PA-ABH_Prior Authorizations_120917 - Aetna Better Health

1 Effective September 1, 2012

A PCP or an Aetna Better Health contracted specialist must request authorization for certain Medically Necessary services. Unauthorized services will not be reimbursed. Please note that authorization is not a guarantee of payment. All out of network services must be authorized. The current list of services which require prior authorization are listed below Please refer to your Provider Relations representative for further information should you have any questions.

CPT Code CPT Description 0183T LOW FREQUENCY WOUND ULTRASOUND 0195T ARTHRODESIS PRESACRAL INTERBODY 0196T ARTHRODESIS PRESACRAL INTERBODY EA INTERSPACE 1991 ANES DX/THER NRV BLK/NJX OTH/THN PRONE POS 1992 ANES DX/THER NERVE BLOCK/INJECTION PRONE POS 1999 UNLISTED ANESTHESIA PROCEDURE

0199T PHYSIO REC TREMOR W/ACCELEROM&GYROSCOPE I&R 0200T PERQ SACRAL AUGMENT UNI +-BALLOON/DEVICE 1+NDL 0201T PERQ SACRAL AUGMENTATION BI +-BALO/DEVICE 2+NDL 0202T POST VERT ARTHROPLASTY +-BONE CEMENT 1 LUM LVL 0203T SLEEP STDY UNATT HEART RT OXSAT RESP&SLEEP TIME 0204T SLEEP STDY UNATT HEART RATE OXSAT RESP ANALYSIS 0213T INJECT PARAVERT FACET JT/NERVE CERV/THORAC 1LVL 0214T INJECT PARAVER FACET JT/NERVE CERV/THORAC LVL 2 0215T INJECT PARAVER FACET JT/NERVE CERV/THORAC 3+LVL 0216T INJECTION PARAVERT FACET JT/NERVE LMBR/SAC 1LVL 0217T INJECTION PARAVERT FACET JT/NERVE LMBR/SAC LVL2 0218T INJECTION PARAVER FACET JT/NERVE LMBR/SAC 3+LVL 0219T PLACE POSTR INFACET IMPLANT GRAFT/DEV 1LVL CERV 0220T PLACE POSTR INFACET IMPLANT GRAFT/DEV 1LVL THOR 0221T PLACE POSTR INFACET IMPLANT GRAFT/DEV 1LVL LMBR 0222T PLACE POSTR INFACET IMPLANT GRAFT/DEV 1LV +LVL 0223T ACOUSTIC/ELECTR CARDGRPHY COMB SINGLE W/INT&REPT 0224T ACSTIC/ELECT CARDGRPHY MULTI AV/VV W/INT&REPT 0225T ACSTIC/ELECT CARDGRPHY MULTI AV+VV W/INT&REPT 0228T INJ ANES AGT&/STRD TFRML EDRL US CRV/THRC 1LVL 0229T INJ ANES AGT&/STRD TFRML EDRL US CRV/THRC + LVL 0230T INJ ANES AGT&/STRD TFRML EDRL US LMBR/SAC 1LVL 0231T INJ ANES AGT&/STRD TFRML EDRL US LMBR/SAC + LVL 0232T INJ PLTLT RICH PLSM INCL IMG GUID HRVSTG&PREP 0233T SKN AGE MEAS MLT-WVELNGTH FLUOR SPCTRSCPY 0239T BIOIMPEDANCE SPECTROSCOPY LIMB DIFFERENCES 0242T GI TRACT TRANSIT&PRESSURE MEAS W/I&R


0243T INTERMIT MEAS WHEEZE RATE BRONCHODIL DX W/I&R 0244T CONT MEAS WHEEZE RATE BRONCHODIL SLEEP 3-24 HRS 0260T TOT BDY SYSTEMIC HYPTHRM PER DAY NEONATE 28D/< 0261T SLCTV HEAD HYPTHRM PER DAY NEONATE 28D/< 0263T IM AUTOL B1 MRW CEL THER 1 LEG COMPL INCL HRVST 0264T IM AUTOL B1 MRW CEL THER 1 LEG COMPL XCL HRVST 0276T BRONCHSCPY FLUORO W/BRONCHIAL THERMPLASTY 1 LOBE 0278T TRNSCUT ELECT MODLATION PAIN REPROCES EA TX SESS 0282T PERC/OPEN IMPLNT NEUROSTIM ELECTRODE SUBQ TRIAL 0283T PERC/OPEN IMPLNT NEUROSTIM ELECTRODE SUBQ PERM 0286T NEAR INFRARED SPECTROSCPY STUDIES LOW EXT WOUNDS 0287T NEARINFRED GUIDANCE VASC ACES RL TIME DIG VISU 0291T INTRAV OPTCL CHERNCE TMGRPHY W/S&I INJ INTL VESL 0292T INTRAV OPTCAL COHRNCE TMGRPHY W/S&I ADL VESL 0293T INS LT ATRL HEMODYN MOTR CMPLETE SYST W/S&I 0294T INS LT ATRL HEMDYN MTR PRSR SENSR LEAD W/S&I 0299T ESW H ENERGY W/TOPCAL APP &DRESNG CARE 1ST WOUND 0300T ESW H ENERGY W/TOPCAL APP &DRESNG CARE ADL WOUND 0301T DEST/REDUC MALIG BRST TUMR W/US THRMORX GUIDANCE 11719 TRIMMING NONDYSTROPHIC NAILS ANY NUMBER 11720 DEBRIDEMENT NAIL ANY METHOD 1-5 11721 DEBRIDEMENT NAIL ANY METHOD 6/> 11920 TATTOOING INCL MICROPIGMENTATION 6.0 CM/< 11921 TATTOOING INCL MICROPIGMENTATION 6.1-20.0 CM 11922 TATTOOING INCL MICROPIGMENTATION EA 20.0 CM 11950 SUBCUTANEOUS INJECTION FILLING MATERIAL 1 CC/< 11951 SUBCUTANEOUS INJECTION FILLING MATRL 1.1-5.0 CC 11952 SUBCUTANEOUS INJECTION FILLING MATRL 5.1-10.0CC 11954 SUBCUTANEOUS INJECTION FILLING MATRL > 10.0 CC 11960 INSERTION TISSUE EXPANDER INCL SBSQ XPNSJ 11970 REPLACEMENT TISS EXPANDER PERMANENT PROSTHESIS 11971 REMOVAL TISS EXPANDER W/O INSERTION PROSTHESIS 15775 PUNCH GRAFT HAIR TRANSPLANT 1-15 PUNCH GRAFTS 15776 PUNCH GRAFT HAIR TRANSPLANT >15 PUNCH GRAFTS 15780 DERMABRASION TOTAL FACE 15781 DERMABRASION SEGMENTAL FACE 15782 DERMABRASION REGIONAL OTHER THAN FACE 15783 DERMABRASION SUPERFICIAL ANY SITE 15786 ABRASION 1 LESION 15787 ABRASION EACH ADDITIONAL 4 LESIONS OR LESS 15788 CHEMICAL PEEL FACIAL EPIDERMAL 15789 CHEMICAL PEEL FACIAL DERMAL 15792 CHEMICAL PEEL NONFACIAL EPIDERMAL


15793 CHEMICAL PEEL NONFACIAL DERMAL 15819 CERVICOPLASTY 15820 BLEPHAROPLASTY LOWER EYELID 15821 BLEPHAROPLASTY LOWER EYELID HERNIATED FAT PAD 15822 BLEPHAROPLASTY UPPER EYELID 15823 BLEPHAROPLASTY UPPER EYELID W/EXCESSIVE SKIN 15824 RHYTIDECTOMY FOREHEAD 15825 RHYTIDECTOMY NECK W/PLATYSMAL TIGHTENING 15826 RHYTIDECTOMY GLABELLAR FROWN LINES 15828 RHYTIDECTOMY CHEEK CHIN&NECK 15829 RHYTIDECTOMY SMAS FLAP 15830 EXCISION SKIN ABD INFRAUMBILICAL PANNICULECTOMY 15832 EXCISION EXCESSIVE SKIN&SUBQ TISSUE THIGH 15833 EXCISION EXCESSIVE SKIN&SUBQ TISSUE LEG 15834 EXCISION EXCESSIVE SKIN&SUBQ TISSUE HIP 15835 EXCISION EXCESSIVE SKIN&SUBQ TISSUE BUTTOCK 15836 EXCISION EXCESSIVE SKIN&SUBQ TISSUE ARM 15837 EXC EXCESSIVE SKIN&SUBQ TISSUE FOREARM/HAND 15838 EXC EXCSV SKIN&SUBQ TISSUE SUBMENTAL FAT PAD 15839 EXCISION EXCESSIVE SKIN&SUBQ TISSUE OTHER AREA 15847 EXCISION EXCESSIVE SKIN & SUBQ TISSUE ABDOMEN 15876 SUCTION ASSISTED LIPECTOMY HEAD&NECK 15877 SUCTION ASSISTED LIPECTOMY TRUNK 15878 SUCTION ASSISTED LIPECTOMY UPPER EXTREMITY 15879 SUCTION ASSISTED LIPECTOMY LOWER EXTREMITY 15920 EXC COCCYGEAL PR ULC W/COCCYGECTOMY W/PRIM SUTR 15922 EXC COCCYGEAL PR ULC W/COCCYGECTOMY W/FLAP CLSR 15931 EXCISION SACRAL PRESSURE ULCER W/PRIMARY SUTURE 15933 EXC SACRAL PRESSURE ULC W/PRIM SUTR W/OSTECTOMY 15934 EXCISION SACRAL PRESSURE ULCER W/SKIN FLAP CLSR 15935 EXC SACRAL PR ULCER W/SKN FLAP CLSR W/OSTECTOMY 15936 EXC SAC PR ULC PREPJ MUSC/MYOQ FLAP/SKN GRF CLSR 15937 EXC SAC PR ULC PREPJ MUSC/MYOQ FLAP/SKN GRF OSTC 15940 EXC ISCHIAL PRESSURE ULCER W/PRIMARY SUTURE 15941 EXC ISCHIAL PR ULC W/PRIM SUTR W/OSTC ISCHIECT 15944 EXC ISCHIAL PRESSURE ULCER W/SKIN FLAP CLOSURE 15945 EXC ISCHIAL PR ULC W/SKN FLAP CLSR W/OSTECTOMY 15946 EXC ISCHIAL PR ULCER W/OSTC MUSC/MYOQ FLAP/SKIN 15950 EXC TROCHANTERIC PRESSURE ULCER W/PRIMARY SUTR 15951 EXC TRCHNTRIC PR ULCER W/PRIM SUTR W/OSTECTOMY 15952 EXC TROCHANTERIC PR ULCER W/SKIN FLAP CLOSURE 15953 EXC TRCHNTRIC PR ULC W/SKN FLAP CLSR W/OSTECTOMY 15956 EXC TROCHANTERIC PR ULCER MUSC/MYOQ FLAP/SKIN


15958 EXC TRCHNTRIC PR ULC MUSC/MYOQ FLAP/SKIN W/OSTC 15999 UNLISTED PROCEDURE EXCISION PRESSURE ULCER 17106 DESTRUCTION CUTANEOUS VASC PROLIFERATIVE <10CM 17107 DESTRUCTION CUTANEOUS VASCULAR PRLF 10.0-50.0CM 17108 DESTRUCTION CUTANEOUS VASCULAR PRLF >50.0CM 17110 DESTRUCTION BENIGN LESIONS UP TO 14 17111 DESTRUCTION BENIGN LESIONS 15/> 17311 MOHS MICROGRAPHIC H/N/H/F/G 1ST STAGE 5 BLOCKS 17312 MOHS MICROGRAPHIC H/N/H/F/G EACH ADDL STAGE 17313 MOHS TRUNK/ARM/LEG 1ST STAGE 5 BLOCKS 17314 MOHS TRUNK/ARM/LEG EA STAGE AFTER 1ST STAGE 17315 MOHS TRUNK/ARM/LEG EA ADDL BLOCK ANY STAGE 17340 CRYOTHERAPY CO2 SLUSH LIQ N2 ACNE 17360 CHEMICAL EXFOLIATION ACNE 17380 ELECTROLYSIS EPILATION EA 30 MINUTES 17999 UNLISTED PX SKIN MUC MEMBRANE &SUBQ TISSUE 19300 MASTECTOMY GYNECOMASTIA 19316 MASTOPEXY 19318 REDUCTION MAMMAPLASTY 19324 MAMMAPLASTY AUGMENTATION W/O PROSTHETIC IMPLANT 19325 MAMMAPLASTY AUGMENTATION W/PROSTHETIC IMPLANT 19328 REMOVAL INTACT MAMMARY IMPLANT 19330 REMOVAL MAMMARY IMPLANT MATERIAL 19340 IMMT INSJ BRST PROSTH FLWG MASTOPEXY MAST/RCNSTJ 19342 DLYD INSJ BRST PROSTH FLWG MASTOPEXY MAST/RCNSTJ 19350 NIPPLE/AREOLA RECONSTRUCTION 19355 CORRECTION INVERTED NIPPLES 19357 BRST RCNSTJ IMMT/DLYD W/TISS EXPANDER SBSQ XPNSJ 19361 BRST RCNSTJ W/LATSMS D/SI FLAP WO PRSTHC IMPL 19364 BREAST RECONSTRUCTION FREE FLAP 19366 BREAST RECONSTRUCTION OTHER TECHNIQUE 19367 BREAST RECONSTRUCTION TRAM FLAP 1 PEDICLE 19368 BREAST RECONSTRUCTION TRAM 1 PEDCL MVASC ANAST 19369 BREAST RECONSTRUCTION TRAM FLAP DOUBLE PEDICLE 19370 OPEN PERIPROSTHETIC CAPSULOTOMY BREAST 19371 PERIPROSTHETIC CAPSULECTOMY BREAST 19380 REVISION RECONSTRUCTED BREAST 19396 PREPARATION MOULAGE CUSTOM BREAST IMPLANT 19499 UNLISTED PROCEDURE BREAST 20552 INJECTION SINGLE/MLT TRIGGER POINT 1/2 MUSCLES 20553 INJECTION SINGLE/MLT TRIGGER POINT 3/> MUSCLES 20694 REMOVAL EXTERNAL FIXATION SYSTEM UNDER ANES 20910 CARTILAGE GRAFT COSTOCHONDRAL


20912 CARTILAGE GRAFT NASAL SEPTUM 20920 FASCIA LATA GRAFT BY STRIPPER 20922 FASCIA LATA GRAFT INCISION & AREA EXPOSURE 20924 TENDON GRAFT FROM A DISTANCE 20926 TISSUE GRAFTS OTHER 20974 ELECTRICAL STIMULATION BONE HEALING NONINVASIVE 20975 ELECTRICAL STIMULATION BONE HEALING INVASIVE 20979 LOW INTENSITY US STIMJ BONE HEALING NONINVASIVE 20982 ABLATION BONE TUMOR RF PERCUTANEOUS CT GUIDANCE 20985 CPTR-ASST SURGICAL NAVIGATION IMAGE-LESS 20999 UNLISTED PROCEDURE MUSCSKELETAL SYSTEM GENERAL 21010 ARTHROTOMY TEMPOROMANDIBULAR JOINT 21011 EXCISION TUMOR SOFT TISS FACE/SCALP SUBQ < 2CM 21012 EXCISION TUMOR SOFT TISS FACE/SCALP SUBQ 2+CM 21013 EXC TUMOR SOFT TISS FACE&SCALP SUBFASCIAL < 2CM 21014 EXC TUMOR SOFT TISS FACE&SCALP SUBFASCIAL 2+CM 21016 RAD RESECTION TUMOR SOFT TISS FACE/SCALP 2+CM 21029 REMOVAL CONTOURING BENIGN TUMOR FACIAL BONE 21030 EXC BENIGN TUMOR/CYST MAXL/ZYGOMA ENCL & CURTG 21031 EXCISION TORUS MANDIBULARIS 21032 EXCISION MAXILLARY TORUS PALATINUS 21040 EXCISION BENIGN TUMOR/CYST MANDIBLE ENCL&/CURTG 21046 EXC BENIGN TUMOR/CYST MNDBL INTRA-ORAL OSTEOT 21047 EXC B9 TUM/CST MNDBL XTR-ORAL OSTEOT&PRTL MNDBLC 21048 EXC BENIGN TUMOR/CYST MAXL INTRA-ORAL OSTEOT 21049 EXC B9 TUM/CST MAXL XTR-ORAL OSTEOT&PRTL MAXLCT 21050 CONDYLECTOMY TEMPOROMANDIBULAR JOINT SPX 21060 MENISCECTOMY PRTL/COMPL TEMPOROMANDIBULAR JT SPX 21070 CORONOIDECTOMY SPX 21073 MANIPULATION TMJ THERAPEUTIC REQUIRE ANESTHESIA 21076 IMPRESSION&PREPARATION SURG OBTURATOR PROSTHESIS 21077 IMPRESSION & PREPARATION ORBITAL PROSTHESIS 21079 IMPRESSION&PREPARATION INTERIM OBTURATOR PROSTH 21080 IMPRESSION&PREPJ DEFINITIVE OBTURATOR PROSTHESIS 21081 IMPRESSION&PREPJ MANDIBULAR RESECTION PROSTHESIS 21082 IMPRESSION&PREPJ PALATAL AUGMENTATION PROSTHESIS 21083 IMPRESSION&PREPARATION PALATAL LIFT PROSTHESIS 21084 IMPRESSION&PREPARATION SPEECH AID PROSTHESIS 21085 IMPRESSION&PREPARATION ORAL SURGICAL SPLINT 21086 IMPRESSION&PREPARATION AURICULAR PROSTHESIS 21087 IMPRESSION&PREPARATION NASAL PROSTHESIS 21088 IMPRESSION&PREPARATION FACIAL PROSTHESIS 21089 UNLISTED MAXILLOFACIAL PROSTHETIC PROCEDURE


21116 INJECTION TEMPOROMANDIBULAR JOINT ARTHROGRAPHY 21120 GENIOPLASTY AUGMENTATION 21121 GENIOPLASTY SLIDING OSTEOTOMY SINGLE PIECE 21122 GENIOPLASTY 2/> SLIDING OSTEOTOMIES 21123 GENIOP SLIDING AGMNTJ W/INTERPOSAL BONE GRAFTS 21125 AGMNTJ MNDBLR BODY/ANGLE PROSTHETIC MATERIAL 21127 AGMNTJ MNDBLR BDY/ANGL W/B1 GRF ONLAY/INTERPOSAL 21137 REDUCTION FOREHEAD CONTOURING ONLY 21138 RDCTJ FHD CNTRG&PROSTHETIC MATRL/BONE GRAFT 21139 RDCTJ FHD CNTRG&SETBACK ANT FRONTAL SINUS WALL 21141 RCNSTJ MIDFACE LEFORT I 1 PIECE W/O BONE GRAFT 21142 RCNSTJ MIDFACE LEFORT I 2 PIECES W/O BONE GRAFT 21143 RCNSTJ MIDFACE LEFORT I 3/>PIECE W/O BONE GRAFT 21145 RCNSTJ MIDFACE LEFORT I 1 PIECE W/BONE GRAFTS 21146 RCNSTJ MIDFACE LEFORT I 2 PIECES W/BONE GRAFTS 21147 RCNSTJ MIDFACE LEFORT I 3/>PIECE W/BONE GRAFTS 21150 RCNSTJ MIDFACE LEFORT II ANTERIOR INTRUSION 21151 RCNSTJ MIDFACE LEFORT II W/BONE GRAFTS 21154 RCNSTJ MIDFACE LEFORT III W/O LEFORT I 21155 RCNSTJ MIDFACE LEFORT III W/LEFORT I 21159 RCNSTJ MIDFACE LEFORT III W/FHD W/O LEFORT I 21160 RCNSTJ MIDFACE LEFORT III W/FHD W/LEFORT I 21172 RCNSTJ SUPERIOR-LATERAL ORBITAL RIM&LOWER FHD 21175 RCNSTJ BIFRONTAL SUPERIOR-LAT ORB RIMS&LWR FHD 21179 RCNSTJ FOREHEAD&/SUPRAORB RIMS W/ALGRF/PROSTC 21180 RCNSTJ FOREHEAD&/SUPRAORBITAL RIMS W/AUTOGRAFT 21181 RCNSTJ CONTOURING BENIGN TUMOR CRNL BONES XTRC 21182 RCNSTJ ORBIT/FHD/NASETHMD EXC B9 TUM GRF <40 CM 21183 RCNSTJ ORBIT/FHD/NASETHMD EXC B9 GRF >40 <80 CM 21184 RCNSTJ ORBIT/FHD/NASETHMD EXC B9 TUM GRF>80 CM 21188 RCNSTJ MDFC OTH/THN LEFORT OSTEOT&BONE GRAFTS 21193 RCNSTJ MNDBLR RAMI HRZNTL/VER/C/L OSTEOT W/O GRF 21194 RCNSTJ MNDBLR RAMI HRZNTL/VER/C/L OSTEOT W/GRF 21195 RCNSTJ MNDBLR RAMI&/BODY SGTL SPLT W/O INT RGD 21196 RCNSTJ MNDBLR RAMI&/BDY SGTL SPLT W/INT RGD FIXJ 21198 OSTEOTOMY MANDIBLE SEGMENTAL 21199 OSTEOTOMY MANDIBLE SGMTL W/GENIOGLOSSUS ADVMNT 21206 OSTEOTOMY MAXILLA SEGMENTAL 21208 OSTEOPLASTY FACIAL BONES AUGMENTATION 21209 OSTEOPLASTY FACIAL BONES REDUCTION 21210 GRAFT BONE NASAL/MAXILLARY/MALAR AREAS 21215 GRAFT BONE MANDIBLE 21230 GRAFT RIB CRTLG AUTOGENOUS FACE/CHIN/NOSE/EAR


21235 GRAFT EAR CRTLG AUTOGENOUS NOSE/EAR 21240 ARTHRP TEMPOROMANDIBULAR JOINT +-AUTOGRAFT 21242 ARTHROPLASTY TEMPOROMANDIBULAR JT W/ALLOGRAFT 21243 ARTHRP TMPRMAND JOINT W/PROSTHETIC REPLACEMENT 21244 RCNSTJ MNDBL XTRORAL W/TRANSOSTEAL BONE PLATE 21245 RCNSTJ MNDBL/MAXL SUBPRIOSTEAL IMPLANT PARTIAL 21246 RCNSTJ MNDBL/MAXL SUBPRIOSTEAL IMPLANT COMPLETE 21247 RCNSTJ MNDBLR CONDYLE W/BONE CARTLG AUTOGRAFTS 21248 RCNSTJ MANDIBLE/MAXL ENDOSTEAL IMPLANT PARTIAL 21249 RCNSTJ MANDIBLE/MAXL ENDOSTEAL IMPLANT COMPLETE 21255 RCNSTJ ZYGMTC ARCH/GLENOID FOSSA W/BONE CARTLG 21256 RECONSTRUCTION ORBIT W/OSTEOTOMIES&BONE GRAFTS 21260 PERIORBITAL OSTEOTOMIES BONE GRAFTS EXTRACRANIAL 21261 PERIORBITAL OSTEOTOMIES W/BONE GRAFTS ICRA&XTRC 21263 PERIORBITAL OSTEOTOMIES W/BONE GRAFTS W/FOREHEAD 21267 ORBITAL REPOSITIONING W/BONE GRAFTS EXTRACRANIAL 21268 ORBITAL REPOSITIONING W/BONE GRAFTS ICRA&XTRC 21270 MALAR AUGMENTATION PROSTHETIC MATERIAL 21275 SECONDARY REVISION ORBITOCRANIOFACIAL RCNSTJ 21280 MEDIAL CANTHOPEXY SPX 21282 LATERAL CANTHOPEXY 21295 REDUCTION MASSETER MUSCLE&BONE EXTRAORAL 21296 REDUCTION MASSETER MUSCLE&BONE INTRAORAL 21299 UNLISTED CRANIOFACIAL&MAXILLOFACIAL PROCEDURE 21497 INTERDENTAL WIRING OTHER THAN FRACTURE 21499 UNLISTED MUSCULOSKELETAL PROCEDURE HEAD 21552 EXC TUMOR SOFT TISSUE NECK/ANT THORAX SUBQ 3+CM 21554 EXC TUMOR SOFT TISSUE NECK/THORAX SUBFASC 5+CM 21555 EXC TUMOR SOFT TISSUE NECK/ANT THORAX SUBQ <3CM 21556 EXC TUMOR SOFT TISS NECK/THORAX SUBFASCIAL <5CM 21558 RAD RESECT TUMOR SOFT TISS NECK/ANT THORAX 5+CM 21600 EXCISION RIB PARTIAL 21610 COSTOTRANSVERSECTOMY SPX 21615 EXCISION 1ST&/CERVICAL RIB 21616 EXCISION 1ST&/CERVICAL RIB W/SYMPATHECTOMY 21620 OSTECTOMY STERNUM PARTIAL 21627 STERNAL DEBRIDEMENT 21685 HYOID MYOTOMY & SUSPENSION 21700 DIVISION SCALENUS ANTICUS W/O RESCJ CERVICAL RIB 21705 DIVISION SCALENUS ANTICUS RESECTION CERVICAL RIB 21720 DIVISION STERNOCLEIDOMASTOID OPEN W/O CAST 21725 DIVISION STERNOCLEIDOMASTOID OPEN CAST 21740 REPAIR PECTUS EXCAVATUM/CARINATUM OPEN


21742 REPAIR PECTUS EXCAVATM/CARINATM MINLY W/O THRSC 21743 REPAIR PECTUS EXCAVATM/CARINATM MINLY W/THRSC 21750 CLOSURE MEDIAN STERNOTOMY SEP +-DEBRIDEMENT SPX 21899 UNLISTED PROCEDURE NECK/THORAX 21931 EXCISION TUMOR SOFT TISSUE BACK/FLANK SUBQ 3+CM 21932 EXC TUMOR SOFT TISS BACK/FLANK SUBFASCIAL <5CM 21933 EXC TUMOR SOFT TISS BACK/FLANK SUBFASCIAL 5+CM 21936 RAD RESECTION TUMOR SOFT TISSUE BACK/FLANK 5+CM 22100 PRTL EXC PST VRT INTRNSC B1Y LES 1 VRT SGM CRV 22101 PRTL EXC PST VRT INTRNSC B1Y LES 1 VRT SGM THRC 22102 PRTL EXC PST VRT INTRNSC B1Y LES 1 VRT SGM LMBR 22103 PRTL EXC PST VRT INTRNSC B1Y LES 1 VRT SGM EA 22110 PRTL EXC VRT BDY B1Y LES W/O SPI CORD 1 SGM CRV 22112 PRTL EXC VRT BDY B1Y LES W/O SPI CORD 1 SGM THRC 22114 PRTL EXC VRT BDY B1Y LES W/O SPI CORD 1 SGM LMBR 22116 PRTL EXC VRT BDY B1Y LES W/O SPI CORD 1 SGM EA 22206 OSTEOTOMY SPINE POSTERIOR 3 COLUMN THORACIC 22207 OSTEOTOMY SPINE POSTERIOR 3 COLUMN LUMBAR 22208 OSTEOTOMY SPINE POSTERIOR 3 COLUMN EA ADDL SGM 22210 OSTEOTOMY SPINE PST/PSTLAT APPR 1 VRT SGM CRV 22212 OSTEOTOMY SPINE PST/PSTLAT APPR 1 VRT SGM THRC 22214 OSTEOTOMY SPINE PST/PSTLAT APPR 1 VRT SGM LMBR 22216 OSTEOT SPI PST/PSTLAT APPR 1 VRT SGM EA VRT SGM 22220 OSTEOTOMY SPINE W/DSKC ANT APPR 1 VRT SGM CRV 22222 OSTEOTOMY SPINE W/DSKC ANT APPR 1 VRT SGM THRC 22224 OSTEOTOMY SPINE W/DSKC ANT APPR 1 VRT SGM LMBR 22226 OSTEOT SPI W/DSKC ANT APPR 1 VRT SGM EA VRT SGM 22505 MANIPULATION SPINE REQUIRING ANESTHESIA 22520 PERCUTANEOUS VERTEBROPLASTY THORACIC 22521 PERCUTANEOUS VERTEBROPLASTY LUMBAR 22522 PERCUTANEOUS VERTEBROPLASTY EA ADDL THRC/LMBR 22523 PERCUTANEOUS VERTEBRAL AUGMENTATION THORACIC 22524 PERCUTANEOUS VERTEBRAL AUGMENTATION LUMBAR 22525 PERQ VERTEBRAL AUGMENTATION EA ADDL THRC/LMBR 22526 PERQ INTRDSCL ELECTROTHRM ANNULOPLASTY 1 LVL 22527 PERQ INTRDSCL ELECTROTHRM ANNULOPLASTY ADDL LVL 22532 ARTHRODESIS LATERAL EXTRACAVITARY THORACIC 22533 ARTHRODESIS LATERAL EXTRACAVITARY LUMBAR 22534 ARTHRODESIS LAT EXTRACAVITARY EA ADDL THRC/LMBR 22548 ARTHRD ANT TRANSORAL/XTRORAL C1-C2 +-EXC ODNTD 22551 ARTHRD ANT INTERBODY DECOMPRESS CERVICAL BELW C2 22552 ARTHRD ANT INTERDY CERVCL BELW C2 EA ADDL NTRSPC 22554 ARTHRODESIS ANTERIOR INTERBODY CERVICAL BELW C2


22556 ARTHRODESIS ANTERIOR INTERBODY THORACIC 22558 ARTHRODESIS ANTERIOR INTERBODY LUMBAR 22585 ARTHRODESIS ANTERIOR INTERBODY EA ADDL NTRSPC 22590 ARTHRODESIS POSTERIOR CRANIOCERVICAL 22595 ARTHRODESIS POSTERIOR ATLAS-AXIS C1-C2 22600 ARTHRODESIS PST/PSTLAT CERVICAL BELW C2 SGM 22610 ARTHRODESIS POSTERIOR/POSTEROLATERAL THORACIC 22612 ARTHRODESIS POSTERIOR/POSTEROLATERAL LUMBAR 22614 ARTHRODESIS POSTERIOR/POSTEROLATERAL EA ADDL 22630 ARTHRODESIS POSTERIOR INTERBODY LUMBAR 22632 ARTHRODESIS POSTERIOR INTERBODY EA ADDL 22633 ARTHDSIS POST/POSTEROLATRL/POSTINTERBODY LUMBAR 22634 ARTHDSIS POST/POSTERLATRL/POSTINTRBDYADL SPC/SEG 22800 ARTHRODESIS POSTERIOR SPINAL DFRM UP 6 VRT SEG 22802 ARTHRODESIS POSTERIOR SPINAL DFRM 7-12 VRT SEG 22804 ARTHRODESIS POSTERIOR SPINAL DFRM 13/> VRT SEG 22808 ARTHRODESIS ANTERIOR SPINAL DFRM 2-3 VRT SEG 22810 ARTHRODESIS ANTERIOR SPINAL DFRM 4-7 VRT SEG 22812 ARTHRODESIS POSTERIOR SPINAL DFRM 8/> VRT SEG 22818 KYPHECTOMY SINGLE OR TWO SEGMENTS 22819 KYPHECTOMY 3 OR MORE SEGMENTS 22830 EXPLORATION SPINAL FUSION 22840 POSTERIOR NON-SEGMENTAL INSTRUMENTATION 22841 INTERNAL SPINAL FIXATION WIRING SPINOUS PROCESS 22842 POSTERIOR SEGMENTAL INSTRUMENTATION 3-6 VRT SEG 22843 POSTERIOR SEGMENTAL INSTRUMENTATION 7-12 VRT SEG 22844 POSTERIOR SEGMENTAL INSTRUMENTATION 13/> VRT SEG 22845 ANTERIOR INSTRUMENTATION 2-3 VERTEBRAL SEGMENTS 22846 ANTERIOR INSTRUMENTATION 4-7 VERTEBRAL SEGMENTS 22847 ANTERIOR INSTRUMENTATION 8/> VERTEBRAL SEGMENTS 22848 PELVIC FIXATION OTHER THAN SACRUM 22849 REINSERTION SPINAL FIXATION DEVICE 22850 REMOVAL POSTERIOR NONSEGMENTAL INSTRUMENTATION 22851 APPLICATION INTERVERTEBRAL BIOMECHANICAL DEVICE 22852 REMOVAL POSTERIOR SEGMENTAL INSTRUMENTATION 22855 REMOVAL ANTERIOR INSTRUMENTATION 22856 TOT DISC ARTHRP ART DISC ANT APPRO 1 NTRSPC CRV 22857 TOT DISC ARTHRP ART DISC ANT APPRO 1 NTRSPC LMBR 22861 REVJ RPLCMT DISC ARTHROPLASTY ANT 1 NTRSPC CRV 22862 REVJ RPLCMT DISC ARTHROPLASTY ANT 1 NTRSPC LMBR 22864 RMVL DISC ARTHROPLASTY ANT 1 INTERSPACE CERVICAL 22865 RMVL DISC ARTHROPLASTY ANT 1 INTERSPACE LUMBAR 22899 UNLISTED PROCEDURE SPINE


22900 EXC TUMOR SOFT TISSUE ABDL WALL SUBFASCIAL <5CM 22901 EXC TUMOR SOFT TISSUE ABDL WALL SUBFASCIAL 5+CM 22902 EXC TUMOR SOFT TISSUE ABDOMINAL WALL SUBQ <3CM 22903 EXC TUMOR SOFT TISSUE ABDOMINAL WALL SUBQ 3+CM 22904 RAD RESECTION TUMOR SOFT TISSUE ABDL WALL <5CM 22905 RAD RESECTION TUMOR SOFT TISSUE ABDL WALL 5+CM 22999 UNLISTED PX ABDOMEN MUSCULOSKELETAL SYSTEM 23000 REMOVAL SUBDELTOID CALCAREOUS DEPOSITS OPEN 23020 CAPSULAR CONTRACTURE RELEASE 23040 ARTHROTOMY GLENOHUMERAL JT EXPL/DRG/RMVL FB 23044 ARTHRT ACROMCLAV STRNCLAV JT EXPL/DRG/RMVL FB 23071 EXCISION TUMOR SOFT TISSUE SHOULDER SUBQ 3+CM 23073 EXC TUMOR SOFT TISSUE SHOULDER SUBFASCIAL 5+CM 23078 RAD RESECTION TUMOR SOFT TISSUE SHOULDER 5+CM 23105 ARTHRT GLENOHUMRL JT W/SYNOVECTOMY +-BIOPSY 23106 ARTHRT GLENOHUMRL JT STRNCLAV JT W/SYNVCT +-BX 23107 ARTHRT GLENOHUMRL JT W/JT EXPL +-RMVL LOOSE/FB 23120 CLAVICULECTOMY PARTIAL 23125 CLAVICULECTOMY TOTAL 23130 PARTIAL REPAIR OR REMOVAL OF SHOULDER BONE 23140 EXC/CURTG BONE CYST/BENIGN TUMOR CLAV/SCAPULA 23145 EXC/CURTG BONE CST/B9 TUM CLAV/SCAPULA W/AGRFT 23146 EXC/CURTG BONE CST/B9 TUM CLAV/SCAPULA W/ALGRFT 23150 EXC/CURTG BONE CYST/BENIGN TUMOR PROX HUMERUS 23155 EXC/CURTG BONE CYST/BENIGN TUM PROX HUM W/AGRFT 23156 EXC/CURTG BONE CYST/BENIGN TUM PROX HUM W/ALGRFT 23190 OSTECTOMY SCAPULA PARTIAL 23195 RESECTION HUMERAL HEAD 23395 MUSCLE TRANSFER SHOULDER/UPPER ARM SINGLE 23397 MUSCLE TRANSFER SHOULDER/UPPER ARM MULTIPLE 23400 SCAPULOPEXY 23405 TENOTOMY SHOULDER AREA 1 TENDON 23406 TENOTOMY SHOULDER MULTIPLE THRU SAME INCISION 23410 OPEN REPAIR OF ROTATOR CUFF ACUTE 23412 OPEN REPAIR OF ROTATOR CUFF CHRONIC 23415 CORACOACROMIAL LIGAMENT RELEASE +-ACROMIOPLASTY 23420 RECONSTRUCTION ROTATOR CUFF AVULSION CHRONIC 23430 TENODESIS LONG TENDON BICEPS 23440 RESECTION/TRANSPLANTATION LONG TENDON BICEPS 23450 CAPSULORRHAPHY ANTERIOR PUTTI-PLATT/MAGNUSON 23455 CAPSULORRHAPHY ANTERIOR W/LABRAL REPAIR 23460 CAPSULORRHAPHY ANTERIOR WITH BONE BLOCK 23462 CAPSULORRHAPHY ANTERIOR W/CORACOID PROCESS TR


23465 CAPSULORRHAPHY GLENOHUMERAL JT PST +-BONE BLK 23466 CAPSULORRHAPHY GLENOHUMRL JT MULTI-DIRIONAL INS 23470 ARTHROPLASTY GLENOHUMRL JT HEMIARTHROPLASTY 23472 ARTHROPLASTY GLENOHUMERAL JOINT TOTAL SHOULDER 23480 OSTEOTOMY CLAVICLE +-INTERNAL FIXATION 23485 OSTEOTOMY CLAV +-INT FIXJ W/B1 GRF NON/MAL 23800 ARTHRODESIS GLENOHUMERAL JOINT 23802 ARTHRODESIS GLENOHUMERAL JT W/AUTOGENOUS GRAFT 23900 INTERTHORACOSCAPULAR AMPUTATION 23920 DISARTICULATION SHOULDER 23921 DISRTCJ SHOULDER SECONDARY CLSR/SCAR REVISION 23929 UNLISTED PROCEDURE SHOULDER 24071 EXC TUMOR SOFT TISSUE UPPER ARM/ELBOW SUBQ 3+CM 24073 EXC TUMOR SOFT TISS UPPER ARM/ELBW SUBFASC 5+CM 24079 RAD RESECT TUMOR SOFT TISS UPPER ARM/ELBOW 5+CM 24105 EXCISION OLECRANON BURSA 24110 EXCISION/CURTG BONE CYST/BENIGN TUMOR HUMERUS 24115 EXC/CURTG BONE CYST/BENIGN TUMOR HUMERUS W/AGRFT 24116 EXC/CURTG BONE CYST/BENIGN TUM HUMERUS W/ALGRFT 24120 EXC/CURTG BONE CYST/BENIGN TUMOR H/N RDS/OLECRN 24125 EXC/CURTG BONE CST/B9 TUM H/N RDS/OLECRN W/AGRFT 24126 EXC/CURTG B1 CST/B9 TUM H/N RDS/OLECRN W/ALGRFT 24130 EXCISION RADIAL HEAD 24149 RAD RESCJ CAPSL TISS&HTRTPC BONE ELBW CONTRCT 24155 RESECTION ELBOW JOINT ARTHRECTOMY 24160 IMPLANT REMOVAL ELBOW JOINT 24164 IMPLANT REMOVAL RADIAL HEAD 24301 MUSCLE/TENDON TRANSFER UPPER ARM/ELBOW SINGLE 24305 TENDON LENGTHENING UPPER ARM/ELBOW EA TENDON 24310 TENOTOMY OPEN ELBOW TO SHOULDER EACH TENDON 24320 TENOPLASTY ELBOW TO SHOULDER SINGLE 24330 FLEXOR-PLASTY ELBOW 24331 FLEXOR-PLASTY ELBOW W/EXTENSOR ADVANCEMENT 24332 TENOLYSIS TRICEPS 24340 TENODESIS BICEPS TENDON ELBOW SPX 24341 REPAIR TENDON/MUSCLE UPPER ARM/ELBOW EA 24342 RINSJ RPTD BICEPS/TRICEPS TDN DSTL +-TDN GRF 24343 REPAIR LATERAL COLLATERAL LIGAMENT ELBOW 24344 RCNSTJ LAT COLTRL LIGM ELBOW W/TENDON GRAFT 24345 REPAIR MEDIAL COLLATERAL LIGAMENT ELBOW 24346 RCNSTJ MEDIAL COLTRL LIGM ELBW W/TDN GRF 24357 TENOTOMY ELBOW LATERAL/MEDIAL PERCUTANEOUS 24358 TNOT ELBOW LATERAL/MEDIAL DEBRIDE OPEN


24359 TNOT ELBOW LATERAL/MEDIAL DEBRIDE OPEN TDN RPR 24360 ARTHROPLASTY ELBOW W/MEMBRANE 24361 ARTHROPLASTY ELBOW W/DISTAL HUMRL PROSTC RPLCMT 24362 ARTHRP ELBOW W/IMPLT&FSCA LATA LIGAMENT RCNSTJ 24363 ARTHRP ELBOW W/DISTAL HUM&PROX UR PROSTC RPLCMT 24365 ARTHROPLASTY RADIAL HEAD 24366 ARTHROPLASTY RADIAL HEAD W/IMPLANT 24400 OSTEOTOMY HUMERUS +-INTERNAL FIXATION 24410 MLT OSTEOT W/RELIGNMT IMED ROD HUMERAL SHAFT 24420 OSTEOPLASTY HUMERUS 24430 REPAIR NON/MALUNION HUMERUS W/O GRAFT 24435 REPAIR NON/MALUNION HUMERUS W/ILIAC/OTH AGRFT 24470 HEMIEPIPHYSEAL ARREST 24800 ARTHRODESIS ELBOW JOINT LOCAL 24802 ARTHRODESIS ELBOW JOINT W/AUTOGENOUS GRAFT 24900 AMPUTATION ARM THRU HUMERUS W/PRIMARY CLOSURE 24920 AMPUTATION ARM THRU HUMERUS OPEN CIRCULAR 24925 AMP ARM THRU HUMERUS SECONDARY CLSR/SCAR REVJ 24930 AMPUTATION ARM THRU HUMERUS RE-AMPUTATION 24931 AMPUTATION ARM THRU HUMERUS W/IMPLANT 24935 STUMP ELONGATION UPPER EXTREMITY 24940 CINEPLASTY UPPER EXTREMITY COMPLETE PROCEDURE 24999 UNLISTED PROCEDURE HUMERUS/ELBOW 25000 INCISION EXTENSOR TENDON SHEATH WRIST 25001 INCISION FLEXOR TENDON SHEATH WRIST 25071 EXC TUMOR SOFT TISS FOREARM AND/WRIST SUBQ 3+CM 25073 EXC TUMOR SFT TISS FOREARM&//WRIST SUBFASC 3+CM 25078 RAD RESCJ TUM SOFT TISSUE FOREARM&/WRIST 3+CM 25085 CAPSULOTOMY WRIST 25101 ARTHRT WRST JT W/JT EXPL +-BX +-RMVL LOOSE/FB 25105 ARTHROTOMY WRIST JOINT WITH SYNOVECTOMY 25107 ARTHROTOMY DSTL RADIOULNAR JOINT RPR CARTILAGE 25109 EXC TENDON FOREARM&/WRIST FLEXOR/EXTENSOR EA 25110 EXCISION LESION TENDON SHEATH FOREARM&/WRIST 25111 EXCISION GANGLION WRIST DORSAL/VOLAR PRIMARY 25112 EXCISION GANGLION WRIST DORSAL/VOLAR RECURRENT 25115 RAD EXC BURSA SYNVA WRST/F/ARM TDN SHTHS FLXRS 25116 RAD EXC BURSA SYNVA WRST/F/ARM TDN SHTHS XTNSRS 25118 SYNOVECTOMY EXTENSOR TENDON SHTH WRIST 1 CMPRT 25119 SYNVCT XTNSR TDN SHTH WRST 1 RESCJ DSTL ULNA 25120 EXCISION/CURETTAGE CYST/TUMOR RADIUS/ULNA 25125 EXC/CURTG CYST/TUMOR RADIUS/ULNA W/AUTOGRAFT 25126 EXC/CURTG CYST/TUMOR RADIUS/ULNA W/ALLOGRAFT


25130 EXCISION/CURETTAGE CYST/TUMOR CARPAL BONES 25135 EXC/CURTG CYST/TUMOR CARPAL BONES W/AUTOGRAFT 25136 EXC/CURTG CYST/TUMOR CARPAL BONES W/ALLOGRAFT 25210 CARPECTOMY 1 BONE 25215 CARPECTOMY ALL BONES PROXIMAL ROW 25230 RADICAL STYLOIDECTOMY SPX 25240 EXCISION DISTAL ULNA PARTIAL/COMPLETE 25250 REMOVAL WRIST PROSTHESIS SPX 25251 REMOVAL WRIST PROSTH COMPLICATED W/TOTAL WRIST 25260 RPR TDN/MUSC FLXR F/ARM&/WRST PRIM 1 EA TDN/MUSC 25263 RPR TDN/MUSC FLXR F/ARM&/WRST SEC 1 EA TDN/MUSC 25265 RPR TDN/MUSC FLXR F/ARM&/WRST SEC FR GRF EA 25270 RPR TDN/MUSC XTNSR F/ARM&/WRST PRIM 1 EA TDN 25272 RPR TDN/MUSC XTNSR F/ARM&/WRST SEC 1 EA TDN/MUSC 25274 RPR TDN/MUSC XTNSR F/ARM&/WRST SEC FR GRF EA TDN 25275 RPR TENDON SHEATH EXTENSOR F/ARM&/WRST W/GRAFT 25280 LNGTH/SHRT FLXR/XTNSR TDN F/ARM&/WRST 1 EA TDN 25290 TNOT FLXR/XTNSR TENDON FOREARM&/WRIST 1 EA 25295 TNOLS FLXR/XTNSR TENDON FOREARM&/WRIST 1 EA 25300 TENODESIS WRIST FLEXORS FINGERS 25301 TENODESIS WRIST EXTENSORS FINGERS 25310 TDN TRNSPLJ/TR FLXR/XTNSR F/ARM&/WRST 1 EA TDN 25312 TDN TRNSPLJ/TR FLXR/XTNSR F/ARM&/WRST 1/TDN GRF 25315 FLEXOR ORIGIN SLIDE FOREARM &/WRIST 25316 FLEXOR ORIGIN SLIDE F/ARM&/WRST TENDON TRANSFER 25320 CAPSL-RHPHY/RCNSTJ WRST OPN CARPL INS 25332 ARTHRP WRST +-INTERPOS +-XTRNL/INT FIXJ 25335 CENTRALIZATION WRST ULNA 25337 RCNSTJ STABLJ DSTL U/DSTL JT 2 SOFT TISS STABLJ 25350 OSTEOTOMY RADIUS DISTAL THIRD 25355 OSTEOTOMY RADIUS MIDDLE/PROXIMAL THIRD 25360 OSTEOTOMY ULNA 25365 OSTEOTOMY RADIUS & ULNA 25370 MLT OSTEOTOMIES W/RELIGNMT IMED ROD RADIUS/ULNA 25375 MLT OSTEOTOMIES W/RELIGNMT IMED ROD RADIUS&ULNA 25390 OSTEOPLASTY RADIUS/ULNA SHORTENING 25391 OSTEOPLASTY RADIUS/ULNA LENGTHENING W/AUTOGRAFT 25392 OSTEOPLASTY RADIUS & ULNA SHORTENING 25393 OSTEOPLASTY RADIUS&ULNA LENGTHENING W/AUTOGRAFT 25394 OSTEOPLASTY CARPAL BONE SHORTENING 25441 ARTHROPLASTY W/PROSTHETIC RPLCMT DISTAL RADIUS 25442 ARTHROPLASTY W/PROSTHETIC RPLCMT DISTAL ULNA 25443 ARTHROPLASTY W/PROSTHETIC RPLCMT SCAPHOID CARPAL


25444 ARTHROPLASTY W/PROSTHETIC REPLACEMENT LUNATE 25445 ARTHROPLASTY W/PROSTHETIC REPLACEMENT TRAPEZIUM 25446 ARTHRP W/PROSTC RPLCMT DSTL RDS&PRTL/CARPUS 25447 ARTHRP INTERPOS INTERCARPAL/METACARPAL JOINTS 25449 REVJ ARTHRP W/RMVL IMPLT WRST JT 25450 EPIPHYSL ARRST EPIPHYSIOD/STAPLING DSTL RDS/U 25455 EPIPHYSL ARRST EPIPHYSIOD/STAPLING DSTL RDS&U 25800 ARTHRD WRST COMPL W/O B1 GRF 25805 ARTHRD WRST W/SLIDING GRF 25810 ARTHRD WRST W/ILIAC/OTH AGRFT 25820 ARTHRODESIS WRIST LIMITED W/O BONE GRAFT 25825 ARTHRODESIS WRIST LIMITED W/AUTOGRAFT 25830 ARTHRD DSTL RAD/ULN JT SGMTL RESCJ U +-B1 GRF 25900 AMPUTATION FOREARM THROUGH RADIUS & ULNA 25905 AMP FOREARM THRU RADIUS&ULNA OPEN CIRCULAR 25907 AMP F/ARM THRU RADIUS&ULNA SEC CLOSURE/SCAR REVJ 25909 AMP FOREARM THRU RADIUS&ULNA RE-AMPUTATION 25915 KRUKENBERG PROCEDURE 25920 DISARTICULATION THROUGH WRIST 25922 DISARTICULATION THRU WRIST SEC CLOSURE/SCAR REVJ 25924 DISARTICULATION THRU WRIST RE-AMPUTATION 25927 TRANSMETACARPAL AMPUTATION 25929 TRANSMETACARPAL AMPUTATION SEC CLOSURE/SCAR REVJ 25931 TRANSMETACARPAL AMPUTATION RE-AMPUTATION 25999 UNLISTED PROCEDURE FOREARM/WRIST 26035 DECOMPRESSION FINGERS&/HAND INJECTION INJURY 26037 DECOMPRESSIVE FASCIOTOMY HAND 26040 FASCIOTOMY PALMAR PERCUTANEOUS 26045 FASCIOTOMY PALMAR OPEN PARTIAL 26055 TENDON SHEATH INCISION 26060 TENOTOMY PERCUTANEOUS SINGLE EACH DIGIT 26111 EX TUM/VASC MALF SFT TISS HAND/FNGR SUBQ 1.5+CM 26113 EX TUM/VASC MAL SFT TIS HAND/FNGR SUBFSC 1.5+CM 26115 EXC TUM/VASC MAL SFT TISS HAND/FNGR SUBQ <1.5CM 26116 EXC TUM/VAS MAL SFT TIS HAND/FNGR SUBFASC<1.5CM 26118 RAD RESCJ TUM SOFT TISSUE HAND/FINGER 3+CM 26121 FASCT PALM +-Z-PLASTY TISS REARGMT/SKN GRF 26123 FASCT PRTL PLMR 1 DGT PROX IPHAL JT +-TISS 26125 FASCT PRTL PLMR 1 DGT PROX IPHAL JT +-Z-PLASTY 26130 SYNOVECTOMY CARPOMETACARPAL JOINT 26135 SYNVCT MTCARPHLNGL JT W/INTRNSC RLS&XTNSR HOOD 26140 SYNVCT PROX IPHAL JT W/XTNSR RCNSTJ EA IPHAL JT 26145 SYNVCT TDN SHTH RAD FLXR TDN PALM&/FNGR EA TDN


26160 EXC LES TDN SHTH/JT CAPSL HAND/FNGR 26170 EXCISION TENDON PALM FLEXOR/EXTENSOR SINGLE EACH 26180 EXCISION TENDON FINGER FLEXOR/EXTENSOR EACH 26185 SESAMOIDECTOMY THUMB/FINGER SPX 26200 EXCISION/CURETTAGE CYST/TUMOR METACARPAL 26205 EXC/CURETTAGE CYST/TUMOR METACARPAL W/AUTOGRAFT 26210 EXCISION/CURETTAGE CYST/TUMOR PHALANX FINGER 26215 EXC/CURETTAGE CYST/TUMOR PHALANX FINGER W/AGRAFT 26350 RPR/ADVMNT FLXR TDN N/Z/2 1/2 W/O FR GRF EA TDN 26352 RPR/ADVMNT FLXR TDN N/Z/2 2W/FR GRF EA TDN 26356 RPR/ADVMNT FLXR TDN ZONE 2 1W/O FR GRF EA TDN 26357 RPR/ADVMNT FLXR TDN ZONE 2 2W/O FR GRF EA TDN 26358 RPR/ADVMNT FLXR TDN ZONE 2 2W/FR GRF EA TDN 26370 RPR/ADVMNT TDN W/NTC SUPFCIS TDN PRIM EA TDN 26372 RPR/ADVMNT TDN W/NTC SUPFCIS TDN 2 W/FR GRF EA 26373 RPR/ADVMNT TDN W/NTC SUPFCIS TDN 2 W/O FR GRF EA 26390 EXC FLXR TDN W/IMPLTJ SYNTH ROD DLYD TDN GRF H/F 26392 RMVL SYNTH ROD&INSJ FLXR TDN GRF H/F EA ROD 26410 REPAIR EXTENSOR TENDON HAND W/O GRAFT EACH 26412 REPAIR EXTENSOR TENDON HAND W/GRAFT EACH 26415 EXC XTNSR TDN W/IMPLTJ SYNTH ROD DLYD GRF H/F EA 26416 RMVL SYNTH ROD&INSJ XTNSR TDN GRF H/F EA ROD 26418 REPAIR EXTENSOR TENDON FINGER W/O GRAFT EACH 26420 REPAIR EXTENSOR TENDON FINGER W/GRAFT EACH 26426 RPR XTNSR TDN CTR SLIP 2 TISS W/LAT BAND EA FNGR 26428 RPR XTNSR TDN CTR SLIP SEC W/FR GRF EA FNGR 26433 REPAIR EXTENSOR TENDON DISTAL INSERTION W/O GRF 26434 REPAIR EXTENSOR TENDON DISTAL INSERTION W/GRAFT 26437 REALIGNMENT EXTENSOR TENDON HAND EACH TENDON 26440 TENOLYSIS FLEXOR TENDON PALM/FINGER EACH TENDON 26442 TENOLYSIS FLEXOR TENDON PALM&FINGER EACH TENDON 26445 TENOLYSIS EXTENSOR TENDON HAND/FINGER EACH 26449 TENOLYSIS CPLX XTNSR TENDON FINGER W/FOREARM EA 26450 TENOTOMY FLEXOR PALM OPEN EACH TENDON 26455 TENOTOMY FLEXOR FINGER OPEN EACH TENDON 26460 TENOTOMY EXTENSOR HAND/FINGER OPEN EACH TENDON 26471 TENODESIS PROXIMAL INTERPHALANGEAL JOINT EACH 26474 TENODESIS DISTAL JOINT EACH 26476 LENGTHENING TENDON EXTENSOR HAND/FINGER EACH 26477 SHORTENING TENDON EXTENSOR HAND/FINGER EACH 26478 LENGTHENING TENDON FLEXOR HAND/FINGER EACH 26479 SHORTENING TENDON FLEXOR HAND/FINGER EACH 26480 TR/TRNSPL TDN CARP/MTCRPL HAND W/O FR GRF EA TDN


26483 TR/TRNSPL TDN CARP/MTCRPL AND W/FR TDN GRF EA 26485 TRANSFER/TRANSPLANT TENDON PALMAR W/O GRAFT EACH 26489 TRANSFER/TRANSPLANT TENDON PALMAR W/GRAFT EACH 26490 OPPONENSPLASTY SUPFCIS TDN TR TYP EA TDN 26492 OPPONENSPLASTY TDN TR W/GRF EA TDN 26494 OPPONENSPLASTY HYPOTHENAR MUSC TR 26496 OPPONENSPLASTY OTH METHS 26497 TR TDN RESTORE INTRNSC FUNCJ RING&SM FNGR 26498 TR TDN RESTORE INTRNSC FUNCJ ALL 4 FNGRS 26499 CORRECTION CLAW FINGER OTHER METHODS 26500 RCNSTJ TENDON PULLEY EACH W/LOCAL TISSUES SPX 26502 RCNSTJ TDN PULLEY EA TDN W/TDN/FSCAL GRF SPX 26508 RELEASE THENAR MUSCLE 26510 CROSS INTRINSIC TRANSFER EACH TENDON 26516 CAPSULODESIS MTCARPHLNGL JOINT SINGLE DIGIT 26517 CAPSULODESIS MTCARPHLNGL JOINT 2 DIGITS 26518 CAPSULODESIS MTCARPHLNGL JOINT 3/4 DIGITS 26520 CAPSULECTOMY/CAPSULOTOMY MTCARPHLNGL JOINT EACH 26525 CAPSULECTOMY/CAPSULOTOMY IPHAL JOINT EACH 26530 ARTHROPLASTY METACARPOPHALANGEAL JOINT EACH 26531 ARTHRP MTCARPHLNGL JT W/PROSTC IMPLT EA JT 26535 ARTHROPLASTY INTERPHALANGEAL JOINT EACH 26536 ARTHROPLASTY INTERPHALANGEAL JT W/PROSTHETIC EA 26540 RPR COLTRL LIGM MTCARPHLNGL/IPHAL JT 26541 RCNSTJ COLTRL LIGM MTCARPHLNGL 1 W/TDN/FSCAL GRF 26542 RCNSTJ COLTRL LIGM MTCARPHLNGL 1 W/LOCAL TISS 26545 RCNSTJ COLTRL LIGM IPHAL JT 1 W/GRF EA JT 26546 RPR NON-UNION MTCRPL/PHALANX 26548 RPR&RCNSTJ FINGER VOLAR PLATE INTERPHALANGEAL JT 26550 POLLICIZATION DIGIT 26551 TR TOE-TO-HAND W/MVASC ANAST GRT TOE WRP/ARND 26553 TR TOE-TO-HAND W/MVASC ANAST OTH/THN GRT TOE 1 26554 TR TOE-TO-HAND W/MVASC ANAST OTH/THN GRT TOE 2 26555 TR FNGR AXH POS W/O MVASC ANAST 26556 TRANSFER FREE TOE JOINT W/MVASC ANASTOMOSIS 26560 REPAIR SYNDACTYLY EACH SPACE W/SKIN FLAPS 26561 REPAIR SYNDACTYLY EACH SPACE W/SKIN FLAPS&GRAFTS 26562 REPAIR SYNDACTYLY EACH SPACE COMPLEX 26565 OSTEOTOMY METACARPAL EACH 26567 OSTEOTOMY PHALANX FINGER EACH 26568 OSTEOPLASTY LENGTHENING METACARPAL/PHALANX 26580 REPAIR CLEFT HAND 26587 RCNSTJ POLYDACTYLOUS DGT SOFT TISS&B1


26590 REPAIR MACRODACTYLIA EACH DIGIT 26591 REPAIR INTRINSIC MUSCLES HAND EACH MUSCLE 26593 RELEASE INTRINSIC MUSCLES HAND EACH MUSCLE 26596 EXC CONSTRICTING RING FNGR W/MLT Z-PLASTIES 26820 FUSION OPPOSITION THUMB W/AUTOGENOUS GRAFT 26841 ARTHRD CARP/MTCRPL JT THMB +-INT FIXJ 26842 ARTHRD CARP/MTCRPL JT THMB +-INT FIXJ W/AGRFT 26843 ARTHRD CARP/MTCRPL JT DGT OTHER THAN THUMB EACH 26844 ARTHRD CARP/MTCRPL JT DGT OTH/THN THMB W/AGRFT 26850 ARTHRD MTCARPHLNGL JT +-INT FIXJ 26852 ARTHRD MTCARPHLNGL JT +-INT FIXJ W/AGRFT 26860 ARTHRD IPHAL JT +-INT FIXJ 26861 ARTHRD IPHAL JT +-INT FIXJ EA IPHAL JT 26862 ARTHRD IPHAL JT +-INT FIXJ W/AGRFT 26863 ARTHRD IPHAL JT +-INT FIXJ W/AGRFT EA JT 26910 AMP MTCRPL W/FNGR/THMB 1 +-INTEROSS TR 26951 AMP F/TH 1/2 JT/PHALANX 1 W/NEURECT W/DIR CLSR 26952 AMP F/TH 1/2 JT/PHALANX 1 W/NEURECT LOCAL FLAP 26989 UNLIS PX HANDS/FNGRS 27000 TENOTOMY ADDUCTOR HIP PERCUTANEOUS SPX 27001 TENOTOMY ADDUCTOR HIP OPEN 27003 TX ADDUXOR SUBQ OPN W/OBTURATOR NEURECTOMY 27005 TENOTOMY HIP FLEXOR OPEN SPX 27006 TENOTOMY ABDUCTORS&/EXTENSOR HIP OPEN SPX 27025 FASCIOTOMY HIP/THIGH ANY TYPE 27030 ARTHROTOMY HIP W/DRAINAGE 27033 ARTHROTOMY HIP EXPLORATION/REMOVAL FOREIGN BODY 27035 DNRVTJ HIP JT INTRAPEL/XTRPEL INTRA-ARTCLR BRNCH 27036 CAPSLCTOMY/CAPSUL HIP W/RLS HIP FLXR MUSC 27043 EXCISION TUMOR SOFT TISSUE PELVIS&HIP SUBQ 3+CM 27045 EXC TUMOR SOFT TISSUE PELVIS & HIP SUBFASC 5+CM 27047 EXC TUMOR SOFT TISSUE PELVIS & HIP SUBQ <3CM 27048 EXC TUMOR SOFT TISSUE PELVIS & HIP SUBFASC <5CM 27054 ARTHROTOMY W/SYNOVECTOMY HIP JOINT 27059 RAD RESECTION TUMOR SOFT TISS PELVIS&HIP 5+CM 27060 EXCISION ISCHIAL BURSA 27062 EXCISION TROCHANTERIC BURSA/CALCIFICATION 27065 EXC B1 CST/B9 TUM SUPFC +-AGRFT 27066 EXC B1 CST/B9 TUM DP +-AGRFT 27067 EXC B1 CST/B9 TUM W/AGRFT REQ SEP INC 27080 COCCYGECTOMY PRIMARY 27090 REMOVAL HIP PROSTHESIS SPX 27091 RMVL HIP PROSTH COMP W/TOT HIP PROSTH MMA


27097 RELEASE/RECESSION HAMSTRING PROXIMAL 27098 TRANSFER ADDUCTOR ISCHIUM 27100 TR XTRNL OBLQ MUSC TRCHNTR W/FSCAL/TDN XTN GRF 27105 TR PARASPI MUSC HIP FASC/TDN XTN GRF 27110 TRANSFER ILIOPSOAS GREATER TROCHANTER FEMUR 27111 TRANSFER ILIOPSOAS FEMORAL NECK 27120 ACETABULOPLASTY 27122 ACETABULOPLASTY RESECTION FEMORAL HEAD 27125 HEMIARTHROPLASTY HIP PARTIAL 27130 ARTHRP ACETBLR/PROX FEM PROSTC AGRFT/ALGRFT 27132 CONV PREVIOUS HIP TOT HIP ARTHRP +-AGRFT/ALGRFT 27134 REVJ TOT HIP ARTHRP BTH +-AGRFT/ALGRFT 27137 REVJ TOT HIP ARTHRP ACTBLR ONLY +-AGRFT/ALGRFT 27138 REVJ TOT HIP ARTHRP FEM ONLY +-ALGRFT 27140 OSTEOTOMY&TRANSFER GREATER TROCHANTER SPX 27146 OSTEOTOMY ILIAC ACETABULAR/INNOMINATE BONE 27147 OSTEOTOMY ILIAC ACETABULAR/INNOMINATE HIP RDCTJ 27151 OSTEOTOMY ILIAC ACETABULAR/INNOMINATE FEM OSTEOT 27156 OSTEOT ILIAC ACTBLR/INNOMINATE B1 OSTEOT RDCTJ 27158 OSTEOTOMY PELVIS BILATERAL 27161 OSTEOTOMY FEMORAL NECK SPX 27165 OSTEOT INTERTRCHNTRIC/SUBTRCHNTRIC W/INT/XTRNL 27170 B1 GRF FEM H/N INTERTRCHNTRIC/SUBTRCHNTRIC AREA 27185 EPIPHYSL ARRST EPIPHYSIOD/STAPLING TRCHNTR FEMUR 27280 ARTHRODESIS SACROILIAC JOINT W/OBTAINING GRAFT 27282 ARTHRODESIS SYMPHYSIS PUBIS W/OBTAINING GRAFT 27284 ARTHRODESIS HIP JOINT W/OBTAINING GRAFT 27286 ARTHRD HIP JT W/OBTG GRF W/SUBTRCHNTRIC OSTEOT 27290 INTERPELVIABDOMINAL AMPUTATION 27295 DISARTICULATION HIP 27299 UNLISTED PROCEDURE PELVIS/HIP JOINT 27305 FASCIOTOMY ILIOTIBIAL OPEN 27306 TENOTOMY PRQ ADDUCTOR/HAMSTRING 1 TENDON SPX 27307 TENOTOMY PRQ ADDUCTOR/HAMSTRING MULTIPLE TENDON 27310 ARTHRT KNE W/EXPL DRG/RMVL FB 27325 NEURECTOMY HAMSTRING MUSCLE 27326 NEURECTOMY POPLITEAL 27327 EXCISION TUMOR SOFT TISSUE THIGH/KNEE SUBQ <3CM 27328 EXC TUMOR SOFT TISSUE THIGH/KNEE SUBFASC <5CM 27330 ARTHROTOMY KNEE W/SYNOVIAL BIOPSY ONLY 27331 ARTHRT KNE W/JT EXPL BX/RMVL LOOSE/FB 27332 ARTHRT W/EXC SEMILUNAR CRTLG KNE MEDIAL/LAT 27333 ARTHRT W/EXC SEMILUNAR CRTLG KNE MEDIAL&LAT


27334 ARTHROTOMY W/SYNOVECTOMY KNEE ANTERIOR/POSTERIOR 27335 ARTHRT W/SYNVCT KNE ANT&PST W/POP AREA 27337 EXCISON TUMOR SOFT TISSUE THIGH/KNEE SUBQ 3+CM 27339 EXC TUMOR SOFT TISSUE THIGH/KNEE SUBFASC 5+CM 27340 EXCISION PREPATELLAR BURSA 27345 EXCISION SYNOVIAL CYST POPLITEAL SPACE 27347 EXCISION LESION MENISCUS/CAPSULE KNEE 27350 PATELLECTOMY/HEMIPATELLECTOMY 27355 EXCISION/CURETTAGE CYST/TUMOR FEMUR 27356 EXCISION/CURETTAGE CYST/TUMOR FEMUR W/ALLOGRAFT 27357 EXCISION/CURETTAGE CYST/TUMOR FEMUR W/AUTOGRAFT 27358 EXCISION/CURETTAGE CYST/TUMOR FEMUR INT FIXATION 27364 RAD RESECTION TUMOR SOFT TISSUE THIGH/KNEE 5+CM 27380 SUTURE INFRAPATELLAR TENDON PRIMARY 27381 SUTR INFRAPATELLAR TDN 2 RCNSTJ W/FSCAL/TDN GRF 27385 SUTURE QUADRICEPS/HAMSTRING RUPTURE PRIMARY 27386 SUTR QUADRICEPS/HAMSTRING MUSC RPT 2 RCNSTJ 27390 TENOTOMY OPEN HAMSTRING KNEE HIP SINGLE TENDON 27391 TENOTOMY OPN HAMSTRING KNEE HIP MULTIPLE 1 LEG 27392 TENOTOMY OPEN HAMSTRING KNEE HIP MULTIPLE BI 27393 LENGTHENING HAMSTRING TENDON SINGLE 27394 LENGTHENING HAMSTRING TENDON MULTIPLE 1 LEG 27395 LENGTHENING HAMSTRING TENDON MULTIPLE BILATERAL 27396 TRANSPLANT/TRANSFER THIGH XTNSR TO FLXR 1 TENDON 27397 TRANSPLANT/TRANSFER THIGH XTNSR TO FLXR MULT TDN 27400 TRANSFER TENDON/MUSCLE HAMSTRINGS FEMUR 27403 ARTHROTOMY W/MENISCUS REPAIR KNEE 27405 RPR PRIMARY TORN LIGM&/CAPSULE KNEE COLLATERAL 27407 REPAIR PRIMARY TORN LIGM&/CAPSULE KNEE CRUCIATE 27409 RPR 1 TORN LIGM&/CAPSL KNE COLTRL&CRUCIATE LIGMS 27412 AUTOLOGOUS CHONDROCYTE IMPLANTATION KNEE 27415 OSTEOCHONDRAL ALLOGRAFT KNEE OPEN 27416 OSTEOCHONDRAL AUTOGRAFT KNEE OPEN MOSAICPLASTY 27418 ANTERIOR TIBIAL TUBERCLEPLASTY 27420 RCNSTJ DISLOCATING PATELLA 27422 RCNSTJ DISLC PATELLA W/XTNSR RELIGNMT&/MUSC RLS 27424 RCNSTJ DISLC PATELLA W/PATELLECTOMY 27425 LATERAL RETINACULAR RELEASE OPEN 27427 LIGAMENTOUS RECONSTRUCTION KNEE EXTRA-ARTICULAR 27428 LIGAMENTOUS RECONSTRUCTION KNEE INTRA-ARTICULAR 27429 LIGMOUS RCNSTJ AGMNTJ KNE INTRA-ARTICULAR XTR 27430 QUADRICEPSPLASTY 27435 CAPSULOTOMY POSTERIOR CAPSULAR RELEASE KNEE


27437 ARTHROPLASTY PATELLA W/O PROSTHESIS 27438 ARTHROPLASTY PATELLA W/PROSTHESIS 27440 ARTHROPLASTY KNEE TIBIAL PLATEAU 27441 ARTHRP KNEE TIBIAL PLATEAU DBRDMT&PRTL SYNVCT 27442 ARTHROPLASTY FEM CONDYLES/TIBIAL PLATEAU KNEE 27443 ARTHRP FEM CONDYLES/TIBL PLATU KNE DBRDMT&PRTL 27445 ARTHROPLASTY KNEE HINGE PROSTHESIS 27446 ARTHRP KNEE CONDYLE&PLATEAU MEDIAL/LAT CMPRT 27447 ARTHRP KNE CONDYLE&PLATU MEDIAL&LAT CMPRTS 27448 OSTEOTOMY FEMUR SHAFT/SUPRACONDYLAR W/O FIXATION 27450 OSTEOTOMY FEMUR SHAFT/SUPRACONDYLAR W/FIXATION 27454 OSTEOT MLT W/RELIGNMT IMED ROD FEM SHFT 27455 OSTEOT PROX TIBIA FIB EXC/OSTEOT BEFORE EPIPHYSL 27457 OSTEOT PROX TIBIA FIB EXC/OSTEOT AFTER EPIPHYSL 27465 OSTEOPLASTY FEMUR SHORTENING EXCLUDING 64876 27466 OSTEOPLASTY FEMUR LENGTHENING 27468 OSTPL FEMUR CMBN LNGTH&SHRT W/FEM SGM TR 27475 ARREST EPIPHYSEAL DISTAL FEMUR 27477 ARREST EPIPHYSEAL TIBIA&FIBULA PROXIMAL 27479 ARRST EPIPHYSL CMBN DSTL FEMUR PROX TIBFIB 27485 ARRST HEMIEPIPHYSL DSTL FEMUR/PROX TIBIA/FIBULA 27486 REVJ TOT KNE ARTHRP +-ALGRFT 1 COMP 27487 REVJ TOT KNE ARTHRP FEM&ENTIRE TIBL COMP 27488 RMVL PROSTH TOT KNE PROSTH MMA +-INSJ SPACER 27580 ARTHRODESIS KNEE ANY TECHNIQUE 27590 AMPUTATION THIGH THROUGH FEMUR ANY LEVEL 27591 AMP THI THRU FEMUR LVL IMMT FITG TQ W/1ST CST 27592 AMPUTATION THIGH THRU FEMUR OPEN CIRCULAR 27594 AMP THIGH THRU FEMUR SEC CLOSURE/SCAR REVISION 27596 AMPUTATION THIGH THROUGH FEMUR RE-AMPUTATION 27598 DISARTICULATION KNEE 27599 UNLISTED PROCEDURE FEMUR/KNEE 27605 TENOTOMY PRQ ACHILLES TENDON SPX LOCAL ANES 27606 TENOTOMY PRQ ACHILLES TENDON SPX GENERAL ANES 27610 ARTHROTOMY ANKLE W/EXPL DRAINAGE/REMOVAL FB 27612 ARTHRT PST CAPSULAR RLS ANKLE +-ACHLL TDN LNGTH 27616 RAD RESCJ TUM SOFT TISSUE LEG/ANKLE 5+CM 27618 EXC TUMOR SOFT TISSUE LEG/ANKLE SUBQ <3CM 27619 EXC TUMOR SOFT TISSUE LEG/ANKLE SUBFASCIAL <5CM 27620 ARTHRT ANKLE W/JT EXPL +-BX +-RMVL LOOSE/FB 27625 ARTHROTOMY W/SYNOVECTOMY ANKLE 27626 ARTHROTOMY W/SYNOVECTOMY ANKLE TENOSYNOVECTOMY 27630 EXCISION LESION TENDON SHEATH/CAPSULE LEG&/ANKLE


27632 EXCISION TUMOR SOFT TISSUE LEG/ANKLE SUBQ 3+CM 27634 EXC TUMOR SOFT TISSUE LEG/ANKLE SUBFASC 5+CM 27635 EXCISION/CURETTAGE BONE CYST/TUMOR TIBIA/FIBULA 27637 EXC/CURETTAGE CYST/TUMOR TIBIA/FIBULA W/AGRAFT 27638 EXC/CURETTAGE CYST/TUMOR TIBIA/FIBULA W/ALGRAFT 27650 REPAIR PRIMARY OPEN/PRQ RUPTURED ACHILLES TENDON 27652 RPR PRIMARY OPEN/PRQ RUPTURED ACHILLES W/GRAFT 27654 REPAIR SECONDARY ACHILLES TENDON +-GRAFT 27656 REPAIR FASCIAL DEFECT LEG 27658 REPAIR FLEXOR TENDON LEG PRIMARY W/O GRAFT EACH 27659 RPR FLEXOR TENDON LEG SECONDARY W/O GRAFT EACH 27664 RPR EXTENSOR TENDON LEG PRIMARY W/O GRAFT EACH 27665 RPR EXTENSOR TENDON LEG SECONDARY +/-GRAFT EACH 27675 RPR DISLOCATING PERONEAL TENDON W/O FIB OSTEOT 27676 REPAIR DISLOCATING PERONEAL TENDON W/FIB OSTEOT 27680 TENOLYSIS FLXR/XTNSR TENDON LEG&/ANKLE 1 EACH 27681 TNOLS FLXR/XTNSR TDN LEG&/ANKLE MLT TDN 27685 LNGTH/SHRT TDN LEG/ANKLE 1 TDN SPX 27686 LNGTH/SHRT TDN LEG/ANKLE MLT TDN SAME INC EA 27687 GASTROCNEMIUS RECESSION 27690 TR/TRNSPL 1 TDN W/MUSC REDIRION/REROUTING SUPFC 27691 TR/TRNSPL 1 TDN W/MUSC REDIRION/REROUTING DP 27692 TR/TRNSPL 1 TDN W/MUSC REDIRION/REROUTING EA TDN 27695 RPR PRIMARY DISRUPTED LIGAMENT ANKLE COLLATERAL 27696 RPR PRIM DISRUPTED LIGM ANKLE BTH COLTRL LIGMS 27698 REPAIR SECONDARY DISRUPTED LIGAMENT ANKLE COLTRL 27700 ARTHROPLASTY ANKLE 27702 ARTHROPLASTY ANKLE W/IMPLANT 27703 ARTHROPLASTY ANKLE REVISION TOTAL ANKLE 27704 REMOVAL ANKLE IMPLANT 27705 OSTEOTOMY TIBIA 27707 OSTEOTOMY FIBULA 27709 OSTEOTOMY TIBIA&FIBULA 27712 OSTEOT MLT W/RELIGNMT IMED ROD 27715 OSTEOPLASTY TIBIA&FIBULA LENGTHENING/SHORTENING 27727 REPAIR CONGENITAL PSEUDARTHROSIS TIBIA 27730 ARREST EPIPHYSEAL OPEN DISTAL TIBIA 27732 ARREST EPIPHYSEAL OPEN DISTAL FIBULA 27734 ARREST EPIPHYSEAL OPEN DISTAL TIBIA&FIBULA 27740 ARRST EPIPHYSL ANY METH TIBFIB 27742 ARRST EPIPHYSL ANY METH TIBFIB&DSTL FEMUR 27870 ARTHRODESIS ANKLE OPEN 27871 ARTHRODESIS TIBIOFIBULAR JOINT PROXIMAL/DISTAL


27880 AMPUTATION LEG THROUGH TIBIA&FIBULA 27881 AMP LEG THRU TIBFIB W/IMMT FITG TQ W/1ST CST 27882 AMPUTATION LEG THRU TIBIA&FIBULA OPEN CIRCULAR 27884 AMP LEG THRU TIBIA&FIBULA SEC CLOSURE/SCAR REVJ 27886 AMP LEG THRU TIBIA&FIBULA RE-AMPUTATION 27888 AMP ANKLE-MALLI TIBFIB W/PLSTC CLSR&RESCJ NRV 27889 ANKLE DISARTICULATION 27899 UNLISTED PROCEDURE LEG/ANKLE 28010 TENOTOMY PERCUTANEOUS TOE SINGLE TENDON 28011 TENOTOMY PERCUTANEOUS TOE MULTIPLE TENDON 28020 ARTHRT W/EXPL DRG/RMVL LOOSE/FB NTRTRSL/TARS JT 28022 ARTHRT W/EXPL DRG/RMVL LOOSE/FB MTTARPHLNGL JT 28024 ARTHRT W/EXPL DRG/RMVL LOOSE/FB IPHAL JT 28035 RELEASE TARSAL TUNNEL 28039 EXCISION TUMOR SOFT TISSUE FOOT/TOE SUBQ 1.5+CM 28041 EXC TUMOR SOFT TISSUE FOOT/TOE SUBFASC 1.5+CM 28043 EXCISION TUMOR SOFT TISSUE FOOT/TOE SUBQ <1.5CM 28045 EXC TUMOR SOFT TISSUE FOOT/TOE SUBFASC <1.5CM 28047 RAD RESECTION TUMOR SOFT TISSUE FOOT/TOE 3+CM 28050 ARTHRT W/BX INTERTARSAL/TARS JT 28052 ARTHRT W/BX METATARSOPHALANGEAL JT 28054 ARTHRT W/BX IPHAL JT 28055 NEURECTOMY INTRINSIC MUSCULATURE OF FOOT 28070 SYNVCT INTERTARSAL/TARSOMETATARSAL JT EA SPX 28072 SYNOVECTOMY METATARSOPHALANGEAL JOINT EACH 28080 EXCISION INTERDIGITAL MORTON NEUROMA SINGLE EACH 28086 SYNOVECTOMY TENDON SHEATH FOOT FLEXOR 28088 SYNOVECTOMY TENDON SHEATH FOOT EXTENSOR 28090 EXC LESION TENDON SHEATH/CAPSULE W/SYNVCT FOOT 28092 EXC LESION TENDON SHEATH/CAPSULE W/SYNVCT TOE EA 28100 EXCISION/CURETTAGE CYST/TUMOR TALUS/CALCANEUS 28102 EXC/CURTG CST/B9 TUM TALUS/CLCNS W/ILIAC/AGRFT 28103 EXC/CURETTAGE CYST/TUMOR TALUS/CALCANEUS ALGRFT 28104 EXC/CURTG CST/B9 TUM TARSAL/METAR 28106 EXC/CURTG CST/B9 TUM TARSAL/METAR W/ILIAC/AGRFT 28107 EXC/CURTG CST/B9 TUM TARSAL/METAR W/ALGRFT 28108 EXC/CURTG CST/B9 TUM PHALANGES FOOT 28110 OSTECTOMY PRTL 5TH METAR HEAD SPX 28111 OSTECTOMY COMPLETE 1ST METATARSAL HEAD 28112 OSTECTOMY COMPLETE OTHER METATARSAL HEAD 2/3/4 28113 OSTECTOMY COMPLETE 5TH METATARSAL HEAD 28114 OSTC COMPL ALL METAR HEADS W/PRTL PROX PHALANGC 28116 OSTECTOMY TARSAL COALITION


28118 OSTECTOMY CALCANEUS 28119 OSTECTOMY CALCANEUS SPUR +-PLNTAR FSCAL RLS 28126 RESECTION PARTIAL/COMPLETE PHALANGEAL BASE EACH 28130 TALECTOMY ASTRAGALECTOMY 28140 METATARSECTOMY 28150 PHALANGECTOMY TOE EA TOE 28153 RESECTION CONDYLE DISTAL END PHALANX EACH TOE 28160 HEMIPHALANGC/IPHAL JT EXC TOE 28200 RPR TDN FLXR FOOT 1/2 W/O FR GRF EA TDN 28202 RPR TDN FLXR FOOT SEC W/FR GRF EA TDN 28208 RPR TDN XTNSR FOOT 1/2 EA TDN 28210 RPR TDN XTNSR FOOT SEC W/FR GRF EA TDN 28220 TENOLYSIS FLEXOR FOOT SINGLE TENDON 28222 TENOLYSIS FLEXOR FOOT MULTIPLE TENDONS 28225 TENOLYSIS EXTENSOR FOOT SINGLE TENDON 28226 TENOLYSIS EXTENSOR FOOT MULTIPLE TENDON 28230 TX OPN TDN FLXR FOOT 1/MLT TDN SPX 28232 TX OPN TDN FLXR TOE 1 TDN SPX 28234 TENOTOMY OPEN EXTENSOR FOOT/TOE EACH TENDON 28238 RCNSTJ PST TIBL TDN W/EXC ACCESSORY TARSL NAVCLR 28240 TENOTOMY LENGTHENING/RLS ABDUCTOR HALLUCIS MUSC 28250 DIVISION PLANTAR FASCIA&MUSCLE SPX 28260 CAPSULOTOMY MIDFOOT MEDIAL RELEASE ONLY SPX 28261 CAPSULOTOMY MIDFOOT W/TENDON LENGTHENING 28262 CAPSUL MIDFOOT W/PST TALOTIBL CAPSUL&TDN LNGTH 28264 CAPSULOTOMY MIDTARSAL 28270 CAPSUL MTTARPHLNGL JT +-TENORRHAPHY EA JT SPX 28272 CAPSUL IPHAL JT EA JT SPX 28280 SYNDACTYLIZATION TOES 28285 CORRECTION HAMMERTOE 28286 CORRECTION COCK-UP 5TH TOE W/PLASTIC CLOSURE 28288 OSTC PRTL EXOSTC/CONDYLC METAR HEAD 28289 HALLUX RGDUS CORRJ W/CHEILC 28290 CORRJ HALLUX VALGUS +-SESMDC SMPL EXOSTECTOMY 28292 KELLER/MCBRIDE/MAYO PROCEDURE 28293 CORRJ HALLUX VALGUS +-SESMDC RESCJ JT W/IMPLT 28294 CORRJ HALLUX VALGUS +-SESMDC W/TDN TRNSPLS 28296 CORRJ HALLUX VALGUS +-SESMDC W/METAR OSTEOT 28297 CORRJ HALLUX VALGUS +-SESMDC LAPIDUS-TYP PX 28298 CORRJ HALLUX VALGUS +-SESMDC PHALANX OSTEOT 28299 CORRJ HALLUX VALGUS +-SESMDC 2 OSTEOT 28300 OSTEOTOMY CALCANEUS +-INTERNAL FIXATION 28302 OSTEOTOMY TALUS


28304 OSTEOTOMY TARSAL BONES OTH/THN CALCANEUS/TALUS 28305 OSTEOT TARSAL OTH/THN CALCANEUS/TALUS W/AGRFT 28306 OSTEOT +-LNGTH SHRT/CORRJ 1ST METAR 28307 OSTEOT +-LNGTH SHRT/CORRJ 1ST METAR XCP 1ST TOE 28308 OSTEOT +-LNGTH SHRT/CORRJ METAR XCP 1ST EA 28309 OSTEOT +-LNGTH SHRT/ANGULAR CORRJ METAR MLT 28310 OSTEOT SHRT CORRJ PROX PHALANX 1ST TOE 28312 OSTEOT SHRT CORRJ OTH PHALANGES ANY TOE 28313 RCNSTJ ANGULAR DFRM TOE SOFT TISS PX ONLY 28315 SESAMOIDECTOMY FIRST TOE SPX 28340 RCNSTJ TOE MACRODACTYLY SOFT TISSUE RESECTION 28341 RCNSTJ TOE MACRODACTYLY REQUIRING BONE RESECTION 28344 RECONSTRUCTION TOE POLYDACTYLY 28345 RCNSTJ TOE SYNDACTYLY +-SKN GRF EA WEB 28360 RECONSTRUCTION CLEFT FOOT 28705 ARTHRODESIS PANTALAR 28715 ARTHRODESIS TRIPLE 28725 ARTHRODESIS SUBTALAR 28730 ARTHRD MIDTARSL/TARS MLT/TRANSVRS 28735 ARTHRD MIDTARSL/TARS MLT/TRANSVRS W/OSTEOT 28737 ARTHRD W/TDN LNGTH&ADVMNT TARSL NVCLR-CUNEIFORM 28740 ARTHRODESIS MIDTARSOMETATARSAL SINGLE JOINT 28750 ARTHRODESIS GREAT TOE METATARSOPHALANGEAL JOINT 28755 ARTHRODESIS GREAT TOE INTERPHALANGEAL JOINT 28760 ARTHRD W/XTNSR HALLUCIS LONGUS TR 1ST METAR NCK 28800 AMPUTATION FOOT MIDTARSAL 28805 AMPUTATION FOOT TRANSMETARSAL 28810 AMPUTATION METATARSAL W/TOE SINGLE 28820 AMPUTATION TOE METATARSOPHALANGEAL JOINT 28825 AMPUTATION TOE INTERPHALANGEAL JOINT 28890 ESWT HI NRG PFRMD PHYS W/US GDN INVG PLNTAR FSCA 28899 UNLISTED PROCEDURE FOOT/TOES 29010 APPLICATION RISSER JACKET LOCALIZER BODY ONLY 29015 APPLICATION RISSER JACKET LOCALIZER BODY W/HEAD 29020 APPLICATION TURNBUCKLE JACKET BODY ONLY 29025 APPLICATION TURNBUCKLE JACKET BODY W/HEAD 29126 APPLICATION SHORT ARM SPLINT DYNAMIC 29131 APPLICATION FINGER SPLINT DYNAMIC 29590 DENIS-BROWNE SPLINT STRAPPING 29799 UNLISTED PROCEDURE CASTING/STRAPPING 29800 ARTHRS TMPRMAND JT DX +-SYNVAL BX SPX 29804 ARTHROSCOPY TEMPOROMANDIBULAR JOINT SURGICAL 29805 ARTHROSCOPY SHOULDER DX +-SYNOVIAL BIOPSY SPX


29806 ARTHROSCOPY SHOULDER SURGICAL CAPSULORRHAPHY 29807 ARTHROSCOPY SHOULDER SURGICAL REPAIR SLAP LESION 29819 ARTHROSCOPY SHOULDER SURGICAL REMOVAL LOOSE/FB 29820 ARTHROSCOPY SHOULDER SURG SYNOVECTOMY PARTIAL 29821 ARTHROSCOPY SHOULDER SURG SYNOVECTOMY COMPLETE 29822 ARTHROSCOPY SHOULDER SURG DEBRIDEMENT LIMITED 29823 ARTHROSCOPY SHOULDER SURG DEBRIDEMENT EXTENSIVE 29824 ARTHROSCOPY SHOULDER DISTAL CLAVICULECTOMY 29825 ARTHROSCOPY SHOULDER LYSIS&RESCJ ADHESION +-MNPJ 29826 SHOULDER SCOPE, BONE SHAVING 29827 ARTHROSCOPY SHOULDER ROTATOR CUFF REPAIR 29828 ARTHROSCOPY SHOULDER BICEPS TENODESIS 29830 ARTHROSCOPY ELBOW DIAGNOSTIC +-SYNOVIAL BX SPX 29834 ARTHROSCOPY ELBOW SURGICAL W/REMOVAL LOOSE/FB 29835 ARTHROSCOPY ELBOW SURGICAL SYNOVECTOMY PARTIAL 29836 ARTHROSCOPY ELBOW SURGICAL SYNOVECTOMY COMPLETE 29837 ARTHROSCOPY ELBOW SURGICAL DEBRIDEMENT LIMITED 29838 ARTHROSCOPY ELBOW SURGICAL DEBRIDEMENT EXTENSIVE 29840 ARTHROSCOPY WRIST DIAGNOSTIC +-SYNOVIAL BX SPX 29843 ARTHROSCOPY WRIST INFECTION LAVAGE&DRAINAGE 29844 ARTHROSCOPY WRIST SURGICAL SYNOVECTOMY PARTIAL 29845 ARTHROSCOPY WRIST SURGICAL SYNOVECTOMY COMPLETE 29846 ARTHRS WRST EXC&/RPR TRIANG FIBROCART&/JT DBRDMT 29847 ARTHRS WRST SURG INT FIXJ F/FX/INS 29848 NDSC WRST SURG W/RLS TRANSVRS CARPL LIGM 29850 ARTHRS AID TX SPI&/FX KNE W/O FIXJ 29851 ARTHRS AID TX SPI&/FX KNE W/FIXJ 29855 ARTHRS AID TIBIAL FRACTURE PROXIMAL UNICONDYLAR 29856 ARTHRS AID TIBIAL FX PROX UNICONDYLAR BICONDYLAR 29860 ARTHROSCOPY HIP DIAGNOSTIC +-SYNOVIAL BIOPSY SPX 29861 ARTHROSCOPY HIP SURGICAL W/REMOVAL LOOSE/FB 29862 ARTHRS HIP DEBRIDEMENT/SHAVING ARTICULAR CRTLG 29863 ARTHROSCOPY HIP SURGICAL W/SYNOVECTOMY 29866 ARTHROSCOPY KNEE OSTEOCHONDRAL AGRFT MOSAICPLAST 29867 ARTHROSCOPY KNEE OSTEOCHONDRAL ALLOGRAFT 29868 ARTHROSCOPY KNEE MENISCAL TRNSPLJ MED/LAT 29870 ARTHROSCOPY KNEE DIAGNOSTIC +-SYNOVIAL BX SPX 29871 ARTHROSCOPY KNEE INFECTION LAVAGE & DRAINAGE 29873 ARTHROSCOPY KNEE LATERAL RELEASE 29874 ARTHROSCOPY KNEE REMOVAL LOOSE/FOREIGN BODY 29875 ARTHROSCOPY KNEE SYNOVECTOMY LIMITED SPX 29876 ARTHROSCOPY KNEE SYNOVECTOMY 2/>COMPARTMENTS 29877 ARTHRS KNEE DEBRIDEMENT/SHAVING ARTCLR CRTLG


29879 ARTHRS KNEE ABRASION ARTHRP/MLT DRLG/MICROFX 29880 ARTHRS KNEE W/MENISCECTOMY MED&LAT W/SHAVING 29881 ARTHRS KNE SURG W/MENISCECTOMY MED/LAT W/SHVG 29882 ARTHROSCOPY KNEE W/MENISCUS RPR MEDIAL/LATERAL 29883 ARTHROSCOPY KNEE W/MENISCUS RPR MEDIAL&LATERAL 29884 ARTHROSCOPY KNEE W/LYSIS ADHESIONS+-MNPJ SPX 29885 ARTHRS KNE DRLG OSTEO DISS GRFG 29886 ARTHRS KNE DRLG OSTEO DISS LES 29887 ARTHRS KNE DRLG OSTEO DISS LES INT FIXJ 29888 ARTHRS AIDED ANT CRUCIATE LIGM RPR/AGMNTJ/RCNSTJ 29889 ARTHRS AIDED PST CRUCIATE LIGM RPR/AGMNTJ/RCNSTJ 29891 ARTHRS ANKLE EXC OSTCHNDRL DFCT W/DRLG DFCT 29892 ARTHRS AID RPR LES/TALAR DOME FX/TIBL PLAFOND FX 29893 ENDOSCOPIC PLANTAR FASCIOTOMY 29894 ARTHROSCOPY ANKLE W/REMOVAL LOOSE/FOREIGN BODY 29895 ARTHROSCOPY ANKLE SURGICAL SYNOVECTOMY PARTIAL 29897 ARTHROSCOPY ANKLE SURGICAL DEBRIDEMENT LIMITED 29898 ARTHROSCOPY ANKLE SURGICAL DEBRIDEMENT EXTENSIVE 29899 ARTHROSCOPY ANKLE SURGICAL W/ANKLE ARTHRODESIS 29900 ARTHROSCOPY METACARPOPHALANGEAL SYNOVIAL BIOPSY 29901 ARTHRS METACARPOPHALANGEAL JOINT DEBRIDEMENT 29902 ARTHRS MTCARPHLNGL JT W/RDCTJ UR COLTRL LIGM 29904 ARTHRS SUBTALAR JOINT REMOVE LOOSE/FOREIGN BODY 29905 ARTHROSCOPY SUBTALAR JOINT WITH SYNOVECTOMY 29906 ARTHROSCOPY SUBTALAR JOINT WITH DEBRIDEMENT 29907 ARTHROSCOPY SUBTALAR JOINT SUBTALAR ARTHRODESIS 29914 ARTHROSCOPY HIP W/FEMOROPLASTY 29915 ARTHROSCOPY HIP W/ACETABULOPLASTY 29916 ARTHROSCOPY HIP W/LABRAL REPAIR 29999 UNLISTED PROCEDURE ARTHROSCOPY 30400 RHINP PRIM LAT&ALAR CRTLGS&/ELVTN NSL TIP 30410 RHINP PRIM COMPLETE XTRNL PARTS 30420 RHINOPLASTY PRIMARY W/MAJOR SEPTAL REPAIR 30430 RHINOPLASTY SECONDARY MINOR REVISION 30435 RHINOPLASTY SECONDARY INTERMEDIATE REVISION 30450 RHINOPLASTY SECONDARY MAJOR REVISION 30460 RHINP DFRM W/COLUM LNGTH TIP ONLY 30462 RHINP DFRM COLUM LNGTH TIP SEPTUM OSTEOT 30465 REPAIR NASAL VESTIBULAR STENOSIS 30520 SEPTOP/SBMCSL RESCJ 30999 UNLISTED PROCEDURE NOSE 31299 UNLISTED PROCEDURE ACCESSORY SINUSES 31599 UNLISTED PROCEDURE LARYNX


31830 REVISION TRACHEOSTOMY SCAR 31899 UNLISTED PROCEDURE TRACHEA BRONCHI 32850 DONOR PNEUMONECTOMY FROM CADAVER DONOR 32851 LUNG TRANSPLANT 1 W/O CARDIOPULMONARY BYPASS 32852 LUNG TRANSPLANT 1 W/CARDIOPULMONARY BYPASS 32853 LUNG TRANSPLANT 2 W/O CARDIOPULMONARY BYPASS 32854 LUNG TRANSPLANT 2 W/CARDIOPULMONARY BYPASS 32855 BKBENCH STANDARD PREPJ CDVR DON LNG ALGRFT UNI 32856 BKBENCH STANDARD PREPJ CDVR DON LNG ALGRFT BI 32999 UNLISTED PROCEDURE LUNGS & PLEURA 33140 TRANSMYOCRD LASER REVSC THORCOM SPX 33141 TRANSMYOCRD LASER REVSC PFRMD TM OTH OPN CAR PX 33930 DONOR CARDIECTOMY-PNEUMONECTOMY 33933 BKBENCH PREPJ CDVR DON HRT/LNG ALGRFT 33935 HRT-LNG TRNSPL W/RCP CARDIECTOMY-PNUMEC 33940 DONOR CARDIECTOMY 33944 BKBENCH STANDARD PREPJ CDVR DON HRT ALGRFT 33945 HEART TRANSPLANT +-RECIPIENT CARDIECTOMY 33975 INSJ VENTR ASSIST DEV XTRCORP 1 VNTRC 33976 INSJ VENTR ASSIST DEV XTRCORP BIVENTR 33979 INSJ VENTR ASSIST DEV IMPLTABLE ICORP 1 VNTRC 33981 RPLCMT XTRCORP VAD 1/BIVENTR PUMP 1/EA PUMP 33982 RPLCMT VAD PMP IMPLTBL ICORP 1 VNTR W/O CARD BYP 33983 RPLCMT VAD PMP IMPLTBL ICORP 1 VNTR W/CARD BYP 33999 UNLISTED CARDIAC SURGERY 36251 SLCTV CATH 1STORD W/WO ART PUNCT/FLUORO/S&I UNI 36252 SLCTV CATH 1STORD W/WO ART PUNCT/FLUOR/S&I BILAT 36253 SUPSLCTV CATH 2ND+ORD RENL&ACCES ARTERY/S&I UNI 36254 SUPSLCTV CATH 2ND+ORD RENL&ACCES ARTER/S&I BILAT 36299 UNLIS PX VASC NJX 36468 1/MLT NJXS SCLRSG SLNS SPIDER VEINS LIMB/TRNK 36469 1/MLT NJXS SCLRSG SLNS SPIDER VEINS FACE 36470 NJX SCLRSG SLN 1 VEIN 36471 NJX SCLRSG SLN MLT VEINS SM LEG 36475 ENDOVEN ABLTJ INCMPTNT VEIN XTR RF 1ST VEIN 36476 ENDOVEN ABLTJ INCMPTNT VEIN XTR RF 2ND+ VEINS 36478 ENDOVEN ABLTJ INCMPTNT VEIN XTR LASER 1ST VEIN 36479 ENDOVEN ABLTJ INCMPTNT VEIN XTR LASER 2ND+ VEINS 36515 THER APHERESIS W/XTRCORP IMMUNODSPTJ&PLSM RENFS 36516 THER APHRS XTRCORP SLCTV ADSRPJ/FILTRJ&RENFS 37210 UTERINE FIBROID EMBOLIZATION PERQ W/RAD GID 37500 VASC NDSC SEPS 37501 UNLIS VASC NDSC PX


37700 LIG&DIV LONG SAPH VEIN SAPHFEM JUNCT/INTERRUPJ 37718 LIG DIV&STRIPPING SHORT SAPHENOUS VEIN 37722 LIG DIV&STRIP LONG SAPH SAPHFEM JUNCT KNE/BELW 37735 LIG&DIV&COMPL STRIP LONG/SHORT SAPH RAD EXC 37760 LIG PRFRATR VEIN SUBFSCAL RAD INCL SKN GRF 1 LEG 37761 LIG PRFRATR VEIN SUBFSCAL OPEN INCL US GID 1 LEG 37765 STAB PHLEBT VARICOSE VEINS 1 XTR 10-20 STAB INCS 37766 STAB PHLEBT VARICOSE VEINS 1 XTR > 20 INCS 37780 LIG&DIV SHORT SAPH VEIN SAPHENOPOP JUNCT SPX 37785 LIG DIV&/EXC VARICOSE VEIN CLUSTER 1 LEG 37788 PEN REVSC ART +-VEIN GRF 37790 PEN VEN OCCLUSIVE PX 37799 UNLIS PX VASC SURG 38129 UNLIS LAPS PX SPLEEN 38204 MGMT RCP HEMATOP PROGENITOR CELL DON SEARCH&CELL 38205 BLD-DRV HEMATOP PROGEN CELL HRVG TRNSPLJ ALGNC 38206 BLD-DRV HEMATOP PROGEN CELL HRVG TRNSPLJ AUTOL 38207 TRNSPL PREPJ HEMATOP PROGEN CELLS CRYOPRSRV&STRG 38208 TRNSPL PREPJ HEMATOP PROGEN THAW PREV HRV 38209 TRNSPL PREPJ HEMATOP PROGEN THAW PREV HRV WASHG 38210 TRNSPL PREPJ HEMATOP PROGEN DEPLJ IN HRV T-CELL 38211 TRNSPL PREPJ HEMATOP PROGEN TUM CELL DEPLJ 38212 TRNSPL PREPJ HEMATOP PROGEN RED BLD CELL RMVL 38213 TRNSPL PREPJ HEMATOP PROGEN PLTLT DEPLJ 38214 TRNSPL PREPJ HEMATOP PROGEN PLSM VOL DEPLJ 38215 TRNSPL PREPJ HEMATOP PROGEN CONCENTRATION PLSM 38230 MARROW HRVG TRNSPLJ 38232 BONE MARROW HARVEST TRANSPLANTATION AUTOLOGOUS 38240 MARROW/BLD-DRV PRPH STEM CELL TRNSPLJ ALLOGENIC 38241 MARROW/BLD-DRV PRPH STEM CELL TRNSPLJ AUTOL 38242 MARROW/BLD-DRV PRPH STEM CELL TRNSPLJ ALGC DON 38589 UNLIS LAPS PX LYMPHATIC SYS 38999 UNLIS PX HEMIC/LYMPHATIC SYS 39499 UNLIS PX MED 39599 UNLIS PX DPHRM 40500 VERMILIONECTOMY LIP SHV W/MUCOSAL ADVMNT 40799 UNLIS PX LIPS 40806 INC LABIAL FRENUM FREXOMY 40842 VESTIBULOPLASTY PST UNI 40843 VESTIBULOPLASTY PST BI 40844 VESTIBULOPLASTY ENTIRE ARCH 40845 VESTIBULOPLASTY CPLX W/RIDGE XTN MUSC RPSG 40899 UNLIS PX VESTIBULE MOUTH


41010 INC LNGL FRENUM FREXOMY 41115 EXC LNGL FRENUM FRENECTOMY 41510 SUTR TONGUE LIP MICROGNATHIA 41512 TONGUE BASE SUSPENSION PERMANENT SUTURE TQ 41520 FRENOPLASTY SURG REVJ FRENUM EG W/Z-PLASTY 41530 SUBMUCOSAL ABLTJ TONGUE RF 1/> SITES PR SESSION 41599 UNLIS PX TONGUE FLOOR MOUTH 41820 GINGIVECTOMY EXC GINGIVA EA QUADRANT 41821 OPRCULECTOMY EXC PRICORONAL TISS 41822 EXC FIBROUS TUBEROSITIES DENTOALVEOLAR STRUXS 41823 EXC OSS TUBEROSITIES DENTOALVEOLAR STRUXS 41825 EXC LES/TUM XCP LISTED ABOVE DENTALVLR 41826 EXC LES/TUM XCP LISTED ABOVE DENTALVLR SMPL RPR 41827 EXC LES/TUM XCP LISTED ABOVE DENTALVLR CPLX RPR 41828 EXC HYPRPLSTC ALVEOLAR MUCOSA EA QUADRANT SPEC 41830 ALVEOLECTOMY W/CURTG OSTEITIS/SEQUESTRECTOMY 41850 DSTRJ LES XCP EXC DENTOALVEOLAR STRUXS 41870 PDONTAL MUCOSAL GRFG 41872 GINGIVOPLASTY EA QUADRANT SPEC 41874 ALVEOLOPLASTY EA QUADRANT SPEC 41899 UNLIS PX DENTOALVEOLAR STRUXS 42140 UVULECTOMY EXC UVULA 42145 PALATOPHARYNGOPLASTY 42299 UNLIS PX PALATE UVULA 42699 UNLIS PX SALIVARY GLNDS/DUXS 42820 TONSILLECTOMY&ADENOIDECTOMY UNDER AGE 12 42821 TONSILLECTOMY&ADENOIDECTOMY AGE 12/> 42825 TONSILLECTOMY 1/2 UNDER AGE 12 42826 TONSILLECTOMY 1/2 AGE 12/> 42830 ADENOIDECTOMY PRIM UNDER AGE 12 42831 ADENOIDECTOMY PRIM AGE 12/> 42835 ADENOIDECTOMY SEC UNDER AGE 12 42836 ADENOIDECTOMY SEC AGE 12/> 42842 RAD RESCJ TONSIL W/O CLSR 42844 RAD RESCJ TONSIL CLSR W/LOCAL FLAP 42845 RAD RESCJ TONSIL CLSR W/OTH FLAP 42870 EXC/DSTRJ LNGL TONSIL ANY METH SPX 42999 UNLIS PX PHARYNX ADENOIDS/TONSILS 43279 LAPS ESOPHAGOMYOTOMY W/FUNDOPLASTY IF PERFORMED 43280 LAPS SURG ESOPG/GSTR FUNDOPLASTY 43281 LAPS RPR PARAESPHGL HRNA INCL FUNDPLSTY W/O MESH 43282 LAPS RPR PARAESPHGL HRNA INCL FUNDPLSTY W/MESH 43283 LAPS ESOPHAGEAL LENGTHENING ADDL


43289 UNLIS LAPS PX ESOPH 43324 ESOPG/GSTR FUNDOPLASTY 43325 ESOPG/GSTR FUNDOPLASTY W/FUNDIC PATCH 43326 ESOPG/GSTR FUNDOPLASTY W/GASTROPLASTY 43327 ESOPG/GSTR FUNDOPLASTY W/LAPT 43328 ESOPG/GSTR FUNDOPLASTY W/THORCOM 43330 ESOPHAGOMYOTOMY HELLER TYP ABDL APPR 43331 ESOPHAGOMYOTOMY HELLER TYP THRC APPR 43332 RPR PARAESOPH HIATAL HERNIA W/LAPT W/O MESH 43333 LAPT RPR PARAESOPH HIATAL HERNIA W/ MESH 43334 RPR PARAESOPH HIATAL HERNIA W/THORCOM W/O MESH 43335 RPR PARAESOPH HIATAL HERNIA W/THORCOM W/MESH 43336 RPR PARAESOPH HIATAL HERNIA THORCOABDOM W/O MESH 43337 RPR PARAESOPH HIATAL HERNIA THORCOABDOM W/MESH 43338 ESOPHAGUS LENGTHENING 43499 UNLIS PX ESOPH 43644 LAPS GSTR RSTCV PX W/BYP ROUX-EN-Y <150 CM 43645 LAPS GSTR RSTCV PX W/BYP&SM INT RCNSTJ 43647 LAPS IMPLTJ/RPLCMT GASTRIC NSTIM ELTRD ANTRUM 43648 LAPS REVISION/RMVL GASTRIC NSTIM ELTRD ANTRUM 43651 LAPS SURG TRNSXJ VAGUS NRV TRUNCAL 43652 LAPS SURG TRNSXJ VAGUS NRV SLCTV/HILY SLCTV 43653 LAPS SURG GASTROSTOMY W/O CONSTJ GSTR TUBE SPX 43659 UNLIS LAPS PX STOMACH 43770 LAPS GASTRIC RESTRICTIVE PROCEDURE PLACE DEVICE 43771 LAPS GASTRIC RESTRICTIVE PX REVISION DEVICE 43772 LAPS GASTRIC RESTRICTIVE PX REMOVE DEVICE 43773 LAPS GASTRIC RESTRICTIVE PX REMOVE&RPLCMT DEVICE 43774 LAPS GASTRIC RESTRICTIVE PX REMOVE DEVICE &PORT 43775 LAPS GSTRC RSTRICTIV PX LONGITUDINAL GASTRECTOMY 43842 GSTR RSTCV W/O BYP VER-BANDED GSTP 43843 GSTR RSTCV W/O BYP OTH/THN VER-BANDED GSTP 43845 GSTR RSTCV W/PRTL GSTRCT 50-100 CM 43846 GSTR RSTCV W/BYP W/SHORT LIMB 150 CM/< 43847 GSTR RSTCV W/BYP W/SM INT RCNSTJ LIMIT ABSRPJ 43848 REVISION OPEN GASTRIC RESTRICTIVE PX NOT DEVICE 43881 IMPLTJ/RPLCMT GASTRIC NSTIM ELTRD ANTRUM OPEN 43882 REVISION/RMVL GASTRIC NSTIM ELTRD ANTRUM OPEN 43886 GSTR RSTCV PX OPN REVJ SUBQ PORT COMPONENT ONLY 43887 GSTR RSTCV PX OPN RMVL SUBQ PORT COMPONENT ONLY 43888 GSTR RSTCV OPN RMVL&RPLCMT SUBQ PORT 43999 UNLIS PX STOMACH 44100 BX INT CAPSL TUBE PRORAL 1+ SPECS


44132 DON ENTRC OPN FROM CDVR DON 44133 DON ENTRC OPN PRTL FROM LIV DON 44135 INTSTINAL ALTRNSPLJ FROM CDVR DON 44136 INTSTINAL ALTRNSPLJ FROM LIV DON 44137 RMVL TRNSPLED INTSTINAL ALGRFT COMPL 44238 UNLIS LAPS PX INT XCP RECTUM 44715 BKBENCH ALGRFT INT FASHIONING ART&VEIN 44720 BKBENCH RCNSTJ INT ALGRFT VEN ANAST EA 44721 BKBENCH RCNSTJ INT ALGRFT ARTL ANAST EA 44799 UNLIS PX INT 44899 UNLIS PX MECKEL'S DIVERTICULUM AND THE MESENTERY 44979 UNLIS LAPS PX APPENDIX 45499 UNLIS LAPS PX RECTUM 45999 UNLIS PX RECTUM 46999 UNLIS PX ANUS 47133 DON HPTC FROM CDVR DON 47135 LVR ALTRNSPLJ ORTHOTOPIC PRTL/WHL DON ANY AGE 47136 LVR ALTRNSPLJ HTRTPC PRTL/WHL DON ANY AGE 47140 DON HPTC LIV DON L LAT SGM ONLY II&III 47141 DON HPTC LIV DON TOT L LOBEC II III&IV 47142 DON HPTC LIV DON TOT R LOBEC V VI VII&VIII 47143 BKBENCH PREPJ CDVR WHL LVR GRF W/O TRISGM/LOBE 47144 BKBENCH PREPJ CDVR WHL LVR GRF I&IV VIII 47145 BKBENCH PREPJ CDVR DON WHL LVR GRF I&V VIII 47146 BKBENCH RCNSTJ LVR GRF VEN ANAST EA 47147 BKBENCH RCNSTJ LVR GRF ARTL ANAST EA 47370 LAPS SURG ABLTJ 1+ LVR TUM RF 47371 LAPS SURG ABLTJ 1+ LVR TUM CRYOSURG 47379 UNLIS LAPAROSCOPIC PX LVR 47380 ABLTJ OPN 1+ LVR TUM RF 47381 ABLTJ OPN 1+ LVR TUM CRYOSURG 47382 ABLTJ 1+ LVR TUM PRQ RF 47399 UNLIS PX LVR 47579 UNLIS LAPS PX BILIARY TRC 47999 UNLIS PX BILIARY TRC 48160 PNCRTECT TOT/STOT W/TRNSPLJ PNCRS/ISLET 48550 DON PNCRTECT +-DUOL SGM F/TRNSPLJ 48551 BKBENCH PREPJ CDVR PNCRS ALGRFT 48552 BKBENCH RCNSTJ CDVR PNCRS ALGRFT VEN ANAST EA 48554 TRNSPLJ PNCRTC ALGRFT 48556 RMVL TRNSPLED PNCRTC ALGRFT 48999 UNLIS PX PNCRS 49250 UMBILECTOMY OMPHALECTOMY EXC UMBILICUS SPX


49329 UNLIS LAPS PX ABD PRTM&OMENTUM 49659 UNLIS LAPS PX HRNAP HERNIORRHAPHY HERNIOTOMY 49999 UNLIS PX ABD PRTM&OMENTUM 50300 DON NFRCT FROM CDVR DON UNI/BI 50320 DON NFRCT OPN FROM LIV DON 50323 BKBENCH PREPJ CDVR RNL ALGRFT 50325 BKBENCH PREPJ LIV RNL ALGRFT OPN/LAPS 50327 BKBENCH RCNSTJ RNL ALGRFT VEN ANAST EA 50328 BKBENCH RCNSTJ RNL ALGRFT ARTL ANAST EA 50329 BKBENCH RCNSTJ ALGRFT URTRL ANAST EA 50340 RCP NFRCT SPX 50360 RNL ALTRNSPLJ IMPLTJ GRF W/O RCP NFRCT 50365 RNL ALTRNSPLJ IMPLTJ GRF W/RCP NFRCT 50370 RMVL TRNSPLED RNL ALGRFT 50380 RNL AUTOTRNSPLJ RIMPLTJ KDN 50549 UNLIS LAPS PX RNL 50949 UNLIS LAPS PX URTR 51999 UNLIS LAPS PX BLDR 53899 UNLIS PX UR SYS 54110 EXC PEN PLAQUE 54111 EXC PEN PLAQUE GRF 5 CM LENGTH 54112 EXC PEN PLAQUE GRF > 5 CM LENGTH 54150 CIRCUMCISION W/CLAMP/OTH DEV W/BLOCK 54161 CIRCUMCISION >28 DAYS 54163 RPR INCOMPL CIRCUMCISION 54164 FRENULOTOMY PNS 54450 FORESKN MNPJ W/LSS PREPUTIAL ADS&STRETCHING 54600 RDCTJ TORSION TSTIS +-FIXJ CLAT TSTIS 54680 TRNSPLJ TSTIS THI 54699 UNLIS LAPS PX TSTIS 55250 VASECT UNI/BI SPX W/PO SEMEN XM 55450 LIG PRQ VAS DEFERENS UNI/BI SPX 55559 UNLIS LAPS SPRMATIC CORD 55870 ELECTROEJACULATION 55899 UNLIS MALE GEN SYS 55970 INTERSEX SURG MALE FEMALE 55980 INTERSEX SURG FEMALE MALE 56700 PRTL HYMENECTOMY/REVJ HYMENAL RING 56800 PLSTC RPR INTROITUS 56805 CLITOROPLASTY F/INTERSEX STATE 57335 VAGINOPLASTY F/INTERSEX STATE 58150 TAH +-RMVL TUBE +-RMVL OVARY 58152 TAH +-RMVL TUBE OVARY COLPO-URTCSTOPEXY


58180 SUPRACRV ABDL HYST +-RMVL TUBE OVARY 58200 TAH W/PRTL VAGNC PEL LYMPH NODE SAMPLING 58210 RAD ABDL HYST W/BI PEL LMPHADEC 58240 PEL EXNTJ GYNECOLOGIC MAL 58260 VAG HYST 250 GM/< 58262 VAG HYST 250 GM/< W/RMVL TUBE&/OVARY 58263 VAG HYST 250 GM/< W/RMVL TUBE OVARY W/RPR NTRCL 58267 VAG HYST 250 GM/< W/COLPO-URTCSTOPEXY 58270 VAG HYST 250 GM/< W/RPR NTRCL 58275 VAG HYST W/TOT/PRTL VAGNC 58280 VAG HYST W/TOT/PRTL VAGNC W/RPR NTRCL 58285 VAG HYST RAD SCHAUTA 58290 VAG HYST F/UTER > 250 GM 58291 VAG HYST > 250 GM RMVL TUBE&/OVARY 58292 VAG HYST > 250 GM RMVL TUBE&/OVARY W/RPR NTRCL 58293 VAG HYST > 250 GM COLPO-URTCSTOPEXY +-NDSC CTRL 58294 VAG HYST > 250 GM RPR NTRCL 58321 ARTIF INSEMINATION INTRA-CRV 58322 ARTIF INSEMINATION INTRA-UTERINE 58323 SPRM WASHG ARTIF INSEMINATION 58340 CATHJ&INTRO SALINE NFS SHG/HSG 58345 TRANSCRV INTRO FLP TUBE CATH +-HSG 58350 CHROMOTUBATION OVIDUX MATRLS 58400 UTERINE SSP SPX 58410 UTERINE SSP PRESAC SYMPTH 58540 HYSTEROPLASTY RPR UTERINE ANOMAL 58541 LAPS SUPRACRV HYST 250 G/< 58542 LAPS SUPRACRV HYST 250 G/< RMVL TUBE/OVARY 58543 LAPS SUPRACRV HYST >250 G 58544 LAPS SUPRACRV HYST >250 G RMVL TUBE/OVARY 58545 LAPS MYOMECTOMY EXC 1-4 250 GM/< 58546 LAPS MYOMECTOMY EXC 5+ > 250 GRAMS 58548 LAPS W/RAD HYST W/BILAT LMPHADEC RMVL TUBE/OVARY 58550 LAPS W/VAG HYST 250 GM/< 58552 LAPS W/VAG HYST 250 GM/< RMVL TUBE&/OVARY 58553 LAPS W/VAG HYST > 250 GRAMS 58554 LAPS VAG HYST > 250 GM RMVL TUBE&/OVARY 58555 HYSTSC DX SPX 58558 HYSTSC BX ENDOMETRIUM&/POLYPC +-D&C 58559 HYSTSC LSS INTRAUTERINE ADS 58560 HYSTSC DIV/RESCJ INTRAUTERINE SEPTUM 58561 HYSTSC RMVL LEIOMYOMATA 58562 HYSTSC RMVL IMPACTED FB


58563 HYSTSC ENDOMETRIAL ABLTJ 58565 HYSTSC OCCLUSION PLMT PRM 58570 LAPAROSCOPY W TOTAL HYSTERECTOMY UTERUS 250 G/< 58571 LAPS TOTAL HYSTERECTOMY 250 G/< W TUBE/OVARY 58572 LAPAROSCOPY TOTAL HYSTERECTOMY UTERUS>250 G 58573 LAPAROSCOPY TOT HYSTERECTOMY >250 G W TUBE/OVARY 58578 UNLIS LAPS UTER 58579 UNLIS HYSTSC UTER 58600 LIG/TRNSXJ FLP TUBE ABDL/VAG APPR UNI/BI 58605 LIG/TRNSXJ FLP TUBE ABDL/VAG POSTPARTUM SPX 58611 LIG/TRNSXJ FLP TUBE DONE TM C DLVR/SURG 58615 OCCLUSION FLP TUBE DEV VAG/SUPRAPUBIC APPR 58660 LAPS LSS ADS SPX 58661 LAPS RMVL ADNEXAL STRUXS 58662 LAPS FULG/EXC OVARY VISCERA/PRTL SURF 58670 LAPS FULG OVIDUXS 58671 LAPS OCCLUSION OVIDUXS DEV 58672 LAPS FIMBRIOPLASTY 58673 LAPS SALPINGOSTOMY 58679 UNLIS LAPS PX OVIDUX OVARY 58700 SALPINGECTOMY COMPL/PRTL UNI/BI SPX 58720 SALPINGO-OOPHORECTOMY COMPL/PRTL UNI/BI SPX 58740 LSS ADS 58750 TUBOTUBAL ANAST 58752 TUBOUTERINE IMPLTJ 58760 FIMBRIOPLASTY 58770 SALPINGOSTOMY 58920 WEDGE RESCJ/BISCTJ OVARY UNI/BI 58925 OVARIAN CSTC UNI/BI 58940 OOPHORECTOMY PRTL/TOT UNI/BI 58943 OOPHORECTOMY PRTL/TOT UNI/BI OVARIAN MAL 58950 RESCJ PRIM PRTL MAL W/BSO&OMNTC 58951 RESCJ PRIM PRTL MAL W/BSO&OMNTC TAH&LMPHADEC 58952 RESCJ PRIM PRTL MAL W/BSO&OMNTC RAD DEBULKING 58953 BSO W/OMNTC TAH&RAD DSJ DEBULKING 58954 BSO W/OMNTC TAH DEBULKING W/LMPHADEC 58956 BSO TOT OMNTC TAH MAL 58957 RESECTION RECRT MAL W/OMENTECTOMY 58958 RESECTION RECRT MAL W/OMENTECTOMY PEL LMPHADEC 58960 LAPT STG/RESTG OVARIAN TUBAL/PRIM MAL 2ND LOOK 58970 FOLLICLE PNXR OOCYTE RETRIEVAL ANY METH 58974 EMBRYO TR INTRAUTERINE 58976 GAMETE ZYGOTE/EMBRYO INTRAFLP TR ANY METH


58999 UNLIS PX FEMALE GEN SYS 59840 INDUCED AB DILAT&CURTG 59841 INDUCED AB DILAT&EVAC 59850 INDUCED AB 1+ IAM NJXS DLVR FETUS 59851 INDUCED AB 1+ IAM NJXS DLVR FETUS D&C&EVAC 59852 INDUCED AB 1+ IAM NJXS DLVR FETUS HYSTOT 59855 INDUCED AB 1+ VAG SUPP DLVR FETUS 59856 INDUCED AB 1+ VAG SUPP DLVR FETUS D&C&/EVAC 59857 INDUCED AB 1+ VAG SUPP DLVR FETUS HYSTOT 59866 MULTIFTL PREGNANCY RDCTJ 59897 UNLIS FTL INVASIVE W/US GID 59898 UNLIS LAPS MATERNITY CARE&DLVR 59899 UNLIS MATERNITY CARE&DLVR 60659 UNLIS LAPS ENDOC SYS 60699 UNLIS ENDOC SYS 61781 STRTCTC CPTR ASSTD PX IDRL CRNL 61782 STRTCTC CPTR ASSTD PX XDRL CRNL 62280 NJX/NFS NULYT SBST SBST SARACH 62281 NJX/NFS NULYT SBST EDRL CRV/THRC 62282 NJX/NFS NULYT SBST EDRL LMBR SAC 62287 DCMPRN PERQ NUCLEUS PULPOSUS 1/> LEVELS LUMBAR 62292 NJX CHEMONUCLEOLSS DISKOGRAPY 1+ LMBR 62310 NJX C+-DX/THER SBST EDRL/SARACH CRV/THRC 62311 NJX C+-DX/THER SBST EDRL/SARACH LMBR SAC 62318 NJX NFS/BOLUS DX/SBST EDRL/SARACH CRV/THRC 62319 NJX NFS/BOLUS DX/SBST EDRL/SARACH LMBR SAC 62350 IMPLTJ REVJ/RPSG ITHCL/EDRL CATH PMP W/O LAM 62351 IMPLTJ REVJ/RPSG ITHCL/EDRL CATH W/LAM 62360 IMPLTJ/RPLCMT ITHCL/EDRL DRUG NFS SUBQ RSVR 62361 IMPLTJ/RPLCMT ITHCL/EDRL NFS NON-PRGRBL PMP 62362 IMPLTJ/RPLCMT ITHCL/EDRL DRUG NFS PRGRBL PMP 63001 LAM W/O FACETEC FORAMOT/DSKC 1/2 VRT SEG CRV 63003 LAM W/O FFD 1/2 VRT SEG THRC 63005 LAM W/O FFD 1/2 VRT SEG LMBR 63011 LAM W/O FFD 1/2 VRT SEG SAC 63012 LAM W/RMVL ABNORMAL FACETS LMBR 63015 LAM W/O FFD > 2 VRT SEG CRV 63016 LAM W/O FFD > 2 VRT SEG THRC 63017 LAM W/O FFD > 2 VRT SEG LMBR 63020 LAMINOTOMY INCL OPN & NDSC 1 INTERSPACE CERVICAL 63030 LAMINOTOMY INCL OPEN & NDSC 1 INTERSPACE LUMBAR 63035 LAMOT INCL OPEN&NDSC EA ADDL INTERSPACE CRV/LMBR 63040 LAMOT PRTL FFD HRNA8 REEXPL 1 NTRSPC CRV


63042 LAMOT PRTL FFD HRNA8 REEXPL 1 NTRSPC LMBR 63043 LAMOT PRTL FFD HRNA8 REEXPL 1 NTRSPC EA CRV 63044 LAMOT W/PRTL FFD HRNA8 REEXPL 1 NTRSPC EA LMBR 63045 LAM FACETEC&FORAMOT 1 SGM CRV 63046 LAM FACETEC&FORAMOT 1 SGM THRC 63047 LAM FACETEC&FORAMOT 1 SGM LMBR 63048 LAM FACETEC&FORAMOT 1 SGM EA CRV THRC/LMBR 63050 LAMOP CRV W/DCMPRN SPI CORD 2/MORE VRT SEG 63051 LAMOP CRV DCMPRN SPI CORD 2+ SEG RCNSTJ B1 63055 TRANSPEDICULAR DCMPRN SPI CORD 1 SGM THRC 63056 TRANSPEDICULAR DCMPRN SPI CORD 1 SGM LMBR 63057 TRANSPEDICULAR DCMPRN 1 SGM EA THRC/LMBR 63064 COSTOVRT DCMPRN THRC 1 SGM 63066 COSTOVRT DCMPRN THRC EA SGM 63075 DSKC ANT DCMPRN CRV 1 NTRSPC 63076 DSKC ANT DCMPRN CRV EA NTRSPC 63077 DSKC ANT DCMPRN THRC 1 NTRSPC 63078 DSKC ANT DCMPRN THRC EA NTRSPC 63081 VCRPEC ANT DCMPRN CRV 1 SGM 63082 VCRPEC ANT DCMPRN CRV EA SGM 63085 VCRPEC TTHRC DCMPRN THRC 1 SGM 63086 VCRPEC TTHRC DCMPRN THRC EA SGM 63087 VCRPEC THORACOLMBR DCMPRN LWR THRC/LMBR 1 SGM 63088 VCRPEC THORACOLMBR DCMPRN LWR THRC/LMBR EA SGM 63090 VCRPEC TRANSPRTL/RPR DCMPRN THRC LMBR/SAC 1 SGM 63091 VCRPEC TRANSPRTL/RPR DCMPRN THRC LMBR/SAC EA SGM 63101 VCRPEC LAT XTRCAVITARY DCMPRN THRC 1 SGM 63102 VCRPEC LAT XTRCAVITARY DCMPRN LMBR 1 SGM 63103 VCRPEC LAT XTRCAVITARY DCMPRN THRC/LMBR EA SGM 63170 LAM W/MYELOTOMY CRV THRC/THORACOLMBR 63172 LAM W/DRG IMED CST/SYRINX SARACH SPACE 63173 LAM W/DRG IMED CST/SYRINX PRTL/PLEURAL SPACE 63180 LAM&SCTJ DENTATE LIGMS CRV 1/2 SEG 63182 LAM&SCTJ DENTATE LIGMS CRV > 2 SEG 63185 LAM W/RHIZOTOMY 1/2 SEG 63190 LAM W/RHIZOTOMY > 2 SEG 63191 LAM W/SCTJ SPI ACCESSORY NRV 63194 LAM CORDOTOMY SCTJ 1 TRC 1 STG CRV 63195 LAM CORDOTOMY SCTJ 1 TRC 1 STG THRC 63196 LAM CORDOTOMY SCTJ BTH TRCS 1 STG CRV 63197 LAM CORDOTOMY SCTJ BTH TRCS 1 STG THRC 63198 LAM CORDOTOMY SCTJ BTH TRCS 2 STGS CRV 63199 LAM CORDOTOMY SCTJ BTH TRCS 2 STGS THRC


63200 LAM RLS TETHERED SPI CORD LMBR 63250 LAM EXC/OCCLUSION AVM SPI CORD CRV 63251 LAM EXC/OCCLUSION AVM SPI CORD THRC 63252 LAM EXC/OCCLUSION AVM SPI CORD THORACOLMBR 63265 LAM EXC/EVAC ISPI LES OTH/THN NEO XDRL CRV 63266 LAM EXC/EVAC ISPI LES OTH/THN NEO XDRL THRC 63267 LAM EXC/EVAC ISPI LES OTH/THN NEO XDRL LMBR 63268 LAM EXC/EVAC ISPI LES OTH/THN NEO XDRL SAC 63270 LAM EXC ISPI LES OTH/THN NEO IDRL CRV 63271 LAM EXC ISPI LES OTH/THN NEO IDRL THRC 63272 LAM EXC ISPI LES OTH/THN NEO IDRL LMBR 63273 LAM EXC ISPI LES OTH/THN NEO IDRL SAC 63275 LAM BX/EXC ISPI NEO XDRL CRV 63276 LAM BX/EXC ISPI NEO XDRL THRC 63277 LAM BX/EXC ISPI NEO XDRL LMBR 63278 LAM BX/EXC ISPI NEO XDRL SAC 63280 LAM BX/EXC ISPI NEO IDRL XMED CRV 63281 LAM BX/EXC ISPI NEO IDRL XMED THRC 63282 LAM BX/EXC ISPI NEO IDRL XMED LMBR 63283 LAM BX/EXC ISPI NEO IDRL SAC 63285 LAM BX/EXC ISPI NEO IDRL IMED CRV 63286 LAM BX/EXC ISPI NEO IDRL IMED THRC 63287 LAM BX/EXC ISPI NEO IDRL IMED THORACOLMBR 63290 LAM BX/EXC ISPI NEO XDRL-IDRL LES ANY LVL 63295 OSTPL RCNSTJ DORSAL SPI ELMNTS FLWG ISPI PX 63300 VCRPEC LES 1 SGM XDRL CRV 63301 VCRPEC LES 1 SGM XDRL THRC TTHRC 63302 VCRPEC LES 1 SGM XDRL THRC THORACOLMBR 63303 VCRPEC LES 1 SGM XDRL LMBR/SAC TRANSPRTL/RPR 63304 VCRPEC LES 1 SGM IDRL CRV 63305 VCRPEC LES 1 SGM IDRL THRC TTHRC 63306 VCRPEC LES 1 SGM IDRL THRC THORACOLMBR 63307 VCRPEC LES 1 SGM IDRL LMBR/SAC TRANSPRTL/RPR 63308 VCRPEC LES 1 SGM EA SGM 63650 PRQ IMPLTJ NSTIM ELTRD RA EDRL 63655 LAM IMPLTJ NSTIM ELTRDS PLATE/PADDLE EDRL 63661 RMVL SPINAL NSTIM ELTRD PRQ ARRAY INCL FLUOR 63662 RMVL SPINAL NSTIM ELTRD PLATE/PADDLE INCL FLUOR 63663 REVJ INCL RPLCMT NSTIM ELTRD PRQ RA INCL FLUOR 63664 REVJ INCL RPLCMT NSTIM ELTRD PLT/PDLE INCL FLUOR 63685 INSJ/RPLCMT SPI NPGR DIR/INDUXIVE COUPLING 63688 REVJ/RMVL IMPLTED SPI NPGR 64448 INJECTION ANES FEMORAL NERVE CONT INFUSION CATH


64449 INJECTION ANES LUMBAR PLEXUS POST CONT NFS CATH 64450 NJX ANES OTH PRPH NRV/BRANCH 64455 NJX ANES&/STEROID PLANTAR COMMON DIGITAL NERVE 64479 NJX ANES&/STRD TFRML EDRL CRV/THRC 1 LVL 64480 NJX ANES&/STRD TFRML EDRL CRV/THRC EA LVL 64483 NJX ANES&/STRD TFRML EDRL LMBR/SAC 1 LVL 64484 NJX ANES&/STRD TFRML EDRL LMBR/SAC EA LVL 64490 NJX DX/THER AGT PVRT FACET JT CRV/THRC 1 LEVEL 64491 NJX DX/THER AGT PVRT FACET JT CRV/THRC 2ND LEVEL 64492 NJX DX/THER AGT PVRT FACET JT CRV/THRC 3+ LEVEL 64493 NJX DX/THER AGT PVRT FACET JT LMBR/SAC 1 LEVEL 64494 NJX DX/THER AGT PVRT FACET JT LMBR/SAC 2ND LEVEL 64495 NJX DX/THER AGT PVRT FACET JT LMBR/SAC 3+ LEVEL 64505 NJX ANES SPHENOPALATINE GANGLION 64508 NJX ANES CRTD SINUS SPX 64510 NJX ANES STELLATE GANGLION CRV SYMPATHETIC 64517 NJX ANES SUPRIOR HYPOGSTR PLEXUS 64520 NJX ANES LMBR/THRC PVRT SYMPATHETIC 64530 NJX ANES CELIAC PLEXUS +-RAD MNTR 64550 APPL SURF TC NSTIM 64553 PRQ IMPLTJ NSTIM ELTRDS CRNL NRV 64555 PRQ IMPLTJ NSTIM ELTRDS PRPH NRV 64560 PRQ IMPLTJ NSTIM ELTRDS AUTONOMIC NRV 64561 PRQ IMPLTJ NSTIM ELTRDS SAC NRV 64565 PRQ IMPLTJ NSTIM ELTRDS NEUROMUSCULAR 64566 POST TIB NEUROSTIMULATION PRQ NEEDLE ELECTRODE 64568 INC IMPLTJ CRNL NRV NSTIM ELTRDS & PULSE GENER 64573 INC IMPLTJ NSTIM ELTRDS CRNL NRV 64575 INC IMPLTJ NSTIM ELTRDS PRPH NRV 64577 INC IMPLTJ NSTIM ELTRDS AUTONOMIC NRV 64580 INC IMPLTJ NSTIM ELTRDS NEUROMUSCULAR 64581 INC IMPLTJ NSTIM ELTRDS SAC NRV 64585 REVJ/RMVL PRPH NSTIM ELTRDS 64590 INSERTION/RPLCMT PERIPHERAL/GASTRIC NPGR 64595 REVISION/RMVL PERIPHERAL/GASTRIC NPGR 64600 DSTRJ TRIGEMINAL NRV SUPRAORB INFRAORB BRANCH 64605 DSTRJ NULYT TRIGEMINAL NRV 2/3 DIV 64610 DSTRJ NULYT TRIGEMINAL NRV 2/3 DIV RAD MNTR 64611 CHEMODENERV PAROTID&SUBMANDIBL SALIVARY GLNDS BI 64612 CHEMODNRVTJ MUSC MUSC INNERVATED FACIAL NRV 64613 CHEMODNRVTJ MUSC NCK MUSC 64614 CHEMODNRVTJ MUSC XTR&/TRNK MUSC 64620 DSTRJ NULYT INTERCOSTAL NRV


64622 DSTRJ NULYT PVRT FACET JT NRV LMBR/SAC 1 LVL 64623 DSTRJ NULYT PVRT FACET JT NRV LMBR/SAC EA LVL 64626 DSTRJ NULYT PVRT FACET JT NRV CRV/THRC 1 LVL 64627 DSTRJ NULYT PVRT FACET JT NRV CRV/THRC EA LVL 64630 DSTRJ NULYT PUDENDAL NRV 64632 DSTRJ NEUROLYTIC PLANTAR COMMON DIGITAL NERVE 64633 DSTR NROLYTC AGNT PARVERTEB FCT SNGL CRVCL/THORA 64634 DSTR NROLYTC AGNT PARVERTEB FCT ADDL CRVCL/THORA 64635 DSTR NROLYTC AGNT PARVERTEB FCT SNGL LMBR/SACRAL 64636 DSTR NROLYTC AGNT PARVERTEB FCT ADDL LMBR/SACRAL 64640 DSTRJ NULYT OTH PRPH NRV/BRANCH 64650 CHEMODNRVTJ ECCRINE GLNDS BTH AX 64653 CHEMODNRVTJ ECCRINE GLNDS OTH AREA PR D 64680 DSTRJ NULYT +-RAD MNTR CELIAC PLEXUS 64681 DSTRJ NULYT +-RAD MNTR SUPRIOR HYPOGSTR PLEXUS 64702 NEURP DGTAL 1/BTH SM DGT 64704 NEURP NRV HAND/FOOT 64708 NEURP MAJOR PRPH NRV ARM/LEG OTH/THN SPECIFIED 64712 NEURP MAJOR PRPH NRV ARM/LEG SCIATIC NRV 64713 NEURP MAJOR PRPH NRV ARM/LEG BRACH PLEXUS 64714 NEURP MAJOR PRPH NRV ARM/LEG LMBR PLEXUS 64716 NEURP&/TRPOS CRNL NRV 64718 NEURP&/TRPOS UR NRV ELBW 64719 NEURP&/TRPOS UR NRV WRST 64721 NEURP&/TRPOS MEDIAN NRV CARPL TUNNEL 64722 DCMPRN UNSPECIFIED NRV 64726 DCMPRN PLNTAR DGTAL NRV 64727 INT NEUROLSS REQ MCRSCP 64732 TRNSXJ/AVLSN SUPRAORB NRV 64734 TRNSXJ/AVLSN INFRAORB NRV 64736 TRNSXJ/AVLSN MENTAL NRV 64738 TRNSXJ/AVLSN INF ALVEOLAR NRV OSTEOM 64740 TRNSXJ/AVLSN LNGL NRV 64742 TRNSXJ/AVLSN FACIAL NRV DIFFIAL/COMPL 64744 TRNSXJ/AVLSN GRTER OCCIPITAL NRV 64746 TRNSXJ/AVLSN PHRENIC NRV 64752 TRNSXJ/AVLSN VAGUS NRV TTHRC 64755 TRNSXJ/AVLSN VAGUS NRV PROX STOMACH 64760 TRNSXJ/AVLSN VAGUS NRV ABDL 64761 TRNSXJ/AVLSN PUDENDAL NRV 64763 TRNSXJ/AVLSN OBTURATOR NRV XTRPEL 64766 TRNSXJ/AVLSN OBTURATOR NRV INTRAPEL 64771 TRNSXJ/AVLSN OTH CRNL NRV XDRL


64772 TRNSXJ/AVLSN OTH SPI NRV XDRL 64784 EXC NEUROMA MAJOR PRPH NRV XCP SCIATIC 64786 EXC NEUROMA SCIATIC NRV 64787 IMPLTJ NRV END IN B1/MUSC 64788 EXC NEUROFIBROMA/NEUROLEMMOMA CUTAN NRV 64790 EXC NEUROFIBROMA/NEUROLEMMOMA MAJOR PRPH NRV 64802 SYMPTH CRV 64804 SYMPTH CERVICOTHRC 64809 SYMPTH THORACOLMBR 64818 SYMPTH LMBR 64820 SYMPTH DGTAL ARTS EA DGT 64821 SYMPTH RDL ART 64822 SYMPTH UR ART 64823 SYMPTH SUPFC PLMR ARCH 64999 UNLIS PX NRVS SYS 65125 MODIFICAJ OC IMPLT W/PLMT/RPLCMT PEGS SPX 65150 RINSJ OC IMPLT +-CJNCL GRF 65155 RINSJ OC IMPLT RNFCMT&/ATTACHMENT MUSC 65175 RMVL OC IMPLT 65400 EXC LES CRN XCP PTERYGIUM 65710 KERATOPLASTY ANTERIOR LAMELLAR 65730 KERATOPLASTY PENTRG EXCEPT APHAKIA/PSEUDOPHAKIA 65750 KERATOPLASTY PENTRG APHK 65755 KERATOPLASTY PENTRG PSEUDOPHAKIA 65756 KERATOPLASTY ENDOTHELIAL 65757 BACKBENCH PREPJ CORNEAL ENDOTHELIAL ALLOGRAFT 65760 KERATOMILEUSIS 65765 KERATOPHAKIA 65767 EPIKERATOPLASTY 65770 KERATOPROSTH 65771 RDL KERATOTOMY 65772 CRNL RELAXING INC CORRJ INDUCED ASTIGMATISM 65775 CRNL WEDGE RESCJ CORRJ INDUCED ASTIGMATISM 65778 PLACE AMNIOTIC MEMB OCULAR SURFACE SELF RETAIN 65779 PLACE AMNIOTIC MEMBRANE OCULAR SURFACE SUTURED 65780 OC SURF RCNSTJ AMNIOTIC MEMB TRNSPLJ 65781 OC SURF RCNSTJ LIMBAL STEM CELL ALGRFT 65782 OC SURF RCNSTJ LIMBAL CJNCL AGRFT 66999 UNLIS ANT SGM EYE 67299 UNLIS POST SGM 67311 STRABISMUS RECESSION/RESCJ 1 HRZNTL MUSC 67312 STRABISMUS RECESSION/RESCJ 2 HRZNTL MUSC 67314 STRABISMUS RECESSION/RESCJ 1 VER MUSC


67316 STRABISMUS RECESSION/RESCJ 2/MORE VER MUSC 67318 STRABISMUS ANY SUPRIOR OBLQ MUSC 67320 TRPOS ANY EO MUSC 67331 STRABISMUS PREVIOUS EYE X INVOLVE EO MUSC 67332 STRABISMUS SCARRING EO MUSC/RSTCV MYOPATHY 67334 STRABISMUS POST FIXJ SUTR TQ +-MUSC RECESSION 67335 PLMT ADJUSTABLE SUTR STRABISMUS 67340 STRABISMUS EXPL&/RPR DETACHED EO MUSC 67343 RLS X10SV SCAR TISS W/O DETACHING EO MUSC SPX 67345 CHEMODNRVTJ EO MUSC 67399 UNLIS OC MUSC 67550 ORB IMPLT INSJ 67560 ORB IMPLT RMVL/REVJ 67599 UNLIS ORBIT 67840 EXC LES EYELID W/O CLSR/W/SMPL DIR CLSR 67850 DSTRJ LES LID MRGN <1 CM 67900 RPR BROW PTOSIS 67901 RPR BLPOS FRNTIS MUSC SUTR/OTH MATRL 67902 RPR BLPOS FRNTIS MUSC AUTOL FSCAL SLING 67903 RPR BLPOS LEVATOR RESCJ/ADVMNT INT 67904 RPR BLPOS LEVATOR RESCJ/ADVMNT XTRNL 67906 RPR BLPOS SUPRIOR RECTUS FSCAL SLING 67908 RPR BLPOS CONJUNCTIVO-TARSO-MUSC-LEVATOR RESCJ 67909 RDCTJ >CORRJ PTOSIS 67911 CORRJ LID RETRCJ 67912 CORRJ LAGOPHTHALMOS IMPLTJ UPR EYELID LID LOAD 67914 RPR ECTROPION SUTR 67915 RPR ECTROPION THERMOCAUT 67916 RPR ECTROPION EXC TARSAL WEDGE 67917 RPR ECTROPION X10SV 67950 CANTHOPLASTY 67961 EXC&RPR EYELID < ONE-4TH LID MRGN 67966 EXC&RPR EYELID > ONE-4TH LID MRGN 67971 RCNSTJ EYELID FULL THKNS < 2-3RD 1 STG 67973 RCNSTJ EYELID FULL THKNS TOT LWR 1 STG 67974 RCNSTJ EYELID FULL THKNS TOT UPR 1 STG 67975 RCNSTJ EYELID FULL THKNS 2ND STG 67999 UNLIS EYELIDS 68399 UNLIS CJNC 68899 UNLIS LACRIMAL SYS 69090 EAR PIERCING 69300 OTOPLASTY PROTRUDING EAR +-SIZE RDCTJ 69399 UNLIS XTRNL EAR


69710 IMPLTJ/RPLCMT EMGNT B1 CNDJ DEV TEMPORAL B1 69714 IMPLTJ OI IMPLT B1 W/O MSTDC 69715 IMPLTJ OI IMPLT B1 MSTDC 69717 RPLCMT OI IMPLT B1 W/O MSTDC 69718 RPLCMT OI IMPLT B1 MSTDC 69799 UNLIS MIDDLE EAR 69949 UNLIS INNER EAR 69979 UNLIS TEMPORAL B1 MIDDLE FOSSA 70336 MRI TMPRMAND JT 70540 MRI ORBIT FACE &/NECK W/O CONTRAST 70542 MRI ORBIT FACE&NCK C+ MATRL 70543 MRI ORBIT FACE&NCK C-/C+ 70544 MRA HEAD C-MATRL 70545 MRA HEAD C+ MATRL 70546 MRA HEAD C-/C+ 70547 MRA NCK C-MATRL 70548 MRA NCK C+ MATRL 70549 MRA NCK C-/C+ 70551 MRI BRN BRN STEM C-MATRL 70552 MRI BRN BRN STEM C+ MATRL 70553 MRI BRN BRN STEM C-/C+ 70554 MRI BRAIN FUNCTIONAL W/O PHYSICIAN ADMNISTRATION 70555 MRI BRAIN FUNCTIONAL W/PHYSICIAN ADMNISTRATION 70557 MRI BRN OPN ICRA PX C-MATRL 70558 MRI BRN OPN ICRA PX C+ MATRL 70559 MRI BRN OPN ICRA PX C-/C+ 71550 MRI CH C-MATRL 71551 MRI CH C+ MATRL 71552 MRI CH C-/C+ 71555 MRA CH C+-MATRL 72141 MRI SPI CANAL&CNTS CRV C-MATRL 72142 MRI SPI CANAL&CNTS CRV C+ MATRL 72146 MRI SPI CANAL&CNTS THRC C-MATRL 72147 MRI SPI CANAL&CNTS THRC C+ MATRL 72148 MRI SPI CANAL&CNTS LMBR C-MATRL 72149 MRI SPI CANAL&CNTS LMBR C+ MATRL 72156 MRI SPI CANAL&CNTS C-/C+ CRV 72157 MRI SPI CANAL&CNTS C-/C+ 72158 MRI SPI CANAL&CNTS C-/C+ LMBR 72159 MRA SPI CANAL&CNTS C+-MATRL 72195 MRI PELVIS C-MATRL 72196 MRI PELVIS C+ MATRL 72197 MRI PELVIS C-/C+


72198 MRA PELVIS C+-MATRL 73218 MRI UXTR OTH/THN JT C-MATRL 73219 MRI UXTR OTH/THN JT C+ MATRL 73220 MRI UXTR OTH/THN JT C-/C+ 73221 MRI ANY JT UXTR C-MATRL 73222 MRI ANY JT UXTR C+ MATRL 73223 MRI ANY JT UXTR C-/C+ 73225 MRA UXTR C+-MATRL 73718 MRI LXTR OTH/THN JT C-MATRL 73719 MRI IMG LXTR OTH/THN JT C+ MATRL 73720 MRI LXTR OTH/THN JT C-/C+ 73721 MRI ANY JT LXTR C-MATRL 73722 MRI ANY JT LXTR C+ MATRL 73723 MRI ANY JT LXTR C-/C+ 73725 MRA LXTR C+-MATRL 74181 MRI ABD C-MATRL 74182 MRI ABD C+ MATRL 74183 MRI ABD C-/C+ 74185 MRA ABD C+-MATRL 75557 CARDIAC MRI MORPHOLOGY & FUNCTION W/O CONTRAST 75559 CARDIAC MRI W/O CONTRAST W STRESS IMAGING 75561 CARDIAC MRI W/W/O CONTRAST & FURTHER SEQ 75563 CARDIAC MRI W/W/O CONTRAST W STRESS 75565 CARDIAC MRI FOR VELOCITY FLOW MAPPING 75600 AORTOGRAPY THRC W/O SRLOGRAPY RS&I 75605 AORTOGRAPY THRC SRLOGRAPY RS&I 75625 AORTOGRAPY ABDL SRLOGRAPY RS&I 75630 AORTOGRAPY ABDL BI ILIOFEM LXTR CATH RS&I 75635 CTA AA&BI ILIOFEM LXTR RS&I C-/C+ POST-PXESSING 75650 ANGRPH CERVICOCERE CATH W/VSL ORIGIN RS&I 75658 ANGRPH BRACH RTRGR RS&I 75660 ANGRPH XTRNL CRTD UNI SLCTV RS&I 75662 ANGRPH XTRNL CRTD BI SLCTV RS&I 75665 ANGRPH CRTD CERE UNI RS&I 75671 ANGRPH CRTD CERE BI RS&I 75676 ANGRPH CRTD CRV UNI RS&I 75680 ANGRPH CRTD CRV BI RS&I 75685 ANGRPH VRT CRV&/ICRA RS&I 75705 ANGRPH SPI SLCTV RS&I 75710 ANGRPH XTR UNI RS&I 75716 ANGRPH XTR BI RS&I 75722 ANGRPH RNL UNI SLCTV W/FLUSH AORTOGRAM RS&I 75724 ANGRPH RNL BI SLCTV W/FLUSH AORTOGRAM RS&I


75726 ANGRPH VISC SLCTV/SUPRASLCTV RS&I 75731 ANGRPH ADRNL UNI SLCTV RS&I 75733 ANGRPH ADRNL BI SLCTV RS&I 75736 ANGRPH PEL SLCTV/SUPRASLCTV RS&I 75741 ANGRPH PULM UNI SLCTV RS&I 75743 ANGRPH PULM BI SLCTV RS&I 75746 ANGRPH PULM NONSLCTV CATH/VEN NJX RS&I 75756 ANGRPH INT MAM RS&I 75774 ANGRPH SLCTV EA VSL STUDIED AFTER BASIC XM RS&I 76390 MRI SPECTROSCOPY 76496 UNLIS FLUOR PX 76497 UNLIS CT PX 76498 UNLIS MRI PX 76499 UNLIS DX RADIOGRAPIC PX 76999 UNLIS US PX 77021 MR GUIDANCE NEEDLE PLACEMENT 77022 MR GUIDANCE &MONITORING TISSUE ABLATION 77058 MRI BREAST UNILATERAL 77059 MRI BREAST BILATERAL 77084 BONE MARROW BLOOD SUPPLY 77299 UNLIS PX THER RAD CLINICAL TX PLNNING 77371 RADIATION DELIVERY STEREOTACTIC CRANIAL COBALT 77372 RADIATION DELIVERY STEREOTACTIC CRANIAL LINEAR 77373 STEREOTACTIC BODY RADIATION DELIVERY 77399 UNLIS MEDICAL RADJ DOSIM TX DEV SPEC SVCS 77432 STERETCTC RADIATION TX MANAGEMENT CRANIAL LESION 77435 STEREOTACTIC BODY RADIATION MANAGEMENT 77499 UNLIS THER RAD TX MGMT 77799 UNLIS CLINICAL BRACHYTX 78099 UNLIS ENDOC PX DX NUC MED 78199 UNLIS HEMATOP RET/ENDO&LYMPHATIC DX NUC MED 78299 UNLIS GI PX DX NUC MED 78399 UNLIS MUSCSKEL PX DX NUC MED 78459 MYOCRD IMG P+ EMIJ TOMOG METAB EVAL 78491 MYOCRD IMG P+ EMIJ TOMOG PRFUJ 1 STD 78492 MYOCRD IMG P+ EMIJ TOMOG PRFUJ MLT STD 78499 UNLIS CV DX NUC MED 78599 UNLIS RESPIR PX DX NUC MED 78608 BRN IMG P+ EMIJ TOMOG METAB EVAL 78609 BRN IMG P+ EMIJ TOMOG PRFUJ EVAL 78699 UNLIS NRVS SYS PX DX NUC MED 78799 UNLIS GENITOUR DX NUC MED 78811 PET IMAGING LIMITED AREA CHEST HEAD/NECK


78812 PET IMAGING SKULL BASE TO MID-THIGH 78813 PET IMAGING WHOLE BODY 78814 PET IMAGING CT FOR ATTENUATION LIMITED AREA 78815 PET IMAGING CT ATTENUATION SKULL BASE MID-THIGH 78816 PET IMAGING FOR CT ATTENUATION WHOLE BODY 78999 UNLIS MISC DX NUC MED 79999 RP THER UNLIS PX 81099 UNLIS URNLS 81211 BRCA1&BRCA2 FULL SEQ ANALYS/COMM DUP/DEL BRCA1 81212 BRCA1&BRCA2 ANAL 185DELAG5385INSC/6174DELT 81213 BRCA1&BRCA2 ANAL UNCOMMON DUP/DEL VARIANTS 81214 BRCA1 FULL SEQ ANAL&COMMON DUP/DEL VARIANTS 81215 BRCA1 GENE ANALYSIS KNOWN FAMILIAL VARIANT 81216 BRCA2 GENE ANALYSIS FULL SEQUENCE ANALYSIS 81217 BRCA2 GENE ANALYSIS KNOWN FAMILIAL VARIANT 81220 CFTR GENE ANALYSIS COMMON VARIANTS 81221 CFTR GENE ANALYSIS KNOWN FAMILIAL VARIANTS 81222 CFTR GENE ANALYSIS DUPLICATION/DELETION VARIANTS 81223 CFTR GENE ANALYSIS FULL GENE SEQUENCE 81224 CFTR GENE ANALYSIS INTRON 8 POLY-T ANALYSIS 81225 CYP2C19 GENE ANALYSIS COMMON VARIANT 81226 CYP2D6 GENE ANALYSIS COMMON VARIANTS 81227 CYP2C9 GENE ANALYSIS COMMON VARIANTS 81228 CYTOGENOM CONST MICROARRAY COPY NUMBER VARIANTS 81229 CYTOGENOM CONST MICROARRAY COPY NUMBER&SNP VAR 81240 F2 GENE ANALYSIS 20210G >A VARIANT 81241 F5 COAGULATION FACTOR V ANAL LEIDEN VARIANT 81242 FANCC GENE ANALYSIS COMMON VARIANT 81243 FMR1 ANALYSIS EVAL TO DETECT ABNORMAL ALLELE 81244 FMR1 GENE ANALYSIS CHARACTERIZATION OF ALLELES 81245 FLT3 GENE ANALYSIS INTERNAL TANDEM DUP VARIANTS 81250 G6PC GENE ANALYSIS COMMON VARIANTS 81251 GBA GLUCOSIDASE/BETA/ACID ANAL COMM VARIANTS 81255 HEXA GENE ANALYSIS COMMON VARIANTS 81256 HFE HEMOCHROMATOSIS GENE ANAL COMMON VARIANTS 81257 HBA1/HBA2 ANALYSIS FOR COMMON DELETIONS/VARIANT 81260 IKBKAP GENE ANALYSIS COMMON VARIANTS 81261 IGH@ REARRANGE ABNORMAL CLONAL POP AMPLIFIED 81262 IGH@ REARRANGE ABNORMAL CLONAL POP DIRECT PROBE 81263 IGH@ VARIABLE REGION SOMATIC MUTATION ANALYSIS 81264 IGK@ GENE REARRANGE DETECT ABNORMAL CLONAL POP 81265 COMPARATIVE ANAL STR MARKERS PATIENT&COMP SPEC 81266 COMPARATIVE ANAL STR MARKERS EA ADDL SPECIMEN


81267 CHIMERISM W/COMP TO BASELINE W/O CELL SELECTION 81268 CHIMERISM W/COMP TO BASELINE W/CELL SELECTION EA 81270 JAK2 GENE ANALYSIS P.VAL617PHE VARIANT 81275 KRAS GENE ANALYSIS VARIANTS IN CODONS 12 AND 13 81280 LONG QT SYNDROME FULL SEQUENCE ANALYSIS 81281 LONG QT SYNDROME ANAL KNOWN FAMILIAL SEQUENCE 81282 LONG QT SYNDROME GENE ANAL DUP/DEL VARIANTS 81290 MCOLN1 MUCOLIPIN1 GENE ANALYSIS COMMON VARIANTS 81291 MTHFR GENE ANALYSIS COMMON VARIANTS 81292 MLH1 GENE ANALYSIS FULL SEQUENCE ANALYSIS 81293 MLH1 GENE ANALYSIS KNOWN FAMILIAL VARIANTS 81294 MLH1 GENE ANALYSIS DUPLICATION/DELETION VARIANTS 81295 MSH2 GENE ANALYSIS FULL SEQUENCE ANALYSIS 81296 MSH2 GENE ANALYSIS KNOWN FAMILIAL VARIANTS 81297 MSH2 GENE ANALYSIS DUPLICATION/DELETION VARIANTS 81298 MSH6 GENE ANALYSIS FULL SEQUENCE ANALYSIS 81299 MSH6 GENE ANALYSIS KNOWN FAMILIAL VARIANTS 81300 MSH6 GENE ANALYSIS DUPLICATION/DELETION VARIA 81301 MICROSATELLITE INSTAB ANAL MISMATCH REPAIR DEF 81302 MECP2 GENE ANALYSIS FULL SEQUENCE 81303 MECP2 GENE ANALYSIS KNOWN FAMILIAL VARIANT 81304 MECP2 GENE ANALYSIS DUPLICATION/DELETION VARIANT 81310 NPM1 NUCLEOPHOSMIN GENE ANAL EXON 12 VARIANTS 81315 PML/RARALPHA COMMON BREAKPOINTS QUAL/QUANT 81316 PML/RARALPHA SINGLE BREAKPOINT QUAL/QUA 81317 PMS2 GENE ANALYSIS FULL SEQUENCE 81318 PMS2 GENE ANALYSIS KNOWN FAMILIAL VARIANTS 81319 PMS2 GENE ANALYSIS DUPLICATION/DELETION VARIANTS 81330 SMPD1 GENE ANALYSIS COMMON VARIANTS 81331 SNRPN/UBE3A METHYLATION ANALYSIS 81332 SERPINA1 GENE ANALYSIS COMMON VARIANTS 81340 TRB@ REARRANGEMENT ANAL AMPLIFICATION METHOD 81341 TRB@ REARRANGEMENT ANAL DIRECT PROBE METHODOLOGY 81342 TRG@ GENE REARRANGEMENT ANALYSIS 81350 UGT1A1 GENE ANALYSIS COMMON VARIANTS 81355 VKORC1 GENE ANALYSIS COMMON VARIANTS 81400 MOLECULAR PATHOLOGY PROCEDURE LEVEL 1 81401 MOLECULAR PATHOLOGY PROCEDURE LEVEL 2 81402 MOLECULAR PATHOLOGY PROCEDURE LEVEL 3 81403 MOLECULAR PATHOLOGY PROCEDURE LEVEL 4 81404 MOLECULAR PATHOLOGY PROCEDURE LEVEL 5 81405 MOLECULAR PATHOLOGY PROCEDURE LEVEL 6 81406 MOLECULAR PATHOLOGY PROCEDURE LEVEL 7


81407 MOLECULAR PATHOLOGY PROCEDURE LEVEL 8 81408 MOLECULAR PATHOLOGY PROCEDURE LEVEL 9 84999 UNLIS CHEMISTRY 85999 UNLIS HEMATOLOGY&COAGJ 86486 SKIN TEST UNLISTED ANTIGEN EACH 86849 UNLIS IMMUNOLOGY 86999 UNLIS TRANSFUSION MED 87999 UNLIS MICROBIOLOGY 88099 UNLIS NECROPSY 88199 UNLIS CYTP 88245 CHRMSM BRKG BASELINE SISTER 20-25 CLL 88248 CHRMSM BRKG BASELINE BRKG 50-100 CLL 88249 CHRMSM BRKG SYNDS SCORE 100 CLL 88261 CHRMSM CNT 5 CLL 1KARYOTYP BANDING 88262 CHRMSM CNT 15-20 CLL 2KARYOTYP BANDING 88263 CHRMSM CNT 45 CLL MOSAICISM 2KARYOTYP 88264 CHRMSM ANALYZE 20-25 CELLS 88267 CHRMSM ALYS AMNIOTIC/VILLUS 15 CLL 1KARYOTYP 88269 CHRMSM SITU AMNIOTIC CLL 6-12 COLONIES 1KARYOTYP 88271 MOLEC CYTOGENETICS DNA PRB EA 88272 MOLEC CYTG CHRMOML ISH 3-5 CLL 88273 MOLEC CYTG CHRMOML ISH 10-30 CLL 88274 MOLEC CYTG INTERPHASE ISH 25-99 CLL 88275 MOLEC CYTG INTERPHASE ISH ANALYZE 100-300 CLL 88280 CHRMSM ALYS ADDL KARYOTYP EA STD 88283 CHRMSM ALYS ADDL SPECIZED BANDING 88285 CHRMSM ALYS ADDL CELLS CNTED EA STD 88289 CHRMSM ALYS ADDL HR STD 88291 CYTOGENETICS&MOLEC CYTOGENETICS I&R 88299 UNLIS CYTOGENETIC STD 88363 EXAM & SELECT ARCHIVE TISSUE MOLECULAR ANALYSIS 88399 UNLIS SURG PATH PX 88749 UNLISTED IN VIVO LAB SERVICE 89240 UNLIS MISC PATH 89250 CUL OOCYTE/EMBRYO < 4 D 89251 CUL OOCYTE/EMBRYO < 4 D CO-CULT OCYTE/EMBRY 89253 ASSTD EMBRYO HATCHING MICROTQS ANY METH 89254 OOCYTE ID FROM FOLLICULAR FLU 89255 PREPJ EMBRYO TR 89257 SPRM ID FROM ASPIR OTH/THN SEMINAL 89258 CRYOPRSRV EMBRYO 89259 CRYOPRSRV SPRM 89260 SPRM ISOL SMPL PREP INSEMINATION/DX SEMEN ALYS


89261 SPRM ISOL CPLX PREP INSEMINATION/DX SEMEN ALYS 89264 SPRM ID FROM TSTIS TISS FRSH/CRYOPRSRVD 89268 INSEMINATION OOCYTES 89272 EXTND CUL OOCYTE/EMBRYO 4-7 D 89280 ASSTD FERTILIZATION MICROTQ < /EQUAL 10 OOCYTES 89281 ASSTD FERTILIZATION MICROTQ > 10 OOCYTES 89290 BX OOCYTE MICROTQ < /EQUAL 5 EMBRY 89291 BX OOCYTE MICROTQ > 5 EMBRY 89300 SEMEN ALYS PRESENCE&/MOTILITY SPRM HUHNER 89310 SEMEN ALYS MOTILITY&CNT X W/HUHNER TST 89320 SEMEN ANALYSIS VOLUME COUNT MOTILITY DIFFERENT 89321 SEMEN ANALYSIS SPERM PRESENCE&/MOTILITY SPRM 89322 SEMEN ANALYSIS STRICT MORPHOLOGIC CRITERIA 89325 SPRM ANTIBODIES 89329 SPRM EVAL HAMSTER PENETRATION TST 89330 SPRM EVAL CRV MUCUS PENETRATION 89331 SPERM EVALUATION RETROGRADE EJACULATION URINE 89335 CRYOPRSRV REPRDTVE TISS TSTICULAR 89342 STORAGE PR YR EMBRYO 89343 STORAGE PR YR SPRM/SEMEN 89344 STORAGE PR YR REPRDTVE TISS TSTICULAR/OVARIAN 89346 STORAGE PR YR OOCYTE 89352 THAWING CRYOPRSRVD EMBRYO 89353 THAWING CRYOPRSRVD SPRM/SEMEN EA ALIQUOT 89354 THAWING CRYOPRSRVD TSTICULAR/OVARIAN 89356 THAWING CRYOPRSRVD OOCYTES EA ALIQUOT 89398 UNLISTED REPRODUCTIVE MEDICINE LAB PROCEDURE 90378 RESPIRATORY SYNCYTIAL VIRUS IG IM 50 MG E 90399 UNLISTED IMMUNE GLOBULIN 90670 PNEUMOCOCCAL CONJ VACCINE 13 VALENT IM 90749 UNLISTED VACCINE/TOXOID 90865 NARCOSYNTHESIS PSYC DX&THER PURPOSES 90867 TRANSCRANIAL MAG STIMJ TX PLANNING 90868 TRANSCRANIAL MAG STIMJ TX DLVR & MGMT 90869 REPET TMS TX SUBSEQ MOTR THRESHLD W/DELIV & MNGT 90870 ELECTROCONVULSIVE THER 90875 INDIV PSYCPHYSTX BFB TRAINJ 20-30 MIN 90876 INDIV PSYCPHYSTX BFB TRAINJ 45-50 MIN 90880 HYPXH 90899 UNLIS PSYC SVC/PX 90901 BFB TRAINJ ANY MODALITY 90911 BFB TRAINJ PRNL MUSC 90999 UNLIS DIAL I/P/O/P


91110 GI TRC IMG INTRAL ESOPH THRU ILE PHYS I&R 91111 GASTROINTESTINAL TRACT IMAGING ESOPHAGUS 91299 UNLIS DX GASTROENTEROLOGY 92065 ORTHOPTIC&/PLEOPTIC TRAINJ 92070 FITG C-LENS TX DISEASE SUPPLY LENS 92071 FIT CONTACT LENS TX OCULAR SURFACE DISEASE 92072 FITTING CONTACT LENS FOR MNGT OF KERATOCONUS 92499 UNLIS OPH SVC 92507 TX SP LANG COMUNICAJ PCX DISORDER INDIV 92508 TX SP LANG COMUNICAJ PCX DISORDER 2/> 92606 THER SVC N-SP-GENRATJ DEV PRGRMG&MODIFICAJ 92609 THER SP-GENRATJ DEV PRGRMG&MODIFICAJ 92630 AUD RHAB PRELNG HEARING LOSS 92633 AUD RHAB POST-LNGL HEARING LOSS 92640 ANALYSIS W/PRGRMG AUD BRAINSTEM IMPLANT PR HR 92700 UNLIS OTORHINOLARYNGOLOGICAL SVC 92970 CARDIOASSIST-METH CRC ASSIST INT 92971 CARDIOASSIST-METH CRC ASSIST XTRNL 93668 PRPH ARTL DISEASE RHAB PR SESS 93797 PHYS SVCS F/O/P CAR RHAB W/O CONT ECG MNTR 93798 PHYS SVCS F/O/P CAR RHAB W/CONT ECG MNTR 93799 UNLIS CV SVC/PX 93998 UNLISTED NONINVASIVE VASCULAR DIAGNOSTIC STUDY 94005 HOME VENTILATOR MGMT CARE OVERSIGHT 30 MIN/> 94667 MNPJ CH WALL FACILITATE LNG FUNCJ 1 DEMO&/EVAL 94772 CIRCADIAN RESPIR PATTERN REC 12-24 HR INFT 94774 PED APNEA MONITOR ATTACHMENT PHYS I&R 94775 PED APNEA MONITOR ATTACHMENT 94776 PED APNEA MONITOR ANALYSES COMPUTER 94777 PED APNEA MONITOR PHYSICIAN REVIEW 94780 CAR SEAT/BED TESTING W/INTERP & REPORT 60 MIN 94781 CAR SEAT/BED TESTNG W/INTERP & REPORT +30MIN 94799 UNLIS PULM SVC/PX 95199 UNLIS ALL/CLINICAL IMMUNOLOGIC SVC/PX 95800 SLP STDY UNATND W/HRT RATE/O2 SAT/RESP/SLP TIME 95801 SLP STDY UNATND W/MIN HRT RATE/O2 SAT/RESP ANAL 95803 ACTIGRAPHY TESTING RECORDING ANALYSIS I&R 95805 MLT SLEEP LATENCY/MAINT OF WAKEFULNESS TSTG 95806 SLEEP STD AIRFLOW HRT RATE&O2 SAT EFFORT UNATTN 95807 SLEEP STD REC VNTJ RESPIR ECG/HRT RATE&O2 ATTN 95808 POLYSM SLEEP STAGING 1-3 ADDL PARAM 95810 POLYSM SLEEP STAGING 4/> ADDL PARAM 95811 POLYSM SLEEP STAGING 4/> ADDL PARAM W/CPAP TX


95950 MNTR F/ID&LATERALIZATION CERE SEIZ FOC EEG 95951 MNTR F/LOCLZJ CERE SEIZ FOC CABLE/RADIO EEG/VID 95953 MNTR F/LOCLZJ CERE SEIZ FOC CPTR PORTABLE EEG 95999 UNLIS NEUROLOGICAL/NEUROMUSCULAR DX PX 96000 COMPRE CPTR MTN ALYS VIDEO TAPING 3-D KINEMATICS 96001 COMPRE CPTR MTN ALYS W/DYN PLNTR PRES MEAS WALKG 96002 DYN SURF EMG WALKG/FUNCJAL ACTV 1-12 MUSC 96003 DYN FINE WIRE EMG WALKG/FUNCJAL ACTV 1 MUSC 96004 PHYS R&I CPTR MTN ALYS WALKG/FUNCJAL ACTV REPRT 96020 TEST SELECTION & ADMN FUNCTIONAL BRAIN MAPPING 96040 MEDICAL GENETICS COUNSELING EA 30 MIN 96101 PSYCHOLOGICAL TESTING PR HR F2F TIME W/PT 96102 PSYCL TSTG PR HR ADMN BY TECH PR HR 96103 PSYCL TSTG PR HR ADMN BY CPTR W/PROF I&R 96118 NUROPSYC TESTING PR HR F2F W/PT + INTERPJ TIME 96119 NUROPSYC TSTG WPROF I&R ADMN BY TECH PR HR 96120 NUROPSYC TSTG ADMN BY CPTR W/PROF I&R 96125 STANDARDIZED COGNITIVE PERFORMANCE TESTING 96379 UNLISTED THERAPEUTIC PROPH/DX IV/IA NJX/NFS 96549 UNLIS CHEMOTX PX 96910 PHOTOCHEMOTX TAR&UVB/PETROLATUM/UVB 96912 PHOTOCHEMOTX PSORALENS&ULTRAVIOLET PUVA 96913 PHOTOCHEMOTX F/PHOTORESPONSIVE DERMATOSES 96920 LASER TX F/PSORIASIS TOT AREA < 250 CM 96921 LASER TX F/PSORIASIS 250-500 SQ CM 96922 LASER TX F/PSORIASIS > 500 SQ CM 96999 UNLIS SPEC DERMATOLOGICAL SVC/PX 97002 PHYSICAL THER RE-EVAL 97004 OCCUPATIONAL THER RE-EVAL 97005 ATHLETIC TRAINJ EVAL 97006 ATHLETIC TRAINJ RE-EVAL 97010 APPL MODALITY 1+ AREAS HOT/COLD PACKS 97012 APPL MODALITY 1+ AREAS TRCJ MCHNL 97014 APPL MODALITY 1+ AREAS ELEC STIMJ UNATTN 97016 APPL MODALITY 1+ AREAS VASOPNEUMATIC DEV 97018 APPL MODALITY 1+ AREAS PARAFFIN BATH 97022 APPL MODALITY 1+ AREAS WP 97024 APPL MODALITY 1+ AREAS DTHRM 97026 APPL MODALITY 1+ AREAS INFRARED 97028 APPL MODALITY 1+ AREAS ULTRAVIOLET 97032 APPL MODALITY 1+ AREAS ELEC STIMJ EA 15 MIN 97033 APPL MODALITY 1+ AREAS IONTOPHORESIS EA 15 MIN 97034 APPL MODALITY 1+ AREAS CNTRST BATHS EA 15 MIN


97035 APPL MODALITY 1+ AREAS US EA 15 MIN 97036 APPL MODALITY 1+ AREAS HUBBARD TANK EA 15 MIN 97039 UNLIS MODALITY SPEC TYP&TM IF CONSTANT ATTN 97110 THER PX 1+ AREAS EA 15 MIN THER XERSS 97112 THER PX 1+ AREAS EA 15 MIN NEUROMUSC REEDUCAJ 97113 THER PX 1+ AREAS EA 15 MIN AQUATIC THER W/XERSS 97116 THER PX 1+ AREAS EA 15 MIN GAIT TRAINJ W/STAIR 97124 THER PX 1+ AREAS EA 15 MIN MASSAGE 97139 UNLIS THER PX SPEC 97140 MNL THER TQS 1+ REGIONS EA 15 MIN 97150 THER PX GRP 2/> INDIVS 97530 THER ACTV DIR PT CONTACT BY PROVIDER EA 15 MIN 97532 DEVELOPMENT OF COGNITIVE SKILLS EA 15 MIN 97533 SENSORY INTEGRATIVE TQS EA 15 MIN 97535 SELF-CARE/HOME MGMT TRAINING EA 15 MIN 97537 COMMUNITY/WORK REINTEGRATION TRAINJ EA 15 MIN 97542 WHEELCHAIR MGMT EA 15 MIN 97545 WORK HARDENING/CONDITIONING 1ST 2 HR 97546 WORK HARDENING/CONDITIONING EA HR 97605 NEG PRESS WND THER < /EQUAL 50 SQ CM 97606 NEG PRESS WND THER > 50 SQ CM 97750 PHYSICAL PERFORMANCE TST/MEAS W/RPRT 15 MIN 97755 ASSTV TECHN ASSMT DIR CNTCT W/REPRT 15 MIN 97799 UNLIS PHYSICAL MED/RHAB SVC/PX 97810 ACUP 1/> NDLS W/O ELEC STIMJ 1ST 15 MIN 97811 ACUP 1/> NDLS W/O ELEC STIMJ EA 15 MIN 97813 ACUP 1/> NDLS W/ELEC STIMJ 1ST 15 MIN 97814 ACUP 1/> NDLS W/ELEC STIMJ EA 15 MIN W/RE-INSJ 98925 OSTEOPATHIC MANIPULATIVE TX 1-2 BDY REGIONS 98926 OSTEOPATHIC MANIPULATIVE TX 3-4 BDY REGIONS 98927 OSTEOPATHIC MANIPULATIVE TX 5-6 BDY REGIONS 98928 OSTEOPATHIC MANIPULATIVE TX 7-8 BDY REGIONS 98929 OSTEOPATHIC MANIPULATIVE TX 9-10 BDY REGIONS 98940 CMT SPI 1-2 REGIONS 98941 CMT SPI 3-4 REGIONS 98942 CMT SPI 5 REGIONS 98943 CMT XTRSPI 1+ REGIONS 99082 UNUSUAL TRAVEL 99183 PHYS ATTN&SUPVJ HYPRBARIC OXYGEN THER PR SESS 99199 UNLIS SPEC SVC PX/REPRT 99341 HOME VST NEW PT LOW SEVERITY 99342 HOME VST NEW PT MOD SEVERITY 99343 HOME VST NEW PT MOD TO HI SEVERITY


99344 HOME VST NEW PT HI SEVERITY 99345 HOME VST NEW PT UNSTABLE/SIGNIFICANT NEW PROBLEM 99347 HOME VST EST PT SELF LIMITED/MINOR 99348 HOME VST EST PT LOW TO MOD SEVERITY 99349 HOME VST EST PT MOD TO HI SEVERITY 99350 HOME VST EST PT UNSTABLE/SIGNIFICANT NEW PROBLEM 99429 UNLIS PREV MED SVC 99499 UNLIS E/M SVC 99500 HOME VST PRENATAL MNTR&ASSMT 99501 HOME VST POSTNATAL ASSMT&F-UP CARE 99502 HOME VST NB CARE&ASSMT 99503 HOME VST RESPIR THER CARE 99504 HOME VST MCHNL VNTJ CARE 99505 HOME VST STOMA CARE&MAINT CLST&CSTOST 99506 HOME VST IM NJXS 99507 HOME VST CARE&MAINT CATH 99509 HOME VST ASSISTANCE DAILY LIV&PRSONAL CARE 99510 HOME VST INDIV FAM/MARRIAGE CNSL 99511 HOME VST FECAL IMPACTION MGMT&ENEMA ADMN 99512 HOME VST HEMO 99600 UNLIS HOME VST SVC/PX 99601 HOME NFS/SPECTY DRUG ADMN PR VST <2 HR 99602 HOME NFS/SPECTY DRUG ADMN PR VST <2 HR EA HR 99605 MEDICATION THERAPY 1ST 15 MIN NEW PATIENT 99606 MEDICATION THERAPY F2F 1ST 15 MIN ESTABLISHED PT 99607 MEDICATION THERAPY F2F EA ADDITIONAL 15 MIN A0021 AMB SERVICE OUTSIDE STATE PER MILE TRANSPORT A0080 NONEMERG TRNSPRT-MILE-VEH VOLUN W/NO VESTED INT A0090 NONEMERG TRNSPRT-MILE-VEH PROV IND W/VESTED INT A0100 NONEMERGENCY TRANSPORTATION; TAXI A0110 NONEMERG TRNSPRT&BUS INTRA-/INTERSTATE CARRIER A0120 NONEMERG TRNSPRT: MINI-BUS MTN AREA/OTH SYS A0130 NONEMERGENCY TRANSPORTATION: WHEELCHAIR VAN A0140 NONEMERG TRNSPRT & AIR TRAVEL INTRA-/INTERSTATE A0160 NONEMERG TRNSPRT: PER MILE-CASE/SOCIAL WORKER A0170 TRANSPORTATION ANCILLARY: PARKING FEES TOLLS OTH A0180 NONEMERG TRANSPORTATION: ANCILLARY: LODGNG-RECIP A0190 NONEMERG TRANSPORTATION: ANCILLARY: MEALS-RECIP A0200 NONEMERG TRANSPORTATION: ANCILLRY: LODGNG-ESCORT A0210 NONEMERG TRANSPORTATION: ANCILLARY: MEALS-ESCORT A0426 AMB SERVICE ALS NONEMERGENCY TRANSPORT LEVEL 1 A0428 AMBULANCE SERVICE BLS NONEMERGENCY TRANSPORT A0430 AMB SERVICE CONVNTION AIR SRVC TRANSPORT 1 WAY


A0431 AMB SERVICE CONVNTION AIR SRVC TRANSPORT 1 WAY A0435 FIXED WING AIR MILEAGE PER STATUTE MILE A0436 ROTARY WING AIR MILEAGE PER STATUTE MILE A0888 NONCOVERED AMBULANCE MILEAGE PER MILE A0999 UNLISTED AMBULANCE SERVICE A4281 TUBING FOR BREAST PUMP REPLACEMENT A4282 ADAPTER FOR BREAST PUMP REPLACEMENT A4283 CAP FOR BREAST PUMP BOTTLE REPLACEMENT A4284 BREAST SHIELD&SPLASH PROTECTR W/BREAST PUMP REPL A4285 POLYCARBONATE BOTTLE USE W/BREAST PUMP REPL A4286 LOCKING RING FOR BREAST PUMP REPLACEMENT A4335 INCONTINENCE SUPPLY; MISCELLANEOUS A4421 OSTOMY SUPPLY; MISCELLANEOUS A4520 INCONTINENCE GARMENT ANY TYPE EACH A4575 TOPICAL HYPERBARIC OXYGEN CHAMBER DISPOSABLE A4641 RADIOPHARMACEUTICAL DIAGNOSTIC NOC A4649 SURGICAL SUPPLY; MISCELLANEOUS A4870 PLUMBING &OR ELEC WORK HOME HEMODIAL EQUIPMENT A4890 CONTRACTS REPAIR&MAINTENANCE HEMODIAL EQUIPMENT A4913 MISCELLANEOUS DIALYSIS SUPPLIES NOS A6261 WOUND FILLER GEL/PASTE STERLE PER FLUID OZ NOS A6550 WND CARE SET NEG PRSS WND TX ELEC PUMP SPL A7020 INTERFACE COUGH STIMULAT DEVC REPLACEMENT ONLY A7025 HI FREQ CHST WALL OSCILLAT SYS VEST REPL PT OWND A7026 HI FREQ CHST WALL OSCILLAT SYS HOSE REPL PT OWND A7027 COMB ORAL/NASAL MASK USED W/CPAP DEVICE EACH A7030 FULL FACE MASK USED W/POS ARWAY PRESS DEVICE EA A7031 FACE MASK INTERFACE REPLCMT FULL FACE MASK EA A7034 NASL INTRFCE POS ARWAY PRSS DEVC W/WO HEAD STRAP A7035 HEADGEAR USED W/POSITIVE AIRWAY PRESSURE DEVICE A7036 CHINSTRAP USED W/POSITIVE AIRWAY PRESSURE DEVICE A7037 TUBING USED WITH POSITIVE AIRWAY PRESSURE DEVICE A7038 FILTER DISPBL USED W/POS ARWAY PRESSURE DEVICE A7039 FILTER NON DISPBL USED W/POS ARWAY PRESS DEVICE A7044 ORAL INTERFACE USED W/POS ARWAY PRESS DEVICE EA A7045 EXHALATION PORT W/WO SWIVEL REPLACEMENT ONLY A7046 WATR CHAMB HUMDIFIR USED W/POS ARWAY PRSS DEVC R A8002 HELMET PROTECTIVE SOFT CUSTOM FAB COMP ACCSSRIES A8003 HELMET PROTECTIVE HARD CUSTOM FAB COMP ACCSSRIES A9150 NONPRESCRIPTION DRUG A9152 SINGLE VIT/MINERAL/TRACE ELEMENT ORAL-DOSE NOS A9153 MX VIT W/WO MINERLS&TRACE ELEMS ORL PER DOSE NOS A9270 NONCOVERED ITEM OR SERVICE


A9272 MECH WOUND SUCTION DISPBL DRESSINGS ACSSORIES EA A9277 TRANSMITTER; EXT INTERSTITIAL CONT GLU MON SYS A9278 RECEIVER MON; EXT INTERSTITIAL CONT GLU MON SYS A9279 MONITOR FEATURE/DEVC STAND-ALONE/INTEGRATED NOC A9280 ALERT OR ALARM DEVICE NOT OTHERWISE CLASSIFIED A9281 REACHING/GRABBING DEVICE ANY TYPE ANY LENGTH EA A9282 WIG ANY TYPE EACH A9300 EXERCISE EQUIPMENT A9900 DME SUP/ACCESS/SRV-COMPON/OTH HCPCS A9999 MISCELLANEOUS DME SUPPLY OR ACCESSORY NOS AAA00 Default Code B4034 ENTERAL FEEDING SUPPLY KIT; SYRINGE FED PER DAY B4035 ENTERAL FEEDING SUPPLY KIT; PUMP FED PER DAY B4036 ENTERAL FEEDING SUPPLY KIT; GRAVITY FED PER DAY B4100 FOOD THICKENER ADMINISTERED ORALLY PER OUNCE B4102 ENTRAL FORMULA ADLT REPL FLS&LYTES 500 ML = 1 U B4103 ENTRAL FORMULA PED REPL FLS&LYTES 500 ML = 1 U B4104 ADDITIVE FOR ENTERAL FORMULA B4149 ENTRAL F MANF BLNDRIZD NAT FOODS W/NUTRIENTS B4150 ENTRAL F NUTRITIONALLY CMPL W/INTACT NUTRIENTS B4152 ENTRAL F NUTRITION CMPL CAL DENSE INTACT NUTRNTS B4153 ENTRAL FORMULA NUTIONALLY CMPL HYDROLYZED PROTS B4154 ENTRAL F NUTRITION CMPL NO INHERITED DZ METAB B4155 ENTRAL F NUTRITIONALLY INCMPL/MODULAR NUTRIENTS B4157 ENTRAL F NUTRITION CMPL INHERITED DZ METAB B4158 ENTRAL F PED NUTRITION CMPL W/INTACT NUTRNTS B4159 ENTRAL F PED NUTRITN CMPL SOY BASD INTCT NUTRNTS B4160 ENTRAL F PED NUTRITION CMPL CAL DENSE NUTRNTS B4161 ENTRAL F PED HYDROLYZED/AA&PEPTIDE CHAIN PROTS B4162 ENTRAL F PED SPCL METAB NEEDS INHERITED DZ METAB B9000 ENTERAL NUTRITION INFUSION PUMP - WITHOUT ALARM B9002 ENTERAL NUTRITION INFUSION PUMP - WITH ALARM B9004 PARENTERAL NUTRITION INFUSION PUMP PORTABLE B9006 PARENTERAL NUTRITION INFUSION PUMP STATIONARY B9998 NOC FOR ENTERAL SUPPLIES B9999 NOC FOR PARENTERAL SUPPLIES C1300 HYPRBR O2 UND PRSS FULL BDY CHAMB-30 MIN INTRVL C1749 ENDO RETRO IMAG/ILLUMINATION COLONOSCOPE DEVICE C8900 MR ANGIOGRAPHY WITH CONTRAST ABDOMEN C8901 MR ANGIOGRAPHY WITHOUT CONTRAST ABDOMEN C8902 MR ANGIO WITHOUT CONTRST FOLLOWED W/CONTRST ABD C8903 MR IMAGING WITH CONTRAST BREAST; UNILATERAL C8904 MR IMAGING WITHOUT CONTRAST BREAST; UNILATERAL


C8905 MR IMAG W/O CONTRST FLWED W/CONTRST BRST; UNI C8906 MR IMAGING WITH CONTRAST BREAST; BILATERAL C8907 MR IMAGING WITHOUT CONTRAST BREAST; BILATERAL C8908 MR IMAG W/O CONTRST FLWED W/CONTRST BRST; BIL C8909 MR ANGIOGRAPHY WITH CONTRAST CHEST C8910 MR ANGIOGRAPHY WITHOUT CONTRAST CHEST C8911 MR ANGIO WITHOUT CONTRST FOLLOWED W/CONTRST CHST C8912 MR ANGIOGRAPHY WITH CONTRAST LOWER EXTREMITY C8913 MR ANGIOGRAPHY WITHOUT CONTRAST LOWER EXTREMITY C8914 MR ANGIO W/O CONTRST FLWED W/CONTRST LOW EXTRM C8918 MR ANGIOGRAPHY WITH CONTRAST PELVIS C8919 MR ANGIOGRAPHY WITHOUT CONTRAST PELVIS C8920 MRA WITHOUT CONTRAST FOLLOWED W/CONTRAST PELVIS C8931 MR ANGIOGRAPHY W/CONTRAST SPINAL CANAL CONTENTS C8932 MR ANGIOGRAPHY W/O CONTRST SPINAL CANAL CONTENTS C8933 MR ANGIO NO CONTRST FLW W/CONTRST SP CANAL CNTN C8934 MR ANGIOGRAPHY WITH CONTRAST UPPER EXTREMITY C8935 MR ANGIOGRAPHY WITHOUT CONTRAST UPPER EXTREMITY C8936 MR ANGIO W/O CONTRST FOLLOWED W/CONTRST UP EXT C9255 INJECTION, PALIPERIDONE PALMITATE, 1 MG C9258 INJECTION TELAVANCIN 10 MG C9259 INJECTION PRALATREXATE 1 MG C9260 INJECTION OFATUMUMAB 10 MG C9261 INJECTION USTEKINUMAB 1 MG C9262 FLUDARABINE PHOSPHATE ORAL 1 MG C9263 INJECTION ECALLANTIDE 1 MG C9270 INJ IG GAMMAPLEX IV NONLYOPHILIZED 500 MG C9272 INJECTION DENOSUMAB 1 MG C9276 INJECTION CABAZITAXEL 1 MG C9277 INJECTION ALGLUCOSIDASE ALFA LUMIZUME 1 MG C9278 INJECTION INCOBOTULINUMTOXINA 1 UNIT C9279 INJECTION IBUPROFEN 100 MG C9280 INJECTION ERIBULIN MESYLATE 1 MG C9281 INJECTION PEGLOTICASE 1 MG c9282 INJECTION CEFTAROLINE FOSAMIL 10 MG C9287 INJECTION BRENTUXIMAB VEDOTIN 1 MG C9291 INJECTION AFLIBERCEPT 2 MG VIA C9399 UNCLASSIFIED DRUGS OR BIOLOGICALS C9727 INSERTION IMPL TO SOFT PALATE; MINIMUM 3 IMPL C9729 PERQ LAMINOTOMY/LAMINECT ENDO WHEN PRFRM; LUMB C9733 NONOPHTHALMIC FLUORESCENT VASCULAR ANGIOGRAPHY E0193 POWERED AIR FLOTATION BED E0194 AIR FLUIDIZED BED


E0221 INFRARED HEATING PAD SYSTEM E0232 WOUND WARMING WOUND COVER E0250 HOSP BED FIX HT W/ANY TYPE SIDE RAILS W/MATTRSS E0251 HOSP BED FIX HT W/ANY TYPE SIDE RAIL W/O MATTRSS E0255 HOS BED VARIBL HT W/ANY TYPE SIDE RAIL W/MATTRSS E0256 HOS BED VARIBL HT ANY TYPE SIDE RAIL W/O MATTRSS E0260 HOS BED SEMI-ELEC W/ANY TYPE SIDE RAIL W/MATTRSS E0261 HOS BED SEMI-ELEC ANY TYPE SIDE RAIL W/O MATTRSS E0265 HOSP BED TOT ELEC W/ANY TYPE SIDE RAIL W/MATTRSS E0266 HOS BED TOT ELEC ANY TYPE SIDE RAIL W/O MATTRSS E0270 HOSP BED INSTITUTIONAL TYPE: W/MATTRSS E0271 MATTRESS INNER SPRING E0272 MATTRESS FOAM RUBBER E0273 BED BOARD E0274 OVER-BED TABLE E0277 POWERED PRESSURE-REDUCING AIR MATTRESS E0280 BED CRADLE ANY TYPE E0290 HOSPITAL BED FIX HT WITHOUT SIDE RAILS W/MATTRSS E0291 HOSPITAL BED FIX HT W/O SIDE RAILS W/O MATTRSS E0292 HOSP BED VARIBL HT HI-LO W/O SIDE RAIL W/MATTRSS E0293 HOS BED VARIBL HT HI-LO W/O SIDE RAIL NO MATTRSS E0294 HOSPITAL BED SEMI-ELEC W/O SIDE RAILS W/MATTRSS E0295 HOSP BED SEMI-ELEC W/O SIDE RAILS W/O MATTRSS E0296 HOSPITAL BED TOTAL ELEC W/O SIDE RAILS W/MATTRSS E0297 HOSP BED TOTAL ELEC W/O SIDE RAILS W/O MATTRSS E0300 PEDIATRIC CRIB HOSPITAL GRADE FULLY ENCLOSED E0301 HOS BED HEVY DUTY XTRA WIDE W/WT CAPACTY>350 PDS E0302 HOS BED XTRA HEVY DUTY WT CAP>600 PDS W/O MTTRSS E0303 HOS BED HEVY DUTY W/WT CAP >350 PDS< =TO 600 PDS E0304 HOS BED EXTRA HEAVY DUTY WT CAP>600 PDS MATTRSS E0305 BEDSIDE RAILS HALF-LENGTH E0310 BEDSIDE RAILS FULL-LENGTH E0315 BED ACCESS: BOARD TABLE/SUPPORT DEVICE ANY TYPE E0316 SFTY ENCLOS FRME/CANOPY USE W/HOSP BED ANY TYPE E0328 HOSPITAL BED PEDIATRIC MANUAL INCLUDES MATTRESS E0329 HOSPITAL BED PEDIATRIC ELECTRIC INCLUDE MATTRESS E0370 AIR PRESSURE ELEVATOR FOR HEEL E0371 NONPWR ADV PRSS RDUC OVRLAY MATTRSS STD LEN&WDTH E0372 PWR AIR OVRLAY MATTRSS STD MATTRSS LENGTH&WIDTH E0373 NONPOWERED ADVANCED PRESSURE REDUCING MATTRESS E0430 PRTBLE GASEOUS O2 SYS PURCH; FLWMTR HUMIDFR&MASK E0431 PRTBLE GASEOUS O2 SYS RENT; FLWMTR HUMIDFR&MASK E0433 PORTABL LIQUID OXYGEN SYS RENTAL; HOME LIQUEFIER


E0434 PRTBLE LQD O2 SYS RENT; RESRVOR HUMIDFR FLWMTR E0435 PRTBLE LQD O2 SYS PURCH; RESRVOR FLWMTR HUMIDFR E0441 STATIONARY O2 CONTENTS GAS 1 MO SUPPLY=1 UNIT E0442 STATIONARY O2 CONTENTS LQD 1 MO SUPPLY = 1 UNIT E0443 PORTABLE O2 CONTENTS GASEOUS 1 MO SUPPLY=1 UNIT E0444 PORTABLE O2 CONTENTS LIQUID 1 MO SUPPLY =1 UNIT E0445 OXIMETER DEVICE MSR BLD O2 LEVLS NON-INVASV E0446 TOPICAL OXYGEN DELIVERY SYSTEM NOS INCL SUPPLIES E0450 VOL CNTRL VENT W/O PRSSURE SUPP INVASV INTERFCE E0455 OXYGEN TENT EXCLUDING CROUP OR PEDIATRIC TENTS E0457 CHEST SHELL E0459 CHEST WRAP E0460 NEG PRESSURE VENTILATOR; PORTABLE/STATIONARY E0461 VOL CNTRL VENT W/O PRSSUR SUPP NONINVASV INTRFCE E0462 ROCKING BED WITH OR WITHOUT SIDE RAILS E0463 PRSSURE SUPP VENT W/VOL CNTRL INVASV INTERFCE E0464 PRSSURE SUPP VENT W/VOL CNTRL NONINVASV INTERFCE E0470 RESP ASST DEVC BI-LEVL PRSS CAPABILITY W/O BACKU E0471 RESP ASST DEVC BI-LEVL PRSS CAPABILITY W/BACK-UP E0472 RESP ASST DEVC BI-LEVL PRSS CAPABILITY W/BACKUP E0480 PERCUSSOR ELECTRIC OR PNEUMATIC HOME MODEL E0481 INTRAPULM PERCUSSIVE VENT SYSTEM&REL ACSSORIES E0482 COUGH STIM DEVICE ALTRNAT POS&NEG ARWAY PRESS E0483 HI FREQ CHST WALL OSCILLAT AIR-PULSE GEN SYS EA E0485 ORL DEVC/APPL RDUC UP ARWAY COLLAPSIBILITY PRFAB E0486 ORL DEVC/APPL RDUC UP AIRWAY COLLAPSIBILITY CSTM E0500 IPPB MACH W/BUILT-IN NEBULIZATION; VALVS; PWR E0565 COMPRS AIR PWR EQP NOT SLF-CONTAIND/CYL DRIVN E0572 AROSL COMPRS ADJSTBL PRSS LGHT DUTY INTERMIT USE E0601 CONTINUOUS AIRWAY PRESSURE DEVICE E0603 BREAST PUMP ELECTRIC ANY TYPE E0604 BREAST PUMP HEVY DUTY HOSP GRADE PISTON OP E0630 PATIENT LIFT HYDRAULIC/MECH INCL SEAT SLING/PAD E0635 PATIENT LIFT ELECTRIC WITH SEAT OR SLING E0636 MX PSTN PT SUPP SYS INTGR LIFT PT ACSSIBLE CNTRL E0637 COMB SIT STAND SYS SZ INCL PED W/SEATLIFT FEATUR E0638 STANDING FRME SYS 1 PSTN ANY SZ INCL PED W/WO WH E0639 PT LIFT MOVEABLE ROOM-ROOM W/DISASSMBL&REASSMBL E0640 PATIENT LIFT FIX SYS INCLUDES ALL CMPNTS/ACCESS E0641 STANDING FRME SYS MX-POSITION 3-WAY SZ INCL PED E0642 STANDING FRAME SYS MOBILE DYN ANY SZ INCL PED E0650 PNEUMATIC COMPRESSOR NONSEGMENTAL HOME MODEL E0651 PNEUMAT COMPRS SEG HOM MDL NO CALBRTD GRDNT PRSS


E0652 PNEUMAT COMPRS SEG HOM MDL W/CALBRTD GRADNT PRSS E0655 NONSEG PNEUMAT APPLINC W/PNEUMAT COMPRS HALF ARM E0656 SEG PNEUMAT APPLIANCE USE W/PNEUMAT COMPRS TRUNK E0657 SEG PNEUMAT APPLIANCE USE W/PNEUMAT COMPRS CHEST E0660 NONSEG PNEUMAT APPLINC W/PNEUMAT COMPRS FULL LEG E0665 NONSEG PNEUMAT APPLINC W/PNEUMAT COMPRS FULL ARM E0666 NONSEG PNEUMAT APPLINC W/PNEUMAT COMPRS HALF LEG E0667 SEG PNEUMAT APPLINC W/PNEUMAT COMPRS FULL LEG E0668 SEG PNEUMAT APPLINC W/PNEUMAT COMPRS FULL ARM E0669 SEG PNEUMAT APPLINC W/PNEUMAT COMPRS HALF LEG E0671 SEGMENTAL GRADENT PRESS PNEUMAT APPLINC FULL LEG E0672 SEGMENTAL GRADENT PRESS PNEUMAT APPLINC FULL ARM E0673 SEGMENTAL GRADENT PRESS PNEUMAT APPLINC HALF LEG E0675 PNEUMAT COMPRS DEVC HI PRSS RAPID INFLATION/DEFL E0676 INTERMITTENT LIMB COMPRESSION DEVICE NOS E0691 UV LT TX SYS PANL W/BULB/LAMP TMR; TX 2 SQ FT/< E0692 UV LT TX SYS PANL W/BULB/LAMP TIMER 4 FT PANEL E0693 UV LT TX SYS PANL W/BULBS/LAMPS TIMER 6 FT PANEL E0694 UV MX DIR LT TX SYS 6 FT CABINET W/BULB/LAMP TMR E0720 TENS DEVICE TWO LEAD LOCALIZED STIMULATION E0730 TENS DEVICE 4/MORE LEADS MULTI NERVE STIMULATION E0731 FORM-FITTING CONDUCTIVE GARMENT DELIV TENS/NMES E0740 INCONT TX SYS PELV FLR STIM MON SENS &OR TRAINER E0744 NEUROMUSCULAR STIMULATOR FOR SCOLIOSIS E0745 NEUROMUSCULAR STIMULATOR ELECTRONIC SHOCK UNIT E0746 ELECTROMYOGRAPHY BIOFEEDBACK DEVICE E0747 OSTOGNS STIM ELEC NONINVASV OTH THAN SP APPLIC E0748 OSTOGNS STIMULATOR ELEC NONINVASV SPINAL APPLIC E0749 OSTEOGENESIS STIMULATOR ELEC SURGICALLY IMPL E0755 ELECTRONIC SALIVARY REFLEX STIMULATOR E0760 OSTOGNS STIM LOW INTENS ULTRASOUND NON-INVASV E0761 NON-THRML PULS RADIOWAV ELECMAGNET ENRGY TX DEVC E0762 TRANSCUT ELEC JOINT STIM DEVC SYS INCL ALL ACCSS E0764 FUNC NEUROMUSC STIM MUSC AMBUL CMPT CNTRL SC INJ E0765 FDA APPRVD NRV STIM W/REPL BATTRY TX NAUSA&VOMIT E0769 ESTIM/ELECTROMAGNETIC WOUND TREATMENT DEVC NOC E0770 FES TRANSQ STIM NERV&/MUSC GRP CMPL SYS NOS E0781 AMB INFUS PUMP 1/MX CHANNL W/ADMN EQP WORN BY PT E0782 INFUSION PUMP IMPLANTABLE NON-PROGRAMMABLE E0783 INFUSION PUMP SYSTEM IMPLANTABLE PROGRAMMABLE E0784 EXTERNAL AMBULATORY INFUSION PUMP INSULIN E0785 IMPLANTABLE INTRASPINL CATHETER USED W/PUMP-REPL E0786 IMPLANTABLE PROGRAMMABLE INFUSION PUMP REPL


E0791 PARNTRAL INFUS PUMP STATIONRY SINGLE/MULTICHANEL E0935 CONTINUOUS PASSIVE MOT EXERCISE DEVC KNEE ONLY E0936 CONT PASSIVE MOTION EXERCISE DEVC OTH THAN KNEE E0950 WHEELCHAIR ACCESSORY TRAY EACH E0951 HEEL LOOP/HOLDER TYPE W/WO ANKLE STRAP EACH E0952 TOE LOOP/HOLDER ANY TYPE EACH E0955 WC ACSS HEADREST CUSHNED FIX MOUNT HARDWARE EA E0956 WC ACSS LAT TRNK/HIP SUPP FIX MOUNT HARDWARE EA E0957 WC ACSS MED THI SUPP FIX MOUNT HARDWARE EA E0958 MANUAL WHLCHAIR ACCESS 1-ARM DRIVE ATTACHMENT EA E0959 MANUAL WHEELCHAIR ACCESS ADAPTER FOR AMPUTEE EA E0960 WC ACSS SHLDR HRNSS/STRAPS/CHST STRAP W/TYPE MOU E0961 MANUAL WHEELCHAIR ACCESS WHEEL LOCK BRAKE EXT EA E0966 MANUAL WHEELCHAIR ACCESS HEADREST EXTENSION EA E0967 MANUAL WC ACCESSORY HAND RIM W/PROJECTIONS EACH E0968 COMMODE SEAT WHEELCHAIR E0969 NARROWING DEVICE WHEELCHAIR E0970 NO 2 FOOTPLATES EXCEPT FOR ELEVATING LEGREST E0971 MNL WHEELCHAIR ACCESSORY ANTI-TIPPING DEVC EACH E0973 WC ACCSS ADJUSTBL HT DTACH ARMRST CMPL ASSMBL EA E0974 MANUAL WHEELCHAIR ACCESS ANTI-ROLLBACK DEVICE EA E0978 WHLCHAIR ACSS PSTN BELT/SFTY BELT/PELV STRAP EA E0980 SAFETY VEST WHEELCHAIR E0981 WHEELCHAIR ACCESS SEAT UPHLSTR REPLCMT ONLY EA E0982 WHEELCHAIR ACCESS BACK UPHLSTR REPLCMT ONLY EA E0983 MNL WC ACSS PWR ADD-ON CONVRT MNL WC MOTRIZD WC E0984 MNL WC ACSS PWR ADD-ON CONVRT MNL WC MOTRIZD WC E0985 WHEELCHAIR ACCESSORY SEAT LIFT MECHANISM E0986 MNL WHLCHAIR ACSS PUSH ACTIVATED POWER ASSIST EA E0988 MANUAL WC ACCESSORY LEVR-ACTIVATD WHL DRIVE PAIR E0990 WHEELCHAIR ACCESS ELEV LEG REST CMPL ASSMBL EA E0992 MANUAL WHEELCHAIR ACCESSORY SOLID SEAT INSERT E0994 ARMREST EACH E0995 WHEELCHAIR ACCESSORY CALF REST/PAD EACH E1002 WHEELCHAIR ACCESS POWER SEATING SYSTEM TILT ONLY E1003 WC ACSS PWR SEAT SYS RECLINE W/O SHEAR RDUC E1004 WC ACSS PWR SEAT SYS RECLINE W/MECH SHEAR RDUC E1005 WC ACSS PWR SEAT SYS RECLINE W/PWR SHEAR RDUC E1006 WC ACSS PWR SEAT SYS TILT&RECLINE NO SHEAR RDUC E1007 WC ACSS PWR SEAT TILT&RECLINE MECH SHEAR RDUC E1008 WC ACSS PWR SEAT TILT&RECLINE W/PWR SHEAR RDUC E1009 WC ACCSS ADD PWR SEAT MECH LINKD LEG ELEV SYS EA E1010 WC ACCSS ADD PWR SEAT SYS PWR LEG ELEV SYS EACH


E1011 MOD PEDIATRIC SIZE WC WIDTH ADJUSTMENT PACKAGE E1014 RECLIN BACK ADDITION PEDIATRIC SIZE WHEELCHAIR E1015 SHOCK ABSORBER FOR MANUAL WHEELCHAIR EACH E1016 SHOCK ABSORBER FOR POWER WHEELCHAIR EACH E1017 HEVY DUTY SHOCK ABSORBR HEVY/XTRA HEVY MNL WC EA E1018 HEVY DUTY SHOCK ABSORBR HEVY/XTRA HEVY PWR WC EA E1020 RESIDUAL LIMB SUPPORT SYSTEM FOR WHEELCHAIR E1028 WC ACCSS MANL SWINGAWAY OTH CNTRL INTRFCE/PSTN E1029 WHEELCHAIR ACCESSORY VENTILATOR TRAY FIXED E1030 WHEELCHAIR ACCESSORY VENTILATOR TRAY GIMBALED E1031 ROLLABOUT CHAIR ANY&ALL TYPES W/CASTERS 5 IN/GT E1035 MULTI-PSTN PT TRNSF SYS W/SEAT PT WT < /= 300 LBS E1036 MULTI-PSTN PT TRNSF SYS EXTRA WIDE PT >300 LBS E1037 TRANSPORT CHAIR PEDIATRIC SIZE E1038 TRNSPRT CHAIR ADLT SZ PT WT CAP TO&INCL 300 LBS E1039 TRNSPRT CHAIR ADLT SZ HEVY DUTY PT WT CAP>300 LB E1050 FULL RECLIN WHLCHAIR; FIX FULL-LEN ARMS LEGRESTS E1060 FULL RECLIN WHLCHAIR; DTACHBLE ARMS LEGRESTS E1070 FULLY RECLIN WHLCHAIR; DTACHBLE ARMS FOOTRESTS E1083 HEMI-WHLCHAIR; FIX FULL-LEN ARMS DTACHBL LEGREST E1084 HEMI-WHLCHAIR; DTACHBLE ARMS DESK/FULL LEGRESTS E1085 HEMI-WHLCHAIR; FIX FULL ARMS DTACHBLE FOOTRESTS E1086 HEMI-WHLCHAIR; DTACHBLE ARMS DESK/FULL FOOTRESTS E1087 HI-STRGTH LGHTWT WHLCHAIR; FIX ARMS DTACH LEGRST E1088 HI-STRGTH LGHTWT WHLCHAIR; DTACHBL ARMS LEGRESTS E1089 HI-STRGTH LGHTWT WHLCHAIR; FIX ARM DTACH FOOTRST E1090 HI-STRGTH LGHTWT WHLCHAIR; DTACHBL ARMS FOOTREST E1092 WIDE HEVY-DUTY WHLCHAIR; DTACHBLE ARMS LEGRESTS E1093 WIDE HEVY-DUTY WHLCHAIR; DTACHBLE ARMS FOOTRESTS E1100 SEMI-RECLIN WHLCHAIR; FIX ARMS DTACHBLE LEGRESTS E1110 SEMI-RECLIN WHLCHAIR; DTACHBLE ARMS ELEV LEGREST E1130 STD WHLCHAIR; FIX FULL-LEN ARMS DTACHBL FOOTRSTS E1140 WHLCHAIR; DTACHBLE ARMS DTACHBLE FOOTRESTS E1150 WHLCHAIR; DTACHBLE ARMS DTACHBLE ELEV LEGRESTS E1160 WHLCHAIR; FIX FULL-LEN ARMS DTACHBL ELEV LEGRSTS E1161 MANUAL ADULT SIZE WHEELCHAIR INCLUDES TILT SPACE E1170 AMPUTEE WHLCHAIR; FIX FULL ARMS DTACHBL LEGRESTS E1171 AMPUTEE WHLCHAIR; FIX FULL ARMS W/O FOOT/LEGREST E1172 AMPUTEE WHLCHAIR; DTACHBL ARMS W/O FOOT/LEGRESTS E1180 AMPUTEE WHLCHAIR; DTACHBL ARMS DTACHBL FOOTRESTS E1190 AMPUTEE WHLCHAIR; DTACHBL ARMS DTACHBL LEGRESTS E1195 HEVY DUTY WHLCHAIR; FIX FULL ARMS DTACHBL LEGRST E1200 AMPUTEE WHLCHAIR; FIX FULL ARMS DTACHBL FOOTRSTS


E1220 WHEELCHAIR; SPECIALLY SIZED OR CONSTRUCTED E1221 WHEELCHAIR WITH FIXED ARM FOOTRESTS E1222 WHEELCHAIR WITH FIXED ARM ELEVATING LEGRESTS E1223 WHEELCHAIR WITH DETACHABLE ARMS FOOTRESTS E1224 WHEELCHAIR W/DETACHABLE ARMS ELEVATING LEGRESTS E1225 WHLCHAIR ACCESS MANUAL SEMIRECLINING BACK EACH E1226 WHLCHAIR ACCESS MANUAL FULL RECLINING BACK EACH E1227 SPECIAL HEIGHT ARMS FOR WHEELCHAIR E1228 SPECIAL BACK HEIGHT FOR WHEELCHAIR E1229 WHEELCHAIR PEDIATRIC SIZE NOS E1230 PWR OPERATED VEH SPEC BRAND NAME & MODEL NUMBER E1231 WC PED SZ TILT-IN-SPACE RIGD ADJUSTBL W/SEAT SYS E1232 WC PED SZ TILT-IN-SPACE FOLD ADJUSTBL W/SEAT SYS E1233 WC PED SZ TILT-IN-SPACE RIGD ADJUSTBL W/O SEAT E1234 WC PED SZ TILT-IN-SPACE FOLD ADJUSTBL W/O SEAT E1235 WHLCHAIR PED SIZE RIGD ADJUSTBL W/SEATING SYSTEM E1236 WHLCHAIR PED SIZE FOLD ADJUSTBL W/SEATING SYSTEM E1237 WHLCHAIR PED SZ RIGD ADJUSTBL W/O SEATING SYSTEM E1238 WHLCHAIR PED SZ FOLD ADJUSTBL W/O SEATING SYSTEM E1239 POWER WHEELCHAIR PEDIATRIC SIZE NOS E1240 LGHTWT WHLCHAIR; DTACHBLE ARMS DTACHBLE LEGREST E1250 LGHTWT WHLCHAIR; FIX FULL ARMS DTACHBL FOOTRESTS E1260 LGHTWT WHLCHAIR; DTACHBL ARMS DTACHBL FOOTRESTS E1270 LGHTWT WHLCHAIR; FIX ARMS DTACHBLE ELEV LEGRESTS E1280 HEVY-DUTY WHLCHAIR; DTACHBLE ARMS ELEV LEGRESTS E1285 HEVY-DUTY WHLCHAIR; FIX ARMS DTACHBLE FOOTRESTS E1290 HEVY-DUTY WC DTCHBL ARMS SWNG AWAY DTCHBL FTRST E1295 HEVY-DUTY WHLCHAIR; FIX FULL ARMS ELEV LEGRESTS E1296 SPECIAL WHEELCHAIR SEAT HEIGHT FROM FLOOR E1297 SPECIAL WHEELCHAIR SEAT DEPTH BY UPHOLSTERY E1298 SPECIAL WHLCHAIR SEAT DEPTH &OR WIDTH CONSTRUCT E1300 WHIRLPOOL PORTABLE E1310 WHIRLPOOL NONPORTABLE E1354 O2 ACCESS WHEELED CART PRTBLE CYL/CONC REPL EA E1356 O2 ACCESS BTTRY PACK/CRTRDGE PRTBLE CONC REPL EA E1357 O2 ACCESS BATTRY CHARGER PRTBLE CONC REPL EA E1358 O2 ACCESS DC POWER ADAPTER PRTBLE CONC REPL EA E1399 DURABLE MEDICAL EQUIPMENT MISCELLANEOUS E1500 CENTRIFUGE FOR DIALYSIS E1510 KIDNEY DIALYSATE DEL SYS KIDNEY MACH PUMP RECIRC E1520 HEPARIN INFUSION PUMP FOR HEMODIALYSIS E1530 AIR BUBBLE DETECTOR HEMODIALYSIS EA REPLACEMENT E1540 PRESSURE ALARM FOR HEMODIALYSIS EACH REPLACEMENT


E1550 BATH CONDUCTIVITY METER FOR HEMODIALYSIS EACH E1560 BLOOD LEAK DETECTOR HEMODIALYSIS EA REPLACEMENT E1570 ADJUSTABLE CHAIR FOR ESRD PATIENTS E1575 TRANSDUCER PROTECTORS/FL BARRIERS HEMODIAL SZ-10 E1580 UNIPUNCTURE CONTROL SYSTEM FOR HEMODIALYSIS E1590 HEMODIALYSIS MACHINE E1592 AUTO INTERMITTENT PERITONEAL DIALYSIS SYSTEM E1594 CYCLER DIALYSIS MACHINE FOR PERITONEAL DIALYSIS E1600 DELIV &OR INSTL CHARGES HEMODIAL EQUIPMENT E1610 RVRS OSMOSIS H2O PURIFICATION SYSTEM HEMODIAL E1615 DEIONIZER WATER PURIFICATION SYSTEM HEMODIALYSIS E1620 BLOOD PUMP FOR HEMODIALYSIS REPLACEMENT E1625 WATER SOFTENING SYSTEM FOR HEMODIALYSIS E1630 RECIPROCATING PERITONEAL DIALYSIS SYSTEM E1632 WEARABLE ARTIFICIAL KIDNEY EACH E1634 PERITONEAL DIALYSIS CLAMPS EACH E1635 COMPACT TRAVEL HEMODIALYZER SYSTEM E1636 SORBENT CARTRIDGES FOR HEMODIALYSIS PER 10 E1637 HEMOSTATS EACH E1639 SCALE EACH E1699 DIALYSIS EQUIPMENT NOT OTHERWISE SPECIFIED E1700 JAW MOTION REHABILITATION SYSTEM E1701 REPL CUSHNS JAW MOTION REHAB SYSTEM PKG SIX E1702 REPL MSR SCLS JAW MOTION REHAB SYSTEM PKG 200 E1800 DYN ADJUSTBL ELB EXT/FLX DEVC W/SFT INTRFCE MATL E1801 STATIC PROGRESSIVE STRETCH ELBOW DEVICE E1802 DYN ADJUSTBL FORARM PRON/SUPIN DEVC INTRFCE MATL E1805 DYN ADJUSTBL WRIST EXT/FLX DEVC W/INTERFCE MATL E1806 STATIC PROGRESSIVE STRETCH WRIST DEVICE E1810 DYN ADJUSTBL KNEE EXT/FLX DEVC W/INTERFCE MATL E1811 STATIC PROGRESSIVE STRETCH KNEE DEVICE E1812 DYN KNEE EXT/FLEX DEVC W/ACTV RESISTANCE CONTROL E1815 DYN ADJ ANKLE EXT/FLEX DEVC INCL SOFT INTF MATL E1816 STATIC PROGRESSIVE STRETCH ANKLE DEVICE E1818 STATIC PROGRESSIVE STRETCH FOREARM DEVICE E1820 REPL SFT INTERFCE MATL DYN ADJUSTBL EXT/FLX DEVC E1821 REPL SFT INTERFCE MATL/CUFF BI-DIR STAT DEVC E1825 DYN ADJUSTBL FNGR EXT/FLX DEVC W/SFT INTRFCE MAT E1830 DYN ADJUSTBL TOE EXT/FLX DEVC W/SFT INTRFCE MATL E1840 SOFT INTERFACE MATERIAL E1841 STATIC PROGRESSIVE STRETCH SHOULDER DEVICE E1902 CMNCT BD NON-ELEC AUG/ALTERNATV CMNCT DEVICE E2100 BLD GLU MONITOR W/INTEGRATED VOICE SYNTHESIZER


E2201 MNL WC ACSS NONSTD SEAT WDTH >/= 20 IN & < 24 IN E2202 MANUAL WC ACSS NONSTD SEAT FRME WIDTH 24-27 IN E2203 MANUAL WC ACSS NONSTD SEAT FRME DEPTH 20 < 22 IN E2204 MANUAL WC ACSS NONSTD SEAT FRME DEPTH 22-25 IN E2205 MANUAL WC ACCESS HANDRIM W/O PROJ REPL ONLY EACH E2206 MNL WHLCHAIR ACCESS WHEEL LOCK ASSMBL CMPL EA E2207 WHEELCHAIR ACCESSORY CRUTCH AND CANE HOLDER EACH E2208 WHEELCHAIR ACCESSORY CYLINDER TANK CARRIER EACH E2209 ARM TROUGH WITH OR WITHOUT HAND SUPPORT EACH E2210 WHEELCHAIR ACCESS BEARINGS ANY TYPE REPL ONLY EA E2211 MNL WHLCHAIR ACSS PNEUMAT PROPULSION TIRE ANY SZ E2212 MNL WC ACESS TUBE PNEUMAT PROPULSION TIRE ANY SZ E2213 MNL WC ACSS INSRT PNEUMAT PROPULSION TIRE ANY SZ E2214 MNL WHLCHAIR ACCESS PNEUMAT CASTER TIRE ANY SIZE E2215 MNL WHLCHAIR ACSS TUBE PNEUMAT CASTR TIRE ANY SZ E2216 MNL WC ACESS FOAM FILL PROPULSION TIRE ANY SZ E2217 MNL WHLCHAIR ACCSS FOAM FILL CASTR TIRE ANY SIZE E2218 MNL WHLCHAIR ACCSS FOAM PROPULSION TIRE ANY SIZE E2219 MNL WHLCHAIR ACCESS FOAM CASTER TIRE ANY SIZE EA E2220 MNL WHLCHAIR ACESS SOLID PROPULSION TIRE ANY SZ E2221 MNL WHEELCHAIR ACESS SOLID CASTER TIRE ANY SZ EA E2222 MNL WC ACSS SOLID CASTR TIRE INTGR WHL ANY SZ EA E2224 MNL WC ACESS PROPULSION WHL EXCLD TIRE ANY SZ EA E2225 MNL WC CASTER WHL EXCLD TIRE ANY SZ REPL ONLY EA E2226 MNL WHLCHAIR ACSS CASTR FORK ANY SZ REPL ONLY EA E2227 MANUAL WC ACCESS GEAR REDUCTION DRIVE WHEEL EACH E2228 MNL WC ACCESS WHEEL BRAKING SYS&LOCK COMPLETE EA E2230 MANUAL WHEELCHAIR ACCESSORY MANUAL STANDING SYS E2231 MNL WC ACCESS SOLID SEAT SUPP BASE INCL HARDWARE E2291 BACK PLANAR PED SZ WC INCL FIX ATTCHING HARDWARE E2292 SEAT PLANAR PED SZ WC INCL FIX ATTCHING HARDWARE E2293 BACK CONTOURED PED WC INCL FIX ATTCH HARDWARE E2294 SEAT CONTOURED PED WC INCL FIX ATTCH HARDWARE E2295 MNL WC ACCESS PED SIZE WC DYNAMIC SEATING FRAME E2300 POWER WHEELCHAIR ACCESS POWER SEAT ELEV SYSTEM E2301 POWER WHEELCHAIR ACCESSORY POWER STANDING SYSTEM E2310 PWR WC ACSS ELEC CNCT BETWN WC CNTRLLER&ONE PWR E2311 PWR WC ACSS ELEC CNCT BETWN WC CNTRLLER&TWO/MORE E2312 POWER WC ACCESS HAND OR CHIN CONTROL INTERFACE E2313 POWER WC ACCESS HARNESS UPGRADE EXP CONTROLLR EA E2321 PWR WC ACSS HND CNTRL REMOT JOYSTCK NO PRPRTNL E2322 PWR WC ACSS HND CNTRL MX MECH SWTCH NO PRPRTNL E2323 PWR WC ACSS SPCLTY JOYSTCK HNDLE HND CNTRL PRFAB


E2324 POWER WHLCHAIR ACSS CHIN CUP CHIN CNTRL INTERFCE E2325 PWR WC ACSS SIP&PUFF INTERFCE NONPROPRTNAL E2326 PWR WC ACSS BREATH TUBE KIT SIP&PUFF INTERFCE E2327 PWR WC ACSS HEAD CNTRL INTERFCE MECH PROPRTNAL E2328 PWR WC ACSS HEAD CNTRL/EXT CNTRL ELEC PRPRTNL E2329 PWR WC ACSS HEAD CNTRL CNTC SWTCH MECH NOPRPRTNL E2330 PWR WC ACCSS HEAD PROX SWITCH MECH NONPRPRTNL E2331 PWR WC ACSS ATTENDANT CONTROL PROPROTIONAL E2340 POWER WC ACCESS NONSTAND SEAT FRAME WD 20-23 IN E2341 PWR WC ACSS NONSTD SEAT FRME WIDTH 24-27 IN E2342 PWR WC ACSS NONSTD SEAT FRME DEPTH 20/21 IN E2343 PWR WC ACSS NONSTD SEAT FRME DEPTH 22-25 IN E2351 PWR WC ACSS ELEC INTERFCE OPERATE SPCH GEN DEVC E2358 PWR WC ACCESS GRP 34 NONSEALED LEAD ACID BATT EA E2359 PWR WC ACCESSORY GRP 34 SEALED LEAD ACID BATT EA E2360 PWR WC ACSS 22 NF NON-SEALED LEAD ACID BATTRY EA E2361 PWR WC ACSS 22NF SEALED LEAD ACID BATTRY EA E2362 PWR WC ACSS GRP 24 NON-SEALED LEAD ACID BATT EA E2363 PWR WC ACSS GRP 24 SEALED LEAD ACID BATTRY EA E2364 PWR WC ACSS U-1 NON-SEALED LEAD ACID BATTRY EA E2365 PWR WHLCHAIR ACSS U-1 SEALED LEAD ACID BATTRY EA E2366 PWR WC ACSS BATTRY CHRGR 1 MODE W/ONLY 1 BATTRY E2367 PWR WC ACSS BATT CHRGR DUL MODE W/EITHER BATT EA E2368 POWER WHEELCHAIR CMPNT MOTOR REPLACEMENT ONLY E2369 POWER WHEELCHAIR CMPNT GEAR BOX REPLACEMENT ONLY E2370 PWR WC CMPNT MOTR&GEAR BOX COMB REPLCMT ONLY E2371 POWER WC ACSS GRP 27 SEALED LEAD ACID BATTERY EA E2372 PWR WC ACSS GRP 27 NONSEALED LEAD ACID BATTRY EA E2373 PWR WC MINI-PROPORTIONAL COMPACT REMOTE JOYSTICK E2374 PWR WC STANDARD REMOTE JOYSTICK REPLACEMENT ONLY E2375 PWR WC NONEXPNDABLE CONTROLLER REPLACEMENT ONLY E2376 PWR WC EXPANDABLE CONTROLLER REPLACEMENT ONLY E2377 PWR WC EXPANDABLE CONTROLLER UPGRADE INIT ISSUE E2381 PWR WC PNEUMATIC DRIVE WHEEL TIRE REPL ONLY EACH E2382 PWR WC TUBE PNEUMATIC DRIVE WHEEL TIRE REPL EACH E2383 PWR WC INSERT PNEUMATIC WHEEL TIRE REPL ONLY EA E2384 PWR WC PNEUMATIC CASTER TIRE REPL ONLY EACH E2385 PWR WC TUBE PNEUMATIC CASTER TIRE REPL ONLY EACH E2386 PWR WC FOAM FILLED DRIVE WHEEL TIRE REPL ONLY EA E2387 PWR WC FOAM FILLED CASTER TIRE REPL ONLY EACH E2388 PWR WC FOAM DRIVE WHEEL TIRE REPL ONLY EACH E2389 PWR WC FOAM CASTER TIRE REPLACEMENT ONLY EACH E2390 PWR WC SOLID DRIVE WHEEL TIRE REPL ONLY EACH


E2391 PWR WC SOLID CASTER TIRE REPLACEMENT ONLY EACH E2392 PWR WC SOLID CASTER TIRE INTEGRTED WHEEL REPL EA E2394 PWR WC DRIVE WHEEL EXCLUDES TIRE REPL ONLY EACH E2395 PWR WC CASTER WHEEL EXCLUDES TIRE REPL ONLY EACH E2396 PWR WC CASTER FORK REPLACEMENT ONLY EACH E2397 POWER WHLCHAIR ACCESSORY LITHIUM-BASED BATTRY EA E2402 NEG PRESS WOUND THERAPY ELEC PUMP STATION/PRTBLE E2500 SPEECH GEN DEVC DIGITIZED < /= 8 MINS REC TIME E2502 SPCH GEN DEVC DIGTIZD>8 MINS < = 20 MINS REC TIME E2504 SPCH GEN DEVC DIGTIZD>20 MINS< /=40 MINS REC TIME E2506 SPEECH GEN DEVICE DIGITIZED >40 MINS REC TIME E2508 SPCH GEN DEVC SYNTHSIZD REQ MESS SPELL & CNTCT E2510 SPCH GEN DEVC SYNTHESIZD MX METH MESS&DEVC ACCSS E2511 SPEECH GEN SOFTWARE PROG PC/PERS DIGITAL ASSIST E2512 ACCESS SPEECH GENERATING DEVICE MOUNTING SYSTEM E2599 ACCESSORY FOR SPEECH GENERATING DEVICE NOC E2601 GENERAL WHLCHAIR SEAT CUSHN WIDTH < 22 IN DEPTH E2602 GENERAL WHLCHAIR SEAT CUSHN WIDTH 22 IN/GT DEPTH E2603 SKN PROTECTION WC SEAT CUSHN WIDTH < 22 IN DEPTH E2604 SKN PROTECTION WC SEAT CUSHN WDTH 22 IN/GT DEPTH E2605 PSTN WHEELCHAIR SEAT CUSHN WIDTH < 22 IN DEPTH E2606 PSTN WHEELCHAIR SEAT CUSHN WIDTH 22 IN/GT DEPTH E2607 SKN PROTECT&PSTN WC SEAT CUSHN WDTH <22 IN DEPTH E2608 SKN PROTCT&PSTN WC SEAT CUSHN WDTH 22 IN/GT DPTH E2609 CUSTOM FABRICATED WHEELCHAIR SEAT CUSHION SIZE E2610 WHEELCHAIR SEAT CUSHION POWERED E2611 GEN WC BACK CUSHN WDTH < 22 IN HT MOUNT HARDWARE E2612 GEN WC BACK CUSHN WDTH 22 IN/GT HT MOUNT HARDWRE E2613 PSTN WC BACK CUSHN POST WIDTH < 22 IN ANY HEIGHT E2614 PSTN WC BACK CUSHN POST WIDTH 22 IN/> ANY HEIGHT E2615 PSTN WC BACK CUSHN POSTLAT WIDTH < 22 IN ANY HT E2616 PSTN WC BACK CUSHN POSTLAT WIDTH 22 IN/> ANY HT E2617 CSTM FAB WC BACK CUSHN ANY SZ ANY MOUNT HARDWARE E2619 REPL COVER WHEELCHAIR SEAT CUSHN/BACK CUSHN EA E2620 PSTN WC BACK CUSHN PLANAR LAT SUPP WDTH <22 IN E2621 PSTN WC BACK CUSHN PLANAR LAT SUPP WDTH 22 IN/> E2622 SKIN PROTECT WC SEAT CUSH WIDTH < 22 IN ANY DEPTH E2623 SKIN PROTCT WC SEAT CUSH WIDTH 22 IN/> ANY DEPTH E2624 SKIN PROTECT & POSITIONING WC CUSH WIDTH < 22 IN E2625 SKIN PROTECT & POSITIONING WC CUSH WIDTH 22 IN/> E2626 WC ACCESS SHLDR ELB MOBIL ARM SUPP WC ADJUSTBLE E2627 WC ACCESS SHLDR ELB M ARM SUPP ADJUSTBL RANCHO E2628 WC ACCESS SHLDR ELB MOBIL ARM SUPP WC RECLINING


E2629 WC ACCESS SHLDR ELB M ARM SUPP FRICTION ARM SUPP E2630 WC ACCESS SHLDR ELB MOBIL MONOSUSP ARM HAND SUPP E2631 WC ACCESS ADD MOBILE ARM SUPPORT ELEV PROX ARM E2632 WC ACCESS ADD MOBIL ARM SUPP OFFSET/LAT RCKR ARM E2633 WC ACCESS ADD MOBILE ARM SUPPORT SUPINATOR E8000 GAIT TRAINER PED SZ POST SUPP W/ALL ACSS&CMPNTS E8001 GAIT TRAINER PED SZ UPRT SUPP W/ALL ACSS&CMPNTS E8002 GAIT TRAINER PED SZ ANT SUPP W/ALL ACSS&CMPNTS G0127 TRIMMING OF DYSTROPHIC NAILS ANY NUMBER G0129 OCCUP TX REQ SKILLS QUAL OCCUP TRPST PER SESSION G0151 SRVC PHYS THERAPIST HOME HLTH/HOSPICE EA 15 MIN G0152 SRVC OCCUP THERAPIST HOME HLTH/HOSPICE EA 15 MIN G0153 SRVC SPCH&LANG PATH HOME HLTH/HOSPICE EA 15 MIN G0154 SRVC SKILLED NURSE HOME HEALTH/HOSPICE EA 15 MIN G0155 SRVC CLINICAL SOCIAL WORKER HH/HOSPICE EA 15 MIN G0156 SRVC HH/HOSPICE AIDE IN HH/HOSPICE SET EA 15 MIN G0157 SERVICES PT ASSIST HOME HEALTH/HOSPICE EA 15 MIN G0158 SERVICE OT ASSIST HOME HEALTH/HOSPICE EA 15 MIN G0159 SERVICES PT HOME HEALTH EST/DEL PROG EA 15 MIN G0160 SERVICES OT HOME HEALTH EST/DEL PROG EA 15 MIN G0161 SERVICE SPCH&LANG PATH HH EST/DEL PROG EA 15 MIN G0162 SKILLED SRVC RN MANAGEMENT & EVAL POC; EA 15 MIN G0163 SKILLED SRVC LPN/RN OBSERV/ASSESS PT EA 15 MIN G0164 SKL SRVC NURSE TRAIN/EDU PT FAM HH/HOSPICE 15 MN G0166 EXTERNAL COUNTERPULSATION PER TREATMENT SESSION G0173 LINR ACCELERATOR STEREOTAC RADIOSURG CMPL 1 SESS G0176 ACTV TX REL CARE&TX PTS DISABL MENTL HLTH-SESS G0177 TRN&ED REL CARE&TX PTS DISABL MENTL HLTH-SESS G0219 PET IMAG WHOLE BODY; MELANOMA NON-COVR INDICATS G0235 PET IMAGING ANY SITE NOT OTHERWISE SPECIFIED G0251 LINR STEREOTAC RADIOSURG TX ALL LES MAX 5 SESS G0252 PET IMAG INIT DX BREST CA&/SURG PLAN NOT COV MCR G0260 INJ PROC SI JNT;ANES STEROID&/TX AGT&ARTHROGRPH G0270 MED NUT TX; REASSESS FLW 2 REF YR W/PT EA 15 MIN G0271 MED NUT TX REASSESS FLW 2 REF YR GRP EA 30 MIN G0293 NONCOVR SURG CONSC SEDAT ANES-MCR QUAL TRIAL-DAY G0294 NONCOVR PROC NO ANES/LOC ANES-MCR QUAL TRIAL-DAY G0295 ELECMAGNET TX 1/>AREA WND CARE NOT G0329/OTH USE G0302 PRE-OP PULM SURG SRVC PREP LVRS CMPL COURSE SRVC G0303 PRE-OP PULM SURG SRVC PREP LVRS 10-15 DA SRVC G0304 PRE-OP PULM SURG PREP LVRS 1-9 DA SRVC G0305 POST-D/C PULM SURG AFTER LVRS MINI 6 DAYS SRVC G0329 ELECMAGNET TX ULCERS NOT HEALING 30 DAYS CARE


G0330 PET IMAGING INITIAL DIAGNOSIS CERVICAL G0331 PET IMAGING RESTAGING OVARIAN G0333 PHARM DISPEN FEE INHAL RX; INITIAL 30-DAY SUPPLY G0339 IMAGE GUID ROBOTIC ACCEL BASE SRS CMPL TX 1 SESS G0340 IMAGE GUID ROBOTIC ACCL SRS FRAC TX LES 2-5 SESS G0341 PERQ ISLET CELL TPLNT INCL PORTL VEIN CATH&INFUS G0342 LAP ISLET CELL TPLNT INCL PORTAL VEIN CATH&INFUS G0343 LAPAROT ISLET CELL TPLNT W/PORTL VEIN CATH&INFUS G0398 HST W/TYPE II PRTBLE MON UNATTENDED MIN 7 CH G0399 HST W/TYPE III PRTBLE MON UNATTENDED MIN 4 CH G0400 HST W/TYPE IV PRTBLE MON UNATTENDED MIN 3 CH G0420 FACE TO FACE EDU SRVC OF CKD; IND PER SESS 1 HR G0421 FACE TO FACE EDU SRVC OF CKD; GRP PER SESS 1 HR G0422 INTENSIVE CARD REHAB; W/WO CONT ECG MON W/EXER G0423 INTENSIVE CARD REHAB; W/WO CONT ECG MON W/O EXER G0424 PULM REHAB INCL EXER 1 HR PER SESS UP 2 PER DAY G9041 LW VISN REHAB SRVC QUALIFIED OT 1 ON 1 EA 15 MIN G9042 LW VIS REHAB SRVC CERT ORNT&MOBIL SPCLIST 15 MIN G9043 LW VISN REHAB SRVC CERT LW VISN TRPST EA 15 MIN G9044 LW VISN REHAB SRVC QUAL REHAB TEACHR EA 15 MIN G9147 OP IV INSULIN TX MEASURE: RQ; &/UUN; &/GLU; &/K+ H0006 ALCOHOL AND/OR DRUG SERVICES; CASE MANAGEMENT H0008 ALCOHOL &OR DRUG SRVC; SUB-ACUTE DTOX HOSP IP H0009 ALCOHOL &OR DRUG SERVICES; ACUTE DTOX HOSP IP H0010 ALCOHOL &/ DRUG SRVC; SUB-ACUTE DTOX RES PROG IP H0011 ALCOHOL &/ DRUG SERVICES; ACUTE DTOX RES PROG IP H0012 ALCOHOL &/ DRUG SRVC; SUB-ACUTE DTOX RES PROG OP H0013 ALCOHOL &/ DRUG SERVICES; ACUTE DTOX RES PROG OP H0014 ALCOHOL &OR DRUG SERVICES; AMB DETOXIFICATION H0015 ALCOHL&/RX SRVC;INTENSV OP;CRISIS INTRVN&ACTV TX H0016 ALCOHOL AND/OR DRUG SERVICES; MEDICAL/SOMATIC H0017 BEHAVIORAL HEALTH; RES W/O ROOM&BOARD PER DIEM H0018 BHVAL HEALTH; SHORT-TERM RES W/O ROOM&BOARD-DIEM H0019 BHVAL HEALTH; LONG-TERM RES W/O ROOM&BOARD-DIEM H0021 ALCOHOL AND/OR DRUG TRAINING SERVICE H0022 ALCOHOL AND/OR DRUG INTERVENTION SERVICE H0023 BEHAVIORAL HEALTH OUTREACH SERVICE H0024 BEHAVIORAL HEALTH PREV INFORM DISSEMIN SERVICE H0025 BEHAVIORAL HEALTH PREVENTION EDUCATION SERVICE H0026 ALCOHL&/RX PREVENTION PROCESS SERVICE CMTY-BASED H0027 ALCOHOL &OR DRUG PREVENTION ENVIR SERVICE H0028 ALCOHL&/RX PREV PROB ID&REF SRVC NOT W/ASSESS H0029 ALCOHOL &OR DRUG PREVENTION ALTERNATIVES SERVICE


H0035 MENTAL HEALTH PARTIAL HOSP TX < 24 HOURS H0039 ASSERTIVE COMMUNITY TX FACE-TO-FACE PER 15 MIN H0040 ASSERTIVE COMMUNITY TREATMENT PROGRAM PER DIEM H0041 FOSTER CARE CHILD NON-THERAPEUTIC PER DIEM H0042 FOSTER CARE CHILD NON-THERAPEUTIC PER MONTH H0043 SUPPORTED HOUSING PER DIEM H0044 SUPPORTED HOUSING PER MONTH H0045 RESPITE CARE SERVICES NOT IN THE HOME PER DIEM H0046 MENTAL HEALTH SERVICES NOT OTHERWISE SPECIFIED H0047 ALCOHOL AND/OR OTHER DRUG ABUSE SERVICES NOS J0128 INJECTION ABARELIX 10 MG J0129 INJECTION ABATACEPT 10 MG J0130 INJECTION ABCIXIMAB 10 MG J0131 INJECTION ACETAMINOPHEN 10 MG J0135 INJECTION ADALIMUMAB 20 MG J0180 INJECTION AGALSIDASE BETA 1 MG J0190 INJECTION BIPERIDEN LACTATE PER 5 MG J0205 INJECTION ALGLUCERASE PER 10 UNITS J0207 INJECTION AMIFOSTINE 500 MG J0215 INJECTION ALEFACEPT 0.5 MG J0220 INJECTION ALGLUCOSIDASE ALFA 10 MG J0221 INJECTION ALGLUCOSIDASE ALFA LUMIZYME 10 MG J0256 INJECTION ALPHA 1-PROTASE INHIBITOR - HUMN 10 MG J0257 INJECTION ALPHA 1 PROTEINASE INHIBITOR 10 MG J0287 INJECTION AMPHOTERICIN B LIPID COMPLEX 10 MG J0288 INJ AMPHOTERICIN B CHOLESTRYL SULFAT CMPLX 10 MG J0289 INJECTION AMPHOTERICIN B LIPOSOME 10 MG J0348 INJECTION ANIDULAFUNGIN 1 MG J0365 INJECTION APROTININ 10000 KIU J0380 INJECTION METARAMINOL BITARTRATE PER 10 MG J0395 INJECTION ARBUTAMINE HCL 1 MG J0400 INJECTION ARIPIPRAZOLE INTRAMUSCULAR 0.25 MG J0585 BOTULINUM TOXIN TYPE A PER UNIT J0586 INJECTION ABOBOTULINUMTOXINA 5 UNITS J0587 INJECTION RIMABOTULINUMTOXINB 100 UNITS J0588 INJECTION INCOBOTULINUMTOXIN A 1 UNIT J0637 INJECTION CASPOFUNGIN ACETATE 5 MG J0638 INJECTION CANAKINUMAB 1 MG J0718 INJECTION CERTOLIZUMAB PEGOL 1 MG J0725 INJECTION CHORIONIC GONADOTROPIN-1000 USP UNITS J0740 INJECTION CIDOFOVIR 375 MG J0775 INJ COLLAGENASE CLOSTRIDIUM HISTOLYTICUM 0.01 MG J0850 INJECTION CYTOMEGALOVIRUS IMMUNE GLOB IV-VIAL


J0878 INJECTION DAPTOMYCIN 1 MG J0881 INJECTION DARBEPOETIN ALFA 1 MCG NON-ESRD USE J0885 INJECTION EPOETIN ALFA FOR NON-ESRD 1000 UNITS J0897 INJECTION DENOSUMAB 1 MG J0900 INJ TESTO ENANTHATE&ESTRADIOL VALERATETOP 1 CC J1060 INJ TESTO CYPIONATE&ESTRADIOL CYPIONATE TO 1 ML J1070 INJECTION TESTOSTERONE CYPIONATE UP TO 100 MG J1080 INJECTION TESTOSTERONE CYPIONATE 1 CC 200 MG J1212 INJECTION DMSO DIMETHYL SULFOXIDE 50% 50 ML J1250 INJECTION DOBUTAMINE HCI PER 250 MG J1260 INJECTION DOLASETRON MESYLATE 10 MG J1267 INJECTION DORIPENEM 10 MG J1290 INJECTION ECALLANTIDE 1 MG J1300 INJECTION ECULIZUMAB 10 MG J1324 INJECTION ENFUVIRTIDE 1 MG J1325 INJECTION EPOPROSTENOL 0.5 MG J1438 INJECTION ETANERCEPT 25 MG J1440 INJECTION FILGRASTIM 300 MCG J1441 INJECTION FILGRASTIM 480 MCG J1452 INJECTION FOMIVIRSEN SODIUM INTRAOCULAR 1.65 MG J1453 INJECTION FOSAPREPITANT 1 MG J1458 INJECTION GALSULFASE 1 MG J1459 INJ IMMUNE GLOBULIN IV NONLYOPHILIZED 500 MG J1460 INJECTION GAMMA GLOBULIN INTRAMUSCULAR 1 CC J1470 INJECTION GAMMA GLOBULIN INTRAMUSCULAR 2 CC J1480 INJECTION GAMMA GLOBULIN INTRAMUSCULAR 3 CC J1490 INJECTION GAMMA GLOBULIN INTRAMUSCULAR 4 CC J1500 INJECTION GAMMA GLOBULIN INTRAMUSCULAR 5 CC J1510 INJECTION GAMMA GLOBULIN INTRAMUSCULAR 6 CC J1520 INJECTION GAMMA GLOBULIN INTRAMUSCULAR 7 CC J1530 INJECTION GAMMA GLOBULIN INTRAMUSCULAR 8 CC J1540 INJECTION GAMMA GLOBULIN INTRAMUSCULAR 9 CC J1550 INJECTION GAMMA GLOBULIN INTRAMUSCULAR 10 CC J1557 INJ IMMUNE GLOBULIN IV NONLYOPHILIZED 500 MG J1559 INJECTION IMMUNE GLOBULIN HIZENTRA 100 MG J1560 INJECTION GAMMA GLOB INTRAMUSCULAR OVER 10 CC J1561 INJ IG GAMUNEX IV NONLYOPHILIZED 500 MG J1562 INJECTION IMMUNE GLOBULIN VIVAGLBIN 100 MG J1566 INJ IG IV LYPHILIZED NOT OTHERWISE SPEC 500 MG J1568 INJ IG OCTOGAM IV NONLYOPHILIZED 500 MG J1569 INJ IG GAMMAGARD LIQ IV NONLYOPHILIZED 500 MG J1571 INJ HEPATITIS B IG HEPAGAM B IM 0.5 ML J1572 INJ IMMUNE GLOBULIN IV NONLYOPHILIZED 500 MG


J1573 INJ HEP B IG HEPAGAM B INTRAVENOUS 0.5 ML J1595 INJECTION GLATIRAMER ACETATE 20 MG J1599 INJ IG IV NONLYOPHILIZED E.G. LIQUID NOS 500 MG J1620 INJECTION GONADORELIN HYDROCHLORIDE PER 100 MCG J1626 INJECTION GRANISETRON HYDROCHLORIDE 100 MCG J1725 INJECTION HYDROXYPROGESTERONE CAPROATE 1 MG J1740 INJECTION IBANDRONATE SODIUM 1 MG J1743 INJECTION IDURSULFASE 1 MG J1745 INJECTION INFLIXIMAB 10 MG J1750 INJECTION IRON DEXTRAN 50 MG J1785 INJECTION IMIGLUCERASE PER UNIT J1786 INJECTION IMIGLUCERASE 10 UNITS J1817 INSULIN ADMINISTRATION THROUGH DME PER 50 UNITS J1825 INJECTION INTERFERON BETA-1A 33 MCG J1826 INJECTION INTERFERON BETA-1A 30 MCG J1830 INJECTION INTERFERON BETA-1B 0.25 MG J1930 INJECTION LANREOTIDE 1 MG J1931 INJECTION LARONIDASE 0.1 MG J2248 INJECTION MICAFUNGIN SODIUM 1 MG J2278 INJECTION ZICONOTIDE 1 MICROGRAM J2320 INJECTION NANDROLONE DECANOATE UP TO 50 MG J2321 INJECTION NANDROLONE DECANOATE UP TO 100 MG J2322 INJECTION NANDROLONE DECANOATE UP TO 200 MG J2323 INJECTION NATALIZUMAB 1 MG J2325 INJECTION NESIRITIDE 0.1 MG J2355 INJECTION OPRELVEKIN 5 MG J2357 INJECTION OMALIZUMAB 5 MG J2358 INJECTION OLANZAPINE LONG-ACTING 1 MG J2405 INJECTION ONDANSETRON HCL PER 1 MG J2425 INJECTION PALIFERMIN 50 MICROGRAMS J2426 INJECTION PALIPERIDONE PALMITATE EXT RLSE 1 MG J2430 INJECTION PAMIDRONATE DISODIUM PER 30 MG J2469 INJECTION PALONOSETRON HCL 25 MCG J2503 INJECTION PEGAPTANIB SODIUM 0.3 MG J2504 INJECTION PEGADEMASE BOVINE 25 IU J2505 INJECTION PEGFILGRASTIM 6 MG J2507 INJECTION PEGLOTICASE 1 MG J2562 INJECTION PLERIXAFOR 1 MG J2725 INJECTION PROTIRELIN PER 250 MCG J2770 INJECTION QUINUPRISTIN/DALFOPRISTIN 500 MG J2778 INJECTION RANIBIZUMAB 0.1 MG J2785 INJECTION REGADENOSON 0.1 MG J2793 INJECTION RILONACEPT 1 MG


J2794 INJECTION RISPERIDONE LONG ACTING 0.5 MG J2796 INJECTION ROMIPLOSTIM 10 MCG J2820 INJECTION SARGRAMOSTIM 50 MCG J2910 INJECTION AUROTHIOGLUCOSE UP TO 50 MG J2940 INJECTION SOMATREM 1 MG J2941 INJECTION SOMATROPIN 1 MG J2950 INJECTION PROMAZINE HCL UP TO 25 MG J3095 INJECTION TELAVANCIN 10 MG J3110 INJECTION TERIPARATIDE 10 MCG J3120 INJECTION TESTOSTERONE ENANTHATE UP TO 100 MG J3130 INJECTION TESTOSTERONE ENANTHATE UP TO 200 MG J3140 INJECTION TESTOSTERONE SUSPENSION UP TO 50 MG J3150 INJECTION TESTOSTERONE PROPIONATE UP TO 100 MG J3240 INJ THYROTROPIN ALPHA 0.9 MG PROV 1.1 MG VIAL J3243 INJECTION TIGECYCLINE 1 MG J3262 INJECTION TOCILIZUMAB 1 MG J3280 INJECTION THIETHYLPERAZINE MALEATE UP TO 10 MG J3285 INJECTION TREPROSTINIL 1 MG J3305 INJECTION TRIMETREXATE GLUCORONATE PER 25 MG J3310 INJECTION PERPHENAZINE UP TO 5 MG J3315 INJECTION TRIPTORELIN PAMOATE 3.75 MG J3320 INJ SPECTINOMYCIN DIHYDROCHLORIDE UP TO 2 GM J3355 INJECTION UROFOLLITROPIN 75 IU J3357 INJECTION USTEKINUMAB 1 MG J3385 INJECTION VELAGLUCERASE ALFA 100 UNITS J3396 INJECTION VERTEPORFIN 0.1 MG J3420 INJECTION VIT B-12 CYANOCOBALAMIN TO 1000 MCG J3465 INJECTION VORICONAZOLE 10 MG J3470 INJECTION HYALURONIDASE UP TO 150 UNITS J3471 INE HYALURONIDASE OVINE PRES FREE 1 USP UNIT J3472 INJ HYALURONIDASE OVINE PRES FREE-1000 USP UNITS J3473 INJECTION HYALURONIDASE RECOMBINANT 1 USP UNIT J3485 INJECTION ZIDOVUDINE 10 MG J3486 INJECTION ZIPRASIDONE MESYLATE 10 MG J3487 INJECTION ZOLEDRONICCID ZOMETA 1 MG J3488 INJECTION ZOLEDRONICCID RECLAST 1 MG J3490 UNCLASSIFIED DRUGS J3520 EDETATE DISODIUM PER 150 MG J3530 NASAL VACCINE INHALATION J3535 DRUG ADMINISTERED THROUGH A METERED DOSE INHALER J3570 LAETRILE AMYGDALIN VITAMIN B17 J3590 UNCLASSIFIED BIOLOGICS J7183 INJ VON WILLEBRAND FACTR COMPLEX WILATE 1 IU:RCO


J7184 INJECTION VWF COMPLEX WILATE PER 100 IU VWF:RCO J7185 INJECTION FACTOR VIII PER IU J7187 INJ VONWILLEBRND FACTOR CMPLX HUMN RISTOCETIN IU J7189 FACTOR VIIA 1 MICROGRAM J7190 FACTOR VIII ANTIHEMOPHILIC FACTOR HUMAN PER IU J7191 FACTOR VIII ANTIHEMOPHILIC FACTOR PROCINE PER IU J7192 FACTOR VIII PER IU NOT OTHERWISE SPECIFIED J7193 FACTOR IX AHF PURIFIED NON-RECOMBINANT PER IU J7194 FACTOR IX COMPLEX PER IU J7195 FACTOR IX PER IU J7196 INJECTION ANTITHROMBIN RECOMBINANT 50 I.U. J7197 ANTITHROMBIN III PER IU J7198 ANTI-INHIBITOR PER IU J7199 HEMOPHILIA CLOTTING FACTOR NOC J7303 CONTRACEPT SUPPLY HORMONE CONTAINING VAG RING EA J7304 CONTRACEPTIVE SUPPLY HORMONE CONTAINING PATCH EA J7306 LEVONORGESTREL CNTRACPTV IMPL SYS INCL IMPL&SPL J7308 AMINOLEVULINIC ACID HCL TOP ADMN 20% 1 U DOSE J7309 METHYL AMINOLEVULINATE MAL TOP ADMIN 16.8% 1 G J7310 GANCICLOVIR 45 MG LONG-ACTING IMPLANT J7311 FLUOCINOLONE ACETONIDE INTRAVITREAL IMPLANT J7312 INJECTION DEXAMETHASONE INTRAVITREAL IMPL 0.1 MG J7321 HYALURONAN/DERIV HYALGAN/SUPARTZ IA INJ PER DOSE J7323 HYALURONAN/DERIVATIVE EUFLEXXA IA INJ PER DOSE J7324 HYALURONAN/DERIV ORTHOVISC IA INJ PER DOSE J7325 HYALURONAN/DERIV SYNVISC/SYNVISC-ONE IA INJ 1 MG J7326 HYALURONAN/DERIV GEL-ONE INTRA-ARTIC INJ PER DOS J7330 AUTOLOGOUS CULTURED CHONDROCYTES IMPLANT J7335 CAPSAICIN 8% PATCH PER 10 SQUARE CM J7504 LYMPHCYT IMMUN GLOB EQUINE PARENTERAL 250 MG J7511 LYMPHCYT IMMUN GLOB RABBIT PARENTERAL 25 MG J7599 IMMUNOSUPPRESSIVE DRUG NOT OTHERWISE CLASSIFIED J7604 ACETYLCYSTEINE INHAL SOL COMP PROD UNIT DOSE P G J7605 ARFORMOTEROL INHAL SOL NONCOMP UNIT DOSE 15 MG J7606 FORMOTEROL FUMARATE INHAL SOL U DOSE FORM 20 MCG J7607 LEVALBUTEROL INHAL CP PROD THRU DME CONC 0.5 MG J7609 ALBUTEROL INHAL CP PROD THRU DME UNIT DOSE 1 MG J7610 ALBUTEROL INHAL SOL ADMIN THRU DME CONC 1 MG J7611 ALBUTEROL INHAL NON-CP THRU DME CONC FORM 1 MG J7612 LEVALBUTEROL INHAL NON-CP THRU DME CONC 0.5 MG J7613 ALBUTEROL INHAL NON-CP PROD THRU DME U DOSE 1 MG J7614 LEVALBUTEROL INHAL NON-CP THRU DME U DOSE 0.5 MG J7615 LEVALBUTEROL INHAL SOL THRU DME UNIT DOSE 0.5 MG


J7622 BECLOMETHASOME INHAL CP PROD UNIT DOSE PER MG J7624 BETAMETHASONE INHAL CP PROD DME UNIT DOSE PER MG J7627 BUDESONIDE INHAL CP PROD UNIT DOSE UP TO 0.5 MG J7628 BITOLTEROL MESYLATE INHAL CP PROD CONC PER MG J7629 BITOLTEROL MESYLATE INHAL CP UNIT DOSE PER MG J7631 CROMOLYN SODIUM INHALATION SOL NONCP UD P 10 MG J7632 CROMOLYN SODIUM INHAL SOL COMP PROD UD 10 MG J7633 BUDESONIDE INHAL NON-CP CONC FORM PER 0.25 MG J7634 BUDESONIDE INHAL CP PROD THRU DME CONC 0.25 MG J7635 ATROPINE INHAL SOL COMP PROD CONC FORM PER MG J7636 ATROPINE INHAL COMP PROD UNIT DOSE FORM PER MG J7637 DEXAMETHASONE INHAL COMP PROD CONC FORM PER MG J7638 DEXAMETHASONE INHAL COMP PROD UNIT DOSE PER MG J7639 DORNASE ALFA INHAL SOL NONCOMP UNIT DOSE PER MG J7640 FORMOTEROL INHAL COMP PROD UNIT DOSE FORM 12 MCG J7641 FLUNISOLIDE INHAL COMP PROD UNIT DOSE PER MG J7642 GLYCOPYRROLATE INHAL COMP PROD CONC FORM PER MG J7643 GLYCOPYRROLATE INHAL COMP UNIT DOSE FORM PER MG J7645 IPRATROPIUM BROMIDE INHAL THRU DME U DOSE PER MG J7647 ISOETHARINE HCL INHAL CP PROD THRU DME PER MG J7650 ISOETHARINE HCI INHAL THRU DME UNIT DOSE PER MG J7657 ISOPROTERENOL HCI INHAL CP PROD THRU DME PER MG J7660 ISOPROTERENOL HCI INHAL THRU DME U DOSE PER MG J7667 METAPROTERENOL SULFATE INHAL CP PROD CONC 10 MG J7670 METAPROTERENOL SULFATE INHAL THRU DME PER 10 MG J7676 PENTAMIDINE ISETHIONATE I SOL CP PROD U D 300 MG J7680 TERBUTALINE SULFATE INHAL COMP CONC FORM PER MG J7681 TERBUTALINE SULFATE INHAL COMP UNIT DOSE PER MG J7682 TOBRAMYCIN INHAL NON-COMP UNIT DOSE PER 300 MG J7683 TRIAMCINOLONE INHAL COMP PROD CONC FORM PER MG J7684 TRIAMCINOLONE INHAL COMP PROD UNIT DOSE PER MG J7685 TOBRAMYCIN INHAL CP PROD THRU DME U DOSE 300 MG J7686 TREPROSTINIL INHAL SOLUTION UNIT DOSE 1.74 MG J7699 NOC DRUGS INHALATION SOLUTION ADMINED THRU DME J7799 NOC RX OTH THAN INHALATION RX ADMINED THRU DME J8501 APREPITANT ORAL 5 MG J8515 CABERGOLINE ORAL 0.25 MG J8561 EVEROLIMUS ORAL 0.25 MG J8562 FLUDARABINE PHOSPHATE ORAL 10 MG J8565 GEFITINIB ORAL 250 MG J8597 ANTIEMETIC DRUG ORAL NOT OTHERWISE SPECIFIED J8650 NABILONE ORAL 1 MG J8700 TEMOZOLOMIDE ORAL 5 MG


J8705 TOPOTECAN ORAL 0.25 MG J8999 PRESCRIPTION DRUG ORAL CHEMOTHERAPEUTIC NOS J9031 BCG PER INSTILLATION J9041 INJECTION BORTEZOMIB 0.1 MG J9043 INJECTION CABAZITAXEL 1 MG J9151 INJ DAUNORUBICIN CITRATE LIPOSOMAL FORM 10 MG J9155 INJECTION DEGARELIX 1 MG J9178 INJECTION EPIRUBICIN HCL 2 MG J9179 INJECTION ERIBULIN MESYLATE 0.1 MG J9202 GOSERELIN ACETATE IMPLANT PER 3.6 MG J9207 INJECTION IXABEPILONE 1 MG J9212 INJECTION INTERFERON ALFACON-1 RECOMBINANT 1 MCG J9213 INJECTION INTERFERON ALFA-2A RECOMBINANT 3 M U J9214 INJECTION INTERFERON ALFA-2B RECOMBINANT 1 M U J9215 INJECTION INTERFERON ALFA-N3 250,000 IU J9216 INJECTION INTERFERON GAMMA-1B 3 MILLION UNITS J9225 HISTRELIN IMPLANT VANTAS 50 MG J9226 HISTRELIN IMPLANT SUPPRELIN LA 50 MG J9228 INJECTION IPILIMUMAB 1 MG J9261 INJECTION NELARABINE 50 MG J9264 INJECTION PACLITAXEL PROTEINBOUND PARTICLES 1 MG J9270 INJECTION PLICAMYCIN 2.5 MG J9302 INJECTION OFATUMUMAB 10 MG J9303 INJECTION PANITUMUMAB 10 MG J9307 INJECTION PRALATREXATE 1 MG J9315 INJECTION ROMIDEPSIN 1 MG J9328 INJECTION TEMOZOLOMIDE 1 MG J9330 INJECTION TEMSIROLIMUS 1 MG J9350 INJECTION TOPOTECAN 4 MG J9351 INJECTION TOPOTECAN 0.1 MG J9355 INJECTION TRASTUZUMAB 10 MG J9357 INJECTION VALRUBICIN INTRAVESICAL 200 MG J9395 INJECTION FULVESTRANT 25 MG J9600 INJECTION PORFIMER SODIUM 75 MG J9999 NOT OTHERWISE CLASSIFIED ANTINEOPLASTIC DRUG K0001 STANDARD WHEELCHAIR K0002 STANDARD HEMI WHEELCHAIR K0003 LIGHTWEIGHT WHEELCHAIR K0004 HIGH STRENGTH LIGHTWEIGHT WHEELCHAIR K0005 ULTRALIGHTWEIGHT WHEELCHAIR K0006 HEAVY-DUTY WHEELCHAIR K0007 EXTRA HEAVY-DUTY WHEELCHAIR K0009 OTHER MANUAL WHEELCHAIR/BASE


K0010 STANDARD-WEIGHT FRAME MOTORIZED/POWER WHEELCHAIR K0011 STD-WT FRME MOTRIZD/PWR WHLCHAIR W/PROG CNTRL K0012 LIGHTWEIGHT PORTABLE MOTORIZED/POWER WHEELCHAIR K0014 OTHER MOTORIZED/POWER WHEELCHAIR BASE K0015 DETACHABLE NONADJUSTABLE HEIGHT ARMREST EACH K0017 DETACHABLE ADJUSTABLE HEIGHT ARMREST BASE EACH K0018 DETACHBLE ADJUSTBLE HEIGHT ARMREST UPPER PRTN EA K0019 ARM PAD EACH K0020 FIXED ADJUSTABLE HEIGHT ARMREST PAIR K0037 HIGH MOUNT FLIP-UP FOOTREST EACH K0038 LEG STRAP EACH K0039 LEG STRAP H STYLE EACH K0040 ADJUSTABLE ANGLE FOOTPLATE EACH K0041 LARGE SIZE FOOTPLATE EACH K0042 STANDARD SIZE FOOTPLATE EACH K0043 FOOTREST LOWER EXTENSION TUBE EACH K0044 FOOTREST UPPER HANGER BRACKET EACH K0045 FOOTREST COMPLETE ASSEMBLY K0046 ELEVATING LEGREST LOWER EXTENSION TUBE EACH K0047 ELEVATING LEGREST UPPER HANGER BRACKET EACH K0050 RATCHET ASSEMBLY K0051 CAM RELEASE ASSEMBLY FOOTREST OR LEGREST EACH K0052 SWINGAWAY DETACHABLE FOOTRESTS EACH K0053 ELEVATING FOOTRESTS ARTICULATING EACH K0056 SEAT HT<17/=TO/>21 IN LTWT/ULTRALTWT WHLCHAIR K0065 SPOKE PROTECTORS EACH K0069 REAR WHL ASSEMBL CMPL W/SOLID TIRE SPOKE/MOLD EA K0070 REAR WHL ASSMBL CMPL-PNEUMAT TIRE SPOKE/MOLD EA K0071 FRONT CASTER ASSEMBLY COMPLETE W/PNEUMAT TIRE EA K0072 FRONT CASTR ASSEMBLY CMPL W/SEMIPNEUMAT TIRE EA K0073 CASTER PIN LOCK EACH K0077 FRONT CASTER ASSEMBLY COMPLETE W/SOLID TIRE EACH K0098 DRIVE BELT FOR POWER WHEELCHAIR K0105 IV HANGER EACH K0108 OTHER ACCESSORIES K0195 ELEVATING LEGREST PAIR K0455 INFUSION PUMP UNINTERRUPTED PARENTERAL ADMIN MED K0462 TEMP REPL PT OWNED EQUIP BEING REPR ANY TYPE K0552 SPL EXT INF PUMP SYRINGE TYPE CARTRIDGE STERL EA K0601 REPL BATTRY EXT INFUS PUMP SILVER OXIDE 1.5 V EA K0602 REPL BATTERY EXT INFUS PUMP SILVER OXIDE 3 V EA K0603 REPL BATTERY EXT INFUS PUMP ALKALINE 1.5 VOLT EA K0604 REPL BATTERY EXT INFUS PUMP LITHIUM 3.6 VOLT EA


K0605 REPL BATTERY EXT INFUS PUMP LITHIUM 4.5 VOLT EA K0606 AUTO EXT DEFIB W/INTGR ECG ANALY GARMENT TYPE K0607 REPL BATTRY AUTO EXT DEFIB GARMNT TYPE ONLY EA K0608 REPLACEMENT GARMENT USE W/AUTO EXTERNAL DEFIB EA K0609 REPL ELEC W/AUTO EXT DEFIB GARMNT TYPE ONLY EA K0669 WC ACCESS WC SEAT/BACK CUSHION NO DME PDAC K0730 CONTROLLED DOSE INHALATION DRUG DELIVERY SYSTEM K0733 PWR WC 12-24 AMP HR SEALED LEAD ACID BATTERY EA K0734 SKIN PROTECTION WC SEAT CUSH ADJ WIDTH < 22 INCH K0735 SKIN PROTECTION WC SEAT CUSH ADJ WIDTH 22 INCH/> K0736 SKIN PROTCT&PSTN WC CUSHN ADJ WDTH < 22 IN DEPTH K0737 SKIN PROTECT& PSTN WC CUSHN ADJ WIDTH 22 IN /> K0738 PORTABLE GASEOUS O2 SYS RENTAL; HOME COMPRESSOR K0739 REPR/SRVC DME NOT O2 RQR TECH CMPNT PER 15 MINS K0740 REPR/SRVC FOR O2 EQP RQR TECH CMPNT PER 15 MINS K0745 ABSRB WD DR HOM MDL PRT PAD>16 SQ IN< /= 48 SQ IN K0800 PWR OP VEH GRP 1 STD PT WT CAP TO & INCL 300 LBS K0801 PWR OP VEH GRP 1 HEAVY DUTY PT 301 TO 450 LBS K0802 PWR OP VEH GRP 1 VERY HEAVY DUTY PT 451-600 LBS K0806 PWR OP VEH GRP 2 STD PT WT CAP TO & INCL 300 LBS K0807 PWR OP VEH GRP 2 HEAVY DUTY PT 301 TO 450 LBS K0808 PWR OP VEH GRP 2 VERY HEAVY DUTY PT 451-600 LBS K0812 POWER OPERATED VEHICLE NOT OTHERWISE CLASSIFIED K0813 PWR WC GRP 1 STD PORT SLING SEAT PT TO 300 LBS K0814 PWR WC GRP 1 STD PORT CAPT CHAIR PT TO 300 LBS K0815 PWR WC GRP 1 STD SLING SEAT PT UP TO &= 300 LBS K0816 PWR WC GRP 1 STD CAPTAINS CHAIR PT TO &=300 LBS K0820 PWR WC GRP 2 STD PORT SLING SEAT PT TO &=300 LBS K0821 PWR WC GRP 2 STD PORT CAPT CHAIR PT TO &=300 LBS K0822 PWR WC GRP 2 STD SLING SEAT PT TO &=300 LBS K0823 PWR WC GRP 2 STD CAPTAINS CHAIR PT TO &=300 LBS K0824 PWR WC GRP 2 HEVY DUTY SLING SEAT PT 301-450 LBS K0825 PWR WC GRP 2 HEVY DUTY CAPT CHAIR PT 301-450 LBS K0826 PWR WC GRP 2 VRY HVY DTY SLNG SEAT PT 451-600 LB K0827 PWR WC GRP 2 VRY HVY DTY CAPT CHR PT 451-600 LBS K0828 PWR WC GRP 2 XTRA HVY DUTY SLING SEAT PT 601LB/> K0829 PWR WC GRP 2 XTRA HVY DUTY CHAIR PT 601 LBS/> K0830 PWR WC GRP 2 STD SEAT ELEV SLING PT TO &=300 LBS K0831 PWR WC GRP 2 STD SEAT ELEV CAP CHR PT TO 300 LB K0835 PWR WC GRP 2 STD 1 PWR SLING SEAT PT TO 300 LBS K0836 PWR WC GRP 2 STD 1 PWR CAPT CHAIR PT TO 300 LBS K0837 PWR WC GRP 2 HVY 1 PWR SLING SEAT PT 301-450 LBS K0838 PWR WC GRP 2 HVY 1 PWR CAPT CHAIR PT 301-450 LBS


K0839 PWR WC GRP 2 VRY HVY 1 PWR SLING PT 451-600 LBS K0840 PWR WC GRP 2 XTRA HVY 1 PWR SLING PT 601 LBS/> K0841 PWR WC GRP 2 MX PWR SLING SEAT PT TO &=300 LBS K0842 PWR WC GRP 2 STD MX PWR CAPT CHR PT TO &=300 LBS K0843 PWR WC GRP 2 HVY MX PWR SLNG SEAT PT 301-450 LBS K0848 PWR WC GRP 3 STD SLING SEAT PT TO & = 300 LBS K0849 PWR WC GRP 3 STD CAPTAIN CHAIR PT TO & = 300 LBS K0850 PWR WC GRP 3 HVY DUTY SLING SEAT PT 301-450 LBS K0851 PWR WC GRP 3 HVY DUTY CAPT CHAIR PT 301-450 LBS K0852 PWR WC GRP 3 V HVY DUTY SLING SEAT PT 451-600 LB K0853 PWR WC GRP 3 HVY DUTY CAPT CHAIR PT 451-600 LBS K0854 PWR WC GRP 3 XTRA HVY DTY SLNG SEAT PT 601 LBS/> K0855 PWR WC GRP 3X HVY DTY CHR PT WT CAP 601 LB/> K0856 PWR WC GRP 3 STD 1 PWR SLING SEAT PT TO &=300 LB K0857 PWR WC GRP 3 STD 1 PWR CAPT CHAIR PT TO &=300 LB K0858 PWR WC GRP 3 HD 1 PWR SLING SEAT PT 301-450 LBS K0859 PWR WC GRP 3 HD 1 PWR CAPT CHAIR PT 301-450 LBS K0860 PWR WC GRP 3 V HD 1 PWR SLING SEAT PT 451-600 LB K0861 PWR WC GRP 3 STD MX PWR SLNG SEAT PT TO &=300 LB K0862 PWR WC GRP 3 HD MX PWR SLING SEAT PT 301-450 LBS K0863 PWR WC GRP 3 V HD MX PWR SLNG SEAT PT 451-600 LB K0864 PWR WC GRP 3 XTR HD MX PWR SLNG SEAT PT 601 LB/> K0868 PWR WC GRP 4 STD SLING SEAT PT TO & = 300 LBS K0869 PWR WC GRP 4 STD CAPTAIN CHAIR PT TO & = 300 LBS K0870 PWR WC GRP 4 HVY DUTY SLING SEAT PT 301-450 LBS K0871 PWR WC GRP 4 V HVY DUTY SLING SEAT PT 451-600 LB K0877 PWR WC GRP 4 STD 1 PWR SLING SEAT PT TO &=300 LB K0878 PWR WC GRP 4 STD 1 PWR CAPT CHAIR PT TO &=300 LB K0879 PWR WC GRP 4 HD 1 PWR SLING SEAT PT 301-450 LBS K0880 PWR WC GRP 4 V HD 1 PWR SLING SEAT PT 451-600 LB K0884 PWR WC GRP 4 STD MX PWR SLNG SEAT PT TO &=300 LB K0885 PWR WC GRP 4 STD MX PWR CAPT CHR PT TO &=300 LBS K0886 PWR WC GRP 4 HD MX PWR SLING SEAT PT 301-450 LBS K0890 PWR WC GRP 5 PED 1 PWR SLING SEAT PT TO &=125 LB K0891 PWR WC GRP 5 PED MX PWR SLNG SEAT PT TO &=125 LB K0898 POWER WHEELCHAIR NOT OTHERWISE CLASSIFIED K0899 PWR MOBILTY DVC NOT CODED DME PDAC/NOT MEET CRIT L0112 CRANIL CERV ORTHOT CONGN TORTICOLLIS TYPE CUSTOM L0113 CRANIAL CERVL ORTHOTIC TORTICOLLIS TYPE PREFAB L0999 ADD TO SPINAL ORTHOTIC NOT OTHERWISE SPECFIED L1499 SPINAL ORTHOTIC NOT OTHERWISE SPECIFIED L2999 LOWER EXTREMITY ORTHOSES NOT OTHERWISE SPECIFIED L3999 UPPER LIMB ORTHOSIS NOT OTHERWISE SPECIFIED


L5781 ADD LW LIMB PROS RESIDUL LIMB VOL MGMT SYS L5856 ADD LOW EXT PROS KNEE-SHIN SYS SWING&STANCE PHSE L5857 ADD LOW EXT PROS KNEE-SHIN SYS SWING PHASE ONLY L5858 ADD LW EXT PROS KNEE SHIN SYS STANCE PHASE ONLY L5973 ENDOSKEL ANK FOOT SYS MICRPROCSS CONTROL PWR SRC L5999 LOWER EXTREMITY PROSTHESIS NOS L6025 TRANSCARPAL/MC/PART HND DISARTIC PROS DEVC L6920 WRST DISARTIC OTTO BOCK/=SWTCH CNTRL TERM DEVC L6925 WRST DISARTIC OTTO BOCK/=MYOELEC CNTRL TERM DEVC L6930 BELW ELB OTTO BOCK/=SWITCH CNTRL TERM DEVC L6935 BELW ELB OTTO BOCK/=MYOELEC CNTRL TERM DEVC L6940 ELB DISARTIC OTTO BOCK/=SWITCH CNTRL TERM DEVC L6945 ELB DISARTIC OTTO BOCK/=MYOELEC CNTRL TERM DEVC L6950 ABVE ELB OTTO BOCK/=SWITCH CNTRL TERM DEVC L6955 ABVE ELB OTTO BOCK/=MYOELEC CNTRL TERM DEVC L6960 SHLDR DISARTIC OTTO BOCK/=SWTCH CNTRL TERM DEVC L6965 SHLDR DISARTIC OTTO BOCK/=MYOELEC CNTRL TERM L6970 INTERSCAP-THOR OTTO BOCK/=SWTCH CNTRL TERM DEVC L6975 INTERSCAP-THOR OTTO BOCK/=MYOELEC CNTRL TERM DVC L7180 ELEC ELB MICROPRC SEQENTIAL CNTRL ELB&TERM DEVC L7181 ELEC ELB MICROPRC SIMULTAN CNTRL ELB&TERM DEVC L7190 ELEC ELB ADOLES VRITY VILLAGE/= MYOELEC CNTRL L7191 ELEC ELB CHLD VRITY VILL/= MYOELECTRNICALY CNTRL L7499 UPPER EXTREMITY PROSTHESIS NOS L8499 UNLISTED PROC MISCELLANEOUS PROSTHETIC SERVICES L8600 IMPLANTABLE BREAST PROSTHESIS SILICONE OR EQUAL L8603 INJ BULK AGT COLL IMPL URIN TRACT 2.5 ML SYRINGE L8606 INJ BULK AGT SYNTH IMPL URIN TRACT 1 ML SYRINGE L8609 ARTIFICIAL CORNEA L8610 OCULAR IMPLANT L8612 AQUEOUS SHUNT L8613 OSSICULA IMPLANT L8614 COCHLEAR DEVICE INCLUDES ALL INT&EXT COMPONENTS L8615 HEADSET/HEADPIECE COCHLEAR IMPLANT DEVICE REPL L8616 MICROPHONE COCHLEAR IMPLANT DEVICE REPLACEMENT L8617 TRANSMITTING COIL COCHLEAR IMPLANT DEVICE REPL L8618 TRANSMITTER CABLE COCHLEAR IMPLANT DEVICE REPL L8619 COCHLEAR IMPL EXT SPEECH PROCESSR/CONTROLLR REPL L8627 COCHLEAR IMPL EXT SPEECH PROCESSR COMPONENT REPL L8628 COCHLEAR IMPLANT EXT CONTROLLER COMPONENT REPL L8629 TRANSMITTING COIL CABLE COCHLEAR IMPL DEV REPL L8630 METACARPOPHALANGEAL JOINT IMPLANT L8631 MPJ REPLCMT TWO/MORE PECES METL CERAM-LIKE MATL


L8641 METATARSAL JOINT IMPLANT L8642 HALLUX IMPLANT L8658 INTERPHALANGEAL JOINT SPACER SILICONE/EQUAL EACH L8659 IP FNGR JNT REPLCMT 2/MORE PECES METL CERAM-LIKE L8670 VASCULAR GRAFT MATERIAL SYNTHETIC IMPLANT L8680 IMPLANTABLE NEUROSTIMULATOR ELECTRODE EACH L8681 PT PROG W/IMPL PROG NEUROSTM PULSE GEN REPL ONLY L8682 IMPLANTABLE NEUROSTIMULATOR RADIOFREQ RECEIVER L8683 RF TRNSMT USE W/IMPLANTABLE NEUROSTIM RF RECV L8684 RF TRNSMT BOWEL & BLADDER MANAGEMENT; REPL L8685 IMPLANT NEUROSTIM 1 ARRAY RECHARGEABLE L8686 IMPLANT NEUROSTIM 1 ARRAY NON-RECHARGEABLE L8687 IMPLANT NEUROSTIM 2 ARRAY RECHARGEABLE L8688 IMPLANT NEUROSTIM 2 ARRAY NON-RECHARGEABLE L8689 EXT RECHARG SYS BATTRY IMPL NEUROSTIM REPL ONLY L8690 AUDITORY OSSEOINTEGRATED DEVC INT/EXT COMPONENTS L8691 AUDITORY OSSEOINTEGRATD DEVC EXT SOUND PROC REPL L8692 AUDITORY OSSEOINTEGRATED DEV EXT SOUND BODY WORN L8693 AUD OSSEOINTEGRATED DEVC ABUT LENGTH REPL ONLY L8695 EXT RECHARGING SYS BATTERY W/IMPL NEUROSTIM REPL L8699 PROSTHETIC IMPLANT NOT OTHERWISE SPECIFIED L9900 ORTHO&PROS SPL ACSS&/SRVC CMPNT OTH HCPCS L CODE M0075 CELLULAR THERAPY M0076 PROLOTHERAPY M0100 INTRAGASTRIC HYPOTHERMIA USING GASTRIC FREEZING M0300 IV CHELATION THERAPY P2031 HAIR ANALYSIS P9603 TRAVEL 1 WAY MED NEC LAB SPEC; PRORAT ACTL MILE Q0138 INJ FERUMOXYTOL TX IRON DEF ANEMIA 1 MG NON-ESRD Q0139 INJ FERUMOXYTOL TX IRON DEF ANEMIA 1 MG FOR ESRD Q0515 INJECTION SERMORELIN ACETATE 1 MICROGRAM Q1003 NEW TECHNOLOGY INTRAOCULAR LENS CATEGORY 3 Q1004 NEW TECH IO LENS CATGY 4 DEFINED FEDERAL REG Q1005 NEW TECH IO LENS CATGY 5 DEFINED FEDERAL REG Q2026 INJECTION RADIESSE 0.1ML Q2027 INJECTION SCULPTRA 0.1ML Q2040 INJECTION INCOBOTULINUMTOXIN A 1 UNIT Q2042 HYDROXYPROGESTERONE CAPROATE Q3014 TELEHEALTH ORIGINATING SITE FACILITY FEE Q4074 ILOPROST INHAL SOL THRU DME UNIT DOSE TO 20 MCG Q4082 DRUG OR BIOLOGICAL NOC PART B DRUG CAP Q5001 HOSPICE CARE PROVIDED IN PATIENTS HOME/RESIDENCE Q5002 HOSPICE CARE PROVIDED ASSISTED LIVING FACILITY


Q5003 HOSPICE CARE PROV NURSING LTC FACL/NON-SKILL NF Q5004 HOSPICE CARE PROVIDED SKILLED NURSING FACILITY Q5005 HOSPICE CARE PROVIDED IN INPATIENT HOSPITAL Q5006 HOSPICE CARE PROV INPATIENT HOSPICE FACILITY Q5007 HOSPICE CARE PROV LONG TERM CARE FACILITY Q5008 HOSPICE CARE PROV INPATIENT PSYCHIATRIC FACILITY Q5009 HOSPICE CARE PROVIDED IN PLACE NOS Q5010 HOSPICE HOME CARE PROVIDED IN A HOSPICE FACILITY R0070 TRANS PRTBL X-RAY EQP&PERS HOM/NRS HOM-TRIP 1 PT R0075 TRANS PRTBL XRAY EQP&PERS HOM/NRS HOM-TRIP>1 PT R0076 TRANSPORTATION PRTBLE EKG FACL/LOCATION PER PT S0012 BUTORPHANOL TARTRATE NASAL SPRAY 25 MG S0014 TACRINE HYDROCHLORIDE 10 MG S0088 IMATINIB 100 MG S0090 SILDENAFIL CITRATE 25 MG S0091 GRANISETRON HYDROCHLORIDE 1 MG S0092 INJECTION HYDROMORPHONE HYDROCHLORIDE 250 MG S0093 INJECTION MORPHINE SULFATE 500 MG S0104 ZIDOVUDINE ORAL 100 MG S0106 BUPROPION HCI SUSTAINED RLSE TAB 150 MG 60 TABS S0108 MERCAPTOPURINE ORAL 50 MG S0109 METHADONE ORAL 5MG S0117 TRETINOIN TOPICAL 5 GRAMS S0119 ONDANSETRON ORAL 4 MG S0122 INJECTION MENOTROPINS 75 IU S0126 INJECTION FOLLITROPIN ALFA 75 IU S0128 INJECTION FOLLITROPIN BETA 75 IU S0132 INJECTION GANIRELIX ACETATE 250 MCG S0136 CLOZAPINE 25 MG S0137 DIDANOSINE 25 MG S0138 FINASTERIDE 5 MG S0139 MINOXIDIL 10 MG S0140 SAQUINAVIR 200 MG S0142 COLISTMTHATE SODIUM INHAL SOL CONC FORM-PER MG S0145 INJ PEGYLATED INTERFERON ALFA2A 180 MCG PER ML S0146 INJ PEGYLATED INTERFERON ALFA-2B 10 MCG 0.5 ML S0148 INJECTION PEGYLATED INTERFERON ALFA-2B 10 MCG S0155 STERILE DILUTANT FOR EPOPROSTENOL 50 ML S0156 EXEMESTANE 25 MG S0157 BECAPLERMIN GEL 0.01% 0.5 GM S0160 DEXTROAMPHETAMINE SULFATE 5 MG S0161 CALCITROL 0.25 MG S0164 INJECTION PANTOPRAZOLE SODIUM 40 MG


S0166 INJECTION OLANZAPINE 2.5 MG S0170 ANASTROZOLE ORAL 1 MG S0171 INJECTION BUMETANIDE 0.5 MG S0172 CHLORAMBUCIL ORAL 2 MG S0174 DOLASETRON MESYLATE ORAL 50 MG S0175 FLUTAMIDE ORAL 125 MG S0176 HYDROXYUREA ORAL 500 MG S0177 LEVAMISOLE HYDROCHLORIDE ORAL 50 MG S0178 LOMUSTINE ORAL 10 MG S0179 MEGESTROL ACETATE ORAL 20 MG S0181 ONDANSETRON HYDROCHLORIDE ORAL 4 MG S0182 PROCARBAZINE HYDROCHLORIDE ORAL 50 MG S0183 PROCHLORPERAZINE MALEATE ORAL 5 MG S0187 TAMOXIFEN CITRATE ORAL 10 MG S0189 TESTOSTERONE PELLET 75 MG S0190 MIFEPRISTONE ORAL 200 MG S0191 MISOPROSTOL ORAL 200 MCG S0196 INJ POLYLLACTIC ACID RESTORATIVE IMPL 1 ML FACE S0199 MED INDUCED AB ORAL INGESTION MED W/SRVC & SPL S0209 WHEELCHAIR VAN MILEAGE PER MILE S0215 NON-EMERGENCY TRANSPORTATION; PER MILE S0250 COMP GERIATRIC ASSESS&TX PLAN PRFRM ASSESS TEAM S0265 GENETIC COUNSELING PHYS SUPERVISION EA 15 MINS S0270 PHYSICIAN MGT PT HOME CARE STD MONTHLY CASE RATE S0271 PHYS MGT PT HOME CARE HOSPICE MONTHLY CASE RATE S0272 PHYS MGT PT HOME CARE EPISODIC CARE MO CASE RATE S0273 PHYS VST MEMBER HOME OUTSIDE CAPITATION ARRNGMNT S0274 NP VST MEMBER HOME OUTSIDE CAPITATION ARRANGMENT S0390 ROUTINE FOOT CARE; PER VISIT S0395 IMPRESSION CASTING FOOT PERFORMED PRACTITIONER S0400 GLOBAL FEE XTRACORP SHOCK WAVE LITH KIDNEY STONE S0590 INTEGRAL LENS SERVICE MISC SERVICES REPORTED SEP S0596 PHAKIC INTRAOCULAR LENS CORRECT REFRACTIVE ERROR S1030 CONT NONINVASIVE GLU MONITORING DEVICE PURCHASE S1031 CONT NONINVAS GLU MON DEVC RENTAL SENSOR REPL S1040 CRANIAL REMOLDING ORTHOTIC PED RIGID CUSTOM FAB S2053 TRANSPLANTATION SMALL INTESTINE&LIVER ALLOGRAFTS S2054 TRANSPLANTATION OF MULTIVISCERAL ORGANS S2055 HARVEST DONOR MX-VISCERAL ORGAN; CADVER DONOR S2060 LOBAR LUNG TRANSPLANTATION S2061 DONOR LOBECTOMY FOR TRANSPLANTATION LIVING DONOR S2065 SIMULTANEOUS PANCREAS KIDNEY TRANSPLANTATION S2066 BREAST RECON W/GLUTEAL ART PERFORATOR FLAP UNI


S2067 BRST RECON 1 BRST DIEP FLAP(S)&/GAP FLAP(S) UNI S2068 BREAST RECON DIEP/SIEA FLAP & CLOS DONR SITE UNI S2079 LAP ESOPHAGOMYOTOMY HELLER TYPE S2080 LASER-ASSISTED UVULOPALATOPLASTY S2083 ADJ GASTRIC BAND DIAM SUBQ PORT INJ/ASPIR SALINE S2095 TRNSCATH OCCL/EMBOLIZ TUMR DESTRUC PERQ METH USI S2102 ISLET CELL TISS TRANSPLANT FROM PANC; ALLOGENEIC S2103 ADRENAL TISSUE TRANSPLANT TO BRAIN S2107 ADOPTIVE IMMUNOTHERAPY PER COURSE OF TREATMENT S2112 ARTHROSCOPY KNEE SURGICAL HARVESTING CARTILAGE S2115 OSTEOTOMY PERIACETABULAR WITH INTERNAL FIXATION S2117 ARTHROEREISIS SUBTALAR S2118 METL-ON-METL TOT HIP RESRFC ACETAB&FEM CMPNT S2140 CORD BLOOD HARVESTING TRANSPLANTATION ALLOGENEIC S2142 CORD BLD-DERIVED STEM-CELL TPLNT ALLOGENEIC S2150 BN MARROW/BLD DERIVD STEM CELLS HARV TPLNT&COMP; S2152 SOLID ORGAN; TRANSPLANTATION & RELATED COMP S2202 ECHOSCLEROTHERAPY S2230 IMPL MAGNET CMPNT SEMI-IMPL HEARING DEVC MID EAR S2235 IMPLANTATION OF AUDITORY BRAIN STEM IMPLANT S2260 INDUCED ABORTION 17 TO 24 WEEKS S2265 INDUCED ABORTION 25 TO 28 WEEKS S2266 INDUCED ABORTION 29 TO 31 WEEKS S2267 INDUCED ABORTION 32 WEEKS OR GREATER S2300 ARTHROSCOPE SHLDR SURG; W/THERML-INDUCD CPSLORR S2325 HIP CORE DECOMPRESSION S2348 DECOMP PERQ INTERVERT DISC RF ENERGY 1/MX LUMB S2350 DISKECT ANT W/OSTEOPHYTECT; LUMBAR 1 INTERSPACE S2351 DISKECT ANT W/OSTEOPHYTECT; LUMB EA ADD INTRSP S2360 PERQ VERTPLSTY 1 VERT BDY UNILAT/BILAT INJ; CERV S2361 EACH ADDITIONAL CERVICAL VERTEBRAL BODY S2400 REPR CONGN DIAPHRAGMAT HERN FETUS PROC IN UTERO S2401 REPR URIN TRACT OBST FETUS PROC PRFRM UTERO S2402 REPR CONGEN CYST ADENOMATOID MALF FETUS IN UTERO S2403 REPR EXTRALOBAR PULM SEQUEST FETUS-UTERO S2404 REPAIR MYELOMENINGOCELE FETUS PROC PRFRM UTERO S2405 REPR SACROCOC TERATOMA FETUS IN UTERO S2409 REP CONGN MALFORM FETUS PROC PRFRM UTERO NOC S2411 FETOSCOPIC LASER TX FOR TREATMENT-TTTS S2900 SURG TECHNIQUES REQUIRING USE ROBOTIC SURG SYS S3713 KRAS MUTATION ANALYSIS TESTING S3721 PROSTATE CANCER ANTIGEN 3 TESTING S3722 DOSE OPTIMIZ AUC ANALY INFUSIONAL 5-FLUOROURACIL


S3818 COMPLETE GENE SEQUENCE ANALYSIS; BRCA1 GENE S3819 COMPLETE GENE SEQUENCE ANALYSIS; BRCA2 GENE S3820 COMPL BRCA1&BRCA2 GENE SEQ ANALY BRST&OVARN CA S3822 SINGLE-MUTAT ANALY SUSCEPT BREAST&OVARIAN CANCER S3823 3-MUTATION BRCA1&BRCA2 ANALYSIS ASHKENAZI IND S3828 COMPLETE GENE SEQUENCE ANALYSIS; MLH1 GENE S3829 COMPLETE GENE SEQUENCE ANALYSIS; MSH2 GENE S3830 CMPL MLH1&MSH2 GENE SEQ ANALY HNPCC GENETIC TEST S3831 SINGLE-MUTATION ANALYSIS HNPCC GENETIC TESTING S3833 CMPL APC GENE SEQ ANALY SUSCPT FAP&ATTENUATD FAP S3834 SINGLE-MUTAT ANALY SUSCEPT FAP&ATTENUATED FAP S3835 CMPL GENE SEQ ANALY CYSTIC FIBROSIS GENETIC TST S3837 CMPL GENE SEQ ANALY HEMOCHROMATOSIS GENETIC TST S3840 DNA ANALYSIS GERMLINE MUTATS RET PROTO-ONCOGENE S3841 GENETIC TESTING FOR RETINOBLASTOMA S3842 GENETIC TESTING FOR VON HIPPEL-LINDAU DISEASE S3843 DNA ANALYSIS F5 GENE FCT V LEIDEN THROMBOPHILIA S3844 DNA ANALY CONNEXIN 26 GENE CONGN PFND DEAFNESS S3845 GENETIC TESTING FOR ALPHA-THALASSEMIA S3846 GENETIC TESTING HEMOGLOBIN E BETA-THALASSEMIA S3847 GENETIC TESTING FOR TAY-SACHS DISEASE S3848 GENETIC TESTING FOR GAUCHER DISEASE S3849 GENETIC TESTING FOR NIEMANN-PICK DISEASES S3850 GENETIC TESTING FOR SICKLE CELL ANEMIA S3851 GENETIC TESTING FOR CANAVAN DISEASE S3852 DNA ANALY APOE EPSILON 4 ALLELE SUSECPT ALZS DZ S3853 GENETIC TESTING FOR MYOTONIC MUSCULAR DYSTROPHY S3854 GENE EXPRSSGENE EXPRSSION PROFILING PANL MGMT BR S3855 GENETIC TEST DETECT MUTATIONS PRESENILIN 1 GENE S3860 GENETIC TESTING COMP CARDIAC ION CHANNEL ANALY S3861 GENETIC TESTING SCN5A & VARIANTS FOR SUSPCTED BS S3862 GENETIC TEST FAMILY-SPECIFIC ION CHANNEL ANALY S3865 COMP GENE SEQ ANALY HYPERTROPHIC CARDIOMYOPATHY S3866 GENETIC ANALY GENE MUTAT HCM INDIV KNOWN HCM FAM S3870 CGH MICROARRAY TEST DD ASD &/ MENTAL RETARDATION S3890 DNA ANALYSIS FECAL COLORECTAL CANCER SCREENING S3902 BALLISTOCARDIOGRAM S4011 IN VITRO FERTILIZATION; S4013 CMPL CYCLE GAMETE INTRAFALLOPIAN TRNSF CASE RATE S4014 CMPL CYCLE ZYGOTE INTRAFALLOPIAN TRNSF CASE RATE S4015 CMPL IN VITRO FERTILIZATION CYCLE CASE RATE NOS S4016 FROZEN IN VITRO FERTILIZATION CYCLE CASE RATE S4017 INCPL CYCLE TX CANCELED PRIOR TO STIM CASE RATE


S4018 FRZN EMB TRANS PROC CANCEL BEFR TRANS CASE RATE S4020 IVF PROC CANCELLED BEFORE ASPIRATION CASE RATE S4021 IVF PROC CANCELLED AFTER ASPIRATION CASE RATE S4022 ASSISTED OOCYTE FERTILIZATION CASE RATE S4023 DONOR EGG CYCLE INCOMPLETE CASE RATE S4025 DONOR SERVICES IN VITRO FERTILIZATION CASE RATE S4026 PROCUREMENT OF DONOR SPERM FROM SPERM BANK S4027 STORAGE OF PREVIOUSLY FROZEN EMBRYOS S4028 MICROSURGICAL EPIDIDYMAL SPERM ASPIRATION S4030 SPERM PROCUREMENT&CRYOPRES SERVICES; INIT VISIT S4031 SPERM PROCUREMENT&CRYOPRES SRVC; SUBSQT VISIT S4035 STIM INTRAUTERINE INSEMINATION CASE RATE S4037 CRYOPRESERVED EMBRYO TRANSFER CASE RATE S4040 MON & STORAGE CRYOPRESERVED EMBRYOS PER 30 DAYS S4042 MANAGEMENT OF OVULATION INDUCTION PER CYCLE S5000 PRESCRIPTION DRUG GENERIC S5001 PRESCRIPTION DRUG BRAND NAME S5035 HOME INFUS THERAPY ROUTINE SERVICE INFUS DEVICE S5036 HOME INFUSION THERAPY REPAIR OF INFUSION DEVICE S5100 DAY CARE SERVICES ADULT; PER 15 MINUTES S5101 DAY CARE SERVICES ADULT; PER HALF DAY S5102 DAY CARE SERVICES ADULT; PER DIEM S5105 DAY CARE SRVC CENTER-BASED; SRVC NOT W/PROGM FEE S5108 HOME CARE TRAINING HOME CARE CLIENT PER 15 MIN S5109 HOME CARE TRAINING HOME CARE CLIENT PER SESSION S5110 HOME CARE TRAINING FAMILY; PER 15 MINUTES S5111 HOME CARE TRAINING FAMILY; PER SESSION S5115 HOME CARE TRAINING NON-FAMILY; PER 15 MINUTES S5116 HOME CARE TRAINING NON-FAMILY; PER SESSION S5120 CHORE SERVICES; PER 15 MINUTES S5121 CHORE SERVICES; PER DIEM S5125 ATTENDANT CARE SERVICES; PER 15 MINUTES S5126 ATTENDANT CARE SERVICES; PER DIEM S5130 HOMEMAKER SERVICE NOS; PER 15 MINUTES S5131 HOMEMAKER SERVICE NOS; PER DIEM S5135 COMPANION CARE ADULT ; PER 15 MINUTES S5136 COMPANION CARE ADULT ; PER DIEM S5140 FOSTER CARE ADULT; PER DIEM S5141 FOSTER CARE ADULT; PER MONTH S5145 FOSTER CARE THERAPEUTIC CHILD; PER DIEM S5146 FOSTER CARE THERAPEUTIC CHILD; PER MONTH S5150 UNSKILLED RESPITE CARE NOT HOSPICE; PER 15 MIN S5151 UNSKILLED RESPITE CARE NOT HOSPICE; PER DIEM


S5160 EMERGENCY RESPONSE SYSTEM; INSTALLATION&TESTING S5161 EMERGENCY RESPONSE SYSTEM; SERVICE FEE PER MONTH S5162 EMERGENCY RESPONSE SYSTEM; PURCHASE ONLY S5165 HOME MODIFICATIONS; PER SERVICE S5170 HOME DELIV MEALS INCLUDING PREPARATION; PER MEAL S5175 LAUNDRY SERVICE EXTERNAL PROFESSIONAL; PER ORDER S5180 HOME HEALTH RESPIRATORY THERAPY INIT EVALUATION S5181 HOME HEALTH RESPIRATORY THERAPY NOS PER DIEM S5185 MED REMINDER SERVICE NON-FACE-TO-FACE; MONTH S5199 PERSONAL CARE ITEM NOS EACH S5497 HOME INFUS TX CATH CARE/MAINT NOC; PER DIEM S5498 HOME INFUS TX CATH CARE/MAINT SIMPLE PER DIEM S5501 HOME INFUS TX CATH CARE/MAINT COMPLEX PER DIEM S5502 HOME INFUS TX CATH CARE IMPL ACCESS DEVC DIEM S5517 HIT ALL SPL NECES RESTOR CATH PATENCY/DECLOT S5518 HOME INFUSION THERAPY ALL SPL NECES CATH REPAIR S5520 HOME INFUSION TX ALL SPL NECES PICC LINE INSERT S5521 HOME INFUS TX ALL SPL NECES MIDLINE CATH INSERT S5522 HOM INFUS TX INSRTION PICC NRS SRVC ONLY S5523 HIT INSERT MIDLINE CVC NRS SRVC ONLY S5560 INSULIN DELIVERY DEVICE REUSABLE PEN; 1.5 ML SZ S5561 INSULIN DELIVERY DEVICE REUSABLE PEN; 3 ML SIZE S5565 INSULIN CARTRIDGE INSULIN DEVC NOT PUMP; 150 U S5566 INSULIN CARTRIDGE INSULIN DEVC NOT PUMP; 300 U S5570 INSULIN DELIV DEVICE DISPOSABLE PEN; 1.5 ML SIZE S5571 INSULIN DELIV DEVICE DISPOSABLE PEN; 3 ML SIZE S8035 MAGNETIC SOURCE IMAGING S8037 MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY S8042 MAGNETIC RESONANCE IMAGING LOW-FIELD S8055 ULTRASOUND GUID MULTIFETAL PG RDUC TECH CMPNT S8080 SCINTIMAMMOGRAPHY UNI INCL SUPPLY RADIOPHARM S8085 F-18 FDG IMAG USING 2-HEAD COINCIDENCE DETCT SYS S8092 ELECTRON BEAM COMPUTED TOMOGRAPHY S8120 O2 CONTENTS GASEOUS 1 UNIT EQULS 1 CUBIC FOOT S8121 OXYGEN CONTENTS LIQUID 1 UNIT EQUALS 1 POUND S8130 INTERFERENTIAL CURRENT STIMULATOR 2 CHANNEL S8131 INTERFERENTIAL CURRENT STIMULATOR 4 CHANNEL S8189 TRACHEOSTOMY SUPPLY NOT OTHERWISE CLASSIFIED S8262 MANDIBULAR ORTHOPEDIC REPOSITIONING DEVICE EACH S8415 SUPPLIES FOR HOME DELIVERY OF INFANT S8930 E-STIM AUR ACUPUNCT PNTS; EA 15 MIN 1-1 CNTC PT S8940 EQUESTRIAN/HIPPOTHERAPY PER SESSION S8948 APPLIC MODAL 1/MORE AREAS; LW-LEVL LASR; EA 15 M


S8950 COMPLEX LYMPHEDEMA THERAPY EACH 15 MINUTES S8990 PHYSICAL/MANIP TX MAINT RATHER THAN RESTORATION S9001 HOME UTERINE MONITOR W/WO ASSOC NURSING SERVICES S9007 ULTRAFILTRATION MONITOR S9025 OMNICARDIOGRAM/CARDIOINTEGRAM S9034 EXTRACORPOREAL SHOCKWAVE LITHOTRIPSY GALL STONES S9055 PROCUREN/OTH GROWTH FCT PREP PROMOTE WND HEALING S9056 COMA STIMULATION PER DIEM S9061 HOME ADMIN AEROSOLIZED DRUG THERAPY PER DIEM S9075 SMOKING CESSATION TREATMENT S9083 GLOBAL FEE URGENT CARE CENTERS S9088 SERVICES PROVIDED IN AN URGENT CARE CENTER S9090 VERTEBRAL AXIAL DECOMPRESSION PER SESSION S9097 HOME VISIT FOR WOUND CARE S9098 HOME VISIT PHOTOTHERAPY SERVICES PER DIEM S9109 CONGESTIVE HEART FAILURE TELEMONITOR PER MONTH S9117 BACK SCHOOL PER VISIT S9122 HOM HLTH AIDE/CERT NURSE ASST PROV CARE HOM;-HR S9123 NURSING CARE THE HOME; REGISTERED NURSE PER HOUR S9124 NURSING CARE IN THE HOME; BY LPN PER HOUR S9125 RESPITE CARE IN THE HOME PER DIEM S9126 HOSPICE CARE IN THE HOME PER DIEM S9127 SOCIAL WORK VISIT IN THE HOME PER DIEM S9128 SPEECH THERAPY IN THE HOME PER DIEM S9129 OCCUPATIONAL THERAPY IN THE HOME PER DIEM S9131 PHYSICAL THERAPY; IN THE HOME PER DIEM S9150 EVALUATION BY OCCULARIST S9152 SPEECH THERAPY RE-EVALUATION S9208 HOME MANAGEMENT OF PRETERM LABOR PER DIEM S9209 HOME MGMT PRETERM PRMAT RUPTURE MEMBRANES DIEM S9211 HOME MGMT GESTATIONAL HYPERTENSION; PER DIEM S9212 HOME MANAGEMENT POSTPARTUM HYPERTENSION PER DIEM S9213 HOME MANAGEMENT OF PREECLAMPSIA; PER DIEM S9214 HOME MANAGEMENT OF GESTATIONAL DIABETES; DIEM S9325 HIT PAIN MANAGEMENT INFUSION; PER DIEM S9326 HIT CONT PAIN MGMT INFUS; CARE COORD PER DIEM S9327 HIT INTERMIT PAIN MGMT INFUS; CARE COORD DIEM S9328 HIT IMPLANTED PUMP PAIN MGMT INFUS; PER DIEM S9329 HOME INFUSION TX CHEMOTHERAPY INFUSION; PER DIEM S9330 HIT CONT CHEMOTHAPY INFUS; CARE COORD PER DIEM S9331 HIT INTERMIT CHEMOTHAPY INFUS; CARE COORD-DIEM S9335 HOM TX HD; ADMIN PROF PHRM SRVC SPL&EQP PER DIEM S9336 HOME INFUS TX CONT ANTICOAGULANT INFUS TX DIEM


S9338 HIT IMMUOTHAPY; CARE COORDINATION PER DIEM S9339 HOME THERAPY; PERITONEAL DIALYSIS PER DIEM S9340 HOME THERAPY; ENTERAL NUTRITION; PER DIEM S9341 HOME TX; ENTERAL NUTRITION VIA GRAVITY; PER DIEM S9342 HOME TX; ENTERAL NUTRITION VIA PUMP; PER DIEM S9343 HOME TX; ENTERAL NUTRITION VIA BOLUS; PER DIEM S9345 HOME INFUSION TX ANTI-HEMOPHILIC AGENT; PER DIEM S9346 HOME INFUS TX ALPHA-1-PROTEINASE INHIBITOR; DIEM S9347 HIT UNINTRPED LNG-TERM CNTRL RATE IV/SUBQ;-DIEM S9348 HIT SYMPATHOMIMETIC/INOTROPIC AGENT PER DIEM S9349 HOME INFUSION THERAPY TOCOLYTIC; PER DIEM S9351 HOME INFUSION THERAPY CONT ANTI-EMETIC; PER DIEM S9353 HOME INFUSION THERAPY CONT INSULIN; PER DIEM S9355 HOME INFUSION THERAPY CHELATION; PER DIEM S9357 HOME INFUSION TX ENZYME REPL IV TX; PER DIEM S9359 HIT ANTI-TUMOR NECROS FACTOR IV TX; PER DIEM S9361 HOME INFUSION THERAPY DIURETIC IV TX; PER DIEM S9363 HIT ANTI-SPASMOTIC TX; CARE SPL&EQP PER DIEM S9364 HIT TOTAL PARENTERAL NUTRITION; CARE COORD DIEM S9365 HOM INFUS TX TPN; 1 LITER-DAY DIEM S9366 HIT TPN; > 1 LITER BUT NOT > 2 LITERS-DA-DIEM S9367 HIT TPN; > 2 LITERS BUT NOT > 3 LITERS-DA -DIEM S9368 HIT TOTAL PARENTERAL NUTRIT; > 3 LITERS-DA -DIEM S9370 HOME THERAPY INTERMITTENT ANTI-EMETIC INJ TX; S9372 HOME THERAPY; INTERMITTENT ANTICOAGULANT INJ TX; S9373 HOME INFUSION THERAPY HYDRATION TX; PER DIEM S9374 HOME INFUSION THERAPY HYDRATION TX; 1 LITER DAY S9375 HIT HYDRATION TX; >1 LITER NO>2 LITERS DAY S9376 HIT HYDRATION TX; >2 LITERS NO>3 LITERS DAY S9377 HOME INFUS THERAPY HYDRATION TX; >3 LITERS DAY S9379 HOME INFUSION THERAPY INFUSION THERAPY NOC; DIEM S9381 DEL/SRVC HI RISK REQ ESCORT/EXTRA PROTECT VISIT S9401 ANTICOAGULAT CLIN INCL ALL SERV NO LAB PER SESS S9430 PHARMACY COMPOUNDING AND DISPENSING SERVICES S9433 MED FOOD NUTR CMPL ORAL 100% NUTRITNL INTAKE S9434 MOD SOLID FOOD SUPPLEMENTS INBORN ERRORS METAB S9435 MEDICAL FOODS FOR INBORN ERRORS OF METABOLISM S9445 PT ED NOC NON-PHYSICIAN PPT ED NOC NON-PHYSICIAN S9446 PT ED NOC NON-PHYSICIAN PROVIDER GROUP SESSION S9447 INFANT SAFETY CLASSES NON-PHYSICIAN PER SESSION S9449 WEIGHT MANAGEMENT CLASSES NON-PHYS PER SESSION S9452 NUTRITION CLASSES NON-PHYSICIAN PER SESSION S9453 SMOKING CESSATION CLASSES NON-PHYSICIAN PER SESS


S9454 STRESS MGMT CLASSES NON-PHYSICIAN PER SESSION S9475 AMB SET SUBSTANCE ABS TX/DTOXFICATION SRVC-DIEM S9476 VESTIBULAR REHAB PROGM NON-PHYSICIAN PROV-DIEM S9482 FAMILY STABILIZATION SERVICES PER 15 MINUTES S9490 HIT CORTICOSTEROID INFUS; ADMN SRVC PROF PHRM SR S9494 HIT ABX ANTIVIRAL/ANTIFUNGAL THERAPY; PER DIEM S9497 HIT ABX ANTIVIRAL/ANTIFUNGAL TX; Q3 HRS DIEM S9500 HIT ABX ANTIVIRAL/ANTIFUNGAL TX; Q24 HRS DIEM S9501 HIT ABX ANTIVIRAL/ANTIFUNGAL TX; Q12 HRS DIEM S9502 HIT ABX ANTIVIRAL/ANTIFUNGAL; Q8 HRS PER DIEM S9503 HIT ANTIBIOTC ANTIVIRAL/ANTIFUNGAL; Q6 HRS; DIEM S9504 HIT ABX ANTIVIRAL/ANTIFUNGAL; Q4 HRS; PER DIEM S9529 HOME OR SKILLED NURSING FACILITY PATIENT S9537 HOME TX HEMATOPOIETIC HORMONE INJ TX;PER DIEM S9538 HOME TRANSFUSION OF BLOOD PRODUCT; PER DIEM S9542 HOME INJ TX NOC W/CARE COORDINATION PER DIEM S9558 HIT GROWTH HORMONE W/CARE COORDINATION PER DIEM S9559 HIT INTERFERON W/CARE COORDINATION PER DIEM S9560 HOME INJECTABLE THERAPY; HORMONAL THERAPY DIEM S9562 HOM INJ TX PALIVIZUMAB W/ADMN PHRM CARE-PER DIEM S9590 HOM TX IRRIG TX; W/ADMN PHRM SRVC CARE-PER DIEM S9810 HOME THERAPY; NOT OTHERWISE CLASSIFIED PER HOUR S9900 SRVC BY AUTH CHRISTIAN SC PRACT PER DIEM NO IP S9970 HEALTH CLUB MEMBERSHIP ANNUAL S9975 TRANSPLANT REL LODG MEALS & TRNSPRT PER DIEM S9976 LODGING PER DIEM NOT OTHERWISE SPECIFIED S9977 MEALS PER DIEM NOT OTHERWISE SPECIFIED S9986 NOT MEDICALLY NECESSARY SERVICE S9988 SERV PROVIDED AS PART OF PHASE 1 CLINICAL TRIAL S9989 SRVC PROVIDED OUTSIDE UNITED STATES OF AMERICA S9990 SERVICES PROVIDED AS PART PHASE II CLIN TRIAL S9991 SERVICES PROVIDED AS PART PHASE III CLIN TRIAL S9992 TRNSPRT COSTS CLIN TRIAL PRTCP & ONE CAREGIVER S9994 LODGNG COSTS CLINICAL TRIAL PRTCP&ONE CAREGIVR S9996 MEALS CLIN TRIAL PRTCP&ONE CAREGIVER/COMPANION T1000 PRIV DUTY/INDEPEND NRS SERVICE LIC UP 15 MIN T1002 RN SERVICES UP TO 15 MINUTES T1003 LPN/LVN SERVICES UP TO 15 MINUTES T1004 SERVICES QUALIFIED NURSING AIDE UP TO 15 MINUTES T1005 RESPITE CARE SERVICES UP TO 15 MINUTES T1009 CHILD SIT-CHILD IND REC ALCOHL&/SUBSTNC ABS SRVC T1010 MEALS FOR IND REC ALCOHOL&/SUBSTANCE ABUSE SRVC T1014 TELEHLTH TRNSMS-MIN PROFESSIONAL SRVC BILL SEP


T1016 CASE MANAGEMENT EACH 15 MINS T1017 TARGETED CASE MANAGEMENT EACH 15 MINS T1018 SCHOOL-BASED IND EDUCATION PROGRAM SERV BUNDLED T1019 PERSONAL CARE SERVICES PER 15 MINUTES T1020 PERSONAL CARE SERVICES PER DIEM T1021 HOME HEALTH AIDE/CERTIFIED NURSE ASST PER VISIT T1022 CONTRACT HOME HEALTH SRVC UNDER CONTRACT DAY T1023 SCR CONSIDER IND PARTICIP SPEC PROG PROJ/TX PER T1024 EVAL&TX TEAM PROV CARE MX/SEV HANDICAP CHLD PER T1025 INTEN MXDISCPLIN SRVC CHILD W/CMPLX IMPAIR DIEM T1026 INTEN MXDISCPLIN SRVC CHILD W/CMPLX IMPAIR HR T1027 FAMILY TRAIN & COUNSEL CHILD DEVELOPMENT 15 MINS T1028 ASSESSMENT HOME PHYSICAL & FAMILY ENVIRONMENT T1029 COMP ENVIR LEAD INVESTIGAT NOT W/LAB ANALY-DWELL T1030 NURSING CARE THE HOME REGISTERED NURSE PER DIEM T1031 NURSING CARE IN THE HOME BY LPN PER DIEM T1502 ADMIN ORL IM&/SUBQ MED HLTH CARE AGCY/PROF-VISIT T1503 ADMN MED NOT ORAL & OR INJ HLTH AGENCY/PROF VST T1999 MISC TX ITEMS & SPL RETAIL PURCHASE NOC T2001 NON-EMERG TRANSPORTATION; PT ATTENDANT/ESCORT T2002 NON-EMERGENCY TRANSPORTATION; PER DIEM T2003 NON-EMERGENCY TRANSPORTATION; ENCOUNTER/TRIP T2004 NON-EMERG TRNSPRT; COMMERCIAL CARRIER MULTI-PASS T2005 NONEMERGENCY TRANSPORTATION; STRETCHER VAN T2007 TRNSPRT WAIT TIME AIR AMB&NON-EMERG VEH 1/2 HR T2010 PASRR LEVL I IDENTIFICATION SCREEN PER SCREEN T2011 PASRR LEVEL II EVALUATION PER EVALUATION T2012 HABILITATION EDUCATIONAL WAIVER; PER DIEM T2013 HABILITATION EDUCATIONAL WAIVER; PER HOUR T2014 HABILITATION PREVOCATIONAL WAIVER; PER DIEM T2015 HABILITATION PREVOCATIONAL WAIVER; PER HOUR T2016 HABILITATION RESIDENTIAL WAIVER; PER DIEM T2017 HABILITATION RESIDENTIAL WAIVER; PER 15 MINUTES T2018 HABILITATION SUPP EMPLOYMENT WAIVER; PER DIEM T2019 HABILITATION SUPP EMPLOYMENT WAIVER; PER 15 MIN T2020 DAY HABILITATION WAIVER; PER DIEM T2021 DAY HABILITATION WAIVER; PER 15 MINUTES T2022 CASE MANAGEMENT; PER MONTH T2023 TARGETED CASE MANAGEMENT; PER MONTH T2024 SERVICE ASSESSMENT/PLAN CARE DEVELOPMENT WAIVER T2025 WAIVER SERVICES; NOT OTHERWISE SPECIFIED T2026 SPECIALIZED CHILDCARE WAIVER; PER DIEM T2027 SPECIALIZED CHILDCARE WAIVER; PER 15 MINUTES


T2028 SPECIALIZED SUPPLY NOT OTH SPECIFIED WAIVER T2029 SPECIALIZED MEDICAL EQUIPMENT NOS WAIVER T2030 ASSISTED LIVING WAIVER; PER MONTH T2031 ASSISTED LIVING WAIVER; PER DIEM T2032 RESIDENTIAL CARE NOS WAIVER; PER MONTH T2033 RESIDENTIAL CARE NOS WAIVER; PER DIEM T2034 CRISIS INTERVENTION WAIVER; PER DIEM T2035 UTIL SRVC SUPP MED EQP&ASSTIV TECH/DEVC WAIVER T2036 THERAPEUTIC CAMPING OVERNIGHT WAIVER; EA SESSION T2037 THERAPEUTIC CAMPING DAY WAIVER; EACH SESSION T2038 COMMUNITY TRANSITION WAIVER; PER SERVICE T2039 VEHICLE MODIFICATIONS WAIVER; PER SERVICE T2040 FINANCIAL MGMT SELF-DIRECTED WAIVER; PER 15 MIN T2041 SUPPORTS BROKERAGE SELF-DIRECTED WAIVER; 15 MIN T2042 HOSPICE ROUTINE HOME CARE; PER DIEM T2043 HOSPICE CONTINUOUS HOME CARE; PER HOUR T2044 HOSPICE INPATIENT RESPITE CARE; PER DIEM T2045 HOSPICE GENERAL INPATIENT CARE; PER DIEM T2046 HOSPICE LONG TERM CARE RM AND BD ONLY PER DIEM T2048 BHVAL HEALTH; LONG-TERM CARE RES W/ROOM&BD-DIEM T2049 NON-EMERG TRNSPRT; STRETCHER VAN MILEAGE; MILE T2101 HUMAN BREAST MILK PROCESSING STORAGE&DSTRB ONLY T4521 ADLT SIZED DISPBL INCONT PROD BRF/DIAPER SM EA T4522 ADLT SIZED DISPBL INCONT PROD BRF/DIAPER MED EA T4523 ADLT SIZED DISPBL INCONT PROD BRF/DIAPER LG EA T4524 ADLT SZD DISPBL INCONT PROD BRF/DIAPER X-LG EA T4525 ADLT SZD DISPBL INCONT PROD UNDWEAR/PULLON SM EA T4526 ADLT SZD DISPBL INCONT PROD UNDWEAR MED EA T4527 ADLT SZD DISPBL INCONT PROD UNDWEAR/PULLON LG EA T4528 ADLT SZD DISPBL INCONT PROD UNDWEAR XTRA LG EA T4529 PED SZD DISPBL INCONT PROD BRF/DIAPER SM/MED EA T4530 PED SZD DISPBL INCONT PROD BRF/DIAPER LG SZ EA T4531 PED SZD DISPBL INCONT PROD UNDWEAR SM/MED EA T4532 PED SZD DISPBL INCONT PROD UNDWEAR/PULLON LG EA T4533 YOUTH SIZED DISPBL INCONT PRODUCT BRF/DIAPER EA T4534 YOUTH SZD DISPBL INCONT PROD UNDWEAR/PULLON EA T4535 DISPBL LINER/SHIELD/GUARD/PAD/UNDGRMNT INCONT EA T4536 INCONT PROD PROTVE UNDWEAR/PULLON REUSBL SIZE EA T4537 INCONT PROD PROTVE UNDPAD REUSABLE BED SIZE EA T4538 DIAPER SERVICE REUSABLE DIAPER EACH DIAPER T4539 INCONTINENCE PRODUCT DIAPER/BRF REUSABLE SIZE EA T4540 INCONT PROD PROTVE UNDPAD REUSABLE CHAIR SIZE EA T4541 INCONTINENCE PRODUCT DISPOSABLE UNDPAD LARGE EA


T4542 INCONTINENCE PRODUCT DISPBL UNDPAD SMALL SIZE EA T4543 DISPBL INCONTINENCE PROD BRF/DIAPER BARIATRIC EA T5001 POSITIONING SEAT PERSON SPECIAL/ORTHOPEDIC NEED T5999 SUPPLY NOT OTHERWISE SPECIFIED V2020 FRAMES PURCHASES V2025 DELUXE FRAME V2100 SPHERE SINGLE VISION PLANO +/- 4.00 PER LENS V2101 SPHERE SINGLE VISION +/- 4.12 +/- 7.00D PER LENS V2102 SPHERE SINGLE VISN +/- 7.12 +/- 20.00D PER LENS V2103 1 VISN PLANO TO+/-4.00D SPHER 0.12-2.00D CYL EA V2104 1 VISN PLANO-+/- 4.00D SPHER 2.12-4.00D CYL EA V2105 1 VISN PLANO-+/- 4.00D SPHER 4.25-6.00D CYL EA V2106 1 VISN PLANO-+/- 4.00D SPHER OVER 6.00D CYL-LENS V2107 1 VISN +/- 4.25-+/ 7.00 SPHER 0.12-2.00D CYL EA V2108 1 VISN +/-4.25D-+/-7.00D SPHER 2.12-4.00D CYL EA V2109 1 VISN+/- 4.25-+/- 7.00D SPHER 4.25-6.00D CYL EA V2110 1 VISN +/- 4.25-7.00D SPHERE OVER 6.00D CYL EA V2111 1 VISN +/-7.25-+/-12.00D SPHER 0.25-2.25D CYL EA V2112 1 VISN +/- 7.25 +/- 12.00D SPH 2.25D-400D CYL EA V2113 1 VISN +/- 7.25 +/- 12.00D SPH 4.25-6.00D CYL EA V2114 SINGLE VISION SPHERE OVER +/- 12.00D PER LENS V2115 LENTICULAR PER LENS SINGLE VISION V2118 ANISEIKONIC LENS SINGLE VISION V2121 LENTICULAR LENS PER LENS SINGLE V2199 NOT OTHERWISE CLASSIFIED SINGLE VISION LENS V2200 SPHERE BIFOCL PLANO TO PLUS/MINUS 4.00D PER LENS V2201 SPHERE BIFOCAL +/- 4.12 TO +/- 7.00D PER LENS V2202 SPHERE BIFOCL +/- 7.12 TO +/- 20.00D PER LENS V2203 BIFOCL PLANO +/- 4.00D SPHER 0.12-2.00D CYL-EA V2204 BIFOCL PLANO +/- 4.00D SPHER 2.12-4.00D CYL-EA V2205 BIFOCL PLANO +/- 4.00D SPHER 4.25-6.00D CYL-EA V2206 BIFOCL PLANO +/- 4.00D SPHER OVR 6.00D CYL-EA V2207 BIFOCL +/-4.25-+/-7.00D SPHER 0.12-2.00D CYL-EA V2208 BIFOCL +/-4.25-+/-7.00D SPHER 2.12-4.00D CYL-EA V2209 BIFOCL +/-4.25-+/-7.00D SPHER 4.25-6.00D CYL-EA V2210 BIFOCL +/-4.25-+/-7.00D SPHER OVR 6.00D CYL-LENS V2211 BIFOCL +/-7.25-+/-12.00D SPHER 0.25-2.25D CYL-EA V2212 BIFOCL +/-7.25-+/-12.00D SPHER 2.25-4.00D CYL-EA V2213 BIFOCL +/-7.25-+/-12.00D SPHER 4.25-6.00D CYL-EA V2214 BIFOCAL SPHERE OVER +/-12.00D PER LENS V2215 LENTICULAR PER LENS BIFOCAL V2218 ANISEIKONIC PER LENS BIFOCAL V2219 BIFOCAL SEG WIDTH OVER 28MM


V2220 BIFOCAL ADD OVER 3.25D V2221 LENTICULAR LENS PER LENS BIFOCAL V2299 SPECIALTY BIFOCAL V2300 SPHERE TRIFOCAL PLANO OR +/-4.00D PER LENS V2301 SPHERE TRIFOCAL +/- 4.12 TO +/- 7.00D PER LENS V2302 SPHERE TRIFOCAL +/- 7.12 TO +/- 20.00 PER LENS V2303 TRIFOCL PLANO +/-4.00D SPHER 0.12-2.00D CYL EA V2304 TRIFOCL PLANO +/-4.00D SPHER 2.25-4.00D CYL EA V2305 TRIFOCL PLANO +/-4.00D SPHER 4.25-6.00 CYL EA V2306 TRIFOCL PLANO +/-4.00D SPHER OVR 6.00D CYL EA V2307 TRIFOCL +/-4.25-+/-7.00D SPHER 0.12-2.00D CYL EA V2308 TRIFOCL +/-4.25-+/-7.00D SPHER 2.12-4.00D CYL EA V2309 TRIFOCL +/-4.25-+/-7.00D SPHER 4.25-6.00D CYL EA V2310 TRIFOCL +/-4.25-+/-7.00D SPHER OVR 6.00D CYL EA V2311 TRIFOCL +/-7.25-+/-12.00D SPHER 0.25-2.25D CYL E V2312 TRIFOCL +/-7.25-+/-12.00D SPHER 2.25-4.00D CYL E V2313 TRIFOCL+/-7.25-+/-12.00D SPHER 4.25-6.00D CYL EA V2314 TRIFOCL SPHER OVER +/-12.00D PER LENS V2315 LENTICULAR PER LENS TRIFOCAL V2318 ANISEIKONIC LENS TRIFOCAL V2319 TRIFOCAL SEG WIDTH OVER 28 MM V2320 TRIFOCAL ADD OVER 3.25D V2321 LENTICULAR LENS PER LENS TRIFOCAL V2399 SPECIALTY TRIFOCAL V2410 VARIBL ASPHRCTY LENS 1 FULL FLD GLASS/PLASTC LNS V2430 VARIBL ASPHRCITY LENS BIFOCL FULL FIELD-LENS V2499 VARIABLE SPHERICITY LENS OTHER TYPE V2500 CONTACT LENS PMMA SPHERICAL PER LENS V2501 CONTACT LENS PMMA TORIC/PRISM BALLAST PER LENS V2502 CONTACT LENS PMMA BIFOCAL PER LENS V2503 CONTACT LENS PMMA COLOR VISION DEFIC PER LENS V2510 CONTACT LENS GAS PERMEABLE SPHERICAL PER LENS V2511 CNTC LENS GAS PERMEABLE TORIC PRISM BALLST-LENS V2512 CONTACT LENS GAS PERMEABLE BIFOCAL PER LENS V2513 CNTC LENS GAS PERMEABLE EXTENDED WEAR PER LENS V2520 CONTACT LENS HYDROPHILIC SPHERICAL PER LENS V2521 CNTC LENS HYDROPHIL TORIC/PRISM BALLST PER LENS V2522 CONTACT LENS HYDROPHILIC BIFOCAL PER LENS V2523 CONTACT LENS HYDROPHILIC EXTENDED WEAR PER LENS V2530 CONTACT LENS SCLERAL GAS IMPERMEABLE PER LENS V2531 CONTACT LENS SCLERAL GAS PERMEABLE PER LENS V2599 CONTACT LENS OTHER TYPE V2600 HAND HELD LOW VISION&OTH NON SPECTACL MOUNT AIDS


V2610 SINGLE LENS SPECTACLE MOUNTED LOW VISION AIDS V2615 TELESCOPIC & OTH COMPOUND LENS SYSTEM V2629 PROSTHETIC EYE OTHER TYPE V2630 ANTERIOR CHAMBER INTRAOCULAR LENS V2631 IRIS SUPPORTED INTRAOCULAR LENS V2632 POSTERIOR CHAMBER INTRAOCULAR LENS V2700 BALANCE LENS PER LENS V2702 DELUXE LENS FEATURE V2710 SLAB OFF PRISM GLASS OR PLASTIC PER LENS V2715 PRISM PER LENS V2718 PRESS-ON LENS FRESNELL PRISM PER LENS V2730 SPECIAL BASE CURVE GLASS OR PLASTIC PER LENS V2744 TINT PHOTOCHROMATIC PER LENS V2745 ADD LENS; TINT COLOR SOLID EXCLD PHOTOCHRMATC V2750 ANTIREFLECTIVE COATING PER LENS V2755 U-V LENS PER LENS V2756 EYE GLASS CASE V2760 SCRATCH RESISTANT COATING PER LENS V2761 MIRROR COAT TYPE SOLID GRADENT/= LENS MATL-LENS V2762 POLARIZATION ANY LENS MATERIAL PER LENS V2770 OCCLUDER LENS PER LENS V2780 OVERSIZE LENS PER LENS V2781 PROGRESSIVE LENS PER LENS V2782 LENS INDX 1.54-1.65 PLSTC/1.60-1.79 GLASS LENS V2783 LENS INDX >/= 1.66 PLSTC/>/= 1.80 GLASS LENS V2784 LENS POLYCARBONATE OR EQUAL ANY INDEX PER LENS V2785 PROCESSING PRES&TRANSPORTING CORNEAL TISSUE V2786 SPECIALTY OCCUPATIONAL MULTIFOCAL LENS PER LENS V2787 ASTIGMATISM CORRECTING FUNCTION INTRAOCULAR LENS V2788 PRESBYOPIA CORRECTION FUNCTION INTRAOCULAR LENS V2790 AMNIOTIC MEMBRANE SURGICAL RECONSTRUCT PER PROC V2797 VISN SPL ACSS &/ SRVC CMPNT ANOTHER HCPCS CODE V2799 VISION SERVICE MISCELLANEOUS V5095 SEMI-IMPLANTABLE MIDDLE EAR HEARING PROSTHESIS V5267 HEARING AID SUPPLIES/ACCESSORIES V5273 ASSTIVE LISTENING DEVICE USE W/COCHLEAR IMPLANT V5274 ASSISTIVE LEARNING DEVICE NOS V5275 EAR IMPRESSION EACH V5298 HEARING AID NOT OTHERWISE CLASSIFIED V5299 HEARING SERVICE MISCELLANEOUS V5336 REPAIR/MOD AUGMENTATIV COMMUNICAT SYSTEM/DEVICE V5362 SPEECH SCREENING V5363 LANGUAGE SCREENING


V5364 DYSPHAGIA SCREENING

PA-ABH_Prior Authorizations_120917 - Aetna Better Health

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