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Physician_Manual_Fee_Schedule_Sect5

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					                                                                                                       Page 1 of 189


NYS Medicaid Physician Surgery Services Fee Schedule
Effective Date: April 1, 2012

FOR MOMS FEES, SEE ENHANCED PROGRAM FEE SCHEDULE


                                                                                                   C
                                                         NON-                                      H
                                                                                                   A
                                                       FACILITY FACILITY PROFESSIONAL              N
                                                       GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION                  FEE      FEE        FEE      BR PA DAYS   E
10021   FINE NEEDLE ASPIRATION; WITHOUT IMAGING            81.61    60.00                 0   0
10022   FINE NEEDLE ASPIRATION; WITH IMAGING GUI           85.59    72.00                 0   0
10040   ACNE SURGERY (EG, MARSUPIALIZATION, OPEN           54.25    39.26                 1  10
10060   INCISION AND DRAINAGE OF ABSCESS (EG, CA           60.50    43.24                 0  10
10061   INCISION AND DRAINAGE OF ABSCESS (EG, CA          103.19    76.76                 0  10
10080   INCISION AND DRAINAGE OF PILONIDAL CYST;           97.93    45.10                 0  10
10081   INCISION AND DRAINAGE OF PILONIDAL CYST;          148.94    76.74                 0  10
10120   INCISION AND REMOVAL OF FOREIGN BODY, SU           78.42    42.79                 0  10
10121   INCISION AND REMOVAL OF FOREIGN BODY, SU          149.18    87.61                 0  10
10140   INCISION AND DRAINAGE OF HEMATOMA, SEROM           85.50    56.28                 0  10
10160   PUNCTURE ASPIRATION OF ABSCESS, HEMATOMA           70.27    45.44                 0  10
10180   INCISION AND DRAINAGE, COMPLEX, POSTOPER          131.00    83.94                 0  10
11000   DEBRIDEMENT OF EXTENSIVE ECZEMATOUS OR I           29.85    15.44                 0   0
11001   DEBRIDEMENT OF EXTENSIVE ECZEMATOUS OR I           12.58     7.82                 0   0
11004   DEBRIDEMENT OF SKIN, SUBCUTANEOUS TISSUE          322.79   268.99                 0   0
11005   DEBRIDEMENT OF SKIN, SUBCUTANEOUS TISSUE          427.08   355.90                 0   0
11006   DEBRIDEMENT OF SKIN, SUBCUTANEOUS TISSUE          404.45   337.05                 0   0
11008   REMOVAL OF PROSTHETIC MATERIAL OR MESH,           156.52   130.43                 0   0
11010   DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN          268.67   134.48                 0  10
11011   DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN          304.47   142.57                 0   0
11012   DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN          426.15   209.71                 0   0
11042   DEBRIDEMENT; SKIN, AND SUBCUTANEOUS TISS           42.77    22.93                 0   0
11043   DEBRIDEMENT; SKIN, SUBCUTANEOUS TISSUE,           153.95   112.00                 0   0
11044   DEBRIDEMENT; SKIN, SUBCUTANEOUS TISSUE,           207.99   156.00                 0   0
11045   DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUD           14.52     6.89                 0   0
                                                                                                   Page 2 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
11046   DEBRIDEMENT, MUSCLE AND/OR FASCIA (INCLU       25.26    14.75                 0   0
11047   DEBRIDEMENT, BONE (INCLUDES EPIDERMIS, D       41.37    25.57                 0   0
11055   PARING OR CUTTING OF BENIGN HYPERKERATOT       26.66    16.00                 0   0
11056   PARING OR CUTTING OF BENIGN HYPERKERATOT       32.79    20.00                 0   0
11057   PARING OR CUTTING OF BENIGN HYPERKERATOT       39.64    24.00                 0   0
11100   BIOPSY OF SKIN, SUBCUTANEOUS TISSUE AND/       55.52    22.07                 0   0
11101   BIOPSY OF SKIN, SUBCUTANEOUS TISSUE AND/       17.90    12.00                 0   0
11200   REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTA       44.93    31.29                 0  10
11201   REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTA       33.00    33.00                 0   0
11300   SHAVING OF EPIDERMAL OR DERMAL LESION, S       37.93    16.00                 0   0
11301   SHAVING OF EPIDERMAL OR DERMAL LESION, S       50.52    23.03                 0   0
11302   SHAVING OF EPIDERMAL OR DERMAL LESION, S       60.10    28.34                 0   0
11303   SHAVING OF EPIDERMAL OR DERMAL LESION, S       71.38    36.00                 0   0
11305   SHAVING OF EPIDERMAL OR DERMAL LESION, S       38.87    17.63                 0   0
11306   SHAVING OF EPIDERMAL OR DERMAL LESION, S       52.75    26.32                 0   0
11307   SHAVING OF EPIDERMAL OR DERMAL LESION, S       61.42    30.47                 0   0
11308   SHAVING OF EPIDERMAL OR DERMAL LESION, S       70.54    37.46                 0   0
11310   SHAVING OF EPIDERMAL OR DERMAL LESION, S       46.49    19.67                 0   0
11311   SHAVING OF EPIDERMAL OR DERMAL LESION, S       57.64    28.55                 0   0
11312   SHAVING OF EPIDERMAL OR DERMAL LESION, S       67.01    32.87                 0   0
11313   SHAVING OF EPIDERMAL OR DERMAL LESION, S       84.61    44.26                 0   0
11400   EXCISION, BENIGN LESION INCLUDING MARGIN       66.94    34.66                 0  10
11401   EXCISION, BENIGN LESION INCLUDING MARGIN       79.91    45.47                 0  10
11402   EXCISION, BENIGN LESION INCLUDING MARGIN       88.74    49.95                 0  10
11403   EXCISION, BENIGN LESION INCLUDING MARGIN      101.70    63.42                 0  10
11404   EXCISION, BENIGN LESION INCLUDING MARGIN      115.54    70.24                 0  10
11406   EXCISION, BENIGN LESION INCLUDING MARGIN      159.31   103.44                 0  10
11420   EXCISION, BENIGN LESION INCLUDING MARGIN       66.71    37.75                 0  10
11421   EXCISION, BENIGN LESION INCLUDING MARGIN       85.02    50.34                 0  10
                                                                                                   Page 3 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
11422   EXCISION, BENIGN LESION INCLUDING MARGIN       95.03    60.33                 0  10
11423   EXCISION, BENIGN LESION INCLUDING MARGIN      110.70    70.10                 0  10
11424   EXCISION, BENIGN LESION INCLUDING MARGIN      126.80    81.05                 0  10
11426   EXCISION, BENIGN LESION INCLUDING MARGIN      179.50   122.31                 0  10
11440   EXCISION, OTHER BENIGN LESION INCLUDING        74.33    45.75                 0  10
11441   EXCISION, OTHER BENIGN LESION INCLUDING        91.59    59.10                 0  10
11442   EXCISION, OTHER BENIGN LESION INCLUDING       102.79    65.56                 0  10
11443   EXCISION, OTHER BENIGN LESION INCLUDING       123.35    80.85                 0  10
11444   EXCISION, OTHER BENIGN LESION INCLUDING       154.84   103.19                 0  10
11446   EXCISION, OTHER BENIGN LESION INCLUDING       206.69   144.76                 0  10
11450   EXCISION OF SKIN AND SUBCUTANEOUS TISSUE      196.85   105.39                 0  90
11451   EXCISION OF SKIN AND SUBCUTANEOUS TISSUE      260.39   139.87                 0  90
11462   EXCISION OF SKIN AND SUBCUTANEOUS TISSUE      195.22   101.56                 0  90
11463   EXCISION OF SKIN AND SUBCUTANEOUS TISSUE      265.28   141.70                 0  90
11470   EXCISION OF SKIN AND SUBCUTANEOUS TISSUE      213.31   119.92                 0  90
11471   EXCISION OF SKIN AND SUBCUTANEOUS TISSUE      273.96   152.01                 0  90
11600   EXCISION, MALIGNANT LESION INCLUDING MAR      100.66    50.25                 0  10
11601   EXCISION, MALIGNANT LESION INCLUDING MAR      119.50    64.51                 0  10
11602   EXCISION, MALIGNANT LESION INCLUDING MAR      130.09    70.05                 0  10
11603   EXCISION, MALIGNANT LESION INCLUDING MAR      147.75    82.93                 0  10
11604   EXCISION, MALIGNANT LESION INCLUDING MAR      163.22    90.90                 0  10
11606   EXCISION, MALIGNANT LESION INCLUDING MAR      227.23   134.39                 0  10
11620   EXCISION, MALIGNANT LESION INCLUDING MAR      101.41    50.67                 0  10
11621   EXCISION, MALIGNANT LESION INCLUDING MAR      120.47    65.32                 0  10
11622   EXCISION, MALIGNANT LESION INCLUDING MAR      135.76    80.00                 0  10
11623   EXCISION, MALIGNANT LESION INCLUDING MAR      158.63    91.99                 0  10
11624   EXCISION, MALIGNANT LESION INCLUDING MAR      179.49   105.27                 0  10
11626   EXCISION, MALIGNANT LESION INCLUDING MAR      221.40   134.46                 0  10
11640   EXCISION, MALIGNANT LESION INCLUDING MAR      106.00    60.00                 0  10
                                                                                                   Page 4 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                         DESCRIPTION             FEE      FEE        FEE      BR PA DAYS   E
11641   EXCISION, MALIGNANT LESION INCLUDING MAR      128.89    80.00                 0  10
11642   EXCISION, MALIGNANT LESION INCLUDING MAR      148.19   100.00                 0  10
11643   EXCISION, MALIGNANT LESION INCLUDING MAR      174.10   110.00                 0  10
11644   EXCISION, MALIGNANT LESION INCLUDING MAR      216.01   130.38                 0  10
11646   EXCISION, MALIGNANT LESION INCLUDING MAR      283.94   184.73                 0  10
11720   DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S);       17.23     8.21                 0   0
11721   DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S);       24.76    14.07                 0   0
11730   AVULSION OF NAIL PLATE, PARTIAL OR COMPL       54.67    28.74                 0   0
11732   AVULSION OF NAIL PLATE, PARTIAL OR COMPL       25.22    14.66                 0   0
11740   EVACUATION OF SUBUNGUAL HEMATOMA               25.04    15.12                 0   0
11750   EXCISION OF NAIL AND NAIL MATRIX, PARTIA      116.84    82.19                 0  10
11752   EXCISION OF NAIL AND NAIL MATRIX, PARTIA      165.65   124.71                 0  10
11755   BIOPSY OF NAIL UNIT (EG, PLATE, BED, MAT       74.09    40.42                 0   0
11760   REPAIR OF NAIL BED                            111.47    64.18                 0  10
11762   RECONSTRUCTION OF NAIL BED WITH GRAFT         148.38    97.40                 0  10
11765   WEDGE EXCISION OF SKIN OF NAIL FOLD (EG,       71.28    31.71                 0  10
11770   EXCISION OF PILONIDAL CYST OR SINUS; SIM      146.57   120.00                 0  10
11771   EXCISION OF PILONIDAL CYST OR SINUS; EXT      289.85   187.40                 0  90
11772   EXCISION OF PILONIDAL CYST OR SINUS; COM      358.84   248.58                 0  90
11900   INJECTION, INTRALESIONAL; UP TO AND INCL       30.31    13.98                 0   0
11901   INJECTION, INTRALESIONAL; MORE THAN SEVE       37.32    21.67                 0   0
11920   TATTOOING, INTRADERMAL INTRODUCTION OF I      112.63    54.27                 0   0
11921   TATTOOING, INTRADERMAL INTRODUCTION OF I      127.37    64.10                 0   0
11922   TATTOOING, INTRADERMAL INTRODUCTION OF I                                  BR 0    0
11950   SUBCUTANEOUS INJECTION OF FILLING MATERI       43.36    23.00             BR 0    0
11951   SUBCUTANEOUS INJECTION OF FILLING MATERI       56.33    31.16             BR 0    0
11952   SUBCUTANEOUS INJECTION OF FILLING MATERI       80.95    46.54             BR 0    0
11954   SUBCUTANEOUS INJECTION OF FILLING MATERI       95.56    53.18             BR 0    0
11960   INSERTION OF TISSUE EXPANDER(S) FOR OTHE      512.38   426.98                 0  90
                                                                                                   Page 5 of 189


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                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
11970   REPLACEMENT OF TISSUE EXPANDER WITH PERM      335.30   279.42                 0  90
11971   REMOVAL OF TISSUE EXPANDER(S) WITHOUT IN      276.06   140.83                 0  90
11976   REMOVAL, IMPLANTABLE CONTRACEPTIVE CAPSU       83.43    57.00                 0   0
11980   SUBCUTANEOUS HORMONE PELLET IMPLANTATION       81.00    81.00                 0   0
11981   INSERTION, NON-BIODEGRADABLE DRUG DELIVE       81.00    81.00                 0   0
11982   REMOVAL, NON-BIODEGRADABLE DRUG DELIVERY       88.93    57.00                 0   0
11983   REMOVAL WITH REINSERTION, NON-BIODEGRADA      133.14   109.50                 0   0
12001   SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF S       84.14    47.35                 0   0
12002   SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF S       89.54    53.08                 0   0
12004   SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF S      104.98    62.26                 0   0
12005   SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF S      130.64    77.28                 0   0
12006   SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF S      162.44    97.83                 0   0
12007   SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF S      182.81   112.35                 0   0
12011   SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF F       89.69    49.11                 0   0
12013   SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF F       98.47    56.21                 0   0
12014   SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF F      115.49    67.32                 0   0
12015   SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF F      144.94    84.28                 0   0
12016   SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF F      171.41   102.65                 0   0
12017   SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF F      149.04   124.20                 0   0
12018   SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF F      178.90   149.08                 0   0
12020   TREATMENT OF SUPERFICIAL WOUND DEHISCENC      153.04    88.16                 0  10
12031   REPAIR, INTERMEDIATE, WOUNDS OF SCALP, A      124.13    68.17                 0  10
12032   REPAIR, INTERMEDIATE, WOUNDS OF SCALP, A      165.83    87.13                 0  10
12034   REPAIR, INTERMEDIATE, WOUNDS OF SCALP, A      161.62    90.00                 0  10
12035   REPAIR, INTERMEDIATE, WOUNDS OF SCALP, A      208.18   109.50                 0  10
12036   REPAIR, INTERMEDIATE, WOUNDS OF SCALP, A      230.18   128.45                 0  10
12037   REPAIR, INTERMEDIATE, WOUNDS OF SCALP, A      258.95   149.34                 0  10
12041   REPAIR, INTERMEDIATE, WOUNDS OF NECK, HA      131.93    73.85                 0  10
12042   REPAIR, INTERMEDIATE, WOUNDS OF NECK, HA      155.62   120.00                 0  10
                                                                                                   Page 6 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
12044   REPAIR, INTERMEDIATE, WOUNDS OF NECK, HA      176.56   130.00                 0  10
12045   REPAIR, INTERMEDIATE, WOUNDS OF NECK, HA      210.34   140.00                 0  10
12046   REPAIR, INTERMEDIATE, WOUNDS OF NECK, HA      248.66   150.00                 0  10
12047   REPAIR, INTERMEDIATE, WOUNDS OF NECK, HA      266.04   160.00                 0  10
12051   REPAIR, INTERMEDIATE, WOUNDS OF FACE, EA      146.06    80.70                 0  10
12052   REPAIR, INTERMEDIATE, WOUNDS OF FACE, EA      160.49   160.00                 0  10
12053   REPAIR, INTERMEDIATE, WOUNDS OF FACE, EA      175.67   160.00                 0  10
12054   REPAIR, INTERMEDIATE, WOUNDS OF FACE, EA      188.40   170.00                 0  10
12055   REPAIR, INTERMEDIATE, WOUNDS OF FACE, EA      229.93   180.00                 0  10
12056   REPAIR, INTERMEDIATE, WOUNDS OF FACE, EA      284.23   190.00                 0  10
12057   REPAIR, INTERMEDIATE, WOUNDS OF FACE, EA      305.52   200.00                 0  10
13100   REPAIR, COMPLEX, TRUNK; 1.1 CM TO 2.5 CM      174.38   107.38                 0  10
13101   REPAIR, COMPLEX, TRUNK; 2.6 CM TO 7.5 CM      216.46   129.73                 0  10
13102   REPAIR, COMPLEX, TRUNK; EACH ADDITIONAL        59.19    34.76                 0   0
13120   REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEG      180.81   111.71                 0  10
13121   REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEG      236.86   144.87                 0  10
13122   REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEG       68.24    39.64                 0   0
13131   REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN,      198.89   126.58                 0  10
13132   REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN,      309.32   209.78                 0  10
13133   REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN,       92.33    61.15                 0   0
13150   REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND      203.63   127.45                 0  10
13151   REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND      225.03   146.92                 0  10
13152   REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND      305.40   196.87                 0  10
13153   REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND      103.03    67.20                 0   0
13160   SECONDARY CLOSURE OF SURGICAL WOUND OR D      450.78   375.65                 0  90
14000   ADJACENT TISSUE TRANSFER OR REARRANGEMEN      359.26   245.24                 0  90
14001   ADJACENT TISSUE TRANSFER OR REARRANGEMEN      465.76   327.83                 0  90
14020   ADJACENT TISSUE TRANSFER OR REARRANGEMEN      400.17   279.95                 0  90
14021   ADJACENT TISSUE TRANSFER OR REARRANGEMEN      522.83   379.09                 0  90
                                                                                                   Page 7 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
14040   ADJACENT TISSUE TRANSFER OR REARRANGEMEN      419.91   300.70                 0  90
14041   ADJACENT TISSUE TRANSFER OR REARRANGEMEN      572.56   413.96                 0  90
14060   ADJACENT TISSUE TRANSFER OR REARRANGEMEN      427.84   316.95                 0  90
14061   ADJACENT TISSUE TRANSFER OR REARRANGEMEN      621.43   448.54                 0  90
14301   ADJACENT TISSUE TRANSFER OR REARRANGEMEN      502.99   352.20                 0  90
14302   ADJACENT TISSUE TRANSFER OR REARRANGEMEN      108.88    90.74                 0   0
14350   FILLETED FINGER OR TOE FLAP, INCLUDING P      423.71   353.09                 0  90
15002   SURGICAL PREPARATION OR CREATION OF RECI      189.25   105.82                 0   0
15003   SURGICAL PREPARATION OR CREATION OF RECI       40.84    20.91                 0   0
15004   SURGICAL PREPARATION OR CREATION OF RECI      227.42   130.86                 0   0
15005   SURGICAL PREPARATION OR CREATION OF RECI       68.14    42.22                 0   0
15040   HARVEST OF SKIN FOR TISSUE CULTURED SKIN      150.77    60.84                 0   0
15050   PINCH GRAFT, SINGLE OR MULTIPLE, TO COVE      301.34   205.79                 0  90
15100   SPLIT-THICKNESS AUTOGRAFT, TRUNK, ARMS,       502.73   338.34                 0  90
15101   SPLIT-THICKNESS AUTOGRAFT, TRUNK, ARMS,       116.68    54.37                 0   0
15110   EPIDERMAL AUTOGRAFT, TRUNK, ARMS, LEGS;       490.40   346.52                 0  90
15111   EPIDERMAL AUTOGRAFT, TRUNK, ARMS, LEGS;        70.19    50.70                 0   0
15115   EPIDERMAL AUTOGRAFT, FACE, SCALP, EYELID      481.25   356.33                 0  90
15116   EPIDERMAL AUTOGRAFT, FACE, SCALP, EYELID       92.60    68.97                 0   0
15120   SPLIT-THICKNESS AUTOGRAFT, FACE, SCALP,       521.38   364.35                 0  90
15121   SPLIT-THICKNESS AUTOGRAFT, FACE, SCALP,       160.25    84.32                 0   0
15130   DERMAL AUTOGRAFT, TRUNK, ARMS, LEGS; FIR      392.39   266.49                 0  90
15131   DERMAL AUTOGRAFT, TRUNK, ARMS, LEGS; EAC       56.47    40.91                 0   0
15135   DERMAL AUTOGRAFT, FACE, SCALP, EYELIDS,       488.56   364.27                 0  90
15136   DERMAL AUTOGRAFT, FACE, SCALP, EYELIDS,        54.03    41.34                 0   0
15150   TISSUE CULTURED SKIN AUTOGRAFT, TRUNK, A      406.13   304.60                 0  90
15151   TISSUE CULTURED SKIN AUTOGRAFT, TRUNK, A       73.90    54.82                 0   0
15152   TISSUE CULTURED SKIN AUTOGRAFT, TRUNK, A       90.83    68.52                 0   0
15155   TISSUE CULTURED SKIN AUTOGRAFT, FACE, SC      419.15   326.74                 0  90
                                                                                                   Page 8 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
15156   TISSUE CULTURED SKIN AUTOGRAFT, FACE, SC       97.39    75.83                 0   0
15157   TISSUE CULTURED SKIN AUTOGRAFT, FACE, SC      108.33    82.69                 0   0
15200   FULL THICKNESS GRAFT, FREE, INCLUDING DI      442.82   299.70                 0  90
15201   FULL THICKNESS GRAFT, FREE, INCLUDING DI       87.51    42.00                 0   0
15220   FULL THICKNESS GRAFT, FREE, INCLUDING DI      423.01   288.11                 0  90
15221   FULL THICKNESS GRAFT, FREE, INCLUDING DI       81.08    40.00                 0   0
15240   FULL THICKNESS GRAFT, FREE, INCLUDING DI      501.51   362.76                 0  90
15241   FULL THICKNESS GRAFT, FREE, INCLUDING DI      104.45    55.00                 0   0
15260   FULL THICKNESS GRAFT, FREE, INCLUDING DI      533.90   390.37                 0  90
15261   FULL THICKNESS GRAFT, FREE, INCLUDING DI      120.03    68.03                 0   0
15570   FORMATION OF DIRECT OR TUBED PEDICLE, WI      497.59   328.93                 0  90
15271   APPLICATION OF SKIN SUBSTITUTE GRAFT TO        65.71    54.76                 0   0
15272   APPLICATION OF SKIN SUBSTITUTE GRAFT TO        12.36    10.30                 0   0
15273   APPLICATION OF SKIN SUBSTITUTE GRAFT TO       134.66   112.22                 0   0
15274   APPLICATION OF SKIN SUBSTITUTE GRAFT TO        31.70    26.42                 0   0
15275   APPLICATION OF SKIN SUBSTITUTE GRAFT TO        70.34    58.62                 0   0
15276   APPLICATION OF SKIN SUBSTITUTE GRAFT TO        15.22    12.69                 0   0
15277   APPLICATION OF SKIN SUBSTITUTE GRAFT TO        97.05    80.88                 0   0
15278   APPLICATION OF SKIN SUBSTITUTE GRAFT TO        37.38    31.15                 0   0
15572   FORMATION OF DIRECT OR TUBED PEDICLE, WI      466.97   325.97                 0  90
15574   FORMATION OF DIRECT OR TUBED PEDICLE, WI      502.91   353.46                 0  90
15576   FORMATION OF DIRECT OR TUBED PEDICLE, WI      447.39   310.89                 0  90
15600   DELAY OF FLAP OR SECTIONING OF FLAP (DIV      204.91    97.95                 0  90
15610   DELAY OF FLAP OR SECTIONING OF FLAP (DIV      184.40   114.91                 0  90
15620   DELAY OF FLAP OR SECTIONING OF FLAP (DIV      257.26   147.94                 0  90
15630   DELAY OF FLAP OR SECTIONING OF FLAP (DIV      262.04   160.32                 0  90
15650   TRANSFER, INTERMEDIATE, OF ANY PEDICLE F      281.66   175.04                 0  90
15731   FOREHEAD FLAP WITH PRESERVATION OF VASCU      609.67   455.55                 0  90
15732   MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS      849.61   611.62                 0  90
                                                                                                   Page 9 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
15734   MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS      875.45   631.31                 0  90
15736   MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS      789.88   547.28                 0  90
15738   MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS      836.63   596.29                 0  90
15740   FLAP; ISLAND PEDICLE                          542.17   389.87                 0  90
15750   FLAP; NEUROVASCULAR PEDICLE                   511.93   426.61                 0  90
15756   FREE MUSCLE OR MYOCUTANEOUS FLAP WITH MI    1,335.05 1,112.55                 0  90
15757   FREE SKIN FLAP WITH MICROVASCULAR ANASTO    1,327.46 1,106.22                 0  90
15758   FREE FASCIAL FLAP WITH MICROVASCULAR ANA    1,326.07 1,105.06                 0  90
15760   GRAFT; COMPOSITE (EG, FULL THICKNESS OF       468.30   327.29                 0  90
15770   GRAFT; DERMA-FAT-FASCIA                       365.69   304.75                 0  90
15775   PUNCH GRAFT FOR HAIR TRANSPLANT; 1 TO 15                                  BR 1    0
15776   PUNCH GRAFT FOR HAIR TRANSPLANT; MORE TH                                  BR 1    0
15777   IMPLANTATION OF BIOLOGIC IMPLANT (EG, AC       96.43    80.36                 1   0    *
15780   DERMABRASION; TOTAL FACE (EG, FOR ACNE S      468.69   308.75                 1  90
15781   DERMABRASION; SEGMENTAL, FACE                 299.71   202.80                 1  90
15782   DERMABRASION; REGIONAL, OTHER THAN FACE       325.26   198.65                 1  90
15783   DERMABRASION; SUPERFICIAL, ANY SITE, (EG                                  BR 1   90
15786   ABRASION; SINGLE LESION (EG, KERATOSIS,       133.75    63.27                 1  10
15787   ABRASION; EACH ADDITIONAL FOUR LESIONS O       31.25     8.81                 1   0
15788   CHEMICAL PEEL, FACIAL; EPIDERMAL              244.22   111.43                 1  90
15789   CHEMICAL PEEL, FACIAL; DERMAL                 320.20   196.28                 1  90
15792   CHEMICAL PEEL, NONFACIAL; EPIDERMAL           238.80   126.81                 1  90
15793   CHEMICAL PEEL, NONFACIAL; DERMAL              259.33   163.61                 1  90
15819   CERVICOPLASTY                                 405.53   337.95                 1  90
15820   BLEPHAROPLASTY, LOWER EYELID;                 297.59   221.34                 1  90
15821   BLEPHAROPLASTY, LOWER EYELID; WITH EXTEN      317.20   234.39                 1  90
15822   BLEPHAROPLASTY, UPPER EYELID;                 236.41   171.58                 1  90
15823   BLEPHAROPLASTY, UPPER EYELID; WITH EXCES      364.45   276.03                 1  90
15824   RHYTIDECTOMY; FOREHEAD                        344.30   286.92                 1   0
                                                                                                   Page 10 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
15825   RHYTIDECTOMY; NECK WITH PLATYSMAL TIGHTE      297.36   247.80                 1   0
15826   RHYTIDECTOMY; GLABELLAR FROWN LINES           248.27   206.89                 1   0
15828   RHYTIDECTOMY; CHEEK, CHIN, AND NECK           846.31   705.26                 1   0
15829   RHYTIDECTOMY; SUPERFICIAL MUSCULOAPONEUR                                  BR 1    0
15830   EXCISION, EXCESSIVE SKIN AND SUBCUTANEOU      652.31   543.59                 1  90
15832   EXCISION, EXCESSIVE SKIN AND SUBCUTANEOU      499.95   416.63                 1  90
15833   EXCISION, EXCESSIVE SKIN AND SUBCUTANEOU      465.59   388.00                 1  90
15834   EXCISION, EXCESSIVE SKIN AND SUBCUTANEOU      475.57   396.31                 1  90
15835   EXCISION, EXCESSIVE SKIN AND SUBCUTANEOU      486.37   405.31                 1  90
15836   EXCISION, EXCESSIVE SKIN AND SUBCUTANEOU      410.20   341.83                 1  90
15837   EXCISION, EXCESSIVE SKIN AND SUBCUTANEOU      429.83   316.36                 1  90
15838   EXCISION, EXCESSIVE SKIN AND SUBCUTANEOU      319.55   266.29                 1  90
15839   EXCISION, EXCESSIVE SKIN AND SUBCUTANEOU      466.93   330.25                 1  90
15840   GRAFT FOR FACIAL NERVE PARALYSIS; FREE F      563.47   469.56                 0  90
15841   GRAFT FOR FACIAL NERVE PARALYSIS; FREE M      932.65   777.21                 0  90
15842   GRAFT FOR FACIAL NERVE PARALYSIS; FREE M    1,480.24 1,233.54                 0  90
15845   GRAFT FOR FACIAL NERVE PARALYSIS; REGION      522.17   480.00                 0  90
15847   EXCISION, EXCESSIVE SKIN AND SUBCUTANEOU                                  BR 1    0
15851   REMOVAL OF SUTURES UNDER ANESTHESIA (OTH       56.12    21.34                 0   0
15852   DRESSING CHANGE (FOR OTHER THAN BURNS) U       26.77    22.31                 0   0
15860   INTRAVENOUS INJECTION OF AGENT (EG, FLUO       63.40    52.83                 0   0
15876   SUCTION ASSISTED LIPECTOMY; HEAD AND NEC                                  BR 1    0
15877   SUCTION ASSISTED LIPECTOMY; TRUNK                                         BR 1    0
15878   SUCTION ASSISTED LIPECTOMY; UPPER EXTREM                                  BR 1    0
15879   SUCTION ASSISTED LIPECTOMY; LOWER EXTREM                                  BR 1    0
15920   EXCISION, COCCYGEAL PRESSURE ULCER, WITH      323.87   269.90                 0  90
15922   EXCISION, COCCYGEAL PRESSURE ULCER, WITH      417.64   348.03                 0  90
15931   EXCISION, SACRAL PRESSURE ULCER, WITH PR      369.86   308.22                 0  90
15933   EXCISION, SACRAL PRESSURE ULCER, WITH PR      457.29   381.08                 0  90
                                                                                                   Page 11 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
15934   EXCISION, SACRAL PRESSURE ULCER, WITH SK      510.36   425.30                 0  90
15935   EXCISION, SACRAL PRESSURE ULCER, WITH SK      605.06   504.22                 0  90
15936   EXCISION, SACRAL PRESSURE ULCER, IN PREP      498.24   415.20                 0  90
15937   EXCISION, SACRAL PRESSURE ULCER, IN PREP      583.46   486.22                 0  90
15940   EXCISION, ISCHIAL PRESSURE ULCER, WITH P      383.08   319.24                 0  90
15941   EXCISION, ISCHIAL PRESSURE ULCER, WITH P      507.11   422.60                 0  90
15944   EXCISION, ISCHIAL PRESSURE ULCER, WITH S      493.33   411.11                 0  90
15945   EXCISION, ISCHIAL PRESSURE ULCER, WITH S      545.63   454.70                 0  90
15946   EXCISION, ISCHIAL PRESSURE ULCER, WITH O      902.45   752.04                 0  90
15950   EXCISION, TROCHANTERIC PRESSURE ULCER, W      318.02   265.02                 0  90
15951   EXCISION, TROCHANTERIC PRESSURE ULCER, W      453.40   377.84                 0  90
15952   EXCISION, TROCHANTERIC PRESSURE ULCER, W      470.95   392.46                 0  90
15953   EXCISION, TROCHANTERIC PRESSURE ULCER, W      525.79   438.16                 0  90
15956   EXCISION, TROCHANTERIC PRESSURE ULCER, I      638.47   532.06                 0  90
15958   EXCISION, TROCHANTERIC PRESSURE ULCER, I      652.72   543.93                 0  90
15999   UNLISTED PROCEDURE, EXCISION PRESSURE UL                                  BR 0    0
16000   INITIAL TREATMENT, FIRST DEGREE BURN, WH       39.31    21.69                 0   0
16020   DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-       47.55    26.71                 0   0
16025   DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-       83.14    53.70                 0   0
16030   DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-      100.22    61.78                 0   0
16035   ESCHAROTOMY; INITIAL INCISION                 121.03   100.86                 0   0
16036   ESCHAROTOMY; EACH ADDITIONAL INCISION (L       48.13    40.11                 0   0
17000   DESTRUCTION (EG, LASER SURGERY, ELECTROS       42.71    24.31             BR 0   10
17003   DESTRUCTION (EG, LASER SURGERY, ELECTROS        4.32     4.00             BR 0    0
17004   DESTRUCTION (EG, LASER SURGERY, ELECTROS       97.88    80.00             BR 0   10
17106   DESTRUCTION OF CUTANEOUS VASCULAR PROLIF      216.62   153.03                 0  90
17107   DESTRUCTION OF CUTANEOUS VASCULAR PROLIF      376.11   274.67                 0  90
17108   DESTRUCTION OF CUTANEOUS VASCULAR PROLIF      505.09   379.07                 0  90
17110   DESTRUCTION (EG, LASER SURGERY, ELECTROS       56.63    28.53                 0  10
                                                                                                   Page 12 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
17111   DESTRUCTION (EG, LASER SURGERY, ELECTROS       68.60    36.66                 0  10
17250   CHEMICAL CAUTERIZATION OF GRANULATION TI       42.80    17.01                 0   0
17260   DESTRUCTION, MALIGNANT LESION (EG, LASER       52.88    30.74                 0  10
17261   DESTRUCTION, MALIGNANT LESION (EG, LASER       75.91    40.70                 0  10
17262   DESTRUCTION, MALIGNANT LESION (EG, LASER       92.11    51.94                 0  10
17263   DESTRUCTION, MALIGNANT LESION (EG, LASER      101.42    57.24                 0  10
17264   DESTRUCTION, MALIGNANT LESION (EG, LASER                                  BR 0   10
17266   DESTRUCTION, MALIGNANT LESION (EG, LASER                                  BR 0   10
17270   DESTRUCTION, MALIGNANT LESION (EG, LASER       79.41    43.82                 0  10
17271   DESTRUCTION, MALIGNANT LESION (EG, LASER       86.80    60.00                 0  10
17272   DESTRUCTION, MALIGNANT LESION (EG, LASER       99.47    80.00                 0  10
17273   DESTRUCTION, MALIGNANT LESION (EG, LASER      110.67   100.00                 0  10
17274   DESTRUCTION, MALIGNANT LESION (EG, LASER      131.59   120.00                 0  10
17276   DESTRUCTION, MALIGNANT LESION (EG, LASER      153.58   140.00                 0  10
17280   DESTRUCTION, MALIGNANT LESION (EG, LASER       74.43    60.00                 0  10
17281   DESTRUCTION, MALIGNANT LESION (EG, LASER       94.13    80.00                 0  10
17282   DESTRUCTION, MALIGNANT LESION (EG, LASER      108.96   100.00                 0  10
17283   DESTRUCTION, MALIGNANT LESION (EG, LASER                                  BR 0   10
17284   DESTRUCTION, MALIGNANT LESION (EG, LASER                                  BR 0   10
17286   DESTRUCTION, MALIGNANT LESION (EG, LASER                                  BR 0   10
17311   MOHS MICROGRAPHIC TECHNIQUE, INCLUDING R      395.50   172.48                 0   0
17312   MOHS MICROGRAPHIC TECHNIQUE, INCLUDING R      239.93    91.85                 0   0
17313   MOHS MICROGRAPHIC TECHNIQUE, INCLUDING R      361.65   154.94                 0   0
17314   MOHS MICROGRAPHIC TECHNIQUE, INCLUDING R      221.81    84.96                 0   0
17315   MOHS MICROGRAPHIC TECHNIQUE, INCLUDING R                                  BR 0    0
17340   CRYOTHERAPY (CO2 SLUSH, LIQUID N2) FOR A       25.51    21.46                 0  10
17360   CHEMICAL EXFOLIATION FOR ACNE (EG, ACNE        71.39    44.93                 0  10
17380   ELECTROLYSIS EPILATION, EACH 1/2 HOUR          19.25    16.04                 1   0
17999   UNLISTED PROCEDURE, SKIN, MUCOUS MEMBRAN                                  BR 0    0
                                                                                                   Page 13 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
19000   PUNCTURE ASPIRATION OF CYST OF BREAST;         66.94    21.74                 0   0
19001   PUNCTURE ASPIRATION OF CYST OF BREAST; E       15.62    10.77                 0   0
19020   MASTOTOMY WITH EXPLORATION OR DRAINAGE O      245.83   130.61                 0  90
19030   INJECTION PROCEDURE ONLY FOR MAMMARY DUC      101.48    38.42                 0   0
19100   BIOPSY OF BREAST; PERCUTANEOUS, NEEDLE C       80.74    60.00                 0   0
19101   BIOPSY OF BREAST; OPEN, INCISIONAL            183.38   122.00                 0  10
19102   BIOPSY OF BREAST; PERCUTANEOUS, NEEDLE C      133.76    72.00                 0   0
19103   BIOPSY OF BREAST; PERCUTANEOUS, AUTOMATE      347.86   143.00                 0   0
19105   ABLATION, CRYOSURGICAL, OF FIBROADENOMA,    1,226.74    88.89                 0   0
19110   NIPPLE EXPLORATION, WITH OR WITHOUT EXCI      247.50   145.75                 0  90
19112   EXCISION OF LACTIFEROUS DUCT FISTULA          238.15   132.01                 0  90
19120   EXCISION OF CYST, FIBROADENOMA, OR OTHER      253.88   182.00                 0  90
19125   EXCISION OF BREAST LESION IDENTIFIED BY       279.61   198.15                 0  90
19126   EXCISION OF BREAST LESION IDENTIFIED BY        89.73    74.78                 0   0
19260   EXCISION OF CHEST WALL TUMOR INCLUDING R      669.35   557.80                 0  90
19271   EXCISION OF CHEST WALL TUMOR INVOLVING R      921.08   767.57                 0  90
19272   EXCISION OF CHEST WALL TUMOR INVOLVING R    1,015.72   846.43                 0  90
19290   PREOPERATIVE PLACEMENT OF NEEDLE LOCALIZ       98.16    40.00                 0   0
19291   PREOPERATIVE PLACEMENT OF NEEDLE LOCALIZ       42.44    20.00                 0   0
19295   IMAGE GUIDED PLACEMENT, METALLIC LOCALIZ       61.51    51.26                 0   0
19296   PLACEMENT OF RADIOTHERAPY AFTERLOADING E                                  BR 0    0
19297   PLACEMENT OF RADIOTHERAPY AFTERLOADING E       52.10    43.42                 0   0
19298   PLACEMENT OF RADIOTHERAPY AFTERLOADING B                                  BR 0    0
19300   MASTECTOMY FOR GYNECOMASTIA                   308.68   175.81                 0  90
19301   MASTECTOMY, PARTIAL (EG, LUMPECTOMY, TYL      320.83   267.36                 0  90
19302   MASTECTOMY, PARTIAL (EG, LUMPECTOMY, TYL      477.17   397.65                 0  90
19303   MASTECTOMY, SIMPLE, COMPLETE                  494.20   411.84                 0  90
19304   MASTECTOMY, SUBCUTANEOUS                      302.15   251.80                 0  90
19305   MASTECTOMY, RADICAL, INCLUDING PECTORAL       592.76   493.97                 0  90
                                                                                                   Page 14 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
19306   MASTECTOMY, RADICAL, INCLUDING PECTORAL       619.70   516.42                 0  90
19307   MASTECTOMY, MODIFIED RADICAL, INCLUDING       623.15   519.30                 0  90
19316   MASTOPEXY                                     438.86   400.00                 0  90
19318   REDUCTION MAMMAPLASTY                         649.87   541.56                 0  90
19324   MAMMAPLASTY, AUGMENTATION; WITHOUT PROST      300.00   300.00                 0  90
19325   MAMMAPLASTY, AUGMENTATION; WITH PROSTHET      362.90   302.42                 0  90
19328   REMOVAL OF INTACT MAMMARY IMPLANT             273.28   227.74                 0  90
19330   REMOVAL OF MAMMARY IMPLANT MATERIAL           347.22   289.35                 0  90
19340   IMMEDIATE INSERTION OF BREAST PROSTHESIS      300.00   300.00                 0  90
19342   DELAYED INSERTION OF BREAST PROSTHESIS F      514.16   428.47                 0  90
19350   NIPPLE/AREOLA RECONSTRUCTION                  507.34   320.44                 0  90
19355   CORRECTION OF INVERTED NIPPLES                408.77   255.73                 0  90
19357   BREAST RECONSTRUCTION, IMMEDIATE OR DELA      867.42   722.85                 0  90
19361   BREAST RECONSTRUCTION WITH LATISSIMUS DO      898.36   748.63                 0  90
19364   BREAST RECONSTRUCTION WITH FREE FLAP        1,568.29 1,306.91                 0  90
19366   BREAST RECONSTRUCTION WITH OTHER TECHNIQ      780.40   650.34                 0  90
19367   BREAST RECONSTRUCTION WITH TRANSVERSE RE    1,026.01   855.01                 0  90
19368   BREAST RECONSTRUCTION WITH TRANSVERSE RE    1,265.17 1,054.31                 0  90
19369   BREAST RECONSTRUCTION WITH TRANSVERSE RE    1,161.88   968.24                 0  90
19370   OPEN PERIPROSTHETIC CAPSULOTOMY, BREAST       381.09   317.58                 0  90
19371   PERIPROSTHETIC CAPSULECTOMY, BREAST           440.10   366.75                 0  90
19380   REVISION OF RECONSTRUCTED BREAST              429.19   357.66                 0  90
19396   PREPARATION OF MOULAGE FOR CUSTOM BREAST                                  BR 0    0
19499   UNLISTED PROCEDURE, BREAST                                                BR 0    0
20005   INCISION OF SOFT TISSUE ABSCESS (EG, SEC      170.97   112.74                 0  10
20100   EXPLORATION OF PENETRATING WOUND (SEPARA      336.98   280.82                 0  10
20101   EXPLORATION OF PENETRATING WOUND (SEPARA      229.76    95.28                 0  10
20102   EXPLORATION OF PENETRATING WOUND (SEPARA      269.10   114.73                 0  10
20103   EXPLORATION OF PENETRATING WOUND (SEPARA      327.11   167.79                 0  10
                                                                                                   Page 15 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                         DESCRIPTION             FEE      FEE        FEE      BR PA DAYS   E
20150   EXCISION OF EPIPHYSEAL BAR, WITH OR WITH      524.47   437.06                 0  90
20200   BIOPSY, MUSCLE; SUPERFICIAL                   110.37    43.99                 0   0
20205   BIOPSY, MUSCLE; DEEP                          150.38    69.53                 0   0
20206   BIOPSY, MUSCLE, PERCUTANEOUS NEEDLE           165.96    30.42                 0   0
20220   BIOPSY, BONE, TROCAR, OR NEEDLE; SUPERFI      117.09    38.10                 0   0
20225   BIOPSY, BONE, TROCAR, OR NEEDLE; DEEP (E      491.85    58.13                 0   0
20240   BIOPSY, BONE, OPEN; SUPERFICIAL (EG, ILI      132.52   110.43                 0  10
20245   BIOPSY, BONE, OPEN; DEEP (EG, HUMERUS, I      359.93   299.94                 0  10
20250   BIOPSY, VERTEBRAL BODY, OPEN; THORACIC        215.98   179.98                 0  10
20251   BIOPSY, VERTEBRAL BODY, OPEN; LUMBAR OR       240.37   200.31                 0  10
20500   INJECTION OF SINUS TRACT; THERAPEUTIC (S       72.49    48.10                 0  10
20501   INJECTION OF SINUS TRACT; DIAGNOSTIC (SI       81.40    19.02                 0   0
20520   REMOVAL OF FOREIGN BODY IN MUSCLE OR TEN      110.88    68.82                 0  10
20525   REMOVAL OF FOREIGN BODY IN MUSCLE OR TEN      283.15   118.85                 0  10
20526   INJECTION, THERAPEUTIC (EG, LOCAL ANESTH       44.06    27.90                 0   0
20527   INJECTION, ENZYME (EG, COLLAGENASE), PAL       34.40    28.66                 0   0    *
20550   INJECTION(S); SINGLE TENDON SHEATH, OR L       33.80    19.76                 0   0
20551   INJECTION(S); SINGLE TENDON ORIGIN/INSER       33.34    20.60                 0   0
20552   INJECTION(S); SINGLE OR MULTIPLE TRIGGER       30.56    18.00                 0   0
20553   INJECTION(S); SINGLE OR MULTIPLE TRIGGER       34.16    18.42                 0   0
20555   PLACEMENT OF NEEDLES OR CATHETERS INTO M      185.66   154.72                 0   0
20600   ARTHROCENTESIS, ASPIRATION AND/OR INJECT       31.48    19.47                 0   0
20605   ARTHROCENTESIS, ASPIRATION AND/OR INJECT       34.16    20.06                 0   0
20610   ARTHROCENTESIS, ASPIRATION AND/OR INJECT       43.55    23.99                 0   0
20612   ASPIRATION AND/OR INJECTION OF GANGLION        33.84    20.82                 0   0
20615   ASPIRATION AND INJECTION FOR TREATMENT O      128.08    76.38                 0  10
20650   INSERTION OF WIRE OR PIN WITH APPLICATIO      112.16    74.80                 0  10
20660   APPLICATION OF CRANIAL TONGS, CALIPER, O      150.94   110.81                 0   0
20661   APPLICATION OF HALO, INCLUDING REMOVAL;       265.45   221.21                 0  90
                                                                                                   Page 16 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
20662   APPLICATION OF HALO, INCLUDING REMOVAL;       267.50   222.92                 0  90
20663   APPLICATION OF HALO, INCLUDING REMOVAL;       254.94   212.45                 0  90
20664   APPLICATION OF HALO, INCLUDING REMOVAL,       423.31   352.76                 0  90
20665   REMOVAL OF TONGS OR HALO APPLIED BY ANOT       74.69    49.94                 0  10
20670   REMOVAL OF IMPLANT; SUPERFICIAL, (EG, BU      265.68    73.94                 0  10
20680   REMOVAL OF IMPLANT; DEEP (EG, BURIED WIR      341.54   190.68                 0  90
20690   APPLICATION OF A UNIPLANE (PINS OR WIRES      281.14   234.28                 0  90
20692   APPLICATION OF A MULTIPLANE (PINS OR WIR      517.19   431.00                 0  90
20693   ADJUSTMENT OR REVISION OF EXTERNAL FIXAT      266.22   221.85                 0  90
20694   REMOVAL, UNDER ANESTHESIA, OF EXTERNAL F      255.02   162.27                 0  90
20802   REPLANTATION, ARM (INCLUDES SURGICAL NEC    1,369.84 1,141.53                 0  90
20805   REPLANTATION, FOREARM (INCLUDES RADIUS A    1,796.24 1,496.87                 0  90
20808   REPLANTATION, HAND (INCLUDES HAND THROUG    2,328.67 1,940.56                 0  90
20816   REPLANTATION, DIGIT, EXCLUDING THUMB (IN    1,416.16 1,180.13                 0  90
20822   REPLANTATION, DIGIT, EXCLUDING THUMB (IN    1,244.69 1,037.25                 0  90
20824   REPLANTATION, THUMB (INCLUDES CARPOMETAC    1,400.95 1,167.46                 0  90
20827   REPLANTATION, THUMB (INCLUDES DISTAL TIP    1,268.90 1,057.42                 0  90
20838   REPLANTATION, FOOT, COMPLETE AMPUTATION     1,340.60 1,117.17                 0  90
20900   BONE GRAFT, ANY DONOR AREA; MINOR OR SMA      356.15   224.19                 0   0
20902   BONE GRAFT, ANY DONOR AREA; MAJOR OR LAR      350.36   291.97                 0   0
20910   CARTILAGE GRAFT; COSTOCHONDRAL                280.00   280.00                 0  90
20912   CARTILAGE GRAFT; NASAL SEPTUM                 280.00   280.00                 0  90
20920   FASCIA LATA GRAFT; BY STRIPPER                230.69   192.25                 0  90
20922   FASCIA LATA GRAFT; BY INCISION AND AREA       341.04   230.47                 0  90
20924   TENDON GRAFT, FROM A DISTANCE (EG, PALMA      291.40   242.84                 0  90
20926   TISSUE GRAFTS, OTHER (EG, PARATENON, FAT      249.58   207.98                 0  90
20931   ALLOGRAFT FOR SPINE SURGERY ONLY; STRUCT       66.19    55.16                 0   0
20937   AUTOGRAFT FOR SPINE SURGERY ONLY (INCLUD      100.15    83.46                 0   0
20938   AUTOGRAFT FOR SPINE SURGERY ONLY (INCLUD      109.24    91.04                 0   0
                                                                                                   Page 17 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
20950   MONITORING OF INTERSTITIAL FLUID PRESSUR      166.57    44.46                 0   0
20955   BONE GRAFT WITH MICROVASCULAR ANASTOMOSI    1,453.84 1,211.54                 0  90
20956   BONE GRAFT WITH MICROVASCULAR ANASTOMOSI    1,548.04 1,290.04                 0  90
20957   BONE GRAFT WITH MICROVASCULAR ANASTOMOSI    1,451.41 1,209.51                 0  90
20962   BONE GRAFT WITH MICROVASCULAR ANASTOMOSI    1,536.68 1,280.57                 0  90
20969   FREE OSTEOCUTANEOUS FLAP WITH MICROVASCU    1,615.96 1,346.63                 0  90
20970   FREE OSTEOCUTANEOUS FLAP WITH MICROVASCU                                  BR 0   90
20972   FREE OSTEOCUTANEOUS FLAP WITH MICROVASCU                                  BR 0   90
20973   FREE OSTEOCUTANEOUS FLAP WITH MICROVASCU                                  BR 0   90
20974   ELECTRICAL STIMULATION TO AID BONE HEALI       35.65    23.14                DVS  0    *
20975   ELECTRICAL STIMULATION TO AID BONE HEALI      103.41    86.18                 0   0
20979   LOW INTENSITY ULTRASOUND STIMULATION TO       100.00   100.00                DVS  0    *
20982   ABLATION, BONE TUMOR(S) (EG, OSTEOID OST                                  BR 0    0
20999   UNLISTED PROCEDURE, MUSCULOSKELETAL SYST                                  BR 0    0
21010   ARTHROTOMY, TEMPOROMANDIBULAR JOINT           412.04   343.37                 0  90
21011   EXCISION, TUMOR, SOFT TISSUE OF FACE OR       192.13   124.16                 0  90
21012   EXCISION, TUMOR, SOFT TISSUE OF FACE OR       203.02   169.18                 0  90
21013   EXCISION, TUMOR, SOFT TISSUE OF FACE AN       296.74   198.90                 0  90
21014   EXCISION, TUMOR, SOFT TISSUE OF FACE AN       312.95   260.80                 0  90
21015   RADICAL RESECTION OF TUMOR (EG, MALIGNAN      244.42   203.69                 0  90
21016   RADICAL RESECTION OF TUMOR (EG, MALIGNAN      625.49   521.24                 0  90
21025   EXCISION OF BONE (EG, FOR OSTEOMYELITIS       560.77   398.60                 0  90
21026   EXCISION OF BONE (EG, FOR OSTEOMYELITIS       332.06   231.19                 0  90
21029   REMOVAL BY CONTOURING OF BENIGN TUMOR OF      422.65   296.84                 0  90
21030   EXCISION OF BENIGN TUMOR OR CYST OF MAXI      276.52   191.47                 0  90
21031   EXCISION OF TORUS MANDIBULARIS                213.64   137.22                 0  90
21032   EXCISION OF MAXILLARY TORUS PALATINUS         217.81   135.16                 0  90
21034   EXCISION OF MALIGNANT TUMOR OF MAXILLA O      756.70   557.98                 0  90
21040   EXCISION OF BENIGN TUMOR OR CYST OF MAND      277.51   187.78                 0  90
                                                                                                   Page 18 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
21044   EXCISION OF MALIGNANT TUMOR OF MANDIBLE;      497.48   414.57                 0  90
21045   EXCISION OF MALIGNANT TUMOR OF MANDIBLE;      689.21   574.34                 0  90
21046   EXCISION OF BENIGN TUMOR OR CYST OF MAND      614.76   512.30                 0  90
21047   EXCISION OF BENIGN TUMOR OR CYST OF MAND      743.59   619.66                 0  90
21048   EXCISION OF BENIGN TUMOR OR CYST OF MAXI      624.65   520.55                 0  90
21049   EXCISION OF BENIGN TUMOR OR CYST OF MAXI      711.98   593.32                 0  90
21050   CONDYLECTOMY, TEMPOROMANDIBULAR JOINT (S      485.77   404.81                 0  90
21060   MENISCECTOMY, PARTIAL OR COMPLETE, TEMPO      448.12   373.43                 0  90
21070   CORONOIDECTOMY (SEPARATE PROCEDURE)           366.74   305.62                 0  90
21073   MANIPULATION OF TEMPOROMANDIBULAR JOINT(                                  BR 0   90
21076   IMPRESSION AND CUSTOM PREPARATION; SURGI                                  BR 0   10
21077   IMPRESSION AND CUSTOM PREPARATION; ORBIT                                  BR 0   90
21079   IMPRESSION AND CUSTOM PREPARATION; INTER                                  BR 0   90
21080   IMPRESSION AND CUSTOM PREPARATION; DEFIN                                  BR 0   90
21081   IMPRESSION AND CUSTOM PREPARATION; MANDI                                  BR 0   90
21082   IMPRESSION AND CUSTOM PREPARATION; PALAT                                  BR 0   90
21083   IMPRESSION AND CUSTOM PREPARATION; PALAT                                  BR 0   90
21084   IMPRESSION AND CUSTOM PREPARATION; SPEEC                                  BR 0   90
21085   IMPRESSION AND CUSTOM PREPARATION; ORAL       399.35   282.34                 0  10
21086   IMPRESSION AND CUSTOM PREPARATION; AURIC                                  BR 0   90
21087   IMPRESSION AND CUSTOM PREPARATION; NASAL                                  BR 0   90
21088   IMPRESSION AND CUSTOM PREPARATION; FACIA      360.70   360.00                 0  90
21089   UNLISTED MAXILLOFACIAL PROSTHETIC PROCED                                  BR 0   90
21100   APPLICATION OF HALO TYPE APPLIANCE FOR M                                  BR 0   90
21110   APPLICATION OF INTERDENTAL FIXATION DEVI      412.94   297.77                 0  90
21116   INJECTION PROCEDURE FOR TEMPOROMANDIBULA      101.97    20.58                 0   0
21120   GENIOPLASTY; AUGMENTATION (AUTOGRAFT, AL      364.28   241.01                 0  90
21121   GENIOPLASTY; SLIDING OSTEOTOMY, SINGLE P      428.12   305.90                 0  90
21122   GENIOPLASTY; SLIDING OSTEOTOMIES, TWO OR      409.40   341.17                 0  90
                                                                                                   Page 19 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
21123   GENIOPLASTY; SLIDING, AUGMENTATION WITH                                   BR 0   90
21125   AUGMENTATION, MANDIBULAR BODY OR ANGLE;     1,703.17   347.67                 0  90
21127   AUGMENTATION, MANDIBULAR BODY OR ANGLE;     1,857.37   410.54                 0  90
21137   REDUCTION FOREHEAD; CONTOURING ONLY                                       BR 0   90
21138   REDUCTION FOREHEAD; CONTOURING AND APPLI      512.21   426.84                 0  90
21139   REDUCTION FOREHEAD; CONTOURING AND SETBA                                  BR 0   90
21141   RECONSTRUCTION MIDFACE, LEFORT I; SINGLE      760.29   633.58                 0  90
21142   RECONSTRUCTION MIDFACE, LEFORT I; TWO PI      743.34   619.45                 0  90
21143   RECONSTRUCTION MIDFACE, LEFORT I; THREE       782.08   651.73                 0  90
21145   RECONSTRUCTION MIDFACE, LEFORT I; SINGLE      877.25   731.04                 0  90
21146   RECONSTRUCTION MIDFACE, LEFORT I; TWO PI      872.13   726.78                 0  90
21147   RECONSTRUCTION MIDFACE, LEFORT I; THREE       936.28   780.24                 0  90
21150   RECONSTRUCTION MIDFACE, LEFORT II; ANTER                                  BR 0   90
21151   RECONSTRUCTION MIDFACE, LEFORT II; ANY D                                  BR 0   90
21154   RECONSTRUCTION MIDFACE, LEFORT III (EXTR    1,194.50   995.42                 0  90
21155   RECONSTRUCTION MIDFACE, LEFORT III (EXTR    1,381.14 1,150.95                 0  90
21159   RECONSTRUCTION MIDFACE, LEFORT III (EXTR                                  BR 0   90
21160   RECONSTRUCTION MIDFACE, LEFORT III (EXTR                                  BR 0   90
21172   RECONSTRUCTION SUPERIOR-LATERAL ORBITAL       991.20   826.00                 0  90
21175   RECONSTRUCTION, BIFRONTAL, SUPERIOR-LATE    1,176.58   980.49                 0  90
21179   RECONSTRUCTION, ENTIRE OR MAJORITY OF FO                                  BR 0   90
21180   RECONSTRUCTION, ENTIRE OR MAJORITY OF FO      947.16   789.30                 0  90
21181   RECONSTRUCTION BY CONTOURING OF BENIGN T      413.25   344.38                 0  90
21182   RECONSTRUCTION OF ORBITAL WALLS, RIMS, F                                  BR 0   90
21183   RECONSTRUCTION OF ORBITAL WALLS, RIMS, F                                  BR 0   90
21184   RECONSTRUCTION OF ORBITAL WALLS, RIMS, F                                  BR 0   90
21188   RECONSTRUCTION MIDFACE, OSTEOTOMIES (OTH      932.00   776.67                 0  90
21193   RECONSTRUCTION OF MANDIBULAR RAMI, HORIZ      707.44   589.54                 0  90
21194   RECONSTRUCTION OF MANDIBULAR RAMI, HORIZ                                  BR 0   90
                                                                                                   Page 20 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
21195   RECONSTRUCTION OF MANDIBULAR RAMI AND/OR                                  BR 0   90
21196   RECONSTRUCTION OF MANDIBULAR RAMI AND/OR      831.13   692.61                 0  90
21198   OSTEOTOMY, MANDIBLE, SEGMENTAL;               650.91   542.43                 0  90
21199   OSTEOTOMY, MANDIBLE, SEGMENTAL; WITH GEN      575.98   479.98                 0  90
21206   OSTEOTOMY, MAXILLA, SEGMENTAL (EG, WASSM      633.08   527.57                 0  90
21208   OSTEOPLASTY, FACIAL BONES; AUGMENTATION       935.26   390.52                 0  90
21209   OSTEOPLASTY, FACIAL BONES; REDUCTION          457.81   304.19                 0  90
21210   GRAFT, BONE; NASAL, MAXILLARY OR MALAR A    1,103.33   392.55                 0  90
21215   GRAFT, BONE; MANDIBLE (INCLUDES OBTAININ    1,853.56   409.41                 0  90
21230   GRAFT; RIB CARTILAGE, AUTOGENOUS, TO FAC      440.00   366.67                 0  90
21235   GRAFT; EAR CARTILAGE, AUTOGENOUS, TO NOS      408.56   280.00                 0  90
21240   ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, W      636.98   530.82                 0  90
21242   ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, W      585.17   487.65                 0  90
21243   ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, W                                  BR 0   90
21244   RECONSTRUCTION OF MANDIBLE, EXTRAORAL, W      591.25   492.71                 0  90
21245   RECONSTRUCTION OF MANDIBLE OR MAXILLA, S      641.70   430.77                 0  90
21246   RECONSTRUCTION OF MANDIBLE OR MAXILLA, S      493.81   411.51                 0  90
21247   RECONSTRUCTION OF MANDIBULAR CONDYLE WIT      924.50   770.42                 0  90
21248   RECONSTRUCTION OF MANDIBLE OR MAXILLA, E      595.33   415.72                 0  90
21249   RECONSTRUCTION OF MANDIBLE OR MAXILLA, E                                  BR 0   90
21255   RECONSTRUCTION OF ZYGOMATIC ARCH AND GLE      795.38   662.82                 0  90
21256   RECONSTRUCTION OF ORBIT WITH OSTEOTOMIES      652.50   600.00                 0  90
21260   PERIORBITAL OSTEOTOMIES FOR ORBITAL HYPE      700.49   600.00                 0  90
21261   PERIORBITAL OSTEOTOMIES FOR ORBITAL HYPE                                  BR 0   90
21263   PERIORBITAL OSTEOTOMIES FOR ORBITAL HYPE    1,093.70   911.42                 0  90
21267   ORBITAL REPOSITIONING, PERIORBITAL OSTEO      896.78   747.32                 0  90
21268   ORBITAL REPOSITIONING, PERIORBITAL OSTEO                                  BR 0   90
21270   MALAR AUGMENTATION, PROSTHETIC MATERIAL       511.57   327.25                 0  90
21275   SECONDARY REVISION OF ORBITOCRANIOFACIAL      455.25   379.38                 0  90
                                                                                                   Page 21 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                      DESCRIPTION                FEE      FEE        FEE      BR PA DAYS   E
21280   MEDIAL CANTHOPEXY (SEPARATE PROCEDURE)        293.06   244.22                 0  90
21282   LATERAL CANTHOPEXY                            196.04   163.37                 0  90
21295   REDUCTION OF MASSETER MUSCLE AND BONE (E                                  BR 0   90
21296   REDUCTION OF MASSETER MUSCLE AND BONE (E                                  BR 0   90
21299   UNLISTED CRANIOFACIAL AND MAXILLOFACIAL                                   BR 0    0
21310   CLOSED TREATMENT OF NASAL BONE FRACTURE        65.61    13.45                 0   0
21315   CLOSED TREATMENT OF NASAL BONE FRACTURE;      149.78    70.47                 0  10
21320   CLOSED TREATMENT OF NASAL BONE FRACTURE;      143.20    65.60                 0  10
21325   OPEN TREATMENT OF NASAL FRACTURE; UNCOMP      281.89   234.91                 0  90
21330   OPEN TREATMENT OF NASAL FRACTURE; COMPLI      341.83   284.86                 0  90
21335   OPEN TREATMENT OF NASAL FRACTURE; WITH C      421.26   351.05                 0  90
21336   OPEN TREATMENT OF NASAL SEPTAL FRACTURE,      371.24   309.37                 0  90
21337   CLOSED TREATMENT OF NASAL SEPTAL FRACTUR      223.91   133.88                 0  90
21338   OPEN TREATMENT OF NASOETHMOID FRACTURE;       451.15   375.96                 0  90
21339   OPEN TREATMENT OF NASOETHMOID FRACTURE;       484.95   404.13                 0  90
21340   PERCUTANEOUS TREATMENT OF NASOETHMOID CO      449.80   374.84                 0  90
21343   OPEN TREATMENT OF DEPRESSED FRONTAL SINU      669.06   557.55                 0  90
21344   OPEN TREATMENT OF COMPLICATED (EG, COMMI      854.69   712.24                 0  90
21345   CLOSED TREATMENT OF NASOMAXILLARY COMPLE      451.94   308.94                 0  90
21346   OPEN TREATMENT OF NASOMAXILLARY COMPLEX       541.04   450.87                 0  90
21347   OPEN TREATMENT OF NASOMAXILLARY COMPLEX       649.58   541.32                 0  90
21348   OPEN TREATMENT OF NASOMAXILLARY COMPLEX       682.45   568.71                 0  90
21355   PERCUTANEOUS TREATMENT OF FRACTURE OF MA      245.09   148.86                 0  10
21356   OPEN TREATMENT OF DEPRESSED ZYGOMATIC AR      279.78   176.75                 0  10
21360   OPEN TREATMENT OF DEPRESSED MALAR FRACTU      299.61   249.68                 0  90
21365   OPEN TREATMENT OF COMPLICATED (EG, COMMI      620.72   517.27                 0  90
21366   OPEN TREATMENT OF COMPLICATED (EG, COMMI      701.24   584.37                 0  90
21385   OPEN TREATMENT OF ORBITAL FLOOR BLOWOUT       404.57   360.00                 0  90
21386   OPEN TREATMENT OF ORBITAL FLOOR BLOWOUT       375.77   360.00                 0  90
                                                                                                   Page 22 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                      DESCRIPTION                FEE      FEE        FEE      BR PA DAYS   E
21387   OPEN TREATMENT OF ORBITAL FLOOR BLOWOUT       430.47   360.00                 0  90
21390   OPEN TREATMENT OF ORBITAL FLOOR BLOWOUT       428.52   360.00                 0  90
21395   OPEN TREATMENT OF ORBITAL FLOOR BLOWOUT       544.45   453.71                 0  90
21400   CLOSED TREATMENT OF FRACTURE OF ORBIT, E       98.27    66.71                 0  90
21401   CLOSED TREATMENT OF FRACTURE OF ORBIT, E      266.38   134.82                 0  90
21406   OPEN TREATMENT OF FRACTURE OF ORBIT, EXC      305.67   254.73                 0  90
21407   OPEN TREATMENT OF FRACTURE OF ORBIT, EXC      360.29   300.24                 0  90
21408   OPEN TREATMENT OF FRACTURE OF ORBIT, EXC      492.03   410.03                 0  90
21421   CLOSED TREATMENT OF PALATAL OR MAXILLARY      403.07   292.01                 0  90
21422   OPEN TREATMENT OF PALATAL OR MAXILLARY F      384.18   340.00                 0  90
21423   OPEN TREATMENT OF PALATAL OR MAXILLARY F      453.04   380.00                 0  90
21431   CLOSED TREATMENT OF CRANIOFACIAL SEPARAT      424.55   353.80                 0  90
21432   OPEN TREATMENT OF CRANIOFACIAL SEPARATIO      379.96   316.64                 0  90
21433   OPEN TREATMENT OF CRANIOFACIAL SEPARATIO      947.32   789.44                 0  90
21435   OPEN TREATMENT OF CRANIOFACIAL SEPARATIO      746.11   621.76                 0  90
21436   OPEN TREATMENT OF CRANIOFACIAL SEPARATIO                                  BR 0   90
21440   CLOSED TREATMENT OF MANDIBULAR OR MAXILL      286.92   202.59                 0  90
21445   OPEN TREATMENT OF MANDIBULAR OR MAXILLAR      412.02   290.03                 0  90
21450   CLOSED TREATMENT OF MANDIBULAR FRACTURE;      300.22   216.34                 0  90
21451   CLOSED TREATMENT OF MANDIBULAR FRACTURE;      400.52   290.09                 0  90
21452   PERCUTANEOUS TREATMENT OF MANDIBULAR FRA      361.51   153.59                 0  90
21453   CLOSED TREATMENT OF MANDIBULAR FRACTURE       461.86   352.47                 0  90
21454   OPEN TREATMENT OF MANDIBULAR FRACTURE WI      312.31   260.26                 0  90
21461   OPEN TREATMENT OF MANDIBULAR FRACTURE; W    1,021.81   433.93                 0  90
21462   OPEN TREATMENT OF MANDIBULAR FRACTURE; W    1,117.49   474.90                 0  90
21465   OPEN TREATMENT OF MANDIBULAR CONDYLAR FR      517.24   431.03                 0  90
21470   OPEN TREATMENT OF COMPLICATED MANDIBULAR      669.20   557.67                 0  90
21480   CLOSED TREATMENT OF TEMPOROMANDIBULAR DI       54.47    20.00                 0   0
21485   CLOSED TREATMENT OF TEMPOROMANDIBULAR DI                                  BR 0   90
                                                                                                   Page 23 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                         DESCRIPTION             FEE      FEE        FEE      BR PA DAYS   E
21490   OPEN TREATMENT OF TEMPOROMANDIBULAR DISL      522.84   435.70                 0  90
21495   OPEN TREATMENT OF HYOID FRACTURE                                          BR 0   90
21497   INTERDENTAL WIRING, FOR CONDITION OTHER                                   BR 0   90
21499   UNLISTED MUSCULOSKELETAL PROCEDURE, HEAD                                  BR 0    0
21501   INCISION AND DRAINAGE, DEEP ABSCESS OR H      248.41   149.17                 0  90
21502   INCISION AND DRAINAGE, DEEP ABSCESS OR H      298.85   249.05                 0  90
21510   INCISION, DEEP, WITH OPENING OF BONE COR      270.68   225.57                 0  90
21550   BIOPSY, SOFT TISSUE OF NECK OR THORAX         143.71    74.23                 0  10
21552   EXCISION, TUMOR, SOFT TISSUE OF NECK OR       269.20   224.34                 0  90
21554   EXCISION, TUMOR, SOFT TISSUE OF NECK OR       441.14   367.62                 0  90
21555   EXCISION TUMOR, SOFT TISSUE OF NECK OR A      241.31   153.10                 0  90
21556   EXCISION TUMOR, SOFT TISSUE OF NECK OR A      230.93   192.45                 0  90
21557   RADICAL RESECTION OF TUMOR (EG, MALIGNAN      327.74   273.12                 0  90
21558   RADICAL RESECTION OF TUMOR (EG, MALIGNAN      826.64   688.87                 0  90
21600   EXCISION OF RIB, PARTIAL                      311.97   259.98                 0  90
21610   COSTOTRANSVERSECTOMY (SEPARATE PROCEDURE      609.62   508.02                 0  90
21615   EXCISION FIRST AND/OR CERVICAL RIB;           388.93   324.11                 0  90
21616   EXCISION FIRST AND/OR CERVICAL RIB; WITH      476.75   420.00                 0  90
21620   OSTECTOMY OF STERNUM, PARTIAL                 300.40   250.33                 0  90
21627   STERNAL DEBRIDEMENT                           315.31   262.76                 0  90
21630   RADICAL RESECTION OF STERNUM;                 719.27   599.40                 0  90
21632   RADICAL RESECTION OF STERNUM; WITH MEDIA      710.62   592.18                 0  90
21685   HYOID MYOTOMY AND SUSPENSION                  558.21   465.18                 0  90
21700   DIVISION OF SCALENUS ANTICUS; WITHOUT RE      243.19   202.66                 0  90
21705   DIVISION OF SCALENUS ANTICUS; WITH RESEC      355.12   295.93                 0  90
21720   DIVISION OF STERNOCLEIDOMASTOID FOR TORT      218.20   181.84                 0  90
21725   DIVISION OF STERNOCLEIDOMASTOID FOR TORT      302.45   252.04                 0  90
21740   RECONSTRUCTIVE REPAIR OF PECTUS EXCAVATU      615.38   512.82                 0  90
21742   RECONSTRUCTIVE REPAIR OF PECTUS EXCAVATU                                  BR 0   90
                                                                                                   Page 24 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
21743   RECONSTRUCTIVE REPAIR OF PECTUS EXCAVATU                                  BR 0   90
21750   CLOSURE OF MEDIAN STERNOTOMY SEPARATION       408.89   340.74                 0  90
21800   CLOSED TREATMENT OF RIB FRACTURE, UNCOMP       55.18    46.60                 0  90
21805   OPEN TREATMENT OF RIB FRACTURE WITHOUT F                                  BR 0   90
21810   TREATMENT OF RIB FRACTURE REQUIRING EXTE                                  BR 0   90
21820   CLOSED TREATMENT OF STERNUM FRACTURE           75.28    62.74                 0  90
21825   OPEN TREATMENT OF STERNUM FRACTURE WITH       326.08   271.73                 0  90
21899   UNLISTED PROCEDURE, NECK OR THORAX                                        BR 0    0
21920   BIOPSY, SOFT TISSUE OF BACK OR FLANK; SU      140.55    72.42                 0  10
21925   BIOPSY, SOFT TISSUE OF BACK OR FLANK; DE      235.63   156.16                 0  90
21930   EXCISION, TUMOR, SOFT TISSUE OF BACK OR       262.89   172.11                 0  90
21931   EXCISION, TUMOR, SOFT TISSUE OF BACK OR       281.41   234.51                 0  90
21932   EXCISION, TUMOR, SOFT TISSUE OF BACK OR       403.99   336.66                 0  90
21933   EXCISION, TUMOR, SOFT TISSUE OF BACK OR       444.70   370.59                 0  90
21935   RADICAL RESECTION OF TUMOR (EG, MALIGNAN      653.36   544.47                 0  90
21936   RADICAL RESECTION OF TUMOR (EG, MALIGNAN      859.48   716.23                 0  90
22010   INCISION AND DRAINAGE, OPEN, OF DEEP ABS      507.76   423.13                 0  90
22015   INCISION AND DRAINAGE, OPEN, OF DEEP ABS      504.25   420.21                 0  90
22100   PARTIAL EXCISION OF POSTERIOR VERTEBRAL       462.13   385.11                 0  90
22101   PARTIAL EXCISION OF POSTERIOR VERTEBRAL       460.31   383.60                 0  90
22102   PARTIAL EXCISION OF POSTERIOR VERTEBRAL       461.61   384.68                 0  90
22103   PARTIAL EXCISION OF POSTERIOR VERTEBRAL        83.46    69.55                 0   0
22110   PARTIAL EXCISION OF VERTEBRAL BODY, FOR       568.96   474.14                 0  90
22112   PARTIAL EXCISION OF VERTEBRAL BODY, FOR       565.21   471.01                 0  90
22114   PARTIAL EXCISION OF VERTEBRAL BODY, FOR       567.19   472.66                 0  90
22116   PARTIAL EXCISION OF VERTEBRAL BODY, FOR        83.86    69.88                 0   0
22206   OSTEOTOMY OF SPINE, POSTERIOR OR POSTERO    1,331.26 1,109.39                 0  90
22207   OSTEOTOMY OF SPINE, POSTERIOR OR POSTERO    1,314.52 1,095.44                 0  90
22208   OSTEOTOMY OF SPINE, POSTERIOR OR POSTERO      335.50   279.58                 0   0
                                                                                                   Page 25 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
22210   OSTEOTOMY OF SPINE, POSTERIOR OR POSTERO    1,004.38   836.99                 0  90
22212   OSTEOTOMY OF SPINE, POSTERIOR OR POSTERO      827.71   689.76                 0  90
22214   OSTEOTOMY OF SPINE, POSTERIOR OR POSTERO      836.26   696.89                 0  90
22216   OSTEOTOMY OF SPINE, POSTERIOR OR POSTERO      219.21   182.68                 0   0
22220   OSTEOTOMY OF SPINE, INCLUDING DISKECTOMY      909.35   757.80                 0  90
22222   OSTEOTOMY OF SPINE, INCLUDING DISKECTOMY      824.57   687.15                 0  90
22224   OSTEOTOMY OF SPINE, INCLUDING DISKECTOMY      894.10   745.08                 0  90
22226   OSTEOTOMY OF SPINE, INCLUDING DISKECTOMY      218.23   181.86                 0   0
22305   CLOSED TREATMENT OF VERTEBRAL PROCESS FR      106.05    80.79                 0  90
22310   CLOSED TREATMENT OF VERTEBRAL BODY FRACT      157.91   121.96                 0  90
22315   CLOSED TREATMENT OF VERTEBRAL FRACTURE(S      485.02   354.97                 0  90
22318   OPEN TREATMENT AND/OR REDUCTION OF ODONT      907.10   755.92                 0  90
22319   OPEN TREATMENT AND/OR REDUCTION OF ODONT                                  BR 0   90
22325   OPEN TREATMENT AND/OR REDUCTION OF VERTE      785.87   654.89                 0  90
22326   OPEN TREATMENT AND/OR REDUCTION OF VERTE      825.23   687.70                 0  90
22327   OPEN TREATMENT AND/OR REDUCTION OF VERTE      812.55   677.13                 0  90
22328   OPEN TREATMENT AND/OR REDUCTION OF VERTE      164.43   137.03                 0   0
22505   MANIPULATION OF SPINE REQUIRING ANESTHES       71.42    59.52                 0  10
22520   PERCUTANEOUS VERTEBROPLASTY (BONE BIOPSY    1,524.64   287.49                 0  10
22521   PERCUTANEOUS VERTEBROPLASTY (BONE BIOPSY    1,454.50   271.50                 0  10
22522   PERCUTANEOUS VERTEBROPLASTY (BONE BIOPSY      145.37   121.15                 0   0
22523   PERCUTANEOUS VERTEBRAL AUGMENTATION, INC      356.76   297.30                 0  10
22524   PERCUTANEOUS VERTEBRAL AUGMENTATION, INC      341.53   284.61                 0  10
22525   PERCUTANEOUS VERTEBRAL AUGMENTATION, INC      158.45   132.04                 0   0
22526   PERCUTANEOUS INTRADISCAL ELECTROTHERMAL     1,300.14   167.07                 0  10
22527   PERCUTANEOUS INTRADISCAL ELECTROTHERMAL     1,069.22    76.77                 0   0
22532   ARTHRODESIS, LATERAL EXTRACAVITARY TECHN      976.61   813.85                 0  90
22533   ARTHRODESIS, LATERAL EXTRACAVITARY TECHN      907.60   756.34                 0  90
22534   ARTHRODESIS, LATERAL EXTRACAVITARY TECHN      215.66   179.72                 0   0
                                                                                                   Page 26 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
22548   ARTHRODESIS, ANTERIOR TRANSORAL OR EXTRA    1,052.57   877.15                 0  90
22551   ARTHRODESIS, ANTERIOR INTERBODY, INCLUDI      803.78   669.82                 0  90
22552   ARTHRODESIS, ANTERIOR INTERBODY, INCLUDI      186.62   155.52                 0   0
22554   ARTHRODESIS, ANTERIOR INTERBODY TECHNIQU      741.23   617.70                 0  90
22556   ARTHRODESIS, ANTERIOR INTERBODY TECHNIQU      938.41   782.01                 0  90
22558   ARTHRODESIS, ANTERIOR INTERBODY TECHNIQU      851.39   709.49                 0  90
22585   ARTHRODESIS, ANTERIOR INTERBODY TECHNIQU      200.50   167.09                 0   0
22590   ARTHRODESIS, POSTERIOR TECHNIQUE, CRANIO      872.76   727.30                 0  90
22595   ARTHRODESIS, POSTERIOR TECHNIQUE, ATLAS-      829.96   691.64                 0  90
22600   ARTHRODESIS, POSTERIOR OR POSTEROLATERAL      710.50   592.09                 0  90
22610   ARTHRODESIS, POSTERIOR OR POSTEROLATERAL      701.49   584.58                 0  90
22612   ARTHRODESIS, POSTERIOR OR POSTEROLATERAL      906.34   755.29                 0  90
22614   ARTHRODESIS, POSTERIOR OR POSTEROLATERAL      233.53   194.61                 0   0
22630   ARTHRODESIS, POSTERIOR INTERBODY TECHNIQ      874.93   729.11                 0  90
22632   ARTHRODESIS, POSTERIOR INTERBODY TECHNIQ      190.00   158.33                 0   0
22633   ARTHRODESIS, COMBINED POSTERIOR OR POST       842.84   702.37                 0  90    *
22634   ARTHRODESIS, COMBINED POSTERIOR OR POST       226.86   189.05                 0   0    *
22800   ARTHRODESIS, POSTERIOR, FOR SPINAL DEFOR      772.99   644.16                 0  90
22802   ARTHRODESIS, POSTERIOR, FOR SPINAL DEFOR    1,227.83 1,023.19                 0  90
22804   ARTHRODESIS, POSTERIOR, FOR SPINAL DEFOR    1,421.02 1,184.19                 0  90
22808   ARTHRODESIS, ANTERIOR, FOR SPINAL DEFORM    1,041.89   868.24                 0  90
22810   ARTHRODESIS, ANTERIOR, FOR SPINAL DEFORM    1,163.85   969.88                 0  90
22812   ARTHRODESIS, ANTERIOR, FOR SPINAL DEFORM    1,273.81 1,061.51                 0  90
22818   KYPHECTOMY, CIRCUMFERENTIAL EXPOSURE OF     1,279.68 1,066.40                 0  90
22819   KYPHECTOMY, CIRCUMFERENTIAL EXPOSURE OF     1,450.93 1,209.11                 0  90
22830   EXPLORATION OF SPINAL FUSION                  463.59   386.33                 0  90
22840   POSTERIOR NON-SEGMENTAL INSTRUMENTATION       457.07   380.90                 0   0
22842   POSTERIOR SEGMENTAL INSTRUMENTATION (EG,      457.12   380.93                 0   0
22843   POSTERIOR SEGMENTAL INSTRUMENTATION (EG,      483.32   402.77                 0   0
                                                                                                   Page 27 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
22844   POSTERIOR SEGMENTAL INSTRUMENTATION (EG,      593.29   494.41                 0   0
22845   ANTERIOR INSTRUMENTATION; 2 TO 3 VERTEBR      437.74   364.78                 0   0
22846   ANTERIOR INSTRUMENTATION; 4 TO 7 VERTEBR      454.90   379.08                 0   0
22847   ANTERIOR INSTRUMENTATION; 8 OR MORE VERT      498.85   415.71                 0   0
22848   PELVIC FIXATION (ATTACHMENT OF CAUDAL EN      215.88   179.90                 0   0
22849   REINSERTION OF SPINAL FIXATION DEVICE         746.40   622.00                 0  90
22850   REMOVAL OF POSTERIOR NONSEGMENTAL INSTRU      409.76   341.47                 0  90
22851   APPLICATION OF INTERVERTEBRAL BIOMECHANI      242.79   202.33                 0   0
22852   REMOVAL OF POSTERIOR SEGMENTAL INSTRUMEN      391.96   326.64                 0  90
22855   REMOVAL OF ANTERIOR INSTRUMENTATION           633.02   527.52                 0  90
22856   TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC      942.07   785.06                 0  90
22857   TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC      994.13   828.44                 0  90
22861   REVISION INCLUDING REPLACEMENT OF TOTAL     1,141.95   951.63                 0  90
22862   REVISION INCLUDING REPLACEMENT OF TOTAL     1,178.21   981.84                 0  90
22864   REMOVAL OF TOTAL DISC ARTHROPLASTY (ARTI    1,051.86   876.55                 0  90
22865   REMOVAL OF TOTAL DISC ARTHROPLASTY (ARTI    1,147.48   956.23                 0  90
22899   UNLISTED PROCEDURE, SPINE                                                 BR 0    0
22900   EXCISION, TUMOR, SOFT TISSUE OF ABDOMINA      225.62   188.02                 0  90
22901   EXCISION, TUMOR, SOFT TISSUE OF ABDOMINA      396.77   330.65                 0  90
22902   EXCISION, TUMOR, SOFT TISSUE OF ABDOMINA      255.40   168.73                 0  90
22903   EXCISION, TUMOR, SOFT TISSUE OF ABDOMINA      263.55   219.63                 0  90
22904   RADICAL RESECTION OF TUMOR (EG, MALIGNAN      619.02   515.85                 0  90
22905   RADICAL RESECTION OF TUMOR (EG, MALIGNAN      802.91   669.10                 0  90
22999   UNLISTED PROCEDURE, ABDOMEN, MUSCULOSKEL                                  BR 0    0
23000   REMOVAL OF SUBDELTOID CALCAREOUS DEPOSIT      307.01   171.14                 0  90
23020   CAPSULAR CONTRACTURE RELEASE (EG, SEVER       395.99   329.99                 0  90
23030   INCISION AND DRAINAGE, SHOULDER AREA; DE      251.36   123.53                 0  10
23031   INCISION AND DRAINAGE, SHOULDER AREA; IN      243.60   106.20                 0  10
23035   INCISION, BONE CORTEX (EG, OSTEOMYELITIS      398.62   332.18                 0  90
                                                                                                   Page 28 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
23040   ARTHROTOMY, GLENOHUMERAL JOINT, INCLUDIN      412.36   343.63                 0  90
23044   ARTHROTOMY, ACROMIOCLAVICULAR, STERNOCLA      327.74   273.12                 0  90
23065   BIOPSY, SOFT TISSUE OF SHOULDER AREA; SU      118.01    77.02                 0  10
23066   BIOPSY, SOFT TISSUE OF SHOULDER AREA; DE      290.12   161.37                 0  90
23071   EXCISION, TUMOR, SOFT TISSUE OF SHOULDER      250.45   208.71                 0  90
23073   EXCISION, TUMOR, SOFT TISSUE OF SHOULDER      414.17   345.14                 0  90
23075   EXCISION, TUMOR, SOFT TISSUE OF SHOULDER      147.34    83.20                 0  90
23076   EXCISION, TUMOR, SOFT TISSUE OF SHOULDER      317.77   264.81                 0  90
23077   RADICAL RESECTION OF TUMOR (EG, MALIGNAN      665.62   554.68                 0  90
23078   RADICAL RESECTION OF TUMOR (EG, MALIGNAN      835.27   696.06                 0  90
23100   ARTHROTOMY, GLENOHUMERAL JOINT, INCLUDIN      278.75   232.29                 0  90
23101   ARTHROTOMY, ACROMIOCLAVICULAR JOINT OR S      258.08   215.07                 0  90
23105   ARTHROTOMY; GLENOHUMERAL JOINT, WITH SYN      365.13   304.28                 0  90
23106   ARTHROTOMY; STERNOCLAVICULAR JOINT, WITH      280.00   280.00                 0  90
23107   ARTHROTOMY, GLENOHUMERAL JOINT, WITH JOI      380.23   316.86                 0  90
23120   CLAVICULECTOMY; PARTIAL                       322.17   268.48                 0  90
23125   CLAVICULECTOMY; TOTAL                         402.37   335.31                 0  90
23130   ACROMIOPLASTY OR ACROMIONECTOMY, PARTIAL      347.60   289.67                 0  90
23140   EXCISION OR CURETTAGE OF BONE CYST OR BE      292.01   243.35                 0  90
23145   EXCISION OR CURETTAGE OF BONE CYST OR BE      394.33   328.61                 0  90
23146   EXCISION OR CURETTAGE OF BONE CYST OR BE      353.23   294.36                 0  90
23150   EXCISION OR CURETTAGE OF BONE CYST OR BE      371.20   309.33                 0  90
23155   EXCISION OR CURETTAGE OF BONE CYST OR BE      451.13   375.94                 0  90
23156   EXCISION OR CURETTAGE OF BONE CYST OR BE      385.57   321.31                 0  90
23170   SEQUESTRECTOMY (EG, FOR OSTEOMYELITIS OR      305.60   254.67                 0  90
23172   SEQUESTRECTOMY (EG, FOR OSTEOMYELITIS OR      314.81   262.34                 0  90
23174   SEQUESTRECTOMY (EG, FOR OSTEOMYELITIS OR      430.36   358.64                 0  90
23180   PARTIAL EXCISION (CRATERIZATION, SAUCERI      403.29   336.08                 0  90
23182   PARTIAL EXCISION (CRATERIZATION, SAUCERI      387.98   323.32                 0  90
                                                                                                   Page 29 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
23184   PARTIAL EXCISION (CRATERIZATION, SAUCERI      435.51   362.93                 0  90
23190   OSTECTOMY OF SCAPULA, PARTIAL (EG, SUPER      317.71   264.76                 0  90
23195   RESECTION, HUMERAL HEAD                       427.83   400.00                 0  90
23200   RADICAL RESECTION FOR TUMOR; CLAVICLE         497.34   414.45                 0  90
23210   RADICAL RESECTION FOR TUMOR; SCAPULA          521.15   434.30                 0  90
23220   RADICAL RESECTION OF TUMOR, PROXIMAL HUM      615.32   512.77                 0  90
23330   REMOVAL OF FOREIGN BODY, SHOULDER; SUBCU      130.26    71.22                 0  10
23331   REMOVAL OF FOREIGN BODY, SHOULDER; DEEP       337.24   281.04                 0  90
23332   REMOVAL OF FOREIGN BODY, SHOULDER; COMPL                                  BR 0   90
23350   INJECTION PROCEDURE FOR SHOULDER ARTHROG       98.03    25.09                 0   0
23395   MUSCLE TRANSFER, ANY TYPE, SHOULDER OR U      735.67   613.06                 0  90
23397   MUSCLE TRANSFER, ANY TYPE, SHOULDER OR U      658.48   548.73                 0  90
23400   SCAPULOPEXY (EG, SPRENGELS DEFORMITY OR       560.95   467.46                 0  90
23405   TENOTOMY, SHOULDER AREA; SINGLE TENDON        362.52   302.10                 0  90
23406   TENOTOMY, SHOULDER AREA; MULTIPLE TENDON      452.47   377.06                 0  90
23410   REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF      518.08   431.74                 0  90
23412   REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF      550.81   459.01                 0  90
23415   CORACOACROMIAL LIGAMENT RELEASE, WITH OR      424.51   353.76                 0  90
23420   RECONSTRUCTION OF COMPLETE SHOULDER (ROT      606.13   505.11                 0  90
23430   TENODESIS OF LONG TENDON OF BICEPS            427.27   356.06                 0  90
23440   RESECTION OR TRANSPLANTATION OF LONG TEN      440.99   367.50                 0  90
23450   CAPSULORRHAPHY, ANTERIOR; PUTTI-PLATT PR      551.48   459.57                 0  90
23455   CAPSULORRHAPHY, ANTERIOR; WITH LABRAL RE      586.81   489.01                 0  90
23460   CAPSULORRHAPHY, ANTERIOR, ANY TYPE; WITH      635.21   529.34                 0  90
23462   CAPSULORRHAPHY, ANTERIOR, ANY TYPE; WITH      620.94   517.45                 0  90
23465   CAPSULORRHAPHY, GLENOHUMERAL JOINT, POST      646.45   538.71                 0  90
23466   CAPSULORRHAPHY, GLENOHUMERAL JOINT, ANY       635.81   529.85                 0  90
23470   ARTHROPLASTY, GLENOHUMERAL JOINT; HEMIAR      704.75   587.30                 0  90
23472   ARTHROPLASTY, GLENOHUMERAL JOINT; TOTAL       867.86   723.22                 0  90
                                                                                                   Page 30 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                      DESCRIPTION                FEE      FEE        FEE      BR PA DAYS   E
23480   OSTEOTOMY, CLAVICLE, WITH OR WITHOUT INT      474.79   395.66                 0  90
23485   OSTEOTOMY, CLAVICLE, WITH OR WITHOUT INT      556.61   463.85                 0  90
23490   PROPHYLACTIC TREATMENT (NAILING, PINNING      468.89   390.75                 0  90
23491   PROPHYLACTIC TREATMENT (NAILING, PINNING      588.53   490.45                 0  90
23500   CLOSED TREATMENT OF CLAVICULAR FRACTURE;      118.23    95.66                 0  90
23505   CLOSED TREATMENT OF CLAVICULAR FRACTURE;      193.55   151.45                 0  90
23515   OPEN TREATMENT OF CLAVICULAR FRACTURE, I      390.04   325.03                 0  90
23520   CLOSED TREATMENT OF STERNOCLAVICULAR DIS      121.98   101.24                 0  90
23525   CLOSED TREATMENT OF STERNOCLAVICULAR DIS      192.24   148.72                 0  90
23530   OPEN TREATMENT OF STERNOCLAVICULAR DISLO      315.66   263.05                 0  90
23532   OPEN TREATMENT OF STERNOCLAVICULAR DISLO      355.96   296.64                 0  90
23540   CLOSED TREATMENT OF ACROMIOCLAVICULAR DI      121.27    96.54                 0  90
23545   CLOSED TREATMENT OF ACROMIOCLAVICULAR DI      173.23   130.83                 0  90
23550   OPEN TREATMENT OF ACROMIOCLAVICULAR DISL      327.47   272.89                 0  90
23552   OPEN TREATMENT OF ACROMIOCLAVICULAR DISL      377.41   314.51                 0  90
23570   CLOSED TREATMENT OF SCAPULAR FRACTURE; W      126.04   105.24                 0  90
23575   CLOSED TREATMENT OF SCAPULAR FRACTURE; W      214.03   167.28                 0  90
23585   OPEN TREATMENT OF SCAPULAR FRACTURE (BOD      520.56   433.80                 0  90
23600   CLOSED TREATMENT OF PROXIMAL HUMERAL (SU      178.03   133.80                 0  90
23605   CLOSED TREATMENT OF PROXIMAL HUMERAL (SU      261.68   199.20                 0  90
23615   OPEN TREATMENT OF PROXIMAL HUMERAL (SURG      491.61   409.68                 0  90
23616   OPEN TREATMENT OF PROXIMAL HUMERAL (SURG      757.06   630.88                 0  90
23620   CLOSED TREATMENT OF GREATER HUMERAL TUBE      145.66   112.36                 0  90
23625   CLOSED TREATMENT OF GREATER HUMERAL TUBE      211.81   164.41                 0  90
23630   OPEN TREATMENT OF GREATER HUMERAL TUBERO      412.84   344.03                 0  90
23650   CLOSED TREATMENT OF SHOULDER DISLOCATION      163.83   121.35                 0  90
23655   CLOSED TREATMENT OF SHOULDER DISLOCATION      212.66   177.22                 0  90
23660   OPEN TREATMENT OF ACUTE SHOULDER DISLOCA      331.73   276.44                 0  90
23665   CLOSED TREATMENT OF SHOULDER DISLOCATION      233.91   182.62                 0  90
                                                                                                   Page 31 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                         DESCRIPTION             FEE      FEE        FEE      BR PA DAYS   E
23670   OPEN TREATMENT OF SHOULDER DISLOCATION,       459.43   382.86                 0  90
23675   CLOSED TREATMENT OF SHOULDER DISLOCATION      307.30   235.78                 0  90
23680   OPEN TREATMENT OF SHOULDER DISLOCATION,       505.70   421.42                 0  90
23700   MANIPULATION UNDER ANESTHESIA, SHOULDER       112.00    93.33                 0  10
23800   ARTHRODESIS, GLENOHUMERAL JOINT;                                          BR 0   90
23802   ARTHRODESIS, GLENOHUMERAL JOINT; WITH AU      694.98   579.15                 0  90
23900   INTERTHORACOSCAPULAR AMPUTATION (FOREQUA      763.76   636.47                 0  90
23920   DISARTICULATION OF SHOULDER;                  618.46   515.38                 0  90
23921   DISARTICULATION OF SHOULDER; SECONDARY C      254.31   211.93                 0  90
23929   UNLISTED PROCEDURE, SHOULDER                                              BR 0    0
23930   INCISION AND DRAINAGE, UPPER ARM OR ELBO      209.20   102.55                 0  10
23931   INCISION AND DRAINAGE, UPPER ARM OR ELBO      169.64    76.15                 0  10
23935   INCISION, DEEP, WITH OPENING OF BONE COR      287.11   239.26                 0  90
24000   ARTHROTOMY, ELBOW, INCLUDING EXPLORATION      268.93   224.11                 0  90
24006   ARTHROTOMY OF THE ELBOW, WITH CAPSULAR E      406.67   338.90                 0  90
24065   BIOPSY, SOFT TISSUE OF UPPER ARM OR ELBO      137.26    76.44                 0  10
24066   BIOPSY, SOFT TISSUE OF UPPER ARM OR ELBO      337.16   187.04                 0  90
24071   EXCISION, TUMOR, SOFT TISSUE OF UPPER AR      243.08   202.57                 0  90
24073   EXCISION, TUMOR, SOFT TISSUE OF UPPER AR      416.61   347.18                 0  90
24075   EXCISION, TUMOR, SOFT TISSUE OF UPPER AR      272.38   146.18                 0  90
24076   EXCISION, TUMOR, SOFT TISSUE OF UPPER AR      267.27   222.73                 0  90
24077   RADICAL RESECTION OF TUMOR (EG, MALIGNAN      462.30   385.25                 0  90
24079   RADICAL RESECTION OF TUMOR (EG, MALIGNAN      770.56   642.13                 0  90
24100   ARTHROTOMY, ELBOW; WITH SYNOVIAL BIOPSY       226.90   200.00                 0  90
24101   ARTHROTOMY, ELBOW; WITH JOINT EXPLORATIO      284.54   237.12                 0  90
24102   ARTHROTOMY, ELBOW; WITH SYNOVECTOMY           352.29   293.58                 0  90
24105   EXCISION, OLECRANON BURSA                     192.16   160.14                 0  90
24110   EXCISION OR CURETTAGE OF BONE CYST OR BE      332.60   277.17                 0  90
24115   EXCISION OR CURETTAGE OF BONE CYST OR BE      383.90   319.92                 0  90
                                                                                                     Page 32 of 189


                                                                                                 C
                                                       NON-                                      H
                                                                                                 A
                                                     FACILITY FACILITY PROFESSIONAL              N
                                                     GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION                FEE      FEE        FEE      BR PA DAYS   E
24116   EXCISION OR CURETTAGE OF BONE CYST OR BE        499.54   416.28                 0  90
24120   EXCISION OR CURETTAGE OF BONE CYST OR BE        298.25   248.55                 0  90
24125   EXCISION OR CURETTAGE OF BONE CYST OR BE        337.04   280.87                 0  90
24126   EXCISION OR CURETTAGE OF BONE CYST OR BE        360.08   300.07                 0  90
24130   EXCISION, RADIAL HEAD                           289.54   241.28                 0  90
24134   SEQUESTRECTOMY (EG, FOR OSTEOMYELITIS OR        436.78   363.99                 0  90
24136   SEQUESTRECTOMY (EG, FOR OSTEOMYELITIS OR        360.13   300.11                 0  90
24138   SEQUESTRECTOMY (EG, FOR OSTEOMYELITIS OR        375.91   313.26                 0  90
24140   PARTIAL EXCISION (CRATERIZATION, SAUCERI        419.21   349.34                 0  90
24145   PARTIAL EXCISION (CRATERIZATION, SAUCERI        353.78   294.82                 0  90
24147   PARTIAL EXCISION (CRATERIZATION, SAUCERI        369.19   307.66                 0  90
24149   RADICAL RESECTION OF CAPSULE, SOFT TISSU        653.32   544.43                 0  90
24150   RADICAL RESECTION OF TUMOR, SHAFT OR DIS        559.46   466.22                 0  90
24152   RADICAL RESECTION OF TUMOR, RADIAL HEAD OR      413.31   365.00                 0  90
24155   RESECTION OF ELBOW JOINT (ARTHRECTOMY)          482.27   401.89                 0  90
24160   IMPLANT REMOVAL; ELBOW JOINT                    346.78   288.99                 0  90
24164   IMPLANT REMOVAL; RADIAL HEAD                    283.87   236.56                 0  90
24200   REMOVAL OF FOREIGN BODY, UPPER ARM OR EL        116.68    64.62                 0  10
24201   REMOVAL OF FOREIGN BODY, UPPER ARM OR EL        327.08   172.89                 0  90
24220   INJECTION PROCEDURE FOR ELBOW ARTHROGRAP        105.97    32.94                 0   0
24300   MANIPULATION, ELBOW, UNDER ANESTHESIA           227.27   189.40                 0  90
24301   MUSCLE OR TENDON TRANSFER, ANY TYPE, UPP        431.37   359.48                 0  90
24305   TENDON LENGTHENING, UPPER ARM OR ELBOW,         331.35   276.13                 0  90
24310   TENOTOMY, OPEN, ELBOW TO SHOULDER, EACH         271.61   226.34                 0  90
24320   TENOPLASTY, WITH MUSCLE TRANSFER, WITH O        437.47   364.56                 0  90
24330   FLEXOR-PLASTY, ELBOW (EG, STEINDLER TYPE        412.05   343.38                 0  90
24331   FLEXOR-PLASTY, ELBOW (EG, STEINDLER TYPE        453.51   377.93                 0  90
24332   TENOLYSIS, TRICEPS                              342.41   285.35                 0  90
24340   TENODESIS OF BICEPS TENDON AT ELBOW (SEP        352.22   293.52                 0  90
                                                                                                   Page 33 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
24341   REPAIR, TENDON OR MUSCLE, UPPER ARM OR E      409.18   340.98                 0  90
24342   REINSERTION OF RUPTURED BICEPS OR TRICEP      452.72   377.27                 0  90
24343   REPAIR LATERAL COLLATERAL LIGAMENT, ELBO      401.96   334.97                 0  90
24344   RECONSTRUCTION LATERAL COLLATERAL LIGAME      622.98   519.15                 0  90
24345   REPAIR MEDIAL COLLATERAL LIGAMENT, ELBOW      399.97   333.31                 0  90
24346   RECONSTRUCTION MEDIAL COLLATERAL LIGAMEN      621.07   517.56                 0  90
24357   TENOTOMY, ELBOW, LATERAL OR MEDIAL (EG,       254.74   212.29                 0  90
24358   TENOTOMY, ELBOW, LATERAL OR MEDIAL (EG,       298.54   248.78                 0  90
24359   TENOTOMY, ELBOW, LATERAL OR MEDIAL (EG,       365.01   304.18                 0  90
24360   ARTHROPLASTY, ELBOW; WITH MEMBRANE (EG,       515.00   429.17                 0  90
24361   ARTHROPLASTY, ELBOW; WITH DISTAL HUMERAL      578.47   482.06                 0  90
24362   ARTHROPLASTY, ELBOW; WITH IMPLANT AND FA      562.63   468.86                 0  90
24363   ARTHROPLASTY, ELBOW; WITH DISTAL HUMERUS      845.14   704.29                 0  90
24365   ARTHROPLASTY, RADIAL HEAD;                    367.42   320.00                 0  90
24366   ARTHROPLASTY, RADIAL HEAD; WITH IMPLANT       393.56   327.97                 0  90
24400   OSTEOTOMY, HUMERUS, WITH OR WITHOUT INTE      472.93   394.11                 0  90
24410   MULTIPLE OSTEOTOMIES WITH REALIGNMENT ON      603.83   503.20                 0  90
24420   OSTEOPLASTY, HUMERUS (EG, SHORTENING OR       560.66   467.22                 0  90
24430   REPAIR OF NONUNION OR MALUNION, HUMERUS;      590.93   492.44                 0  90
24435   REPAIR OF NONUNION OR MALUNION, HUMERUS;      606.73   600.00                 0  90
24470   HEMIEPIPHYSEAL ARREST (EG, CUBITUS VARUS      377.72   314.77                 0  90
24495   DECOMPRESSION FASCIOTOMY, FOREARM, WITH       382.45   318.71                 0  90
24498   PROPHYLACTIC TREATMENT (NAILING, PINNING      503.14   419.28                 0  90
24500   CLOSED TREATMENT OF HUMERAL SHAFT FRACTU      192.88   142.27                 0  90
24505   CLOSED TREATMENT OF HUMERAL SHAFT FRACTU      280.13   211.30                 0  90
24515   OPEN TREATMENT OF HUMERAL SHAFT FRACTURE      504.45   420.38                 0  90
24516   TREATMENT OF HUMERAL SHAFT FRACTURE, WIT      498.17   415.14                 0  90
24530   CLOSED TREATMENT OF SUPRACONDYLAR OR TRA      207.89   153.76                 0  90
24535   CLOSED TREATMENT OF SUPRACONDYLAR OR TRA      348.95   268.44                 0  90
                                                                                                   Page 34 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                      DESCRIPTION                FEE      FEE        FEE      BR PA DAYS   E
24538   PERCUTANEOUS SKELETAL FIXATION OF SUPRAC      429.01   357.51                 0  90
24545   OPEN TREATMENT OF HUMERAL SUPRACONDYLAR       512.20   426.83                 0  90
24546   OPEN TREATMENT OF HUMERAL SUPRACONDYLAR       613.63   511.36                 0  90
24560   CLOSED TREATMENT OF HUMERAL EPICONDYLAR       174.34   124.98                 0  90
24565   CLOSED TREATMENT OF HUMERAL EPICONDYLAR       290.62   221.88                 0  90
24566   PERCUTANEOUS SKELETAL FIXATION OF HUMERA      394.04   328.37                 0  90
24575   OPEN TREATMENT OF HUMERAL EPICONDYLAR FR      425.69   354.74                 0  90
24576   CLOSED TREATMENT OF HUMERAL CONDYLAR FRA      183.32   134.72                 0  90
24577   CLOSED TREATMENT OF HUMERAL CONDYLAR FRA      300.87   229.81                 0  90
24579   OPEN TREATMENT OF HUMERAL CONDYLAR FRACT      479.50   399.59                 0  90
24582   PERCUTANEOUS SKELETAL FIXATION OF HUMERA      447.97   373.31                 0  90
24586   OPEN TREATMENT OF PERIARTICULAR FRACTURE      631.62   526.35                 0  90
24587   OPEN TREATMENT OF PERIARTICULAR FRACTURE      626.45   522.04                 0  90
24600   TREATMENT OF CLOSED ELBOW DISLOCATION; W      205.90   151.69                 0  90
24605   TREATMENT OF CLOSED ELBOW DISLOCATION; R      258.65   215.54                 0  90
24615   OPEN TREATMENT OF ACUTE OR CHRONIC ELBOW      411.25   342.71                 0  90
24620   CLOSED TREATMENT OF MONTEGGIA TYPE OF FR      312.87   260.73                 0  90
24635   OPEN TREATMENT OF MONTEGGIA TYPE OF FRAC      481.53   401.28                 0  90
24640   CLOSED TREATMENT OF RADIAL HEAD SUBLUXAT       69.08    39.52                 0  10
24650   CLOSED TREATMENT OF RADIAL HEAD OR NECK       141.65   103.07                 0  90
24655   CLOSED TREATMENT OF RADIAL HEAD OR NECK       244.34   183.73                 0  90
24665   OPEN TREATMENT OF RADIAL HEAD OR NECK FR      371.97   309.98                 0  90
24666   OPEN TREATMENT OF RADIAL HEAD OR NECK FR      420.04   350.04                 0  90
24670   CLOSED TREATMENT OF ULNAR FRACTURE, PROX      158.75   115.68                 0  90
24675   CLOSED TREATMENT OF ULNAR FRACTURE, PROX      256.03   194.49                 0  90
24685   OPEN TREATMENT OF ULNAR FRACTURE, PROXIM      374.45   312.05                 0  90
24800   ARTHRODESIS, ELBOW JOINT; LOCAL               458.95   382.46                 0  90
24802   ARTHRODESIS, ELBOW JOINT; WITH AUTOGENOU      569.56   474.63                 0  90
24900   AMPUTATION, ARM THROUGH HUMERUS; WITH PR      405.10   337.58                 0  90
                                                                                                   Page 35 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
24920   AMPUTATION, ARM THROUGH HUMERUS; OPEN, C      400.28   333.57                 0  90
24925   AMPUTATION, ARM THROUGH HUMERUS; SECONDA      308.15   256.79                 0  90
24930   AMPUTATION, ARM THROUGH HUMERUS; RE-AMPU      421.88   351.57                 0  90
24931   AMPUTATION, ARM THROUGH HUMERUS; WITH IM      447.40   372.83                 0  90
24935   STUMP ELONGATION, UPPER EXTREMITY                                         BR 0   90
24940   CINEPLASTY, UPPER EXTREMITY, COMPLETE PR      410.77   342.31                 0  90
24999   UNLISTED PROCEDURE, HUMERUS OR ELBOW                                      BR 0    0
25000   INCISION, EXTENSOR TENDON SHEATH, WRIST       216.21   180.18                 0  90
25001   INCISION, FLEXOR TENDON SHEATH, WRIST (E      188.09   156.75                 0  90
25020   DECOMPRESSION FASCIOTOMY, FOREARM AND/OR      346.07   288.39                 0  90
25023   DECOMPRESSION FASCIOTOMY, FOREARM AND/OR      648.68   540.57                 0  90
25024   DECOMPRESSION FASCIOTOMY, FOREARM AND/OR      426.38   355.32                 0  90
25025   DECOMPRESSION FASCIOTOMY, FOREARM AND/OR      645.93   538.28                 0  90
25028   INCISION AND DRAINAGE, FOREARM AND/OR WR      303.12   252.60                 0  90
25031   INCISION AND DRAINAGE, FOREARM AND/OR WR      239.96   199.97                 0  90
25035   INCISION, DEEP, BONE CORTEX, FOREARM AND      418.24   348.53                 0  90
25040   ARTHROTOMY, RADIOCARPAL OR MIDCARPAL JOI      333.43   277.86                 0  90
25065   BIOPSY, SOFT TISSUE OF FOREARM AND/OR WR      137.42    76.78                 0  10
25066   BIOPSY, SOFT TISSUE OF FOREARM AND/OR WR      233.78   194.82                 0  90
25071   EXCISION, TUMOR, SOFT TISSUE OF FOREARM       254.87   212.39                 0  90
25073   EXCISION, TUMOR, SOFT TISSUE OF FOREARM       318.19   265.16                 0  90
25075   EXCISION, TUMOR, SOFT TISSUE OF FOREARM       202.73   168.95                 0  90
25076   EXCISION, TUMOR, SOFT TISSUE OF FOREARM       286.22   238.52                 0  90
25077   RADICAL RESECTION OF TUMOR (EG, MALIGNAN      458.91   382.43                 0  90
25078   RADICAL RESECTION OF TUMOR (EG, MALIGNAN      673.26   561.05                 0  90
25085   CAPSULOTOMY, WRIST (EG, CONTRACTURE)          276.88   230.73                 0  90
25100   ARTHROTOMY, WRIST JOINT; WITH BIOPSY          205.15   170.96                 0  90
25101   ARTHROTOMY, WRIST JOINT; WITH JOINT EXPL      239.49   199.58                 0  90
25105   ARTHROTOMY, WRIST JOINT; WITH SYNOVECTOM      292.28   243.57                 0  90
                                                                                                   Page 36 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
25107   ARTHROTOMY, DISTAL RADIOULNAR JOINT INCL      354.59   295.50                 0  90
25109   EXCISION OF TENDON, FOREARM AND/OR WRIST      289.57   241.31                 0  90
25110   EXCISION, LESION OF TENDON SHEATH, FOREA      226.22   188.52                 0  90
25111   EXCISION OF GANGLION, WRIST (DORSAL OR V      184.50   153.75                 0  90
25112   EXCISION OF GANGLION, WRIST (DORSAL OR V      224.05   186.71                 0  90
25115   RADICAL EXCISION OF BURSA, SYNOVIA OF WR      494.36   411.97                 0  90
25116   RADICAL EXCISION OF BURSA, SYNOVIA OF WR      413.55   344.63                 0  90
25118   SYNOVECTOMY, EXTENSOR TENDON SHEATH, WRI      227.24   200.00                 0  90
25119   SYNOVECTOMY, EXTENSOR TENDON SHEATH, WRI      301.79   300.00                 0  90
25120   EXCISION OR CURETTAGE OF BONE CYST OR BE      359.72   299.77                 0  90
25125   EXCISION OR CURETTAGE OF BONE CYST OR BE      406.06   338.38                 0  90
25126   EXCISION OR CURETTAGE OF BONE CYST OR BE      416.35   346.96                 0  90
25130   EXCISION OR CURETTAGE OF BONE CYST OR BE      263.75   219.79                 0  90
25135   EXCISION OR CURETTAGE OF BONE CYST OR BE      326.66   272.22                 0  90
25136   EXCISION OR CURETTAGE OF BONE CYST OR BE      290.16   241.80                 0  90
25145   SEQUESTRECTOMY (EG, FOR OSTEOMYELITIS OR      366.49   305.41                 0  90
25150   PARTIAL EXCISION (CRATERIZATION, SAUCERI      343.00   285.83                 0  90
25151   PARTIAL EXCISION (CRATERIZATION, SAUCERI      407.25   339.38                 0  90
25170   RADICAL RESECTION OF TUMOR, RADIUS OR UL      548.60   457.17                 0  90
25210   CARPECTOMY; ONE BONE                          288.05   240.04                 0  90
25215   CARPECTOMY; ALL BONES OF PROXIMAL ROW         372.46   310.38                 0  90
25230   RADIAL STYLOIDECTOMY (SEPARATE PROCEDURE      256.43   213.70                 0  90
25240   EXCISION DISTAL ULNA PARTIAL OR COMPLETE      265.32   221.10                 0  90
25246   INJECTION PROCEDURE FOR WRIST ARTHROGRAP      107.73    36.66                 0   0
25248   EXPLORATION WITH REMOVAL OF DEEP FOREIGN      277.11   230.93                 0  90
25250   REMOVAL OF WRIST PROSTHESIS; (SEPARATE P                                  BR 0   90
25251   REMOVAL OF WRIST PROSTHESIS; COMPLICATED                                  BR 0   90
25259   MANIPULATION, WRIST, UNDER ANESTHESIA         226.60   188.84                 0  90
25260   REPAIR, TENDON OR MUSCLE, FLEXOR, FOREAR      430.21   358.51                 0  90
                                                                                                   Page 37 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
25263   REPAIR, TENDON OR MUSCLE, FLEXOR, FOREAR      426.03   355.03                 0  90
25265   REPAIR, TENDON OR MUSCLE, FLEXOR, FOREAR      499.84   416.53                 0  90
25270   REPAIR, TENDON OR MUSCLE, EXTENSOR, FORE      354.28   295.24                 0  90
25272   REPAIR, TENDON OR MUSCLE, EXTENSOR, FORE      394.71   328.93                 0  90
25274   REPAIR, TENDON OR MUSCLE, EXTENSOR, FORE      456.71   380.60                 0  90
25275   REPAIR, TENDON SHEATH, EXTENSOR, FOREARM      382.49   318.75                 0  90
25280   LENGTHENING OR SHORTENING OF FLEXOR OR E      396.76   330.64                 0  90
25290   TENOTOMY, OPEN, FLEXOR OR EXTENSOR TENDO      367.30   306.08                 0  90
25295   TENOLYSIS, FLEXOR OR EXTENSOR TENDON, FO      372.19   310.16                 0  90
25300   TENODESIS AT WRIST; FLEXORS OF FINGERS        395.57   329.65                 0  90
25301   TENODESIS AT WRIST; EXTENSORS OF FINGERS      377.32   314.44                 0  90
25310   TENDON TRANSPLANTATION OR TRANSFER, FLEX      429.21   357.68                 0  90
25312   TENDON TRANSPLANTATION OR TRANSFER, FLEX      483.80   403.17                 0  90
25315   FLEXOR ORIGIN SLIDE (EG, FOR CEREBRAL PA      515.81   429.85                 0  90
25316   FLEXOR ORIGIN SLIDE (EG, FOR CEREBRAL PA      595.85   496.54                 0  90
25320   CAPSULORRHAPHY OR RECONSTRUCTION, WRIST,      550.37   458.64                 0  90
25332   ARTHROPLASTY, WRIST, WITH OR WITHOUT INT      484.66   403.89                 0  90
25335   CENTRALIZATION OF WRIST ON ULNA (EG, RAD      558.66   465.55                 0  90
25337   RECONSTRUCTION FOR STABILIZATION OF UNST      512.18   426.82                 0  90
25350   OSTEOTOMY, RADIUS; DISTAL THIRD               466.16   388.47                 0  90
25355   OSTEOTOMY, RADIUS; MIDDLE OR PROXIMAL TH      514.43   428.69                 0  90
25360   OSTEOTOMY; ULNA                               455.15   379.29                 0  90
25365   OSTEOTOMY; RADIUS AND ULNA                    602.58   502.15                 0  90
25370   MULTIPLE OSTEOTOMIES, WITH REALIGNMENT O      644.64   537.20                 0  90
25375   MULTIPLE OSTEOTOMIES, WITH REALIGNMENT O      629.84   524.87                 0  90
25390   OSTEOPLASTY, RADIUS OR ULNA; SHORTENING       519.58   432.98                 0  90
25391   OSTEOPLASTY, RADIUS OR ULNA; LENGTHENING      648.97   540.81                 0  90
25392   OSTEOPLASTY, RADIUS AND ULNA; SHORTENING      648.32   540.27                 0  90
25393   OSTEOPLASTY, RADIUS AND ULNA; LENGTHENIN      731.52   609.60                 0  90
                                                                                                   Page 38 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                      DESCRIPTION                FEE      FEE        FEE      BR PA DAYS   E
25394   OSTEOPLASTY, CARPAL BONE, SHORTENING          439.07   365.89                 0  90
25400   REPAIR OF NONUNION OR MALUNION, RADIUS O      545.28   454.40                 0  90
25405   REPAIR OF NONUNION OR MALUNION, RADIUS O      678.32   565.27                 0  90
25415   REPAIR OF NONUNION OR MALUNION, RADIUS A      639.32   532.77                 0  90
25420   REPAIR OF NONUNION OR MALUNION, RADIUS A      750.70   625.58                 0  90
25425   REPAIR OF DEFECT WITH AUTOGRAFT; RADIUS       691.79   576.49                 0  90
25426   REPAIR OF DEFECT WITH AUTOGRAFT; RADIUS       707.03   589.20                 0  90
25430   INSERTION OF VASCULAR PEDICLE INTO CARPA      400.83   334.03                 0  90
25431   REPAIR OF NONUNION OF CARPAL BONE (EXCLU      453.83   378.19                 0  90
25440   REPAIR OF NONUNION, SCAPHOID CARPAL (NAV      452.70   377.25                 0  90
25441   ARTHROPLASTY WITH PROSTHETIC REPLACEMENT      538.04   448.37                 0  90
25442   ARTHROPLASTY WITH PROSTHETIC REPLACEMENT      460.26   383.55                 0  90
25443   ARTHROPLASTY WITH PROSTHETIC REPLACEMENT      442.24   368.54                 0  90
25444   ARTHROPLASTY WITH PROSTHETIC REPLACEMENT      471.54   392.95                 0  90
25445   ARTHROPLASTY WITH PROSTHETIC REPLACEMENT      414.76   345.64                 0  90
25446   ARTHROPLASTY WITH PROSTHETIC REPLACEMENT      675.59   562.99                 0  90
25447   ARTHROPLASTY, INTERPOSITION, INTERCARPAL      463.09   385.91                 0  90
25449   REVISION OF ARTHROPLASTY, INCLUDING REMO      593.49   494.58                 0  90
25450   EPIPHYSEAL ARREST BY EPIPHYSIODESIS OR S      365.30   304.42                 0  90
25455   EPIPHYSEAL ARREST BY EPIPHYSIODESIS OR S      434.96   362.47                 0  90
25490   PROPHYLACTIC TREATMENT (NAILING, PINNING      478.22   398.52                 0  90
25491   PROPHYLACTIC TREATMENT (NAILING, PINNING      502.18   418.48                 0  90
25492   PROPHYLACTIC TREATMENT (NAILING, PINNING      594.80   495.67                 0  90
25500   CLOSED TREATMENT OF RADIAL SHAFT FRACTUR      143.74   106.45                 0  90
25505   CLOSED TREATMENT OF RADIAL SHAFT FRACTUR      280.78   213.68                 0  90
25515   OPEN TREATMENT OF RADIAL SHAFT FRACTURE,      383.60   319.67                 0  90
25520   CLOSED TREATMENT OF RADIAL SHAFT FRACTUR      308.36   243.02                 0  90
25525   OPEN TREATMENT OF RADIAL SHAFT FRACTURE,      473.78   394.82                 0  90
25526   OPEN TREATMENT OF RADIAL SHAFT FRACTURE,      587.00   489.17                 0  90
                                                                                                   Page 39 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                      DESCRIPTION                FEE      FEE        FEE      BR PA DAYS   E
25530   CLOSED TREATMENT OF ULNAR SHAFT FRACTURE      140.53   102.75                 0  90
25535   CLOSED TREATMENT OF ULNAR SHAFT FRACTURE      269.09   209.47                 0  90
25545   OPEN TREATMENT OF ULNAR SHAFT FRACTURE,       364.15   303.46                 0  90
25560   CLOSED TREATMENT OF RADIAL AND ULNAR SHA      145.72   105.03                 0  90
25565   CLOSED TREATMENT OF RADIAL AND ULNAR SHA      292.75   220.78                 0  90
25574   OPEN TREATMENT OF RADIAL AND ULNAR SHAFT      372.85   310.71                 0  90
25575   OPEN TREATMENT OF RADIAL AND ULNAR SHAFT      507.93   423.28                 0  90
25600   CLOSED TREATMENT OF DISTAL RADIAL FRACTU      160.09   116.59                 0  90
25605   CLOSED TREATMENT OF DISTAL RADIAL FRACTU      339.18   264.81                 0  90
25606   PERCUTANEOUS SKELETAL FIXATION OF DISTAL      386.23   321.86                 0  90
25607   OPEN TREATMENT OF DISTAL RADIAL EXTRA-AR      398.46   332.05                 0  90
25608   OPEN TREATMENT OF DISTAL RADIAL INTRA-AR      454.83   379.03                 0  90
25609   OPEN TREATMENT OF DISTAL RADIAL INTRA-AR      579.25   482.71                 0  90
25622   CLOSED TREATMENT OF CARPAL SCAPHOID (NAV      164.56   119.50                 0  90
25624   CLOSED TREATMENT OF CARPAL SCAPHOID (NAV      258.32   193.73                 0  90
25628   OPEN TREATMENT OF CARPAL SCAPHOID (NAVIC      405.38   337.82                 0  90
25630   CLOSED TREATMENT OF CARPAL BONE FRACTURE      167.83   122.02                 0  90
25635   CLOSED TREATMENT OF CARPAL BONE FRACTURE      244.03   174.44                 0  90
25645   OPEN TREATMENT OF CARPAL BONE FRACTURE (      326.32   271.93                 0  90
25650   CLOSED TREATMENT OF ULNAR STYLOID FRACTU      174.25   129.42                 0  90
25651   PERCUTANEOUS SKELETAL FIXATION OF ULNAR       266.11   221.76                 0  90
25652   OPEN TREATMENT OF ULNAR STYLOID FRACTURE      350.63   292.20                 0  90
25660   CLOSED TREATMENT OF RADIOCARPAL OR INTER      222.99   185.83                 0  90
25670   OPEN TREATMENT OF RADIOCARPAL OR INTERCA      349.42   291.18                 0  90
25671   PERCUTANEOUS SKELETAL FIXATION OF DISTAL      295.51   246.26                 0  90
25675   CLOSED TREATMENT OF DISTAL RADIOULNAR DI      238.52   180.93                 0  90
25676   OPEN TREATMENT OF DISTAL RADIOULNAR DISL      362.10   301.75                 0  90
25680   CLOSED TREATMENT OF TRANS-SCAPHOPERILUNA      253.72   211.44                 0  90
25685   OPEN TREATMENT OF TRANS-SCAPHOPERILUNAR       416.84   347.37                 0  90
                                                                                                   Page 40 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
25690   CLOSED TREATMENT OF LUNATE DISLOCATION,       261.03   217.53                 0  90
25695   OPEN TREATMENT OF LUNATE DISLOCATION          362.33   301.95                 0  90
25800   ARTHRODESIS, WRIST; COMPLETE, WITHOUT BO      433.92   361.60                 0  90
25805   ARTHRODESIS, WRIST; WITH SLIDING GRAFT        498.01   415.01                 0  90
25810   ARTHRODESIS, WRIST; WITH ILIAC OR OTHER       498.58   415.49                 0  90
25820   ARTHRODESIS, WRIST; LIMITED, WITHOUT BON      356.29   296.91                 0  90
25825   ARTHRODESIS, WRIST; WITH AUTOGRAFT (INCL      434.29   361.91                 0  90
25830   ARTHRODESIS, DISTAL RADIOULNAR JOINT WIT      560.51   467.10                 0  90
25900   AMPUTATION, FOREARM, THROUGH RADIUS AND       459.98   383.32                 0  90
25905   AMPUTATION, FOREARM, THROUGH RADIUS AND       451.12   375.94                 0  90
25907   AMPUTATION, FOREARM, THROUGH RADIUS AND       403.46   336.22                 0  90
25909   AMPUTATION, FOREARM, THROUGH RADIUS AND       449.18   374.32                 0  90
25915   KRUKENBERG PROCEDURE                          726.50   605.42                 0  90
25920   DISARTICULATION THROUGH WRIST;                389.92   324.94                 0  90
25922   DISARTICULATION THROUGH WRIST; SECONDARY      343.18   285.99                 0  90
25924   DISARTICULATION THROUGH WRIST; RE-AMPUTA      382.14   318.45                 0  90
25927   TRANSMETACARPAL AMPUTATION;                   462.12   385.10                 0  90
25929   TRANSMETACARPAL AMPUTATION; SECONDARY CL      324.96   270.80                 0  90
25931   TRANSMETACARPAL AMPUTATION; RE-AMPUTATIO      431.23   359.36                 0  90
25999   UNLISTED PROCEDURE, FOREARM OR WRIST                                      BR 0    0
26010   DRAINAGE OF FINGER ABSCESS; SIMPLE            154.17    62.03                 0  10
26011   DRAINAGE OF FINGER ABSCESS; COMPLICATED       238.17    87.73                 0  10
26020   DRAINAGE OF TENDON SHEATH, DIGIT AND/OR       242.18   201.82                 0  90
26025   DRAINAGE OF PALMAR BURSA; SINGLE, BURSA       236.69   197.24                 0  90
26030   DRAINAGE OF PALMAR BURSA; MULTIPLE BURSA      278.18   260.00                 0  90
26034   INCISION, BONE CORTEX, HAND OR FINGER (E      302.17   251.81                 0  90
26035   DECOMPRESSION FINGERS AND/OR HAND, INJEC                                  BR 0   90
26037   DECOMPRESSIVE FASCIOTOMY, HAND (EXCLUDES      323.54   269.62                 0  90
26040   FASCIOTOMY, PALMAR (EG, DUPUYTREN'S CONT      175.22   146.02                 0  90
                                                                                                   Page 41 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
26045   FASCIOTOMY, PALMAR (EG, DUPUYTREN'S CONT      265.30   221.08                 0  90
26055   TENDON SHEATH INCISION (EG, FOR TRIGGER       358.79   138.61                 0  90
26060   TENOTOMY, PERCUTANEOUS, SINGLE, EACH DIG      149.00   124.17                 0  90
26070   ARTHROTOMY, WITH EXPLORATION, DRAINAGE,       165.79   138.16                 0  90
26075   ARTHROTOMY, WITH EXPLORATION, DRAINAGE,       178.10   148.42                 0  90
26080   ARTHROTOMY, WITH EXPLORATION, DRAINAGE,       216.77   180.65                 0  90
26100   ARTHROTOMY WITH BIOPSY; CARPOMETACARPAL       183.89   153.24                 0  90
26105   ARTHROTOMY WITH BIOPSY; METACARPOPHALANG      187.18   155.99                 0  90
26110   ARTHROTOMY WITH BIOPSY; INTERPHALANGEAL       178.93   149.11                 0  90
26111   EXCISION, TUMOR OR VASCULAR MALFORMATION      248.09   206.75                 0  90
26113   EXCISION, TUMOR, SOFT TISSUE, OR VASCULA      326.50   272.09                 0  90
26115   EXCISION, TUMOR OR VASCULAR MALFORMATION      375.50   169.96                 0  90
26116   EXCISION, TUMOR, SOFT TISSUE, OR VASCULA      272.64   227.20                 0  90
26117   RADICAL RESECTION OF TUMOR (EG, MALIGNAN      367.36   306.13                 0  90
26118   RADICAL RESECTION OF TUMOR (EG, MALIGNAN      637.65   531.38                 0  90
26121   FASCIECTOMY, PALM ONLY, WITH OR WITHOUT       340.28   283.57                 0  90
26123   FASCIECTOMY, PARTIAL PALMAR WITH RELEASE      459.20   382.67                 0  90
26125   FASCIECTOMY, PARTIAL PALMAR WITH RELEASE      162.73   135.61                 0   0
26130   SYNOVECTOMY, CARPOMETACARPAL JOINT            259.05   215.88                 0  90
26135   SYNOVECTOMY, METACARPOPHALANGEAL JOINT I      314.17   261.81                 0  90
26140   SYNOVECTOMY, PROXIMAL INTERPHALANGEAL JO      285.95   238.30                 0  90
26145   SYNOVECTOMY, TENDON SHEATH, RADICAL (TEN      290.33   241.95                 0  90
26160   EXCISION OF LESION OF TENDON SHEATH OR J      345.28   150.73                 0  90
26170   EXCISION OF TENDON, PALM, FLEXOR OR EXTE      228.44   190.37                 0  90
26180   EXCISION OF TENDON, FINGER, FLEXOR OR EX      248.88   207.40                 0  90
26185   SESAMOIDECTOMY, THUMB OR FINGER (SEPARAT      292.23   243.53                 0  90
26200   EXCISION OR CURETTAGE OF BONE CYST OR BE      255.38   212.82                 0  90
26205   EXCISION OR CURETTAGE OF BONE CYST OR BE      343.39   286.16                 0  90
26210   EXCISION OR CURETTAGE OF BONE CYST OR BE      249.13   207.61                 0  90
                                                                                                   Page 42 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
26215   EXCISION OR CURETTAGE OF BONE CYST OR BE      314.18   261.82                 0  90
26230   PARTIAL EXCISION (CRATERIZATION, SAUCERI      286.56   238.80                 0  90
26235   PARTIAL EXCISION (CRATERIZATION, SAUCERI      280.97   234.14                 0  90
26236   PARTIAL EXCISION (CRATERIZATION, SAUCERI      249.63   208.03                 0  90
26250   RADICAL RESECTION OF TUMOR, METACARPAL        328.93   274.11                 0  90
26260   RADICAL RESECTION OF TUMOR, PROXIMAL OR       310.77   258.98                 0  90
26262   RADICAL RESECTION OF TUMOR, DISTAL PHALA      260.60   217.17                 0  90
26320   REMOVAL OF IMPLANT FROM FINGER OR HAND        194.96   162.47                 0  90
26340   MANIPULATION, FINGER JOINT, UNDER ANESTH      178.95   149.13                 0  90
26341   MANIPULATION, PALMAR FASCIAL CORD (IE, D       45.02    37.52                 0  10    *
26350   REPAIR OR ADVANCEMENT, FLEXOR TENDON, NO      442.17   368.48                 0  90
26352   REPAIR OR ADVANCEMENT, FLEXOR TENDON, NO      496.48   413.74                 0  90
26356   REPAIR OR ADVANCEMENT, FLEXOR TENDON, IN      630.75   525.63                 0  90
26357   REPAIR OR ADVANCEMENT, FLEXOR TENDON, IN      526.40   438.67                 0  90
26358   REPAIR OR ADVANCEMENT, FLEXOR TENDON, IN      559.04   465.87                 0  90
26370   REPAIR OR ADVANCEMENT OF PROFUNDUS TENDO      474.35   395.29                 0  90
26372   REPAIR OR ADVANCEMENT OF PROFUNDUS TENDO      546.13   455.11                 0  90
26373   REPAIR OR ADVANCEMENT OF PROFUNDUS TENDO      519.45   432.88                 0  90
26390   EXCISION FLEXOR TENDON, WITH IMPLANTATIO      498.34   415.29                 0  90
26392   REMOVAL OF SYNTHETIC ROD AND INSERTION O      590.39   492.00                 0  90
26410   REPAIR, EXTENSOR TENDON, HAND, PRIMARY O      352.82   294.02                 0  90
26412   REPAIR, EXTENSOR TENDON, HAND, PRIMARY O      421.28   351.07                 0  90
26415   EXCISION OF EXTENSOR TENDON, WITH IMPLAN                                  BR 0   90
26416   REMOVAL OF SYNTHETIC ROD AND INSERTION O                                  BR 0   90
26418   REPAIR, EXTENSOR TENDON, FINGER, PRIMARY      355.36   296.14                 0  90
26420   REPAIR, EXTENSOR TENDON, FINGER, PRIMARY      439.45   366.21                 0  90
26426   REPAIR OF EXTENSOR TENDON, CENTRAL SLIP,      373.04   310.87                 0  90
26428   REPAIR OF EXTENSOR TENDON, CENTRAL SLIP,      457.78   381.48                 0  90
26432   CLOSED TREATMENT OF DISTAL EXTENSOR TEND      307.27   256.06                 0  90
                                                                                                   Page 43 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
26433   REPAIR OF EXTENSOR TENDON, DISTAL INSERT      329.54   274.62                 0  90
26434   REPAIR OF EXTENSOR TENDON, DISTAL INSERT      386.20   321.84                 0  90
26437   REALIGNMENT OF EXTENSOR TENDON, HAND, EA      378.51   315.43                 0  90
26440   TENOLYSIS, FLEXOR TENDON; PALM OR FINGER      390.19   325.16                 0  90
26442   TENOLYSIS, FLEXOR TENDON; PALM AND FINGE      562.76   468.97                 0  90
26445   TENOLYSIS, EXTENSOR TENDON, HAND OR FING      366.68   305.57                 0  90
26449   TENOLYSIS, COMPLEX, EXTENSOR TENDON, FIN      477.67   398.06                 0  90
26450   TENOTOMY, FLEXOR, PALM, OPEN, EACH TENDO      243.10   202.58                 0  90
26455   TENOTOMY, FLEXOR, FINGER, OPEN, EACH TEN      241.19   201.00                 0  90
26460   TENOTOMY, EXTENSOR, HAND OR FINGER, OPEN      234.59   195.50                 0  90
26471   TENODESIS; OF PROXIMAL INTERPHALANGEAL J      372.25   310.21                 0  90
26474   TENODESIS; OF DISTAL JOINT, EACH JOINT        360.72   300.60                 0  90
26476   LENGTHENING OF TENDON, EXTENSOR, HAND OR      349.77   291.48                 0  90
26477   SHORTENING OF TENDON, EXTENSOR, HAND OR       353.94   294.95                 0  90
26478   LENGTHENING OF TENDON, FLEXOR, HAND OR F      381.23   317.69                 0  90
26479   SHORTENING OF TENDON, FLEXOR, HAND OR FI      376.58   313.82                 0  90
26480   TRANSFER OR TRANSPLANT OF TENDON, CARPOM      464.99   387.49                 0  90
26483   TRANSFER OR TRANSPLANT OF TENDON, CARPOM      515.60   429.67                 0  90
26485   TRANSFER OR TRANSPLANT OF TENDON, PALMAR      497.64   414.70                 0  90
26489   TRANSFER OR TRANSPLANT OF TENDON, PALMAR      508.93   424.11                 0  90
26490   OPPONENSPLASTY; SUPERFICIALIS TENDON TRA      467.56   389.64                 0  90
26492   OPPONENSPLASTY; TENDON TRANSFER WITH GRA      517.79   431.49                 0  90
26494   OPPONENSPLASTY; HYPOTHENAR MUSCLE TRANSF      476.45   397.04                 0  90
26496   OPPONENSPLASTY; OTHER METHODS                 510.59   425.49                 0  90
26497   TRANSFER OF TENDON TO RESTORE INTRINSIC       512.92   427.43                 0  90
26498   TRANSFER OF TENDON TO RESTORE INTRINSIC       677.10   564.25                 0  90
26499   CORRECTION CLAW FINGER, OTHER METHODS                                     BR 0   90
26500   RECONSTRUCTION OF TENDON PULLEY, EACH TE      379.30   316.09                 0  90
26502   RECONSTRUCTION OF TENDON PULLEY, EACH TE      422.84   352.37                 0  90
                                                                                                   Page 44 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
26508   RELEASE OF THENAR MUSCLE(S) (EG, THUMB C      385.70   321.42                 0  90
26510   CROSS INTRINSIC TRANSFER, EACH TENDON                                     BR 0   90
26516   CAPSULODESIS, METACARPOPHALANGEAL JOINT;      424.86   354.05                 0  90
26517   CAPSULODESIS, METACARPOPHALANGEAL JOINT;      491.63   409.70                 0  90
26518   CAPSULODESIS, METACARPOPHALANGEAL JOINT;      492.25   410.21                 0  90
26520   CAPSULECTOMY OR CAPSULOTOMY; METACARPOPH      407.67   339.73                 0  90
26525   CAPSULECTOMY OR CAPSULOTOMY; INTERPHALAN      409.82   341.52                 0  90
26530   ARTHROPLASTY, METACARPOPHALANGEAL JOINT;      303.49   252.91                 0  90
26531   ARTHROPLASTY, METACARPOPHALANGEAL JOINT;      353.08   294.24                 0  90
26535   ARTHROPLASTY, INTERPHALANGEAL JOINT; EAC      220.64   183.87                 0  90
26536   ARTHROPLASTY, INTERPHALANGEAL JOINT; WIT      385.53   321.28                 0  90
26540   REPAIR OF COLLATERAL LIGAMENT, METACARPO      400.16   333.47                 0  90
26541   RECONSTRUCTION, COLLATERAL LIGAMENT, MET      483.15   402.63                 0  90
26542   RECONSTRUCTION, COLLATERAL LIGAMENT, MET      411.48   342.90                 0  90
26545   RECONSTRUCTION, COLLATERAL LIGAMENT, INT      419.83   349.86                 0  90
26546   REPAIR NON-UNION, METACARPAL OR PHALANX,      573.01   477.51                 0  90
26548   REPAIR AND RECONSTRUCTION, FINGER, VOLAR      458.72   382.27                 0  90
26550   POLLICIZATION OF A DIGIT                      890.35   741.96                 0  90
26551   TRANSFER, TOE-TO-HAND WITH MICROVASCULAR                                  BR 0   90
26553   TRANSFER, TOE-TO-HAND WITH MICROVASCULAR                                  BR 0   90
26554   TRANSFER, TOE-TO-HAND WITH MICROVASCULAR                                  BR 0   90
26555   TRANSFER, FINGER TO ANOTHER POSITION WIT                                  BR 0   90
26556   TRANSFER, FREE TOE JOINT, WITH MICROVASC                                  BR 0   90
26560   REPAIR OF SYNDACTYLY (WEB FINGER) EACH W      332.41   277.01                 0  90
26561   REPAIR OF SYNDACTYLY (WEB FINGER) EACH W      525.65   438.05                 0  90
26562   REPAIR OF SYNDACTYLY (WEB FINGER) EACH W      703.90   586.58                 0  90
26565   OSTEOTOMY; METACARPAL, EACH                   409.35   341.13                 0  90
26567   OSTEOTOMY; PHALANX OF FINGER, EACH            410.89   342.41                 0  90
26568   OSTEOPLASTY, LENGTHENING, METACARPAL OR                                   BR 0   90
                                                                                                   Page 45 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
26580   REPAIR CLEFT HAND                                                         BR 0   90
26587   RECONSTRUCTION OF POLYDACTYLOUS DIGIT, S      539.65   449.71                 0  90
26590   REPAIR MACRODACTYLIA, EACH DIGIT              764.78   637.32                 0  90
26591   REPAIR, INTRINSIC MUSCLES OF HAND, EACH       273.14   227.62                 0  90
26593   RELEASE, INTRINSIC MUSCLES OF HAND, EACH      360.43   300.36                 0  90
26596   EXCISION OF CONSTRICTING RING OF FINGER,      416.94   347.45                 0  90
26600   CLOSED TREATMENT OF METACARPAL FRACTURE,      149.06   110.68                 0  90
26605   CLOSED TREATMENT OF METACARPAL FRACTURE,      176.88   132.23                 0  90
26607   CLOSED TREATMENT OF METACARPAL FRACTURE,      267.17   222.65                 0  90
26608   PERCUTANEOUS SKELETAL FIXATION OF METACA      271.80   226.50                 0  90
26615   OPEN TREATMENT OF METACARPAL FRACTURE, S      299.51   249.59                 0  90
26641   CLOSED TREATMENT OF CARPOMETACARPAL DISL      196.39   146.64                 0  90
26645   CLOSED TREATMENT OF CARPOMETACARPAL FRAC      226.70   171.90                 0  90
26650   PERCUTANEOUS SKELETAL FIXATION OF CARPOM      269.51   224.60                 0  90
26665   OPEN TREATMENT OF CARPOMETACARPAL FRACTU      338.18   281.82                 0  90
26670   CLOSED TREATMENT OF CARPOMETACARPAL DISL      181.97   132.16                 0  90
26675   CLOSED TREATMENT OF CARPOMETACARPAL DISL      245.63   186.64                 0  90
26676   PERCUTANEOUS SKELETAL FIXATION OF CARPOM      285.55   237.96                 0  90
26685   OPEN TREATMENT OF CARPOMETACARPAL DISLOC      314.52   262.10                 0  90
26686   OPEN TREATMENT OF CARPOMETACARPAL DISLOC      352.11   293.43                 0  90
26700   CLOSED TREATMENT OF METACARPOPHALANGEAL       170.98   129.56                 0  90
26705   CLOSED TREATMENT OF METACARPOPHALANGEAL       225.77   170.30                 0  90
26706   PERCUTANEOUS SKELETAL FIXATION OF METACA      244.69   203.91                 0  90
26715   OPEN TREATMENT OF METACARPOPHALANGEAL DI      302.40   252.00                 0  90
26720   CLOSED TREATMENT OF PHALANGEAL SHAFT FRA      106.11    78.17                 0  90
26725   CLOSED TREATMENT OF PHALANGEAL SHAFT FRA      190.22   138.63                 0  90
26727   PERCUTANEOUS SKELETAL FIXATION OF UNSTAB      267.62   223.02                 0  90
26735   OPEN TREATMENT OF PHALANGEAL SHAFT FRACT      313.15   260.96                 0  90
26740   CLOSED TREATMENT OF ARTICULAR FRACTURE,       123.07    95.18                 0  90
                                                                                                   Page 46 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
26742   CLOSED TREATMENT OF ARTICULAR FRACTURE,       206.46   153.39                 0  90
26746   OPEN TREATMENT OF ARTICULAR FRACTURE, IN      373.04   310.87                 0  90
26750   CLOSED TREATMENT OF DISTAL PHALANGEAL FR       98.72    77.56                 0  90
26755   CLOSED TREATMENT OF DISTAL PHALANGEAL FR      174.04   122.27                 0  90
26756   PERCUTANEOUS SKELETAL FIXATION OF DISTAL      237.21   197.68                 0  90
26765   OPEN TREATMENT OF DISTAL PHALANGEAL FRAC      252.49   210.41                 0  90
26770   CLOSED TREATMENT OF INTERPHALANGEAL JOIN      146.90   108.06                 0  90
26775   CLOSED TREATMENT OF INTERPHALANGEAL JOIN      210.14   153.38                 0  90
26776   PERCUTANEOUS SKELETAL FIXATION OF INTERP      252.07   210.06                 0  90
26785   OPEN TREATMENT OF INTERPHALANGEAL JOINT       273.41   227.85                 0  90
26820   FUSION IN OPPOSITION, THUMB, WITH AUTOGE      472.72   393.94                 0  90
26841   ARTHRODESIS, CARPOMETACARPAL JOINT, THUM      444.38   370.32                 0  90
26842   ARTHRODESIS, CARPOMETACARPAL JOINT, THUM      476.08   396.74                 0  90
26843   ARTHRODESIS, CARPOMETACARPAL JOINT, DIGI      439.69   366.41                 0  90
26844   ARTHRODESIS, CARPOMETACARPAL JOINT, DIGI      487.99   406.66                 0  90
26850   ARTHRODESIS, METACARPOPHALANGEAL JOINT,       419.27   349.40                 0  90
26852   ARTHRODESIS, METACARPOPHALANGEAL JOINT,       473.81   394.84                 0  90
26860   ARTHRODESIS, INTERPHALANGEAL JOINT, WITH      344.10   286.75                 0  90
26861   ARTHRODESIS, INTERPHALANGEAL JOINT, WITH       61.70    51.42                 0   0
26862   ARTHRODESIS, INTERPHALANGEAL JOINT, WITH      435.16   362.63                 0  90
26863   ARTHRODESIS, INTERPHALANGEAL JOINT, WITH      137.59   114.66                 0   0
26910   AMPUTATION, METACARPAL, WITH FINGER OR T      422.44   352.03                 0  90
26951   AMPUTATION, FINGER OR THUMB, PRIMARY OR       363.68   303.07                 0  90
26952   AMPUTATION, FINGER OR THUMB, PRIMARY OR       392.29   326.91                 0  90
26989   UNLISTED PROCEDURE, HANDS OR FINGERS                                      BR 0    0
26990   INCISION AND DRAINAGE, PELVIS OR HIP JOI      352.44   293.70                 0  90
26991   INCISION AND DRAINAGE, PELVIS OR HIP JOI      410.62   245.18                 0  90
26992   INCISION, BONE CORTEX, PELVIS AND/OR HIP      552.83   460.70                 0  90
27000   TENOTOMY, ADDUCTOR OF HIP, PERCUTANEOUS       258.01   215.01                 0  90
                                                                                                   Page 47 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
27001   TENOTOMY, ADDUCTOR OF HIP, OPEN               311.06   259.22                 0  90
27003   TENOTOMY, ADDUCTOR, SUBCUTANEOUS, OPEN,       332.65   277.21                 0  90
27005   TENOTOMY, HIP FLEXOR(S), OPEN (SEPARATE       418.06   348.38                 0  90
27006   TENOTOMY, ABDUCTORS AND/OR EXTENSOR(S) O      423.49   352.91                 0  90
27025   FASCIOTOMY, HIP OR THIGH, ANY TYPE            506.17   421.81                 0  90
27027   DECOMPRESSION FASCIOTOMY(IES), PELVIC         493.11   410.93                 0  90
27030   ARTHROTOMY, HIP, WITH DRAINAGE (EG, INFE      544.77   453.98                 0  90
27033   ARTHROTOMY, HIP, INCLUDING EXPLORATION O      563.27   469.39                 0  90
27035   DENERVATION, HIP JOINT, INTRAPELVIC OR E                                  BR 0   90
27036   CAPSULECTOMY OR CAPSULOTOMY, HIP, WITH O      573.49   477.91                 0  90
27040   BIOPSY, SOFT TISSUE OF PELVIS AND HIP AR      193.40    93.89                 0  10
27041   BIOPSY, SOFT TISSUE OF PELVIS AND HIP AR      388.21   323.51                 0  90
27043   EXCISION, TUMOR, SOFT TISSUE OF PELVIS A      280.94   234.12                 0  90
27045   EXCISION, TUMOR, SOFT TISSUE OF PELVIS A      446.02   371.68                 0  90
27047   EXCISION, TUMOR, SOFT TISSUE OF PELVIS A      350.31   241.88                 0  90
27048   EXCISION, TUMOR, SOFT TISSUE OF PELVIS A      267.73   223.11                 0  90
27049   RADICAL RESECTION OF TUMOR, (EG, MALIGNA      560.81   467.34                 0  90
27050   ARTHROTOMY, WITH BIOPSY; SACROILIAC JOIN      280.00   280.00                 0  90
27052   ARTHROTOMY, WITH BIOPSY; HIP JOINT            314.57   280.00                 0  90
27054   ARTHROTOMY WITH SYNOVECTOMY, HIP JOINT        388.71   323.93                 0  90
27057   DECOMPRESSION FASCIOTOMY(IES), PELVIC         545.04   681.30                 0  90
27059   RADICAL RESECTION OF TUMOR (EG, MALIGNAN    1,089.59   907.99                 0  90
27060   EXCISION; ISCHIAL BURSA                       243.47   202.89                 0  90
27062   EXCISION; TROCHANTERIC BURSA OR CALCIFIC      256.88   214.07                 0  90
27065   EXCISION OF BONE CYST OR BENIGN TUMOR; S      282.55   235.46                 0  90
27066   EXCISION OF BONE CYST OR BENIGN TUMOR; D      461.55   384.63                 0  90
27067   EXCISION OF BONE CYST OR BENIGN TUMOR; W      579.07   482.56                 0  90
27070   PARTIAL EXCISION (CRATERIZATION, SAUCERI      484.07   403.39                 0  90
27071   PARTIAL EXCISION (CRATERIZATION, SAUCERI      522.52   435.43                 0  90
                                                                                                    Page 48 of 189


                                                                                                C
                                                      NON-                                      H
                                                                                                A
                                                    FACILITY FACILITY PROFESSIONAL              N
                                                    GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
27075   RADICAL RESECTION OF TUMOR; WING OF ILIU     1,312.60 1,093.83                 0  90
27076   RADICAL RESECTION OF TUMOR; ILIUM, INCLU       914.75   762.30                 0  90
27077   RADICAL RESECTION OF TUMOR; INNOMINATE B     1,530.43 1,275.36                 0  90
27078   RADICAL RESECTION OF TUMOR; ISCHIAL TUBER      577.55   481.30                 0  90
27080   COCCYGECTOMY, PRIMARY                          275.62   229.68                 0  90
27086   REMOVAL OF FOREIGN BODY, PELVIS OR HIP;        145.24    70.58                 0  10
27087   REMOVAL OF FOREIGN BODY, PELVIS OR HIP;        359.90   299.92                 0  90
27090   REMOVAL OF HIP PROSTHESIS; (SEPARATE PRO       479.29   399.41                 0  90
27091   REMOVAL OF HIP PROSTHESIS; COMPLICATED,        910.63   758.86                 0  90
27093   INJECTION PROCEDURE FOR HIP ARTHROGRAPHY       123.11    34.29                 0   0
27095   INJECTION PROCEDURE FOR HIP ARTHROGRAPHY       149.90    38.57                 0   0
27096   INJECTION PROCEDURE FOR SACROILIAC JOINT       114.97    32.02                 0   0
27097   RELEASE OR RECESSION, HAMSTRING, PROXIMA       379.29   316.08                 0  90
27098   TRANSFER, ADDUCTOR TO ISCHIUM                  355.97   296.64                 0  90
27100   TRANSFER EXTERNAL OBLIQUE MUSCLE TO GREA       468.37   390.31                 0  90
27105   TRANSFER PARASPINAL MUSCLE TO HIP (INCLU                                   BR 0   90
27110   TRANSFER ILIOPSOAS; TO GREATER TROCHANTE       541.39   460.00                 0  90
27111   TRANSFER ILIOPSOAS; TO FEMORAL NECK            509.91   460.00                 0  90
27120   ACETABULOPLASTY; (EG, WHITMAN, COLONNA,        738.02   615.02                 0  90
27122   ACETABULOPLASTY; RESECTION, FEMORAL HEAD       636.45   530.38                 0  90
27125   HEMIARTHROPLASTY, HIP, PARTIAL (EG, FEMO       641.87   534.90                 0  90
27130   ARTHROPLASTY, ACETABULAR AND PROXIMAL FE       828.44   690.37                 0  90
27132   CONVERSION OF PREVIOUS HIP SURGERY TO TO       969.05   807.54                 0  90
27134   REVISION OF TOTAL HIP ARTHROPLASTY; BOTH     1,125.89   938.25                 0  90
27137   REVISION OF TOTAL HIP ARTHROPLASTY; ACET       858.88   715.74                 0  90
27138   REVISION OF TOTAL HIP ARTHROPLASTY; FEMO       893.43   744.53                 0  90
27140   OSTEOTOMY AND TRANSFER OF GREATER TROCHA       518.89   432.41                 0  90
27146   OSTEOTOMY, ILIAC, ACETABULAR OR INNOMINA       729.66   608.05                 0  90
27147   OSTEOTOMY, ILIAC, ACETABULAR OR INNOMINA       837.81   698.18                 0  90
                                                                                                   Page 49 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
27151   OSTEOTOMY, ILIAC, ACETABULAR OR INNOMINA      832.52   693.77                 0  90
27156   OSTEOTOMY, ILIAC, ACETABULAR OR INNOMINA      992.62   827.18                 0  90
27158   OSTEOTOMY, PELVIS, BILATERAL (EG, CONGEN      774.46   645.39                 0  90
27161   OSTEOTOMY, FEMORAL NECK (SEPARATE PROCED      704.86   587.38                 0  90
27165   OSTEOTOMY, INTERTROCHANTERIC OR SUBTROCH      780.58   650.48                 0  90
27170   BONE GRAFT, FEMORAL HEAD, NECK, INTERTRO      678.90   565.75                 0  90
27175   TREATMENT OF SLIPPED FEMORAL EPIPHYSIS;       368.05   306.71                 0  90
27176   TREATMENT OF SLIPPED FEMORAL EPIPHYSIS;       522.44   435.37                 0  90
27177   OPEN TREATMENT OF SLIPPED FEMORAL EPIPHY      636.95   530.80                 0  90
27178   OPEN TREATMENT OF SLIPPED FEMORAL EPIPHY      509.45   424.55                 0  90
27179   OPEN TREATMENT OF SLIPPED FEMORAL EPIPHY      561.65   468.04                 0  90
27181   OPEN TREATMENT OF SLIPPED FEMORAL EPIPHY      606.92   505.77                 0  90
27185   EPIPHYSEAL ARREST BY EPIPHYSIODESIS OR S      425.59   354.66                 0  90
27187   PROPHYLACTIC TREATMENT (NAILING, PINNING      575.09   479.24                 0  90
27193   CLOSED TREATMENT OF PELVIC RING FRACTURE      263.30   220.65                 0  90
27194   CLOSED TREATMENT OF PELVIC RING FRACTURE      418.31   348.60                 0  90
27200   CLOSED TREATMENT OF COCCYGEAL FRACTURE         97.44    82.02                 0  90
27202   OPEN TREATMENT OF COCCYGEAL FRACTURE                                      BR 0   90
27215   OPEN TREATMENT OF ILIAC SPINE(S), TUBERO      425.51   354.60                 0  90
27216   PERCUTANEOUS SKELETAL FIXATION OF POSTER      610.85   509.04                 0  90
27217   OPEN TREATMENT OF ANTERIOR PELVIC BONE F      584.39   486.99                 0  90
27218   OPEN TREATMENT OF POSTERIOR PELVIC BONE       785.30   654.42                 0  90
27220   CLOSED TREATMENT OF ACETABULUM (HIP SOCK      296.33   244.90                 0  90
27222   CLOSED TREATMENT OF ACETABULUM (HIP SOCK      562.10   468.42                 0  90
27226   OPEN TREATMENT OF POSTERIOR OR ANTERIOR       577.31   481.09                 0  90
27227   OPEN TREATMENT OF ACETABULAR FRACTURE(S)      959.79   799.83                 0  90
27228   OPEN TREATMENT OF ACETABULAR FRACTURE(S)    1,098.97   915.81                 0  90
27230   CLOSED TREATMENT OF FEMORAL FRACTURE, PR      266.15   216.67                 0  90
27232   CLOSED TREATMENT OF FEMORAL FRACTURE, PR      443.18   369.32                 0  90
                                                                                                   Page 50 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
27235   PERCUTANEOUS SKELETAL FIXATION OF FEMORA      525.01   437.51                 0  90
27236   OPEN TREATMENT OF FEMORAL FRACTURE, PROX      677.68   564.73                 0  90
27238   CLOSED TREATMENT OF INTERTROCHANTERIC, P      255.76   213.13                 0  90
27240   CLOSED TREATMENT OF INTERTROCHANTERIC, P      545.08   454.23                 0  90
27244   TREATMENT OF INTERTROCHANTERIC, PERTROCH      668.40   557.00                 0  90
27245   TREATMENT OF INTERTROCHANTERIC, PERTROCH      818.48   682.07                 0  90
27246   CLOSED TREATMENT OF GREATER TROCHANTERIC      217.93   181.61                 0  90
27248   OPEN TREATMENT OF GREATER TROCHANTERIC F      437.68   364.73                 0  90
27250   CLOSED TREATMENT OF HIP DISLOCATION, TRA      270.84   225.70                 0   0
27252   CLOSED TREATMENT OF HIP DISLOCATION, TRA      431.50   359.59                 0  90
27253   OPEN TREATMENT OF HIP DISLOCATION, TRAUM      546.15   455.13                 0  90
27254   OPEN TREATMENT OF HIP DISLOCATION, TRAUM      732.79   610.66                 0  90
27256   TREATMENT OF SPONTANEOUS HIP DISLOCATION      171.32   116.73                 0  10
27257   TREATMENT OF SPONTANEOUS HIP DISLOCATION      190.60   158.84                 0  10
27258   OPEN TREATMENT OF SPONTANEOUS HIP DISLOC      637.27   531.06                 0  90
27259   OPEN TREATMENT OF SPONTANEOUS HIP DISLOC      885.20   737.67                 0  90
27265   CLOSED TREATMENT OF POST HIP ARTHROPLAST      226.21   188.51                 0  90
27266   CLOSED TREATMENT OF POST HIP ARTHROPLAST      331.34   276.12                 0  90
27267   CLOSED TREATMENT OF FEMORAL FRACTURE, PR      238.12   198.44                 0  90
27268   CLOSED TREATMENT OF FEMORAL FRACTURE, PR      292.35   243.63                 0  90
27269   OPEN TREATMENT OF FEMORAL FRACTURE, PROX      691.80   576.50                 0  90
27275   MANIPULATION, HIP JOINT, REQUIRING GENER      104.30    86.92                 0  10
27280   ARTHRODESIS, SACROILIAC JOINT (INCLUDING                                  BR 0   90
27282   ARTHRODESIS, SYMPHYSIS PUBIS (INCLUDING                                   BR 0   90
27284   ARTHRODESIS, HIP JOINT (INCLUDING OBTAIN      926.23   771.86                 0  90
27286   ARTHRODESIS, HIP JOINT (INCLUDING OBTAIN      929.60   774.67                 0  90
27290   INTERPELVIABDOMINAL AMPUTATION (HINDQUAR                                  BR 0   90
27295   DISARTICULATION OF HIP                        722.48   602.07                 0  90
27299   UNLISTED PROCEDURE, PELVIS OR HIP JOINT                                   BR 0    0
                                                                                                   Page 51 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                         DESCRIPTION             FEE      FEE        FEE      BR PA DAYS   E
27301   INCISION AND DRAINAGE, DEEP ABSCESS, BUR      384.34   233.11                 0  90
27303   INCISION, DEEP, WITH OPENING OF BONE COR      365.65   304.71                 0  90
27305   FASCIOTOMY, ILIOTIBIAL (TENOTOMY), OPEN       268.23   223.53                 0  90
27306   TENOTOMY, PERCUTANEOUS, ADDUCTOR OR HAMS      222.39   185.33                 0  90
27307   TENOTOMY, PERCUTANEOUS, ADDUCTOR OR HAMS      269.78   224.82                 0  90
27310   ARTHROTOMY, KNEE, WITH EXPLORATION, DRAI      414.47   345.40                 0  90
27323   BIOPSY, SOFT TISSUE OF THIGH OR KNEE ARE      147.43    82.87                 0  10
27324   BIOPSY, SOFT TISSUE OF THIGH OR KNEE ARE      216.32   180.27                 0  90
27325   NEURECTOMY, HAMSTRING MUSCLE                                              BR 0   90
27326   NEURECTOMY, POPLITEAL (GASTROCNEMIUS)         281.06   234.22                 0  90
27327   EXCISION, TUMOR, SOFT TISSUE OF THIGH OR      254.77   163.70                 0  90
27328   EXCISION, TUMOR, SOFT TISSUE OF THIGH OR      237.43   197.86                 0  90
27329   RADICAL RESECTION OF TUMOR (EG, MALIGNAN      583.66   486.38                 0  90
27330   ARTHROTOMY, KNEE; WITH SYNOVIAL BIOPSY O      230.53   200.00                 0  90
27331   ARTHROTOMY, KNEE; INCLUDING JOINT EXPLOR      270.87   225.73                 0  90
27332   ARTHROTOMY, WITH EXCISION OF SEMILUNAR C      365.14   304.28                 0  90
27333   ARTHROTOMY, WITH EXCISION OF SEMILUNAR C      331.95   300.00                 0  90
27334   ARTHROTOMY, WITH SYNOVECTOMY, KNEE; ANTE      389.38   324.49                 0  90
27335   ARTHROTOMY, WITH SYNOVECTOMY, KNEE; ANTE      439.57   366.31                 0  90
27337   EXCISION, TUMOR, SOFT TISSUE OF THIGH OR      250.97   209.15                 0  90
27339   EXCISION, TUMOR, SOFT TISSUE OF THIGH OR      450.91   375.76                 0  90
27340   EXCISION, PREPATELLAR BURSA                   208.21   173.51                 0  90
27345   EXCISION OF SYNOVIAL CYST OF POPLITEAL S      274.04   228.37                 0  90
27347   EXCISION OF LESION OF MENISCUS OR CAPSUL      287.61   239.68                 0  90
27350   PATELLECTOMY OR HEMIPATELLECTOMY              372.06   310.05                 0  90
27355   EXCISION OR CURETTAGE OF BONE CYST OR BE      345.50   287.92                 0  90
27356   EXCISION OR CURETTAGE OF BONE CYST OR BE      421.17   350.98                 0  90
27357   EXCISION OR CURETTAGE OF BONE CYST OR BE      467.91   389.93                 0  90
27358   EXCISION OR CURETTAGE OF BONE CYST OR BE      168.46   140.38                 0   0
                                                                                                   Page 52 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
27360   PARTIAL EXCISION (CRATERIZATION, SAUCERI      489.65   408.05                 0  90
27364   PARTIAL EXCISION (CRATERIZATION, SAUCERI      939.34   782.78                 0  90
27365   RADICAL RESECTION OF TUMOR, FEMUR OR KNE      700.75   583.96                 0  90
27370   INJECTION PROCEDURE FOR KNEE ARTHROGRAPH      104.19    24.89                 0   0
27372   REMOVAL OF FOREIGN BODY, DEEP, THIGH REG      349.31   192.24                 0  90
27380   SUTURE OF INFRAPATELLAR TENDON; PRIMARY       341.71   284.76                 0  90
27381   SUTURE OF INFRAPATELLAR TENDON; SECONDAR      462.58   385.48                 0  90
27385   SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE      365.23   304.36                 0  90
27386   SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE      480.70   400.59                 0  90
27390   TENOTOMY, OPEN, HAMSTRING, KNEE TO HIP;       249.55   207.96                 0  90
27391   TENOTOMY, OPEN, HAMSTRING, KNEE TO HIP;       327.40   272.83                 0  90
27392   TENOTOMY, OPEN, HAMSTRING, KNEE TO HIP;       404.70   337.25                 0  90
27393   LENGTHENING OF HAMSTRING TENDON; SINGLE       290.16   241.80                 0  90
27394   LENGTHENING OF HAMSTRING TENDON; MULTIPL      374.71   312.26                 0  90
27395   LENGTHENING OF HAMSTRING TENDON; MULTIPL      505.46   421.22                 0  90
27396   TRANSPLANT OR TRANSFER (WITH MUSCLE REDI      352.17   293.48                 0  90
27397   TRANSPLANT OR TRANSFER (WITH MUSCLE REDI      509.43   424.53                 0  90
27400   TRANSFER, TENDON OR MUSCLE, HAMSTRINGS T      386.68   322.24                 0  90
27403   ARTHROTOMY WITH MENISCUS REPAIR, KNEE         368.59   307.16                 0  90
27405   REPAIR, PRIMARY, TORN LIGAMENT AND/OR CA      387.55   322.96                 0  90
27407   REPAIR, PRIMARY, TORN LIGAMENT AND/OR CA      445.28   371.07                 0  90
27409   REPAIR, PRIMARY, TORN LIGAMENT AND/OR CA      551.66   459.72                 0  90
27415   OSTEOCHONDRAL ALLOGRAFT, KNEE, OPEN           801.36   667.80                 0  90
27416   OSTEOCHONDRAL AUTOGRAFT(S), KNEE, OPEN (      544.32   453.60                 0  90
27418   ANTERIOR TIBIAL TUBERCLEPLASTY (EG, MAQU      479.06   399.22                 0  90
27420   RECONSTRUCTION OF DISLOCATING PATELLA; (      430.40   358.67                 0  90
27422   RECONSTRUCTION OF DISLOCATING PATELLA; W      429.00   357.50                 0  90
27424   RECONSTRUCTION OF DISLOCATING PATELLA; W      429.47   357.89                 0  90
27425   LATERAL RETINACULAR RELEASE, OPEN             253.98   225.00                 0  90
                                                                                                   Page 53 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
27427   LIGAMENTOUS RECONSTRUCTION (AUGMENTATION      412.48   343.73                 0  90
27428   LIGAMENTOUS RECONSTRUCTION (AUGMENTATION      629.53   524.61                 0  90
27429   LIGAMENTOUS RECONSTRUCTION (AUGMENTATION                                  BR 0   90
27430   QUADRICEPSPLASTY (EG, BENNETT OR THOMPSO      425.65   354.71                 0  90
27435   CAPSULOTOMY, POSTERIOR CAPSULAR RELEASE,      453.89   378.24                 0  90
27437   ARTHROPLASTY, PATELLA; WITHOUT PROSTHESI                                  BR 0   90
27438   ARTHROPLASTY, PATELLA; WITH PROSTHESIS                                    BR 0   90
27440   ARTHROPLASTY, KNEE, TIBIAL PLATEAU;           424.70   400.00                 0  90
27441   ARTHROPLASTY, KNEE, TIBIAL PLATEAU; WITH      448.84   400.00                 0  90
27442   ARTHROPLASTY, FEMORAL CONDYLES OR TIBIAL      500.99   417.49                 0  90
27443   ARTHROPLASTY, FEMORAL CONDYLES OR TIBIAL      471.11   400.00                 0  90
27445   ARTHROPLASTY, KNEE, HINGE PROSTHESIS (EG      727.68   606.40                 0  90
27446   ARTHROPLASTY, KNEE, CONDYLE AND PLATEAU;      647.96   539.97                 0  90
27447   ARTHROPLASTY, KNEE, CONDYLE AND PLATEAU;      890.00   741.67                 0  90
27448   OSTEOTOMY, FEMUR, SHAFT OR SUPRACONDYLAR      473.98   394.99                 0  90
27450   OSTEOTOMY, FEMUR, SHAFT OR SUPRACONDYLAR      588.78   490.65                 0  90
27454   OSTEOTOMY, MULTIPLE, WITH REALIGNMENT ON      743.27   619.40                 0  90
27455   OSTEOTOMY, PROXIMAL TIBIA, INCLUDING FIB      544.70   453.92                 0  90
27457   OSTEOTOMY, PROXIMAL TIBIA, INCLUDING FIB      560.36   466.97                 0  90
27465   OSTEOPLASTY, FEMUR; SHORTENING (EXCLUDIN      684.54   570.45                 0  90
27466   OSTEOPLASTY, FEMUR; LENGTHENING               681.38   567.82                 0  90
27468   OSTEOPLASTY, FEMUR; COMBINED, LENGTHENIN      768.39   640.33                 0  90
27470   REPAIR, NONUNION OR MALUNION, FEMUR, DIS      679.33   566.11                 0  90
27472   REPAIR, NONUNION OR MALUNION, FEMUR, DIS      735.27   612.73                 0  90
27475   ARREST, EPIPHYSEAL, ANY METHOD (EG, EPIP      375.74   313.12                 0  90
27477   ARREST, EPIPHYSEAL, ANY METHOD (EG, EPIP      420.16   350.14                 0  90
27479   ARREST, EPIPHYSEAL, ANY METHOD (EG, EPIP      556.35   463.63                 0  90
27485   ARREST, HEMIEPIPHYSEAL, DISTAL FEMUR OR       385.96   321.64                 0  90
27486   REVISION OF TOTAL KNEE ARTHROPLASTY, WIT      811.90   676.59                 0  90
                                                                                                   Page 54 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
27487   REVISION OF TOTAL KNEE ARTHROPLASTY, WIT    1,023.84   853.20                 0  90
27488   REMOVAL OF PROSTHESIS, INCLUDING TOTAL K      687.01   572.51                 0  90
27495   PROPHYLACTIC TREATMENT (NAILING, PINNING      654.38   545.32                 0  90
27496   DECOMPRESSION FASCIOTOMY, THIGH AND/OR K      288.22   240.19                 0  90
27497   DECOMPRESSION FASCIOTOMY, THIGH AND/OR K      311.17   259.31                 0  90
27498   DECOMPRESSION FASCIOTOMY, THIGH AND/OR K      339.20   282.67                 0  90
27499   DECOMPRESSION FASCIOTOMY, THIGH AND/OR K      380.55   317.13                 0  90
27500   CLOSED TREATMENT OF FEMORAL SHAFT FRACTU      291.18   222.97                 0  90
27501   CLOSED TREATMENT OF SUPRACONDYLAR OR TRA      285.34   232.66                 0  90
27502   CLOSED TREATMENT OF FEMORAL SHAFT FRACTU      453.95   378.30                 0  90
27503   CLOSED TREATMENT OF SUPRACONDYLAR OR TRA      459.38   382.82                 0  90
27506   OPEN TREATMENT OF FEMORAL SHAFT FRACTURE      761.84   634.87                 0  90
27507   OPEN TREATMENT OF FEMORAL SHAFT FRACTURE      569.44   474.53                 0  90
27508   CLOSED TREATMENT OF FEMORAL FRACTURE, DI      295.40   229.56                 0  90
27509   PERCUTANEOUS SKELETAL FIXATION OF FEMORA      372.13   310.11                 0  90
27510   CLOSED TREATMENT OF FEMORAL FRACTURE, DI      399.16   332.63                 0  90
27511   OPEN TREATMENT OF FEMORAL SUPRACONDYLAR       596.62   497.19                 0  90
27513   OPEN TREATMENT OF FEMORAL SUPRACONDYLAR       751.21   626.01                 0  90
27514   OPEN TREATMENT OF FEMORAL FRACTURE, DIST      623.98   519.98                 0  90
27516   CLOSED TREATMENT OF DISTAL FEMORAL EPIPH                                  BR 0   90
27517   CLOSED TREATMENT OF DISTAL FEMORAL EPIPH                                  BR 0   90
27519   OPEN TREATMENT OF DISTAL FEMORAL EPIPHYS      558.48   465.40                 0  90
27520   CLOSED TREATMENT OF PATELLAR FRACTURE, W      176.66   130.00                 0  90
27524   OPEN TREATMENT OF PATELLAR FRACTURE, WIT      435.36   362.80                 0  90
27530   CLOSED TREATMENT OF TIBIAL FRACTURE, PRO      220.49   168.77                 0  90
27532   CLOSED TREATMENT OF TIBIAL FRACTURE, PRO      349.18   273.76                 0  90
27535   OPEN TREATMENT OF TIBIAL FRACTURE, PROXI      532.13   443.44                 0  90
27536   OPEN TREATMENT OF TIBIAL FRACTURE, PROXI      680.89   567.41                 0  90
27538   CLOSED TREATMENT OF INTERCONDYLAR SPINE(      263.39   203.49                 0  90
                                                                                                   Page 55 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
27540   OPEN TREATMENT OF INTERCONDYLAR SPINE(S)      486.97   405.81                 0  90
27550   CLOSED TREATMENT OF KNEE DISLOCATION; WI      274.49   210.29                 0  90
27552   CLOSED TREATMENT OF KNEE DISLOCATION; RE      355.08   295.90                 0  90
27556   OPEN TREATMENT OF KNEE DISLOCATION, INCL      551.52   459.60                 0  90
27557   OPEN TREATMENT OF KNEE DISLOCATION, INCL      654.13   545.11                 0  90
27558   OPEN TREATMENT OF KNEE DISLOCATION, INCL      716.71   597.26                 0  90
27560   CLOSED TREATMENT OF PATELLAR DISLOCATION      199.97   144.29                 0  90
27562   CLOSED TREATMENT OF PATELLAR DISLOCATION      256.12   213.43                 0  90
27566   OPEN TREATMENT OF PATELLAR DISLOCATION,       516.73   430.61                 0  90
27570   MANIPULATION OF KNEE JOINT UNDER GENERAL       84.50    70.42                 0  10
27580   ARTHRODESIS, KNEE, ANY TECHNIQUE              834.55   695.46                 0  90
27590   AMPUTATION, THIGH, THROUGH FEMUR, ANY LE      468.10   390.09                 0  90
27591   AMPUTATION, THIGH, THROUGH FEMUR, ANY LE      524.50   437.09                 0  90
27592   AMPUTATION, THIGH, THROUGH FEMUR, ANY LE      397.09   330.91                 0  90
27594   AMPUTATION, THIGH, THROUGH FEMUR, ANY LE      290.96   242.47                 0  90
27596   AMPUTATION, THIGH, THROUGH FEMUR, ANY LE      420.34   350.28                 0  90
27598   DISARTICULATION AT KNEE                       425.91   354.93                 0  90
27599   UNLISTED PROCEDURE, FEMUR OR KNEE                                         BR 0    0
27600   DECOMPRESSION FASCIOTOMY, LEG; ANTERIOR       242.89   202.41                 0  90
27601   DECOMPRESSION FASCIOTOMY, LEG; POSTERIOR      250.16   208.47                 0  90
27602   DECOMPRESSION FASCIOTOMY, LEG; ANTERIOR       297.97   248.31                 0  90
27603   INCISION AND DRAINAGE, LEG OR ANKLE; DEE      300.06   183.60                 0  90
27604   INCISION AND DRAINAGE, LEG OR ANKLE; INF      262.30   165.26                 0  90
27605   TENOTOMY, PERCUTANEOUS, ACHILLES TENDON       226.07    98.36                 0  10
27606   TENOTOMY, PERCUTANEOUS, ACHILLES TENDON       173.67   144.73                 0  10
27607   INCISION (EG, OSTEOMYELITIS OR BONE ABSC      349.18   290.99                 0  90
27610   ARTHROTOMY, ANKLE, INCLUDING EXPLORATION      376.66   313.88                 0  90
27612   ARTHROTOMY, POSTERIOR CAPSULAR RELEASE,       327.56   272.97                 0  90
27613   BIOPSY, SOFT TISSUE OF LEG OR ANKLE AREA      137.08    77.73                 0  10
                                                                                                   Page 56 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
27614   BIOPSY, SOFT TISSUE OF LEG OR ANKLE AREA      317.44   197.67                 0  90
27615   RADICAL RESECTION OF TUMOR (EG, MALIGNAN      510.53   425.44                 0  90
27616   RADICAL RESECTION OF TUMOR (EG, MALIGNAN      767.53   639.61                 0  90
27618   EXCISION, TUMOR, SOFT TISSUE OF LEG OR A      274.48   180.94                 0  90
27619   EXCISION, TUMOR, SOFT TISSUE OF LEG OR A      441.16   282.72                 0  90
27620   ARTHROTOMY, ANKLE, WITH JOINT EXPLORATIO      268.61   223.85                 0  90
27625   ARTHROTOMY, WITH SYNOVECTOMY, ANKLE;          346.71   288.93                 0  90
27626   ARTHROTOMY, WITH SYNOVECTOMY, ANKLE; INC      372.82   310.69                 0  90
27630   EXCISION OF LESION OF TENDON SHEATH OR C      306.80   180.19                 0  90
27632   EXCISION, TUMOR, SOFT TISSUE OF LEG OR A      247.86   206.55                 0  90
27634   EXCISION, TUMOR, SOFT TISSUE OF LEG OR A      403.61   336.35                 0  90
27635   EXCISION OR CURETTAGE OF BONE CYST OR BE      343.28   286.07                 0  90
27637   EXCISION OR CURETTAGE OF BONE CYST OR BE      431.96   359.97                 0  90
27638   EXCISION OR CURETTAGE OF BONE CYST OR BE      452.09   376.74                 0  90
27640   PARTIAL EXCISION (CRATERIZATION, SAUCERI      508.27   423.56                 0  90
27641   PARTIAL EXCISION (CRATERIZATION, SAUCERI      409.08   340.90                 0  90
27645   RADICAL RESECTION OF TUMOR; TIBIA             612.02   510.02                 0  90
27646   RADICAL RESECTION OF TUMOR; FIBULA            545.64   454.70                 0  90
27647   RADICAL RESECTION OF TUMOR; TALUS OR CAL      476.09   396.75                 0  90
27648   INJECTION PROCEDURE FOR ANKLE ARTHROGRAP      100.25    24.89                 0   0
27650   REPAIR, PRIMARY, OPEN OR PERCUTANEOUS, R      406.82   339.02                 0  90
27652   REPAIR, PRIMARY, OPEN OR PERCUTANEOUS, R      433.95   361.63                 0  90
27654   REPAIR, SECONDARY, ACHILLES TENDON, WITH      407.83   339.86                 0  90
27656   REPAIR, FASCIAL DEFECT OF LEG                 312.86   166.99                 0  90
27658   REPAIR, FLEXOR TENDON, LEG; PRIMARY, WIT      224.26   186.89                 0  90
27659   REPAIR, FLEXOR TENDON, LEG; SECONDARY, W      294.22   245.19                 0  90
27664   REPAIR, EXTENSOR TENDON, LEG; PRIMARY, W      215.71   179.76                 0  90
27665   REPAIR, EXTENSOR TENDON, LEG; SECONDARY,                                  BR 0   90
27675   REPAIR, DISLOCATING PERONEAL TENDONS; WI      301.00   250.84                 0  90
                                                                                                   Page 57 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
27676   REPAIR, DISLOCATING PERONEAL TENDONS; WI      360.00   300.00                 0  90
27680   TENOLYSIS, FLEXOR OR EXTENSOR TENDON, LE      253.27   211.06                 0  90
27681   TENOLYSIS, FLEXOR OR EXTENSOR TENDON, LE      303.02   252.52                 0  90
27685   LENGTHENING OR SHORTENING OF TENDON, LEG      353.84   232.93                 0  90
27686   LENGTHENING OR SHORTENING OF TENDON, LEG      328.77   273.98                 0  90
27687   GASTROCNEMIUS RECESSION (EG, STRAYER PRO      271.67   226.39                 0  90
27690   TRANSFER OR TRANSPLANT OF SINGLE TENDON       356.93   297.44                 0  90
27691   TRANSFER OR TRANSPLANT OF SINGLE TENDON       424.00   353.34                 0  90
27692   TRANSFER OR TRANSPLANT OF SINGLE TENDON        65.60    54.67                 0   0
27695   REPAIR, PRIMARY, DISRUPTED LIGAMENT, ANK      290.17   241.81                 0  90
27696   REPAIR, PRIMARY, DISRUPTED LIGAMENT, ANK      345.37   287.81                 0  90
27698   REPAIR, SECONDARY, DISRUPTED LIGAMENT, A      384.50   320.42                 0  90
27700   ARTHROPLASTY, ANKLE;                          357.98   300.00                 0  90
27702   ARTHROPLASTY, ANKLE; WITH IMPLANT (TOTAL      580.03   483.36                 0  90
27703   ARTHROPLASTY, ANKLE; REVISION, TOTAL ANK                                  BR 0   90
27704   REMOVAL OF ANKLE IMPLANT                      323.48   269.57                 0  90
27705   OSTEOTOMY; TIBIA                              446.18   371.82                 0  90
27707   OSTEOTOMY; FIBULA                             228.23   190.20                 0  90
27709   OSTEOTOMY; TIBIA AND FIBULA                   615.20   512.67                 0  90
27712   OSTEOTOMY; MULTIPLE, WITH REALIGNMENT ON      624.07   520.06                 0  90
27715   OSTEOPLASTY, TIBIA AND FIBULA, LENGTHENI      613.58   511.32                 0  90
27720   REPAIR OF NONUNION OR MALUNION, TIBIA; W      508.77   423.98                 0  90
27722   REPAIR OF NONUNION OR MALUNION, TIBIA; W      506.91   422.43                 0  90
27724   REPAIR OF NONUNION OR MALUNION, TIBIA; W      741.44   617.87                 0  90
27725   REPAIR OF NONUNION OR MALUNION, TIBIA; B      687.88   573.24                 0  90
27726   REPAIR OF FIBULA NONUNION AND/OR MALUNIO      510.79   425.66                 0  90
27727   REPAIR OF CONGENITAL PSEUDARTHROSIS, TIB                                  BR 0   90
27730   ARREST, EPIPHYSEAL (EPIPHYSIODESIS), OPE      338.12   281.77                 0  90
27732   ARREST, EPIPHYSEAL (EPIPHYSIODESIS), OPE      238.88   220.00                 0  90
                                                                                                   Page 58 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
27734   ARREST, EPIPHYSEAL (EPIPHYSIODESIS), OPE      361.62   330.00                 0  90
27740   ARREST, EPIPHYSEAL (EPIPHYSIODESIS), ANY      409.78   341.48                 0  90
27742   ARREST, EPIPHYSEAL (EPIPHYSIODESIS), ANY      400.00   400.00                 0  90
27745   PROPHYLACTIC TREATMENT (NAILING, PINNING      437.66   364.72                 0  90
27750   CLOSED TREATMENT OF TIBIAL SHAFT FRACTUR      190.60   143.45                 0  90
27752   CLOSED TREATMENT OF TIBIAL SHAFT FRACTUR      303.34   234.12                 0  90
27756   PERCUTANEOUS SKELETAL FIXATION OF TIBIAL      326.12   271.77                 0  90
27758   OPEN TREATMENT OF TIBIAL SHAFT FRACTURE,      510.77   425.65                 0  90
27759   TREATMENT OF TIBIAL SHAFT FRACTURE (WITH      579.47   482.89                 0  90
27760   CLOSED TREATMENT OF MEDIAL MALLEOLUS FRA      184.07   135.96                 0  90
27762   CLOSED TREATMENT OF MEDIAL MALLEOLUS FRA      273.23   208.41                 0  90
27766   OPEN TREATMENT OF MEDIAL MALLEOLUS FRACT      354.56   295.47                 0  90
27767   CLOSED TREATMENT OF POSTERIOR MALLEOLUS       146.81   122.96                 0  90
27768   CLOSED TREATMENT OF POSTERIOR MALLEOLUS       225.53   187.95                 0  90
27769   OPEN TREATMENT OF POSTERIOR MALLEOLUS FR      386.36   321.97                 0  90
27780   CLOSED TREATMENT OF PROXIMAL FIBULA OR S      163.76   120.88                 0  90
27781   CLOSED TREATMENT OF PROXIMAL FIBULA OR S      235.43   181.02                 0  90
27784   OPEN TREATMENT OF PROXIMAL FIBULA OR SHA      385.49   321.25                 0  90
27786   CLOSED TREATMENT OF DISTAL FIBULAR FRACT      174.50   127.37                 0  90
27788   CLOSED TREATMENT OF DISTAL FIBULAR FRACT      239.54   181.77                 0  90
27792   OPEN TREATMENT OF DISTAL FIBULAR FRACTUR      394.10   328.42                 0  90
27808   CLOSED TREATMENT OF BIMALLEOLAR ANKLE FR      182.87   133.93                 0  90
27810   CLOSED TREATMENT OF BIMALLEOLAR ANKLE FR      268.04   203.27                 0  90
27814   OPEN TREATMENT OF BIMALLEOLAR ANKLE FRAC      449.63   374.70                 0  90
27816   CLOSED TREATMENT OF TRIMALLEOLAR ANKLE F      173.26   127.57                 0  90
27818   CLOSED TREATMENT OF TRIMALLEOLAR ANKLE F      276.93   208.62                 0  90
27822   OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRA      500.22   416.85                 0  90
27823   OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRA      566.91   472.43                 0  90
27824   CLOSED TREATMENT OF FRACTURE OF WEIGHT B      170.45   135.08                 0  90
                                                                                                   Page 59 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
27825   CLOSED TREATMENT OF FRACTURE OF WEIGHT B      309.89   235.27                 0  90
27826   OPEN TREATMENT OF FRACTURE OF WEIGHT BEA      465.63   388.03                 0  90
27827   OPEN TREATMENT OF FRACTURE OF WEIGHT BEA      634.42   528.69                 0  90
27828   OPEN TREATMENT OF FRACTURE OF WEIGHT BEA      748.84   624.04                 0  90
27829   OPEN TREATMENT OF DISTAL TIBIOFIBULAR JO      367.01   305.84                 0  90
27830   CLOSED TREATMENT OF PROXIMAL TIBIOFIBULA      195.04   151.66                 0  90
27831   CLOSED TREATMENT OF PROXIMAL TIBIOFIBULA      215.56   179.63                 0  90
27832   OPEN TREATMENT OF PROXIMAL TIBIOFIBULAR       387.26   322.72                 0  90
27840   CLOSED TREATMENT OF ANKLE DISLOCATION; W      196.42   163.68                 0  90
27842   CLOSED TREATMENT OF ANKLE DISLOCATION; R      274.33   228.61                 0  90
27846   OPEN TREATMENT OF ANKLE DISLOCATION, WIT      426.70   355.59                 0  90
27848   OPEN TREATMENT OF ANKLE DISLOCATION, WIT      489.39   407.83                 0  90
27860   MANIPULATION OF ANKLE UNDER GENERAL ANES      102.25    85.21                 0  10
27870   ARTHRODESIS, ANKLE, OPEN                      604.96   504.13                 0  90
27871   ARTHRODESIS, TIBIOFIBULAR JOINT, PROXIMA      401.81   334.84                 0  90
27880   AMPUTATION, LEG, THROUGH TIBIA AND FIBUL      520.08   433.40                 0  90
27881   AMPUTATION, LEG, THROUGH TIBIA AND FIBUL      516.36   430.30                 0  90
27882   AMPUTATION, LEG, THROUGH TIBIA AND FIBUL      366.69   305.58                 0  90
27884   AMPUTATION, LEG, THROUGH TIBIA AND FIBUL      337.39   281.16                 0  90
27886   AMPUTATION, LEG, THROUGH TIBIA AND FIBUL      382.69   318.91                 0  90
27888   AMPUTATION, ANKLE, THROUGH MALLEOLI OF T      409.08   340.90                 0  90
27889   ANKLE DISARTICULATION                         398.23   331.86                 0  90
27892   DECOMPRESSION FASCIOTOMY, LEG; ANTERIOR       316.04   263.37                 0  90
27893   DECOMPRESSION FASCIOTOMY, LEG; POSTERIOR      313.88   261.57                 0  90
27894   DECOMPRESSION FASCIOTOMY, LEG; ANTERIOR       476.63   397.20                 0  90
27899   UNLISTED PROCEDURE, LEG OR ANKLE                                          BR 0    0
28001   INCISION AND DRAINAGE, BURSA, FOOT            149.38    89.42                 0  10
28002   INCISION AND DRAINAGE BELOW FASCIA, WITH      275.14   184.98                 0  10
28003   INCISION AND DRAINAGE BELOW FASCIA, WITH      380.29   273.43                 0  90
                                                                                                   Page 60 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
28005   INCISION, BONE CORTEX (EG, OSTEOMYELITIS      358.34   298.62                 0  90
28008   FASCIOTOMY, FOOT AND/OR TOE                   236.48   150.72                 0  90
28010   TENOTOMY, PERCUTANEOUS, TOE; SINGLE TEND      131.43   104.19                 0  90
28011   TENOTOMY, PERCUTANEOUS, TOE; MULTIPLE TE      186.13   147.32                 0  90
28020   ARTHROTOMY, INCLUDING EXPLORATION, DRAIN      284.17   178.77                 0  90
28022   ARTHROTOMY, INCLUDING EXPLORATION, DRAIN      259.47   165.57                 0  90
28024   ARTHROTOMY, INCLUDING EXPLORATION, DRAIN      248.36   158.36                 0  90
28035   RELEASE, TARSAL TUNNEL (POSTERIOR TIBIAL      282.40   178.93                 0  90
28039   EXCISION, TUMOR, SOFT TISSUE OF FOOT OR       289.85   170.62                 0  90
28041   EXCISION, TUMOR, SOFT TISSUE OF FOOT OR       269.26   224.39                 0  90
28043   EXCISION, TUMOR, SOFT TISSUE OF FOOT OR       189.16   129.94                 0  90
28045   EXCISION, TUMOR, SOFT TISSUE OF FOOT OR       264.07   163.04                 0  90
28046   RADICAL RESECTION OF TUMOR (EG, MALIGNAN      481.36   330.37                 0  90
28047   RADICAL RESECTION OF TUMOR (EG, MALIGNAN      564.62   470.52                 0  90
28050   ARTHROTOMY WITH BIOPSY; INTERTARSAL OR T      247.00   154.97                 0  90
28052   ARTHROTOMY WITH BIOPSY; METATARSOPHALANG      231.08   142.12                 0  90
28054   ARTHROTOMY WITH BIOPSY; INTERPHALANGEAL       216.59   129.63                 0  90
28055   NEURECTOMY, INTRINSIC MUSCULATURE OF FOO      230.51   192.10                 0  90
28060   FASCIECTOMY, PLANTAR FASCIA; PARTIAL (SE      278.27   179.18                 0  90
28062   FASCIECTOMY, PLANTAR FASCIA; RADICAL (SE      329.28   207.74                 0  90
28070   SYNOVECTOMY; INTERTARSAL OR TARSOMETATAR      276.41   176.81                 0  90
28072   SYNOVECTOMY; METATARSOPHALANGEAL JOINT,       271.03   172.53                 0  90
28080   EXCISION, INTERDIGITAL (MORTON) NEUROMA,      262.60   168.59                 0  90
28086   SYNOVECTOMY, TENDON SHEATH, FOOT; FLEXOR      310.73   183.46                 0  90
28088   SYNOVECTOMY, TENDON SHEATH, FOOT; EXTENS      250.21   150.26                 0  90
28090   EXCISION OF LESION, TENDON, TENDON SHEAT      251.00   155.03                 0  90
28092   EXCISION OF LESION, TENDON, TENDON SHEAT      230.05   138.80                 0  90
28100   EXCISION OR CURETTAGE OF BONE CYST OR BE      332.84   201.69                 0  90
28102   EXCISION OR CURETTAGE OF BONE CYST OR BE      317.71   264.76                 0  90
                                                                                                   Page 61 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
28103   EXCISION OR CURETTAGE OF BONE CYST OR BE      260.70   217.25                 0  90
28104   EXCISION OR CURETTAGE OF BONE CYST OR BE      277.69   176.65                 0  90
28106   EXCISION OR CURETTAGE OF BONE CYST OR BE      275.96   229.97                 0  90
28107   EXCISION OR CURETTAGE OF BONE CYST OR BE      306.32   190.04                 0  90
28108   EXCISION OR CURETTAGE OF BONE CYST OR BE      232.50   145.56                 0  90
28110   OSTECTOMY, PARTIAL EXCISION, FIFTH METAT      245.87   144.80                 0  90
28111   OSTECTOMY, COMPLETE EXCISION; FIRST META      283.05   169.02                 0  90
28112   OSTECTOMY, COMPLETE EXCISION; OTHER META      266.37   158.60                 0  90
28113   OSTECTOMY, COMPLETE EXCISION; FIFTH META      311.63   203.30                 0  90
28114   OSTECTOMY, COMPLETE EXCISION; ALL METATA      576.61   394.99                 0  90
28116   OSTECTOMY, EXCISION OF TARSAL COALITION       405.35   279.14                 0  90
28118   OSTECTOMY, CALCANEUS;                         316.18   203.80                 0  90
28119   OSTECTOMY, CALCANEUS; FOR SPUR, WITH OR       282.50   200.00                 0  90
28120   PARTIAL EXCISION (CRATERIZATION, SAUCERI      321.73   196.32                 0  90
28122   PARTIAL EXCISION (CRATERIZATION, SAUCERI      364.62   249.91                 0  90
28124   PARTIAL EXCISION (CRATERIZATION, SAUCERI      257.84   167.28                 0  90
28126   RESECTION, PARTIAL OR COMPLETE, PHALANGE      207.91   126.91                 0  90
28130   TALECTOMY (ASTRAGALECTOMY)                    376.58   313.82                 0  90
28140   METATARSECTOMY                                349.18   227.82                 0  90
28150   PHALANGECTOMY, TOE, EACH TOE                  234.31   144.60                 0  90
28153   RESECTION, CONDYLE(S), DISTAL END OF PHA      215.79   129.17                 0  90
28160   HEMIPHALANGECTOMY OR INTERPHALANGEAL JOI      222.29   137.87                 0  90
28171   RADICAL RESECTION OF TUMOR; TARSAL (EXCE                                  BR 0   90
28173   RADICAL RESECTION OF TUMOR; METATARSAL        410.68   275.57                 0  90
28175   RADICAL RESECTION OF TUMOR; PHALANX OF T      300.48   193.79                 0  90
28190   REMOVAL OF FOREIGN BODY, FOOT; SUBCUTANE      136.33    66.64                 0  10
28192   REMOVAL OF FOREIGN BODY, FOOT; DEEP           259.54   161.32                 0  90
28193   REMOVAL OF FOREIGN BODY, FOOT; COMPLICAT      293.81   189.68                 0  90
28200   REPAIR, TENDON, FLEXOR, FOOT; PRIMARY OR      255.90   159.93                 0  90
                                                                                                   Page 62 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
28202   REPAIR, TENDON, FLEXOR, FOOT; SECONDARY       346.83   221.75                 0  90
28208   REPAIR, TENDON, EXTENSOR, FOOT; PRIMARY       244.69   152.43                 0  90
28210   REPAIR, TENDON, EXTENSOR, FOOT; SECONDAR      319.20   205.70                 0  90
28220   TENOLYSIS, FLEXOR, FOOT; SINGLE TENDON        242.54   155.15                 0  90
28222   TENOLYSIS, FLEXOR, FOOT; MULTIPLE TENDON      281.02   185.78                 0  90
28225   TENOLYSIS, EXTENSOR, FOOT; SINGLE TENDON      212.63   129.20                 0  90
28226   TENOLYSIS, EXTENSOR, FOOT; MULTIPLE TEND      250.15   160.46                 0  90
28230   TENOTOMY, OPEN, TENDON FLEXOR; FOOT, SIN      234.34   150.16                 0  90
28232   TENOTOMY, OPEN, TENDON FLEXOR; TOE, SING      208.58   127.88                 0  90
28234   TENOTOMY, OPEN, EXTENSOR, FOOT OR TOE, E      214.73   132.39                 0  90
28238   RECONSTRUCTION (ADVANCEMENT), POSTERIOR       376.40   248.65                 0  90
28240   TENOTOMY, LENGTHENING, OR RELEASE, ABDUC      237.82   151.63                 0  90
28250   DIVISION OF PLANTAR FASCIA AND MUSCLE (E      302.50   198.55                 0  90
28260   CAPSULOTOMY, MIDFOOT; MEDIAL RELEASE ONL      372.47   257.28                 0  90
28261   CAPSULOTOMY, MIDFOOT; WITH TENDON LENGTH      535.99   388.83                 0  90
28262   CAPSULOTOMY, MIDFOOT; EXTENSIVE, INCLUDI      763.63   549.81                 0  90
28264   CAPSULOTOMY, MIDTARSAL (EG, HEYMAN TYPE       471.64   343.61                 0  90
28270   CAPSULOTOMY; METATARSOPHALANGEAL JOINT,       257.39   167.11                 0  90
28272   CAPSULOTOMY; INTERPHALANGEAL JOINT, EACH      211.96   130.28                 0  90
28280   SYNDACTYLIZATION, TOES (EG, WEBBING OR K      289.84   184.93                 0  90
28285   CORRECTION, HAMMERTOE (EG, INTERPHALANGE      250.53   159.55                 0  90
28286   CORRECTION, COCK-UP FIFTH TOE, WITH PLAS      246.19   153.88                 0  90
28288   OSTECTOMY, PARTIAL, EXOSTECTOMY OR CONDY      312.17   209.28                 0  90
28289   HALLUX RIGIDUS CORRECTION WITH CHEILECTO      402.73   270.80                 0  90
28290   CORRECTION, HALLUX VALGUS (BUNION), WITH      312.91   201.69                 0  90
28292   CORRECTION, HALLUX VALGUS (BUNION), WITH      417.70   285.32                 0  90
28293   CORRECTION, HALLUX VALGUS (BUNION), WITH      562.13   343.33                 0  90
28294   CORRECTION, HALLUX VALGUS (BUNION), WITH      408.56   264.38                 0  90
28296   CORRECTION, HALLUX VALGUS (BUNION), WITH      435.05   285.22                 0  90
                                                                                                   Page 63 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                      DESCRIPTION                FEE      FEE        FEE      BR PA DAYS   E
28297   CORRECTION, HALLUX VALGUS (BUNION), WITH      458.65   302.01                 0  90
28298   CORRECTION, HALLUX VALGUS (BUNION), WITH      390.25   254.04                 0  90
28299   CORRECTION, HALLUX VALGUS (BUNION), WITH      500.94   340.34                 0  90
28300   OSTEOTOMY; CALCANEUS (EG, DWYER OR CHAMB      391.59   326.33                 0  90
28302   OSTEOTOMY; TALUS                              389.38   324.48                 0  90
28304   OSTEOTOMY, TARSAL BONES, OTHER THAN CALC      433.43   292.69                 0  90
28305   OSTEOTOMY, TARSAL BONES, OTHER THAN CALC      399.49   332.91                 0  90
28306   OSTEOTOMY, WITH OR WITHOUT LENGTHENING,       327.15   198.79                 0  90
28307   OSTEOTOMY, WITH OR WITHOUT LENGTHENING,       400.49   224.22                 0  90
28308   OSTEOTOMY, WITH OR WITHOUT LENGTHENING,       293.20   181.16                 0  90
28309   OSTEOTOMY, WITH OR WITHOUT LENGTHENING,                                   BR 0   90
28310   OSTEOTOMY, SHORTENING, ANGULAR OR ROTATI      291.31   177.95                 0  90
28312   OSTEOTOMY, SHORTENING, ANGULAR OR ROTATI      265.76   160.35                 0  90
28313   RECONSTRUCTION, ANGULAR DEFORMITY OF TOE      274.31   186.34                 0  90
28315   SESAMOIDECTOMY, FIRST TOE (SEPARATE PROC      256.76   162.49                 0  90
28320   REPAIR, NONUNION OR MALUNION; TARSAL BON      373.57   311.31                 0  90
28322   REPAIR, NONUNION OR MALUNION; METATARSAL      433.06   286.44                 0  90
28340   RECONSTRUCTION, TOE, MACRODACTYLY; SOFT       341.47   220.77                 0  90
28341   RECONSTRUCTION, TOE, MACRODACTYLY; REQUI      389.33   259.84                 0  90
28344   RECONSTRUCTION, TOE(S); POLYDACTYLY           249.15   150.20                 0  90
28345   RECONSTRUCTION, TOE(S); SYNDACTYLY, WITH      310.16   203.50                 0  90
28360   RECONSTRUCTION, CLEFT FOOT                    558.06   465.05                 0  90
28400   CLOSED TREATMENT OF CALCANEAL FRACTURE;       139.19   105.53                 0  90
28405   CLOSED TREATMENT OF CALCANEAL FRACTURE;       224.89   177.57                 0  90
28406   PERCUTANEOUS SKELETAL FIXATION OF CALCAN      308.42   257.02                 0  90
28415   OPEN TREATMENT OF CALCANEAL FRACTURE, IN      675.23   562.69                 0  90
28420   OPEN TREATMENT OF CALCANEAL FRACTURE, IN      701.53   584.61                 0  90
28430   CLOSED TREATMENT OF TALUS FRACTURE; WITH      130.76    94.82                 0  90
28435   CLOSED TREATMENT OF TALUS FRACTURE; WITH      179.52   140.79                 0  90
                                                                                                   Page 64 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                      DESCRIPTION                FEE      FEE        FEE      BR PA DAYS   E
28436   PERCUTANEOUS SKELETAL FIXATION OF TALUS       246.93   205.78                 0  90
28445   OPEN TREATMENT OF TALUS FRACTURE, INCLUD      627.70   523.08                 0  90
28446   OPEN OSTEOCHONDRAL AUTOGRAFT, TALUS (INC      667.10   555.92                 0  90
28450   TREATMENT OF TARSAL BONE FRACTURE (EXCEP      120.47    88.71                 0  90
28455   TREATMENT OF TARSAL BONE FRACTURE (EXCEP      162.18   128.59                 0  90
28456   PERCUTANEOUS SKELETAL FIXATION OF TARSAL      162.93   135.78                 0  90
28465   OPEN TREATMENT OF TARSAL BONE FRACTURE (      353.40   294.50                 0  90
28470   CLOSED TREATMENT OF METATARSAL FRACTURE;      120.14    88.63                 0  90
28475   CLOSED TREATMENT OF METATARSAL FRACTURE;      150.09   117.49                 0  90
28476   PERCUTANEOUS SKELETAL FIXATION OF METATA      197.25   164.38                 0  90
28485   OPEN TREATMENT OF METATARSAL FRACTURE, I      302.79   252.33                 0  90
28490   CLOSED TREATMENT OF FRACTURE GREAT TOE,        76.54    55.58                 0  90
28495   CLOSED TREATMENT OF FRACTURE GREAT TOE,        94.73    71.76                 0  90
28496   PERCUTANEOUS SKELETAL FIXATION OF FRACTU      249.46   110.67                 0  90
28505   OPEN TREATMENT OF FRACTURE, GREAT TOE, P      364.90   223.69                 0  90
28510   CLOSED TREATMENT OF FRACTURE, PHALANX OR       65.71    53.94                 0  90
28515   CLOSED TREATMENT OF FRACTURE, PHALANX OR       85.33    67.01                 0  90
28525   OPEN TREATMENT OF FRACTURE, PHALANX OR P      314.93   181.64                 0  90
28530   CLOSED TREATMENT OF SESAMOID FRACTURE                                     BR 0   90
28531   OPEN TREATMENT OF SESAMOID FRACTURE, WIT                                  BR 0   90
28540   CLOSED TREATMENT OF TARSAL BONE DISLOCAT      112.21    89.00                 0  90
28545   CLOSED TREATMENT OF TARSAL BONE DISLOCAT      130.65   102.52                 0  90
28546   PERCUTANEOUS SKELETAL FIXATION OF TARSAL      262.99   147.79                 0  90
28555   OPEN TREATMENT OF TARSAL BONE DISLOCATIO      472.06   303.76                 0  90
28570   CLOSED TREATMENT OF TALOTARSAL JOINT DIS      100.47    76.75                 0  90
28575   CLOSED TREATMENT OF TALOTARSAL JOINT DIS      181.80   144.33                 0  90
28576   PERCUTANEOUS SKELETAL FIXATION OF TALOTA      208.43   173.69                 0  90
28585   OPEN TREATMENT OF TALOTARSAL JOINT DISLO      483.58   340.63                 0  90
28600   CLOSED TREATMENT OF TARSOMETATARSAL JOIN      117.56    89.97                 0  90
                                                                                                   Page 65 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
28605   CLOSED TREATMENT OF TARSOMETATARSAL JOIN      152.14   120.43                 0  90
28606   PERCUTANEOUS SKELETAL FIXATION OF TARSOM      228.20   190.17                 0  90
28615   OPEN TREATMENT OF TARSOMETATARSAL JOINT       441.73   368.11                 0  90
28630   CLOSED TREATMENT OF METATARSOPHALANGEAL        81.57    52.39                 0  10
28635   CLOSED TREATMENT OF METATARSOPHALANGEAL        98.15    67.03                 0  10
28636   PERCUTANEOUS SKELETAL FIXATION OF METATA      167.84   103.16                 0  10
28645   OPEN TREATMENT OF METATARSOPHALANGEAL JO      325.01   215.46                 0  90
28660   CLOSED TREATMENT OF INTERPHALANGEAL JOIN       59.91    39.88                 0  10
28665   CLOSED TREATMENT OF INTERPHALANGEAL JOIN       85.58    66.19                 0  10
28666   PERCUTANEOUS SKELETAL FIXATION OF INTERP      118.27    98.56                 0  10
28675   OPEN TREATMENT OF INTERPHALANGEAL JOINT       310.83   181.30                 0  90
28705   ARTHRODESIS; PANTALAR                         764.29   636.91                 0  90
28715   ARTHRODESIS; TRIPLE                           567.03   472.53                 0  90
28725   ARTHRODESIS; SUBTALAR                         471.57   392.98                 0  90
28730   ARTHRODESIS, MIDTARSAL OR TARSOMETATARSA      487.36   406.14                 0  90
28735   ARTHRODESIS, MIDTARSAL OR TARSOMETATARSA      465.49   387.91                 0  90
28737   ARTHRODESIS, WITH TENDON LENGTHENING AND      412.58   343.82                 0  90
28740   ARTHRODESIS, MIDTARSAL OR TARSOMETATARSA      480.31   305.10                 0  90
28750   ARTHRODESIS, GREAT TOE; METATARSOPHALANG      475.26   292.07                 0  90
28755   ARTHRODESIS, GREAT TOE; INTERPHALANGEAL       276.79   166.47                 0  90
28760   ARTHRODESIS, WITH EXTENSOR HALLUCIS LONG      425.49   282.18                 0  90
28800   AMPUTATION, FOOT; MIDTARSAL (EG, CHOPART      335.31   279.43                 0  90
28805   AMPUTATION, FOOT; TRANSMETATARSAL             424.57   353.81                 0  90
28810   AMPUTATION, METATARSAL, WITH TOE, SINGLE      257.42   214.52                 0  90
28820   AMPUTATION, TOE; METATARSOPHALANGEAL JOI      300.62   169.92                 0  90
28825   AMPUTATION, TOE; INTERPHALANGEAL JOINT        260.77   140.19                 0  90
28899   UNLISTED PROCEDURE, FOOT OR TOES                                          BR 0    0
29000   APPLICATION OF HALO TYPE BODY CAST (SEE       140.99    80.57                 0   0
29010   APPLICATION OF RISSER JACKET, LOCALIZER,      146.32    78.24                 0   0
                                                                                                   Page 66 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
29015   APPLICATION OF RISSER JACKET, LOCALIZER,      136.39    78.59                 0   0
29020   APPLICATION OF TURNBUCKLE JACKET, BODY;       135.53    70.08                 0   0
29025   APPLICATION OF TURNBUCKLE JACKET, BODY;       147.13    86.11                 0   0
29035   APPLICATION OF BODY CAST, SHOULDER TO HI      132.52    66.75                 0   0
29040   APPLICATION OF BODY CAST, SHOULDER TO HI      123.91    73.52                 0   0
29044   APPLICATION OF BODY CAST, SHOULDER TO HI      143.98    77.33                 0   0
29046   APPLICATION OF BODY CAST, SHOULDER TO HI      153.56    89.82                 0   0
29049   APPLICATION, CAST; FIGURE-OF-EIGHT             50.77    28.98                 0   0
29055   APPLICATION, CAST; SHOULDER SPICA             114.49    63.62                 0   0
29058   APPLICATION, CAST; PLASTER VELPEAU             65.17    39.75                 0   0
29065   APPLICATION, CAST; SHOULDER TO HAND (LON       53.21    32.65                 0   0
29075   APPLICATION, CAST; ELBOW TO FINGER (SHOR       49.44    29.31                 0   0
29085   APPLICATION, CAST; HAND AND LOWER FOREAR       52.24    31.03                 0   0
29086   APPLICATION, CAST; FINGER (EG, CONTRACTU       39.42    22.60                 0   0
29105   APPLICATION OF LONG ARM SPLINT (SHOULDER       49.09    27.78                 0   0
29125   APPLICATION OF SHORT ARM SPLINT (FOREARM       37.99    19.76                 0   0
29126   APPLICATION OF SHORT ARM SPLINT (FOREARM       44.65    24.08                 0   0
29305   APPLICATION OF HIP SPICA CAST; ONE LEG        130.81    75.17                 0   0
29325   APPLICATION OF HIP SPICA CAST; ONE AND O      140.68    83.19                 0   0
29345   APPLICATION OF LONG LEG CAST (THIGH TO T       76.22    48.76                 0   0
29355   APPLICATION OF LONG LEG CAST (THIGH TO T       77.98    52.06                 0   0
29358   APPLICATION OF LONG LEG CAST BRACE             85.02    65.00                 0   0
29365   APPLICATION OF CYLINDER CAST (THIGH TO A       68.46    42.29                 0   0
29405   APPLICATION OF SHORT LEG CAST (BELOW KNE       50.54    31.25                 0   0
29425   APPLICATION OF SHORT LEG CAST (BELOW KNE       54.26    34.35                 0   0
29435   APPLICATION OF PATELLAR TENDON BEARING (       66.49    41.67                 0   0
29440   ADDING WALKER TO PREVIOUSLY APPLIED CAST       29.87    16.49                 0   0
29445   APPLICATION OF RIGID TOTAL CONTACT LEG C       83.80    54.24                 0   0
29450   APPLICATION OF CLUBFOOT CAST WITH MOLDIN       86.12    60.70                 0   0
                                                                                                   Page 67 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
29505   APPLICATION OF LONG LEG SPLINT (THIGH TO       43.75    22.51                 0   0
29515   APPLICATION OF SHORT LEG SPLINT (CALF TO       39.25    23.48                 0   0
29580   STRAPPING; UNNA BOOT                           29.43    17.56                 0   0
29581   APPLICATION OF MULTI-LAYER COMPRESSION S       54.82    16.34                 0   0
29582   APPLICATION OF MULTI-LAYER COMPRESSION S       32.04    26.70                 0   0    *
29583   APPLICATION OF MULTI-LAYER COMPRESSION S       19.82    16.52                 0   0    *
29584   APPLICATION OF MULTI-LAYER COMPRESSION S       32.04    26.70                 0   0    *
29590   DENIS-BROWNE SPLINT STRAPPING                  31.09    20.16                 0   0
29700   REMOVAL OR BIVALVING; GAUNTLET, BOOT OR        36.02    16.49                 0   0
29705   REMOVAL OR BIVALVING; FULL ARM OR FULL L       37.89    22.96                 0   0
29710   REMOVAL OR BIVALVING; SHOULDER OR HIP SP       67.03    39.45                 0   0
29715   REMOVAL OR BIVALVING; TURNBUCKLE JACKET        50.54    26.33                 0   0
29720   REPAIR OF SPICA, BODY CAST OR JACKET           45.15    21.42                 0   0
29730   WINDOWING OF CAST                              36.94    21.97                 0   0
29740   WEDGING OF CAST (EXCEPT CLUBFOOT CASTS)        53.81    32.33                 0   0
29750   WEDGING OF CLUBFOOT CAST                       56.53    36.65                 0   0
29799   UNLISTED PROCEDURE, CASTING OR STRAPPING                                  BR 0    0
29800   ARTHROSCOPY, TEMPOROMANDIBULAR JOINT, DI      302.40   252.00                 0  90
29804   ARTHROSCOPY, TEMPOROMANDIBULAR JOINT, SU      372.64   310.54                 0  90
29805   ARTHROSCOPY, SHOULDER, DIAGNOSTIC, WITH       271.84   226.53                 0  90
29806   ARTHROSCOPY, SHOULDER, SURGICAL; CAPSULO      613.62   511.35                 0  90
29807   ARTHROSCOPY, SHOULDER, SURGICAL; REPAIR       598.39   498.66                 0  90
29819   ARTHROSCOPY, SHOULDER, SURGICAL; WITH RE      339.14   282.62                 0  90
29820   ARTHROSCOPY, SHOULDER, SURGICAL; SYNOVEC      312.98   305.00                 0  90
29821   ARTHROSCOPY, SHOULDER, SURGICAL; SYNOVEC      341.94   305.00                 0  90
29822   ARTHROSCOPY, SHOULDER, SURGICAL; DEBRIDE      332.81   277.34                 0  90
29823   ARTHROSCOPY, SHOULDER, SURGICAL; DEBRIDE      363.32   302.77                 0  90
29824   ARTHROSCOPY, SHOULDER, SURGICAL; DISTAL       384.97   320.81                 0  90
29825   ARTHROSCOPY, SHOULDER, SURGICAL; WITH LY      338.89   282.41                 0  90
                                                                                                   Page 68 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
29826   ARTHROSCOPY, SHOULDER, SURGICAL; DECOMPR      388.34   323.62                 0   0
29827   ARTHROSCOPY, SHOULDER, SURGICAL; WITH RO      631.82   526.52                 0  90
29828   ARTHROSCOPY, SHOULDER, SURGICAL; BICEPS       515.39   429.50                 0  90
29830   ARTHROSCOPY, ELBOW, DIAGNOSTIC, WITH OR       261.74   218.12                 0  90
29834   ARTHROSCOPY, ELBOW, SURGICAL; WITH REMOV      285.00   237.50                 0  90
29835   ARTHROSCOPY, ELBOW, SURGICAL; SYNOVECTOM      305.00   305.00                 0  90
29836   ARTHROSCOPY, ELBOW, SURGICAL; SYNOVECTOM      334.51   305.00                 0  90
29837   ARTHROSCOPY, ELBOW, SURGICAL; DEBRIDEMEN      305.68   254.73                 0  90
29838   ARTHROSCOPY, ELBOW, SURGICAL; DEBRIDEMEN      342.26   285.22                 0  90
29840   ARTHROSCOPY, WRIST, DIAGNOSTIC, WITH OR       255.44   212.87                 0  90
29843   ARTHROSCOPY, WRIST, SURGICAL; FOR INFECT      272.88   227.40                 0  90
29844   ARTHROSCOPY, WRIST, SURGICAL; SYNOVECTOM      305.00   305.00                 0  90
29845   ARTHROSCOPY, WRIST, SURGICAL; SYNOVECTOM      325.45   305.00                 0  90
29846   ARTHROSCOPY, WRIST, SURGICAL; EXCISION A      300.42   250.35                 0  90
29847   ARTHROSCOPY, WRIST, SURGICAL; INTERNAL F      345.00   345.00                 0  90
29848   ENDOSCOPY, WRIST, SURGICAL, WITH RELEASE      280.42   233.69                 0  90
29850   ARTHROSCOPICALLY AIDED TREATMENT OF INTE      315.02   262.52                 0  90
29851   ARTHROSCOPICALLY AIDED TREATMENT OF INTE      541.49   451.24                 0  90
29855   ARTHROSCOPICALLY AIDED TREATMENT OF TIBI      455.39   379.49                 0  90
29856   ARTHROSCOPICALLY AIDED TREATMENT OF TIBI      580.43   483.70                 0  90
29860   ARTHROSCOPY, HIP, DIAGNOSTIC WITH OR WIT      373.50   311.25                 0  90
29861   ARTHROSCOPY, HIP, SURGICAL; WITH REMOVAL      407.79   339.83                 0  90
29862   ARTHROSCOPY, HIP, SURGICAL; WITH DEBRIDE      458.85   382.38                 0  90
29863   ARTHROSCOPY, HIP, SURGICAL; WITH SYNOVEC      452.63   377.20                 0  90
29866   ARTHROSCOPY, KNEE, SURGICAL; OSTEOCHONDR      605.57   504.64                 0  90
29867   ARTHROSCOPY, KNEE, SURGICAL; OSTEOCHONDR      732.20   610.17                 0  90
29868   ARTHROSCOPY, KNEE, SURGICAL; MENISCAL TR      982.43   818.70                 0  90
29870   ARTHROSCOPY, KNEE, DIAGNOSTIC, WITH OR W      234.86   195.72                 0  90
29871   ARTHROSCOPY, KNEE, SURGICAL; FOR INFECTI      294.86   245.72                 0  90
                                                                                                   Page 69 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                     DESCRIPTION                 FEE      FEE        FEE      BR PA DAYS   E
29873   ARTHROSCOPY, KNEE, SURGICAL; WITH LATERA      297.45   247.88                 0  90
29874   ARTHROSCOPY, KNEE, SURGICAL; FOR REMOVAL      307.09   255.91                 0  90
29875   ARTHROSCOPY, KNEE, SURGICAL; SYNOVECTOMY      305.00   305.00                 0  90
29876   ARTHROSCOPY, KNEE, SURGICAL; SYNOVECTOMY      371.42   309.52                 0  90
29877   ARTHROSCOPY, KNEE, SURGICAL; DEBRIDEMENT      351.66   293.05                 0  90
29879   ARTHROSCOPY, KNEE, SURGICAL; ABRASION AR      425.00   425.00                 0  90
29880   ARTHROSCOPY, KNEE, SURGICAL; WITH MENISC      392.62   335.00                 0  90
29881   ARTHROSCOPY, KNEE, SURGICAL; WITH MENISC      366.02   305.02                 0  90
29882   ARTHROSCOPY, KNEE, SURGICAL; WITH MENISC      395.08   329.23                 0  90
29883   ARTHROSCOPY, KNEE, SURGICAL; WITH MENISC      485.19   404.33                 0  90
29884   ARTHROSCOPY, KNEE, SURGICAL; WITH LYSIS       350.23   291.86                 0  90
29885   ARTHROSCOPY, KNEE, SURGICAL; DRILLING FO      424.69   400.00                 0  90
29886   ARTHROSCOPY, KNEE, SURGICAL; DRILLING FO      358.03   298.36                 0  90
29887   ARTHROSCOPY, KNEE, SURGICAL; DRILLING FO      422.31   351.93                 0  90
29888   ARTHROSCOPICALLY AIDED ANTERIOR CRUCIATE      570.27   475.23                 0  90
29889   ARTHROSCOPICALLY AIDED POSTERIOR CRUCIAT      696.35   580.29                 0  90
29891   ARTHROSCOPY, ANKLE, SURGICAL, EXCISION O      398.73   332.28                 0  90
29892   ARTHROSCOPICALLY AIDED REPAIR OF LARGE O      411.22   342.68                 0  90
29893   ENDOSCOPIC PLANTAR FASCIOTOMY                 324.19   203.91                 0  90
29894   ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBUL      299.42   249.52                 0  90
29895   ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBUL      291.66   243.05                 0  90
29897   ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBUL      305.56   254.64                 0  90
29898   ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBUL      340.54   283.79                 0  90
29899   ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBUL      607.58   506.32                 0  90
29900   ARTHROSCOPY, METACARPOPHALANGEAL JOINT,       267.84   223.20                 0  90
29901   ARTHROSCOPY, METACARPOPHALANGEAL JOINT,       295.22   246.02                 0  90
29902   ARTHROSCOPY, METACARPOPHALANGEAL JOINT,       306.93   255.78                 0  90
29904   ARTHROSCOPY, SUBTALAR JOINT, SURGICAL; W      346.60   288.84                 0  90
29905   ARTHROSCOPY, SUBTALAR JOINT, SURGICAL; W      373.88   311.57                 0  90
                                                                                                   Page 70 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
29906   ARTHROSCOPY, SUBTALAR JOINT, SURGICAL; W      393.81   328.18                 0  90
29907   ARTHROSCOPY, SUBTALAR JOINT, SURGICAL; W      481.31   401.09                 0  90
29914   ARTHROSCOPY, HIP, SURGICAL; WITH FEMOROP      480.02   400.02                 0  90
29915   ARTHROSCOPY, HIP, SURGICAL; WITH ACETABU      489.01   407.51                 0  90
29916   ARTHROSCOPY, HIP, SURGICAL; WITH LABRAL       489.01   407.51                 0  90
29999   UNLISTED PROCEDURE, ARTHROSCOPY                                           BR 0    0
30000   DRAINAGE ABSCESS OR HEMATOMA, NASAL, INT      131.79    55.06                 0  10
30020   DRAINAGE ABSCESS OR HEMATOMA, NASAL SEPT      123.91    56.29                 0  10
30100   BIOPSY, INTRANASAL                             76.92    33.34                 0   0
30110   EXCISION, NASAL POLYP(S), SIMPLE              124.61    61.59                 0  10
30115   EXCISION, NASAL POLYP(S), EXTENSIVE           243.37   202.81                 0  90
30117   EXCISION OR DESTRUCTION (EG, LASER), INT      456.61   157.16                 0  90
30118   EXCISION OR DESTRUCTION (EG, LASER), INT      436.28   363.57                 0  90
30120   EXCISION OR SURGICAL PLANING OF SKIN OF       287.24   213.94                 0  90
30124   EXCISION DERMOID CYST, NOSE; SIMPLE, SKI      159.64   133.03                 0  90
30125   EXCISION DERMOID CYST, NOSE; COMPLEX, UN      354.99   295.83                 0  90
30130   EXCISION INFERIOR TURBINATE, PARTIAL OR       214.80   179.00                 0  90
30140   SUBMUCOUS RESECTION INFERIOR TURBINATE,       242.44   202.03                 0  90
30150   RHINECTOMY; PARTIAL                           460.31   383.59                 0  90
30160   RHINECTOMY; TOTAL                             456.41   380.34                 0  90
30200   INJECTION INTO TURBINATE(S), THERAPEUTIC       62.13    29.01                 0   0
30210   DISPLACEMENT THERAPY (PROETZ TYPE)             81.35    46.88                 0  10
30220   INSERTION, NASAL SEPTAL PROSTHESIS (BUTT      158.24    59.06                 0  10
30300   REMOVAL FOREIGN BODY, INTRANASAL; OFFICE      133.12    58.22                 0  10
30310   REMOVAL FOREIGN BODY, INTRANASAL; REQUIR      118.00    98.33                 0  10
30320   REMOVAL FOREIGN BODY, INTRANASAL; BY LAT      266.81   222.35                 0  90
30400   RHINOPLASTY, PRIMARY; LATERAL AND ALAR C      601.37   501.14                 0  90
30410   RHINOPLASTY, PRIMARY; COMPLETE, EXTERNAL      726.77   605.65                 0  90
30420   RHINOPLASTY, PRIMARY; INCLUDING MAJOR SE      787.48   656.24                 0  90
                                                                                                   Page 71 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
30430   RHINOPLASTY, SECONDARY; MINOR REVISION (      540.05   450.04                 0  90
30435   RHINOPLASTY, SECONDARY; INTERMEDIATE REV      709.62   591.35                 0  90
30450   RHINOPLASTY, SECONDARY; MAJOR REVISION (      917.27   764.40                 0  90
30460   RHINOPLASTY FOR NASAL DEFORMITY SECONDAR      446.77   372.31                 0  90
30462   RHINOPLASTY FOR NASAL DEFORMITY SECONDAR      897.39   747.83                 0  90
30465   REPAIR OF NASAL VESTIBULAR STENOSIS (EG,      556.45   463.71                 0  90
30520   SEPTOPLASTY OR SUBMUCOUS RESECTION, WITH      331.21   276.01                 0  90
30540   REPAIR CHOANAL ATRESIA; INTRANASAL            394.01   328.35                 0  90
30545   REPAIR CHOANAL ATRESIA; TRANSPALATINE         556.18   463.49                 0  90
30560   LYSIS INTRANASAL SYNECHIA                     152.23    66.36                 0  10
30580   REPAIR FISTULA; OROMAXILLARY (COMBINE WI      353.78   239.03                 0  90
30600   REPAIR FISTULA; ORONASAL                      326.75   210.76                 0  90
30620   SEPTAL OR OTHER INTRANASAL DERMATOPLASTY      351.68   293.07                 0  90
30630   REPAIR NASAL SEPTAL PERFORATIONS              353.11   294.26                 0  90
30801   ABLATION, SOFT TISSUE OF INFERIOR TURBIN      128.59    62.04                 0  10
30802   ABLATION, SOFT TISSUE OF INFERIOR TURBIN      163.43    87.99                 0  10
30901   CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMP       59.75    29.08                 0   0
30903   CONTROL NASAL HEMORRHAGE, ANTERIOR, COMP      108.27    38.13                 0   0
30905   CONTROL NASAL HEMORRHAGE, POSTERIOR, WIT      135.71    49.51                 0   0
30906   CONTROL NASAL HEMORRHAGE, POSTERIOR, WIT      155.21    65.56                 0   0
30915   LIGATION ARTERIES; ETHMOIDAL                  325.13   270.94                 0  90
30920   LIGATION ARTERIES; INTERNAL MAXILLARY AR      463.74   386.45                 0  90
30930   FRACTURE NASAL INFERIOR TURBINATE(S), TH       69.00    60.00                 0  10
30999   UNLISTED PROCEDURE, NOSE                                                  BR 0    0
31000   LAVAGE BY CANNULATION; MAXILLARY SINUS (      100.46    49.68                 0  10
31002   LAVAGE BY CANNULATION; SPHENOID SINUS         115.86    96.55                 0  10
31020   SINUSOTOMY, MAXILLARY (ANTROTOMY); INTRA      278.38   166.35                 0  90
31030   SINUSOTOMY, MAXILLARY (ANTROTOMY); RADIC      404.65   246.96                 0  90
31032   SINUSOTOMY, MAXILLARY (ANTROTOMY); RADIC      323.35   269.46                 0  90
                                                                                                   Page 72 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                      DESCRIPTION                FEE      FEE        FEE      BR PA DAYS   E
31040   PTERYGOMAXILLARY FOSSA SURGERY, ANY APPR                                  BR 0   90
31050   SINUSOTOMY, SPHENOID, WITH OR WITHOUT BI      277.70   231.42                 0  90
31051   SINUSOTOMY, SPHENOID, WITH OR WITHOUT BI      364.67   303.89                 0  90
31070   SINUSOTOMY FRONTAL; EXTERNAL, SIMPLE (TR      245.74   204.78                 0  90
31075   SINUSOTOMY FRONTAL; TRANSORBITAL, UNILAT      443.26   369.39                 0  90
31080   SINUSOTOMY FRONTAL; OBLITERATIVE WITHOUT      580.76   483.97                 0  90
31081   SINUSOTOMY FRONTAL; OBLITERATIVE, WITHOU      702.52   585.43                 0  90
31084   SINUSOTOMY FRONTAL; OBLITERATIVE, WITH O      652.61   543.85                 0  90
31085   SINUSOTOMY FRONTAL; OBLITERATIVE, WITH O      703.49   586.25                 0  90
31086   SINUSOTOMY FRONTAL; NONOBLITERATIVE, WIT      633.93   528.28                 0  90
31087   SINUSOTOMY FRONTAL; NONOBLITERATIVE, WIT      623.74   519.79                 0  90
31090   SINUSOTOMY, UNILATERAL, THREE OR MORE PA      562.81   469.01                 0  90
31200   ETHMOIDECTOMY; INTRANASAL, ANTERIOR           314.18   261.82                 0  90
31201   ETHMOIDECTOMY; INTRANASAL, TOTAL              415.47   346.23                 0  90
31205   ETHMOIDECTOMY; EXTRANASAL, TOTAL              492.04   410.04                 0  90
31225   MAXILLECTOMY; WITHOUT ORBITAL EXENTERATI    1,014.98   845.82                 0  90
31230   MAXILLECTOMY; WITH ORBITAL EXENTERATION     1,142.00   951.67                 0  90
31231   NASAL ENDOSCOPY, DIAGNOSTIC, UNILATERAL       110.39    37.24                 0   0
31233   NASAL/SINUS ENDOSCOPY, DIAGNOSTIC WITH M      154.32    67.48                 0   0
31235   NASAL/SINUS ENDOSCOPY, DIAGNOSTIC WITH S      177.25    80.23                 0   0
31237   NASAL/SINUS ENDOSCOPY, SURGICAL; WITH BI      191.29    89.47                 0   0
31238   NASAL/SINUS ENDOSCOPY, SURGICAL; WITH CO      196.37    97.19                 0   0
31239   NASAL/SINUS ENDOSCOPY, SURGICAL; WITH DA      379.77   316.48                 0  10
31240   NASAL/SINUS ENDOSCOPY, SURGICAL; WITH CO       95.60    79.67                 0   0
31254   NASAL/SINUS ENDOSCOPY, SURGICAL; WITH ET      163.70   136.42                 0   0
31255   NASAL/SINUS ENDOSCOPY, SURGICAL; WITH ET      241.89   201.58                 0   0
31256   NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MA      118.91    99.10                 0   0
31267   NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MA      191.26   159.39                 0   0
31276   NASAL/SINUS ENDOSCOPY, SURGICAL WITH FRO      304.56   253.80                 0   0
                                                                                                   Page 73 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                      DESCRIPTION                FEE      FEE        FEE      BR PA DAYS   E
31287   NASAL/SINUS ENDOSCOPY, SURGICAL, WITH SP      139.42   116.19                 0   0
31288   NASAL/SINUS ENDOSCOPY, SURGICAL, WITH SP      161.57   134.64                 0   0
31290   NASAL/SINUS ENDOSCOPY, SURGICAL, WITH RE      668.58   557.15                 0  10
31291   NASAL/SINUS ENDOSCOPY, SURGICAL, WITH RE      705.88   588.23                 0  10
31292   NASAL/SINUS ENDOSCOPY, SURGICAL; WITH ME      579.15   482.63                 0  10
31293   NASAL/SINUS ENDOSCOPY, SURGICAL; WITH ME      630.16   525.13                 0  10
31294   NASAL/SINUS ENDOSCOPY, SURGICAL; WITH OP      724.22   603.52                 0  10
31295   NASAL/SINUS ENDOSCOPY, SURGICAL; WITH DI      821.28   136.36                 0   0
31296   NASAL/SINUS ENDOSCOPY, SURGICAL; WITH DI     1844.81   162.89                 0   0
31297   NASAL/SINUS ENDOSCOPY, SURGICAL; WITH DI     1828.15   133.47                 0   0
31299   UNLISTED PROCEDURE, ACCESSORY SINUSES                                     BR 0    0
31300   LARYNGOTOMY (THYROTOMY, LARYNGOFISSURE);      710.76   592.30                 0  90
31320   LARYNGOTOMY (THYROTOMY, LARYNGOFISSURE);      376.81   314.01                 0  90
31360   LARYNGECTOMY; TOTAL, WITHOUT RADICAL NEC    1,087.51   906.26                 0  90
31365   LARYNGECTOMY; TOTAL, WITH RADICAL NECK D    1,363.38 1,136.15                 0  90
31367   LARYNGECTOMY; SUBTOTAL SUPRAGLOTTIC, WIT    1,203.68 1,003.07                 0  90
31368   LARYNGECTOMY; SUBTOTAL SUPRAGLOTTIC, WIT    1,357.18 1,130.98                 0  90
31370   PARTIAL LARYNGECTOMY (HEMILARYNGECTOMY);    1,141.85   951.55                 0  90
31375   PARTIAL LARYNGECTOMY (HEMILARYNGECTOMY);    1,073.13   894.28                 0  90
31380   PARTIAL LARYNGECTOMY (HEMILARYNGECTOMY);    1,063.01   885.84                 0  90
31382   PARTIAL LARYNGECTOMY (HEMILARYNGECTOMY);    1,159.44   966.20                 0  90
31390   PHARYNGOLARYNGECTOMY, WITH RADICAL NECK     1,530.67 1,275.56                 0  90
31395   PHARYNGOLARYNGECTOMY, WITH RADICAL NECK     1,642.20 1,368.50                 0  90
31400   ARYTENOIDECTOMY OR ARYTENOIDOPEXY, EXTER      576.31   480.26                 0  90
31420   EPIGLOTTIDECTOMY                              472.90   394.09                 0  90
31500   INTUBATION, ENDOTRACHEAL, EMERGENCY PROC       63.14    52.62                 0   0
31505   LARYNGOSCOPY, INDIRECT; DIAGNOSTIC (SEPA       49.08    23.67                 0   0
31510   LARYNGOSCOPY, INDIRECT; WITH BIOPSY           122.99    58.81                 0   0
31511   LARYNGOSCOPY, INDIRECT; WITH REMOVAL OF       122.87    61.58                 0   0
                                                                                                   Page 74 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                      DESCRIPTION                FEE      FEE        FEE      BR PA DAYS   E
31512   LARYNGOSCOPY, INDIRECT; WITH REMOVAL OF       122.27    63.33                 0   0
31513   LARYNGOSCOPY, INDIRECT; WITH VOCAL CORD                                   BR 0    0
31515   LARYNGOSCOPY DIRECT, WITH OR WITHOUT TRA      122.93    53.22                 0   0
31520   LARYNGOSCOPY DIRECT, WITH OR WITHOUT TRA       90.59    75.50                 0   0
31525   LARYNGOSCOPY DIRECT, WITH OR WITHOUT TRA      145.85    78.27                 0   0
31526   LARYNGOSCOPY DIRECT, WITH OR WITHOUT TRA      140.00   140.00                 0   0
31527   LARYNGOSCOPY DIRECT, WITH OR WITHOUT TRA                                  BR 0    0
31528   LARYNGOSCOPY DIRECT, WITH OR WITHOUT TRA      120.00   120.00                 0   0
31529   LARYNGOSCOPY DIRECT, WITH OR WITHOUT TRA                                  BR 0    0
31530   LARYNGOSCOPY, DIRECT, OPERATIVE, WITH FO      120.00   120.00                 0   0
31531   LARYNGOSCOPY, DIRECT, OPERATIVE, WITH FO      160.00   160.00                 0   0
31535   LARYNGOSCOPY, DIRECT, OPERATIVE, WITH BI      112.59    93.83                 0   0
31536   LARYNGOSCOPY, DIRECT, OPERATIVE, WITH BI      160.00   160.00                 0   0
31540   LARYNGOSCOPY, DIRECT, OPERATIVE, WITH EX      144.44   120.37                 0   0
31541   LARYNGOSCOPY, DIRECT, OPERATIVE, WITH EX      160.00   160.00                 0   0
31545   LARYNGOSCOPY, DIRECT, OPERATIVE, WITH OP      210.50   175.42                 0   0
31546   LARYNGOSCOPY, DIRECT, OPERATIVE, WITH OP      319.48   266.23                 0   0
31560   LARYNGOSCOPY, DIRECT, OPERATIVE, WITH AR      200.00   200.00                 0   0
31561   LARYNGOSCOPY, DIRECT, OPERATIVE, WITH AR      203.27   200.00                 0   0
31570   LARYNGOSCOPY, DIRECT, WITH INJECTION INT      208.07   120.00                 0   0
31571   LARYNGOSCOPY, DIRECT, WITH INJECTION INT      149.15   124.29                 0   0
31575   LARYNGOSCOPY, FLEXIBLE FIBEROPTIC; DIAGN       68.80    40.00                 0   0
31576   LARYNGOSCOPY, FLEXIBLE FIBEROPTIC; WITH       131.59    60.03                 0   0
31577   LARYNGOSCOPY, FLEXIBLE FIBEROPTIC; WITH       143.09   120.00                 0   0
31578   LARYNGOSCOPY, FLEXIBLE FIBEROPTIC; WITH       164.99   100.00                 0   0
31579   LARYNGOSCOPY, FLEXIBLE OR RIGID FIBEROPT      131.87    68.67                 0   0
31580   LARYNGOPLASTY; FOR LARYNGEAL WEB, TWO ST      683.67   569.73                 0  90
31582   LARYNGOPLASTY; FOR LARYNGEAL STENOSIS, W    1,101.58   917.99                 0  90
31584   LARYNGOPLASTY; WITH OPEN REDUCTION OF FR      865.39   721.16                 0  90
                                                                                                   Page 75 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                      DESCRIPTION                FEE      FEE        FEE      BR PA DAYS   E
31587   LARYNGOPLASTY, CRICOID SPLIT                  550.73   458.95                 0  90
31588   LARYNGOPLASTY, NOT OTHERWISE SPECIFIED (      643.72   536.43                 0  90
31590   LARYNGEAL REINNERVATION BY NEUROMUSCULAR      523.34   436.12                 0  90
31595   SECTION RECURRENT LARYNGEAL NERVE, THERA                                  BR 0   90
31599   UNLISTED PROCEDURE, LARYNX                                                BR 0    0
31600   TRACHEOSTOMY, PLANNED (SEPARATE PROCEDUR      231.62   193.02                 0   0
31601   TRACHEOSTOMY, PLANNED (SEPARATE PROCEDUR      150.53   125.45                 0   0
31603   TRACHEOSTOMY, EMERGENCY PROCEDURE; TRANS      130.15   108.46                 0   0
31605   TRACHEOSTOMY, EMERGENCY PROCEDURE; CRICO      106.36    88.63                 0   0
31610   TRACHEOSTOMY, FENESTRATION PROCEDURE WIT      404.19   336.83                 0  90
31611   CONSTRUCTION OF TRACHEOESOPHAGEAL FISTUL      305.06   254.22                 0  90
31612   TRACHEAL PUNCTURE, PERCUTANEOUS WITH TRA       47.16    40.00                 0   0
31613   TRACHEOSTOMA REVISION; SIMPLE, WITHOUT F      253.37   211.14                 0  90
31614   TRACHEOSTOMA REVISION; COMPLEX, WITH FLA      411.09   342.58                 0  90
31615   TRACHEOBRONCHOSCOPY THROUGH ESTABLISHED       107.51    61.50                 0   0
31620   ENDOBRONCHIAL ULTRASOUND (EBUS) DURING B      174.46    60.00                 0   0
31622   BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDI      194.95    70.78                 0   0
31623   BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR      214.37    71.38                 0   0
31624   BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR      198.62    71.38                 0   0
31625   BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR      211.69    83.30                 0   0
31626   BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDI      266.17   107.74                 0   0
31628   BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR      253.70    92.67                 0   0
31629   BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR      410.41    98.77                 0   0
31630   BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR      121.72   120.00                 0   0
31631   BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR      135.75   120.00                 0   0
31632   BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR       45.56    26.48                 0   0
31633   BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR       53.86    32.58                 0   0
31634   BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDI      872.36   159.62                 0   0
31635   BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR      219.54   100.00                 0   0
                                                                                                   Page 76 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
31636   BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR      132.94   110.78                 0   0
31637   BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR       46.94    39.12                 0   0
31638   BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR      147.90   123.25                 0   0
31640   BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR      155.20   129.34                 0   0
31641   BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDI      151.88   126.57                 0   0
31643   BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDI      103.44    86.20                 0   0
31645   BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDI      189.35    78.01                 0   0
31646   BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDI      172.96    67.84                 0   0
31656   BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDI      207.36    60.00                 0   0
31715   TRANSTRACHEAL INJECTION FOR BRONCHOGRAPH       31.66    26.39                 0   0
31717   CATHETERIZATION WITH BRONCHIAL BRUSH BIO      219.99    80.00                 0   0
31720   CATHETER ASPIRATION (SEPARATE PROCEDURE)       40.00    40.00                 0   0
31725   CATHETER ASPIRATION (SEPARATE PROCEDURE)       55.29    46.08                 0   0
31730   TRANSTRACHEAL (PERCUTANEOUS) INTRODUCTIO      406.70    70.25                 0   0
31750   TRACHEOPLASTY; CERVICAL                       764.58   637.15                 0  90
31755   TRACHEOPLASTY; TRACHEOPHARYNGEAL FISTULI      977.14   814.28                 0  90
31760   TRACHEOPLASTY; INTRATHORACIC                  795.19   700.00                 0  90
31766   CARINAL RECONSTRUCTION                                                    BR 0   90
31770   BRONCHOPLASTY; GRAFT REPAIR                   774.10   645.09                 0  90
31775   BRONCHOPLASTY; EXCISION STENOSIS AND ANA      830.26   691.88                 0  90
31780   EXCISION TRACHEAL STENOSIS AND ANASTOMOS      683.50   569.58                 0  90
31781   EXCISION TRACHEAL STENOSIS AND ANASTOMOS      824.20   700.00                 0  90
31785   EXCISION OF TRACHEAL TUMOR OR CARCINOMA;      628.81   524.01                 0  90
31786   EXCISION OF TRACHEAL TUMOR OR CARCINOMA;      870.69   725.58                 0  90
31800   SUTURE OF TRACHEAL WOUND OR INJURY; CERV      403.73   336.45                 0  90
31805   SUTURE OF TRACHEAL WOUND OR INJURY; INTR      478.77   398.98                 0  90
31820   SURGICAL CLOSURE TRACHEOSTOMY OR FISTULA      243.68   155.90                 0  90
31825   SURGICAL CLOSURE TRACHEOSTOMY OR FISTULA      340.48   229.79                 0  90
31830   REVISION OF TRACHEOSTOMY SCAR                 246.55   162.80                 0  90
                                                                                                   Page 77 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
31899   UNLISTED PROCEDURE, TRACHEA, BRONCHI                                      BR 0    0
32035   THORACOSTOMY; WITH RIB RESECTION FOR EMP      403.72   336.43                 0  90
32036   THORACOSTOMY; WITH OPEN FLAP DRAINAGE FO      438.00   365.00                 0  90
32096   THORACOTOMY, WITH DIAGNOSTIC BIOPSY(IES       372.07   310.06                 0  90
32097   THORACOTOMY, WITH DIAGNOSTIC BIOPSY(IES       372.07   310.06                 0  90
32098   THORACOTOMY, WITH BIOPSY(IES) OF PLEURA       349.67   291.40                 0  90
32100   THORACOTOMY; WITH EXPLORATION                 561.05   467.55                 0  90
32110   THORACOTOMY; WITH CONTROL OF TRAUMATIC H      839.35   699.46                 0  90
32120   THORACOTOMY; FOR POSTOPERATIVE COMPLICAT      498.45   415.38                 0  90
32124   THORACOTOMY; WITH OPEN INTRAPLEURAL PNEU      530.00   441.67                 0  90
32140   THORACOTOMY; WITH CYST(S) REMOVAL, INCLU      567.44   472.87                 0  90
32141   THORACOTOMY; WITH RESECTION-PLICATION OF      816.35   680.29                 0  90
32150   THORACOTOMY; WITH REMOVAL OF INTRAPLEURA      572.08   476.74                 0  90
32151   THORACOTOMY; WITH REMOVAL OF INTRAPULMON      584.92   487.43                 0  90
32160   THORACOTOMY; WITH CARDIAC MASSAGE             432.05   360.05                 0  90
32200   PNEUMONOSTOMY; WITH OPEN DRAINAGE OF ABS      638.96   532.47                 0  90
32201   PNEUMONOSTOMY; WITH PERCUTANEOUS DRAINAG      586.10   107.00                 0   0
32215   PLEURAL SCARIFICATION FOR REPEAT PNEUMOT      463.60   386.33                 0  90
32220   DECORTICATION, PULMONARY (SEPARATE PROCE      925.35   771.13                 0  90
32225   DECORTICATION, PULMONARY (SEPARATE PROCE      571.81   476.51                 0  90
32310   PLEURECTOMY, PARIETAL (SEPARATE PROCEDUR      530.50   442.08                 0  90
32320   DECORTICATION AND PARIETAL PLEURECTOMY        921.47   767.89                 0  90
32400   BIOPSY, PLEURA; PERCUTANEOUS NEEDLE            90.83    43.29                 0   0
32405   BIOPSY, LUNG OR MEDIASTINUM, PERCUTANEOU       58.60    48.43                 0   0
32420   PNEUMOCENTESIS, PUNCTURE OF LUNG FOR ASP       64.42    53.68                 0   0
32421   THORACENTESIS, PUNCTURE OF PLEURAL CAVIT      100.50    37.40                 0   0
32422   THORACENTESIS WITH INSERTION OF TUBE, IN      122.48    61.05                 0   0
32440   REMOVAL OF LUNG, PNEUMONECTOMY;               930.53   775.44                 0  90
32442   REMOVAL OF LUNG, PNEUMONECTOMY; WITH RES                                  BR 0   90
                                                                                                   Page 78 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                          DESCRIPTION            FEE      FEE        FEE      BR PA DAYS   E
32445   REMOVAL OF LUNG, PNEUMONECTOMY; EXTRAPLE    1,835.03 1,529.20                 0  90
32480   REMOVAL OF LUNG, OTHER THAN PNEUMONECTOM      877.17   730.98                 0  90
32482   REMOVAL OF LUNG, OTHER THAN PNEUMONECTOM      934.63   778.86                 0  90
32484   REMOVAL OF LUNG, OTHER THAN PNEUMONECTOM      842.50   702.08                 0  90
32486   REMOVAL OF LUNG, OTHER THAN PNEUMONECTOM     1295.52  1079.60                 0  90
32488   REMOVAL OF LUNG, OTHER THAN PNEUMONECTOM     1320.94  1100.79                 0  90
32491   REMOVAL OF LUNG, OTHER THAN PNEUMONECTOM      862.81   719.01                 0  90
32501   RESECTION AND REPAIR OF PORTION OF BRONC      145.51   121.26                 0   0
32503   RESECTION OF APICAL LUNG TUMOR (EG, PANC    1,077.73   898.11                 0  90
32504   RESECTION OF APICAL LUNG TUMOR (EG, PANC    1,228.39 1,023.66                 0  90
32505   THORACOTOMY; WITH THERAPEUTIC WEDGE RESE      429.37   357.81                 0  90
32506   THORACOTOMY; WITH THERAPEUTIC WEDGE RESE       72.18    60.15                 0   0
32507   THORACOTOMY; WITH DIAGNOSTIC WEDGE RESEC       72.18    60.15                 0   0
32540   EXTRAPLEURAL ENUCLEATION OF EMPYEMA (EMP      923.24   769.37                 0  90
32550   INSERTION OF INDWELLING TUNNELED PLEURAL      524.44   200.00                 0   0
32551   TUBE THORACOSTOMY, INCLUDES WATER SEAL (      105.41    87.84                 0   0
32552   REMOVAL OF INDWELLING TUNNELED PLEURAL C      111.05    81.47                 0  10
32553   PLACEMENT OF INTERSTITIAL DEVICE(S) FOR       366.94   104.08                 0   0
32560   INSTILLATION, VIA CHEST TUBE/CATHETER, A      191.65    54.70                 0   0
32561   INSTILLATION(S), VIA CHEST TUBE/CATHETER       57.97    36.46                 0   0
32562   INSTILLATION(S), VIA CHEST TUBE/CATHETER       51.52    32.64                 0   0
32601   THORACOSCOPY, DIAGNOSTIC (SEPARATE PROCE      183.59   152.99                 0   0
32604   THORACOSCOPY, DIAGNOSTIC (SEPARATE PROCE      286.96   239.13                 0   0
32606   THORACOSCOPY, DIAGNOSTIC (SEPARATE PROCE      276.17   230.15                 0   0
32607   THORACOSCOPY; WITH DIAGNOSTIC BIOPSY(IES      142.36   118.64                 0   0
32608   THORACOSCOPY; WITH DIAGNOSTIC BIOPSY(IES      174.79   145.66                 0   0
32609   THORACOSCOPY; WITH BIOPSY(IES) OF PLEURA      120.98   100.82                 0   0
32650   THORACOSCOPY, SURGICAL; WITH PLEURODESIS      402.83   335.70                 0  90
32651   THORACOSCOPY, SURGICAL; WITH PARTIAL PUL      607.50   506.25                 0  90
                                                                                                   Page 79 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
32652   THORACOSCOPY, SURGICAL; WITH TOTAL PULMO      915.01   762.51                 0  90
32653   THORACOSCOPY, SURGICAL; WITH REMOVAL OF       589.28   491.07                 0  90
32654   THORACOSCOPY, SURGICAL; WITH CONTROL OF       644.45   537.05                 0  90
32655   THORACOSCOPY, SURGICAL; WITH EXCISION-PL      544.79   453.99                 0  90
32656   THORACOSCOPY, SURGICAL; WITH PARIETAL PL      482.76   402.30                 0  90
32658   THORACOSCOPY, SURGICAL; WITH REMOVAL OF       434.19   361.83                 0  90
32659   THORACOSCOPY, SURGICAL; WITH CREATION OF      441.49   367.91                 0  90
32661   THORACOSCOPY, SURGICAL; WITH EXCISION OF      484.55   403.79                 0  90
32662   THORACOSCOPY, SURGICAL; WITH EXCISION OF      543.71   453.10                 0  90
32663   THORACOSCOPY, SURGICAL; WITH LOBECTOMY,       810.62   675.52                 0  90
32664   THORACOSCOPY, SURGICAL; WITH THORACIC SY      505.39   421.16                 0  90
32665   THORACOSCOPY, SURGICAL; WITH RESECTION-P      691.75   576.46                 0  90
32666   THORACOSCOPY, SURGICAL; WITH THERAPEUTIC      401.78   334.82                 0  90
32667   THORACOSCOPY, SURGICAL; WITH THERAPEUTIC       72.18    60.15                 0   0
32668   THORACOSCOPY, SURGICAL; WITH DIAGNOSTIC        72.72    60.60                 0   0
32669   THORACOSCOPY, SURGICAL; WITH REMOVAL OF       617.81   514.85                 0  90    *
32670   THORACOSCOPY, SURGICAL; WITH REMOVAL OF       736.90   614.08                 0  90    *
32671   THORACOSCOPY, SURGICAL; WITH REMOVAL OF       818.12   681.77                 0  90    *
32672   THORACOSCOPY, SURGICAL; WITH RESECTION-       699.91   583.26                 0  90    *
32673   THORACOSCOPY, SURGICAL; WITH RESECTION O      551.56   459.63                 0  90    *
32674   THORACOSCOPY, SURGICAL; WITH MEDIASTINAL       98.93    82.45                 0   0    *
32800   REPAIR LUNG HERNIA THROUGH CHEST WALL         539.32   449.44                 0  90
32810   CLOSURE OF CHEST WALL FOLLOWING OPEN FLA      524.65   437.21                 0  90
32815   OPEN CLOSURE OF MAJOR BRONCHIAL FISTULA     1,453.79 1,211.49                 0  90
32820   MAJOR RECONSTRUCTION, CHEST WALL (POSTTR                                  BR 0   90
32851   LUNG TRANSPLANT, SINGLE; WITHOUT CARDIOP    1,549.91 1,291.59                 0  90
32852   LUNG TRANSPLANT, SINGLE; WITH CARDIOPULM    1,732.54 1,443.78                 0  90
32853   LUNG TRANSPLANT, DOUBLE (BILATERAL SEQUE    1,853.06 1,544.22                 0  90
32854   LUNG TRANSPLANT, DOUBLE (BILATERAL SEQUE    2,006.71 1,672.26                 0  90
                                                                                                   Page 80 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
32900   RESECTION OF RIBS, EXTRAPLEURAL, ALL STA      788.89   657.41                 0  90
32905   THORACOPLASTY, SCHEDE TYPE OR EXTRAPLEUR      785.88   654.90                 0  90
32906   THORACOPLASTY, SCHEDE TYPE OR EXTRAPLEUR      969.20   807.67                 0  90
32940   PNEUMONOLYSIS, EXTRAPERIOSTEAL, INCLUDIN      719.27   599.39                 0  90
32960   PNEUMOTHORAX, THERAPEUTIC, INTRAPLEURAL        82.48    47.00                 0   0
32997   TOTAL LUNG LAVAGE (UNILATERAL)                207.85   173.21                 0   0
32998   ABLATION THERAPY FOR REDUCTION OR ERADIC    1,853.17   144.11                 0   0
32999   UNLISTED PROCEDURE, LUNGS AND PLEURA                                      BR 0    0
33010   PERICARDIOCENTESIS; INITIAL                    71.19    59.33                 0   0
33011   PERICARDIOCENTESIS; SUBSEQUENT                 72.89    60.75                 0   0
33015   TUBE PERICARDIOSTOMY                          311.06   259.22                 0  90
33020   PERICARDIOTOMY FOR REMOVAL OF CLOT OR FO      505.70   421.42                 0  90
33025   CREATION OF PERICARDIAL WINDOW OR PARTIA      469.32   400.00                 0  90
33030   PERICARDIECTOMY, SUBTOTAL OR COMPLETE; W      747.83   623.19                 0  90
33031   PERICARDIECTOMY, SUBTOTAL OR COMPLETE; W      828.25   690.21                 0  90
33050   RESECTION OF PERICARDIAL CYST OR TUMOR        800.00   800.00                 0  90
33120   EXCISION OF INTRACARDIAC TUMOR, RESECTIO      913.57   800.00                 0  90
33130   RESECTION OF EXTERNAL CARDIAC TUMOR                                       BR 0   90
33140   TRANSMYOCARDIAL LASER REVASCULARIZATION,      901.88   751.57                 0  90
33141   TRANSMYOCARDIAL LASER REVASCULARIZATION,      188.00   188.00                 0   0
33202   INSERTION OF EPICARDIAL ELECTRODE(S); OP      456.38   401.00                 0  90
33203   INSERTION OF EPICARDIAL ELECTRODE(S); EN      466.19   411.00                 0  90
33206   INSERTION OF NEW OR REPLACEMENT OF PERMA      278.80   232.34                 0  90
33207   INSERTION OF NEW OR REPLACEMENT OF PERMA      297.97   248.31                 0  90
33208   INSERTION OF NEW OR REPLACEMENT OF PERMA      318.77   265.64                 0  90
33210   INSERTION OR REPLACEMENT OF TEMPORARY TR      125.00   125.00                 0   0
33211   INSERTION OR REPLACEMENT OF TEMPORARY TR      109.69    91.41                 0   0
33212   INSERTION OF PACEMAKER PULSE GENERATOR O      208.93   174.11                 0  90
33213   INSERTION OF PACEMAKER PULSE GENERATOR O      237.58   197.99                 0  90
                                                                                                   Page 81 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
33214   UPGRADE OF IMPLANTED PACEMAKER SYSTEM, C      298.01   248.35                 0  90
33215   REPOSITIONING OF PREVIOUSLY IMPLANTED TR      190.14   158.45                 0  90
33216   INSERTION OF A TRANSVENOUS ELECTRODE; SI      234.28   195.24                 0  90
33217   INSERTION OF 2 TRANSVENOUS ELECTRODE; PE      233.27   194.40                 0  90
33218   REPAIR OF SINGLE TRANSVENOUS ELECTRODE,       242.42   202.02                 0  90
33220   REPAIR OF 2 TRANSVENOUS ELECTRODES FOR P      243.31   202.76                 0  90
33221   INSERTION OF PACEMAKER PULSE GENERATOR O      161.51   134.60                 0  90    *
33222   REVISION OR RELOCATION OF SKIN POCKET FO      217.45   181.21                 0  90
33223   REVISION OF SKIN POCKET FOR CARDIOVERTER      259.31   216.10                 0  90
33224   INSERTION OF PACING ELECTRODE, CARDIAC V      306.10   255.09                 0   0
33225   INSERTION OF PACING ELECTRODE, CARDIAC V      273.72   228.10                 0   0
33226   REPOSITIONING OF PREVIOUSLY IMPLANTED CA      295.63   246.36                 0   0
33227   REMOVAL OF PERMANENT PACEMAKER PULSE GEN      154.18   128.48                 0  90    *
33228   REMOVAL OF PERMANENT PACEMAKER PULSE GEN      160.75   133.96                 0  90    *
33229   REMOVAL OF PERMANENT PACEMAKER PULSE GEN      167.33   139.44                 0  90    *
33230   INSERTION OF PACING CARDIOVERTER-DEFIBRI      173.74   144.79                 0  90    *
33231   INSERTION OF PACING CARDIOVERTER-DEFIBRI      180.32   150.27                 0  90    *
33233   REMOVAL OF PERMANENT PACEMAKER PULSE GEN      153.32   127.77                 0  90
33234   REMOVAL OF TRANSVENOUS PACEMAKER ELECTRO      300.68   250.57                 0  90
33235   REMOVAL OF TRANSVENOUS PACEMAKER ELECTRO      391.94   326.62                 0  90
33236   REMOVAL OF PERMANENT EPICARDIAL PACEMAKE      465.94   388.28                 0  90
33237   REMOVAL OF PERMANENT EPICARDIAL PACEMAKE      510.77   425.64                 0  90
33238   REMOVAL OF PERMANENT TRANSVENOUS ELECTRO      557.59   464.66                 0  90
33240   INSERTION OF PACING CARDIOVERTER-DEFIBRI      285.55   237.96                 0  90
33241   REMOVAL OF PACING CARDIOVERTER-DEFIBRILL      143.89   119.91                 0  90
33243   REMOVAL OF SINGLE OR DUAL CHAMBER PACING      800.63   667.20                 0  90
33244   REMOVAL OF SINGLE OR DUAL CHAMBER PACING      530.40   442.00                 0  90
33249   INSERTION OR REPLACEMENT OF PERMANENT PA      551.77   459.81                 0  90
33250   OPERATIVE ABLATION OF SUPRAVENTRICULAR A      867.41   722.85                 0  90
                                                                                                   Page 82 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
33251   OPERATIVE ABLATION OF SUPRAVENTRICULAR A      947.12   789.27                 0  90
33254   OPERATIVE TISSUE ABLATION AND RECONSTRUC      796.76   663.97                 0  90
33255   OPERATIVE TISSUE ABLATION AND RECONSTRUC      958.31   798.59                 0  90
33256   OPERATIVE TISSUE ABLATION AND RECONSTRUC    1,143.64   953.03                 0  90
33257   OPERATIVE TISSUE ABLATION AND RECONSTRUC      351.12   292.60                 0   0
33258   OPERATIVE TISSUE ABLATION AND RECONSTRUC      396.45   330.38                 0   0
33259   OPERATIVE TISSUE ABLATION AND RECONSTRUC      520.45   433.71                 0   0
33261   OPERATIVE ABLATION OF VENTRICULAR ARRHYT      954.07   795.06                 0  90
33262   REMOVAL OF PACING CARDIOVERTER-DEFIBRILL      164.47   139.56                 0  90    *
33263   REMOVAL OF PACING CARDIOVERTER-DEFIBRILL      174.05   145.04                 0  90    *
33264   REMOVAL OF PACING CARDIOVERTER-DEFIBRILL      180.61   150.52                 0  90    *
33265   ENDOSCOPY, SURGICAL; OPERATIVE TISSUE AB      796.76   663.97                 0  90
33266   ENDOSCOPY, SURGICAL; OPERATIVE TISSUE AB    1,088.72   907.27                 0  90
33282   IMPLANTATION OF PATIENT-ACTIVATED CARDIA      202.75   168.96                 0  90
33284   REMOVAL OF AN IMPLANTABLE, PATIENT-ACTIV      150.16   125.13                 0  90
33300   REPAIR OF CARDIAC WOUND; WITHOUT BYPASS     1,274.78 1,062.32                 0  90
33305   REPAIR OF CARDIAC WOUND; WITH CARDIOPULM    2,078.43 1,732.03                 0  90
33310   CARDIOTOMY, EXPLORATORY (INCLUDES REMOVA      691.64   576.37                 0  90
33315   CARDIOTOMY, EXPLORATORY (INCLUDES REMOVA      866.63   722.19                 0  90
33320   SUTURE REPAIR OF AORTA OR GREAT VESSELS;      623.11   519.26                 0  90
33321   SUTURE REPAIR OF AORTA OR GREAT VESSELS;      711.50   592.92                 0  90
33322   SUTURE REPAIR OF AORTA OR GREAT VESSELS;      805.27   671.06                 0  90
33330   INSERTION OF GRAFT, AORTA OR GREAT VESSE      820.25   800.00                 0  90
33332   INSERTION OF GRAFT, AORTA OR GREAT VESSE                                  BR 0   90
33335   INSERTION OF GRAFT, AORTA OR GREAT VESSE    1,103.73   919.78                 0  90
33400   VALVULOPLASTY, AORTIC VALVE; OPEN, WITH     1,308.86 1,090.72                 0  90
33401   VALVULOPLASTY, AORTIC VALVE; OPEN, WITH       871.03   725.86                 0  90
33403   VALVULOPLASTY, AORTIC VALVE; USING TRANS                                  BR 0   90
33404   CONSTRUCTION OF APICAL-AORTIC CONDUIT       1,061.81   884.84                 0  90
                                                                                                   Page 83 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
33405   REPLACEMENT, AORTIC VALVE, WITH CARDIOPU    1,371.45 1,142.88                 0  90
33406   REPLACEMENT, AORTIC VALVE, WITH CARDIOPU    1,656.55 1,380.46                 0  90
33410   REPLACEMENT, AORTIC VALVE, WITH CARDIOPU                                  BR 0   90
33411   REPLACEMENT, AORTIC VALVE; WITH AORTIC A    1,877.42 1,564.52                 0  90
33412   REPLACEMENT, AORTIC VALVE; WITH TRANSVEN    1,487.48 1,239.57                 0  90
33413   REPLACEMENT, AORTIC VALVE; BY TRANSLOCAT    1,911.91 1,593.26                 0  90
33414   REPAIR OF LEFT VENTRICULAR OUTFLOW TRACT    1,254.15 1,045.13                 0  90
33415   RESECTION OR INCISION OF SUBVALVULAR TIS    1,161.75   968.13                 0  90
33416   VENTRICULOMYOTOMY (-MYECTOMY) FOR IDIOPA    1,175.33   979.44                 0  90
33417   AORTOPLASTY (GUSSET) FOR SUPRAVALVULAR S      998.98   832.48                 0  90
33420   VALVOTOMY, MITRAL VALVE; CLOSED HEART         799.36   666.13                 0  90
33422   VALVOTOMY, MITRAL VALVE; OPEN HEART, WIT    1,000.50   833.75                 0  90
33425   VALVULOPLASTY, MITRAL VALVE, WITH CARDIO    1,485.77 1,238.14                 0  90
33426   VALVULOPLASTY, MITRAL VALVE, WITH CARDIO    1,398.40 1,165.33                 0  90
33427   VALVULOPLASTY, MITRAL VALVE, WITH CARDIO    1,480.55 1,233.79                 0  90
33430   REPLACEMENT, MITRAL VALVE, WITH CARDIOPU    1,591.42 1,326.18                 0  90
33460   VALVECTOMY, TRICUSPID VALVE, WITH CARDIO    1,308.13 1,090.11                 0  90
33463   VALVULOPLASTY, TRICUSPID VALVE; WITHOUT     1,650.93 1,375.78                 0  90
33464   VALVULOPLASTY, TRICUSPID VALVE; WITH RIN    1,362.65 1,135.55                 0  90
33465   REPLACEMENT, TRICUSPID VALVE, WITH CARDI    1,507.74 1,256.45                 0  90
33468   TRICUSPID VALVE REPOSITIONING AND PLICAT    1,116.74   930.62                 0  90
33470   VALVOTOMY, PULMONARY VALVE, CLOSED HEART      687.22   600.00                 0  90
33471   VALVOTOMY, PULMONARY VALVE, CLOSED HEART      804.77   800.00                 0  90
33472   VALVOTOMY, PULMONARY VALVE, OPEN HEART;       801.37   800.00                 0  90
33474   VALVOTOMY, PULMONARY VALVE, OPEN HEART;     1,167.00   972.50                 0  90
33475   REPLACEMENT, PULMONARY VALVE                1,347.80 1,123.17                 0  90
33476   RIGHT VENTRICULAR RESECTION FOR INFUNDIB      868.26   800.00                 0  90
33478   OUTFLOW TRACT AUGMENTATION (GUSSET), WIT      942.39   800.00                 0  90
33496   REPAIR OF NON-STRUCTURAL PROSTHETIC VALV      992.58   827.15                 0  90
                                                                                                   Page 84 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
33500   REPAIR OF CORONARY ARTERIOVENOUS OR ARTE      931.54   875.00                 0  90
33501   REPAIR OF CORONARY ARTERIOVENOUS OR ARTE                                  BR 0   90
33502   REPAIR OF ANOMALOUS CORONARY ARTERY FROM                                  BR 0   90
33503   REPAIR OF ANOMALOUS CORONARY ARTERY; BY       800.00   800.00                 0  90
33504   REPAIR OF ANOMALOUS CORONARY ARTERY; BY       867.41   800.00                 0  90
33505   REPAIR OF ANOMALOUS CORONARY ARTERY; WIT    1,177.02   980.85                 0  90
33506   REPAIR OF ANOMALOUS CORONARY ARTERY; BY     1,211.78 1,009.82                 0  90
33507   REPAIR OF ANOMALOUS (EG, INTRAMURAL) AOR    1,035.43   862.86                 0  90
33508   ENDOSCOPY, SURGICAL, INCLUDING VIDEO-ASS        9.62     8.02                 0   0
33510   CORONARY ARTERY BYPASS, VEIN ONLY; SINGL    1,170.75   975.63                 0  90
33511   CORONARY ARTERY BYPASS, VEIN ONLY; TWO C    1,269.16 1,130.00                 0  90
33512   CORONARY ARTERY BYPASS, VEIN ONLY; THREE    1,413.03 1,200.00                 0  90
33513   CORONARY ARTERY BYPASS, VEIN ONLY; FOUR     1,453.88 1,252.00                 0  90
33514   CORONARY ARTERY BYPASS, VEIN ONLY; FIVE     1,521.82 1,296.00                 0  90
33516   CORONARY ARTERY BYPASS, VEIN ONLY; SIX O    1,580.93 1,335.00                 0  90
33517   CORONARY ARTERY BYPASS, USING VENOUS GRA      106.07    97.00                 0   0
33518   CORONARY ARTERY BYPASS, USING VENOUS GRA      226.63   188.86                 0   0
33519   CORONARY ARTERY BYPASS, USING VENOUS GRA      304.66   253.89                 0   0
33521   CORONARY ARTERY BYPASS, USING VENOUS GRA      371.93   309.94                 0   0
33522   CORONARY ARTERY BYPASS, USING VENOUS GRA      427.42   356.18                 0   0
33523   CORONARY ARTERY BYPASS, USING VENOUS GRA      490.66   408.88                 0   0
33530   REOPERATION, CORONARY ARTERY BYPASS PROC      363.00   363.00                 0   0
33533   CORONARY ARTERY BYPASS, USING ARTERIAL G    1,146.16 1,072.00                 0  90
33534   CORONARY ARTERY BYPASS, USING ARTERIAL G    1,316.77 1,269.00                 0  90
33535   CORONARY ARTERY BYPASS, USING ARTERIAL G    1,447.70 1,376.00                 0  90
33536   CORONARY ARTERY BYPASS, USING ARTERIAL G    1,546.76 1,482.00                 0  90
33542   MYOCARDIAL RESECTION (EG, VENTRICULAR AN    1,447.45 1,206.21                 0  90
33545   REPAIR OF POSTINFARCTION VENTRICULAR SEP    1,719.20 1,432.67                 0  90
33548   SURGICAL VENTRICULAR RESTORATION PROCEDU    1,701.11 1,417.59                 0  90
                                                                                                   Page 85 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
33572   CORONARY ENDARTERECTOMY, OPEN, ANY METHO      139.17   115.98                 0   0
33600   CLOSURE OF ATRIOVENTRICULAR VALVE (MITRA    1,018.22   900.00                 0  90
33602   CLOSURE OF SEMILUNAR VALVE (AORTIC OR PU      972.00   900.00                 0  90
33606   ANASTOMOSIS OF PULMONARY ARTERY TO AORTA    1,054.11   900.00                 0  90
33608   REPAIR OF COMPLEX CARDIAC ANOMALY OTHER     1,085.69   904.74                 0  90
33610   REPAIR OF COMPLEX CARDIAC ANOMALIES (EG,    1,074.13   900.00                 0  90
33611   REPAIR OF DOUBLE OUTLET RIGHT VENTRICLE     1,148.65 1,000.00                 0  90
33612   REPAIR OF DOUBLE OUTLET RIGHT VENTRICLE     1,226.36 1,021.97                 0  90
33615   REPAIR OF COMPLEX CARDIAC ANOMALIES (EG,    1,158.50 1,000.00                 0  90
33617   REPAIR OF COMPLEX CARDIAC ANOMALIES (EG,    1,290.86 1,075.72                 0  90
33619   REPAIR OF SINGLE VENTRICLE WITH AORTIC O    1,614.35 1,345.30                 0  90
33620   APPLICATION OF RIGHT AND LEFT PULMONARY       794.81   662.34                 0  90
33621   TRANSTHORACIC INSERTION OF CATHETER FOR       427.28   356.07                 0  90
33622   RECONSTRUCTION OF COMPLEX CARDIAC ANOMAL    1,674.73 1,395.61                 0  90
33641   REPAIR ATRIAL SEPTAL DEFECT, SECUNDUM, W      926.59   800.00                 0  90
33645   DIRECT OR PATCH CLOSURE, SINUS VENOSUS,       932.49   800.00                 0  90
33647   REPAIR OF ATRIAL SEPTAL DEFECT AND VENTR      999.92   833.27                 0  90
33660   REPAIR OF INCOMPLETE OR PARTIAL ATRIOVEN    1,060.34   883.62                 0  90
33665   REPAIR OF INTERMEDIATE OR TRANSITIONAL A    1,119.59   932.99                 0  90
33670   REPAIR OF COMPLETE ATRIOVENTRICULAR CANA    1,205.48 1,004.57                 0  90
33675   CLOSURE OF MULTIPLE VENTRICULAR SEPTAL D    1,231.09 1,025.91                 0  90
33676   CLOSURE OF MULTIPLE VENTRICULAR SEPTAL D    1,269.87 1,058.23                 0  90
33677   CLOSURE OF MULTIPLE VENTRICULAR SEPTAL D    1,319.87 1,099.90                 0  90
33681   CLOSURE OF SINGLE VENTRICULAR SEPTAL DEF    1,095.59   913.00                 0  90
33684   CLOSURE OF VENTRICULAR SEPTAL DEFECT, WI    1,107.23   922.69                 0  90
33688   CLOSURE OF VENTRICULAR SEPTAL DEFECT, WI    1,085.66   904.72                 0  90
33690   BANDING OF PULMONARY ARTERY                   687.83   573.20                 0  90
33692   COMPLETE REPAIR TETRALOGY OF FALLOT WITH    1,155.62   963.02                 0  90
33694   COMPLETE REPAIR TETRALOGY OF FALLOT WITH    1,141.52   951.27                 0  90
                                                                                                   Page 86 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
33697   COMPLETE REPAIR TETRALOGY OF FALLOT WITH    1,248.36 1,040.30                 0  90
33702   REPAIR SINUS OF VALSALVA FISTULA, WITH C      920.05   800.00                 0  90
33710   REPAIR SINUS OF VALSALVA FISTULA, WITH C    1,160.00 1,160.00                 0  90
33720   REPAIR SINUS OF VALSALVA ANEURYSM, WITH       922.63   800.00                 0  90
33722   CLOSURE OF AORTICO-LEFT VENTRICULAR TUNN                                  BR 0   90
33724   REPAIR OF ISOLATED PARTIAL ANOMALOUS PUL      907.48   756.24                 0  90
33726   REPAIR OF PULMONARY VENOUS STENOSIS         1,194.48   995.40                 0  90
33730   COMPLETE REPAIR OF ANOMALOUS VENOUS RETU    1,180.04   983.37                 0  90
33732   REPAIR OF COR TRIATRIATUM OR SUPRAVALVUL      991.00   825.84                 0  90
33735   ATRIAL SEPTECTOMY OR SEPTOSTOMY; CLOSED       739.02   615.85                 0  90
33736   ATRIAL SEPTECTOMY OR SEPTOSTOMY; OPEN HE      856.87   714.06                 0  90
33737   ATRIAL SEPTECTOMY OR SEPTOSTOMY; OPEN HE                                  BR 0   90
33750   SHUNT; SUBCLAVIAN TO PULMONARY ARTERY (B      717.98   598.32                 0  90
33755   SHUNT; ASCENDING AORTA TO PULMONARY ARTE                                  BR 0   90
33762   SHUNT; DESCENDING AORTA TO PULMONARY ART      760.51   633.76                 0  90
33764   SHUNT; CENTRAL, WITH PROSTHETIC GRAFT         761.53   634.61                 0  90
33766   SHUNT; SUPERIOR VENA CAVA TO PULMONARY A      808.78   673.99                 0  90
33767   SHUNT; SUPERIOR VENA CAVA TO PULMONARY A      847.91   706.60                 0  90
33768   ANASTOMOSIS, CAVOPULMONARY, SECOND SUPER      245.24   207.00                 0   0
33770   REPAIR OF TRANSPOSITION OF THE GREAT ART    1,252.48 1,043.73                 0  90
33771   REPAIR OF TRANSPOSITION OF THE GREAT ART    1,269.09 1,057.58                 0  90
33774   REPAIR OF TRANSPOSITION OF THE GREAT ART    1,082.32   901.94                 0  90
33775   REPAIR OF TRANSPOSITION OF THE GREAT ART    1,090.88   909.07                 0  90
33776   REPAIR OF TRANSPOSITION OF THE GREAT ART    1,139.69 1,020.00                 0  90
33777   REPAIR OF TRANSPOSITION OF THE GREAT ART    1,130.71 1,020.00                 0  90
33778   REPAIR OF TRANSPOSITION OF THE GREAT ART    1,400.75 1,167.29                 0  90
33779   REPAIR OF TRANSPOSITION OF THE GREAT ART    1,288.73 1,073.95                 0  90
33780   REPAIR OF TRANSPOSITION OF THE GREAT ART    1,374.08 1,145.07                 0  90
33781   REPAIR OF TRANSPOSITION OF THE GREAT ART    1,315.88 1,096.57                 0  90
                                                                                                   Page 87 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
33782   AORTIC ROOT TRANSLOCATION WITH VENTRICUL    1,979.54 1,649.62                 0  90
33783   AORTIC ROOT TRANSLOCATION WITH VENTRICUL    2,139.47 1,782.89                 0  90
33786   TOTAL REPAIR, TRUNCUS ARTERIOSUS (RASTEL    1,359.34 1,132.79                 0  90
33788   REIMPLANTATION OF AN ANOMALOUS PULMONARY      895.47   746.23                 0  90
33800   AORTIC SUSPENSION (AORTOPEXY) FOR TRACHE      590.63   492.20                 0  90
33802   DIVISION OF ABERRANT VESSEL (VASCULAR RI      634.55   528.80                 0  90
33803   DIVISION OF ABERRANT VESSEL (VASCULAR RI                                  BR 0   90
33813   OBLITERATION OF AORTOPULMONARY SEPTAL DE      746.55   622.13                 0  90
33814   OBLITERATION OF AORTOPULMONARY SEPTAL DE      909.25   757.71                 0  90
33820   REPAIR OF PATENT DUCTUS ARTERIOSUS; BY L      580.33   483.61                 0  90
33822   REPAIR OF PATENT DUCTUS ARTERIOSUS; BY D      603.19   502.66                 0  90
33824   REPAIR OF PATENT DUCTUS ARTERIOSUS; BY D      701.99   584.99                 0  90
33840   EXCISION OF COARCTATION OF AORTA, WITH O      723.07   602.56                 0  90
33845   EXCISION OF COARCTATION OF AORTA, WITH O      792.16   660.13                 0  90
33851   EXCISION OF COARCTATION OF AORTA, WITH O      757.97   631.64                 0  90
33852   REPAIR OF HYPOPLASTIC OR INTERRUPTED AOR      865.62   721.35                 0  90
33853   REPAIR OF HYPOPLASTIC OR INTERRUPTED AOR    1,094.06   911.72                 0  90
33860   ASCENDING AORTA GRAFT, WITH CARDIOPULMON    1,791.52 1,492.93                 0  90
33863   ASCENDING AORTA GRAFT, WITH CARDIOPULMON    1,817.35 1,514.46                 0  90
33864   ASCENDING AORTA GRAFT, WITH CARDIOPULMON    1,870.54 1,558.79                 0  90
33870   TRANSVERSE ARCH GRAFT, WITH CARDIOPULMON    1,512.79 1,260.66                 0  90
33875   DESCENDING THORACIC AORTA GRAFT, WITH OR    1,170.42   975.35                 0  90
33877   REPAIR OF THORACOABDOMINAL AORTIC ANEURY    1,998.11 1,665.09                 0  90
33880   ENDOVASCULAR REPAIR OF DESCENDING THORAC    1,065.55   887.96                 0  90
33881   ENDOVASCULAR REPAIR OF DESCENDING THORAC      920.19   766.83                 0  90
33883   PLACEMENT OF PROXIMAL EXTENSION PROSTHES      677.68   564.74                 0  90
33884   PLACEMENT OF PROXIMAL EXTENSION PROSTHES      243.97   203.31                 0   0
33886   PLACEMENT OF DISTAL EXTENSION PROSTHESIS      586.90   489.09                 0  90
33889   OPEN SUBCLAVIAN TO CAROTID ARTERY TRANSP      486.56   405.47                 0   0
                                                                                                   Page 88 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
33891   BYPASS GRAFT, WITH OTHER THAN VEIN, TRAN      626.66   522.22                 0   0
33910   PULMONARY ARTERY EMBOLECTOMY; WITH CARDI      967.31   806.09                 0  90
33915   PULMONARY ARTERY EMBOLECTOMY; WITHOUT CA      769.98   641.65                 0  90
33916   PULMONARY ENDARTERECTOMY, WITH OR WITHOU      932.84   777.37                 0  90
33917   REPAIR OF PULMONARY ARTERY STENOSIS BY R      869.83   724.86                 0  90
33920   REPAIR OF PULMONARY ATRESIA WITH VENTRIC    1,049.93   874.94                 0  90
33922   TRANSECTION OF PULMONARY ARTERY WITH CAR      821.51   684.60                 0  90
33924   LIGATION AND TAKEDOWN OF A SYSTEMIC-TO-P      172.67   143.90                 0   0
33925   REPAIR OF PULMONARY ARTERY ARBORIZATION                                   BR 0   90
33926   REPAIR OF PULMONARY ARTERY ARBORIZATION     1,451.49 1,209.58                 0  90
33935   HEART-LUNG TRANSPLANT WITH RECIPIENT CAR    2,098.94 2,000.00                 0  90
33945   HEART TRANSPLANT, WITH OR WITHOUT RECIPI    2,595.69 2,163.08                 0  90
33960   PROLONGED EXTRACORPOREAL CIRCULATION FOR      579.40   482.83                 0   0
33961   PROLONGED EXTRACORPOREAL CIRCULATION FOR      323.67   269.73                 0   0
33967   INSERTION OF INTRA-AORTIC BALLOON ASSIST      159.00   132.50                 0   0
33968   REMOVAL OF INTRA-AORTIC BALLOON ASSIST D       20.45    17.05                 0   0
33970   INSERTION OF INTRA-AORTIC BALLOON ASSIST      300.00   300.00                 0   0
33971   REMOVAL OF INTRA-AORTIC BALLOON ASSIST D      419.07   349.23                 0  90
33973   INSERTION OF INTRA-AORTIC BALLOON ASSIST      316.69   263.91                 0   0
33974   REMOVAL OF INTRA-AORTIC BALLOON ASSIST D      536.02   446.68                 0  90
33975   INSERTION OF VENTRICULAR ASSIST DEVICE;       651.76   543.14                 0   0
33976   INSERTION OF VENTRICULAR ASSIST DEVICE;       729.30   607.75                 0   0
33977   REMOVAL OF VENTRICULAR ASSIST DEVICE; EX      724.85   604.04                 0   0
33978   REMOVAL OF VENTRICULAR ASSIST DEVICE; EX      806.57   672.15                 0   0
33979   INSERTION OF VENTRICULAR ASSIST DEVICE,     1,441.16 1,200.97                 0   0
33980   REMOVAL OF VENTRICULAR ASSIST DEVICE, IM                                  BR 0    0
33981   REPLACEMENT OF EXTRACORPOREAL VENTRICULA                                  BR 0    0
33982   REPLACEMENT OF VENTRICULAR ASSIST DEVICE                                  BR 0    0
33983   REPLACEMENT OF VENTRICULAR ASSIST DEVICE                                  BR 0    0
                                                                                                   Page 89 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
33999   UNLISTED PROCEDURE, CARDIAC SURGERY                                       BR 0    0
34001   EMBOLECTOMY OR THROMBECTOMY, WITH OR WIT      565.39   471.16                 0  90
34051   EMBOLECTOMY OR THROMBECTOMY, WITH OR WIT      581.98   484.98                 0  90
34101   EMBOLECTOMY OR THROMBECTOMY, WITH OR WIT      371.84   309.87                 0  90
34111   EMBOLECTOMY OR THROMBECTOMY, WITH OR WIT      371.37   309.48                 0  90
34151   EMBOLECTOMY OR THROMBECTOMY, WITH OR WIT      853.51   711.26                 0  90
34201   EMBOLECTOMY OR THROMBECTOMY, WITH OR WIT      575.30   479.42                 0  90
34203   EMBOLECTOMY OR THROMBECTOMY, WITH OR WIT      592.43   493.69                 0  90
34401   THROMBECTOMY, DIRECT OR WITH CATHETER; V      854.00   711.67                 0  90
34421   THROMBECTOMY, DIRECT OR WITH CATHETER; V      447.45   372.88                 0  90
34451   THROMBECTOMY, DIRECT OR WITH CATHETER; V      922.48   768.74                 0  90
34471   THROMBECTOMY, DIRECT OR WITH CATHETER; S      617.15   514.30                 0  90
34490   THROMBECTOMY, DIRECT OR WITH CATHETER; A      373.09   310.91                 0  90
34501   VALVULOPLASTY, FEMORAL VEIN                   577.95   481.63                 0  90
34502   RECONSTRUCTION OF VENA CAVA, ANY METHOD       930.28   775.24                 0  90
34510   VENOUS VALVE TRANSPOSITION, ANY VEIN DON      664.93   554.11                 0  90
34520   CROSS-OVER VEIN GRAFT TO VENOUS SYSTEM        630.77   525.64                 0  90
34530   SAPHENOPOPLITEAL VEIN ANASTOMOSIS             590.99   492.50                 0  90
34800   ENDOVASCULAR REPAIR OF INFRARENAL ABDOMI      695.28   579.40                 0  90
34802   ENDOVASCULAR REPAIR OF INFRARENAL ABDOMI      757.43   631.20                 0  90
34803   ENDOVASCULAR REPAIR OF INFRARENAL ABDOMI      774.53   645.45                 0  90
34804   ENDOVASCULAR REPAIR OF INFRARENAL ABDOMI      755.53   629.61                 0  90
34805   ENDOVASCULAR REPAIR OF INFRARENAL ABDOMI      714.26   595.22                 0  90
34806   TRANSCATHETER PLACEMENT OF WIRELESS PHYS       61.23    51.03                 0   0
34808   ENDOVASCULAR PLACEMENT OF ILIAC ARTERY O      127.15   105.96                 0   0
34812   OPEN FEMORAL ARTERY EXPOSURE FOR DELIVER      212.14   176.79                 0   0
34813   PLACEMENT OF FEMORAL-FEMORAL PROSTHETIC       146.31   121.93                 0   0
34820   OPEN ILIAC ARTERY EXPOSURE FOR DELIVERY       302.41   252.01                 0   0
34825   PLACEMENT OF PROXIMAL OR DISTAL EXTENSIO      427.34   356.12                 0  90
                                                                                                   Page 90 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
34826   PLACEMENT OF PROXIMAL OR DISTAL EXTENSIO      124.76   103.97                 0   0
34830   OPEN REPAIR OF INFRARENAL AORTIC ANEURYS    1,114.30   928.58                 0  90
34831   OPEN REPAIR OF INFRARENAL AORTIC ANEURYS    1,165.46   971.22                 0  90
34832   OPEN REPAIR OF INFRARENAL AORTIC ANEURYS    1,206.64 1,005.54                 0  90
34833   OPEN ILIAC ARTERY EXPOSURE WITH CREATION                                  BR 0    0
34834   OPEN BRACHIAL ARTERY EXPOSURE TO ASSIST                                   BR 0    0
34900   ENDOVASCULAR GRAFT PLACEMENT FOR REPAIR                                   BR 0   90
35001   DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYS      697.95   600.00                 0  90
35002   DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYS                                  BR 0   90
35005   DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYS      645.01   600.00                 0  90
35011   DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYS      610.48   508.74                 0  90
35013   DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYS      755.57   629.65                 0  90
35021   DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYS      735.20   612.67                 0  90
35022   DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYS      845.51   704.59                 0  90
35045   DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYS      600.00   600.00                 0  90
35081   DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYS    1,044.05   870.05                 0  90
35082   DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYS    1,323.27 1,102.73                 0  90
35091   DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYS    1,126.99   939.16                 0  90
35092   DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYS    1,576.25 1,313.54                 0  90
35102   DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYS    1,134.00   945.00                 0  90
35103   DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYS    1,367.60 1,139.67                 0  90
35111   DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYS      845.63   704.70                 0  90
35112   DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYS    1,024.90   854.09                 0  90
35121   DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYS    1,012.45   843.71                 0  90
35122   DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYS    1,188.76   990.64                 0  90
35131   DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYS      860.29   716.91                 0  90
35132   DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYS    1,037.72   864.77                 0  90
35141   DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYS      685.30   571.08                 0  90
35142   DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYS      815.33   679.44                 0  90
                                                                                                   Page 91 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
35151   DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYS      771.61   643.01                 0  90
35152   DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYS      895.06   745.88                 0  90
35180   REPAIR, CONGENITAL ARTERIOVENOUS FISTULA      491.24   409.37                 0  90
35182   REPAIR, CONGENITAL ARTERIOVENOUS FISTULA                                  BR 0   90
35184   REPAIR, CONGENITAL ARTERIOVENOUS FISTULA                                  BR 0   90
35188   REPAIR, ACQUIRED OR TRAUMATIC ARTERIOVEN      526.85   439.04                 0  90
35189   REPAIR, ACQUIRED OR TRAUMATIC ARTERIOVEN                                  BR 0   90
35190   REPAIR, ACQUIRED OR TRAUMATIC ARTERIOVEN      456.70   380.59                 0  90
35201   REPAIR BLOOD VESSEL, DIRECT; NECK             572.43   477.03                 0  90
35206   REPAIR BLOOD VESSEL, DIRECT; UPPER EXTRE      468.80   390.67                 0  90
35207   REPAIR BLOOD VESSEL, DIRECT; HAND, FINGE      426.82   355.69                 0  90
35211   REPAIR BLOOD VESSEL, DIRECT; INTRATHORAC      822.01   685.01                 0  90
35216   REPAIR BLOOD VESSEL, DIRECT; INTRATHORAC    1,081.44   901.20                 0  90
35221   REPAIR BLOOD VESSEL, DIRECT; INTRA-ABDOM      842.19   701.83                 0  90
35226   REPAIR BLOOD VESSEL, DIRECT; LOWER EXTRE      518.81   432.35                 0  90
35231   REPAIR BLOOD VESSEL WITH VEIN GRAFT; NEC      710.35   591.96                 0  90
35236   REPAIR BLOOD VESSEL WITH VEIN GRAFT; UPP      595.21   496.01                 0  90
35241   REPAIR BLOOD VESSEL WITH VEIN GRAFT; INT      860.14   716.78                 0  90
35246   REPAIR BLOOD VESSEL WITH VEIN GRAFT; INT      926.21   771.85                 0  90
35251   REPAIR BLOOD VESSEL WITH VEIN GRAFT; INT    1,003.91   836.60                 0  90
35256   REPAIR BLOOD VESSEL WITH VEIN GRAFT; LOW      627.43   522.86                 0  90
35261   REPAIR BLOOD VESSEL WITH GRAFT OTHER THA      628.57   523.81                 0  90
35266   REPAIR BLOOD VESSEL WITH GRAFT OTHER THA      522.15   435.13                 0  90
35271   REPAIR BLOOD VESSEL WITH GRAFT OTHER THA      819.39   682.83                 0  90
35276   REPAIR BLOOD VESSEL WITH GRAFT OTHER THA      861.67   718.06                 0  90
35281   REPAIR BLOOD VESSEL WITH GRAFT OTHER THA      958.42   798.69                 0  90
35286   REPAIR BLOOD VESSEL WITH GRAFT OTHER THA      577.55   481.29                 0  90
35301   THROMBOENDARTERECTOMY, INCLUDING PATCH G      644.83   537.36                 0  90
35302   THROMBOENDARTERECTOMY, INCLUDING PATCH G      671.02   582.00                 0  90
                                                                                                   Page 92 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
35303   THROMBOENDARTERECTOMY, INCLUDING PATCH G      736.73   640.00                 0  90
35304   THROMBOENDARTERECTOMY, INCLUDING PATCH G      766.64   666.00                 0  90
35305   THROMBOENDARTERECTOMY, INCLUDING PATCH G      736.73   640.00                 0  90
35306   THROMBOENDARTERECTOMY, INCLUDING PATCH G      275.07   240.00                 0   0
35311   THROMBOENDARTERECTOMY, WITH OR WITHOUT P      921.78   768.15                 0  90
35321   THROMBOENDARTERECTOMY, WITH OR WITHOUT P      549.41   457.85                 0  90
35331   THROMBOENDARTERECTOMY, WITH OR WITHOUT P      896.21   746.84                 0  90
35341   THROMBOENDARTERECTOMY, WITH OR WITHOUT P      852.70   710.58                 0  90
35351   THROMBOENDARTERECTOMY, WITH OR WITHOUT P      787.93   656.61                 0  90
35355   THROMBOENDARTERECTOMY, WITH OR WITHOUT P      641.33   600.00                 0  90
35361   THROMBOENDARTERECTOMY, WITH OR WITHOUT P      969.64   808.03                 0  90
35363   THROMBOENDARTERECTOMY, WITH OR WITHOUT P    1,038.19   865.16                 0  90
35371   THROMBOENDARTERECTOMY, WITH OR WITHOUT P      509.93   424.94                 0  90
35372   THROMBOENDARTERECTOMY, WITH OR WITHOUT P      611.05   509.21                 0  90
35390   REOPERATION, CAROTID, THROMBOENDARTERECT       98.58    82.15                 0   0
35400   ANGIOSCOPY (NON-CORONARY VESSELS OR GRAF       93.23    77.69                 0   0
35450   TRANSLUMINAL BALLOON ANGIOPLASTY, OPEN;       313.63   261.36                 0   0
35452   TRANSLUMINAL BALLOON ANGIOPLASTY, OPEN;       219.35   182.79                 0   0
35458   TRANSLUMINAL BALLOON ANGIOPLASTY, OPEN;       299.07   249.23                 0   0
35460   TRANSLUMINAL BALLOON ANGIOPLASTY, OPEN;       191.16   159.30                 0   0
35471   TRANSLUMINAL BALLOON ANGIOPLASTY, PERCUT    2,267.58   272.04                 0   0
35472   TRANSLUMINAL BALLOON ANGIOPLASTY, PERCUT    1,531.44   185.28                 0   0
35475   TRANSLUMINAL BALLOON ANGIOPLASTY, PERCUT    1,497.32   244.02                 0   0
35476   TRANSLUMINAL BALLOON ANGIOPLASTY, PERCUT    1,138.78   155.87                 0   0
35500   HARVEST OF UPPER EXTREMITY VEIN, ONE SEG      196.82   164.02                 0   0
35501   BYPASS GRAFT, WITH VEIN; COMMON CAROTID-      924.14   770.12                 0  90
35506   BYPASS GRAFT, WITH VEIN; CAROTID-SUBCLAV      798.16   665.13                 0  90
35508   BYPASS GRAFT, WITH VEIN; CAROTID-VERTEBR      817.07   680.90                 0  90
35509   BYPASS GRAFT, WITH VEIN; CAROTID-CONTRAL      899.95   749.96                 0  90
                                                                                                   Page 93 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                         DESCRIPTION             FEE      FEE        FEE      BR PA DAYS   E
35510   BYPASS GRAFT, WITH VEIN; CAROTID-BRACHIA      763.30   636.09                 0  90
35511   BYPASS GRAFT, WITH VEIN; SUBCLAVIAN-SUBC      726.21   605.18                 0  90
35512   BYPASS GRAFT, WITH VEIN; SUBCLAVIAN-BRAC      748.19   623.49                 0  90
35515   BYPASS GRAFT, WITH VEIN; SUBCLAVIAN-VERT      819.04   682.54                 0  90
35516   BYPASS GRAFT, WITH VEIN; SUBCLAVIAN-AXIL      719.99   600.00                 0  90
35518   BYPASS GRAFT, WITH VEIN; AXILLARY-AXILLA      729.31   607.76                 0  90
35521   BYPASS GRAFT, WITH VEIN; AXILLARY-FEMORA      778.74   648.95                 0  90
35522   BYPASS GRAFT, WITH VEIN; AXILLARY-BRACHI      729.19   607.66                 0  90
35523   BYPASS GRAFT, WITH VEIN; BRACHIAL-ULNAR       764.62   637.19                 0  90
35525   BYPASS GRAFT, WITH VEIN; BRACHIAL-BRACHI      690.19   575.16                 0  90
35526   BYPASS GRAFT, WITH VEIN; AORTOSUBCLAVIAN    1,050.49   875.41                 0  90
35531   BYPASS GRAFT, WITH VEIN; AORTOCELIAC OR     1,231.32 1,026.10                 0  90
35533   BYPASS GRAFT, WITH VEIN; AXILLARY-FEMORA      955.42   796.19                 0  90
35535   BYPASS GRAFT, WITH VEIN; HEPATORENAL        1,243.36 1,036.14                 0  90
35536   BYPASS GRAFT, WITH VEIN; SPLENORENAL        1,065.83   888.20                 0  90
35537   BYPASS GRAFT, WITH VEIN; AORTOILIAC         1,302.95 1,085.79                 0  90
35538   BYPASS GRAFT, WITH VEIN; AORTOBI-ILIAC      1,454.57 1,212.14                 0  90
35539   BYPASS GRAFT, WITH VEIN; AORTOFEMORAL       1,364.21 1,136.84                 0  90
35540   BYPASS GRAFT, WITH VEIN; AORTOBIFEMORAL     1,520.65 1,267.21                 0  90
35556   BYPASS GRAFT, WITH VEIN; FEMORAL-POPLITE      838.73   698.94                 0  90
35558   BYPASS GRAFT, WITH VEIN; FEMORAL-FEMORAL      751.00   625.83                 0  90
35560   BYPASS GRAFT, WITH VEIN; AORTORENAL         1,093.00   910.83                 0  90
35563   BYPASS GRAFT, WITH VEIN; ILIOILIAC            848.21   706.85                 0  90
35565   BYPASS GRAFT, WITH VEIN; ILIOFEMORAL          809.58   674.65                 0  90
35566   BYPASS GRAFT, WITH VEIN; FEMORAL-ANTERIO    1,004.81   837.34                 0  90
35570   BYPASS GRAFT, WITH VEIN; TIBIAL-TIBIAL        961.10   800.92                 0  90
35571   BYPASS GRAFT, WITH VEIN; POPLITEAL-TIBIA      828.25   690.21                 0  90
35572   HARVEST OF FEMOROPOPLITEAL VEIN, ONE SEG      212.47   177.06                 0   0
35583   IN-SITU VEIN BYPASS; FEMORAL-POPLITEAL        866.11   721.76                 0  90
                                                                                                        Page 94 of 189


                                                                                                    C
                                                          NON-                                      H
                                                                                                    A
                                                        FACILITY FACILITY PROFESSIONAL              N
                                                        GLOBAL GLOBAL      COMPONENT          FU    G
CODE                         DESCRIPTION                  FEE      FEE        FEE      BR PA DAYS   E
35585   IN-SITU VEIN BYPASS; FEMORAL-ANTERIOR TI         1,022.61   852.18                 0  90
35587   IN-SITU VEIN BYPASS; POPLITEAL-TIBIAL, P           856.96   714.14                 0  90
35600   HARVEST OF UPPER EXTREMITY ARTERY, ONE S           155.84   129.87                 0   0
35601   BYPASS GRAFT, WITH OTHER THAN VEIN; COMM           868.92   724.10                 0  90
35606   BYPASS GRAFT, WITH OTHER THAN VEIN; CARO           717.74   598.12                 0  90
35612   BYPASS GRAFT, WITH OTHER THAN VEIN; SUBC           562.55   480.00                 0  90
35616   BYPASS GRAFT, WITH OTHER THAN VEIN; SUBC           680.48   567.07                 0  90
35621   BYPASS GRAFT, WITH OTHER THAN VEIN; AXIL           683.37   569.48                 0  90
35623   BYPASS GRAFT, WITH OTHER THAN VEIN; AXIL           837.04   697.53                 0  90
35626   BYPASS GRAFT, WITH OTHER THAN VEIN; AORT           958.55   798.80                 0  90
35631   BYPASS GRAFT, WITH OTHER THAN VEIN; AORT         1,144.16   953.47                 0  90
35632   BYPASS GRAFT, WITH OTHER THAN VEIN; ILIO         1,180.63   983.86                 0  90
35633   BYPASS GRAFT, WITH OTHER THAN VEIN; ILIO         1,274.71 1,062.26                 0  90
35634   BYPASS GRAFT, WITH OTHER THAN VEIN; ILIORENAL    1,155.53   962.94                 0  90
35636   BYPASS GRAFT, WITH OTHER THAN VEIN; SPLE         1,008.19   840.16                 0  90
35637   BYPASS GRAFT, WITH OTHER THAN VEIN; AORT         1,033.61   861.35                 0  90
35638   BYPASS GRAFT, WITH OTHER THAN VEIN; AORT         1,049.98   874.99                 0  90
35642   BYPASS GRAFT, WITH OTHER THAN VEIN; CARO           619.23   516.03                 0  90
35645   BYPASS GRAFT, WITH OTHER THAN VEIN; SUBC           630.49   525.41                 0  90
35646   BYPASS GRAFT, WITH OTHER THAN VEIN; AORT         1,059.80   883.17                 0  90
35647   BYPASS GRAFT, WITH OTHER THAN VEIN; AORT           957.80   798.17                 0  90
35650   BYPASS GRAFT, WITH OTHER THAN VEIN; AXIL           659.06   549.22                 0  90
35654   BYPASS GRAFT, WITH OTHER THAN VEIN; AXIL           847.47   706.23                 0  90
35656   BYPASS GRAFT, WITH OTHER THAN VEIN; FEMO           669.07   557.56                 0  90
35661   BYPASS GRAFT, WITH OTHER THAN VEIN; FEMO           670.45   558.71                 0  90
35663   BYPASS GRAFT, WITH OTHER THAN VEIN; ILIO           775.58   646.32                 0  90
35665   BYPASS GRAFT, WITH OTHER THAN VEIN; ILIO           728.08   606.74                 0  90
35666   BYPASS GRAFT, WITH OTHER THAN VEIN; FEMO           786.89   655.75                 0  90
35671   BYPASS GRAFT, WITH OTHER THAN VEIN; POPL           692.92   577.43                 0  90
                                                                                                   Page 95 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
35681   BYPASS GRAFT; COMPOSITE, PROSTHETIC AND       150.00   150.00                 0   0
35682   BYPASS GRAFT; AUTOGENOUS COMPOSITE, TWO       220.03   220.00                 0   0
35683   BYPASS GRAFT; AUTOGENOUS COMPOSITE, THRE      259.10   250.00                 0   0
35685   PLACEMENT OF VEIN PATCH OR CUFF AT DISTA      123.83   103.19                 0   0
35686   CREATION OF DISTAL ARTERIOVENOUS FISTULA      103.05    85.88                 0   0
35691   TRANSPOSITION AND/OR REIMPLANTATION; VER      608.66   507.22                 0  90
35693   TRANSPOSITION AND/OR REIMPLANTATION; VER      539.26   449.39                 0  90
35694   TRANSPOSITION AND/OR REIMPLANTATION; SUB      635.87   529.89                 0  90
35695   TRANSPOSITION AND/OR REIMPLANTATION; CAR      656.93   547.45                 0  90
35697   REIMPLANTATION, VISCERAL ARTERY TO INFRA       92.04    76.70                 0   0
35700   REOPERATION, FEMORAL-POPLITEAL OR FEMORA       94.58    78.82                 0   0
35701   EXPLORATION (NOT FOLLOWED BY SURGICAL RE      327.41   272.85                 0  90
35721   EXPLORATION (NOT FOLLOWED BY SURGICAL RE      281.20   234.33                 0  90
35741   EXPLORATION (NOT FOLLOWED BY SURGICAL RE      305.65   254.71                 0  90
35761   EXPLORATION (NOT FOLLOWED BY SURGICAL RE      227.51   189.59                 0  90
35800   EXPLORATION FOR POSTOPERATIVE HEMORRHAGE      290.30   241.92                 0  90
35820   EXPLORATION FOR POSTOPERATIVE HEMORRHAGE    1,042.41   868.68                 0  90
35840   EXPLORATION FOR POSTOPERATIVE HEMORRHAGE      376.15   313.46                 0  90
35860   EXPLORATION FOR POSTOPERATIVE HEMORRHAGE      246.01   205.01                 0  90
35870   REPAIR OF GRAFT-ENTERIC FISTULA               783.17   652.64                 0  90
35875   THROMBECTOMY OF ARTERIAL OR VENOUS GRAFT      365.45   304.55                 0  90
35876   THROMBECTOMY OF ARTERIAL OR VENOUS GRAFT      581.50   484.59                 0  90
35879   REVISION, LOWER EXTREMITY ARTERIAL BYPAS      572.00   476.67                 0  90
35881   REVISION, LOWER EXTREMITY ARTERIAL BYPAS      636.12   530.10                 0  90
35883   REVISION, FEMORAL ANASTOMOSIS OF SYNTHET      751.72   626.43                 0  90
35884   REVISION, FEMORAL ANASTOMOSIS OF SYNTHET      798.08   665.07                 0  90
35901   EXCISION OF INFECTED GRAFT; NECK              311.69   259.75                 0  90
35903   EXCISION OF INFECTED GRAFT; EXTREMITY         354.17   295.15                 0  90
35905   EXCISION OF INFECTED GRAFT; THORAX          1,074.37   895.31                 0  90
                                                                                                   Page 96 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
35907   EXCISION OF INFECTED GRAFT; ABDOMEN         1,176.87   980.73                 0  90
36000   INTRODUCTION OF NEEDLE OR INTRACATHETER,       20.00    20.00                 0   0
36002   INJECTION PROCEDURES (EG, THROMBIN) FOR       106.67    55.26                 0   0
36005   INJECTION PROCEDURE FOR EXTREMITY VENOGR      218.96    24.34                 0   0
36010   INTRODUCTION OF CATHETER, SUPERIOR OR IN      428.42    61.27                 0   0
36011   SELECTIVE CATHETER PLACEMENT, VENOUS SYS      654.29    79.67                 0   0
36012   SELECTIVE CATHETER PLACEMENT, VENOUS SYS      559.40    89.20                 0   0
36013   INTRODUCTION OF CATHETER, RIGHT HEART OR      551.26    64.16                 0   0
36014   SELECTIVE CATHETER PLACEMENT, LEFT OR RI      547.07    76.87                 0   0
36015   SELECTIVE CATHETER PLACEMENT, SEGMENTAL       596.12    86.57                 0   0
36100   INTRODUCTION OF NEEDLE OR INTRACATHETER,      354.45    80.03                 0   0
36120   INTRODUCTION OF NEEDLE OR INTRACATHETER;      289.30    49.52                 0   0
36140   INTRODUCTION OF NEEDLE OR INTRACATHETER;      330.85    50.92                 0   0
36147   INTRODUCTION OF NEEDLE AND/OR CATHETER,       384.83    76.09                 0   0
36148   INTRODUCTION OF NEEDLE AND/OR CATHETER,       121.40    20.30                 0   0
36160   INTRODUCTION OF NEEDLE OR INTRACATHETER,      365.42    67.22                 0   0
36200   INTRODUCTION OF CATHETER, AORTA               438.67    76.58                 0   0
36215   SELECTIVE CATHETER PLACEMENT, ARTERIAL S      753.76   120.31                 0   0
36216   SELECTIVE CATHETER PLACEMENT, ARTERIAL S      817.89   135.19                 0   0
36217   SELECTIVE CATHETER PLACEMENT, ARTERIAL S    1,385.83   162.39                 0   0
36218   SELECTIVE CATHETER PLACEMENT, ARTERIAL S      131.23    25.88                 0   0
36245   SELECTIVE CATHETER PLACEMENT, ARTERIAL S      851.88   124.14                 0   0
36246   SELECTIVE CATHETER PLACEMENT, ARTERIAL S      822.91   135.89                 0   0
36247   SELECTIVE CATHETER PLACEMENT, ARTERIAL S    1,304.80   161.93                 0   0
36248   SELECTIVE CATHETER PLACEMENT, ARTERIAL S      111.04    25.88                 0   0
36251   SELECTIVE CATHETER PLACEMENT (FIRST-ORDE      677.00   564.17                 0   0    *
36252   SELECTIVE CATHETER PLACEMENT (FIRST-ORDE      742.29   618.58                 0   0    *
36253   SUPERSELECTIVE CATHETER PLACEMENT (ONE O    1,036.20   863.50                 0   0    *
36254   SUPERSELECTIVE CATHETER PLACEMENT (ONE O    1,077.84   898.20                 0   0    *
                                                                                                   Page 97 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
36260   INSERTION OF IMPLANTABLE INTRA-ARTERIAL       346.57   288.81                 0  90
36261   REVISION OF IMPLANTED INTRA-ARTERIAL INF      211.73   176.45                 0  90
36262   REMOVAL OF IMPLANTED INTRA-ARTERIAL INFU      162.05   135.04                 0  90
36299   UNLISTED PROCEDURE, VASCULAR INJECTION                                    BR 0    0
36400   VENIPUNCTURE, UNDER AGE 3 YEARS, NECESSI       15.21     8.78             BR 0    0
36405   VENIPUNCTURE, UNDER AGE 3 YEARS, NECESSI       13.58    12.00             BR 0    0
36406   VENIPUNCTURE, UNDER AGE 3 YEARS, NECESSI       10.33     8.00             BR 0    0
36420   VENIPUNCTURE, CUTDOWN; UNDER AGE 1 YEAR        28.10    23.42                 0   0
36425   VENIPUNCTURE, CUTDOWN; AGE 1 OR OVER           22.04    18.37             BR 0    0
36430   TRANSFUSION, BLOOD OR BLOOD COMPONENTS         25.22    21.02                 0   0
36440   PUSH TRANSFUSION, BLOOD, 2 YEARS OR UNDE       29.98    24.98                 0   0
36450   EXCHANGE TRANSFUSION, BLOOD; NEWBORN          120.00   120.00                 0   0
36455   EXCHANGE TRANSFUSION, BLOOD; OTHER THAN       100.00   100.00                 0   0
36460   TRANSFUSION, INTRAUTERINE, FETAL              201.88   168.23                 0   0
36468   SINGLE OR MULTIPLE INJECTIONS OF SCLEROS       26.09    21.74                 0   0
36469   SINGLE OR MULTIPLE INJECTIONS OF SCLEROS       32.01    26.68                 0   0
36470   INJECTION OF SCLEROSING SOLUTION; SINGLE       87.70    34.94                 0  10
36471   INJECTION OF SCLEROSING SOLUTION; MULTIP      106.34    48.84                 0  10
36475   ENDOVENOUS ABLATION THERAPY OF INCOMPETE    1,086.52   171.10                 0   0
36476   ENDOVENOUS ABLATION THERAPY OF INCOMPETE      230.49    83.51                 0   0
36478   ENDOVENOUS ABLATION THERAPY OF INCOMPETE      930.73   187.20                 0   0
36479   ENDOVENOUS ABLATION THERAPY OF INCOMPETE      262.30    91.59                 0   0
36481   PERCUTANEOUS PORTAL VEIN CATHETERIZATION      215.90   179.92                 0   0
36500   VENOUS CATHETERIZATION FOR SELECTIVE ORG      108.34    90.28                 0   0
36510   CATHETERIZATION OF UMBILICAL VEIN FOR DI       85.53    29.64                 0   0
36511   THERAPEUTIC APHERESIS; FOR WHITE BLOOD C      150.00   150.00                 0   0
36512   THERAPEUTIC APHERESIS; FOR RED BLOOD CEL      150.00   150.00                 0   0
36513   THERAPEUTIC APHERESIS; FOR PLATELETS          150.00   150.00                 0   0
36514   THERAPEUTIC APHERESIS; FOR PLASMA PHERES      375.41   150.00                 0   0
                                                                                                   Page 98 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
36515   THERAPEUTIC APHERESIS; WITH EXTRACORPORE    1,413.79   150.00                 0   0
36516   THERAPEUTIC APHERESIS; WITH EXTRACORPORE    1,671.89   150.00                 0   0
36522   PHOTOPHERESIS, EXTRACORPOREAL                 896.43   150.00                 0   0
36555   INSERTION OF NON-TUNNELED CENTRALLY INSE      174.80    71.00                 0   0
36556   INSERTION OF NON-TUNNELED CENTRALLY INSE      159.60    60.00                 0   0
36557   INSERTION OF TUNNELED CENTRALLY INSERTED      563.29   148.23                 0  10
36558   INSERTION OF TUNNELED CENTRALLY INSERTED      552.83   143.00                 0  10
36560   INSERTION OF TUNNELED CENTRALLY INSERTED      768.33   177.00                 0  10
36561   INSERTION OF TUNNELED CENTRALLY INSERTED      773.81   176.00                 0  10
36563   INSERTION OF TUNNELED CENTRALLY INSERTED      759.44   178.58                 0  10
36565   INSERTION OF TUNNELED CENTRALLY INSERTED      655.19   168.40                 0  10
36566   INSERTION OF TUNNELED CENTRALLY INSERTED    1,837.15   179.98                 0  10
36568   INSERTION OF PERIPHERALLY INSERTED CENTR      206.53    85.00                 0   0
36569   INSERTION OF PERIPHERALLY INSERTED CENTR      186.80    70.00                 0   0
36570   INSERTION OF PERIPHERALLY INSERTED CENTR      791.42   227.00                 0  10
36571   INSERTION OF PERIPHERALLY INSERTED CENTR      832.53   204.00                 0  10
36575   REPAIR OF TUNNELED OR NON-TUNNELED CENTR      108.74    80.00                 0   0
36576   REPAIR OF CENTRAL VENOUS ACCESS DEVICE,       228.10    93.28                 0  10
36578   REPLACEMENT, CATHETER ONLY, OF CENTRAL V      325.93   107.32                 0  10
36580   REPLACEMENT, COMPLETE, OF A NON-TUNNELED      165.05    79.00                 0   0
36581   REPLACEMENT, COMPLETE, OF A TUNNELED CEN      505.66   101.00                 0  10
36582   REPLACEMENT, COMPLETE, OF A TUNNELED CEN      696.14   146.75                 0  10
36583   REPLACEMENT, COMPLETE, OF A TUNNELED CEN      697.81   147.93                 0  10
36584   REPLACEMENT, COMPLETE, OF A PERIPHERALLY      163.46    80.00                 0   0
36585   REPLACEMENT, COMPLETE, OF A PERIPHERALLY      722.74   138.35                 0  10
36589   REMOVAL OF TUNNELED CENTRAL VENOUS CATHE      102.19    69.98                 0  10
36590   REMOVAL OF TUNNELED CENTRAL VENOUS ACCES      163.69    98.67                 0  10
36591   COLLECTION OF BLOOD SPECIMEN FROM A COMP       13.52    11.27                 0   0
36593   DECLOTTING BY THROMBOLYTIC AGENT OF IMPL       23.08    19.23                 0   0
                                                                                                   Page 99 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
36595   MECHANICAL REMOVAL OF PERICATHETER OBSTR      423.74   402.00                 0   0
36596   MECHANICAL REMOVAL OF INTRALUMINAL (INTR       93.45    91.00                 0   0
36597   REPOSITIONING OF PREVIOUSLY PLACED CENTR       81.01    80.00                 0   0
36598   CONTRAST INJECTION(S) FOR RADIOLOGIC EVA       75.99    75.00                 0   0
36600   ARTERIAL PUNCTURE, WITHDRAWAL OF BLOOD F       19.00     7.50             BR 0    0
36620   ARTERIAL CATHETERIZATION OR CANNULATION        29.65    24.71                 0   0
36625   ARTERIAL CATHETERIZATION OR CANNULATION        61.74    51.45                 0   0
36640   ARTERIAL CATHETERIZATION FOR PROLONGED I       71.46    59.55                 0   0
36660   CATHETERIZATION, UMBILICAL ARTERY, NEWBO       41.98    34.99                 0   0
36680   PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INF       36.63    30.53                 0   0
36800   INSERTION OF CANNULA FOR HEMODIALYSIS, O      200.00   200.00                 0   0
36810   INSERTION OF CANNULA FOR HEMODIALYSIS, O      200.00   200.00                 0   0
36815   INSERTION OF CANNULA FOR HEMODIALYSIS, O      125.00   125.00                 0   0
36818   ARTERIOVENOUS ANASTOMOSIS, OPEN; BY UPPE      413.13   344.28                 0  90
36819   ARTERIOVENOUS ANASTOMOSIS, OPEN; BY UPPE      479.14   399.28                 0  90
36820   ARTERIOVENOUS ANASTOMOSIS, OPEN; BY FORE      480.64   400.53                 0  90
36821   ARTERIOVENOUS ANASTOMOSIS, OPEN; DIRECT,      320.23   266.86                 0  90
36822   INSERTION OF CANNULA(S) FOR PROLONGED EX      230.06   220.00                 0  90
36823   INSERTION OF ARTERIAL AND VENOUS CANNULA      752.43   627.03                 0  90
36825   CREATION OF ARTERIOVENOUS FISTULA BY OTH      348.67   290.56                 0  90
36830   CREATION OF ARTERIOVENOUS FISTULA BY OTH      400.00   400.00                 0  90
36831   THROMBECTOMY, OPEN, ARTERIOVENOUS FISTUL      275.71   229.76                 0  90
36832   REVISION, OPEN, ARTERIOVENOUS FISTULA; W      350.80   292.33                 0  90
36833   REVISION, OPEN, ARTERIOVENOUS FISTULA; W      395.53   329.61                 0  90
36835   INSERTION OF THOMAS SHUNT (SEPARATE PROC      272.75   227.29                 0  90
36838   DISTAL REVASCULARIZATION AND INTERVAL LI      710.65   592.21                 0  90
36860   EXTERNAL CANNULA DECLOTTING (SEPARATE PR      106.74    49.57                 0   0
36861   EXTERNAL CANNULA DECLOTTING (SEPARATE PR       90.73    75.61                 0   0
36870   THROMBECTOMY, PERCUTANEOUS, ARTERIOVENOU    1,267.22   154.00                 0  90
                                                                                                   Page 100 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
37140   VENOUS ANASTOMOSIS, OPEN; PORTOCAVAL          796.93   664.11                 0  90
37145   VENOUS ANASTOMOSIS, OPEN; RENOPORTAL          868.78   723.99                 0  90
37160   VENOUS ANASTOMOSIS, OPEN; CAVAL-MESENTER      747.02   622.52                 0  90
37180   VENOUS ANASTOMOSIS, OPEN; SPLENORENAL, P      849.40   707.83                 0  90
37181   VENOUS ANASTOMOSIS, OPEN; SPLENORENAL, D      897.50   747.92                 0  90
37182   INSERTION OF TRANSVENOUS INTRAHEPATIC PO      521.25   434.38                 0   0
37183   REVISION OF TRANSVENOUS INTRAHEPATIC POR      248.75   207.30                 0   0
37184   PRIMARY PERCUTANEOUS TRANSLUMINAL MECHAN    1,687.03   225.11                 0   0
37185   PRIMARY PERCUTANEOUS TRANSLUMINAL MECHAN      555.31    82.71                 0   0
37186   SECONDARY PERCUTANEOUS TRANSLUMINAL THRO    1,145.65   129.00                 0   0
37187   PERCUTANEOUS TRANSLUMINAL MECHANICAL THR    1,633.54   209.04                 0   0
37188   PERCUTANEOUS TRANSLUMINAL MECHANICAL THR    1,408.13   160.00                 0   0
37191   INSERTION OF INTRAVASCULAR VENA CAVA FIL    1,234.10 1,028.42                 0   0
37192   REPOSITIONING OF INTRAVASCULAR VENA CAVA      824.71   687.27                 0   0    *
37193   RETRIEVAL (REMOVAL) OF INTRAVASCULAR VEN      786.73   655.61                 0   0    *
37195   THROMBOLYSIS, CEREBRAL, BY INTRAVENOUS I      209.20   174.33                 0   0
37200   TRANSCATHETER BIOPSY                          137.87   114.90                 0   0
37201   TRANSCATHETER THERAPY, INFUSION FOR THRO      169.19   141.00                 0   0
37202   TRANSCATHETER THERAPY, INFUSION OTHER TH      203.80   169.84                 0   0
37203   TRANSCATHETER RETRIEVAL, PERCUTANEOUS, O      884.70   133.03                 0   0
37204   TRANSCATHETER OCCLUSION OR EMBOLIZATION       552.23   460.20                 0   0
37205   TRANSCATHETER PLACEMENT OF AN INTRAVASCU    1,566.83   223.60                 0   0
37206   TRANSCATHETER PLACEMENT OF AN INTRAVASCU      927.39   106.67                 0   0
37207   TRANSCATHETER PLACEMENT OF AN INTRAVASCU      263.15   219.29                 0   0
37208   TRANSCATHETER PLACEMENT OF AN INTRAVASCU      126.65   105.55                 0   0
37209   EXCHANGE OF A PREVIOUSLY PLACED INTRAVAS       68.17    56.81                 0   0
37210   UTERINE FIBROID EMBOLIZATION (UFE, EMBOL    2,280.08   266.87                 0   0
37215   TRANSCATHETER PLACEMENT OF INTRAVASCULAR      658.28   548.57                 0  90
37216   TRANSCATHETER PLACEMENT OF INTRAVASCULAR      587.44   489.53                 0  90
                                                                                                   Page 101 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
37220   REVASCULARIZATION, ENDOVASCULAR, OPEN OR    1,530.10   167.02                 0   0
37221   REVASCULARIZATION, ENDOVASCULAR, OPEN OR    2,263.91   203.46                 0   0
37222   REVASCULARIZATION, ENDOVASCULAR, OPEN OR      439.23    75.75                 0   0
37223   REVASCULARIZATION, ENDOVASCULAR, OPEN OR    2,255.40    86.04                 0   0
37224   REVASCULARIZATION, ENDOVASCULAR, OPEN OR    1,839.37   183.95                 0   0
37225   REVASCULARIZATION, ENDOVASCULAR, OPEN OR    3,212.19   247.75                 0   0
37226   REVASCULARIZATION, ENDOVASCULAR, OPEN OR    3,212.19   205.02                 0   0
37227   REVASCULARIZATION, ENDOVASCULAR, OPEN OR    3,212.19   229.20                 0   0
37228   REVASCULARIZATION, ENDOVASCULAR, OPEN OR    2,620.46   224.70                 0   0
37229   REVASCULARIZATION, ENDOVASCULAR, OPEN OR    3,212.19   290.08                 0   0
37230   REVASCULARIZATION, ENDOVASCULAR, OPEN OR    3,212.19   280.17                 0   0
37231   REVASCULARIZATION, ENDOVASCULAR, OPEN OR    3,212.19   304.49                 0   0
37232   REVASCULARIZATION, ENDOVASCULAR, OPEN OR      586.40    81.08                 0   0
37233   REVASCULARIZATION, ENDOVASCULAR, OPEN OR      714.53   133.58                 0   0
37234   REVASCULARIZATION, ENDOVASCULAR, OPEN OR    1,877.61   111.38                 0   0
37235   REVASCULARIZATION, ENDOVASCULAR, OPEN OR    2,003.49   158.03                 0   0
37250   INTRAVASCULAR ULTRASOUND (NON-CORONARY V       66.29    55.24                 0   0
37251   INTRAVASCULAR ULTRASOUND (NON-CORONARY V       49.74    41.45                 0   0
37500   VASCULAR ENDOSCOPY, SURGICAL, WITH LIGAT      420.16   350.13                 0  90
37501   UNLISTED VASCULAR ENDOSCOPY PROCEDURE                                     BR 0    0
37565   LIGATION, INTERNAL JUGULAR VEIN               406.52   338.77                 0  90
37600   LIGATION; EXTERNAL CAROTID ARTERY             425.81   354.85                 0  90
37605   LIGATION; INTERNAL OR COMMON CAROTID ART      486.46   405.38                 0  90
37606   LIGATION; INTERNAL OR COMMON CAROTID ART      321.52   267.93                 0  90
37607   LIGATION OR BANDING OF ANGIOACCESS ARTER      226.36   188.63                 0  90
37609   LIGATION OR BIOPSY, TEMPORAL ARTERY           176.78    96.87                 0  10
37615   LIGATION, MAJOR ARTERY (EG, POST-TRAUMAT      273.76   228.13                 0  90
37616   LIGATION, MAJOR ARTERY (EG, POST-TRAUMAT      634.84   529.03                 0  90
37617   LIGATION, MAJOR ARTERY (EG, POST-TRAUMAT      760.72   633.93                 0  90
                                                                                                   Page 102 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                         DESCRIPTION             FEE      FEE        FEE      BR PA DAYS   E
37618   LIGATION, MAJOR ARTERY (EG, POST-TRAUMAT      222.37   185.31                 0  90
37619   LIGATION OF INFERIOR VENA CAVA                746.66   622.22                 0  90
37650   LIGATION OF FEMORAL VEIN                      304.16   253.47                 0  90
37660   LIGATION OF COMMON ILIAC VEIN                 713.96   594.97                 0  90
37700   LIGATION AND DIVISION OF LONG SAPHENOUS       152.35   126.96                 0  90
37718   LIGATION, DIVISION, AND STRIPPING, SHORT      239.83   199.86                 0  90
37722   LIGATION, DIVISION, AND STRIPPING, LONG       283.98   236.65                 0  90
37735   LIGATION AND DIVISION AND COMPLETE STRIP      379.37   316.14                 0  90
37760   LIGATION OF PERFORATOR VEINS, SUBFASCIAL      371.24   309.37                 0  90
37761   LIGATION OF PERFORATOR VEIN(S), SUBFASCI      350.57   292.15                 0  90
37765   STAB PHLEBECTOMY OF VARICOSE VEINS, ONE       267.16   222.64                 0  90
37766   STAB PHLEBECTOMY OF VARICOSE VEINS, ONE       322.77   268.98                 0  90
37780   LIGATION AND DIVISION OF SHORT SAPHENOUS      155.41   129.51                 0  90
37785   LIGATION, DIVISION, AND/OR EXCISION OF V      215.68   130.31                 0  90
37788   PENILE REVASCULARIZATION, ARTERY, WITH O                                  BR 1   90
37790   PENILE VENOUS OCCLUSIVE PROCEDURE             301.18   250.99                 1  90
37799   UNLISTED PROCEDURE, VASCULAR SURGERY                                      BR 0    0
38100   SPLENECTOMY; TOTAL (SEPARATE PROCEDURE)       600.76   500.63                 0  90
38101   SPLENECTOMY; PARTIAL (SEPARATE PROCEDURE      608.84   507.37                 0  90
38102   SPLENECTOMY; TOTAL, EN BLOC FOR EXTENSIV      147.13   122.61                 0   0
38115   REPAIR OF RUPTURED SPLEEN (SPLENORRHAPHY      665.12   554.27                 0  90
38120   LAPAROSCOPY, SURGICAL, SPLENECTOMY            572.96   477.47                 0  90
38129   UNLISTED LAPAROSCOPY PROCEDURE, SPLEEN                                    BR 0    0
38200   INJECTION PROCEDURE FOR SPLENOPORTOGRAPH       81.27    67.73                 0   0
38220   BONE MARROW; ASPIRATION ONLY                  101.89    62.00                 0   0
38221   BONE MARROW; BIOPSY, NEEDLE OR TROCAR         112.31    66.00                 0   0
38230   BONE MARROW HARVESTING FOR TRANSPLANTATI      187.07   155.89                 0   0
38232   BONE MARROW HARVESTING FOR TRANSPLANTATI       83.62    69.68                 0   0    *
38240   BONE MARROW OR BLOOD-DERIVED PERIPHERAL        72.24    60.20                 0   0
                                                                                                   Page 103 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
38241   BONE MARROW OR BLOOD-DERIVED PERIPHERAL        72.49    60.41                 0   0
38242   BONE MARROW OR BLOOD-DERIVED PERIPHERAL        54.76    45.63                 0   0
38300   DRAINAGE OF LYMPH NODE ABSCESS OR LYMPHA      157.04    85.54                 0  10
38305   DRAINAGE OF LYMPH NODE ABSCESS OR LYMPHA      259.79   216.50                 0  90
38308   LYMPHANGIOTOMY OR OTHER OPERATIONS ON LY      246.09   205.08                 0  90
38380   SUTURE AND/OR LIGATION OF THORACIC DUCT;      318.87   300.00                 0  90
38381   SUTURE AND/OR LIGATION OF THORACIC DUCT;      472.85   394.05                 0  90
38382   SUTURE AND/OR LIGATION OF THORACIC DUCT;      383.18   319.32                 0  90
38500   BIOPSY OR EXCISION OF LYMPH NODE(S); OPE      179.26   115.34                 0  10
38505   BIOPSY OR EXCISION OF LYMPH NODE(S); BY        76.39    36.58                 0   0
38510   BIOPSY OR EXCISION OF LYMPH NODE(S); OPE      287.29   194.69                 0  10
38520   BIOPSY OR EXCISION OF LYMPH NODE(S); OPE      256.67   213.89                 0  90
38525   BIOPSY OR EXCISION OF LYMPH NODE(S); OPE      230.69   192.25                 0  90
38530   BIOPSY OR EXCISION OF LYMPH NODE(S); OPE      298.47   248.73                 0  90
38542   DISSECTION, DEEP JUGULAR NODE(S)              241.31   201.10                 0  90
38550   EXCISION OF CYSTIC HYGROMA, AXILLARY OR       263.42   219.52                 0  90
38555   EXCISION OF CYSTIC HYGROMA, AXILLARY OR       550.86   459.05                 0  90
38562   LIMITED LYMPHADENECTOMY FOR STAGING (SEP      391.88   326.57                 0  90
38564   LIMITED LYMPHADENECTOMY FOR STAGING (SEP      400.00   400.00                 0  90
38570   LAPAROSCOPY, SURGICAL; WITH RETROPERITON      313.15   260.96                 0  10
38571   LAPAROSCOPY, SURGICAL; WITH BILATERAL TO      478.76   398.97                 0  10
38572   LAPAROSCOPY, SURGICAL; WITH BILATERAL TO      547.24   456.03                 0  10
38589   UNLISTED LAPAROSCOPY PROCEDURE, LYMPHATI                                  BR 0    0
38700   SUPRAHYOID LYMPHADENECTOMY                    432.03   360.03                 0  90
38720   CERVICAL LYMPHADENECTOMY (COMPLETE)           710.69   592.25                 0  90
38724   CERVICAL LYMPHADENECTOMY (MODIFIED RADIC      768.29   640.24                 0  90
38740   AXILLARY LYMPHADENECTOMY; SUPERFICIAL         367.70   306.42                 0  90
38745   AXILLARY LYMPHADENECTOMY; COMPLETE            467.92   389.94                 0  90
38746   THORACIC LYMPHADENECTOMY BY THORACOTOMY       152.98   127.48                 0   0
                                                                                                   Page 104 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                         DESCRIPTION             FEE      FEE        FEE      BR PA DAYS   E
38747   ABDOMINAL LYMPHADENECTOMY, REGIONAL, INC      150.20   125.17                 0   0
38760   INGUINOFEMORAL LYMPHADENECTOMY, SUPERFIC      462.08   385.07                 0  90
38765   INGUINOFEMORAL LYMPHADENECTOMY, SUPERFIC      711.32   592.77                 0  90
38770   PELVIC LYMPHADENECTOMY, INCLUDING EXTERN      470.03   391.69                 0  90
38780   RETROPERITONEAL TRANSABDOMINAL LYMPHADEN      599.81   499.84                 0  90
38790   INJECTION PROCEDURE; LYMPHANGIOGRAPHY          47.80    40.00                 0   0
38792   INJECTION PROCEDURE; RADIOACTIVE TRACER        40.00    40.00                 0   0
38794   CANNULATION, THORACIC DUCT                                                BR 0   90
38900   INTRAOPERATIVE IDENTIFICATION (EG, MAPPI       63.23    52.69                 0   0
38999   UNLISTED PROCEDURE, HEMIC OR LYMPHATIC S                                  BR 0    0
39000   MEDIASTINOTOMY WITH EXPLORATION, DRAINAG      282.70   235.58                 0  90
39010   MEDIASTINOTOMY WITH EXPLORATION, DRAINAG      477.75   398.13                 0  90
39200   RESECTION OF MEDIASTINAL CYST                 521.48   434.57                 0  90
39220   RESECTION OF MEDIASTINAL TUMOR                666.29   555.25                 0  90
39400   MEDIASTINOSCOPY, INCLUDES BIOPSY(IES), W      292.31   243.59                 0  10
39499   UNLISTED PROCEDURE, MEDIASTINUM                                           BR 0    0
39501   REPAIR, LACERATION OF DIAPHRAGM, ANY APP      474.50   395.42                 0  90
39503   REPAIR, NEONATAL DIAPHRAGMATIC HERNIA, W    3,212.19 2,676.83                 0  90
39540   REPAIR, DIAPHRAGMATIC HERNIA (OTHER THAN      483.26   402.72                 0  90
39541   REPAIR, DIAPHRAGMATIC HERNIA (OTHER THAN      518.92   432.44                 0  90
39545   IMBRICATION OF DIAPHRAGM FOR EVENTRATION      517.05   430.88                 0  90
39560   RESECTION, DIAPHRAGM; WITH SIMPLE REPAIR      445.55   371.30                 0  90
39561   RESECTION, DIAPHRAGM; WITH COMPLEX REPAI      687.63   573.03                 0  90
39599   UNLISTED PROCEDURE, DIAPHRAGM                                             BR 0    0
40490   BIOPSY OF LIP                                  71.45    33.70                 0  10
40500   VERMILIONECTOMY (LIP SHAVE), WITH MUCOSA      279.41   170.29                 0  90
40510   EXCISION OF LIP; TRANSVERSE WEDGE EXCISI      272.04   168.05                 0  90
40520   EXCISION OF LIP; V-EXCISION WITH PRIMARY      286.78   171.30                 0  90
40525   EXCISION OF LIP; FULL THICKNESS, RECONST      317.59   264.66                 0  90
                                                                                                   Page 105 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                         DESCRIPTION             FEE      FEE        FEE      BR PA DAYS   E
40527   EXCISION OF LIP; FULL THICKNESS, RECONST      375.61   313.01                 0  90
40530   RESECTION OF LIP, MORE THAN ONE-FOURTH,       313.09   193.64                 0  90
40650   REPAIR LIP, FULL THICKNESS; VERMILION ON      241.12   136.12                 0  90
40652   REPAIR LIP, FULL THICKNESS; UP TO HALF V      284.32   169.05                 0  90
40654   REPAIR LIP, FULL THICKNESS; OVER ONE-HAL      328.59   201.22                 0  90
40700   PLASTIC REPAIR OF CLEFT LIP/NASAL DEFORM      524.66   437.22                 0  90
40701   PLASTIC REPAIR OF CLEFT LIP/NASAL DEFORM      620.43   517.03                 0  90
40702   PLASTIC REPAIR OF CLEFT LIP/NASAL DEFORM      488.22   406.85                 0  90
40720   PLASTIC REPAIR OF CLEFT LIP/NASAL DEFORM      576.02   480.02                 0  90
40761   PLASTIC REPAIR OF CLEFT LIP/NASAL DEFORM      604.77   503.98                 0  90
40799   UNLISTED PROCEDURE, LIPS                                                  BR 0    0
40800   DRAINAGE OF ABSCESS, CYST, HEMATOMA, VES      110.93    60.24                 0  10
40801   DRAINAGE OF ABSCESS, CYST, HEMATOMA, VES      168.86   104.00                 0  10
40804   REMOVAL OF EMBEDDED FOREIGN BODY, VESTIB      116.55    61.44                 0  10
40805   REMOVAL OF EMBEDDED FOREIGN BODY, VESTIB                                  BR 0   10
40806   INCISION OF LABIAL FRENUM (FRENOTOMY)          59.58    25.00                 0   0
40808   BIOPSY, VESTIBULE OF MOUTH                     99.21    50.27                 0  10
40810   EXCISION OF LESION OF MUCOSA AND SUBMUCO      111.01    59.69                 0  10
40812   EXCISION OF LESION OF MUCOSA AND SUBMUCO      155.44    92.82                 0  10
40814   EXCISION OF LESION OF MUCOSA AND SUBMUCO      210.59   144.11                 0  90
40816   EXCISION OF LESION OF MUCOSA AND SUBMUCO      220.88   150.22                 0  90
40818   EXCISION OF MUCOSA OF VESTIBULE OF MOUTH                                  BR 0   90
40819   EXCISION OF FRENUM, LABIAL OR BUCCAL (FR      167.57   110.72                 0  90
40820   DESTRUCTION OF LESION OR SCAR OF VESTIBU      142.60    79.25                 0  10
40830   CLOSURE OF LACERATION, VESTIBULE OF MOUT      136.14    75.92                 0  10
40831   CLOSURE OF LACERATION, VESTIBULE OF MOUT      179.54   120.00                 0  10
40840   VESTIBULOPLASTY; ANTERIOR                     452.38   302.54                 0  90
40842   VESTIBULOPLASTY; POSTERIOR, UNILATERAL                                    BR 0   90
40843   VESTIBULOPLASTY; POSTERIOR, BILATERAL                                     BR 0   90
                                                                                                   Page 106 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
40844   VESTIBULOPLASTY; ENTIRE ARCH                                              BR 0   90
40845   VESTIBULOPLASTY; COMPLEX (INCLUDING RIDG      842.93   603.38                 0  90
40899   UNLISTED PROCEDURE, VESTIBULE OF MOUTH                                    BR 0    0
41000   INTRAORAL INCISION AND DRAINAGE OF ABSCE       89.63    52.75                 0  10
41005   INTRAORAL INCISION AND DRAINAGE OF ABSCE      123.14    59.96                 0  10
41006   INTRAORAL INCISION AND DRAINAGE OF ABSCE      200.60   123.89                 0  90
41007   INTRAORAL INCISION AND DRAINAGE OF ABSCE      200.12   118.16                 0  90
41008   INTRAORAL INCISION AND DRAINAGE OF ABSCE      204.24   127.54                 0  90
41009   INTRAORAL INCISION AND DRAINAGE OF ABSCE      217.61   139.51                 0  90
41010   INCISION OF LINGUAL FRENUM (FRENOTOMY)        113.66    52.06                 0  10
41015   EXTRAORAL INCISION AND DRAINAGE OF ABSCE      235.88   159.86                 0  90
41016   EXTRAORAL INCISION AND DRAINAGE OF ABSCE      241.49   164.94                 0  90
41017   EXTRAORAL INCISION AND DRAINAGE OF ABSCE      243.71   166.17                 0  90
41018   EXTRAORAL INCISION AND DRAINAGE OF ABSCE      278.99   193.12                 0  90
41019   PLACEMENT OF NEEDLES, CATHETERS, OR OTHE      274.26   228.55                 0   0
41100   BIOPSY OF TONGUE; ANTERIOR TWO-THIRDS          94.40    52.83                 0  10
41105   BIOPSY OF TONGUE; POSTERIOR ONE-THIRD          93.63    52.80                 0  10
41108   BIOPSY OF FLOOR OF MOUTH                       80.63    42.79                 0  10
41110   EXCISION OF LESION OF TONGUE WITHOUT CLO      160.00   160.00                 0  10
41112   EXCISION OF LESION OF TONGUE WITH CLOSUR      182.69   160.00                 0  90
41113   EXCISION OF LESION OF TONGUE WITH CLOSUR      199.70   160.00                 0  90
41114   EXCISION OF LESION OF TONGUE WITH CLOSUR                                  BR 0   90
41115   EXCISION OF LINGUAL FRENUM (FRENECTOMY)       132.01    70.02                 0  10
41116   EXCISION, LESION OF FLOOR OF MOUTH            177.76   103.83                 0  90
41120   GLOSSECTOMY; LESS THAN ONE-HALF TONGUE        605.42   504.52                 0  90
41130   GLOSSECTOMY; HEMIGLOSSECTOMY                  732.44   610.37                 0  90
41135   GLOSSECTOMY; PARTIAL, WITH UNILATERAL RA    1,206.19 1,005.16                 0  90
41140   GLOSSECTOMY; COMPLETE OR TOTAL, WITH OR     1,257.61 1,048.01                 0  90
41145   GLOSSECTOMY; COMPLETE OR TOTAL, WITH OR     1,555.25 1,296.05                 0  90
                                                                                                   Page 107 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
41150   GLOSSECTOMY; COMPOSITE PROCEDURE WITH RE    1,234.25 1,028.55                 0  90
41153   GLOSSECTOMY; COMPOSITE PROCEDURE WITH RE    1,327.07 1,105.89                 0  90
41155   GLOSSECTOMY; COMPOSITE PROCEDURE WITH RE    1,619.49 1,349.58                 0  90
41250   REPAIR OF LACERATION 2.5 CM OR LESS; FLO      124.66    64.71                 0  10
41251   REPAIR OF LACERATION 2.5 CM OR LESS; POS      134.94    77.17                 0  10
41252   REPAIR OF LACERATION OF TONGUE, FLOOR OF      171.81   120.00                 0  10
41500   FIXATION OF TONGUE, MECHANICAL, OTHER TH                                  BR 0   90
41510   SUTURE OF TONGUE TO LIP FOR MICROGNATHIA      252.39   210.33                 0  90
41512   TONGUE BASE SUSPENSION, PERMANENT             353.29   294.41                 0  90
41520   FRENOPLASTY (SURGICAL REVISION OF FRENUM      191.08   122.73                 0  90
41530   SUBMUCOSAL ABLATION OF THE TONGUE BASE      1,805.78   192.87                 0  10
41599   UNLISTED PROCEDURE, TONGUE, FLOOR OF MOU                                  BR 0    0
41800   DRAINAGE OF ABSCESS, CYST, HEMATOMA FROM      118.55    57.78                 0  10
41805   REMOVAL OF EMBEDDED FOREIGN BODY FROM DE      119.18    74.71                 0  10
41806   REMOVAL OF EMBEDDED FOREIGN BODY FROM DE      179.84   118.70                 0  10
41820   GINGIVECTOMY, EXCISION GINGIVA, EACH QUA                                  BR 0    0
41821   OPERCULECTOMY, EXCISION PERICORONAL TISS                                  BR 0    0
41822   EXCISION OF FIBROUS TUBEROSITIES, DENTOA                                  BR 0   10
41823   EXCISION OF OSSEOUS TUBEROSITIES, DENTOA                                  BR 0   90
41825   EXCISION OF LESION OR TUMOR (EXCEPT LIST                                  BR 0   10
41826   EXCISION OF LESION OR TUMOR (EXCEPT LIST                                  BR 0   10
41827   EXCISION OF LESION OR TUMOR (EXCEPT LIST      233.51   142.09                 0  90
41828   EXCISION OF HYPERPLASTIC ALVEOLAR MUCOSA                                  BR 0   10
41830   ALVEOLECTOMY, INCLUDING CURETTAGE OF OST      213.56   134.90                 0  10
41850   DESTRUCTION OF LESION (EXCEPT EXCISION),                                  BR 0    0
41870   PERIODONTAL MUCOSAL GRAFTING                                              BR 0    0
41872   GINGIVOPLASTY, EACH QUADRANT (SPECIFY)                                    BR 0   90
41874   ALVEOLOPLASTY, EACH QUADRANT (SPECIFY)        203.27   122.23                 0  90
41899   UNLISTED PROCEDURE, DENTOALVEOLAR STRUCT                                  BR 0    0
                                                                                                   Page 108 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
42000   DRAINAGE OF ABSCESS OF PALATE, UVULA           90.20    48.72                 0  10
42100   BIOPSY OF PALATE, UVULA                        83.69    51.90                 0  10
42104   EXCISION, LESION OF PALATE, UVULA; WITHO      160.00   160.00                 0  10
42106   EXCISION, LESION OF PALATE, UVULA; WITH       160.00   160.00                 0  10
42107   EXCISION, LESION OF PALATE, UVULA; WITH                                   BR 0   90
42120   RESECTION OF PALATE OR EXTENSIVE RESECTI      546.43   455.36                 0  90
42140   UVULECTOMY, EXCISION OF UVULA                 138.66    73.71                 0  90
42145   PALATOPHARYNGOPLASTY (EG, UVULOPALATOPHA      395.44   329.54                 0  90
42160   DESTRUCTION OF LESION, PALATE OR UVULA (      180.00   180.00                 0  10
42180   REPAIR, LACERATION OF PALATE; UP TO 2 CM      135.41    87.41                 0  10
42182   REPAIR, LACERATION OF PALATE; OVER 2 CM       184.03   128.34                 0  10
42200   PALATOPLASTY FOR CLEFT PALATE, SOFT AND/      513.64   428.04                 0  90
42205   PALATOPLASTY FOR CLEFT PALATE, WITH CLOS      527.02   439.18                 0  90
42210   PALATOPLASTY FOR CLEFT PALATE, WITH CLOS      620.28   516.90                 0  90
42215   PALATOPLASTY FOR CLEFT PALATE; MAJOR REV      413.68   344.74                 0  90
42220   PALATOPLASTY FOR CLEFT PALATE; SECONDARY      333.04   280.00                 0  90
42225   PALATOPLASTY FOR CLEFT PALATE; ATTACHMEN      577.32   481.10                 0  90
42226   LENGTHENING OF PALATE, AND PHARYNGEAL FL      559.28   466.07                 0  90
42227   LENGTHENING OF PALATE, WITH ISLAND FLAP       551.77   459.81                 0  90
42235   REPAIR OF ANTERIOR PALATE, INCLUDING VOM      451.12   375.94                 0  90
42260   REPAIR OF NASOLABIAL FISTULA                  479.68   329.60                 0  90
42299   UNLISTED PROCEDURE, PALATE, UVULA                                         BR 0    0
42300   DRAINAGE OF ABSCESS; PAROTID, SIMPLE          116.80    72.72                 0  10
42305   DRAINAGE OF ABSCESS; PAROTID, COMPLICATE      245.98   204.99                 0  90
42310   DRAINAGE OF ABSCESS; SUBMAXILLARY OR SUB       91.24    59.22                 0  10
42320   DRAINAGE OF ABSCESS; SUBMAXILLARY, EXTER      139.54    85.11                 0  10
42330   SIALOLITHOTOMY; SUBMANDIBULAR (SUBMAXILL      130.41    78.12                 0  10
42335   SIALOLITHOTOMY; SUBMANDIBULAR (SUBMAXILL      206.30   123.93                 0  90
42340   SIALOLITHOTOMY; PAROTID, EXTRAORAL OR CO      261.23   162.93                 0  90
                                                                                                   Page 109 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
42400   BIOPSY OF SALIVARY GLAND; NEEDLE               62.13    28.40                 0   0
42405   BIOPSY OF SALIVARY GLAND; INCISIONAL          171.68   108.61                 0  10
42408   EXCISION OF SUBLINGUAL SALIVARY CYST (RA      255.35   156.80                 0  90
42409   MARSUPIALIZATION OF SUBLINGUAL SALIVARY       185.32   107.88                 0  90
42410   EXCISION OF PAROTID TUMOR OR PAROTID GLA      356.21   296.85                 0  90
42415   EXCISION OF PAROTID TUMOR OR PAROTID GLA      639.13   532.61                 0  90
42420   EXCISION OF PAROTID TUMOR OR PAROTID GLA      733.21   611.01                 0  90
42425   EXCISION OF PAROTID TUMOR OR PAROTID GLA      485.17   404.31                 0  90
42426   EXCISION OF PAROTID TUMOR OR PAROTID GLA      784.15   653.46                 0  90
42440   EXCISION OF SUBMANDIBULAR (SUBMAXILLARY)      263.72   219.77                 0  90
42450   EXCISION OF SUBLINGUAL GLAND                  255.56   171.95                 0  90
42500   PLASTIC REPAIR OF SALIVARY DUCT, SIALODO      242.94   163.89                 0  90
42505   PLASTIC REPAIR OF SALIVARY DUCT, SIALODO      316.78   219.68                 0  90
42507   PAROTID DUCT DIVERSION, BILATERAL (WILKE                                  BR 0   90
42508   PAROTID DUCT DIVERSION, BILATERAL (WILKE                                  BR 0   90
42509   PAROTID DUCT DIVERSION, BILATERAL (WILKE                                  BR 0   90
42510   PAROTID DUCT DIVERSION, BILATERAL (WILKE      364.18   303.49                 0  90
42550   INJECTION PROCEDURE FOR SIALOGRAPHY            94.75    31.37                 0   0
42600   CLOSURE SALIVARY FISTULA                      270.78   168.02                 0  90
42650   DILATION SALIVARY DUCT                         46.62    28.39                 0   0
42660   DILATION AND CATHETERIZATION OF SALIVARY       59.65    37.41                 0   0
42665   LIGATION SALIVARY DUCT, INTRAORAL             170.50    99.22                 0  90
42699   UNLISTED PROCEDURE, SALIVARY GLANDS OR D                                  BR 0    0
42700   INCISION AND DRAINAGE ABSCESS; PERITONSI      105.45    64.49                 0  10
42720   INCISION AND DRAINAGE ABSCESS; RETROPHAR      255.88   186.98                 0  10
42725   INCISION AND DRAINAGE ABSCESS; RETROPHAR      459.22   382.68                 0  90
42800   BIOPSY; OROPHARYNX                             88.55    53.69                 0  10
42802   BIOPSY; HYPOPHARYNX                           143.96    67.06                 0  10
42804   BIOPSY; NASOPHARYNX, VISIBLE LESION, SIM      118.04    56.53                 0  10
                                                                                                   Page 110 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
42806   BIOPSY; NASOPHARYNX, SURVEY FOR UNKNOWN       132.81    65.97                 0  10
42808   EXCISION OR DESTRUCTION OF LESION OF PHA      129.31    79.25                 0  10
42809   REMOVAL OF FOREIGN BODY FROM PHARYNX           97.01    61.16                 0  10
42810   EXCISION BRANCHIAL CLEFT CYST OR VESTIGE      220.88   136.28                 0  90
42815   EXCISION BRANCHIAL CLEFT CYST, VESTIGE,       317.35   264.46                 0  90
42820   TONSILLECTOMY AND ADENOIDECTOMY; UNDER A      167.56   139.64                 0  90
42821   TONSILLECTOMY AND ADENOIDECTOMY; AGE 12       175.90   146.59                 0  90
42825   TONSILLECTOMY, PRIMARY OR SECONDARY; UND      150.88   125.74                 0  90
42826   TONSILLECTOMY, PRIMARY OR SECONDARY; AGE      145.74   121.45                 0  90
42830   ADENOIDECTOMY, PRIMARY; UNDER AGE 12          119.09    99.24                 0  90
42831   ADENOIDECTOMY, PRIMARY; AGE 12 OR OVER        128.70   107.25                 0  90
42835   ADENOIDECTOMY, SECONDARY; UNDER AGE 12        104.40    87.00                 0  90
42836   ADENOIDECTOMY, SECONDARY; AGE 12 OR OVER      140.57   117.15                 0  90
42842   RADICAL RESECTION OF TONSIL, TONSILLAR P      544.64   453.87                 0  90
42844   RADICAL RESECTION OF TONSIL, TONSILLAR P      774.88   645.73                 0  90
42845   RADICAL RESECTION OF TONSIL, TONSILLAR P    1,250.77 1,042.31                 0  90
42860   EXCISION OF TONSIL TAGS                       107.76    89.80                 0  90
42870   EXCISION OR DESTRUCTION LINGUAL TONSIL,       333.52   277.94                 0  90
42890   LIMITED PHARYNGECTOMY                         771.67   643.06                 0  90
42892   RESECTION OF LATERAL PHARYNGEAL WALL OR     1,002.46   835.39                 0  90
42894   RESECTION OF PHARYNGEAL WALL REQUIRING C    1,288.81 1,074.01                 0  90
42900   SUTURE PHARYNX FOR WOUND OR INJURY            199.99   166.66                 0  10
42950   PHARYNGOPLASTY (PLASTIC OR RECONSTRUCTIV      465.08   387.57                 0  90
42953   PHARYNGOESOPHAGEAL REPAIR                     593.20   494.34                 0  90
42955   PHARYNGOSTOMY (FISTULIZATION OF PHARYNX,      435.20   362.67                 0  90
42960   CONTROL OROPHARYNGEAL HEMORRHAGE, PRIMAR       97.52    81.27                 0  10
42961   CONTROL OROPHARYNGEAL HEMORRHAGE, PRIMAR      242.37   201.98                 0  90
42962   CONTROL OROPHARYNGEAL HEMORRHAGE, PRIMAR      298.85   249.05                 0  90
42970   CONTROL OF NASOPHARYNGEAL HEMORRHAGE, PR      221.74   184.78                 0  90
                                                                                                   Page 111 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
42971   CONTROL OF NASOPHARYNGEAL HEMORRHAGE, PR      263.31   219.43                 0  90
42972   CONTROL OF NASOPHARYNGEAL HEMORRHAGE, PR      299.23   249.36                 0  90
42999   UNLISTED PROCEDURE, PHARYNX, ADENOIDS, O                                  BR 0    0
43020   ESOPHAGOTOMY, CERVICAL APPROACH, WITH RE      308.75   257.29                 0  90
43030   CRICOPHARYNGEAL MYOTOMY                       300.54   250.45                 0  90
43045   ESOPHAGOTOMY, THORACIC APPROACH, WITH RE      747.37   622.81                 0  90
43100   EXCISION OF LESION, ESOPHAGUS, WITH PRIM      356.55   297.13                 0  90
43101   EXCISION OF LESION, ESOPHAGUS, WITH PRIM      584.10   486.75                 0  90
43107   TOTAL OR NEAR TOTAL ESOPHAGECTOMY, WITHO    1,439.98 1,199.99                 0  90
43108   TOTAL OR NEAR TOTAL ESOPHAGECTOMY, WITHO    2,254.59 1,878.83                 0  90
43112   TOTAL OR NEAR TOTAL ESOPHAGECTOMY, WITH     1,543.10 1,285.92                 0  90
43113   TOTAL OR NEAR TOTAL ESOPHAGECTOMY, WITH     2,227.12 1,855.94                 0  90
43116   PARTIAL ESOPHAGECTOMY, CERVICAL, WITH FR    2,540.77 2,117.31                 0  90
43117   PARTIAL ESOPHAGECTOMY, DISTAL TWO-THIRDS    1,403.75 1,169.79                 0  90
43118   PARTIAL ESOPHAGECTOMY, DISTAL TWO-THIRDS    1,891.34 1,576.12                 0  90
43121   PARTIAL ESOPHAGECTOMY, DISTAL TWO-THIRDS    1,526.20 1,271.83                 0  90
43122   PARTIAL ESOPHAGECTOMY, THORACOABDOMINAL     1,425.32 1,187.77                 0  90
43123   PARTIAL ESOPHAGECTOMY, THORACOABDOMINAL     2,276.25 1,896.88                 0  90
43124   TOTAL OR PARTIAL ESOPHAGECTOMY, WITHOUT     1,949.45 1,624.55                 0  90
43130   DIVERTICULECTOMY OF HYPOPHARYNX OR ESOPH      450.88   375.73                 0  90
43135   DIVERTICULECTOMY OF HYPOPHARYNX OR ESOPH      806.58   672.15                 0  90
43200   ESOPHAGOSCOPY, RIGID OR FLEXIBLE; DIAGNO      132.08    60.00                 0   0
43201   ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH D      172.27    80.00                 0   0
43202   ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH B      173.75    80.00                 0   0
43204   ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH I      126.76   105.63                 0   0
43205   ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH B      127.51   106.26                 0   0
43215   ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH R      100.00   100.00                 0   0
43216   ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH R      104.33    79.00                 0   0
43217   ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH R      231.55    80.36                 0   0
                                                                                                   Page 112 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                     DESCRIPTION                 FEE      FEE        FEE      BR PA DAYS   E
43219   ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH I      100.00   100.00                 0   0
43220   ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH B       80.00    80.00                 0   0
43226   ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH I       80.55    80.00                 0   0
43227   ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH C      119.14   100.00                 0   0
43228   ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH A      126.67   105.56                 0   0
43231   ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH E      107.93    89.95                 0   0
43232   ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH T      150.62   125.52                 0   0
43234   UPPER GASTROINTESTINAL ENDOSCOPY, SIMPLE      171.83    60.00                 0   0
43235   UPPER GASTROINTESTINAL ENDOSCOPY INCLUDI      181.65    80.00                 0   0
43236   UPPER GASTROINTESTINAL ENDOSCOPY INCLUDI      225.73   100.00                 0   0
43237   UPPER GASTROINTESTINAL ENDOSCOPY INCLUDI      137.03   114.20                 0   0
43238   UPPER GASTROINTESTINAL ENDOSCOPY INCLUDI      167.95   139.96                 0   0
43239   UPPER GASTROINTESTINAL ENDOSCOPY INCLUDI      208.53   100.00                 0   0
43240   UPPER GASTROINTESTINAL ENDOSCOPY INCLUDI      224.91   187.43                 0   0
43241   UPPER GASTROINTESTINAL ENDOSCOPY INCLUDI      100.00   100.00                 0   0
43242   UPPER GASTROINTESTINAL ENDOSCOPY INCLUDI      239.90   199.92                 0   0
43243   UPPER GASTROINTESTINAL ENDOSCOPY INCLUDI      151.76   126.47                 0   0
43244   UPPER GASTROINTESTINAL ENDOSCOPY INCLUDI      168.05   140.04                 0   0
43245   UPPER GASTROINTESTINAL ENDOSCOPY INCLUDI      140.00   140.00                 0   0
43246   UPPER GASTROINTESTINAL ENDOSCOPY INCLUDI      240.00   240.00                 0   0
43247   UPPER GASTROINTESTINAL ENDOSCOPY INCLUDI      240.00   240.00                 0   0
43248   UPPER GASTROINTESTINAL ENDOSCOPY INCLUDI      107.26    89.38                 0   0
43249   UPPER GASTROINTESTINAL ENDOSCOPY INCLUDI       98.74    82.28                 0   0
43250   UPPER GASTROINTESTINAL ENDOSCOPY INCLUDI      107.12    97.00                 0   0
43251   UPPER GASTROINTESTINAL ENDOSCOPY INCLUDI      123.67   103.06                 0   0
43255   UPPER GASTROINTESTINAL ENDOSCOPY INCLUDI      160.51   133.76                 0   0
43256   UPPER GASTROINTESTINAL ENDOSCOPY INCLUDI      144.44   120.37                 0   0
43258   UPPER GASTROINTESTINAL ENDOSCOPY INCLUDI      151.30   126.08                 0   0
43259   UPPER GASTROINTESTINAL ENDOSCOPY INCLUDI      171.35   142.79                 0   0
                                                                                                   Page 113 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                      DESCRIPTION                FEE      FEE        FEE      BR PA DAYS   E
43260   ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATO      196.79   164.00                 0   0
43261   ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATO      206.92   172.44                 0   0
43262   ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATO      242.98   202.49                 0   0
43263   ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATO      239.42   199.52                 0   0
43264   ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATO      291.53   280.00                 0   0
43265   ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATO      327.36   272.80                 0   0
43267   ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATO      238.80   220.00                 0   0
43268   ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATO      246.19   205.16                 0   0
43269   ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATO      269.14   224.28                 0   0
43271   ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATO      242.74   202.28                 0   0
43272   ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATO      243.47   202.90                 0   0
43273   ENDOSCOPIC CANNULATION OF PAPILLA WITH         77.17    64.31                 0   0
43279   LAPAROSCOPY, SURGICAL, ESOPHAGOMYOTOMY        717.43   597.86                 0  90
43280   LAPAROSCOPY, SURGICAL, ESOPHAGOGASTRIC F      589.79   491.50                 0  90
43281   LAPAROSCOPY, SURGICAL, REPAIR OF PARAESO      936.38   780.32                 0  90
43282   LAPAROSCOPY, SURGICAL, REPAIR OF PARAESO    1,052.74   877.28                 0  90
43283   LAPAROSCOPY, SURGICAL, ESOPHAGEAL LENGTH       75.66    68.05                 0   0
43289   UNLISTED LAPAROSCOPY PROCEDURE, ESOPHAGU                                  BR 0    0
43300   ESOPHAGOPLASTY (PLASTIC REPAIR OR RECONS      358.30   298.58                 0  90
43305   ESOPHAGOPLASTY (PLASTIC REPAIR OR RECONS      635.71   529.76                 0  90
43310   ESOPHAGOPLASTY (PLASTIC REPAIR OR RECONS      872.16   726.80                 0  90
43312   ESOPHAGOPLASTY (PLASTIC REPAIR OR RECONS      959.48   799.57                 0  90
43313   ESOPHAGOPLASTY FOR CONGENITAL DEFECT (PL                                  BR 0   90
43314   ESOPHAGOPLASTY FOR CONGENITAL DEFECT (PL                                  BR 0   90
43320   ESOPHAGOGASTROSTOMY (CARDIOPLASTY), WITH      753.79   628.16                 0  90
43325   ESOPHAGOGASTRIC FUNDOPLASTY; WITH FUNDIC      728.40   607.00                 0  90
43327   ESOPHAGOGASTRIC FUNDOPLASTY PARTIAL OR C      382.39   318.66                 0  90
43328   ESOPHAGOGASTRIC FUNDOPLASTY PARTIAL OR C      559.54   466.28                 0  90
43330   ESOPHAGOMYOTOMY (HELLER TYPE); ABDOMINAL      714.08   595.07                 0  90
                                                                                                   Page 114 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
43331   ESOPHAGOMYOTOMY (HELLER TYPE); THORACIC       775.33   646.11                 0  90
43332   REPAIR, PARAESOPHAGEAL HIATAL HERNIA (IN      546.75   455.63                 0  90
43333   REPAIR, PARAESOPHAGEAL HIATAL HERNIA (IN      593.48   494.56                 0  90
43334   REPAIR, PARAESOPHAGEAL HIATAL HERNIA (IN      599.29   499.41                 0  90
43335   REPAIR, PARAESOPHAGEAL HIATAL HERNIA (IN      645.51   537.92                 0  90
43336   REPAIR, PARAESOPHAGEAL HIATAL HERNIA (IN      707.23   589.36                 0  90
43337   REPAIR, PARAESOPHAGEAL HIATAL HERNIA (IN      772.77   643.98                 0  90
43338   ESOPHAGEAL LENGTHENING PROCEDURE (EG, CO       62.90    52.42                 0   0
43340   ESOPHAGOJEJUNOSTOMY (WITHOUT TOTAL GASTR      746.42   622.02                 0  90
43341   ESOPHAGOJEJUNOSTOMY (WITHOUT TOTAL GASTR      799.49   666.24                 0  90
43350   ESOPHAGOSTOMY, FISTULIZATION OF ESOPHAGU      637.49   531.24                 0  90
43351   ESOPHAGOSTOMY, FISTULIZATION OF ESOPHAGU      756.02   630.02                 0  90
43352   ESOPHAGOSTOMY, FISTULIZATION OF ESOPHAGU      608.14   506.79                 0  90
43360   GASTROINTESTINAL RECONSTRUCTION FOR PREV    1,294.84 1,079.04                 0  90
43361   GASTROINTESTINAL RECONSTRUCTION FOR PREV    1,460.80 1,217.33                 0  90
43400   LIGATION, DIRECT, ESOPHAGEAL VARICES          847.31   706.09                 0  90
43401   TRANSECTION OF ESOPHAGUS WITH REPAIR, FO      840.64   700.54                 0  90
43405   LIGATION OR STAPLING AT GASTROESOPHAGEAL      814.10   678.42                 0  90
43410   SUTURE OF ESOPHAGEAL WOUND OR INJURY; CE                                  BR 0   90
43415   SUTURE OF ESOPHAGEAL WOUND OR INJURY; TR      955.03   795.86                 0  90
43420   CLOSURE OF ESOPHAGOSTOMY OR FISTULA; CER      554.94   462.45                 0  90
43425   CLOSURE OF ESOPHAGOSTOMY OR FISTULA; TRA      827.99   690.00                 0  90
43450   DILATION OF ESOPHAGUS, BY UNGUIDED SOUND       96.21    42.23                 0   0
43453   DILATION OF ESOPHAGUS, OVER GUIDE WIRE        185.64    45.59                 0   0
43456   DILATION OF ESOPHAGUS, BY BALLOON OR DIL      386.41    73.43                 0   0
43458   DILATION OF ESOPHAGUS WITH BALLOON (30 M      234.84    85.97                 0   0
43460   ESOPHAGOGASTRIC TAMPONADE, WITH BALLOON       124.23   103.53                 0   0
43496   FREE JEJUNUM TRANSFER WITH MICROVASCULAR      669.61   600.00                 0  90
43499   UNLISTED PROCEDURE, ESOPHAGUS                                             BR 0    0
                                                                                                   Page 115 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
43500   GASTROTOMY; WITH EXPLORATION OR FOREIGN       418.13   348.44                 0  90
43501   GASTROTOMY; WITH SUTURE REPAIR OF BLEEDI      719.92   599.94                 0  90
43502   GASTROTOMY; WITH SUTURE REPAIR OF PRE-EX      818.17   681.81                 0  90
43510   GASTROTOMY; WITH ESOPHAGEAL DILATION AND      533.03   444.19                 0  90
43520   PYLOROMYOTOMY, CUTTING OF PYLORIC MUSCLE      383.30   319.42                 0  90
43605   BIOPSY OF STOMACH; BY LAPAROTOMY              444.73   370.61                 0  90
43610   EXCISION, LOCAL; ULCER OR BENIGN TUMOR O      525.29   437.74                 0  90
43611   EXCISION, LOCAL; MALIGNANT TUMOR OF STOM      651.50   542.92                 0  90
43620   GASTRECTOMY, TOTAL; WITH ESOPHAGOENTEROS    1,062.68   885.57                 0  90
43621   GASTRECTOMY, TOTAL; WITH ROUX-EN-Y RECON    1,194.85   995.71                 0  90
43622   GASTRECTOMY, TOTAL; WITH FORMATION OF IN    1,219.74 1,016.45                 0  90
43631   GASTRECTOMY, PARTIAL, DISTAL; WITH GASTR      783.23   652.69                 0  90
43632   GASTRECTOMY, PARTIAL, DISTAL; WITH GASTR    1,033.10   860.92                 0  90
43633   GASTRECTOMY, PARTIAL, DISTAL; WITH ROUX-      989.45   824.55                 0  90
43634   GASTRECTOMY, PARTIAL, DISTAL; WITH FORMA                                  BR 0   90
43635   VAGOTOMY WHEN PERFORMED WITH PARTIAL DIS       63.02    52.52                 0   0
43640   VAGOTOMY INCLUDING PYLOROPLASTY, WITH OR      626.91   522.43                 0  90
43641   VAGOTOMY INCLUDING PYLOROPLASTY, WITH OR      636.71   530.59                 0  90
43644   LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTI      930.03   775.03                 0  90
43645   LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTI      996.42   830.35                 0  90
43647   LAPAROSCOPY, SURGICAL; IMPLANTATION OR R      561.84   468.20                 0   0
43648   LAPAROSCOPY, SURGICAL; REVISION OR REMOV      561.84   468.20                 0   0
43651   LAPAROSCOPY, SURGICAL; TRANSECTION OF VA      352.00   293.34                 0  90
43652   LAPAROSCOPY, SURGICAL; TRANSECTION OF VA      417.41   347.85                 0  90
43653   LAPAROSCOPY, SURGICAL; GASTROSTOMY, WITH      300.02   250.02                 0  90
43659   UNLISTED LAPAROSCOPY PROCEDURE, STOMACH                                   BR 0    0
43752   NASO- OR ORO-GASTRIC TUBE PLACEMENT, REQ       23.30    19.42                 0   0
43753   GASTRIC INTUBATION AND ASPIRATION(S) THE        9.56     7.96                 0   0
43754   GASTRIC INTUBATION AND ASPIRATION, DIAGN       37.82    12.33                 0   0
                                                                                                   Page 116 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
43755   GASTRIC INTUBATION AND ASPIRATION, DIAGN       57.35    22.44                 0   0
43756   DUODENAL INTUBATION AND ASPIRATION, DIAG      105.10    20.24                 0   0
43757   DUODENAL INTUBATION AND ASPIRATION, DIAG      135.01    29.18                 0   0
43760   CHANGE OF GASTROSTOMY TUBE, PERCUTANEOUS      119.76    24.94                 0   0
43761   REPOSITIONING OF A NASO- OR ORO-GASTRIC        71.01    60.00                 0   0
43770   LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTI      599.53   499.61                 0  90
43771   LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTI      684.31   570.26                 0  90
43772   LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTI      514.81   429.01                 0  90
43773   LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTI      684.29   570.24                 0  90
43774   LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTI      517.88   431.57                 0  90
43775   LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTI      807.47   672.90                 0   0
43800   PYLOROPLASTY                                  498.40   415.33                 0  90
43810   GASTRODUODENOSTOMY                            537.91   448.26                 0  90
43820   GASTROJEJUNOSTOMY; WITHOUT VAGOTOMY           681.20   567.67                 0  90
43825   GASTROJEJUNOSTOMY; WITH VAGOTOMY, ANY TY      694.40   578.67                 0  90
43830   GASTROSTOMY, OPEN; WITHOUT CONSTRUCTION       370.82   309.02                 0  90
43831   GASTROSTOMY, OPEN; NEONATAL, FOR FEEDING      310.31   258.60                 0  90
43832   GASTROSTOMY, OPEN; WITH CONSTRUCTION OF       567.99   473.33                 0  90
43840   GASTRORRHAPHY, SUTURE OF PERFORATED DUOD      693.09   577.58                 0  90
43842   GASTRIC RESTRICTIVE PROCEDURE, WITHOUT G      700.00   700.00                 0  90
43843   GASTRIC RESTRICTIVE PROCEDURE, WITHOUT G      700.00   700.00                 0  90
43845   GASTRIC RESTRICTIVE PROCEDURE WITH PARTI                                  BR 0   90
43846   GASTRIC RESTRICTIVE PROCEDURE, WITH GAST      873.69   800.00                 0  90
43847   GASTRIC RESTRICTIVE PROCEDURE, WITH GAST      957.86   800.00                 0  90
43848   REVISION, OPEN, OF GASTRIC RESTRICTIVE P    1,036.25   863.54                 0  90
43850   REVISION OF GASTRODUODENAL ANASTOMOSIS (      871.50   726.25                 0  90
43855   REVISION OF GASTRODUODENAL ANASTOMOSIS (      907.34   756.12                 0  90
43860   REVISION OF GASTROJEJUNAL ANASTOMOSIS (G      880.39   733.66                 0  90
43865   REVISION OF GASTROJEJUNAL ANASTOMOSIS (G      918.11   765.10                 0  90
                                                                                                   Page 117 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
43870   CLOSURE OF GASTROSTOMY, SURGICAL              376.66   313.89                 0  90
43880   CLOSURE OF GASTROCOLIC FISTULA                861.44   717.87                 0  90
43881   IMPLANTATION OR REPLACEMENT OF GASTRIC N      499.42   416.18                 0   0
43882   REVISION OR REMOVAL OF GASTRIC NEUROSTIM      499.42   416.18                 0   0
43886   GASTRIC RESTRICTIVE PROCEDURE, OPEN; REV      179.28   149.40                 0  90
43887   GASTRIC RESTRICTIVE PROCEDURE, OPEN; REM      169.51   141.26                 0  90
43888   GASTRIC RESTRICTIVE PROCEDURE, OPEN; REM      240.77   200.64                 0  90
43999   UNLISTED PROCEDURE, STOMACH                                               BR 0    0
44005   ENTEROLYSIS (FREEING OF INTESTINAL ADHES      587.12   489.27                 0  90
44010   DUODENOTOMY, FOR EXPLORATION, BIOPSY(S),      461.38   384.49                 0  90
44015   TUBE OR NEEDLE CATHETER JEJUNOSTOMY FOR       160.00   160.00                 0   0
44020   ENTEROTOMY, SMALL INTESTINE, OTHER THAN       517.99   431.66                 0  90
44021   ENTEROTOMY, SMALL INTESTINE, OTHER THAN       522.28   435.24                 0  90
44025   COLOTOMY, FOR EXPLORATION, BIOPSY(S), OR      526.64   438.87                 0  90
44050   REDUCTION OF VOLVULUS, INTUSSUSCEPTION,       501.89   418.24                 0  90
44055   CORRECTION OF MALROTATION BY LYSIS OF DU      798.19   665.16                 0  90
44100   BIOPSY OF INTESTINE BY CAPSULE, TUBE, PE       64.77    53.98                 0   0
44110   EXCISION OF ONE OR MORE LESIONS OF SMALL      451.77   376.48                 0  90
44111   EXCISION OF ONE OR MORE LESIONS OF SMALL      527.67   439.73                 0  90
44120   ENTERECTOMY, RESECTION OF SMALL INTESTIN      648.65   540.55                 0  90
44121   ENTERECTOMY, RESECTION OF SMALL INTESTIN      136.12   113.44                 0   0
44125   ENTERECTOMY, RESECTION OF SMALL INTESTIN      633.39   527.83                 0  90
44126   ENTERECTOMY, RESECTION OF SMALL INTESTIN    1,303.84 1,086.54                 0  90
44127   ENTERECTOMY, RESECTION OF SMALL INTESTIN    1,517.51 1,264.59                 0  90
44128   ENTERECTOMY, RESECTION OF SMALL INTESTIN      138.02   115.02                 0   0
44130   ENTEROENTEROSTOMY, ANASTOMOSIS OF INTEST      665.59   554.66                 0  90
44133   DONOR ENTERECTOMY (INCLUDING COLD PRESER    1,242.43 1,035.36                 0   0
44135   INTESTINAL ALLOTRANSPLANTATION; FROM CAD    1,975.25 1,646.04                 0   0
44136   INTESTINAL ALLOTRANSPLANTATION; FROM LIV    2,227.26 1,856.05                 0   0
                                                                                                   Page 118 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
44137   REMOVAL OF TRANSPLANTED INTESTINAL ALLOG                                  BR 0    0
44139   MOBILIZATION (TAKE-DOWN) OF SPLENIC FLEX       67.95    56.63                 0   0
44140   COLECTOMY, PARTIAL; WITH ANASTOMOSIS          724.97   604.15                 0  90
44141   COLECTOMY, PARTIAL; WITH SKIN LEVEL CECO      933.44   777.87                 0  90
44143   COLECTOMY, PARTIAL; WITH END COLOSTOMY A      890.47   742.06                 0  90
44144   COLECTOMY, PARTIAL; WITH RESECTION, WITH      920.43   767.03                 0  90
44145   COLECTOMY, PARTIAL; WITH COLOPROCTOSTOMY      904.18   753.48                 0  90
44146   COLECTOMY, PARTIAL; WITH COLOPROCTOSTOMY    1,116.46   930.38                 0  90
44147   COLECTOMY, PARTIAL; ABDOMINAL AND TRANSA      981.96   818.30                 0  90
44150   COLECTOMY, TOTAL, ABDOMINAL, WITHOUT PRO      983.48   819.57                 0  90
44151   COLECTOMY, TOTAL, ABDOMINAL, WITHOUT PRO    1,123.45   936.21                 0  90
44155   COLECTOMY, TOTAL, ABDOMINAL, WITH PROCTE    1,101.40   917.83                 0  90
44156   COLECTOMY, TOTAL, ABDOMINAL, WITH PROCTE    1,211.59 1,009.66                 0  90
44157   COLECTOMY, TOTAL, ABDOMINAL, WITH PROCTE    1,233.28 1,027.73                 0  90
44158   COLECTOMY, TOTAL, ABDOMINAL, WITH PROCTE    1,264.96 1,054.13                 0  90
44160   COLECTOMY, PARTIAL, WITH REMOVAL OF TERM      665.08   554.23                 0  90
44180   LAPAROSCOPY, SURGICAL, ENTEROLYSIS (FREE      499.99   416.66                 0  90
44186   LAPAROSCOPY, SURGICAL; JEJUNOSTOMY (EG,       354.13   295.11                 0  90
44187   LAPAROSCOPY, SURGICAL; ILEOSTOMY OR JEJU      598.30   498.58                 0  90
44188   LAPAROSCOPY, SURGICAL, COLOSTOMY OR SKIN      657.76   548.13                 0  90
44202   LAPAROSCOPY, SURGICAL; ENTERECTOMY, RESE      750.74   625.62                 0  90
44203   LAPAROSCOPY, SURGICAL; EACH ADDITIONAL S      135.65   113.04                 0   0
44204   LAPAROSCOPY, SURGICAL; COLECTOMY, PARTIA      838.14   698.45                 0  90
44205   LAPAROSCOPY, SURGICAL; COLECTOMY, PARTIA      733.25   611.04                 0  90
44206   LAPAROSCOPY, SURGICAL; COLECTOMY, PARTIA      949.82   791.52                 0  90
44207   LAPAROSCOPY, SURGICAL; COLECTOMY, PARTIA      996.84   830.70                 0  90
44208   LAPAROSCOPY, SURGICAL; COLECTOMY, PARTIA    1,087.77   906.48                 0  90
44210   LAPAROSCOPY, SURGICAL; COLECTOMY, TOTAL,      970.26   808.55                 0  90
44211   LAPAROSCOPY, SURGICAL; COLECTOMY, TOTAL,    1,194.08   995.07                 0  90
                                                                                                   Page 119 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
44212   LAPAROSCOPY, SURGICAL; COLECTOMY, TOTAL,    1,115.39   929.50                 0  90
44213   LAPAROSCOPY, SURGICAL, MOBILIZATION (TAK      106.85    89.04                 0   0
44227   LAPAROSCOPY, SURGICAL, CLOSURE OF ENTERO      904.91   754.10                 0  90
44238   UNLISTED LAPAROSCOPY PROCEDURE, INTESTIN                                  BR 0   90
44300   PLACEMENT, ENTEROSTOMY OR CECOSTOMY, TUB      450.33   375.28                 0  90
44310   ILEOSTOMY OR JEJUNOSTOMY, NON-TUBE            562.76   468.97                 0  90
44312   REVISION OF ILEOSTOMY; SIMPLE (RELEASE O      317.47   264.56                 0  90
44314   REVISION OF ILEOSTOMY; COMPLICATED (RECO      542.48   452.07                 0  90
44316   CONTINENT ILEOSTOMY (KOCK PROCEDURE) (SE      746.57   622.14                 0  90
44320   COLOSTOMY OR SKIN LEVEL CECOSTOMY;            641.52   534.60                 0  90
44322   COLOSTOMY OR SKIN LEVEL CECOSTOMY; WITH       520.49   433.75                 0  90
44340   REVISION OF COLOSTOMY; SIMPLE (RELEASE O      321.53   267.94                 0  90
44345   REVISION OF COLOSTOMY; COMPLICATED (RECO      562.12   468.44                 0  90
44346   REVISION OF COLOSTOMY; WITH REPAIR OF PA      628.85   524.05                 0  90
44360   SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY        89.09    80.00                 0   0
44361   SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY       100.00   100.00                 0   0
44363   SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY       116.83   105.00                 0   0
44364   SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY       124.65   120.00                 0   0
44365   SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY       110.97   103.00                 0   0
44366   SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY       147.32   122.77                 0   0
44369   SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY       149.86   124.89                 0   0
44370   SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY       161.96   134.97                 0   0
44372   SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY       145.04   130.00                 0   0
44373   SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY       120.00   120.00                 0   0
44376   SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY       171.86   143.22                 0   0
44377   SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY       181.90   151.59                 0   0
44378   SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY       234.25   195.21                 0   0
44379   SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY       250.34   208.62                 0   0
44380   ILEOSCOPY, THROUGH STOMA; DIAGNOSTIC, WI       80.00    80.00                 0   0
                                                                                                   Page 120 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
44382   ILEOSCOPY, THROUGH STOMA; WITH BIOPSY, S      100.00   100.00                 0   0
44383   ILEOSCOPY, THROUGH STOMA; WITH TRANSENDO      100.18   100.00                 0   0
44385   ENDOSCOPIC EVALUATION OF SMALL INTESTINA      142.09    80.00                 0   0
44386   ENDOSCOPIC EVALUATION OF SMALL INTESTINA      211.49   100.00                 0   0
44388   COLONOSCOPY THROUGH STOMA; DIAGNOSTIC, W      201.13    78.40                 0   0
44389   COLONOSCOPY THROUGH STOMA; WITH BIOPSY,       239.11   150.00                 0   0
44390   COLONOSCOPY THROUGH STOMA; WITH REMOVAL       275.30   150.00                 0   0
44391   COLONOSCOPY THROUGH STOMA; WITH CONTROL                                   BR 0    0
44392   COLONOSCOPY THROUGH STOMA; WITH REMOVAL       257.29   150.00                 0   0
44393   COLONOSCOPY THROUGH STOMA; WITH ABLATION      291.77   150.00                 0   0
44394   COLONOSCOPY THROUGH STOMA; WITH REMOVAL       299.51   150.00                 0   0
44397   COLONOSCOPY THROUGH STOMA; WITH TRANSEND      153.43   127.86                 0   0
44500   INTRODUCTION OF LONG GASTROINTESTINAL TU       14.82    12.35                 0   0
44602   SUTURE OF SMALL INTESTINE (ENTERORRHAPHY      722.99   602.49                 0  90
44603   SUTURE OF SMALL INTESTINE (ENTERORRHAPHY      826.10   688.42                 0  90
44604   SUTURE OF LARGE INTESTINE (COLORRHAPHY)       570.13   475.11                 0  90
44605   SUTURE OF LARGE INTESTINE (COLORRHAPHY)       705.05   587.55                 0  90
44615   INTESTINAL STRICTUROPLASTY (ENTEROTOMY A      578.08   481.74                 0  90
44620   CLOSURE OF ENTEROSTOMY, LARGE OR SMALL I      460.21   383.51                 0  90
44625   CLOSURE OF ENTEROSTOMY, LARGE OR SMALL I      546.17   455.15                 0  90
44626   CLOSURE OF ENTEROSTOMY, LARGE OR SMALL I      871.30   726.08                 0  90
44640   CLOSURE OF INTESTINAL CUTANEOUS FISTULA       758.90   632.42                 0  90
44650   CLOSURE OF ENTEROENTERIC OR ENTEROCOLIC       788.42   657.02                 0  90
44660   CLOSURE OF ENTEROVESICAL FISTULA; WITHOU      756.96   630.80                 0  90
44661   CLOSURE OF ENTEROVESICAL FISTULA; WITH I      852.80   710.67                 0  90
44680   INTESTINAL PLICATION (SEPARATE PROCEDURE      571.59   476.33                 0  90
44700   EXCLUSION OF SMALL INTESTINE FROM PELVIS      554.09   461.75                 0  90
44701   INTRAOPERATIVE COLONIC LAVAGE (LIST SEPA       93.97    78.31                 0   0
44799   UNLISTED PROCEDURE, INTESTINE                                             BR 0    0
                                                                                                   Page 121 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
44800   EXCISION OF MECKEL'S DIVERTICULUM (DIVER      410.45   342.04                 0  90
44820   EXCISION OF LESION OF MESENTERY (SEPARAT      449.89   374.91                 0  90
44850   SUTURE OF MESENTERY (SEPARATE PROCEDURE)      399.92   333.27                 0  90
44899   UNLISTED PROCEDURE, MECKEL'S DIVERTICULU                                  BR 0    0
44900   INCISION AND DRAINAGE OF APPENDICEAL ABS      403.22   336.02                 0  90
44901   INCISION AND DRAINAGE OF APPENDICEAL ABS      661.00    86.00                 0   0
44950   APPENDECTOMY;                                 346.88   289.07                 0  90
44955   APPENDECTOMY; WHEN DONE FOR INDICATED PU      160.00   160.00                 0   0
44960   APPENDECTOMY; FOR RUPTURED APPENDIX WITH      462.37   385.31                 0  90
44970   LAPAROSCOPY, SURGICAL, APPENDECTOMY           318.21   265.18                 0  90
44979   UNLISTED LAPAROSCOPY PROCEDURE, APPENDIX                                  BR 0   90
45000   TRANSRECTAL DRAINAGE OF PELVIC ABSCESS        218.68   182.24                 0  90
45005   INCISION AND DRAINAGE OF SUBMUCOSAL ABSC      145.34    71.07                 0  10
45020   INCISION AND DRAINAGE OF DEEP SUPRALEVAT      280.52   233.77                 0  90
45100   BIOPSY OF ANORECTAL WALL, ANAL APPROACH       154.50   128.75                 0  90
45108   ANORECTAL MYOMECTOMY                          188.50   160.00                 0  90
45110   PROCTECTOMY; COMPLETE, COMBINED ABDOMINO      997.81   831.51                 0  90
45111   PROCTECTOMY; PARTIAL RESECTION OF RECTUM      585.71   488.10                 0  90
45112   PROCTECTOMY, COMBINED ABDOMINOPERINEAL,     1,023.07   852.56                 0  90
45113   PROCTECTOMY, PARTIAL, WITH RECTAL MUCOSE    1,051.19   876.00                 0  90
45114   PROCTECTOMY, PARTIAL, WITH ANASTOMOSIS;       961.07   800.89                 0  90
45116   PROCTECTOMY, PARTIAL, WITH ANASTOMOSIS;       869.26   724.39                 0  90
45119   PROCTECTOMY, COMBINED ABDOMINOPERINEAL P    1,051.39   876.16                 0  90
45120   PROCTECTOMY, COMPLETE (FOR CONGENITAL ME      839.62   699.69                 0  90
45121   PROCTECTOMY, COMPLETE (FOR CONGENITAL ME      923.58   769.65                 0  90
45123   PROCTECTOMY, PARTIAL, WITHOUT ANASTOMOSI      593.25   494.38                 0  90
45126   PELVIC EXENTERATION FOR COLORECTAL MALIG    1,551.38 1,292.82                 0  90
45130   EXCISION OF RECTAL PROCIDENTIA, WITH ANA      580.75   483.96                 0  90
45135   EXCISION OF RECTAL PROCIDENTIA, WITH ANA      714.55   595.46                 0  90
                                                                                                   Page 122 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
45136   EXCISION OF ILEOANAL RESERVOIR WITH ILEO      989.55   824.63                 0  90
45150   DIVISION OF STRICTURE OF RECTUM               208.94   174.12                 0  90
45160   EXCISION OF RECTAL TUMOR BY PROCTOTOMY,       528.67   440.56                 0  90
45171   EXCISION OF RECTAL TUMOR, TRANSANAL APPR      281.85   234.88                 0  90
45172   EXCISION OF RECTAL TUMOR, TRANSANAL APPR      385.60   321.34                 0  90
45190   DESTRUCTION OF RECTAL TUMOR (EG, ELECTRO      360.11   300.09                 0  90
45300   PROCTOSIGMOIDOSCOPY, RIGID; DIAGNOSTIC,        59.95    21.86                 0   0
45303   PROCTOSIGMOIDOSCOPY, RIGID; WITH DILATIO      506.96    36.48                 0   0
45305   PROCTOSIGMOIDOSCOPY, RIGID; WITH BIOPSY,       99.58    34.58                 0   0
45307   PROCTOSIGMOIDOSCOPY, RIGID; WITH REMOVAL      114.51    43.13                 0   0
45308   PROCTOSIGMOIDOSCOPY, RIGID; WITH REMOVAL       96.98    36.31                 0   0
45309   PROCTOSIGMOIDOSCOPY, RIGID; WITH REMOVAL      113.55    44.99                 0   0
45315   PROCTOSIGMOIDOSCOPY, RIGID; WITH REMOVAL      122.42    48.90                 0   0
45317   PROCTOSIGMOIDOSCOPY, RIGID; WITH CONTROL      115.52    51.36                 0   0
45320   PROCTOSIGMOIDOSCOPY, RIGID; WITH ABLATIO      117.75    55.00                 0   0
45321   PROCTOSIGMOIDOSCOPY, RIGID; WITH DECOMPR       56.08    46.74                 0   0
45327   PROCTOSIGMOIDOSCOPY, RIGID; WITH TRANSEN       64.07    53.39                 0   0
45330   SIGMOIDOSCOPY, FLEXIBLE; DIAGNOSTIC, WIT       80.56    29.40                 0   0
45331   SIGMOIDOSCOPY, FLEXIBLE; WITH BIOPSY, SI      103.69    35.34                 0   0
45332   SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF      169.91    51.97                 0   0
45333   SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF      169.69    51.57                 0   0
45334   SIGMOIDOSCOPY, FLEXIBLE; WITH CONTROL OF       93.08    77.57                 0   0
45335   SIGMOIDOSCOPY, FLEXIBLE; WITH DIRECTED S      137.70    64.00                 0   0
45337   SIGMOIDOSCOPY, FLEXIBLE; WITH DECOMPRESS       80.48    67.07                 0   0
45338   SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF      189.09    66.72                 0   0
45339   SIGMOIDOSCOPY, FLEXIBLE; WITH ABLATION O      183.24    88.51                 0   0
45340   SIGMOIDOSCOPY, FLEXIBLE; WITH DILATION B      244.15    96.00                 0   0
45341   SIGMOIDOSCOPY, FLEXIBLE; WITH ENDOSCOPIC       88.59    73.83                 0   0
45342   SIGMOIDOSCOPY, FLEXIBLE; WITH TRANSENDOS      134.99   112.50                 0   0
                                                                                                   Page 123 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
45345   SIGMOIDOSCOPY, FLEXIBLE; WITH TRANSENDOS       97.45    81.21                 0   0
45355   COLONOSCOPY, RIGID OR FLEXIBLE, TRANSABD      116.11    96.76                 0   0
45378   COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLEN      236.36   102.22                 0   0
45379   COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLEN      297.92   160.00                 0   0
45380   COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLEN      282.33   160.00                 0   0
45381   COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLEN      274.87   160.00                 0   0
45382   COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLEN      374.88   160.00                 0   0
45383   COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLEN      333.15   160.00                 0   0
45384   COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLEN      276.52   140.00                 0   0
45385   COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLEN      316.76   145.42                 0   0
45386   COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLEN      406.85   160.00                 0   0
45387   COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLEN      194.53   162.11                 0   0
45391   COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLEN      169.61   141.34                 0   0
45392   COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLEN      213.05   177.54                 0   0
45395   LAPAROSCOPY, SURGICAL; PROCTECTOMY, COMP    1,078.35   898.63                 0  90
45397   LAPAROSCOPY, SURGICAL; PROCTECTOMY, COMB    1,163.41   969.51                 0  90
45400   LAPAROSCOPY, SURGICAL; PROCTOPEXY (FOR P      623.13   519.28                 0  90
45402   LAPAROSCOPY, SURGICAL; PROCTOPEXY (FOR P      832.25   693.54                 0  90
45499   UNLISTED LAPAROSCOPY PROCEDURE, RECTUM                                    BR 0   90
45500   PROCTOPLASTY; FOR STENOSIS                    271.24   226.04                 0  90
45505   PROCTOPLASTY; FOR PROLAPSE OF MUCOUS MEM      296.14   246.79                 0  90
45520   PERIRECTAL INJECTION OF SCLEROSING SOLUT       67.62    40.00                 0   0
45540   PROCTOPEXY (EG, FOR PROLAPSE); ABDOMINAL      564.85   470.71                 0  90
45541   PROCTOPEXY FOR PROLAPSE; PERINEAL APPROA      489.44   407.87                 0  90
45550   PROCTOPEXY (EG, FOR PROLAPSE); WITH SIGM      785.87   654.90                 0  90
45560   REPAIR OF RECTOCELE (SEPARATE PROCEDURE)      388.69   323.91                 0  90
45562   EXPLORATION, REPAIR, AND PRESACRAL DRAIN      590.72   492.27                 0  90
45563   EXPLORATION, REPAIR, AND PRESACRAL DRAIN      866.78   722.32                 0  90
45800   CLOSURE OF RECTOVESICAL FISTULA;              657.58   547.99                 0  90
                                                                                                   Page 124 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
45805   CLOSURE OF RECTOVESICAL FISTULA; WITH CO      758.00   631.67                 0  90
45820   CLOSURE OF RECTOURETHRAL FISTULA;             654.17   545.15                 0  90
45825   CLOSURE OF RECTOURETHRAL FISTULA; WITH C      779.23   649.36                 0  90
45900   REDUCTION OF PROCIDENTIA (SEPARATE PROCE      106.10    88.42                 0  10
45905   DILATION OF ANAL SPHINCTER (SEPARATE PRO       90.50    75.42                 0  10
45910   DILATION OF RECTAL STRICTURE (SEPARATE P      107.27    89.40                 0  10
45915   REMOVAL OF FECAL IMPACTION OR FOREIGN BO      176.00   101.55                 0  10
45999   UNLISTED PROCEDURE, RECTUM                                                BR 0    0
46020   PLACEMENT OF SETON                            135.89    98.89                 0  10
46030   REMOVAL OF ANAL SETON, OTHER MARKER            68.27    39.26                 0  10
46040   INCISION AND DRAINAGE OF ISCHIORECTAL AN      269.38   178.54                 0  90
46045   INCISION AND DRAINAGE OF INTRAMURAL, INT      214.48   178.74                 0  90
46050   INCISION AND DRAINAGE, PERIANAL ABSCESS,       98.57    41.95                 0  10
46060   INCISION AND DRAINAGE OF ISCHIORECTAL OR      236.53   197.11                 0  90
46070   INCISION, ANAL SEPTUM (INFANT)                115.37    96.14                 0  90
46080   SPHINCTEROTOMY, ANAL, DIVISION OF SPHINC      124.66    71.28                 0  10
46083   INCISION OF THROMBOSED HEMORRHOID, EXTER       92.39    46.23                 0  10
46200   FISSURECTOMY, INCLUDING SPHINCTEROTOMY,       204.45   134.07                 0  90
46220   EXCISION OF SINGLE EXTERNAL PAPILLA OR T      101.50    50.95                 0  10
46221   HEMORRHOIDECTOMY, INTERNAL, BY RUBBER BA      130.72    81.86                 0  10
46230   EXCISION OF MULTIPLE EXTERNAL PAPILLAE O      140.54    76.51                 0  10
46250   HEMORRHOIDECTOMY, EXTERNAL, 2 OR MORE CO      234.39   135.64                 0  90
46255   HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL,      262.55   154.40                 0  90
46257   HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL,      212.93   177.45                 0  90
46258   HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL,      232.27   193.56                 0  90
46260   HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL,      242.20   201.84                 0  90
46261   HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL,      270.68   225.57                 0  90
46262   HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL,      281.21   234.34                 0  90
46270   SURGICAL TREATMENT OF ANAL FISTULA (FIST      248.62   159.61                 0  90
                                                                                                   Page 125 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
46275   SURGICAL TREATMENT OF ANAL FISTULA (FIST      258.69   171.28                 0  90
46280   SURGICAL TREATMENT OF ANAL FISTULA (FIST      235.51   196.26                 0  90
46285   SURGICAL TREATMENT OF ANAL FISTULA (FIST      245.08   167.32                 0  90
46288   CLOSURE OF ANAL FISTULA WITH RECTAL ADVA      277.02   230.85                 0  90
46320   EXCISION OF THROMBOSED HEMORRHOID, EXTER       93.05    48.62                 0  10
46500   INJECTION OF SCLEROSING SOLUTION, HEMORR      107.35    55.42                 0  10
46505   CHEMODENERVATION OF INTERNAL ANAL SPHINC      144.88    99.40                 0  10
46600   ANOSCOPY; DIAGNOSTIC, WITH OR WITHOUT CO       48.43    17.59                 0   0
46604   ANOSCOPY; WITH DILATION (EG, BALLOON, GU      290.33    31.31                 0   0
46606   ANOSCOPY; WITH BIOPSY, SINGLE OR MULTIPL      120.85    32.41                 0   0
46608   ANOSCOPY; WITH REMOVAL OF FOREIGN BODY        130.43    37.52                 0   0
46610   ANOSCOPY; WITH REMOVAL OF SINGLE TUMOR,       125.78    36.94                 0   0
46611   ANOSCOPY; WITH REMOVAL OF SINGLE TUMOR,       102.80    39.31                 0   0
46612   ANOSCOPY; WITH REMOVAL OF MULTIPLE TUMOR      158.46    48.17                 0   0
46614   ANOSCOPY; WITH CONTROL OF BLEEDING (EG,        77.31    41.00                 0   0
46615   ANOSCOPY; WITH ABLATION OF TUMOR(S), POL       89.93    49.10                 0   0
46700   ANOPLASTY, PLASTIC OPERATION FOR STRICTU      333.73   278.11                 0  90
46705   ANOPLASTY, PLASTIC OPERATION FOR STRICTU      265.15   220.96                 0  90
46706   REPAIR OF ANAL FISTULA WITH FIBRIN GLUE        89.13    74.28                 0  10
46707   REPAIR OF ANORECTAL FISTULA WITH PLUG (E      274.56   228.80                 0  90
46710   REPAIR OF ILEOANAL POUCH FISTULA/SINUS (      566.40   472.00                 0  90
46712   REPAIR OF ILEOANAL POUCH FISTULA/SINUS (    1,181.09   984.25                 0  90
46715   REPAIR OF LOW IMPERFORATE ANUS; WITH ANO      264.61   220.51                 0  90
46716   REPAIR OF LOW IMPERFORATE ANUS; WITH TRA      601.50   501.25                 0  90
46730   REPAIR OF HIGH IMPERFORATE ANUS WITHOUT       972.91   810.76                 0  90
46735   REPAIR OF HIGH IMPERFORATE ANUS WITHOUT     1,151.17   959.31                 0  90
46740   REPAIR OF HIGH IMPERFORATE ANUS WITH REC    1,087.28   906.07                 0  90
46742   REPAIR OF HIGH IMPERFORATE ANUS WITH REC                                  BR 0   90
46744   REPAIR OF CLOACAL ANOMALY BY ANORECTOVAG    1,820.05 1,516.71                 0  90
                                                                                                   Page 126 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
46746   REPAIR OF CLOACAL ANOMALY BY ANORECTOVAG                                  BR 0   90
46748   REPAIR OF CLOACAL ANOMALY BY ANORECTOVAG    2,072.65 1,727.21                 0  90
46750   SPHINCTEROPLASTY, ANAL, FOR INCONTINENCE      403.02   335.85                 0  90
46751   SPHINCTEROPLASTY, ANAL, FOR INCONTINENCE      337.05   280.88                 0  90
46753   GRAFT (THIERSCH OPERATION) FOR RECTAL IN      304.79   254.00                 0  90
46754   REMOVAL OF THIERSCH WIRE OR SUTURE, ANAL                                  BR 0   10
46760   SPHINCTEROPLASTY, ANAL, FOR INCONTINENCE      573.32   477.77                 0  90
46761   SPHINCTEROPLASTY, ANAL, FOR INCONTINENCE      495.05   412.54                 0  90
46762   SPHINCTEROPLASTY, ANAL, FOR INCONTINENCE      482.06   401.72                 0  90
46900   DESTRUCTION OF LESION(S), ANUS (EG, COND      119.54    62.08                 0  10
46910   DESTRUCTION OF LESION(S), ANUS (EG, COND      126.17    70.00                 0  10
46916   DESTRUCTION OF LESION(S), ANUS (EG, COND      126.10    70.00                 0  10
46917   DESTRUCTION OF LESION(S), ANUS (EG, COND      263.71    70.00                 0  10
46922   DESTRUCTION OF LESION(S), ANUS (EG, COND      134.72    80.00                 0  10
46924   DESTRUCTION OF LESION(S), ANUS (EG, COND      287.56    81.51                 0  10
46930   DESTRUCTION OF INTERNAL HEMORRHOID(S)         119.58    71.49                 0  90
46940   CURETTAGE OR CAUTERY OF ANAL FISSURE, IN      112.23    65.84                 0  10
46942   CURETTAGE OR CAUTERY OF ANAL FISSURE, IN      103.31    58.82                 0  10
46945   HEMORRHOIDECTOMY, INTERNAL, BY LIGATION       147.02    95.85                 0  90
46946   HEMORRHOIDECTOMY, INTERNAL, BY LIGATION       162.01   100.96                 0  90
46947   HEMORRHOIDOPEXY (EG, FOR PROLAPSING INTE      200.39   166.99                 0  90
46999   UNLISTED PROCEDURE, ANUS                                                  BR 0    0
47000   BIOPSY OF LIVER, NEEDLE; PERCUTANEOUS         173.56    48.03                 0   0
47001   BIOPSY OF LIVER, NEEDLE; WHEN DONE FOR I       58.34    48.62                 0   0
47010   HEPATOTOMY; FOR OPEN DRAINAGE OF ABSCESS      639.65   533.04                 0  90
47011   HEPATOTOMY; FOR PERCUTANEOUS DRAINAGE OF      111.26    92.72                 0   0
47015   LAPAROTOMY, WITH ASPIRATION AND/OR INJEC      608.97   507.48                 0  90
47100   BIOPSY OF LIVER, WEDGE                        447.16   372.63                 0  90
47120   HEPATECTOMY, RESECTION OF LIVER; PARTIAL    1,256.29 1,046.91                 0  90
                                                                                                   Page 127 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
47122   HEPATECTOMY, RESECTION OF LIVER; TRISEGM    1,867.88 1,556.57                 0  90
47125   HEPATECTOMY, RESECTION OF LIVER; TOTAL L    1,676.56 1,397.13                 0  90
47130   HEPATECTOMY, RESECTION OF LIVER; TOTAL R    1,801.91 1,501.59                 0  90
47135   LIVER ALLOTRANSPLANTATION; ORTHOTOPIC, P    2,652.91 2,210.76                 0  90
47300   MARSUPIALIZATION OF CYST OR ABSCESS OF L      596.56   497.13                 0  90
47350   MANAGEMENT OF LIVER HEMORRHAGE; SIMPLE S      731.51   609.60                 0  90
47360   MANAGEMENT OF LIVER HEMORRHAGE; COMPLEX       993.05   827.55                 0  90
47361   MANAGEMENT OF LIVER HEMORRHAGE; EXPLORAT    1,644.67 1,370.56                 0  90
47362   MANAGEMENT OF LIVER HEMORRHAGE; RE-EXPLO      755.71   629.76                 0  90
47370   LAPAROSCOPY, SURGICAL, ABLATION OF ONE O      673.92   561.60                 0  90
47371   LAPAROSCOPY, SURGICAL, ABLATION OF ONE O      677.75   564.79                 0  90
47379   UNLISTED LAPAROSCOPIC PROCEDURE, LIVER                                    BR 0    0
47380   ABLATION, OPEN, OF ONE OR MORE LIVER TUM      783.92   653.27                 0  90
47381   ABLATION, OPEN, OF ONE OR MORE LIVER TUM      801.31   667.76                 0  90
47382   ABLATION, ONE OR MORE LIVER TUMOR(S), PE      482.72   402.27                 0  10
47399   UNLISTED PROCEDURE, LIVER                                                 BR 0    0
47400   HEPATICOTOMY OR HEPATICOSTOMY WITH EXPLO    1,133.99   945.00                 0  90
47420   CHOLEDOCHOTOMY OR CHOLEDOCHOSTOMY WITH E      719.44   599.54                 0  90
47425   CHOLEDOCHOTOMY OR CHOLEDOCHOSTOMY WITH E      726.73   605.61                 0  90
47460   TRANSDUODENAL SPHINCTEROTOMY OR SPHINCTE      681.40   567.84                 0  90
47480   CHOLECYSTOTOMY OR CHOLECYSTOSTOMY WITH E      454.10   378.42                 0  90
47490   PERCUTANEOUS CHOLECYSTOSTOMY                  307.59   256.33                 0  10
47500   INJECTION PROCEDURE FOR PERCUTANEOUS TRA       59.27    49.40                 0   0
47505   INJECTION PROCEDURE FOR CHOLANGIOGRAPHY        27.00    27.00                 0   0
47510   INTRODUCTION OF PERCUTANEOUS TRANSHEPATI      290.93   242.45                 0  90
47511   INTRODUCTION OF PERCUTANEOUS TRANSHEPATI      357.67   298.06                 0  90
47525   CHANGE OF PERCUTANEOUS BILIARY DRAINAGE       489.41   157.01                 0   0
47530   REVISION AND/OR REINSERTION OF TRANSHEPA      922.46   181.73                 0  90
47550   BILIARY ENDOSCOPY, INTRAOPERATIVE (CHOLE       92.77    77.31                 0   0
                                                                                                   Page 128 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
47552   BILIARY ENDOSCOPY, PERCUTANEOUS VIA T-TU      192.29   160.24                 0   0
47553   BILIARY ENDOSCOPY, PERCUTANEOUS VIA T-TU      190.78   158.98                 0   0
47554   BILIARY ENDOSCOPY, PERCUTANEOUS VIA T-TU      287.96   239.97                 0   0
47555   BILIARY ENDOSCOPY, PERCUTANEOUS VIA T-TU      228.44   190.37                 0   0
47556   BILIARY ENDOSCOPY, PERCUTANEOUS VIA T-TU      258.08   215.07                 0   0
47560   LAPAROSCOPY, SURGICAL; WITH GUIDED TRANS      149.93   124.94                 0   0
47561   LAPAROSCOPY, SURGICAL; WITH GUIDED TRANS      163.33   136.11                 0   0
47562   LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY        396.34   330.28                 0  90
47563   LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY W      408.37   340.31                 0  90
47564   LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY W      472.13   393.45                 0  90
47570   LAPAROSCOPY, SURGICAL; CHOLECYSTOENTEROS      420.59   350.50                 0  90
47579   UNLISTED LAPAROSCOPY PROCEDURE, BILIARY                                   BR 0    0
47600   CHOLECYSTECTOMY;                              558.91   465.76                 0  90
47605   CHOLECYSTECTOMY; WITH CHOLANGIOGRAPHY         526.72   438.93                 0  90
47610   CHOLECYSTECTOMY WITH EXPLORATION OF COMM      672.87   560.73                 0  90
47612   CHOLECYSTECTOMY WITH EXPLORATION OF COMM      678.43   565.36                 0  90
47620   CHOLECYSTECTOMY WITH EXPLORATION OF COMM      735.82   613.18                 0  90
47630   BILIARY DUCT STONE EXTRACTION, PERCUTANE      328.33   273.61                 0  90
47700   EXPLORATION FOR CONGENITAL ATRESIA OF BI      562.01   468.35                 0  90
47701   PORTOENTEROSTOMY (EG, KASAI PROCEDURE)        938.81   782.34                 0  90
47711   EXCISION OF BILE DUCT TUMOR, WITH OR WIT      835.00   695.83                 0  90
47712   EXCISION OF BILE DUCT TUMOR, WITH OR WIT    1,070.04   891.70                 0  90
47715   EXCISION OF CHOLEDOCHAL CYST                  702.65   585.55                 0  90
47720   CHOLECYSTOENTEROSTOMY; DIRECT                 605.89   504.91                 0  90
47721   CHOLECYSTOENTEROSTOMY; WITH GASTROENTERO      713.33   594.44                 0  90
47740   CHOLECYSTOENTEROSTOMY; ROUX-EN-Y              690.41   575.34                 0  90
47741   CHOLECYSTOENTEROSTOMY; ROUX-EN-Y WITH GA      782.98   652.48                 0  90
47760   ANASTOMOSIS, OF EXTRAHEPATIC BILIARY DUC    1,149.04   957.54                 0  90
47765   ANASTOMOSIS, OF INTRAHEPATIC DUCTS AND G    1,476.78 1,230.65                 0  90
                                                                                                   Page 129 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
47780   ANASTOMOSIS, ROUX-EN-Y, OF EXTRAHEPATIC     1,250.12 1,041.77                 0  90
47785   ANASTOMOSIS, ROUX-EN-Y, OF INTRAHEPATIC     1,613.48 1,344.57                 0  90
47800   RECONSTRUCTION, PLASTIC, OF EXTRAHEPATIC      844.43   703.69                 0  90
47801   PLACEMENT OF CHOLEDOCHAL STENT                586.48   488.73                 0  90
47802   U-TUBE HEPATICOENTEROSTOMY                    808.57   673.81                 0  90
47900   SUTURE OF EXTRAHEPATIC BILIARY DUCT FOR       732.92   610.77                 0  90
47999   UNLISTED PROCEDURE, BILIARY TRACT                                         BR 0    0
48000   PLACEMENT OF DRAINS, PERIPANCREATIC, FOR    1,002.62   835.52                 0  90
48001   PLACEMENT OF DRAINS, PERIPANCREATIC, FOR    1,240.50 1,033.75                 0  90
48020   REMOVAL OF PANCREATIC CALCULUS                618.18   515.15                 0  90
48100   BIOPSY OF PANCREAS, OPEN (EG, FINE NEEDL      471.76   393.14                 0  90
48102   BIOPSY OF PANCREAS, PERCUTANEOUS NEEDLE       317.85   124.39                 0  10
48105   RESECTION OR DEBRIDEMENT OF PANCREAS AND    1,523.68 1,269.73                 0  90
48120   EXCISION OF LESION OF PANCREAS (EG, CYST      589.76   491.47                 0  90
48140   PANCREATECTOMY, DISTAL SUBTOTAL, WITH OR      835.24   696.04                 0  90
48145   PANCREATECTOMY, DISTAL SUBTOTAL, WITH OR      866.29   721.91                 0  90
48146   PANCREATECTOMY, DISTAL, NEAR-TOTAL WITH       993.76   828.14                 0  90
48148   EXCISION OF AMPULLA OF VATER                  659.49   549.58                 0  90
48150   PANCREATECTOMY, PROXIMAL SUBTOTAL WITH T    1,677.96 1,398.30                 0  90
48152   PANCREATECTOMY, PROXIMAL SUBTOTAL WITH T    1,550.48 1,292.07                 0  90
48153   PANCREATECTOMY, PROXIMAL SUBTOTAL WITH N    1,676.29 1,396.91                 0  90
48154   PANCREATECTOMY, PROXIMAL SUBTOTAL WITH N                                  BR 0   90
48155   PANCREATECTOMY, TOTAL                         961.50   801.25                 0  90
48160   PANCREATECTOMY, TOTAL OR SUBTOTAL, WITH                                   BR 0    0
48400   INJECTION PROCEDURE FOR INTRAOPERATIVE P       59.23    49.36                 0   0
48500   MARSUPIALIZATION OF PANCREATIC CYST           598.16   498.47                 0  90
48510   EXTERNAL DRAINAGE, PSEUDOCYST OF PANCREA      574.24   478.53                 0  90
48511   EXTERNAL DRAINAGE, PSEUDOCYST OF PANCREA      592.50   100.37                 0   0
48520   INTERNAL ANASTOMOSIS OF PANCREATIC CYST       581.32   484.44                 0  90
                                                                                                   Page 130 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
48540   INTERNAL ANASTOMOSIS OF PANCREATIC CYST       700.36   583.63                 0  90
48545   PANCREATORRHAPHY FOR INJURY                   706.21   588.51                 0  90
48547   DUODENAL EXCLUSION WITH GASTROJEJUNOSTOM      949.60   791.34                 0  90
48548   PANCREATICOJEJUNOSTOMY, SIDE-TO-SIDE ANA      890.79   742.33                 0  90
48554   TRANSPLANTATION OF PANCREATIC ALLOGRAFT     1,327.24 1,106.03                 0  90
48556   REMOVAL OF TRANSPLANTED PANCREATIC ALLOG      652.15   543.46                 0  90
48999   UNLISTED PROCEDURE, PANCREAS                                              BR 0    0
49000   EXPLORATORY LAPAROTOMY, EXPLORATORY CELI      418.07   348.40                 0  90
49002   REOPENING OF RECENT LAPAROTOMY                529.07   440.90                 0  90
49010   EXPLORATION, RETROPERITONEAL AREA WITH O      508.85   424.05                 0  90
49020   DRAINAGE OF PERITONEAL ABSCESS OR LOCALI      851.03   709.20                 0  90
49021   DRAINAGE OF PERITONEAL ABSCESS OR LOCALI      574.41   159.00                 0   0
49040   DRAINAGE OF SUBDIAPHRAGMATIC OR SUBPHREN      532.27   443.56                 0  90
49041   DRAINAGE OF SUBDIAPHRAGMATIC OR SUBPHREN      572.32   104.00                 0   0
49060   DRAINAGE OF RETROPERITONEAL ABSCESS; OPE      595.81   496.51                 0  90
49061   DRAINAGE OF RETROPERITONEAL ABSCESS; PER      565.10    99.00                 0   0
49062   DRAINAGE OF EXTRAPERITONEAL LYMPHOCELE T      408.17   340.15                 0  90
49082   ABDOMINAL PARACENTESIS (DIAGNOSTIC OR TH       74.86    62.39                 0   0
49083   ABDOMINAL PARACENTESIS (DIAGNOSTIC OR TH      141.74   118.12                 0   0
49084   PERITONEAL LAVAGE, INCLUDING IMAGING GUI       44.00    36.67                 0   0
49180   BIOPSY, ABDOMINAL OR RETROPERITONEAL MAS      106.13    43.33                 0   0
49203   EXCISION OR DESTRUCTION, OPEN, INTRA-ABD      647.58   539.65                 0  90
49204   EXCISION OR DESTRUCTION, OPEN, INTRA-ABD      824.84   687.37                 0  90
49205   EXCISION OR DESTRUCTION, OPEN, INTRA-ABD      943.31   786.10                 0  90
49215   EXCISION OF PRESACRAL OR SACROCOCCYGEAL     1,195.84   996.53                 0  90
49220   STAGING LAPAROTOMY FOR HODGKINS DISEASE                                   BR 0   90
49250   UMBILECTOMY, OMPHALECTOMY, EXCISION OF U      312.22   260.19                 0  90
49255   OMENTECTOMY, EPIPLOECTOMY, RESECTION OF       423.71   353.10                 0  90
49320   LAPAROSCOPY, ABDOMEN, PERITONEUM, AND OM      189.00   189.00                 0  10
                                                                                                   Page 131 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
49321   LAPAROSCOPY, SURGICAL; WITH BIOPSY (SING      189.78   158.15                 0  10
49322   LAPAROSCOPY, SURGICAL; WITH ASPIRATION O      206.76   172.30                 0  10
49323   LAPAROSCOPY, SURGICAL; WITH DRAINAGE OF       346.62   288.85                 0  90
49324   LAPAROSCOPY, SURGICAL; WITH INSERTION OF      212.98   177.48                 0  10
49325   LAPAROSCOPY, SURGICAL; WITH REVISION OF       229.04   190.87                 0  10
49326   LAPAROSCOPY, SURGICAL; WITH OMENTOPEXY (      103.90    86.58                 0   0
49327   LAPAROSCOPY, SURGICAL; WITH PLACEMENT OF       60.97    50.81                 0   0
49329   UNLISTED LAPAROSCOPY PROCEDURE, ABDOMEN,                                  BR 0    0
49400   INJECTION OF AIR OR CONTRAST INTO PERITO      110.01    47.58                 0   0
49402   REMOVAL OF PERITONEAL FOREIGN BODY FROM       457.94   381.62                 0  90
49411   PLACEMENT OF INTERSTITIAL DEVICE(S) FOR       319.39   101.19                 0   0
49412   PLACEMENT OF INTERSTITIAL DEVICE(S) FOR        37.97    31.64                 0   0
49418   INSERTION OF TUNNELED INTRAPERITONEAL CA      732.62   180.54                 0   0
49419   INSERTION OF INTRAPERITONEAL CANNULA OR       247.77   206.48                 0  90
49421   INSERTION OF INTRAPERITONEAL CANNULA OR       213.70   178.09                 0   0
49422   REMOVAL OF PERMANENT INTRAPERITONEAL CAN      214.01   178.34                 0  10
49423   EXCHANGE OF PREVIOUSLY PLACED ABSCESS OR      366.39    37.67                 0   0
49424   CONTRAST INJECTION FOR ASSESSMENT OF ABS      100.10    19.84                 0   0
49425   INSERTION OF PERITONEAL-VENOUS SHUNT          415.96   346.64                 0  90
49426   REVISION OF PERITONEAL-VENOUS SHUNT           354.31   295.26                 0  90
49427   INJECTION PROCEDURE (EG, CONTRAST MEDIA)       27.28    22.73                 0   0
49428   LIGATION OF PERITONEAL-VENOUS SHUNT           241.70   201.42                 0  10
49429   REMOVAL OF PERITONEAL-VENOUS SHUNT            253.23   211.03                 0  10
49435   INSERTION OF SUBCUTANEOUS EXTENSION TO I       67.43    56.19                 0   0
49436   DELAYED CREATION OF EXIT SITE FROM EMBED      102.07    85.06                 0  10
49440   INSERTION OF GASTROSTOMY TUBE, PERCUTANE      713.05   190.00                 0  10
49441   INSERTION OF DUODENOSTOMY OR JEJUNOSTOMY      845.39   160.00                 0  10
49442   INSERTION OF CECOSTOMY OR OTHER COLONIC       688.96   160.00                 0  10
49446   CONVERSION OF GASTROSTOMY TUBE TO GASTRO      705.97   150.00                 0   0
                                                                                                   Page 132 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                          DESCRIPTION            FEE      FEE        FEE      BR PA DAYS   E
49450   REPLACEMENT OF GASTROSTOMY OR CECOSTOMY       496.49   160.00                 0   0
49451   REPLACEMENT OF DUODENOSTOMY OR JEJUNOSTO      525.11   160.00                 0   0
49452   REPLACEMENT OF GASTRO-JEJUNOSTOMY TUBE,       641.06   160.00                 0   0
49460   MECHANICAL REMOVAL OF OBSTRUCTIVE MATERI      527.57   150.00                 0   0
49465   CONTRAST INJECTION(S) FOR RADIOLOGICAL E      109.16    49.00                 0   0
49491   REPAIR, INITIAL INGUINAL HERNIA, PRETERM      403.83   336.53                 0  90
49492   REPAIR, INITIAL INGUINAL HERNIA, PRETERM      505.10   420.92                 0  90
49495   REPAIR, INITIAL INGUINAL HERNIA, FULL TE      216.30   180.25                 0  90
49496   REPAIR, INITIAL INGUINAL HERNIA, FULL TE      321.59   267.99                 0  90
49500   REPAIR INITIAL INGUINAL HERNIA, AGE 6 MO      216.62   180.52                 0  90
49501   REPAIR INITIAL INGUINAL HERNIA, AGE 6 MO      318.58   265.49                 0  90
49505   REPAIR INITIAL INGUINAL HERNIA, AGE 5 YE      277.72   231.44                 0  90
49507   REPAIR INITIAL INGUINAL HERNIA, AGE 5 YE      341.50   284.59                 0  90
49520   REPAIR RECURRENT INGUINAL HERNIA, ANY AG      339.34   282.78                 0  90
49521   REPAIR RECURRENT INGUINAL HERNIA, ANY AG      413.60   344.67                 0  90
49525   REPAIR INGUINAL HERNIA, SLIDING, ANY AGE      306.80   255.67                 0  90
49540   REPAIR LUMBAR HERNIA                          363.05   302.55                 0  90
49550   REPAIR INITIAL FEMORAL HERNIA, ANY AGE;       308.91   257.43                 0  90
49553   REPAIR INITIAL FEMORAL HERNIA, ANY AGE;       337.30   281.08                 0  90
49555   REPAIR RECURRENT FEMORAL HERNIA; REDUCIB      321.08   267.57                 0  90
49557   REPAIR RECURRENT FEMORAL HERNIA; INCARCE      389.29   324.41                 0  90
49560   REPAIR INITIAL INCISIONAL OR VENTRAL HER      399.14   332.62                 0  90
49561   REPAIR INITIAL INCISIONAL OR VENTRAL HER      500.53   417.11                 0  90
49565   REPAIR RECURRENT INCISIONAL OR VENTRAL H      411.62   343.02                 0  90
49566   REPAIR RECURRENT INCISIONAL OR VENTRAL H      505.70   421.42                 0  90
49568   IMPLANTATION OF MESH OR OTHER PROSTHESIS      149.71   124.76                 0   0
49570   REPAIR EPIGASTRIC HERNIA (EG, PREPERITON      219.22   182.68                 0  90
49572   REPAIR EPIGASTRIC HERNIA (EG, PREPERITON      268.31   223.60                 0  90
49580   REPAIR UMBILICAL HERNIA, UNDER AGE 5 YEA      169.98   141.65                 0  90
                                                                                                    Page 133 of 189


                                                                                                C
                                                      NON-                                      H
                                                                                                A
                                                    FACILITY FACILITY PROFESSIONAL              N
                                                    GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION                FEE      FEE        FEE      BR PA DAYS   E
49582   REPAIR UMBILICAL HERNIA, UNDER AGE 5 YEA       251.78   209.82                 0  90
49585   REPAIR UMBILICAL HERNIA, AGE 5 YEARS OR        234.88   195.73                 0  90
49587   REPAIR UMBILICAL HERNIA, AGE 5 YEARS OR        278.20   231.84                 0  90
49590   REPAIR SPIGELIAN HERNIA                        305.85   254.88                 0  90
49600   REPAIR OF SMALL OMPHALOCELE, WITH PRIMAR       395.36   329.47                 0  90
49605   REPAIR OF LARGE OMPHALOCELE OR GASTROSCH     2,673.50 2,227.92                 0  90
49606   REPAIR OF LARGE OMPHALOCELE OR GASTROSCH       619.25   516.05                 0  90
49610   REPAIR OF OMPHALOCELE (GROSS TYPE OPERAT       374.06   311.72                 0  90
49611   REPAIR OF OMPHALOCELE (GROSS TYPE OPERAT       343.96   286.63                 0  90
49650   LAPAROSCOPY, SURGICAL; REPAIR INITIAL IN       229.98   191.65                 0  90
49651   LAPAROSCOPY, SURGICAL; REPAIR RECURRENT        296.41   247.01                 0  90
49652   LAPAROSCOPY, SURGICAL, REPAIR, VENTRAL         436.60   363.83                 0  90
49653   LAPAROSCOPY, SURGICAL, REPAIR, VENTRAL         545.06   454.22                 0  90
49654   LAPAROSCOPY, SURGICAL, REPAIR, INCISIONAL      500.90   417.42                 0  90
49655   LAPAROSCOPY, SURGICAL, REPAIR, INCISIONAL      602.96   502.47                 0  90
49656   LAPAROSCOPY, SURGICAL, REPAIR, RECURRENT       502.76   418.97                 0  90
49657   LAPAROSCOPY, SURGICAL, REPAIR, RECURRENT       725.21   604.35                 0  90
49659   UNLISTED LAPAROSCOPY PROCEDURE, HERNIOPL                                   BR 0    0
49900   SUTURE, SECONDARY, OF ABDOMINAL WALL FOR       440.72   367.27                 0  90
49904   OMENTAL FLAP, EXTRA-ABDOMINAL (EG, FOR R       846.23   705.19                 0  90
49905   OMENTAL FLAP, INTRA-ABDOMINAL (LIST SEPA       199.30   166.08                 0   0
49906   FREE OMENTAL FLAP WITH MICROVASCULAR ANA     1,033.43   861.19                 0  90
49999   UNLISTED PROCEDURE, ABDOMEN, PERITONEUM                                    BR 0    0
50010   RENAL EXPLORATION, NOT NECESSITATING OTH       415.55   346.29                 0  90
50020   DRAINAGE OF PERIRENAL OR RENAL ABSCESS;        594.91   495.76                 0  90
50021   DRAINAGE OF PERIRENAL OR RENAL ABSCESS;        599.76   140.00                 0   0
50040   NEPHROSTOMY, NEPHROTOMY WITH DRAINAGE          551.83   459.86                 0  90
50045   NEPHROTOMY, WITH EXPLORATION                   549.41   457.84                 0  90
50060   NEPHROLITHOTOMY; REMOVAL OF CALCULUS           684.69   570.58                 0  90
                                                                                                   Page 134 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
50065   NEPHROLITHOTOMY; SECONDARY SURGICAL OPER      704.62   587.19                 0  90
50070   NEPHROLITHOTOMY; COMPLICATED BY CONGENIT      715.63   596.36                 0  90
50075   NEPHROLITHOTOMY; REMOVAL OF LARGE STAGHO      877.80   731.50                 0  90
50080   PERCUTANEOUS NEPHROSTOLITHOTOMY OR PYELO      524.60   437.17                 0  90
50081   PERCUTANEOUS NEPHROSTOLITHOTOMY OR PYELO      768.23   640.20                 0  90
50100   TRANSECTION OR REPOSITIONING OF ABERRANT      575.39   479.49                 0  90
50120   PYELOTOMY; WITH EXPLORATION                   570.64   475.54                 0  90
50125   PYELOTOMY; WITH DRAINAGE, PYELOSTOMY          597.94   498.29                 0  90
50130   PYELOTOMY; WITH REMOVAL OF CALCULUS (PYE      620.26   516.89                 0  90
50135   PYELOTOMY; COMPLICATED (EG, SECONDARY OP      674.39   561.99                 0  90
50200   RENAL BIOPSY; PERCUTANEOUS, BY TROCAR OR       87.87    73.23                 0   0
50205   RENAL BIOPSY; BY SURGICAL EXPOSURE OF KI      407.30   339.42                 0  90
50220   NEPHRECTOMY, INCLUDING PARTIAL URETERECT      614.74   512.29                 0  90
50225   NEPHRECTOMY, INCLUDING PARTIAL URETERECT      712.99   594.16                 0  90
50230   NEPHRECTOMY, INCLUDING PARTIAL URETERECT      766.78   638.99                 0  90
50234   NEPHRECTOMY WITH TOTAL URETERECTOMY AND       780.44   650.37                 0  90
50236   NEPHRECTOMY WITH TOTAL URETERECTOMY AND       882.77   735.65                 0  90
50240   NEPHRECTOMY, PARTIAL                          790.73   658.95                 0  90
50250   ABLATION, OPEN, ONE OR MORE RENAL MASS L      735.70   613.09                 0  90
50280   EXCISION OR UNROOFING OF CYST(S) OF KIDN      566.40   472.00                 0  90
50290   EXCISION OF PERINEPHRIC CYST                  532.91   444.10                 0  90
50320   DONOR NEPHRECTOMY (INCLUDING COLD PRESER      790.19   658.50                 0  90
50340   RECIPIENT NEPHRECTOMY (SEPARATE PROCEDUR      495.97   413.31                 0  90
50360   RENAL ALLOTRANSPLANTATION, IMPLANTATION     1,331.57 1,109.65                 0  90
50365   RENAL ALLOTRANSPLANTATION, IMPLANTATION     1,494.68 1,245.57                 0  90
50370   REMOVAL OF TRANSPLANTED RENAL ALLOGRAFT       620.00   516.67                 0  90
50380   RENAL AUTOTRANSPLANTATION, REIMPLANTATIO    1,009.16   840.97                 0  90
50382   REMOVAL (VIA SNARE/CAPTURE) AND REPLACEM      889.16   442.00                 0   0
50384   REMOVAL (VIA SNARE/CAPTURE) OF INTERNALL      797.07   427.00                 0   0
                                                                                                   Page 135 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                         DESCRIPTION             FEE      FEE        FEE      BR PA DAYS   E
50385   REMOVAL (VIA SNARE/CAPTURE) AND REPLACEM      850.78   485.00                 0   0
50386   REMOVAL (VIA SNARE/CAPTURE) OF INTERNALL      548.90   376.00                 0   0
50387   REMOVAL AND REPLACEMENT OF EXTERNALLY AC      422.99   214.00                 0   0
50389   REMOVAL OF NEPHROSTOMY TUBE, REQUIRING F      263.27   146.00                 0   0
50390   ASPIRATION AND/OR INJECTION OF RENAL CYS       59.27    49.40                 0   0
50391   INSTILLATION(S) OF THERAPEUTIC AGENT INT       79.66    49.77                 0   0
50392   INTRODUCTION OF INTRACATHETER OR CATHETE      110.72    92.27                 0   0
50393   INTRODUCTION OF URETERAL CATHETER OR STE      134.50   112.08                 0   0
50394   INJECTION PROCEDURE FOR PYELOGRAPHY (AS        72.76    26.59                 0   0
50395   INTRODUCTION OF GUIDE INTO RENAL PELVIS       111.19    92.66                 0   0
50396   MANOMETRIC STUDIES THROUGH NEPHROSTOMY O       72.14    60.12                 0   0
50398   CHANGE OF NEPHROSTOMY OR PYELOSTOMY TUBE      378.45    37.67                 0   0
50400   PYELOPLASTY (FOLEY Y-PYELOPLASTY), PLAST      693.60   578.00                 0  90
50405   PYELOPLASTY (FOLEY Y-PYELOPLASTY), PLAST      834.13   695.11                 0  90
50500   NEPHRORRHAPHY, SUTURE OF KIDNEY WOUND OR      685.40   571.17                 0  90
50520   CLOSURE OF NEPHROCUTANEOUS OR PYELOCUTAN      620.84   517.37                 0  90
50525   CLOSURE OF NEPHROVISCERAL FISTULA (EG, R      791.33   659.44                 0  90
50526   CLOSURE OF NEPHROVISCERAL FISTULA (EG, R      799.19   666.00                 0  90
50540   SYMPHYSIOTOMY FOR HORSESHOE KIDNEY WITH       691.15   575.96                 0  90
50541   LAPAROSCOPY, SURGICAL; ABLATION OF RENAL      554.21   461.84                 0  90
50542   LAPAROSCOPY, SURGICAL; ABLATION OF RENAL      701.14   584.28                 0  90
50543   LAPAROSCOPY, SURGICAL; PARTIAL NEPHRECTO      894.20   745.17                 0  90
50544   LAPAROSCOPY, SURGICAL; PYELOPLASTY            755.92   629.93                 0  90
50545   LAPAROSCOPY, SURGICAL; RADICAL NEPHRECTO      809.65   674.71                 0  90
50546   LAPAROSCOPY, SURGICAL; NEPHRECTOMY, INCL      719.79   599.83                 0  90
50547   LAPAROSCOPY, SURGICAL; DONOR NEPHRECTOMY      887.90   739.92                 0  90
50548   LAPAROSCOPY, SURGICAL; NEPHRECTOMY WITH       816.32   680.27                 0  90
50549   UNLISTED LAPAROSCOPY PROCEDURE, RENAL                                     BR 0    0
50551   RENAL ENDOSCOPY THROUGH ESTABLISHED NEPH      230.54   149.87                 0   0
                                                                                                   Page 136 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
50553   RENAL ENDOSCOPY THROUGH ESTABLISHED NEPH      239.91   158.29                 0   0
50555   RENAL ENDOSCOPY THROUGH ESTABLISHED NEPH      264.95   174.23                 0   0
50557   RENAL ENDOSCOPY THROUGH ESTABLISHED NEPH      266.51   176.15                 0   0
50561   RENAL ENDOSCOPY THROUGH ESTABLISHED NEPH      300.82   201.05                 0   0
50562   RENAL ENDOSCOPY THROUGH ESTABLISHED NEPH      357.97   298.31                 0  90
50570   RENAL ENDOSCOPY THROUGH NEPHROTOMY OR PY      300.26   250.22                 0   0
50572   RENAL ENDOSCOPY THROUGH NEPHROTOMY OR PY      326.19   271.83                 0   0
50574   RENAL ENDOSCOPY THROUGH NEPHROTOMY OR PY      346.93   289.11                 0   0
50575   RENAL ENDOSCOPY THROUGH NEPHROTOMY OR PY      437.22   364.35                 0   0
50576   RENAL ENDOSCOPY THROUGH NEPHROTOMY OR PY      345.23   287.69                 0   0
50580   RENAL ENDOSCOPY THROUGH NEPHROTOMY OR PY      371.82   309.85                 0   0
50590   LITHOTRIPSY, EXTRACORPOREAL SHOCK WAVE        574.36   281.12                 0  90
50592   ABLATION, ONE OR MORE RENAL TUMOR(S), PE    2,911.92   184.46                 0  10
50593   ABLATION, RENAL TUMOR(S), UNILATERAL, PE                                  BR 0   10
50600   URETEROTOMY WITH EXPLORATION OR DRAINAGE      560.00   466.67                 0  90
50605   URETEROTOMY FOR INSERTION OF INDWELLING       552.42   460.35                 0  90
50610   URETEROLITHOTOMY; UPPER ONE-THIRD OF URE      577.72   481.43                 0  90
50620   URETEROLITHOTOMY; MIDDLE ONE-THIRD OF UR      543.85   453.21                 0  90
50630   URETEROLITHOTOMY; LOWER ONE-THIRD OF URE      530.79   442.33                 0  90
50650   URETERECTOMY, WITH BLADDER CUFF (SEPARAT      620.00   516.67                 0  90
50660   URETERECTOMY, TOTAL, ECTOPIC URETER, COM      686.78   572.32                 0  90
50684   INJECTION PROCEDURE FOR URETEROGRAPHY OR      126.67    25.16                 0   0
50686   MANOMETRIC STUDIES THROUGH URETEROSTOMY       103.93    44.56                 0   0
50688   CHANGE OF URETEROSTOMY TUBE OR EXTERNALL       50.53    42.11                 0  10
50690   INJECTION PROCEDURE FOR VISUALIZATION OF       65.57    35.98                 0   0
50700   URETEROPLASTY, PLASTIC OPERATION ON URET      561.56   467.97                 0  90
50715   URETEROLYSIS, WITH OR WITHOUT REPOSITION      678.74   565.62                 0  90
50722   URETEROLYSIS FOR OVARIAN VEIN SYNDROME        591.59   492.99                 0  90
50725   URETEROLYSIS FOR RETROCAVAL URETER, WITH      650.84   542.37                 0  90
                                                                                                   Page 137 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
50727   REVISION OF URINARY-CUTANEOUS ANASTOMOSI      303.37   252.81                 0  90
50728   REVISION OF URINARY-CUTANEOUS ANASTOMOSI      418.76   348.97                 0  90
50740   URETEROPYELOSTOMY, ANASTOMOSIS OF URETER      656.20   546.84                 0  90
50750   URETEROCALYCOSTOMY, ANASTOMOSIS OF URETE      695.39   579.50                 0  90
50760   URETEROURETEROSTOMY                           657.35   547.79                 0  90
50770   TRANSURETEROURETEROSTOMY, ANASTOMOSIS OF      694.51   578.76                 0  90
50780   URETERONEOCYSTOSTOMY; ANASTOMOSIS OF SIN      655.85   546.55                 0  90
50782   URETERONEOCYSTOSTOMY; ANASTOMOSIS OF DUP      663.89   553.25                 0  90
50783   URETERONEOCYSTOSTOMY; WITH EXTENSIVE URE      689.11   574.26                 0  90
50785   URETERONEOCYSTOSTOMY; WITH VESICO-PSOAS       722.76   602.30                 0  90
50800   URETEROENTEROSTOMY, DIRECT ANASTOMOSIS O      550.33   458.61                 0  90
50810   URETEROSIGMOIDOSTOMY, WITH CREATION OF S      750.77   625.65                 0  90
50815   URETEROCOLON CONDUIT, INCLUDING INTESTIN      729.71   608.10                 0  90
50820   URETEROILEAL CONDUIT (ILEAL BLADDER), IN      782.50   652.08                 0  90
50825   CONTINENT DIVERSION, INCLUDING INTESTINE      989.11   824.26                 0  90
50830   URINARY UNDIVERSION (EG, TAKING DOWN OF     1,080.53   900.45                 0  90
50840   REPLACEMENT OF ALL OR PART OF URETER BY       736.36   613.63                 0  90
50845   CUTANEOUS APPENDICO-VESICOSTOMY               746.45   622.04                 0  90
50860   URETEROSTOMY, TRANSPLANTATION OF URETER       569.40   474.50                 0  90
50900   URETERORRHAPHY, SUTURE OF URETER (SEPARA      503.15   419.30                 0  90
50920   CLOSURE OF URETEROCUTANEOUS FISTULA           527.81   439.84                 0  90
50930   CLOSURE OF URETEROVISCERAL FISTULA (INCL      652.60   543.84                 0  90
50940   DELIGATION OF URETER                          524.89   437.41                 0  90
50945   LAPAROSCOPY, SURGICAL; URETEROLITHOTOMY       596.11   496.76                 0  90
50947   LAPAROSCOPY, SURGICAL; URETERONEOCYSTOST      842.23   701.86                 0  90
50948   LAPAROSCOPY, SURGICAL; URETERONEOCYSTOST      766.43   638.69                 0  90
50949   UNLISTED LAPAROSCOPY PROCEDURE, URETER                                    BR 0    0
50951   URETERAL ENDOSCOPY THROUGH ESTABLISHED U      240.31   156.17                 0   0
50953   URETERAL ENDOSCOPY THROUGH ESTABLISHED U      251.81   171.29                 0   0
                                                                                                   Page 138 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
50955   URETERAL ENDOSCOPY THROUGH ESTABLISHED U      290.68   186.66                 0   0
50957   URETERAL ENDOSCOPY THROUGH ESTABLISHED U      271.44   180.88                 0   0
50961   URETERAL ENDOSCOPY THROUGH ESTABLISHED U      244.47   161.48                 0   0
50970   URETERAL ENDOSCOPY THROUGH URETEROTOMY,       227.35   189.46                 0   0
50972   URETERAL ENDOSCOPY THROUGH URETEROTOMY,       219.36   182.80                 0   0
50974   URETERAL ENDOSCOPY THROUGH URETEROTOMY,       286.04   238.37                 0   0
50976   URETERAL ENDOSCOPY THROUGH URETEROTOMY,       284.20   236.84                 0   0
50980   URETERAL ENDOSCOPY THROUGH URETEROTOMY,       217.96   181.64                 0   0
51020   CYSTOTOMY OR CYSTOSTOMY; WITH FULGURATIO      278.59   240.00                 0  90
51030   CYSTOTOMY OR CYSTOSTOMY; WITH CRYOSURGIC      278.70   240.00                 0  90
51040   CYSTOSTOMY, CYSTOTOMY WITH DRAINAGE           200.00   200.00                 0  90
51045   CYSTOTOMY, WITH INSERTION OF URETERAL CA      280.06   233.39                 0  90
51050   CYSTOLITHOTOMY, CYSTOTOMY WITH REMOVAL O      281.85   234.88                 0  90
51060   TRANSVESICAL URETEROLITHOTOMY                 348.74   290.62                 0  90
51065   CYSTOTOMY, WITH CALCULUS BASKET EXTRACTI      345.04   287.53                 0  90
51080   DRAINAGE OF PERIVESICAL OR PREVESICAL SP      244.69   203.91                 0  90
51100   ASPIRATION OF BLADDER; BY NEEDLE               39.76    20.00                 0   0
51101   ASPIRATION OF BLADDER; BY TROCAR OR INTR       82.42    26.23                 0   0
51102   ASPIRATION OF BLADDER; WITH INSERTION OF      210.32   126.46                 0   0
51500   EXCISION OF URACHAL CYST OR SINUS, WITH       378.47   315.39                 0  90
51520   CYSTOTOMY; FOR SIMPLE EXCISION OF VESICA      356.39   296.99                 0  90
51525   CYSTOTOMY; FOR EXCISION OF BLADDER DIVER      513.80   428.17                 0  90
51530   CYSTOTOMY; FOR EXCISION OF BLADDER TUMOR      462.43   385.36                 0  90
51535   CYSTOTOMY FOR EXCISION, INCISION, OR REP      474.59   395.50                 0  90
51550   CYSTECTOMY, PARTIAL; SIMPLE                   568.40   473.67                 0  90
51555   CYSTECTOMY, PARTIAL; COMPLICATED (EG, PO      754.48   628.74                 0  90
51565   CYSTECTOMY, PARTIAL, WITH REIMPLANTATION      775.46   646.22                 0  90
51570   CYSTECTOMY, COMPLETE; (SEPARATE PROCEDUR      881.92   734.93                 0  90
51575   CYSTECTOMY, COMPLETE; WITH BILATERAL PEL    1,092.99   910.83                 0  90
                                                                                                     Page 139 of 189


                                                                                                 C
                                                     NON-                                        H
                                                                                                 A
                                                   FACILITY FACILITY PROFESSIONAL                N
                                                   GLOBAL GLOBAL      COMPONENT            FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE        BR PA DAYS   E
51580   CYSTECTOMY, COMPLETE, WITH URETEROSIGMOI    1,137.65   948.04                   0  90
51585   CYSTECTOMY, COMPLETE, WITH URETEROSIGMOI    1,265.61 1,054.68                   0  90
51590   CYSTECTOMY, COMPLETE, WITH URETEROILEAL     1,156.24   963.54                   0  90
51595   CYSTECTOMY, COMPLETE, WITH URETEROILEAL     1,312.18 1,093.48                   0  90
51596   CYSTECTOMY, COMPLETE, WITH CONTINENT DIV    1,408.78 1,173.99                   0  90
51597   PELVIC EXENTERATION, COMPLETE, FOR VESIC    1,363.72 1,136.43                   0  90
51600   INJECTION PROCEDURE FOR CYSTOGRAPHY OR V      133.39    22.35                   0   0
51605   INJECTION PROCEDURE AND PLACEMENT OF CHA       23.47    19.56                   0   0
51610   INJECTION PROCEDURE FOR RETROGRADE URETH       74.57    32.41                   0   0
51700   BLADDER IRRIGATION, SIMPLE, LAVAGE AND/O       57.34    22.35                   0   0
51703   INSERTION OF TEMPORARY INDWELLING BLADDE       93.67    40.73               BR 0    0
51710   CHANGE OF CYSTOSTOMY TUBE; COMPLICATED        107.63    47.45               BR 0   10
51715   ENDOSCOPIC INJECTION OF IMPLANT MATERIAL      184.90   100.35                   0   0
51720   BLADDER INSTILLATION OF ANTICARCINOGENIC       75.08    42.67                   0   0
51725   SIMPLE CYSTOMETROGRAM (CMG) (EG, SPINAL       194.07   194.07         57.89     0   0
51726   COMPLEX CYSTOMETROGRAM (EG, CALIBRATED E      273.68   273.68         65.85     0   0
51727   COMPLEX CYSTOMETROGRAM (IE, CALIBRATED E      181.41   181.41         65.21     0   0
51728   COMPLEX CYSTOMETROGRAM (IE, CALIBRATED E      181.29   181.29         64.40     0   0
51729   COMPLEX CYSTOMETROGRAM (IE, CALIBRATED E      194.92   194.92         76.65     0   0
51736   SIMPLE UROFLOWMETRY (UFR) (EG, STOP-WATC       40.71    40.71         23.81     0   0
51741   COMPLEX UROFLOWMETRY (EG, CALIBRATED ELE       63.74    63.74         44.11     0   0
51784   ELECTROMYOGRAPHY STUDIES (EMG) OF ANAL O      168.20   168.20         58.78     0   0
51785   NEEDLE ELECTROMYOGRAPHY STUDIES (EMG) OF      181.76   181.76         58.50     0   0
51792   STIMULUS EVOKED RESPONSE (EG, MEASUREMEN      203.54   203.54         42.37     0   0
51797   VOIDING PRESSURE STUDIES, INTRA-ABDOMINA      151.49   151.49         36.26     0   0
51798   MEASUREMENT OF POST-VOIDING RESIDUAL URI       13.36    11.14                   0   0
51800   CYSTOPLASTY OR CYSTOURETHROPLASTY, PLAST      624.64   520.53                   0  90
51820   CYSTOURETHROPLASTY WITH UNILATERAL OR BI      657.32   547.77                   0  90
51840   ANTERIOR VESICOURETHROPEXY, OR URETHROPE      393.22   327.68                   0  90
                                                                                                   Page 140 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                      DESCRIPTION                FEE      FEE        FEE      BR PA DAYS   E
51841   ANTERIOR VESICOURETHROPEXY, OR URETHROPE      468.39   390.33                 0  90
51845   ABDOMINO-VAGINAL VESICAL NECK SUSPENSION      353.97   294.98                 0  90
51860   CYSTORRHAPHY, SUTURE OF BLADDER WOUND, I      434.78   362.32                 0  90
51865   CYSTORRHAPHY, SUTURE OF BLADDER WOUND, I      532.46   443.72                 0  90
51880   CLOSURE OF CYSTOSTOMY (SEPARATE PROCEDUR      282.41   235.35                 0  90
51900   CLOSURE OF VESICOVAGINAL FISTULA, ABDOMI      495.40   412.84                 0  90
51920   CLOSURE OF VESICOUTERINE FISTULA;             465.50   387.92                 0  90
51925   CLOSURE OF VESICOUTERINE FISTULA; WITH H      658.57   548.81                 0  90
51940   CLOSURE, EXSTROPHY OF BLADDER                 963.37   802.81                 0  90
51960   ENTEROCYSTOPLASTY, INCLUDING INTESTINAL       828.18   690.15                 0  90
51980   CUTANEOUS VESICOSTOMY                         426.14   355.12                 0  90
51990   LAPAROSCOPY, SURGICAL; URETHRAL SUSPENSI      450.53   375.44                 0  90
51992   LAPAROSCOPY, SURGICAL; SLING OPERATION F      489.67   408.06                 0  90
51999   UNLISTED LAPAROSCOPY PROCEDURE, BLADDER                                   BR 0    0
52000   CYSTOURETHROSCOPY (SEPARATE PROCEDURE)        134.21    61.60                 0   0
52001   CYSTOURETHROSCOPY WITH IRRIGATION AND EV      244.29   145.33                 0   0
52005   CYSTOURETHROSCOPY, WITH URETERAL CATHETE      191.30    66.72                 0   0
52007   CYSTOURETHROSCOPY, WITH URETERAL CATHETE      400.81    83.79                 0   0
52010   CYSTOURETHROSCOPY, WITH EJACULATORY DUCT      298.20    83.60                 0   0
52204   CYSTOURETHROSCOPY, WITH BIOPSY(S)             337.47    70.59                 0   0
52214   CYSTOURETHROSCOPY, WITH FULGURATION (INC      795.37   100.23                 0   0
52224   CYSTOURETHROSCOPY, WITH FULGURATION (INC      752.60    85.91                 0   0
52234   CYSTOURETHROSCOPY, WITH FULGURATION (INC      149.96   124.97                 0   0
52235   CYSTOURETHROSCOPY, WITH FULGURATION (INC      176.12   146.77                 0   0
52240   CYSTOURETHROSCOPY, WITH FULGURATION (INC      307.64   256.37                 0   0
52250   CYSTOURETHROSCOPY WITH INSERTION OF RADI      147.20   122.67                 0   0
52260   CYSTOURETHROSCOPY, WITH DILATION OF BLAD      127.10   105.92                 0   0
52265   CYSTOURETHROSCOPY, WITH DILATION OF BLAD      321.41    80.59                 0   0
52270   CYSTOURETHROSCOPY, WITH INTERNAL URETHRO      296.23    92.21                 0   0
                                                                                                   Page 141 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                      DESCRIPTION                FEE      FEE        FEE      BR PA DAYS   E
52275   CYSTOURETHROSCOPY, WITH INTERNAL URETHRO      409.04   126.13                 0   0
52276   CYSTOURETHROSCOPY WITH DIRECT VISION INT      161.52   134.60                 0   0
52277   CYSTOURETHROSCOPY, WITH RESECTION OF EXT      198.49   165.41                 0   0
52281   CYSTOURETHROSCOPY, WITH CALIBRATION AND/      214.07    78.31                 0   0
52282   CYSTOURETHROSCOPY, WITH INSERTION OF URE      204.56   170.47                 0   0
52283   CYSTOURETHROSCOPY, WITH STEROID INJECTIO      180.29   101.43                 0   0
52285   CYSTOURETHROSCOPY FOR TREATMENT OF THE F      181.93    98.49                 0   0
52290   CYSTOURETHROSCOPY; WITH URETERAL MEATOTO      148.57   123.81                 0   0
52300   CYSTOURETHROSCOPY; WITH RESECTION OR FUL      171.64   143.03                 0   0
52301   CYSTOURETHROSCOPY; WITH RESECTION OR FUL      179.83   149.86                 0   0
52305   CYSTOURETHROSCOPY; WITH INCISION OR RESE      170.16   141.80                 0   0
52310   CYSTOURETHROSCOPY, WITH REMOVAL OF FOREI      168.79    80.00                 0   0
52315   CYSTOURETHROSCOPY, WITH REMOVAL OF FOREI      302.72   145.00                 0   0
52317   LITHOLAPAXY: CRUSHING OR FRAGMENTATION O      714.05   200.00                 0   0
52318   LITHOLAPAXY: CRUSHING OR FRAGMENTATION O      289.70   250.00                 0   0
52320   CYSTOURETHROSCOPY (INCLUDING URETERAL CA      150.37   125.31                 0   0
52325   CYSTOURETHROSCOPY (INCLUDING URETERAL CA      195.77   163.15                 0   0
52327   CYSTOURETHROSCOPY (INCLUDING URETERAL CA      530.90   134.57                 0   0
52330   CYSTOURETHROSCOPY (INCLUDING URETERAL CA      839.99   134.33                 0   0
52332   CYSTOURETHROSCOPY, WITH INSERTION OF IND      285.89    78.68                 0   0
52334   CYSTOURETHROSCOPY WITH INSERTION OF URET      156.07   130.06                 0   0
52341   CYSTOURETHROSCOPY; WITH TREATMENT OF URE      199.06   165.88                 0   0
52342   CYSTOURETHROSCOPY; WITH TREATMENT OF URE      214.11   178.43                 0   0
52343   CYSTOURETHROSCOPY; WITH TREATMENT OF INT      235.51   196.26                 0   0
52344   CYSTOURETHROSCOPY WITH URETEROSCOPY; WIT      254.23   211.86                 0   0
52345   CYSTOURETHROSCOPY WITH URETEROSCOPY; WIT      269.53   224.61                 0   0
52346   CYSTOURETHROSCOPY WITH URETEROSCOPY; WIT      301.06   250.89                 0   0
52351   CYSTOURETHROSCOPY, WITH URETEROSCOPY AND      191.30   159.42                 0   0
52352   CYSTOURETHROSCOPY, WITH URETEROSCOPY AND      224.54   199.00                 0   0
                                                                                                   Page 142 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
52353   CYSTOURETHROSCOPY, WITH URETEROSCOPY AND      258.43   220.00                 0   0
52354   CYSTOURETHROSCOPY, WITH URETEROSCOPY AND      238.91   199.10                 0   0
52355   CYSTOURETHROSCOPY, WITH URETEROSCOPY AND      284.78   237.32                 0   0
52400   CYSTOURETHROSCOPY WITH INCISION, FULGURA      332.81   277.34                 0  90
52402   CYSTOURETHROSCOPY WITH TRANSURETHRAL RES      163.76   136.47                 0   0
52450   TRANSURETHRAL INCISION OF PROSTATE            280.57   233.81                 0  90
52500   TRANSURETHRAL RESECTION OF BLADDER NECK       329.40   274.50                 0  90
52601   TRANSURETHRAL ELECTROSURGICAL RESECTION       494.57   412.15                 0  90
52630   TRANSURETHRAL RESECTION; RESIDUAL OR REG      320.00   320.00                 0  90
52640   TRANSURETHRAL RESECTION; OF POSTOPERATIV      242.03   201.69                 0  90
52647   LASER COAGULATION OF PROSTATE, INCLUDING    1,670.69   320.40                 0  90
52648   LASER VAPORIZATION OF PROSTATE, INCLUDIN    1,696.07   341.96                 0  90
52649   LASER ENUCLEATION OF THE PROSTATE WITH M      604.45   503.71                 0  90
52700   TRANSURETHRAL DRAINAGE OF PROSTATIC ABSC      261.07   217.56                 0  90
53000   URETHROTOMY OR URETHROSTOMY, EXTERNAL (S       91.49    76.24                 0  10
53010   URETHROTOMY OR URETHROSTOMY, EXTERNAL (S      177.08   147.57                 0  90
53020   MEATOTOMY, CUTTING OF MEATUS (SEPARATE P       59.00    49.17                 0   0
53025   MEATOTOMY, CUTTING OF MEATUS (SEPARATE P       41.21    34.35                 0   0
53040   DRAINAGE OF DEEP PERIURETHRAL ABSCESS         239.13   199.28                 0  90
53060   DRAINAGE OF SKENE'S GLAND ABSCESS OR CYS      111.72    79.98                 0  10
53080   DRAINAGE OF PERINEAL URINARY EXTRAVASATI      285.32   237.77                 0  90
53085   DRAINAGE OF PERINEAL URINARY EXTRAVASATI      391.59   326.33                 0  90
53200   BIOPSY OF URETHRA                              94.49    71.15                 0   0
53210   URETHRECTOMY, TOTAL, INCLUDING CYSTOSTOM      464.72   387.27                 0  90
53215   URETHRECTOMY, TOTAL, INCLUDING CYSTOSTOM      559.75   466.46                 0  90
53220   EXCISION OR FULGURATION OF CARCINOMA OF       271.70   226.42                 0  90
53230   EXCISION OF URETHRAL DIVERTICULUM (SEPAR      363.15   302.63                 0  90
53235   EXCISION OF URETHRAL DIVERTICULUM (SEPAR      383.15   319.30                 0  90
53240   MARSUPIALIZATION OF URETHRAL DIVERTICULU      257.56   214.64                 0  90
                                                                                                   Page 143 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
53250   EXCISION OF BULBOURETHRAL GLAND (COWPER'      236.44   197.04                 0  90
53260   EXCISION OR FULGURATION; URETHRAL POLYP(      124.63    89.09                 0  10
53265   EXCISION OR FULGURATION; URETHRAL CARUNC      138.98    92.85                 0  10
53270   EXCISION OR FULGURATION; SKENE'S GLANDS       127.58    93.19                 0  10
53275   EXCISION OR FULGURATION; URETHRAL PROLAP      161.65   134.71                 0  10
53400   URETHROPLASTY; FIRST STAGE, FOR FISTULA,      482.01   401.68                 0  90
53405   URETHROPLASTY; SECOND STAGE (FORMATION O      525.83   438.19                 0  90
53410   URETHROPLASTY, ONE-STAGE RECONSTRUCTION       589.59   491.33                 0  90
53415   URETHROPLASTY, TRANSPUBIC OR PERINEAL, O      671.95   559.96                 0  90
53420   URETHROPLASTY, TWO-STAGE RECONSTRUCTION       493.27   411.06                 0  90
53425   URETHROPLASTY, TWO-STAGE RECONSTRUCTION       566.53   472.11                 0  90
53430   URETHROPLASTY, RECONSTRUCTION OF FEMALE       573.18   477.65                 0  90
53431   URETHROPLASTY WITH TUBULARIZATION OF POS      695.12   579.27                 0  90
53440   SLING OPERATION FOR CORRECTION OF MALE U      521.18   434.32                 0  90
53442   REMOVAL OR REVISION OF SLING FOR MALE UR                                  BR 0   90
53444   INSERTION OF TANDEM CUFF (DUAL CUFF)          479.04   399.20                 0  90
53445   INSERTION OF INFLATABLE URETHRAL/BLADDER      527.44   439.54                 0  90
53446   REMOVAL OF INFLATABLE URETHRAL/BLADDER N      388.77   323.98                 0  90
53447   REMOVAL AND REPLACEMENT OF INFLATABLE UR      492.19   410.16                 0  90
53448   REMOVAL AND REPLACEMENT OF INFLATABLE UR      771.36   642.80                 0  90
53449   REPAIR OF INFLATABLE URETHRAL/BLADDER NE                                  BR 0   90
53450   URETHROMEATOPLASTY, WITH MUCOSAL ADVANCE      244.62   203.85                 0  90
53460   URETHROMEATOPLASTY, WITH PARTIAL EXCISIO      274.97   229.14                 0  90
53500   URETHROLYSIS, TRANSVAGINAL, SECONDARY, O      450.37   375.31                 0  90
53502   URETHRORRHAPHY, SUTURE OF URETHRAL WOUND                                  BR 0   90
53505   URETHRORRHAPHY, SUTURE OF URETHRAL WOUND      292.45   243.71                 0  90
53510   URETHRORRHAPHY, SUTURE OF URETHRAL WOUND      385.36   321.13                 0  90
53515   URETHRORRHAPHY, SUTURE OF URETHRAL WOUND      482.21   401.84                 0  90
53520   CLOSURE OF URETHROSTOMY OR URETHROCUTANE      335.84   279.87                 0  90
                                                                                                   Page 144 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
53600   DILATION OF URETHRAL STRICTURE BY PASSAG       54.88    32.60                 0   0
53601   DILATION OF URETHRAL STRICTURE BY PASSAG       53.99    26.94                 0   0
53605   DILATION OF URETHRAL STRICTURE OR VESICA       39.53    32.94                 0   0
53620   DILATION OF URETHRAL STRICTURE BY PASSAG       81.14    44.24                 0   0
53621   DILATION OF URETHRAL STRICTURE BY PASSAG       77.57    36.75                 0   0
53660   DILATION OF FEMALE URETHRA INCLUDING SUP       47.96    20.90                 0   0
53661   DILATION OF FEMALE URETHRA INCLUDING SUP       47.72    20.28                 0   0
53665   DILATION OF FEMALE URETHRA, GENERAL OR C       23.27    19.40                 0   0
53850   TRANSURETHRAL DESTRUCTION OF PROSTATE TI    1,982.91   282.78                 0  90
53852   TRANSURETHRAL DESTRUCTION OF PROSTATE TI    1,897.30   307.63                 0  90
53855   INSERTION OF A TEMPORARY PROSTATIC URETH      418.28    42.13                 0   0
53860   TRANSURETHRAL RADIOFREQUENCY MICRO-REMOD      704.93   180.44                 0  90
53899   UNLISTED PROCEDURE, URINARY SYSTEM                                        BR 0    0
54000   SLITTING OF PREPUCE, DORSAL OR LATERAL (      103.13    53.13                 0  10
54001   SLITTING OF PREPUCE, DORSAL OR LATERAL (      125.35    68.97                 0  10
54015   INCISION AND DRAINAGE OF PENIS, DEEP          188.09   156.75                 0  10
54050   DESTRUCTION OF LESION(S), PENIS (EG, CON       73.79    47.75                 0  10
54055   DESTRUCTION OF LESION(S), PENIS (EG, CON       70.39    43.28                 0  10
54056   DESTRUCTION OF LESION(S), PENIS (EG, CON       77.03    49.84                 0  10
54057   DESTRUCTION OF LESION(S), PENIS (EG, CON       87.31    45.68                 0  10
54060   DESTRUCTION OF LESION(S), PENIS (EG, CON      119.07    63.34                 0  10
54065   DESTRUCTION OF LESION(S), PENIS (EG, CON                                  BR 0   10
54100   BIOPSY OF PENIS; (SEPARATE PROCEDURE)         116.75    56.48                 0   0
54105   BIOPSY OF PENIS; DEEP STRUCTURES              178.87   109.06                 0  10
54110   EXCISION OF PENILE PLAQUE (PEYRONIE DISE      377.58   314.65                 0  90
54111   EXCISION OF PENILE PLAQUE (PEYRONIE DISE      482.89   402.41                 0  90
54112   EXCISION OF PENILE PLAQUE (PEYRONIE DISE      566.47   472.06                 0  90
54115   REMOVAL FOREIGN BODY FROM DEEP PENILE TI      273.71   210.25                 0  90
54120   AMPUTATION OF PENIS; PARTIAL                  377.55   314.63                 0  90
                                                                                                     Page 145 of 189


                                                                                                 C
                                                     NON-                                        H
                                                                                                 A
                                                   FACILITY FACILITY PROFESSIONAL                N
                                                   GLOBAL GLOBAL      COMPONENT            FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE        BR PA DAYS   E
54125   AMPUTATION OF PENIS; COMPLETE                 486.91   405.76                   0  90
54130   AMPUTATION OF PENIS, RADICAL; WITH BILAT      718.96   599.13                   0  90
54135   AMPUTATION OF PENIS, RADICAL; IN CONTINU      912.21   760.18                   0  90
54150   CIRCUMCISION, USING CLAMP OR OTHER DEVIC      119.33    50.22                   0   0
54160   CIRCUMCISION, SURGICAL EXCISION OTHER TH      152.96    72.29                   0  10
54161   OLDER THAN 28 DAYS OF AGE                     118.64    98.87                   0  10
54162   LYSIS OR EXCISION OF PENILE POST-CIRCUMC      178.02    97.49                   0  10
54163   REPAIR INCOMPLETE CIRCUMCISION                131.26   109.39                   0  10
54164   FRENULOTOMY OF PENIS                          115.96    96.64                   0  10
54200   INJECTION PROCEDURE FOR PEYRONIE DISEASE       70.82    43.23                   0  10
54205   INJECTION PROCEDURE FOR PEYRONIE DISEASE      325.03   270.86                   0  90
54220   IRRIGATION OF CORPORA CAVERNOSA FOR PRIA      141.29    67.90                   0   0
54230   INJECTION PROCEDURE FOR CORPORA CAVERNOS       59.89    40.27                   0   0
54240   PENILE PLETHYSMOGRAPHY                         76.85    76.85         50.24     0   0
54250   NOCTURNAL PENILE TUMESCENCE AND/OR RIGID       94.15    94.15         84.98     0   0
54300   PLASTIC OPERATION OF PENIS FOR STRAIGHTE      394.12   328.43                   0  90
54304   PLASTIC OPERATION ON PENIS FOR CORRECTIO      461.86   384.89                   0  90
54308   URETHROPLASTY FOR SECOND STAGE HYPOSPADI      405.68   338.07                   0  90
54312   URETHROPLASTY FOR SECOND STAGE HYPOSPADI      516.16   430.13                   0  90
54316   URETHROPLASTY FOR SECOND STAGE HYPOSPADI      612.40   510.34                   0  90
54318   URETHROPLASTY FOR THIRD STAGE HYPOSPADIA      412.40   343.67                   0  90
54322   ONE STAGE DISTAL HYPOSPADIAS REPAIR (WIT      480.57   400.48                   0  90
54324   ONE STAGE DISTAL HYPOSPADIAS REPAIR (WIT      598.42   498.69                   0  90
54326   ONE STAGE DISTAL HYPOSPADIAS REPAIR (WIT      577.73   481.45                   0  90
54328   ONE STAGE DISTAL HYPOSPADIAS REPAIR (WIT      569.33   474.44                   0  90
54332   ONE STAGE PROXIMAL PENILE OR PENOSCROTAL      617.91   514.93                   0  90
54336   ONE STAGE PERINEAL HYPOSPADIAS REPAIR RE      703.72   586.43                   0  90
54340   REPAIR OF HYPOSPADIAS COMPLICATIONS (IE,      350.01   291.68                   0  90
54344   REPAIR OF HYPOSPADIAS COMPLICATIONS (IE,      592.27   493.56                   0  90
                                                                                                   Page 146 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
54348   REPAIR OF HYPOSPADIAS COMPLICATIONS (IE,      625.55   521.30                 0  90
54352   REPAIR OF HYPOSPADIAS CRIPPLE REQUIRING       889.89   741.58                 0  90
54360   PLASTIC OPERATION ON PENIS TO CORRECT AN      442.89   369.08                 0  90
54380   PLASTIC OPERATION ON PENIS FOR EPISPADIA      487.22   406.02                 0  90
54385   PLASTIC OPERATION ON PENIS FOR EPISPADIA                                  BR 0   90
54390   PLASTIC OPERATION ON PENIS FOR EPISPADIA      702.72   585.60                 0  90
54400   INSERTION OF PENILE PROSTHESIS; NON-INFL      324.04   270.04                 1  90
54401   INSERTION OF PENILE PROSTHESIS; INFLATAB      396.45   330.38                 1  90
54405   INSERTION OF MULTI-COMPONENT, INFLATABLE      487.70   406.42                 1  90
54406   REMOVAL OF ALL COMPONENTS OF A MULTI-COM      440.00   366.67                 0  90
54408   REPAIR OF COMPONENT(S) OF A MULTI-COMPON      472.40   393.67                 1  90
54410   REMOVAL AND REPLACEMENT OF ALL COMPONENT      557.34   464.45                 1  90
54411   REMOVAL AND REPLACEMENT OF ALL COMPONENT      610.06   508.38                 1  90
54415   REMOVAL OF NON-INFLATABLE (SEMI-RIGID) O      317.21   264.34                 0  90
54416   REMOVAL AND REPLACEMENT OF NON-INFLATABL      422.87   352.39                 1  90
54417   REMOVAL AND REPLACEMENT OF NON-INFLATABL      535.59   446.33                 1  90
54420   CORPORA CAVERNOSA-SAPHENOUS VEIN SHUNT (      427.94   356.62                 0  90
54430   CORPORA CAVERNOSA-CORPUS SPONGIOSUM SHUN      387.50   322.92                 0  90
54435   CORPORA CAVERNOSA-GLANS PENIS FISTULIZAT      252.44   210.37                 0  90
54440   PLASTIC OPERATION OF PENIS FOR INJURY                                     BR 0   90
54450   FORESKIN MANIPULATION INCLUDING LYSIS OF       46.89    30.05                 0   0
54500   BIOPSY OF TESTIS, NEEDLE (SEPARATE PROCE       45.14    37.62                 0   0
54505   BIOPSY OF TESTIS, INCISIONAL (SEPARATE P      130.63   108.86                 0  10
54512   EXCISION OF EXTRAPARENCHYMAL LESION OF T      324.04   270.03                 0  90
54520   ORCHIECTOMY, SIMPLE (INCLUDING SUBCAPSUL      198.28   165.23                 0  90
54522   ORCHIECTOMY, PARTIAL                          355.63   296.36                 0  90
54530   ORCHIECTOMY, RADICAL, FOR TUMOR; INGUINA      331.59   276.33                 0  90
54535   ORCHIECTOMY, RADICAL, FOR TUMOR; WITH AB      440.90   367.42                 0  90
54550   EXPLORATION FOR UNDESCENDED TESTIS (INGU      293.87   244.90                 0  90
                                                                                                   Page 147 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
54560   EXPLORATION FOR UNDESCENDED TESTIS WITH       412.37   343.64                 0  90
54600   REDUCTION OF TORSION OF TESTIS, SURGICAL      271.89   226.58                 0  90
54620   FIXATION OF CONTRALATERAL TESTIS (SEPARA      183.16   152.64                 0  10
54640   ORCHIOPEXY, INGUINAL APPROACH, WITH OR W      280.22   233.52                 0  90
54650   ORCHIOPEXY, ABDOMINAL APPROACH, FOR INTR      411.95   343.30                 0  90
54660   INSERTION OF TESTICULAR PROSTHESIS (SEPA      215.38   179.48                 0  90
54670   SUTURE OR REPAIR OF TESTICULAR INJURY         247.11   205.93                 0  90
54680   TRANSPLANTATION OF TESTIS(ES) TO THIGH (      480.23   400.19                 0  90
54690   LAPAROSCOPY, SURGICAL; ORCHIECTOMY            388.96   324.13                 0  90
54692   LAPAROSCOPY, SURGICAL; ORCHIOPEXY FOR IN      467.23   389.36                 0  90
54699   UNLISTED LAPAROSCOPY PROCEDURE, TESTIS                                    BR 0    0
54700   INCISION AND DRAINAGE OF EPIDIDYMIS, TES      129.66   108.05                 0  10
54800   BIOPSY OF EPIDIDYMIS, NEEDLE                   78.76    65.63                 0   0
54830   EXCISION OF LOCAL LESION OF EPIDIDYMIS        221.26   184.39                 0  90
54840   EXCISION OF SPERMATOCELE, WITH OR WITHOU      195.88   163.23                 0  90
54860   EPIDIDYMECTOMY; UNILATERAL                    250.50   208.75                 0  90
54861   EPIDIDYMECTOMY; BILATERAL                     339.44   282.87                 0  90
54865   EXPLORATION OF EPIDIDYMIS, WITH OR WITHO      213.22   177.68                 0  90
55000   PUNCTURE ASPIRATION OF HYDROCELE, TUNICA       79.91    42.39                 0   0
55040   EXCISION OF HYDROCELE; UNILATERAL             203.90   169.92                 0  90
55041   EXCISION OF HYDROCELE; BILATERAL              303.81   253.18                 0  90
55060   REPAIR OF TUNICA VAGINALIS HYDROCELE (BO      226.38   188.65                 0  90
55100   DRAINAGE OF SCROTAL WALL ABSCESS              140.82    81.46                 0  10
55110   SCROTAL EXPLORATION                           230.40   192.00                 0  90
55120   REMOVAL OF FOREIGN BODY IN SCROTUM            211.57   176.31                 0  90
55150   RESECTION OF SCROTUM                          290.14   241.79                 0  90
55175   SCROTOPLASTY; SIMPLE                          216.35   180.30                 0  90
55180   SCROTOPLASTY; COMPLICATED                     413.05   344.21                 0  90
55200   VASOTOMY, CANNULIZATION WITH OR WITHOUT       349.48   140.90                 0  90
                                                                                                   Page 148 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
55250   VASECTOMY, UNILATERAL OR BILATERAL (SEPA      310.78   115.21                 0  90
55400   VASOVASOSTOMY, VASOVASORRHAPHY                304.81   254.01                 0  90
55450   LIGATION (PERCUTANEOUS) OF VAS DEFERENS,      249.29   125.50                 0  10
55500   EXCISION OF HYDROCELE OF SPERMATIC CORD,      226.84   189.04                 0  90
55520   EXCISION OF LESION OF SPERMATIC CORD (SE      237.66   198.05                 0  90
55530   EXCISION OF VARICOCELE OR LIGATION OF SP      213.58   177.98                 0  90
55535   EXCISION OF VARICOCELE OR LIGATION OF SP      256.31   213.59                 0  90
55540   EXCISION OF VARICOCELE OR LIGATION OF SP      287.36   239.47                 0  90
55550   LAPAROSCOPY, SURGICAL, WITH LIGATION OF       254.11   211.76                 0  90
55559   UNLISTED LAPAROSCOPY PROCEDURE, SPERMATI                                  BR 0    0
55600   VESICULOTOMY;                                 255.97   213.31                 0  90
55605   VESICULOTOMY; COMPLICATED                     300.01   250.01                 0  90
55650   VESICULECTOMY, ANY APPROACH                   432.05   360.04                 0  90
55680   EXCISION OF MULLERIAN DUCT CYST               320.00   320.00                 0  90
55700   BIOPSY, PROSTATE; NEEDLE OR PUNCH, SINGL      152.29    66.00                 0   0
55705   BIOPSY, PROSTATE; INCISIONAL, ANY APPROA      163.82   136.52                 0  10
55720   PROSTATOTOMY, EXTERNAL DRAINAGE OF PROST      284.81   237.35                 0  90
55725   PROSTATOTOMY, EXTERNAL DRAINAGE OF PROST      350.20   291.83                 0  90
55801   PROSTATECTOMY, PERINEAL, SUBTOTAL (INCLU      651.28   542.74                 0  90
55810   PROSTATECTOMY, PERINEAL RADICAL;              790.45   658.71                 0  90
55812   PROSTATECTOMY, PERINEAL RADICAL; WITH LY      961.87   801.56                 0  90
55815   PROSTATECTOMY, PERINEAL RADICAL; WITH BI    1,062.34   885.28                 0  90
55821   PROSTATECTOMY (INCLUDING CONTROL OF POST      524.40   437.00                 0  90
55831   PROSTATECTOMY (INCLUDING CONTROL OF POST      568.18   473.48                 0  90
55840   PROSTATECTOMY, RETROPUBIC RADICAL, WITH       805.30   671.09                 0  90
55842   PROSTATECTOMY, RETROPUBIC RADICAL, WITH       862.49   718.74                 0  90
55845   PROSTATECTOMY, RETROPUBIC RADICAL, WITH       985.72   821.43                 0  90
55860   EXPOSURE OF PROSTATE, ANY APPROACH, FOR       527.23   439.36                 0  90
55862   EXPOSURE OF PROSTATE, ANY APPROACH, FOR       667.60   556.33                 0  90
                                                                                                   Page 149 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
55865   EXPOSURE OF PROSTATE, ANY APPROACH, FOR       800.90   667.42                 0  90
55866   LAPAROSCOPY, SURGICAL PROSTATECTOMY, RET    1,047.22   872.68                 0  90
55873   CRYOSURGICAL ABLATION OF THE PROSTATE (I      692.98   577.49                 0  90
55875   TRANSPERINEAL PLACEMENT OF NEEDLES OR CA      459.91   383.26                 0  90
55876   PLACEMENT OF INTERSTITIAL DEVICE(S) FOR        92.46    56.13                 0   0
55899   UNLISTED PROCEDURE, MALE GENITAL SYSTEM                                   BR 0    0
55920   PLACEMENT OF NEEDLES OR CATHETERS INTO P      259.93   216.61                 0   0
56405   INCISION AND DRAINAGE OF VULVA OR PERINE       64.48    51.68                 0  10
56420   INCISION AND DRAINAGE OF BARTHOLIN'S GLA       79.09    45.61                 0  10
56440   MARSUPIALIZATION OF BARTHOLIN'S GLAND CY      106.15    88.46                 0  10
56441   LYSIS OF LABIAL ADHESIONS                      88.36    67.89                 0  10
56442   HYMENOTOMY, SIMPLE INCISION                    28.25    24.00                 0   0
56501   DESTRUCTION OF LESION(S), VULVA; SIMPLE        77.65    54.86                 0  10
56515   DESTRUCTION OF LESION(S), VULVA; EXTENSI      130.07    94.25                 0  10
56605   BIOPSY OF VULVA OR PERINEUM (SEPARATE PR       50.01    29.37                 0   0
56606   BIOPSY OF VULVA OR PERINEUM (SEPARATE PR       23.28    14.48                 0   0
56620   VULVECTOMY SIMPLE; PARTIAL                    305.35   254.46                 0  90
56625   VULVECTOMY SIMPLE; COMPLETE                   342.32   285.27                 0  90
56630   VULVECTOMY, RADICAL, PARTIAL;                 494.31   411.93                 0  90
56631   VULVECTOMY, RADICAL, PARTIAL; WITH UNILA      632.04   526.70                 0  90
56632   VULVECTOMY, RADICAL, PARTIAL; WITH BILAT      726.25   605.21                 0  90
56633   VULVECTOMY, RADICAL, COMPLETE;                643.70   536.42                 0  90
56634   VULVECTOMY, RADICAL, COMPLETE; WITH UNIL      683.37   569.48                 0  90
56637   VULVECTOMY, RADICAL, COMPLETE; WITH BILA      810.87   675.73                 0  90
56640   VULVECTOMY, RADICAL, COMPLETE, WITH INGU      807.46   672.89                 0  90
56700   PARTIAL HYMENECTOMY OR REVISION OF HYMEN      108.04    90.04                 0  10
56740   EXCISION OF BARTHOLIN'S GLAND OR CYST         171.36   142.80                 0  10
56800   PLASTIC REPAIR OF INTROITUS                   140.56   117.13                 0  10
56805   CLITOROPLASTY FOR INTERSEX STATE              661.69   551.41                 0  90
                                                                                                   Page 150 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
56810   PERINEOPLASTY, REPAIR OF PERINEUM, NONOB      151.31   126.09                 0  10
56820   COLPOSCOPY OF THE VULVA;                       65.39    40.96                 0   0
56821   COLPOSCOPY OF THE VULVA; WITH BIOPSY(S)        88.16    56.04                 0   0
57000   COLPOTOMY; WITH EXPLORATION                   110.48    92.07                 0  10
57010   COLPOTOMY; WITH DRAINAGE OF PELVIC ABSCE      247.12   205.93                 0  90
57020   COLPOCENTESIS (SEPARATE PROCEDURE)             55.79    39.53                 0   0
57022   INCISION AND DRAINAGE OF VAGINAL HEMATOM       96.92    80.77                 0  10
57023   INCISION AND DRAINAGE OF VAGINAL HEMATOM      178.56   148.80                 0  10
57061   DESTRUCTION OF VAGINAL LESION(S); SIMPLE       68.45    47.41                 0  10
57065   DESTRUCTION OF VAGINAL LESION(S); EXTENS      113.89    83.01                 0  10
57100   BIOPSY OF VAGINAL MUCOSA; SIMPLE (SEPARA       52.81    31.71                 0   0
57105   BIOPSY OF VAGINAL MUCOSA; EXTENSIVE, REQ       81.08    61.00                 0  10
57106   VAGINECTOMY, PARTIAL REMOVAL OF VAGINAL       270.43   225.36                 0  90
57107   VAGINECTOMY, PARTIAL REMOVAL OF VAGINAL       799.75   666.46                 0  90
57109   VAGINECTOMY, PARTIAL REMOVAL OF VAGINAL       913.43   761.20                 0  90
57110   VAGINECTOMY, COMPLETE REMOVAL OF VAGINAL      518.48   432.07                 0  90
57111   VAGINECTOMY, COMPLETE REMOVAL OF VAGINAL      931.73   776.45                 0  90
57112   VAGINECTOMY, COMPLETE REMOVAL OF VAGINAL      968.40   807.00                 0  90
57120   COLPOCLEISIS (LE FORT TYPE)                   295.12   245.94                 0  90
57130   EXCISION OF VAGINAL SEPTUM                    107.03    77.71                 0  10
57135   EXCISION OF VAGINAL CYST OR TUMOR             114.56    83.99                 0  10
57150   IRRIGATION OF VAGINA AND/OR APPLICATION        33.37    14.27                 0   0
57155   INSERTION OF UTERINE TANDEMS AND/OR VAGI      247.42   206.18                 0   0
57156   INSERTION OF A VAGINAL RADIATION AFTERLO       59.13    39.95                 0   0
57160   FITTING AND INSERTION OF PESSARY OR OTHE       45.67    23.09                 0   0
57180   INTRODUCTION OF ANY HEMOSTATIC AGENT OR        86.41    53.14                 0  10
57200   COLPORRHAPHY, SUTURE OF INJURY OF VAGINA      171.21   142.68                 0  90
57210   COLPOPERINEORRHAPHY, SUTURE OF INJURY OF      211.31   176.09                 0  90
57220   PLASTIC OPERATION ON URETHRAL SPHINCTER,      184.09   153.41                 0  90
                                                                                                   Page 151 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
57230   PLASTIC REPAIR OF URETHROCELE                 225.75   188.13                 0  90
57240   ANTERIOR COLPORRHAPHY, REPAIR OF CYSTOCE      361.48   301.24                 0  90
57250   POSTERIOR COLPORRHAPHY, REPAIR OF RECTOC      353.79   294.83                 0  90
57260   COMBINED ANTEROPOSTERIOR COLPORRHAPHY;        446.35   371.96                 0  90
57265   COMBINED ANTEROPOSTERIOR COLPORRHAPHY; W      505.47   421.23                 0  90
57267   INSERTION OF MESH OR OTHER PROSTHESIS FO      156.84   130.70                 0   0
57268   REPAIR OF ENTEROCELE, VAGINAL APPROACH (      275.06   229.22                 0  90
57270   REPAIR OF ENTEROCELE, ABDOMINAL APPROACH      457.46   381.22                 0  90
57280   COLPOPEXY, ABDOMINAL APPROACH                 553.45   461.21                 0  90
57282   COLPOPEXY, VAGINAL; EXTRA-PERITONEAL APP      293.56   244.63                 0  90
57283   COLPOPEXY, VAGINAL; INTRA-PERITONEAL APP      395.12   329.27                 0  90
57284   PARAVAGINAL DEFECT REPAIR (INCLUDING REP      484.18   403.49                 0  90
57285   PARAVAGINAL DEFECT REPAIR (INCLUDING REP      376.12   313.43                 0  90
57287   REMOVAL OR REVISION OF SLING FOR STRESS       400.42   333.69                 0  90
57288   SLING OPERATION FOR STRESS INCONTINENCE       470.09   391.75                 0  90
57289   PEREYRA PROCEDURE, INCLUDING ANTERIOR CO      442.79   369.00                 0  90
57291   CONSTRUCTION OF ARTIFICIAL VAGINA; WITHO      315.99   263.33                 0  90
57292   CONSTRUCTION OF ARTIFICIAL VAGINA; WITH       477.36   397.80                 0  90
57295   REVISION (INCLUDING REMOVAL) OF PROSTHET      283.32   236.10                 0  90
57296   REVISION (INCLUDING REMOVAL) OF PROSTHET      537.67   448.06                 0  90
57300   CLOSURE OF RECTOVAGINAL FISTULA; VAGINAL      302.03   251.70                 0  90
57305   CLOSURE OF RECTOVAGINAL FISTULA; ABDOMIN      503.17   419.31                 0  90
57307   CLOSURE OF RECTOVAGINAL FISTULA; ABDOMIN      563.78   469.82                 0  90
57308   CLOSURE OF RECTOVAGINAL FISTULA; TRANSPE      363.28   302.74                 0  90
57310   CLOSURE OF URETHROVAGINAL FISTULA;            275.26   229.38                 0  90
57311   CLOSURE OF URETHROVAGINAL FISTULA; WITH                                   BR 0   90
57320   CLOSURE OF VESICOVAGINAL FISTULA; VAGINA      313.25   261.04                 0  90
57330   CLOSURE OF VESICOVAGINAL FISTULA; TRANSV      450.21   375.18                 0  90
57335   VAGINOPLASTY FOR INTERSEX STATE               656.12   546.77                 0  90
                                                                                                   Page 152 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
57400   DILATION OF VAGINA UNDER ANESTHESIA            78.03    65.03                 0   0
57410   PELVIC EXAMINATION UNDER ANESTHESIA            61.88    51.57             BR 0    0
57415   REMOVAL OF IMPACTED VAGINAL FOREIGN BODY       91.15    75.96                 0  10
57420   COLPOSCOPY OF THE ENTIRE VAGINA, WITH CE       68.69    43.30                 0   0
57421   COLPOSCOPY OF THE ENTIRE VAGINA, WITH CE       93.35    59.75                 0   0
57423   PARAVAGINAL DEFECT REPAIR (INCLUDING REP      524.03   436.69                 0  90
57425   LAPAROSCOPY, SURGICAL, COLPOPEXY (SUSPEN      551.65   459.71                 0  90
57426   REVISION (INCLUDING REMOVAL) OF PROSTHET      521.82   434.85                 0  90
57452   COLPOSCOPY OF THE CERVIX INCLUDING UPPER       64.90    44.24                 0   0
57454   COLPOSCOPY OF THE CERVIX INCLUDING UPPER       91.20    73.00                 0   0
57455   COLPOSCOPY OF THE CERVIX INCLUDING UPPER       85.57    53.88                 0   0
57456   COLPOSCOPY OF THE CERVIX INCLUDING UPPER       80.86    50.36                 0   0
57460   COLPOSCOPY OF THE CERVIX INCLUDING UPPER      189.87    79.68                 0   0
57461   COLPOSCOPY OF THE CERVIX INCLUDING UPPER      210.62    97.00                 0   0
57500   BIOPSY OF CERVIX, SINGLE OR MULTIPLE, OR       83.38    35.84                 0   0
57505   ENDOCERVICAL CURETTAGE (NOT DONE AS PART       60.99    60.00                 0  10
57510   CAUTERY OF CERVIX; ELECTRO OR THERMAL          79.06    56.45                 0  10
57511   CAUTERY OF CERVIX; CRYOCAUTERY, INITIAL        86.41    76.00                 0  10
57513   CAUTERY OF CERVIX; LASER ABLATION             149.00   149.00                 0  10
57520   CONIZATION OF CERVIX, WITH OR WITHOUT FU      204.00   204.00                 0  90
57522   CONIZATION OF CERVIX, WITH OR WITHOUT FU      204.00   204.00                 0  90
57530   TRACHELECTOMY (CERVICECTOMY), AMPUTATION      198.67   165.56                 0  90
57531   RADICAL TRACHELECTOMY, WITH BILATERAL TO      978.66   815.55                 0  90
57540   EXCISION OF CERVICAL STUMP, ABDOMINAL AP      446.47   372.06                 0  90
57545   EXCISION OF CERVICAL STUMP, ABDOMINAL AP      472.45   393.71                 0  90
57550   EXCISION OF CERVICAL STUMP, VAGINAL APPR      240.00   240.00                 0  90
57555   EXCISION OF CERVICAL STUMP, VAGINAL APPR      346.48   288.73                 0  90
57556   EXCISION OF CERVICAL STUMP, VAGINAL APPR      330.00   330.00                 0  90
57558   DILATION AND CURETTAGE OF CERVICAL STUMP       73.72    60.00                 0  10
                                                                                                   Page 153 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
57700   CERCLAGE OF UTERINE CERVIX, NONOBSTETRIC      173.92   144.94                 0  90
57720   TRACHELORRHAPHY, PLASTIC REPAIR OF UTERI      215.00   215.00                 0  90
57800   DILATION OF CERVICAL CANAL, INSTRUMENTAL       35.99    23.84                 0   0
58100   ENDOMETRIAL SAMPLING (BIOPSY) WITH OR WI       65.60    42.77                 0   0
58110   ENDOMETRIAL SAMPLING (BIOPSY) PERFORMED        29.35    20.15                 0   0
58120   DILATION AND CURETTAGE, DIAGNOSTIC AND/O      152.00   152.00                 0  10
58140   MYOMECTOMY, EXCISION OF FIBROID TUMOR(S)      524.54   437.12                 0  90
58145   MYOMECTOMY, EXCISION OF FIBROID TUMOR(S)      312.61   260.51                 0  90
58146   MYOMECTOMY, EXCISION OF FIBROID TUMOR(S)      666.59   555.50                 0  90
58150   TOTAL ABDOMINAL HYSTERECTOMY (CORPUS AND      565.62   471.35                 0  90
58152   TOTAL ABDOMINAL HYSTERECTOMY (CORPUS AND      719.50   599.59                 0  90
58180   SUPRACERVICAL ABDOMINAL HYSTERECTOMY (SU      543.11   452.59                 0  90
58200   TOTAL ABDOMINAL HYSTERECTOMY, INCLUDING       749.75   624.79                 0  90
58210   RADICAL ABDOMINAL HYSTERECTOMY, WITH BIL      998.02   831.68                 0  90
58240   PELVIC EXENTERATION FOR GYNECOLOGIC MALI    1,529.27 1,274.39                 0  90
58260   VAGINAL HYSTERECTOMY, FOR UTERUS 250 GRA      475.02   395.85                 0  90
58262   VAGINAL HYSTERECTOMY, FOR UTERUS 250 GRA      530.60   442.17                 0  90
58263   VAGINAL HYSTERECTOMY, FOR UTERUS 250 GRA      571.46   476.22                 0  90
58267   VAGINAL HYSTERECTOMY, FOR UTERUS 250 GRA      607.19   505.99                 0  90
58270   VAGINAL HYSTERECTOMY, FOR UTERUS 250 GRA      509.34   424.45                 0  90
58275   VAGINAL HYSTERECTOMY, WITH TOTAL OR PART      564.89   470.74                 0  90
58280   VAGINAL HYSTERECTOMY, WITH TOTAL OR PART      605.00   504.17                 0  90
58285   VAGINAL HYSTERECTOMY, RADICAL (SCHAUTA T      756.40   630.33                 0  90
58290   VAGINAL HYSTERECTOMY, FOR UTERUS GREATER      666.01   555.01                 0  90
58291   VAGINAL HYSTERECTOMY, FOR UTERUS GREATER      722.80   602.33                 0  90
58292   VAGINAL HYSTERECTOMY, FOR UTERUS GREATER      763.18   635.99                 0  90
58293   VAGINAL HYSTERECTOMY, FOR UTERUS GREATER      793.19   661.00                 0  90
58294   VAGINAL HYSTERECTOMY, FOR UTERUS GREATER      701.57   584.65                 0  90
58300   INSERTION OF INTRAUTERINE DEVICE (IUD)         49.00    49.00                 0   0
                                                                                                   Page 154 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                      DESCRIPTION                FEE      FEE        FEE      BR PA DAYS   E
58301   REMOVAL OF INTRAUTERINE DEVICE (IUD)           58.36    36.00                 0   0
58340   CATHETERIZATION AND INTRODUCTION OF SALI       85.33    29.07                 0   0
58346   INSERTION OF HEYMAN CAPSULES FOR CLINICA      259.55   216.29                 0  90
58353   ENDOMETRIAL ABLATION, THERMAL, WITHOUT H      802.56   107.24                 0  10
58356   ENDOMETRIAL CRYOABLATION WITH ULTRASONIC    1,279.21   179.65                 0  10
58400   UTERINE SUSPENSION, WITH OR WITHOUT SHOR      256.96   214.14                 0  90
58410   UTERINE SUSPENSION, WITH OR WITHOUT SHOR      459.46   382.88                 0  90
58520   HYSTERORRHAPHY, REPAIR OF RUPTURED UTERU      447.76   373.13                 0  90
58540   HYSTEROPLASTY, REPAIR OF UTERINE ANOMALY                                  BR 0   90
58541   LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYS      485.91   404.93                 0  90
58542   LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYS      536.69   447.24                 0  90
58543   LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYS      545.56   454.64                 0  90
58544   LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYS      589.59   491.33                 0  90
58545   LAPAROSCOPY, SURGICAL, MYOMECTOMY, EXCIS      515.83   429.86                 0  90
58546   LAPAROSCOPY, SURGICAL, MYOMECTOMY, EXCIS      653.36   544.47                 0  90
58548   LAPAROSCOPY, SURGICAL, WITH RADICAL HYST    1,027.62   856.35                 0  90
58550   LAPAROSCOPY SURGICAL, WITH VAGINAL HYSTE      509.42   424.52                 0  90
58552   LAPAROSCOPY SURGICAL, WITH VAGINAL HYSTE      560.77   467.31                 0  90
58553   LAPAROSCOPY, SURGICAL, WITH VAGINAL HYST      656.15   546.80                 0  90
58554   LAPAROSCOPY, SURGICAL, WITH VAGINAL HYST      749.60   624.67                 0  90
58555   HYSTEROSCOPY, DIAGNOSTIC (SEPARATE PROCE      137.92    92.58                 0   0
58558   HYSTEROSCOPY, SURGICAL; WITH SAMPLING (B      180.80   130.37                 0   0
58559   HYSTEROSCOPY, SURGICAL; WITH LYSIS OF IN      201.04   167.53                 0   0
58560   HYSTEROSCOPY, SURGICAL; WITH DIVISION OR      228.06   190.05                 0   0
58561   HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF       322.16   268.47                 0   0
58562   HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF       192.64   142.28                 0   0
58563   HYSTEROSCOPY, SURGICAL; WITH ENDOMETRIAL    1,292.57   167.74                 0   0
58565   HYSTEROSCOPY, SURGICAL; WITH BILATERAL F      320.00   265.60                 0  90
58570   LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTER      521.27   434.40                 0  90
                                                                                                   Page 155 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
58571   LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTER      569.95   474.96                 0  90
58572   LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTER      646.31   538.59                 0  90
58573   LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTER      727.45   606.21                 0  90
58578   UNLISTED LAPAROSCOPY PROCEDURE, UTERUS                                    BR 0    0
58579   UNLISTED HYSTEROSCOPY PROCEDURE, UTERUS                                   BR 0    0
58600   LIGATION OR TRANSECTION OF FALLOPIAN TUB      320.00   320.00                 0  90
58605   LIGATION OR TRANSECTION OF FALLOPIAN TUB      246.00   246.00                 0  90
58611   LIGATION OR TRANSECTION OF FALLOPIAN TUB      120.00   120.00                 0   0
58615   OCCLUSION OF FALLOPIAN TUBE(S) BY DEVICE      200.00   200.00                 0  10
58660   LAPAROSCOPY, SURGICAL; WITH LYSIS OF ADH      386.98   322.49                 0  90
58661   LAPAROSCOPY, SURGICAL; WITH REMOVAL OF A      372.65   310.54                 0  10
58662   LAPAROSCOPY, SURGICAL; WITH FULGURATION       408.38   340.32                 0  90
58670   LAPAROSCOPY, SURGICAL; WITH FULGURATION       211.16   181.00                 0  90
58671   LAPAROSCOPY, SURGICAL; WITH OCCLUSION OF      211.39   201.00                 0  90
58673   LAPAROSCOPY, SURGICAL; WITH SALPINGOSTOM      467.65   389.71                 0  90
58679   UNLISTED LAPAROSCOPY PROCEDURE, OVIDUCT,                                  BR 0    0
58700   SALPINGECTOMY, COMPLETE OR PARTIAL, UNIL      437.27   364.39                 0  90
58720   SALPINGO-OOPHORECTOMY, COMPLETE OR PARTI      411.42   406.00                 0  90
58740   LYSIS OF ADHESIONS (SALPINGOLYSIS, OVARI      502.53   418.78                 0  90
58770   SALPINGOSTOMY (SALPINGONEOSTOMY)              494.73   412.28                 0  90
58800   DRAINAGE OF OVARIAN CYST(S), UNILATERAL       186.77   142.72                 0  90
58805   DRAINAGE OF OVARIAN CYST(S), UNILATERAL       230.94   192.45                 0  90
58820   DRAINAGE OF OVARIAN ABSCESS; VAGINAL APP      182.29   151.91                 0  90
58822   DRAINAGE OF OVARIAN ABSCESS; ABDOMINAL A      392.70   327.25                 0  90
58823   DRAINAGE OF PELVIC ABSCESS, TRANSVAGINAL      582.94    85.23                 0   0
58825   TRANSPOSITION, OVARY(S)                       399.26   332.72                 0  90
58900   BIOPSY OF OVARY, UNILATERAL OR BILATERAL      235.90   196.58                 0  90
58920   WEDGE RESECTION OR BISECTION OF OVARY, U      404.96   337.47                 0  90
58925   OVARIAN CYSTECTOMY, UNILATERAL OR BILATE      417.95   348.29                 0  90
                                                                                                     Page 156 of 189


                                                                                                 C
                                                     NON-                                        H
                                                                                                 A
                                                   FACILITY FACILITY PROFESSIONAL                N
                                                   GLOBAL GLOBAL      COMPONENT            FU    G
CODE                         DESCRIPTION             FEE      FEE        FEE        BR PA DAYS   E
58940   OOPHORECTOMY, PARTIAL OR TOTAL, UNILATER      286.29   238.58                   0  90
58943   OOPHORECTOMY, PARTIAL OR TOTAL, UNILATER      641.02   534.18                   0  90
58950   RESECTION (INITIAL) OF OVARIAN, TUBAL OR      610.66   508.89                   0  90
58951   RESECTION OF OVARIAN, TUBAL OR PRIMARY P      786.48   655.40                   0  90
58952   RESECTION OF OVARIAN, TUBAL OR PRIMARY P      887.67   739.73                   0  90
58953   BILATERAL SALPINGO-OOPHORECTOMY WITH OME    1,101.51   917.93                   0  90
58954   BILATERAL SALPINGO-OOPHORECTOMY WITH OME    1,195.90   996.59                   0  90
58956   BILATERAL SALPINGO-OOPHORECTOMY WITH TOT      784.94   654.12                   0  90
58957   RESECTION (TUMOR DEBULKING) OF RECURRENT      833.60   694.67                   0  90
58958   RESECTION (TUMOR DEBULKING) OF RECURRENT      921.86   768.22                   0  90
58960   LAPAROTOMY, FOR STAGING OR RESTAGING OF       527.80   439.84                   0  90
58999   UNLISTED PROCEDURE, FEMALE GENITAL SYSTE                                    BR 0    0
59000   AMNIOCENTESIS; DIAGNOSTIC                      80.39    65.00                   0   0
59001   AMNIOCENTESIS; THERAPEUTIC AMNIOTIC FLUI      107.64    89.70                   0   0
59012   CORDOCENTESIS (INTRAUTERINE), ANY METHOD      121.61   101.35                   0   0
59015   CHORIONIC VILLUS SAMPLING, ANY METHOD          93.06    66.07                   0   0
59020   FETAL CONTRACTION STRESS TEST                  52.40    52.40         28.06     0   0
59025   FETAL NON-STRESS TEST                          45.92    45.92         30.40     0   0
59030   FETAL SCALP BLOOD SAMPLING                     66.12    55.10                   0   0
59050   FETAL MONITORING DURING LABOR BY CONSULT       30.42    25.35                   0   0
59070   TRANSABDOMINAL AMNIOINFUSION, INCLUDING       264.29   162.59                   0   0
59072   FETAL UMBILICAL CORD OCCLUSION, INCLUDIN      327.50   272.92                   0   0
59074   FETAL FLUID DRAINAGE (EG, VESICOCENTESIS      259.03   164.59                   0   0
59076   FETAL SHUNT PLACEMENT, INCLUDING ULTRASO      322.78   269.82                   0   0
59100   HYSTEROTOMY, ABDOMINAL (EG, FOR HYDATIDI      484.59   403.83                   0  90
59120   SURGICAL TREATMENT OF ECTOPIC PREGNANCY;      460.85   384.04                   0  90
59121   SURGICAL TREATMENT OF ECTOPIC PREGNANCY;      464.31   386.93                   0  90
59130   SURGICAL TREATMENT OF ECTOPIC PREGNANCY;      523.55   436.30                   0  90
59135   SURGICAL TREATMENT OF ECTOPIC PREGNANCY;      528.36   440.30                   0  90
                                                                                                   Page 157 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
59136   SURGICAL TREATMENT OF ECTOPIC PREGNANCY;      501.27   417.73                 0  90
59140   SURGICAL TREATMENT OF ECTOPIC PREGNANCY;                                  BR 0   90
59150   LAPAROSCOPIC TREATMENT OF ECTOPIC PREGNA      449.38   374.49                 0  90
59151   LAPAROSCOPIC TREATMENT OF ECTOPIC PREGNA      441.09   367.58                 0  90
59160   CURETTAGE, POSTPARTUM                         134.96    92.17                 0  10
59200   INSERTION OF CERVICAL DILATOR (EG, LAMIN       46.58    22.41                 0   0
59300   EPISIOTOMY OR VAGINAL REPAIR, BY OTHER T      115.58    71.71                 0   0
59320   CERCLAGE OF CERVIX, DURING PREGNANCY; VA       91.33    80.00                 0   0
59325   CERCLAGE OF CERVIX, DURING PREGNANCY; AB      200.00   200.00                 0   0
59350   HYSTERORRHAPHY OF RUPTURED UTERUS             164.98   160.00                 0   0
59400   ROUTINE OBSTETRIC CARE INCLUDING ANTEPAR    1,720.75 1,720.75                 0   0
59409   VAGINAL DELIVERY ONLY (WITH OR WITHOUT E      763.98   763.98                 0   0
59410   VAGINAL DELIVERY ONLY (WITH OR WITHOUT E      881.74   881.74                 0   0
59412   EXTERNAL CEPHALIC VERSION, WITH OR WITHO       73.77    73.77             BR 0    0
59414   DELIVERY OF PLACENTA (SEPARATE PROCEDURE       54.73    45.61                 0   0
59425   ANTEPARTUM CARE ONLY; 4-6 VISITS              427.42   326.92                 0   0
59426   ANTEPARTUM CARE ONLY; 7 OR MORE VISITS        817.52   577.09                 0   0
59430   POSTPARTUM CARE ONLY (SEPARATE PROCEDURE      156.29   124.96                 0   0
59510   ROUTINE OBSTETRIC CARE INCLUDING ANTEPAR    1,948.09 1,948.09                 0   0
59514   CESAREAN DELIVERY ONLY;                       974.28   903.11                 0   0
59515   CESAREAN DELIVERY ONLY; INCLUDING POSTPA    1,061.96 1,061.96                 0   0
59525   SUBTOTAL OR TOTAL HYSTERECTOMY AFTER CES      286.25   240.00                 0   0
59610   ROUTINE OBSTETRIC CARE INCLUDING ANTEPAR    1,811.21 1,811.21                 0   0
59612   VAGINAL DELIVERY ONLY, AFTER PREVIOUS CE      856.17   856.17                 0   0
59614   VAGINAL DELIVERY ONLY, AFTER PREVIOUS CE      956.82   956.82                 0   0
59618   ROUTINE OBSTETRIC CARE INCLUDING ANTEPAR    2,038.10 2,038.10                 0   0
59620   CESAREAN DELIVERY ONLY, FOLLOWING ATTEMP      985.48   985.48                 0   0
59622   CESAREAN DELIVERY ONLY, FOLLOWING ATTEMP    1,153.16 1,153.16                 0   0
59812   TREATMENT OF INCOMPLETE ABORTION, ANY TR      180.42   171.00                 0  90
                                                                                                   Page 158 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
59820   TREATMENT OF MISSED ABORTION, COMPLETED       221.41   194.00                 0  90
59821   TREATMENT OF MISSED ABORTION, COMPLETED       225.97   220.00                 0  90
59830   TREATMENT OF SEPTIC ABORTION, COMPLETED       256.43   213.70                 0  90
59840   INDUCED ABORTION, BY DILATION AND CURETT      230.00   230.00                 0  10
59841   INDUCED ABORTION, BY DILATION AND EVACUA      350.00   350.00                 0  10
59850   INDUCED ABORTION, BY ONE OR MORE INTRA-A      322.00   322.00                 0  90
59851   INDUCED ABORTION, BY ONE OR MORE INTRA-A      235.87   196.56                 0  90
59852   INDUCED ABORTION, BY ONE OR MORE INTRA-A      317.69   264.74                 0  90
59855   INDUCED ABORTION, BY ONE OR MORE VAGINAL      244.27   230.00                 0  90
59856   INDUCED ABORTION, BY ONE OR MORE VAGINAL      350.00   350.00                 0  90
59857   INDUCED ABORTION, BY ONE OR MORE VAGINAL      338.03   281.70                 0  90
59870   UTERINE EVACUATION AND CURETTAGE FOR HYD      271.62   226.35                 0  90
59871   REMOVAL OF CERCLAGE SUTURE UNDER ANESTHE       79.90    66.59                 0   0
59897   UNLISTED FETAL INVASIVE PROCEDURE, INCLU                                  BR 0    0
59898   UNLISTED LAPAROSCOPY PROCEDURE, MATERNIT                                  BR 0    0
59899   UNLISTED PROCEDURE, MATERNITY CARE AND D                                  BR 0    0
60000   INCISION AND DRAINAGE OF THYROGLOSSAL DU       89.22    67.99                 0  10
60100   BIOPSY THYROID, PERCUTANEOUS CORE NEEDLE       67.46    38.99                 0   0
60200   EXCISION OF CYST OR ADENOMA OF THYROID,       366.25   305.21                 0  90
60210   PARTIAL THYROID LOBECTOMY, UNILATERAL; W      388.82   324.02                 0  90
60212   PARTIAL THYROID LOBECTOMY, UNILATERAL; W      556.70   463.92                 0  90
60220   TOTAL THYROID LOBECTOMY, UNILATERAL; WIT      425.83   354.86                 0  90
60225   TOTAL THYROID LOBECTOMY, UNILATERAL; WIT      512.45   427.04                 0  90
60240   THYROIDECTOMY, TOTAL OR COMPLETE              544.02   453.35                 0  90
60252   THYROIDECTOMY, TOTAL OR SUBTOTAL FOR MAL      731.02   609.19                 0  90
60254   THYROIDECTOMY, TOTAL OR SUBTOTAL FOR MAL      948.17   790.15                 0  90
60260   THYROIDECTOMY, REMOVAL OF ALL REMAINING       612.20   510.17                 0  90
60270   THYROIDECTOMY, INCLUDING SUBSTERNAL THYR      766.61   638.84                 0  90
60271   THYROIDECTOMY, INCLUDING SUBSTERNAL THYR      591.02   492.52                 0  90
                                                                                                   Page 159 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
60280   EXCISION OF THYROGLOSSAL DUCT CYST OR SI      248.11   206.76                 0  90
60281   EXCISION OF THYROGLOSSAL DUCT CYST OR SI      331.46   276.22                 0  90
60300   ASPIRATION AND/OR INJECTION, THYROID CYS       62.37    24.29                 0   0
60500   PARATHYROIDECTOMY OR EXPLORATION OF PARA      561.26   467.72                 0  90
60502   PARATHYROIDECTOMY OR EXPLORATION OF PARA      707.00   589.17                 0  90
60505   PARATHYROIDECTOMY OR EXPLORATION OF PARA      776.96   647.47                 0  90
60512   PARATHYROID AUTOTRANSPLANTATION (LIST SE      137.21   114.35                 0   0
60520   THYMECTOMY, PARTIAL OR TOTAL; TRANSCERVI      585.98   488.32                 0  90
60521   THYMECTOMY, PARTIAL OR TOTAL; STERNAL SP      670.90   559.09                 0  90
60522   THYMECTOMY, PARTIAL OR TOTAL; STERNAL SP      807.29   672.74                 0  90
60540   ADRENALECTOMY, PARTIAL OR COMPLETE, OR E      599.66   499.72                 0  90
60545   ADRENALECTOMY, PARTIAL OR COMPLETE, OR E      686.57   572.15                 0  90
60600   EXCISION OF CAROTID BODY TUMOR; WITHOUT       803.09   669.25                 0  90
60605   EXCISION OF CAROTID BODY TUMOR; WITH EXC    1,006.63   838.86                 0  90
60650   LAPAROSCOPY, SURGICAL, WITH ADRENALECTOM      670.36   558.63                 0  90
60659   UNLISTED LAPAROSCOPY PROCEDURE, ENDOCRIN                                  BR 0    0
60699   UNLISTED PROCEDURE, ENDOCRINE SYSTEM                                      BR 0    0
61000   SUBDURAL TAP THROUGH FONTANELLE, OR SUTU       61.96    51.63                 0   0
61001   SUBDURAL TAP THROUGH FONTANELLE, OR SUTU       60.28    50.24                 0   0
61020   VENTRICULAR PUNCTURE THROUGH PREVIOUS BU       74.88    62.40                 0   0
61026   VENTRICULAR PUNCTURE THROUGH PREVIOUS BU       74.92    62.44                 0   0
61050   CISTERNAL OR LATERAL CERVICAL (C1-C2) PU       63.07    52.56                 0   0
61055   CISTERNAL OR LATERAL CERVICAL (C1-C2) PU       80.41    67.01                 0   0
61070   PUNCTURE OF SHUNT TUBING OR RESERVOIR FO       48.47    40.40                 0   0
61105   TWIST DRILL HOLE FOR SUBDURAL OR VENTRIC      248.74   207.28                 0  90
61107   TWIST DRILL HOLE(S) FOR SUBDURAL, INTRAC      184.36   160.00                 0   0
61108   TWIST DRILL HOLE FOR SUBDURAL OR VENTRIC      485.01   404.18                 0  90
61120   BURR HOLE(S) FOR VENTRICULAR PUNCTURE (I      398.63   332.19                 0  90
61140   BURR HOLE(S) OR TREPHINE; WITH BIOPSY OF      691.33   576.11                 0  90
                                                                                                   Page 160 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
61150   BURR HOLE(S) OR TREPHINE; WITH DRAINAGE       739.94   616.62                 0  90
61151   BURR HOLE(S) OR TREPHINE; WITH SUBSEQUEN      541.37   451.15                 0  90
61154   BURR HOLE(S) WITH EVACUATION AND/OR DRAI      689.89   574.91                 0  90
61156   BURR HOLE(S); WITH ASPIRATION OF HEMATOM      690.26   575.22                 0  90
61210   BURR HOLE(S); FOR IMPLANTING VENTRICULAR      214.84   179.03                 0   0
61215   INSERTION OF SUBCUTANEOUS RESERVOIR, PUM      262.19   218.49                 0  90
61250   BURR HOLE(S) OR TREPHINE, SUPRATENTORIAL      470.34   391.95                 0  90
61253   BURR HOLE(S) OR TREPHINE, INFRATENTORIAL      519.82   433.18                 0  90
61304   CRANIECTOMY OR CRANIOTOMY, EXPLORATORY;       914.52   762.10                 0  90
61305   CRANIECTOMY OR CRANIOTOMY, EXPLORATORY;     1,091.28   909.40                 0  90
61312   CRANIECTOMY OR CRANIOTOMY FOR EVACUATION    1,129.09   940.91                 0  90
61313   CRANIECTOMY OR CRANIOTOMY FOR EVACUATION    1,086.32   905.27                 0  90
61314   CRANIECTOMY OR CRANIOTOMY FOR EVACUATION    1,001.57   834.64                 0  90
61315   CRANIECTOMY OR CRANIOTOMY FOR EVACUATION    1,151.44   959.54                 0  90
61316   INCISION AND SUBCUTANEOUS PLACEMENT OF C       49.91    41.60                 0   0
61320   CRANIECTOMY OR CRANIOTOMY, DRAINAGE OF I    1,063.10   885.92                 0  90
61321   CRANIECTOMY OR CRANIOTOMY, DRAINAGE OF I    1,176.96   980.80                 0  90
61322   CRANIECTOMY OR CRANIOTOMY, DECOMPRESSIVE    1,274.86 1,062.38                 0  90
61323   CRANIECTOMY OR CRANIOTOMY, DECOMPRESSIVE    1,304.18 1,086.82                 0  90
61330   DECOMPRESSION OF ORBIT ONLY, TRANSCRANIA      876.46   730.38                 0  90
61332   EXPLORATION OF ORBIT (TRANSCRANIAL APPRO    1,041.58   867.98                 0  90
61333   EXPLORATION OF ORBIT (TRANSCRANIAL APPRO    1,033.82   861.52                 0  90
61334   EXPLORATION OF ORBIT (TRANSCRANIAL APPRO      679.11   565.93                 0  90
61340   SUBTEMPORAL CRANIAL DECOMPRESSION (PSEUD      797.59   664.66                 0  90
61343   CRANIECTOMY, SUBOCCIPITAL WITH CERVICAL     1,221.95 1,018.29                 0  90
61345   OTHER CRANIAL DECOMPRESSION, POSTERIOR F    1,124.42   937.02                 0  90
61440   CRANIOTOMY FOR SECTION OF TENTORIUM CERE    1,099.37   916.14                 0  90
61450   CRANIECTOMY, SUBTEMPORAL, FOR SECTION, C    1,042.15   868.46                 0  90
61458   CRANIECTOMY, SUBOCCIPITAL; FOR EXPLORATI    1,117.81   931.51                 0  90
                                                                                                   Page 161 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
61460   CRANIECTOMY, SUBOCCIPITAL; FOR SECTION O    1,131.46   942.88                 0  90
61470   CRANIECTOMY, SUBOCCIPITAL; FOR MEDULLARY    1,037.58   864.65                 0  90
61480   CRANIECTOMY, SUBOCCIPITAL; FOR MESENCEPH    1,009.65   841.38                 0  90
61490   CRANIOTOMY FOR LOBOTOMY, INCLUDING CINGU    1,060.25   883.55                 0  90
61500   CRANIECTOMY; WITH EXCISION OF TUMOR OR O      745.73   621.45                 0  90
61501   CRANIECTOMY; FOR OSTEOMYELITIS                632.86   527.39                 0  90
61510   CRANIECTOMY, TREPHINATION, BONE FLAP CRA    1,204.28 1,003.57                 0  90
61512   CRANIECTOMY, TREPHINATION, BONE FLAP CRA    1,428.28 1,190.24                 0  90
61514   CRANIECTOMY, TREPHINATION, BONE FLAP CRA    1,054.95   879.13                 0  90
61516   CRANIECTOMY, TREPHINATION, BONE FLAP CRA    1,030.82   859.02                 0  90
61517   IMPLANTATION OF BRAIN INTRACAVITARY CHEM       50.41    42.01                 0   0
61518   CRANIECTOMY FOR EXCISION OF BRAIN TUMOR,    1,536.35 1,280.30                 0  90
61519   CRANIECTOMY FOR EXCISION OF BRAIN TUMOR,    1,654.97 1,379.15                 0  90
61520   CRANIECTOMY FOR EXCISION OF BRAIN TUMOR,    2,105.56 1,754.64                 0  90
61521   CRANIECTOMY FOR EXCISION OF BRAIN TUMOR,    1,782.46 1,485.39                 0  90
61522   CRANIECTOMY, INFRATENTORIAL OR POSTERIOR    1,208.36 1,006.97                 0  90
61524   CRANIECTOMY, INFRATENTORIAL OR POSTERIOR    1,154.34   961.95                 0  90
61526   CRANIECTOMY, BONE FLAP CRANIOTOMY, TRANS    1,898.97 1,582.48                 0  90
61530   CRANIECTOMY, BONE FLAP CRANIOTOMY, TRANS    1,613.62 1,344.69                 0  90
61531   SUBDURAL IMPLANTATION OF STRIP ELECTRODE      658.62   548.85                 0  90
61533   CRANIOTOMY WITH ELEVATION OF BONE FLAP;       837.86   698.22                 0  90
61534   CRANIOTOMY WITH ELEVATION OF BONE FLAP;       899.48   749.57                 0  90
61535   CRANIOTOMY WITH ELEVATION OF BONE FLAP;       534.18   445.15                 0  90
61536   CRANIOTOMY WITH ELEVATION OF BONE FLAP;     1,445.69 1,204.75                 0  90
61537   CRANIOTOMY WITH ELEVATION OF BONE FLAP;     1,288.72 1,073.94                 0  90
61538   CRANIOTOMY WITH ELEVATION OF BONE FLAP;     1,373.27 1,144.40                 0  90
61539   CRANIOTOMY WITH ELEVATION OF BONE FLAP;     1,309.47 1,091.23                 0  90
61540   CRANIOTOMY WITH ELEVATION OF BONE FLAP;     1,238.51 1,032.09                 0  90
61541   CRANIOTOMY WITH ELEVATION OF BONE FLAP;     1,174.40   978.67                 0  90
                                                                                                   Page 162 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
61542   CRANIOTOMY WITH ELEVATION OF BONE FLAP;     1,280.49 1,067.08                 0  90
61543   CRANIOTOMY WITH ELEVATION OF BONE FLAP;     1,178.51   982.09                 0  90
61544   CRANIOTOMY WITH ELEVATION OF BONE FLAP;     1,036.51   863.76                 0  90
61545   CRANIOTOMY WITH ELEVATION OF BONE FLAP;     1,761.24 1,467.70                 0  90
61546   CRANIOTOMY FOR HYPOPHYSECTOMY OR EXCISIO    1,273.29 1,061.08                 0  90
61548   HYPOPHYSECTOMY OR EXCISION OF PITUITARY       852.11   710.10                 0  90
61550   CRANIECTOMY FOR CRANIOSYNOSTOSIS; SINGLE      491.96   409.97                 0  90
61552   CRANIECTOMY FOR CRANIOSYNOSTOSIS; MULTIP      699.31   582.76                 0  90
61556   CRANIOTOMY FOR CRANIOSYNOSTOSIS; FRONTAL      897.55   747.96                 0  90
61557   CRANIOTOMY FOR CRANIOSYNOSTOSIS; BIFRONT      938.23   781.86                 0  90
61558   EXTENSIVE CRANIECTOMY FOR MULTIPLE CRANI      923.78   769.82                 0  90
61559   EXTENSIVE CRANIECTOMY FOR MULTIPLE CRANI    1,345.16 1,120.97                 0  90
61563   EXCISION, INTRA AND EXTRACRANIAL, BENIGN                                  BR 0   90
61564   EXCISION, INTRA AND EXTRACRANIAL, BENIGN    1,348.53 1,123.78                 0  90
61566   CRANIOTOMY WITH ELEVATION OF BONE FLAP;     1,238.95 1,032.46                 0  90
61567   CRANIOTOMY WITH ELEVATION OF BONE FLAP;     1,387.90 1,156.59                 0  90
61570   CRANIECTOMY OR CRANIOTOMY; WITH EXCISION    1,014.20   845.17                 0  90
61571   CRANIECTOMY OR CRANIOTOMY; WITH TREATMEN    1,096.22   913.52                 0  90
61575   TRANSORAL APPROACH TO SKULL BASE, BRAIN     1,303.13 1,085.95                 0  90
61576   TRANSORAL APPROACH TO SKULL BASE, BRAIN     2,023.19 1,686.00                 0  90
61580   CRANIOFACIAL APPROACH TO ANTERIOR CRANIA    1,372.52 1,143.77                 0  90
61581   CRANIOFACIAL APPROACH TO ANTERIOR CRANIA    1,512.76 1,260.64                 0  90
61582   CRANIOFACIAL APPROACH TO ANTERIOR CRANIA    1,586.02 1,321.69                 0  90
61583   CRANIOFACIAL APPROACH TO ANTERIOR CRANIA    1,618.42 1,348.69                 0  90
61584   ORBITOCRANIAL APPROACH TO ANTERIOR CRANI    1,573.65 1,311.38                 0  90
61585   ORBITOCRANIAL APPROACH TO ANTERIOR CRANI    1,659.80 1,383.17                 0  90
61586   BICORONAL, TRANSZYGOMATIC AND/OR LEFORT     1,211.48 1,009.57                 0  90
61590   INFRATEMPORAL PRE-AURICULAR APPROACH TO     1,733.47 1,444.56                 0  90
61591   INFRATEMPORAL POST-AURICULAR APPROACH TO    1,749.70 1,458.09                 0  90
                                                                                                   Page 163 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
61592   ORBITOCRANIAL ZYGOMATIC APPROACH TO MIDD    1,759.43 1,466.19                 0  90
61595   TRANSTEMPORAL APPROACH TO POSTERIOR CRAN    1,309.68 1,091.40                 0  90
61596   TRANSCOCHLEAR APPROACH TO POSTERIOR CRAN    1,437.28 1,197.74                 0  90
61597   TRANSCONDYLAR (FAR LATERAL) APPROACH TO     1,599.28 1,332.74                 0  90
61598   TRANSPETROSAL APPROACH TO POSTERIOR CRAN    1,429.63 1,191.36                 0  90
61600   RESECTION OR EXCISION OF NEOPLASTIC, VAS    1,180.67   983.90                 0  90
61601   RESECTION OR EXCISION OF NEOPLASTIC, VAS    1,309.91 1,091.59                 0  90
61605   RESECTION OR EXCISION OF NEOPLASTIC, VAS    1,235.30 1,029.42                 0  90
61606   RESECTION OR EXCISION OF NEOPLASTIC, VAS    1,659.50 1,382.92                 0  90
61607   RESECTION OR EXCISION OF NEOPLASTIC, VAS    1,539.34 1,282.79                 0  90
61608   RESECTION OR EXCISION OF NEOPLASTIC, VAS    1,820.06 1,516.72                 0  90
61609   TRANSECTION OR LIGATION, CAROTID ARTERY       358.78   298.99                 0   0
61610   TRANSECTION OR LIGATION, CAROTID ARTERY     1,075.13   895.95                 0   0
61611   TRANSECTION OR LIGATION, CAROTID ARTERY       261.70   218.09                 0   0
61612   TRANSECTION OR LIGATION, CAROTID ARTERY       907.67   756.40                 0   0
61613   OBLITERATION OF CAROTID ANEURYSM, ARTERI    1,766.83 1,472.36                 0  90
61615   RESECTION OR EXCISION OF NEOPLASTIC, VAS    1,375.35 1,146.13                 0  90
61616   RESECTION OR EXCISION OF NEOPLASTIC, VAS    1,824.68 1,520.57                 0  90
61618   SECONDARY REPAIR OF DURA FOR CEREBROSPIN      719.61   599.68                 0  90
61619   SECONDARY REPAIR OF DURA FOR CEREBROSPIN      832.16   693.47                 0  90
61623   ENDOVASCULAR TEMPORARY BALLOON ARTERIAL       322.56   268.80                 0   0
61624   TRANSCATHETER PERMANENT OCCLUSION OR EMB      629.14   524.28                 0   0
61626   TRANSCATHETER PERMANENT OCCLUSION OR EMB      508.15   423.46                 0   0
61630   BALLOON ANGIOPLASTY, INTRACRANIAL (EG, A                                  BR 0    0
61635   TRANSCATHETER PLACEMENT OF INTRAVASCULAR                                  BR 0    0
61640   BALLOON DILATATION OF INTRACRANIAL VASOS                                  BR 0    0
61641   BALLOON DILATATION OF INTRACRANIAL VASOS                                  BR 0    0
61642   BALLOON DILATATION OF INTRACRANIAL VASOS                                  BR 0    0
61680   SURGERY OF INTRACRANIAL ARTERIOVENOUS MA    1,260.31 1,050.26                 0  90
                                                                                                   Page 164 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
61682   SURGERY OF INTRACRANIAL ARTERIOVENOUS MA    2,384.66 1,987.22                 0  90
61684   SURGERY OF INTRACRANIAL ARTERIOVENOUS MA    1,599.83 1,333.20                 0  90
61686   SURGERY OF INTRACRANIAL ARTERIOVENOUS MA    2,551.60 2,126.34                 0  90
61690   SURGERY OF INTRACRANIAL ARTERIOVENOUS MA    1,201.50 1,001.25                 0  90
61692   SURGERY OF INTRACRANIAL ARTERIOVENOUS MA    2,050.27 1,708.56                 0  90
61697   SURGERY OF COMPLEX INTRACRANIAL ANEURYSM    2,275.90 1,896.59                 0  90
61698   SURGERY OF COMPLEX INTRACRANIAL ANEURYSM    2,404.03 2,003.36                 0  90
61700   SURGERY OF SIMPLE INTRACRANIAL ANEURYSM,    1,959.72 1,633.10                 0  90
61702   SURGERY OF SIMPLE INTRACRANIAL ANEURYSM,    2,122.89 1,769.08                 0  90
61703   SURGERY OF INTRACRANIAL ANEURYSM, CERVIC      725.61   604.68                 0  90
61705   SURGERY OF ANEURYSM, VASCULAR MALFORMATI    1,436.59 1,197.16                 0  90
61708   SURGERY OF ANEURYSM, VASCULAR MALFORMATI    1,182.39   985.33                 0  90
61710   SURGERY OF ANEURYSM, VASCULAR MALFORMATI    1,075.75   896.46                 0  90
61711   ANASTOMOSIS, ARTERIAL, EXTRACRANIAL-INTR    1,461.83 1,218.19                 0  90
61720   CREATION OF LESION BY STEREOTACTIC METHO      640.00   533.34                 0  90
61735   CREATION OF LESION BY STEREOTACTIC METHO      777.41   647.85                 0  90
61750   STEREOTACTIC BIOPSY, ASPIRATION, OR EXCI      774.09   645.08                 0  90
61751   STEREOTACTIC BIOPSY, ASPIRATION, OR EXCI      755.88   629.90                 0  90
61760   STEREOTACTIC IMPLANTATION OF DEPTH ELECT      831.18   692.65                 0  90
61770   STEREOTACTIC LOCALIZATION, INCLUDING BUR      823.54   686.28                 0  90
61781   STEREOTACTIC COMPUTER-ASSISTED (NAVIGATI      111.46    92.88                 0   0
61782   STEREOTACTIC COMPUTER-ASSISTED (NAVIGATI       91.69    76.41                 0   0
61783   STEREOTACTIC COMPUTER-ASSISTED (NAVIGATI       95.54    79.62                 0   0
61790   CREATION OF LESION BY STEREOTACTIC METHO      465.69   388.08                 0  90
61791   CREATION OF LESION BY STEREOTACTIC METHO                                  BR 0   90
61796   STEREOTACTIC RADIOSURGERY (PARTICLE BEAM      443.37   370.00                 0  90
61797   STEREOTACTIC RADIOSURGERY (PARTICLE BEAM      120.40   100.34                 0   0
61798   STEREOTACTIC RADIOSURGERY (PARTICLE BEAM      443.37   370.00                 0  90
61799   STEREOTACTIC RADIOSURGERY (PARTICLE BEAM      166.45   138.71                 0   0
                                                                                                   Page 165 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
61800   APPLICATION OF STEREOTACTIC HEADFRAME FO       85.38    71.15                 0   0
61850   TWIST DRILL OR BURR HOLE(S) FOR IMPLANTA      534.46   445.39                 0  90
61860   CRANIECTOMY OR CRANIOTOMY FOR IMPLANTATI      854.44   712.04                 0  90
61863   TWIST DRILL, BURR HOLE, CRANIOTOMY, OR C      839.43   699.53                 0  90
61864   TWIST DRILL, BURR HOLE, CRANIOTOMY, OR C      262.24   218.54                 0   0
61867   TWIST DRILL, BURR HOLE, CRANIOTOMY, OR C    1,216.13 1,013.45                 0  90
61868   TWIST DRILL, BURR HOLE, CRANIOTOMY, OR C      369.14   307.62                 0   0
61870   CRANIECTOMY FOR IMPLANTATION OF NEUROSTI      657.03   547.53                 0  90
61875   CRANIECTOMY FOR IMPLANTATION OF NEUROSTI      571.23   476.03                 0  90
61880   REVISION OR REMOVAL OF INTRACRANIAL NEUR      297.34   247.79                 0  90
61885   INSERTION OR REPLACEMENT OF CRANIAL NEUR      338.45   282.05                 0  90
61886   INSERTION OR REPLACEMENT OF CRANIAL NEUR      425.95   354.96                 0  90
61888   REVISION OR REMOVAL OF CRANIAL NEUROSTIM      223.87   186.56                 0  10
62000   ELEVATION OF DEPRESSED SKULL FRACTURE; S      467.75   389.79                 0  90
62005   ELEVATION OF DEPRESSED SKULL FRACTURE; C      671.14   559.29                 0  90
62010   ELEVATION OF DEPRESSED SKULL FRACTURE; W      839.61   699.68                 0  90
62100   CRANIOTOMY FOR REPAIR OF DURAL/CEREBROSP      892.48   743.73                 0  90
62115   REDUCTION OF CRANIOMEGALIC SKULL (EG, TR      901.51   751.26                 0  90
62116   REDUCTION OF CRANIOMEGALIC SKULL (EG, TR      974.23   811.86                 0  90
62117   REDUCTION OF CRANIOMEGALIC SKULL (EG, TR    1,024.56   853.80                 0  90
62120   REPAIR OF ENCEPHALOCELE, SKULL VAULT, IN    1,005.92   838.27                 0  90
62121   CRANIOTOMY FOR REPAIR OF ENCEPHALOCELE,       927.01   772.51                 0  90
62140   CRANIOPLASTY FOR SKULL DEFECT; UP TO 5 C      581.41   484.51                 0  90
62141   CRANIOPLASTY FOR SKULL DEFECT; LARGER TH      636.44   530.37                 0  90
62142   REMOVAL OF BONE FLAP OR PROSTHETIC PLATE      482.57   402.15                 0  90
62143   REPLACEMENT OF BONE FLAP OR PROSTHETIC P      568.84   474.03                 0  90
62145   CRANIOPLASTY FOR SKULL DEFECT WITH REPAR      769.31   641.09                 0  90
62146   CRANIOPLASTY WITH AUTOGRAFT (INCLUDES OB      667.69   556.41                 0  90
62147   CRANIOPLASTY WITH AUTOGRAFT (INCLUDES OB      791.11   659.26                 0  90
                                                                                                       Page 166 of 189


                                                                                                   C
                                                       NON-                                        H
                                                                                                   A
                                                     FACILITY FACILITY PROFESSIONAL                N
                                                     GLOBAL GLOBAL      COMPONENT            FU    G
CODE                        DESCRIPTION                FEE      FEE        FEE        BR PA DAYS   E
62148   INCISION AND RETRIEVAL OF SUBCUTANEOUS C         71.26    59.38                   0   0
62160   NEUROENDOSCOPY, INTRACRANIAL, FOR PLACEM        110.96    92.47                   0   0
62161   NEUROENDOSCOPY, INTRACRANIAL; WITH DISSE        845.66   704.72                   0  90
62162   NEUROENDOSCOPY, INTRACRANIAL; WITH FENES      1,040.10   866.75                   0  90
62163   NEUROENDOSCOPY, INTRACRANIAL; WITH RETRI        660.71   550.60                   0  90
62164   NEUROENDOSCOPY, INTRACRANIAL; WITH EXCIS      1,098.24   915.20                   0  90
62165   NEUROENDOSCOPY, INTRACRANIAL; WITH EXCIS        848.56   707.13                   0  90
62180   VENTRICULOCISTERNOSTOMY (TORKILDSEN TYPE        873.44   727.87                   0  90
62190   CREATION OF SHUNT; SUBARACHNOID/SUBDURAL        487.16   405.97                   0  90
62192   CREATION OF SHUNT; SUBARACHNOID/SUBDURAL        530.72   442.27                   0  90
62194   REPLACEMENT OR IRRIGATION, SUBARACHNOID/        205.19   171.00                   0  10
62200   VENTRICULOCISTERNOSTOMY, THIRD VENTRICLE        761.14   634.28                   0  90
62201   VENTRICULOCISTERNOSTOMY, THIRD VENTRICLE        650.50   542.09                   0  90
62220   CREATION OF SHUNT; VENTRICULO-ATRIAL, -J        565.24   471.04                   0  90
62223   CREATION OF SHUNT; VENTRICULO-PERITONEAL        570.74   475.62                   0  90
62225   REPLACEMENT OR IRRIGATION, VENTRICULAR C        273.78   228.15                   0  90
62230   REPLACEMENT OR REVISION OF CEREBROSPINAL        460.96   384.13                   0  90
62252   REPROGRAMMING OF PROGRAMMABLE CEREBROSPI         74.57    74.57         34.01     0   0
62256   REMOVAL OF COMPLETE CEREBROSPINAL FLUID         318.08   265.07                   0  90
62258   REMOVAL OF COMPLETE CEREBROSPINAL FLUID         622.76   518.97                   0  90
62263   PERCUTANEOUS LYSIS OF EPIDURAL ADHESIONS        412.60   216.00                   0  10
62264   PERCUTANEOUS LYSIS OF EPIDURAL ADHESIONS        260.61   173.00                   0  10
62267   PERCUTANEOUS ASPIRATION WITHIN THE NUCLEUS      148.70    80.60                   0   0
62268   PERCUTANEOUS ASPIRATION, SPINAL CORD CYS        330.74   129.18                   0   0
62269   BIOPSY OF SPINAL CORD, PERCUTANEOUS NEED        368.18   127.57                   0   0
62270   SPINAL PUNCTURE, LUMBAR, DIAGNOSTIC              96.04    36.56                   0   0
62272   SPINAL PUNCTURE, THERAPEUTIC, FOR DRAINA        114.56    39.89                   0   0
62273   INJECTION, EPIDURAL, OF BLOOD OR CLOT PA        100.61    52.06                   0   0
62280   INJECTION/INFUSION OF NEUROLYTIC SUBSTAN        202.75    72.57                   0  10
                                                                                                   Page 167 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                         DESCRIPTION             FEE      FEE        FEE      BR PA DAYS   E
62281   INJECTION/INFUSION OF NEUROLYTIC SUBSTAN      178.35    68.43                 0  10
62282   INJECTION/INFUSION OF NEUROLYTIC SUBSTAN      204.41    63.69                 0  10
62284   INJECTION PROCEDURE FOR MYELOGRAPHY AND/      142.24    43.05                 0   0
62287   DECOMPRESSION PROCEDURE, PERCUTANEOUS, O      315.57   262.98                 0  90
62290   INJECTION PROCEDURE FOR DISKOGRAPHY, EAC      209.58    81.13                 0   0
62291   INJECTION PROCEDURE FOR DISKOGRAPHY, EAC      190.43    77.89                 0   0
62292   INJECTION PROCEDURE FOR CHEMONUCLEOLYSIS      295.28   246.07                 0  90
62294   INJECTION PROCEDURE, ARTERIAL, FOR OCCLU      437.20   364.33                 0  90
62310   INJECTION(S), OF DIAGNOSTIC OR THERAPEUT      137.61    47.00                 0   0
62311   INJECTION(S), OF DIAGNOSTIC OR THERAPEUT      126.82    39.43                 0   0
62318   INJECTION(S), INCLUDING INDWELLING CATHE      152.95    48.08                 0   0
62319   INJECTION(S), INCLUDING INDWELLING CATHE      136.45    44.59                 0   0
62350   IMPLANTATION, REVISION OR REPOSITIONING       284.44   237.03                 0  10
62351   IMPLANTATION, REVISION OR REPOSITIONING       467.86   389.88                 0  90
62355   REMOVAL OF PREVIOUSLY IMPLANTED INTRATHE      232.78   193.99                 0  10
62360   IMPLANTATION OR REPLACEMENT OF DEVICE FO      154.83   129.03                 0  10
62361   IMPLANTATION OR REPLACEMENT OF DEVICE FO      250.57   208.81                 0  10
62362   IMPLANTATION OR REPLACEMENT OF DEVICE FO      312.69   260.58                 0  10
62365   REMOVAL OF SUBCUTANEOUS RESERVOIR OR PUM      243.32   202.77                 0  10
62367   ELECTRONIC ANALYSIS OF PROGRAMMABLE, IMP       25.00    25.00                 0   0
62368   ELECTRONIC ANALYSIS OF PROGRAMMABLE, IMP       32.15    25.00                 0   0
62370   ELECTRONIC ANALYSIS OF PROGRAMMABLE, IMP       59.68    49.73                 0   0    *
63001   LAMINECTOMY WITH EXPLORATION AND/OR DECO      679.26   566.05                 0  90
63003   LAMINECTOMY WITH EXPLORATION AND/OR DECO      684.85   570.71                 0  90
63005   LAMINECTOMY WITH EXPLORATION AND/OR DECO      650.21   541.85                 0  90
63011   LAMINECTOMY WITH EXPLORATION AND/OR DECO      610.67   508.89                 0  90
63012   LAMINECTOMY WITH REMOVAL OF ABNORMAL FAC      664.38   553.65                 0  90
63015   LAMINECTOMY WITH EXPLORATION AND/OR DECO      821.25   684.38                 0  90
63016   LAMINECTOMY WITH EXPLORATION AND/OR DECO      838.55   698.79                 0  90
                                                                                                   Page 168 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                      DESCRIPTION                FEE      FEE        FEE      BR PA DAYS   E
63017   LAMINECTOMY WITH EXPLORATION AND/OR DECO      687.59   572.99                 0  90
63020   LAMINOTOMY (HEMILAMINECTOMY), WITH DECOM      651.69   543.08                 0  90
63030   LAMINOTOMY (HEMILAMINECTOMY), WITH DECOM      542.84   452.37                 0  90
63035   LAMINOTOMY (HEMILAMINECTOMY), WITH DECOM      116.14    96.79                 0   0
63040   LAMINOTOMY (HEMILAMINECTOMY), WITH DECOM      794.27   661.90                 0  90
63042   LAMINOTOMY (HEMILAMINECTOMY), WITH DECOM      745.48   621.23                 0  90
63043   LAMINOTOMY (HEMILAMINECTOMY), WITH DECOM      151.28   126.07                 0   0
63044   LAMINOTOMY (HEMILAMINECTOMY), WITH DECOM      161.12   134.27                 0   0
63045   LAMINECTOMY, FACETECTOMY AND FORAMINOTOM      707.93   589.95                 0  90
63046   LAMINECTOMY, FACETECTOMY AND FORAMINOTOM      675.28   562.73                 0  90
63047   LAMINECTOMY, FACETECTOMY AND FORAMINOTOM      620.05   516.71                 0  90
63048   LAMINECTOMY, FACETECTOMY AND FORAMINOTOM      123.75   103.13                 0   0
63050   LAMINOPLASTY, CERVICAL, WITH DECOMPRESSI      842.59   702.16                 0  90
63051   LAMINOPLASTY, CERVICAL, WITH DECOMPRESSI      949.65   791.38                 0  90
63055   TRANSPEDICULAR APPROACH WITH DECOMPRESSI      911.68   759.73                 0  90
63056   TRANSPEDICULAR APPROACH WITH DECOMPRESSI      845.29   704.41                 0  90
63057   TRANSPEDICULAR APPROACH WITH DECOMPRESSI      191.32   159.43                 0   0
63064   COSTOVERTEBRAL APPROACH WITH DECOMPRESSI    1,000.67   833.89                 0  90
63066   COSTOVERTEBRAL APPROACH WITH DECOMPRESSI      117.20    97.67                 0   0
63075   DISKECTOMY, ANTERIOR, WITH DECOMPRESSION      785.68   654.73                 0  90
63076   DISKECTOMY, ANTERIOR, WITH DECOMPRESSION      148.12   123.43                 0   0
63077   DISKECTOMY, ANTERIOR, WITH DECOMPRESSION      847.63   706.36                 0  90
63078   DISKECTOMY, ANTERIOR, WITH DECOMPRESSION      116.99    97.49                 0   0
63081   VERTEBRAL CORPECTOMY (VERTEBRAL BODY RES      997.19   831.00                 0  90
63082   VERTEBRAL CORPECTOMY (VERTEBRAL BODY RES      159.64   133.04                 0   0
63085   VERTEBRAL CORPECTOMY (VERTEBRAL BODY RES    1,056.75   880.63                 0  90
63086   VERTEBRAL CORPECTOMY (VERTEBRAL BODY RES      112.33    93.61                 0   0
63087   VERTEBRAL CORPECTOMY (VERTEBRAL BODY RES    1,347.04 1,122.54                 0  90
63088   VERTEBRAL CORPECTOMY (VERTEBRAL BODY RES      152.74   127.29                 0   0
                                                                                                   Page 169 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                      DESCRIPTION                FEE      FEE        FEE      BR PA DAYS   E
63090   VERTEBRAL CORPECTOMY (VERTEBRAL BODY RES    1,097.35   914.46                 0  90
63091   VERTEBRAL CORPECTOMY (VERTEBRAL BODY RES      104.65    87.21                 0   0
63101   VERTEBRAL CORPECTOMY (VERTEBRAL BODY RES    1,267.37 1,056.14                 0  90
63102   VERTEBRAL CORPECTOMY (VERTEBRAL BODY RES    1,264.91 1,054.09                 0  90
63103   VERTEBRAL CORPECTOMY (VERTEBRAL BODY RES      165.92   138.27                 0   0
63170   LAMINECTOMY WITH MYELOTOMY (EG, BISCHOF       834.29   695.24                 0  90
63172   LAMINECTOMY WITH DRAINAGE OF INTRAMEDULL      769.25   641.05                 0  90
63173   LAMINECTOMY WITH DRAINAGE OF INTRAMEDULL      946.01   788.34                 0  90
63180   LAMINECTOMY AND SECTION OF DENTATE LIGAM      775.12   645.94                 0  90
63182   LAMINECTOMY AND SECTION OF DENTATE LIGAM      805.72   671.43                 0  90
63185   LAMINECTOMY WITH RHIZOTOMY; ONE OR TWO S      617.08   514.24                 0  90
63190   LAMINECTOMY WITH RHIZOTOMY; MORE THAN TW      698.73   582.28                 0  90
63191   LAMINECTOMY WITH SECTION OF SPINAL ACCES      705.79   588.16                 0  90
63194   LAMINECTOMY WITH CORDOTOMY, WITH SECTION      803.89   669.91                 0  90
63195   LAMINECTOMY WITH CORDOTOMY, WITH SECTION      833.96   694.97                 0  90
63196   LAMINECTOMY WITH CORDOTOMY, WITH SECTION      977.35   814.46                 0  90
63197   LAMINECTOMY WITH CORDOTOMY, WITH SECTION      851.74   709.78                 0  90
63198   LAMINECTOMY WITH CORDOTOMY WITH SECTION                                   BR 0   90
63199   LAMINECTOMY WITH CORDOTOMY WITH SECTION                                   BR 0   90
63200   LAMINECTOMY, WITH RELEASE OF TETHERED SP      834.55   695.46                 0  90
63250   LAMINECTOMY FOR EXCISION OR OCCLUSION OF    1,598.00 1,331.67                 0  90
63251   LAMINECTOMY FOR EXCISION OR OCCLUSION OF    1,685.59 1,404.66                 0  90
63252   LAMINECTOMY FOR EXCISION OR OCCLUSION OF    1,677.97 1,398.31                 0  90
63265   LAMINECTOMY FOR EXCISION OR EVACUATION O      922.80   769.00                 0  90
63266   LAMINECTOMY FOR EXCISION OR EVACUATION O      950.26   791.89                 0  90
63267   LAMINECTOMY FOR EXCISION OR EVACUATION O      765.74   638.12                 0  90
63268   LAMINECTOMY FOR EXCISION OR EVACUATION O      755.15   629.29                 0  90
63270   LAMINECTOMY FOR EXCISION OF INTRASPINAL     1,138.41   948.68                 0  90
63271   LAMINECTOMY FOR EXCISION OF INTRASPINAL     1,143.50   952.92                 0  90
                                                                                                   Page 170 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
63272   LAMINECTOMY FOR EXCISION OF INTRASPINAL     1,054.35   878.63                 0  90
63273   LAMINECTOMY FOR EXCISION OF INTRASPINAL     1,016.72   847.27                 0  90
63275   LAMINECTOMY FOR BIOPSY/EXCISION OF INTRA      994.48   828.73                 0  90
63276   LAMINECTOMY FOR BIOPSY/EXCISION OF INTRA      987.74   823.12                 0  90
63277   LAMINECTOMY FOR BIOPSY/EXCISION OF INTRA      870.38   725.32                 0  90
63278   LAMINECTOMY FOR BIOPSY/EXCISION OF INTRA      850.33   708.61                 0  90
63280   LAMINECTOMY FOR BIOPSY/EXCISION OF INTRA    1,175.00   979.17                 0  90
63281   LAMINECTOMY FOR BIOPSY/EXCISION OF INTRA    1,164.76   970.64                 0  90
63282   LAMINECTOMY FOR BIOPSY/EXCISION OF INTRA    1,097.09   914.24                 0  90
63283   LAMINECTOMY FOR BIOPSY/EXCISION OF INTRA    1,045.05   870.88                 0  90
63285   LAMINECTOMY FOR BIOPSY/EXCISION OF INTRA    1,448.26 1,206.89                 0  90
63286   LAMINECTOMY FOR BIOPSY/EXCISION OF INTRA    1,447.50 1,206.25                 0  90
63287   LAMINECTOMY FOR BIOPSY/EXCISION OF INTRA    1,519.07 1,265.89                 0  90
63290   LAMINECTOMY FOR BIOPSY/EXCISION OF INTRA    1,523.85 1,269.88                 0  90
63295   OSTEOPLASTIC RECONSTRUCTION OF DORSAL SP      180.65   150.54                 0   0
63300   VERTEBRAL CORPECTOMY (VERTEBRAL BODY RES    1,024.67   853.89                 0  90
63301   VERTEBRAL CORPECTOMY (VERTEBRAL BODY RES    1,128.92   940.77                 0  90
63302   VERTEBRAL CORPECTOMY (VERTEBRAL BODY RES    1,122.02   935.02                 0  90
63303   VERTEBRAL CORPECTOMY (VERTEBRAL BODY RES    1,180.12   983.43                 0  90
63304   VERTEBRAL CORPECTOMY (VERTEBRAL BODY RES    1,261.18 1,050.98                 0  90
63305   VERTEBRAL CORPECTOMY (VERTEBRAL BODY RES    1,296.32 1,080.27                 0  90
63306   VERTEBRAL CORPECTOMY (VERTEBRAL BODY RES    1,333.66 1,111.39                 0  90
63307   VERTEBRAL CORPECTOMY (VERTEBRAL BODY RES    1,200.00 1,000.00                 0  90
63308   VERTEBRAL CORPECTOMY (VERTEBRAL BODY RES      191.92   159.93                 0   0
63600   CREATION OF LESION OF SPINAL CORD BY STE                                  BR 0   90
63610   STEREOTACTIC STIMULATION OF SPINAL CORD,                                  BR 0    0
63615   STEREOTACTIC BIOPSY, ASPIRATION, OR EXCI                                  BR 0   90
63620   STEREOTACTIC RADIOSURGERY (PARTICLE BEAM      443.37   370.00                 0  90
63621   STEREOTACTIC RADIOSURGERY (PARTICLE BEAM      138.43   115.36                 0   0
                                                                                                   Page 171 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
63650   PERCUTANEOUS IMPLANTATION OF NEUROSTIMUL      241.53   201.28                 0  10
63655   LAMINECTOMY FOR IMPLANTATION OF NEUROSTI      466.84   389.03                 0  90
63661   REMOVAL OF SPINAL NEUROSTIMULATOR ELECTR      266.38   122.01                 0  10
63662   REMOVAL OF SPINAL NEUROSTIMULATOR ELECTR      332.71   277.26                 0  90
63663   REVISION INCLUDING REPLACEMENT, WHEN PER      391.16   185.93                 0  10
63664   REVISION INCLUDING REPLACEMENT, WHEN PER      346.25   288.54                 0  90
63685   INSERTION OR REPLACEMENT OF SPINAL NEURO      280.16   233.47                 0  10
63688   REVISION OR REMOVAL OF IMPLANTED SPINAL       231.55   192.96                 0  10
63700   REPAIR OF MENINGOCELE; LESS THAN 5 CM DI      681.99   568.33                 0  90
63702   REPAIR OF MENINGOCELE; LARGER THAN 5 CM       744.44   620.37                 0  90
63704   REPAIR OF MYELOMENINGOCELE; LESS THAN 5       859.07   715.90                 0  90
63706   REPAIR OF MYELOMENINGOCELE; LARGER THAN       996.75   830.63                 0  90
63707   REPAIR OF DURAL/CEREBROSPINAL FLUID LEAK      503.43   419.53                 0  90
63709   REPAIR OF DURAL/CEREBROSPINAL FLUID LEAK      612.58   510.49                 0  90
63710   DURAL GRAFT, SPINAL                           612.73   510.61                 0  90
63740   CREATION OF SHUNT, LUMBAR, SUBARACHNOID-      513.38   427.82                 0  90
63741   CREATION OF SHUNT, LUMBAR, SUBARACHNOID-      340.40   283.67                 0  90
63744   REPLACEMENT, IRRIGATION OR REVISION OF L      359.03   299.20                 0  90
63746   REMOVAL OF ENTIRE LUMBOSUBARACHNOID SHUN      298.62   248.85                 0  90
64400   INJECTION, ANESTHETIC AGENT; TRIGEMINAL        65.14    30.00                 0   0
64402   INJECTION, ANESTHETIC AGENT; FACIAL NERV       64.67    34.21                 0   0
64405   INJECTION, ANESTHETIC AGENT; GREATER OCC       60.92    33.74                 0   0
64408   INJECTION, ANESTHETIC AGENT; VAGUS NERVE       68.14    41.82                 0   0
64410   INJECTION, ANESTHETIC AGENT; PHRENIC NER       85.61    36.48                 0   0
64412   INJECTION, ANESTHETIC AGENT; SPINAL ACCE       84.72    32.04                 0   0
64413   INJECTION, ANESTHETIC AGENT; CERVICAL PL       69.19    35.30                 0   0
64415   INJECTION, ANESTHETIC AGENT; BRACHIAL PL       84.08    34.58                 0   0
64416   INJECTION, ANESTHETIC AGENT; BRACHIAL PL      101.02    84.19                 0   0
64417   INJECTION, ANESTHETIC AGENT; AXILLARY NE       86.78    34.79                 0   0
                                                                                                   Page 172 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
64418   INJECTION, ANESTHETIC AGENT; SUPRASCAPUL       84.07    33.56                 0   0
64420   INJECTION, ANESTHETIC AGENT; INTERCOSTAL      103.18    30.40                 0   0
64421   INJECTION, ANESTHETIC AGENT; INTERCOSTAL      155.39    41.31                 0   0
64425   INJECTION, ANESTHETIC AGENT; ILIOINGUINA       74.78    43.04                 0   0
64430   INJECTION, ANESTHETIC AGENT; PUDENDAL NE       92.44    40.32                 0   0
64435   INJECTION, ANESTHETIC AGENT; PARACERVICA       88.88    40.43                 0   0
64445   INJECTION, ANESTHETIC AGENT; SCIATIC NER       85.28    37.23                 0   0
64446   INJECTION, ANESTHETIC AGENT; SCIATIC NER       96.39    80.33                 0   0
64447   INJECTION, ANESTHETIC AGENT; FEMORAL NER       39.99    33.33                 0   0
64448   INJECTION, ANESTHETIC AGENT; FEMORAL NER       87.40    72.84                 0   0
64449   INJECTION, ANESTHETIC AGENT; LUMBAR PLEX       86.39    72.00                 0   0
64450   INJECTION, ANESTHETIC AGENT; OTHER PERIP       59.89    33.91                 0   0
64455   INJECTION, ANESTHETIC AGENT AND/OR STERO       30.18    19.71                 0   0
64479   INJECTION, ANESTHETIC AGENT AND/OR STERO      185.97    57.14                 0   0
64480   INJECTION, ANESTHETIC AGENT AND/OR STERO       87.91    36.96                 0   0
64483   INJECTION, ANESTHETIC AGENT AND/OR STERO      185.39    50.51                 0   0
64484   INJECTION, ANESTHETIC AGENT AND/OR STERO       89.21    31.27                 0   0
64490   INJECTION(S), DIAGNOSTIC OR THERAPEUTIC        80.54    43.43                 0   0
64491   INJECTION(S), DIAGNOSTIC OR THERAPEUTIC        39.28    24.78                 0   0
64492   INJECTION(S), DIAGNOSTIC OR THERAPEUTIC        39.82    25.24                 0   0
64493   INJECTION(S), DIAGNOSTIC OR THERAPEUTIC        73.10    36.92                 0   0
64494   INJECTION(S), DIAGNOSTIC OR THERAPEUTIC        35.32    21.17                 0   0
64495   INJECTION(S), DIAGNOSTIC OR THERAPEUTIC        35.86    21.63                 0   0
64505   INJECTION, ANESTHETIC AGENT; SPHENOPALAT       59.09    39.40                 0   0
64508   INJECTION, ANESTHETIC AGENT; CAROTID SIN       90.47    33.76                 0   0
64510   INJECTION, ANESTHETIC AGENT; STELLATE GA       92.33    31.61                 0   0
64517   INJECTION, ANESTHETIC AGENT; SUPERIOR HY      102.07    55.52                 0   0
64520   INJECTION, ANESTHETIC AGENT; LUMBAR OR T      124.37    35.35                 0   0
64530   INJECTION, ANESTHETIC AGENT; CELIAC PLEX      123.55    42.05                 0   0
                                                                                                   Page 173 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
64553   PERCUTANEOUS IMPLANTATION OF NEUROSTIMUL      125.00   125.00                 0  10
64555   PERCUTANEOUS IMPLANTATION OF NEUROSTIMUL      123.43    70.05                 0  10
64561   PERCUTANEOUS IMPLANTATION OF NEUROSTIMUL      767.18   196.92                 0  10
64565   PERCUTANEOUS IMPLANTATION OF NEUROSTIMUL                                  BR 0   10
64566   POSTERIOR TIBIAL NEUROSTIMULATION, PERCU       62.17    11.51                 0   0
64568   INCISION FOR IMPLANTATION OF CRANIAL NER      300.29   250.24                 0  90
64569   REVISION OR REPLACEMENT OF CRANIAL NERVE      290.23   241.86                 0  90
64570   REMOVAL OF CRANIAL NERVE (EG, VAGUS NERV      255.48   212.59                 0  90
64575   INCISION FOR IMPLANTATION OF NEUROSTIMUL      161.24   134.37                 0  90
64580   INCISION FOR IMPLANTATION OF NEUROSTIMUL      169.70   141.42                 0  90
64581   INCISION FOR IMPLANTATION OF NEUROSTIMUL                                  BR 0   90
64585   REVISION OR REMOVAL OF PERIPHERAL NEUROS      258.56    84.41                 0  10
64590   INSERTION OR REPLACEMENT OF PERIPHERAL O      220.25    93.30                 0  10
64595   REVISION OR REMOVAL OF PERIPHERAL OR GAS      247.18    75.34                 0  10
64600   DESTRUCTION BY NEUROLYTIC AGENT, TRIGEMI      260.20    98.90                 0  10
64605   DESTRUCTION BY NEUROLYTIC AGENT, TRIGEMI      338.94   156.11                 0  10
64610   DESTRUCTION BY NEUROLYTIC AGENT, TRIGEMI      403.71   224.65                 0  10
64611   CHEMODENERVATION OF PAROTID AND SUBMANDI       47.15    35.32                 0  10
64612   CHEMODENERVATION OF MUSCLE(S); MUSCLE(S)       92.75    62.94                 0  10
64613   CHEMODENERVATION OF MUSCLE(S); NECK MUSC       95.71    59.86                 0  10
64614   CHEMODENERVATION OF MUSCLE(S); EXTREMITY      106.76    66.20                 0  10
64620   DESTRUCTION BY NEUROLYTIC AGENT, INTERCO      165.76    77.43                 0  10
64630   DESTRUCTION BY NEUROLYTIC AGENT; PUDENDA      134.26    88.71                 0  10
64632   DESTRUCTION BY NEUROLYTIC AGENT; PLANTAR       49.36    34.92                 0  10
64633   DESTRUCTION BY NEUROLYTIC AGENT, PARAVER      206.53   172.11                 0  10
64634   DESTRUCTION BY NEUROLYTIC AGENT, PARAVER       94.98    79.15                 0   0
64635   DESTRUCTION BY NEUROLYTIC AGENT, PARAVER      202.94   169.12                 0  10
64636   DESTRUCTION BY NEUROLYTIC AGENT, PARAVER       85.49    71.24                 0   0
64640   DESTRUCTION BY NEUROLYTIC AGENT; OTHER P      144.50    86.17                 0  10
                                                                                                   Page 174 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
64650   CHEMODENERVATION OF ECCRINE GLANDS; BOTH       35.16    17.82                 0   0
64653   CHEMODENERVATION OF ECCRINE GLANDS; OTHE       40.07    22.32                 0   0
64680   DESTRUCTION BY NEUROLYTIC AGENT, WITH OR      192.68    75.04                 0  10
64681   DESTRUCTION BY NEUROLYTIC AGENT, WITH OR      257.21   103.80                 0  10
64702   NEUROPLASTY; DIGITAL, ONE OR BOTH, SAME       249.63   208.03                 0  90
64704   NEUROPLASTY; NERVE OF HAND OR FOOT            189.00   157.50                 0  90
64708   NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM      260.04   216.70                 0  90
64712   NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM      299.18   249.32                 0  90
64713   NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM      418.13   348.44                 0  90
64714   NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM      345.27   287.73                 0  90
64716   NEUROPLASTY AND/OR TRANSPOSITION; CRANIA      300.00   300.00                 0  90
64718   NEUROPLASTY AND/OR TRANSPOSITION; ULNAR       317.85   264.88                 0  90
64719   NEUROPLASTY AND/OR TRANSPOSITION; ULNAR       223.74   186.45                 0  90
64721   NEUROPLASTY AND/OR TRANSPOSITION; MEDIAN      239.15   198.68                 0  90
64722   DECOMPRESSION; UNSPECIFIED NERVE(S) (SPE      181.74   151.45                 0  90
64726   DECOMPRESSION; PLANTAR DIGITAL NERVE          167.01   139.18                 0  90
64727   INTERNAL NEUROLYSIS, REQUIRING USE OF OP                                  BR 0    0
64732   TRANSECTION OR AVULSION OF; SUPRAORBITAL      208.37   173.65                 0  90
64734   TRANSECTION OR AVULSION OF; INFRAORBITAL      235.57   196.31                 0  90
64736   TRANSECTION OR AVULSION OF; MENTAL NERVE      211.67   176.39                 0  90
64738   TRANSECTION OR AVULSION OF; INFERIOR ALV      265.89   221.58                 0  90
64740   TRANSECTION OR AVULSION OF; LINGUAL NERV                                  BR 0   90
64742   TRANSECTION OR AVULSION OF; FACIAL NERVE                                  BR 0   90
64744   TRANSECTION OR AVULSION OF; GREATER OCCI      237.46   197.88                 0  90
64746   TRANSECTION OR AVULSION OF; PHRENIC NERV      253.15   210.96                 0  90
64752   TRANSECTION OR AVULSION OF; VAGUS NERVE       275.11   229.26                 0  90
64755   TRANSECTION OR AVULSION OF; VAGUS NERVES      483.83   403.19                 0  90
64760   TRANSECTION OR AVULSION OF; VAGUS NERVE                                   BR 0   90
64761   TRANSECTION OR AVULSION OF; PUDENDAL NER                                  BR 0   90
                                                                                                   Page 175 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
64763   TRANSECTION OR AVULSION OF OBTURATOR NER      285.34   237.79                 0  90
64766   TRANSECTION OR AVULSION OF OBTURATOR NER      337.10   280.92                 0  90
64771   TRANSECTION OR AVULSION OF OTHER CRANIAL      329.05   274.21                 0  90
64772   TRANSECTION OR AVULSION OF OTHER SPINAL       313.03   260.86                 0  90
64774   EXCISION OF NEUROMA; CUTANEOUS NERVE, SU      229.67   191.40                 0  90
64776   EXCISION OF NEUROMA; DIGITAL NERVE, ONE       220.75   183.96                 0  90
64778   EXCISION OF NEUROMA; DIGITAL NERVE, EACH      107.05    89.21                 0   0
64782   EXCISION OF NEUROMA; HAND OR FOOT, EXCEP      255.64   213.04                 0  90
64783   EXCISION OF NEUROMA; HAND OR FOOT, EACH       126.61   105.51                 0   0
64784   EXCISION OF NEUROMA; MAJOR PERIPHERAL NE      405.09   337.58                 0  90
64786   EXCISION OF NEUROMA; SCIATIC NERVE            612.62   510.52                 0  90
64787   IMPLANTATION OF NERVE END INTO BONE OR M      146.89   122.41                 0   0
64788   EXCISION OF NEUROFIBROMA OR NEUROLEMMOMA      213.91   178.26                 0  90
64790   EXCISION OF NEUROFIBROMA OR NEUROLEMMOMA      466.13   388.44                 0  90
64792   EXCISION OF NEUROFIBROMA OR NEUROLEMMOMA      587.33   489.44                 0  90
64795   BIOPSY OF NERVE                               109.76    91.47                 0   0
64802   SYMPATHECTOMY, CERVICAL                       344.32   286.93                 0  90
64804   SYMPATHECTOMY, CERVICOTHORACIC                532.09   443.41                 0  90
64809   SYMPATHECTOMY, THORACOLUMBAR                  489.44   407.87                 0  90
64818   SYMPATHECTOMY, LUMBAR                         377.42   314.52                 0  90
64820   SYMPATHECTOMY; DIGITAL ARTERIES, EACH DI      423.61   353.01                 0  90
64821   SYMPATHECTOMY; RADIAL ARTERY                  386.12   321.77                 0  90
64822   SYMPATHECTOMY; ULNAR ARTERY                   384.76   320.64                 0  90
64823   SYMPATHECTOMY; SUPERFICIAL PALMAR ARCH        435.30   362.75                 0  90
64831   SUTURE OF DIGITAL NERVE, HAND OR FOOT; O      409.04   340.87                 0  90
64832   SUTURE OF DIGITAL NERVE, HAND OR FOOT; E      198.97   165.81                 0   0
64834   SUTURE OF ONE NERVE; HAND OR FOOT, COMMO      419.73   349.78                 0  90
64835   SUTURE OF ONE NERVE; MEDIAN MOTOR THENAR      455.34   379.45                 0  90
64836   SUTURE OF ONE NERVE; ULNAR MOTOR              455.72   379.77                 0  90
                                                                                                   Page 176 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
64837   SUTURE OF EACH ADDITIONAL NERVE, HAND OR      220.61   183.84                 0   0
64840   SUTURE OF POSTERIOR TIBIAL NERVE              507.89   423.25                 0  90
64856   SUTURE OF MAJOR PERIPHERAL NERVE, ARM OR      570.36   475.30                 0  90
64857   SUTURE OF MAJOR PERIPHERAL NERVE, ARM OR      596.54   497.12                 0  90
64858   SUTURE OF SCIATIC NERVE                       686.35   571.96                 0  90
64859   SUTURE OF EACH ADDITIONAL MAJOR PERIPHER      150.20   125.17                 0   0
64861   SUTURE OF; BRACHIAL PLEXUS                    783.02   652.52                 0  90
64862   SUTURE OF; LUMBAR PLEXUS                      795.80   663.17                 0  90
64864   SUTURE OF FACIAL NERVE; EXTRACRANIAL          499.73   416.44                 0  90
64865   SUTURE OF FACIAL NERVE; INFRATEMPORAL, W      667.65   556.38                 0  90
64866   ANASTOMOSIS; FACIAL-SPINAL ACCESSORY          685.70   571.42                 0  90
64868   ANASTOMOSIS; FACIAL-HYPOGLOSSAL               595.19   495.99                 0  90
64870   ANASTOMOSIS; FACIAL-PHRENIC                   581.90   484.92                 0  90
64872   SUTURE OF NERVE; REQUIRING SECONDARY OR        69.95    58.30                 0   0
64874   SUTURE OF NERVE; REQUIRING EXTENSIVE MOB      104.36    86.97                 0   0
64876   SUTURE OF NERVE; REQUIRING SHORTENING OF                                  BR 0    0
64885   NERVE GRAFT (INCLUDES OBTAINING GRAFT),       646.71   538.93                 0  90
64886   NERVE GRAFT (INCLUDES OBTAINING GRAFT),       764.20   636.83                 0  90
64890   NERVE GRAFT (INCLUDES OBTAINING GRAFT),       614.05   511.71                 0  90
64891   NERVE GRAFT (INCLUDES OBTAINING GRAFT),       600.06   500.05                 0  90
64892   NERVE GRAFT (INCLUDES OBTAINING GRAFT),       595.84   496.53                 0  90
64893   NERVE GRAFT (INCLUDES OBTAINING GRAFT),       640.38   533.65                 0  90
64895   NERVE GRAFT (INCLUDES OBTAINING GRAFT),       726.08   605.07                 0  90
64896   NERVE GRAFT (INCLUDES OBTAINING GRAFT),       795.20   662.67                 0  90
64897   NERVE GRAFT (INCLUDES OBTAINING GRAFT),       710.93   592.45                 0  90
64898   NERVE GRAFT (INCLUDES OBTAINING GRAFT),       773.43   644.53                 0  90
64901   NERVE GRAFT, EACH ADDITIONAL NERVE; SING      348.38   290.32                 0   0
64902   NERVE GRAFT, EACH ADDITIONAL NERVE; MULT      406.50   338.75                 0   0
64905   NERVE PEDICLE TRANSFER; FIRST STAGE           541.54   451.28                 0  90
                                                                                                   Page 177 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
64907   NERVE PEDICLE TRANSFER; SECOND STAGE          709.52   591.27                 0  90
64910   NERVE REPAIR; WITH SYNTHETIC CONDUIT OR       382.49   318.74                 0  90
64911   NERVE REPAIR; WITH AUTOGENOUS VEIN GRAFT      463.72   386.44                 0  90
64999   UNLISTED PROCEDURE, NERVOUS SYSTEM                                        BR 0    0
65091   EVISCERATION OF OCULAR CONTENTS; WITHOUT      338.28   281.90                 0  90
65093   EVISCERATION OF OCULAR CONTENTS; WITH IM      339.98   283.32                 0  90
65101   ENUCLEATION OF EYE; WITHOUT IMPLANT           388.43   323.70                 0  90
65103   ENUCLEATION OF EYE; WITH IMPLANT, MUSCLE      404.44   337.03                 0  90
65105   ENUCLEATION OF EYE; WITH IMPLANT, MUSCLE      444.09   370.08                 0  90
65110   EXENTERATION OF ORBIT (DOES NOT INCLUDE       641.75   534.80                 0  90
65112   EXENTERATION OF ORBIT (DOES NOT INCLUDE       762.47   635.40                 0  90
65114   EXENTERATION OF ORBIT (DOES NOT INCLUDE       785.26   654.39                 0  90
65125   MODIFICATION OF OCULAR IMPLANT WITH PLAC                                  BR 0   90
65130   INSERTION OF OCULAR IMPLANT SECONDARY; A      382.86   319.05                 0  90
65135   INSERTION OF OCULAR IMPLANT SECONDARY; A      389.50   324.59                 0  90
65140   INSERTION OF OCULAR IMPLANT SECONDARY; A      422.08   351.74                 0  90
65150   REINSERTION OF OCULAR IMPLANT; WITH OR W      311.51   259.60                 0  90
65155   REINSERTION OF OCULAR IMPLANT; WITH USE       449.61   374.68                 0  90
65175   REMOVAL OF OCULAR IMPLANT                     345.32   287.77                 0  90
65205   REMOVAL OF FOREIGN BODY, EXTERNAL EYE; C       30.04    18.88                 0   0
65210   REMOVAL OF FOREIGN BODY, EXTERNAL EYE; C       36.75    22.83                 0   0
65220   REMOVAL OF FOREIGN BODY, EXTERNAL EYE; C       30.98    18.85                 0   0
65222   REMOVAL OF FOREIGN BODY, EXTERNAL EYE; C       40.33    24.79                 0   0
65235   REMOVAL OF FOREIGN BODY, INTRAOCULAR; FR      353.81   294.84                 0  90
65260   REMOVAL OF FOREIGN BODY, INTRAOCULAR; FR      489.95   408.30                 0  90
65265   REMOVAL OF FOREIGN BODY, INTRAOCULAR; FR      549.62   458.02                 0  90
65270   REPAIR OF LACERATION; CONJUNCTIVA, WITH       152.43    60.78                 0  10
65272   REPAIR OF LACERATION; CONJUNCTIVA, BY MO      268.08   145.88                 0  90
65273   REPAIR OF LACERATION; CONJUNCTIVA, BY MO      193.00   160.83                 0  90
                                                                                                   Page 178 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
65275   REPAIR OF LACERATION; CORNEA, NONPERFORA      286.50   189.74                 0  90
65280   REPAIR OF LACERATION; CORNEA AND/OR SCLE      337.92   281.60                 0  90
65285   REPAIR OF LACERATION; CORNEA AND/OR SCLE      525.48   437.90                 0  90
65286   REPAIR OF LACERATION; APPLICATION OF TIS      381.83   207.03                 0  90
65290   REPAIR OF WOUND, EXTRAOCULAR MUSCLE, TEN      249.46   207.89                 0  90
65400   EXCISION OF LESION, CORNEA (KERATECTOMY,      348.98   251.85                 0  90
65410   BIOPSY OF CORNEA                               77.98    44.89                 0   0
65420   EXCISION OR TRANSPOSITION OF PTERYGIUM;       284.60   162.10                 0  90
65426   EXCISION OR TRANSPOSITION OF PTERYGIUM;       351.28   202.08                 0  90
65430   SCRAPING OF CORNEA, DIAGNOSTIC, FOR SMEA       60.75    45.09                 0   0
65435   REMOVAL OF CORNEAL EPITHELIUM; WITH OR W       42.56    30.34                 0   0
65436   REMOVAL OF CORNEAL EPITHELIUM; WITH APPL      197.59   157.07                 0  90
65450   DESTRUCTION OF LESION OF CORNEA BY CRYOT      167.20   137.28                 0  90
65600   MULTIPLE PUNCTURES OF ANTERIOR CORNEA (E      202.94   141.43                 0  90
65710   KERATOPLASTY (CORNEAL TRANSPLANT); ANTER      563.88   469.90                 0  90
65730   KERATOPLASTY (CORNEAL TRANSPLANT); PENET      624.78   520.65                 0  90
65750   KERATOPLASTY (CORNEAL TRANSPLANT); PENET      633.27   527.73                 0  90
65755   KERATOPLASTY (CORNEAL TRANSPLANT); PENET      629.50   524.58                 0  90
65756   KERATOPLASTY (CORNEAL TRANSPLANT); ENDOT      613.74   511.45                 0  90
65760   KERATOMILEUSIS                                942.53   785.44                 0   0
65765   KERATOPHAKIA                                1,030.97   859.14                 0   0
65767   EPIKERATOPLASTY                                                           BR 0    0
65770   KERATOPROSTHESIS                              721.48   601.24                 0  90
65771   RADIAL KERATOTOMY                             412.62   343.85                 0   0
65772   CORNEAL RELAXING INCISION FOR CORRECTION      233.71   200.00                 0  90
65775   CORNEAL WEDGE RESECTION FOR CORRECTION O                                  BR 0   90
65800   PARACENTESIS OF ANTERIOR CHAMBER OF EYE        80.33    56.69                 0   0
65805   PARACENTESIS OF ANTERIOR CHAMBER OF EYE        88.70    56.89                 0   0
65810   PARACENTESIS OF ANTERIOR CHAMBER OF EYE       236.20   196.84                 0  90
                                                                                                   Page 179 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
65815   PARACENTESIS OF ANTERIOR CHAMBER OF EYE       345.47   200.32                 0  90
65820   GONIOTOMY                                     390.73   325.61                 0  90
65850   TRABECULOTOMY AB EXTERNO                      435.02   362.52                 0  90
65855   TRABECULOPLASTY BY LASER SURGERY, ONE OR      300.00   300.00                 0  10
65860   SEVERING ADHESIONS OF ANTERIOR SEGMENT,       200.00   200.00                 0  90
65865   SEVERING ADHESIONS OF ANTERIOR SEGMENT O      248.68   207.24                 0  90
65870   SEVERING ADHESIONS OF ANTERIOR SEGMENT O      303.25   252.71                 0  90
65875   SEVERING ADHESIONS OF ANTERIOR SEGMENT O      321.43   267.86                 0  90
65880   SEVERING ADHESIONS OF ANTERIOR SEGMENT O      338.63   282.19                 0  90
65900   REMOVAL OF EPITHELIAL DOWNGROWTH, ANTERI      498.17   415.14                 0  90
65920   REMOVAL OF IMPLANTED MATERIAL, ANTERIOR       400.49   333.75                 0  90
65930   REMOVAL OF BLOOD CLOT, ANTERIOR SEGMENT       331.60   276.33                 0  90
66020   INJECTION, ANTERIOR CHAMBER OF EYE (SEPA      102.88    60.00                 0  10
66030   INJECTION, ANTERIOR CHAMBER OF EYE (SEPA       92.03    60.00                 0  10
66130   EXCISION OF LESION, SCLERA                    377.50   246.28                 0  90
66150   FISTULIZATION OF SCLERA FOR GLAUCOMA; TR      442.17   368.48                 0  90
66155   FISTULIZATION OF SCLERA FOR GLAUCOMA; TH      440.31   366.93                 0  90
66160   FISTULIZATION OF SCLERA FOR GLAUCOMA; SC      498.79   415.66                 0  90
66165   FISTULIZATION OF SCLERA FOR GLAUCOMA; IR      432.57   360.48                 0  90
66170   FISTULIZATION OF SCLERA FOR GLAUCOMA; TR      603.41   502.85                 0  90
66172   FISTULIZATION OF SCLERA FOR GLAUCOMA; TR      756.44   630.37                 0  90
66174   TRANSLUMINAL DILATION OF AQUEOUS OUTFLOW      460.03   383.16                 0  90
66175   TRANSLUMINAL DILATION OF AQUEOUS OUTFLOW      517.63   431.31                 0  90
66180   AQUEOUS SHUNT TO EXTRAOCULAR RESERVOIR (      594.68   495.57                 0  90
66185   REVISION OF AQUEOUS SHUNT TO EXTRAOCULAR      377.14   314.29                 0  90
66220   REPAIR OF SCLERAL STAPHYLOMA; WITHOUT GR                                  BR 0   90
66225   REPAIR OF SCLERAL STAPHYLOMA; WITH GRAFT                                  BR 0   90
66250   REVISION OR REPAIR OF OPERATIVE WOUND OF      405.55   233.35                 0  90
66500   IRIDOTOMY BY STAB INCISION (SEPARATE PRO      186.10   155.08                 0  90
                                                                                                   Page 180 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                          DESCRIPTION            FEE      FEE        FEE      BR PA DAYS   E
66505   IRIDOTOMY BY STAB INCISION (SEPARATE PRO      203.29   169.41                 0  90
66600   IRIDECTOMY, WITH CORNEOSCLERAL OR CORNEA      414.29   345.24                 0  90
66605   IRIDECTOMY, WITH CORNEOSCLERAL OR CORNEA      542.50   452.08                 0  90
66625   IRIDECTOMY, WITH CORNEOSCLERAL OR CORNEA      221.75   200.00                 0  90
66630   IRIDECTOMY, WITH CORNEOSCLERAL OR CORNEA      287.89   239.91                 0  90
66635   IRIDECTOMY, WITH CORNEOSCLERAL OR CORNEA      290.48   242.07                 0  90
66680   REPAIR OF IRIS, CILIARY BODY (AS FOR IRI      260.53   217.11                 0  90
66682   SUTURE OF IRIS, CILIARY BODY (SEPARATE P      316.86   264.05                 0  90
66700   CILIARY BODY DESTRUCTION; DIATHERMY           232.04   200.00                 0  90
66710   CILIARY BODY DESTRUCTION; CYCLOPHOTOCOAG      228.62   200.00                 0  90
66711   CILIARY BODY DESTRUCTION; CYCLOPHOTOCOAG      320.87   267.39                 0  90
66720   CILIARY BODY DESTRUCTION; CRYOTHERAPY         242.35   200.00                 0  90
66740   CILIARY BODY DESTRUCTION; CYCLODIALYSIS       226.90   200.00                 0  90
66761   IRIDOTOMY/IRIDECTOMY BY LASER SURGERY (E      234.59   173.75                 0  10
66762   IRIDOPLASTY BY PHOTOCOAGULATION (ONE OR       244.63   179.25                 0  90
66770   DESTRUCTION OF CYST OR LESION IRIS OR CI                                  BR 0   90
66820   DISCISSION OF SECONDARY MEMBRANOUS CATAR      212.92   177.43                 0  90
66821   DISCISSION OF SECONDARY MEMBRANOUS CATAR      167.60   130.64                 0  90
66825   REPOSITIONING OF INTRAOCULAR LENS PROSTH      396.26   330.22                 0  90
66830   REMOVAL OF SECONDARY MEMBRANOUS CATARACT      361.09   300.91                 0  90
66840   REMOVAL OF LENS MATERIAL; ASPIRATION TEC      354.00   295.00                 0  90
66850   REMOVAL OF LENS MATERIAL; PHACOFRAGMENTA      401.64   334.70                 0  90
66852   REMOVAL OF LENS MATERIAL; PARS PLANA APP      429.75   358.13                 0  90
66920   REMOVAL OF LENS MATERIAL; INTRACAPSULAR       383.95   320.00                 0  90
66930   REMOVAL OF LENS MATERIAL; INTRACAPSULAR,      435.16   362.64                 0  90
66940   REMOVAL OF LENS MATERIAL; EXTRACAPSULAR       396.25   330.21                 0  90
66982   EXTRACAPSULAR CATARACT REMOVAL WITH INSE      548.38   456.98                 0  90
66983   INTRACAPSULAR CATARACT EXTRACTION WITH I      440.00   440.00                 0  90
66984   EXTRACAPSULAR CATARACT REMOVAL WITH INSE      440.00   440.00                 0  90
                                                                                                   Page 181 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
66985   INSERTION OF INTRAOCULAR LENS PROSTHESIS      386.09   321.75                 0  90
66986   EXCHANGE OF INTRAOCULAR LENS                  475.89   396.58                 0  90
66990   USE OF OPHTHALMIC ENDOSCOPE (LIST SEPARA       47.41    39.51                 0   0
66999   UNLISTED PROCEDURE, ANTERIOR SEGMENT OF                                   BR 0    0
67005   REMOVAL OF VITREOUS, ANTERIOR APPROACH (      440.00   440.00                 0  90
67010   REMOVAL OF VITREOUS, ANTERIOR APPROACH (      440.00   440.00                 0  90
67015   ASPIRATION OR RELEASE OF VITREOUS, SUBRE      300.02   250.02                 0  90
67025   INJECTION OF VITREOUS SUBSTITUTE, PARS P      379.33   265.45                 0  90
67027   IMPLANTATION OF INTRAVITREAL DRUG DELIVE      440.00   440.00                 0  90
67028   INTRAVITREAL INJECTION OF A PHARMACOLOGI      200.00   200.00                 0   0
67030   DISCISSION OF VITREOUS STRANDS (WITHOUT       440.00   440.00                 0  90
67031   SEVERING OF VITREOUS STRANDS, VITREOUS F      440.00   440.00                 0  90
67036   VITRECTOMY, MECHANICAL, PARS PLANA APPRO      491.62   440.00                 0  90
67039   VITRECTOMY, MECHANICAL, PARS PLANA APPRO      631.88   526.57                 0  90
67040   VITRECTOMY, MECHANICAL, PARS PLANA APPRO      727.42   606.18                 0  90
67041   VITRECTOMY, MECHANICAL, PARS PLANA APPRO      662.21   551.85                 0  90
67042   VITRECTOMY, MECHANICAL, PARS PLANA APPRO      756.88   630.73                 0  90
67043   VITRECTOMY, MECHANICAL, PARS PLANA APPRO      795.40   662.83                 0  90
67101   REPAIR OF RETINAL DETACHMENT, ONE OR MOR      400.55   400.00                 0  90
67105   REPAIR OF RETINAL DETACHMENT, ONE OR MOR      369.37   271.30                 0  90
67107   REPAIR OF RETINAL DETACHMENT; SCLERAL BU      616.63   513.86                 0  90
67108   REPAIR OF RETINAL DETACHMENT; WITH VITRE      818.41   682.01                 0  90
67110   REPAIR OF RETINAL DETACHMENT; BY INJECTI      450.04   325.82                 0  90
67112   REPAIR OF RETINAL DETACHMENT; BY SCLERAL      674.05   561.71                 0  90
67113   REPAIR OF COMPLEX RETINAL DETACHMENT (EG      874.04   728.37                 0  90
67115   RELEASE OF ENCIRCLING MATERIAL (POSTERIO      249.64   208.03                 0  90
67120   REMOVAL OF IMPLANTED MATERIAL, POSTERIOR      343.79   233.99                 0  90
67121   REMOVAL OF IMPLANTED MATERIAL, POSTERIOR      459.64   383.03                 0  90
67141   PROPHYLAXIS OF RETINAL DETACHMENT (EG, R      400.00   400.00                 0  90
                                                                                                   Page 182 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                      DESCRIPTION                FEE      FEE        FEE      BR PA DAYS   E
67145   PROPHYLAXIS OF RETINAL DETACHMENT (EG, R      268.00   208.77                 0  90
67208   DESTRUCTION OF LOCALIZED LESION OF RETIN      305.31   243.56                 0  90
67210   DESTRUCTION OF LOCALIZED LESION OF RETIN      354.17   283.25                 0  90
67218   DESTRUCTION OF LOCALIZED LESION OF RETIN      713.69   594.74                 0  90
67220   DESTRUCTION OF LOCALIZED LESION OF CHORO      545.94   429.73                 0  90
67221   DESTRUCTION OF LOCALIZED LESION OF CHORO      164.03   160.00                 0   0
67225   DESTRUCTION OF LOCALIZED LESION OF CHORO       80.00    80.00                 0   0
67227   DESTRUCTION OF EXTENSIVE OR PROGRESSIVE       312.84   241.22                 0  90
67228   TREATMENT OF EXTENSIVE OR PROGRESSIVE RE      601.78   436.47                 0  90
67229   TREATMENT OF EXTENSIVE OR PROGRESSIVE RE      576.75   480.63                 0  90
67250   SCLERAL REINFORCEMENT (SEPARATE PROCEDUR      410.81   342.35                 0  90
67255   SCLERAL REINFORCEMENT (SEPARATE PROCEDUR      438.78   365.65                 0  90
67299   UNLISTED PROCEDURE, POSTERIOR SEGMENT                                     BR 0    0
67311   STRABISMUS SURGERY, RECESSION OR RESECTI      304.87   254.06                 0  90
67312   STRABISMUS SURGERY, RECESSION OR RESECTI      362.39   301.99                 0  90
67314   STRABISMUS SURGERY, RECESSION OR RESECTI      340.23   283.53                 0  90
67316   STRABISMUS SURGERY, RECESSION OR RESECTI      407.44   339.53                 0  90
67318   STRABISMUS SURGERY, ANY PROCEDURE, SUPER      356.50   297.09                 0  90
67320   TRANSPOSITION PROCEDURE (EG, FOR PARETIC      280.00   280.00                 0   0
67331   STRABISMUS SURGERY ON PATIENT WITH PREVI      240.00   240.00                 0   0
67332   STRABISMUS SURGERY ON PATIENT WITH SCARR      240.00   240.00                 0   0
67334   STRABISMUS SURGERY BY POSTERIOR FIXATION      240.00   240.00                 0   0
67335   PLACEMENT OF ADJUSTABLE SUTURE(S) DURING      240.00   240.00                 0   0
67340   STRABISMUS SURGERY INVOLVING EXPLORATION      240.00   240.00                 0   0
67343   RELEASE OF EXTENSIVE SCAR TISSUE WITHOUT      332.27   276.90                 0  90
67345   CHEMODENERVATION OF EXTRAOCULAR MUSCLE        123.11    91.72                 0  10
67346   BIOPSY OF EXTRAOCULAR MUSCLE                  105.07    87.56                 0   0
67399   UNLISTED PROCEDURE, OCULAR MUSCLE                                         BR 0    0
67400   ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR      490.91   409.09                 0  90
                                                                                                   Page 183 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
67405   ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR      416.62   347.19                 0  90
67412   ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR      457.88   381.57                 0  90
67413   ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR      456.95   380.80                 0  90
67414   ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR      668.88   557.40                 0  90
67420   ORBITOTOMY WITH BONE FLAP OR WINDOW, LAT      856.39   713.66                 0  90
67430   ORBITOTOMY WITH BONE FLAP OR WINDOW, LAT      654.50   545.42                 0  90
67440   ORBITOTOMY WITH BONE FLAP OR WINDOW, LAT      634.47   528.73                 0  90
67445   ORBITOTOMY WITH BONE FLAP OR WINDOW, LAT      727.88   606.57                 0  90
67450   ORBITOTOMY WITH BONE FLAP OR WINDOW, LAT      655.96   546.63                 0  90
67500   RETROBULBAR INJECTION; MEDICATION (SEPAR       45.81    40.00                 0   0
67505   RETROBULBAR INJECTION; ALCOHOL                 43.57    40.00                 0   0
67515   INJECTION OF MEDICATION OR OTHER SUBSTAN       45.91    40.00                 0   0
67550   ORBITAL IMPLANT (IMPLANT OUTSIDE MUSCLE       511.28   426.07                 0  90
67560   ORBITAL IMPLANT (IMPLANT OUTSIDE MUSCLE       517.41   431.18                 0  90
67570   OPTIC NERVE DECOMPRESSION (EG, INCISION       607.88   506.57                 0  90
67599   UNLISTED PROCEDURE, ORBIT                                                 BR 0    0
67700   BLEPHAROTOMY, DRAINAGE OF ABSCESS, EYELI      156.85    49.70                 0  10
67710   SEVERING OF TARSORRHAPHY                      134.18    42.09                 0  10
67715   CANTHOTOMY (SEPARATE PROCEDURE)               140.06   100.00                 0  10
67800   EXCISION OF CHALAZION; SINGLE                  66.76    44.77                 0  10
67801   EXCISION OF CHALAZION; MULTIPLE, SAME LI       85.28    57.74                 0  10
67805   EXCISION OF CHALAZION; MULTIPLE, DIFFERE      105.96    71.48                 0  10
67808   EXCISION OF CHALAZION; UNDER GENERAL ANE      186.38   155.32                 0  90
67810   BIOPSY OF EYELID                              121.06    40.18                 0   0
67820   CORRECTION OF TRICHIASIS; EPILATION, BY        28.30    23.79                 1   0
67825   CORRECTION OF TRICHIASIS; EPILATION BY O      100.00   100.00                 1  10
67830   CORRECTION OF TRICHIASIS; INCISION OF LI      153.94   140.00                 0  10
67835   CORRECTION OF TRICHIASIS; INCISION OF LI      228.31   200.00                 0  90
67840   EXCISION OF LESION OF EYELID (EXCEPT CHA      159.62    68.62                 0  10
                                                                                                   Page 184 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
67850   DESTRUCTION OF LESION OF LID MARGIN (UP                                   BR 0   10
67875   TEMPORARY CLOSURE OF EYELIDS BY SUTURE (       99.04    42.55                 0   0
67880   CONSTRUCTION OF INTERMARGINAL ADHESIONS,      243.98   155.32                 0  90
67882   CONSTRUCTION OF INTERMARGINAL ADHESIONS,      297.45   199.48                 0  90
67900   REPAIR OF BROW PTOSIS (SUPRACILIARY, MID      347.33   221.97                 0  90
67901   REPAIR OF BLEPHAROPTOSIS; FRONTALIS MUSC      341.81   246.90                 0  90
67902   REPAIR OF BLEPHAROPTOSIS; FRONTALIS MUSC      356.11   296.76                 0  90
67903   REPAIR OF BLEPHAROPTOSIS; (TARSO) LEVATO      340.84   240.00                 0  90
67904   REPAIR OF BLEPHAROPTOSIS; (TARSO) LEVATO      388.15   249.62                 0  90
67906   REPAIR OF BLEPHAROPTOSIS; SUPERIOR RECTU      320.00   320.00                 0  90
67908   REPAIR OF BLEPHAROPTOSIS; CONJUNCTIVO-TA      262.07   240.00                 0  90
67909   REDUCTION OF OVERCORRECTION OF PTOSIS         293.41   192.21                 0  90
67911   CORRECTION OF LID RETRACTION                  278.42   232.02                 0  90
67912   CORRECTION OF LAGOPHTHALMOS, WITH IMPLAN      528.28   285.00                 0  90
67914   REPAIR OF ECTROPION; SUTURE                   216.40   160.00                 0  90
67915   REPAIR OF ECTROPION; THERMOCAUTERIZATION      195.92   111.38                 0  90
67916   REPAIR OF ECTROPION; EXCISION TARSAL WED      293.35   187.85                 0  90
67917   REPAIR OF ECTROPION; EXTENSIVE (EG, TARS      318.86   207.27                 0  90
67921   REPAIR OF ENTROPION; SUTURE                   206.72   117.30                 0  90
67922   REPAIR OF ENTROPION; THERMOCAUTERIZATION      190.44   107.43                 0  90
67923   REPAIR OF ENTROPION; EXCISION TARSAL WED      307.10   201.98                 0  90
67924   REPAIR OF ENTROPION; EXTENSIVE (EG, TARS      320.77   194.50                 0  90
67930   SUTURE OF RECENT WOUND, EYELID, INVOLVIN      202.23   105.77                 0  10
67935   SUTURE OF RECENT WOUND, EYELID, INVOLVIN      324.71   195.93                 0  90
67938   REMOVAL OF EMBEDDED FOREIGN BODY, EYELID      142.39    49.54                 0  10
67950   CANTHOPLASTY (RECONSTRUCTION OF CANTHUS)      316.40   205.22                 0  90
67961   EXCISION AND REPAIR OF EYELID, INVOLVING      315.41   199.67                 0  90
67966   EXCISION AND REPAIR OF EYELID, INVOLVING      400.01   273.25                 0  90
67971   RECONSTRUCTION OF EYELID, FULL THICKNESS      378.91   315.76                 0  90
                                                                                                   Page 185 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                        DESCRIPTION              FEE      FEE        FEE      BR PA DAYS   E
67973   RECONSTRUCTION OF EYELID, FULL THICKNESS      490.93   409.11                 0  90
67974   RECONSTRUCTION OF EYELID, FULL THICKNESS      488.99   407.50                 0  90
67975   RECONSTRUCTION OF EYELID, FULL THICKNESS      357.91   298.26                 0  90
67999   UNLISTED PROCEDURE, EYELIDS                                               BR 0    0
68020   INCISION OF CONJUNCTIVA, DRAINAGE OF CYS       62.11    47.86                 0  10
68040   EXPRESSION OF CONJUNCTIVAL FOLLICLES (EG       34.52    23.23                 0   0
68100   BIOPSY OF CONJUNCTIVA                          98.30    42.75                 0   0
68110   EXCISION OF LESION, CONJUNCTIVA; UP TO 1      126.99    64.19                 0  10
68115   EXCISION OF LESION, CONJUNCTIVA; OVER 1       178.11    79.72                 0  10
68130   EXCISION OF LESION, CONJUNCTIVA; WITH AD                                  BR 0   90
68135   DESTRUCTION OF LESION, CONJUNCTIVA             81.86    65.35                 0  10
68200   SUBCONJUNCTIVAL INJECTION                      22.48    15.04                 0   0
68320   CONJUNCTIVOPLASTY; WITH CONJUNCTIVAL GRA      388.99   225.71                 0  90
68325   CONJUNCTIVOPLASTY; WITH BUCCAL MUCOUS ME      337.37   281.14                 0  90
68326   CONJUNCTIVOPLASTY, RECONSTRUCTION CUL-DE      327.49   272.91                 0  90
68328   CONJUNCTIVOPLASTY, RECONSTRUCTION CUL-DE      369.33   307.78                 0  90
68330   REPAIR OF SYMBLEPHARON; CONJUNCTIVOPLAST      327.56   194.21                 0  90
68335   REPAIR OF SYMBLEPHARON; WITH FREE GRAFT       327.91   273.26                 0  90
68340   REPAIR OF SYMBLEPHARON; DIVISION OF SYMB      297.37   167.82                 0  90
68360   CONJUNCTIVAL FLAP; BRIDGE OR PARTIAL (SE      286.01   173.33                 0  90
68362   CONJUNCTIVAL FLAP; TOTAL (SUCH AS GUNDER      332.14   276.79                 0  90
68399   UNLISTED PROCEDURE, CONJUNCTIVA                                           BR 0    0
68400   INCISION, DRAINAGE OF LACRIMAL GLAND          163.78    61.83                 0  10
68420   INCISION, DRAINAGE OF LACRIMAL SAC (DACR      182.40    77.55                 0  10
68440   SNIP INCISION OF LACRIMAL PUNCTUM              61.92    42.58                 0  10
68500   EXCISION OF LACRIMAL GLAND (DACRYOADENEC      504.26   420.22                 0  90
68505   EXCISION OF LACRIMAL GLAND (DACRYOADENEC      506.57   422.15                 0  90
68510   BIOPSY OF LACRIMAL GLAND                      253.33   124.76                 0   0
68520   EXCISION OF LACRIMAL SAC (DACRYOCYSTECTO      354.79   295.66                 0  90
                                                                                                   Page 186 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
68525   BIOPSY OF LACRIMAL SAC                        139.38   116.15                 0   0
68530   REMOVAL OF FOREIGN BODY OR DACRYOLITH, L      248.47   114.15                 0  10
68540   EXCISION OF LACRIMAL GLAND TUMOR; FRONTA      475.25   396.04                 0  90
68550   EXCISION OF LACRIMAL GLAND TUMOR; INVOLV      580.21   483.51                 0  90
68700   PLASTIC REPAIR OF CANALICULI                  305.61   254.68                 0  90
68705   CORRECTION OF EVERTED PUNCTUM, CAUTERY        133.25    71.87                 0  10
68720   DACRYOCYSTORHINOSTOMY (FISTULIZATION OF       390.79   325.66                 0  90
68745   CONJUNCTIVORHINOSTOMY (FISTULIZATION OF       392.19   326.83                 0  90
68750   CONJUNCTIVORHINOSTOMY (FISTULIZATION OF       404.23   336.86                 0  90
68760   CLOSURE OF THE LACRIMAL PUNCTUM; BY THER      113.02    63.01                 0  10
68761   CLOSURE OF THE LACRIMAL PUNCTUM; BY PLUG       80.07    50.94                 0  10
68770   CLOSURE OF LACRIMAL FISTULA (SEPARATE PR      282.86   235.72                 0  90
68801   DILATION OF LACRIMAL PUNCTUM, WITH OR WI       66.60    47.09                 0  10
68810   PROBING OF NASOLACRIMAL DUCT, WITH OR WI      142.88   101.64                 0  10
68811   PROBING OF NASOLACRIMAL DUCT, WITH OR WI      107.45    89.54                 0  10
68815   PROBING OF NASOLACRIMAL DUCT, WITH OR WI      250.27   111.95                 0  10
68816   PROBING OF NASOLACRIMAL DUCT, WITH OR WI      378.57   105.46                 0  10
68840   PROBING OF LACRIMAL CANALICULI, WITH OR        65.45    47.36                 0  10
68850   INJECTION OF CONTRAST MEDIUM FOR DACRYOC       36.81    27.39                 0   0
68899   UNLISTED PROCEDURE, LACRIMAL SYSTEM                                       BR 0    0
69000   DRAINAGE EXTERNAL EAR, ABSCESS OR HEMATO      103.47    54.85                 0  10
69005   DRAINAGE EXTERNAL EAR, ABSCESS OR HEMATO      120.23    74.97                 0  10
69020   DRAINAGE EXTERNAL AUDITORY CANAL, ABSCES      132.71    68.35                 0  10
69100   BIOPSY EXTERNAL EAR                            60.94    22.27                 0   0
69105   BIOPSY EXTERNAL AUDITORY CANAL                 80.23    30.97                 0   0
69110   EXCISION EXTERNAL EAR; PARTIAL, SIMPLE R      257.06   156.18                 0  90
69120   EXCISION EXTERNAL EAR; COMPLETE AMPUTATI      233.74   194.78                 0  90
69140   EXCISION EXOSTOSIS(ES), EXTERNAL AUDITOR      504.78   420.65                 0  90
69145   EXCISION SOFT TISSUE LESION, EXTERNAL AU      216.47   117.43                 0  90
                                                                                                   Page 187 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
69150   RADICAL EXCISION EXTERNAL AUDITORY CANAL      608.86   507.39                 0  90
69155   RADICAL EXCISION EXTERNAL AUDITORY CANAL      963.89   803.24                 0  90
69200   REMOVAL FOREIGN BODY FROM EXTERNAL AUDIT       72.97    26.15             BR 0    0
69205   REMOVAL FOREIGN BODY FROM EXTERNAL AUDIT       58.81    49.01                 0  10
69220   DEBRIDEMENT, MASTOIDECTOMY CAVITY, SIMPL       79.03    40.00                 0   0
69222   DEBRIDEMENT, MASTOIDECTOMY CAVITY, COMPL      127.90    80.00                 0  10
69300   OTOPLASTY, PROTRUDING EAR, WITH OR WITHO      336.51   223.61                 0   0
69310   RECONSTRUCTION OF EXTERNAL AUDITORY CANA      631.72   526.43                 0  90
69320   RECONSTRUCTION EXTERNAL AUDITORY CANAL F      894.22   745.19                 0  90
69399   UNLISTED PROCEDURE, EXTERNAL EAR                                          BR 0    0
69400   EUSTACHIAN TUBE INFLATION, TRANSNASAL; W       79.77    29.15                 0   0
69401   EUSTACHIAN TUBE INFLATION, TRANSNASAL; W       47.83    24.28                 0   0
69405   EUSTACHIAN TUBE CATHETERIZATION, TRANSTY      146.82    92.82                 0  10
69420   MYRINGOTOMY INCLUDING ASPIRATION AND/OR       109.79    57.24                 0  10
69421   MYRINGOTOMY INCLUDING ASPIRATION AND/OR        88.52    73.77                 0  10
69433   TYMPANOSTOMY (REQUIRING INSERTION OF VEN      113.44    61.92                 0  10
69436   TYMPANOSTOMY (REQUIRING INSERTION OF VEN      100.00   100.00                 0  10
69440   MIDDLE EAR EXPLORATION THROUGH POSTAURIC      389.47   324.56                 0  90
69450   TYMPANOLYSIS, TRANSCANAL                      320.00   320.00                 0  90
69501   TRANSMASTOID ANTROTOMY (SIMPLE MASTOIDEC      420.04   350.04                 0  90
69502   MASTOIDECTOMY; COMPLETE                       554.80   462.34                 0  90
69505   MASTOIDECTOMY; MODIFIED RADICAL               700.36   583.64                 0  90
69511   MASTOIDECTOMY; RADICAL                        717.81   598.18                 0  90
69530   PETROUS APICECTOMY INCLUDING RADICAL MAS      956.00   796.67                 0  90
69535   RESECTION TEMPORAL BONE, EXTERNAL APPROA                                  BR 0   90
69540   EXCISION AURAL POLYP                          121.06    61.92                 0  10
69550   EXCISION AURAL GLOMUS TUMOR; TRANSCANAL       604.07   503.39                 0  90
69552   EXCISION AURAL GLOMUS TUMOR; TRANSMASTOI      915.98   763.32                 0  90
69554   EXCISION AURAL GLOMUS TUMOR; EXTENDED (E    1,463.30 1,219.42                 0  90
                                                                                                   Page 188 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
69601   REVISION MASTOIDECTOMY; RESULTING IN COM      598.58   498.82                 0  90
69602   REVISION MASTOIDECTOMY; RESULTING IN MOD      623.70   519.75                 0  90
69603   REVISION MASTOIDECTOMY; RESULTING IN RAD      741.43   617.86                 0  90
69604   REVISION MASTOIDECTOMY; RESULTING IN TYM      638.80   532.34                 0  90
69605   REVISION MASTOIDECTOMY; WITH APICECTOMY       907.76   756.47                 0  90
69610   TYMPANIC MEMBRANE REPAIR, WITH OR WITHOU      227.66   142.34                 0  10
69620   MYRINGOPLASTY (SURGERY CONFINED TO DRUMH      403.19   320.00                 0  90
69631   TYMPANOPLASTY WITHOUT MASTOIDECTOMY (INC      500.33   416.95                 0  90
69632   TYMPANOPLASTY WITHOUT MASTOIDECTOMY (INC      614.55   600.00                 0  90
69633   TYMPANOPLASTY WITHOUT MASTOIDECTOMY (INC      600.00   600.00                 0  90
69635   TYMPANOPLASTY WITH ANTROTOMY OR MASTOIDO      704.29   600.00                 0  90
69636   TYMPANOPLASTY WITH ANTROTOMY OR MASTOIDO      801.25   680.00                 0  90
69637   TYMPANOPLASTY WITH ANTROTOMY OR MASTOIDO      796.97   680.00                 0  90
69641   TYMPANOPLASTY WITH MASTOIDECTOMY (INCLUD      594.92   495.77                 0  90
69642   TYMPANOPLASTY WITH MASTOIDECTOMY (INCLUD      767.41   680.00                 0  90
69643   TYMPANOPLASTY WITH MASTOIDECTOMY (INCLUD      700.10   583.42                 0  90
69644   TYMPANOPLASTY WITH MASTOIDECTOMY (INCLUD      861.41   717.85                 0  90
69645   TYMPANOPLASTY WITH MASTOIDECTOMY (INCLUD      843.46   702.88                 0  90
69646   TYMPANOPLASTY WITH MASTOIDECTOMY (INCLUD      895.72   746.43                 0  90
69650   STAPES MOBILIZATION                           455.12   379.27                 0  90
69660   STAPEDECTOMY OR STAPEDOTOMY WITH REESTAB      532.14   443.45                 0  90
69661   STAPEDECTOMY OR STAPEDOTOMY WITH REESTAB      697.63   650.00                 0  90
69662   REVISION OF STAPEDECTOMY OR STAPEDOTOMY       667.30   556.09                 0  90
69666   REPAIR OVAL WINDOW FISTULA                    461.13   410.00                 0  90
69667   REPAIR ROUND WINDOW FISTULA                   462.10   410.00                 0  90
69670   MASTOID OBLITERATION (SEPARATE PROCEDURE      540.49   450.41                 0  90
69676   TYMPANIC NEURECTOMY                           476.87   397.39                 0  90
69700   CLOSURE POSTAURICULAR FISTULA, MASTOID (      404.74   337.29                 0  90
69710   IMPLANTATION OR REPLACEMENT OF ELECTROMA      380.00   380.00                 0   0
                                                                                                   Page 189 of 189


                                                                                               C
                                                     NON-                                      H
                                                                                               A
                                                   FACILITY FACILITY PROFESSIONAL              N
                                                   GLOBAL GLOBAL      COMPONENT          FU    G
CODE                       DESCRIPTION               FEE      FEE        FEE      BR PA DAYS   E
69711   REMOVAL OR REPAIR OF ELECTROMAGNETIC BON                                  BR 0   90
69714   IMPLANTATION, OSSEOINTEGRATED IMPLANT, T      618.35   515.30                 0  90
69715   IMPLANTATION, OSSEOINTEGRATED IMPLANT, T      766.22   638.52                 0  90
69717   REPLACEMENT (INCLUDING REMOVAL OF EXISTI      657.48   547.90                 0  90
69718   REPLACEMENT (INCLUDING REMOVAL OF EXISTI      814.59   678.83                 0  90
69720   DECOMPRESSION FACIAL NERVE, INTRATEMPORA      674.81   562.35                 0  90
69725   DECOMPRESSION FACIAL NERVE, INTRATEMPORA    1,084.72   903.93                 0  90
69740   SUTURE FACIAL NERVE, INTRATEMPORAL, WITH      666.62   555.52                 0  90
69745   SUTURE FACIAL NERVE, INTRATEMPORAL, WITH      677.30   564.42                 0  90
69799   UNLISTED PROCEDURE, MIDDLE EAR                                            BR 0    0
69801   LABYRINTHOTOMY, WITH OR WITHOUT CRYOSURG      426.19   400.00                 0   0
69805   ENDOLYMPHATIC SAC OPERATION; WITHOUT SHU      602.32   501.94                 0  90
69806   ENDOLYMPHATIC SAC OPERATION; WITH SHUNT       541.89   500.00                 0  90
69820   FENESTRATION SEMICIRCULAR CANAL               496.81   414.01                 0  90
69840   REVISION FENESTRATION OPERATION               530.62   442.18                 0  90
69905   LABYRINTHECTOMY; TRANSCANAL                   523.42   436.19                 0  90
69910   LABYRINTHECTOMY; WITH MASTOIDECTOMY           586.40   500.00                 0  90
69915   VESTIBULAR NERVE SECTION, TRANSLABYRINTH                                  BR 0   90
69930   COCHLEAR DEVICE IMPLANTATION, WITH OR WI      732.81   610.68                 0  90
69949   UNLISTED PROCEDURE, INNER EAR                                             BR 0    0
69950   VESTIBULAR NERVE SECTION, TRANSCRANIAL A                                  BR 0   90
69955   TOTAL FACIAL NERVE DECOMPRESSION AND/OR     1,154.23   961.86                 0  90
69960   DECOMPRESSION INTERNAL AUDITORY CANAL       1,112.57   927.14                 0  90
69970   REMOVAL OF TUMOR, TEMPORAL BONE             1,238.46 1,032.05                 0  90
69979   UNLISTED PROCEDURE, TEMPORAL BONE, MIDDL                                  BR 0    0
A4264   PERMANENT IMPLANTABLE CONTRACEPTIVE INTR        cost     cost                 0   0
A4648   TISSUE MARKER, IMPLANTABLE, ANY TYPE, EA        cost     cost             BR 0    0

				
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