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OH_MedicaidAddendumB_2010

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OH_MedicaidAddendumB_2010 Powered By Docstoc
					HCPCS                                             Relative   Iowa Medicaid   Iowa Medicaid
  Code               Short Descriptor   SI APC    Weight      Fee Schedule      Coverage
0001F    Heart failure composite        M                                      Not Covered
0005F    Osteoarthritis composite       M                                      Not Covered
00100    Anesth, salivary gland         N                                        Covered
00102    Anesth, repair of cleft lip    N                                        Covered
00103    Anesth, blepharoplasty         N                                        Covered
00104    Anesth, electroshock           N                                        Covered
00120    Anesth, ear surgery            N                                        Covered
00124    Anesth, ear exam               N                                        Covered
00126    Anesth, tympanotomy            N                                        Covered
0012F    Cap bacterial assess           M                                      Not Covered
0012F    Cap bacterial assess           M                                      Not Covered
00140    Anesth, procedures on eye      N                                        Covered
00142    Anesth, lens surgery           N                                        Covered
00144    Anesth, corneal transplant     N                                        Covered
00145    Anesth, vitreoretinal surg     N                                        Covered
00147    Anesth, iridectomy             N                                        Covered
00148    Anesth, eye exam               N                                        Covered
0014F    Comp preop assess cat surg     M                                      Not Covered
0015F    Melan follow-up complete       M                                      Not Covered
00160    Anesth, nose/sinus surgery     N                                        Covered
00162    Anesth, nose/sinus surgery     N                                        Covered
00164    Anesth, biopsy of nose         N                                        Covered
0016T    Thermotx choroid vasc lesion   T 00235     5.8498                     Not Covered
00170    Anesth, procedure on mouth     N                                        Covered
00172    Anesth, cleft palate repair    N                                        Covered
00174    Anesth, pharyngeal surgery     N                                        Covered
00176    Anesth, pharyngeal surgery     C                                      Not Covered
0017T    Photocoagulat macular drusen   T 00235     5.8498                     Not Covered
00190    Anesth, face/skull bone surg   N                                        Covered
00192    Anesth, facial bone surgery    C                                      Not Covered
0019T    Extracorp shock wv tx,ms nos   A                                      Not Covered
00210    Anesth, cranial surg nos       N                                      Not Covered
00211    Anesth, cran surg, hemotoma    C                                      Not Covered
00212    Anesth, skull drainage         N                                        Covered
00214    Anesth, skull drainage         C                                      Not Covered
00215    Anesth, skull repair/fract     C                                      Not Covered
00216    Anesth, head vessel surgery    N                                        Covered
00218    Anesth, special head surgery   N                                        Covered
00220    Anesth, intrcrn nerve          N                                        Covered
00222    Anesth, head nerve surgery     N                                        Covered
0026T    Measure remnant lipoproteins   D                                      Not Covered
0027T    Endoscopic epidural lysis      D                                      Not Covered
0028T    Dexa body composition study    D                                      Not Covered
0029T    Magnetic tx for incontinence   D                                      Not Covered
00300    Anesth, head/neck/ptrunk       N                                        Covered
0030T    Antiprothrombin antibody       A                                      Not Covered
0031T    Speculoscopy                   D                                      Not Covered
00320    Anesth, neck organ, 1 & over   N                                        Covered
00322    Anesth, biopsy of thyroid      N                                        Covered
00326    Anesth, larynx/trach, < 1 yr   N                                        Covered
0032T   Speculoscopy w/direct sample   D   Not Covered
00350   Anesth, neck vessel surgery    N    Covered
00352   Anesth, neck vessel surgery    N    Covered
00400   Anesth, skin, ext/per/atrunk   N    Covered
00402   Anesth, surgery of breast      N    Covered
00404   Anesth, surgery of breast      N    Covered
00406   Anesth, surgery of breast      N    Covered
00410   Anesth, correct heart rhythm   N    Covered
0041T   Detect ur infect agnt w/cpas   D   Not Covered
0042T   Ct perfusion w/contrast, cbf   N   Not Covered
0043T   Co expired gas analysis        D   Not Covered
00450   Anesth, surgery of shoulder    N    Covered
00452   Anesth, surgery of shoulder    C   Not Covered
00454   Anesth, collar bone biopsy     N    Covered
0046T   Cath lavage, mammary duct(s)   D   Not Covered
00470   Anesth, removal of rib         N    Covered
00472   Anesth, chest wall repair      N    Covered
00474   Anesth, surgery of rib(s)      C   Not Covered
0047T   Cath lavage, mammary duct(s)   D   Not Covered
0048T   Implant ventricular device     C   Not Covered
0049T   External circulation assist    D   Not Covered
00500   Anesth, esophageal surgery     N    Covered
0050T   Removal circulation assist     C   Not Covered
0051T   Implant total heart system     C   Not Covered
00520   Anesth, chest procedure        N    Covered
00522   Anesth, chest lining biopsy    N    Covered
00524   Anesth, chest drainage         C   Not Covered
00528   Anesth, chest partition view   N    Covered
00529   Anesth, chest partition view   N    Covered
0052T   Replace component heart syst   C   Not Covered
00530   Anesth, pacemaker insertion    N    Covered
00532   Anesth, vascular access        N    Covered
00534   Anesth, cardioverter/defib     N    Covered
00537   Anesth, cardiac electrophys    N    Covered
00539   Anesth, trach-bronch reconst   N    Covered
0053T   Replace component heart syst   C   Not Covered
00540   Anesth, chest surgery          C   Not Covered
00541   Anesth, one lung ventilation   N    Covered
00542   Anesth, release of lung        C   Not Covered
00546   Anesth, lung,chest wall surg   C   Not Covered
00548   Anesth, trachea,bronchi surg   N    Covered
0054T   Bone surgery using computer    N   Not Covered
00550   Anesth, sternal debridement    N    Covered
0055T   Bone surgery using computer    N   Not Covered
00560   Anesth, heart surg w/o pump    C   Not Covered
00561   Anesth, heart surg < age 1     C   Not Covered
00562   Anesth hrt surg w/pmp age 1+   C   Not Covered
00563   Anesth, heart surg w/arrest    N    Covered
00566   Anesth, cabg w/o pump          N    Covered
00567   Anesth, cabg w/pump            C   Not Covered
00580   Anesth, heart/lung transplnt   C   Not Covered
0058T   Cryopreservation, ovary tiss   D   Not Covered
0059T   Cryopreservation, oocyte       D                   Not Covered
00600   Anesth, spine, cord surgery    N                     Covered
00604   Anesth, sitting procedure      C                   Not Covered
0060T   Electrical impedance scan      D                   Not Covered
0061T   Destruction of tumor, breast   D                   Not Covered
00620   Anesth, spine, cord surgery    N                     Covered
00622   Anesth, removal of nerves      C                   Not Covered
00625   Anes spine tranthor w/o vent   N                    By Report
00626   Anes, spine transthor w/vent   N                     Covered
0062T   Rep intradisc annulus;1 lev    D                   Not Covered
00630   Anesth, spine, cord surgery    N                     Covered
00632   Anesth, removal of nerves      C                   Not Covered
00634   Anesth for chemonucleolysis    N                     Covered
00635   Anesth, lumbar puncture        N                     Covered
0063T   Rep intradisc annulus;>1lev    D                   Not Covered
00640   Anesth, spine manipulation     N                     Covered
0064T   Spectroscop eval expired gas   D                   Not Covered
0066T   Ct colonography;screen         D                   Not Covered
00670   Anesth, spine, cord surgery    C                   Not Covered
0067T   Ct colonography;dx             D                   Not Covered
0068T   Interp/rept heart sound        D                   Not Covered
0069T   Analysis only heart sound      D                   Not Covered
00700   Anesth, abdominal wall surg    N                     Covered
00702   Anesth, for liver biopsy       N                     Covered
0070T   Interp only heart sound        D                   Not Covered
0071T   U/s leiomyomata ablate <200    S 00067   52.9891   Not Covered
0072T   U/s leiomyomata ablate >200    S 00067   52.9891   Not Covered
00730   Anesth, abdominal wall surg    N                     Covered
0073T   Delivery, comp imrt            S 00412    6.2490   Not Covered
00740   Anesth, upper gi visualize     N                     Covered
00750   Anesth, repair of hernia       N                     Covered
00752   Anesth, repair of hernia       N                     Covered
00754   Anesth, repair of hernia       N                     Covered
00756   Anesth, repair of hernia       N                     Covered
0075T   Perq stent/chest vert art      C                   Not Covered
0076T   S&i stent/chest vert art       C                   Not Covered
00770   Anesth, blood vessel repair    N                     Covered
0077T   Cereb therm perfusion probe    D                   Not Covered
0078T   Endovasc aort repr w/device    C                   Not Covered
00790   Anesth, surg upper abdomen     N                     Covered
00792   Anesth, hemorr/excise liver    C                   Not Covered
00794   Anesth, pancreas removal       C                   Not Covered
00796   Anesth, for liver transplant   C                   Not Covered
00797   Anesth, surgery for obesity    N                     Covered
0079T   Endovasc visc extnsn repr      C                   Not Covered
00800   Anesth, abdominal wall surg    N                     Covered
00802   Anesth, fat layer removal      C                   Not Covered
0080T   Endovasc aort repr rad s&i     C                   Not Covered
00810   Anesth, low intestine scope    N                     Covered
0081T   Endovasc visc extnsn s&i       C                   Not Covered
00820   Anesth, abdominal wall surg    N                     Covered
00830   Anesth, repair of hernia       N                     Covered
00832   Anesth, repair of hernia       N    Covered
00834   Anesth, hernia repair< 1 yr    N    Covered
00836   Anesth hernia repair preemie   N    Covered
00840   Anesth, surg lower abdomen     N    Covered
00842   Anesth, amniocentesis          N    Covered
00844   Anesth, pelvis surgery         C   Not Covered
00846   Anesth, hysterectomy           C   Not Covered
00848   Anesth, pelvic organ surg      C   Not Covered
0084T   Temp prostate urethral stent   D   Not Covered
00851   Anesth, tubal ligation         N    Covered
0085T   Breath test heart reject       E   Not Covered
00860   Anesth, surgery of abdomen     N    Covered
00862   Anesth, kidney/ureter surg     N    Covered
00864   Anesth, removal of bladder     C   Not Covered
00865   Anesth, removal of prostate    C   Not Covered
00866   Anesth, removal of adrenal     C   Not Covered
00868   Anesth, kidney transplant      C   Not Covered
0086T   L ventricle fill pressure      D   Not Covered
00870   Anesth, bladder stone surg     N    Covered
00872   Anesth kidney stone destruct   N    Covered
00873   Anesth kidney stone destruct   N    Covered
0087T   Sperm eval hyaluronan          D   Not Covered
00880   Anesth, abdomen vessel surg    N    Covered
00882   Anesth, major vein ligation    C   Not Covered
0088T   Rf tongue base vol reduxn      D   Not Covered
0089T   Actigraphy testing, 3-day      D   Not Covered
00902   Anesth, anorectal surgery      N    Covered
00904   Anesth, perineal surgery       C   Not Covered
00906   Anesth, removal of vulva       N    Covered
00908   Anesth, removal of prostate    C   Not Covered
0090T   Cervical artific disc          D   Not Covered
00910   Anesth, bladder surgery        N    Covered
00912   Anesth, bladder tumor surg     N    Covered
00914   Anesth, removal of prostate    N    Covered
00916   Anesth, bleeding control       N    Covered
00918   Anesth, stone removal          N    Covered
00920   Anesth, genitalia surgery      N    Covered
00921   Anesth, vasectomy              N    Covered
00922   Anesth, sperm duct surgery     N    Covered
00924   Anesth, testis exploration     N    Covered
00926   Anesth, removal of testis      N    Covered
00928   Anesth, removal of testis      N    Covered
0092T   Artific disc addl              C   Not Covered
00930   Anesth, testis suspension      N    Covered
00932   Anesth, amputation of penis    C   Not Covered
00934   Anesth, penis, nodes removal   C   Not Covered
00936   Anesth, penis, nodes removal   C   Not Covered
00938   Anesth, insert penis device    N   Not Covered
0093T   Cervical artific diskectomy    D   Not Covered
00940   Anesth, vaginal procedures     N    Covered
00942   Anesth, surg on vag/urethral   N    Covered
00944   Anesth, vaginal hysterectomy   C   Not Covered
00948   Anesth, repair of cervix       N                       Covered
00950   Anesth, vaginal endoscopy      N                       Covered
00952   Anesth, hysteroscope/graph     N                       Covered
0095T   Artific diskectomy addl        C                      Not Covered
0096T   Rev cervical artific disc      D                      Not Covered
0098T   Rev artific disc addl          C                      Not Covered
0099T   Implant corneal ring           T    00233   16.2485   Not Covered
0100T   Prosth retina receive&gen      T    00672   39.9643   Not Covered
0101T   Extracorp shockwv tx,hi enrg   T    00050   31.7717   Not Covered
0102T   Extracorp shockwv tx,anesth    T    00050   31.7717   Not Covered
0103T   Holotranscobalamin             A                      Not Covered
0104T   At rest cardio gas rebreathe   A                      Not Covered
0105T   Exerc cardio gas rebreathe     A                      Not Covered
0106T   Touch quant sensory test       X    00341    0.0799   Not Covered
0107T   Vibrate quant sensory test     X    00341    0.0799   Not Covered
0108T   Cool quant sensory test        X    00341    0.0799   Not Covered
0109T   Heat quant sensory test        X    00341    0.0799   Not Covered
0110T   Nos quant sensory test         X    00341    0.0799   Not Covered
01112   Anesth, bone aspirate/bx       N                       Covered
0111T   Rbc membranes fatty acids      A                      Not Covered
01120   Anesth, pelvis surgery         N                       Covered
01130   Anesth, body cast procedure    N                       Covered
01140   Anesth, amputation at pelvis   C                      Not Covered
01150   Anesth, pelvic tumor surgery   C                      Not Covered
01160   Anesth, pelvis procedure       N                       Covered
01170   Anesth, pelvis surgery         N                       Covered
01173   Anesth, fx repair, pelvis      N                       Covered
01180   Anesth, pelvis nerve removal   N                       Covered
01190   Anesth, pelvis nerve removal   N                       Covered
01200   Anesth, hip joint procedure    N                       Covered
01202   Anesth, arthroscopy of hip     N                       Covered
01210   Anesth, hip joint surgery      N                       Covered
01212   Anesth, hip disarticulation    C                      Not Covered
01214   Anesth, hip arthroplasty       C                      Not Covered
01215   Anesth, revise hip repair      N                       Covered
01220   Anesth, procedure on femur     N                       Covered
01230   Anesth, surgery of femur       N                       Covered
01232   Anesth, amputation of femur    C                      Not Covered
01234   Anesth, radical femur surg     C                      Not Covered
0123T   Scleral fistulization          T    00234   24.4021   Not Covered
0124T   Conjunctival drug placement    T    00232    4.5074   Not Covered
01250   Anesth, upper leg surgery      N                       Covered
01260   Anesth, upper leg veins surg   N                       Covered
0126T   Chd risk imt study             Q1   00340    0.6693   Not Covered
01270   Anesth, thigh arteries surg    N                       Covered
01272   Anesth, femoral artery surg    C                      Not Covered
01274   Anesth, femoral embolectomy    C                      Not Covered
0130T   Chron care drug investigatn    B                      Not Covered
01320   Anesth, knee area surgery      N                       Covered
01340   Anesth, knee area procedure    N                       Covered
01360   Anesth, knee area surgery      N                       Covered
0137T   Prostate saturation sampling   D                      Not Covered
01380   Anesth, knee joint procedure   N                      Covered
01382   Anesth, dx knee arthroscopy    N                      Covered
01390   Anesth, knee area procedure    N                      Covered
01392   Anesth, knee area surgery      N                      Covered
01400   Anesth, knee joint surgery     N                      Covered
01402   Anesth, knee arthroplasty      C                     Not Covered
01404   Anesth, amputation at knee     C                     Not Covered
0140T   Exhaled breath condensate ph   A                     Not Covered
0141T   Perq islet transplant          E                     Not Covered
0141T   Perq islet transplant          E                     Not Covered
01420   Anesth, knee joint casting     N                      Covered
0142T   Open islet transplant          E                     Not Covered
01430   Anesth, knee veins surgery     N                      Covered
01432   Anesth, knee vessel surg       N                      Covered
0143T   Laparoscopic islet transplnt   E                     Not Covered
01440   Anesth, knee arteries surg     N                      Covered
01442   Anesth, knee artery surg       C                     Not Covered
01444   Anesth, knee artery repair     C                     Not Covered
0144T   CT heart wo dye; qual calc     D                     Not Covered
0145T   CT heart w/wo dye funct        D                     Not Covered
01462   Anesth, lower leg procedure    N                      Covered
01464   Anesth, ankle/ft arthroscopy   N                      Covered
0146T   CCTA w/wo dye                  D                     Not Covered
01470   Anesth, lower leg surgery      N                      Covered
01472   Anesth, achilles tendon surg   N                      Covered
01474   Anesth, lower leg surgery      N                      Covered
0147T   CCTA w/wo, quan calcium        D                     Not Covered
01480   Anesth, lower leg bone surg    N                      Covered
01482   Anesth, radical leg surgery    N                      Covered
01484   Anesth, lower leg revision     N                      Covered
01486   Anesth, ankle replacement      C                     Not Covered
0148T   CCTA w/wo, strxr               D                     Not Covered
01490   Anesth, lower leg casting      N                      Covered
0149T   CCTA w/wo, strxr quan calc     D                     Not Covered
01500   Anesth, leg arteries surg      N                      Covered
01502   Anesth, lwr leg embolectomy    C                     Not Covered
0150T   CCTA w/wo, disease strxr       D                     Not Covered
0151T   CT heart funct add-on          D                     Not Covered
01520   Anesth, lower leg vein surg    N                      Covered
01522   Anesth, lower leg vein surg    N                      Covered
0155T   Lap impl gast curve electrd    T   00130   38.0540   Not Covered
0156T   Lap remv gast curve electrd    T   00130   38.0540   Not Covered
0157T   Open impl gast curve electrd   C                     Not Covered
0158T   Open remv gast curve electrd   C                     Not Covered
0159T   Cad breast mri                 N                     Not Covered
0160T   Tcranial magn stim tx plan     S   00216    2.6831   Not Covered
01610   Anesth, surgery of shoulder    N                      Covered
0161T   Tcranial magn stim tx deliv    S   00216    2.6831   Not Covered
01620   Anesth, shoulder procedure     N                      Covered
01622   Anes dx shoulder arthroscopy   N                      Covered
0162T   Anal program gast neurostim    D                     Not Covered
01630   Anesth, surgery of shoulder    N                      Covered
01632   Anesth, surgery of shoulder    D                     Not Covered
01634   Anesth, shoulder joint amput   C                     Not Covered
01636   Anesth, forequarter amput      C                     Not Covered
01638   Anesth, shoulder replacement   C                     Not Covered
0163T   Lumb artif diskectomy addl     C                     Not Covered
0164T   Remove lumb artif disc addl    C                     Not Covered
01650   Anesth, shoulder artery surg   N                      Covered
01652   Anesth, shoulder vessel surg   C                     Not Covered
01654   Anesth, shoulder vessel surg   C                     Not Covered
01656   Anesth, arm-leg vessel surg    C                     Not Covered
0165T   Revise lumb artif disc addl    C                     Not Covered
0166T   Tcath vsd close w/o bypass     C                     Not Covered
01670   Anesth, shoulder vein surg     N                      Covered
0167T   Tcath vsd close w bypass       C                     Not Covered
01680   Anesth, shoulder casting       N                      Covered
01682   Anesth, airplane cast          N                      Covered
0168T   Rhinophototx light app bilat   T   00251    3.4250   Not Covered
0169T   Place stereo cath brain        C                     Not Covered
0170T   Anorectal fistula plug rpr     D                     Not Covered
01710   Anesth, elbow area surgery     N                      Covered
01712   Anesth, uppr arm tendon surg   N                      Covered
01714   Anesth, uppr arm tendon surg   N                      Covered
01716   Anesth, biceps tendon repair   N                      Covered
0171T   Lumbar spine proces distract   T   00052   88.6521   Not Covered
0172T   Lumbar spine process addl      T   00052   88.6521   Not Covered
01730   Anesth, uppr arm procedure     N                      Covered
01732   Anesth, dx elbow arthroscopy   N                      Covered
0173T   Iop monit io pressure          N                     Not Covered
01740   Anesth, upper arm surgery      N                      Covered
01742   Anesth, humerus surgery        N                      Covered
01744   Anesth, humerus repair         N                      Covered
0174T   Cad cxr with interp            N                     Not Covered
01756   Anesth, radical humerus surg   C                     Not Covered
01758   Anesth, humeral lesion surg    N                      Covered
0175T   Cad cxr remote                 N                     Not Covered
01760   Anesth, elbow replacement      N                      Covered
0176T   Aqu canal dilat w/o retent     T   00673   41.8840   Not Covered
01770   Anesth, uppr arm artery surg   N                      Covered
01772   Anesth, uppr arm embolectomy   N                      Covered
0177T   Aqu canal dilat w retent       T   00673   41.8840   Not Covered
01780   Anesth, upper arm vein surg    N                      Covered
01782   Anesth, uppr arm vein repair   N                      Covered
0178T   64 lead ecg w i&r              B                     Not Covered
0179T   64 lead ecg w tracing          X   00100    2.6136   Not Covered
0180T   64 lead ecg w i&r only         B                     Not Covered
01810   Anesth, lower arm surgery      N                      Covered
0181T   Corneal hysteresis             S   00230    0.5945   Not Covered
01820   Anesth, lower arm procedure    N                      Covered
01829   Anesth, dx wrist arthroscopy   N                      Covered
0182T   Hdr elect brachytherapy        S   00313   11.5353   Not Covered
01830   Anesth, lower arm surgery      N                      Covered
01832   Anesth, wrist replacement      N                      Covered
0183T   Wound ultrasound               T   00013    0.8789   Not Covered
01840   Anesth, lwr arm artery surg    N                      Covered
01842   Anesth, lwr arm embolectomy    N                      Covered
01844   Anesth, vascular shunt surg    N                      Covered
0184T   Exc rectal tumor endoscopic    C                     Not Covered
01850   Anesth, lower arm vein surg    N                      Covered
01852   Anesth, lwr arm vein repair    N                      Covered
0185T   Comptr probability analysis    N                     Not Covered
01860   Anesth, lower arm casting      N                      Covered
0186T   Suprachoroidal drug delivery   T   00237   20.7145   Not Covered
0187T   Ophthalmic dx image anterior   S   00230    0.5945   Not Covered
0188T   Videoconf crit care 74 min     M                     Not Covered
0188T   Videoconf crit care 74 min     M                     Not Covered
0189T   Videoconf crit care addl 30    M                     Not Covered
0190T   Place intraoc radiation src    T   00237   20.7145   Not Covered
01916   Anesth, dx arteriography       N                      Covered
0191T   Insert ant segment drain int   T   00234   24.4021   Not Covered
01920   Anesth, catheterize heart      N                      Covered
01922   Anesth, cat or MRI scan        N                      Covered
01924   Anes, ther interven rad, art   N                      Covered
01925   Anes, ther interven rad, car   N                      Covered
01926   Anes, tx interv rad hrt/cran   N                      Covered
0192T   Insert ant segment drain ext   T   00673   41.8840   Not Covered
01930   Anes, ther interven rad, vei   N                      Covered
01931   Anes, ther interven rad, tip   N                      Covered
01932   Anes, tx interv rad, th vein   N                      Covered
01933   Anes, tx interv rad, cran v    N                      Covered
01935   Anesth, perc img dx sp proc    N                      Covered
01936   Anesth, perc img tx sp proc    N                      Covered
0193T   Rf bladder neck microremodel   T   00165   20.0243   Not Covered
0194T   Procalcitonin (pct)            D                     Not Covered
01951   Anesth, burn, less 4 percent   N                      Covered
01952   Anesth, burn, 4-9 percent      N                      Covered
01953   Anesth, burn, each 9 percent   N                      Covered
01958   Anesth, antepartum manipul     N                      Covered
0195T   Arthrod presac interbody       C                     Not Covered
01960   Anesth, vaginal delivery       N                      Covered
01961   Anesth, cs delivery            N                      Covered
01962   Anesth, emer hysterectomy      N                      Covered
01963   Anesth, cs hysterectomy        N                      Covered
01965   Anesth, inc/missed ab proc     N                      Covered
01966   Anesth, induced ab procedure   N                      Covered
01967   Anesth/analg, vag delivery     N                     Not Covered
01968   Anes/analg cs deliver add-on   N                      Covered
01969   Anesth/analg cs hyst add-on    N                     Not Covered
0196T   Arthrod presac interbody eac   C                     Not Covered
0197T   Intrafraction track motion     N                     Not Covered
0198T   Ocular blood flow measure      S   00230    0.5945   Not Covered
01990   Support for organ donor        C                     Not Covered
01991   Anesth, nerve block/inj        N                      Covered
01992   Anesth, n block/inj, prone     N                      Covered
01996   Hosp manage cont drug admin    N                     Not Covered
01999   Unlisted anesth procedure      N                       Covered
0199T   Physiologic tremor record      S    00215    0.6135   Not Covered
0200T   Perq sacral augmt unilat inj   T    00049   22.0149   Not Covered
0201T   Perq sacral augmt bilat inj    T    00050   31.7717   Not Covered
0202T   Post vert arthrplst 1 lumbar   C                      Not Covered
0203T   Unattend sleep study w/time    S    00213    2.4043   Not Covered
0204T   Unattended sleep study         S    00213    2.4043   Not Covered
0205T   Inirs each vessel add-on       N                      Not Covered
0206T   Remote algorithm analys ecg    Q1   00340    0.6693   Not Covered
0207T   Clear eyelid gland w/heat      S    00230    0.5945   Not Covered
0208T   Automated audiometry air       X    00035    0.2320   Not Covered
0209T   Auto audiometry air/bone       X    00035    0.2320   Not Covered
0210T   Auto audiometry sp thresh      X    00035    0.2320   Not Covered
0211T   Auto audiometry sp thresh      X    00035    0.2320   Not Covered
0212T   Comprehen auto audiometry      X    00364    0.4700   Not Covered
0213T   Us facet jt inj cerv/t 1 lev   T    00207    7.2002   Not Covered
0214T   Us facet jt inj cerv/t 2 lev   T    00204    2.5558   Not Covered
0215T   Us facet jt inj cerv/t 3 lev   T    00204    2.5558   Not Covered
0216T   Us facet jt inj ls 1 level     T    00207    7.2002   Not Covered
0217T   Us facet jt inj ls 2 level     T    00204    2.5558   Not Covered
0218T   Us facet jt inj ls 3 level     T    00204    2.5558   Not Covered
0219T   Fuse spine facet jt cerv       C                      Not Covered
0220T   Fuse spine facet jt thor       C                      Not Covered
0221T   Fuse spine facet jt lumbar     T    00050   31.7717   Not Covered
0222T   Fuse spine facet jt add seg    T    00050   31.7717   Not Covered
0500F   Initial prenatal care visit    M                      Not Covered
0501F   Prenatal flow sheet            M                      Not Covered
0502F   Subsequent prenatal care       M                      Not Covered
0503F   Postpartum care visit          M                      Not Covered
0505F   Hemodialysis plan docd         M                      Not Covered
0507F   Periton dialysis plan docd     M                      Not Covered
0509F   Urine incon plan docd          M                      Not Covered
0513F   Elev bp plan of care docd      M                      Not Covered
0514F   Care plan hgb docd esa pt      M                      Not Covered
0516F   Anemia plan of care docd       M                      Not Covered
0517F   Glaucoma plan of care docd     M                      Not Covered
0518F   Fall plan of care docd         M                      Not Covered
0519F   Pland chemo docd b/4 txmnt     M                      Not Covered
0520F   Rad dos limts b/4 3d rad       M                      Not Covered
0521F   Plan of care 4 pain docd       M                      Not Covered
0525F   Initial visit for episode      M                      Not Covered
0526F   Subs visit for episode         M                      Not Covered
0528F   Rcmnd flw-up 10 yrs docd       E                      Not Covered
0529F   Intrvl 3+yrs pts clnscp docd   M                      Not Covered
0535F   Dyspnea mngmnt plan docd       E                      Not Covered
0540F   Gluco Mngmnt Plan Docd         M                      Not Covered
0545F   Follow up care plan mdd docd   E                      Not Covered
0575F   HIV rna plan care docd         E                      Not Covered
1000F   Tobacco use assessed           M                      Not Covered
10021   Fna w/o image                  T    00002    1.5111    Covered
10022   Fna w/image                    T    00004    4.5991    Covered
1002F   Assess anginal symptom/level   M                      Not Covered
1003F   Level of activity assess       M                               Not Covered
10040   Acne surgery                   T   00013    0.8789              Covered
1004F   Clin symp vol ovrld assess     M                               Not Covered
1005F   Asthma symptoms evaluate       M                               Not Covered
10060   Drainage of skin abscess       T   00006    1.4557              Covered
10061   Drainage of skin abscess       T   00006    1.4557              Covered
1006F   Osteoarthritis assess          M                               Not Covered
1007F   Anti-inflm/anlgsc otc assess   M                               Not Covered
10080   Drainage of pilonidal cyst     T   00006    1.4557              Covered
10081   Drainage of pilonidal cyst     T   00007   12.6217              Covered
1008F   Gi/renal risk assess           M                               Not Covered
10120   Remove foreign body            T   00016    2.7982              Covered
10121   Remove foreign body            T   00021   17.4975              Covered
10140   Drainage of hematoma/fluid     T   00007   12.6217              Covered
1015F   Copd symptoms assess           M                               Not Covered
1015F   Copd symptoms assess           M                               Not Covered
10160   Puncture drainage of lesion    T   00006    1.4557              Covered
10180   Complex drainage, wound        T   00008   19.4063              Covered
1018F   Assess dyspnea not present     M                               Not Covered
1018F   Assess dyspnea not present     M                               Not Covered
1019F   Assess dyspnea present         M                               Not Covered
1022F   Pneumo imm status assess       M                               Not Covered
1026F   Co-morbid condition assess     M                               Not Covered
1026F   Co-morbid condition assess     M                               Not Covered
1030F   Influenza imm status assess    M                               Not Covered
1030F   Influenza imm status assess    M                               Not Covered
1034F   Current tobacco smoker         M                               Not Covered
1034F   Current tobacco smoker         M                               Not Covered
1035F   Smokeless tobacco user         M                               Not Covered
1035F   Smokeless tobacco user         M                               Not Covered
1036F   Tobacco non-user               M                               Not Covered
1036F   Tobacco non-user               M                               Not Covered
1038F   Persistent asthma              M                               Not Covered
1038F   Persistent asthma              M                               Not Covered
1039F   Intermittent asthma            M                               Not Covered
1039F   Intermittent asthma            M                               Not Covered
1040F   Dsm-iv™ info mdd doc'd         M                               Not Covered
1050F   History of mole changes        M                               Not Covered
1055F   Visual funct status assess     M                               Not Covered
1060F   Doc perm/cont/parox atr. fib   M                               Not Covered
1061F   Doc lack perm+cont+parox fib   M                               Not Covered
1065F   Ischm stroke symp lt3 hrsb/4   M                               Not Covered
1066F   Ischm stroke symp ge3 hrsb/4   M                               Not Covered
1070F   Alarm symp assessed-absent     M                               Not Covered
1071F   Alarm symp assessed-1+ prsnt   M                               Not Covered
1090F   Pres/absn urine incon assess   M                               Not Covered
1091F   Urine incon characterized      M                               Not Covered
11000   Debride infected skin          T   00015    1.5412              Covered
11001   Debride infected skin add-on   T   00013    0.8789              Covered
11004   Debride genitalia & perineum   C                     $555.60    Covered
11005   Debride abdom wall             C                     $754.84    Covered
11006   Debride genit/per/abdom wall   C                     $692.98    Covered
11008   Remove mesh from abd wall      C                     $280.48    Covered
1100F   Ptfalls assess-doc'd ge2+/yr   M                               Not Covered
11010   Debride skin, fx               T   00019    4.3625              Covered
11011   Debride skin/muscle, fx        T   00019    4.3625              Covered
11012   Debride skin/muscle/bone, fx   T   00019    4.3625              Covered
1101F   Pt falls assess-doc'd le1/yr   M                               Not Covered
11040   Debride skin, partial          T   00015    1.5412              Covered
11041   Debride skin, full             T   00015    1.5412              Covered
11042   Debride skin/tissue            T   00016    2.7982              Covered
11043   Debride tissue/muscle          T   00016    2.7982              Covered
11044   Debride tissue/muscle/bone     T   00020    8.2028              Covered
11055   Trim skin lesion               T   00013    0.8789              Covered
11056   Trim skin lesions, 2 to 4      T   00013    0.8789              Covered
11057   Trim skin lesions, over 4      T   00013    0.8789              Covered
11100   Biopsy, skin lesion            T   00015    1.5412              Covered
11101   Biopsy, skin add-on            T   00013    0.8789              Covered
1110F   Pt lft inpt fac w/in 60 days   M                               Not Covered
1111F   Dschrg med/current med merge   M                               Not Covered
1116F   Auric/peri pain assessed       M                               Not Covered
1118F   GERD symps assessed 12 month   M                               Not Covered
1119F   Init eval for condition        M                               Not Covered
11200   Removal of skin tags           T   00013    0.8789              Covered
11201   Remove skin tags add-on        T   00013    0.8789              Covered
1121F   Subs eval for condition        M                               Not Covered
1123F   Acp discuss/dscn mkr docd      M                               Not Covered
1124F   Acp discuss-no dscnmkr docd    M                               Not Covered
1125F   Amnt pain noted pain prsnt     M                               Not Covered
1126F   Amnt pain noted none prsnt     M                               Not Covered
1127F   New episode for condition      D                               Not Covered
1128F   Subs episode for condition     D                               Not Covered
11300   Shave skin lesion              T   00013    0.8789              Covered
11301   Shave skin lesion              T   00013    0.8789              Covered
11302   Shave skin lesion              T   00013    0.8789              Covered
11303   Shave skin lesion              T   00015    1.5412              Covered
11305   Shave skin lesion              T   00013    0.8789              Covered
11306   Shave skin lesion              T   00013    0.8789              Covered
11307   Shave skin lesion              T   00013    0.8789              Covered
11308   Shave skin lesion              T   00013    0.8789              Covered
1130F   Bk pain + fxn assessed         M                               Not Covered
11310   Shave skin lesion              T   00013    0.8789              Covered
11311   Shave skin lesion              T   00013    0.8789              Covered
11312   Shave skin lesion              T   00013    0.8789              Covered
11313   Shave skin lesion              T   00013    0.8789              Covered
1134F   Epsd bk pain for =< 6 wks      M                               Not Covered
1135F   Epsd bk pain for > 6 wks       M                               Not Covered
1136F   Epsd bk pain for <= 12 wks     M                               Not Covered
1137F   Epsd bk pain for > 12 wks      M                               Not Covered
11400   Exc tr-ext b9+marg 0.5 < cm    T   00019    4.3625              Covered
11401   Exc tr-ext b9+marg 0.6-1 cm    T   00019    4.3625              Covered
11402   Exc tr-ext b9+marg 1.1-2 cm    T   00019    4.3625              Covered
11403   Exc tr-ext b9+marg 2.1-3 cm    T   00020    8.2028              Covered
11404   Exc tr-ext b9+marg 3.1-4 cm    T   00021   17.4975              Covered
11406   Exc tr-ext b9+marg > 4.0 cm    T   00021   17.4975    Covered
11420   Exc h-f-nk-sp b9+marg 0.5 <    T   00020    8.2028    Covered
11421   Exc h-f-nk-sp b9+marg 0.6-1    T   00020    8.2028    Covered
11422   Exc h-f-nk-sp b9+marg 1.1-2    T   00020    8.2028    Covered
11423   Exc h-f-nk-sp b9+marg 2.1-3    T   00021   17.4975    Covered
11424   Exc h-f-nk-sp b9+marg 3.1-4    T   00021   17.4975    Covered
11426   Exc h-f-nk-sp b9+marg > 4 cm   T   00022   23.3880    Covered
11440   Exc face-mm b9+marg 0.5 < cm   T   00019    4.3625    Covered
11441   Exc face-mm b9+marg 0.6-1 cm   T   00019    4.3625    Covered
11442   Exc face-mm b9+marg 1.1-2 cm   T   00020    8.2028    Covered
11443   Exc face-mm b9+marg 2.1-3 cm   T   00020    8.2028    Covered
11444   Exc face-mm b9+marg 3.1-4 cm   T   00020    8.2028    Covered
11446   Exc face-mm b9+marg > 4 cm     T   00022   23.3880    Covered
11450   Removal, sweat gland lesion    T   00022   23.3880    Covered
11451   Removal, sweat gland lesion    T   00022   23.3880    Covered
11462   Removal, sweat gland lesion    T   00022   23.3880    Covered
11463   Removal, sweat gland lesion    T   00022   23.3880    Covered
11470   Removal, sweat gland lesion    T   00022   23.3880    Covered
11471   Removal, sweat gland lesion    T   00022   23.3880    Covered
1150F   Doc pt rsk death w/in 1yr      E                     Not Covered
1151F   Doc no pt rsk death w/in 1yr   E                     Not Covered
1152F   Doc advncd dis comfort 1st     E                     Not Covered
1153F   Doc advncd dis cmfrt not 1st   E                     Not Covered
1157F   Advnc care plan in rcrd        E                     Not Covered
1158F   Advnc care plan tlk docd       M                     Not Covered
1159F   Med list docd in rcrd          E                     Not Covered
11600   Exc tr-ext mlg+marg 0.5 < cm   T   00020    8.2028    Covered
11601   Exc tr-ext mlg+marg 0.6-1 cm   T   00019    4.3625    Covered
11602   Exc tr-ext mlg+marg 1.1-2 cm   T   00019    4.3625    Covered
11603   Exc tr-ext mlg+marg 2.1-3 cm   T   00020    8.2028    Covered
11604   Exc tr-ext mlg+marg 3.1-4 cm   T   00020    8.2028    Covered
11606   Exc tr-ext mlg+marg > 4 cm     T   00021   17.4975    Covered
1160F   Rvw meds by Rx/Dr in rcrd      E                     Not Covered
11620   Exc h-f-nk-sp mlg+marg 0.5 <   T   00020    8.2028    Covered
11621   Exc h-f-nk-sp mlg+marg 0.6-1   T   00019    4.3625    Covered
11622   Exc h-f-nk-sp mlg+marg 1.1-2   T   00020    8.2028    Covered
11623   Exc h-f-nk-sp mlg+marg 2.1-3   T   00021   17.4975    Covered
11624   Exc h-f-nk-sp mlg+marg 3.1-4   T   00021   17.4975    Covered
11626   Exc h-f-nk-sp mlg+mar > 4 cm   T   00022   23.3880    Covered
11640   Exc face-mm malig+marg 0.5 <   T   00020    8.2028    Covered
11641   Exc face-mm malig+marg 0.6-1   T   00020    8.2028    Covered
11642   Exc face-mm malig+marg 1.1-2   T   00020    8.2028    Covered
11643   Exc face-mm malig+marg 2.1-3   T   00020    8.2028    Covered
11644   Exc face-mm malig+marg 3.1-4   T   00021   17.4975    Covered
11646   Exc face-mm mlg+marg > 4 cm    T   00022   23.3880    Covered
1170F   Fxnl status assessed           M                     Not Covered
11719   Trim nail(s)                   T   00012    0.4436    Covered
11720   Debride nail, 1-5              T   00013    0.8789    Covered
11721   Debride nail, 6 or more        T   00013    0.8789    Covered
11730   Removal of nail plate          T   00013    0.8789    Covered
11732   Remove nail plate, add-on      T   00013    0.8789    Covered
11740   Drain blood from under nail    T   00012    0.4436    Covered
11750   Removal of nail bed            T   00019    4.3625              Covered
11752   Remove nail bed/finger tip     T   00022   23.3880              Covered
11755   Biopsy, nail unit              T   00019    4.3625              Covered
11760   Repair of nail bed             T   00133    1.3542              Covered
11762   Reconstruction of nail bed     T   00136   16.0542              Covered
11765   Excision of nail fold, toe     T   00013    0.8789              Covered
11770   Removal of pilonidal lesion    T   00022   23.3880              Covered
11771   Removal of pilonidal lesion    T   00022   23.3880              Covered
11772   Removal of pilonidal lesion    T   00022   23.3880              Covered
1180F   Thromboemb risk assessed       E                               Not Covered
11900   Injection into skin lesions    T   00013    0.8789              Covered
11901   Added skin lesions injection   T   00013    0.8789              Covered
11920   Correct skin color defects     T   00134    3.1508             Not Covered
11921   Correct skin color defects     T   00134    3.1508             Not Covered
11922   Correct skin color defects     T   00134    3.1508             Not Covered
11950   Therapy for contour defects    T   00133    1.3542              Covered
11951   Therapy for contour defects    T   00133    1.3542              Covered
11952   Therapy for contour defects    T   00133    1.3542              Covered
11954   Therapy for contour defects    T   00133    1.3542              Covered
11960   Insert tissue expander(s)      T   00137   23.9317              Covered
11970   Replace tissue expander        T   00051   46.5786              Covered
11971   Remove tissue expander(s)      T   00022   23.3880              Covered
11975   Insert contraceptive cap       E                     $120.04    Covered
11976   Removal of contraceptive cap   T   00019    4.3625              Covered
11977   Removal/reinsert contra cap    E                     $206.35    Covered
11980   Implant hormone pellet(s)      X   00340    0.6693              Covered
11981   Insert drug implant device     X   00340    0.6693              Covered
11982   Remove drug implant device     X   00340    0.6693              Covered
11983   Remove/insert drug implant     X   00340    0.6693              Covered
12001   Repair superficial wound(s)    T   00133    1.3542              Covered
12002   Repair superficial wound(s)    T   00133    1.3542              Covered
12004   Repair superficial wound(s)    T   00133    1.3542              Covered
12005   Repair superficial wound(s)    T   00133    1.3542              Covered
12006   Repair superficial wound(s)    T   00133    1.3542              Covered
12007   Repair superficial wound(s)    T   00133    1.3542              Covered
1200F   Seizure type(s)+ frq docd      E                               Not Covered
12011   Repair superficial wound(s)    T   00133    1.3542              Covered
12013   Repair superficial wound(s)    T   00133    1.3542              Covered
12014   Repair superficial wound(s)    T   00133    1.3542              Covered
12015   Repair superficial wound(s)    T   00133    1.3542              Covered
12016   Repair superficial wound(s)    T   00133    1.3542              Covered
12017   Repair superficial wound(s)    T   00133    1.3542              Covered
12018   Repair superficial wound(s)    T   00133    1.3542              Covered
12020   Closure of split wound         T   00135    4.4386              Covered
12021   Closure of split wound         T   00134    3.1508              Covered
12031   Intmd wnd repair s/tr/ext      T   00133    1.3542              Covered
12032   Intmd wnd repair s/tr/ext      T   00134    3.1508              Covered
12034   Intmd wnd repair s/tr/ext      T   00133    1.3542              Covered
12035   Intmd wnd repair s/tr/ext      T   00133    1.3542              Covered
12036   Intmd wnd repair s/tr/ext      T   00134    3.1508              Covered
12037   Intmd wnd repair s/tr/ext      T   00134    3.1508              Covered
12041   Intmd wnd repair n-hf/genit    T   00133    1.3542              Covered
12042   Intmd wnd repair n-hg/genit    T   00133    1.3542    Covered
12044   Intmd wnd repair n-hg/genit    T   00133    1.3542    Covered
12045   Intmd wnd repair n-hg/genit    T   00134    3.1508    Covered
12046   Intmd wnd repair n-hg/genit    T   00134    3.1508    Covered
12047   Intmd wnd repair n-hg/genit    T   00134    3.1508    Covered
12051   Intmd wnd repair face/mm       T   00133    1.3542    Covered
12052   Intmd wnd repair face/mm       T   00133    1.3542    Covered
12053   Intmd wnd repair face/mm       T   00133    1.3542    Covered
12054   Intmd wnd repair, face/mm      T   00133    1.3542    Covered
12055   Intmd wnd repair face/mm       T   00134    3.1508    Covered
12056   Intmd wnd repair face/mm       T   00134    3.1508    Covered
12057   Intmd wnd repair face/mm       T   00134    3.1508    Covered
1205F   EPI etiol synd rvwd and docd   E                     Not Covered
1220F   Pt screened for depression     M                     Not Covered
13100   Repair of wound or lesion      T   00135    4.4386    Covered
13101   Repair of wound or lesion      T   00135    4.4386    Covered
13102   Repair wound/lesion add-on     T   00135    4.4386    Covered
13120   Repair of wound or lesion      T   00134    3.1508    Covered
13121   Repair of wound or lesion      T   00134    3.1508    Covered
13122   Repair wound/lesion add-on     T   00133    1.3542    Covered
13131   Repair of wound or lesion      T   00134    3.1508    Covered
13132   Repair of wound or lesion      T   00135    4.4386    Covered
13133   Repair wound/lesion add-on     T   00134    3.1508    Covered
13150   Repair of wound or lesion      T   00135    4.4386    Covered
13151   Repair of wound or lesion      T   00135    4.4386    Covered
13152   Repair of wound or lesion      T   00135    4.4386    Covered
13153   Repair wound/lesion add-on     T   00134    3.1508    Covered
13160   Late closure of wound          T   00137   23.9317    Covered
14000   Skin tissue rearrangement      T   00136   16.0542    Covered
14001   Skin tissue rearrangement      T   00136   16.0542    Covered
14020   Skin tissue rearrangement      T   00136   16.0542    Covered
14021   Skin tissue rearrangement      T   00136   16.0542    Covered
14040   Skin tissue rearrangement      T   00136   16.0542    Covered
14041   Skin tissue rearrangement      T   00136   16.0542    Covered
14060   Skin tissue rearrangement      T   00136   16.0542    Covered
14061   Skin tissue rearrangement      T   00136   16.0542    Covered
14300   Skin tissue rearrangement      D                     Not Covered
14301   Skin tissue rearrangement      T   00137   23.9317    Covered
14302   Skin tissue rearrange add-on   T   00137   23.9317    Covered
14350   Skin tissue rearrangement      T   00137   23.9317    Covered
15002   Wound prep, trk/arm/leg        T   00135    4.4386    Covered
15003   Wound prep, addl 100 cm        T   00135    4.4386    Covered
15004   Wound prep, f/n/hf/g           T   00135    4.4386    Covered
15005   Wnd prep, f/n/hf/g, addl cm    T   00135    4.4386    Covered
15040   Harvest cultured skin graft    T   00134    3.1508    Covered
15050   Skin pinch graft               T   00135    4.4386    Covered
15100   Skin splt grft, trnk/arm/leg   T   00137   23.9317    Covered
15101   Skin splt grft t/a/l, add-on   T   00137   23.9317    Covered
15110   Epidrm autogrft trnk/arm/leg   T   00135    4.4386    Covered
15111   Epidrm autogrft t/a/l add-on   T   00135    4.4386    Covered
15115   Epidrm a-grft face/nck/hf/g    T   00135    4.4386    Covered
15116   Epidrm a-grft f/n/hf/g addl    T   00135    4.4386    Covered
15120   Skn splt a-grft fac/nck/hf/g   T   00137   23.9317   Covered
15121   Skn splt a-grft f/n/hf/g add   T   00137   23.9317   Covered
15130   Derm autograft, trnk/arm/leg   T   00136   16.0542   Covered
15131   Derm autograft t/a/l add-on    T   00136   16.0542   Covered
15135   Derm autograft face/nck/hf/g   T   00136   16.0542   Covered
15136   Derm autograft, f/n/hf/g add   T   00136   16.0542   Covered
15150   Cult epiderm grft t/arm/leg    T   00135    4.4386   Covered
15151   Cult epiderm grft t/a/l addl   T   00135    4.4386   Covered
15152   Cult epiderm graft t/a/l +%    T   00135    4.4386   Covered
15155   Cult epiderm graft, f/n/hf/g   T   00135    4.4386   Covered
15156   Cult epidrm grft f/n/hfg add   T   00135    4.4386   Covered
15157   Cult epiderm grft f/n/hfg +%   T   00135    4.4386   Covered
15170   Acell graft trunk/arms/legs    T   00135    4.4386   Covered
15171   Acell graft t/arm/leg add-on   T   00134    3.1508   Covered
15175   Acellular graft, f/n/hf/g      T   00135    4.4386   Covered
15176   Acell graft, f/n/hf/g add-on   T   00135    4.4386   Covered
15200   Skin full graft, trunk         T   00136   16.0542   Covered
15201   Skin full graft trunk add-on   T   00136   16.0542   Covered
15220   Skin full graft sclp/arm/leg   T   00136   16.0542   Covered
15221   Skin full graft add-on         T   00135    4.4386   Covered
15240   Skin full grft face/genit/hf   T   00136   16.0542   Covered
15241   Skin full graft add-on         T   00135    4.4386   Covered
15260   Skin full graft een & lips     T   00136   16.0542   Covered
15261   Skin full graft add-on         T   00136   16.0542   Covered
15300   Apply skinallogrft, t/arm/lg   T   00135    4.4386   Covered
15301   Apply sknallogrft t/a/l addl   T   00135    4.4386   Covered
15320   Apply skin allogrft f/n/hf/g   T   00135    4.4386   Covered
15321   Aply sknallogrft f/n/hfg add   T   00135    4.4386   Covered
15330   Aply acell alogrft t/arm/leg   T   00135    4.4386   Covered
15331   Aply acell grft t/a/l add-on   T   00135    4.4386   Covered
15335   Apply acell graft, f/n/hf/g    T   00135    4.4386   Covered
15336   Aply acell grft f/n/hf/g add   T   00135    4.4386   Covered
15340   Apply cult skin substitute     T   00134    3.1508   Covered
15341   Apply cult skin sub add-on     T   00134    3.1508   Covered
15360   Apply cult derm sub, t/a/l     T   00134    3.1508   Covered
15361   Aply cult derm sub t/a/l add   T   00134    3.1508   Covered
15365   Apply cult derm sub f/n/hf/g   T   00134    3.1508   Covered
15366   Apply cult derm f/hf/g add     T   00134    3.1508   Covered
15400   Apply skin xenograft, t/a/l    T   00135    4.4386   Covered
15401   Apply skn xenogrft t/a/l add   T   00135    4.4386   Covered
15420   Apply skin xgraft, f/n/hf/g    T   00135    4.4386   Covered
15421   Apply skn xgrft f/n/hf/g add   T   00135    4.4386   Covered
15430   Apply acellular xenograft      T   00135    4.4386   Covered
15431   Apply acellular xgraft add     T   00135    4.4386   Covered
15570   Form skin pedicle flap         T   00137   23.9317   Covered
15572   Form skin pedicle flap         T   00137   23.9317   Covered
15574   Form skin pedicle flap         T   00137   23.9317   Covered
15576   Form skin pedicle flap         T   00137   23.9317   Covered
15600   Skin graft                     T   00137   23.9317   Covered
15610   Skin graft                     T   00137   23.9317   Covered
15620   Skin graft                     T   00137   23.9317   Covered
15630   Skin graft                     T   00137   23.9317   Covered
15650   Transfer skin pedicle flap     T   00137   23.9317                Covered
15731   Forehead flap w/vasc pedicle   T   00137   23.9317                Covered
15732   Muscle-skin graft, head/neck   T   00137   23.9317                Covered
15734   Muscle-skin graft, trunk       T   00137   23.9317                Covered
15736   Muscle-skin graft, arm         T   00137   23.9317                Covered
15738   Muscle-skin graft, leg         T   00137   23.9317                Covered
15740   Island pedicle flap graft      T   00136   16.0542                Covered
15750   Neurovascular pedicle graft    T   00137   23.9317                Covered
15756   Free myo/skin flap microvasc   C                     $2,275.51    Covered
15757   Free skin flap, microvasc      C                     $2,278.08    Covered
15758   Free fascial flap, microvasc   C                     $2,271.05    Covered
15760   Composite skin graft           T   00137   23.9317                Covered
15770   Derma-fat-fascia graft         T   00137   23.9317                Covered
15775   Hair transplant punch grafts   T   00133    1.3542               Not Covered
15776   Hair transplant punch grafts   T   00133    1.3542               Not Covered
15780   Abrasion treatment of skin     T   00022   23.3880                Covered
15781   Abrasion treatment of skin     T   00019    4.3625                Covered
15782   Abrasion treatment of skin     T   00019    4.3625                Covered
15783   Abrasion treatment of skin     T   00016    2.7982                Covered
15786   Abrasion, lesion, single       T   00013    0.8789                Covered
15787   Abrasion, lesions, add-on      T   00013    0.8789                Covered
15788   Chemical peel, face, epiderm   T   00013    0.8789                Covered
15789   Chemical peel, face, dermal    T   00015    1.5412                Covered
15792   Chemical peel, nonfacial       T   00015    1.5412                Covered
15793   Chemical peel, nonfacial       T   00013    0.8789                Covered
15819   Plastic surgery, neck          T   00134    3.1508                Covered
15820   Revision of lower eyelid       T   00137   23.9317                Covered
15821   Revision of lower eyelid       T   00137   23.9317                Covered
15822   Revision of upper eyelid       T   00137   23.9317                Covered
15823   Revision of upper eyelid       T   00137   23.9317                Covered
15824   Removal of forehead wrinkles   T   00137   23.9317               Not Covered
15825   Removal of neck wrinkles       T   00137   23.9317               Not Covered
15826   Removal of brow wrinkles       T   00137   23.9317               Not Covered
15828   Removal of face wrinkles       T   00137   23.9317               Not Covered
15829   Removal of skin wrinkles       T   00137   23.9317               Not Covered
15830   Exc skin abd                   T   00022   23.3880                Covered
15832   Excise excessive skin tissue   T   00022   23.3880                Covered
15833   Excise excessive skin tissue   T   00022   23.3880                Covered
15834   Excise excessive skin tissue   T   00022   23.3880                Covered
15835   Excise excessive skin tissue   T   00022   23.3880                Covered
15836   Excise excessive skin tissue   T   00021   17.4975                Covered
15837   Excise excessive skin tissue   T   00021   17.4975                Covered
15838   Excise excessive skin tissue   T   00021   17.4975                Covered
15839   Excise excessive skin tissue   T   00021   17.4975                Covered
15840   Graft for face nerve palsy     T   00137   23.9317                Covered
15841   Graft for face nerve palsy     T   00137   23.9317                Covered
15842   Flap for face nerve palsy      T   00137   23.9317                Covered
15845   Skin and muscle repair, face   T   00137   23.9317                Covered
15847   Exc skin abd add-on            T   00022   23.3880                Covered
15850   Removal of sutures             T   00016    2.7982                Covered
15851   Removal of sutures             T   00016    2.7982                Covered
15852   Dressing change not for burn   X   00340    0.6693                Covered
15860   Test for blood flow in graft   X   00340    0.6693             Covered
15876   Suction assisted lipectomy     T   00137   23.9317            Not Covered
15877   Suction assisted lipectomy     T   00137   23.9317            Not Covered
15878   Suction assisted lipectomy     T   00137   23.9317            Not Covered
15879   Suction assisted lipectomy     T   00137   23.9317            Not Covered
15920   Removal of tail bone ulcer     T   00019    4.3625             Covered
15922   Removal of tail bone ulcer     T   00137   23.9317             Covered
15931   Remove sacrum pressure sore    T   00022   23.3880             Covered
15933   Remove sacrum pressure sore    T   00022   23.3880             Covered
15934   Remove sacrum pressure sore    T   00137   23.9317             Covered
15935   Remove sacrum pressure sore    T   00137   23.9317             Covered
15936   Remove sacrum pressure sore    T   00136   16.0542             Covered
15937   Remove sacrum pressure sore    T   00137   23.9317             Covered
15940   Remove hip pressure sore       T   00022   23.3880             Covered
15941   Remove hip pressure sore       T   00022   23.3880             Covered
15944   Remove hip pressure sore       T   00137   23.9317             Covered
15945   Remove hip pressure sore       T   00137   23.9317             Covered
15946   Remove hip pressure sore       T   00137   23.9317             Covered
15950   Remove thigh pressure sore     T   00022   23.3880             Covered
15951   Remove thigh pressure sore     T   00022   23.3880             Covered
15952   Remove thigh pressure sore     T   00136   16.0542             Covered
15953   Remove thigh pressure sore     T   00136   16.0542             Covered
15956   Remove thigh pressure sore     T   00136   16.0542             Covered
15958   Remove thigh pressure sore     T   00136   16.0542             Covered
15999   Removal of pressure sore       T   00019    4.3625             Covered
16000   Initial treatment of burn(s)   T   00013    0.8789             Covered
16020   Dress/debrid p-thick burn, s   T   00015    1.5412             Covered
16025   Dress/debrid p-thick burn, m   T   00015    1.5412             Covered
16030   Dress/debrid p-thick burn, l   T   00015    1.5412             Covered
16035   Incision of burn scab, initi   T   00015    1.5412             Covered
16036   Escharotomy; add'l incision    C                     $84.01    Covered
17000   Destruct premalg lesion        T   00013    0.8789             Covered
17003   Destruct premalg les, 2-14     T   00012    0.4436             Covered
17004   Destroy premlg lesions 15+     T   00016    2.7982             Covered
17106   Destruction of skin lesions    T   00016    2.7982             Covered
17107   Destruction of skin lesions    T   00016    2.7982             Covered
17108   Destruction of skin lesions    T   00016    2.7982             Covered
17110   Destruct b9 lesion, 1-14       T   00013    0.8789             Covered
17111   Destruct lesion, 15 or more    T   00015    1.5412             Covered
17250   Chemical cautery, tissue       T   00015    1.5412             Covered
17260   Destruction of skin lesions    T   00015    1.5412             Covered
17261   Destruction of skin lesions    T   00015    1.5412             Covered
17262   Destruction of skin lesions    T   00015    1.5412             Covered
17263   Destruction of skin lesions    T   00015    1.5412             Covered
17264   Destruction of skin lesions    T   00015    1.5412             Covered
17266   Destruction of skin lesions    T   00016    2.7982             Covered
17270   Destruction of skin lesions    T   00015    1.5412             Covered
17271   Destruction of skin lesions    T   00015    1.5412             Covered
17272   Destruction of skin lesions    T   00015    1.5412             Covered
17273   Destruction of skin lesions    T   00016    2.7982             Covered
17274   Destruction of skin lesions    T   00016    2.7982             Covered
17276   Destruction of skin lesions    T   00016    2.7982             Covered
17280   Destruction of skin lesions    T   00015    1.5412                Covered
17281   Destruction of skin lesions    T   00016    2.7982                Covered
17282   Destruction of skin lesions    T   00016    2.7982                Covered
17283   Destruction of skin lesions    T   00016    2.7982                Covered
17284   Destruction of skin lesions    T   00016    2.7982                Covered
17286   Destruction of skin lesions    T   00016    2.7982                Covered
17311   Mohs, 1 stage, h/n/hf/g        T   00694    4.9337                Covered
17312   Mohs addl stage                T   00694    4.9337                Covered
17313   Mohs, 1 stage, t/a/l           T   00694    4.9337                Covered
17314   Mohs, addl stage, t/a/l        T   00694    4.9337                Covered
17315   Mohs surg, addl block          T   00694    4.9337                Covered
17340   Cryotherapy of skin            T   00013    0.8789                Covered
17360   Skin peel therapy              T   00013    0.8789               Not Covered
17380   Hair removal by electrolysis   T   00013    0.8789               Not Covered
17999   Skin tissue procedure          T   00012    0.4436                Covered
19000   Drainage of breast lesion      T   00004    4.5991                Covered
19001   Drain breast lesion add-on     T   00002    1.5111                Covered
19020   Incision of breast lesion      T   00008   19.4063                Covered
19030   Injection for breast x-ray     N                                  Covered
19100   Bx breast percut w/o image     T   00004    4.5991                Covered
19101   Biopsy of breast, open         T   00028   24.7516                Covered
19102   Bx breast percut w/image       T   00005    7.8145                Covered
19103   Bx breast percut w/device      T   00037   15.5003                Covered
19105   Cryosurg ablate fa, each       T   00029   34.1654                Covered
19110   Nipple exploration             T   00028   24.7516                Covered
19112   Excise breast duct fistula     T   00028   24.7516                Covered
19120   Removal of breast lesion       T   00028   24.7516                Covered
19125   Excision, breast lesion        T   00028   24.7516                Covered
19126   Excision, addl breast lesion   T   00028   24.7516                Covered
19260   Removal of chest wall lesion   T   00021   17.4975                Covered
19271   Revision of chest wall         C                     $1,226.23    Covered
19272   Extensive chest wall surgery   C                     $1,317.01    Covered
19290   Place needle wire, breast      N                                  Covered
19291   Place needle wire, breast      N                                  Covered
19295   Place breast clip, percut      N                                  Covered
19296   Place po breast cath for rad   T   00648   58.2278                Covered
19297   Place breast cath for rad      T   00648   58.2278                Covered
19298   Place breast rad tube/caths    T   00648   58.2278                Covered
19300   Removal of breast tissue       T   00028   24.7516                Covered
19301   Partical mastectomy            T   00028   24.7516                Covered
19302   P-mastectomy w/ln removal      T   00030   41.9997                Covered
19303   Mast, simple, complete         T   00029   34.1654                Covered
19304   Mast, subq                     T   00029   34.1654                Covered
19305   Mast, radical                  C                     $902.49      Covered
19306   Mast, rad, urban type          C                     $937.51      Covered
19307   Mast, mod rad                  T   00030   41.9997                Covered
19316   Suspension of breast           T   00029   34.1654                Covered
19318   Reduction of large breast      T   00030   41.9997                Covered
19324   Enlarge breast                 T   00030   41.9997               Not Covered
19325   Enlarge breast with implant    T   00648   58.2278               Not Covered
19328   Removal of breast implant      T   00029   34.1654                Covered
19330   Removal of implant material    T   00029   34.1654                Covered
19340   Immediate breast prosthesis    T   00030   41.9997                Covered
19342   Delayed breast prosthesis      T   00648   58.2278                Covered
19350   Breast reconstruction          T   00028   24.7516                Covered
19355   Correct inverted nipple(s)     T   00029   34.1654               Not Covered
19357   Breast reconstruction          T   00648   58.2278                Covered
19361   Breast reconstr w/lat flap     C                     $1,308.97    Covered
19364   Breast reconstruction          C                     $2,302.64    Covered
19366   Breast reconstruction          T   00029   34.1654                Covered
19367   Breast reconstruction          C                     $1,618.67    Covered
19368   Breast reconstruction          C                     $1,927.45    Covered
19369   Breast reconstruction          C                     $1,825.18    Covered
19370   Surgery of breast capsule      T   00029   34.1654                Covered
19371   Removal of breast capsule      T   00029   34.1654                Covered
19380   Revise breast reconstruction   T   00030   41.9997                Covered
19396   Design custom breast implant   T   00029   34.1654               Not Covered
19499   Breast surgery procedure       T   00028   24.7516                Covered
20000   Incision of abscess            T   00006    1.4557                Covered
20005   Incision of deep abscess       T   00049   22.0149                Covered
2000F   Blood pressure measure         M                                 Not Covered
2001F   Weight record                  M                                 Not Covered
2002F   Clin sign vol ovrld assess     M                                 Not Covered
2004F   Initial exam involved joints   M                                 Not Covered
20100   Explore wound, neck            T   00252    7.6196                Covered
20101   Explore wound, chest           T   00137   23.9317                Covered
20102   Explore wound, abdomen         T   00137   23.9317                Covered
20103   Explore wound, extremity       T   00007   12.6217                Covered
2010F   Vital signs recorded           M                                 Not Covered
2010F   Vital signs recorded           M                                 Not Covered
2014F   Mental status assess           M                                 Not Covered
2014F   Mental status assess           M                                 Not Covered
20150   Excise epiphyseal bar          T   00051   46.5786                Covered
2018F   Hydration status assess        M                                 Not Covered
2018F   Hydration status assess        M                                 Not Covered
2019F   Dilated macul exam done        M                                 Not Covered
2019F   Dilated macul exam done        M                                 Not Covered
20200   Muscle biopsy                  T   00021   17.4975                Covered
20205   Deep muscle biopsy             T   00021   17.4975                Covered
20206   Needle biopsy, muscle          T   00005    7.8145                Covered
2020F   Dilated fundus eval done       M                                 Not Covered
2020F   Dilated fundus eval done       M                                 Not Covered
2021F   Dilat macul+ exam done         M                                 Not Covered
2021F   Dilat macul+ exam done         M                                 Not Covered
20220   Bone biopsy, trocar/needle     T   00020    8.2028                Covered
20225   Bone biopsy, trocar/needle     T   00021   17.4975                Covered
2022F   Dil retina exam interp rev     M                                 Not Covered
2022F   Dil retina exam interp rev     M                                 Not Covered
20240   Bone biopsy, excisional        T   00022   23.3880                Covered
20245   Bone biopsy, excisional        T   00022   23.3880                Covered
2024F   7 field photo interp doc rev   M                                 Not Covered
2024F   7 field photo interp doc rev   M                                 Not Covered
20250   Open bone biopsy               T   00049   22.0149                Covered
20251   Open bone biopsy               T   00049   22.0149                Covered
2026F   Eye image valid to dx rev      M                                 Not Covered
2026F   Eye image valid to dx rev      M                                 Not Covered
2027F   Optic nerve head eval done     M                                 Not Covered
2028F   Foot exam performed            M                                 Not Covered
2028F   Foot exam performed            M                                 Not Covered
2029F   Complete phys skin exam done   M                                 Not Covered
2030F   H2O stat doc'd, normal         M                                 Not Covered
2031F   H2O stat doc'd, dehydrated     M                                 Not Covered
2035F   Tymp memb motion examd         M                                 Not Covered
2040F   Bk pn xm on init visit date    M                                 Not Covered
2044F   Doc mntl tst b/4 bk trxmnt     M                                 Not Covered
20500   Injection of sinus tract       T   00252    7.6196                Covered
20501   Inject sinus tract for x-ray   N                                  Covered
2050F   Wound char size etc docd       E                                 Not Covered
20520   Removal of foreign body        T   00019    4.3625                Covered
20525   Removal of foreign body        T   00022   23.3880                Covered
20526   Ther injection, carp tunnel    T   00204    2.5558                Covered
20550   Inj tendon sheath/ligament     T   00204    2.5558                Covered
20551   Inj tendon origin/insertion    T   00204    2.5558                Covered
20552   Inj trigger point, 1/2 muscl   T   00204    2.5558                Covered
20553   Inject trigger points, =/> 3   T   00204    2.5558                Covered
20555   Place ndl musc/tis for rt      T   00050   31.7717                Covered
20600   Drain/inject, joint/bursa      T   00204    2.5558                Covered
20605   Drain/inject, joint/bursa      T   00204    2.5558                Covered
2060F   Pt talk eval hlthwkr re mdd    E                                 Not Covered
20610   Drain/inject, joint/bursa      T   00204    2.5558                Covered
20612   Aspirate/inj ganglion cyst     T   00204    2.5558                Covered
20615   Treatment of bone cyst         T   00004    4.5991                Covered
20650   Insert and remove bone pin     T   00049   22.0149                Covered
20660   Apply, rem fixation device     T   00138    4.7946                Covered
20661   Application of head brace      C                     $369.92      Covered
20662   Application of pelvis brace    T   00049   22.0149                Covered
20663   Application of thigh brace     T   00049   22.0149                Covered
20664   Halo brace application         C                     $527.24      Covered
20665   Removal of fixation device     X   00340    0.6693                Covered
20670   Removal of support implant     T   00021   17.4975                Covered
20680   Removal of support implant     T   00022   23.3880                Covered
20690   Apply bone fixation device     T   00050   31.7717                Covered
20692   Apply bone fixation device     T   00050   31.7717                Covered
20693   Adjust bone fixation device    T   00049   22.0149                Covered
20694   Remove bone fixation device    T   00049   22.0149                Covered
20696   Comp multiplane ext fixation   T   00050   31.7717                Covered
20697   Comp ext fixate strut change   T   00139   18.3962                Covered
20802   Replantation, arm, complete    C                                 Not Covered
20805   Replant forearm, complete      C                     $3,405.92    Covered
20808   Replantation hand, complete    C                                 Not Covered
20816   Replantation digit, complete   C                     $2,395.41    Covered
20822   Replantation digit, complete   T   00054   28.2376                Covered
20824   Replantation thumb, complete   C                     $2,369.36    Covered
20827   Replantation thumb, complete   C                     $2,066.70    Covered
20838   Replantation foot, complete    C                     $2,733.30    Covered
20900   Removal of bone for graft      T   00050   31.7717                Covered
20902   Removal of bone for graft      T   00050   31.7717                Covered
20910   Remove cartilage for graft     T   00137   23.9317                Covered
20912   Remove cartilage for graft     T   00137   23.9317                Covered
20920   Removal of fascia for graft    T   00136   16.0542                Covered
20922   Removal of fascia for graft    T   00136   16.0542                Covered
20924   Removal of tendon for graft    T   00050   31.7717                Covered
20926   Removal of tissue for graft    T   00135    4.4386                Covered
20930   Sp bone algrft morsel add-on   C                     $129.93      Covered
20931   Sp bone algrft struct add-on   C                     $121.30      Covered
20936   Sp bone agrft local add-on     C                     $172.26      Covered
20937   Sp bone agrft morsel add-on    C                     $183.60      Covered
20938   Sp bone agrft struct add-on    C                     $200.49      Covered
20950   Fluid pressure, muscle         T   00006    1.4557                Covered
20955   Fibula bone graft, microvasc   C                     $2,620.70    Covered
20956   Iliac bone graft, microvasc    C                     $2,487.88    Covered
20957   Mt bone graft, microvasc       C                     $2,419.28    Covered
20962   Other bone graft, microvasc    C                     $2,457.21    Covered
20969   Bone/skin graft, microvasc     C                     $2,924.86    Covered
20970   Bone/skin graft, iliac crest   C                     $2,869.07    Covered
20972   Bone/skin graft, metatarsal    T   00056   52.5258                Covered
20973   Bone/skin graft, great toe     T   00056   52.5258                Covered
20974   Electrical bone stimulation    A                      $92.05      Covered
20975   Electrical bone stimulation    N                                  Covered
20979   Us bone stimulation            X   00340    0.6693                Covered
20982   Ablate, bone tumor(s) perq     T   00051   46.5786                Covered
20985   Cptr-asst dir ms px            N                                  Covered
20986   Cptr-asst dir ms px io img     D                                 Not Covered
20987   Cptr-asst dir ms px pre img    D                                 Not Covered
20999   Musculoskeletal surgery        T   00049   22.0149                Covered
21010   Incision of jaw joint          T   00254   24.9637                Covered
21011   Exc face les sc < 2 cm         T   00020    8.2028                Covered
21012   Exc face les sc = 2 cm         T   00020    8.2028                Covered
21013   Exc face tum deep < 2 cm       T   00020    8.2028                Covered
21014   Exc face tum deep = 2 cm       T   00020    8.2028                Covered
21015   Resection of facial tumor      T   00021   17.4975                Covered
21016   Resect face tum = 2 cm         T   00022   23.3880                Covered
21025   Excision of bone, lower jaw    T   00256   42.9827                Covered
21026   Excision of facial bone(s)     T   00256   42.9827                Covered
21029   Contour of face bone lesion    T   00256   42.9827                Covered
21030   Excise max/zygoma b9 tumor     T   00254   24.9637                Covered
21031   Remove exostosis, mandible     T   00254   24.9637                Covered
21032   Remove exostosis, maxilla      T   00254   24.9637                Covered
21034   Excise max/zygoma mlg tumor    T   00256   42.9827                Covered
21040   Excise mandible lesion         T   00254   24.9637                Covered
21044   Removal of jaw bone lesion     T   00256   42.9827                Covered
21045   Extensive jaw surgery          C                     $1,037.53    Covered
21046   Remove mandible cyst complex   T   00256   42.9827                Covered
21047   Excise lwr jaw cyst w/repair   T   00256   42.9827                Covered
21048   Remove maxilla cyst complex    T   00256   42.9827                Covered
21049   Excis uppr jaw cyst w/repair   T   00256   42.9827                Covered
21050   Removal of jaw joint           T   00256   42.9827                Covered
21060   Remove jaw joint cartilage     T   00256   42.9827                Covered
21070   Remove coronoid process        T   00256   42.9827                Covered
21073   Mnpj of tmj w/anesth           T   00252    7.6196                Covered
21076   Prepare face/oral prosthesis   T   00254   24.9637                Covered
21077   Prepare face/oral prosthesis   T   00256   42.9827                Covered
21079   Prepare face/oral prosthesis   T   00256   42.9827                Covered
21080   Prepare face/oral prosthesis   T   00256   42.9827                Covered
21081   Prepare face/oral prosthesis   T   00256   42.9827                Covered
21082   Prepare face/oral prosthesis   T   00256   42.9827                Covered
21083   Prepare face/oral prosthesis   T   00256   42.9827                Covered
21084   Prepare face/oral prosthesis   T   00256   42.9827                Covered
21085   Prepare face/oral prosthesis   T   00253   17.1879                Covered
21086   Prepare face/oral prosthesis   T   00256   42.9827                Covered
21087   Prepare face/oral prosthesis   T   00256   42.9827                Covered
21088   Prepare face/oral prosthesis   T   00256   42.9827                Covered
21089   Prepare face/oral prosthesis   T   00250    1.1522                Covered
21100   Maxillofacial fixation         T   00256   42.9827                Covered
21110   Interdental fixation           T   00252    7.6196                Covered
21116   Injection, jaw joint x-ray     N                                  Covered
21120   Reconstruction of chin         T   00254   24.9637                Covered
21121   Reconstruction of chin         T   00254   24.9637                Covered
21122   Reconstruction of chin         T   00254   24.9637                Covered
21123   Reconstruction of chin         T   00254   24.9637                Covered
21125   Augmentation, lower jaw bone   T   00254   24.9637                Covered
21127   Augmentation, lower jaw bone   T   00256   42.9827                Covered
21137   Reduction of forehead          T   00254   24.9637                Covered
21138   Reduction of forehead          T   00256   42.9827                Covered
21139   Reduction of forehead          T   00256   42.9827                Covered
21141   Reconstruct midface, lefort    C                     $1,136.58    Covered
21142   Reconstruct midface, lefort    C                     $1,203.32    Covered
21143   Reconstruct midface, lefort    C                     $1,198.13    Covered
21145   Reconstruct midface, lefort    C                     $1,198.95    Covered
21146   Reconstruct midface, lefort    C                     $1,243.47    Covered
21147   Reconstruct midface, lefort    C                                 Not Covered
21150   Reconstruct midface, lefort    T   00256   42.9827                Covered
21151   Reconstruct midface, lefort    C                     $1,779.80    Covered
21154   Reconstruct midface, lefort    C                     $1,863.40    Covered
21155   Reconstruct midface, lefort    C                     $2,081.65    Covered
21159   Reconstruct midface, lefort    C                     $2,607.68    Covered
21160   Reconstruct midface, lefort    C                     $2,772.77    Covered
21172   Reconstruct orbit/forehead     T   00256   42.9827                Covered
21175   Reconstruct orbit/forehead     T   00256   42.9827                Covered
21179   Reconstruct entire forehead    C                     $1,434.84    Covered
21180   Reconstruct entire forehead    C                     $1,605.87    Covered
21181   Contour cranial bone lesion    T   00254   24.9637                Covered
21182   Reconstruct cranial bone       C                     $2,028.94    Covered
21183   Reconstruct cranial bone       C                     $2,187.03    Covered
21184   Reconstruct cranial bone       C                     $2,455.42    Covered
21188   Reconstruction of midface      C                     $1,411.02    Covered
21193   Reconst lwr jaw w/o graft      C                     $1,052.29    Covered
21194   Reconst lwr jaw w/graft        C                     $1,217.20    Covered
21195   Reconst lwr jaw w/o fixation   T   00256   42.9827                Covered
21196   Reconst lwr jaw w/fixation     C                     $1,180.85    Covered
21198   Reconstr lwr jaw segment       T   00256   42.9827               Covered
21199   Reconstr lwr jaw w/advance     T   00256   42.9827               Covered
21206   Reconstruct upper jaw bone     T   00256   42.9827               Covered
21208   Augmentation of facial bones   T   00256   42.9827               Covered
21209   Reduction of facial bones      T   00256   42.9827               Covered
21210   Face bone graft                T   00256   42.9827               Covered
21215   Lower jaw bone graft           T   00256   42.9827               Covered
21230   Rib cartilage graft            T   00256   42.9827               Covered
21235   Ear cartilage graft            T   00254   24.9637               Covered
21240   Reconstruction of jaw joint    T   00256   42.9827               Covered
21242   Reconstruction of jaw joint    T   00256   42.9827               Covered
21243   Reconstruction of jaw joint    T   00256   42.9827               Covered
21244   Reconstruction of lower jaw    T   00256   42.9827               Covered
21245   Reconstruction of jaw          T   00256   42.9827               Covered
21246   Reconstruction of jaw          T   00256   42.9827               Covered
21247   Reconstruct lower jaw bone     C                     $1,579.21   Covered
21248   Reconstruction of jaw          T   00256   42.9827               Covered
21249   Reconstruction of jaw          T   00256   42.9827               Covered
21255   Reconstruct lower jaw bone     C                     $1,146.25   Covered
21256   Reconstruction of orbit        T   00256   42.9827               Covered
21260   Revise eye sockets             T   00256   42.9827               Covered
21261   Revise eye sockets             T   00256   42.9827               Covered
21263   Revise eye sockets             T   00256   42.9827               Covered
21267   Revise eye sockets             T   00256   42.9827               Covered
21268   Revise eye sockets             C                     $1,520.38   Covered
21270   Augmentation, cheek bone       T   00256   42.9827               Covered
21275   Revision, orbitofacial bones   T   00256   42.9827               Covered
21280   Revision of eyelid             T   00256   42.9827               Covered
21282   Revision of eyelid             T   00253   17.1879               Covered
21295   Revision of jaw muscle/bone    T   00252    7.6196               Covered
21296   Revision of jaw muscle/bone    T   00254   24.9637               Covered
21299   Cranio/maxillofacial surgery   T   00250    1.1522               Covered
21310   Treatment of nose fracture     T   00250    1.1522               Covered
21315   Treatment of nose fracture     T   00253   17.1879               Covered
21320   Treatment of nose fracture     T   00253   17.1879               Covered
21325   Treatment of nose fracture     T   00254   24.9637               Covered
21330   Treatment of nose fracture     T   00254   24.9637               Covered
21335   Treatment of nose fracture     T   00254   24.9637               Covered
21336   Treat nasal septal fracture    T   00062   25.8446               Covered
21337   Treat nasal septal fracture    T   00253   17.1879               Covered
21338   Treat nasoethmoid fracture     T   00254   24.9637               Covered
21339   Treat nasoethmoid fracture     T   00254   24.9637               Covered
21340   Treatment of nose fracture     T   00256   42.9827               Covered
21343   Treatment of sinus fracture    C                      $822.58    Covered
21344   Treatment of sinus fracture    C                     $1,147.14   Covered
21345   Treat nose/jaw fracture        T   00254   24.9637               Covered
21346   Treat nose/jaw fracture        C                      $722.44    Covered
21347   Treat nose/jaw fracture        C                      $826.25    Covered
21348   Treat nose/jaw fracture        C                     $1,016.53   Covered
21355   Treat cheek bone fracture      T   00256   42.9827               Covered
21356   Treat cheek bone fracture      T   00254   24.9637               Covered
21360   Treat cheek bone fracture      T   00254   24.9637               Covered
21365   Treat cheek bone fracture     T   00256   42.9827               Covered
21366   Treat cheek bone fracture     C                     $1,095.48   Covered
21385   Treat eye socket fracture     T   00256   42.9827               Covered
21386   Treat eye socket fracture     T   00256   42.9827               Covered
21387   Treat eye socket fracture     T   00256   42.9827               Covered
21390   Treat eye socket fracture     T   00256   42.9827               Covered
21395   Treat eye socket fracture     C                     $817.46     Covered
21400   Treat eye socket fracture     T   00252    7.6196               Covered
21401   Treat eye socket fracture     T   00253   17.1879               Covered
21406   Treat eye socket fracture     T   00256   42.9827               Covered
21407   Treat eye socket fracture     T   00256   42.9827               Covered
21408   Treat eye socket fracture     T   00256   42.9827               Covered
21421   Treat mouth roof fracture     T   00254   24.9637               Covered
21422   Treat mouth roof fracture     C                      $598.58    Covered
21423   Treat mouth roof fracture     C                      $701.45    Covered
21431   Treat craniofacial fracture   C                      $472.05    Covered
21432   Treat craniofacial fracture   C                      $584.09    Covered
21433   Treat craniofacial fracture   C                     $1,565.60   Covered
21435   Treat craniofacial fracture   C                     $1,108.83   Covered
21436   Treat craniofacial fracture   C                     $1,624.10   Covered
21440   Treat dental ridge fracture   T   00254   24.9637               Covered
21445   Treat dental ridge fracture   T   00254   24.9637               Covered
21450   Treat lower jaw fracture      T   00251    3.4250               Covered
21451   Treat lower jaw fracture      T   00252    7.6196               Covered
21452   Treat lower jaw fracture      T   00253   17.1879               Covered
21453   Treat lower jaw fracture      T   00256   42.9827               Covered
21454   Treat lower jaw fracture      T   00254   24.9637               Covered
21461   Treat lower jaw fracture      T   00256   42.9827               Covered
21462   Treat lower jaw fracture      T   00256   42.9827               Covered
21465   Treat lower jaw fracture      T   00256   42.9827               Covered
21470   Treat lower jaw fracture      T   00256   42.9827               Covered
21480   Reset dislocated jaw          T   00250    1.1522               Covered
21485   Reset dislocated jaw          T   00253   17.1879               Covered
21490   Repair dislocated jaw         T   00256   42.9827               Covered
21495   Treat hyoid bone fracture     T   00253   17.1879               Covered
21497   Interdental wiring            T   00253   17.1879               Covered
21499   Head surgery procedure        T   00250    1.1522               Covered
21501   Drain neck/chest lesion       T   00008   19.4063               Covered
21502   Drain chest lesion            T   00049   22.0149               Covered
21510   Drainage of bone lesion       C                     $419.81     Covered
21550   Biopsy of neck/chest          T   00021   17.4975               Covered
21552   Exc neck les sc = 3 cm        T   00022   23.3880               Covered
21554   Exc neck tum deep = 5 cm      T   00022   23.3880               Covered
21555   Remove lesion, neck/chest     T   00021   17.4975               Covered
21556   Remove lesion, neck/chest     T   00022   23.3880               Covered
21557   Remove tumor, neck/chest      T   00021   17.4975               Covered
21558   Resect neck tum = 5 cm        T   00022   23.3880               Covered
21600   Partial removal of rib        T   00050   31.7717               Covered
21610   Partial removal of rib        T   00050   31.7717               Covered
21615   Removal of rib                C                     $732.24     Covered
21616   Removal of rib and nerves     C                     $817.06     Covered
21620   Partial removal of sternum    C                     $538.30     Covered
21627   Sternal debridement            C                      $616.38    Covered
21630   Extensive sternum surgery      C                     $1,142.54   Covered
21632   Extensive sternum surgery      C                     $1,186.87   Covered
21685   Hyoid myotomy & suspension     T   00252    7.6196               Covered
21700   Revision of neck muscle        T   00049   22.0149               Covered
21705   Revision of neck muscle/rib    C                     $585.71     Covered
21720   Revision of neck muscle        T   00049   22.0149               Covered
21725   Revision of neck muscle        T   00006    1.4557               Covered
21740   Reconstruction of sternum      C                     $1,089.51   Covered
21742   Repair stern/nuss w/o scope    T   00051   46.5786               Covered
21743   Repair sternum/nuss w/scope    T   00051   46.5786               Covered
21750   Repair of sternum separation   C                     $788.76     Covered
21800   Treatment of rib fracture      T   00129    1.6576               Covered
21805   Treatment of rib fracture      T   00062   25.8446               Covered
21810   Treatment of rib fracture(s)   C                     $523.69     Covered
21820   Treat sternum fracture         T   00129    1.6576               Covered
21825   Treat sternum fracture         C                     $630.89     Covered
21899   Neck/chest surgery procedure   T   00250    1.1522               Covered
21920   Biopsy soft tissue of back     T   00020    8.2028               Covered
21925   Biopsy soft tissue of back     T   00022   23.3880               Covered
21930   Remove lesion, back or flank   T   00021   17.4975               Covered
21931   Exc back les sc = 3 cm         T   00022   23.3880               Covered
21932   Exc back tum deep < 5 cm       T   00021   17.4975               Covered
21933   Exc back tum deep = 5 cm       T   00022   23.3880               Covered
21935   Remove tumor, back             T   00021   17.4975               Covered
21936   Resect back tum = 5 cm         T   00022   23.3880               Covered
22010   I&d, p-spine, c/t/cerv-thor    C                     $419.81     Covered
22015   I&d, p-spine, l/s/ls           C                     $419.81     Covered
22100   Remove part of neck vertebra   T   00208   49.2256               Covered
22101   Remove part, thorax vertebra   T   00208   49.2256               Covered
22102   Remove part, lumbar vertebra   T   00208   49.2256               Covered
22103   Remove extra spine segment     T   00208   49.2256               Covered
22110   Remove part of neck vertebra   C                      $862.23    Covered
22112   Remove part, thorax vertebra   C                      $854.46    Covered
22114   Remove part, lumbar vertebra   C                      $834.75    Covered
22116   Remove extra spine segment     C                      $152.89    Covered
22206   Cut spine 3 col, thor          C                     $1,780.84   Covered
22207   Cut spine 3 col, lumb          C                     $1,758.87   Covered
22208   Cut spine 3 col, addl seg      C                      $446.57    Covered
22210   Revision of neck spine         C                     $1,481.35   Covered
22212   Revision of thorax spine       C                     $1,311.20   Covered
22214   Revision of lumbar spine       C                     $1,291.31   Covered
22216   Revise, extra spine segment    C                      $385.84    Covered
22220   Revision of neck spine         C                     $1,407.88   Covered
22222   Revision of thorax spine       T   00208   49.2256               Covered
22224   Revision of lumbar spine       C                     $1,360.70   Covered
22226   Revise, extra spine segment    C                      $383.54    Covered
22305   Treat spine process fracture   T   00129    1.6576               Covered
22310   Treat spine fracture           T   00138    4.7946               Covered
22315   Treat spine fracture           T   00139   18.3962               Covered
22318   Treat odontoid fx w/o graft    C                     $1,366.44   Covered
22319   Treat odontoid fx w/graft      C                     $1,543.19   Covered
22325   Treat spine fracture           C                     $1,105.59     Covered
22326   Treat neck spine fracture      C                     $1,332.64     Covered
22327   Treat thorax spine fracture    C                     $1,298.40     Covered
22328   Treat each add spine fx        C                      $305.67      Covered
22505   Manipulation of spine          T   00045   15.2922                 Covered
22520   Percut vertebroplasty thor     T   00050   31.7717                 Covered
22521   Percut vertebroplasty lumb     T   00050   31.7717                 Covered
22522   Percut vertebroplasty add'l    T   00050   31.7717                 Covered
22523   Percut kyphoplasty, thor       T   00052   88.6521                 Covered
22524   Percut kyphoplasty, lumbar     T   00052   88.6521                 Covered
22525   Percut kyphoplasty, add-on     T   00052   88.6521                 Covered
22526   Idet, single level             E                                 Not Covered
22527   Idet, 1 or more levels         E                                 Not Covered
22532   Lat thorax spine fusion        C                     $1,410.94     Covered
22533   Lat lumbar spine fusion        C                     $1,322.65     Covered
22534   Lat thor/lumb, add'l seg       C                      $332.93      Covered
22548   Neck spine fusion              C                     $1,765.77     Covered
22554   Neck spine fusion              C                     $1,343.63     Covered
22556   Thorax spine fusion            C                     $1,606.49     Covered
22558   Lumbar spine fusion            C                     $1,495.47     Covered
22585   Additional spinal fusion       C                      $369.58      Covered
22590   Spine & skull spinal fusion    C                     $1,474.84     Covered
22595   Neck spinal fusion             C                     $1,409.84     Covered
22600   Neck spine fusion              C                     $1,181.12     Covered
22610   Thorax spine fusion            C                     $1,166.08     Covered
22612   Lumbar spine fusion            T   00208   49.2256                 Covered
22614   Spine fusion, extra segment    T   00208   49.2256                 Covered
22630   Lumbar spine fusion            C                     $1,431.75     Covered
22632   Spine fusion, extra segment    C                      $345.70      Covered
22800   Fusion of spine                C                     $1,302.23     Covered
22802   Fusion of spine                C                     $2,067.38     Covered
22804   Fusion of spine                C                     $2,321.72     Covered
22808   Fusion of spine                C                     $1,687.57     Covered
22810   Fusion of spine                C                     $1,853.34     Covered
22812   Fusion of spine                C                     $2,103.23     Covered
22818   Kyphectomy, 1-2 segments       C                     $2,113.87     Covered
22819   Kyphectomy, 3 or more          C                     $2,325.41     Covered
22830   Exploration of spinal fusion   C                      $802.10      Covered
22840   Insert spine fixation device   C                      $741.23      Covered
22841   Insert spine fixation device   C                                  By Report
22842   Insert spine fixation device   C                      $735.79      Covered
22843   Insert spine fixation device   C                      $808.38      Covered
22844   Insert spine fixation device   C                     $1,006.25     Covered
22845   Insert spine fixation device   C                      $719.07      Covered
22846   Insert spine fixation device   C                      $781.71      Covered
22847   Insert spine fixation device   C                      $846.72      Covered
22848   Insert pelv fixation device    C                      $415.10      Covered
22849   Reinsert spinal fixation       C                     $1,167.31     Covered
22850   Remove spine fixation device   C                      $682.18      Covered
22851   Apply spine prosth device      T   00049   22.0149                 Covered
22852   Remove spine fixation device   C                     $668.18       Covered
22855   Remove spine fixation device   C                     $932.78       Covered
22856   Cerv artific diskectomy        C                               Not Covered
22857   Lumbar artif diskectomy        C                               Not Covered
22861   Revise cerv artific disc       C                               Not Covered
22862   Revise lumbar artif disc       C                               Not Covered
22864   Remove cerv artif disc         C                               Not Covered
22865   Remove lumb artif disc         C                               Not Covered
22899   Spine surgery procedure        T   00049   22.0149              Covered
22900   Remove abdominal wall lesion   T   00022   23.3880              Covered
22901   Exc back tum deep = 5 cm       T   00022   23.3880              Covered
22902   Exc abd les sc < 3 cm          T   00021   17.4975              Covered
22903   Exc abd les sc > 3 cm          T   00022   23.3880              Covered
22904   Resect abd tum < 5 cm          T   00021   17.4975              Covered
22905   Resect abd tum > 5 cm          T   00022   23.3880              Covered
22999   Abdomen surgery procedure      T   00049   22.0149              Covered
23000   Removal of calcium deposits    T   00021   17.4975              Covered
23020   Release shoulder joint         T   00051   46.5786              Covered
23030   Drain shoulder lesion          T   00008   19.4063              Covered
23031   Drain shoulder bursa           T   00008   19.4063              Covered
23035   Drain shoulder bone lesion     T   00049   22.0149              Covered
23040   Exploratory shoulder surgery   T   00050   31.7717              Covered
23044   Exploratory shoulder surgery   T   00050   31.7717              Covered
23065   Biopsy shoulder tissues        T   00020    8.2028              Covered
23066   Biopsy shoulder tissues        T   00022   23.3880              Covered
23071   Exc shoulder les sc > 3 cm     T   00022   23.3880              Covered
23073   Exc shoulder tum deep > 5 cm   T   00022   23.3880              Covered
23075   Removal of shoulder lesion     T   00021   17.4975              Covered
23076   Removal of shoulder lesion     T   00021   17.4975              Covered
23077   Remove tumor of shoulder       T   00021   17.4975              Covered
23078   Resect shoulder tum > 5 cm     T   00022   23.3880              Covered
23100   Biopsy of shoulder joint       T   00049   22.0149              Covered
23101   Shoulder joint surgery         T   00050   31.7717              Covered
23105   Remove shoulder joint lining   T   00050   31.7717              Covered
23106   Incision of collarbone joint   T   00050   31.7717              Covered
23107   Explore treat shoulder joint   T   00050   31.7717              Covered
23120   Partial removal, collar bone   T   00050   31.7717              Covered
23125   Removal of collar bone         T   00050   31.7717              Covered
23130   Remove shoulder bone, part     T   00051   46.5786              Covered
23140   Removal of bone lesion         T   00049   22.0149              Covered
23145   Removal of bone lesion         T   00050   31.7717              Covered
23146   Removal of bone lesion         T   00050   31.7717              Covered
23150   Removal of humerus lesion      T   00050   31.7717              Covered
23155   Removal of humerus lesion      T   00050   31.7717              Covered
23156   Removal of humerus lesion      T   00050   31.7717              Covered
23170   Remove collar bone lesion      T   00050   31.7717              Covered
23172   Remove shoulder blade lesion   T   00050   31.7717              Covered
23174   Remove humerus lesion          T   00050   31.7717              Covered
23180   Remove collar bone lesion      T   00050   31.7717              Covered
23182   Remove shoulder blade lesion   T   00050   31.7717              Covered
23184   Remove humerus lesion          T   00050   31.7717              Covered
23190   Partial removal of scapula     T   00050   31.7717              Covered
23195   Removal of head of humerus     T   00050   31.7717              Covered
23200   Removal of collar bone         C                     $859.49    Covered
23210   Removal of shoulder blade      C                       $860.42     Covered
23220   Partial removal of humerus     C                      $1,025.88    Covered
23221   Partial removal of humerus     D                                  Not Covered
23222   Partial removal of humerus     D                                  Not Covered
23330   Remove shoulder foreign body   T   00020     8.2028                Covered
23331   Remove shoulder foreign body   T   00022    23.3880                Covered
23332   Remove shoulder foreign body   C                      $808.08      Covered
23350   Injection for shoulder x-ray   N                                   Covered
23395   Muscle transfer,shoulder/arm   T   00051    46.5786                Covered
23397   Muscle transfers               T   00052    88.6521                Covered
23400   Fixation of shoulder blade     T   00050    31.7717                Covered
23405   Incision of tendon & muscle    T   00050    31.7717                Covered
23406   Incise tendon(s) & muscle(s)   T   00050    31.7717                Covered
23410   Repair rotator cuff, acute     T   00051    46.5786                Covered
23412   Repair rotator cuff, chronic   T   00051    46.5786                Covered
23415   Release of shoulder ligament   T   00051    46.5786                Covered
23420   Repair of shoulder             T   00051    46.5786                Covered
23430   Repair biceps tendon           T   00051    46.5786                Covered
23440   Remove/transplant tendon       T   00051    46.5786                Covered
23450   Repair shoulder capsule        T   00052    88.6521                Covered
23455   Repair shoulder capsule        T   00052    88.6521                Covered
23460   Repair shoulder capsule        T   00052    88.6521                Covered
23462   Repair shoulder capsule        T   00051    46.5786                Covered
23465   Repair shoulder capsule        T   00052    88.6521                Covered
23466   Repair shoulder capsule        T   00051    46.5786                Covered
23470   Reconstruct shoulder joint     T   00425   118.7670                Covered
23472   Reconstruct shoulder joint     C                      $1,231.36    Covered
23480   Revision of collar bone        T   00051    46.5786                Covered
23485   Revision of collar bone        T   00052    88.6521                Covered
23490   Reinforce clavicle             T   00051    46.5786                Covered
23491   Reinforce shoulder bones       T   00052    88.6521                Covered
23500   Treat clavicle fracture        T   00129     1.6576                Covered
23505   Treat clavicle fracture        T   00139    18.3962                Covered
23515   Treat clavicle fracture        T   00064    65.4752                Covered
23520   Treat clavicle dislocation     T   00138     4.7946                Covered
23525   Treat clavicle dislocation     T   00138     4.7946                Covered
23530   Treat clavicle dislocation     T   00063    45.4678                Covered
23532   Treat clavicle dislocation     T   00062    25.8446                Covered
23540   Treat clavicle dislocation     T   00129     1.6576                Covered
23545   Treat clavicle dislocation     T   00138     4.7946                Covered
23550   Treat clavicle dislocation     T   00063    45.4678                Covered
23552   Treat clavicle dislocation     T   00063    45.4678                Covered
23570   Treat shoulder blade fx        T   00129     1.6576                Covered
23575   Treat shoulder blade fx        T   00138     4.7946                Covered
23585   Treat scapula fracture         T   00064    65.4752                Covered
23600   Treat humerus fracture         T   00129     1.6576                Covered
23605   Treat humerus fracture         T   00139    18.3962                Covered
23615   Treat humerus fracture         T   00064    65.4752                Covered
23616   Treat humerus fracture         T   00064    65.4752                Covered
23620   Treat humerus fracture         T   00129     1.6576                Covered
23625   Treat humerus fracture         T   00139    18.3962                Covered
23630   Treat humerus fracture         T   00064    65.4752                Covered
23650   Treat shoulder dislocation     T   00129    1.6576                Covered
23655   Treat shoulder dislocation     T   00045   15.2922                Covered
23660   Treat shoulder dislocation     T   00063   45.4678                Covered
23665   Treat dislocation/fracture     T   00138    4.7946                Covered
23670   Treat dislocation/fracture     T   00064   65.4752                Covered
23675   Treat dislocation/fracture     T   00129    1.6576                Covered
23680   Treat dislocation/fracture     T   00063   45.4678                Covered
23700   Fixation of shoulder           T   00045   15.2922                Covered
23800   Fusion of shoulder joint       T   00052   88.6521                Covered
23802   Fusion of shoulder joint       T   00051   46.5786                Covered
23900   Amputation of arm & girdle     C                     $1,231.01    Covered
23920   Amputation at shoulder joint   C                     $1,020.54    Covered
23921   Amputation follow-up surgery   T   00136   16.0542                Covered
23929   Shoulder surgery procedure     T   00129    1.6576                Covered
23930   Drainage of arm lesion         T   00008   19.4063                Covered
23931   Drainage of arm bursa          T   00008   19.4063                Covered
23935   Drain arm/elbow bone lesion    T   00049   22.0149                Covered
24000   Exploratory elbow surgery      T   00050   31.7717                Covered
24006   Release elbow joint            T   00050   31.7717                Covered
24065   Biopsy arm/elbow soft tissue   T   00021   17.4975                Covered
24066   Biopsy arm/elbow soft tissue   T   00021   17.4975                Covered
24071   Exc arm/elbow les sc = 3 cm    T   00022   23.3880                Covered
24073   Ex arm/elbow tum deep > 5 cm   T   00022   23.3880                Covered
24075   Remove arm/elbow lesion        T   00021   17.4975                Covered
24076   Remove arm/elbow lesion        T   00021   17.4975                Covered
24077   Remove tumor of arm/elbow      T   00021   17.4975                Covered
24079   Resect arm/elbow tum > 5 cm    T   00022   23.3880                Covered
24100   Biopsy elbow joint lining      T   00049   22.0149                Covered
24101   Explore/treat elbow joint      T   00050   31.7717                Covered
24102   Remove elbow joint lining      T   00050   31.7717                Covered
24105   Removal of elbow bursa         T   00049   22.0149                Covered
24110   Remove humerus lesion          T   00049   22.0149                Covered
24115   Remove/graft bone lesion       T   00050   31.7717                Covered
24116   Remove/graft bone lesion       T   00050   31.7717                Covered
24120   Remove elbow lesion            T   00049   22.0149                Covered
24125   Remove/graft bone lesion       T   00050   31.7717                Covered
24126   Remove/graft bone lesion       T   00050   31.7717                Covered
24130   Removal of head of radius      T   00050   31.7717                Covered
24134   Removal of arm bone lesion     T   00050   31.7717                Covered
24136   Remove radius bone lesion      T   00050   31.7717                Covered
24138   Remove elbow bone lesion       T   00050   31.7717                Covered
24140   Partial removal of arm bone    T   00050   31.7717                Covered
24145   Partial removal of radius      T   00050   31.7717                Covered
24147   Partial removal of elbow       T   00050   31.7717                Covered
24149   Radical resection of elbow     T   00050   31.7717                Covered
24150   Extensive humerus surgery      T   00051   46.5786                Covered
24151   Extensive humerus surgery      D                                 Not Covered
24152   Extensive radius surgery       T   00051   46.5786                Covered
24153   Extensive radius surgery       D                                 Not Covered
24155   Removal of elbow joint         T   00051   46.5786                Covered
24160   Remove elbow joint implant     T   00050   31.7717                Covered
24164   Remove radius head implant     T   00050   31.7717                Covered
24200   Removal of arm foreign body    T   00019     4.3625   Covered
24201   Removal of arm foreign body    T   00021    17.4975   Covered
24220   Injection for elbow x-ray      N                      Covered
24300   Manipulate elbow w/anesth      T   00045    15.2922   Covered
24301   Muscle/tendon transfer         T   00050    31.7717   Covered
24305   Arm tendon lengthening         T   00050    31.7717   Covered
24310   Revision of arm tendon         T   00049    22.0149   Covered
24320   Repair of arm tendon           T   00051    46.5786   Covered
24330   Revision of arm muscles        T   00052    88.6521   Covered
24331   Revision of arm muscles        T   00051    46.5786   Covered
24332   Tenolysis, triceps             T   00049    22.0149   Covered
24340   Repair of biceps tendon        T   00051    46.5786   Covered
24341   Repair arm tendon/muscle       T   00051    46.5786   Covered
24342   Repair of ruptured tendon      T   00051    46.5786   Covered
24343   Repr elbow lat ligmnt w/tiss   T   00050    31.7717   Covered
24344   Reconstruct elbow lat ligmnt   T   00052    88.6521   Covered
24345   Repr elbw med ligmnt w/tissu   T   00050    31.7717   Covered
24346   Reconstruct elbow med ligmnt   T   00051    46.5786   Covered
24357   Repair elbow, perc             T   00050    31.7717   Covered
24358   Repair elbow w/deb, open       T   00050    31.7717   Covered
24359   Repair elbow deb/attch open    T   00050    31.7717   Covered
24360   Reconstruct elbow joint        T   00047    39.8877   Covered
24361   Reconstruct elbow joint        T   00425   118.7670   Covered
24362   Reconstruct elbow joint        T   00048    58.0838   Covered
24363   Replace elbow joint            T   00425   118.7670   Covered
24365   Reconstruct head of radius     T   00047    39.8877   Covered
24366   Reconstruct head of radius     T   00425   118.7670   Covered
24400   Revision of humerus            T   00051    46.5786   Covered
24410   Revision of humerus            T   00051    46.5786   Covered
24420   Revision of humerus            T   00051    46.5786   Covered
24430   Repair of humerus              T   00052    88.6521   Covered
24435   Repair humerus with graft      T   00052    88.6521   Covered
24470   Revision of elbow joint        T   00051    46.5786   Covered
24495   Decompression of forearm       T   00050    31.7717   Covered
24498   Reinforce humerus              T   00052    88.6521   Covered
24500   Treat humerus fracture         T   00129     1.6576   Covered
24505   Treat humerus fracture         T   00129     1.6576   Covered
24515   Treat humerus fracture         T   00064    65.4752   Covered
24516   Treat humerus fracture         T   00064    65.4752   Covered
24530   Treat humerus fracture         T   00129     1.6576   Covered
24535   Treat humerus fracture         T   00138     4.7946   Covered
24538   Treat humerus fracture         T   00062    25.8446   Covered
24545   Treat humerus fracture         T   00064    65.4752   Covered
24546   Treat humerus fracture         T   00064    65.4752   Covered
24560   Treat humerus fracture         T   00129     1.6576   Covered
24565   Treat humerus fracture         T   00129     1.6576   Covered
24566   Treat humerus fracture         T   00062    25.8446   Covered
24575   Treat humerus fracture         T   00064    65.4752   Covered
24576   Treat humerus fracture         T   00129     1.6576   Covered
24577   Treat humerus fracture         T   00138     4.7946   Covered
24579   Treat humerus fracture         T   00064    65.4752   Covered
24582   Treat humerus fracture         T   00062    25.8446   Covered
24586   Treat elbow fracture           T   00064   65.4752             Covered
24587   Treat elbow fracture           T   00064   65.4752             Covered
24600   Treat elbow dislocation        T   00129    1.6576             Covered
24605   Treat elbow dislocation        T   00045   15.2922             Covered
24615   Treat elbow dislocation        T   00064   65.4752             Covered
24620   Treat elbow fracture           T   00139   18.3962             Covered
24635   Treat elbow fracture           T   00064   65.4752             Covered
24640   Treat elbow dislocation        T   00129    1.6576             Covered
24650   Treat radius fracture          T   00129    1.6576             Covered
24655   Treat radius fracture          T   00138    4.7946             Covered
24665   Treat radius fracture          T   00063   45.4678             Covered
24666   Treat radius fracture          T   00064   65.4752             Covered
24670   Treat ulnar fracture           T   00129    1.6576             Covered
24675   Treat ulnar fracture           T   00129    1.6576             Covered
24685   Treat ulnar fracture           T   00063   45.4678             Covered
24800   Fusion of elbow joint          T   00051   46.5786             Covered
24802   Fusion/graft of elbow joint    T   00051   46.5786             Covered
24900   Amputation of upper arm        C                     $673.70   Covered
24920   Amputation of upper arm        C                     $667.93   Covered
24925   Amputation follow-up surgery   T   00049   22.0149             Covered
24930   Amputation follow-up surgery   C                     $728.36   Covered
24931   Amputate upper arm & implant   C                     $835.89   Covered
24935   Revision of amputation         T   00052   88.6521             Covered
24940   Revision of upper arm          C                     $805.75   Covered
24999   Upper arm/elbow surgery        T   00129    1.6576             Covered
25000   Incision of tendon sheath      T   00049   22.0149             Covered
25001   Incise flexor carpi radialis   T   00049   22.0149             Covered
25020   Decompress forearm 1 space     T   00050   31.7717             Covered
25023   Decompress forearm 1 space     T   00050   31.7717             Covered
25024   Decompress forearm 2 spaces    T   00050   31.7717             Covered
25025   Decompress forearm 2 spaces    T   00050   31.7717             Covered
25028   Drainage of forearm lesion     T   00049   22.0149             Covered
25031   Drainage of forearm bursa      T   00049   22.0149             Covered
25035   Treat forearm bone lesion      T   00049   22.0149             Covered
25040   Explore/treat wrist joint      T   00050   31.7717             Covered
25065   Biopsy forearm soft tissues    T   00020    8.2028             Covered
25066   Biopsy forearm soft tissues    T   00022   23.3880             Covered
25071   Exc forearm les sc > 3 cm      T   00022   23.3880             Covered
25073   Exc forearm tum deep = 3 cm    T   00022   23.3880             Covered
25075   Removal forearm lesion subcu   T   00021   17.4975             Covered
25076   Removal forearm lesion deep    T   00021   17.4975             Covered
25077   Remove tumor, forearm/wrist    T   00021   17.4975             Covered
25078   Resect forearm/wrist tum=3cm   T   00022   23.3880             Covered
25085   Incision of wrist capsule      T   00049   22.0149             Covered
25100   Biopsy of wrist joint          T   00049   22.0149             Covered
25101   Explore/treat wrist joint      T   00050   31.7717             Covered
25105   Remove wrist joint lining      T   00050   31.7717             Covered
25107   Remove wrist joint cartilage   T   00050   31.7717             Covered
25109   Excise tendon forearm/wrist    T   00049   22.0149             Covered
25110   Remove wrist tendon lesion     T   00049   22.0149             Covered
25111   Remove wrist tendon lesion     T   00049   22.0149             Covered
25112   Reremove wrist tendon lesion   T   00049   22.0149             Covered
25115   Remove wrist/forearm lesion    T   00049   22.0149    Covered
25116   Remove wrist/forearm lesion    T   00049   22.0149    Covered
25118   Excise wrist tendon sheath     T   00050   31.7717    Covered
25119   Partial removal of ulna        T   00050   31.7717    Covered
25120   Removal of forearm lesion      T   00050   31.7717    Covered
25125   Remove/graft forearm lesion    T   00050   31.7717    Covered
25126   Remove/graft forearm lesion    T   00050   31.7717    Covered
25130   Removal of wrist lesion        T   00050   31.7717    Covered
25135   Remove & graft wrist lesion    T   00050   31.7717    Covered
25136   Remove & graft wrist lesion    T   00050   31.7717    Covered
25145   Remove forearm bone lesion     T   00050   31.7717    Covered
25150   Partial removal of ulna        T   00050   31.7717    Covered
25151   Partial removal of radius      T   00050   31.7717    Covered
25170   Extensive forearm surgery      T   00051   46.5786    Covered
25210   Removal of wrist bone          T   00050   31.7717    Covered
25215   Removal of wrist bones         T   00050   31.7717    Covered
25230   Partial removal of radius      T   00050   31.7717    Covered
25240   Partial removal of ulna        T   00050   31.7717    Covered
25246   Injection for wrist x-ray      N                      Covered
25248   Remove forearm foreign body    T   00049   22.0149    Covered
25250   Removal of wrist prosthesis    T   00050   31.7717    Covered
25251   Removal of wrist prosthesis    T   00050   31.7717    Covered
25259   Manipulate wrist w/anesthes    T   00139   18.3962    Covered
25260   Repair forearm tendon/muscle   T   00050   31.7717    Covered
25263   Repair forearm tendon/muscle   T   00050   31.7717    Covered
25265   Repair forearm tendon/muscle   T   00050   31.7717   Not Covered
25270   Repair forearm tendon/muscle   T   00050   31.7717    Covered
25272   Repair forearm tendon/muscle   T   00050   31.7717    Covered
25274   Repair forearm tendon/muscle   T   00050   31.7717    Covered
25275   Repair forearm tendon sheath   T   00050   31.7717    Covered
25280   Revise wrist/forearm tendon    T   00050   31.7717    Covered
25290   Incise wrist/forearm tendon    T   00050   31.7717    Covered
25295   Release wrist/forearm tendon   T   00049   22.0149    Covered
25300   Fusion of tendons at wrist     T   00050   31.7717    Covered
25301   Fusion of tendons at wrist     T   00050   31.7717    Covered
25310   Transplant forearm tendon      T   00051   46.5786    Covered
25312   Transplant forearm tendon      T   00051   46.5786    Covered
25315   Revise palsy hand tendon(s)    T   00051   46.5786    Covered
25316   Revise palsy hand tendon(s)    T   00052   88.6521   Not Covered
25320   Repair/revise wrist joint      T   00051   46.5786    Covered
25332   Revise wrist joint             T   00047   39.8877    Covered
25335   Realignment of hand            T   00051   46.5786    Covered
25337   Reconstruct ulna/radioulnar    T   00051   46.5786    Covered
25350   Revision of radius             T   00051   46.5786    Covered
25355   Revision of radius             T   00051   46.5786    Covered
25360   Revision of ulna               T   00051   46.5786    Covered
25365   Revise radius & ulna           T   00051   46.5786    Covered
25370   Revise radius or ulna          T   00051   46.5786    Covered
25375   Revise radius & ulna           T   00051   46.5786    Covered
25390   Shorten radius or ulna         T   00051   46.5786    Covered
25391   Lengthen radius or ulna        T   00051   46.5786    Covered
25392   Shorten radius & ulna          T   00050   31.7717    Covered
25393   Lengthen radius & ulna         T   00051    46.5786   Covered
25394   Repair carpal bone, shorten    T   00051    46.5786   Covered
25400   Repair radius or ulna          T   00051    46.5786   Covered
25405   Repair/graft radius or ulna    T   00052    88.6521   Covered
25415   Repair radius & ulna           T   00052    88.6521   Covered
25420   Repair/graft radius & ulna     T   00052    88.6521   Covered
25425   Repair/graft radius or ulna    T   00051    46.5786   Covered
25426   Repair/graft radius & ulna     T   00051    46.5786   Covered
25430   Vasc graft into carpal bone    T   00051    46.5786   Covered
25431   Repair nonunion carpal bone    T   00051    46.5786   Covered
25440   Repair/graft wrist bone        T   00052    88.6521   Covered
25441   Reconstruct wrist joint        T   00425   118.7670   Covered
25442   Reconstruct wrist joint        T   00425   118.7670   Covered
25443   Reconstruct wrist joint        T   00048    58.0838   Covered
25444   Reconstruct wrist joint        T   00048    58.0838   Covered
25445   Reconstruct wrist joint        T   00048    58.0838   Covered
25446   Wrist replacement              T   00425   118.7670   Covered
25447   Repair wrist joint(s)          T   00047    39.8877   Covered
25449   Remove wrist joint implant     T   00047    39.8877   Covered
25450   Revision of wrist joint        T   00051    46.5786   Covered
25455   Revision of wrist joint        T   00051    46.5786   Covered
25490   Reinforce radius               T   00051    46.5786   Covered
25491   Reinforce ulna                 T   00051    46.5786   Covered
25492   Reinforce radius and ulna      T   00051    46.5786   Covered
25500   Treat fracture of radius       T   00129     1.6576   Covered
25505   Treat fracture of radius       T   00138     4.7946   Covered
25515   Treat fracture of radius       T   00063    45.4678   Covered
25520   Treat fracture of radius       T   00138     4.7946   Covered
25525   Treat fracture of radius       T   00063    45.4678   Covered
25526   Treat fracture of radius       T   00063    45.4678   Covered
25530   Treat fracture of ulna         T   00129     1.6576   Covered
25535   Treat fracture of ulna         T   00129     1.6576   Covered
25545   Treat fracture of ulna         T   00063    45.4678   Covered
25560   Treat fracture radius & ulna   T   00129     1.6576   Covered
25565   Treat fracture radius & ulna   T   00138     4.7946   Covered
25574   Treat fracture radius & ulna   T   00064    65.4752   Covered
25575   Treat fracture radius/ulna     T   00064    65.4752   Covered
25600   Treat fracture radius/ulna     T   00129     1.6576   Covered
25605   Treat fracture radius/ulna     T   00138     4.7946   Covered
25606   Treat fx distal radial         T   00062    25.8446   Covered
25607   Treat fx rad extra-articul     T   00064    65.4752   Covered
25608   Treat fx rad intra-articul     T   00064    65.4752   Covered
25609   Treat fx radial 3+ frag        T   00064    65.4752   Covered
25622   Treat wrist bone fracture      T   00129     1.6576   Covered
25624   Treat wrist bone fracture      T   00138     4.7946   Covered
25628   Treat wrist bone fracture      T   00063    45.4678   Covered
25630   Treat wrist bone fracture      T   00129     1.6576   Covered
25635   Treat wrist bone fracture      T   00138     4.7946   Covered
25645   Treat wrist bone fracture      T   00063    45.4678   Covered
25650   Treat wrist bone fracture      T   00129     1.6576   Covered
25651   Pin ulnar styloid fracture     T   00062    25.8446   Covered
25652   Treat fracture ulnar styloid   T   00063    45.4678   Covered
25660   Treat wrist dislocation        T   00129    1.6576               Covered
25670   Treat wrist dislocation        T   00062   25.8446               Covered
25671   Pin radioulnar dislocation     T   00062   25.8446               Covered
25675   Treat wrist dislocation        T   00129    1.6576               Covered
25676   Treat wrist dislocation        T   00062   25.8446               Covered
25680   Treat wrist fracture           T   00129    1.6576               Covered
25685   Treat wrist fracture           T   00062   25.8446               Covered
25690   Treat wrist dislocation        T   00139   18.3962               Covered
25695   Treat wrist dislocation        T   00062   25.8446               Covered
25800   Fusion of wrist joint          T   00052   88.6521               Covered
25805   Fusion/graft of wrist joint    T   00051   46.5786               Covered
25810   Fusion/graft of wrist joint    T   00052   88.6521               Covered
25820   Fusion of hand bones           T   00051   46.5786               Covered
25825   Fuse hand bones with graft     T   00052   88.6521               Covered
25830   Fusion, radioulnar jnt/ulna    T   00052   88.6521               Covered
25900   Amputation of forearm          C                     $682.17     Covered
25905   Amputation of forearm          C                     $704.31     Covered
25907   Amputation follow-up surgery   T   00049   22.0149               Covered
25909   Amputation follow-up surgery   C                      $665.16    Covered
25915   Amputation of forearm          C                     $1,195.09   Covered
25920   Amputate hand at wrist         C                      $604.97    Covered
25922   Amputate hand at wrist         T   00049   22.0149               Covered
25924   Amputation follow-up surgery   C                     $604.74     Covered
25927   Amputation of hand             C                     $650.52     Covered
25929   Amputation follow-up surgery   T   00136   16.0542               Covered
25931   Amputation follow-up surgery   T   00049   22.0149               Covered
25999   Forearm or wrist surgery       T   00129    1.6576               Covered
26010   Drainage of finger abscess     T   00006    1.4557               Covered
26011   Drainage of finger abscess     T   00007   12.6217               Covered
26020   Drain hand tendon sheath       T   00053   17.0420               Covered
26025   Drainage of palm bursa         T   00053   17.0420               Covered
26030   Drainage of palm bursa(s)      T   00053   17.0420               Covered
26034   Treat hand bone lesion         T   00053   17.0420               Covered
26035   Decompress fingers/hand        T   00053   17.0420               Covered
26037   Decompress fingers/hand        T   00053   17.0420               Covered
26040   Release palm contracture       T   00054   28.2376               Covered
26045   Release palm contracture       T   00054   28.2376               Covered
26055   Incise finger tendon sheath    T   00053   17.0420               Covered
26060   Incision of finger tendon      T   00053   17.0420               Covered
26070   Explore/treat hand joint       T   00053   17.0420               Covered
26075   Explore/treat finger joint     T   00053   17.0420               Covered
26080   Explore/treat finger joint     T   00053   17.0420               Covered
26100   Biopsy hand joint lining       T   00053   17.0420               Covered
26105   Biopsy finger joint lining     T   00053   17.0420               Covered
26110   Biopsy finger joint lining     T   00053   17.0420               Covered
26111   Exc hand les sc > 1.5 cm       T   00022   23.3880               Covered
26113   Exc hand tum deep > 1.5 cm     T   00022   23.3880               Covered
26115   Removal hand lesion subcut     T   00021   17.4975               Covered
26116   Removal hand lesion, deep      T   00021   17.4975               Covered
26117   Remove tumor, hand/finger      T   00021   17.4975               Covered
26118   Exc hand tum ra > 3 cm         T   00022   23.3880               Covered
26121   Release palm contracture       T   00054   28.2376               Covered
26123   Release palm contracture       T   00054   28.2376    Covered
26125   Release palm contracture       T   00053   17.0420    Covered
26130   Remove wrist joint lining      T   00053   17.0420    Covered
26135   Revise finger joint, each      T   00054   28.2376    Covered
26140   Revise finger joint, each      T   00053   17.0420    Covered
26145   Tendon excision, palm/finger   T   00053   17.0420    Covered
26160   Remove tendon sheath lesion    T   00053   17.0420    Covered
26170   Removal of palm tendon, each   T   00053   17.0420    Covered
26180   Removal of finger tendon       T   00053   17.0420    Covered
26185   Remove finger bone             T   00053   17.0420    Covered
26200   Remove hand bone lesion        T   00053   17.0420    Covered
26205   Remove/graft bone lesion       T   00054   28.2376    Covered
26210   Removal of finger lesion       T   00053   17.0420    Covered
26215   Remove/graft finger lesion     T   00053   17.0420    Covered
26230   Partial removal of hand bone   T   00053   17.0420    Covered
26235   Partial removal, finger bone   T   00053   17.0420    Covered
26236   Partial removal, finger bone   T   00053   17.0420    Covered
26250   Extensive hand surgery         T   00053   17.0420    Covered
26255   Extensive hand surgery         D                     Not Covered
26260   Extensive finger surgery       T   00053   17.0420    Covered
26261   Extensive finger surgery       D                     Not Covered
26262   Partial removal of finger      T   00053   17.0420    Covered
26320   Removal of implant from hand   T   00021   17.4975    Covered
26340   Manipulate finger w/anesth     T   00138    4.7946    Covered
26350   Repair finger/hand tendon      T   00054   28.2376    Covered
26352   Repair/graft hand tendon       T   00054   28.2376    Covered
26356   Repair finger/hand tendon      T   00054   28.2376    Covered
26357   Repair finger/hand tendon      T   00054   28.2376    Covered
26358   Repair/graft hand tendon       T   00054   28.2376    Covered
26370   Repair finger/hand tendon      T   00054   28.2376    Covered
26372   Repair/graft hand tendon       T   00054   28.2376    Covered
26373   Repair finger/hand tendon      T   00054   28.2376    Covered
26390   Revise hand/finger tendon      T   00054   28.2376    Covered
26392   Repair/graft hand tendon       T   00054   28.2376    Covered
26410   Repair hand tendon             T   00053   17.0420    Covered
26412   Repair/graft hand tendon       T   00054   28.2376    Covered
26415   Excision, hand/finger tendon   T   00054   28.2376    Covered
26416   Graft hand or finger tendon    T   00054   28.2376    Covered
26418   Repair finger tendon           T   00053   17.0420    Covered
26420   Repair/graft finger tendon     T   00054   28.2376    Covered
26426   Repair finger/hand tendon      T   00054   28.2376    Covered
26428   Repair/graft finger tendon     T   00054   28.2376    Covered
26432   Repair finger tendon           T   00053   17.0420    Covered
26433   Repair finger tendon           T   00053   17.0420    Covered
26434   Repair/graft finger tendon     T   00054   28.2376    Covered
26437   Realignment of tendons         T   00053   17.0420    Covered
26440   Release palm/finger tendon     T   00053   17.0420    Covered
26442   Release palm & finger tendon   T   00054   28.2376    Covered
26445   Release hand/finger tendon     T   00053   17.0420    Covered
26449   Release forearm/hand tendon    T   00054   28.2376    Covered
26450   Incision of palm tendon        T   00053   17.0420    Covered
26455   Incision of finger tendon      T   00053   17.0420    Covered
26460   Incise hand/finger tendon      T   00053   17.0420               Covered
26471   Fusion of finger tendons       T   00053   17.0420               Covered
26474   Fusion of finger tendons       T   00053   17.0420               Covered
26476   Tendon lengthening             T   00053   17.0420               Covered
26477   Tendon shortening              T   00053   17.0420               Covered
26478   Lengthening of hand tendon     T   00053   17.0420               Covered
26479   Shortening of hand tendon      T   00053   17.0420               Covered
26480   Transplant hand tendon         T   00054   28.2376               Covered
26483   Transplant/graft hand tendon   T   00054   28.2376               Covered
26485   Transplant palm tendon         T   00054   28.2376               Covered
26489   Transplant/graft palm tendon   T   00054   28.2376               Covered
26490   Revise thumb tendon            T   00054   28.2376               Covered
26492   Tendon transfer with graft     T   00054   28.2376               Covered
26494   Hand tendon/muscle transfer    T   00054   28.2376               Covered
26496   Revise thumb tendon            T   00054   28.2376               Covered
26497   Finger tendon transfer         T   00054   28.2376               Covered
26498   Finger tendon transfer         T   00054   28.2376               Covered
26499   Revision of finger             T   00054   28.2376               Covered
26500   Hand tendon reconstruction     T   00053   17.0420               Covered
26502   Hand tendon reconstruction     T   00054   28.2376               Covered
26508   Release thumb contracture      T   00053   17.0420               Covered
26510   Thumb tendon transfer          T   00054   28.2376               Covered
26516   Fusion of knuckle joint        T   00054   28.2376               Covered
26517   Fusion of knuckle joints       T   00054   28.2376               Covered
26518   Fusion of knuckle joints       T   00054   28.2376               Covered
26520   Release knuckle contracture    T   00053   17.0420               Covered
26525   Release finger contracture     T   00053   17.0420               Covered
26530   Revise knuckle joint           T   00047   39.8877               Covered
26531   Revise knuckle with implant    T   00048   58.0838               Covered
26535   Revise finger joint            T   00047   39.8877               Covered
26536   Revise/implant finger joint    T   00048   58.0838               Covered
26540   Repair hand joint              T   00053   17.0420               Covered
26541   Repair hand joint with graft   T   00054   28.2376               Covered
26542   Repair hand joint with graft   T   00053   17.0420               Covered
26545   Reconstruct finger joint       T   00054   28.2376               Covered
26546   Repair nonunion hand           T   00054   28.2376               Covered
26548   Reconstruct finger joint       T   00054   28.2376               Covered
26550   Construct thumb replacement    T   00054   28.2376               Covered
26551   Great toe-hand transfer        C                     $3,065.77   Covered
26553   Single transfer, toe-hand      C                     $3,040.06   Covered
26554   Double transfer, toe-hand      C                     $3,579.72   Covered
26555   Positional change of finger    T   00054   28.2376               Covered
26556   Toe joint transfer             C                     $3,147.00   Covered
26560   Repair of web finger           T   00053   17.0420               Covered
26561   Repair of web finger           T   00054   28.2376               Covered
26562   Repair of web finger           T   00054   28.2376               Covered
26565   Correct metacarpal flaw        T   00054   28.2376               Covered
26567   Correct finger deformity       T   00054   28.2376               Covered
26568   Lengthen metacarpal/finger     T   00054   28.2376               Covered
26580   Repair hand deformity          T   00053   17.0420               Covered
26587   Reconstruct extra finger       T   00053   17.0420               Covered
26590   Repair finger deformity        T   00053   17.0420               Covered
26591   Repair muscles of hand         T   00054   28.2376   Covered
26593   Release muscles of hand        T   00053   17.0420   Covered
26596   Excision constricting tissue   T   00053   17.0420   Covered
26600   Treat metacarpal fracture      T   00129    1.6576   Covered
26605   Treat metacarpal fracture      T   00129    1.6576   Covered
26607   Treat metacarpal fracture      T   00139   18.3962   Covered
26608   Treat metacarpal fracture      T   00062   25.8446   Covered
26615   Treat metacarpal fracture      T   00063   45.4678   Covered
26641   Treat thumb dislocation        T   00129    1.6576   Covered
26645   Treat thumb fracture           T   00138    4.7946   Covered
26650   Treat thumb fracture           T   00062   25.8446   Covered
26665   Treat thumb fracture           T   00063   45.4678   Covered
26670   Treat hand dislocation         T   00129    1.6576   Covered
26675   Treat hand dislocation         T   00138    4.7946   Covered
26676   Pin hand dislocation           T   00062   25.8446   Covered
26685   Treat hand dislocation         T   00062   25.8446   Covered
26686   Treat hand dislocation         T   00064   65.4752   Covered
26700   Treat knuckle dislocation      T   00129    1.6576   Covered
26705   Treat knuckle dislocation      T   00129    1.6576   Covered
26706   Pin knuckle dislocation        T   00139   18.3962   Covered
26715   Treat knuckle dislocation      T   00062   25.8446   Covered
26720   Treat finger fracture, each    T   00129    1.6576   Covered
26725   Treat finger fracture, each    T   00129    1.6576   Covered
26727   Treat finger fracture, each    T   00062   25.8446   Covered
26735   Treat finger fracture, each    T   00062   25.8446   Covered
26740   Treat finger fracture, each    T   00129    1.6576   Covered
26742   Treat finger fracture, each    T   00129    1.6576   Covered
26746   Treat finger fracture, each    T   00062   25.8446   Covered
26750   Treat finger fracture, each    T   00129    1.6576   Covered
26755   Treat finger fracture, each    T   00129    1.6576   Covered
26756   Pin finger fracture, each      T   00062   25.8446   Covered
26765   Treat finger fracture, each    T   00062   25.8446   Covered
26770   Treat finger dislocation       T   00129    1.6576   Covered
26775   Treat finger dislocation       T   00045   15.2922   Covered
26776   Pin finger dislocation         T   00062   25.8446   Covered
26785   Treat finger dislocation       T   00062   25.8446   Covered
26820   Thumb fusion with graft        T   00054   28.2376   Covered
26841   Fusion of thumb                T   00054   28.2376   Covered
26842   Thumb fusion with graft        T   00054   28.2376   Covered
26843   Fusion of hand joint           T   00054   28.2376   Covered
26844   Fusion/graft of hand joint     T   00054   28.2376   Covered
26850   Fusion of knuckle              T   00054   28.2376   Covered
26852   Fusion of knuckle with graft   T   00054   28.2376   Covered
26860   Fusion of finger joint         T   00054   28.2376   Covered
26861   Fusion of finger jnt, add-on   T   00054   28.2376   Covered
26862   Fusion/graft of finger joint   T   00054   28.2376   Covered
26863   Fuse/graft added joint         T   00054   28.2376   Covered
26910   Amputate metacarpal bone       T   00054   28.2376   Covered
26951   Amputation of finger/thumb     T   00053   17.0420   Covered
26952   Amputation of finger/thumb     T   00053   17.0420   Covered
26989   Hand/finger surgery            T   00129    1.6576   Covered
26990   Drainage of pelvis lesion      T   00049   22.0149   Covered
26991   Drainage of pelvis bursa       T   00049   22.0149                Covered
26992   Drainage of bone lesion        C                     $899.58      Covered
27000   Incision of hip tendon         T   00049   22.0149                Covered
27001   Incision of hip tendon         T   00050   31.7717                Covered
27003   Incision of hip tendon         T   00050   31.7717                Covered
27005   Incision of hip tendon         C                     $588.81      Covered
27006   Incision of hip tendons        T   00050   31.7717                Covered
27025   Incision of hip/thigh fascia   C                     $705.56      Covered
27027   Buttock fasciotomy             T   00049   22.0149                Covered
27030   Drainage of hip joint          C                     $901.38      Covered
27033   Exploration of hip joint       T   00051   46.5786                Covered
27035   Denervation of hip joint       T   00051   46.5786                Covered
27036   Excision of hip joint/muscle   C                     $922.25      Covered
27040   Biopsy of soft tissues         T   00020    8.2028                Covered
27041   Biopsy of soft tissues         T   00020    8.2028                Covered
27043   Exc hip pelvis les sc > 3 cm   T   00022   23.3880                Covered
27045   Exc hip/pelv tum deep > 5 cm   T   00022   23.3880                Covered
27047   Remove hip/pelvis lesion       T   00021   17.4975                Covered
27048   Remove hip/pelvis lesion       T   00021   17.4975                Covered
27049   Remove tumor, hip/pelvis       T   00021   17.4975                Covered
27050   Biopsy of sacroiliac joint     T   00049   22.0149                Covered
27052   Biopsy of hip joint            T   00049   22.0149                Covered
27054   Removal of hip joint lining    C                     $660.38      Covered
27057   Buttock fasciotomy w/dbrdmt    T   00049   22.0149                Covered
27059   Resect hip/pelv tum > 5 cm     T   00022   23.3880                Covered
27060   Removal of ischial bursa       T   00049   22.0149                Covered
27062   Remove femur lesion/bursa      T   00049   22.0149                Covered
27065   Removal of hip bone lesion     T   00049   22.0149                Covered
27066   Removal of hip bone lesion     T   00050   31.7717                Covered
27067   Remove/graft hip bone lesion   T   00050   31.7717                Covered
27070   Partial removal of hip bone    C                      $814.68     Covered
27071   Partial removal of hip bone    C                      $870.89     Covered
27075   Extensive hip surgery          C                     $1,167.30    Covered
27076   Extensive hip surgery          C                     $1,462.46    Covered
27077   Extensive hip surgery          C                     $1,552.39    Covered
27078   Extensive hip surgery          C                      $914.28     Covered
27079   Extensive hip surgery          D                                 Not Covered
27080   Removal of tail bone           T   00050   31.7717                Covered
27086   Remove hip foreign body        T   00020    8.2028                Covered
27087   Remove hip foreign body        T   00049   22.0149                Covered
27090   Removal of hip prosthesis      C                      $770.16     Covered
27091   Removal of hip prosthesis      C                     $1,492.69    Covered
27093   Injection for hip x-ray        N                                  Covered
27095   Injection for hip x-ray        N                                  Covered
27096   Inject sacroiliac joint        B                                 Not Covered
27097   Revision of hip tendon         T   00050   31.7717                Covered
27098   Transfer tendon to pelvis      T   00050   31.7717                Covered
27100   Transfer of abdominal muscle   T   00051   46.5786                Covered
27105   Transfer of spinal muscle      T   00051   46.5786                Covered
27110   Transfer of iliopsoas muscle   T   00051   46.5786                Covered
27111   Transfer of iliopsoas muscle   T   00051   46.5786                Covered
27120   Reconstruction of hip socket   C                     $1,258.79    Covered
27122   Reconstruction of hip socket   C                     $1,101.99   Covered
27125   Partial hip replacement        C                     $1,075.34   Covered
27130   Total hip arthroplasty         C                     $1,453.33   Covered
27132   Total hip arthroplasty         C                     $1,669.71   Covered
27134   Revise hip joint replacement   C                     $2,021.34   Covered
27137   Revise hip joint replacement   C                     $1,526.13   Covered
27138   Revise hip joint replacement   C                     $1,588.79   Covered
27140   Transplant femur ridge         C                      $857.25    Covered
27146   Incision of hip bone           C                     $1,126.56   Covered
27147   Revision of hip bone           C                     $1,371.49   Covered
27151   Incision of hip bones          C                     $1,365.19   Covered
27156   Revision of hip bones          C                     $1,586.93   Covered
27158   Revision of pelvis             C                     $1,250.09   Covered
27161   Incision of neck of femur      C                     $1,133.67   Covered
27165   Incision/fixation of femur     C                     $1,234.51   Covered
27170   Repair/graft femur head/neck   C                     $1,140.42   Covered
27175   Treat slipped epiphysis        C                      $459.92    Covered
27176   Treat slipped epiphysis        C                      $805.64    Covered
27177   Treat slipped epiphysis        C                      $988.58    Covered
27178   Treat slipped epiphysis        C                      $803.54    Covered
27179   Revise head/neck of femur      T   00052   88.6521               Covered
27181   Treat slipped epiphysis        C                      $950.58    Covered
27185   Revision of femur epiphysis    C                      $534.99    Covered
27187   Reinforce hip bones            C                     $1,003.60   Covered
27193   Treat pelvic ring fracture     T   00129    1.6576               Covered
27194   Treat pelvic ring fracture     T   00045   15.2922               Covered
27200   Treat tail bone fracture       T   00129    1.6576               Covered
27202   Treat tail bone fracture       T   00063   45.4678               Covered
27215   Treat pelvic fracture(s)       E                      $748.18    Covered
27216   Treat pelvic ring fracture     E                      $857.41    Covered
27217   Treat pelvic ring fracture     E                     $1,008.06   Covered
27218   Treat pelvic ring fracture     E                     $1,238.73   Covered
27220   Treat hip socket fracture      T   00129    1.6576               Covered
27222   Treat hip socket fracture      C                      $767.08    Covered
27226   Treat hip wall fracture        C                     $1,062.99   Covered
27227   Treat hip fracture(s)          C                     $1,545.62   Covered
27228   Treat hip fracture(s)          C                     $1,727.91   Covered
27230   Treat thigh fracture           T   00129    1.6576               Covered
27232   Treat thigh fracture           C                     $719.47     Covered
27235   Treat thigh fracture           T   00050   31.7717               Covered
27236   Treat thigh fracture           C                     $1,114.76   Covered
27238   Treat thigh fracture           T   00138    4.7946               Covered
27240   Treat thigh fracture           C                      $820.06    Covered
27244   Treat thigh fracture           C                     $1,119.75   Covered
27245   Treat thigh fracture           C                     $1,330.34   Covered
27246   Treat thigh fracture           T   00138    4.7946               Covered
27248   Treat thigh fracture           C                     $768.60     Covered
27250   Treat hip dislocation          T   00129    1.6576               Covered
27252   Treat hip dislocation          T   00045   15.2922               Covered
27253   Treat hip dislocation          C                      $911.96    Covered
27254   Treat hip dislocation          C                     $1,163.61   Covered
27256   Treat hip dislocation          T   00129    1.6576               Covered
27257   Treat hip dislocation          T   00045   15.2922               Covered
27258   Treat hip dislocation          C                     $1,064.34   Covered
27259   Treat hip dislocation          C                     $1,418.40   Covered
27265   Treat hip dislocation          T   00129    1.6576               Covered
27266   Treat hip dislocation          T   00045   15.2922               Covered
27267   Cltx thigh fx                  T   00129    1.6576               Covered
27268   Cltx thigh fx w/mnpj           C                     $388.93     Covered
27269   Optx thigh fx                  C                     $925.96     Covered
27275   Manipulation of hip joint      T   00045   15.2922               Covered
27280   Fusion of sacroiliac joint     C                      $925.97    Covered
27282   Fusion of pubic bones          C                      $780.52    Covered
27284   Fusion of hip joint            C                     $1,128.65   Covered
27286   Fusion of hip joint            C                     $1,179.45   Covered
27290   Amputation of leg at hip       C                     $1,628.25   Covered
27295   Amputation of leg at hip       C                     $1,252.44   Covered
27299   Pelvis/hip joint surgery       T   00129    1.6576               Covered
27301   Drain thigh/knee lesion        T   00008   19.4063               Covered
27303   Drainage of bone lesion        C                     $642.02     Covered
27305   Incise thigh tendon & fascia   T   00049   22.0149               Covered
27306   Incision of thigh tendon       T   00049   22.0149               Covered
27307   Incision of thigh tendons      T   00049   22.0149               Covered
27310   Exploration of knee joint      T   00050   31.7717               Covered
27323   Biopsy, thigh soft tissues     T   00020    8.2028               Covered
27324   Biopsy, thigh soft tissues     T   00022   23.3880               Covered
27325   Neurectomy, hamstring          T   00220   18.7200               Covered
27326   Neurectomy, popliteal          T   00220   18.7200               Covered
27327   Removal of thigh lesion        T   00022   23.3880               Covered
27328   Removal of thigh lesion        T   00021   17.4975               Covered
27329   Remove tumor, thigh/knee       T   00021   17.4975               Covered
27330   Biopsy, knee joint lining      T   00050   31.7717               Covered
27331   Explore/treat knee joint       T   00050   31.7717               Covered
27332   Removal of knee cartilage      T   00050   31.7717               Covered
27333   Removal of knee cartilage      T   00050   31.7717               Covered
27334   Remove knee joint lining       T   00050   31.7717               Covered
27335   Remove knee joint lining       T   00050   31.7717               Covered
27337   Exc thigh/knee les sc > 3 cm   T   00022   23.3880               Covered
27339   Exc thigh/knee tum deep >5cm   T   00022   23.3880               Covered
27340   Removal of kneecap bursa       T   00049   22.0149               Covered
27345   Removal of knee cyst           T   00049   22.0149               Covered
27347   Remove knee cyst               T   00049   22.0149               Covered
27350   Removal of kneecap             T   00050   31.7717               Covered
27355   Remove femur lesion            T   00050   31.7717               Covered
27356   Remove femur lesion/graft      T   00050   31.7717               Covered
27357   Remove femur lesion/graft      T   00050   31.7717               Covered
27358   Remove femur lesion/fixation   T   00050   31.7717               Covered
27360   Partial removal, leg bone(s)   T   00050   31.7717               Covered
27364   Resect thigh/knee tum >5 cm    T   00022   23.3880               Covered
27365   Extensive leg surgery          C                     $1,116.24   Covered
27370   Injection for knee x-ray       N                                 Covered
27372   Removal of foreign body        T   00022   23.3880               Covered
27380   Repair of kneecap tendon       T   00049   22.0149               Covered
27381   Repair/graft kneecap tendon    T   00049   22.0149               Covered
27385   Repair of thigh muscle         T   00049    22.0149               Covered
27386   Repair/graft of thigh muscle   T   00049    22.0149               Covered
27390   Incision of thigh tendon       T   00049    22.0149               Covered
27391   Incision of thigh tendons      T   00049    22.0149               Covered
27392   Incision of thigh tendons      T   00049    22.0149               Covered
27393   Lengthening of thigh tendon    T   00050    31.7717               Covered
27394   Lengthening of thigh tendons   T   00050    31.7717               Covered
27395   Lengthening of thigh tendons   T   00051    46.5786               Covered
27396   Transplant of thigh tendon     T   00050    31.7717               Covered
27397   Transplants of thigh tendons   T   00051    46.5786               Covered
27400   Revise thigh muscles/tendons   T   00051    46.5786               Covered
27403   Repair of knee cartilage       T   00050    31.7717               Covered
27405   Repair of knee ligament        T   00051    46.5786               Covered
27407   Repair of knee ligament        T   00052    88.6521               Covered
27409   Repair of knee ligaments       T   00051    46.5786               Covered
27412   Autochondrocyte implant knee   T   00052    88.6521               Covered
27415   Osteochondral knee allograft   T   00052    88.6521               Covered
27416   Osteochondral knee autograft   T   00051    46.5786               Covered
27418   Repair degenerated kneecap     T   00051    46.5786               Covered
27420   Revision of unstable kneecap   T   00051    46.5786               Covered
27422   Revision of unstable kneecap   T   00051    46.5786               Covered
27424   Revision/removal of kneecap    T   00051    46.5786               Covered
27425   Lat retinacular release open   T   00050    31.7717               Covered
27427   Reconstruction, knee           T   00051    46.5786               Covered
27428   Reconstruction, knee           T   00052    88.6521               Covered
27429   Reconstruction, knee           T   00052    88.6521               Covered
27430   Revision of thigh muscles      T   00051    46.5786               Covered
27435   Incision of knee joint         T   00051    46.5786               Covered
27437   Revise kneecap                 T   00047    39.8877               Covered
27438   Revise kneecap with implant    T   00048    58.0838               Covered
27440   Revision of knee joint         T   00047    39.8877               Covered
27441   Revision of knee joint         T   00047    39.8877               Covered
27442   Revision of knee joint         T   00047    39.8877               Covered
27443   Revision of knee joint         T   00047    39.8877               Covered
27445   Revision of knee joint         C                      $1,269.35   Covered
27446   Revision of knee joint         T   00425   118.7670               Covered
27447   Total knee arthroplasty        C                      $1,537.92   Covered
27448   Incision of thigh              C                       $830.07    Covered
27450   Incision of thigh              C                      $1,027.92   Covered
27454   Realignment of thigh bone      C                      $1,197.46   Covered
27455   Realignment of knee            C                       $908.53    Covered
27457   Realignment of knee            C                       $948.72    Covered
27465   Shortening of thigh bone       C                       $982.96    Covered
27466   Lengthening of thigh bone      C                      $1,131.59   Covered
27468   Shorten/lengthen thighs        C                      $1,268.40   Covered
27470   Repair of thigh                C                      $1,177.08   Covered
27472   Repair/graft of thigh          C                      $1,305.36   Covered
27475   Surgery to stop leg growth     T   00050    31.7717               Covered
27477   Surgery to stop leg growth     C                      $735.53     Covered
27479   Surgery to stop leg growth     T   00050    31.7717               Covered
27485   Surgery to stop leg growth     C                       $625.49    Covered
27486   Revise/replace knee joint      C                      $1,388.82   Covered
27487   Revise/replace knee joint      C                     $1,795.88   Covered
27488   Removal of knee prosthesis     C                     $1,128.07   Covered
27495   Reinforce thigh                C                     $1,157.57   Covered
27496   Decompression of thigh/knee    T   00050   31.7717               Covered
27497   Decompression of thigh/knee    T   00049   22.0149               Covered
27498   Decompression of thigh/knee    T   00050   31.7717               Covered
27499   Decompression of thigh/knee    T   00050   31.7717               Covered
27500   Treatment of thigh fracture    T   00138    4.7946               Covered
27501   Treatment of thigh fracture    T   00129    1.6576               Covered
27502   Treatment of thigh fracture    T   00139   18.3962               Covered
27503   Treatment of thigh fracture    T   00129    1.6576               Covered
27506   Treatment of thigh fracture    C                     $1,195.18   Covered
27507   Treatment of thigh fracture    C                     $1,017.20   Covered
27508   Treatment of thigh fracture    T   00129    1.6576               Covered
27509   Treatment of thigh fracture    T   00062   25.8446               Covered
27510   Treatment of thigh fracture    T   00138    4.7946               Covered
27511   Treatment of thigh fracture    C                     $1,004.37   Covered
27513   Treatment of thigh fracture    C                     $1,227.40   Covered
27514   Treatment of thigh fracture    C                     $1,184.44   Covered
27516   Treat thigh fx growth plate    T   00129    1.6576               Covered
27517   Treat thigh fx growth plate    T   00129    1.6576               Covered
27519   Treat thigh fx growth plate    C                     $1,029.88   Covered
27520   Treat kneecap fracture         T   00129    1.6576               Covered
27524   Treat kneecap fracture         T   00063   45.4678               Covered
27530   Treat knee fracture            T   00129    1.6576               Covered
27532   Treat knee fracture            T   00139   18.3962               Covered
27535   Treat knee fracture            C                      $842.74    Covered
27536   Treat knee fracture            C                     $1,008.67   Covered
27538   Treat knee fracture(s)         T   00129    1.6576               Covered
27540   Treat knee fracture            C                     $869.51     Covered
27550   Treat knee dislocation         T   00129    1.6576               Covered
27552   Treat knee dislocation         T   00045   15.2922               Covered
27556   Treat knee dislocation         C                     $1,007.65   Covered
27557   Treat knee dislocation         C                     $1,161.62   Covered
27558   Treat knee dislocation         C                     $1,201.25   Covered
27560   Treat kneecap dislocation      T   00129    1.6576               Covered
27562   Treat kneecap dislocation      T   00045   15.2922               Covered
27566   Treat kneecap dislocation      T   00063   45.4678               Covered
27570   Fixation of knee joint         T   00045   15.2922               Covered
27580   Fusion of knee                 C                     $1,292.70   Covered
27590   Amputate leg at thigh          C                      $831.12    Covered
27591   Amputate leg at thigh          C                      $926.27    Covered
27592   Amputate leg at thigh          C                      $714.58    Covered
27594   Amputation follow-up surgery   T   00049   22.0149               Covered
27596   Amputation follow-up surgery   C                     $730.64     Covered
27598   Amputate lower leg at knee     C                     $765.12     Covered
27599   Leg surgery procedure          T   00129    1.6576               Covered
27600   Decompression of lower leg     T   00049   22.0149               Covered
27601   Decompression of lower leg     T   00049   22.0149               Covered
27602   Decompression of lower leg     T   00049   22.0149               Covered
27603   Drain lower leg lesion         T   00008   19.4063               Covered
27604   Drain lower leg bursa          T   00049   22.0149               Covered
27605   Incision of achilles tendon    T   00055   21.8439               Covered
27606   Incision of achilles tendon    T   00049   22.0149               Covered
27607   Treat lower leg bone lesion    T   00049   22.0149               Covered
27610   Explore/treat ankle joint      T   00050   31.7717               Covered
27612   Exploration of ankle joint     T   00050   31.7717               Covered
27613   Biopsy lower leg soft tissue   T   00020    8.2028               Covered
27614   Biopsy lower leg soft tissue   T   00022   23.3880               Covered
27615   Remove tumor, lower leg        T   00021   17.4975               Covered
27616   Resect leg/ankle tum > 5 cm    T   00022   23.3880               Covered
27618   Remove lower leg lesion        T   00021   17.4975               Covered
27619   Remove lower leg lesion        T   00021   17.4975               Covered
27620   Explore/treat ankle joint      T   00050   31.7717               Covered
27625   Remove ankle joint lining      T   00050   31.7717               Covered
27626   Remove ankle joint lining      T   00050   31.7717               Covered
27630   Removal of tendon lesion       T   00049   22.0149               Covered
27632   Exc leg/ankle les sc > 3 cm    T   00022   23.3880               Covered
27634   Exc leg/ankle tum deep >5 cm   T   00022   23.3880               Covered
27635   Remove lower leg bone lesion   T   00050   31.7717               Covered
27637   Remove/graft leg bone lesion   T   00050   31.7717               Covered
27638   Remove/graft leg bone lesion   T   00050   31.7717               Covered
27640   Partial removal of tibia       T   00051   46.5786               Covered
27641   Partial removal of fibula      T   00050   31.7717               Covered
27645   Extensive lower leg surgery    C                     $1,021.16   Covered
27646   Extensive lower leg surgery    C                      $950.27    Covered
27647   Extensive ankle/heel surgery   T   00051   46.5786               Covered
27648   Injection for ankle x-ray      N                                 Covered
27650   Repair achilles tendon         T   00051   46.5786               Covered
27652   Repair/graft achilles tendon   T   00052   88.6521               Covered
27654   Repair of achilles tendon      T   00051   46.5786               Covered
27656   Repair leg fascia defect       T   00049   22.0149               Covered
27658   Repair of leg tendon, each     T   00049   22.0149               Covered
27659   Repair of leg tendon, each     T   00049   22.0149               Covered
27664   Repair of leg tendon, each     T   00050   31.7717               Covered
27665   Repair of leg tendon, each     T   00050   31.7717               Covered
27675   Repair lower leg tendons       T   00049   22.0149               Covered
27676   Repair lower leg tendons       T   00050   31.7717               Covered
27680   Release of lower leg tendon    T   00050   31.7717               Covered
27681   Release of lower leg tendons   T   00050   31.7717               Covered
27685   Revision of lower leg tendon   T   00050   31.7717               Covered
27686   Revise lower leg tendons       T   00050   31.7717               Covered
27687   Revision of calf tendon        T   00050   31.7717               Covered
27690   Revise lower leg tendon        T   00051   46.5786               Covered
27691   Revise lower leg tendon        T   00051   46.5786               Covered
27692   Revise additional leg tendon   T   00051   46.5786               Covered
27695   Repair of ankle ligament       T   00050   31.7717               Covered
27696   Repair of ankle ligaments      T   00050   31.7717               Covered
27698   Repair of ankle ligament       T   00050   31.7717               Covered
27700   Revision of ankle joint        T   00047   39.8877               Covered
27702   Reconstruct ankle joint        C                     $1,001.71   Covered
27703   Reconstruction, ankle joint    C                     $1,054.16   Covered
27704   Removal of ankle implant       T   00049   22.0149               Covered
27705   Incision of tibia              T   00051   46.5786               Covered
27707   Incision of fibula             T   00049   22.0149               Covered
27709   Incision of tibia & fibula     T   00050   31.7717               Covered
27712   Realignment of lower leg       C                      $964.33    Covered
27715   Revision of lower leg          C                     $1,008.95   Covered
27720   Repair of tibia                T   00063   45.4678               Covered
27722   Repair/graft of tibia          T   00064   65.4752               Covered
27724   Repair/graft of tibia          C                     $1,099.33   Covered
27725   Repair of lower leg            C                     $1,031.92   Covered
27726   Repair fibula nonunion         T   00063   45.4678               Covered
27727   Repair of lower leg            C                     $924.47     Covered
27730   Repair of tibia epiphysis      T   00050   31.7717               Covered
27732   Repair of fibula epiphysis     T   00050   31.7717               Covered
27734   Repair lower leg epiphyses     T   00050   31.7717               Covered
27740   Repair of leg epiphyses        T   00050   31.7717               Covered
27742   Repair of leg epiphyses        T   00051   46.5786               Covered
27745   Reinforce tibia                T   00052   88.6521               Covered
27750   Treatment of tibia fracture    T   00129    1.6576               Covered
27752   Treatment of tibia fracture    T   00139   18.3962               Covered
27756   Treatment of tibia fracture    T   00062   25.8446               Covered
27758   Treatment of tibia fracture    T   00063   45.4678               Covered
27759   Treatment of tibia fracture    T   00064   65.4752               Covered
27760   Cltx medial ankle fx           T   00129    1.6576               Covered
27762   Cltx med ankle fx w/mnpj       T   00139   18.3962               Covered
27766   Optx medial ankle fx           T   00063   45.4678               Covered
27767   Cltx post ankle fx             T   00129    1.6576               Covered
27768   Cltx post ankle fx w/mnpj      T   00129    1.6576               Covered
27769   Optx post ankle fx             T   00063   45.4678               Covered
27780   Treatment of fibula fracture   T   00129    1.6576               Covered
27781   Treatment of fibula fracture   T   00139   18.3962               Covered
27784   Treatment of fibula fracture   T   00063   45.4678               Covered
27786   Treatment of ankle fracture    T   00129    1.6576               Covered
27788   Treatment of ankle fracture    T   00129    1.6576               Covered
27792   Treatment of ankle fracture    T   00063   45.4678               Covered
27808   Treatment of ankle fracture    T   00129    1.6576               Covered
27810   Treatment of ankle fracture    T   00138    4.7946               Covered
27814   Treatment of ankle fracture    T   00063   45.4678               Covered
27816   Treatment of ankle fracture    T   00129    1.6576               Covered
27818   Treatment of ankle fracture    T   00138    4.7946               Covered
27822   Treatment of ankle fracture    T   00063   45.4678               Covered
27823   Treatment of ankle fracture    T   00064   65.4752               Covered
27824   Treat lower leg fracture       T   00129    1.6576               Covered
27825   Treat lower leg fracture       T   00139   18.3962               Covered
27826   Treat lower leg fracture       T   00063   45.4678               Covered
27827   Treat lower leg fracture       T   00064   65.4752               Covered
27828   Treat lower leg fracture       T   00064   65.4752               Covered
27829   Treat lower leg joint          T   00063   45.4678               Covered
27830   Treat lower leg dislocation    T   00129    1.6576               Covered
27831   Treat lower leg dislocation    T   00139   18.3962               Covered
27832   Treat lower leg dislocation    T   00063   45.4678               Covered
27840   Treat ankle dislocation        T   00138    4.7946               Covered
27842   Treat ankle dislocation        T   00045   15.2922               Covered
27846   Treat ankle dislocation        T   00063   45.4678               Covered
27848   Treat ankle dislocation        T   00063   45.4678             Covered
27860   Fixation of ankle joint        T   00045   15.2922             Covered
27870   Fusion of ankle joint, open    T   00052   88.6521             Covered
27871   Fusion of tibiofibular joint   T   00052   88.6521             Covered
27880   Amputation of lower leg        C                     $797.29   Covered
27881   Amputation of lower leg        C                     $878.58   Covered
27882   Amputation of lower leg        C                     $668.28   Covered
27884   Amputation follow-up surgery   T   00049   22.0149             Covered
27886   Amputation follow-up surgery   C                     $654.67   Covered
27888   Amputation of foot at ankle    C                     $713.76   Covered
27889   Amputation of foot at ankle    T   00050   31.7717             Covered
27892   Decompression of leg           T   00050   31.7717             Covered
27893   Decompression of leg           T   00050   31.7717             Covered
27894   Decompression of leg           T   00050   31.7717             Covered
27899   Leg/ankle surgery procedure    T   00129    1.6576             Covered
28001   Drainage of bursa of foot      T   00007   12.6217             Covered
28002   Treatment of foot infection    T   00049   22.0149             Covered
28003   Treatment of foot infection    T   00049   22.0149             Covered
28005   Treat foot bone lesion         T   00055   21.8439             Covered
28008   Incision of foot fascia        T   00055   21.8439             Covered
28010   Incision of toe tendon         T   00055   21.8439             Covered
28011   Incision of toe tendons        T   00055   21.8439             Covered
28020   Exploration of foot joint      T   00055   21.8439             Covered
28022   Exploration of foot joint      T   00055   21.8439             Covered
28024   Exploration of toe joint       T   00055   21.8439             Covered
28035   Decompression of tibia nerve   T   00220   18.7200             Covered
28039   Exc foot/toe tum sc > 1.5 cm   T   00022   23.3880             Covered
28041   Exc foot/toe tum deep >1.5cm   T   00022   23.3880             Covered
28043   Excision of foot lesion        T   00021   17.4975             Covered
28045   Excision of foot lesion        T   00021   17.4975             Covered
28046   Resection of tumor, foot       T   00021   17.4975             Covered
28047   Resect foot/toe tumor > 3 cm   T   00022   23.3880             Covered
28050   Biopsy of foot joint lining    T   00055   21.8439             Covered
28052   Biopsy of foot joint lining    T   00055   21.8439             Covered
28054   Biopsy of toe joint lining     T   00055   21.8439             Covered
28055   Neurectomy, foot               T   00220   18.7200             Covered
28060   Partial removal, foot fascia   T   00055   21.8439             Covered
28062   Removal of foot fascia         T   00055   21.8439             Covered
28070   Removal of foot joint lining   T   00055   21.8439             Covered
28072   Removal of foot joint lining   T   00055   21.8439             Covered
28080   Removal of foot lesion         T   00055   21.8439             Covered
28086   Excise foot tendon sheath      T   00055   21.8439             Covered
28088   Excise foot tendon sheath      T   00055   21.8439             Covered
28090   Removal of foot lesion         T   00055   21.8439             Covered
28092   Removal of toe lesions         T   00055   21.8439             Covered
28100   Removal of ankle/heel lesion   T   00055   21.8439             Covered
28102   Remove/graft foot lesion       T   00056   52.5258             Covered
28103   Remove/graft foot lesion       T   00056   52.5258             Covered
28104   Removal of foot lesion         T   00055   21.8439             Covered
28106   Remove/graft foot lesion       T   00056   52.5258             Covered
28107   Remove/graft foot lesion       T   00056   52.5258             Covered
28108   Removal of toe lesions         T   00055   21.8439             Covered
28110   Part removal of metatarsal     T   00055   21.8439   Covered
28111   Part removal of metatarsal     T   00055   21.8439   Covered
28112   Part removal of metatarsal     T   00055   21.8439   Covered
28113   Part removal of metatarsal     T   00055   21.8439   Covered
28114   Removal of metatarsal heads    T   00055   21.8439   Covered
28116   Revision of foot               T   00055   21.8439   Covered
28118   Removal of heel bone           T   00055   21.8439   Covered
28119   Removal of heel spur           T   00055   21.8439   Covered
28120   Part removal of ankle/heel     T   00055   21.8439   Covered
28122   Partial removal of foot bone   T   00055   21.8439   Covered
28124   Partial removal of toe         T   00055   21.8439   Covered
28126   Partial removal of toe         T   00055   21.8439   Covered
28130   Removal of ankle bone          T   00055   21.8439   Covered
28140   Removal of metatarsal          T   00055   21.8439   Covered
28150   Removal of toe                 T   00055   21.8439   Covered
28153   Partial removal of toe         T   00055   21.8439   Covered
28160   Partial removal of toe         T   00055   21.8439   Covered
28171   Extensive foot surgery         T   00055   21.8439   Covered
28173   Extensive foot surgery         T   00055   21.8439   Covered
28175   Extensive foot surgery         T   00055   21.8439   Covered
28190   Removal of foot foreign body   T   00020    8.2028   Covered
28192   Removal of foot foreign body   T   00021   17.4975   Covered
28193   Removal of foot foreign body   T   00020    8.2028   Covered
28200   Repair of foot tendon          T   00055   21.8439   Covered
28202   Repair/graft of foot tendon    T   00055   21.8439   Covered
28208   Repair of foot tendon          T   00055   21.8439   Covered
28210   Repair/graft of foot tendon    T   00056   52.5258   Covered
28220   Release of foot tendon         T   00055   21.8439   Covered
28222   Release of foot tendons        T   00055   21.8439   Covered
28225   Release of foot tendon         T   00055   21.8439   Covered
28226   Release of foot tendons        T   00055   21.8439   Covered
28230   Incision of foot tendon(s)     T   00055   21.8439   Covered
28232   Incision of toe tendon         T   00055   21.8439   Covered
28234   Incision of foot tendon        T   00055   21.8439   Covered
28238   Revision of foot tendon        T   00056   52.5258   Covered
28240   Release of big toe             T   00055   21.8439   Covered
28250   Revision of foot fascia        T   00055   21.8439   Covered
28260   Release of midfoot joint       T   00055   21.8439   Covered
28261   Revision of foot tendon        T   00055   21.8439   Covered
28262   Revision of foot and ankle     T   00055   21.8439   Covered
28264   Release of midfoot joint       T   00056   52.5258   Covered
28270   Release of foot contracture    T   00055   21.8439   Covered
28272   Release of toe joint, each     T   00055   21.8439   Covered
28280   Fusion of toes                 T   00055   21.8439   Covered
28285   Repair of hammertoe            T   00055   21.8439   Covered
28286   Repair of hammertoe            T   00055   21.8439   Covered
28288   Partial removal of foot bone   T   00055   21.8439   Covered
28289   Repair hallux rigidus          T   00055   21.8439   Covered
28290   Correction of bunion           T   00057   31.5534   Covered
28292   Correction of bunion           T   00057   31.5534   Covered
28293   Correction of bunion           T   00057   31.5534   Covered
28294   Correction of bunion           T   00057   31.5534   Covered
28296   Correction of bunion           T   00057   31.5534   Covered
28297   Correction of bunion           T   00057   31.5534   Covered
28298   Correction of bunion           T   00057   31.5534   Covered
28299   Correction of bunion           T   00057   31.5534   Covered
28300   Incision of heel bone          T   00056   52.5258   Covered
28302   Incision of ankle bone         T   00055   21.8439   Covered
28304   Incision of midfoot bones      T   00056   52.5258   Covered
28305   Incise/graft midfoot bones     T   00056   52.5258   Covered
28306   Incision of metatarsal         T   00055   21.8439   Covered
28307   Incision of metatarsal         T   00055   21.8439   Covered
28308   Incision of metatarsal         T   00055   21.8439   Covered
28309   Incision of metatarsals        T   00056   52.5258   Covered
28310   Revision of big toe            T   00055   21.8439   Covered
28312   Revision of toe                T   00055   21.8439   Covered
28313   Repair deformity of toe        T   00055   21.8439   Covered
28315   Removal of sesamoid bone       T   00055   21.8439   Covered
28320   Repair of foot bones           T   00056   52.5258   Covered
28322   Repair of metatarsals          T   00056   52.5258   Covered
28340   Resect enlarged toe tissue     T   00055   21.8439   Covered
28341   Resect enlarged toe            T   00055   21.8439   Covered
28344   Repair extra toe(s)            T   00055   21.8439   Covered
28345   Repair webbed toe(s)           T   00055   21.8439   Covered
28360   Reconstruct cleft foot         T   00056   52.5258   Covered
28400   Treatment of heel fracture     T   00129    1.6576   Covered
28405   Treatment of heel fracture     T   00139   18.3962   Covered
28406   Treatment of heel fracture     T   00062   25.8446   Covered
28415   Treat heel fracture            T   00064   65.4752   Covered
28420   Treat/graft heel fracture      T   00063   45.4678   Covered
28430   Treatment of ankle fracture    T   00129    1.6576   Covered
28435   Treatment of ankle fracture    T   00129    1.6576   Covered
28436   Treatment of ankle fracture    T   00062   25.8446   Covered
28445   Treat ankle fracture           T   00063   45.4678   Covered
28446   Osteochondral talus autogrft   T   00056   52.5258   Covered
28450   Treat midfoot fracture, each   T   00129    1.6576   Covered
28455   Treat midfoot fracture, each   T   00129    1.6576   Covered
28456   Treat midfoot fracture         T   00062   25.8446   Covered
28465   Treat midfoot fracture, each   T   00063   45.4678   Covered
28470   Treat metatarsal fracture      T   00129    1.6576   Covered
28475   Treat metatarsal fracture      T   00129    1.6576   Covered
28476   Treat metatarsal fracture      T   00062   25.8446   Covered
28485   Treat metatarsal fracture      T   00063   45.4678   Covered
28490   Treat big toe fracture         T   00129    1.6576   Covered
28495   Treat big toe fracture         T   00129    1.6576   Covered
28496   Treat big toe fracture         T   00062   25.8446   Covered
28505   Treat big toe fracture         T   00062   25.8446   Covered
28510   Treatment of toe fracture      T   00129    1.6576   Covered
28515   Treatment of toe fracture      T   00129    1.6576   Covered
28525   Treat toe fracture             T   00062   25.8446   Covered
28530   Treat sesamoid bone fracture   T   00129    1.6576   Covered
28531   Treat sesamoid bone fracture   T   00062   25.8446   Covered
28540   Treat foot dislocation         T   00129    1.6576   Covered
28545   Treat foot dislocation         T   00062   25.8446   Covered
28546   Treat foot dislocation         T   00062   25.8446             Covered
28555   Repair foot dislocation        T   00063   45.4678             Covered
28570   Treat foot dislocation         T   00138    4.7946             Covered
28575   Treat foot dislocation         T   00139   18.3962             Covered
28576   Treat foot dislocation         T   00062   25.8446             Covered
28585   Repair foot dislocation        T   00062   25.8446             Covered
28600   Treat foot dislocation         T   00129    1.6576             Covered
28605   Treat foot dislocation         T   00129    1.6576             Covered
28606   Treat foot dislocation         T   00062   25.8446             Covered
28615   Repair foot dislocation        T   00063   45.4678             Covered
28630   Treat toe dislocation          T   00129    1.6576             Covered
28635   Treat toe dislocation          T   00045   15.2922             Covered
28636   Treat toe dislocation          T   00062   25.8446             Covered
28645   Repair toe dislocation         T   00062   25.8446             Covered
28660   Treat toe dislocation          T   00129    1.6576             Covered
28665   Treat toe dislocation          T   00045   15.2922             Covered
28666   Treat toe dislocation          T   00062   25.8446             Covered
28675   Repair of toe dislocation      T   00062   25.8446             Covered
28705   Fusion of foot bones           T   00056   52.5258             Covered
28715   Fusion of foot bones           T   00052   88.6521             Covered
28725   Fusion of foot bones           T   00056   52.5258             Covered
28730   Fusion of foot bones           T   00056   52.5258             Covered
28735   Fusion of foot bones           T   00056   52.5258             Covered
28737   Revision of foot bones         T   00056   52.5258             Covered
28740   Fusion of foot bones           T   00056   52.5258             Covered
28750   Fusion of big toe joint        T   00056   52.5258             Covered
28755   Fusion of big toe joint        T   00055   21.8439             Covered
28760   Fusion of big toe joint        T   00056   52.5258             Covered
28800   Amputation of midfoot          C                     $574.28   Covered
28805   Amputation thru metatarsal     T   00055   21.8439             Covered
28810   Amputation toe & metatarsal    T   00055   21.8439             Covered
28820   Amputation of toe              T   00055   21.8439             Covered
28825   Partial amputation of toe      T   00055   21.8439             Covered
28890   High energy eswt, plantar f    T   00050   31.7717             Covered
28899   Foot/toes surgery procedure    T   00129    1.6576             Covered
29000   Application of body cast       S   00058    1.0537             Covered
29010   Application of body cast       S   00426    2.3457             Covered
29015   Application of body cast       S   00426    2.3457             Covered
29020   Application of body cast       S   00058    1.0537             Covered
29025   Application of body cast       S   00058    1.0537             Covered
29035   Application of body cast       S   00426    2.3457             Covered
29040   Application of body cast       S   00058    1.0537             Covered
29044   Application of body cast       S   00426    2.3457             Covered
29046   Application of body cast       S   00426    2.3457             Covered
29049   Application of figure eight    S   00058    1.0537             Covered
29055   Application of shoulder cast   S   00426    2.3457             Covered
29058   Application of shoulder cast   S   00058    1.0537             Covered
29065   Application of long arm cast   S   00426    2.3457             Covered
29075   Application of forearm cast    S   00426    2.3457             Covered
29085   Apply hand/wrist cast          S   00058    1.0537             Covered
29086   Apply finger cast              S   00058    1.0537             Covered
29105   Apply long arm splint          S   00058    1.0537             Covered
29125   Apply forearm splint           S   00058    1.0537    Covered
29126   Apply forearm splint           S   00058    1.0537    Covered
29130   Application of finger splint   S   00058    1.0537    Covered
29131   Application of finger splint   S   00058    1.0537    Covered
29200   Strapping of chest             S   00058    1.0537    Covered
29220   Strapping of low back          D                     Not Covered
29240   Strapping of shoulder          S   00058    1.0537    Covered
29260   Strapping of elbow or wrist    S   00058    1.0537    Covered
29280   Strapping of hand or finger    S   00058    1.0537    Covered
29305   Application of hip cast        S   00426    2.3457    Covered
29325   Application of hip casts       S   00426    2.3457    Covered
29345   Application of long leg cast   S   00426    2.3457    Covered
29355   Application of long leg cast   S   00426    2.3457    Covered
29358   Apply long leg cast brace      S   00426    2.3457    Covered
29365   Application of long leg cast   S   00426    2.3457    Covered
29405   Apply short leg cast           S   00426    2.3457    Covered
29425   Apply short leg cast           S   00426    2.3457    Covered
29435   Apply short leg cast           S   00426    2.3457    Covered
29440   Addition of walker to cast     S   00058    1.0537    Covered
29445   Apply rigid leg cast           S   00426    2.3457    Covered
29450   Application of leg cast        S   00058    1.0537    Covered
29505   Application, long leg splint   S   00058    1.0537    Covered
29515   Application lower leg splint   S   00058    1.0537    Covered
29520   Strapping of hip               S   00058    1.0537    Covered
29530   Strapping of knee              S   00058    1.0537    Covered
29540   Strapping of ankle and/or ft   S   00058    1.0537    Covered
29550   Strapping of toes              S   00058    1.0537    Covered
29580   Application of paste boot      S   00058    1.0537    Covered
29581   Apply multlay comprs lwr leg   S   00058    1.0537    Covered
29590   Application of foot splint     S   00058    1.0537    Covered
29700   Removal/revision of cast       S   00058    1.0537    Covered
29705   Removal/revision of cast       S   00058    1.0537    Covered
29710   Removal/revision of cast       S   00426    2.3457    Covered
29715   Removal/revision of cast       S   00058    1.0537    Covered
29720   Repair of body cast            S   00058    1.0537    Covered
29730   Windowing of cast              S   00058    1.0537    Covered
29740   Wedging of cast                S   00058    1.0537    Covered
29750   Wedging of clubfoot cast       S   00058    1.0537    Covered
29799   Casting/strapping procedure    S   00058    1.0537    Covered
29800   Jaw arthroscopy/surgery        T   00041   29.9198    Covered
29804   Jaw arthroscopy/surgery        T   00041   29.9198    Covered
29805   Shoulder arthroscopy, dx       T   00041   29.9198    Covered
29806   Shoulder arthroscopy/surgery   T   00042   48.8176    Covered
29807   Shoulder arthroscopy/surgery   T   00042   48.8176    Covered
29819   Shoulder arthroscopy/surgery   T   00042   48.8176    Covered
29820   Shoulder arthroscopy/surgery   T   00042   48.8176    Covered
29821   Shoulder arthroscopy/surgery   T   00042   48.8176    Covered
29822   Shoulder arthroscopy/surgery   T   00041   29.9198    Covered
29823   Shoulder arthroscopy/surgery   T   00042   48.8176    Covered
29824   Shoulder arthroscopy/surgery   T   00041   29.9198    Covered
29825   Shoulder arthroscopy/surgery   T   00042   48.8176    Covered
29826   Shoulder arthroscopy/surgery   T   00042   48.8176    Covered
29827   Arthroscop rotator cuff repr   T   00042   48.8176   Covered
29828   Arthroscopy biceps tenodesis   T   00042   48.8176   Covered
29830   Elbow arthroscopy              T   00041   29.9198   Covered
29834   Elbow arthroscopy/surgery      T   00041   29.9198   Covered
29835   Elbow arthroscopy/surgery      T   00041   29.9198   Covered
29836   Elbow arthroscopy/surgery      T   00041   29.9198   Covered
29837   Elbow arthroscopy/surgery      T   00041   29.9198   Covered
29838   Elbow arthroscopy/surgery      T   00041   29.9198   Covered
29840   Wrist arthroscopy              T   00041   29.9198   Covered
29843   Wrist arthroscopy/surgery      T   00041   29.9198   Covered
29844   Wrist arthroscopy/surgery      T   00041   29.9198   Covered
29845   Wrist arthroscopy/surgery      T   00041   29.9198   Covered
29846   Wrist arthroscopy/surgery      T   00041   29.9198   Covered
29847   Wrist arthroscopy/surgery      T   00042   48.8176   Covered
29848   Wrist endoscopy/surgery        T   00041   29.9198   Covered
29850   Knee arthroscopy/surgery       T   00041   29.9198   Covered
29851   Knee arthroscopy/surgery       T   00042   48.8176   Covered
29855   Tibial arthroscopy/surgery     T   00042   48.8176   Covered
29856   Tibial arthroscopy/surgery     T   00042   48.8176   Covered
29860   Hip arthroscopy, dx            T   00042   48.8176   Covered
29861   Hip arthroscopy/surgery        T   00042   48.8176   Covered
29862   Hip arthroscopy/surgery        T   00042   48.8176   Covered
29863   Hip arthroscopy/surgery        T   00042   48.8176   Covered
29866   Autgrft implnt, knee w/scope   T   00042   48.8176   Covered
29867   Allgrft implnt, knee w/scope   T   00042   48.8176   Covered
29868   Meniscal trnspl, knee w/scpe   T   00042   48.8176   Covered
29870   Knee arthroscopy, dx           T   00041   29.9198   Covered
29871   Knee arthroscopy/drainage      T   00041   29.9198   Covered
29873   Knee arthroscopy/surgery       T   00041   29.9198   Covered
29874   Knee arthroscopy/surgery       T   00041   29.9198   Covered
29875   Knee arthroscopy/surgery       T   00041   29.9198   Covered
29876   Knee arthroscopy/surgery       T   00041   29.9198   Covered
29877   Knee arthroscopy/surgery       T   00041   29.9198   Covered
29879   Knee arthroscopy/surgery       T   00041   29.9198   Covered
29880   Knee arthroscopy/surgery       T   00041   29.9198   Covered
29881   Knee arthroscopy/surgery       T   00041   29.9198   Covered
29882   Knee arthroscopy/surgery       T   00041   29.9198   Covered
29883   Knee arthroscopy/surgery       T   00041   29.9198   Covered
29884   Knee arthroscopy/surgery       T   00041   29.9198   Covered
29885   Knee arthroscopy/surgery       T   00042   48.8176   Covered
29886   Knee arthroscopy/surgery       T   00041   29.9198   Covered
29887   Knee arthroscopy/surgery       T   00041   29.9198   Covered
29888   Knee arthroscopy/surgery       T   00052   88.6521   Covered
29889   Knee arthroscopy/surgery       T   00052   88.6521   Covered
29891   Ankle arthroscopy/surgery      T   00042   48.8176   Covered
29892   Ankle arthroscopy/surgery      T   00052   88.6521   Covered
29893   Scope, plantar fasciotomy      T   00055   21.8439   Covered
29894   Ankle arthroscopy/surgery      T   00041   29.9198   Covered
29895   Ankle arthroscopy/surgery      T   00041   29.9198   Covered
29897   Ankle arthroscopy/surgery      T   00041   29.9198   Covered
29898   Ankle arthroscopy/surgery      T   00041   29.9198   Covered
29899   Ankle arthroscopy/surgery      T   00042   48.8176   Covered
29900   Mcp joint arthroscopy, dx      T   00041   29.9198    Covered
29901   Mcp joint arthroscopy, surg    T   00041   29.9198    Covered
29902   Mcp joint arthroscopy, surg    T   00041   29.9198    Covered
29904   Subtalar arthro w/fb rmvl      T   00041   29.9198    Covered
29905   Subtalar arthro w/exc          T   00041   29.9198    Covered
29906   Subtalar arthro w/deb          T   00041   29.9198    Covered
29907   Subtalar arthro w/fusion       T   00042   48.8176    Covered
29999   Arthroscopy of joint           T   00041   29.9198    Covered
30000   Drainage of nose lesion        T   00251    3.4250    Covered
30020   Drainage of nose lesion        T   00251    3.4250    Covered
3006F   Cxr doc rev                    M                     Not Covered
3006F   Cxr doc rev                    M                     Not Covered
3008F   Body mass index docd           E                     Not Covered
30100   Intranasal biopsy              T   00252    7.6196    Covered
30110   Removal of nose polyp(s)       T   00253   17.1879    Covered
30115   Removal of nose polyp(s)       T   00253   17.1879    Covered
30117   Removal of intranasal lesion   T   00253   17.1879    Covered
30118   Removal of intranasal lesion   T   00254   24.9637    Covered
3011F   Lipid panel doc rev            M                     Not Covered
3011F   Lipid panel doc rev            M                     Not Covered
30120   Revision of nose               T   00254   24.9637    Covered
30124   Removal of nose lesion         T   00252    7.6196    Covered
30125   Removal of nose lesion         T   00256   42.9827    Covered
30130   Excise inferior turbinate      T   00253   17.1879    Covered
30140   Resect inferior turbinate      T   00254   24.9637    Covered
3014F   Screen mammo doc rev           M                     Not Covered
3014F   Screen mammo doc rev           M                     Not Covered
30150   Partial removal of nose        T   00256   42.9827    Covered
3015F   Cerv cancer screen docd        E                     Not Covered
30160   Removal of nose                T   00256   42.9827    Covered
3016F   Pt scrnd unhlthy OH use        M                     Not Covered
3017F   Colorectal ca screen doc rev   M                     Not Covered
3017F   Colorectal ca screen doc rev   M                     Not Covered
3018F   Pre-prxd rsk et al docd        E                     Not Covered
30200   Injection treatment of nose    T   00252    7.6196    Covered
3020F   Lvf assess                     M                     Not Covered
30210   Nasal sinus therapy            T   00252    7.6196    Covered
3021F   Lvef mod/sever deprs syst      M                     Not Covered
3021F   Lvef mod/sever deprs syst      M                     Not Covered
30220   Insert nasal septal button     T   00252    7.6196    Covered
3022F   Lvef =40% systolic             M                     Not Covered
3022F   Lvef >=40% systolic            M                     Not Covered
3023F   Spirom doc rev                 M                     Not Covered
3023F   Spirom doc rev                 M                     Not Covered
3025F   Spirom fev/fvc<70% w copd      M                     Not Covered
3025F   Spirom fev/fvc<70% w copd      M                     Not Covered
3027F   Spirom fev/fvc=70%/ w/o copd   M                     Not Covered
3027F   Spirom fev/fvc>=70%/w/o copd   M                     Not Covered
3028F   O2 saturation doc rev          M                     Not Covered
3028F   O2 saturation doc rev          M                     Not Covered
30300   Remove nasal foreign body      X   00340    0.6693   Not Covered
30310   Remove nasal foreign body      T   00253   17.1879    Covered
30320   Remove nasal foreign body      T   00253   17.1879    Covered
3035F   O2 saturation =88% /pa0 =55    M                     Not Covered
3035F   O2 saturation<=88% /pao<=55    M                     Not Covered
3037F   O2 saturation> 88% /pao>55     M                     Not Covered
3037F   O2 saturation> 88% /pao>55     M                     Not Covered
3038F   Pulm fx w/in 12 mon b/4 surg   E                     Not Covered
30400   Reconstruction of nose         T   00256   42.9827    Covered
3040F   Fev<40% predicted value        M                     Not Covered
3040F   Fev<40% predicted value        M                     Not Covered
30410   Reconstruction of nose         T   00256   42.9827    Covered
30420   Reconstruction of nose         T   00256   42.9827    Covered
3042F   Fev= 40% predicted value       M                     Not Covered
3042F   Fev>=40% predicted value       M                     Not Covered
30430   Revision of nose               T   00254   24.9637    Covered
30435   Revision of nose               T   00256   42.9827    Covered
3044F   Hg a1c level lt 7.0%           M                     Not Covered
30450   Revision of nose               T   00256   42.9827    Covered
3045F   Hg a1c level 7.0–9.0%          M                     Not Covered
30460   Revision of nose               T   00256   42.9827    Covered
30462   Revision of nose               T   00256   42.9827    Covered
30465   Repair nasal stenosis          T   00256   42.9827    Covered
3046F   Hemoglobin a1c level > 9.0%    M                     Not Covered
3048F   Ldl-c <100 mg/dl               M                     Not Covered
3048F   Ldl-c <100 mg/dl               M                     Not Covered
3049F   Ldl-c 100-129 mg/dl            M                     Not Covered
3049F   Ldl-c 100-129 mg/dl            M                     Not Covered
3050F   Ldl-c = 130 mg/dl              M                     Not Covered
3050F   Ldl-c >= 130 mg/dl             M                     Not Covered
30520   Repair of nasal septum         T   00254   24.9637    Covered
30540   Repair nasal defect            T   00256   42.9827    Covered
30545   Repair nasal defect            T   00256   42.9827    Covered
30560   Release of nasal adhesions     T   00251    3.4250    Covered
30580   Repair upper jaw fistula       T   00256   42.9827    Covered
30600   Repair mouth/nose fistula      T   00256   42.9827    Covered
3060F   Pos microalbuminuria rev       M                     Not Covered
3060F   Pos microalbuminuria rev       M                     Not Covered
3061F   Neg microalbuminuria rev       M                     Not Covered
3061F   Neg microalbuminuria rev       M                     Not Covered
30620   Intranasal reconstruction      T   00256   42.9827    Covered
3062F   Pos macroalbuminuria rev       M                     Not Covered
3062F   Pos macroalbuminuria rev       M                     Not Covered
30630   Repair nasal septum defect     T   00254   24.9637    Covered
3066F   Nephropathy doc tx             M                     Not Covered
3066F   Nephropathy doc tx             M                     Not Covered
3072F   Low risk for retinopathy       M                     Not Covered
3072F   Low risk for retinopathy       M                     Not Covered
3073F   Pre-surg eye measures doc'd    M                     Not Covered
3074F   Syst bp lt 130 mm hg           M                     Not Covered
3075F   Syst bp ge 130 - 139mm hg      M                     Not Covered
3077F   Syst bp = 140 mm hg6 it        M                     Not Covered
3077F   Syst bp >= 140 mm hg6 it       M                     Not Covered
3078F   Diast bp < 80 mm hg            M                     Not Covered
3078F   Diast bp < 80 mm hg            M                     Not Covered
3079F   Diast bp 80-89 mm hg           M                     Not Covered
3079F   Diast bp 80-89 mm hg           M                     Not Covered
30801   Ablate inf turbinate, superf   T   00252    7.6196    Covered
30802   Cauterization, inner nose      T   00253   17.1879    Covered
3080F   Diast bp = 90 mm hg            M                     Not Covered
3080F   Diast bp >= 90 mm hg           M                     Not Covered
3082F   Kt/v lt1.2                     M                     Not Covered
3083F   Kt/v ge 1.2 and <1.7           M                     Not Covered
3084F   Kt/v ge 1.7                    M                     Not Covered
3085F   Suicide risk assessed          M                     Not Covered
3088F   MDD, mild                      M                     Not Covered
3089F   MDD, moderate                  M                     Not Covered
30901   Control of nosebleed           T   00250    1.1522    Covered
30903   Control of nosebleed           T   00250    1.1522    Covered
30905   Control of nosebleed           T   00250    1.1522    Covered
30906   Repeat control of nosebleed    T   00250    1.1522    Covered
3090F   MDD, severe; w/o psych         M                     Not Covered
30915   Ligation, nasal sinus artery   T   00092   26.5713    Covered
3091F   Mdd, severe; w/ psych          M                     Not Covered
30920   Ligation, upper jaw artery     T   00092   26.5713    Covered
3092F   MDD, in remission              M                     Not Covered
30930   Ther fx, nasal inf turbinate   T   00253   17.1879    Covered
3093F   Doc new diag 1st/addl. mdd     M                     Not Covered
3095F   Central dexa results doc'd     M                     Not Covered
3096F   Central dexa ordered           M                     Not Covered
30999   Nasal surgery procedure        T   00250    1.1522    Covered
31000   Irrigation, maxillary sinus    T   00251    3.4250    Covered
31002   Irrigation, sphenoid sinus     T   00252    7.6196    Covered
3100F   Image test ref carot diam      M                     Not Covered
31020   Exploration, maxillary sinus   T   00254   24.9637    Covered
31030   Exploration, maxillary sinus   T   00256   42.9827    Covered
31032   Explore sinus, remove polyps   T   00256   42.9827    Covered
31040   Exploration behind upper jaw   T   00254   24.9637    Covered
31050   Exploration, sphenoid sinus    T   00256   42.9827    Covered
31051   Sphenoid sinus surgery         T   00256   42.9827    Covered
31070   Exploration of frontal sinus   T   00254   24.9637    Covered
31075   Exploration of frontal sinus   T   00256   42.9827    Covered
31080   Removal of frontal sinus       T   00256   42.9827    Covered
31081   Removal of frontal sinus       T   00256   42.9827    Covered
31084   Removal of frontal sinus       T   00256   42.9827    Covered
31085   Removal of frontal sinus       T   00256   42.9827    Covered
31086   Removal of frontal sinus       T   00256   42.9827    Covered
31087   Removal of frontal sinus       T   00256   42.9827    Covered
31090   Exploration of sinuses         T   00256   42.9827    Covered
3110F   Pres/absn hmrhg/lesion doc'd   M                     Not Covered
3111F   Ct/mri brain done w/in 24hrs   M                     Not Covered
3112F   Ct/mri brain done gt24 hrs     M                     Not Covered
31200   Removal of ethmoid sinus       T   00256   42.9827    Covered
31201   Removal of ethmoid sinus       T   00256   42.9827    Covered
31205   Removal of ethmoid sinus       T   00256   42.9827    Covered
3120F   12-lead ecg performed          M                     Not Covered
31225   Removal of upper jaw           C                     $1,326.91    Covered
31230   Removal of upper jaw           C                     $1,503.94    Covered
31231   Nasal endoscopy, dx            T   00072    1.8425                Covered
31233   Nasal/sinus endoscopy, dx      T   00072    1.8425                Covered
31235   Nasal/sinus endoscopy, dx      T   00074   21.6572                Covered
31237   Nasal/sinus endoscopy, surg    T   00074   21.6572                Covered
31238   Nasal/sinus endoscopy, surg    T   00074   21.6572                Covered
31239   Nasal/sinus endoscopy, surg    T   00075   29.2718                Covered
31240   Nasal/sinus endoscopy, surg    T   00074   21.6572                Covered
31254   Revision of ethmoid sinus      T   00075   29.2718                Covered
31255   Removal of ethmoid sinus       T   00075   29.2718                Covered
31256   Exploration maxillary sinus    T   00075   29.2718                Covered
31267   Endoscopy, maxillary sinus     T   00075   29.2718                Covered
31276   Sinus endoscopy, surgical      T   00075   29.2718                Covered
31287   Nasal/sinus endoscopy, surg    T   00075   29.2718                Covered
31288   Nasal/sinus endoscopy, surg    T   00075   29.2718                Covered
31290   Nasal/sinus endoscopy, surg    C                     $1,153.48    Covered
31291   Nasal/sinus endoscopy, surg    C                     $1,220.35    Covered
31292   Nasal/sinus endoscopy, surg    T   00075   29.2718                Covered
31293   Nasal/sinus endoscopy, surg    T   00075   29.2718                Covered
31294   Nasal/sinus endoscopy, surg    T   00075   29.2718                Covered
31299   Sinus surgery procedure        T   00250    1.1522                Covered
31300   Removal of larynx lesion       T   00254   24.9637                Covered
3130F   Upper gi endoscopy performed   M                                 Not Covered
31320   Diagnostic incision, larynx    T   00256   42.9827                Covered
3132F   Doc ref. upper gi endoscopy    M                                 Not Covered
31360   Removal of larynx              C                     $1,281.59    Covered
31365   Removal of larynx              C                     $1,761.54    Covered
31367   Partial removal of larynx      C                     $1,508.45    Covered
31368   Partial removal of larynx      C                     $1,951.07    Covered
31370   Partial removal of larynx      C                     $1,489.85    Covered
31375   Partial removal of larynx      C                     $1,358.27    Covered
31380   Partial removal of larynx      C                     $1,405.33    Covered
31382   Partial removal of larynx      C                     $1,436.15    Covered
31390   Removal of larynx & pharynx    C                     $1,978.77    Covered
31395   Reconstruct larynx & pharynx   C                     $2,310.30    Covered
31400   Revision of larynx             T   00256   42.9827                Covered
3140F   Upper gi endo shows barrtt's   M                                 Not Covered
3141F   Upper gi endo not barrtt's     M                                 Not Covered
31420   Removal of epiglottis          T   00256   42.9827                Covered
3142F   Barium swallow test ordered    M                                 Not Covered
31500   Insert emergency airway        S   00094    2.4553                Covered
31502   Change of windpipe airway      S   00078    1.4142                Covered
31505   Diagnostic laryngoscopy        T   00071    0.8007                Covered
3150F   Forceps esoph biopsy done      M                                 Not Covered
31510   Laryngoscopy with biopsy       T   00074   21.6572                Covered
31511   Remove foreign body, larynx    T   00072    1.8425                Covered
31512   Removal of larynx lesion       T   00074   21.6572                Covered
31513   Injection into vocal cord      T   00072    1.8425                Covered
31515   Laryngoscopy for aspiration    T   00074   21.6572                Covered
31520   Dx laryngoscopy, newborn       T   00072    1.8425                Covered
31525   Dx laryngoscopy excl nb        T   00074   21.6572                Covered
31526   Dx laryngoscopy w/oper scope   T   00074   21.6572                Covered
31527   Laryngoscopy for treatment     T   00075   29.2718                Covered
31528   Laryngoscopy and dilation      T   00074   21.6572                Covered
31529   Laryngoscopy and dilation      T   00074   21.6572                Covered
31530   Laryngoscopy w/fb removal      T   00074   21.6572                Covered
31531   Laryngoscopy w/fb & op scope   T   00074   21.6572                Covered
31535   Laryngoscopy w/biopsy          T   00074   21.6572                Covered
31536   Laryngoscopy w/bx & op scope   T   00074   21.6572                Covered
31540   Laryngoscopy w/exc of tumor    T   00074   21.6572                Covered
31541   Larynscop w/tumr exc + scope   T   00074   21.6572                Covered
31545   Remove vc lesion w/scope       T   00075   29.2718                Covered
31546   Remove vc lesion scope/graft   T   00075   29.2718                Covered
3155F   Cytogen test marrow b/4 tx     M                                 Not Covered
31560   Laryngoscop w/arytenoidectom   T   00075   29.2718                Covered
31561   Larynscop, remve cart + scop   T   00075   29.2718                Covered
31570   Laryngoscope w/vc inj          T   00074   21.6572                Covered
31571   Laryngoscop w/vc inj + scope   T   00075   29.2718                Covered
31575   Diagnostic laryngoscopy        T   00072    1.8425                Covered
31576   Laryngoscopy with biopsy       T   00074   21.6572                Covered
31577   Remove foreign body, larynx    T   00073    4.4119                Covered
31578   Removal of larynx lesion       T   00075   29.2718                Covered
31579   Diagnostic laryngoscopy        T   00073    4.4119                Covered
31580   Revision of larynx             T   00256   42.9827                Covered
31582   Revision of larynx             T   00256   42.9827                Covered
31584   Treat larynx fracture          C                     $1,275.57    Covered
31587   Revision of larynx             C                      $799.83     Covered
31588   Revision of larynx             T   00256   42.9827                Covered
31590   Reinnervate larynx             T   00256   42.9827                Covered
31595   Larynx nerve surgery           T   00256   42.9827                Covered
31599   Larynx surgery procedure       T   00250    1.1522                Covered
31600   Incision of windpipe           T   00254   24.9637                Covered
31601   Incision of windpipe           T   00254   24.9637                Covered
31603   Incision of windpipe           T   00252    7.6196                Covered
31605   Incision of windpipe           T   00252    7.6196                Covered
3160F   Doc fe+ stores b/4 epo thx     M                                 Not Covered
3160F   Doc fe+ stores b/4 epo thx     M                                 Not Covered
31610   Incision of windpipe           T   00254   24.9637                Covered
31611   Surgery/speech prosthesis      T   00254   24.9637                Covered
31612   Puncture/clear windpipe        T   00254   24.9637                Covered
31613   Repair windpipe opening        T   00254   24.9637                Covered
31614   Repair windpipe opening        T   00256   42.9827                Covered
31615   Visualization of windpipe      T   00252    7.6196                Covered
31620   Endobronchial us add-on        N                                  Covered
31622   Dx bronchoscope/wash           T   00076   10.3707                Covered
31623   Dx bronchoscope/brush          T   00076   10.3707                Covered
31624   Dx bronchoscope/lavage         T   00076   10.3707                Covered
31625   Bronchoscopy w/biopsy(s)       T   00076   10.3707                Covered
31626   Bronchoscopy w/markers         T   00076   10.3707                Covered
31627   Navigational bronchoscopy      N                                  Covered
31628   Bronchoscopy/lung bx, each     T   00076   10.3707                Covered
31629   Bronchoscopy/needle bx, each   T   00076   10.3707                Covered
31630   Bronchoscopy dilate/fx repr    T   00415   25.9024                Covered
31631   Bronchoscopy, dilate w/stent   T   00415   25.9024                Covered
31632   Bronchoscopy/lung bx, add'l    T   00076   10.3707                Covered
31633   Bronchoscopy/needle bx add'l   T   00076   10.3707                Covered
31635   Bronchoscopy w/fb removal      T   00076   10.3707                Covered
31636   Bronchoscopy, bronch stents    T   00415   25.9024                Covered
31637   Bronchoscopy, stent add-on     T   00076   10.3707                Covered
31638   Bronchoscopy, revise stent     T   00415   25.9024                Covered
31640   Bronchoscopy w/tumor excise    T   00415   25.9024                Covered
31641   Bronchoscopy, treat blockage   T   00415   25.9024                Covered
31643   Diag bronchoscope/catheter     T   00076   10.3707                Covered
31645   Bronchoscopy, clear airways    T   00076   10.3707                Covered
31646   Bronchoscopy, reclear airway   T   00076   10.3707                Covered
31656   Bronchoscopy, inj for x-ray    T   00076   10.3707                Covered
3170F   Flow cyto done b/4 tx          M                                 Not Covered
3170F   Flow cyto done b/4 tx          M                                 Not Covered
31715   Injection for bronchus x-ray   N                                  Covered
31717   Bronchial brush biopsy         T   00073    4.4119                Covered
31720   Clearance of airways           S   00077    0.4058                Covered
31725   Clearance of airways           C                     $110.01      Covered
31730   Intro, windpipe wire/tube      T   00073    4.4119                Covered
31750   Repair of windpipe             T   00256   42.9827                Covered
31755   Repair of windpipe             T   00256   42.9827                Covered
31760   Repair of windpipe             C                     $1,303.02    Covered
31766   Reconstruction of windpipe     C                     $1,820.62    Covered
31770   Repair/graft of bronchus       C                     $1,431.63    Covered
31775   Reconstruct bronchus           C                     $1,548.52    Covered
31780   Reconstruct windpipe           C                     $1,238.72    Covered
31781   Reconstruct windpipe           C                     $1,519.69    Covered
31785   Remove windpipe lesion         T   00254   24.9637                Covered
31786   Remove windpipe lesion         C                     $1,474.76    Covered
31800   Repair of windpipe injury      C                      $494.20     Covered
31805   Repair of windpipe injury      C                      $918.84     Covered
31820   Closure of windpipe lesion     T   00254   24.9637                Covered
31825   Repair of windpipe defect      T   00254   24.9637                Covered
31830   Revise windpipe scar           T   00254   24.9637                Covered
31899   Airways surgical procedure     T   00076   10.3707                Covered
3200F   Barium swallow test not req    M                                 Not Covered
3200F   Barium swallow test not req    M                                 Not Covered
32035   Exploration of chest           C                     $642.05      Covered
32036   Exploration of chest           C                     $709.83      Covered
32095   Biopsy through chest wall      C                     $662.58      Covered
32100   Exploration/biopsy of chest    C                     $875.55      Covered
3210F   Grp a strep test performed     M                                 Not Covered
3210F   Grp a strep test performed     M                                 Not Covered
32110   Explore/repair chest           C                      $957.61     Covered
32120   Re-exploration of chest        C                      $842.13     Covered
32124   Explore chest free adhesions   C                      $895.48     Covered
32140   Removal of lung lesion(s)      C                     $1,005.07    Covered
32141   Remove/treat lung lesions      C                      $991.32     Covered
32150   Removal of lung lesion(s)      C                      $960.80     Covered
32151   Remove lung foreign body       C                      $964.57     Covered
3215F   Pt immunity to hep a docd      M                                 Not Covered
32160   Open chest heart massage       C                     $659.46      Covered
3216F   Pt immunity to hep b docd      M                                 Not Covered
3218F   RNA tstng hep C doc'd-done     M                                 Not Covered
32200   Drain, open, lung lesion       C                     $896.71      Covered
32201   Drain, percut, lung lesion     T   00070    5.5521                Covered
3220F   Hep c quant rna tstng docd     M                                 Not Covered
32215   Treat chest lining             C                      $801.95     Covered
32220   Release of lung                C                     $1,316.92    Covered
32225   Partial release of lung        C                      $991.87     Covered
3230F   Note hring tst w/in 6 mon      M                                 Not Covered
32310   Removal of chest lining        C                      $955.27     Covered
32320   Free/remove chest lining       C                     $1,400.19    Covered
32400   Needle biopsy chest lining     T   00685    9.6666                Covered
32402   Open biopsy chest lining       C                     $622.03      Covered
32405   Biopsy, lung or mediastinum    T   00685    9.6666                Covered
32420   Puncture/clear lung            T   00070    5.5521                Covered
32421   Thoracentesis for aspiration   T   00070    5.5521                Covered
32422   Thoracentesis w/tube insert    T   00070    5.5521                Covered
32440   Removal of lung                C                     $1,438.97    Covered
32442   Sleeve pneumonectomy           C                     $1,643.01    Covered
32445   Removal of lung                C                     $1,641.36    Covered
32480   Partial removal of lung        C                     $1,270.14    Covered
32482   Bilobectomy                    C                     $1,343.15    Covered
32484   Segmentectomy                  C                     $1,388.19    Covered
32486   Sleeve lobectomy               C                     $1,547.81    Covered
32488   Completion pneumonectomy       C                     $1,643.62    Covered
32491   Lung volume reduction          C                     $1,396.87    Covered
32500   Partial removal of lung        C                     $1,040.40    Covered
32501   Repair bronchus add-on         C                      $294.14     Covered
32503   Resect apical lung tumor       C                     $1,270.14    Covered
32504   Resect apical lung tum/chest   C                     $1,270.14    Covered
3250F   Nonprim loc anat bx site tum   M                                 Not Covered
32540   Removal of lung lesion         C                     $1,024.09    Covered
32550   Insert pleural cath            T   00652   30.4602                Covered
32551   Insertion of chest tube        T   00070    5.5521                Covered
32552   Remove lung catheter           S   00078    1.4142                Covered
32553   Ins mark thor for rt perq      X   00310   13.7576                Covered
32560   Treat lung lining chemically   T   00070    5.5521                Covered
32561   Lyse chest fibrin init day     T   00070    5.5521                Covered
32562   Lyse chest fibrin subq day     T   00070    5.5521                Covered
32601   Thoracoscopy, diagnostic       T   00069   34.0084                Covered
32602   Thoracoscopy, diagnostic       T   00069   34.0084                Covered
32603   Thoracoscopy, diagnostic       T   00069   34.0084                Covered
32604   Thoracoscopy, diagnostic       T   00069   34.0084                Covered
32605   Thoracoscopy, diagnostic       T   00069   34.0084                Covered
32606   Thoracoscopy, diagnostic       T   00069   34.0084                Covered
3260F   Pt cat/pn cat/hist grd docd    M                                 Not Covered
32650   Thoracoscopy, surgical         C                      $749.91     Covered
32651   Thoracoscopy, surgical         C                      $913.00     Covered
32652   Thoracoscopy, surgical         C                     $1,265.31    Covered
32653   Thoracoscopy, surgical         C                      $896.44     Covered
32654   Thoracoscopy, surgical         C                      $858.56     Covered
32655   Thoracoscopy, surgical         C                   $949.21       Covered
32656   Thoracoscopy, surgical         C                   $955.42       Covered
32657   Thoracoscopy, surgical         C                   $986.75       Covered
32658   Thoracoscopy, surgical         C                   $892.06       Covered
32659   Thoracoscopy, surgical         C                   $891.18       Covered
3265F   Rna tstng hepc vir ord/docd    M                               Not Covered
32660   Thoracoscopy, surgical         C                   $1,320.23     Covered
32661   Thoracoscopy, surgical         C                    $912.41      Covered
32662   Thoracoscopy, surgical         C                               Not Covered
32663   Thoracoscopy, surgical         C                   $1,281.31     Covered
32664   Thoracoscopy, surgical         C                    $939.41      Covered
32665   Thoracoscopy, surgical         C                   $1,066.06     Covered
3266F   Hepc gn tstng docd b/4txmnt    M                               Not Covered
3268F   Psa/t/glsc docd b/4 txmnt      M                               Not Covered
3269F   Bone scn b/4 txmnt/aftr Dx     M                               Not Covered
3270F   No bone scn b/4 txmnt/aftrDx   M                               Not Covered
3271F   Low risk prostate cancer       M                               Not Covered
3272F   Med risk prostate cancer       M                               Not Covered
3273F   High risk prostate cancer      M                               Not Covered
3274F   Prost Cncr rsk not lw/md/hgh   M                               Not Covered
3278F   Serum lvls CA/iPTH/lpd ord     M                               Not Covered
3279F   Hgb lvl >/= 13 g/dl            M                               Not Covered
32800   Repair lung hernia             C                   $916.16       Covered
3280F   Hgb lvl 11-12.9 g/dL           M                               Not Covered
32810   Close chest after drainage     C                    $851.01      Covered
32815   Close bronchial fistula        C                   $1,503.18     Covered
3281F   Hgb lvl <11 g/dl               M                               Not Covered
32820   Reconstruct injured chest      C                   $1,450.46     Covered
3284F   IOP down >15% of pre-svc lvl   M                               Not Covered
32850   Donor pneumonectomy            C                                By Report
32851   Lung transplant, single        C                   $2,429.94     Covered
32852   Lung transplant with bypass    C                   $2,616.35     Covered
32853   Lung transplant, double        C                   $2,969.92     Covered
32854   Lung transplant with bypass    C                   $3,167.88     Covered
32855   Prepare donor lung, single     C                               Not Covered
32856   Prepare donor lung, double     C                               Not Covered
3285F   IOP down <15% of pre-svc lvl   M                               Not Covered
3288F   Fall risk assessment doc'd     M                               Not Covered
32900   Removal of rib(s)              C                   $1,205.96     Covered
32905   Revise & repair chest wall     C                   $1,304.35     Covered
32906   Revise & repair chest wall     C                   $1,649.37     Covered
3290F   Pt=D(Rh)- and unsensitized     M                               Not Covered
3291F   Pt=d(rh)+ or sensitized        M                               Not Covered
3292F   Hiv tstng asked/docd/revwd     M                               Not Covered
3293F   Abo rh blood typing docd       E                               Not Covered
32940   Revision of lung               C                   $1,220.92     Covered
3294F   Grp b strep screening docd     E                               Not Covered
32960   Therapeutic pneumothorax       T 00070    5.5521                 Covered
32997   Total lung lavage              C                   $309.58       Covered
32998   Perq rf ablate tx, pul tumor   T 00423   51.3618                 Covered
32999   Chest surgery procedure        T 00070    5.5521                 Covered
3300F   AJCC stage docd b/4 thxpy      M                               Not Covered
33010   Drainage of heart sac          T   00070     5.5521                Covered
33011   Repeat drainage of heart sac   T   00070     5.5521                Covered
33015   Incision of heart sac          C                      $435.41      Covered
3301F   Cancer stage docd metast       M                                  Not Covered
33020   Incision of heart sac          C                      $920.81      Covered
33025   Incision of heart sac          C                      $909.62      Covered
3302F   AJCC stage 0 doc'd             D                                  Not Covered
33030   Partial removal of heart sac   C                      $1,395.03    Covered
33031   Partial removal of heart sac   C                      $1,422.73    Covered
3303F   Ajcc stage ia docd             D                                  Not Covered
3304F   Ajcc stage ib docd             D                                  Not Covered
33050   Removal of heart sac lesion    C                      $959.52      Covered
3305F   Ajcc stage ic docd             D                                  Not Covered
3306F   Ajcc stage iia docd            D                                  Not Covered
3307F   Ajcc stage iib docd            D                                  Not Covered
3308F   Ajcc stage iic docd            D                                  Not Covered
3309F   Ajcc stage iiia docd           D                                  Not Covered
3310F   Ajcc stage iiib docd           D                                  Not Covered
3311F   Ajcc stage iiic docd           D                                  Not Covered
33120   Removal of heart lesion        C                      $1,841.01    Covered
3312F   Ajcc stage iva docd            D                                  Not Covered
33130   Removal of heart lesion        C                      $1,362.75    Covered
3313F   AJCC stage IVB doc'd           D                                  Not Covered
33140   Heart revascularize (tmr)      C                      $1,233.63    Covered
33141   Heart tmr w/other procedure    C                       $240.68     Covered
3314F   AJCC stage IVC doc'd           D                                  Not Covered
3315F   Er+ or pr+ breast cancer       M                                  Not Covered
3316F   ER- or PR- breast cancer       M                                  Not Covered
3317F   Path rpt malig cancer docd     M                                  Not Covered
3318F   Path rpt malig cancer docd     M                                  Not Covered
3319F   X-ray/ct/ultrsnd et al ord     M                                  Not Covered
33202   Insert epicard eltrd, open     C                      $697.60      Covered
33203   Insert epicard eltrd, endo     C                      $719.25      Covered
33206   Insertion of heart pacemaker   T   00089   118.8826                Covered
33207   Insertion of heart pacemaker   T   00089   118.8826                Covered
33208   Insertion of heart pacemaker   T   00655   142.1623                Covered
3320F   No xray/ct/ et al ordd         M                                  Not Covered
33210   Insertion of heart electrode   T   00106    48.9361                Covered
33211   Insertion of heart electrode   T   00106    48.9361                Covered
33212   Insertion of pulse generator   T   00090    98.1576                Covered
33213   Insertion of pulse generator   T   00654   108.1692                Covered
33214   Upgrade of pacemaker system    T   00655   142.1623                Covered
33215   Reposition pacing-defib lead   T   00105    22.9412                Covered
33216   Insert lead pace-defib, one    T   00106    48.9361                Covered
33217   Insert lead pace-defib, dual   T   00106    48.9361                Covered
33218   Repair lead pace-defib, one    T   00105    22.9412                Covered
3321F   AJCC cncr 0/IA melan docd      E                                  Not Covered
33220   Repair lead pace-defib, dual   T   00105    22.9412                Covered
33222   Revise pocket, pacemaker       T   00136    16.0542                Covered
33223   Revise pocket, pacing-defib    T   00136    16.0542                Covered
33224   Insert pacing lead & connect   T   00418   204.1256                Covered
33225   L ventric pacing lead add-on   T   00418   204.1256                Covered
33226   Reposition l ventric lead      T   00105    22.9412                Covered
3322F   Melan >AJCC stage 0 or IA      E                                  Not Covered
33233   Removal of pacemaker system    T   00105    22.9412                Covered
33234   Removal of pacemaker system    T   00105    22.9412                Covered
33235   Removal pacemaker electrode    T   00105    22.9412                Covered
33236   Remove electrode/thoracotomy   C                      $764.71      Covered
33237   Remove electrode/thoracotomy   C                      $927.45      Covered
33238   Remove electrode/thoracotomy   C                      $973.29      Covered
3323F   Clin node stgng docdb/4 surg   M                                  Not Covered
33240   Insert pulse generator         T   00107   325.8288                Covered
33241   Remove pulse generator         T   00105    22.9412                Covered
33243   Remove eltrd/thoracotomy       C                      $1,297.17    Covered
33244   Remove eltrd, transven         T   00105    22.9412                Covered
33249   Eltrd/insert pace-defib        T   00108   412.3722                Covered
3324F   Mri ct scan ord rvwd rqstd     E                                  Not Covered
33250   Ablate heart dysrhythm focus   C                      $1,323.95    Covered
33251   Ablate heart dysrhythm focus   C                      $1,622.82    Covered
33254   Ablate atria, lmtd             C                      $1,216.72    Covered
33255   Ablate atria w/o bypass, ext   C                      $1,467.35    Covered
33256   Ablate atria w/bypass, exten   C                      $1,751.32    Covered
33257   Ablate atria, lmtd, add-on     C                       $474.25     Covered
33258   Ablate atria, x10sv, add-on    C                       $535.32     Covered
33259   Ablate atria w/bypass add-on   C                       $699.51     Covered
3325F   Preop asses 4 cataract surg    M                                  Not Covered
33261   Ablate heart dysrhythm focus   C                      $1,566.25    Covered
33265   Ablate atria, lmtd, endo       C                      $1,216.72    Covered
33266   Ablate atria, x10sv, endo      C                      $1,665.12    Covered
33282   Implant pat-active ht record   S   00680    78.0661                Covered
33284   Remove pat-active ht record    T   00020     8.2028                Covered
3328F   Prfrmnc docd 2 wks b/4 surg    E                                  Not Covered
33300   Repair of heart wound          C                      $1,233.02    Covered
33305   Repair of heart wound          C                      $1,477.91    Covered
3330F   Imaging study ordered (bkp)    M                                  Not Covered
33310   Exploratory heart surgery      C                      $1,234.74    Covered
33315   Exploratory heart surgery      C                      $1,468.17    Covered
3331F   Bk imaging tst not ordered     M                                  Not Covered
33320   Repair major blood vessel(s)   C                      $1,161.96    Covered
33321   Repair major vessel            C                                  Not Covered
33322   Repair major blood vessel(s)   C                      $1,511.42    Covered
33330   Insert major vessel graft      C                      $1,353.53    Covered
33332   Insert major vessel graft      C                                  Not Covered
33335   Insert major vessel graft      C                      $1,833.55    Covered
33400   Repair of aortic valve         C                      $1,874.83    Covered
33401   Valvuloplasty, open            C                      $1,740.44    Covered
33403   Valvuloplasty, w/cp bypass     C                      $1,847.87    Covered
33404   Prepare heart-aorta conduit    C                      $2,107.62    Covered
33405   Replacement of aortic valve    C                      $2,146.93    Covered
33406   Replacement of aortic valve    C                      $2,315.76    Covered
3340F   Mammo assess inc xray docd     M                                  Not Covered
33410   Replacement of aortic valve    C                      $2,068.24    Covered
33411   Replacement of aortic valve    C                      $2,330.41    Covered
33412   Replacement of aortic valve    C                      $2,514.27    Covered
33413   Replacement of aortic valve    C   $2,564.28    Covered
33414   Repair of aortic valve         C   $2,268.81    Covered
33415   Revision, subvalvular tissue   C   $2,008.03    Covered
33416   Revise ventricle muscle        C   $2,099.59    Covered
33417   Repair of aortic valve         C   $2,151.88    Covered
3341F   Mammo assess negative docd     M               Not Covered
33420   Revision of mitral valve       C   $1,421.34    Covered
33422   Revision of mitral valve       C   $1,900.05    Covered
33425   Repair of mitral valve         C   $1,961.37    Covered
33426   Repair of mitral valve         C   $2,194.60    Covered
33427   Repair of mitral valve         C   $2,366.72    Covered
3342F   Mammo assess bengn docd        M               Not Covered
33430   Replacement of mitral valve    C   $2,259.67    Covered
3343F   Mammo probably bengn docd      M               Not Covered
3344F   Mammo assess susp, docd        M               Not Covered
3345F   Mammo assess hghlymalig doc    M               Not Covered
33460   Revision of tricuspid valve    C   $1,731.50    Covered
33463   Valvuloplasty, tricuspid       C   $1,872.28    Covered
33464   Valvuloplasty, tricuspid       C   $1,990.30    Covered
33465   Replace tricuspid valve        C   $2,083.75    Covered
33468   Revision of tricuspid valve    C   $2,304.29    Covered
33470   Revision of pulmonary valve    C   $1,372.46    Covered
33471   Valvotomy, pulmonary valve     C   $1,520.23    Covered
33472   Revision of pulmonary valve    C   $1,568.34    Covered
33474   Revision of pulmonary valve    C   $1,701.05    Covered
33475   Replacement, pulmonary valve   C   $2,082.96    Covered
33476   Revision of heart chamber      C   $1,784.60    Covered
33478   Revision of heart chamber      C   $1,984.92    Covered
33496   Repair, prosth valve clot      C   $2,025.79    Covered
33500   Repair heart vessel fistula    C   $1,854.41    Covered
33501   Repair heart vessel fistula    C   $1,212.27    Covered
33502   Coronary artery correction     C   $1,513.90    Covered
33503   Coronary artery graft          C   $1,551.36    Covered
33504   Coronary artery graft          C   $1,890.59    Covered
33505   Repair artery w/tunnel         C   $1,897.88    Covered
33506   Repair artery, translocation   C   $1,918.60    Covered
33507   Repair art, intramural         C   $1,513.90    Covered
33508   Endoscopic vein harvest        N                Covered
3350F   Mammo bx proven malig docd     M               Not Covered
33510   CABG, vein, single             C   $1,838.90    Covered
33511   CABG, vein, two                C   $1,989.58    Covered
33512   CABG, vein, three              C   $2,136.42    Covered
33513   CABG, vein, four               C   $2,293.22    Covered
33514   CABG, vein, five               C   $2,500.39    Covered
33516   Cabg, vein, six or more        C   $2,662.15    Covered
33517   CABG, artery-vein, single      C    $171.65     Covered
33518   CABG, artery-vein, two         C    $323.93     Covered
33519   CABG, artery-vein, three       C    $475.26     Covered
3351F   Neg scrn dep symp by deptool   E               Not Covered
33521   CABG, artery-vein, four        C   $627.28      Covered
33522   CABG, artery-vein, five        C   $778.70      Covered
33523   Cabg, art-vein, six or more    C   $931.41      Covered
3352F   No sig dep symp by dep tool    E               Not Covered
33530   Coronary artery, bypass/reop   C    $391.13     Covered
33533   CABG, arterial, single         C   $1,887.06    Covered
33534   CABG, arterial, two            C   $2,075.19    Covered
33535   CABG, arterial, three          C   $2,268.30    Covered
33536   Cabg, arterial, four or more   C   $2,459.37    Covered
3353F   Mild-mod dep symp by deptool   E               Not Covered
33542   Removal of heart lesion        C   $2,104.45    Covered
33545   Repair of heart damage         C   $2,542.71    Covered
33548   Restore/remodel, ventricle     C   $2,542.71    Covered
3354F   Clin sig dep sym by dep tool   E               Not Covered
33572   Open coronary endarterectomy   C               Not Covered
33600   Closure of valve               C   $2,078.92    Covered
33602   Closure of valve               C   $2,007.01    Covered
33606   Anastomosis/artery-aorta       C   $2,213.08    Covered
33608   Repair anomaly w/conduit       C   $2,294.68    Covered
33610   Repair by enlargement          C   $2,246.21    Covered
33611   Repair double ventricle        C   $2,331.23    Covered
33612   Repair double ventricle        C   $2,460.59    Covered
33615   Repair, modified fontan        C   $2,385.86    Covered
33617   Repair single ventricle        C   $2,552.31    Covered
33619   Repair single ventricle        C   $2,869.85    Covered
33641   Repair heart septum defect     C   $1,548.52    Covered
33645   Revision of heart veins        C   $1,836.24    Covered
33647   Repair heart septum defects    C   $2,132.86    Covered
33660   Repair of heart defects        C   $1,910.17    Covered
33665   Repair of heart defects        C   $2,106.95    Covered
33670   Repair of heart chambers       C   $2,215.97    Covered
33675   Close mult vsd                 C   $1,937.23    Covered
33676   Close mult vsd w/resection     C   $1,994.18    Covered
33677   Cl mult vsd w/rem pul band     C   $2,072.79    Covered
33681   Repair heart septum defect     C   $2,074.59    Covered
33684   Repair heart septum defect     C   $2,143.82    Covered
33688   Repair heart septum defect     C   $2,040.26    Covered
33690   Reinforce pulmonary artery     C   $1,472.59    Covered
33692   Repair of heart defects        C   $2,199.82    Covered
33694   Repair of heart defects        C   $2,240.51    Covered
33697   Repair of heart defects        C   $2,394.35    Covered
33702   Repair of heart defects        C   $1,989.53    Covered
3370F   AJCC brst cncr stage 0 docd    M               Not Covered
33710   Repair of heart defects        C   $2,132.31    Covered
33720   Repair of heart defect         C   $1,957.96    Covered
33722   Repair of heart defect         C   $2,109.35    Covered
33724   Repair venous anomaly          C   $1,388.39    Covered
33726   Repair pul venous stenosis     C   $1,834.17    Covered
3372F   AJCC brst cncr stage 1 +docd   M               Not Covered
33730   Repair heart-vein defect(s)    C   $2,178.46    Covered
33732   Repair heart-vein defect       C   $2,046.90    Covered
33735   Revision of heart chamber      C   $1,595.55    Covered
33736   Revision of heart chamber      C   $1,786.73    Covered
33737   Revision of heart chamber      C   $1,563.33    Covered
3374F   AJCC brst cncr stage 1 +docd   M               Not Covered
33750   Major vessel shunt             C   $1,469.89    Covered
33755   Major vessel shunt             C   $1,447.44    Covered
33762   Major vessel shunt             C   $1,486.41    Covered
33764   Major vessel shunt & graft     C   $1,490.20    Covered
33766   Major vessel shunt             C   $1,654.85    Covered
33767   Major vessel shunt             C   $1,697.53    Covered
33768   Cavopulmonary shunting         C   $1,697.53    Covered
3376F   AJCC brstcncr stage 2 docd     M               Not Covered
33770   Repair great vessels defect    C   $2,325.22    Covered
33771   Repair great vessels defect    C   $2,305.36    Covered
33774   Repair great vessels defect    C   $2,124.51    Covered
33775   Repair great vessels defect    C   $2,093.97    Covered
33776   Repair great vessels defect    C   $2,242.95    Covered
33777   Repair great vessels defect    C   $2,150.42    Covered
33778   Repair great vessels defect    C   $2,517.62    Covered
33779   Repair great vessels defect    C   $2,443.41    Covered
33780   Repair great vessels defect    C   $2,527.24    Covered
33781   Repair great vessels defect    C   $2,410.25    Covered
33782   Nikaidoh proc                  C   $2,741.30    Covered
33783   Nikaidoh proc w/ostia implt    C   $2,975.97    Covered
33786   Repair arterial trunk          C   $2,340.73    Covered
33788   Revision of pulmonary artery   C   $1,802.33    Covered
3378F   AJCC brstcncr stage 3 docd     M               Not Covered
33800   Aortic suspension              C   $1,209.06    Covered
33802   Repair vessel defect           C   $1,365.89    Covered
33803   Repair vessel defect           C   $1,367.94    Covered
3380F   AJCC brstcncr stage 4 docd     M               Not Covered
33813   Repair septal defect           C   $1,509.55    Covered
33814   Repair septal defect           C   $1,922.91    Covered
33820   Revise major vessel            C   $1,263.69    Covered
33822   Revise major vessel            C   $1,220.12    Covered
33824   Revise major vessel            C   $1,471.87    Covered
3382F   AJCC cln cncr stage 0 docd     M               Not Covered
33840   Remove aorta constriction      C   $1,581.59    Covered
33845   Remove aorta constriction      C   $1,660.22    Covered
3384F   AJCC cln cncr stage 1 docd     M               Not Covered
33851   Remove aorta constriction      C   $1,659.69    Covered
33852   Repair septal defect           C   $1,804.38    Covered
33853   Repair septal defect           C   $2,387.23    Covered
33860   Ascending aortic graft         C   $2,380.50    Covered
33861   Ascending aortic graft         C   $2,400.17    Covered
33863   Ascending aortic graft         C   $2,491.05    Covered
33864   Ascending aortic graft         C   $2,540.47    Covered
3386F   AJCC cln cncr stage 2 docd     M               Not Covered
33870   Transverse aortic arch graft   C   $2,844.13    Covered
33875   Thoracic aortic graft          C   $2,251.69    Covered
33877   Thoracoabdominal graft         C   $2,948.19    Covered
33880   Endovasc taa repr incl subcl   C   $1,825.32    Covered
33881   Endovasc taa repr w/o subcl    C   $1,566.66    Covered
33883   Insert endovasc prosth, taa    C   $1,151.40    Covered
33884   Endovasc prosth, taa, add-on   C    $431.16     Covered
33886   Endovasc prosth, delayed       C    $993.21     Covered
33889   Artery transpose/endovas taa   C                     $854.86       Covered
3388F   AJCC cln cncr stage 3 docd     M                                 Not Covered
33891   Car-car bp grft/endovas taa    C                     $1,089.53     Covered
3390F   AJCC cln cncr stage 4 docd     M                                 Not Covered
33910   Remove lung artery emboli      C                     $1,559.11     Covered
33915   Remove lung artery emboli      C                     $1,252.01     Covered
33916   Surgery of great vessel        C                     $1,644.60     Covered
33917   Repair pulmonary artery        C                     $1,830.46     Covered
33920   Repair pulmonary atresia       C                     $2,326.93     Covered
33922   Transect pulmonary artery      C                     $1,745.68     Covered
33924   Remove pulmonary shunt         C                      $329.93      Covered
33925   Rpr pul art unifocal w/o cpb   C                     $1,233.02     Covered
33926   Repr pul art, unifocal w/cpb   C                     $1,233.02     Covered
33930   Removal of donor heart/lung    C                                 Not Covered
33933   Prepare donor heart/lung       C                                 Not Covered
33935   Transplantation, heart/lung    C                     $3,235.04     Covered
33940   Removal of donor heart         C                                 Not Covered
33944   Prepare donor heart            C                                 Not Covered
33945   Transplantation of heart       C                     $2,980.59     Covered
33960   External circulation assist    C                      $972.92      Covered
33961   External circulation assist    C                      $629.79      Covered
33967   Insert ia percut device        C                      $254.94      Covered
33968   Remove aortic assist device    C                       $38.38      Covered
33970   Aortic circulation assist      C                      $451.12      Covered
33971   Aortic circulation assist      C                      $648.22      Covered
33973   Insert balloon device          C                      $593.11      Covered
33974   Remove intra-aortic balloon    C                      $893.04      Covered
33975   Implant ventricular device     C                     $1,376.51     Covered
33976   Implant ventricular device     C                     $1,600.17     Covered
33977   Remove ventricular device      C                     $1,223.52     Covered
33978   Remove ventricular device      C                     $1,375.33     Covered
33979   Insert intracorporeal device   C                     $2,234.48     Covered
33980   Remove intracorporeal device   C                     $2,871.72     Covered
33981   Replace vad pump ext           C                                  By Report
33982   Replace vad intra w/o bp       C                                  By Report
33983   Replace vad intra w/bp         C                                  By Report
33999   Cardiac surgery procedure      T   00070    5.5521                 Covered
34001   Removal of artery clot         C                     $795.09       Covered
34051   Removal of artery clot         C                     $892.81       Covered
34101   Removal of artery clot         T   00088   40.9003                 Covered
34111   Removal of arm artery clot     T   00088   40.9003                 Covered
34151   Removal of artery clot         C                     $1,014.56     Covered
34201   Removal of artery clot         T   00088   40.9003                 Covered
34203   Removal of leg artery clot     T   00088   40.9003                 Covered
34401   Removal of vein clot           C                     $752.72       Covered
34421   Removal of vein clot           T   00088   40.9003                 Covered
34451   Removal of vein clot           C                     $879.72       Covered
34471   Removal of vein clot           T   00088   40.9003                 Covered
34490   Removal of vein clot           T   00088   40.9003                 Covered
34501   Repair valve, femoral vein     T   00088   40.9003                 Covered
34502   Reconstruct vena cava          C                     $1,610.57     Covered
3450F   Dyspnea scrnd, no-mild dysp    E                                 Not Covered
34510   Transposition of vein valve    T   00088   40.9003                Covered
3451F   Dyspnea scrnd mod-high dysp    E                                 Not Covered
34520   Cross-over vein graft          T   00088   40.9003                Covered
3452F   Dyspnea not screened           E                                 Not Covered
34530   Leg vein fusion                T   00088   40.9003                Covered
3455F   TB scrng done-interpd 6mon     M                                 Not Covered
3470F   RA disease activity, low       M                                 Not Covered
3471F   RA disease activity, mod       M                                 Not Covered
3472F   RA disease activity, high      M                                 Not Covered
3475F   Disease progn RA poor docd     M                                 Not Covered
3476F   Disease progn RA good docd     M                                 Not Covered
34800   Endovas aaa repr w/sm tube     C                     $1,104.77    Covered
34802   Endovas aaa repr w/2-p part    C                     $1,219.21    Covered
34803   Endovas aaa repr w/3-p part    C                     $1,342.21    Covered
34804   Endovas aaa repr w/1-p part    C                     $1,219.21    Covered
34805   Endovas aaa repr w/long tube   C                     $1,109.11    Covered
34806   Aneurysm press sensor add-on   C                       $82.92     Covered
34808   Endovas iliac a device addon   C                      $222.34     Covered
34812   Xpose for endoprosth, femorl   C                      $363.89     Covered
34813   Femoral endovas graft add-on   C                      $258.57     Covered
34820   Xpose for endoprosth, iliac    C                      $525.42     Covered
34825   Endovasc extend prosth, init   C                      $696.63     Covered
34826   Endovasc exten prosth, add'l   C                      $222.34     Covered
34830   Open aortic tube prosth repr   C                     $1,818.31    Covered
34831   Open aortoiliac prosth repr    C                     $1,965.95    Covered
34832   Open aortofemor prosth repr    C                     $1,965.95    Covered
34833   Xpose for endoprosth, iliac    C                      $603.71     Covered
34834   Xpose, endoprosth, brachial    C                      $281.52     Covered
34900   Endovasc iliac repr w/graft    C                      $882.71     Covered
3490F   History - AIDS-defining cond   M                                 Not Covered
3491F   HIV unsure baby of HIV+moms    E                                 Not Covered
3492F   History CD4+ cell count <350   M                                 Not Covered
3493F   No hist CD4+cell cnt<350       M                                 Not Covered
3494F   CD4+cell count <200cells/mm3   M                                 Not Covered
3495F   CD4+cell cnt 200-499 cells     M                                 Not Covered
3496F   CD4+ cell count >=500 cells    M                                 Not Covered
3497F   CD4+ cell percentage <15%      E                                 Not Covered
3498F   CD4+ cell percentage >=15%     E                                 Not Covered
35001   Repair defect of artery        C                     $1,227.66    Covered
35002   Repair artery rupture, neck    C                     $1,219.56    Covered
35005   Repair defect of artery        C                     $1,006.94    Covered
3500F   CD4 +cell cnt/% docd as done   M                                 Not Covered
35011   Repair defect of artery        T   00653   46.6883                Covered
35013   Repair artery rupture, arm     C                     $1,082.42    Covered
35021   Repair defect of artery        C                     $1,282.54    Covered
35022   Repair artery rupture, chest   C                     $1,333.75    Covered
3502F   HIV rna vrl ld <lmts quantif   M                                 Not Covered
3503F   HIV rna vrl ldnot<lmts quntf   M                                 Not Covered
35045   Repair defect of arm artery    C                      $780.25     Covered
35081   Repair defect of artery        C                     $1,711.05    Covered
35082   Repair artery rupture, aorta   C                     $2,098.25    Covered
35091   Repair defect of artery        C                     $2,073.77    Covered
35092   Repair artery rupture, aorta   C                     $2,262.23    Covered
35102   Repair defect of artery        C                     $1,845.79    Covered
35103   Repair artery rupture, groin   C                     $2,036.49    Covered
3510F   Doc tb scrng-rslts interpd     E                                 Not Covered
35111   Repair defect of artery        C                     $1,097.65    Covered
35112   Repair artery rupture,spleen   C                     $1,065.76    Covered
3511F   Chlmyd/gonrh tsts docd done    M                                 Not Covered
35121   Repair defect of artery        C                     $1,573.40    Covered
35122   Repair artery rupture, belly   C                     $1,880.74    Covered
3512F   Syph scrng docd as done        M                                 Not Covered
35131   Repair defect of artery        C                     $1,174.25    Covered
35132   Repair artery rupture, groin   C                     $1,369.98    Covered
3513F   Hep B scrng docd as done       E                                 Not Covered
35141   Repair defect of artery        C                      $965.21     Covered
35142   Repair artery rupture, thigh   C                     $1,050.14    Covered
3514F   Hep C scrng docd as done       E                                 Not Covered
35151   Repair defect of artery        C                     $1,091.90    Covered
35152   Repair artery rupture, knee    C                      $968.19     Covered
3515F   Pt has docd immun to hep C     E                                 Not Covered
35180   Repair blood vessel lesion     T   00093   35.5969                Covered
35182   Repair blood vessel lesion     C                     $1,057.88    Covered
35184   Repair blood vessel lesion     T   00093   35.5969                Covered
35188   Repair blood vessel lesion     T   00088   40.9003                Covered
35189   Repair blood vessel lesion     C                     $1,086.89    Covered
35190   Repair blood vessel lesion     T   00093   35.5969                Covered
35201   Repair blood vessel lesion     T   00093   35.5969                Covered
35206   Repair blood vessel lesion     T   00093   35.5969                Covered
35207   Repair blood vessel lesion     T   00088   40.9003                Covered
35211   Repair blood vessel lesion     C                     $1,436.36    Covered
35216   Repair blood vessel lesion     C                     $1,174.13    Covered
35221   Repair blood vessel lesion     C                      $979.58     Covered
35226   Repair blood vessel lesion     T   00020    8.2028                Covered
35231   Repair blood vessel lesion     T   00093   35.5969                Covered
35236   Repair blood vessel lesion     T   00093   35.5969                Covered
35241   Repair blood vessel lesion     C                     $1,511.04    Covered
35246   Repair blood vessel lesion     C                     $1,333.42    Covered
35251   Repair blood vessel lesion     C                      $994.87     Covered
35256   Repair blood vessel lesion     T   00093   35.5969                Covered
35261   Repair blood vessel lesion     T   00653   46.6883                Covered
35266   Repair blood vessel lesion     T   00653   46.6883                Covered
35271   Repair blood vessel lesion     C                     $1,421.24    Covered
35276   Repair blood vessel lesion     C                     $1,207.39    Covered
35281   Repair blood vessel lesion     C                     $1,096.27    Covered
35286   Repair blood vessel lesion     T   00653   46.6883                Covered
35301   Rechanneling of artery         C                     $1,167.17    Covered
35302   Rechanneling of artery         C                     $1,035.77    Covered
35303   Rechanneling of artery         C                     $1,138.58    Covered
35304   Rechanneling of artery         C                     $1,184.67    Covered
35305   Rechanneling of artery         C                     $1,138.58    Covered
35306   Rechanneling of artery         C                      $427.32     Covered
35311   Rechanneling of artery         C                     $1,566.04    Covered
35321   Rechanneling of artery         T   00093   35.5969                Covered
35331   Rechanneling of artery        C                     $1,357.77    Covered
35341   Rechanneling of artery        C                     $1,500.97    Covered
35351   Rechanneling of artery        C                     $1,223.58    Covered
35355   Rechanneling of artery        C                     $1,048.99    Covered
35361   Rechanneling of artery        C                     $1,462.26    Covered
35363   Rechanneling of artery        C                     $1,576.84    Covered
35371   Rechanneling of artery        C                      $788.75     Covered
35372   Rechanneling of artery        C                      $852.43     Covered
35390   Reoperation, carotid add-on   C                      $177.52     Covered
35400   Angioscopy                    C                      $176.78     Covered
35450   Repair arterial blockage      C                      $672.54     Covered
35452   Repair arterial blockage      C                      $407.65     Covered
35454   Repair arterial blockage      C                                 Not Covered
35456   Repair arterial blockage      C                     $495.16      Covered
35458   Repair arterial blockage      T   00083   50.6809                Covered
35459   Repair arterial blockage      T   00083   50.6809                Covered
35460   Repair venous blockage        T   00083   50.6809                Covered
35470   Repair arterial blockage      T   00083   50.6809                Covered
35471   Repair arterial blockage      T   00083   50.6809                Covered
35472   Repair arterial blockage      T   00083   50.6809                Covered
35473   Repair arterial blockage      T   00083   50.6809                Covered
35474   Repair arterial blockage      T   00083   50.6809                Covered
35475   Repair arterial blockage      T   00083   50.6809                Covered
35476   Repair venous blockage        T   00083   50.6809                Covered
35480   Atherectomy, open             C                     $734.63      Covered
35481   Atherectomy, open             C                     $444.86      Covered
35482   Atherectomy, open             C                     $451.87      Covered
35483   Atherectomy, open             C                     $545.69      Covered
35484   Atherectomy, open             T   00082   93.3244                Covered
35485   Atherectomy, open             T   00082   93.3244                Covered
35490   Atherectomy, percutaneous     T   00082   93.3244                Covered
35491   Atherectomy, percutaneous     T   00082   93.3244                Covered
35492   Atherectomy, percutaneous     T   00082   93.3244                Covered
35493   Atherectomy, percutaneous     T   00082   93.3244                Covered
35494   Atherectomy, percutaneous     T   00082   93.3244                Covered
35495   Atherectomy, percutaneous     T   00082   93.3244                Covered
35500   Harvest vein for bypass       T   00103   17.8436                Covered
35501   Artery bypass graft           C                     $1,231.13    Covered
35506   Artery bypass graft           C                     $1,287.04    Covered
35508   Artery bypass graft           C                     $1,225.59    Covered
35509   Artery bypass graft           C                     $1,198.95    Covered
3550F   Low rsk thromboembolism       E                                 Not Covered
35510   Artery bypass graft           C                     $1,198.95    Covered
35511   Artery bypass graft           C                      $988.79     Covered
35512   Artery bypass graft           C                      $988.79     Covered
35515   Artery bypass graft           C                     $1,090.60    Covered
35516   Artery bypass graft           C                     $1,090.37    Covered
35518   Artery bypass graft           C                     $1,031.01    Covered
3551F   Intrmed rsk thromboembolism   E                                 Not Covered
35521   Artery bypass graft           C                     $1,092.34    Covered
35522   Artery bypass graft           C                     $1,092.34    Covered
35523   Artery bypass graft           C                     $1,040.83    Covered
35525   Artery bypass graft            C   $1,092.34    Covered
35526   Artery bypass graft            C   $1,200.45    Covered
3552F   Hgh risk for thromboembolism   E               Not Covered
35531   Artery bypass graft            C   $1,572.84    Covered
35533   Artery bypass graft            C   $1,348.48    Covered
35535   Artery bypass graft            C   $1,878.51    Covered
35536   Artery bypass graft            C   $1,480.92    Covered
35537   Artery bypass graft            C   $2,003.78    Covered
35538   Artery bypass graft            C   $2,239.07    Covered
35539   Artery bypass graft            C   $2,104.32    Covered
35540   Artery bypass graft            C   $2,345.81    Covered
35548   Artery bypass graft            C   $1,377.07    Covered
35549   Artery bypass graft            C   $1,494.57    Covered
35551   Artery bypass graft            C   $1,604.79    Covered
35556   Artery bypass graft            C   $1,370.87    Covered
35558   Artery bypass graft            C    $956.35     Covered
3555F   Pt inr measurement performed   E               Not Covered
35560   Artery bypass graft            C   $1,491.15    Covered
35563   Artery bypass graft            C    $879.08     Covered
35565   Artery bypass graft            C   $1,028.49    Covered
35566   Artery bypass graft            C   $1,697.53    Covered
35570   Artery bypass graft            C   $1,450.72    Covered
35571   Artery bypass graft            C   $1,263.76    Covered
35572   Harvest femoropopliteal vein   N                Covered
35583   Vein bypass graft              C   $1,446.97    Covered
35585   Vein bypass graft              C   $1,789.42    Covered
35587   Vein bypass graft              C   $1,330.83    Covered
35600   Harvest art for cabg add-on    C    $271.33     Covered
35601   Artery bypass graft            C   $1,171.90    Covered
35606   Artery bypass graft            C   $1,207.98    Covered
35612   Artery bypass graft            C   $1,057.74    Covered
35616   Artery bypass graft            C   $1,054.62    Covered
35621   Artery bypass graft            C    $991.19     Covered
35623   Bypass graft, not vein         C    $940.18     Covered
35626   Artery bypass graft            C   $1,507.58    Covered
35631   Artery bypass graft            C   $1,487.03    Covered
35632   Artery bypass graft            C   $1,783.16    Covered
35633   Artery bypass graft            C   $1,925.77    Covered
35634   Artery bypass graft            C   $1,745.06    Covered
35636   Artery bypass graft            C   $1,303.94    Covered
35637   Artery bypass graft            C   $1,642.85    Covered
35638   Artery bypass graft            C   $1,668.77    Covered
35642   Artery bypass graft            C   $1,022.92    Covered
35645   Artery bypass graft            C   $1,028.56    Covered
35646   Artery bypass graft            C   $1,652.95    Covered
35647   Artery bypass graft            C   $1,517.14    Covered
35650   Artery bypass graft            C    $969.47     Covered
35651   Artery bypass graft            C   $1,614.86    Covered
35654   Artery bypass graft            C   $1,256.99    Covered
35656   Artery bypass graft            C   $1,248.29    Covered
35661   Artery bypass graft            C    $898.00     Covered
35663   Artery bypass graft            C    $969.50     Covered
35665   Artery bypass graft            C                     $1,044.81    Covered
35666   Artery bypass graft            C                     $1,321.39    Covered
35671   Artery bypass graft            C                     $1,030.47    Covered
35681   Composite bypass graft         C                      $267.76     Covered
35682   Composite bypass graft         C                      $491.55     Covered
35683   Composite bypass graft         C                      $551.28     Covered
35685   Bypass graft patency/patch     T   00093   35.5969                Covered
35686   Bypass graft/av fist patency   T   00093   35.5969                Covered
35691   Arterial transposition         C                     $1,211.11    Covered
35693   Arterial transposition         C                      $896.80     Covered
35694   Arterial transposition         C                     $1,066.77    Covered
35695   Arterial transposition         C                     $1,066.94    Covered
35697   Reimplant artery each          C                      $150.71     Covered
35700   Reoperation, bypass graft      C                      $207.25     Covered
35701   Exploration, carotid artery    C                      $386.94     Covered
3570F   Rprt bone scint x-refw/x-ray   M                                 Not Covered
35721   Exploration, femoral artery    C                     $391.39      Covered
3572F   Pt consid poss risk fx         E                                 Not Covered
3573F   Pt not consid poss risk fx     E                                 Not Covered
35741   Exploration popliteal artery   C                     $390.64      Covered
35761   Exploration of artery/vein     T   00093   35.5969                Covered
35800   Explore neck vessels           C                     $445.32      Covered
35820   Explore chest vessels          C                     $747.44      Covered
35840   Explore abdominal vessels      C                     $607.03      Covered
35860   Explore limb vessels           T   00093   35.5969                Covered
35870   Repair vessel graft defect     C                     $1,248.35    Covered
35875   Removal of clot in graft       T   00088   40.9003                Covered
35876   Removal of clot in graft       T   00088   40.9003                Covered
35879   Revise graft w/vein            T   00088   40.9003                Covered
35881   Revise graft w/vein            T   00088   40.9003                Covered
35883   Revise graft w/nonauto graft   T   00088   40.9003                Covered
35884   Revise graft w/vein            T   00088   40.9003                Covered
35901   Excision, graft, neck          C                     $555.77      Covered
35903   Excision, graft, extremity     T   00093   35.5969                Covered
35905   Excision, graft, thorax        C                     $1,058.20    Covered
35907   Excision, graft, abdomen       C                     $1,053.94    Covered
36000   Place needle in vein           N                                  Covered
36002   Pseudoaneurysm injection trt   S   00267    2.3005                Covered
36005   Injection ext venography       N                                  Covered
36010   Place catheter in vein         N                                  Covered
36011   Place catheter in vein         N                                  Covered
36012   Place catheter in vein         N                                  Covered
36013   Place catheter in artery       N                                  Covered
36014   Place catheter in artery       N                                  Covered
36015   Place catheter in artery       N                                  Covered
36100   Establish access to artery     N                                  Covered
36120   Establish access to artery     N                                  Covered
36140   Establish access to artery     N                                  Covered
36145   Artery to vein shunt           D                                 Not Covered
36147   Access av dial grft for eval   T   00676    2.3954                Covered
36148   Access av dial grft for proc   N                                  Covered
36160   Establish access to aorta      N                                  Covered
36200   Place catheter in aorta        N                               Covered
36215   Place catheter in artery       N                               Covered
36216   Place catheter in artery       N                               Covered
36217   Place catheter in artery       N                               Covered
36218   Place catheter in artery       N                               Covered
36245   Place catheter in artery       N                               Covered
36246   Place catheter in artery       N                               Covered
36247   Place catheter in artery       N                               Covered
36248   Place catheter in artery       N                               Covered
36260   Insertion of infusion pump     T   00623   30.4396             Covered
36261   Revision of infusion pump      T   00105   22.9412             Covered
36262   Removal of infusion pump       T   00105   22.9412             Covered
36299   Vessel injection procedure     N                              By Report
36400   Bl draw < 3 yrs fem/jugular    N                               Covered
36405   Bl draw < 3 yrs scalp vein     N                               Covered
36406   Bl draw < 3 yrs other vein     N                               Covered
36410   Non-routine bl draw > 3 yrs    N                               Covered
36415   Routine venipuncture           A                     $3.00     Covered
36416   Capillary blood draw           N                               Covered
36420   Vein access cutdown < 1 yr     X   00035    0.2320             Covered
36425   Vein access cutdown > 1 yr     X   00035    0.2320             Covered
36430   Blood transfusion service      S   00110    3.3809             Covered
36440   Bl push transfuse, 2 yr or <   S   00110    3.3809             Covered
36450   Bl exchange/transfuse, nb      S   00110    3.3809             Covered
36455   Bl exchange/transfuse non-nb   S   00110    3.3809             Covered
36460   Transfusion service, fetal     S   00110    3.3809             Covered
36468   Injection(s), spider veins     T   00013    0.8789           Not Covered
36469   Injection(s), spider veins     T   00013    0.8789           Not Covered
36470   Injection therapy of vein      T   00013    0.8789             Covered
36471   Injection therapy of veins     T   00013    0.8789             Covered
36475   Endovenous rf, 1st vein        T   00091   45.0292             Covered
36476   Endovenous rf, vein add-on     T   00092   26.5713             Covered
36478   Endovenous laser, 1st vein     T   00092   26.5713             Covered
36479   Endovenous laser vein addon    T   00092   26.5713             Covered
36481   Insertion of catheter, vein    N                               Covered
36500   Insertion of catheter, vein    N                               Covered
3650F   Eeg ordered rvwd reqstd        E                             Not Covered
36510   Insertion of catheter, vein    N                               Covered
36511   Apheresis wbc                  S   00111   11.9424             Covered
36512   Apheresis rbc                  S   00111   11.9424             Covered
36513   Apheresis platelets            S   00111   11.9424             Covered
36514   Apheresis plasma               S   00111   11.9424             Covered
36515   Apheresis, adsorp/reinfuse     S   00112   33.3206             Covered
36516   Apheresis, selective           S   00112   33.3206             Covered
36522   Photopheresis                  S   00112   33.3206             Covered
36555   Insert non-tunnel cv cath      T   00621   11.1660             Covered
36556   Insert non-tunnel cv cath      T   00621   11.1660             Covered
36557   Insert tunneled cv cath        T   00622   25.3344             Covered
36558   Insert tunneled cv cath        T   00622   25.3344             Covered
36560   Insert tunneled cv cath        T   00623   30.4396             Covered
36561   Insert tunneled cv cath        T   00623   30.4396             Covered
36563   Insert tunneled cv cath        T   00623   30.4396             Covered
36565   Insert tunneled cv cath         T   00623   30.4396                Covered
36566   Insert tunneled cv cath         T   00623   30.4396                Covered
36568   Insert picc cath                T   00621   11.1660                Covered
36569   Insert picc cath                T   00621   11.1660                Covered
36570   Insert picvad cath              T   00622   25.3344                Covered
36571   Insert picvad cath              T   00622   25.3344                Covered
36575   Repair tunneled cv cath         T   00121    6.3742                Covered
36576   Repair tunneled cv cath         T   00621   11.1660                Covered
36578   Replace tunneled cv cath        T   00622   25.3344                Covered
36580   Replace cvad cath               T   00621   11.1660                Covered
36581   Replace tunneled cv cath        T   00622   25.3344                Covered
36582   Replace tunneled cv cath        T   00623   30.4396                Covered
36583   Replace tunneled cv cath        T   00623   30.4396                Covered
36584   Replace picc cath               T   00621   11.1660                Covered
36585   Replace picvad cath             T   00622   25.3344                Covered
36589   Removal tunneled cv cath        T   00121    6.3742                Covered
36590   Removal tunneled cv cath        T   00621   11.1660                Covered
36591   Draw blood off venous device   Q1   00624    0.6132                Covered
36592   Collect blood from picc        Q1   00624    0.6132                Covered
36593   Declot vascular device          T   00676    2.3954                Covered
36595   Mech remov tunneled cv cath     T   00622   25.3344                Covered
36596   Mech remov tunneled cv cath     T   00621   11.1660                Covered
36597   Reposition venous catheter      T   00621   11.1660                Covered
36598   Inj w/fluor, eval cv device     T   00676    2.3954                Covered
36600   Withdrawal of arterial blood   Q1   00035    0.2320                Covered
36620   Insertion catheter, artery      N                                  Covered
36625   Insertion catheter, artery      N                                  Covered
36640   Insertion catheter, artery      T   00623   30.4396                Covered
36660   Insertion catheter, artery      C                      $69.22      Covered
36680   Insert needle, bone cavity      T   00002    1.5111                Covered
36800   Insertion of cannula            T   00115   30.9784                Covered
36810   Insertion of cannula            T   00115   30.9784                Covered
36815   Insertion of cannula            T   00115   30.9784                Covered
36818   Av fuse, uppr arm, cephalic     T   00088   40.9003                Covered
36819   Av fuse, uppr arm, basilic      T   00088   40.9003                Covered
36820   Av fusion/forearm vein          T   00088   40.9003                Covered
36821   Av fusion direct any site       T   00088   40.9003                Covered
36822   Insertion of cannula(s)         C                      $490.07     Covered
36823   Insertion of cannula(s)         C                     $1,169.45    Covered
36825   Artery-vein autograft           T   00088   40.9003                Covered
36830   Artery-vein nonautograft        T   00088   40.9003                Covered
36831   Open thrombect av fistula       T   00088   40.9003                Covered
36832   Av fistula revision, open       T   00088   40.9003                Covered
36833   Av fistula revision             T   00088   40.9003                Covered
36834   Repair A-V aneurysm             D                                 Not Covered
36835   Artery to vein shunt            T   00115   30.9784                Covered
36838   Dist revas ligation, hemo       T   00088   40.9003                Covered
36860   External cannula declotting     T   00676    2.3954                Covered
36861   Cannula declotting              T   00115   30.9784                Covered
36870   Percut thrombect av fistula     T   00653   46.6883                Covered
37140   Revision of circulation         C                     $1,329.55    Covered
37145   Revision of circulation         C                     $1,390.86    Covered
37160   Revision of circulation        C                     $1,324.58    Covered
37180   Revision of circulation        C                     $1,398.98    Covered
37181   Splice spleen/kidney veins     C                     $1,521.13    Covered
37182   Insert hepatic shunt (tips)    C                      $844.03     Covered
37183   Remove hepatic shunt (tips)    T   00229   97.2910                Covered
37184   Prim art mech thrombectomy     T   00088   40.9003                Covered
37185   Prim art m-thrombect add-on    T   00088   40.9003                Covered
37186   Sec art m-thrombect add-on     T   00088   40.9003                Covered
37187   Venous mech thrombectomy       T   00088   40.9003                Covered
37188   Venous m-thrombectomy add-on   T   00088   40.9003                Covered
37195   Thrombolytic therapy, stroke   T   00676    2.3954                Covered
37200   Transcatheter biopsy           T   00623   30.4396                Covered
37201   Transcatheter therapy infuse   T   00103   17.8436                Covered
37202   Transcatheter therapy infuse   T   00103   17.8436                Covered
37203   Transcatheter retrieval        T   00623   30.4396                Covered
37204   Transcatheter occlusion        T   00082   93.3244                Covered
37205   Transcath iv stent, percut     T   00229   97.2910                Covered
37206   Transcath iv stent/perc addl   T   00229   97.2910                Covered
37207   Transcath iv stent, open       T   00229   97.2910                Covered
37208   Transcath iv stent/open addl   T   00229   97.2910                Covered
37209   Change iv cath at thromb tx    T   00623   30.4396                Covered
37210   Embolization uterine fibroid   T   00229   97.2910                Covered
37215   Transcath stent, cca w/eps     T   00229   97.2910                Covered
37216   Transcath stent, cca w/o eps   E                     $1,034.96    Covered
37250   Iv us first vessel add-on      N                                  Covered
37251   Iv us each add vessel add-on   N                                  Covered
37500   Endoscopy ligate perf veins    T   00091   45.0292                Covered
37501   Vascular endoscopy procedure   T   00092   26.5713                Covered
37565   Ligation of neck vein          T   00093   35.5969                Covered
37600   Ligation of neck artery        T   00093   35.5969                Covered
37605   Ligation of neck artery        T   00091   45.0292                Covered
37606   Ligation of neck artery        T   00092   26.5713                Covered
37607   Ligation of a-v fistula        T   00092   26.5713                Covered
37609   Temporal artery procedure      T   00021   17.4975                Covered
37615   Ligation of neck artery        T   00092   26.5713                Covered
37616   Ligation of chest artery       C                     $944.17      Covered
37617   Ligation of abdomen artery     C                     $895.06      Covered
37618   Ligation of extremity artery   C                     $339.46      Covered
37620   Revision of major vein         T   00091   45.0292                Covered
37650   Revision of major vein         T   00092   26.5713                Covered
37660   Revision of major vein         C                     $621.90      Covered
37700   Revise leg vein                T   00092   26.5713                Covered
37718   Ligate/strip short leg vein    T   00092   26.5713                Covered
37722   Ligate/strip long leg vein     T   00091   45.0292                Covered
37735   Removal of leg veins/lesion    T   00091   45.0292                Covered
37760   Ligation, leg veins, open      T   00092   26.5713                Covered
37761   Ligate leg veins open          T   00092   26.5713                Covered
37765   Phleb veins - extrem - to 20   T   00092   26.5713                Covered
37766   Phleb veins - extrem 20+       T   00092   26.5713               Not Covered
37780   Revision of leg vein           T   00092   26.5713                Covered
37785   Ligate/divide/excise vein      T   00092   26.5713                Covered
37788   Revascularization, penis       C                                 Not Covered
37790   Penile venous occlusion        T   00181   34.8837                Covered
37799   Vascular surgery procedure     X   00624    0.6132                Covered
38100   Removal of spleen, total       C                     $768.83      Covered
38101   Removal of spleen, partial     C                     $776.19      Covered
38102   Removal of spleen, total       C                     $263.01      Covered
38115   Repair of ruptured spleen      C                     $806.33      Covered
38120   Laparoscopy, splenectomy       T   00131   46.8400                Covered
38129   Laparoscope proc, spleen       T   00130   38.0540                Covered
38200   Injection for spleen x-ray     N                                  Covered
38204   Bl donor search management     N                                 Not Covered
38205   Harvest allogenic stem cells   B                                 Not Covered
38206   Harvest auto stem cells        S   00111   11.9424                Covered
38207   Cryopreserve stem cells        S   00110    3.3809               Not Covered
38208   Thaw preserved stem cells      S   00110    3.3809               Not Covered
38209   Wash harvest stem cells        S   00110    3.3809               Not Covered
38210   T-cell depletion of harvest    S   00393    5.7873               Not Covered
38211   Tumor cell deplete of harvst   S   00393    5.7873               Not Covered
38212   Rbc depletion of harvest       S   00393    5.7873               Not Covered
38213   Platelet deplete of harvest    S   00393    5.7873               Not Covered
38214   Volume deplete of harvest      S   00393    5.7873               Not Covered
38215   Harvest stem cell concentrte   S   00393    5.7873               Not Covered
38220   Bone marrow aspiration         T   00003    3.0998                Covered
38221   Bone marrow biopsy             T   00003    3.0998                Covered
38230   Bone marrow collection         S   00112   33.3206                Covered
38240   Bone marrow/stem transplant    S   00112   33.3206                Covered
38241   Bone marrow/stem transplant    S   00112   33.3206                Covered
38242   Lymphocyte infuse transplant   S   00111   11.9424                Covered
38300   Drainage, lymph node lesion    T   00007   12.6217                Covered
38305   Drainage, lymph node lesion    T   00008   19.4063                Covered
38308   Incision of lymph channels     T   00113   24.6146                Covered
38380   Thoracic duct procedure        C                     $495.54      Covered
38381   Thoracic duct procedure        C                     $851.51      Covered
38382   Thoracic duct procedure        C                     $628.58      Covered
38500   Biopsy/removal, lymph nodes    T   00113   24.6146                Covered
38505   Needle biopsy, lymph nodes     T   00005    7.8145                Covered
38510   Biopsy/removal, lymph nodes    T   00113   24.6146                Covered
38520   Biopsy/removal, lymph nodes    T   00113   24.6146                Covered
38525   Biopsy/removal, lymph nodes    T   00113   24.6146                Covered
38530   Biopsy/removal, lymph nodes    T   00113   24.6146                Covered
38542   Explore deep node(s), neck     T   00114   48.7561                Covered
38550   Removal, neck/armpit lesion    T   00113   24.6146                Covered
38555   Removal, neck/armpit lesion    T   00113   24.6146                Covered
38562   Removal, pelvic lymph nodes    C                     $632.07      Covered
38564   Removal, abdomen lymph nodes   C                     $656.45      Covered
38570   Laparoscopy, lymph node biop   T   00131   46.8400                Covered
38571   Laparoscopy, lymphadenectomy   T   00132   72.9582                Covered
38572   Laparoscopy, lymphadenectomy   T   00131   46.8400                Covered
38589   Laparoscope proc, lymphatic    T   00130   38.0540                Covered
38700   Removal of lymph nodes, neck   T   00113   24.6146                Covered
38720   Removal of lymph nodes, neck   T   00113   24.6146                Covered
38724   Removal of lymph nodes, neck   C                     $1,074.35    Covered
38740   Remove armpit lymph nodes      T   00114   48.7561                Covered
38745   Remove armpit lymph nodes       T   00114   48.7561                 Covered
38746   Remove thoracic lymph nodes     C                     $245.69       Covered
38747   Remove abdominal lymph nodes    C                     $266.91       Covered
38760   Remove groin lymph nodes        T   00113   24.6146                 Covered
38765   Remove groin lymph nodes        C                     $1,012.92     Covered
38770   Remove pelvis lymph nodes       C                      $878.54      Covered
38780   Remove abdomen lymph nodes      C                     $1,072.23     Covered
38790   Inject for lymphatic x-ray      N                                   Covered
38792   Identify sentinel node         Q1   00392    2.6817                 Covered
38794   Access thoracic lymph duct      N                                   Covered
38999   Blood/lymph system procedure    S   00110    3.3809                 Covered
39000   Exploration of chest            C                      $517.79      Covered
39010   Exploration of chest            C                      $896.26      Covered
39200   Removal chest lesion            C                      $977.59      Covered
39220   Removal chest lesion            C                     $1,207.23     Covered
39400   Visualization of chest          T   00069   34.0084                 Covered
39499   Chest procedure                 C                                  By Report
39501   Repair diaphragm laceration     C                      $852.14      Covered
39502   Repair paraesophageal hernia    C                      $999.96      Covered
39503   Repair of diaphragm hernia      C                     $2,159.20     Covered
39520   Repair of diaphragm hernia      C                     $1,056.43     Covered
39530   Repair of diaphragm hernia      C                     $1,017.74     Covered
39531   Repair of diaphragm hernia      C                      $979.41      Covered
39540   Repair of diaphragm hernia      C                      $890.77      Covered
39541   Repair of diaphragm hernia      C                      $927.79      Covered
39545   Revision of diaphragm           C                      $865.30      Covered
39560   Resect diaphragm, simple        C                      $762.59      Covered
39561   Resect diaphragm, complex       C                     $1,047.64     Covered
39599   Diaphragm surgery procedure     C                                  By Report
4000F   Tobacco use txmnt counseling   M                                  Not Covered
4001F   Tobacco use txmnt, pharmacol   M                                  Not Covered
4002F   Statin therapy, rx             M                                  Not Covered
4003F   Pt ed write/oral, pts w/ hf    M                                  Not Covered
4004F   Pt tobacco use done rcvd tlk   E                                  Not Covered
4005F   Pharm thx for op rx'd          M                                  Not Covered
4006F   Beta-blocker therapy rx        M                                  Not Covered
4009F   Ace/arb inhibitor therapy rx   M                                  Not Covered
4011F   Oral antiplatelet therapy rx   M                                  Not Covered
4012F   Warfarin therapy rx            M                                  Not Covered
4014F   Written discharge instr prvd   M                                  Not Covered
4015F   Persist asthma medicine ctrl   M                                  Not Covered
4016F   Anti-inflm/anlgsc agent rx     M                                  Not Covered
4017F   Gi prophylaxis for nsaid rx    M                                  Not Covered
4018F   Therapy exercise joint rx      M                                  Not Covered
4019F   Doc recpt counsl vit d/calc+   M                                  Not Covered
4025F   Inhaled bronchodilator rx      M                                  Not Covered
4025F   Inhaled bronchodilator rx      M                                  Not Covered
4030F   Oxygen therapy rx              M                                  Not Covered
4030F   Oxygen therapy rx              M                                  Not Covered
4033F   Pulmonary rehab rec            M                                  Not Covered
4033F   Pulmonary rehab rec            M                                  Not Covered
4035F   Influenza imm rec              M                                  Not Covered
4035F   Influenza imm rec              M                     Not Covered
4037F   Influenza imm order/admin      M                     Not Covered
4037F   Influenza imm order/admin      M                     Not Covered
4040F   Pneumoc vac/admin/rcvd         M                     Not Covered
4040F   Pneumoc vac/admin/rcvd         M                     Not Covered
4041F   Doc order cefazolin/cefurox    M                     Not Covered
4042F   Doc antibio not given          M                     Not Covered
4043F   Doc order given stop antibio   M                     Not Covered
4044F   Doc order given vte prophylx   M                     Not Covered
4045F   Empiric antibiotic rx          M                     Not Covered
4045F   Empiric antibiotic rx          M                     Not Covered
4046F   Doc antibio given b/4 surg     M                     Not Covered
4047F   Doc antibio given b/4 surg     M                     Not Covered
4048F   Doc antibio given b/4 surg     M                     Not Covered
40490   Biopsy of lip                  T   00251    3.4250    Covered
4049F   Doc order given stop antibio   M                     Not Covered
40500   Partial excision of lip        T   00253   17.1879    Covered
4050F   Ht care plan doc               M                     Not Covered
4050F   Ht care plan doc               M                     Not Covered
40510   Partial excision of lip        T   00254   24.9637    Covered
4051F   Referred for an AV fistula     M                     Not Covered
40520   Partial excision of lip        T   00253   17.1879    Covered
40525   Reconstruct lip with flap      T   00254   24.9637    Covered
40527   Reconstruct lip with flap      T   00254   24.9637    Covered
4052F   Hemodialysis via AV fistula    M                     Not Covered
40530   Partial removal of lip         T   00254   24.9637    Covered
4053F   Hemodialysis via AV graft      M                     Not Covered
4054F   Hemodialysis via catheter      M                     Not Covered
4055F   Pt. rcvng periton dialysis     M                     Not Covered
4056F   Approp. oral rehyd. recomm'd   M                     Not Covered
4058F   Ped gastro ed given, caregvr   M                     Not Covered
4060F   Psych svcs provided            M                     Not Covered
4062F   Pt referral psych doc'd        M                     Not Covered
4063F   Antidepres rxthxpy not rxd     E                     Not Covered
4064F   Antidepressant rx              M                     Not Covered
40650   Repair lip                     T   00252    7.6196    Covered
40652   Repair lip                     T   00252    7.6196    Covered
40654   Repair lip                     T   00252    7.6196    Covered
4065F   Antipsychotic rx               M                     Not Covered
4066F   ECT provided                   M                     Not Covered
4067F   Pt referral for ECT doc'd      M                     Not Covered
40700   Repair cleft lip/nasal         T   00256   42.9827    Covered
40701   Repair cleft lip/nasal         T   00256   42.9827    Covered
40702   Repair cleft lip/nasal         T   00256   42.9827    Covered
4070F   Dvt prophylx recv'd day 2      M                     Not Covered
40720   Repair cleft lip/nasal         T   00256   42.9827    Covered
4073F   Oral antiplat thx rx dischrg   M                     Not Covered
4075F   Anticoag thx rx at dischrg     M                     Not Covered
40761   Repair cleft lip/nasal         T   00256   42.9827    Covered
4077F   Doc t-pa admin considered      M                     Not Covered
40799   Lip surgery procedure          T   00250    1.1522    Covered
4079F   Doc rehab svcs considered      M                     Not Covered
40800   Drainage of mouth lesion       T   00006    1.4557    Covered
40801   Drainage of mouth lesion       T   00252    7.6196    Covered
40804   Removal, foreign body, mouth   X   00340    0.6693    Covered
40805   Removal, foreign body, mouth   T   00252    7.6196    Covered
40806   Incision of lip fold           T   00251    3.4250    Covered
40808   Biopsy of mouth lesion         T   00251    3.4250    Covered
40810   Excision of mouth lesion       T   00253   17.1879    Covered
40812   Excise/repair mouth lesion     T   00253   17.1879    Covered
40814   Excise/repair mouth lesion     T   00253   17.1879    Covered
40816   Excision of mouth lesion       T   00254   24.9637    Covered
40818   Excise oral mucosa for graft   T   00251    3.4250    Covered
40819   Excise lip or cheek fold       T   00252    7.6196    Covered
40820   Treatment of mouth lesion      T   00253   17.1879    Covered
40830   Repair mouth laceration        T   00251    3.4250    Covered
40831   Repair mouth laceration        T   00252    7.6196    Covered
40840   Reconstruction of mouth        T   00254   24.9637    Covered
40842   Reconstruction of mouth        T   00254   24.9637    Covered
40843   Reconstruction of mouth        T   00254   24.9637    Covered
40844   Reconstruction of mouth        T   00256   42.9827    Covered
40845   Reconstruction of mouth        T   00256   42.9827    Covered
4084F   Aspirin recv'd w/in 24 hrs     M                     Not Covered
40899   Mouth surgery procedure        T   00250    1.1522    Covered
4090F   Pt rcvng epo thxpy             M                     Not Covered
4090F   Pt rcvng epo thxpy             M                     Not Covered
4095F   Pt not rcvng epo thxpy         M                     Not Covered
4095F   Pt not rcvng epo thxpy         M                     Not Covered
41000   Drainage of mouth lesion       T   00253   17.1879    Covered
41005   Drainage of mouth lesion       T   00251    3.4250    Covered
41006   Drainage of mouth lesion       T   00254   24.9637    Covered
41007   Drainage of mouth lesion       T   00253   17.1879    Covered
41008   Drainage of mouth lesion       T   00253   17.1879    Covered
41009   Drainage of mouth lesion       T   00251    3.4250    Covered
4100F   Biphos thxpy vein ord/rec'vd   M                     Not Covered
4100F   Biphos thxpy vein ord/recvd    M                     Not Covered
41010   Incision of tongue fold        T   00252    7.6196    Covered
41015   Drainage of mouth lesion       T   00251    3.4250    Covered
41016   Drainage of mouth lesion       T   00252    7.6196    Covered
41017   Drainage of mouth lesion       T   00252    7.6196    Covered
41018   Drainage of mouth lesion       T   00252    7.6196    Covered
41019   Place needles h&n for rt       T   00254   24.9637    Covered
41100   Biopsy of tongue               T   00252    7.6196    Covered
41105   Biopsy of tongue               T   00253   17.1879    Covered
41108   Biopsy of floor of mouth       T   00019    4.3625    Covered
4110F   Int. mam art used for cabg     M                     Not Covered
4110F   Int mam art used for cabg      M                     Not Covered
41110   Excision of tongue lesion      T   00253   17.1879    Covered
41112   Excision of tongue lesion      T   00253   17.1879    Covered
41113   Excision of tongue lesion      T   00253   17.1879    Covered
41114   Excision of tongue lesion      T   00254   24.9637    Covered
41115   Excision of tongue fold        T   00252    7.6196    Covered
41116   Excision of mouth lesion       T   00253   17.1879    Covered
41120   Partial removal of tongue      T   00254   24.9637    Covered
41130   Partial removal of tongue      C                      $739.87     Covered
41135   Tongue and neck surgery        C                     $1,477.37    Covered
41140   Removal of tongue              C                     $1,586.36    Covered
41145   Tongue removal, neck surgery   C                     $1,902.65    Covered
41150   Tongue, mouth, jaw surgery     C                     $1,498.79    Covered
41153   Tongue, mouth, neck surgery    C                     $1,647.78    Covered
41155   Tongue, jaw, & neck surgery    C                     $1,929.63    Covered
4115F   Beta blckr admin w/in 24 hrs   M                                 Not Covered
4115F   Beta blckr admin w/in 24 hrs   M                                 Not Covered
4120F   Antibiot rx'd/given            M                                 Not Covered
4120F   Antibiot rxd/given             M                                 Not Covered
4124F   Antibiot not rx'd/given        M                                 Not Covered
4124F   Antibiot not rxd/given         M                                 Not Covered
41250   Repair tongue laceration       T   00250    1.1522                Covered
41251   Repair tongue laceration       T   00251    3.4250                Covered
41252   Repair tongue laceration       T   00252    7.6196                Covered
4130F   Topical prep rx aoe            M                                 Not Covered
4131F   Syst antimicrobial thx rx      M                                 Not Covered
4132F   No syst antimicrobial thx rx   M                                 Not Covered
4133F   Antihist/decong rx/recom       M                                 Not Covered
4134F   No antihist/decong rx/recom    M                                 Not Covered
4135F   Systemic corticosteroids rx    M                                 Not Covered
4136F   Syst corticosteroids not rx    M                                 Not Covered
4148F   Hep A vac injxn admin/recvd    M                                 Not Covered
4149F   Hep B vac injxn admin/recvd    M                                 Not Covered
41500   Fixation of tongue             T   00254   24.9637                Covered
4150F   Pt recvng antivir txmnt hepc   M                                 Not Covered
41510   Tongue to lip surgery          T   00253   17.1879                Covered
41512   Tongue suspension              T   00252    7.6196                Covered
4151F   Pt not recvng antiv hep c      M                                 Not Covered
41520   Reconstruction, tongue fold    T   00252    7.6196                Covered
4152F   Docd pegintf/rib thxy consd    D                                 Not Covered
41530   Tongue base vol reduction      T   00254   24.9637                Covered
4153F   Combo pegintf/rib rx           M                                 Not Covered
4154F   Hep A vac series recommended   D                                 Not Covered
4155F   Hep A vac series prev recvd    M                                 Not Covered
4156F   Hep B vac series recommended   D                                 Not Covered
4157F   Hep B vac series prev recvd    M                                 Not Covered
4158F   Pt edu re alcoh drnkng done    M                                 Not Covered
41599   Tongue and mouth surgery       T   00250    1.1522                Covered
4159F   Contrcp talk b/4 antiv txmnt   M                                 Not Covered
4163F   Pt couns 4 txmnt opt prost     M                                 Not Covered
4164F   Adjv hrmnl thxpy rxd           M                                 Not Covered
4165F   3d-crt/imrt received           M                                 Not Covered
4167F   Hd bed tilted 1st day vent     M                                 Not Covered
4168F   Pt care icu&vent w/in 24hrs    M                                 Not Covered
4169F   No pt care ICU/vent in 24hrs   M                                 Not Covered
4171F   Pt rcvng esa thxpy             M                                 Not Covered
4172F   Pt. not rcvng esa thxpy        M                                 Not Covered
4174F   Couns potent glauc impct       M                                 Not Covered
4175F   Vis of >= 20/40 w/in 90 days   M                                 Not Covered
4176F   Talk re uv light pt/crgvr      M                                 Not Covered
4177F   Talk pt/crgvr re areds prev    M                     Not Covered
4178F   Antid glbln rcvd w/in 26wks    M                     Not Covered
4179F   Tamoxifen/AI prescribed        M                     Not Covered
41800   Drainage of gum lesion         T   00006    1.4557    Covered
41805   Removal foreign body, gum      T   00254   24.9637    Covered
41806   Removal foreign body,jawbone   T   00253   17.1879    Covered
4180F   Adjv thxpyrxd/rcvd stg3a-c     M                     Not Covered
4181F   Conformal rad'n thxpy rcv'd    M                     Not Covered
41820   Excision, gum, each quadrant   T   00252    7.6196    Covered
41821   Excision of gum flap           T   00252    7.6196    Covered
41822   Excision of gum lesion         T   00253   17.1879    Covered
41823   Excision of gum lesion         T   00254   24.9637    Covered
41825   Excision of gum lesion         T   00253   17.1879    Covered
41826   Excision of gum lesion         T   00254   24.9637    Covered
41827   Excision of gum lesion         T   00254   24.9637    Covered
41828   Excision of gum lesion         T   00253   17.1879    Covered
4182F   No conformal radn thxpy        M                     Not Covered
41830   Removal of gum tissue          T   00253   17.1879    Covered
41850   Treatment of gum lesion        T   00253   17.1879    Covered
4185F   Continuous ppi or h2ra rcvd    M                     Not Covered
4186F   No cont ppi or h2ra rcvd       M                     Not Covered
41870   Gum graft                      T   00254   24.9637    Covered
41872   Repair gum                     T   00253   17.1879    Covered
41874   Repair tooth socket            T   00254   24.9637    Covered
4187F   Anti rheum drugthxpyrxd/gvn    M                     Not Covered
4188F   Approp ACE/ARB tstng done      M                     Not Covered
41899   Dental surgery procedure       T   00250    1.1522    Covered
4189F   Approp digoxin tstng done      M                     Not Covered
4190F   Approp diuretic tstng done     M                     Not Covered
4191F   Approp anticonvuls tstng       M                     Not Covered
4192F   Pt not rcvng glucoco thxpy     M                     Not Covered
4193F   Pt rcvng<10mg daily predniso   M                     Not Covered
4194F   Pt rcvng>10mg daily predniso   M                     Not Covered
4195F   Pt rcvng anti-rheum thxpy RA   M                     Not Covered
4196F   Ptnot rcvng anti-rhm thxpyRA   M                     Not Covered
42000   Drainage mouth roof lesion     T   00251    3.4250    Covered
4200F   External beam to prost only    M                     Not Covered
4201F   Extrnl beam other than prost   M                     Not Covered
42100   Biopsy roof of mouth           T   00252    7.6196    Covered
42104   Excision lesion, mouth roof    T   00253   17.1879    Covered
42106   Excision lesion, mouth roof    T   00253   17.1879    Covered
42107   Excision lesion, mouth roof    T   00254   24.9637    Covered
4210F   ACE/ARB thxpy for >= 6 mons    M                     Not Covered
42120   Remove palate/lesion           T   00256   42.9827    Covered
42140   Excision of uvula              T   00252    7.6196    Covered
42145   Repair palate, pharynx/uvula   T   00254   24.9637    Covered
42160   Treatment mouth roof lesion    T   00253   17.1879    Covered
42180   Repair palate                  T   00251    3.4250    Covered
42182   Repair palate                  T   00256   42.9827    Covered
42200   Reconstruct cleft palate       T   00256   42.9827    Covered
42205   Reconstruct cleft palate       T   00256   42.9827    Covered
4220F   Digoxin thxpy for >= 6 mons    M                     Not Covered
42210   Reconstruct cleft palate       T   00256   42.9827                Covered
42215   Reconstruct cleft palate       T   00256   42.9827                Covered
4221F   Diuretic thxpy for >= 6 mons   M                                 Not Covered
42220   Reconstruct cleft palate       T   00256   42.9827                Covered
42225   Reconstruct cleft palate       T   00256   42.9827                Covered
42226   Lengthening of palate          T   00256   42.9827                Covered
42227   Lengthening of palate          T   00256   42.9827                Covered
42235   Repair palate                  T   00253   17.1879                Covered
42260   Repair nose to lip fistula     T   00254   24.9637                Covered
42280   Preparation, palate mold       T   00251    3.4250               Not Covered
42281   Insertion, palate prosthesis   T   00253   17.1879                Covered
42299   Palate/uvula surgery           T   00250    1.1522                Covered
42300   Drainage of salivary gland     T   00253   17.1879                Covered
42305   Drainage of salivary gland     T   00253   17.1879                Covered
4230F   Anticonv thxpy for >= 6 mons   M                                 Not Covered
42310   Drainage of salivary gland     T   00251    3.4250                Covered
42320   Drainage of salivary gland     T   00251    3.4250                Covered
42330   Removal of salivary stone      T   00253   17.1879                Covered
42335   Removal of salivary stone      T   00253   17.1879                Covered
42340   Removal of salivary stone      T   00253   17.1879                Covered
42400   Biopsy of salivary gland       T   00005    7.8145                Covered
42405   Biopsy of salivary gland       T   00254   24.9637                Covered
42408   Excision of salivary cyst      T   00253   17.1879                Covered
42409   Drainage of salivary cyst      T   00253   17.1879                Covered
4240F   Instr xrcz 4bk pn >12 weeks    M                                 Not Covered
42410   Excise parotid gland/lesion    T   00256   42.9827                Covered
42415   Excise parotid gland/lesion    T   00256   42.9827                Covered
42420   Excise parotid gland/lesion    T   00256   42.9827                Covered
42425   Excise parotid gland/lesion    T   00256   42.9827                Covered
42426   Excise parotid gland/lesion    C                     $1,483.12    Covered
4242F   Sprvsd xrcz bk pn >12 weeks    M                                 Not Covered
42440   Excise submaxillary gland      T   00256   42.9827                Covered
42450   Excise sublingual gland        T   00254   24.9637                Covered
4245F   Pt instr nrml lifest           M                                 Not Covered
4248F   Pt instr-no bd rest>= 4 days   M                                 Not Covered
42500   Repair salivary duct           T   00254   24.9637                Covered
42505   Repair salivary duct           T   00256   42.9827                Covered
42507   Parotid duct diversion         T   00256   42.9827                Covered
42508   Parotid duct diversion         T   00256   42.9827                Covered
42509   Parotid duct diversion         T   00256   42.9827                Covered
4250F   Wrmng 4 surg - normothermia    M                                 Not Covered
42510   Parotid duct diversion         T   00256   42.9827                Covered
42550   Injection for salivary x-ray   N                                  Covered
4255F   Anesth >= 60 min as docd       M                                 Not Covered
4256F   Anesth < 60 min as docd        M                                 Not Covered
42600   Closure of salivary fistula    T   00253   17.1879                Covered
4260F   Wound srfc culturetech used    E                                 Not Covered
4261F   Tech other than surfc cultr    E                                 Not Covered
42650   Dilation of salivary duct      T   00252    7.6196                Covered
4265F   Wet-dry dressings Rx-recmd     E                                 Not Covered
42660   Dilation of salivary duct      T   00251    3.4250                Covered
42665   Ligation of salivary duct      T   00254   24.9637                Covered
4266F   No Wet-dry drssings Rx-recmd   E                                 Not Covered
4267F   Comprssion thxpy prescribed    M                                 Not Covered
4268F   Pt ed re comp thxpy rcvd       E                                 Not Covered
42699   Salivary surgery procedure     T   00250    1.1522                Covered
4269F   Appropos mthd offloading Rxd   E                                 Not Covered
42700   Drainage of tonsil abscess     T   00251    3.4250                Covered
4270F   Pt rcvng anti r-viral thxpy    E                                 Not Covered
4271F   Pt rcvng anti r-viral thxpy    M                                 Not Covered
42720   Drainage of throat abscess     T   00253   17.1879                Covered
42725   Drainage of throat abscess     T   00256   42.9827                Covered
4274F   Flu immuno admin'd rcvd        M                                 Not Covered
4275F   Hep B vac inj admin/rcvd       E                                 Not Covered
4276F   Potent antivir thxpy Rxd       M                                 Not Covered
4279F   PCP prophylaxis Rxd            E                                 Not Covered
42800   Biopsy of throat               T   00253   17.1879                Covered
42802   Biopsy of throat               T   00253   17.1879                Covered
42804   Biopsy of upper nose/throat    T   00253   17.1879                Covered
42806   Biopsy of upper nose/throat    T   00254   24.9637                Covered
42808   Excise pharynx lesion          T   00254   24.9637                Covered
42809   Remove pharynx foreign body    X   00340    0.6693                Covered
4280F   PCP prophylax Rxd 3mon low %   E                                 Not Covered
42810   Excision of neck cyst          T   00254   24.9637                Covered
42815   Excision of neck cyst          T   00256   42.9827                Covered
42820   Remove tonsils and adenoids    T   00254   24.9637                Covered
42821   Remove tonsils and adenoids    T   00254   24.9637                Covered
42825   Removal of tonsils             T   00254   24.9637                Covered
42826   Removal of tonsils             T   00254   24.9637                Covered
42830   Removal of adenoids            T   00254   24.9637                Covered
42831   Removal of adenoids            T   00254   24.9637                Covered
42835   Removal of adenoids            T   00254   24.9637                Covered
42836   Removal of adenoids            T   00254   24.9637                Covered
42842   Extensive surgery of throat    T   00254   24.9637                Covered
42844   Extensive surgery of throat    T   00256   42.9827                Covered
42845   Extensive surgery of throat    C                     $1,548.00    Covered
42860   Excision of tonsil tags        T   00254   24.9637                Covered
42870   Excision of lingual tonsil     T   00254   24.9637                Covered
42890   Partial removal of pharynx     T   00256   42.9827                Covered
42892   Revision of pharyngeal walls   T   00256   42.9827                Covered
42894   Revision of pharyngeal walls   C                     $1,443.04    Covered
42900   Repair throat wound            T   00252    7.6196                Covered
4290F   Pt scrned for inj drug use     M                                 Not Covered
4293F   Pt scrnd - hgh-rsk sex behav   M                                 Not Covered
42950   Reconstruction of throat       T   00254   24.9637                Covered
42953   Repair throat, esophagus       C                     $593.19      Covered
42955   Surgical opening of throat     T   00254   24.9637                Covered
42960   Control throat bleeding        T   00250    1.1522                Covered
42961   Control throat bleeding        C                     $325.10      Covered
42962   Control throat bleeding        T   00256   42.9827                Covered
42970   Control nose/throat bleeding   T   00250    1.1522                Covered
42971   Control nose/throat bleeding   C                     $373.76      Covered
42972   Control nose/throat bleeding   T   00253   17.1879                Covered
42999   Throat surgery procedure       T   00250    1.1522                Covered
4300F   Pt rcvng warf thxpy            E                                 Not Covered
4301F   Pt not rcvng warf thxpy        E                                 Not Covered
43020   Incision of esophagus          T   00252    7.6196                Covered
43030   Throat muscle surgery          T   00253   17.1879                Covered
43045   Incision of esophagus          C                     $1,238.29    Covered
4305F   Pt ed re ft care inspct rcvd   E                                 Not Covered
4306F   Pt tlk psych & Rx opd addic    E                                 Not Covered
43100   Excision of esophagus lesion   C                      $586.07     Covered
43101   Excision of esophagus lesion   C                      $982.45     Covered
43107   Removal of esophagus           C                     $1,827.18    Covered
43108   Removal of esophagus           C                     $2,097.13    Covered
43112   Removal of esophagus           C                     $1,943.29    Covered
43113   Removal of esophagus           C                     $2,166.25    Covered
43116   Partial removal of esophagus   C                     $1,977.67    Covered
43117   Partial removal of esophagus   C                     $1,939.40    Covered
43118   Partial removal of esophagus   C                     $2,054.19    Covered
43121   Partial removal of esophagus   C                     $1,846.49    Covered
43122   Partial removal of esophagus   C                     $1,800.29    Covered
43123   Partial removal of esophagus   C                     $2,094.12    Covered
43124   Removal of esophagus           C                     $1,763.29    Covered
43130   Removal of esophagus pouch     T   00256   42.9827                Covered
43135   Removal of esophagus pouch     C                     $1,045.98    Covered
43200   Esophagus endoscopy            T   00141    8.7462                Covered
43201   Esoph scope w/submucous inj    T   00141    8.7462                Covered
43202   Esophagus endoscopy, biopsy    T   00141    8.7462                Covered
43204   Esoph scope w/sclerosis inj    T   00141    8.7462                Covered
43205   Esophagus endoscopy/ligation   T   00141    8.7462                Covered
4320F   Pt talk psychsoc+rx oh dpnd    E                                 Not Covered
43215   Esophagus endoscopy            T   00141    8.7462                Covered
43216   Esophagus endoscopy/lesion     T   00141    8.7462                Covered
43217   Esophagus endoscopy            T   00141    8.7462                Covered
43219   Esophagus endoscopy            T   00384   26.4913                Covered
43220   Esoph endoscopy, dilation      T   00141    8.7462                Covered
43226   Esoph endoscopy, dilation      T   00141    8.7462                Covered
43227   Esoph endoscopy, repair        T   00141    8.7462                Covered
43228   Esoph endoscopy, ablation      T   00422   24.2703                Covered
43231   Esoph endoscopy w/us exam      T   00141    8.7462                Covered
43232   Esoph endoscopy w/us fn bx     T   00141    8.7462                Covered
43234   Upper GI endoscopy, exam       T   00141    8.7462                Covered
43235   Uppr gi endoscopy, diagnosis   T   00141    8.7462                Covered
43236   Uppr gi scope w/submuc inj     T   00141    8.7462                Covered
43237   Endoscopic us exam, esoph      T   00141    8.7462                Covered
43238   Uppr gi endoscopy w/us fn bx   T   00141    8.7462                Covered
43239   Upper GI endoscopy, biopsy     T   00141    8.7462                Covered
43240   Esoph endoscope w/drain cyst   T   00141    8.7462                Covered
43241   Upper GI endoscopy with tube   T   00141    8.7462                Covered
43242   Uppr gi endoscopy w/us fn bx   T   00141    8.7462                Covered
43243   Upper gi endoscopy & inject    T   00141    8.7462                Covered
43244   Upper GI endoscopy/ligation    T   00141    8.7462                Covered
43245   Uppr gi scope dilate strictr   T   00141    8.7462                Covered
43246   Place gastrostomy tube         T   00141    8.7462                Covered
43247   Operative upper GI endoscopy   T   00141    8.7462                Covered
43248   Uppr gi endoscopy/guide wire   T   00141    8.7462                Covered
43249   Esoph endoscopy, dilation      T   00141    8.7462                Covered
43250   Upper GI endoscopy/tumor       T   00141    8.7462                Covered
43251   Operative upper GI endoscopy   T   00141    8.7462                Covered
43255   Operative upper GI endoscopy   T   00141    8.7462                Covered
43256   Uppr gi endoscopy w/stent      T   00384   26.4913                Covered
43257   Uppr gi scope w/thrml txmnt    T   00422   24.2703                Covered
43258   Operative upper GI endoscopy   T   00141    8.7462                Covered
43259   Endoscopic ultrasound exam     T   00141    8.7462                Covered
43260   Endo cholangiopancreatograph   T   00151   22.6111                Covered
43261   Endo cholangiopancreatograph   T   00151   22.6111                Covered
43262   Endo cholangiopancreatograph   T   00151   22.6111                Covered
43263   Endo cholangiopancreatograph   T   00151   22.6111                Covered
43264   Endo cholangiopancreatograph   T   00151   22.6111                Covered
43265   Endo cholangiopancreatograph   T   00151   22.6111                Covered
43267   Endo cholangiopancreatograph   T   00151   22.6111                Covered
43268   Endo cholangiopancreatograph   T   00384   26.4913                Covered
43269   Endo cholangiopancreatograph   T   00384   26.4913                Covered
43271   Endo cholangiopancreatograph   T   00151   22.6111                Covered
43272   Endo cholangiopancreatograph   T   00151   22.6111                Covered
43273   Endoscopic pancreatoscopy      T   00151   22.6111                Covered
43279   Lap myotomy, heller            C                     $1,087.70    Covered
43280   Laparoscopy, fundoplasty       T   00132   72.9582                Covered
43281   Lap paraesophag hern repair    C                     $1,367.19    Covered
43282   Lap paraesoph her rpr w/mesh   C                     $1,537.86    Covered
43289   Laparoscope proc, esoph        T   00130   38.0540                Covered
43300   Repair of esophagus            C                      $657.34     Covered
43305   Repair esophagus and fistula   C                     $1,127.71    Covered
4330F   Cnslng epi spec sfty issues    E                                 Not Covered
43310   Repair of esophagus            C                     $1,682.66    Covered
43312   Repair esophagus and fistula   C                     $1,835.64    Covered
43313   Esophagoplasty congenital      C                     $2,557.69    Covered
43314   Tracheo-esophagoplasty cong    C                     $2,815.61    Covered
43320   Fuse esophagus & stomach       C                     $1,022.25    Covered
43324   Revise esophagus & stomach     C                     $1,009.57    Covered
43325   Revise esophagus & stomach     C                      $993.94     Covered
43326   Revise esophagus & stomach     C                      $943.25     Covered
43330   Repair of esophagus            C                      $974.87     Covered
43331   Repair of esophagus            C                     $1,082.53    Covered
43340   Fuse esophagus & intestine     C                     $1,016.04    Covered
43341   Fuse esophagus & intestine     C                     $1,067.55    Covered
43350   Surgical opening, esophagus    C                      $778.03     Covered
43351   Surgical opening, esophagus    C                      $927.29     Covered
43352   Surgical opening, esophagus    C                      $808.49     Covered
43360   Gastrointestinal repair        C                     $1,794.09    Covered
43361   Gastrointestinal repair        C                     $2,045.82    Covered
43400   Ligate esophagus veins         C                      $999.34     Covered
43401   Esophagus surgery for veins    C                     $1,026.67    Covered
43405   Ligate/staple esophagus        C                     $1,045.54    Covered
4340F   Cnslng chldbrng+ women epi     E                                 Not Covered
43410   Repair esophagus wound         C                      $743.05     Covered
43415   Repair esophagus wound         C                     $1,087.01    Covered
43420   Repair esophagus opening       T   00254   24.9637                Covered
43425   Repair esophagus opening       C                     $1,051.58    Covered
43450   Dilate esophagus               T   00140    5.9622                Covered
43453   Dilate esophagus               T   00140    5.9622                Covered
43456   Dilate esophagus               T   00140    5.9622                Covered
43458   Dilate esophagus               T   00141    8.7462                Covered
43460   Pressure treatment esophagus   C                     $200.14      Covered
43496   Free jejunum flap, microvasc   C                                 By Report
43499   Esophagus surgery procedure    T   00141    8.7462                Covered
43500   Surgical opening of stomach    C                     $512.19      Covered
43501   Surgical repair of stomach     C                     $873.79      Covered
43502   Surgical repair of stomach     C                     $986.62      Covered
43510   Surgical opening of stomach    T   00141    8.7462                Covered
43520   Incision of pyloric muscle     C                     $471.03      Covered
43600   Biopsy of stomach              T   00141    8.7462                Covered
43605   Biopsy of stomach              C                      $541.71     Covered
43610   Excision of stomach lesion     C                      $678.88     Covered
43611   Excision of stomach lesion     C                      $791.51     Covered
43620   Removal of stomach             C                     $1,335.04    Covered
43621   Removal of stomach             C                     $1,356.65    Covered
43622   Removal of stomach             C                     $1,420.66    Covered
43631   Removal of stomach, partial    C                     $1,141.32    Covered
43632   Removal of stomach, partial    C                     $1,140.08    Covered
43633   Removal of stomach, partial    C                     $1,159.70    Covered
43634   Removal of stomach, partial    C                     $1,405.92    Covered
43635   Removal of stomach, partial    C                      $112.93     Covered
43640   Vagotomy & pylorus repair      C                      $883.29     Covered
43641   Vagotomy & pylorus repair      C                      $898.43     Covered
43644   Lap gastric bypass/roux-en-y   C                     $1,601.92    Covered
43645   Lap gastr bypass incl smll i   C                     $1,674.05    Covered
43647   Lap impl electrode, antrum     S   00061   86.5171                Covered
43648   Lap revise/remv eltrd antrum   T   00130   38.0540                Covered
43651   Laparoscopy, vagus nerve       T   00132   72.9582                Covered
43652   Laparoscopy, vagus nerve       T   00132   72.9582                Covered
43653   Laparoscopy, gastrostomy       T   00131   46.8400                Covered
43659   Laparoscope proc, stom         T   00130   38.0540                Covered
43752   Nasal/orogastric w/stent       X   00272    1.2693                Covered
43760   Change gastrostomy tube        T   00676    2.3954                Covered
43761   Reposition gastrostomy tube    T   00141    8.7462                Covered
43770   Lap place gastr adj device     C                     $1,601.92    Covered
43771   Lap revise gastr adj device    C                     $1,601.92    Covered
43772   Lap rmvl gastr adj device      C                     $1,601.92    Covered
43773   Lap replace gastr adj device   C                     $1,601.92    Covered
43774   Lap rmvl gastr adj all parts   C                     $1,601.92    Covered
43775   Lap sleeve gastrectomy         C                     $1,146.98    Covered
43800   Reconstruction of pylorus      C                      $625.83     Covered
43810   Fusion of stomach and bowel    C                      $668.28     Covered
43820   Fusion of stomach and bowel    C                      $706.99     Covered
43825   Fusion of stomach and bowel    C                      $889.80     Covered
43830   Place gastrostomy tube         T   00422   24.2703                Covered
43831   Place gastrostomy tube         T   00141    8.7462                Covered
43832   Place gastrostomy tube         C                     $713.74      Covered
43840   Repair of stomach lesion       C                      $705.24      Covered
43842   V-band gastroplasty            E                      $990.22      Covered
43843   Gastroplasty w/o v-band        C                      $982.42      Covered
43845   Gastroplasty duodenal switch   C                     $1,203.82     Covered
43846   Gastric bypass for obesity     C                     $1,203.82     Covered
43847   Gastric bypass incl small i    C                     $1,323.82     Covered
43848   Revision gastroplasty          C                     $1,415.96     Covered
43850   Revise stomach-bowel fusion    C                     $1,126.76     Covered
43855   Revise stomach-bowel fusion    C                     $1,152.46     Covered
43860   Revise stomach-bowel fusion    C                     $1,134.83     Covered
43865   Revise stomach-bowel fusion    C                     $1,224.01     Covered
43870   Repair stomach opening         T   00141    8.7462                 Covered
43880   Repair stomach-bowel fistula   C                     $1,070.34     Covered
43881   Impl/redo electrd, antrum      C                                  By Report
43882   Revise/remove electrd antrum   C                                  By Report
43886   Revise gastric port, open      T   00137   23.9317                 Covered
43887   Remove gastric port, open      T   00135    4.4386                 Covered
43888   Change gastric port, open      T   00137   23.9317                 Covered
43999   Stomach surgery procedure      T   00141    8.7462                 Covered
44005   Freeing of bowel adhesion      C                     $800.48       Covered
44010   Incision of small bowel        C                     $638.69       Covered
44015   Insert needle cath bowel       C                     $170.49       Covered
44020   Explore small intestine        C                     $704.28       Covered
44021   Decompress small bowel         C                     $701.64       Covered
44025   Incision of large bowel        C                     $714.96       Covered
44050   Reduce bowel obstruction       C                     $680.44       Covered
44055   Correct malrotation of bowel   C                     $756.63       Covered
44100   Biopsy of bowel                T   00141    8.7462                 Covered
44110   Excise intestine lesion(s)     C                      $618.26      Covered
44111   Excision of bowel lesion(s)    C                      $759.23      Covered
44120   Removal of small intestine     C                      $851.20      Covered
44121   Removal of small intestine     C                      $243.56      Covered
44125   Removal of small intestine     C                      $896.05      Covered
44126   Enterectomy w/o taper, cong    C                     $1,941.46     Covered
44127   Enterectomy w/taper, cong      C                     $2,233.16     Covered
44128   Enterectomy cong, add-on       C                      $236.42      Covered
44130   Bowel to bowel fusion          C                      $740.14      Covered
44132   Enterectomy, cadaver donor     C                                 Not Covered
44133   Enterectomy, live donor        C                                 Not Covered
44135   Intestine transplnt, cadaver   C                                  By Report
44136   Intestine transplant, live     C                                 Not Covered
44137   Remove intestinal allograft    C                                 Not Covered
44139   Mobilization of colon          C                      $122.30      Covered
44140   Partial removal of colon       C                     $1,067.03     Covered
44141   Partial removal of colon       C                     $1,174.31     Covered
44143   Partial removal of colon       C                     $1,212.26     Covered
44144   Partial removal of colon       C                     $1,137.81     Covered
44145   Partial removal of colon       C                     $1,326.38     Covered
44146   Partial removal of colon       C                     $1,451.83     Covered
44147   Partial removal of colon       C                     $1,143.72     Covered
44150   Removal of colon               C                     $1,309.04     Covered
44151   Removal of colon/ileostomy     C                     $1,183.87     Covered
44155   Removal of colon/ileostomy     C                     $1,491.89   Covered
44156   Removal of colon/ileostomy     C                     $1,349.45   Covered
44157   Colectomy w/ileoanal anast     C                     $1,830.10   Covered
44158   Colectomy w/neo-rectum pouch   C                     $1,877.41   Covered
44160   Removal of colon               C                      $975.02    Covered
44180   Lap, enterolysis               T   00131   46.8400               Covered
44186   Lap, jejunostomy               T   00131   46.8400               Covered
44187   Lap, ileo/jejuno-stomy         C                      $810.77    Covered
44188   Lap, colostomy                 C                      $810.77    Covered
44202   Lap, enterectomy               C                     $1,267.51   Covered
44203   Lap resect s/intestine, addl   C                      $230.30    Covered
44204   Laparo partial colectomy       C                     $1,330.62   Covered
44205   Lap colectomy part w/ileum     C                     $1,179.06   Covered
44206   Lap part colectomy w/stoma     T   00132   72.9582               Covered
44207   L colectomy/coloproctostomy    T   00132   72.9582               Covered
44208   L colectomy/coloproctostomy    T   00132   72.9582               Covered
44210   Laparo total proctocolectomy   C                     $1,433.78   Covered
44211   Lap colectomy w/proctectomy    C                     $1,783.28   Covered
44212   Laparo total proctocolectomy   C                     $1,664.92   Covered
44213   Lap, mobil splenic fl add-on   T   00130   38.0540               Covered
44227   Lap, close enterostomy         C                     $810.77     Covered
44238   Laparoscope proc, intestine    T   00130   38.0540               Covered
44300   Open bowel to skin             C                     $549.52     Covered
44310   Ileostomy/jejunostomy          C                     $748.18     Covered
44312   Revision of ileostomy          T   00137   23.9317               Covered
44314   Revision of ileostomy          C                     $702.93     Covered
44316   Devise bowel pouch             C                     $969.45     Covered
44320   Colostomy                      C                     $810.77     Covered
44322   Colostomy with biopsies        C                     $798.48     Covered
44340   Revision of colostomy          T   00137   23.9317               Covered
44345   Revision of colostomy          C                     $645.38     Covered
44346   Revision of colostomy          C                     $728.93     Covered
44360   Small bowel endoscopy          T   00142    9.8503               Covered
44361   Small bowel endoscopy/biopsy   T   00142    9.8503               Covered
44363   Small bowel endoscopy          T   00142    9.8503               Covered
44364   Small bowel endoscopy          T   00142    9.8503               Covered
44365   Small bowel endoscopy          T   00142    9.8503               Covered
44366   Small bowel endoscopy          T   00142    9.8503               Covered
44369   Small bowel endoscopy          T   00142    9.8503               Covered
44370   Small bowel endoscopy/stent    T   00384   26.4913               Covered
44372   Small bowel endoscopy          T   00142    9.8503               Covered
44373   Small bowel endoscopy          T   00142    9.8503               Covered
44376   Small bowel endoscopy          T   00142    9.8503               Covered
44377   Small bowel endoscopy/biopsy   T   00142    9.8503               Covered
44378   Small bowel endoscopy          T   00142    9.8503               Covered
44379   S bowel endoscope w/stent      T   00384   26.4913               Covered
44380   Small bowel endoscopy          T   00142    9.8503               Covered
44382   Small bowel endoscopy          T   00142    9.8503               Covered
44383   Ileoscopy w/stent              T   00384   26.4913               Covered
44385   Endoscopy of bowel pouch       T   00143    9.1051               Covered
44386   Endoscopy, bowel pouch/biop    T   00143    9.1051               Covered
44388   Colonoscopy                    T   00143    9.1051               Covered
44389   Colonoscopy with biopsy        T   00143    9.1051                 Covered
44390   Colonoscopy for foreign body   T   00143    9.1051                 Covered
44391   Colonoscopy for bleeding       T   00143    9.1051                 Covered
44392   Colonoscopy & polypectomy      T   00143    9.1051                 Covered
44393   Colonoscopy, lesion removal    T   00143    9.1051                 Covered
44394   Colonoscopy w/snare            T   00143    9.1051                 Covered
44397   Colonoscopy w/stent            T   00384   26.4913                 Covered
44500   Intro, gastrointestinal tube   T   00121    6.3742                 Covered
44602   Suture, small intestine        C                      $642.95      Covered
44603   Suture, small intestine        C                      $822.32      Covered
44604   Suture, large intestine        C                      $811.98      Covered
44605   Repair of bowel lesion         C                      $894.71      Covered
44615   Intestinal stricturoplasty     C                      $787.21      Covered
44620   Repair bowel opening           C                      $622.96      Covered
44625   Repair bowel opening           C                      $803.62      Covered
44626   Repair bowel opening           C                     $1,251.78     Covered
44640   Repair bowel-skin fistula      C                      $819.82      Covered
44650   Repair bowel fistula           C                      $851.40      Covered
44660   Repair bowel-bladder fistula   C                      $832.46      Covered
44661   Repair bowel-bladder fistula   C                     $1,046.46     Covered
44680   Surgical revision, intestine   C                      $828.00      Covered
44700   Suspend bowel w/prosthesis     C                      $880.55      Covered
44701   Intraop colon lavage add-on    N                                   Covered
44715   Prepare donor intestine        C                                 Not Covered
44720   Prep donor intestine/venous    C                                 Not Covered
44721   Prep donor intestine/artery    C                                 Not Covered
44799   Unlisted procedure intestine   T   00153   27.1855                 Covered
44800   Excision of bowel pouch        C                     $626.25       Covered
44820   Excision of mesentery lesion   C                     $596.79       Covered
44850   Repair of mesentery            C                     $558.94       Covered
44899   Bowel surgery procedure        C                                  By Report
44900   Drain app abscess, open        C                     $509.34       Covered
44901   Drain app abscess, percut      T   00037   15.5003                 Covered
44950   Appendectomy                   T   00153   27.1855                 Covered
44955   Appendectomy add-on            T   00153   27.1855                 Covered
44960   Appendectomy                   C                     $624.02       Covered
44970   Laparoscopy, appendectomy      T   00131   46.8400                 Covered
44979   Laparoscope proc, app          T   00130   38.0540                 Covered
45000   Drainage of pelvic abscess     T   00155   14.1140                 Covered
45005   Drainage of rectal abscess     T   00155   14.1140                 Covered
45020   Drainage of rectal abscess     T   00155   14.1140                 Covered
45100   Biopsy of rectum               T   00149   23.9703                 Covered
45108   Removal of anorectal lesion    T   00149   23.9703                 Covered
45110   Removal of rectum              C                     $1,421.88     Covered
45111   Partial removal of rectum      C                     $1,001.82     Covered
45112   Removal of rectum              C                     $1,504.71     Covered
45113   Partial proctectomy            C                     $1,490.98     Covered
45114   Partial removal of rectum      C                     $1,367.87     Covered
45116   Partial removal of rectum      C                     $1,175.05     Covered
45119   Remove rectum w/reservoir      C                     $1,510.87     Covered
45120   Removal of rectum              C                     $1,459.10     Covered
45121   Removal of rectum and colon    C                     $1,482.78     Covered
45123   Partial proctectomy            C                      $887.44     Covered
45126   Pelvic exenteration            C                     $1,951.23    Covered
45130   Excision of rectal prolapse    C                      $821.97     Covered
45135   Excision of rectal prolapse    C                     $1,065.75    Covered
45136   Excise ileoanal reservior      C                     $1,496.27    Covered
45150   Excision of rectal stricture   T   00149   23.9703                Covered
45160   Excision of rectal lesion      T   00149   23.9703                Covered
45170   Excision of rectal lesion      D                                 Not Covered
45171   Exc rect tum transanal part    T   00155   14.1140                Covered
45172   Exc rect tum transanal full    T   00149   23.9703                Covered
45190   Destruction, rectal tumor      T   00149   23.9703                Covered
45300   Proctosigmoidoscopy dx         T   00146    5.7747                Covered
45303   Proctosigmoidoscopy dilate     T   00147    9.2450                Covered
45305   Proctosigmoidoscopy w/bx       T   00147    9.2450                Covered
45307   Proctosigmoidoscopy fb         T   00428   22.8208                Covered
45308   Proctosigmoidoscopy removal    T   00147    9.2450                Covered
45309   Proctosigmoidoscopy removal    T   00147    9.2450                Covered
45315   Proctosigmoidoscopy removal    T   00147    9.2450                Covered
45317   Proctosigmoidoscopy bleed      T   00147    9.2450                Covered
45320   Proctosigmoidoscopy ablate     T   00428   22.8208                Covered
45321   Proctosigmoidoscopy volvul     T   00428   22.8208                Covered
45327   Proctosigmoidoscopy w/stent    T   00384   26.4913                Covered
45330   Diagnostic sigmoidoscopy       T   00146    5.7747                Covered
45331   Sigmoidoscopy and biopsy       T   00146    5.7747                Covered
45332   Sigmoidoscopy w/fb removal     T   00146    5.7747                Covered
45333   Sigmoidoscopy & polypectomy    T   00147    9.2450                Covered
45334   Sigmoidoscopy for bleeding     T   00147    9.2450                Covered
45335   Sigmoidoscopy w/submuc inj     T   00146    5.7747                Covered
45337   Sigmoidoscopy & decompress     T   00146    5.7747                Covered
45338   Sigmoidoscopy w/tumr remove    T   00147    9.2450                Covered
45339   Sigmoidoscopy w/ablate tumr    T   00147    9.2450                Covered
45340   Sig w/balloon dilation         T   00147    9.2450                Covered
45341   Sigmoidoscopy w/ultrasound     T   00147    9.2450                Covered
45342   Sigmoidoscopy w/us guide bx    T   00147    9.2450                Covered
45345   Sigmoidoscopy w/stent          T   00384   26.4913                Covered
45355   Surgical colonoscopy           T   00143    9.1051                Covered
45378   Diagnostic colonoscopy         T   00143    9.1051                Covered
45379   Colonoscopy w/fb removal       T   00143    9.1051                Covered
45380   Colonoscopy and biopsy         T   00143    9.1051                Covered
45381   Colonoscopy, submucous inj     T   00143    9.1051                Covered
45382   Colonoscopy/control bleeding   T   00143    9.1051                Covered
45383   Lesion removal colonoscopy     T   00143    9.1051                Covered
45384   Lesion remove colonoscopy      T   00143    9.1051                Covered
45385   Lesion removal colonoscopy     T   00143    9.1051                Covered
45386   Colonoscopy dilate stricture   T   00143    9.1051                Covered
45387   Colonoscopy w/stent            T   00384   26.4913                Covered
45391   Colonoscopy w/endoscope us     T   00143    9.1051                Covered
45392   Colonoscopy w/endoscopic fnb   T   00143    9.1051                Covered
45395   Lap, removal of rectum         C                     $1,143.72    Covered
45397   Lap, remove rectum w/pouch     C                      $810.77     Covered
45400   Laparoscopic proc              C                      $466.60     Covered
45402   Lap proctopexy w/sig resect    C                      $810.77     Covered
45499   Laparoscope proc, rectum       T   00130   38.0540                Covered
45500   Repair of rectum               T   00149   23.9703                Covered
45505   Repair of rectum               T   00150   32.1812                Covered
45520   Treatment of rectal prolapse   T   00013    0.8789                Covered
45540   Correct rectal prolapse        C                     $796.11      Covered
45541   Correct rectal prolapse        T   00150   32.1812                Covered
45550   Repair rectum/remove sigmoid   C                     $1,066.70    Covered
45560   Repair of rectocele            T   00150   32.1812                Covered
45562   Exploration/repair of rectum   C                      $723.30     Covered
45563   Exploration/repair of rectum   C                     $1,115.27    Covered
45800   Repair rect/bladder fistula    C                      $831.78     Covered
45805   Repair fistula w/colostomy     C                     $1,005.82    Covered
45820   Repair rectourethral fistula   C                      $844.30     Covered
45825   Repair fistula w/colostomy     C                      $982.37     Covered
45900   Reduction of rectal prolapse   T   00148    5.3650                Covered
45905   Dilation of anal sphincter     T   00149   23.9703                Covered
45910   Dilation of rectal narrowing   T   00149   23.9703                Covered
45915   Remove rectal obstruction      T   00155   14.1140                Covered
45990   Surg dx exam, anorectal        T   00149   23.9703                Covered
45999   Rectum surgery procedure       T   00148    5.3650                Covered
46020   Placement of seton             T   00149   23.9703                Covered
46030   Removal of rectal marker       T   00148    5.3650                Covered
46040   Incision of rectal abscess     T   00149   23.9703                Covered
46045   Incision of rectal abscess     T   00149   23.9703                Covered
46050   Incision of anal abscess       T   00155   14.1140                Covered
46060   Incision of rectal abscess     T   00149   23.9703                Covered
46070   Incision of anal septum        T   00155   14.1140                Covered
46080   Incision of anal sphincter     T   00149   23.9703                Covered
46083   Incise external hemorrhoid     T   00164    2.0194                Covered
46200   Removal of anal fissure        T   00149   23.9703                Covered
46210   Removal of anal crypt          D                                 Not Covered
46211   Removal of anal crypts         D                                 Not Covered
46220   Removal of anal tag            T   00155   14.1140                Covered
46221   Ligation of hemorrhoid(s)      T   00148    5.3650                Covered
46230   Removal of anal tags           T   00149   23.9703                Covered
46250   Hemorrhoidectomy               T   00149   23.9703                Covered
46255   Hemorrhoidectomy               T   00149   23.9703                Covered
46257   Remove hemorrhoids & fissure   T   00149   23.9703                Covered
46258   Remove hemorrhoids & fistula   T   00149   23.9703                Covered
46260   Hemorrhoidectomy               T   00149   23.9703                Covered
46261   Remove hemorrhoids & fissure   T   00149   23.9703                Covered
46262   Remove hemorrhoids & fistula   T   00149   23.9703                Covered
46270   Removal of anal fistula        T   00149   23.9703                Covered
46275   Removal of anal fistula        T   00149   23.9703                Covered
46280   Removal of anal fistula        T   00149   23.9703                Covered
46285   Removal of anal fistula        T   00149   23.9703                Covered
46288   Repair anal fistula            T   00149   23.9703                Covered
46320   Removal of hemorrhoid clot     T   00149   23.9703                Covered
46500   Injection into hemorrhoid(s)   T   00155   14.1140                Covered
46505   Chemodenervation anal musc     T   00149   23.9703                Covered
46600   Diagnostic anoscopy            X   00340    0.6693                Covered
46604   Anoscopy and dilation          T   00147    9.2450                Covered
46606   Anoscopy and biopsy            T   00146    5.7747                Covered
46608   Anoscopy, remove for body      T   00147    9.2450                Covered
46610   Anoscopy, remove lesion        T   00428   22.8208                Covered
46611   Anoscopy                       T   00147    9.2450                Covered
46612   Anoscopy, remove lesions       T   00428   22.8208                Covered
46614   Anoscopy, control bleeding     T   00146    5.7747                Covered
46615   Anoscopy                       T   00428   22.8208                Covered
46700   Repair of anal stricture       T   00149   23.9703                Covered
46705   Repair of anal stricture       C                     $415.67      Covered
46706   Repr of anal fistula w/glue    T   00150   32.1812                Covered
46707   Repair anorectal fist w/plug   T   00150   32.1812                Covered
46710   Repr per/vag pouch sngl proc   C                     $1,046.46    Covered
46712   Repr per/vag pouch dbl proc    C                     $1,143.72    Covered
46715   Rep perf anoper fistu          C                      $429.43     Covered
46716   Rep perf anoper/vestib fistu   C                      $717.82     Covered
46730   Construction of absent anus    C                     $1,256.08    Covered
46735   Construction of absent anus    C                     $1,490.31    Covered
46740   Construction of absent anus    C                     $1,323.84    Covered
46742   Repair of imperforated anus    C                     $1,764.83    Covered
46744   Repair of cloacal anomaly      C                     $1,913.36    Covered
46746   Repair of cloacal anomaly      C                     $2,156.49    Covered
46748   Repair of cloacal anomaly      C                     $2,337.32    Covered
46750   Repair of anal sphincter       T   00150   32.1812                Covered
46751   Repair of anal sphincter       C                     $508.08      Covered
46753   Reconstruction of anus         T   00149   23.9703                Covered
46754   Removal of suture from anus    T   00149   23.9703                Covered
46760   Repair of anal sphincter       T   00150   32.1812                Covered
46761   Repair of anal sphincter       T   00150   32.1812                Covered
46762   Implant artificial sphincter   T   00150   32.1812                Covered
46900   Destruction, anal lesion(s)    T   00016    2.7982                Covered
46910   Destruction, anal lesion(s)    T   00017   21.2653                Covered
46916   Cryosurgery, anal lesion(s)    T   00015    1.5412                Covered
46917   Laser surgery, anal lesions    T   00017   21.2653                Covered
46922   Excision of anal lesion(s)     T   00017   21.2653                Covered
46924   Destruction, anal lesion(s)    T   00017   21.2653                Covered
46930   Destroy internal hemorrhoids   T   00148    5.3650                Covered
46934   Destruction of hemorrhoids     D                                 Not Covered
46935   Destruction of hemorrhoids     D                                 Not Covered
46936   Destruction of hemorrhoids     D                                 Not Covered
46937   Cryotherapy of rectal lesion   D                                 Not Covered
46938   Cryotherapy of rectal lesion   D                                 Not Covered
46940   Treatment of anal fissure      T   00149   23.9703                Covered
46942   Treatment of anal fissure      T   00148    5.3650                Covered
46945   Ligation of hemorrhoids        T   00155   14.1140                Covered
46946   Ligation of hemorrhoids        T   00155   14.1140                Covered
46947   Hemorrhoidopexy by stapling    T   00150   32.1812                Covered
46999   Anus surgery procedure         T   00148    5.3650                Covered
47000   Needle biopsy of liver         T   00685    9.6666                Covered
47001   Needle biopsy, liver add-on    N                                  Covered
47010   Open drainage, liver lesion    C                     $626.06      Covered
47011   Percut drain, liver lesion     T   00037   15.5003                Covered
47015   Inject/aspirate liver cyst     C                     $596.11      Covered
47100   Wedge biopsy of liver          C                       $434.62     Covered
47120   Partial removal of liver       C                      $1,314.97    Covered
47122   Extensive removal of liver     C                      $1,988.37    Covered
47125   Partial removal of liver       C                      $1,813.22    Covered
47130   Partial removal of liver       C                      $1,962.62    Covered
47133   Removal of donor liver         C                                  Not Covered
47135   Transplantation of liver       C                      $4,866.07    Covered
47136   Transplantation of liver       C                                  Not Covered
47140   Partial removal, donor liver   C                      $2,147.82    Covered
47141   Partial removal, donor liver   C                      $1,813.22    Covered
47142   Partial removal, donor liver   C                      $1,962.62    Covered
47143   Prep donor liver, whole        C                                  Not Covered
47144   Prep donor liver, 3-segment    C                                  Not Covered
47145   Prep donor liver, lobe split   C                                  Not Covered
47146   Prep donor liver/venous        C                                  Not Covered
47147   Prep donor liver/arterial      C                                  Not Covered
47300   Surgery for liver lesion       C                       $613.29     Covered
47350   Repair liver wound             C                       $744.32     Covered
47360   Repair liver wound             C                      $1,030.36    Covered
47361   Repair liver wound             C                      $1,684.98    Covered
47362   Repair liver wound             C                       $671.84     Covered
47370   Laparo ablate liver tumor rf   T   00174   109.9237                Covered
47371   Laparo ablate liver cryosurg   T   00174   109.9237                Covered
47379   Laparoscope procedure, liver   T   00130    38.0540                Covered
47380   Open ablate liver tumor rf     C                      $1,098.23    Covered
47381   Open ablate liver tumor cryo   C                      $1,085.53    Covered
47382   Percut ablate liver rf         T   00423    51.3618                Covered
47399   Liver surgery procedure        T   00004     4.5991                Covered
47400   Incision of liver duct         C                      $1,137.42    Covered
47420   Incision of bile duct          C                       $965.56     Covered
47425   Incision of bile duct          C                      $1,006.09    Covered
47460   Incise bile duct sphincter     C                       $999.31     Covered
47480   Incision of gallbladder        C                       $594.35     Covered
47490   Incision of gallbladder        T   00152    30.7430                Covered
47500   Injection for liver x-rays     N                                   Covered
47505   Injection for liver x-rays     N                                   Covered
47510   Insert catheter, bile duct     T   00152    30.7430                Covered
47511   Insert bile duct drain         T   00152    30.7430                Covered
47525   Change bile duct catheter      T   00427    15.3103                Covered
47530   Revise/reinsert bile tube      T   00427    15.3103                Covered
47550   Bile duct endoscopy add-on     C                      $165.15      Covered
47552   Biliary endoscopy thru skin    T   00152    30.7430                Covered
47553   Biliary endoscopy thru skin    T   00152    30.7430                Covered
47554   Biliary endoscopy thru skin    T   00152    30.7430                Covered
47555   Biliary endoscopy thru skin    T   00152    30.7430                Covered
47556   Biliary endoscopy thru skin    T   00152    30.7430                Covered
47560   Laparoscopy w/cholangio        T   00130    38.0540                Covered
47561   Laparo w/cholangio/biopsy      T   00130    38.0540                Covered
47562   Laparoscopic cholecystectomy   T   00131    46.8400                Covered
47563   Laparo cholecystectomy/graph   T   00131    46.8400                Covered
47564   Laparo cholecystectomy/explr   T   00131    46.8400                Covered
47570   Laparo cholecystoenterostomy   C                      $758.46      Covered
47579   Laparoscope proc, biliary      T   00130   38.0540                 Covered
47600   Removal of gallbladder         C                      $685.11      Covered
47605   Removal of gallbladder         C                      $738.13      Covered
47610   Removal of gallbladder         C                      $919.59      Covered
47612   Removal of gallbladder         C                     $1,004.99     Covered
47620   Removal of gallbladder         C                     $1,022.94     Covered
47630   Remove bile duct stone         T   00152   30.7430                 Covered
47700   Exploration of bile ducts      C                      $880.48      Covered
47701   Bile duct revision             C                     $1,519.29     Covered
47711   Excision of bile duct tumor    C                     $1,139.36     Covered
47712   Excision of bile duct tumor    C                     $1,417.21     Covered
47715   Excision of bile duct cyst     C                      $914.33      Covered
47720   Fuse gallbladder & bowel       C                      $819.99      Covered
47721   Fuse upper gi structures       C                      $984.67      Covered
47740   Fuse gallbladder & bowel       C                      $937.54      Covered
47741   Fuse gallbladder & bowel       C                                 Not Covered
47760   Fuse bile ducts and bowel      C                     $1,239.79     Covered
47765   Fuse liver ducts & bowel       C                     $1,281.30     Covered
47780   Fuse bile ducts and bowel      C                     $1,292.38     Covered
47785   Fuse bile ducts and bowel      C                     $1,479.61     Covered
47800   Reconstruction of bile ducts   C                     $1,172.82     Covered
47801   Placement, bile duct support   C                      $721.07      Covered
47802   Fuse liver duct & intestine    C                     $1,067.39     Covered
47900   Suture bile duct injury        C                     $1,048.44     Covered
47999   Bile tract surgery procedure   T   00152   30.7430                 Covered
48000   Drainage of abdomen            C                      $834.57      Covered
48001   Placement of drain, pancreas   C                     $1,033.17     Covered
48020   Removal of pancreatic stone    C                      $782.21      Covered
48100   Biopsy of pancreas, open       C                      $616.51      Covered
48102   Needle biopsy, pancreas        T   00685    9.6666                 Covered
48105   Resect/debride pancreas        C                     $2,357.81     Covered
48120   Removal of pancreas lesion     C                      $854.90      Covered
48140   Partial removal of pancreas    C                     $1,220.96     Covered
48145   Partial removal of pancreas    C                     $1,310.42     Covered
48146   Pancreatectomy                 C                     $1,443.37     Covered
48148   Removal of pancreatic duct     C                      $908.09      Covered
48150   Partial removal of pancreas    C                     $2,453.27     Covered
48152   Pancreatectomy                 C                     $2,281.30     Covered
48153   Pancreatectomy                 C                     $2,451.02     Covered
48154   Pancreatectomy                 C                     $2,287.22     Covered
48155   Removal of pancreas            C                     $1,459.70     Covered
48160   Pancreas removal/transplant    E                                  By Report
48400   Injection, intraop add-on      C                     $102.41       Covered
48500   Surgery of pancreatic cyst     C                     $800.73       Covered
48510   Drain pancreatic pseudocyst    C                     $744.89       Covered
48511   Drain pancreatic pseudocyst    T   00037   15.5003                 Covered
48520   Fuse pancreas cyst and bowel   C                      $869.68      Covered
48540   Fuse pancreas cyst and bowel   C                     $1,065.38     Covered
48545   Pancreatorrhaphy               C                      $924.11      Covered
48547   Duodenal exclusion             C                     $1,289.35     Covered
48548   Fuse pancreas and bowel        C                     $1,370.96     Covered
48550   Donor pancreatectomy           E                                 Not Covered
48551   Prep donor pancreas            C                                 Not Covered
48552   Prep donor pancreas/venous     C                                 Not Covered
48554   Transpl allograft pancreas     C                     $1,873.55    Covered
48556   Removal, allograft pancreas    C                      $883.95     Covered
48999   Pancreas surgery procedure     T   00004    4.5991                Covered
49000   Exploration of abdomen         C                     $681.49      Covered
49002   Reopening of abdomen           C                     $619.29      Covered
49010   Exploration behind abdomen     C                     $722.46      Covered
49020   Drain abdominal abscess        C                     $872.33      Covered
49021   Drain abdominal abscess        T   00037   15.5003                Covered
49040   Drain, open, abdom abscess     C                     $604.78      Covered
49041   Drain, percut, abdom abscess   T   00037   15.5003                Covered
49060   Drain, open, retrop abscess    C                     $658.61      Covered
49061   Drain, percut, retroper absc   T   00037   15.5003                Covered
49062   Drain to peritoneal cavity     C                     $703.68      Covered
49080   Puncture, peritoneal cavity    T   00070    5.5521                Covered
49081   Removal of abdominal fluid     T   00070    5.5521                Covered
49180   Biopsy, abdominal mass         T   00685    9.6666                Covered
49203   Exc abd tum 5 cm or less       C                      $877.49     Covered
49204   Exc abd tum over 5 cm          C                     $1,119.02    Covered
49205   Exc abd tum over 10 cm         C                     $1,280.33    Covered
49215   Excise sacral spine tumor      C                     $1,230.49    Covered
49220   Multiple surgery, abdomen      C                      $931.66     Covered
49250   Excision of umbilicus          T   00153   27.1855                Covered
49255   Removal of omentum             C                     $631.48      Covered
49320   Diag laparo separate proc      T   00130   38.0540                Covered
49321   Laparoscopy, biopsy            T   00130   38.0540                Covered
49322   Laparoscopy, aspiration        T   00130   38.0540                Covered
49323   Laparo drain lymphocele        T   00130   38.0540                Covered
49324   Lap insertion perm ip cath     T   00130   38.0540                Covered
49325   Lap revision perm ip cath      T   00130   38.0540                Covered
49326   Lap w/omentopexy add-on        T   00130   38.0540                Covered
49329   Laparo proc, abdm/per/oment    T   00130   38.0540                Covered
49400   Air injection into abdomen     N                                  Covered
49402   Remove foreign body, adbomen   T   00153   27.1855                Covered
49411   Ins mark abd/pel for rt perq   X   00310   13.7576                Covered
49419   Insrt abdom cath for chemotx   T   00115   30.9784                Covered
49420   Insert abdom drain, temp       T   00652   30.4602                Covered
49421   Insert abdom drain, perm       T   00652   30.4602                Covered
49422   Remove perm cannula/catheter   T   00105   22.9412                Covered
49423   Exchange drainage catheter     T   00427   15.3103                Covered
49424   Assess cyst, contrast inject   N                                  Covered
49425   Insert abdomen-venous drain    C                     $719.24      Covered
49426   Revise abdomen-venous shunt    T   00153   27.1855                Covered
49427   Injection, abdominal shunt     N                                  Covered
49428   Ligation of shunt              C                     $144.95      Covered
49429   Removal of shunt               T   00105   22.9412                Covered
49435   Insert subq exten to ip cath   T   00427   15.3103                Covered
49436   Embedded ip cath exit-site     T   00427   15.3103                Covered
49440   Place gastrostomy tube perc    T   00141    8.7462                Covered
49441   Place duod/jej tube perc       T   00141    8.7462                Covered
49442   Place cecostomy tube perc      T   00155   14.1140                Covered
49446   Change g-tube to g-j perc      T    00141    8.7462                Covered
49450   Replace g/c tube perc          T    00121    6.3742                Covered
49451   Replace duod/jej tube perc     T    00121    6.3742                Covered
49452   Replace g-j tube perc          T    00121    6.3742                Covered
49460   Fix g/colon tube w/device      T    00121    6.3742                Covered
49465   Fluoro exam of g/colon tube    Q1   00276    1.2985                Covered
49491   Rpr hern preemie reduc         T    00154   31.9682                Covered
49492   Rpr ing hern premie, blocked   T    00154   31.9682                Covered
49495   Rpr ing hernia baby, reduc     T    00154   31.9682                Covered
49496   Rpr ing hernia baby, blocked   T    00154   31.9682                Covered
49500   Rpr ing hernia, init, reduce   T    00154   31.9682                Covered
49501   Rpr ing hernia, init blocked   T    00154   31.9682                Covered
49505   Prp i/hern init reduc >5 yr    T    00154   31.9682                Covered
49507   Prp i/hern init block >5 yr    T    00154   31.9682                Covered
49520   Rerepair ing hernia, reduce    T    00154   31.9682                Covered
49521   Rerepair ing hernia, blocked   T    00154   31.9682                Covered
49525   Repair ing hernia, sliding     T    00154   31.9682                Covered
49540   Repair lumbar hernia           T    00154   31.9682                Covered
49550   Rpr rem hernia, init, reduce   T    00154   31.9682                Covered
49553   Rpr fem hernia, init blocked   T    00154   31.9682                Covered
49555   Rerepair fem hernia, reduce    T    00154   31.9682                Covered
49557   Rerepair fem hernia, blocked   T    00154   31.9682                Covered
49560   Rpr ventral hern init, reduc   T    00154   31.9682                Covered
49561   Rpr ventral hern init, block   T    00154   31.9682                Covered
49565   Rerepair ventrl hern, reduce   T    00154   31.9682                Covered
49566   Rerepair ventrl hern, block    T    00154   31.9682                Covered
49568   Hernia repair w/mesh           T    00154   31.9682                Covered
49570   Rpr epigastric hern, reduce    T    00154   31.9682                Covered
49572   Rpr epigastric hern, blocked   T    00154   31.9682                Covered
49580   Rpr umbil hern, reduc < 5 yr   T    00154   31.9682                Covered
49582   Rpr umbil hern, block < 5 yr   T    00154   31.9682                Covered
49585   Rpr umbil hern, reduc > 5 yr   T    00154   31.9682                Covered
49587   Rpr umbil hern, block > 5 yr   T    00154   31.9682                Covered
49590   Repair spigelian hernia        T    00154   31.9682                Covered
49600   Repair umbilical lesion        T    00154   31.9682                Covered
49605   Repair umbilical lesion        C                      $1,309.52    Covered
49606   Repair umbilical lesion        C                      $1,124.73    Covered
49610   Repair umbilical lesion        C                       $618.82     Covered
49611   Repair umbilical lesion        C                       $607.46     Covered
49650   Lap ing hernia repair init     T    00131   46.8400                Covered
49651   Lap ing hernia repair recur    T    00131   46.8400                Covered
49652   Lap vent/abd hernia repair     T    00132   72.9582                Covered
49653   Lap vent/abd hern proc comp    T    00132   72.9582                Covered
49654   Lap inc hernia repair          T    00132   72.9582                Covered
49655   Lap inc hern repair comp       T    00132   72.9582                Covered
49656   Lap inc hernia repair recur    T    00132   72.9582                Covered
49657   Lap inc hern recur comp        T    00132   72.9582                Covered
49659   Laparo proc, hernia repair     T    00130   38.0540                Covered
49900   Repair of abdominal wall       C                       $656.84     Covered
49904   Omental flap, extra-abdom      C                      $1,271.97    Covered
49905   Omental flap, intra-abdom      C                       $359.63     Covered
49906   Free omental flap, microvasc   C                                  By Report
49999   Abdomen surgery procedure      T   00153   27.1855                 Covered
50010   Exploration of kidney          C                     $701.06       Covered
50020   Renal abscess, open drain      T   00162   25.5223                 Covered
50021   Renal abscess, percut drain    T   00037   15.5003                 Covered
50040   Drainage of kidney             C                     $861.52       Covered
50045   Exploration of kidney          C                     $901.96       Covered
5005F   Pt counsld on exam for moles   M                                 Not Covered
50060   Removal of kidney stone        C                     $1,108.99     Covered
50065   Incision of kidney             C                     $1,205.00     Covered
50070   Incision of kidney             C                     $1,172.03     Covered
50075   Removal of kidney stone        C                     $1,462.59     Covered
50080   Removal of kidney stone        T   00429   46.6800                 Covered
50081   Removal of kidney stone        T   00429   46.6800                 Covered
50100   Revise kidney blood vessels    C                     $984.27       Covered
5010F   Macul+ fndngs to dr mng dm     M                                 Not Covered
50120   Exploration of kidney          C                      $937.42      Covered
50125   Explore and drain kidney       C                      $973.52      Covered
50130   Removal of kidney stone        C                     $1,033.16     Covered
50135   Exploration of kidney          C                     $1,193.55     Covered
5015F   Doc fx & test/txmnt for op     M                                 Not Covered
50200   Biopsy of kidney               T   00685    9.6666                 Covered
50205   Biopsy of kidney               C                     $640.44       Covered
5020F   Txmnts 2 main Dr by 1 mon      E                                 Not Covered
50220   Remove kidney, open            C                     $1,042.66     Covered
50225   Removal kidney open, complex   C                     $1,232.45     Covered
50230   Removal kidney open, radical   C                     $1,344.87     Covered
50234   Removal of kidney & ureter     C                     $1,327.28     Covered
50236   Removal of kidney & ureter     C                     $1,486.95     Covered
50240   Partial removal of kidney      C                     $1,332.59     Covered
50250   Cryoablate renal mass open     C                      $640.44      Covered
50280   Removal of kidney lesion       C                      $928.90      Covered
50290   Removal of kidney lesion       C                      $855.93      Covered
50300   Remove cadaver donor kidney    C                                 Not Covered
50320   Remove kidney, living donor    C                     $1,330.22     Covered
50323   Prep cadaver renal allograft   C                      $176.56      Covered
50325   Prep donor renal graft         C                                 Not Covered
50327   Prep renal graft/venous        C                                  By Report
50328   Prep renal graft/arterial      C                                 Not Covered
50329   Prep renal graft/ureteral      C                                 Not Covered
50340   Removal of kidney              C                      $851.99      Covered
50360   Transplantation of kidney      C                     $1,952.95     Covered
50365   Transplantation of kidney      C                     $2,320.01     Covered
50370   Remove transplanted kidney     C                      $888.89      Covered
50380   Reimplantation of kidney       C                     $1,193.69     Covered
50382   Change ureter stent, percut    T   00162   25.5223                 Covered
50384   Remove ureter stent, percut    T   00161   17.0344                 Covered
50385   Change stent via transureth    T   00162   25.5223                 Covered
50386   Remove stent via transureth    T   00160    7.1342                 Covered
50387   Change ext/int ureter stent    T   00427   15.3103                 Covered
50389   Remove renal tube w/fluoro     T   00160    7.1342                 Covered
50390   Drainage of kidney lesion      T   00685    9.6666                 Covered
50391   Instll rx agnt into rnal tub   T   00126    1.0958                 Covered
50392   Insert kidney drain            T   00161    17.0344                 Covered
50393   Insert ureteral tube           T   00162    25.5223                 Covered
50394   Injection for kidney x-ray     N                                    Covered
50395   Create passage to kidney       T   00162    25.5223                 Covered
50396   Measure kidney pressure        T   00164     2.0194                 Covered
50398   Change kidney tube             T   00427    15.3103                 Covered
50400   Revision of kidney/ureter      C                      $1,144.88     Covered
50405   Revision of kidney/ureter      C                      $1,430.83     Covered
50500   Repair of kidney wound         C                      $1,165.29     Covered
5050F   Plan 2 main Dr. by 1 month     M                                  Not Covered
50520   Close kidney-skin fistula      C                      $1,017.28     Covered
50525   Repair renal-abdomen fistula   C                      $1,300.90     Covered
50526   Repair renal-abdomen fistula   C                      $1,298.03     Covered
50540   Revision of horseshoe kidney   C                      $1,165.15     Covered
50541   Laparo ablate renal cyst       T   00130    38.0540                 Covered
50542   Laparo ablate renal mass       T   00174   109.9237                 Covered
50543   Laparo partial nephrectomy     T   00131    46.8400                 Covered
50544   Laparoscopy, pyeloplasty       T   00130    38.0540                 Covered
50545   Laparo radical nephrectomy     C                                   By Report
50546   Laparoscopic nephrectomy       C                      $1,057.63     Covered
50547   Laparo removal donor kidney    C                      $1,354.73     Covered
50548   Laparo remove w/ureter         C                      $1,243.21     Covered
50549   Laparoscope proc, renal        T   00130    38.0540                 Covered
50551   Kidney endoscopy               T   00160     7.1342                 Covered
50553   Kidney endoscopy               T   00162    25.5223                 Covered
50555   Kidney endoscopy & biopsy      T   00160     7.1342                 Covered
50557   Kidney endoscopy & treatment   T   00162    25.5223                 Covered
50561   Kidney endoscopy & treatment   T   00162    25.5223                 Covered
50562   Renal scope w/tumor resect     T   00160     7.1342                 Covered
50570   Kidney endoscopy               T   00160     7.1342                 Covered
50572   Kidney endoscopy               T   00160     7.1342                 Covered
50574   Kidney endoscopy & biopsy      T   00160     7.1342                 Covered
50575   Kidney endoscopy               T   00163    36.2009                 Covered
50576   Kidney endoscopy & treatment   T   00161    17.0344                 Covered
50580   Kidney endoscopy & treatment   T   00161    17.0344                 Covered
50590   Fragmenting of kidney stone    T   00169    41.3626                 Covered
50592   Perc rf ablate renal tumor     T   00423    51.3618                 Covered
50593   Perc cryo ablate renal tum     T   00423    51.3618                 Covered
50600   Exploration of ureter          C                      $914.37       Covered
50605   Insert ureteral support        C                      $838.78       Covered
5060F   Fndngs mammo 2pt w/in 3 days   M                                  Not Covered
50610   Removal of ureter stone        C                      $959.24       Covered
50620   Removal of ureter stone        C                      $914.88       Covered
5062F   Doc f2fmammo fndng in 5 days   M                                  Not Covered
50630   Removal of ureter stone        C                       $927.17      Covered
50650   Removal of ureter              C                      $1,030.39     Covered
50660   Removal of ureter              C                      $1,134.02     Covered
50684   Injection for ureter x-ray     N                                    Covered
50686   Measure ureter pressure        T   00126     1.0958                 Covered
50688   Change of ureter tube/stent    T   00427    15.3103                 Covered
50690   Injection for ureter x-ray     N                                    Covered
50700   Revision of ureter             C                      $945.22       Covered
50715   Release of ureter              C                     $1,108.37    Covered
50722   Release of ureter              C                      $960.55     Covered
50725   Release/revise ureter          C                     $1,087.42    Covered
50727   Revise ureter                  T   00165   20.0243                Covered
50728   Revise ureter                  C                      $731.86     Covered
50740   Fusion of ureter & kidney      C                     $1,097.62    Covered
50750   Fusion of ureter & kidney      C                     $1,157.67    Covered
50760   Fusion of ureters              C                     $1,101.97    Covered
50770   Splicing of ureters            C                     $1,178.30    Covered
50780   Reimplant ureter in bladder    C                     $1,103.57    Covered
50782   Reimplant ureter in bladder    C                     $1,162.38    Covered
50783   Reimplant ureter in bladder    C                     $1,203.30    Covered
50785   Reimplant ureter in bladder    C                     $1,228.57    Covered
50800   Implant ureter in bowel        C                      $969.25     Covered
50810   Fusion of ureter & bowel       C                     $1,208.59    Covered
50815   Urine shunt to intestine       C                     $1,299.54    Covered
50820   Construct bowel bladder        C                     $1,369.39    Covered
50825   Construct bowel bladder        C                     $1,859.62    Covered
50830   Revise urine flow              C                     $1,819.36    Covered
50840   Replace ureter by bowel        C                     $1,185.55    Covered
50845   Appendico-vesicostomy          C                     $1,203.15    Covered
50860   Transplant ureter to skin      C                      $922.53     Covered
50900   Repair of ureter               C                      $826.56     Covered
50920   Closure ureter/skin fistula    C                      $852.59     Covered
50930   Closure ureter/bowel fistula   C                     $1,095.12    Covered
50940   Release of ureter              C                      $878.33     Covered
50945   Laparoscopy ureterolithotomy   T   00131   46.8400                Covered
50947   Laparo new ureter/bladder      T   00131   46.8400                Covered
50948   Laparo new ureter/bladder      T   00131   46.8400                Covered
50949   Laparoscope proc, ureter       T   00130   38.0540                Covered
50951   Endoscopy of ureter            T   00160    7.1342                Covered
50953   Endoscopy of ureter            T   00160    7.1342                Covered
50955   Ureter endoscopy & biopsy      T   00162   25.5223                Covered
50957   Ureter endoscopy & treatment   T   00162   25.5223                Covered
50961   Ureter endoscopy & treatment   T   00162   25.5223                Covered
50970   Ureter endoscopy               T   00160    7.1342                Covered
50972   Ureter endoscopy & catheter    T   00160    7.1342                Covered
50974   Ureter endoscopy & biopsy      T   00161   17.0344                Covered
50976   Ureter endoscopy & treatment   T   00161   17.0344                Covered
50980   Ureter endoscopy & treatment   T   00162   25.5223                Covered
5100F   Rsk fx ref w/n 24 hrs x-ray    E                                 Not Covered
51020   Incise & treat bladder         T   00162   25.5223                Covered
51030   Incise & treat bladder         T   00162   25.5223                Covered
51040   Incise & drain bladder         T   00162   25.5223                Covered
51045   Incise bladder/drain ureter    T   00160    7.1342                Covered
51050   Removal of bladder stone       T   00162   25.5223                Covered
51060   Removal of ureter stone        T   00163   36.2009                Covered
51065   Remove ureter calculus         T   00162   25.5223                Covered
51080   Drainage of bladder abscess    T   00008   19.4063                Covered
51100   Drain bladder by needle        T   00164    2.0194                Covered
51101   Drain bladder by trocar/cath   T   00126    1.0958                Covered
51102   Drain bl w/cath insertion      T   00165   20.0243                Covered
51500   Removal of bladder cyst        T   00154   31.9682                Covered
51520   Removal of bladder lesion      T   00162   25.5223                Covered
51525   Removal of bladder lesion      C                     $848.45      Covered
51530   Removal of bladder lesion      C                     $758.27      Covered
51535   Repair of ureter lesion        T   00162   25.5223                Covered
51550   Partial removal of bladder     C                      $928.65     Covered
51555   Partial removal of bladder     C                     $1,203.73    Covered
51565   Revise bladder & ureter(s)     C                     $1,289.53    Covered
51570   Removal of bladder             C                     $1,401.01    Covered
51575   Removal of bladder & nodes     C                     $1,813.82    Covered
51580   Remove bladder/revise tract    C                     $1,790.86    Covered
51585   Removal of bladder & nodes     C                     $2,066.54    Covered
51590   Remove bladder/revise tract    C                     $1,938.21    Covered
51595   Remove bladder/revise tract    C                     $2,300.31    Covered
51596   Remove bladder/create pouch    C                     $2,429.61    Covered
51597   Removal of pelvic structures   C                     $2,311.35    Covered
51600   Injection for bladder x-ray    N                                  Covered
51605   Preparation for bladder xray   N                                  Covered
51610   Injection for bladder x-ray    N                                  Covered
51700   Irrigation of bladder          T   00164    2.0194                Covered
51701   Insert bladder catheter        X   00340    0.6693                Covered
51702   Insert temp bladder cath       X   00340    0.6693                Covered
51703   Insert bladder cath, complex   T   00126    1.0958                Covered
51705   Change of bladder tube         T   00164    2.0194                Covered
51710   Change of bladder tube         T   00121    6.3742                Covered
51715   Endoscopic injection/implant   T   00168   31.3770                Covered
51720   Treatment of bladder lesion    T   00156    3.0214                Covered
51725   Simple cystometrogram          T   00156    3.0214                Covered
51726   Complex cystometrogram         T   00156    3.0214                Covered
51727   Cystometrogram w/up            T   00156    3.0214                Covered
51728   Cystometrogram w/vp            T   00156    3.0214                Covered
51729   Cystometrogram w/vp&up         T   00156    3.0214                Covered
51736   Urine flow measurement         T   00126    1.0958                Covered
51741   Electro-uroflowmetry, first    T   00126    1.0958                Covered
51772   Urethra pressure profile       D                                 Not Covered
51784   Anal/urinary muscle study      T   00126    1.0958                Covered
51785   Anal/urinary muscle study      T   00164    2.0194                Covered
51792   Urinary reflex study           T   00126    1.0958                Covered
51795   Urine voiding pressure study   D                                 Not Covered
51797   Intraabdominal pressure test   T   00164    2.0194                Covered
51798   Us urine capacity measure      X   00340    0.6693                Covered
51800   Revision of bladder/urethra    C                     $1,027.47    Covered
51820   Revision of urinary tract      C                      $982.71     Covered
51840   Attach bladder/urethra         C                      $678.89     Covered
51841   Attach bladder/urethra         C                      $823.14     Covered
51845   Repair bladder neck            T   00202   44.9894                Covered
51860   Repair of bladder wound        T   00162   25.5223                Covered
51865   Repair of bladder wound        C                     $911.19      Covered
51880   Repair of bladder opening      T   00162   25.5223                Covered
51900   Repair bladder/vagina lesion   C                     $830.43      Covered
51920   Close bladder-uterus fistula   C                     $698.88      Covered
51925   Hysterectomy/bladder repair    C                     $925.11      Covered
51940   Correction of bladder defect   C                     $1,653.25    Covered
51960   Revision of bladder & bowel    C                     $1,463.55    Covered
51980   Construct bladder opening      C                      $681.19     Covered
51990   Laparo urethral suspension     T   00131   46.8400                Covered
51992   Laparo sling operation         T   00131   46.8400                Covered
51999   Laparoscope proc, bla          T   00130   38.0540                Covered
52000   Cystoscopy                     T   00160    7.1342                Covered
52001   Cystoscopy, removal of clots   T   00161   17.0344                Covered
52005   Cystoscopy & ureter catheter   T   00162   25.5223                Covered
52007   Cystoscopy and biopsy          T   00162   25.5223                Covered
5200F   Eval appros surg thxpy epi     E                                 Not Covered
52010   Cystoscopy & duct catheter     T   00160    7.1342                Covered
52204   Cystoscopy w/biopsy(s)         T   00162   25.5223                Covered
52214   Cystoscopy and treatment       T   00162   25.5223                Covered
52224   Cystoscopy and treatment       T   00162   25.5223                Covered
52234   Cystoscopy and treatment       T   00162   25.5223                Covered
52235   Cystoscopy and treatment       T   00162   25.5223                Covered
52240   Cystoscopy and treatment       T   00162   25.5223                Covered
52250   Cystoscopy and radiotracer     T   00162   25.5223                Covered
52260   Cystoscopy and treatment       T   00161   17.0344                Covered
52265   Cystoscopy and treatment       T   00160    7.1342                Covered
52270   Cystoscopy & revise urethra    T   00161   17.0344                Covered
52275   Cystoscopy & revise urethra    T   00162   25.5223                Covered
52276   Cystoscopy and treatment       T   00162   25.5223                Covered
52277   Cystoscopy and treatment       T   00162   25.5223                Covered
52281   Cystoscopy and treatment       T   00161   17.0344                Covered
52282   Cystoscopy, implant stent      T   00163   36.2009                Covered
52283   Cystoscopy and treatment       T   00162   25.5223                Covered
52285   Cystoscopy and treatment       T   00161   17.0344                Covered
52290   Cystoscopy and treatment       T   00162   25.5223                Covered
52300   Cystoscopy and treatment       T   00162   25.5223                Covered
52301   Cystoscopy and treatment       T   00162   25.5223                Covered
52305   Cystoscopy and treatment       T   00162   25.5223                Covered
52310   Cystoscopy and treatment       T   00161   17.0344                Covered
52315   Cystoscopy and treatment       T   00162   25.5223                Covered
52317   Remove bladder stone           T   00162   25.5223                Covered
52318   Remove bladder stone           T   00162   25.5223                Covered
52320   Cystoscopy and treatment       T   00162   25.5223                Covered
52325   Cystoscopy, stone removal      T   00162   25.5223                Covered
52327   Cystoscopy, inject material    T   00163   36.2009                Covered
52330   Cystoscopy and treatment       T   00162   25.5223                Covered
52332   Cystoscopy and treatment       T   00162   25.5223                Covered
52334   Create passage to kidney       T   00162   25.5223                Covered
52341   Cysto w/ureter stricture tx    T   00162   25.5223                Covered
52342   Cysto w/up stricture tx        T   00162   25.5223                Covered
52343   Cysto w/renal stricture tx     T   00162   25.5223                Covered
52344   Cysto/uretero, stricture tx    T   00162   25.5223                Covered
52345   Cysto/uretero w/up stricture   T   00162   25.5223                Covered
52346   Cystouretero w/renal strict    T   00162   25.5223                Covered
52351   Cystouretero & or pyeloscope   T   00162   25.5223                Covered
52352   Cystouretero w/stone remove    T   00162   25.5223                Covered
52353   Cystouretero w/lithotripsy     T   00163   36.2009                Covered
52354   Cystouretero w/biopsy          T   00162    25.5223                Covered
52355   Cystouretero w/excise tumor    T   00162    25.5223                Covered
52400   Cystouretero w/congen repr     T   00162    25.5223                Covered
52402   Cystourethro cut ejacul duct   T   00162    25.5223                Covered
52450   Incision of prostate           T   00162    25.5223                Covered
52500   Revision of bladder neck       T   00162    25.5223                Covered
52601   Prostatectomy (TURP)           T   00163    36.2009                Covered
52606   Control postop bleeding        D                                  Not Covered
52612   Prostatectomy, first stage     D                                  Not Covered
52614   Prostatectomy, second stage    D                                  Not Covered
52620   Remove residual prostate       D                                  Not Covered
52630   Remove prostate regrowth       T   00163    36.2009                Covered
52640   Relieve bladder contracture    T   00162    25.5223                Covered
52647   Laser surgery of prostate      T   00429    46.6800                Covered
52648   Laser surgery of prostate      T   00429    46.6800                Covered
52649   Prostate laser enucleation     T   00429    46.6800                Covered
52700   Drainage of prostate abscess   T   00162    25.5223                Covered
53000   Incision of urethra            T   00166    20.3374                Covered
53010   Incision of urethra            T   00166    20.3374                Covered
53020   Incision of urethra            T   00166    20.3374                Covered
53025   Incision of urethra            T   00166    20.3374                Covered
53040   Drainage of urethra abscess    T   00166    20.3374                Covered
53060   Drainage of urethra abscess    T   00166    20.3374                Covered
53080   Drainage of urinary leakage    T   00166    20.3374                Covered
53085   Drainage of urinary leakage    T   00166    20.3374                Covered
53200   Biopsy of urethra              T   00166    20.3374                Covered
53210   Removal of urethra             T   00168    31.3770                Covered
53215   Removal of urethra             T   00166    20.3374                Covered
53220   Treatment of urethra lesion    T   00168    31.3770                Covered
53230   Removal of urethra lesion      T   00168    31.3770                Covered
53235   Removal of urethra lesion      T   00166    20.3374                Covered
53240   Surgery for urethra pouch      T   00168    31.3770                Covered
53250   Removal of urethra gland       T   00166    20.3374                Covered
53260   Treatment of urethra lesion    T   00166    20.3374                Covered
53265   Treatment of urethra lesion    T   00166    20.3374                Covered
53270   Removal of urethra gland       T   00166    20.3374                Covered
53275   Repair of urethra defect       T   00166    20.3374                Covered
53400   Revise urethra, stage 1        T   00168    31.3770                Covered
53405   Revise urethra, stage 2        T   00168    31.3770                Covered
53410   Reconstruction of urethra      T   00168    31.3770                Covered
53415   Reconstruction of urethra      C                      $1,099.13    Covered
53420   Reconstruct urethra, stage 1   T   00168    31.3770                Covered
53425   Reconstruct urethra, stage 2   T   00168    31.3770                Covered
53430   Reconstruction of urethra      T   00168    31.3770                Covered
53431   Reconstruct urethra/bladder    T   00168    31.3770                Covered
53440   Male sling procedure           S   00385    98.0867                Covered
53442   Remove/revise male sling       T   00168    31.3770                Covered
53444   Insert tandem cuff             S   00385    98.0867                Covered
53445   Insert uro/ves nck sphincter   S   00386   164.3200                Covered
53446   Remove uro sphincter           T   00168    31.3770                Covered
53447   Remove/replace ur sphincter    S   00386   164.3200                Covered
53448   Remov/replc ur sphinctr comp   C                      $1,235.72    Covered
53449   Repair uro sphincter           T   00168   31.3770                Covered
53450   Revision of urethra            T   00168   31.3770                Covered
53460   Revision of urethra            T   00166   20.3374                Covered
53500   Urethrlys, transvag w/ scope   T   00168   31.3770                Covered
53502   Repair of urethra injury       T   00166   20.3374                Covered
53505   Repair of urethra injury       T   00168   31.3770                Covered
53510   Repair of urethra injury       T   00166   20.3374                Covered
53515   Repair of urethra injury       T   00168   31.3770                Covered
53520   Repair of urethra defect       T   00168   31.3770                Covered
53600   Dilate urethra stricture       T   00156    3.0214                Covered
53601   Dilate urethra stricture       T   00126    1.0958                Covered
53605   Dilate urethra stricture       T   00161   17.0344                Covered
53620   Dilate urethra stricture       T   00165   20.0243                Covered
53621   Dilate urethra stricture       T   00164    2.0194                Covered
53660   Dilation of urethra            T   00126    1.0958                Covered
53661   Dilation of urethra            T   00126    1.0958                Covered
53665   Dilation of urethra            T   00166   20.3374                Covered
53850   Prostatic microwave thermotx   T   00429   46.6800                Covered
53852   Prostatic rf thermotx          T   00429   46.6800                Covered
53853   Prostatic water thermother     D                                 Not Covered
53855   Insert prost urethral stent    T   00164    2.0194                Covered
53899   Urology surgery procedure      T   00126    1.0958                Covered
54000   Slitting of prepuce            T   00166   20.3374                Covered
54001   Slitting of prepuce            T   00166   20.3374                Covered
54015   Drain penis lesion             T   00008   19.4063                Covered
54050   Destruction, penis lesion(s)   T   00013    0.8789                Covered
54055   Destruction, penis lesion(s)   T   00017   21.2653                Covered
54056   Cryosurgery, penis lesion(s)   T   00013    0.8789                Covered
54057   Laser surg, penis lesion(s)    T   00017   21.2653                Covered
54060   Excision of penis lesion(s)    T   00017   21.2653                Covered
54065   Destruction, penis lesion(s)   T   00017   21.2653                Covered
54100   Biopsy of penis                T   00021   17.4975                Covered
54105   Biopsy of penis                T   00022   23.3880                Covered
54110   Treatment of penis lesion      T   00181   34.8837                Covered
54111   Treat penis lesion, graft      T   00181   34.8837                Covered
54112   Treat penis lesion, graft      T   00181   34.8837                Covered
54115   Treatment of penis lesion      T   00008   19.4063                Covered
54120   Partial removal of penis       T   00181   34.8837                Covered
54125   Removal of penis               C                      $864.83     Covered
54130   Remove penis & nodes           C                     $1,215.93    Covered
54135   Remove penis & nodes           C                     $1,546.41    Covered
54150   Circumcision w/regionl block   T   00183   23.2838                Covered
54160   Circumcision, neonate          T   00183   23.2838                Covered
54161   Circum 28 days or older        T   00183   23.2838                Covered
54162   Lysis penil circumic lesion    T   00183   23.2838                Covered
54163   Repair of circumcision         T   00183   23.2838                Covered
54164   Frenulotomy of penis           T   00183   23.2838                Covered
54200   Treatment of penis lesion      T   00164    2.0194                Covered
54205   Treatment of penis lesion      T   00181   34.8837                Covered
54220   Treatment of penis lesion      T   00164    2.0194                Covered
54230   Prepare penis study            N                                  Covered
54231   Dynamic cavernosometry         T   00165   20.0243                Covered
54235   Penile injection               T   00164     2.0194               Not Covered
54240   Penis study                    T   00126     1.0958                Covered
54250   Penis study                    T   00164     2.0194                Covered
54300   Revision of penis              T   00181    34.8837                Covered
54304   Revision of penis              T   00181    34.8837                Covered
54308   Reconstruction of urethra      T   00181    34.8837                Covered
54312   Reconstruction of urethra      T   00181    34.8837                Covered
54316   Reconstruction of urethra      T   00181    34.8837                Covered
54318   Reconstruction of urethra      T   00181    34.8837                Covered
54322   Reconstruction of urethra      T   00181    34.8837                Covered
54324   Reconstruction of urethra      T   00181    34.8837                Covered
54326   Reconstruction of urethra      T   00181    34.8837                Covered
54328   Revise penis/urethra           T   00181    34.8837                Covered
54332   Revise penis/urethra           T   00181    34.8837                Covered
54336   Revise penis/urethra           T   00181    34.8837                Covered
54340   Secondary urethral surgery     T   00181    34.8837                Covered
54344   Secondary urethral surgery     T   00181    34.8837                Covered
54348   Secondary urethral surgery     T   00181    34.8837                Covered
54352   Reconstruct urethra/penis      T   00181    34.8837                Covered
54360   Penis plastic surgery          T   00181    34.8837                Covered
54380   Repair penis                   T   00181    34.8837                Covered
54385   Repair penis                   T   00181    34.8837                Covered
54390   Repair penis and bladder       C                      $1,297.37    Covered
54400   Insert semi-rigid prosthesis   S   00385    98.0867               Not Covered
54401   Insert self-contd prosthesis   S   00386   164.3200               Not Covered
54405   Insert multi-comp penis pros   S   00386   164.3200               Not Covered
54406   Remove muti-comp penis pros    T   00181    34.8837               Not Covered
54408   Repair multi-comp penis pros   T   00181    34.8837               Not Covered
54410   Remove/replace penis prosth    S   00386   164.3200               Not Covered
54411   Remov/replc penis pros, comp   C                                  Not Covered
54415   Remove self-contd penis pros   T   00181    34.8837               Not Covered
54416   Remv/repl penis contain pros   S   00386   164.3200               Not Covered
54417   Remv/replc penis pros, compl   C                                  Not Covered
54420   Revision of penis              T   00181    34.8837                Covered
54430   Revision of penis              C                      $633.88      Covered
54435   Revision of penis              T   00181    34.8837                Covered
54440   Repair of penis                T   00181    34.8837                Covered
54450   Preputial stretching           T   00156     3.0214                Covered
54500   Biopsy of testis               T   00037    15.5003                Covered
54505   Biopsy of testis               T   00183    23.2838                Covered
54512   Excise lesion testis           T   00183    23.2838                Covered
54520   Removal of testis              T   00183    23.2838                Covered
54522   Orchiectomy, partial           T   00183    23.2838                Covered
54530   Removal of testis              T   00154    31.9682                Covered
54535   Extensive testis surgery       T   00181    34.8837                Covered
54550   Exploration for testis         T   00154    31.9682                Covered
54560   Exploration for testis         T   00183    23.2838                Covered
54600   Reduce testis torsion          T   00183    23.2838                Covered
54620   Suspension of testis           T   00183    23.2838                Covered
54640   Suspension of testis           T   00154    31.9682                Covered
54650   Orchiopexy (Fowler-Stephens)   C                      $684.37      Covered
54660   Revision of testis             T   00183    23.2838               Not Covered
54670   Repair testis injury           T   00183   23.2838                Covered
54680   Relocation of testis(es)       T   00183   23.2838                Covered
54690   Laparoscopy, orchiectomy       T   00131   46.8400                Covered
54692   Laparoscopy, orchiopexy        T   00132   72.9582                Covered
54699   Laparoscope proc, testis       T   00130   38.0540                Covered
54700   Drainage of scrotum            T   00183   23.2838                Covered
54800   Biopsy of epididymis           T   00004    4.5991                Covered
54830   Remove epididymis lesion       T   00183   23.2838                Covered
54840   Remove epididymis lesion       T   00183   23.2838                Covered
54860   Removal of epididymis          T   00183   23.2838                Covered
54861   Removal of epididymis          T   00183   23.2838                Covered
54865   Explore epididymis             T   00183   23.2838                Covered
54900   Fusion of spermatic ducts      T   00183   23.2838               Not Covered
54901   Fusion of spermatic ducts      T   00183   23.2838               Not Covered
55000   Drainage of hydrocele          T   00004    4.5991                Covered
55040   Removal of hydrocele           T   00154   31.9682                Covered
55041   Removal of hydroceles          T   00154   31.9682                Covered
55060   Repair of hydrocele            T   00183   23.2838                Covered
55100   Drainage of scrotum abscess    T   00007   12.6217                Covered
55110   Explore scrotum                T   00183   23.2838                Covered
55120   Removal of scrotum lesion      T   00183   23.2838                Covered
55150   Removal of scrotum             T   00183   23.2838                Covered
55175   Revision of scrotum            T   00183   23.2838                Covered
55180   Revision of scrotum            T   00183   23.2838                Covered
55200   Incision of sperm duct         T   00183   23.2838                Covered
55250   Removal of sperm duct(s)       T   00183   23.2838                Covered
55300   Prepare, sperm duct x-ray      N                                  Covered
55400   Repair of sperm duct           T   00183   23.2838                Covered
55450   Ligation of sperm duct         T   00183   23.2838                Covered
55500   Removal of hydrocele           T   00183   23.2838                Covered
55520   Removal of sperm cord lesion   T   00183   23.2838                Covered
55530   Revise spermatic cord veins    T   00183   23.2838                Covered
55535   Revise spermatic cord veins    T   00154   31.9682                Covered
55540   Revise hernia & sperm veins    T   00154   31.9682                Covered
55550   Laparo ligate spermatic vein   T   00131   46.8400                Covered
55559   Laparo proc, spermatic cord    T   00130   38.0540                Covered
55600   Incise sperm duct pouch        T   00183   23.2838                Covered
55605   Incise sperm duct pouch        C                     $482.92      Covered
55650   Remove sperm duct pouch        C                     $678.37      Covered
55680   Remove sperm pouch lesion      T   00183   23.2838                Covered
55700   Biopsy of prostate             T   00184   12.4313                Covered
55705   Biopsy of prostate             T   00184   12.4313                Covered
55706   Prostate saturation sampling   T   00184   12.4313                Covered
55720   Drainage of prostate abscess   T   00162   25.5223                Covered
55725   Drainage of prostate abscess   T   00162   25.5223                Covered
55801   Removal of prostate            C                     $1,056.76    Covered
55810   Extensive prostate surgery     C                     $1,358.88    Covered
55812   Extensive prostate surgery     C                     $1,582.32    Covered
55815   Extensive prostate surgery     C                     $1,847.58    Covered
55821   Removal of prostate            C                      $913.37     Covered
55831   Removal of prostate            C                      $992.06     Covered
55840   Extensive prostate surgery     C                     $1,354.06    Covered
55842   Extensive prostate surgery     C                       $1,475.25    Covered
55845   Extensive prostate surgery     C                       $1,762.87    Covered
55860   Surgical exposure, prostate    T    00165    20.0243                Covered
55862   Extensive prostate surgery     C                       $1,073.35    Covered
55865   Extensive prostate surgery     C                       $1,495.60    Covered
55866   Laparo radical prostatectomy   C                       $1,505.76    Covered
55870   Electroejaculation             T    00189     3.4085               Not Covered
55873   Cryoablate prostate            T    00674   113.8626                Covered
55875   Transperi needle place, pros   Q3   00163    36.2009                Covered
55876   Place rt device/marker, pros   X    00310    13.7576                Covered
55899   Genital surgery procedure      T    00126     1.0958                Covered
55920   Place needles pelvic for rt    T    00153    27.1855                Covered
55970   Sex transformation, M to F     E                                   Not Covered
55980   Sex transformation, F to M     E                                   Not Covered
56405   I & D of vulva/perineum        T    00188     1.5277                Covered
56420   Drainage of gland abscess      T    00188     1.5277                Covered
56440   Surgery for vulva lesion       T    00193    20.0452                Covered
56441   Lysis of labial lesion(s)      T    00193    20.0452                Covered
56442   Hymenotomy                     T    00193    20.0452                Covered
56501   Destroy, vulva lesions, sim    T    00017    21.2653                Covered
56515   Destroy vulva lesion/s compl   T    00017    21.2653                Covered
56605   Biopsy of vulva/perineum       T    00189     3.4085                Covered
56606   Biopsy of vulva/perineum       T    00188     1.5277                Covered
56620   Partial removal of vulva       T    00193    20.0452                Covered
56625   Complete removal of vulva      T    00193    20.0452                Covered
56630   Extensive vulva surgery        C                        $836.95     Covered
56631   Extensive vulva surgery        C                       $1,103.76    Covered
56632   Extensive vulva surgery        C                       $1,293.41    Covered
56633   Extensive vulva surgery        C                       $1,066.35    Covered
56634   Extensive vulva surgery        C                       $1,212.19    Covered
56637   Extensive vulva surgery        C                       $1,426.43    Covered
56640   Extensive vulva surgery        C                       $1,405.18    Covered
56700   Partial removal of hymen       T    00193    20.0452                Covered
56740   Remove vagina gland lesion     T    00193    20.0452                Covered
56800   Repair of vagina               T    00193    20.0452                Covered
56805   Repair clitoris                T    00193    20.0452                Covered
56810   Repair of perineum             T    00193    20.0452                Covered
56820   Exam of vulva w/scope          T    00188     1.5277                Covered
56821   Exam/biopsy of vulva w/scope   T    00188     1.5277                Covered
57000   Exploration of vagina          T    00193    20.0452                Covered
57010   Drainage of pelvic abscess     T    00193    20.0452                Covered
57020   Drainage of pelvic fluid       T    00192     6.7949                Covered
57022   I & d vaginal hematoma, pp     T    00007    12.6217                Covered
57023   I & d vag hematoma, non-ob     T    00008    19.4063                Covered
57061   Destroy vag lesions, simple    T    00193    20.0452                Covered
57065   Destroy vag lesions, complex   T    00193    20.0452                Covered
57100   Biopsy of vagina               T    00192     6.7949                Covered
57105   Biopsy of vagina               T    00193    20.0452                Covered
57106   Remove vagina wall, partial    T    00193    20.0452                Covered
57107   Remove vagina tissue, part     T    00195    35.2666                Covered
57109   Vaginectomy partial w/nodes    T    00195    35.2666                Covered
57110   Remove vagina wall, complete   C                       $805.80      Covered
57111   Remove vagina tissue, compl    C                     $1,427.43   Covered
57112   Vaginectomy w/nodes, compl     C                     $1,521.73   Covered
57120   Closure of vagina              T   00195   35.2666               Covered
57130   Remove vagina lesion           T   00193   20.0452               Covered
57135   Remove vagina lesion           T   00193   20.0452               Covered
57150   Treat vagina infection         T   00188    1.5277               Covered
57155   Insert uteri tandems/ovoids    T   00192    6.7949               Covered
57160   Insert pessary/other device    T   00188    1.5277               Covered
57170   Fitting of diaphragm/cap       T   00191    0.1320               Covered
57180   Treat vaginal bleeding         T   00188    1.5277               Covered
57200   Repair of vagina               T   00193   20.0452               Covered
57210   Repair vagina/perineum         T   00193   20.0452               Covered
57220   Revision of urethra            T   00202   44.9894               Covered
57230   Repair of urethral lesion      T   00195   35.2666               Covered
57240   Repair bladder & vagina        T   00195   35.2666               Covered
57250   Repair rectum & vagina         T   00195   35.2666               Covered
57260   Repair of vagina               T   00195   35.2666               Covered
57265   Extensive repair of vagina     T   00202   44.9894               Covered
57267   Insert mesh/pelvic flr addon   T   00195   35.2666               Covered
57268   Repair of bowel bulge          T   00195   35.2666               Covered
57270   Repair of bowel pouch          C                     $688.39     Covered
57280   Suspension of vagina           C                     $850.39     Covered
57282   Colpopexy, extraperitoneal     T   00202   44.9894               Covered
57283   Colpopexy, intraperitoneal     T   00202   44.9894               Covered
57284   Repair paravag defect, open    T   00202   44.9894               Covered
57285   Repair paravag defect, vag     T   00202   44.9894               Covered
57287   Revise/remove sling repair     T   00195   35.2666               Covered
57288   Repair bladder defect          T   00202   44.9894               Covered
57289   Repair bladder & vagina        T   00195   35.2666               Covered
57291   Construction of vagina         T   00195   35.2666               Covered
57292   Construct vagina with graft    T   00195   35.2666               Covered
57295   Revise vag graft via vagina    T   00193   20.0452               Covered
57296   Revise vag graft, open abd     C                     $828.24     Covered
57300   Repair rectum-vagina fistula   T   00195   35.2666               Covered
57305   Repair rectum-vagina fistula   C                     $786.79     Covered
57307   Fistula repair & colostomy     C                     $858.78     Covered
57308   Fistula repair, transperine    C                     $607.81     Covered
57310   Repair urethrovaginal lesion   T   00202   44.9894               Covered
57311   Repair urethrovaginal lesion   C                     $486.65     Covered
57320   Repair bladder-vagina lesion   T   00195   35.2666               Covered
57330   Repair bladder-vagina lesion   T   00195   35.2666               Covered
57335   Repair vagina                  T   00195   35.2666               Covered
57400   Dilation of vagina             T   00193   20.0452               Covered
57410   Pelvic examination             T   00193   20.0452               Covered
57415   Remove vaginal foreign body    T   00193   20.0452               Covered
57420   Exam of vagina w/scope         T   00189    3.4085               Covered
57421   Exam/biopsy of vag w/scope     T   00189    3.4085               Covered
57423   Repair paravag defect, lap     T   00202   44.9894               Covered
57425   Laparoscopy, surg, colpopexy   T   00130   38.0540               Covered
57426   Revise prosth vag graft lap    T   00193   20.0452               Covered
57452   Exam of cervix w/scope         T   00188    1.5277               Covered
57454   Bx/curett of cervix w/scope    T   00189    3.4085               Covered
57455   Biopsy of cervix w/scope       T   00189    3.4085                Covered
57456   Endocerv curettage w/scope     T   00189    3.4085                Covered
57460   Bx of cervix w/scope, leep     T   00193   20.0452                Covered
57461   Conz of cervix w/scope, leep   T   00193   20.0452                Covered
57500   Biopsy of cervix               T   00192    6.7949                Covered
57505   Endocervical curettage         T   00192    6.7949                Covered
57510   Cauterization of cervix        T   00193   20.0452                Covered
57511   Cryocautery of cervix          T   00188    1.5277                Covered
57513   Laser surgery of cervix        T   00193   20.0452                Covered
57520   Conization of cervix           T   00193   20.0452                Covered
57522   Conization of cervix           T   00193   20.0452                Covered
57530   Removal of cervix              T   00195   35.2666                Covered
57531   Removal of cervix, radical     C                     $1,614.78    Covered
57540   Removal of residual cervix     C                      $693.37     Covered
57545   Remove cervix/repair pelvis    C                      $688.48     Covered
57550   Removal of residual cervix     T   00195   35.2666                Covered
57555   Remove cervix/repair vagina    T   00195   35.2666                Covered
57556   Remove cervix, repair bowel    T   00202   44.9894                Covered
57558   D&c of cervical stump          T   00193   20.0452                Covered
57700   Revision of cervix             T   00193   20.0452                Covered
57720   Revision of cervix             T   00193   20.0452                Covered
57800   Dilation of cervical canal     T   00193   20.0452                Covered
58100   Biopsy of uterus lining        T   00188    1.5277                Covered
58110   Bx done w/colposcopy add-on    N                                  Covered
58120   Dilation and curettage         T   00193   20.0452                Covered
58140   Myomectomy abdom method        C                     $829.68      Covered
58145   Myomectomy vag method          T   00195   35.2666                Covered
58146   Myomectomy abdom complex       C                     $1,004.72    Covered
58150   Total hysterectomy             C                      $879.98     Covered
58152   Total hysterectomy             C                      $917.07     Covered
58180   Partial hysterectomy           C                      $886.13     Covered
58200   Extensive hysterectomy         C                     $1,239.29    Covered
58210   Extensive hysterectomy         C                     $1,650.96    Covered
58240   Removal of pelvis contents     C                     $2,295.39    Covered
58260   Vaginal hysterectomy           T   00195   35.2666                Covered
58262   Vag hyst including t/o         T   00195   35.2666                Covered
58263   Vag hyst w/t/o & vag repair    T   00195   35.2666                Covered
58267   Vag hyst w/urinary repair      C                     $897.44      Covered
58270   Vag hyst w/enterocele repair   T   00195   35.2666                Covered
58275   Hysterectomy/revise vagina     C                      $888.13     Covered
58280   Hysterectomy/revise vagina     C                      $897.68     Covered
58285   Extensive hysterectomy         C                     $1,078.21    Covered
58290   Vag hyst complex               T   00202   44.9894                Covered
58291   Vag hyst incl t/o, complex     T   00202   44.9894                Covered
58292   Vag hyst t/o & repair, compl   T   00202   44.9894                Covered
58293   Vag hyst w/uro repair, compl   C                     $897.44      Covered
58294   Vag hyst w/enterocele, compl   T   00202   44.9894                Covered
58300   Insert intrauterine device     E                      $75.37      Covered
58301   Remove intrauterine device     T   00188    1.5277                Covered
58321   Artificial insemination        T   00189    3.4085               Not Covered
58322   Artificial insemination        T   00189    3.4085               Not Covered
58323   Sperm washing                  T   00189    3.4085               Not Covered
58340   Catheter for hysterography     N                                 Covered
58345   Reopen fallopian tube          T   00193   20.0452               Covered
58346   Insert heyman uteri capsule    T   00193   20.0452               Covered
58350   Reopen fallopian tube          T   00195   35.2666               Covered
58353   Endometr ablate, thermal       T   00195   35.2666               Covered
58356   Endometrial cryoablation       T   00202   44.9894               Covered
58400   Suspension of uterus           C                     $410.09     Covered
58410   Suspension of uterus           C                     $695.03     Covered
58520   Repair of ruptured uterus      C                     $636.86     Covered
58540   Revision of uterus             C                     $773.90     Covered
58541   Lsh, uterus 250 g or less      T   00132   72.9582               Covered
58542   Lsh w/t/o ut 250 g or less     T   00132   72.9582               Covered
58543   Lsh uterus above 250 g         T   00132   72.9582               Covered
58544   Lsh w/t/o uterus above 250 g   T   00132   72.9582               Covered
58545   Laparoscopic myomectomy        T   00130   38.0540               Covered
58546   Laparo-myomectomy, complex     T   00131   46.8400               Covered
58548   Lap radical hyst               C                     $1,584.61   Covered
58550   Laparo-asst vag hysterectomy   T   00132   72.9582               Covered
58552   Laparo-vag hyst incl t/o       T   00131   46.8400               Covered
58553   Laparo-vag hyst, complex       T   00131   46.8400               Covered
58554   Laparo-vag hyst w/t/o, compl   T   00131   46.8400               Covered
58555   Hysteroscopy, dx, sep proc     T   00190   22.5926               Covered
58558   Hysteroscopy, biopsy           T   00190   22.5926               Covered
58559   Hysteroscopy, lysis            T   00190   22.5926               Covered
58560   Hysteroscopy, resect septum    T   00387   37.2199               Covered
58561   Hysteroscopy, remove myoma     T   00387   37.2199               Covered
58562   Hysteroscopy, remove fb        T   00190   22.5926               Covered
58563   Hysteroscopy, ablation         T   00387   37.2199               Covered
58565   Hysteroscopy, sterilization    T   00202   44.9894               Covered
58570   Tlh, uterus 250 g or less      T   00131   46.8400               Covered
58571   Tlh w/t/o 250 g or less        T   00131   46.8400               Covered
58572   Tlh, uterus over 250 g         T   00131   46.8400               Covered
58573   Tlh w/t/o uterus over 250 g    T   00131   46.8400               Covered
58578   Laparo proc, uterus            T   00130   38.0540               Covered
58579   Hysteroscope procedure         T   00190   22.5926               Covered
58600   Division of fallopian tube     T   00195   35.2666               Covered
58605   Division of fallopian tube     C                     $234.91     Covered
58611   Ligate oviduct(s) add-on       C                     $241.67     Covered
58615   Occlude fallopian tube(s)      T   00193   20.0452               Covered
58660   Laparoscopy, lysis             T   00131   46.8400               Covered
58661   Laparoscopy, remove adnexa     T   00131   46.8400               Covered
58662   Laparoscopy, excise lesions    T   00131   46.8400               Covered
58670   Laparoscopy, tubal cautery     T   00131   46.8400               Covered
58671   Laparoscopy, tubal block       T   00131   46.8400               Covered
58672   Laparoscopy, fimbrioplasty     T   00131   46.8400               Covered
58673   Laparoscopy, salpingostomy     T   00131   46.8400               Covered
58679   Laparo proc, oviduct-ovary     T   00130   38.0540               Covered
58700   Removal of fallopian tube      C                     $428.47     Covered
58720   Removal of ovary/tube(s)       C                     $668.50     Covered
58740   Adhesiolysis tube, ovary       C                     $400.10     Covered
58750   Repair oviduct                 C                     $802.54     Covered
58752   Revise ovarian tube(s)         C                     $804.86     Covered
58760   Fimbrioplasty                  C                     $702.80      Covered
58770   Create new tubal opening       T   00195   35.2666                Covered
58800   Drainage of ovarian cyst(s)    T   00193   20.0452                Covered
58805   Drainage of ovarian cyst(s)    T   00195   35.2666                Covered
58820   Drain ovary abscess, open      T   00195   35.2666                Covered
58822   Drain ovary abscess, percut    C                     $539.96      Covered
58823   Drain pelvic abscess, percut   T   00193   20.0452                Covered
58825   Transposition, ovary(s)        C                     $370.91      Covered
58900   Biopsy of ovary(s)             T   00193   20.0452                Covered
58920   Partial removal of ovary(s)    T   00195   35.2666                Covered
58925   Removal of ovarian cyst(s)     T   00195   35.2666                Covered
58940   Removal of ovary(s)            C                      $466.66     Covered
58943   Removal of ovary(s)            C                     $1,082.86    Covered
58950   Resect ovarian malignancy      C                      $925.93     Covered
58951   Resect ovarian malignancy      C                     $1,347.22    Covered
58952   Resect ovarian malignancy      C                     $1,486.25    Covered
58953   Tah, rad dissect for debulk    C                     $1,794.02    Covered
58954   Tah rad debulk/lymph remove    C                     $1,950.59    Covered
58956   Bso, omentectomy w/tah         C                     $1,264.97    Covered
58957   Resect recurrent gyn mal       C                     $1,282.89    Covered
58958   Resect recur gyn mal w/lym     C                     $1,420.72    Covered
58960   Exploration of abdomen         C                      $927.89     Covered
58970   Retrieval of oocyte            T   00189    3.4085               Not Covered
58974   Transfer of embryo             T   00189    3.4085               Not Covered
58976   Transfer of embryo             T   00189    3.4085               Not Covered
58999   Genital surgery procedure      T   00191    0.1320                Covered
59000   Amniocentesis, diagnostic      T   00189    3.4085                Covered
59001   Amniocentesis, therapeutic     T   00192    6.7949                Covered
59012   Fetal cord puncture,prenatal   T   00189    3.4085                Covered
59015   Chorion biopsy                 T   00189    3.4085                Covered
59020   Fetal contract stress test     T   00188    1.5277                Covered
59025   Fetal non-stress test          T   00188    1.5277                Covered
59030   Fetal scalp blood sample       T   00189    3.4085                Covered
59050   Fetal monitor w/report         M                      $55.87      Covered
59051   Fetal monitor/interpret only   B                                 Not Covered
59070   Transabdom amnioinfus w/us     T   00188    1.5277                Covered
59072   Umbilical cord occlud w/us     T   00189    3.4085                Covered
59074   Fetal fluid drainage w/us      T   00189    3.4085                Covered
59076   Fetal shunt placement, w/us    T   00189    3.4085                Covered
59100   Remove uterus lesion           T   00195   35.2666                Covered
59120   Treat ectopic pregnancy        C                     $699.38      Covered
59121   Treat ectopic pregnancy        C                     $663.38      Covered
59130   Treat ectopic pregnancy        C                     $793.67      Covered
59135   Treat ectopic pregnancy        C                     $848.60      Covered
59136   Treat ectopic pregnancy        C                     $750.05      Covered
59140   Treat ectopic pregnancy        C                     $360.51      Covered
59150   Treat ectopic pregnancy        T   00131   46.8400                Covered
59151   Treat ectopic pregnancy        T   00131   46.8400                Covered
59160   D & c after delivery           T   00193   20.0452                Covered
59200   Insert cervical dilator        T   00188    1.5277                Covered
59300   Episiotomy or vaginal repair   T   00193   20.0452                Covered
59320   Revision of cervix             T   00193   20.0452                Covered
59325   Revision of cervix             C                     $247.85    Covered
59350   Repair of uterus               C                     $293.79    Covered
59400   Obstetrical care               B                               Not Covered
59409   Obstetrical care               T   00193   20.0452              Covered
59410   Obstetrical care               B                               Not Covered
59412   Antepartum manipulation        T   00193   20.0452              Covered
59414   Deliver placenta               T   00193   20.0452              Covered
59425   Antepartum care only           B                               Not Covered
59426   Antepartum care only           B                               Not Covered
59430   Care after delivery            B                               Not Covered
59510   Cesarean delivery              B                               Not Covered
59514   Cesarean delivery only         C                     $940.49    Covered
59515   Cesarean delivery              B                               Not Covered
59525   Remove uterus after cesarean   C                     $464.76    Covered
59610   Vbac delivery                  B                               Not Covered
59612   Vbac delivery only             T   00193   20.0452             Not Covered
59614   Vbac care after delivery       B                               Not Covered
59618   Attempted vbac delivery        B                               Not Covered
59620   Attempted vbac delivery only   C                               Not Covered
59622   Attempted vbac after care      B                               Not Covered
59812   Treatment of miscarriage       T   00193   20.0452              Covered
59820   Care of miscarriage            T   00193   20.0452              Covered
59821   Treatment of miscarriage       T   00193   20.0452              Covered
59830   Treat uterus infection         C                     $388.36    Covered
59840   Abortion                       T   00193   20.0452              Covered
59841   Abortion                       T   00193   20.0452              Covered
59850   Abortion                       C                     $351.80    Covered
59851   Abortion                       C                     $363.61    Covered
59852   Abortion                       C                     $502.93    Covered
59855   Abortion                       C                     $373.61    Covered
59856   Abortion                       C                     $452.29    Covered
59857   Abortion                       C                     $557.50    Covered
59866   Abortion (mpr)                 T   00189    3.4085             Not Covered
59870   Evacuate mole of uterus        T   00193   20.0452              Covered
59871   Remove cerclage suture         T   00193   20.0452              Covered
59897   Fetal invas px w/us            T   00191    0.1320              Covered
59898   Laparo proc, ob care/deliver   T   00130   38.0540              Covered
59899   Maternity care procedure       T   00191    0.1320              Covered
60000   Drain thyroid/tongue cyst      T   00252    7.6196              Covered
6005F   Care level rationale doc       M                               Not Covered
6005F   Care level rationale doc       M                               Not Covered
60100   Biopsy of thyroid              T   00004    4.5991              Covered
6010F   Dysphag test done b/4 eating   M                               Not Covered
6015F   Dysphag test done b/4 eating   M                               Not Covered
60200   Remove thyroid lesion          T   00114   48.7561              Covered
6020F   Npo (nothing-mouth) ordered    M                               Not Covered
60210   Partial thyroid excision       T   00114   48.7561              Covered
60212   Partial thyroid excision       T   00114   48.7561              Covered
60220   Partial removal of thyroid     T   00114   48.7561              Covered
60225   Partial removal of thyroid     T   00114   48.7561              Covered
60240   Removal of thyroid             T   00114   48.7561              Covered
60252   Removal of thyroid             T   00256   42.9827              Covered
60254   Extensive thyroid surgery      C                     $1,509.05    Covered
60260   Repeat thyroid surgery         T   00256   42.9827                Covered
60270   Removal of thyroid             C                     $1,155.37    Covered
60271   Removal of thyroid             T   00256   42.9827                Covered
60280   Remove thyroid duct lesion     T   00114   48.7561                Covered
60281   Remove thyroid duct lesion     T   00114   48.7561                Covered
60300   Aspir/inj thyroid cyst         T   00004    4.5991                Covered
6030F   Max sterile barriers follwd    M                                 Not Covered
6040F   Appro rad ds dvcs techs docd   M                                 Not Covered
6045F   Radxps in end rprt4fluro pxd   M                                 Not Covered
60500   Explore parathyroid glands     T   00256   42.9827                Covered
60502   Re-explore parathyroids        T   00256   42.9827                Covered
60505   Explore parathyroid glands     C                     $1,286.80    Covered
60512   Autotransplant parathyroid     T   00022   23.3880                Covered
60520   Removal of thymus gland        T   00256   42.9827                Covered
60521   Removal of thymus gland        C                     $1,246.29    Covered
60522   Removal of thymus gland        C                     $1,429.70    Covered
60540   Explore adrenal gland          C                     $1,007.48    Covered
60545   Explore adrenal gland          C                     $1,190.45    Covered
60600   Remove carotid body lesion     C                     $1,160.91    Covered
60605   Remove carotid body lesion     C                     $1,280.91    Covered
60650   Laparoscopy adrenalectomy      C                     $1,067.87    Covered
60659   Laparo proc, endocrine         T   00130   38.0540                Covered
60699   Endocrine surgery procedure    T   00114   48.7561                Covered
6070F   Pt asked/cnsld aed effects     E                                 Not Covered
61000   Remove cranial cavity fluid    T   00207    7.2002                Covered
61001   Remove cranial cavity fluid    T   00207    7.2002                Covered
61020   Remove brain cavity fluid      T   00207    7.2002                Covered
61026   Injection into brain canal     T   00207    7.2002                Covered
61050   Remove brain canal fluid       T   00207    7.2002                Covered
61055   Injection into brain canal     T   00207    7.2002                Covered
61070   Brain canal shunt procedure    T   00121    6.3742                Covered
61105   Twist drill hole               C                      $375.58     Covered
61107   Drill skull for implantation   C                      $356.97     Covered
61108   Drill skull for drainage       C                      $742.67     Covered
61120   Burr hole for puncture         C                      $568.67     Covered
61140   Pierce skull for biopsy        C                     $1,078.02    Covered
61150   Pierce skull for drainage      C                     $1,166.77    Covered
61151   Pierce skull for drainage      C                      $691.90     Covered
61154   Pierce skull & remove clot     C                     $1,079.82    Covered
61156   Pierce skull for drainage      C                     $1,142.00    Covered
61210   Pierce skull, implant device   C                      $408.75     Covered
61215   Insert brain-fluid device      T   00224   41.0288                Covered
61250   Pierce skull & explore         C                      $689.03     Covered
61253   Pierce skull & explore         C                      $809.19     Covered
61304   Open skull for exploration     C                     $1,555.31    Covered
61305   Open skull for exploration     C                     $1,877.80    Covered
61312   Open skull for drainage        C                     $1,696.75    Covered
61313   Open skull for drainage        C                     $1,712.87    Covered
61314   Open skull for drainage        C                     $1,706.17    Covered
61315   Open skull for drainage        C                     $1,857.48    Covered
61316   Implt cran bone flap to abdo   C                       $77.42     Covered
61320   Open skull for drainage        C                   $1,645.92   Covered
61321   Open skull for drainage        C                   $1,797.89   Covered
61322   Decompressive craniotomy       C                   $1,609.51   Covered
61323   Decompressive lobectomy        C                   $1,669.33   Covered
61330   Decompress eye socket          T 00256   42.9827               Covered
61332   Explore/biopsy eye socket      C                   $1,800.64   Covered
61333   Explore orbit/remove lesion    C                   $1,755.13   Covered
61334   Explore orbit/remove object    T 00256   42.9827               Covered
61340   Subtemporal decompression      C                   $1,231.06   Covered
61343   Incise skull (press relief)    C                   $2,073.16   Covered
61345   Relieve cranial pressure       C                   $1,754.42   Covered
61440   Incise skull for surgery       C                   $1,660.50   Covered
61450   Incise skull for surgery       C                   $1,686.69   Covered
61458   Incise skull for brain wound   C                   $1,888.02   Covered
61460   Incise skull for surgery       C                   $1,890.75   Covered
61470   Incise skull for surgery       C                   $1,548.81   Covered
61480   Incise skull for surgery       C                   $1,615.93   Covered
61490   Incise skull for surgery       C                   $1,514.93   Covered
61500   Removal of skull lesion        C                   $1,272.47   Covered
61501   Remove infected skull bone     C                   $1,052.83   Covered
61510   Removal of brain lesion        C                   $1,944.53   Covered
61512   Remove brain lining lesion     C                   $2,314.67   Covered
61514   Removal of brain abscess       C                   $1,755.35   Covered
61516   Removal of brain lesion        C                   $1,747.11   Covered
61517   Implt brain chemotx add-on     C                     $69.00    Covered
61518   Removal of brain lesion        C                   $2,456.77   Covered
61519   Remove brain lining lesion     C                   $2,680.09   Covered
61520   Removal of brain lesion        C                   $3,390.12   Covered
61521   Removal of brain lesion        C                   $2,853.40   Covered
61522   Removal of brain abscess       C                   $1,875.63   Covered
61524   Removal of brain lesion        C                   $1,928.25   Covered
61526   Removal of brain lesion        C                   $3,200.12   Covered
61530   Removal of brain lesion        C                   $2,826.29   Covered
61531   Implant brain electrodes       C                   $1,041.72   Covered
61533   Implant brain electrodes       C                   $1,328.45   Covered
61534   Removal of brain lesion        C                   $1,197.17   Covered
61535   Remove brain electrodes        C                    $745.70    Covered
61536   Removal of brain lesion        C                   $2,222.62   Covered
61537   Removal of brain tissue        C                   $1,571.68   Covered
61538   Removal of brain tissue        C                   $1,911.91   Covered
61539   Removal of brain tissue        C                   $2,065.37   Covered
61540   Removal of brain tissue        C                   $1,782.25   Covered
61541   Incision of brain tissue       C                   $1,837.77   Covered
61542   Removal of brain tissue        C                   $1,966.19   Covered
61543   Removal of brain tissue        C                   $1,798.90   Covered
61544   Remove & treat brain lesion    C                   $1,771.72   Covered
61545   Excision of brain tumor        C                   $2,702.50   Covered
61546   Removal of pituitary gland     C                   $2,094.50   Covered
61548   Removal of pituitary gland     C                   $1,529.26   Covered
61550   Release of skull seams         C                    $907.62    Covered
61552   Release of skull seams         C                   $1,159.08   Covered
61556   Incise skull/sutures           C                   $1,376.24   Covered
61557   Incise skull/sutures           C                   $1,406.53   Covered
61558   Excision of skull/sutures      C                   $1,618.57   Covered
61559   Excision of skull/sutures      C                   $2,095.31   Covered
61563   Excision of skull tumor        C                   $1,696.95   Covered
61564   Excision of skull tumor        C                   $2,034.62   Covered
61566   Removal of brain tissue        C                   $1,537.90   Covered
61567   Incision of brain tissue       C                   $1,537.90   Covered
61570   Remove foreign body, brain     C                   $1,537.90   Covered
61571   Incise skull for brain wound   C                   $1,666.25   Covered
61575   Skull base/brainstem surgery   C                   $2,335.84   Covered
61576   Skull base/brainstem surgery   C                   $3,133.24   Covered
61580   Craniofacial approach, skull   C                   $1,879.09   Covered
61581   Craniofacial approach, skull   C                   $2,117.89   Covered
61582   Craniofacial approach, skull   C                   $1,993.56   Covered
61583   Craniofacial approach, skull   C                   $2,310.48   Covered
61584   Orbitocranial approach/skull   C                   $2,201.31   Covered
61585   Orbitocranial approach/skull   C                   $2,445.76   Covered
61586   Resect nasopharynx, skull      C                   $1,644.34   Covered
61590   Infratemporal approach/skull   C                   $2,594.95   Covered
61591   Infratemporal approach/skull   C                   $2,739.85   Covered
61592   Orbitocranial approach/skull   C                   $2,525.03   Covered
61595   Transtemporal approach/skull   C                   $1,851.55   Covered
61596   Transcochlear approach/skull   C                   $2,223.35   Covered
61597   Transcondylar approach/skull   C                   $2,382.79   Covered
61598   Transpetrosal approach/skull   C                   $2,105.46   Covered
61600   Resect/excise cranial lesion   C                   $1,605.55   Covered
61601   Resect/excise cranial lesion   C                   $1,773.21   Covered
61605   Resect/excise cranial lesion   C                   $1,814.79   Covered
61606   Resect/excise cranial lesion   C                   $2,473.80   Covered
61607   Resect/excise cranial lesion   C                   $2,304.77   Covered
61608   Resect/excise cranial lesion   C                   $2,687.03   Covered
61609   Transect artery, sinus         C                    $619.66    Covered
61610   Transect artery, sinus         C                   $1,839.94   Covered
61611   Transect artery, sinus         C                    $453.84    Covered
61612   Transect artery, sinus         C                   $1,735.81   Covered
61613   Remove aneurysm, sinus         C                   $2,619.25   Covered
61615   Resect/excise lesion, skull    C                   $2,018.60   Covered
61616   Resect/excise lesion, skull    C                   $2,757.15   Covered
61618   Repair dura                    C                   $1,083.57   Covered
61619   Repair dura                    C                   $1,312.80   Covered
61623   Endovasc tempory vessel occl   T 00082   93.3244               Covered
61624   Transcath occlusion, cns       C                   $1,140.19   Covered
61626   Transcath occlusion, non-cns   T 00082   93.3244               Covered
61630   Intracranial angioplasty       C                    $502.43    Covered
61635   Intracran angioplsty w/stent   C                   $1,074.18   Covered
61640   Dilate ic vasospasm, init      E                    $502.43    Covered
61641   Dilate ic vasospasm add-on     E                    $502.43    Covered
61642   Dilate ic vasospasm add-on     E                    $502.43    Covered
61680   Intracranial vessel surgery    C                   $2,140.44   Covered
61682   Intracranial vessel surgery    C                   $3,754.33   Covered
61684   Intracranial vessel surgery    C                   $2,592.35   Covered
61686   Intracranial vessel surgery    C                   $3,931.49   Covered
61690   Intracranial vessel surgery    C                      $1,985.91     Covered
61692   Intracranial vessel surgery    C                      $3,126.15     Covered
61697   Brain aneurysm repr, complx    C                                  Not Covered
61698   Brain aneurysm repr, complx    C                                   By Report
61700   Brain aneurysm repr, simple    C                                  Not Covered
61702   Inner skull vessel surgery     C                      $3,120.32     Covered
61703   Clamp neck artery              C                      $1,122.56     Covered
61705   Revise circulation to head     C                      $2,366.62     Covered
61708   Revise circulation to head     C                      $2,022.93     Covered
61710   Revise circulation to head     C                      $1,677.42     Covered
61711   Fusion of skull arteries       C                      $2,445.26     Covered
61720   Incise skull/brain surgery     T   00221    37.2806                 Covered
61735   Incise skull/brain surgery     C                      $1,292.72     Covered
61750   Incise skull/brain biopsy      C                      $1,181.28     Covered
61751   Brain biopsy w/ct/mr guide     C                      $1,261.61     Covered
61760   Implant brain electrodes       C                      $1,300.96     Covered
61770   Incise skull for treatment     T   00221    37.2806                 Covered
61790   Treat trigeminal nerve         T   00220    18.7200                 Covered
61791   Treat trigeminal tract         T   00203    13.2439                 Covered
61793   Focus radiation beam           D                                  Not Covered
61795   Brain surgery using computer   N                                    Covered
61796   Srs, cranial lesion simple     B                                  Not Covered
61797   Srs, cran les simple, addl     B                                  Not Covered
61798   Srs, cranial lesion complex    B                                  Not Covered
61799   Srs, cran les complex, addl    B                                  Not Covered
61800   Apply srs headframe add-on     B                                  Not Covered
61850   Implant neuroelectrodes        C                       $848.53      Covered
61860   Implant neuroelectrodes        C                      $1,233.11     Covered
61863   Implant neuroelectrode         C                       $886.53      Covered
61864   Implant neuroelectrde, addl    C                       $254.90      Covered
61867   Implant neuroelectrode         C                      $1,349.77     Covered
61868   Implant neuroelectrde, add'l   C                       $431.79      Covered
61870   Implant neuroelectrodes        C                       $841.92      Covered
61875   Implant neuroelectrodes        C                       $893.11      Covered
61880   Revise/remove neuroelectrode   T   00687    19.6381                 Covered
61885   Insrt/redo neurostim 1 array   S   00039   206.1011                 Covered
61886   Implant neurostim arrays       S   00315   274.7397                 Covered
61888   Revise/remove neuroreceiver    T   00688    28.6636                 Covered
62000   Treat skull fracture           T   00254    24.9637                 Covered
62005   Treat skull fracture           C                      $1,001.59     Covered
62010   Treatment of head injury       C                      $1,362.39     Covered
62100   Repair brain fluid leakage     C                      $1,526.33     Covered
62115   Reduction of skull defect      C                      $1,322.48     Covered
62116   Reduction of skull defect      C                      $1,499.22     Covered
62117   Reduction of skull defect      C                      $1,715.64     Covered
62120   Repair skull cavity lesion     C                      $1,484.70     Covered
62121   Incise skull repair            C                      $1,420.98     Covered
62140   Repair of skull defect         C                       $947.36      Covered
62141   Repair of skull defect         C                      $1,075.47     Covered
62142   Remove skull plate/flap        C                       $783.84      Covered
62143   Replace skull plate/flap       C                       $851.50      Covered
62145   Repair of skull & brain        C                      $1,215.17     Covered
62146   Repair of skull with graft     C                      $1,032.51    Covered
62147   Repair of skull with graft     C                      $1,221.82    Covered
62148   Retr bone flap to fix skull    C                       $107.21     Covered
62160   Neuroendoscopy add-on          N                                   Covered
62161   Dissect brain w/scope          C                      $1,107.94    Covered
62162   Remove colloid cyst w/scope    C                      $1,411.06    Covered
62163   Neuroendoscopy w/fb removal    C                       $891.49     Covered
62164   Remove brain tumor w/scope     C                      $1,530.98    Covered
62165   Remove pituit tumor w/scope    C                      $1,208.97    Covered
62180   Establish brain cavity shunt   C                      $1,347.39    Covered
62190   Establish brain cavity shunt   C                       $801.44     Covered
62192   Establish brain cavity shunt   C                       $889.14     Covered
62194   Replace/irrigate catheter      T   00207     7.2002                Covered
62200   Establish brain cavity shunt   C                      $1,260.18    Covered
62201   Brain cavity shunt w/scope     C                       $934.48     Covered
62220   Establish brain cavity shunt   C                       $941.87     Covered
62223   Establish brain cavity shunt   C                       $929.88     Covered
62225   Replace/irrigate catheter      T   00427    15.3103                Covered
62230   Replace/revise brain shunt     T   00224    41.0288                Covered
62252   Csf shunt reprogram            S   00691     2.5406                Covered
62256   Remove brain cavity shunt      C                       $477.76     Covered
62258   Replace brain cavity shunt     C                      $1,014.66    Covered
62263   Epidural lysis mult sessions   T   00207     7.2002                Covered
62264   Epidural lysis on single day   T   00203    13.2439                Covered
62267   Interdiscal perq aspir, dx     T   00004     4.5991                Covered
62268   Drain spinal cord cyst         T   00207     7.2002                Covered
62269   Needle biopsy, spinal cord     T   00685     9.6666                Covered
62270   Spinal fluid tap, diagnostic   T   00206     3.7221                Covered
62272   Drain cerebro spinal fluid     T   00206     3.7221                Covered
62273   Inject epidural patch          T   00206     3.7221                Covered
62280   Treat spinal cord lesion       T   00207     7.2002                Covered
62281   Treat spinal cord lesion       T   00207     7.2002                Covered
62282   Treat spinal canal lesion      T   00207     7.2002                Covered
62284   Injection for myelogram        N                                   Covered
62287   Percutaneous diskectomy        T   00221    37.2806                Covered
62290   Inject for spine disk x-ray    N                                   Covered
62291   Inject for spine disk x-ray    N                                   Covered
62292   Injection into disk lesion     T   00207     7.2002                Covered
62294   Injection into spinal artery   T   00207     7.2002                Covered
62310   Inject spine c/t               T   00207     7.2002                Covered
62311   Inject spine l/s (cd)          T   00207     7.2002                Covered
62318   Inject spine w/cath, c/t       T   00207     7.2002                Covered
62319   Inject spine w/cath l/s (cd)   T   00207     7.2002                Covered
62350   Implant spinal canal cath      T   00224    41.0288                Covered
62351   Implant spinal canal cath      T   00208    49.2256               Not Covered
62355   Remove spinal canal catheter   T   00203    13.2439                Covered
62360   Insert spine infusion device   T   00224    41.0288                Covered
62361   Implant spine infusion pump    T   00227   198.6572                Covered
62362   Implant spine infusion pump    T   00227   198.6572                Covered
62365   Remove spine infusion device   T   00221    37.2806                Covered
62367   Analyze spine infusion pump    S   00691     2.5406                Covered
62368   Analyze spine infusion pump    S   00691     2.5406                Covered
63001   Removal of spinal lamina       T   00208   49.2256                Covered
63003   Removal of spinal lamina       T   00208   49.2256                Covered
63005   Removal of spinal lamina       T   00208   49.2256                Covered
63011   Removal of spinal lamina       T   00208   49.2256                Covered
63012   Removal of spinal lamina       T   00208   49.2256                Covered
63015   Removal of spinal lamina       T   00208   49.2256                Covered
63016   Removal of spinal lamina       T   00208   49.2256                Covered
63017   Removal of spinal lamina       T   00208   49.2256                Covered
63020   Neck spine disk surgery        T   00208   49.2256                Covered
63030   Low back disk surgery          T   00208   49.2256                Covered
63035   Spinal disk surgery add-on     T   00208   49.2256                Covered
63040   Laminotomy, single cervical    T   00208   49.2256                Covered
63042   Laminotomy, single lumbar      T   00208   49.2256                Covered
63043   Laminotomy, add'l cervical     C                                 By Report
63044   Laminotomy, add'l lumbar       C                                 By Report
63045   Removal of spinal lamina       T   00208   49.2256                Covered
63046   Removal of spinal lamina       T   00208   49.2256                Covered
63047   Removal of spinal lamina       T   00208   49.2256                Covered
63048   Remove spinal lamina add-on    T   00208   49.2256                Covered
63050   Cervical laminoplasty          C                     $1,331.64    Covered
63051   C-laminoplasty w/graft/plate   C                     $1,525.49    Covered
63055   Decompress spinal cord         T   00208   49.2256                Covered
63056   Decompress spinal cord         T   00208   49.2256                Covered
63057   Decompress spine cord add-on   T   00208   49.2256                Covered
63064   Decompress spinal cord         T   00208   49.2256                Covered
63066   Decompress spine cord add-on   T   00208   49.2256                Covered
63075   Neck spine disk surgery        T   00208   49.2256                Covered
63076   Neck spine disk surgery        T   00208   49.2256                Covered
63077   Spine disk surgery, thorax     C                     $1,432.39    Covered
63078   Spine disk surgery, thorax     C                      $205.29     Covered
63081   Removal of vertebral body      C                     $1,712.88    Covered
63082   Remove vertebral body add-on   C                      $304.09     Covered
63085   Removal of vertebral body      C                     $1,884.03    Covered
63086   Remove vertebral body add-on   C                      $220.34     Covered
63087   Removal of vertebral body      C                     $2,296.44    Covered
63088   Remove vertebral body add-on   C                      $297.77     Covered
63090   Removal of vertebral body      C                     $1,948.27    Covered
63091   Remove vertebral body add-on   C                      $195.45     Covered
63101   Removal of vertebral body      C                     $1,862.91    Covered
63102   Removal of vertebral body      C                     $1,862.91    Covered
63103   Remove vertebral body add-on   C                      $195.45     Covered
63170   Incise spinal cord tract(s)    C                     $1,387.21    Covered
63172   Drainage of spinal cyst        C                     $1,296.61    Covered
63173   Drainage of spinal cyst        C                     $1,437.82    Covered
63180   Revise spinal cord ligaments   C                     $1,162.08    Covered
63182   Revise spinal cord ligaments   C                     $1,335.94    Covered
63185   Incise spinal column/nerves    C                     $1,049.60    Covered
63190   Incise spinal column/nerves    C                     $1,253.64    Covered
63191   Incise spinal column/nerves    C                     $1,127.22    Covered
63194   Incise spinal column & cord    C                     $1,235.90    Covered
63195   Incise spinal column & cord    C                     $1,244.21    Covered
63196   Incise spinal column & cord    C                     $1,405.08    Covered
63197   Incise spinal column & cord    C                      $1,338.76    Covered
63198   Incise spinal column & cord    C                      $1,519.91    Covered
63199   Incise spinal column & cord    C                      $1,759.72    Covered
63200   Release of spinal cord         C                      $1,223.96    Covered
63250   Revise spinal cord vessels     C                      $2,498.07    Covered
63251   Revise spinal cord vessels     C                      $2,495.86    Covered
63252   Revise spinal cord vessels     C                      $2,584.72    Covered
63265   Excise intraspinal lesion      C                      $1,506.84    Covered
63266   Excise intraspinal lesion      C                      $1,593.81    Covered
63267   Excise intraspinal lesion      C                      $1,283.30    Covered
63268   Excise intraspinal lesion      C                      $1,144.80    Covered
63270   Excise intraspinal lesion      C                      $1,706.25    Covered
63271   Excise intraspinal lesion      C                      $1,863.26    Covered
63272   Excise intraspinal lesion      C                      $1,714.11    Covered
63273   Excise intraspinal lesion      C                      $1,564.81    Covered
63275   Biopsy/excise spinal tumor     C                      $1,682.49    Covered
63276   Biopsy/excise spinal tumor     C                      $1,658.50    Covered
63277   Biopsy/excise spinal tumor     C                      $1,480.83    Covered
63278   Biopsy/excise spinal tumor     C                      $1,460.32    Covered
63280   Biopsy/excise spinal tumor     C                      $1,962.22    Covered
63281   Biopsy/excise spinal tumor     C                      $1,936.97    Covered
63282   Biopsy/excise spinal tumor     C                      $1,790.36    Covered
63283   Biopsy/excise spinal tumor     C                      $1,588.77    Covered
63285   Biopsy/excise spinal tumor     C                      $2,279.77    Covered
63286   Biopsy/excise spinal tumor     C                      $2,333.16    Covered
63287   Biopsy/excise spinal tumor     C                      $2,340.47    Covered
63290   Biopsy/excise spinal tumor     C                      $2,390.01    Covered
63295   Repair of laminectomy defect   C                       $304.19     Covered
63300   Removal of vertebral body      C                      $1,561.79    Covered
63301   Removal of vertebral body      C                      $1,723.53    Covered
63302   Removal of vertebral body      C                      $1,786.85    Covered
63303   Removal of vertebral body      C                      $1,846.12    Covered
63304   Removal of vertebral body      C                                  Not Covered
63305   Removal of vertebral body      C                      $2,009.83    Covered
63306   Removal of vertebral body      C                      $2,025.39    Covered
63307   Removal of vertebral body      C                      $1,977.93    Covered
63308   Remove vertebral body add-on   C                       $331.75     Covered
63600   Remove spinal cord lesion      T   00220    18.7200                Covered
63610   Stimulation of spinal cord     T   00220    18.7200                Covered
63615   Remove lesion of spinal cord   T   00220    18.7200                Covered
63620   Srs, spinal lesion             B                                  Not Covered
63621   Srs, spinal lesion, addl       B                                  Not Covered
63650   Implant neuroelectrodes        S   00040    65.7095                Covered
63655   Implant neuroelectrodes        S   00061    86.5171                Covered
63660   Revise/remove neuroelectrode   D                                  Not Covered
63661   Remove spine eltrd perq aray   T   00687    19.6381                Covered
63662   Remove spine eltrd plate       T   00687    19.6381                Covered
63663   Revise spine eltrd perq aray   T   00687    19.6381                Covered
63664   Revise spine eltrd plate       T   00687    19.6381                Covered
63685   Insrt/redo spine n generator   S   00039   206.1011                Covered
63688   Revise/remove neuroreceiver    T   00688    28.6636                Covered
63700   Repair of spinal herniation    C                      $1,047.77    Covered
63702   Repair of spinal herniation    C                     $1,179.99    Covered
63704   Repair of spinal herniation    C                     $1,329.77    Covered
63706   Repair of spinal herniation    C                     $1,475.00    Covered
63707   Repair spinal fluid leakage    C                      $810.51     Covered
63709   Repair spinal fluid leakage    C                     $1,021.54    Covered
63710   Graft repair of spine defect   C                      $907.29     Covered
63740   Install spinal shunt           C                      $823.62     Covered
63741   Install spinal shunt           T   00224   41.0288                Covered
63744   Revision of spinal shunt       T   00224   41.0288                Covered
63746   Removal of spinal shunt        T   00203   13.2439                Covered
64400   N block inj, trigeminal        T   00204    2.5558                Covered
64402   N block inj, facial            T   00204    2.5558                Covered
64405   N block inj, occipital         T   00206    3.7221                Covered
64408   N block inj, vagus             T   00207    7.2002                Covered
64410   N block inj, phrenic           T   00207    7.2002                Covered
64412   N block inj, spinal accessor   T   00207    7.2002                Covered
64413   N block inj, cervical plexus   T   00206    3.7221                Covered
64415   N block inj, brachial plexus   T   00206    3.7221                Covered
64416   N block cont infuse, b plex    T   00207    7.2002                Covered
64417   N block inj, axillary          T   00206    3.7221                Covered
64418   N block inj, suprascapular     T   00206    3.7221                Covered
64420   N block inj, intercost, sng    T   00206    3.7221                Covered
64421   N block inj, intercost, mlt    T   00207    7.2002                Covered
64425   N block inj, ilio-ing/hypogi   T   00206    3.7221                Covered
64430   N block inj, pudendal          T   00207    7.2002                Covered
64435   N block inj, paracervical      T   00206    3.7221                Covered
64445   N block inj, sciatic, sng      T   00207    7.2002                Covered
64446   N blk inj, sciatic, cont inf   T   00207    7.2002                Covered
64447   N block inj fem, single        T   00206    3.7221                Covered
64448   N block inj fem, cont inf      T   00207    7.2002                Covered
64449   N block inj, lumbar plexus     T   00207    7.2002                Covered
64450   N block, other peripheral      T   00206    3.7221                Covered
64455   N block inj, plantar digit     T   00204    2.5558                Covered
64470   Inj paravertebral c/t          D                                 Not Covered
64472   Inj paravertebral c/t add-on   D                                 Not Covered
64475   Inj paravertebral l/s          D                                 Not Covered
64476   Inj paravertebral l/s add-on   D                                 Not Covered
64479   Inj foramen epidural c/t       T   00207    7.2002                Covered
64480   Inj foramen epidural add-on    T   00206    3.7221                Covered
64483   Inj foramen epidural l/s       T   00207    7.2002                Covered
64484   Inj foramen epidural add-on    T   00206    3.7221                Covered
64490   Inj paravert f jnt c/t 1 lev   T   00207    7.2002                Covered
64491   Inj paravert f jnt c/t 2 lev   T   00204    2.5558                Covered
64492   Inj paravert f jnt c/t 3 lev   T   00204    2.5558                Covered
64493   Inj paravert f jnt l/s 1 lev   T   00207    7.2002                Covered
64494   Inj paravert f jnt l/s 2 lev   T   00204    2.5558                Covered
64495   Inj paravert f jnt l/s 3 lev   T   00204    2.5558                Covered
64505   N block, spenopalatine gangl   T   00204    2.5558                Covered
64508   N block, carotid sinus s/p     T   00204    2.5558                Covered
64510   N block, stellate ganglion     T   00207    7.2002                Covered
64517   N block inj, hypogas plxs      T   00207    7.2002                Covered
64520   N block, lumbar/thoracic       T   00207    7.2002                Covered
64530   N block inj, celiac pelus      T   00207     7.2002            Covered
64550   Apply neurostimulator          A                      $25.96   Covered
64553   Implant neuroelectrodes        S   00040    65.7095            Covered
64555   Implant neuroelectrodes        S   00040    65.7095            Covered
64560   Implant neuroelectrodes        S   00040    65.7095            Covered
64561   Implant neuroelectrodes        S   00040    65.7095            Covered
64565   Implant neuroelectrodes        S   00040    65.7095            Covered
64573   Implant neuroelectrodes        S   00225   157.9390            Covered
64575   Implant neuroelectrodes        S   00061    86.5171            Covered
64577   Implant neuroelectrodes        S   00061    86.5171            Covered
64580   Implant neuroelectrodes        S   00061    86.5171            Covered
64581   Implant neuroelectrodes        S   00061    86.5171            Covered
64585   Revise/remove neuroelectrode   T   00687    19.6381            Covered
64590   Insrt/redo pn/gastr stimul     S   00039   206.1011            Covered
64595   Revise/rmv pn/gastr stimul     T   00688    28.6636            Covered
64600   Injection treatment of nerve   T   00203    13.2439            Covered
64605   Injection treatment of nerve   T   00220    18.7200            Covered
64610   Injection treatment of nerve   T   00220    18.7200            Covered
64612   Destroy nerve, face muscle     T   00204     2.5558            Covered
64613   Destroy nerve, neck muscle     T   00206     3.7221            Covered
64614   Destroy nerve, extrem musc     T   00206     3.7221            Covered
64620   Injection treatment of nerve   T   00207     7.2002            Covered
64622   Destr paravertebrl nerve l/s   T   00203    13.2439            Covered
64623   Destr paravertebral n add-on   T   00207     7.2002            Covered
64626   Destr paravertebrl nerve c/t   T   00207     7.2002            Covered
64627   Destr paravertebral n add-on   T   00204     2.5558            Covered
64630   Injection treatment of nerve   T   00207     7.2002            Covered
64632   N block inj, common digit      T   00204     2.5558            Covered
64640   Injection treatment of nerve   T   00207     7.2002            Covered
64650   Chemodenerv eccrine glands     T   00204     2.5558            Covered
64653   Chemodenerv eccrine glands     T   00204     2.5558            Covered
64680   Injection treatment of nerve   T   00207     7.2002            Covered
64681   Injection treatment of nerve   T   00203    13.2439            Covered
64702   Revise finger/toe nerve        T   00220    18.7200            Covered
64704   Revise hand/foot nerve         T   00220    18.7200            Covered
64708   Revise arm/leg nerve           T   00220    18.7200            Covered
64712   Revision of sciatic nerve      T   00220    18.7200            Covered
64713   Revision of arm nerve(s)       T   00220    18.7200            Covered
64714   Revise low back nerve(s)       T   00220    18.7200            Covered
64716   Revision of cranial nerve      T   00220    18.7200            Covered
64718   Revise ulnar nerve at elbow    T   00220    18.7200            Covered
64719   Revise ulnar nerve at wrist    T   00220    18.7200            Covered
64721   Carpal tunnel surgery          T   00220    18.7200            Covered
64722   Relieve pressure on nerve(s)   T   00220    18.7200            Covered
64726   Release foot/toe nerve         T   00220    18.7200            Covered
64727   Internal nerve revision        T   00220    18.7200            Covered
64732   Incision of brow nerve         T   00220    18.7200            Covered
64734   Incision of cheek nerve        T   00220    18.7200            Covered
64736   Incision of chin nerve         T   00220    18.7200            Covered
64738   Incision of jaw nerve          T   00220    18.7200            Covered
64740   Incision of tongue nerve       T   00220    18.7200            Covered
64742   Incision of facial nerve       T   00220    18.7200            Covered
64744   Incise nerve, back of head     T   00220   18.7200             Covered
64746   Incise diaphragm nerve         T   00220   18.7200             Covered
64752   Incision of vagus nerve        C                     $441.73   Covered
64755   Incision of stomach nerves     C                     $823.37   Covered
64760   Incision of vagus nerve        C                     $455.12   Covered
64761   Incision of pelvis nerve       T   00220   18.7200             Covered
64763   Incise hip/thigh nerve         T   00220   18.7200             Covered
64766   Incise hip/thigh nerve         T   00221   37.2806             Covered
64771   Sever cranial nerve            T   00220   18.7200             Covered
64772   Incision of spinal nerve       T   00220   18.7200             Covered
64774   Remove skin nerve lesion       T   00220   18.7200             Covered
64776   Remove digit nerve lesion      T   00220   18.7200             Covered
64778   Digit nerve surgery add-on     T   00220   18.7200             Covered
64782   Remove limb nerve lesion       T   00220   18.7200             Covered
64783   Limb nerve surgery add-on      T   00220   18.7200             Covered
64784   Remove nerve lesion            T   00220   18.7200             Covered
64786   Remove sciatic nerve lesion    T   00221   37.2806             Covered
64787   Implant nerve end              T   00220   18.7200             Covered
64788   Remove skin nerve lesion       T   00220   18.7200             Covered
64790   Removal of nerve lesion        T   00220   18.7200             Covered
64792   Removal of nerve lesion        T   00221   37.2806             Covered
64795   Biopsy of nerve                T   00220   18.7200             Covered
64802   Remove sympathetic nerves      T   00220   18.7200             Covered
64804   Remove sympathetic nerves      T   00220   18.7200             Covered
64809   Remove sympathetic nerves      C                     $848.59   Covered
64818   Remove sympathetic nerves      C                     $664.25   Covered
64820   Remove sympathetic nerves      T   00220   18.7200             Covered
64821   Remove sympathetic nerves      T   00054   28.2376             Covered
64822   Remove sympathetic nerves      T   00054   28.2376             Covered
64823   Remove sympathetic nerves      T   00054   28.2376             Covered
64831   Repair of digit nerve          T   00221   37.2806             Covered
64832   Repair nerve add-on            T   00221   37.2806             Covered
64834   Repair of hand or foot nerve   T   00221   37.2806             Covered
64835   Repair of hand or foot nerve   T   00221   37.2806             Covered
64836   Repair of hand or foot nerve   T   00221   37.2806             Covered
64837   Repair nerve add-on            T   00221   37.2806             Covered
64840   Repair of leg nerve            T   00221   37.2806             Covered
64856   Repair/transpose nerve         T   00221   37.2806             Covered
64857   Repair arm/leg nerve           T   00221   37.2806             Covered
64858   Repair sciatic nerve           T   00221   37.2806             Covered
64859   Nerve surgery                  T   00221   37.2806             Covered
64861   Repair of arm nerves           T   00221   37.2806             Covered
64862   Repair of low back nerves      T   00221   37.2806             Covered
64864   Repair of facial nerve         T   00221   37.2806             Covered
64865   Repair of facial nerve         T   00221   37.2806             Covered
64866   Fusion of facial/other nerve   C                     $977.05   Covered
64868   Fusion of facial/other nerve   C                     $912.96   Covered
64870   Fusion of facial/other nerve   T   00221   37.2806             Covered
64872   Subsequent repair of nerve     T   00221   37.2806             Covered
64874   Repair & revise nerve add-on   T   00221   37.2806             Covered
64876   Repair nerve/shorten bone      T   00221   37.2806             Covered
64885   Nerve graft, head or neck      T   00221   37.2806             Covered
64886   Nerve graft, head or neck      T   00221   37.2806             Covered
64890   Nerve graft, hand or foot      T   00221   37.2806             Covered
64891   Nerve graft, hand or foot      T   00221   37.2806             Covered
64892   Nerve graft, arm or leg        T   00221   37.2806             Covered
64893   Nerve graft, arm or leg        T   00221   37.2806             Covered
64895   Nerve graft, hand or foot      T   00221   37.2806             Covered
64896   Nerve graft, hand or foot      T   00221   37.2806             Covered
64897   Nerve graft, arm or leg        T   00221   37.2806             Covered
64898   Nerve graft, arm or leg        T   00221   37.2806             Covered
64901   Nerve graft add-on             T   00221   37.2806             Covered
64902   Nerve graft add-on             T   00221   37.2806             Covered
64905   Nerve pedicle transfer         T   00221   37.2806             Covered
64907   Nerve pedicle transfer         T   00221   37.2806             Covered
64910   Nerve repair w/allograft       T   00221   37.2806             Covered
64911   Neurorraphy w/vein autograft   T   00221   37.2806             Covered
64999   Nervous system surgery         T   00204    2.5558             Covered
65091   Revise eye                     T   00242   39.0115             Covered
65093   Revise eye with implant        T   00242   39.0115             Covered
65101   Removal of eye                 T   00242   39.0115             Covered
65103   Remove eye/insert implant      T   00242   39.0115             Covered
65105   Remove eye/attach implant      T   00242   39.0115             Covered
65110   Removal of eye                 T   00242   39.0115             Covered
65112   Remove eye/revise socket       T   00242   39.0115             Covered
65114   Remove eye/revise socket       T   00242   39.0115             Covered
65125   Revise ocular implant          T   00241   26.8396             Covered
65130   Insert ocular implant          T   00241   26.8396             Covered
65135   Insert ocular implant          T   00241   26.8396             Covered
65140   Attach ocular implant          T   00242   39.0115             Covered
65150   Revise ocular implant          T   00241   26.8396             Covered
65155   Reinsert ocular implant        T   00242   39.0115             Covered
65175   Removal of ocular implant      T   00240   18.1580             Covered
65205   Remove foreign body from eye   S   00698    0.9553             Covered
65210   Remove foreign body from eye   S   00698    0.9553             Covered
65220   Remove foreign body from eye   S   00698    0.9553             Covered
65222   Remove foreign body from eye   S   00698    0.9553             Covered
65235   Remove foreign body from eye   T   00233   16.2485             Covered
65260   Remove foreign body from eye   T   00235    5.8498             Covered
65265   Remove foreign body from eye   T   00237   20.7145             Covered
65270   Repair of eye wound            T   00240   18.1580             Covered
65272   Repair of eye wound            T   00234   24.4021             Covered
65273   Repair of eye wound            C                     $297.75   Covered
65275   Repair of eye wound            T   00234   24.4021             Covered
65280   Repair of eye wound            T   00237   20.7145             Covered
65285   Repair of eye wound            T   00672   39.9643             Covered
65286   Repair of eye wound            T   00232    4.5074             Covered
65290   Repair of eye socket wound     T   00243   23.4694             Covered
65400   Removal of eye lesion          T   00233   16.2485             Covered
65410   Biopsy of cornea               T   00233   16.2485             Covered
65420   Removal of eye lesion          T   00233   16.2485             Covered
65426   Removal of eye lesion          T   00234   24.4021             Covered
65430   Corneal smear                  S   00698    0.9553             Covered
65435   Curette/treat cornea           T   00239    7.6421             Covered
65436   Curette/treat cornea          T   00233    16.2485                 Covered
65450   Treatment of corneal lesion   S   00231     1.9575                 Covered
65600   Revision of cornea            T   00240    18.1580                 Covered
65710   Corneal transplant            T   00244    37.5388                 Covered
65730   Corneal transplant            T   00244    37.5388                 Covered
65750   Corneal transplant            T   00244    37.5388                 Covered
65755   Corneal transplant            T   00244    37.5388                 Covered
65756   Corneal trnspl, endothelial   T   00244    37.5388                 Covered
65757   Prep corneal endo allograft   N                                   By Report
65760   Revision of cornea            E                                  Not Covered
65765   Revision of cornea            E                      $1,260.83     Covered
65767   Corneal tissue transplant     E                      $1,260.83     Covered
65770   Revise cornea with implant    T   00293   101.0161                 Covered
65771   Radial keratotomy             E                                  Not Covered
65772   Correction of astigmatism     T   00233    16.2485                 Covered
65775   Correction of astigmatism     T   00233    16.2485                 Covered
65780   Ocular reconst, transplant    T   00244    37.5388                 Covered
65781   Ocular reconst, transplant    T   00244    37.5388                 Covered
65782   Ocular reconst, transplant    T   00244    37.5388                 Covered
65800   Drainage of eye               T   00233    16.2485                 Covered
65805   Drainage of eye               T   00233    16.2485                 Covered
65810   Drainage of eye               T   00234    24.4021                 Covered
65815   Drainage of eye               T   00234    24.4021                 Covered
65820   Relieve inner eye pressure    T   00232     4.5074                 Covered
65850   Incision of eye               T   00234    24.4021                 Covered
65855   Laser surgery of eye          T   00247     5.3014                 Covered
65860   Incise inner eye adhesions    T   00247     5.3014                 Covered
65865   Incise inner eye adhesions    T   00233    16.2485                 Covered
65870   Incise inner eye adhesions    T   00234    24.4021                 Covered
65875   Incise inner eye adhesions    T   00234    24.4021                 Covered
65880   Incise inner eye adhesions    T   00233    16.2485                 Covered
65900   Remove eye lesion             T   00233    16.2485                 Covered
65920   Remove implant of eye         T   00234    24.4021                 Covered
65930   Remove blood clot from eye    T   00234    24.4021                 Covered
66020   Injection treatment of eye    T   00233    16.2485                 Covered
66030   Injection treatment of eye    T   00232     4.5074                 Covered
66130   Remove eye lesion             T   00234    24.4021                 Covered
66150   Glaucoma surgery              T   00234    24.4021                 Covered
66155   Glaucoma surgery              T   00234    24.4021                 Covered
66160   Glaucoma surgery              T   00234    24.4021                 Covered
66165   Glaucoma surgery              T   00234    24.4021                 Covered
66170   Glaucoma surgery              T   00234    24.4021                 Covered
66172   Incision of eye               T   00234    24.4021                 Covered
66180   Implant eye shunt             T   00673    41.8840                 Covered
66185   Revise eye shunt              T   00234    24.4021                 Covered
66220   Repair eye lesion             T   00672    39.9643                 Covered
66225   Repair/graft eye lesion       T   00673    41.8840               Not Covered
66250   Follow-up surgery of eye      T   00233    16.2485                 Covered
66500   Incision of iris              T   00232     4.5074                 Covered
66505   Incision of iris              T   00232     4.5074                 Covered
66600   Remove iris and lesion        T   00234    24.4021                 Covered
66605   Removal of iris               T   00234    24.4021                 Covered
66625   Removal of iris                T   00233   16.2485    Covered
66630   Removal of iris                T   00234   24.4021    Covered
66635   Removal of iris                T   00234   24.4021    Covered
66680   Repair iris & ciliary body     T   00234   24.4021    Covered
66682   Repair iris & ciliary body     T   00234   24.4021    Covered
66700   Destruction, ciliary body      T   00233   16.2485    Covered
66710   Ciliary transsleral therapy    T   00233   16.2485    Covered
66711   Ciliary endoscopic ablation    T   00233   16.2485    Covered
66720   Destruction, ciliary body      T   00233   16.2485    Covered
66740   Destruction, ciliary body      T   00234   24.4021    Covered
66761   Revision of iris               T   00247    5.3014    Covered
66762   Revision of iris               T   00247    5.3014    Covered
66770   Removal of inner eye lesion    T   00247    5.3014    Covered
66820   Incision, secondary cataract   T   00232    4.5074    Covered
66821   After cataract laser surgery   T   00247    5.3014    Covered
66825   Reposition intraocular lens    T   00234   24.4021    Covered
66830   Removal of lens lesion         T   00232    4.5074    Covered
66840   Removal of lens material       T   00245   15.8085    Covered
66850   Removal of lens material       T   00249   30.3293    Covered
66852   Removal of lens material       T   00249   30.3293    Covered
66920   Extraction of lens             T   00249   30.3293    Covered
66930   Extraction of lens             T   00249   30.3293    Covered
66940   Extraction of lens             T   00245   15.8085    Covered
66982   Cataract surgery, complex      T   00246   24.2879    Covered
66983   Cataract surg w/iol, 1 stage   T   00246   24.2879    Covered
66984   Cataract surg w/iol, 1 stage   T   00246   24.2879    Covered
66985   Insert lens prosthesis         T   00246   24.2879    Covered
66986   Exchange lens prosthesis       T   00246   24.2879    Covered
66990   Ophthalmic endoscope add-on    N                     Not Covered
66999   Eye surgery procedure          T   00232    4.5074    Covered
67005   Partial removal of eye fluid   T   00237   20.7145    Covered
67010   Partial removal of eye fluid   T   00672   39.9643    Covered
67015   Release of eye fluid           T   00672   39.9643    Covered
67025   Replace eye fluid              T   00237   20.7145    Covered
67027   Implant eye drug system        T   00672   39.9643    Covered
67028   Injection eye drug             T   00238    3.2267    Covered
67030   Incise inner eye strands       T   00237   20.7145    Covered
67031   Laser surgery, eye strands     T   00247    5.3014    Covered
67036   Removal of inner eye fluid     T   00672   39.9643    Covered
67039   Laser treatment of retina      T   00672   39.9643    Covered
67040   Laser treatment of retina      T   00672   39.9643    Covered
67041   Vit for macular pucker         T   00672   39.9643    Covered
67042   Vit for macular hole           T   00672   39.9643    Covered
67043   Vit for membrane dissect       T   00672   39.9643    Covered
67101   Repair detached retina         T   00237   20.7145    Covered
67105   Repair detached retina         T   00247    5.3014    Covered
67107   Repair detached retina         T   00672   39.9643    Covered
67108   Repair detached retina         T   00672   39.9643    Covered
67110   Repair detached retina         T   00237   20.7145    Covered
67112   Rerepair detached retina       T   00672   39.9643    Covered
67113   Repair retinal detach, cplx    T   00672   39.9643    Covered
67115   Release encircling material    T   00237   20.7145    Covered
67120   Remove eye implant material    T   00237   20.7145   Covered
67121   Remove eye implant material    T   00237   20.7145   Covered
67141   Treatment of retina            T   00235    5.8498   Covered
67145   Treatment of retina            T   00247    5.3014   Covered
67208   Treatment of retinal lesion    T   00235    5.8498   Covered
67210   Treatment of retinal lesion    T   00247    5.3014   Covered
67218   Treatment of retinal lesion    T   00237   20.7145   Covered
67220   Treatment of choroid lesion    T   00235    5.8498   Covered
67221   Ocular photodynamic ther       T   00235    5.8498   Covered
67225   Eye photodynamic ther add-on   T   00235    5.8498   Covered
67227   Treatment of retinal lesion    T   00237   20.7145   Covered
67228   Treatment of retinal lesion    T   00247    5.3014   Covered
67229   Tr retinal les preterm inf     T   00247    5.3014   Covered
67250   Reinforce eye wall             T   00240   18.1580   Covered
67255   Reinforce/graft eye wall       T   00237   20.7145   Covered
67299   Eye surgery procedure          T   00235    5.8498   Covered
67311   Revise eye muscle              T   00243   23.4694   Covered
67312   Revise two eye muscles         T   00243   23.4694   Covered
67314   Revise eye muscle              T   00243   23.4694   Covered
67316   Revise two eye muscles         T   00243   23.4694   Covered
67318   Revise eye muscle(s)           T   00243   23.4694   Covered
67320   Revise eye muscle(s) add-on    T   00243   23.4694   Covered
67331   Eye surgery follow-up add-on   T   00243   23.4694   Covered
67332   Rerevise eye muscles add-on    T   00243   23.4694   Covered
67334   Revise eye muscle w/suture     T   00243   23.4694   Covered
67335   Eye suture during surgery      T   00243   23.4694   Covered
67340   Revise eye muscle add-on       T   00243   23.4694   Covered
67343   Release eye tissue             T   00243   23.4694   Covered
67345   Destroy nerve of eye muscle    T   00238    3.2267   Covered
67346   Biopsy, eye muscle             T   00699   15.5407   Covered
67399   Eye muscle surgery procedure   T   00243   23.4694   Covered
67400   Explore/biopsy eye socket      T   00240   18.1580   Covered
67405   Explore/drain eye socket       T   00241   26.8396   Covered
67412   Explore/treat eye socket       T   00240   18.1580   Covered
67413   Explore/treat eye socket       T   00241   26.8396   Covered
67414   Explr/decompress eye socket    T   00242   39.0115   Covered
67415   Aspiration, orbital contents   T   00240   18.1580   Covered
67420   Explore/treat eye socket       T   00242   39.0115   Covered
67430   Explore/treat eye socket       T   00242   39.0115   Covered
67440   Explore/drain eye socket       T   00242   39.0115   Covered
67445   Explr/decompress eye socket    T   00242   39.0115   Covered
67450   Explore/biopsy eye socket      T   00242   39.0115   Covered
67500   Inject/treat eye socket        S   00231    1.9575   Covered
67505   Inject/treat eye socket        T   00238    3.2267   Covered
67515   Inject/treat eye socket        T   00238    3.2267   Covered
67550   Insert eye socket implant      T   00242   39.0115   Covered
67560   Revise eye socket implant      T   00241   26.8396   Covered
67570   Decompress optic nerve         T   00242   39.0115   Covered
67599   Orbit surgery procedure        T   00238    3.2267   Covered
67700   Drainage of eyelid abscess     T   00238    3.2267   Covered
67710   Incision of eyelid             T   00239    7.6421   Covered
67715   Incision of eyelid fold        T   00240   18.1580   Covered
67800   Remove eyelid lesion          T   00238    3.2267   Covered
67801   Remove eyelid lesions         T   00239    7.6421   Covered
67805   Remove eyelid lesions         T   00238    3.2267   Covered
67808   Remove eyelid lesion(s)       T   00240   18.1580   Covered
67810   Biopsy of eyelid              T   00238    3.2267   Covered
67820   Revise eyelashes              S   00698    0.9553   Covered
67825   Revise eyelashes              T   00238    3.2267   Covered
67830   Revise eyelashes              T   00239    7.6421   Covered
67835   Revise eyelashes              T   00240   18.1580   Covered
67840   Remove eyelid lesion          T   00239    7.6421   Covered
67850   Treat eyelid lesion           T   00239    7.6421   Covered
67875   Closure of eyelid by suture   T   00239    7.6421   Covered
67880   Revision of eyelid            T   00233   16.2485   Covered
67882   Revision of eyelid            T   00240   18.1580   Covered
67900   Repair brow defect            T   00241   26.8396   Covered
67901   Repair eyelid defect          T   00240   18.1580   Covered
67902   Repair eyelid defect          T   00241   26.8396   Covered
67903   Repair eyelid defect          T   00240   18.1580   Covered
67904   Repair eyelid defect          T   00240   18.1580   Covered
67906   Repair eyelid defect          T   00240   18.1580   Covered
67908   Repair eyelid defect          T   00240   18.1580   Covered
67909   Revise eyelid defect          T   00240   18.1580   Covered
67911   Revise eyelid defect          T   00240   18.1580   Covered
67912   Correction eyelid w/implant   T   00240   18.1580   Covered
67914   Repair eyelid defect          T   00240   18.1580   Covered
67915   Repair eyelid defect          T   00240   18.1580   Covered
67916   Repair eyelid defect          T   00240   18.1580   Covered
67917   Repair eyelid defect          T   00240   18.1580   Covered
67921   Repair eyelid defect          T   00240   18.1580   Covered
67922   Repair eyelid defect          T   00240   18.1580   Covered
67923   Repair eyelid defect          T   00240   18.1580   Covered
67924   Repair eyelid defect          T   00240   18.1580   Covered
67930   Repair eyelid wound           T   00240   18.1580   Covered
67935   Repair eyelid wound           T   00240   18.1580   Covered
67938   Remove eyelid foreign body    S   00231    1.9575   Covered
67950   Revision of eyelid            T   00240   18.1580   Covered
67961   Revision of eyelid            T   00240   18.1580   Covered
67966   Revision of eyelid            T   00240   18.1580   Covered
67971   Reconstruction of eyelid      T   00240   18.1580   Covered
67973   Reconstruction of eyelid      T   00241   26.8396   Covered
67974   Reconstruction of eyelid      T   00240   18.1580   Covered
67975   Reconstruction of eyelid      T   00240   18.1580   Covered
67999   Revision of eyelid            T   00238    3.2267   Covered
68020   Incise/drain eyelid lining    T   00238    3.2267   Covered
68040   Treatment of eyelid lesions   S   00698    0.9553   Covered
68100   Biopsy of eyelid lining       T   00232    4.5074   Covered
68110   Remove eyelid lining lesion   T   00699   15.5407   Covered
68115   Remove eyelid lining lesion   T   00240   18.1580   Covered
68130   Remove eyelid lining lesion   T   00233   16.2485   Covered
68135   Remove eyelid lining lesion   T   00239    7.6421   Covered
68200   Treat eyelid by injection     S   00698    0.9553   Covered
68320   Revise/graft eyelid lining    T   00241   26.8396   Covered
68325   Revise/graft eyelid lining     T   00241   26.8396                Covered
68326   Revise/graft eyelid lining     T   00240   18.1580                Covered
68328   Revise/graft eyelid lining     T   00241   26.8396                Covered
68330   Revise eyelid lining           T   00234   24.4021                Covered
68335   Revise/graft eyelid lining     T   00241   26.8396                Covered
68340   Separate eyelid adhesions      T   00240   18.1580                Covered
68360   Revise eyelid lining           T   00234   24.4021                Covered
68362   Revise eyelid lining           T   00234   24.4021                Covered
68371   Harvest eye tissue, alograft   T   00233   16.2485                Covered
68399   Eyelid lining surgery          T   00238    3.2267                Covered
68400   Incise/drain tear gland        T   00238    3.2267                Covered
68420   Incise/drain tear sac          T   00240   18.1580                Covered
68440   Incise tear duct opening       T   00238    3.2267                Covered
68500   Removal of tear gland          T   00241   26.8396                Covered
68505   Partial removal, tear gland    T   00241   26.8396                Covered
68510   Biopsy of tear gland           T   00240   18.1580                Covered
68520   Removal of tear sac            T   00241   26.8396                Covered
68525   Biopsy of tear sac             T   00240   18.1580                Covered
68530   Clearance of tear duct         T   00238    3.2267                Covered
68540   Remove tear gland lesion       T   00240   18.1580                Covered
68550   Remove tear gland lesion       T   00241   26.8396                Covered
68700   Repair tear ducts              T   00240   18.1580                Covered
68705   Revise tear duct opening       T   00238    3.2267                Covered
68720   Create tear sac drain          T   00241   26.8396                Covered
68745   Create tear duct drain         T   00241   26.8396                Covered
68750   Create tear duct drain         T   00241   26.8396                Covered
68760   Close tear duct opening        T   00238    3.2267                Covered
68761   Close tear duct opening        T   00238    3.2267                Covered
68770   Close tear system fistula      T   00241   26.8396                Covered
68801   Dilate tear duct opening       S   00698    0.9553                Covered
68810   Probe nasolacrimal duct        T   00238    3.2267                Covered
68811   Probe nasolacrimal duct        T   00240   18.1580                Covered
68815   Probe nasolacrimal duct        T   00240   18.1580                Covered
68816   Probe nl duct w/balloon        T   00240   18.1580                Covered
68840   Explore/irrigate tear ducts    S   00231    1.9575                Covered
68850   Injection for tear sac x-ray   N                                  Covered
68899   Tear duct system surgery       T   00238    3.2267                Covered
69000   Drain external ear lesion      T   00006    1.4557                Covered
69005   Drain external ear lesion      T   00008   19.4063                Covered
69020   Drain outer ear canal lesion   T   00006    1.4557                Covered
69090   Pierce earlobes                E                                 Not Covered
69100   Biopsy of external ear         T   00251    3.4250                Covered
69105   Biopsy of external ear canal   T   00253   17.1879                Covered
69110   Remove external ear, partial   T   00021   17.4975                Covered
69120   Removal of external ear        T   00254   24.9637                Covered
69140   Remove ear canal lesion(s)     T   00254   24.9637                Covered
69145   Remove ear canal lesion(s)     T   00021   17.4975                Covered
69150   Extensive ear canal surgery    T   00252    7.6196                Covered
69155   Extensive ear/neck surgery     C                     $1,326.96    Covered
69200   Clear outer ear canal          X   00340    0.6693                Covered
69205   Clear outer ear canal          T   00022   23.3880                Covered
69210   Remove impacted ear wax        X   00340    0.6693                Covered
69220   Clean out mastoid cavity       T   00013    0.8789               Covered
69222   Clean out mastoid cavity       T   00253   17.1879               Covered
69300   Revise external ear            T   00254   24.9637               Covered
69310   Rebuild outer ear canal        T   00256   42.9827               Covered
69320   Rebuild outer ear canal        T   00256   42.9827               Covered
69399   Outer ear surgery procedure    T   00250    1.1522               Covered
69400   Inflate middle ear canal       T   00251    3.4250               Covered
69401   Inflate middle ear canal       T   00251    3.4250               Covered
69405   Catheterize middle ear canal   T   00252    7.6196               Covered
69420   Incision of eardrum            T   00251    3.4250               Covered
69421   Incision of eardrum            T   00253   17.1879               Covered
69424   Remove ventilating tube        T   00253   17.1879               Covered
69433   Create eardrum opening         T   00252    7.6196               Covered
69436   Create eardrum opening         T   00253   17.1879               Covered
69440   Exploration of middle ear      T   00254   24.9637               Covered
69450   Eardrum revision               T   00256   42.9827               Covered
69501   Mastoidectomy                  T   00256   42.9827               Covered
69502   Mastoidectomy                  T   00254   24.9637               Covered
69505   Remove mastoid structures      T   00256   42.9827               Covered
69511   Extensive mastoid surgery      T   00256   42.9827               Covered
69530   Extensive mastoid surgery      T   00256   42.9827               Covered
69535   Remove part of temporal bone   C                     $2,235.80   Covered
69540   Remove ear lesion              T   00253   17.1879               Covered
69550   Remove ear lesion              T   00256   42.9827               Covered
69552   Remove ear lesion              T   00256   42.9827               Covered
69554   Remove ear lesion              C                     $2,053.05   Covered
69601   Mastoid surgery revision       T   00256   42.9827               Covered
69602   Mastoid surgery revision       T   00256   42.9827               Covered
69603   Mastoid surgery revision       T   00256   42.9827               Covered
69604   Mastoid surgery revision       T   00256   42.9827               Covered
69605   Mastoid surgery revision       T   00256   42.9827               Covered
69610   Repair of eardrum              T   00254   24.9637               Covered
69620   Repair of eardrum              T   00254   24.9637               Covered
69631   Repair eardrum structures      T   00256   42.9827               Covered
69632   Rebuild eardrum structures     T   00256   42.9827               Covered
69633   Rebuild eardrum structures     T   00256   42.9827               Covered
69635   Repair eardrum structures      T   00256   42.9827               Covered
69636   Rebuild eardrum structures     T   00256   42.9827               Covered
69637   Rebuild eardrum structures     T   00256   42.9827               Covered
69641   Revise middle ear & mastoid    T   00256   42.9827               Covered
69642   Revise middle ear & mastoid    T   00256   42.9827               Covered
69643   Revise middle ear & mastoid    T   00256   42.9827               Covered
69644   Revise middle ear & mastoid    T   00256   42.9827               Covered
69645   Revise middle ear & mastoid    T   00256   42.9827               Covered
69646   Revise middle ear & mastoid    T   00256   42.9827               Covered
69650   Release middle ear bone        T   00254   24.9637               Covered
69660   Revise middle ear bone         T   00256   42.9827               Covered
69661   Revise middle ear bone         T   00256   42.9827               Covered
69662   Revise middle ear bone         T   00256   42.9827               Covered
69666   Repair middle ear structures   T   00256   42.9827               Covered
69667   Repair middle ear structures   T   00256   42.9827               Covered
69670   Remove mastoid air cells       T   00256   42.9827               Covered
69676   Remove middle ear nerve        T    00256    42.9827                Covered
69700   Close mastoid fistula          T    00256    42.9827                Covered
69710   Implant/replace hearing aid    E                       $1,208.61    Covered
69711   Remove/repair hearing aid      T    00256    42.9827                Covered
69714   Implant temple bone w/stimul   T    00425   118.7670                Covered
69715   Temple bne implnt w/stimulat   T    00425   118.7670                Covered
69717   Temple bone implant revision   T    00425   118.7670                Covered
69718   Revise temple bone implant     T    00425   118.7670                Covered
69720   Release facial nerve           T    00256    42.9827                Covered
69725   Release facial nerve           T    00256    42.9827                Covered
69740   Repair facial nerve            T    00256    42.9827                Covered
69745   Repair facial nerve            T    00256    42.9827                Covered
69799   Middle ear surgery procedure   T    00250     1.1522                Covered
69801   Incise inner ear               T    00254    24.9637                Covered
69802   Incise inner ear               T    00254    24.9637                Covered
69805   Explore inner ear              T    00256    42.9827                Covered
69806   Explore inner ear              T    00256    42.9827                Covered
69820   Establish inner ear window     T    00256    42.9827                Covered
69840   Revise inner ear window        T    00256    42.9827                Covered
69905   Remove inner ear               T    00256    42.9827                Covered
69910   Remove inner ear & mastoid     T    00256    42.9827                Covered
69915   Incise inner ear nerve         T    00256    42.9827                Covered
69930   Implant cochlear device        T    00259   428.8363                Covered
69949   Inner ear surgery procedure    T    00250     1.1522                Covered
69950   Incise inner ear nerve         C                       $1,592.25    Covered
69955   Release facial nerve           T    00256    42.9827                Covered
69960   Release inner ear canal        T    00256    42.9827                Covered
69970   Remove inner ear lesion        T    00256    42.9827                Covered
69979   Temporal bone surgery          T    00250     1.1522                Covered
69990   Microsurgery add-on            N                                    Covered
70010   Contrast x-ray of brain        Q2   00274     7.2260                Covered
70015   Contrast x-ray of brain        Q2   00274     7.2260                Covered
70030   X-ray eye for foreign body     X    00260     0.6661                Covered
70100   X-ray exam of jaw              X    00260     0.6661                Covered
7010F   Pt info into recall system     M                                   Not Covered
70110   X-ray exam of jaw              X    00260     0.6661                Covered
70120   X-ray exam of mastoids         X    00260     0.6661                Covered
70130   X-ray exam of mastoids         X    00260     0.6661                Covered
70134   X-ray exam of middle ear       X    00261     1.1161                Covered
70140   X-ray exam of facial bones     X    00260     0.6661                Covered
70150   X-ray exam of facial bones     X    00260     0.6661                Covered
70160   X-ray exam of nasal bones      X    00260     0.6661                Covered
70170   X-ray exam of tear duct        Q2   00263     3.1192                Covered
70190   X-ray exam of eye sockets      X    00260     0.6661                Covered
70200   X-ray exam of eye sockets      X    00260     0.6661                Covered
7020F   Mammo assess cat in dbase      M                                   Not Covered
70210   X-ray exam of sinuses          X    00260     0.6661                Covered
70220   X-ray exam of sinuses          X    00260     0.6661                Covered
70240   X-ray exam, pituitary saddle   X    00260     0.6661                Covered
70250   X-ray exam of skull            X    00260     0.6661                Covered
7025F   Pt infosys alarm 4 nxt mammo   M                                   Not Covered
7025F   Pt infosys alarm 4 nxt mammo   M                                   Not Covered
70260   X-ray exam of skull             X   00261   1.1161   Covered
70300   X-ray exam of teeth             X   00262   0.4469   Covered
70310   X-ray exam of teeth             X   00262   0.4469   Covered
70320   Full mouth x-ray of teeth       X   00262   0.4469   Covered
70328   X-ray exam of jaw joint         X   00260   0.6661   Covered
70330   X-ray exam of jaw joints        X   00260   0.6661   Covered
70332   X-ray exam of jaw joint        Q2   00275   3.9361   Covered
70336   Magnetic image, jaw joint      Q3   00336   5.1855   Covered
70350   X-ray head for orthodontia      X   00260   0.6661   Covered
70355   Panoramic x-ray of jaws         X   00260   0.6661   Covered
70360   X-ray exam of neck              X   00260   0.6661   Covered
70370   Throat x-ray & fluoroscopy      X   00272   1.2693   Covered
70371   Speech evaluation, complex      X   00272   1.2693   Covered
70373   Contrast x-ray of larynx       Q2   00263   3.1192   Covered
70380   X-ray exam of salivary gland    X   00260   0.6661   Covered
70390   X-ray exam of salivary duct    Q2   00263   3.1192   Covered
70450   Ct head/brain w/o dye          Q3   00332   2.8940   Covered
70460   Ct head/brain w/dye            Q3   00283   4.4066   Covered
70470   Ct head/brain w/o & w/dye      Q3   00333   4.9479   Covered
70480   Ct orbit/ear/fossa w/o dye     Q3   00332   2.8940   Covered
70481   Ct orbit/ear/fossa w/dye       Q3   00283   4.4066   Covered
70482   Ct orbit/ear/fossa w/o&w/dye   Q3   00333   4.9479   Covered
70486   Ct maxillofacial w/o dye       Q3   00332   2.8940   Covered
70487   Ct maxillofacial w/dye         Q3   00283   4.4066   Covered
70488   Ct maxillofacial w/o & w/dye   Q3   00333   4.9479   Covered
70490   Ct soft tissue neck w/o dye    Q3   00332   2.8940   Covered
70491   Ct soft tissue neck w/dye      Q3   00283   4.4066   Covered
70492   Ct sft tsue nck w/o & w/dye    Q3   00333   4.9479   Covered
70496   Ct angiography, head           Q3   00662   5.0511   Covered
70498   Ct angiography, neck           Q3   00662   5.0511   Covered
70540   Mri orbit/face/neck w/o dye    Q3   00336   5.1855   Covered
70542   Mri orbit/face/neck w/dye      Q3   00284   6.2901   Covered
70543   Mri orbt/fac/nck w/o & w/dye   Q3   00337   7.9432   Covered
70544   Mr angiography head w/o dye    Q3   00336   5.1855   Covered
70545   Mr angiography head w/dye      Q3   00284   6.2901   Covered
70546   Mr angiograph head w/o&w/dye   Q3   00337   7.9432   Covered
70547   Mr angiography neck w/o dye    Q3   00336   5.1855   Covered
70548   Mr angiography neck w/dye      Q3   00284   6.2901   Covered
70549   Mr angiograph neck w/o&w/dye   Q3   00337   7.9432   Covered
70551   Mri brain w/o dye              Q3   00336   5.1855   Covered
70552   Mri brain w/dye                Q3   00284   6.2901   Covered
70553   Mri brain w/o & w/dye          Q3   00337   7.9432   Covered
70554   Fmri brain by tech             Q3   00336   5.1855   Covered
70555   Fmri brain by phys/psych        S   00336   5.1855   Covered
70557   Mri brain w/o dye               S   00336   5.1855   Covered
70558   Mri brain w/dye                 S   00284   6.2901   Covered
70559   Mri brain w/o & w/dye           S   00337   7.9432   Covered
71010   Chest x-ray                     X   00260   0.6661   Covered
71015   Chest x-ray                     X   00260   0.6661   Covered
71020   Chest x-ray                     X   00260   0.6661   Covered
71021   Chest x-ray                     X   00260   0.6661   Covered
71022   Chest x-ray                     X   00260   0.6661   Covered
71023   Chest x-ray and fluoroscopy     X   00272   1.2693    Covered
71030   Chest x-ray                     X   00260   0.6661    Covered
71034   Chest x-ray and fluoroscopy     X   00272   1.2693    Covered
71035   Chest x-ray                     X   00260   0.6661    Covered
71040   Contrast x-ray of bronchi      Q2   00263   3.1192    Covered
71060   Contrast x-ray of bronchi      Q2   00263   3.1192    Covered
71090   X-ray & pacemaker insertion    N                      Covered
71100   X-ray exam of ribs              X   00260   0.6661    Covered
71101   X-ray exam of ribs/chest        X   00260   0.6661    Covered
71110   X-ray exam of ribs              X   00260   0.6661    Covered
71111   X-ray exam of ribs/chest        X   00261   1.1161    Covered
71120   X-ray exam of breastbone        X   00260   0.6661    Covered
71130   X-ray exam of breastbone        X   00260   0.6661    Covered
71250   Ct thorax w/o dye              Q3   00332   2.8940    Covered
71260   Ct thorax w/dye                Q3   00283   4.4066    Covered
71270   Ct thorax w/o & w/dye          Q3   00333   4.9479    Covered
71275   Ct angiography, chest          Q3   00662   5.0511    Covered
71550   Mri chest w/o dye              Q3   00336   5.1855    Covered
71551   Mri chest w/dye                Q3   00284   6.2901    Covered
71552   Mri chest w/o & w/dye          Q3   00337   7.9432    Covered
71555   Mri angio chest w or w/o dye    B                    Not Covered
72010   X-ray exam of spine             X   00261   1.1161    Covered
72020   X-ray exam of spine             X   00260   0.6661    Covered
72040   X-ray exam of neck spine        X   00260   0.6661    Covered
72050   X-ray exam of neck spine        X   00261   1.1161    Covered
72052   X-ray exam of neck spine        X   00261   1.1161    Covered
72069   X-ray exam of trunk spine       X   00260   0.6661    Covered
72070   X-ray exam of thoracic spine    X   00260   0.6661    Covered
72072   X-ray exam of thoracic spine    X   00260   0.6661    Covered
72074   X-ray exam of thoracic spine    X   00260   0.6661    Covered
72080   X-ray exam of trunk spine       X   00260   0.6661    Covered
72090   X-ray exam of trunk spine       X   00261   1.1161    Covered
72100   X-ray exam of lower spine       X   00260   0.6661    Covered
72110   X-ray exam of lower spine       X   00261   1.1161    Covered
72114   X-ray exam of lower spine       X   00261   1.1161    Covered
72120   X-ray exam of lower spine       X   00261   1.1161    Covered
72125   Ct neck spine w/o dye          Q3   00332   2.8940    Covered
72126   Ct neck spine w/dye            Q3   00283   4.4066    Covered
72127   Ct neck spine w/o & w/dye      Q3   00333   4.9479    Covered
72128   Ct chest spine w/o dye         Q3   00332   2.8940    Covered
72129   Ct chest spine w/dye           Q3   00283   4.4066    Covered
72130   Ct chest spine w/o & w/dye     Q3   00333   4.9479    Covered
72131   Ct lumbar spine w/o dye        Q3   00332   2.8940    Covered
72132   Ct lumbar spine w/dye          Q3   00283   4.4066    Covered
72133   Ct lumbar spine w/o & w/dye    Q3   00333   4.9479    Covered
72141   Mri neck spine w/o dye         Q3   00336   5.1855    Covered
72142   Mri neck spine w/dye           Q3   00284   6.2901    Covered
72146   Mri chest spine w/o dye        Q3   00336   5.1855    Covered
72147   Mri chest spine w/dye          Q3   00284   6.2901    Covered
72148   Mri lumbar spine w/o dye       Q3   00336   5.1855    Covered
72149   Mri lumbar spine w/dye         Q3   00284   6.2901    Covered
72156   Mri neck spine w/o & w/dye     Q3   00337   7.9432    Covered
72157   Mri chest spine w/o & w/dye    Q3   00337    7.9432              Covered
72158   Mri lumbar spine w/o & w/dye   Q3   00337    7.9432              Covered
72159   Mr angio spine w/o&w/dye        E                     $439.48    Covered
72170   X-ray exam of pelvis            X   00260    0.6661              Covered
72190   X-ray exam of pelvis            X   00260    0.6661              Covered
72191   Ct angiograph pelv w/o&w/dye   Q3   00662    5.0511              Covered
72192   Ct pelvis w/o dye              Q3   00332    2.8940              Covered
72193   Ct pelvis w/dye                Q3   00283    4.4066              Covered
72194   Ct pelvis w/o & w/dye          Q3   00333    4.9479              Covered
72195   Mri pelvis w/o dye             Q3   00336    5.1855              Covered
72196   Mri pelvis w/dye               Q3   00284    6.2901              Covered
72197   Mri pelvis w/o & w/dye         Q3   00337    7.9432              Covered
72198   Mr angio pelvis w/o & w/dye     B                               Not Covered
72200   X-ray exam sacroiliac joints    X   00260    0.6661              Covered
72202   X-ray exam sacroiliac joints    X   00260    0.6661              Covered
72220   X-ray exam of tailbone          X   00260    0.6661              Covered
72240   Contrast x-ray of neck spine   Q2   00274    7.2260              Covered
72255   Contrast x-ray, thorax spine   Q2   00274    7.2260              Covered
72265   Contrast x-ray, lower spine    Q2   00274    7.2260              Covered
72270   Contrast x-ray, spine          Q2   00274    7.2260              Covered
72275   Epidurography                  N                                 Covered
72285   X-ray c/t spine disk           Q2   00388   25.8604              Covered
72291   Perq vertebroplasty, fluor     N                                 Covered
72292   Perq vertebroplasty, ct        N                                 Covered
72295   X-ray of lower spine disk      Q2   00388   25.8604              Covered
73000   X-ray exam of collar bone       X   00260    0.6661              Covered
73010   X-ray exam of shoulder blade    X   00260    0.6661              Covered
73020   X-ray exam of shoulder          X   00260    0.6661              Covered
73030   X-ray exam of shoulder          X   00260    0.6661              Covered
73040   Contrast x-ray of shoulder     Q2   00275    3.9361              Covered
73050   X-ray exam of shoulders         X   00260    0.6661              Covered
73060   X-ray exam of humerus           X   00260    0.6661              Covered
73070   X-ray exam of elbow             X   00260    0.6661              Covered
73080   X-ray exam of elbow             X   00260    0.6661              Covered
73085   Contrast x-ray of elbow        Q2   00275    3.9361              Covered
73090   X-ray exam of forearm           X   00260    0.6661              Covered
73092   X-ray exam of arm, infant       X   00260    0.6661              Covered
73100   X-ray exam of wrist             X   00260    0.6661              Covered
73110   X-ray exam of wrist             X   00260    0.6661              Covered
73115   Contrast x-ray of wrist        Q2   00275    3.9361              Covered
73120   X-ray exam of hand              X   00260    0.6661              Covered
73130   X-ray exam of hand              X   00260    0.6661              Covered
73140   X-ray exam of finger(s)         X   00260    0.6661              Covered
73200   Ct upper extremity w/o dye     Q3   00332    2.8940              Covered
73201   Ct upper extremity w/dye       Q3   00283    4.4066              Covered
73202   Ct uppr extremity w/o&w/dye    Q3   00333    4.9479              Covered
73206   Ct angio upr extrm w/o&w/dye   Q3   00662    5.0511              Covered
73218   Mri upper extremity w/o dye    Q3   00336    5.1855              Covered
73219   Mri upper extremity w/dye      Q3   00284    6.2901              Covered
73220   Mri uppr extremity w/o&w/dye   Q3   00337    7.9432              Covered
73221   Mri joint upr extrem w/o dye   Q3   00336    5.1855              Covered
73222   Mri joint upr extrem w/dye     Q3   00284    6.2901              Covered
73223   Mri joint upr extr w/o&w/dye   Q3   00337   7.9432              Covered
73225   Mr angio upr extr w/o&w/dye     E                    $395.98    Covered
73500   X-ray exam of hip               X   00260   0.6661              Covered
73510   X-ray exam of hip               X   00260   0.6661              Covered
73520   X-ray exam of hips              X   00261   1.1161              Covered
73525   Contrast x-ray of hip          Q2   00275   3.9361              Covered
73530   X-ray exam of hip              N                                Covered
73540   X-ray exam of pelvis & hips     X   00260   0.6661              Covered
73542   X-ray exam, sacroiliac joint   Q2   00275   3.9361              Covered
73550   X-ray exam of thigh             X   00260   0.6661              Covered
73560   X-ray exam of knee, 1 or 2      X   00260   0.6661              Covered
73562   X-ray exam of knee, 3           X   00260   0.6661              Covered
73564   X-ray exam, knee, 4 or more     X   00260   0.6661              Covered
73565   X-ray exam of knees             X   00260   0.6661              Covered
73580   Contrast x-ray of knee joint   Q2   00275   3.9361              Covered
73590   X-ray exam of lower leg         X   00260   0.6661              Covered
73592   X-ray exam of leg, infant       X   00260   0.6661              Covered
73600   X-ray exam of ankle             X   00260   0.6661              Covered
73610   X-ray exam of ankle             X   00260   0.6661              Covered
73615   Contrast x-ray of ankle        Q2   00275   3.9361              Covered
73620   X-ray exam of foot              X   00260   0.6661              Covered
73630   X-ray exam of foot              X   00260   0.6661              Covered
73650   X-ray exam of heel              X   00260   0.6661              Covered
73660   X-ray exam of toe(s)            X   00260   0.6661              Covered
73700   Ct lower extremity w/o dye     Q3   00332   2.8940              Covered
73701   Ct lower extremity w/dye       Q3   00283   4.4066              Covered
73702   Ct lwr extremity w/o&w/dye     Q3   00333   4.9479              Covered
73706   Ct angio lwr extr w/o&w/dye    Q3   00662   5.0511              Covered
73718   Mri lower extremity w/o dye    Q3   00336   5.1855              Covered
73719   Mri lower extremity w/dye      Q3   00284   6.2901              Covered
73720   Mri lwr extremity w/o&w/dye    Q3   00337   7.9432              Covered
73721   Mri jnt of lwr extre w/o dye   Q3   00336   5.1855              Covered
73722   Mri joint of lwr extr w/dye    Q3   00284   6.2901              Covered
73723   Mri joint lwr extr w/o&w/dye   Q3   00337   7.9432              Covered
73725   Mr ang lwr ext w or w/o dye     B                              Not Covered
74000   X-ray exam of abdomen           X   00260   0.6661              Covered
74010   X-ray exam of abdomen           X   00260   0.6661              Covered
74020   X-ray exam of abdomen           X   00260   0.6661              Covered
74022   X-ray exam series, abdomen      X   00261   1.1161              Covered
74150   Ct abdomen w/o dye             Q3   00332   2.8940              Covered
74160   Ct abdomen w/dye               Q3   00283   4.4066              Covered
74170   Ct abdomen w/o & w/dye         Q3   00333   4.9479              Covered
74175   Ct angio abdom w/o & w/dye     Q3   00662   5.0511              Covered
74181   Mri abdomen w/o dye            Q3   00336   5.1855              Covered
74182   Mri abdomen w/dye              Q3   00284   6.2901              Covered
74183   Mri abdomen w/o & w/dye        Q3   00337   7.9432              Covered
74185   Mri angio, abdom w orw/o dye    B                              Not Covered
74190   X-ray exam of peritoneum       Q2   00263   3.1192              Covered
74210   Contrst x-ray exam of throat    S   00276   1.2985              Covered
74220   Contrast x-ray, esophagus       S   00276   1.2985              Covered
74230   Cine/vid x-ray, throat/esoph    S   00276   1.2985              Covered
74235   Remove esophagus obstruction   N                                Covered
74240   X-ray exam, upper gi tract      S   00276    1.2985    Covered
74241   X-ray exam, upper gi tract      S   00276    1.2985    Covered
74245   X-ray exam, upper gi tract      S   00277    2.1001    Covered
74246   Contrst x-ray uppr gi tract     S   00276    1.2985    Covered
74247   Contrst x-ray uppr gi tract     S   00276    1.2985    Covered
74249   Contrst x-ray uppr gi tract     S   00277    2.1001    Covered
74250   X-ray exam of small bowel       S   00276    1.2985    Covered
74251   X-ray exam of small bowel       S   00277    2.1001    Covered
74260   X-ray exam of small bowel       S   00276    1.2985    Covered
74261   Ct colonography, w/o dye       Q3   00332    2.8940   Not Covered
74262   Ct colonography, w/dye         Q3   00283    4.4066   Not Covered
74263   Ct colonography, screen         E                     Not Covered
74270   Contrast x-ray exam of colon    S   00276    1.2985    Covered
74280   Contrast x-ray exam of colon    S   00277    2.1001    Covered
74283   Contrast x-ray exam of colon    S   00276    1.2985    Covered
74290   Contrast x-ray, gallbladder     S   00276    1.2985    Covered
74291   Contrast x-rays, gallbladder    S   00276    1.2985    Covered
74300   X-ray bile ducts/pancreas      N                       Covered
74301   X-rays at surgery add-on       N                       Covered
74305   X-ray bile ducts/pancreas      Q2   00263    3.1192    Covered
74320   Contrast x-ray of bile ducts   Q2   00317    5.6012    Covered
74327   X-ray bile stone removal       N                       Covered
74328   X-ray bile duct endoscopy       N                      Covered
74329   X-ray for pancreas endoscopy    N                      Covered
74330   X-ray bile/panc endoscopy       N                      Covered
74340   X-ray guide for GI tube         N                      Covered
74355   X-ray guide, intestinal tube    N                      Covered
74360   X-ray guide, GI dilation        N                      Covered
74363   X-ray, bile duct dilation       N                      Covered
74400   Contrst x-ray, urinary tract    S   00278    2.5460    Covered
74410   Contrst x-ray, urinary tract    S   00278    2.5460    Covered
74415   Contrst x-ray, urinary tract    S   00278    2.5460    Covered
74420   Contrst x-ray, urinary tract    S   00278    2.5460    Covered
74425   Contrst x-ray, urinary tract   Q2   00278    2.5460    Covered
74430   Contrast x-ray, bladder        Q2   00278    2.5460    Covered
74440   X-ray, male genital tract      Q2   00278    2.5460    Covered
74445   X-ray exam of penis            Q2   00278    2.5460    Covered
74450   X-ray, urethra/bladder         Q2   00278    2.5460    Covered
74455   X-ray, urethra/bladder         Q2   00278    2.5460    Covered
74470   X-ray exam of kidney lesion    Q2   00263    3.1192    Covered
74475   X-ray control, cath insert     Q2   00161   17.0344    Covered
74480   X-ray control, cath insert     Q2   00161   17.0344    Covered
74485   X-ray guide, GU dilation       Q2   00161   17.0344    Covered
74710   X-ray measurement of pelvis     X   00261    1.1161    Covered
74740   X-ray, female genital tract    Q2   00263    3.1192    Covered
74742   X-ray, fallopian tube          N                       Covered
74775   X-ray exam of perineum          S   00278    2.5460    Covered
75557   Cardiac mri for morph          Q3   00336    5.1855   Not Covered
75558   Cardiac mri flow/velocity      D                      Not Covered
75559   Cardiac mri w/stress img       Q3   00336    5.1855   Not Covered
75560   Cardiac mri flow/vel/stress    D                      Not Covered
75561   Cardiac mri for morph w/dye    Q3   00337    7.9432   Not Covered
75562   Card mri flow/vel w/dye        D                      Not Covered
75563   Card mri w/stress img & dye    Q3   00337    7.9432   Not Covered
75564   Ht mri w/flo/vel/strs & dye    D                      Not Covered
75565   Card mri vel flw map add-on    N                      Not Covered
75571   Ct hrt w/o dye w/ca test        X   00340    0.6693    Covered
75572   Ct hrt w/3d image               S   00383    3.9929    Covered
75573   Ct hrt w/3d image, congen       S   00383    3.9929    Covered
75574   Ct angio hrt w/3d image         S   00383    3.9929    Covered
75600   Contrast x-ray exam of aorta   Q2   00279   29.1126    Covered
75605   Contrast x-ray exam of aorta   Q2   00279   29.1126    Covered
75625   Contrast x-ray exam of aorta   Q2   00279   29.1126    Covered
75630   X-ray aorta, leg arteries      Q2   00279   29.1126    Covered
75635   Ct angio abdominal arteries    Q2   00662    5.0511    Covered
75650   Artery x-rays, head & neck     Q2   00280   45.8793    Covered
75658   Artery x-rays, arm             Q2   00279   29.1126    Covered
75660   Artery x-rays, head & neck     Q2   00280   45.8793    Covered
75662   Artery x-rays, head & neck     Q2   00280   45.8793    Covered
75665   Artery x-rays, head & neck     Q2   00279   29.1126    Covered
75671   Artery x-rays, head & neck     Q2   00280   45.8793    Covered
75676   Artery x-rays, neck            Q2   00279   29.1126    Covered
75680   Artery x-rays, neck            Q2   00279   29.1126    Covered
75685   Artery x-rays, spine           Q2   00279   29.1126    Covered
75705   Artery x-rays, spine           Q2   00279   29.1126    Covered
75710   Artery x-rays, arm/leg         Q2   00279   29.1126    Covered
75716   Artery x-rays, arms/legs       Q2   00279   29.1126    Covered
75722   Artery x-rays, kidney          Q2   00279   29.1126    Covered
75724   Artery x-rays, kidneys         Q2   00279   29.1126    Covered
75726   Artery x-rays, abdomen         Q2   00279   29.1126    Covered
75731   Artery x-rays, adrenal gland   Q2   00279   29.1126    Covered
75733   Artery x-rays, adrenals        Q2   00279   29.1126    Covered
75736   Artery x-rays, pelvis          Q2   00279   29.1126    Covered
75741   Artery x-rays, lung            Q2   00279   29.1126    Covered
75743   Artery x-rays, lungs           Q2   00279   29.1126    Covered
75746   Artery x-rays, lung            Q2   00668   10.2978    Covered
75756   Artery x-rays, chest           Q2   00668   10.2978    Covered
75774   Artery x-ray, each vessel      N                       Covered
75790   Visualize A-V shunt            D                      Not Covered
75791   Av dialysis shunt imaging      Q2   00676    2.3954    Covered
75801   Lymph vessel x-ray, arm/leg    Q2   00317    5.6012    Covered
75803   Lymph vessel x-ray,arms/legs   Q2   00317    5.6012    Covered
75805   Lymph vessel x-ray, trunk      Q2   00317    5.6012    Covered
75807   Lymph vessel x-ray, trunk      Q2   00317    5.6012    Covered
75809   Nonvascular shunt, x-ray       Q2   00261    1.1161    Covered
75810   Vein x-ray, spleen/liver       Q2   00279   29.1126    Covered
75820   Vein x-ray, arm/leg            Q2   00668   10.2978    Covered
75822   Vein x-ray, arms/legs          Q2   00668   10.2978    Covered
75825   Vein x-ray, trunk              Q2   00279   29.1126    Covered
75827   Vein x-ray, chest              Q2   00668   10.2978    Covered
75831   Vein x-ray, kidney             Q2   00279   29.1126    Covered
75833   Vein x-ray, kidneys            Q2   00279   29.1126    Covered
75840   Vein x-ray, adrenal gland      Q2   00279   29.1126    Covered
75842   Vein x-ray, adrenal glands     Q2   00279   29.1126    Covered
75860   Vein x-ray, neck               Q2   00668   10.2978             Covered
75870   Vein x-ray, skull              Q2   00668   10.2978             Covered
75872   Vein x-ray, skull              Q2   00668   10.2978             Covered
75880   Vein x-ray, eye socket         Q2   00668   10.2978             Covered
75885   Vein x-ray, liver              Q2   00279   29.1126             Covered
75887   Vein x-ray, liver              Q2   00668   10.2978             Covered
75889   Vein x-ray, liver              Q2   00279   29.1126             Covered
75891   Vein x-ray, liver              Q2   00279   29.1126             Covered
75893   Venous sampling by catheter    Q2   00279   29.1126             Covered
75894   X-rays, transcath therapy       N                               Covered
75896   X-rays, transcath therapy       N                               Covered
75898   Follow-up angiography          Q1   00261    1.1161             Covered
75900   Intravascular cath exchange     C                     $741.04   Covered
75901   Remove cva device obstruct     N                                Covered
75902   Remove cva lumen obstruct      N                                Covered
75940   X-ray placement, vein filter   N                                Covered
75945   Intravascular us               Q2   00267    2.3005             Covered
75946   Intravascular us add-on        N                                Covered
75952   Endovasc repair abdom aorta     C                     $225.29   Covered
75953   Abdom aneurysm endovas rpr      C                      $87.55   Covered
75954   Iliac aneurysm endovas rpr      C                      $78.95   Covered
75956   Xray, endovasc thor ao repr     C                     $384.40   Covered
75957   Xray, endovasc thor ao repr     C                     $329.34   Covered
75958   Xray, place prox ext thor ao    C                     $219.59   Covered
75959   Xray, place dist ext thor ao    C                     $192.24   Covered
75960   Transcath iv stent rs&i        N                                Covered
75961   Retrieval, broken catheter     N                                Covered
75962   Repair arterial blockage       Q2   00083   50.6809             Covered
75964   Repair artery blockage, each   N                                Covered
75966   Repair arterial blockage       Q2   00083   50.6809             Covered
75968   Repair artery blockage, each   N                                Covered
75970   Vascular biopsy                N                                Covered
75978   Repair venous blockage         Q2   00093   35.5969             Covered
75980   Contrast xray exam bile duct   N                                Covered
75982   Contrast xray exam bile duct   N                                Covered
75984   Xray control catheter change   N                                Covered
75989   Abscess drainage under x-ray    N                               Covered
75992   Atherectomy, x-ray exam        N                                Covered
75993   Atherectomy, x-ray exam        N                                Covered
75994   Atherectomy, x-ray exam        N                                Covered
75995   Atherectomy, x-ray exam        N                                Covered
75996   Atherectomy, x-ray exam        N                                Covered
76000   Fluoroscope examination        Q1   00272    1.2693             Covered
76001   Fluoroscope exam, extensive     N                               Covered
76010   X-ray, nose to rectum           X   00260    0.6661             Covered
76080   X-ray exam of fistula          Q2   00263    3.1192             Covered
76098   X-ray exam, breast specimen    Q2   00317    5.6012             Covered
76100   X-ray exam of body section      X   00261    1.1161             Covered
76101   Complex body section x-ray      X   00263    3.1192             Covered
76102   Complex body section x-rays     X   00263    3.1192             Covered
76120   Cine/video x-rays               X   00272    1.2693             Covered
76125   Cine/video x-rays add-on       N                                Covered
76140   X-ray consultation             E                      $2.61    Covered
76150   X-ray exam, dry process        X    00260   0.6661             Covered
76350   Special x-ray contrast study   N                               Covered
76376   3d render w/o postprocess      N                               Covered
76377   3d rendering w/postprocess     N                               Covered
76380   CAT scan follow-up study       S    00282   1.6291             Covered
76390   Mr spectroscopy                E                     $395.98   Covered
76496   Fluoroscopic procedure         X    00272   1.2693             Covered
76497   Ct procedure                   S    00282   1.6291             Covered
76498   Mri procedure                  S    00336   5.1855             Covered
76499   Radiographic procedure         X    00260   0.6661             Covered
76506   Echo exam of head              S    00265   0.9267             Covered
76510   Ophth us, b & quant a          T    00232   4.5074             Covered
76511   Ophth us, quant a only         S    00266   1.4434             Covered
76512   Ophth us, b w/non-quant a      S    00266   1.4434             Covered
76513   Echo exam of eye, water bath   S    00266   1.4434             Covered
76514   Echo exam of eye, thickness    X    00035   0.2320             Covered
76516   Echo exam of eye               S    00265   0.9267             Covered
76519   Echo exam of eye               S    00266   1.4434             Covered
76529   Echo exam of eye               S    00265   0.9267             Covered
76536   Us exam of head and neck       S    00266   1.4434             Covered
76604   Us exam, chest                 Q3   00265   0.9267             Covered
76645   Us exam, breast(s)             S    00265   0.9267             Covered
76700   Us exam, abdom, complete       Q3   00266   1.4434             Covered
76705   Echo exam of abdomen           Q3   00266   1.4434             Covered
76770   Us exam abdo back wall, comp   Q3   00266   1.4434             Covered
76775   Us exam abdo back wall, lim    Q3   00266   1.4434             Covered
76776   Us exam k transpl w/doppler    Q3   00266   1.4434             Covered
76800   Us exam, spinal canal          S    00266   1.4434             Covered
76801   Ob us < 14 wks, single fetus   S    00266   1.4434             Covered
76802   Ob us < 14 wks, add'l fetus    S    00265   0.9267             Covered
76805   Ob us >/= 14 wks, sngl fetus   S    00266   1.4434             Covered
76810   Ob us >/= 14 wks, addl fetus   S    00266   1.4434             Covered
76811   Ob us, detailed, sngl fetus    S    00267   2.3005             Covered
76812   Ob us, detailed, addl fetus    S    00265   0.9267             Covered
76813   Ob us nuchal meas, 1 gest      S    00265   0.9267             Covered
76814   Ob us nuchal meas, add-on      S    00265   0.9267             Covered
76815   Ob us, limited, fetus(s)       S    00265   0.9267             Covered
76816   Ob us, follow-up, per fetus    S    00265   0.9267             Covered
76817   Transvaginal us, obstetric     S    00265   0.9267             Covered
76818   Fetal biophys profile w/nst    S    00266   1.4434             Covered
76819   Fetal biophys profil w/o nst   S    00266   1.4434             Covered
76820   Umbilical artery echo          S    00265   0.9267             Covered
76821   Middle cerebral artery echo    S    00265   0.9267             Covered
76825   Echo exam of fetal heart       S    00270   8.8425             Covered
76826   Echo exam of fetal heart       S    00269   6.6903             Covered
76827   Echo exam of fetal heart       S    00265   0.9267             Covered
76828   Echo exam of fetal heart       S    00265   0.9267             Covered
76830   Transvaginal us, non-ob        S    00266   1.4434             Covered
76831   Echo exam, uterus              Q3   00267   2.3005             Covered
76856   Us exam, pelvic, complete      Q3   00266   1.4434             Covered
76857   Us exam, pelvic, limited       Q3   00265   0.9267             Covered
76870   Us exam, scrotum               Q3   00266   1.4434             Covered
76872   Us, transrectal                 S   00266   1.4434             Covered
76873   Echograp trans r, pros study    S   00266   1.4434             Covered
76880   Us exam, extremity              S   00266   1.4434             Covered
76885   Us exam infant hips, dynamic    S   00265   0.9267             Covered
76886   Us exam infant hips, static     S   00265   0.9267             Covered
76930   Echo guide, cardiocentesis     N                               Covered
76932   Echo guide for heart biopsy    N                               Covered
76936   Echo guide for artery repair    S   00096   1.6075             Covered
76937   Us guide, vascular access       N                              Covered
76940   Us guide, tissue ablation       N                              Covered
76941   Echo guide for transfusion      N                              Covered
76942   Echo guide for biopsy           N                              Covered
76945   Echo guide, villus sampling     N                              Covered
76946   Echo guide for amniocentesis    N                              Covered
76948   Echo guide, ova aspiration      N                              Covered
76950   Echo guidance radiotherapy      N                              Covered
76965   Echo guidance radiotherapy      N                              Covered
76970   Ultrasound exam follow-up       S   00265   0.9267            Not Covered
76975   GI endoscopic ultrasound       Q2   00267   2.3005             Covered
76977   Us bone density measure         X   00340   0.6693             Covered
76998   Us guide, intraop              N                               Covered
76999   Echo examination procedure      S   00265   0.9267             Covered
77001   Fluoroguide for vein device    N                               Covered
77002   Needle localization by xray    N                               Covered
77003   Fluoroguide for spine inject   N                               Covered
77011   Ct scan for localization       N                               Covered
77012   Ct scan for needle biopsy      N                               Covered
77013   Ct guide for tissue ablation   N                               Covered
77014   Ct scan for therapy guide      N                               Covered
77021   Mr guidance for needle place   N                               Covered
77022   Mri for tissue ablation        N                               Covered
77031   Stereotact guide for brst bx   N                               Covered
77032   Guidance for needle, breast    N                               Covered
77051   Computer dx mammogram add-on    A                    $12.56    Covered
77052   Comp screen mammogram add-on    A                    $12.56    Covered
77053   X-ray of mammary duct          Q2   00263   3.1192             Covered
77054   X-ray of mammary ducts         Q2   00263   3.1192             Covered
77055   Mammogram, one breast           A                    $39.74    Covered
77056   Mammogram, both breasts         A                    $49.90    Covered
77057   Mammogram, screening            A                    $43.05    Covered
77058   Mri, one breast                 B                             Not Covered
77059   Mri, both breasts               B                             Not Covered
77071   X-ray stress view              X    00260   0.6661             Covered
77072   X-rays for bone age            X    00260   0.6661             Covered
77073   X-rays, bone length studies    X    00260   0.6661             Covered
77074   X-rays, bone survey, limited   X    00261   1.1161             Covered
77075   X-rays, bone survey complete   X    00261   1.1161             Covered
77076   X-rays, bone survey, infant    X    00261   1.1161             Covered
77077   Joint survey, single view      X    00260   0.6661             Covered
77078   Ct bone density, axial          S   00288   1.0755             Covered
77079   Ct bone density, peripheral     S   00282   1.6291             Covered
77080   Dxa bone density, axial        S   00288     1.0755    Covered
77081   Dxa bone density/peripheral    S   00665     0.4318    Covered
77082   Dxa bone density, vert fx      X   00260     0.6661    Covered
77083   Radiographic absorptiometry    X   00261     1.1161    Covered
77084   Magnetic image, bone marrow    S   00336     5.1855    Covered
77261   Radiation therapy planning     B                      Not Covered
77262   Radiation therapy planning     B                      Not Covered
77263   Radiation therapy planning     B                      Not Covered
77280   Set radiation therapy field    X   00304     1.5271    Covered
77285   Set radiation therapy field    X   00305     3.9510    Covered
77290   Set radiation therapy field    X   00305     3.9510    Covered
77295   Set radiation therapy field    X   00310    13.7576    Covered
77299   Radiation therapy planning     X   00304     1.5271    Covered
77300   Radiation therapy dose plan    X   00304     1.5271    Covered
77301   Radiotherapy dose plan, imrt   X   00310    13.7576    Covered
77305   Teletx isodose plan simple     X   00304     1.5271    Covered
77310   Teletx isodose plan intermed   X   00304     1.5271    Covered
77315   Teletx isodose plan complex    X   00305     3.9510    Covered
77321   Special teletx port plan       X   00305     3.9510    Covered
77326   Brachytx isodose calc simp     X   00304     1.5271    Covered
77327   Brachytx isodose calc interm   X   00305     3.9510    Covered
77328   Brachytx isodose plan compl    X   00305     3.9510    Covered
77331   Special radiation dosimetry    X   00304     1.5271    Covered
77332   Radiation treatment aid(s)     X   00303     2.8279    Covered
77333   Radiation treatment aid(s)     X   00303     2.8279    Covered
77334   Radiation treatment aid(s)     X   00303     2.8279    Covered
77336   Radiation physics consult      X   00304     1.5271    Covered
77338   Design mlc device for imrt     X   00303     2.8279    Covered
77370   Radiation physics consult      X   00304     1.5271    Covered
77371   Srs, multisource               S   00127   108.9558    Covered
77372   Srs, linear based              B                      Not Covered
77373   Sbrt delivery                  B                      Not Covered
77399   External radiation dosimetry   X   00304     1.5271    Covered
77401   Radiation treatment delivery   S   00300     1.3764    Covered
77402   Radiation treatment delivery   S   00300     1.3764    Covered
77403   Radiation treatment delivery   S   00300     1.3764    Covered
77404   Radiation treatment delivery   S   00300     1.3764    Covered
77406   Radiation treatment delivery   S   00301     2.3030    Covered
77407   Radiation treatment delivery   S   00300     1.3764    Covered
77408   Radiation treatment delivery   S   00300     1.3764    Covered
77409   Radiation treatment delivery   S   00300     1.3764    Covered
77411   Radiation treatment delivery   S   00301     2.3030    Covered
77412   Radiation treatment delivery   S   00301     2.3030    Covered
77413   Radiation treatment delivery   S   00301     2.3030    Covered
77414   Radiation treatment delivery   S   00301     2.3030    Covered
77416   Radiation treatment delivery   S   00301     2.3030    Covered
77417   Radiology port film(s)         N                       Covered
77418   Radiation tx delivery, imrt    S   00412     6.2490    Covered
77421   Stereoscopic x-ray guidance    N                       Covered
77422   Neutron beam tx, simple        S   00301     2.3030    Covered
77423   Neutron beam tx, complex       S   00301     2.3030    Covered
77427   Radiation tx management, x5    B                      Not Covered
77431   Radiation therapy management   B                      Not Covered
77432   Stereotactic radiation trmt    B                      Not Covered
77435   Sbrt management                N                       Covered
77470   Special radiation treatment    S    00299    5.6461    Covered
77499   Radiation therapy management   B                      Not Covered
77520   Proton trmt, simple w/o comp   S    00664   13.9796    Covered
77522   Proton trmt, simple w/comp     S    00664   13.9796    Covered
77523   Proton trmt, intermediate      S    00667   18.2873    Covered
77525   Proton treatment, complex      S    00667   18.2873    Covered
77600   Hyperthermia treatment         S    00299    5.6461    Covered
77605   Hyperthermia treatment         S    00299    5.6461    Covered
77610   Hyperthermia treatment         S    00299    5.6461    Covered
77615   Hyperthermia treatment         S    00299    5.6461    Covered
77620   Hyperthermia treatment         S    00299    5.6461    Covered
77750   Infuse radioactive materials   S    00301    2.3030    Covered
77761   Apply intrcav radiat simple    S    00312    4.4846    Covered
77762   Apply intrcav radiat interm    S    00312    4.4846    Covered
77763   Apply intrcav radiat compl     S    00312    4.4846    Covered
77776   Apply interstit radiat simpl   S    00312    4.4846    Covered
77777   Apply interstit radiat inter   S    00312    4.4846    Covered
77778   Apply interstit radiat compl   Q3   00651   13.2555    Covered
77781   High intensity brachytherapy   D                      Not Covered
77782   High intensity brachytherapy   D                      Not Covered
77783   High intensity brachytherapy   D                      Not Covered
77784   High intensity brachytherapy   D                      Not Covered
77785   Hdr brachytx, 1 channel        S    00313   11.5353    Covered
77786   Hdr brachytx, 2-12 channel     S    00313   11.5353    Covered
77787   Hdr brachytx over 12 chan      S    00313   11.5353    Covered
77789   Apply surface radiation        S    00300    1.3764    Covered
77790   Radiation handling             N                       Covered
77799   Radium/radioisotope therapy    S    00312    4.4846    Covered
78000   Thyroid, single uptake         S    00389    1.6695    Covered
78001   Thyroid, multiple uptakes      S    00389    1.6695    Covered
78003   Thyroid suppress/stimul        S    00389    1.6695    Covered
78006   Thyroid imaging with uptake    S    00391    3.2894    Covered
78007   Thyroid image, mult uptakes    S    00391    3.2894    Covered
78010   Thyroid imaging                S    00390    2.1595    Covered
78011   Thyroid imaging with flow      S    00390    2.1595    Covered
78015   Thyroid met imaging            S    00406    4.3034    Covered
78016   Thyroid met imaging/studies    S    00406    4.3034    Covered
78018   Thyroid met imaging, body      S    00406    4.3034    Covered
78020   Thyroid met uptake             N                       Covered
78070   Parathyroid nuclear imaging    S    00391    3.2894    Covered
78075   Adrenal nuclear imaging        S    00408   14.2874    Covered
78099   Endocrine nuclear procedure    S    00390    2.1595    Covered
78102   Bone marrow imaging, ltd       S    00400    3.8342    Covered
78103   Bone marrow imaging, mult      S    00400    3.8342    Covered
78104   Bone marrow imaging, body      S    00400    3.8342    Covered
78110   Plasma volume, single          S    00393    5.7873    Covered
78111   Plasma volume, multiple        S    00393    5.7873    Covered
78120   Red cell mass, single          S    00393    5.7873    Covered
78121   Red cell mass, multiple        S    00393    5.7873    Covered
78122   Blood volume                   S   00393    5.7873            Covered
78130   Red cell survival study        S   00393    5.7873            Covered
78135   Red cell survival kinetics     S   00393    5.7873            Covered
78140   Red cell sequestration         S   00393    5.7873            Covered
78185   Spleen imaging                 S   00400    3.8342            Covered
78190   Platelet survival, kinetics    S   00392    2.6817            Covered
78191   Platelet survival              S   00392    2.6817            Covered
78195   Lymph system imaging           S   00400    3.8342            Covered
78199   Blood/lymph nuclear exam       S   00400    3.8342            Covered
78201   Liver imaging                  S   00394    4.3139            Covered
78202   Liver imaging with flow        S   00394    4.3139            Covered
78205   Liver imaging (3D)             S   00394    4.3139            Covered
78206   Liver image (3d) with flow     S   00394    4.3139            Covered
78215   Liver and spleen imaging       S   00394    4.3139            Covered
78216   Liver & spleen image/flow      S   00394    4.3139            Covered
78220   Liver function study           S   00394    4.3139            Covered
78223   Hepatobiliary imaging          S   00394    4.3139            Covered
78230   Salivary gland imaging         S   00395    3.6702            Covered
78231   Serial salivary imaging        S   00395    3.6702            Covered
78232   Salivary gland function exam   S   00395    3.6702            Covered
78258   Esophageal motility study      S   00395    3.6702            Covered
78261   Gastric mucosa imaging         S   00395    3.6702            Covered
78262   Gastroesophageal reflux exam   S   00395    3.6702            Covered
78264   Gastric emptying study         S   00395    3.6702            Covered
78267   Breath tst attain/anal c-14    A                     $11.48   Covered
78268   Breath test analysis, c-14     A                     $98.35   Covered
78270   Vit B-12 absorption exam       S   00392    2.6817            Covered
78271   Vit b-12 absrp exam, int fac   S   00392    2.6817            Covered
78272   Vit B-12 absorp, combined      S   00392    2.6817            Covered
78278   Acute GI blood loss imaging    S   00395    3.6702            Covered
78282   GI protein loss exam           S   00395    3.6702            Covered
78290   Meckel's divert exam           S   00395    3.6702            Covered
78291   Leveen/shunt patency exam      S   00395    3.6702            Covered
78299   GI nuclear procedure           S   00395    3.6702            Covered
78300   Bone imaging, limited area     S   00396    3.6707            Covered
78305   Bone imaging, multiple areas   S   00396    3.6707            Covered
78306   Bone imaging, whole body       S   00396    3.6707            Covered
78315   Bone imaging, 3 phase          S   00396    3.6707            Covered
78320   Bone imaging (3D)              S   00396    3.6707            Covered
78350   Bone mineral, single photon    E                     $26.83   Covered
78351   Bone mineral, dual photon      E                     $25.95   Covered
78399   Musculoskeletal nuclear exam   S   00396    3.6707            Covered
78414   Non-imaging heart function     S   00398    4.5366            Covered
78428   Cardiac shunt imaging          S   00398    4.5366            Covered
78445   Vascular flow imaging          S   00397    2.9679            Covered
78451   Ht muscle image spect, sing    S   00377   11.4989            Covered
78452   Ht muscle image spect, mult    S   00377   11.4989            Covered
78453   Ht muscle image,planar,sing    S   00377   11.4989            Covered
78454   Ht musc image, planar, mult    S   00377   11.4989            Covered
78456   Acute venous thrombus image    S   00397    2.9679            Covered
78457   Venous thrombosis imaging      S   00397    2.9679            Covered
78458   Ven thrombosis images, bilat   S   00397    2.9679            Covered
78459   Heart muscle imaging (PET)     S   00307   21.2573     Covered
78460   Heart muscle blood, single     D                     Not Covered
78461   Heart muscle blood, multiple   D                     Not Covered
78464   Heart image (3d), single       D                     Not Covered
78465   Heart image (3d), multiple     D                     Not Covered
78466   Heart infarct image            S   00398    4.5366     Covered
78468   Heart infarct image (ef)       S   00398    4.5366     Covered
78469   Heart infarct image (3D)       S   00398    4.5366     Covered
78472   Gated heart, planar, single    S   00398    4.5366     Covered
78473   Gated heart, multiple          S   00398    4.5366     Covered
78478   Heart wall motion add-on       D                     Not Covered
78480   Heart function add-on          D                     Not Covered
78481   Heart first pass, single       S   00398    4.5366     Covered
78483   Heart first pass, multiple     S   00398    4.5366     Covered
78491   Heart image (pet), single      S   00307   21.2573     Covered
78492   Heart image (pet), multiple    S   00307   21.2573     Covered
78494   Heart image, spect             S   00398    4.5366     Covered
78496   Heart first pass add-on        N                       Covered
78499   Cardiovascular nuclear exam    S   00398    4.5366     Covered
78580   Lung perfusion imaging         S   00401    3.0625     Covered
78584   Lung V/Q image single breath   S   00378    4.8032     Covered
78585   Lung V/Q imaging               S   00378    4.8032     Covered
78586   Aerosol lung image, single     S   00401    3.0625     Covered
78587   Aerosol lung image, multiple   S   00401    3.0625     Covered
78588   Perfusion lung image           S   00378    4.8032     Covered
78591   Vent image, 1 breath, 1 proj   S   00401    3.0625     Covered
78593   Vent image, 1 proj, gas        S   00401    3.0625     Covered
78594   Vent image, mult proj, gas     S   00401    3.0625     Covered
78596   Lung differential function     S   00378    4.8032     Covered
78599   Respiratory nuclear exam       S   00401    3.0625     Covered
78600   Brain image < 4 views          S   00403    2.9181     Covered
78601   Brain image w/flow < 4 views   S   00402    8.5845     Covered
78605   Brain image 4+ views           S   00403    2.9181     Covered
78606   Brain image w/flow 4 + views   S   00402    8.5845     Covered
78607   Brain imaging (3D)             S   00402    8.5845     Covered
78608   Brain imaging (PET)            S   00308   15.3895     Covered
78609   Brain imaging (PET)            E                      By Report
78610   Brain flow imaging only        S   00403    2.9181     Covered
78630   Cerebrospinal fluid scan       S   00402    8.5845     Covered
78635   CSF ventriculography           S   00402    8.5845     Covered
78645   CSF shunt evaluation           S   00403    2.9181     Covered
78647   Cerebrospinal fluid scan       S   00402    8.5845     Covered
78650   CSF leakage imaging            S   00402    8.5845     Covered
78660   Nuclear exam of tear flow      S   00403    2.9181     Covered
78699   Nervous system nuclear exam    S   00403    2.9181     Covered
78700   Kidney imaging, morphol        S   00404    4.8221     Covered
78701   Kidney imaging with flow       S   00404    4.8221     Covered
78707   K flow/funct image w/o drug    S   00404    4.8221     Covered
78708   K flow/funct image w/drug      S   00404    4.8221     Covered
78709   K flow/funct image, multiple   S   00404    4.8221     Covered
78710   Kidney imaging (3D)            S   00404    4.8221     Covered
78725   Kidney function study          S   00392    2.6817     Covered
78730   Urinary bladder retention       S   00389    1.6695             Covered
78740   Ureteral reflux study           S   00404    4.8221             Covered
78761   Testicular imaging w/flow       S   00404    4.8221             Covered
78799   Genitourinary nuclear exam      S   00404    4.8221             Covered
78800   Tumor imaging, limited area     S   00406    4.3034             Covered
78801   Tumor imaging, mult areas       S   00414    7.5722             Covered
78802   Tumor imaging, whole body       S   00414    7.5722             Covered
78803   Tumor imaging (3D)              S   00414    7.5722             Covered
78804   Tumor imaging, whole body       S   00408   14.2874             Covered
78805   Abscess imaging, ltd area       S   00414    7.5722             Covered
78806   Abscess imaging, whole body     S   00414    7.5722             Covered
78807   Nuclear localization/abscess    S   00406    4.3034             Covered
78808   Iv inj ra drug dx study        Q1   00392    2.6817             Covered
78811   Pet image, ltd area             S   00308   15.3895             Covered
78812   Pet image, skull-thigh          S   00308   15.3895             Covered
78813   Pet image, full body            S   00308   15.3895             Covered
78814   Pet image w/ct, lmtd            S   00308   15.3895             Covered
78815   Pet image w/ct, skull-thigh     S   00308   15.3895             Covered
78816   Pet image w/ct, full body       S   00308   15.3895             Covered
78890   Nuclear medicine data proc      D                              Not Covered
78891   Nuclear med data proc           D                              Not Covered
78999   Nuclear diagnostic exam         S   00389    1.6695             Covered
79005   Nuclear rx, oral admin          S   00407    3.2356             Covered
79101   Nuclear rx, iv admin            S   00407    3.2356             Covered
79200   Nuclear rx, intracav admin      S   00413    5.2007             Covered
79300   Nuclr rx, interstit colloid     S   00407    3.2356             Covered
79403   Hematopoietic nuclear tx        S   00413    5.2007             Covered
79440   Nuclear rx, intra-articular     S   00413    5.2007             Covered
79445   Nuclear rx, intra-arterial      S   00407    3.2356             Covered
79999   Nuclear medicine therapy        S   00407    3.2356             Covered
80047   Metabolic panel ionized ca      A                              Not Covered
80048   Metabolic panel total ca        A                     $12.36    Covered
80050   General health panel            E                     $53.56    Covered
80051   Electrolyte panel               A                     $10.24    Covered
80053   Comprehen metabolic panel       A                     $15.44    Covered
80055   Obstetric panel                 E                     $27.74    Covered
80061   Lipid panel                     A                     $19.57    Covered
80069   Renal function panel            A                     $12.68    Covered
80074   Acute hepatitis panel           A                     $61.19    Covered
80076   Hepatic function panel          A                     $11.93    Covered
80100   Drug screen, qualitate/multi    E                     $21.23    Covered
80101   Drug screen, single             E                     $20.11    Covered
80102   Drug confirmation               A                     $19.34    Covered
80103   Drug analysis, tissue prep      N                              Not Covered
80150   Assay of amikacin               A                     $22.01    Covered
80152   Assay of amitriptyline          A                     $26.14    Covered
80154   Assay of benzodiazepines        A                     $27.00    Covered
80156   Assay, carbamazepine, total     A                     $21.26    Covered
80157   Assay, carbamazepine, free      A                     $19.36    Covered
80158   Assay of cyclosporine           A                     $26.36    Covered
80160   Assay of desipramine            A                     $22.96    Covered
80162   Assay of digoxin                A                     $19.39    Covered
80164   Assay, dipropylacetic acid     A                   $19.78   Covered
80166   Assay of doxepin               A                   $21.19   Covered
80168   Assay of ethosuximide          A                   $23.86   Covered
80170   Assay of gentamicin            A                   $23.93   Covered
80172   Assay of gold                  A                   $22.00   Covered
80173   Assay of haloperidol           A                   $21.26   Covered
80174   Assay of imipramine            A                   $21.19   Covered
80176   Assay of lidocaine             A                   $21.45   Covered
80178   Assay of lithium               A                    $9.65   Covered
80182   Assay of nortriptyline         A                   $19.78   Covered
80184   Assay of phenobarbital         A                   $16.72   Covered
80185   Assay of phenytoin, total      A                   $19.36   Covered
80186   Assay of phenytoin, free       A                   $20.10   Covered
80188   Assay of primidone             A                   $24.23   Covered
80190   Assay of procainamide          A                   $24.46   Covered
80192   Assay of procainamide          A                   $24.46   Covered
80194   Assay of quinidine             A                   $21.31   Covered
80195   Assay of sirolimus             A                   $20.04   Covered
80196   Assay of salicylate            A                   $10.36   Covered
80197   Assay of tacrolimus            A                   $20.04   Covered
80198   Assay of theophylline          A                   $20.66   Covered
80200   Assay of tobramycin            A                   $23.53   Covered
80201   Assay of topiramate            A                   $17.40   Covered
80202   Assay of vancomycin            A                   $19.78   Covered
80299   Quantitative assay, drug       A                   $19.99   Covered
80400   Acth stimulation panel         A                   $47.62   Covered
80402   Acth stimulation panel         A                  $126.94   Covered
80406   Acth stimulation panel         A                   $87.76   Covered
80408   Aldosterone suppression eval   A                  $183.24   Covered
80410   Calcitonin stimul panel        A                  $117.30   Covered
80412   CRH stimulation panel          A                  $481.26   Covered
80414   Testosterone response          A                   $75.40   Covered
80415   Estradiol response panel       A                   $81.60   Covered
80416   Renin stimulation panel        A                  $192.72   Covered
80417   Renin stimulation panel        A                   $64.24   Covered
80418   Pituitary evaluation panel     A                  $846.24   Covered
80420   Dexamethasone panel            A                  $105.18   Covered
80422   Glucagon tolerance panel       A                   $66.54   Covered
80424   Glucagon tolerance panel       A                   $73.74   Covered
80426   Gonadotropin hormone panel     A                  $216.72   Covered
80428   Growth hormone panel           A                   $97.36   Covered
80430   Growth hormone panel           A                  $113.83   Covered
80432   Insulin suppression panel      A                  $196.04   Covered
80434   Insulin tolerance panel        A                  $146.50   Covered
80435   Insulin tolerance panel        A                  $149.15   Covered
80436   Metyrapone panel               A                  $117.18   Covered
80438   TRH stimulation panel          A                   $73.59   Covered
80439   TRH stimulation panel          A                   $98.12   Covered
80440   TRH stimulation panel          A                   $84.90   Covered
80500   Lab pathology consultation     X 00433   0.2482             Covered
80502   Lab pathology consultation     X 00342   0.1546             Covered
81000   Urinalysis, nonauto w/scope    A                   $4.63    Covered
81001   Urinalysis, auto w/scope       A   $4.63        Covered
81002   Urinalysis nonauto w/o scope   A   $3.74        Covered
81003   Urinalysis, auto, w/o scope    A   $3.28        Covered
81005   Urinalysis                     A   $3.16        Covered
81007   Urine screen for bacteria      A   $3.75        Covered
81015   Microscopic exam of urine      A   $4.43        Covered
81020   Urinalysis, glass test         A   $5.38        Covered
81025   Urine pregnancy test           A   $9.24        Covered
81050   Urinalysis, volume measure     A   $4.37        Covered
81099   Urinalysis test procedure      A            Review Required
82000   Assay of blood acetaldehyde    A   $18.09       Covered
82003   Assay of acetaminophen         A   $29.55       Covered
82009   Test for acetone/ketones       A    $6.59       Covered
82010   Acetone assay                  A   $11.71       Covered
82013   Acetylcholinesterase assay     A   $16.31       Covered
82016   Acylcarnitines, qual           A   $20.24       Covered
82017   Acylcarnitines, quant          A   $24.63       Covered
82024   Assay of acth                  A   $56.40       Covered
82030   Assay of adp & amp             A   $19.84       Covered
82040   Assay of serum albumin         A    $7.23       Covered
82042   Assay of urine albumin         A    $7.56       Covered
82043   Microalbumin, quantitative     A    $8.45       Covered
82044   Microalbumin, semiquant        A    $6.68       Covered
82045   Albumin, ischemia modified     A               By Report
82055   Assay of ethanol               A   $15.78       Covered
82075   Assay of breath ethanol        A   $17.60       Covered
82085   Assay of aldolase              A   $14.17       Covered
82088   Assay of aldosterone           A   $59.50       Covered
82101   Assay of urine alkaloids       A   $43.83       Covered
82103   Alpha-1-antitrypsin, total     A   $19.61       Covered
82104   Alpha-1-antitrypsin, pheno     A   $21.11       Covered
82105   Alpha-fetoprotein, serum       A   $24.49       Covered
82106   Alpha-fetoprotein, amniotic    A   $24.49       Covered
82107   Alpha-fetoprotein l3           A   $94.04       Covered
82108   Assay of aluminum              A   $37.20       Covered
82120   Amines, vaginal fluid qual     A    $5.17       Covered
82127   Amino acid, single qual        A   $20.24       Covered
82128   Amino acids, mult qual         A   $20.24       Covered
82131   Amino acids, single quant      A   $24.63       Covered
82135   Assay, aminolevulinic acid     A   $24.04       Covered
82136   Amino acids, quant, 2-5        A   $24.63       Covered
82139   Amino acids, quan, 6 or more   A   $24.63       Covered
82140   Assay of ammonia               A   $21.28       Covered
82143   Amniotic fluid scan            A   $10.03       Covered
82145   Assay of amphetamines          A   $22.70       Covered
82150   Assay of amylase               A    $9.46       Covered
82154   Androstanediol glucuronide     A   $33.46       Covered
82157   Assay of androstenedione       A   $42.74       Covered
82160   Assay of androsterone          A   $33.58       Covered
82163   Assay of angiotensin II        A   $29.90       Covered
82164   Angiotensin I enzyme test      A   $21.31       Covered
82172   Assay of apolipoprotein        A   $22.62       Covered
82175   Assay of arsenic               A   $27.70    Covered
82180   Assay of ascorbic acid         A   $14.43    Covered
82190   Atomic absorption              A   $21.77    Covered
82205   Assay of barbiturates          A   $16.72    Covered
82232   Assay of beta-2 protein        A   $19.84    Covered
82239   Bile acids, total              A   $12.31    Covered
82240   Bile acids, cholylglycine      A    $4.20    Covered
82247   Bilirubin, total               A    $7.33    Covered
82248   Bilirubin, direct              A    $7.33    Covered
82252   Fecal bilirubin test           A    $6.64    Covered
82261   Assay of biotinidase           A   $24.63    Covered
82270   Occult blood, feces            A    $4.75    Covered
82271   Occult blood, other sources    A    $4.75    Covered
82272   Occult bld feces, 1-3 tests    A    $4.75    Covered
82274   Assay test for blood, fecal    A   $23.22    Covered
82286   Assay of bradykinin            A   $10.06    Covered
82300   Assay of cadmium               A   $33.79    Covered
82306   Assay of vitamin D             A   $43.22    Covered
82307   Assay of vitamin D             D            Not Covered
82308   Assay of calcitonin            A   $39.10    Covered
82310   Assay of calcium               A    $7.53    Covered
82330   Assay of calcium               A   $19.95    Covered
82331   Calcium infusion test          A    $7.56    Covered
82340   Assay of calcium in urine      A    $8.81    Covered
82355   Calculus analysis, qual        A   $16.89    Covered
82360   Calculus assay, quant          A   $18.80    Covered
82365   Calculus spectroscopy          A   $10.60    Covered
82370   X-ray assay, calculus          A   $18.29    Covered
82373   Assay, c-d transfer measure    A   $26.37    Covered
82374   Assay, blood carbon dioxide    A    $7.14    Covered
82375   Assay, carboxyhb, quant        A   $18.00    Covered
82376   Assay, carboxyhb, qual         A    $4.20    Covered
82378   Carcinoembryonic antigen       A   $27.70    Covered
82379   Assay of carnitine             A   $24.63    Covered
82380   Assay of carotene              A   $13.47    Covered
82382   Assay, urine catecholamines    A   $25.10    Covered
82383   Assay, blood catecholamines    A   $36.59    Covered
82384   Assay, three catecholamines    A   $36.87    Covered
82387   Assay of cathepsin-d           A   $30.38    Covered
82390   Assay of ceruloplasmin         A   $15.68    Covered
82397   Chemiluminescent assay         A   $20.63    Covered
82415   Assay of chloramphenicol       A   $18.50    Covered
82435   Assay of blood chloride        A    $6.70    Covered
82436   Assay of urine chloride        A    $7.34    Covered
82438   Assay, other fluid chlorides   A    $7.14    Covered
82441   Test for chlorohydrocarbons    A    $8.76    Covered
82465   Assay, bld/serum cholesterol   A    $6.05    Covered
82480   Assay, serum cholinesterase    A   $11.51    Covered
82482   Assay, rbc cholinesterase      A   $11.22    Covered
82485   Assay, chondroitin sulfate     A   $30.15    Covered
82486   Gas/liquid chromatography      A   $26.37    Covered
82487   Paper chromatography           A   $19.84    Covered
82488   Paper chromatography           A   $19.84     Covered
82489   Thin layer chromatography      A   $19.84     Covered
82491   Chromotography, quant, sing    A   $26.37     Covered
82492   Chromotography, quant, mult    A   $26.37     Covered
82495   Assay of chromium              A    $7.61     Covered
82507   Assay of citrate               A   $40.60     Covered
82520   Assay of cocaine               A   $22.13     Covered
82523   Collagen crosslinks            A   $27.29     Covered
82525   Assay of copper                A   $18.12     Covered
82528   Assay of corticosterone        A   $32.86     Covered
82530   Cortisol, free                 A   $24.41     Covered
82533   Total cortisol                 A   $23.81     Covered
82540   Assay of creatine              A    $6.76     Covered
82541   Column chromotography, qual    A   $26.37     Covered
82542   Column chromotography, quant   A   $26.37     Covered
82543   Column chromotograph/isotope   A   $26.37     Covered
82544   Column chromotograph/isotope   A   $26.37     Covered
82550   Assay of ck (cpk)              A    $9.51     Covered
82552   Assay of cpk in blood          A   $19.56     Covered
82553   Creatine, MB fraction          A   $16.86     Covered
82554   Creatine, isoforms             A   $17.33     Covered
82565   Assay of creatinine            A    $7.48     Covered
82570   Assay of urine creatinine      A    $7.56     Covered
82575   Creatinine clearance test      A   $13.79     Covered
82585   Assay of cryofibrinogen        A   $12.52     Covered
82595   Assay of cryoglobulin          A    $9.45     Covered
82600   Assay of cyanide               A   $28.33     Covered
82607   Vitamin B-12                   A   $22.01     Covered
82608   B-12 binding capacity          A   $20.91     Covered
82610   Cystatin c                     A            Not Covered
82615   Test for urine cystines        A   $11.92     Covered
82626   Dehydroepiandrosterone         A   $36.90     Covered
82627   Dehydroepiandrosterone         A   $32.46     Covered
82633   Desoxycorticosterone           A   $34.78     Covered
82634   Deoxycortisol                  A   $34.78     Covered
82638   Assay of dibucaine number      A   $17.88     Covered
82646   Assay of dihydrocodeinone      A   $29.90     Covered
82649   Assay of dihydromorphinone     A   $37.53     Covered
82651   Assay of dihydrotestosterone   A   $37.69     Covered
82652   Assay of dihydroxyvitamin d    A   $56.20     Covered
82654   Assay of dimethadione          A   $20.22     Covered
82656   Pancreatic elastase, fecal     A             By Report
82657   Enzyme cell activity           A   $26.37     Covered
82658   Enzyme cell activity, ra       A   $26.37     Covered
82664   Electrophoretic test           A   $50.16     Covered
82666   Assay of epiandrosterone       A   $31.37     Covered
82668   Assay of erythropoietin        A   $27.45     Covered
82670   Assay of estradiol             A   $40.80     Covered
82671   Assay of estrogens             A   $47.15     Covered
82672   Assay of estrogen              A   $31.66     Covered
82677   Assay of estriol               A   $31.38     Covered
82679   Assay of estrone               A   $36.45     Covered
82690   Assay of ethchlorvynol         A   $25.24   Covered
82693   Assay of ethylene glycol       A   $21.75   Covered
82696   Assay of etiocholanolone       A   $34.43   Covered
82705   Fats/lipids, feces, qual       A    $7.43   Covered
82710   Fats/lipids, feces, quant      A   $19.97   Covered
82715   Assay of fecal fat             A    $8.55   Covered
82725   Assay of blood fatty acids     A   $19.44   Covered
82726   Long chain fatty acids         A   $26.37   Covered
82728   Assay of ferritin              A   $19.89   Covered
82731   Assay of fetal fibronectin     A   $94.04   Covered
82735   Assay of fluoride              A   $27.08   Covered
82742   Assay of flurazepam            A   $28.90   Covered
82746   Blood folic acid serum         A   $21.47   Covered
82747   Assay of folic acid, rbc       A   $25.29   Covered
82757   Assay of semen fructose        A   $25.32   Covered
82759   Assay of rbc galactokinase     A   $31.37   Covered
82760   Assay of galactose             A   $16.35   Covered
82775   Assay galactose transferase    A   $29.90   Covered
82776   Galactose transferase test     A   $12.24   Covered
82784   Assay of gammaglobulin igm     A   $13.58   Covered
82785   Assay of gammaglobulin ige     A   $24.05   Covered
82787   Igg 1, 2, 3 or 4, each         A    $5.08   Covered
82800   Blood pH                       A   $11.82   Covered
82803   Blood gases: pH, pO2 & pCO2    A   $22.96   Covered
82805   Blood gases w/02 saturation    A   $28.53   Covered
82810   Blood gases, O2 sat only       A    $5.57   Covered
82820   Hemoglobin-oxygen affinity     A   $14.17   Covered
82926   Assay of gastric acid          A    $7.96   Covered
82928   Assay of gastric acid          A    $9.56   Covered
82938   Gastrin test                   A   $25.83   Covered
82941   Assay of gastrin               A   $25.75   Covered
82943   Assay of glucagon              A   $20.37   Covered
82945   Glucose other fluid            A    $5.49   Covered
82946   Glucagon tolerance test        A    $8.55   Covered
82947   Assay, glucose, blood quant    A    $5.49   Covered
82948   Reagent strip/blood glucose    A    $4.63   Covered
82950   Glucose test                   A    $6.93   Covered
82951   Glucose tolerance test (GTT)   A   $14.93   Covered
82952   GTT-added samples              A    $5.72   Covered
82953   Glucose-tolbutamide test       A   $22.12   Covered
82955   Assay of g6pd enzyme           A   $10.21   Covered
82960   Test for G6PD enzyme           A    $8.84   Covered
82962   Glucose blood test             A    $2.64   Covered
82963   Assay of glucosidase           A   $31.37   Covered
82965   Assay of gdh enzyme            A    $8.55   Covered
82975   Assay of glutamine             A   $23.13   Covered
82977   Assay of GGT                   A   $10.51   Covered
82978   Assay of glutathione           A   $20.81   Covered
82979   Assay, rbc glutathione         A    $9.92   Covered
82980   Assay of glutethimide          A   $26.75   Covered
82985   Glycated protein               A   $22.01   Covered
83001   Gonadotropin (FSH)             A   $27.14   Covered
83002   Gonadotropin (LH)              A   $27.04   Covered
83003   Assay, growth hormone (hgh)    A   $24.34   Covered
83008   Assay of guanosine             A   $24.51   Covered
83009   H pylori (c-13), blood         A   $98.35   Covered
83010   Assay of haptoglobin, quant    A   $18.37   Covered
83012   Assay of haptoglobins          A   $25.10   Covered
83013   H pylori (c-13), breath        A   $98.35   Covered
83014   H pylori drug admin            A   $11.48   Covered
83015   Heavy metal screen             A   $27.50   Covered
83018   Quantitative screen, metals    A   $10.82   Covered
83020   Hemoglobin electrophoresis     A    $7.61   Covered
83021   Hemoglobin chromotography      A   $26.37   Covered
83026   Hemoglobin, copper sulfate     A    $3.45   Covered
83030   Fetal hemoglobin, chemical     A   $12.08   Covered
83033   Fetal hemoglobin assay, qual   A    $8.70   Covered
83036   Glycosylated hemoglobin test   A   $14.17   Covered
83037   Glycosylated hb, home device   A   $14.17   Covered
83045   Blood methemoglobin test       A    $7.24   Covered
83050   Blood methemoglobin assay      A    $4.28   Covered
83051   Assay of plasma hemoglobin     A   $10.67   Covered
83055   Blood sulfhemoglobin test      A    $7.19   Covered
83060   Blood sulfhemoglobin assay     A   $12.08   Covered
83065   Assay of hemoglobin heat       A    $5.17   Covered
83068   Hemoglobin stability screen    A   $12.37   Covered
83069   Assay of urine hemoglobin      A    $5.17   Covered
83070   Assay of hemosiderin, qual     A    $4.88   Covered
83071   Assay of hemosiderin, quant    A    $5.99   Covered
83080   Assay of b hexosaminidase      A   $24.63   Covered
83088   Assay of histamine             A   $43.12   Covered
83090   Assay of homocystine           A   $24.63   Covered
83150   Assay of for hva               A   $28.25   Covered
83491   Assay of corticosteroids       A   $25.21   Covered
83497   Assay of 5-hiaa                A   $10.21   Covered
83498   Assay of progesterone          A   $39.66   Covered
83499   Assay of progesterone          A   $36.80   Covered
83500   Assay, free hydroxyproline     A   $33.07   Covered
83505   Assay, total hydroxyproline    A   $35.49   Covered
83516   Immunoassay, nonantibody       A   $16.85   Covered
83518   Immunoassay, dipstick          A   $12.38   Covered
83519   Immunoassay, nonantibody       A   $19.73   Covered
83520   Immunoassay, RIA               A   $18.91   Covered
83525   Assay of insulin               A   $16.69   Covered
83527   Assay of insulin               A   $12.05   Covered
83528   Assay of intrinsic factor      A   $23.22   Covered
83540   Assay of iron                  A    $9.46   Covered
83550   Iron binding test              A   $11.00   Covered
83570   Assay of idh enzyme            A   $12.91   Covered
83582   Assay of ketogenic steroids    A   $20.69   Covered
83586   Assay 17- ketosteroids         A   $18.69   Covered
83593   Fractionation, ketosteroids    A   $38.40   Covered
83605   Assay of lactic acid           A   $15.59   Covered
83615   Lactate (LD) (LDH) enzyme      A    $8.81   Covered
83625   Assay of ldh enzymes           A   $18.69     Covered
83630   Lactoferrin, fecal (qual)      A             By Report
83631   Lactoferrin, fecal (quant)     A   $28.66     Covered
83632   Placental lactogen             A   $29.51     Covered
83633   Test urine for lactose         A    $8.04     Covered
83634   Assay of urine for lactose     A   $16.83     Covered
83655   Assay of lead                  A   $17.67     Covered
83661   L/s ratio, fetal lung          A   $32.09     Covered
83662   Foam stability, fetal lung     A   $27.62     Covered
83663   Fluoro polarize, fetal lung    A   $27.62     Covered
83664   Lamellar bdy, fetal lung       A   $27.62     Covered
83670   Assay of lap enzyme            A   $11.27     Covered
83690   Assay of lipase                A   $10.06     Covered
83695   Assay of lipoprotein(a)        A   $18.91     Covered
83698   Assay lipoprotein pla2         A   $49.56     Covered
83700   Lipopro bld, electrophoretic   A            Not Covered
83701   Lipoprotein bld, hr fraction   A   $36.24     Covered
83704   Lipoprotein, bld, by nmr       A   $46.07     Covered
83718   Assay of lipoprotein           A   $11.96     Covered
83719   Assay of blood lipoprotein     A   $13.85     Covered
83721   Assay of blood lipoprotein     A   $11.16     Covered
83727   Assay of lrh hormone           A   $25.10     Covered
83735   Assay of magnesium             A    $9.78     Covered
83775   Assay of md enzyme             A   $10.77     Covered
83785   Assay of manganese             A   $29.90     Covered
83788   Mass spectrometry qual         A   $26.37     Covered
83789   Mass spectrometry quant        A   $26.37     Covered
83805   Assay of meprobamate           A   $25.74     Covered
83825   Assay of mercury               A   $23.46     Covered
83835   Assay of metanephrines         A   $24.74     Covered
83840   Assay of methadone             A   $23.84     Covered
83857   Assay of methemalbumin         A   $15.68     Covered
83858   Assay of methsuximide          A   $21.64     Covered
83864   Mucopolysaccharides            A   $29.07     Covered
83866   Mucopolysaccharides screen     A   $14.39     Covered
83872   Assay synovial fluid mucin     A    $8.56     Covered
83873   Assay of csf protein           A   $25.12     Covered
83874   Assay of myoglobin             A   $18.86     Covered
83876   Assay, myeloperoxidase         A   $18.91     Covered
83880   Natriuretic peptide            A   $49.56     Covered
83883   Assay, nephelometry not spec   A   $19.85     Covered
83885   Assay of nickel                A   $35.77     Covered
83887   Assay of nicotine              A   $34.58     Covered
83890   Molecule isolate               A    $5.85     Covered
83891   Molecule isolate nucleic       A    $5.85     Covered
83892   Molecular diagnostics          A    $5.85     Covered
83893   Molecule dot/slot/blot         A    $5.85     Covered
83894   Molecule gel electrophor       A    $5.85     Covered
83896   Molecular diagnostics          A    $5.85     Covered
83897   Molecule nucleic transfer      A    $5.85     Covered
83898   Molecule nucleic ampli, each   A   $24.47     Covered
83900   Molecule nucleic ampli 2 seq   A            Not Covered
83901   Molecule nucleic ampli addon   A   $24.47    Covered
83902   Molecular diagnostics          A   $20.72    Covered
83903   Molecule mutation scan         A   $24.47    Covered
83904   Molecule mutation identify     A   $24.47    Covered
83905   Molecule mutation identify     A   $24.47    Covered
83906   Molecule mutation identify     A   $24.47    Covered
83907   Lyse cells for nucleic ext     A   $19.50    Covered
83908   Nucleic acid, signal ampli     A   $24.47    Covered
83909   Nucleic acid, high resolute    A   $24.47    Covered
83912   Genetic examination            A    $5.85    Covered
83913   Molecular, rna stabilization   A   $19.50    Covered
83914   Mutation ident ola/sbce/aspe   A   $24.47    Covered
83915   Assay of nucleotidase          A   $16.29    Covered
83916   Oligoclonal bands              A   $29.36    Covered
83918   Organic acids, total, quant    A   $24.04    Covered
83919   Organic acids, qual, each      A   $24.04    Covered
83921   Organic acid, single, quant    A   $24.04    Covered
83925   Assay of opiates               A   $28.41    Covered
83930   Assay of blood osmolality      A    $9.65    Covered
83935   Assay of urine osmolality      A    $9.95    Covered
83937   Assay of osteocalcin           A   $26.77    Covered
83945   Assay of oxalate               A   $18.80    Covered
83950   Oncoprotein, her-2/neu         A   $94.04    Covered
83951   Oncoprotein, dcp               A   $94.04    Covered
83970   Assay of parathormone          A   $60.27    Covered
83986   Assay of body fluid acidity    A    $5.22    Covered
83987   Exhaled breath condensate      A            Not Covered
83992   Assay for phencyclidine        A   $21.46    Covered
83993   Assay for calprotectin fecal   A            Not Covered
84022   Assay of phenothiazine         A   $22.74    Covered
84030   Assay of blood pku             A    $8.04    Covered
84035   Assay of phenylketones         A    $5.34    Covered
84060   Assay acid phosphatase         A   $10.78    Covered
84061   Phosphatase, forensic exam     A   $11.55    Covered
84066   Assay prostate phosphatase     A   $14.10    Covered
84075   Assay alkaline phosphatase     A    $7.56    Covered
84078   Assay alkaline phosphatase     A   $10.66    Covered
84080   Assay alkaline phosphatases    A   $21.59    Covered
84081   Amniotic fluid enzyme test     A   $24.12    Covered
84085   Assay of rbc pg6d enzyme       A    $9.84    Covered
84087   Assay phosphohexose enzymes    A   $15.07    Covered
84100   Assay of phosphorus            A    $6.93    Covered
84105   Assay of urine phosphorus      A    $7.56    Covered
84106   Test for porphobilinogen       A    $6.25    Covered
84110   Assay of porphobilinogen       A   $12.34    Covered
84119   Test urine for porphyrins      A   $12.57    Covered
84120   Assay of urine porphyrins      A   $21.47    Covered
84126   Assay of feces porphyrins      A   $37.19    Covered
84127   Assay of feces porphyrins      A   $17.01    Covered
84132   Assay of serum potassium       A    $6.70    Covered
84133   Assay of urine potassium       A    $6.28    Covered
84134   Assay of prealbumin            A   $21.30    Covered
84135   Assay of pregnanediol          A   $27.94    Covered
84138   Assay of pregnanetriol         A   $27.65    Covered
84140   Assay of pregnenolone          A   $20.07    Covered
84143   Assay of 17-hydroxypregneno    A   $20.07    Covered
84144   Assay of progesterone          A   $30.46    Covered
84145   Procalcitonin (pct)            A   $27.76    Covered
84146   Assay of prolactin             A   $28.30    Covered
84150   Assay of prostaglandin         A   $29.74    Covered
84152   Assay of psa, complexed        A   $26.85    Covered
84153   Assay of psa, total            A   $26.85    Covered
84154   Assay of psa, free             A   $26.85    Covered
84155   Assay of protein, serum        A    $5.35    Covered
84156   Assay of protein, urine        A    $5.35    Covered
84157   Assay of protein, other        A    $5.35    Covered
84160   Assay of protein, any source   A    $7.56    Covered
84163   Pappa, serum                   A            By Report
84165   Protein e-phoresis, serum      A   $15.68    Covered
84166   Protein e-phoresis/urine/csf   A   $26.04    Covered
84181   Western blot test              A    $9.97    Covered
84182   Protein, western blot test     A    $9.97    Covered
84202   Assay RBC protoporphyrin       A   $20.95    Covered
84203   Test RBC protoporphyrin        A   $12.57    Covered
84206   Assay of proinsulin            A   $26.01    Covered
84207   Assay of vitamin b-6           A   $41.02    Covered
84210   Assay of pyruvate              A   $14.93    Covered
84220   Assay of pyruvate kinase       A   $13.77    Covered
84228   Assay of quinine               A   $16.99    Covered
84233   Assay of estrogen              A   $94.04    Covered
84234   Assay of progesterone          A   $94.72    Covered
84235   Assay of endocrine hormone     A    $6.79    Covered
84238   Assay, nonendocrine receptor   A   $53.39    Covered
84244   Assay of renin                 A   $32.12    Covered
84252   Assay of vitamin b-2           A   $29.55    Covered
84255   Assay of selenium              A   $16.99    Covered
84260   Assay of serotonin             A   $45.23    Covered
84270   Assay of sex hormone globul    A   $31.73    Covered
84275   Assay of sialic acid           A   $19.61    Covered
84285   Assay of silica                A   $34.38    Covered
84295   Assay of serum sodium          A    $7.02    Covered
84300   Assay of urine sodium          A    $4.20    Covered
84302   Assay of sweat sodium          A    $4.20    Covered
84305   Assay of somatomedin           A   $31.04    Covered
84307   Assay of somatostatin          A   $26.70    Covered
84311   Spectrophotometry              A   $10.20    Covered
84315   Body fluid specific gravity    A    $3.66    Covered
84375   Chromatogram assay, sugars     A   $28.62    Covered
84376   Sugars, single, qual           A    $8.04    Covered
84377   Sugars, multiple, qual         A    $8.04    Covered
84378   Sugars, single, quant          A   $16.83    Covered
84379   Sugars multiple quant          A   $16.83    Covered
84392   Assay of urine sulfate         A    $6.93    Covered
84402   Assay of testosterone          A   $37.18    Covered
84403   Assay of total testosterone    A   $37.70     Covered
84425   Assay of vitamin b-1           A   $31.01     Covered
84430   Assay of thiocyanate           A   $16.99     Covered
84431   Thromboxane, urine             A   $18.54     Covered
84432   Assay of thyroglobulin         A   $23.45     Covered
84436   Assay of total thyroxine       A   $10.03     Covered
84437   Assay of neonatal thyroxine    A    $9.45     Covered
84439   Assay of free thyroxine        A   $11.00     Covered
84442   Assay of thyroid activity      A   $21.59     Covered
84443   Assay thyroid stim hormone     A   $24.53     Covered
84445   Assay of tsi                   A   $74.24     Covered
84446   Assay of vitamin e             A   $20.70     Covered
84449   Assay of transcortin           A   $16.73     Covered
84450   Transferase (AST) (SGOT)       A    $7.55     Covered
84460   Alanine amino (ALT) (SGPT)     A    $7.73     Covered
84466   Assay of transferrin           A   $18.64     Covered
84478   Assay of triglycerides         A    $8.40     Covered
84479   Assay of thyroid (t3 or t4)    A    $9.45     Covered
84480   Assay, triiodothyronine (t3)   A   $18.61     Covered
84481   Free assay (FT-3)              A   $24.74     Covered
84482   T3 reverse                     A   $23.01     Covered
84484   Assay of troponin, quant       A   $14.37     Covered
84485   Assay duodenal fluid trypsin   A   $10.96     Covered
84488   Test feces for trypsin         A    $9.92     Covered
84490   Assay of feces for trypsin     A   $11.11     Covered
84510   Assay of tyrosine              A   $15.18     Covered
84512   Assay of troponin, qual        A   $11.24     Covered
84520   Assay of urea nitrogen         A    $5.76     Covered
84525   Urea nitrogen semi-quant       A    $5.17     Covered
84540   Assay of urine/urea-n          A    $6.93     Covered
84545   Urea-N clearance test          A    $9.64     Covered
84550   Assay of blood/uric acid       A    $6.59     Covered
84560   Assay of urine/uric acid       A    $6.93     Covered
84577   Assay of feces/urobilinogen    A   $18.22     Covered
84578   Test urine urobilinogen        A    $4.74     Covered
84580   Assay of urine urobilinogen    A   $10.36     Covered
84583   Assay of urine urobilinogen    A    $7.34     Covered
84585   Assay of urine vma             A   $22.64     Covered
84586   Assay of vip                   A    $8.70     Covered
84588   Assay of vasopressin           A   $49.56     Covered
84590   Assay of vitamin a             A   $16.93     Covered
84591   Assay of nos vitamin           A   $16.93     Covered
84597   Assay of vitamin k             A   $20.01     Covered
84600   Assay of volatiles             A   $23.47     Covered
84620   Xylose tolerance test          A   $17.29     Covered
84630   Assay of zinc                  A   $16.63     Covered
84681   Assay of c-peptide             A   $30.38     Covered
84702   Chorionic gonadotropin test    A   $21.98     Covered
84703   Chorionic gonadotropin assay   A   $10.97     Covered
84704   Hcg, free betachain test       A            Not Covered
84830   Ovulation tests                A   $14.65     Covered
84999   Clinical chemistry test        A             By Report
85002   Bleeding time test             A                   $6.57    Covered
85004   Automated diff wbc count       A                   $9.45    Covered
85007   Bl smear w/diff wbc count      A                   $5.02    Covered
85008   Bl smear w/o diff wbc count    A                   $5.02    Covered
85009   Manual diff wbc count b-coat   A                   $5.43    Covered
85013   Spun microhematocrit           A                   $3.11    Covered
85014   Hematocrit                     A                   $3.11    Covered
85018   Hemoglobin                     A                   $3.11    Covered
85025   Complete cbc w/auto diff wbc   A                  $11.35    Covered
85027   Complete cbc, automated        A                   $9.45    Covered
85032   Manual cell count, each        A                   $6.28    Covered
85041   Automated rbc count            A                   $4.40    Covered
85044   Manual reticulocyte count      A                   $6.28    Covered
85045   Automated reticulocyte count   A                   $5.85    Covered
85046   Reticyte/hgb concentrate       A                   $8.15    Covered
85048   Automated leukocyte count      A                   $3.71    Covered
85049   Automated platelet count       A                   $6.53    Covered
85055   Reticulated platelet assay     A                  $39.09    Covered
85060   Blood smear interpretation     B                           Not Covered
85097   Bone marrow interpretation     X 00343   0.5301             Covered
85130   Chromogenic substrate assay    A                  $17.37    Covered
85170   Blood clot retraction          A                   $4.88    Covered
85175   Blood clot lysis time          A                   $6.64    Covered
85210   Blood clot factor II test      A                   $7.61    Covered
85220   Blood clot factor V test       A                  $19.84    Covered
85230   Blood clot factor VII test     A                  $19.84    Covered
85240   Blood clot factor VIII test    A                  $19.84    Covered
85244   Blood clot factor VIII test    A                  $29.81    Covered
85245   Blood clot factor VIII test    A                  $33.51    Covered
85246   Blood clot factor VIII test    A                  $33.51    Covered
85247   Blood clot factor VIII test    A                  $33.51    Covered
85250   Blood clot factor IX test      A                  $19.84    Covered
85260   Blood clot factor X test       A                  $19.84    Covered
85270   Blood clot factor XI test      A                  $19.84    Covered
85280   Blood clot factor XII test     A                  $19.84    Covered
85290   Blood clot factor XIII test    A                  $19.84    Covered
85291   Blood clot factor XIII test    A                  $12.98    Covered
85292   Blood clot factor assay        A                  $19.84    Covered
85293   Blood clot factor assay        A                  $19.02    Covered
85300   Antithrombin III test          A                   $8.55    Covered
85301   Antithrombin III test          A                  $15.79    Covered
85302   Blood clot inhibitor antigen   A                  $17.55    Covered
85303   Blood clot inhibitor test      A                  $19.01    Covered
85305   Blood clot inhibitor assay     A                  $16.93    Covered
85306   Blood clot inhibitor test      A                  $22.37    Covered
85307   Assay activated protein c      A                  $22.37    Covered
85335   Factor inhibitor test          A                   $8.55    Covered
85337   Thrombomodulin                 A                  $15.22    Covered
85345   Coagulation time               A                   $5.29    Covered
85347   Coagulation time               A                   $3.95    Covered
85348   Coagulation time               A                   $5.44    Covered
85360   Euglobulin lysis               A                  $12.26    Covered
85362   Fibrin degradation products    A   $10.06       Covered
85366   Fibrinogen test                A    $8.97       Covered
85370   Fibrinogen test                A   $16.58       Covered
85378   Fibrin degrade, semiquant      A   $10.41       Covered
85379   Fibrin degradation, quant      A   $11.83       Covered
85380   Fibrin degradation, vte        A   $11.83       Covered
85384   Fibrinogen                     A   $12.40       Covered
85385   Fibrinogen                     A   $12.40       Covered
85390   Fibrinolysins screen           A    $3.95       Covered
85396   Clotting assay, whole blood    N                Covered
85397   Clotting funct activity        A   $33.51       Covered
85400   Fibrinolytic plasmin           A   $12.91       Covered
85410   Fibrinolytic antiplasmin       A   $11.26       Covered
85415   Fibrinolytic plasminogen       A    $7.61       Covered
85420   Fibrinolytic plasminogen       A    $9.52       Covered
85421   Fibrinolytic plasminogen       A   $14.87       Covered
85441   Heinz bodies, direct           A    $6.14       Covered
85445   Heinz bodies, induced          A    $9.95       Covered
85460   Hemoglobin, fetal              A    $8.55       Covered
85461   Hemoglobin, fetal              A    $6.70       Covered
85475   Hemolysin                      A   $12.95       Covered
85520   Heparin assay                  A    $9.37       Covered
85525   Heparin neutralization         A    $6.79       Covered
85530   Heparin-protamine tolerance    A    $6.79       Covered
85536   Iron stain peripheral blood    A    $9.45       Covered
85540   Wbc alkaline phosphatase       A   $12.56       Covered
85547   RBC mechanical fragility       A   $12.56       Covered
85549   Muramidase                     A   $27.39       Covered
85555   RBC osmotic fragility          A    $9.76       Covered
85557   RBC osmotic fragility          A   $19.50       Covered
85576   Blood platelet aggregation     A   $31.37       Covered
85597   Platelet neutralization        A   $26.25       Covered
85610   Prothrombin time               A    $5.11       Covered
85611   Prothrombin test               A    $5.11       Covered
85612   Viper venom prothrombin time   A    $9.92       Covered
85613   Russell viper venom, diluted   A    $9.92       Covered
85635   Reptilase test                 A   $14.38       Covered
85651   Rbc sed rate, nonautomated     A    $5.18       Covered
85652   Rbc sed rate, automated        A    $3.94       Covered
85660   RBC sickle cell test           A    $8.06       Covered
85670   Thrombin time, plasma          A    $8.44       Covered
85675   Thrombin time, titer           A   $10.00       Covered
85705   Thromboplastin inhibition      A    $6.79       Covered
85730   Thromboplastin time, partial   A    $7.61       Covered
85732   Thromboplastin time, partial   A    $9.45       Covered
85810   Blood viscosity examination    A   $15.24       Covered
85999   Hematology procedure           A            Review Required
86000   Agglutinins, febrile           A   $10.19       Covered
86001   Allergen specific igg          A    $7.62       Covered
86003   Allergen specific IgE          A    $7.62       Covered
86005   Allergen specific IgE          A   $11.64       Covered
86021   WBC antibody identification    A   $21.98       Covered
86022   Platelet antibodies            A                  $26.82    Covered
86023   Immunoglobulin assay           A                  $18.19    Covered
86038   Antinuclear antibodies         A                  $17.65    Covered
86039   Antinuclear antibodies (ANA)   A                  $16.30    Covered
86060   Antistreptolysin o, titer      A                  $10.66    Covered
86063   Antistreptolysin o, screen     A                   $8.44    Covered
86077   Physician blood bank service   X 00433   0.2482             Covered
86078   Physician blood bank service   X 00343   0.5301             Covered
86079   Physician blood bank service   X 00433   0.2482            Not Covered
86140   C-reactive protein             A                   $7.56    Covered
86141   C-reactive protein, hs         A                  $18.91    Covered
86146   Glycoprotein antibody          A                  $37.14    Covered
86147   Cardiolipin antibody           A                  $37.14    Covered
86148   Phospholipid antibody          A                  $23.45    Covered
86155   Chemotaxis assay               A                  $16.85    Covered
86156   Cold agglutinin, screen        A                   $9.31    Covered
86157   Cold agglutinin, titer         A                  $11.77    Covered
86160   Complement, antigen            A                  $17.53    Covered
86161   Complement/function activity   A                  $17.53    Covered
86162   Complement, total (CH50)       A                  $29.67    Covered
86171   Complement fixation, each      A                   $5.17    Covered
86185   Counterimmunoelectrophoresis   A                  $13.06    Covered
86200   Ccp antibody                   A                  $18.91    Covered
86215   Deoxyribonuclease, antibody    A                  $18.61    Covered
86225   DNA antibody                   A                  $20.06    Covered
86226   DNA antibody, single strand    A                  $17.68    Covered
86235   Nuclear antigen antibody       A                  $20.81    Covered
86243   Fc receptor                    A                  $29.96    Covered
86255   Fluorescent antibody, screen   A                  $17.60    Covered
86256   Fluorescent antibody, titer    A                  $17.60    Covered
86277   Growth hormone antibody        A                  $22.98    Covered
86280   Hemagglutination inhibition    A                   $8.55    Covered
86294   Immunoassay, tumor, qual       A                  $28.64    Covered
86300   Immunoassay, tumor, ca 15-3    A                  $30.38    Covered
86301   Immunoassay, tumor, ca 19-9    A                  $30.38    Covered
86304   Immunoassay, tumor, ca 125     A                  $30.38    Covered
86305   Human epididymis protein 4     A                  $29.81    Covered
86308   Heterophile antibodies         A                   $7.56    Covered
86309   Heterophile antibodies         A                   $9.45    Covered
86310   Heterophile antibodies         A                  $10.21    Covered
86316   Immunoassay, tumor other       A                  $30.38    Covered
86317   Immunoassay,infectious agent   A                  $21.89    Covered
86318   Immunoassay,infectious agent   A                  $18.91    Covered
86320   Serum immunoelectrophoresis    A                  $32.72    Covered
86325   Other immunoelectrophoresis    A                  $32.65    Covered
86327   Immunoelectrophoresis assay    A                  $33.13    Covered
86329   Immunodiffusion                A                  $20.51    Covered
86331   Immunodiffusion ouchterlony    A                  $17.50    Covered
86332   Immune complex assay           A                  $35.59    Covered
86334   Immunofix e-phoresis, serum    A                  $32.62    Covered
86335   Immunfix e-phorsis/urine/csf   A                  $42.85    Covered
86336   Inhibin A                      A                  $18.90    Covered
86337   Insulin antibodies             A                    $31.27    Covered
86340   Intrinsic factor antibody      A                    $22.00    Covered
86341   Islet cell antibody            A                    $16.73    Covered
86343   Leukocyte histamine release    A                    $18.20    Covered
86344   Leukocyte phagocytosis         A                    $11.66    Covered
86352   Cell function assay w/stim     A                    $97.30    Covered
86353   Lymphocyte transformation      A                    $71.58    Covered
86355   B cells, total count           A                    $26.77    Covered
86356   Mononuclear cell antigen       A                             Not Covered
86357   Nk cells, total count          A                    $26.77    Covered
86359   T cells, total count           A                    $26.77    Covered
86360   T cell, absolute count/ratio   A                    $26.77    Covered
86361   T cell, absolute count         A                    $39.09    Covered
86367   Stem cells, total count        A                    $26.77    Covered
86376   Microsomal antibody            A                    $21.25    Covered
86378   Migration inhibitory factor    A                    $28.75    Covered
86382   Neutralization test, viral     A                    $19.84    Covered
86384   Nitroblue tetrazolium dye      A                    $16.63    Covered
86403   Particle agglutination test    A                    $14.88    Covered
86406   Particle agglutination test    A                    $13.39    Covered
86430   Rheumatoid factor test         A                     $8.29    Covered
86431   Rheumatoid factor, quant       A                     $8.29    Covered
86480   Tb test, cell immun measure    A                    $90.49    Covered
86485   Skin test, candida             X   00341   0.0799             Covered
86486   Skin test, nos antigen         X   00341   0.0799             Covered
86490   Coccidioidomycosis skin test   X   00341   0.0799             Covered
86510   Histoplasmosis skin test       X   00341   0.0799             Covered
86580   TB intradermal test            X   00341   0.0799             Covered
86590   Streptokinase, antibody        A                    $12.77    Covered
86592   Blood serology, qualitative    A                     $6.23    Covered
86593   Blood serology, quantitative   A                     $6.43    Covered
86602   Antinomyces antibody           A                     $9.31    Covered
86603   Adenovirus antibody            A                    $18.79    Covered
86606   Aspergillus antibody           A                    $21.98    Covered
86609   Bacterium antibody             A                    $18.81    Covered
86611   Bartonella antibody            A                     $9.31    Covered
86612   Blastomyces antibody           A                    $18.84    Covered
86615   Bordetella antibody            A                    $19.25    Covered
86617   Lyme disease antibody          A                    $22.61    Covered
86618   Lyme disease antibody          A                    $24.87    Covered
86619   Borrelia antibody              A                    $19.54    Covered
86622   Brucella antibody              A                    $13.05    Covered
86625   Campylobacter antibody         A                    $19.16    Covered
86628   Candida antibody               A                    $17.53    Covered
86631   Chlamydia antibody             A                    $17.27    Covered
86632   Chlamydia igm antibody         A                    $18.53    Covered
86635   Coccidioides antibody          A                    $16.75    Covered
86638   Q fever antibody               A                     $5.16    Covered
86641   Cryptococcus antibody          A                    $21.05    Covered
86644   CMV antibody                   A                    $21.02    Covered
86645   CMV antibody, IgM              A                    $24.60    Covered
86648   Diphtheria antibody            A                    $22.21    Covered
86651   Encephalitis antibody        A   $19.25   Covered
86652   Encephalitis antibody        A   $19.25   Covered
86653   Encephalitis antibody        A   $19.25   Covered
86654   Encephalitis antibody        A   $19.25   Covered
86658   Enterovirus antibody         A   $19.03   Covered
86663   Epstein-barr antibody        A   $19.16   Covered
86664   Epstein-barr antibody        A   $22.34   Covered
86665   Epstein-barr antibody        A   $26.48   Covered
86666   Ehrlichia antibody           A    $9.31   Covered
86668   Francisella tularensis       A   $12.68   Covered
86671   Fungus antibody              A   $11.86   Covered
86674   Giardia lamblia antibody     A   $21.50   Covered
86677   Helicobacter pylori          A   $21.19   Covered
86682   Helminth antibody            A   $15.12   Covered
86684   Hemophilus influenza         A   $23.13   Covered
86687   Htlv-i antibody              A   $12.25   Covered
86688   Htlv-ii antibody             A   $14.57   Covered
86689   HTLV/HIV confirmatory test   A    $9.97   Covered
86692   Hepatitis, delta agent       A   $25.06   Covered
86694   Herpes simplex test          A   $21.02   Covered
86695   Herpes simplex test          A   $19.25   Covered
86696   Herpes simplex type 2        A    $9.97   Covered
86698   Histoplasma                  A   $18.25   Covered
86701   HIV-1                        A    $9.78   Covered
86702   HIV-2                        A   $19.74   Covered
86703   HIV-1/HIV-2, single assay    A   $13.95   Covered
86704   Hep b core antibody, total   A   $17.60   Covered
86705   Hep b core antibody, igm     A    $9.78   Covered
86706   Hep b surface antibody       A   $15.68   Covered
86707   Hep be antibody              A   $16.89   Covered
86708   Hep a antibody, total        A   $18.09   Covered
86709   Hep a antibody, igm          A   $16.44   Covered
86710   Influenza virus antibody     A   $19.80   Covered
86713   Legionella antibody          A   $22.31   Covered
86717   Leishmania antibody          A   $17.89   Covered
86720   Leptospira antibody          A   $19.25   Covered
86723   Listeria monocytogenes ab    A   $19.25   Covered
86727   Lymph choriomeningitis ab    A   $18.79   Covered
86729   Lympho venereum antibody     A   $17.44   Covered
86732   Mucormycosis antibody        A   $19.25   Covered
86735   Mumps antibody               A   $19.06   Covered
86738   Mycoplasma antibody          A   $19.34   Covered
86741   Neisseria meningitidis       A   $19.25   Covered
86744   Nocardia antibody            A   $19.25   Covered
86747   Parvovirus antibody          A   $21.95   Covered
86750   Malaria antibody             A   $19.25   Covered
86753   Protozoa antibody nos        A    $8.55   Covered
86756   Respiratory virus antibody   A   $18.82   Covered
86757   Rickettsia antibody          A    $9.97   Covered
86759   Rotavirus antibody           A   $19.25   Covered
86762   Rubella antibody             A   $21.02   Covered
86765   Rubeola antibody             A   $18.81   Covered
86768   Salmonella antibody            A                    $19.25        Covered
86771   Shigella antibody              A                    $19.25        Covered
86774   Tetanus antibody               A                    $21.61        Covered
86777   Toxoplasma antibody            A                    $21.02        Covered
86778   Toxoplasma antibody, igm       A                    $21.03        Covered
86780   Treponema pallidum             A                    $18.97        Covered
86781   Treponema pallidum, confirm    D                                Not Covered
86784   Trichinella antibody           A                      $9.31       Covered
86787   Varicella-zoster antibody      A                     $18.81       Covered
86788   West nile virus ab, igm        A                     $24.60       Covered
86789   West nile virus antibody       A                     $21.02       Covered
86790   Virus antibody nos             A                     $18.81       Covered
86793   Yersinia antibody              A                     $19.25       Covered
86800   Thyroglobulin antibody         A                     $23.22       Covered
86803   Hepatitis c ab test            A                     $20.84       Covered
86804   Hep c ab test, confirm         A                     $22.61       Covered
86805   Lymphocytotoxicity assay       A                     $76.34       Covered
86806   Lymphocytotoxicity assay       A                     $69.48       Covered
86807   Cytotoxic antibody screening   A                     $57.77       Covered
86808   Cytotoxic antibody screening   A                     $43.33       Covered
86812   HLA typing, A, B, or C         A                     $37.68       Covered
86813   HLA typing, A, B, or C         A                     $84.66       Covered
86816   HLA typing, DR/DQ              A                     $40.67       Covered
86817   HLA typing, DR/DQ              A                     $94.00       Covered
86821   Lymphocyte culture, mixed      A                     $82.44       Covered
86822   Lymphocyte culture, primed     A                     $53.38       Covered
86825   Hla x-match, non-cytotoxic     A                    $115.04       Covered
86826   Hla x-match, non-cyt add-on    A                     $38.35       Covered
86849   Immunology procedure           A                              Review Required
86850   RBC antibody screen            X   00345   0.2195                 Covered
86860   RBC antibody elution           X   00346   0.3734                 Covered
86870   RBC antibody identification    X   00346   0.3734                 Covered
86880   Coombs test, direct            X   00409   0.1161                 Covered
86885   Coombs test, indirect, qual    X   00409   0.1161                 Covered
86886   Coombs test, indirect, titer   X   00409   0.1161                 Covered
86890   Autologous blood process       X   00347   0.7384                 Covered
86891   Autologous blood, op salvage   X   00345   0.2195                 Covered
86900   Blood typing, ABO              X   00409   0.1161                 Covered
86901   Blood typing, Rh (D)           X   00409   0.1161                 Covered
86903   Blood typing, antigen screen   X   00345   0.2195                 Covered
86904   Blood typing, patient serum    X   00345   0.2195                 Covered
86905   Blood typing, RBC antigens     X   00345   0.2195                 Covered
86906   Blood typing, Rh phenotype     X   00345   0.2195                 Covered
86910   Blood typing, paternity test   E                    $27.89        Covered
86911   Blood typing, antigen system   E                     $7.92        Covered
86920   Compatibility test, spin       X   00345   0.2195                 Covered
86921   Compatibility test, incubate   X   00345   0.2195                 Covered
86922   Compatibility test, antiglob   X   00346   0.3734                 Covered
86923   Compatibility test, electric   X   00345   0.2195                 Covered
86927   Plasma, fresh frozen           X   00345   0.2195                 Covered
86930   Frozen blood prep              X   00347   0.7384                 Covered
86931   Frozen blood thaw              X   00347   0.7384                 Covered
86932   Frozen blood freeze/thaw       X   00347   0.7384             Covered
86940   Hemolysins/agglutinins, auto   A                    $10.64    Covered
86941   Hemolysins/agglutinins         A                    $17.68    Covered
86945   Blood product/irradiation      X   00345   0.2195             Covered
86950   Leukacyte transfusion          X   00345   0.2195             Covered
86960   Vol reduction of blood/prod    X   00345   0.2195             Covered
86965   Pooling blood platelets        X   00346   0.3734             Covered
86970   RBC pretreatment               X   00345   0.2195             Covered
86971   RBC pretreatment               X   00345   0.2195             Covered
86972   RBC pretreatment               X   00345   0.2195             Covered
86975   RBC pretreatment, serum        X   00346   0.3734             Covered
86976   RBC pretreatment, serum        X   00345   0.2195             Covered
86977   RBC pretreatment, serum        X   00347   0.7384             Covered
86978   RBC pretreatment, serum        X   00346   0.3734             Covered
86985   Split blood or products        X   00345   0.2195             Covered
86999   Transfusion procedure          X   00345   0.2195             Covered
87001   Small animal inoculation       A                      $9.92   Covered
87003   Small animal inoculation       A                     $24.58   Covered
87015   Specimen concentration         A                      $9.75   Covered
87040   Blood culture for bacteria     A                     $15.07   Covered
87045   Feces culture, bacteria        A                     $13.77   Covered
87046   Stool cultr, bacteria, each    A                     $13.77   Covered
87070   Culture, bacteria, other       A                     $12.57   Covered
87071   Culture bacteri aerobic othr   A                     $13.77   Covered
87073   Culture bacteria anaerobic     A                     $13.77   Covered
87075   Cultr bacteria, except blood   A                      $8.55   Covered
87076   Culture anaerobe ident, each   A                     $10.60   Covered
87077   Culture aerobic identify       A                     $10.60   Covered
87081   Culture screen only            A                      $8.55   Covered
87084   Culture of specimen by kit     A                     $11.00   Covered
87086   Urine culture/colony count     A                     $11.79   Covered
87088   Urine bacteria culture         A                     $11.82   Covered
87101   Skin fungi culture             A                     $11.26   Covered
87102   Fungus isolation culture       A                      $8.55   Covered
87103   Blood fungus culture           A                     $13.17   Covered
87106   Fungi identification, yeast    A                     $15.07   Covered
87107   Fungi identification, mold     A                     $15.07   Covered
87109   Mycoplasma                     A                      $4.20   Covered
87110   Chlamydia culture              A                     $28.60   Covered
87116   Mycobacteria culture           A                     $15.78   Covered
87118   Mycobacteric identification    A                     $15.98   Covered
87140   Culture type immunofluoresc    A                      $8.14   Covered
87143   Culture typing, glc/hplc       A                     $18.29   Covered
87147   Culture type, immunologic      A                      $4.61   Covered
87149   Culture type, nucleic acid     A                     $29.27   Covered
87150   Dna/rna, amplified probe       A                     $50.27   Covered
87152   Culture type pulse field gel   A                      $7.64   Covered
87153   Dna/rna sequencing             A                    $165.22   Covered
87158   Culture typing, added method   A                      $7.64   Covered
87164   Dark field examination         A                      $5.99   Covered
87166   Dark field examination         A                     $16.49   Covered
87168   Macroscopic exam arthropod     A                      $6.23   Covered
87169   Macroscopic exam parasite      A    $6.23   Covered
87172   Pinworm exam                   A    $6.23   Covered
87176   Tissue homogenization, cultr   A    $8.59   Covered
87177   Ova and parasites smears       A   $12.99   Covered
87181   Microbe susceptible, diffuse   A    $6.93   Covered
87184   Microbe susceptible, disk      A   $10.07   Covered
87185   Microbe susceptible, enzyme    A    $6.93   Covered
87186   Microbe susceptible, mic       A   $12.62   Covered
87187   Microbe susceptible, mlc       A   $13.53   Covered
87188   Microbe suscept, macrobroth    A    $9.37   Covered
87190   Microbe suscept, mycobacteri   A    $8.25   Covered
87197   Bactericidal level, serum      A   $21.93   Covered
87205   Smear, gram stain              A    $6.23   Covered
87206   Smear, fluorescent/acid stai   A    $3.43   Covered
87207   Smear, special stain           A    $5.17   Covered
87209   Smear, complex stain           A   $15.52   Covered
87210   Smear, wet mount, saline/ink   A    $6.23   Covered
87220   Tissue exam for fungi          A    $6.23   Covered
87230   Assay, toxin or antitoxin      A   $28.83   Covered
87250   Virus inoculate, eggs/animal   A   $12.77   Covered
87252   Virus inoculation, tissue      A   $38.06   Covered
87253   Virus inoculate tissue, addl   A   $18.04   Covered
87254   Virus inoculation, shell via   A   $12.77   Covered
87255   Genet virus isolate, hsv       A   $49.44   Covered
87260   Adenovirus ag, if              A   $17.52   Covered
87265   Pertussis ag, if               A   $17.52   Covered
87267   Enterovirus antibody, dfa      A   $17.52   Covered
87269   Giardia ag, if                 A   $17.52   Covered
87270   Chlamydia trachomatis ag, if   A   $17.52   Covered
87271   Cytomegalovirus dfa            A   $17.52   Covered
87272   Cryptosporidium ag, if         A   $17.52   Covered
87273   Herpes simplex 2, ag, if       A   $17.52   Covered
87274   Herpes simplex 1, ag, if       A   $17.52   Covered
87275   Influenza b, ag, if            A   $17.52   Covered
87276   Influenza a, ag, if            A   $17.52   Covered
87277   Legionella micdadei, ag, if    A   $17.52   Covered
87278   Legion pneumophilia ag, if     A   $17.52   Covered
87279   Parainfluenza, ag, if          A   $17.52   Covered
87280   Respiratory syncytial ag, if   A   $17.52   Covered
87281   Pneumocystis carinii, ag, if   A   $17.52   Covered
87283   Rubeola, ag, if                A   $17.52   Covered
87285   Treponema pallidum, ag, if     A   $17.52   Covered
87290   Varicella zoster, ag, if       A   $17.52   Covered
87299   Antibody detection, nos, if    A   $17.52   Covered
87300   Ag detection, polyval, if      A   $17.52   Covered
87301   Adenovirus ag, eia             A   $17.52   Covered
87305   Aspergillus ag, eia            A   $17.52   Covered
87320   Chylmd trach ag, eia           A   $17.52   Covered
87324   Clostridium ag, eia            A   $17.52   Covered
87327   Cryptococcus neoform ag, eia   A   $17.52   Covered
87328   Cryptosporidium ag, eia        A   $17.52   Covered
87329   Giardia ag, eia                A   $17.52   Covered
87332   Cytomegalovirus ag, eia        A   $17.52    Covered
87335   E coli 0157 ag, eia            A   $17.52    Covered
87336   Entamoeb hist dispr, ag, eia   A   $17.52    Covered
87337   Entamoeb hist group, ag, eia   A   $17.52    Covered
87338   Hpylori, stool, eia            A   $17.51    Covered
87339   H pylori ag, eia               A   $17.52    Covered
87340   Hepatitis b surface ag, eia    A   $14.13    Covered
87341   Hepatitis b surface, ag, eia   A   $14.13    Covered
87350   Hepatitis be ag, eia           A   $16.83    Covered
87380   Hepatitis delta ag, eia        A   $23.98    Covered
87385   Histoplasma capsul ag, eia     A   $17.52    Covered
87390   Hiv-1 ag, eia                  A   $19.53    Covered
87391   Hiv-2 ag, eia                  A   $19.53    Covered
87400   Influenza a/b, ag, eia         A   $17.52    Covered
87420   Resp syncytial ag, eia         A   $17.52    Covered
87425   Rotavirus ag, eia              A   $17.52    Covered
87427   Shiga-like toxin ag, eia       A   $17.52    Covered
87430   Strep a ag, eia                A   $17.52    Covered
87449   Ag detect nos, eia, mult       A   $17.52    Covered
87450   Ag detect nos, eia, single     A   $13.99    Covered
87451   Ag detect polyval, eia, mult   A   $13.99    Covered
87470   Bartonella, dna, dir probe     A   $29.27    Covered
87471   Bartonella, dna, amp probe     A   $51.25    Covered
87472   Bartonella, dna, quant         A   $62.54    Covered
87475   Lyme dis, dna, dir probe       A   $29.27    Covered
87476   Lyme dis, dna, amp probe       A   $51.25    Covered
87477   Lyme dis, dna, quant           A   $62.54    Covered
87480   Candida, dna, dir probe        A   $29.27    Covered
87481   Candida, dna, amp probe        A   $51.25    Covered
87482   Candida, dna, quant            A   $60.95    Covered
87485   Chylmd pneum, dna, dir probe   A   $29.27    Covered
87486   Chylmd pneum, dna, amp probe   A   $51.25    Covered
87487   Chylmd pneum, dna, quant       A   $62.54    Covered
87490   Chylmd trach, dna, dir probe   A   $29.27    Covered
87491   Chylmd trach, dna, amp probe   A   $51.25    Covered
87492   Chylmd trach, dna, quant       A   $51.04    Covered
87493   C diff amplified probe         A   $50.27    Covered
87495   Cytomeg, dna, dir probe        A   $29.27    Covered
87496   Cytomeg, dna, amp probe        A   $51.25    Covered
87497   Cytomeg, dna, quant            A   $62.54    Covered
87498   Enterovirus, dna, amp probe    A   $51.25    Covered
87500   Vanomycin, dna, amp probe      A            Not Covered
87510   Gardner vag, dna, dir probe    A   $29.27    Covered
87511   Gardner vag, dna, amp probe    A   $51.25    Covered
87512   Gardner vag, dna, quant        A   $60.95    Covered
87515   Hepatitis b, dna, dir probe    A   $29.27    Covered
87516   Hepatitis b, dna, amp probe    A   $51.25    Covered
87517   Hepatitis b, dna, quant        A   $62.54    Covered
87520   Hepatitis c, rna, dir probe    A   $29.27    Covered
87521   Hepatitis c, rna, amp probe    A   $51.25    Covered
87522   Hepatitis c, rna, quant        A   $62.54    Covered
87525   Hepatitis g, dna, dir probe    A   $29.27    Covered
87526   Hepatitis g, dna, amp probe    A    $51.25   Covered
87527   Hepatitis g, dna, quant        A    $60.95   Covered
87528   Hsv, dna, dir probe            A    $29.27   Covered
87529   Hsv, dna, amp probe            A    $51.25   Covered
87530   Hsv, dna, quant                A    $62.54   Covered
87531   Hhv-6, dna, dir probe          A    $29.27   Covered
87532   Hhv-6, dna, amp probe          A    $51.25   Covered
87533   Hhv-6, dna, quant              A    $60.95   Covered
87534   Hiv-1, dna, dir probe          A    $29.27   Covered
87535   Hiv-1, dna, amp probe          A    $51.25   Covered
87536   Hiv-1, dna, quant              A   $124.24   Covered
87537   Hiv-2, dna, dir probe          A    $29.27   Covered
87538   Hiv-2, dna, amp probe          A    $51.25   Covered
87539   Hiv-2, dna, quant              A    $62.54   Covered
87540   Legion pneumo, dna, dir prob   A    $29.27   Covered
87541   Legion pneumo, dna, amp prob   A    $51.25   Covered
87542   Legion pneumo, dna, quant      A    $60.95   Covered
87550   Mycobacteria, dna, dir probe   A    $29.27   Covered
87551   Mycobacteria, dna, amp probe   A    $51.25   Covered
87552   Mycobacteria, dna, quant       A    $62.54   Covered
87555   M.tuberculo, dna, dir probe    A    $29.27   Covered
87556   M.tuberculo, dna, amp probe    A    $51.25   Covered
87557   M.tuberculo, dna, quant        A    $62.54   Covered
87560   M.avium-intra, dna, dir prob   A    $29.27   Covered
87561   M.avium-intra, dna, amp prob   A    $51.25   Covered
87562   M.avium-intra, dna, quant      A    $62.54   Covered
87580   M.pneumon, dna, dir probe      A    $29.27   Covered
87581   M.pneumon, dna, amp probe      A    $51.25   Covered
87582   M.pneumon, dna, quant          A    $60.95   Covered
87590   N.gonorrhoeae, dna, dir prob   A    $29.27   Covered
87591   N.gonorrhoeae, dna, amp prob   A    $51.25   Covered
87592   N.gonorrhoeae, dna, quant      A    $62.54   Covered
87620   Hpv, dna, dir probe            A    $29.27   Covered
87621   Hpv, dna, amp probe            A    $51.25   Covered
87622   Hpv, dna, quant                A    $60.95   Covered
87640   Staph a, dna, amp probe        A    $51.25   Covered
87641   Mr-staph, dna, amp probe       A    $51.25   Covered
87650   Strep a, dna, dir probe        A    $29.27   Covered
87651   Strep a, dna, amp probe        A    $51.25   Covered
87652   Strep a, dna, quant            A    $60.95   Covered
87653   Strep b, dna, amp probe        A    $51.25   Covered
87660   Trichomonas vagin, dir probe   A    $29.27   Covered
87797   Detect agent nos, dna, dir     A    $29.27   Covered
87798   Detect agent nos, dna, amp     A    $51.25   Covered
87799   Detect agent nos, dna, quant   A    $62.54   Covered
87800   Detect agnt mult, dna, direc   A    $58.56   Covered
87801   Detect agnt mult, dna, ampli   A   $102.49   Covered
87802   Strep b assay w/optic          A    $17.52   Covered
87803   Clostridium toxin a w/optic    A    $17.52   Covered
87804   Influenza assay w/optic        A    $17.52   Covered
87807   Rsv assay w/optic              A    $17.52   Covered
87808   Trichomonas assay w/optic      A    $17.52   Covered
87809   Adenovirus assay w/optic       A                                Not Covered
87810   Chylmd trach assay w/optic     A                     $17.52       Covered
87850   N. gonorrhoeae assay w/optic   A                     $17.52       Covered
87880   Strep a assay w/optic          A                     $17.52       Covered
87899   Agent nos assay w/optic        A                     $17.52       Covered
87900   Phenotype, infect agent drug   A                    $190.31       Covered
87901   Genotype, dna, hiv reverse t   A                    $375.88       Covered
87902   Genotype, dna, hepatitis C     A                    $375.88       Covered
87903   Phenotype, dna hiv w/culture   A                    $713.43       Covered
87904   Phenotype, dna hiv w/clt add   A                     $38.06       Covered
87905   Sialidase enzyme assay         A                     $17.27       Covered
87999   Microbiology procedure         A                              Review Required
88000   Autopsy (necropsy), gross      E                              Review Required
88005   Autopsy (necropsy), gross      E                              Review Required
88007   Autopsy (necropsy), gross      E                              Review Required
88012   Autopsy (necropsy), gross      E                              Review Required
88014   Autopsy (necropsy), gross      E                              Review Required
88016   Autopsy (necropsy), gross      E                              Review Required
88020   Autopsy (necropsy), complete   E                              Review Required
88025   Autopsy (necropsy), complete   E                              Review Required
88027   Autopsy (necropsy), complete   E                              Review Required
88028   Autopsy (necropsy), complete   E                              Review Required
88029   Autopsy (necropsy), complete   E                              Review Required
88036   Limited autopsy                E                              Review Required
88037   Limited autopsy                E                              Review Required
88040   Forensic autopsy (necropsy)    E                              Review Required
88045   Coroner's autopsy (necropsy)   E                              Review Required
88099   Necropsy (autopsy) procedure   E                              Review Required
88104   Cytopath fl nongyn, smears     X   00433   0.2482                 Covered
88106   Cytopath fl nongyn, filter     X   00433   0.2482                 Covered
88107   Cytopath fl nongyn, sm/fltr    X   00343   0.5301                 Covered
88108   Cytopath, concentrate tech     X   00433   0.2482                 Covered
88112   Cytopath, cell enhance tech    X   00343   0.5301                 Covered
88125   Forensic cytopathology         X   00433   0.2482                 Covered
88130   Sex chromatin identification   A                    $21.97        Covered
88140   Sex chromatin identification   A                    $11.67        Covered
88141   Cytopath, c/v, interpret       N                                  Covered
88142   Cytopath, c/v, thin layer      A                    $29.58        Covered
88143   Cytopath c/v thin layer redo   A                    $29.58        Covered
88147   Cytopath, c/v, automated       A                                 By Report
88148   Cytopath, c/v, auto rescreen   A                    $22.19        Covered
88150   Cytopath, c/v, manual          A                    $15.42        Covered
88152   Cytopath, c/v, auto redo       A                    $15.42        Covered
88153   Cytopath, c/v, redo            A                    $15.42        Covered
88154   Cytopath, c/v, select          A                    $15.42        Covered
88155   Cytopath, c/v, index add-on    A                     $7.61        Covered
88160   Cytopath smear, other source   X   00433   0.2482                 Covered
88161   Cytopath smear, other source   X   00433   0.2482                 Covered
88162   Cytopath smear, other source   X   00343   0.5301                 Covered
88164   Cytopath tbs, c/v, manual      A                    $15.42        Covered
88165   Cytopath tbs, c/v, redo        A                    $15.42        Covered
88166   Cytopath tbs, c/v, auto redo   A                    $15.42        Covered
88167   Cytopath tbs, c/v, select      A                    $15.42    Covered
88172   Cytopathology eval of fna      X   00343   0.5301             Covered
88173   Cytopath eval, fna, report     X   00343   0.5301             Covered
88174   Cytopath, c/v auto, in fluid   A                    $31.19    Covered
88175   Cytopath c/v auto fluid redo   A                    $38.68    Covered
88182   Cell marker study              X   00343   0.5301             Covered
88184   Flowcytometry/ tc, 1 marker    X   00433   0.2482             Covered
88185   Flowcytometry/tc, add-on       X   00433   0.2482             Covered
88187   Flowcytometry/read, 2-8        X   00342   0.1546             Covered
88188   Flowcytometry/read, 9-15       X   00343   0.5301             Covered
88189   Flowcytometry/read, 16 & >     X   00343   0.5301             Covered
88199   Cytopathology procedure        X   00342   0.1546             Covered
88230   Tissue culture, lymphocyte     A                    $170.10   Covered
88233   Tissue culture, skin/biopsy    A                    $205.48   Covered
88235   Tissue culture, placenta       A                    $215.00   Covered
88237   Tissue culture, bone marrow    A                    $184.41   Covered
88239   Tissue culture, tumor          A                    $215.39   Covered
88240   Cell cryopreserve/storage      A                      $9.02   Covered
88241   Frozen cell preparation        A                      $9.02   Covered
88245   Chromosome analysis, 20-25     A                    $217.35   Covered
88248   Chromosome analysis, 50-100    A                    $252.84   Covered
88249   Chromosome analysis, 100       A                    $252.84   Covered
88261   Chromosome analysis, 5         A                    $258.05   Covered
88262   Chromosome analysis, 15-20     A                    $181.98   Covered
88263   Chromosome analysis, 45        A                    $219.42   Covered
88264   Chromosome analysis, 20-25     A                    $181.98   Covered
88267   Chromosome analys, placenta    A                    $262.47   Covered
88269   Chromosome analys, amniotic    A                    $242.84   Covered
88271   Cytogenetics, dna probe        A                     $31.27   Covered
88272   Cytogenetics, 3-5              A                     $39.09   Covered
88273   Cytogenetics, 10-30            A                     $46.91   Covered
88274   Cytogenetics, 25-99            A                     $50.82   Covered
88275   Cytogenetics, 100-300          A                     $58.64   Covered
88280   Chromosome karyotype study     A                     $36.64   Covered
88283   Chromosome banding study       A                    $100.15   Covered
88285   Chromosome count, additional   A                     $27.74   Covered
88289   Chromosome study, additional   A                     $32.23   Covered
88291   Cyto/molecular report          M                      $5.95   Covered
88299   Cytogenetic study              X   00342   0.1546             Covered
88300   Surgical path, gross           X   00433   0.2482             Covered
88302   Tissue exam by pathologist     X   00433   0.2482             Covered
88304   Tissue exam by pathologist     X   00343   0.5301             Covered
88305   Tissue exam by pathologist     X   00343   0.5301             Covered
88307   Tissue exam by pathologist     X   00344   0.8028             Covered
88309   Tissue exam by pathologist     X   00344   0.8028             Covered
88311   Decalcify tissue               X   00342   0.1546             Covered
88312   Special stains                 X   00433   0.2482             Covered
88313   Special stains                 X   00433   0.2482             Covered
88314   Histochemical stain            X   00433   0.2482             Covered
88318   Chemical histochemistry        X   00433   0.2482             Covered
88319   Enzyme histochemistry          X   00344   0.8028             Covered
88321   Microslide consultation        X   00433   0.2482             Covered
88323   Microslide consultation        X   00343   0.5301              Covered
88325   Comprehensive review of data   X   00344   0.8028              Covered
88329   Path consult introp            X   00433   0.2482              Covered
88331   Path consult intraop, 1 bloc   X   00343   0.5301              Covered
88332   Path consult intraop, add'l    X   00433   0.2482              Covered
88333   Intraop cyto path consult, 1   X   00433   0.2482              Covered
88334   Intraop cyto path consult, 2   X   00433   0.2482              Covered
88342   Immunohistochemistry           X   00343   0.5301              Covered
88346   Immunofluorescent study        X   00343   0.5301              Covered
88347   Immunofluorescent study        X   00343   0.5301              Covered
88348   Electron microscopy            X   00661   2.4450              Covered
88349   Scanning electron microscopy   X   00661   2.4450              Covered
88355   Analysis, skeletal muscle      X   00343   0.5301              Covered
88356   Analysis, nerve                X   00344   0.8028              Covered
88358   Analysis, tumor                X   00343   0.5301              Covered
88360   Tumor immunohistochem/manual   X   00343   0.5301              Covered
88361   Tumor immunohistochem/comput   X   00344   0.8028              Covered
88362   Nerve teasing preparations     X   00344   0.8028              Covered
88365   Insitu hybridization (fish)    X   00344   0.8028              Covered
88367   Insitu hybridization, auto     X   00344   0.8028              Covered
88368   Insitu hybridization, manual   X   00344   0.8028              Covered
88371   Protein, western blot tissue   A                     $9.97     Covered
88372   Protein analysis w/probe       A                    $28.85     Covered
88380   Microdissection, laser         N                              By Report
88381   Microdissection, manual        N                               Covered
88384   Eval molecular probes, 11-50   X   00433   0.2482              Covered
88385   Eval molecul probes, 51-250    X   00343   0.5301              Covered
88386   Eval molecul probes, 251-500   X   00344   0.8028              Covered
88387   Tiss exam molecular study      N                               Covered
88388   Tiss ex molecul study add-on   N                               Covered
88399   Surgical pathology procedure   X   00342   0.1546              Covered
88400   Bilirubin total transcut       D                             Not Covered
88720   Bilirubin total transcut       A                    $7.33      Covered
88738   Hgb quant transcutaneous       A                    $7.19      Covered
88740   Transcutaneous carboxyhb       A                    $7.33      Covered
88741   Transcutaneous methb           A                    $7.33      Covered
89049   Chct for mal hyperthermia      X   00342   0.1546              Covered
89050   Body fluid cell count          A                     $6.90     Covered
89051   Body fluid cell count          A                     $8.04     Covered
89055   Leukocyte assessment, fecal    A                     $6.23     Covered
89060   Exam,synovial fluid crystals   A                    $10.44     Covered
89100   Sample intestinal contents     X   00360   1.5203              Covered
89105   Sample intestinal contents     X   00360   1.5203              Covered
89125   Specimen fat stain             A                    $6.30      Covered
89130   Sample stomach contents        X   00360   1.5203              Covered
89132   Sample stomach contents        X   00360   1.5203              Covered
89135   Sample stomach contents        X   00360   1.5203              Covered
89136   Sample stomach contents        X   00360   1.5203              Covered
89140   Sample stomach contents        X   00360   1.5203              Covered
89141   Sample stomach contents        X   00360   1.5203              Covered
89160   Exam feces for meat fibers     A                    $5.38      Covered
89190   Nasal smear for eosinophils    A                    $4.88      Covered
89220   Sputum specimen collection     X   00433   0.2482               Not Covered
89225   Starch granules, feces         A                     $4.88        Covered
89230   Collect sweat for test         X   00343   0.5301                 Covered
89235   Water load test                A                                 By Report
89240   Pathology lab procedure        X   00342   0.1546                 Covered
89250   Cultr oocyte/embryo <4 days    X   00344   0.8028                 Covered
89251   Cultr oocyte/embryo <4 days    X   00344   0.8028               Not Covered
89253   Embryo hatching                X   00344   0.8028               Not Covered
89254   Oocyte identification          X   00344   0.8028               Not Covered
89255   Prepare embryo for transfer    X   00344   0.8028               Not Covered
89257   Sperm identification           X   00344   0.8028               Not Covered
89258   Cryopreservation; embryo(s)    X   00344   0.8028               Not Covered
89259   Cryopreservation, sperm        X   00344   0.8028               Not Covered
89260   Sperm isolation, simple        X   00344   0.8028               Not Covered
89261   Sperm isolation, complex       X   00344   0.8028               Not Covered
89264   Identify sperm tissue          X   00344   0.8028               Not Covered
89268   Insemination of oocytes        X   00344   0.8028               Not Covered
89272   Extended culture of oocytes    X   00344   0.8028               Not Covered
89280   Assist oocyte fertilization    X   00344   0.8028               Not Covered
89281   Assist oocyte fertilization    X   00344   0.8028               Not Covered
89290   Biopsy, oocyte polar body      X   00344   0.8028               Not Covered
89291   Biopsy, oocyte polar body      X   00344   0.8028               Not Covered
89300   Semen analysis w/huhner        A                    $13.02        Covered
89310   Semen analysis w/count         A                    $12.57        Covered
89320   Semen anal vol/count/mot       A                    $17.60        Covered
89321   Semen anal, sperm detection    A                    $17.60        Covered
89322   Semen anal, strict criteria    A                    $22.63        Covered
89325   Sperm antibody test            A                                Not Covered
89329   Sperm evaluation test          A                              Review Required
89330   Evaluation, cervical mucus     A                    $13.02        Covered
89331   Retrograde ejaculation anal    A                                Not Covered
89335   Cryopreserve testicular tiss   X   00344   0.8028               Not Covered
89342   Storage/year; embryo(s)        X   00344   0.8028               Not Covered
89343   Storage/year; sperm/semen      X   00344   0.8028               Not Covered
89344   Storage/year; reprod tissue    X   00344   0.8028               Not Covered
89346   Storage/year; oocyte(s)        X   00344   0.8028               Not Covered
89352   Thawing cryopresrved; embryo   X   00344   0.8028               Not Covered
89353   Thawing cryopresrved; sperm    X   00344   0.8028               Not Covered
89354   Thaw cryoprsvrd; reprod tiss   X   00344   0.8028               Not Covered
89356   Thawing cryopresrved; oocyte   X   00344   0.8028               Not Covered
89398   Unlisted reprod med lab proc   X   00342   0.1546                 Covered
90281   Human ig, im                   E                     $26.86       Covered
90283   Human ig, iv                   E                    $187.09       Covered
90284   Human ig, sc                   E                                 By Report
90287   Botulinum antitoxin            E                                 By Report
90288   Botulism ig, iv                E                                 By Report
90291   Cmv ig, iv                     E                    $364.81       Covered
90296   Diphtheria antitoxin           E                                 By Report
90371   Hep b ig, im                   K   01630            $609.91       Covered
90375   Rabies ig, im/sc               K   09133            $143.82       Covered
90376   Rabies ig, heat treated        K   09134            $143.82       Covered
90378   Rsv ig, im, 50mg               K   09003            $778.35       Covered
90379   Rsv ig, iv                     D                              Not Covered
90384   Rh ig, full-dose, im           E                    $101.02     Covered
90385   Rh ig, minidose, im            N                                Covered
90386   Rh ig, iv                      E                    $132.84     Covered
90389   Tetanus ig, im                 E                    $101.02     Covered
90393   Vaccina ig, im                 E                               By Report
90396   Varicella-zoster ig, im        K   09135            $116.93     Covered
90399   Immune globulin                E                               By Report
90465   Immune admin 1 inj, < 8 yrs    B                              Not Covered
90466   Immune admin addl inj, < 8 y   B                              Not Covered
90467   Immune admin o or n, < 8 yrs   B                              Not Covered
90468   Immune admin o/n, addl < 8 y   B                              Not Covered
90470   Immune admin H1N1 im/nasal     E                    $20.15      Covered
90471   Immunization admin             S   00436   0.3809               Covered
90472   Immunization admin, each add   S   00436   0.3809               Covered
90473   Immune admin oral/nasal        S   00436   0.3809               Covered
90474   Immune admin oral/nasal addl   S   00436   0.3809               Covered
90476   Adenovirus vaccine, type 4     K   01254                       By Report
90477   Adenovirus vaccine, type 7     E                               By Report
90581   Anthrax vaccine, sc            E                               By Report
90585   Bcg vaccine, percut            K   09137                       By Report
90586   Bcg vaccine, intravesical      B                              Not Covered
90632   Hep a vaccine, adult im        N                                Covered
90633   Hep a vacc, ped/adol, 2 dose   N                                Covered
90634   Hep a vacc, ped/adol, 3 dose   N                               By Report
90636   Hep a/hep b vacc, adult im     N                                Covered
90644   HIB/men/tt vaccine, im         E                               By Report
90645   Hib vaccine, hboc, im          N                                Covered
90646   Hib vaccine, prp-d, im         N                                Covered
90647   Hib vaccine, prp-omp, im       N                                Covered
90648   Hib vaccine, prp-t, im         N                                Covered
90649   Hpv vaccine 4 valent, im       M                    $151.50     Covered
90650   Hpv vaccine 2 valent, im       M                               By Report
90655   Flu vaccine no preserv 6-35m   L                    $14.91      Covered
90656   Flu vaccine no preserv 3 & >   L                    $13.46      Covered
90657   Flu vaccine, 3 yrs, im         L                     $5.49      Covered
90658   Flu vaccine, 3 yrs & >, im     L                     $9.65      Covered
90660   Flu vaccine, nasal             L                    $54.22      Covered
90661   Flu vacc cell cult prsv free   E                              Not Covered
90662   Flu vacc prsv free inc antig   E                              Not Covered
90663   Flu vacc pandemic              E                              Not Covered
90665   Lyme disease vaccine, im       K   01216                       By Report
90669   Pneumococcal vacc, ped <5      L                    $67.82      Covered
90670   Pneumococcal vacc, 13 val im   E                               By Report
90675   Rabies vaccine, im             K   09139            $121.60     Covered
90676   Rabies vaccine, id             K   09140                       By Report
90680   Rotovirus vacc 3 dose, oral    K   01255            $46.04      Covered
90681   Rotavirus vacc 2 dose oral     K   01239            $39.50      Covered
90690   Typhoid vaccine, oral          N                               By Report
90691   Typhoid vaccine, im            N                               By Report
90692   Typhoid vaccine, h-p, sc/id    N                               By Report
90693   Typhoid vaccine, akd, sc       B                              Not Covered
90696   Dtap-ipv vacc 4-6 yr im        N                       Covered
90698   Dtap-hib-ip vaccine, im        N                       Covered
90700   Dtap vaccine, < 7 yrs, im      N                       Covered
90701   Dtp vaccine, im                N                       Covered
90702   Dt vaccine < 7, im             N                       Covered
90703   Tetanus vaccine, im            N                       Covered
90704   Mumps vaccine, sc              N                       Covered
90705   Measles vaccine, sc            N                       Covered
90706   Rubella vaccine, sc            N                       Covered
90707   Mmr vaccine, sc                N                       Covered
90708   Measles-rubella vaccine, sc    N                       Covered
90710   Mmrv vaccine, sc               N                       Covered
90712   Oral poliovirus vaccine        N                       Covered
90713   Poliovirus, ipv, sc/im         N                       Covered
90714   Td vaccine no prsrv >/= 7 im   N                       Covered
90715   Tdap vaccine >7 im             N                       Covered
90716   Chicken pox vaccine, sc        M           $47.63      Covered
90717   Yellow fever vaccine, sc       N                       Covered
90718   Td vaccine > 7, im             N                       Covered
90719   Diphtheria vaccine, im         N                       Covered
90720   Dtp/hib vaccine, im            N                       Covered
90721   Dtap/hib vaccine, im           N                       Covered
90723   Dtap-hep b-ipv vaccine, im     E           $79.60      Covered
90725   Cholera vaccine, injectable    K   01271    $7.85      Covered
90727   Plague vaccine, im             E                     Not Covered
90732   Pneumococcal vaccine           L           $24.21      Covered
90733   Meningococcal vaccine, sc      K   09143   $70.50      Covered
90734   Meningococcal vaccine, im      K   09145   $94.99      Covered
90735   Encephalitis vaccine, sc       K   09144              By Report
90736   Zoster vacc, sc                M           $169.22     Covered
90738   Inactivated je vacc im         M           $108.00     Covered
90740   Hepb vacc, ill pat 3 dose im   F           $190.67     Covered
90743   Hep b vacc, adol, 2 dose, im   F            $24.88     Covered
90744   Hepb vacc ped/adol 3 dose im   F            $55.01     Covered
90746   Hep b vaccine, adult, im       F            $55.01     Covered
90747   Hepb vacc, ill pat 4 dose im   F                      By Report
90748   Hep b/hib vaccine, im          E           $55.05      Covered
90749   Vaccine toxoid                 N                       Covered
90760   Hydration iv infusion, init    D                     Not Covered
90761   Hydrate iv infusion, add-on    D                     Not Covered
90765   Ther/proph/diag iv inf, init   D                     Not Covered
90766   Ther/proph/dg iv inf, add-on   D                     Not Covered
90767   Tx/proph/dg addl seq iv inf    D                     Not Covered
90768   Ther/diag concurrent inf       D                     Not Covered
90769   Sc ther infusion, up to 1 hr   D                     Not Covered
90770   Sc ther infusion, addl hr      D                     Not Covered
90771   Sc ther infusion, reset pump   D                     Not Covered
90772   Ther/proph/diag inj, sc/im     D                     Not Covered
90773   Ther/proph/diag inj, ia        D                     Not Covered
90774   Ther/proph/diag inj, iv push   D                     Not Covered
90775   Tx/pro/dx inj new drug addon   D                     Not Covered
90776   Tx/pro/dx inj same drug adon   D                     Not Covered
90779   Ther/prop/diag inj/inf proc    D                               Not Covered
90801   Psy dx interview               Q3   00323   1.6690             Not Covered
90802   Intac psy dx interview         Q3   00323   1.6690             Not Covered
90804   Psytx, office, 20-30 min       Q3   00322   1.1958             Not Covered
90805   Psytx, off, 20-30 min w/e&m    Q3   00322   1.1958             Not Covered
90806   Psytx, off, 45-50 min          Q3   00323   1.6690             Not Covered
90807   Psytx, off, 45-50 min w/e&m    Q3   00323   1.6690             Not Covered
90808   Psytx, office, 75-80 min       Q3   00323   1.6690             Not Covered
90809   Psytx, off, 75-80, w/e&m       Q3   00323   1.6690             Not Covered
90810   Intac psytx, off, 20-30 min    Q3   00322   1.1958             Not Covered
90811   Intac psytx, 20-30, w/e&m      Q3   00322   1.1958             Not Covered
90812   Intac psytx, off, 45-50 min    Q3   00323   1.6690             Not Covered
90813   Intac psytx, 45-50 min w/e&m   Q3   00323   1.6690             Not Covered
90814   Intac psytx, off, 75-80 min    Q3   00323   1.6690             Not Covered
90815   Intac psytx, 75-80 w/e&m       Q3   00323   1.6690             Not Covered
90816   Psytx, hosp, 20-30 min         P                               Not Covered
90817   Psytx, hosp, 20-30 min w/e&m   P                               Not Covered
90818   Psytx, hosp, 45-50 min         P                               Not Covered
90819   Psytx, hosp, 45-50 min w/e&m   P                               Not Covered
90821   Psytx, hosp, 75-80 min         P                               Not Covered
90822   Psytx, hosp, 75-80 min w/e&m   P                               Not Covered
90823   Intac psytx, hosp, 20-30 min   P                               Not Covered
90824   Intac psytx, hsp 20-30 w/e&m   P                               Not Covered
90826   Intac psytx, hosp, 45-50 min   P                               Not Covered
90827   Intac psytx, hsp 45-50 w/e&m   P                               Not Covered
90828   Intac psytx, hosp, 75-80 min   P                               Not Covered
90829   Intac psytx, hsp 75-80 w/e&m   P                               Not Covered
90845   Psychoanalysis                 Q3   00323   1.6690             Not Covered
90846   Family psytx w/o patient       Q3   00324   2.2103              Covered
90847   Family psytx w/patient         Q3   00324   2.2103             Not Covered
90849   Multiple family group psytx    Q3   00325   0.8905             Not Covered
90853   Group psychotherapy            Q3   00325   0.8905             Not Covered
90857   Intac group psytx              Q3   00325   0.8905             Not Covered
90862   Medication management          Q3   00606   1.3222              Covered
90865   Narcosynthesis                 Q3   00323   1.6690              Covered
90870   Electroconvulsive therapy      S    00320   5.8620              Covered
90875   Psychophysiological therapy    E                      $71.68    Covered
90876   Psychophysiological therapy    E                     $106.76    Covered
90880   Hypnotherapy                   Q3   00323   1.6690             Not Covered
90882   Environmental manipulation     E                               Not Covered
90885   Psy evaluation of records      N                                Covered
90887   Consultation with family       N                               Not Covered
90889   Preparation of report          N                               Not Covered
90899   Psychiatric service/therapy    Q3   00322   1.1958              Covered
90901   Biofeedback train, any meth    A                               Not Covered
90911   Biofeedback peri/uro/rectal    T    00126   1.0958             Not Covered
90918   ESRD related services, month   D                               Not Covered
90919   ESRD related services, month   D                               Not Covered
90920   ESRD related services, month   D                               Not Covered
90921   ESRD related services, month   D                               Not Covered
90922   ESRD related services, day     D                               Not Covered
90923   Esrd related services, day     D                               Not Covered
90924   Esrd related services, day     D                              Not Covered
90925   Esrd related services, day     D                              Not Covered
90935   Hemodialysis, one evaluation   S   00170   6.8212               Covered
90937   Hemodialysis, repeated eval    B                              Not Covered
90940   Hemodialysis access study      N                               By Report
90945   Dialysis, one evaluation       V   00608   2.4853               Covered
90947   Dialysis, repeated eval        B                              Not Covered
90951   Esrd serv, 4 visits p mo, <2   M                    $913.81     Covered
90952   Esrd serv, 2-3 vsts p mo, <2   M                               By Report
90953   Esrd serv, 1 visit p mo, <2    M                               By Report
90954   Esrd serv, 4 vsts p mo, 2-11   M                    $751.73     Covered
90955   Esrd srv 2-3 vsts p mo, 2-11   M                    $425.11     Covered
90956   Esrd srv, 1 visit p mo, 2-11   M                    $288.01     Covered
90957   Esrd srv, 4 vsts p mo, 12-19   M                    $602.94     Covered
90958   Esrd srv 2-3 vsts p mo 12-19   M                    $406.53     Covered
90959   Esrd serv, 1 vst p mo, 12-19   M                    $266.92     Covered
90960   Esrd srv, 4 visits p mo, 20+   M                    $266.68     Covered
90961   Esrd srv, 2-3 vsts p mo, 20+   M                    $215.45     Covered
90962   Esrd serv, 1 visit p mo, 20+   M                    $155.97     Covered
90963   Esrd home pt, serv p mo, <2    M                    $516.40     Covered
90964   Esrd home pt serv p mo, 2-11   M                    $431.46     Covered
90965   Esrd home pt serv p mo 12-19   M                    $410.52     Covered
90966   Esrd home pt, serv p mo, 20+   M                    $213.26     Covered
90967   Esrd home pt serv p day, <2    M                     $18.43     Covered
90968   Esrd home pt srv p day, 2-11   M                     $14.43     Covered
90969   Esrd home pt srv p day 12-19   M                     $14.07     Covered
90970   Esrd home pt serv p day, 20+   M                      $7.40     Covered
90989   Dialysis training, complete    B                              Not Covered
90993   Dialysis training, incompl     B                              Not Covered
90997   Hemoperfusion                  B                              Not Covered
90999   Dialysis procedure             B                              Not Covered
91000   Esophageal intubation          X   00361   4.0839               Covered
91010   Esophagus motility study       X   00361   4.0839               Covered
91011   Esophagus motility study       X   00361   4.0839               Covered
91012   Esophagus motility study       X   00361   4.0839               Covered
91020   Gastric motility studies       X   00361   4.0839               Covered
91022   Duodenal motility study        X   00361   4.0839               Covered
91030   Acid perfusion of esophagus    X   00361   4.0839               Covered
91034   Gastroesophageal reflux test   X   00361   4.0839               Covered
91035   G-esoph reflx tst w/electrod   X   00361   4.0839               Covered
91037   Esoph imped function test      X   00361   4.0839               Covered
91038   Esoph imped funct test > 1h    X   00361   4.0839               Covered
91040   Esoph balloon distension tst   X   00360   1.5203               Covered
91052   Gastric analysis test          X   00361   4.0839               Covered
91055   Gastric intubation for smear   X   00360   1.5203               Covered
91065   Breath hydrogen test           X   00360   1.5203               Covered
91100   Pass intestine bleeding tube   D                              Not Covered
91105   Gastric intubation treatment   X   00360   1.5203               Covered
91110   Gi tract capsule endoscopy     T   00142   9.8503               Covered
91111   Esophageal capsule endoscopy   T   00141   8.7462               Covered
91120   Rectal sensation test          T   00126   1.0958               Covered
91122   Anal pressure record           T   00156   3.0214               Covered
91123   Irrigate fecal impaction       N                               By Report
91132   Electrogastrography            X   00360    1.5203              Covered
91133   Electrogastrography w/test     X   00360    1.5203              Covered
91299   Gastroenterology procedure     X   00360    1.5203              Covered
92002   Eye exam, new patient          V   00606    1.3222              Covered
92004   Eye exam, new patient          V   00606    1.3222              Covered
92012   Eye exam established pat       V   00604    0.8593              Covered
92014   Eye exam & treatment           V   00605    1.0337              Covered
92015   Refraction                     E                     $15.69     Covered
92018   New eye exam & treatment       T   00699   15.5407              Covered
92019   Eye exam & treatment           T   00699   15.5407              Covered
92020   Special eye evaluation         S   00230    0.5945              Covered
92025   Corneal topography             S   00698    0.9553              Covered
92060   Special eye evaluation         S   00698    0.9553              Covered
92065   Orthoptic/pleoptic training    S   00698    0.9553              Covered
92070   Fitting of contact lens        N                                Covered
92081   Visual field examination(s)    S   00230    0.5945              Covered
92082   Visual field examination(s)    S   00698    0.9553              Covered
92083   Visual field examination(s)    S   00698    0.9553              Covered
92100   Serial tonometry exam(s)       N                                Covered
92120   Tonography & eye evaluation    S   00698    0.9553              Covered
92130   Water provocation tonography   S   00230    0.5945              Covered
92135   Ophth dx imaging post seg      S   00230    0.5945              Covered
92136   Ophthalmic biometry            S   00698    0.9553              Covered
92140   Glaucoma provocative tests     S   00230    0.5945              Covered
92225   Special eye exam, initial      S   00230    0.5945              Covered
92226   Special eye exam, subsequent   S   00698    0.9553              Covered
92230   Eye exam with photos           S   00231    1.9575              Covered
92235   Eye exam with photos           S   00231    1.9575              Covered
92240   Icg angiography                S   00231    1.9575              Covered
92250   Eye exam with photos           S   00698    0.9553              Covered
92260   Ophthalmoscopy/dynamometry     S   00230    0.5945              Covered
92265   Eye muscle evaluation          S   00698    0.9553              Covered
92270   Electro-oculography            S   00230    0.5945              Covered
92275   Electroretinography            S   00231    1.9575              Covered
92283   Color vision examination       S   00230    0.5945              Covered
92284   Dark adaptation eye exam       S   00698    0.9553              Covered
92285   Eye photography                S   00698    0.9553              Covered
92286   Internal eye photography       S   00231    1.9575              Covered
92287   Internal eye photography       S   00231    1.9575              Covered
92310   Contact lens fitting           E                     $82.60     Covered
92311   Contact lens fitting           S   00698    0.9553              Covered
92312   Contact lens fitting           S   00698    0.9553              Covered
92313   Contact lens fitting           S   00230    0.5945              Covered
92314   Prescription of contact lens   E                     $52.02     Covered
92315   Prescription of contact lens   S   00230    0.5945              Covered
92316   Prescription of contact lens   S   00698    0.9553              Covered
92317   Prescription of contact lens   S   00230    0.5945              Covered
92325   Modification of contact lens   S   00230    0.5945              Covered
92326   Replacement of contact lens    S   00698    0.9553              Covered
92340   Fitting of spectacles          E                              Not Covered
92341   Fitting of spectacles          E                     $37.26     Covered
92342   Fitting of spectacles          E                    $41.14    Covered
92352   Special spectacles fitting     S   00698   0.9553             Covered
92353   Special spectacles fitting     S   00230   0.5945             Covered
92354   Special spectacles fitting     S   00230   0.5945             Covered
92355   Special spectacles fitting     S   00230   0.5945             Covered
92358   Eye prosthesis service         S   00230   0.5945             Covered
92370   Repair & adjust spectacles     E                             Not Covered
92371   Repair & adjust spectacles     S   00230   0.5945             Covered
92499   Eye service or procedure       S   00230   0.5945             Covered
92502   Ear and throat examination     T   00251   3.4250             Covered
92504   Ear microscopy examination     N                              Covered
92506   Speech/hearing evaluation      A                    $91.35    Covered
92507   Speech/hearing therapy         A                    $72.13    Covered
92508   Speech/hearing therapy         A                    $70.04    Covered
92511   Nasopharyngoscopy              T   00071   0.8007             Covered
92512   Nasal function studies         X   00363   0.9061             Covered
92516   Facial nerve function test     X   00660   1.5019             Covered
92520   Laryngeal function studies     X   00660   1.5019             Covered
92526   Oral function therapy          A                    $73.59    Covered
92531   Spontaneous nystagmus study    N                              Covered
92532   Positional nystagmus test      N                              Covered
92533   Caloric vestibular test        N                              Covered
92534   Optokinetic nystagmus test     N                              Covered
92540   Basic vestibular evaluation    X   00660   1.5019             Covered
92541   Spontaneous nystagmus test     X   00363   0.9061             Covered
92542   Positional nystagmus test      X   00363   0.9061             Covered
92543   Caloric vestibular test        X   00660   1.5019             Covered
92544   Optokinetic nystagmus test     X   00363   0.9061             Covered
92545   Oscillating tracking test      X   00363   0.9061             Covered
92546   Sinusoidal rotational test     X   00660   1.5019             Covered
92547   Supplemental electrical test   N                              Covered
92548   Posturography                  X   00660   1.5019             Covered
92550   Tympanometry & reflex thresh   X   00364   0.4700             Covered
92551   Pure tone hearing test, air    E                    $14.72    Covered
92552   Pure tone audiometry, air      X   00364   0.4700             Covered
92553   Audiometry, air & bone         X   00365   1.2675             Covered
92555   Speech threshold audiometry    X   00364   0.4700             Covered
92556   Speech audiometry, complete    X   00364   0.4700             Covered
92557   Comprehensive hearing test     X   00365   1.2675             Covered
92559   Group audiometric testing      E                    $16.99    Covered
92560   Bekesy audiometry, screen      E                    $28.88    Covered
92561   Bekesy audiometry, diagnosis   X   00364   0.4700             Covered
92562   Loudness balance test          X   00364   0.4700             Covered
92563   Tone decay hearing test        X   00364   0.4700             Covered
92564   Sisi hearing test              X   00364   0.4700             Covered
92565   Stenger test, pure tone        X   00364   0.4700             Covered
92567   Tympanometry                   X   00364   0.4700             Covered
92568   Acoustic refl threshold tst    X   00364   0.4700             Covered
92569   Acoustic reflex decay test     D                             Not Covered
92570   Acoustic immittance testing    X   00364   0.4700             Covered
92571   Filtered speech hearing test   X   00364   0.4700             Covered
92572   Staggered spondaic word test   X   00366   1.6243             Covered
92575   Sensorineural acuity test      X   00364    0.4700              Covered
92576   Synthetic sentence test        X   00364    0.4700              Covered
92577   Stenger test, speech           X   00366    1.6243              Covered
92579   Visual audiometry (vra)        X   00365    1.2675              Covered
92582   Conditioning play audiometry   X   00365    1.2675              Covered
92583   Select picture audiometry      X   00364    0.4700              Covered
92584   Electrocochleography           S   00216    2.6831              Covered
92585   Auditor evoke potent, compre   S   00216    2.6831              Covered
92586   Auditor evoke potent, limit    S   00218    1.1965              Covered
92587   Evoked auditory test           X   00363    0.9061              Covered
92588   Evoked auditory test           X   00363    0.9061              Covered
92590   Hearing aid exam, one ear      E                     $44.17     Covered
92591   Hearing aid exam, both ears    E                     $59.44     Covered
92592   Hearing aid check, one ear     E                     $16.99     Covered
92593   Hearing aid check, both ears   E                     $16.99     Covered
92594   Electro hearng aid test, one   E                     $16.99     Covered
92595   Electro hearng aid tst, both   E                     $16.99     Covered
92596   Ear protector evaluation       X   00364    0.4700              Covered
92597   Oral speech device eval        A                     $94.52     Covered
92601   Cochlear implt f/up exam < 7   X   00366    1.6243              Covered
92602   Reprogram cochlear implt < 7   X   00366    1.6243              Covered
92603   Cochlear implt f/up exam 7 >   X   00366    1.6243              Covered
92604   Reprogram cochlear implt 7 >   X   00366    1.6243              Covered
92605   Eval for nonspeech device rx   A                               Not Covered
92606   Non-speech device service      A                               Not Covered
92607   Ex for speech device rx, 1hr   A                      $93.14    Covered
92608   Ex for speech device rx addl   A                      $13.12    Covered
92609   Use of speech device service   A                      $50.40    Covered
92610   Evaluate swallowing function   A                     $110.49    Covered
92611   Motion fluoroscopy/swallow     A                               Not Covered
92612   Endoscopy swallow tst (fees)   A                               Not Covered
92613   Endoscopy swallow tst (fees)   B                               Not Covered
92614   Laryngoscopic sensory test     A                               Not Covered
92615   Eval laryngoscopy sense tst    E                               Not Covered
92616   Fees w/laryngeal sense test    A                               Not Covered
92617   Interprt fees/laryngeal test   E                               Not Covered
92620   Auditory function, 60 min      X   00365    1.2675              Covered
92621   Auditory function, + 15 min    N                                Covered
92625   Tinnitus assessment            X   00365    1.2675              Covered
92626   Eval aud rehab status          X   00366    1.6243              Covered
92627   Eval aud status rehab add-on   N                                Covered
92630   Aud rehab pre-ling hear loss   E                     $24.28     Covered
92633   Aud rehab postling hear loss   E                     $24.28     Covered
92640   Aud brainstem implt programg   X   00365    1.2675              Covered
92700   Ent procedure/service          X   00364    0.4700              Covered
92950   Heart/lung resuscitation cpr   S   00094    2.4553              Covered
92953   Temporary external pacing      S   00094    2.4553              Covered
92960   Cardioversion electric, ext    S   00679    5.5047              Covered
92961   Cardioversion, electric, int   S   00679    5.5047              Covered
92970   Cardioassist, internal         C                     $213.41    Covered
92971   Cardioassist, external         C                      $98.57    Covered
92973   Percut coronary thrombectomy   T   00088   40.9003              Covered
92974   Cath place, cardio brachytx    T   00103   17.8436                 Covered
92975   Dissolve clot, heart vessel    C                     $425.47       Covered
92977   Dissolve clot, heart vessel    T   00676    2.3954                 Covered
92978   Intravasc us, heart add-on     N                                   Covered
92979   Intravasc us, heart add-on     N                                   Covered
92980   Insert intracoronary stent     T   00104   84.7773                 Covered
92981   Insert intracoronary stent     T   00104   84.7773                 Covered
92982   Coronary artery dilation       T   00083   50.6809                 Covered
92984   Coronary artery dilation       T   00083   50.6809                 Covered
92986   Revision of aortic valve       T   00083   50.6809                 Covered
92987   Revision of mitral valve       T   00083   50.6809                 Covered
92990   Revision of pulmonary valve    T   00083   50.6809                 Covered
92992   Revision of heart chamber      C                     $1,311.80     Covered
92993   Revision of heart chamber      C                                  By Report
92995   Coronary atherectomy           T   00082   93.3244                 Covered
92996   Coronary atherectomy add-on    T   00082   93.3244                 Covered
92997   Pul art balloon repr, percut   T   00083   50.6809                 Covered
92998   Pul art balloon repr, percut   T   00083   50.6809                 Covered
93000   Electrocardiogram, complete    M                      $26.74       Covered
93005   Electrocardiogram, tracing     S   00099    0.3940                 Covered
93010   Electrocardiogram report       B                                 Not Covered
93012   Transmission of ecg            N                                   Covered
93014   Report on transmitted ecg      B                                 Not Covered
93015   Cardiovascular stress test     B                                 Not Covered
93016   Cardiovascular stress test     B                                 Not Covered
93017   Cardiovascular stress test     X   00100    2.6136                 Covered
93018   Cardiovascular stress test     B                                 Not Covered
93024   Cardiac drug stress test       X   00100    2.6136                 Covered
93025   Microvolt t-wave assess        X   00100    2.6136                 Covered
93040   Rhythm ECG with report         B                                 Not Covered
93041   Rhythm ECG, tracing            X   00035    0.2320                 Covered
93042   Rhythm ECG, report             B                                 Not Covered
93224   ECG monitor/report, 24 hrs     M                     $155.04       Covered
93225   ECG monitor/record, 24 hrs     S   00097    0.9848                 Covered
93226   ECG monitor/report, 24 hrs     S   00097    0.9848                 Covered
93227   ECG monitor/review, 24 hrs     M                      $33.21       Covered
93228   Remote 30 day ecg rev/report   M                      $24.40       Covered
93229   Remote 30 day ecg tech supp    S   00209   11.4315                 Covered
93230   ECG monitor/report, 24 hrs     M                     $164.69       Covered
93231   Ecg monitor/record, 24 hrs     S   00097    0.9848                 Covered
93232   ECG monitor/report, 24 hrs     S   00097    0.9848                 Covered
93233   ECG monitor/review, 24 hrs     M                      $33.21       Covered
93235   ECG monitor/report, 24 hrs     M                     $121.32       Covered
93236   ECG monitor/report, 24 hrs     S   00097    0.9848                 Covered
93237   ECG monitor/review, 24 hrs     M                      $28.73       Covered
93268   ECG record/review              M                     $158.47       Covered
93270   ECG recording                  S   00097    0.9848                 Covered
93271   Ecg/monitoring and analysis    S   00692    1.6000                 Covered
93272   Ecg/review, interpret only     M                      $29.86       Covered
93278   ECG/signal-averaged            X   00035    0.2320                 Covered
93279   Pm device progr eval, sngl     S   00690    0.3506                 Covered
93280   Pm device progr eval, dual     S   00690    0.3506                 Covered
93281   Pm device progr eval, multi    S   00690    0.3506            Covered
93282   Icd device prog eval, 1 sngl   S   00689    0.5680            Covered
93283   Icd device progr eval, dual    S   00689    0.5680            Covered
93284   Icd device progr eval, mult    S   00689    0.5680            Covered
93285   Ilr device eval progr          S   00690    0.3506            Covered
93286   Pre-op pm device eval          N                              Covered
93287   Pre-op icd device eval         N                              Covered
93288   Pm device eval in person       S   00690    0.3506            Covered
93289   Icd device interrogate         S   00689    0.5680            Covered
93290   Icm device eval                S   00690    0.3506            Covered
93291   Ilr device interrogate         S   00690    0.3506            Covered
93292   Wcd device interrogate         S   00689    0.5680            Covered
93293   Pm phone r-strip device eval   S   00689    0.5680            Covered
93294   Pm device interrogate remote   M                     $34.58   Covered
93295   Icd device interrogat remote   M                     $62.59   Covered
93296   Pm/icd remote tech serv        S   00689    0.5680            Covered
93297   Icm device interrogat remote   M                     $24.40   Covered
93298   Ilr device interrogat remote   M                     $27.85   Covered
93299   Icm/ilr remote tech serv       S   00689    0.5680            Covered
93303   Echo transthoracic             S   00270    8.8425            Covered
93304   Echo transthoracic             S   00269    6.6903            Covered
93306   Tte w/doppler, complete        S   00269    6.6903            Covered
93307   Tte w/o doppler, complete      S   00697    3.9223            Covered
93308   Tte, f-up or lmtd              S   00697    3.9223            Covered
93312   Echo transesophageal           S   00270    8.8425            Covered
93313   Echo transesophageal           S   00269    6.6903            Covered
93314   Echo transesophageal           N                              Covered
93315   Echo transesophageal           S   00270    8.8425            Covered
93316   Echo transesophageal           S   00270    8.8425            Covered
93317   Echo transesophageal           N                              Covered
93318   Echo transesophageal intraop   S   00270    8.8425            Covered
93320   Doppler echo exam, heart       N                              Covered
93321   Doppler echo exam, heart       N                              Covered
93325   Doppler color flow add-on      N                              Covered
93350   Stress tte only                S   00269    6.6903            Covered
93351   Stress tte complete            S   00270    8.8425            Covered
93352   Admin ecg contrast agent       M                     $33.84   Covered
93501   Right heart catheterization    T   00080   39.8099            Covered
93503   Insert/place heart catheter    T   00103   17.8436            Covered
93505   Biopsy of heart lining         T   00103   17.8436            Covered
93508   Cath placement, angiography    T   00080   39.8099            Covered
93510   Left heart catheterization     T   00080   39.8099            Covered
93511   Left heart catheterization     T   00080   39.8099            Covered
93514   Left heart catheterization     T   00080   39.8099            Covered
93524   Left heart catheterization     T   00080   39.8099            Covered
93526   Rt & Lt heart catheters        T   00080   39.8099            Covered
93527   Rt & Lt heart catheters        T   00080   39.8099            Covered
93528   Rt & Lt heart catheters        T   00080   39.8099            Covered
93529   Rt, lt heart catheterization   T   00080   39.8099            Covered
93530   Rt heart cath, congenital      T   00080   39.8099            Covered
93531   R & l heart cath, congenital   T   00080   39.8099            Covered
93532   R & l heart cath, congenital   T   00080   39.8099            Covered
93533   R & l heart cath, congenital   T    00080    39.8099    Covered
93539   Injection, cardiac cath        N                        Covered
93540   Injection, cardiac cath        N                        Covered
93541   Injection for lung angiogram   N                        Covered
93542   Injection for heart x-rays     N                        Covered
93543   Injection for heart x-rays     N                        Covered
93544   Injection for aortography      N                        Covered
93545   Inject for coronary x-rays     N                        Covered
93555   Imaging, cardiac cath          N                        Covered
93556   Imaging, cardiac cath          N                        Covered
93561   Cardiac output measurement     N                        Covered
93562   Cardiac output measurement     N                        Covered
93571   Heart flow reserve measure     N                        Covered
93572   Heart flow reserve measure     N                        Covered
93580   Transcath closure of asd       T    00434   147.3728    Covered
93581   Transcath closure of vsd       T    00434   147.3728    Covered
93600   Bundle of His recording        S    00084    10.8110    Covered
93602   Intra-atrial recording         S    00084    10.8110    Covered
93603   Right ventricular recording    S    00084    10.8110    Covered
93609   Map tachycardia, add-on        N                        Covered
93610   Intra-atrial pacing            S    00084    10.8110    Covered
93612   Intraventricular pacing        S    00084    10.8110    Covered
93613   Electrophys map 3d, add-on     N                        Covered
93615   Esophageal recording           S    00084    10.8110    Covered
93616   Esophageal recording           S    00084    10.8110    Covered
93618   Heart rhythm pacing            S    00084    10.8110    Covered
93619   Electrophysiology evaluation   Q3   00085    52.3882    Covered
93620   Electrophysiology evaluation   Q3   00085    52.3882    Covered
93621   Electrophysiology evaluation   N                        Covered
93622   Electrophysiology evaluation   N                        Covered
93623   Stimulation, pacing heart      N                        Covered
93624   Electrophysiologic study       T    00085    52.3882    Covered
93631   Heart pacing, mapping          N                        Covered
93640   Evaluation heart device        N                        Covered
93641   Electrophysiology evaluation   N                        Covered
93642   Electrophysiology evaluation   S    00084    10.8110    Covered
93650   Ablate heart dysrhythm focus   Q3   00085    52.3882    Covered
93651   Ablate heart dysrhythm focus   Q3   00086   106.9978    Covered
93652   Ablate heart dysrhythm focus   Q3   00086   106.9978    Covered
93660   Tilt table evaluation          S    00101     4.3705    Covered
93662   Intracardiac ecg (ice)         N                        Covered
93668   Peripheral vascular rehab      E                       Not Covered
93701   Bioimpedance, thoracic         S    00099     0.3940    Covered
93720   Total body plethysmography     B                       Not Covered
93721   Plethysmography tracing        X    00368     0.8495    Covered
93722   Plethysmography report         B                       Not Covered
93724   Analyze pacemaker system       S    00690     0.3506    Covered
93727   Analyze ilr system             D                       Not Covered
93731   Analyze pacemaker system       D                       Not Covered
93732   Analyze pacemaker system       D                       Not Covered
93733   Telephone analy, pacemaker     D                       Not Covered
93734   Analyze pacemaker system       D                       Not Covered
93735   Analyze pacemaker system       D                              Not Covered
93736   Telephonic analy, pacemaker    D                              Not Covered
93740   Temperature gradient studies   X   00368   0.8495              Covered
93741   Analyze ht pace device sngl    D                              Not Covered
93742   Analyze ht pace device sngl    D                              Not Covered
93743   Analyze ht pace device dual    D                              Not Covered
93744   Analyze ht pace device dual    D                              Not Covered
93745   Set-up cardiovert-defibrill    S   00689   0.5680             Not Covered
93750   Interrogation vad, in person   S   00692   1.6000              Covered
93760   Cephalic thermogram            D                              Not Covered
93762   Peripheral thermogram          D                              Not Covered
93770   Measure venous pressure        N                               Covered
93784   Ambulatory BP monitoring       E                    $135.92    Covered
93786   Ambulatory BP recording        S   00097   0.9848              Covered
93788   Ambulatory BP analysis         S   00097   0.9848              Covered
93790   Review/report BP recording     M                    $33.97     Covered
93797   Cardiac rehab                  S   00095   0.5691             Not Covered
93798   Cardiac rehab/monitor          S   00095   0.5691             Not Covered
93799   Cardiovascular procedure       S   00097   0.9848              Covered
93875   Extracranial study             S   00096   1.6075              Covered
93880   Extracranial study             S   00267   2.3005              Covered
93882   Extracranial study             S   00267   2.3005              Covered
93886   Intracranial study             S   00267   2.3005              Covered
93888   Intracranial study             S   00265   0.9267              Covered
93890   Tcd, vasoreactivity study      S   00266   1.4434              Covered
93892   Tcd, emboli detect w/o inj     S   00266   1.4434              Covered
93893   Tcd, emboli detect w/inj       S   00266   1.4434              Covered
93922   Extremity study                S   00097   0.9848              Covered
93923   Extremity study                S   00096   1.6075              Covered
93924   Extremity study                S   00096   1.6075              Covered
93925   Lower extremity study          S   00267   2.3005              Covered
93926   Lower extremity study          S   00266   1.4434              Covered
93930   Upper extremity study          S   00267   2.3005              Covered
93931   Upper extremity study          S   00266   1.4434              Covered
93965   Extremity study                S   00096   1.6075              Covered
93970   Extremity study                S   00267   2.3005              Covered
93971   Extremity study                S   00266   1.4434              Covered
93975   Vascular study                 S   00267   2.3005              Covered
93976   Vascular study                 S   00267   2.3005              Covered
93978   Vascular study                 S   00267   2.3005              Covered
93979   Vascular study                 S   00266   1.4434              Covered
93980   Penile vascular study          S   00267   2.3005              Covered
93981   Penile vascular study          S   00267   2.3005              Covered
93982   Aneurysm pressure sens study   S   00097   0.9848             Not Covered
93990   Doppler flow testing           S   00266   1.4434              Covered
94002   Vent mgmt inpat, init day      S   00079   3.0865              Covered
94003   Vent mgmt inpat, subq day      S   00079   3.0865              Covered
94004   Vent mgmt nf per day           B                              Not Covered
94005   Home vent mgmt supervision     M                              Not Covered
94010   Breathing capacity test        X   00368   0.8495              Covered
94011   Up to 2 yrs old, spirometry    X   00368   0.8495              Covered
94012   = 2 yrs, spiromtry w/dilator   X   00368   0.8495              Covered
94013   = 2 yrs, lung volumes           X   00369   2.6228             Covered
94014   Patient recorded spirometry     X   00367   0.5968             Covered
94015   Patient recorded spirometry     X   00367   0.5968            Not Covered
94016   Review patient spirometry       A                    $26.15    Covered
94060   Evaluation of wheezing         S    00078   1.4142             Covered
94070   Evaluation of wheezing          X   00369   2.6228             Covered
94150   Vital capacity test             X   00367   0.5968             Covered
94200   Lung function test (MBC/MVV)    X   00367   0.5968             Covered
94240   Residual lung capacity          X   00368   0.8495             Covered
94250   Expired gas collection          X   00368   0.8495             Covered
94260   Thoracic gas volume             X   00368   0.8495             Covered
94350   Lung nitrogen washout curve     X   00368   0.8495             Covered
94360   Measure airflow resistance      X   00367   0.5968             Covered
94370   Breath airway closing volume    X   00035   0.2320             Covered
94375   Respiratory flow volume loop    X   00368   0.8495             Covered
94400   CO2 breathing response curve    X   00367   0.5968             Covered
94450   Hypoxia response curve          X   00368   0.8495             Covered
94452   Hast w/report                   X   00368   0.8495            Not Covered
94453   Hast w/oxygen titrate           X   00368   0.8495            Not Covered
94610   Surfactant admin thru tube     S    00077   0.4058             Covered
94620   Pulmonary stress test/simple    X   00368   0.8495             Covered
94621   Pulm stress test/complex        X   00369   2.6228             Covered
94640   Airway inhalation treatment     S   00077   0.4058             Covered
94642   Aerosol inhalation treatment    S   00078   1.4142             Covered
94644   Cbt, 1st hour                   X   00340   0.6693             Covered
94645   Cbt, each addl hour             X   00340   0.6693             Covered
94660   Pos airway pressure, CPAP       S   00078   1.4142             Covered
94662   Neg press ventilation, cnp      S   00079   3.0865             Covered
94664   Evaluate pt use of inhaler      S   00077   0.4058             Covered
94667   Chest wall manipulation         S   00077   0.4058             Covered
94668   Chest wall manipulation         S   00077   0.4058             Covered
94680   Exhaled air analysis, o2        X   00369   2.6228             Covered
94681   Exhaled air analysis, o2/co2    X   00368   0.8495             Covered
94690   Exhaled air analysis            X   00367   0.5968             Covered
94720   Monoxide diffusing capacity     X   00368   0.8495             Covered
94725   Membrane diffusion capacity     X   00368   0.8495             Covered
94750   Pulmonary compliance study      X   00367   0.5968             Covered
94760   Measure blood oxygen level      N                              Covered
94761   Measure blood oxygen level      N                              Covered
94762   Measure blood oxygen level     Q1   00097   0.9848             Covered
94770   Exhaled carbon dioxide test     X   00367   0.5968             Covered
94772   Breath recording, infant        X   00369   2.6228             Covered
94774   Ped home apnea rec, compl      B                              Not Covered
94775   Ped home apnea rec, hk-up       S   00097   0.9848             Covered
94776   Ped home apnea rec, downld      S   00097   0.9848             Covered
94777   Ped home apnea rec, report     B                              Not Covered
94799   Pulmonary service/procedure     X   00367   0.5968             Covered
95004   Percut allergy skin tests       X   00381   0.4312             Covered
95010   Percut allergy titrate test     X   00381   0.4312             Covered
95012   Exhaled nitric oxide meas       X   00367   0.5968             Covered
95015   Id allergy titrate-drug/bug     X   00381   0.4312             Covered
95024   Id allergy test, drug/bug       X   00381   0.4312             Covered
95027   Id allergy titrate-airborne    X   00381    0.4312             Covered
95028   Id allergy test-delayed type   X   00381    0.4312             Covered
95044   Allergy patch tests            X   00381    0.4312             Covered
95052   Photo patch test               X   00381    0.4312             Covered
95056   Photosensitivity tests         X   00370    1.4598             Covered
95060   Eye allergy tests              X   00370    1.4598             Covered
95065   Nose allergy test              X   00381    0.4312             Covered
95070   Bronchial allergy tests        X   00369    2.6228             Covered
95071   Bronchial allergy tests        X   00369    2.6228             Covered
95075   Ingestion challenge test       X   00361    4.0839             Covered
95115   Immunotherapy, one injection   S   00436    0.3809             Covered
95117   Immunotherapy injections       S   00436    0.3809             Covered
95120   Immunotherapy, one injection   E                     $7.42     Covered
95125   Immunotherapy, many antigens   E                     $7.42     Covered
95130   Immunotherapy, insect venom    E                     $7.72     Covered
95131   Immunotherapy, insect venoms   E                     $7.72     Covered
95132   Immunotherapy, insect venoms   E                     $7.72     Covered
95133   Immunotherapy, insect venoms   E                     $7.72     Covered
95134   Immunotherapy, insect venoms   E                     $7.72     Covered
95144   Antigen therapy services       S   00437    0.5555             Covered
95145   Antigen therapy services       S   00437    0.5555             Covered
95146   Antigen therapy services       S   00438    1.1229             Covered
95147   Antigen therapy services       S   00438    1.1229             Covered
95148   Antigen therapy services       S   00437    0.5555             Covered
95149   Antigen therapy services       S   00437    0.5555             Covered
95165   Antigen therapy services       S   00436    0.3809             Covered
95170   Antigen therapy services       S   00437    0.5555             Covered
95180   Rapid desensitization          X   00370    1.4598             Covered
95199   Allergy immunology services    X   00381    0.4312             Covered
95250   Glucose monitoring, cont       V   00607    1.6830             Covered
95251   Gluc monitor, cont, phys i&r   B                              Not Covered
95803   Actigraphy testing             S   00218    1.1965             Covered
95805   Multiple sleep latency test    S   00209   11.4315             Covered
95806   Sleep study, unattended        S   00213    2.4043             Covered
95807   Sleep study, attended          S   00209   11.4315             Covered
95808   Polysomnography, 1-3           S   00209   11.4315             Covered
95810   Polysomnography, 4 or more     S   00209   11.4315             Covered
95811   Polysomnography w/cpap         S   00209   11.4315             Covered
95812   Eeg, 41-60 minutes             S   00213    2.4043             Covered
95813   Eeg, over 1 hour               S   00213    2.4043             Covered
95816   Eeg, awake and drowsy          S   00213    2.4043             Covered
95819   Eeg, awake and asleep          S   00213    2.4043             Covered
95822   Eeg, coma or sleep only        S   00213    2.4043             Covered
95824   Eeg, cerebral death only       S   00216    2.6831             Covered
95827   Eeg, all night recording       S   00213    2.4043             Covered
95829   Surgery electrocorticogram     N                               Covered
95830   Insert electrodes for EEG      B                              Not Covered
95831   Limb muscle testing, manual    A                     $28.32    Covered
95832   Hand muscle testing, manual    A                     $27.33    Covered
95833   Body muscle testing, manual    A                     $36.07    Covered
95834   Body muscle testing, manual    A                     $42.83    Covered
95851   Range of motion measurements   A                     $24.88    Covered
95852   Range of motion measurements   A                     $20.97   Covered
95857   Tensilon test                  S   00218    1.1965            Covered
95860   Muscle test, one limb          S   00218    1.1965            Covered
95861   Muscle test, 2 limbs           S   00218    1.1965            Covered
95863   Muscle test, 3 limbs           S   00218    1.1965            Covered
95864   Muscle test, 4 limbs           S   00218    1.1965            Covered
95865   Muscle test, larynx            S   00218    1.1965            Covered
95866   Muscle test, hemidiaphragm     S   00218    1.1965            Covered
95867   Muscle test cran nerv unilat   S   00218    1.1965            Covered
95868   Muscle test cran nerve bilat   S   00218    1.1965            Covered
95869   Muscle test, thor paraspinal   S   00215    0.6135            Covered
95870   Muscle test, nonparaspinal     S   00215    0.6135            Covered
95872   Muscle test, one fiber         S   00218    1.1965            Covered
95873   Guide nerv destr, elec stim    N                              Covered
95874   Guide nerv destr, needle emg   N                              Covered
95875   Limb exercise test             S   00215    0.6135            Covered
95900   Motor nerve conduction test    S   00215    0.6135            Covered
95903   Motor nerve conduction test    S   00215    0.6135            Covered
95904   Sense nerve conduction test    S   00215    0.6135            Covered
95905   Motor/sens nrve conduct test   S   00215    0.6135            Covered
95920   Intraop nerve test add-on      N                              Covered
95921   Autonomic nerv function test   S   00218    1.1965            Covered
95922   Autonomic nerv function test   S   00215    0.6135            Covered
95923   Autonomic nerv function test   S   00218    1.1965            Covered
95925   Somatosensory testing          S   00216    2.6831            Covered
95926   Somatosensory testing          S   00216    2.6831            Covered
95927   Somatosensory testing          S   00216    2.6831            Covered
95928   C motor evoked, uppr limbs     S   00218    1.1965            Covered
95929   C motor evoked, lwr limbs      S   00218    1.1965            Covered
95930   Visual evoked potential test   S   00216    2.6831            Covered
95933   Blink reflex test              S   00215    0.6135            Covered
95934   H-reflex test                  S   00215    0.6135            Covered
95936   H-reflex test                  S   00215    0.6135            Covered
95937   Neuromuscular junction test    S   00218    1.1965            Covered
95950   Ambulatory eeg monitoring      S   00209   11.4315            Covered
95951   EEG monitoring/videorecord     S   00209   11.4315            Covered
95953   EEG monitoring/computer        S   00209   11.4315            Covered
95954   EEG monitoring/giving drugs    S   00218    1.1965            Covered
95955   EEG during surgery             N                              Covered
95956   Eeg monitoring, cable/radio    S   00209   11.4315            Covered
95957   EEG digital analysis           N                              Covered
95958   EEG monitoring/function test   S   00213    2.4043            Covered
95961   Electrode stimulation, brain   S   00216    2.6831            Covered
95962   Electrode stim, brain add-on   S   00216    2.6831            Covered
95965   Meg, spontaneous               S   00067   52.9891            Covered
95966   Meg, evoked, single            S   00065   14.2808            Covered
95967   Meg, evoked, each add'l        S   00065   14.2808            Covered
95970   Analyze neurostim, no prog     S   00218    1.1965            Covered
95971   Analyze neurostim, simple      S   00692    1.6000            Covered
95972   Analyze neurostim, complex     S   00692    1.6000            Covered
95973   Analyze neurostim, complex     S   00692    1.6000            Covered
95974   Cranial neurostim, complex     S   00692    1.6000            Covered
95975   Cranial neurostim, complex     S    00692   1.6000              Covered
95978   Analyze neurostim brain/1h     S    00692   1.6000              Covered
95979   Analyz neurostim brain addon   S    00692   1.6000              Covered
95980   Io anal gast n-stim init       N                                Covered
95981   Io anal gast n-stim subsq      S    00218   1.1965              Covered
95982   Io ga n-stim subsq w/reprog    S    00692   1.6000              Covered
95990   Spin/brain pump refil & main   S    00439   1.8808              Covered
95991   Spin/brain pump refil & main   S    00439   1.8808              Covered
95992   Canalith repositioning proc    E                              Not Covered
95999   Neurological procedure         S    00215   0.6135              Covered
96000   Motion analysis, video/3d      S    00216   2.6831              Covered
96001   Motion test w/ft press meas    S    00216   2.6831              Covered
96002   Dynamic surface emg            S    00218   1.1965              Covered
96003   Dynamic fine wire emg          S    00215   0.6135              Covered
96004   Phys review of motion tests    B                              Not Covered
96020   Functional brain mapping       N                                Covered
96040   Genetic counseling, 30 min     B                              Not Covered
96101   Psycho testing by psych/phys   Q3   00382   2.6683   $64.12     Covered
96102   Psycho testing by technician   Q3   00382   2.6683              Covered
96103   Psycho testing admin by comp   Q3   00373   0.9758              Covered
96105   Assessment of aphasia          A                     $60.22     Covered
96110   Developmental test, lim        Q3   00373   0.9758              Covered
96111   Developmental test, extend     Q3   00373   0.9758              Covered
96116   Neurobehavioral status exam    Q3   00382   2.6683              Covered
96118   Neuropsych tst by psych/phys   Q3   00382   2.6683              Covered
96119   Neuropsych testing by tec      Q3   00382   2.6683   $64.12     Covered
96120   Neuropsych tst admin w/comp    Q3   00382   2.6683              Covered
96125   Cognitive test by hc pro       A                     $77.40     Covered
96150   Assess hlth/behave, init       Q3   00432   0.6013            Not Covered
96151   Assess hlth/behave, subseq     Q3   00432   0.6013            Not Covered
96152   Intervene hlth/behave, indiv   Q3   00432   0.6013            Not Covered
96153   Intervene hlth/behave, group   Q3   00432   0.6013              Covered
96154   Interv hlth/behav, fam w/pt    Q3   00432   0.6013            Not Covered
96155   Interv hlth/behav fam no pt    E                              Not Covered
96360   Hydration iv infusion, init    S    00438   1.1229              Covered
96361   Hydrate iv infusion, add-on    S    00436   0.3809              Covered
96365   Ther/proph/diag iv inf, init   S    00439   1.8808              Covered
96366   Ther/proph/diag iv inf addon   S    00436   0.3809              Covered
96367   Tx/proph/dg addl seq iv inf    S    00437   0.5555              Covered
96368   Ther/diag concurrent inf       N                                Covered
96369   Sc ther infusion, up to 1 hr   S    00439   1.8808              Covered
96370   Sc ther infusion, addl hr      S    00437   0.5555              Covered
96371   Sc ther infusion, reset pump   S    00436   0.3809              Covered
96372   Ther/proph/diag inj, sc/im     S    00436   0.3809              Covered
96373   Ther/proph/diag inj, ia        S    00437   0.5555              Covered
96374   Ther/proph/diag inj, iv push   S    00437   0.5555              Covered
96375   Tx/pro/dx inj new drug addon   S    00437   0.5555              Covered
96376   Tx/pro/dx inj new drug adon    N                               By Report
96379   Ther/prop/diag inj/inf proc    S    00436   0.3809              Covered
96401   Chemo, anti-neopl, sq/im       S    00437   0.5555              Covered
96402   Chemo hormon antineopl sq/im   S    00437   0.5555              Covered
96405   Chemo intralesional, up to 7   S    00437   0.5555              Covered
96406   Chemo intralesional over 7      S   00439   1.8808             Covered
96409   Chemo, iv push, sngl drug      S    00439   1.8808             Covered
96411   Chemo, iv push, addl drug      S    00438   1.1229             Covered
96413   Chemo, iv infusion, 1 hr       S    00440   3.2632             Covered
96415   Chemo, iv infusion, addl hr     S   00437   0.5555             Covered
96416   Chemo prolong infuse w/pump     S   00440   3.2632             Covered
96417   Chemo iv infus each addl seq    S   00438   1.1229             Covered
96420   Chemo, ia, push tecnique        S   00438   1.1229             Covered
96422   Chemo ia infusion up to 1 hr    S   00440   3.2632             Covered
96423   Chemo ia infuse each addl hr   S    00438   1.1229             Covered
96425   Chemotherapy,infusion method    S   00440   3.2632             Covered
96440   Chemotherapy, intracavitary     S   00439   1.8808             Covered
96445   Chemotherapy, intracavitary     S   00440   3.2632             Covered
96450   Chemotherapy, into CNS          S   00440   3.2632             Covered
96521   Refill/maint, portable pump     S   00439   1.8808             Covered
96522   Refill/maint pump/resvr syst    S   00439   1.8808             Covered
96523   Irrig drug delivery device     Q1   00624   0.6132             Covered
96542   Chemotherapy injection          S   00438   1.1229             Covered
96549   Chemotherapy, unspecified       S   00436   0.3809             Covered
96567   Photodynamic tx, skin           T   00016   2.7982            Not Covered
96570   Photodynamic tx, 30 min         T   00015   1.5412             Covered
96571   Photodynamic tx, addl 15 min    T   00015   1.5412             Covered
96900   Ultraviolet light therapy       S   00001   0.5302             Covered
96902   Trichogram                      N                             Not Covered
96904   Whole body photography          N                             Not Covered
96910   Photochemotherapy with UV-B     S   00001   0.5302             Covered
96912   Photochemotherapy with UV-A     S   00001   0.5302             Covered
96913   Photochemotherapy, UV-A or B    S   00683   2.6790             Covered
96920   Laser tx, skin < 250 sq cm      T   00015   1.5412             Covered
96921   Laser tx, skin 250-500 sq cm    T   00015   1.5412             Covered
96922   Laser tx, skin > 500 sq cm      T   00015   1.5412             Covered
96999   Dermatological procedure        T   00012   0.4436             Covered
97001   Pt evaluation                   A                    $65.97    Covered
97002   Pt re-evaluation                A                    $35.13    Covered
97003   Ot evaluation                   A                    $69.25    Covered
97004   Ot re-evaluation                A                    $46.22    Covered
97005   Athletic train eval             E                             Not Covered
97006   Athletic train reeval           E                             Not Covered
97010   Hot or cold packs therapy       A                     $9.83    Covered
97012   Mechanical traction therapy     A                    $13.26    Covered
97014   Electric stimulation therapy    E                    $13.38    Covered
97016   Vasopneumatic device therapy    A                    $11.69    Covered
97018   Paraffin bath therapy           A                     $6.53    Covered
97022   Whirlpool therapy               A                    $15.38    Covered
97024   Diathermy eg, microwave         A                     $4.16    Covered
97026   Infrared therapy                A                     $4.16    Covered
97028   Ultraviolet therapy             A                     $5.25    Covered
97032   Electrical stimulation          A                    $16.67    Covered
97033   Electric current therapy        A                    $14.21    Covered
97034   Contrast bath therapy           A                    $12.81    Covered
97035   Ultrasound therapy              A                    $10.76    Covered
97036   Hydrotherapy                    A                    $22.20    Covered
97039   Physical therapy treatment     A                    $10.05     Covered
97110   Therapeutic exercises          A                    $25.94     Covered
97112   Neuromuscular reeducation      A                    $27.06     Covered
97113   Aquatic therapy/exercises      A                    $28.28     Covered
97116   Gait training therapy          A                    $22.48     Covered
97124   Massage therapy                A                    $20.39     Covered
97139   Physical medicine procedure    A                    $14.61     Covered
97140   Manual therapy                 A                    $24.27     Covered
97150   Group therapeutic procedures   A                    $17.30     Covered
97530   Therapeutic activities         A                    $32.13     Covered
97532   Cognitive skills development   A                    $22.38     Covered
97533   Sensory integration            A                    $23.72     Covered
97535   Self care mngment training     A                    $29.09     Covered
97537   Community/work reintegration   A                    $23.78     Covered
97542   Wheelchair mngment training    A                    $24.43     Covered
97545   Work hardening                 A                              Not Covered
97546   Work hardening add-on          A                              Not Covered
97597   Active wound care/20 cm or <   T   00015   1.5412              Covered
97598   Active wound care > 20 cm      T   00015   1.5412              Covered
97602   Wound(s) care non-selective    T   00013   0.8789              Covered
97605   Neg press wound tx, < 50 cm    T   00013   0.8789             Not Covered
97606   Neg press wound tx, > 50 cm    T   00015   1.5412             Not Covered
97750   Physical performance test      A                    $25.35     Covered
97755   Assistive technology assess    A                              Not Covered
97760   Orthotic mgmt and training     A                     $27.95    Covered
97761   Prosthetic training            A                     $25.40    Covered
97762   C/o for orthotic/prosth use    A                     $25.49    Covered
97799   Physical medicine procedure    A                    $302.60    Covered
97802   Medical nutrition, indiv, in   A                      $8.19    Covered
97803   Med nutrition, indiv, subseq   A                              Not Covered
97804   Medical nutrition, group       A                              Not Covered
97810   Acupunct w/o stimul 15 min     E                              Not Covered
97811   Acupunct w/o stimul addl 15m   E                              Not Covered
97813   Acupunct w/stimul 15 min       E                              Not Covered
97814   Acupunct w/stimul addl 15m     E                              Not Covered
98925   Osteopathic manipulation       S   00060   0.3808              Covered
98926   Osteopathic manipulation       S   00060   0.3808              Covered
98927   Osteopathic manipulation       S   00060   0.3808              Covered
98928   Osteopathic manipulation       S   00060   0.3808              Covered
98929   Osteopathic manipulation       S   00060   0.3808              Covered
98940   Chiropractic manipulation      S   00060   0.3808             Not Covered
98941   Chiropractic manipulation      S   00060   0.3808             Not Covered
98942   Chiropractic manipulation      S   00060   0.3808             Not Covered
98943   Chiropractic manipulation      E                              Not Covered
98960   Self-mgmt educ & train, 1 pt   E                    $24.28     Covered
98961   Self-mgmt educ/train, 2-4 pt   E                    $24.28     Covered
98962   Self-mgmt educ/train, 5-8 pt   E                    $24.28     Covered
98966   Hc pro phone call 5-10 min     E                              Not Covered
98967   Hc pro phone call 11-20 min    E                              Not Covered
98968   Hc pro phone call 21-30 min    E                              Not Covered
98969   Online service by hc pro       E                              Not Covered
99000   Specimen handling              E                     $3.30     Covered
99001   Specimen handling              E                      $3.30      Covered
99002   Device handling                 B                              Not Covered
99024   Postop follow-up visit          B                              Not Covered
99026   In-hospital on call service     E                              Not Covered
99027   Out-of-hosp on call service     E                              Not Covered
99050   Medical services after hrs      B                              Not Covered
99051   Med serv, eve/wkend/holiday     B                              Not Covered
99053   Med serv 10pm-8am, 24 hr fac    B                              Not Covered
99056   Med service out of office       B                              Not Covered
99058   Office emergency care           B                              Not Covered
99060   Out of office emerg med serv    B                              Not Covered
99070   Special supplies                B                              Not Covered
99071   Patient education materials     B                              Not Covered
99075   Medical testimony               E                              Not Covered
99078   Group health education          N                              Not Covered
99080   Special reports or forms        B                              Not Covered
99082   Unusual physician travel        B                              Not Covered
99090   Computer data analysis          B                              Not Covered
99091   Collect/review data from pt     N                              Not Covered
99100   Special anesthesia service      B                              Not Covered
99116   Anesthesia with hypothermia     B                              Not Covered
99135   Special anesthesia procedure    B                              Not Covered
99140   Emergency anesthesia            B                              Not Covered
99143   Mod cs by same phys, < 5 yrs    N                              Not Covered
99144   Mod cs by same phys, 5 yrs +    N                              Not Covered
99145   Mod cs by same phys add-on      N                              Not Covered
99148   Mod cs diff phys < 5 yrs        N                              Not Covered
99149   Mod cs diff phys 5 yrs +        N                              Not Covered
99150   Mod cs diff phys add-on         N                              Not Covered
99170   Anogenital exam, child          T   00191   0.1320               Covered
99172   Ocular function screen          E                               By Report
99173   Visual acuity screen            E                               By Report
99174   Ocular photoscreening           E                              Not Covered
99175   Induction of vomiting           N                                Covered
99183   Hyperbaric oxygen therapy       B                              Not Covered
99185   Regional hypothermia            D                              Not Covered
99186   Total body hypothermia          D                              Not Covered
99190   Special pump services           C                    $169.88     Covered
99191   Special pump services           C                    $127.40     Covered
99192   Special pump services           C                     $84.94     Covered
99195   Phlebotomy                      X   00624   0.6132               Covered
99199   Special service/proc/report     B                              Not Covered
99201   Office/outpatient visit, new    V   00604   0.8593               Covered
99202   Office/outpatient visit, new    V   00605   1.0337               Covered
99203   Office/outpatient visit, new    V   00606   1.3222               Covered
99204   Office/outpatient visit, new    V   00607   1.6830               Covered
99205   Office/outpatient visit, new   Q3   00608   2.4853               Covered
99211   Office/outpatient visit, est    V   00604   0.8593               Covered
99212   Office/outpatient visit, est    V   00605   1.0337               Covered
99213   Office/outpatient visit, est    V   00605   1.0337               Covered
99214   Office/outpatient visit, est    V   00606   1.3222               Covered
99215   Office/outpatient visit, est   Q3   00607   1.6830               Covered
99217   Observation care discharge      B                              Not Covered
99218   Observation care                B                    $11.25     Covered
99219   Observation care                B                              Not Covered
99220   Observation care                B                              Not Covered
99221   Initial hospital care          B                               Not Covered
99222   Initial hospital care          B                               Not Covered
99223   Initial hospital care          B                               Not Covered
99231   Subsequent hospital care       B                               Not Covered
99232   Subsequent hospital care       B                               Not Covered
99233   Subsequent hospital care       B                               Not Covered
99234   Observ/hosp same date           B                              Not Covered
99235   Observ/hosp same date           B                              Not Covered
99236   Observ/hosp same date           B                              Not Covered
99238   Hospital discharge day         B                               Not Covered
99239   Hospital discharge day         B                               Not Covered
99241   Office consultation             E                     $52.50    Covered
99242   Office consultation             E                     $86.93    Covered
99243   Office consultation             E                    $111.24    Covered
99244   Office consultation             E                    $154.84    Covered
99245   Office consultation             E                    $201.34    Covered
99251   Inpatient consultation          E                     $42.17    Covered
99252   Inpatient consultation          E                     $73.26    Covered
99253   Inpatient consultation          E                     $98.44    Covered
99254   Inpatient consultation          E                    $138.23    Covered
99255   Inpatient consultation          E                    $188.79    Covered
99281   Emergency dept visit            V   00609   0.7886              Covered
99282   Emergency dept visit            V   00613   1.3033              Covered
99283   Emergency dept visit            V   00614   2.0796              Covered
99284   Emergency dept visit           Q3   00615   3.3109              Covered
99285   Emergency dept visit           Q3   00616   4.8917              Covered
99288   Direct advanced life support    B                              Not Covered
99289   Ped crit care transport         D                              Not Covered
99290   Ped crit care transport addl    D                              Not Covered
99291   Critical care, first hour      Q3   00617   7.3492              Covered
99292   Critical care, add'l 30 min     N                               Covered
99293   Ped critical care, initial      D                              Not Covered
99294   Ped critical care, subseq       D                              Not Covered
99295   Neonate crit care, initial      D                              Not Covered
99296   Neonate critical care subseq    D                              Not Covered
99298   Ic for lbw infant < 1500 gm     D                              Not Covered
99299   Ic, lbw infant 1500-2500 gm     D                              Not Covered
99300   Ic, infant pbw 2501-5000 gm     D                              Not Covered
99304   Nursing facility care, init     B                              Not Covered
99305   Nursing facility care, init     B                              Not Covered
99306   Nursing facility care, init     B                              Not Covered
99307   Nursing fac care, subseq        B                              Not Covered
99308   Nursing fac care, subseq        B                              Not Covered
99309   Nursing fac care, subseq        B                              Not Covered
99310   Nursing fac care, subseq        B                              Not Covered
99315   Nursing fac discharge day       B                              Not Covered
99316   Nursing fac discharge day       B                              Not Covered
99318   Annual nursing fac assessmnt    B                              Not Covered
99324   Domicil/r-home visit new pat   B             Not Covered
99325   Domicil/r-home visit new pat   B             Not Covered
99326   Domicil/r-home visit new pat   B             Not Covered
99327   Domicil/r-home visit new pat   B             Not Covered
99328   Domicil/r-home visit new pat   B             Not Covered
99334   Domicil/r-home visit est pat   B             Not Covered
99335   Domicil/r-home visit est pat   B             Not Covered
99336   Domicil/r-home visit est pat   B             Not Covered
99337   Domicil/r-home visit est pat   B             Not Covered
99339   Domicil/r-home care supervis   B             Not Covered
99340   Domicil/r-home care supervis   B             Not Covered
99341   Home visit, new patient        B             Not Covered
99342   Home visit, new patient        B             Not Covered
99343   Home visit, new patient        B             Not Covered
99344   Home visit, new patient        B             Not Covered
99345   Home visit, new patient        B             Not Covered
99347   Home visit, est patient        B             Not Covered
99348   Home visit, est patient        B             Not Covered
99349   Home visit, est patient        B             Not Covered
99350   Home visit, est patient        B             Not Covered
99354   Prolonged service, office      N              Covered
99355   Prolonged service, office      N              Covered
99356   Prolonged service, inpatient   C   $88.99     Covered
99357   Prolonged service, inpatient   C   $89.57     Covered
99358   Prolonged serv, w/o contact    N             Not Covered
99359   Prolonged serv, w/o contact    N             Not Covered
99360   Physician standby services     B             Not Covered
99363   Anticoag mgmt, init            B             Not Covered
99364   Anticoag mgmt, subseq          B             Not Covered
99366   Team conf w/pat by hc pro      N             Not Covered
99367   Team conf w/o pat by phys      N             Not Covered
99368   Team conf w/o pat by hc pro    N             Not Covered
99374   Home health care supervision   B             Not Covered
99375   Home health care supervision   E             Not Covered
99377   Hospice care supervision       B             Not Covered
99378   Hospice care supervision       E             Not Covered
99379   Nursing fac care supervision   B             Not Covered
99380   Nursing fac care supervision   B             Not Covered
99381   Init pm e/m, new pat, inf      E    $92.47    Covered
99382   Init pm e/m, new pat 1-4 yrs   E    $99.24    Covered
99383   Prev visit, new, age 5-11      E    $98.57    Covered
99384   Prev visit, new, age 12-17     E   $109.70    Covered
99385   Prev visit, new, age 18-39     E   $106.35    Covered
99386   Prev visit, new, age 40-64     E   $128.08    Covered
99387   Init pm e/m, new pat 65+ yrs   E   $139.68    Covered
99391   Per pm reeval, est pat, inf    E    $75.46    Covered
99392   Prev visit, est, age 1-4       E    $83.30    Covered
99393   Prev visit, est, age 5-11      E    $82.97    Covered
99394   Prev visit, est, age 12-17     E    $93.87    Covered
99395   Prev visit, est, age 18-39     E    $91.52    Covered
99396   Prev visit, est, age 40-64     E   $102.00    Covered
99397   Per pm reeval est pat 65+ yr   E   $112.92    Covered
99401   Preventive counseling, indiv   E                              Not Covered
99402   Preventive counseling, indiv   E                    $20.81      Covered
99403   Preventive counseling, indiv   E                              Not Covered
99404   Preventive counseling, indiv   E                              Not Covered
99406   Behav chng smoking 3-10 min    X   00031   0.3448             Not Covered
99407   Behav chng smoking > 10 min    X   00031   0.3448             Not Covered
99408   Audit/dast, 15-30 min          E                              Not Covered
99409   Audit/dast, over 30 min        E                              Not Covered
99411   Preventive counseling, group   E                              Not Covered
99412   Preventive counseling, group   E                              Not Covered
99420   Health risk assessment test    E                              Not Covered
99429   Unlisted preventive service    E                              Not Covered
99431   Initial care, normal newborn   D                              Not Covered
99432   Newborn care, not in hosp      D                              Not Covered
99433   Normal newborn care/hospital   D                              Not Covered
99435   Newborn discharge day hosp     D                              Not Covered
99436   Attendance, birth              D                              Not Covered
99440   Newborn resuscitation          D                              Not Covered
99441   Phone e/m by phys 5-10 min     E                              Not Covered
99442   Phone e/m by phys 11-20 min    E                              Not Covered
99443   Phone e/m by phys 21-30 min    E                              Not Covered
99444   Online e/m by phys             E                              Not Covered
99450   Basic life disability exam     E                               By Report
99455   Work related disability exam   B                              Not Covered
99456   Disability examination         B                              Not Covered
99460   Init nb em per day, hosp       V   00605   1.0337               Covered
99461   Init nb em per day, non-fac    M                     $0.00      Covered
99462   Sbsq nb em per day, hosp       C                    $38.54      Covered
99463   Same day nb discharge          V   00605   1.0337               Covered
99464   Attendance at delivery         N                                Covered
99465   Nb resuscitation               S   00094   2.4553               Covered
99466   Ped crit care transport        N                                Covered
99467   Ped crit care transport addl   N                                Covered
99468   Neonate crit care, initial     C                    $772.46     Covered
99469   Neonate crit care, subsq       C                    $386.18     Covered
99471   Ped critical care, initial     C                    $772.46     Covered
99472   Ped critical care, subsq       C                    $386.18     Covered
99475   Ped crit care age 2-5, init    C                    $506.91     Covered
99476   Ped crit care age 2-5, subsq   C                    $302.74     Covered
99477   Init day hosp neonate care     C                              Not Covered
99478   Ic, lbw inf < 1500 gm subsq    C                    $139.86     Covered
99479   Ic lbw inf 1500-2500 g subsq   C                    $127.74     Covered
99480   Ic inf pbw 2501-5000 g subsq   C                    $123.04     Covered
99499   Unlisted e&m service           B                              Not Covered
99500   Home visit, prenatal           E                              Not Covered
99501   Home visit, postnatal          E                              Not Covered
99502   Home visit, nb care            E                              Not Covered
99503   Home visit, resp therapy       E                              Not Covered
99504   Home visit mech ventilator     E                              Not Covered
99505   Home visit, stoma care         E                              Not Covered
99506   Home visit, im injection       E                              Not Covered
99507   Home visit, cath maintain      E                              Not Covered
99509   Home visit day life activity   E           Not Covered
99510   Home visit, sing/m/fam couns   E           Not Covered
99511   Home visit, fecal/enema mgmt   E           Not Covered
99512   Home visit for hemodialysis    E           Not Covered
99600   Home visit nos                 E           Not Covered
99601   Home infusion/visit, 2 hrs     E           Not Covered
99602   Home infusion, each addtl hr   E           Not Covered
99605   Mtms by pharm, np, 15 min      E           Not Covered
99606   Mtms by pharm, est, 15 min     E           Not Covered
99607   Mtms by pharm, addl 15 min     E           Not Covered
A0021   Outside state ambulance serv   E           Not Covered
A0080   Noninterest escort in non er   E           Not Covered
A0090   Interest escort in non er      E           Not Covered
A0100   Nonemergency transport taxi    E           Not Covered
A0110   Nonemergency transport bus     E           Not Covered
A0120   Noner transport mini-bus       E           Not Covered
A0130   Noner transport wheelch van    E           Not Covered
A0140   Nonemergency transport air     E           Not Covered
A0160   Noner transport case worker    E           Not Covered
A0170   Transport parking fees/tolls   E           Not Covered
A0180   Noner transport lodgng recip   E           Not Covered
A0190   Noner transport meals recip    E           Not Covered
A0200   Noner transport lodgng escrt   E           Not Covered
A0210   Noner transport meals escort   E           Not Covered
A0225   Neonatal emergency transport   E           Not Covered
A0380   Basic life support mileage     E           Not Covered
A0382   Basic support routine suppls   A           Not Covered
A0384   Bls defibrillation supplies    A           Not Covered
A0390   Advanced life support mileag   E           Not Covered
A0392   Als defibrillation supplies    A           Not Covered
A0394   Als IV drug therapy supplies   A           Not Covered
A0396   Als esophageal intub suppls    A           Not Covered
A0398   Als routine disposble suppls   A           Not Covered
A0420   Ambulance waiting 1/2 hr       A           Not Covered
A0422   Ambulance 02 life sustaining   A           Not Covered
A0424   Extra ambulance attendant      A           Not Covered
A0425   Ground mileage                 A           Not Covered
A0426   Als 1                          A           Not Covered
A0427   ALS1-emergency                 A           Not Covered
A0428   bls                            A           Not Covered
A0429   BLS-emergency                  A           Not Covered
A0430   Fixed wing air transport       A           Not Covered
A0431   Rotary wing air transport      A           Not Covered
A0432   PI volunteer ambulance co      A           Not Covered
A0433   als 2                          A           Not Covered
A0434   Specialty care transport       A           Not Covered
A0435   Fixed wing air mileage         A           Not Covered
A0436   Rotary wing air mileage        A           Not Covered
A0888   Noncovered ambulance mileage   E           Not Covered
A0998   Ambulance response/treatment   E           Not Covered
A0999   Unlisted ambulance service     A           Not Covered
A4206   1 CC sterile syringe&needle    E   $0.31    Covered
A4207   2 CC sterile syringe&needle    E            Not Covered
A4208   3 CC sterile syringe&needle    E   $0.16      Covered
A4209   5+ CC sterile syringe&needle   E   $0.32      Covered
A4210   Nonneedle injection device     E            Not Covered
A4211   Supp for self-adm injections   E            Not Covered
A4212   Non coring needle or stylet    B            Not Covered
A4213   20+ CC syringe only            E   $1.01      Covered
A4215   Sterile needle                 E   $0.23      Covered
A4216   Sterile water/saline, 10 ml    A            Not Covered
A4217   Sterile water/saline, 500 ml   A            Not Covered
A4218   Sterile saline or water        N            Not Covered
A4220   Infusion pump refill kit       N            Not Covered
A4221   Maint drug infus cath per wk   Y            Not Covered
A4222   Infusion supplies with pump    Y   $44.17     Covered
A4223   Infusion supplies w/o pump     E            Not Covered
A4230   Infus insulin pump non needl   N            Not Covered
A4231   Infusion insulin pump needle   N            Not Covered
A4232   Syringe w/needle insulin 3cc   E            Not Covered
A4233   Alkalin batt for glucose mon   Y            Not Covered
A4234   J-cell batt for glucose mon    Y            Not Covered
A4235   Lithium batt for glucose mon   Y            Not Covered
A4236   Silvr oxide batt glucose mon   Y            Not Covered
A4244   Alcohol or peroxide per pint   E   $3.05      Covered
A4245   Alcohol wipes per box          E   $0.05      Covered
A4246   Betadine/phisohex solution     E   $3.55      Covered
A4247   Betadine/iodine swabs/wipes    E   $0.10      Covered
A4248   Chlorhexidine antisept         N            Not Covered
A4250   Urine reagent strips/tablets   E            Not Covered
A4252   Blood ketone test or strip     E             By Report
A4253   Blood glucose/reagent strips   Y            Not Covered
A4255   Glucose monitor platforms      Y    $4.11     Covered
A4256   Calibrator solution/chips      Y   $11.44     Covered
A4257   Replace Lensshield Cartridge   Y            Not Covered
A4258   Lancet device each             Y            Not Covered
A4259   Lancets per box                Y            Not Covered
A4261   Cervical cap contraceptive     E            Not Covered
A4262   Temporary tear duct plug       N            Not Covered
A4263   Permanent tear duct plug       N            Not Covered
A4264   Intratubal occlusion device    E             By Report
A4265   Paraffin                       Y            Not Covered
A4266   Diaphragm                      E            Not Covered
A4267   Male condom                    E            Not Covered
A4268   Female condom                  E            Not Covered
A4269   Spermicide                     E            Not Covered
A4270   Disposable endoscope sheath    N            Not Covered
A4280   Brst prsths adhsv attchmnt     A            Not Covered
A4281   Replacement breastpump tube    E             By Report
A4282   Replacement breastpump adpt    E            Not Covered
A4283   Replacement breastpump cap     E            Not Covered
A4284   Replcmnt breast pump shield    E            Not Covered
A4285   Replcmnt breast pump bottle    E            Not Covered
A4286   Replcmnt breastpump lok ring   E            Not Covered
A4290   Sacral nerve stim test lead    B            Not Covered
A4300   Cath impl vasc access portal   N            Not Covered
A4301   Implantable access syst perc   N            Not Covered
A4305   Drug delivery system >=50 ML   N            Not Covered
A4306   Drug delivery system <=50 ml   N            Not Covered
A4310   Insert tray w/o bag/cath       A            Not Covered
A4311   Catheter w/o bag 2-way latex   A            Not Covered
A4312   Cath w/o bag 2-way silicone    A            Not Covered
A4313   Catheter w/bag 3-way           A            Not Covered
A4314   Cath w/drainage 2-way latex    A            Not Covered
A4315   Cath w/drainage 2-way silcne   A            Not Covered
A4316   Cath w/drainage 3-way          A            Not Covered
A4320   Irrigation tray                A            Not Covered
A4321   Cath therapeutic irrig agent   A            Not Covered
A4322   Irrigation syringe             A            Not Covered
A4326   Male external catheter         A            Not Covered
A4327   Fem urinary collect dev cup    A            Not Covered
A4328   Fem urinary collect pouch      A            Not Covered
A4330   Stool collection pouch         A   $7.15      Covered
A4331   Extension drainage tubing      A   $3.18      Covered
A4332   Lube sterile packet            A            Not Covered
A4333   Urinary cath anchor device     A   $2.20      Covered
A4334   Urinary cath leg strap         A   $4.93      Covered
A4335   Incontinence supply            A             By Report
A4336   Urethral insert                A             By Report
A4338   Indwelling catheter latex      A   $12.26     Covered
A4340   Indwelling catheter special    A   $30.35     Covered
A4344   Cath indw foley 2 way silicn   A   $16.02     Covered
A4346   Cath indw foley 3 way          A   $19.59     Covered
A4349   Disposable male external cat   A    $2.02     Covered
A4351   Straight tip urine catheter    A    $1.81     Covered
A4352   Coude tip urinary catheter     A    $6.42     Covered
A4353   Intermittent urinary cath      A    $7.00     Covered
A4354   Cath insertion tray w/bag      A   $11.80     Covered
A4355   Bladder irrigation tubing      A    $8.82     Covered
A4356   Ext ureth clmp or compr dvc    A   $43.34     Covered
A4357   Bedside drainage bag           A    $9.12     Covered
A4358   Urinary leg or abdomen bag     A    $5.64     Covered
A4360   Disposable ext urethral dev    A    $0.49     Covered
A4361   Ostomy face plate              A   $15.61     Covered
A4362   Solid skin barrier             A    $3.46     Covered
A4363   Ostomy clamp, replacement      A    $2.36     Covered
A4364   Adhesive, liquid or equal      A    $2.93     Covered
A4365   Adhesive remover wipes         D            Not Covered
A4366   Ostomy vent                    A            Not Covered
A4367   Ostomy belt                    A            Not Covered
A4368   Ostomy filter                  A   $0.26      Covered
A4369   Skin barrier liquid per oz     A            Not Covered
A4371   Skin barrier powder per oz     A            Not Covered
A4372   Skin barrier solid 4x4 equiv   A            Not Covered
A4373   Skin barrier with flange       A            Not Covered
A4375   Drainable plastic pch w fcpl   A            Not Covered
A4376   Drainable rubber pch w fcplt   A            Not Covered
A4377   Drainable plstic pch w/o fp    A            Not Covered
A4378   Drainable rubber pch w/o fp    A            Not Covered
A4379   Urinary plastic pouch w fcpl   A            Not Covered
A4380   Urinary rubber pouch w fcplt   A            Not Covered
A4381   Urinary plastic pouch w/o fp   A            Not Covered
A4382   Urinary hvy plstc pch w/o fp   A   $24.62    Covered
A4383   Urinary rubber pouch w/o fp    A            Not Covered
A4384   Ostomy faceplt/silicone ring   A            Not Covered
A4385   Ost skn barrier sld ext wear   A            Not Covered
A4387   Ost clsd pouch w att st barr   A            Not Covered
A4388   Drainable pch w ex wear barr   A            Not Covered
A4389   Drainable pch w st wear barr   A            Not Covered
A4390   Drainable pch ex wear convex   A            Not Covered
A4391   Urinary pouch w ex wear barr   A            Not Covered
A4392   Urinary pouch w st wear barr   A            Not Covered
A4393   Urine pch w ex wear bar conv   A            Not Covered
A4394   Ostomy pouch liq deodorant     A            Not Covered
A4395   Ostomy pouch solid deodorant   A            Not Covered
A4396   Peristomal hernia supprt blt   A            Not Covered
A4397   Irrigation supply sleeve       A            Not Covered
A4398   Ostomy irrigation bag          A            Not Covered
A4399   Ostomy irrig cone/cath w brs   A   $10.42    Covered
A4400   Ostomy irrigation set          A            Not Covered
A4402   Lubricant per ounce            A            Not Covered
A4404   Ostomy ring each               A            Not Covered
A4405   Nonpectin based ostomy paste   A            Not Covered
A4406   Pectin based ostomy paste      A            Not Covered
A4407   Ext wear ost skn barr <=4sq"   A            Not Covered
A4408   Ext wear ost skn barr >4sq"    A            Not Covered
A4409   Ost skn barr convex <=4 sq i   A            Not Covered
A4410   Ost skn barr extnd >4 sq       A            Not Covered
A4411   Ost skn barr extnd =4sq        A   $5.10     Covered
A4412   Ost pouch drain high output    A   $2.70     Covered
A4413   2 pc drainable ost pouch       A            Not Covered
A4414   Ost sknbar w/o conv<=4 sq in   A            Not Covered
A4415   Ost skn barr w/o conv >4 sqi   A            Not Covered
A4416   Ost pch clsd w barrier/filtr   A            Not Covered
A4417   Ost pch w bar/bltinconv/fltr   A            Not Covered
A4418   Ost pch clsd w/o bar w filtr   A            Not Covered
A4419   Ost pch for bar w flange/flt   A            Not Covered
A4420   Ost pch clsd for bar w lk fl   A            Not Covered
A4421   Ostomy supply misc             E            Not Covered
A4422   Ost pouch absorbent material   A            Not Covered
A4423   Ost pch for bar w lk fl/fltr   A            Not Covered
A4424   Ost pch drain w bar & filter   A            Not Covered
A4425   Ost pch drain for barrier fl   A            Not Covered
A4426   Ost pch drain 2 piece system   A            Not Covered
A4427   Ost pch drain/barr lk flng/f   A            Not Covered
A4428   Urine ost pouch w faucet/tap   A            Not Covered
A4429   Urine ost pouch w bltinconv    A            Not Covered
A4430   Ost urine pch w b/bltin conv   A            Not Covered
A4431   Ost pch urine w barrier/tapv   A            Not Covered
A4432   Os pch urine w bar/fange/tap   A            Not Covered
A4433   Urine ost pch bar w lock fln   A            Not Covered
A4434   Ost pch urine w lock flng/ft   A            Not Covered
A4450   Non-waterproof tape            A            Not Covered
A4452   Waterproof tape                A            Not Covered
A4455   Adhesive remover per ounce     A            Not Covered
A4456   Adhesive remover, wipes        A   $0.26      Covered
A4458   Reusable enema bag             E            Not Covered
A4461   Surgicl dress hold non-reuse   A            Not Covered
A4463   Surgical dress holder reuse    A            Not Covered
A4465   Non-elastic extremity binder   N            Not Covered
A4466   Elastic garment/covering       E             By Report
A4470   Gravlee jet washer             N            Not Covered
A4480   Vabra aspirator                N            Not Covered
A4481   Tracheostoma filter            A    $0.38     Covered
A4483   Moisture exchanger             A    $0.00     Covered
A4490   Above knee surgical stocking   E    $7.79     Covered
A4495   Thigh length surg stocking     E   $12.11     Covered
A4500   Below knee surgical stocking   E            Not Covered
A4510   Full length surg stocking      E            Not Covered
A4520   Incontinence garment anytype   E            Not Covered
A4550   Surgical trays                 B            Not Covered
A4554   Disposable underpads           E            Not Covered
A4556   Electrodes, pair               Y            Not Covered
A4557   Lead wires, pair               Y            Not Covered
A4558   Conductive gel or paste        Y   $5.30      Covered
A4559   Coupling gel or paste          Y             By Report
A4561   Pessary rubber, any type       N              Covered
A4562   Pessary, non rubber,any type   N            Not Covered
A4565   Slings                         N              Covered
A4570   Splint                         E   $7.49      Covered
A4575   Hyperbaric o2 chamber disps    E            Not Covered
A4580   Cast supplies (plaster)        E             By Report
A4590   Special casting material       E            Not Covered
A4595   TENS suppl 2 lead per month    Y            Not Covered
A4600   Sleeve, inter limb comp dev    Y            Not Covered
A4601   Lith ion batt, non-pros use    Y            Not Covered
A4604   Tubing with heating element    Y            Not Covered
A4605   Trach suction cath close sys   Y   $16.40     Covered
A4606   Oxygen probe used w oximeter   A            Not Covered
A4608   Transtracheal oxygen cath      Y            Not Covered
A4611   Heavy duty battery             Y            Not Covered
A4612   Battery cables                 Y            Not Covered
A4613   Battery charger                Y            Not Covered
A4614   Hand-held PEFR meter           Y   $31.98     Covered
A4615   Cannula nasal                  Y    $0.83     Covered
A4616   Tubing (oxygen) per foot       Y            Not Covered
A4617   Mouth piece                    Y            Not Covered
A4618   Breathing circuits             Y   $6.54      Covered
A4619   Face tent                      Y   $1.21      Covered
A4620   Variable concentration mask    Y            Not Covered
A4623   Tracheostomy inner cannula     A   $5.57      Covered
A4624   Tracheal suction tube          Y            Not Covered
A4625   Trach care kit for new trach   A   $5.89      Covered
A4626   Tracheostomy cleaning brush    A   $3.19      Covered
A4627   Spacer bag/reservoir           E            Not Covered
A4628   Oropharyngeal suction cath     Y            Not Covered
A4629   Tracheostomy care kit          A            Not Covered
A4630   Repl bat t.e.n.s. own by pt    Y            Not Covered
A4633   Uvl replacement bulb           Y            Not Covered
A4634   Replacement bulb th lightbox   A            Not Covered
A4635   Underarm crutch pad            Y            Not Covered
A4636   Handgrip for cane etc          Y            Not Covered
A4637   Repl tip cane/crutch/walker    Y            Not Covered
A4638   Repl batt pulse gen sys        Y            Not Covered
A4639   Infrared ht sys replcmnt pad   Y            Not Covered
A4640   Alternating pressure pad       Y   $63.32     Covered
A4641   Radiopharm dx agent noc        N              Covered
A4642   In111 satumomab                N              Covered
A4648   Implantable tissue marker      N            Not Covered
A4649   Surgical supplies              N             By Report
A4650   Implant radiation dosimeter    N            Not Covered
A4651   Calibrated microcap tube       A            Not Covered
A4652   Microcapillary tube sealant    A            Not Covered
A4653   PD catheter anchor belt        A            Not Covered
A4657   Syringe w/wo needle            N            Not Covered
A4660   Sphyg/bp app w cuff and stet   N            Not Covered
A4663   Dialysis blood pressure cuff   N             By Report
A4670   Automatic bp monitor, dial     E   $51.45     Covered
A4671   Disposable cycler set          B            Not Covered
A4672   Drainage ext line, dialysis    B            Not Covered
A4673   Ext line w easy lock connect   B            Not Covered
A4674   Chem/antisept solution, 8oz    B            Not Covered
A4680   Activated carbon filter, ea    N            Not Covered
A4690   Dialyzer, each                 N            Not Covered
A4706   Bicarbonate conc sol per gal   N            Not Covered
A4707   Bicarbonate conc pow per pac   N            Not Covered
A4708   Acetate conc sol per gallon    N            Not Covered
A4709   Acid conc sol per gallon       N            Not Covered
A4714   Treated water per gallon       N            Not Covered
A4719   "Y set" tubing                 N            Not Covered
A4720   Dialysat sol fld vol > 249cc   N             By Report
A4721   Dialysat sol fld vol > 999cc   N             By Report
A4722   Dialys sol fld vol > 1999cc    N             By Report
A4723   Dialys sol fld vol > 2999cc    N             By Report
A4724   Dialys sol fld vol > 3999cc    N             By Report
A4725   Dialys sol fld vol > 4999cc    N             By Report
A4726   Dialys sol fld vol > 5999cc    N             By Report
A4728   Dialysate solution, non-dex    B            Not Covered
A4730   Fistula cannulation set, ea    N            Not Covered
A4736   Topical anesthetic, per gram   N             By Report
A4737   Inj anesthetic per 10 ml       N             By Report
A4740   Shunt accessory                N            Not Covered
A4750   Art or venous blood tubing     N            Not Covered
A4755   Comb art/venous blood tubing   N            Not Covered
A4760   Dialysate sol test kit, each   N            Not Covered
A4765   Dialysate conc pow per pack    N            Not Covered
A4766   Dialysate conc sol add 10 ml   N             By Report
A4770   Blood collection tube/vacuum   N            Not Covered
A4771   Serum clotting time tube       N            Not Covered
A4772   Blood glucose test strips      N            Not Covered
A4773   Occult blood test strips       N            Not Covered
A4774   Ammonia test strips            N            Not Covered
A4802   Protamine sulfate per 50 mg    N            Not Covered
A4860   Disposable catheter tips       N            Not Covered
A4870   Plumb/elec wk hm hemo equip    N            Not Covered
A4890   Repair/maint cont hemo equip   N            Not Covered
A4911   Drain bag/bottle               N             By Report
A4913   Misc dialysis supplies noc     N            Not Covered
A4918   Venous pressure clamp          N            Not Covered
A4927   Non-sterile gloves             N            Not Covered
A4928   Surgical mask                  N              Covered
A4929   Tourniquet for dialysis, ea    N             By Report
A4930   Sterile, gloves per pair       N            Not Covered
A4931   Reusable oral thermometer      N            Not Covered
A4932   Reusable rectal thermometer    E            Not Covered
A5051   Pouch clsd w barr attached     A            Not Covered
A5052   Clsd ostomy pouch w/o barr     A            Not Covered
A5053   Clsd ostomy pouch faceplate    A            Not Covered
A5054   Clsd ostomy pouch w/flange     A            Not Covered
A5055   Stoma cap                      A            Not Covered
A5061   Pouch drainable w barrier at   A            Not Covered
A5062   Drnble ostomy pouch w/o barr   A   $2.09      Covered
A5063   Drain ostomy pouch w/flange    A            Not Covered
A5071   Urinary pouch w/barrier        A            Not Covered
A5072   Urinary pouch w/o barrier      A    $3.52     Covered
A5073   Urinary pouch on barr w/flng   A    $3.13     Covered
A5081   Continent stoma plug           A    $3.30     Covered
A5082   Continent stoma catheter       A   $10.11     Covered
A5083   Stoma absorptive cover         A            Not Covered
A5093   Ostomy accessory convex inse   A    $1.95     Covered
A5102   Bedside drain btl w/wo tube    A   $22.42     Covered
A5105   Urinary suspensory             A   $40.76     Covered
A5112   Urinary leg bag                A            Not Covered
A5113   Latex leg strap                A    $4.70     Covered
A5114   Foam/fabric leg strap          A    $7.60     Covered
A5120   Skin barrier, wipe or swab     A    $0.24     Covered
A5121   Solid skin barrier 6x6         A    $7.46     Covered
A5122   Solid skin barrier 8x8         A   $12.85     Covered
A5126   Disk/foam pad +or- adhesive    A            Not Covered
A5131   Appliance cleaner              A   $13.48     Covered
A5200   Percutaneous catheter anchor   A   $11.29     Covered
A5500   Diab shoe for density insert   Y            Not Covered
A5501   Diabetic custom molded shoe    Y            Not Covered
A5503   Diabetic shoe w/roller/rockr   Y            Not Covered
A5504   Diabetic shoe with wedge       Y             Not Covered
A5505   Diab shoe w/metatarsal bar     Y             Not Covered
A5506   Diabetic shoe w/off set heel   Y             Not Covered
A5507   Modification diabetic shoe     Y             Not Covered
A5508   Diabetic deluxe shoe           Y             Not Covered
A5510   Compression form shoe insert   E             Not Covered
A5512   Multi den insert direct form   Y             Not Covered
A5513   Multi den insert custom mold   Y             Not Covered
A6000   Wound warming wound cover      E             Not Covered
A6010   Collagen based wound filler    A   $30.96      Covered
A6011   Collagen gel/paste wound fil   A             Not Covered
A6021   Collagen dressing <=16 sq in   A    $21.02     Covered
A6022   Collagen drsg>6<=48 sq in      A    $21.02     Covered
A6023   Collagen dressing >48 sq in    A   $190.30     Covered
A6024   Collagen dsg wound filler      A     $6.19     Covered
A6025   Silicone gel sheet, each       E              By Report
A6154   Wound pouch each               A   $14.36      Covered
A6196   Alginate dressing <=16 sq in   A    $7.35      Covered
A6197   Alginate drsg >16 <=48 sq in   A   $16.44      Covered
A6198   alginate dressing > 48 sq in   A              By Report
A6199   Alginate drsg wound filler     A    $5.29      Covered
A6200   Compos drsg <=16 no border     D             Not Covered
A6201   Compos drsg >16<=48 no bdr     D             Not Covered
A6202   Compos drsg >48 no border      D             Not Covered
A6203   Composite drsg <= 16 sq in     A    $3.35      Covered
A6204   Composite drsg >16<=48 sq in   A    $6.23      Covered
A6205   Composite drsg > 48 sq in      A              By Report
A6206   Contact layer <= 16 sq in      A              By Report
A6207   Contact layer >16<= 48 sq in   A    $7.34      Covered
A6208   Contact layer > 48 sq in       A              By Report
A6209   Foam drsg <=16 sq in w/o bdr   A    $7.48      Covered
A6210   Foam drg >16<=48 sq in w/o b   A   $19.92      Covered
A6211   Foam drg > 48 sq in w/o brdr   A   $29.37      Covered
A6212   Foam drg <=16 sq in w/border   A    $9.70      Covered
A6213   Foam drg >16<=48 sq in w/bdr   A              By Report
A6214   Foam drg > 48 sq in w/border   A   $10.29      Covered
A6215   Foam dressing wound filler     A              By Report
A6216   Non-sterile gauze<=16 sq in    A    $0.05      Covered
A6217   Non-sterile gauze>16<=48 sq    A              By Report
A6218   Non-sterile gauze > 48 sq in   A              By Report
A6219   Gauze <= 16 sq in w/border     A    $0.95      Covered
A6220   Gauze >16 <=48 sq in w/bordr   A    $2.58      Covered
A6221   Gauze > 48 sq in w/border      A              By Report
A6222   Gauze <=16 in no w/sal w/o b   A    $2.13      Covered
A6223   Gauze >16<=48 no w/sal w/o b   A    $2.42      Covered
A6224   Gauze > 48 in no w/sal w/o b   A    $3.61      Covered
A6228   Gauze <= 16 sq in water/sal    A              By Report
A6229   Gauze >16<=48 sq in watr/sal   A    $3.61      Covered
A6230   Gauze > 48 sq in water/salne   A              By Report
A6231   Hydrogel dsg<=16 sq in         A    $4.68      Covered
A6232   Hydrogel dsg>16<=48 sq in      A    $6.88      Covered
A6233   Hydrogel dressing >48 sq in    A   $19.19      Covered
A6234   Hydrocolld drg <=16 w/o bdr    A    $6.54     Covered
A6235   Hydrocolld drg >16<=48 w/o b   A   $16.82     Covered
A6236   Hydrocolld drg > 48 in w/o b   A   $27.25     Covered
A6237   Hydrocolld drg <=16 in w/bdr   A    $7.91     Covered
A6238   Hydrocolld drg >16<=48 w/bdr   A   $22.79     Covered
A6239   Hydrocolld drg > 48 in w/bdr   A             By Report
A6240   Hydrocolld drg filler paste    A   $12.24     Covered
A6241   Hydrocolloid drg filler dry    A    $2.57     Covered
A6242   Hydrogel drg <=16 in w/o bdr   A    $6.07     Covered
A6243   Hydrogel drg >16<=48 w/o bdr   A   $12.31     Covered
A6244   Hydrogel drg >48 in w/o bdr    A   $39.28     Covered
A6245   Hydrogel drg <= 16 in w/bdr    A    $7.27     Covered
A6246   Hydrogel drg >16<=48 in w/b    A    $9.92     Covered
A6247   Hydrogel drg > 48 sq in w/b    A   $23.78     Covered
A6248   Hydrogel drsg gel filler       A   $16.24     Covered
A6250   Skin seal protect moisturizr   A             By Report
A6251   Absorpt drg <=16 sq in w/o b   A   $1.99      Covered
A6252   Absorpt drg >16 <=48 w/o bdr   A   $3.25      Covered
A6253   Absorpt drg > 48 sq in w/o b   A   $6.34      Covered
A6254   Absorpt drg <=16 sq in w/bdr   A   $1.21      Covered
A6255   Absorpt drg >16<=48 in w/bdr   A   $3.03      Covered
A6256   Absorpt drg > 48 sq in w/bdr   A             By Report
A6257   Transparent film <= 16 sq in   A    $1.53     Covered
A6258   Transparent film >16<=48 in    A    $4.30     Covered
A6259   Transparent film > 48 sq in    A   $10.94     Covered
A6260   Wound cleanser any type/size   A             By Report
A6261   Wound filler gel/paste /oz     A             By Report
A6262   Wound filler dry form / gram   A             By Report
A6266   Impreg gauze no h20/sal/yard   A   $1.92      Covered
A6402   Sterile gauze <= 16 sq in      A   $0.12      Covered
A6403   Sterile gauze>16 <= 48 sq in   A   $0.43      Covered
A6404   Sterile gauze > 48 sq in       A             By Report
A6407   Packing strips, non-impreg     A            Not Covered
A6410   Sterile eye pad                A            Not Covered
A6411   Non-sterile eye pad            A            Not Covered
A6412   Occlusive eye patch            E            Not Covered
A6413   Adhesive bandage, first-aid    E            Not Covered
A6441   Pad band w>=3" <5"/yd          A            Not Covered
A6442   Conform band n/s w<3"/yd       A            Not Covered
A6443   Conform band n/s w>=3"<5"/yd   A            Not Covered
A6444   Conform band n/s w>=5"/yd      A            Not Covered
A6445   Conform band s w <3"/yd        A            Not Covered
A6446   Conform band s w>=3" <5"/yd    A            Not Covered
A6447   Conform band s w >=5"/yd       A            Not Covered
A6448   Lt compres band <3"/yd         A            Not Covered
A6449   Lt compres band >=3" <5"/yd    A            Not Covered
A6450   Lt compres band >=5"/yd        A            Not Covered
A6451   Mod compres band w>=3"<5"/yd   A            Not Covered
A6452   High compres band w>=3"<5"yd   A            Not Covered
A6453   Self-adher band w <3"/yd       A            Not Covered
A6454   Self-adher band w>=3" <5"/yd   A            Not Covered
A6455   Self-adher band >=5"/yd        A            Not Covered
A6456   Zinc paste band w >=3"<5"/yd   A             Not Covered
A6457   Tubular dressing               A             Not Covered
A6501   Compres burngarment bodysuit   A              By Report
A6502   Compres burngarment chinstrp   A              By Report
A6503   Compres burngarment facehood   A              By Report
A6504   Cmprsburngarment glove-wrist   A              By Report
A6505   Cmprsburngarment glove-elbow   A              By Report
A6506   Cmprsburngrmnt glove-axilla    A              By Report
A6507   Cmprs burngarment foot-knee    A              By Report
A6508   Cmprs burngarment foot-thigh   A              By Report
A6509   Compres burn garment jacket    A              By Report
A6510   Compres burn garment leotard   A              By Report
A6511   Compres burn garment panty     A              By Report
A6512   Compres burn garment, noc      A              By Report
A6513   Compress burn mask face/neck   B             Not Covered
A6530   Compression stocking BK18-30   E   $31.65      Covered
A6531   Compression stocking BK30-40   A   $43.27      Covered
A6532   Compression stocking BK40-50   A   $60.96      Covered
A6533   Gc stocking thighlngth 18-30   E   $43.95      Covered
A6534   Gc stocking thighlngth 30-40   E   $43.95      Covered
A6535   Gc stocking thighlngth 40-50   E   $43.95      Covered
A6536   Gc stocking full lngth 18-30   E   $43.95      Covered
A6537   Gc stocking full lngth 30-40   E   $43.95      Covered
A6538   Gc stocking full lngth 40-50   E   $43.95      Covered
A6539   Gc stocking waistlngth 18-30   E   $43.95      Covered
A6540   Gc stocking waistlngth 30-40   E   $43.95      Covered
A6541   Gc stocking waistlngth 40-50   E   $43.95      Covered
A6542   Gc stocking custom made        D             Not Covered
A6543   Gc stocking lymphedema         D             Not Covered
A6544   Gc stocking garter belt        E   $43.95      Covered
A6545   Grad comp non-elastic BK       A              By Report
A6549   G compression stocking         E   $43.95      Covered
A6550   Neg pres wound ther drsg set   Y             Not Covered
A7000   Disposable canister for pump   Y             Not Covered
A7001   Nondisposable pump canister    Y             Not Covered
A7002   Tubing used w suction pump     Y    $3.83      Covered
A7003   Nebulizer administration set   Y    $2.74      Covered
A7004   Disposable nebulizer sml vol   Y    $1.80      Covered
A7005   Nondisposable nebulizer set    Y   $30.83      Covered
A7006   Filtered nebulizer admin set   Y    $9.54      Covered
A7007   Lg vol nebulizer disposable    Y             Not Covered
A7008   Disposable nebulizer prefill   Y   $11.00      Covered
A7009   Nebulizer reservoir bottle     Y   $42.04      Covered
A7010   Disposable corrugated tubing   Y   $23.59      Covered
A7011   Nondispos corrugated tubing    Y             Not Covered
A7012   Nebulizer water collec devic   Y    $3.78      Covered
A7013   Disposable compressor filter   Y    $0.83      Covered
A7014   Compressor nondispos filter    Y    $4.49      Covered
A7015   Aerosol mask used w nebulize   Y             Not Covered
A7016   Nebulizer dome & mouthpiece    Y    $7.25      Covered
A7017   Nebulizer not used w oxygen    Y   $134.04     Covered
A7018   Water distilled w/nebulizer    Y    $0.38      Covered
A7025   Replace chest compress vest    Y             Not Covered
A7026   Replace chst cmprss sys hose   Y             Not Covered
A7027   Combination oral/nasal mask    Y             Not Covered
A7028   Repl oral cushion combo mask   Y             Not Covered
A7029   Repl nasal pillow comb mask    Y             Not Covered
A7030   CPAP full face mask            Y             Not Covered
A7031   Replacement facemask interfa   Y             Not Covered
A7032   Replacement nasal cushion      Y             Not Covered
A7033   Replacement nasal pillows      Y             Not Covered
A7034   Nasal application device       Y             Not Covered
A7035   Pos airway press headgear      Y             Not Covered
A7036   Pos airway press chinstrap     Y             Not Covered
A7037   Pos airway pressure tubing     Y             Not Covered
A7038   Pos airway pressure filter     Y             Not Covered
A7039   Filter, non disposable w pap   Y             Not Covered
A7040   One way chest drain valve      A             Not Covered
A7041   Water seal drain container     A             Not Covered
A7042   Implanted pleural catheter     N             Not Covered
A7043   Vacuum drainagebottle/tubing   A             Not Covered
A7044   PAP oral interface             Y             Not Covered
A7045   Repl exhalation port for PAP   Y   $19.47      Covered
A7046   Repl water chamber, PAP dev    Y             Not Covered
A7501   Tracheostoma valve w diaphra   A   $105.03     Covered
A7502   Replacement diaphragm/fplate   A    $49.91     Covered
A7503   HMES filter holder or cap      A    $11.33     Covered
A7504   Tracheostoma HMES filter       A     $0.67     Covered
A7505   HMES or trach valve housing    A     $4.68     Covered
A7506   HMES/trachvalve adhesivedisk   A     $0.33     Covered
A7507   Integrated filter & holder     A     $2.49     Covered
A7508   Housing & Integrated Adhesiv   A     $2.87     Covered
A7509   Heat & moisture exchange sys   A     $1.41     Covered
A7520   Trach/laryn tube non-cuffed    A             Not Covered
A7521   Trach/laryn tube cuffed        A             Not Covered
A7522   Trach/laryn tube stainless     A             Not Covered
A7523   Tracheostomy shower protect    A             Not Covered
A7524   Tracheostoma stent/stud/bttn   A             Not Covered
A7525   Tracheostomy mask              A             Not Covered
A7526   Tracheostomy tube collar       A             Not Covered
A7527   Trach/laryn tube plug/stop     A    $3.58      Covered
A8000   Soft protect helmet prefab     Y              By Report
A8001   Hard protect helmet prefab     Y              By Report
A8002   Soft protect helmet custom     Y              By Report
A8003   Hard protect helmet custom     Y              By Report
A8004   Repl soft interface, helmet    Y              By Report
A9150   Misc/exper non-prescript dru   B             Not Covered
A9152   Single vitamin nos             E             Not Covered
A9153   Multi-vitamin nos              E             Not Covered
A9155   Artificial saliva              B             Not Covered
A9180   Lice treatment, topical        E             Not Covered
A9270   Non-covered item or service    E             Not Covered
A9274   Ext amb insulin delivery sys   E             Not Covered
A9275   Disp home glucose monitor      E             Not Covered
A9276   Disposable sensor, CGM sys     E                    Not Covered
A9277   External transmitter, CGM      E                    Not Covered
A9278   External receiver, CGM sys     E                    Not Covered
A9279   Monitoring feature/deviceNOC   E                    Not Covered
A9280   Alert device, noc              E                    Not Covered
A9281   Reaching/grabbing device       E                    Not Covered
A9282   Wig any type                   E                    Not Covered
A9283   Foot press off load supp dev   E                    Not Covered
A9284   Non-electronic spirometer      N                    Not Covered
A9300   Exercise equipment             E                    Not Covered
A9500   Tc99m sestamibi                N                      Covered
A9501   Technetium TC-99m teboroxime   N                    Not Covered
A9502   Tc99m tetrofosmin              N                      Covered
A9503   Tc99m medronate                N                      Covered
A9504   Tc99m apcitide                 N                      Covered
A9505   TL201 thallium                 N                      Covered
A9507   In111 capromab                 N                     By Report
A9508   I131 iodobenguate, dx          N                     By Report
A9509   Iodine I-123 sod iodide mil    N                    Not Covered
A9510   Tc99m disofenin                N                      Covered
A9512   Tc99m pertechnetate            N                    Not Covered
A9516   Iodine I-123 sod iodide mic    N                      Covered
A9517   I131 iodide cap, rx            K   01064             By Report
A9521   Tc99m exametazime              N                     By Report
A9524   I131 serum albumin, dx         N                    Not Covered
A9526   Nitrogen N-13 ammonia          N                    Not Covered
A9527   Iodine I-125 sodium iodide     U   02632   0.5626   Not Covered
A9528   Iodine I-131 iodide cap, dx    N                    Not Covered
A9529   I131 iodide sol, dx            N                    Not Covered
A9530   I131 iodide sol, rx            K   01150            Not Covered
A9531   I131 max 100uCi                N                    Not Covered
A9532   I125 serum albumin, dx         N                    Not Covered
A9535   Injection, methylene blue      D                    Not Covered
A9536   Tc99m depreotide               N                     By Report
A9537   Tc99m mebrofenin               N                      Covered
A9538   Tc99m pyrophosphate            N                      Covered
A9539   Tc99m pentetate                N                      Covered
A9540   Tc99m MAA                      N                     By Report
A9541   Tc99m sulfur colloid           N                      Covered
A9542   In111 ibritumomab, dx          N                     By Report
A9543   Y90 ibritumomab, rx            K   01643             By Report
A9544   I131 tositumomab, dx           N                     By Report
A9545   I131 tositumomab, rx           K   01645            Not Covered
A9546   Co57/58                        N                     By Report
A9547   In111 oxyquinoline             N                     By Report
A9548   In111 pentetate                N                     By Report
A9550   Tc99m gluceptate               N                     By Report
A9551   Tc99m succimer                 N                     By Report
A9552   F18 fdg                        N                      Covered
A9553   Cr51 chromate                  N                      Covered
A9554   I125 iothalamate, dx           N                      Covered
A9555   Rb82 rubidium                  N                      Covered
A9556   Ga67 gallium                   N                      By Report
A9557   Tc99m bicisate                 N                      By Report
A9558   Xe133 xenon 10mci              N                      By Report
A9559   Co57 cyano                     N                      By Report
A9560   Tc99m labeled rbc              N                      By Report
A9561   Tc99m oxidronate               N                      By Report
A9562   Tc99m mertiatide               N                      By Report
A9563   P32 Na phosphate               K   01675              By Report
A9564   P32 chromic phosphate          K   01676              By Report
A9566   Tc99m fanolesomab              N                      By Report
A9567   Technetium TC-99m aerosol      N                       Covered
A9568   Technetium tc99m arcitumomab   N                      By Report
A9569   Technetium TC-99m auto WBC     N                     Not Covered
A9570   Indium In-111 auto WBC         N                     Not Covered
A9571   Indium IN-111 auto platelet    N                     Not Covered
A9572   Indium In-111 pentetreotide    N                     Not Covered
A9576   Inj prohance multipack         N                     Not Covered
A9577   Inj multihance                 N                     Not Covered
A9578   Inj multihance multipack       N                     Not Covered
A9579   Gad-base MR contrast NOS,1ml   N                      By Report
A9580   Sodium fluoride F-18           N                      By Report
A9581   Gadoxetate disodium inj        G   09246   $14.04      Covered
A9582   Iodine I-123 iobenguane        G   09247   $17.67      Covered
A9583   Gadofosveset trisodium inj     G   01299              By Report
A9600   Sr89 strontium                 K   00701              By Report
A9604   Sm 153 lexidronam              K   01295              By Report
A9605   Sm 153 lexidronm               D                     Not Covered
A9698   Non-rad contrast materialNOC   N                      By Report
A9699   Radiopharm rx agent noc        N                      By Report
A9700   Echocardiography Contrast      B                     Not Covered
A9900   Supply/accessory/service       Y                      By Report
A9901   Delivery/set up/dispensing     A                     Not Covered
A9999   DME supply or accessory, nos   Y                      By Report
B4034   Enter feed supkit syr by day   Y             $5.68     Covered
B4035   Enteral feed supp pump per d   Y            $10.68     Covered
B4036   Enteral feed sup kit grav by   Y             $7.40     Covered
B4081   Enteral ng tubing w/ stylet    Y            $28.88     Covered
B4082   Enteral ng tubing w/o stylet   Y            $15.94     Covered
B4083   Enteral stomach tube levine    Y             $2.36     Covered
B4087   Gastro/jejuno tube, std        A            $38.60     Covered
B4088   Gastro/jejuno tube, low-pro    A           $201.26     Covered
B4100   Food thickener oral            E                      By Report
B4102   EF adult fluids and electro    Y                      By Report
B4103   EF ped fluid and electrolyte   Y            $5.20      Covered
B4104   Additive for enteral formula   E                      By Report
B4149   EF blenderized foods           Y                      By Report
B4150   EF complet w/intact nutrient   Y                      By Report
B4152   EF calorie dense>/=1.5Kcal     Y                      By Report
B4153   EF hydrolyzed/amino acids      Y                      By Report
B4154   EF spec metabolic noninherit   Y                      By Report
B4155   EF incomplete/modular          Y                      By Report
B4157   EF special metabolic inherit   Y                      By Report
B4158   EF ped complete intact nut     Y                               By Report
B4159   EF ped complete soy based      Y                               By Report
B4160   EF ped caloric dense>/=0.7kc   Y                               By Report
B4161   EF ped hydrolyzed/amino acid   Y                               By Report
B4162   EF ped specmetabolic inherit   Y                               By Report
B4164   Parenteral 50% dextrose solu   Y                    $14.42      Covered
B4168   Parenteral sol amino acid 3.   Y                    $40.03      Covered
B4172   Parenteral sol amino acid 5.   Y                    $31.76      Covered
B4176   Parenteral sol amino acid 7-   Y                    $81.68      Covered
B4178   Parenteral sol amino acid >    Y                    $81.68      Covered
B4180   Parenteral sol carb > 50%      Y                    $32.37      Covered
B4185   Parenteral sol 10 gm lipids    B                              Not Covered
B4189   Parenteral sol amino acid &    Y                    $57.09      Covered
B4193   Parenteral sol 52-73 gm prot   Y                    $71.17      Covered
B4197   Parenteral sol 74-100 gm pro   Y                    $83.62      Covered
B4199   Parenteral sol > 100gm prote   Y                    $95.40      Covered
B4216   Parenteral nutrition additiv   Y                              Not Covered
B4220   Parenteral supply kit premix   Y                              Not Covered
B4222   Parenteral supply kit homemi   Y                              Not Covered
B4224   Parenteral administration ki   Y                    $667.23     Covered
B5000   Parenteral sol renal-amirosy   Y                              Not Covered
B5100   Parenteral sol hepatic-fream   Y                              Not Covered
B5200   Parenteral sol stres-brnch c   Y                              Not Covered
B9000   Enter infusion pump w/o alrm   Y                              Not Covered
B9002   Enteral infusion pump w/ ala   Y                              Not Covered
B9004   Parenteral infus pump portab   Y                              Not Covered
B9006   Parenteral infus pump statio   Y                              Not Covered
B9998   Enteral supp not otherwise c   Y                               By Report
B9999   Parenteral supp not othrws c   Y                               By Report
C1300   HYPERBARIC Oxygen              S   00659   1.5880               Covered
C1713   Anchor/screw bn/bn,tis/bn      N                              Not Covered
C1714   Cath, trans atherectomy, dir   N                              Not Covered
C1715   Brachytherapy needle           N                              Not Covered
C1716   Brachytx, non-str, Gold-198    U   01716   0.6357             Not Covered
C1717   Brachytx, non-str,HDR Ir-192   U   01717   3.4326             Not Covered
C1719   Brachytx, NS, Non-HDRIr-192    U   01719   0.9497             Not Covered
C1721   AICD, dual chamber             N                              Not Covered
C1722   AICD, single chamber           N                              Not Covered
C1724   Cath, trans atherec,rotation   N                              Not Covered
C1725   Cath, translumin non-laser     N                              Not Covered
C1726   Cath, bal dil, non-vascular    N                              Not Covered
C1727   Cath, bal tis dis, non-vas     N                              Not Covered
C1728   Cath, brachytx seed adm        N                              Not Covered
C1729   Cath, drainage                 N                              Not Covered
C1730   Cath, EP, 19 or few elect      N                              Not Covered
C1731   Cath, EP, 20 or more elec      N                              Not Covered
C1732   Cath, EP, diag/abl, 3D/vect    N                              Not Covered
C1733   Cath, EP, othr than cool-tip   N                              Not Covered
C1750   Cath, hemodialysis,long-term   N                              Not Covered
C1751   Cath, inf, per/cent/midline    N                              Not Covered
C1752   Cath,hemodialysis,short-term   N                              Not Covered
C1753   Cath, intravas ultrasound      N                              Not Covered
C1754   Catheter, intradiscal          N   Not Covered
C1755   Catheter, intraspinal          N   Not Covered
C1756   Cath, pacing, transesoph       N   Not Covered
C1757   Cath, thrombectomy/embolect    N   Not Covered
C1758   Catheter, ureteral             N   Not Covered
C1759   Cath, intra echocardiography   N   Not Covered
C1760   Closure dev, vasc              N   Not Covered
C1762   Conn tiss, human(inc fascia)   N   Not Covered
C1763   Conn tiss, non-human           N   Not Covered
C1764   Event recorder, cardiac        N   Not Covered
C1765   Adhesion barrier               N   Not Covered
C1766   Intro/sheath,strble,non-peel   N   Not Covered
C1767   Generator, neuro non-recharg   N   Not Covered
C1768   Graft, vascular                N   Not Covered
C1769   Guide wire                     N   Not Covered
C1770   Imaging coil, MR, insertable   N   Not Covered
C1771   Rep dev, urinary, w/sling      N   Not Covered
C1772   Infusion pump, programmable    N   Not Covered
C1773   Ret dev, insertable            N   Not Covered
C1776   Joint device (implantable)     N   Not Covered
C1777   Lead, AICD, endo single coil   N   Not Covered
C1778   Lead, neurostimulator          N   Not Covered
C1779   Lead, pmkr, transvenous VDD    N   Not Covered
C1780   Lens, intraocular (new tech)   N   Not Covered
C1781   Mesh (implantable)             N   Not Covered
C1782   Morcellator                    N   Not Covered
C1783   Ocular imp, aqueous drain de   N   Not Covered
C1784   Ocular dev, intraop, det ret   N   Not Covered
C1785   Pmkr, dual, rate-resp          N   Not Covered
C1786   Pmkr, single, rate-resp        N   Not Covered
C1787   Patient progr, neurostim       N   Not Covered
C1788   Port, indwelling, imp          N   Not Covered
C1789   Prosthesis, breast, imp        N   Not Covered
C1813   Prosthesis, penile, inflatab   N   Not Covered
C1814   Retinal tamp, silicone oil     N   Not Covered
C1815   Pros, urinary sph, imp         N   Not Covered
C1816   Receiver/transmitter, neuro    N   Not Covered
C1817   Septal defect imp sys          N   Not Covered
C1818   Integrated keratoprosthesis    N   Not Covered
C1819   Tissue localization-excision   N   Not Covered
C1820   Generator neuro rechg bat sy   N   Not Covered
C1821   Interspinous implant           N   Not Covered
C1874   Stent, coated/cov w/del sys    N   Not Covered
C1875   Stent, coated/cov w/o del sy   N   Not Covered
C1876   Stent, non-coa/non-cov w/del   N   Not Covered
C1877   Stent, non-coat/cov w/o del    N   Not Covered
C1878   Matrl for vocal cord           N   Not Covered
C1879   Tissue marker, implantable     N   Not Covered
C1880   Vena cava filter               N   Not Covered
C1881   Dialysis access system         N   Not Covered
C1882   AICD, other than sing/dual     N   Not Covered
C1883   Adapt/ext, pacing/neuro lead   N   Not Covered
C1884   Embolization Protect syst      N                       Not Covered
C1885   Cath, translumin angio laser   N                       Not Covered
C1887   Catheter, guiding              N                       Not Covered
C1888   Endovas non-cardiac abl cath   N                       Not Covered
C1891   Infusion pump,non-prog, perm   N                       Not Covered
C1892   Intro/sheath,fixed,peel-away   N                       Not Covered
C1893   Intro/sheath, fixed,non-peel   N                       Not Covered
C1894   Intro/sheath, non-laser        N                       Not Covered
C1895   Lead, AICD, endo dual coil     N                       Not Covered
C1896   Lead, AICD, non sing/dual      N                       Not Covered
C1897   Lead, neurostim test kit       N                       Not Covered
C1898   Lead, pmkr, other than trans   N                       Not Covered
C1899   Lead, pmkr/AICD combination    N                       Not Covered
C1900   Lead, coronary venous          N                       Not Covered
C2614   Probe, perc lumb disc          N                       Not Covered
C2615   Sealant, pulmonary, liquid     N                       Not Covered
C2616   Brachytx, non-str,Yttrium-90   U    02616   234.0942   Not Covered
C2617   Stent, non-cor, tem w/o del    N                       Not Covered
C2618   Probe, cryoablation            N                       Not Covered
C2619   Pmkr, dual, non rate-resp      N                       Not Covered
C2620   Pmkr, single, non rate-resp    N                       Not Covered
C2621   Pmkr, other than sing/dual     N                       Not Covered
C2622   Prosthesis, penile, non-inf    N                       Not Covered
C2625   Stent, non-cor, tem w/del sy   N                       Not Covered
C2626   Infusion pump, non-prog,temp   N                       Not Covered
C2627   Cath, suprapubic/cystoscopic   N                       Not Covered
C2628   Catheter, occlusion            N                       Not Covered
C2629   Intro/sheath, laser            N                       Not Covered
C2630   Cath, EP, cool-tip             N                       Not Covered
C2631   Rep dev, urinary, w/o sling    N                       Not Covered
C2634   Brachytx, non-str, HA, I-125   U    02634     0.8871   Not Covered
C2635   Brachytx, non-str, HA, P-103   U    02635     0.4242   Not Covered
C2636   Brachy linear, non-str,P-103   U    02636     0.2873   Not Covered
C2637   Brachy,non-str,Ytterbium-169   B                       Not Covered
C2638   Brachytx, stranded, I-125      U    02638     0.6302   Not Covered
C2639   Brachytx, non-stranded,I-125   U    02639     0.5368   Not Covered
C2640   Brachytx, stranded, P-103      U    02640     0.8955   Not Covered
C2641   Brachytx, non-stranded,P-103   U    02641     0.8474   Not Covered
C2642   Brachytx, stranded, C-131      U    02642     1.6295   Not Covered
C2643   Brachytx, non-stranded,C-131   U    02643     0.9805   Not Covered
C2698   Brachytx, stranded, NOS        U    02698     0.6302   Not Covered
C2699   Brachytx, non-stranded, NOS    U    02699     0.4242   Not Covered
C8900   MRA w/cont, abd                Q3   00284     6.2901   Not Covered
C8901   MRA w/o cont, abd              Q3   00336     5.1855   Not Covered
C8902   MRA w/o fol w/cont, abd        Q3   00337     7.9432   Not Covered
C8903   MRI w/cont, breast, uni        Q3   00284     6.2901   Not Covered
C8904   MRI w/o cont, breast, uni      Q3   00336     5.1855   Not Covered
C8905   MRI w/o fol w/cont, brst, un   Q3   00337     7.9432   Not Covered
C8906   MRI w/cont, breast, bi         Q3   00284     6.2901   Not Covered
C8907   MRI w/o cont, breast, bi       Q3   00336     5.1855   Not Covered
C8908   MRI w/o fol w/cont, breast,    Q3   00337     7.9432   Not Covered
C8909   MRA w/cont, chest              Q3   00284     6.2901   Not Covered
C8910   MRA w/o cont, chest            Q3   00336   5.1855             Not Covered
C8911   MRA w/o fol w/cont, chest      Q3   00337   7.9432             Not Covered
C8912   MRA w/cont, lwr ext            Q3   00284   6.2901             Not Covered
C8913   MRA w/o cont, lwr ext          Q3   00336   5.1855             Not Covered
C8914   MRA w/o fol w/cont, lwr ext    Q3   00337   7.9432             Not Covered
C8918   MRA w/cont, pelvis             Q3   00284   6.2901             Not Covered
C8919   MRA w/o cont, pelvis           Q3   00336   5.1855             Not Covered
C8920   MRA w/o fol w/cont, pelvis     Q3   00337   7.9432             Not Covered
C8921   TTE w or w/o fol w/cont, com   S    00128   9.6604             Not Covered
C8922   TTE w or w/o fol w/cont, f/u   S    00128   9.6604             Not Covered
C8923   2D TTE w or w/o fol w/con,co   S    00128   9.6604             Not Covered
C8924   2D TTE w or w/o fol w/con,fu   S    00128   9.6604             Not Covered
C8925   2D TEE w or w/o fol w/con,in   S    00128   9.6604             Not Covered
C8926   TEE w or w/o fol w/cont,cong   S    00128   9.6604             Not Covered
C8927   TEE w or w/o fol w/cont, mon   S    00128   9.6604             Not Covered
C8928   TTE w or w/o fol w/con,stres   S    00128   9.6604             Not Covered
C8929   TTE w or wo fol wcon,Doppler   S    00128   9.6604               Covered
C8930   TTE w or w/o contr, cont ECG   S    00128   9.6604               Covered
C8957   Prolonged IV inf, req pump     S    00440   3.2632             Not Covered
C9003   Palivizumab, per 50 mg         D                               Not Covered
C9113   Inj pantoprazole sodium, via   N                               Not Covered
C9121   Injection, argatroban          K    09121                      Not Covered
C9237   Inj, lanreotide acetate        D                               Not Covered
C9238   Inj, levetiracetam             D                               Not Covered
C9239   Inj, temsirolimus              D                               Not Covered
C9240   Injection, ixabepilone         D                               Not Covered
C9241   Injection, doripenem           D                               Not Covered
C9242   Injection, fosaprepitant       D                               Not Covered
C9243   Injection, bendamustine hcl    D                               Not Covered
C9244   Injection, regadenoson         D                               Not Covered
C9245   Injection, romiplostim         D                               Not Covered
C9246   Inj, gadoxetate disodium       D                               Not Covered
C9246   Inj, gadoxetate disodium       D                               Not Covered
C9247   Inj, iobenguane, I-123, dx     D                               Not Covered
C9247   Inj, iobenguane, I-123, dx     D                               Not Covered
C9248   Inj, clevidipine butyrate      G    09248                       By Report
C9248   Inj, clevidipine butyrate      G    09248                      Not Covered
C9249   Inj, certolizumab pegol        D                               Not Covered
C9250   Artiss fibrin sealant          G    09250            $180.50     Covered
C9251   Inj, C1 esterase inhibitor     D                               Not Covered
C9252   Injection, plerixafor          D                               Not Covered
C9253   Injection, temozolomide        D                               Not Covered
C9254   Injection, lacosamide          K    09254             $0.19      Covered
C9255   Paliperidone palmitate inj     G    09255             $6.84      Covered
C9256   Dexamethasone intravitreal     G    09256            $199.80     Covered
C9257   Bevacizumab injection          K    01281             $1.72      Covered
C9352   Neuragen nerve guide, per cm   N                               Not Covered
C9353   Neurawrap nerve protector,cm   N                               Not Covered
C9354   Veritas collagen matrix, cm2   N                               Not Covered
C9355   Neuromatrix nerve cuff, cm     N                               Not Covered
C9356   TenoGlide tendon prot, cm2     G    09356                       By Report
C9357   Flowable wound matrix, 1 cc    D                               Not Covered
C9358   SurgiMend, 0.5cm2              G   09358              By Report
C9359   Implant, bone void filler      G   09359              By Report
C9360   SurgiMend, neonatal            G   09360              By Report
C9361   NeuroMend nerve wrap           G   09361              By Report
C9362   Implnt,bon void filler-strip   G   09362              By Report
C9363   Integra Meshed Bil Wound Mat   G   09363              By Report
C9364   Porcine implant, Permacol      G   09364              By Report
C9399   Unclassified drugs or biolog   A                     Not Covered
C9716   Radiofrequency energy to anu   T   00150   32.1812   Not Covered
C9723   Dyn IR Perf Img                D                     Not Covered
C9724   EPS gast cardia plic           T   00422   24.2703     Covered
C9725   Place endorectal app           T   00148    5.3650     Covered
C9726   Rxt breast appl place/remov    T   00028   24.7516   Not Covered
C9727   Insert palate implants         T   00252    7.6196   Not Covered
C9728   Place device/marker, non pro   X   00310   13.7576   Not Covered
C9898   Inpnt stay radiolabeled item   N                      By Report
C9899   Inpt implant pros dev,no cov   A                      By Report
D0120   Periodic oral evaluation       E                     Not Covered
D0140   Limit oral eval problm focus   E                     Not Covered
D0145   Oral evaluation, pt < 3yrs     E                     Not Covered
D0150   Comprehensve oral evaluation   S   00330   10.3227   Not Covered
D0160   Extensv oral eval prob focus   E                     Not Covered
D0170   Re-eval,est pt,problem focus   E                     Not Covered
D0180   Comp periodontal evaluation    E                     Not Covered
D0210   Intraor complete film series   E                     Not Covered
D0220   Intraoral periapical first f   E                     Not Covered
D0230   Intraoral periapical ea add    E                     Not Covered
D0240   Intraoral occlusal film        S   00330   10.3227   Not Covered
D0250   Extraoral first film           S   00330   10.3227   Not Covered
D0260   Extraoral ea additional film   S   00330   10.3227   Not Covered
D0270   Dental bitewing single film    S   00330   10.3227   Not Covered
D0272   Dental bitewings two films     S   00330   10.3227   Not Covered
D0273   Bitewings - three films        E                     Not Covered
D0274   Dental bitewings four films    S   00330   10.3227   Not Covered
D0277   Vert bitewings-sev to eight    S   00330   10.3227   Not Covered
D0290   Dental film skull/facial bon   E                     Not Covered
D0310   Dental saliography             E                     Not Covered
D0320   Dental tmj arthrogram incl i   E                     Not Covered
D0321   Dental other tmj films         E                     Not Covered
D0322   Dental tomographic survey      E                     Not Covered
D0330   Dental panoramic film          E                     Not Covered
D0340   Dental cephalometric film      E                     Not Covered
D0350   Oral/facial photo images       E                     Not Covered
D0360   Cone beam ct                   E                     Not Covered
D0362   Cone beam, two dimensional     E                     Not Covered
D0363   Cone beam, three dimensional   E                     Not Covered
D0415   Collection of microorganisms   E                     Not Covered
D0416   Viral culture                  B                     Not Covered
D0417   Collect & prep saliva sample   E                     Not Covered
D0418   Analysis of saliva sample      E                     Not Covered
D0421   Gen tst suscept oral disease   B                     Not Covered
D0425   Caries susceptibility test     E                     Not Covered
D0431   Diag tst detect mucos abnorm   B                     Not Covered
D0460   Pulp vitality test             S   00330   10.3227   Not Covered
D0470   Diagnostic casts               E                     Not Covered
D0472   Gross exam, prep & report      B                     Not Covered
D0473   Micro exam, prep & report      B                     Not Covered
D0474   Micro w exam of surg margins   B                     Not Covered
D0475   Decalcification procedure      B                     Not Covered
D0476   Spec stains for microorganis   B                     Not Covered
D0477   Spec stains not for microorg   B                     Not Covered
D0478   Immunohistochemical stains     B                     Not Covered
D0479   Tissue in-situ hybridization   B                     Not Covered
D0480   Cytopath smear prep & report   B                     Not Covered
D0481   Electron microscopy diagnost   B                     Not Covered
D0482   Direct immunofluorescence      B                     Not Covered
D0483   Indirect immunofluorescence    B                     Not Covered
D0484   Consult slides prep elsewher   B                     Not Covered
D0485   Consult inc prep of slides     B                     Not Covered
D0486   Accession of brush biopsy      E                     Not Covered
D0502   Other oral pathology procedu   B                     Not Covered
D0999   Unspecified diagnostic proce   B                     Not Covered
D1110   Dental prophylaxis adult       E                     Not Covered
D1120   Dental prophylaxis child       E                     Not Covered
D1203   Topical fluor w/o prophy chi   E                     Not Covered
D1204   Topical fluor w/o prophy adu   E                     Not Covered
D1206   Topical fluoride varnish       E                     Not Covered
D1310   Nutri counsel-control caries   E                     Not Covered
D1320   Tobacco counseling             E                     Not Covered
D1330   Oral hygiene instruction       E                     Not Covered
D1351   Dental sealant per tooth       E                     Not Covered
D1510   Space maintainer fxd unilat    S   00330   10.3227   Not Covered
D1515   Fixed bilat space maintainer   S   00330   10.3227   Not Covered
D1520   Remove unilat space maintain   S   00330   10.3227   Not Covered
D1525   Remove bilat space maintain    S   00330   10.3227   Not Covered
D1550   Recement space maintainer      S   00330   10.3227   Not Covered
D1555   Remove fix space maintainer    E                     Not Covered
D2140   Amalgam one surface permanen   E                     Not Covered
D2150   Amalgam two surfaces permane   E                     Not Covered
D2160   Amalgam three surfaces perma   E                     Not Covered
D2161   Amalgam 4 or > surfaces perm   E                     Not Covered
D2330   Resin one surface-anterior     E                     Not Covered
D2331   Resin two surfaces-anterior    E                     Not Covered
D2332   Resin three surfaces-anterio   E                     Not Covered
D2335   Resin 4/> surf or w incis an   E                     Not Covered
D2390   Ant resin-based cmpst crown    E                     Not Covered
D2391   Post 1 srfc resinbased cmpst   E                     Not Covered
D2392   Post 2 srfc resinbased cmpst   E                     Not Covered
D2393   Post 3 srfc resinbased cmpst   E                     Not Covered
D2394   Post >=4srfc resinbase cmpst   E                     Not Covered
D2410   Dental gold foil one surface   E                     Not Covered
D2420   Dental gold foil two surface   E                     Not Covered
D2430   Dental gold foil three surfa   E                     Not Covered
D2510   Dental inlay metalic 1 surf    E                     Not Covered
D2520   Dental inlay metallic 2 surf   E   Not Covered
D2530   Dental inlay metl 3/more sur   E   Not Covered
D2542   Dental onlay metallic 2 surf   E   Not Covered
D2543   Dental onlay metallic 3 surf   E   Not Covered
D2544   Dental onlay metl 4/more sur   E   Not Covered
D2610   Inlay porcelain/ceramic 1 su   E   Not Covered
D2620   Inlay porcelain/ceramic 2 su   E   Not Covered
D2630   Dental onlay porc 3/more sur   E   Not Covered
D2642   Dental onlay porcelin 2 surf   E   Not Covered
D2643   Dental onlay porcelin 3 surf   E   Not Covered
D2644   Dental onlay porc 4/more sur   E   Not Covered
D2650   Inlay composite/resin one su   E   Not Covered
D2651   Inlay composite/resin two su   E   Not Covered
D2652   Dental inlay resin 3/mre sur   E   Not Covered
D2662   Dental onlay resin 2 surface   E   Not Covered
D2663   Dental onlay resin 3 surface   E   Not Covered
D2664   Dental onlay resin 4/mre sur   E   Not Covered
D2710   Crown resin-based indirect     E   Not Covered
D2712   Crown 3/4 resin-based compos   E   Not Covered
D2720   Crown resin w/ high noble me   E   Not Covered
D2721   Crown resin w/ base metal      E   Not Covered
D2722   Crown resin w/ noble metal     E   Not Covered
D2740   Crown porcelain/ceramic subs   E   Not Covered
D2750   Crown porcelain w/ h noble m   E   Not Covered
D2751   Crown porcelain fused base m   E   Not Covered
D2752   Crown porcelain w/ noble met   E   Not Covered
D2780   Crown 3/4 cast hi noble met    E   Not Covered
D2781   Crown 3/4 cast base metal      E   Not Covered
D2782   Crown 3/4 cast noble metal     E   Not Covered
D2783   Crown 3/4 porcelain/ceramic    E   Not Covered
D2790   Crown full cast high noble m   E   Not Covered
D2791   Crown full cast base metal     E   Not Covered
D2792   Crown full cast noble metal    E   Not Covered
D2794   Crown-titanium                 E   Not Covered
D2799   Provisional crown              E   Not Covered
D2910   Recement inlay onlay or part   E   Not Covered
D2915   Recement cast or prefab post   E   Not Covered
D2920   Dental recement crown          E   Not Covered
D2930   Prefab stnlss steel crwn pri   E   Not Covered
D2931   Prefab stnlss steel crown pe   E   Not Covered
D2932   Prefabricated resin crown      E   Not Covered
D2933   Prefab stainless steel crown   E   Not Covered
D2934   Prefab steel crown primary     E   Not Covered
D2940   Dental sedative filling        E   Not Covered
D2950   Core build-up incl any pins    E   Not Covered
D2951   Tooth pin retention            E   Not Covered
D2952   Post and core cast + crown     E   Not Covered
D2953   Each addtnl cast post          E   Not Covered
D2954   Prefab post/core + crown       E   Not Covered
D2955   Post removal                   E   Not Covered
D2957   Each addtnl prefab post        E   Not Covered
D2960   Laminate labial veneer         E   Not Covered
D2961   Lab labial veneer resin        E                     Not Covered
D2962   Lab labial veneer porcelain    E                     Not Covered
D2970   Temp crown (fractured tooth)   E                     Not Covered
D2971   Add proc construct new crown   E                     Not Covered
D2975   Coping                         E                     Not Covered
D2980   Crown repair                   E                     Not Covered
D2999   Dental unspec restorative pr   S   00330   10.3227   Not Covered
D3110   Pulp cap direct                E                     Not Covered
D3120   Pulp cap indirect              E                     Not Covered
D3220   Therapeutic pulpotomy          E                     Not Covered
D3221   Gross pulpal debridement       E                     Not Covered
D3222   Part pulp for apexogenesis     E                     Not Covered
D3230   Pulpal therapy anterior prim   E                     Not Covered
D3240   Pulpal therapy posterior pri   E                     Not Covered
D3310   Anterior                       E                     Not Covered
D3320   Root canal therapy 2 canals    E                     Not Covered
D3330   Root canal therapy 3 canals    E                     Not Covered
D3331   Non-surg tx root canal obs     E                     Not Covered
D3332   Incomplete endodontic tx       E                     Not Covered
D3333   Internal root repair           E                     Not Covered
D3346   Retreat root canal anterior    E                     Not Covered
D3347   Retreat root canal bicuspid    E                     Not Covered
D3348   Retreat root canal molar       E                     Not Covered
D3351   Apexification/recalc initial   E                     Not Covered
D3352   Apexification/recalc interim   E                     Not Covered
D3353   Apexification/recalc final     E                     Not Covered
D3410   Apicoect/perirad surg anter    E                     Not Covered
D3421   Root surgery bicuspid          E                     Not Covered
D3425   Root surgery molar             E                     Not Covered
D3426   Root surgery ea add root       E                     Not Covered
D3430   Retrograde filling             E                     Not Covered
D3450   Root amputation                E                     Not Covered
D3460   Endodontic endosseous implan   S   00330   10.3227   Not Covered
D3470   Intentional replantation       E                     Not Covered
D3910   Isolation- tooth w rubb dam    E                     Not Covered
D3920   Tooth splitting                E                     Not Covered
D3950   Canal prep/fitting of dowel    E                     Not Covered
D3999   Endodontic procedure           S   00330   10.3227   Not Covered
D4210   Gingivectomy/plasty per quad   E                     Not Covered
D4211   Gingivectomy/plasty per toot   E                     Not Covered
D4230   Ana crown exp 4 or> per quad   E                     Not Covered
D4231   Ana crown exp 1-3 per quad     E                     Not Covered
D4240   Gingival flap proc w/ planin   E                     Not Covered
D4241   Gngvl flap w rootplan 1-3 th   E                     Not Covered
D4245   Apically positioned flap       E                     Not Covered
D4249   Crown lengthen hard tissue     E                     Not Covered
D4260   Osseous surgery per quadrant   S   00330   10.3227   Not Covered
D4261   Osseous surgl-3teethperquad    E                     Not Covered
D4263   Bone replce graft first site   S   00330   10.3227   Not Covered
D4264   Bone replce graft each add     S   00330   10.3227   Not Covered
D4265   Bio mtrls to aid soft/os reg   E                     Not Covered
D4266   Guided tiss regen resorble     E                     Not Covered
D4267   Guided tiss regen nonresorb    E                     Not Covered
D4268   Surgical revision procedure    S   00330   10.3227   Not Covered
D4270   Pedicle soft tissue graft pr   S   00330   10.3227   Not Covered
D4271   Free soft tissue graft proc    S   00330   10.3227   Not Covered
D4273   Subepithelial tissue graft     S   00330   10.3227   Not Covered
D4274   Distal/proximal wedge proc     E                     Not Covered
D4275   Soft tissue allograft          E                     Not Covered
D4276   Con tissue w dble ped graft    E                     Not Covered
D4320   Provision splnt intracoronal   E                     Not Covered
D4321   Provisional splint extracoro   E                     Not Covered
D4341   Periodontal scaling & root     E                     Not Covered
D4342   Periodontal scaling 1-3teeth   E                     Not Covered
D4355   Full mouth debridement         S   00330   10.3227   Not Covered
D4381   Localized delivery antimicro   S   00330   10.3227   Not Covered
D4910   Periodontal maint procedures   E                     Not Covered
D4920   Unscheduled dressing change    E                     Not Covered
D4999   Unspecified periodontal proc   E                     Not Covered
D5110   Dentures complete maxillary    E                     Not Covered
D5120   Dentures complete mandible     E                     Not Covered
D5130   Dentures immediat maxillary    E                     Not Covered
D5140   Dentures immediat mandible     E                     Not Covered
D5211   Dentures maxill part resin     E                     Not Covered
D5212   Dentures mand part resin       E                     Not Covered
D5213   Dentures maxill part metal     E                     Not Covered
D5214   Dentures mandibl part metal    E                     Not Covered
D5225   Maxillary part denture flex    E                     Not Covered
D5226   Mandibular part denture flex   E                     Not Covered
D5281   Removable partial denture      E                     Not Covered
D5410   Dentures adjust cmplt maxil    E                     Not Covered
D5411   Dentures adjust cmplt mand     E                     Not Covered
D5421   Dentures adjust part maxill    E                     Not Covered
D5422   Dentures adjust part mandbl    E                     Not Covered
D5510   Dentur repr broken compl bas   E                     Not Covered
D5520   Replace denture teeth complt   E                     Not Covered
D5610   Dentures repair resin base     E                     Not Covered
D5620   Rep part denture cast frame    E                     Not Covered
D5630   Rep partial denture clasp      E                     Not Covered
D5640   Replace part denture teeth     E                     Not Covered
D5650   Add tooth to partial denture   E                     Not Covered
D5660   Add clasp to partial denture   E                     Not Covered
D5670   Replc tth&acrlc on mtl frmwk   E                     Not Covered
D5671   Replc tth&acrlc mandibular     E                     Not Covered
D5710   Dentures rebase cmplt maxil    E                     Not Covered
D5711   Dentures rebase cmplt mand     E                     Not Covered
D5720   Dentures rebase part maxill    E                     Not Covered
D5721   Dentures rebase part mandbl    E                     Not Covered
D5730   Denture reln cmplt maxil ch    E                     Not Covered
D5731   Denture reln cmplt mand chr    E                     Not Covered
D5740   Denture reln part maxil chr    E                     Not Covered
D5741   Denture reln part mand chr     E                     Not Covered
D5750   Denture reln cmplt max lab     E                     Not Covered
D5751   Denture reln cmplt mand lab    E                     Not Covered
D5760   Denture reln part maxil lab    E                     Not Covered
D5761   Denture reln part mand lab     E                     Not Covered
D5810   Denture interm cmplt maxill    E                     Not Covered
D5811   Denture interm cmplt mandbl    E                     Not Covered
D5820   Denture interm part maxill     E                     Not Covered
D5821   Denture interm part mandbl     E                     Not Covered
D5850   Denture tiss conditn maxill    E                     Not Covered
D5851   Denture tiss condtin mandbl    E                     Not Covered
D5860   Overdenture complete           E                     Not Covered
D5861   Overdenture partial            E                     Not Covered
D5862   Precision attachment           E                     Not Covered
D5867   Replacement of precision att   E                     Not Covered
D5875   Prosthesis modification        E                     Not Covered
D5899   Removable prosthodontic proc   E                     Not Covered
D5911   Facial moulage sectional       S   00330   10.3227   Not Covered
D5912   Facial moulage complete        S   00330   10.3227   Not Covered
D5913   Nasal prosthesis               E                     Not Covered
D5914   Auricular prosthesis           E                     Not Covered
D5915   Orbital prosthesis             E                     Not Covered
D5916   Ocular prosthesis              E                     Not Covered
D5919   Facial prosthesis              E                     Not Covered
D5922   Nasal septal prosthesis        E                     Not Covered
D5923   Ocular prosthesis interim      E                     Not Covered
D5924   Cranial prosthesis             E                     Not Covered
D5925   Facial augmentation implant    E                     Not Covered
D5926   Replacement nasal prosthesis   E                     Not Covered
D5927   Auricular replacement          E                     Not Covered
D5928   Orbital replacement            E                     Not Covered
D5929   Facial replacement             E                     Not Covered
D5931   Surgical obturator             E                     Not Covered
D5932   Postsurgical obturator         E                     Not Covered
D5933   Refitting of obturator         E                     Not Covered
D5934   Mandibular flange prosthesis   E                     Not Covered
D5935   Mandibular denture prosth      E                     Not Covered
D5936   Temp obturator prosthesis      E                     Not Covered
D5937   Trismus appliance              E                     Not Covered
D5951   Feeding aid                    E                     Not Covered
D5952   Pediatric speech aid           E                     Not Covered
D5953   Adult speech aid               E                     Not Covered
D5954   Superimposed prosthesis        E                     Not Covered
D5955   Palatal lift prosthesis        E                     Not Covered
D5958   Intraoral con def inter plt    E                     Not Covered
D5959   Intraoral con def mod palat    E                     Not Covered
D5960   Modify speech aid prosthesis   E                     Not Covered
D5982   Surgical stent                 E                     Not Covered
D5983   Radiation applicator           S   00330   10.3227   Not Covered
D5984   Radiation shield               S   00330   10.3227   Not Covered
D5985   Radiation cone locator         S   00330   10.3227   Not Covered
D5986   Fluoride applicator            E                     Not Covered
D5987   Commissure splint              S   00330   10.3227   Not Covered
D5988   Surgical splint                E                     Not Covered
D5991   Topical medicament carrier     E                     Not Covered
D5999   Maxillofacial prosthesis       E   Not Covered
D6010   Odontics endosteal implant     E   Not Covered
D6012   Endosteal implant              E   Not Covered
D6040   Odontics eposteal implant      E   Not Covered
D6050   Odontics transosteal implnt    E   Not Covered
D6053   Implnt/abtmnt spprt remv dnt   E   Not Covered
D6054   Implnt/abtmnt spprt remvprtl   E   Not Covered
D6055   Implant connecting bar         E   Not Covered
D6056   Prefabricated abutment         E   Not Covered
D6057   Custom abutment                E   Not Covered
D6058   Abutment supported crown       E   Not Covered
D6059   Abutment supported mtl crown   E   Not Covered
D6060   Abutment supported mtl crown   E   Not Covered
D6061   Abutment supported mtl crown   E   Not Covered
D6062   Abutment supported mtl crown   E   Not Covered
D6063   Abutment supported mtl crown   E   Not Covered
D6064   Abutment supported mtl crown   E   Not Covered
D6065   Implant supported crown        E   Not Covered
D6066   Implant supported mtl crown    E   Not Covered
D6067   Implant supported mtl crown    E   Not Covered
D6068   Abutment supported retainer    E   Not Covered
D6069   Abutment supported retainer    E   Not Covered
D6070   Abutment supported retainer    E   Not Covered
D6071   Abutment supported retainer    E   Not Covered
D6072   Abutment supported retainer    E   Not Covered
D6073   Abutment supported retainer    E   Not Covered
D6074   Abutment supported retainer    E   Not Covered
D6075   Implant supported retainer     E   Not Covered
D6076   Implant supported retainer     E   Not Covered
D6077   Implant supported retainer     E   Not Covered
D6078   Implnt/abut suprtd fixd dent   E   Not Covered
D6079   Implnt/abut suprtd fixd dent   E   Not Covered
D6080   Implant maintenance            E   Not Covered
D6090   Repair implant                 E   Not Covered
D6091   Repl semi/precision attach     E   Not Covered
D6092   Recement supp crown            E   Not Covered
D6093   Recement supp part denture     E   Not Covered
D6094   Abut support crown titanium    E   Not Covered
D6095   Odontics repr abutment         E   Not Covered
D6100   Removal of implant             E   Not Covered
D6190   Radio/surgical implant index   E   Not Covered
D6194   Abut support retainer titani   E   Not Covered
D6199   Implant procedure              E   Not Covered
D6205   Pontic-indirect resin based    E   Not Covered
D6210   Prosthodont high noble metal   E   Not Covered
D6211   Bridge base metal cast         E   Not Covered
D6212   Bridge noble metal cast        E   Not Covered
D6214   Pontic titanium                E   Not Covered
D6240   Bridge porcelain high noble    E   Not Covered
D6241   Bridge porcelain base metal    E   Not Covered
D6242   Bridge porcelain nobel metal   E   Not Covered
D6245   Bridge porcelain/ceramic       E   Not Covered
D6250   Bridge resin w/high noble      E                   Not Covered
D6251   Bridge resin base metal        E                   Not Covered
D6252   Bridge resin w/noble metal     E                   Not Covered
D6253   Provisional pontic             E                   Not Covered
D6545   Dental retainr cast metl       E                   Not Covered
D6548   Porcelain/ceramic retainer     E                   Not Covered
D6600   Porcelain/ceramic inlay 2srf   E                   Not Covered
D6601   Porc/ceram inlay >= 3 surfac   E                   Not Covered
D6602   Cst hgh nble mtl inlay 2 srf   E                   Not Covered
D6603   Cst hgh nble mtl inlay >=3sr   E                   Not Covered
D6604   Cst bse mtl inlay 2 surfaces   E                   Not Covered
D6605   Cst bse mtl inlay >= 3 surfa   E                   Not Covered
D6606   Cast noble metal inlay 2 sur   E                   Not Covered
D6607   Cst noble mtl inlay >=3 surf   E                   Not Covered
D6608   Onlay porc/crmc 2 surfaces     E                   Not Covered
D6609   Onlay porc/crmc >=3 surfaces   E                   Not Covered
D6610   Onlay cst hgh nbl mtl 2 srfc   E                   Not Covered
D6611   Onlay cst hgh nbl mtl >=3srf   E                   Not Covered
D6612   Onlay cst base mtl 2 surface   E                   Not Covered
D6613   Onlay cst base mtl >=3 surfa   E                   Not Covered
D6614   Onlay cst nbl mtl 2 surfaces   E                   Not Covered
D6615   Onlay cst nbl mtl >=3 surfac   E                   Not Covered
D6624   Inlay titanium                 E                   Not Covered
D6634   Onlay titanium                 E                   Not Covered
D6710   Crown-indirect resin based     E                   Not Covered
D6720   Retain crown resin w hi nble   E                   Not Covered
D6721   Crown resin w/base metal       E                   Not Covered
D6722   Crown resin w/noble metal      E                   Not Covered
D6740   Crown porcelain/ceramic        E                   Not Covered
D6750   Crown porcelain high noble     E                   Not Covered
D6751   Crown porcelain base metal     E                   Not Covered
D6752   Crown porcelain noble metal    E                   Not Covered
D6780   Crown 3/4 high noble metal     E                   Not Covered
D6781   Crown 3/4 cast based metal     E                   Not Covered
D6782   Crown 3/4 cast noble metal     E                   Not Covered
D6783   Crown 3/4 porcelain/ceramic    E                   Not Covered
D6790   Crown full high noble metal    E                   Not Covered
D6791   Crown full base metal cast     E                   Not Covered
D6792   Crown full noble metal cast    E                   Not Covered
D6793   Provisional retainer crown     E                   Not Covered
D6794   Crown titanium                 E                   Not Covered
D6920   Dental connector bar           S 00330   10.3227   Not Covered
D6930   Dental recement bridge         E                   Not Covered
D6940   Stress breaker                 E                   Not Covered
D6950   Precision attachment           E                   Not Covered
D6970   Post & core plus retainer      E                   Not Covered
D6972   Prefab post & core plus reta   E                   Not Covered
D6973   Core build up for retainer     E                   Not Covered
D6975   Coping metal                   E                   Not Covered
D6976   Each addtnl cast post          E                   Not Covered
D6977   Each addtl prefab post         E                   Not Covered
D6980   Bridge repair                  E                   Not Covered
D6985   Pediatric partial denture fx   E                     Not Covered
D6999   Fixed prosthodontic proc       E                     Not Covered
D7111   Extraction coronal remnants    S   00330   10.3227   Not Covered
D7140   Extraction erupted tooth/exr   S   00330   10.3227   Not Covered
D7210   Rem imp tooth w mucoper flp    S   00330   10.3227   Not Covered
D7220   Impact tooth remov soft tiss   S   00330   10.3227   Not Covered
D7230   Impact tooth remov part bony   S   00330   10.3227   Not Covered
D7240   Impact tooth remov comp bony   S   00330   10.3227   Not Covered
D7241   Impact tooth rem bony w/comp   S   00330   10.3227   Not Covered
D7250   Tooth root removal             S   00330   10.3227   Not Covered
D7260   Oral antral fistula closure    S   00330   10.3227   Not Covered
D7261   Primary closure sinus perf     S   00330   10.3227   Not Covered
D7270   Tooth reimplantation           E                     Not Covered
D7272   Tooth transplantation          E                     Not Covered
D7280   Exposure impact tooth orthod   E                     Not Covered
D7282   Mobilize erupted/malpos toot   E                     Not Covered
D7283   Place device impacted tooth    B                     Not Covered
D7285   Biopsy of oral tissue hard     E                     Not Covered
D7286   Biopsy of oral tissue soft     E                     Not Covered
D7287   Exfoliative cytolog collect    E                     Not Covered
D7288   Brush biopsy                   B                     Not Covered
D7290   Repositioning of teeth         E                     Not Covered
D7291   Transseptal fiberotomy         S   00330   10.3227   Not Covered
D7292   Screw retained plate           E                     Not Covered
D7293   Temp anchorage dev w flap      E                     Not Covered
D7294   Temp anchorage dev w/o flap    E                     Not Covered
D7310   Alveoplasty w/ extraction      E                     Not Covered
D7311   Alveoloplasty w/extract 1-3    E                     Not Covered
D7320   Alveoplasty w/o extraction     E                     Not Covered
D7321   Alveoloplasty not w/extracts   B                     Not Covered
D7340   Vestibuloplasty ridge extens   E                     Not Covered
D7350   Vestibuloplasty exten graft    E                     Not Covered
D7410   Rad exc lesion up to 1.25 cm   E                     Not Covered
D7411   Excision benign lesion>1.25c   E                     Not Covered
D7412   Excision benign lesion compl   E                     Not Covered
D7413   Excision malig lesion<=1.25c   E                     Not Covered
D7414   Excision malig lesion>1.25cm   E                     Not Covered
D7415   Excision malig les complicat   E                     Not Covered
D7440   Malig tumor exc to 1.25 cm     E                     Not Covered
D7441   Malig tumor > 1.25 cm          E                     Not Covered
D7450   Rem odontogen cyst to 1.25cm   E                     Not Covered
D7451   Rem odontogen cyst > 1.25 cm   E                     Not Covered
D7460   Rem nonodonto cyst to 1.25cm   E                     Not Covered
D7461   Rem nonodonto cyst > 1.25 cm   E                     Not Covered
D7465   Lesion destruction             E                     Not Covered
D7471   Rem exostosis any site         E                     Not Covered
D7472   Removal of torus palatinus     E                     Not Covered
D7473   Remove torus mandibularis      E                     Not Covered
D7485   Surg reduct osseoustuberosit   E                     Not Covered
D7490   Maxilla or mandible resectio   E                     Not Covered
D7510   I&d absc intraoral soft tiss   E                     Not Covered
D7511   Incision/drain abscess intra   B                     Not Covered
D7520   I&d abscess extraoral          E                   Not Covered
D7521   Incision/drain abscess extra   B                   Not Covered
D7530   Removal fb skin/areolar tiss   E                   Not Covered
D7540   Removal of fb reaction         E                   Not Covered
D7550   Removal of sloughed off bone   E                   Not Covered
D7560   Maxillary sinusotomy           E                   Not Covered
D7610   Maxilla open reduct simple     E                   Not Covered
D7620   Clsd reduct simpl maxilla fx   E                   Not Covered
D7630   Open red simpl mandible fx     E                   Not Covered
D7640   Clsd red simpl mandible fx     E                   Not Covered
D7650   Open red simp malar/zygom fx   E                   Not Covered
D7660   Clsd red simp malar/zygom fx   E                   Not Covered
D7670   Closd rductn splint alveolus   E                   Not Covered
D7671   Alveolus open reduction        E                   Not Covered
D7680   Reduct simple facial bone fx   E                   Not Covered
D7710   Maxilla open reduct compound   E                   Not Covered
D7720   Clsd reduct compd maxilla fx   E                   Not Covered
D7730   Open reduct compd mandble fx   E                   Not Covered
D7740   Clsd reduct compd mandble fx   E                   Not Covered
D7750   Open red comp malar/zygma fx   E                   Not Covered
D7760   Clsd red comp malar/zygma fx   E                   Not Covered
D7770   Open reduc compd alveolus fx   E                   Not Covered
D7771   Alveolus clsd reduc stblz te   E                   Not Covered
D7780   Reduct compnd facial bone fx   E                   Not Covered
D7810   Tmj open reduct-dislocation    E                   Not Covered
D7820   Closed tmp manipulation        E                   Not Covered
D7830   Tmj manipulation under anest   E                   Not Covered
D7840   Removal of tmj condyle         E                   Not Covered
D7850   Tmj meniscectomy               E                   Not Covered
D7852   Tmj repair of joint disc       E                   Not Covered
D7854   Tmj excisn of joint membrane   E                   Not Covered
D7856   Tmj cutting of a muscle        E                   Not Covered
D7858   Tmj reconstruction             E                   Not Covered
D7860   Tmj cutting into joint         E                   Not Covered
D7865   Tmj reshaping components       E                   Not Covered
D7870   Tmj aspiration joint fluid     E                   Not Covered
D7871   Lysis + lavage w catheters     E                   Not Covered
D7872   Tmj diagnostic arthroscopy     E                   Not Covered
D7873   Tmj arthroscopy lysis adhesn   E                   Not Covered
D7874   Tmj arthroscopy disc reposit   E                   Not Covered
D7875   Tmj arthroscopy synovectomy    E                   Not Covered
D7876   Tmj arthroscopy discectomy     E                   Not Covered
D7877   Tmj arthroscopy debridement    E                   Not Covered
D7880   Occlusal orthotic appliance    E                   Not Covered
D7899   Tmj unspecified therapy        E                   Not Covered
D7910   Dent sutur recent wnd to 5cm   E                   Not Covered
D7911   Dental suture wound to 5 cm    E                   Not Covered
D7912   Suture complicate wnd > 5 cm   E                   Not Covered
D7920   Dental skin graft              E                   Not Covered
D7940   Reshaping bone orthognathic    S 00330   10.3227   Not Covered
D7941   Bone cutting ramus closed      E                   Not Covered
D7943   Cutting ramus open w/graft     E                   Not Covered
D7944   Bone cutting segmented         E   Not Covered
D7945   Bone cutting body mandible     E   Not Covered
D7946   Reconstruction maxilla total   E   Not Covered
D7947   Reconstruct maxilla segment    E   Not Covered
D7948   Reconstruct midface no graft   E   Not Covered
D7949   Reconstruct midface w/graft    E   Not Covered
D7950   Mandible graft                 E   Not Covered
D7951   Sinus aug w bone/bone sup      E   Not Covered
D7953   Bone replacement graft         E   Not Covered
D7955   Repair maxillofacial defects   E   Not Covered
D7960   Frenulectomy/frenulotomy       E   Not Covered
D7963   Frenuloplasty                  E   Not Covered
D7970   Excision hyperplastic tissue   E   Not Covered
D7971   Excision pericoronal gingiva   E   Not Covered
D7972   Surg redct fibrous tuberosit   E   Not Covered
D7980   Sialolithotomy                 E   Not Covered
D7981   Excision of salivary gland     E   Not Covered
D7982   Sialodochoplasty               E   Not Covered
D7983   Closure of salivary fistula    E   Not Covered
D7990   Emergency tracheotomy          E   Not Covered
D7991   Dental coronoidectomy          E   Not Covered
D7995   Synthetic graft facial bones   E   Not Covered
D7996   Implant mandible for augment   E   Not Covered
D7997   Appliance removal              E   Not Covered
D7998   Intraoral place of fix dev     E   Not Covered
D7999   Oral surgery procedure         E    By Report
D8010   Limited dental tx primary      E   Not Covered
D8020   Limited dental tx transition   E   Not Covered
D8030   Limited dental tx adolescent   E   Not Covered
D8040   Limited dental tx adult        E   Not Covered
D8050   Intercep dental tx primary     E   Not Covered
D8060   Intercep dental tx transitn    E   Not Covered
D8070   Compre dental tx transition    E   Not Covered
D8080   Compre dental tx adolescent    E   Not Covered
D8090   Compre dental tx adult         E   Not Covered
D8210   Orthodontic rem appliance tx   E   Not Covered
D8220   Fixed appliance therapy habt   E   Not Covered
D8660   Preorthodontic tx visit        E   Not Covered
D8670   Periodic orthodontc tx visit   E   Not Covered
D8680   Orthodontic retention          E   Not Covered
D8690   Orthodontic treatment          E   Not Covered
D8691   Repair ortho appliance         E   Not Covered
D8692   Replacement retainer           E   Not Covered
D8693   Rebond/cement/repair retain    E   Not Covered
D8999   Orthodontic procedure          E   Not Covered
D9110   Tx dental pain minor proc      N   Not Covered
D9120   Fix partial denture section    E   Not Covered
D9210   Dent anesthesia w/o surgery    E   Not Covered
D9211   Regional block anesthesia      E   Not Covered
D9212   Trigeminal block anesthesia    E   Not Covered
D9215   Local anesthesia               E   Not Covered
D9220   General anesthesia             E   Not Covered
D9221   General anesthesia ea ad 15m   E                     Not Covered
D9230   Analgesia                      N                     Not Covered
D9241   Intravenous sedation           E                     Not Covered
D9242   IV sedation ea ad 30 m         E                     Not Covered
D9248   Sedation (non-iv)              N                     Not Covered
D9310   Dental consultation            E                     Not Covered
D9410   Dental house call              E                     Not Covered
D9420   Hospital call                  E                     Not Covered
D9430   Office visit during hours      E                     Not Covered
D9440   Office visit after hours       E                     Not Covered
D9450   Case presentation tx plan      E                     Not Covered
D9610   Dent therapeutic drug inject   E                     Not Covered
D9612   Thera par drugs 2 or > admin   E                     Not Covered
D9630   Other drugs/medicaments        S   00330   10.3227   Not Covered
D9910   Dent appl desensitizing med    E                     Not Covered
D9911   Appl desensitizing resin       E                     Not Covered
D9920   Behavior management            E                     Not Covered
D9930   Treatment of complications     S   00330   10.3227   Not Covered
D9940   Dental occlusal guard          S   00330   10.3227   Not Covered
D9941   Fabrication athletic guard     E                     Not Covered
D9942   Repair/reline occlusal guard   E                     Not Covered
D9950   Occlusion analysis             S   00330   10.3227   Not Covered
D9951   Limited occlusal adjustment    S   00330   10.3227   Not Covered
D9952   Complete occlusal adjustment   S   00330   10.3227   Not Covered
D9970   Enamel microabrasion           E                     Not Covered
D9971   Odontoplasty 1-2 teeth         E                     Not Covered
D9972   Extrnl bleaching per arch      E                     Not Covered
D9973   Extrnl bleaching per tooth     E                     Not Covered
D9974   Intrnl bleaching per tooth     E                     Not Covered
D9999   Adjunctive procedure           E                     Not Covered
E0100   Cane adjust/fixed with tip     Y                     Not Covered
E0105   Cane adjust/fixed quad/3 pro   Y                     Not Covered
E0110   Crutch forearm pair            Y                     Not Covered
E0111   Crutch forearm each            Y                     Not Covered
E0112   Crutch underarm pair wood      Y                     Not Covered
E0113   Crutch underarm each wood      Y                     Not Covered
E0114   Crutch underarm pair no wood   Y                     Not Covered
E0116   Crutch underarm each no wood   Y                     Not Covered
E0117   Underarm springassist crutch   Y                     Not Covered
E0118   Crutch substitute              E                     Not Covered
E0130   Walker rigid adjust/fixed ht   Y                     Not Covered
E0135   Walker folding adjust/fixed    Y                     Not Covered
E0140   Walker w trunk support         Y                     Not Covered
E0141   Rigid wheeled walker adj/fix   Y                     Not Covered
E0143   Walker folding wheeled w/o s   Y                     Not Covered
E0144   Enclosed walker w rear seat    Y                     Not Covered
E0147   Walker variable wheel resist   Y                     Not Covered
E0148   Heavyduty walker no wheels     Y                     Not Covered
E0149   Heavy duty wheeled walker      Y                     Not Covered
E0153   Forearm crutch platform atta   Y                     Not Covered
E0154   Walker platform attachment     Y                     Not Covered
E0155   Walker wheel attachment,pair   Y                     Not Covered
E0156   Walker seat attachment         Y             Not Covered
E0157   Walker crutch attachment       Y             Not Covered
E0158   Walker leg extenders set of4   Y             Not Covered
E0159   Brake for wheeled walker       Y             Not Covered
E0160   Sitz type bath or equipment    Y             Not Covered
E0161   Sitz bath/equipment w/faucet   Y             Not Covered
E0162   Sitz bath chair                Y             Not Covered
E0163   Commode chair with fixed arm   Y             Not Covered
E0165   Commode chair with detacharm   Y             Not Covered
E0167   Commode chair pail or pan      Y             Not Covered
E0168   Heavyduty/wide commode chair   Y             Not Covered
E0170   Commode chair electric         Y   $160.72     Covered
E0171   Commode chair non-electric     Y             Not Covered
E0172   Seat lift mechanism toilet     E             Not Covered
E0175   Commode chair foot rest        Y             Not Covered
E0181   Press pad alternating w/ pum   Y             Not Covered
E0182   Replace pump, alt press pad    Y             Not Covered
E0184   Dry pressure mattress          Y             Not Covered
E0185   Gel pressure mattress pad      Y             Not Covered
E0186   Air pressure mattress          Y             Not Covered
E0187   Water pressure mattress        Y             Not Covered
E0188   Synthetic sheepskin pad        Y             Not Covered
E0189   Lambswool sheepskin pad        Y             Not Covered
E0190   Positioning cushion            E              By Report
E0191   Protector heel or elbow        Y             Not Covered
E0193   Powered air flotation bed      Y             Not Covered
E0194   Air fluidized bed              Y             Not Covered
E0196   Gel pressure mattress          Y             Not Covered
E0197   Air pressure pad for mattres   Y             Not Covered
E0198   Water pressure pad for mattr   Y             Not Covered
E0199   Dry pressure pad for mattres   Y             Not Covered
E0200   Heat lamp without stand        Y             Not Covered
E0202   Phototherapy light w/ photom   Y             Not Covered
E0203   Therapeutic lightbox tabletp   E             Not Covered
E0205   Heat lamp with stand           Y             Not Covered
E0210   Electric heat pad standard     Y             Not Covered
E0215   Electric heat pad moist        Y             Not Covered
E0217   Water circ heat pad w pump     Y             Not Covered
E0218   Water circ cold pad w pump     Y             Not Covered
E0220   Hot water bottle               Y             Not Covered
E0221   Infrared heating pad system    Y             Not Covered
E0225   Hydrocollator unit             Y             Not Covered
E0230   Ice cap or collar              Y             Not Covered
E0231   Wound warming device           E             Not Covered
E0232   Warming card for NWT           E             Not Covered
E0235   Paraffin bath unit portable    Y             Not Covered
E0236   Pump for water circulating p   Y             Not Covered
E0238   Heat pad non-electric moist    Y             Not Covered
E0239   Hydrocollator unit portable    Y             Not Covered
E0240   Bath/shower chair              E             Not Covered
E0241   Bath tub wall rail             E             Not Covered
E0242   Bath tub rail floor            E             Not Covered
E0243   Toilet rail                    E             Not Covered
E0244   Toilet seat raised             E             Not Covered
E0245   Tub stool or bench             E             Not Covered
E0246   Transfer tub rail attachment   E             Not Covered
E0247   Trans bench w/wo comm open     E             Not Covered
E0248   HDtrans bench w/wo comm open   E             Not Covered
E0249   Pad water circulating heat u   Y             Not Covered
E0250   Hosp bed fixed ht w/ mattres   Y             Not Covered
E0251   Hosp bed fixd ht w/o mattres   Y             Not Covered
E0255   Hospital bed var ht w/ mattr   Y             Not Covered
E0256   Hospital bed var ht w/o matt   Y             Not Covered
E0260   Hosp bed semi-electr w/ matt   Y             Not Covered
E0261   Hosp bed semi-electr w/o mat   Y             Not Covered
E0265   Hosp bed total electr w/ mat   Y             Not Covered
E0266   Hosp bed total elec w/o matt   Y             Not Covered
E0270   Hospital bed institutional t   E             Not Covered
E0271   Mattress innerspring           Y             Not Covered
E0272   Mattress foam rubber           Y             Not Covered
E0273   Bed board                      E             Not Covered
E0274   Over-bed table                 E             Not Covered
E0275   Bed pan standard               Y             Not Covered
E0276   Bed pan fracture               Y             Not Covered
E0277   Powered pres-redu air mattrs   Y             Not Covered
E0280   Bed cradle                     Y             Not Covered
E0290   Hosp bed fx ht w/o rails w/m   Y             Not Covered
E0291   Hosp bed fx ht w/o rail w/o    Y             Not Covered
E0292   Hosp bed var ht w/o rail w/o   Y             Not Covered
E0293   Hosp bed var ht w/o rail w/    Y             Not Covered
E0294   Hosp bed semi-elect w/ mattr   Y             Not Covered
E0295   Hosp bed semi-elect w/o matt   Y             Not Covered
E0296   Hosp bed total elect w/ matt   Y             Not Covered
E0297   Hosp bed total elect w/o mat   Y             Not Covered
E0300   Enclosed ped crib hosp grade   Y             Not Covered
E0301   HD hosp bed, 350-600 lbs       Y             Not Covered
E0302   Ex hd hosp bed > 600 lbs       Y             Not Covered
E0303   Hosp bed hvy dty xtra wide     Y             Not Covered
E0304   Hosp bed xtra hvy dty x wide   Y             Not Covered
E0305   Rails bed side half length     Y             Not Covered
E0310   Rails bed side full length     Y             Not Covered
E0315   Bed accessory brd/tbl/supprt   E             Not Covered
E0316   Bed safety enclosure           Y   $211.28    Covered
E0325   Urinal male jug-type           Y             Not Covered
E0326   Urinal female jug-type         Y             Not Covered
E0328   Ped hospital bed, manual       Y             Not Covered
E0329   Ped hospital bed semi/elect    Y             Not Covered
E0350   Control unit bowel system      E             Not Covered
E0352   Disposable pack w/bowel syst   E             Not Covered
E0370   Air elevator for heel          E             Not Covered
E0371   Nonpower mattress overlay      Y             Not Covered
E0372   Powered air mattress overlay   Y             Not Covered
E0373   Nonpowered pressure mattress   Y   $614.47    Covered
E0424   Stationary compressed gas 02   Y             Not Covered
E0425   Gas system stationary compre   E             Not Covered
E0430   Oxygen system gas portable     E             Not Covered
E0431   Portable gaseous 02            Y             Not Covered
E0433   Portable liquid oxygen sys     Y             Not Covered
E0434   Portable liquid 02             Y             Not Covered
E0435   Oxygen system liquid portabl   E             Not Covered
E0439   Stationary liquid 02           Y             Not Covered
E0440   Oxygen system liquid station   E             Not Covered
E0441   Oxygen contents, gaseous       Y             Not Covered
E0442   Oxygen contents, liquid        Y             Not Covered
E0443   Portable 02 contents, gas      Y             Not Covered
E0444   Portable 02 contents, liquid   Y             Not Covered
E0445   Oximeter non-invasive          N             Not Covered
E0450   Vol control vent invasiv int   Y             Not Covered
E0455   Oxygen tent excl croup/ped t   Y             Not Covered
E0457   Chest shell                    Y             Not Covered
E0459   Chest wrap                     Y             Not Covered
E0460   Neg press vent portabl/statn   Y             Not Covered
E0461   Vol control vent noninv int    Y             Not Covered
E0462   Rocking bed w/ or w/o side r   Y             Not Covered
E0463   Press supp vent invasive int   Y             Not Covered
E0464   Press supp vent noninv int     Y             Not Covered
E0470   RAD w/o backup non-inv intfc   Y             Not Covered
E0471   RAD w/backup non inv intrfc    Y             Not Covered
E0472   RAD w backup invasive intrfc   Y             Not Covered
E0480   Percussor elect/pneum home m   Y             Not Covered
E0481   Intrpulmnry percuss vent sys   E             Not Covered
E0482   Cough stimulating device       Y             Not Covered
E0483   Chest compression gen system   Y             Not Covered
E0484   Non-elec oscillatory pep dvc   Y             Not Covered
E0485   Oral device/appliance prefab   Y             Not Covered
E0486   Oral device/appliance cusfab   Y             Not Covered
E0487   Electronic spirometer          N             Not Covered
E0500   Ippb all types                 Y             Not Covered
E0550   Humidif extens supple w ippb   Y             Not Covered
E0555   Humidifier for use w/ regula   Y             Not Covered
E0560   Humidifier supplemental w/ i   Y             Not Covered
E0561   Humidifier nonheated w PAP     Y             Not Covered
E0562   Humidifier heated used w PAP   Y             Not Covered
E0565   Compressor air power source    Y             Not Covered
E0570   Nebulizer with compression     Y             Not Covered
E0571   Aerosol compressor for svneb   Y             Not Covered
E0572   Aerosol compressor adjust pr   Y             Not Covered
E0574   Ultrasonic generator w svneb   Y             Not Covered
E0575   Nebulizer ultrasonic           Y             Not Covered
E0580   Nebulizer for use w/ regulat   Y   $134.04    Covered
E0585   Nebulizer w/ compressor & he   Y             Not Covered
E0600   Suction pump portab hom modl   Y             Not Covered
E0601   Cont airway pressure device    Y             Not Covered
E0602   Manual breast pump             Y             Not Covered
E0603   Electric breast pump           N             Not Covered
E0604   Hosp grade elec breast pump    A             Not Covered
E0605   Vaporizer room type            Y             Not Covered
E0606   Drainage board postural        Y             Not Covered
E0607   Blood glucose monitor home     Y             Not Covered
E0610   Pacemaker monitr audible/vis   Y             Not Covered
E0615   Pacemaker monitr digital/vis   Y             Not Covered
E0616   Cardiac event recorder         N             Not Covered
E0617   Automatic ext defibrillator    Y             Not Covered
E0618   Apnea monitor                  Y             Not Covered
E0619   Apnea monitor w recorder       Y             Not Covered
E0620   Cap bld skin piercing laser    Y             Not Covered
E0621   Patient lift sling or seat     Y             Not Covered
E0625   Patient lift bathroom or toi   E             Not Covered
E0627   Seat lift incorp lift-chair    Y             Not Covered
E0628   Seat lift for pt furn-electr   Y             Not Covered
E0629   Seat lift for pt furn-non-el   Y             Not Covered
E0630   Patient lift hydraulic         Y             Not Covered
E0635   Patient lift electric          Y             Not Covered
E0636   PT support & positioning sys   Y             Not Covered
E0637   Combination sit to stand sys   E             Not Covered
E0638   Standing frame sys             E             Not Covered
E0639   Moveable patient lift system   E             Not Covered
E0640   Fixed patient lift system      E             Not Covered
E0641   Multi-position stnd fram sys   E             Not Covered
E0642   Dynamic standing frame         E             Not Covered
E0650   Pneuma compresor non-segment   Y             Not Covered
E0651   Pneum compressor segmental     Y             Not Covered
E0652   Pneum compres w/cal pressure   Y             Not Covered
E0655   Pneumatic appliance half arm   Y   $81.05      Covered
E0656   Segmental pneumatic trunk      Y             Not Covered
E0657   Segmental pneumatic chest      Y             Not Covered
E0660   Pneumatic appliance full leg   Y             Not Covered
E0665   Pneumatic appliance full arm   Y             Not Covered
E0666   Pneumatic appliance half leg   Y             Not Covered
E0667   Seg pneumatic appl full leg    Y             Not Covered
E0668   Seg pneumatic appl full arm    Y             Not Covered
E0669   Seg pneumatic appli half leg   Y             Not Covered
E0671   Pressure pneum appl full leg   Y             Not Covered
E0672   Pressure pneum appl full arm   Y             Not Covered
E0673   Pressure pneum appl half leg   Y             Not Covered
E0675   Pneumatic compression device   Y             Not Covered
E0676   Inter limb compress dev NOS    Y             Not Covered
E0691   Uvl pnl 2 sq ft or less        Y             Not Covered
E0692   Uvl sys panel 4 ft             Y             Not Covered
E0693   Uvl sys panel 6 ft             Y             Not Covered
E0694   Uvl md cabinet sys 6 ft        Y             Not Covered
E0700   Safety equipment               E              By Report
E0705   Transfer device                B             Not Covered
E0710   Restraints any type            E             Not Covered
E0720   Tens two lead                  Y             Not Covered
E0730   Tens four lead                 Y             Not Covered
E0731   Conductive garment for tens/   Y             Not Covered
E0740   Incontinence treatment systm   Y   $522.87     Covered
E0744   Neuromuscular stim for scoli   Y             Not Covered
E0745   Neuromuscular stim for shock   Y             Not Covered
E0746   Electromyograph biofeedback    N             Not Covered
E0747   Elec osteogen stim not spine   Y             Not Covered
E0748   Elec osteogen stim spinal      Y             Not Covered
E0749   Elec osteogen stim implanted   N             Not Covered
E0755   Electronic salivary reflex s   E             Not Covered
E0760   Osteogen ultrasound stimltor   Y             Not Covered
E0761   Nontherm electromgntc device   E             Not Covered
E0762   Trans elec jt stim dev sys     B             Not Covered
E0764   Functional neuromuscularstim   Y             Not Covered
E0765   Nerve stimulator for tx n&v    Y             Not Covered
E0769   Electric wound treatment dev   B             Not Covered
E0770   Functional electric stim NOS   Y              By Report
E0776   Iv pole                        Y             Not Covered
E0779   Amb infusion pump mechanical   Y             Not Covered
E0780   Mech amb infusion pump <8hrs   Y             Not Covered
E0781   External ambulatory infus pu   Y             Not Covered
E0782   Non-programble infusion pump   N             Not Covered
E0783   Programmable infusion pump     N             Not Covered
E0784   Ext amb infusn pump insulin    Y             Not Covered
E0785   Replacement impl pump cathet   N             Not Covered
E0786   Implantable pump replacement   N             Not Covered
E0791   Parenteral infusion pump sta   Y             Not Covered
E0830   Ambulatory traction device     N             Not Covered
E0840   Tract frame attach headboard   Y             Not Covered
E0849   Cervical pneum trac equip      Y   $515.31     Covered
E0850   Traction stand free standing   Y             Not Covered
E0855   Cervical traction equipment    Y             Not Covered
E0856   Cervic collar w air bladder    Y             Not Covered
E0860   Tract equip cervical tract     Y             Not Covered
E0870   Tract frame attach footboard   Y             Not Covered
E0880   Trac stand free stand extrem   Y             Not Covered
E0890   Traction frame attach pelvic   Y             Not Covered
E0900   Trac stand free stand pelvic   Y             Not Covered
E0910   Trapeze bar attached to bed    Y             Not Covered
E0911   HD trapeze bar attach to bed   Y             Not Covered
E0912   HD trapeze bar free standing   Y             Not Covered
E0920   Fracture frame attached to b   Y             Not Covered
E0930   Fracture frame free standing   Y             Not Covered
E0935   Cont pas motion exercise dev   Y             Not Covered
E0936   CPM device, other than knee    E             Not Covered
E0940   Trapeze bar free standing      Y             Not Covered
E0941   Gravity assisted traction de   Y             Not Covered
E0942   Cervical head harness/halter   Y             Not Covered
E0944   Pelvic belt/harness/boot       Y             Not Covered
E0945   Belt/harness extremity         Y             Not Covered
E0946   Fracture frame dual w cross    Y             Not Covered
E0947   Fracture frame attachmnts pe   Y             Not Covered
E0948   Fracture frame attachmnts ce   Y             Not Covered
E0950   Tray                           Y             Not Covered
E0951   Loop heel                      Y             Not Covered
E0952   Toe loop/holder, each          Y             Not Covered
E0955   Cushioned headrest             Y             Not Covered
E0956   W/c lateral trunk/hip suppor   Y             Not Covered
E0957   W/c medial thigh support       Y             Not Covered
E0958   Whlchr att- conv 1 arm drive   Y             Not Covered
E0959   Amputee adapter                B             Not Covered
E0960   W/c shoulder harness/straps    Y             Not Covered
E0961   Wheelchair brake extension     B             Not Covered
E0966   Wheelchair head rest extensi   B             Not Covered
E0967   Manual wc hand rim w project   Y             Not Covered
E0968   Wheelchair commode seat        Y             Not Covered
E0969   Wheelchair narrowing device    Y             Not Covered
E0970   Wheelchair no. 2 footplates    E             Not Covered
E0971   Wheelchair anti-tipping devi   B             Not Covered
E0973   W/Ch access det adj armrest    B             Not Covered
E0974   W/Ch access anti-rollback      B             Not Covered
E0978   W/C acc,saf belt pelv strap    B             Not Covered
E0980   Wheelchair safety vest         Y             Not Covered
E0981   Seat upholstery, replacement   Y             Not Covered
E0982   Back upholstery, replacement   Y             Not Covered
E0983   Add pwr joystick               Y             Not Covered
E0984   Add pwr tiller                 Y             Not Covered
E0985   W/c seat lift mechanism        Y             Not Covered
E0986   Man w/c push-rim pow assist    Y             Not Covered
E0990   Wheelchair elevating leg res   B             Not Covered
E0992   Wheelchair solid seat insert   B             Not Covered
E0994   Wheelchair arm rest            Y             Not Covered
E0995   Wheelchair calf rest           B             Not Covered
E1002   Pwr seat tilt                  Y             Not Covered
E1003   Pwr seat recline               Y             Not Covered
E1004   Pwr seat recline mech          Y             Not Covered
E1005   Pwr seat recline pwr           Y             Not Covered
E1006   Pwr seat combo w/o shear       Y             Not Covered
E1007   Pwr seat combo w/shear         Y             Not Covered
E1008   Pwr seat combo pwr shear       Y             Not Covered
E1009   Add mech leg elevation         Y             Not Covered
E1010   Add pwr leg elevation          Y             Not Covered
E1011   Ped wc modify width adjustm    Y             Not Covered
E1014   Reclining back add ped w/c     Y   $365.14     Covered
E1015   Shock absorber for man w/c     Y             Not Covered
E1016   Shock absorber for power w/c   Y             Not Covered
E1017   HD shck absrbr for hd man wc   Y             Not Covered
E1018   HD shck absrber for hd powwc   Y             Not Covered
E1020   Residual limb support system   Y             Not Covered
E1028   W/c manual swingaway           Y             Not Covered
E1029   W/c vent tray fixed            Y             Not Covered
E1030   W/c vent tray gimbaled         Y             Not Covered
E1031   Rollabout chair with casters   Y             Not Covered
E1035   Patient transfer system        Y              By Report
E1036   Patient transfer system >300   Y             Not Covered
E1037   Transport chair, ped size      Y             Not Covered
E1038   Transport chair pt wt<=300lb   Y             Not Covered
E1039   Transport chair pt wt >300lb   Y   $34.20      Covered
E1050   Whelchr fxd full length arms   Y             Not Covered
E1060   Wheelchair detachable arms     Y             Not Covered
E1070   Wheelchair detachable foot r   Y             Not Covered
E1083   Hemi-wheelchair fixed arms     Y             Not Covered
E1084   Hemi-wheelchair detachable a   Y             Not Covered
E1085   Hemi-wheelchair fixed arms     E             Not Covered
E1086   Hemi-wheelchair detachable a   E             Not Covered
E1087   Wheelchair lightwt fixed arm   Y             Not Covered
E1088   Wheelchair lightweight det a   Y             Not Covered
E1089   Wheelchair lightwt fixed arm   E             Not Covered
E1090   Wheelchair lightweight det a   E             Not Covered
E1092   Wheelchair wide w/ leg rests   Y             Not Covered
E1093   Wheelchair wide w/ foot rest   Y             Not Covered
E1100   Whchr s-recl fxd arm leg res   Y             Not Covered
E1110   Wheelchair semi-recl detach    Y   $101.66     Covered
E1130   Whlchr stand fxd arm ft rest   E             Not Covered
E1140   Wheelchair standard detach a   E             Not Covered
E1150   Wheelchair standard w/ leg r   Y             Not Covered
E1160   Wheelchair fixed arms          Y             Not Covered
E1161   Manual adult wc w tiltinspac   Y             Not Covered
E1170   Whlchr ampu fxd arm leg rest   Y             Not Covered
E1171   Wheelchair amputee w/o leg r   Y             Not Covered
E1172   Wheelchair amputee detach ar   Y             Not Covered
E1180   Wheelchair amputee w/ foot r   Y             Not Covered
E1190   Wheelchair amputee w/ leg re   Y             Not Covered
E1195   Wheelchair amputee heavy dut   Y             Not Covered
E1200   Wheelchair amputee fixed arm   Y             Not Covered
E1220   Whlchr special size/constrc    Y             Not Covered
E1221   Wheelchair spec size w foot    Y             Not Covered
E1222   Wheelchair spec size w/ leg    Y             Not Covered
E1223   Wheelchair spec size w foot    Y             Not Covered
E1224   Wheelchair spec size w/ leg    Y             Not Covered
E1225   Manual semi-reclining back     Y             Not Covered
E1226   Manual fully reclining back    B             Not Covered
E1227   Wheelchair spec sz spec ht a   Y             Not Covered
E1228   Wheelchair spec sz spec ht b   Y             Not Covered
E1229   Pediatric wheelchair NOS       Y              By Report
E1230   Power operated vehicle         Y             Not Covered
E1231   Rigid ped w/c tilt-in-space    Y             Not Covered
E1232   Folding ped wc tilt-in-space   Y             Not Covered
E1233   Rig ped wc tltnspc w/o seat    Y             Not Covered
E1234   Fld ped wc tltnspc w/o seat    Y             Not Covered
E1235   Rigid ped wc adjustable        Y             Not Covered
E1236   Folding ped wc adjustable      Y             Not Covered
E1237   Rgd ped wc adjstabl w/o seat   Y             Not Covered
E1238   Fld ped wc adjstabl w/o seat   Y             Not Covered
E1239   Ped power wheelchair NOS       Y             Not Covered
E1240   Whchr litwt det arm leg rest   Y             Not Covered
E1250   Wheelchair lightwt fixed arm   E             Not Covered
E1260   Wheelchair lightwt foot rest   E             Not Covered
E1270   Wheelchair lightweight leg r   Y             Not Covered
E1280   Whchr h-duty det arm leg res   Y   Not Covered
E1285   Wheelchair heavy duty fixed    E   Not Covered
E1290   Wheelchair hvy duty detach a   E   Not Covered
E1295   Wheelchair heavy duty fixed    Y   Not Covered
E1296   Wheelchair special seat heig   Y   Not Covered
E1297   Wheelchair special seat dept   Y   Not Covered
E1298   Wheelchair spec seat depth/w   Y   Not Covered
E1300   Whirlpool portable             E   Not Covered
E1310   Whirlpool non-portable         Y   Not Covered
E1340   Repair for DME, per 15 min     D   Not Covered
E1353   Oxygen supplies regulator      Y   Not Covered
E1354   Wheeled cart, port cyl/conc    Y   Not Covered
E1355   Oxygen supplies stand/rack     Y   Not Covered
E1356   Batt pack/cart, port conc      Y   Not Covered
E1357   Battery charger, port conc     Y   Not Covered
E1358   DC power adapter, port conc    Y   Not Covered
E1372   Oxy suppl heater for nebuliz   Y   Not Covered
E1390   Oxygen concentrator            Y   Not Covered
E1391   Oxygen concentrator, dual      Y   Not Covered
E1392   Portable oxygen concentrator   Y   Not Covered
E1399   Durable medical equipment mi   Y   Not Covered
E1405   O2/water vapor enrich w/heat   Y   Not Covered
E1406   O2/water vapor enrich w/o he   Y   Not Covered
E1500   Centrifuge                     A    By Report
E1510   Kidney dialysate delivry sys   A    By Report
E1520   Heparin infusion pump          A   Not Covered
E1530   Replacement air bubble detec   A   Not Covered
E1540   Replacement pressure alarm     A   Not Covered
E1550   Bath conductivity meter        A   Not Covered
E1560   Replace blood leak detector    A   Not Covered
E1570   Adjustable chair for esrd pt   A   Not Covered
E1575   Transducer protect/fld bar     A   Not Covered
E1580   Unipuncture control system     A   Not Covered
E1590   Hemodialysis machine           A   Not Covered
E1592   Auto interm peritoneal dialy   A   Not Covered
E1594   Cycler dialysis machine        A   Not Covered
E1600   Deli/install chrg hemo equip   A   Not Covered
E1610   Reverse osmosis h2o puri sys   A   Not Covered
E1615   Deionizer H2O puri system      A   Not Covered
E1620   Replacement blood pump         A   Not Covered
E1625   Water softening system         A   Not Covered
E1630   Reciprocating peritoneal dia   A    By Report
E1632   Wearable artificial kidney     A   Not Covered
E1634   Peritoneal dialysis clamp      B   Not Covered
E1635   Compact travel hemodialyzer    A   Not Covered
E1636   Sorbent cartridges per 10      A   Not Covered
E1637   Hemostats for dialysis, each   A    By Report
E1639   Dialysis scale                 A    By Report
E1699   Dialysis equipment noc         A   Not Covered
E1700   Jaw motion rehab system        Y   Not Covered
E1701   Repl cushions for jaw motion   Y   Not Covered
E1702   Repl measr scales jaw motion   Y   Not Covered
E1800   Adjust elbow ext/flex device   Y             Not Covered
E1801   SPS elbow device               Y             Not Covered
E1802   Adjst forearm pro/sup device   Y             Not Covered
E1805   Adjust wrist ext/flex device   Y             Not Covered
E1806   SPS wrist device               Y             Not Covered
E1810   Adjust knee ext/flex device    Y             Not Covered
E1811   SPS knee device                Y             Not Covered
E1812   Knee ext/flex w act res ctrl   Y             Not Covered
E1815   Adjust ankle ext/flex device   Y             Not Covered
E1816   SPS ankle device               Y             Not Covered
E1818   SPS forearm device             Y             Not Covered
E1820   Soft interface material        Y             Not Covered
E1821   Replacement interface SPSD     Y             Not Covered
E1825   Adjust finger ext/flex devc    Y             Not Covered
E1830   Adjust toe ext/flex device     Y             Not Covered
E1840   Adj shoulder ext/flex device   Y             Not Covered
E1841   Static str shldr dev rom adj   Y             Not Covered
E1902   AAC non-electronic board       Y             Not Covered
E2000   Gastric suction pump hme mdl   Y             Not Covered
E2100   Bld glucose monitor w voice    Y   $643.19     Covered
E2101   Bld glucose monitor w lance    Y             Not Covered
E2120   Pulse gen sys tx endolymp fl   Y             Not Covered
E2201   Man w/ch acc seat w>=20"<24"   Y             Not Covered
E2202   Seat width 24-27 in            Y             Not Covered
E2203   Frame depth less than 22 in    Y             Not Covered
E2204   Frame depth 22 to 25 in        Y             Not Covered
E2205   Manual wc accessory, handrim   Y   $32.10      Covered
E2206   Complete wheel lock assembly   Y   $40.01      Covered
E2207   Crutch and cane holder         Y             Not Covered
E2208   Cylinder tank carrier          Y             Not Covered
E2209   Arm trough each                Y             Not Covered
E2210   Wheelchair bearings            Y             Not Covered
E2211   Pneumatic propulsion tire      Y             Not Covered
E2212   Pneumatic prop tire tube       Y             Not Covered
E2213   Pneumatic prop tire insert     Y             Not Covered
E2214   Pneumatic caster tire each     Y             Not Covered
E2215   Pneumatic caster tire tube     Y             Not Covered
E2216   Foam filled propulsion tire    Y             Not Covered
E2217   Foam filled caster tire each   Y             Not Covered
E2218   Foam propulsion tire each      Y             Not Covered
E2219   Foam caster tire any size ea   Y             Not Covered
E2220   Solid propulsion tire each     Y             Not Covered
E2221   Solid caster tire each         Y             Not Covered
E2222   Solid caster integrated whl    Y             Not Covered
E2223   Valve replacement only each    D             Not Covered
E2224   Propulsion whl excludes tire   Y             Not Covered
E2225   Caster wheel excludes tire     Y             Not Covered
E2226   Caster fork replacement only   Y             Not Covered
E2227   Gear reduction drive wheel     Y             Not Covered
E2228   Mwc acc, wheelchair brake      Y             Not Covered
E2230   Manual standing system         E              By Report
E2231   Solid seat support base        Y   $161.36     Covered
E2291   Planar back for ped size wc    Y              By Report
E2292   Planar seat for ped size wc    Y              By Report
E2293   Contour back for ped size wc   Y              By Report
E2294   Contour seat for ped size wc   Y              By Report
E2295   Ped dynamic seating frame      Y              By Report
E2300   Pwr seat elevation sys         Y             Not Covered
E2301   Pwr standing                   Y             Not Covered
E2310   Electro connect btw control    Y             Not Covered
E2311   Electro connect btw 2 sys      Y             Not Covered
E2312   Mini-prop remote joystick      Y             Not Covered
E2313   PWC harness, expand control    Y             Not Covered
E2321   Hand interface joystick        Y             Not Covered
E2322   Mult mech switches             Y             Not Covered
E2323   Special joystick handle        Y             Not Covered
E2324   Chin cup interface             Y             Not Covered
E2325   Sip and puff interface         Y             Not Covered
E2326   Breath tube kit                Y             Not Covered
E2327   Head control interface mech    Y             Not Covered
E2328   Head/extremity control inter   Y             Not Covered
E2329   Head control nonproportional   Y             Not Covered
E2330   Head control proximity switc   Y             Not Covered
E2331   Attendant control              Y             Not Covered
E2340   W/c wdth 20-23 in seat frame   Y             Not Covered
E2341   W/c wdth 24-27 in seat frame   Y             Not Covered
E2342   W/c dpth 20-21 in seat frame   Y             Not Covered
E2343   W/c dpth 22-25 in seat frame   Y             Not Covered
E2351   Electronic SGD interface       Y             Not Covered
E2360   22nf nonsealed leadacid        Y             Not Covered
E2361   22nf sealed leadacid battery   Y             Not Covered
E2362   Gr24 nonsealed leadacid        Y             Not Covered
E2363   Gr24 sealed leadacid battery   Y             Not Covered
E2364   U1nonsealed leadacid battery   Y             Not Covered
E2365   U1 sealed leadacid battery     Y             Not Covered
E2366   Battery charger, single mode   Y             Not Covered
E2367   Battery charger, dual mode     Y             Not Covered
E2368   Power wc motor replacement     Y   $516.57     Covered
E2369   Pwr wc gear box replacement    Y   $449.94     Covered
E2370   Pwr wc motor/gear box combo    Y   $802.84     Covered
E2371   Gr27 sealed leadacid battery   Y             Not Covered
E2372   Gr27 non-sealed leadacid       Y             Not Covered
E2373   Hand/chin ctrl spec joystick   Y             Not Covered
E2374   Hand/chin ctrl std joystick    Y             Not Covered
E2375   Non-expandable controller      Y             Not Covered
E2376   Expandable controller, repl    Y             Not Covered
E2377   Expandable controller, initl   Y             Not Covered
E2381   Pneum drive wheel tire         Y             Not Covered
E2382   Tube, pneum wheel drive tire   Y             Not Covered
E2383   Insert, pneum wheel drive      Y             Not Covered
E2384   Pneumatic caster tire          Y             Not Covered
E2385   Tube, pneumatic caster tire    Y             Not Covered
E2386   Foam filled drive wheel tire   Y             Not Covered
E2387   Foam filled caster tire        Y             Not Covered
E2388   Foam drive wheel tire          Y                              Not Covered
E2389   Foam caster tire               Y                              Not Covered
E2390   Solid drive wheel tire         Y                              Not Covered
E2391   Solid caster tire              Y                              Not Covered
E2392   Solid caster tire, integrate   Y                              Not Covered
E2393   Valve, pneumatic tire tube     D                              Not Covered
E2394   Drive wheel excludes tire      Y                              Not Covered
E2395   Caster wheel excludes tire     Y                              Not Covered
E2396   Caster fork                    Y                              Not Covered
E2397   Pwc acc, lith-based battery    Y                              Not Covered
E2399   Noc interface                  D                              Not Covered
E2402   Neg press wound therapy pump   Y                              Not Covered
E2500   SGD digitized pre-rec <=8min   Y                              Not Covered
E2502   SGD prerec msg >8min <=20min   Y                              Not Covered
E2504   SGD prerec msg>20min <=40min   Y                              Not Covered
E2506   SGD prerec msg > 40 min        Y                              Not Covered
E2508   SGD spelling phys contact      Y                              Not Covered
E2510   SGD w multi methods msg/accs   Y                              Not Covered
E2511   SGD sftwre prgrm for PC/PDA    Y                              Not Covered
E2512   SGD accessory, mounting sys    Y                              Not Covered
E2599   SGD accessory noc              Y                              Not Covered
E2601   Gen w/c cushion wdth < 22 in   Y                     $61.16    Covered
E2602   Gen w/c cushion wdth >=22 in   Y                    $119.40    Covered
E2603   Skin protect wc cus wd <22in   Y                    $151.59    Covered
E2604   Skin protect wc cus wd>=22in   Y                    $188.41    Covered
E2605   Position wc cush wdth <22 in   Y                    $269.17    Covered
E2606   Position wc cush wdth>=22 in   Y                    $419.93    Covered
E2607   Skin pro/pos wc cus wd <22in   Y                    $289.85    Covered
E2608   Skin pro/pos wc cus wd>=22in   Y                    $348.09    Covered
E2609   Custom fabricate w/c cushion   Y                    $830.42    Covered
E2610   Powered w/c cushion            B                              Not Covered
E2611   Gen use back cush wdth <22in   Y                    $312.35    Covered
E2612   Gen use back cush wdth>=22in   Y                    $422.54    Covered
E2613   Position back cush wd <22in    Y                    $393.04    Covered
E2614   Position back cush wd>=22in    Y                    $543.93    Covered
E2615   Pos back post/lat wdth <22in   Y                    $452.32    Covered
E2616   Pos back post/lat wdth>=22in   Y                              Not Covered
E2617   Custom fab w/c back cushion    Y                    $822.92    Covered
E2619   Replace cover w/c seat cush    Y                              Not Covered
E2620   WC planar back cush wd <22in   Y                              Not Covered
E2621   WC planar back cush wd>=22in   Y                              Not Covered
E8000   Posterior gait trainer         E                              Not Covered
E8001   Upright gait trainer           E                              Not Covered
E8002   Anterior gait trainer          E                              Not Covered
G0008   Admin influenza virus vac      S   00350   0.3809             Not Covered
G0009   Admin pneumococcal vaccine     S   00350   0.3809             Not Covered
G0010   Admin hepatitis b vaccine      B                              Not Covered
G0027   Semen analysis                 A                              Not Covered
G0101   CA screen;pelvic/breast exam   V   00604   0.8593             Not Covered
G0102   Prostate ca screening; dre     N                              Not Covered
G0103   PSA screening                  A                              Not Covered
G0104   CA screen;flexi sigmoidscope   S   00159   3.7227              Covered
G0105   Colorectal scrn; hi risk ind   T   00158    8.0912             Covered
G0106   Colon CA screen;barium enema   S   00157    1.2511            Not Covered
G0108   Diab manage trn per indiv      A                              Not Covered
G0109   Diab manage trn ind/group      A                              Not Covered
G0117   Glaucoma scrn hgh risk direc   S   00698    0.9553            Not Covered
G0118   Glaucoma scrn hgh risk direc   S   00230    0.5945            Not Covered
G0120   Colon ca scrn; barium enema    S   00157    1.2511            Not Covered
G0121   Colon ca scrn not hi rsk ind   T   00158    8.0912             Covered
G0122   Colon ca scrn; barium enema    E                              Not Covered
G0123   Screen cerv/vag thin layer     A                              Not Covered
G0124   Screen c/v thin layer by MD    B                              Not Covered
G0127   Trim nail(s)                   T   00012    0.4436            Not Covered
G0128   CORF skilled nursing service   B                              Not Covered
G0129   Partial hosp prog service      P                              Not Covered
G0130   Single energy x-ray study      X   00260    0.6661            Not Covered
G0141   Scr c/v cyto,autosys and md    B                              Not Covered
G0143   Scr c/v cyto,thinlayer,rescr   A                              Not Covered
G0144   Scr c/v cyto,thinlayer,rescr   A                              Not Covered
G0145   Scr c/v cyto,thinlayer,rescr   A                              Not Covered
G0147   Scr c/v cyto, automated sys    A                              Not Covered
G0148   Scr c/v cyto, autosys, rescr   A                              Not Covered
G0151   HHCP-serv of pt,ea 15 min      B                              Not Covered
G0152   HHCP-serv of ot,ea 15 min      B                              Not Covered
G0153   HHCP-svs of s/l path,ea 15mn   B                              Not Covered
G0154   HHCP-svs of rn,ea 15 min       B                              Not Covered
G0155   HHCP-svs of csw,ea 15 min      B                              Not Covered
G0156   HHCP-svs of aide,ea 15 min     B                              Not Covered
G0166   Extrnl counterpulse, per tx    T   00678    1.5463            Not Covered
G0168   Wound closure by adhesive      B                              Not Covered
G0173   Linear acc stereo radsur com   S   00067   52.9891             Covered
G0175   OPPS Service,sched team conf   V   00607    1.6830            Not Covered
G0176   OPPS/PHP;activity therapy      P                              Not Covered
G0177   OPPS/PHP; train & educ serv    N                              Not Covered
G0179   MD recertification HHA PT      M                              Not Covered
G0180   MD certification HHA patient   M                              Not Covered
G0181   Home health care supervision   M                              Not Covered
G0182   Hospice care supervision       M                              Not Covered
G0186   Dstry eye lesn,fdr vssl tech   T   00235    5.8498            Not Covered
G0202   Screeningmammographydigital    A                     $82.13    Covered
G0204   Diagnosticmammographydigital   A                     $89.90    Covered
G0206   Diagnosticmammographydigital   A                     $71.70    Covered
G0219   PET img wholbod melano nonco   E                              Not Covered
G0235   PET not otherwise specified    E                              Not Covered
G0237   Therapeutic procd strg endur   S   00077    0.4058            Not Covered
G0238   Oth resp proc, indiv           S   00077    0.4058            Not Covered
G0239   Oth resp proc, group           S   00077    0.4058             Covered
G0245   Initial foot exam pt lops      V   00604    0.8593            Not Covered
G0246   Followup eval of foot pt lop   V   00605    1.0337            Not Covered
G0247   Routine footcare pt w lops     T   00013    0.8789            Not Covered
G0248   Demonstrate use home inr mon   V   00607    1.6830            Not Covered
G0249   Provide INR test mater/equip   V   00607    1.6830            Not Covered
G0250   MD INR test revie inter mgmt   M                              Not Covered
G0251   Linear acc based stero radio   S   00065    14.2808            Not Covered
G0252   PET imaging initial dx         E                               Not Covered
G0255   Current percep threshold tst   E                               Not Covered
G0257   Unsched dialysis ESRD pt hos   S   00170     6.8212            Not Covered
G0259   Inject for sacroiliac joint    N                               Not Covered
G0260   Inj for sacroiliac jt anesth   T   00207     7.2002              Covered
G0268   Removal of impacted wax md     N                               Not Covered
G0269   Occlusive device in vein art   N                               Not Covered
G0270   MNT subs tx for change dx      A                               Not Covered
G0271   Group MNT 2 or more 30 mins    A                               Not Covered
G0275   Renal angio, cardiac cath      N                               Not Covered
G0278   Iliac art angio,cardiac cath   N                               Not Covered
G0281   Elec stim unattend for press   A                               Not Covered
G0282   Elect stim wound care not pd   E                               Not Covered
G0283   Elec stim other than wound     A                      $12.56     Covered
G0288   Recon, CTA for surg plan       N                                By Report
G0289   Arthro, loose body + chondro   N                                 Covered
G0290   Drug-eluting stents, single    T   00656   110.7870            Not Covered
G0291   Drug-eluting stents,each add   T   00656   110.7870            Not Covered
G0293   Non-cov surg proc,clin trial   X   00340     0.6693            Not Covered
G0294   Non-cov proc, clinical trial   X   00340     0.6693            Not Covered
G0295   Electromagnetic therapy onc    E                               Not Covered
G0302   Pre-op service LVRS complete   S   00209    11.4315            Not Covered
G0303   Pre-op service LVRS 10-15dos   S   00209    11.4315            Not Covered
G0304   Pre-op service LVRS 1-9 dos    S   00213     2.4043            Not Covered
G0305   Post op service LVRS min 6     S   00213     2.4043            Not Covered
G0306   CBC/diffwbc w/o platelet       A                               Not Covered
G0307   CBC without platelet           A                               Not Covered
G0308   ESRD related svc 4+mo < 2yrs   D                               Not Covered
G0309   ESRD related svc 2-3mo <2yrs   D                               Not Covered
G0310   ESRD related svc 1 vst <2yrs   D                               Not Covered
G0311   ESRD related svs 4+mo 2-11yr   D                               Not Covered
G0312   ESRD relate svs 2-3 mo 2-11y   D                               Not Covered
G0313   ESRD related svs 1 mon 2-11y   D                               Not Covered
G0314   ESRD related svs 4+ mo 12-19   D                               Not Covered
G0315   ESRD related svs 2-3mo/12-19   D                               Not Covered
G0316   ESRD related svs 1vis/12-19y   D                               Not Covered
G0317   ESRD related svs 4+mo 20+yrs   D                               Not Covered
G0318   ESRD related svs 2-3 mo 20+y   D                               Not Covered
G0319   ESRD related svs 1visit 20+y   D                               Not Covered
G0320   ESD related svs home undr 2    D                               Not Covered
G0321   ESRDrelatedsvs home mo 2-11y   D                               Not Covered
G0322   ESRD related svs hom mo12-19   D                               Not Covered
G0323   ESRD related svs home mo 20+   D                               Not Covered
G0324   ESRD relate svs home/dy <2yr   D                               Not Covered
G0325   ESRD relate home/day/ 2-11yr   D                               Not Covered
G0326   ESRD relate home/dy 12-19yr    D                               Not Covered
G0327   ESRD relate home/dy 20+yrs     D                               Not Covered
G0328   Fecal blood scrn immunoassay   A                               Not Covered
G0329   Electromagntic tx for ulcers   A                               Not Covered
G0332   Preadmin IV immunoglobulin     D                               Not Covered
G0333   Dispense fee initial 30 day    M                               Not Covered
G0337   Hospice evaluation preelecti   B                                  Not Covered
G0339   Robot lin-radsurg com, first   S    00067   52.9891               Not Covered
G0340   Robt lin-radsurg fractx 2-5    S    00066   36.9119               Not Covered
G0341   Percutaneous islet celltrans   C                                  Not Covered
G0342   Laparoscopy islet cell trans   C                                  Not Covered
G0343   Laparotomy islet cell transp   C                                  Not Covered
G0344   Initial preventive exam        D                                  Not Covered
G0364   Bone marrow aspirate &biopsy   X    00340    0.6693                Covered
G0365   Vessel mapping hemo access     S    00267    2.3005               Not Covered
G0366   EKG for initial prevent exam   D                                  Not Covered
G0367   EKG tracing for initial prev   D                                  Not Covered
G0368   EKG interpret & report preve   D                                  Not Covered
G0372   MD service required for PMD    M                                  Not Covered
G0378   Hospital observation per hr    N                                  Not Covered
G0379   Direct admit hospital observ   Q3   00604    0.8593               Not Covered
G0380   Lev 1 hosp type B ED visit     V    00626    0.6796                Covered
G0381   Lev 2 hosp type B ED visit     V    00627    0.9229                Covered
G0382   Lev 3 hosp type B ED visit     V    00628    1.4572                Covered
G0383   Lev 4 hosp type B ED visit     V    00629    2.1041                Covered
G0384   Lev 5 hosp type B ED visit     Q3   00630    3.4466                Covered
G0389   Ultrasound exam AAA screen     S    00266    1.4434                Covered
G0390   Trauma Respons w/hosp criti    S    00618   12.3717                Covered
G0392   AV fistula or graft arterial   D                                  Not Covered
G0393   AV fistula or graft venous     D                                  Not Covered
G0394   Blood occult test,colorectal   D                                  Not Covered
G0396   Alcohol/subs interv 15-30mn    S    00432    0.6013               Not Covered
G0397   Alcohol/subs interv >30 min    S    00432    0.6013               Not Covered
G0398   Home sleep test/type 2 Porta   S    00213    2.4043               Not Covered
G0399   Home sleep test/type 3 Porta   S    00213    2.4043               Not Covered
G0400   Home sleep test/type 4 Porta   S    00213    2.4043               Not Covered
G0402   Initial preventive exam        V    00607    1.6830               Not Covered
G0403   EKG for initial prevent exam   M                                  Not Covered
G0404   EKG tracing for initial prev   S    00099    0.3940               Not Covered
G0405   EKG interpret & report preve   B                                  Not Covered
G0406   Telhealth inpt consult 15min   C                                  Not Covered
G0407   Telheath inpt consult 25min    C                                  Not Covered
G0408   Telhealth inpt consult 35min   C                                  Not Covered
G0409   CORF related serv 15 mins ea   M                                  Not Covered
G0410   Grp psych partial hosp 45-50   P                                  Not Covered
G0411   Inter active grp psych parti   P                                  Not Covered
G0412   Open tx iliac spine uni/bil    C                      $618.43      Covered
G0413   Pelvic ring fracture uni/bil   T    00050   31.7717                Covered
G0414   Pelvic ring fx treat int fix   C                       $858.38     Covered
G0415   Open tx post pelvic fracture   C                      $1,176.00    Covered
G0416   Sat biopsy prostate 1-20 spc   S    01505                          Covered
G0417   Sat biopsy prostate 21-40      S    01507                          Covered
G0418   Sat biopsy prostate 41-60      S    01511                          Covered
G0419   Sat biopsy prostate: >60       S    01513                          Covered
G0420   Ed svc CKD ind per session     A                                  Not Covered
G0421   Ed svc CKD grp per session     A                                  Not Covered
G0422   Intens cardiac rehab w/exerc   S    00095    0.5691                Covered
G0423   Intens cardiac rehab no exer   S    00095    0.5691                Covered
G0424   Pulmonary rehab w exer         S 00102    0.7486             Covered
G0425   Inpt telehealth consult 30m    C                            Not Covered
G0426   Inpt telehealth consult 50m    C                            Not Covered
G0427   Inpt telehealth con 70/>m      C                            Not Covered
G0430   Drug screen multi class        A                   $20.83    Covered
G0431   Drug screen single class       A                   $19.72    Covered
G3001   Admin + supply, tositumomab    S 00442   25.7674            Not Covered
G8006   AMI pt recd aspirin at arriv   M                            Not Covered
G8007   AMI pt did not receiv aspiri   M                            Not Covered
G8008   AMI pt ineligible for aspiri   M                            Not Covered
G8009   AMI pt recd Bblock at arr      M                            Not Covered
G8010   AMI pt did not rec bblock      M                            Not Covered
G8011   AMI pt inelig Bbloc at arriv   M                            Not Covered
G8012   Pneum pt recv antibiotic 4 h   M                            Not Covered
G8013   Pneum pt w/o antibiotic 4 hr   M                            Not Covered
G8014   Pneum pt not elig antibiotic   M                            Not Covered
G8015   Diabetic pt w/ HBA1c>9%        M                            Not Covered
G8016   Diabetic pt w/ HBA1c<or=9%     M                            Not Covered
G8017   DM pt inelig for HBA1c measu   M                            Not Covered
G8018   Care not provided for HbA1c    M                            Not Covered
G8019   Diabetic pt w/LDL>= 100mg/dl   M                            Not Covered
G8020   Diab pt w/LDL< 100mg/dl        M                            Not Covered
G8021   Diab pt inelig for LDL meas    M                            Not Covered
G8022   Care not provided for LDL      M                            Not Covered
G8023   DM pt w BP>=140/80             M                            Not Covered
G8024   Diabetic pt wBP<140/80         M                            Not Covered
G8025   Diabetic pt inelig for BP me   M                            Not Covered
G8026   Diabet pt w no care re BP me   M                            Not Covered
G8027   HF p w/LVSD on ACE-I/ARB       M                            Not Covered
G8028   HF pt w/LVSD not on ACE-I/AR   M                            Not Covered
G8029   HF pt not elig for ACE-I/ARB   M                            Not Covered
G8030   HF pt w/LVSD on Bblocker       M                            Not Covered
G8031   HF pt w/LVSD not on Bblocker   M                            Not Covered
G8032   HF pt not elig for Bblocker    M                            Not Covered
G8033   PMI-CAD pt on Bblocker         M                            Not Covered
G8034   PMI-CAD pt not on Bblocker     M                            Not Covered
G8035   PMI-CAD pt inelig Bblocker     M                            Not Covered
G8036   AMI-CAD pt doc on antiplatel   M                            Not Covered
G8037   AMI-CAD pt not docu on antip   M                            Not Covered
G8038   AMI-CAD inelig antiplate mea   M                            Not Covered
G8039   CAD pt w/LDL>100mg/dl          M                            Not Covered
G8040   CAD pt w/LDL<or=100mg/dl       M                            Not Covered
G8041   CAD pt not eligible for LDL    M                            Not Covered
G8051   Osteoporosis assess            M                            Not Covered
G8052   Osteopor pt not assess         M                            Not Covered
G8053   Pt inelig for osteopor meas    M                            Not Covered
G8054   Falls assess not docum 12 mo   M                            Not Covered
G8055   Falls assess w/ 12 mon         M                            Not Covered
G8056   Not elig for falls assessmen   M                            Not Covered
G8057   Hearing assess receive         M                            Not Covered
G8058   Pt w/o hearing assess          M                            Not Covered
G8059   Pt inelig for hearing assess   M                            Not Covered
G8060   Urinary incont pt assess       M   Not Covered
G8061   Pt not assess for urinary in   M   Not Covered
G8062   Pt not elig for urinary inco   M   Not Covered
G8075   ESRD pt w/ dialy of URR>=65%   M   Not Covered
G8076   ESRD pt w/ dialy of URR<65%    M   Not Covered
G8077   ESRD pt not elig for URR/KtV   M   Not Covered
G8078   ESRD pt w/Hct>or=33            M   Not Covered
G8079   ESRD pt w/Hct<33               M   Not Covered
G8080   ESRD pt inelig for HCT/Hgb     M   Not Covered
G8081   ESRD pt w/ auto AV fistula     M   Not Covered
G8082   ESRD pt w other fistula        M   Not Covered
G8085   ESRD PT inelig auto AV FISTU   M   Not Covered
G8093   COPD pt rec smoking cessat     M   Not Covered
G8094   COPD pt w/o smoke cessat int   M   Not Covered
G8099   Osteopo pt given Ca+VitD sup   M   Not Covered
G8100   Osteop pt inelig for Ca+VitD   M   Not Covered
G8103   New dx osteo pt w/antiresorp   M   Not Covered
G8104   Osteo pt inelig for antireso   M   Not Covered
G8106   Bone dens meas test perf       M   Not Covered
G8107   Bone dens meas test inelig     M   Not Covered
G8108   Pt receiv influenza vacc       M   Not Covered
G8109   Pt w/o influenza vacc          M   Not Covered
G8110   Pt inelig for influenza vacc   M   Not Covered
G8111   Pt receiv mammogram            M   Not Covered
G8112   Pt not doc mammogram           M   Not Covered
G8113   Pt ineligible mammography      M   Not Covered
G8114   Care not provided for mamogr   M   Not Covered
G8115   Pt receiv pneumo vacc          M   Not Covered
G8116   Pt did not rec pneumo vacc     M   Not Covered
G8117   Pt was inelig for pneumo vac   M   Not Covered
G8126   Pt treat w/antidepress12wks    M   Not Covered
G8127   Pt not treat w/antidepres12w   M   Not Covered
G8128   Pt inelig for antidepres med   M   Not Covered
G8129   Pt treat w/antidepres for 6m   M   Not Covered
G8130   Pt not treat w/antidepres 6m   M   Not Covered
G8131   Pt inelig for antidepres med   M   Not Covered
G8152   Pt w/AB 1 hr prior to incisi   M   Not Covered
G8153   Pt not doc for AB 1 hr prior   M   Not Covered
G8154   Pt ineligi for AB therapy      M   Not Covered
G8155   Pt recd thromboemb prophylax   M   Not Covered
G8156   Pt did not rec thromboembo     M   Not Covered
G8157   Pt ineligi for thrombolism     M   Not Covered
G8159   Pt w/CABG w/o IMA              M   Not Covered
G8162   Iso CABG pt w/o preop Bblock   M   Not Covered
G8164   Iso CABG pt w/prolng intub     M   Not Covered
G8165   Iso CABG pt w/o prolng intub   M   Not Covered
G8166   Iso CABG req surg rexpo        M   Not Covered
G8167   Iso CABG w/o surg explo        M   Not Covered
G8170   CEA/ext bypass pt on aspirin   M   Not Covered
G8171   Pt w/carot endarct/ext bypas   M   Not Covered
G8172   CEA/ext bypass pt not on asp   M   Not Covered
G8182   CAD pt care not prov LDL       M   Not Covered
G8183   HF/atrial fib pt on warfarin   M   Not Covered
G8184   HF/atrial fib pt inelig warf   M   Not Covered
G8185   Osteoarth pt w/ assess pain    M   Not Covered
G8186   Osteoarth pt inelig assess     M   Not Covered
G8193   Antibio not doc prior surg     M   Not Covered
G8196   Antibio not docum prior surg   M   Not Covered
G8200   Cefazolin not docum prophy     M   Not Covered
G8204   MD not doc order to d/c anti   M   Not Covered
G8209   Clinician did not doc          M   Not Covered
G8214   Clini not doc order VTE        M   Not Covered
G8217   Pt not received DVT proph      M   Not Covered
G8219   Received DVT proph day 2       M   Not Covered
G8220   Pt not rec DVT proph day 2     M   Not Covered
G8221   Pt inelig for DVT proph        M   Not Covered
G8223   Pt not doc for presc antipla   M   Not Covered
G8226   Pt no prescr anticoa at D/C    M   Not Covered
G8231   Pt not doc for admin t-PA      M   Not Covered
G8234   Pt not doc dysphagia screen    M   Not Covered
G8238   Pt not doc to rec rehab serv   M   Not Covered
G8240   Inter carotid stenosis30-99%   M   Not Covered
G8243   Pt not doc MRI/CT w/o lesion   M   Not Covered
G8246   Pt inelig hx w new/chg mole    M   Not Covered
G8248   Pt w/one alarm symp not doc    M   Not Covered
G8251   Pt not doc w/Barretts, endo    M   Not Covered
G8254   Pt w/no doc order for barium   M   Not Covered
G8257   Pt not doc rev meds D/C        M   Not Covered
G8260   Pt not doc to have dec maker   M   Not Covered
G8263   Pt not doc assess urinary in   M   Not Covered
G8266   Pt not doc charc urin incon    M   Not Covered
G8268   Pt not doc rec care urin inc   M   Not Covered
G8271   Pt no doc screen fall          M   Not Covered
G8274   Clini not doc pres/abs alarm   M   Not Covered
G8276   Pt not doc mole change         M   Not Covered
G8279   Pt not doc rec PE              M   Not Covered
G8282   Pt not doc to rec couns        M   Not Covered
G8285   Pt did not rec pres osteo      M   Not Covered
G8289   Pt not doc rec Ca/Vit D        M   Not Covered
G8293   COPD pt w/o spir results       M   Not Covered
G8296   COPD pt not doc bronch ther    M   Not Covered
G8298   Pt doc optic nerve eval        M   Not Covered
G8299   Pt not doc optic nerv eval     M   Not Covered
G8302   Pt doc w/ target IOP           M   Not Covered
G8303   Pt not doc w/ IOP              M   Not Covered
G8304   Clin doc pt inelig IOP         M   Not Covered
G8305   Clin not prov care POAG        M   Not Covered
G8306   POAG w/ IOP rec care plan      M   Not Covered
G8307   POAG w/ IOP no care plan       M   Not Covered
G8308   POAG w/ IOP not doc plan       M   Not Covered
G8310   Pt not doc rec antiox          M   Not Covered
G8314   Pt not doc to rec mac exam     M   Not Covered
G8318   Pt doc not have visual func    M   Not Covered
G8322   Pt not doc pre axial leng      M   Not Covered
G8326   Pt not doc rec fundus exam     M   Not Covered
G8330   Pt not doc rec dilated mac     M   Not Covered
G8334   Doc of macular not giv MD      M   Not Covered
G8338   Clin not doc pt test osteo     M   Not Covered
G8341   Pt not doc for DEXA            M   Not Covered
G8345   Pt not doc have DEXA           M   Not Covered
G8351   Pt not doc ECG                 M   Not Covered
G8354   Pt not rec aspirin prior ER    M   Not Covered
G8357   Pt not doc to have ECG         M   Not Covered
G8360   Pt not doc vital signs recor   M   Not Covered
G8362   Pt not doc 02 SAT assess       M   Not Covered
G8365   Pt not doc mental status       M   Not Covered
G8367   Pt not doc have empiric AB     M   Not Covered
G8370   Asthma pt w survey not docum   M   Not Covered
G8371   Chemother not rec stg3 colon   M   Not Covered
G8372   Chemother rec stg3 colon ca    M   Not Covered
G8373   Chemo plan documen prior che   M   Not Covered
G8374   Chemo plan not doc prior che   M   Not Covered
G8375   CLL pt w/o doc flow cytometr   M   Not Covered
G8376   Brst ca pt inelig tamoxifen    M   Not Covered
G8377   MD doc colon ca pt inelig ch   M   Not Covered
G8378   MD doc pt inelig radiation     M   Not Covered
G8379   Doc radiat tx recom 12mo ov    M   Not Covered
G8380   Pt w stgIC-3Brst ca not rec    M   Not Covered
G8381   Pt w stgIC-3Brst ca rec tam    M   Not Covered
G8382   MM pt w/o doc IV bisphophon    M   Not Covered
G8383   No doc radiation rec 12mo ov   M   Not Covered
G8384   Base cytogen test MDS notper   M   Not Covered
G8385   Diabet pt no do Hgb A1c 12m    M   Not Covered
G8386   Diabet pt nodoc LDLiprotei     M   Not Covered
G8387   ESRD pt w Hct/Hgb not docume   M   Not Covered
G8388   ESRD pt w URR/Ktv notdoc eli   M   Not Covered
G8389   MDS pt no doc FE st prio EPO   M   Not Covered
G8390   Diabetic w/o document BP 12m   M   Not Covered
G8391   Pt w asthma no doc med or tx   M   Not Covered
G8395   LVEF>=40% doc normal or mild   M   Not Covered
G8396   LVEF not performed             M   Not Covered
G8397   Dil macula/fundus exam/w doc   M   Not Covered
G8398   Dil macular/fundus not perfo   M   Not Covered
G8399   Pt w/DXA document or order     M   Not Covered
G8400   Pt w/DXA no document or orde   M   Not Covered
G8401   Pt inelig osteo screen measu   M   Not Covered
G8402   Smoke preven interven counse   M   Not Covered
G8403   Smoke preven nocounsel         M   Not Covered
G8404   Low extemity neur exam docum   M   Not Covered
G8405   Low extemity neur not perfor   M   Not Covered
G8406   Pt inelig lower extrem neuro   M   Not Covered
G8407   ABI documented                 M   Not Covered
G8408   ABI not documented             M   Not Covered
G8409   Pt inelig for ABI measure      M   Not Covered
G8410   Eval on foot documented        M   Not Covered
G8415   Eval on foot not performed     M   Not Covered
G8416   Pt inelig footwear evaluatio   M   Not Covered
G8417   Calc BMI abv up param f/u      M   Not Covered
G8418   Calc BMI blw low param f/u     M   Not Covered
G8419   Calc BMI out nrm param nof/u   M   Not Covered
G8420   Calc BMI norm parameters       M   Not Covered
G8421   BMI not calculated             M   Not Covered
G8422   Pt inelig BMI calculation      M   Not Covered
G8423   Pt screen flu vac & counsel    M   Not Covered
G8424   Flu vaccine not screen         M   Not Covered
G8425   Flu vaccine screen not curre   M   Not Covered
G8426   Pt not approp screen & counc   M   Not Covered
G8427   Doc meds verified w/pt or re   M   Not Covered
G8428   Meds document w/o verifica     M   Not Covered
G8429   Incomplete doc pt on meds      M   Not Covered
G8430   Pt inelig med check            M   Not Covered
G8431   Pos Clin depres scrn f/u doc   M   Not Covered
G8432   Clin depression screen not d   M   Not Covered
G8433   Pt inelig; Scrn clin dep       M   Not Covered
G8434   Cognitive impairment screen    M   Not Covered
G8435   Cognitive screen not documen   M   Not Covered
G8436   Pt inelig for cognitive impa   M   Not Covered
G8437   Care plan develop & document   M   Not Covered
G8438   Pt inelig for devlp care pln   M   Not Covered
G8439   Care plan develp & not docum   M   Not Covered
G8440   Pain assess f/u pln document   M   Not Covered
G8441   No document of pain assess     M   Not Covered
G8442   Pt inelig pain assessment      M   Not Covered
G8443   Prescription by E-Prescrib s   M   Not Covered
G8445   Prescrip not gen at encounte   M   Not Covered
G8446   Some prescrib print or call    M   Not Covered
G8447   Pt vis doc use CCHIT cer EHR   M   Not Covered
G8448   Pt vis doc w/non-CCHIT EHR     M   Not Covered
G8449   Pt not doc w/EMR due to syst   M   Not Covered
G8450   Beta-bloc rx pt w/abn lvef     M   Not Covered
G8451   Pt w/abn lvef inelig b-bloc    M   Not Covered
G8452   Pt w/abn lvef b-bloc no rx     M   Not Covered
G8453   Tob use cess int counsel       M   Not Covered
G8454   Tob use cess int no counsel    M   Not Covered
G8455   Current tobacco smoker         M   Not Covered
G8456   Smokeless tobacco user         M   Not Covered
G8457   Cur tobacco non-user           M   Not Covered
G8458   Pt inelig geno no antvir tx    M   Not Covered
G8459   Doc pt rec antivir treat       M   Not Covered
G8460   Pt inelig RNA no antvir tx     M   Not Covered
G8461   Pt rec antivir treat hep c     M   Not Covered
G8462   Pt inelig couns no antvir tx   M   Not Covered
G8463   Pt rec antiviral treat doc     M   Not Covered
G8464   Pt inelig; lo to no dter rsk   M   Not Covered
G8465   High risk recurrence pro ca    M   Not Covered
G8466   Pt inelig suic; MDD remis      M   Not Covered
G8467   New dx init/rec episode MDD    M   Not Covered
G8468   ACE/ARB rx pt w/abn lvef       M   Not Covered
G8469   Pt w/abn lvef inelig ACE/ARB   M   Not Covered
G8470   Pt w/ normal lvef              M   Not Covered
G8471   LVEF not performed/doc         M   Not Covered
G8472   ACE/ARB no rx pt w/abn lvef    M   Not Covered
G8473   ACE/ARB thxpy rx'd             M   Not Covered
G8474   ACE/ARB not rx'd; doc reas     M   Not Covered
G8475   ACE/ARB thxpy not rx'd         M   Not Covered
G8476   BP sys <130 and dias <80       M   Not Covered
G8477   BP sys>=130 and/or dias >=80   M   Not Covered
G8478   BP not performed/doc           M   Not Covered
G8479   MD rx'd ACE/ARB thxpy          M   Not Covered
G8480   Pt inelig ACE/ARB thxpy        M   Not Covered
G8481   MD not rx'd ACE/ARB thxpy      M   Not Covered
G8482   Flu immunize order/admin       M   Not Covered
G8483   Flu imm no ord/admin doc rea   M   Not Covered
G8484   Flu immunize no order/admin    M   Not Covered
G8485   Report, Diabetes measures      M   Not Covered
G8486   Report, Prev Care Measures     M   Not Covered
G8487   Report CKD Measures            M   Not Covered
G8488   Report ESRD Measures           M   Not Covered
G8489   CAD measures grp               M   Not Covered
G8490   RA measures grp                M   Not Covered
G8491   HIV/AIDS measures grp          M   Not Covered
G8492   Prev Care measures grp         M   Not Covered
G8493   Back pain measures grp         M   Not Covered
G8494   DM meas qual act perform       M   Not Covered
G8495   CKD meas qual act perform      M   Not Covered
G8496   PC meas qual act perform       M   Not Covered
G8497   CABG meas qual act perform     M   Not Covered
G8498   CAD meas qual act perform      M   Not Covered
G8499   RA meas qual act perform       M   Not Covered
G8500   HIV meas qual act perform      M   Not Covered
G8501   Perio meas qual act perform    M   Not Covered
G8502   BP meas qual act perform       M   Not Covered
G8503   Doc proph antibx w/in 1 hr     D   Not Covered
G8504   Doc ord pro antbx w/in 1 hr    D   Not Covered
G8505   No doc proph antibx w/in 1hr   D   Not Covered
G8506   Pt rec ACE/ARB                 M   Not Covered
G8507   Pt inelig pt verif meds        M   Not Covered
G8508   Pt inelig; pain asses no f/u   M   Not Covered
G8509   Pain assess no f/u pln doc     M   Not Covered
G8510   Pt inelig neg scrn depres      M   Not Covered
G8511   Clin depres scrn no f/u doc    M   Not Covered
G8512   Pain sev quant present         D   Not Covered
G8513   ABI meas & doc                 D   Not Covered
G8514   PT inelig; ABI measure         D   Not Covered
G8515   No ABI measurement             D   Not Covered
G8516   Scrn fal rsk >2 fal or w/inj   D   Not Covered
G8517   Scrn fall rsk; <2 falls        D   Not Covered
G8518   Clin stg b/f lun/eso ca surg   M   Not Covered
G8519   Pt in; clin ca stg b/f surg    M   Not Covered
G8520   Clin stg b/f surg not doc      M   Not Covered
G8521   Antplt recd 48 hrs & disch     D   Not Covered
G8522   Pt inelig; antiplt therapy     D   Not Covered
G8523   Antplt not recd reas no spec   D   Not Covered
G8524   Patch closure conv CEA         M   Not Covered
G8525   No patch closure CEA           M   Not Covered
G8526   No patch closure conv CEA      M   Not Covered
G8527   Doc ord antimic prophy         D   Not Covered
G8528   Pt inelig; proph antibiot      D   Not Covered
G8529   No doc ord antimic prophy      D   Not Covered
G8530   Auto AV fistula recd           M   Not Covered
G8531   Pt inelig; auto AV fistula     M   Not Covered
G8532   No auto AV fistula; no reas    M   Not Covered
G8533   Partic in clin data base reg   D   Not Covered
G8534   Doc elder mal scrn f/u plan    M   Not Covered
G8535   Pt inelig no eld mal scrn      M   Not Covered
G8536   No doc elder mal scrn          M   Not Covered
G8537   Pt inelig eldmal scrn no f/u   M   Not Covered
G8538   Eld mal scrn no f/u pln        M   Not Covered
G8539   Cur funct assess & care pln    M   Not Covered
G8540   Pt inelig funct assess         M   Not Covered
G8541   No doc cur funct assess        M   Not Covered
G8542   Pt inelig func asses no pln    M   Not Covered
G8543   Cur funct asses; no care pln   M   Not Covered
G8544   CABG measures grp              M   Not Covered
G8545   HepC measures grp              M   Not Covered
G8546   CAP measures grp               M   Not Covered
G8547   IVD measures grp               M   Not Covered
G8548   HF measures grp                M   Not Covered
G8549   HepC MG qual act perform       M   Not Covered
G8550   CAP MG qual act perform        M   Not Covered
G8551   HF MG qual act perform         M   Not Covered
G8552   IVD MG qual act perform        M   Not Covered
G8553   1 Rx via qualified eRx sys     M   Not Covered
G8556   Ref to doc otolog eval         M   Not Covered
G8557   Pt inelig ref otolog eval      M   Not Covered
G8558   No ref to doc otolog eval      M   Not Covered
G8559   Pt ref doc oto eval            M   Not Covered
G8560   Pt hx act drain prev 90 days   M   Not Covered
G8561   Pt inelig for ref oto eval     M   Not Covered
G8562   Pt no hx act drain 90 d        M   Not Covered
G8563   Pt no ref oto reas no spec     M   Not Covered
G8564   Pt ref oto eval                M   Not Covered
G8565   Ver doc hear loss              M   Not Covered
G8566   Pt inelig ref oto eval         M   Not Covered
G8567   Pt no doc hear loss            M   Not Covered
G8568   Pt no ref otolo no spec        M   Not Covered
G8569   Prol intubation req            M   Not Covered
G8570   No prol intub req              M   Not Covered
G8571   Ster wd ifx 30 d postop        M   Not Covered
G8572   No ster wd ifx                 M   Not Covered
G8573   Stk/CVA CABG                   M   Not Covered
G8574   No strk/CVA CABG               M   Not Covered
G8575   Postop ren insuf              M   Not Covered
G8576   No postop ren insuf           M   Not Covered
G8577   Reop req bld grft oth         M   Not Covered
G8578   No reop req bld grft oth      M   Not Covered
G8579   Antplt med disch              M   Not Covered
G8580   Antplt med contraind          M   Not Covered
G8581   no antplt med disch           M   Not Covered
G8582   Bblock disch                  M   Not Covered
G8583   Bblock contraind              M   Not Covered
G8584   No bblock disch               M   Not Covered
G8585   Antilipid treat disch         M   Not Covered
G8586   Antlip disch contra           M   Not Covered
G8587   No antlipid treat disch       M   Not Covered
G8588   Sys BP <140                   M   Not Covered
G8589   Sys BP >= 140                 M   Not Covered
G8590   Dia BP < 90                   M   Not Covered
G8591   Dia BP >= 90                  M   Not Covered
G8592   No BP measure                 M   Not Covered
G8593   Lipid pn results              M   Not Covered
G8594   No lipid prof perf            M   Not Covered
G8595   Ldl < 100                     M   Not Covered
G8596   No LDL perf                   M   Not Covered
G8597   Ldl >= 100                    M   Not Covered
G8598   Asp therp used                M   Not Covered
G8599   No asp therp used             M   Not Covered
G8600   tPA initi w/in 3 hrs          M   Not Covered
G8601   No elig tPA init w/in 3 hrs   M   Not Covered
G8602   No tPA init w/in 3 hrs        M   Not Covered
G8603   Spok lang comp score          M   Not Covered
G8604   No high score spok lang       M   Not Covered
G8605   No spok lang comp score       M   Not Covered
G8606   Attention score               M   Not Covered
G8607   No high score attention       M   Not Covered
G8608   No attention score            M   Not Covered
G8609   Memory score                  M   Not Covered
G8610   No high score memory          M   Not Covered
G8611   No memory score               M   Not Covered
G8612   Moto speech score             M   Not Covered
G8613   No high score moto speech     M   Not Covered
G8614   No moto speech score          M   Not Covered
G8615   Reading score                 M   Not Covered
G8616   No high score reading         M   Not Covered
G8617   No reading score              M   Not Covered
G8618   Spok lang exp score           M   Not Covered
G8619   No high score spok lang exp   M   Not Covered
G8620   No spok lang exp score        M   Not Covered
G8621   Writing score                 M   Not Covered
G8622   No high score writing         M   Not Covered
G8623   No writing score              M   Not Covered
G8624   Swallowing score              M   Not Covered
G8625   No high score swallowing      M   Not Covered
G8626   No swallowing score           M   Not Covered
G8627   Surg proc w/in 30 days         M   Not Covered
G8628   No surg proc w/in 30 days      M   Not Covered
G9001   MCCD, initial rate             B   Not Covered
G9002   MCCD,maintenance rate          B   Not Covered
G9003   MCCD, risk adj hi, initial     B   Not Covered
G9004   MCCD, risk adj lo, initial     B   Not Covered
G9005   MCCD, risk adj, maintenance    B   Not Covered
G9006   MCCD, Home monitoring          B   Not Covered
G9007   MCCD, sch team conf            B   Not Covered
G9008   Mccd,phys coor-care ovrsght    B   Not Covered
G9009   MCCD, risk adj, level 3        B   Not Covered
G9010   MCCD, risk adj, level 4        B   Not Covered
G9011   MCCD, risk adj, level 5        B   Not Covered
G9012   Other Specified Case Mgmt      B   Not Covered
G9013   ESRD demo bundle level I       E   Not Covered
G9014   ESRD demo bundle-level II      E   Not Covered
G9016   Demo-smoking cessation coun    E   Not Covered
G9017   Amantadine HCL 100mg oral      A   Not Covered
G9018   Zanamivir,inhalation pwd 10m   A   Not Covered
G9019   Oseltamivir phosphate 75mg     A   Not Covered
G9020   Rimantadine HCL 100mg oral     A   Not Covered
G9033   Amantadine HCL oral brand      A   Not Covered
G9034   Zanamivir, inh pwdr, brand     A   Not Covered
G9035   Oseltamivir phosp, brand       A   Not Covered
G9036   Rimantadine HCL, brand         A   Not Covered
G9041   Low vision rehab occupationa   A   Not Covered
G9042   Low vision rehab orient/mobi   A   Not Covered
G9043   Low vision lowvision therapi   A   Not Covered
G9044   Low vision rehabilate teache   A   Not Covered
G9050   Oncology work-up evaluation    E   Not Covered
G9051   Oncology tx decision-mgmt      E   Not Covered
G9052   Onc surveillance for disease   E   Not Covered
G9053   Onc expectant management pt    E   Not Covered
G9054   Onc supervision palliative     E   Not Covered
G9055   Onc visit unspecified NOS      E   Not Covered
G9056   Onc prac mgmt adheres guide    E   Not Covered
G9057   Onc pract mgmt differs trial   E   Not Covered
G9058   Onc prac mgmt disagree w/gui   E   Not Covered
G9059   Onc prac mgmt pt opt alterna   E   Not Covered
G9060   Onc prac mgmt dif pt comorb    E   Not Covered
G9061   Onc prac cond noadd by guide   E   Not Covered
G9062   Onc prac guide differs nos     E   Not Covered
G9063   Onc dx nsclc stgI no progres   M   Not Covered
G9064   Onc dx nsclc stg2 no progres   M   Not Covered
G9065   Onc dx nsclc stg3A no progre   M   Not Covered
G9066   Onc dx nsclc stg3B-4 metasta   M   Not Covered
G9067   Onc dx nsclc dx unknown nos    M   Not Covered
G9068   Onc dx sclc/nsclc limited      M   Not Covered
G9069   Onc dx sclc/nsclc ext at dx    M   Not Covered
G9070   Onc dx sclc/nsclc ext unknwn   M   Not Covered
G9071   Onc dx brst stg1-2B HR,nopro   M   Not Covered
G9072   Onc dx brst stg1-2 noprogres   M   Not Covered
G9073   Onc dx brst stg3-HR, no pro    M   Not Covered
G9074   Onc dx brst stg3-noprogress    M   Not Covered
G9075   Onc dx brst metastic/ recur    M   Not Covered
G9077   Onc dx prostate T1no progres   M   Not Covered
G9078   Onc dx prostate T2no progres   M   Not Covered
G9079   Onc dx prostate T3b-T4noprog   M   Not Covered
G9080   Onc dx prostate w/rise PSA     M   Not Covered
G9083   Onc dx prostate unknwn nos     M   Not Covered
G9084   Onc dx colon t1-3,n1-2,no pr   M   Not Covered
G9085   Onc dx colon T4, N0 w/o prog   M   Not Covered
G9086   Onc dx colon T1-4 no dx prog   M   Not Covered
G9087   Onc dx colon metas evid dx     M   Not Covered
G9088   Onc dx colon metas noevid dx   M   Not Covered
G9089   Onc dx colon extent unknown    M   Not Covered
G9090   Onc dx rectal T1-2 no progr    M   Not Covered
G9091   Onc dx rectal T3 N0 no prog    M   Not Covered
G9092   Onc dx rectal T1-3,N1-2noprg   M   Not Covered
G9093   Onc dx rectal T4,N,M0 no prg   M   Not Covered
G9094   Onc dx rectal M1 w/mets prog   M   Not Covered
G9095   Onc dx rectal extent unknwn    M   Not Covered
G9096   Onc dx esophag T1-T3 noprog    M   Not Covered
G9097   Onc dx esophageal T4 no prog   M   Not Covered
G9098   Onc dx esophageal mets recur   M   Not Covered
G9099   Onc dx esophageal unknown      M   Not Covered
G9100   Onc dx gastric no recurrence   M   Not Covered
G9101   Onc dx gastric p R1-R2noprog   M   Not Covered
G9102   Onc dx gastric unresectable    M   Not Covered
G9103   Onc dx gastric recurrent       M   Not Covered
G9104   Onc dx gastric unknown NOS     M   Not Covered
G9105   Onc dx pancreatc p R0 res no   M   Not Covered
G9106   Onc dx pancreatc p R1/R2 no    M   Not Covered
G9107   Onc dx pancreatic unresectab   M   Not Covered
G9108   Onc dx pancreatic unknwn NOS   M   Not Covered
G9109   Onc dx head/neck T1-T2no prg   M   Not Covered
G9110   Onc dx head/neck T3-4 noprog   M   Not Covered
G9111   Onc dx head/neck M1 mets rec   M   Not Covered
G9112   Onc dx head/neck ext unknown   M   Not Covered
G9113   Onc dx ovarian stg1A-B no pr   M   Not Covered
G9114   Onc dx ovarian stg1A-B or 2    M   Not Covered
G9115   Onc dx ovarian stg3/4 noprog   M   Not Covered
G9116   Onc dx ovarian recurrence      M   Not Covered
G9117   Onc dx ovarian unknown NOS     M   Not Covered
G9123   Onc dx CML chronic phase       M   Not Covered
G9124   Onc dx CML acceler phase       M   Not Covered
G9125   Onc dx CML blast phase         M   Not Covered
G9126   Onc dx CML remission           M   Not Covered
G9128   Onc dx multi myeloma stage I   M   Not Covered
G9129   Onc dx mult myeloma stg2 hig   M   Not Covered
G9130   Onc dx multi myeloma unknown   M   Not Covered
G9131   Onc dx brst unknown NOS        M   Not Covered
G9132   Onc dx prostate mets no cast   M   Not Covered
G9133   Onc dx prostate clinical met   M   Not Covered
G9134   Onc NHLstg 1-2 no relap no     M                              Not Covered
G9135   Onc dx NHL stg 3-4 not relap   M                              Not Covered
G9136   Onc dx NHL trans to lg Bcell   M                              Not Covered
G9137   Onc dx NHL relapse/refractor   M                              Not Covered
G9138   Onc dx NHL stg unknown         M                              Not Covered
G9139   Onc dx CML dx status unknown   M                              Not Covered
G9140   Frontier extended stay demo    A                              Not Covered
G9141   Influenza A H1N1,admin w cou   S   00350   0.3809               Covered
G9142   Influenza A H1N1, vaccine      E                              Not Covered
G9143   Warfarin respon genetic test   A                              Not Covered
J0120   Tetracyclin injection          N                                Covered
J0128   Abarelix injection             E                    $71.33      Covered
J0129   Abatacept injection            K   09230                       By Report
J0130   Abciximab injection            K   01605            $549.70     Covered
J0132   Acetylcysteine injection       K   01272             $2.29      Covered
J0133   Acyclovir injection            N                                Covered
J0135   Adalimumab injection           K   01083            $352.47     Covered
J0150   Injection adenosine 6 MG       K   00379             $38.27     Covered
J0152   Adenosine injection            K   00917             $81.88     Covered
J0170   Adrenalin epinephrin inject    N                                Covered
J0180   Agalsidase beta injection      K   09208            $125.89     Covered
J0190   Inj biperiden lactate/5 mg     N                                Covered
J0200   Alatrofloxacin mesylate        N                                Covered
J0205   Alglucerase injection          K   00900             $40.22     Covered
J0207   Amifostine                     K   07000            $485.37     Covered
J0210   Methyldopate hcl injection     K   02210             $12.74     Covered
J0215   Alefacept                      K   01633             $31.99     Covered
J0220   Alglucosidase alfa injection   K   09234            $136.35     Covered
J0256   Alpha 1 proteinase inhibitor   K   00901              $2.85     Covered
J0270   Alprostadil for injection      B                              Not Covered
J0275   Alprostadil urethral suppos    B                              Not Covered
J0278   Amikacin sulfate injection     N                                Covered
J0280   Aminophyllin 250 MG inj        N                                Covered
J0282   Amiodarone HCl                 N                                Covered
J0285   Amphotericin B                 N                                Covered
J0287   Amphotericin b lipid complex   K   09024            $22.18      Covered
J0288   Ampho b cholesteryl sulfate    K   00735            $15.42      Covered
J0289   Amphotericin b liposome inj    K   00736            $36.35      Covered
J0290   Ampicillin 500 MG inj          N                                Covered
J0295   Ampicillin sodium per 1.5 gm   N                                Covered
J0300   Amobarbital 125 MG inj         N                                Covered
J0330   Succinycholine chloride inj    N                                Covered
J0348   Anidulafungin injection        K   00760                       By Report
J0350   Injection anistreplase 30 u    E                              Not Covered
J0360   Hydralazine hcl injection      N                                Covered
J0364   Apomorphine hydrochloride      N                               By Report
J0365   Aprotonin, 10,000 kiu          K   01682             $2.86      Covered
J0380   Inj metaraminol bitartrate     N                                Covered
J0390   Chloroquine injection          N                                Covered
J0395   Arbutamine hcl injection       E                    $195.45     Covered
J0400   Aripiprazole injection         N                                Covered
J0456   Azithromycin                   N                                Covered
J0460   Atropine sulfate injection     D                     Not Covered
J0461   Atropine sulfate injection     N                       Covered
J0470   Dimecaprol injection           K   01273    $25.36     Covered
J0475   Baclofen 10 MG injection       K   09032   $218.43     Covered
J0476   Baclofen intrathecal trial     K   01631    $85.51     Covered
J0480   Basiliximab                    K   01683              By Report
J0500   Dicyclomine injection          N                       Covered
J0515   Inj benztropine mesylate       N                       Covered
J0520   Bethanechol chloride inject    N                       Covered
J0530   Penicillin g benzathine inj    D                     Not Covered
J0540   Penicillin g benzathine inj    D                     Not Covered
J0550   Penicillin g benzathine inj    D                     Not Covered
J0559   PenG benzathine/procaine inj   N                       Covered
J0560   Penicillin g benzathine inj    N                       Covered
J0570   Penicillin g benzathine inj    N                       Covered
J0580   Penicillin g benzathine inj    N                       Covered
J0583   Bivalirudin                    K   03041    $1.77      Covered
J0585   Botulinum toxin a per unit     K   00902    $5.40      Covered
J0586   AbobotulinumtoxintypeA         K   01289    $7.67      Covered
J0587   Botulinum toxin type B         K   09018    $9.41      Covered
J0592   Buprenorphine hydrochloride    N                       Covered
J0594   Busulfan injection             K   01178              By Report
J0595   Butorphanol tartrate 1 mg      N                       Covered
J0598   C1 esterase inhibitor inj      G   09251   $37.26      Covered
J0600   Edetate calcium disodium inj   K   01274   $47.25      Covered
J0610   Calcium gluconate injection    N                       Covered
J0620   Calcium glycer & lact/10 ML    N                       Covered
J0630   Calcitonin salmon injection    K   01220   $41.16      Covered
J0636   Inj calcitriol per 0.1 mcg     N                       Covered
J0637   Caspofungin acetate            K   09019   $35.31      Covered
J0640   Leucovorin calcium injection   N                       Covered
J0641   Levoleucovorin injection       G   01236    $1.39      Covered
J0670   Inj mepivacaine HCL/10 ml      N                       Covered
J0690   Cefazolin sodium injection     N                       Covered
J0692   Cefepime HCl for injection     N                       Covered
J0694   Cefoxitin sodium injection     N                       Covered
J0696   Ceftriaxone sodium injection   N                       Covered
J0697   Sterile cefuroxime injection   N                       Covered
J0698   Cefotaxime sodium injection    N                       Covered
J0702   Betamethasone acet&sod phosp   N                       Covered
J0704   Betamethasone sod phosp/4 MG   N                       Covered
J0706   Caffeine citrate injection     N                       Covered
J0710   Cephapirin sodium injection    N                       Covered
J0713   Inj ceftazidime per 500 mg     N                       Covered
J0715   Ceftizoxime sodium / 500 MG    N                       Covered
J0718   Certolizumab pegol inj         G   09249    $3.95      Covered
J0720   Chloramphenicol sodium injec   N                       Covered
J0725   Chorionic gonadotropin/1000u   N                       Covered
J0735   Clonidine hydrochloride        K   00935    $59.10     Covered
J0740   Cidofovir injection            K   09033   $903.93     Covered
J0743   Cilastatin sodium injection    N                       Covered
J0744   Ciprofloxacin iv               N                       Covered
J0745   Inj codeine phosphate /30 MG   N                       Covered
J0760   Colchicine injection           N                       Covered
J0770   Colistimethate sodium inj      N                       Covered
J0780   Prochlorperazine injection     N                       Covered
J0795   Corticorelin ovine triflutal   K   01684     $4.98     Covered
J0800   Corticotropin injection        K   01280    $99.58     Covered
J0833   Cosyntropin injection NOS      K   00835   $107.92     Covered
J0834   Cosyntropin cortrosyn inj      K   01298   $115.11     Covered
J0835   Inj cosyntropin per 0.25 MG    D                     Not Covered
J0850   Cytomegalovirus imm IV /vial   K   00903   $762.98     Covered
J0878   Daptomycin injection           K   09124     $0.39     Covered
J0881   Darbepoetin alfa, non-esrd     K   01685     $5.35     Covered
J0882   Darbepoetin alfa, esrd use     A             $5.35     Covered
J0885   Epoetin alfa, non-esrd         K   01686    $14.17     Covered
J0886   Epoetin alfa 1000 units ESRD   A            $14.17     Covered
J0894   Decitabine injection           K   09231              By Report
J0895   Deferoxamine mesylate inj      N                       Covered
J0900   Testosterone enanthate inj     N                       Covered
J0945   Brompheniramine maleate inj    K   01256    $1.02      Covered
J0970   Estradiol valerate injection   N                       Covered
J1000   Depo-estradiol cypionate inj   N                       Covered
J1020   Methylprednisolone 20 MG inj   N                       Covered
J1030   Methylprednisolone 40 MG inj   N                       Covered
J1040   Methylprednisolone 80 MG inj   N                       Covered
J1051   Medroxyprogesterone inj        N                       Covered
J1055   Medrxyprogester acetate inj    E           $51.94      Covered
J1056   MA/EC contraceptiveinjection   E           $26.37      Covered
J1060   Testosterone cypionate 1 ML    N                       Covered
J1070   Testosterone cypionat 100 MG   N                       Covered
J1080   Testosterone cypionat 200 MG   N                       Covered
J1094   Inj dexamethasone acetate      N                       Covered
J1100   Dexamethasone sodium phos      N                       Covered
J1110   Inj dihydroergotamine mesylt   N                       Covered
J1120   Acetazolamid sodium injectio   N                       Covered
J1160   Digoxin injection              N                       Covered
J1162   Digoxin immune fab (ovine)     K   01687              By Report
J1165   Phenytoin sodium injection     N                       Covered
J1170   Hydromorphone injection        N                       Covered
J1180   Dyphylline injection           N                       Covered
J1190   Dexrazoxane HCl injection      K   00726   $250.70     Covered
J1200   Diphenhydramine hcl injectio   N                       Covered
J1205   Chlorothiazide sodium inj      K   00747   $11.23      Covered
J1212   Dimethyl sulfoxide 50% 50 ML   K   01221   $47.79      Covered
J1230   Methadone injection            N                       Covered
J1240   Dimenhydrinate injection       N                       Covered
J1245   Dipyridamole injection         N                       Covered
J1250   Inj dobutamine HCL/250 mg      N                       Covered
J1260   Dolasetron mesylate            N                       Covered
J1265   Dopamine injection             N                       Covered
J1267   Doripenem injection            G   09241    $0.86      Covered
J1270   Injection, doxercalciferol     N                       Covered
J1300   Eculizumab injection           K   09236   $189.07     Covered
J1320   Amitriptyline injection        N                         Covered
J1324   Enfuvirtide injection          K   01257                By Report
J1325   Epoprostenol injection         N                         Covered
J1327   Eptifibatide injection         K   01607    $13.75       Covered
J1330   Ergonovine maleate injection   N                         Covered
J1335   Ertapenem injection            N                         Covered
J1364   Erythro lactobionate /500 MG   N                         Covered
J1380   Estradiol valerate 10 MG inj   N                         Covered
J1390   Estradiol valerate 20 MG inj   N                         Covered
J1410   Inj estrogen conjugate 25 MG   K   09038    $65.91       Covered
J1430   Ethanolamine oleate 100 mg     K   01688                By Report
J1435   Injection estrone per 1 MG     N                         Covered
J1436   Etidronate disodium inj        K   01436    $82.46       Covered
J1438   Etanercept injection           K   01608   $158.60       Covered
J1440   Filgrastim 300 mcg injection   K   00728   $199.19       Covered
J1441   Filgrastim 480 mcg injection   K   07049   $336.52       Covered
J1450   Fluconazole                    N                         Covered
J1451   Fomepizole, 15 mg              K   01689    $13.34       Covered
J1452   Intraocular Fomivirsen na      E           $1,017.94     Covered
J1453   Fosaprepitant injection        G   09242     $1.71       Covered
J1455   Foscarnet sodium injection     N                         Covered
J1457   Gallium nitrate injection      K   00878    $1.34        Covered
J1458   Galsulfase injection           K   09224                By Report
J1459   Inj IVIG privigen 500 mg       G   01214    $48.62       Covered
J1460   Gamma globulin 1 CC inj        K   03043    $13.05       Covered
J1470   Gamma globulin 2 CC inj        K   01282    $26.09       Covered
J1480   Gamma globulin 3 CC inj        K   01283    $39.18       Covered
J1490   Gamma globulin 4 CC inj        K   00904    $52.17       Covered
J1500   Gamma globulin 5 CC inj        K   01284    $65.23       Covered
J1510   Gamma globulin 6 CC inj        K   00920    $78.09       Covered
J1520   Gamma globulin 7 CC inj        K   00921    $91.20       Covered
J1530   Gamma globulin 8 CC inj        K   00922   $104.34       Covered
J1540   Gamma globulin 9 CC inj        K   00923   $117.50       Covered
J1550   Gamma globulin 10 CC inj       K   00924   $130.42       Covered
J1560   Gamma globulin > 10 CC inj     K   00933     $1.83       Covered
J1561   Gamunex injection              K   00948    $51.69       Covered
J1562   Vivaglobin, inj                K   01275                By Report
J1565   RSV-ivig                       D                       Not Covered
J1566   Immune globulin, powder        K   02731    $69.43       Covered
J1568   Octagam injection              K   00943    $60.02       Covered
J1569   Gammagard liquid injection     K   00944                By Report
J1570   Ganciclovir sodium injection   N                         Covered
J1571   Hepagam b im injection         G   00946                By Report
J1572   Flebogamma injection           K   00947                By Report
J1573   Hepagam b intravenous, inj     G   01138                By Report
J1580   Garamycin gentamicin inj       N                         Covered
J1590   Gatifloxacin injection         N                         Covered
J1595   Injection glatiramer acetate   K   01015    $38.95       Covered
J1600   Gold sodium thiomaleate inj    N                         Covered
J1610   Glucagon hydrochloride/1 MG    K   09042    $48.86       Covered
J1620   Gonadorelin hydroch/ 100 mcg   K   07005   $216.42       Covered
J1626   Granisetron hcl injection      N                         Covered
J1630   Haloperidol injection          N                       Covered
J1631   Haloperidol decanoate inj      N                       Covered
J1640   Hemin, 1 mg                    K   01690             Not Covered
J1642   Inj heparin sodium per 10 u    N                       Covered
J1644   Inj heparin sodium per 1000u   N                       Covered
J1645   Dalteparin sodium              N                       Covered
J1650   Inj enoxaparin sodium          N                       Covered
J1652   Fondaparinux sodium            K   01276    $8.87      Covered
J1655   Tinzaparin sodium injection    N                       Covered
J1670   Tetanus immune globulin inj    K   01670   $128.26     Covered
J1675   Histrelin acetate              B                     Not Covered
J1680   Human fibrinogen conc inj      G   01290    $0.10      Covered
J1700   Hydrocortisone acetate inj     N                       Covered
J1710   Hydrocortisone sodium ph inj   N                       Covered
J1720   Hydrocortisone sodium succ i   N                       Covered
J1730   Diazoxide injection            K   01740   $131.74     Covered
J1740   Ibandronate sodium injection   K   09229              By Report
J1742   Ibutilide fumarate injection   K   09044   $269.33     Covered
J1743   Idursulfase injection          K   09232   $497.68     Covered
J1745   Infliximab injection           K   07043    $70.40     Covered
J1750   Inj iron dextran               K   01237             Not Covered
J1751   Iron dextran 165 injection     D                     Not Covered
J1752   Iron dextran 267 injection     D                     Not Covered
J1756   Iron sucrose injection         K   09046    $0.71      Covered
J1785   Injection imiglucerase /unit   K   00916    $4.02      Covered
J1790   Droperidol injection           N                       Covered
J1800   Propranolol injection          N                       Covered
J1810   Droperidol/fentanyl inj        E           $10.11      Covered
J1815   Insulin injection              N                     Not Covered
J1817   Insulin for insulin pump use   K   01277             Not Covered
J1825   Interferon beta-1a             E           $250.72     Covered
J1830   Interferon beta-1b / .25 MG    K   00910    $61.07     Covered
J1835   Itraconazole injection         N                       Covered
J1840   Kanamycin sulfate 500 MG inj   N                       Covered
J1850   Kanamycin sulfate 75 MG inj    N                       Covered
J1885   Ketorolac tromethamine inj     N                       Covered
J1890   Cephalothin sodium injection   N                       Covered
J1930   Lanreotide injection           K   09237   $30.67      Covered
J1931   Laronidase injection           K   09209   $24.36      Covered
J1940   Furosemide injection           N                       Covered
J1945   Lepirudin                      K   01693   $174.06     Covered
J1950   Leuprolide acetate /3.75 MG    K   00800   $554.32     Covered
J1953   Levetiracetam injection        G   09238    $0.71      Covered
J1955   Inj levocarnitine per 1 gm     B                     Not Covered
J1956   Levofloxacin injection         N                       Covered
J1960   Levorphanol tartrate inj       N                       Covered
J1980   Hyoscyamine sulfate inj        N                       Covered
J1990   Chlordiazepoxide injection     N                       Covered
J2001   Lidocaine injection            N                       Covered
J2010   Lincomycin injection           N                       Covered
J2020   Linezolid injection            K   09001   $39.57      Covered
J2060   Lorazepam injection            N                       Covered
J2150   Mannitol injection             N                         Covered
J2170   Mecasermin injection           N                        By Report
J2175   Meperidine hydrochl /100 MG    N                         Covered
J2180   Meperidine/promethazine inj    N                         Covered
J2185   Meropenem                      N                         Covered
J2210   Methylergonovin maleate inj    N                         Covered
J2248   Micafungin sodium injection    K   09227                By Report
J2250   Inj midazolam hydrochloride    N                         Covered
J2260   Inj milrinone lactate / 5 MG   N                         Covered
J2270   Morphine sulfate injection     N                         Covered
J2271   Morphine so4 injection 100mg   N                         Covered
J2275   Morphine sulfate injection     N                         Covered
J2278   Ziconotide injection           K   01694    $7.48        Covered
J2280   Inj, moxifloxacin 100 mg       N                         Covered
J2300   Inj nalbuphine hydrochloride   N                         Covered
J2310   Inj naloxone hydrochloride     N                         Covered
J2315   Naltrexone, depot form         K   00759                By Report
J2320   Nandrolone decanoate 50 MG     K   01285    $4.12        Covered
J2321   Nandrolone decanoate 100 MG    K   01260                By Report
J2322   Nandrolone decanoate 200 MG    K   01286                By Report
J2323   Natalizumab injection          K   09126     $8.27       Covered
J2325   Nesiritide injection           K   01695    $34.07       Covered
J2353   Octreotide injection, depot    K   01207    $94.07       Covered
J2354   Octreotide inj, non-depot      N                         Covered
J2355   Oprelvekin injection           K   07011   $271.90       Covered
J2357   Omalizumab injection           K   09300    $16.41       Covered
J2360   Orphenadrine injection         N                         Covered
J2370   Phenylephrine hcl injection    N                         Covered
J2400   Chloroprocaine hcl injection   N                         Covered
J2405   Ondansetron hcl injection      N                         Covered
J2410   Oxymorphone hcl injection      N                         Covered
J2425   Palifermin injection           K   01696    $13.26       Covered
J2430   Pamidronate disodium /30 MG    K   00730   $284.89       Covered
J2440   Papaverin hcl injection        N                         Covered
J2460   Oxytetracycline injection      E             $1.02       Covered
J2469   Palonosetron hcl               K   09210    $34.48       Covered
J2501   Paricalcitol                   N                         Covered
J2503   Pegaptanib sodium injection    K   01697                By Report
J2504   Pegademase bovine, 25 iu       K   01739    $189.01      Covered
J2505   Injection, pegfilgrastim 6mg   K   09119   $2,844.86     Covered
J2510   Penicillin g procaine inj      N                         Covered
J2513   Pentastarch 10% solution       K   01222                By Report
J2515   Pentobarbital sodium inj       N                         Covered
J2540   Penicillin g potassium inj     N                         Covered
J2543   Piperacillin/tazobactam        N                         Covered
J2545   Pentamidine non-comp unit      B                       Not Covered
J2550   Promethazine hcl injection     N                         Covered
J2560   Phenobarbital sodium inj       N                         Covered
J2562   Plerixafor injection           G   09252   $281.25       Covered
J2590   Oxytocin injection             N                         Covered
J2597   Inj desmopressin acetate       N                         Covered
J2650   Prednisolone acetate inj       N                         Covered
J2670   Totazoline hcl injection       N                       Covered
J2675   Inj progesterone per 50 MG     N                       Covered
J2680   Fluphenazine decanoate 25 MG   N                       Covered
J2690   Procainamide hcl injection     N                       Covered
J2700   Oxacillin sodium injeciton     N                       Covered
J2710   Neostigmine methylslfte inj    N                       Covered
J2720   Inj protamine sulfate/10 MG    N                       Covered
J2724   Protein c concentrate          K   01139   $13.09      Covered
J2725   Inj protirelin per 250 mcg     N                       Covered
J2730   Pralidoxime chloride inj       K   01023   $110.32     Covered
J2760   Phentolaine mesylate inj       N                       Covered
J2765   Metoclopramide hcl injection   N                       Covered
J2770   Quinupristin/dalfopristin      K   02770   $122.78     Covered
J2778   Ranibizumab injection          K   09233   $443.14     Covered
J2780   Ranitidine hydrochloride inj   N                       Covered
J2783   Rasburicase                    K   00738             Not Covered
J2785   Regadenoson injection          G   09244    $56.93     Covered
J2788   Rho d immune globulin 50 mcg   K   09023    $37.25     Covered
J2790   Rho d immune globulin inj      K   00884   $107.49     Covered
J2791   Rhophylac injection            K   00945              By Report
J2792   Rho(D) immune globulin h, sd   K   01609   $22.03      Covered
J2793   Rilonacept injection           K   01291   $24.55      Covered
J2794   Risperidone, long acting       K   09125    $4.93      Covered
J2795   Ropivacaine HCl injection      N                       Covered
J2796   Romiplostim injection          G   09245   $46.82      Covered
J2800   Methocarbamol injection        N                       Covered
J2805   Sincalide injection            N                       Covered
J2810   Inj theophylline per 40 MG     N                       Covered
J2820   Sargramostim injection         K   00731   $31.14      Covered
J2850   Inj secretin synthetic human   K   01700   $24.49      Covered
J2910   Aurothioglucose injeciton      N                       Covered
J2916   Na ferric gluconate complex    N                       Covered
J2920   Methylprednisolone injection   N                       Covered
J2930   Methylprednisolone injection   N                       Covered
J2940   Somatrem injection             K   01225             Not Covered
J2941   Somatropin injection           K   07034             Not Covered
J2950   Promazine hcl injection        N                       Covered
J2993   Reteplase injection            K   09005             Not Covered
J2995   Inj streptokinase /250000 IU   K   01226             Not Covered
J2997   Alteplase recombinant          K   07048   $39.32      Covered
J3000   Streptomycin injection         N                       Covered
J3010   Fentanyl citrate injeciton     N                       Covered
J3030   Sumatriptan succinate / 6 MG   K   03030   $28.46      Covered
J3070   Pentazocine injection          N                       Covered
J3100   Tenecteplase injection         D                     Not Covered
J3101   Tenecteplase injection         K   09002   $54.09      Covered
J3105   Terbutaline sulfate inj        N                       Covered
J3110   Teriparatide injection         B                     Not Covered
J3120   Testosterone enanthate inj     N                       Covered
J3130   Testosterone enanthate inj     N                       Covered
J3140   Testosterone suspension inj    N                       Covered
J3150   Testosteron propionate inj     N                       Covered
J3230   Chlorpromazine hcl injection   N                       Covered
J3240   Thyrotropin injection          K   09108             Not Covered
J3243   Tigecycline injection          K   09228              By Report
J3246   Tirofiban HCl                  K   07041             Not Covered
J3250   Trimethobenzamide hcl inj      N                       Covered
J3260   Tobramycin sulfate injection   N                       Covered
J3265   Injection torsemide 10 mg/ml   N                       Covered
J3280   Thiethylperazine maleate inj   N                       Covered
J3285   Treprostinil injection         K   01701   $62.69      Covered
J3300   Triamcinolone A inj PRS-free   K   01253    $3.49      Covered
J3301   Triamcinolone acet inj NOS     N                       Covered
J3302   Triamcinolone diacetate inj    N                       Covered
J3303   Triamcinolone hexacetonl inj   N                       Covered
J3305   Inj trimetrexate glucoronate   K   07045   $152.69     Covered
J3310   Perphenazine injeciton         N                       Covered
J3315   Triptorelin pamoate            K   09122   $427.13     Covered
J3320   Spectinomycn di-hcl inj        N                       Covered
J3350   Urea injection                 N                     Not Covered
J3355   Urofollitropin, 75 iu          K   01741   $75.22      Covered
J3360   Diazepam injection             N                       Covered
J3364   Urokinase 5000 IU injection    N                       Covered
J3365   Urokinase 250,000 IU inj       K   07036   $548.09     Covered
J3370   Vancomycin hcl injection       N                       Covered
J3396   Verteporfin injection          K   01203   $10.32      Covered
J3400   Triflupromazine hcl inj        N                       Covered
J3410   Hydroxyzine hcl injection      N                       Covered
J3411   Thiamine hcl 100 mg            N                       Covered
J3415   Pyridoxine hcl 100 mg          N                     Not Covered
J3420   Vitamin b12 injection          N                       Covered
J3430   Vitamin k phytonadione inj     N                       Covered
J3465   Injection, voriconazole        K   01052             Not Covered
J3470   Hyaluronidase injection        N                       Covered
J3471   Ovine, up to 999 USP units     N                       Covered
J3472   Ovine, 1000 USP units          N                       Covered
J3473   Hyaluronidase recombinant      N                      By Report
J3475   Inj magnesium sulfate          N                       Covered
J3480   Inj potassium chloride         N                       Covered
J3485   Zidovudine                     N                       Covered
J3486   Ziprasidone mesylate           N                       Covered
J3487   Zoledronic acid                K   09115   $231.31     Covered
J3488   Reclast injection              K   00951   $236.70     Covered
J3490   Drugs unclassified injection   N                      By Report
J3520   Edetate disodium per 150 mg    E            $1.09      Covered
J3530   Nasal vaccine inhalation       N                     Not Covered
J3535   Metered dose inhaler drug      E                      By Report
J3570   Laetrile amygdalin vit B17     E                     Not Covered
J3590   Unclassified biologics         N                      By Report
J7030   Normal saline solution infus   N                       Covered
J7040   Normal saline solution infus   N                       Covered
J7042   5% dextrose/normal saline      N                       Covered
J7050   Normal saline solution infus   N                       Covered
J7060   5% dextrose/water              N                       Covered
J7070   D5w infusion                   N                       Covered
J7100   Dextran 40 infusion            N                       Covered
J7110   Dextran 75 infusion            N                       Covered
J7120   Ringers lactate infusion       N                       Covered
J7130   Hypertonic saline solution     N                       Covered
J7185   Xyntha inj                     K   01268    $1.49      Covered
J7186   Antihemophilic viii/vwf comp   K   01213              By Report
J7187   Humate-P, inj                  K   01704              By Report
J7189   Factor viia                    K   01705    $0.01      Covered
J7190   Factor viii                    K   00925    $0.94      Covered
J7191   Factor VIII (porcine)          K   01279             Not Covered
J7192   Factor viii recombinant        K   00927             Not Covered
J7193   Factor IX non-recombinant      K   00931             Not Covered
J7194   Factor ix complex              K   00928             Not Covered
J7195   Factor IX recombinant          K   00932             Not Covered
J7197   Antithrombin iii injection     K   01263    $1.53      Covered
J7198   Anti-inhibitor                 K   00929    $1.53      Covered
J7199   Hemophilia clot factor noc     B                     Not Covered
J7300   Intraut copper contraceptive   E           $307.57     Covered
J7302   Levonorgestrel iu contracept   E           $482.45     Covered
J7303   Contraceptive vaginal ring     E                     Not Covered
J7304   Contraceptive hormone patch    E           $10.84      Covered
J7306   Levonorgestrel implant sys     E                      By Report
J7307   Etonogestrel implant system    E           $594.26     Covered
J7308   Aminolevulinic acid hcl top    K   07308             Not Covered
J7310   Ganciclovir long act implant   K   00913             Not Covered
J7311   Fluocinolone acetonide implt   K   09225              By Report
J7321   Hyalgan/supartz inj per dose   K   00873   $131.81     Covered
J7322   Synvisc inj per dose           D                     Not Covered
J7323   Euflexxa inj per dose          K   00875   $132.61     Covered
J7324   Orthovisc inj per dose         K   00877   $237.57     Covered
J7325   Synvisc or Synvisc-One         K   00874    $15.84     Covered
J7330   Cultured chondrocytes implnt   B                     Not Covered
J7340   Metabolic active D/E tissue    D                     Not Covered
J7341   Non-human, metabolic tissue    D                     Not Covered
J7342   Metabolically active tissue    D                     Not Covered
J7343   Nonmetabolic act d/e tissue    D                     Not Covered
J7344   Nonmetabolic active tissue     D                     Not Covered
J7346   Injectable human tissue        D                     Not Covered
J7347   Integra matrix tissue          D                     Not Covered
J7348   Tissuemend tissue              D                     Not Covered
J7349   Primatrix tissue               D                     Not Covered
J7500   Azathioprine oral 50mg         N                       Covered
J7501   Azathioprine parenteral        K   00887    $47.24     Covered
J7502   Cyclosporine oral 100 mg       K   01292     $3.92     Covered
J7504   Lymphocyte immune globulin     K   00890   $289.31     Covered
J7505   Monoclonal antibodies          K   07038   $882.38     Covered
J7506   Prednisone oral                N                     Not Covered
J7507   Tacrolimus oral per 1 MG       K   00891             Not Covered
J7509   Methylprednisolone oral        N                     Not Covered
J7510   Prednisolone oral per 5 mg     N                     Not Covered
J7511   Antithymocyte globuln rabbit   K   09104   $298.48     Covered
J7513   Daclizumab, parenteral         K   01612   $380.18     Covered
J7515   Cyclosporine oral 25 mg        K   01294     $0.99     Covered
J7516   Cyclosporin parenteral 250mg   K   01204    $21.29     Covered
J7517   Mycophenolate mofetil oral     K   09015             Not Covered
J7518   Mycophenolic acid              N                       Covered
J7520   Sirolimus, oral                K   09020    $6.84      Covered
J7525   Tacrolimus injection           K   09006   $126.18     Covered
J7599   Immunosuppressive drug noc     N                      By Report
J7602   Albuterol inh non-comp con     D                     Not Covered
J7603   Albuterol inh non-comp u d     D                     Not Covered
J7604   Acetylcysteine comp unit       M                      By Report
J7605   Arformoterol non-comp unit     M            $5.23      Covered
J7606   Formoterol fumarate, inh       M            $2.78      Covered
J7607   Levalbuterol comp con          M                      By Report
J7608   Acetylcysteine non-comp unit   M            $2.78      Covered
J7609   Albuterol comp unit            M                      By Report
J7610   Albuterol comp con             M                      By Report
J7611   Albuterol non-comp con         M            $0.06      Covered
J7612   Levalbuterol non-comp con      M            $0.92      Covered
J7613   Albuterol non-comp unit        M            $0.09      Covered
J7614   Levalbuterol non-comp unit     M            $1.45      Covered
J7615   Levalbuterol comp unit         M                      By Report
J7620   Albuterol ipratrop non-comp    M            $0.84      Covered
J7622   Beclomethasone comp unit       M                     Not Covered
J7624   Betamethasone comp unit        M                     Not Covered
J7626   Budesonide non-comp unit       M            $4.39      Covered
J7627   Budesonide comp unit           M                      By Report
J7628   Bitolterol mesylate comp con   M            $0.19      Covered
J7629   Bitolterol mesylate comp unt   M            $0.19      Covered
J7631   Cromolyn sodium noncomp unit   M            $0.71      Covered
J7632   Cromolyn sodium comp unit      M                      By Report
J7633   Budesonide non-comp con        M            $0.03      Covered
J7634   Budesonide comp con            M                      By Report
J7635   Atropine comp con              M            $0.25      Covered
J7636   Atropine comp unit             M            $0.07      Covered
J7637   Dexamethasone comp con         M            $0.01      Covered
J7638   Dexamethasone comp unit        M            $0.13      Covered
J7639   Dornase alfa non-comp unit     M           $19.02      Covered
J7640   Formoterol comp unit           E            $2.86      Covered
J7641   Flunisolide comp unit          M                     Not Covered
J7642   Glycopyrrolate comp con        M                     Not Covered
J7643   Glycopyrrolate comp unit       M                     Not Covered
J7644   Ipratropium bromide non-comp   M            $0.22      Covered
J7645   Ipratropium bromide comp       M                      By Report
J7647   Isoetharine comp con           M                     Not Covered
J7648   Isoetharine non-comp con       M                     Not Covered
J7649   Isoetharine non-comp unit      M                     Not Covered
J7650   Isoetharine comp unit          M                     Not Covered
J7657   Isoproterenol comp con         M                      By Report
J7658   Isoproterenol non-comp con     M            $0.57      Covered
J7659   Isoproterenol non-comp unit    M            $0.57      Covered
J7660   Isoproterenol comp unit        M                      By Report
J7667   Metaproterenol comp con        M                      By Report
J7668   Metaproterenol non-comp con    M            $0.23      Covered
J7669   Metaproterenol non-comp unit   M                     Not Covered
J7670   Metaproterenol comp unit       M                      By Report
J7674   Methacholine chloride, neb     N                     Not Covered
J7676   Pentamidine comp unit dose     M                     Not Covered
J7680   Terbutaline sulf comp con      M            $0.02      Covered
J7681   Terbutaline sulf comp unit     M           $15.77      Covered
J7682   Tobramycin non-comp unit       M           $51.51      Covered
J7683   Triamcinolone comp con         M            $0.61      Covered
J7684   Triamcinolone comp unit        M            $0.61      Covered
J7685   Tobramycin comp unit           M                      By Report
J7699   Inhalation solution for DME    M                      By Report
J7799   Non-inhalation drug for DME    N                      By Report
J8498   Antiemetic rectal/supp NOS     B                     Not Covered
J8499   Oral prescrip drug non chemo   E                      By Report
J8501   Oral aprepitant                K   00868             Not Covered
J8510   Oral busulfan                  N                       Covered
J8515   Cabergoline, oral 0.25mg       E           $16.68      Covered
J8520   Capecitabine, oral, 150 mg     K   07042    $2.47      Covered
J8521   Capecitabine, oral, 500 mg     K   00934    $8.24      Covered
J8530   Cyclophosphamide oral 25 MG    N                       Covered
J8540   Oral dexamethasone             N                       Covered
J8560   Etoposide oral 50 MG           K   00802   $48.49      Covered
J8565   Gefitinib oral                 E           $60.18      Covered
J8597   Antiemetic drug oral NOS       N                      By Report
J8600   Melphalan oral 2 MG            N                       Covered
J8610   Methotrexate oral 2.5 MG       N                       Covered
J8650   Nabilone oral                  N                      By Report
J8700   Temozolomide                   K   01086    $6.62      Covered
J8705   Topotecan oral                 G   01238   $74.03      Covered
J8999   Oral prescription drug chemo   B                     Not Covered
J9000   Doxorubicin hcl injection      N                       Covered
J9001   Doxorubicin hcl liposome inj   K   07046   $399.43     Covered
J9010   Alemtuzumab injection          K   09110   $626.34     Covered
J9015   Aldesleukin injection          K   00807   $786.97     Covered
J9017   Arsenic trioxide injection     K   09012    $37.38     Covered
J9020   Asparaginase injection         K   00814    $67.08     Covered
J9025   Azacitidine injection          K   01709     $4.78     Covered
J9027   Clofarabine injection          K   01710   $135.61     Covered
J9031   Bcg live intravesical vac      K   00809   $171.58     Covered
J9033   Bendamustine injection         G   09243    $20.25     Covered
J9035   Bevacizumab injection          K   09214    $61.16     Covered
J9040   Bleomycin sulfate injection    N                       Covered
J9041   Bortezomib injection           K   09207   $30.41      Covered
J9045   Carboplatin injection          N                       Covered
J9050   Carmustine injection           K   00812   $144.65     Covered
J9055   Cetuximab injection            K   09215    $53.19     Covered
J9060   Cisplatin 10 MG injection      N                       Covered
J9062   Cisplatin 50 MG injection      N                       Covered
J9065   Inj cladribine per 1 MG        K   00858   $62.66      Covered
J9070   Cyclophosphamide 100 MG inj    N                       Covered
J9080   Cyclophosphamide 200 MG inj    N                          Covered
J9090   Cyclophosphamide 500 MG inj    N                          Covered
J9091   Cyclophosphamide 1.0 grm inj   N                          Covered
J9092   Cyclophosphamide 2.0 grm inj   N                          Covered
J9093   Cyclophosphamide lyophilized   N                          Covered
J9094   Cyclophosphamide lyophilized   N                          Covered
J9095   Cyclophosphamide lyophilized   N                          Covered
J9096   Cyclophosphamide lyophilized   N                          Covered
J9097   Cyclophosphamide lyophilized   N                          Covered
J9098   Cytarabine liposome inj        K   01166                Not Covered
J9100   Cytarabine hcl 100 MG inj      N                          Covered
J9110   Cytarabine hcl 500 MG inj      N                          Covered
J9120   Dactinomycin injection         K   00752    $14.87        Covered
J9130   Dacarbazine 100 mg inj         N                          Covered
J9140   Dacarbazine 200 MG inj         N                          Covered
J9150   Daunorubicin injection         K   00820    $75.36        Covered
J9151   Daunorubicin citrate inj       K   00821    $69.23        Covered
J9155   Degarelix injection            G   01296     $4.20        Covered
J9160   Denileukin diftitox inj        K   01084   $1,426.13      Covered
J9165   Diethylstilbestrol injection   K   01209    $15.44        Covered
J9170   Docetaxel injection            D                        Not Covered
J9171   Docetaxel injection            K   00823    $20.90        Covered
J9175   Elliotts b solution per ml     N                          Covered
J9178   Inj, epirubicin hcl, 2 mg      K   01167                Not Covered
J9181   Etoposide injection            N                          Covered
J9182   Etoposide 100 MG inj           D                        Not Covered
J9185   Fludarabine phosphate inj      K   00842    $353.94       Covered
J9190   Fluorouracil injection         N                          Covered
J9200   Floxuridine injection          K   00827    $140.70       Covered
J9201   Gemcitabine hcl injection      K   00828    $131.45       Covered
J9202   Goserelin acetate implant      K   00810    $478.42       Covered
J9206   Irinotecan injection           K   00830    $155.21       Covered
J9207   Ixabepilone injection          G   09240     $69.12       Covered
J9208   Ifosfomide injection           K   00831    $152.65       Covered
J9209   Mesna injection                K   00732     $35.68       Covered
J9211   Idarubicin hcl injection       K   00832    $449.98       Covered
J9212   Interferon alfacon-1 inj       K   01266      $4.38       Covered
J9213   Interferon alfa-2a inj         K   00834     $37.38       Covered
J9214   Interferon alfa-2b inj         K   00836     $15.95       Covered
J9215   Interferon alfa-n3 inj         K   00865      $7.97       Covered
J9216   Interferon gamma 1-b inj       K   00838    $224.19       Covered
J9217   Leuprolide acetate suspnsion   K   09217    $478.42       Covered
J9218   Leuprolide acetate injeciton   K   00861     $25.47       Covered
J9219   Leuprolide acetate implant     K   07051   $2,364.04      Covered
J9225   Vantas implant                 G   01711                 By Report
J9226   Supprelin LA implant           G   01142   $15,907.50     Covered
J9230   Mechlorethamine hcl inj        K   00751     $12.87       Covered
J9245   Inj melphalan hydrochl 50 MG   K   00840    $450.14       Covered
J9250   Methotrexate sodium inj        N                          Covered
J9260   Methotrexate sodium inj        N                          Covered
J9261   Nelarabine injection           K   00825                 By Report
J9263   Oxaliplatin                    K   01738     $9.61        Covered
J9264   Paclitaxel protein bound       K   01712    $9.78        Covered
J9265   Paclitaxel injection           N                         Covered
J9266   Pegaspargase injection         K   00843   $1,654.14     Covered
J9268   Pentostatin injection          K   00844   $1,865.50     Covered
J9270   Plicamycin (mithramycin) inj   N                         Covered
J9280   Mitomycin 5 MG inj             K   01232    $129.33      Covered
J9290   Mitomycin 20 MG inj            K   01233    $328.09      Covered
J9291   Mitomycin 40 MG inj            K   01234    $305.38      Covered
J9293   Mitoxantrone hydrochl / 5 MG   K   00864    $364.78      Covered
J9300   Gemtuzumab ozogamicin inj      K   09004   $2,339.97     Covered
J9303   Panitumumab injection          K   09235               Not Covered
J9305   Pemetrexed injection           K   09213    $43.44       Covered
J9310   Rituximab injection            K   00849   $509.35       Covered
J9320   Streptozocin injection         K   00850   $151.58       Covered
J9328   Temozolomide injection         G   09253     $1.78       Covered
J9330   Temsirolimus injection         K   01168    $51.88       Covered
J9340   Thiotepa injection             K   00851    $95.00       Covered
J9350   Topotecan injection            K   00852   $810.73       Covered
J9355   Trastuzumab injection          K   01613    $59.01       Covered
J9357   Valrubicin injection           K   01235   $564.34       Covered
J9360   Vinblastine sulfate inj        N                         Covered
J9370   Vincristine sulfate 1 MG inj   N                         Covered
J9375   Vincristine sulfate 2 MG inj   N                         Covered
J9380   Vincristine sulfate 5 MG inj   N                         Covered
J9390   Vinorelbine tartrate inj       N                         Covered
J9395   Injection, Fulvestrant         K   09120    $88.90       Covered
J9600   Porfimer sodium injection      K   00856   $2,789.85     Covered
J9999   Chemotherapy drug              N                        By Report
K0001   Standard wheelchair            Y                       Not Covered
K0002   Stnd hemi (low seat) whlchr    Y                       Not Covered
K0003   Lightweight wheelchair         Y                       Not Covered
K0004   High strength ltwt whlchr      Y                       Not Covered
K0005   Ultralightweight wheelchair    Y                       Not Covered
K0006   Heavy duty wheelchair          Y                       Not Covered
K0007   Extra heavy duty wheelchair    Y                       Not Covered
K0009   Other manual wheelchair/base   Y                       Not Covered
K0010   Stnd wt frame power whlchr     Y                       Not Covered
K0011   Stnd wt pwr whlchr w control   Y                       Not Covered
K0012   Ltwt portbl power whlchr       Y                       Not Covered
K0014   Other power whlchr base        Y                       Not Covered
K0015   Detach non-adjus hght armrst   Y                       Not Covered
K0017   Detach adjust armrest base     Y                       Not Covered
K0018   Detach adjust armrst upper     Y                       Not Covered
K0019   Arm pad each                   Y                       Not Covered
K0020   Fixed adjust armrest pair      Y                       Not Covered
K0037   High mount flip-up footrest    Y                       Not Covered
K0038   Leg strap each                 Y                       Not Covered
K0039   Leg strap h style each         Y                       Not Covered
K0040   Adjustable angle footplate     Y                       Not Covered
K0041   Large size footplate each      Y                       Not Covered
K0042   Standard size footplate each   Y                       Not Covered
K0043   Ftrst lower extension tube     Y                       Not Covered
K0044   Ftrst upper hanger bracket     Y             Not Covered
K0045   Footrest complete assembly     Y             Not Covered
K0046   Elevat legrst low extension    Y             Not Covered
K0047   Elevat legrst up hangr brack   Y             Not Covered
K0050   Ratchet assembly               Y             Not Covered
K0051   Cam relese assem ftrst/lgrst   Y             Not Covered
K0052   Swingaway detach footrest      Y             Not Covered
K0053   Elevate footrest articulate    Y             Not Covered
K0056   Seat ht <17 or >=21 ltwt wc    Y             Not Covered
K0065   Spoke protectors               Y             Not Covered
K0069   Rear whl complete solid tire   Y             Not Covered
K0070   Rear whl compl pneum tire      Y             Not Covered
K0071   Front castr compl pneum tire   Y             Not Covered
K0072   Frnt cstr cmpl sem-pneum tir   Y             Not Covered
K0073   Caster pin lock each           Y             Not Covered
K0077   Front caster assem complete    Y             Not Covered
K0098   Drive belt power wheelchair    Y             Not Covered
K0105   Iv hanger                      Y             Not Covered
K0108   W/c component-accessory NOS    Y             Not Covered
K0195   Elevating whlchair leg rests   Y             Not Covered
K0455   Pump uninterrupted infusion    Y             Not Covered
K0462   Temporary replacement eqpmnt   Y             Not Covered
K0552   Supply/ext inf pump syr type   Y    $2.61      Covered
K0601   Repl batt silver oxide 1.5 v   Y             Not Covered
K0602   Repl batt silver oxide 3 v     Y             Not Covered
K0603   Repl batt alkaline 1.5 v       Y             Not Covered
K0604   Repl batt lithium 3.6 v        Y             Not Covered
K0605   Repl batt lithium 4.5 v        Y             Not Covered
K0606   AED garment w elec analysis    Y             Not Covered
K0607   Repl batt for AED              Y             Not Covered
K0608   Repl garment for AED           Y             Not Covered
K0609   Repl electrode for AED         Y             Not Covered
K0669   Seat/back cus no sadmerc ver   Y             Not Covered
K0672   Removable soft interface LE    A   $76.40      Covered
K0730   Ctrl dose inh drug deliv sys   Y              By Report
K0733   12-24hr sealed lead acid       Y             Not Covered
K0734   Adj skin pro w/c cus wd<22in   Y   $331.47     Covered
K0735   Adj skin pro wc cus wd>=22in   Y   $421.78     Covered
K0736   Adj skin pro/pos wc cus<22in   Y   $334.19     Covered
K0737   Adj skin pro/pos wc cus>=22"   Y   $423.06     Covered
K0738   Portable gas oxygen system     Y             Not Covered
K0739   Repair/svc DME non-oxygen eq   Y             Not Covered
K0740   Repair/svc oxygen equipment    E             Not Covered
K0800   POV group 1 std up to 300lbs   Y             Not Covered
K0801   POV group 1 hd 301-450 lbs     Y             Not Covered
K0802   POV group 1 vhd 451-600 lbs    Y             Not Covered
K0806   POV group 2 std up to 300lbs   Y             Not Covered
K0807   POV group 2 hd 301-450 lbs     Y             Not Covered
K0808   POV group 2 vhd 451-600 lbs    Y             Not Covered
K0812   Power operated vehicle NOC     Y             Not Covered
K0813   PWC gp 1 std port seat/back    Y             Not Covered
K0814   PWC gp 1 std port cap chair    Y             Not Covered
K0815   PWC gp 1 std seat/back         Y   Not Covered
K0816   PWC gp 1 std cap chair         Y   Not Covered
K0820   PWC gp 2 std port seat/back    Y   Not Covered
K0821   PWC gp 2 std port cap chair    Y   Not Covered
K0822   PWC gp 2 std seat/back         Y   Not Covered
K0823   PWC gp 2 std cap chair         Y   Not Covered
K0824   PWC gp 2 hd seat/back          Y   Not Covered
K0825   PWC gp 2 hd cap chair          Y   Not Covered
K0826   PWC gp 2 vhd seat/back         Y   Not Covered
K0827   PWC gp vhd cap chair           Y   Not Covered
K0828   PWC gp 2 xtra hd seat/back     Y   Not Covered
K0829   PWC gp 2 xtra hd cap chair     Y   Not Covered
K0830   PWC gp2 std seat elevate s/b   Y   Not Covered
K0831   PWC gp2 std seat elevate cap   Y   Not Covered
K0835   PWC gp2 std sing pow opt s/b   Y   Not Covered
K0836   PWC gp2 std sing pow opt cap   Y   Not Covered
K0837   PWC gp 2 hd sing pow opt s/b   Y   Not Covered
K0838   PWC gp 2 hd sing pow opt cap   Y   Not Covered
K0839   PWC gp2 vhd sing pow opt s/b   Y   Not Covered
K0840   PWC gp2 xhd sing pow opt s/b   Y   Not Covered
K0841   PWC gp2 std mult pow opt s/b   Y   Not Covered
K0842   PWC gp2 std mult pow opt cap   Y   Not Covered
K0843   PWC gp2 hd mult pow opt s/b    Y   Not Covered
K0848   PWC gp 3 std seat/back         Y   Not Covered
K0849   PWC gp 3 std cap chair         Y   Not Covered
K0850   PWC gp 3 hd seat/back          Y   Not Covered
K0851   PWC gp 3 hd cap chair          Y   Not Covered
K0852   PWC gp 3 vhd seat/back         Y   Not Covered
K0853   PWC gp 3 vhd cap chair         Y   Not Covered
K0854   PWC gp 3 xhd seat/back         Y   Not Covered
K0855   PWC gp 3 xhd cap chair         Y   Not Covered
K0856   PWC gp3 std sing pow opt s/b   Y   Not Covered
K0857   PWC gp3 std sing pow opt cap   Y   Not Covered
K0858   PWC gp3 hd sing pow opt s/b    Y   Not Covered
K0859   PWC gp3 hd sing pow opt cap    Y   Not Covered
K0860   PWC gp3 vhd sing pow opt s/b   Y   Not Covered
K0861   PWC gp3 std mult pow opt s/b   Y   Not Covered
K0862   PWC gp3 hd mult pow opt s/b    Y   Not Covered
K0863   PWC gp3 vhd mult pow opt s/b   Y   Not Covered
K0864   PWC gp3 xhd mult pow opt s/b   Y   Not Covered
K0868   PWC gp 4 std seat/back         Y   Not Covered
K0869   PWC gp 4 std cap chair         Y   Not Covered
K0870   PWC gp 4 hd seat/back          Y   Not Covered
K0871   PWC gp 4 vhd seat/back         Y   Not Covered
K0877   PWC gp4 std sing pow opt s/b   Y   Not Covered
K0878   PWC gp4 std sing pow opt cap   Y   Not Covered
K0879   PWC gp4 hd sing pow opt s/b    Y   Not Covered
K0880   PWC gp4 vhd sing pow opt s/b   Y   Not Covered
K0884   PWC gp4 std mult pow opt s/b   Y   Not Covered
K0885   PWC gp4 std mult pow opt cap   Y   Not Covered
K0886   PWC gp4 hd mult pow s/b        Y   Not Covered
K0890   PWC gp5 ped sing pow opt s/b   Y   Not Covered
K0891   PWC gp5 ped mult pow opt s/b   Y               Not Covered
K0898   Power wheelchair NOC           Y               Not Covered
K0899   Pow mobil dev no SADMERC       Y               Not Covered
L0112   Cranial cervical orthosis      A               Not Covered
L0113   Cranial cervical torticollis   A                By Report
L0120   Cerv flexible non-adjustable   A    $28.52       Covered
L0130   Flex thermoplastic collar mo   A   $131.55       Covered
L0140   Cervical semi-rigid adjustab   A    $68.82       Covered
L0150   Cerv semi-rig adj molded chn   A   $115.56       Covered
L0160   Cerv semi-rig wire occ/mand    A   $140.42       Covered
L0170   Cervical collar molded to pt   A   $529.93       Covered
L0172   Cerv col thermplas foam 2 pi   A   $103.51       Covered
L0174   Cerv col foam 2 piece w thor   A   $234.46       Covered
L0180   Cer post col occ/man sup adj   A   $300.97       Covered
L0190   Cerv collar supp adj cerv ba   A   $423.12       Covered
L0200   Cerv col supp adj bar & thor   A   $507.99       Covered
L0210   Thoracic rib belt              D               Not Covered
L0220   Thor rib belt custom fabrica   A    $110.04      Covered
L0430   Dewall posture protector       A   $1,125.96     Covered
L0450   TLSO flex prefab thoracic      A               Not Covered
L0452   tlso flex custom fab thoraci   A               Not Covered
L0454   TLSO flex prefab sacrococ-T9   A   $297.62       Covered
L0456   TLSO flex prefab               A               Not Covered
L0458   TLSO 2Mod symphis-xipho pre    A               Not Covered
L0460   TLSO2Mod symphysis-stern pre   A               Not Covered
L0462   TLSO 3Mod sacro-scap pre       A               Not Covered
L0464   TLSO 4Mod sacro-scap pre       A               Not Covered
L0466   TLSO rigid frame pre soft ap   A               Not Covered
L0468   TLSO rigid frame prefab pelv   A               Not Covered
L0470   TLSO rigid frame pre subclav   A               Not Covered
L0472   TLSO rigid frame hyperex pre   A               Not Covered
L0480   TLSO rigid plastic custom fa   A               Not Covered
L0482   TLSO rigid lined custom fab    A               Not Covered
L0484   TLSO rigid plastic cust fab    A               Not Covered
L0486   TLSO rigidlined cust fab two   A               Not Covered
L0488   TLSO rigid lined pre one pie   A               Not Covered
L0490   TLSO rigid plastic pre one     A               Not Covered
L0491   TLSO 2 piece rigid shell       A               Not Covered
L0492   TLSO 3 piece rigid shell       A               Not Covered
L0621   SIO flex pelvisacral prefab    A    $97.01       Covered
L0622   SIO flex pelvisacral custom    A   $248.92       Covered
L0623   SIO panel prefab               A                By Report
L0624   SIO panel custom               A                By Report
L0625   LO flexibl L1-below L5 pre     A    $47.26       Covered
L0626   LO sag stays/panels pre-fab    A    $66.90       Covered
L0627   LO sagitt rigid panel prefab   A   $352.72       Covered
L0628   LO flex w/o rigid stays pre    A    $71.99       Covered
L0629   LSO flex w/rigid stays cust    A     $0.00       Covered
L0630   LSO post rigid panel pre       A   $138.96       Covered
L0631   LSO sag-coro rigid frame pre   A   $880.91       Covered
L0632   LSO sag rigid frame cust       A                By Report
L0633   LSO flexion control prefab     A   $246.07       Covered
L0634   LSO flexion control custom     A                By Report
L0635   LSO sagit rigid panel prefab   A    $863.05      Covered
L0636   LSO sagittal rigid panel cus   A   $1,419.60     Covered
L0637   LSO sag-coronal panel prefab   A   $1,022.04     Covered
L0638   LSO sag-coronal panel custom   A   $1,131.77     Covered
L0639   LSO s/c shell/panel prefab     A   $1,022.04     Covered
L0640   LSO s/c shell/panel custom     A    $897.92      Covered
L0700   Ctlso a-p-l control molded     A   $2,173.52     Covered
L0710   Ctlso a-p-l control w/ inter   A   $1,803.36     Covered
L0810   Halo cervical into jckt vest   A               Not Covered
L0820   Halo cervical into body jack   A               Not Covered
L0830   Halo cerv into milwaukee typ   A               Not Covered
L0859   MRI compatible system          A               Not Covered
L0861   Halo repl liner/interface      A               Not Covered
L0970   Tlso corset front              A    $92.15       Covered
L0972   Lso corset front               A    $84.39       Covered
L0974   Tlso full corset               A   $153.80       Covered
L0976   Lso full corset                A   $143.65       Covered
L0978   Axillary crutch extension      A   $205.76       Covered
L0980   Peroneal straps pair           A    $14.08       Covered
L0982   Stocking supp grips set of f   A    $15.08       Covered
L0984   Protective body sock each      A    $56.20       Covered
L0999   Add to spinal orthosis NOS     A                By Report
L1000   Ctlso milwauke initial model   A   $1,712.17     Covered
L1001   CTLSO infant immobilizer       A                By Report
L1005   Tension based scoliosis orth   A   $2,746.49     Covered
L1010   Ctlso axilla sling             A     $60.39      Covered
L1020   Kyphosis pad                   A     $69.69      Covered
L1025   Kyphosis pad floating          A    $100.55      Covered
L1030   Lumbar bolster pad             A     $51.29      Covered
L1040   Lumbar or lumbar rib pad       A     $63.58      Covered
L1050   Sternal pad                    A     $67.13      Covered
L1060   Thoracic pad                   A     $79.33      Covered
L1070   Trapezius sling                A     $72.55      Covered
L1080   Outrigger                      A     $44.62      Covered
L1085   Outrigger bil w/ vert extens   A    $124.11      Covered
L1090   Lumbar sling                   A     $74.66      Covered
L1100   Ring flange plastic/leather    A    $141.03      Covered
L1110   Ring flange plas/leather mol   A    $259.45      Covered
L1120   Covers for upright each        A     $32.02      Covered
L1200   Furnsh initial orthosis only   A   $1,463.23     Covered
L1210   Lateral thoracic extension     A    $210.98      Covered
L1220   Anterior thoracic extension    A    $184.93      Covered
L1230   Milwaukee type superstructur   A    $458.35      Covered
L1240   Lumbar derotation pad          A     $62.61      Covered
L1250   Anterior asis pad              A     $58.25      Covered
L1260   Anterior thoracic derotation   A     $61.00      Covered
L1270   Abdominal pad                  A     $62.47      Covered
L1280   Rib gusset (elastic) each      A     $69.56      Covered
L1290   Lateral trochanteric pad       A     $63.37      Covered
L1300   Body jacket mold to patient    A   $1,450.24     Covered
L1310   Post-operative body jacket     A   $1,545.79     Covered
L1499   Spinal orthosis NOS            A                By Report
L1500   Thkao mobility frame           A               Not Covered
L1510   Thkao standing frame           A   $1,111.50     Covered
L1520   Thkao swivel walker            A               Not Covered
L1600   Abduct hip flex frejka w cvr   A   $103.90       Covered
L1610   Abduct hip flex frejka covr    A    $41.68       Covered
L1620   Abduct hip flex pavlik harne   A   $111.49       Covered
L1630   Abduct control hip semi-flex   A   $149.58       Covered
L1640   Pelv band/spread bar thigh c   A   $419.98       Covered
L1650   HO abduction hip adjustable    A   $196.62       Covered
L1652   HO bi thighcuffs w sprdr bar   A               Not Covered
L1660   HO abduction static plastic    A    $137.99      Covered
L1680   Pelvic & hip control thigh c   A   $1,196.46     Covered
L1685   Post-op hip abduct custom fa   A    $959.11      Covered
L1686   HO post-op hip abduction       A    $735.52      Covered
L1690   Combination bilateral HO       A   $1,659.34     Covered
L1700   Leg perthes orth toronto typ   A   $1,347.64     Covered
L1710   Legg perthes orth newington    A   $1,441.43     Covered
L1720   Legg perthes orthosis trilat   A   $1,248.01     Covered
L1730   Legg perthes orth scottish r   A   $1,003.04     Covered
L1755   Legg perthes patten bottom t   A   $1,306.28     Covered
L1800   Knee orthoses elas w stays     D               Not Covered
L1810   Ko elastic with joints         A    $80.71       Covered
L1815   Elastic with condylar pads     D               Not Covered
L1820   Ko elas w/ condyle pads & jo   A   $107.04       Covered
L1825   Ko elastic knee cap            D               Not Covered
L1830   Ko immobilizer canvas longit   A    $73.48       Covered
L1831   Knee orth pos locking joint    A               Not Covered
L1832   KO adj jnt pos rigid support   A   $490.22       Covered
L1834   Ko w/0 joint rigid molded to   A   $675.97       Covered
L1836   Rigid KO wo joints             A               Not Covered
L1840   Ko derot ant cruciate custom   A    $759.58      Covered
L1843   KO single upright custom fit   A    $769.96      Covered
L1844   Ko w/adj jt rot cntrl molded   A   $1,622.49     Covered
L1845   Ko w/ adj flex/ext rotat cus   A    $659.05      Covered
L1846   Ko w adj flex/ext rotat mold   A    $900.77      Covered
L1847   KO adjustable w air chambers   A    $493.55      Covered
L1850   Ko swedish type                A    $240.56      Covered
L1860   Ko supracondylar socket mold   A   $1,099.34     Covered
L1900   Afo sprng wir drsflx calf bd   A    $226.52      Covered
L1901   Prefab ankle orthosis          D               Not Covered
L1902   Afo ankle gauntlet             A    $67.93       Covered
L1904   Afo molded ankle gauntlet      A   $381.15       Covered
L1906   Afo multiligamentus ankle su   A    $96.97       Covered
L1907   AFO supramalleolar custom      A               Not Covered
L1910   Afo sing bar clasp attach sh   A   $215.63       Covered
L1920   Afo sing upright w/ adjust s   A   $281.89       Covered
L1930   Afo plastic                    A   $222.93       Covered
L1932   Afo rig ant tib prefab TCF/=   A   $765.74       Covered
L1940   Afo molded to patient plasti   A   $436.69       Covered
L1945   Afo molded plas rig ant tib    A   $746.41       Covered
L1950   Afo spiral molded to pt plas   A   $627.64       Covered
L1951   AFO spiral prefabricated       A               Not Covered
L1960   Afo pos solid ank plastic mo   A   $446.94      Covered
L1970   Afo plastic molded w/ankle j   A   $685.79      Covered
L1971   AFO w/ankle joint, prefab      A               Not Covered
L1980   Afo sing solid stirrup calf    A    $328.27     Covered
L1990   Afo doub solid stirrup calf    A    $414.88     Covered
L2000   Kafo sing fre stirr thi/calf   A    $817.84     Covered
L2005   KAFO sng/dbl mechanical act    A   $3,516.28    Covered
L2010   Kafo sng solid stirrup w/o j   A    $749.55     Covered
L2020   Kafo dbl solid stirrup band/   A    $941.50     Covered
L2030   Kafo dbl solid stirrup w/o j   A    $869.93     Covered
L2034   KAFO pla sin up w/wo k/a cus   A   $1,779.81    Covered
L2035   KAFO plastic pediatric size    A    $148.64     Covered
L2036   Kafo plas doub free knee mol   A   $1,495.99    Covered
L2037   Kafo plas sing free knee mol   A   $1,343.01    Covered
L2038   Kafo w/o joint multi-axis an   A   $1,152.83    Covered
L2040   Hkafo torsion bil rot straps   A    $143.16     Covered
L2050   Hkafo torsion cable hip pelv   A    $384.10     Covered
L2060   Hkafo torsion ball bearing j   A    $484.70     Covered
L2070   Hkafo torsion unilat rot str   A    $112.27     Covered
L2080   Hkafo unilat torsion cable     A    $315.17     Covered
L2090   Hkafo unilat torsion ball br   A    $391.64     Covered
L2106   Afo tib fx cast plaster mold   A    $548.23     Covered
L2108   Afo tib fx cast molded to pt   A    $861.52     Covered
L2112   Afo tibial fracture soft       A    $376.19     Covered
L2114   Afo tib fx semi-rigid          A    $494.43     Covered
L2116   Afo tibial fracture rigid      A    $607.66     Covered
L2126   Kafo fem fx cast thermoplas    A    $965.54     Covered
L2128   Kafo fem fx cast molded to p   A   $1,382.63    Covered
L2132   Kafo femoral fx cast soft      A    $650.44     Covered
L2134   Kafo fem fx cast semi-rigid    A    $779.86     Covered
L2136   Kafo femoral fx cast rigid     A    $962.77     Covered
L2180   Plas shoe insert w ank joint   A     $95.14     Covered
L2182   Drop lock knee                 A     $88.66     Covered
L2184   Limited motion knee joint      A     $99.88     Covered
L2186   Adj motion knee jnt lerman t   A    $125.93     Covered
L2188   Quadrilateral brim             A    $241.49     Covered
L2190   Waist belt                     A     $74.43     Covered
L2192   Pelvic band & belt thigh fla   A    $364.22     Covered
L2200   Limited ankle motion ea jnt    A     $38.34     Covered
L2210   Dorsiflexion assist each joi   A     $54.20     Covered
L2220   Dorsi & plantar flex ass/res   A     $67.70     Covered
L2230   Split flat caliper stirr & p   A     $63.70     Covered
L2232   Rocker bottom, contact AFO     A     $83.76     Covered
L2240   Round caliper and plate atta   A     $71.05     Covered
L2250   Foot plate molded stirrup at   A    $337.55     Covered
L2260   Reinforced solid stirrup       A    $161.64     Covered
L2265   Long tongue stirrup            A     $96.91     Covered
L2270   Varus/valgus strap padded/li   A               Not Covered
L2275   Plastic mod low ext pad/line   A   $128.58      Covered
L2280   Molded inner boot              A   $365.12      Covered
L2300   Abduction bar jointed adjust   A   $225.43      Covered
L2310   Abduction bar-straight         A     $99.19     Covered
L2320   Non-molded lacer               A    $177.38     Covered
L2330   Lacer molded to patient mode   A    $335.55     Covered
L2335   Anterior swing band            A    $244.24     Covered
L2340   Pre-tibial shell molded to p   A    $362.67     Covered
L2350   Prosthetic type socket molde   A    $786.02     Covered
L2360   Extended steel shank           A     $44.63     Covered
L2370   Patten bottom                  A    $275.99     Covered
L2375   Torsion ank & half solid sti   A     $98.26     Covered
L2380   Torsion straight knee joint    A    $120.00     Covered
L2385   Straight knee joint heavy du   A    $109.82     Covered
L2387   Add LE poly knee custom KAFO   A    $133.44     Covered
L2390   Offset knee joint each         A     $88.26     Covered
L2395   Offset knee joint heavy duty   A    $132.71     Covered
L2397   Suspension sleeve lower ext    A    $108.64     Covered
L2405   Knee joint drop lock ea jnt    A     $74.80     Covered
L2415   Knee joint cam lock each joi   A    $104.23     Covered
L2425   Knee disc/dial lock/adj flex   A    $122.99     Covered
L2430   Knee jnt ratchet lock ea jnt   A    $122.99     Covered
L2492   Knee lift loop drop lock rin   A     $82.22     Covered
L2500   Thi/glut/ischia wgt bearing    A    $254.98     Covered
L2510   Th/wght bear quad-lat brim m   A    $633.72     Covered
L2520   Th/wght bear quad-lat brim c   A    $371.45     Covered
L2525   Th/wght bear nar m-l brim mo   A   $1,076.80    Covered
L2526   Th/wght bear nar m-l brim cu   A    $552.29     Covered
L2530   Thigh/wght bear lacer non-mo   A    $208.24     Covered
L2540   Thigh/wght bear lacer molded   A    $340.90     Covered
L2550   Thigh/wght bear high roll cu   A    $231.58     Covered
L2570   Hip clevis type 2 posit jnt    A    $441.85     Covered
L2580   Pelvic control pelvic sling    A               Not Covered
L2600   Hip clevis/thrust bearing fr   A    $165.60     Covered
L2610   Hip clevis/thrust bearing lo   A    $195.82     Covered
L2620   Pelvic control hip heavy dut   A    $272.21     Covered
L2622   Hip joint adjustable flexion   A    $259.97     Covered
L2624   Hip adj flex ext abduct cont   A    $314.95     Covered
L2627   Plastic mold recipro hip & c   A   $1,382.27    Covered
L2628   Metal frame recipro hip & ca   A   $1,350.91    Covered
L2630   Pelvic control band & belt u   A    $199.66     Covered
L2640   Pelvic control band & belt b   A    $270.97     Covered
L2650   Pelv & thor control gluteal    A    $119.44     Covered
L2660   Thoracic control thoracic ba   A    $150.28     Covered
L2670   Thorac cont paraspinal uprig   A    $139.77     Covered
L2680   Thorac cont lat support upri   A    $141.40     Covered
L2750   Plating chrome/nickel pr bar   A     $74.44     Covered
L2755   Carbon graphite lamination     A    $112.13     Covered
L2760   Extension per extension per    A     $48.99     Covered
L2768   Ortho sidebar disconnect       A    $111.83     Covered
L2770   Low ext orthosis per bar/jnt   D               Not Covered
L2780   Non-corrosive finish           A    $54.57      Covered
L2785   Drop lock retainer each        A    $27.27      Covered
L2795   Knee control full kneecap      A    $68.51      Covered
L2800   Knee cap medial or lateral p   A    $86.01      Covered
L2810   Knee control condylar pad      A   $62.98      Covered
L2820   Soft interface below knee se   A   $70.02      Covered
L2830   Soft interface above knee se   A   $75.75      Covered
L2840   Tibial length sock fx or equ   A   $36.45      Covered
L2850   Femoral lgth sock fx or equa   A   $66.57      Covered
L2860   Torsion mechanism knee/ankle   D             Not Covered
L2861   Torsion mechanism knee/ankle   E              By Report
L2999   Lower extremity orthosis NOS   A              By Report
L3000   Ft insert ucb berkeley shell   A             Not Covered
L3001   Foot insert remov molded spe   A   $113.49     Covered
L3002   Foot insert plastazote or eq   A   $138.60     Covered
L3003   Foot insert silicone gel eac   A   $149.54     Covered
L3010   Foot longitudinal arch suppo   A   $149.54     Covered
L3020   Foot longitud/metatarsal sup   A   $170.26     Covered
L3030   Foot arch support remov prem   A    $65.49     Covered
L3031   Foot lamin/prepreg composite   A             Not Covered
L3040   Ft arch suprt premold longit   A   $40.39      Covered
L3050   Foot arch supp premold metat   A   $40.39      Covered
L3060   Foot arch supp longitud/meta   A   $63.28      Covered
L3070   Arch suprt att to sho longit   A   $27.29      Covered
L3080   Arch supp att to shoe metata   A   $27.29      Covered
L3090   Arch supp att to shoe long/m   A   $34.92      Covered
L3100   Hallus-valgus nght dynamic s   A   $37.11      Covered
L3140   Abduction rotation bar shoe    A   $76.40      Covered
L3150   Abduct rotation bar w/o shoe   A   $69.85      Covered
L3160   Shoe styled positioning dev    A              By Report
L3170   Foot plastic heel stabilizer   A   $43.65      Covered
L3201   Oxford w supinat/pronat inf    A   $49.40      Covered
L3202   Oxford w/ supinat/pronator c   A   $49.40      Covered
L3203   Oxford w/ supinator/pronator   A   $49.40      Covered
L3204   Hightop w/ supp/pronator inf   A   $49.40      Covered
L3206   Hightop w/ supp/pronator chi   A   $49.40      Covered
L3207   Hightop w/ supp/pronator jun   A   $49.40      Covered
L3208   Surgical boot each infant      A   $12.65      Covered
L3209   Surgical boot each child       A   $12.26      Covered
L3211   Surgical boot each junior      A   $12.65      Covered
L3212   Benesch boot pair infant       A   $49.40      Covered
L3213   Benesch boot pair child        A   $49.40      Covered
L3214   Benesch boot pair junior       A   $49.40      Covered
L3215   Orthopedic ftwear ladies oxf   E   $57.65      Covered
L3216   Orthoped ladies shoes dpth i   E             Not Covered
L3217   Ladies shoes hightop depth i   E    $57.65     Covered
L3219   Orthopedic mens shoes oxford   E    $59.89     Covered
L3221   Orthopedic mens shoes dpth i   E    $74.73     Covered
L3222   Mens shoes hightop depth inl   E    $74.73     Covered
L3224   Woman's shoe oxford brace      A    $57.95     Covered
L3225   Man's shoe oxford brace        A    $67.41     Covered
L3230   Custom shoes depth inlay       A   $236.88     Covered
L3250   Custom mold shoe remov prost   A   $236.88     Covered
L3251   Shoe molded to pt silicone s   A   $236.88     Covered
L3252   Shoe molded plastazote cust    A   $236.88     Covered
L3253   Shoe molded plastazote cust    A   $236.88     Covered
L3254   Orth foot non-stndard size/w   A              By Report
L3255   Orth foot non-standard size/   A              By Report
L3257   Orth foot add charge split s   A             Not Covered
L3260   Ambulatory surgical boot eac   E    $18.82     Covered
L3265   Plastazote sandal each         A    $48.66     Covered
L3300   Sho lift taper to metatarsal   A    $44.76     Covered
L3310   Shoe lift elev heel/sole neo   A    $69.85     Covered
L3320   Shoe lift elev heel/sole cor   A    $65.12     Covered
L3330   Lifts elevation metal extens   A   $485.63     Covered
L3332   Shoe lifts tapered to one-ha   A    $63.28     Covered
L3334   Shoe lifts elevation heel /i   A    $32.73     Covered
L3340   Shoe wedge sach                A    $73.13     Covered
L3350   Shoe heel wedge                A    $19.65     Covered
L3360   Shoe sole wedge outside sole   A    $30.55     Covered
L3370   Shoe sole wedge between sole   A    $42.55     Covered
L3380   Shoe clubfoot wedge            A    $42.55     Covered
L3390   Shoe outflare wedge            A    $42.55     Covered
L3400   Shoe metatarsal bar wedge ro   A    $34.92     Covered
L3410   Shoe metatarsal bar between    A    $79.67     Covered
L3420   Full sole/heel wedge btween    A    $46.93     Covered
L3430   Sho heel count plast reinfor   A   $137.52     Covered
L3440   Heel leather reinforced        A    $65.49     Covered
L3450   Shoe heel sach cushion type    A    $90.58     Covered
L3455   Shoe heel new leather standa   A    $34.92     Covered
L3460   Shoe heel new rubber standar   A    $29.46     Covered
L3465   Shoe heel thomas with wedge    A    $50.22     Covered
L3470   Shoe heel thomas extend to b   A    $53.49     Covered
L3480   Shoe heel pad & depress for    A    $53.49     Covered
L3485   Shoe heel pad removable for    A    $19.22     Covered
L3500   Ortho shoe add leather insol   A    $25.09     Covered
L3510   Orthopedic shoe add rub insl   A    $25.09     Covered
L3520   O shoe add felt w leath insl   A    $27.29     Covered
L3530   Ortho shoe add half sole       A             Not Covered
L3540   Ortho shoe add full sole       A             Not Covered
L3550   O shoe add standard toe tap    A    $7.67      Covered
L3560   O shoe add horseshoe toe tap   A   $19.65      Covered
L3570   O shoe add instep extension    A   $73.13      Covered
L3580   O shoe add instep velcro clo   A   $55.68      Covered
L3590   O shoe convert to sof counte   A   $45.85      Covered
L3595   Ortho shoe add march bar       A   $35.99      Covered
L3600   Trans shoe calip plate exist   A   $65.49      Covered
L3610   Trans shoe caliper plate new   A   $86.22      Covered
L3620   Trans shoe solid stirrup exi   A             Not Covered
L3630   Trans shoe solid stirrup new   A   $86.22      Covered
L3640   Shoe dennis browne splint bo   A   $37.11      Covered
L3649   Orthopedic shoe modifica NOS   A              By Report
L3650   Shlder fig 8 abduct restrain   A   $55.54      Covered
L3651   Prefab shoulder orthosis       D             Not Covered
L3652   Prefab dbl shoulder orthosis   D             Not Covered
L3660   Abduct restrainer canvas&web   A   $101.56     Covered
L3670   Acromio/clavicular canvas&we   A   $118.97     Covered
L3671   SO cap design w/o jnts CF      A   $703.67     Covered
L3672   SO airplane w/o jnts CF        A   $875.10       Covered
L3673   SO airplane w/joint CF         A   $953.76       Covered
L3675   Canvas vest SO                 A   $137.03       Covered
L3677   SO hard plastic stabilizer     E                By Report
L3700   Elbow orthoses elas w stays    D               Not Covered
L3701   Prefab elbow orthosis          D               Not Covered
L3702   EO w/o joints CF               A   $225.52       Covered
L3710   Elbow elastic with metal joi   A    $97.54       Covered
L3720   Forearm/arm cuffs free motio   A   $540.34       Covered
L3730   Forearm/arm cuffs ext/flex a   A   $846.99       Covered
L3740   Cuffs adj lock w/ active con   A   $895.88       Covered
L3760   EO withjoint, Prefabricated    A   $390.55       Covered
L3762   Rigid EO wo joints             A               Not Covered
L37