 Repair nose to lip fistula 01/01/00 2 252.46 201.97 30 4 2-17-91 OPEN

42280 Preparation, palate mold 01/01/00 2 90.25 85.43 0

42281 Insertion, palate prosthesis 01/01/00 2 90.67 79.80 20 3 2-17-91 12/31/03

42299 Palate/uvula surgery 05/01/94 1 BR 0

* 42300 Drainage of salivary gland 01/01/04 2 125.89 84.82 10 1 2-17-91 OPEN

42305 Drainage of salivary gland 01/01/00 2 238.44 190.75 14 2 2-17-91 OPEN



42325 Create salivary cyst drain 01/01/00 2 131.53 117.01 30 2 2-17-91 OPEN

42326 Create salivary cyst drain 01/01/00 2 208.65 194.89 30

42330 Removal of salivary stone 01/01/00 2 95.40 79.97 21

42335 Removal of salivary stone 01/01/00 2 159.11 140.21 30 3 1-1-96 12/31/03 2 2-17-91 12-31-95

42340 Removal of salivary stone 01/01/00 2 236.96 215.58 30 2 2-17-91 OPEN

* 42400 Biopsy of salivary gland 01/01/04 2 87.70 49.09 0

42405 Biopsy of salivary gland 01/01/00 2 137.35 117.71 30 2 2-17-91 OPEN

42408 Excision of salivary cyst 01/01/00 2 213.22 189.36 30 3 2-17-91 OPEN

42409 Drainage of salivary cyst 01/01/00 2 151.61 136.71 30 3 2-17-91 OPEN

42410 Excise parotid gland/lesion 01/01/00 2 429.10 371.92 60 3 2-17-91 OPEN

42415 Excise parotid gland/lesion 01/01/00 2 804.62 718.61 60 7 01/01/04 OPEN



42426 Excise parotid gland/lesion 01/01/00 2 1,181.05 1,108.36 60

42440 Excision submaxillary gland 01/01/00 2 393.05 365.65 60 3 2-17-91 OPEN

42450 Excision sublingual gland 01/01/00 2 219.15 191.97 60 2 2-17-91 OPEN

42500 Repair salivary duct 01/01/00 2 238.11 215.21 60 3 2-17-91 OPEN

42505 Repair salivary duct 01/01/00 2 342.73 331.20 60 4 2-17-91 OPEN

42507 Parotid duct diversion 01/01/00 2 303.22 266.06 30 3 2-17-91 OPEN




42550 Injection for salivary x-ray 01/01/00 2 51.33 41.06 0 3 1-1-01 9/30/04

42600 Closure of salivary fistula 01/01/00 2 242.18 210.28 30 1 2-17-91 OPEN

* 42650 Dilation of salivary duct 01/01/04 2 50.96 33.84 0

5101:3-1-60 Page 83







* 42660 Dilation of salivary duct 01/01/04 2 63.38 46.62 0

42665 Ligation of salivary duct 01/01/00 2 129.85 111.17 7 1 2-17-91 9/30/04

42699 Salivary surgery procedure 05/01/94 1 BR 0

* 42700 Drainage of tonsil abscess 01/01/04 2 132.49 74.50 10 1 2-17-91 OPEN

42720 Drainage of throat abscess 01/01/00 2 139.15 111.32 15 1 2-17-91 OPEN

42725 Drainage of throat abscess 01/01/00 2 371.66 297.33 15 2 2-17-91 OPEN

42800 Biopsy of throat 01/01/00 2 63.84 51.07 0

42802 Biopsy of throat 01/01/00 2 77.27 62.06 0 1 2-17-91 OPEN

42804 Biopsy of upper nose/throat 01/01/00 2 70.06 56.71 0 1 2-17-91 OPEN

42806 Biopsy of upper nose/throat 01/01/00 2 88.16 72.70 7 2 2-17-91 OPEN

42808 Excise pharynx lesion 01/01/00 2 137.41 118.80 7 2 2-17-91 OPEN

42809 Remove pharynx foreign body 01/01/00 2 78.71 62.97 7

42810 Excision of neck cyst 01/01/00 2 184.22 160.31 30 3 2-17-91 OPEN

42815 Excision of neck cyst 01/01/00 2 409.68 383.48 30 5 2-17-91 OPEN

42820 Remove tonsils and adenoids 01/01/00 2 185.55 166.09 30 3 01/01/04 OPEN 4 2-17-91 12/31/03

42821 Remove tonsils and adenoids 01/01/00 2 225.21 199.66 30 5 2-17-91 OPEN

42825 Removal of tonsils 01/01/00 2 170.74 145.60 30 4 2-17-91 OPEN

42826 Removal of tonsils 01/01/00 2 193.96 175.45 30 4 2-17-91 OPEN

42830 Removal of adenoids 01/01/00 2 126.15 109.02 30 4 2-17-91 OPEN




42842 Extensive surgery of throat 01/01/00 2 422.73 366.16 30

42844 Extensive surgery of throat 01/01/00 2 680.64 585.10 30

42845 Extensive surgery of throat 01/01/00 2 1,154.60 1,005.95 30

42860 Excision of tonsil tags 01/01/00 2 117.62 99.78 30 3 1-1-96 OPEN 2 2-17-91 12-31-95

42870 Excision of lingual tonsil 01/01/00 2 228.01 183.36 30 3 2-17-91 OPEN

42880 Excise nose/throat lesion 04/01/97 3 NC 240.22 0 5 2-17-91 OPEN

42890 Partial removal of pharynx 01/01/00 2 603.52 511.18 90 7 01/01/04 OPEN

42892 Revision of pharyngeal walls 01/01/00 2 729.93 615.75 30 7 01/01/04 OPEN

42894 Revision of pharyngeal walls 01/01/00 2 1,053.99 908.91 7

42900 Repair throat wound 01/01/00 2 258.17 228.82 7 1 2-17-91 OPEN

42950 Reconstruction of throat 01/01/00 2 456.08 437.45 60 2 2-17-91 OPEN

42953 Repair throat, esophagus 01/01/00 2 431.20 365.20 60

42955 Surgical opening of throat 01/01/00 2 303.30 242.64 60 2 2-17-91 OPEN

42960 Control throat bleeding 01/01/00 2 99.29 82.40 0 1 2-17-91 OPEN

42961 Control throat bleeding 01/01/00 2 211.35 169.08 90

42962 Control throat bleeding 01/01/00 2 355.56 312.94 0 2 2-17-91 OPEN

5101:3-1-60 Page 84







42970 Control nose/throat bleeding 01/01/00 2 175.99 140.79 0

42971 Control nose/throat bleeding 01/01/00 2 260.26 208.21 90

42972 Control nose/throat bleeding 01/01/00 2 327.89 279.48 90 3 01/01/04 OPEN

42999 Throat surgery procedure 05/01/94 1 BR 0

43020 Incision of esophagus 01/01/00 2 391.41 353.30 90

43030 Throat muscle surgery 01/01/00 2 434.87 410.86 30

43045 Incision of esophagus 01/01/00 2 897.52 795.73 90

43100 Excision of esophagus lesion 01/01/00 2 438.27 368.53 60

43101 Excision of esophagus lesion 01/01/00 2 711.13 626.55 90

43107 Removal of esophagus 01/01/00 2 1,392.39 1,278.00 90




43116 Partial removal of esophagus 01/01/00 2 1,561.49 1,409.30 90







43130 Removal of esophagus pouch 01/01/00 2 612.54 536.52 60

43135 Removal of esophagus pouch 01/01/00 2 763.97 684.95 60

43200 Esophagus endoscopy 01/01/00 2 114.08 91.26 0 1 2-17-91 OPEN

43201 Esoph scope w/submucous inj 07/01/03 1 165.26 0 1 01/01/04 OPEN

43202 Esophagus endoscopy, biopsy 01/01/00 2 131.03 108.16 0 1 2-17-91 OPEN

43204 Esophagus endoscopy & inject 01/01/00 2 196.41 209.69 15 1 2-17-91 OPEN

43205 Esophagus endoscopy/ligation 01/01/00 2 164.39 157.08 14 1 01/01/04 OPEN


43216 Esophagus endoscopy/lesion 01/01/00 2 128.89 148.58 14 1 2-17-91 OPEN



43220 Esophagus endoscopy,dilation 01/01/00 2 111.70 118.33 15 1 2-17-91 OPEN

43226 Esophagus endoscopy,dilation 01/01/00 2 122.99 131.13 0 1 2-17-91 OPEN

43227 Esophagus endoscopy, repair 01/01/00 2 187.71 200.09 15 2 2-17-91 OPEN

43228 Esophagus endoscopy,ablation 01/01/00 2 197.28 209.29 0 2 2-17-91 OPEN

43231 Esoph endoscopy w/us exam 01/01/01 1 172.74 0 2 01/01/04 OPEN

43232 Esoph endoscopy w/us fn bx 01/01/01 1 200.57 0 2 01/01/04 OPEN

43234 Upper gi endoscopy, exam 01/01/00 2 125.47 114.43 0 1 2-17-91 OPEN

5101:3-1-60 Page 85







43235 Upper gi endoscopy,diagnosis 01/01/00 2 156.43 134.69 0 1 2-17-91 OPEN

43236 Uppr gi scope w/submuc inj 07/01/03 1 193.54 0 2 01/01/04 OPEN

43237 Endoscopic Us Exam, Esoph 01/01/04 1 150.46 0

43238 Uppr Gi Endoscopy W/Us Fn Bx 01/01/04 1 186.30 0

43239 Upper gi endoscopy, biopsy 01/01/00 2 172.53 151.34 0 2 2-17-91 OPEN

43240 Esoph endoscope w/drain cyst 01/01/01 1 305.30 0 2 01/01/04 OPEN

43241 Upper gi endoscopy with tube 01/01/00 2 138.17 147.25 0 2 2-17-91 OPEN

43242 Uppr gi endoscopy w/us fn bx 01/01/01 1 219.79 0 2 01/01/04 OPEN

43243 Upper gi endoscopy & inject. 01/01/00 2 237.08 247.89 0 2 2-17-91 OPEN

43244 Upper gi endoscopy/ligation 01/01/00 2 206.94 199.68 14 2 01/01/04 OPEN

43245 Operative upper gi endoscopy 01/01/00 2 178.40 190.43 15 2 2-17-91 OPEN

43246 Place gastrostomy tube 07/01/02 2 226.05 227.54 0 2 2-17-91 OPEN


43248 Upper gi endoscopy/guidewire 01/01/00 2 165.47 176.33 14 2 1-1-96 OPEN

43249 Upper gi endoscopy, w balloon dil 01/01/95 1 145.61 0 2 10/01/04 OPEN

43250 Upper gi endoscopy/tumor 01/01/00 2 169.75 192.55 14 2 2-17-91 OPEN



43256 Uppr gi endoscopy w stent 01/01/01 1 173.02 0 3 01/01/04 OPEN43257 Uppr gi scope w/thrml txmnt 01/01/05 1 224.83 0


43259 Endoscopic ultrasound exam 01/01/00 2 224.95 217.89 14 3 1-1-96 OPEN

43260 Endoscopy,bile duct/pancreas 01/01/00 2 294.70 289.24 0 2 2-17-91 OPEN











43280 Laparoscopy, esophagogastric fundoplasty 01/01/00 1 797.61 90

43289 Unlisted laparoscopy, procedure, esophagus 01/01/00 1 BR 14

43300 Repair of esophagus 01/01/00 2 516.53 507.03 90

43305 Repair esophagus and fistula 01/01/00 2 861.62 745.09 90

43310 Repair of esophagus 01/01/00 2 1,166.92 1,050.21 90

5101:3-1-60 Page 86







43312 Repair esophagus and fistula 01/01/00 2 1,193.69 1,025.57 90

43313 Esophagoplasty defect,w/o repair fist 01/01/02 1 1,919.73 90

43314 Esophagoplasty c defect,w repair fist 01/01/02 1 2,108.97 90

43320 Fuse esophagus & stomach 01/01/00 2 757.40 666.10 90

43324 Revise esophagus & stomach 01/01/00 2 778.80 699.42 90

43325 Revise esophagus & stomach 01/01/00 2 763.46 673.97 90

43326 Revise esophagus & stomach 07/01/03 2 808.67 BR 90



43340 Fuse esophagus & intestine 01/01/00 2 779.88 687.43 90

43341 Fuse esophagus & intestine 01/01/00 2 743.66 631.59 90

43350 Surgical opening, esophagus 01/01/00 2 569.67 478.86 90



43360 Gastrointestinal repair 01/01/00 2 1,355.42 1,218.81 90

43361 Gastrointestinal repair 01/01/00 2 1,558.07 1,409.30 90

43400 Ligate esophagus veins 01/01/00 2 756.96 661.29 90

43401 Esophagus surgery for veins 01/01/00 2 765.21 657.95 90

43405 Ligate/staple esophagus 01/01/00 2 823.77 749.86 90

43410 Repair esophagus wound 01/01/00 2 545.08 472.63 90

43415 Repair esophagus wound 01/01/00 2 816.58 735.09 90

43420 Repair esophagus opening 01/01/00 2 488.79 398.45 90

43425 Repair esophagus opening 01/01/00 2 737.23 644.00 90 7 01/01/97 OPEN

* 43450 Dilate esophagus 01/01/04 2 75.41 56.34 0 1 2-17-91 OPEN

43453 Dilate esophagus 01/01/00 2 75.09 73.45 15 1 2-17-91 OPEN

43456 Dilate esophagus 01/01/00 2 126.56 146.89 15 2 2-17-91 OPEN

43458 Dilation of esophagus 01/01/00 2 121.90 114.96 14 2 2-17-91 OPEN

43460 Pressure treatment esophagus 05/01/94 2 121.74 62.12 15

43496 Microvascular jejunum transfer 01/01/97 1 BR 90

43499 Esophagus surgery procedure 05/01/94 1 BR 0

43500 Surgical opening of stomach 01/01/00 2 393.76 352.63 45

43501 Surgical repair of stomach 01/01/00 2 652.09 574.53 45

43502 Surgical repair of stomach 01/01/00 2 718.33 621.83 45

43510 Surgical opening of stomach 01/01/00 2 481.22 435.32 45

43520 Incision of pyloric muscle 01/01/00 2 333.74 292.25 45

43600 Biopsy of stomach 01/01/00 2 65.23 58.52 7 1 2-17-91 OPEN

43605 Biopsy of stomach 01/01/00 2 411.16 365.03 30

43610 Excision of stomach lesion 01/01/00 2 524.92 472.33 30

5101:3-1-60 Page 87







43611 Excision of stomach lesion 01/01/00 2 594.69 528.04 45

43620 Removal of stomach 01/01/00 2 1,026.84 936.40 90



43631 Removal of stomach, partial 01/01/00 2 871.18 785.15 45

43632 Removal stomach, partial 01/01/00 2 871.42 785.15 45


43634 Removal stomach, partial 01/01/00 2 1,145.25 1,068.24 45

43635 Partial removal of stomach 01/01/00 2 85.56 80.68 60

43638 Partial removal of stomach 01/01/00 2 938.51 843.67 60


43640 Vagotomy & pylorus repair 01/01/00 2 681.21 610.08 60

43641 Vagotomy & pylorus repair 01/01/00 2 687.00 609.82 6043644 Lap gastric bypass/roux-en-y 01/01/05 1 NC43645 Lap gastr bypass incl smll i 01/01/05 1 NC

43651 Laparoscopy, vagus nerves 01/01/00 1 418.77 90

43652 Laparoscopy, vagus nerves 01/01/00 1 505.63 90

43653 Laparoscopic gastrostomy 01/01/00 1 376.28 90 9 01/01/04 OPEN

43659 Unlisted laparoscopy, procedure, stomach 01/01/00 1 BR 14

43750 Place gastrostomy tube 01/01/00 2 229.42 250.43 7 2 2-17-91 OPEN

43752 Nasal/orogastric w/stent 01/01/01 1 NC 90

* 43760 Change gastrostomy tube 01/01/04 2 68.81 50.02 0 1 2-17-91 OPEN

43761 Reposition gastrostomy tube 01/01/00 2 82.44 78.76 0

43800 Reconstruction of pylorus 01/01/00 2 473.01 419.35 45

43810 Fusion of stomach and bowel 01/01/00 2 511.64 454.96 45



43830 Place gastrostomy tube 01/01/00 2 359.33 287.46 45



43840 Repair of stomach lesion 01/01/00 2 537.02 471.71 45

43842 Gastroplasty for obesity 05/01/94 1 NC

43843 Gastroplasty for obesity 05/01/94 1 NC43845 Gastroplasty duodenal switch 01/01/05 1 NC

43846 Gastric bypass for obesity 05/01/94 1 NC

43847 Gastric bypass for obesity 01/01/95 1 NC

43848 Revision of gastric bypass for obesity 01/01/95 1 NC

43850 Revise stomach-bowel fusion 01/01/00 2 845.75 757.92 60

5101:3-1-60 Page 88










43870 Repair stomach opening 01/01/00 2 357.17 317.93 45 1 2-17-91 OPEN

43880 Repair stomach-bowel fistula 01/01/00 2 770.77 668.25 90

43999 Stomach surgery procedure 05/01/94 1 BR 0

44005 Freeing of bowel adhesion 01/01/00 2 603.02 533.72 45

44010 Incision of small bowel 01/01/00 2 481.79 415.37 60

44015 Insert needle catheter,bowel 07/01/02 2 134.14 141.26 90

44020 Exploration of small bowel 01/01/00 2 537.46 476.53 60

44021 Decompress small bowel 01/01/00 2 521.89 457.12 60

44025 Incision of large bowel 01/01/00 2 541.30 483.05 60

44050 Reduce bowel obstruction 01/01/00 2 521.19 460.00 90

44055 Correct malrotation of bowel 01/01/00 2 567.61 501.38 60

44100 Biopsy of bowel 01/01/00 2 87.53 83.00 7 1 2-17-91 OPEN

44110 Excision of bowel lesion(s) 01/01/00 2 481.49 431.22 60

44111 Excision of bowel lesion(s) 01/01/00 2 596.32 540.00 60

44120 Removal of small intestine 01/01/00 2 651.23 582.59 60



44126 Enterectomy sm intestine, w/o taper 01/01/02 1 1,423.71 90

44127 Enterectomy sm intestine, cong,w taper 01/01/02 1 1,637.38 90

44128 Enterectomy sm intest,,ea added resec 01/01/02 1 176.74 90

44130 Bowel to bowel fusion 01/01/00 2 571.96 511.06 90

44132 Enterectomy, cadaver donor 01/01/01 3 NC 90

44133 Enterectomy, live donor 01/01/01 3 NC 90

44135 Intestine transplnt, cadaver 01/01/01 3 NC 90

44136 Intestine transplant, live 01/01/01 3 NC 9044137 Remove intestinal allograft 01/01/05 1 BR 0

44139 Mobilization of colon 01/01/00 2 92.61 87.06 90

44140 Partial removal of colon 01/01/00 2 807.52 727.49 90





44146 Partial removal of colon 01/01/00 2 1,077.29 954.59 90


44150 Removal of colon 01/01/00 2 986.03 875.80 90

5101:3-1-60 Page 89







44151 Removal of colon/ileostomy 01/01/00 2 850.67 720.02 90

44152 Removal of colon/ileostomy 01/01/00 2 1,108.36 988.91 90

44153 Removal of colon/ileostomy 01/01/00 2 1,254.18 1,125.89 90

44155 Removal of colon 01/01/00 2 1,125.54 998.66 90

44156 Removal of colon/ileostomy 01/01/00 2 964.52 815.50 90

44160 Removal of colon 01/01/00 2 765.33 689.82 90

44200 Laparoscopic enterolysis 01/01/00 1 619.9 90

44201 Laparoscopic jejunostomy 07/01/03 2 388.12 BR 90

44202 Laparoscopic intestinal resection 01/01/00 1 956.53 90

44203 Laparoscopic resection sm intestine 01/01/02 1 172.13 90

44204 Laparoscopic part colectomy,w amastom 01/01/02 1 988.24 90

44205 Laparoscopic part colec, w. rem ileum 01/01/02 1 875.30 90

44206 Laparo colect part w/colost clo dist seg 07/01/03 1 1017.00 90

44207 Laparo colect part w/anasto w/coloproc 07/01/03 1 1113.52 90

44208 Lap colect part with anas/coloproc/colos 07/01/03 1 1203.54 90

44209 Unlisted laparoscopy, procedure, intestine 07/01/03 3 NC BR 14

44210 Lap colect tot abdo w/o proc 07/01/03 1 1065.26 90

44211 Lap colect tot abdo w/proc 07/01/03 1 1322.88 90

44212 Lap colect tot abdo w/proc w/ileostomy 07/01/03 1 1235.97 90

44238 Laparoscope proc, intestine 07/01/03 1 900.00 90

44239 Laparoscope proc, rectum 07/01/03 1 1200.00 90

44300 Open bowel to skin 01/01/00 2 412.15 356.72 30

44310 Ileostomy/jejunostomy 01/01/00 2 546.00 463.49 60

44312 Revision of ileostomy 01/01/00 2 249.54 209.82 30 1 2-17-91 OPEN

44314 Revision of ileostomy 01/01/00 2 497.36 417.52 30

44316 Devise bowel pouch 01/01/00 2 695.66 582.26 90

44320 Colostomy 01/01/00 2 576.57 483.34 60

44322 Colostomy with biopsies 01/01/00 2 590.63 501.95 60

44340 Revision of colostomy 01/01/00 2 206.64 165.31 7 3 2-17-91 OPEN

44345 Revision of colostomy 01/01/00 2 455.41 377.76 60 4 2-17-91 12/31/03

44346 Revision of colostomy 01/01/00 2 531.62 453.81 60 4 2-17-91 12/31/03

44360 Small bowel endoscopy 07/01/02 2 144.98 153.47 0 2 2-17-91 OPEN

44361 Small bowel endoscopy,biopsy 07/01/02 2 159.10 169.36 5 2 2-17-91 OPEN






5101:3-1-60 Page 90







44370 Small bowel endoscopy/stent 01/01/01 1 172.45 0 9 01/01/04 OPEN



44376 Small bowel endoscopy 01/01/00 2 246.19 235.49 14 2 01/01/97 OPEN



44379 S bowel endoscope w/stent 01/01/01 1 281.77 0 9 01/01/04 OPEN



44383 Ileoscopy w/stent 01/01/01 1 96.12 0 9 01/01/04 OPEN

44385 Endoscopy of bowel pouch 01/01/00 2 120.04 105.42 0 1 2-17-91 OPEN

44386 Endoscopy,bowel pouch,biopsy 01/01/00 2 112.25 89.80 0 1 2-17-91 OPEN

44388 Colon endoscopy 01/01/00 2 180.98 162.65 0 1 2-17-91 OPEN

44389 Colonoscopy with biopsy 01/01/00 2 198.19 177.71 0 1 2-17-91 OPEN

44390 Colonoscopy for foreign body 01/01/00 2 179.34 158.99 0 1 2-17-91 OPEN

44391 Colonoscopy for bleeding 01/01/00 2 246.03 237.02 0 1 2-17-91 OPEN

44392 Colonoscopy & polypectomy 01/01/00 2 246.16 227.05 0 1 2-17-91 OPEN

44393 Colonoscopy, lesion removal 01/01/00 2 276.81 257.24 0 1 1-1-96 OPEN

44394 Colonoscopy w/snare 01/01/00 2 262.75 241.70 14 1 2-17-91 OPEN

44397 Colonoscopy w stent 01/01/01 1 180.20 0

44500 Intro, gastrointestinal tube 01/01/00 2 21.88 20.47 0

44602 Suture, small intestine 01/01/00 2 497.36 448.83 14

44603 Suture, small intestine 01/01/00 2 630.21 567.60 14

44604 Suture, large intestine 01/01/00 2 607.80 532.44 45

44605 Repair of bowel lesion 01/01/00 2 677.21 598.79 90

44615 Intestinal stricturoplasty 01/01/00 2 580.55 502.96 45

44620 Repair bowel opening 01/01/00 2 462.66 399.73 90

44625 Repair bowel opening 01/01/00 2 623.22 560.37 90

44626 Closure of enterostomy with resection 01/01/00 2 924.57 863.20 90

44640 Repair bowel-skin fistula 01/01/00 2 592.12 503.61 90

44650 Repair bowel fistula 01/01/00 2 622.12 534.49 90

44660 Repair bowel-bladder fistula 01/01/00 2 618.74 536.25 90

44661 Repair bowel-bladder fistula 01/01/00 2 824.99 752.33 90

44680 Surgical revision, intestine 01/01/00 2 640.85 573.57 90

44700 Suspension of bowel with prosthesis 01/01/00 2 697.89 665.33 90

44701 Intraop colon lavage add-on 07/01/03 1 110.78 9044715 Prepare donor intestine 01/01/05 1 BR 044720 Prep donor intestine/venous 01/01/05 1 198.11 0

5101:3-1-60 Page 91






APPR VISIT CODE DESCRIPTION DATE CODE PRICE PRICE INDIC. DAYS GROUP DATE DATE GROUP DATE DATE44721 Prep donor intestine/artery 01/01/05 1 289.63 0

44799 Intestine surgery procedure 05/01/94 1 BR 0

44800 Excision of bowel pouch 01/01/00 2 453.32 389.82 45

44820 Excision of mesentery lesion 01/01/00 2 441.90 386.43 45

44850 Repair of mesentery 01/01/00 2 417.39 365.02 45

44899 Bowel surgery procedure 05/01/94 1 BR 0

44900 Drainage of appendix abscess 01/01/00 2 365.14 308.60 45

44901 Percutaneous incis. & drain. of appendix abscess 01/01/00 2 165.75 147.19 14

44950 Appendectomy 01/01/00 2 353.21 282.57 14

44955 Appendectomy 07/01/02 2 79.74 90.09 45

44960 Appendectomy 01/01/00 2 457.71 400.53 45

44970 Laparoscopy, appendectomy 01/01/00 1 353.21 90

44979 Unlisted laparoscopy, procedure, appendix 01/01/00 1 BR 14

45000 Drainage of pelvic abscess 01/01/00 2 175.14 145.09 15 1 2-17-91 OPEN

45005 Drainage of rectal abscess 01/01/00 2 102.24 81.79 15 2 2-17-91 OPEN

45020 Drainage of rectal abscess 01/01/00 2 205.43 178.07 30 2 2-17-91 OPEN

45100 Biopsy of rectum 01/01/00 2 164.03 132.88 0 1 2-17-91 OPEN

45108 Removal of anorectal lesion 01/01/00 2 218.18 176.84 30 2 2-17-91 OPEN

45110 Removal of rectum 01/01/00 2 1,086.94 979.52 90

45111 Partial removal of rectum 01/01/00 2 769.94 690.86 90

45112 Removal of rectum 01/01/00 2 1,140.69 1,028.01 90

45113 Partial proctectomy 01/01/00 2 1,138.35 1,044.09 90

45114 Partial removal of rectum 01/01/00 2 1,048.15 941.98 90

45116 Partial removal of rectum 01/01/00 2 867.47 763.20 90

45119 Proctectomy with colonic reservoir 01/01/00 2 1,147.69 1,081.65 90

45120 Removal of rectum 01/01/00 2 1,113.63 1,010.32 90

45121 Removal of rectum and colon 01/01/00 2 1,038.36 896.23 90

45123 Partial proctectomy 01/01/00 2 702.40 650.04 90

45126 Pelvic exenteration 01/01/00 2 1,209.57 1,366.92 90

45130 Excision of rectal prolapse 01/01/00 2 620.36 561.56 90

45135 Excision of rectal prolapse 01/01/00 2 868.36 821.10 90

45136 Excison of ileoanal reservoir 01/01/02 1 1,113.67 90

45150 Excision of rectal stricture 01/01/00 2 254.71 219.31 90 2 2-17-91 OPEN

45160 Excision of rectal lesion 01/01/00 2 559.88 505.89 90 2 01/01/04 OPEN

45170 Excision of rectal lesion 01/01/00 2 395.11 355.36 60 2 2-17-91 OPEN

45190 Destruction rectal tumor 01/01/00 2 364.49 332.82 60 9 01/01/04 OPEN

45300 Proctosigmoidoscopy 01/01/00 2 38.90 31.12 0

45303 Proctosigmoidoscopy 01/01/00 2 37.04 29.63 0

5101:3-1-60 Page 92







45305 Proctosigmoidoscopy; biopsy 01/01/00 2 58.68 46.94 0 1 2-17-91 OPEN

45307 Proctosigmoidoscopy 01/01/00 2 93.20 74.56 0 1 2-17-91 OPEN







45327 Proctosigmoidoscopy w/stent 01/01/01 1 67.43 0

45330 Sigmoidoscopy, diagnostic 01/01/00 2 67.65 54.12 0 1 1-4-88 9/30/04

45331 Sigmoidoscopy and biopsy 01/01/00 2 88.43 70.74 0 1 2-17-91 OPEN

45332 Sigmoidoscopy 01/01/00 2 114.03 91.22 0 1 2-17-91 OPEN

45333 Sigmoidoscopy & polypectomy 01/01/00 2 128.30 104.70 0 1 2-17-91 OPEN

45334 Sigmoidoscopy for bleeding 07/01/02 2 141.45 142.68 0 1 2-17-91 OPEN

45335 Sigmoidoscope w/submuc inj 07/01/03 1 97.29 0 1 01/01/04 OPEN

45337 Sigmoidoscopy, decompression 07/01/02 2 122.75 126.37 0 1 2-17-91 OPEN



45340 Sig w/balloon dilation 07/01/03 1 220.26 0 1 01/01/04 OPEN

45341 Sigmoidoscopy w/ultrasound 07/01/02 1 147.76 150.07 0

45342 Sigmoidoscopy w/us guide bx 01/01/01 1 173.02 0

45345 Sigmodoscopy w/stent 01/01/01 1 115.92 0

45355 Surgical colonoscopy 01/01/00 2 126.89 113.72 0 1 2-17-91 OPEN

45378 Diagnostic colonoscopy 07/01/02 2 199.74 216.79 0 2 2-17-91 OPEN

45379 Colonoscopy 01/01/00 2 270.38 246.18 0 2 2-17-91 OPEN

45380 Colonoscopy and biopsy 01/01/00 2 237.81 215.56 0 2 2-17-91 OPEN

45381 Colonoscope, submucous inj 07/01/03 1 263.59 0 2 01/01/04 OPEN

45382 Colonoscopy,control bleeding 01/01/00 2 308.92 281.72 0 2 2-17-91 OPEN


45384 Colonoscopy 01/01/00 2 269.18 279.07 14 2 2-17-91 OPEN


45386 Colonoscope dilate stricture 07/01/03 1 497.09 0 2 01/01/04 OPEN

45387 Colonoscopy w/stent 01/01/01 1 235.00 045391 Colonoscopy w/endoscope us 01/01/05 1 208.91 045392 Colonoscopy w/endoscopic fnb 01/01/05 1 263.77 0

45500 Repair of rectum 01/01/00 2 358.21 324.53 90 2 2-17-91 OPEN

45505 Repair of rectum 01/01/00 2 326.41 307.57 90 2 2-17-91 OPEN

45520 Treatment of rectal prolapse 01/01/00 2 31.71 29.64 0

5101:3-1-60 Page 93







45540 Correct rectal prolapse 01/01/00 2 618.28 566.32 90

45541 Correct rectal prolapse 01/01/00 2 556.83 518.59 90

45550 Repair rectum;remove sigmoid 01/01/00 2 804.38 643.50 90

45560 Repair of rectocele 01/01/00 2 363.52 313.63 60 2 2-17-91 OPEN

45562 Exploration/ repair of rectum 01/01/00 2 548.36 491.70 60

45563 Exploration/ repair of rectum 01/01/00 2 847.28 775.59 60

45800 Repair rectumbladder fistula 01/01/00 2 634.58 566.70 90

45805 Repair fistula; colostomy 01/01/00 2 776.35 703.48 90

45820 Repair rectourethral fistula 01/01/00 2 626.41 555.42 90

45825 Repair fistula; colostomy 01/01/00 2 725.49 638.01 90

* 45900 Reduction of rectal prolapse 01/01/04 2 102.20 67.63 10 1 2-17-91 OPEN

* 45905 Dilation of anal sphincter 01/01/04 2 182.43 69.35 10 1 2-17-91 OPEN

* 45910 Dilation of rectal narrowing 01/01/04 2 245.92 84.74 10 1 2-17-91 OPEN

* 45915 Remove rectal obstruction 01/01/04 2 211.19 87.80 10 1 2-17-91 OPEN

45999 Rectum surgery procedure 05/01/94 1 BR 0

46020 Placement of anal seton 01/01/02 1 162.62 10 3 1-1-02 OPEN

46030 Removal of rectal marker 01/01/00 2 49.64 39.71 15 1 2-17-91 OPEN

46040 Incision of rectal abscess 01/01/00 2 194.17 164.80 15 3 2-17-91 OPEN


* 46050 Incision of anal abscess 01/01/04 2 127.02 54.80 10 1 2-17-91 OPEN


46070 Incision of anal septum 01/01/00 2 119.23 102.75 7

* 46080 Incision of anal sphincter 01/01/04 2 167.96 130.78 10 3 2-17-91 OPEN

46083 Incise external hemorrhoid 01/01/00 2 61.00 48.80 14

46200 Removal of anal fissure 01/01/00 2 185.17 164.23 90 2 2-17-91 OPEN

46210 Removal of anal crypt 01/01/00 2 102.01 81.61 30 2 2-17-91 OPEN

46211 Removal of anal crypts 01/01/00 2 182.81 150.67 90 2 2-17-91 OPEN

46220 Removal of anal tab 01/01/00 2 61.89 53.66 15 1 2-17-91 OPEN

46221 Ligation of hemorrhoid(s) 01/01/00 2 64.66 51.73 15

46230 Removal of anal tabs 01/01/00 2 103.09 82.47 15

46250 Hemorrhoidectomy 01/01/00 2 210.78 180.92 90 3 2-17-91 OPEN


46257 Remove hemorrhoids & fissure 01/01/00 2 309.46 287.53 90 3 2-17-91 OPEN

46258 Remove hemorrhoids & fistula 01/01/00 2 336.54 315.04 30 3 2-17-91 OPEN


46261 Remove hemorrhoids & fissure 01/01/00 2 398.84 341.89 90 4 2-17-91 OPEN

46262 Remove hemorrhoids & fistula 01/01/00 2 416.51 350.96 90 4 2-17-91 OPEN

46270 Removal of anal fistula 01/01/00 2 164.22 136.28 30 3 2-17-91 OPEN

5101:3-1-60 Page 94










46288 Repair anal fistula 01/01/00 2 296.71 266.42 60 4 01/01/04 OPEN

46320 Removal of hemorrhoid clot 01/01/00 2 70.85 56.68 0

46500 Injection into hemorrhoids 01/01/00 2 56.94 45.55 0

46600 Diagnostic anoscopy 01/01/00 2 22.99 19.15 0 1 2-17-91 9/30/04

46604 Anoscopy and dilation 01/01/00 2 47.72 41.64 0

46606 Anoscopy and biopsy 01/01/00 2 33.91 29.18 0

46608 Anoscopy;remove foreign body 01/01/00 2 72.28 63.68 0 1 2-17-91 OPEN

46610 Anoscopy; remove lesion 01/01/00 2 62.04 54.87 0 1 2-17-91 OPEN

46611 Anoscopy 01/01/00 2 76.88 66.64 14 1 2-17-91 OPEN

46612 Anoscopy; remove lesions 01/01/00 2 103.41 92.93 0 1 2-17-91 OPEN

46614 Anoscopy; control bleeding 01/01/00 2 96.69 89.93 0

46615 Anoscopy 01/01/00 2 115.74 106.01 14 2 01/01/04 OPEN

46700 Repair of anal stricture 01/01/00 2 359.39 325.06 90 3 2-17-91 OPEN

46705 Repair of anal stricture 01/01/00 2 302.77 254.77 90

46706 Repr of anal fistula w/glue 07/01/03 1 95.73 10

46715 Repair of anovaginal fistula 01/01/00 2 307.21 262.40 60

46716 Repair of anovaginal fistula 01/01/00 2 505.04 451.46 60

46730 Construction of absent anus 01/01/00 2 893.59 801.40 90

46735 Construction of absent anus 01/01/00 2 1,084.26 972.46 90

46740 Construction of absent anus 01/01/00 2 952.20 861.41 60

46742 Repair, imperforated anus 01/01/00 2 1,299.20 1,166.95 45

46744 Repair, cloacal anomaly 01/01/00 2 1,454.45 1,310.06 45



46750 Repair of anal sphincter 01/01/00 2 384.72 344.17 60 3 2-17-91 OPEN

46751 Repair of anal sphincter 01/01/00 2 356.23 303.67 60

46753 Reconstruction of anus 01/01/00 2 309.78 282.35 30 3 2-17-91 OPEN

46754 Removal of suture from anus 01/01/00 2 97.00 77.60 0 2 2-17-91 OPEN

46760 Repair of anal sphincter 01/01/00 2 501.87 445.51 90 2 2-17-91 OPEN

46761 Repair of anal sphincter 01/01/00 2 483.49 433.86 60 3 01/01/04 OPEN

46762 Implant artificial sphincter 01/01/00 2 431.40 383.40 60 7 01/01/04 OPEN

* 46900 Destruction, anal lesion(s) 01/01/04 2 145.09 67.34 10

* 46910 Destruction, anal lesion(s) 01/01/04 2 151.80 75.09 10

46916 Cryosurgery, anal lesion(s) 01/01/00 2 75.31 60.25 0

46917 Laser surgery,anal lesion(s) 01/01/00 2 113.69 95.53 0 1 01/01/04 OPEN

5101:3-1-60 Page 95







46922 Excision of anal lesion(s) 01/01/00 2 96.11 78.46 0 1 2-17-91 OPEN

46924 Destruction, anal lesion(s) 01/01/00 2 155.36 135.08 0 1 2-17-91 OPEN

46934 Destruction of hemorrhoids 01/01/00 2 154.55 123.64 0



46937 Cryotherapy of rectal lesion 01/01/00 2 145.14 128.84 0 2 2-17-91 OPEN

46938 Cryotherapy of rectal lesion 01/01/00 2 201.17 176.30 0 2 2-17-91 OPEN

46940 Treatment of anal fissure 01/01/00 2 85.51 68.89 0

46942 Treatment of anal fissure 01/01/00 2 74.59 60.78 14

46945 Ligation of hemorrhoids 01/01/00 2 87.97 90.88 15

46946 Ligation of hemorrhoids 01/01/00 2 120.87 122.74 1446947 Hemorrhoidopexy by stapling 01/01/05 1 240.74 90

46999 Anus surgery procedure 05/01/94 1 BR 0

* 47000 Needle biopsy of liver 01/01/04 2 268.77 101.03 0 1 2-17-91 OPEN

47001 Needle biopsy, liver 01/01/00 2 84.69 80.82 0

47010 Drainage of liver lesion 01/01/00 2 472.43 392.58 60

47011 Hepatotomy for percutaneous drainage 01/01/00 2 194.96 161.12 60

47015 Inject/aspirate liver cyst 01/01/00 2 448.06 393.31 60

47100 Wedge biopsy of liver 01/01/00 2 303.09 254.06 45

47120 Partial removal of liver 01/01/00 2 958.80 816.39 45

47122 Extensive removal of liver 01/01/00 2 1,457.03 1,273.06 42

47125 Partial removal of liver 01/01/00 2 1,342.55 1,177.47 45

47130 Partial removal of liver 01/01/00 2 1,458.46 1,293.83 45

47133 Removal of donor liver 05/01/94 1 NC

47134 Partial removal, donaor liver 01/01/04 3 NC 1,628.22 90

47135 Transplantation of liver 07/01/03 2 3,332.77 BR 90

47136 Transplantation of liver 01/01/00 2 2,888.72 75.73 90

47140 Partial Removal, Donor Liver 01/01/04 1 2116.99 90

47141 Partial Removal, Donor Liver 01/01/04 1 2558.10 90

47142 Partial Removal, Donor Liver 01/01/04 1 2816.33 9047143 Prep donor liver, whole 01/01/05 1 BR 047144 Prep donor liver, 3-segment 01/01/05 1 BR 9047145 Prep donor liver, lobe split 01/01/05 1 BR 9047146 Prep donor liver/venous 01/01/05 1 248.13 047147 Prep donor liver/arterial 01/01/05 1 289.63 0

47300 Surgery for liver lesion 01/01/00 2 475.29 425.23 60

47350 Repair liver wound 01/01/00 2 548.21 478.90 45

47355 Repair liver wound 04/01/96 3 NC 447.02 45

5101:3-1-60 Page 96








47361 Repair liver wound 01/01/00 2 1,237.46 1,092.50 90


47370 Laparosc radiofreq ablat l tumor, radio 01/01/02 1 689.05 90

47371 Laparosc radiofreq ablat l tumor, cyro 01/01/02 1 649.69 90

47379 Laparoscope procedure, liver 01/01/01 2 BR 90

47380 Ablation of liver tumor, 1 or more 01/01/02 1 809.32 90

47381 Open cryosurgical ablation liver tumor 01/01/02 1 800.09 90

47382 Perc radiofreq ablation liver tumor 01/01/02 1 481.63 10

47399 Liver surgery procedure 05/01/94 1 BR

47400 Incision of liver duct 01/01/00 2 808.58 682.71 45

47420 Incision of bile duct 01/01/00 2 717.95 634.15 45

47425 Incision of bile duct 01/01/00 2 774.38 684.15 60

47460 Incise bile duct sphincter 01/01/00 2 792.20 746.25 60

47480 Incision of gallbladder 01/01/00 2 459.23 406.83 45

47490 Incision of gallbladder 01/01/00 2 295.01 236.01 7

47500 Injection for liver x-rays 01/01/00 2 86.95 85.02 0

47505 Injection for liver x-rays 01/01/00 2 55.16 44.13 0

47510 Insert catheter, bile duct 01/01/00 2 311.48 249.18 7 2 2-17-91 OPEN

47511 Insert bile duct drain 01/01/00 2 387.13 309.70 0 9 01/01/04 OPEN

47525 Change bile duct catheter 01/01/00 2 197.45 170.19 0 1 2-17-91 OPEN

47530 Revise, reinsert bile tube 01/01/00 2 211.41 169.13 0 1 2-17-91 OPEN

47550 Bile duct endoscopy 01/01/00 2 123.96 116.95 90

47552 Biliary endoscopy, thru skin 01/01/00 2 200.96 181.35 0 2 2-17-91 OPEN




47556 Biliary endoscopy, thru skin 01/01/00 2 295.18 273.08 0

47560 Peritoneoscopy w/cholangio 01/01/00 1 199.7 90 3 1-1-01 OPEN

* 47561 Peritoneoscopy w/biopsy 01/01/00 1 237.91 0 3 1-1-01 OPEN

47562 Laparoscopic cholecystectomy 01/01/00 1 515.68 90



47570 Laparoscopy, cholecystoenterostomy 01/01/00 1 588.14 90

47579 Unlisted laparoscopy, procedure, biliary tract 01/01/00 1 BR 14

47600 Removal of gallbladder 01/01/00 2 517.29 468.13 45



5101:3-1-60 Page 97









47630 Remove bile duct stone 01/01/00 2 335.88 295.13 7 3 2-17-91 OPEN

47700 Exploration of bile ducts 01/01/00 2 623.76 544.13 60

47701 Bile duct revision 01/01/00 2 1,024.61 873.33 60

47711 Excision of bile duct tumor 01/01/00 2 857.39 773.30 60

47712 Excision of bile duct tumor 01/01/00 2 1,032.63 907.30 60

47715 Excision of bile duct cyst 01/01/00 2 663.20 578.89 42

47716 Fusion of bile duct cyst 01/01/00 2 570.37 489.19 42

47720 Fuse gallbladder & bowel 01/01/00 2 616.66 543.45 60

47721 Fuse upper gi structures 01/01/00 2 750.26 668.93 60



47760 Fuse bile ducts and bowel 01/01/00 2 914.68 807.34 90

47765 Fuse liver ducts & bowel 01/01/00 2 968.61 865.48 90

47780 Fuse bile ducts and bowel 01/01/00 2 965.56 856.96 90

47785 Fuse gallbladder & bowel 01/01/00 2 1,083.31 953.25 90

47800 Reconstruction of bile ducts 01/01/00 2 885.69 788.16 90

47801 Placement, bile duct support 01/01/00 2 505.91 416.28 60

47802 Fuse liver duct & intestine 01/01/00 2 776.15 662.86 60

47900 Suture bile duct injury 01/01/00 2 803.13 738.21 90

47999 Bile tract surgery procedure 05/01/94 1 BR 0

48000 Drainage of abdomen 01/01/00 2 614.07 510.74 60

48001 Placement of drain, pancreas 01/01/00 2 755.39 606.38 45

48005 Resect/debride pancreas 01/01/00 2 857.04 685.63 45

48020 Removal of pancreatic stone 01/01/00 2 585.79 506.03 60

48100 Biopsy of pancreas 01/01/00 2 425.62 360.67 60

48102 Needle biopsy, pancreas 01/01/00 2 209.54 167.63 1 1 2-17-91 OPEN

48120 Removal of pancreas lesion 01/01/00 2 655.83 581.14 60

48140 Partial removal of pancreas 01/01/00 2 926.63 813.36 90

48145 Partial removal of pancreas 01/01/00 2 1,011.33 896.56 90

48146 Pancreatectomy 01/01/00 2 1,069.48 946.21 45

48148 Removal of pancreatic duct 01/01/00 2 658.49 576.19 60

48150 Partial removal of pancreas 01/01/00 2 1,810.60 1,600.67 90

48152 Pancreatectomy 01/01/00 2 1,710.15 1,510.62 45

48153 Pancreatectomy 01/01/00 2 1,807.22 1,600.67 45

48154 Pancreatectomy 01/01/00 2 1,710.64 1,510.62 45

48155 Removal of pancreas 01/01/00 2 1,160.94 1,039.52 90

5101:3-1-60 Page 98







48160 Pancreas removal, transplant 05/01/94 1 BR 90

48180 Fuse pancreas and bowel 01/01/00 2 956.30 855.24 90

48400 Injection, intraoperative 01/01/00 2 80.43 76.39 14

48500 Surgery of pancreas cyst 01/01/00 2 609.99 525.60 60

48510 Drain pancreatic pseudocyst 01/01/00 2 562.12 477.77 60

48511 Drainage of pancreas pseudocyst 01/01/00 2 199.68 174.07 60

48520 Fuse pancreas cyst and bowel 01/01/00 2 688.30 630.60 60

48540 Fuse pancreas cyst and bowel 01/01/00 2 825.64 734.41 60

48545 Pancreatorrhaphy 01/01/00 2 670.76 571.77 45

48547 Duodenal exclusion 01/01/00 2 950.84 826.55 45

48550 Donor pancreatectomy 05/01/94 1 NC48551 Prep donor pancreas 01/01/05 1 BR 048552 Prep donor pancreas/venous 01/01/05 1 169.69 0

48554 Transplantallograft pancreas 07/01/03 2 1250.24 BR 90

48556 Removal, allograft pancreas 07/01/03 2 647.56 BR 45

48999 Pancreas surgery procedure 05/01/94 1 BR 0

49000 Exploration of abdomen 01/01/00 2 503.87 406.12 90 4 2-17-91 12/31/03

49002 Reopening of abdomen 01/01/00 2 455.17 394.28 90

49010 Exploration behind abdomen 01/01/00 2 524.26 460.31 90

49020 Drain abdominal abscess 01/01/00 2 438.10 350.48 90

49021 Drain peritoneal abscess 01/01/00 2 215.26 332.42 90


49041 Drainage of abdominal abscess 01/01/00 2 204.69 174.07 90


49061 Drainage of retroperitoneal abscess 01/01/00 2 192.27 161.12 90

49062 Drainage of lymphocele to peritoneal cavity 01/01/00 2 513.19 476.93 90

* 49080 Puncture, peritoneal cavity 01/01/04 2 152.98 67.84 0 2 2-17-91 OPEN

* 49081 Removal of abdominal fluid 01/01/04 2 115.88 61.40 0 2 2-17-91 OPEN

49085 Remove abdomen foreign body 01/01/00 2 345.55 285.78 90 2 2-17-91 OPEN

* 49180 Biopsy, abdominal mass 01/01/04 2 263.36 102.90 0 1 2-17-91 OPEN

49200 Removal of abdominal lesion 01/01/00 2 506.51 454.77 60

49201 Removal of abdominal lesion 01/01/00 2 733.67 665.73 60

49215 Excise sacral spine tumor 01/01/00 2 847.96 739.50 60

49220 Multiple surgery, abdomen 01/01/00 2 733.06 672.49 42

49250 Excision of umbilicus 01/01/00 2 354.82 305.53 60 4 1-1-96 OPEN

49255 Removal of omentum 01/01/00 2 304.73 243.78 45

49320 Pelvis laparoscopy, dx 01/01/00 1 258.46 10 3 1-1-01 OPEN

49321 Pelvic laparoscopy; biopsy 01/01/00 1 272.11 10 4 1-1-01 OPEN

5101:3-1-60 Page 99







49322 Laparoscopy; aspiration 01/01/00 1 290.2 10 4 1-1-01 OPEN

49323 Laparoscopic drainage to peritoneal cavity 01/01/00 1 422.04 90

49329 Unlisted laparoscopy procedure, abdomen 01/01/00 1 BR 14

* 49400 Air injection into abdomen 01/01/00 2 79.57 74.98 0 1 2-17-91 12/31/03

49419 Insrt abdom cath for chemotx 07/01/03 1 277.34 90

* 49420 Insert abdominal drain 01/01/00 2 100.62 94.38 0 1 2-17-91 OPEN

49421 Insert abdominal drain 01/01/00 2 265.61 232.31 0 1 2-17-91 OPEN

49422 Remove perm cannula/catheter 01/01/00 2 279.88 255.36 0 1 01/01/04 OPEN

49423 Exchange of drainage catheter 01/01/00 2 67.11 63.46 0

49424 Injection of contrast for assess via existing catheter 01/01/00 2 35.55 33.03 0

49425 Insert abdomen-venous drain 01/01/00 2 539.21 483.81 0 2 2-17-91 12/31/03

49426 Revise abdomen-venous shunt 01/01/00 2 413.64 355.76 30 2 2-17-91 OPEN

49427 Injection, abdominal shunt 01/01/00 2 36.72 33.30 0

49428 Ligation of shunt 01/01/00 2 96.41 77.33 0

49429 Removal of shunt 01/01/00 2 299.40 247.68 0

49491 Inguinal hernia repair-pret infant, hydro 01/01/02 1 469.41 90

49492 Inguinal hernia repair-pret infant,incar 01/01/02 1 577.20 90

49495 Repair inguinal hernia, init 01/01/00 2 291.22 276.61 45 4 01/01/04 OPEN


49500 Repair inguinal hernia 01/01/00 2 257.64 243.48 45 4 2-17-91 OPEN



49507 Repair, inguinal hernia 01/01/00 2 365.66 319.95 45 9 01/01/04 OPEN

49520 Rerepair inguinal hernia 01/01/00 2 368.40 336.10 45 7 2-17-91 OPEN

49521 Repair inguinal hernia, rec 01/01/00 2 419.56 368.69 45 9 01/01/04 OPEN


49540 Repair lumbar hernia 01/01/00 2 386.18 336.85 45 2 2-17-91 OPEN

49550 Repair femoral hernia 01/01/00 2 326.34 297.03 45 5 10/01/04 OPEN 4 2-17-91 9/30/04

49553 Repair femoral hernia, init 01/01/00 2 348.17 307.36 45 9 01/01/04 OPEN

49555 Repair femoral hernia 01/01/00 2 374.56 345.34 45 5 2-17-91 OPEN

49557 Repair femoral hernia, recur 01/01/00 2 424.60 379.92 45 9 01/01/04 OPEN

49560 Repair abdominal hernia 01/01/00 2 425.18 386.58 45 4 2-17-91 OPEN

49561 Repair incisional hernia 01/01/00 2 489.43 432.21 45 9 01/01/04 OPEN

49565 Rerepair abdominal hernia 01/01/00 2 445.94 407.96 45 4 2-17-91 OPEN

49566 Repair incisional hernia 01/01/00 2 512.26 453.59 45 9 01/01/04 OPEN

49568 Hernia repair w/mesh 01/01/00 2 202.45 190.73 45 7 01/01/04 OPEN

49570 Repair epigastric hernia 01/01/00 2 250.13 229.99 45 4 2-17-91 OPEN

49572 Repair, epigastric hernia 01/01/00 2 307.88 286.02 45 9 01/01/04 OPEN

5101:3-1-60 Page 100







49580 Repair umbilical hernia 01/01/00 2 203.00 196.22 45 4 2-17-91 OPEN

49582 Repair umbilical hernia 01/01/00 2 282.44 252.08 45 9 01/01/04 OPEN

49585 Repair umbilical hernia 01/01/00 2 265.29 242.44 45 4 2-17-91 OPEN

49587 Repair umbilical hernia 01/01/00 2 297.68 265.98 45 9 01/01/04 OPEN

49590 Repair abdominal hernia 01/01/00 2 351.42 316.53 45 3 2-17-91 OPEN

49600 Repair umbilical lesion 01/01/00 2 421.65 367.03 60 4 01/01/04 OPEN

49605 Repair umbilical lesion 01/01/00 2 863.96 766.56 60




49650 Laparoscopic hernia repair 01/01/00 1 292.58 90 4 1-1-01 OPEN

49651 Laparoscopic hernia repair 01/01/00 1 367.57 90 7 1-1-01 OPEN

49659 Unlisted laparoscopy procedure, hernia 01/01/00 1 BR 14

49900 Repair of abdominal wall 01/01/00 2 264.31 211.45 30

49904 Omental flap, extra-abdom 07/01/03 1 951.37 90

49905 Omental flap 01/01/00 2 273.12 255.52 30

49906 Free Omental Flap 01/01/97 1 BR 90

49999 Abdomen surgery procedure 05/01/94 1 BR 0

50010 Exploration of kidney 01/01/00 2 535.55 488.06 90

50020 Drainage of kidney abscess 01/01/00 2 593.11 474.49 90 2 2-17-91 12/31/03

50021 Drainage of renal abscess 01/01/00 2 183.99 147.19 90

50040 Drainage of kidney 01/01/00 2 601.02 510.68 90 3 2-17-91 12/31/03


50060 Removal of kidney stone 01/01/00 2 822.76 742.01 90

50065 Incision of kidney 01/01/00 2 903.70 822.74 90

50070 Incision of kidney 01/01/00 2 867.55 787.31 90

50075 Removal of kidney stone 01/01/00 2 1,094.18 1,002.95 90



50100 Revise kidney blood vessels 01/01/00 2 706.30 632.67 90


50125 Explore and drain kidney 01/01/00 2 716.40 651.20 90



* 50200 Biopsy of kidney 01/01/00 2 131.02 132.08 0 1 2-17-91 OPEN

50205 Biopsy of kidney 01/01/00 2 455.61 450.73 90 3 2-17-91 12-31-95

50220 Removal of kidney 01/01/00 2 789.50 723.24 90


5101:3-1-60 Page 101







50230 Removal of kidney 01/01/00 2 1,036.68 959.58 90

50234 Removal of kidney & ureter 01/01/00 2 1,006.93 928.10 90

50236 Removal of kidney & ureter 01/01/00 2 1,110.12 1,008.52 90

50240 Partial removal of kidney 01/01/00 2 994.98 893.67 90

50280 Removal of kidney lesion 01/01/00 2 693.66 628.16 90

50290 Removal of kidney lesion 01/01/00 2 627.48 561.02 90

50300 Removal of donor kidney 05/01/94 1 NC

50320 Removal of donor kidney 01/01/00 2 1,011.69 946.16 4250323 Prep cadaver renal allograft 01/01/05 1 BR 050325 Prep donor renal graft 01/01/05 1 BR 050327 Prep renal graft/venous 01/01/05 1 157.75 050328 Prep renal graft/arterial 01/01/05 1 138.14 050329 Prep renal graft/ureteral 01/01/05 1 131.88 0


50360 Transplantation of kidney 01/01/00 2 1,498.94 1,314.24 42

50365 Transplantation of kidney 01/01/00 2 1,774.40 1,579.76 42

50370 Remove transplanted kidney 01/01/00 2 667.34 567.96 42

50380 Reimplantation of kidney 01/01/00 2 837.44 669.95 42

* 50390 Drainage of kidney lesion 01/01/00 2 94.50 120.11 0 1 2-17-91 OPEN50391 Instll rx agnt into rnal tub 01/01/05 1 101.75 0

50392 Insert kidney drain 01/01/00 2 147.96 193.07 7 1 2-17-91 OPEN

50393 Insert ureteral tube 01/01/00 2 183.44 240.38 7 1 2-17-91 OPEN

50394 Injection for kidney x-ray 01/01/00 2 40.06 32.05 0 1 2-17-91 12-31-95

50395 Create passage to kidney 07/01/02 2 166.41 169.12 7 1 2-17-91 OPEN

50396 Measure kidney pressure 01/01/00 2 69.02 62.85 0 1 2-17-91 OPEN

* 50398 Change kidney tube 01/01/04 2 72.64 54.30 0 1 2-17-91 OPEN

50400 Revision of kidney/ureter 01/01/00 2 859.73 779.62 90

50405 Revision of kidney/ureter 01/01/00 2 1,072.87 977.14 90

50500 Repair of kidney wound 01/01/00 2 850.94 764.21 90

50520 Close kidney-skin fistula 01/01/00 2 741.59 656.17 90 1 2-17-91 12/31/03

50525 Repair renal-abdomen fistula 01/01/00 2 938.67 832.24 90

50526 Repair renal-abdomen fistula 01/01/00 2 892.07 759.19 90

50540 Revision of horseshoe kidney 01/01/00 2 870.95 804.44 90

50541 Laparoscopy, ablation of renal cysts 01/01/00 1 633.78 90

50542 Laparo ablate renal mass 07/01/03 1 750.56 90

50543 Laparo partial nephrectomy 07/01/03 1 944.10 90

50544 Laparoscopy, pyeloplasty 01/01/00 1 873.51 90

50545 Laparo radical nephrectomy 01/01/01 1 987.92 90

5101:3-1-60 Page 102







50546 Laparoscopy, nephrectomy 01/01/00 1 810.63 90

50547 Laparoscopy, donor nephrectomy 01/01/00 1 1040.74 90

50548 Laparoscopically assisted nephroureterectomy 01/01/00 1 950.95 90

50549 Unlisted laparoscopy procedure, renal 01/01/00 1 BR 14

50551 Kidney endoscopy 01/01/00 2 218.17 189.69 3 1 2-17-91 OPEN

50553 Kidney endoscopy 01/01/00 2 232.46 185.97 3 1 2-17-91 OPEN

50555 Kidney endoscopy & biopsy 01/01/00 2 344.13 275.30 3 1 2-17-91 OPEN

50557 Kidney endoscopy & treatment 01/01/00 2 337.40 278.70 3 1 2-17-91 OPEN

50559 Renal endoscopy; radiotracer 01/01/05 3 NC 220.11 3 1 2-17-91 OPEN

50561 Kidney endoscopy & treatment 01/01/00 2 389.16 311.33 3 1 2-17-91 OPEN

50562 Renal scope w/tumor resect 07/01/03 1 399.28 90

50570 Kidney endoscopy 01/01/00 2 298.93 265.67 3 1 2-17-91 12/31/03

50572 Kidney endoscopy 01/01/00 2 450.11 432.74 3 1 2-17-91 12/31/03

50574 Kidney endoscopy & biopsy 01/01/00 2 463.15 442.16 3 1 2-17-91 12/31/03

50575 Kidney endoscopy 01/01/00 2 609.62 586.54 14

50576 Kidney endoscopy & treatment 01/01/00 2 497.46 481.41 3 1 2-17-91 12/31/03

50578 Renal endoscopy; radiotracer 01/01/05 3 NC 419.24 3 1 2-17-91 12/31/03

50580 Kidney endoscopy & treatment 01/01/00 2 410.38 375.23 3 1 2-17-91 12/31/03

50590 Fragmenting of kidney stone 01/01/00 2 485.78 485.94 90 8 1-1-96 OPEN

50600 Exploration of ureter 01/01/00 2 671.45 601.30 90

50605 Insert ureteral support 01/01/00 2 580.67 500.21 90

50610 Removal of ureter stone 01/01/00 2 719.59 654.66 90



50650 Removal of ureter 01/01/00 2 768.33 698.77 90

50660 Removal of ureter 01/01/00 2 843.29 766.18 90

50684 Injection for ureter x-ray 01/01/00 2 38.35 30.68 0 1 2-17-91 12/31/03

50686 Measure ureter pressure 01/01/00 2 57.13 45.70 0

* 50688 Change of ureter tube 01/01/04 2 77.49 46.59 10 1 2-17-91 OPEN

50690 Injection for ureter x-ray 01/01/00 2 44.89 35.91 0 1 2-17-91 12/31/03

50700 Revision of ureter 01/01/00 2 718.11 657.69 90

50715 Release of ureter 01/01/00 2 807.28 716.52 90


50725 Release/revise ureter 01/01/00 2 814.54 730.05 90

50727 Revise ureter 01/01/00 2 363.27 317.06 90

50728 Revise ureter 01/01/00 2 526.47 466.78 90

50740 Fusion of ureter & kidney 01/01/00 2 828.49 755.68 90

50750 Fusion of ureter & kidney 01/01/00 2 871.36 787.42 90

5101:3-1-60 Page 103







50760 Fusion of ureters 01/01/00 2 830.28 755.53 90

50770 Splicing of ureters 01/01/00 2 897.60 821.39 90

50780 Reimplant ureter in bladder 01/01/00 2 833.98 762.09 90




50800 Implant ureter in bowel 01/01/00 2 750.87 687.10 90

50810 Fusion of ureter & bowel 01/01/00 2 871.89 766.39 90

50815 Urine shunt to bowel 01/01/00 2 1,030.71 955.58 90

50820 Construct bowel bladder 01/01/00 2 1,063.65 979.50 90

50825 Construct bowel bladder 01/01/00 2 1,489.73 1,409.17 60

50830 Revise urine flow 01/01/00 2 1,361.36 1,237.77 60

50840 Replace ureter by bowel 01/01/00 2 873.54 773.31 90

50845 Appendico-vesicostomy 01/01/00 2 909.09 818.97 45

50860 Transplant ureter to skin 01/01/00 2 686.83 614.16 90

50900 Repair of ureter 01/01/00 2 618.32 558.63 90

50920 Closure ureter/skin fistula 01/01/00 2 625.16 559.46 90

50930 Closure ureter/bowel fistula 01/01/00 2 812.26 738.60 90


50945 Laparoscopy, surgical, ureterolithotomy 01/01/00 1 670.03 90

50947 Laparo new ureter/bladder 01/01/01 1 1,062.52 90 9 01/01/04 OPEN

50948 Laparo new ureter/bladder 01/01/01 1 971.85 90 9 01/01/04 OPEN

50949 Laparoscope proc, ureter 01/01/01 2 BR 90

50951 Endoscopy of ureter 01/01/00 2 214.78 182.60 3 1 2-17-91 OPEN

50953 Endoscopy of ureter 01/01/00 2 239.65 191.72 3 1 2-17-91 OPEN

50955 Ureter endoscopy & biopsy 01/01/00 2 283.16 226.53 3 1 2-17-91 OPEN

50957 Ureter endoscopy & treatment 01/01/00 2 280.06 226.35 3 1 2-17-91 OPEN

50959 Ureter endoscopy & tracer 01/01/05 3 NC 198.11 3 1 2-17-91 OPEN


50970 Ureter endoscopy 01/01/00 2 314.59 302.43 3 1 2-17-91 OPEN

50972 Ureter endoscopy & catheter 01/01/00 2 227.73 204.59 3 1 2-17-91 OPEN

50974 Ureter endoscopy & biopsy 01/01/00 2 410.59 396.39 3 1 2-17-91 OPEN


50978 Ureter endoscopy & tracer 01/01/05 3 NC 236.69 3 1 2-17-91 OPEN


* 51000 Drainage of bladder 01/01/04 2 71.29 38.66 0

* 51005 Drainage of bladder 01/01/04 2 109.35 44.99 10 1 2-17-91 12/31/03

51010 Drainage of bladder 01/01/00 2 107.35 85.88 7 1 2-17-91 OPEN

5101:3-1-60 Page 104







51020 Incise & treat bladder 01/01/00 2 354.36 319.11 90 4 2-17-91 OPEN

51030 Incise & treat bladder 01/01/00 2 303.40 259.15 90 4 2-17-91 OPEN

51040 Incise & drain bladder 01/01/00 2 248.73 236.16 60 4 1-1-96 OPEN

51045 Incise bladder, drain ureter 01/01/00 2 313.67 270.72 30 4 2-17-91 OPEN

51050 Removal of bladder stone 01/01/00 2 363.10 325.01 90 4 01/01/04 OPEN


51065 Removal of ureter stone 01/01/00 2 417.92 372.62 30 4 01/01/04 OPEN

51080 Drainage of bladder abscess 01/01/00 2 296.35 262.39 90 1 01/01/04 OPEN

51500 Removal of bladder cyst 01/01/00 2 458.74 416.09 90 4 2-17-91 OPEN

51520 Removal of bladder lesion 01/01/00 2 463.20 425.08 90 4 01/01/04 OPEN

51525 Removal of bladder lesion 01/01/00 2 639.63 576.87 90

51530 Removal of bladder lesion 01/01/00 2 566.48 508.45 90

51535 Repair of ureter lesion 01/01/00 2 545.41 480.30 90

51550 Partial removal of bladder 01/01/00 2 689.95 618.03 90

51555 Partial removal of bladder 01/01/00 2 880.36 783.21 90

51565 Revise bladder & ureter(s) 01/01/00 2 972.52 883.74 90

51570 Removal of bladder 01/01/00 2 1,042.02 930.00 90

51575 Removal of bladder & nodes 01/01/00 2 1,374.56 1,248.80 90

51580 Remove bladder; revise tract 01/01/00 2 1,331.11 1,183.43 90

51585 Removal of bladder & nodes 01/01/00 2 1,558.88 1,407.38 90



51596 Remove bladder, create pouch 01/01/00 2 1,894.27 1,753.35 90

51597 Removal of pelvic structures 01/01/00 2 1,796.25 1,654.17 90

* 51600 Injection for bladder x-ray 01/01/04 2 149.01 35.34 0 1 2-17-91 12/31/03

51605 Preparation for bladder xray 01/01/00 2 43.41 34.73 0 1 2-17-91 12/31/03

51610 Injection for bladder x-ray 01/01/00 2 56.05 44.84 0 1 2-17-91 12/31/03

* 51700 Irrigation of bladder 01/01/04 2 55.52 33.31 0

51701 Insert bladder catheter 07/01/03 1 39.43 0

51702 Insert temp bladder cath 07/01/03 1 61.75 0

51703 Insert bladder cath, complex 07/01/03 1 86.65 0

* 51705 Change of bladder tube 01/01/04 2 65.85 41.81 10

* 51710 Change of bladder tube 01/01/04 2 144.56 61.96 10 1 2-17-91 OPEN

51715 Endoscopic injection/implant 01/01/00 2 177.23 157.03 45 3 01/01/04 OPEN

51720 Treatment of bladder lesion 01/01/00 2 73.24 58.59 0

51725 Simple cystometrogram 01/01/00 2 66.86 62.06 Q 0 1 2-17-91 12/31/03

51726 Complex cystometrogram 01/01/00 2 79.30 73.75 D 0 1 2-17-91 OPEN

51736 Urine flow measurement 01/01/00 2 26.84 30.53 Q 0

5101:3-1-60 Page 105







51741 Electro-uroflowmetry, first 01/01/00 2 45.72 51.98 Q 0

51772 Urethra pressure profile 01/01/00 2 68.92 62.87 D 0 1 1-1-96 OPEN

51784 Anal/urinary muscle study 01/01/00 2 68.23 63.22 D 0

51785 Anal/urinary muscle study 01/01/00 2 68.23 63.22 C 0 1 1-1-96 OPEN

51792 Urinary reflex study 01/01/00 2 82.62 75.46 K 0

51795 Urine voiding pressure study 01/01/00 2 80.70 73.61 M 0

51797 Intraabdominal pressure test 01/01/00 2 68.94 62.83 D 0

51798 Us urine capacity measure 07/01/03 1 13.49 0

51800 Revision of bladder/urethra 01/01/00 2 772.41 702.80 90

51820 Revision of urinary tract 01/01/00 2 696.36 602.18 90

51840 Attach bladder/urethra 01/01/00 2 524.45 476.88 45

51841 Attach bladder/urethra 01/01/00 2 632.45 578.96 45

51845 Repair bladder neck 01/01/00 2 523.39 489.21 45

51860 Repair of bladder wound 01/01/00 2 522.58 464.92 90

51865 Repair of bladder wound 01/01/00 2 681.67 617.86 90 4 2-17-91 12/31/03

51880 Repair of bladder opening 01/01/00 2 337.30 299.33 90 1 2-17-91 OPEN

51900 Repair bladder/vagina lesion 01/01/00 2 642.19 581.43 90 4 2-17-91 12/31/03

51920 Close bladder-uterus fistula 01/01/00 2 508.48 443.43 90 3 2-17-91 12/31/03

51925 Hysterectomy/bladder repair 01/01/00 2 706.46 627.18 90

51940 Correction of bladder defect 01/01/00 2 1,204.00 1,088.39 90

51960 Revision of bladder & bowel 01/01/00 2 1,140.20 1,053.01 90

51980 Construct bladder opening 01/01/00 2 497.06 439.44 7

51990 Laparoscopy, urethral suspension 01/01/00 1 518.72 90

51992 Laparoscopy, sling operation 01/01/00 1 564.86 90

52000 Cystoscopy 01/01/00 2 98.33 82.12 0 1 2-17-91 OPEN

52001 Cystourethroscopy- remove clots 01/01/02 1 96.92 0 2 1-1-02 OPEN

52005 Cystoscopy & ureter catheter 01/01/00 2 136.56 112.61 0 2 2-17-91 OPEN

52007 Cystoscopy and biopsy 01/01/00 2 147.87 143.87 0 2 2-17-91 OPEN

52010 Cystoscopy & duct catheter 01/01/00 2 148.70 120.88 3 2 2-17-91 OPEN

52204 Cystoscopy 01/01/00 2 144.89 117.22 0 2 2-17-91 OPEN

52214 Cystoscopy and treatment 01/01/00 2 190.98 159.98 7 2 2-17-91 OPEN





52250 Cystoscopy & radiotracer 01/01/00 2 190.11 180.57 30 4 2-17-91 OPEN

52260 Cystoscopy & treatment 01/01/00 2 157.88 147.78 30 2 2-17-91 OPEN

52265 Cystoscopy & treatment 01/01/00 2 125.12 104.91 30

5101:3-1-60 Page 106







52270 Cystoscopy & revise urethra 01/01/00 2 198.23 180.14 30 2 2-17-91 OPEN

52275 Cystoscopy & revise urethra 01/01/00 2 235.10 199.40 30 2 2-17-91 OPEN




52282 Cystourethroscopy with stent 01/01/00 2 306.49 269.58 0 9 01/01/04 OPEN





52301 Cystourethroscopy 01/01/00 2 232.23 209.52 1 2 01/01/97 OPEN




52317 Remove bladder stone 01/01/00 2 396.70 317.36 7 1 2-17-91 OPEN

52318 Remove bladder stone 01/01/00 2 430.93 419.74 7 2 2-17-91 OPEN


52325 Cystoscopy, stone removal 07/01/02 2 304.21 322.76 30 4 2-17-91 OPEN

52327 Cytoscopy, inject material 01/01/00 2 227.16 217.83 30 2 01/01/04 OPEN



52334 Create passage to kidney 01/01/00 2 209.77 200.47 7 3 1-1-96 OPEN

52335 Endoscopy of urinary tract 04/01/01 3 NC 267.80 7 3 2-17-91 OPEN

52336 Cystoscopy, stone removal 04/01/01 3 NC 365.35 30 4 2-17-91 OPEN

52337 Cystoscopy, stone removal 04/01/01 3 NC 421.47 15 4 2-17-91 OPEN

52338 Cystoscopy and treatment 04/01/01 3 NC 336.16 15 4 2-17-91 OPEN

52339 Cystoscopy and treatment 04/01/01 3 NC 377.20 30

52340 Cystoscopy and treatment 04/01/01 3 NC 393.85 30 3 2-17-91 OPEN

52341 Cysto w/ureter stricture tx 01/01/01 1 245.04 0 3 01/01/04 OPEN

52342 Cysto w/up stricture tx 01/01/01 1 265.13 0 3 01/01/04 OPEN

52343 Cysto w/renal stricture tx 01/01/01 1 293.82 0 3 01/01/04 OPEN

52344 Cysto/uretero, stone remove 01/01/01 1 313.91 0 3 01/01/04 OPEN

52345 Cysto/uretero w/up stricture 01/01/01 1 334.57 0 3 01/01/04 OPEN

52346 Cystouretero w/renal strict 01/01/01 1 376.46 0 3 01/01/04 OPEN

52347 Cystourethros-trans resect ejac ducts 01/01/05 3 NC 204.98 0

52351 Cystouretro & or pyeloscope 01/01/01 1 249.63 0 3 1-1-01 OPEN

52352 Cystouretro w/stone remove 01/01/01 1 308.46 0 4 1-1-01 OPEN

52353 Cystouretero w/lithotripsy 01/01/01 1 357.24 0 4 1-1-01 OPEN

5101:3-1-60 Page 107







52354 Cystouretero w/biopsy 01/01/01 1 313.05 0 4 1-1-01 OPEN

52355 Cystouretero w/excise tumor 01/01/01 1 368.14 0 4 01/01/04 OPEN

52400 Cystouretero w/congen repr 01/01/01 1 436.43 90 3 1-1-01 OPEN52402 Cystourethro cut ejacul duct 01/01/05 1 206.35 0

52450 Incision of prostate 01/01/00 2 341.57 295.41 45 3 1-1-96 OPEN

52500 Revision of bladder neck 01/01/00 2 418.33 375.55 90 3 2-17-91 OPEN

52510 Dilation prostatic urethra 01/01/00 2 367.41 337.87 90 3 01/01/04 OPEN

52601 Prostatectomy (turp) 01/01/00 2 624.83 576.24 90 4 2-17-91 OPEN

52606 Control postop bleeding 01/01/00 2 314.59 264.35 30 1 2-17-91 OPEN

52612 Prostatectomy, first stage 01/01/00 2 435.97 400.14 90 2 2-17-91 OPEN

52614 Prostatectomy, second stage 01/01/00 2 365.19 323.82 90 1 2-17-91 OPEN

52620 Remove residual prostate 01/01/00 2 320.09 279.41 90 1 2-17-91 OPEN

52630 Remove prostate regrowth 01/01/00 2 404.64 376.88 90 2 2-17-91 OPEN

52640 Relieve bladder contracture 01/01/00 2 342.99 307.26 60 2 2-17-91 OPEN

52647 Laser surgery of prostate 01/01/00 2 559.66 536.14 90 9 01/01/04 OPEN

52648 Laser surgery of prostate 01/01/00 2 592.53 556.55 90 9 01/01/04 OPEN

52700 Drainage of prostate abscess 01/01/00 2 281.36 235.33 60 2 2-17-91 OPEN

53000 Incision of urethra 01/01/00 2 115.85 92.68 15 1 2-17-91 OPEN



53025 Incision of urethra 01/01/00 2 59.24 47.39 7

53040 Drainage of urethra abscess 01/01/00 2 239.11 191.29 30 2 2-17-91 OPEN

53060 Drainage of urethra abscess 01/01/00 2 94.19 75.35 15

53080 Drainage of urinary leakage 01/01/00 2 295.89 243.05 15 3 01/01/04 OPEN

53085 Drainage of urinary leakage 01/01/00 2 466.67 403.75 60

53200 Biopsy of urethra 01/01/00 2 112.88 90.30 7 1 2-17-91 OPEN

53210 Removal of urethra 01/01/00 2 514.32 449.47 60 5 2-17-91 OPEN

53215 Removal of urethra 01/01/00 2 669.56 602.53 60 5 2-17-91 OPEN

53220 Treatment of urethra lesion 01/01/00 2 314.91 279.11 15 2 2-17-91 OPEN

53230 Removal of urethra lesion 01/01/00 2 456.40 417.78 60 2 2-17-91 OPEN

53235 Removal of urethra lesion 01/01/00 2 407.38 357.32 60 3 2-17-91 OPEN

53240 Surgery for urethra pouch 01/01/00 2 289.98 254.86 30 2 2-17-91 OPEN

53250 Removal of urethra gland 01/01/00 2 264.95 239.05 60 2 2-17-91 OPEN



53270 Removal of urethra gland 01/01/00 2 117.59 94.07 30 2 01/01/04 OPEN

53275 Repair of urethra defect 01/01/00 2 188.64 165.27 30 2 2-17-91 OPEN

53400 Revise urethra, 1st stage 01/01/00 2 536.54 472.58 60 3 2-17-91 OPEN

5101:3-1-60 Page 108







53405 Revise urethra, 2nd stage 01/01/00 2 651.01 596.16 60 2 2-17-91 OPEN

53410 Reconstruction of urethra 01/01/00 2 662.56 590.69 60 2 2-17-91 OPEN

53415 Reconstruction of urethra 01/01/00 2 804.14 743.84 30

53420 Reconstruct urethra, stage 1 01/01/00 2 648.37 593.40 60 3 2-17-91 OPEN

53425 Reconstruct urethra, stage 2 01/01/00 2 664.87 597.58 60 2 2-17-91 OPEN

53430 Reconstruction of urethra 01/01/00 2 630.63 555.57 60 2 2-17-91 OPEN

53431 Urethroplasty 01/01/02 1 769.41 90 2 1-1-02 OPEN

53440 Correct bladder function 01/01/00 2 652.57 610.54 60 2 2-17-91 OPEN

53442 Remove perineal prosthesis 01/01/00 2 375.25 334.23 30 1 2-17-91 OPEN

53443 Urethroplsty w/ tubulariz. 04/01/02 3 NC 791.36 60

53444 Insertion of tandem cuff 01/01/02 1 550.59 90 2 1-1-02 OPEN

53445 Correct urine flow control 01/01/00 2 761.12 750.71 60 1 1-1-02 OPEN

53446 Remove urethral/bladder n sphincter 01/01/02 1 507.15 90 1 1-1-02 OPEN

53447 Remove artificial sphincter 01/01/00 2 584.30 528.31 30 1 2-17-91 OPEN

53448 Remove/repl ureth/bladder n sphincter 01/01/02 1 916.84 90

53449 Correct artificial sphincter 01/01/00 2 470.51 432.36 45 1 2-17-91 OPEN

53450 Revision of urethra 01/01/00 2 244.81 206.63 30 1 2-17-91 OPEN


53500 Urethrlys, Transvag W/ Scope 01/01/04 1 494.60 90

53502 Repair of urethra injury 01/01/00 2 338.65 300.57 90 2 2-17-91 OPEN




53520 Repair of urethra defect 01/01/00 2 385.17 345.54 60 2 2-17-91 OPEN

* 53600 Dilate urethra stricture 01/01/04 2 57.49 46.66 0 1 2-17-91 9/30/04


53605 Dilate urethra stricture 01/01/00 2 47.46 42.49 0 2 2-17-91 OPEN



* 53640 Relieve bladder retention 01/01/00 3 NC 48.61 0

* 53660 Dilation of urethra 01/01/04 2 47.09 30.24 0

* 53661 Dilation of urethra 01/01/04 2 45.95 29.69 0

53665 Dilation of urethra 01/01/00 2 31.14 27.47 0 1 2-17-91 OPEN

* 53670 Insert urinary catheter 07/01/03 3 NC 21.91 0

* 53675 Insert urinary catheter 07/01/03 3 NC 59.10 0

53850 Prostatic microwave thermotherapy 01/01/00 2 429.95 396.74 0 9 01/01/04 OPEN

53852 Prostatic radiofrequency thermotherapy 01/01/00 2 448.51 414.67 0

53853 Prostatic water-induced thermotherapy 01/01/02 1 1,472.85 90

5101:3-1-60 Page 109







53899 Urology surgery procedure 05/01/94 1 BR 0

54000 Slitting of prepuce 01/01/00 2 64.89 51.91 0 2 01/01/04 OPEN

54001 Slitting of prepuce 01/01/00 2 91.01 72.81 21 2 2-17-91 OPEN

54015 Drain penis lesion 01/01/00 2 181.38 145.10 7 4 1-1-96 OPEN

* 54050 Destruction, penis lesion(s) 01/01/04 2 108.05 47.49 10

* 54055 Destruction, penis lesion(s) 01/01/04 2 180.69 54.99 10

54056 Cryosurgery, penis lesion(s) 01/01/00 2 52.08 41.66 0

54057 Laser surg, penis lesion(s) 01/01/00 2 79.01 68.54 7 1 2-17-91 OPEN

54060 Excision of penis lesion(s) 01/01/00 2 93.55 74.84 30 1 1-1-96 OPEN

54065 Destruction, penis lesion(s) 01/01/00 2 143.34 119.53 30 1 2-17-91 OPEN

54100 Biopsy of penis 01/01/00 2 77.76 62.21 7 1 2-17-91 OPEN

54105 Biopsy of penis 01/01/00 2 135.81 108.65 14 1 2-17-91 OPEN

54110 Treatment of penis lesion 01/01/00 2 438.73 384.82 60 2 2-17-91 OPEN

54111 Treat penis lesion, graft 01/01/00 2 605.29 546.64 60 2 01/01/04 OPEN

54112 Treat penis lesion, graft 01/01/00 2 707.54 639.44 60 2 01/01/04 OPEN

54115 Treatment of penis lesion 01/01/00 2 303.49 242.79 60 1 2-17-91 OPEN

54120 Partial removal of penis 01/01/00 2 444.05 385.01 60 2 2-17-91 OPEN

54125 Removal of penis 01/01/00 2 656.18 600.41 60 2 2-17-91 12/31/03

54130 Remove penis & nodes 01/01/00 2 906.46 821.80 90

54135 Remove penis & nodes 01/01/00 2 1,150.33 1,049.09 90

* 54150 Circumcision 01/01/04 2 104.74 70.39 10 1 01/01/04 OPEN

54152 Circumcision 01/01/00 2 109.85 100.81 15 1 2-17-91 OPEN

54160 Circumcision 01/01/00 2 126.88 101.50 30 2 01/01/04 OPEN

54161 Circumcision 01/01/00 2 144.15 132.60 30 2 2-17-91 OPEN

54162 Lysis of penile circumcision adhesions 01/01/02 1 159.64 10 2 1-1-02 OPEN

54163 Repair of incomplete circumcision 01/01/02 1 150.14 10 2 1-1-02 OPEN

54164 Frenulotomy of the penis 01/01/02 1 131.67 10 2 1-1-02 OPEN

* 54200 Treatment of penis lesion 01/01/04 2 104.74 40.38 10

54205 Treatment of penis lesion 01/01/00 2 354.40 302.00 60 4 1-1-96 OPEN 1 2-17-91 12-31-95

54220 Treatment of penis lesion 01/01/00 2 108.48 98.42 30 1 2-17-91

54230 Prepare penis study 07/01/02 2 66.42 66.64 0 3 1-1-96 9/30/04 1 2-17-91 12-31-95

54231 Dynamic cavernosometry 01/01/00 2 94.58 85.34 14

54235 Penile injection 01/01/00 2 45.71 39.39 4

54240 Penis study 01/01/00 2 62.08 57.06 D 0

54250 Penis study 01/01/00 2 81.37 67.27 Q 0

54300 Revision of penis 01/01/00 2 471.78 420.15 30 3 2-17-91 OPEN

54304 Revision of penis 01/01/00 2 568.54 511.41 60 3 01/01/04 OPEN

54308 Reconstruction of urethra 01/01/00 2 502.61 429.90 30 3 01/01/04 OPEN

5101:3-1-60 Page 110













54328 Revise penis, urethra 01/01/00 2 704.12 631.09 60 3 01/01/04 OPEN

54332 Revise penis, urethra 01/01/00 2 776.39 702.19 60

54336 Revise penis, urethra 01/01/00 2 1,001.66 918.62 60

54340 Secondary urethral surgery 01/01/00 2 404.44 358.57 60 3 01/01/04 OPEN



54352 Reconstruct urethra, penis 01/01/00 2 1,074.68 978.88 60 3 01/01/04 OPEN

54360 Penis plastic surgery 01/01/00 2 512.24 451.96 0 3 2-17-91 OPEN

54380 Repair penis 01/01/00 2 593.84 535.95 60 3 01/01/04 OPEN

54385 Repair penis 01/01/00 2 680.20 615.07 60 3 01/01/04 OPEN

54390 Repair penis and bladder 01/01/00 2 937.46 852.80 60

54400 Insert semi-rigid prosthesis 07/01/03 2 382.67 BR 60 3 01/01/04 OPEN

54401 Insert self-contd prosthesis 07/01/03 2 436.90 BR 90 3 01/01/04 OPEN

54402 Rem. replace penile prosthesis 04/01/02 3 NC BR

54405 Insert multi-comp prosthesis 07/01/03 2 548.46 BR 60 3 01/01/04 OPEN

54406 Removal of penile prosthesis 01/01/02 1 501.45 90 3 01/01/04 OPEN

54407 Rem., rep,repl inflat. pen prosth 04/01/02 3 NC BR 60

54408 Repair of penile prosthesis 01/01/02 1 528.33 90 3 01/01/04 OPEN

54409 Surg. hydr abnor infl prosthe 04/01/02 3 NC BR 60

54410 Remove/replace, penile prosth, sa oper 01/01/02 1 625.25 90 3 01/01/04 OPEN

54411 Remove/rep, penile prosth, irrig/debr 01/01/02 1 680.09 90

54415 Remove penile prosthesis, w/o replace 01/01/02 1 371.40 90 3 01/01/04 OPEN

54416 Remove/replace penile prosth, sa op. 01/01/02 1 483.80 90 3 01/01/04 OPEN

54417 Remove/rep, penile prosth, irrig/debr 01/01/02 1 597.02 90


54430 Revision of penis 01/01/00 2 460.24 406.08 60


54440 Repair of penis 05/01/94 1 BR 60 4 2-17-91 OPEN

54450 Preputial stretching 01/01/00 2 49.42 44.16 0 1 2-17-91 OPEN

54500 Biopsy of testis 01/01/00 2 53.44 42.75 0 1 2-17-91 OPEN

54505 Biopsy of testis 01/01/00 2 145.96 129.84 0 1 2-17-91 OPEN

54510 Excision of local lesion on testis 04/01/02 3 NC 229.10 7 2 2-17-91 3-31-02 1 1-4-88 2-16-91

5101:3-1-60 Page 111







54512 Excise lesion testis 01/01/01 1 389.66 30 2 1-01-02 OPEN

54520 Removal of testis 01/01/00 2 272.37 252.55 30 3 2-17-91 OPEN

54522 Orchiectomy, partial 01/01/01 1 442.45 90 3 01/01/04 OPEN

54530 Removal of testis 01/01/00 2 413.42 379.37 90 4 2-17-91 OPEN

54535 Extensive testis surgery 01/01/00 2 545.34 494.92 30

54550 Exploration for testis 01/01/00 2 345.84 311.82 30 4 2-17-91 OPEN

54560 Exploration for testis 01/01/00 2 485.59 436.45 60

54600 Reduce testis torsion 01/01/00 2 307.65 275.68 30 4 2-17-91 OPEN

54620 Suspension of testis 01/01/00 2 217.59 196.63 30 3 2-17-91 OPEN

54640 Suspension of testis 01/01/00 2 373.30 358.54 60 4 2-17-91 OPEN

54650 Orchiopexy (fowler-stephens) 01/01/00 2 509.47 463.71 45

54660 Revision of testis 01/01/00 2 226.35 201.35 21 2 2-17-91 OPEN

54670 Repair testis injury 01/01/00 2 284.82 254.39 30 3 2-17-91 OPEN

54680 Relocation of testis(es) 01/01/00 2 546.49 483.75 60 3 2-17-91 OPEN

54690 Laparoscopy, orchiectomy 01/01/00 1 501.7 90 9 01/01/04 OPEN

54692 Laparoscopy, orchiopexy for intra-abdominal testis 01/01/00 1 519.27 90

54699 Unlisted laparoscopy procedure, testis 01/01/00 1 BR 14

54700 Drainage of scrotum 01/01/00 2 130.58 104.46 14 2 2-17-91 OPEN

54800 Biopsy of epididymis 01/01/00 2 130.75 105.65 0 1 2-17-91 OPEN

54820 Exploration of epididymis 01/01/00 2 211.26 180.39 14 1 2-17-91 OPEN

54830 Remove epididymis lesion 01/01/00 2 238.10 211.61 14 3 2-17-91 OPEN

54840 Remove epididymis lesion 01/01/00 2 261.77 242.75 14 4 2-17-91 OPEN

54860 Removal of epididymis 01/01/00 2 300.65 274.79 60 3 2-17-91 OPEN

54861 Removal of epididymis 01/01/00 2 420.01 389.65 60 4 2-17-91 OPEN

54900 Fusion of spermatic ducts 01/01/00 2 577.61 528.78 60 4 2-17-91 OPEN

54901 Fusion of spermatic ducts 01/01/00 2 787.04 725.86 60 4 2-17-91 OPEN

* 55000 Drainage of hydrocele 01/01/04 2 98.14 54.90 0

55040 Removal of hydrocele 01/01/00 2 267.17 248.80 60 3 2-17-91 OPEN

55041 Removal of hydroceles 01/01/00 2 392.11 367.95 60 5 2-17-91 OPEN

55060 Repair of hydrocele 01/01/00 2 255.50 231.89 60 4 2-17-91 OPEN

* 55100 Drainage of scrotum abscess 01/01/04 2 266.99 81.10 10 1 2-17-91 OPEN

55110 Explore scrotum 01/01/00 2 245.06 215.46 7 2 2-17-91 OPEN

55120 Removal of scrotum lesion 01/01/00 2 190.71 160.89 7 2 2-17-91 OPEN

55150 Removal of scrotum 01/01/00 2 333.37 297.59 30 1 2-17-91 OPEN

55175 Revision of scrotum 01/01/00 2 255.89 232.86 14 1 2-17-91 OPEN

55180 Revision of scrotum 01/01/00 2 467.53 418.22 30 2 2-17-91 OPEN

55200 Incision of sperm duct 01/01/00 2 170.63 149.37 30 2 2-17-91 OPEN

55250 Removal of sperm duct(s) 01/01/00 2 180.13 144.10 90 2 2-17-91 OPEN

5101:3-1-60 Page 112







55300 Preparation,sperm duct x-ray 01/01/00 2 159.74 152.88 0

55400 Repair of sperm duct 01/01/00 2 396.59 363.29 30 1 2-17-91 OPEN

55450 Ligation of sperm duct 01/01/00 2 189.43 161.47 30

55500 Removal of hydrocele 01/01/00 2 261.77 237.90 45 3 2-17-91 OPEN

55520 Removal of sperm cord lesion 01/01/00 2 249.55 221.38 30 4 2-17-91 OPEN

55530 Revise spermatic cord veins 01/01/00 2 283.91 264.56 45 4 2-17-91 OPEN

55535 Revise spermatic cord veins 01/01/00 2 291.11 261.74 45 4 2-17-91 OPEN

55540 Revise hernia & sperm veins 01/01/00 2 332.62 300.64 45 5 2-17-91 OPEN

55550 Laparoscopy, spermatic veins 01/01/00 1 287.51 90 9 01/01/04 OPEN

55559 Unlisted laparoscopy procedure, spermatic cord 01/01/00 1 BR 14

55600 Incise sperm duct pouch 01/01/00 2 287.05 257.91 60 1 2-17-91 12/31/03

55605 Incise sperm duct pouch 01/01/00 2 359.03 325.05 60 1 2-17-91 12/31/03

55650 Remove sperm duct pouch 01/01/00 2 501.26 454.16 90 1 2-17-91 12/31/03

55680 Remove sperm pouch lesion 01/01/00 2 251.45 226.31 30 1 2-17-91 OPEN

55700 Biopsy of prostate 01/01/00 2 93.01 75.68 0 2 2-17-91 OPEN

55705 Biopsy of prostate 01/01/00 2 212.97 191.30 30 2 2-17-91 OPEN

55720 Drainage of prostate abscess 01/01/00 2 305.97 270.41 60 1 2-17-91 OPEN

55725 Drainage of prostate abscess 01/01/00 2 380.94 326.64 60 2 01/01/04 OPEN

55801 Removal of prostate 01/01/00 2 797.24 717.45 90

55810 Extensive prostate surgery 01/01/00 2 1,041.36 961.57 90

55812 Extensive prostate surgery 01/01/00 2 1,180.06 1,067.95 90




55840 Extensive prostate surgery 01/01/00 2 1,018.52 928.35 90



55859 Percut/needle insert, pros 01/01/00 2 434.96 347.97 90 9 01/01/04 OPEN

55860 Surgical exposure, prostate 01/01/00 2 576.12 500.29 60

55862 Extensive prostate surgery 01/01/00 2 786.60 707.15 60


55866 Laparo radical prostatectomy 07/01/03 1 1110.66 90

55870 Electroejaculation 05/01/94 1 NC

55873 Cyrosurgical ablation of prostrate 01/01/01 1 $808.87 90

55899 Genital surgery procedure 05/01/94 1 BR 0

55970 Sex transformation, m to f 05/01/94 1 NC

55980 Sex transformation, f to m 05/01/94 1 NC

56300 Pelvis laparoscopy, dx 04/01/00 3 NC 216.47 14 3 2-17-91 12-31-00

5101:3-1-60 Page 113







56301 Laparoscopy; tubal cautery 04/01/00 3 NC 228.19 10 4 2-17-91 12-31-00

56302 Laparoscopy; tubal block 04/01/00 3 NC 180.04 10 2-17-91 12-31-00

56303 Laparoscopy; excise lesions 04/01/00 3 NC 292.08 10 5 2-17-91 12-31-00

56304 Laparoscopy; lysis 04/01/00 3 NC 262.99 10 5 2-17-91 12-31-00

56305 Pelvic laparoscopy; biopsy 04/01/00 3 NC 226.32 10 4 2-17-91 12-31-00

56306 Laparoscopy; aspiration 04/01/00 3 NC 232.17 10 4 2-17-91 12-31-00

56307 Laparoscopy; remove adnexa 04/01/00 3 NC 338.23 10 5 2-17-91 12-31-00

56308 Laparoscopy; hysterectomy 04/01/00 3 NC 599.56 30

56309 Laparoscopy; remove myoma 04/01/00 3 NC 269.07 10 5 1-1-96 12-31-00

56310 Laparoscopic enterolysis 04/01/00 3 NC 580.38 45

56311 Laparoscopic lymph node biop 04/01/00 3 NC 397.12 45

56312 Laparoscopic lymphadenectomy 04/01/00 3 NC 505.92 45

56313 Laparoscopic lymphadenectomy 04/01/00 3 NC 622.90 45

56314 Laparoscopic drainage to peritoneal cavity 04/01/00 3 NC 397.92 45

* 56315 Laparoscopic appendectomy 04/01/00 3 NC 282.57 45

56316 Laparoscopic hernia repair 04/01/00 3 NC 274.78 45 4 1-1-96 12-31-00

56317 Laparoscopic hernia repair 04/01/00 3 NC 336.10 45 7 1-1-96 12-31-00

56318 Laparoscopic orchiectomy 04/01/00 3 NC 448.71 45

56320 Laparoscopy, spermatic veins 04/01/00 3 NC 261.74 45

56321 Laparoscopy, adrenalectomy 04/01/00 3 NC 90

56322 Laparoscopy, vagus nerves 04/01/00 3 NC 378.40 45

56323 Laparoscopy, vagus nerves 04/01/00 3 NC 454.31 45

56324 Laparoscopy, cholecystoenter 04/01/00 3 NC 543.45 45

56340 Laparoscopic cholecystectomy 04/01/00 3 NC 482.68 45



56343 Laparoscopy with salpingostomy 04/01/00 3 NC 315.61 90

56344 Laparoscopy with fimbrioplasty 04/01/00 3 NC 318.57 90

56345 Laparoscopic splenectomy 04/01/00 3 NC 90

56346 Laparoscopic gastrostomy 04/01/00 3 NC 357.24 90

56347 Laparoscopic jejunostomy 04/01/00 3 NC 90

56348 Laparoscopic intestinal resection 04/01/00 3 NC 902.59 90

56349 Laparoscopic esophagogastric fundoplasty 04/01/00 3 NC 749.93 90

56350 Hysteroscopy; diagnostic 04/01/00 3 NC 113.90 0 1 2-17-91 12-31-00

56351 Hysteroscopy; biopsy 04/01/00 3 NC 124.95 10 3 1-1-96 12-31-00

56352 Hysteroscopy; lysis 04/01/00 3 NC 182.88 10 2 2-17-91 12-31-00

56353 Hysteroscopy; resect septum 04/01/00 3 NC 191.76 30

56354 Hysteroscopy; remove myoma 04/01/00 3 NC 237.79 10 3 2-17-91 12-31-00

5101:3-1-60 Page 114







56355 Hysteroscopy; remove impact 04/01/00 3 NC 130.71 10

56356 Hysteroscopy; ablation 04/01/00 3 NC 220.23 10 4 1-1-96 12-31-00

56360 Peritoneoscopy 04/01/97 3 NC 175.77 14 2 2-17-91 12-31-00

56361 Peritoneoscopy w/biopsy 04/01/97 3 NC 207.02 14 3 2-17-91 12-31-00

56362 Peritoneoscopy w/cholangio 04/01/00 3 NC 185.35 14 3 2-17-91 12-31-00

56363 Peritoneoscopy w/biopsy 04/01/00 3 NC 225.34 14 3 2-17-91 12-31-00

56399 Laparoscopy procedure 04/01/00 3 NC 14

56405 I & d of vulva/perineum 01/01/00 2 68.13 54.50 10 2 2-17-91 12/31/03

56420 Drainage of gland abscess 01/01/00 2 67.13 53.70 15

56440 Surgery for vulva lesion 01/01/00 2 156.68 140.12 30 2 2-17-91 OPEN

56441 Lysis of labial lesion(s) 01/01/00 2 104.75 91.31 30 1 1-1-96 OPEN

56501 Destruction, vulva lesion(s) 01/01/00 2 63.30 50.64 0

56515 Destruction, vulva lesion(s) 01/01/00 2 124.91 114.95 30 3 2-17-91 OPEN

56600 Biopsy of vulva/perineum 01/01/93 3 NC 18.64 14

56605 Biopsy vulva or perineum; separate procedure one le 01/01/93 1 28.90 14

56606 Biopsy of vulva/perineum 01/01/00 2 25.41 20.33 14

56620 Partial removal of vulva 01/01/00 2 379.77 343.12 60 5 2-17-91 OPEN

56625 Complete removal of vulva 01/01/00 2 480.18 448.92 60 7 2-17-91 OPEN

56630 Extensive vulva surgery 01/01/00 2 702.38 641.37 60


56632 Extensive vulva surgery 01/01/00 2 1,114.49 1,048.34 45


56634 Extensive vulva surgery 01/01/00 2 1,014.25 987.96 60



56700 Partial removal of hymen 01/01/00 2 125.56 108.46 30 1 2-17-91 OPEN

* 56720 Incision of hymen 01/01/00 2 37.58 30.06 0 1 2-17-91 OPEN

56740 Remove vagina gland lesion 01/01/00 2 184.70 165.80 30 3 2-17-91 OPEN

56800 Repair of vagina 01/01/00 2 187.45 170.57 30 3 2-17-91 OPEN

56805 Repair clitoris 07/01/03 2 751.86 BR 45

56810 Repair of perineum 01/01/00 2 185.82 167.97 30 5 2-17-91 OPEN

56820 Exam of vulva w/scope 07/01/03 1 81.20 0

56821 Exam/biopsy of vulva w/scope 07/01/03 1 105.33 0

57000 Exploration of vagina 01/01/00 2 138.32 125.25 30 1 2-17-91 OPEN

57010 Drainage of pelvic abscess 01/01/00 2 241.48 203.23 30 2 2-17-91 OPEN

* 57020 Drainage of pelvic fluid 01/01/04 2 85.48 63.47 0 2 2-17-91 OPEN

57022 I &d vaginal hematoma, ob 01/01/01 1 119.94 10

57023 I &d vag hematoma, trauma 01/01/01 1 119.94 10 1 01/01/04 OPEN

5101:3-1-60 Page 115







57061 Destruction vagina lesion(s) 01/01/00 2 64.67 51.81 0

57065 Destruction vagina lesion(s) 01/01/00 2 156.73 154.99 0 1 2-17-91 OPEN

* 57100 Biopsy of vagina 01/01/04 2 64.26 48.11 0

57105 Biopsy of vagina 01/01/00 2 95.92 83.53 0 2 2-17-91 OPEN

57106 Remove vagina wall, partial 01/01/00 2 203.05 231.47 90

57107 Remove vagina tissue/partial 01/01/00 2 670.45 774.88 90

57108 Partial removal of vagina 04/01/99 3 NC 284.86 0

57109 Vaginectomy partial w/nodes 01/01/00 2 840.97 952.70 90

57110 Removal of vagina 01/01/00 2 605.61 547.92 60

57111 Remove vagina tissue complete 01/01/00 2 838.71 944.26 90

57112 Vaginectomy complete w/nodes 01/01/00 2 893.77 1,005.41 90

57120 Closure of vagina 01/01/00 2 390.37 359.20 60

57130 Remove vagina lesion 01/01/00 2 139.02 131.29 30 2 2-17-91 OPEN

57135 Remove vagina lesion 01/01/00 2 131.61 117.01 30 2 2-17-91 OPEN

* 57150 Treat vagina infection 01/01/04 2 42.36 24.50 0

57155 Insertion uterine tandems/vag brachyth 01/01/02 1 278.55 90

* 57160 Insertion of pessary 01/01/04 2 55.28 35.43 0

57170 Fitting of diaphragm/cap 01/01/00 2 38.34 30.67 0

57180 Treat vaginal bleeding 01/01/00 2 65.08 52.06 0 1 2-17-91 OPEN


57210 Repair vagina/perineum 01/01/00 2 232.77 204.59 60 2 2-17-91 OPEN


57230 Repair of urethral lesion 01/01/00 2 259.35 225.48 60 3 2-17-91 OPEN

57240 Repair bladder & vagina 01/01/00 2 349.45 327.26 60 5 2-17-91 OPEN

57250 Repair rectum & vagina 01/01/00 2 322.99 306.93 60 5 2-17-91 OPEN


57265 Extensive repair of vagina 01/01/00 2 556.16 444.93 60 7 2-17-91 OPEN57267 Insert mesh/pelvic flr addon 01/01/05 1 208.91 0

57268 Repair of bowel bulge 01/01/00 2 371.92 345.47 60 3 2-17-91 OPEN

57270 Repair of bowel pouch 01/01/00 2 461.14 368.91 60

57280 Suspension of vagina 01/01/00 2 552.28 441.82 60

57282 Repair of vaginal prolapse 01/01/00 2 473.64 440.21 6057283 Colpopexy, intraperitoneal 01/01/05 1 493.99 90

57284 Repair paravaginal defect 01/01/00 2 557.43 507.57 90

57287 Revise/remove sling repair 01/01/01 1 512.18 90

57288 Repair bladder defect 01/01/00 2 619.00 575.06 30

57289 Repair bladder & vagina 01/01/00 2 461.19 368.95 45 5 01/01/04 OPEN

57291 Construction of vagina 01/01/00 2 367.46 331.24 60 5 01/01/04 OPEN

5101:3-1-60 Page 116







57292 Construct vagina with graft 01/01/00 2 540.77 480.59 60

57300 Repair rectum-vagina fistula 01/01/00 2 417.29 405.63 90 3 2-17-91 OPEN

57305 Repair rectum-vagina fistula 01/01/00 2 583.69 542.77 90

57307 Fistula repair & colostomy 01/01/00 2 610.98 554.64 90

57308 Closure of rectovaginal fistula 01/01/00 2 459.00 439.65 90

57310 Repair urethrovaginal lesion 01/01/00 2 298.29 257.08 60 3 2-17-91 12/31/03

57311 Repair urethrovaginal lesion 01/01/00 2 354.28 311.13 30 4 2-17-91 12/31/03

57320 Repair bladder-vagina lesion 01/01/00 2 441.43 423.98 90 3 2-17-91 12/31/03

57330 Repair bladder-vagina lesion 01/01/00 2 541.08 489.65 90

57335 Repair vagina 07/01/03 2 740.96 BR 45

* 57400 Dilation of vagina 01/01/04 2 97.37 36.21 0 2 2-17-91 OPEN

* 57410 Pelvic examination 01/01/04 2 117.81 29.55 0 2 2-17-91 OPEN

57415 Removal vaginal foreign body 01/01/00 2 39.15 31.32 14 2 01/01/04 OPEN

57420 Exam of vagina w/scope 07/01/03 1 84.58 0

57421 Exam/biopsy of vag w/scope 07/01/03 1 110.52 0

57425 Laparoscopy, Surg, Colpopexy 01/01/04 1 620.03 90

* 57452 Examination of vagina 01/01/04 2 87.80 50.87 0

* 57454 Vagina examination & biopsy 01/01/04 2 120.34 72.10 0

57455 Biopsy of cervix w/scope 07/01/03 1 101.70 0

57456 Endocerv curettage w/scope 07/01/03 1 96.25 0

57460 Leep procedure 01/01/00 2 134.72 125.66 14

57461 Conz of cervix w/scope, leep 07/01/03 1 225.45 0

* 57500 Biopsy of cervix 01/01/04 2 81.69 46.92 0

57505 Endocervical curettage 01/01/00 2 54.79 43.83 15

57510 Cauterization of cervix 01/01/00 2 73.20 58.56 0

* 57511 Cryocautery of cervix 01/01/04 2 118.01 82.90 10

57513 Laser surgery of cervix 01/01/00 2 119.37 164.58 0 2 2-17-91 OPEN

57520 Conization of cervix 01/01/00 2 211.98 192.23 45 2 2-17-91 OPEN

57522 Conization of cervix 01/01/00 2 192.30 175.42 45 2 1-1-96 OPEN

57530 Removal of cervix 01/01/00 2 233.17 208.19 45 3 2-17-91 OPEN

57531 Radical trachelectomy 01/01/00 2 1,235.00 1,033.59 45

57540 Removal of residual cervix 01/01/00 2 420.28 336.22 45

57545 Remove cervix, repair pelvis 01/01/00 2 362.14 289.71 45

57550 Removal of residual cervix 01/01/00 2 319.57 300.09 45 3 2-17-91 OPEN

57555 Remove cervix, repair vagina 01/01/00 2 505.96 480.68 45

57556 Remove cervix, repair bowel 01/01/00 2 470.00 445.36 45 5 01/01/04 OPEN

57700 Revision of cervix 01/01/00 2 161.53 142.32 45 1 2-17-91 OPEN

57720 Revision of cervix 01/01/00 2 191.71 168.51 60 3 2-17-91 OPEN

5101:3-1-60 Page 117







* 57800 Dilation of cervical canal 01/01/04 2 43.16 38.42 0 1 2-17-91 12/31/03

57820 D&c of residual cervix 01/01/00 2 108.11 97.97 0 3 2-17-91 OPEN

* 58100 Biopsy of uterus lining 01/01/04 2 81.32 40.95 0

58120 Dilation and curettage (d&c) 01/01/00 2 168.21 134.57 15 2 2-17-91 OPEN

58140 Removal of uterus lesion 01/01/00 2 519.93 415.94 45

58145 Removal of uterus lesion 01/01/00 2 433.41 403.57 45 5 2-17-91 OPEN

58146 Myomectomy abdom complex 07/01/03 1 747.45 90

58150 Total hysterectomy 01/01/00 2 673.00 583.02 45

58152 Total hysterectomy 01/01/00 2 728.20 677.52 60

58180 Partial hysterectomy 01/01/00 2 616.88 493.50 45

58200 Extensive hysterectomy 01/01/00 2 941.39 855.25 90

58210 Extensive hysterectomy 01/01/00 2 1,264.26 1,078.72 90

58240 Removal of pelvis contents 01/01/00 2 1,804.31 1,502.05 90

58260 Vaginal hysterectomy 01/01/00 2 581.48 540.00 45



58267 Hysterectomy & vagina repair 01/01/00 2 711.12 659.90 90

58270 Hysterectomy & vagina repair 01/01/00 2 639.37 594.06 45

58275 Hysterectomy, revise vagina 01/01/00 2 697.23 645.92 45

58280 Hysterectomy, revise vagina 01/01/00 2 698.59 642.21 45

58285 Extensive hysterectomy 01/01/00 2 826.66 751.88 45

58290 Vag hyst complex 07/01/03 1 746.93 90

58291 Vag hyst incl t/o, complex 07/01/03 1 821.39 90

58292 Vag hyst t/o & repair, compl 07/01/03 1 870.16 90

58293 Vag hyst w/uro repair, compl 07/01/03 1 904.15 90

58294 Vag hyst w/enterocele, compl 07/01/03 1 801.15 90

* 58300 Insert intrauterine device 01/01/00 2 50.92 45.03 0

58301 Remove intrauterine device 01/01/00 2 37.26 29.81 0

58321 Artificial insemination 05/01/94 1 NC

58322 Artificial insemination 05/01/94 1 NC

58323 Sperm washing 05/01/94 1 NC

58340 Inject for uterus/tube x-ray 05/01/94 1 NC

58345 Reopen fallopian tube 05/01/94 1 NC

58346 Insertion Heyman caps, clin brachyther 01/01/02 1 297.01 90

58350 Reopen fallopian tube 05/01/94 1 NC 3 01/01/04 OPEN

58353 Endometr ablate, thermal 01/01/01 1 164.99 10 4 10/01/04 OPEN 2 1-1-02 9/30/0458356 Endometrial cryoablation 01/01/05 1 385.99 10

58400 Suspension of uterus 01/01/00 2 324.98 293.86 45

5101:3-1-60 Page 118







58410 Suspension of uterus 01/01/00 2 387.65 310.12 45

58520 Repair of ruptured uterus 01/01/00 2 342.78 274.22 45

58540 Revision of uterus 01/01/00 2 477.19 381.75 45

58545 Laparoscopic myomectomy 07/01/03 1 600.34 90 9 01/01/04 OPEN

58546 Laparo-myomectomy, complex 07/01/03 1 756.79 90 9 01/01/04 OPEN

58550 Laparoscopy; hysterectomy 01/01/00 1 636.77 90 9 01/01/04 OPEN

58551 Laparoscopy; remove myoma 07/01/03 3 NC 336.34 10 5 1-1-01 12/31/03

58552 Laparo-vag hyst incl t/o 07/01/03 1 584.52 90

58553 Laparo-vag hyst, complex 07/01/03 1 751.86 90

58554 Laparo-vag hyst w/t/o, compl 07/01/03 1 744.33 90

58555 Hysteroscopy; diagnostic 01/01/00 1 142.38 0 1 1-1-01 OPEN

58558 Hysteroscopy; biopsy 01/01/00 1 156.19 0 3 1-1-01 OPEN

58559 Hysteroscopy; lysis 01/01/00 1 228.6 0 2 1-1-01 OPEN

58560 Hysteroscopy; resect septum 01/01/00 1 239.7 0 3 01/01/04 OPEN

58561 Hysteroscopy; remove myoma 01/01/00 1 297.24 0 3 1-1-01 OPEN

58562 Hysteroscopy; remove impact 01/01/00 1 163.39 0 3 01/01/04 OPEN

58563 Hysteroscopy; ablation 01/01/00 1 275.29 0 4 1-1-01 OPEN58565 Hysteroscopy, sterilization 01/01/05 1 1553.89 90

58578 Unlisted laparoscopy procedure, uterus 01/01/00 1 BR 14

58579 Unlisted hysterectomy procedure, uterus 01/01/00 1 BR 14

58600 Division of fallopian tube 01/01/00 2 228.67 233.99 45 4 2-17-91 OPEN

58605 Division of fallopian tube 01/01/00 2 195.80 286.53 45

58611 Ligate oviduct(s) 01/01/00 2 30.35 40.54 45

58615 Occlude fallopian tube(s) 01/01/00 2 181.38 167.63 14 4 2-17-91 OPEN

58660 Laparoscopy; lysis 01/01/00 1 328.74 90 5 1-1-01 OPEN

58661 Laparoscopy; remove adnexa 01/01/00 1 422.79 10 5 1-1-01 OPEN

58662 Laparoscopy; excise lesions 01/01/00 1 365.1 90 5 1-1-01 OPEN

58670 Laparoscopy; tubal cautery 01/01/00 1 285.24 90 3 10/01/04 OPEN 4 1-1-01 9/30/04

58671 Laparoscopy; tubal block 01/01/00 1 225.05 90 3 10/01/04 OPEN 4 1-1-01 9/30/04

58672 Laparoscopy with fimbrioplasty 01/01/00 1 398.21 90 5 1-1-01 OPEN

58673 Laparoscopy with salpingostomy 01/01/00 1 394.51 90 5 1-1-01 OPEN

58679 Unlisted laparoscopy procedure, oviduct, ovary 01/01/00 1 BR 14

58700 Removal of fallopian tube 01/01/00 2 343.33 319.64 45

58720 Removal of ovary/tube(s) 01/01/00 2 451.43 361.14 45

58740 Lysis of adhesions 01/01/00 2 340.92 328.55 30

58750 Repair oviduct(s) 05/01/94 1 NC

58752 Revise ovarian tube(s) 05/01/94 1 NC

58760 Remove tubal obstruction 05/01/94 1 NC

5101:3-1-60 Page 119







58770 Create new tubal opening 05/01/94 1 NC

58800 Drainage of ovarian cyst(s) 01/01/00 2 194.91 165.04 30 3 2-17-91 OPEN

58805 Drainage of ovarian cyst(s) 01/01/00 2 328.17 310.52 60 4 2-17-91 12-31-95

58820 Drainage of ovarian abscess 01/01/00 2 192.53 170.41 30 3 2-17-91 OPEN

58822 Drainage of ovarian abscess 01/01/00 2 312.31 249.85 60

58823 Drainage of pelvic abscess 01/01/00 2 160.01 147.19 30

58825 Transposition, ovary(s) 01/01/00 2 280.81 250.63 0

58900 Biopsy of ovary(s) 01/01/00 2 301.98 277.24 60 3 2-17-91 OPEN

58920 Partial removal of ovary(s) 01/01/00 2 364.18 341.07 60

58925 Removal of ovarian cyst(s) 01/01/00 2 422.73 338.18 60

58940 Removal of ovary(s) 01/01/00 2 369.66 338.68 60

58943 Removal of ovary(s) 01/01/00 2 829.79 762.67 60

58950 Resect ovarian malignancy 01/01/00 2 718.85 655.10 60

58951 Resect ovarian malignancy 01/01/00 2 1,078.20 1,006.06 60

58952 Resect ovarian malignancy 01/01/00 2 1,163.72 1,024.82 60

58953 Bilat. salpingo-ooppho : hysterec 01/01/02 1 1,341.18 90

58954 Hysterec /rem tubes/ovaries w/ rad dis 01/01/02 1 1,457.92 9058956 Bso, omentectomy w/tah 01/01/05 1 976.05 90

58960 Exploration of abdomen 01/01/00 2 748.60 614.13 30

58970 Retrieval of oocyte 05/01/94 1 NC

58972 Fertilization of oocyte 04/01/96 1 NC

58974 Transfer of embryo 05/01/94 1 NC

58976 Transfer of embryo 05/01/94 1 NC

58999 Genital surgery procedure 05/01/94 1 BR 0

* 59000 Amniocentesis 01/01/04 2 90.47 65.94 0

59001 Therapeutic amniotic fluid reduction 01/01/02 1 121.63 0

59012 Fetal cord puncture,prenatal 01/01/00 2 156.95 150.40 0

59015 Chorion biopsy 01/01/00 2 90.40 82.70 0

* 59020 Fetal contract stress test 01/01/00 2 52.75 77.10 D 0

59025 Fetal non-stress test 01/01/00 2 30.98 42.39 D 0

* 59030 Fetal scalp blood sample 01/01/04 2 92.85 89.11 0

59050 Fetal monitor w/report 01/01/00 2 44.47 43.63 0

59051 Fetal monitor/interpretation only 01/01/00 2 40.30 40.03 0

59070 Transabdom Amnioinfus W/ Us 01/01/04 1 272.20 0

59072 Umbilical Cord Occlud W/ Us 01/01/04 1 328.85 0

59074 Fetal Fluid Drainage W/ Us 01/01/04 1 259.02 0

59076 Fetal Shunt Placement, W/ Us 01/01/04 1 328.85 0

59100 Remove uterus lesion 01/01/00 2 327.28 261.82 60

5101:3-1-60 Page 120







59120 Treat ectopic pregnancy 01/01/00 2 484.86 387.89 60








59160 D&c after delivery 01/01/00 2 158.59 143.83 45 3 01/01/04 OPEN

59200 Insert cervical dilator 01/01/00 2 40.87 34.07 0

59300 Episiotomy or vaginal repair 01/01/00 2 94.17 82.96 45

59320 Revision of cervix 01/01/00 2 116.57 110.52 0 1 01/01/04 OPEN

59325 Revision of cervix 01/01/00 2 183.12 170.93 0

59350 Repair of uterus 01/01/00 2 227.19 220.34 45

59400 Obstetrical care 05/01/94 1 NC

59409 Obstetrical care 01/01/00 2 616.15 590.74 1

59410 Obstetrical care 01/01/00 2 677.14 642.33 45

59412 Antepartum manipulation 01/01/00 2 110.43 108.89 90

59414 Deliver placenta 01/01/00 2 102.65 102.45 0

59420 Prenatal visit 07/01/03 3 NC 44.00 1

59425 Antepartum care only 05/01/94 1 NC

59426 Antepartum care only 05/01/94 1 NC

59430 Care after delivery 01/01/00 2 65.81 58.70 1

59510 Cesarean delivery 05/01/94 1 NC

59514 Cesarean delivery only 01/01/00 2 674.73 635.79 1

59515 Cesarean delivery 01/01/00 2 736.89 683.46 45

59525 Remove uterus after cesarean 01/01/00 2 335.97 314.22 45

59610 VBAC delivery 01/01/96 3 NC

59612 VBAC delivery only 01/01/00 2 703.99 673.08 1

59614 VBAC care after delivery 01/01/00 2 764.22 727.32 45

59618 Attempted VBAC delivery 01/01/96 1 NC

59620 Attempted VBAC delivery only 01/01/00 2 817.88 773.75 1

59622 Attempted VBAC care after delivery 01/01/00 2 882.79 828.75 45

59812 Treatment of miscarriage 01/01/00 2 197.70 176.24 30 5 01/01/04 OPEN

59820 Care of miscarriage 01/01/00 2 221.83 194.56 45 5 01/01/04 OPEN

59821 Treatment of miscarriage 01/01/00 2 211.17 180.01 0 5 01/01/04 OPEN

59830 Treat uterus infection 01/01/00 2 281.73 259.52 45

59840 Abortion 01/01/00 2 184.27 160.76 45 5 01/01/04 OPEN

5101:3-1-60 Page 121







59841 Abortion 01/01/00 2 228.18 182.54 30 5 01/01/04 OPEN

59850 Abortion 01/01/00 2 266.69 243.83 45

59851 Abortion 01/01/00 2 275.81 254.81 42

59852 Abortion 01/01/00 2 375.88 342.69 45

59855 Abortion 01/01/00 2 279.58 257.98 45

59856 Abortion 01/01/00 2 342.98 318.57 45

59857 Abortion 01/01/00 2 420.45 387.43 45

59870 Evacuate mole of uterus 01/01/00 2 201.48 181.29 30 5 01/01/04 OPEN

59871 Removal of cerclage suture 01/01/00 2 109.44 109.55 30 5 01/01/04 OPEN

59897 Fetal Invas Px W/ Us 01/01/04 1 BR 0

59898 Unlisted laparoscopy procedure, maternity care 01/01/00 1 BR 14

59899 Maternity care procedure 05/01/94 1 BR 0

* 60000 Drain thyroid/tongue cyst 01/01/04 2 113.14 71.19 10 1 2-17-91 OPEN

60001 Aspirtate/inject thyroid cyst 01/01/00 2 59.70 50.26 0

* 60100 Biopsy of thyroid 01/01/04 2 70.74 62.45 0

60200 Remove thyroid lesion 01/01/00 2 428.96 375.59 45 2 2-17-91 OPEN

60210 Partial excision thyroid 01/01/00 2 529.95 492.03 45

60212 Partial thyroid excision 01/01/00 2 682.82 621.86 45

60220 Partial removal of thyroid 01/01/00 2 517.58 472.21 45 2 2-17-91 12/31/03

60225 Partial removal of thyroid 01/01/00 2 667.78 567.49 45 3 2-17-91 12/31/03

60240 Removal of thyroid 01/01/00 2 725.71 666.85 45


60254 Extensive thyroid surgery 01/01/00 2 1,145.48 916.38 45

60260 Repeat thyroid surgery 01/01/00 2 529.15 428.11 45



60280 Remove thyroid duct lesion 01/01/00 2 348.37 323.21 45 4 2-17-91 OPEN

60281 Remove thyroid duct lesion 01/01/00 2 376.85 331.05 45 4 2-17-91 OPEN

60500 Explore parathyroid glands 01/01/00 2 746.43 687.27 45

60502 Re-explore parathyroids 01/01/00 2 865.31 780.91 45

60505 Explore parathyroid glands 01/01/00 2 947.87 842.95 60

60512 Autotransplant, parathyroid 01/01/00 2 184.60 173.43 90

60520 Removal of thymus gland 01/01/00 2 814.97 750.82 60

60521 Removal of thymus gland 01/01/00 2 882.16 798.37 60

60522 Removal of thymus gland 01/01/00 2 1,000.71 893.46 60

60540 Explore adrenal gland 01/01/00 2 776.45 704.82 90

60545 Explore adrenal gland 01/01/00 2 909.05 828.99 90

60600 Remove carotid body lesion 01/01/00 2 811.70 696.15 60

5101:3-1-60 Page 122







60605 Remove carotid body lesion 01/01/00 2 895.73 737.16 60

60650 Laparoscopy, adrenalectomy 07/01/03 1 759.12 BR 14

60659 Unlisted laparoscopy procedure, endocrine system 01/01/00 1 BR 14

60699 Endocrine surgery procedure 05/01/94 1 BR 0

* 61000 Remove cranial cavity fluid 01/01/00 2 74.10 66.63 0

* 61001 Remove cranial cavity fluid 01/01/04 2 72.71 67.74 0

* 61020 Remove brain cavity fluid 01/01/04 2 83.96 79.84 0 1 2-17-91 OPEN

61026 Injection into brain canal 01/01/00 2 96.71 92.41 7 1 2-17-91 OPEN

* 61050 Remove brain canal fluid 01/01/04 2 77.67 75.07 0 1 2-17-91 OPEN

61055 Injection into brain canal 01/01/00 2 105.01 98.08 7 1 2-17-91 OPEN

* 61070 Brain canal shunt procedure 01/01/04 2 53.72 41.63 0 1 2-17-91 OPEN

61105 Drill skull for examination 01/01/00 2 294.46 385.12 60

61106 Drill skull for exam/surgery 04/01/99 3 NC 345.81 60

61107 Drill skull for implantation 01/01/00 2 285.54 263.35 30

61108 Drill skull for drainage 01/01/00 2 577.40 590.24 30

61120 Pierce skull for examination 01/01/00 2 403.68 386.54 21

61130 Pierce skull, exam/surgery 04/01/99 3 NC 290.11 30

61140 Pierce skull for biopsy 01/01/00 2 810.19 743.27 30

61150 Pierce skull for drainage 01/01/00 2 869.86 793.63 30


61154 Pierce skull, remove clot 01/01/00 2 845.81 809.98 60


61210 Pierce skull; implant device 01/01/00 2 327.08 289.81 30

61215 Insert brain-fluid device 01/01/00 2 294.67 487.76 7 3 2-17-91 OPEN

61250 Pierce skull & explore 01/01/00 2 501.69 484.37 30

61253 Pierce skull & explore 01/01/00 2 598.37 574.25 30

61304 Open skull for exploration 01/01/00 2 1,234.73 1,209.79 90

61305 Open skull for exploration 01/01/00 2 1,473.10 1,386.22 90

61312 Open skull for drainage 01/01/00 2 1,303.06 1,156.21 90




61316 Implt cran bone flap to abdo 07/01/03 1 60.19 90



61322 Decompressive craniotomy 07/01/03 1 1219.89 90

61323 Decompressive lobectomy 07/01/03 1 1263.21 90

61330 Decompress eye socket 01/01/00 2 877.80 702.24 90

5101:3-1-60 Page 123







61332 Explore/biopsy eye socket 01/01/00 2 1,301.12 1,168.36 90

61333 Explore orbit; remove lesion 01/01/00 2 1,317.57 1,191.24 90

61334 Explore orbit; remove object 01/01/00 2 876.06 789.85 90

61340 Relieve cranial pressure 01/01/00 2 849.08 679.26 90

61343 Incise skull,pressure relief 01/01/00 2 1,598.03 1,487.91 90

61345 Relieve cranial pressure 01/01/00 2 1,263.66 1,133.54 90

61440 Incise skull for surgery 01/01/00 2 1,257.88 1,144.17 90


61458 Incise skull for brain wound 01/01/00 2 1,457.49 1,368.77 90


61470 Incise skull for surgery 01/01/00 2 1,096.34 879.24 90

61480 Incise skull for surgery 01/01/00 2 989.00 791.20 90

61490 Incise skull for surgery 01/01/00 2 871.48 697.18 90

61500 Removal of skull lesion 01/01/00 2 1,005.25 954.68 60

61501 Remove infected skull bone 01/01/00 2 842.67 807.31 90

61510 Removal of brain lesion 01/01/00 2 1,487.90 1,302.12 90

61512 Remove brain lining lesion 01/01/00 2 1,722.21 1,377.77 90

61514 Removal of brain abscess 01/01/00 2 1,358.19 1,265.83 90


61517 Implt brain chemotx add-on 07/01/03 1 51.11 90


61519 Remove brain lining lesion 01/01/00 2 1,972.16 1,670.38 90



61522 Removal of brain abscess 01/01/00 2 1,352.72 1,212.53 90



61530 Removal of brain lesion 01/01/00 2 691.18 BR 90

61531 Implant brain electrodes 01/01/00 2 773.76 877.96 14

61533 Implant brain electrodes 01/01/00 2 998.95 1,034.46 30

61534 Removal of brain lesion 01/01/00 2 793.34 655.78 90

61535 Remove brain electrodes 01/01/00 2 530.84 451.90 30


61537 Removal Of Brain Tissue 01/01/04 1 1175.49 90

61538 Removal of brain tissue 01/01/00 2 1,486.36 1,462.26 90



61541 Incision of brain tissue 01/01/00 2 1,330.12 1,194.23 90

5101:3-1-60 Page 124








61543 Removal of brain tissue 01/01/00 2 1,188.90 951.12 90

61544 Remove & treat brain lesion 01/01/00 2 1,345.03 1,265.08 90

61545 Excision of brain tumor 01/01/00 2 1,907.17 1,534.93 90

61546 Removal of pituitary gland 01/01/00 2 1,570.56 1,441.02 90

61548 Removal of pituitary gland 01/01/00 2 1,204.45 1,150.72 90

61550 Release of skull seams 01/01/00 2 681.59 639.16 90

61552 Release of skull seams 01/01/00 2 897.32 840.37 90

61556 Incise skull/sutures 01/01/00 2 1,075.34 BR 90

61557 Incise skull/sutures 01/01/00 2 1,105.55 BR 90

61558 Excision of skull/sutures 01/01/00 2 1,276.90 BR 90

61559 Excision of skull/sutures 01/01/00 2 1,652.56 BR 90

61563 Excision of skull tumor 01/01/00 2 1,329.08 BR 90

61564 Excision of skull tumor 01/01/00 2 1,588.03 BR 90


61567 Incision Of Brain Tissue 01/01/04 1 1605.27 90

61570 Remove brain foreign body 01/01/00 2 1,120.12 1,003.04 60

61571 Incise skull for brain wound 01/01/00 2 1,214.16 1,088.40 90

61575 Skull base/brainstem surgery 01/01/00 2 1,794.58 1,656.13 60

61576 Skull base/brainstem surgery 01/01/00 2 1,943.14 1,554.51 90

61580 Craniofacial approach, skull 01/01/00 2 1,411.50 1,276.75 45




61584 Orbitocranial approach/skull 01/01/00 2 1,602.43 1,453.36 45


61586 Bicoronal/transzygomatic/lefort approach 01/01/00 2 1,232.34 1,065.62 45

61590 Infratemporal approach/skull 01/01/00 2 1,951.45 1,768.20 45

61591 Infratemporal approach/skull 01/01/00 2 2,029.90 1,854.49 45


61595 Transtemporal approach/skull 01/01/00 2 1,385.97 1,242.49 45

61596 Transcochlear approach/skull 01/01/00 2 1,670.39 1,509.85 45

61597 Transcondylar approach/skull 01/01/00 2 1,730.66 1,595.88 45

61598 Transpetrosal approach/skull 01/01/00 2 1,557.37 1,406.07 45

61600 Resect/excise cranial lesion 01/01/00 2 1,200.26 1,078.18 45




5101:3-1-60 Page 125









61609 Transect, artery, sinus 01/01/00 2 462.85 436.84 45

61610 Transect, artery, sinus 01/01/00 2 1,365.94 1,310.79 45

61611 Transect, artery, sinus 01/01/00 2 343.10 327.89 45

61612 Transect, artery, sinus 01/01/00 2 1,289.33 1,231.84 45

61613 Remove aneurysm, sinus 01/01/00 2 1,899.73 1,742.46 45

61615 Resect/excise lesion, skull 01/01/00 2 1,495.37 1,341.29 45

61616 Resect/excise lesion, skull 01/01/00 2 2,010.38 1,824.46 45

61618 Repair dura 01/01/00 2 785.53 690.04 45

61619 Repair dura 01/01/00 2 962.35 862.36 45

61623 Endovasc tempory vessel occl 07/01/03 1 371.26 0

61624 Occlusion/embolization cath 01/01/00 2 936.45 877.40 90

61626 Occlusion/embolization cath 01/01/00 2 767.86 723.46 90

61680 Intracranial vessel surgery 01/01/00 2 1,653.52 1,729.92 90

61682 Intracranial vessel surgery 01/01/04 3 NC 2,474.40 90





61697 Brain aneurysm repr, complx 01/01/01 1 2,462.20 90

61698 Brain aneurysm repr, complx 01/01/01 1 2,369.80 90

61700 Inner skull vessel surgery 01/01/00 2 2,127.89 1,702.31 90

61702 Inner skull vessel surgery 01/01/00 2 2,288.94 1,936.38 90

61703 Clamp neck artery 01/01/00 2 811.09 725.74 30

61705 Revise circulation to head 01/01/00 2 1,778.45 1,654.32 90



61711 Fusion of skull arteries 01/01/00 2 1,864.51 1,741.49 90

61712 Skull or spine microsurgery 04/01/99 3 NC 209.26 90

61720 Incise skull/brain surgery 01/01/00 2 955.25 945.70 90

61735 Incise skull/brain surgery 01/01/00 2 898.26 743.72 90

61750 Incise skull; brain biopsy 01/01/00 2 823.51 658.81 90

61751 Brain biopsy with cat scan 01/01/00 2 1,004.40 919.94 90

61760 Implant brain electrodes 01/01/00 2 993.34 981.93 21

61770 Incise skull for treatment 01/01/00 2 1,094.63 892.17 30

61790 Treat trigeminal nerve 01/01/00 2 619.82 625.03 60 3 2-17-91 OPEN

61791 Treat trigeminal tract 01/01/00 2 597.39 477.91 60 3 2-17-91 OPEN

5101:3-1-60 Page 126







61793 Focus radiation beam 01/01/00 2 936.47 937.14 90

61795 Brain surgery using computer 01/01/00 2 243.03 255.76 45

61850 Implant neuroelectrodes 01/01/00 2 651.17 706.08 60

61855 Implant neuroelectrodes 04/01/00 3 NC 584.75 60



61863 Implant Neuroelectrode 01/01/04 1 713.83 90

61864 Implant Neuroelectrde, Add'L 01/01/04 1 202.63 0


61867 Implant Neuroelectrode 01/01/04 1 1063.50 90

61868 Implant Neuroelectrde, Addæl 01/01/04 1 336.76 0



61880 Revise/remove neuroelectrode 01/01/00 2 303.58 263.23 90

61885 Implant neuroreceiver 01/01/00 2 135.56 108.45 14 2 2-17-91 OPEN

61886 Implant neuroelectrodes with connection to arrays 01/01/00 1 413.83 90 3 01/01/04 OPEN

61888 Revise/remove neuroreceiver 01/01/00 2 171.09 136.87 90 1 2-17-91 OPEN

62000 Repair of skull fracture 01/01/00 2 493.46 425.05 60

62005 Repair of skull fracture 01/01/00 2 740.32 658.80 90

62010 Treatment of head injury 01/01/00 2 1,043.92 966.06 60

62100 Repair brain fluid leakage 01/01/00 2 1,169.11 1,086.00 60

62115 Reduction of skull defect 01/01/00 2 1,029.49 BR 60



62120 Repair skull cavity lesion 01/01/00 2 1,158.00 BR 90

62121 Incise skull repair 01/01/00 2 1,069.64 971.77 60

62140 Repair of skull defect 01/01/00 2 724.80 669.94 60

62141 Repair of skull defect 01/01/00 2 845.25 821.00 60

62142 Remove skull plate/flap 01/01/00 2 618.37 594.12 60

62143 Replace skull plate/flap 01/01/00 2 609.27 541.61 60

62145 Repair of skull & brain 01/01/00 2 874.24 782.51 90

62146 Repair of skull with graft 01/01/00 2 746.86 667.81 90

62147 Repair of skull with graft 01/01/00 2 895.21 800.90 90

62148 Retr bone flap to fix skull 07/01/03 1 81.98 90

62160 Neuroendoscopy add-on 07/01/03 1 118.30 90

62161 Dissect brain w/scope 07/01/03 1 842.40 90

62162 Remove colloid cyst w/scope 07/01/03 1 1081.61 90

62163 Neuroendoscopy w/fb removal 07/01/03 1 684.40 90

5101:3-1-60 Page 127







62164 Remove brain tumor w/scope 07/01/03 1 1169.56 90

62165 Remove pituit tumor w/scope 07/01/03 1 915.56 90

62180 Establish brain cavity shunt 01/01/00 2 872.18 697.74 90



62194 Replace/irrigate catheter 01/01/00 2 147.09 117.67 30 1 2-17-91 OPEN





62225 Replace/irrigate catheter 01/01/00 2 272.87 237.18 30 1 2-17-91 OPEN

62230 Replace/revise brain shunt 01/01/00 2 550.26 503.33 90 2 2-17-91 OPEN

62252 Csf shunt reprogram 01/01/01 1 59.97 K 0

62256 Remove brain cavity shunt 01/01/00 2 354.62 316.74 30 2 2-17-91 12/31/03

62258 Replace brain cavity shunt 01/01/00 2 782.06 728.04 90

62263 Percutaneous lysis of epidual adhesions 01/01/00 1 308.38 0 1 10/01/04 OPEN

62264 Epidural lysis on single day 07/01/03 1 399.80 10

* 62268 Drain spinal cord cyst 01/01/04 2 207.44 206.44 0 1 2-17-91 OPEN

* 62269 Needle biopsy spinal cord 01/01/04 2 206.22 180.89 0 1 2-17-91 OPEN

* 62270 Spinal fluid tap, diagnostic 01/01/04 2 130.83 48.76 0 1 2-17-91 OPEN

* 62272 Drain spinal fluid 01/01/04 2 166.55 62.46 0 1 2-17-91 OPEN

62273 Treat lumbar spine lesion 01/01/00 2 91.00 83.75 7 1 2-17-91 OPEN

62274 Inject spinal anesthetic 04/01/00 3 NC 63.92 7 1 2-17-91 OPEN

* 62275 Inject spinal anesthetic 04/01/00 3 NC 61.25 0 1 1-1-96 OPEN





62280 Treat spinal cord lesion 01/01/00 2 102.10 81.68 15 1 2-17-91 OPEN

62281 Treat spinal cord lesion 01/01/00 2 108.44 89.61 10 1 01/01/04 OPEN

62282 Treat spinal canal lesion 01/01/00 2 127.52 103.64 7 1 2-17-91 OPEN

62284 Injection for myelogram 01/01/00 2 107.62 90.72 7

62287 Percutaneous diskectomy 01/01/00 2 406.33 325.06 7 9 01/01/04 OPEN

62288 Injection into spinal canal 04/01/00 3 NC 73.39 7 1 2-17-91 OPEN

62289 Injection into spinal canal 04/01/00 3 NC 71.12 7 1 2-17-91 OPEN

* 62290 Inject for spine disk x-ray 01/01/04 2 309.47 142.91 0

* 62291 Inject for spine disk x-ray 01/01/04 2 273.41 142.48 0

62292 Injection into disk lesion 01/01/00 2 450.35 426.32 90

5101:3-1-60 Page 128







62294 Injection into spinal artery 01/01/00 2 429.51 343.61 90 3 2-17-91 OPEN

* 62298 Injection into spinal canal 04/01/00 3 NC 79.82 0

62310 Injection,single, of diagnostic/therapeutic substance 01/01/00 1 143.07 0 1 1-1-01 OPEN

62311 Injection, lumbar,sacral (caudal) 01/01/00 1 143.62 0 1 1-1-01 OPEN

62318 Injection of diagnostic/therapeutic substances 01/01/00 1 149.66 0 1 1-1-01 OPEN

62319 Injection, lumbar, sacral (caudal) 01/01/00 1 145.54 0 1 1-1-01 OPEN

62350 Implant spinal canal catheter 01/01/00 2 290.96 255.50 90 2 1-1-01 OPEN

62351 Implant spinal canal catheter 01/01/00 2 435.54 377.78 90 2 1-1-01 12/31/03

62355 Remove spinal canal catheter 01/01/00 2 239.15 212.04 90 2 01/01/04 OPEN

62360 Insert spine infusion device 01/01/01 2 133.14 BR 90 2 1-1-01 OPEN

62361 Implant spine infusion pump 01/01/01 2 259.68 BR 90 2 1-1-01 OPEN

62362 Implant spine infusion pump 01/01/01 2 333.13 BR 90 2 1-1-01 OPEN

62365 Remove spine infusion device 01/01/01 2 257.67 BR 90 2 1-1-01 OPEN

62367 Analyze spine infusion pump 01/01/00 2 21.14 BR 90 2 1-1-01 12/31/03

62368 Analyze spine infusion pump 01/01/00 2 32.4 BR 90 2 1-1-01 12/31/03

63001 Removal of spinal lamina 01/01/00 2 894.42 857.64 90





63015 Removal of spinal lamina 01/01/00 2 1,093.25 988.19 90

63016 Removal of spinal lamina 01/01/00 2 1,086.15 1,030.95 90


63020 Neck spine disk surgery 01/01/00 2 840.41 752.15 90

63030 Low back disk surgery 01/01/00 2 690.02 715.27 90

63035 Added spinal disk surgery 01/01/00 2 180.11 186.98 90

63040 Neck spine disk surgery 01/01/00 2 1,069.43 1,043.00 90

63042 Low back disk surgery 01/01/00 2 1,004.61 1,029.42 90

63043 Laminotomy, addl cervical 01/01/01 1 267.36 90

63044 Laminotomy, addl lumbar 01/01/01 1 251.15 90




63048 Removal of spinal lamina 01/01/00 2 192.09 199.45 9063050 Cervical laminoplasty 01/01/05 1 1034.03 9063051 C-laminoplasty w/graft/plate 01/01/05 1 1177.00 90

63055 Decompress spinal cord 01/01/00 2 1,221.93 1,143.11 90


5101:3-1-60 Page 129







63057 Decompress spinal cord 01/01/00 2 226.39 181.11 90


63066 Decompress spinal cord 01/01/00 2 157.15 146.21 90

63075 Neck spine disk surgery 01/01/00 2 1,001.38 956.53 90

63076 Neck spine disk surgery 01/01/00 2 231.61 240.12 90

63077 Spine disk surgery, thorax 01/01/00 2 1,079.19 986.40 90

63078 Spine disk surgery, thorax 01/01/00 2 160.05 149.65 90

63081 Removal of vertebral body 01/01/00 2 1,328.46 1,242.73 90

63082 Removal of vertebral body 01/01/00 2 253.31 263.50 90







63101 Removal Of Vertebral Body 01/01/04 1 1459.55 90

63102 Removal Of Vertebral Body 01/01/04 1 1459.55 90

63103 Remove Vertebral Body Add-On 01/01/04 1 170.75 0

63170 Incise spinal cord tract(s) 01/01/00 2 1,042.20 949.97 90

63172 Drainage of spinal cyst 01/01/00 2 1,013.13 969.00 90

63173 Drainage of spinal cyst 01/01/00 2 1,006.17 888.24 90

63180 Revise spinal cord ligaments 01/01/00 2 814.38 718.77 90

63182 Revise spinal cord ligaments 01/01/00 2 979.54 884.72 90

63185 Incise spinal column/nerves 01/01/00 2 821.81 761.25 60



63194 Incise spinal column & cord 01/01/00 2 878.08 776.74 90




63198 Incise spinal column & cord 01/01/00 2 1,129.74 991.91 90

63199 Incise spinal column & cord 01/01/00 2 1,270.59 1,127.45 90

63200 Release of spinal cord 01/01/00 2 858.10 755.08 90

63250 Revise spinal cord vessels 01/01/00 2 1,838.09 1,698.81 90



63265 Excise intraspinal lesion 01/01/00 2 1,166.53 1,081.68 90


5101:3-1-60 Page 130







63267 Excise intraspinal lesion 01/01/00 2 1,022.79 994.76 90

63268 Excise intraspinal lesion 01/01/00 2 854.61 763.32 90





63275 Biopsy/excise spinal tumor 01/01/00 2 1,332.95 1,292.53 90











63290 Biopsy/excise spinal tumor 01/01/00 2 1,741.13 1,578.25 9063295 Repair of laminectomy defect 01/01/05 1 234.78 0

63300 Removal of vertebral body 01/01/00 2 1,113.93 991.73 90









63600 Remove spinal cord lesion 01/01/00 2 669.16 624.66 90 2 2-17-91 OPEN

63610 Stimulation of spinal cord 01/01/00 2 423.23 415.29 60 1 2-17-91 OPEN

63615 Remove lesion of spinal cord 01/01/00 2 760.89 684.48 60

63650 Implant neuroelectrodes 07/01/02 2 359.17 383.68 0 2 2-17-91 OPEN


63660 Revise/remove neuroelectrode 01/01/00 2 348.55 334.18 0 1 2-17-91 OPEN

63685 Implant neuroreceiver 01/01/00 2 385.09 356.71 0 2 2-17-91 OPEN

63688 Revise/remove neuroreceiver 01/01/00 2 305.56 285.51 0 1 2-17-91 OPEN

63690 Analysis of neuroreceiver 04/01/99 3 NC 27.07 45

63691 Analysis of neuroreceiver 04/01/99 3 NC 27.74 45

5101:3-1-60 Page 131







63700 Repair of spinal herniation 01/01/00 2 768.04 690.04 90

63702 Repair of spinal herniation 01/01/00 2 861.94 776.30 90

63704 Repair of spinal herniation 07/01/03 2 946.96 BR 90

63706 Repair of spinal herniation 01/01/00 2 1,140.97 BR 90

63707 Repair spinal fluid leakage 01/01/00 2 643.08 604.21 90

63709 Repair spinal fluid leakage 01/01/00 2 818.08 788.83 90

63710 Graft repair of spine defect 01/01/00 2 652.58 574.65 90

63740 Install spinal shunt 01/01/00 2 658.48 630.54 90

63741 Install spinal shunt 01/01/00 2 479.40 439.92 7

63744 Revision of spinal shunt 01/01/00 2 440.48 392.35 90 3 2-17-91 OPEN

63746 Removal of spinal shunt 01/01/00 2 318.83 287.66 60 2 2-17-91 OPEN

63750 Insert spinal canal catheter 04/01/96 3 NC 541.85 90 4 2-17-91 OPEN

63780 Insert spinal canal catheter 04/01/96 3 NC 188.79 3 2 2-17-91 OPEN

64400 Injection for nerve block 01/01/00 2 48.58 38.86 3



64408 Injection for nerve block 01/01/00 2 72.57 60.34 3 1 2-17-91 9/30/04

64410 Injection for nerve block 01/01/00 2 66.04 54.32 3 1 2-17-91 OPEN




64416 N block cont infuse, b plex 07/01/03 1 110.00 10








64440 Injection for nerve block 04/01/00 3 NC 52.46 3

64441 Injection for nerve block 04/01/00 3 NC 69.04 3

64442 Injection for nerve block 04/01/00 3 NC 65.03 3 1 2-17-91 OPEN

64443 Injection for nerve block 04/01/00 3 NC 49.82 3 1 2-17-91 OPEN


64446 N blk inj, sciatic, cont inf 07/01/03 1 113.38 10

64447 N block inj fem, single 07/01/03 1 53.19 0

64448 N block inj fem, cont inf 07/01/03 1 104.29 10

64449 N Block Inj, Lumbar Plexus 01/01/04 1 104.61 10

5101:3-1-60 Page 132








64470 Injection, anesthetic agent and/or steriod, joint 01/01/00 1 146.64 0 1 10/01/04 OPEN

64472 Injection, cervical orthoracis, each added level 01/01/00 1 122.47 0 1 10/01/04 OPEN

64475 Injection, lumbar, sacral (caudal) 01/01/00 1 129.89 0 1 1-1-01 OPEN

64476 Injection, lumbar, sacral (caudal),each added level 01/01/00 1 122.20 0 1 1-1-01 OPEN

64479 Injection,anesthetic agent and/or steriod, epidural 01/01/00 1 159.54 0 1 10/01/04 OPEN

64480 Injection, cervical or thoracic, each added level 01/01/00 1 143.07 0 1 10/01/04 OPEN

64483 Injection, lumbar orsacral, single level 01/01/00 1 146.91 0 1 10/01/04 OPEN

64484 Injection,lumbar or sacral, each added level 01/01/00 1 135.10 0 1 10/01/04 OPEN




64517 N Block Inj, Hypogas Plxs 01/01/04 1 128.85 0



64550 Apply neurostimulator 01/01/00 2 16.24 15.36 0

64553 Implant neuroelectrodes 07/01/03 2 109.74 BR 14 1 01/01/04 OPEN

64555 Implant neuroelectrodes 07/01/03 2 121.42 BR 14


64561 Perc implant neurostimular electrode 01/01/02 1 575.30 10



64575 Implant neuroelectrodes 07/01/03 2 194.32 BR 14 1 2-17-91 OPEN



64581 Incision neurostimulator electrode imp 01/01/02 1 544.07 90

64585 Revise/remove neuroelectrode 07/01/03 2 142.69 BR 14 1 01/01/04 OPEN

64590 Implant neuroreceiver 07/01/03 2 126.35 BR 14 2 2-17-91 OPEN

64595 Revise/remove neuroreceiver 07/01/03 2 96.51 BR 14 1 2-17-91 OPEN

64600 Injection treatment of nerve 01/01/00 2 140.18 124.46 7 1 2-17-91 OPEN



64612 Destroy nerve, face muscle 01/01/00 2 98.33 83.21 45

64613 Destroy nerve, spine muscle 01/01/00 2 90.81 83.21 45

64614 Destroy nerve, extrem musc 01/01/01 1 158.10 45




5101:3-1-60 Page 133







64626 Destruction by neurolytic agent,cervical, single level 01/01/00 1 188.10 10 1 10/01/04 OPEN

64627 Destruction by neurolytic agent, cervical, added level 01/01/00 1 110.94 10 1 10/01/04 OPEN


64640 Injection treatment of nerve 01/01/00 2 103.80 83.04 7


64681 Injection Treatment Of Nerve 01/01/04 1 315.68 10

64702 Revise finger/toe nerve 01/01/00 2 230.87 210.45 90 1 2-17-91 OPEN

64704 Revise hand/foot nerve 01/01/00 2 252.77 247.97 90 1 2-17-91 OPEN

64708 Revise arm/leg nerve 01/01/00 2 349.22 335.64 90 2 2-17-91 OPEN

64712 Revision of sciatic nerve 01/01/00 2 434.02 424.44 90 2 2-17-91 OPEN

64713 Revision of arm nerve(s) 01/01/00 2 543.53 506.12 90 2 2-17-91 OPEN

64714 Revise low back nerve(s) 01/01/00 2 443.80 412.47 90 2 2-17-91 OPEN

64716 Revision of cranial nerve 01/01/00 2 304.58 266.32 90 3 2-17-91 OPEN

64718 Revise ulnar nerve at elbow 01/01/00 2 340.89 313.38 90 2 2-17-91 OPEN

64719 Revise ulnar nerve at wrist 01/01/00 2 268.53 247.70 90 2 2-17-91 OPEN

64721 Carpal tunnel surgery 01/01/00 2 254.17 228.52 45 2 2-17-91 OPEN

64722 Relieve pressure on nerve(s) 01/01/00 2 265.76 265.37 15 1 2-17-91 OPEN

64726 Release foot/toe nerve 01/01/00 2 138.42 113.51 30 1 2-17-91 OPEN

64727 Internal nerve revision 01/01/00 2 167.74 162.22 30 1 2-17-91 OPEN

64732 Incision of brow nerve 01/01/00 2 234.75 216.13 60 2 2-17-91 OPEN

64734 Incision of cheek nerve 01/01/00 2 254.18 232.97 60 2 2-17-91 OPEN

64736 Incision of chin nerve 01/01/00 2 233.22 217.92 30 2 2-17-91 OPEN

64738 Incision of jaw nerve 01/01/00 2 283.37 261.14 30 2 2-17-91 OPEN

64740 Incision of tongue nerve 01/01/00 2 281.69 260.54 0 2 2-17-91 OPEN

64742 Incision of facial nerve 01/01/00 2 298.69 266.99 60 2 2-17-91 OPEN

64744 Incise nerve, back of head 01/01/00 2 296.47 283.85 60 2 2-17-91 OPEN

64746 Incise diaphragm nerve 01/01/00 2 268.04 240.40 30 2 2-17-91 OPEN

64752 Incision of vagus nerve 01/01/00 2 305.71 270.57 45

64755 Incision of stomach nerves 01/01/00 2 647.45 610.75 45

64760 Incision of vagus nerve 01/01/00 2 369.13 346.64 45

64761 Incision of pelvis nerve 01/01/00 2 290.87 265.33 45

64763 Incise hip/thigh nerve 01/01/00 2 333.02 294.08 45

64766 Incise hip/thigh nerve 01/01/00 2 420.73 381.98 60

64771 Sever cranial nerve 01/01/00 2 368.27 332.64 30 2 2-17-91 OPEN

64772 Incision of spinal nerve 01/01/00 2 377.49 350.30 60 2 2-17-91 OPEN

64774 Remove skin nerve lesion 01/01/00 2 218.27 190.55 60 2 1-1-96 OPEN 3 2-17-91 12-31-95

64776 Remove digit nerve lesion 01/01/00 2 216.02 190.45 60 3 2-17-91 OPEN

64778 Added digit nerve surgery 01/01/00 2 154.84 147.79 60 2 2-17-91 OPEN

5101:3-1-60 Page 134







64782 Remove limb nerve lesion 01/01/00 2 286.00 258.26 60 3 2-17-91 OPEN

64783 Added limb nerve surgery 01/01/00 2 184.86 175.53 60 2 2-17-91 OPEN

64784 Remove nerve lesion 01/01/00 2 425.81 380.03 60 3 2-17-91 OPEN

64786 Remove sciatic nerve lesion 01/01/00 2 759.04 705.35 60 3 2-17-91 OPEN

64787 Implant nerve end 01/01/00 2 206.89 197.54 0 2 2-17-91 OPEN

64788 Remove skin nerve lesion 01/01/00 2 222.92 198.65 14 3 2-17-91 OPEN

64790 Removal of nerve lesion 01/01/00 2 506.34 455.90 30 3 2-17-91 OPEN

64792 Removal of nerve lesion 01/01/00 2 657.65 592.75 0 3 2-17-91 OPEN

64795 Biopsy of nerve 01/01/00 2 144.26 136.40 15 2 2-17-91 OPEN

64802 Remove sympathetic nerves 01/01/00 2 397.48 348.35 60 2 2-17-91 OPEN

64804 Remove sympathetic nerves 01/01/00 2 730.73 680.67 60




64821 Sympathectomy,,radial artery 01/01/02 1 442.26 90 4 01/01/04 OPEN

64822 Sympathectomy,ulnar artery 01/01/02 1 442.26 90

64823 Sympathectomy, superf palmar arch 01/01/02 1 510.68 90

64830 Microrepair of nerve 04/01/99 3 NC 129.88 0 5 2-17-91 OPEN

64831 Repair of digit nerve 01/01/00 2 364.90 303.50 90 4 2-17-91 OPEN

64832 Repair additional nerve 01/01/00 2 199.83 173.90 90 1 2-17-91 OPEN

64834 Repair of hand or foot nerve 01/01/00 2 386.75 328.56 90 2 2-17-91 OPEN



64837 Repair additional nerve 01/01/00 2 291.07 273.29 0 1 2-17-91 OPEN

64840 Repair of leg nerve 01/01/00 2 605.65 547.70 90 2 2-17-91 OPEN

64856 Repair/transpose nerve 01/01/00 2 609.99 531.72 90 2 2-17-91 OPEN

64857 Repair arm/leg nerve 01/01/00 2 658.75 578.71 90 2 2-17-91 OPEN

64858 Repair sciatic nerve 01/01/00 2 756.06 674.25 90 2 1-1-96 OPEN

64859 Additional nerve surgery 01/01/00 2 208.06 196.76 30 1 2-17-91 OPEN

64861 Repair of arm nerves 01/01/00 2 870.16 771.54 90 3 2-17-91 OPEN

64862 Repair of low back nerves 01/01/00 2 1,041.54 967.60 90 3 2-17-91 OPEN

64864 Repair of facial nerve 01/01/00 2 559.76 493.55 90 3 2-17-91 OPEN

64865 Repair of facial nerve 01/01/00 2 734.79 672.19 90 4 2-17-91 OPEN

64866 Fusion of facial/other nerve 01/01/00 2 734.14 660.40 90

64868 Fusion of facial/other nerve 01/01/00 2 674.42 613.06 90

64870 Fusion of facial/other nerve 01/01/00 2 785.33 724.80 90 4 2-17-91 OPEN

64872 Subsequent repair of nerve 01/01/02 2 94.74 BR 30 2 2-17-91 OPEN

64874 Repair & revise nerve 01/01/02 2 140.32 BR 30 3 2-17-91 OPEN

5101:3-1-60 Page 135







64876 Repair nerve; shorten bone 01/01/00 2 156.31 149.40 30 3 2-17-91 OPEN

64885 Nerve graft, head or neck 01/01/00 2 810.38 728.40 90 2 01/01/04 OPEN

64886 Nerve graft, head or neck 01/01/00 2 960.48 868.67 90 2 01/01/04 OPEN

64890 Nerve graft, hand or foot 01/01/00 2 746.85 677.73 60 2 2-17-91 OPEN


64892 Nerve graft, arm or leg 01/01/00 2 692.77 627.00 60 2 2-17-91 OPEN






64901 Additional nerve graft 01/01/00 2 522.34 498.95 30 2 2-17-91 OPEN

64902 Additional nerve graft 01/01/00 2 610.10 580.75 30 2 2-17-91 OPEN

64905 Nerve pedicle transfer 01/01/00 2 612.91 549.35 30 2 2-17-91 OPEN

64907 Nerve pedicle transfer 01/01/00 2 873.55 791.21 30 1 2-17-91 OPEN

64999 Nervous system surgery 05/01/94 1 BR 0

65091 Revise eye 01/01/00 2 371.88 335.81 30 3 2-17-91 OPEN

65093 Revise eye with implant 01/01/00 2 398.38 357.18 30 3 2-17-91 OPEN

65101 Removal of eye 01/01/00 2 405.54 358.70 30 3 2-17-91 OPEN

65103 Remove eye/insert implant 01/01/00 2 433.23 388.15 30 3 2-17-91 OPEN

65105 Remove eye/attach implant 01/01/00 2 482.84 429.76 30 4 2-17-91 OPEN

65110 Removal of eye 01/01/00 2 775.88 709.68 60 5 2-17-91 OPEN

65112 Remove eye, revise socket 01/01/00 2 789.85 675.44 60 7 2-17-91 OPEN

65114 Remove eye, revise socket 01/01/00 2 849.36 738.02 60 7 2-17-91 OPEN

65125 Revise ocular implant 01/01/02 2 187.55 BR 45

65130 Insert ocular implant 01/01/00 2 409.56 371.59 30 3 2-17-91 OPEN

65135 Insert ocular implant 01/01/00 2 363.40 298.76 30 2 2-17-91 OPEN

65140 Attach ocular implant 01/01/00 2 398.28 329.20 90 3 2-17-91 OPEN

65150 Revise ocular implant 01/01/00 2 365.20 331.61 60 2 2-17-91 OPEN

65155 Reinsert ocular implant 01/01/00 2 497.11 459.19 7 3 2-17-91 OPEN

65175 Removal of ocular implant 01/01/00 2 361.53 323.17 7 1 2-17-91 OPEN

* 65205 Remove foreign body from eye 01/01/04 2 36.29 34.59 0

* 65210 Remove foreign body from eye 01/01/04 2 43.74 39.26 0 1 2-17-91 9/30/04



65235 Remove foreign body from eye 01/01/00 2 356.85 306.38 45 2 2-17-91 OPEN



5101:3-1-60 Page 136







65270 Repair of eye wound 01/01/00 2 91.06 72.85 15 2 2-17-91 OPEN


65273 Repair of eye wound 01/01/00 2 207.78 172.09 14




65286 Repair of eye wound 01/01/00 2 284.78 239.37 60

65290 Repair of eye socket wound 01/01/00 2 307.84 272.13 30 3 2-17-91 OPEN

65400 Removal of eye lesion 01/01/00 2 339.27 290.75 30 1 2-17-91 OPEN

* 65410 Biopsy of cornea 01/01/04 2 86.19 81.58 0 2 2-17-91 OPEN



* 65430 Corneal smear 01/01/04 2 129.43 42.44 0

* 65435 Curette/treat cornea 01/01/04 2 60.77 47.25 0

65436 Curette/treat cornea 01/01/00 2 165.88 132.70 7

65450 Treatment of corneal lesion 01/01/00 2 188.00 152.75 7

65600 Revision of cornea 01/01/00 2 168.36 138.88 30

65710 Corneal transplant 01/01/00 2 674.41 540.68 90 7 2-17-91 OPEN




65760 Revision of cornea 05/01/94 1 NC

65765 Revision of cornea 05/01/94 1 NC

65767 Corneal tissue transplant 05/01/94 1 NC

65770 Revise cornea with implant 01/01/00 2 844.82 730.26 90 7 1-1-96 OPEN

65771 Radial keratotomy 05/01/94 1 NC

65772 Correction of astigmatism 01/01/00 2 244.41 222.42 21 4 01/01/04 OPEN

65775 Correction of astigmatism 01/01/00 2 336.76 301.87 21 4 01/01/04 OPEN

65780 Ocular Reconst, Transplant 01/01/04 1 523.85 90



65800 Drainage of eye 01/01/00 2 97.97 87.58 30 1 2-17-91 OPEN




65820 Relieve inner eye pressure 01/01/00 2 466.12 412.76 30

65850 Incision of eye 01/01/00 2 578.81 558.78 60 4 2-17-91 OPEN

65855 Laser surgery of eye 01/01/00 2 270.52 261.77 60

5101:3-1-60 Page 137







65860 Incise inner eye adhesions 01/01/00 2 199.21 188.50 60

65865 Incise inner eye adhesions 01/01/00 2 317.92 298.42 60 1 2-17-91 OPEN




65900 Remove eye lesion 01/01/00 2 537.00 454.01 30 5 2-17-91 OPEN

65920 Remove implant from eye 01/01/00 2 443.95 391.31 60 7 2-17-91 OPEN

65930 Remove blood clot from eye 01/01/00 2 406.15 354.16 60 5 2-17-91 OPEN

66020 Injection treatment of eye 01/01/00 2 91.41 85.64 15 1 2-17-91 OPEN

66030 Injection treatment of eye 01/01/00 2 52.35 41.88 7 1 2-17-91 OPEN

66130 Remove eye lesion 01/01/00 2 348.35 308.44 15 7 2-17-91 OPEN

66150 Glaucoma surgery 01/01/00 2 464.84 418.89 45 4 2-17-91 OPEN





66172 Incision of eye 01/01/00 2 720.70 621.02 45 4 2-17-91 OPEN

66180 Implant eye shunt 01/01/00 2 794.74 697.78 45 5 1-1-96 OPEN

66185 Revise eye shunt 01/01/00 2 456.58 423.76 45 2 1-1-96 OPEN

66220 Repair eye lesion 01/01/00 2 384.46 319.94 60 3 1-1-96 OPEN 2 2-17-91 12-31-95

66225 Repair/graft eye lesion 01/01/00 2 609.27 582.92 60 4 2-17-91 OPEN

66250 Follow-up surgery of eye 01/01/00 2 340.31 308.85 45 2 2-17-91 OPEN

66500 Incision of iris 01/01/00 2 207.76 197.15 30 1 2-17-91 OPEN

66505 Incision of iris 01/01/00 2 199.41 173.17 30 1 2-17-91 OPEN

66600 Remove iris and lesion 01/01/00 2 475.10 423.79 45 3 2-17-91 OPEN

66605 Removal of iris 01/01/00 2 664.07 583.72 45 3 2-17-91 OPEN




66680 Repair iris & ciliary body 01/01/00 2 308.91 278.55 45 3 2-17-91 OPEN

66682 Repair iris and ciliary body 01/01/00 2 350.88 317.33 15 2 2-17-91 OPEN

66700 Destruction, ciliary body 01/01/00 2 276.91 250.95 45 2 2-17-91 OPEN

66710 Destruction, ciliary body 01/01/00 2 277.57 252.47 45 2 2-17-91 OPEN66711 Ciliary endoscopic ablation 01/01/05 1 368.36 90



66761 Revision of iris 01/01/00 2 227.70 218.64 30

66762 Revision of iris 01/01/00 2 255.25 252.80 30 1 2-17-91 9/30/04

5101:3-1-60 Page 138







66770 Removal of inner eye lesion 01/01/00 2 283.16 270.75 45

66820 Incision, secondary cataract 01/01/00 2 230.88 207.22 45

66821 After cataract laser surgery 01/01/00 2 137.81 162.94 90 2 2-17-91 OPEN

66825 Reposition intraocular lens 01/01/00 2 418.81 362.24 45 4 01/01/04 OPEN

66830 Removal of lens lesion 01/01/00 2 426.39 372.17 45 4 2-17-91 OPEN

66840 Removal of lens material 01/01/00 2 438.01 412.95 30 4 2-17-91 OPEN



66920 Extraction of lens 01/01/00 2 487.15 464.85 90 4 2-17-91 OPEN



66950 Excision cataract 07/01/03 3 NC BR

66982 Cataract surgery, complex 01/01/01 1 644.46 90 8 1-01-02 OPEN

66983 Remove cataract, insert lens 01/01/00 2 484.05 478.40 90 8 2-17-91 OPEN

66984 Remove cataract, insert lens 01/01/00 2 560.36 549.74 90 8 2-17-91 OPEN

66985 Insert lens prosthesis 01/01/00 2 456.87 435.53 90 6 2-17-91 OPEN

66986 Exchange lens prosthesis 01/01/00 2 635.40 576.77 90 6 2-17-91 OPEN

66990 Ophthalmic endoscope add-on 07/01/03 1 57.34 90

66999 Eye surgery procedure 05/01/94 1 BR 0

67005 Partial removal of eye fluid 07/01/02 2 305.45 315.01 60 4 2-17-91 OPEN

67010 Partial removal of eye fluid 07/01/02 2 368.51 374.34 90 4 2-17-91 OPEN

67015 Release of eye fluid 01/01/00 2 361.08 316.46 15 1 2-17-91 OPEN

67025 Replace eye fluid 01/01/00 2 389.20 317.54 30 1 2-17-91 OPEN

67027 Implantation of intravitreal drug delivery system 01/01/00 2 549.49 478.54 4 01/01/04 OPEN

67028 Injection eye drug 01/01/00 2 168.27 138.43 14

67030 Incise inner eye strands 01/01/00 2 279.36 250.30 60 1 2-17-91 OPEN

67031 Laser surgery, eye strands 01/01/00 2 213.70 241.27 60 2 1-1-96 OPEN

67036 Removal of inner eye fluid 01/01/00 2 658.37 666.86 90 4 2-17-91 OPEN

67038 Strip retinal membrane 01/01/00 2 1,155.81 1,119.61 90 5 2-17-91 OPEN

67039 Laser treatment of retina 01/01/00 2 803.79 784.28 90 7 2-17-91 OPEN

67040 Laser treatment of retina 01/01/00 2 946.60 908.93 90 7 2-17-91 OPEN

67101 Repair, detached retina 01/01/00 2 431.38 390.12 90 4 2-17-91 9/30/04

67105 Repair, detached retina 01/01/00 2 434.23 398.05 60 5 2-17-91 9/30/04

67107 Repair detached retina 01/01/00 2 813.70 771.85 90 5 2-17-91 OPEN

67108 Repair detached retina 01/01/00 2 1,142.74 1,102.74 90 7 2-17-91 OPEN

67109 Repair detached retina 04/01/96 3 NC 723.70 90 5 2-17-91 OPEN

67110 Repair detached retina 01/01/00 2 530.96 461.56 14

67112 Re-repair detached retina 01/01/00 2 877.54 785.73 90 7 2-17-91 OPEN

5101:3-1-60 Page 139







67115 Release, encircling material 01/01/00 2 285.14 257.67 30 2 2-17-91 OPEN

67120 Remove eye implant material 01/01/00 2 360.85 307.71 30 2 2-17-91 OPEN

67121 Remove eye implant material 01/01/00 2 544.33 471.23 30 2 2-17-91 OPEN

67141 Treatment of retina 01/01/00 2 299.50 272.68 30 2 2-17-91 OPEN

67145 Treatment of retina 01/01/00 2 308.71 282.25 30

67208 Treatment of retinal lesion 01/01/00 2 374.85 353.45 30 1 2-17-91 9/30/04

67210 Treatment of retinal lesion 01/01/00 2 460.39 445.04 30

67218 Treatment of retinal lesion 01/01/00 2 711.43 626.65 30 5 2-17-91 OPEN

67220 Treatment of choroid lesion 01/01/00 2 389.37 476.59 90

67221 Destruction of lesion of choriod 01/01/01 1 247.05 30

67225 Ocular photodynamic therapy 01/01/02 1 31.76 30

67227 Treatment of retinal lesion 01/01/00 2 370.56 346.90 30 1 2-17-91 OPEN

67228 Treatment of retinal lesion 01/01/00 2 584.69 523.60 30

67250 Reinforce eye wall 01/01/00 2 433.61 370.13 45 3 2-17-91 OPEN

67255 Reinforce/graft eye wall 01/01/00 2 505.73 467.98 45 3 2-17-91 OPEN

67299 Eye surgery procedure 05/01/94 1 BR 0

67311 Revise eye muscle 01/01/00 2 370.61 346.81 30 3 2-17-91 OPEN

67312 Revise two eye muscles 01/01/00 2 468.90 414.80 30 4 2-17-91 OPEN


67316 Revise two eye muscles 01/01/00 2 521.34 443.54 45 4 2-17-91 OPEN

67318 Revise eye muscle(s) 01/01/00 2 382.09 328.73 45 4 2-17-91 OPEN

67320 Revise eye muscle(s) 07/01/02 2 232.17 354.98 30 4 2-17-91 OPEN

67331 Eye surgery follow-up 07/01/02 2 220.12 324.69 30 4 2-17-91 OPEN

67332 Rerevise eye muscles 07/01/02 2 240.63 361.84 30 4 2-17-91 OPEN

67334 Revise eye muscle w/suture 07/01/02 2 212.81 268.87 30 4 01/01/04 OPEN

67335 Eye suture during surgery 07/01/02 2 133.53 148.94 21 4 01/01/04 OPEN


67343 Release eye tissue 01/01/00 2 360.32 308.76 30

67345 Destroy nerve of eye muscle 01/01/00 2 146.69 127.05 21

67350 Biopsy eye muscle 01/01/00 2 144.56 126.66 30 1 2-17-91 OPEN

67399 Eye muscle surgery procedure 05/01/94 1 BR 0

67400 Explore/biopsy eye socket 01/01/00 2 547.54 485.18 30 3 2-17-91 OPEN

67405 Explore/drain eye socket 01/01/00 2 457.28 411.36 30 4 2-17-91 OPEN

67412 Explore/treat eye socket 01/01/00 2 548.40 503.01 30 5 2-17-91 OPEN


67414 Explore/decompress eye socke 01/01/00 2 551.28 444.10 45

67415 Aspiration orbital contents 07/01/02 2 93.40 95.66 7 1 2-17-91 OPEN


5101:3-1-60 Page 140








67440 Explore/drain eye socket 01/01/00 2 735.94 685.53 30 5 2-17-91 OPEN

67445 Explore/decompress eye socke 01/01/00 2 703.59 588.82 45

67450 Explore/biopsy eye socket 01/01/00 2 757.68 677.75 30 5 2-17-91 OPEN

* 67500 Inject/treat eye socket 01/01/00 2 46.40 37.12 0

67505 Inject/treat eye socket 01/01/00 2 56.13 44.90 0

* 67515 Inject/treat eye socket 01/01/04 2 39.03 35.21 0

67550 Insert eye socket implant 01/01/00 2 537.87 469.60 30 4 2-17-91 OPEN

67560 Revise eye socket implant 01/01/00 2 516.41 443.79 30 2 2-17-91 OPEN

67570 Decompress optic nerve 01/01/00 2 602.86 482.75 45

67599 Orbit surgery procedure 05/01/94 1 BR 0

* 67700 Drainage of eyelid abscess 01/01/04 2 232.67 53.93 10

* 67710 Incision of eyelid 01/01/04 2 227.06 59.78 10

67715 Incision of eyelid fold 07/01/02 2 65.53 71.33 14 1 2-17-91 OPEN

67800 Remove eyelid lesion 01/01/00 2 68.88 55.10 15

67801 Remove eyelid lesions 01/01/00 2 97.12 78.12 15 2 2-17-91 9/30/04

67805 Remove eyelid lesions 01/01/00 2 106.96 85.57 15

67808 Remove eyelid lesion(s) 01/01/00 2 168.91 137.07 30 2 2-17-91 OPEN

* 67810 Biopsy of eyelid 01/01/04 2 185.69 69.08 0

67820 Revise eyelashes 01/01/00 2 38.18 30.54 15

67825 Revise eyelashes 01/01/00 2 67.14 53.71 15

67830 Revise eyelashes 01/01/00 2 115.29 92.23 30 2 2-17-91 OPEN

67835 Revise eyelashes 01/01/00 2 305.92 298.97 60 2 2-17-91 OPEN

* 67840 Remove eyelid lesion 01/01/04 2 262.69 96.69 10

* 67850 Treat eyelid lesion 01/01/04 2 141.68 74.16 10

67875 Closure of eyelid by suture 01/01/00 2 93.63 74.90 14



67900 Repair brow defect 01/01/00 2 250.25 200.20 45 4 01/01/04 OPEN

67901 Repair eyelid defect 01/01/00 2 390.63 378.88 60 5 2-17-91 OPEN






67909 Revise eyelid defect 01/01/00 2 317.07 289.93 30 4 2-17-91 OPEN

67911 Revise eyelid defect 01/01/00 2 309.97 292.18 30 3 2-17-91 OPEN

67912 Correction Eyelid W/ Implant 01/01/04 1 666.40 90

5101:3-1-60 Page 141








67915 Repair eyelid defect 01/01/00 2 130.86 104.69 15




67922 Repair eyelid defect 01/01/00 2 125.55 100.44 15



67930 Repair eyelid wound 01/01/00 2 145.56 116.45 30 2 2-17-91 9/30/04

67935 Repair eyelid wound 01/01/00 2 297.74 238.19 30 2 2-17-91 OPEN

67938 Remove eyelid foreign body 01/01/00 2 54.18 43.34 7 2 2-17-91 9/30/04




67971 Reconstruction of eyelid 01/01/00 2 532.82 489.10 30 3 2-17-91 OPEN




67999 Eyelid surgery procedure 05/01/94 1 BR 0

68020 Incise/drain eyelid lining 01/01/00 2 55.10 44.08 0

68040 Treatment of eyelid lesions 01/01/00 2 38.96 31.17 7

68100 Biopsy of eyelid lining 01/01/00 2 70.61 56.49 15

68110 Remove eyelid lining lesion 01/01/00 2 89.16 71.33 15 1 2-17-91 9/30/04

68115 Remove eyelid lining lesion 01/01/00 2 127.79 102.23 15 2 2-17-91 OPEN

68130 Remove eyelid lining lesion 01/01/00 2 249.42 212.81 15 2 2-17-91 OPEN

* 68135 Remove eyelid lining lesion 01/01/04 2 257.49 76.08 10

* 68200 Treat eyelid by injection 01/01/04 2 33.16 30.46 0

68320 Revise/graft eyelid lining 01/01/00 2 294.78 275.11 30 4 2-17-91 OPEN




68330 Revise eyelid lining 01/01/00 2 276.67 249.78 60 4 2-17-91 OPEN


68340 Separate eyelid adhesions 01/01/00 2 212.46 169.97 60 4 2-17-91 OPEN



68371 Harvest Eye Tissue, Alograft 01/01/04 1 247.69 10

68399 Eyelid lining surgery 05/01/94 1 BR 0

5101:3-1-60 Page 142







68400 Incise/drain tear gland 01/01/00 2 79.60 63.68 0

68420 Incise/drain tear sac 01/01/00 2 98.49 78.79 0

* 68440 Incise tear duct opening 01/01/04 2 222.53 49.63 10

68500 Removal of tear gland 01/01/00 2 511.78 443.82 45 3 2-17-91 OPEN

68505 Partial removal tear gland 01/01/00 2 530.93 459.89 45 3 2-17-91 OPEN

68510 Biopsy of tear gland 01/01/00 2 243.97 201.87 15 1 2-17-91 OPEN

68520 Removal of tear sac 01/01/00 2 414.78 390.97 45 3 2-17-91 OPEN

68525 Biopsy of tear sac 01/01/00 2 211.12 196.04 15 1 2-17-91 OPEN

68530 Clearance of tear duct 01/01/00 2 194.90 155.92 15

68540 Remove tear gland lesion 01/01/00 2 508.07 444.52 45 3 2-17-91 OPEN

68550 Remove tear gland lesion 01/01/00 2 650.23 581.11 90 3 2-17-91 OPEN

68700 Repair tear ducts 01/01/00 2 267.46 213.97 45 2 2-17-91 OPEN

68705 Revise tear duct opening 01/01/00 2 90.96 72.77 0

68720 Create tear sac drain 01/01/00 2 494.58 427.36 60 4 2-17-91 OPEN

68745 Create tear duct drain 01/01/00 2 411.88 358.49 60 4 2-17-91 OPEN

68750 Create tear duct drain 01/01/00 2 483.11 457.41 60 4 2-17-91 OPEN

68760 Close tear duct opening 01/01/00 2 77.89 62.31 15

68761 Close tear duct opening 01/01/00 2 66.79 53.43 30

68770 Close tear system fistula 01/01/00 2 326.74 261.39 30 4 01/01/04 OPEN

* 68800 Dilate tear duct opening(s) 04/01/97 3 NC 33.64 0

* 68801 Dilation of lacrimal punctum 01/01/04 2 48.82 37.09 10

68810 Probing of nasolacrimal duct 01/01/00 2 51.58 41.26 10 1 10/01/04 OPEN

68811 Probing of nasolacrimal duct w/anesthesia 01/01/00 2 107.21 85.77 10 2 10/01/04 OPEN 1 01/01/00 9/30/04

68815 Probing of nasolacrimal duct 01/01/00 2 140.70 112.56 10 2 01/01/97 OPEN

* 68820 Explore tear duct system 04/01/97 3 NC 44.92 0

68825 Explore tear duct system 04/01/97 3 NC 67.05 0 2 2-17-91 OPEN

68830 Reopen tear duct channel 04/01/97 3 NC 89.19 15 2 2-17-91 OPEN

* 68840 Explore/irrigate tear ducts 01/01/04 2 76.02 51.53 10

* 68850 Injection for tear sac x-ray 01/01/04 2 205.85 39.80 0

68899 Tear duct system surgery 05/01/94 1 BR 0

* 69000 Drain external ear lesion 01/01/04 2 96.86 52.94 10

69005 Drain external ear lesion 01/01/00 2 92.86 79.19 7

* 69020 Drain outer ear canal lesion 01/01/04 2 101.06 57.01 10

69090 Pierce earlobes 05/01/94 1 NC

69100 Biopsy of external ear 01/01/00 2 42.89 35.06 0

69105 Biopsy of external ear canal 01/01/00 2 46.87 40.92 0 1 2-17-91 12-31-95

69110 Partial removal external ear 01/01/00 2 166.41 149.51 30 1 2-17-91 OPEN

69120 Removal of external ear 01/01/00 2 143.00 114.40 90 2 2-17-91 OPEN

5101:3-1-60 Page 143







69140 Remove ear canal lesion(s) 01/01/00 2 436.66 389.01 90 2 2-17-91 OPEN

69145 Remove ear canal lesion(s) 01/01/00 2 140.43 125.28 0 2 2-17-91 OPEN

69150 Extensive ear canal surgery 01/01/00 2 654.49 582.43 90 3 2-17-91 OPEN

69155 Extensive ear/neck surgery 01/01/00 2 983.18 812.48 90

69200 Clear outer ear canal 01/01/00 2 35.74 29.07 0

69205 Clear outer ear canal 01/01/00 2 61.90 54.78 0 1 2-17-91 OPEN

69210 Remove impacted ear wax 01/01/00 2 25.50 20.40 0

69220 Clean out mastoid cavity 01/01/00 2 39.52 32.59 0

69222 Clean out mastoid cavity 01/01/00 2 63.04 51.31 0

69300 Revise external ear 07/01/03 2 280.71 BR 90 3 01/01/04 OPEN

69310 Rebuild outer ear canal 01/01/00 2 561.70 505.88 90 3 2-17-91 OPEN

69320 Rebuild outer ear canal 01/01/00 2 853.90 774.50 90 7 2-17-91 OPEN

69399 Outer ear surgery procedure 05/01/94 1 BR 0

69400 Inflate middle ear canal 01/01/00 2 38.61 31.45 0

69401 Inflate middle ear canal 01/01/00 2 26.99 21.59 0

69405 Catheterize middle ear canal 01/01/00 2 92.38 73.90 0

69410 Inset middle ear baffle 01/01/00 2 27.52 23.37 0

69420 Incision of eardrum 01/01/00 2 60.44 48.49 0 1 2-17-91 12-31-95

* 69421 Incision of eardrum 01/01/04 2 117.78 82.14 10 3 2-17-91 OPEN

69424 Remove ventilating tube 01/01/00 2 42.83 35.60 0 1 2-17-91 12/31/03

* 69433 Create eardrum opening 01/01/04 2 104.50 79.98 10

69436 Create eardrum opening 01/01/00 2 108.17 143.18 7 3 2-17-91 OPEN

69440 Exploration of middle ear 01/01/00 2 431.86 397.11 30 3 2-17-91 OPEN

69450 Eardrum revision 01/01/00 2 333.74 318.39 90 1 2-17-91 OPEN

69501 Mastoidectomy 01/01/00 2 513.22 489.57 90 7 2-17-91 OPEN

69502 Mastoidectomy 01/01/00 2 686.52 628.36 90 7 2-17-91 OPEN

69505 Remove mastoid structures 01/01/00 2 730.35 713.83 90 7 2-17-91 OPEN

69511 Extensive mastoid surgery 01/01/00 2 758.34 743.32 90 7 2-17-91 OPEN

69530 Extensive mastoid surgery 01/01/00 2 957.02 857.53 90 7 2-17-91 OPEN

69535 Remove part of temporal bone 01/01/00 2 1,650.07 1,476.48 90

69540 Remove ear lesion 01/01/00 2 69.49 60.10 30

69550 Remove ear lesion 01/01/00 2 631.15 619.83 90 5 2-17-91 OPEN

69552 Remove ear lesion 01/01/00 2 964.43 880.75 90 7 2-17-91 OPEN

69554 Remove ear lesion 01/01/00 2 1,501.82 1,206.83 90

69601 Mastoid surgery revision 01/01/00 2 730.20 665.86 90 7 2-17-91 OPEN




5101:3-1-60 Page 144








69610 Repair of eardrum 01/01/00 2 157.14 128.90 42 2 2-17-91 12-31-95

69620 Repair of eardrum 01/01/00 2 340.74 334.51 90 2 2-17-91 OPEN

69631 Repair eardrum structures 01/01/00 2 564.69 548.59 90 5 2-17-91 OPEN

69632 Rebuild eardrum structures 01/01/00 2 719.76 703.68 90 5 2-17-91 OPEN


69635 Repair eardrum structures 01/01/00 2 750.68 740.44 90 7 2-17-91 OPEN



69641 Revise middle ear & mastoid 01/01/00 2 718.26 700.94 90 7 2-17-91 OPEN





69646 Revise middle ear & mastoid 01/01/00 2 1,002.60 978.05 90 7 2-17-91 OPEN

69650 Release middle ear bone 01/01/00 2 547.82 533.54 90 7 2-17-91 OPEN

69660 Revise middle ear bone 01/01/00 2 672.35 665.16 90 5 2-17-91 OPEN



69666 Repair middle ear structures 01/01/00 2 561.91 543.56 90 4 2-17-91 OPEN

69667 Repair middle ear structures 01/01/00 2 560.17 541.46 90 4 2-17-91 OPEN

69670 Remove mastoid air cells 01/01/00 2 590.17 524.67 90 3 2-17-91 OPEN

69676 Remove middle ear nerve 01/01/00 2 493.43 437.79 90 3 2-17-91 OPEN

69700 Close mastoid fistula 01/01/00 2 419.04 391.77 60 3 2-17-91 OPEN

69710 Implant/replace hearing aid 05/01/94 1 BR 30 3 2-17-91 12/31/03

69711 Remove/repair hearing aid 01/01/00 2 510.07 446.68 0 1 2-17-91 OPEN

69714 Implant temple bone w/stimul 01/01/01 1 660.81 90 9 01/01/04 OPEN

69715 Temple bne implnt w/stimulat 01/01/01 1 837.57 90 9 01/01/04 OPEN

69717 Temple bone implant revision 01/01/01 1 681.47 90 9 01/01/04 OPEN

69718 Revise temple bone implant 01/01/01 1 847.61 90 9 01/01/04 OPEN

69720 Release facial nerve 01/01/00 2 813.82 791.33 90 5 2-17-91 OPEN

69725 Release facial nerve 01/01/00 2 1,034.80 827.84 90 5 2-17-91 OPEN

69740 Repair facial nerve 01/01/00 2 759.76 681.98 90 5 2-17-91 OPEN

69745 Repair facial nerve 01/01/00 2 859.67 788.80 90 5 2-17-91 OPEN

69799 Middle ear surgery procedure 05/01/94 1 BR 0

69801 Incise inner ear 01/01/00 2 502.08 482.14 90 5 2-17-91 OPEN

69802 Incise inner ear 01/01/00 2 659.69 585.75 90 7 2-17-91 OPEN

69805 Explore inner ear 01/01/00 2 734.46 596.75 90 7 2-17-91 OPEN

5101:3-1-60 Page 145







69806 Explore inner ear 01/01/00 2 714.94 693.02 90 7 2-17-91 OPEN

69820 Establish inner ear window 01/01/00 2 533.07 470.49 90 5 2-17-91 OPEN

69840 Revise inner ear window 01/01/00 2 519.27 447.91 90 5 2-17-91 OPEN

69905 Remove inner ear 01/01/00 2 638.29 621.61 90 7 2-17-91 OPEN

69910 Remove inner ear & mastoid 01/01/00 2 774.72 756.03 90 7 2-17-91 OPEN

69915 Incise inner ear nerve 01/01/00 2 1,045.78 932.35 90 7 2-17-91 OPEN

69930 Implant cochlear device 01/01/00 2 957.43 843.83 90 7 2-17-91 OPEN

69949 Inner ear surgery procedure 05/01/94 1 BR 0

69950 Incise inner ear nerve 05/20/86 3 NC 480.00 90

69955 Release facial nerve 01/01/00 2 1,265.77 1,050.29 90

69960 Release inner ear canal 01/01/00 2 1,162.36 929.89 90

69970 Remove inner ear lesion 01/01/00 2 1,301.78 1,041.42 90

69979 Temporal bone surgery 05/01/94 1 BR 0

69990 Use of operating microscope 01/01/00 2 120.84 128.90

70010 Contrast x-ray of brain 01/01/00 2 170.62 163.58 I

70015 Contrast x-ray of brain 01/01/00 2 86.25 84.71 L

70030 X-ray eye for foreign body 01/01/00 2 18.88 18.32 C

70100 X-ray exam of jaw 01/01/00 2 22.28 21.46 J

70110 X-ray exam of jaw 01/01/00 2 28.00 27.09 C

70120 X-ray exam of mastoids 01/01/00 2 25.13 24.09 J

70130 X-ray exam of mastoids 01/01/00 2 36.25 35.05 C

70134 X-ray exam of middle ear 01/01/00 2 34.82 33.75 C

70140 X-ray exam of facial bones 01/01/00 2 25.40 24.37 J

70150 X-ray exam of facial bones 01/01/00 2 33.14 31.82 J

70160 X-ray exam of nasal bones 01/01/00 2 21.75 20.93 J

70170 X-ray exam of tear duct 01/01/00 2 39.37 37.63 J

70190 X-ray exam of eye sockets 01/01/00 2 26.15 25.18 J

70200 X-ray exam of eye sockets 01/01/00 2 33.89 32.63 J

70210 X-ray exam of sinuses 01/01/00 2 24.59 23.56 I

70220 X-ray exam of sinuses 01/01/00 2 32.80 31.54 J

70240 X-ray exam pituitary saddle 01/01/00 2 19.69 19.13 C

70250 X-ray exam of skull 01/01/00 2 27.53 26.55 C

70260 X-ray exam of skull 01/01/00 2 39.42 37.95 C

70300 X-ray exam of teeth 01/01/00 2 11.86 11.43 C

70310 X-ray exam of teeth 01/01/00 2 18.47 17.79 C

70320 Full mouth x-ray of teeth 01/01/00 2 31.58 30.20 I

70328 X-ray exam of jaw joint 01/01/00 2 21.44 20.68 C

70330 X-ray exam of jaw joints 01/01/00 2 33.83 32.31 I

5101:3-1-60 Page 146







70332 X-ray exam of jaw joint 01/01/00 2 81.68 78.33 I

70336 Magnetic image jaw joint 01/01/00 2 372.11 336.48 G

70350 X-ray head for orthodontia 01/01/00 2 17.83 16.99 C

70355 Panoramic x-ray of jaws 01/01/00 2 24.44 23.34 J

70360 X-ray exam of neck 01/01/00 2 18.88 18.32 C

70370 Throat x-ray & fluoroscopy 01/01/00 2 50.00 47.87 I

70371 Speech evaluation, complex 01/01/00 2 93.79 90.53 C

70373 Contrast x-ray of larynx 01/01/00 2 68.48 65.60 I

70380 X-ray exam of salivary gland 01/01/00 2 25.96 24.86 I

70390 X-ray exam of salivary duct 01/01/00 2 65.98 63.17 H

70450 Cat scan of head or brain 01/01/00 2 168.71 160.53 G

70460 Contrast cat scan of head 01/01/00 2 206.28 196.83 H

70470 Contrast cat scans of head 01/01/00 2 252.17 239.99 G

70480 Cat scan of skull 01/01/00 2 185.96 178.15 I

70481 Contrast cat scan of skull 01/01/00 2 216.19 206.84 I

70482 Contrast cat scans of skull 01/01/00 2 259.32 247.30 H

70486 Cat scan of face, jaw 01/01/00 2 179.99 172.19 I

70487 Contrast cat scan, face/jaw 01/01/00 2 213.08 203.60 I

70488 Contrast cat scans face/jaw 01/01/00 2 258.23 246.22 H

70490 Cat scan of neck tissue 01/01/00 2 185.96 178.15 I

70491 Contrast cat of neck tissue 01/01/00 2 216.19 206.84 I

70492 Contrast cat of neck tissue 01/01/00 2 259.25 247.30 H

70496 Ct angiography, head 01/01/01 1 291.68 H

70498 Ct angiography, neck 01/01/01 1 291.68 H

70540 Magnetic image, face, neck 01/01/00 2 377.90 358.18 G

70541 Magnetic image, head (mra) 04/01/01 3 NC 387.63 G

70542 Mri orbit/face/neck w/dye 01/01/01 1 445.02 F

70543 Mri orbt/fac/nck w/o&w dye 01/01/01 1 799.14 F

70544 Mr angiography head w/o dye 01/01/01 1 386.56 F

70545 Mr angiography head w/dye 01/01/01 1 386.56 F

70546 Mr angiograph head w/o&w dye 01/01/01 1 731.19 F

70547 Mr angiography neck w/o dye 01/01/01 1 386.56 F

70548 Mr angiography neck w/dye 01/01/01 1 386.56 F

70549 Mr angiograph neck w/o&w dye 01/01/01 1 731.19 F

70551 Magnetic image, brain (mri) 01/01/00 2 377.96 358.18 G

70552 Magnetic image, brain (mri) 01/01/00 2 453.72 430.15 G

70553 Magnetic image, brain 01/01/00 2 802.67 758.01 G

70557 Mri Brain W/O Dye 01/01/04 1 437.34 I

5101:3-1-60 Page 147







70558 Mri Brain W/ Dye 01/01/04 1 514.36 I

70559 Mri Brain W/O & W/ Dye 01/01/04 1 851.08 G

71010 Chest x-ray 01/01/00 2 20.72 19.90 C

71015 X-ray exam of chest 01/01/00 2 23.37 22.54 C

71020 Chest x-ray 01/01/00 2 26.49 25.45 J

71021 Chest x-ray 01/01/00 2 31.98 30.79 J

71022 Chest x-ray 01/01/00 2 33.54 32.41 C

71023 Chest x-ray and fluoroscopy 01/01/00 2 37.75 36.70 C

71030 Chest x-ray 01/01/00 2 34.97 33.71 C

71034 Chest x-ray & fluoroscopy 01/01/00 2 59.63 57.24 J

71035 Chest x-ray 01/01/00 2 22.09 21.20 J

71036 X-ray guidance for biopsy 04/01/01 3 NC 66.86 J

71038 X-ray guidance for biopsy 04/01/99 3 NC 67.33 J

71040 Contrast x-ray of bronchi 01/01/00 2 65.05 62.91 C

71060 Contrast x-ray of bronchi 01/01/00 2 92.86 89.34 J

71090 X-ray & pacemaker insertion 01/01/00 2 70.55 67.33 J

71100 X-ray exam of ribs 01/01/00 2 25.48 24.44 C

71101 X-ray exam of ribs, chest 01/01/00 2 30.18 29.20 C

71110 X-ray exam of ribs 01/01/00 2 33.61 32.35 J

71111 X-ray exam of ribs, chest 01/01/00 2 38.61 37.14 J

71120 X-ray exam of breastbone 01/01/00 2 26.52 25.42 J

71130 X-ray exam of breastbone 01/01/00 2 28.83 27.53 J

71250 Cat scan of chest 01/01/00 2 214.38 204.45 H

71260 Contrast cat scan of chest 01/01/00 2 250.79 238.61 G

71270 Contrast cat scans of chest 01/01/00 2 306.47 290.91 G

71275 Ct angiography, chest 01/01/01 1 314.63 G

71550 Magnetic image, chest 01/01/00 2 382.93 363.32 G

71551 Mri chest w/dye 01/01/01 1 451.75 F

71552 Mri chest w/o&w dye 01/01/01 1 800.05 F

71555 Magnetic imaging/chest (mra) 01/01/00 2 390.34 369.63 G

72010 X-ray exam of spine 01/01/00 2 47.21 45.68 C

72020 X-ray exam of spine 01/01/00 2 18.13 17.51 J

72040 X-ray exam of neck spine 01/01/00 2 25.96 24.93 J



72069 X-ray exam of trunk spine 01/01/00 2 22.80 22.04 C

72070 X-ray exam of thorax spine 01/01/00 2 27.33 26.23 J

72072 X-ray exam of thoracic spine 01/01/00 2 29.85 28.61 I

5101:3-1-60 Page 148







72074 X-ray exam of thoracic spine 01/01/00 2 34.98 33.32 I

72080 X-ray exam of trunk spine 01/01/00 2 27.86 26.75 J

72090 X-ray exam of trunk spine 01/01/00 2 30.52 29.47 C

72100 X-ray exam of lower spine 01/01/00 2 27.86 26.75 J



72120 X-ray exam of lower spine 01/01/00 2 34.45 32.80 I

72125 Cat scan of neck spine 01/01/00 2 214.38 204.45 H

72126 Contrast cat scan of neck 01/01/00 2 249.78 237.54 G

72127 Contrast cat scans of neck 01/01/00 2 302.27 286.59 G

72128 Cat scan of thorax spine 01/01/00 2 214.38 204.45 H

72129 Contrast cat scan of thorax 01/01/00 2 249.78 237.54 G

72130 Contrast cat scans of thorax 01/01/00 2 302.27 286.59 G

72131 Cat scan of lower spine 01/01/00 2 214.38 204.45 H

72132 Contrast cat of lower spine 01/01/00 2 249.85 237.54 G

72133 Contrast cat scans,low spine 01/01/00 2 302.27 286.59 G

72141 Magnetic image, neck spine 01/01/00 2 382.93 363.32 G


72146 Magnetic image, chest spine 01/01/00 2 418.05 396.07 G


72148 Magnetic image, lumbar spine 01/01/00 2 413.08 390.93 G





72159 Magnetic imaging/spine (mra) 01/01/00 2 423.71 400.33 G

72170 X-ray exam of pelvis 01/01/00 2 21.55 20.67 J

72190 X-ray exam of pelvis 01/01/00 2 27.58 26.48 J

72191 Ct angiograph pelv w/o&w dye 01/01/01 1 304.53 G

72192 Cat scan of pelvis 01/01/00 2 211.44 201.46 H

72193 Contrast cat scan of pelvis 01/01/00 2 240.88 229.07 G

72194 Contrast cat scans of pelvis 01/01/00 2 289.63 274.72 G

72195 Mri pelvis w/o dye 01/01/01 1 377.68 F

72196 Magnetic image, pelvis 01/01/00 2 382.86 363.32 G

72197 Mri pelvis w/o & w dye 01/01/01 1 806.79 F

72198 Magnetic imaging/pelvis(mra) 01/01/00 2 390.06 369.35 G

72200 X-ray exam sacroiliac joints 01/01/00 2 21.75 20.93 J

72202 X-ray exam sacroiliac joints 01/01/00 2 25.40 24.37 J

5101:3-1-60 Page 149







72220 X-ray exam of tailbone 01/01/00 2 23.29 22.26 J

72240 Contrast x-ray of neck spine 01/01/00 2 171.73 163.48 H

72255 Contrast x-ray thorax spine 01/01/00 2 159.55 152.45 H

72265 Contrast x-ray lower spine 01/01/00 2 149.59 142.68 H

72270 Contrast x-ray of spine 01/01/00 2 226.89 216.46 H

72275 Epidurography, radiological supervision & inter. 01/01/00 1 60.14 H

72285 X-ray of neck spine disk 01/01/00 2 271.69 256.93 G

72295 X-ray of lower spine disk 01/01/00 2 256.90 242.75 G

73000 X-ray exam of collarbone 01/01/00 2 21.28 20.39 J

73010 X-ray exam of shoulder blade 01/01/00 2 21.75 20.93 J

73020 X-ray exam of shoulder 01/01/00 2 19.63 18.81 J

73030 X-ray exam of shoulder 01/01/00 2 23.63 22.53 J

73040 Contrast x-ray of shoulder 01/01/00 2 81.61 78.33 I

73050 X-ray exam of shoulders 01/01/00 2 27.05 25.94 J

73060 X-ray exam of humerus 01/01/00 2 23.29 22.26 J

73070 X-ray exam of elbow 01/01/00 2 21.00 20.12 I

73080 X-ray exam of elbow 01/01/00 2 23.29 22.26 J

73085 Contrast x-ray of elbow 01/01/00 2 81.68 78.33 I

73090 X-ray exam of forearm 01/01/00 2 21.28 20.39 J

73092 X-ray exam of arm, infant 01/01/00 2 20.43 19.61 J

73100 X-ray exam of wrist 01/01/00 2 20.43 19.61 J

73110 X-ray exam of wrist 01/01/00 2 22.01 21.19 J

73115 Contrast x-ray of wrist 01/01/00 2 66.93 64.44 J

73120 X-ray exam of hand 01/01/00 2 20.43 19.61 J

73130 X-ray exam of hand 01/01/00 2 22.01 21.19 J

73140 X-ray exam of finger(s) 01/01/00 2 17.32 16.70 J

73200 Cat scan of arm 01/01/00 2 184.38 176.28 H

73201 Contrast cat scan of arm 01/01/00 2 214.38 204.45 H

73202 Contrast cat scans of arm 01/01/00 2 259.86 246.98 G

73206 Ct angio upr extrm w/o&w dye 01/01/01 1 273.93 G

73218 Mri upper extremity w/o dye 01/01/01 1 371.56 F

73219 Mri upper extremity w/dye 01/01/01 1 445.02 F

73220 Magnetic image, arm, hand 01/01/00 2 377.96 358.18 G

73221 Magnetic image, joint of arm 01/01/00 2 372.17 336.48 G

73222 Mri joint upr extrem w/ dye 01/01/01 1 445.02 F

73223 Mri joint upr extr w/o&w dye 01/01/01 1 799.14 F

73225 Magnetic imaging/upper (mra) 01/01/00 2 386.47 365.59 G

73500 X-ray exam of hip 01/01/00 2 20.38 19.62 J

5101:3-1-60 Page 150







73510 X-ray exam of hip 01/01/00 2 24.91 23.88 J

73520 X-ray exam of hips 01/01/00 2 29.71 28.66 C

73525 Contrast x-ray of hip 01/01/00 2 81.61 78.33 I

73530 X-ray exam of hip 01/01/00 2 26.59 25.81 K

73540 X-ray exam of pelvis & hips 01/01/00 2 24.57 23.60 J

73542 Epidurography, radiological supervision & inter. 01/01/00 1 77.16 H

73550 X-ray exam of thigh 01/01/00 2 23.29 22.26 J

73560 X-ray exam of knee 01/01/00 2 21.62 20.67 J




73580 Contrast x-ray of knee joint 01/01/00 2 96.66 92.51 H

73590 X-ray exam of lower leg 01/01/00 2 21.55 20.67 J

73592 X-ray exam of leg, infant 01/01/00 2 20.43 19.61 J

73600 X-ray exam of ankle 01/01/00 2 20.43 19.61 J

73610 X-ray exam of ankle 01/01/00 2 22.01 21.19 J

73615 Contrast x-ray of ankle 01/01/00 2 81.81 78.33 I

73620 X-ray exam of foot 01/01/00 2 20.43 19.61 J

73630 X-ray exam of foot 01/01/00 2 22.01 21.19 J

73650 X-ray exam of heel 01/01/00 2 19.91 19.09 J

73660 X-ray exam of toe(s) 01/01/00 2 17.32 16.70 J

73700 Cat scan of leg 01/01/00 2 184.38 176.28 H

73701 Contrast cat scan of leg 01/01/00 2 214.38 204.45 H

73702 Contrast cat scans of leg 01/01/00 2 259.86 246.98 G

73706 Ct angio lwr extr w/o&w dye 01/01/01 1 273.93 G

73718 Mri lower extremity w/o dye 01/01/01 1 371.56 F

73719 Mri lower extremity w/dye 01/01/01 1 445.02 F

73720 Magnetic image, leg, foot 01/01/00 2 377.90 358.18 G

73721 Magnetic image, joint of leg 01/01/00 2 372.17 336.48 G

73722 Mri joint of lwr extr w/dye 01/01/01 1 445.02 F

73723 Mri joint lwr extr w/o&w dye 01/01/01 1 799.14 F

73725 Magnetic imaging/lower (mra) 01/01/00 2 387.90 368.06 G

74000 X-ray exam of abdomen 01/01/00 2 22.09 21.20 J

74010 X-ray exam of abdomen 01/01/00 2 25.95 24.98 C

74020 X-ray exam of abdomen 01/01/00 2 28.81 27.90 C

74022 X-ray exam series, abdomen 01/01/00 2 34.01 32.94 C

74150 Cat scan of abdomen 01/01/00 2 208.39 198.99 H

74160 Contrast cat scan of abdomen 01/01/00 2 245.58 233.68 H

5101:3-1-60 Page 151







74170 Contrast cat scans, abdomen 01/01/00 2 297.26 282.58 G

74175 Ct angio abdom w/o&w dye 01/01/01 1 304.53 G

74181 Magnetic image, abdomen (mri 01/01/00 2 382.93 363.32 G

74182 Mri abdomen w/dye 01/01/01 1 451.75 F

74183 Mri abdomen w/o&w dye 01/01/01 1 806.79 F

74185 Magnetic image/abdomen (mra) 01/01/00 2 390.06 369.35 G

74190 X-ray exam of peritoneum 01/01/00 2 54.27 51.74 G

74210 Contrast xray exam of throat 01/01/00 2 48.00 46.07 J

74220 Contrast xray exam,esophagus 01/01/00 2 52.12 50.41 C

74230 Cinema xray throat/esophagus 01/01/00 2 58.62 56.82 C

74235 Remove esophagus obstruction 01/01/00 2 122.48 118.53 C

74240 X-ray exam upper gi tract 01/01/00 2 69.81 67.52 C



74246 Contrast xray upper gi tract 01/01/00 2 75.00 72.49 C

74247 Contrast xray upper gi tract 01/01/00 2 76.34 73.56 C

74249 Contrast xray upper gi tract 01/01/00 2 110.04 105.81 J

74250 X-ray exam of small bowel 01/01/00 2 55.76 53.84 C

74251 X-ray exam of small bowel 01/01/00 2 62.26 59.88 J

74260 X-ray exam of small bowel 01/01/00 2 62.42 60.16 J

74270 Contrast x-ray exam of colon 01/01/00 2 76.93 74.08 C

74280 Contrast x-ray exam of colon 01/01/00 2 103.62 100.43 C

74283 Contrast x-ray exam of colon 01/01/00 2 154.56 151.10 L

74290 Contrast x-ray, gallbladder 01/01/00 2 34.01 32.94 C

74291 Contrast x-rays, gallbladder 01/01/00 2 19.96 19.41 C

74300 X-ray bile ducts, pancreas 01/01/00 2 73.04 69.08 G

74301 Additional x-rays at surgery 01/01/00 1 8.55 C

74305 X-ray bile ducts, pancreas 01/01/00 2 39.37 38.32 K

74320 Contrast x-ray of bile ducts 01/01/00 2 111.48 106.10 G

74327 X-ray for bile stone removal 01/01/00 2 78.77 75.92 C

74328 Xray for bile duct endoscopy 01/01/00 2 118.07 112.61 H

74329 X-ray for pancreas endoscopy 01/01/00 2 118.07 112.61 H

74330 Xray,bile/pancreas endoscopy 01/01/00 2 123.89 112.61 H

74340 X-ray guide for gi tube 01/01/00 2 96.66 92.51 H

74350 X-ray guide, stomach tube 01/01/00 2 120.44 115.03 I

74355 X-ray guide, intestinal tube 01/01/00 2 105.62 101.44 I

74360 X-ray guide, gi dilation 01/01/00 2 111.74 106.10 G

74363 X-ray, bile duct dilation 01/01/00 2 209.09 198.30 D

5101:3-1-60 Page 152







74400 Contrast x-ray urinary tract 01/01/00 2 67.70 64.89 J

74405 Contrast x-ray urinary tract 01/01/99 3 NC 73.02 I

74410 Contrast x-ray urinary tract 01/01/00 2 75.01 71.95 I


74420 Contrast x-ray urinary tract 01/01/00 2 89.19 84.64 G


74430 Contrast x-ray of bladder 01/01/00 2 42.92 41.33 J

74440 Xray exam male genital tract 01/01/00 2 47.31 45.87 J

74445 X-ray exam of penis 01/01/00 2 78.02 76.77 L

74450 X-ray exam urethra/bladder 01/01/00 2 54.94 52.34 H

74455 X-ray exam urethra/bladder 01/01/00 2 58.31 55.49 H

74470 X-ray exam of kidney lesion 01/01/00 2 57.46 55.79 C

74475 Xray control catheter insert 01/01/00 2 137.82 130.75 G

74480 Xray control catheter insert 01/01/00 2 137.82 130.75 G

74485 X-ray guide, gu dilation 01/01/00 2 111.48 106.10 G

74710 X-ray measurement of pelvis 01/01/00 2 43.73 42.14 J

74740 X-ray female genital tract 01/01/00 2 52.17 50.33 I

74742 X-ray fallopian tube 01/01/00 2 113.60 108.02 H

74775 X-ray exam of perineum 01/01/00 2 66.74 64.52 C

75552 Magnetic image, myocardium 01/01/00 2 383.00 363.32 G

75553 Magnetic image, myocardium 01/01/00 2 394.59 374.30 G

75554 Cardiac mri/function 01/01/00 2 390.24 369.64 G

75555 Cardiac mri/limited study 01/01/00 2 388.22 367.17 G

75556 Cardiac mri/flow mapping 05/01/94 1 NC

75600 Contrast x-ray exam of aorta 01/01/00 2 377.97 354.47 G



75630 X-ray aorta, leg arteries 01/01/00 2 440.12 402.26 G

75635 Ct angio abdominal arteries 01/01/01 1 333.30 H

75650 Artery x-rays, head & neck 01/01/00 2 417.96 395.40 G

75658 X-ray exam of arm arteries 01/01/00 2 411.47 388.09 G





75676 Artery x-rays, neck 01/01/00 2 410.82 388.09 G

75680 Artery x-rays, neck 01/01/00 2 424.83 402.44 G

75685 Artery x-rays, spine 01/01/00 2 410.69 388.09 G

5101:3-1-60 Page 153







75705 Artery x-rays, spine 01/01/00 2 446.22 424.12 G

75710 Artery x-rays, arm/leg 01/01/00 2 403.76 381.05 G

75716 Artery x-rays, arms/legs 01/01/00 2 410.69 388.09 G

75722 Artery x-rays, kidney 01/01/00 2 403.89 381.05 G

75724 Artery x-rays, kidneys 01/01/00 2 418.87 395.40 G

75726 Artery x-rays, abdomen 01/01/00 2 403.63 381.05 G

75731 Artery x-rays, adrenal gland 01/01/00 2 403.56 381.05 G

75733 Artery x-rays,adrenal glands 01/01/00 2 410.69 388.09 G

75736 Artery x-rays, pelvis 01/01/00 2 403.63 381.05 G

75741 Artery x-rays, lung 01/01/00 2 410.69 388.09 G

75743 Artery x-rays, lungs 01/01/00 2 424.83 402.44 G

75746 Artery x-rays, lung 01/01/00 2 403.76 381.05 G

75756 Artery x-rays, chest 01/01/00 2 404.74 381.05 G

75774 Artery x-ray, each vessel 01/01/00 2 372.37 349.05 G

75790 Visualize a-v shunt 01/01/00 2 112.79 111.78 M

75801 Lymph vessel x-ray, arm/leg 01/01/00 2 186.80 177.22 G

75803 Lymph vessel x-ray,arms/legs 01/01/00 2 200.75 191.62 H

75805 Lymph vessel x-ray, trunk 01/01/00 2 206.15 195.30 G

75807 Lymph vessel x-ray, trunk 01/01/00 2 220.17 209.70 H

75809 Nonvascular shunt, x-ray 01/01/00 2 40.81 39.69 K

75810 Vein x-ray, spleen/liver 01/01/00 2 403.56 381.05 G

75820 Vein x-ray, arm/leg 01/01/00 2 55.60 54.16 L

75822 Vein x-ray, arms/legs 01/01/00 2 84.59 82.68 K

75825 Vein x-ray, trunk 01/01/00 2 403.63 381.05 G

75827 Vein x-ray, chest 01/01/00 2 403.63 381.05 G

75831 Vein x-ray, kidney 01/01/00 2 403.56 381.05 G

75833 Vein x-ray, kidneys 01/01/00 2 418.03 395.40 G

75840 Vein x-ray, adrenal gland 01/01/00 2 403.82 104.12 G

75842 Vein x-ray, adrenal glands 01/01/00 2 417.89 395.40 G

75860 Vein x-ray, neck 01/01/00 2 403.63 381.05 G

75870 Vein x-ray, skull 01/01/00 2 403.69 381.05 G

75872 Vein x-ray, skull 01/01/00 2 403.63 381.05 G

75880 Vein x-ray, eye socket 01/01/00 2 55.60 54.16 L

75885 Vein x-ray, liver 01/01/00 2 415.87 393.51 G

75887 Vein x-ray, liver 01/01/00 2 415.87 393.51 G

75889 Vein x-ray, liver 01/01/00 2 403.56 381.05 G

75891 Vein x-ray, liver 01/01/00 2 403.63 381.05 G

75893 Venous sampling by catheter 01/01/00 2 379.83 356.91 G

5101:3-1-60 Page 154







75894 Xrays, transcatheter therapy 01/01/00 2 738.32 694.21 G

75896 Xrays, transcatheter therapy 01/01/00 2 649.25 610.60 G

75898 Follow-up angiogram 01/01/00 2 96.72 95.81 M

75900 Arterial catheter exchange 01/01/00 2 615.78 577.27 F

75901 Remove cva device obstruct 07/01/03 1 70.57 H

75902 Remove cva lumen obstruct 07/01/03 1 66.69 G

75940 X-ray placement, vein filter 01/01/00 2 379.90 356.91 G



75952 Endovasc repair abdom aorta 01/01/01 1 188.23

75953 Abdom aneurysm endovas rpr 01/01/01 1 77.74

75954 Iliac aneurysm endovas rpr 07/01/03 1 339.00 G

75960 Transcatheter intro, stent 01/01/00 2 456.54 429.09 G

75961 Retrieval, broken catheter 01/01/00 2 469.57 452.81 C

75962 Repair arterial blockage 01/01/00 2 469.30 440.26 G

75964 Repair artery blockage, each 01/01/00 2 252.84 237.40 G

75966 Repair arterial blockage 01/01/00 2 500.35 471.44 G

75968 Repair artery blockage, each 01/01/00 2 252.84 237.40 G

75970 Vascular biopsy 01/01/00 2 361.87 340.80 G

75978 Repair venous blockage 01/01/00 2 474.00 446.25 G

75980 Contrast xray exam bile duct 01/01/00 2 211.97 202.99 I

75982 Contrast xray exam bile duct 01/01/00 2 231.39 221.07 I

75984 Xray control catheter change 01/01/00 2 84.74 81.71 C

75989 Abscess drainage under x-ray 01/01/00 2 137.10 132.13 C

75992 Atherectomy, x-ray exam 01/01/00 2 469.37 440.26 G





75998 Fluoroguide For Vein Device 01/01/04 1 52.28 I

76000 Fluoroscope examination 01/01/00 2 43.75 41.38 G

76001 Fluoroscope exam, extensive 01/01/00 2 102.23 97.93 I

76003 Needle localization by x-ray 01/01/00 2 58.89 57.09 C

76005 Fluoriscopic guidance, epidural,subarchnoid nerve 01/01/00 1 57.12 J

76006 X-ray, stress view 01/01/00 2 12.89 15.04

76010 X-ray, nose to rectum 01/01/00 2 22.09 21.20 J

76012 Percut vertebroplasty fluor 01/01/01 1 87.84

76013 Percut vertebroplasty, ct 01/01/01 1 71.62

5101:3-1-60 Page 155







76020 X-rays for bone age 01/01/00 2 22.56 21.73 J

76040 X-rays, bone evaluation 01/01/00 2 33.61 32.35 J

76061 X-rays, bone survey 01/01/00 2 46.43 44.90 C

76062 X-rays, bone survey 01/01/00 2 62.91 60.77 C

76065 X-rays, bone evaluation 01/01/00 2 32.45 31.32 C

76066 Joint(s) survey, single film 01/01/00 2 44.21 42.36 I

76070 Ct scan, bone density study 01/01/00 2 94.42 88.94 G

76071 Ct bone density, peripheral 07/01/03 1 86.06 F

76075 Dual energy x-ray study 01/01/00 2 100.01 94.25 G

76076 Dual energy x-ray study 01/01/00 2 30.93 49.65 G76077 Dxa bone density/v-fracture 01/01/05 1 30.01 H

76078 Photodensitometry 01/01/00 2 30.32 28.89 I

76080 X-ray exam of fistula 01/01/00 2 51.81 50.55 K

76082 Computer Mammogram Add-On 01/01/04 1 13.77 G

76083 Computer Mammogram Add-On 01/01/04 1 13.77 G

76085 Computer screening mammography 01/01/03 3 NC 10.71 H

76086 X-ray of mammary duct 01/01/00 2 89.32 84.90 G

76088 X-ray of mammary ducts 01/01/00 2 122.08 115.67 G

76090 Mammogram, one breast 01/01/00 2 49.94 38.63 I

76091 Mammogram, both breasts 01/01/00 2 61.68 51.41 J

76092 Mamm0gram, screening 01/01/00 2 36.30 33.00 J

76093 Magnetic image, breast 01/01/00 2 566.01 534.50 F

76094 Magnetic image, both breasts 01/01/00 2 744.38 424.25 F

76095 Stereotactic breast biopsy 01/01/00 2 268.10 255.60 I

76096 X-ray of needle wire, breast 01/01/00 2 59.64 57.90 C

76098 X-ray exam, breast specimen 01/01/00 2 18.41 17.79 C

76100 X-ray exam of body section 01/01/00 2 59.01 57.41 C

76101 Complex body section x-ray 01/01/00 2 63.94 61.86 C

76102 Complex body section x-rays 01/01/00 2 72.96 70.25 J

76120 Cinematic x-rays 01/01/00 2 45.28 43.79 C

76125 Cinematic x-rays 01/01/00 2 33.48 32.09 J

76140 X-ray consultation 05/01/94 1 NC

76150 X-ray exam, dry process 01/01/00 2 11.88 11.28

76350 Special x-ray contrast study 05/01/94 1 BR

76355 Cat scan for localization 01/01/00 2 282.86 268.43 G

76360 Cat scan for needle biopsy 01/01/00 2 280.57 266.27 G

76362 CAT guidance for tissue ablation 01/01/02 1 405.43 C

76365 Cat scan for cyst aspiration 04/01/01 3 NC 280.57 G

5101:3-1-60 Page 156







76370 Cat scan for therapy guide 01/01/00 2 118.21 113.34 I

76375 Cat scans, other planes 01/01/00 2 106.92 100.33 G

76380 Cat scan follow-up study 01/01/00 2 138.89 133.43 I

76390 Magnetic resonance spectroscopy 01/01/00 2 376.61 356.26 G

76393 Mr guidance for needle place 01/01/01 1 397.27 G

76394 MRI guidance for tissue ablation 01/01/02 1 492.89 I

76400 Magnetic image, bone marrow 01/01/97 2 363.32 332.82 G

76490 US guidance for tissue ablation 01/01/04 3 NC 125.39 L

76490 US guidance for tissue ablation 01/01/02 1 125.39 L

76496 Fluoroscopic procedure 07/01/03 1 79.98 C

76497 Ct procedure 07/01/03 1 148.33 H

76498 Mri procedure 07/01/03 1 77.49 G

76499 Radiographic procedure 05/01/94 1 BR

76506 Echo exam of head 01/01/00 2 66.17 63.76 C76510 Ophth us, b & quant a 01/01/05 1 131.28 K

76511 Echo exam of eye 01/01/00 2 70.16 66.77 K

76512 Echo exam of eye 01/01/00 2 71.31 68.02 C

76513 Echo exam of eye, water bath 01/01/00 2 71.24 68.02 C

76514 Echo Exam Of Eye, Thickness 01/01/04 1 8.99 G

76516 Echo exam of eye 01/01/00 2 58.24 55.79 C

76519 Echo exam of eye 01/01/00 2 58.31 55.79 C

76529 Echo exam of eye 01/01/00 2 62.63 60.03 C

76536 Echo exam of head and neck 01/01/00 2 63.20 61.06 C

76604 Echo exam of chest 01/01/00 2 59.43 57.63 C

76645 Echo exam of breast 01/01/00 2 51.81 50.55 K

76700 Echo exam of abdomen 01/01/00 2 88.71 85.74 C

76705 Echo exam of abdomen 01/01/00 2 64.22 62.14 C

76770 Echo exam abdomen back wall 01/01/00 2 86.07 83.04 C

76775 Echo exam abdomen back wall 01/01/00 2 63.94 61.86 C

76778 Echo exam kidney transplant 01/01/00 2 86.07 83.04 C

76800 Echo exam spinal canal 01/01/00 2 85.97 84.11 L

76801 Ob us < 14 wks, single fetus 07/01/03 1 67.25 L

76802 Ob us < 14 wks, addl fetus 07/01/03 1 52.86 L

76805 Echo exam of pregnant uterus 01/01/00 2 99.87 96.76 C


76811 Ob us, detailed, sngl fetus 07/01/03 1 174.90 C

76812 Ob us, detailed, addl fetus 07/01/03 1 104.88 L


5101:3-1-60 Page 157







76816 Echo exam followup or repeat 01/01/00 2 54.85 53.20 K

76817 Transvaginal us, obstetric 07/01/03 1 69.18 C

76818 Fetal biophysical profile 01/01/00 2 77.46 74.69 C

76819 Fetl biophys profil w/o strs 01/01/01 1 75.60 J76820 Umbilical artery echo 01/01/05 1 70.64 I76821 Middle cerebral artery echo 01/01/05 1 79.13 J

76825 Echo exam of fetal heart 01/01/00 2 114.39 89.88 C

76826 Echo exam of fetal heart 01/01/00 2 60.51 60.83 M

76827 Echo exam of fetal heart 01/01/00 2 81.51 81.80 C

76828 Echo exam of fetal heart 01/01/00 2 55.40 53.45 D

76830 Echo exam, transvaginal 01/01/00 2 71.68 69.37 C

76831 Hysterosonography 01/01/00 2 72.57 70.25 C

76856 Echo exam of pelvis 01/01/00 2 71.68 69.37 C

76857 Echo exam of pelvis 01/01/00 2 45.15 43.79 J

76870 Echo exam of scrotum 01/01/00 2 69.15 66.93 C

76872 Echo exam, transrectal 01/01/00 2 71.81 69.37 C

76873 Echography,prostate volume study 01/01/00 1 109.02 K

76880 Echo exam of extremity 01/01/00 2 64.35 62.14 C

76885 Echography of infant hips 01/01/00 2 73.12 70.79 C

76886 Echography of infant hips 01/01/00 2 65.17 63.01 C

76930 Echo guide for heart sac tap 01/01/00 2 71.32 68.56 C

76932 Echo guide for heart biopsy 01/01/00 2 71.39 68.56 C

76934 Echo guide for chest tap 04/01/01 3 NC 70.86 C

76936 Echo guide for artery repair 01/01/00 2 266.32 257.02 H

76937 Us Guide, Vascular Access 01/01/04 1 25.02 K

76938 Echo exam for drainage 04/01/01 3 NC 70.86 C

76940 Us Guide, Tissue Ablation 01/01/04 1 123.95 L

76941 Echo guide for transfusion 01/01/00 2 98.08 96.18 L

76942 Echo guide for biopsy 01/01/00 2 71.00 68.56 C

76945 Echo guide, villus sampling 01/01/00 2 78.35 77.79 K

76946 Echo guide for amniocentesis 01/01/00 2 58.77 56.38 I

76948 Echo guide, ova aspiration 01/01/00 2 58.70 56.38 I

76950 Echo guidance radiotherapy 01/01/00 2 60.65 58.71 C

76960 Echo guidance radiotherapy 04/01/01 3 NC 60.65 C

76965 Echo guidance radiotherapy 01/01/00 2 233.55 243.99 C

76970 Ultrasound exam follow-up 01/01/00 2 46.10 44.60 C

76975 Gi endoscopic ultrasound 01/01/00 2 75.82 73.18 C

76977 Ultrasound bone density measurement 01/01/00 2 13.97 32.37 I

5101:3-1-60 Page 158







76986 Echo exam at surgery 01/01/00 2 123.21 119.07 C

76999 Echo examination procedure 05/01/94 1 BR

77261 Radiation therapy planning 01/01/00 2 56.37 56.90 O



77280 Set radiation therapy field 01/01/00 2 127.17 121.26 H

77285 Set radiation therapy field 01/01/00 2 200.52 190.93 H

77290 Set radiation therapy field 01/01/00 2 248.24 236.95 I

77295 Set radiation therapy field 01/01/00 2 977.22 928.06 G

77299 Radiation therapy planning 05/01/94 1 BR

77300 Radiation therapy dose plan 01/01/00 2 63.05 61.11 C

77301 Intensity mod radiotherapy plan 01/01/02 1 1,080.47 I



77315 Radiation therapy dose plan 01/01/00 2 138.97 135.03 K

77321 Radiation therapy port plan 01/01/00 2 153.37 146.20 I




77331 Special radiation dosimetry 01/01/00 2 49.37 49.14 M

77332 Radiation treatment aid(s) 01/01/00 2 60.07 58.13 C



77336 Radiation physics consult 01/01/00 2 84.67 79.16

77370 Radiation physics consult 01/01/00 2 99.09 92.78

77380 Proton beam delivery 04/01/00 1 NC

77381 Proton beam treatment 04/01/00 1 NC

77399 External radiation dosimetry 05/01/94 1 BR

77401 Radiation treatment delivery 01/01/00 2 50.50 47.19










5101:3-1-60 Page 159










77417 Radiology port film(s) 01/01/00 2 16.81 15.74

77418 Intensity mod treatment delivery 01/01/02 1 442.50

77419 Weekly radiation therapy 04/01/00 3 NC 147.39 O



77427 Radiation treatment management 01/01/00 1 129.17


77431 Radiation therapy management 01/01/00 2 73.74 74.24 O

77432 Stereotactic radiation trmt 01/01/00 2 348.96 357.84 O

77470 Special radiation treatment 01/01/00 2 400.85 381.26 H

77499 Radiation therapy management 05/01/94 1 BR

77520 Proton beam treatment to single treatment area 01/01/00 1 BR

77522 Proton trmt, simple w/comp 01/01/01 2 BR

77523 Proton beam treatment to 1-2 treatment areas 01/01/00 1 BR

77525 Proton treatment, complex 01/01/01 2 BR

77600 Hyperthermia treatment 01/01/00 2 149.64 144.95 K





77750 Infuse radioactive materials 01/01/00 2 232.03 223.43 D

77761 Radioelement application 01/01/00 2 221.87 212.63 M



77776 Radioelement application 01/01/00 2 249.51 249.25 D


77778 Radioelement application 01/01/00 2 589.30 564.91 L

77781 High intensity brachytherapy 01/01/00 2 642.86 602.55 G



77784 High intensity brachytherapy 01/01/00 2 798.95 753.74 I

77789 Radioelement application 01/01/00 2 56.97 54.89 D

77790 Radioelement handling 01/01/00 2 56.21 56.19 D

77799 Radium/radioisotope therapy 05/01/94 1 BR

78000 Thyroid, single uptake 01/01/00 2 35.39 33.54 C

5101:3-1-60 Page 160







78001 Thyroid, multiple uptakes 01/01/00 2 47.70 45.44 H

78003 Thyroid suppress/stimul 01/01/00 2 40.97 39.23 J

78006 Thyroid,imaging with uptake 01/01/00 2 87.51 83.49 H

78007 Thyroid, image, mult uptakes 01/01/00 2 93.43 89.00 H

78010 Thyroid imaging 01/01/00 2 67.30 64.23 H

78011 Thyroid imaging with flow 01/01/00 2 86.87 82.66 H

78015 Thyroid met imaging 01/01/00 2 100.86 96.33 I

78016 Thyroid met imaging/studies 01/01/00 2 132.40 126.66 I

78017 Thyroid met imaging, mult 04/01/99 3 NC 134.57 I

78018 Thyroid, met imaging, body 01/01/00 2 190.23 183.18 I

78020 Thyroid metastases uptake 01/01/00 2 20.00 23.33 C

78070 Parathyroid nuclear imaging 01/01/00 2 81.64 69.37 I

78075 Adrenal nuclear imaging 01/01/00 2 184.41 174.78 G

78099 Endocrine nuclear procedure 05/01/94 1 BR

78102 Bone marrow imaging, ltd 01/01/00 2 80.39 77.04 I

78103 Bone marrow imaging, mult 01/01/00 2 120.49 115.02 I

78104 Bone marrow imaging, body 01/01/00 2 148.34 141.30 H

78110 Plasma volume, single 01/01/00 2 34.87 33.02 H

78111 Plasma volume, multiple 01/01/00 2 82.54 77.65 G

78120 Red cell mass, single 01/01/00 2 59.12 55.90 G

78121 Red cell mass, multiple 01/01/00 2 95.59 90.31 G

78122 Blood volume 01/01/00 2 148.95 140.84 G

78130 Red cell survival study 01/01/00 2 105.63 100.93 H

78135 Red cell survival kinetics 01/01/00 2 164.16 155.77 G

78140 Red cell sequestration 01/01/00 2 136.64 129.78 G

78160 Plasma iron turnover 01/01/00 2 117.61 110.78 G

78162 Iron absorption exam 01/01/00 2 109.48 103.34 G

78170 Red cell iron utilization 01/01/00 2 167.33 157.82 G

78172 Total body iron estimation 01/01/00 2 108.68 106.15 G

78185 Spleen imaging 01/01/00 2 83.54 79.46 G

78190 Platelet survival, kinetics 01/01/00 2 206.12 196.48 H

78191 Platelet survival 01/01/00 2 232.96 219.93 G

78195 Lymph system imaging 01/01/00 2 159.14 137.26 G

78199 Blood/lymph nuclear exam 05/01/94 1 BR

78201 Liver imaging 01/01/00 2 84.90 80.82 H

78202 Liver imaging with flow 01/01/00 2 102.42 97.67 H

78205 Liver imaging (3d) 01/01/00 2 196.97 186.54 G

78206 Liver imaging (spect) 01/01/00 2 71.80 197.23 G

5101:3-1-60 Page 161







78215 Liver and spleen imaging 01/01/00 2 102.88 97.87 G

78216 Liver & spleen image, flow 01/01/00 2 121.86 116.10 G

78220 Liver function study 01/01/00 2 125.21 118.85 G

78223 Hepatobiliary imaging 01/01/00 2 138.14 131.93 I

78230 Salivary gland imaging 01/01/00 2 80.24 76.64 H

78231 Serial salivary imaging 01/01/00 2 111.25 105.81 G

78232 Salivary gland function exam 01/01/00 2 119.46 113.32 G

78258 Esophageal motility study 01/01/00 2 111.92 107.14 I

78261 Gastric mucosa imaging 01/01/00 2 144.98 137.76 G

78262 Gastroesophageal reflux exam 01/01/00 2 148.69 141.16 G

78264 Gastric emptying study 01/01/00 2 149.22 141.79 H

78267 Urea breath test 01/01/00 1 10.86

78268 Urea breath test, analysis 01/01/00 1 93.09

78270 Vit b-12 absorption exam 01/01/00 2 52.48 49.55 G

78271 Vit b-12 absorp exam, if 01/01/00 2 55.08 52.16 G

78272 Vit b-12 absorp, combined 01/01/00 2 77.48 73.26 G

78278 Acute gi blood loss imaging 01/01/00 2 178.50 170.42 H

78282 Gi protein loss exam 01/01/00 2 76.45 170.42 G

78290 Meckel's divert exam 01/01/00 2 114.15 108.90 H

78291 Leveen/shunt patency exam 01/01/00 2 122.37 117.29 I

78299 Gi nuclear procedure 05/01/94 1 BR

78300 Bone imaging, limited area 01/01/00 2 96.06 92.07 I

78305 Bone imaging, multiple areas 01/01/00 2 137.87 131.65 H

78306 Bone imaging, whole body 01/01/00 2 156.28 149.00 H

78315 Bone imaging, 3 phase 01/01/00 2 176.78 168.61 H

78320 Bone imaging (3d) 01/01/00 2 209.74 199.56 G

78350 Bone mineral, single photon 01/01/00 2 30.93 29.42 I

78351 Bone mineral, dual photon 05/01/94 1 NC

78399 Musculoskeletal nuclear exam 05/01/94 1 BR

78414 Non-imaging heart function 01/01/00 2 181.93 179.96 F

78428 Cardiac shunt imaging 01/01/00 2 96.18 92.26 J

78445 Vascular flow imaging 01/01/00 2 73.22 70.13 I

78455 Venous thrombosis study 01/01/00 2 142.85 135.97 H

78456 Acute venous thrombosis imaging, peptide 01/01/00 1 156.71 H

78457 Venous thrombosis imaging 01/01/00 2 106.94 102.49 I

78458 Ven thrombosis images, bilat 01/01/00 2 150.69 143.53 H

78459 Heart muscle imaging, PET 07/01/03 2 750.56 BR F

78460 Heart muscle blood single 01/01/00 2 102.37 98.42 C

5101:3-1-60 Page 162







78461 Heart muscle blood multiple 01/01/00 2 184.03 175.70 I

78464 Heart image (3d) single 01/01/00 2 244.80 232.38 G

78465 Heart image (3d) multiple 01/01/00 2 394.55 372.82 G

78466 Heart infarct image 01/01/00 2 103.04 98.74 I

78468 Heart infarct image, ef 01/01/00 2 136.42 130.02 H

78469 Heart infarct image (3d) 01/01/00 2 185.71 176.60 G

78472 Gated heart, resting 01/01/00 2 196.70 186.92 G

78473 Gated heart, multiple 01/01/00 2 293.93 279.27 G

78478 Heart wall motion (add-on) 01/01/00 2 69.58 66.90 C

78480 Heart function, (add-on) 01/01/00 2 69.58 66.90 C

78481 Heart first pass single 01/01/00 2 188.47 179.31 H

78483 Heart first pass multiple 01/01/00 2 283.72 269.05 H

78491 Myocardial imaging, PET 07/01/03 2 136.50 BR F

78492 Myocardial imaging, PET 07/01/03 2 257.75 BR F

78494 Cardiac blood pool imaging 01/01/99 1 200.65 G

78496 Cardiac blood pool imaging 01/01/99 1 70.27 I

78499 Cardiovascular nuclear exam 05/01/94 1 BR

78580 Lung perfusion imaging 01/01/00 2 127.62 121.83 H

78584 Lung v/q image single breath 01/01/00 2 131.04 125.83 J

78585 Lung v/q imaging 01/01/00 2 203.84 194.11 H

78586 Aerosol lung image, single 01/01/00 2 90.03 85.48 G

78587 Aerosol lung image, multiple 01/01/00 2 99.16 94.49 G

78588 Pulmonary perfusion imaging 01/01/00 2 61.13 136.66 I

78591 Vent image, 1 breath, 1 proj 01/01/00 2 97.14 92.28 G

78593 Vent image, 1 proj, gas 01/01/00 2 117.60 111.79 G

78594 Vent image, mult proj, gas 01/01/00 2 163.09 154.58 G

78596 Lung differential function 01/01/00 2 252.24 239.99 G

78599 Respiratory nuclear exam 05/01/94 1 BR

78600 Brain imaging, ltd static 01/01/00 2 99.55 94.68 G

78601 Brain ltd imaging & flow 01/01/00 2 117.54 111.56 G

78605 Brain imaging, complete 01/01/00 2 118.35 112.37 G

78606 Brain imaging comp & flow 01/01/00 2 135.54 129.01 G

78607 Brain imaging (3d) 01/01/00 2 235.79 224.16 H

78608 Brain imaging (pet) 05/01/94 1 NC

78609 Brain imaging (pet) 05/01/94 1 NC

78610 Brain flow imaging only 01/01/00 2 57.29 54.41 H

78615 Cerebral blood flow imaging 01/01/00 2 126.45 119.56 G

78630 Cerebrospinal fluid scan 01/01/00 2 170.95 162.14 G

5101:3-1-60 Page 163







78635 Csf ventriculography 01/01/00 2 97.54 92.83 I

78645 Csf shunt evaluation 01/01/00 2 120.49 114.80 G

78647 Cerebrospinal fluid scan 01/01/00 2 204.45 194.13 G

78650 Csf leakage imaging 01/01/00 2 156.58 148.38 G

78655 Nuclear exam of eye lesion 04/01/96 2 NC 141.86 G

78660 Nuclear exam of tear flow 01/01/00 2 81.86 78.57 I

78699 Nervous system nuclear exam 05/01/94 1 BR

78700 Kidney imaging, static 01/01/00 2 104.42 99.15 G

78701 Kidney imaging with flow 01/01/00 2 120.54 114.39 G

78704 Imaging renogram 01/01/00 2 142.54 135.72 H

78707 Kidney flow & function image 01/01/00 2 165.53 157.21 H

78708 Kidney flow & function imaging 01/01/00 2 172.86 164.74 I

78709 Kidney flow & function imaging 01/01/00 2 178.69 170.23 I

78710 Kidney imaging (3d) 01/01/00 2 194.94 184.39 G

78715 Renal vascular flow exam 01/01/00 2 57.29 54.41 H

78725 Kidney function study 01/01/00 2 65.98 63.17 H

78726 Kidney function w/intervent 04/01/98 3 NC 114.41 J

78727 Kidney transplant evaluation 04/01/98 3 NC 146.81 I

78730 Urinary bladder retention 01/01/00 2 56.09 53.42 I

78740 Ureteral reflux study 01/01/00 2 83.22 79.93 I

78760 Testicular imaging 01/01/00 2 102.90 98.40 I

78761 Testicular imaging & flow 01/01/00 2 120.04 114.44 H

78799 Genitourinary nuclear exam 05/01/94 1 BR

78800 Tumor imaging, limited area 01/01/00 2 123.36 117.24 H

78801 Tumor imaging, mult areas 01/01/00 2 152.04 144.96 H

78802 Tumor imaging, whole body 01/01/00 2 192.36 182.56 G

78803 Tumor imaging (3d) 01/01/00 2 230.08 218.47 G

78804 Tumor Imaging, Whole Body 01/01/04 1 161.33 H

78805 Abscess imaging, ltd area 01/01/00 2 126.30 120.23 H

78806 Abscess imaging, whole body 01/01/00 2 217.62 206.14 G

78807 Nuclear localization/abscess 01/01/97 2 218.47 197.30 G

78810 Tumor imaging, PET 01/01/05 3 NC 1,647.00 F78811 Tumor imaging (pet), limited 01/01/05 1 625.30 F78812 Tumor image (pet)/skul-thigh 01/01/05 1 773.10 F78813 Tumor image (pet) full body 01/01/05 1 799.60 F78814 Tumor image pet/ct, limited 01/01/05 1 875.40 F78815 Tumorimage pet/ct skul-thigh 01/01/05 1 966.40 F78816 Tumor image pet/ct full body 01/01/05 1 989.10 F

5101:3-1-60 Page 164







78890 Nuclear medicine data proc 01/01/00 2 38.84 36.56 G

78891 Nuclear med data proc 01/01/00 2 79.00 74.46 G

78990 Provide diag radionuclide(s) 01/01/05 3 NC 78.75

78999 Nuclear diagnostic exam 05/01/94 1 BR

79000 Intial hyperthyroid therapy 01/01/05 3 NC 147.46 K

79001 Repeat hyperthyroid therapy 01/01/05 3 NC 79.06 L79005 Nuclear rx, oral admin 01/01/05 1 152.80 K

79020 Thyroid ablation 01/01/05 3 NC 147.60 K

79030 Thyroid ablation, carcinoma 01/01/05 3 NC 159.57 L

79035 Thyroid metastatic therapy 01/01/05 3 NC 176.68 L

79100 Hematopoetic nuclear therapy 01/01/05 3 NC 127.92 C79101 Nuclear rx, iv admin 01/01/05 1 159.47 K

79200 Intracavitary nuc treatment 01/01/00 2 155.63 151.86 L

79300 Interstitial nuclear therapy 01/01/00 2 155.63 151.86 J

79400 Radionuclide therapy 01/01/05 3 NC 153.66 L

79403 Hematopoetic Nuclear Therapy 01/01/04 1 205.45 C

79420 Intravascular nuc therapy 01/01/05 3 NC 153.66 C

79440 Nuclear joint therapy 01/01/00 2 155.37 151.86 L79445 Nuclear rx, intra-arterial 01/01/05 1 178.88 K

79900 Provide ther radionuclide(s) 01/01/05 3 NC 231.00

79999 Nuclear medicine therapy 05/01/94 1 BR

80002 2 Tests-Lab.Profile 04/01/98 3 NC 6.26











80016 13-16 Clinical Chemistry Tests 04/01/98 3 NC 15.00

80018 17-18 Clinical Chemistry Tests 04/01/98 3 NC 15.11

80019 19 Or More Clinical Chemistry Tests 04/01/98 3 NC 15.69

80048 Basic metabolic panel 01/01/00 1 8.73

80049 Basic metabolic panel 04/01/00 1 NC

80050 General Health Screen Panel 04/01/98 1 NC

5101:3-1-60 Page 165







80051 Electrolyte panel 01/01/98 1 6.26

80053 Comprehensive metabolic panel 01/01/00 1 14.61

80054 Comprehensive Metabolic Panel 04/01/00 3 NC 12.48

80055 Obstetric Profile 01/01/94 1 82.21

80058 Hepatic Function Panel 04/01/00 3 NC 6.10

80059 Hepatitis Panel 04/01/00 3 NC 81.02

80061 Lipid Panel 01/01/99 2 17.57 17.88

80069 Renal function panel 01/01/00 1 12.00

80072 Arthritis panel 04/01/02 3 NC 35.67

80074 Acute hepatitis panel 01/01/00 1 62.89

80076 Hepatic Function Panel 01/01/00 1 8.73

80090 Torch Antibody Panel 07/01/03 3 NC 79.56

80091 Thyroid Panel 04/01/00 3 NC 18.95

80092 Thyroid Panel With Tsh 04/01/00 3 NC 42.79

80100 Drug Screen;Multipl Drug Classes, Ea Proc 01/01/97 2 11.95 11.64

80101 Drug Screen;Sing Drug Class, Ea Drug Clas 01/01/98 2 19.03 19.55

80102 Drug,Confirmation,Each Procedure 01/01/98 2 18.31 18.80

80103 Drug Analysis,Tissue Prep 07/01/03 2 61.75 BR

80150 Amikacin 01/01/98 2 20.83 21.39

80152 Amitriptyline 01/01/98 2 24.74 25.41

80154 Benzodiazepines 01/01/98 2 25.56 26.25

80156 Carbamazepine 01/01/98 2 20.12 20.66

80157 Assay, carbamazepine, free 01/01/01 1 13.74

80158 Cyclosporine 01/01/98 2 24.95 25.63

80160 Desipramine 01/01/98 2 23.79 24.43

80162 Digoxin 01/01/98 2 18.35 18.85

80164 Dipropylacetic 01/01/97 2 13.25 12.90

80166 Doxepin 01/01/98 2 21.42 22.00

80168 Ethosuximide 01/01/98 2 22.58 23.19

80170 Gentamicin 01/01/98 2 22.65 23.26

80172 Gold 01/01/98 2 22.52 23.13

80173 Assay of haloperidol 01/01/01 1 20.12

80174 Imipramine 01/01/98 2 23.79 24.29

80176 Lidocaine 01/01/98 2 20.30 20.85

80178 Lithium 01/01/98 2 9.13 9.38

80182 Nortrptyline 01/01/97 2 13.25 12.90

80184 Phenobarbital 01/01/97 2 12.95 12.61

80185 Phenytoin;Total 01/01/98 2 18.32 18.82

5101:3-1-60 Page 166







80186 Phenytion;Free 01/01/98 2 19.03 19.54

80188 Primidone 01/01/98 2 22.93 23.55

80190 Procainamide 01/01/98 2 23.15 23.77

80192 Procainamide;With Metabolites 01/01/98 2 23.15 23.77

80194 Quinidine 01/01/98 2 20.17 20.72

80196 Salicylate 01/01/98 2 9.81 10.07

80197 Tacrolimus 01/01/98 1 18.97 10.07

80198 Theophylline 01/01/98 2 19.56 20.09

80200 Tobrmycin 01/01/98 2 22.27 22.88

80201 Topiramate 01/01/99 2 16.48 BR

80202 Vancomycin 01/01/97 2 13.25 12.90

80299 Quantitation Of Drugs,Nes 01/01/97 2 14.63 14.25

80400 Acth Stimulation Panel 01/01/98 2 45.06 46.28



80408 Aldosterone Suppression Eval 01/01/98 2 161.22 164.26

80410 Calcium-Pentagastrin Stimul 01/01/98 2 111.03 114.03

80412 Crh Stimulation Panel 01/01/98 2 455.46 467.82

80414 Testosterone Response 01/01/97 2 56.30 54.82

80415 Estradiol Response Panel 01/01/98 2 77.24 79.32

80416 Renin stimulation panel 01/01/97 2 145.74 141.90

80417 Renin stimulation panel 01/01/97 2 48.58 47.30

80418 Pituitary Evaluation Panel 01/01/98 2 800.92 822.56

80420 Dexamethasone Panel 01/01/98 2 99.54 102.24

80422 Glucagon Tolerance Panel 01/01/98 2 63.69 65.40

80424 Glucagon Tolerance Panel 01/01/98 2 69.80 71.68

80426 Gonadotropin Hormone Panel 01/01/98 2 205.16 210.68

80428 Growth Hormone Panel 01/01/98 2 92.16 94.64

80430 Growth Hormone Panel 01/01/98 2 108.42 111.35

80432 Insulin Suppression Panel 01/01/98 2 186.66 188.03

80434 Insulin Tolerance Panel 01/01/98 2 139.75 143.55

80435 Insulin Tolerance Panel 01/01/98 2 142.30 146.15

80436 Metyrapone Panel 01/01/98 2 125.98 129.38

80438 Trh Stimulation Panel 01/01/98 2 69.63 71.52



80500 Clinical Pathology Consultation; 07/01/03 2 14.35 2.87

80502 Clinical Pathology Consultation; 07/01/03 2 51.95 10.39

5101:3-1-60 Page 167







81000 Urinalysis,Reagent Strips With Microscop 01/01/98 2 4.37 4.49

81001 Urinalysis, auto, w/scope 01/01/98 2 4.37 4.49

81002 Urinalysis Routine Wo.Microscopy,Nonauto 01/01/97 2 3.26 3.17

81003 Urinalysis Routine Wo Microscopy,Automat 01/01/99 2 3.10 3.18

81005 Urinalysis Qual/Semi Not Immunoassay 01/01/98 2 3.00 3.08

81007 Urinalysis;Bacteria Screen,Non-Cult,Kit 01/01/98 2 3.55 3.65

81015 Urinalysis Microscopic 01/01/98 2 4.20 4.31

81020 Urinalysis, glass test 01/01/98 2 5.09 5.23

81025 Urine Preg Test,Visual Color Comparison 01/01/98 2 8.74 8.98

81050 Volume Measurement,Time Collect,Each 01/01/98 2 4.14 4.26

81099 Unlisted Urinalysis Procedure 01/01/94 1 BR

82000 Acetaldehyde Blood 01/01/98 2 17.12 17.59

82003 Acetaminophen 01/01/98 2 27.96 28.72

82009 Acetone Or Other Ketones Qualitative 01/01/97 2 4.73 4.61

82010 Acetone Or Other Ketones Quantitative 01/01/97 2 10.50 10.22

82013 Acetylcholinesterase 01/01/98 2 15.44 15.85

82016 Acylcarnitines; qualitative, each specimen 01/01/99 1 19.16

82017 Acylcarnitines; quantitative, each specimen 01/01/99 1 23.31

82024 Adrenocorticotrophic Hormone (Acth) Ria 01/01/98 2 53.38 54.83

82030 Adenosine; 5-Monophosp 01/01/98 2 35.65 36.62

82040 Albumin; Serum 01/01/98 2 6.85 7.03

82042 Albumin, Urine, Quantitative 01/01/98 2 7.15 7.34

82043 Urine,Microalbumin,Quant 01/01/98 2 8.00 8.22

82044 Urine,Microalbumin;Semiquantitative 01/01/98 2 6.33 6.5082045 Albumin, ischemia modified 01/01/05 1 47.43

82055 Alcohol (Ethanol) Any Spec But Breath 01/01/98 2 14.93 15.34

82075 Alcohol,(Ethanol) Breath 01/01/97 2 15.94 15.52

82085 Aldolase 01/01/98 2 13.42 13.78

82088 Aldosterone 01/01/98 2 56.32 57.84

82101 Alkaloids, Urine, Quantitive 01/01/97 2 11.19 10.90

82103 Alpha-1- Antitrypsin;Total 01/01/98 2 18.56 19.06

82104 Alpha-1-Antitrypsin;Phenotype 01/01/98 2 19.98 20.52

82105 Alpha-Fetoprotein;Serum 01/01/98 2 23.18 23.81

82106 Alpha-Fetoprotein,Amniotic Fluid 01/01/98 2 23.18 23.81

82108 Aluminum 01/01/98 2 35.22 36.17

82120 Amines, vaginal fluid, qualitative 01/01/00 1 5.19

82127 Amino Acids; single. qualitative, each 01/01/99 1 19.16

82128 Amino Acids Qualitative 01/01/98 2 19.16 19.68

5101:3-1-60 Page 168







82130 Amino Acid Urin-Cromatog.Fract&Quantit 04/01/99 3 NC 37.53

82131 Amino Acids,Frac/Quant,Each 01/01/98 2 23.31 23.94

82135 Aminolevulinic Acid Delta (Ala) 01/01/97 2 21.09 20.54

82136 Amino Acids; 2 to 5 amino acids, quantitative, each 01/01/99 1 23.31

82139 Amino Acids; 6 or more amino acides, quant., each 01/01/99 1 23.31

82140 Ammonia 01/01/98 2 20.14 20.68

82142 Ammonium Chloride Loading Test 01/01/95 1 NC

82143 Amniotic Fluid Acan (Spectrophotometric) 01/01/98 2 9.50 9.76

82145 Amphetamine, Or Methamphetamine 01/01/98 2 21.48 22.06

82150 Amylase 01/01/98 2 8.96 9.20

82154 Androstanediol Glucuronide 01/01/98 2 39.85 40.93

82157 Androstenedione 01/01/98 2 40.46 41.55

82160 Androsterone 01/01/98 2 34.57 35.50

82163 Angiotensin Ii 01/01/98 2 28.37 29.14

82164 Angiotension-Converting Enzyme (Ace) 01/01/98 2 20.17 20.72

82172 Apolipoprotein Each 01/01/98 2 21.41 21.99

82175 Arsenic 01/01/97 2 21.09 20.54

82180 Ascorbic Acid (Vitamin C),Blood 01/01/98 2 13.66 14.03

82190 Atomic Absorption Spectro,Ea Analyte 01/01/98 2 20.60 21.16

82205 Barbiturates Blood Quantitative 01/01/97 2 12.95 12.61

82232 Beta-2 Microglobulin 01/01/97 2 20.06 19.53

82239 Bile Acids, Total 01/01/98 2 23.67 24.31

82240 Bile Acids; Cholyglycine 01/01/98 2 36.73 37.72

82247 Bilirubin; total 01/01/99 1 5.57

82248 Bilirubin; direct 01/01/99 1 5.57

82250 Bilirubin, Not Otherwise Specified 04/01/99 3 NC 5.57

82251 Bilirubin, Total And Direct 04/01/01 3 NC 7.33

82252 Bilirubin,Feces,Qualitative 01/01/98 2 6.28 6.45

82261 Biotinidase, each specimen 01/01/99 1 23.31

82270 Blood Occult Feces Screening 01/01/98 2 3.50 3.59

82273 Blood, Occult; Other Sources 01/01/98 2 4.49 4.61

82274 Fecal hemoglobin immunoassy test 01/01/02 1 4.49

82286 Bradykinin 01/01/98 2 9.52 9.77

82300 Cadmium 01/01/98 2 31.98 32.84

82306 Calcifediol(25-Oh Vitamin D-3) 01/01/98 2 40.91 42.01

82307 Calciferol (Vitamin D) 01/01/98 2 44.53 45.74

82308 Calcitonin 01/01/98 2 37.01 38.01

82310 Calcium; Total 01/01/98 2 7.12 7.31

5101:3-1-60 Page 169







82330 Calcium; Ionized 01/01/98 2 18.88 19.40

82331 Calcium, After Calcium Infusion Test 01/01/98 2 7.15 7.34

82335 Calcium Urin Qualitative Sulkowitch 04/01/01 3 NC 7.10

82340 Calcium Urin Quant, Times Spec 01/01/98 2 8.34 8.57

82355 Calculus Stone Qualitative Chemical 01/01/97 2 12.09 11.77

82360 Calculus Stone Quantitative Chemical 01/01/97 2 16.08 15.66

82365 Calculus Infrared, Spectroscopy 01/01/98 2 17.82 18.30

82370 Calculus X-Ray Diffraction 01/01/97 2 16.08 15.66

82373 Assay, c-d transfer measure 01/01/01 1 9.95

82374 Carbon Dioxide (Bicarbonate) 01/01/98 2 6.76 6.94

82375 Carbon Monoxide Quantitative 01/01/97 2 16.08 15.66

82376 Carbon Monoxide Qualitative 01/01/98 2 8.28 8.50

82378 Carcinoembryonic Antigen (Cea) 01/01/98 2 26.22 26.93

82379 Carnitine (total & free); quant., each 01/01/99 1 23.31

82380 Carotene 01/01/98 2 12.75 13.09

82382 Catecholamines; Total Urine 01/01/98 2 23.76 24.40

82383 Catecholamines; Blood 01/01/98 2 34.63 35.57

82384 Catecholamines Fractionated 01/01/98 2 34.90 35.84

82387 Cathepsin-D 01/01/98 2 28.75 29.53

82390 Ceruloplasmin 01/01/98 2 14.84 15.25

82397 Chemliuminescent 01/01/98 2 19.53 20.06

82415 Chloramphenicol 01/01/98 2 17.51 17.98

82435 Chlorides; Blood 01/01/98 2 6.35 6.52

82436 Chlorides; Urine 01/01/98 2 6.95 7.14

82438 Chloride; Spinal Fluid 01/01/98 2 6.76 6.94

82441 Chlorinated Hydrocarbons, Screen 01/01/98 2 8.30 8.52

82465 Chloesterol, Serum, Total 01/01/98 2 6.02 6.18

82480 Cholinesterase; Serum 01/01/98 2 10.89 11.19

82482 Cholinesterase; Rbc 01/01/98 2 10.62 10.91

82485 Chondroitin B Sulfate, Quantitative 01/01/98 2 28.54 29.31

82486 Chromatography,Qual;Column Analytc Nes 01/01/98 2 24.96 25.63

82487 Chromatography Qual;Paper 1 Analytc Nes 01/01/98 2 22.06 22.66

82488 Chromatography Qual;Paper 2 Analytc Nes 01/01/98 2 29.53 30.32

82489 Chromatography Thin Layer,Analytc Nes 01/01/98 2 25.56 26.25

82491 Chromatography,Quant;Column Analyte Nes 01/01/98 2 24.96 25.63

82492 Chromatography, quant., column; mult. analytes 01/01/99 1 24.96

82495 Chromium 01/01/98 2 28.03 28.79

82507 Citrate 01/01/98 2 38.43 39.47

5101:3-1-60 Page 170







82520 Cocaine Or Metabolite 01/01/98 2 20.94 21.51

82523 Collagen cross links, any method 01/01/98 1 25.83 20.00

82525 Copper 01/01/98 2 17.15 17.62

82528 Corticosterone 01/01/98 2 31.11 31.95

82530 Cortisol;Free 01/01/98 2 23.10 23.72

82533 Cortisol; Total 01/01/98 2 22.53 23.14

82540 Creatine 01/01/97 2 6.31 6.14

82541 Column chromatography/mass spectrometry 01/01/99 1 24.96




82550 Creatinekinase (Ck),(Cpk);Total 01/01/98 2 9.01 9.25

82552 Creatinekinase (Ck) (Cpk);Isoenzymes 01/01/98 2 18.51 19.01

82553 Creatinine Kinase (Cpk);Mb Fraction 01/01/97 2 12.57 12.24

82554 Creatinine Kinase (Cpk);Isoforms 01/01/98 2 16.40 16.84

82565 Creatining;Kinase (Ck) (Cpk);Isoforms 01/01/98 2 7.07 7.27

82570 Creatinine Urine 01/01/98 2 7.15 7.34

82575 Creatinine Clearance 01/01/98 2 13.06 13.41

82585 Cryofibrinogen 01/01/97 2 5.53 5.38

82595 Cryoglobulin 01/01/98 2 8.95 9.19

82600 Cyanide 01/01/97 2 26.48 25.78

82607 Cyanocobalamin (Vitamin B12); 01/01/98 2 20.83 21.39

82608 Cyamocobalamin;Unsaturated Binding Cap. 01/01/98 2 19.80 20.33

82615 Cystine And Homocystine Urine Qualitativ 01/01/97 2 10.28 10.01

82626 Dehydroepiandrosterone (Dhea) 01/01/98 2 34.93 35.87

82627 Dehydropiandrosterone-Sulfate (Dhea-S) 01/01/98 2 30.72 31.56

82633 Desoxycorticosterone 11 01/01/98 2 42.81 43.97

82634 Desoxycorticosol 11 01/01/98 2 40.46 41.55

82638 Dibucaine Number 01/01/98 2 16.92 17.38

82646 Dihydrocodeinone 01/01/98 2 28.54 29.31

82649 Dihydromorphinone 01/01/98 2 35.52 36.48

82651 Dihydrotestosterone Dht 01/01/98 2 35.68 36.64

82652 Dihydroxyvitamin D, Test (1,25-) 01/01/98 2 53.19 54.63

82654 Dimethadione 01/01/98 2 19.14 19.6582656 Pancreatic elastase, fecal 01/01/05 1 16.12

82657 Enzyme activity in blood cells 01/01/99 1 24.96

82658 Enzyme activity in blood cells 01/01/99 1 24.96

82664 Electrophoretic Technique Nos 01/01/98 2 47.48 48.76

5101:3-1-60 Page 171







82666 Epiandrosterone 01/01/97 2 26.48 25.78

82668 Erythropoietin 01/01/98 2 25.97 26.68

82670 Estradiol 01/01/98 2 38.62 39.66

82671 Estrogens; Fractionated 01/01/98 2 44.64 45.84

82672 Estrogens; Total 01/01/98 2 29.97 30.78

82677 Estriol 01/01/98 2 33.43 34.33

82679 Estrone 01/01/97 2 28.15 27.41

82690 Ethchlorvynol 01/01/97 2 22.44 21.85

82693 Ethylene Gylcol 01/01/98 2 20.59 21.14

82696 Etiocholanolone 01/01/98 2 32.60 33.48

82705 Fat Or Lipids Feces, Qual 01/01/97 2 2.19 2.13

82710 Fat/Lipids Feces, Quant 01/01/98 2 23.21 23.84

82715 Fat Differential,Feces, Quantitative 01/01/98 2 23.79 24.43

82725 Fatty Acids, Non Esterified 01/01/98 2 18.40 18.90

82726 Very long chain fatty acids 01/01/99 1 24.96

82728 Ferritin 01/01/98 2 18.83 19.33

82731 Fetal fibronectin 01/01/01 1 89.01

82735 Floride 01/01/98 2 25.63 26.32

82742 Flurazepam 01/01/98 2 27.36 28.10

82746 Folic Acid; Serum 01/01/98 2 20.32 20.87

82747 Folic Acid;Rbs 01/01/98 2 23.93 24.58

82757 Fructose, Semen 01/01/97 2 3.24 3.15

82759 Galactokinase Rbc 01/01/97 2 15.94 15.52

82760 Galactose 01/01/98 2 15.47 15.89

82775 Galactose-1-Phosph Uridyl Trans Quantit 01/01/98 2 29.11 29.90

82776 Galactose-1-Phosph Uridyl Trans Screen 01/01/98 2 11.59 11.90

82784 Gammaglobulin A D G M Each 01/01/98 2 12.85 13.20

82785 Gammaglobulin Ige 01/01/98 2 22.76 23.38

82787 Gammaglobulin;Subclasses Igg 01/01/02 2 11.09 44.33

82800 Gases, Blood; Ph Only 01/01/98 2 11.71 12.02

82803 Gases Blood Ph Pc02 By Simultaneous 01/01/98 2 26.74 27.47

82805 Blood Gases W/02 Saturation 01/01/98 2 39.21 40.27

82810 Blood Gases 02 Sat Only 01/01/98 2 12.06 12.39

82820 Hemoglobin-02 Affinity 01/01/97 2 12.67 12.34

82926 Gastric Acid Free And Total Ea Ch Spec 01/01/98 2 7.53 7.74

82927 Gastric Acid Free And Total Ea Add Spec 04/01/01 3 NC 9.27

82928 Gastric Acid, Free Or Total; Each Spec 01/01/98 2 9.05 9.29

82938 Gastrin After Secretin Stimulation 01/01/98 2 24.46 25.12

5101:3-1-60 Page 172







82941 Gastrin 01/01/98 2 24.38 25.03

82943 Glucagon 01/01/98 2 19.75 20.28

82945 Glucose other fluid 01/01/01 1 5.42

82946 Glucagon Tolerance Test 01/01/97 2 17.47 17.01

82947 Glucose; Quantitative 01/01/98 2 5.42 5.57

82948 Glucose; Blood, Reagent Strip 01/01/98 2 4.37 4.49

82950 Glucose;Post Glucose Dose Include Glucos 01/01/98 2 6.56 6.74

82951 Gtt 3 Specimens (Includes Glucose) 01/01/97 2 13.51 13.15

82952 Glucose Tolerance Test >3 Specim Ea Sp 01/01/97 2 5.27 5.13

82953 Glucose Tolbutamide Tolerance Test 01/01/98 2 20.93 21.50

82955 Glucose-6-Phosph Dehydrogenase Quantit 01/01/97 2 6.30 6.13

82960 Glucose-6-Phosph Dehydrogenase Screen 01/01/98 2 8.38 8.60

82962 Glucose, Clia Waived Methodology 01/01/02 2 3.23 4.37

82963 Glucosidase, Beta 01/01/97 2 6.30 6.13

82965 Glutamate Dehydrogenase 01/01/97 2 6.30 6.13

82975 Glutamine (Glutamicacidamide) 01/01/98 2 21.88 22.47

82977 Glutamyltransferase, Gamma (Gtt) 01/01/98 2 9.95 10.21

82978 Glutathione 01/01/97 2 17.11 16.66

82979 Glutathione Reductase Rbc 01/01/98 2 9.52 9.77

82980 Glutethimide 01/01/98 2 25.32 26.00

82985 Glycated Protein 01/01/97 2 7.32 7.13

83001 Gonadotropin; Fsh 01/01/98 2 25.69 26.38

83002 Gonadotropin; Luteinzing Hormone (Lh) 01/01/98 2 25.60 26.29

83003 Growth Hormone(Hgh) Somatotropin 01/01/98 2 23.04 23.66

83008 Guanosine Monophophate (Gmp) Cyclic 01/01/98 2 23.20 23.8383009 H pylori (c-13), blood 01/01/05 1 94.11

83010 Haptoglobin; Quantitative 01/01/98 2 17.38 17.85

83012 Haptoglobin; Phenotypes 01/01/97 2 22.51 21.92

83013 Helicobacter pylori, breath test analysis 01/01/00 2 93.09 88.80

83014 Helicobacter pylori; drug admin. & sample collection 01/01/99 1 10.86

83015 Heavy Metal; Screen Arsenic Bism, Etc. 01/01/97 2 17.62 17.16

83018 Heavy Metal; Quantitative, Each 01/01/98 2 30.35 31.17

83019 Breath isotope test 04/01/99 3 NC BR

83020 Hemoglobin Electrophoresis (E.G.,A2,S,C) 01/01/98 2 17.80 18.28

83021 Hemoglobin fractionation & quantitation 01/01/99 1 24.96

83026 Hemoglobin;By Coper Sulfate Method 01/01/98 2 3.26 3.35

83030 Hemoglobin; F Fetal Chemical 01/01/97 2 10.55 10.27

83033 Hemoglobin F Fetal Qualitatat Apt Fecal 01/01/98 2 8.24 8.46

5101:3-1-60 Page 173







83036 Hemoglobin; Glycated 01/01/98 2 13.42 13.78

83045 Hemoglobin; Methemaglobin, Qualitative 01/01/98 2 6.85 7.04

83050 Hemoglobin; Methemaglobin, Quantitative 01/01/98 2 10.12 10.40

83051 Hemoglobin; Plasma 01/01/98 2 10.10 10.37

83055 Hemoglobin; Sulfhemoglobin, Quantitative 01/01/98 2 6.80 6.98

83060 Hemoglobin; Sulfhemoglobin, Qualitative 01/01/98 2 11.43 11.74

83065 Hemoglobin; Thermolabile 01/01/98 2 9.52 9.77

83068 Hemoglobin; Unstable Screen 01/01/98 2 11.71 12.02

83069 Hemoglobin; Urine 01/01/98 2 5.45 5.60

83070 Hemosiderin; Qualitative 01/01/97 2 4.25 4.14

83071 Hemosiderin; Quantitative 01/01/98 2 9.50 9.76

83080 B-hexosaminidase, each assay 01/01/99 1 23.31

83088 Histamine 01/01/98 2 40.81 41.91

83090 Assay of homocystine 01/01/01 1 23.31

83150 Homovanillic Acid (Hva) 01/01/98 2 26.74 27.47

83491 Hydroxycorticosteriods,17-(17-Ohcs) 01/01/98 2 24.21 24.86

83497 Hydroxyindolacetic Acid 5-(Hiaa) 01/01/98 2 17.82 18.30

83498 Hydroxyprogesterone 17D 01/01/98 2 37.54 38.55

83499 Hydroxyprogesterone 20- 01/01/98 2 34.83 35.77

83500 Hydroxyproline; Free 01/01/97 2 19.63 19.11

83505 Hydroxyproline; Total 01/01/97 2 18.93 18.43

83516 Immunoassay, non antibody 01/01/98 2 15.95 16.38

83518 Immunoassay,For Analyte Not Ab, Qual/Semi 01/01/98 2 11.72 12.04

83519 Immunoassay,Analyte By Radionuclide Meth 01/01/98 2 18.67 19.17

83520 Immunoassay, Analyte,Nos 01/01/98 2 17.89 18.38

83525 Insulin 01/01/98 2 15.81 16.23

83527 Assay Of Insulin 01/01/98 2 17.90 18.38

83528 Intrinsic Factor 01/01/98 2 21.98 22.57

83540 Iron 01/01/98 2 8.95 9.20

83550 Iron Binding Capacity 01/01/98 2 12.08 12.40

83570 Isocitric Dehydrog(Idh) 01/01/98 2 12.22 12.56

83582 Ketogenic Steriods, Fractionation 01/01/98 2 19.59 20.12

83586 Ketosteriods 17-(17-Ks); Total 01/01/98 2 17.69 18.17

83593 Ketosteriods17-(17-Ks);Fractionation 01/01/98 2 36.35 37.33

83597 Ketosteriods 17-(17-Ks)Urine 11Des/Oxy 04/01/95 2 NC 28.94

83605 Lactic (Lactic Acid) 01/01/98 2 14.76 15.15

83615 Lactic Dehydrogen Ase (Ld) (Ldh); 01/01/98 2 8.35 8.57

83625 Lactic Dehydrog Isoenzymes,Sep & Quant 01/01/98 2 17.69 18.16

5101:3-1-60 Page 174






APPR VISIT CODE DESCRIPTION DATE CODE PRICE PRICE INDIC. DAYS GROUP DATE DATE GROUP DATE DATE83630 Lactoferrin, fecal (qual) 01/01/05 1 16.12

83632 Lactogen Placental(Hpl)Chorion Somat 01/01/98 2 27.93 28.68

83633 Lactose, Urine; Qualitative 01/01/98 2 7.61 7.81

83634 Lactose, Urine; Quantitative 01/01/97 2 10.28 10.01

83655 Lead 01/01/98 2 16.72 17.18

83661 Lecithin-Spingomyelin Ratio Amnio Fluid 01/01/98 2 30.38 31.20

83662 L/S Ratio;Form Stability Test 01/01/97 2 20.96 20.41

83663 Fluoro polarize, fetal lung 01/01/01 1 10.48

83664 Lamellar bdy, fetal lung 01/01/01 1 5.24

83670 Leucine Aminopeptid Ase (Lap) 01/01/98 2 12.66 13.00

83690 Lipase 01/01/98 2 9.52 9.77

83715 Lipoprotein,Bld,Electrophor.Separ&Quant. 01/01/97 2 15.29 14.89

83716 Lipoprotein, blood 01/01/99 1 34.30

83717 Lipoprotein Blood Ultracentrifug Analyt 04/01/99 3 NC 34.30

83718 Lipoprotein, Dir; Hdl Cholesterol 01/01/98 2 11.31 11.62

83719 Lipoprotein Vldl Cholesterol 01/01/98 2 16.08 16.51

83721 Lipoprotein;Ldl Cholesterol 01/01/98 2 13.18 13.54

83727 Luteinizing Releasing Factor (Lrh) 01/01/98 2 23.76 24.40

83735 Magnesium 01/01/97 2 7.97 7.76

83775 Malate Dehydrogenase 01/01/98 2 10.19 10.47

83785 Maganese 01/01/98 2 33.98 34.90

83788 Mass spectrometry, qualitative 01/01/99 1 24.96

83789 Mass spectrometry, quantitative 01/01/99 1 24.96

83805 Meprobamate 01/01/98 2 24.36 25.02

83825 Mercury, Quantitative 01/01/98 2 22.47 23.07

83835 Metanephrines 01/01/98 2 23.41 24.05

83840 Methadone 01/01/97 2 8.49 8.27

83857 Methemalbumin 01/01/98 2 14.84 15.25

83858 Methsuximide 01/01/98 2 20.48 21.04

83864 Mucopolysaccharides,Acid,Quantitative 01/01/97 2 7.32 7.13

83866 Mucopolysaccharides Acid; Screen 01/01/98 2 13.62 13.98

83872 Mucin Synovial Fluid (Ropes Test) 01/01/98 2 8.10 8.32

83873 Myelin Basic Protein, Csf 01/01/98 2 23.78 24.42

83874 Myoglobin 01/01/98 2 17.84 18.32

83880 Natriuretic peptide 07/01/03 1 47.43

83883 Nephelometry, Ea Analyte,Nes 01/01/98 2 18.79 19.30

83885 Nickel 01/01/98 2 33.86 34.78

83887 Nicotine 01/01/97 2 23.78 23.15

5101:3-1-60 Page 175







83890 Nuclear Molecular Diag;Isolation Or Ext 01/01/98 2 5.54 5.69

83891 Molecule Isolate Nucleic 01/01/99 1 5.54

83892 Nuclear Molecular Iag;Enzymatic Or Ext 01/01/98 2 5.54 5.69

83893 Molecular dot/slot blot 01/01/99 1 5.54

83894 Nuclear Molecular Iag;Separation 01/01/98 2 5.54 5.69

83896 Nuclear Molecular Diag;Nucleic Probe,Ea 01/01/98 2 5.54 5.69

83897 Molecule Nucleic Transfer 01/01/99 1 5.54

83898 Nuclear Molecular Diag;Amp Nulceic Adic 01/01/98 2 23.17 37.61

83901 Molecule Nucleic Amp. 01/01/99 1 23.17

83902 Molecular diagnosistics, reverse transcription 01/01/98 1 19.61 5.69

83903 Molecule Mutation Scan 01/01/99 1 23.17

83904 Molecule Mutation Identify 01/01/99 1 23.17



83912 Nucleic Acid Probe,Interp. & Report 01/01/98 2 5.54 5.69

83915 Nucleotidase 5- 01/01/98 2 15.41 15.83

83916 Oligoclonal Immuno Globulin (Bands) 01/01/98 2 27.79 28.54

83918 Organic Acids Quantitative 01/01/98 2 22.75 23.36

83919 Organic Acids; qualitative, each specimen 01/01/99 1 22.75

83921 Organic acid, single, quant 01/01/01 1 22.75

83925 Opiates,(E.G., Morphine Meperidine) 01/01/97 2 21.89 21.31

83930 Osmolality; Blood 01/01/98 2 9.13 9.38

83935 Osmolality; Urne 01/01/98 2 9.42 9.67

83937 Assay For Osteocalcin 01/01/98 2 41.26 42.37

83945 Oxalate 01/01/98 2 17.80 18.28

83950 Oncoprotein, HER-2/neu 01/01/02 1 89.01

83970 Parathormone (Parathyroid Hormone) 01/01/98 2 57.04 58.58

83986 Ph, Body Fluid, Excpet Blood 01/01/98 2 4.95 5.08

83992 Phencyclidine (Pcp) 01/01/98 2 20.31 20.86

84022 Phenothiazine 01/01/98 2 21.53 22.11

84030 Phenylalanine 01/01/98 2 7.61 7.81

84035 Phenylketones,Qualitative 01/01/97 2 3.24 3.15

84060 Phosphatase; Acid Total 01/01/98 2 10.20 10.48

84061 Phosphatase;Forensic Examination 01/01/98 2 10.94 11.23

84066 Phosphatase; Prostatic 01/01/98 2 13.35 13.71

84075 Phosphatase; Alkaline 01/01/98 2 7.15 7.34

84078 Phosphatase; Heat Stable 01/01/98 2 10.09 10.36

84080 Phosphatase; Isoenzymes 01/01/98 2 20.44 20.99

5101:3-1-60 Page 176







84081 Phosphatydylglycerol 01/01/98 2 22.84 23.45

84085 Phosphogluconate 6-Dehydrogenase Rbc 01/01/97 2 8.49 8.27

84087 Phosphohexose Isomerase 01/01/98 2 14.27 14.65

84100 Phosphorus Inorganic (Phosphate); 01/01/98 2 6.56 6.73

84105 Phosphate; Urine 01/01/98 2 7.15 7.34

84106 Porphobilinogen,Urine,Qualitative 01/01/98 2 5.92 6.08

84110 Porhoblinogen Urne Quantative 01/01/98 2 11.68 11.99

84119 Porphyrins Urine Qualitative 01/01/97 2 10.55 10.27

84120 Porphyrins,Quantitation & Fractionation 01/01/98 2 20.33 20.88

84126 Porphyrins Feces; Quantitative 01/01/98 2 35.20 36.15

84127 Porphyrins,Feces;Qualitative 01/01/98 2 16.10 16.54

84132 Potassium; Serum 01/01/98 2 6.35 6.52

84133 Potassium; Urine 01/01/98 2 5.94 6.10

84134 Prealbumin 01/01/98 2 20.16 20.70

84135 Pregnanediol 01/01/97 2 21.09 20.54

84138 Pregnanetriol 01/01/98 2 26.16 26.87

84140 Assay For Pregnenolone 01/01/98 2 28.58 29.35

84143 Assay/17-Hydroxypregnenolone 01/01/98 2 31.54 32.39

84144 Progesterone 01/01/97 2 26.48 25.78

84146 Prolactin 01/01/98 2 26.78 27.50

84150 Prostaglandin 01/01/98 2 34.50 35.43

84152 Assay of psa, complexed 01/01/01 1 25.42

84153 Prostate Specific Antigen(Psa) 01/01/98 2 25.42 26.11

84154 Prostate Specific Antigen (free) 01/01/99 1 25.42

84155 Protein; Total, Except Refractometry 01/01/98 2 5.06 5.20

84156 Assay Of Protein, Urine 04/01/04 1 5.12 5.25

84157 Assay Of Protein, Other 04/01/04 1 5.12 5.25

84160 Protein; Refractometric 01/01/98 2 7.15 7.3484163 Pappa, serum 01/01/05 1 21.03

84165 Protein, Electrophoretic Fraction&Quan 01/01/98 2 14.84 15.2584166 Protein e-phoresis/urine/csf 01/01/05 1 24.92

84181 Protein;Eastern Blot W Interp & Report 01/01/97 2 21.12 20.56

84182 Protein;Western Bl,Imm Probe Band Id 01/01/98 2 24.87 25.54

84202 Protoporphyrin Rbc Quantitative 01/01/98 2 19.83 20.37

84203 Protoporphyrin Rbc Screen 01/01/98 2 11.89 12.21

84206 Proinsulin 01/01/98 2 24.62 25.29

84207 Pyridoxal Phosphate (Vitamin B-6) 01/01/98 2 38.82 39.87

84210 Pyruvate 01/01/98 2 15.01 15.41

5101:3-1-60 Page 177







84220 Pyruvate Kinase 01/01/98 2 13.04 13.39

84228 Quinine 01/01/97 2 8.49 8.27

84233 Receptor Assay;Estrogen 01/01/98 2 89.01 91.41

84234 Receptor Assay;Progesterone 01/01/98 2 89.64 92.07

84235 Receptor Assay;Endocrine (Nes Horm.) 01/01/98 2 72.31 74.27

84238 Receptor Assay;Non-Endocrine(Spec Recept 01/01/98 2 50.53 51.90

84244 Renin 01/01/97 2 24.29 23.65

84246 Renin; Furosemide Test 01/01/95 1 NC

84252 Riboflavin (Vitamin B-2) 01/01/98 2 27.96 28.72

84255 Selenium 01/01/98 2 35.28 36.24

84260 Serotonin 01/01/98 2 42.81 43.97

84270 Sex Hormone Binding Globulin (Shbg) 01/01/97 2 26.48 25.78

84275 Sialic Acid 01/01/98 2 18.56 19.06

84285 Silica 01/01/98 2 32.55 33.42

84295 Sodium; Serum 01/01/98 2 6.65 6.82

84300 Sodium; Urine 01/01/98 2 6.72 6.90

84302 Assay of sweat sodium 07/01/03 1 6.79

84305 Somtomedin 01/01/98 2 29.38 30.17

84307 Somatosation 01/01/98 2 25.27 25.95

84311 Spectrophotometry,Analyte Nes 01/01/98 2 9.66 9.89

84315 Specific Gravity,Excluding Urine 01/01/98 2 3.46 3.56

84375 Sugars, Tcl Or Paperchromatograpphy 01/01/98 2 27.09 27.82

84376 Sugars; single qualitative, each specimen 01/01/99 1 7.61

84377 Sugars; multiple qualitative, each specimen 01/01/99 1 7.61

84378 Sugars; single quantitative, each specimen 01/01/99 1 10.28

84379 Sugars; multiple quantitative, each specimen 01/01/99 1 10.28

84392 Sulfate, Urine 01/01/98 2 6.56 6.74

84402 Testosterone;Free 01/01/98 2 35.19 36.14

84403 Testosterone; Total 01/01/97 2 28.15 27.41

84425 Thiamine (Vitamin B-1) 01/01/98 2 29.35 30.14

84430 Thiocyanate 01/01/97 2 10.55 10.27

84432 Thyroglobulin 01/01/98 2 22.20 22.80

84436 Thyroxine, Total 01/01/98 2 9.50 9.76

84437 Thyroxine; Requiring Elution 01/01/98 2 8.95 9.19

84439 Thyroxine, Free 01/01/98 2 12.46 12.80

84442 Thyroxine Binding Globulin (Tbg) 01/01/98 2 20.44 20.99

84443 Thyroid Stimulating Hormone (Tsh) 01/01/98 2 23.21 23.84

84445 Thyroid Stimulating Immunoglobulins(Tsi) 01/01/98 2 70.28 72.18

5101:3-1-60 Page 178







84446 Tocopherol Alpha (Vitamin E) 01/01/98 2 19.60 20.12

84449 Assay For Transcortin 01/01/98 2 24.87 25.54

84450 Transaminase(Sgot);Aspartateamino (Ast) 01/01/98 2 7.14 7.33

84460 Transaminase(Sgpt);Alanineamino (Alt) 01/01/98 2 7.32 7.52

84466 Transferrin 01/01/97 2 16.76 16.32

84478 Triglycerides 01/01/98 2 7.95 8.16

84479 Tridothyronine(T-3),Resin Uptake 01/01/98 2 8.95 9.19

84480 Tridothyronine;Total (Tt3) 01/01/98 2 19.60 20.12

84481 Tridothyronine,Free, 01/01/98 2 23.41 24.05

84482 Tridithyronine;Reverse 01/01/98 2 21.78 22.37

84484 Troponin 01/01/98 2 13.60 10.00

84485 Trypsin Duodenal Fluid 01/01/98 2 10.37 10.66

84488 Trypsin,Feces,Qualitative 01/01/98 2 10.09 10.36

84490 Trypsin Feces Quantative 24 Hour 01/01/98 2 10.52 10.80

84510 Tyrosin 01/01/98 2 14.38 14.77

84512 Troponin, qualitative 01/01/99 2 10.00 BR

84520 Urea Nitrogen, (Bun) Quantitative 01/01/98 2 5.45 5.60

84525 Urea Nitrogen,Semiquant (Reagent Strip) 01/01/98 2 5.19 5.34

84540 Urea Nitrogen,Urine 01/01/98 2 6.56 6.74

84545 Urea Nitrogen,Urine,Clearance 01/01/98 2 9.12 9.37

84550 Uric Acid, Blood, Chemical 01/01/98 2 6.25 6.41

84560 Uric Acid,Urine 01/01/98 2 6.56 6.74

84577 Urobilinogen Feces Quantitative 01/01/97 2 2.43 2.37

84578 Urobilinogen,Urine,Qualitative 01/01/98 2 4.48 4.61

84580 Urobilogen,Urine Quant, Time Specimen 01/01/98 2 9.81 10.07

84583 Urobilogen, Urine Semiquantitative 01/01/97 2 3.98 3.88

84585 Vanillymandelic Acid(Vma) Urine 01/01/98 2 21.42 22.00

84586 Vip Assay 01/01/98 2 48.83 50.14

84588 Vasopressin(Antidiuretic Hormone) Adh 01/01/98 2 46.91 48.18

84590 Vitamin A 01/01/98 2 16.02 16.45

84591 Assay of nos vitamin 01/01/01 1 16.02

84597 Vitamin K 01/01/98 2 18.94 19.46

84600 Volatiles (Acetic Anhydride Etc) 01/01/98 2 22.21 22.81

84620 Xylose Absorption Test,Blood And Or Urin 01/01/97 2 13.51 13.15

84630 Zinc 01/01/98 2 15.74 16.17

84681 C-Peptide 01/01/98 2 28.75 28.79

84702 Gonadotropin Chorionic;Quantitative 01/01/98 2 20.80 21.36

84703 Gonadotropin Chorionic;Qualitative 01/01/98 2 10.38 10.66

5101:3-1-60 Page 179







84830 Ovulation Tests,Vis Color Comp 01/01/98 2 13.87 14.24

84999 Unlisted Chemistry Procedure 01/01/94 1 BR

85002 Bleeding Time 01/01/98 2 6.22 6.39

85004 Automated diff wbc count 07/01/03 1 9.04

85007 Blood Count; Manual Differential 01/01/98 2 4.76 4.89

85008 Bld Cnt; Manual Blood Smera Wo Diff Par 01/01/97 2 2.19 2.13

85009 Blood Count Differential Wbc Buffy Coat 01/01/98 2 5.14 5.27

85013 Spun Microhematocrit 01/01/98 2 3.27 3.36

85014 Hematocrit Other Than Spun 01/01/98 2 3.27 3.36

85018 Blood Count Hemoglobin 01/01/98 2 3.27 3.36

85021 Auto Cbc Rbc Wbc Hgb Ht & Indices 07/01/03 3 NC 7.72

85022 Blood Ct.Auto Cbc & Manual Diff 07/01/03 3 NC 7.59

85023 Automated Cbc,Plt,Manua;L Diff 07/01/03 3 NC 11.18

85024 Auto.Cbc,Plt,Auto.Partial Diff 07/01/03 3 NC 11.18

85025 Auto.Cbc,Plt,Auto Complt. Diff 01/01/98 2 10.74 11.04

85027 Automated Cbc W/ Platelet Count 01/01/98 2 8.95 9.19

85029 Add Auto Indices;Rwd,Mpv,Histograms,1T03 04/01/99 3 NC 2.06

85030 Add Auto Indices; 4 Or More 04/01/99 3 NC 2.12

85031 Manual Complt Cbc And Diff 07/01/03 3 NC 8.18

85032 Manual cell count, each 07/01/03 1 6.01

85041 Red Blood Cell (Rbc) Only 01/01/97 2 3.98 3.88

85044 Reticulocyte Count, Manual 01/01/98 2 5.94 6.10

85045 Reticulocyte Count,Flow Cyometry 01/01/98 2 5.54 5.68

85046 Reticyte, HGB concentrate 01/01/99 1 7.72

85048 White Blood Cell (Wbc) 01/01/98 2 3.52 3.61

85049 Automated platelet count 07/01/03 1 6.25

85055 Reticulated Platelet Assay 04/01/04 1 37.41 38.38

85060 Bloodsmear,Interpretation By Physician 07/01/03 2 8.05 1.61

85095 Bone marrow; aspiration only 04/01/02 3 NC 7.50

85097 Bone Marrow Smear; Interpretatin Only 07/01/03 2 18.15 3.63

85102 Bone marrow biopsy, needle troc 04/01/02 3 NC 10.88

85130 Chromogen Subtrate Assay 01/01/98 2 16.44 16.88

85170 Clot Retraction 01/01/97 2 2.19 2.13

85175 Clot Lysis Time,Whole Blood Dilution 01/01/98 2 6.28 6.45

85210 Clotng Fctrs Plsma Ii Prthmbin Asay. 01/01/97 2 6.30 6.13

85220 Clotng Fctrs Plsma V Acg Or Pro Acclrn 01/01/97 2 6.30 6.13

85230 Clotng Fctrs-Factor Vii (Proconvertin) 01/01/97 2 6.30 6.13

85240 Clotng Fctr Viii(Ahg)One Stage 01/01/97 2 6.30 6.13

5101:3-1-60 Page 180







85244 Clotting Factor Viii Rel. Antigen Quan. 01/01/97 2 6.30 6.13

85245 Clot Fact Viii,Vw Fact,Ristocetin Cof 01/01/98 2 31.72 32.57

85246 Clot Fact Viii,Vw Fact Antigen 01/01/98 2 31.72 32.57

85247 Clot Fac Viii,Vw Fact,Multimet Anaysis 01/01/98 2 31.72 32.57

85250 Clotng Fctrs Plsma.Fctr Ix Ptc.Or Xmas 01/01/97 2 6.30 6.13

85260 Clotng Fctrs Plsma Fctr X Sturt.Prwer. 01/01/97 2 6.30 6.13

85270 Clotng Fctrs Plsma Fctr Xi Pta. 01/01/97 2 6.30 6.13

85280 Clotng Fctrs Plsma.Fctr Xii Hgeman 01/01/97 2 6.30 6.13

85290 Clotng Fctrs Plsma.Fctr Xiii.Fibrn.Stbzl 01/01/97 2 12.73 12.40

85291 Clotng Fctr Xiii Fibrin Stab Screen Solu 01/01/98 2 12.28 12.62

85292 Clotting; 01/01/98 2 26.17 26.88

85293 Clotting; 01/01/98 2 26.17 26.88

85300 Clotng.Inhbtrs.Or Anti Coglnts Ati Thrbn 01/01/98 2 16.38 16.82

85301 Clotting Inhibitors Or Anticoagulants; 01/01/98 2 14.95 15.35

85302 Clot Inhb/Anticoag;Protein C,Ag 01/01/98 2 16.61 17.06

85303 Clot Inhb/Anticoag;Protein C,Activity 01/01/98 2 19.11 19.63

85305 Clot Inhib/Anticoa,Protein S Tdt 01/01/98 2 16.02 16.45

85306 Clot Inhb/Anticoag;Protein S,Free 01/01/98 2 21.18 21.75

85307 Assay activated protein c 01/01/01 1 21.18

85335 Factor Inhibitor Test 01/01/98 2 17.80 18.28

85337 Thrombomodulin 01/01/98 2 14.41 14.80

85345 Coagulation Time Lee + White 01/01/98 2 5.94 6.10

85347 Coagulation Time Activated 01/01/98 2 5.88 6.04

85348 Coagulation Time Other Methods 01/01/98 2 5.14 5.28

85360 Euglobulin Lysis 01/01/97 2 10.55 10.27

85362 Fibrin Degrad Prod(Fdp)(Fsp)Agglut Slide 01/01/98 2 9.52 9.77

85366 Rin Degrad;Paracoagulation 01/01/98 2 11.90 12.22

85370 Fibrin Degrad;Quantitative 01/01/98 2 15.70 16.12

85378 Fibrin Degrad;D-Dimer;Semiqnt 01/01/98 2 9.86 10.12

85379 Fibrin Degrad,D-Dimer;Quant 01/01/98 2 14.06 14.44

85380 Fibrin degradation, vte 07/01/03 1 14.22

85384 Fibrinogen;Activity 01/01/98 2 11.74 12.05

85385 Fibrinogen;Antigen 01/01/98 2 11.74 12.05

85390 Fibrinolysins Screen; Intrp & Rep. 01/01/98 2 7.13 7.32

85396 Clotting Assay, Whole Blood 01/01/04 1 19.67

85400 Fibrinolytic Fact/Inhib; Plasmin 01/01/97 2 10.55 10.27

85410 Fibrinolytic Mechanism Anti-Plasmin 01/01/97 2 10.55 10.27

85415 Plasminogen Activator 01/01/97 2 12.73 12.40

5101:3-1-60 Page 181







85420 Fibrinolytic Mechanism Plasminogen 01/01/98 2 9.04 9.28

85421 Fibrinolytic Mechanisms; 01/01/97 2 10.55 10.27

85441 Heinz Bodies;Direct 01/01/97 2 4.25 4.14

85445 Heinz Bodies Induced Acety Phenylhydraz 01/01/98 2 9.42 9.51

85460 Hemoglobin Fetal Differential Lysis 01/01/98 2 10.69 10.98

85461 Hemoglobin, fetal 01/01/97 2 8.35 8.13

85475 Hemolysin,Acid 01/01/97 2 6.43 6.26

85520 Heparin Assay 01/01/98 2 18.09 18.58

85525 Heparin Neutralization 01/01/97 2 12.67 12.34

85530 Heparin-Protamine Tolerance Test 01/01/98 2 19.60 20.12

85535 Iron statin (RBC or bone mar 04/01/02 3 NC 6.43

85536 Iron stain peripheral blood 01/01/01 1 6.43

85540 Leucocyte Alkaline Phosphatase W Cnt 01/01/98 2 11.88 12.21

85547 Mechanical Fragility Rbc 01/01/98 2 11.88 12.21

85549 Muramidase 01/01/98 2 25.92 26.62

85555 Osmotic Fragility Rbc; Unincubated 01/01/98 2 9.24 9.48

85557 Osmotic Fragility Rbc;Incubated 01/01/97 2 15.94 15.52

85576 Platelet; Each Agent 01/01/97 2 13.77 13.41

85585 Platelet Estimate On Smear, Only 07/01/03 3 NC 4.76

85590 Platelet; Manual Count 07/01/03 3 NC 5.94

85595 Platelet; Automated Count 07/01/03 3 NC 6.18

85597 Platelet Neutralization 01/01/98 2 24.84 25.51

85610 Prothrombin Time 01/01/98 2 5.43 5.58

85611 Prothrombin Time Sub,Plasma Frac,Ea 01/01/98 2 5.45 5.59

85612 Prothrombin Time Russell Viper Venom 01/01/97 2 7.97 7.76

85613 Russell Viper Venom Time Diluted 01/01/97 2 7.97 7.76

85635 Reptilase Test 01/01/97 2 7.97 7.76

85651 Sedimentation Rate Erythrocyte Nonauto 01/01/98 2 4.91 5.04

85652 Sedimentation Rate Erythrocyte, Auto. 01/01/98 2 3.73 3.78

85660 Sickling Of Red Blood Cells 01/01/98 2 7.63 7.84

85670 Thrombin Time Plasma 01/01/97 2 6.43 6.26

85675 Thrombin Time Titer 01/01/98 2 9.47 9.73

85705 Thromboplastin Inhib;Tissue 01/01/98 2 13.31 13.67

85730 Thrmplstn Time Partial Ptt Plasm Whl Bld 01/01/98 2 8.30 8.52

85732 Thrmplstn Time Partial Ptt Substit Plas 01/01/98 2 8.95 9.19

85810 Viscosity.Bld. 01/01/98 2 16.14 16.58

85999 Unlisted Hematology Procedure 01/01/94 1 BR

86000 Agglutinins; Febrile, Ea Antigen 01/01/98 2 9.65 9.91

5101:3-1-60 Page 182







86001 Allergen specific igg 01/01/01 1 7.22

86003 Allergen Specific Ige 01/01/98 2 7.22 7.41

86005 Allergen Specific Ige 01/01/97 2 10.45 10.18

86021 Antibody Identification Leukocyte Antibd 01/01/98 2 20.80 21.36

86022 Antibody Identification Platelet Antibod 01/01/98 2 25.38 26.07

86023 Antibody I.D. Platelet Assoc.Immunoglob. 01/01/98 2 17.21 17.68

86038 Antinuclear Antibodies (Ana) 01/01/98 2 16.70 17.15

86039 Antinuclear Antibodies (Ana);Titer 01/01/98 2 15.43 15.85

86060 Antistreptolysin O Titer 01/01/98 2 10.09 10.36

86063 Antistreptolysin O Screen 01/01/98 2 7.98 8.2086064 B cells, total count 01/01/05 1 52.70

86077 Physician; Interp And Rpt Diff X-Match/A 07/01/03 2 19.10 3.82

86078 Physician; Interp And Rpt On Tr Invest 07/01/03 2 12.50 2.50

86079 Physician; Deviation From Std Proced 07/01/03 2 12.75 2.55

86140 C Reactive Protein 01/01/98 2 7.15 7.34

86141 High sensitivity C-reactive protein 01/01/02 1 17.89

86146 Glycoprotein antibody 01/01/01 1 32.94

86147 Cardiolipin (Phospholipid) Antibody 01/01/97 2 32.94 32.07

86148 Phospholipid antidbody 01/01/99 2 22.20 BR

86155 Chemotaxis Assay 01/01/98 2 22.08 22.68

86156 Cold Agglutinin; Screen 01/01/97 2 7.92 7.71

86157 Cold Agglutinin Titer 01/01/98 2 11.14 11.45

86160 Complement;Ag,Ea Component 01/01/98 2 16.59 17.04

86161 Complement;Func Activ,Ea Component 01/01/98 2 16.59 17.04

86162 Complement Total (Ch 50) Hemolytic 01/01/98 2 28.08 28.83

86171 Complement Fixation Tests, Ea Antigen 01/01/98 2 13.85 14.22

86185 Counterelectrophoresis Ea Antigen 01/01/98 2 12.37 12.70

86215 Deoxyribonuclease Antibody 01/01/98 2 18.32 18.81

86225 Deoxyribonucleic Acid (Dna) Ab,Double 01/01/98 2 18.99 19.50

86226 Dna Antibody;Sing Stranded 01/01/98 2 16.73 17.18

86235 Extractable Nuclear Antigen (Ena)Antibod 01/01/98 2 24.78 25.45

86243 Fc Receptor 01/01/97 2 24.29 23.65

86255 Fluorescent Antibody;Screen,Ea Antibody 01/01/98 2 16.66 17.11

86256 Fluorescent Antibody;Titer,Ea Ab 01/01/98 2 16.66 17.11

86277 Growth Hormone, Human (Hgh),Antibody 01/01/98 2 21.75 22.34

86280 Hemagglutination Inhibition Test (Hai) 01/01/98 2 11.31 11.62

86287 Hepatitis B Surface Ag (Hbsag) 04/01/98 3 NC 12.86

86289 Hepatitis B Core Antibody (Hbcab)Igg&Igm 04/01/98 3 NC 17.11

5101:3-1-60 Page 183







86290 Hepatitis B Core Igm,Antibody0 04/01/98 3 NC 16.70

86291 Hepatitis B Surface Antibody (Hbsab) 04/01/98 3 NC 15.25

86293 Hepatitis Be Antigen (Hbeag) 04/01/98 3 NC 16.36

86294 Immunoassay, tumor qual 01/01/01 1 9.88

86295 Hepatitis Be Antibody (Hbeab) 04/01/98 3 NC 16.42

86296 Hepatitis A Antibody (Haab);G&M 04/01/98 3 NC 17.59

86299 Hepatitis A Antibody (Haab);Igm 04/01/98 3 NC 15.98

86300 Immunoassay, tumor ca 15-3 01/01/01 1 19.76

86301 Immunoassay, tumor, ca 19-9 01/01/01 1 19.76

86302 Hepatits C Antibody 04/01/98 3 NC 18.21

86303 Hepatitis C antibody 04/01/98 3 NC 21.98

86304 Immunoassay, tumor ca 125 01/01/01 1 19.76

86306 Hepatits,Delta Agent 01/01/98 2 NC 23.30

86308 Heterophile Antibodies;Screen 01/01/98 2 7.15 7.34

86309 Heterophile Antibodies;Titer 01/01/98 2 8.95 9.19

86310 Heterophile Antibodies,Absorp.Beef&G Pig 01/01/98 2 10.19 10.47

86311 Hiv Antigen 04/01/98 3 NC 15.44

86313 Immunoassay, infectious agent 04/01/98 3 NC 17.02

86315 Immunoassay, infectious agent 04/01/98 3 NC 13.46

86316 Immunoassay For Tumor Antigen Each 01/01/97 2 19.76 19.24

86317 Immunoassay For Infectious Ag Or Ab;Nes 01/01/98 2 20.72 21.28

86318 Immunoassay For Infect Agent Ab Qual/Sem 01/01/98 2 17.89 18.38

86320 Immunoelectrophoresis Serum 01/01/98 2 30.98 31.81

86325 Immunoelectrophoresis;Other 01/01/98 2 30.90 31.74

86327 Immunoelectrophoresis; Crossed(2-D) 01/01/98 2 31.35 32.20

86329 Immunodiffusion Nes 01/01/98 2 19.40 19.93

86331 Immunodiffusion;Gel Dif Qual,Ea Ag Or Ab 01/01/98 2 16.56 17.01

86332 Immune Complex Assay 01/01/98 2 33.68 34.60

86334 Immunofixation Electrophoresis 01/01/98 2 30.87 31.7186335 Immunfix e-phorsis/urine/csf 01/01/05 1 41.00

86336 Inhibin A 01/01/02 1 19.76

86337 Insulin Antibodies 01/01/98 2 29.59 30.39

86340 Intrinsic Factor Antibodies 01/01/98 2 20.83 21.39

86341 Islet Cell Antibody 01/01/97 2 24.71 24.06

86343 Leukocyte Histamine Release Test(Lhr) 01/01/98 2 17.22 17.69

86344 Leukocyte Phagocytosis 01/01/98 2 11.04 11.34

86353 Lymphocyte Transformation Mitogen 01/01/98 2 67.75 69.58

86359 T Cells Total Count 01/01/98 2 52.13 53.54

5101:3-1-60 Page 184







86360 T Cell Ratio 01/01/98 2 64.93 66.68

86361 T cells absolute count 01/01/99 2 37.00 BR

86376 Microsomal Antibody (Thyroid); Each 01/01/98 2 20.11 20.65

86378 Migration Inhibitory Factor Test (Mif) 01/01/97 2 18.38 17.9086379 Nk cells, total count 01/01/05 1 52.70

86382 Neutralization Test Viral 01/01/98 2 23.36 23.99

86384 Nitroblue Tetrazolium Dye Test (Ntd) 01/01/98 2 15.74 16.17

86403 Particle Agglutination,Abor Ag,Each 01/01/98 2 14.08 14.46

86406 Particle agglutination test 01/01/97 2 8.35 8.13

86430 Rheumatoid Factor Qualitative 01/01/98 2 7.85 8.06

86431 Rheumatiod Factor;Quantitative 01/01/98 2 7.85 8.06

86485 Skin Test;Candida 01/01/94 1 10.00

86490 Skin Test Coccidioidomycosis 01/01/94 1 4.89

86510 Skn Tst.Histoplasmosis 01/01/94 1 4.89

86580 Skin Test Tuberculosis Patch Intradermal 01/01/94 1 4.89

86585 Skin Test Tuberculosis- Tine Test 01/01/94 1 4.89

86586 Skin Test,Unlisted Antigen,Ea 07/01/03 2 86.65 BR86587 Stem cells, total count 01/01/05 1 52.70

86588 Streptococcus,Screen,Direct 04/01/00 3 NC 13.41

86590 Streptokinase Antibody 01/01/98 2 15.24 15.66

86592 Syphilis Test; Qualitative 01/01/98 2 5.90 6.06

86593 Syphilis Test; Quantitative 01/01/98 2 6.09 6.25

86602 Antibody;Actinomyces 01/01/98 2 14.06 14.44

86603 Antibody;Adenovirus 01/01/98 2 17.79 18.27

86606 Antibody;Aspirgillus 01/01/97 2 19.00 18.50

86609 Antibody;Bacterium,Nes 01/01/98 2 17.81 18.29

86611 Bartonella antibody 01/01/01 1 14.06

86612 Antibody;Blastomyces 01/01/98 2 17.83 18.32

86615 Antibody;Bordetella 01/01/98 2 18.23 18.72

86617 Lyme disease antibody 01/01/98 2 21.40 21.98

86618 Ab;Borellia Burgdorferi(Lyme Diease) 01/01/98 2 23.54 24.18

86619 Antibody;Borrelia (Relapsing Fever) 01/01/98 2 18.49 18.99

86622 Antibody;Brucella 01/01/98 2 12.35 12.68

86625 Antibody;Campylobacter 01/01/98 2 18.13 18.62

86628 Antibody;Candida 01/01/98 2 16.60 17.05

86631 Antibody;Chlamydia 01/01/98 2 16.35 16.79

86632 Antibody;Chlamydia,Igm 01/01/98 2 17.55 18.02

86635 Antibody;Coccidoides 01/01/98 2 15.85 16.28

5101:3-1-60 Page 185







86638 Antibody;Coxiella Brunetii (Q Fever) 01/01/98 2 16.75 17.21

86641 Antibody;Cryptococcus 01/01/97 2 19.00 18.50

86644 Antibody;Cytomegalovirus (Cmv) 01/01/98 2 19.89 20.43

86645 Antibody;Cytomegalovirus (Cmv),Igm 01/01/98 2 23.28 23.91

86648 Antibody;Diphtheria 01/01/97 2 19.00 18.50

86651 Antibody;Encephalitis,Calf, (La Crosse) 01/01/98 2 18.23 18.72

86652 Antibody;Encephalitis,Eastern Equine 01/01/98 2 18.23 18.72

86653 Antibody;Encephalitis,St. Louis 01/01/98 2 18.23 18.72

86654 Antibody;Encephalitis,Western Equine 01/01/98 2 18.23 18.72

86658 Ab;Enterovirus(E.G., Coxsakie,Echo,Poli) 01/01/98 2 18.01 18.50

86663 Antibody;Epstein-Barr (Eb)Virus,Early Ag 01/01/98 2 18.13 18.62

86664 Ab;Epstein-Barr Virus Nuclear Ag(Ebna 01/01/97 2 19.00 18.50

86665 Epstein Barr Virus,Viral Capsid 01/01/97 2 19.00 18.50

86666 Ehrlichia antibody 01/01/01 1 14.06

86668 Antibody;Francisella Tularensis 01/01/98 2 14.38 14.77

86671 Antibody;Fungus,Nes 01/01/98 2 16.95 17.40

86674 Antibody;Giardia Lamblia 01/01/98 2 20.34 20.89

86677 Antibody;Helicobacter Pylori 01/01/98 2 20.05 20.60

86682 Antibody;Helminth,Nes 01/01/98 2 17.97 18.46

86683 Antibody: hemoglobin, fecal 04/01/02 3 NC 3.50

86684 Antibody;Hemophilus Influenza 01/01/98 2 21.90 22.49

86687 Htlv-1 01/01/98 2 11.60 11.91

86688 Antibody;Htlv-Ii 01/01/98 2 19.37 19.89

86689 Htlv Or Hiv Antibody;Confirmatory 01/01/98 2 26.75 27.47

86692 Antibody;Hepatitis,Delta Agent 01/01/98 2 23.72 24.36

86694 Ab;Herpes Simplex,Non-Specific Type Te 01/01/98 2 19.89 20.43

86695 Antibody;Herpes Simplex,Type 1 01/01/98 2 18.23 18.72

86696 Herpes simplex type 2 01/01/01 1 26.75

86698 Antibody;Histoplasma 01/01/98 2 17.28 17.75

86701 Antibody;Hiv-1 01/01/98 2 12.28 12.61

86702 Antibody;Hiv-2 01/01/98 2 18.69 19.19

86703 Antibody;Hiv-1And Hiv-2,Single Assay 01/01/98 2 18.96 19.47

86704 Hepatitis B core antibody 01/01/98 1 16.66

86705 Hepatitis B core antibody 01/01/98 1 16.27

86706 Hepatitis B core surface antibody 01/01/98 1 14.84

86707 Hepatitis Be antibody 01/01/98 1 15.98

86708 Hepatitis A antibody 01/01/98 1 17.12

86709 Hepatitis A antibody 01/01/98 1 15.55

5101:3-1-60 Page 186







86710 Antibody;Influenza Virus 01/01/98 2 18.74 19.24

86713 Antibody;Legionella 01/01/98 2 21.15 21.72

86717 Antibody;Leishmania 01/01/98 2 16.93 17.39

86720 Antibody;Leptospira 01/01/98 2 18.23 18.72

86723 Antibody;Listeria Monocytogenes 01/01/98 2 18.23 18.72

86727 Antibody;Lymphocytic Choriomeningitis 01/01/98 2 17.79 18.27

86729 Antibody;Lymphogranuloma Venereum 01/01/98 2 16.51 16.96

86732 Antibody;Mucormycosis 01/01/98 2 18.23 18.72

86735 Antibody;Mumps 01/01/98 2 18.03 18.52

86738 Antibody;Mycoplasma 01/01/98 2 18.31 18.80

86741 Antibody;Neisseria Meningititis 01/01/98 2 18.23 18.72

86744 Antibody;Nocardia 01/01/98 2 18.23 18.72

86747 Antibody;Parovirus 01/01/98 2 20.77 21.33

86750 Antibody;Plasmodium(Malaria) 01/01/98 2 18.23 18.72

86753 Antibody;Protozoa,Nes 01/01/98 2 17.12 17.59

86756 Antibody;Respiratory Syncytial Virus 01/01/98 2 17.81 18.29

86757 Rickettsia antibody 01/01/01 1 26.75

86759 Antibody;Rotavirus 01/01/98 2 18.23 18.72

86762 Antibody;Rubella 01/01/98 2 19.89 20.43

86765 Antibody;Rubeola 01/01/98 2 17.81 18.29

86768 Antibody;Salmonella 01/01/98 2 18.23 18.72

86771 Antibody;Shigella 01/01/98 2 18.23 18.72

86774 Antibody;Tetanus 01/01/98 2 20.45 21.00

86777 Antibody;Toxoplasma 01/01/98 2 19.89 20.43

86778 Antibody;Toxoplasma,Igm 01/01/98 2 19.90 20.44

86781 Ab;Treponema Pallidum,Confirmatory T 01/01/98 2 18.30 18.79

86784 Antibody;Trichinella 01/01/98 2 17.36 17.83

86787 Antibody;Varicella-Zoster 01/01/98 2 17.81 18.29

86790 Antibody;Virus,Nes 01/01/98 2 17.81 18.29

86793 Antibody;Yersinia 01/01/98 2 18.23 18.72

86800 Thyroglobulin Antibody 01/01/98 2 21.98 22.57

86803 Hepatitis C antibody 01/01/98 1 18.21

86804 Hepatitis C antibody 01/01/98 1 21.40

86805 Lyphocytotox Assy,Vis Crosmtch,W/ Titra 01/01/98 2 72.26 74.21

86806 Lymphocytox Assy,Vis Crsmtch,W/O Titra 01/01/98 2 65.76 67.54

86807 Serum Screening Cytoxic Pra, Std Method 01/01/98 2 54.69 56.16

86808 Serum Screening Cytoxic Pra, Quikmethod 01/01/98 2 41.02 42.13

86812 Hla Typing A B Or C, Single Antigen 01/01/98 2 35.66 36.62

5101:3-1-60 Page 187







86813 Hla Typing A B Or C,Multi. Antigens 01/01/98 2 80.13 82.30

86816 Hla Typing, Dr/Dq Single Antigen 01/01/98 2 38.49 39.54

86817 Hla Typing. Dr/Dq Multiple Antigens 01/01/98 2 88.98 91.38

86821 Lymphocyte Culture, Mixed (Mlc) 01/01/97 2 44.61 43.44

86822 Lymphocyte Culture, Primed (Plc) 01/01/97 2 44.61 43.44

86849 Unlisted Immunology Precedure 01/01/94 1 BR

86850 Antibody Screen,Rbc,Ea Serum Technique 01/01/97 2 11.84 11.53

86860 Antibody Elution (Rbc),Ea Elution 01/01/97 2 29.96 29.17

86870 Antibody Id,Rbc Ab,Ea Panel,Ea Technique 01/01/97 2 25.09 24.43

86880 Agh Tst;Direct,Ea Antiserum(Direct Coomb 01/01/98 2 7.42 7.62

86885 Coombs Test 01/01/98 2 7.90 8.12

86886 Agh Test;Indirect,Titer,Ea Antiserum 01/01/98 2 7.15 7.34

86890 Autologous Bld Or Comp,Collect,Proc,Sto 07/01/03 2 13.49 BR

86891 Auto Donor Blood;Intra/Postop Salvage 07/01/03 2 1110.66 BR

86900 Blood Typing;Abo 01/01/98 2 4.12 4.23

86901 Blood Typing;Rh(D) 01/01/97 2 6.96 6.78

86903 Ag Screen For Blood Using Reag,Per Unit 01/01/98 2 13.05 13.40

86904 Ag Screen For Bld Using Pat Serum,Pre Un 01/01/98 2 13.14 13.49

86905 Rbc Antigens,Other Than Abo Or Rh,Ea 01/01/98 2 5.28 5.43

86906 Rh Phenotyping,Complete 01/01/98 2 10.71 11.00

86910 Typing For Paternity Test,Ea Ag System 01/01/94 1 NC

86911 Paternity Test, Ea Add Ag System 01/01/94 1 NC

86915 Bone Marrow Mod Or Treat To Elimin Cells 07/01/03 3 NC BR

86920 Compatibil Test Ea Unit;Immediate Spin 01/01/97 2 23.83 23.20

86921 Compatibil Test Ea Unit;Incubation Tech 01/01/97 2 23.83 23.20

86922 Compatibility Test Ea Unit;Ahg Technique 01/01/97 2 23.83 23.20

86927 Fresh Frozen Plasma,Thawing Ea Unit 01/01/97 2 9.76 9.50

86930 Frozen Blood,Prep For Freezing Ea Unit 01/01/97 2 23.83 23.20

86931 Frozen Blood;Thawing Ea Unit 01/01/97 2 35.96 35.01

86932 Frozen Bld; With Freezing&Thawing,Ea Unit 01/01/97 2 47.65 46.40

86940 Hemolysins Agglutinins, Auto,Screen,Each 01/01/98 2 11.33 11.64

86941 Hemolysins Agglut,Auto,Screen,Ea;Incubat 01/01/98 2 16.73 17.18

86945 Irradiation Of Blood Product,Ea Unit 01/01/97 2 11.71 11.40

86950 Leukocyte Transfusion 01/01/97 2 31.76 30.94

86965 Pooling Of Platelets Or Other Blood Prod 01/01/94 1 15.00

86970 Pretreat Rbc W Chem Agents Or Drugs,Ea 01/01/97 2 16.03 15.61

86971 Pretreat Rbc & Incubation W Enzymes 01/01/97 2 16.03 15.61

86972 Pretreat Rbc By Density Gradient Separat 01/01/97 2 19.51 19.00

5101:3-1-60 Page 188







86975 Pretreat Serum For Ab Id;Ancu Drugs 01/01/97 2 16.03 15.61

86976 Pretreat Serum For Ab Id;By Dilition 01/01/97 2 16.03 15.61

86977 Pretreat Serum Ab Id;Incub W Inhib 01/01/97 2 16.03 15.61

86978 Pretreat Serum By Autoabsorption 01/01/97 2 19.51 19.00

86985 Splitting Of Bld Or Bld Products,Ea Unit 01/01/94 1 15.00

86999 Unlisted Transfusion Medicine Service 01/01/94 1 BR

87001 Animal Inoculation Small W Observation 01/01/98 2 18.27 18.76

87003 Animal Inoculation Small Observ Dissect 01/01/98 2 23.26 23.89

87015 Concentration For Parasites Ova Tb Bacil 01/01/97 2 7.97 7.76

87040 Culture, Bacterial, Definitive; Blood 01/01/98 2 14.27 14.65

87045 Culture Bact Definitive Aerobic Stool0 01/01/98 2 13.04 13.39

87046 Stool cultr, bacteria, each 01/01/01 1 3.26

87060 Culture Bact Defin Aerobic Throat/Nose 04/01/01 3 NC 11.90

87070 Culture Bact Defin Aerobic Other Source 01/01/98 2 11.90 12.22

87071 Culture bacteri aerobic othr 01/01/01 1 6.52

87072 Culture Of Direct Bac Id,Ea Organism,Kit 04/01/01 3 NC 11.16

87073 Culture bacteria anaerobic 01/01/01 1 6.52

87075 Culture Bacterial Any Source Anaerobic 01/01/98 2 13.08 13.43

87076 Culture,Bac,An;Id,Ea Anaerobic Organism 01/01/02 2 11.16 17.80

87077 Culture aerobic identify 01/01/01 1 11.16

87081 Culture Bacterial Screening Single Organ 01/01/98 2 9.16 9.41

87082 Cul.Presump.Comm.Kit,Screen,Single Org. 04/01/01 3 NC 10.13

87083 Cult.Presump.Comm.Kit,Screen,Mult.Organ. 04/01/01 3 NC 11.61

87084 Culture Presumptive,Kit W Colony Estim. 01/01/98 2 11.90 12.22

87085 Cult.Presump.Com.Kit,Screen,Colony Count 04/01/01 3 NC 11.90

87086 Culture Bact Urine Quantit Colony Count 01/01/98 2 11.16 11.46

87087 Culture Bact Urine Commercial Kit 04/01/01 3 NC 8.94

87088 Culture Bact Urine Identification 01/01/98 2 11.18 11.48

87101 Culture Fungi Isolation Skin 01/01/98 2 10.66 10.94

87102 Culture,Fungi,Isolation;Other Source 01/01/98 2 11.61 11.92

87103 Culture,Fungi,Isolation;Blood 01/01/98 2 12.46 12.80

87106 Culture,Fungi,Def.Id Ea Fungus 01/01/98 2 14.27 14.65

87107 Fungi identification, mold 01/01/01 1 14.27

87109 Culture Mycoplasma Any Source 01/01/98 2 21.26 21.83

87110 Culture,Chlamydia 01/01/98 2 27.08 27.81

87116 Culture Tubercle/Acid Fast Bacil Isolatn 01/01/98 2 14.93 15.34

87117 Culture Tub/Acid Fast Bacil Conc Isolatn 04/01/01 3 NC 7.97

87118 Culture Tub/Acid Fast Bacil Defin Identf 01/01/98 2 15.13 15.53

5101:3-1-60 Page 189







87140 Culture Typing Fluorescent Method 01/01/98 2 7.71 7.92

87143 Culture Typing Gas Liquid Chromatog Glc 01/01/98 2 17.32 17.78

87145 Culture Typing Phage Method 04/01/01 3 NC 9.51

87147 Culture Typing Serologic Agglut Grouping 01/01/97 2 6.30 6.13

87149 Culture type, nucleic acid 01/01/01 1 27.71

87151 Culture Typing Serologic Speciation 04/01/01 3 NC 6.30

87152 Culture type pulse field gel 01/01/01 1 7.23

87155 Culture Typing Precipitin Grouping 04/01/01 3 NC 6.71

87158 Culture Typing Other Methods 01/01/98 2 7.23 7.43

87163 Culture Special Extensive Diag Studies 04/01/01 3 NC 15.30

87164 Darkfield Exam Any Source W Spec Collect 01/01/98 2 14.84 15.25

87166 Darkfield Exam Any Source Wo Spec Collct 01/01/98 2 15.61 16.03

87168 Macroscopic exam arthropod 01/01/01 1 5.90

87169 Macacroscopic exam parasite 01/01/01 1 5.90

87172 Pinworm exam 01/01/01 1 5.90

87174 Endotoxin Bacterial Chemical 04/01/01 3 NC 11.90

87175 Endotoxin,Bacterial;Bioassay 04/01/01 3 NC 14.86

87176 Endotoxin Bacterial Homogen Tissue Cult 01/01/98 2 8.13 8.35

87177 Ova Parasites Direct Smears Conc Identif 01/01/98 2 12.30 12.63

87178 Microb Ident, Nucleic Acid Probe, Ea.Prb 04/01/98 3 NC 23.60

87179 Microb Id,Nucleic Acid Probes W/Amplific 04/01/98 3 NC 23.81

87181 Sensitiv Studies Antibiot Agar Diffusion 01/01/97 2 2.43 2.37

87184 Sensitiv Studies Antibiot Disc Method 01/01/98 2 9.53 9.79

87185 Microbe susceptible, enzyme 01/01/01 1 2.43

87186 Sensitiv Studies Microtiter(Mic)<8 Antib 01/01/97 2 10.67 10.39

87187 Sensitivity Studies;Antbiotic;Mbc 01/01/97 2 12.45 12.12

87188 Sensitiv Studies Tube Dilution Ea Antibi 01/01/98 2 9.17 9.42

87190 Sensitivity Study Tuber.Bacill.One Drug 01/01/98 2 7.81 8.02

87192 Sensitivity,Antibiotic;Fungi,Ea Drug 04/01/01 3 NC 12.54

87197 Serum Bactericidal Titer 01/01/98 2 20.76 21.32

87198 Cytomegalovirus antibody (DFA) 01/01/02 1 16.58

87199 Enterovirus antibody (DFA) 01/01/02 1 16.58

87205 Smear W Interpret Primary Source Routine 01/01/98 2 5.90 6.06

87206 Smear W Interp Fluorescent/Acid Fast Stn 01/01/98 2 7.42 7.62

87207 Smear W Interp Spec Inclus/Intrcell Para 01/01/97 2 7.97 7.76

87208 Smear W Interp Direct/Conc Dry Ova Paras 04/01/01 3 NC 7.47

87210 Smear W Interp Wet Mount Simple Stain 01/01/98 2 5.90 6.06

87211 Smear W Interp Wet & Dry Mount Ova Paras 04/01/01 3 NC 6.30

5101:3-1-60 Page 190







87220 Tissue Exam For Fungi (Leg,Koh Slide) 01/01/98 2 5.90 6.06

87230 Toxin Or Antitoxin,Tissue Culture 01/01/98 2 27.28 28.02

87250 Virus Inoc Embryo Eggs/Tiss Cult W Obsrv 01/01/98 2 27.02 27.76

87252 Virus Id;Tissue Cult Inoculation & Obser 01/01/98 2 36.02 37.00

87253 Virus Id;Tissue Culture,Add Studies 01/01/98 2 27.91 28.67

87254 Virus inoculation, shell via 01/01/01 1 6.76

87255 Genet virus isolate, hsv 07/01/03 1 47.31

87260 Adenovirus antigen detection by DFA 01/01/98 1 16.58

87265 Pertussis antigen detection by DFA 01/01/98 1 16.58

87267 Enterovirus antibody, dfa 07/01/03 1 16.76

87269 Giardia Ag, If 04/01/04 1 16.76 17.20

87270 Chlamydia trachomatis antigen detection by DFA 01/01/98 1 16.58

87271 Cryptosporidum/gardia ag, if 07/01/03 1 16.76

87272 Cryptosporidum antigen detection by DFA 01/01/98 1 16.58

87273 Herpes simplex 2, ag, if 01/01/01 1 16.58

87274 Herpes simplex antigen detection by DFA 01/01/98 1 16.58

87275 Influenza b, ag, if 01/01/01 1 16.58

87276 Influenza A, ag det 01/01/02 1 16.58

87276 Influenza A antigen detection by DFA 01/01/98 1 16.58

87277 Legionella micdadei, ag, if 01/01/01 1 16.58

87278 Legionella pneumophila antigen detection by DFA 01/01/98 1 16.58

87279 Parainfluenza, ag, if 01/01/01 1 16.58

87280 Respiratory synctial antigen detection by DFA 01/01/98 1 16.58

87281 Pneumocystis carinii, ag, if 01/01/01 1 16.58

87283 Rubeola, ag, if 01/01/01 1 16.58

87285 Treponema pallidum antigen detection by DFA 01/01/98 1 16.58

87290 Varicella antigen detection by DFA 01/01/98 1 16.58

87299 Infectious agent antigen detection, NOS, by DFA 01/01/98 1 16.58

87300 Ag detection, polyval, if 01/01/01 1 8.29

87301 Adenovirus antigen detection by EIA 01/01/98 1 16.58

87320 Chlamydia trachomatis antigen detection by EIA 01/01/98 1 16.58

87324 Clostridium difficile toxin A antigen detection by EIA 01/01/98 1 16.58

87327 Cryptococcus neoform ag, eia 01/01/01 1 16.58

87328 Cryptosporidum antigen detection by EIA 01/01/98 1 16.58

87329 Giardia Ag, Eia 04/01/04 1 16.76 17.20

87332 Cytomegalovirus antigen detection by EIA 01/01/98 1 16.58

87335 E. coli 0157 antigen detection by EIA 01/01/98 1 16.58

87336 Entamoeb hist dispr, ag, eia 01/01/01 1 16.58

5101:3-1-60 Page 191







87337 Entamoeb hist group, ag, eia 01/01/01 1 16.58

87338 Helicobacter pylori, stool 04/01/02 2 19.88 BR

87339 Hpylori ag, eia 01/01/01 1 16.58

87340 Hepatitis B surface antigen detection by EIA 01/01/98 1 12.86

87341 Hepatitis b surface, ag, eia 01/01/01 1 12.86

87350 Hepatitis Be antigen detection by EIA code 01/01/98 1 15.92

87380 Hepatitis, delta agent antigen detection by EIA 01/01/98 1 22.69

87385 Histoplasma capsulatum antigen detection by EIA 01/01/98 1 16.58

87390 HIV-1 antigen detection by EIA 01/01/98 1 15.44

87391 HIV-2 antigen detection by EIA 01/01/98 1 15.44

87400 Influenza a/b, ag, eia 01/01/01 1 8.29

87420 Respiratory synctial antigen detection by EIA 01/01/98 1 16.58

87425 Rotavirus antigen detection by EIA 01/01/98 1 16.58

87427 Shiga-like toxin ag, eia 01/01/01 1 16.58

87430 Streptococcus A antigen detection by EIA 01/01/98 1 16.58

87449 Infectious agent antigen detection by EIA, NOS 01/01/98 1 16.58

87450 Infectious agent antigen detection by EIA, NOS 01/01/98 1 13.25

87451 Ag detect polyval, eia, mult 01/01/01 1 13.25

87470 Bartonella detection by DNA, direct probe 01/01/98 1 27.71

87471 Bartonella detection by DNA, amplified probe 01/01/98 1 48.50

87472 Bartonella detection by DNA, quantification 01/01/99 2 59.20 BR

87475 Lyme disease detection by DNA, direct probe 01/01/98 1 27.71

87476 Lyme disease detection by DNA, amplified probe 01/01/98 1 48.50

87477 Lyme disease detection by DNA, quantification 01/01/99 2 59.20 BR

87480 Candida detection by DNA, direct probe 01/01/98 1 27.71

87481 Candida detection by DNA, amplified probe 01/01/98 1 48.50

87482 Candida detection by DNA, quantification 01/01/99 2 57.69 BR

87485 Chlamydia pneumoniae detection by DNA, dir. probe 01/01/98 1 27.71

87486 Chlamydia pneumoniae detection by DNA, amp. probe 01/01/98 1 48.50

87487 Chlamydia pneumoniae detection by DNA, quantif. 01/01/99 2 59.20 BR

87490 Chlamydia trachomatis detection by DNA, dir. probe 01/01/98 1 27.71

87491 Chlamydia trachomatis detection by DNA, amp. probe 01/01/98 1 48.50

87492 Chlamydia trachomatis detection by DNA, quantif. 01/01/99 2 20.00 BR

87495 Cytomegalovirus detection by DNA, direct probe 01/01/98 1 27.71

87496 Cytomegalovirus detection by DNA, amplified probe 01/01/98 1 48.50

87497 Cytomegalovirus detection by DNA, quantification 01/01/99 2 59.20 BR

87510 Gardnerella vaginalis detection by DNA, direct probe 01/01/98 1 27.71

87511 Gardnerella vaginalis detection by DNA, amp. probe 01/01/98 1 48.50

5101:3-1-60 Page 192







87512 Gardnerella vaginalis detection by DNA, quantif. 01/01/99 2 57.69 BR

87515 Hepatitis B detection by DNA, direct probe 01/01/98 1 27.71

87516 Hepatitis B detection by DNA, amplified probe 01/01/98 1 48.50

87517 Hepatitis B detection by DNA, quantification 01/01/99 2 59.20 BR

87520 Hepatitis C detection by RNA, direct probe 01/01/98 1 27.71

87521 Hepatitis C detection by RNA, amplified probe 01/01/98 1 48.50

87522 Hepatitis C detection by RNA, quantification 01/01/99 2 59.20 BR

87525 Hepatitis G detection by DNA, direct probe 01/01/98 1 27.71

87526 Hepatitis G detection by DNA, amplified probe 01/01/98 1 48.50

87527 Hepatitis G detection by DNA, quantification 01/01/99 2 57.69 BR

87528 Herpes simplex detection by DNA, direct probe 01/01/98 1 27.71

87529 Herpes simplex detection by DNA, amplified probe 01/01/98 1 48.50

87530 Herpes simplex detection by DNA, quantification 01/01/99 2 59.20 BR

87531 Herpes virus-6 detection by DNA, direct probe 01/01/98 1 27.71

87532 Herpes virus-6 detection by DNA, amplified probe 01/01/98 1 48.50

87533 Herpes virus-6 detection by DNA, quantification 01/01/99 2 57.69 BR

87534 HIV-1 detection by DNA, direct probe 01/01/98 1 27.71

87535 HIV-1 detection by DNA, amplified probe 01/01/98 1 48.50

87536 HIV-1 detection by DNA, quantification 01/01/00 2 117.59 BR

87537 HIV-2 detection by DNA, direct probe 01/01/98 1 27.71

87538 HIV-2 detection by DNA, amplified probe 01/01/98 1 48.50

87539 HIV-2 detection by DNA, quantification 01/01/99 2 59.20 BR

87540 Legionella pneumophila detection by DNA, dir. probe 01/01/97 1 27.71

87541 Legionella pneumophila detection by DNA, amp. probe 01/01/98 1 48.50

87542 Legionella pneumophila detection by DNA, quantif. 01/01/99 2 57.69 BR

87550 Mycobacteria detection by DNA, direct probe 01/01/98 1 27.71

87551 Mycobacteria detection by DNA, amplified probe 01/01/98 1 48.50

87552 Mycobacteria detection by DNA, quantification 01/01/99 2 59.20 BR

87555 M. tuberculosis detection by DNA, direct probe 01/01/98 1 27.71

87556 M. tuberculosis detection by DNA, amplified probe 01/01/98 1 48.50

87557 M. tuberculosis detection by DNA, quantification 01/01/99 2 59.20 BR

87560 M. avium-intracellulare by DNA, direct probe 01/01/98 1 27.71

87561 M. avium-intracellulare by DNA, amplified probe 01/01/98 1 48.50

87562 M. avium-intracellulare by DNA, quantification 01/01/99 2 59.20 BR

87580 M. pneumoniae by DNA, direct probe 01/01/98 1 27.71

87581 M. pneumoniae by DNA, amplified probe 01/01/98 1 48.50

87582 M. pneumoniae by DNA, quantification 01/01/99 2 57.69 BR

87590 N. gonorrhoeae by DNA, direct probe 01/01/98 1 27.71

5101:3-1-60 Page 193







87591 N. gonorrhoeae by DNA, amplified probe 01/01/98 1 48.50

87592 N. gonorrhoeae by DNA, quantification 01/01/99 2 20.00 BR

87620 HPV by DNA, direct probe 01/01/98 1 27.71

87621 HPV by DNA, amplified probe 01/01/98 1 48.50

87622 HPV by DNA, quantification 01/01/99 2 57.69 BR

87650 Strep A by DNA, direct probe 01/01/98 1 27.71

87651 Strep A by DNA, amplified probe 01/01/98 1 48.50

87652 Strep A by DNA, quantification 01/01/99 2 57.69 BR

87660 Trichomonas Vagin, Dir Probe 04/01/04 1 28.02 28.74

87797 Infect agent detect by nucleic acid, NOS, dir. probe 01/01/98 1 27.71

87798 Infect agent detect by nucleic acid, NOS, amp. probe 01/01/98 1 48.50

87799 Infect agent detect by nucleic acid, NOS, quantif. 01/01/99 2 59.20 BR

87800 Detect agnt mult, dna, direc 01/01/01 1 27.71

87801 Detect agnt mult, dna, ampli 01/01/01 1 48.50

87802 Strep B detection immunoassay 01/01/02 1 16.58

87803 Clostr difficile toxin A immuno detec 01/01/02 1 16.58

87804 Influenza immunoassay detect w optic 01/01/02 1 16.5887807 Rsv assay w/optic 01/01/05 1 16.76

87810 Chlamydia trachomatis detection by immunoassay 01/01/98 1 16.58

87850 N. gonorrhoeae detection by immunoassay 01/01/98 1 16.58

87880 Strep A detection by immunoassay 01/01/98 1 16.58

87899 Infect agent detect by immunoassay, NOS 01/01/98 1 16.58

87901 Genotype, dna, hiv reverse t 01/01/01 1 355.78

87902 Hepatitis C genotype analysis 01/01/02 1 355.78

87903 Phenotype, dna hiv w/culture 01/01/01 1 675.29

87904 Phenotype, dna hiv w/clt add 01/01/01 1 36.02

87999 Unlisted Microbiology Procedure 01/01/94 1 BR

88000 Necropsy(Autopsy)Gross Exam Only Wo Cns 01/01/94 1 NC

88005 Necropsy(Autopsy)Gross Exam Only W Brain 01/01/94 1 NC

88007 Necropsy(Autopsy)Gross Exam W Brain Spin Cord 01/01/94 1 NC

88012 Necropsy(Autopsy)Gross Infant W Brain 01/01/94 1 NC

88014 Necropsy(Autopsy)Still/Newborn W Brain 01/01/94 1 NC

88016 Necropsy(Autopsy)Macerated Stillborn 01/01/94 1 NC

88020 Necropsy(Autopsy)Gross Micro Wo Cns 01/01/94 1 NC

88025 Necropsy(Autopsy)Gross Micro W Brain 01/01/94 1 NC

88027 Necropsy(Autopsy)Gross Micro Brain Sp Cd 01/01/94 1 NC

88028 Necropsy(Autopsy)Gross Micro Infnt W Brn 01/01/94 1 NC

88029 Necropsy(Autopsy)Gross Mic Still/Newborn 01/01/94 1 NC

5101:3-1-60 Page 194







88036 Necropsy(Autopsy)Ltd Gross/Nicro Regionl 01/01/94 1 NC

88037 Necropsy(Autopsy)Ltd Single Organ 01/01/94 1 NC

88040 Necropsy(Autopsy)Forensic Exam 01/01/94 1 NC

88045 Necropsy(Autopsy)Coroners Call 01/01/94 1 NC

88099 Unlisted Necropsy(Autopsy)Procedure 01/01/94 1 NC

88104 Cytopath Wash/Brush Ex.Cer/Vag. Interp. 01/01/04 2 30.85 6.17 D

88106 Cytopath Fluids Centrf Filter Method Int 01/01/04 2 29.35 5.87 D

88107 Cytopath Fluids Centrf Smears Filter Prp 01/01/04 2 38.95 7.79 D

88108 Cytopathology, Fluids, Washing Or Brush 01/01/04 2 31.20 6.24 D

88112 Cytopath, Cell Enhance Tech 01/01/04 1 110.32 K

88125 Cytopathology Forensic 10/01/84 3 NC BR

88130 Sex Chromatin Id; Barr Bodies 01/01/98 2 20.79 21.36

88140 Cytopath.Smears(Wbc)Chromosom Sex Determ 01/01/98 2 11.05 11.35

88141 Cytopath, cerv/vag interpretation 07/01/03 2 21.86 5.92

88142 Cytopath, cerv/vag thin layer preparation 01/01/98 1 23.68

88143 Cytopath. cerv/vag, thin layer, redo 04/01/02 2 27.35 BR

88144 Cytopath. cerv/vag, thin layer, auto redo 07/01/03 3 NC 27.35

88145 Cytopath. cerv/vag, thin layer, selection 07/01/03 3 NC 27.35

88147 Cytopath. cerv/vag, automated 04/01/02 2 14.60 BR

88148 Cytopath., cerv/vag, auto rescreening 04/01/02 2 14.60 BR

88150 Cytopath Cerv/Vag(Pap)Screen Int <3 Smrs 04/01/02 2 14.60 7.15

88151 Cytopath Smears,Cervical/Vag.,Upto3;Phys 04/01/98 3 NC 7.34 E

88152 Cytopathology, cerv/vag automated 04/01/02 2 14.60 7.15

88153 Cytopathology, cerv/vag, redo 04/01/02 2 14.60 7.15

88154 Cytopathology, cerv/vag, selection 04/01/02 2 14.60 7.15

88155 Cytopath Cerv/Vag Hormon Evaluation 01/01/98 2 8.28 8.50

88156 Cyto,Cervical/Vaginal Bethesda System 04/01/99 3 NC 7.15

88157 Cyto,Cervical/Vaginal Bethesda Sys Intp 04/01/98 3 NC 7.34 E

88158 Cytopathology, cerv/vag TBS automated 04/01/99 3 NC 7.15

88160 Cytopath Other Source Screen Interpret 01/01/04 2 25.95 5.19 D

88161 Cytopathology, Any Other Source; 01/01/04 2 27.05 5.41 D

88162 Cyto; Other, Extended > 5 Slides' 01/01/04 2 45.60 9.12 D

88164 Cytopath, TBS, cerv/vag, manual 04/01/02 2 14.60 7.15

88165 Cytopath, TBS, cerv/vag, redo 04/01/02 2 14.60 7.15

88166 Cytopath, TBS, cerv/vag, auto redo 04/01/02 2 14.60 7.15

88167 Cytopath, TBS, cerv/vag, selection 04/01/02 2 14.60 7.15

88170 Fine needle aspiration, super 04/01/02 3 NC 14.02 E

88171 Fine needle aspiration, deep tiss 04/01/02 3 NC 15.41 E

5101:3-1-60 Page 195







88172 Evaluation Asp; Immed Cytohist Study 01/01/04 2 37.55 7.51 D

88173 Evaluation Asp; Cytohist Inter And Rpt 01/01/04 2 71.35 14.27 D

88174 Cytopath, c/v auto, in fluid 07/01/03 1 28.39

88175 Cytopath c/v auto fluid redo 07/01/03 1 31.71

88180 Flow Cytometry; Cell Marker 01/01/05 3 NC 20.55 D

88182 Flow Cytometry; Cell Cycle Ordna 01/01/04 2 47.45 9.49 D88184 Flowcytometry/ tc, 1 marker 01/01/05 1 47.7588185 Flowcytometry/tc, add-on 01/01/05 1 23.5088187 Flowcytometry/read, 2-8 01/01/05 1 67.84 O88188 Flowcytometry/read, 9-15 01/01/05 1 84.51 O88189 Flowcytometry/read, 16 & > 01/01/05 1 111.42 O

88199 Unlisted Cytopathology Procedure 04/01/92 1 BR

88230 Tiss Cult Chromosome Anal;Lyphocyte 01/01/98 2 161.00 165.35

88233 Tiss Cult Chromosome;Skin/Solid Tiss Bio 01/01/98 2 194.49 199.74

88235 Tiss Cult Chromosome;Amnio Or Cv Cells 01/01/98 2 203.50 209.00

88237 Tiss Cult Chromosome;Bone Marrow Cells 01/01/98 2 174.55 179.27

88239 Tiss Cult Chromosome Anal;Other Tissure 01/01/98 2 203.88 209.39

88240 Cell cryopreservation/storage 01/01/01 2 13.96 NC

88241 Frozen cell preparation 01/01/01 2 13.96 NC

88245 Chromosome Break Synd;Sce 25,Cnt 5,1K Ba 01/01/98 2 205.72 211.28

88248 Chromosome Break Syn;Sce 100,Cnt 20,2K,Ba 01/01/98 2 239.32 245.79

88249 Chromosome Analysis, 100 01/01/99 1 239.32

88250 Chromosome Fragx Mr;Sce100;Cnt20,2K,Band 04/01/99 3 NC 209.24

88260 Chromosome Analysis Lymphocyte 1-4 Cells 04/01/99 3 NC 154.29

88261 Chromosome Analysis Lymph 1-4 Cll Ikaryo 01/01/98 2 244.24 250.85

88262 Chromosome Analysis Lymph 1-20 Cll 2Karyo 01/01/98 2 172.25 176.91

88263 Chromosome;Cnt45,2 Karyotypes W Banding 01/01/98 2 207.67 213.29

88264 Chromosome Analysis, 20-25 01/01/99 1 172.25

88267 Chromosome Analysis Amniot 1-4Cll 1Karyo 01/01/98 2 248.44 255.15

88269 Chromosome,In Situ Amnio,Cnt6-12 Col,Ik 01/01/98 2 229.85 236.06

88271 Cytogenetics, DNA probe 01/01/00 2 29.60 BR

88272 Cytogenetics, 3-5 01/01/00 2 37.00 BR

88273 Cytogenetics, 10-30 01/01/00 2 44.00 BR

88274 Cytogenetics, 25-99 01/01/00 2 48.10 BR

88275 Cytogenetics, 100-300 01/01/00 2 55.50 BR

88280 Chromosome Analysis Additional Karyotyp 01/01/98 2 34.68 35.48

88283 Chromosome;Add Banding,Spec Technique 01/01/98 2 94.79 97.36

88285 Chromosome Analysis Additional Cll Count 01/01/98 2 26.26 26.96

5101:3-1-60 Page 196







88289 Chromosome;Add High Resolution Study 01/01/98 2 47.58 48.87

88291 Cyto/Molecular report 01/01/99 2 5.54

88299 Unlisted Cytogenetic Study 01/01/94 1 BR

88300 Leveli-Surg Path Gross Exam Only 01/01/04 2 7.15 1.43 D

88302 Levelii Surg Path Gross & Micro Exam 01/01/04 2 12.05 2.41 D

88304 Level Iii Surg Path Gross & Micro Exam 01/01/04 2 18.10 3.62 D

88305 Leveliv Surg Path Gross & Micro Exam 01/01/04 2 50.00 10.00 D

88307 Level V Surg Path Gross & Micro Exam 01/01/04 2 92.40 18.48 D

88309 Level Vi Surg Path Gross & Micro Exam 01/01/04 2 127.15 25.43 D

88311 Surg Pathol Gr & Mc Decalcificat Proced 01/01/04 2 13.70 2.74 D

88312 Special Stains Group I For Microorganism 01/01/04 2 26.40 5.28 D

88313 Special Stains Group Ii Other 01/01/04 2 13.70 2.74 D

88314 Histochemical Staining W/ Frozen Section 01/01/04 2 31.00 6.20 D

88318 Histochemistry To Id Chemical Components 01/01/04 2 21.00 4.20 D

88319 Histochemistry To Id Enzyme Components 01/01/04 2 30.80 6.16 D

88321 Consult Report Referred Slides Prep Elsw 07/01/03 2 27.45 5.49

88323 Consult Report Referred Matrl W Slde Prp 01/01/04 2 67.60 13.52 D

88325 Surg Pathol,Comprehens.Review&Detailed 07/01/03 2 65.45 13.09

88329 Consultation During Surgery 07/01/03 2 33.15 6.63

88331 Consult During Surgery W Frozen Sectn(S) 07/01/03 2 68.10 13.62 D

88332 Cons Surg Ea Add Tiss Sectn Wfroz 07/01/03 2 34.20 6.84 D

88342 Immunohistochemistry Ea Antibody 01/01/04 2 45.70 9.14 D

88346 Immunofluroescent Study, Each Antibody 01/01/04 2 45.35 9.07 D

88347 Immunofluroescent Study,Each Ab;Indirect 01/01/04 2 39.50 7.90 D

88348 Electron Microscopy Diagnostic 01/01/04 2 105.15 21.03 D

88349 Electron Microscopy Scanning 01/01/04 2 60.75 12.15 D

88355 Morphometric Analysis;Skeletal Muscle 01/01/04 2 107.95 21.59 D

88356 Morphometric Analysis; Nerve 01/01/04 2 171.55 34.31 D

88358 Morphometric Analysis;Tumor 01/01/04 2 154.60 30.92 D88360 Tumor immunohistochem/manual 01/01/05 1 106.11 L

88361 Immunohistochemistry, Tumor 01/01/04 1 125.78 C

88362 Nerve Teasing Preparations 01/01/04 2 123.25 24.65 D

88365 Tiss In Situ Hybridiz, Interprt + Report 01/01/04 2 51.05 10.21 D88367 Insitu hybridization, auto 01/01/05 1 199.72 J88368 Insitu hybridization, manual 01/01/05 1 181.91 C

88371 Protein Analysis Of Tiss Western Blot 07/01/03 2 18.71 30.09

88372 Protein Anal West Blot;Im Probe Band Id 07/01/03 2 19.79 31.44

88380 Microdisection 01/01/02 1 5.00

5101:3-1-60 Page 197







88399 Unlisted Surgical Pathology Procedure 01/01/94 1 BR

88400 Bilirubin total transcut 01/01/01 1 2.79

89050 Cell Count,Miscell.Fluid Not Bld. 01/01/97 2 5.27 5.13

89051 Cell Count,Miscell.Fluid Not Bld,Differ 01/01/98 2 7.61 7.82

89055 Leukocyte assessment, fecal 07/01/03 1 5.96

89060 Crystal Synovial Fluid Identification 01/01/98 2 9.88 10.15

89100 Duodenal Intubation + Aspiration,Sing 07/01/03 2 13.15 2.63

89105 Duodenal Intub & Aspir; Mult 07/01/03 2 13.15 2.63

89125 Fat Stain Feces Urine Sputum 01/01/98 2 5.96 6.13

89130 Gastric Intubation And Aspiration 07/01/03 2 10.00 2.00

89132 Gastric Intubation Aspirat W Stimulation 07/01/03 2 8.35 2.50

89135 Gastric Intub Aspir Fractnl Coll 1 Hour 07/01/03 2 15.00 3.00

89136 Gastric Intub Aspir Fractnl Coll 2.Hour 07/01/03 2 10.59 3.24

89140 Gastric Intub Aspr Frtnl 2 Hrs Stimulatn 07/01/03 2 40.35 8.07

89141 Gastric Intub Aspr Frtnl 3 Hrs Stimulatn 07/01/03 2 24.25 4.85

89160 Meat Fibers Feces 01/01/97 2 2.19 2.13

89190 Nasal Smear For Eosinophils 01/01/97 2 4.62 4.50

89220 Sputum Specimen Collection 01/01/04 1 NC

89225 Starch Granules, Feces 04/01/04 1 2.21 2.27

89230 Collect Sweat For Test 01/01/04 1 15.39

89235 Water Load Test 04/01/04 1 7.69 7.89

89240 Pathology Lab Procedure 01/01/04 1 BR NC

89250 Culture & fertilization of oocyte(s) 01/01/96 1 NC

89251 Culture of oocytes with embryos 01/01/98 1 NC

89252 Assisted oocyte fertilization code 01/01/98 1 NC

89253 Assisted embryo hatching 01/01/98 1 NC

89254 Oocyte identification 01/01/98 1 NC

89255 Preparation of embryo for transfer 01/01/98 1 NC

89256 Preparation of cryopreserved embryos for transfer 01/01/98 1 NC

89257 Sperm identification 01/01/98 1 NC

89258 Cryopreservation of embryo 01/01/98 1 NC

89259 Cryopreservation of sperm 01/01/98 1 NC

89260 Sperm isolation 01/01/98 1 NC

89261 Sperm isolation 01/01/98 1 NC

89264 Sperm tissue identification 01/01/99 1 NC

89268 Insemination Of Oocytes 01/01/04 1 NC

89272 Extended Culture Of Oocytes 01/01/04 1 NC

89280 Assist Oocyte Fertilization 01/01/04 1 NC

5101:3-1-60 Page 198







89281 Assist Oocyte Fertilization 01/01/04 1 NC

89290 Biopsy, Oocyte Polar Body 01/01/04 1 NC

89291 Biopsy, Oocyte Polar Body 01/01/04 1 NC

89300 Semen Analysis-Sperm/Motility(+Huhner) 01/01/98 2 12.32 12.65

89310 Semen Analysis Motility + Count 01/01/97 2 10.79 10.51

89320 Semen Analysis Complete Vol Cnt Mot Diff 01/01/98 2 16.66 17.11

89321 Semen analysis 01/01/01 1 NC

89323 Sperm Immobilization 01/01/94 1 NC

89325 1Perm Agglutination W Antibody Titer 01/01/97 2 6.30 6.13

89329 Sperm Evaluation;Hamster Penetration 01/01/98 2 28.98 29.76

89330 Cervical Mucus Penetration Test 01/01/98 2 13.68 14.05

89335 Cryopreserve Testicular Tiss 01/01/04 1 NC

89342 Storage/Year; Embryo(S) 01/01/04 1 NC

89343 Storage/Year; Sperm/Semen 01/01/04 1 NC

89344 Storage/Year; Reprod Tissue 01/01/04 1 NC

89346 Storage/Year; Oocyte 01/01/04 1 NC

89350 Sputum,Obtain Specimen-Aerosol Technique 05/09/86 3 NC 6.00

89352 Thawing Cryopresrved; Embryo 01/01/04 1 NC

89353 Thawing Cryopresrved; Sperm 01/01/04 1 NC

89354 Thaw Cryoprsvrd; Reprod Tiss 01/01/04 1 NC

89355 Starch Granules Feces 01/01/04 3 NC 2.19

89356 Thawing Cryopresrved; Oocyte 01/01/04 1 NC

89360 Sweat.Test By Ionophoresis 01/01/04 3 NC 15.39

89365 Water Load Test 01/01/04 3 NC 7.61

89399 Unlisted Patholog/Laborat.Service.Proc. 01/01/04 3 NC BR E

90281 Human immune globulin, intramuscular 01/01/03 2 13.64 NC

90283 Human immune globulin, IV 01/01/99 1 NC

90287 Botulinum antitoxin 07/01/03 2 40.99 BR

90288 Botulism immune globulin, IV 01/01/03 2 NC BR

90291 Cytomegalovirus immune globulin, IV 01/01/03 2 14.04 BR

90296 Diphtheria antitoxin 01/01/99 1 BR

90371 Hepatitis B immune globulin, intramuscular 01/01/99 1 169.50

90375 Rabies immune globulin, intramusc. or subcut. 01/01/99 1 BR

90376 Rabies immune globulin, heat treated 01/01/99 1 BR

90378 Respiratory syncytial virus immune globulin IM 50mg 08/01/02 2 659.86 BR

90379 Respiratory syncytial virus immune globulin 01/01/03 3 NC BR

90384 RHO(D) immune globulin, full dose 01/01/03 2 119.83 BR

90385 RHO(D) immune globulin, mini dose 01/01/03 2 51.20 BR

5101:3-1-60 Page 199







90386 RHO(D) immune globulin, IV 01/01/03 3 NC BR

90389 Tetanus immune globulin 01/01/99 1 6.23

90393 Vaccinia immune globulin 01/01/99 1 BR

90396 Varicella zoster immune globulin 01/01/99 1 BR

90399 Unlisted immune globulin 01/01/99 1 NC90465 Immune admin 1 inj, < 8 yrs 01/01/05 1 NC90466 Immune admin addl inj, < 8 y 01/01/05 1 NC90467 Immune admin o or n, < 8 yrs 01/01/05 1 NC90468 Immune admin o/n, addl < 8 y 01/01/05 1 NC

90471 Immunization administration 01/01/99 1 NC

90472 Immunization administration 01/01/99 1 NC

90473 Immunization administration intranas/oral 01/01/02 1 NC

90474 Immunization administration, ea add vaccine 01/01/02 1 NC

90476 Adenovirus vaccine, type 4, live, oral 01/01/99 1 NC

90477 Adenovirus vaccine, type 7, live, oral 01/01/99 1 NC

90581 Anthrax vaccine, subcut. 01/01/99 1 NC

90585 Bacillus calmette-guerin vaccine 01/01/02 2 173.75 4.54

90586 Bacillus calmette-guerin vaccine 01/01/02 2 173.75 4.54

90592 Cholera vaccine, live, oral 04/01/00 1 NC

90632 Hepatitis A vaccine, adult 01/01/99 1 56.76

90633 Hepatitis A vaccine, ped/adolescent 10/01/00 2 BR NC

90634 Hepatitis A vaccine, ped/adolescent 10/01/00 2 BR NC

90636 Hepatitis A and Hepatitis B vaccine, adult 04/01/04 2 89.68 226.26

90645 HIB vaccine 01/01/99 1 5.00

90646 HIB vaccine 01/01/99 1 5.00

90647 HIB vaccine 01/01/99 1 5.00

90648 HIB vaccine 01/01/99 1 5.00

90655 Flu Vaccine, 6-35 Mo, Im 10/01/04 2 5.00 NC90656 Flu vaccine no preserv 3 & > 01/01/05 1 NC

90657 Influenza virus vaccine, split, age 0-35 mo 10/01/00 2 5.00 NC

90658 Influenza virus vaccine, split, age 3-18 07/01/03 2 6.65 5.00

90659 Influenza virus vaccine, whole, adult 01/01/04 3 NC 6.32

90660 Influenza virus vaccine, live, intranasal, adult 01/01/99 1 6.32

90665 Lyme disease vaccine, adult 01/01/99 1 NC

90669 Pneumococcal conjugate vaccine,pediatric 10/01/00 2 5.00 NC

90675 Rabies vaccine, intramuscular 01/01/99 1 153.38

90676 Rabies vaccine, intradermal 01/01/99 1 76.88

90680 Rotavirus vaccine 07/28/99 3 NC 43.76

5101:3-1-60 Page 200







90690 Typhoid vaccine, live, oral 01/01/99 1 NC

90691 Typhoid vaccine, VI capsular polysaccharide 01/01/99 1 NC

90692 Typhoid vaccine, heat- and phenol-inactivated 01/01/99 1 NC

90693 Typhoid vaccine, acetone killed, dried 01/01/99 1 NC

90698 Dtap-Hib-Ip Vaccine, Im 01/01/04 1 NC

90700 Dtap immunization 10/01/94 1 5.00

90701 Dtp immunization 04/01/00 3 NC 5.00

90702 Dt immunization 10/01/94 1 5.00

90703 Tetanus immunization 07/01/03 2 14.61 5.00

90704 Mumps immunization 01/01/00 3 NC 5.00

90705 Measles immunization 01/01/00 3 NC 5.00

90706 Rubella immunization 01/01/00 3 NC 5.00

90707 Mmr virus immunization 10/01/94 1 5.00

90708 Measles-rubella immunization 01/01/00 3 NC 5.00

90709 Rubella & mumps immunization 01/01/00 3 NC 5.00

90710 Combined vaccine 01/01/94 1 BR

90711 Combined vaccine 01/01/99 3 NC BR

90712 Oral poliovirus immunization 10/01/94 1 5.00

90713 Poliomyelitis immunization 10/01/94 1 5.00

90714 Typhoid immunization 04/01/99 3 NC 2.68

90715 Tdap Vaccine >7 Im 01/01/04 1 NC

90716 Chicken pox vaccine 01/01/97 2 5.00 42.01

90717 Yellow fever immunization 07/01/71 3 NC

90718 Td immunization 07/01/03 2 11.46 5.00

90719 Diphtheria immunization 05/09/86 1 NC

90720 Dtp/HIB vaccine 04/01/00 3 NC 5.00

90721 DTaP/HIB vaccine 01/01/96 1 NC

90723 Dtap-hep b-ipv vaccine, im 03/23/03 2 5.00 NC

90724 Influenza immunization 01/01/99 3 NC 5.00

90725 Cholera immunization 01/01/00 2 4.44 4.04

90726 Rabies immunization 04/01/99 3 NC 111.69

90727 Plague immunization 05/19/86 1 NC

90728 Bcg immunization 04/01/99 3 NC 4.54

90730 Hepatitis A vaccine 04/01/99 3 NC BR

90731 Hepatitis B immunization ped 04/01/96 3 NC 5.00

90732 Pneumococcal immunization 01/01/00 2 10.04 9.13

90733 Meningococcal immunization 03/15/85 1 BR

90734 Meningococcal Vaccine, Im 01/01/04 1 NC

5101:3-1-60 Page 201







90735 Encephalitis virus vaccine 01/01/94 1 BR

90737 Influenza b immunization 04/01/99 3 NC 5.00

90740 Hep b vacc, ill pat 3 dose im 04/01/02 2 69.73 67.62

90741 Passive immunization, isg 05/19/86 1 NC

90742 Special passive immunization 05/08/86 1 NC

90743 Hep b vacc, adol, 2 dose, im 01/01/01 3 NC

90744 Hepatitis B vaccine, under 11 01/01/96 1 5.00

90745 Hepatitis B vaccine, 11-18 04/01/00 1 NC

90746 Hepatitis B vaccine, 19 and over 01/01/00 2 55.23 50.21

90747 Hepatitis B vaccine, any age 04/01/02 2 57.96 56.63

90748 Hepatitis B/HIB combined vaccine 01/01/98 1 5.00

90749 Immunization procedure 05/01/79 1 BR

90780 Iv infusion therapy, 1 hour 01/01/00 2 31.86 28.05

90781 Iv infusion, additional hour 01/01/00 2 16.03 14.02

90782 Injection (sc)/(im) 01/01/03 1 3.00 NC

90783 Injection (ia) 01/01/03 1 11.21 NC

90784 Injection (iv) 01/01/03 1 13.14 NC

90788 Injection of antibiotic 01/01/03 1 3.28 NC

90799 Therapeutic/diag injection 05/01/94 1 BR

90801 Psychiatric interview 01/01/00 2 65.38 59.44

90802 Interactive psychiatric diagnostic interview 01/01/00 2 83.99 76.35

90804 Individual psychotherapy, 20-30 minutes 01/01/00 2 36.69 33.35

90805 Individual psychotherapy, 20-30 minutes, with E&M 01/01/00 2 45.52 41.38





90810 Interactive psychotherapy, office, 20-30 minutes 01/01/00 2 45.28 41.16

90811 Interact psychotherapy, office, 20-30 min, w/E&M 01/01/00 2 54.85 49.86


90813 Interact psychotherapy, office, 45-50 min, w/E&M 01/01/00 2 68.83 62.57


90815 Interact psychotherapy, office 75-80 min, w/E&M 01/01/00 2 99.24 90.22

90816 Individual psychotherapy, hospital, 20-30 minutes 01/01/00 2 39.88 36.25

90817 Individual psychotherapy, hospital, 20-30 min, w/E&M 01/01/00 2 49.93 45.39



90820 Diagnostic interview 04/01/98 3 59.85 NC

5101:3-1-60 Page 202









90823 Interactive psychotherapy, hospital, 20-30 minutes 01/01/00 2 48.72 44.29

90824 Interact psychotherapy, hospital, 20-30 min, w/E&M 01/01/00 2 59.51 54.10

90825 Evaluation of tests/records 04/01/98 3 NC 26.40





90830 Psychological testing 04/01/96 3 NC 36.47

90835 Special interview 05/01/94 1 NC

90841 Psychotherapy 05/01/94 1 NC

90842 Psychotherapy, 75-80 min 04/01/98 3 NC 78.38

90843 Psychotherapy 20-30 min. 04/01/98 3 NC 30.02

90844 Psychotherapy 45-50 min. 04/01/98 3 NC 47.15

90845 Medical psychoanalysis 01/01/00 2 49.87 45.34

90846 Special family therapy 01/01/00 2 55.86 50.78



90853 Special group therapy 01/01/00 2 15.96 14.51

90855 Individual psychotherapy 04/01/98 3 NC 50.17

90857 Special group therapy 01/01/00 2 13.30 12.09

90862 Medication management 01/01/00 2 30.14 27.40

90865 Narcosynthesis 01/01/98 1 NC

90870 Electroconvulsive therapy 01/01/00 2 53.86 48.96

90871 Electroconvulsive therapy 01/01/00 2 81.57 74.15

90875 Indiv. Psychophysiological Therapy 01/01/97 1 NC

90876 Indiv. Psychophysiological Therapy 01/01/97 1 NC

90880 Medical hypnotherapy 05/01/94 1 NC

90882 Environmental manipulation 05/01/94 1 NC

90885 Psychiatric evaluation of records 01/01/98 1 BR

90887 Consultation with family 05/01/94 1 NC

90889 Preparation of report 05/01/94 1 NC

90899 Psychiatric service/therapy 05/01/94 1 BR

90900 Biofeedback, electromyogram 05/01/94 1 NC

90901 Biofeedback Training by any modality 01/01/97 1 NC

90902 Biofeedback, nerve impulse 05/01/94 1 NC

90904 Biofeedback, blood pressure 05/01/94 1 NC

5101:3-1-60 Page 203







90906 Biofeedback, blood flow 05/01/94 1 NC

90908 Biofeedback, brain waves 05/01/94 1 NC

90910 Biofeedback, oculogram 05/01/94 1 NC

90911 Anorectal biofeedback 05/01/94 1 NC

90915 Biofeedback, unspecified 05/01/94 1 NC

90918 Esrd related services, month 01/01/00 2 315.02 282.82





90923 ESRD related services, day 01/01/00 2 8.41 7.53



90935 Hemodialysis, one evaluation 01/01/00 2 55.49 57.79

90937 Hemodialysis, repeated eval. 01/01/00 2 95.28 101.57

90939 Hemodialysis access flow study 01/01/02 3 NC

90940 Hemodialysis access study 01/01/01 3 NC

90941 Dialysis, one evaluation 04/01/01 3 NC 127.50

90942 Dialysis 04/01/01 3 NC 127.50

90943 Dialysis 04/01/01 3 NC 127.50

90944 Dialysis 03/13/02 3 NC 127.50

90945 Dialysis 03/13/02 2 57.48 57.48

90947 Dialysis, repeated eval. 03/13/02 2 95.99 95.99

90951 Dialysis 04/01/01 3 NC 140.25

90952 Dialysis 04/01/01 3 NC 140.25

90953 Dialysis 04/01/01 3 NC 140.25

90954 Dialysis 04/01/01 3 NC 140.25

90955 Dialysis 04/01/01 3 NC 140.25

90956 Dialysis 04/01/01 3 NC 140.25

90957 Dialysis 04/01/01 3 NC 140.25

90958 Dialysis 04/01/01 3 NC 140.25

90966 Dialysis 04/01/01 3 NC 140.25

90967 Dialysis 04/01/01 3 NC 140.25

90968 Dialysis 04/01/01 3 NC 140.25

90969 Dialysis 04/01/01 3 NC 140.25

90976 Dialysis 04/01/01 3 NC 140.25

90977 Dialysis 04/01/01 3 NC 140.25

90978 Dialysis 04/01/01 3 NC 140.25

5101:3-1-60 Page 204







90979 Dialysis 04/01/01 3 NC 140.25

90982 Dialysis 04/01/01 3 NC 140.25

90983 Dialysis 04/01/01 3 NC 140.25

90984 Dialysis 04/01/01 3 NC 140.25

90985 Dialysis 04/01/01 3 NC 140.25

90989 Dialysis training/complete 05/01/94 1 NC

90993 Dialysis training/incomplete 05/01/94 1 NC

90997 Hemoperfusion 01/01/00 2 83.60 89.42

90999 Dialysis procedure 05/01/94 1 BR

91000 Esophageal intubation 07/01/02 2 38.43 42.54 Q

91010 Esophagus motility study 01/01/00 2 104.43 95.88 D



91020 Esophagogastric study 01/01/00 2 113.69 106.90 D

91030 Acid perfusion of esophagus 01/01/00 2 46.89 42.84 Q

91032 Esophagus, acid reflux test 01/01/05 3 NC 97.28 D

91033 Prolonged acid reflux test 01/01/05 3 NC 125.09 M91034 Gastroesophageal reflux test 01/01/05 1 204.65 G91035 G-esoph reflx tst w/electrod 01/01/05 1 403.84 G91037 Esoph imped function test 01/01/05 1 130.97 J91038 Esoph imped funct test > 1h 01/01/05 1 112.56 K91040 Esoph balloon distension tst 01/01/05 1 393.26 F

91052 Gastric analysis test 01/01/00 2 50.27 61.52 Q

91055 Gastric intubation for smear 01/01/00 2 54.03 50.48 Q

91060 Gastric saline load test 07/01/02 2 27.05 35.20 D

91065 Breath hydrogen test 01/01/00 2 24.19 30.98 M

91100 Pass intestine bleeding tube 01/01/00 2 50.69 39.96

91105 Gastric intubation treatment 07/01/02 2 21.10 23.10

91110 Gi Tract Capsule Endoscopy 01/01/04 1 754.78 G91120 Rectal sensation test 01/01/05 1 388.15 F

91122 Anal pressure record 01/01/00 2 111.77 87.50 D

91123 Pulsed irrigation- fecal impaction 01/01/02 3 NC

91132 Electrogastrography 01/01/01 2 BR D

91133 Electrogastrography w/test 01/01/01 2 BR D

91299 Gastroenterology procedure 07/01/97 2 BR 17.50

92002 Eye exam, new patient 01/01/00 2 26.14 23.09

92004 Eye exam, new patient 01/01/00 2 41.07 29.24

92012 Eye exam established pt 01/01/00 2 23.39 23.09

5101:3-1-60 Page 205







92014 Eye exam & treatment 01/01/00 2 36.48 29.24

92015 Refraction 01/01/00 2 16.20 12.10

92018 New eye exam & treatment 01/01/00 2 37.10 34.09

92019 Eye exam & treatment 01/01/00 2 32.64 30.66

92020 Special eye evaluation 01/01/00 2 12.54 11.25

92060 Special eye evaluation 01/01/00 2 19.53 15.28 D

92065 Orthoptic/pleoptic training 01/01/00 2 12.78 12.38 D

92070 Fitting of contact lens 07/01/02 2 63.65 71.76

92081 Visual field examination(s) 01/01/00 2 11.84 11.56 D



92100 Serial tonometry exam(s) 01/01/00 2 22.20 20.03

92120 Tonography & eye evaluation 01/01/00 2 21.35 19.30

92130 Water provocation tonography 01/01/00 2 24.08 22.23

92135 Ophthalmic diagnostic imaging 01/01/00 2 8.57 14.57 L

92136 Opthalmic biometry 01/01/02 1 36.92 J

92140 Glaucoma provocative tests 01/01/00 2 16.12 13.64

92225 Special eye exam, initial 01/01/00 2 17.46 17.63

92226 Special eye exam, subsequent 01/01/00 2 16.07 15.45

92230 Eye exam with photos 01/01/00 2 28.61 22.24

92235 Eye exam with photos 01/01/00 2 42.14 41.23 D

92240 Indocyanine Green Angiography 01/01/00 2 47.73 44.64 L

92250 Eye exam with photos 01/01/00 2 15.11 14.74 D

92260 Ophthalmoscopy/dynamometry 01/01/00 2 11.80 17.91

92265 Eye muscle evaluation 01/01/00 2 20.21 18.97 D

92270 Electro-oculography 01/01/00 2 26.25 25.70 D

92275 Electroretinography 01/01/00 2 33.48 32.87 D

92280 Special eye evaluation 04/01/96 3 NC 18.60 D

92283 Color vision examination 01/01/00 2 7.72 9.36 D

92284 Dark adaptation eye exam 01/01/00 2 11.43 14.03 D

92285 Eye photography 01/01/00 2 8.39 8.33 D

92286 Internal eye photography 01/01/00 2 31.63 32.44 D

92287 Internal eye photography 01/01/00 2 47.58 40.08

92310 Contact lens fitting 01/01/00 2 180.30 155.30




92314 Prescription of contact lens 01/01/00 2 49.33 49.24

5101:3-1-60 Page 206










92325 Modification of contact lens 01/01/00 2 6.87 6.36

92326 Replacement of contact lens 01/01/00 2 28.49 26.47

92330 Fitting of artificial eye 07/01/94 2 0.00 35.19

92335 Fitting of artificial eye 07/01/94 2 0.00 38.44

92340 Fitting of spectacles 01/01/00 2 22.44 18.64



92352 Special spectacles fitting 01/01/00 2 20.19 20.46




92358 Eye prosthesis service 01/01/00 2 17.05 15.92

92370 Repair & adjust spectacles 05/01/94 1 NC

92371 Repair & adjust spectacles 05/01/94 1 NC

92390 Supply of spectacles 05/01/94 1 BR

92391 Supply of contact lenses 05/01/94 1 NC

92392 Supply of low vision aids 05/01/94 1 NC

92393 Supply of artificial eye 05/01/94 1 NC

92395 Supply of spectacles 01/01/00 2 24.69 23.15

92396 Supply of contact lenses 05/01/94 1 NC

92499 Eye service or procedure 05/01/94 1 BR

92502 Ear and throat examination 01/01/00 2 70.99 69.45

92504 Ear microscopy examination 01/01/00 2 14.86 11.52

92506 Speech & hearing evaluation 01/01/03 2 62.16 52.91

92507 Speech/hearing therapy 01/01/03 2 38.18 34.52

92508 Speech/hearing therapy 01/01/03 2 23.10 19.63

92510 Rehab for ear implant 01/01/00 2 78.30 75.87

92511 Nasopharyngoscopy 01/01/00 2 46.18 44.81

92512 Nasal function studies 01/01/00 2 29.92 26.98

92516 Facial nerve function test 01/01/00 2 23.85 21.87

92520 Laryngeal function studies 01/01/00 2 34.66 33.85

92525 Oral function evaluation 07/01/03 3 NC 69.15

92526 Oral function therapy 01/01/00 2 30.83 26.21

92531 Spontaneous nystagmus study 05/01/94 1 NC

92532 Positional nystagmus study 05/01/94 1 NC

5101:3-1-60 Page 207







92533 Caloric vestibular test 05/01/94 1 NC

92534 Optokinetic nystagmus 05/01/94 1 NC

92541 Spontaneous nystagmus test 01/01/00 2 28.01 28.55 D

92542 Positional nystagmus test 01/01/00 2 24.58 25.28 P

92543 Caloric vestibular test 01/01/00 2 8.34 32.24 M

92544 Optokinetic nystagmus test 01/01/00 2 19.26 19.52 M

92545 Oscillating tracking test 01/01/00 2 17.14 16.77 M

92546 Torsion swing recording 01/01/00 2 21.50 21.76 M

92547 Supplemental electrical test 01/01/00 2 15.59 14.57

92548 Computerized Dynamic Postuography 01/01/00 2 64.97 62.12 C

92551 Pure tone hearing test, air 01/01/00 2 6.27 5.70

92552 Pure tone audiometry, air 01/01/00 2 12.03 11.34

92553 Audiometry, air & bone 01/01/00 2 18.09 17.28

92555 Speech threshold audiometry 01/01/00 2 10.38 9.87

92556 Speech audiometry, complete 01/01/00 2 15.83 14.81

92557 Comprehensive hearing test 01/01/00 2 32.88 31.12

92559 Group audiometric testing 01/01/00 2 4.35 3.95

92560 Bekesy audiometry, screen 01/01/00 2 21.68 19.71

92561 Bekesy audiometry, diagnosis 01/01/00 2 19.50 18.50

92562 Loudness balance test 01/01/00 2 11.17 10.61

92563 Tone decay hearing test 01/01/00 2 10.38 9.87

92564 Sisi hearing test 01/01/00 2 13.10 12.34

92565 Stenger test, pure tone 01/01/00 2 10.87 10.36

92567 Tympanometry 01/01/00 2 14.67 13.84

92568 Acoustic reflex testing 01/01/00 2 10.38 9.87

92569 Acoustic reflex decay test 01/01/00 2 11.17 10.61

92571 Filtered speech hearing test 01/01/00 2 10.62 10.12

92572 Staggered spondaic word test 01/01/00 2 2.48 2.22

92573 Lombard test 01/01/00 2 9.64 9.14

92574 Swinging story test 04/01/96 3 NC 28.13

92575 Sensorineural acuity test 01/01/00 2 8.20 7.89

92576 Synthetic sentence test 01/01/00 2 12.31 11.61

92577 Stenger test, speech 01/01/00 2 19.72 18.77

92578 Delayed auditory feedback 04/01/96 3 NC 13.02

92579 Visual reinforcement audiometry 01/01/00 2 19.68 18.75

92580 Electrodermal audiometry 04/01/96 3 NC 15.81

92582 Conditioning play audiometry 01/01/00 2 19.62 18.75

92583 Select picture audiometry 01/01/00 2 24.52 23.19

5101:3-1-60 Page 208







92584 Electrocochleography 01/01/00 2 68.21 64.40

92585 Brainstem evoked audiometry 07/01/02 2 90.39 97.39 K

92586 Auditor evoke potent, limit 01/01/01 1 53.08

92587 Evoked auditory test 01/01/00 2 41.74 39.83 G

92588 Evoked auditory test 01/01/00 2 57.25 55.11 C

92589 Auditory function test(s) 01/01/05 3 NC 14.91

92590 Hearing aid exam, one ear 04/01/92 1 NC

92591 Hearing aid exam, both ears 04/01/92 1 NC

92592 Hearing aid check, one ear 05/01/94 1 NC

92593 Hearing aid check, both ears 05/01/94 1 NC

92594 Electro hearing aid test,one 05/01/94 1 NC

92595 Electro hearingaid test,both 05/01/94 1 NC

92596 Ear protector evaluation 05/01/94 1 NC

92597 Speech prosthetic evaluation 01/01/01 2 66.01 56.20

92598 Speech prosthetic modification 07/01/03 3 NC 46.07

92599 Ent procedure/service 07/01/03 3 NC BR

92601 Cochlear implt f/up exam < 7 07/01/03 1 87.17

92602 Reprogram cochlear implt < 7 07/01/03 1 61.23

92603 Cochlear implt f/up exam 7 > 07/01/03 1 58.89

92604 Reprogram cochlear implt 7 > 07/01/03 1 40.21

92605 Eval for nonspeech device rx 07/01/03 3 NC

92606 Non-speech device service 07/01/03 3 NC

92607 Ex for speech device rx, 1hr 07/01/03 1 72.64

92608 Ex for speech device rx addl 07/01/03 1 14.53

92609 Use of speech device service 07/01/03 1 39.43

92610 Evaluate swallowing function 07/01/03 1 28.28

92611 Motion fluoroscopy/swallow 07/01/03 1 30.61

92612 Endoscopy swallow tst evaluation 07/01/03 1 116.49

92613 Endoscopy swallow tst interpre/report 07/01/03 3 NC

92614 Laryngoscopic sensory test evaluation 07/01/03 1 90.29

92615 Laryngoscopic sensory test interp/report 07/01/03 3 NC

92616 Eval endo swallow + laryn sensory tst 07/01/03 1 124.01

92617 Interp/report endo swal + laryn sens tst 07/01/03 3 NC92620 Auditory function, 60 min 01/01/05 1 32.1292621 Auditory function, + 15 min 01/01/05 1 8.2492625 Tinnitus assessment 01/01/05 1 31.55

92700 Unlisted otorhino service or proc 07/01/03 1 BR

92950 Heart/lung resuscitation(cpr 01/01/00 2 156.12 147.28

5101:3-1-60 Page 209







92953 Temporary external pacing 01/01/00 2 15.53 24.37

92960 Heart electroconversion 01/01/00 2 109.48 100.92

92961 Cardioversion, internal procedure 01/01/00 1 85.13

92970 Cardioassist, internal 07/01/02 2 175.18 186.62

92971 Cardioassist, external 01/01/00 2 75.09 69.82

92973 Perc coronary thrombectomy 01/01/02 1 127.60

92974 Place- radiat del device- cor brachyther 01/01/02 1 143.35

92975 Dissolve clot, heart vessel 01/01/00 2 359.53 314.83

92977 Dissolve clot, heart vessel 01/01/00 2 215.74 188.66



92980 Insert intracoronary stent 07/01/02 2 770.32 796.04

92981 Insert intracoronary stent 07/01/02 2 216.22 220.27

92982 Coronary artery dilation 07/01/02 2 569.29 596.83

92984 Coronary artery dilation 07/01/02 2 154.14 160.09

92986 Revision of aortic valve 01/01/00 2 890.51 785.54

92987 Revision of mitral valve 01/01/00 2 919.01 797.85 90

92990 Revision of pulmonary valve 01/01/00 2 709.20 625.97

92992 Revision of heart chamber 05/01/94 1 BR

92993 Revision of heart chamber 05/01/94 1 BR

92995 Coronary atherectomy 07/01/02 2 627.13 653.40

92996 Coronary atherectomy 07/01/02 2 169.30 174.11

92997 Pulmonary artery balloon repair, percutaneous 07/01/02 2 606.49 640.31

92998 Pulmonary artery balloon repair, percutaneous 01/01/00 2 254.13 241.96

93000 Electrocardiogram, complete 01/01/00 2 20.14 18.54

93005 Electrocardiogram, tracing 01/01/00 2 11.99 10.56

93010 Electrocardiogram report 01/01/00 2 8.15 7.98

93012 Transmission of ecg 01/01/00 2 64.50 56.84

93014 Report on transmitted ecg 01/01/00 2 23.64 22.87

93015 Cardiovascular stress test 01/01/00 2 81.62 76.57




93024 Cardiac drug stress test 01/01/00 2 92.26 92.25 M

93025 Microvolt T-wave assessment cardiogr 01/01/02 1 187.60

93040 Rhythm ecg with report 01/01/00 2 10.98 10.27

93041 Rhythm ecg, tracing 01/01/00 2 3.89 3.44

93042 Rhythm ecg, report 01/01/00 2 7.10 6.83

5101:3-1-60 Page 210







93201 Phonocardiogram & ecg lead 01/01/00 2 38.52 35.83



93205 Special phonocardiogram 01/01/00 2 35.33 32.87



93210 Intracardiac phonocardiogram 01/01/00 2 69.66 64.80 L

93220 Vectorcardiogram 01/01/00 2 30.91 28.75

93221 Vectorcardiogram tracing 01/01/00 2 15.29 14.23

93222 Vectorcardiogram report 01/01/00 2 15.61 14.52

93224 Ecg monitor/report, 24 hrs 01/01/00 2 119.65 109.88

93225 Ecg monitor/record, 24 hrs 01/01/00 2 33.33 29.16


93227 Ecg monitor/review, 24 hrs 07/01/02 2 26.47 27.41


93231 Ecg monitor/record, 24 hrs 01/01/00 2 40.98 35.82






93268 Ecg record/review 01/01/00 2 101.84 108.87 L

93270 ECG recording 01/01/00 2 33.33 29.16

93271 ECG monitoring and analysis 01/01/00 2 64.50 56.84

93272 ECG/review, interpretation only 01/01/00 2 23.64 22.87

93278 Ecg/signal-averaged 01/01/00 2 45.65 48.28 K

93303 Transthoracic echocardiography, complete 01/01/00 2 162.25 144.37 L

93304 Transthoracic echocardiography, lmtd stdy 01/01/00 2 88.11 78.97 L

93307 Echo exam of heart 01/01/00 2 151.53 134.48 C



93313 Echo exam of heart 01/01/00 2 74.27 39.60

93314 Echo exam of heart 01/01/00 2 153.06 129.98 I

93315 Transesophageal echo, image ACQ, probe RPT 01/01/00 2 210.32 185.40 K

93316 Transesophageal echo, placement of probe 01/01/00 2 45.04 37.70

93317 Transesophageal echo, image ACQ, int. reprt 01/01/00 2 168.87 147.47 L

93318 Echo transesophageal intraop 01/01/01 2 BR L

93320 Doppler echo exam, heart 01/01/00 2 66.43 61.76 C

5101:3-1-60 Page 211







93321 Doppler echo exam, heart 01/01/00 2 38.24 34.87 I

93325 Doppler color flow 01/01/00 2 81.76 71.81 K

93350 Echo exam of heart 01/01/00 2 88.96 107.51 K

93501 Right heart catheterization 01/01/00 2 610.34 560.83 I

93503 Insert/place heart catheter 07/01/02 2 133.88 136.50

93505 Biopsy of heart lining 01/01/00 2 244.22 233.26 D

93508 Catheter placement for coronary angiography 01/01/00 2 509.15 460.55 C

93510 Left heart catheterization 01/01/00 2 1,175.83 1,048.59 G


93514 Left heart catheterization 01/01/00 2 1,259.88 1,128.69 H


93526 Rt & lt heart catheters 01/01/00 2 1,576.83 1,413.77 G

93527 Rt & lt heart catheters 01/01/00 2 1,615.03 1,455.73 H

93528 Rt & lt heart catheters 01/01/00 2 1,606.40 1,430.99 H

93529 Rt, lt heart catheterization 01/01/00 2 1,454.42 1,293.17 G

93530 Rt heart catheterization, congenital 01/01/00 2 650.35 590.37 I

93531 Rt & lt heart catheterization, congenital 01/01/00 2 1,643.62 1,471.65 G

93532 Rt & lt heart catheterization, congenital 01/01/00 2 1,691.04 1,522.26 I

93533 Rt & lt heart catheterization, congenital 01/01/00 2 1,507.27 1,339.92 G

93536 Percu insert intra-aortic ballcath 04/01/02 3 NC 266.71

93539 Injection, cardiac cath 01/01/00 2 35.95 32.09

93540 Injection, cardiac cath 01/01/00 2 36.78 35.45

93541 Injection for lung angiogram 07/01/02 2 14.82 18.88

93542 Injection for heart x-rays 07/01/02 2 14.82 19.80

93543 Injection for heart x-rays 01/01/00 2 23.69 22.74

93544 Injection for aortography 01/01/00 2 22.54 22.74

93545 Injection for coronary xrays 01/01/00 2 27.98 36.52

93555 Imaging, cardiac cath 01/01/00 2 195.28 172.48 G

93556 Imaging, cardiac cath 01/01/00 2 295.28 261.49 F

93561 Cardiac output measurement 01/01/00 2 41.51 60.15 D

93562 Cardiac output measurement 01/01/00 2 18.35 28.74 P

93571 Heart flow reserve measurement 01/01/00 2 87.33 174.14 I

93572 Heart flow reserve measurement 01/01/00 2 73.90 159.37 I

93580 Transcath closure of asd 07/01/03 1 669.36

93581 Transcath closure of vsd 07/01/03 1 895.59

93600 Bundle of his recording 01/01/00 2 164.27 164.66 P

93602 Intra-atrial recording 01/01/00 2 128.22 120.96 D

93603 Right ventricular recording 01/01/00 2 152.43 144.35 P

5101:3-1-60 Page 212







93607 Left ventricular recording 04/01/02 3 NC 180.36

93609 Mapping of tachycardia 07/01/02 2 351.74 440.77 D

93610 Intra-atrial pacing 01/01/00 2 171.63 161.38 D

93612 Intraventricular pacing 01/01/00 2 179.06 168.27 P

93613 3-D intracardiac mapping 01/01/02 1 550.96 D

93615 Esophageal recording 01/01/00 2 42.98 39.59 D

93616 Esophageal recording 01/01/00 2 78.27 76.13 Q

93618 Heart rhythm pacing 01/01/00 2 330.13 331.06 P

93619 Electrophysiology evaluation 01/01/00 2 593.13 591.97 M

93620 Electrophysiology evaluation 01/01/00 2 842.78 840.64 P

93621 Electrophysiology evaluation 01/01/00 2 825.44 615.63 D

93622 Electrophysiology evaluation 01/01/00 2 828.73 836.08 D

93623 Stimulation, pacing heart 01/01/00 2 175.74 171.05 D

93624 Electrophysiologic study 01/01/00 2 253.04 235.55 D

93631 Heart pacing, mapping 01/01/00 2 515.65 482.00 M

93640 Evaluation heart device 01/01/00 2 382.61 374.40 L

93641 Electrophysiology evaluation 01/01/00 2 503.52 485.57 L

93642 Electrophysiology evaluation 01/01/00 2 451.32 443.29 L

93650 Ablate heart dysrhythm focus 07/01/02 2 542.56 568.85 D

93651 Ablate heart dysrhythm focus 07/01/02 2 842.31 868.04

93652 Ablate heart dysrhythm focus 01/01/00 2 908.09 864.73

93660 Tilt table evaluation 01/01/00 2 107.13 103.13 D

93662 Intracardiac ecg (ice) 01/01/01 1 225.82 K

93668 Peripheral vascular rehab 01/01/01 1 NC

93701 Thoracic bioimpedance 01/01/02 1 24.98 H

93720 Total body plethysmography 01/01/00 2 28.85 26.90

93721 Plethysmography tracing 01/01/00 2 19.19 17.04

93722 Plethysmography report 07/01/02 2 8.48 9.65

93724 Analyze pacemaker system 01/01/00 2 307.25 281.83 M

93727 Electronic analysis of implantable loop recorder 01/01/00 1 20.05

93731 Analyze pacemaker system 01/01/00 2 33.06 30.58 L


93733 Telephone analysis,pacemaker 01/01/00 2 28.91 26.84 C



93736 Telephone analysis,pacemaker 01/01/00 2 25.39 23.88 C

93737 Elect. anal. card-defibril; w/o rep 04/01/02 3 NC 31.96 L

93738 Elect. anal. cardio-defib; w/ repro 04/01/02 3 NC 48.05 M

5101:3-1-60 Page 213







93740 Temperature gradient studies 01/01/00 2 15.12 15.11 P

93741 Electronic analysis of pacing cardioverterdefibrillator 01/01/00 1 49.43 K

93742 Electronic analysis, single chamber, reprogramming 01/01/00 1 61.50 C

93743 Electronic analysis, dual chamber, no reprogram 01/01/00 1 69.75 K

93744 Electronic analysis, dual chamber, reprogramming 01/01/00 1 69.75 K93745 Set-up cardiovert-defibrill 01/01/05 1 BR

93760 Cephalic thermogram 05/01/94 1 NC

93762 Peripheral thermogram 05/01/94 1 NC

93770 Measure venous pressure 01/01/00 2 9.03 8.91 Q

93784 Ambulatory bp monitoring 05/01/94 1 NC

93786 Ambulatory bp recording 05/01/94 1 NC

93788 Ambulatory bp analysis 05/01/94 1 NC

93790 Review/report bp recording 05/01/94 1 NC

93797 Cardiac rehab 01/01/00 2 11.07 11.66

93798 Cardiac rehab/monitor 01/01/00 2 19.56 18.45

93799 Cardiovascular procedure 05/01/94 1 BR

93875 Extracranial study 01/01/00 2 42.73 40.84 C

93880 Extracranial study 01/01/00 2 128.08 115.33 H

93882 Extracranial study 01/01/00 2 85.02 76.65 F

93886 Intracranial study 01/01/00 2 152.44 136.41 I

93888 Intracranial study 01/01/00 2 101.35 90.95 H93890 Tcd, vasoreactivity study 01/01/05 1 171.68 H93892 Tcd, emboli detect w/o inj 01/01/05 1 182.76 H93893 Tcd, emboli detect w/inj 01/01/05 1 179.35 H

93922 Extremity study 01/01/00 2 45.87 42.27 I



93925 Lower extremity study 01/01/00 2 128.06 115.31 H

93926 Lower extremity study 01/01/00 2 85.53 77.12 F

93930 Upper extremity study 01/01/00 2 131.43 118.20 G

93931 Upper extremity study 01/01/00 2 87.35 78.64 F

93965 Extremity study 01/01/00 2 49.24 47.17 C

93970 Extremity study 01/01/00 2 142.52 127.92 H

93971 Extremity study 01/01/00 2 94.52 85.27 G

93975 Vascular study 01/01/00 2 189.19 168.81 C

93976 Vascular study 01/01/00 2 126.21 112.94 I

93978 Vascular study 01/01/00 2 133.64 120.03 H

93979 Vascular study 01/01/00 2 88.93 79.94 G

5101:3-1-60 Page 214







93980 Penile vascular study 01/01/00 2 149.22 149.67 K

93981 Penile vascular study 01/01/00 2 110.00 104.32 I

93990 Doppler flow testing 01/01/00 2 80.51 71.91 G

94010 Breathing capacity test 01/01/00 2 21.89 20.84 K

94014 Patient recorded spirometry 01/01/00 2 18.38 27.94 L

94015 Patient recorded spirometry 07/01/02 2 10.26 11.26

94016 Review patient spirometry 01/01/00 2 15.19 18.13

94060 Evaluation of wheezing 01/01/00 2 41.02 38.66 C

94070 Evaluation of wheezing 01/01/00 2 63.89 58.03 C

94150 Vital capacity test 01/01/00 2 6.40 7.71 M

94160 Vital capacity screening 04/01/97 3 NC 11.93 M

94200 Lung function test (mbc/mvv) 01/01/00 2 12.60 12.06 K

94240 Residual lung capacity 01/01/00 2 30.76 28.07 C

94250 Expired gas collection 01/01/00 2 9.39 9.30 M

94260 Thoracic gas volume 07/01/02 2 19.02 21.51 C

94350 Lung nitrogen washout curve 01/01/00 2 26.23 24.14 K

94360 Measure airflow resistance 07/01/02 2 28.46 37.12 I

94370 Breath airway closing volume 01/01/00 2 17.57 16.12 L

94375 Respiratory flow volume loop 01/01/00 2 25.83 23.72 K

94400 Co2 breathing response curve 01/01/00 2 32.61 31.97 P

94450 Hypoxia response curve 01/01/00 2 26.72 24.77 L94452 Hast w/report 01/01/05 1 37.23 I94453 Hast w/oxygen titrate 01/01/05 1 52.87 I

94620 Pulmonary stress testing 01/01/00 2 77.60 71.64 K

94621 Pulmonary stress testing, comples 01/01/00 2 36.69 64.04 L

94640 Airway inhalation treatment 01/01/00 2 10.89 9.65

94642 Aerosol inhalation treatment 05/01/94 1 NC

94650 Pressure breathing (ippb) 07/01/03 3 NC 10.34



94656 Initial ventilator mgmt 07/01/02 2 56.99 58.74

94657 Cont. ventilator 01/01/00 2 36.65 35.32

94660 Pos airway pressure, cpap 01/01/00 2 38.06 35.95

94662 Neg pressure ventilation,cnp 01/01/00 2 27.92 25.59

94664 Aerosol or vapor inhalations 01/01/00 2 14.11 12.41

94665 Aerosol or vapor inhalations 07/01/03 3 NC 13.35

94667 Chest wall manipulation 01/01/00 2 15.79 13.80

94668 Chest wall manipulation 01/01/00 2 9.61 8.51

5101:3-1-60 Page 215







94680 Exhaled air analysis: o2 01/01/00 2 27.80 27.46 K

94681 Exhaled air analysis: o2,co2 01/01/00 2 48.60 45.11 I

94690 Exhaled air analysis 01/01/00 2 17.20 15.45 G

94720 Monoxide diffusing capacity 01/01/00 2 34.96 31.74 C

94725 Membrane diffusion capacity 07/01/02 2 37.37 58.03 G

94750 Pulmonary compliance study 01/01/00 2 27.39 25.95 K

94760 Measure blood oxygen level 05/01/94 1 NC



94770 Exhaled carbon dioxide test 01/01/00 2 16.20 16.71 K

94772 Breath recording, infant 01/01/00 2 40.70 37.00 D

94799 Pulmonary service/procedure 05/01/94 1 BR

95004 Allergy skin tests 01/01/00 2 2.73 2.22

95010 Sensitivity skin tests 01/01/00 2 8.37 7.98

95015 Sensitivity skin tests 01/01/00 2 8.73 5.76


95027 Skin end point titration 01/01/00 2 3.89 3.10


95044 Allergy patch tests 01/01/00 2 5.42 4.21

95052 Photo patch test 01/01/00 2 6.64 5.32

95056 Photosensitivity tests 01/01/00 2 4.74 3.77

95060 Eye allergy tests 01/01/00 2 9.37 7.32

95065 Nose allergy test 01/01/00 2 5.42 4.21

95070 Bronchial allergy tests 01/01/00 2 58.35 46.99

95071 Bronchial allergy tests 01/01/00 2 74.49 60.29

95075 Ingestion challenge test 07/01/02 2 62.35 68.47

95078 Provocative testing 01/01/00 2 6.92 5.54

95115 Immunotherapy, one injection 01/01/00 2 10.34 9.76

95117 Immunotherapy injections 01/01/97 2 14.85 13.50

95120 Immunotherapy,single antigen 04/01/93 1 NC

95125 Immunotherapy, many antigens 04/01/93 1 NC

95130 Immunotherapy, insect venom 01/01/97 2 8.80 8.00

95131 Immunotherapy, insect venoms 01/01/97 2 13.20 12.00




95144 Antigen therapy services 01/01/00 2 5.80 4.27


5101:3-1-60 Page 216













95180 Rapid desensitization 01/01/00 2 64.10 47.34

95199 Allergy immunology services 05/01/94 1 BR

95250 Glucose continuous monitoring 01/01/02 1 37.19

95805 Multiple sleep latency test 01/01/00 2 185.67 169.08 I

95806 Sleep study, unattended 01/01/98 1 NC

95807 Sleep study 01/01/00 2 239.98 237.89 C

95808 Polysomnography, 1-3 01/01/00 2 276.33 259.97 K

95810 Polysomnography, 4 or more 01/01/00 2 298.34 279.59 K

95811 Polysomnography, with CPAP 01/01/00 2 315.36 295.83 K

95812 Electroencephalogram (EEG) 01/01/00 2 72.21 66.75 K

95813 Electroencephalogram (EEG) 01/01/00 2 88.73 81.24 L

95816 Electroencephalogram (eeg) 01/01/00 2 65.43 59.72 K

95819 Electroencephalogram (eeg) 01/01/00 2 70.68 65.46 K

95822 Sleep electroencephalogram 01/01/00 2 82.80 76.55 K

95824 Electroencephalography 01/01/00 2 40.25 38.88 P

95827 Night electroencephalogram 01/01/00 2 100.56 94.47 K

95829 Surgery electrocorticogram 01/01/00 2 171.72 152.13 Q

95830 Insert electrodes for eeg 01/01/00 2 71.45 56.06

95831 Limb muscle testing, manual 01/01/00 2 14.43 13.09

95832 Hand muscle testing, manual 01/01/00 2 13.44 12.23

95833 Body muscle testing, manual 01/01/00 2 21.26 19.70

95834 Body muscle testing, manual 01/01/00 2 29.05 27.70

95851 Range of motion measurements 01/01/00 2 10.51 11.79

95852 Range of motion measurements 01/01/00 2 7.40 7.88

95857 Tensilon test 01/01/00 2 25.13 23.34

95858 Tensilon test & myogram 01/01/00 2 62.37 58.48 Q

95860 Muscle test, one limb 01/01/00 2 48.23 46.58 D

95861 Muscle test, two limbs 01/01/00 2 82.60 79.78 D

95863 Muscle test, 3 limbs 01/01/00 2 98.45 94.59 D

95864 Muscle test, 4 limbs 01/01/00 2 128.92 123.71 M

95867 Muscle test, head or neck 01/01/00 2 45.92 39.85 M

95868 Muscle test, head or neck 01/01/00 2 71.94 77.60 D

5101:3-1-60 Page 217







95869 Muscle test, limited 01/01/00 2 21.36 20.64 D

95870 Needle EMG 01/01/00 2 21.31 20.65 D

95872 Muscle test, one fiber 01/01/00 2 66.68 62.48 D

95875 Limb exercise test 01/01/00 2 49.44 44.93 D

95880 Cerebral aphasia testing 04/01/96 3 NC 36.47

95881 Cerebral developmental test 04/01/96 3 NC 36.47

95882 Cognitive function testing 04/01/96 3 NC 36.47

95883 Neuropsychological testing 04/01/96 3 NC 36.47

95900 Motor nerve conduction test 01/01/00 2 24.58 23.66 P

95903 Motor nerve conduction test 01/01/00 2 28.52 27.04 D

95904 Sense nerve conduction test 01/01/00 2 20.94 20.39 P

95920 Intraoperative nerve testing 01/01/00 2 113.79 108.24 P

95921 Nervous System testing, cardiovagal 01/01/00 2 38.41 24.76 M

95922 Nervous System testing, vasomotor 01/01/00 2 40.37 26.04 M

95923 Nervous System testing, sudomotor 01/01/00 2 38.47 24.76 M

95925 Somatosensory testing 01/01/00 2 48.51 46.81 L

95926 Somatosensory testing 01/01/00 2 48.56 46.81 L

95927 Somatosensory testing 01/01/00 2 48.56 46.81 L95928 C motor evoked, uppr limbs 01/01/05 1 108.88 K95929 C motor evoked, lwr limbs 01/01/05 1 113.31 K

95930 Visual evoked potential testing 01/01/00 2 26.38 26.54 D

95933 Blink reflex test 01/01/00 2 44.10 41.95 L

95934 H-reflex test 01/01/00 2 25.19 23.97 D

95935 "h" or "f" reflex study 04/01/96 3 NC 23.37 D

95936 H-reflex test 01/01/00 2 26.24 24.87 D

95937 Neuromuscular junction test 01/01/00 2 33.82 31.32 P

95950 Ambulatory eeg monitoring 01/01/00 2 217.71 201.17 I

95951 Eeg monitoring/videorecord 01/01/00 2 369.75 286.60 C

95953 Eeg monitoring/computer 01/01/00 2 257.86 236.18 C

95954 Eeg monitoring/giving drugs 01/01/00 2 112.93 110.31 Q

95955 Eeg during surgery 01/01/00 2 95.29 90.94 K

95956 Eeg monitoring/cable/radio 01/01/00 2 263.54 242.55 C

95957 EEG digital analysis 01/01/00 2 104.62 95.99 J

95958 Eeg monitoring/function test 01/01/00 2 216.99 210.46 D

95961 Electrode stimulation, brain 01/01/00 2 135.84 127.42 D

95962 Electrode stimulation, brain 01/01/00 2 141.84 132.77 D

95965 Magnetoenceph.,record/analysis 01/01/02 1 480.67 C

95966 Magnetoenceph. evok flds, 1 mode 01/01/02 1 462.19 C

5101:3-1-60 Page 218







95967 Magnetoenceph., ea add mode 01/01/02 1 221.85 C

95970 Neurostimulator analysis, no programming 01/01/00 2 13.47 14.78

95971 Simple neurostimulator analysis 01/01/00 2 21.68 24.07

95972 Complex neurostimulator analysis 01/01/00 2 39.57 44.19

95973 Complex neurostimulator analysis 01/01/00 2 25.18 28.04

95974 Complex cranial neurostimulator 01/01/00 2 77.75 89.58

95975 Complex cranial neurostimulator 01/01/00 2 45.47 53.3295978 Analyze neurostim brain/1h 01/01/05 1 135.2495979 Analyz neurostim brain addon 01/01/05 1 62.32

95990 Spin/brain pump refil & main 07/01/03 1 32.60

95991 Spin/Brain Pump Refil & Main 01/01/04 1 50.93

95999 Neurological procedure 05/01/94 1 BR

96000 Motion analysis, by videotaping 01/01/02 1 58.35

96001 Motion analysis, press meas walk 01/01/02 1 69.65

96002 Motion analysis, walking/oth act 01/01/02 1 13.65

96003 Dyn fine wire electromy, 1 muscle 01/01/02 1 12.71

96004 Motion analysis, MD review/interpret 01/01/02 1 59.53

96100 Psychological testing 01/01/00 2 42.51 40.25 0

96105 Assessment of aphasia 01/01/00 2 42.51 40.25

96110 CNS Test: Developmental testing, limited 01/01/00 2 26.57 24.15

96111 CNS Test: Developmental testing, extended 01/01/00 2 42.51 40.25

96115 CNS Test: Neurobehavioral status exam 01/01/00 2 42.51 40.25

96117 CNS Test: Neuropsychological testing battery 01/01/00 2 42.51 40.25

96150 Health/behavior assessment,ea 15 min 01/01/02 1 NC

96151 Health/behavior re-assessment 01/01/02 1 NC

96152 Health/behavior interve, ea 15 min 01/01/02 1 NC

96153 Health/behavior intervent,grp (2 >) 01/01/02 1 NC

96154 Health/beh intervent, fam (w patient) 01/01/02 1 NC

96155 Health/behav intervent,fam (w/o pat) 01/01/02 1 NC

96400 Chemotherapy, (sc)/(im) 01/01/00 2 3.46 3.22

96405 Intralesional chemo admin 01/01/00 2 28.22 21.90

96406 Intralesional chemo admin 01/01/00 2 40.24 32.98

96408 Chemotherapy, push technique 01/01/00 2 24.13 22.48

96410 Chemotherapy,infusion method 01/01/00 2 38.35 35.77



96420 Chemotherapy, push technique 01/01/00 2 31.33 29.39


5101:3-1-60 Page 219









96440 Chemotherapy, intracavitary 01/01/00 2 108.92 76.89

96445 Chemotherapy, intracavitary 01/01/00 2 106.83 77.44

96450 Chemotherapy, into cns 01/01/00 2 88.97 66.73

96520 Pump refilling, maintenance 01/01/00 2 22.37 20.89

96530 Pump refilling, maintenance 01/01/00 2 26.36 24.78

96542 Chemotherapy injection 01/01/00 2 73.71 62.23

96545 Provide chemotherapy agent 05/01/94 1 NC

96549 Chemotherapy, unspecified 05/01/94 1 BR

96567 Photo dynamic therapy of skin 01/01/02 1 39.78

96570 Photodynamic therapy, first 30 minutes 07/01/02 1 56.45 56.57

96571 Photodynamic therapy, each added 15 minutes 07/01/02 1 27.88 31.3

96900 Ultraviolet light therapy 01/01/00 2 9.88 9.42

96902 Trichogram 01/01/98 1 NC

96910 Photochemotherapy with uv-b 01/01/00 2 14.48 13.54

96912 Photochemotherapy with uv-a 01/01/00 2 16.63 15.62

96913 Photochemotherapy, uv-a or b 01/01/02 2 35.37 BR

96920 Laser tx, skin < 250 sq cm 07/01/03 1 95.40

96921 Laser tx, skin 250-500 sq cm 07/01/03 1 97.83

96922 Laser tx, skin > 500 sq cm 07/01/03 1 135.36

96999 Dermatological procedure 05/01/94 1 BR

97001 Physical therapy evaluation 01/01/00 2 45.35 34.09

97002 Physical therapy re-evaluation 01/01/00 2 19.22 17.05

97003 Occupational therapy evaluation 01/01/98 1 NC

97004 Occupational therapy re-evaluation 01/01/98 1 NC

97005 Athletic training evaluation 01/01/02 1 NC

97006 Athletic training re-evaluation 01/01/02 1 NC

97010 Hot or cold packs therapy 07/01/02 3 NC 7.53

97012 Mechanical traction therapy 01/01/00 2 12.50 10.07

97014 Electric stimulation therapy 07/01/02 3 NC 10.70

97016 Vasopneumatic device therapy 07/01/02 2 11.57 11.68

97018 Paraffin bath therapy 07/01/02 2 6.59 8.05

97020 Microwave therapy 07/01/02 3 NC 7.33

97022 Whirlpool therapy 01/01/00 2 10.23 10.07

97024 Diathermy treatment 07/01/02 2 4.20 7.53

97026 Infrared therapy 05/09/86 1 NC

97028 Ultraviolet therapy 05/09/86 1 NC

5101:3-1-60 Page 220







97032 Electrical stimulation 01/01/00 2 11.02 17.54

97033 Iontophoresis, each 15 min. 07/01/02 3 NC 11.79

97034 Contrast bath therapy 01/01/00 2 9.14 14.07

97035 Ultrasound therapy 01/01/00 2 9.34 14.49

97036 Hydrotherapy 01/01/00 2 13.97 26.77

97039 Physical therapy treatment 05/09/86 1 NC

97110 Therapeutic exercises 01/01/00 2 16.95 26.51

97112 Neuromuscular reeducation 01/01/00 2 16.39 26.04

97113 Aquatic therapy/exercises 01/01/00 2 18.11 29.03

97116 Gait training therapy 01/01/00 2 14.63 22.96

97122 Manual traction therapy 01/01/99 3 NC 25.19

97124 Massage therapy 01/01/00 2 13.19 20.73

97139 Physical medicine procedure 05/01/94 1 NC

97140 Manual therapy techniques 01/01/00 2 13.60 27.82

97150 Group therapeutic procedures 01/01/00 2 13.24 10.72

97250 Myofascial release 04/01/99 3 NC 18.38

97260 Regional manipulation 04/01/99 3 NC 8.94

97261 Supplemental manipulations 04/01/99 3 NC

97265 Joint mobilization 04/01/99 3 NC 18.38

97500 Orthotics training 04/01/97 3 NC 13.06

97501 Supplemental training 05/01/94 1 NC

97504 Orthotics Fitting & Training 01/01/00 2 16.76 12.63

97520 Prosthetic training 01/01/00 2 17.21 31.08


97530 Kinetic therapy 05/01/94 3 NC

97532 Cognitive skills development 01/01/01 1 20.20

97533 Sensory integration 01/01/01 1 22.04

97535 Self care mgt training 01/01/96 1 NC

97537 Community/work reintegration 01/01/96 1 NC

97540 Training for daily living 04/01/96 1 NC


97542 Wheelchair mgt training 01/01/96 1 NC

97545 Work hardening 05/01/94 1 NC

97546 Work hardening 05/01/94 1 NC97597 Active wound care/20 cm or < 01/01/05 1 37.9097598 Active wound care > 20 cm 01/01/05 1 48.21

97601 Wound care selective 01/01/05 3 NC 30.61

97602 Wound care non-selective 01/01/01 1 NC

5101:3-1-60 Page 221






APPR VISIT CODE DESCRIPTION DATE CODE PRICE PRICE INDIC. DAYS GROUP DATE DATE GROUP DATE DATE97605 Neg press wound tx, < 50 cm 01/01/05 1 NC97606 Neg press wound tx, > 50 cm 01/01/05 1 NC

97700 Training checkout 04/01/96 3 NC 5.52

97701 Supplemental checkout 04/01/96 1 NC

97703 Prosthetic checkout 01/01/00 2 11.78 20.18

97721 Supplemental limb testing 05/01/94 1 NC

97750 Physical performance test 01/01/00 2 19.04 31.64

97752 Muscle testing with exercise 03/31/95 3 NC 22.17 P

97755 Assistive Technology Assess 01/01/04 1 25.58

97770 Cognitive skills development 04/01/01 3 NC 19.48

97780 Acupuncture 01/01/98 1 NC

97781 Acupuncture 01/01/98 1 NC

97799 Physical medicine procedure 05/01/94 1 NC

97802 Medical nutrition, indiv, in 01/01/01 1 NC

97803 Med nutrition, indiv, subseq 01/01/01 1 NC

97804 Medical nutrition, group 01/01/01 1 NC97810 Acupunct w/o stimul 15 min 01/01/05 1 NC97811 Acupunct w/o stimul addl 15m 01/01/05 1 NC97813 Acupunct w/stimul 15 min 01/01/05 1 NC97814 Acupunct w/stimul addl 15m 01/01/05 1 NC

98925 Osteopathic manipulation 01/01/00 2 12.68 5.70





98940 Chiro manipulative treatment, one-two reg. 01/01/00 2 16.45 15.53

98941 Chiro manipulative trmt, three-four region 01/01/00 2 21.24 15.53

98942 Chiro manipulative trmts, five regions 01/01/00 2 26.42 15.53

98943 Chiropractic manipulation 10/01/99 1 NC

99000 Specimen handling 05/09/86 1 NC

99001 Specimen handling 05/09/86 1 NC

99002 Device handling 05/01/94 1 NC

99024 Post-op follow-up visit 05/01/94 1 NC

99025 Initial surgical evaluation 05/01/94 1 NC

99026 In-hospital on call service 07/01/03 3 NC

99027 Out-of-hosp on call service 07/01/03 3 NC

99050 Medical services after hrs 01/01/00 2 16.50 15.00

99052 Medical services at night 01/01/00 2 22.00 20.00

5101:3-1-60 Page 222







99054 Medical services,unusual hrs 05/01/94 1 NC

99056 Non-office medical services 05/01/94 1 NC

99058 Office emergency care 05/01/94 1 NC

99070 Special supplies 05/01/94 1 NC

99071 Patient education materials 05/01/94 1 NC

99075 Medical testimony 05/01/94 1 NC

99078 Group health education 05/01/94 1 NC

99080 Special reports or forms 05/01/94 1 NC

99082 Unusual physician travel 05/01/94 1 NC

99090 Computer data analysis 05/01/94 1 NC

99091 Collect/interpret patient transmit data 01/01/02 3 NC

99100 Special anesthesia service 05/01/94 1 NC

99116 Anesthesia with hypothermia 05/01/94 1 NC

99135 Special anesthesia procedure 05/01/94 1 NC

99140 Emergency anesthesia 05/01/94 1 NC

99141 Sedation 01/01/98 1 NC

99142 Sedation 01/01/98 1 NC

99170 Anogenital exam for suspected childhood trauma 01/01/00 1 97.76

99172 Ocular function screen 01/01/01 1 NC

99173 Screening test of visual acuity, quantitative 01/01/00 1 NC

99175 Induction of vomiting 01/01/00 2 35.02 29.95

99178 Development evaluation tests 04/01/96 3 NC 12.42

99183 Hyperbaric oxygen therapy 01/01/00 2 93.83 88.10

99185 Regional hypothermia 01/01/00 2 15.91 13.89

99186 Total body hypothermia 01/01/00 2 52.77 46.66

99190 Special pump services 05/01/94 1 68.79

99191 Special pump services 01/01/97 2 68.79 42.10

99192 Special pump services 01/01/00 2 34.13 31.03

99195 Phlebotomy 01/01/00 2 10.18 9.55

99199 Special service or report 05/09/86 1 BR

99201 Office/outpatient visit, new 01/01/00 2 21.81 17.24





99211 Office/outpatient visit, est 01/01/00 2 13.43 10.83



5101:3-1-60 Page 223









99217 Observation care discharge 01/01/00 2 31.70 27.88

99218 Observation care 01/01/00 2 34.60 30.68



99221 Initial hospital care 01/01/00 2 34.52 30.17



99231 Subsequent hospital care 01/01/00 2 17.49 15.47



99234 Observation or inpatient hospital care 01/01/00 2 58.36 56.08



99238 Hospital discharge day 01/01/00 2 31.62 27.21

99239 Hospital discharge day 01/01/00 2 40.31 39.04

99241 Office consultation 01/01/00 2 24.07 21.13





99251 Initial inpatient consult 01/01/00 2 23.15 21.62





99261 Follow-up inpatient consult 01/01/00 2 13.34 12.09



99271 Confirmatory consultation 01/01/00 2 18.45 18.43





99281 Emergency dept visit 01/01/00 2 11.62 11.07



5101:3-1-60 Page 224









99288 Direct advanced life support 05/01/94 1 NC

99289 Patient transport, crit ill 1st 30-74 min 01/01/02 1 95.19

99290 Patient transport, crit ill, ea adD 30 min 01/01/02 1 46.32

99291 Critical care, first hour 01/01/00 2 95.19 87.70

99292 Critical care, addl 30 min 01/01/00 2 46.32 42.54

99293 Ped critical care, initial 07/01/03 1 258.13

99294 Ped critical care, subseq 07/01/03 1 127.73

99295 Neonatal critical care 01/01/00 2 271.81 231.44


99297 Neonatal critical care 07/01/03 3 NC 75.57


99299 Ic, lbw infant 1500-2500 gm 07/01/03 1 45.25

99301 Nursing facility care 01/01/00 2 32.25 26.22



99311 Nursing facility care,subseq 01/01/00 2 18.08 15.34



99315 Nursing facility discharge day management 01/01/00 2 31.99 28.41

99316 Nursing facility discharge day management 01/01/00 2 39.57 34.76

99321 Rest home visit, new patient 01/01/00 2 20.92 18.74



99331 Rest home visit, estab pat 01/01/00 2 17.50 15.21



99341 Home visit, new patient 01/01/00 2 38.08 37.36





99347 Home visit, established patient 01/01/00 2 29.81 27.42




99351 Home visit, estab patient 04/01/98 3 NC 28.97

5101:3-1-60 Page 225









99354 Prolonged service, office 05/01/94 1 NC

99355 Prolonged service, office 05/01/94 1 NC

99356 Prolonged service, inpatient 05/01/94 1 NC

99357 Prolonged service, inpatient 05/01/94 1 NC

99358 Prolonged serv, w/o contact 05/01/94 1 NC

99359 Prolonged serv, w/o contact 05/01/94 1 NC

99360 Physician standby services 05/01/94 1 NC

99361 Physician/team conference 05/01/94 1 NC

99362 Physician/team conference 05/01/94 1 NC

99371 Physician phone consultation 05/01/94 1 NC



99374 Home health agency care supervision 01/01/98 1 NC

99375 Care plan oversight/30-60 05/01/94 1 NC

99376 Care plan oversight/over 60 05/01/94 1 NC

99377 Hospice patient care supervision 01/01/98 1 NC

99378 Hospice patient care supervision 01/01/98 1 NC

99379 Nursing facility care supervision 01/01/98 1 NC

99380 Nursing facility care supervision 01/01/98 1 NC

99381 Preventive visit,new,infant 01/01/00 2 50.70 47.25

99382 Preventive visit,new, 1-4 yrs. old 01/01/00 2 57.61 48.11

99383 Preventive visit, new, 5-11 yrs. old 01/01/00 2 57.51 48.40



99386 Preventive visit, new, 40-64 yrs. old 05/01/94 3 NC

99387 Preventive visit, new, 65 & over 05/01/94 3 NC

99391 Preventive visit, estab, infant 01/01/00 2 44.18 36.81

99392 Preventive visit, estab, 1-4 yrs. old 01/01/00 2 51.12 38.56




99396 Preventive visit, estab, 40-64 yrs. old 05/01/94 1 NC

99397 Preventive visit, estab, 65 and over 05/01/94 1 NC

99401 Preventive counceling, indiv., 15 min. 05/01/94 1 NC

99402 Preventive counceling, indiv., 30 min. 01/01/00 2 36.01 16.50


5101:3-1-60 Page 226








99411 Preventive counceling, group., 30 min. 05/01/94 1 NC

99412 Preventive counceling, group., 60 min. 05/01/94 1 NC

99420 Admin & interp of health risk assessment 05/01/94 1 NC

99429 Unlisted preventive medicine service 05/01/94 1 NC

99431 History & exam of newborn infant 01/01/00 2 55.41 47.48

99432 Newborn care, not hospital/birth room 01/01/00 2 61.34 47.48

99433 Subsequent hosp. care, per day, newborn 01/01/00 2 28.83 25.08

99435 Hospital newborn discharge day 01/01/00 2 70.21 68.59

99436 Attendance at delivery and initial stab 01/01/00 2 70.67 61.99

99438 Infant care to age one, max of 12 visits 04/01/92 1 NC

99440 Newborn resuscitation, care of big H risk 07/01/02 2 148.58 153.31

99450 Life disability evaluation 01/01/95 1 NC

99455 Disability Evaluation 01/01/95 3 NC

99456 Disability Evaluation 01/01/95 1 NC

99499 Unlisted e/m service 05/01/94 1 NC

99500 Home visit- prenat assess 01/01/02 1 NC

99501 Home visit- post natal asses 01/01/02 1 NC

99502 Home visit- newborn assess 01/01/02 1 NC

99503 Home visit-resp therapy 01/01/02 1 NC

99504 Home visit-pat rec mech ventil 01/01/02 1 NC

99505 Home visit for stoma care 01/01/02 1 NC

99506 Home visit- intramusc injection 01/01/02 1 NC

99507 Home visit- catheter maint 01/01/02 1 NC

99508 Home visit for sleep studies 01/01/02 1 NC

99509 Home visit-assistance- ADLs 01/01/02 1 NC

99510 Home visit-indiv,fam couns 01/01/02 1 NC

99511 Home visit-fecal impaction 01/01/02 1 NC

99512 Home visit for hemodialysis 01/01/02 1 NC

99539 Home visit ,NOS 01/01/02 1 NC

99551 Home infusion- pain mgmt 01/01/02 1 NC

99552 Home infusion-pain mgmt epi 01/01/02 1 NC

99553 Home infusion-tocolytic ther 01/01/02 1 NC

99554 Home infusion- hormones 01/01/02 1 NC

99555 Home infusion-chemotherapy 01/01/02 1 NC

99556 Home infusion-antibiotics 01/01/02 1 NC

99557 Home infusion-anticoag ther 01/01/02 1 NC

99558 Home infusion-immunotherapy 01/01/02 1 NC

5101:3-1-60 Page 227







99559 Home infusion-peri dialysis 01/01/02 1 NC

99560 Home infusion- par nutrition 01/01/02 1 NC

99561 Home infusion- hydration ther 01/01/02 1 NC

99562 Home infusion- pare nutrition 01/01/02 1 NC

99563 Home infusion- aeros pentam 01/01/02 1 NC

99564 Home infusion-anti-hemo age 01/01/02 1 NC

99565 Home infus- alpha-1 prot inh 01/01/02 1 NC

99566 Home infusion- LT intrav treat 01/01/02 1 NC

99567 Home infusion-sym agents 01/01/02 1 NC

99568 Home infusion of misc. drugs 01/01/02 1 NC

99569 Home infusion , ea add ther 01/01/02 1 NC

99600 Home visit nos 07/01/03 1 NC

99601 Home Infusion/Visit, 2 Hrs 01/01/04 1 NC

99602 Home Infusion, Each Addtl Hr 01/01/04 1 NC

0001F Blood Pressure, Measured 01/01/04 1 NC

0001T Repair, abd aortic aneury, bif. prosth. 01/01/02 1 NC

0002F Tobacco Use, Smoking, Assess 01/01/04 1 NC

0002T Repair, abd aortic aneur, aorto- prosth. 01/01/02 1 NC

0003F Tobacco Use, Non-Smoking 01/01/04 1 NC

0003T Cervicography 01/01/02 1 NC

0004F Tobacco Use Txmnt Counseling 01/01/04 1 NC

0005F Tobacco Use Txmnt, Pharmacol 01/01/04 1 NC

0005T Perc. cereb. artery stent, 1st vess. 01/01/02 1 NC

0006F Statin Therapy, Prescribed 01/01/04 1 NC

0006T Perc. cereb. artery stent, ea.add.. 01/01/02 1 NC

0007F Beta-Blocker Thx Prescribed 01/01/04 1 NC

0007T Perc. cere. art stent, rad. superv ea. 01/01/02 1 NC

0008F Ace Inhibitor Thx Prescribed 01/01/04 1 NC

0008T Upper GI endoscopy, sut esoph junc. 01/01/02 1 NC

0009F Assess Anginal Symptom/Level 01/01/04 1 NC

0009T Endometrial cryoablation 01/01/02 1 NC

0010F Assess Anginal Symptom/Level 01/01/04 1 NC

0010T Tuberculosis test, cell med. immunity 01/01/02 1 NC

0011F Oral Antiplat Thx Prescribed 01/01/04 1 NC

0012T Osteochondral knee autograft 01/01/02 1 NC

0013T Osteochondral knee allograft 01/01/02 1 NC

0014T Meniscal transplant of knee 01/01/02 1 NC

0016T Thermotherapy of choroidal eye lesion 01/01/02 1 NC

5101:3-1-60 Page 228







0017T Photocoagulation of macular drusen 01/01/02 1 NC

0018T Transcranial magnetic stimulation 01/01/02 1 NC

0019T Extracorpor shock wave therapy, musc 01/01/02 1 NC

0020T Extracorpor shock wave therapy,pl fas 01/01/02 1 NC

0021T Fetal oximetry, insertion 01/01/02 1 NC

0023T Phenotype drug test, HIV 1 01/01/02 1 NC

0024T Transcatheter cardiac reduction 01/01/02 1 NC

0025T Ultrasonic pachymetry 01/01/02 1 NC

0026T Remnant lipoproteins, dir measure 01/01/02 1 NC

0027T Endoscopic epidural lysis 07/01/03 1 NC

0028T Dexa body composition study 07/01/03 1 NC

0029T Magnetic tx for incontinence 07/01/03 1 NC

0030T Antiprothrombin antibody 07/01/03 1 NC

0031T Speculoscopy 07/01/03 1 NC

0032T Speculoscopy w/direct sample+E183 07/01/03 1 NC

0033T Endovasc taa repr incl subcl 07/01/03 1 NC

0034T Endovasc taa repr w/o subcl 07/01/03 1 NC

0035T Insert endovasc prosth, taa 07/01/03 1 NC

0036T Endovasc prosth, taa, add-on 07/01/03 1 NC

0037T Artery transpose/endovas taa 07/01/03 1 NC

0038T Rad endovasc taa rpr w/cover 07/01/03 1 NC

0039T Rad s/i, endovasc taa repair 07/01/03 1 NC

0040T Rad s/i, endovasc taa prosth 07/01/03 1 NC

0041T Detect ur infect agnt w/cpas 07/01/03 1 NC

0042T Ct perfusion w/contrast, cbf 07/01/03 1 NC

0043T Co expired gas analysis 07/01/03 1 NC

0044T Whole body photography 07/01/03 1 NC

0045T Whole Body Photography 01/01/04 1 NC

0046T Cath Lavage, Mammary Duct(S 01/01/04 1 NC

0047T Cath Lavage, Mammary Duct(S) 01/01/04 1 NC

0048T Implant Ventricular Device 01/01/04 1 NC

0049T External Circulation Assist 01/01/04 1 NC

0050T Removal Circulation Assist 01/01/04 1 NC

0051T Implant Total Heart System 01/01/04 1 NC

0052T Replace Component Heart Syst 01/01/04 1 NC

0053T Replace Component Heart Syst 01/01/04 1 NC

0054T Bone Surgery Using Computer 01/01/04 1 NC


5101:3-1-60 Page 229








0057T Uppr Gi Scope W/ Thrml Txmnt 01/01/04 1 NC

0058T Cryopreservation, Ovary Tiss 01/01/04 1 NC

0059T Cryopreservation, Oocyte 01/01/04 1 NC

0060T Electrical Impedance Scan 01/01/04 1 NC

0061T Destruction Of Tumor, Breast 01/01/04 1 NC0062T Rep intradisc annulus;1 lev 01/01/05 1 NC0063T Rep intradisc annulus;>1lev 01/01/05 1 NC0064T Spectroscop eval expired gas 01/01/05 1 NC0065T Ocular photoscreen bilat 01/01/05 1 NC0066T Ct colonography;screen 01/01/05 1 NC0067T Ct colonography;dx 01/01/05 1 NC0068T Interp/rept heart sound 01/01/05 1 NC0069T Analysis only heart sound 01/01/05 1 NC0070T Interp only heart sound 01/01/05 1 NC0071T U/s leiomyomata ablate <200 01/01/05 1 NC0072T U/s leiomyomata ablate >200 01/01/05 1 NC0073T Delivery, comp imrt 01/01/05 1 NC0074T Online physician e/m 01/01/05 1 NC0075T Perq stent/chest vert art 01/01/05 1 NC0076T S&i stent/chest vert art 01/01/05 1 NC0077T Cereb therm perfusion probe 01/01/05 1 NC0078T Endovasc aort repr w/device 01/01/05 1 NC0079T Endovasc visc extnsn repr 01/01/05 1 NC0080T Endovasc aort repr rad s&i 01/01/05 1 NC0081T Endovasc visc extnsn s&i 01/01/05 1 NC0082T Stereotactic rad delivery 01/01/05 1 NC0083T Stereotactic rad tx mngmt 01/01/05 1 NC0084T Temp prostate urethral stent 01/01/05 1 NC0085T Breath test heart reject 01/01/05 1 NC0086T L ventricle fill pressure 01/01/05 1 NC0087T Sperm eval hyaluronan 01/01/05 1 NC0088T Rf tongue base vol reduxn 01/01/05 1 NC0500F Initial prenatal care visit 01/01/05 1 NC0501F Prenatal flow sheet 01/01/05 1 NC0502F Subsequent prenatal care 01/01/05 1 NC0503F Postpartum care visit 01/01/05 1 NC1000F Tobacco use, smoking, assess 01/01/05 1 NC

5101:3-1-60 Page 230






APPR VISIT CODE DESCRIPTION DATE CODE PRICE PRICE INDIC. DAYS GROUP DATE DATE GROUP DATE DATE1001F Tobacco use, non-smoking 01/01/05 1 NC1002F Assess anginal symptom/level 01/01/05 1 NC2000F Blood pressure, measured 01/01/05 1 NC4000F Tobacco cessation, counseling 01/01/05 1 NC4001F Tobacco cessation, pharmacologic therapy 01/01/05 1 NC4002F Statin therapy, prescribed 01/01/05 1 NC4006F Beta-blocker therapy, prescribed 01/01/05 1 NC4009F ACE inhibitor therapy, prescribed 01/01/05 1 NC4011F Oral antiplatelet therapy, prescribed 01/01/05 1 NC

A0010 Ambulance Service, Basic Life Support 12/01/97 3 NC 55.77

A0020 Ambulance Service, (BLS) Per Mile, Tran 12/01/97 3 NC 0.01

A0040 Ambulance Service, Air, Helicopter Serv 04/01/02 3 NC BR

A0070 Ambulance Service, Oxygen, Administrati 12/01/97 3 NC 6.73

A0130 Non-Emergency Transportation: Wheel-Chai 10/01/97 2 23.61 18.89

A0140 Non-Emergency Transportation And Air Tra 04/01/02 3 NC BR

A0150 Non-Emergency Transportation, Ambulance 12/01/97 3 NC 55.77

A0160 Non-Emergency Transportation: Per Mile- 04/01/02 3 NC 0.01

A0220 Ambulance Service, Advanced Life Suppor 12/01/97 3 NC 107.53

A0221 Ambulance Service, (ALS) Per Mile, Tran 12/01/97 3 NC 0.01

A0320 Ambulance Service, basic life support, nonemergency 03/15/02 3 NC 82.21

A0322 Ambulance Service, basic life support, emergency 03/15/02 3 NC 85.95

A0324 Ambulance Services, ALS, nonemerg. no spec. svcs. 03/15/02 3 NC 84.09

A0326 Ambulance Services, ALS, nonemerg. w/spec. svcs. 03/15/02 3 NC 85.95

A0328 Ambulance Services, ALS, emergency, no spec. svcs. 03/15/02 3 NC 158.50

A0330 Ambulance Services, ALS, emergency, w/spec. svcs. 03/15/02 3 NC 165.70

A0380 Ambulance Services, basic life support, per mile 03/15/02 3 NC 0.01

A0390 Ambulance Services, advanced life support, per mile 03/15/02 3 NC 0.01

A0424 Extra ambulance attendant, ground or air 10/01/03 1 9.02

A0425 Ground mileage, per statute mile 01/01/02 1 FP 0.01

A0426 Ambulance Service, ALS1, non-emergency 07/01/01 1 85.95

A0427 Ambulance Service,ALS 1, emergency 07/01/01 1 165.70

A0428 Ambulance Serv, BLS, non-emergency 07/01/01 1 82.21

A0429 Ambulance Serv, BLS-emergency 07/01/01 1 85.95

A0430 Air ambulance service, one-way,fixed wing 01/01/02 2 1,503.40 BR

A0431 Air ambulance Serv ,one-way,rotary wing 01/01/02 2 1,747.97 BR

A0432 Paramedic Intercept,Rural Area,Trans by Vol.Ambul. Co 01/01/02 1 NC

A0433 Advanced Life Support, Level 2, (ALS 2) 07/01/01 1 165.70

A0434 Specialty Care Transport, (SCT) 07/01/01 1 165.70

5101:3-1-60 Page 231







A0435 Fixed Wing Air Mileage, Per Statue Mile 01/01/02 1 FP TM

A0436 Rotary Wing Air Mileage, Per Statue Mile 01/01/02 1 FP TM

A2000 Manipulation Of Spine By Chiropractor 07/01/97 3 NC 15.53

A4190 Transp. Film, Wound Dress. 48 Sq. In. Or Less 06/01/96 3 NC 1.86

A4200 Gauze Pads, Sterile Or Nonsterile 06/01/96 3 NC 50.00

A4202 Gauze Bandage, Elastic Sterile/ Nonsterile 06/01/96 3 NC 2.00

A4203 Gauze Bandage, Non-Elastic, Sterile/Nonste 06/01/96 3 NC 1.00

A4206 Syringe With Needle, Sterile Icc 05/01/90 1 0.23

A4207 Syringe With Needle, Sterile 2cc 05/01/90 1 0.23

A4208 Syringe With Needle, Sterile 3cc 05/01/90 1 0.17

A4209 Syringe With Needle, Sterile 5cc Or More 05/01/90 1 0.27

A4212 Huber-Type Needle 04/01/97 2 3.60 0.00

A4213 Syringe W/O Needle, Sterile 20cc Or More 11/22/90 2 0.60 0.25

A4214 Sterile Saline Or Water,30 cc Vial 10/01/04 3 NC 0.25

A4215 Needles Only, Sterile, Any Size 01/01/00 2 0.25 0.19

A4216 10 ml sterile water/saline 10/01/04 1 0.25

A4217 Sterile water/saline, 500 ml 10/01/04 1 2.50

A4221 Supplies for the maintenance of drug inf. cath., per week 01/01/98 1 20.55A4222 Supplies for external drug infus. pump, per cassette or bag 01/01/05 2 40.00 22.00A4223 Infusion Supplies Not Used With Pump 01/01/05 1 15.00

A4230 Infusion set with drainage tubing (not for nutrition) 10/01/04 1 4.00

A4232 Syringe w/ Needle for External Insulin Pump, Sterile 3cc 01/01/01 1 NC

A4244 Peroxide, Per Pint 05/01/90 1 0.56

A4245 Alcohol Wipes, Per Box 01/01/05 2 2.00 0.03

A4246 Betadine Or Phisohex Solution, Per Pint 06/20/90 1 10.00A4247 Betadine/Iodine Wipe/Swab Per Box 01/01/05 2 19.00 0.19A4250 Urine Test Or Reagent Strips (Per 100) 01/01/05 2 26.00 0.26

A4253 Blood Glucose Test Strips,Glucometer, 50 01/01/92 1 35.00

A4254 Replacement Battery, Glucose Monitor 01/01/96 1 NC

A4256 Normal, Low,High Calibration Solu/Chips 05/01/90 1 6.25

A4258 Spring-Powered Lancet Device 01/01/00 2 13.75 NC

A4259 Lancets, Per Box Of 100 02/01/95 1 7.00

A4260 Levonorgestrel contraceptive implant- Norplant 10/01/03 1 418.00

A4261 Cervical Cap for Contraceptive Use 01/01/99 1 17.65

A4265 Paraffin For Use In Med Nec. Unit, Refill 12/15/02 2 3.37 18.31

A4266 Diaphragm for Contraceptive Use 04/01/03 1 25.46

A4267 Contraceptive Supply, Condom, Male, Ea 04/01/03 1 0.40

A4268 Contraceptive Supply, Condom, Female, Ea 04/01/03 1 2.10

5101:3-1-60 Page 232







A4269 Contraceptive Supply, Spermicide, Ea 04/01/03 1 10.05

A4290 Sacral Nerve Stimulation Test Lead, Ea 01/01/01 1 NC

A4305 Disp Drug Del Syst,Flow 50Ml Per Hour 04/01/93 1 12.73

A4306 Disp Drug Del Syst,Flow 5Ml Per Hour 04/01/93 1 12.73

A4310 Cath Insert . Tray W/O Drain Bag, W/O Cath 05/01/90 1 3.90

A4311 Ins. Tray W/O Bag, W/2Way Cath Latex W/Coa 05/01/90 1 6.75

A4312 Ins. Tray W/O Bag,W/2 Way Cath,Silicone 05/01/90 1 10.00

A4313 Ins. Tray W/O Bag ,W/3 Way Cath, Silicone 05/01/90 1 14.00

A4314 Ins. Tray W/Bag ,W/2 Way Cath, Latex W/Coat 05/01/90 1 10.75

A4315 Ins. Tray W/Bag,W/2 Way Cath, All Silicone 05/01/90 1 14.00

A4316 Ins. Tray W/Bag, W/3 Way Cath, Contin. Irrig 05/01/90 1 18.00

A4319 Sterile Water Irrigation Solution 10/01/04 3 NC 1.75

A4320 Irrig Tray, Bladder, W/Bulb Or Pist. Syring 04/01/92 1 2.50

A4322 Irrigation Syringe, Bulb Or Piston 06/20/90 1 1.60

A4323 Sterile Saline Irrig Solu - 1000 ml 10/01/04 3 NC 2.50A4324 Male Urinary Catheter, W/ Adhesive Coating 01/01/05 3 NC 1.39A4325 Male Urinary Catheter, W/ Adhesive Strip 01/01/05 3 NC 1.02

A4326 Male External Catheter, Specialty Type 08/01/97 2 9.00 0.00

A4327 Female Extern.Ur. Collec. Dvce ,Meatal Cup 08/01/97 2 37.00 0.00

A4328 Female Extern.Uri.Collec.Device; Pouch 04/01/01 2 8.33 7.79

A4329 Extern. Cath Start Set, Male/Female, Complt 04/01/02 3 NC 24.30

A4330 Perianal Fecal Collec Pouch W/Adhesv 04/01/01 2 5.80 11.06

A4331 Extension Drainage Tubing w/ Connector 04/01/01 2 3.04 2.90

A4332 Lubricant, Individual Sterile Packet 01/01/01 1 NC

A4333 Urinary Catheter Anchoring Device, Skin Attachment 04/01/01 2 1.37 1.27

A4334 Urinary Catheter, Anchoring Device, Leg Strap 01/01/01 1 3.00A4335 Incontinence Supply; Miscellaneous 05/01/90 1 PA 0.00

A4338 Indw Cath Foley ,2-Way Latex W/Coating 05/01/90 1 4.20

A4340 Indw. Cath;Specialty Type (Eg.,Coude.Etc) 08/01/97 2 24.00 0.00

A4344 Indwelling Catheter,Foley,2 Way,Silicone 04/01/92 1 9.39

A4346 Indwell.Cath,Foley,3Way For Contin. Irrig 05/01/90 1 12.50

A4348 Male Ext. Catheter w/ Collec Comp, Extended Ware 01/01/01 1 NCA4349 Male External Catheter, Disposable, Each 01/01/05 1 1.39

A4351 Intermittent Urinary Catheter, straight tip 01/01/96 1 0.79

A4352 Intermittent Urinary Catheter, coude tip 01/01/96 1 2.00

A4353 Intermittent urinary cath 10/01/04 1 3.49

A4354 Cath Insert Tray W/O Cath,Incl Tube&Bag 05/01/90 1 7.40

A4355 3-Way Irrigation Set For Catheter 05/01/90 1 2.70

5101:3-1-60 Page 233







A4356 External Urethral Clamp/Compress. Device 05/01/90 1 30.01

A4357 Bedside Drainage Bag, Day/Nite,W,W/O Tube 06/20/90 1 6.00

A4358 Urinary Leg/Abdominal Bag,Vinyl, W/ Or W/O Tube,w/strap04/01/01 2 6.26 3.35

A4359 Urinary Suspensory W/O Leg Bag 05/01/90 1 25.00

A4360 Adult incontinence garment 01/01/02 1 NC

A4361 Ostomy, Face Plate 04/01/01 2 17.52 23.34

A4362 Skin Barrier,Solid,4X4 Or Equiv. 04/01/01 2 3.22 3.16

A4364 Adhesv;Liquid or equal, any type per oz 04/01/01 2 2.38 3.05

A4365 Adhesive Remover Wipes 01/01/01 1 NC

A4367 Ostomy Belt 04/01/01 2 6.96 6.65

A4369 Skin Barrier,Liquid, Spray/Brush Per Oz. 01/01/00 1 2.30

A4370 Skin Barrier,Paste Per Oz. 07/01/03 3 NC 3.27

A4371 Skin Barrier,Powder,Per Oz. 04/01/01 2 3.48 3.30

A4372 Skin barrier, solid 4X4, or equiv stand w.conv 01/01/00 1 3.78

A4373 Skin barrier, w/flange std wear w/conv 04/01/01 2 5.99 5.69

A4374 Skin barrier, w/flange extended wear, w/ convexity 07/01/03 3 NC 7.67

A4375 Pouch, drainable, w/faceplate, plastic 01/01/00 1 15.56

A4376 Pouch, drainable, w/faceplate, rubber 01/01/00 1 43.11

A4377 Pouch, drainable, for use on FP, plastic 01/01/00 1 3.89

A4378 Pouch, drainable, for use on FP, rubber 01/01/00 1 27.86

A4379 Pouch, urinary with FP attached, plastic 01/01/00 1 13.61

A4380 Pouch, urinary with FP attached, rubber 01/01/00 1 33.82

A4381 Pouch, urinary for use on FP, plastic 01/01/00 1 4.18

A4382 Pouch, urinary for use on FP, heavy plastic 01/01/00 1 22.31

A4383 Pouch, urinary, for use on faceplate, rubber 01/01/00 1 25.55

A4384 Ostomy faceplate equivalent, silicone ring 01/01/00 1 8.72

A4385 Skin barrier, 4X4 extended wear 04/01/01 2 4.00 4.62

A4386 Skin barrier, w/flange extended wear, w/o convexity 07/01/02 3 NC 5.68

A4387 Pouch closed, w/stand. wear barrier w/ convexity 04/01/01 2 2.74 3.64

A4388 Pouch, drainable w/ext wear barrier w/o conv 04/01/01 2 3.87 3.95

A4389 Pouch, drainable, w/std wear barrier with conv 04/01/01 2 5.55 5.63

A4390 Pouch, drainable, w/extended wear barrier 04/01/01 2 8.94 8.71

A4391 Pouch, urinary, w/ext wear barrier w/o conv 04/01/01 2 6.04 6.40

A4392 Pouch, urinary, with standard wear barrier, w/ conv. 04/01/01 2 6.34 6.02

A4393 Pouch, urinary, w/ext wear barrier w/conv 04/01/01 2 7.81 8.31

A4394 Ostomy deodorant, liquid 01/01/00 1 NC

A4395 Ostomy deodorant, solid, per tablet 01/01/00 1 NC

A4396 Ostomy Belt W/ Periostomal Hernia Support 10/01/04 2 24.20 NC

5101:3-1-60 Page 234







A4397 Irrigation Supply; Sleeve 04/01/01 2 4.41 4.35

A4398 Irrigation Supply; Bag 04/01/01 2 13.17 21.88

A4399 Irrigation Supply ; Cone/Catheter 01/01/98 2 9.95 8.96

A4400 Ostomy Irrigation Set 08/01/97 2 45.00 42.00

A4402 Ostomy Lubricant, Per Oz. 08/01/98 2 0.65 1.50

A4404 Ostomy, Rings 04/01/01 2 1.47 1.45

A4405 Ostomy Skin Barrier, Non-Pectin Based Paste, Per oz 04/01/03 1 3.27

A4406 Ostomy Skin Barrier, Pectin Based Paste, Per oz 04/01/03 1 3.27

A4407 Ostomy Skin Barrier, w/ Flange, Ext Wear; Cnvx; <= 4x4 04/01/03 1 7.67

A4408 Ostomy Skin Barrier, w/ Flange, Ext Wear; Cnvx; >4x4 04/01/03 1 7.67

A4409 Ost. Skin Barrier, w/ Flange, Ext Wear; w/o Convx;<=4x4 04/01/03 1 5.68

A4410 Ost. Skin Barrier, w/ Flange, Ext Wear; w/o Cnvx; >4x4 04/01/03 1 5.68

A4414 Ost. Skin Barrier, w/Flange; w/o Cnvx; <= 4x4 04/01/03 1 4.24

A4415 Ost. Skin Barrier, w/ Flange; w/o Cnvx; >4x4 04/01/03 1 4.24A4420 Ostomy Supplies,Necess, Not Part Of Set 01/01/05 3 NC 11.00A4421 Ostomy Supply ; Miscellaneous 05/01/90 1 PA 0.00

A4450 Tape, non-waterproof, per 18 square inches 10/01/04 1 0.08

A4452 Tape, waterproof, per 18 square inches 10/01/04 1 0.32

A4454 Tape, All Types, All Sizes (One Roll) 06/01/96 3 NC 3.00

A4455 Adhes Removr/Solvent (For Tape ,Cement ,Etc) per oz 04/01/01 2 1.36 8.80

A4458 Enema bag with tubing, reusable 10/01/04 1 8.00

A4460 Elastic Bandages (Ace) , Any Size 10/01/04 3 NC 1.14

A4464 Joint Supportive Device/Garment, Elastic or Equal 01/01/01 1 NC

A4481 Tracheostoma filter, any type, any size 10/01/04 1 NCA4483 Moisture Exchanger, disposable for use with IMV 01/01/05 2 4.15 NCA4490 Surgical Stockings Above Knee Ea 05/01/90 1 PA 0.00A4495 Surgical Stockings Thigh Length Ea 05/01/90 1 PA 0.00A4500 Surgical Stockings Below Knee Length Ea 05/01/90 1 PA 0.00A4510 Surgical Stockings Full Leotard Ea Pair 05/01/90 1 PA 0.00A4520 Incontinence Garment, Any Type 01/01/05 1 NCA4521 Adult-Sized Incontinence Product, Diaper, Small Size 01/01/05 3 NC 0.61A4522 Adult-Sized Incontinence Product, Diaper, Medium Size 01/01/05 3 NC 0.70A4523 Adult-Sized Incontinence Product, Diaper, Large Size 01/01/05 3 NC 0.79A4524 Adult-Sized Incontinence Product, Diaper, Extra-Large 01/01/05 3 NC 0.88A4525 Adult-Sized Incontinence Product, Brief, Small Size 01/01/05 3 NC 0.61A4526 Adult-Sized Incontinence Product, Brief, Medium Size 01/01/05 3 NC 0.70A4527 Adult-Sized Incontinence Product, Brief, Large Size 01/01/05 3 NC 0.79A4528 Adult-Sized Incontinence Product, Brief, Extra-Large 01/01/05 3 NC 0.88A4529 Child-Sized Incontinence Product, Diaper, Small/Medium 01/01/05 3 NC 0.40

5101:3-1-60 Page 235






APPR VISIT CODE DESCRIPTION DATE CODE PRICE PRICE INDIC. DAYS GROUP DATE DATE GROUP DATE DATEA4530 Child-Sized Incontinence Product, Diaper, Large, Size 01/01/05 3 NC 0.40A4531 Child-Sized Incontinence Product, Brief, Small/Medium Size01/01/05 3 NC 0.40A4532 Child-Sized Incontinence Product, Brief, Large Size 01/01/05 3 NC 0.40A4533 Youth-Sized Incontinence Product, Diaper 01/01/05 3 NC 0.46A4534 Youth-Sized Incontinence Product, Brief 01/01/05 3 NC 0.46A4535 Disposable Liner/Shield For Incontinence 01/01/05 3 NC 0.40A4536 Protective Underwear, Washable, Any Size 01/01/05 3 NC 11.00A4537 Under Pad, Reusable/Washable, Any Size 01/01/05 3 NC BRA4538 Diaper Service, Reusable Diaper 01/01/05 3 NC 0.53A4554 Disposable Underpads, All Sizes 01/01/05 3 NC 0.28

A4556 Electrodes (e.g., Apnea monitor) 10/01/04 1 9.41

A4557 Lead wires (e.g., Apnea monitor) 10/01/04 1 16.36

A4558 Conductive paste or gel 10/01/04 1 4.23

A4560 Pessary 04/01/01 3 NC 10.24

A4561 Pessary, Rubber, Any Type 01/01/01 1 10.24

A4562 Pessary, Non-Rubber, Any Type 01/01/01 1 10.24

A4565 Slings 07/01/02 2 6.30 8.00

A4570 Splints, All Types, Incl Wood Surgi Shoe 05/01/90 1 10.00

A4580 Cast Supplies Plaster, Repair Only 11/01/92 1 2.55

A4581 Supplies For Risser Jacket 08/01/98 3 NC 0.00

A4590 Special Cast Materials, Light,Repair Only 11/01/92 1 15.00

A4595 Tens Supplies, fo 2 or 4 lead 01/01/96 1 25.00A4605 Tracheal Suction Catheter, Closed System 01/01/05 1 13.12A4606 Oxygen probe for use with oximeter device, replacement 10/01/04 1 PA 0.00

A4608 Trantracheal Oxygen Catheter, Ea 01/01/01 1 NC

A4609 Tracheal suction catheter, closed system, for less than 72 hours of use10/01/04 1 NC

A4610 Tracheal suction catheter, closed system, for 72 or more hours of use10/01/04 1 NC

A4611 Battery ,Heavy Duty;Replc Recip Ownd Vent 05/01/90 1 100.00

A4612 Battery Cables ;Replc For Recip Ownd Vent 05/01/90 1 60.00

A4613 Battery Chargr ;Replc For Recip-Ownd Vent 05/01/90 1 60.00

A4614 Peak Expiratory Flow Rate Meter 01/01/99 1 22.00

A4615 Cannula, nasal 10/01/04 1 NC

A4616 Tubing; Aerosol, (Per Foot) 05/01/90 1 0.25

A4617 Mouth Piece 05/01/90 1 1.00

A4618 Breathing Circuits, IPPB 05/01/90 1 2.60

A4619 Oxygen Face Tent 01/01/02 2 1.21 1.89

A4620 Variable Concentration Mask 05/01/90 1 2.00

A4621 Tracheostomy Mask Or Collar 10/01/04 3 NC 1.39

A4622 Tracheostomy Tube 10/01/04 3 NC 48.15

5101:3-1-60 Page 236







A4623 Tracheostomy ,Inner Cannula,Replcmnt Only 01/01/94 1 4.38

A4624 Tracheal Suction Catheter, Adult 05/01/90 1 0.80

A4625 Tracheostomy Care/Clean Kit 01/01/96 2 3.55 2.40

A4626 Tracheostomy Cleaning Brush 01/01/93 1 1.38

A4627 Spacer, Bag Or Reservoir, W/ Or W/O Mask 02/01/95 2 23.00 18.00

A4628 Oropharyngeal Suction Catheter 01/01/96 1 2.70

A4629 Tracheostomy Care Kit , Established Trach 01/01/96 1 2.55

A4631 Replacement, Battery, Whlchr, 24 Gel Only 06/01/96 3 NC 125.00

A4635 Underarm Pad, Replacement, Each 05/25/91 1 1.50

A4636 Replacement ,Handgrip ,Cane ,Crutch ,Walker 05/25/91 1 1.66

A4637 Replacement,Tip,Cane,Crutch,Walker,Each 05/25/91 1 1.90

A4640 Replacement Pad ,Alt .Press.Pad,Recip .Ownd 05/25/91 1 31.28

A4641 Radiodiagnostic imaging agent;any dose 01/01/94 1 50.00

A4643 High dose contrast MRI 07/01/03 1 185.70

A4644 Low osmolar materials;100-199 mgs 07/01/02 2 0.65 66.00



A4647 Paramagnetic Contrast Material 05/01/90 1 96.55A4649 Surgical Supplies, NOS (Not For Ostomy) 05/01/90 1 PA 0.00

A4660 Sphygmomanometer/Blood Press.Set ,Complet 05/01/90 1 30.00

A4663 Blood Pressure Cuff Only, Replcmnt 05/01/90 1 13.00

A4670 Automatic Blood Pressure Monitor 05/01/90 1 47.00

A4719 "Y set" tubing 10/01/04 1 5.00

A4927 Surgical Gloves, Non-Sterile, per 100 04/01/03 2 8.69 0.22

A4930 Gloves, Sterile, per pair 04/01/03 1 0.55

A5051 Pouch, Closed ,W/Barrier Attachd(1 Pc) 04/01/01 2 1.91 2.00

A5052 Pouch,Closed ;W/O Barrier Attached (1 Pc) 04/01/01 2 1.36 1.55

A5053 Pouch ,Closed ; For Use On Face Plate 01/01/98 2 1.58 1.49

A5054 Pouch, Closed Use On Barr . W/Flange (2 Pc 04/01/01 2 1.35 1.30

A5055 Stoma Cap 04/01/01 2 1.27 1.52

A5061 Ostomy Pouch Drainable; W/Barrier (1 Pc) 04/01/01 2 2.45 2.89

A5062 Ostomy Pouch Drainable; W/O Barrier (1 Pc) 08/01/97 2 1.90 1.83

A5063 Pouch Drainable;Use On Barr. W/Flnge (2 Pc 04/01/01 2 2.13 2.11

A5064 Ostomy Pouch Drainable;W/Face Plate Atta 07/01/97 3 NC 14.00

A5065 Ostomy Pouch Drainable;Use On Face Plate 07/01/97 3 NC 2.80

A5071 Ostomy Pouch Urinary;W/Barrier Attac(1Pc 04/01/01 2 4.15 4.53

A5072 Ostomy Pouch Urinary;W/O Barrier(1Pc) 04/01/01 2 3.10 3.16

A5073 Ostomy Pouch Urin;Use On Barr .W/Flng(2Pc 04/01/01 2 2.98 3.35

5101:3-1-60 Page 237







A5074 Ostomy Pouch Urinary;W/Face Plate Attach 07/01/97 3 NC 13.00

A5075 Ostomy Pouch,Urinary,Use On Face Plate 07/01/97 3 NC 3.51

A5081 Ostomy Contin .Device;Plug For Cont .Stoma 01/01/98 2 3.00 2.83

A5082 Ostomy Contin.Device;Cath. For Cont.Stoma 01/01/98 2 10.75 10.21

A5093 Ostomy Accessory; Convex Insert 04/01/01 2 1.58 1.51

A5102 Bedside Drain. Btl;Rigid Or Expand ,W/Tube 04/01/01 2 21.39 23.00

A5105 Urinary Suspensory;W/Leg Bag,W/W/O Tube 07/01/02 2 40.32 59.00

A5112 Urinary Leg Bag; Latex 07/01/02 2 31.16 31.25

A5113 Leg Strap; Latex , Pair 11/15/93 1 1.30

A5114 Leg Strap; Foam Or Fabric , Pair 04/01/01 2 4.25 4.00

A5119 Skin Barrier; Wipes , Box Of 50 04/01/01 2 8.36 8.60

A5121 Ostomy Skin Barrier; Solid 6X6 Or Equiv 05/01/90 1 6.70

A5122 Ostomy Skin Barrier; Solid, 8X8 Or Equiv 04/01/01 2 12.26 11.65

A5123 Ostomy Skin Barrier;W/Flange, Any Type,Sz 07/01/03 3 NC 4.24

A5126 Adhesive or non-adhesive; Disk Or Foam Pad 07/01/02 2 1.11 1.15

A5131 Appliance Cleaner, Incont & Ostom,16 Oz 01/01/98 2 12.25 12.00

A5149 Incontinence/Ostomy Supply;Miscellaneous 04/01/96 3 NC 0.00

A5200 Percutaneous catheter/tube anchoring device 01/01/99 1 NC

A5501 For Diabetics Only, Custom Molded Shoe 01/01/00 2 165.14 125.00

A6010 Collagen-based wound filler, dry form 01/01/02 1 100.00A6011 Collagen Based Wound Filler Gel/Paste 01/01/05 1 1.82

A6020 Collagen-based wound dressing 04/01/02 3 NC 0.00A6021 Collagen Dressing, 16 sq in or less 01/01/01 1 PA 0.00A6022 Collagen Dressing, >16 but < or = to 48 sq in 01/01/01 1 PA 0.00A6023 Collagen Dressing, more than 48 sq in 01/01/01 1 PA 0.00

A6024 Collagen Dressing Wound Filler, per 6 inches 01/01/01 1 NC

A6154 Wound Pouch, for surgical wound drainage 01/01/97 1 11.40 NC

A6196 Alginate or Other Fiber Gelling Dressing, 16 sq in or less 01/01/97 1 6.00

A6197 Alginate or Other Fiber Gelling Dressing, >16 but < 48 sq in01/01/97 1 12.50A6198 Alginate or Other Fiber Gelling Dressing, more than 48 sq in01/01/97 1 PA 0.00

A6199 Alginate or Other Fiber Gelling Dressing, wound filler 01/01/97 1 100.00A6200 Composite Dressing, 16 sq in or less 01/01/99 1 PA 0.00A6201 Composite Dressing, > 16 but < 48 sq in 01/01/99 1 PA 0.00A6202 Composite Dressing, more than 48 sq in 01/01/99 1 PA 0.00

A6203 Composite Dressing, 16 sq in or less 01/01/97 1 3.02

A6204 Composite Dressing, > 16 but < 48 sq in 01/01/97 1 4.50A6205 Composite Dressing, more than 48 sq in 01/01/97 1 PA 0.00A6206 Contact Layer, 16 sq in or less 01/01/97 1 PA 0.00

5101:3-1-60 Page 238







A6207 Contact Layer, >16 but <48 sq in 01/01/97 1 5.30A6208 Contact Layer, more than 48 sq in 01/01/97 1 PA 0.00

A6209 Foam Dressing, 16 sq in or less, w/o adh. bord. 01/01/97 1 6.17

A6210 Foam Dressing, >16 but <48 sq in, w/o adh. bord. 01/01/97 1 14.35

A6211 Foam Dressing, more than 48 sq in, w/o adh. bord. 01/01/99 2 25.21 0.00

A6212 Foam Dressing, 16 sq in or less, any size adh. bord. 01/01/97 1 7.00A6213 Foam Dressing, > 16 but < 48 sq in, any size adh. bord. 01/01/97 1 PA 0.00

A6214 Foam Dressing, more than 48 sq in, any size adh. bord. 01/01/97 1 7.45

A6215 Foam Dressing, wound filler 01/01/97 1 100.00

A6216 Gauze, non-impreg., 16 sq in or less, w/o adh. bord. 01/01/97 1 50.00

A6217 Gauze, non-impreg., >16 but <48 sq in, w/o adh. bord. 01/01/97 1 50.00

A6218 Gauze, non-impreg., more than 48 sq in, w/o adh. bord. 01/01/97 1 50.00

A6219 Gauze, non-impreg., 16 sq in or less, any size adh. bord. 01/01/97 1 50.00

A6220 Gauze, non-impreg., >16 but <48 sq in, any sz adh. bord. 01/01/97 1 50.00

A6221 Gauze, non-impreg., >48 sq in, any size adh. bord. 01/01/97 1 50.00

A6222 Gauze, impreg., 16 sq in or less, w/o adh. bord. 01/01/97 1 1.65

A6223 Gauze, impreg., >16 but < 48 sq in, w/o adh. bord. 01/01/97 1 1.75

A6224 Gauze, impreg., >48 sq in , w/o adh. bord. 01/01/97 1 2.60

A6228 Gauze, impreg., 16 sq in or less, w/o adh. bord. 01/01/97 1 NC

A6229 Gauze, impreg., >16 but <48 sq in, w/o adh. bord. 01/01/97 1 NC

A6230 Gauze, impreg., > 48 sq in, w/o adh. bord. 01/01/97 1 NC

A6231 Gauze, Impreg, Hydrogel, 16 sq in or less 01/01/01 1 1.65

A6232 Gauze, Impreg, Hydrogel, >16sq in <= 48 sq in 01/01/01 1 1.75

A6233 Gauze, Impreg, Hydrogel, more than 48 sq in 01/01/01 1 2.60

A6234 Hydrocolloid Dressing, 16 sq in or less, w/o adh. bord. 01/01/97 1 4.80

A6235 Hydrocolloid Dressing, >16 but <48 sq in, w/o adh. bord. 01/01/97 1 12.15

A6236 Hydrocolloid Dressing, > 48 sq in, w/o adh. bord. 01/01/97 1 19.65

A6237 Hydrocolloid Dressing, 16 sq in or less, w/ adh. bord. 01/01/97 1 5.80

A6238 Hydrocolloid Dressing, >16 but <48 sq in, w/ adh. bord. 01/01/97 1 16.75A6239 Hydrocolloid Dressing, >48 sq in, w/ adh. bord. 01/01/97 1 PA 0.00

A6240 Hydrocolloid Dressing, wound filler, paste 01/01/97 1 100.00

A6241 Hydrocolloid Dressing, wound filler, dry form 01/01/97 1 100.00

A6242 Hydrogel Dressing, 16 sq in or less, w/o adh. bord. 01/01/97 1 4.80

A6243 Hydrogel Dressing, >16 but <48 sq in, w/o adh. bord. 01/01/97 1 8.75

A6244 Hydrogel Dressing, >48 sq in, w/o adh. bord. 01/01/97 1 28.30

A6245 Hydrogel Dressing, 16 sq in or less, w/ adh. bord. 01/01/97 1 5.90

A6246 Hydrogel Dressing, >16 but <48 sq in, w/ adh. bord. 01/01/97 1 7.15

A6247 Hydrogel Dressing, >48 sq in, w/ adh. bord. 01/01/97 1 17.15

5101:3-1-60 Page 239







A6248 Hydrogel Dressing, wound filler, gel 01/01/97 1 100.00

A6249 Hydrogel Dressing, wound filler, dry form 01/01/97 1 100.00

A6250 Skin Sealants, Protectants, Moisturizers 01/01/97 1 NC

A6251 Spec. Absorp. Dressing, 16 sq in or less, w/o adh. bord. 01/01/97 1 0.90

A6252 Spec. Absorp. Dressing, >16 but <48 sq in 01/01/97 1 2.35

A6253 Spec. Absorp. Dressing, >48 sq in, w/o adh. bord. 01/01/97 1 4.60

A6254 Spec. Absorp. Dressing, 16 sq in or less, w/ adh. bord. 01/01/97 1 0.90

A6255 Spec. Absorp. Dressing, >16 but <48 sq in, w/adh. bord. 01/01/97 1 2.20A6256 Spec. Absorp. Dressing, >48 sq in, w/ adh. bord. 01/01/97 1 PA 0.00

A6257 Transparent Film, 16 sq in or less 01/01/97 1 1.10

A6258 Transparent Film, >16 but <48 sq in 01/01/97 1 3.10

A6259 Transparent Film, >48 sq in 01/01/97 1 7.90

A6260 Wound Cleansers, any type, any size 01/01/97 1 NC

A6261 Wound Filler, not elsewhere classified, gel/paste 01/01/97 1 100.00

A6262 Wound Filler, not elsewhere classified, dry form 01/01/97 1 100.00A6263 Gauze, elastic, nonsterile, all types 01/01/05 3 NC 2.00

A6264 Gauze, nonelastic, nonsterile 10/01/04 3 NC 2.00

A6265 Tape, all types, all sizes 10/01/04 3 NC 3.00

A6266 Gauze, impreg., other than water or normal saline 08/01/97 2 1.75 0.00

A6402 Gauze, nonimpreg, sterile, 16 sq in or less 01/01/97 1 50.00

A6403 Gauze, non-impreg., sterile, >16 but <48 sq in 01/01/97 1 50.00

A6404 Gauze, non-impreg., sterile, more than 48 sq in 01/01/97 1 50.00

A6405 Gauze, elastic, sterile, all types 10/01/04 3 NC 1.20

A6406 Gauze, nonelastic, sterile 10/01/04 3 NC 2.80A6441 Padding Bandage, Non-Elastic, >=3", <5" per yard 01/01/05 1 0.54A6442 Conforming Bandage, Non-Sterile, <3" per yard 01/01/05 1 0.14A6443 Conforming Bandage, Non-Sterile, >=3",<5" per yard 01/01/05 1 0.23A6444 Conforming Bandage, Non-Sterile >=5" per yard 01/01/05 1 0.45A6445 Conforming Bandage, Sterile <3" per yard 01/01/05 1 0.26A6446 Conforming Bandage, Sterile >=3", <5" per yard 01/01/05 1 0.33A6447 Conforming Bandage, Sterile >=5" per yard 01/01/05 1 0.54

A6448 Light compression bandage width <3 per yard 10/01/04 1 1.04

A6449 Light compression bandage width >=3” <5 per yard 10/01/04 1 1.05

A6450 Light compression bandage width >=5" per yard 01/01/05 1 1.60A6451 Moderate Compression Bandage >=3", <5" per yard 01/01/05 1 3.19

A6452 High compression bandage width>=3”<5 per yard 10/01/04 1 5.32

A6453 Self-adherent bandage width <3 per yard 10/01/04 1 0.55

A6454 Self-adherent bandage width >=3” <5 per yard 10/01/04 1 0.69

5101:3-1-60 Page 240







A6455 Self-adherent bandage width >=5 per yard 10/01/04 1 1.25

A6501 Compression Burn Garment, Bodysuit 10/01/04 1 PAA6502 Compression Burn Garment, Chin Strap 10/01/04 1 PAA6503 Compression Burn Garment, Facial Hood 10/01/04 1 PAA6504 Compression Burn Garment, Glove to Wrist 10/01/04 1 PAA6505 Compression Burn Garment, Glove to Elbow 10/01/04 1 PAA6506 Compression Burn Garment, Glove to Axilla 10/01/04 1 PAA6507 Compression Burn Garment, Foot to Knee Length 10/01/04 1 PAA6508 Compression Burn Garment, Foot to Thigh Length 10/01/04 1 PAA6509 Compression Burn Garment, Vest 10/01/04 1 PAA6510 Compression Burn Garment, Leotard 10/01/04 1 PAA6511 Compression Burn Garment, Panty 10/01/04 1 PAA6512 Compression Burn Garment, NOC 10/01/04 1 PA

A7000 Canister, disposable, used with suction pump 01/01/00 1 7.50

A7001 Canister, non-disposable, used with suctin pump 01/01/00 1 NC

A7002 Tubing, used with suction pump, incl. connector/adaptor 01/01/00 1 3.75

A7003 Admin. set w/ small vol. nonfilt. pneum, nebulizer, disp. 01/01/00 1 2.15

A7004 Small volume nonfiltered pneumatic nebulizer, disp. 10/01/04 1 1.44

A7005 Administration Set, small vol, nonfilt. nebulizer 01/01/00 1 20.00

A7006 Admin.Set Sm.Vol.Filtrd Pneum. Nebul, Disp. Pent 01/01/00 1 8.00

A7007 Large volume nebulizer, disposable, unfilled, used with aerosol compressor10/01/04 1 4.00

A7008 Large volume nebulizer, disposable, prefilled, used with aerosol compressor10/01/04 1 NC

A7009 Reservoir bottle, non-disposable, used with large volume ultrasonic nebulizer10/01/04 1 NC

A7010 Corrugated tubing, disposable, used with large volume nebulizer10/01/04 1 NC

A7011 Corrugated tubing, non-disposable, used with large volume nebulizer10/01/04 1 NC

A7012 Water Collection Device, Used W/Large Vol Neb 01/01/00 1 1.80

A7013 Filter, disposable, used with aerosol compressor 10/01/04 1 NC

A7014 Filter, non-disposable, used with aerosol compressor or ultrasonic generator10/01/04 1 NC

A7015 Aerosol Mask, Used With DME Nebulizer 07/01/02 2 1.63 1.67

A7016 Dome and mouthpiece, used with small volume ultrasonic nebulizer10/01/04 1 NC

A7017 Nebulizer, durable, glass or autoclavable plastic, bottle type, not used with oxygen10/01/04 1 NC

A7018 Water, Distilled, Used w/ Large Vol Nebulizer, 1000ml 01/01/01 1 0.28

A7025 High freq chest wall oscillation syst. Vest, replacement for use w/patient-owned equip10/01/04 1 400.00

A7026 High freq chest wall oscillation syst. Hose, replacement for use w/patient-owned equip10/01/04 1 NC

A7030 Full face mask used with positive airway pressure device 10/01/04 1 NC

A7031 Face mask interface, replacement for full face mask 10/01/04 1 NC

A7032 Replacement cushion for nasal application device 10/01/04 1 21.36

A7033 Replacement pillows for nasal application device, pair 10/01/04 1 21.36

A7034 Nasal interface used w/ CPAP w/ or w/o head strap 10/01/04 1 66.71

5101:3-1-60 Page 241







A7035 Headgear used w/ Positive Airway Pressure Device 04/01/03 1 34.95

A7036 Chinstrap used w/ Positive Airway Pressure Device 04/01/03 1 13.60

A7037 Tubing used w/ Positive Airway Pressure Device 04/01/03 1 28.75

A7038 Filter, Disposable, used w/ Positive Airway Pres. Device 04/01/03 1 3.25

A7039 Filter, Non-Dispos, used w/ Positive Airway Pres. Device 04/01/03 1 12.30

A7044 Oral interface used with positive airway pressure device 10/01/04 1 NC

A7046 Water chamber for humidifier, used with positive airway pressure device, replacement10/01/04 1 NC

A7501 Tracheostoma Valve, Including Diaphragm, Ea 01/01/01 1 NC

A7502 Rplacement Diaphragm/Faceplate for Trach Valve, Ea 01/01/01 1 NC

A7503 Filter Holder/Cap, Reusable, for Trach Heat/Moist Sys 01/01/01 1 NC

A7504 Filter for Trach Heat/Moist Exchange System 10/01/04 2 0.54 NC

A7505 Housing, Reusable w/o Adhesive, for Trach H/M System 10/01/04 2 3.74 NC

A7506 Adhesive Disc for Trach Heat/Moist Exchange System 10/01/04 2 0.26 NC

A7507 Filter Holder w/o Adhesive, for Trach Heat/Moist Sys 10/01/04 2 1.99 NC

A7508 Housing/Int Adhesive, for Trach Heat/Moist System 10/01/04 2 2.30 NC

A7509 Filter Hold/Int Housing w/ Adh for Trach Heat/Moist Sys 10/01/04 2 1.13 NC

A7520 Tracheostomy/laryngectomy tube, non-cuffed, PVC, silicone or equal10/01/04 1 47.48

A7521 Tracheostomy/laryngectomy tube, cuffed, PVC, silicone or equal10/01/04 1 47.05

A7522 Tracheostomy/laryngectomy tube, stainless steel or equal (sterilizable/reusable)10/01/04 1 45.16

A7523 Tracheostomy shower protector 10/01/04 1 NC

A7524 Tracheostoma stent/stud/button 10/01/04 1 NC

A7525 Tracheostomy Mask 10/01/04 1 1.39

A7526 Tracheostomy tube collar/holder 10/01/04 1 3.00

+ A9040 Hearing Aid Incl. Ear Mold And Battery 11/01/04 3 NC 413.88

A9150 Misc/exper non-prescript dru 07/01/03 1 NC

A9270 Non-covered item or service 07/01/03 1 NC

A9300 Exercise equipment 07/01/03 1 NC

A9500 Technetium TC 99m sestamibi 07/01/03 1 NC

A9502 Technetium TC99M tetrofosmin 07/01/03 1 NC

A9503 Technetium TC 99m medronate 07/01/03 1 NC

A9504 Technetium tc 99m apcitide 07/01/03 1 NC

A9505 Thallous chloride TL 201/mci 07/01/03 1 NC

A9507 Indium/111 capromab pendetid 07/01/03 1 NC

A9508 Iobenguane sulfate I-131 07/01/03 1 NC

A9510 Technetium TC99m Disofenin 07/01/03 1 NC

A9511 Technetium TC 99m depreotide 07/01/03 1 NC

A9512 Technetiumtc99mpertechnetate 07/01/03 1 NC

A9513 Technetium tc-99m mebrofenin 07/01/03 1 NC

5101:3-1-60 Page 242







A9514 Technetiumtc99mpyrophosphate+E117 07/01/03 1 NC

A9515 Technetium tc-99m pentetate 07/01/03 1 NC

A9516 I-123 sodium iodide capsule 07/01/03 1 NC

A9517 I-131 sodium iodide capsule 07/01/03 1 NC

A9518 I-131 sodium iodide solution 07/01/03 1 NC

A9519 Technetiumtc-99mmacroag albu 07/01/03 1 NC

A9520 Technetiumtc-99m sulfur clld 07/01/03 1 NC

A9521 Technetiumtc-99m exametazine 07/01/03 1 NC

A9522 Indium111ibritumomabtiuxetan 07/01/03 1 NC

A9523 Yttrium90ibritumomabtiuxetan 07/01/03 1 NC

A9524 Iodinated I-131 serumalbumin 07/01/03 1 NC

A9600 Strontium-89 chloride, per MCL 07/01/03 3 NC BR

A9603 I-131sodiumiodidecap per mci 07/01/03 1 NC

A9605 Samarium sm 153 lexidronamm, 50 mci 07/01/03 3 NC BR

A9699 Noc therapeutic radiopharm 07/01/03 1 NC

A9700 Echocardiography Contrast 07/01/03 1 NC

A9900 Misc DME Supply/Acc/Serv of another HCPCS code 07/01/03 1 NC

A9901 DME Delivery/Set-up/Disp Serv of another HCPCS code 07/01/03 1 NC

B4034 Enterral Feedg Supply Kit;Syringe(Monthly 05/25/91 1 3.84

B4035 Enteral Feedg Supp Kit;Pump(Mnthly(Incl 05/25/91 1 7.00

B4036 Enteral Feedg Supp Kit;Gravity Fed(Month 05/25/91 1 5.00

B4081 NG Tube W/Stylet 04/01/02 2 19.78 21.25

B4082 NG Tube W/O Stylet 04/01/02 2 14.73 17.32

B4083 Stomach Tube, Levine Type 05/01/90 1 2.11

B4084 Gastrostomy/Jejunostomy Tubing 04/01/02 3 NC 16.52

B4085 Gastrostomy Tube, Silicone w/ sliding ring 04/01/02 3 NC 40.00

B4086 Gastrostomy/Jejunostomy Tube; any material, any type 12/15/02 2 32.66 40.00B4102 Enteral Formula, Adult, Electrolyte Replacement 01/01/05 1 NCB4103 Enteral Formula, Pediatric, Electrolyte Replacement 01/01/05 1 NCB4104 Additive for Enteral Formula 01/01/05 1 NCB4149 Enteral Formula, Blenderized Natural Foods 01/01/05 1 NCB4150 Enteral Formula,Intact Nutrients (100 cal = 1 un) 10/01/04 2 0.63 0.00

++ B4151 Enteral Formu ,Categ I Naturl Intct Prote(100 cal = 1 un) 01/01/05 3 NC 0.80B4152 Enteral Formula, Calorically Dense (100 cal = 1 un) 10/01/04 2 0.53 0.00B4153 Enteral Formula, Hydrolyzed Proteins (100 cal= 1 un) 10/01/04 2 1.80 0.00B4154 Enteral Formula, Special Metabolic Needs Noninherited (100 cal = 1 un) 10/01/04 2 1.15 0.00B4155 Enteral Formula, Imcomplete/Modular Nutrients (100cal=1un)10/01/04 2 0.90 0.00

++ B4156 Enteral Formula ,Categ VI Standardiz Nutrin(100 cal = 1 un)01/01/05 3 NC 1.28B4157 Enteral Formula, Special Metabolic Needs Inherited (100 cal = 1 un) 01/01/05 1 PA

5101:3-1-60 Page 243






APPR VISIT CODE DESCRIPTION DATE CODE PRICE PRICE INDIC. DAYS GROUP DATE DATE GROUP DATE DATEB4158 Enteral Formula, Pediatric, Intact Nutrients (100 cal = 1 un)01/01/05 1 PAB4159 Enteral Formula, Pediatric, Soy Based, Intact Nutrients (100 cal = 1 un)01/01/05 1 PAB4160 Enteral Formula, Pediatric, Calorically Dense (100 cal = 1 un)01/01/05 1 PAB4161 Enteral Formula, Pediatric, Hydrolyzed Proteins (100 cal = 1 un)01/01/05 1 PAB4162 Enteral Formula, Pediatric, Special Metabolic Needs, Inherited (100 cal = 1 un)01/01/05 1 PA

B4164 Parntl Nutri Soln:Carbohy 50%Dxtr Homemx 01/01/99 3 NC 0.00

B4168 Parentl Nutri Soln:Amino Acid 3.5%Homemx 01/01/99 3 NC 0.00

B4172 Parentl Nutri;Amino Acid 5.5%-7% Homemix 01/01/99 3 NC 0.00

B4176 Parentl Nutri;Amino Acid 7%-8.5% Homemix 01/01/99 3 NC 0.00

B4178 Parentl Nutri;Amino Acid,Abve 8.5%Homemx 01/01/99 3 NC 0.00

B4180 Parent Nutri;Carbo (Dextr) Above 50%Homemx 01/01/99 3 NC 0.00

B4184 Parent Nutri;Lipids,10% W/Admin. Set 01/01/99 3 NC 0.00

B4186 Parent Nutri;Lipids,20% W/Admin Set 01/01/99 3 NC 0.00

B4189 Paren Nutri Cmpnd Amino Aci&Carb W/Elect 01/01/99 3 NC 0.00

B4193 Parn Nutr Sol Cmpnd Amino Aci&Crb W/Elec 01/01/99 3 NC 0.00



B4216 Parent Nutri;Add Vit ,Trce ,Help ,Home Mx 01/01/99 3 NC 0.00

B4220 Paren Nutri Supply Kit,1 Mo Complt ,Premx 05/25/91 1 4.67

B4222 Parent Nutri Supply Kit For 1 Mo,Complet 05/25/91 1 7.17

B4224 Paren Nutri Admin Kit For 1 Mo, Complete 05/25/91 1 15.00

B4239 IV Administr Set W/Drain Tubing(Not For) 10/01/04 3 NC 4.00

B4240 IV Admn Set W/Y-Attach&Drain, Tubg(Nt For 10/01/04 3 NC 5.00

B4251 Destruclip (Not For Nutrition) 07/01/97 3 NC 5.00

B5000 Paren Nutri,Cmpnd ,Etc ,Renal,Incl Prep 01/01/99 3 NC 0.00

B5100 Paren Nutri,Cmpnd,Etc,Hepatic,Incl Prep 01/01/99 3 NC 0.00

B5200 Paren Nutri,Cmpnd Etc, Stress,Incl Prep 01/01/99 3 NC 0.00

B9000 Enteral Nutrition Infusion Pump W/O Alrm 05/01/90 1 500.00

B9002 Enteral Nutrition Infusion Pump W/Alarm 05/01/90 1 700.00

B9004 Paren Nutrition Infusion Pump-Portable 04/01/02 2 2,238.00 3,000.00

B9006 Paren Nutrition Infusion Pump-Stationary 04/01/02 2 2,238.00 3,000.00B9998 Enteral Supplies,Not Otherwise Specified 05/01/90 1 PA 0.00B9999 Parenteral Supplies,Not Otherwise Specif 05/01/90 1 PA 0.00

D0110 Initial Oral Examination 04/01/00 3 NC 26.35

D0120 Periodic Oral Examination 01/01/00 2 17.08 11.68

D0130 Emergency Dental Examination 04/01/00 3 NC 22.58

D0140 Limited oral evaluation - problem focused 01/01/00 1 22.58

D0150 Comprehensive oral evaluation 01/01/00 1 26.35

5101:3-1-60 Page 244







D0160 Extensv oral eval prob focus 01/01/04 1 NC

D0170 Re-eval,est pt,problem focus 01/01/04 1 NC

D0180 Comp periodontal evaluation 01/01/04 1 NC

D0210 Intraoral - Complete Series (Including B 01/01/00 2 60.00 45.00

D0220 Intraoral- Periapical Single, First Film 01/01/00 2 5.00 3.75

D0230 Intraoral- Periapical Each Additional Fi 01/01/00 2 5.00 3.75

D0240 Intraoral-Occlusal 01/01/00 2 12.00 8.67

D0250 Extraoral, Single First Film 01/01/00 2 13.46 10.35

D0260 Extraoral ea additional film 01/01/04 1 NC

D0270 Bitewing- Single Film 01/01/00 2 5.00 3.75

D0272 Bitewings, Two Films 01/01/00 2 10.00 7.50

D0274 Bitewings-Four Films 01/01/00 2 20.00 15.00

D0277 Vert bitewings-sev to eight 01/01/04 1 NC

D0290 Dental film skull/facial bon 01/01/04 1 NC

D0310 Dental saliography 01/01/04 1 NC

D0320 Dental tmj arthrogram incl i 01/01/04 1 NC

D0321 Temporomandibular Joint Film 04/13/89 2 51.77 51.00

D0322 Dental tomographic survey 01/01/04 1 NC

D0330 Panoramic- Maxilla And Mandible Film 01/01/00 2 46.32 30.00

D0340 Cephalometric Film 01/01/00 2 60.00 41.41

D0350 Oral/ Facial Images (Incl. Intra And Extraoral Images) 10/01/03 1 12.31

D0415 Bacteriologic study 01/01/04 1 NC

D0415 Collection microorganism culture and sensitivity 01/01/05 1 NC

D0416 Viral Culture 01/01/05 1 NC

D0421 Genetic test susceptability to oral disease 01/01/05 1 NC

D0425 Caries susceptibility test 01/01/04 1 NC

D0431 Adjunct pre-diagnostic test for mucosal abnormal 01/01/05 1 NC

D0460 Pulp vitality test 01/01/04 1 NC

D0470 Diagnostic Models 01/01/00 1 22.02

D0471 Diagnostic Photographs 04/01/04 3 NC 12.31

D0472 Gross exam, prep & report 01/01/04 1 NC

D0473 Micro exam, prep & report 01/01/04 1 NC

D0474 Micro w exam of surg margins 01/01/04 1 NC

D0475 Decalcification procedure 01/01/05 1 NC

D0476 Special stains for microorganisms 01/01/05 1 NC

D0477 Special stains not for micororganisms 01/01/05 1 NC

D0478 Immunohistochemical stains 01/01/05 1 NC

D0479 Tissue in-stiu hybridization include interpretation 01/01/05 1 NC

5101:3-1-60 Page 245







D0480 Cytopath smear prep & report 01/01/04 1 NC

D0481 Electron microscopy - diagnostic 01/01/05 1 NC

D0482 Direct immunofluorescence 01/01/05 1 NC

D0483 Indirect immunofluorescence 01/01/05 1 NC

D0484 Consult on slides prepared elsewhere 01/01/05 1 NC

D0485 Consult include prep of slides from biopsy 01/01/05 1 NC

D0502 Other oral pathology procedu 01/01/04 1 NC

D0999 Unspecified diagnostic proce 01/01/04 1 NC

D1110 Prophylaxis, Adults 01/01/00 2 34.13 21.29

D1120 Prophylaxis, Children 01/01/00 2 20.00 15.59

D1201 Topical fluor w prophy child 01/01/04 1 NC

D1203 Top Appl-Fluoride (Excl Prophy)-Child 01/01/00 2 15.00 10.35

D1204 Topical fluor w/o prophy adu 01/01/04 1 NC

D1205 Topical fluoride w/ prophy a 01/01/04 1 NC

D1310 Nutri counsel-control caries 01/01/04 1 NC

D1320 Tobacco counseling 01/01/04 1 NC

D1330 Oral hygiene instruction 01/01/04 1 NC

D1351 Sealant Per Tooth 01/01/00 2 22.00 18.00

D1510 Space Maintainers, Fixed Unilateral 01/01/00 2 113.71 78.10

D1515 Space Maintainers, Fixed Bilateral 01/01/00 2 163.28 119.66

D1520 Space Maintainers, Removable Unilateral 01/01/00 2 125.08 85.91

D1525 Space Maintainer, Removable Bilateral 01/01/00 2 133.79 98.05

D1550 Recement space maintainer 01/01/04 1 NC

D2110 Amalgam-One Surface, Primary 10/01/03 3 NC 40.00

D2120 Amalgam-Two Surfaces, Primary 10/01/03 3 NC 54.00

D2130 Amalgam-Three Surfaces, Primary 10/01/03 3 NC 65.00

D2140 Amalgam- One Surface, Primary or Permanent 10/01/03 1 40.00 27.20

D2150 Amlgam- Two Surfaces, Primary or Permanent 10/01/03 1 54.00 33.90

D2160 Amalgam- Three Surfaces, Primary or Permanent 10/01/03 1 65.00 55.00

D2161 Amalgam, four or more surfaces, prim or perm tooth 01/01/00 1 76.54

D2330 Composite Resin- One Surface, anterior 10/01/03 3 51.21 33.18

D2331 Resin Restoration, Two Surface, anterior 01/01/00 2 63.49 38.76

D2332 Resin Restoration, Three Surfaces, anterior 01/01/00 2 76.62 42.34

D2335 Comp Resin 4 Or More Surf,Incis Angle (anterior) 01/01/00 2 94.95 63.33

D2390 Ant resin-based cmpst crown 01/01/04 1 NC

D2391 Resin Restoration - One Surface Posterior 10/01/03 1 51.21

D2392 Resin Restoration - Two Surfaces Posterior 01/01/04 1 54.00

D2393 Resin Restoration - Three Surfaces posterior 01/01/04 1 65.00

5101:3-1-60 Page 246







D2394 Resin restoration - Four or more Surface Posterior 01/01/04 1 76.54

D2410 Dental gold foil one surface 01/01/04 1 NC

D2420 Dental gold foil two surface 01/01/04 1 NC

D2430 Dental gold foil three surfa 01/01/04 1 NC

D2510 Dental inlay metalic 1 surf 01/01/04 1 NC

D2520 Dental inlay metallic 2 surf 01/01/04 1 NC

D2530 Dental inlay metl 3/more sur 01/01/04 1 NC

D2542 Dental onlay metallic 2 surf 01/01/04 1 NC

D2543 Dental onlay metallic 3 surf 01/01/04 1 NC

D2544 Dental onlay metl 4/more sur 01/01/04 1 NC

D2610 Inlay porcelain/ceramic 1 su 01/01/04 1 NC

D2620 Inlay porcelain/ceramic 2 su 01/01/04 1 NC

D2630 Dental onlay porc 3/more sur 01/01/04 1 NC

D2642 Dental onlay porcelin 2 surf 01/01/04 1 NC

D2643 Dental onlay porcelin 3 surf 01/01/04 1 NC

D2644 Dental onlay porc 4/more sur 01/01/04 1 NC

D2650 Inlay composite/resin one su 01/01/04 1 NC

D2651 Inlay composite/resin two su 01/01/04 1 NC

D2652 Dental inlay resin 3/mre sur 01/01/04 1 NC

D2662 Dental onlay resin 2 surface 01/01/04 1 NC

D2663 Dental onlay resin 3 surface 01/01/04 1 NC

D2664 Dental onlay resin 4/mre sur 01/01/04 1 NC

D2710 Crown resin laboratory 01/01/04 1 NC

D2712 Crown 3/4 resin indirect not includ facial veneers 01/01/05 1 NC

D2720 Crown resin w/ high noble me 01/01/04 1 NC

D2721 Crown resin w/ base metal 01/01/04 1 NC

D2722 Plastic With Semi Precious Metal 12/31/95 3 NC 165.65

D2740 Crown porcelain/ceramic subs 01/01/04 1 NC

D2750 Crown porcelain w/ h noble m 01/01/04 1 NC

D2751 Crown porcelain fused base m 01/01/04 1 NC

D2752 Porcelain With Semiprecious Metal 01/01/00 2 427.29 234.00

D2780 Crown 3/4 cast hi noble met 01/01/04 1 NC

D2781 Crown 3/4 cast base metal 01/01/04 1 NC

D2782 Crown 3/4 cast noble metal 01/01/04 1 NC

D2783 Crown 3/4 porcelain/ceramic 01/01/04 1 NC

D2790 Crown full cast high noble m 01/01/04 1 NC

D2791 Crown full cast base metal 01/01/04 1 NC

D2792 Crown full cast noble metal 01/01/04 1 NC

5101:3-1-60 Page 247







D2794 Crown titanium 01/01/05 1 NC

D2799 Provisional crown 01/01/04 1 NC

D2910 Dental recement inlay 01/01/04 1 NC

D2915 Recement cast or prefabricated post and core 01/01/05 1 NC

D2920 Dental recement crown 01/01/04 1 NC

D2930 Prefab Stainless Steel Crown-Prim. Tooth 01/01/00 2 101.92 63.33

D2931 Prefab Stainless Steel Crown-Perm. Tooth 01/01/00 2 116.51 63.33

D2932 Prefabricated resin crown 01/01/04 1 NC

D2933 Open Face Stainless Steel Crown 01/01/00 2 153.00 92.14

D2934 Prefab esthetic coated stls steel crown primary 01/01/05 1 NC

D2940 Dental sedative filling 01/01/04 1 NC

D2950 Core build-up incl any pins 01/01/04 1 NC

D2951 Pin Retention-Per Tooth In Add To Rest 01/01/00 2 16.49 8.99

D2952 Cast Post And Core Addition To Crown 01/01/00 2 136.32 69.00

D2953 Each addtnl cast post 01/01/04 1 NC

D2954 Prefab post/core + crown 01/01/04 1 NC

D2955 Post removal 01/01/04 1 NC

D2957 Each addtnl prefab post 01/01/04 1 NC

D2960 Laminate labial veneer 01/01/04 1 NC

D2961 Lab labial veneer resin 01/01/04 1 NC

D2962 Lab labial veneer porcelain 01/01/04 1 NC

D2970 Temporary- fractured tooth 01/01/04 1 NC

D2971 Add proced construct crown under partial dentur 01/01/05 1 NC

D2975 Coping 01/01/05 1 NC

D2980 Crown repair 01/01/04 1 NC

D2999 Dental unspec restorative pr 01/01/04 1 NC

D3110 Pulp cap direct 01/01/04 1 NC

D3120 Pulp cap indirect 01/01/04 1 NC

D3220 Vital Pulpotomy (Excludes Final Restorat 01/01/00 2 63.74 35.70

D3221 Gross pulpal debridement 01/01/04 1 NC

D3230 Pulpal therapy anterior prim 01/01/04 1 NC

D3240 Pulpal therapy posterior pri 01/01/04 1 NC

D3310 Root Canal Therapy, Anterior Tooth 01/01/00 2 247.63 124.00

D3320 Root Canal Therapy, Bicuspids 01/01/00 2 298.10 150.00

D3330 Root Canal Therapy, Molar 01/01/00 2 379.02 202.00

D3331 Non-surg tx root canal obs 01/01/04 1 NC

D3332 Incomplete endodontic tx 01/01/04 1 NC

D3333 Internal root repair 01/01/04 1 NC

5101:3-1-60 Page 248







D3346 Retreat root canal anterior 01/01/04 1 NC

D3347 Retreat root canal bicuspid 01/01/04 1 NC

D3348 Retreat root canal molar 01/01/04 1 NC

D3351 Apexification Initial visit 01/01/00 2 60.00 70.00

D3352 Apexification interim medication replacement 01/01/00 1 40.00

D3353 Apexification, final visit 01/01/00 1 40.00

D3410 Apicoectomy, Performed As A Surgical Ser 01/01/00 2 178.00 89.00

D3421 Root surgery bicuspid 01/01/04 1 NC

D3425 Root surgery molar 01/01/04 1 NC

D3426 Root surgery ea add root 01/01/04 1 NC

D3430 Retrograde filling 01/01/04 1 NC

D3450 Root amputation 01/01/04 1 NC

D3460 Endodontic endosseous implan 01/01/04 1 NC

D3470 Intentional replantation 01/01/04 1 NC

D3910 Isolation- tooth w rubb dam 01/01/04 1 NC

D3920 Tooth splitting 01/01/04 1 NC

D3950 Canal prep/fitting of dowel 01/01/04 1 NC

D3999 Endodontic procedure 01/01/04 1 NC

D4210 Gingivectomy Or Gingivoplasty - Per Quad 01/01/00 2 197.20 118.00

D4211 Gingivectomy/plasty per toot 01/01/04 1 NC

D4240 Gingival flap proc w/ planin 01/01/04 1 NC

D4241 Gngvl flap w rootplan 1-3 th 01/01/04 1 NC

D4245 Apically positioned flap 01/01/04 1 NC

D4249 Crown lengthen hard tissue 01/01/04 1 NC

D4260 Osseous surgery per quadrant 01/01/04 1 NC

D4261 Osseous surgl-3teethperquad 01/01/04 1 NC

D4263 Bone replce graft first site 01/01/04 1 NC

D4264 Bone replce graft each add 01/01/04 1 NC

D4265 Bio mtrls to aid soft/os reg 01/01/04 1 NC

D4266 Guided tiss regen resorble 01/01/04 1 NC

D4267 Guided tiss regen nonresorb 01/01/04 1 NC

D4268 Surgical revision procedure 01/01/04 1 NC

D4270 Pedicle soft tissue graft pr 01/01/04 1 NC

D4271 Free soft tissue graft proc 01/01/04 1 NC

D4273 Subepithelial tissue graft 01/01/04 1 NC

D4274 Distal/proximal wedge proc 01/01/04 1 NC

D4275 Soft tissue allograft 01/01/04 1 NC

D4276 Con tissue w dble ped graft 01/01/04 1 NC

5101:3-1-60 Page 249







D4320 Provision splnt intracoronal 01/01/04 1 NC

D4321 Provisional splint extracoro 01/01/04 1 NC

D4341 Periodontal scaling & root 01/01/04 1 NC

D4342 Periodontal scaling 1-3teeth 01/01/04 1 NC

D4355 Full mouth debridement 01/01/04 1 NC

D4381 Localized chemo delivery 01/01/04 1 NC

D4910 Periodontal maint procedures 01/01/04 1 NC

D4920 Unscheduled dressing change 01/01/04 1 NC

D4999 Unspecified periodontal proc 01/01/04 1 NC

D5110 Complete Denture - maxillary 01/01/00 2 400.00 243.00

D5120 Complete Denture - mandibular 01/01/00 2 400.00 243.00

D5130 Dentures immediat maxillary 04/01/04 1 NC

D5140 Dentures immediat mandible 01/01/04 1 NC

D5211 Base Maxillary partial denture 01/01/00 2 205.00 98.35

D5212 Mandibular partial denture 01/01/00 2 205.00 98.35

D5213 Up .Partial ,Cast Metal Base Acrylic Sad 2 Clasp 01/01/00 2 540.25 295.00

D5214 Low .Partial ,Cast Metal Base Acryl. Sad 2 Clasp 01/01/00 2 540.03 295.00

D5225 Maxillary partial denture flexible base 01/01/05 1 NC

D5226 Mandibular partial denture flexible base 01/01/05 1 NC

D5281 Removable partial denture 01/01/04 1 NC

D5310 Each Additional Clasp With Rest 04/01/04 3 NC 40.00

D5410 Dentures adjust cmplt maxil 01/01/04 1 NC

D5411 Dentures adjust cmplt mand 01/01/04 1 NC

D5421 Dentures adjust part maxill 01/01/04 1 NC

D5422 Dentures adjust part mandbl 01/01/04 1 NC

D5510 Repair Broken Complete Denture Base 01/01/00 2 50.00 37.42

D5520 Replace Miss/Brkn Tooth, Comp Dt .Ea Tooth 01/01/00 2 40.00 23.73

D5610 Repair Acrylic Saddle Or Base ,Part . Dent 01/01/00 2 50.00 33.86

D5620 Repair Cast Framework On Part . Denture 01/01/00 2 78.00 46.07

D5630 Repair Or Replace Broken Clasp 01/01/00 2 74.00 43.16

D5640 Replace Brkn Tooth On Prt .Dent .Per Tooth 01/01/00 2 40.00 23.73

D5650 Add Tooth To Existing Part .Denture 01/01/00 2 40.00 33.76

D5660 Add Clasp To Existing Partial Denture 01/01/00 2 74.00 46.05

D5670 Replc tth&acrlc on mtl frmwk 01/01/04 1 NC

D5671 Replc tth&acrlc mandibular 01/01/04 1 NC

D5710 Dentures rebase cmplt maxil 01/01/04 1 NC

D5711 Dentures rebase cmplt mand 01/01/04 1 NC

D5720 Dentures rebase part maxill 01/01/04 1 NC

5101:3-1-60 Page 250







D5721 Dentures rebase part mandbl 01/01/04 1 NC

D5730 Denture reln cmplt maxil ch 01/01/04 1 NC

D5731 Denture reln cmplt mand chr 01/01/04 1 NC

D5740 Denture reln part maxil chr 01/01/04 1 NC

D5741 Denture reln part mand chr 01/01/04 1 NC

D5750 Relining Complete Maxillary Denture (Lab) 01/01/00 2 175.51 98.00

D5751 Relining Complete Mandibular Denture (Lab) 01/01/00 2 175.80 98.00

D5760 Relining Partial Maxillary Denture 01/01/00 2 140.00 76.00

D5761 Relining Partial Mandibular Denture 01/01/00 2 140.00 76.00

D5810 Denture interm cmplt maxill 01/01/04 1 NC

D5811 Denture interm cmplt mandbl 01/01/04 1 NC

D5820 Denture interm part maxill 01/01/04 1 NC

D5821 Denture interm part mandbl 01/01/04 1 NC

D5850 Denture tiss conditn maxill 01/01/04 1 NC

D5851 Denture tiss condtin mandbl 01/01/04 1 NC

D5860 Overdenture complete 01/01/04 1 NC

D5861 Overdenture partial 01/01/04 1 NC

D5862 Precision attachment 01/01/04 1 NC

D5867 Replacement of precision att 01/01/04 1 NC

D5875 Prosthesis modification 01/01/04 1 NC

D5899 Unspecified Removeable Prosthodontic Procedure 10/01/03 1 40.00

D5911 Facial moulage sectional 01/01/04 1 NC

D5912 Facial moulage complete 01/01/04 1 NC

D5913 Nasal Prosthesis 05/09/86 1 PA

D5914 Auricular prosthesis 01/01/04 1 NC

D5915 Orbital Prosthesis 05/09/86 1 PA

D5916 Ocular Prosthesis 05/09/86 1 PA

D5919 Facial prosthesis 01/01/04 1 NC

D5922 Nasal septal prosthesis 01/01/04 1 NC

D5923 Ocular prosthesis interim 01/01/04 1 NC

D5924 Cranial prosthesis 01/01/04 1 NC

D5925 Facial augmentation implant 01/01/04 1 NC

D5926 Replacement nasal prosthesis 01/01/04 1 NC

D5927 Auricular replacement 01/01/04 1 NC

D5928 Orbital replacement 01/01/04 1 NC

D5929 Facial replacement 01/01/04 1 NC

D5931 Surgical Obturator 05/09/86 1 PA

D5932 Postsurgical Obturator 05/09/86 1 PA

5101:3-1-60 Page 251







D5933 Refitting of obturator 01/01/04 1 NC

D5934 Mandibular Resection(Flange) .Prosthesis 05/09/86 1 PA

D5935 Mandibular Resection (Denture) Prosthesis 05/09/86 1 PA

D5936 Temp obturator prosthesis 01/01/04 1 NC

D5937 Trismus appliance 01/01/04 1 NC

D5951 Feeding aid 01/01/04 1 NC

D5952 Pediatric speech aid 01/01/04 1 NC

D5953 Adult speech aid 01/01/04 1 NC

D5954 Superimposed prosthesis 01/01/04 1 NC

D5955 Palatal Lift Prosthesis 05/09/86 1 PA

D5956 Obturator 05/09/86 1 PA

D5957 Speech Bulb 05/09/86 1 PA

D5958 Intraoral con def inter plt 01/01/04 1 NC

D5959 Intraoral con def mod palat 01/01/04 1 NC

D5960 Modify speech aid prosthesis 01/01/04 1 NC

D5982 Surgical stent 01/01/04 1 NC

D5983 Radiation applicator 01/01/04 1 NC

D5984 Radiation shield 01/01/04 1 NC

D5985 Radiation cone locator 01/01/04 1 NC

D5986 Fluoride applicator 01/01/04 1 NC

D5987 Commissure splint 01/01/04 1 NC

D5988 Surgical splint 01/01/04 1 NC

D5999 Unspecified Maxillofacial Prosthesis 10/01/03 1 PA

D6010 Odontics endosteal implant 01/01/04 1 NC

D6020 Odontics abutment placement 01/01/04 1 NC

D6040 Odontics eposteal implant 01/01/04 1 NC

D6050 Odontics transosteal implnt 01/01/04 1 NC

D6053 Implnt/abtmnt spprt remv dnt 01/01/04 1 NC

D6054 Implnt/abtmnt spprt remvprtl 01/01/04 1 NC

D6055 Implant connecting bar 01/01/04 1 NC

D6056 Prefabricated abutment 01/01/04 1 NC

D6057 Custom abutment 01/01/04 1 NC

D6058 Abutment supported crown 01/01/04 1 NC

D6059 Abutment supported mtl crown 01/01/04 1 NC





5101:3-1-60 Page 252








D6065 Implant supported crown 01/01/04 1 NC

D6066 Implant supported mtl crown 01/01/04 1 NC

D6067 Implant supported mtl crown 01/01/04 1 NC

D6068 Abutment supported retainer 01/01/04 1 NC







D6075 Implant supported retainer 01/01/04 1 NC



D6078 Implnt/abut suprtd fixd dent 01/01/04 1 NC

D6079 Implnt/abut suprtd fixd dent 01/01/04 1 NC

D6080 Implant maintenance 01/01/04 1 NC

D6090 Repair implant 01/01/04 1 NC

D6094 Abutment supported crown titanium 01/01/05 1 NC

D6095 Odontics repr abutment 01/01/04 1 NC

D6100 Removal of implant 01/01/04 1 NC

D6190 Radiographic/surgical implant index by report 01/01/05 1 NC

D6194 Abutment supprt retainer crown for FPD titanium 01/01/05 1 NC

D6199 Implant procedure 01/01/04 1 NC

D6205 Pontic crown indirect resin based composite 01/01/05 1 NC

D6210 Prosthodont high noble metal 01/01/04 1 NC

D6211 Bridge base metal cast 01/01/04 1 NC

D6212 Bridge noble metal cast 01/01/04 1 NC

D6214 Pontic crown titanium 01/01/05 1 NC

D6240 Bridge porcelain high noble 01/01/04 1 NC

D6241 Bridge porcelain base metal 01/01/04 1 NC

D6242 Bridge porcelain nobel metal 01/01/04 1 NC

D6245 Bridge porcelain/ceramic 01/01/04 1 NC

D6250 Bridge resin w/high noble 01/01/04 1 NC

D6251 Bridge resin base metal 01/01/04 1 NC

D6252 Bridge resin w/noble metal 01/01/04 1 NC

D6253 Provisional pontic 01/01/04 1 NC

D6545 Dental retainr cast metl 01/01/04 1 NC

5101:3-1-60 Page 253







D6548 Porcelain/ceramic retainer 01/01/04 1 NC

D6600 Porcelain/ceramic inlay 2srf 01/01/04 1 NC

D6601 Porc/ceram inlay >= 3 surfac 01/01/04 1 NC

D6602 Cst hgh nble mtl inlay 2 srf 01/01/04 1 NC

D6603 Cst hgh nble mtl inlay >=3sr 01/01/04 1 NC

D6604 Cst bse mtl inlay 2 surfaces 01/01/04 1 NC

D6605 Cst bse mtl inlay >= 3 surfa 01/01/04 1 NC

D6606 Cast noble metal inlay 2 sur 01/01/04 1 NC

D6607 Cst noble mtl inlay >=3 surf 01/01/04 1 NC

D6608 Onlay porc/crmc 2 surfaces 01/01/04 1 NC

D6609 Onlay porc/crmc >=3 surfaces 01/01/04 1 NC

D6610 Onlay cst hgh nbl mtl 2 srfc 01/01/04 1 NC

D6611 Onlay cst hgh nbl mtl >=3srf 01/01/04 1 NC

D6612 Onlay cst base mtl 2 surface 01/01/04 1 NC

D6613 Onlay cst base mtl >=3 surfa 01/01/04 1 NC

D6614 Onlay cst nbl mtl 2 surfaces 01/01/04 1 NC

D6615 Onlay cst nbl mtl >=3 surfac 01/01/04 1 NC

D6624 Inlay titanium 01/01/05 1 NC

D6634 Onlay titanium 01/01/05 1 NC

D6710 Crown indirect resin based composite 01/01/05 1 NC

D6720 Retain crown resin w hi nble 01/01/04 1 NC

D6721 Crown resin w/base metal 01/01/04 1 NC

D6722 Crown resin w/noble metal 01/01/04 1 NC

D6740 Crown porcelain/ceramic 01/01/04 1 NC

D6750 Crown porcelain high noble 01/01/04 1 NC

D6751 Crown porcelain base metal 01/01/04 1 NC

D6752 Crown porcelain noble metal 01/01/04 1 NC

D6780 Crown 3/4 high noble metal 01/01/04 1 NC

D6781 Crown 3/4 cast based metal 01/01/04 1 NC

D6782 Crown 3/4 cast noble metal 01/01/04 1 NC

D6783 Crown 3/4 porcelain/ceramic 01/01/04 1 NC

D6790 Crown full high noble metal 01/01/04 1 NC

D6791 Crown full base metal cast 01/01/04 1 NC

D6792 Crown full noble metal cast 01/01/04 1 NC

D6793 Provisional retainer crown 01/01/04 1 NC

D6794 Crown titanium 01/01/05 1 NC

D6795 Coping metal 01/01/05 1 NC

D6920 Dental connector bar 01/01/04 1 NC

5101:3-1-60 Page 254







D6930 Dental recement bridge 01/01/04 1 NC

D6940 Stress breaker 01/01/04 1 NC

D6950 Precision attachment 01/01/04 1 NC

D6970 Post & core plus retainer 01/01/04 1 NC

D6971 Cast post bridge retainer 01/01/04 1 NC

D6972 Prefab post & core plus reta 01/01/04 1 NC

D6973 Core build up for retainer 01/01/04 1 NC

D6975 Coping metal 01/01/04 1 NC

D6976 Each addtnl cast post 01/01/04 1 NC

D6977 Each addtl prefab post 01/01/04 1 NC

D6980 Bridge repair 01/01/04 1 NC

D6985 Pediatric partial denture fx 01/01/04 1 NC

D6999 Fixed prosthodontic proc 01/01/04 1 NC

D7110 Extraction Single Tooth 10/01/03 3 NC 52.45

D7111 Coronal remnants deciduous t 01/01/04 1 NC

D7120 Extraction, Each Additional Tooth 10/01/03 3 NC 48.34

D7130 Root Recovery 10/01/03 3 NC 60.00

D7140 Extraction, Erupted Tooth Or Exposed Root 10/01/03 1 52.45

D7210 Rem imp tooth w mucoper flp 01/01/04 1 NC

D7220 Soft Tissue Impaction Remov 01/01/00 2 102.00 51.00

D7230 Part Bony Impact W/Remov Bone,Tooth Sect 01/01/00 2 151.46 86.00

D7240 Comp Bony Impact W/Remov Sect,Bone,Tooth 01/01/00 2 188.80 115.00

D7241 Complete Bony Impact With Compli. 01/01/00 2 200.00 135.00

D7250 Root Recovery, Complications 05/09/86 1 PA

D7260 Oral antral fistula closure 01/01/04 1 NC

D7261 Primary closure sinus perf 01/01/04 1 NC

D7270 Tooth Replantation And/Or Stabilization 05/09/86 1 BR

D7272 Tooth transplantation 01/01/04 1 NC

D7280 Surgical Exposure Of Impacted Or Unerupt 01/01/00 2 152.30 83.00

D7281 Exposure tooth aid eruption 01/01/04 1 NC

D7282 Mobilize erupted/malpos toot 01/01/04 1 NC

D7283 Placement of device facil erupt of impacted tooth 01/01/05 1 NC

D7285 Biopsy Oral Tissue - hard (bone,tooth) 01/01/00 2 150.00 75.00

D7286 Biopsy of oral tissue - soft (all others) 01/01/00 2 130.00 64.82

D7287 Cytology sample collection 01/01/04 1 NC

D7288 Brush biopsy transepithelial sample collection 01/01/05 1 NC

D7290 Repositioning of teeth 01/01/04 1 NC

D7291 Transseptal fiberotomy 01/01/04 1 NC

5101:3-1-60 Page 255







D7310 Alveol .In Conjunct .W. Extract .Per Quad. 01/01/00 2 99.06 50.30

D7311 Alveoplasty w/extract 1-3 teeth/space - quad 01/01/05 1 NC

D7320 Alveolectomy Edentulous Quadrants 01/01/00 2 120.64 60.32

D7321 Alveoplasty w/o extract 1-3 teeth/space - quad 01/01/05 1 NC

D7340 Vestibuloplasty ridge extens 01/01/04 1 NC

D7350 Vestibuloplasty exten graft 01/01/04 1 NC

D7410 Rad exc lesion up to 1.25 cm 01/01/04 1 NC

D7411 Excision benign lesion>1.25c 01/01/04 1 NC

D7412 Excision benign lesion compl 01/01/04 1 NC

D7413 Excision malig lesion<=1.25c 01/01/04 1 NC

D7414 Excision malig lesion>1.25cm 01/01/04 1 NC

D7415 Excision malig les complicat 01/01/04 1 NC

D7440 Malig tumor exc to 1.25 cm 01/01/04 1 NC

D7441 Malig tumor > 1.25 cm 01/01/04 1 NC

D7450 Odontogenic Cyst Or Tumor, Up To 1.25 Cm 07/01/71 1 BR

D7451 Odontogenic Cyst Or Tumor, Over 1.25 Cm 07/01/71 1 BR

D7460 Nonodontogenic Cyst Or Tumor, Up To 1.25 07/01/71 1 BR

D7461 Nonodontogenic Cyst Or Tumor Over 1.25 C 07/01/71 1 BR

D7465 Lesion destruction 01/01/04 1 NC

D7470 Removal Of Exostosis - Mandible Or Maxil 04/01/04 3 NC 0.00

D7471 Removal Of Exostosis - Mandible Or Maxil 10/01/03 1 PA

D7472 Removal of torus palatinus 01/01/04 1 NC

D7473 Remove torus mandibularis 01/01/04 1 NC

D7485 Surg reduct osseoustuberosit 01/01/04 1 NC

D7490 Mandible resection 01/01/04 1 NC

D7510 Incision And Drainage Of Abscess Intraor 05/09/86 1 BR

D7511 Incision/drain intraoral soft tissue complicated 01/01/05 1 NC

D7520 Incision And Drainage Of Abscess Extraor 05/09/86 1 BR

D7521 Incision/drain extraoral soft tissue complicated 01/01/05 1 NC

D7530 Removal fb skin/areolar tiss 01/01/04 1 NC

D7540 Removal of fb reaction 01/01/04 1 NC

D7550 Removal of sloughed off bone 01/01/04 1 NC

D7560 Maxillary sinusotomy 01/01/04 1 NC

D7610 Maxilla open reduct simple 01/01/04 1 NC

D7620 Clsd reduct simpl maxilla fx 01/01/04 1 NC

D7630 Open red simpl mandible fx 01/01/04 1 NC

D7640 Clsd red simpl mandible fx 01/01/04 1 NC

D7650 Open red simp malar/zygom fx 01/01/04 1 NC

5101:3-1-60 Page 256







D7660 Clsd red simp malar/zygom fx 01/01/04 1 NC

D7670 Alveol-Stabil Teeth Open Reduc Splint Si 01/01/04 3 NC 0.00

D7671 Alveol-Open Reduction, May Incl. Stabilization Of Teeth 10/01/03 1 BR

D7680 Reduct simple facial bone fx 01/01/04 1 NC

D7710 Maxilla open reduct compound 01/01/04 1 NC

D7720 Clsd reduct compd maxilla fx 01/01/04 1 NC

D7730 Open reduct compd mandble fx 01/01/04 1 NC

D7740 Clsd reduct compd mandble fx 01/01/04 1 NC

D7750 Open red comp malar/zygma fx 01/01/04 1 NC

D7760 Clsd red comp malar/zygma fx 01/01/04 1 NC

D7770 Open reduc compd alveolus fx 01/01/04 1 NC

D7771 Alveolus clsd reduc stblz te 01/01/04 1 NC

D7780 Reduct compnd facial bone fx 01/01/04 1 NC

D7810 Tmj open reduct-dislocation 01/01/04 1 NC

D7820 Closed tmp manipulation 01/01/04 1 NC

D7830 Tmj manipulation under anest 01/01/04 1 NC

D7840 Removal of tmj condyle 01/01/04 1 NC

D7850 Tmj meniscectomy 01/01/04 1 NC

D7852 Tmj repair of joint disc 01/01/04 1 NC

D7854 Tmj excisn of joint membrane 01/01/04 1 NC

D7856 Tmj cutting of a muscle 01/01/04 1 NC

D7858 Tmj reconstruction 01/01/04 1 NC

D7860 Tmj cutting into joint 01/01/04 1 NC

D7865 Tmj reshaping components 01/01/04 1 NC

D7870 Tmj aspiration joint fluid 01/01/04 1 NC

D7871 Lysis + lavage w catheters 01/01/04 1 NC

D7872 Tmj diagnostic arthroscopy 01/01/04 1 NC

D7873 Tmj arthroscopy lysis adhesn 01/01/04 1 NC

D7874 Tmj arthroscopy disc reposit 01/01/04 1 NC

D7875 Tmj arthroscopy synovectomy 01/01/04 1 NC

D7876 Tmj arthroscopy discectomy 01/01/04 1 NC

D7877 Tmj arthroscopy debridement 01/01/04 1 NC

D7880 Occlusal orthotic appliance 01/01/04 1 NC

D7899 Unspecified TMD Therapy 10/01/03 1 482.50

D7910 Dent sutur recent wnd to 5cm 01/01/04 1 NC

D7911 Dental suture wound to 5 cm 01/01/04 1 NC

D7912 Suture complicate wnd > 5 cm 01/01/04 1 NC

D7920 Dental skin graft 01/01/04 1 NC

5101:3-1-60 Page 257







D7940 Reshaping bone orthognathic 01/01/04 1 NC

D7941 Bone cutting ramus closed 01/01/04 1 NC

D7943 Cutting ramus open w/graft 01/01/04 1 NC

D7944 Bone cutting segmented 01/01/04 1 NC

D7945 Bone cutting body mandible 01/01/04 1 NC

D7946 Reconstruction maxilla total 01/01/04 1 NC

D7947 Reconstruct maxilla segment 01/01/04 1 NC

D7948 Reconstruct midface no graft 01/01/04 1 NC

D7949 Reconstruct midface w/graft 01/01/04 1 NC

D7950 Mandible graft 01/01/04 1 NC

D7953 Bone replcment graft ridge preservation per site 01/01/05 1 NC

D7955 Repair maxillofacial defects 01/01/04 1 NC

D7960 Frenulectomy, Separate Procedure (Frenec 01/01/00 2 119.13 71.00

D7963 Frenuloplasty 01/01/05 1 NC

D7970 Excision Of Hyperplastic Tissue, Per Arc 04/13/89 1 PA

D7971 Excision pericoronal gingiva 01/01/04 1 NC

D7972 Surg redct fibrous tuberosit 01/01/04 1 NC

D7980 Sialolithotomy 01/01/04 1 NC

D7981 Excision of salivary gland 01/01/04 1 NC

D7982 Sialodochoplasty 01/01/04 1 NC

D7983 Closure of salivary fistula 01/01/04 1 NC

D7990 Emergency tracheotomy 01/01/04 1 NC

D7991 Dental coronoidectomy 01/01/04 1 NC

D7995 Synthetic graft facial bones 01/01/04 1 NC

D7996 Implant mandible for augment 01/01/04 1 NC

D7997 Appliance removal 01/01/04 1 NC

D7999 Oral surgery procedure 01/01/04 1 NC

D8010 Limited dental tx primary 01/01/04 1 NC

D8020 Limited dental tx transition 01/01/04 1 NC

D8030 Limited dental tx adolescent 01/01/04 1 NC

D8040 Limited dental tx adult 01/01/04 1 NC

D8050 Intercep dental tx primary 01/01/04 1 NC

D8060 Intercep dental tx transitn 01/01/04 1 NC

D8070 Compre dental tx transition 01/01/04 1 NC

D8080 Comp. Orthodontic Treatment Of Adolescent Dentition 10/01/03 1 624.00

D8090 Compre dental tx adult 01/01/04 1 NC

D8110 Removable Appliance Therapy 04/01/04 1 NC 205.00

D8120 Fixed Or Cemented Appliance Therapy 04/01/04 3 NC 300.00

5101:3-1-60 Page 258







D8210 Removable Appliance Therapy (Control Harmful Habits) 10/01/03 2 205.00 140.00

D8220 Fixed Appliance Therapy (Control Harmful Habits) 10/01/03 2 300.00 161.00

D8660 Preorthodontic tx visit 01/01/04 1 NC

D8670 Comp. Orthodontic Treatment Visit (As Part Of Contract) 10/01/03 1 261.94

D8680 Ortho. Reten (Rem. of Appli.,Construct,Place. Retainer) 10/01/03 1 205.00

D8690 Orthodontic treatment 01/01/04 1 NC

D8691 Repair ortho appliance 01/01/04 1 NC

D8692 Replacement retainer 01/01/04 1 NC

D8750 Post Treat . Stabilization 04/01/04 3 NC 205.00

D8999 Orthodontic Treat Sub. Qts. 04/01/04 3 NC 261.94

D9110 Tx dental pain minor proc 01/01/04 1 NC

D9210 Dent anesthesia w/o surgery 01/01/04 1 NC

D9211 Regional block anesthesia 01/01/04 1 NC

D9212 Trigeminal block anesthesia 01/01/04 1 NC

D9215 Local anesthesia 01/01/04 1 NC

D9220 General Anesthesia 01/01/00 2 95.65 83.10

D9221 General anesthesia ea ad 15m 01/01/04 1 NC

D9230 Analgesia 01/01/04 1 NC

D9241 Intravenous sedation 01/01/04 1 NC

D9242 IV sedation ea ad 30 m 01/01/04 1 NC

D9248 Sedation (non-iv) 01/01/04 1 NC

D9310 Dental consultation 01/01/04 1 NC

D9410 Dental house call 01/01/04 1 NC

D9420 Hospital call 01/01/04 1 NC

D9430 Office visit during hours 01/01/04 1 NC

D9440 Office visit after hours 01/01/04 1 NC

D9450 Case presentation tx plan 01/01/04 1 NC

D9610 Therapeutic Drug Injection (By Report) 05/09/86 1 BR

D9630 Other drugs/medicaments 01/01/04 1 NC

D9910 Dent appl desensitizing med 01/01/04 1 NC

D9911 Appl desensitizing resin 01/01/04 1 NC

D9920 Behavior management 01/01/04 1 NC

D9930 Treatment of complications 01/01/04 1 NC

D9940 Dental occlusal guard 01/01/04 1 NC

D9941 Fabrication athletic guard 01/01/04 1 NC

D9942 Repair and/or reline of occlusal guard 01/01/05 1 NC

D9950 Occlusion analysis 01/01/04 1 NC

D9951 Limited occlusal adjustment 01/01/04 1 NC

5101:3-1-60 Page 259







D9952 Complete occlusal adjustment 01/01/04 1 NC

D9970 Enamel microabrasion 01/01/04 1 NC

D9971 Odontoplasty 1-2 teeth 01/01/04 1 NC

D9972 Extrnl bleaching per arch 01/01/04 1 NC

D9973 Extrnl bleaching per tooth 01/01/04 1 NC

D9974 Intrnl bleaching per tooth 01/01/04 1 NC

D9998 TMJ Therapy 04/01/04 3 NC 482.50

D9999 Misc. Service, Complications 04/13/89 1 PA

E0100 Canes ,All Mater ,Adj. Pr Fixed W/Tip 05/01/90 1 10.19

E0105 Canes ,Quad Or Tri Pronged ,All ,W/Tips 05/01/90 1 27.50

E0110 Crutches, Forearm,All,Incl Tips&Hndgrips 01/01/92 1 50.00

E0111 Crutch,Forearm,All,Incl Tip And Handgrip 01/01/92 1 25.00

E0112 Crutch,Undrarm,Wood,All,W/Pads,Tips&Grip 05/01/90 1 19.25

E0113 Crutch ,Underarm,Wood,All,W/Pad,Tip&Grip 05/01/90 1 10.30

E0114 Crutches,Underarm,Alum.W/Pads,Tip&Grips 05/01/90 1 23.85

E0116 Crutch,Underarm,Alum.W/Pad,Tip&Handgrip 05/01/90 1 11.95

E0130 Walker,Rigid ,Adj.Or Fixd Ht.W/Tip&Grips 05/01/90 1 35.00

E0135 Walker,Folding ,Adj.Or Fxd Ht.W/Tips&Grip 02/17/91 1 47.00

E0141 Walker, Rigid, Wheeled, Without Seat 11/01/92 1 58.00

E0142 Rigid Walker, Wheeled, With Seat 11/01/92 1 59.00

E0143 Folding Walker,Wheeled, Without Seat 05/01/90 1 66.00

E0144 Walker, 4 Sided, Rigid/Folding, Wheeled w/Seat 10/01/04 1 150.00

E0145 Folding Walker,Wheeld,W/Seat&Crtch Attch 10/01/04 3 NC 100.00

E0146 Folding Walker,Wheeled,With Seat 10/01/04 3 NC 79.00

E0147 Heavy Duty,Variable Wheel Resist Walker 05/01/90 1 150.00

E0148 Walker, Heavy Duty, Without Wheels, Rigid or Folding 01/01/01 1 109.07

E0149 Walker, Heavy Duty, With Wheels, Rigid or Folding 01/01/01 1 135.00

E0153 Platform Attachment, Forearm Crutch 05/01/90 1 46.50

E0154 Platform Attachment, Walker 01/01/99 2 51.44 31.25

E0155 Wheel Attachment ,Rigid Pick-Up Walker 05/01/90 1 16.25

E0156 Seat Attachment, Walker 05/01/90 1 15.00

E0157 Crutch Attachment, Walker 05/01/90 1 62.50

E0158 Leg Extensions, Walker 05/01/90 1 12.64

E0159 Brake Attach Wheeled Walker, Repl, Ea 10/01/04 1 15.00

E0163 Commode Chair,Stationary W/Fixed Arms 05/01/90 1 52.80

E0164 Commode Chair, Mobile W/Fixed Arms 05/01/90 1 81.98

E0165 Commode Chair,Station.W/Detach/Drop Arms 05/01/90 1 104.00

E0166 Commode Chair,Mobile W/Detach./Drop Arms 05/01/90 1 150.00

5101:3-1-60 Page 260







E0167 Pail/Pan,For Commode Chair(Replcmnt Only 05/01/90 1 5.25

E0168 Commode Chair, Extra Wide/Heavy Duty 01/01/01 1 129.56E0176 Air Pressure Pad/Cushion, Nonpositioning 01/01/05 3 NC 10.00E0177 Water Pressure Pad/Cushion,Nonpositinng 01/01/05 3 NC 10.00E0178 Gel Pressure Pad/Cushion,Nonpositioning 01/01/05 3 NC 10.00E0179 Dry Pressure Pad/Cushion,Nonpositioning 01/01/05 3 NC 10.00

E0180 Pressure Pad,Alternating,W/Pump,Complete 05/01/90 1 138.00

E0181 Pressure Pad,Alternat.W/Pump,Hvy Duty 05/01/90 1 148.00

E0182 Pump For Alternating Pressure Pad 11/01/92 1 105.00

E0183 Flota.Pad For Whlchair (Gel Or Water Fill 05/01/90 1 53.00

E0184 Dry pressure mattress 10/01/04 2 463.00 25.00

E0185 Decub.Care Pd,Mat.Siz,Flota/Gel W/Lvl Pd 05/01/90 1 102.00E0186 Air Pressure Mattress 05/25/91 1 PA 0.00

E0187 Water Pressure Mattress,E.G., Aquapedic 12/15/02 2 231.00 463.00

E0188 Synthetic Sheepskin Pad, WC Size 05/01/90 1 5.00

E0189 Lambswool/Sheepskin Pad, Bed Size 07/01/02 2 43.95 58.00

E0190 Decub. Care Matt ,Flotat Or Gel (e.g. Sol) 05/01/90 1 232.00

E0191 Heel Or Elbow Protector 04/01/01 2 9.00 5.55

E0192 Low Press&Positiong Equaliz Pad,Whlchair 01/01/05 2 NC 330.00

E0193 Powdered Flotation Bed,Low Air Loss/Bead 01/01/92 1 32.50

E0194 Air Fluidized Bed 01/01/92 1 38.00E0196 Gel Pressure Mattress 05/25/91 1 PA 0.00E0197 Air Pressure Pad For Mattress 05/25/91 1 PA 0.00E0198 Water Pressure Pad For Mattress 05/25/91 1 PA 0.00

E0199 Dry Pressure Pad For Mattress, (Eggcrate) 05/25/91 1 20.00

E0202 Phototherapy (Bilirubin) Light With Photometer 01/01/98 2 95.50 60.00

E0210 Electric Heat Pad, Standard 05/01/90 1 15.09

E0215 Electric Heat Pad, Moist 05/01/90 1 25.00

E0220 Hot Water Bottle 05/01/90 1 7.09

E0230 Ice Cap Or Collar 05/01/90 1 6.77

E0235 Paraffin Bath Unit ,Port .Complete W/Wax 05/01/90 1 133.00

E0237 Water Circulating Health Pad, Moist 10/01/04 3 NC

E0238 Nonelec .Heat Pad ,Moist (Hydrocltor Packs) 05/01/90 1 8.38

E0241 Bathroom Wall Rail 01/01/97 2 24.00 16.24

E0243 Toilet Rail 04/01/99 2 40.00 29.86

E0244 Raised Toilet Seat 04/01/99 2 49.25 24.95

E0245 Tub Stool Or Bench 01/01/97 2 45.00 34.40

E0246 Transfer Tub Rail Attachment 04/01/99 2 42.00 34.59

5101:3-1-60 Page 261







E0247 Transfer Bench 10/01/04 1 80.00 NC

E0248 Transfer Bench, heavy duty 10/01/04 1 80.00 NC

E0250 Hospital Bed,Fxd Ht,W/Side Rail&Mattress 11/01/98 3 NC 538.00

E0251 Hosp Bed,Fxd Ht,W/Sde Rails,W/O Mattress 11/01/98 3 NC 468.00

E0255 Hospital Bed,Variable Height ,W/Mattress 05/25/91 1 677.00

E0256 Hosp .Bed, Var Ht, W/Side Rails ,W/O Matt 05/25/91 1 580.00

E0260 Hosp. Bd,Semi Elec,W/Sde Rls&Matt ,Adj H/F 05/01/90 1 989.00

E0261 Hosp.Bed, Semi-Elec,W/Side Rls,W/O Matt 05/25/91 1 892.00

E0271 Mattress,Innerspring 05/01/90 1 97.00

E0272 Mattress, Foam Rubber 05/01/90 1 92.00

E0275 Bed Pan,Standard,Metal Or Plastic 05/01/90 1 4.00

E0276 Bed Pan,Fracture,Metal Or Plastic 05/01/90 1 3.00E0277 Alternating Pressure Mattress 04/01/92 1 PA 0.00

E0290 Hosp.Bed,Fxd Ht,W/O Side Rails,W/Matt 11/01/98 3 NC 428.00

E0291 Hosp. Bed,Fxd Ht ,W/O Side Rails, W/O Matt 11/01/98 3 NC 331.00

E0292 Hosp .Bed,Var Ht,Hi-Lo, W/O Sd Rls,W/Matt 05/25/91 1 567.00

E0293 Hosp .Bed,Var Ht ,Hi-Lo, W/O Sd Rls,W/O Mat 05/25/91 1 470.00

E0294 Hosp .Bed,Semi-Elec,W/O Side Rls, W/Matt 05/25/91 1 879.00

E0295 Hosp .Bed,Semi-Elec,W/O Sd Rls, W/O Matt 05/25/91 1 782.00

E0298 Hospital Bed, Hvy Duty/Extra Wide w/Side Rails w/ Matt 04/01/02 3 NC 0.00

E0300 Mattress,Replcmnt For Recip-Ownd Bed 08/01/98 2 115.00 97.00E0301 Heavy Duty Hospital Bed, >350 <600lbs, No Mattress 01/01/05 1 2,096.80E0302 Heavy Duty Hospital Bed, >600lbs, No Mattress 01/01/05 1 5,723.50E0303 Heavy Duty Hospital Bed, >350 <600lbs, w/Mattress 01/01/05 1 2,431.80E0304 Heavy Duty Hospital Bed, >600lbs, w/Mattress 01/01/05 1 6,165.40

E0305 Bed, Side Rails,Half Length,Attachment 05/01/90 1 57.21

E0310 Bed, Side Rails,Full Length,Attachment 05/01/90 1 48.25

E0325 Urinal,Male, Jug Type, Any Materal 05/01/90 1 2.50

E0326 Urinal Female, Jug Type, Any Material 05/01/90 1 3.50E0371 Nonpower adjust. pressure reducing mattress overlay 08/01/98 1 PA 0.00E0372 Powered air overlay for mattress 08/01/98 1 PA 0.00E0373 Nonpowered advanced pressure reducing mattress 08/01/98 1 PA 0.00

E0424 Stationary Compressed Gas System Rental 07/01/93 1 193.44

E0425 Stationary compressed gas system, purchase 10/01/04 1 NC

E0430 Portable gaseous oxygen system, purchase 10/01/04 1 NC

E0431 Portable, Gaseous Oxygen System, Rental 01/01/01 1 NC

E0434 Portable liquid oxygen system, rental 10/01/04 1 NC

E0435 Portable liquid oxygen system, purchase 10/01/04 1 NC

5101:3-1-60 Page 262







E0439 Stationary Liquid Oxygen System Rental 07/01/93 1 193.44

E0440 Stationary liquid Oxygen System, purchase 10/01/04 1 NC

E0441 Oxygen Contents, Gaseous,Incl Supplies 01/01/02 2 163.47 184.14

E0442 Oxygen Contents,Liquid,Incl Supplies 01/01/02 2 163.47 184.14

E0443 Portable Oxygen Contents, Gaseous 01/01/01 1 NC

E0444 Portable Oxygen Contents, Liquid 01/01/01 1 NCE0445 Oximeter device for measuring blood oxygen levels non-invasively10/01/04 1 PA 0.00E0450 Volume Control Vent, w/o Pressure Support, invasive interface05/01/90 1 750.00

E0452 Intermitten Assist Device w/ CPAP-APAP 07/01/00 3 NC 1,900.00

E0453 Therapeutic Ventilator (IPPV) 07/01/00 3 NC 0.00++ E0454 Pressure support ventilator with volume control 01/01/05 3 NC 750.00

E0455 Oxygn Tnt/Canopy (Rplcmnt Recip-Ownd Eqpt 05/01/90 1 8.00

E0457 Chest Shell (Cuirass) 05/01/90 1 450.00

E0459 Chest Wrap 05/01/90 1 352.00

E0460 Pressure Ventilator,Portable/Stationary 07/01/92 1 305.00

E0461 Volume ventilator, with backup rate feature, used w/non-invasive interface10/01/04 1 NC

E0462 Rocking bed 10/01/04 1 NCE0463 Pressure Support Vent w/Volume Cont, Invasive 01/01/05 1 750.00E0464 Pressure Support Vent w/Volume Cont, Non-Invasive 01/01/05 1 NC

E0470 Respiratory assist device, bi-level pressure, without backup rate, non-invasive10/01/04 1 1,900.00

E0471 Respiratory assist device, bi-level pressure, with backup rate, non-invasive10/01/04 1 320.00

E0472 Respiratory assist device, bi-level pressure, with backup rate, invasive10/01/04 1 320.00

E0480 Percussor,Elec. Or Pneumatic,Home Model 05/01/90 1 321.00

E0481 Intrapulmonary percussive ventilation system w/related accessories10/01/04 1 4,724.50E0482 Cough stimulating device, alternating positive and negative airway pressure01/01/05 2 3,440.00 NC

E0483 High frequency chest wall oscillation air-pulse generator system (includes hoses and vest)10/01/04 1 12,190.00

E0484 Non-elecric oscillatory pep device 10/01/04 1 36.92

E0500 IPPB W/Man. Vlvs, Ext Pwr Srce,Incl Rg,Neb 04/01/92 1 65.00

E0550 Humidifier, durable for extensive supplemental humidification during IPPB or oxygen10/01/04 1 NC

E0555 Humidifier, durable, glass or autoclavable plastic bottle type10/01/04 1 NC

E0560 Humidifier, durable for supplemental humidification during IPPB or oxygen10/01/04 1 NC

E0561 Humidifier nonheated w PAP 10/01/04 1 106.30

E0562 Humidifier heated w PAP 10/01/04 1 225.92

E0565 Comprssr Air Pwr Srce For Equip Not Self 04/01/96 2 525.00 155.00

E0570 Nebulizer,W/Compressor,E.G.,Devilb Pulmo 01/01/92 2 133.00 123.00

E0571 Aerosol Compressor, Bat Power, w/ Sm Vol Neb 01/01/01 1 NC

E0572 Aerosol Compressor, Adj Pres, Light Duty, Intermit use 01/01/01 1 NC

E0574 Ultrasonic Generator w/ Sm Vol Ultrasonic Nebulizer 01/01/01 1 NC

5101:3-1-60 Page 263







E0575 Nebulizer, Ultrasonic, Large Volume 04/01/96 2 430.00 500.00

E0580 Nebulizer Durable,G., P-B All Purpose 05/01/90 1 115.00

E0585 Nebulizer, with compressor and heater 10/01/04 1 NC

E0600 Suction Pump ,Home Model,Portable or Stationary,Complet05/01/90 1 217.00

E0601 Nasal Continuous Airway Pressure (CPAP) 04/01/92 1 775.00

E0602 Manual breast pump 10/01/04 1 15.00

E0603 Breast Pump Electric 01/01/02 1 31.00

E0604 Breast Pump, Heavy Duty Electric (Rental) 01/01/02 1 2.25

E0605 Vaporizer, Room Type 05/01/90 1 20.00

E0607 Home Blood Glucose Monitor Complete 07/01/93 1 55.00

E0608 Apnea Monitor; Including Alarms, Maint. 07/01/03 3 NC 250.00

E0609 Blood Glucose Monitor W/Special Features 04/01/02 3 NC 0.00

E0617 External Defib w/ Integrated Electrocardiogram Analysis 01/01/01 1 NC

E0618 Apnea Monitor w/o Record; Incl alarm, maint, supplies 04/01/03 1 250.00

E0619 Apnea Monitor w/ Record; Incl alarm, maint, supplies 04/01/03 1 250.00

E0621 Sling Or Seat For Patient Lift,Canvas 01/01/99 2 89.70 75.00

E0625 Patient Lift, Bathroom Or Toilet 05/01/90 1 447.00

E0630 Patient Lift,Hydraul,W/Seat/Sling,Portab 01/01/96 2 952.00 800.00

E0650 Pneumatic Compressor, Nonsegmental, Home 01/01/94 1 510.00

E0651 Pneumatic Compressor,Segmen Home W/O Cal 07/01/02 2 776.80 866.25

E0655 Pneumatic Appliance, Half Arm,Non Custom 01/01/94 1 77.50

E0660 Pneumatic Appliance, Full Leg,Non Custom 07/01/02 2 135.12 138.71

E0665 Pneumatic Appliance, Full Arm,Non Custom 01/01/94 1 101.50

E0666 Pneumatic Appliance, Half Leg, Non Custom 01/01/94 1 95.00

E0667 Pneum.Appli For Use W/Segmen Compres,Leg 01/01/94 1 172.30

E0668 Pneum.Appli For Use W/Segmen Compres,Arm 01/01/94 1 150.00

E0669 Segmental Pneum.Appliance,Half Leg 01/01/94 1 143.75E0670 Segmental Pneum.Appliance,Half Arm 01/01/94 1 PA 0.00

E0690 Ultraviolet Cabinet, Appropriate For Home Use 10/01/04 3 NC

E0700 Safety Equipment (E.G., Belt, Harness,Vest 05/01/90 1 10.82

E0720 TNS Unit,2 Lead,Local Stim(Incl Supplies 05/01/90 1 300.00

E0730 TNS Unit ,4Lead ,Multi.Nerve Stim(Incl Sup 03/31/94 1 322.39

E0747 Osteogenesis Stimulator, Noninvasive 04/01/92 1 1,750.00

E0748 Osteogenesis Stimulator, Spinal, Noninvasive 08/01/97 1 1,750.00

E0765 Nerve Stim, Replc Bat, for Treatment of N/V 01/01/01 1 NC

E0776 IV Pole 05/01/90 1 75.00

E0781 Ambul Infus Pump W/Admin Eq,Non Nutritn 01/01/92 2 8.73 4.35

E0784 External Ambulatory Infusion Pump, Insulin 01/01/96 1 4,000.00

5101:3-1-60 Page 264







E0785 Implantable intraspinal catheter 01/01/99 1 NC

E0791 Parentrl Infusion Pump ,Station. (Non-Nutr 05/01/90 1 8.73

E0830 Ambulatory Traction Device, All Types, Ea 01/01/01 1 NC

E0840 Traction Frame, Headboard,Cervical,Complt 05/01/90 1 42.21

E0850 Tract.Stand,Free Standng,Cervical,Complt 05/01/90 1 64.56

E0860 Tract.Equipment,Overdoor,Cervic., Complet 05/01/90 1 15.35

E0870 Tract.Frame,Ftboard,Extremity,Complete 07/01/02 2 115.73 118.81

E0880 Tract.Stand,Free Stand, Extrem,Complete 05/01/90 1 94.00

E0890 Traction Frame,Footboard,Pelvic,Complete 05/01/90 1 75.25

E0900 Tract.Stand,Free Standing ,Pelvic,Complet 05/01/90 1 79.39

E0910 Trapeze Bar, Bed Mounted W/Grab Bar 05/01/90 1 101.00

E0920 Fracture Frame, Attached To Bed,Incl Wts 05/01/90 1 315.00

E0930 Fracture Frame, Freestanding,Incl Weight 11/01/92 1 352.00

E0935 Passive Motion Exercse Device 11/01/92 1 75.00

E0940 Trapeze Bar,Freestandng,Complt W/Grab Ba 05/01/90 1 130.00E0941 Gravity Assisted Traction Device,Any Typ 05/01/90 1 PA 0.00

E0942 Cervical Head Harness/Halter 05/01/90 1 7.44

E0943 Cervical Pillow 10/01/04 3 NC

E0944 Pelvic Belt/Harness/Boot 05/01/90 1 22.40

E0945 Extremity Belt/Harness 05/01/90 1 37.07E0946 Fract.Frame,Dul W/X Bars,Attachd To Bd 05/01/90 1 PA 0.00E0947 Fract.Frame,Attachmnts For Complex Pelvi 05/01/90 1 PA 0.00E0948 Fract. Frame,Attachmnts For Complex Cervi 05/01/90 1 PA 0.00

E0950 WC acess; tray each 10/01/04 1 116.00

E0951 WC,Heel loop/holder, w or w/o ankle strap, each 10/01/04 1 14.00

E0952 WC access; toe loop/holder,ea 10/01/04 1 11.00

E0955 WC, cushioned, prefabricated headrest 10/01/04 1 192.00

E0956 WC, lat trunk/hip support, prefabricated, ea 10/01/04 1 94.00

E0957 WC, medical thigh support, prefabricated, each 10/01/04 1 132.00

E0958 WC access;one arm drive attach, ea 10/01/04 1 434.20

E0959 WC access; adapter for amputee, ea 10/01/04 1 25.28

E0960 WC, shoulder harness/straps or chest strap 10/01/04 1 86.00

E0961 WC access; wheel lock brake extension handle 10/01/04 1 25.28

E0962 1" Cushion For Wheelchair 01/01/05 2 NC 27.19

E0963 2" Cushion For Wheelchair 01/01/05 2 NC 40.00

E0964 3" Cushion, For Wheelchair 01/01/05 2 NC 51.42

E0965 4" Cushion, For Wheelchair 01/01/05 2 NC 55.00

E0966 WC, access; headrest extension, each 10/01/04 1 50.00

5101:3-1-60 Page 265







E0967 WC access; handrim with projections, each 10/01/04 1 59.25

E0968 Commode Seat, Wheelchair 05/01/90 1 127.00

E0971 WC access; anti-tipping device 10/01/04 1 49.00

E0972 WC access; transfer board or device, each 10/01/04 1 46.62

E0973 WC access; adjust hgt detachable armrest, each 10/01/04 1 70.00

E0974 WC access; anti-rollback device, each 10/01/04 1 60.00

E0978 WC access; safety belt/plevic, each 10/01/04 1 32.00

E0980 Safety Vest, Wheelchair 08/01/98 3 NC 36.00E0983 WC access, power add-on to MWC, joystick 10/01/04 1 PA 0.00

E0984 WC access, power add-on to MWC, tiller 10/01/04 1 1,623.99

E0986 WC access; push-rim activated power assist, ea 10/01/04 1 4,450.00

E0990 WC access, elevating legrest, complete, each 10/01/04 1 83.00

E0992 WC access; solid seat insert 10/01/04 1 81.00

E1002 WC power seating system, tilt only 10/01/04 1 3,800.00

E1003 WC power seating, recline only wo shear reduct 10/01/04 1 4,000.00

E1004 WC pow seat sys; recline w mech shear reduct 10/01/04 1 4,500.00

E1005 Wc pow seat sys; recline w power shear reduct 10/01/04 1 4,900.00

E1006 WC pow seat comb tilt/relcine wo shear reduct 10/01/04 1 6,000.00

E1007 PWC seat;comb tilt/recline w mech shear reduct 10/01/04 1 7,800.00

E1008 PWC seat; comb tilt & recline w pow shear reduct 10/01/04 1 8,000.00

E1009 PWC; Add mech leg elevating system 10/01/04 1 BR

E1010 PWC; Add power leg elevating system 10/01/04 1 980.00

E1012 Ped. WC; Integrated seating system, planar 10/01/04 3 NC 480.00

E1013 Ped. WC; Integrated seating system, contoured 10/01/04 3 NC 750.00

E1014 Ped. Wc, reclining back 10/01/04 1 340.00

E1015 Mwc Accessory Shock Absorber, Each 10/01/04 1 98.00

E1016 Pwc Acces, Shock Absorber , Each 10/01/04 1 122.00

E1017 Mwc, Heavy Duty Shock Absorber, Each 10/01/04 1 BR

E1018 Pwc, Heavy Duty Shock Absorber, Each 10/01/04 1 BR

E1020 Wc; residual limb support system 10/01/04 1 215.00

E1025 Ped. WC, lateral thoracic support, non-contoured 10/01/04 3 NC 110.00

E1026 Ped. WC lateral/anterior support, contoured 10/01/04 3 NC 178.00

E1027 Ped. WC lateral/anterior support, each 10/01/04 3 NC 255.00

E1028 WC access; manual swingaway, hw for joystick 10/01/04 1 186.00

E1029 WC access; ventilator tray, fixed 10/01/04 1 350.00

E1030 WC access, ventilator tray, gimbaled 10/01/04 1 1,120.00

E1035 Multi-Positional Pt Transfer Sys w/ Int Seat, Op by Crgvr 01/01/01 1 NC

E1050 Full Reclng WC,Fixd Fl Arms,Sw Det Elv L 07/01/97 3 NC 892.00

5101:3-1-60 Page 266







E1060 Full Reclng WC,Det Arms,Desk/Full,Sw Lr 07/01/97 3 NC 1,016.00

E1065 Power Attach. (To Convert To Motorized WC 10/01/04 2 2,629.73 2,382.89

E1070 Full Reclng WC,Fixd Or Detach.Arms,Sw Fr 07/01/97 3 NC 895.00

E1083 Hemi-WC, Fixd Full Arms,Sw Detach Elev Lr 07/01/97 3 NC 750.00

E1084 Hemi-WC,Detach Arms Desk/Full,Sw Elev Lr 07/01/97 3 NC 820.00

E1085 Hemi-WC, Fixd Full Arms,Sw Detach Footers 07/01/97 3 NC 730.50

E1086 Hemi-WC, Detach Arms,Desk/Full,Sw Det Fr 07/01/97 3 NC 800.00

E1087 Hi Strngth Ltwt WC,Fxd Fl Arms Sw Det Fr 07/01/97 3 NC 1,175.00

E1088 Hi Strngth Ltwt WC,Det. Arms,Sw Det Elv L 07/01/97 3 NC 1,278.00

E1089 Hi Strngth Ltwt WC, Fxd Fl Arms,Sw Det Fr 07/01/97 3 NC 1,003.00

E1090 Hi Strength Ltwt WC, Fxd/Det Arm,Sw Det Fr 07/01/97 3 NC 1,270.00

E1091 Youth WC W/Support System (Any Type) 07/01/97 3 NC 1,281.00

E1092 Wide Hvy Dty WC,Detach Arms,Sw Det Elv L 07/01/97 3 NC 1,087.00

E1093 Wide Hvy Duty WC,Detach Arms,Se Det Fr 07/01/97 3 NC 991.00

E1100 Semi-Reclng WC,Fxd Fl Arms,Sw Det Elv Lr 07/01/97 3 NC 883.00

E1110 Semi-Reclng WC,Det Arms,Sw Det Elv Lr 07/01/97 3 NC 908.00

E1120 Semi-Reclng WC,Detach Arms (Desk Or Full 07/01/97 3 NC 856.00

E1130 Std WC, Fxd Full Arms,Fxd/Sw Detach Fr 07/01/97 3 NC 0.00

E1140 Std WC,Detach Arms (Dsk/Full) ,Sw Det Fr 07/01/97 3 NC 0.00

E1150 Std WC, Detach Arms,Sw Detach Elv Lr 07/01/97 3 NC 0.00

E1160 Std WC,Fxd Fl Arms, Sw Detach Elv Lr 07/01/97 3 NC 0.00

E1161 Manual Adult size wheelchair, includes tilt in space 10/01/04 1 PA

E1170 Amputee WC, Fxd Fl Arms,Sw Detach Evl Lr 07/01/97 3 NC 560.00

E1171 Amputee WC,Fxd Fl Arms, W/O Ftr Or Legre 07/01/97 3 NC 452.00

E1172 Amputee WC,Detach Arms, W/O Ftr Or Legr 07/01/97 3 NC 586.00

E1180 Amputee WC,Detach Arms,Sw Detach Ft Rst 07/01/97 3 NC 830.00

E1190 Amputee WC,Detach Arms, Sw Detach Elv Lr 07/01/97 3 NC 956.00

E1195 Hvy Duty Amputee WC,Fxd Fl Arms,Sw Det E 07/01/97 3 NC 612.00

E1200 Amputee WC,Fxd Fl Arms,Sw Detach Footers 07/01/97 3 NC 482.00

E1210 Mtrizd WC,Fxd Fl Arms, Sw Detach Elv Lr 07/01/97 3 NC 3,784.00

E1211 Mtrizd WC,Detach Arms,Sw Detach Elv Lr 07/01/97 3 NC 3,894.00

E1212 Mtrizd WC, Fxd Fl Arms,Sw Detach Ft Rests 07/01/97 3 NC 3,590.00

E1213 Mtrizd,Detach Arms, Sw Detach Ft Rests 07/01/97 3 NC 3,700.00

E1220 Special Sizd/Constructd WC(List Model Et 07/01/97 3 NC 2,800.00

E1225 MWC access; semi-reclining back, each 10/01/04 1 420.00

E1226 MWC access; fully reclining back 10/01/04 1 460.00

E1230 Power vehicle, 3 wheel, non-highway 10/01/04 1 2,022.00 BR

E1231 WC, ped.sz tilt-in-space, rigid, adj w seating syst. 10/01/04 1 BR

5101:3-1-60 Page 267







E1232 Wc ped. Sz, tilt-in-space, fold, adj w seat system 10/01/04 1 BR

E1233 WC, ped sz tilt-in-space wo seating system 10/01/04 1 BR

E1234 WC, ped, tilt-in-space, fold, adj wo seat system 10/01/04 1 BR

E1235 WC, ped sz, rigid, adj, with seating system 10/01/04 1 BR

E1236 WC, ped sz, folding, adj, w seating system 10/01/04 1 BR

E1237 WC, ped sz, rigid, adj, wo seating system 10/01/04 1 BR

E1238 WC, ped sz, folding, adj, wo seating system 10/01/04 1 BR

E1240 Ltwt WC, Detach Arms,Sw Detach Elv Lr 07/01/97 3 NC 1,007.00

E1250 Ltwt WC,Fxd Arms, Sw Detach Ft Rests 07/01/97 3 NC 817.00

E1260 Ltwt WC,Detach Arms,Sw Detach Ft Rests 07/01/97 3 NC 863.00

E1270 Ltwt WC, Fxd Fl Arms, Sw Detach Elv Lr 07/01/97 3 NC 912.00

E1280 Hvy Duty WC, Detach Arms,Sw Detach Elv Lr 07/01/97 3 NC 1,134.00

E1285 Hvy Duty WC, Fxd Fl Arms, Sw Detach Ft Res 07/01/97 3 NC 834.00

E1290 Hvy Duyt WC,Detach Arms,Sw Detach Ft Res 07/01/97 3 NC 1,051.00

E1295 Hvy Duty WC,Fxd Full Lngth Arms,Elev Lr 07/01/97 3 NC 945.00

+ E1296 Special Wheelchair Seat Height From Flor 10/01/04 3 NC 304.00

+ E1297 Special Wheelchair Seat Depth, By Uphols 10/01/04 3 NC 72.00

+ E1298 Special Wheelchair Seat Depth, By Constr 10/01/04 3 NC 291.00

E1300 Whirlpool, Portable (Overtub Type) 05/01/90 1 170.00

E1340 Repair, Non-Routine Svc, DME Labor, per 15 min 10/01/04 2 PA NCE1350 Repair,Non-Routine Svc, DME Major Repair, Pers. Res. 05/01/90 1 PA 0.00E1351 Repair, Non-Routine Svc, DME Major Repair, LTCF 01/01/96 1 PA 0.00

E1353 Oxygen Regulator 05/01/90 1 97.64

E1355 Stand/Rack, Replacement Bag/Cart 08/01/98 3 NC 20.00

E1370 Compressed Air Cylinder (25.4 Cu. Ft) 05/01/90 1 8.50

E1372 Immersion External Heater For Nebulizer 05/01/90 1 118.00

E1375 Nebulizer, Portable, W/Small Compressor, 04/01/01 3 NC 116.00

E1390 Oxygen concentrator, single delivery port 10/01/04 3 NC

E1391 Oxygen concentrator, dual delivery port 10/01/04 3 NCE1399 Durable Medical Equipment, NOS 05/01/90 1 PA 0.00

E1400 Non-Medical Equipment (Not Covered) 07/01/94 3 NC

E1405 Oxygen and water vapor enriching system w/heated delivery10/01/04 3 NC

E1406 Oxygen and water vapor enriching system w/o heated delivery10/01/04 3 NC

E1800 Dynamic Adj. Elbow Ext/Flex Device 01/01/01 1 NC

E1805 Dynamic Adj. Wrist Ext/Flex Device 01/01/01 1 NC

E1810 Dynamic Adj. Knee Ext/Flex Device w/ Interface Material 01/01/01 1 75.00

E1815 Dynamic Adj. Wrist Ext/Flex Device 01/01/01 1 NC

E1825 Dynamic Adj. Finger Ext/Felx Device 01/01/01 1 NC

5101:3-1-60 Page 268







E1830 Dynamic Adj. Toe Ext/Flex Device 01/01/01 1 NCE2100 Blood Glucose Monitor w/ integrated voice synthesizer 01/01/02 1 PA 0.00E2101 Blood Glucose Monitor w/ integrated lancing/blood sample 01/01/02 1 PA 0.00

E2201 MWC; non-stand seat frame, width >eq 20 <24 in 10/01/04 1 347.00

E2202 MWC;nonstand seat frame, width 24-27 inches 10/01/04 1 437.00

E2203 MWC;nonstand seat frame depth, >eq 20 & <22 in 10/01/04 1 444.00

E2204 MWC;nonstand seat frame depth 22-25 inches 10/01/04 1 750.00

E2205 Mwc, Handrimm Wo Projections, Any, Rpl 01/01/05 1 30.00

E2206 Mwc, Wheel Lock Assmbly, Comp, Ea 01/01/05 1 38.00

E2291 Ped Wc, Back, Planar, Incl Fx Hw 01/01/05 1 253.00

E2292 Ped Wc, Seat, Planar, Incl Fx Hw 01/01/05 1 253.00

E2293 Ped Wc, Back, Contoured, Incl Fx Hw 01/01/05 1 418.00

E2294 Ped Wc, Seat, Contoured, Incl Fx Hw 01/01/05 1 418.00

E2310 Mwc, Elect. Connect, Bwn Contr & Seat 10/01/04 1 1,100.00

E2311 Mwc, Elect. Connect, Bwn 2/M Contr & Seat 10/01/04 1 2,200.00

E2320 PWC hand or chin control interface 10/01/04 1 925.00

E2321 PWC hand control interface 10/01/04 1 1,417.00

E2322 PWC hand control interface, MULT SWITCHES 10/01/04 1 1,350.00

E2323 PWC, specialty joystick handle, prefabricated 10/01/04 1 61.00

E2324 PWC; chin cup for chin control 10/01/04 1 40.00

E2325 PWC, sip and puff interface 10/01/04 1 1,244.00

E2326 PWC; breath tube kit for sip and puff 10/01/04 1 298.00

E2327 PWC; head control interface, mechanical 10/01/04 1 2,130.00

E2328 PWC; head or extremity control interface, electron 10/01/04 1 3,600.00

E2329 PWC; head control interface, contact swtch, mech 10/01/04 1 1,600.00

E2330 PWC, head control, prox switch 10/01/04 1 3,080.00

E2340 PWC access, nonstandard seat width, 20-23 in 10/01/04 1 314.00

E2341 PWC access, nonstandard seat width, 24-27 in 10/01/04 1 462.00

E2342 PWC access, nonstandard seat depth, 20/21 in 10/01/04 1 448.00

E2343 PWC access, nonstandard seat depth, 22-25 in 10/01/04 1 259.00

E2360 Pwc, 22 Nf Non-Sealed Lead Acid Battery 10/01/04 1 99.00

E2361 Pwc Acces, 22 Nf Sealed Lead Acid Batt 10/01/04 1 128.50

E2362 Pwc, Group 24 Non-Sealed Lead Acid Batt 10/01/04 1 85.00

E2363 Pwc Acc, Group 24 Sealed Lead Acid Batt 10/01/04 1 173.00

E2364 Pwc Acces, U-1 Non-Sealed Lead Acid Batt 10/01/04 1 99.00

E2365 Pwr W/C Acces, U-1 Sealed Lead Acid Batt 10/01/04 1 104.00

E2366 10/01/04 1 202.00

5101:3-1-60 Page 269






APPR VISIT CODE DESCRIPTION DATE CODE PRICE PRICE INDIC. DAYS GROUP DATE DATE GROUP DATE DATEE2367 Pwr W/C Acces, U-1 Sealed Lead Acid Batt 10/01/04 1 378.00E2500 Speech Gen Device <= 8 Min 10/1/04 1 275.00E2502 Speech Gen Device, > 8 Min but <= 20 min 01/01/05 2 837.06 350.00E2504 Speech Gen Device, > 20 but < 40 min 01/01/05 2 1104.19 550.00E2506 Speech Gen Device, > 40 min 10/1/04 1 2195.00E2508 Speech Gen Device, syn speech message form. by

spell10/1/04 1 3558.93

E2510 Speech Gen Device, synth speech, multiple meth message

01/01/05 2 6768.25 7000.00E2511 Speech Gen Software 10/1/04 1 PAE2512 Acc for Speech Gen Dev, Mount 10/1/04 1 1076.00E2599 Acc for Speech Gen dev, NOS 10/1/04 1 PA

E2601 Wc cushion, width < 22 inc, any depth 01/01/05 1 PA

E2602 WC cushion; width 22 in or greater, any dpth 01/01/05 1 PA

E2603 WC skin pro. Seat cushion wdth <22 in any dpth 01/01/05 1 PA

E2604 WC skin pro. Seat cushion wdth 22 or >, any dpth 01/01/05 1 PA

E2605 Wc positioning seat cushion, wdt<22 in, any dpth 01/01/05 1 PA

E2606 WC positioning seat cushion, wdt22 or >, any dpth 01/01/05 1 PA

E2607 WC skin pro posit. Cushion,wdth <22 in, any dpth 01/01/05 1 PA

E2608 WC skn pro & posit cushion, wdt 22 or >, any dpth 01/01/05 1 PA

E2609 WC custom fabricated seat, any size 01/01/05 1 PA

E2610 WC, seat cushion , powered 01/01/05 1 PA

E2611 WC back cushion, wdth <22, any hgt 01/01/05 1 PA

E2612 WC back cushion, wdth 22 or greater, any hgt 01/01/05 1 PA

E2613 WC posterior back cushion, wdt, <22 in, any hgt 01/01/05 1 PA

E2614 WC poster back cushion, wdt, 22 or >in, any hgt 01/01/05 1 PA

E2615 WC post/lat back cushion, wdth <22, any hgt 01/01/05 1 PA

E2616 WC post/lat back cushion, wdth 22 or >, any hgt 01/01/05 1 PA

E2617 WC back cushion, custom fabricated, any size 01/01/05 1 PA

E2618 WC, solid seat support base 01/01/05 3 NCE2620 Pos wc planar bk cush w lat sup, <22in 01/01/05 1 PAE2621 Pos wc planar bk cush w lat sup, 22in or >22in 01/01/05 1 PA

G0001 Drawing blood for specimen 01/01/04 1 NC

G0008 Admin influenza virus vac 01/01/04 1 NC

G0009 Admin pneumococcal vaccine 01/01/04 1 NC

G0010 Admin hepatitis b vaccine 01/01/04 1 NC

G0026 Fecal leukocyte examinations 04/01/04 3 NC 5.90

G0027 Semen analysis 01/01/04 1 NC

G0030 PET imaging prev PET single 01/01/04 1 NC

G0031 PET imaging prev PET multple 01/01/04 1 NC

5101:3-1-60 Page 270







G0032 PET follow SPECT 78464 singl 01/01/04 1 NC

G0033 PET follow SPECT 78464 mult 01/01/04 1 NC

G0034 PET follow SPECT 76865 singl 01/01/04 1 NC

G0035 PET follow SPECT 78465 mult 01/01/04 1 NC

G0036 PET follow cornry angio sing 01/01/04 1 NC

G0037 PET follow cornry angio mult 01/01/04 1 NC

G0038 PET follow myocard perf sing 01/01/04 1 NC

G0039 PET follow myocard perf mult 01/01/04 1 NC

G0040 PET follow stress echo singl 01/01/04 1 NC

G0041 PET follow stress echo mult 01/01/04 1 NC

G0042 PET follow ventriculogm sing 01/01/04 1 NC

G0043 PET follow ventriculogm mult 01/01/04 1 NC

G0044 PET following rest ECG singl 01/01/04 1 NC

G0045 PET following rest ECG mult 01/01/04 1 NC

G0046 PET follow stress ECG singl 01/01/04 1 NC

G0047 PET follow stress ECG mult 01/01/04 1 NC

G0054 Blood Cholesterol Test 01/01/96 1 NC

G0101 CA screen;pelvic/breast exam 01/01/04 1 NC

G0102 Prostate ca screening; dre 01/01/04 1 NC

G0103 Psa, total screening 01/01/04 1 NC

G0104 CA screen;flexi sigmoidscope 01/01/04 1 NC

G0105 Colorectal scrn; hi risk ind 01/01/04 1 NC

G0106 Colon CA screen;barium enema 01/01/04 1 NC

G0107 CA screen; fecal blood test 01/01/04 1 NC

G0108 Diab manage trn per indiv 01/01/04 1 NC

G0109 Diab manage trn ind/group 01/01/04 1 NC

G0110 Nett pulm-rehab educ; ind 01/01/04 1 NC

G0111 Nett pulm-rehab educ; group 01/01/04 1 NC

G0112 Nett;nutrition guid, initial 01/01/04 1 NC

G0113 Nett;nutrition guid,subseqnt 01/01/04 1 NC

G0114 Nett; psychosocial consult 01/01/04 1 NC

G0115 Nett; psychological testing 01/01/04 1 NC

G0116 Nett; psychosocial counsel 01/01/04 1 NC

G0117 Glaucoma scrn hgh risk direc 01/01/04 1 NC

G0118 Glaucoma scrn hgh risk direc 01/01/04 1 NC

G0120 Colon ca scrn; barium enema 01/01/04 1 NC

G0121 Colon ca scrn not hi rsk ind 01/01/04 1 NC

G0122 Colon ca scrn; barium enema 01/01/04 1 NC

5101:3-1-60 Page 271







G0123 Screen cerv/vag thin layer 01/01/04 1 NC

G0124 Screen c/v thin layer by MD 01/01/04 1 NC

G0125 PET image pulmonary nodule 01/01/04 1 NC

G0127 Trim nail(s) 01/01/04 1 NC

G0128 CORF skilled nursing service 01/01/04 1 NC

G0130 Single energy x-ray study 01/01/04 1 NC

G0141 Scr c/v cyto,autosys and md 01/01/04 1 NC

G0143 Scr c/v cyto,thinlayer,rescr 01/01/04 1 NC



G0147 Scr c/v cyto, automated sys 01/01/04 1 NC

G0148 Scr c/v cyto, autosys, rescr 01/01/04 1 NC

G0166 Extrnl counterpulse, per tx 01/01/04 1 NC

G0167 Hyperbaric oz tx;no md reqrd 01/01/04 1 NC

G0168 Wound closure by adhesive 01/01/04 1 NC

G0173 Stereo radoisurgery,complete 01/01/04 1 NC

G0175 OPPS Service,sched team conf 01/01/04 1 NC

G0176 OPPS/PHP;activity therapy 01/01/04 1 NC

G0177 OPPS/PHP; train & educ serv 01/01/04 1 NC

G0179 MD recertification HHA PT 01/01/04 1 NC

G0180 MD certification HHA patient 01/01/04 1 NC

G0181 Home health care supervision 01/01/04 1 NC

G0182 Hospice care supervision 01/01/04 1 NC

G0186 Dstry eye lesn,fdr vssl tech 01/01/04 1 NC

G0202 Screeningmammographydigital 01/01/04 1 NC

G0204 Diagnosticmammographydigital 01/01/04 1 NC

G0206 Diagnosticmammographydigital 01/01/04 1 NC

G0210 PET img wholebody dxlung 01/01/04 1 NC

G0211 PET img wholbody init lung 01/01/04 1 NC

G0212 PET img wholebod restag lung 01/01/04 1 NC

G0213 PET img wholbody dx 01/01/04 1 NC

G0214 PET img wholebod init 01/01/04 1 NC

G0215 PETimg wholebod restag 01/01/04 1 NC

G0216 PET img wholebod dx melanoma 01/01/04 1 NC

G0217 PET img wholebod init melan 01/01/04 1 NC

G0218 PET img wholebod restag mela 01/01/04 1 NC

G0219 PET img wholbod melano nonco 01/01/04 1 NC

G0220 PET img wholebod dx lymphoma 01/01/04 1 NC

5101:3-1-60 Page 272







G0221 PET imag wholbod init lympho 01/01/04 1 NC

G0222 PET imag wholbod resta lymph 01/01/04 1 NC

G0223 PET imag wholbod reg dx head 01/01/04 1 NC

G0224 PET imag wholbod reg ini hea 01/01/04 1 NC

G0225 PET whol restag headneckonly 01/01/04 1 NC

G0226 PET img wholbody dx esophagl 01/01/04 1 NC

G0227 PET img wholbod ini esophage 01/01/04 1 NC

G0228 PET img wholbod restg esopha 01/01/04 1 NC

G0229 PET img metaboloc brain pres 01/01/04 1 NC

G0230 PET myocard viability post 01/01/04 1 NC

G0231 PET WhBD colorec; gamma cam 01/01/04 1 NC

G0232 PET whbd lymphoma; gamma cam 01/01/04 1 NC

G0233 PET whbd melanoma; gamma cam 01/01/04 1 NC

G0234 PET WhBD pulm nod; gamma cam 01/01/04 1 NC

G0236 Digital film convert diag ma 01/01/04 1 NC

G0237 Therapeutic procd strg endur 01/01/04 1 NC

G0238 Oth resp proc, indiv 01/01/04 1 NC

G0239 Oth resp proc, group 01/01/04 1 NC

G0242 Multisource photon ster plan 01/01/04 1 NC

G0243 Multisour photon stero treat 01/01/04 1 NC

G0244 Observ care by facility topt 01/01/04 1 NC

G0245 Initial foot exam pt lops 01/01/04 1 NC

G0246 Followup eval of foot pt lop 01/01/04 1 NC

G0247 Routine footcare pt w lops 01/01/04 1 NC

G0248 Demonstrate use home inr mon 01/01/04 1 NC

G0249 Provide test material,equipm 01/01/04 1 NC

G0250 MD review interpret of test 01/01/04 1 NC

G0251 Linear acc based stero radio 01/01/04 1 NC

G0252 PET imaging initial dx 01/01/04 1 NC

G0253 PET image brst dection recur 01/01/04 1 NC

G0254 PET image brst eval to tx 01/01/04 1 NC

G0255 Current percep threshold tst 01/01/04 1 NC

G0256 Prostate brachy w palladium 01/01/04 1 NC

G0257 Unsched dialysis ESRD pt hos 01/01/04 1 NC

G0258 IV infusion during obs stay 01/01/04 1 NC

G0259 Inject for sacroiliac joint 01/01/04 1 NC

G0260 Inj for sacroiliac jt anesth 01/01/04 1 NC

G0261 Prostate brachy w iodine see 01/01/04 1 NC

5101:3-1-60 Page 273







G0262 Sm intestinal image capsule 01/01/04 1 NC

G0263 Adm with CHF, CP, asthma 01/01/04 1 NC

G0264 Assmt otr CHF, CP, asthma 01/01/04 1 NC

G0265 Cryopresevation Freeze+stora 01/01/04 1 NC

G0266 Thawing + expansion froz cel 01/01/04 1 NC

G0267 Bone marrow or psc harvest 01/01/04 1 NC

G0268 Removal of impacted wax md 01/01/04 1 NC

G0269 Occlusive device in vein art 01/01/04 1 NC

G0270 MNT subs tx for change dx 01/01/04 1 NC

G0271 Group MNT 2 or more 30 mins 01/01/04 1 NC

G0272 Naso/oro gastric tube pl MD 01/01/04 1 NC

G0273 Pretx planning, non-Hodgkins 01/01/04 1 NC

G0274 Radiopharm tx, non-Hodgkins 01/01/04 1 NC

G0275 Renal angio, cardiac cath 01/01/04 1 NC

G0278 Iliac art angio,cardiac cath 01/01/04 1 NC

G0279 Excorp shock tx, elbow epi 01/01/04 1 NC

G0280 Excorp shock tx other than 01/01/04 1 NC

G0281 Elec stim unattend for press 01/01/04 1 NC

G0282 Elect stim wound care not pd 01/01/04 1 NC

G0283 Elec stim other than wound 01/01/04 1 NC

G0288 Recon, CTA for surg plan 01/01/04 1 NC

G0289 Arthro, loose body + chondro 01/01/04 1 NC

G0290 Drug-eluting stents, single 01/01/04 1 NC

G0291 Drug-eluting stents,each add 01/01/04 1 NC

G0292 Adm exp drugs,clinical trial 01/01/04 1 NC

G0293 Non-cov surg proc,clin trial 01/01/04 1 NC

G0294 Non-cov proc, clinical trial 01/01/04 1 NC

G0295 Electromagnetic therapy onc 01/01/04 1 NC

G0296 PET imge restag thyrod cance 01/01/04 1 NC

G0297 Insert single chamber/cd 01/01/04 1 NC

G0298 Insert dual chamber/cd 01/01/04 1 NC

G0299 Inser/repos single icd+leads 01/01/04 1 NC

G0300 Insert reposit lead dual+gen 01/01/04 1 NC

G0302 Pre-op service LVRS complete 01/01/04 1 NC

G0303 Pre-op service LVRS 10-15dos 01/01/04 1 NC

G0304 Pre-op service LVRS 1-9 dos 01/01/04 1 NC

G0305 Post op service LVRS min 6 01/01/04 1 NC

G0306 CBC/diffwbc w/o platelet 01/01/04 1 NC

5101:3-1-60 Page 274







G0307 CBC without platelet 01/01/04 1 NC

G0308 ESRD Rel Svc, 4+ monthly visits, age <2 01/01/04 1 NC

G0309 ESRD Rel Svc, 2-3 monthly visits, age <2 01/01/04 1 NC

G0310 ESRD Rel Svc, 1 monthly visit, age <2 01/01/04 1 NC

G0311 ESRD Rel Svc, 4+ mon visits, age 2 to 11 01/01/04 1 NC

G0312 ESRD Rel Svc, 2-3 mon vsits, age 2 to 11 01/01/04 1 NC

G0313 ESRD Rel Svc, 1 mon visit, age 2 to 11 01/01/04 1 NC

G0314 ESRD Rel Svc, 4+ mon vsits, age 12 to 19 01/01/04 1 NC

G0315 ESRD Rel Svc 2-3 mon vsits, age 12 to 19 01/01/04 1 NC

G0316 ESRD Rel Svc, 1 mon visit, age 12 to 19 01/01/04 1 NC

G0317 ESRD Rel Svc, 4+ mon visits, age 20 > 01/01/04 1 NC

G0318 ESRD Rel Svc, 2-3 mon visits, age 20 > 01/01/04 1 NC

G0319 ESRD Rel Svc, 1 monthly visit, age 20 > 01/01/04 1 NC

G0320 ESRD Rel Svc, whole month, age <2 01/01/04 1 NC

G0321 ESRD Rel Svc, whole month, age 12 to 19 01/01/04 1 NC

G0322 ESRD Rel Svc, whole month, age 2 to 11 01/01/04 1 NC

G0323 ESRD Rel Sev, whole month, age 20 > 01/01/04 1 NC

G0324 ESRD Rel Svc, partial mon/per day age <2 01/01/04 1 NC

G0325 EDRD Rel Svc part mon/per day age 12-19 01/01/04 1 NC

G0326 EDRD Rel Svc part mon/per day age 2-11 01/01/04 1 NC

G0327 EDRD Rel Svc partial mon/per day age 20> 01/01/04 1 NC

G0328 Fecal Blood Scrn Immunoassay 01/01/04 1 NCG0329 Electromagnetic therapy, ulcers 01/01/05 1 NCG0336 Pet Imaging, brain Imaging alzheimer's 01/01/05 1 NCG0337 Hospice Eval/ Counseling, Pre-Election 01/01/05 1 NCG0341 Percut Islet Cell Transplant, Incl portal vein Cath 01/01/05 1 NCG0342 Laparoscopy, Islet Cell Transplant 01/01/05 1 NCG0343 Laparotomy Islet Cell Transplant,cath. infusion 01/01/05 1 NCG0344 Init prevent phys exam; face-to-face,1st six mo 01/01/05 1 NCG0345 Intravenous infusion, hydration; initial, 01/01/05 1 NCG0346 Each Add Hour, Up To Eight (8) Hours 01/01/05 1 NCG0347 Intraven Infusion, thera/diagn Initial 01/01/05 1 NCG0348 Each Additional Hour, Up To Eight (8) Hours 01/01/05 1 NCG0349 Additional Sequential Infusion, Up To One Hour 01/01/05 1 NCG0350 Concurrent Infusion 01/01/05 1 NCG0351 Therapeutic Or Diagnostic Injection 01/01/05 1 NCG0353 Intrave Push, Single Init Sub/Drug 01/01/05 1 NCG0354 Each Additional Sequential Intravenous Push 01/01/05 1 NC

5101:3-1-60 Page 275






APPR VISIT CODE DESCRIPTION DATE CODE PRICE PRICE INDIC. DAYS GROUP DATE DATE GROUP DATE DATEG0355 Chemotherapy Administration, subcut 01/01/05 1 NCG0356 Hormonal Antineoplastic 01/01/05 1 NCG0357 Intravenous, Push Technique, Single 01/01/05 1 NCG0358 Intravenous, Push Technique, Each Add Drug 01/01/05 1 NCG0359 Chemotherapy Adm, Intrav Infus; Up 1 Hour 01/01/05 1 NCG0360 Each Additional Hour, One To Eight (8) Hours 01/01/05 1 NCG0361 Initiation Of Prolonged Chemotherapy Infusion 01/01/05 1 NCG0362 Each Additional Sequential Infusion 01/01/05 1 NCG0363 Irrigation Implan Ven Access Device 01/01/05 1 NCG0364 Bone Mar Aspir W Biopsy Same Incis 01/01/05 1 NCG0365 Vessel Mapping Vessels Hemodialy Access 01/01/05 1 NCG0366 Electrocardiogram, routine Ecg w 12 Leads 01/01/05 1 NCG0367 Tracing, w/o Interpret, Report, comp Init Prev P E 01/01/05 1 NCG0368 Interepr Report,Comp Initial Prev P E 01/01/05 1 NCG9013 Esrd Demo Basic Bundle Level I 01/01/05 1 NCG9014 Esrd demo expan bund Inc Venous Access 01/01/05 1 NCG9017 Amantadine Hydrochloride, Oral, Per 100 Mg 01/01/05 1 NCG9018 Zanamivir, Inhal Powd Admin Inhaler, Per 10 Mg 01/01/05 1 NCG9019 Oseltamivir Phosphate, Oral, Per 75 Mg 01/01/05 1 NCG9020 Rimantadine Hydrochloride, Oral, Per 100 Mg 01/01/05 1 NC

G3001 Admin + supply, tositumomab 01/01/04 1 NC

G9001 MCCD, initial rate 01/01/04 1 NC

G9002 MCCD,maintenance rate 01/01/04 1 NC

G9003 MCCD, risk adj hi, initial 01/01/04 1 NC

G9004 MCCD, risk adj lo, initial 01/01/04 1 NC

G9005 MCCD, risk adj, maintenance 01/01/04 1 NC

G9006 MCCD, Home monitoring 01/01/04 1 NC

G9007 MCCD, sch team conf 01/01/04 1 NC

G9008 Coordinated care fee, physician oversight services 01/01/04 1 8.00

G9009 MCCD, risk adj, level 3 01/01/04 1 NC



G9012 Other Specified Case Mgmt 01/01/04 1 NC

G9016 Demo-smoking cessation coun 01/01/04 1 NC

H0045 Respite care service, not in the home, per diem 01/01/04 1 WP

H1000 Prenatal care: at risk assessment 07/01/03 1 12.10

H1001 Prenatal care: antepartum management 07/01/03 1 12.10

H1002 Prenatal care: care coordination 07/01/03 1 12.10

5101:3-1-60 Page 276







H1003 Prenatal care: individual education 07/01/03 1 14.52

H1004 Follow up home visit/prental 01/01/04 1 NC

H1005 Prenatalcare enhanced srv pk 01/01/04 1 NC

H1010 Nonmed family planning ed 01/01/04 1 NC

H1011 Non-medical family planning educational visit 10/01/03 1 24.20

H5010 Psychotherapy, Indv, By Soc. Work. PerHr 10/01/03 3 NC 33.20

H5020 Psychotherapy,Grp,Soc. Work. 45-50 Mins 10/01/03 3 NC 11.00

H5025 Psychotherapy,Grp,By Nonphys,900Rmoremin 10/01/03 3 NC 16.50

H5180 Nursing Project 07/01/94 1 0.01

H5190 Private Duty Nursing (Individual-Rn) 01/01/99 3 NC 23.52

H5192 Pvt Duty Nursing (Home Hlth Agency-Rn) 01/01/99 3 NC 28.04

H5195 Pvy Duty Nursing (Home Hlth Agency-Lpn) 01/01/99 3 NC 23.56

H5200 Group Nursing (Home Hlth Agency-Rn) 01/01/99 3 NC 21.00

J0120 Tetracycline,Up To 250 Mg 07/01/02 2 4.48 14.85

J0128 Abarelix, 10 mg 01/01/05 1 80.27

J0130 Abciximab, 10 mg 10/01/04 2 459.02 513.02

J0135 Adalimumab, 20 mg 01/01/05 1 293.31

J0150 Adenosine, 6mg 12/15/02 2 BR 32.54

J0151 Adenosine 90mg 01/01/04 3 NC 212.56

J0152 Inj, Adenosine 30 mg (not for any adenosine phosphate) 10/01/04 2 66.56 77.62

J0170 Adrenalin, Epinephrine, Up To 1ml Ampule 07/01/02 2 0.58 3.35

J0180 Agalsidase beta, 1 mg 01/01/05 1 116.48

J0190 Biperiden lactate, per 5 mg 04/01/95 1 5.58

J0200 Alatrofloxacin Mesylate 100 mg 10/01/04 2 17.03 18.59

J0205 Alglucerase ,Per 10 Units 10/01/04 2 37.13 37.53

J0207 Amifostine, 500 MG 04/01/02 2 372.46 389.78

J0210 Methyldopate Hcl Up To 250 Mg 07/01/02 2 1.63 3.50

J0215 Inj, Alefacept, 0.5 mg 10/01/04 2 28.19 44.33

J0256 Alpha 1-Proteinase Inhib-Human, 10 mg 10/01/04 2 2.38 92.00

J0270 Alprostadil inj, 1.25 mcg 10/01/04 2 0.31 NC

J0275 Alprostadil urethral suppository 10/01/04 2 18.17 18.76

J0280 Aminophyllin Up To 250 Mg 10/01/04 2 0.94 1.05

J0282 Amiodarone hydrochloride, 30 MG 10/01/04 2 5.51 5.94

J0285 Amphotericin B, 50 mg 10/01/04 2 9.30 10.28

J0286 Amphotericin B, any lipid formulation, 50 mg 07/01/03 3 NC 88.66

J0287 Amphotericin B, Lipid Complex, 10 mg 10/01/04 2 19.55 25.58

J0288 Ampho B, Chol SO4 Complex, 10 mg 10/01/04 2 13.60 17.74

J0289 Amphotericin B, Liposome, 10 mg 10/01/04 2 32.03 35.80

5101:3-1-60 Page 277







J0290 Ampicillin Up To 500 Mg 12/15/02 2 1.04 1.49

J0295 Ampicillin Na/Sulbactam Na, Per 1.5 Gm 10/01/04 2 6.64 7.13

J0300 Amobarbital, Up To 125 Mg 07/01/02 2 2.20 4.24

J0330 Succinylcholine, Up To 20 Mg 07/01/02 2 0.10 5.85

J0340 Nandrolone Phenpropionate, Up To 50 Mg 04/01/02 3 NC 9.25

J0350 Anistreplase, Per 30 Units 01/01/99 2 2,546.18 2,268.00

J0360 Hydralazine Hcl, Up To 20 Mg 10/01/04 2 14.34 16.92

J0380 Metaraminol, per 10 Mg 10/01/04 2 1.14 1.27

J0390 Chloroquine Hcl,Up To 250 mg 10/01/04 2 17.61 17.92

J0395 Arbutamine HCL, 1 mg 10/01/04 2 163.20 BR

J0400 Trimethaphan, Up To 50 Mg 04/01/02 3 NC 4.97

J0456 Azithromycin 500 mg 10/01/04 2 22.72 23.22

J0460 Atropine Sulfate, Up To 0.3 Mg 10/01/04 2 0.74 2.00

J0470 Dimercaprol, per 100 Mg 10/01/04 2 21.18 6.34

J0475 Baclofen, 10 mg inj 10/01/04 2 192.53 222.02

J0476 Baclofen, 50 mcg, for intrathecal trial 10/01/04 2 71.40 79.80

J0500 Dicyclomine, Up To 20 Mg 01/01/99 2 5.20 10.17

J0510 Benzquinamide Hcl, Up To 50 Mg 04/01/02 3 NC 8.15

J0515 Benztropine 1mg 10/01/04 2 3.49 3.71

J0520 Bethanecol Chloride, up to 5 mg 10/01/04 2 4.78 5.33

J0530 Penicillin G Benzathine & G Procaine,600,000 01/01/99 2 8.08 9.84

J0540 Penicillin,C-R,Up To 1,200,000 Units 01/01/99 2 13.95 12.96

J0550 Penicillin,C-R,Up To 2,400,000 Units 01/01/99 2 32.71 30.17

J0560 Penicillin G Benzathine,600,000U 04/01/02 2 5.37 10.65

J0570 Penicillin G Benzathine,1,200,000U 07/01/02 2 5.65 16.98

J0580 Penicillin G Benzathine, Up To 2,400,000 Units 04/01/02 2 10.74 32.71

J0583 Inj, Bivalirudin, 1 mg 10/01/04 2 1.43 1.59

J0585 Botulium Toxin Type A, per unit 10/01/04 2 4.43 4.65

J0587 Botulinum Toxin Type B, per 100 units 10/01/04 2 7.86 8.79

J0590 Bronkephrine Hcl, 1 Ml 04/01/02 3 NC 6.70

J0592 Buprenorphine HCl, 0.1 mg 10/01/04 2 0.92 0.97

J0595 Inj, Butorphanol Tartrate, 1 mg 10/01/04 2 3.94 6.16

J0600 Edetate Calcium Disodium Up To 1000 mg 10/01/04 2 39.46 8.02

J0610 Calcium Gluconate, Up To 10 Ml 10/01/04 2 0.90 1.23

J0620 Calcium Phosphate&Calcium Lact, per 10 ml 10/01/04 2 5.55 4.89

J0630 Calcitonin salmon,Up To 400 Units 04/01/02 2 28.29 41.00

J0635 Calcitriol, 1mcg Amp 07/01/03 3 NC 13.18

J0636 Calcitrol, 0.1 mcg 10/01/04 2 1.24 1.38

5101:3-1-60 Page 278







J0637 Caspofungin Acetate, 5 mg 10/01/04 2 29.48 34.20

J0640 Calcium Leucovorin, per 50 Mg 10/01/04 2 3.00 10.66

J0670 Mepivicaine, per 10 ml 10/01/04 2 1.85 3.13

J0680 Deslanoside, Up To 0.4 Mg 04/01/96 3 NC 3.96

J0690 Cefazolin Sodium, 500Mg 10/01/04 2 2.01 1.68

J0692 Cefepime hydrochloride inj, 500 mg 10/01/04 2 7.28 7.60

J0694 Cefoxitin Sodium 1gm 10/01/04 2 9.56 9.84

J0695 Cefonicid Sodium, 1 Gram 04/01/02 3 NC 28.10

J0696 Ceftriaxone Sodium, Per 250 Mg 10/01/04 2 13.35 14.17

J0697 Cefuroxime Sodium sterile Per 750 Mg 10/01/04 2 5.75 6.42

J0698 Cefotaxime Sodium, Per Gm 10/01/04 2 8.51 10.45

J0702 Betamethasone Acetate / Na Po4 Per 3 Mg 10/01/04 2 4.45 4.63

J0704 Betametha Sodium Phosphate, Per 4 Mg 10/01/04 2 0.96 2.24

J0706 Caffeine citrate inj, 5 mg 10/01/04 2 3.07 3.24

J0710 Cephapirin Sodium, Up To 1 gm 07/01/02 2 1.56 3.64

J0713 Ceftazidime, Per 500 Mg 10/01/04 2 6.04 6.75

J0715 Ceftizoxime Sodium, Per 500 Mg 10/01/04 2 4.44 5.41

J0720 Chloramphenicol Na Succinate, Up to1Gm 10/01/04 2 6.46 6.81

J0725 Chorionic Gonadotropin Up To 5 Mu 10/01/04 2 2.39 3.16

J0730 Chlorpheniramine Maleate Up To 40Mg 04/01/02 3 NC 7.87

J0735 Clonidine Hydrochloride, 1 MG 10/01/04 2 49.35 55.16

J0740 Cidofovir 375 mg 10/01/04 2 754.80 803.70

J0743 Cilastatin Sodium;Imipenem 250 Mg 10/01/04 2 14.20 14.73

J0744 Ciprofloxacin inj for IV infusion, 200 mg 10/01/04 2 12.25 13.68

J0745 Codeine Phosphate, per 30 mg 10/01/04 2 0.41 1.00

J0760 Colchicine, per 1 mg 10/01/04 2 6.32 7.07

J0770 Colistimethate Sodium,Up To 150 Mg 07/01/02 2 39.90 44.28

J0780 Prochlorperazine, Up To 10 Mg 07/01/02 2 2.98 3.98

J0800 Corticotropin, Up To 40 Units 04/01/02 2 26.27 20.41

J0810 Cortisone, Up To 50 Mg 04/01/02 3 NC 3.13

J0820 Cortigel 40, Up To 40 Units 04/01/96 3 NC 5.12

J0835 Cosyntropin, Per 0.25 Mg 07/01/02 2 15.34 16.85

J0850 Cytomegalovirus IMG IV (Human), Per Vial 01/01/03 3 NC BR

J0878 Daptomycin, 1 mg 01/01/05 1 0.29

J0880 Darbepoetin Alfa, 5 mcg 10/01/04 2 21.20 23.69

J0895 Deferoxamine Mesylate,500 Mg 07/01/02 2 13.50 17.08

J0900 Testosterone Enanth&Estradl Valerate, up to 1cc 10/01/04 2 1.46 1.63

J0945 Brompheniramine Maleate, per 10 mg 07/01/02 2 0.85 3.13

5101:3-1-60 Page 279







J0970 Estradiol Valerate, Up To 40 Mg 10/01/04 2 1.44 1.62

J1000 Depo-Estradiol Cypionate, Up To 5 Mg 10/01/04 2 1.70 3.85

J1020 Methylprednisolone Acetate, 20 Mg 07/01/02 2 2.38 3.13

J1030 Methylprednisolone Acetate, 40 Mg 10/01/04 2 3.70 5.69

J1040 Methylprednisolone Acetate, 80 Mg 04/01/95 1 4.69

J1050 Medroxyprogesterone Acetate Upto100M 07/01/03 3 NC 30.68

J1051 Medroxyprogesterone Acetate, 50 mg 10/01/04 2 4.50 15.34

J1055 Medroxyprogesterone Acetate 150mg 01/01/01 2 53.27 48.48

J1056 Medroxyprogesterone ace/Estradiol cyp inj, 5mg/25mg 10/01/04 2 22.02 23.70

J1060 Testosterone & Estradiol Cypionate, up to 1 ml 04/01/02 2 3.52 6.66

J1070 Testosterone Cypionate ,Up To 100 Mg 04/01/02 2 4.09 3.31

J1080 Testosterone Cypionate, 1Cc, 200 Mg 04/01/02 2 7.12 3.49

J1090 Testosterone Cypionate, 1 Cc,50 Mg 04/01/02 3 NC 3.13

J1094 Dexamethasone Acetate, 1 mg 04/01/03 1 0.52

J1095 Dexamethasone Acetate, Per 8 Mg 07/01/03 3 NC 2.31

J1100 Dexamethasone Sodium Phosp 1 mg 10/01/04 2 0.10 0.18

J1110 Dihydroergortamine, per 1 Mg 07/01/02 2 14.59 17.64

J1120 Acetazolamide Sodium, Up To 500 Mg 10/01/04 2 18.36 23.88

J1160 Digoxin, Up To 0.5 Mg 10/01/04 2 1.59 4.54

J1165 Phenytoin Sodium, per 50 mg 07/01/02 2 0.73 4.46

J1170 Hydromorphone, Up To 4 Mg 12/15/02 2 1.22 1.28

J1180 Dyphylline, Up To 500 Mg 04/01/95 1 3.13

J1190 Dexrazoxane hydrochloride, per 250 mg 04/01/02 2 184.80 180.28

J1200 Diphenhydramine Hcl,Up To 50 Mg 07/01/02 2 0.80 3.13

J1205 Chlorothiazide Na, per 500 mg 10/01/04 2 9.38 9.50

J1212 DMSO, 50%, 50 ml 10/01/04 2 39.91 41.75

J1230 Methadone Hcl, Up To 10 Mg 10/01/04 2 0.68 0.75

J1240 Dimenhydrinate, Up To 50 Mg 10/01/04 2 0.34 0.38

J1245 Dipyridamole, Per 10 Mg 10/01/04 2 5.10 21.89

J1250 Dobutamine Hydrochloride, per 250 Mg 04/01/03 2 3.86 6.76

J1260 Dolasetron 10mg 10/01/04 2 13.85 15.63

J1270 Doxercalciferol inj, 1 mcg 12/15/02 2 4.58 BR

J1320 Amitripyline Hcl, Up To 20 Mg 10/01/04 2 2.15 2.20

J1325 Epoprostenol, 0.5 MG 04/01/03 2 12.64 BR

J1327 Eptifibatide injection 5 mg 01/01/01 2 4.48 3.61

J1330 Ergonovine Maleate,Up To 0.2Mg 07/01/02 2 4.50 6.68

J1335 Inj, Ertapenem Na, 500 mg 10/01/04 2 21.24 23.74

J1340 Aqueous Or Saline Placebo 04/01/96 3 NC 3.39

5101:3-1-60 Page 280







J1362 Erythromycin Gluceptate, Per 250 Mg 04/01/02 3 NC 7.99

J1364 Erythromycin Lactobionate, Per 500 Mg 10/01/04 2 3.14 3.51

J1380 Estradiol Valerate,Up To 10Mg 10/01/04 2 0.48 3.13

J1390 Estradiol Valerate,Up To 20Mg 10/01/04 2 1.02 1.25

J1410 Estrogen, 25mg 04/01/02 2 52.35 34.21

J1435 Estrone, per 1 mg 07/01/02 2 0.19 3.13

J1436 Etidronate Disodium, Per 300 Mg 07/01/02 2 63.65 69.28

J1438 Etanercept injection 25 mg 04/01/02 2 133.98 552.28

J1440 Filgrastim (G-Csf) 300 MCG 10/01/04 2 158.50 182.68

J1441 Filgrastim (G-Csf) 480 MCG 10/01/04 2 267.79 289.68

J1450 Fluconazole 200 mg 10/01/04 2 85.83 9.09

J1452 FOmivirsen sodium, intraocular, 1.65 MG 10/01/04 2 850.00 BR

J1455 Foscarnet Sodium,Per 1000 Mg 04/01/02 2 11.02 14.91

J1457 Gallium nitrate, 1 mg 01/01/05 1 BR

J1460 Gammaglobulin Im 1Cc 01/01/03 3 NC 1.71

J1470 Gammaglobulin, Im, 2Cc 01/01/03 3 NC 3.42








J1550 Gammaglobulin, Im,10Cc 01/01/03 3 NC 17.10

J1560 Gammaglobulin, Over 10Cc 01/01/03 3 NC 18.45

J1561 Immune Globulin, per 500 Mg 01/01/03 3 NC 54.00

J1562 Immune Globulin, Per 5 Grams 01/01/98 2 370.50 287.61

J1563 Immune Globulin, intravenous, 1G 01/01/01 1 BR

J1564 Immune Globulin, 10 mg 10/01/04 2 0.72 1.08

J1565 Respiratory Synctial Virus Immune Globulin, IV, 50 MG 01/01/03 3 NC BR

J1570 Ganciclovir Sodium 500 MG 10/01/04 2 31.53 33.89

J1580 Garamycin,Gentamicin,Up To 80 Mg 10/01/04 2 1.70 1.90

J1590 Gatifloxacin inj, 10 mg 10/01/04 2 0.81 0.85

J1595 Inj, Glatiramer Acetate, 20 mg 10/01/04 2 30.13 1,010.21

J1600 Gold Sodium Thiomalate,Up To 50Mg 07/01/02 2 11.22 15.12

J1610 Glucagon Hydrochloride, Per 1 Mg 10/01/04 2 40.80 45.60

J1620 Gonadorelin Hydrochloride, Per 100 Mcg 10/01/04 2 180.72 182.75

J1625 Granisetron Hydrochloride, Per 1 Mg 04/01/98 3 NC 177.20

5101:3-1-60 Page 281







J1626 Granisetron Hydrochloride, 100 mcg 10/01/04 2 15.62 185.40

J1630 Haloperidol, Up To 5 Mg 07/01/02 2 4.28 5.17

J1631 Haloperidol Decanoate, Per 50 Mg 10/01/04 2 8.16 25.68

J1642 Heparin Lock Flush, Per 10 Units 12/15/02 2 0.05 0.06

J1644 Heparin Sodium, Per 1000 Units 03/01/01 2 0.14 BR

J1645 Dalteparin Sodium, per 2500 iu 10/01/04 2 14.04 14.58

J1650 Enoxaparin Sodium, 10 Mg 10/01/04 2 5.46 16.59

J1652 Fondaparinux Na, 0.5 mg 10/01/04 2 7.40 8.27

J1655 Tinzaparin sodium, inj, 1000 IU 10/01/04 2 3.43 3.99

J1660 Histamine, Up To 2.75 Mg 04/01/96 3 NC 4.36

J1670 Tetanus,Human Img,Up To 250 Units 04/01/95 1 26.80

J1690 Prednisolone Tebulate, Up To 20 Mg 04/01/02 3 NC 11.57

J1700 Hydrocortisone Acetate,Up To 25Mg 10/01/04 2 0.30 0.34

J1710 Hydrocortisone Na Po4,Up To 50 Mg 10/01/04 2 4.98 5.04

J1720 Hydrocortisone Na Succin Up To100Mg 10/01/04 2 1.55 1.72

J1730 Diazoxide, Up To 300 Mg 10/01/04 2 110.01 117.03

J1739 Hydroxyprogesterone Caproate 125Mgml 04/01/02 3 NC 5.30

J1741 Hydroxyprogesterone Caproate 250Mgml 04/01/02 3 NC 8.60

J1742 Ibutilide Fumarate, 1 MG 10/01/04 2 224.89 234.68

J1745 Infliximab injection 10 mg 10/01/04 2 58.79 65.70

J1750 Iron Dextran 50 mg 10/01/04 2 16.03 17.91

J1755 Iron sucrose, inj, 20 mg 07/01/03 3 NC 13.07

J1756 Iron Sucrose, 1 mg 10/01/04 2 0.58 0.66

J1760 Iron Dextran, 2Cc 10/01/04 3 NC 38.95

J1770 Iron Dextran,5cc 10/01/04 3 NC 112.72

J1780 Iron Dextran, 10Cc 10/01/04 3 NC 186.48

J1785 Imiglucerase, Per Unit 10/01/04 2 3.71 BR

J1790 Droperidol, Up To 5 Mg 10/01/04 2 2.50 2.80

J1800 Propranolol, Hcl, Up To 1 Mg 10/01/04 2 8.45 9.60

J1810 Droperidol&Fentanyl Citrate,2Ml Amp 07/01/02 2 8.24 12.56

J1815 Insulin, per 5 units 10/01/04 2 0.09 0.12

J1817 Insulin for admin thru DME (Pump), per 50 units 04/01/03 1 1.20

J1820 Insulin, Up To 100 Units 07/01/03 3 NC 2.29

J1825 Interferon Beta-1A, 33 mcg 04/01/02 2 213.97 224.88

J1830 Interferon Beta-1B, Per 0.25 Mg 10/01/04 2 60.14 81.43

J1835 Itraconazole inj, 50 mg 10/01/04 2 32.97 35.12

J1840 Kanamycin Sulfate,Up To 500Mg 10/01/04 2 2.94 3.16

J1850 Kanamycin Sulfate, Up To 75 Mg 10/01/04 2 0.44 0.48

5101:3-1-60 Page 282







J1885 Ketorolac Tromethamine,Per 15 MG 07/01/02 2 1.59 7.97

J1890 Cephalothin Sodium, Up To 1Gm 10/01/04 2 9.18 9.61

J1910 Kutapressin, Up To 2 Ml 01/01/04 3 NC 13.28

J1930 Propiomazine, Up To 20 Mg 04/01/02 3 NC 6.45

J1931 Laronidase, 0.1 mg 01/01/05 1 26.81

J1940 Furosemide, Up To 20 Mg 10/01/04 2 0.88 0.98

J1950 Leuprolide Acetate Per 3.75 Mg 10/01/04 2 453.79 492.71

J1955 Levocarnitine, Per 1 Gm 10/01/04 2 30.60 34.20

J1956 Levofloxacin, 250 mg 10/01/04 2 18.62 19.66

J1960 Levorphanol Tartrate, Up To 2 Mg 10/01/04 2 3.37 3.76

J1970 Methotrimeprazine,Up To 20Mg 04/01/02 3 NC 26.01

J1980 Hyoscyamine Sulfate,Up To 0.25Mg 07/01/02 2 7.53 9.69

J1990 Chlordiazepoxide,,Hcl,Up to 100 Mg 10/01/04 2 22.37 23.74

J2000 Lidocaine, Hcl, 50 Cc 01/01/04 3 NC 2.16

J2001 Inj, Lidocaine HCl for IV Inf, 10 mg 10/01/04 2 0.88 2.14

J2010 Lincomycin,Up To 300 Mg 10/01/04 2 2.84 4.42

J2020 Linezolid inj, 200 mg 10/01/04 2 32.93 3.83

J2050 Liver, Up To 20 Mcg 04/01/97 3 NC 3.67

J2060 Lorazepam inj, 2 mg 10/01/04 2 2.81 2.85

J2070 Alprostadil, per 1.25 mcg 10/01/04 3 NC 48.03

J2100 Luminal Sodium, Up To 130 Mg 04/01/96 3 NC 4.68

J2150 Mannitol, 25% In 50 Ml 07/01/02 2 2.78 4.19

J2175 Meperdine inj, per 100 mg 10/01/04 2 0.48 0.56

J2180 Meperidine&promethazine,Hcl,To 50Mg 04/01/02 2 3.73 5.69

J2185 Inj, Meropenem, 100 mg 10/01/04 2 4.40 5.22

J2190 Mersalyl With Theophylline,Up To 2Ml 04/01/96 3 NC 2.94

J2210 Methylergonovine Maleate,Up To 0.2Mg 04/01/02 2 3.37 5.91

J2240 Metocurine Iodine, Up To 2 Mg 04/01/02 3 NC 2.90

J2250 Midazolam Hydrochloride, Per 1 Mg 07/01/02 2 0.86 5.29

J2260 Milrinone Lactate inj, 5 mg 04/01/02 2 41.92 40.55

J2270 Morphine sulfate,up to 10 mg 10/01/04 2 0.60 0.65

J2271 Morphine sulfate, 100 mg 10/01/04 2 6.99 8.23

J2275 Morphine Sulfate,Per 10 Mg, Preserv Free 10/01/04 2 1.70 2.00

J2280 Inj, Moxifloxacin, 100 mg 10/01/04 2 9.30 10.39

J2300 Nalbuphine Hydrochloride, Per 10 mg 12/15/02 2 1.30 1.44

J2310 Naloxone HCl inj, per 1 mg 10/01/04 2 2.12 NC

J2320 Nandrolone Deconoate, Up To 50 Mg 10/01/04 2 3.43 6.35

J2321 Nandrolone Decanoate, Up To 100 Mg 10/01/04 2 6.25 12.69

5101:3-1-60 Page 283







J2322 Nandrolone Decanoate, Up To 200 Mg. 10/01/04 2 14.08 24.23

J2324 Nesiritide, 0.5 mg 10/01/04 2 135.66 144.40

J2330 Thiothixene,Up To 4 Mg 04/01/02 3 NC 4.87

J2350 Niacinamide, Niacin, Up To 100 Mg 04/01/02 3 NC 3.13

J2352 Octreotide Acetate injection 1 mg 01/01/04 3 NC 132.40

J2353 Inj, Octreotide, Depot for IM inj, 1 mg 10/01/04 2 71.09 154.45

J2354 Inj, Octreotide, Non-Depot for SQ or IV inj, 25 mcg 10/01/04 2 3.81 90.95

J2355 Oprelvekin, 5 mg 07/01/02 2 236.31 250.68

J2357 Omalizumab, 5 mg 01/01/05 1 15.33

J2360 Orphenadrine,Up To 60 Mg 07/01/02 2 1.71 4.38

J2370 Phenylephrine, Up To 1 ml 10/01/04 2 1.15 2.12

J2400 Chloroprocaine Hcl, per 30 ml 10/01/04 2 5.72 10.36

J2405 Ondansetron Hydrochloride,Per 1Mg 10/01/04 2 5.58 6.09

J2469 Palonosetron hcl, 25 mcg 01/01/05 1 27.54

J2410 Oxymorphone, Hcl,Up To 1 Mg 10/01/04 2 2.64 2.80

J2430 Pamidronate Disodium, Per 30 Mg 10/01/04 2 237.88 265.87

J2440 Papaverine Hcl, Up To 60 Mg 10/01/04 2 2.98 3.66

J2460 Oxytetracycline,Hcl,Up To 50 Mg 10/01/04 2 0.91 0.92

J2480 Hydrocl Opium Alkaloids To20Mg 04/01/02 3 NC 5.14

J2500 Paricalcitol 5 mcg 07/01/03 3 NC 26.02

J2501 Paricalcitol, 1 mcg 10/01/04 2 4.49 5.03

J2505 Inj, Pegfilgrastim, 6 mg 10/01/04 2 2,507.50 2,802.50

J2510 Penicillin G Procn,Aq,To 600000 Unit 04/01/95 2 2.24

J2512 Pentagastrin 04/01/02 3 NC 37.81

J2515 Pentobarbital Sodium, per 50 mg 10/01/04 2 1.18 1.06

J2540 Penicillin G Potassium To 600000 Un 10/01/04 2 0.26 0.88

J2543 Piperacillin/tazobactam Sodium 1 gram /0.125 grams 10/01/04 2 4.39 4.95

J2545 Pentamidine isethionte/300mg 04/01/04 1 NC

J2550 Promethazine,Hcl,Up To 50 Mg 07/01/02 2 0.93 3.13

J2560 Phenobarbital Sodium, Up To 120 Mg 10/01/04 2 1.44 2.42

J2590 Oxytocin,Up To 10 Units 07/01/02 2 0.77 4.56

J2597 Desmopressin Acetate, Per 4 1 Mcg 10/01/04 2 3.09 16.48

J2640 Prednisolone Na Phosphate,To 20 Mg 04/01/02 3 NC 13.41

J2650 Prednisolone Acetate,Up To 1 Ml 10/01/04 2 0.22 0.59

J2670 Tolazoline,Hcl,Up To 25 Mg 10/01/04 2 3.51 3.71

J2675 Progesterone inj, per 50 mg 10/01/04 2 3.18 3.39

J2680 Fluphenazine Decanoate,Up To 25 Mg 04/01/02 2 7.08 12.51

J2690 Procainamide, Hcl, Up To 1 Gm 10/01/04 2 1.24 1.72

5101:3-1-60 Page 284







J2700 Oxacillin Sodium,Up To 250 Mg 07/01/02 2 0.66 3.75

J2710 Neostigmine Methylsulfate,Up To 0.5Mg 10/01/04 2 0.59 0.65

J2720 Protamine Sulfate, 10 mg 04/01/03 2 0.48 0.65

J2725 Protirelin, Per 250 Mcg 10/01/04 2 21.83 24.40

J2730 Pralidoxime Chloride,Up To 1Gm 01/01/99 2 32.93 30.95

J2760 Phentolamine Mesylate,Up To 5Mg 10/01/04 2 28.56 33.25

J2765 Metoclopramide,Hcl,Up To 10Mg 10/01/04 2 1.67 1.89

J2770 Quinupristin/Dalfopristin, 500 MG 07/01/02 2 102.06 105.41

J2780 Ranitidine Hydrochloride inj 25 mg 10/01/04 2 1.29 1.43

J2783 Inj, Rasburicase, 0.5 mg 10/01/04 2 105.54 353.88

J2788 Rho D Immune Globulin, Human, 50 mcg 04/01/03 1 41.33

J2790 Rho-D Immune Globulin,Human,50 ug 01/01/03 3 NC 100.32

J2792 Rho-D immune globulin, IV, human, solvent deter. 100 iu 01/01/99 1 14.41

J2794 Risperidone, long acting 0.5 mg 01/01/05 1 4.64

J2795 Ropivacaine Hydrochloride, 1 MG 10/01/04 2 0.06 0.09

J2800 Methocarbamol,Up To 10 Ml 10/01/04 2 3.40 3.80

J2810 Theophylline, 40 mg 07/01/02 2 1.08 4.06

J2820 Sargramostim (Gm-Csf), 50mcg 10/01/04 2 24.47 27.61

J2860 Secobarital Sodium,Up To 100 Mg 04/01/02 3 NC 4.96

J2910 Aurothioglucose, Up To 50 Mg 04/01/02 2 13.84 17.62

J2912 Sodium Chloride 01/01/01 2 BR 3.23

J2914 Sodium Salicylate 04/01/96 3 NC 9.67

J2915 Sodium ferric gluconate complex in sucrose inj, 62.5 MG 07/01/03 3 NC 40.85

J2916 Sodium Ferric Gluconate Cmplx in Sucrose, 12.5 mg 10/01/04 2 7.31 8.17

J2920 Methylpredisolone Na Succinate T0 40Mg 10/01/04 2 1.41 1.58

J2930 Methylpredisolone Na Succinate T0 125Mg 10/01/04 2 1.72 1.92

J2940 Somatrem inj, 1 mg 10/01/04 2 40.76 45.55

J2941 Somatropin inj, 1 mg 10/01/04 2 41.09 43.74

J2950 Promazine,Hcl,Up To 25 Mg 10/01/04 2 0.41 0.46

J2970 Methicillin Sodium, Up To 1 Gm 04/01/02 3 NC 13.02

J2993 Reteplase, 18.1 MG 01/01/01 1 112.28

J2994 Reteplase, 37.6mg 12/15/02 3 NC BR

J2995 Streptokinase,IV, Per 250,000 iu 10/01/04 2 79.69 101.20

J2996 Alteplase Recombinant,Per 10 Mg 01/01/01 2 BR 277.01

J2997 Alteplase Recombinant, 1 MG 07/01/02 2 26.13 28.68

J3000 Streptomycin, Up To 1 Gm 04/01/95 1 3.13

J3005 Strontium-89 Chloride, PER 10 Ml 04/01/98 3 NC 2,031.89

J3010 Fentanyl Citrate, 0.1 mg 10/01/04 2 0.83 1.10

5101:3-1-60 Page 285







J3030 Sumatriptan Succinate, 6 Mg 10/01/04 2 23.76 25.94

J3070 Pentazocine,Up To 30 Mg 04/01/02 2 2.26 6.11

J3080 Chlorprothiene,Up To 50 Mg 04/01/02 3 NC 12.88

J3100 Tenecteplase inj, 50 mg 10/01/04 2 2,407.63 2,612.50

J3105 Terbutaline Sulfate, Up To 1 Mg. 07/01/02 2 2.13 3.96

J3110 Teriparatide, 10 mcg 01/01/05 1 7.43

J3120 Testosterone Enanthate,Up To 100 Mg 07/01/02 2 0.57 3.13

J3130 Testosterone Enanthate,Up To 200 Mg 07/01/02 2 1.14 3.45

J3140 Testosterone,Aqueous,Up To 50 Mg 04/01/03 2 0.67 0.81

J3150 Testosterone Propionate, Up To 100Mg 10/01/04 2 0.84 0.94

J3230 Chlorpromazine Hcl,Up To 50Mg 04/01/02 2 3.29 4.10

J3240 Thytropar,Thyrotropin,Alpha,0.9 mg in 1.1 mg vial 09/08/04 2 673.20 463.58

J3245 Tirofiban Hydrochloride 12.5 mg 01/01/05 3 NC 414.59

J3246 Tirofiban, hcl, 0.25 mg 01/01/05 1 8.43

J3250 Trimethobenzamide, Hcl ,To 200Mg 04/01/02 2 1.18 2.58

J3260 Tobramycin Sulfate,Up To 80 Mg 10/01/04 2 3.99 5.91

J3265 Torsemide, Per 10 Mg 10/01/04 2 1.39 2.09

J3270 Imipramine,Up To 25 Mg 04/01/02 3 NC 4.44

J3280 Thiethyperazine Maleate,To10Mg 04/01/03 2 4.34 4.60

J3301 Triamcinolone Acetonide Per 10Mg 12/15/02 2 0.81 1.44

J3302 Triamcinolone Diacetate, Per 5 Mg 04/01/02 2 0.19 3.13

J3303 Triamcinolone Hexacetinide, Per 5 Mg 10/01/04 2 0.90 2.47

J3305 Trimetrexate Glucuronate, per 25 Mg 04/01/02 2 112.81 87.68

J3310 Perphenazine,Up To 5 Mg 07/01/02 2 6.93 8.42

J3315 Triptorelin Pamoate, 3.75 mg 10/01/04 2 356.66 415.24

J3320 Spectinomycin Dihydrochloride, To 2Mg 10/01/04 2 25.30 25.46

J3340 Cryptenamine Acetate,Up To 2 Ml 04/01/96 3 NC 18.52

J3350 Injection, Urea, Up To 40 Gm 04/01/04 1 NC

J3360 Diazepam, 5 mg 10/01/04 2 0.77 2.19

J3364 Urokinase, 5000 Iu Vial 10/01/04 2 50.65 56.61

J3365 Urokinase,250,000 Iu/Vial 10/01/04 2 457.66 466.17

J3370 Vancomycin, Hcl, Up To 500 Mg 10/01/04 2 2.58 5.20

J3380 Isoxsuprine, Hcl,Up To 10 Mg 04/01/96 3 NC 5.05

J3390 Methoxamine, Up To 20 Mg 04/01/02 3 NC 26.42

J3395 Verteporfin inj, 15 mg 01/01/05 3 NC 1,307.75

J3396 Verteporfin inj, 0.1 mg 01/01/05 1 9.56

J3400 Triflupromazine, Up To 20 Mg 07/01/02 2 11.86 14.48

J3410 Hydroxyzine, Up To 25 Mg 07/01/02 2 0.68 3.13

5101:3-1-60 Page 286







J3411 Inj, Thiamine HCl, 100 mg 10/01/04 2 0.81 1.33

J3415 Inj, Pyridoxine HCl, 100 mg 10/01/04 2 0.47 2.68

J3420 Vitamin B- 12, Up To 1000 Mcg 04/01/02 2 0.11 3.93

J3430 Vitamin K, per 1 mg 10/01/04 2 1.98 2.21

J3450 Mephentermine Sulfate,Up To 30 Mg 04/01/02 3 NC 4.02

J3465 Inj, Voriconazole, 10 mg 10/01/04 2 4.51 5.05

J3470 Hyaluronidase,Up To 150 Units 04/01/02 2 5.89 25.37

J3475 Magnesium Sulfate, Per 500 Mg 10/01/04 2 0.20 0.29

J3480 Potassium Chloride, Per 2 Meq 10/01/04 2 0.07 0.11

J3485 Zidovudine, 10 MG 10/01/04 2 0.91 1.01

J3486 Inj, Ziprasidone Mesylate, 10 mg 10/01/04 2 18.60 20.78

J3487 Zoledronic Acid, 1 mg 10/01/04 2 194.54 203.40

J3490 Unclassified Drugs 11/15/04 2 BR NC

J3520 Endrate/Chelation Therapy 04/01/04 1 NC

J3530 Nasal Vaccine Inhalation 04/01/04 1 NC

J3535 Metered Dose Inhaler Drug 11/15/04 2 BR NC

J3570 Laetrile, Amygdalin, Vitamin B17 04/01/04 1 NC

J3590 Unclassified biologics 11/15/04 2 BR NC

J7030 Saline Solu.,normal 1000 Cc 04/01/95 1 7.66

J7040 Normal Saline Sol.Ster. 500 Ml Infus = 1 unit 10/01/04 2 5.64 7.56

J7042 Dextrose 5%/Normal saline (500 Ml =1 Un 10/01/04 2 8.45 9.43

J7050 Normal Saline Solu,250 Cc, Infus 10/01/04 2 2.22 4.46

J7051 Sterile Saline Or Water, up to 5cc 10/01/04 2 0.68 NC

J7060 Dextrose 5%/Water (500 Ml = 1 Unit) 12/15/02 2 6.21 8.82

J7070 Dextrose 5%/Water, 1000 Cc 10/01/04 2 9.78 11.45

J7100 Dextran 40, 500 Ml 10/01/04 2 22.47 42.00

J7110 Dextran 75, 500 Ml 10/01/04 2 12.72 64.85

J7120 Ringers Lactate,Iv,Up To 1000 Units 10/01/04 2 11.13 11.74

J7130 Hypertonic Saline Solution 50 Or 100 Meq 04/01/04 1 NC

J7190 Factor Viii,Heat-Treated,Per Unit 04/01/03 2 0.87 BR

J7191 Factor Viii (Antihemophilic Factor (Porcine)), Per Iu 04/01/03 2 2.04 BR

J7192 Factor Viii,(Recombinant) 04/01/04 1 NC

J7193 Factor IX (antihem factor, purified, non-recomb), per I.U. 04/01/03 2 1.12 BR

J7194 Factor 1X,Complex,Heat Treated, Per Unit 04/01/03 2 0.33 BR

J7195 Factor IX (antihemophilic factor, recombinant), per I.U. 10/01/04 2 0.95 1.12

J7196 Oth Heme Clot Fac;Anti-Inhib,E.G., 1 Iu 10/01/04 3 NC BR

J7197 Antithrombin III (human), per IU injection 10/01/04 2 1.50 NC

J7198 Anti-inhibitor per i.u. 04/01/03 2 1.43 BR

5101:3-1-60 Page 287







J7199 Hemophilia clot factor noc 01/01/00 1 BR

J7300 Intrauterine copper contraceptive 10/01/04 2 344.00 322.93

J7302 Levonorgestrel-releasing intrauterine contracep sys, 52 mg01/01/02 1 391.62

J7303 Contracept, Hormone Containing Vaginal Ring, Ea 01/01/04 1 37.71

J7304 Contraceptive supply, hormon w patch, each 01/01/05 1 10.03

J7308 Aminolevulenic Acid, topical 20%, single ud (354 mg) 10/01/04 2 90.31 BR

J7310 Gancyclovir implant 4.5 mg 01/01/01 1 4,002.28

J7315 Sodium hyaluronate, 20 mg 04/01/02 3 NC 112.00

J7316 Sodium hylauronate, intra-articular inj, 5 mg 07/01/03 3 NC BR

J7317 Na Hyaluronate, per 20-25 mg dose, intra-articular inj 10/01/04 2 124.11 BR

J7320 Hylan G-F 20 16 mg 10/01/04 2 201.24 223.25

J7330 Autologous cultured chondrocytes, implant 01/01/01 1 BR

J7340 Dermal/Epidermal human tissue, per square centimeter 01/01/02 1 BR

J7343 Dermal Tissue, non-human, per sq cm 01/01/05 1 BR

J7342 Dermal Tissue, Human, w/ Metab Active Elem; per sq cm 04/01/03 1 BR

J7344 Dermal Tissue, Human w/wo oth bioeng process 01/01/05 1 BR

J7350 Dermal Tissue, Human, Inj, w/o Metab Active, per 10 mg 04/01/03 1 BR

J7500 Azathioprine Oral Tab, 50 Mg 10/01/04 2 1.11 1.21

J7501 Azathioprine Parenteral,100Mg 10/01/04 2 53.54 59.84

J7502 Cyclosporine Oral, 100Mg 04/01/97 3 NC 7.33

J7503 Cyclosporine, IV, 10X5MLX250MG 10/01/04 3 NC 293.86

J7504 Lymphocyte IG,Antithimyocyte,Equine 250mg 01/01/01 2 54.73 253.76

J7505 Muromonab-CD3, 5 mg parenteral 01/01/01 2 698.28 566.50

J7506 Prednisone, oral, per 5 mg 10/01/04 2 0.03 NC

J7507 Tacrolimus, Oral, Per 1 Mg 01/01/01 2 2.94 2.37

J7508 Tacrolimus, Oral, Per 5 Mg 01/01/04 3 NC 14.73

J7509 Methylprednisolone Oral, Per 4 Mg 10/01/04 2 0.44 0.50

J7510 Prednisolone Oral, per 5 Mg 12/15/02 2 0.03 0.05

J7511 Lymphocyte IG; Antithymocyte, Rabbit, 25 mg 07/01/02 2 251.75 267.28

J7513 Daclizumab, parenteral, 25 mg 10/01/04 2 380.36 397.29

J7515 Cyclosporine oral 25 mg 10/01/04 2 1.17 1.31

J7516 Cyclosporin parenteral 250mg 07/01/02 2 25.08 31.44

J7517 Mycophenolate Mofetil oral 250 mg 04/01/02 2 2.53 2.25

J7518 Mycophenoic acid, oral, 180 mg 01/01/05 1 2.39

J7520 Sirolimus, oral, 1 MG 01/01/01 1 5.47

J7525 Tacrolimus, parenteral, 5 MG 10/01/04 2 106.29 113.15

J7599 Immunosuppressive Drug, Not otherwise classified 01/01/96 1 BR

J7608 Acetylcysteine inh sol ud, per gm 12/15/02 2 5.27 BR

5101:3-1-60 Page 288







J7611 Albuterol, inhalation sol, concentr form, 1 mg, 01/01/05 1 0.06

J7612 Levalbuterol, inhal sol, concen form, 0.5 mg 01/01/05 1 BR

J7613 Albuterol, inhalation sol, unit dose, 1 mg, 01/01/05 1 0.18

J7614 Levalbuterol, inhal sol, unit dose, 0.5 mg 01/01/05 1 BR

J7616 Albuterol up to 5 mg & ipratropium brom up 1 mg 01/01/05 1 BR

J7617 Levalbuterol, up 2.5 mg & ipratropi brom up 1 mg 01/01/05 1 BR

J7618 Albuterol inh sol con, per mg albuterol 01/01/05 3 NC 0.12

J7619 Albuterol inh sol ud Admin. , per mg albuterol 01/01/05 3 NC 0.39

J7621 Albu up to 5mg or Levoalb 2.5mg/Ipratrop up to 1mg Cpd 01/01/05 3 NC 1.90

J7622 Beclomethasone inh soln, ud, per mg 01/01/02 1 BR

J7624 Betamethasone inh soln, ud, per mg 01/01/02 1 BR

J7626 Budesonide inh soln, ud, 0.25 mg to 0.5 mg 01/01/02 1 2.28

J7628 Bitolterol mes inhal sol con, per mg Admin. through DME 12/15/02 2 0.25 BR

J7629 Bitolterol mes inh sol ud Admin. , per mg 12/15/02 2 0.32 BR

J7631 Cromolyn sodium inh sol ud, per 10 mg 10/01/04 2 0.31 0.37

J7633 Budesonide Inh, conc, per 0.25 mg 10/01/04 2 0.05 3.99

J7635 Atropine inhal sol con Admin. ud, per mg 12/15/02 2 0.16 BR

J7636 Atropine inhal sol unit dose, per mg 10/01/04 2 0.32 0.34

J7637 Dexamethasone inhal sol con Admin. u d , per mg 01/01/00 1 BR

J7638 Dexamethasone inhal sol ud, per mg 01/01/00 1 BR

J7639 Dornase alfa inhal sol u d, per Mg 10/01/04 2 14.92 16.67

J7641 Flunisolide inh soln, ud, per mg 10/01/04 2 0.63 2.28

J7642 Glycopyrrolate inhal sol con, per mg 12/15/02 2 0.31 BR

J7643 Glycopyrrolate inhal sol u d, per mg 12/15/02 2 0.76 BR

J7644 Ipratropium brom inh sol u d, per mg 01/01/00 1 BR

J7645 Ipratropium Bromide 0.02%, Per Ml 04/01/01 3 0.45 0.71

J7648 Isoetharine hcl inh sol con, per mg 12/15/02 2 0.17 BR

J7649 Isoetharine hcl inh sol u d, per mg 12/15/02 2 0.21 BR

J7658 Isoproterenol hcl inh sol con, per mg 01/01/00 1 BR

J7659 Isoproterenol hcl inh sol ud, per mg 01/01/00 1 BR

J7668 Metaproterenol inh sol con, per 10 mg 12/15/02 2 0.25 BR

J7669 Metaproterenol inh sol u d, per 10 mg 12/15/02 2 1.09 BR

J7674 Methacholine chloride as inhal sol per 1 mg, nebul 01/01/05 1 BR

J7680 Terbutaline so4 inh sol con, per mg 12/15/02 2 4.44 BR

J7681 Terbutaline so4 inh sol u d, per mg 12/15/02 2 4.62 BR

J7682 Tobramycin inhalation sol, ud, 300 mg 10/01/04 2 44.08 46.92

J7683 Triamcinolone inh sol con, per mg 10/01/04 2 0.10 0.11

J7684 Triamcinolone inh sol ud, per mg 10/01/04 2 0.17 0.21

5101:3-1-60 Page 289







J7699 Inhalation solution for DME 11/15/04 2 BR NC

J7799 Non-inhalation drug for DME 11/15/04 2 BR NC

J8499 Oral prescrip drug non chemo 11/15/04 2 BR NC

J8501 Aprepitant, oral, 5 mg 01/01/05 1 5.38

J8510 Busulfan Oral 2mg 10/01/04 2 1.86 1.98

J8520 Capecitabine Oral 150 mg 12/15/02 2 2.67 BR

J8521 Capecitabine Oral 500 mg 12/15/02 2 8.92 BR

J8530 Cyclophosphamide; Oral, 25 Mg 07/01/97 2 1.55 4.99

J8560 Etoposide; Oral, 50 Mg 07/01/97 2 33.55 38.43

J8565 Gefitinib, oral, 250 mg 01/01/05 1 1,722.14

J8600 Melphalan; Oral, 2 Mg 01/01/99 2 1.75 1.58

J8610 Methotrexate; Oral, 2.5 Mg 04/01/02 2 2.64 1.43

J8700 Temozolomide, oral, 5 MG 01/01/01 1 5.01

J8999 Oral prescription drug chemo 11/15/04 2 BR NC

J9000 Doxorubicin Hcl, 10 Mg 10/01/04 2 8.16 41.28

J9001 Doxorubicin Hcl Liposome inj all lipid form. 10 mg 04/01/02 2 341.01 BR

J9010 Alemtuzumab, 10 mg 04/01/03 1 511.22

J9015 Aldesleukin, Per single use vial 10/01/04 2 657.15 672.60

J9017 Arsenic Trioxide, 1 mg 12/15/02 2 31.35 BR

J9020 Asparaginase, Up To 10000 Unt 10/01/04 2 56.02 56.72

J9031 Bcg Live (Intravesical), per instillation 10/01/04 2 143.28 166.49

J9035 Bevacizumab, 10 mg 01/01/05 1 58.44

J9040 Bleomycin Sulfate 15 Un 10/01/04 2 150.61 289.37

J9041 Bortezomib, 0.1 mg 01/01/05 1 27.89

J9045 Carboplatin, Per 50 Mg 04/01/02 2 117.95 98.12

J9050 Carmustine, 100 Mg 01/01/99 2 97.58 85.97

J9055 Cetuximab, 10 mg 01/01/05 1 48.96

J9060 Cisplatin, 10 Mg 10/01/04 2 13.56 42.18

J9062 Cisplatin, 50 MG 10/01/04 2 67.79 204.46

J9065 Cladribine, Per 1 Mg 10/01/04 2 45.90 58.48

J9070 Cyclophosphamide 100 Mg 10/01/04 2 5.13 5.98

J9080 Cyclophosphamide, 200 MG 10/01/04 2 9.74 11.34

J9090 Cyclophosphamide, 500 MG 10/01/04 2 20.45 23.81

J9091 Cyclophosphamide, 1 GM 10/01/04 2 40.92 47.64

J9092 Cyclophosphamide, 2 GM 10/01/04 2 81.82 95.27

J9093 Cyclophosphamide, lyophilized, 100 MG 10/01/04 2 5.21 6.13



5101:3-1-60 Page 290







J9096 Cyclophosphamide, lyophilized, 1GM 10/01/04 2 40.92 48.86

J9097 Cyclophosphamide, lyophilized, 2GM 10/01/04 2 83.95 97.75

J9098 Cytarabine Lipsome, 10 mg 10/01/04 2 332.35 371.45

J9100 Cytarabine 100 Mg 07/01/02 2 5.94 6.67

J9110 Cytarabine 500 MG 10/01/04 2 7.65 15.13

J9120 Dactinomycin, 0.5Mg 10/01/04 2 12.41 13.23

J9130 Dacarbazine, 100 Mg 10/01/04 2 10.04 12.68

J9140 Dacarbazine, 200 MG 10/01/04 2 19.47 22.52

J9150 Daunorubicin,10MG 10/01/04 2 66.42 76.63

J9151 Daunorubicin citrate, liposomal formulation, 10 mg 01/01/99 1 51.80

J9160 Denileukin diftitox, 300 MCG 10/01/04 2 1,190.85 BR

J9165 Diethystilbestrol Dipo4,Per 250 Mg 10/01/04 2 12.89 14.41

J9170 Docetaxel, 20 MG 01/01/01 2 300.86 497.23

J9178 Inj, Epirubicin HCl, 2 mg 10/01/04 2 24.73 27.46

J9180 Epirubicin hydrochloride, 50 MG 01/01/04 3 NC 623.44

J9181 Etoposide, 10 mg 10/01/04 2 1.53 9.93

J9182 Etoposide, 100 MG 10/01/04 2 15.30 BR

J9185 Fludarabine Phosphate, 50 MG 04/01/02 2 276.96 253.48

J9190 Flurouracil, 500 Mg 10/01/04 2 1.85 2.47

J9200 Floxuridine,500 Mg 10/01/04 2 122.40 129.56

J9201 Gemcitabine HCL, 200 MG 04/01/02 2 97.02 101.83

J9202 Goserelin Acetate Implant Per 3.6 Mg 10/01/04 2 375.99 446.49

J9206 Irinotecan, 20 MG 10/01/04 2 122.73 127.54

J9208 Ifosfamide, Per Gm. 10/01/04 2 134.55 148.82

J9209 Mesna, Per 200 Mg 10/01/04 2 31.45 36.48

J9211 Idarubicin Hydrochloride,5 Mg 10/01/04 2 375.73 391.60

J9212 Interferon alfacon-1, recom., 1 mcg 10/01/04 2 3.67 3.89

J9213 Interferon,Alfa-2A,Recom. 3Million Unit 10/01/04 2 31.21 33.14

J9214 Interferon,Alfa-2B,Recomb 1Million Unit 04/01/02 2 10.73 12.58

J9215 Interferon,Alfa-N3 250000 Iu 10/01/04 2 7.03 7.86

J9216 Interferon,Gamma 1-B 3Million Units 10/01/04 2 187.19 271.37

J9217 Leuprolide Acetate, Depot Suspen, 7.5 Mg 10/01/04 2 500.58 592.60

J9218 Leuprolide Acetate,Per 1Mg 10/01/04 2 23.26 31.64

J9219 Leuprolide acetate implant 65 MG 10/01/04 2 4,831.40 BR

J9230 Mechlorethamine,Hcl,10Mg 10/01/04 2 10.74 12.01

J9245 Melphalan Hydrochloride, 50 Mg 01/01/01 2 369.59 321.96

J9250 Methotrexate Sodium, 5 mg 10/01/04 2 0.35 0.62

J9260 Methotrexate Sodium 50 Mg 10/01/04 2 4.25 6.18

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J9263 Inj, Oxaliplatin, 0.5 mg 10/01/04 2 8.45 9.45

J9265 Paclitaxel, 30 MG 10/01/04 2 138.28 162.17

J9266 Pegasparagase, Per single dose vial 10/01/04 2 1,277.13 1,321.65

J9268 Pentostatin, 10 MG 04/01/02 2 1,636.91 1,557.27

J9270 Plicamycin, 2.5 mg 10/01/04 2 83.93 93.80

J9280 Mitomycin, 5 mg 10/01/04 2 57.12 121.65

J9290 Mitomycin,20 mg 10/01/04 2 185.64 412.87

J9291 Mitomycin,40 mg 10/01/04 2 255.00 869.25

J9293 Mitoxantrone Hcl, Per 5 Mg 04/01/02 2 232.00 227.65

J9295 Polyestradiol Phosphate 40 Mg 04/01/96 3 NC 41.74

J9300 Gemtuzumab Ozogamicin, 5 mg 10/01/04 2 1,953.94 BR

J9305 Pemetrexed, 10 mg 01/01/05 1 41.44

J9310 Rituximab, 100 mg 10/01/04 2 427.28 431.82

J9320 Streptozocin, 1 GM 07/01/02 2 117.64 126.11

J9340 Thiotepa 15 MG 04/01/95 1 68.41

J9350 Topotecan, 4 MG 12/15/02 2 695.01 636.43

J9355 Trastuzumab 10 mg 10/01/04 2 52.01 52.83

J9357 Valrubicin 200 mg 10/01/04 2 471.24 526.68

J9360 Vinblastine Sulfate, 1mg 10/01/04 2 2.81 3.14

J9370 Vincristine Sulfate,1Mg 10/01/04 2 30.40 32.07

J9375 Vincristine Sulfate, 2 mg 01/01/99 2 40.25 74.11

J9380 Vincristine Sulfate, 5 mg 10/01/04 2 152.02 154.57

J9390 Vinorelbine Tartrate, Per 10 Mg 10/01/04 2 76.19 99.28

J9395 Inj, Fulvestrant, 25 mg 01/01/04 1 87.57

J9600 Porfimer Sodium, 75 MG 10/01/04 2 2,329.60 BR

J9999 Inj.Not Otwse Classif,Antineoplastic Drg 03/15/85 1 BRK0001 Standard Wheelchair 01/01/97 1 PA 0.00K0002 Standard Hemi (low seat) Wheelchair 01/01/97 1 PA 0.00K0003 Lightweight Wheelchair 01/01/97 1 PA 0.00K0004 High strength, lightweight Wheelchair 01/01/97 1 PA 0.00K0005 Ultralight Wheelchair 01/01/97 1 PA 0.00K0006 Heavy duty Wheelchair 01/01/97 1 PA 0.00K0007 Extra Heavy duty Wheelchair 01/01/97 1 PA 0.00

K0008 Custom Manual Wheelchair/Base 04/01/02 3 NC 0.00K0009 Other Manual Wheelchair/Base 01/01/97 1 PA 0.00K0010 Standard Wt/Frm Power Wheelchair 01/01/97 1 PA 0.00K0011 Standard Wt/Frm Power WC, programmable 01/01/97 1 PA 0.00K0012 Lightweight Port. Power WC Base 01/01/97 1 PA 0.00

5101:3-1-60 Page 292







K0013 Custom Power Wheelchair Base 04/01/02 3 NC 0.00K0014 Other Motorized/Power Wheelchair Base 01/01/97 1 PA 0.00

+ K0016 Det.Adj.Height Armrest.Complete,Each 10/01/04 3 NC 55.00

K0020 WC access; adjustable height armrest, pair 07/01/94 1 40.82

+ K0021 Anti-Tipping Device 10/01/04 3 NC 49.00

++ K0023 Solid Back Insert, W/ Straps 01/01/05 3 NC 77.82

++ K0024 Solid Back Insert,W/ Adj. Hook-On 01/01/05 3 NC 89.25

+ K0025 Hook-On Headrest Extension 10/01/04 3 NC 50.00

+ K0028 Fully Reclin.Back (Manually Operated) 10/01/04 3 NC 400.00

+ K0030 Solid Seat Insert 10/01/04 3 NC 63.00

+ K0031 Safety Belt/Pelvic Strap 10/01/04 3 NC 28.00

K0034 Heel Loop, Each 10/01/04 3 NC 10.00

K0035 Heel Loop, With Ankle Strap 10/01/04 3 NC 19.50

K0036 Toe Loop, Each 10/01/04 3 NC 11.00

K0037 High Mount Flip-Up Footrest 07/01/94 1 35.98

K0038 Leg Strap 07/01/94 1 20.00

K0039 Leg Strap, H Style 07/01/94 1 41.25

K0040 Adjustable Angle Footplate 07/01/94 1 55.00

K0041 Large Size (No. 2) Footplate 07/01/94 1 31.00

+ K0048 Elevating Legrest, Complete Assembly, Each 10/01/04 3 NC 83.00

+ K0052 Swing Away Detachable Footrest, Each 01/01/05 2 80 NC

K0053 Elevating Legrests Articulating, Each 01/01/97 1 85.00

+ K0054 Seat Width For Hi Strgth Or Ultra Lt.Wt. WC 10/01/04 3 NC 89.28

+ K0055 Seat Dpth For Hi Strgth Or Ultra Lt.Wt. 10/01/04 3 NC 81.15

K0056 St.Ht. For Hi Strgt. Lt. Wt. Or Ult. Lt. Wt. 10/01/04 2 90.00 81.15

+ K0057 Seat Width For Heavy Duty/Xtra Heavy Duty WC 10/01/04 3 NC 105.97

+ K0058 Seat Dpth For Motorized/Power Wheelchair 10/01/04 3 NC 51.50

++ K0059 Plastic Coated Handrim, Each 01/01/05 3 NC 27.50

K0061 Aluminum handrim each 01/01/05 3 NC 36.00

+ K0062 Handrim With 8-10 Vert. Or Oblique Projs 10/01/04 3 NC 44.50

+ K0063 Handrim With 12-16 Vert. Or Oblique Projs 10/01/04 3 NC 59.25

K0064 Zero Pressure Tube(Flat Free Insert) 07/01/94 1 25.00

K0065 Spoke protectors, each 10/01/04 1 41.00

K0067 Pneumatic Tire 07/01/02 2 34.60 35.00

K0073 Caster Pin Lock 07/01/94 1 27.00

K0074 Pneumatic Caster Tire, Any Size, Each 07/01/02 2 30.45 31.00

K0075 Semi-Pneum. Caster Tire, Any Size, Each 07/01/94 1 32.00

+ K0079 Wheel Lock Extension, Pair 10/01/04 3 NC 22.00

5101:3-1-60 Page 293







+ K0080 Anti-Rollback Device (Grade Aid) Pair 10/01/04 3 NC 60.00

K0082 22 NF Deep Cycle Lead Acid Battery, Each 10/01/04 3 NC 60.00

K0083 22 NF Gel Cell Battery, Each 10/01/04 3 NC 100.00

K0084 Group 24 Deep Cycle Lead Acid Battery Eac 10/01/04 3 NC 60.00

K0085 Group 24 Gel Cell Battery, Each 10/01/04 3 NC 100.00

K0086 U-1 Lead Acid Battery, Each 08/01/98 3 NC

K0087 U-1 Gel Cell Battery, Each 10/01/04 3 NC 100.00

K0088 Battery Charger, Lead Acid Or Gel Cell 10/01/04 3 NC 150.00

K0089 Battery Charger, dual mode 10/01/04 3 NC 150.00

K0093 PWC, Rear wheel zero press tire tube insert 01/01/05 1 140.00

K0097 PWC,wheel zer press tire tube, any size 01/01/05 1 57.00

K0100 Amputee Adapter, Pair 10/01/04 3 NC 54.00

+ K0101 One Arm Drive Attachment 10/01/04 3 NC 434.20

K0102 Crutch And Cane Holder 07/01/94 1 23.00

K0103 Transfer Board, <25" 10/01/04 3 NC 46.62

K0104 Cylinder Tank Carrier 07/01/94 1 91.25

K0105 IV Hanger 07/01/94 1 79.50

K0106 Arm Trough 07/01/94 1 94.18

K0107 Wheelchair Tray, Positioning Only 06/01/96 3 NC 116.00

K0108 Other Accessories, Wheelchair 01/01/95 1 BR

K0114 WC back support sys prefabricated inner frame 10/01/04 1 NC

++ K0115 WC seat sys; custom fabricated for attach 01/01/05 3 NC 810.00

++ K0116 WC seat sys; comb seat & back custom molded 01/01/05 3 NC 1,700.00

+ K0117 Unlisted Item,Orth.Seating,Back Module 10/01/04 3 NC 0.00

K0183 Nasal Application Device, Used With CPAP 10/01/04 3 NC 66.71

K0184 Nasal Sngl Pc Intrfc, Repl.For CPAP App.Device 10/01/04 3 NC 21.36

K0190 Canister, disposable, used w/ suction pump 04/01/00 3 NC 7.50

K0191 Canister, nondisposable, used w/ suction pump 01/01/96 1 NC

K0192 Tubing, used with suction pump 04/01/00 3 NC 3.75

K0195 WC, elevating legrest, pair 10/01/04 1 NC

K0196 Alginate Dressing, 16 sq in or less 06/30/97 3 NC 6.00

K0197 Alginate Dressing, >16 but < 48 sq in 06/30/97 3 NC 12.50

K0198 Alginate Dressing, more than 48 sq in 06/30/97 3 NC 0.00

K0199 Alginate Dressing, wound filler 06/30/97 3 NC 100.00

K0203 Composite Dressing, 16 sq in or less 06/30/97 3 NC 3.02

K0204 Composite Dressing, > 16 but < 48 sq in 06/30/97 3 NC 4.50

K0205 Composite Dressing, more than 48 sq in 06/30/97 3 NC 0.00

K0206 Contact Layer, 16 sq in or less 06/30/97 3 NC 0.00

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K0207 Contact Layer, >16 but <48 sq in 06/30/97 3 NC 5.30

K0208 Contact Layer, more than 48 sq in 06/30/97 3 NC 0.00

K0209 Foam Dressing, 16 sq in or less, w/o adh. bord. 06/30/97 3 NC 6.17

K0210 Foam Dressing, >16 but <48 sq in, w/o adh. bord. 06/30/97 3 NC 14.35

K0211 Foam Dressing, more than 48 sq in, w/o adh. bord. 06/30/97 3 NC 0.00

K0212 Foam Dressing, 16 sq in or less, any size adh. bord. 06/30/97 3 NC 7.00

K0213 Foam Dressing, > 16 but < 48 sq in, any size adh. bord. 06/30/97 3 NC 0.00

K0214 Foam Dressing, more than 48 sq in, any size adh. bord. 06/30/97 3 NC 7.45

K0215 Foam Dressing, wound filler 06/30/97 3 NC 100.00

K0216 Gauze, non-impreg., 16 sq in or less, w/o adh. bord. 06/30/97 3 NC 50.00

K0217 Gauze, non-impreg., >16 but <48 sq in, w/o adh. bord. 06/30/97 3 NC 50.00

K0218 Gauze, non-impreg., more than 48 sq in, w/o adh. bord. 06/30/97 3 NC 50.00

K0219 Gauze, non-impreg., 16 sq in or less, any size adh. bord. 06/30/97 3 NC 50.00

K0220 Gauze, non-impreg., >16 but <48 sq in, any sz adh. bord. 06/30/97 3 NC 50.00

K0221 Gauze, non-impreg., >48 sq in, any size adh. bord. 06/30/97 3 NC 50.00

K0222 Gauze, impreg., 16 sq in or less, w/o adh. bord. 06/30/97 3 NC 1.65

K0223 Gauze, impreg., >16 but < 48 sq in, w/o adh. bord. 06/30/97 3 NC 1.75

K0224 Gauze, impreg., >48 sq in , w/o adh. bord. 06/30/97 3 NC 2.60

K0228 Gauze, impreg., 16 sq in or less, w/o adh. bord. 01/01/96 1 NC

K0229 Gauze, impreg., >16 but <48 sq in, w/o adh. bord. 01/01/96 1 NC

K0230 Gauze, impreg., > 48 sq in, w/o adh. bord. 01/01/96 1 NC

K0234 Hydrocolloid Dressing, 16 sq in or less, w/o adh. bord. 06/30/97 3 NC 4.80

K0235 Hydrocolloid Dressing, >16 but <48 sq in, w/o adh. bord. 06/30/97 3 NC 12.15

K0236 Hydrocolloid Dressing, > 48 sq in, w/o adh. bord. 06/30/97 3 NC 19.65

K0237 Hydrocolloid Dressing, 16 sq in or less, w/ adh. bord. 06/30/97 3 NC 5.80

K0238 Hydrocolloid Dressing, >16 but <48 sq in, w/ adh. bord. 06/30/97 3 NC 16.75

K0239 Hydrocolloid Dressing, >48 sq in, w/ adh. bord. 06/30/97 3 NC 0.00

K0240 Hydrocolloid Dressing, wound filler, paste 06/30/97 3 NC 100.00

K0241 Hydrocolloid Dressing, wound filler, dry form 06/30/97 3 NC 100.00

K0242 Hydrogel Dressing, 16 sq in or less, w/o adh. bord. 06/30/97 3 NC 4.80

K0243 Hydrogel Dressing, >16 but <48 sq in, w/o adh. bord. 06/30/97 3 NC 8.95

K0244 Hydrogel Dressing, >48 sq in, w/o adh. bord. 06/30/97 3 NC 28.30

K0245 Hydrogel Dressing, 16 sq in or less, w/ adh. bord. 06/30/97 3 NC 5.90

K0246 Hydrogel Dressing, >16 but <48 sq in, w/ adh. bord. 06/30/97 3 NC 7.15

K0247 Hydrogel Dressing, >48 sq in, w/ adh. bord. 06/30/97 3 NC 17.15

K0248 Hydrogel Dressing, wound filler, gel 06/30/97 3 NC 100.00

K0249 Hydrogel Dressing, wound filler, dry form 06/30/97 3 NC 100.00

K0250 Skin Sealants, Protectants, Moisturizers 01/01/96 1 NC

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K0251 Spec. Absorp. Dressing, 16 sq in or less, w/o adh. bord. 06/30/97 3 NC 0.90

K0252 Spec. Absorp. Dressing, >16 but <48 sq in 06/30/97 3 NC 2.35

K0253 Spec. Absorp. Dressing, >48 sq in, w/o adh. bord. 06/30/97 3 NC 4.60

K0254 Spec. Absorp. Dressing, 16 sq in or less, w/ adh. bord. 06/30/97 3 NC 0.90

K0255 Spec. Absorp. Dressing, >16 but <48 sq in, w/adh. bord. 06/30/97 3 NC 2.20

K0256 Spec. Absorp. Dressing, >48 sq in, w/ adh. bord. 06/30/97 3 NC 0.00

K0257 Transparent Film, 16 sq in or less 06/30/97 3 NC 1.10

K0258 Transparent Film, >16 but <48 sq in 06/30/97 3 NC 3.10

K0259 Transparent Film, >48 sq in 06/30/97 3 NC 7.90

K0260 Wound Cleansers, any type, any size 01/01/96 1 NC

K0261 Wound Filler, not elsewhere classified, gel/paste 06/30/97 3 NC 100.00

K0262 Wound Filler, not elsewhere classified, dry form 06/30/97 3 NC 100.00

K0263 Gauze, elastic, nonsterile, all types 06/30/97 3 NC 2.00

K0264 Gauze, nonelastic, nonsterile 06/30/97 3 NC 1.00

K0265 Tape, all types, all sizes 06/30/97 3 NC 3.00

K0266 Gauze, impreg., other than water or normal saline 06/30/97 3 NC 0.00

+ K0268 Humidifier, for use with CPAP device 10/01/04 3 NC 106.30

K0277 Skin barrier, solid 4X4, or equiv stand w.conv 07/01/00 3 NC 3.78

K0278 Skin barrier, w/flange std wear w/conv 07/01/00 3 NC 5.69

K0279 Skin barrier, w/flange extended wear 07/01/00 3 NC 7.65

K0280 Extension Drainage Tubing 10/01/04 3 NC 2.90

K0281 Lubricant, indiv. sterile packet 01/01/96 1 NC

K0402 Gauze, nonimpreg, sterile, 16 sq in or less 06/30/97 3 NC 50.00

K0403 Gauze, non-impreg., sterile, >16 but <48 sq in 06/30/97 3 NC 50.00

K0404 Gauze, non-impreg., sterile, more than 48 sq in 06/30/97 3 NC 50.00

K0405 Gauze, elastic, sterile, all types 06/30/97 3 NC 0.30

K0406 Gauze, nonelastic, sterile 06/30/97 3 NC 0.30

K0407 Urinary Cath. Anchoring Device 04/01/01 3 NC 1.27

K0408 Urinary Cath. Anchoring Device 04/01/01 3 NC 3.00

K0409 Sterile Water Irrigation Solution 04/01/01 3 NC 1.75

K0410 Male External Catheter 04/01/01 3 NC 1.44

K0411 Male External Catheter 04/01/01 3 NC 1.00

K0419 Pouch, drainable, w/faceplate, plastic 04/01/00 3 NC 15.56

K0420 Pouch, drainable, w/faceplate, rubber 07/01/00 3 NC 43.11

K0421 Pouch, drainable, for use on FP, plastic 04/01/00 3 NC 3.89

K0422 Pouch, drainable, for use on FP, rubber 04/01/00 3 NC 27.86

K0423 Pouch, urinary with FP attached, plastic 04/01/00 3 NC 13.61

K0424 Pouch, urinary with FP attached, rubber 07/01/00 3 NC 33.82

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K0425 Pouch, urinary for use on FP, plastic 07/01/00 3 NC 4.18

K0426 Pouch, urinary for use on FP, heavy plastic 07/01/00 3 NC 22.31

K0427 Pouch, urinary, for use on faceplate, rubber 07/01/00 3 NC 25.55

K0428 Ostomy faceplate equivalent, silicone ring 04/01/00 3 NC 8.72

K0429 Skin barrier, 4X4 extended wear 04/01/00 3 NC 4.62

K0430 Skin barrier, w/flange extended wear 04/01/00 3 NC 6.09

K0431 Pouch closed, w/stand. wear barrier/conv 04/01/00 3 NC 3.64

K0432 Pouch, drainable w/ext wear barrier w/o conv 04/01/00 3 NC 3.95

K0433 Pouch, drainable, w/std wear barrier with conv 04/01/00 3 NC 5.63

K0434 Pouch, drainable, w/extended wear barrier 04/01/00 3 NC 8.71

K0435 Pouch, urinary, w/ext wear barrier w/o conv 04/01/00 3 NC 6.40

K0436 Pouch, urinary, with standard wear barrier 04/01/00 3 NC 6.02

K0437 Pouch, urinary, w/ext wear barrier w/conv 04/01/00 3 NC 8.31

K0438 Ostomy deodorant, liquid 01/01/97 1 NC 0.00

K0439 Ostomy deodorant, solid, per tablet 01/01/97 1 NC 0.00

K0452 Wheelchair bearings, any type 10/01/04 1 6.00

K0453 Amphotericin B, 50 MG 10/01/04 3 NC 19.29

K0456 Hospital Bed, heavy duty, extra wide w/mattress 04/01/01 2 NC 0.00

K0457 Extra wide/heavy duty commode chair, each 04/01/01 3 NC 129.56

K0458 Heavy Duty Walker, without wheels, each 04/01/01 3 NC 109.07

K0459 Heavy Duty Wheeled Walker 04/01/01 3 NC 135.00

K0460 Power Add-on to manual wheelchair, joystick control 01/01/99 1 NC

K0461 Power Add-on to manual wheelchair, tiller control 01/01/99 1 NC

+ K0532 Resp. assist device, w/o back-up, w/ non-invasive 10/01/04 3 NC 1,900.00

+ K0533 Respiratory assist device, bi-level, non-invasive interf. 10/01/04 3 NC 320.00

+ K0534 Respiratory assist device, bi-level, invasive interface 10/01/04 3 NC 320.00

K0538 Neg Press Wound Therapy Elec Pump/ Stat or Port, Ea 01/01/01 1 NC

K0539 Dressing Set for Neg Pres Wound Therapy Pump 01/01/01 1 NC

K0540 Canister Set for Neg Pres Wound Therapy Pump 01/01/01 1 NC

+ K0541 Speech Gen Device;Dig;Prerecord;less than/equal to 8min10/01/04 3 NC 389.13

+ K0542 Speech Gen Device;Dig;Prerecord; greater than 8 min 10/01/04 3 NC 1,504.03

+ K0543 Speech Gen Device;Synth speech w/ physical contact 10/01/04 3 NC 3,558.93

+ K0544 Speech Gen Device; Synthesized 10/01/04 3 NC 6,734.78

+ K0545 Speech Gen Software Program for PC/PDA 10/01/04 3 NC 0.00

+ K0546 Acc for Speech Gen Device; Mounting System 10/01/04 3 NC 0.00

+ K0547 Acc for Speech Gen Device, NOS 10/01/04 3 NC 0.00

K0549 Hospital Bed, Hvy duty, extra wide, w/side rails, w/matt 01/01/02 1 NC 0.00

K0618 TLSO, segmented spinal system, two rigid plastic shells, prefabricated10/01/04 1 NC

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K0619 TLSO, segmented spinal system, three rigid plastic shells, prefabricated10/01/04 1 NC

K0628 Diabetic only, MDI, direct formed prefabricated 10/01/04 1 NC

K0629 Diabetic only, MDI, custom molded from model, custom fabricated10/01/04 1 NC

K0630 SO, flexible, prefabricated 10/01/04 1 56.79

K0631 SO, flexible, custom fabricated 10/01/04 1 NC

K0632 SO, rigid or semi-rigid panels, prefabricated 10/01/04 1 NC

K0633 SO, rigid or semi-rigid panels, custom fabricated 10/01/04 1 NC

K0634 LO, flexible, extends from L-1 to L-5 vertebra, prefabricated10/01/04 1 87.34

K0635 LO, sagittal control, from L-1 to L-5 vertebra, prefabricated 10/01/04 1 147.95

K0636 LO, sagittal control, anterior and posterior panels, L-1 to L-5 vertebra, prefabricated10/01/04 1 147.95

K0637 LSO, flexible, from sacrococcygeal to T-9 vertebra, prefabricated10/01/04 1 87.34

K0638 LSO, flexible, from sacrococcygeal to T-9 vertebra, custom fabricated10/01/04 1 169.75

K0639 LSO, rigid posterior panels, from sacrococcygeal to T-9 vertebra, prefabricated10/01/04 1 147.95

K0640 LSO, rigid anterior and posterior panels, sacrococcygeal to T-9, prefabricated10/01/04 1 147.95

K0641 LSO, rigid anterior and posterior panels, sacrococcygeal to T-9, custom fabricated10/01/04 1 147.95

K0642 LSO, rigid posterior frame/panel(s), sacrococcygeal to T-9, prefabricated10/01/04 1 253.79

K0643 LSO, rigid posterior frame/panel(s), sacrococcygeal to T-9, custom fabricated10/01/04 1 253.79

K0644 LSO, lumbar flexion, rigid posterior frame/panel(s), sacrococcygeal to T-9, prefab10/01/04 1 280.29

K0645 LSO, lumbar flexion, rigid posterior frame/panel(s), sacrococcygeal to T-9, custom fab10/01/04 1 280.29

K0646 LSO, rigid anterior and posterior frame/panel(s), sacrococcygeal to T-9, prefab10/01/04 1 NC

K0647 LSO, rigid anterior and posterior frame/panel(s), sacrococcygeal to T-9, custom fab10/01/04 1 NC

K0648 LSO, rigid shell(s)/panel(s), anterior and posterior extensions, prefabricated10/01/04 1 853.29

K0649 LSO, rigid shell(s)/panel(s), anterior and posterior extensions, custom fabricated10/01/04 1 1,089.91

++ K0650 Wc cushion, width < 22 inc, any depth 01/01/05 3 NC PA

++ K0651 WC cushion; width 22 inches or greater, any dpth 01/01/05 3 NC PA

++ K0652 WC skin pro. Seat cushion wdth <22 in any dpth 01/01/05 3 NC PA

++ K0653 WC skin pro. Seat cushion wdth 22 or >, any dpth 01/01/05 3 NC PA

++ K0654 Wc positioning seat cushion, wdt<22 in, any dpth 01/01/05 3 NC PA

++ K0655 WC positioning seat cushion, wdt22 or >, any dpth 01/01/05 3 NC PA

++ K0656 WC skin pro posit. Cushion,wdth <22 in, any dpth 01/01/05 3 NC PA

++ K0657 WC skn pro & posit cushion, wdt 22 or >, any dpth 01/01/05 3 NC PA

++ K0658 WC custom fabricated seat, any size 01/01/05 3 NC PA

++ K0659 WC, seat cushion , powered 01/01/05 3 NC PA

++ K0660 WC back cushion, wdth <22, any hgt 01/01/05 3 NC PA

++ K0661 WC back cushion, wdth 22 or greater, any hgt 01/01/05 3 NC PA

++ K0662 WC posterior back cushion, wdt, <22 in, any hgt 01/01/05 3 NC PA

++ K0663 WC posterior back cushion, wdt, 22 or >in, any hgt 01/01/05 3 NC PA

++ K0664 WC post/lat back cushion, wdth <22, any hgt 01/01/05 3 NC PA

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++ K0665 WC post/lat back cushion, wdth 22 or >, any hgt 01/01/05 3 NC PA

++ K0666 WC back cushion, custom fabricated, any size 01/01/05 3 NC PA

++ K0667 Mnting hdwr, any type for seat attch 01/01/05 3 NC PA

++ K0668 Replace. cover for WC seat or back cushion, ea 01/01/05 3 NC PA

L0100 Cranial Orthosis, Helmet Mld/Pat Mdl 01/01/00 2 454.91 385.54

L0110 Cranial Orthosis, Helmet, Non-Molded 01/01/00 2 106.61 103.68

L0112 Cranial Cervical Orthosis, congenital torticollis type 01/01/04 1 NC

L0120 Flexible, Non/Adj, (Foam Collar) 01/01/00 2 17.41 15.66

L0130 Cervical, Flexible, thermoplastic collar 10/01/88 1 NC

L0140 Semi-Rigid,Adj(Plastic Collar) 01/01/00 2 39.43 31.06

L0150 Cervical, semi-rigid, molded chin cup 10/01/88 1 NC

L0160 Cervical, semi-rigid, wire frame 10/01/88 1 NC

L0170 Collar, Molded To Patient Model 01/01/00 2 529.58 444.94

L0172 Cervical Collar Semirigid Thrm/Plas 2Pc 01/01/00 2 93.28 80.00

L0174 Cer.Coll.Semi Rig.Therm.2Pc.W Thora. 01/01/00 2 183.42 126.31

L0180 Mult Post Collar, Occ/Man Support Adj 01/01/00 2 297.18 252.63

L0190 Mult Collar,Occip/Mand Supp(Somi,Etc) 01/01/00 2 350.46 271.59

L0200 Mult P/Collar Occ/Man Sup,Adj Bar Th/Ext 01/01/00 2 406.50 329.48

L0210 Rib Belt, Custom Fitted 01/01/00 2 32.02 30.78

L0220 Rib Belt, Custom Fabricated 01/01/00 2 85.10 80.00

+ L0300 TLSO, Flex, Custom Fitted 10/01/04 3 NC 107.04

+ L0310 TLSO, Flex, Cust Fabricated 10/01/04 3 NC 208.32

+ L0315 TLSO D/L Elastic Rigid Posterior Panel 10/01/04 3 NC 201.57

+ L0317 TLSO D/L Hyperexten Elas Rigid Post Panl 10/01/04 3 NC 241.85

+ L0320 TLSO,Ant/Pos Contrl.Taylor Type.Apron Fr 10/01/04 3 NC 249.90

+ L0321 TLSO, ant/post control, rigid or semi-rigid, prefabricated 01/01/02 1 NC

+ L0330 TLSO,A/P/L Cntrl(Knight-Taylor)Apron Fr. 10/01/04 3 NC 313.18

L0331 TLSO, ant/post/lat control, rigid or semi-rigid, prefabricated01/01/02 1 NC

+ L0340 TLSO, (Arnold,Etc) With Apron Front 10/01/04 3 NC 426.41

+ L0350 TLSO,Flex Comp Jacket, (Custom Fitted) 10/01/04 3 NC 658.17

+ L0360 TLSO, Flex Comp Jkt ,Mld To Pat Model 10/01/04 3 NC 892.98

+ L0370 TLSO,Hyperextension(Jewett, Lennox,Etc) 10/01/04 3 NC 266.66

+ L0380 TLSO, With Anterior Extensions 10/01/04 3 NC 440.32

+ L0390 TLSO,Body Jacket,Mld To Patient Model 10/01/04 3 NC 994.87

L0391 TLSO, ant/post/lat/rot control, rigid or semi-rigid, prefabricated01/01/02 1 NC

+ L0400 TLSO,Body Jkt,Mld To Pat Model,Interface 10/01/04 3 NC 1,111.28

+ L0410 TLSO Ant.Pos.Lat.Bd Jac 2Pc Mold To Pat. 10/01/04 3 NC 1,200.14

+ L0420 TLSO Ant.Pos.Lat.2Pc.Mold Pat Winterf 10/01/04 3 NC 1,347.81

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+ L0430 TLSO Ant.Pos.Lat. W Interfac.Cust .Fit 10/01/04 3 NC 1,004.18

+ L0440 TLSO Ant.Pos.Lat.Overlap Sec.Cus.Fit 10/01/04 3 NC 850.22

L0450 TLSO, upper thoracic, prefabricated 10/01/04 1 130.83

L0452 TLSO, upper thoracic, custom fabricated 10/01/04 1 208.32

L0454 TLSO, from sacrococcygeal to T-9 vertebra, prefabricated 10/01/04 1 201.57

L0456 TLSO, from sacrococcygeal to scapular spine, prefabricated10/01/04 1 NC

L0458 TLSO, posterior from sacrococcygeal to scapular spine, anterior to xiphoid, prefab10/01/04 1 NC

L0460 TLSO, posterior from sacrococcygeal to scapular spine, anterior to sternal notch, prefab10/01/04 1 NC

L0462 TLSO, anterior to sternal notch, three rigid plastic shells, prefab10/01/04 1 NC

L0464 TLSO, anterior to sternal notch, four rigid plastic shells, prefab10/01/04 1 NC

L0466 TLSO, sagittal control, prefabricated 10/01/04 1 249.90

L0468 TLSO, sagittal-coronal control, prefabricated 10/01/04 1 313.18

L0470 TLSO, from sacrococcygeal to scapula, lateral strenght by pelvic, prefabricated10/01/04 1 426.41

L0472 TLSO, hyperextension, from symphysis pubis to sternal notch, prefabricated10/01/04 1 266.66

L0476 TLSO, sagittal-coronal control, flexion compression jacket, prefabricated01/01/05 3 NC 658.17

L0478 TLSO, sagittal-coronal control, flexion compression jacket, custom fabricated01/01/05 3 NC 892.98

L0480 TLSO, one piece rigid plastic shell without interface liner, carved plaster or CAD-CAM model10/01/04 1 994.87

L0482 TLSO, one piece rigid plastic shell with interface liner, carved plaster or CAD-CAM model10/01/04 1 1,111.28

L0484 TLSO, two piece without liner, carved plaster or CAD-CAM model10/01/04 1 1,200.14

L0486 TLSO, two piece with liner, carved plaster or CAD-CAM model10/01/04 1 1,347.81

L0488 TLSO, one piece shell, restricts motion in sagittal, coronal and transverse planes, prefab10/01/04 1 1,004.18

L0490 TLSO, sagittal-coronal, one piece plastic shell, prefabricated10/01/04 1 NC

+ L0500 LSO, Flex (L/S Surg Support)Cust Fitted 10/01/04 3 NC 87.34

+ L0510 LSO, Flex,(L/S Surg Supp) Custom Fabrica 10/01/04 3 NC 169.75

+ L0515 LSO Ant/Post Cont W Rigid/s-rig Pos.Panel 10/01/04 3 NC 147.95

+ L0520 LSO,(Knight,Wilcox) With Apron Front 10/01/04 3 NC 253.79

+ L0540 LSO, (Williams Flexion Type) 10/01/04 3 NC 280.29

+ L0550 LSO, Molded To Patient Model 10/01/04 3 NC 958.58

+ L0560 LSO,Molded To Pat Model, Interface 10/01/04 3 NC 1,089.81

L0561 LSO, ant/pot/lat cont, rigid/semi-rigid, prefabricated 01/01/02 1 NC

+ L0565 LSO Ant.Pos.Lat Control Custom Fit 10/01/04 3 NC 853.29

+ L0600 Sacro, Flex(Surg Supp) Custom Fitted 10/01/04 3 NC 56.79

L0700 CTLSO, Minerva 01/01/00 2 1,311.22 1,043.82

L0710 CTLSO,Mld To Pat Model, Interface 01/01/00 2 1,441.40 1,134.34

L0810 Halo Proc,Cerv Halo On Thoracic Jacket 01/01/00 2 1,760.52 1,501.78

L0820 Halo Proc,Cerv Halo, Plaster Body Jacket 10/01/88 1 NC

L0830 Halo Proc,Cerv Halo, Milwaukee Type 10/01/88 1 NC

L0860 Add On Halo For Mri Compatibility 01/01/00 2 750.27 619.26

5101:3-1-60 Page 300







L0861 Add On Halo, Replace liner/interface 01/01/04 1 NC

L0900 Torso Support, ptosis support 10/01/88 1 NC

L0910 Torso Support, ptosis support, custom fabricated 10/01/88 1 NC

L0920 Torso Support, pendulous abdomen 10/01/88 1 NC

L0930 Torso Support, pendulous abdomen, custom fabricated 10/01/88 1 NC

L0940 Torso Support, postsurgical 10/01/88 1 NC

L0950 Torso Support, postsurgical, custom fabricated 10/01/88 1 NC

L0960 Torso Support, postsurgical, pads 10/01/88 1 NC

L0970 TLSO, Corset Front 01/01/00 2 70.39 61.64

L0972 LSO, Corset Front 01/01/00 2 64.06 59.07

L0974 TLSO, Full Corset 01/01/00 2 115.10 91.82

L0976 LSO, Full Corset 01/01/00 2 98.47 76.70

L0978 Axillary Crutch Extension 01/01/00 2 123.94 100.84

L0980 Peritioneal Straps, Pair 01/01/00 2 11.27 9.66

L0982 Stocking supporter grips, set of 4 10/01/88 1 NC

L0984 Protective Body Sock , Each 01/01/00 2 44.59 37.74

L0986 Add to spinal orthosis, rigid/semi-rigid, prebaricated 01/01/02 1 NC

L1000 Ctlso,Milwaukee,Incl Init Orth,Incl Modl 01/01/00 2 1,335.63 1,104.77

L1005 Tension based scoliosis othosis and pads 01/01/02 1 NC

L1010 Add To CLSO(Scoliosis Orth) Axilla Sling 01/01/00 2 55.11 47.50

L1020 Add To CLSO Or Scol/Orth,Kyphosis Pad 01/01/00 2 70.98 55.89

L1025 Add To CTLSO Or Scoli.Kypha.Pad Float 01/01/00 2 102.39 87.78

L1030 Add To CTLSO Or Scol/Orth,Lumb Bolst Pad 01/01/00 2 51.56 37.41

L1040 Add To CTLSO Or Scol/Or,Lumb Rib Pad 01/01/00 2 58.40 47.77

L1050 Add To CTLSO,Scol/Or, Sternal Pad 01/01/00 2 66.08 48.70

L1060 Add To CTLSO Or Scol/Or, Thoracic Pad 01/01/00 2 71.33 59.37

L1070 Add To CTLSO Or Scol/Or, Trapeze Sling 01/01/00 2 73.89 63.21

L1080 Add To CTLSO Or Scol/Or, Outrigger 01/01/00 2 34.46 29.12

L1085 Add CTLSO Or Scoli.Outrig Bial. Vert.Ext 01/01/00 2 115.37 103.54

L1090 Add To CTLSO Or Scol/Or, Lumbar Sling 01/01/00 2 66.29 57.38

L1100 Add To CTLSO, Ring Flange, Plas Or Leath 01/01/00 2 125.08 108.74

L1110 Add To,Ring Flang,Plas/Leath Mld To Pat 01/01/00 2 209.72 175.75

L1120 Add To, Covers For Upright, Each 01/01/00 2 25.04 22.71

L1200 TLSO Initial Orthosis Only (Low/Profile) 01/01/00 2 1,178.69 1,024.72

L1210 Add To TLSO (Low Profile)Lat Thor Extnen 01/01/00 2 161.15 149.73

L1220 Add To TLSO (Low Prof) Ant Thor Exten 01/01/00 2 156.85 121.97

L1230 Add To TLSO,Low Prof,Milwake Type Super 01/01/00 2 439.42 353.68

L1240 Add TLSO Lumbar Derotation Pad 01/01/00 2 59.90 37.83

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L1250 Add TLSO Anterior Asis Pad 01/01/00 2 52.07 36.22

L1260 Add TLSO Anter.Thoracic Derotat.Pad 01/01/00 2 62.13 50.93

L1270 Add TLSO Abdominal Pad 01/01/00 2 54.61 36.77

L1280 Add TLSO Rib Gusset Elastic Ea 01/01/00 2 57.53 55.78

L1290 Add TLSO Lateral Trochanteric Pad 01/01/00 2 51.18 36.73

L1300 Scol Proc, Body Jacket Mld To Pat Model 01/01/00 2 1,135.19 871.79

L1310 Scol Proc, Psot-Op Jkt Mld To Model 01/01/00 2 1,182.40 910.27

L1499 Unlisted Procedure For Spinal Orthosis 10/01/88 1 0.00

L1500 THKAO,Mobility Frame (Newington, Etc) 01/01/00 2 1,271.76 877.87

L1510 THKAO, Standing Frame, (No Joints); w/ or w/o tray or acc01/01/00 2 783.43 644.73

L1520 THKAO,Standing Fr,No Jts,Swivel Walker 01/01/00 2 1,405.03 1,155.16

L1600 Flex HO,Abd Hip Jts, Frejka Type/Cover 01/01/00 2 84.88 79.72

L1620 Flex HO, Abd Hip Jts, Pavlik Harness 01/01/00 2 103.50 95.30

L1630 HO Abduction Cont.Hip Jnt .Semi-Flex 01/01/00 2 139.15 0.00

L1640 HO,Abd Hp Jts,Static,Pelv Band,Thigh Cuf 01/01/00 2 311.79 255.32

L1650 HO,Abd Hp Jts, Static, Adj, Prefab 01/01/00 2 162.43 159.90

L1652 HO, Bilat Thigh Cuffs w/adj abd spreader bar, prefab 01/01/03 1 NC

L1660 HO,Abd Hp Jts, Static,Plas, Prefab 01/01/00 2 119.03 94.08

L1680 HO,Abd Hp Jsts, Dynamic, Adj Hip Action 01/01/00 2 750.39 592.34

L1685 HO Abduct Contr Of Hip Int Post Oper 01/01/00 2 732.57 567.06

L1686 HO Post-Op Hip Abduction Prefab 01/01/00 2 617.19 597.92

L1690 Combo, bilateral, lumbo-sacral, hip, femur orthosis 01/01/99 1 0.00

L1720 L/P Orth, Trilateral (Tachdijan Type) 01/01/00 2 971.64 695.98

L1730 L/P Orth, Scottish Rite Type 01/01/00 2 820.28 671.52

L1750 L/P Orth, Legg Perthes Sling (Sam Brown) 01/01/00 2 121.17 101.30

L1755 Legg Perthes Orthosis Patten Bottom Type 01/01/00 2 1,179.33 816.54

L1800 KO, Elastic With Stays 01/01/00 2 41.40 39.59

L1810 KO, Elastic With Joints 01/01/00 2 67.80 61.49

L1815 KO Elastic W Condi/Lar Pads 01/01/00 2 62.06 44.26

L1820 KO, Elastic With Condyle Pads And Joints 01/01/00 2 93.61 80.61

L1825 KO, Elastic Knee Cap 01/01/00 2 39.10 30.22

L1830 KO, Immobilizer, Canvas Longitudinal 01/01/00 2 54.77 44.40

L1831 KO, Lock Knee Jnts, Prefabricated 01/01/04 1 NC

L1832 KO Adj Knee Jts Rigid Support, Prefab 04/13/89 1 0.00

L1834 KO Without Knee Jt Rigid Mold Pt Model 01/01/00 2 478.07 375.39

L1836 KO, rigid, wo joints, prefabricated 01/01/03 1 NC

L1840 KO,Derotation, Fab To Pat Model (Lenox Hl 01/01/00 2 619.41 488.12

L1843 KO, Single Upright, Thigh and Calf, adj. flexion, ext. joint 01/01/00 1 355.67

5101:3-1-60 Page 302







L1844 KO, Single Upright, Thigh and Calf, Flex and Extension 01/01/00 2 1,003.04 849.00

L1845 KO Dbl, Thigh Calf Adjust Filex, Prefab 01/01/00 2 551.73 407.10

L1846 KO Dbl, Thigh Calf Adjus. Flexmold To Pat 01/01/00 2 738.62 566.71

L1847 KO, double upright with adjust. joint w/air support cham. 01/01/99 1 0.00

L1850 KO, Swedish Type 01/01/00 2 187.65 152.93

L1855 KO,Mold Plas Thigh Calf Mold To Pat Mod 01/01/00 2 731.18 629.22

L1858 KO Molded Plas. Polycen. Knee Jnt. Ko Pad 01/01/00 2 835.02 666.45

L1860 KO, All Plastic Form Patient Model (Sk) 01/01/00 2 821.33 648.98

L1870 KO,Doub/Up,Thigh&Calf Lacer,Jts,Pat Mod 01/01/00 2 716.82 690.22

L1880 KO,Dbl Uprite, Non-Mld Thigh &Calf Cuffs 01/01/00 2 473.26 400.65

+ L1885 KO, Single or Double Upright, Thigh and Calf, FAR cont. 10/01/04 3 NC 681.57

L1900 AFO, Spring Wire, Dorsiflex Assist Calf 01/01/00 2 187.92 154.17

L1901 AO, elastic, prefabricated 10/01/04 1 11.94

L1902 AFO Ankle Gauntlet, Prefab 01/01/00 2 49.16 37.79

L1904 AFO, Ankle Gauntlet, Custom Fitted 10/01/88 1 NC

L1906 AFO Multiligament Us Ank Supp(Air Cast) 01/01/00 2 74.07 58.35

L1907 AFO, Supremalleolar, custom fabricated 01/01/04 1 NC

L1910 AFO, Posterior, single bar 10/01/88 1 NC

L1920 AFO, Sing Uprite/Static/Adj Stop (Phelps) 01/01/00 2 270.58 208.84

L1930 AFO, Plastic or Other Material,Premolded, Prefab 10/01/04 2 203.88 165.94

L1932 AFO, Rigid Anter. Tibial Section, Carbon Fiber 01/01/05 1 NC

L1940 AFO,Molded To Patient Model, Plastic or Other Material 01/01/00 2 320.73 270.10

L1945 AFO Molded Pt Model Plas Floor Reaction 01/01/00 2 739.32 645.46

L1950 AFO, Spiral, Plastic, custom fabricated 10/01/88 1 NC

L1951 AFO, Spiral, Plastic or other material, prefabricated 01/01/04 1 NC

L1960 AFO, Post/Solid/Ankle,Mld To Pat Model 01/01/00 2 408.27 364.05

L1970 AFO,Plastic Mld To P/Model, With Ank/Jts 01/01/00 2 455.88 362.33

L1971 AFO, Plastic or Other Material with ankle joint, prefabricated01/01/04 1 NC

L1980 AFO, (Single Bar "Bk" Orthosis) 01/01/00 2 265.96 220.87

L1990 AFO (Basic/Double Bar "Bk" Orthosis) 01/01/00 2 307.80 253.86

L2000 KAFO (Single Bar"Ak" Orthosis) Free K/A 01/01/00 2 736.82 489.70

L2005 KAFO, sin/doub upright, auto lock, any type, custom 01/01/05 1 NC

L2010 KAFO (Single Bar"Ak"Orth) W/O Knee Joint 01/01/00 2 574.71 445.38

L2020 KAFO (Double Bar "Ak"Orth) Free Knee/Ank 01/01/00 2 725.84 551.27

L2030 KAFO,(Double Bar "Ak"Orth)W/O Knee Joint 01/01/00 2 713.45 499.96

L2035 KAFO, full plastic, stat. prefab. pediatric size 01/01/00 1 114.10

L2036 KAFO Full Plastic Mold To Patient Model 01/01/00 2 1,221.12 1,055.66

L2037 KAFO Plas Sgl Uprt Free Knee, Mold Model 01/01/00 2 1,092.27 959.28

5101:3-1-60 Page 303







L2038 KAFO Plas W/ Knee Jt Mold Model Lively 01/01/00 2 880.53 699.62

L2039 KAFO Full Plas Sgl Uprt Poly-axial hinge Mold Model 01/01/00 2 1,463.79 0.00

L2040 HKAFO, Bilat Elastic Str.Pelv Band/Belt 01/01/00 2 133.25 90.30

L2050 HKAFO, Bilat Torsion Cables,Hp Jt.Pelvic 01/01/00 2 320.97 260.43

L2060 HKAFO,Bilat Cable, Ball/Bear Hip Jt 01/01/00 2 401.45 350.79

L2070 HKAFO, Unilateral , pelvic band/belt, custom fabricated 10/01/88 1 NC

L2080 HKAFO, Unilateral, hip joint, pelvic band/belt, custom fabricated10/01/88 1 NC

L2090 HKAFO, Unilateral, ball bearing hip joint, custom fabricated10/01/88 1 NC

L2102 AFO, Plaster Casting, Custom Fabricated 10/01/88 1 NC

L2104 AFO, Synthetic Casting, Custom Fabricated 10/01/88 1 NC

L2106 AFO Frac.Orth.Tib.Cast Thermpla Type 01/01/00 2 519.17 473.27

L2108 AFO Frac Ortho. Tib Frac.Cast Hold Mod. 01/01/00 2 757.23 608.91

L2112 AFO Frac.Orth Tib Frac. Soft, Prefab 01/01/00 2 332.29 323.14

L2114 AFO Frac.Orth Tib.Frac Semi Rigid Fit 01/01/00 2 416.20 347.36

L2116 AFO Frac.Orth.Tib.Frac.Rig., Prefab 01/01/00 2 507.67 455.54

L2122 Knee Ank.Ft. Frac.Orth. Plas.Type Mold 10/01/04 3 NC 639.44

L2124 Knee Ank. Ft. Frac.Orth Synth Type 10/01/04 3 NC 737.35

L2126 KAFO Frac. Orth.Thermpla. Type Pt Mold 01/01/00 2 841.05 670.83

L2128 KAFO Frac.Orth.Molded To Patient Model 01/01/00 2 1,056.06 913.28

L2132 KAFO Frac Orth. Soft, Prefab 01/01/00 2 641.01 562.86

L2134 KAFO Frac. Orth.Semi Rigid, Prefab 01/01/00 2 759.03 593.43

L2136 KAFO Frac. Orth. Rigid, Prefab 01/01/00 2 830.64 665.60

L2180 Add Low Extre. Frac. Plas. Shoe Insert 01/01/00 2 87.31 69.04

L2182 Add Low Extre Frac. Orth.Drop Lock Kn. 01/01/00 2 75.26 64.86

L2184 Add Low Extre. Frac. Limit Mot. Kn. Jnt. 01/01/00 2 76.29 60.25

L2186 Add Low Extre. Frac. Adjust. Mot. Knee 01/01/00 2 101.47 91.11

L2188 Add Low Extreme Frac. Orth. Quan. Brim 01/01/00 2 184.45 157.31

L2190 Add Low Extrem. Erac. Orth. Waist Belt 01/01/00 2 56.19 46.66

L2192 Add Low Extre. Frac Hip Jnt. Pelv. Belt 01/01/00 2 219.60 171.81

L2200 Limited Ankle Motion, Each Joint 04/01/95 1 33.22

L2210 Doriflexion Assist (Plantar Flex Resist 01/01/00 2 41.40 33.69

L2220 Doriflex And Plant/Flex Assist/Resist 01/01/00 2 53.29 46.18

L2230 Split Flat Caliper Stirrups &Plate Attac 01/01/00 2 63.01 49.17

L2232 Add Low Extrem ortho, Rocker Bottom, Cust Fab 01/01/05 1 NC

L2240 Round Caliper And Plate Attachment 01/01/00 2 62.69 39.23

L2250 Foot Plate, Mlded To Pat,Stirrup Attach 01/01/00 2 220.01 171.37

L2260 Reinfor Solid Stirrup (Scott-Craig Type 01/01/00 2 123.45 101.86

L2265 Add On Lower Extrem Long Tongue Stirrup 01/01/00 2 88.52 71.57

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L2270 Varus/Valgus "T"Strap,Padded/Lined 01/01/00 2 40.60 31.75

L2275 Addition to Lower Extremity, Torsion Control, Ank. Jt. 01/01/00 2 85.86 72.67

L2280 Molded Inner Boot 01/01/00 2 371.83 313.65

L2300 Abd Bar (Bilateral) Jointed, Adjustable 01/01/00 2 165.82 127.10

L2310 Abduction Bar-Straight,Non-Adjustable 01/01/00 2 75.77 73.29

L2320 Non Molded Lacer 01/01/00 2 127.04 104.62

L2330 Lacer Molded To Patient Model 01/01/00 2 241.82 203.90

L2335 Add Low Extreme. Anter. Swing Band 01/01/00 2 185.15 162.46

L2340 Per-Tibial Shell, Mlded To Patient Model 01/01/00 2 275.26 212.42

L2350 Pros Type(Bk) Skt Mlded To Pat Model Ptb 01/01/00 2 548.77 438.08

L2360 Extended Steel Shank 01/01/00 2 33.98 25.30

L2370 Add Low Extreme. Patten Bottom 01/01/00 2 210.80 188.62

L2375 Add Low Extreme Torsi On Contr.Ank. Jnt. 01/01/00 2 81.03 70.94

L2380 Add Low Extrem.Tors.Contr.Knee Ea 01/01/00 2 85.00 82.55

L2385 Add Low Extre. Stra.Knee Jnt Heavy Duty 01/01/00 2 96.78 90.15

L2390 Add Low Extre.Offset Knee Jnt Ea Jnt 01/01/00 2 67.41 51.37

L2395 Add Low Extrem. Offset Knee Heavy Duty 01/01/00 2 96.36 72.13

L2397 Addition to Lower Extremity, Orthosis, Suspen. Sleeve 01/01/00 2 80.40 68.06

L2405 Add Knee Jnt.Drop Lock Ea.Jnt. 01/01/00 2 41.79 34.91

L2415 Add Knee Lock W/Integrated Release MechEa Jnt 07/01/02 2 96.75 98.28

L2425 Add Knee Jnt Disc Dial Lock Adjust Knee 07/01/02 2 114.15 115.96

L2430 Add Low Extrem, orthosis, incr lock at knee joint 01/01/00 2 64.76 0.00

L2435 Add Knee Jnt Poli/Centric Jnt. Ea Jnt. 01/01/05 3 NC 125.75

L2492 Add Knee Jnt. Lift Loop Drop Lock Ring 01/01/00 2 77.25 70.16

L2500 Gluteal/Ischial Wt Bearing ,Ring 01/01/00 2 206.12 163.67

L2510 Quadrilateral Brim, Mlded To Patient Mod 01/01/00 2 531.22 412.45

L2520 Quarilateral Brim, Custom Fitted 01/01/00 2 354.02 232.33

L2525 Add On L Ext I Cont/Ml Brim Pt Model 01/01/00 2 750.74 600.65

L2526 Add On Ext L Cont/Ml Brim Custom Fit 01/01/00 2 421.84 339.97

L2530 Lacer, Non-Molded 01/01/00 2 157.96 123.50

L2540 Lacer, Molded To Patient Model 01/01/00 2 298.89 223.90

L2550 High Roll Cuff 01/01/00 2 224.11 187.18

L2560 Add On to Lower Extremity, Gluteal/Ischial Weight Bearing10/01/88 1 NC

L2570 2 Postion Locking Hip Joint 01/01/00 2 293.34 232.60

L2580 Pelvic/Buttock Bands/Sling,Bilateral 01/01/00 2 285.83 217.31

L2600 Pelv Contrl,Hp Jt,Clevis Type, Free,Each 01/01/00 2 140.47 108.69

L2610 Pelv Control, Hp Jt, Clevis, Lock,Each 01/01/00 2 155.23 130.25

L2620 Pelv Contrl, Hp Jt, Heavy Duty, Each 01/01/00 2 164.67 129.54

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L2622 Add Low Extrem Pelvic Contr.Hip Jnt Ea 01/01/00 2 209.59 170.75

L2624 Add Low Extrem.Pelvic Contr.Abduccon Ea. 01/01/00 2 256.99 225.49

L2627 Add L Ext Rgo Plastic Pelvic Hip Jt Cabl 01/01/00 2 1,407.71 1,183.57

L2628 Add Rgo Metal Pelvic & Hips & Cables 01/01/00 2 1,031.83 817.94

L2630 Pelv Contrl, Band & Belt, Unilateral 01/01/00 2 152.50 124.73

L2640 Pelv Contrl,Band & Belt, Bilateral 01/01/00 2 206.97 163.85

L2650 Pelv & Thoracic Contrl,Gluteal Pad, Each 01/01/00 2 91.15 77.81

L2660 Thoracic Control, Thoracic Band 01/01/00 2 118.02 99.94

L2670 Thoracic Control, Paraspinal Uprights 10/01/88 1 NC

L2680 Thoracic Control, Lateral Supp Uprights 01/01/00 2 96.37 78.91

L2750 Add Low Extrem Orthosis, Plating Chrome or Nickel 10/01/88 1 NC

L2755 Add Low Extrem Orthosis,Hi-Str, Lt-Wt Mat 01/01/00 2 86.07 0.00

L2760 Extension, Per Bar (Adj For Growth) 01/01/00 2 37.42 29.28

L2768 Orthotic Side Bar Disconnect Device 10/01/04 1 NC

L2770 Stainless Steel-Per Bar Or Joint 01/01/00 2 38.11 37.45

L2780 Noncorrosive addition to lower extremity, per bar 10/01/88 1 NC

L2785 Add Low Extre Orth. Drop Lock Retain Ea 01/01/00 2 19.52 15.26

L2795 Add Low Extreme Orth Knee Contr. Full 01/01/00 2 53.99 44.30

L2800 Add Low Extrem.Orth.Knee Contr.Knee Cap 01/01/00 2 66.34 55.14

L2810 Add Low Extrem.Orth.Knee Condylar Pad 01/01/00 2 53.79 44.26

L2820 Add Low Extrem.Orth.Soft Interface Mold 01/01/00 2 53.48 42.16

L2830 Add Low Extre. Orth Soft Above Knee Sec 01/01/00 2 57.86 46.82

L2840 Add On Tibial Length Fracture Sock Each 01/01/00 2 28.41 24.69

L2850 Add On Femoral Length Fracture Sock,Each 01/01/00 2 39.84 33.31

L2860 Addition to Lower Extremity Joint, Knee or Ankle 01/01/00 2 238.58 204.79

L2999 Unlisted Proc For Lower Extrem Orthoses 10/01/88 1 0.00

L3000 Insert, Remov, Mlded To Pat Mod,Ucb Type 01/01/00 2 138.64 119.00

L3001 Insert, Remov,Mlded To Pat Mod,Spenco,Ea 01/01/00 2 12.57 10.79

L3002 Insert,Remov,Mlded To Pat, Plastazote,Ea 01/01/00 2 66.06 56.70

L3010 Ins,Remov,Mld/Pat,Longitud Arch Supp, Ea 01/01/00 2 99.08 85.05

L3020 Ins,Remov,Mld/Pat,Long/Metatar Supp,Ea 01/01/00 2 105.69 90.72

L3030 Ins,Remov, Formed To Pat Foot, Each 01/01/00 2 69.04 59.26

L3031 Ins/Plate,Remov addition to lower extremity 01/01/04 1 NC

L3040 Arch Supp, Remov, Premld, Longitud, Each 01/01/00 2 13.21 11.34

L3050 Arch Supp, Remov, Premld, Metatarsal, Ea 01/01/00 2 13.21 11.34

L3060 Arch Supp/Rem, Premld, Long/Metatar, Ea 01/01/00 2 35.36 30.35

L3100 Hallus-Valgus Night Dynamic Splint 01/01/00 2 26.42 22.68

L3140 Abd/Rot Bars(Dennis Browne) ,Att To Shoe 01/01/00 2 39.63 34.02

5101:3-1-60 Page 306







L3150 Abd/Rot Bars(Dennis Browne)Clapped To Sh 01/01/00 2 45.17 38.77

L3160 Foot, Adjust. Shoe-Styled Positioning Device 01/01/00 2 99.08 85.05

L3170 Plastic Heel Stabilizer 01/01/00 2 10.57 9.07

L3201 Orthopedic Shoe Oxford Supin Infant 01/01/00 2 57.09 49.00

L3202 Orthopedic Shoe Oxford Child 01/01/00 2 57.09 49.00

L3203 Orthopedic Shoes Oxford Junior 01/01/00 2 59.45 51.03

L3204 Orthopedic Shoes Hightop Infant 01/01/00 2 59.45 51.03

L3206 Orthopedic Shoes Hightop Child 01/01/00 2 55.92 48.00

L3207 Orthopedic Shoes Hightop Junior 01/01/00 2 54.76 47.00

L3208 Surgical Boot Each Infant 01/01/00 2 27.74 23.81

L3209 Surgical Boot Each Child 01/01/00 2 27.74 23.81

L3211 Surgical Boot Each Junior 01/01/00 2 27.74 23.81

L3215 Ortho Footwear, Ladies Shoes, Oxford 01/01/00 2 93.20 80.00

L3216 Orthopedic Shoes Ladies Depth Inlay 01/01/00 2 105.69 90.72

L3217 Orthopedic Shoes Ladies Hightop Dpth Inl 01/01/00 2 117.58 100.93

L3218 Orthopedic Shoes Ladies Surg. Boot Ea. 10/01/04 3 NC 52.84

L3219 Ortho Footwear, Mens Shoes, Oxford 01/01/00 2 93.20 80.00

L3221 Orthopedic Mens Shoes Depth Inlay 01/01/00 2 116.26 99.79

L3222 Orthopedic Mens Shoes Hightop Dpt Inlay 01/01/00 2 121.54 104.33

L3223 Orthopedic Mens Surgical Boot Ea. 10/01/04 3 NC 52.84

L3224 Orthopedic footwear, woman's oxford, part of brace 01/01/00 1 44.51

L3225 Orthopedic footwear, men's shoe, oxford, part of brace 01/01/00 1 48.61

L3230 Orthopedic Custom Shoes Depth Inlay 01/01/00 2 330.28 283.50

L3251 Foot Shoe Molded To Patient Silic Ea 01/01/00 2 165.14 141.75

L3252 Custom Made Shoe/Made Over Pat Model 01/01/00 2 87.38 75.00

L3253 Foot Molded Shoe Plastazote Cus Fit Ea 01/01/00 2 66.06 56.70

L3257 Orthopedic Shoes Split Size Mismates 01/01/00 2 142.86 122.63

L3300 Elevat,Heel Tapered To Metar/Per Inch 01/01/00 2 44.92 38.56

L3303 Ins,Remov,Mld/Pat,Silicon Gel,Ea 10/01/88 1 NC

L3310 Elevat, Heel&Sole,Neoprene/Per Inch 01/01/00 2 52.84 45.36

L3320 Elevat, Heel & Sole, Cork, Per Inch 01/01/00 2 66.06 56.70

L3332 Elevat,Inside Shoe,Tapered,Up To 1/2 In 01/01/00 2 26.59 22.82

L3334 Elevation, Heel Per Inch 01/01/00 2 31.05 26.65

L3340 Heel Wedge, Sach 01/01/00 2 19.81 17.00

L3350 Heel Wedge 01/01/00 2 10.57 9.07

L3360 Sole Wedge, Outside Sole 01/01/00 2 18.50 15.88

L3370 Sole Wedge, Between Sole 01/01/00 2 27.74 23.81

L3380 Clubfoot Wedge 01/01/00 2 16.31 14.00

5101:3-1-60 Page 307







L3390 Outflare Wedge 01/01/00 2 27.74 23.81

L3400 Metatarsal Bar Wedge, Rocker 01/01/00 2 33.03 28.35

L3410 Metatarsal Bar Wedge, Between Sole 01/01/00 2 38.32 32.89

L3420 Full Sole And Heel Wedge, Between Sole 01/01/00 2 44.92 38.56

L3430 Heel, Counter, Plastic Reinforced 01/01/00 2 39.63 34.02

L3440 Heel, Counter, Leather Reinforced 01/01/00 2 34.22 29.37

L3455 Heel, New Leather, Standard 01/01/00 2 15.86 13.61

L3460 Heel. New Rubber, Standard 01/01/00 2 14.53 12.47

L3465 Heel, Thomas With Wedge 01/01/00 2 18.19 15.61

L3470 Heel, Thomas Extended To Ball 01/01/00 2 38.45 33.00

L3480 Heel, Pad And Depression For Spur 01/01/00 2 19.81 17.00

L3500 Misc. Shoe Add, Insole, Leather 01/01/00 2 17.17 14.74

L3510 Misc Shoe Add, Insole, Rubber 01/01/00 2 11.95 10.26

L3520 Misc Shoe Add, Insole, Felt Cov/Leather 01/01/00 2 23.08 19.81

L3530 Misc Shoe Additions, Sole, Half 01/01/00 2 19.93 17.11

L3540 Misc Shoe Additions, Sole, Full 01/01/00 2 24.59 21.11

L3550 Misc Shoe Add, Toe Tap, Standard 01/01/00 2 5.29 4.54

L3570 Misc Modified Gusset (Leather W/Eye) 01/01/00 2 71.30 61.20

L3580 Misc Shoe Add, Conv Instep To Velcro Cls 01/01/00 2 26.42 22.68

L3595 Misc Shoe Additions, March Bar 01/01/00 2 33.03 28.35

L3600 Trans Of Orth/Fr Shoes,Caliper Existing 01/01/00 2 38.60 33.13

L3610 Trans Orth/Between Shoes, New Caliper Pl 01/01/00 2 59.45 51.03

L3620 Trans Orthosis/Shoes,Solid Stirrup Exist 01/01/00 2 50.06 42.97

L3630 Trans Orthosis/Shoes,New Solid Stirrup 01/01/00 2 65.22 55.98

L3649 Unlisted Proc For Ortho Shoe,Modif&Trans 10/01/88 1 0.00

L3650 SO, Figure '8' Design Abd Restrainer 01/01/00 2 43.20 41.54

L3651 SO, Single Shoulder, Elastic, Prefabricated 01/01/03 1 NC

L3652 SO, Souble Shoulder, Elastic, Prefabricated 01/01/03 1 NC

L3670 SO,Acromio/Clavicular (Canv&Web Type) 01/01/00 2 68.14 54.28

L3675 SO, vest type abduction restrainer, canvas or equal 01/01/99 1 0.00

L3677 SO, plastic, stabilizer, prefabricated 01/01/02 1 NC

L3700 Elbow Orthoses (Ed) Elastic With Stays 01/01/00 2 45.48 40.33

L3701 Elbow orthosis, elastic, prefabricated 10/01/04 1 11.94

L3710 EO, Plastic With Metal Joints 01/01/00 2 85.60 83.79

L3720 EO, Dbl Up W/Forearm/Arm Cuff,Free Motion 01/01/00 2 409.56 346.10

L3730 EO, Dbl Up W/Forearm/Arm Cuff,F/E Assist 01/01/00 2 543.27 435.76

L3740 EO/Forearm-Arm Cuff-Active Contrl Lock 01/01/00 2 644.09 522.37

L3760 EO/Adjustable Posistion Locking Joint, Prefabricated 01/01/01 1 NC

5101:3-1-60 Page 308







L3762 EO, Rigid, WO Joints, Prefabricated 01/01/03 1 NC

L3767 Lithium Ion Battery, Rlacement 01/01/03 1 NC

L3800 WHFO, Short Opponens, No Attachments 04/01/95 1 132.46

L3805 WHFO, Long Opponens,No Attachments 01/01/00 2 0.00 169.35

L3807 WHFO, Without Joints, Prefab 01/01/01 1 NC

L3810 WHFO, Add To S&L Opponen, Thumb Abd,"C"Br 01/01/00 2 52.07 45.06

L3815 WHFO,Add To S&L Oppon,2Nd Mp,Abd Assist 01/01/00 2 48.34 41.58

L3820 WHFO,Add Ip Ext Asst,W/Mp Ext Stop 01/01/00 2 74.76 70.29

L3825 WHFO,Add To S&L Oppon,M.P. Ext Stop 01/01/00 2 51.77 42.84

L3830 WHFO,Add To S&L Oppon,M.P.Ext Assist 01/01/00 2 61.43 58.10

L3835 WHFO, Add S&L Oppon,M.P. Spring Ext Asst 01/01/00 2 57.89 51.82

L3840 WHFO,Add To S&L Oppon,Spring Swivl Thumb 01/01/00 2 47.85 42.93

L3845 WHFO,Add Thumb Ip/Ext Asst W/Mp Stop 01/01/00 2 65.23 56.18

L3850 WHFO,Add Action Wrist/Dorsiflx Assist 01/01/00 2 79.11 72.77

L3855 WHFO, Add S&L Oppon,Adj Mp Flex Control 01/01/00 2 90.85 82.68

L3860 WHFO,Adj Mp Flex Contrl & I.P Dyn Flex 01/01/00 2 123.94 111.23

L3890 Addition to Upper Extremity Joint, Wrist or Elbow 01/01/00 2 238.58 204.79

L3900 WHFO,Dyn Flex Hng,Wrist Driven 01/01/00 2 971.06 877.85

L3901 WHFO,Dyn Flex Hng, Cable Driven 01/01/00 2 1,272.64 1,128.41

L3906 WHFO, Wrist(Gauntlet) Mld To Pat Model 01/01/00 2 303.77 252.25

L3907 WHFO Wrist Gauntlet W Thmb,Mold Pt Model 01/01/00 2 332.76 284.35

L3908 WHFO,Wrist Ext Cont (Cock-Up) Non/Mlded 04/01/95 1 45.01

L3909 Wrist orthosis, elastic, prefabricated 10/01/04 1 10.30

L3910 WHFO, Swanson Design 04/01/95 1 244.15

L3911 WHFO, Elastic, Prefabricated 01/01/03 1 NC

L3912 WHFO, Flex Glove W/Elastic Finger Contrl 01/01/00 2 63.16 55.78

L3914 WHFO; Wrist Extension Cock Up 01/01/00 2 58.68 54.73

L3916 Wrist Ext (Cock-Up)With Outrigger 01/01/00 2 93.63 75.76

L3917 HO, Metacarpal Frac, Prefabricated 01/01/04 1 NC

L3918 Knuckle Bender 01/01/00 2 60.75 41.22

L3920 Knuckle Bender, With Outrigger 01/01/00 2 74.13 48.12

L3922 Knuckle Bender, 2 Segment To Flex Joint 01/01/00 2 70.89 48.42

L3923 HFO, w/o joint(s), prefabricated, any type 01/01/01 1 NC

L3924 Oppenheimer 01/01/00 2 84.07 68.70

L3926 Thomas Suspension 01/01/00 2 68.01 54.86

L3928 Finger Extension, W.Clock Spring 01/01/00 2 41.48 35.67

L3930 Finger Extension, W/Wrist Support 01/01/00 2 48.14 39.28

L3932 Safety Pin, Spring Wire 01/01/00 2 36.02 32.34

5101:3-1-60 Page 309







L3934 Safety Pin, Modified 01/01/00 2 38.67 34.18

L3936 Palmer (Dorsal Pad W/Palmer Mp Bar) 01/01/00 2 71.58 58.77

L3938 Dorsal Wrist Suppport 01/01/00 2 70.18 56.90

L3940 Dorsal Wrist, W/Outrigger Attachment 01/01/00 2 78.83 72.10

L3942 Reverse Knuckle Bender 01/01/00 2 58.72 40.49

L3944 Reverse Knuckle Bender W/Outrigger 01/01/00 2 74.21 49.09

L3946 Composite Elastic 01/01/00 2 56.03 43.54

L3948 Finger Knuckle Bender 01/01/00 2 44.28 37.28

L3950 Comb Oppenheimer, W/Knuck Bender & 2 Att 01/01/00 2 119.72 101.26

L3952 Comb Oppenheimer,W/Reverse Knuck& 2 Attc 01/01/00 2 133.74 105.11

L3954 Spreading Hand 01/01/00 2 73.37 57.87

L3956 Add Joint Upper Extrem Orthosis, any mat. per joint 01/01/98 1 0.00

L3960 Sewho,Abd Posit, Airplane Design 01/01/00 2 478.09 422.40

L3963 Sewho, Mold Shoulder Arm Etc. Articu 01/01/00 2 1,005.43 769.03

L3980 Fx Orthosis, Humeral 01/01/00 2 231.90 206.72

L3982 Fx Orth, Radius/Ulnar 01/01/00 2 235.46 205.02

L3984 Fx Orthosis, Wrist 01/01/00 2 207.43 185.77

L3985 Upperextrem Frac Orth Forearm W Hinge 01/01/00 2 355.80 271.61

L3986 Fx Orth, Combo Humeral, Rad/Ulnar, Wrist 01/01/00 2 386.80 347.74

L3995 Add On Upper Extremity Fracture Sock, Ea 01/01/00 2 24.62 22.66

L3999 Unlisted Procedures For Upper Limb Orth 10/01/88 1 0.00

L4000 Replace Girdle For Spinal Orthosis 01/01/00 2 870.36 717.59

L4002 Replac. Strap, Any Ortho, Any Length, Any Type 01/01/05 1 NC

L4010 Replace Trilateral Socket Brim 01/01/00 2 529.03 314.86

L4020 Replace Quad/Socket Brim,Mld To Pat Modl 01/01/00 2 635.49 488.16

L4030 Replace Quad/Socket Brim, Custom Fitted 01/01/00 2 403.85 235.94

L4040 Replace Molded Thigh Lacer 01/01/00 2 273.50 237.98

L4045 Replace Non-Molded Thigh Lacer 01/01/00 2 202.02 113.90

L4050 Replace Molded Calf Lacer 01/01/00 2 270.86 237.98

L4055 Replace Non-Molded Calf Lacer 01/01/00 2 164.64 89.50

L4060 Replace High Roll Cuff 04/01/95 1 217.64

L4070 Replace Prox & Dist Upright Kafo 04/01/95 1 189.57

L4080 Replace Metal Bands Kafo, Prox Thigh 04/01/95 1 66.31

L4090 Replace Bands,Kafo-Afo,Distal Thi/Calf 01/01/00 2 55.65 54.92

L4100 Replace Leather Cuff Kafo, Prox Thigh 01/01/00 2 66.89 56.36

L4110 Repl Leather Cuff Kafo-Afo,Calf/Dist Thg 01/01/00 2 52.23 42.00

L4130 Replace Retibial Shell 01/01/00 2 315.69 268.49

L4205 Repair of Orthotic Device, labor, per 15 minutes 10/01/04 1 NC

5101:3-1-60 Page 310







L4210 Repair or Replace Minor Parts of Orthotic Device 10/01/04 1 NC

L4310 Multi-Podus Ortho Prep Lower Extremities 01/01/99 3 NC 284.58

L4320 Add On Afo Multi-Podus Flex Position Cus 01/01/99 3 NC 66.23

L4350 Pneumatic Ankle Control Splint Air Cast 01/01/00 2 63.74 52.02

L4360 Pneumatic Walking Splint Aircast Or Equa 01/01/00 2 170.53 130.97

L4370 Pneumatic Full Leg Splint Aircast Or Eq 01/01/00 2 155.02 134.47

L4380 Pneumatic Knee Splint Aircast Or Equal 01/01/00 2 75.37 62.58

L4386 Non-pneumatic walking splint 01/01/03 1 NC

L4392 Repl Soft Int-face Mat Static AFO 01/01/01 1 15.50

L4396 Static AFO incl soft intface mat; Adjustable; Prefab 01/01/01 1 110.54

L4398 Foot Drop Splint, Prefab 01/01/01 1 NC

L5000 P/F,Shoe Insw/Longitud Arch, Toe Filler 01/01/00 2 378.22 283.11

L5010 P/F,Ankle Height With Toe Filler 01/01/00 2 1,056.80 791.91

L5020 P/F, Tibial Tubercle Height 01/01/00 2 1,655.66 1,261.37

L5050 Symes, Molded Socket, Sach Foot 01/01/00 2 1,808.29 1,486.48

L5060 Symes,Metal Fr,Mld Leath Sock,Art/Foot 01/01/00 2 2,229.10 1,847.18

L5100 Molded Socket, Shin, Sach Foot 01/01/00 2 1,800.56 1,463.62

L5105 Bk Plastic Sock Jts Thi Lacer Sach Foot 01/01/00 2 2,540.97 2,198.73

L5150 Mld Sock,Ext Knee Jts,Shin,Sach Foot 01/01/00 2 2,824.96 2,230.91

L5160 Mld Sock,Bent Knee Config,Ext Kn Jts,Shn 01/01/00 2 3,101.66 2,628.26

L5200 Mld Skt,Sing Ax,Cons Frict Kn,Sach Foot 01/01/00 2 2,398.91 1,911.96

L5210 Short Pros,No Kn/Ank Jt"Stubbies"W/Ft Bl 01/01/00 2 1,904.73 1,611.08

L5220 Above Knee Short Prost W Articu Ank +Ft 01/01/00 2 2,098.19 1,826.58

L5230 Pffd Ak Pros, Cons Frict Kn/Sach Foot 01/01/00 2 3,146.98 2,343.45

L5250 Canad Type,Mld Sock,Hp Jt ,1 Axis/Frict/K 01/01/00 2 3,689.91 2,910.18

L5280 Hemipelvectomy, Canadian Type,Mld Skt,Hp 01/01/00 2 3,996.30 3,127.62

L5300 B/K Mld Skt,Sach,Endo,Incl Soft Cover 04/01/02 3 NC 2,180.86

L5301 B/K Mld Skt, Shin, Sach, Endo system 07/01/02 2 2,137.58 2,180.86

L5310 K/D Mld Skt,Sach, Endo Sys, Incl Cover 04/01/02 3 NC 3,523.84

L5311 K/D Mld skt, Ext Knee joint, Shin, Sach, Endo system 07/01/02 2 3,367.90 3,523.84

L5320 A/K Mld Skt,Op End,Sach,Endo Sys.Sing Ax 04/01/02 3 NC 3,114.41

L5321 A/K Mld Skt, Open End, Endo Sys, Single Axis 07/01/02 2 2,850.39 3,114.41

L5330 Canad Type,Endo Sys,Hp Jt,Sach,Sing Axis 04/01/02 3 NC 4,444.80

L5331 Canad Type,Endo Sys,Hp Jt,Sach,Sing Axis 07/01/02 2 4,174.79 4,444.80

L5340 Hemipelvect,Canad Type,Endo Sys,Hp Jt,Sf 04/01/02 3 NC 4,662.29

L5341 Hemipelvect, Canad Type, Endo Sys, Hip Joint, Sach Foot07/01/02 2 4,437.73 4,662.29

L5400 B/K,Post Surg,Initial,Incl One Cast Chg 01/01/00 2 1,052.91 900.54

L5410 B/K,Immed/Fit,Each Additional Cast Chang 01/01/00 2 290.89 246.62

5101:3-1-60 Page 311







L5420 A/K,Kn/Dis,Init Fit,Align Incl 1 Cast Ch 01/01/00 2 1,329.78 1,135.27

L5430 Imm Tost Surg Rigid Dress Ea Cast Change 01/01/00 2 360.96 268.95

L5510 PTB, plastic socket, molded to model 10/01/04 2 1,420.40 0.00

L5520 PTB, thermoplastic or equal, direct form 10/01/88 1 NC

L5530 PTB, thermoplastic or equal, molded to model 04/01/92 3 NC 1,053.00

L5535 PTB, prefabricated, open end socket 10/01/04 2 1,560.30 NC

L5540 PTB, laminated socket, molded to model 10/01/04 2 1,652.60 NC

L5560 Prep, above knee, plaster socket, molded to model 10/01/04 2 1,883.00 NC

L5570 Prep, above knee, thermoplastic or equal, direct form 10/01/88 1 NC

L5580 Prep, above knee, thermoplastic or equal, molded to model10/01/04 2 2,268.20 NC

L5585 Prep, above knee, prefabricated adjustable open end socket10/01/04 2 2,656.30 NC

L5590 Prep, above knee, laminated socket, molded to model 10/01/04 2 2,364.90 NC

L5595 Prep Hd Thermoplastic Of Equal Mld Model 01/01/00 2 3,023.73 2,693.13

L5600 Prep Hd Laminated Socket Molded Pt Model 01/01/00 2 3,441.45 3,152.47

L5610 Above Knee, Hydracadence 01/01/00 2 1,659.79 1,235.18

L5611 Add On Ak/Kd Ohc 4-Bar Frict Swing Cntrl 01/01/00 2 1,057.15 0.00

L5613 Add Ak/Kd Ohc 4-Bar Hydraulic Swing Ctrl 01/01/00 2 1,607.99 0.00

L5614 Add to Lower Extremity, K-K Dis., 4-Bar Link w/ PSPC 01/01/00 2 1,113.63 2,551.63

L5616 A/K Univ Multiplex Sys,Friction Sw/Phase 01/01/00 2 969.58 682.78

L5617 Addition to Lower Extremity, Quick Change, Self Align. 01/01/00 1 369.26

L5618 Test Socket, Symes 01/01/00 2 220.50 195.40

L5620 Test Socket, Below Knee 01/01/00 2 195.64 163.52

L5622 Test Socket, Knee Disarticulation 01/01/00 2 263.57 260.43

L5624 Test Socket,Above Knee 01/01/00 2 263.49 233.26

L5626 Test Socket, Hip Disartiulation 01/01/00 2 417.11 345.20

L5628 Test Socket, Hemipelvectomy 01/01/00 2 422.39 345.43

L5629 Add On Bk Acrylic Socket 01/01/00 2 208.52 161.93

L5630 Symes Type,Expandable Wall Socket 01/01/00 2 362.30 292.07

L5631 Add On Ak/Kd Acrylic Socket 01/01/00 2 288.30 242.38

L5632 Symes Type,"Ptb" Brim Design Socket 01/01/00 2 177.68 137.75

L5634 Symes Type, Post Open(Canadian) Socket 01/01/00 2 222.22 154.78

L5636 Symes Type, Medial Opening Socket 01/01/00 2 169.85 133.30

L5637 Add On Bk Total Contact 01/01/00 2 252.74 218.87

L5638 Below Knee, Leather Socket 01/01/00 2 425.76 361.41

L5639 Add On Bk Wood Socket 01/01/00 2 735.65 629.91

L5640 Knee Disarticulation,Leather Socket 01/01/00 2 483.55 387.94

L5642 Above Knee, Leather Socket 01/01/00 2 448.24 405.64

L5643 Add L Extrm Hip Disart Flex Sock Ext Frm 01/01/00 2 1,322.06 1,165.76

5101:3-1-60 Page 312







L5645 Add L Extrm Bk Flex In Sock Extern Frame 01/01/00 2 642.90 563.13

L5646 Below Knee, Air Cushion Socket 04/01/95 1 411.10

L5647 Add L Extrm,Bk,Suction Socket 01/01/00 2 521.93 395.03

L5648 Above Knee, Air Cushion Socket 04/01/95 1 490.15

L5649 Add L Extrm Cat Cam Socket 01/01/00 2 1,617.57 1,354.14

L5650 Total Contact,A/K Or Kn Disartic Socket 01/01/00 2 320.31 259.49

L5651 Add L Extrm Ak Flex In Sock Extrn Frame 01/01/00 2 938.50 831.48

L5652 Suction Suspen,A/K Or Knee Disartic Skt 01/01/00 2 286.06 223.83

L5653 Knee Disartic, Expandable Wall Socket 01/01/00 2 446.32 401.46

L5654 Socket Insert,Symes(Pelite Plastaz,Etc) 01/01/00 2 258.72 166.44

L5655 Skt Ins,B/K(Kembol,Pelite,Aliplast,Etc) 01/01/00 2 186.81 153.39

L5656 Skt Ins, Kn/Disart(Kemblo,Aliplast,Etc) 01/01/00 2 283.82 216.37

L5658 Skt Ins,A/K (Kemplo,Pelite,Aliplast,Etc) 01/01/00 2 299.58 229.17

+ L5660 Skt Ins,Syme, Silicone Gel Or Equal 10/01/04 3 NC 458.51

L5661 Add Low Extre Sock Inser Multi Dvromet 01/01/00 2 429.80 375.75

+ L5662 Skt Ins,B/K, Silicone Gel Or Equal 10/01/04 3 NC 399.22

+ L5663 Skt Ins, Knee Disartic,Silicone Gel Or= 10/01/04 3 NC 571.66

+ L5664 Skt In,A/K,Silicone Gel Or Equal 10/01/04 3 NC 580.81

L5665 Add Low Extre Sock Laser Knee Bk Mlt Du 01/01/00 2 382.13 298.84

L5666 Below Knee,Cuff Suspension 01/01/00 2 50.59 43.28

L5667 Add. to Lower Extremity, Below Knee, Socket Insert 04/01/02 3 NC 1,187.73

L5668 Below Knee, Molded Distal Cushion 01/01/00 2 75.38 71.56

L5669 Add to Lower Extrem., Below K, Sock. Ins. w/o Lock 04/01/02 3 NC 910.74

L5670 B/K,Mold Supracondl Susp (Pts Or Sim) 01/01/00 2 178.05 136.66

L5671 Add lower extremity, suspension locking mechanism, excludes socket insert01/01/02 1 NC

L5672 Below Knee,Removable Medial Brim Suspen 01/01/00 2 235.60 176.10

L5673 Add to Lower Extrem, Below Knee/Above Knee, Socket Insert10/01/04 1 633.97

L5674 Below Knee Latex & Neoprene Suspension 01/01/05 3 NC 41.94

L5675 Add Low Extre Below Knee Heavy Duty Ea 01/01/05 3 NC 56.84

L5676 Below Knee, Knee Joints, Pair 01/01/00 2 237.76 201.17

L5677 Add Low Extre Below Knee Polycen Pair 01/01/00 2 364.15 298.30

L5678 Below Knee, Joint Covers, Pair 01/01/00 2 26.05 19.38

L5679 Add to Lower Extrem, Below Knee/Above Knee, Socket Insert10/01/04 1 528.30

L5680 Below Knee, Thigh Lacer, Non-Molded 01/01/00 2 199.71 159.42

L5681 Add to Lower Extrem, Below Knee/Above Knee, Socket Insert10/01/04 1 1,061.04

L5682 B/K.Thigh Lacer,Lguteal/Ishcial, Molded 01/01/00 2 410.34 383.69

L5683 Add to Lower Extrem, Below Knee/Above Knee, Socket Insert10/01/04 1 1,061.04

L5684 Below Knee, Fork Strap 01/01/00 2 31.58 27.38

5101:3-1-60 Page 313







L5685 Add Low Extrem Pros, Lower Knee, Susp/Seal Sleeve 01/01/05 1 56.84

L5686 Below Knee, Back Check(Extension Control 01/01/00 2 37.98 33.99

L5688 Below Knee, Waist Belt, Webbing 01/01/00 2 40.34 34.26

L5690 Below Knee, Waist Belt, Padded And Lined 01/01/00 2 82.34 72.86

L5692 A/K, Pelvic Control Belt,Light Duty 01/01/00 2 87.19 56.92

L5694 A/K,Pelic Control Belt, Padded/Lined 01/01/00 2 119.04 91.05

L5695 Add On Ak Pelvic Ctrl Sleeve Suspen Tes 01/01/00 2 107.00 82.66

L5696 A/K Or Knee Disartic, Pelvic Joint 01/01/00 2 129.26 101.24

L5697 A/K Or Knee Disartic, Pelvic Band 01/01/00 2 61.39 58.02

L5698 A/K Or Knee Disartic, Silesian Belt 01/01/00 2 78.74 64.65

L5699 All Low/Extrem Prosthesis, Shldr Harness 01/01/00 2 134.58 98.65

L5700 Replace. Socket, Below K, Molded to Patient Model 01/01/00 2 2,024.29 1,713.48

L5701 Replace. Socket, Hip Dis., Inc. Att. Plate, Molded 01/01/00 2 2,511.30 2,125.73

L5702 Replace. Socket, Hip Dis., Including Hip Joint, Molded 01/01/00 2 3,165.11 2,679.16

L5704 Custom Shaped Prot. Cover, Above Knee 01/01/00 2 412.74 349.38

L5705 Custom Shaped Prot. Cover, Above Knee 01/01/00 2 756.69 640.51

L5706 Custom Shaped Prot. Cover, Knee Dis. 01/01/00 2 738.07 624.75

L5707 Cust. Shaped Prot. Cover, Hip Dis. 01/01/00 2 991.60 839.35

L5710 Single Axis,Manual Lock 01/01/00 2 235.99 182.29

L5711 Add Exoske Knee Shin Single Ultra Light 01/01/00 2 396.05 304.81

L5712 Friction Swing & Stance,Safety Knee 01/01/00 2 282.73 281.86

L5714 Single Axis,Variable Frict,Sw/Ph Cont 01/01/00 2 287.67 237.96

L5716 Polycentric,Mechanical Stance Phase Lock 01/01/00 2 568.84 476.73

L5718 Polycentric Friction Sw/Stance Ph Contrl 01/01/00 2 608.27 541.46

L5722 Single Axis, Pneumatic Swing Phase 01/01/00 2 739.69 652.22

L5724 Single Axis, Fluid Swing Control 01/01/00 2 1,140.12 836.02

L5728 Single Axis,Fluid Control,Swing & Stance 01/01/00 2 1,590.66 1,211.23

L5781 Add Lower Limb Pros, Vacuum Pump 01/01/03 1 NC

L5782 Add Lower Limb Pros, Vacuum Pump, Heavy Duty 01/01/03 1 NC

L5785 Add Endoske Below Knee Ultra Light Mat 01/01/00 2 340.90 256.72

L5790 Add Exoske Above Knee Ultra Light Mat 01/01/00 2 492.01 372.54

L5795 Add Exoske Hip Disart Ultra Light Mat 01/01/00 2 704.49 514.27

L5810 Add Endoske Knee Single Manual Lock 01/01/00 2 375.36 332.54

L5811 Add Endosk Knee Sing Manual Ultra Light 01/01/00 2 517.98 489.65

L5812 Add Endoske Knee Sing Fric Swng Safe Kn 01/01/00 2 389.79 303.53

L5814 Add Endoske Knee Shin, Polycentric, Hyd Swing Phase 01/01/00 1 2,450.96

L5816 Add Endoske Knee Shin Polycen Mechanical 01/01/00 2 558.01 428.43

L5818 Add Endoske Knee Polyce Fric Swing Cnt 01/01/00 2 630.11 489.90

5101:3-1-60 Page 314







L5822 Add Endosk Knee Sing Pneu Swing Fric 01/01/00 2 1,155.90 955.90

L5824 Add Endosk Knee Sing. Fluid Swing Phase 01/01/00 2 1,092.67 805.42

L5826 Add Endosk Knee-Shin, Sing. Axis Hyd. Swing Phase 01/01/00 1 2,060.95

L5828 Add Endosk. Sing. Fluid Swing + Stance 01/01/00 2 1,944.68 1,612.93

L5830 Add Endosk,. Knee Sing. Pneu. Hydrapneu. 01/01/00 2 1,311.22 1,083.73

L5840 Add., Endoskel., Knee-Shin System, Multiaxial PSPC 01/01/00 2 2,573.61 1,307.78

L5845 Add., Endoskel, knee-shin, stance flex., adjustable 01/01/00 1 1,182.87

L5846 Add., Endoskel, knee-shin, microprocessor control 01/01/05 3 NC 3,577.33

L5847 Add., Endoskel, knee-shin, microprocessor, stance phase 01/01/02 1 NC

L5848 Add Endoskel, knee-shin, hydrolic stance extension 01/01/03 1 NC

L5850 Add Endosk Above Knee Hip Disart. Ext As 01/01/00 2 83.94 63.34

L5855 Add Endoskel Sys, Hip Dis., Mech. Hip Ext. Assist 01/01/00 2 202.63 171.53

L5856 Add., Endoskel, knee-shin, microprocessor, stance phase 01/01/05 1 NC

L5857 Add., Endoskel, knee-shin, microprocessor control, Swing only01/01/05 1 3,577.33

L5910 Add Endosk System Below Knee Align Sys 01/01/00 2 237.63 180.15

L5920 Add Endosk Sys Above Knee Hip Dis Alng 01/01/00 2 348.14 256.01

L5925 Add. Endoskel. Sys., Above K, K Dis., or Hip Dis. 01/01/00 2 220.47 186.62

L5930 Add., Endoskel., High Activity Knee Control Frame 01/01/00 1 2,221.32

L5940 Add Endosk Below Knee Ultra Light 01/01/00 2 329.12 273.83

L5950 Add Endosk Above Knee Ultra Light 01/01/00 2 510.48 404.22

L5960 Add Endosk Hip Disart Ultra Light Mat 01/01/00 2 763.29 559.00

L5962 Add Endoskel., Sys., Below K, Flex Prot Outer Surf. 01/01/00 2 385.67 326.46

L5964 Add Endoskel., Sys. Above K, Flex Prot Outer Surf. 01/01/00 2 739.79 626.21

L5966 Add Endoskel., Sys., Hip Dis., Flex Prot Outer Surf. 01/01/00 2 952.97 806.66

L5968 All lower ext pros, ankle, multiaxial shock absorbing 01/01/99 1 0.00

L5970 All Low/Ext Pros,Feet Ext Keel Sach Ft 01/01/00 2 143.36 110.83

L5972 All Lower Extremity Protheses Safe Foot 01/01/00 2 261.14 180.16

L5974 All Low/Ext Pros Feet Sgl Ax Ank/Foot 01/01/00 2 152.90 119.44

L5975 All lower ext pros, combo single axial ankle 01/01/99 1 0.00

L5976 All Lower Extreme Pros Energy Stor. Ft 01/01/00 2 387.84 303.22

L5978 All Low/Ext, Feet,Multiax Ank/Ft(Greiss) 01/01/00 2 205.52 149.72

L5979 All Lower Extrem. Prostheses, Multiax., A/F, Dyn Resp 01/01/00 2 1,645.42 1,392.79

L5980 All Lower Extremity Flex Foot System 01/01/00 2 2,506.95 0.00

L5981 All Lower Entremity Prosthesis, flex walk system 01/01/00 1 2,251.87

L5982 All Low/Ext, Axial Rotation Unit (Weber) 01/01/00 2 423.03 325.70

L5984 All Endoskel Low Exter Pros Axial Rota 01/01/00 2 424.34 317.11

L5985 All Endoskel Lower Ext. Prosth., Dynamic Prosth. Pylon 01/01/00 1 186.36

L5986 All Low/Ext Multi-Axial Rot Unit (Mcp/=) 01/01/00 2 511.86 346.09

5101:3-1-60 Page 315







L5987 All Lower Extremity Prosthesis, Shank Foot System 01/01/00 1 4,747.49

L5988 All lower ext pros, combo vertical shock 01/01/99 1 0.00

L5989 Add, lower, ext pros, integrated elec force sensors 01/01/02 1 NC

L5990 Add lower ext pros, user adj heel height 01/01/02 1 NC

L5995 Add lower ext pros, heavy duty, >300 lbs 01/01/03 1 NC

L5999 Unlisted Proc For Lower Ext Prosthesis 10/01/88 1 0.00

L6000 Robin Aids, Thumb Remaining Or Equal 01/01/00 2 1,162.39 1,022.02

L6010 Robin Aids, Some Fingers Remaining 01/01/00 2 1,293.56 1,034.76

L6020 Robin Aids, No Fingers Remaining 01/01/00 2 1,206.04 1,042.27

L6025 Transcarpal/metacarpal or patial hand pros 01/01/03 1 NC

L6050 Mld Skt, Flex Elbow Hinges, Tricep Pad 01/01/00 2 1,640.45 1,294.84

L6055 Wrist Disart Mold Sock W Expan Interfa 01/01/00 2 2,092.48 1,834.86

L6100 Mdl Skt, Flex Elbow Hng. Triceps Pad 01/01/00 2 1,660.09 1,182.42

L6110 Molded Socket (Muenster/Nw Suspension) 01/01/00 2 1,756.25 1,271.48

L6120 Mlmld Dbl Wall,Step/Up Hng,Half Cuff 01/01/00 2 1,986.33 1,432.64

L6130 Mld Dbl Wall Stump Activated Lkg/Hinge 01/01/00 2 2,095.63 1,520.33

L6200 Mld Skt,Outside Locking Hinge,Forearm 01/01/00 2 2,158.74 1,624.77

L6205 Elbow Disart Mold Sock W Expan Interfa 01/01/00 2 2,977.96 2,623.62

L6250 Mld Dbl Wall Skt,Int Lk/Elbow, Forearm 01/01/00 2 2,123.84 1,598.46

L6300 Mld Skt,Sh Bulk/Hhum Sect,Int Lk/Elb,Fr 01/01/00 2 2,929.34 2,124.44

L6310 Passive Restoration(Complete Prothesis) 01/01/00 2 2,654.80 2,034.38

L6320 Passive Restorative (Shoulder Cap Only) 01/01/00 2 1,383.62 1,258.57

L6350 Mld Skt, Sh B/H,Hum Sect,Int L/K Elb,F/A 01/01/00 2 3,209.65 2,456.72

L6360 Passive Restoration (Complete Prothesis 01/01/00 2 2,786.54 2,190.66

L6370 Passive Restoration (Shoulder Cap Only) 01/01/00 2 1,616.00 1,501.47

L6400 Mld Skt,Endo Sys, Inc Soft Pros Cover 01/01/00 2 1,795.80 1,497.72

L6450 Mld Skt,Endo Sys,Incl Soft Rpos Cover 01/01/00 2 2,347.03 1,902.92

L6500 Mld Skt,Endo Sys,Incl Soft Pros Cover 01/01/00 2 2,304.72 1,849.60

L6550 Mld Skt,Endo Sys,Incl Soft Pros Cover 01/01/00 2 2,985.07 2,364.38

L6570 Mld Ski,Endo Sys,Incl Soft Pros Cover 01/01/00 2 3,332.45 2,640.05

L6600 Polycentric Hinge, Pair 01/01/00 2 149.70 141.94

L6605 Single Pivot Hinge, Pair 01/01/00 2 154.08 111.32

L6610 Flexible Metal Hinge, Pair 01/01/00 2 145.65 110.96

L6615 Disconnect Locking Wrist Unit 01/01/00 2 141.37 109.02

L6616 Add On Up Ext Additional Disc Inserts 01/01/00 2 42.56 32.30

L6620 Flexion-Friction Wrist Unit 01/01/00 2 247.17 187.46

L6623 Upper Extreme Add Spring Assisted Wrst 01/01/00 2 470.85 393.61

L6625 Rotation Wrist Unit With Cable Lock 01/01/00 2 348.97 252.54

5101:3-1-60 Page 316







L6628 Upper Extreme Add Quick Discon Hook Adap 01/01/00 2 375.62 315.11

L6629 Upper Extrem Quick Discon Lamin Collar 01/01/00 2 128.00 82.89

L6630 Stainless Steel, Any Wrist 01/01/00 2 188.55 167.48

L6632 Upper Extrem Add Latex Suspen Sleeve Ea 01/01/00 2 42.63 34.11

L6635 List Assist For Elbow 01/01/00 2 136.28 112.62

L6637 Upper Extrem Add Nudge Control Elbow 01/01/00 2 266.81 252.83

L6638 Apper Extrem Add, Electric Locking, Manual 01/01/03 1 NC

L6640 Shoulder Abduction Joint, Pair 01/01/00 2 222.20 174.94

L6641 Upper Extrem Add Excurs Amplif Pulley 01/01/00 2 129.39 106.39

L6642 Upper Extrem Add Excur Amplier Lever 01/01/00 2 190.23 160.88

L6645 Shoulder Flexion-Abduction Joint, Each 01/01/00 2 240.29 181.87

L6646 Add Upper Extrem, Shoulder Jnt, body/external Powered 01/01/03 1 NC

L6647 Add Upper Extrem, Shoulder Lock, Body Powered 01/01/03 1 NC

L6648 Add Upper Extrem, Shoulder Lock, External Powered 01/01/03 1 NC

L6650 Shoulder Universal Joint Each 01/01/00 2 260.62 215.76

L6655 Standard Control Cable, Extra 01/01/00 2 50.54 50.31

L6660 Heavy Duty Control Cable 01/01/00 2 67.65 63.06

L6665 Teflon, Or Equal, Cable Lining 01/01/00 2 30.22 27.23

L6670 Hook To Hand, Cable Adapter 01/01/00 2 31.47 30.30

L6672 Harness, Chest Or Shoulder, Saddle Type 01/01/00 2 144.41 123.74

L6675 Harness, Firgure "8",For Single Control 01/01/00 2 78.79 67.55

L6676 Harness, Figure "8", For Dual Control 01/01/00 2 82.43 75.39

L6680 Test Skt, Wrist Disartic Or Below/Elbow 01/01/00 2 202.97 167.34

L6682 Test Skt, Elbow Disartic Or Above/Elbow 01/01/00 2 224.41 179.10

L6684 Test Skt,Sh Disartic Or In/Scap Thoracic 01/01/00 2 304.95 246.38

L6686 Upper Extrem Add Suction Socket 01/01/00 2 452.50 425.93

L6687 Upper Extrem Frame Type Below Elbow Add 01/01/00 2 378.46 295.42

L6688 Upper Extrem Add Frame Type Above Elb 01/01/00 2 418.85 401.08

L6689 Up Extrm Add Frm Sock Should Disartic 01/01/00 2 499.20 421.85

L6690 Upper Extrem Add Frame Type Interscap 01/01/00 2 587.75 513.25

L6691 Upper Extrem Add Removable Insert Ea 01/01/00 2 231.99 181.58

L6692 Add On Up Ext Silicone Gell Insert/Equal 01/01/00 2 422.07 369.34

L6693 Upper Extremity Addition, external locking elbow 01/01/99 1 0.00

L6694 Add to Upper Extr Pros, Below/Above Elbow,Use Lock Sys01/01/05 1 NC

L6695 Add to Upper Extr Pros, Below/Above Elbow,Not For Lock Sys01/01/05 1 NC

L6696 Add Upp Ext, B/A Elbow, For Cong. Or Atyp. Trauma Amputee01/01/05 1 NC

L6697 Add Upp Ext, B/A Elbow, Other Than Cong. Or Atyp. Trauma Amputee01/01/05 1 NC

L6698 Add Upp Extr Pros, B?A Elbow, Lock Mech, Excl Sock Insert01/01/05 1 NC

5101:3-1-60 Page 317







L6700 Hooks, Dorrance, Or Equal Model#3 01/01/00 2 369.96 320.30

L6705 Hooks, Dorrance,Or Equal, Model #5 01/01/00 2 236.92 174.15

L6710 Hooks, Dorrance, Or Equal, Model #5X 01/01/00 2 295.38 210.42

L6715 Hooks, Dorrance, Or Equal, Model #5Xa 01/01/00 2 265.37 204.60

L6720 Hooks, Dorrance, Or Equal, Model #6 01/01/00 2 629.03 508.58

L6725 Hooks, Dorrance, Or Equal Model#7 01/01/00 2 350.78 297.52

L6730 Hooks, Dorrance, Or Equal, Model #7L0 01/01/00 2 467.84 372.95




L6750 Hooks, Dorrance, Or Equal, Model #10P 01/01/00 2 258.62 201.92

L6755 Hooks, Dorrance,Or Equal, Model #10X 01/01/00 2 258.97 202.64

L6765 Hooks, Dorrance, Or Equal, Model #12P 01/01/00 2 271.01 211.17



L6780 Hocks, Dorrance, Or Equal, Model #Ss555 01/01/00 2 326.60 251.66

L6790 Hooks, Accu Hook, Or Equal 04/01/95 1 357.48

L6795 Hooks-2 Load, Or Equal 01/01/00 2 924.32 721.55

L6800 Hooks-Aprl Vc, Or Equal 01/01/00 2 763.53 621.49

L6805 Modifer Wrist Flexion Unit 01/01/00 2 253.11 207.20

L6810 Terminal Device Pincher Tool Otto Bock= 01/01/00 2 134.55 107.48

L6825 Hands, Dorance, Vo 01/01/00 2 767.67 607.95

L6830 Hands, Aprl, Vc 01/01/00 2 1,012.59 805.14

L6835 Hands, Sierra, Vo 01/01/00 2 924.23 732.69

L6840 Hands, Becker Imperial 01/01/00 2 611.77 472.44

L6845 Hands, Becker Lock Grip 01/01/00 2 552.50 452.99

L6850 Hands, Becker Plylite 01/01/00 2 478.73 371.34

L6855 Hands, Robin-Aids, Vo 01/01/00 2 594.99 460.38

L6860 Hands, Robin-Aids, Vo Soft 01/01/00 2 488.01 372.63

L6865 Hands, Passive Hand 01/01/00 2 231.19 175.23

L6870 Hands, Child Mitt 01/01/00 2 172.68 132.85

L6875 Hands, Bock, Vc 01/01/00 2 628.71 477.18

L6880 Hands, Bock, Vo 01/01/00 2 441.14 354.42

L6881 Auto grasp, add upper limb pros terminal device 01/01/02 1 NC

L6882 Micropros cont, add upper limb pros terminal device 01/01/02 1 NC

L6890 Ter Device, Produc Glove For Above Hand 01/01/00 2 131.80 118.11

L6900 Incl Cst ,Shad&Measure)W/Glove,Th/Fin Rem 01/01/00 2 1,279.84 1,020.46

L6905 H/R, W/Glove, Multiple Fingers Remaining 01/01/00 2 1,266.68 1,003.39

5101:3-1-60 Page 318







L6910 H/R, W/Glove, No Fingers Remaining 01/01/00 2 1,245.23 990.06

L6915 H/R, Replacment Glove For Above 01/01/00 2 535.04 473.74

L7181 Electron Elbow, Micropros Simultan Control Elbow & Terminal01/01/05 1 NC

L7368 Lithium Ion Battery Charger 01/01/03 1 NC

L7499 Unlisted Procedures For Up/Extrem Pros 10/01/88 1 0.00

L7500 Repair of prosthetic device, hourly rate 10/01/04 1 NC

L7510 Repair or replace minor parts of prosthetic device 10/01/04 1 NC

L7520 Repair prosthetic device, labor, per 15 minutes 10/01/04 1 NC

L8000 Mastectomy Bra 10/01/88 1 30.00

L8001 Mastectomy Bra, Intergrated Breast, Unilateral 01/01/02 1 NC

L8002 Mastectomy Bra, Intergrated Breast, Bilateral 01/01/02 1 NC

L8010 Mastectomy Sleeve 07/01/02 2 48.11 48.87

L8015 External Breast Prosthesis Garment 01/01/99 1 0.00

L8020 Mastectomy Form, Each 01/01/00 2 149.21 143.17

L8030 Breast Prothesis, Silicone Or Equal 04/01/95 1 240.00

L8035 Custom breast prosthesis 01/01/99 1 0.00

L8040 Nasal Prosthesis, Provided by Non-Physician 01/01/01 1 NC

L8041 Midfacial Prosthesis, Provided by Non-Physician 01/01/01 1 NC

L8042 Orbital Prosthesis, Provided by Non-Physician 01/01/01 1 NC

L8043 Upper Facial Prosthesis, Provided by Non-Physician 01/01/01 1 NC

L8044 Hemi-Facial Prosthesis, Provided by Non-Physician 01/01/01 1 NC

L8045 Auricular Prosthesis, Provided by Non-Physician 01/01/01 1 NC

L8046 Partial Facial Prosthesis, Provided by Non-Physician 01/01/01 1 NC

L8047 Nasal Septal Prosthesis, Provided by Non-Physician 01/01/01 1 NC

L8048 Unspecified Maxillofacial Prosthesis, Prov by Non-Phys 01/01/01 1 NC

L8049 Repair/Mod Maxillofacial Pros, Labor, by Non-Physician 01/01/01 1 NC

L8100 Grad comp stocking, below knee, 18-30 each 10/01/04 1 43.27



L8130 Grad comp stocking, thigh, 18-30 each 10/01/04 1 43.27



L8160 Grad comp stocking, chap, 18-30 each 10/01/04 1 43.27



L8190 Grad comp stocking, waist, 18-30 each 10/01/04 1 43.27

L8195 Grad comp stocking, waist, 30-40 each 10/01/04 2 43.27 0.00

L8200 Grad comp stocking, waist, 40-50 each 10/01/04 1 60.96

5101:3-1-60 Page 319







L8210 Grad comp stocking, custom made 10/01/04 2 43.27 0.00

L8220 Grad comp stocking, lymphedema 10/01/04 1 43.27

L8230 Grad comp stocking, garter belt 10/01/04 1 43.27

L8239 Grad comp stocking, not otherwise specified 10/01/04 1 NC

L8300 Truss, Single With Standard Pad 04/01/95 1 60.95

L8310 Truss, Double With Standard Pads 01/01/00 2 98.06 77.21

L8320 Truss Addition To Standard Pad,Water Pad 04/01/95 1 42.80

L8330 Truss Addition To Standard Pads,Scrot Pd 01/01/00 2 32.39 24.22

L8400 Prosthetic Sheath, B/K,Each 01/01/00 2 10.33 8.78

L8410 Prosthetic Sheath, A/K, Each 01/01/00 2 13.60 11.35

L8415 Prosthetic Sheath Upper Limb Ea 01/01/00 2 14.07 11.18

L8417 Prosthetic sock/sheath, gel liner, below or above knee 01/01/00 1 49.63

L8420 Prosthetic Sock, Wool, B/K, Each 01/01/00 2 13.77 10.82

L8430 Prosthetic Sock, Wool, A/K, Each 01/01/00 2 15.58 12.66

L8435 Prosthtic Sock Wool Upper Limb Ea 01/01/00 2 14.81 11.35

L8440 Prosthetic Shrinker, B/K, Each 01/01/00 2 30.77 26.62

L8460 Prosthetic Shrinker, A/K, Each 01/01/00 2 43.73 37.22

L8465 Prosthetic Shrinker Upper Limb Ea 01/01/00 2 40.43 31.30

L8470 Stump Sock, Sing Ply, Fitting B/K, Each 01/01/00 2 4.38 3.71

L8480 Stump Sock, Sing Ply, Fitting, A/K, Each 01/01/00 2 6.04 4.69

L8485 Stump Sock, Single Ply, Fitting, Upper Limb, Each 01/01/00 2 8.13 6.88

L8490 Add. to Prosthetic Sheath/Sock, Air Seal Suction 01/01/05 3 NC 115.89

L8499 Unlisted Proc For Misc Prosthetic Servic 10/01/88 1 0.00

L8500 Artificial Larynx 01/01/00 2 434.28 0.00

L8501 Tracheostomy Speaking Valve 05/25/91 1 86.25

L8505 Artificial Larynx Replacement Bat/Acces, Any Type 01/01/02 1 NC

L8507 Tracheo-esopageal voice pros, pateint inserted 01/01/02 1 NC

L8509 Tracheo-esopageal voice pros, professional inserted 01/01/02 1 NC

L8510 Voice Amplifier 01/01/02 1 NC

L8511 Replacement Only, Insert indwelling Trach Pros, Each 01/01/04 1 NC

L8512 Gel Caps, Trach Voice Pros, Replace Only, Per 10 01/01/04 1 NC

L8513 Cleaning Device, Trach Voice Device, Replace Only, Each01/01/04 1 NC

L8514 Trach Puncture Dialator, Replace Only, Each 01/01/04 1 NC

L8606 Inj Bulking Agent, urinary tract, 1ml 01/01/01 1 NC

L8631 Metacarpal phalangeal joint replacement, two or more pieces01/01/04 1 NC

L8659 Interphalangeal fin jnt replacement, 2> pieces, any size 01/01/04 1 NC

M0064 Visit for drug monitoring 01/01/04 1 NC

M0075 Cellular therapy 01/01/04 1 NC

5101:3-1-60 Page 320







M0076 Prolotherapy 01/01/04 1 NC

M0100 Intragastric hypothermia 01/01/04 1 NC

M0300 IV chelationtherapy 01/01/04 1 NC

M0301 Fabric wrapping of aneurysm 01/01/04 1 NC

M0838 Rast Unit Charge Per Test Ea Add Over 5 01/01/98 3 NC 4.63

MC00A HMO Healthy Start Mother 03/01/95 3 NC 0.01

MC00B HMO Healthy Start Child 03/01/95 3 NC 0.01

MC00C HMO Healthy Start Infant 03/01/95 3 NC 0.01

MC00D HMO ABD Female; Age 14 - 34 03/01/95 3 NC 0.01

MC00E HMO ADC Female; Age > 34 03/01/95 3 NC 0.01

MC00F HMO ADC Other 03/01/95 3 NC 0.01

MC00G HMO ADC Infant; Age 6 Months Or Less 03/01/95 3 NC 0.01

P2028 Cephalin floculation test 04/01/04 1 NC

P2029 Congo red blood test 04/01/04 1 NC

P2031 Hair analysis 04/01/04 1 NC

P2033 Blood thymol turbidity 04/01/04 1 NC

P2038 Blood mucoprotein 04/01/04 1 NC

P3000 Screen pap by tech w md supv 04/01/04 1 NC

P3001 Screening pap smear by phys 04/01/04 1 NC

P7001 Culture bacterial urine 04/01/04 1 NC

P9010 Whole blood for transfusion 04/01/04 1 NC

P9011 Blood split unit 04/01/04 1 NC

P9012 Cryoprecipitate each unit 04/01/04 1 NC

P9016 RBC leukocytes reduced 04/01/04 1 NC

P9017 Plasma 1 donor frz w/in 8 hr 04/01/04 1 NC

P9019 Platelets, each unit 04/01/04 1 NC

P9020 Plaelet rich plasma unit 04/01/04 1 NC

P9021 Red blood cells unit 04/01/04 1 NC

P9022 Washed red blood cells unit 04/01/04 1 NC

P9023 Frozen plasma, pooled, sd 04/01/04 1 NC

P9031 Platelets leukocytes reduced 04/01/04 1 NC

P9032 Platelets, irradiated 04/01/04 1 NC

P9033 Platelets leukoreduced irrad 04/01/04 1 NC

P9034 Platelets, pheresis 04/01/04 1 NC

P9035 Platelet pheres leukoreduced 04/01/04 1 NC

P9036 Platelet pheresis irradiated 04/01/04 1 NC

P9037 Plate pheres leukoredu irrad 04/01/04 1 NC

P9038 RBC irradiated 04/01/04 1 NC

5101:3-1-60 Page 321







P9039 RBC deglycerolized 04/01/04 1 NC

P9040 RBC leukoreduced irradiated 04/01/04 1 NC

P9041 Albumin (human),5%, 50ml 04/01/04 1 NC

P9043 Plasma protein fract,5%,50ml 04/01/04 1 NC

P9044 Cryoprecipitatereducedplasma 04/01/04 1 NC

P9045 Albumin (human), 5%, 250 ml 04/01/04 1 NC

P9046 Albumin (human), 25%, 20 ml 04/01/04 1 NC

P9047 Albumin (human), 25%, 50ml 04/01/04 1 NC

P9048 Plasmaprotein fract,5%,250ml 04/01/04 1 NC

P9050 Granulocytes, pheresis unit 04/01/04 1 NC

P9051 Blood, l/r, cmv-neg 04/01/04 1 NC

P9052 Platelets, hla-m, l/r, unit 04/01/04 1 NC

P9053 Plt, pher, l/r cmv-neg, irr 04/01/04 1 NC

P9054 Blood, l/r, froz/degly/wash 04/01/04 1 NC

P9055 Plt, aph/pher, l/r, cmv-neg 04/01/04 1 NC

P9056 Blood, l/r, irradiated 04/01/04 1 NC

P9057 RBC, frz/deg/wsh, l/r, irrad 04/01/04 1 NC

P9058 RBC, l/r, cmv-neg, irrad 04/01/04 1 NC

P9059 Plasma, frz between 8-24hour 04/01/04 1 NC

P9060 Fr frz plasma donor retested 04/01/04 1 NC

P9603 One-way allow prorated miles 04/01/04 1 NC

P9604 One-way allow prorated trip 04/01/04 1 NC

P9605 Ven/Cap Punc Col Spec Sgl Home/Ltcf Pt. 07/01/01 3 NC 3.00

P9610 Cath-Collect Spec,Sgl,Home-Bound-Ltcf Pt 04/01/99 3 NC 3.00

P9612 Catheter Collection, Single Patient 01/01/99 1 3.00

P9615 Cath-Coll. Spec Noff, Ind Lab Mult Pt)Licf 03/15/85 1 3.00

PP474 Passport Case Management 12/01/86 1 999.99

PP476 Passport Home Modifications 12/01/86 1 9,999.99

PP477 Passport Personal Care 12/01/86 1 2,999.99

PP478 Passport Respite Care 12/01/86 1 2,999.99

PP495 Passport Nursing Service 12/01/86 1 9,999.99

PP500 Passport Adult Day Care W/O Transportatn 12/01/86 1 1,999.99

PP501 Passport Adult Day Care W Transportation 12/01/86 1 2,999.99

PP502 Passport Adaptive/Assistive Equipment 12/01/86 1 4,999.99

PP503 Passport Home Delivered Meals 12/01/86 1 299.99

PP504 Passport Physical Therapy 12/01/86 1 999.99

PP505 Passport Home Health Aide 12/01/86 1 2,999.99

PP506 Passport Homemaker 12/01/86 1 999.99

5101:3-1-60 Page 322







PP507 Passport Medical Supplies 12/01/86 1 999.99

Q0035 Cardiokymography 01/01/04 1 NC

Q0036 Oxygen Concentrator, Including Supplies 07/01/93 1 193.44

Q0040 Portable Oxygen Contents, Recip-Ownd Equi 05/01/90 1 10.00

Q0046 Portable Oxygen System Rental,Incl Suppl 05/01/90 1 28.25

Q0091 Obtaining screen pap smear 01/01/04 1 NC

Q0092 Set up port xray equipment 01/01/04 1 NC

Q0095 Urine Preg Tests; Screening Kits 09/01/92 1 11.15

Q0097 Hemoglobin, Cooper Sulfate,Nonautomated 01/01/01 3 NC 3.53

Q0098 Blood Glucose; Waivered Method 01/01/01 3 NC 4.72

Q0099 Fecal Occult Blood 01/01/01 3 NC 8.60

Q0100 Dipstick Urine;One Or More Components 01/01/01 3 NC 2.93

Q0101 Spun Microhematocrit 01/01/01 3 NC 3.33

Q0102 Erythocytc Sedimentation Rate 01/01/01 3 NC 5.29

Q0103 Physical Therapy Evaluation, Initial 04/01/98 3 NC 34.09

Q0104 Physical Therapy Re-Evaluation,Periodic 04/01/98 3 NC 17.05

Q0111 Wet Mounts 01/01/98 2 5.90 6.06

Q0112 Potassium Hydroxide Preps 01/01/98 2 5.90 6.06

Q0113 Pinworms Examinations 01/01/98 2 7.47 7.68

Q0114 Fern Test 01/01/98 2 9.88 10.15

Q0115 Post-coital mucous exam 01/01/04 1 NC

Q0116 Hemoglobin,Single Analyte Exam 04/01/97 3 NC 3.77

Q0136 Epoetin alpha inj, 1000 units (non-ESRD) 10/01/04 2 11.62 NC

Q0137 Darbepoetin Alfa inj, 1 mcg (non-ESRD use) 10/01/04 2 4.24 4.74

Q0144 Azithromycin Dihydrate, oral cap/powder, 1 gram 01/01/97 1 NC

Q0156 Infusion, Albumin (human), 5%, 500 ml 04/01/01 1 NC

Q0157 Infusion, Albumin (human), 25%, 50 ml 04/01/01 1 NC

Q0158 HIB/Hep B (combined) vaccine 04/01/98 3 NC 5.00

Q0163 Diphenhydramine HCl 50mg 01/01/04 1 NC

Q0164 Prochlorperazine maleate 5mg 01/01/04 1 NC

Q0165 Prochlorperazine maleate10mg 01/01/04 1 NC

Q0166 Granisetron HCl 1 mg oral 01/01/04 1 NC

Q0167 Dronabinol 2.5mg oral 01/01/04 1 NC

Q0168 Dronabinol 5mg oral 01/01/04 1 NC

Q0169 Promethazine HCl 12.5mg oral 01/01/04 1 NC

Q0170 Promethazine HCl 25 mg oral 01/01/04 1 NC

Q0171 Chlorpromazine HCl 10mg oral 01/01/04 1 NC

Q0172 Chlorpromazine HCl 25mg oral 01/01/04 1 NC

5101:3-1-60 Page 323







Q0173 Trimethobenzamide HCl 250mg 01/01/04 1 NC

Q0174 Thiethylperazine maleate10mg 01/01/04 1 NC

Q0175 Perphenazine 4mg oral 01/01/04 1 NC

Q0176 Perphenazine 8mg oral 01/01/04 1 NC

Q0177 Hydroxyzine pamoate 25mg 01/01/04 1 NC

Q0178 Hydroxyzine pamoate 50mg 01/01/04 1 NC

Q0179 Ondansetron HCl 8mg oral 01/01/04 1 NC

Q0180 Dolasetron mesylate oral 01/01/04 1 NC

Q0181 Unspecified oral anti-emetic 01/01/04 1 NC

Q0182 Nonmetabolic act d/e tissue 01/01/04 1 NC

Q0183 Nonmetabolic active tissue 01/01/04 1 NC

Q0184 Metabolically active tissue 01/01/04 1 NC

Q0187 Factor viia recombinant 01/01/04 1 NC

Q1001 Ntiol category 1 01/01/04 1 NC





Q2001 Cabergoline Oral 0.5mg 01/01/01 1 30.06

Q2002 Elliotts B Soln 01/01/01 1 BR

Q2003 Aprotinin 10,000 kiu 01/01/01 1 95.75

Q2004 Bladder calculi irrig sol 01/01/04 1 NC

Q2005 Corticorelin Ovine Triflutate per ose 01/01/01 1 374.78

Q2006 Digoxin Immune Fab per vial 01/01/01 1 560.64

Q2007 Ethanolamine Oleate 100mg 04/01/02 2 42.43 30.86

Q2008 Fomepizole 1.5mg 01/01/01 1 BR

Q2009 Fosphenytoin 50mg 10/01/04 2 5.44 7.79

Q2010 Glatiramer Acetate per dose 04/01/02 2 33.93 32.42

Q2011 Hemin 1mg 10/01/04 2 6.62 BR

Q2012 Pegademase Bovine 25 IU 01/01/01 1 BR

Q2013 Pentastarch 01/01/01 1 BR

Q2014 Sermorelin Acetate 0.5mg 01/01/01 1 12.04

Q2015 Somatrem 5mg 04/01/02 3 NC BR

Q2016 Somatropin 1mg 04/01/02 3 NC BR

Q2017 Teniposide 50mg 04/01/02 2 227.42 210.47

Q2018 Urofollitropin 75 IU 04/01/02 2 75.37 71.89

Q2019 Basiliximab 20mg 01/01/01 1 1,318.08

Q2020 Histrelin Acetate 10mg 01/01/01 1 159.18

5101:3-1-60 Page 324







Q2021 Lepirudin 50mg 04/01/02 2 141.18 133.32

Q2022 Von Willebrands Factor Complex Human, Per IU 12/15/02 2 0.95 BR

Q3000 Rubidium RB-82 01/01/04 1 NC

Q3001 Brachytherapy Radioelements 01/01/04 1 NC

Q3002 Gallium ga 67 01/01/04 1 NC

Q3003 Technetium tc99m bicisate 01/01/04 1 NC

Q3004 Xenon xe 133 01/01/04 1 NC

Q3005 Technetium tc99m mertiatide 01/01/04 1 NC

Q3006 Technetium tc99m glucepatate 01/01/04 1 NC

Q3007 Sodium phosphate p32 01/01/04 1 NC

Q3008 Indium 111-in pentetreotide 01/01/04 1 NC

Q3009 Technetium tc99m oxidronate 01/01/04 1 NC

Q3010 Technetium tc99mlabeledrbcs 01/01/04 1 NC

Q3011 Chromic phosphate p32 01/01/04 1 NC

Q3012 Cyanocobalamin cobalt co57 01/01/04 1 NC

Q3014 Telehealth originating site fee 01/01/02 1 NC

Q3019 ALS emer trans no ALS serv 01/01/04 1 NC

Q3020 ALS nonemer trans no ALS ser 01/01/04 1 NC

Q3025 IM inj interferon beta 1-a, 11 mcg 10/01/04 2 76.23 NC

Q3026 Subc inj interferon beta-1a 01/01/04 1 NC

Q3031 Collagen skin test 01/01/04 1 NC

Q4001 Cast sup body cast plaster 10/01/03 1 18.14

Q4002 Cast sup body cast fiberglas 10/01/03 1 68.57

Q4003 Cast sup shoulder cast plstr 10/01/03 1 13.03

Q4004 Cast sup shoulder cast fbrgl 10/01/03 1 45.12

Q4005 Cast sup long arm adult plst 10/01/03 1 4.80

Q4006 Cast sup long arm adult fbrg 10/01/03 1 10.83

Q4007 Cast sup long arm ped plster 10/01/03 1 2.41

Q4008 Cast sup long arm ped fbrgls 10/01/03 1 5.42

Q4009 Cast sup sht arm adult plstr 10/01/03 1 3.21

Q4010 Cast sup sht arm adult fbrgl 10/01/03 1 7.22

Q4011 Cast sup sht arm ped plaster 10/01/03 1 1.60

Q4012 Cast sup sht arm ped fbrglas 10/01/03 1 3.61

Q4013 Cast sup gauntlet plaster 10/01/03 1 5.84

Q4014 Cast sup gauntlet fiberglass 10/01/03 1 9.85

Q4015 Cast sup gauntlet ped plster 10/01/03 1 2.92

Q4016 Cast sup gauntlet ped fbrgls 10/01/03 1 4.93

Q4017 Cast sup lng arm splint plst 10/01/03 1 3.38

5101:3-1-60 Page 325







Q4018 Cast sup lng arm splint fbrg 10/01/03 1 5.39

Q4019 Cast sup lng arm splnt ped p 10/01/03 1 1.69

Q4020 Cast sup lng arm splnt ped f 10/01/03 1 2.70

Q4021 Cast sup sht arm splint plst 10/01/03 1 2.50

Q4022 Cast sup sht arm splint fbrg 10/01/03 1 4.51

Q4023 Cast sup sht arm splnt ped p 10/01/03 1 1.26

Q4024 Cast sup sht arm splnt ped f 10/01/03 1 2.26

Q4025 Cast sup hip spica plaster 10/01/03 1 14.01

Q4026 Cast sup hip spica fiberglas 10/01/03 1 43.74

Q4027 Cast sup hip spica ped plstr 10/01/03 1 7.01

Q4028 Cast sup hip spica ped fbrgl 10/01/03 1 21.88

Q4029 Cast sup long leg plaster 10/01/03 1 10.71

Q4030 Cast sup long leg fiberglass 10/01/03 1 28.20

Q4031 Cast sup lng leg ped plaster 10/01/03 1 5.36

Q4032 Cast sup lng leg ped fbrgls 10/01/03 1 14.10

Q4033 Cast sup lng leg cylinder pl 10/01/03 1 9.99

Q4034 Cast sup lng leg cylinder fb 10/01/03 1 24.86

Q4035 Cast sup lngleg cylndr ped p 10/01/03 1 5.00

Q4036 Cast sup lngleg cylndr ped f 10/01/03 1 12.43

Q4037 Cast sup shrt leg plaster 10/01/03 1 6.10

Q4038 Cast sup shrt leg fiberglass 10/01/03 1 15.27

Q4039 Cast sup shrt leg ped plster 10/01/03 1 3.06

Q4040 Cast sup shrt leg ped fbrgls 10/01/03 1 7.64

Q4041 Cast sup lng leg splnt plstr 10/01/03 1 7.41

Q4042 Cast sup lng leg splnt fbrgl 10/01/03 1 12.66

Q4043 Cast sup lng leg splnt ped p 10/01/03 1 3.71

Q4044 Cast sup lng leg splnt ped f 10/01/03 1 6.33

Q4045 Cast sup sht leg splnt plstr 10/01/03 1 4.30

Q4046 Cast sup sht leg splnt fbrgl 10/01/03 1 6.92

Q4047 Cast sup sht leg splnt ped p 10/01/03 1 2.15

Q4048 Cast sup sht leg splnt ped f 10/01/03 1 3.47

Q4049 Finger splint, static 01/01/04 1 NC

Q4050 Cast supplies unlisted 01/01/04 1 NC

Q4051 Splint supplies misc 01/01/04 1 NC

Q4052 Octreotide injection, depot 01/01/04 1 NC

Q4053 Pegfilgrastim, 1 mg 01/01/04 1 NC

Q4054 Darbepoetin Alfa inj, 1 mcg (for ESRD on Dialysis) 10/01/04 2 4.24 4.74

Q4055 Epoetin Alfa inj, 1000 units (for ESRD on Dialysis) 10/01/04 2 11.62 10.00

5101:3-1-60 Page 326







Q4056 Acyclovir, 5 mg 01/01/04 1 NC

Q4057 Dopamine hcl, 40 mg 01/01/04 1 NC

Q4058 Treprostinil, 1 mg 01/01/04 1 NC

Q4059 Ammonia N-13, per dose 01/01/04 1 NC

Q4075 Inj, Acyclovir, 5 mg 10/01/04 2 0.42 0.47

Q4076 Inj, Dopamine HCl, 40 mg 01/01/04 1 0.45

Q4077 Inj, Treprostinil, 1 mg 01/01/04 1 BR

Q9920 Injection of EPO, Per 1000 units, Hct of 20 or less 01/01/04 3 NC 10.00

Q9921 Injection of EPO, Per 1000 units, Hct of 21 01/01/04 3 NC 10.00



















Q9940 Injection of EPO, Per 1000 units, Hct of 40 or more 01/01/04 3 NC 10.00

R0070 Trns Port Xray Eqp/Per-Hm/N.Hm P/Tp 1+Pt 04/13/89 1 7.45

R0075 Transport port x-ray multipl 01/01/04 1 NC

R0076 Transport portable EKG 01/01/04 1 NC

S0009 Injection, butorphanol tartr 01/01/04 1 NC

S0012 Butorphanol tartrate, nasal 01/01/04 1 NC

S0014 Tacrine hydrochloride, 10 mg 01/01/04 1 NC

S0016 Injection, amikacin sulfate 01/01/04 1 NC

S0017 Injection, aminocaproic acid 01/01/04 1 NC

S0020 Injection, bupivicaine hydro 01/01/04 1 NC

S0021 Injection, cefoperazone sod 01/01/04 1 NC

5101:3-1-60 Page 327







S0023 Injection, cimetidine hydroc 01/01/04 1 NC

S0028 Injection, famotidine, 20 mg 01/01/04 1 NC

S0030 Injection, metronidazole 01/01/04 1 NC

S0032 Injection, nafcillin sodium 01/01/04 1 NC

S0034 Injection, ofloxacin, 400 mg 01/01/04 1 NC

S0039 Injection, sulfamethoxazole 01/01/04 1 NC

S0040 Injection, ticarcillin disod 01/01/04 1 NC

S0071 Injection, acyclovir sodium 01/01/04 1 NC

S0072 Injection, amikacin sulfate 01/01/04 1 NC

S0073 Injection, aztreonam, 500 mg 01/01/04 1 NC

S0074 Injection, cefotetan disodiu 01/01/04 1 NC

S0077 Injection, clindamycin phosp 01/01/04 1 NC

S0078 Injection, fosphenytoin sodi 01/01/04 1 NC

S0079 Octreotide 100 mcg 01/01/04 1 NC

S0080 Injection, pentamidine iseth 01/01/04 1 NC

S0081 Injection, piperacillin sodi 01/01/04 1 NC

S0088 Imatinib 100 mg 01/01/04 1 NC

S0090 Sildenafil citrate, 25 mg 01/01/04 1 NC

S0091 Granisetron 1mg 01/01/04 1 NC

S0092 Hydromorphone 250 mg 01/01/04 1 NC

S0093 Morphine 500 mg 01/01/04 1 NC

S0104 Zidovudine, oral, 100 mg 01/01/04 1 NC

S0106 Bupropion HCL SR 60 tablets 01/01/04 1 NC

S0107 Inj, omalizumab 25 mg 01/01/04 1 85.70

S0108 Mercaptopurine 50 mg 01/01/04 1 NC

S0114 Inj treprostinil 0.5 mg 01/01/04 1 NC

S0115 Bortezomib 3.5 mg 01/01/04 1 NC

S0122 Inj menotropins 75 iu 01/01/04 1 NC

S0124 Inj urofollitropin 75 iu 01/01/04 1 NC

S0126 Inj follitropin alfa 75 iu 01/01/04 1 NC

S0128 Inj follitropin beta 75 iu 01/01/04 1 NC

S0130 Inj c gonadotropin 5000 iu 01/01/04 1 NC

S0132 Inj ganirelix acetat 250 mcg 01/01/04 1 NC

S0135 Pegfilgrastim injection 6mg 01/01/04 1 NC

S0136 Clozapine, 25 mg 01/01/04 1 NC

S0137 Didanosine, 25 mg 01/01/04 1 NC

S0138 Finasteride, 5 mg 01/01/04 1 NC

S0139 Minoxidil, 10 mg 01/01/04 1 NC

5101:3-1-60 Page 328







S0140 Saquinavir, 200 mg 01/01/04 1 NC

S0141 Zalcitabine, 0.375 mg 01/01/04 1 NC

S0155 Epoprostenol dilutant 01/01/04 1 NC

S0156 Exemestane, 25 mg 01/01/04 1 NC

S0157 Becaplermin gel 1%, 0.5 gm 01/01/04 1 NC

S0163 Injection, Risperdone, Long Acting, 12.5 mg 01/01/05 2 NC 111.04

S0170 Anastrozole 1 mg 01/01/04 1 NC

S0171 Bumetanide 0.5 mg 01/01/04 1 NC

S0172 Chlorambucil 2 mg 01/01/04 1 NC

S0173 Dexamethasone 4 mg 01/01/04 1 NC

S0174 Dolasetron 50 mg 01/01/04 1 NC

S0175 Flutamide 125 mg 01/01/04 1 NC

S0176 Hydroxyurea 500 mg 01/01/04 1 NC

S0177 Levamisole 50 mg 01/01/04 1 NC

S0178 Lomustine 10 mg 01/01/04 1 NC

S0179 Megestrol 20 mg 01/01/04 1 NC

S0181 Ondansetron 4 mg 01/01/04 1 NC

S0182 Procarbazine 5 mg 01/01/04 1 NC

S0183 Prochlorperazine 5 mg 01/01/04 1 NC

S0187 Tamoxifen 10 mg 01/01/04 1 NC

S0189 Testosterone pellet 75 mg 01/01/04 1 NC

S0190 Mifepristone, oral, 200 mg 01/01/04 1 NC

S0191 Misoprostol, oral, 200 mcg 01/01/04 1 NC

S0193 Inj alefacept 7.5 mg 01/01/04 1 NC

S0195 Pneumo vaccine 5-9 yrs 01/01/04 1 NC

S0199 Med abortion inc all ex drug 01/01/04 1 NC

S0201 Partial hospitalization serv 01/01/04 1 NC

S0207 Paramedicintercep nonhospals 01/01/04 1 NC

S0208 Paramed intrcept nonvol 01/01/04 1 NC

S0209 WC Van Mileage per mile 10/01/03 1 FP TM

S0215 Nonemerg transp mileage 01/01/04 1 WP

S0220 Medical conference by physic 01/01/04 1 NC

S0221 Medical conference, 60 min 01/01/04 1 NC

S0250 Comp geriatr assmt team 01/01/04 1 NC

S0255 Hospice refer visit nonmd 01/01/04 1 NC

S0260 H&P for surgery 01/01/04 1 NC

S0302 Completed EPSDT 01/01/04 1 NC

S0310 Hospitalist visit 01/01/04 1 NC

5101:3-1-60 Page 329







S0315 Disease management program 01/01/04 1 NC

S0316 Follow-up/reassessment 01/01/04 1 NC

S0317 Disease mgmt per diem 01/01/04 1 NC

S0320 RN telephone calls to DMP 01/01/04 1 NC

S0340 Lifestyle mod 1st stage 01/01/04 1 NC

S0341 Lifestyle mod 2 or 3 stage 01/01/04 1 NC

S0342 Lifestyle mod 4th stage 01/01/04 1 NC

S0390 Rout foot care per visit 01/01/04 1 NC

S0395 Impression casting ft 01/01/04 1 NC

S0400 Global eswl kidney 01/01/04 1 NC

S0500 Dispos cont lens 01/01/04 1 NC

S0504 Singl prscrp lens 01/01/04 1 NC

S0506 Bifoc prscp lens 01/01/04 1 NC

S0508 Trifoc prscrp lens 01/01/04 1 NC

S0510 Non-prscrp lens 01/01/04 1 NC

S0512 Daily cont lens 01/01/04 1 NC

S0514 Color cont lens 01/01/04 1 NC

S0516 Safety frames 01/01/04 1 NC

S0518 Sunglass frames 01/01/04 1 NC

S0580 SV polycarbonate lens each 10/01/03 1 PC

S0581 Industrial thickness SV or bif 10/01/03 1 PC

S0590 Misc integral lens serv 01/01/04 1 NC

S0592 Comp cont lens eval 01/01/04 1 NC

S0601 Screening proctoscopy 01/01/04 1 NC

S0605 Digital rectal examination, 01/01/04 1 NC

S0610 Annual gynecological exam, new patient 01/01/04 2 66.18 48.40

S0612 Annual gynecological exam, established patient 01/01/04 2 55.98 34.35

S0620 Routine ophthalmological exa 01/01/04 1 NC

S0621 Routine ophthalmological exa 01/01/04 1 NC

S0622 Phys exam for college 01/01/04 1 NC

S0630 Removal of sutures 01/01/04 1 NC

S0800 Laser in situ keratomileusis 01/01/04 1 NC

S0810 Photorefractive keratectomy 01/01/04 1 NC

S0812 Phototherap keratect 01/01/04 1 NC

S0820 Computerized corneal topogra 01/01/04 1 NC

S0830 Ultrasound pachymetry 01/01/04 1 NC

S1001 Deluxe item 01/01/04 1 NC

S1002 Custom item 01/01/04 1 NC

5101:3-1-60 Page 330







S1015 IV tubing extension set 01/01/04 1 NC

S1016 Non-pvc intravenous administ 01/01/04 1 NC

S1025 Inhal nitric oxide neonate 01/01/04 1 NC

S1030 Gluc monitor purchase 01/01/04 1 NC

S1031 Gluc monitor rental 01/01/04 1 NC

S1040 Cranial remolding orthosis 01/01/04 1 NC

S2053 Transplantation of small int 01/01/04 1 NC

S2054 Transplantation of multivisc 01/01/04 1 NC

S2055 Harvesting of donor multivis 01/01/04 1 NC

S2060 Lobar lung transplantation 01/01/04 1 NC

S2061 Donor lobectomy (lung) 01/01/04 1 NC

S2065 Simult panc kidn trans 01/01/04 1 NC

S2070 Cysto laser tx ureteral calc 01/01/04 1 NC

S2080 Laup 01/01/04 1 NC

S2085 Laparoscop gastric bypass 01/01/04 1 NC

S2090 Open cryosurg renal 01/01/04 1 NC

S2091 Perc cryosurg renal 01/01/04 1 NC

S2095 Transcath emboliz microspher 01/01/04 1 NC

S2102 Islet cell tissue transplant 01/01/04 1 NC

S2103 Adrenal tissue transplant 01/01/04 1 NC

S2107 Adoptive immunotherapy 01/01/04 1 NC

S2112 Knee arthroscp harv 01/01/04 1 NC

S2113 Arthro chondrocyte implant 01/01/04 1 NC

S2115 Periacetabular osteotomy 01/01/04 1 NC

S2120 Low density lipoprotein(LDL) 01/01/04 1 NC

S2130 Endo RF ablation saph vein 01/01/04 1 NC

S2135 Neurolysis interspace foot 01/01/04 1 NC

S2140 Cord blood harvesting 01/01/04 1 NC

S2142 Cord blood-derived stem-cell 01/01/04 1 NC

S2150 BMT harv/transpl 28d pkg 01/01/04 1 NC

S2202 Echosclerotherapy 01/01/04 1 NC

S2205 Minimally invasive direct co 01/01/04 1 NC





S2211 Transv carotid stent placemt 01/01/04 1 NC

S2213 Implant gastric stim 01/01/04 1 NC

5101:3-1-60 Page 331







S2225 Myringotomy laser-assist 01/01/04 1 NC

S2230 Implant semi-imp hear 01/01/04 1 NC

S2235 Implant auditory brain imp 01/01/04 1 NC

S2250 Uterine artery emboliz 01/01/04 1 NC

S2260 Induced abortion 17-24 weeks 01/01/04 1 NC

S2262 Abortion maternal indic>=25w 01/01/04 1 NC

S2265 Abortion 25-28wks fetal indi 01/01/04 1 NC

S2266 Abortion 29-31wks fetal indi 01/01/04 1 NC

S2267 Abortion >=32wks fetal indic 01/01/04 1 NC

S2300 Arthroscopy, shoulder, surgi 01/01/04 1 NC

S2340 Chemodenervation of abductor 01/01/04 1 NC

S2341 Chemodenerv adduct vocal 01/01/04 1 NC

S2342 Nasal endoscop po debrid 01/01/04 1 NC

S2350 Diskectomy, anterior, with d 01/01/04 1 NC

S2351 Diskectomy, anterior, with d 01/01/04 1 NC

S2360 Vertebroplast cerv 1st 01/01/04 1 NC

S2361 Vertebroplast cerv addl 01/01/04 1 NC

S2362 Kyphoplasty, first vertebra 01/01/04 1 NC

S2363 Kyphoplasty, each addl 01/01/04 1 NC

S2370 Intradiscal electrothermal 01/01/04 1 NC

S2371 Each additional interspace 01/01/04 1 NC

S2400 Fetal surg congen hernia 01/01/04 1 NC

S2401 Fetal surg urin trac obstr 01/01/04 1 NC

S2402 Fetal surg cong cyst malf 01/01/04 1 NC

S2403 Fetal surg pulmon sequest 01/01/04 1 NC

S2404 Fetal surg myelomeningo 01/01/04 1 NC

S2405 Fetal surg sacrococ teratoma 01/01/04 1 NC

S2409 Fetal surg noc 01/01/04 1 NC

S2411 Fetoscop laser ther TTTS 01/01/04 1 NC

S3000 Bilat dil retinal exam 01/01/04 1 NC

S3600 Stat lab 01/01/04 1 NC

S3601 Stat lab home/nf 01/01/04 1 NC

S3620 Newborn metabolic screening 02/01/03 1 33.75

S3625 Maternal triple screen test 01/01/04 1 NC

S3630 Eosinophil blood count 01/01/04 1 NC

S3645 HIV-1 antibody testing of or 01/01/04 1 NC

S3650 Saliva test, hormone level; 01/01/04 1 NC

S3652 Saliva test, hormone level; 01/01/04 1 NC

5101:3-1-60 Page 332







S3655 Antisperm antibodies test 01/01/04 1 NC

S3701 NMP-22 assay 01/01/04 1 NC

S3708 Gastrointestinal fat absorpt 01/01/04 1 NC

S3818 BRCA1 gene anal 01/01/04 1 NC

S3819 BRCA2 gene anal 01/01/04 1 NC

S3820 Comp BRCA1/BRCA2 01/01/04 1 NC

S3822 Sing mutation brst/ovar 01/01/04 1 NC

S3823 3 mutation brst/ovar 01/01/04 1 NC

S3828 Comp MLH1 gene 01/01/04 1 NC

S3829 Comp MLH2 gene 01/01/04 1 NC

S3830 Gene test HNPCC comp 01/01/04 1 NC

S3831 Gene test HNPCC single 01/01/04 1 NC

S3833 Comp APC sequence 01/01/04 1 NC

S3834 Sing mutation APC 01/01/04 1 NC

S3835 Gene test cystic fibrosis 01/01/04 1 NC

S3837 Gene test hemochromato 01/01/04 1 NC

S3840 DNA analysis RET-oncogene 01/01/04 1 NC

S3841 Gene test retinoblastoma 01/01/04 1 NC

S3842 Gene test Hippel-Lindau 01/01/04 1 NC

S3843 DNA analysis factor v 01/01/04 1 NC

S3844 DNA analysis deafness 01/01/04 1 NC

S3845 Gene test alpha-thalassemia 01/01/04 1 NC

S3846 Gene test beta-thalassemia 01/01/04 1 NC

S3847 Gene test Tay-Sachs 01/01/04 1 NC

S3848 Gene test Gaucher 01/01/04 1 NC

S3849 Gene test Niemann-Pick 01/01/04 1 NC

S3850 Gene test sickle cell 01/01/04 1 NC

S3851 Gene test canavan 01/01/04 1 NC

S3852 DNA analysis APOE alzheimer 01/01/04 1 NC

S3853 Gene test myo musclr dyst 01/01/04 1 NC

S3900 Surface EMG 01/01/04 1 NC

S3902 Ballistocardiogram 01/01/04 1 NC

S3904 Masters two step 01/01/04 1 NC

S4005 Interim labor facility globa 01/01/04 1 NC

S4011 IVF package 01/01/04 1 NC

S4013 Compl GIFT case rate 01/01/04 1 NC

S4014 Compl ZIFT case rate 01/01/04 1 NC

S4015 Complete IVF nos case rate 01/01/04 1 NC

5101:3-1-60 Page 333







S4016 Frozen IVF case rate 01/01/04 1 NC

S4017 IVF canc a stim case rate 01/01/04 1 NC

S4018 F EMB trns canc case rate 01/01/04 1 NC

S4020 IVF canc a aspir case rate 01/01/04 1 NC

S4021 IVF canc p aspir case rate 01/01/04 1 NC

S4022 Asst oocyte fert case rate 01/01/04 1 NC

S4023 Incompl donor egg case rate 01/01/04 1 NC

S4025 Donor serv IVF case rate 01/01/04 1 NC

S4026 Procure donor sperm 01/01/04 1 NC

S4027 Store prev froz embryos 01/01/04 1 NC

S4028 Microsurg epi sperm asp 01/01/04 1 NC

S4030 Sperm procure init visit 01/01/04 1 NC

S4031 Sperm procure subs visit 01/01/04 1 NC

S4035 Stimulated IUI case rate 01/01/04 1 NC

S4036 Intravag cult case rate 01/01/04 1 NC

S4037 Cryo embryo transf case rate 01/01/04 1 NC

S4040 Monit store cryo embryo 30 d 01/01/04 1 NC

S4981 Insert levonorgestrel ius 01/01/04 1 NC

S4989 Contraceptive intrauterine device, e.g. Progestacert 10/01/03 1 93.75

S4990 Nicotine patch legend 01/01/04 1 NC

S4991 Nicotine patch nonlegend 01/01/04 1 NC

S4993 Contraceptive pills for bc 01/01/04 1 NC

S4995 Smoking cessation gum 01/01/04 1 NC

S5000 Prescription drug, generic 01/01/04 1 NC

S5001 Prescription drug,brand name 01/01/04 1 NC

S5010 5% dextrose and 0.45% saline 01/01/04 1 NC

S5011 5% dextrose in lactated ring 01/01/04 1 NC

S5012 5% dextrose with potassium 01/01/04 1 NC

S5013 5%dextrose/0.45%saline1000ml 01/01/04 1 NC

S5014 D5W/0.45NS w KCl and MGS04 01/01/04 1 NC

S5035 HIT routine device maint 01/01/04 1 NC

S5036 HIT device repair 01/01/04 1 NC

S5100 Adult daycare services 15min 01/01/04 1 NC

S5101 Adult day care per half day 01/01/04 1 NC

S5102 Adult day care per diem 01/01/04 1 WP

S5105 Centerbased day care perdiem 01/01/04 1 NC

S5108 Homecare train pt 15 min 01/01/04 1 NC

S5109 Homecare train pt session 01/01/04 1 NC

5101:3-1-60 Page 334







S5110 Family homecare training 15m 01/01/04 1 NC

S5111 Family homecare train/sessio 01/01/04 1 NC

S5115 Nonfamily homecare train/15m 01/01/04 1 NC

S5116 Nonfamily HC train/session 01/01/04 1 NC

S5120 Chore services per 15 min 01/01/04 1 NC

S5121 Chore services per diem 01/01/04 1 NC

S5125 Attendant care service /15m 01/01/04 1 NC

S5126 Attendant care service /diem 01/01/04 1 NC

S5130 Homaker service nos per 15m 01/01/04 1 NC

S5131 Homemaker service nos /diem 01/01/04 1 NC

S5135 Adult companioncare per 15m 01/01/04 1 NC

S5136 Adult companioncare per diem 01/01/04 1 NC

S5140 Adult foster care per diem 01/01/04 1 NC

S5141 Adult foster care per month 01/01/04 1 NC

S5145 Child fostercare th per diem 01/01/04 1 NC

S5146 Ther fostercare child /month 01/01/04 1 NC

S5150 Unskilled respite care /15m 01/01/04 1 NC

S5151 Unskilled respitecare /diem 01/01/04 1 NC

S5160 Emer response sys instal&tst 01/01/04 1 WP

S5161 Emer rspns sys serv permonth 01/01/04 1 WP

S5162 Emer rspns system purchase 01/01/04 1 NC

S5165 Home modifications per serv 01/01/04 1 WP

S5170 Homedelivered prepared meal 01/01/04 1 WP

S5175 Laundry serv,ext,prof,/order 01/01/04 1 NC

S5180 HH respiratory thrpy in eval 01/01/04 1 NC

S5181 HH respiratory thrpy nos/day 01/01/04 1 NC

S5185 Med reminder serv per month 01/01/04 1 NC

S5190 Wellness assessment by nonph 01/01/04 1 NC

S5199 Personal care item nos each 01/01/04 1 NC

S5497 HIT cath care noc 01/01/04 1 NC

S5498 HIT simple cath care 01/01/04 1 NC

S5501 HIT complex cath care 01/01/04 1 NC

S5502 HIT interim cath care 01/01/04 1 NC

S5517 HIT declotting kit 01/01/04 1 NC

S5518 HIT cath repair kit 01/01/04 1 NC

S5520 HIT picc insert kit 01/01/04 1 NC

S5521 HIT midline cath insert kit 01/01/04 1 NC

S5522 HIT picc insert no supp 01/01/04 1 NC

5101:3-1-60 Page 335







S5523 HIP midline cath insert kit 01/01/04 1 NC

S5550 Insulin rapid 5 u 01/01/04 1 NC

S5551 Insulin most rapid 5 u 01/01/04 1 NC

S5552 Insulin intermed 5 u 01/01/04 1 NC

S5553 Insulin long acting 5 u 01/01/04 1 NC

S5560 Insulin reuse pen 1.5 ml 10/01/04 2 40.00 NC

S5561 Insulin reuse pen 3 ml 10/01/04 2 40.00 NC

S5565 Insulin cartridge 150 u 01/01/04 1 NC

S5566 Insulin cartridge 300 u 01/01/04 1 NC

S5570 Insulin dispos pen 1.5 ml 01/01/04 1 NC

S5571 Insulin dispos pen 3 ml 01/01/04 1 NC

S8004 Wholebody radiopharm trgcell 01/01/04 1 NC

S8030 Tantalum ring application 01/01/04 1 NC

S8035 Magnetic source imaging 01/01/04 1 NC

S8037 mrcp 01/01/04 1 NC

S8040 Topographic brain mapping 01/01/04 1 NC

S8042 MRI low field 01/01/04 1 NC

S8049 Intraoperative radiation the 01/01/04 1 NC

S8055 Us guidance fetal reduct 01/01/04 1 NC

S8075 CAD of digital mammogr 01/01/04 1 NC

S8080 Scintimammography 01/01/04 1 NC

S8085 Fluorine-18 fluorodeoxygluco 01/01/04 1 NC

S8092 Electron beam computed tomog 01/01/04 1 NC

S8095 Wig (for medically-induced h 01/01/04 1 NC

S8096 Portable peak flow meter 01/01/04 1 NC

S8097 Asthma kit 01/01/04 1 NC

S8100 Spacer without mask 01/01/04 1 NC

S8101 Spacer with mask 01/01/04 1 NC

S8110 Peak expiratory flow rate (p 01/01/04 1 NC

S8120 O2 contents gas cubic ft 01/01/04 1 NC

S8121 O2 contents liquid lb 01/01/04 1 NC

S8180 Trach shower protector 01/01/04 1 NC

S8181 Trach tube holder 01/01/04 1 NC

S8182 Humidifier non-servo 10/01/04 2 75.00 NC

S8183 Humidifier dual servo 10/01/04 2 75.00 NC

S8185 Flutter device 01/01/04 1 NC

S8186 Swivel adaptor 01/01/04 1 NC

S8189 Trach supply noc 01/01/04 1 NC

5101:3-1-60 Page 336







S8190 Electronic spirometer 01/01/04 1 NC

S8210 Mucus Trap 01/01/01 1 NC

S8260 Oral orthotic for treatment 01/01/04 1 NC

S8262 Mandib ortho repos device 01/01/04 1 NC

S8265 Haberman feeder 01/01/04 1 NC

S8400 Incontinence Pants, Each 01/01/01 1 NC

S8402 Diapers, Each 01/01/01 1 NC

S8405 Incontinence Liners, Each 01/01/01 1 NC

S8415 Supplies for home delivery 01/01/04 1 NC

S8420 Custom gradient sleev/glov 01/01/04 1 NC

S8421 Ready gradient sleev/glov 01/01/04 1 NC

S8422 Custom grad sleeve med 01/01/04 1 NC

S8423 Custom grad sleeve heavy 01/01/04 1 NC

S8424 Ready gradient sleeve 01/01/04 1 NC

S8425 Custom grad glove med 01/01/04 1 NC

S8426 Custom grad glove heavy 01/01/04 1 NC

S8427 Ready gradient glove 01/01/04 1 NC

S8428 Ready gradient gauntlet 01/01/04 1 NC

S8429 Gradient pressure wrap 01/01/04 1 NC

S8430 Padding for comprssn bdg 01/01/04 1 NC

S8431 Compression bandage 01/01/04 1 NC

S8450 Splint digit 01/01/04 1 NC

S8451 Splint wrist or ankle 01/01/04 1 NC

S8452 Splint elbow 01/01/04 1 NC

S8460 Camisole post-mast 01/01/04 1 NC

S8470 Stander positioning device 01/01/04 1 NC

S8490 100 insulin syringes 01/01/04 1 NC

S8945 PT phonophoresis 30 mins 01/01/04 1 NC

S8948 Low-level laser trmt 15 min 01/01/04 1 NC

S8950 Complex lymphedema therapy, 01/01/04 1 NC

S8990 Pt or manip for maint 01/01/04 1 NC

S8999 Resuscitation Bag 01/01/01 1 NC

S9001 Home uterine monitor with or 01/01/04 1 NC

S9007 Ultrafiltration monitor 01/01/04 1 NC

S9015 Automated EEG monitoring 01/01/04 1 NC

S9022 Digital subtraction angiogra 01/01/04 1 NC

S9024 Paranasal sinus ultrasound 01/01/04 1 NC

S9025 Omnicardiogram/cardiointegra 01/01/04 1 NC

5101:3-1-60 Page 337







S9034 ESWL for gallstones 01/01/04 1 NC

S9055 Procuren or other growth fac 01/01/04 1 NC

S9056 Coma stimulation per diem 01/01/04 1 NC

S9061 Medical supplies and equipme 01/01/04 1 NC

S9075 Smoking cessation treatment 01/01/04 1 NC

S9083 Urgent care center global 01/01/04 1 NC

S9088 Services provided in urgent 01/01/04 1 NC

S9090 Vertebral axial decompressio 01/01/04 1 NC

S9092 Canolith repositioning 01/01/04 1 NC

S9098 Home phototherapy visit 01/01/04 1 NC

S9109 CHF telemonitoring month 01/01/04 1 NC

S9117 Back school visit 01/01/04 1 NC

S9122 Home health aide or certifie 01/01/04 1 NC

S9123 Nursing care in home RN 01/01/04 1 NC

S9124 Nursing care, in the home; b 01/01/04 1 NC

S9125 Respite care, in the home, p 01/01/04 1 NC

S9126 Hospice care, in the home, p 01/01/04 1 NC

S9127 Social work visit, in the ho 01/01/04 1 NC

S9128 Speech therapy, in the home, 01/01/04 1 NC

S9129 Occupational therapy, in the 01/01/04 1 NC

S9131 PT in the home per diem 01/01/04 1 NC

S9140 Diabetic Management Program, 01/01/04 1 NC


S9145 Insulin pump initiation 01/01/04 1 NC

S9150 Evaluation by ocularist 01/01/04 1 NC

S9208 Home mgmt preterm labor 01/01/04 1 NC

S9209 Home mgmt PPROM 01/01/04 1 NC

S9211 Home mgmt gest hypertension 01/01/04 1 NC

S9212 Hm postpar hyper per diem 01/01/04 1 NC

S9213 Hm preeclamp per diem 01/01/04 1 NC

S9214 Hm gest dm per diem 01/01/04 1 NC

S9325 HIT pain mgmt per diem 01/01/04 1 NC

S9326 HIT cont pain per diem 01/01/04 1 NC

S9327 HIT int pain per diem 01/01/04 1 NC

S9328 HIT pain imp pump diem 01/01/04 1 NC

S9329 HIT chemo per diem 01/01/04 1 NC

S9330 HIT cont chem diem 01/01/04 1 NC

S9331 HIT intermit chemo diem 01/01/04 1 NC

5101:3-1-60 Page 338







S9335 HT hemodialysis diem 01/01/04 1 NC

S9336 HIT cont anticoag diem 01/01/04 1 NC

S9338 HIT immunotherapy diem 01/01/04 1 NC

S9339 HIT periton dialysis diem 01/01/04 1 NC

S9340 HIT enteral per diem 01/01/04 1 NC

S9341 HIT enteral grav diem 01/01/04 1 NC

S9342 HIT enteral pump diem 01/01/04 1 NC

S9343 HIT enteral bolus nurs 01/01/04 1 NC

S9345 HIT anti-hemophil diem 01/01/04 1 NC

S9346 HIT alpha-1-proteinas diem 01/01/04 1 NC

S9347 HIT longterm infusion diem 01/01/04 1 NC

S9348 HIT sympathomim diem 01/01/04 1 NC

S9349 HIT tocolysis diem 01/01/04 1 NC

S9351 HIT cont antiemetic diem 01/01/04 1 NC

S9353 HIT cont insulin diem 01/01/04 1 NC

S9355 HIT chelation diem 01/01/04 1 NC

S9357 HIT enzyme replace diem 01/01/04 1 NC

S9359 HIT anti-tnf per diem 01/01/04 1 NC

S9361 HIT diuretic infus diem 01/01/04 1 NC

S9363 HIT anti-spasmotic diem 01/01/04 1 NC

S9364 HIT tpn total diem 01/01/04 1 NC

S9365 HIT tpn 1 liter diem 01/01/04 1 NC



S9368 HIT tpn over 3l diem 01/01/04 1 NC

S9370 HT inj antiemetic diem 01/01/04 1 NC

S9372 HT inj anticoag diem 01/01/04 1 NC

S9373 HIT hydra total diem 01/01/04 1 NC

S9374 HIT hydra 1 liter diem 01/01/04 1 NC



S9377 HIT hydra over 3l diem 01/01/04 1 NC

S9379 HIT noc per diem 01/01/04 1 NC

S9381 HIT high risk/escort 01/01/04 1 NC

S9401 Anticoag clinic per session 01/01/04 1 NC

S9430 Pharmacy comp/disp serv 01/01/04 1 NC

S9434 Mod solid food suppl 01/01/04 1 NC

S9435 Medical foods for inborn err 01/01/04 1 NC

5101:3-1-60 Page 339







S9436 Childbirth prep. classes/Lamaze classes non-physician 07/01/03 1 48.00

S9437 Childbirth refresher classes, non-physician 07/01/03 1 12.10

S9438 Cesarean birth class 01/01/04 1 NC

S9439 VBAC class 01/01/04 1 NC

S9441 Asthma education 01/01/04 1 NC

S9442 Birthing class 01/01/04 1 NC

S9443 Lactation class 01/01/04 1 NC

S9444 Baby parenting classes, non-physician 07/01/03 1 12.10

S9445 PT education noc individ 01/01/04 1 NC

S9446 PT education noc group 01/01/04 1 NC

S9447 Infant safety (includes CPR) classes, non-physician 07/01/03 1 12.10

S9449 Weight mgmt class 01/01/04 1 NC

S9451 Exercise class 01/01/04 1 NC

S9452 Prenatal nutrition classes, non-physician 07/01/03 1 12.10

S9453 Smoking cessation class 01/01/04 1 NC

S9454 Stress mgmt class 01/01/04 1 NC




S9470 Prenatal nutrition counseling, dietician visit 10/01/03 1 PC

S9472 Cardiac rehabilitation progr 01/01/04 1 NC

S9473 Pulmonary rehabilitation pro 01/01/04 1 NC

S9474 Enterostomal therapy by a re 01/01/04 1 NC

S9475 Ambulatory setting substance 01/01/04 1 NC

S9476 Vestibular rehab per diem 01/01/04 1 NC

S9480 Intensive outpatient psychia 01/01/04 1 NC

S9484 Crisis intervention per hour 01/01/04 1 NC

S9485 Crisis intervention mental h 01/01/04 1 NC

S9490 HIT corticosteroid/diem 01/01/04 1 NC

S9494 HIT antibiotic total diem 01/01/04 1 NC

S9497 HIT antibiotic q3h diem 01/01/04 1 NC






S9524 Nursing services related to 01/01/04 1 NC

S9529 Venipuncture home/snf 01/01/04 1 NC

5101:3-1-60 Page 340







S9537 HT hem horm inj diem 01/01/04 1 NC

S9538 HIT blood products diem 01/01/04 1 NC

S9542 HT inj noc per diem 01/01/04 1 NC

S9546 Home inf blood prod nurs ser 01/01/04 1 NC

S9558 HT inj growth horm diem 01/01/04 1 NC

S9559 HIT inj interferon diem 01/01/04 1 NC

S9560 HT inj hormone diem 01/01/04 1 NC

S9562 HT inj palivizumab diem 01/01/04 1 NC

S9590 HT irrigation diem 01/01/04 1 NC

S9802 HT nursing visit 01/01/04 1 NC

S9803 HT nursing addl hr 01/01/04 1 NC

S9806 RN infusion suite visit 01/01/04 1 NC

S9810 HT pharm per hour 01/01/04 1 NC

S9900 Christian Sci Pract visit 01/01/04 1 NC

S9970 Health club membership yr 01/01/04 1 NC

S9975 Transplant related per diem 01/01/04 1 NC

S9981 Med record copy admin 01/01/04 1 NC

S9982 Med record copy per page 01/01/04 1 NC

S9986 Not medically necessary svc 01/01/04 1 NC

S9989 Services outside US 01/01/04 1 NC

S9990 Services provided as part of 01/01/04 1 NC

S9991 Services provided as part of 01/01/04 1 NC

S9992 Transportation costs to and 01/01/04 1 NC

S9994 Lodging costs (e.g. hotel ch 01/01/04 1 NC

S9996 Meals for clinical trial par 01/01/04 1 NC

S9999 Sales tax 01/01/04 1 NC

T1000 Private duty/independent nsg 01/01/04 1 NC

T1001 Nursing assessment/evaluatn 01/01/04 1 NC

T1002 RN services up to 15 minutes 01/01/04 1 NC

T1003 LPN/LVN services up to 15min 01/01/04 1 NC

T1004 Nsg aide service up to 15min 01/01/04 1 NC

T1005 Respite care service 15 min 01/01/04 1 NC

T1006 Family/Couple Counseling 01/01/04 1 NC

T1007 Treatment Plan Development 01/01/04 1 NC

T1008 Day Treatment for Individual 01/01/04 1 NC

T1009 Child Sitting Services 01/01/04 1 NC

T1010 Meals when Receive Services 01/01/04 1 NC

T1011 Alcohol/Substance Abuse NOC 01/01/04 1 NC

5101:3-1-60 Page 341







T1012 Alcohol/Substance Abuse Skil 01/01/04 1 NC

T1013 Sign Lang/Oral Interpreter 01/01/04 1 NC

T1014 Telehealth transmit, per min 01/01/04 1 NC

T1015 Clinic visit/encounter, all-inclusive 10/01/03 1 PC

T1016 Case management 01/01/04 1 NC

T1017 Targeted case management 01/01/04 1 NC

T1018 School-based IEP ser bundled 01/01/04 1 NC

T1019 Personal care ser per 15 min 01/01/04 1 NC

T1020 Personal care ser per diem 01/01/04 1 NC

T1021 HH Aide or cn aide per visit 01/01/04 1 NC

T1022 Contracted services per day 01/01/04 1 NC

T1023 Program intake assessment 01/01/04 1 NC

T1024 Team evaluation & management 01/01/04 1 NC

T1025 Ped compr care pkg, per diem 01/01/04 1 NC

T1026 Ped compr care pkg, per hour 01/01/04 1 NC

T1027 Family training & counseling 01/01/04 1 NC

T1028 Home environment assessment 01/01/04 1 NC

T1029 Dwelling lead investigation 01/01/04 1 NC

T1030 RN home care per diem 01/01/04 1 NC

T1031 LPN home care per diem 01/01/04 1 NC++ T1500 Reusable diaper/pant 01/01/05 2 NC 0.00

T1502 Medication admin visit 01/01/04 1 NC

T1999 NOC retail items andsupplies 01/01/04 1 NC

T2001 Non-emergency transportation attendant/escort 10/01/03 1 9.02

T2002 N-et; per diem 01/01/04 1 NC

T2003 N-et; encounter/trip 07/01/03 1 IC

T2004 N-et; commerc carrier pass 01/01/04 1 NC

T2005 N-et; stretcher van 01/01/04 1 NC

T2006 Amb response & trt, no trans 01/01/04 1 NC

T2007 Non-emer transport wait time 01/01/04 1 NC

T2010 PASRR Level I 01/01/04 1 NC

T2011 PASRR Level II 01/01/04 1 NC

T2012 Habil ed waiver, per diem 01/01/04 1 NC

T2013 Habil ed waiver per hour 01/01/04 1 NC

T2014 Habil prevoc waiver, per d 01/01/04 1 NC

T2015 Habil prevoc waiver per hr 01/01/04 1 NC

T2016 Habil res waiver per diem 01/01/04 1 NC

T2017 Habil res waiver 15 min 01/01/04 1 NC

5101:3-1-60 Page 342







T2018 Habil sup empl waiver/diem 01/01/04 1 NC

T2019 Habil sup empl waiver 15min 01/01/04 1 NC

T2020 Day habil waiver per diem 01/01/04 1 NC

T2021 Day habil waiver per 15 min 01/01/04 1 NC

T2022 Case management, per month 01/01/04 1 NC

T2023 Targeted case mgmt per month 01/01/04 1 NC

T2024 Serv asmnt/care plan waiver 01/01/04 1 NC

T2025 Waiver service, nos 01/01/04 1 NC

T2026 Special childcare waiver/d 01/01/04 1 NC

T2027 Spec childcare waiver 15 min 01/01/04 1 NC

T2028 Special supply, nos waiver 01/01/04 1 NC

T2029 Special med equip, noswaiver 01/01/04 1 WP

T2030 Assist living waiver/month 01/01/04 1 NC

T2031 Assist living waiver/diem 01/01/04 1 NC

T2032 Res care, nos waiver/month 01/01/04 1 NC

T2033 Res, nos waiver per diem 01/01/04 1 NC

T2034 Crisis interven waiver/diem 01/01/04 1 NC

T2035 Utility services waiver 01/01/04 1 NC

T2036 Camp overnite waiver/session 01/01/04 1 NC

T2037 Camp day waiver/session 01/01/04 1 NC

T2038 Comm trans waiver/service 01/01/04 1 NC

T2039 Vehicle mod waiver/service 01/01/04 1 NC

T2040 Financial mgt waiver/15min 01/01/04 1 NC

T2041 Support broker waiver/15 min 01/01/04 1 NC

T2042 Hospice routine home care 01/01/04 1 PC

T2043 Hospice continuous home care 01/01/04 1 PC

T2044 Hospice respite care 01/01/04 1 PC

T2045 Hospice general care 01/01/04 1 PC

T2046 Hospice long term care, r&b 01/01/04 1 FP PC

T2048 Bh ltc res r&b, per diem 01/01/04 1 NC

T2101 Breast milk proc/store/dist 01/01/04 1 NCT4521 Adult Disp Incontinence, Brief/Diaper, Small 01/01/05 1 0.61T4522 Adult Disp Incontinence, Brief/Diaper, Medium 01/01/05 1 0.70T4523 Adult Disp Incontinence, Brief/Diaper, Large 01/01/05 1 0.79T4524 Adult Disp Incontinence, Brief/Diaper, Extra Large 01/01/05 1 0.88T4525 Adult Disp. Incontinence, Underwear/Pull-On, Small 01/01/05 1 0.61T4526 Adult Disp. Incontinence, Underwear/Pull-On, Medium 01/01/05 1 0.70T4527 Adult Disp. Incontinence, Underwear/Pull-On, Large 01/01/05 1 0.79

5101:3-1-60 Page 343






APPR VISIT CODE DESCRIPTION DATE CODE PRICE PRICE INDIC. DAYS GROUP DATE DATE GROUP DATE DATET4528 Adult Disp. Incontinence, Underwear/Pull-On, Extra Large 01/01/05 1 0.88T4529 Pediatric Disp Incontinence, Brief/Diaper, Small/Medium 01/01/05 1 0.40T4530 Pediatric Disp Incontinence, Brief/Diaper, Large 01/01/05 1 0.40T4531 Pediatric Disp Incontinence, Pull-On, Small/Medium 01/01/05 1 0.40T4532 Pediatric Disp Incontinence, Pull-On, Large 01/01/05 1 0.40T4533 Youth Disp. Incontinence, Brief/Diaper 01/01/05 1 0.46T4534 Youth Disp. Incontinence, Underwear/Pull-On 01/01/05 1 0.46T4535 Disp. Incontinence Liner/Shield/Guard/Pad/Undergarment 01/01/05 1 0.40T4536 Incontinence, Reusable, Underwear/Pull-On, Any Size 01/01/05 1 11.00T4537 Incontinence, Reusable, Underpad, Bed Size 01/01/05 1 20.00T4538 Diaper Service, Reusable Diaper 01/01/05 1 0.53T4539 Incontinence, Reusable, Diaper/Brief, Any Size 01/01/05 1 PAT4540 Incontinence, Reusable, Underpad, Chair Size 01/01/05 1 10.00T4541 Incontinence, Disp, Underpad, Large 01/01/05 1 0.28T4542 Incontinence, Disp, Underpad, Small 01/01/05 1 0.28

T5001 Special position seat/vehicl 01/01/04 1 NC

T5999 Supply, nos 01/01/04 1 NC

V2020 Frames, purchases 01/01/04 1 PC

V2025 Deluxe frame 01/01/04 1 NC

V2100 Lens spher single plano 4.00 01/01/04 1 PC

V2101 Single visn sphere 4.12-7.00 01/01/04 1 PC

V2102 Singl visn sphere 7.12-20.00 01/01/04 1 PC

V2103 Spherocylindr 4.00d/12-2.00d 01/01/04 1 PC

V2104 Spherocylindr 4.00d/2.12-4d 01/01/04 1 PC

V2105 Spherocylinder 4.00d/4.25-6d 01/01/04 1 PC

V2106 Spherocylinder 4.00d/>6.00d 01/01/04 1 PC

V2107 Spherocylinder 4.25d/12-2d 01/01/04 1 PC



V2110 Spherocylinder 4.25d/over 6d 01/01/04 1 PC

V2111 Spherocylindr 7.25d/.25-2.25 01/01/04 1 PC



V2114 Spherocylinder over 12.00d 01/01/04 1 PC

V2115 Lens lenticular bifocal 01/01/04 1 PC

V2116 Nonaspheric lens bifocal 01/01/05 3 NC PC

V2117 Aspheric lens bifocal 01/01/05 3 NC PC

V2118 Lens aniseikonic single 01/01/04 1 PC

V2121 Lenticular lens, single 01/01/05 2 PC NC

5101:3-1-60 Page 344







V2199 Lens single vision not oth c 01/01/04 1 PC

V2200 Lens spher bifoc plano 4.00d 01/01/04 1 PC

V2201 Lens sphere bifocal 4.12-7.0 01/01/04 1 PC

V2202 Lens sphere bifocal 7.12-20. 01/01/04 1 PC

V2203 Lens sphcyl bifocal 4.00d/.1 01/01/04 1 PC

V2204 Lens sphcy bifocal 4.00d/2.1 01/01/04 1 PC

V2205 Lens sphcy bifocal 4.00d/4.2 01/01/04 1 PC

V2206 Lens sphcy bifocal 4.00d/ove 01/01/04 1 PC

V2207 Lens sphcy bifocal 4.25-7d/. 01/01/04 1 PC

V2208 Lens sphcy bifocal 4.25-7/2. 01/01/04 1 PC

V2209 Lens sphcy bifocal 4.25-7/4. 01/01/04 1 PC

V2210 Lens sphcy bifocal 4.25-7/ov 01/01/04 1 PC

V2211 Lens sphcy bifo 7.25-12/.25- 01/01/04 1 PC

V2212 Lens sphcyl bifo 7.25-12/2.2 01/01/04 1 PC

V2213 Lens sphcyl bifo 7.25-12/4.2 01/01/04 1 PC

V2214 Lens sphcyl bifocal over 12. 01/01/04 1 PC

V2215 Lens lenticular bifocal 01/01/04 1 PC

V2216 Lens lenticular nonaspheric 01/01/05 3 NC PC

V2217 Lens lenticular aspheric bif 01/01/05 3 NC PC

V2218 Lens aniseikonic bifocal 01/01/04 1 PC

V2219 Lens bifocal seg width over 01/01/04 1 PC

V2220 Lens bifocal add over 3.25d 01/01/04 1 PC

V2221 Lenticular lens, bifocal 01/01/05 2 PC NC

V2299 Lens bifocal speciality 01/01/04 1 PC

V2300 Lens sphere trifocal 4.00d 01/01/04 1 PC

V2301 Lens sphere trifocal 4.12-7. 01/01/04 1 PC

V2302 Lens sphere trifocal 7.12-20 01/01/04 1 PC

V2303 Lens sphcy trifocal 4.0/.12- 01/01/04 1 PC

V2304 Lens sphcy trifocal 4.0/2.25 01/01/04 1 PC

V2305 Lens sphcy trifocal 4.0/4.25 01/01/04 1 PC

V2306 Lens sphcyl trifocal 4.00/>6 01/01/04 1 PC

V2307 Lens sphcy trifocal 4.25-7/. 01/01/04 1 PC

V2308 Lens sphc trifocal 4.25-7/2. 01/01/04 1 PC

V2309 Lens sphc trifocal 4.25-7/4. 01/01/04 1 PC

V2310 Lens sphc trifocal 4.25-7/>6 01/01/04 1 PC

V2311 Lens sphc trifo 7.25-12/.25- 01/01/04 1 PC

V2312 Lens sphc trifo 7.25-12/2.25 01/01/04 1 PC

V2313 Lens sphc trifo 7.25-12/4.25 01/01/04 1 PC

5101:3-1-60 Page 345







V2314 Lens sphcyl trifocal over 12 01/01/04 1 PC

V2315 Lens lenticular trifocal 01/01/04 1 PC

V2316 Lens lenticular nonaspheric 01/01/05 3 NC PC

V2317 Lens lenticular aspheric tri 01/01/05 3 NC PC

V2318 Lens aniseikonic trifocal 01/01/04 1 PC

V2319 Lens trifocal seg width > 28 01/01/04 1 PC

V2320 Lens trifocal add over 3.25d 01/01/04 1 PC

V2321 Lenticular lens, trifocal 01/01/05 2 PC NC

V2399 Lens trifocal speciality 01/01/04 1 NC

V2410 Lens variab asphericity sing 01/01/04 1 PC

V2430 Lens variable asphericity bi 01/01/04 1 PC

V2499 Variable asphericity lens 01/01/04 1 NC

V2500 Pmma,Spherical,Per Lens 04/13/89 1 31.06 30.60

V2501 Pmma,Toric Or Prism Ballast, Per Lens 04/13/89 1 51.77 51.00

V2502 Pmma,Bifocal,Per Lens 04/13/89 1 51.77 51.00

V2503 Pmma,Color Vision Deficiency,Per Lens 04/13/89 1 51.77 51.00

V2510 Gas Permeable, Spherical, Per Lens 04/13/89 1 51.77 51.00

V2511 Gas Permeable, Toric,Prism Ballast,Per 04/13/89 1 77.65 76.50

V2512 Gas Permeable, Bifocal, Per Lens 04/13/89 1 103.53 102.00

V2513 Gas Permeable ,Extended Wear, Per Lens 04/13/89 1 103.53 102.00

V2520 Hydrophylic, Spherical, Per Lens 04/13/89 1 62.12 61.20

V2521 Hydrophylic, Toric Or Prism Ballast, Per 04/13/89 1 72.47 71.40

V2522 Hydrophylic, Bifocal, Per Lens 04/13/89 1 77.65 76.50

V2523 Hydrophylic, Extenede Wear, Per Lens 01/01/99 2 100.00 77.65

V2530 Scleral, Per Lens 04/13/89 1 62.12 61.20

V2531 Contact lens gas permeable 01/01/04 1 NC

V2599 Contact Lens,Not Otherwise Classified 10/01/99 2 PA 77.65

V2600 Hand Held Low Vision Aids And Other Aids 04/13/89 1 PA 0.00

V2610 Single Lens Spectacle Mntd Low Vision Ad 08/01/73 1 PA 0.00

V2615 Telescope And Other Compound Lens System 08/01/73 1 PA 0.00

V2623 Prosthetic Eye,Plastic, Custom 01/01/97 2 606.85 258.83

V2624 Polish/resurface ocular prosthesis 01/01/97 1 39.18

V2625 Enlargement of ocular prosthesis 01/01/97 1 310.27

V2626 Reduction of ocular prosthesis 01/01/97 1 128.39

V2627 Scleral cover shell 01/01/97 1 798.13

V2628 Fabrication/Fitting of ocular conformer 01/01/97 1 195.80

V2629 Prosthetic Eye, Not Otherwise Classified 01/01/97 2 PA 258.83

V2630 Anterior Chamber Intraocular Lens 03/21/96 3 NC 300.00

5101:3-1-60 Page 346







V2631 Iris Supported Intraocular Lens 03/21/96 3 NC 300.00

V2632 Posterior Chamber Intraocular Lens 03/21/96 3 NC 300.00

V2700 Balance lens 01/01/04 1 PC

V2710 Glass/plastic slab off prism 01/01/04 1 PC

V2715 Prism lens/es 01/01/04 1 PC

V2718 Fresnell prism press-on lens 01/01/04 1 PC

V2730 Special base curve 01/01/04 1 PC

V2740 Rose tint plastic 01/01/05 3 NC PC

V2741 Non-rose tint plastic 01/01/05 3 NC PC

V2742 Rose tint glass 01/01/05 3 NC PC

V2743 Non-rose tint glass 01/01/05 3 NC PC

V2744 Tint photochromatic lens/es 01/01/04 1 PC

V2745 Tint, any color/solid/grad 01/01/05 2 PC NC

V2750 Anti-reflective coating 01/01/04 1 PC

V2755 UV lens/es 01/01/04 1 PC

V2756 Eye glass case 01/01/04 1 NC

V2760 Scratch resistant coating 01/01/04 1 PC

V2761 Mirror coating 01/01/04 1 NC

V2762 Polarization, any lens 01/01/04 1 NC

V2770 Occluder lens/es 01/01/04 1 PC

V2780 Oversize lens/es 01/01/04 1 PC

V2781 Progressive lens per lens 01/01/04 1 PC

V2782 Lens, 1.54-1.65 p/1.60-1.79g 01/01/04 1 NC

V2783 Lens, >= 1.66 p/>=1.80 g 01/01/04 1 NC

V2784 Lens polycarb or equal 01/01/04 1 NC

V2785 Corneal Tissue Implanted in ASC 01/01/04 1 1,049.00

V2786 Occupational multifocal lens 01/01/04 1 NC

V2790 Amniotic membrane 01/01/04 1 PC

V2797 Vis item/svc in other code 01/01/04 1 NC

V2799 Miscellaneous vision service 01/01/04 3 NC

V5008 Hearing screening 01/01/04 1 NC

V5010 Assessment for hearing aid 01/01/04 1 NC

V5011 Hearing aid fitting/checking 01/01/04 1 NC

V5014 Repair, modification of hearing aid 01/01/04 1 NC

V5020 Conformity evaluation 01/01/04 1 NC

V5030 Body-worn hearing aid air 11/01/04 2 413.88 NC

V5040 Body-worn hearing aid bone 11/01/04 2 413.88 NC

V5050 Hearing aid monaural in ear 11/01/04 2 413.88 NC

5101:3-1-60 Page 347







V5060 Behind ear hearing aid 11/01/04 2 413.88 NC

V5070 Glasses air conduction 11/01/04 1 NC

V5080 Glasses bone conduction 11/01/04 1 NC

V5090 Hearing aid dispensing fee 01/01/04 1 NC

V5095 Implant mid ear hearing pros 01/01/04 1 NC

V5100 Body-worn bilat hearing aid 01/01/04 1 NC

V5110 Hearing aid dispensing fee 01/01/04 1 NC

V5120 Body-worn binaur hearing aid 01/01/04 1 NC

V5130 In ear binaural hearing aid 11/01/04 2 827.76 NC

V5140 Behind ear binaur hearing aid 11/01/04 2 827.76 NC

V5150 Glasses binaural hearing aid 11/01/04 1 NC

V5160 Dispensing fee binaural 11/01/04 1 NC

V5170 Within ear cros hearing aid 11/01/04 2 413.88 NC

V5180 Behind ear cros hearing aid 11/01/04 2 413.88 NC

V5190 Glasses cros hearing aid 11/01/04 1 NC

V5200 Cros hearing aid dispens fee 11/01/04 1 NC

V5210 In ear bicros hearing aid 11/01/04 2 413.88 NC

V5220 Behind ear bicros hearing aid 11/01/04 2 413.88 NC

V5230 Glasses bicros hearing aid 11/01/04 1 NC

V5240 Dispensing fee bicros 11/01/04 1 NC

V5241 Dispensing fee, monaural 11/01/04 1 NC

V5242 Hearing aid, monaural, cic 01/01/04 1 NC

V5243 Hearing aid, monaural, itc 01/01/04 1 NC

V5244 Hearing aid, prog, mon, cic 01/01/04 1 NC

V5245 Hearing aid, prog, mon, itc 01/01/04 1 NC

V5246 Hearing aid, prog, mon, ite 11/01/04 1 NC

V5247 Hearing aid, prog, mon, bte 11/01/04 1 NC

V5248 Hearing aid, binaural, cic 01/01/04 1 NC

V5249 Hearing aid, binaural, itc 01/01/04 1 NC

V5250 Hearing aid, prog, bin, cic 01/01/04 1 NC

V5251 Hearing aid, prog, bin, itc 01/01/04 1 NC

V5252 Hearing aid, prog, bin, ite, for children 11/01/04 1 NC

V5252 Hearing aid, prog, bin, ite, for adults 11/01/04 1 NC

V5253 Hearing aid, prog, bin, bte, for children 11/01/04 1 NC

V5253 Hearing aid, prog, bin, bte, for adults 11/01/04 1 NC

V5254 Hearing id, digit, mon, cic 01/01/04 1 NC

V5255 Hearing aid, digit, mon, itc 01/01/04 1 NC

V5256 Hearing aid, digit, mon, ite, for children 11/01/04 1 NC

5101:3-1-60 Page 348







V5256 Hearing aid, digit, mon, ite, for adults 11/01/04 1 NC

V5257 Hearing aid, digit, mon, bte, for children 11/01/04 1 NC

V5257 Hearing aid, digit, mon, bte, for adults 11/01/04 1 NC

V5258 Hearing aid, digit, bin, cic 01/01/04 1 NC

V5259 Hearing aid, digit, bin, itc 01/01/04 1 NC

V5260 Hearing aid, digit, bin, ite, for children 11/01/04 1 NC

V5260 Hearing aid, digit, bin, ite, for adults 11/01/04 1 NC

V5261 Hearing aid, digit, bin, bte, for children 11/01/04 1 NC

V5261 Hearing aid, digit, bin, bte, for adults 11/01/04 1 NC

V5262 Hearing aid, disp, monaural 01/01/04 1 NC

V5263 Hearing aid, disp, binaural 01/01/04 1 NC

V5264 Ear mold, insert 11/01/04 2 25.00 NC

V5265 Ear mold/insert, disp 01/01/04 1 NCV5266 Battery for hearing aid device 11/01/04 2 1.00 NCV5267 Hearing aid supplies/ accessories 11/01/04 2 PA NC

V5268 ALD Telephone Amplifier 01/01/04 1 NC

V5269 Alerting device, any type 01/01/04 1 NC

V5270 ALD, TV amplifier, any type 01/01/04 1 NC

V5271 ALD, TV caption decoder 01/01/04 1 NC

V5272 Tdd 01/01/04 1 NC

V5273 ALD for cochlear implant 01/01/04 1 NC

V5274 ALD unspecified 01/01/04 1 NC

V5275 Ear impression 01/01/04 1 NC

V5298 Hearing aid noc 01/01/04 1 NC

V5299 Hearing service 01/01/04 1 NC

V5336 Repair communication device 01/01/04 1 NC

V5362 Speech screening 01/01/04 1 NC

V5363 Language screening 01/01/04 1 NC

V5364 Dysphagia screening 01/01/04 1 NC

W0001 Medical Services 10/01/03 3 NC 0.01

W0002 Dental Encounter 10/01/03 3 NC 0.01

W0003 Mental Health Encounter 10/01/03 3 NC 0.01

W0004 Vision Care Encounter 10/01/03 3 NC 0.01

W0005 Speech Therapy 10/01/03 3 NC 0.01

W0006 Physical Therapy Encounter 10/01/03 3 NC 0.01

W0007 Lab Unit 10/01/03 3 NC 0.01

W0008 X-Ray Unit 10/01/03 3 NC 0.01

W0009 Transpportation Unit 10/01/03 3 NC 0.01

5101:3-1-60 Page 349







W0020 Rural Health Encounter 10/01/03 3 NC 0.01

W0021 Neonatal Diagnostic Screening Kit 02/01/03 3 NC 8.00

W0658 Influenza, split vaccine, adult >18 07/01/03 3 NC 6.32

W0703 Tetanus, Adult, 19 or older 07/01/03 3 NC 11.02

W0706 Rubella, adult 19 or older 07/01/03 3 NC 15.00

W0718 TD, Adult, 19 or older 07/01/03 3 NC 4.00

W0724 Influenza, Adult, 19 or older 04/01/99 3 NC 6.32

W0731 Hepatitis-B Vaccine Adult Dose 04/01/96 3 NC 50.00

W2004 Comp Vision Serv New Age 1-20 And 60 04/01/04 3 NC 41.07

W2006 Refraction,Medicare Elig Aphakia Patient 07/31/97 3 NC 13.46

W2014 Est Patient Comp Svc Age 1-20 And 60 04/01/04 3 NC 36.48

W2048 Low Vision Exam And Report 01/01/04 3 NC 36.24

W3001 ICF-MR Component (ICF-MR Residents) 01/01/90 1 0.01

W3002 ICF-MR Component (Waiver Participant) 01/01/90 1 0.01

W3010 Medical Services (By Licensed Physician) 07/01/89 1 0.01

W3015 Health Services (By Lpn Or Rn) 07/01/89 1 0.01

W3020 Non-Skilled Health Services 07/01/89 1 0.01

W3025 Speech / Audiology 07/01/89 1 0.01

W3030 Psychology Services 01/01/89 1 0.01

W3035 Occupational Therapy Services 07/01/89 1 0.01

W3040 Physical Therapy Services 07/01/89 1 0.01

W3045 Transportation 07/01/89 1 0.01

W3050 Social Work/Counseling-Cafs 08/02/93 1 0.01

W8600 Hart- Blvd 2120 complete frame 01/01/04 3 NC 0.01

W8601 Hart- Blvd 2120 frame front 01/01/04 3 NC 0.01

W8602 Hart- Blvd 2120 frame temples 01/01/04 3 NC 0.01

W8603 Limited Edition- Diedre complete frame 01/01/04 3 NC 0.01

W8604 Limited Edition- Diedre frame front 01/01/04 3 NC 0.01

W8605 Limited Edition-Diedre frame temples 01/01/04 3 NC 0.01




W8609 Limited Edition- Brockport complete frame 01/01/04 3 NC 0.01

W8610 Limited Edition- Brockport frame front 01/01/04 3 NC 0.01

W8611 Limited Edition- Brockport frame temples 01/01/04 3 NC 0.01

W8612 Hart- Looking Glass 7146 complete frame 01/01/04 3 NC 0.01

W8613 Hart- Looking Glass 7146 frame front 01/01/04 3 NC 0.01

W8614 Hart- Looking Glass 7146 frame temples 01/01/04 3 NC 0.01

5101:3-1-60 Page 350










W8618 Limited Edition- Walt complete frame 01/01/04 3 NC 0.01

W8619 Limited Edition- Walt frame front 01/01/04 3 NC 0.01

W8620 Limited Edition- Walt frame temples 01/01/04 3 NC 0.01

W8621 Limited Edition- Franco complete frame 01/01/04 3 NC 0.01

W8622 Limited Edition- Franco frame front 01/01/04 3 NC 0.01

W8623 Limited Edition- Franco frame temples 01/01/04 3 NC 0.01

W8624 Limited Edition-Romper 123 complete frame 01/01/04 3 NC 0.01

W8625 Limited Edition- Romper 123 frame front 01/01/04 3 NC 0.01

W8626 Limited Edition- Romper 123 frame temples 01/01/04 3 NC 0.01

W8627 Eye Q - SW 501 complete frame 01/01/04 3 NC 0.01

W8628 Eye Q - SW 501 frame front 01/01/04 3 NC 0.01

W8629 Eye Q - SW 501 frame temples 01/01/04 3 NC 0.01

W8641 Sv Plastic 12.25-16.00D 01/01/04 3 NC 0.01

W8642 Sv Plastic 16.25-20.00D 01/01/04 3 NC 0.01

W8643 Sv Plastic 12.25-16.00S/0.25-3.00C 01/01/04 3 NC 0.01

W8644 Sv Plastic 12.25-16.00S/3.25-6.00C 01/01/04 3 NC 0.01

W8645 Sv Plastic 16.25-20.00S/0.25-6.00C 01/01/04 3 NC 0.01

W8646 Bf Plastic Flattop 25 Pl-4.00D 01/01/04 3 NC 0.01

W8647 Bf Plastic Flattop 25 4.25-8.00D 01/01/04 3 NC 0.01



W8650 Bf Plastic Flat Top 25 16.25-20.00D 01/01/04 3 NC 0.01

W8651 Bf Plastic Round Pl-4.00D 01/01/04 3 NC 0.01

W8652 Bf Plastic Round 4.25-8. 00D 01/01/04 3 NC 0.01

W8653 Bf Plastic Round 8.25-12.00D 01/01/04 3 NC 0.01



W8656 Bf Plastic Exec Pl-4.00D 01/01/04 3 NC 0.01

W8657 Bf Plastic Exec 4.25 D-8.00D 01/01/04 3 NC 0.01

W8658 Bf Plastic Flattop25 Pl-4.00S/0.25-3.00C 01/01/04 3 NC 0.01

W8659 Bf Plastic Flattop25 Pl-4.00S/3.25-6.00C 01/01/04 3 NC 0.01

W8660 Bf Plastic Flattop 4.25-8.00S/0.25-3.00C 01/01/04 3 NC 0.01

W8661 Bf Plastic Flattop 4.25-8.00S/3.25-6.00C 01/01/04 3 NC 0.01

W8662 Bf Plastic Flattop 8.25-12.00S/0.25-3.00 01/01/04 3 NC 0.01


5101:3-1-60 Page 351










W8667 Bf Plastic Rd Pl-4.00S/0.25-3.00C 01/01/04 3 NC 0.01

W8668 Bf Plastic Rd Pl-4.00S/3.25-6.00C 01/01/04 3 NC 0.01

W8669 Bf Plastic Rd 4.25-8.00S/0.25-3.00C 01/01/04 3 NC 0.01




W8673 Bf Plastic Rd 12.25-16 .00S/0.25-3.00C 01/01/04 3 NC 0.01



W8676 Bf Plastic Exex Pl-4.00S/0.25-3.00C 01/01/04 3 NC 0.01

W8677 Bf Plastic Exec Pl-4.00/3.25-6.00C 01/01/04 3 NC 0.01

W8678 Bf Plastic Executive4 .25-8.00S/0.25-3.0 01/01/04 3 NC 0.01

W8679 Bf Plastic Exec 4.25-8.00S/3.25-6.00C 01/01/04 3 NC 0.01

W8680 Aspheric Lenticular Sv One Lens 01/01/04 3 NC 0.01

W8681 Aspheric Lenticular Sv Pair 01/01/04 3 NC 0.01

W8682 Aspheric Lenticular Bf Rd One Lens 01/01/04 3 NC 0.01

W8683 Aspheric Lenticular Bf Rd Pair 01/01/04 3 NC 0.01

W8684 Aspheric Lenticular Bf Flat-Top One Lens 01/01/04 3 NC 0.01

W8685 Aspheric Lenticular Bf Flat-Top Pair 01/01/04 3 NC 0.01

W8686 Full Field Aspheric Sv One Lens 01/01/04 3 NC 0.01

W8687 Full Field Aspheric Sv Pair 01/01/04 3 NC 0.01

W8688 Full Field Aspheric Bf Rd One Lens 01/01/04 3 NC 0.01

W8689 Full Field Aspheric Bf Rd Pair 01/01/04 3 NC 0.01

W8691 One Sv Lens >20.00D 01/01/04 3 NC 0.01

W8692 One Bf Lens >20.00D 01/01/04 3 NC 0.01

W8693 Adds Greater Than 3.50D To 6.00D 01/01/04 3 NC 0.01

W8696 Full Field Aspheric.Bf Flat-Top One Lens 01/01/04 3 NC 0.01

W8697 Full Field Aspheric. Bf Flat-Top Pair 01/01/04 3 NC 0.01

W8698 Welch-4-Drop Rd One Lens 01/01/04 3 NC 0.01

W8699 Welch-4Drop Rd Pair 01/01/04 3 NC 0.01

W8700 Welch-4-Drop Flat-Top One Lens 01/01/04 3 NC 0.01

W8701 Welch-4-Drop Flat-Top Pair 01/01/04 3 NC 0.01

W8702 Balance Lens Sv 01/01/04 3 NC 0.01

W8703 Balance Lens Bifocal 01/01/04 3 NC 0.01

W8704 Trifocal Glass Pl-4.00D 01/01/04 3 NC 0.01

5101:3-1-60 Page 352







W8705 Trifocal Glass 4.25-8.00D 01/01/04 3 NC 0.01

W8706 Trifocal Glass Pl-8.00S/0.25-6.00C 01/01/04 3 NC 0.01

W8707 Trifocal Plastic Pl-12.00D 01/01/04 3 NC 0.01

W8708 Trifocal Plastic Pl-8.00S/0.25-6.00C 01/01/04 3 NC 0.01

W8709 High Adds Trifocals 3.50D-6.00D One Lens 01/01/04 3 NC 0.01

W8710 Sv Polycarbonate Lenses Each 01/01/04 3 NC 0.01

W8711 Bf Polycarbonate Lenses Each 01/01/04 3 NC 0.01

W8790 Glass Bf D-25 12.25-16.00S 01/01/04 3 NC 0.01

W8791 Bf Glass D-25 16.25-20.00S 01/01/04 3 NC 0.01

W8792 Bf Glass D-25 12.25-16.00S/0.25-3.00C 01/01/04 3 NC 0.01

W8793 Bf Glass D-25 12.25-16.00S/3.25-6.00C 01/01/04 3 NC 0.01

W8794 Bf Glass D-25 16.25-20.00/0.25-6.00C 01/01/04 3 NC 0.01

W8795 Bf Glass Kryp 12.25-16.00S 01/01/04 3 NC 0.01

W8796 Bf Glass Kryp 16.25-20.00S 01/01/04 3 NC 0.01

W8797 Bf Glass Kryp 12.25-16.00S/0.25-3.00C 01/01/04 3 NC 0.01



W8800 Sv Glass Sphere + Or - Pl To 4.00 01/01/04 3 NC 0.01

W8801 Sv Glass Sphere + Or - 4.25 To 8.00 01/01/04 3 NC 0.01

W8802 Sv Glass Sphere + Or - 8.25 To 12.00 01/01/04 3 NC 0.01

W8803 Sv Plastic Sphere + Or - Pl To 4.00 01/01/04 3 NC 0.01

W8804 Sv Plastic Sphere + Or - 4.25 To 8.00 01/01/04 3 NC 0.01

W8805 Sv Plastic Sphere + Or - 8.25 To 12.00 01/01/04 3 NC 0.01

W8806 Bf Glass Flattop 25 Pl-4.00D 01/01/04 3 NC 0.01

W8807 Bf Glass Flattop 25 4.25-8.00D 01/01/04 3 NC 0.01

W8808 Rnd Seg Cve Top Ft 22-25 8.25 To 12.00 01/01/04 3 NC 0.01

W8809 Bf Glass Kryptok Pl-4.00D 01/01/04 3 NC 0.01

W8810 Bf Glass Kryptok 4.25-8.00D 01/01/04 3 NC 0.01

W8811 Kryptok Sphere + Or - 8.25 To 12.00 01/01/04 3 NC 0.01

W8812 Bf Glass Executive Pl-4.00D 01/01/04 3 NC 0.01

W8813 Bf Glass Executive 4.25-8.00D 01/01/04 3 NC 0.01

W8814 Sv Glass Sph Cyl Pl-4.00S/0.25-3.00C 01/01/04 3 NC 0.01

W8815 Sv Glass Sph Cyl Pl To 4.00S/3.25-6.00C 01/01/04 3 NC 0.01

W8816 Sv Glass Sph Cyl 4.25-8.00S/0.25-3.00C 01/01/04 3 NC 0.01




W8820 Sv Plastic Sph Cyl Pl-4.00S/0.25-3.00C 01/01/04 3 NC 0.01

5101:3-1-60 Page 353







W8821 Sv Plast Sph Cyl Pl-4.00S/3.25-6.00C 01/01/04 3 NC 0.01

W8822 Sv Plast Sph Cyl 4.25-8.00S/0.25-3.00C 01/01/04 3 NC 0.01




W8826 Bf Glass Sph Cyl Flattop Pl-4.00S/0.25-3 01/01/04 3 NC 0.01

W8827 Bf Glass Flattop Pl-4.00S/3.25-6.00C 01/01/04 3 NC 0.01

W8828 Bf Glass Flattop 4.25-8.00S/0.25-3.00C 01/01/04 3 NC 0.01

W8829 Bf Glass Flattop 4.25-8.00S/3.25-6.00C 01/01/04 3 NC 0.01

W8830 Rnd Cve Ft Sph Cl 8.25-12.00S/0.25-3.00C 01/01/04 3 NC 0.01

W8831 Rnd Cve Ft Sph Cl 8.25-12.00S/3.25-6.00C 01/01/04 3 NC 0.01

W8832 Bf Glass Kryptok Pl-4.00S/0.25-3.00C 01/01/04 3 NC 0.01

W8833 Bf Glass Kryptok Pl-4.00S/3.25-6.00C 01/01/04 3 NC 0.01

W8834 Bf Glass Kryptok 4.25-8.00S/0.25-3.00C 01/01/04 3 NC 0.01

W8835 Bf Glass Kryptok 4.25-8.00S/3.25-6.00C 01/01/04 3 NC 0.01

W8836 Kryptok Sph Cyl 8.25-12.00S/0.25-3.00C 01/01/04 3 NC 0.01

W8837 Bf Glass Executive Pl-4.00S/0.25-3.00C 01/01/04 3 NC 0.01

W8838 Bf Glass Executive Pl-4.00S/3.25-6.00C 01/01/04 3 NC 0.01

W8839 Bf Glass Executive 4.25-8.00S/0.25-3.00C 01/01/04 3 NC 0.01

W8840 Bf Glass Executive 4.25-8.00S/3.25-6.00C 01/01/04 3 NC 0.01

W8842 XYL Combination Frame 05/19/86 3 NC

W8843 Discontinued Frame XYL or XYL Combination 05/19/86 3 NC

W8844 One Cataract Lens 05/19/86 3 NC BR

W8845 Bf Glass Exec 8.25-12.00 01/01/04 3 NC 0.01

W8847 Bf Glass Kryp 8.25-12.00/3.25-6.00C 01/01/04 3 NC 0.01

W8849 Trifocals 01/01/04 3 NC 0.01

W8850 Two Single Vision With Prism 01/01/04 3 NC 0.01

W8851 Trifocal Oversize 01/01/04 3 NC 0.01

W8852 Two Bifocal With Prism 01/01/04 3 NC 0.01

W8853 Sv Industrial Thickness 01/01/04 3 NC 0.01

W8854 Two Single Vision > 12.00D 01/01/04 3 NC 0.01

W8855 Bf Industrial Thickness 01/01/04 3 NC 0.01

W8856 Two Bifocal > 12.00D 01/01/04 3 NC 0.01

W8857 Bf High Index Glass 01/01/04 3 NC 0.01

W8858 Sv High Index Glass 01/01/04 3 NC 0.01

W8859 Myodisc Sv 01/01/04 3 NC 0.01

W8860 Myodisc Bf 01/01/04 3 NC 0.01

W8861 Slab Off 01/01/04 3 NC 0.01

5101:3-1-60 Page 354







W8862 Fresnel 01/01/04 3 NC 0.01

W8863 Oversize Sv 01/01/04 3 NC 0.01

W8864 Oversize Bf 01/01/04 3 NC 0.01

W8865 Tint Sv 01/01/04 3 NC 0.01

W8866 Tint Bf 01/01/04 3 NC 0.01

W8867 Photochromatic Sv 01/01/04 3 NC 0.01

W8868 Photochromatic Bf 01/01/04 3 NC 0.01

W8869 Cyclinder 6.25 Sv 01/01/04 3 NC 0.01

W8870 Cyclinder 6.25 Bf 01/01/04 3 NC 0.01

W8871 Special Base Curve Sv 01/01/04 3 NC 0.01

W8872 Special Base Curve Bf 01/01/04 3 NC 0.01

W8873 Scratch Resistant 08/01/90 3 NC 0.01

W8876 Uv-400 Sv 01/01/04 3 NC 0.01

W8877 Uv-400 Bf 01/01/04 3 NC 0.01

W8878 Frosted Lens 01/01/04 3 NC 0.01

W8879 Engrave Name Temple 01/01/04 3 NC 0.01

W8880 Balance Lens 01/01/04 3 NC 0.01

W8881 Li-1 Complete 01/01/04 3 NC 0.01

W8882 Li-1 Front Only 01/01/04 3 NC 0.01

W8883 Li-1 Temples Only 01/01/04 3 NC 0.01

W8884 Mv-20 Complete 01/01/04 3 NC 0.01

W8885 Mv-20 Front Only 01/01/04 3 NC 0.01

W8886 Mv-20 Temples Only 01/01/04 3 NC 0.01

W8887 Four Seasons Frame Complete 01/01/04 3 NC 0.01

W8888 Four Seasons Frame Fornt 01/01/04 3 NC 0.01

W8889 Four Seasons Frame Temples Only 01/01/04 3 NC 0.01

W8890 Far Horizons Frame Complete 01/01/04 3 NC 0.01

W8891 Far Horizons Frame Front 01/01/04 3 NC 0.01

W8892 Far Horizons Frame Temples 01/01/04 3 NC 0.01

W8893 Ronbelle Frame Complete 01/01/04 3 NC 0.01

W8894 Ronbelle Frame Front 01/01/04 3 NC 0.01

W8895 Ronbelle Frame Temples 01/01/04 3 NC 0.01

W8896 Stadium Frame Complete 01/01/04 3 NC 0.01

W8897 Stadium Frame Fornt 01/01/04 3 NC 0.01

W8898 Stadium Frame Temples 01/01/04 3 NC 0.01

W8902 Flatter Fit 2 Frame Complete 01/01/04 3 NC 0.01

W8903 Flatter Fit 2 Frame Front 01/01/04 3 NC 0.01

W8904 Flatter Fit 2 Frame Temples 01/01/04 3 NC 0.01

5101:3-1-60 Page 355







W8905 Trix 1 Frame Complete 04/01/99 3 NC 0.01

W8906 Trix 1 Frame Front 01/01/00 3 NC 0.01

W8907 Trix 1 Frame Temples 01/01/00 3 NC 0.01

W8908 Explorer Frame Complete 04/01/99 3 NC 0.01

W8909 Explorer Frame Fornt 01/01/00 3 NC 0.01

W8910 Explorer Frame Temples 01/01/00 3 NC 0.01

W8911 Bmx Frame Complete 01/01/04 3 NC 0.01

W8912 Bmx Frame Front 01/01/04 3 NC 0.01

W8913 Bmx Frame Temples 01/01/04 3 NC 0.01

W8914 Trix 2 Frame Complete 01/01/04 3 NC 0.01

W8915 Trix 2 Frame Front 01/01/04 3 NC 0.01

W8916 Trix 2 Frame Temples 01/01/04 3 NC 0.01

W8917 Par Nine Jr Frame Complete 01/01/04 3 NC 0.01

W8918 Par Nine Jr Frame Front 01/01/04 3 NC 0.01

W8919 Par Nine Jr Frame Temples 01/01/04 3 NC 0.01

W8920 Winner Frame Complete 01/01/04 3 NC 0.01

W8921 Winner Frame Front 01/01/04 3 NC 0.01

W8922 Winner Frame Temples 01/01/04 3 NC 0.01

W8923 Yank Frame Complete 04/01/99 3 NC 0.01

W8924 Yank Frame Front 01/01/00 3 NC 0.01

W8925 Yank Frame Temples 01/01/00 3 NC 0.01

W8926 Other Half Complete 04/01/99 3 NC 0.01

W8927 Other Half Front Only 01/01/00 3 NC 0.01

W8928 Only Half Temple Only 01/01/00 3 NC 0.01

W8929 S-300 Frame Complete 01/01/04 3 NC 0.01

W8930 S-300 Frame Front 01/01/04 3 NC 0.01

W8931 S-300 Frame Temples 01/01/04 3 NC 0.01

W8932 S-400 Frame Complete 01/01/04 3 NC 0.01

W8933 S-400 Frame Front 01/01/04 3 NC 0.01

W8934 S-400 Frame Temples. 01/01/04 3 NC 0.01

W8935 Flatter Fit 1 Frame Complete 01/01/04 3 NC 0.01

W8936 Flatter Fit 1 Frame Front 01/01/04 3 NC 0.01

W8937 Flatter Fit 1 Frame Temples 01/01/04 3 NC 0.01

W8938 Toddle Goggle Frame Complete 01/01/04 3 NC 0.01

W8939 Toddle Goggle Frame Front 01/01/04 3 NC 0.01

W8940 Toddle Goggle Frame Temples 01/01/04 3 NC 0.01

W8941 Cb-4 Frame Complete 01/01/04 3 NC 0.01

W8942 Cb-4 Frame Front 01/01/04 3 NC 0.01

5101:3-1-60 Page 356







W8943 Cb-4 Frame Temples 01/01/04 3 NC 0.01




W8947 Mv-23 Complete 01/01/04 3 NC 0.01

W8948 Mv-23 Front Only 01/01/04 3 NC 0.01


W8950 Li-5 Frame Complete 01/01/04 3 NC 0.01

W8951 Li-5 Frame Front 01/01/04 3 NC 0.01

W8952 Li-5 Frame Temples 01/01/04 3 NC 0.01

W8953 Li-6 Frame Complete 01/01/04 3 NC 0.01

W8954 Li-6 Frame Front 01/01/04 3 NC 0.01

W8955 Li-6 Frame Temples 01/01/04 3 NC 0.01

W8956 World Class Frame Complete 01/01/04 3 NC 0.01

W8957 World Class Frame Front 01/01/04 3 NC 0.01

W8958 World Class Frame Temples 01/01/04 3 NC 0.01

W8959 Ronsir Zyl Frame Complete 01/01/04 3 NC 0.01

W8960 Ronsir Zyl Frame Front 01/01/04 3 NC 0.01

W8961 Ronsir Zyl Frame Temples 01/01/04 3 NC 0.01

W8962 Classic 14 Frame Complete 01/01/04 3 NC 0.01

W8963 Classic 14 Frame Front 01/01/04 3 NC 0.01

W8964 Classic 14 Frame Temples 01/01/04 3 NC 0.01

W8965 Kitten Complete 04/01/99 3 NC 0.01

W8966 Kitten Front Only 01/01/00 3 NC 0.01

W8967 Kitten Temples Only 01/01/00 3 NC 0.01

W8968 Miss Dreamboat Complete 04/01/99 3 NC 0.01

W8969 Miss Dreamboat Front Only 01/01/00 3 NC 0.01

W8970 Miss Dreamboat Temples Only 01/01/00 3 NC 0.01

W8971 Chiklette Frame Complete 01/01/04 3 NC 0.01

W8972 Chiklette Frame Front 01/01/04 3 NC 0.01

W8973 Chiklette Frame Temples 01/01/04 3 NC 0.01

W8974 Clic Frame Complete 01/01/04 3 NC 0.01

W8975 Clic Frame Front 01/01/04 3 NC 0.01

W8976 Clic Frame Temples 01/01/04 3 NC 0.01

W8977 Leading Lady Art Rim Frame Complete 01/01/04 3 NC 0.01

W8978 Leading Lady Art Rim Frame Front 01/01/04 3 NC 0.01

W8979 Leading Lady Art Rim Frame Temples 01/01/04 3 NC 0.01


5101:3-1-60 Page 357












W8986 Classic 1 Frame Complete 01/01/04 3 NC 0.01

W8987 Classic 1 Frame Front 01/01/04 3 NC 0.01

W8988 Classic 1 Frame Temples 01/01/04 3 NC 0.01

W8989 Mv-22 Complete 01/01/04 3 NC 0.01

W8990 Mv-22 Front Only 01/01/04 3 NC 0.01


W8992 Li6 Jr Frame Complete 04/01/99 3 NC 0.01

W8993 Li6 Jr Frame Fornt 01/01/00 3 NC 0.01

W8994 Li6 Jr Frame Front 01/01/00 3 NC 0.01

W8995 Li2 Jr Frame Complete 04/01/99 3 NC 0.01

W8996 Li 2 Jr Frame Front 01/01/00 3 NC 0.01

W8997 Li2 Jr Frame Temples 01/01/00 3 NC 0.01

W8998 Mv-21 Complete 01/01/04 3 NC 0.01

W8999 Mv-21 Front Only 01/01/04 3 NC 0.01


W9001 Passport 8 Complete 01/01/04 3 NC 0.01

W9002 Passport 8 Front Only 01/01/04 3 NC 0.01

W9003 Pasport 8 Temples Only 01/01/04 3 NC 0.01

W9004 Mv 7 Complete 01/01/04 3 NC 0.01

W9005 Mv 7 Front Only 01/01/04 3 NC 0.01

W9006 Mv 7 Temples Only 01/01/04 3 NC 0.01

W9007 Mv 13 Complete 04/01/99 3 NC 0.01

W9008 Mv 13 Front Only 01/01/00 3 NC 0.01


W9010 Optones Complete 01/01/04 3 NC 0.01

W9011 Optones Front Only 01/01/04 3 NC 0.01

W9012 Optones Temples Only 01/01/04 3 NC 0.01

W9013 Flatter-Fit 6 Complete 04/01/99 3 NC 0.01

W9014 Flatter-Fit 6 Front Only 01/01/00 3 NC 0.01

W9015 Flatter-Fit 6 Temples Only 01/01/00 3 NC 0.01

W9016 Passport 1-101 Complete 01/01/04 3 NC 0.01

W9017 Passport 1-101 Front Only 01/01/04 3 NC 0.01

W9018 Passport 1-101 Temples Only 01/01/04 3 NC 0.01

5101:3-1-60 Page 358







W9019 Clubman Art-Rim Complete 01/01/04 3 NC 0.01

W9020 Clubman Art-Rim Front Only 01/01/04 3 NC 0.01

W9021 Clubman Art-Rim Temples Only 01/01/04 3 NC 0.01

W9022 Harvard Complete 01/01/04 3 NC 0.01

W9023 Harvard Front Only 01/01/04 3 NC 0.01

W9024 Harvard Temples Only 01/01/04 3 NC 0.01

W9025 Flatter-Fit 5 Complete 04/01/99 3 NC 0.01

W9026 Flatter-Fit 5 Front Only 01/01/00 3 NC 0.01

W9027 Flatter-Fit 5 Temples Only 01/01/00 3 NC 0.01

W9028 Annie V Complete 01/01/04 3 NC 0.01

W9029 Annie V Front Only 01/01/04 3 NC 0.01

W9030 Annie V Temples Only 01/01/04 3 NC 0.01

W9031 Mv-6 Complete 01/01/04 3 NC 0.01

W9032 Mv-6 Front Only 01/01/04 3 NC 0.01


W9034 Veronica Complete 01/01/04 3 NC 0.01

W9035 Veronica Front Only 01/01/04 3 NC 0.01

W9036 Veronica Temples Only 01/01/04 3 NC 0.01

W9037 Tweety Complete 01/01/04 3 NC 0.01

W9038 Tweety Front Only 01/01/04 3 NC 0.01

W9039 Tweety Temples Only 01/01/04 3 NC 0.01

W9040 Wrangler Complete 01/01/04 3 NC 0.01

W9041 Wrangler Front Only 01/01/04 3 NC 0.01

W9042 Wrangler Temples Only 01/01/04 3 NC 0.01

W9043 Mv 2 Complete 04/01/99 3 NC 0.01

W9044 Mv 2 Front Only 01/01/00 3 NC 0.01


W9046 S-307 Complete 01/01/04 3 NC 0.01

W9047 S-307 Front Only 01/01/04 3 NC 0.01

W9048 S-307 Temples Only 01/01/04 3 NC 0.01

W9049 Best Half Men'S Complete 01/01/04 3 NC 0.01

W9050 Best Half Men'S Front Only 01/01/04 3 NC 0.01

W9051 Best Half Men'S Temples Only 01/01/04 3 NC 0.01

W9052 Opticolor Jr Boy'S Complete 01/01/04 3 NC 0.01

W9053 Opticolor Jr Boy'S Front Only 01/01/04 3 NC 0.01

W9054 Opticolor Jr Boy'S Temples Only 01/01/04 3 NC 0.01

W9055 Spectra Frame Complete 01/01/04 3 NC 0.01

W9056 Spectra Frame Front Only 01/01/04 3 NC 0.01

5101:3-1-60 Page 359







W9057 Sprectra Frame Temples Only 01/01/04 3 NC 0.01

W9058 Ethel Frame Complete 01/01/04 3 NC 0.01

W9059 Ethel Frame Front Only 01/01/04 3 NC 0.01

W9060 Ethel Frame Temples Only 01/01/04 3 NC 0.01

W9061 Taffy Frame Complete 01/01/04 3 NC 0.01

W9062 Taffy Frame Front Only 01/01/04 3 NC 0.01

W9063 Taffy Frame Temples Only 01/01/04 3 NC 0.01

W9064 Doodle Frame Complete 01/01/04 3 NC 0.01

W9065 Doodle Frame Front Only 01/01/04 3 NC 0.01

W9066 Doodle Frame Temples Only 01/01/04 3 NC 0.01

W9067 Kirsten Frame Complete 01/01/04 3 NC 0.01

W9068 Kirsten Frame Front Only 01/01/04 3 NC 0.01

W9069 Kirsten Frame Temples Only 01/01/04 3 NC 0.01

W9070 Laurel Frame Complete 01/01/04 3 NC 0.01

W9071 Laurel Frame Fronts Only 01/01/04 3 NC 0.01

W9072 Laurel Frame Temples Only 01/01/04 3 NC 0.01

W9073 Schoolmate Frame Complete 01/01/04 3 NC 0.01

W9074 Schoolmate Frame Front Only 01/01/04 3 NC 0.01

W9075 Schoolmate Frame Temples Only 01/01/04 3 NC 0.01

W9076 499 Frame Complete 01/01/04 3 NC 0.01

W9077 Schoolmate Frame Front Only 01/01/04 3 NC 0.01

W9078 Schoolmate Frame Front Temples Only 01/01/04 3 NC 0.01

W9079 Andy Frame Complete 01/01/04 3 NC 0.01

W9080 Andy Frame Front Only 01/01/04 3 NC 0.01

W9081 Andy Frame Temples Only 01/01/04 3 NC 0.01

W9082 Pegasus Flex Frame Complete 01/01/04 3 NC 0.01

W9083 Pegasus Flex Frame Front Only 01/01/04 3 NC 0.01

W9084 Pegasus Flex Frame Temples Only 01/01/04 3 NC 0.01

W9085 Blvd 1203 Frame Complete 01/01/04 3 NC 0.01

W9086 Blvd 1203 Frame Front Only 01/01/04 3 NC 0.01

W9087 Blvd 1203 Frame Temples Only 01/01/04 3 NC 0.01

W9088 NearSite Frame Complete 01/01/04 3 NC 0.01

W9089 NearSite Frame Front Only 01/01/04 3 NC 0.01

W9090 NearSite Frame Temples Only 01/01/04 3 NC 0.01

W9091 Barry Flex Frame Complete 01/01/04 3 NC 0.01

W9092 Barry Flex Frame Front Only 01/01/04 3 NC 0.01

W9093 Barry Flex Frame Temples Only 01/01/04 3 NC 0.01

W9094 Annabelle Frame Complete 01/01/04 3 NC 0.01

5101:3-1-60 Page 360







W9095 Annebelle Frame Front 01/01/04 3 NC 0.01

W9096 Annebelle Frame Temples 01/01/04 3 NC 0.01

W9097 Sylvia Frame Complete 01/01/04 3 NC 0.01

W9098 Sylvia Frame Front 01/01/04 3 NC 0.01

W9099 Sylvia Frame Temples 01/01/04 3 NC 0.01

W9100 Q910 Frame Complete 01/01/04 3 NC 0.01

W9101 Q910 Frame Front 01/01/04 3 NC 0.01

W9102 Q910 Frame Temples 01/01/04 3 NC 0.01

W9103 Lizzy Frame Complete 01/01/04 3 NC 0.01

W9104 Lizzy Frame Front 01/01/04 3 NC 0.01

W9105 Lizzy Frame Temples 01/01/04 3 NC 0.01

W9106 Q901 Frame Complete 01/01/04 3 NC 0.01

W9107 Q901 Frame Front 01/01/04 3 NC 0.01

W9108 Q901 Frame Temples 01/01/04 3 NC 0.01

W9109 Walter Frame Complete 01/01/04 3 NC 0.01

W9110 Walter Frame Front 01/01/04 3 NC 0.01

W9111 Walter Frame Temples 01/01/04 3 NC 0.01

W9112 Libby Frame Complete 01/01/04 3 NC 0.01

W9113 Libby Frame Front 01/01/04 3 NC 0.01

W9114 Libby Frame Temples 01/01/04 3 NC 0.01

W9115 Ron Frame Complete 01/01/04 3 NC 0.01

W9116 Ron Frame Front 01/01/04 3 NC 0.01

W9117 Ron Frame Temples 01/01/04 3 NC 0.01

W9118 Britain Frame Complete 01/01/04 3 NC 0.01

W9119 Britain Frame Front 01/01/04 3 NC 0.01

W9120 Britain Frame Temples 01/01/04 3 NC 0.01

W9121 Jerry Frame Complete 01/01/04 3 NC 0.01

W9122 Jerry Frame Front 01/01/04 3 NC 0.01

W9123 Jerry Frame Temples 01/01/04 3 NC 0.01


W9125 407 Frame Front 01/01/04 3 NC 0.01

W9126 407 Frame Temples 01/01/04 3 NC 0.01

W9127 Santa Fe Frame Complet 01/01/04 3 NC 0.01

W9128 Santa Fe Frame Front 01/01/04 3 NC 0.01

W9129 Santa Fe Frame Temples 01/01/04 3 NC 0.01

W9130 Happy Frame Complete 01/01/04 3 NC 0.01

W9131 Happy Frame Front 01/01/04 3 NC 0.01

W9132 Happy Frame Temples 01/01/04 3 NC 0.01

5101:3-1-60 Page 361








W9134 415 Frame Front 01/01/04 3 NC 0.01

W9135 415 Frame Temples 01/01/04 3 NC 0.01

X0001 Temp Fqhc/Ahc Medical Encounter 07/01/02 3 NC 40.50

X0101 Routine Homecare 01/01/04 3 NC 0.01

X0102 Continuous Homecare 01/01/04 3 NC 0.01

X0103 Inpatient Respite Care 01/01/04 3 NC 0.01

X0104 General Inpatient 01/01/04 3 NC 0.01

X0105 Room And Board Rate 01/01/04 3 NC 200.00

X0690 Pact Management Fee 01/01/04 3 NC 8.00

X0701 Acellular Dtp Vaccine 10/01/94 3 NC 2.07

X0702 Interferon,Alpha-2A Or 2B,Recom,10Mmu 07/01/02 3 NC 85.66

X0703 Interferon,Alpha-1A Or 2B,Recom 18Mmu 07/01/02 3 NC 152.73

X0704 Interferon;Alpha-2A Or 2B,Recom 25Mmu 07/01/02 3 NC 211.07

X0705 Interferon;Alpha-N3,Up To 2.5 Mmu 07/01/02 3 NC 63.00

X0706 Interferon;Gamma-Ib,100 Mcg=3Mmu 07/01/02 3 NC 262.47

X0707 Leupron Depot 3.75 Suspension 07/01/02 3 NC 362.63

X0708 Rho-D Immune Globulin,Human,300 ug 07/01/02 3 NC 88.00

X0726 Rabies; Hyperimmune Gamma Globulin, 2Ml 07/01/02 3 NC 127.12

X0731 Hepatitis-B,Hyperimm Gamma Glob., .O5Ml 07/01/02 3 NC 27.00

X0742 Specific Hyperimmune Globulin, Specify 07/01/02 3 NC 0.00

X0743 Varicella-Zoster;Hyperimmune Globulin 07/01/02 3 NC BR

X0799 Epoetin (Epo) ;Phys Off/Clinic, per 1000 units 01/01/96 3 NC BR

X1050 Depo-Provera, 150 Mg, Contraceptive 01/01/00 3 NC 38.88

X1400 Oral Contraceptives,All Types 1 Mo.Supp. 10/01/03 3 NC 3.11






X1406 Contracep.Kit Foam 20-30 Gm Vial W/Appl. 10/01/03 3 NC 2.07

X1407 Contracep Refill Foam 20-30Gm One Vial 10/01/03 3 NC 1.55

X1408 Contracep Refill Foam 20-30Gm Two Vials 10/01/03 3 NC 3.11

X1409 Contracep Refill Foam 20-30Gm Three Vls 10/01/03 3 NC 4.66

X1410 Contracep Refill Foam 45-6Ogm One Vial 10/01/03 3 NC 2.07

X1411 Contracep Refill Foam 45-60Gm Two Vials 10/01/03 3 NC 4.14

X1412 Contracep Refill Foam 45-60Gm Three Vial 10/01/03 3 NC 6.21

X1413 Contracep Refill Foam 45-60Gm Four Vials 10/01/03 3 NC 8.28

5101:3-1-60 Page 362







X1414 Contr.Kit Pre Jell.Crm. 70-85 Gm W/Appl. 10/01/03 3 NC 3.11

X1415 Contr. Refill. Jell. Crm. 70-126Gm 1 Tube 10/01/03 3 NC 2.59

X1416 Contr. Refill. Jell. Crm. 70-126Gm 2 Tubes 10/01/03 3 NC 4.81




X1420 Contr. Refill Jell. Crm. 70-126Gm 6 Tubes 10/01/03 3 NC 13.46

X1421 Diaphragm, All Types, Each 10/01/03 3 NC 5.18

X1422 Condoms, All Types, Per Twelve 10/01/03 3 NC 2.07

X1423 Condoms, All Types, Per Twenty Four 10/01/03 3 NC 4.14

X1424 Condoms, All Types Per Thirty Six 10/01/03 3 NC 6.21

X1425 Condoms, All Types, Per Seventy Two 10/01/03 3 NC 8.28

X1426 Intrauterine Device, Progestrsert 10/01/03 3 NC 93.75

X1427 Intrauterine Device, Paragard 10/01/03 3 NC 232.00

X1428 Contra. Vaginal Suppository Type Pkg 12 10/01/03 3 NC 3.11

X1450 Minimal Family Planning Visit 10/01/03 3 NC 12.22

X1451 Family Planning Counseling 10/01/03 3 NC 24.20

X1452 Gyn Exam Not Performed By A Physician 10/01/03 3 NC 36.30

X1453 Gyn Exam Performed By A Physician 10/01/03 3 NC 48.40

X1454 Subdermal Contraceptive Implants, 60 Mnth 10/01/03 3 NC 418.00

X1456 Removal Contraceptive Implants 07/01/97 3 NC 100.00

X1470 Detailed family or pedigree consturction; initial 10/01/03 3 NC 100.00

X1471 Detailed family or pedigree construction; periodic 10/01/03 3 NC 25.00

X1472 Psychosocial genetic assessment;standard 10/01/03 3 NC 31.06

X1473 Psychosocial genetic assessment; complex 10/01/03 3 NC 62.00

X1474 Medical genetic counseling; initial 10/01/03 3 NC 50.00

X1475 Medical genetic counseling; follwo-up 10/01/03 3 NC 25.00

X1476 Psychosocial genetic counseling; initial 10/01/03 3 NC 31.06

X1478 Psychosocial genetic counseling; follow-up 10/01/03 3 NC 25.00

X3960 Ecmo Management Services, Each Hour 07/01/02 3 NC 15.00

X5400 Prenatal Risk Assessment, All Preg. Wom. 07/01/03 3 NC 12.10

X5411 Individual Preg. Counseling & Education 07/01/03 3 NC 14.52

X5412 Pregnancy Related Group Education 07/01/03 3 NC 12.10

X5422 Nutrition Intervention, Preg Related 07/01/03 3 NC 26.62

X5431 Prenatal Care Coordination 07/01/03 3 NC 12.10

X5432 High-Risk Patient Monitoring 07/01/03 3 NC 12.10

X5500 Home Visit Travel, Pregnancy Related 07/01/03 3 NC 6.27

X7210 Wet mount, preps for vaginal, cervical or skin 04/01/99 3 NC 5.90

5101:3-1-60 Page 363







X7211 Pinworm examinations 04/01/99 3 NC 6.13

X7212 Fecal leukocyte examinations 01/01/99 3 NC 0.00

X7220 Potassium hydroxide preps 04/01/99 3 NC 5.90

X9070 Cast Supplies; Surg Code Not Applicable 10/01/03 3 NC 48.00

X9099 Transportation To Clinic 07/01/03 3 NC 10.00

X9331 Subq Sick Newborn Care; Low Complex Ea Day 12/31/92 3 NC 15.70

X9332 Subq Newborn Sick Care; Mod Complex Ea Day 12/31/92 3 NC 19.82

X9333 Subq Sick Newborn Care; High Complex Ea Day 12/31/92 3 NC 29.42

X9334 Critical Newborn Care W Vent Man; Subq 12/31/92 3 NC 76.01

X9335 Critical Care Newborn W Vent Mang; 1St Day 12/31/92 3 NC 93.18

X9354 Physican Services; Evocative Test, Nonhosp. 07/01/02 3 NC 26.75

X9356 Physician Services; Evocative Test Hosp 07/01/02 3 NC 5.89

X9360 Stand-by Services, high risk new-born 04/01/99 3 NC 61.99

X9380 Pre-Delivery Physician Visit 07/01/03 3 NC 34.35

X9400 Pulmonary Consultation 07/01/03 3 NC 100.00

X9420 Monthly Prenatal Care Services. 9 Month 01/01/02 3 NC 80.00

X9422 Prenatal Care Bonus, 9 Month 01/01/02 3 NC 143.00

X9423 Prenatal Care Bonus, 8 Month 01/01/02 3 NC 73.00

XX001 Sterile Saline, Nebulizer Solution Vials 10/01/04 3 NC 0.21

XX002 Blood Glucose Test Strips,Glucometer,25 10/01/04 3 NC 17.50

XX004 Urinary Intermittent Cath. w/ insertion tray 10/01/04 3 NC 3.49

XX005 Therapeutic Agent, Urin. Cath. Irrigation 01/01/96 3 NC

XX006 Ostomy Deodorant 01/01/96 3 NC

XX007 Adhesive Remover, wipes, 50 01/01/96 3 NC

XX008 Blood Glucose Monitoring Strips, noninsulin, per 50 09/01/98 3 NC 35.00

XX009 Blood Glucose Monitoring Strips, noninsulin, per 25 09/01/98 3 NC 17.50

XX010 Lancets, per 100, noninsulin 09/01/98 3 NC 7.00

Y0001 FQHC Medical Encounter 10/01/03 3 NC 0.01

Y0002 FQHC Soc Wk And Psychology Encounter 10/01/03 3 NC 0.01

Y0003 FQHC Physical Therapy Encounter 10/01/03 3 NC 0.01

Y0004 FQHC Sp Pathology And Audiology Encounter 10/01/03 3 NC 0.01

Y0005 FQHC Dental Encounter 10/01/03 3 NC 0.01

Y0006 FQHC Podiatry Encounter 10/01/03 3 NC 0.01

Y0007 FQHC Optometric/Optician Encounter 10/01/03 3 NC 0.01

Y0008 FQHC Chiropractor Encounter 10/01/03 3 NC 0.01

Y0009 FQHC Transportation Encounter 10/01/03 3 NC 0.01

Y0015 FQHC Dental Follow Up Code 10/01/03 3 NC 0.01

Y0021 Stand. Manual Wheelchair, Short-term rental, per month 10/01/04 3 NC 45.00

5101:3-1-60 Page 364







Y0022 Stand. Hemi Wheelchair, Short-term rental, per month 10/01/04 3 NC 55.00

Y0023 Lightwgt. Manual Wheelchair, short-term rent, per month 10/01/04 3 NC 60.00

Y0024 Pediatric Manual Wheelchair, short-term rent, per month 10/01/04 3 NC 65.00

+ Y0499 Elastic Back Support 10/01/04 3 NC 27.73

+ Y0500 Lumbo-Sacral/Dorso-Lumber Support 10/01/04 3 NC 58.25Y0840 Breast Prosthesis, Mastectomy Gauntlet 01/01/97 1 PA 0.00Y0850 Breast Prosthesis, Mastectomy Sh. Flap 01/01/97 1 PA 0.00

Y1352 Sealant Per Tooth 2Nd Molars 01/01/04 3 NC 22.00

Y1889 Elastic Support Ankle Wrist Elbow 10/01/04 3 NC 11.94

+ Y1901 Ankle Foot Orthosis, Wheaton Brace 10/01/04 3 NC 203.88

+ Y2000 Pediatric Walker, Wheeled 10/01/04 3 NC BRY2001 Heavy Duty Commde Chair, W.Detch/Drop Arm 05/01/90 1 PA 0.00

Y2002 Pediatric Position Commde (Incl Tray) 05/01/90 1 280.00Y2003 Cover For E0192 01/01/05 3 NC 20.00

+ Y2004 Decub. Care Matt. (E.G. Comfortex, Aquapedi 10/01/04 3 NC 463.00

+ Y2005 Specialized Walker Adult 10/01/04 3 NC BR

Y2006 Nonelectric Heat Pad, Dry 04/01/92 1 2.80

Y2009 BR wall rail, 90 deg. 01/01/97 1 44.00

Y2010 Transfer Bench 01/01/92 1 80.00Y2011 Pediatric Positioning Bath Chair 08/01/98 2 PA 300.00Y2012 Rehab, Shower Chair (For Quadraplegics) 08/01/98 2 PA 630.00

Y2013 Crutches, Custom, Frarm, Wood, Mtl Bnds, Pair 10/01/04 3 NC 145.00

Y2014 Crutch, Custom, Forearm, Wooded, Metal Bands 01/01/94 1 72.50

Y2020 Syringe Infusion Pump 01/01/92 1 4.35

Y2022 Pediatric Crib For Home Use (W/O Top) 08/01/95 1 2,078.00

Y2023 Mattress For Pediatric Crib 08/01/95 1 143.00

Y2024 Wedge, Bed Position Cush., Foam W, W/O Covr 01/01/04 3 NC 24.00

Y2032 Back-Up Ventilator (Under Spec Conditions) 05/01/90 1 375.00

+ Y2033 Ultrasonic Nebulizer 10/01/04 3 NC 500.00

+ Y2034 Suction Pump. Battery Operated 10/01/04 3 NC 350.00

Y2039 Pneumogram 05/01/90 1 200.00

Y2040 Gastrostomy Buttom (Replacement 05/01/90 1 150.00

Y2041 Insulin Infusion Pump 06/01/96 3 NC 4,000.00

+ Y2042 Custom Molded Seating 10/01/04 3 NC BR

+ Y2043 Specially Adaptive Seating Devices 10/01/04 3 NC BR

Y2048 Apnea monitor, download report 10/01/97 1 175.00

+ Y2049 Sip and puff control 10/01/04 3 NC BR

+ Y2050 Wheelchair Tray, positioning only 10/01/04 3 NC BR

5101:3-1-60 Page 365







+ Y2051 Zero Sheer Reclining Back For Power WC 10/01/04 3 NC 4,041.00

+ Y2052 Power Drive Chin Control 10/01/04 3 NC 712.00

+ Y2053 Reclining Trough Arms 10/01/04 3 NC 200.00

+ Y2054 Respirator Tray For Power Wheelchair 10/01/04 3 NC 725.00

Y2055 Heavy Duty Power Wheelchair 07/01/97 3 NC 5,700.00

+ Y2056 Special WC Width, By Construction 10/01/04 3 NC 180.00

+ Y2057 Whirlpool Football 10/01/04 3 NC 75.00

+ Y2058 Manual Tilt-In-Space 10/01/04 3 NC 485.00

Y2059 DME Minor Repair (Recip-Owned Equip, Only) 05/01/90 1 100.00

Y2061 Cmpresd Air/Oxygen, H/Lh Tank. Admin Pentam 10/01/04 3 NC 22.00

Y2062 Pediatric APAP For Support Ventilation 04/01/92 1 260.00

+ Y2063 Service/Maintenance, Recip.-Owned Ventil 10/01/04 3 NC 41.41

+ Y2064 Oximeter Probes 10/01/04 3 NC 0.00

Y2065 Oximeter, Diagnostic, 24 Hour 07/01/93 1 57.00

+ Y2067 Oxmtr Probe Tape For Use Wirecp Ownd Oxm 10/01/04 3 NC 0.00

+ Y2068 Oximeter 10/01/04 3 NC 0.00

+ Y2070 Intrapulmonary percussive ventilator 10/01/04 3 NC 4,299.76

+ Y2071 IPV breathing circuit 10/01/04 3 NC 367.69

+ Y2072 IPV seal kit 10/01/04 3 NC 57.05

+ Y2073 Vest Percussive Device (hi freq chest wall oscillation) 10/01/04 3 NC 0.00

Y2076 Oxygen Concentr, LTCF Resid., No Supplies 07/01/93 1 178.56

Y2078 Oxygen Contents, Gaseous. LTCF Resid, No Su 07/01/93 1 178.56

Y2079 Oxygen Contents, Liq, LTCF Resid, No Supplies 07/01/93 1 178.56

Y2080 Portable Oxygen Contents, LTCF Residents 05/01/90 1 10.00

Y2081 Oxygen, LTCF, 501-750 Cu Ft Or Equiv. 05/25/91 1 72.00



Y2090 Home Dialysis For ESRD 05/01/90 1 1,200.00

Y2091 CAPD Home Dialysis 05/01/90 1 1,200.00

Y2092 CCPD Home Dialysis 09/05/90 1 1,500.00Y2096 Wheelchair major repair, LTCF 10/01/04 1 PA BRY2097 Wheelchair major repair, personal residence 10/01/04 1 PA BR

Y2098 Wheelchair minor repair, personal residence 10/01/04 1 100.00

Y2222 Gilette/Gaffney Ankle Joints (Pair) 10/01/04 3 NC 277.43

+ Y2224 Custom Molded Ankle Joints (Pair) 10/01/04 3 NC 330.28

+ Y2226 Carbon Reinforcement Ankle Inserts (Pr) 10/01/04 3 NC 66.06

+ Y2271 Addition To AFO, Tone Reducing 10/01/04 3 NC 71.34

Y2845 Add Strap, Fig 8, Ankle, Ovr Instep 10/01/04 3 NC 38.32

5101:3-1-60 Page 366







+ Y3258 Ipos Anti-Adduction Shoe 10/01/04 3 NC 73.98

+ Y3510 Press. Grad. Stocking, Chaps Style, 35 mmHg 10/01/04 3 NC 0.00

Y3806 Digital Latex Shield 10/01/04 3 NC 52.84

+ Y3901 Surg. Garment, Pressure. Grad., Upper Limb 10/01/04 3 NC 0.00

+ Y3902 Surg. Garment, Pressure. Grad., Lower Limb 10/01/04 3 NC 0.00

+ Y3903 Surg. Garment, Pressure. Grad., Torso 10/01/04 3 NC 0.00

+ Y3904 Surg. Garment, Pressure. Grad., Body Suit 10/01/04 3 NC 0.00

Y4211 Repair Of Orthotic Dev Replac Parts < or = $120 01/01/00 2 120.00 100.00Y4212 Repair Of Orth Dev Replace Major Pt >$120 10/01/88 1 PA 0.00

Y5065 Endolite Mutiflex Ankle 10/01/04 3 NC 250.00

+ Y5325 Above Knee Socket Replacement 10/01/04 3 NC 2,137.55

+ Y5545 Prep Bk Prosth. Complete 10/01/04 3 NC 2,437.18

+ Y5592 Prep Ak Prosth, Complete 10/01/04 3 NC 4,896.50

Y5706 Bk Endo External Covers (Pair) 10/01/04 3 NC 13.88

Y5708 Ak Endo External Covers (Pair) 10/01/04 3 NC 24.14

+ Y5814 Titanium Friction Lock Endo Knee 10/01/04 3 NC 627.43

+ Y5912 Carbob Copy Systen III (Includes Foot) 10/01/04 3 NC 1,065.98

+ Y5977 Multi Axis Ankle (E.G. Seattle) 10/01/04 3 NC 214.07

+ Y5979 Endolite Multiflex Ankle 10/01/04 3 NC 330.28

Y7255 Surgical Removal Of Supernumerary 11/15/93 1 PA

Y7511 Repair Prosth. Dev. Minor Parts <=$120 01/01/00 2 120.00 100.00

Y7512 Repair Prosthetic Dev Major Parts >$120 10/01/88 2 PA 0.00

+ Y8402 Silicone Prosthetic Sock/Sheath 10/01/04 3 NC 85.87

Y8988 Orthodontic Treat, First Quarter 04/01/04 3 NC 624.00

+ Y9036 Communicators/Assistive Comm. Devices 10/01/04 3 NC 7,000.00

Y9038 Hearing Aid Battery, Mercury Each 11/01/04 2 NC 0.70

Y9039 Ear Mold 11/01/04 2 NC 25.00

Y9041 Hearing Aid Repair Minor 10/01/04 2 100.00 20.00

Y9042 Hearing Aid Repair Major 10/01/04 2 PA 100.00

Y9043 Hearing Aid Battery, Zinc Air, Each 11/01/04 2 NC 1.40

Y9044 Hearing Aid Access/Devices NOS 11/01/04 2 NC 0.00

+ Y9045 Communicator Mounting Device 10/01/04 3 NC 1,076.00

+ Y9046 Communicator Access Device Incl Switch 10/01/04 3 NC 1,050.00

+ Y9047 Adapted Access Software/Speech Synthszr 10/01/04 3 NC 0.00

+ Y9048 Software Application Package for ACD 10/01/04 3 NC 0.00

+ Y9049 Multiple Location Configuration/Overlays 10/01/04 3 NC 0.00

Y9051 Repair of SGD, Minor, Parts & Labor 01/01/97 1 100.00

Y9052 Repair of SGD, Major, Parts & Labor 01/01/97 1 PA

5101:3-1-60 Page 367







Y9101 Mask For Use With Inhaler Spacer 02/01/95 1 8.00

Y9102 Aerosol Inhaler Spacer Replacement Bags 06/20/90 1 2.50

Y9103 Breast Pump, Manual , Complete 10/01/04 3 NC 15.00

Y9104 Breast Pump, Heavy Duty Electric (Rental) 04/01/02 3 NC 2.25

Y9105 Breast Pump Electric 04/01/02 3 NC 31.00

Y9106 Fountain Syringe 10/01/04 3 NC 8.00

Y9107 Insulin Injector, Manual 10/01/04 3 NC 40.00

Y9109 Thermometer, Family Planning Only 10/01/04 3 NC 7.58

Y9110 Invalid Ring 10/01/04 3 NC 9.40

Y9111 Apnea Monitor Supplies (After Capped Ren) 10/01/04 3 NC 30.00

Y9112 Cast Boot 10/01/04 3 NC 10.00

Y9113 Disinfection Solution For Respir Equip. 05/01/91 1 12.75

Y9118 Syringe With Needle, Less Than 1 cc 10/01/04 3 NC 0.23

Y9119 Cotton Tipped Applicators, Sterile, 100S 06/20/90 1 4.00

+ Y9120 Medical/Surgical Supplies, NOS 10/01/04 3 NC 0.00

Y9121 Intrauterine Device, Progestesert 10/01/04 3 NC 103.02

Y9122 Intrauterine Device, Paragard 04/01/03 3 NC 322.93

Y9123 Diaphragm, All Types 04/01/03 3 NC 25.46

Y9124 Condoms, Package Of 12 04/01/03 3 NC 4.75

Y9125 Contraceptive Sponge 10/01/04 3 NC 1.20

Y9126 Contraceptive Jellies, Creams, Foams 04/01/03 3 NC 10.05

Y9127 Enema Continence Catheter 10/01/04 3 NC 115.00

Y9128 Female Condoms 04/01/03 3 NC 2.10

Y9131 Incontinence Garment, Disposable, Large 04/01/03 3 NC 0.90

Y9132 Incontinence Garment, Disposable, Sm-Med A 04/01/03 3 NC 0.69

Y9133 Incontinence Garment, Disposable, Child 04/01/03 3 NC 0.45

Y9134 Incontinence Garment, Rental (Diaper Ser) 04/01/03 3 NC 0.60

Y9135 Incontinence Garment (Pant) Reusable 04/01/03 3 NC 12.50

Y9136 Incontinence Pads/Liners, Disposable 04/01/03 3 NC 0.45

+ Y9137 Incontinence Garment, Reuse Cloth Diaper 10/01/04 3 NC 0.00

Y9138 Incontinence Garment, Child X-Lge/Youth 04/01/03 3 NC 0.52

+ Y9139 Incontinence Supplies, Not Otherwise Spec. 10/01/04 3 NC 10.00

Y9140 Incontin, Garment, Disposable, Med, Adult 04/01/03 3 NC 0.80

Y9141 Irrigat Solu-500Ml (Saline Or Sterile H20) 10/01/04 3 NC 2.50

Y9142 Skin Barrier, Power, (Not Karaya), Per Oz. 10/01/04 3 NC 6.30

Y9143 Drain Tube Attachment Device 10/01/04 3 NC 5.90

Y9144 Barrier, 2 Pc W/Convexity, Durahesive, Tape 10/01/04 3 NC 7.47

Y9145 Ostomy Pouch, Urinary, W/Barrier, W/Convex 07/01/97 3 NC 7.27

5101:3-1-60 Page 368







Y9146 Pouch, Drainable, W/Barrier, W/Convexity 10/01/04 3 NC 4.17

Y9147 Ostomy Skin Barrier W/Flnge, Durhes.Cnvx 10/01/04 3 NC 6.43

+ Y9149 Nephrostomy/Billiary Drainage Pouch 10/01/04 3 NC 0.00

Y9150 Skin Barrier, Solid, 4X4 Equiv., Pediatric 10/01/04 3 NC 3.13

Y9151 Skin Barrier W Flange, Any Size Type. Ped. 10/01/04 3 NC 4.68

Y9152 Pouch, Drainbl W/Barrier Attachd, 1Pc, Ped 10/01/04 3 NC 2.87

Y9153 Pouch, Drainable W/O Barrier (1Pc) Ped. 10/01/04 3 NC 1.93

Y9154 Pouch, Drain Use On Barr W/Flnge (2Pc) 10/01/04 3 NC 2.20

Y9155 Pouch, Urin Use On Barr W/Flnge (2Pc), Ped 10/01/04 3 NC 3.34

Y9156 Pouch, Urin W/Barr Attchd (1Pc) Ped 10/01/04 3 NC 3.84

Y9157 Pouch, Urin W/O Barr Attchd (1Pc) Ped 10/01/04 3 NC 2.75

Y9159 Pouch, 1Pc, Drainable, W/Convex., Durahesive 10/01/04 3 NC 8.61

Y9160 Thermal Humidifying Filer, Use W/Trach./CPAP 10/01/04 3 NC 4.15

Y9161 Broncho Saline For Admin Of Med. 240 Cc 10/01/04 3 NC 5.35

Y9162 Wound Dressings, Packing 04/01/96 3 NC 100.00

Y9163 Hickman Catheter Injection Caps 08/01/98 3 NC 0.81

Y9164 Ambu/Resusitation Bag Reusable 06/20/90 1 138.00

Y9165 Ambu/Resusitation Bag, Dispsable 01/01/92 1 31.00

Y9166 Tracheal Suction Catheter, Pediatric 06/20/90 1 0.70

Y9167 Sharps Disposal Container, Capacity 200 06/20/90 1 4.00

Y9168 Stomach Tube, Pediatric, Single Use 10/01/04 3 NC 0.90

Y9169 Gastrostomy Button Feeder Attachment 07/01/97 2 10.50 6.38

Y9170 Stethoscope (Replacmnt For Blood Pres. Set) 10/01/04 3 NC 7.00

Y9171 Central Venous Line Sterile Dressing Kit 11/01/98 3 NC 5.14

Y9172 Twill Tape (Trach Ties) Per Yd 01/01/92 1 0.14

Y9173 Yankauer Suction Unit 10/01/04 3 NC 2.15

Y9174 Nebulizer W/Air Heater Adapter 10/01/04 3 NC 4.00

Y9176 Farrell Valve 01/01/92 1 8.16

Y9177 Subcutaneous Infusion Set (Ea) 11/01/98 3 NC 6.00

Y9178 IV Catheter/IV Needle 11/01/98 3 NC 0.00

+ Y9179 Enteral Feed Supply Kit, Pump Fed, Ambul 10/01/04 3 NC 12.60

Y9180 Surgical Gloves, Sterile 07/01/03 3 NC 0.55

Y9182 Mucus Clearance Device (FLUTTER) 10/01/04 3 NC 48.00

Y9183 IV Start Kit 11/01/98 3 NC 0.00

Y9184 100cc Cassette Drug Delivery System 11/01/98 3 NC 0.00

Y9185 50cc Cassette Drug Delivery System 11/01/98 3 NC 0.00

Y9186 Remote Reservoir 11/01/98 3 NC 0.00

Y9187 Sharps Container, Capacity 100 01/01/96 1 2.00

5101:3-1-60 Page 369







Y9188 Trach Tube Holder 10/01/04 3 NC 3.00

Y9189 Home Terb. Ther., Supplies, Drug, Nursing 01/01/97 1 120.00

Y9190 Supplies for external drug infus. pump, per cassette 10/01/04 3 NC 40.00

Y9410 Dental Sterlization Fee 01/01/96 3 NC 3.00

Y9411 Exam Other Than In Office 01/01/96 3 NC 5.18

Y9998 Visit Home/Nursing Home Hospital 10/01/04 3 NC 25.63

Z0040 Extra Attendant 10/01/03 3 NC 9.02

Z0050 Ambulette-Second Passenger 10/01/03 3 NC 11.81

Z0051 Ambulette-Three Or More Passengers 10/01/03 3 NC 7.88

Z0060 Non-Emerg. Ambulance (Second Passenger) 10/01/03 3 NC 42.97

Z0061 Non-Emerg. Ambulance (3 Or More Persons) 10/01/03 3 NC 28.65

Z0070 Basic Life Support-Second Passenger 10/01/03 3 NC 42.97

Z0071 Bls-Three Or More Passengers 10/01/03 3 NC 28.65

Z0080 Advanced Life Supp-Second Passenger 10/01/03 3 NC 82.87

Z0081 ALS-Three Or More Passengers 10/01/03 3 NC 55.23

Z0160 Ambulette/Wheelchair, Loaded Mileage 10/01/03 3 NC 0.01

Z0474 Case Management 07/27/92 3 NC 1,500.00

Z0475 Habilitation Services, Waiver Only 07/27/92 3 NC 2,000.00

Z0476 Home Modifications And Supplies, Waiver 07/27/92 3 NC 9,999.99

Z0477 Personal Care, Waiver Only 07/27/92 3 NC 2,000.00

Z0478 Respite Care, Waiver Only 07/27/92 3 NC 2,000.00

Z0479 Transportation, Waiver Only 07/27/92 3 NC 500.00

Z0480 Monthly Waiver Services, Open Doors 07/27/92 3 NC 4,000.00

Z0700 ODADAS Assessment 11/01/03 3 NC 3,600.00

Z0701 ODADAS Crisis Intervention 11/01/03 3 NC 3,600.00

Z0702 ODADAS Ind Counselinng 11/01/03 3 NC 3,600.00

Z0703 ODADAS Group Counseling 11/01/03 3 NC 3,600.00

Z0704 ODADAS Med Somatic 11/01/03 3 NC 3,600.00

Z0705 ODADAS Drug Screening/Urinalysis 11/01/03 3 NC 3,600.00

Z0706 ODADAS Methadone Administration 11/01/03 3 NC 3,600.00

Z0707 ODADAS Case Mgmt 11/01/03 3 NC 3,600.00

Z0708 ODADAS Intensive Outpatient 11/01/03 3 NC 3,600.00

Z0709 ODADAS Amb Med/Soc Detox 11/01/03 3 NC 3,600.00

Z0729 Cuyahoga Cnty Php Capitation 11/01/03 3 NC 3,600.00

Z0730 Pre-Hospital Screening Services 11/01/03 3 NC 3,600.00

Z0731 Medication/Somatic Services 11/01/03 3 NC 3,600.00

Z0732 Diagnostic Assessment Services 11/01/03 3 NC 3,600.00

Z0733 Counseling Individual 11/01/03 3 NC 3,600.00

5101:3-1-60 Page 370







Z0734 Counseling, Group 11/01/03 3 NC 3,600.00

Z0735 Psychotherapy, Individual 11/01/03 3 NC 3,600.00

Z0736 Psychotherapy, Group 11/01/03 3 NC 3,600.00

Z0737 Emergency Services 11/01/03 3 NC 3,600.00

Z0738 Partial Hospitalization Services 11/01/03 3 NC 3,600.00

Z0739 Case Management 11/01/03 3 NC 3,600.00

Z0745 Habilitation Services 05/29/86 1 999.99

Z0746 MARP Fee 04/08/88 1 6,000.00

Z0802 Psychological, Individual Psychotherapy 10/01/02 3 NC 31.06

Z0808 Psychological, Group Psychotherapy 10/01/02 3 NC 9.32

Z0809 Psych Test, Indiv. Mental Disorder 1 Hr 10/01/02 3 NC 36.24

Z0811 Psych Test, Indiv. Mental Dis. Add 30 Min 10/01/02 3 NC 10.35

Z0816 Pscy Test, Group Adm; Mental Disord. 1Hr 10/01/02 3 NC 11.18

Z0817 Psych Test, Indiv. Develop. Assmt/Ld 1 Hr 10/01/02 3 NC 41.41

Z0818 Psych Test, Indiv- Dev. As./Ld Add. 30 Min 10/01/02 3 NC 10.35

Z0819 Psych Test, Group Adm For Intel. Asmt 1.Hr 10/01/02 3 NC 11.18

Z1860 Maintenance Hemodialysis 10/01/03 3 NC 131.37

Z1861 Maintenance Peritoneal Dialysis 10/01/03 3 NC 131.37

Z1862 Hemodialysis, IPD, or CCPD Training 10/01/03 3 NC 151.37

Z1863 CAPD Training & Facility Services 10/01/03 3 NC 143.37

Z1864 CAPD 10/01/03 3 NC 56.30

Z1865 CCPD 10/01/03 3 NC 56.30

Z1866 CAPD & CCPD Support Services 10/01/03 3 NC 75.00

Z2585 Speech Evaluation 01/01/03 3 NC 52.91

Z2586 Speech Therapy, Individual, Approx .5 Hour 01/01/03 3 NC 34.52

Z2590 Speech Therapy, Individual, Approx .1 Hour 01/01/03 3 NC 69.04

Z2591 Speech Therapy, Group, Approx .5 Hour 01/01/03 3 NC 19.63

Z2592 Speech Therapy, Group, Approx .1 Hour 01/01/03 3 NC 39.26

Z2593 Language Evaluation 01/01/03 3 NC 52.91

Z2594 Hearing/Hearing Aid/Lang/Speech; Reck/Cns 01/01/00 3 NC 12.42

Z2595 Battery Of Audiological Tests 01/01/03 3 NC 22.78

Z5831 Total Pt. Evaluation Phys. Therapy 01/01/00 3 NC 28.47

Z7002 Incont. Supply, Other Item 01/01/96 1 NC

Z7007 Large Surgical Pad, Sterile Or Non Steri 06/01/96 3 NC 1.14

+ Z7009 Decubitus Ulcer Dressing 10/01/04 3 NC 0.00

Z7014 Catheter Or Tube Holder/Strap 06/01/96 3 NC 3.00

Z7015 Connector Tubing, Adaptor, Etc. 06/01/96 3 NC 2.60

Z7020 Ostomy Skin Barrier; Washer 10/01/04 3 NC 1.53

5101:3-1-60 Page 371







Z7036 Ostomy Pouch Urinary; Use On Face Plate 05/01/90 1 3.51

Z7037 Ostomy Belt-Hernia (Binder) 10/01/04 3 NC 24.20

Z7038 Ankle Strap, wheelchair 10/01/04 3 NC 10.00

Z7050 IV Solution And Administration Set 08/01/98 3 NC 6.30

Z7210 Whirlpool Body Immersion 07/01/02 3 NC 10.25

Z7217 Massage Body 03/30/95 3 NC

Z7225 Joint Mobilization 03/30/95 3 NC

Z7226 Tilt Table 07/01/02 3 NC 13.66

Z7228 Home Visit Travel And Mileage 07/01/03 3 NC 5.74

Z7352 Catheter Plug/Clamp 05/01/90 1 0.50

Z9060 Methadone Treatment Dispensing 04/13/89 1 4.14

Z9999 MR/DD Case Management 10/01/89 1 0.01

C FORTY - SIXTY

D EIGHTY - TWENTY

E PROFESSIONAL COMPONENT- 400

F TEN - NINETY

G TWENTY - EIGHTY

H TWENTY-FIVE - SEVENTY-FIVE

I THIRTY - SEVENTY

J THIRTY-FIVE - SIXTY-FIVE

K FIFTY - FIFTY

L SIXTY - FORTY

M SEVENTY - THIRTY

O ONE HUNDRED - ZERO

P SEVENTY-FIVE - TWENTY-FIVE

Q NINETY- TEN

KEY FOR CURRENT/PREVIOUS PRICE:

BR BY REPORT

FP FORMULA PRICING

IC INFORMATIONAL CODE

NC NON-COVERED SERVICE

PA PRIOR AUTHORIZATION-PRICED DURING PRIOR AUTH.

PC PROVIDER CHARGE-PRICED INDIVIDUALLY BY PROVIDER

5101:3-1-60 Page 372







TM TRANSPORTATION MILEAGE

WP WAIVER PRICING

RCC DIALYSIS CLINIC REVENUE CENTER CODES

0821 Hemodialysis compositie rate 10/01/03 1 131.37

0825 Hemodialysis support services 10/01/03 1 75.00

0829 Hemodialysis training composite rate 10/01/03 1 151.37

0831 Peritoneal composite rate 10/01/03 1 131.37

0835 Peritoneal support services 10/01/03 1 75.00

0839 Peritoneal training composite rate 10/01/03 1 151.37

0841 CAPD composite rate 10/01/03 1 56.30

0845 CAPD support services 10/01/03 1 75.00

0849 CAPD training composite rate 10/01/03 1 143.37

0851 CCPD composite rate 10/01/03 1 56.30

0855 CCPD support services 10/01/03 1 75.00

0859 CCPD training composite rate 10/01/03 1 151.37

"+" MEANS THE CODE IS NO LONGER VALID

FOR PA REQUESTS MADE ON OR AFTER

OCTOBER 1, 2004. REIMBURSEMENT CAN

CONTINUE TO BE MADE FOR THESE CODES

WITH AN APPROVED PA PRIOR TO OCTOBER 1,

2004, IF THE SERVICE DISPENSED PRIOR TO

JANUARY 1, 2005.

"++" MEANS THE CODE IS NO LONGER VALID FOR

PA REQUESTS MADE ON OR AFTER JANUARY

1, 2005. REIMBURSEMENT CAN CONTINUE TO

BE MADE FOR THESE CODES WITH AN

APPROVED PA PRIOR TO JANUARY 1, 2005,

IF THE SERVICE DISPENSED PRIOR TO

APRIL 1, 2005.

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3-1-60... · 5101:3-1-60 Page 1 Appendix DD STATUS CODES: (1) PAY CURRENT PRICE (2) PAY CURRENT...

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