PHYSICIAN AND OTHER PROFESSIONAL SERVICES ...

TABLE G. — PHYSICIAN AND OTHER PROFESSIONAL SERVICES RELATIVE VALUE UNITS (RVUs) BY CPT/HCPCS CODE

v3.25 (January - December 2019)

PAGE 1 of 144

NOTE: CPT Codes and descriptions only are copyright American Medical Association. All rights reserved. Applicable FARS/DFARS apply.

1, 2, 3 - See end of the table for notes regarding these fields.

CPT/

HCPCS

Code

Modifier 1 CPT/HCPCS Code Description Conversion Factor/GAAF Category

Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

01996 Blank DAILY HOSP MGMT EDRL/SARACH CONT DRUG ADMN Anesthesia Blank Blank Blank Blank 2.56 5% Sample

10004 Blank FNA BX W/O IMG GDN EA ADDL Surgery Blank 0.80 0.34 0.58 Blank RBRVS

10005 Blank FNA BX W/US GDN 1ST LES Surgery Blank 1.46 0.49 1.98 Blank RBRVS

10006 Blank FNA BX W/US GDN EA ADDL Surgery Blank 1.00 0.33 0.61 Blank RBRVS

10007 Blank FNA BX W/FLUOR GDN 1ST LES Surgery Blank 1.81 0.70 6.09 Blank RBRVS

10008 Blank FNA BX W/FLUOR GDN EA ADDL Surgery Blank 1.18 0.46 3.26 Blank RBRVS

10009 Blank FNA BX W/CT GDN 1ST LES Surgery Blank 2.26 0.79 10.76 Blank RBRVS

10010 Blank FNA BX W/CT GDN EA ADDL Surgery Blank 1.65 0.58 6.17 Blank RBRVS

10011 Blank FNA BX W/MR GDN 1ST LES Surgery Blank 1.27 0.48 2.60 Blank Other

10012 Blank FNA BX W/MR GDN EA ADDL Surgery Blank 1.27 0.48 2.60 Blank Other

10021 Blank FINE NEEDLE ASPIRATION W/O IMAGING GUIDANCE Surgery Blank 1.27 0.55 2.03 Blank RBRVS

10030 Blank IMAGE-GUIDED CATHETER FLUID COLLECTION DRAINAGE Surgery Blank 2.75 0.98 13.04 Blank RBRVS

10035 Blank PERQ SFT TISS LOC DEVICE PLMT 1ST LES W/GDNCE Surgery Blank 1.70 0.62 12.84 Blank RBRVS

10036 Blank PERQ SFT TISS LOC DEVICE PLMT ADD LES W/GDNCE Surgery Blank 0.85 0.31 11.98 Blank RBRVS

10040 Blank ACNE SURGERY Surgery Blank 0.91 1.01 2.09 Blank RBRVS

10060 Blank INCISION & DRAINAGE ABSCESS SIMPLE/SINGLE Surgery Blank 1.22 1.44 2.03 Blank RBRVS

10061 Blank INCISION & DRAINAGE ABSCESS COMPLICATED/MULTIPLE Surgery Blank 2.45 2.40 3.13 Blank RBRVS

10080 Blank INCISION & DRAINAGE PILONIDAL CYST SIMPLE Surgery Blank 1.22 1.54 3.72 Blank RBRVS

10081 Blank INCISION & DRAINAGE PILONIDAL CYST COMPLICATED Surgery Blank 2.50 2.03 4.84 Blank RBRVS

10120 Blank INCISION & REMOVAL FOREIGN BODY SUBQ TISS SIMPLE Surgery Blank 1.22 1.61 3.02 Blank RBRVS

10121 Blank INCISION & REMOVAL FOREIGN BODY SUBQ TISS COMPL Surgery Blank 2.74 2.18 4.70 Blank RBRVS

10140 Blank I&D HEMATOMA SEROMA/FLUID COLLECTION Surgery Blank 1.58 1.62 2.91 Blank RBRVS

10160 Blank PUNCTURE ASPIRATION ABSCESS HEMATOMA BULLA/CYST Surgery Blank 1.25 1.32 2.30 Blank RBRVS

10180 Blank INCISION & DRAINAGE COMPLEX PO WOUND INFECTION Surgery Blank 2.30 2.33 4.26 Blank RBRVS

11000 Blank DBRDMT EXTENSV ECZEMA/INFECT SKN UP 10% BDY SURF Surgery Blank 0.60 0.17 0.91 Blank RBRVS

11001 Blank DBRDMT EXTNSVE ECZEMA/INFECT SKN EA 10% BDY SURF Surgery Blank 0.30 0.08 0.28 Blank RBRVS

11004 Blank DBRDMT SKN SUBQ T/M/F NECRO INFCTJ GENT&PR Surgery Blank 10.80 3.93 3.93 Blank RBRVS

11005 Blank DBRDMT SKN SUBQ T/M/F NECRO INFCTJ ABDL WALL Surgery Blank 14.24 5.21 5.21 Blank RBRVS

11006 Blank DBRDMT SKN SUBQ T/M/F NECRO INFCTJ GENT/ABDL Surgery Blank 13.10 4.75 4.75 Blank RBRVS

11008 Blank REMOVAL PROSTHETIC MATRL ABDL WALL FOR INFECTION Surgery Blank 5.00 1.83 1.83 Blank RBRVS

11010 Blank DBRDMT W/RMVL FM FX&/DISLC SKIN&SUBQ TISSUS Surgery Blank 4.19 3.20 9.43 Blank RBRVS

11011 Blank DBRDMT W/RMVL FM FX&/DISLC SKN SUBQ T/M/F MUSC Surgery Blank 4.94 2.78 9.58 Blank RBRVS

11012 Blank DBRDMT FX&/DISLC SUBQ T/M/F BONE Surgery Blank 6.87 4.07 12.04 Blank RBRVS

11042 Blank DEBRIDEMENT SUBCUTANEOUS TISSUE 20 SQ CM/< Surgery Blank 1.01 0.65 2.22 Blank RBRVS

11043 Blank DEBRIDEMENT MUSCLE & FASCIA 20 SQ CM/< Surgery Blank 2.70 1.39 3.45 Blank RBRVS

11044 Blank DEBRIDEMENT BONE MUSCLE &/FASCIA 20 SQ CM/< Surgery Blank 4.10 1.89 4.20 Blank RBRVS

11045 Blank DBRDMT SUBCUTANEOUS TISSUE EA ADDL 20 SQ CM Surgery Blank 0.50 0.18 0.60 Blank RBRVS

11046 Blank DEBRIDEMENT MUSCLE &/FASCIA EA ADDL 20 SQ CM Surgery Blank 1.03 0.41 0.88 Blank RBRVS

11047 Blank DEBRIDEMENT BONE EACH ADDITIONAL 20 SQ CM Surgery Blank 1.80 0.73 1.41 Blank RBRVS

11055 Blank PARING/CUTTING BENIGN HYPERKERATOTIC LESION 1 Surgery Blank 0.35 0.09 1.00 Blank RBRVS

11056 Blank PARING/CUTTING BENIGN HYPERKERATOTIC LESION 2-4 Surgery Blank 0.50 0.12 1.14 Blank RBRVS

11057 Blank PARING/CUTTING BENIGN HYPERKERATOTIC LESION >4 Surgery Blank 0.65 0.16 1.19 Blank RBRVS

11102 Blank TANGNTL BX SKIN SINGLE LES Surgery Blank 0.66 0.39 2.05 Blank RBRVS

11103 Blank TANGNTL BX SKIN EA SEP/ADDL Surgery Blank 0.38 0.23 1.08 Blank RBRVS

11104 Blank PUNCH BX SKIN SINGLE LESION Surgery Blank 0.83 0.49 2.58 Blank RBRVS

11105 Blank PUNCH BX SKIN EA SEP/ADDL Surgery Blank 0.45 0.27 1.22 Blank RBRVS

11106 Blank INCAL BX SKN SINGLE LES Surgery Blank 1.01 0.59 3.11 Blank RBRVS

11107 Blank INCAL BX SKN EA SEP/ADDL Surgery Blank 0.54 0.32 1.43 Blank RBRVS

11200 Blank REMOVAL SKN TAGS MLT FIBRQ TAGS ANY AREA UPW/15 Surgery Blank 0.82 1.18 1.62 Blank RBRVS

11201 Blank REMOVAL SK TGS MLT FIBRQ TAGS ANY AREA EA 10 Surgery Blank 0.29 0.16 0.22 Blank RBRVS

11300 Blank SHAVING SKIN LESION 1 TRUNK/ARM/LEG DIAM 0.5CM/< Surgery Blank 0.60 0.34 2.11 Blank RBRVS

11301 Blank SHVG SKIN LESION 1 TRUNK/ARM/LEG DIAM 0.6-1.0 CM Surgery Blank 0.90 0.52 2.40 Blank RBRVS

11302 Blank SHVG SKN LESION 1 TRUNK/ARM/LEG DIAM 1.1-2.0 CM Surgery Blank 1.05 0.62 2.83 Blank RBRVS

11303 Blank SHVG SKIN LESION 1 TRUNK/ARM/LEG DIAM >2.0 CM Surgery Blank 1.25 0.71 3.02 Blank RBRVS

11305 Blank SHAVING SKIN LESION 1 S/N/H/F/G DIAM 0.5 CM/< Surgery Blank 0.80 0.25 1.95 Blank RBRVS

11306 Blank SHAVING SKIN LESION 1 S/N/H/F/G DIAM 0.6-1.0 CM Surgery Blank 0.96 0.43 2.41 Blank RBRVS

11307 Blank SHAVING SKIN LESION 1 S/N/H/F/G DIAM 1.1-2.0 CM Surgery Blank 1.20 0.58 2.78 Blank RBRVS

11308 Blank SHAVING SKIN LESION 1 S/N/H/F/G DIAM >2.0 CM Surgery Blank 1.46 0.53 2.71 Blank RBRVS

11310 Blank SHAVING SKIN LESION 1 F/E/E/N/L/M DIAM 0.5 CM/< Surgery Blank 0.80 0.46 2.34 Blank RBRVS

11311 Blank SHVG SKIN LESION 1 F/E/E/N/L/M DIAM 0.6-1.0 CM Surgery Blank 1.10 0.64 1.93 Blank RBRVS

11312 Blank SHVG SKIN LESION 1 F/E/E/N/L/M DIAM 1.1-2.0 CM Surgery Blank 1.30 0.76 3.09 Blank RBRVS

11313 Blank SHAVING SKIN LESION 1 F/E/E/N/L/M DIAM >2.0 CM Surgery Blank 1.68 0.97 3.38 Blank RBRVS

11400 Blank EXC B9 LESION MRGN XCP SK TG T/A/L 0.5 CM/< Surgery Blank 0.90 1.29 2.55 Blank RBRVS

11401 Blank EXC B9 LESION MRGN XCP SK TG T/A/L 0.6-1.0 CM Surgery Blank 1.28 1.51 2.80 Blank RBRVS


11403 Blank EXC B9 LESION MRGN XCP SK TG T/A/L 2.1-3.0 CM/< Surgery Blank 1.84 2.09 3.35 Blank RBRVS


11406 Blank EXC B9 LESION MRGN XCP SK TG T/A/L >4.0 CM Surgery Blank 3.52 2.89 4.77 Blank RBRVS

11420 Blank EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 0.5 CM/< Surgery Blank 1.03 1.18 2.35 Blank RBRVS

11421 Blank EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 0.6-1.0CM Surgery Blank 1.47 1.48 2.81 Blank RBRVS





PAGE 2 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3


11426 Blank EXC B9 LESION MRGN XCP SK TG S/N/H/F/G > 4.0CM Surgery Blank 4.09 3.10 4.73 Blank RBRVS

11440 Blank EXC B9 LESION MRGN XCP SK TG F/E/E/N/L/M 0.5CM/< Surgery Blank 1.05 1.78 2.69 Blank RBRVS

11441 Blank EXC B9 LES MRGN XCP SK TG F/E/E/N/L/M 0.6-1.0CM Surgery Blank 1.53 2.02 3.05 Blank RBRVS




11446 Blank EXC B9 LESION MRGN XCP SK TG F/E/E/N/L/M > 4.0CM Surgery Blank 4.80 3.77 5.57 Blank RBRVS

11450 Blank EXCISION HIDRADENITIS AXILLARY SMPL/INTRM RPR Surgery Blank 3.22 3.37 7.05 Blank RBRVS

11451 Blank EXCISION HIDRADENITIS AXILLARY COMPLEX REPAIR Surgery Blank 4.43 3.99 8.55 Blank RBRVS

11462 Blank EXCISION HIDRADENITIS INGUINAL SMPL/INTRM RPR Surgery Blank 3.00 3.34 7.09 Blank RBRVS

11463 Blank EXCISION HIDRADENITIS INGUINAL COMPLEX REPAIR Surgery Blank 4.43 4.09 8.75 Blank RBRVS

11470 Blank EXCISION H/P/P/U SIMPLE/INTERMEDIATE REPAIR Surgery Blank 3.74 3.61 7.34 Blank RBRVS

11471 Blank EXCISION H/P/P/U COMPLEX REPAIR Surgery Blank 4.89 4.27 8.82 Blank RBRVS

11600 Blank EXCISION MAL LESION TRUNK/ARM/LEG 0.5 CM/< Surgery Blank 1.63 1.57 3.65 Blank RBRVS

11601 Blank EXCISION MAL LESION TRUNK/ARM/LEG 0.6-1.0 CM Surgery Blank 2.07 1.91 4.16 Blank RBRVS


11603 Blank EXCISION MAL LESION TRUNK/ARM/LEG 2.1-3.0 CM/< Surgery Blank 2.82 2.39 4.85 Blank RBRVS


11606 Blank EXCISION MALIGNANT LESION TRUNK/ARM/LEG > 4.0 CM Surgery Blank 5.02 3.33 6.95 Blank RBRVS

11620 Blank EXCISION MALIGNANT LESION S/N/H/F/G 0.5 CM/< Surgery Blank 1.64 1.59 3.67 Blank RBRVS

11621 Blank EXCISION MALIGNANT LESION S/N/H/F/G 0.6-1.0 CM Surgery Blank 2.08 1.92 4.17 Blank RBRVS


11623 Blank EXCISION MALIGNANT LESION S/N/H/F/G 2.1-3.0 CM/< Surgery Blank 3.11 2.52 4.99 Blank RBRVS


11626 Blank EXCISION MALIGNANT LESION S/N/H/F/G >4.0 CM Surgery Blank 4.61 3.06 6.22 Blank RBRVS

11640 Blank EXCISION MALIGNANT LESION F/E/E/N/L 0.5 CM/< Surgery Blank 1.67 1.68 3.81 Blank RBRVS

11641 Blank EXCISION MALIGNANT LESION F/E/E/N/L 0.6-1.0 CM Surgery Blank 2.17 2.00 4.29 Blank RBRVS




11646 Blank EXCISION MALIGNANT LESION F/E/E/N/L >4.0 CM Surgery Blank 6.26 4.09 7.37 Blank RBRVS

11719 Blank TRIMMING NONDYSTROPHIC NAILS ANY NUMBER Surgery Blank 0.17 0.04 0.23 Blank RBRVS

11720 Blank DEBRIDEMENT NAIL ANY METHOD 1-5 Surgery Blank 0.32 0.08 0.60 Blank RBRVS

11721 Blank DEBRIDEMENT NAIL ANY METHOD 6/> Surgery Blank 0.54 0.13 0.71 Blank RBRVS

11730 Blank AVULSION NAIL PLATE PARTIAL/COMPLETE SIMPLE 1 Surgery Blank 1.05 0.46 1.88 Blank RBRVS

11732 Blank AVULSION NAIL PLATE PARTIAL/COMP SIMPLE EA ADDL Surgery Blank 0.38 0.10 0.49 Blank RBRVS

11740 Blank EVACUATION SUBUNGUAL HEMATOMA Surgery Blank 0.37 0.54 1.03 Blank RBRVS

11750 Blank EXCISION NAIL MATRIX PERMANENT REMOVAL Surgery Blank 1.58 1.21 2.67 Blank RBRVS

11755 Blank BIOPSY NAIL UNIT SEPARATE PROCEDURE Surgery Blank 1.31 0.80 2.34 Blank RBRVS

11760 Blank REPAIR NAIL BED Surgery Blank 1.63 1.45 3.54 Blank RBRVS

11762 Blank RECONSTRUCTION NAIL BED W/GRAFT Surgery Blank 2.94 2.05 4.77 Blank RBRVS

11765 Blank WEDGE EXCISION SKIN NAIL FOLD Surgery Blank 1.22 1.37 3.46 Blank RBRVS

11770 Blank EXCISION PILONIDAL CYST/SINUS SIMPLE Surgery Blank 2.66 2.09 4.67 Blank RBRVS

11771 Blank EXCISION PILONIDAL CYST/SINUS EXTENSIVE Surgery Blank 6.09 5.07 9.02 Blank RBRVS

11772 Blank EXCISION PILONIDAL CYST/SINUS COMPLICATED Surgery Blank 7.35 7.58 10.89 Blank RBRVS

11900 Blank INJECTION INTRALESIONAL UP TO & INCLUD 7 LESIONS Surgery Blank 0.52 0.31 1.01 Blank RBRVS

11901 Blank INJECTION INTRALESIONAL >7 LESIONS Surgery Blank 0.80 0.49 1.10 Blank RBRVS

11920 Blank TATTOOING INCL MICROPIGMENTATION 6.0 CM/< Surgery Blank 1.61 1.41 3.04 Blank RBRVS

11921 Blank TATTOOING INCL MICROPIGMENTATION 6.1-20.0 CM Surgery Blank 1.93 1.61 3.40 Blank RBRVS

11922 Blank TATTOOING INCL MICROPIGMENTATION EA 20.0 CM Surgery Blank 0.49 0.29 1.18 Blank RBRVS

11950 Blank SUBCUTANEOUS INJECTION FILLING MATERIAL 1 CC/< Surgery Blank 0.84 0.41 1.05 Blank RBRVS

11951 Blank SUBCUTANEOUS INJECTION FILLING MATRL 1.1-5.0 CC Surgery Blank 1.19 0.69 1.51 Blank RBRVS

11952 Blank SUBCUTANEOUS INJECTION FILLING MATRL 5.1-10.0CC Surgery Blank 1.69 0.84 1.78 Blank RBRVS

11954 Blank SUBCUTANEOUS INJECTION FILLING MATRL >10.0 CC Surgery Blank 1.85 1.09 2.29 Blank RBRVS

11960 Blank INSERTION TISSUE EXPANDER INCL SBSQ XPNSJ Surgery Blank 11.49 13.87 13.87 Blank RBRVS

11970 Blank REPLACEMENT TISS EXPANDER PERMANENT PROSTHESIS Surgery Blank 8.01 8.13 8.13 Blank RBRVS

11971 Blank REMOVAL TISS EXPANDER W/O INSERTION PROSTHESIS Surgery Blank 3.41 5.16 9.45 Blank RBRVS

11976 Blank REMOVAL IMPLANTABLE CONTRACEPTIVE CAPSULES Surgery Blank 1.78 0.70 2.11 Blank RBRVS

11980 Blank SUBCUTANEOUS HORMONE PELLET IMPLANTATION Surgery Blank 1.10 0.40 1.49 Blank RBRVS

11981 Blank INSJ NON-BIODEGRADABLE DRUG DELIVERY IMPLANT Surgery Blank 1.48 0.66 2.31 Blank RBRVS

11982 Blank REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT Surgery Blank 1.78 0.80 2.46 Blank RBRVS

11983 Blank RMVL W/RINSJ NON-BIODEGRADABLE DRUG DLVR IMPLT Surgery Blank 3.30 1.34 2.77 Blank RBRVS

12001 Blank SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.5CM/< Surgery Blank 0.84 0.32 1.64 Blank RBRVS

12002 Blank SMPL REPAIR SCALP/NECK/AX/GENIT/TRUNK 2.6-7.5CM Surgery Blank 1.14 0.39 1.86 Blank RBRVS

12004 Blank SIMPLE RPR SCALP/NECK/AX/GENIT/TRUNK 7.6-12.5CM Surgery Blank 1.44 0.46 2.05 Blank RBRVS

12005 Blank SMPL RPR SCALP/NECK/AX/GENIT/TRUNK 12.6-20.0CM Surgery Blank 1.97 0.48 2.39 Blank RBRVS

12006 Blank SMPL RPR SCALP/NECK/AX/GENIT/TRUNK 20.1-30.0CM Surgery Blank 2.39 0.61 2.77 Blank RBRVS

12007 Blank SIMPLE REPAIR SCALP/NECK/AX/GENIT/TRUNK >30.0CM Surgery Blank 2.90 0.84 2.99 Blank RBRVS

12011 Blank SIMPLE REPAIR F/E/E/N/L/M 2.5CM/< Surgery Blank 1.07 0.37 1.95 Blank RBRVS

12013 Blank SIMPLE REPAIR F/E/E/N/L/M 2.6CM-5.0 CM Surgery Blank 1.22 0.27 1.92 Blank RBRVS






PAGE 3 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3




12018 Blank SIMPLE REPAIR F/E/E/N/L/M >30.0 CM Surgery Blank 3.61 0.79 0.79 Blank RBRVS

12020 Blank TX SUPERFICIAL WOUND DEHISCENCE SIMPLE CLOSURE Surgery Blank 2.67 2.34 4.93 Blank RBRVS

12021 Blank TX SUPERFICIAL WOUND DEHISCENCE W/PACKING Surgery Blank 1.89 1.78 2.48 Blank RBRVS

12031 Blank REPAIR INTERMEDIATE S/A/T/E 2.5 CM/< Surgery Blank 2.00 2.11 4.48 Blank RBRVS

12032 Blank REPAIR INTERMEDIATE S/A/T/E 2.6-7.5 CM Surgery Blank 2.52 2.72 5.72 Blank RBRVS


12035 Blank REPAIR INTERMEDIATE S/A/T/E 12.6-20.0CM Surgery Blank 3.50 2.83 6.76 Blank RBRVS


12037 Blank REPAIR INTERMEDIATE S/A/T/E >30.0 CM Surgery Blank 5.00 3.50 7.76 Blank RBRVS

12041 Blank REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.5CM/< Surgery Blank 2.10 1.93 4.37 Blank RBRVS

12042 Blank REPAIR INTERMEDIATE N/H/F/XTRNL GENT 2.6-7.5 CM Surgery Blank 2.79 2.57 5.04 Blank RBRVS

12044 Blank REPAIR INTERMEDIATE N/H/F/XTRNL GENT 7.6-12.5CM Surgery Blank 3.19 2.52 6.58 Blank RBRVS

12045 Blank REPAIR INTERMEDIATE N/H/F/XTRNL GENT 12.6-20 CM Surgery Blank 3.75 3.41 7.06 Blank RBRVS

12046 Blank RPR INTERMEDIATE N/H/F/XTRNL GENT 20.1-30.0 CM Surgery Blank 4.30 3.64 8.37 Blank RBRVS

12047 Blank REPAIR INTERMEDIATE N/H/F/XTRNL GENT >30.0 CM Surgery Blank 4.95 3.88 8.95 Blank RBRVS

12051 Blank REPAIR INTERMEDIATE F/E/E/N/L&/MUC 2.5 CM/< Surgery Blank 2.33 2.26 4.68 Blank RBRVS

12052 Blank REPAIR INTERMEDIATE F/E/E/N/L&/MUC 2.6-5.0 CM Surgery Blank 2.87 2.58 5.09 Blank RBRVS



12055 Blank REPAIR INTERMEDIATE F/E/E/N/L&/MUC 12.6-20.0CM Surgery Blank 4.50 3.56 8.07 Blank RBRVS

12056 Blank REPAIR INTERMEDIATE F/E/E/N/L&/MUC 20.1-30.0CM Surgery Blank 5.30 4.88 9.67 Blank RBRVS

12057 Blank REPAIR INTERMEDIATE F/E/E/N/L&/MUC >30.0 CM Surgery Blank 6.00 5.41 9.82 Blank RBRVS

13100 Blank REPAIR COMPLEX TRUNK 1.1-2.5 CM Surgery Blank 3.00 2.48 6.08 Blank RBRVS

13101 Blank REPAIR COMPLEX TRUNK 2.6-7.5 CM Surgery Blank 3.50 3.28 7.25 Blank RBRVS

13102 Blank REPAIR COMPLEX TRUNK EACH ADDITIONAL 5 CM/< Surgery Blank 1.24 0.70 2.02 Blank RBRVS

13120 Blank REPAIR COMPLEX SCALP/ARM/LEG 1.1-2.5 CM Surgery Blank 3.23 3.10 6.26 Blank RBRVS

13121 Blank REPAIR COMPLEX SCALP/ARM/LEG 2.6-7.5 CM Surgery Blank 4.00 3.12 7.57 Blank RBRVS

13122 Blank REPAIR COMPLEX SCALP/ARM/LEG EA ADDL 5 CM/< Surgery Blank 1.44 0.80 2.11 Blank RBRVS

13131 Blank REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 1.1-2.5 CM Surgery Blank 3.73 2.93 6.69 Blank RBRVS

13132 Blank REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 2.6-7.5 CM Surgery Blank 4.78 3.59 8.07 Blank RBRVS

13133 Blank REPAIR COMPLEX F/C/C/M/N/AX/G/H/F EA ADDL 5 CM/< Surgery Blank 2.19 1.27 2.56 Blank RBRVS

13151 Blank REPAIR COMPLEX EYELID/NOSE/EAR/LIP 1.1-2.5 CM Surgery Blank 4.34 3.29 7.02 Blank RBRVS

13152 Blank REPAIR COMPLEX EYELID/NOSE/EAR/LIP 2.6-7.5 CM Surgery Blank 5.34 3.90 8.28 Blank RBRVS

13153 Blank REPAIR COMPLX EYELID/NOSE/EAR/LIP EA ADDL 5 CM/< Surgery Blank 2.38 1.33 2.76 Blank RBRVS

13160 Blank SECONDARY CLOSURE SURG WOUND/DEHSN EXTSV/COMPLIC Surgery Blank 12.04 8.82 8.82 Blank RBRVS

14000 Blank ADJACENT TISSUE TRANSFER/REARGMT TRUNK 10 SQCM/< Surgery Blank 6.37 6.94 10.25 Blank RBRVS

14001 Blank ADJNT TIS TRANSFR/REARRANGE TRUNK 10.1-30.0 SQCM Surgery Blank 8.78 8.55 12.57 Blank RBRVS

14020 Blank ADJT TIS TRNSFR/REARGMT SCALP/ARM/LEG 10 SQ CM/< Surgery Blank 7.22 7.94 11.46 Blank RBRVS

14021 Blank ADJT/REARRGMT SCALP/ARM/LEG 10.1-30.0 SQ CM Surgery Blank 9.72 9.42 13.57 Blank RBRVS

14040 Blank ADJT TIS TRNS/REARGMT F/C/C/M/N/A/G/H/F 10SQCM/< Surgery Blank 8.60 8.28 11.81 Blank RBRVS

14041 Blank ADJT/REARGMT F/C/C/M/N/AX/G/H/F 10.1-30.0 SQ CM Surgery Blank 10.83 9.93 14.42 Blank RBRVS

14060 Blank ADJT TIS TRNSFR/REARRGMT E/N/E/L DFCT 10 SQ CM/< Surgery Blank 9.23 8.77 11.55 Blank RBRVS

14061 Blank ADJT TIS REARGMT EYE/NOSE/EAR/LIP 10.1-30.0 SQCM Surgery Blank 11.48 10.74 15.71 Blank RBRVS

14301 Blank ADJNT TIS TRNSFR/REARGMT ANY AREA 30.1-60 SQ CM Surgery Blank 12.65 10.62 15.96 Blank RBRVS

14302 Blank ADJT TIS TRNSFR/REARGMT DEFEC EA ADDL 30 SQCM/< Surgery Blank 3.73 2.00 2.00 Blank RBRVS

14350 Blank FILLETED FINGER/TOE FLAP W/PREPJ RECIPIENT SITE Surgery Blank 11.05 7.49 7.49 Blank RBRVS

15002 Blank PREP SITE TRUNK/ARM/LEG 1ST 100 SQ CM/1PCT Surgery Blank 3.65 2.24 5.64 Blank RBRVS

15003 Blank PREP SITE TRUNK/ARM/LEG ADDL 100 SQ CM/1PCT Surgery Blank 0.80 0.37 1.20 Blank RBRVS

15004 Blank PREP SITE F/S/N/H/F/G/M/D GT 1ST 100 SQ CM/1PCT Surgery Blank 4.58 2.53 6.18 Blank RBRVS

15005 Blank PREP SITE F/S/N/H/F/G/M/D GT ADDL 100 SQ CM/1PCT Surgery Blank 1.60 0.74 1.67 Blank RBRVS

15040 Blank HARVEST SKIN TISSUE CLTR SKIN AGRFT 100 CM/< Surgery Blank 2.00 1.25 4.77 Blank RBRVS

15050 Blank PINCH GRAFT 1/MLT SM ULCER TIP/OTH AREA 2CM Surgery Blank 5.57 6.27 9.50 Blank RBRVS

15100 Blank SPLIT AGRFT T/A/L 1ST 100 CM/&/1% BDY INFT/CHLD Surgery Blank 9.90 8.77 12.69 Blank RBRVS

15101 Blank SPLIT AGRFT T/A/L EA 100 CM/EA 1% BDY INFT/CHLD Surgery Blank 1.72 1.12 3.21 Blank RBRVS

15110 Blank EPIDRM AGRFT T/A/L 1ST 100 CM/&/1% BDY INFT/CHLD Surgery Blank 10.97 7.07 9.94 Blank RBRVS

15111 Blank EPIDRM AGRFT T/A/L EA 100 CM/EA 1% BDY INFT/CHLD Surgery Blank 1.85 0.75 1.08 Blank RBRVS

15115 Blank EPIDERMAL AGRFT F/S/N/H/F/G/M/D GT 1ST 100 CM/< Surgery Blank 11.28 6.89 9.71 Blank RBRVS

15116 Blank EPIDERMAL AGRFT F/S/N/H/F/G/M/D GT EA 100 CM Surgery Blank 2.50 1.48 1.92 Blank RBRVS

15120 Blank SPLIT AGRFT F/S/N/H/F/G/M/D GT 1ST 100 CM/</1 % Surgery Blank 10.15 8.16 12.36 Blank RBRVS

15121 Blank SPLIT AGRFT F/S/N/H/F/G/M/D GT EA 100 CM/EA 1 % Surgery Blank 2.00 1.45 3.53 Blank RBRVS

15130 Blank DERMAL AUTOGRAFT TRUNK/ARM/LEG 1ST 100 CM Surgery Blank 7.53 6.93 9.82 Blank RBRVS

15131 Blank DERMAL AUTOGRAFT TRUNK/ARM/LEG EA 100 CM/EA Surgery Blank 1.50 0.88 1.11 Blank RBRVS

15135 Blank DERMAL AUTOGRAFT F/S/N/H/F/G/M/D GT 1ST 100 Surgery Blank 11.03 8.70 11.60 Blank RBRVS

15136 Blank DERMAL AGRFT F/S/N/H/F/G/M/D GT EA 100 CM/EA Surgery Blank 1.50 0.88 1.08 Blank RBRVS

15150 Blank CLTR SKIN AUTOGRAFT T/A/L 1ST 25 CM/< Surgery Blank 9.39 6.60 8.27 Blank RBRVS

15151 Blank CLTR SKIN AGRFT T/A/L ADDL 1 CM-75 CM Surgery Blank 2.00 0.71 0.98 Blank RBRVS

15152 Blank CLTR SKIN AGRFT T/A/L EA 100 CM/EA 1%BODY AREA Surgery Blank 2.50 1.14 1.41 Blank RBRVS

15155 Blank CLTR SKIN AGRFT F/S/N/H/F/G/M/D GT 1ST 25CM/< Surgery Blank 10.14 9.27 11.01 Blank RBRVS

15156 Blank CLTR SKIN AGRFT F/S/N/H/F/G/M/D GT ADDL 1-75CM Surgery Blank 2.75 0.97 1.24 Blank RBRVS





PAGE 4 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

15157 Blank CLTR SKIN AGRFT F/S/N/H/F/G/M/D GT EA 100 EA Surgery Blank 3.00 1.06 1.46 Blank RBRVS

15200 Blank FTH/GFT FREE W/DIRECT CLOSURE TRUNK 20 CM/< Surgery Blank 9.15 8.62 13.01 Blank RBRVS

15201 Blank FTH/GFT FR W/DIR CLSR TRNK EA ADDL 20 CM/< Surgery Blank 1.32 0.72 2.65 Blank RBRVS

15220 Blank FTH/GFT FREE W/DIRECT CLOSURE S/A/L 20 CM/< Surgery Blank 8.09 8.29 12.58 Blank RBRVS

15221 Blank FTH/GFT FR W/DIR CLSR S/A/L EA ADDL 20 CM/< Surgery Blank 1.19 0.66 2.48 Blank RBRVS

15240 Blank FTH/GFT FR W/DIR CLSR F/C/C/M/N/AX/G/H/F 20 CM/< Surgery Blank 10.41 10.99 14.55 Blank RBRVS

15241 Blank FTH/GT FR W/DIR CLSR F/C/C/M/N/AX/G/H/F EA20CM/< Surgery Blank 1.86 1.03 3.08 Blank RBRVS

15260 Blank FTH/GFT FREE W/DIRECT CLOSURE N/E/E/L 20 SQ CM/< Surgery Blank 11.64 11.40 15.55 Blank RBRVS

15261 Blank FTH/GFT FREE W/DIR CLSR N/E/E/L EA 20 SQ CM/< Surgery Blank 2.23 1.45 3.54 Blank RBRVS

15271 Blank APP SKN SUB GRFT T/A/L AREA/100SQ CM /<1ST 25 Surgery Blank 1.50 0.72 2.32 Blank RBRVS

15272 Blank APP SKN SUB GRFT T/A/L AREA/100SQ CM EA ADL 25SC Surgery Blank 0.33 0.13 0.40 Blank RBRVS

15273 Blank APP SKN SUBGRFT T/A/L AREA/100SQ CM 1ST 100SQ CM Surgery Blank 3.50 1.73 4.44 Blank RBRVS

15274 Blank APP SKN SUB GRFT T/A/L AREA>/=100SCM ADL 100SQCM Surgery Blank 0.80 0.36 1.06 Blank RBRVS

15275 Blank SUB GRFT F/S/N/H/F/G/M/D <100SQ CM 1ST 25 SQ CM Surgery Blank 1.83 0.74 2.25 Blank RBRVS

15276 Blank SUB GRFT F/S/N/H/F/G/M/D<100SQ CM EA ADDL25SQ CM Surgery Blank 0.50 0.17 0.43 Blank RBRVS

15277 Blank SUB GRFT F/S/N/H/F/G/M/D >/= 100SCM 1ST 100SQ CM Surgery Blank 4.00 1.93 4.70 Blank RBRVS

15278 Blank SUB GRFT F/S/N/H/F/G/M/D >/= 100SCM ADL 100SQ CM Surgery Blank 1.00 0.47 1.23 Blank RBRVS

15570 Blank FRMJ DIRECT/TUBED PEDICLE W/WO TRANSFER TRUNK Surgery Blank 10.21 9.12 14.05 Blank RBRVS

15572 Blank FRMJ DIRECT/TUBE PEDICLE W/WO TR SCALP ARMS/LEGS Surgery Blank 10.12 9.60 13.52 Blank RBRVS

15574 Blank FRMJ DIR/TUBE PEDCL W/WOTR FH/CH/CH/M/N/AX/G/H/F Surgery Blank 10.70 9.50 13.51 Blank RBRVS

15576 Blank FRMJ DIRECT/TUBED PEDICLE W/WOTR E/N/E/L/NTRORAL Surgery Blank 9.37 8.53 12.23 Blank RBRVS

15600 Blank DELAY FLAP/SECTIONING FLAP TRUNK Surgery Blank 2.01 3.58 6.87 Blank RBRVS

15610 Blank DELAY FLAP/SECTIONING FLAP SCALP ARMS/LEGS Surgery Blank 2.52 3.99 7.21 Blank RBRVS

15620 Blank DELAY FLAP/SECTIONING FLAP F/C/C/N/AX/G/H/F Surgery Blank 3.75 4.94 8.08 Blank RBRVS

15630 Blank DELAY FLAP/SCTJ FLAP EYELIDS NOSE EARS/LIPS Surgery Blank 4.08 5.20 8.33 Blank RBRVS

15650 Blank TRANSFER ANY PEDICLE FLAP ANY LOCATION Surgery Blank 4.77 5.42 8.80 Blank RBRVS

15730 Blank MDFC FLAP W/PRSRV VASC PEDCL Surgery Blank 13.50 11.10 28.92 Blank RBRVS

15731 Blank FOREHEAD FLAP W/PRESERVATION VASCULAR PEDICLE Surgery Blank 14.38 12.18 15.37 Blank RBRVS

15733 Blank MUSC MYOQ/FSCQ FLP H&N PEDCL Surgery Blank 15.68 12.35 12.35 Blank RBRVS

15734 Blank MUSC MYOCUTANEOUS/FASCIOCUTANEOUS FLAP TRUNK Surgery Blank 23.00 16.01 16.01 Blank RBRVS

15736 Blank MUSC MYOCUTANEOUS/FASCIOCUTANEOUS FLAP UXTR Surgery Blank 17.04 15.27 15.27 Blank RBRVS

15738 Blank MUSC MYOCUTANEOUS/FASCIOCUTANEOUS FLAP LXTR Surgery Blank 19.04 15.60 15.60 Blank RBRVS

15740 Blank FLAP ISLAND PEDICLE ANATOMIC NAMED AXIAL ARTERY Surgery Blank 11.80 10.81 15.34 Blank RBRVS

15750 Blank FLAP NEUROVASCULAR PEDICLE Surgery Blank 12.96 11.11 11.11 Blank RBRVS

15756 Blank FREE MUSCLE/MYOCUTANEOUS FLAP W/MVASC ANAST Surgery Blank 36.94 23.38 23.38 Blank RBRVS

15757 Blank FREE SKIN FLAP W/MICROVASCULAR ANASTOMOSIS Surgery Blank 37.15 22.22 22.22 Blank RBRVS

15758 Blank FREE FASCIAL FLAP W/MICROVASCULAR ANASTOMOSIS Surgery Blank 36.90 23.09 23.09 Blank RBRVS

15760 Blank GRAFT COMPOSITE W/PRIMARY CLOSURE DONOR AREA Surgery Blank 9.86 8.98 12.93 Blank RBRVS

15770 Blank GRAFT DERMA-FAT-FASCIA Surgery Blank 8.96 8.65 8.65 Blank RBRVS

15775 Blank PUNCH GRAFT HAIR TRANSPLANT 1-15 PUNCH GRAFTS Surgery Blank 3.95 1.96 4.16 Blank RBRVS

15776 Blank PUNCH GRAFT HAIR TRANSPLANT >15 PUNCH GRAFTS Surgery Blank 5.53 3.87 7.45 Blank RBRVS

15777 Blank IMPLNT BIO IMPLNT FOR SOFT TISSUE REINFORCEMENT Surgery Blank 3.65 1.96 1.96 Blank RBRVS

15780 Blank DERMABRASION TOTAL FACE Surgery Blank 8.73 10.44 16.71 Blank RBRVS

15781 Blank DERMABRASION SEGMENTAL FACE Surgery Blank 5.02 6.56 9.98 Blank RBRVS

15782 Blank DERMABRASION REGIONAL OTHER THAN FACE Surgery Blank 4.44 7.31 12.14 Blank RBRVS

15783 Blank DERMABRASION SUPERFICIAL ANY SITE Surgery Blank 4.41 5.71 8.79 Blank RBRVS

15786 Blank ABRASION 1 LESION Surgery Blank 2.08 1.62 4.77 Blank RBRVS

15787 Blank ABRASION EACH ADDITIONAL 4 LESIONS OR LESS Surgery Blank 0.33 0.15 1.06 Blank RBRVS

15788 Blank CHEMICAL PEEL FACIAL EPIDERMAL Surgery Blank 2.09 4.67 10.79 Blank RBRVS

15789 Blank CHEMICAL PEEL FACIAL DERMAL Surgery Blank 4.91 6.09 10.03 Blank RBRVS

15792 Blank CHEMICAL PEEL NONFACIAL EPIDERMAL Surgery Blank 1.86 5.20 10.32 Blank RBRVS

15793 Blank CHEMICAL PEEL NONFACIAL DERMAL Surgery Blank 3.96 6.00 9.53 Blank RBRVS

15819 Blank CERVICOPLASTY Surgery Blank 10.65 10.28 10.28 Blank RBRVS

15820 Blank BLEPHAROPLASTY LOWER EYELID Surgery Blank 6.27 7.58 9.20 Blank RBRVS

15821 Blank BLEPHAROPLASTY LOWER EYELID HERNIATED FAT PAD Surgery Blank 6.84 8.08 9.89 Blank RBRVS

15822 Blank BLEPHAROPLASTY UPPER EYELID Surgery Blank 4.62 6.03 7.62 Blank RBRVS

15823 Blank BLEPHAROPLASTY UPPER EYELID W/EXCESSIVE SKIN Surgery Blank 6.81 8.17 10.00 Blank RBRVS

15824 Blank RHYTIDECTOMY FOREHEAD Surgery Blank Blank Blank Blank 29.42 ERBRVS

15825 Blank RHYTIDECTOMY NECK W/PLATYSMAL TIGHTENING Surgery Blank Blank Blank Blank 33.10 ERBRVS

15826 Blank RHYTIDECTOMY GLABELLAR FROWN LINES Surgery Blank Blank Blank Blank 23.90 ERBRVS

15828 Blank RHYTIDECTOMY CHEEK CHIN & NECK Surgery Blank Blank Blank Blank 50.56 FAIR Health

15829 Blank RHYTIDECTOMY SMAS FLAP Surgery Blank Blank Blank Blank 37.00 FAIR Health

15830 Blank EXCISION SKIN ABD INFRAUMBILICAL PANNICULECTOMY Surgery Blank 17.11 13.55 13.55 Blank RBRVS

15832 Blank EXCISION EXCESSIVE SKIN & SUBQ TISSUE THIGH Surgery Blank 12.85 11.09 11.09 Blank RBRVS

15833 Blank EXCISION EXCESSIVE SKIN & SUBQ TISSUE LEG Surgery Blank 11.90 11.11 11.11 Blank RBRVS

15834 Blank EXCISION EXCESSIVE SKIN & SUBQ TISSUE HIP Surgery Blank 12.17 11.28 11.28 Blank RBRVS

15835 Blank EXCISION EXCESSIVE SKIN & SUBQ TISSUE BUTTOCK Surgery Blank 12.99 11.74 11.74 Blank RBRVS

15836 Blank EXCISION EXCESSIVE SKIN & SUBQ TISSUE ARM Surgery Blank 10.61 10.26 10.26 Blank RBRVS

15837 Blank EXC EXCESSIVE SKIN &SUBQ TISSUE FOREARM/HAND Surgery Blank 9.55 9.53 13.55 Blank RBRVS

15838 Blank EXC EXCSV SKIN & SUBQ TISSUE SUBMENTAL FAT PAD Surgery Blank 8.25 8.65 8.65 Blank RBRVS

15839 Blank EXCISION EXCESSIVE SKIN & SUBQ TISSUE OTHER AREA Surgery Blank 10.50 8.83 12.86 Blank RBRVS

15840 Blank GRAFT FACIAL NERVE PARALYSIS FREE FASCIAL GRAFT Surgery Blank 14.99 11.41 11.41 Blank RBRVS





PAGE 5 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

15841 Blank GRAFT FACIAL NERVE PARALYSIS FREE MUSCLE GRAFT Surgery Blank 25.99 20.85 20.85 Blank RBRVS

15842 Blank GRF FACIAL NRV PALYSS FR MUSCLE FLAP MICROSURG Surgery Blank 41.01 30.19 30.19 Blank RBRVS

15845 Blank GRF FACIAL NERVE PARALYSIS REGIONAL MUSCLE TR Surgery Blank 14.32 12.94 12.94 Blank RBRVS

15847 Blank EXCISION EXCESSIVE SKIN & SUBQ TISSUE ABDOMEN Surgery Blank Blank Blank Blank 16.54 FAIR Health

15850 Blank REMOVAL SUTURES UNDER ANESTHESIA SAME SURGEON Surgery Blank 0.78 0.30 1.65 Blank RBRVS

15851 Blank REMOVAL SUTURES UNDER ANESTHESIA OTHER SURGEON Surgery Blank 0.86 0.37 1.88 Blank RBRVS

15852 Blank DRESSING CHANGE UNDER ANESTHESIA Surgery Blank 0.86 0.35 0.35 Blank RBRVS

15860 Blank IV INJECTION TEST VASCULAR FLOW FLAP/GRAFT Surgery Blank 1.95 0.83 0.83 Blank RBRVS

15876 Blank SUCTION ASSISTED LIPECTOMY HEAD & NECK Surgery Blank Blank Blank Blank 14.40 FAIR Health

15877 Blank SUCTION ASSISTED LIPECTOMY TRUNK Surgery Blank Blank Blank Blank 20.94 FAIR Health

15878 Blank SUCTION ASSISTED LIPECTOMY UPPER EXTREMITY Surgery Blank Blank Blank Blank 13.00 v3.23

15879 Blank SUCTION ASSISTED LIPECTOMY LOWER EXTREMITY Surgery Blank Blank Blank Blank 29.96 FAIR Health

15920 Blank EXC COCCYGEAL PR ULC W/COCCYGECTOMY W/PRIM SUTR Surgery Blank 8.29 7.36 7.36 Blank RBRVS

15922 Blank EXC COCCYGEAL PR ULC W/COCCYGECTOMY W/FLAP CLSR Surgery Blank 10.38 10.29 10.29 Blank RBRVS

15931 Blank EXCISION SACRAL PRESSURE ULCER W/PRIMARY SUTURE Surgery Blank 10.07 7.49 7.49 Blank RBRVS

15933 Blank EXC SACRAL PRESSURE ULC W/PRIM SUTR W/OSTECTOMY Surgery Blank 11.77 10.09 10.09 Blank RBRVS

15934 Blank EXCISION SACRAL PRESSURE ULCER W/SKIN FLAP CLSR Surgery Blank 13.68 10.42 10.42 Blank RBRVS

15935 Blank EXC SACRAL PR ULCER W/SKN FLAP CLSR W/OSTECTOMY Surgery Blank 15.78 12.46 12.46 Blank RBRVS

15936 Blank EXC SAC PR ULC PREPJ MUSC/MYOQ FLAP/SKN GRF CLSR Surgery Blank 13.16 9.79 9.79 Blank RBRVS

15937 Blank EXC SAC PR ULC PREPJ MUSC/MYOQ FLAP/SKN GRF OSTC Surgery Blank 15.14 11.64 11.64 Blank RBRVS

15940 Blank EXC ISCHIAL PRESSURE ULCER W/PRIMARY SUTURE Surgery Blank 10.20 7.72 7.72 Blank RBRVS

15941 Blank EXC ISCHIAL PR ULC W/PRIM SUTR W/OSTC ISCHIECT Surgery Blank 12.41 11.12 11.12 Blank RBRVS

15944 Blank EXC ISCHIAL PRESSURE ULCER W/SKIN FLAP CLOSURE Surgery Blank 12.44 10.70 10.70 Blank RBRVS

15945 Blank EXC ISCHIAL PR ULC W/SKN FLAP CLSR W/OSTECTOMY Surgery Blank 13.75 12.01 12.01 Blank RBRVS

15946 Blank EXC ISCHIAL PR ULCER W/OSTC MUSC/MYOQ FLAP/SKIN Surgery Blank 24.12 18.38 18.38 Blank RBRVS

15950 Blank EXC TROCHANTERIC PRESSURE ULCER W/PRIMARY SUTR Surgery Blank 8.03 7.34 7.34 Blank RBRVS

15951 Blank EXC TRCHNTRIC PR ULCER W/PRIM SUTR W/OSTECTOMY Surgery Blank 11.58 11.68 11.68 Blank RBRVS

15952 Blank EXC TROCHANTERIC PR ULCER W/SKIN FLAP CLOSURE Surgery Blank 12.31 11.55 11.55 Blank RBRVS

15953 Blank EXC TRCHNTRIC PR ULC W/SKN FLAP CLSR W/OSTECTOMY Surgery Blank 13.57 12.68 12.68 Blank RBRVS

15956 Blank EXC TROCHANTERIC PR ULCER MUSC/MYOQ FLAP/SKIN Surgery Blank 16.79 13.09 13.09 Blank RBRVS

15958 Blank EXC TRCHNTRIC PR ULC MUSC/MYOQ FLAP/SKIN W/OSTC Surgery Blank 16.75 13.97 13.97 Blank RBRVS

15999 Blank UNLISTED PROCEDURE EXCISION PRESSURE ULCER Surgery Blank Blank Blank Blank 24.10 Unlisted

16000 Blank INITIAL TX 1ST DEGREE BURN LOCAL TX Surgery Blank 0.89 0.33 0.96 Blank RBRVS

16020 Blank DRS&/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ SMALL Surgery Blank 0.71 0.76 1.54 Blank RBRVS

16025 Blank DRS&/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ MEDIUM Surgery Blank 1.74 1.21 2.22 Blank RBRVS

16030 Blank DRS&/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ LARGE Surgery Blank 2.08 1.45 2.91 Blank RBRVS

16035 Blank ESCHAROTOMY FIRST INCISION Surgery Blank 3.74 1.37 1.37 Blank RBRVS

16036 Blank ESCHAROTOMY EACH ADDITIONAL INCISION Surgery Blank 1.50 0.59 0.59 Blank RBRVS

17000 Blank DESTRUCTION PREMALIGNANT LESION 1ST Surgery Blank 0.61 0.82 1.19 Blank RBRVS

17003 Blank DESTRUCTION PREMALIGNANT LESION 2-14 EA Surgery Blank 0.04 0.02 0.10 Blank RBRVS

17004 Blank DESTRUCTION PREMALIGNANT LESION 15/> Surgery Blank 1.37 1.29 2.55 Blank RBRVS

17106 Blank DESTRUCTION CUTANEOUS VASC PROLIFERATIVE <10CM Surgery Blank 3.69 3.75 5.61 Blank RBRVS

17107 Blank DSTRJ CUTANEOUS VASCULAR LESIONS 10.0-50.0 SQ CM Surgery Blank 4.79 4.55 7.03 Blank RBRVS

17108 Blank DSTRJ CUTANEOUS VASCULAR LESIONS >50.0 SQ CM Surgery Blank 7.49 6.61 9.81 Blank RBRVS

17110 Blank DESTRUCTION BENIGN LESIONS UP TO 14 Surgery Blank 0.70 1.21 2.39 Blank RBRVS

17111 Blank DESTRUCTION BENIGN LESIONS 15/> Surgery Blank 0.97 1.36 2.66 Blank RBRVS

17250 Blank CHEMICAL CAUTERIZATION GRANULATION TISSUE Surgery Blank 0.50 0.50 1.72 Blank RBRVS

17260 Blank DESTRUCTION MALIGNANT LESION T/A/L 0.5 CM/< Surgery Blank 0.96 0.91 1.62 Blank RBRVS

17261 Blank DESTRUCTION MAL LESION TRUNK/ARM/LEG 0.6-1.0 CM Surgery Blank 1.22 1.23 2.71 Blank RBRVS

17262 Blank DESTRUCTION MAL LESION TRUNK/ARM/LEG 1.1-2.0CM Surgery Blank 1.63 1.48 3.14 Blank RBRVS



17266 Blank DESTRUCTION MAL LESION TRUNK/ARM/LEG > 4.0 CM Surgery Blank 2.39 1.91 3.89 Blank RBRVS

17270 Blank DESTRUCTION MALIGNANT LESION S/N/H/F/G 0.5 CM/> Surgery Blank 1.37 1.30 2.74 Blank RBRVS

17271 Blank DESTRUCTION MALIGNANT LESION S/N/H/F/G 0.6-1.0CM Surgery Blank 1.54 1.42 2.90 Blank RBRVS




17276 Blank DSTRJ MAL LESION S/N/H/F/G LESION DIAM > 4.0 CM Surgery Blank 3.25 2.37 4.38 Blank RBRVS

17280 Blank DESTRUCTION MALIGNANT LESION F/E/E/N/L/M 0.5CM/< Surgery Blank 1.22 1.21 2.63 Blank RBRVS

17281 Blank DESTRUCTION MAL LESION F/E/E/N/L/M 0.6-1.0CM Surgery Blank 1.77 1.56 3.05 Blank RBRVS




17286 Blank DESTRUCTION MAL LESION F/E/E/N/L/M >4.0 CM Surgery Blank 4.48 2.94 5.05 Blank RBRVS

17311 Blank MOHS MICROGRAPHIC H/N/H/F/G 1ST STAGE 5 BLOCKS Surgery Blank 6.20 3.77 11.70 Blank RBRVS

17312 Blank MOHS MICROGRAPHIC H/N/H/F/G EACH ADDL STAGE Surgery Blank 3.30 2.01 7.27 Blank RBRVS

17313 Blank MOHS TRUNK/ARM/LEG 1ST STAGE 5 BLOCKS Surgery Blank 5.56 3.39 11.21 Blank RBRVS

17314 Blank MOHS TRUNK/ARM/LEG EA STAGE AFTER 1ST STAGE Surgery Blank 3.06 1.87 7.04 Blank RBRVS

17315 Blank MOHS TRUNK/ARM/LEG EA ADDL BLOCK ANY STAGE Surgery Blank 0.87 0.53 1.28 Blank RBRVS

17340 Blank CRYOTHERAPY CO2 SLUSH LIQUID N2 ACNE Surgery Blank 0.77 0.54 0.64 Blank RBRVS

17360 Blank CHEMICAL EXFOLIATION ACNE Surgery Blank 1.46 1.14 1.98 Blank RBRVS





PAGE 6 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

17380 Blank ELECTROLYSIS EPILATION EACH 30 MINUTES Surgery Blank Blank Blank Blank 2.28 FAIR Health

17999 Blank UNLISTED PX SKIN MUC MEMBRANE & SUBQ TISSUE Surgery Blank Blank Blank Blank 1.79 Unlisted

19000 Blank PUNCTURE ASPIRATION CYST BREAST Surgery Blank 0.84 0.31 2.25 Blank RBRVS

19001 Blank PUNCTURE ASPIRATION BREAST EACH ADDITIONAL CYST Surgery Blank 0.42 0.15 0.30 Blank RBRVS

19020 Blank MASTOTOMY W/EXPLORATION/DRAINAGE ABSCESS DEEP Surgery Blank 3.83 4.15 8.88 Blank RBRVS

19030 Blank INJECTION MAMMARY DUCTOGRAM/GALACTOGRAM Surgery Blank 1.53 0.57 3.01 Blank RBRVS

19081 Blank BX BREAST W/DEVICE 1ST LESION STEREOTACTIC GUID Surgery Blank 3.29 1.20 15.98 Blank RBRVS

19082 Blank BX BREAST W/DEVICE ADDL LESION STEREOTACT GUID Surgery Blank 1.65 0.61 14.37 Blank RBRVS

19083 Blank BX BREAST W/DEVICE 1ST LESION ULTRASOUND GUID Surgery Blank 3.10 1.13 15.66 Blank RBRVS

19084 Blank BX BREAST W/DEVICE ADDL LESION ULTRASOUND GUID Surgery Blank 1.55 0.57 13.85 Blank RBRVS

19085 Blank BX BREAST W/DEVICE 1ST LESION MAGNETIC RES GUID Surgery Blank 3.64 1.34 24.57 Blank RBRVS

19086 Blank BX BREAST W/DEVICE ADDL LESION MAGNET RES GUID Surgery Blank 1.82 0.68 21.13 Blank RBRVS

19100 Blank BX BREAST NEEDLE CORE W/O IMAGING GUIDANCE SPX Surgery Blank 1.27 0.46 2.73 Blank RBRVS

19101 Blank BIOPSY BREAST OPEN INCISIONAL Surgery Blank 3.23 2.41 5.78 Blank RBRVS

19105 Blank ABLTJ CRYOSURGICAL W/US GID EA FIBROADENOMA Surgery Blank 3.69 1.56 79.63 Blank RBRVS

19110 Blank NIPPLE EXPLORATION Surgery Blank 4.44 4.38 8.44 Blank RBRVS

19112 Blank EXCISION LACTIFEROUS DUCT FISTULA Surgery Blank 3.81 4.26 8.44 Blank RBRVS

19120 Blank EXC CYST/ABERRANT BREAST TISSUE OPEN 1/> LESION Surgery Blank 5.92 4.59 6.85 Blank RBRVS

19125 Blank EXC BREAST LES PREOP PLMT RAD MARKER OPEN 1 LES Surgery Blank 6.69 4.92 7.40 Blank RBRVS

19126 Blank EXC BRST LES PREOP PLMT RAD MARKER OPN EA ADDL Surgery Blank 2.93 1.04 1.04 Blank RBRVS

19260 Blank EXCISION CHEST WALL TUMOR INCLUDING RIBS Surgery Blank 17.78 12.77 12.77 Blank RBRVS

19271 Blank EXC CHEST TUMOR W/RCNSTJ W/O MEDSTNL LMPHADEC Surgery Blank 22.19 19.53 19.53 Blank RBRVS

19272 Blank EXC CHEST TUMOR W/RCNSTJ W/MEDSTNL LMPHADEC Surgery Blank 25.17 19.95 19.95 Blank RBRVS

19281 Blank PERQ DEVICE PLACEMENT BREAST LOC 1ST LES W/GDNCE Surgery Blank 2.00 0.73 4.65 Blank RBRVS

19282 Blank PERQ DEVICE PLACEMT BREAST LOC EA LESION W/GDNCE Surgery Blank 1.00 0.37 3.65 Blank RBRVS

19283 Blank PERQ BREAST LOC DEVICE PLACEMT 1ST STRTCTC GDNCE Surgery Blank 2.00 0.72 5.51 Blank RBRVS

19284 Blank PERQ BREAST LOC DEVICE PLACEMT EA LESION STRTCTC Surgery Blank 1.00 0.36 4.68 Blank RBRVS

19285 Blank PERQ BREAST LOC DEVICE PLACEMT 1ST LESIO US IMAG Surgery Blank 1.70 0.63 12.86 Blank RBRVS

19286 Blank PERQ BREAST LOC DEVICE PLACEMT EACH LES US IMAGE Surgery Blank 0.85 0.31 11.95 Blank RBRVS

19287 Blank PERQ BREAST LOC DEVICE PLACEMT 1ST LESIO MR GUID Surgery Blank 2.55 0.93 21.65 Blank RBRVS

19288 Blank PERQ BREAST LOC DEVICE PLACEMT ADD LESIO MR GUID Surgery Blank 1.28 0.48 18.35 Blank RBRVS

19294 Blank PREP TUM CAV IORT PRTL MAST Surgery Blank 3.00 1.16 1.16 Blank RBRVS

19296 Blank PLMT EXPANDABLE CATH BRST FOLLOWING PRTL MAST Surgery Blank 3.63 1.63 108.70 Blank RBRVS

19297 Blank PLMT EXPANDABLE CATH BRST CONCURRENT PRTL MAST Surgery Blank 1.72 0.62 0.62 Blank RBRVS

19298 Blank PLMT RADTHX BRACHYTX BRST FOLLOWING PRTL MAST Surgery Blank 5.75 2.56 21.90 Blank RBRVS

19300 Blank MASTECTOMY GYNECOMASTIA Surgery Blank 5.31 5.42 8.55 Blank RBRVS

19301 Blank MASTECTOMY PARTIAL Surgery Blank 10.13 6.28 6.28 Blank RBRVS

19302 Blank MASTECTOMY PARTIAL W/AXILLARY LYMPHADENECTOMY Surgery Blank 13.99 8.59 8.59 Blank RBRVS

19303 Blank MASTECTOMY SIMPLE COMPLETE Surgery Blank 15.00 9.11 9.11 Blank RBRVS

19304 Blank MASTECTOMY SUBCUTANEOUS Surgery Blank 7.95 6.84 6.84 Blank RBRVS

19305 Blank MAST RAD W/PECTORAL MUSCLES AXILLARY LYMPH NODES Surgery Blank 17.46 11.01 11.01 Blank RBRVS

19306 Blank MAST RAD W/PECTORAL MUSC AX INT MAM LYMPH NODES Surgery Blank 18.13 12.08 12.08 Blank RBRVS

19307 Blank MAST MODF RAD W/AX LYMPH NOD W/WO PECT/ALIS MIN Surgery Blank 18.23 11.92 11.92 Blank RBRVS

19316 Blank MASTOPEXY Surgery Blank 11.09 9.04 9.04 Blank RBRVS

19318 Blank REDUCTION MAMMAPLASTY Surgery Blank 16.03 12.93 12.93 Blank RBRVS

19324 Blank MAMMAPLASTY AUGMENTATION W/O PROSTHETIC IMPLANT Surgery Blank 6.80 7.28 7.28 Blank RBRVS

19325 Blank MAMMAPLASTY AUGMENTATION W/PROSTHETIC IMPLANT Surgery Blank 8.64 8.37 8.37 Blank RBRVS

19328 Blank REMOVAL INTACT MAMMARY IMPLANT Surgery Blank 6.48 6.63 6.63 Blank RBRVS

19330 Blank REMOVAL MAMMARY IMPLANT MATERIAL Surgery Blank 8.54 8.18 8.18 Blank RBRVS

19340 Blank IMMT INSJ BRST PROSTH FLWG MASTOPEXY MAST/RCNSTJ Surgery Blank 13.99 12.44 12.44 Blank RBRVS

19342 Blank DLYD INSJ BRST PROSTH FLWG MASTOPEXY MAST/RCNSTJ Surgery Blank 12.63 11.77 11.77 Blank RBRVS

19350 Blank NIPPLE/AREOLA RECONSTRUCTION Surgery Blank 9.11 8.67 12.91 Blank RBRVS

19355 Blank CORRECTION INVERTED NIPPLES Surgery Blank 8.52 7.88 11.58 Blank RBRVS

19357 Blank BRST RCNSTJ IMMT/DLYD W/TISS EXPANDER SBSQ XPNSJ Surgery Blank 18.50 21.64 21.64 Blank RBRVS

19361 Blank BRST RCNSTJ W/LATSMS D/SI FLAP WO PRSTHC IMPL Surgery Blank 23.36 18.02 18.02 Blank RBRVS

19364 Blank BREAST RECONSTRUCTION FREE FLAP Surgery Blank 42.58 29.62 29.62 Blank RBRVS

19366 Blank BREAST RECONSTRUCTION OTHER TECHNIQUE Surgery Blank 21.84 14.83 14.83 Blank RBRVS

19367 Blank BREAST RECONSTRUCTION TRAM FLAP 1 PEDICLE Surgery Blank 26.80 20.31 20.31 Blank RBRVS

19368 Blank BREAST RECONSTRUCTION TRAM 1 PEDCL MVASC ANAST Surgery Blank 33.90 23.76 23.76 Blank RBRVS

19369 Blank BREAST RECONSTRUCTION TRAM FLAP DOUBLE PEDICLE Surgery Blank 31.31 22.22 22.22 Blank RBRVS

19370 Blank OPEN PERIPROSTHETIC CAPSULOTOMY BREAST Surgery Blank 9.17 8.97 8.97 Blank RBRVS

19371 Blank PERIPROSTHETIC CAPSULECTOMY BREAST Surgery Blank 10.62 10.08 10.08 Blank RBRVS

19380 Blank REVISION RECONSTRUCTED BREAST Surgery Blank 10.41 10.05 10.05 Blank RBRVS

19396 Blank PREPARATION MOULAGE CUSTOM BREAST IMPLANT Surgery Blank 2.17 1.67 5.80 Blank RBRVS

19499 Blank UNLISTED PROCEDURE BREAST Surgery Blank Blank Blank Blank 9.22 Unlisted

20100 Blank EXPLORATION PENETRATING WOUND SPX NECK Surgery Blank 10.38 4.94 4.94 Blank RBRVS

20101 Blank EXPLORATION PENETRATING WOUND SPX CHEST Surgery Blank 3.23 2.03 8.90 Blank RBRVS

20102 Blank EXPL PENETRATING WOUND SPX ABDOMEN/FLANK/BACK Surgery Blank 3.98 2.51 9.13 Blank RBRVS

20103 Blank EXPLORATION PENETRATING WOUND SPX EXTREMITY Surgery Blank 5.34 3.77 10.45 Blank RBRVS

20150 Blank EXCISION EPIPHYSEAL BAR Surgery Blank 14.75 11.37 11.37 Blank RBRVS

20200 Blank BIOPSY MUSCLE SUPERFICIAL Surgery Blank 1.46 0.92 4.07 Blank RBRVS

20205 Blank BIOPSY MUSCLE DEEP Surgery Blank 2.35 1.52 5.28 Blank RBRVS





PAGE 7 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

20206 Blank BIOPSY MUSCLE PERCUTANEOUS NEEDLE Surgery Blank 0.99 0.61 5.61 Blank RBRVS

20220 Blank BIOPSY BONE TROCAR/NEEDLE SUPERFICIAL Surgery Blank 1.27 0.69 3.39 Blank RBRVS

20225 Blank BIOPSY BONE TROCAR/NEEDLE DEEP Surgery Blank 1.87 1.04 12.72 Blank RBRVS

20240 Blank BIOPSY BONE OPEN SUPERFICIAL Surgery Blank 2.61 1.41 1.41 Blank RBRVS

20245 Blank BIOPSY BONE OPEN DEEP Surgery Blank 6.00 3.18 3.18 Blank RBRVS

20250 Blank BIOPSY VERTEBRAL BODY OPEN THORACIC Surgery Blank 5.19 4.63 4.63 Blank RBRVS

20251 Blank BIOPSY VERTEBRAL BODY OPEN LUMBAR/CERVICAL Surgery Blank 5.72 4.98 4.98 Blank RBRVS

20500 Blank INJECTION SINUS TRACT THERAPEUTIC SEPARATE PROC Surgery Blank 1.28 1.01 1.59 Blank RBRVS

20501 Blank INJECTION SINUS TRACT DIAGNOSTIC Surgery Blank 0.76 0.26 2.52 Blank RBRVS

20520 Blank REMOVAL FOREIGN BODY MUSCLE/TENDON SHEATH SIMPLE Surgery Blank 1.90 2.06 3.69 Blank RBRVS

20525 Blank RMVL FOREIGN BODY MUSCLE/TENDON SHEATH DEEP/COMP Surgery Blank 3.54 2.96 9.53 Blank RBRVS

20526 Blank INJECTION THERAPEUTIC CARPAL TUNNEL Surgery Blank 0.94 0.56 1.11 Blank RBRVS

20527 Blank INJECTION ENZYME PALMAR FASCIAL CORD Surgery Blank 1.00 0.73 1.23 Blank RBRVS

20550 Blank INJECTION 1 TENDON SHEATH/LIGAMENT APONEUROSIS Surgery Blank 0.75 0.29 0.67 Blank RBRVS

20551 Blank INJECTION SINGLE TENDON ORIGIN/INSERTION Surgery Blank 0.75 0.40 0.90 Blank RBRVS

20552 Blank INJECTION SINGLE/MLT TRIGGER POINT 1/2 MUSCLES Surgery Blank 0.66 0.36 0.84 Blank RBRVS

20553 Blank INJECTION SINGLE/MLT TRIGGER POINT 3/> MUSCLES Surgery Blank 0.75 0.41 0.98 Blank RBRVS

20555 Blank PLACEMENT NEEDLES MUSCLE SUBSEQUENT RADIOELEMENT Surgery Blank 6.00 2.73 2.73 Blank RBRVS

20600 Blank ARTHROCENTESIS ASPIR&/INJ SMALL JT/BURSA W/O US Surgery Blank 0.66 0.29 0.64 Blank RBRVS

20604 Blank ARTHROCNT ASPIR&/INJ SMALL JT/BURSAW/US REC RPRT Surgery Blank 0.89 0.34 1.06 Blank RBRVS

20605 Blank ARTHROCENTESIS ASPIR&/INJ INTERM JT/BURS W/O US Surgery Blank 0.68 0.32 0.68 Blank RBRVS

20606 Blank ARTHROCENTESIS ASPIR&/INJ INTERM JT/BURS W/US Surgery Blank 1.00 0.41 1.16 Blank RBRVS

20610 Blank ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/O US Surgery Blank 0.79 0.42 0.81 Blank RBRVS

20611 Blank ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/US Surgery Blank 1.10 0.51 1.33 Blank RBRVS

20612 Blank ASPIRATION&/INJECTION GANGLION CYST ANY LOCATJ Surgery Blank 0.70 0.42 0.93 Blank RBRVS

20615 Blank ASPIRATION & INJECTION TREATMENT BONE CYST Surgery Blank 2.33 2.00 4.24 Blank RBRVS

20650 Blank INSERTION WIRE/PIN W/APPL SKELETAL TRACTION SPX Surgery Blank 2.28 1.96 3.45 Blank RBRVS

20660 Blank APPL CRANIAL TONG/STRTCTC FRAME W/REMOVAL SPX Surgery Blank 4.00 1.85 1.85 Blank RBRVS

20661 Blank APPLICATION HALO CRANIAL INCLUDING REMOVAL Surgery Blank 5.26 7.41 7.41 Blank RBRVS

20662 Blank APPLICATION HALO PELVIC INCLUDING REMOVAL Surgery Blank 6.38 7.03 7.03 Blank RBRVS

20663 Blank APPLICATION HALO FEMORAL INCLUDING REMOVAL Surgery Blank 5.74 6.59 6.59 Blank RBRVS

20664 Blank APPL HALO 6/> PINS THIN SKULL OSTEOLOGY Surgery Blank 10.06 11.07 11.07 Blank RBRVS

20665 Blank REMOVAL TONG/HALO APPLIED BY ANOTHER INDIVIDUAL Surgery Blank 1.36 1.16 1.61 Blank RBRVS

20670 Blank REMOVAL IMPLANT SUPERFICIAL SEPARATE PROCEDURE Surgery Blank 1.79 2.15 8.75 Blank RBRVS

20680 Blank REMOVAL IMPLANT DEEP Surgery Blank 5.96 5.22 10.73 Blank RBRVS

20690 Blank APPLICATION UNIPLANE EXTERNAL FIXATION SYSTEM Surgery Blank 8.78 6.68 6.68 Blank RBRVS

20692 Blank APPLICATION MULTIPLANE EXTERNAL FIXATION SYSTEM Surgery Blank 16.27 13.12 13.12 Blank RBRVS

20693 Blank ADJUSTMENT/REVJ XTRNL FIXATION SYSTEM REQ ANES Surgery Blank 6.06 5.71 5.71 Blank RBRVS

20694 Blank REMOVAL EXTERNAL FIXATION SYSTEM UNDER ANES Surgery Blank 4.28 4.68 7.13 Blank RBRVS

20696 Blank XTRNL FIXJ W/STEREOTACTIC ADJUSTMENT 1ST & SUBQ Surgery Blank 17.56 13.83 13.83 Blank RBRVS

20697 Blank XTRNL FIXJ W/STRTCTC ADJUSTMENT EXCHANGE STRUT Surgery a Blank 60.42 60.42 Blank RBRVS

20802 Blank REPLANTATION ARM COMPLETE AMPUTATION Surgery Blank 42.62 28.40 28.40 Blank RBRVS

20805 Blank REPLANTATION FOREARM COMPLETE AMPUTATION Surgery Blank 51.46 32.99 32.99 Blank RBRVS

20808 Blank REPLANTATION HAND COMPLETE AMPUTATION Surgery Blank 63.09 38.87 38.87 Blank RBRVS

20816 Blank RPLJ DGT EXCEPT THMB MTCARPHLNGL JT COMPL AMP Surgery Blank 31.95 21.27 21.27 Blank RBRVS

20822 Blank RPLJ DGT EXCLUDING THMB SUBLIMIS TDN COMPL AMP Surgery Blank 26.66 19.18 19.18 Blank RBRVS

20824 Blank RPLJ THMB CARP/MTCRPL JT MP JT COMPL AMPUTATION Surgery Blank 31.95 21.37 21.37 Blank RBRVS

20827 Blank RPLJ THUMB DISTAL TIP MP JOINT COMPL AMPUTATION Surgery Blank 27.48 19.60 19.60 Blank RBRVS

20838 Blank REPLANTATION FOOT COMPLETE AMPUTATION Surgery Blank 42.88 21.52 21.52 Blank RBRVS

20900 Blank BONE GRAFT ANY DONOR AREA MINOR/SMALL Surgery Blank 3.00 1.91 8.36 Blank RBRVS

20902 Blank BONE GRAFT ANY DONOR AREA MAJOR/LARGE Surgery Blank 4.58 2.79 2.79 Blank RBRVS

20910 Blank CARTILAGE GRAFT COSTOCHONDRAL Surgery Blank 5.53 6.78 6.78 Blank RBRVS

20912 Blank CARTILAGE GRAFT NASAL SEPTUM Surgery Blank 6.54 6.01 6.01 Blank RBRVS

20920 Blank FASCIA LATA GRAFT BY STRIPPER Surgery Blank 5.51 5.06 5.06 Blank RBRVS

20922 Blank FASCIA LATA GRAFT INCISION & AREA EXPOSURE Surgery Blank 6.93 5.67 8.53 Blank RBRVS

20924 Blank TENDON GRAFT FROM A DISTANCE Surgery Blank 6.68 6.68 6.68 Blank RBRVS

20926 Blank TISSUE GRAFTS OTHER Surgery Blank 5.79 5.37 5.37 Blank RBRVS

20930 Blank ALLOGRAFT FOR SPINE SURGERY ONLY MORSELIZED Surgery Blank Blank Blank Blank 5.36 FAIR Health

20931 Blank ALLOGRAFT FOR SPINE SURGERY ONLY STRUCTURAL Surgery Blank 1.81 0.86 0.86 Blank RBRVS

20932 Blank OSTEOART ALGRFT W/SURF & B1 Surgery Blank 13.01 5.48 5.48 Blank RBRVS

20933 Blank HEMICRT INTRCLRY ALGRFT PRTL Surgery Blank 11.94 5.03 5.03 Blank RBRVS

20934 Blank INTERCALARY ALGRFT COMPL Surgery Blank 13.00 5.48 5.48 Blank RBRVS

20936 Blank AUTOGRAFT SPINE SURGERY LOCAL FROM SAME INCISION Surgery Blank Blank Blank Blank 6.55 FAIR Health

20937 Blank AUTOGRAFT SPINE SURGERY MORSELIZED SEP INCISION Surgery Blank 2.79 1.37 1.37 Blank RBRVS

20938 Blank AUTOGRAFT SPINE SURGERY BICORT/TRICORT SEP INC Surgery Blank 3.02 1.45 1.45 Blank RBRVS

20939 Blank BONE MARROW ASPIR BONE GRFG Surgery Blank 1.16 0.59 0.59 Blank RBRVS

20950 Blank MNTR INTERSTITIAL FLUID PRESSURE CMPRT SYNDROME Surgery Blank 1.26 1.12 5.63 Blank RBRVS

20955 Blank BONE GRAFT MICROVASCULAR ANASTOMOSIS FIBULA Surgery Blank 40.26 24.73 24.73 Blank RBRVS

20956 Blank BONE GRAFT MICROVASCULAR ANAST ILIAC CREST Surgery Blank 41.18 27.07 27.07 Blank RBRVS

20957 Blank BONE GRAFT MICROVASCULAR ANAST METATARSAL Surgery Blank 42.61 28.40 28.40 Blank RBRVS

20962 Blank BONE GRF W/MVASC ANAST OTH/THN ILIAC CREST/METAR Surgery Blank 39.21 29.92 29.92 Blank RBRVS

20969 Blank FREE OSTQ FLAP W/MVASC ANAST METAR/GREAT TOE Surgery Blank 45.43 26.53 26.53 Blank RBRVS





PAGE 8 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

20970 Blank FREE OSTQ FLAP W/MVASC ANASTOMOSIS ILIAC CREST Surgery Blank 44.58 29.24 29.24 Blank RBRVS

20972 Blank FREE OSTQ FLAP W/MVASC ANASTOMOSIS METATARSAL Surgery Blank 44.51 29.17 29.17 Blank RBRVS

20973 Blank FR OSTQ FLAP W/MVASC ANAST GRT TOE W/WEB SPACE Surgery Blank 47.27 30.48 30.48 Blank RBRVS

20974 Blank ELECTRICAL STIMULATION BONE HEALING NONINVASIVE Surgery Blank 0.62 0.70 1.44 Blank RBRVS

20975 Blank ELECTRICAL STIMULATION BONE HEALING INVASIVE Surgery Blank 2.60 1.91 1.91 Blank RBRVS

20979 Blank LOW INTENSITY US STIMJ BONE HEALING NONINVASIVE Surgery Blank 0.62 0.23 0.77 Blank RBRVS

20982 Blank ABLATION BONE TUMOR RF PERQ W/IMG GDN WHEN DONE Surgery Blank 7.02 2.75 103.54 Blank RBRVS

20983 Blank ABLATJ BONE TUMOR CRYO PERQ W/IMG GDN WHEN PRFMD Surgery Blank 6.88 2.79 163.06 Blank RBRVS

20985 Blank CPTR-ASST SURGICAL NAVIGATION IMAGE-LESS Surgery Blank 2.50 1.26 1.26 Blank RBRVS

20999 Blank UNLISTED PROCEDURE MUSCSKELETAL SYSTEM GENERAL Surgery Blank Blank Blank Blank 1.57 Unlisted

21010 Blank ARTHROTOMY TEMPOROMANDIBULAR JOINT Surgery Blank 11.04 9.06 9.06 Blank RBRVS

21011 Blank EXCISION TUMOR SOFT TISS FACE/SCALP SUBQ <2CM Surgery Blank 2.99 3.90 6.38 Blank RBRVS

21012 Blank EXCISION TUMOR SOFT TISS FACE/SCALP SUBQ 2 CM/> Surgery Blank 4.45 4.43 4.43 Blank RBRVS

21013 Blank EXC TUMOR SOFT TISS FACE&SCALP SUBFASCIAL <2CM Surgery Blank 5.42 5.16 8.47 Blank RBRVS

21014 Blank EXC TUMOR SOFT TISS FACE&SCALP SUBFASCIAL 2 CM/> Surgery Blank 7.13 6.59 6.59 Blank RBRVS

21015 Blank RAD RESECTION TUMOR SOFT TISS FACE/SCALP < 2CM Surgery Blank 9.89 8.71 8.71 Blank RBRVS

21016 Blank RAD RESECTION TUMOR SOFT TISS FACE/SCALP 2 CM/> Surgery Blank 15.26 11.19 11.19 Blank RBRVS

21025 Blank EXCISION BONE MANDIBLE Surgery Blank 10.03 9.85 13.74 Blank RBRVS

21026 Blank EXCISION FACIAL BONE Surgery Blank 5.70 7.67 10.97 Blank RBRVS

21029 Blank REMOVAL CONTOURING BENIGN TUMOR FACIAL BONE Surgery Blank 8.39 8.70 12.40 Blank RBRVS

21030 Blank EXC BENIGN TUMOR/CYST MAXL/ZYGOMA ENCL & CURTG Surgery Blank 4.91 6.25 9.13 Blank RBRVS

21031 Blank EXCISION TORUS MANDIBULARIS Surgery Blank 3.30 4.66 7.55 Blank RBRVS

21032 Blank EXCISION MAXILLARY TORUS PALATINUS Surgery Blank 3.34 4.48 7.60 Blank RBRVS

21034 Blank EXCISION MALIGNANT TUMOR MAXILLA/ZYGOMA Surgery Blank 17.38 12.93 17.30 Blank RBRVS

21040 Blank EXCISION BENIGN TUMOR/CYST MANDIBLE ENCL & CURT Surgery Blank 4.91 6.27 9.23 Blank RBRVS

21044 Blank EXCISION MALIGNANT TUMOR MANDIBLE Surgery Blank 12.80 10.22 10.22 Blank RBRVS

21045 Blank EXCISION MALIGNANT TUMOR MANDIBLE RADICAL Surgery Blank 18.37 13.88 13.88 Blank RBRVS

21046 Blank EXC BENIGN TUMOR/CYST MNDBL INTRA-ORAL OSTEOT Surgery Blank 14.21 15.49 15.49 Blank RBRVS

21047 Blank EXC B9 TUM/CST MNDBL XTR-ORAL OSTEOT&PRTL MNDB Surgery Blank 20.07 14.41 14.41 Blank RBRVS

21048 Blank EXC BENIGN TUMOR/CYST MAXL INTRA-ORAL OSTEOT Surgery Blank 14.71 15.54 15.54 Blank RBRVS

21049 Blank EXC B9 TUM/CST MAXL XTR-ORAL OSTEOT&PRTL MAXLC Surgery Blank 19.32 12.26 12.26 Blank RBRVS

21050 Blank CONDYLECTOMY TEMPOROMANDIBULAR JOINT SPX Surgery Blank 11.76 12.20 12.20 Blank RBRVS

21060 Blank MENISCECTOMY PRTL/COMPL TEMPOROMANDIBULAR JT SPX Surgery Blank 11.07 10.66 10.66 Blank RBRVS

21070 Blank CORONOIDECTOMY SEPARATE PROCEDURE Surgery Blank 8.62 8.47 8.47 Blank RBRVS

21073 Blank MANIPULATION TMJ THERAPEUTIC REQUIRE ANESTHESIA Surgery Blank 3.45 3.24 7.00 Blank RBRVS

21076 Blank IMPRESSION&PREPARATION SURG OBTURATOR PROSTHES Surgery Blank 13.40 8.11 12.65 Blank RBRVS

21077 Blank IMPRESSION & PREPARATION ORBITAL PROSTHESIS Surgery Blank 33.70 20.64 31.76 Blank RBRVS

21079 Blank IMPRESSION & PREPARATION INTERIM OBTURATOR PROST Surgery Blank 22.31 13.98 21.93 Blank RBRVS

21080 Blank IMPRESSION & PREPJ DEFINITIVE OBTURATOR PROSTHES Surgery Blank 25.06 15.40 24.78 Blank RBRVS

21081 Blank IMPRESSION & PREPJ MANDIBULAR RESECTION PROSTHES Surgery Blank 22.85 14.23 23.01 Blank RBRVS

21082 Blank IMPRESSION & PREPJ PALATAL AUGMENTATION PROSTHES Surgery Blank 20.84 13.92 22.48 Blank RBRVS

21083 Blank IMPRESSION & PREPARATION PALATAL LIFT PROSTHESIS Surgery Blank 19.27 13.03 22.10 Blank RBRVS

21084 Blank IMPRESSION & PREPARATION SPEECH AID PROSTHESIS Surgery Blank 22.48 14.86 24.92 Blank RBRVS

21085 Blank IMPRESSION & PREPARATION ORAL SURGICAL SPLINT Surgery Blank 8.99 5.68 11.02 Blank RBRVS

21086 Blank IMPRESSION & PREPARATION AURICULAR PROSTHESIS Surgery Blank 24.88 15.19 23.68 Blank RBRVS

21087 Blank IMPRESSION & PREPARATION NASAL PROSTHESIS Surgery Blank 24.88 14.91 23.76 Blank RBRVS

21088 Blank IMPRESSION & PREPARATION FACIAL PROSTHESIS Surgery Blank Blank Blank Blank 17.77 FAIR Health

21089 Blank UNLISTED MAXILLOFACIAL PROSTHETIC PROCEDURE Surgery Blank Blank Blank Blank 32.43 Unlisted

21100 Blank APPL HALO APPLIANCE MAXILLOFACIAL FIXATION SPX Surgery Blank 4.73 6.23 15.14 Blank RBRVS

21110 Blank APPL INTERDENTAL FIXATION DEVICE NON-FX/DISLC Surgery Blank 5.99 12.15 15.85 Blank RBRVS

21116 Blank INJECTION TEMPOROMANDIBULAR JOINT ARTHROGRAPHY Surgery Blank 0.81 0.43 3.73 Blank RBRVS

21120 Blank GENIOPLASTY AUGMENTATION Surgery Blank 5.10 9.66 13.71 Blank RBRVS

21121 Blank GENIOPLASTY SLIDING OSTEOTOMY SINGLE PIECE Surgery Blank 7.81 9.69 12.89 Blank RBRVS

21122 Blank GENIOPLASTY 2/> SLIDING OSTEOTOMIES Surgery Blank 8.71 12.66 12.66 Blank RBRVS

21123 Blank GENIOP SLIDING AGMNTJ W/INTERPOSAL BONE GRAFTS Surgery Blank 11.34 13.21 13.21 Blank RBRVS

21125 Blank AGMNTJ MNDBLR BODY/ANGLE PROSTHETIC MATERIAL Surgery Blank 10.80 9.56 71.80 Blank RBRVS

21127 Blank AGMNTJ MNDBLR BDY/ANGL W/GRF ONLAY/INTERPOSAL Surgery Blank 12.44 11.02 93.45 Blank RBRVS

21137 Blank REDUCTION FOREHEAD CONTOURING ONLY Surgery Blank 10.24 9.69 9.69 Blank RBRVS

21138 Blank RDCTJ FHD CNTRG & PROSTHETIC MATRL/BONE GRAFT Surgery Blank 12.87 11.43 11.43 Blank RBRVS

21139 Blank RDCTJ FHD CNTRG & SETBACK ANT FRONTAL SINUS WALL Surgery Blank 15.02 14.89 14.89 Blank RBRVS

21141 Blank RCNSTJ MIDFACE LEFORT I 1 PIECE W/O BONE GRAFT Surgery Blank 19.57 16.34 16.34 Blank RBRVS

21142 Blank RCNSTJ MIDFACE LEFORT I 2 PIECES W/O BONE GRAFT Surgery Blank 20.28 16.61 16.61 Blank RBRVS

21143 Blank RCNSTJ MIDFACE LEFORT I 3/> PIECE W/O BONE GRAFT Surgery Blank 21.05 17.71 17.71 Blank RBRVS

21145 Blank RCNSTJ MIDFACE LEFORT I 1 PIECE W/BONE GRAFTS Surgery Blank 23.94 18.04 18.04 Blank RBRVS

21146 Blank RCNSTJ MIDFACE LEFORT I 2 PIECES W/BONE GRAFTS Surgery Blank 24.87 18.90 18.90 Blank RBRVS

21147 Blank RCNSTJ MIDFACE LEFORT I 3/> PIECE W/BONE GRAFTS Surgery Blank 26.47 19.65 19.65 Blank RBRVS

21150 Blank RCNSTJ MIDFACE LEFORT II ANTERIOR INTRUSION Surgery Blank 25.96 17.90 17.90 Blank RBRVS

21151 Blank RCNSTJ MIDFACE LEFORT II W/BONE GRAFTS Surgery Blank 29.02 17.79 17.79 Blank RBRVS

21154 Blank RCNSTJ MIDFACE LEFORT III W/O LEFORT I Surgery Blank 31.29 20.52 20.52 Blank RBRVS

21155 Blank RCNSTJ MIDFACE LEFORT III W/LEFORT I Surgery Blank 35.22 22.17 22.17 Blank RBRVS

21159 Blank RCNSTJ MIDFACE LEFORT III W/FHD W/O LEFORT I Surgery Blank 43.14 25.50 25.50 Blank RBRVS

21160 Blank RCNSTJ MIDFACE LEFORT III W/FHD W/LEFORT I Surgery Blank 47.19 27.20 27.20 Blank RBRVS





PAGE 9 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

21172 Blank RCNSTJ SUPERIOR-LATERAL ORBITAL RIM & LOWER FHD Surgery Blank 28.20 20.40 20.40 Blank RBRVS

21175 Blank RCNSTJ BIFRONTAL SUPERIOR-LAT ORB RIMS & LWR FHD Surgery Blank 33.56 24.52 24.52 Blank RBRVS

21179 Blank RCNSTJ FOREHEAD &/ SUPRAORB RIMS W/ALGRF/PROSTC Surgery Blank 22.65 17.29 17.29 Blank RBRVS

21180 Blank RCNSTJ FOREHEAD &/ SUPRAORBITAL RIMS W/AUTOGRAFT Surgery Blank 25.58 19.12 19.12 Blank RBRVS

21181 Blank RCNSTJ CONTOURING BENIGN TUMOR CRNL BONES XTRC Surgery Blank 10.28 9.29 9.29 Blank RBRVS

21182 Blank RCNSTJ ORBIT/FHD/NASETHMD EXCBONE TUM GRF<40SQCM Surgery Blank 32.58 23.22 23.22 Blank RBRVS

21183 Blank RCNSTJ ORBIT/FHD/NASETHMD EXC BONE GRF>40 <80 Surgery Blank 35.70 25.07 25.07 Blank RBRVS

21184 Blank RCNSTJ ORBIT/FHD/NASETHMD EXC BONE TUM GRF>80SQ Surgery Blank 38.62 26.80 26.80 Blank RBRVS

21188 Blank RCNSTJ MDFC OTH/THN LEFORT OSTEOT & BONE GRAFTS Surgery Blank 23.15 21.54 21.54 Blank RBRVS

21193 Blank RCNSTJ MNDBLR RAMI HRZNTL/VER/C/L OSTEOT W/O GRF Surgery Blank 18.90 14.73 14.73 Blank RBRVS

21194 Blank RCNSTJ MNDBLR RAMI HRZNTL/VER/C/L OSTEOT W/GRAFT Surgery Blank 21.82 16.67 16.67 Blank RBRVS

21195 Blank RCNSTJ MNDBLR RAMI&/BODY SGTL SPLT W/O INT RGD Surgery Blank 19.16 18.94 18.94 Blank RBRVS

21196 Blank RCNSTJ MNDBLR RAMI&/BDY SGTL SPLT W/INT RGD FI Surgery Blank 20.83 18.49 18.49 Blank RBRVS

21198 Blank OSTEOTOMY MANDIBLE SEGMENTAL Surgery Blank 15.71 15.42 15.42 Blank RBRVS

21199 Blank OSTEOTOMY MANDIBLE SGMTL W/GENIOGLOSSUS ADVMNT Surgery Blank 16.73 11.53 11.53 Blank RBRVS

21206 Blank OSTEOTOMY MAXILLA SEGMENTAL Surgery Blank 15.59 16.31 16.31 Blank RBRVS

21208 Blank OSTEOPLASTY FACIAL BONES AUGMENTATION Surgery Blank 11.42 10.69 37.36 Blank RBRVS

21209 Blank OSTEOPLASTY FACIAL BONES REDUCTION Surgery Blank 7.82 10.09 16.24 Blank RBRVS

21210 Blank GRAFT BONE NASAL/MAXILLARY/MALAR AREAS Surgery Blank 11.69 10.96 50.18 Blank RBRVS

21215 Blank GRAFT BONE MANDIBLE Surgery Blank 12.23 11.39 96.96 Blank RBRVS

21230 Blank GRAFT RIB CRTLG AUTOGENOUS FACE/CHIN/NOSE/EAR Surgery Blank 11.17 8.37 8.37 Blank RBRVS

21235 Blank GRAFT EAR CRTLG AUTOGENOUS NOSE/EAR Surgery Blank 7.50 7.55 12.02 Blank RBRVS

21240 Blank ARTHRP TEMPOROMANDIBULAR JOINT W/WO AUTOGRAFT Surgery Blank 16.07 13.49 13.49 Blank RBRVS

21242 Blank ARTHROPLASTY TEMPOROMANDIBULAR JT W/ALLOGRAFT Surgery Blank 14.59 12.86 12.86 Blank RBRVS

21243 Blank ARTHRP TMPRMAND JOINT W/PROSTHETIC REPLACEMENT Surgery Blank 24.53 20.60 20.60 Blank RBRVS

21244 Blank RCNSTJ MNDBL XTRORAL W/TRANSOSTEAL BONE PLATE Surgery Blank 13.62 14.59 14.59 Blank RBRVS

21245 Blank RCNSTJ MNDBL/MAXL SUBPRIOSTEAL IMPLANT PARTIAL Surgery Blank 13.12 12.14 19.23 Blank RBRVS

21246 Blank RCNSTJ MNDBL/MAXL SUBPRIOSTEAL IMPLANT COMPLETE Surgery Blank 12.92 10.29 10.29 Blank RBRVS

21247 Blank RCNSTJ MNDBLR CONDYLE W/BONE CARTLG AUTOGRAFTS Surgery Blank 24.37 18.75 18.75 Blank RBRVS

21248 Blank RCNSTJ MANDIBLE/MAXL ENDOSTEAL IMPLANT PARTIAL Surgery Blank 12.74 11.03 16.78 Blank RBRVS

21249 Blank RCNSTJ MANDIBLE/MAXL ENDOSTEAL IMPLANT COMPLETE Surgery Blank 18.77 14.75 22.67 Blank RBRVS

21255 Blank RCNSTJ ZYGMTC ARCH/GLENOID FOSSA W/BONE CARTLG Surgery Blank 18.46 19.42 19.42 Blank RBRVS

21256 Blank RECONSTRUCTION ORBIT W/OSTEOTOMIES & BONE GRAFTS Surgery Blank 17.66 15.23 15.23 Blank RBRVS

21260 Blank PERIORBITAL OSTEOTOMIES BONE GRAFTS EXTRACRANIAL Surgery Blank 17.90 19.67 19.67 Blank RBRVS

21261 Blank PERIORBITAL OSTEOTOMIES W/BONE GRAFTS ICRA & XTR Surgery Blank 34.07 31.96 31.96 Blank RBRVS

21263 Blank PERIORBITAL OSTEOTOMIES W/BONE GRAFTS W/FOREHEAD Surgery Blank 31.01 30.15 30.15 Blank RBRVS

21267 Blank ORBITAL REPOSITIONING W/BONE GRAFTS EXTRACRANIAL Surgery Blank 20.69 23.35 23.35 Blank RBRVS

21268 Blank ORBITAL REPOSITIONING W/BONE GRAFTS ICRA & XTRC Surgery Blank 27.07 27.81 27.81 Blank RBRVS

21270 Blank MALAR AUGMENTATION PROSTHETIC MATERIAL Surgery Blank 10.63 9.29 16.78 Blank RBRVS

21275 Blank SECONDARY REVISION ORBITOCRANIOFACIAL RCNSTJ Surgery Blank 11.76 10.37 10.37 Blank RBRVS

21280 Blank MEDIAL CANTHOPEXY SEPARATE PROCEDURE Surgery Blank 7.13 8.53 8.53 Blank RBRVS

21282 Blank LATERAL CANTHOPEXY Surgery Blank 4.27 6.15 6.15 Blank RBRVS

21295 Blank REDUCTION MASSETER MUSCLE & BONE EXTRAORAL Surgery Blank 1.90 3.14 3.14 Blank RBRVS

21296 Blank REDUCTION MASSETER MUSCLE & BONE INTRAORAL Surgery Blank 4.78 6.34 6.34 Blank RBRVS

21299 Blank UNLISTED CRANIOFACIAL & MAXILLOFACIAL PROCEDURE Surgery Blank Blank Blank Blank 20.00 Unlisted

21310 Blank CLOSED TREATMENT NASAL FRACTURE W/O MANIPULATION Surgery Blank 0.58 0.12 3.21 Blank RBRVS

21315 Blank CLOSED TX NASAL FRACTURE W/O STABILIZATION Surgery Blank 1.83 2.21 5.69 Blank RBRVS

21320 Blank CLOSED TREATMENT NASAL FRACTURE W/STABILIZATION Surgery Blank 1.88 1.67 5.05 Blank RBRVS

21325 Blank OPEN TREATMENT NASAL FRACTURE UNCOMPLICATED Surgery Blank 4.18 8.55 8.55 Blank RBRVS

21330 Blank OPEN TX NASAL FX COMP W/INT&/XTRNL SKELETAL FI Surgery Blank 5.79 9.46 9.46 Blank RBRVS

21335 Blank OPEN TX NASAL FX W/CONCOMITANT OPTX FXD SEPTUM Surgery Blank 9.02 10.19 10.19 Blank RBRVS

21336 Blank OPEN TX NASAL SEPTAL FRACTURE W/WO STABILIZATION Surgery Blank 6.77 10.54 10.54 Blank RBRVS

21337 Blank CLOSED TX NASAL SEPTAL FRACT W/WO STABILIZATION Surgery Blank 3.39 4.48 7.56 Blank RBRVS

21338 Blank OPEN TX NASOETHMOID FX W/O EXTERNAL FIXATION Surgery Blank 6.87 10.92 10.92 Blank RBRVS

21339 Blank OPEN TX NASOETHMOID FX W/EXTERNAL FIXATION Surgery Blank 8.50 11.61 11.61 Blank RBRVS

21340 Blank PERCUTANEOUS TX NASOETHMOID COMPLEX FRACTURE Surgery Blank 11.49 7.99 7.99 Blank RBRVS

21343 Blank OPEN TX DEPRESSED FRONTAL SINUS FRACTURE Surgery Blank 14.32 14.26 14.26 Blank RBRVS

21344 Blank OPEN TX COMPLICATED FRONTAL SINUS FRACTURE Surgery Blank 21.57 14.65 14.65 Blank RBRVS

21345 Blank CLOSED TX NASOMAXILLARY COMPLEX FRACTURE Surgery Blank 9.06 7.37 11.58 Blank RBRVS

21346 Blank OPTX NASOMAX CPLX FX LEFT II TYPE W/WIRG & FXJ Surgery Blank 11.45 12.41 12.41 Blank RBRVS

21347 Blank OPTX NASOMAX CPLX FX LEFT II TYPE REQ MLT OPN Surgery Blank 13.53 13.22 13.22 Blank RBRVS

21348 Blank OPTX NASOMAX CPLX FX LEFT II TYPE W/BONE GRAFT Surgery Blank 17.52 10.66 10.66 Blank RBRVS

21355 Blank PERCUTANEOUS TX MALAR AREA FRACTURE Surgery Blank 4.45 3.96 6.94 Blank RBRVS

21356 Blank OPEN TX DEPRESSED ZYGOMATIC ARCH FRACTURE Surgery Blank 4.83 5.22 8.71 Blank RBRVS

21360 Blank OPEN TX DEPRESSED MALAR FRACTURE Surgery Blank 7.19 7.19 7.19 Blank RBRVS

21365 Blank OPEN TX COMP FX MALAR W/INTERNAL FX&MULT SURG Surgery Blank 16.77 12.52 12.52 Blank RBRVS

21366 Blank OPEN TX COMP FRACTURE MALAR AREA W/BONE GRAFT Surgery Blank 18.60 14.99 14.99 Blank RBRVS

21385 Blank OPEN TX ORBITAL FLOOR BLOWOUT FX TRANSANTRAL Surgery Blank 9.57 10.79 10.79 Blank RBRVS

21386 Blank OPEN TX ORBITAL FLOOR BLOWOUT FX PERIORBITAL Surgery Blank 9.57 8.87 8.87 Blank RBRVS

21387 Blank OPEN TX ORBITAL FLOOR BLOWOUT FX COMBINED APPR Surgery Blank 10.11 11.10 11.10 Blank RBRVS

21390 Blank OPTX ORB FLOOR BLWT FX PRI/BITAL APPR W/ALLPLSTC Surgery Blank 11.23 10.13 10.13 Blank RBRVS

21395 Blank OPTX ORB FLOOR BLWT FX PRI/BITAL APPR W/BONE GRF Surgery Blank 14.70 11.88 11.88 Blank RBRVS





PAGE 10 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

21400 Blank CLSD TX FX ORBIT EXCEPT BLOWOUT W/O MANIPULATION Surgery Blank 1.50 2.76 3.77 Blank RBRVS

21401 Blank CLOSED TX FX ORBIT EXCEPT BLOWOUT W/MANIPULATION Surgery Blank 3.68 4.94 10.55 Blank RBRVS

21406 Blank OPEN TX FX ORBIT EXCEPT BLOWOUT W/O IMPLANT Surgery Blank 7.42 7.82 7.82 Blank RBRVS

21407 Blank OPEN TX FX ORBIT EXCEPT BLOWOUT W/IMPLANT Surgery Blank 9.02 8.19 8.19 Blank RBRVS

21408 Blank OPEN TX FX ORBIT EXCEPT BLOWOUT W/BONE GRAFT Surgery Blank 12.78 10.99 10.99 Blank RBRVS

21421 Blank CLOSED TX PALATAL/MAXILLARY FX W/FIXATION/SPLINT Surgery Blank 6.02 10.84 14.12 Blank RBRVS

21422 Blank OPEN TREATMENT PALATAL/MAXILLARY FRACTURE Surgery Blank 8.73 9.14 9.14 Blank RBRVS

21423 Blank OPEN TX PALATAL/MAXILLARY FX COMP MULTIPLE APPR Surgery Blank 10.85 9.96 9.96 Blank RBRVS

21431 Blank CLOSED TX CRANIOFACIAL SEPARATION Surgery Blank 7.90 11.41 11.41 Blank RBRVS

21432 Blank OPEN TX CRANIOFACIAL SEP W/WIRING&/INT FIXJ Surgery Blank 8.82 10.38 10.38 Blank RBRVS

21433 Blank OPEN TX CRANIOFACIAL SEP COMPLICATED MLT APPR Surgery Blank 26.29 19.46 19.46 Blank RBRVS

21435 Blank OPEN TX CRANIOFACIAL SEP COMP W/INT&/XTRNL FIX Surgery Blank 20.26 16.81 16.81 Blank RBRVS

21436 Blank OPTX CRNFCL SEP LFT III TYP COMP INT FIXJ W/BONE Surgery Blank 30.30 23.49 23.49 Blank RBRVS

21440 Blank CLTX MANDIBULAR/MAXILLARY ALVEOLAR RIDGE FX SPX Surgery Blank 3.44 9.46 12.59 Blank RBRVS

21445 Blank OPTX MANDIBULAR/MAXILLARY ALVEOLAR RIDGE FX SPX Surgery Blank 6.26 10.66 14.89 Blank RBRVS

21450 Blank CLOSED TX MANDIBULAR FRACTURE W/O MANIPULATION Surgery Blank 3.71 8.93 11.83 Blank RBRVS

21451 Blank CLOSED TX MANDIBULAR FRACTURE W/MANIPULATION Surgery Blank 5.65 11.45 14.88 Blank RBRVS

21452 Blank PERCUTANEOUS TX MANDIBULAR FX W/EXTERNAL FIXJ Surgery Blank 2.40 7.91 15.50 Blank RBRVS

21453 Blank CLOSED TX MANDIBULAR FX W/INTERDENTAL FIXATION Surgery Blank 6.64 14.67 18.41 Blank RBRVS

21454 Blank OPEN TX MANDIBULAR FX W/EXTERNAL FIXATION Surgery Blank 7.36 7.61 7.61 Blank RBRVS

21461 Blank OPEN TX MANDIBULAR FX W/O INTERDENTAL FIXATION Surgery Blank 9.31 16.11 50.31 Blank RBRVS

21462 Blank OPEN TX MANDIBULAR FX W/INTERDENTAL FIXATION Surgery Blank 11.01 17.27 52.35 Blank RBRVS

21465 Blank OPEN TREATMENT MANDIBULAR CONDYLAR FRACTURE Surgery Blank 13.12 11.43 11.43 Blank RBRVS

21470 Blank OPTX COMP MANDIBULAR FX MLT APPR W/INT FIXATION Surgery Blank 17.54 14.23 14.23 Blank RBRVS

21480 Blank CLOSED TX TEMPOROMANDIBULAR DISLOCATION 1ST/SBSQ Surgery Blank 0.61 0.22 2.12 Blank RBRVS

21485 Blank CLOSED TX TEMPOROMANDIBULAR DISLC COMP 1ST/SBSQ Surgery Blank 4.77 12.70 16.68 Blank RBRVS

21490 Blank OPEN TREATMENT TEMPOROMANDIBULAR DISLOCATION Surgery Blank 12.95 11.28 11.28 Blank RBRVS

21497 Blank INTERDENTAL WIRING OTHER THAN FRACTURE Surgery Blank 4.64 10.81 13.81 Blank RBRVS

21499 Blank UNLISTED MUSCULOSKELETAL PROCEDURE HEAD Surgery Blank Blank Blank Blank 17.21 Unlisted

21501 Blank I&D DEEP ABSC/HMTMA SOFT TISSUE NECK/THORAX Surgery Blank 3.98 4.46 8.18 Blank RBRVS

21502 Blank I&D DP ABSC/HMTMA SOFT TISS NCK/THORAX PRTL RI Surgery Blank 7.55 5.17 5.17 Blank RBRVS

21510 Blank INCISION DEEP OPENING BONE CORTEX THORAX Surgery Blank 6.20 5.04 5.04 Blank RBRVS

21550 Blank BIOPSY SOFT TISSUE NECK/THORAX Surgery Blank 2.11 2.10 5.05 Blank RBRVS

21552 Blank EXC TUMOR SOFT TIS NECK/ANT THORAX SUBQ 3 CM/> Surgery Blank 6.49 4.93 4.93 Blank RBRVS

21554 Blank EXC TUMOR SOFT TISSUE NECK/THORAX SUBFASC 5 CM/> Surgery Blank 11.13 7.59 7.59 Blank RBRVS

21555 Blank EXC TUMOR SOFT TISSUE NECK/ANT THORAX SUBQ <3CM Surgery Blank 3.96 4.02 7.12 Blank RBRVS

21556 Blank EXC TUMOR SOFT TISS NECK/THORAX SUBFASCIAL <5CM Surgery Blank 7.66 6.02 6.02 Blank RBRVS

21557 Blank RAD RESECT TUMOR SOFT TISS NECK/ANT THORAX <5CM Surgery Blank 14.75 9.78 9.78 Blank RBRVS

21558 Blank RAD RESECT TUMOR SOFT TISS NECK/ANT THORAX 5CM/> Surgery Blank 21.58 12.72 12.72 Blank RBRVS

21600 Blank EXCISION RIB PARTIAL Surgery Blank 7.26 7.09 7.09 Blank RBRVS

21610 Blank COSTOTRANSVERSECTOMY SEPARATE PROCEDURE Surgery Blank 15.91 12.61 12.61 Blank RBRVS

21615 Blank EXCISION 1ST &/CERVICAL RIB Surgery Blank 10.45 4.95 4.95 Blank RBRVS

21616 Blank EXCISION 1ST &/CERVICAL RIB W/SYMPATHECTOMY Surgery Blank 12.69 5.08 5.08 Blank RBRVS

21620 Blank OSTECTOMY STERNUM PARTIAL Surgery Blank 7.28 5.66 5.66 Blank RBRVS

21627 Blank STERNAL DEBRIDEMENT Surgery Blank 7.30 6.62 6.62 Blank RBRVS

21630 Blank RADICAL RESECTION STERNUM Surgery Blank 19.18 12.38 12.38 Blank RBRVS

21632 Blank RADICAL RESECTION STERNUM W/MEDSTNL LMPHADEC Surgery Blank 19.68 10.50 10.50 Blank RBRVS

21685 Blank HYOID MYOTOMY & SUSPENSION Surgery Blank 15.26 10.66 10.66 Blank RBRVS

21700 Blank DIVISION SCALENUS ANTICUS W/O RESCJ CERVICAL RIB Surgery Blank 6.31 2.62 2.62 Blank RBRVS

21705 Blank DIVISION SCALENUS ANTICUS RESECTION CERVICAL RIB Surgery Blank 9.92 3.33 3.33 Blank RBRVS

21720 Blank DIVISION STERNOCLEIDOMASTOID OPEN W/O CAST Surgery Blank 5.80 6.99 6.99 Blank RBRVS

21725 Blank DIVISION STERNOCLEIDOMASTOID OPEN W/CAST Surgery Blank 7.19 6.92 6.92 Blank RBRVS

21740 Blank REPAIR PECTUS EXCAVATUM/CARINATUM OPEN Surgery Blank 17.57 8.14 8.14 Blank RBRVS

21742 Blank REPAIR PECTUS EXCAVATM/CARINATM MINLY W/O THRSC Surgery Blank Blank Blank Blank 33.98 FAIR Health

21743 Blank REPAIR PECTUS EXCAVATM/CARINATM MINLY W/THRSC Surgery Blank Blank Blank Blank 48.79 FAIR Health

21750 Blank CLOSE MEDIAN STERNOTOMY SEP W/WO DEBRIDEMENT SPX Surgery Blank 11.40 5.73 5.73 Blank RBRVS

21811 Blank OPEN TX RIB FX W/FIXJ THORACOSCOPIC VIS 1-3 RIBS Surgery Blank 10.79 4.14 4.14 Blank RBRVS

21812 Blank OPEN TX RIB FX W/FIXJ THORACOSCOPIC VIS 4-6 RIBS Surgery Blank 13.00 5.18 5.18 Blank RBRVS

21813 Blank OPEN TX RIB FX W/FIXJ THORACOSCOPIC VIS 7+ RIBS Surgery Blank 17.61 6.80 6.80 Blank RBRVS

21820 Blank CLOSED TREATMENT STERNUM FRACTURE Surgery Blank 1.36 2.53 2.47 Blank RBRVS

21825 Blank OPEN TX STERNUM FRACTURE W/WO SKELETAL FIXATION Surgery Blank 7.76 6.00 6.00 Blank RBRVS

21899 Blank UNLISTED PROCEDURE NECK/THORAX Surgery Blank Blank Blank Blank 11.42 Unlisted

21920 Blank BIOPSY SOFT TISSUE BACK/FLANK SUPERFICIAL Surgery Blank 2.11 2.17 4.92 Blank RBRVS

21925 Blank BIOPSY SOFT TISSUE BACK/FLANK DEEP Surgery Blank 4.63 4.63 7.27 Blank RBRVS

21930 Blank EXCISION TUMOR SOFT TISSUE BACK/FLANK SUBQ <3CM Surgery Blank 4.94 4.55 7.62 Blank RBRVS

21931 Blank EXCISION TUMOR SOFT TIS BACK/FLANK SUBQ 3 CM/> Surgery Blank 6.88 5.12 5.12 Blank RBRVS

21932 Blank EXC TUMOR SOFT TISS BACK/FLANK SUBFASCIAL <5CM Surgery Blank 9.82 7.06 7.06 Blank RBRVS

21933 Blank EXC TUMOR SOFT TISS BACK/FLANK SUBFASCIAL 5 CM/> Surgery Blank 11.13 7.67 7.67 Blank RBRVS

21935 Blank RAD RESECTION TUMOR SOFT TISSUE BACK/FLANK <5CM Surgery Blank 15.72 10.50 10.50 Blank RBRVS

21936 Blank RAD RESECTION TUMOR SOFT TISSUE BACK/FLANK 5CM/> Surgery Blank 22.55 13.38 13.38 Blank RBRVS

22010 Blank I&D DEEP ABSCESS PST SPINE CRV THRC/CERVICOTHR Surgery Blank 12.75 11.21 11.21 Blank RBRVS

22015 Blank I&D DEEP ABSCESS PST SPINE LUMBAR SAC/LUMBOSAC Surgery Blank 12.64 11.20 11.20 Blank RBRVS





PAGE 11 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

22100 Blank PRTL EXC PST VRT INTRNSC B1Y LES 1 VRT SGM CRV Surgery Blank 11.00 10.74 10.74 Blank RBRVS

22101 Blank PRTL EXC PST VRT INTRNSC B1Y LES 1 VRT SGM THRC Surgery Blank 11.08 10.44 10.44 Blank RBRVS

22102 Blank PRTL EXC PST VRT INTRNSC B1Y LES 1 VRT SGM LMBR Surgery Blank 11.08 9.49 9.49 Blank RBRVS

22103 Blank PRTL EXC PST VRT INTRNSC B1Y LES 1 VRT SGM EA Surgery Blank 2.34 1.14 1.14 Blank RBRVS

22110 Blank PRTL EXC VRT BDY B1Y LES W/O SPI CORD 1 SGM CRV Surgery Blank 14.00 11.84 11.84 Blank RBRVS

22112 Blank PRTL EXC VRT BDY B1Y LES W/O SPI CORD 1 SGM THRC Surgery Blank 14.07 12.80 12.80 Blank RBRVS

22114 Blank PRTL EXC VRT BDY B1Y LES W/O SPI CORD 1 SGM LMBR Surgery Blank 14.07 12.80 12.80 Blank RBRVS

22116 Blank PRTL EXC VRT BDY B1Y LES W/O SPI CORD 1 SGM EA Surgery Blank 2.32 1.10 1.10 Blank RBRVS

22206 Blank OSTEOTOMY SPINE POSTERIOR 3 COLUMN THORACIC Surgery Blank 37.18 23.18 23.18 Blank RBRVS

22207 Blank OSTEOTOMY SPINE POSTERIOR 3 COLUMN LUMBAR Surgery Blank 36.68 23.07 23.07 Blank RBRVS

22208 Blank OSTEOTOMY SPINE POSTERIOR 3 COLUMN EA ADDL SGM Surgery Blank 9.66 4.64 4.64 Blank RBRVS

22210 Blank OSTEOTOMY SPINE PST/PSTLAT APPR 1 VRT SGM CRV Surgery Blank 25.38 18.84 18.84 Blank RBRVS

22212 Blank OSTEOTOMY SPINE PST/PSTLAT APPR 1 VRT SGM THRC Surgery Blank 20.99 16.54 16.54 Blank RBRVS

22214 Blank OSTEOTOMY SPINE PST/PSTLAT APPR 1 VRT SGM LMBR Surgery Blank 21.02 16.56 16.56 Blank RBRVS

22216 Blank OSTEOT SPI PST/PSTLAT APPR 1 VRT SGM EA VRT SGM Surgery Blank 6.03 2.95 2.95 Blank RBRVS

22220 Blank OSTEOTOMY SPINE W/DSKC ANT APPR 1 VRT SGM CRV Surgery Blank 22.94 17.12 17.12 Blank RBRVS

22222 Blank OSTEOTOMY SPINE W/DSKC ANT APPR 1 VRT SGM THRC Surgery Blank 23.09 18.36 18.36 Blank RBRVS

22224 Blank OSTEOTOMY SPINE W/DSKC ANT APPR 1 VRT SGM LMBR Surgery Blank 23.09 17.24 17.24 Blank RBRVS

22226 Blank OSTEOT SPI W/DSKC ANT APPR 1 VRT SGM EA VRT SGM Surgery Blank 6.03 2.90 2.90 Blank RBRVS

22310 Blank CLTX VRT BDY FX W/O MANJ REQ&W/CSTING/BRACING Surgery Blank 3.89 3.46 4.18 Blank RBRVS

22315 Blank CLTX VRT FX&/DISLC CSTING/BRACING MANJ/TRCJ Surgery Blank 10.11 9.63 12.84 Blank RBRVS

22318 Blank OPTX&/RDCTJ ODNTD FX&/DISLC ANT FIXJ W/O GRAFT Surgery Blank 22.72 16.37 16.37 Blank RBRVS

22319 Blank OPTX&/RDCTJ ODNTD FX&/DISLC ANT W/INT FIXJ Surgery Blank 25.33 17.73 17.73 Blank RBRVS

22325 Blank OPTX&/RDCTJ VRT FX&/DISLC PST 1 VRT SGM LM Surgery Blank 19.87 15.90 15.90 Blank RBRVS

22326 Blank OPTX&/RDCTJ VRT FX&/DISLC PST 1 VRT SGM CR Surgery Blank 20.84 15.59 15.59 Blank RBRVS

22327 Blank OPTX&/RDCTJ VRT FX&/DISLC PST 1 VRT SGM TH Surgery Blank 20.77 16.34 16.34 Blank RBRVS

22328 Blank OPTX&/RDCTJ VRT FX&/DISLC PST 1 VRT SGM EA Surgery Blank 4.60 2.19 2.19 Blank RBRVS

22505 Blank MANIPULATION SPINE REQUIRING ANESTHESIA Surgery Blank 1.87 1.57 1.57 Blank RBRVS

22510 Blank PERQ VERTEBROPLASTY UNI/BI INJX CERVICOTHORACIC Surgery Blank 7.90 3.74 39.14 Blank RBRVS

22511 Blank PERQ VERTEBROPLASTY UNI/BI INJECTION LUMBOSACRAL Surgery Blank 7.33 3.56 39.17 Blank RBRVS

22512 Blank VERTEBROPLASTY EACH ADDL CERVICOTHOR/LUMBOSACRAL Surgery Blank 4.00 1.45 22.61 Blank RBRVS

22513 Blank PERQ VERT AGMNTJ CAVITY CRTJ UNI/BI CANNULATION Surgery Blank 8.65 4.78 193.30 Blank RBRVS

22514 Blank PERQ VERT AGMNTJ CAVITY CRTJ UNI/BI CANNULJ LMBR Surgery Blank 7.99 4.52 193.12 Blank RBRVS

22515 Blank PERQ VERT AGMNTJ CAVITY CRTJ UNI/BI CANNULJ EACH Surgery Blank 4.00 1.70 117.86 Blank RBRVS

22526 Blank PERQ INTRDSCL ELECTROTHRM ANNULOPLASTY 1 LEVEL Surgery Blank 5.85 3.12 59.96 Blank RBRVS

22527 Blank PERQ INTRDSCL ELECTROTHRM ANNULOPLASTY ADDL LVL Surgery Blank 3.03 1.17 52.81 Blank RBRVS

22532 Blank ARTHRODESIS LATERAL EXTRACAVITARY THORACIC Surgery Blank 25.99 18.08 18.08 Blank RBRVS

22533 Blank ARTHRODESIS LATERAL EXTRACAVITARY LUMBAR Surgery Blank 24.79 17.40 17.40 Blank RBRVS

22534 Blank ARTHRODESIS LAT EXTRACAVITARY EA ADDL THRC/LMBR Surgery Blank 5.99 2.90 2.90 Blank RBRVS

22548 Blank ARTHRD ANT TRANSORL/XTRORAL C1-C2 W/WO EXC ODNTD Surgery Blank 27.06 19.27 19.27 Blank RBRVS

22551 Blank ARTHRD ANT INTERBODY DECOMPRESS CERVICAL BELW C2 Surgery Blank 25.00 16.73 16.73 Blank RBRVS

22552 Blank ARTHRD ANT INTERDY CERVCL BELW C2 EA ADDL NTRSPC Surgery Blank 6.50 3.10 3.10 Blank RBRVS

22554 Blank ARTHRD ANT MIN DISCECT INTERBODY CERV BELOW C2 Surgery Blank 17.69 13.34 13.34 Blank RBRVS

22556 Blank ARTHRD ANT MIN DISCECTOMY INTERBODY THORACIC Surgery Blank 24.70 16.62 16.62 Blank RBRVS

22558 Blank ARTHRODESIS ANTERIOR INTERBODY LUMBAR Surgery Blank 23.53 15.01 15.01 Blank RBRVS

22585 Blank ARTHRODESIS ANTERIOR INTERBODY EA ADDL NTRSPC Surgery Blank 5.52 2.54 2.54 Blank RBRVS

22586 Blank ARTHRODESIS PRESACRAL INTRBDY W/INSTRUMENT L5-S1 Surgery Blank 28.12 18.67 18.67 Blank RBRVS

22590 Blank ARTHRODESIS POSTERIOR CRANIOCERVICAL Surgery Blank 21.76 16.49 16.49 Blank RBRVS

22595 Blank ARTHRODESIS POSTERIOR ATLAS-AXIS C1-C2 Surgery Blank 20.64 15.96 15.96 Blank RBRVS

22600 Blank ARTHRODESIS PST/PSTLAT CERVICAL BELW C2 SGM Surgery Blank 17.40 14.32 14.32 Blank RBRVS

22610 Blank ARTHRODESIS POSTERIOR/POSTEROLATERAL THORACIC Surgery Blank 17.28 14.13 14.13 Blank RBRVS

22612 Blank ARTHRODESIS POSTERIOR/POSTEROLATERAL LUMBAR Surgery Blank 23.53 16.19 16.19 Blank RBRVS

22614 Blank ARTHRODESIS POSTERIOR/POSTEROLATERAL EA ADDL Surgery Blank 6.43 3.10 3.10 Blank RBRVS

22630 Blank ARTHRODESIS POSTERIOR INTERBODY LUMBAR Surgery Blank 22.09 16.25 16.25 Blank RBRVS

22632 Blank ARTHRODESIS POSTERIOR INTERBODY EA ADDL Surgery Blank 5.22 2.47 2.47 Blank RBRVS

22633 Blank ARTHDSIS POST/POSTEROLATRL/POSTINTERBODY LUMBAR Surgery Blank 27.75 18.04 18.04 Blank RBRVS

22634 Blank ARTHDSIS POST/POSTERLATRL/POSTINTRBDYADL SPC/SEG Surgery Blank 8.16 3.91 3.91 Blank RBRVS

22800 Blank ARTHRODESIS POSTERIOR SPINAL DFRM UP 6 VRT SEG Surgery Blank 19.50 14.69 14.69 Blank RBRVS

22802 Blank ARTHRODESIS POSTERIOR SPINAL DFRM 7-12 VRT SEG Surgery Blank 32.11 20.93 20.93 Blank RBRVS

22804 Blank ARTHRODESIS POSTERIOR SPINAL DFRM 13/> VRT SEG Surgery Blank 37.50 23.60 23.60 Blank RBRVS

22808 Blank ARTHRODESIS ANTERIOR SPINAL DFRM 2-3 VRT SEG Surgery Blank 27.51 18.25 18.25 Blank RBRVS

22810 Blank ARTHRODESIS ANTERIOR SPINAL DFRM 4-7 VRT SEG Surgery Blank 31.50 19.34 19.34 Blank RBRVS

22812 Blank ARTHRODESIS POSTERIOR SPINAL DFRM 8/> VRT SEG Surgery Blank 34.25 22.88 22.88 Blank RBRVS

22818 Blank KYPHECTOMY SINGLE OR TWO SEGMENTS Surgery Blank 34.33 21.65 21.65 Blank RBRVS

22819 Blank KYPHECTOMY 3 OR MORE SEGMENTS Surgery Blank 39.38 24.98 24.98 Blank RBRVS

22830 Blank EXPLORATION SPINAL FUSION Surgery Blank 11.22 9.27 9.27 Blank RBRVS

22840 Blank POSTERIOR NON-SEGMENTAL INSTRUMENTATION Surgery Blank 12.52 6.04 6.04 Blank RBRVS

22841 Blank INTERNAL SPINAL FIXATION WIRING SPINOUS PROCESS Surgery Blank Blank Blank Blank 20.63 FAIR Health

22842 Blank POSTERIOR SEGMENTAL INSTRUMENTATION 3-6 VRT SEG Surgery Blank 12.56 6.05 6.05 Blank RBRVS

22843 Blank POSTERIOR SEGMENTAL INSTRUMENTATION 7-12 VRT SEG Surgery Blank 13.44 6.50 6.50 Blank RBRVS

22844 Blank POSTERIOR SEGMENTAL INSTRUMENTATION 13/> VRT SE Surgery Blank 16.42 8.05 8.05 Blank RBRVS

22845 Blank ANTERIOR INSTRUMENTATION 2-3 VERTEBRAL SEGMENTS Surgery Blank 11.94 5.69 5.69 Blank RBRVS





PAGE 12 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

22846 Blank ANTERIOR INSTRUMENTATION 4-7 VERTEBRAL SEGMENTS Surgery Blank 12.40 5.92 5.92 Blank RBRVS

22847 Blank ANTERIOR INSTRUMENTATION 8/> VERTEBRAL SEGMENTS Surgery Blank 13.78 6.97 6.97 Blank RBRVS

22848 Blank PELVIC FIXATION OTHER THAN SACRUM Surgery Blank 5.99 2.94 2.94 Blank RBRVS

22849 Blank REINSERTION SPINAL FIXATION DEVICE Surgery Blank 19.17 13.21 13.21 Blank RBRVS

22850 Blank REMOVAL POSTERIOR NONSEGMENTAL INSTRUMENTATION Surgery Blank 9.82 8.38 8.38 Blank RBRVS

22852 Blank REMOVAL POSTERIOR SEGMENTAL INSTRUMENTATION Surgery Blank 9.37 8.15 8.15 Blank RBRVS

22853 Blank INSJ BIOMECHANICAL DEVICE Surgery Blank 4.25 2.03 2.03 Blank RBRVS


22855 Blank REMOVAL ANTERIOR INSTRUMENTATION Surgery Blank 15.86 11.53 11.53 Blank RBRVS

22856 Blank TOT DISC ARTHRP ART DISC ANT APPRO 1 NTRSPC CRV Surgery Blank 24.05 16.16 16.16 Blank RBRVS

22857 Blank TOT DISC ARTHRP ART DISC ANT APPRO 1 NTRSPC LMBR Surgery Blank 27.13 15.35 15.35 Blank RBRVS

22858 Blank TOT DISC ARTHRP ANT APPR DISC 2ND LEVEL CERVICAL Surgery Blank 8.40 4.06 4.06 Blank RBRVS


22861 Blank REVJ RPLCMT DISC ARTHROPLASTY ANT 1 NTRSPC CRV Surgery Blank 33.36 21.20 21.20 Blank RBRVS

22862 Blank REVJ RPLCMT DISC ARTHROPLASTY ANT 1 NTRSPC LMBR Surgery Blank 32.63 21.91 21.91 Blank RBRVS

22864 Blank RMVL DISC ARTHROPLASTY ANT 1 INTERSPACE CERVICAL Surgery Blank 29.40 19.37 19.37 Blank RBRVS

22865 Blank RMVL DISC ARTHROPLASTY ANT 1 INTERSPACE LUMBAR Surgery Blank 31.75 19.67 19.67 Blank RBRVS

22867 Blank INSJ STABLJ DEV W/DCMPRN Surgery Blank 13.50 10.46 10.46 Blank RBRVS

22868 Blank INSJ STABLJ DEV W/DCMPRN Surgery Blank 4.00 1.89 1.89 Blank RBRVS

22869 Blank INSJ STABLJ DEV W/O DCMPRN Surgery Blank 7.03 6.55 6.55 Blank RBRVS

22870 Blank INSJ STABLJ DEV W/O DCMPRN Surgery Blank 2.34 1.09 1.09 Blank RBRVS

22899 Blank UNLISTED PROCEDURE SPINE Surgery Blank Blank Blank Blank 18.61 Unlisted

22900 Blank EXC TUMOR SOFT TISSUE ABDL WALL SUBFASCIAL <5CM Surgery Blank 8.32 6.11 6.11 Blank RBRVS

22901 Blank EXC TUMOR SOFT TISSUE ABDL WALL SUBFASCIAL 5CM/> Surgery Blank 10.11 6.81 6.81 Blank RBRVS

22902 Blank EXC TUMOR SOFT TISSUE ABDOMINAL WALL SUBQ <3CM Surgery Blank 4.42 4.10 7.15 Blank RBRVS

22903 Blank EXC TUMOR SOFT TISSUE ABDOMINAL WALL SUBQ 3 CM/> Surgery Blank 6.39 4.80 4.80 Blank RBRVS

22904 Blank RAD RESECTION TUMOR SOFT TISSUE ABDL WALL <5CM Surgery Blank 16.69 10.03 10.03 Blank RBRVS

22905 Blank RAD RESECTION TUMOR SOFT TISSUE ABDL WALL 5 CM/> Surgery Blank 21.58 12.14 12.14 Blank RBRVS

22999 Blank UNLISTED PX ABDOMEN MUSCULOSKELETAL SYSTEM Surgery Blank Blank Blank Blank 11.19 Unlisted

23000 Blank REMOVAL SUBDELTOID CALCAREOUS DEPOSITS OPEN Surgery Blank 4.48 5.23 11.24 Blank RBRVS

23020 Blank CAPSULAR CONTRACTURE RELEASE Surgery Blank 9.36 8.67 8.67 Blank RBRVS

23030 Blank I&D SHOULDER DEEP ABSCESS/HEMATOMA Surgery Blank 3.47 3.23 8.62 Blank RBRVS

23031 Blank I&D SHOULDER INFECTED BURSA Surgery Blank 2.79 2.90 8.64 Blank RBRVS

23035 Blank INCISION BONE CORTEX SHOULDER AREA Surgery Blank 9.16 8.59 8.59 Blank RBRVS

23040 Blank ARTHROTOMY GLENOHUMERAL JT EXPL/DRG/RMVL FB Surgery Blank 9.75 8.98 8.98 Blank RBRVS

23044 Blank ARTHRT ACROMCLAV STRNCLAV JT EXPL/DRG/RMVL FB Surgery Blank 7.59 7.12 7.12 Blank RBRVS

23065 Blank BIOPSY SOFT TISSUE SHOULDER SUPERFICIAL Surgery Blank 2.30 2.17 3.58 Blank RBRVS

23066 Blank BIOPSY SOFT TISSUE SHOULDER DEEP Surgery Blank 4.30 5.11 10.83 Blank RBRVS

23071 Blank EXCISION TUMOR SOFT TISSUE SHOULDER SUBQ 3 CM/> Surgery Blank 5.91 4.87 4.87 Blank RBRVS

23073 Blank EXC TUMOR SOFT TISSUE SHOULDER SUBFASCIAL 5 CM/> Surgery Blank 10.13 7.71 7.71 Blank RBRVS

23075 Blank EXCISION TUMOR SOFT TISSUE SHOULDER SUBQ <3CM Surgery Blank 4.21 4.32 8.41 Blank RBRVS

23076 Blank EXC TUMOR SOFT TISS SHOULDER SUBFASC <5CM Surgery Blank 7.41 6.54 6.54 Blank RBRVS

23077 Blank RAD RESECTION TUMOR SOFT TISSUE SHOULDER <5CM Surgery Blank 17.66 11.40 11.40 Blank RBRVS

23078 Blank RAD RESECTION TUMOR SOFT TISSUE SHOULDER 5 CM/> Surgery Blank 22.55 14.18 14.18 Blank RBRVS

23100 Blank ARTHROTOMY GLENOHUMERAL JOINT W/BIOPSY Surgery Blank 6.20 6.94 6.94 Blank RBRVS

23101 Blank ARTHRT ACROMCLAV/STRNCLAV JT W/BX&/EXC CRTLG Surgery Blank 5.72 6.24 6.24 Blank RBRVS

23105 Blank ARTHRT GLENOHUMRL JT W/SYNOVECTOMY W/WO BIOPSY Surgery Blank 8.48 8.23 8.23 Blank RBRVS

23106 Blank ARTHRT GLENOHUMRL JT STRNCLAV JT W/SYNVCT W/WOBX Surgery Blank 6.13 6.90 6.90 Blank RBRVS

23107 Blank ARTHRT GLENOHMRL JT W/JT EXPL W/WO RMVL LOOSE/FB Surgery Blank 8.87 8.44 8.44 Blank RBRVS

23120 Blank CLAVICULECTOMY PARTIAL Surgery Blank 7.39 7.96 7.96 Blank RBRVS

23125 Blank CLAVICULECTOMY TOTAL Surgery Blank 9.64 8.83 8.83 Blank RBRVS

23130 Blank PARTIAL REPAIR OR REMOVAL OF SHOULDER BONE Surgery Blank 7.77 8.20 8.20 Blank RBRVS

23140 Blank EXC/CURTG BONE CYST/BENIGN TUMOR CLAV/SCAPULA Surgery Blank 7.12 6.79 6.79 Blank RBRVS

23145 Blank EXC/CURTG BONE CST/B9 TUM CLAV/SCAPULA W/AGRFT Surgery Blank 9.40 8.71 8.71 Blank RBRVS

23146 Blank EXC/CURTG BONE CST/B9 TUM CLAV/SCAPULA W/ALGRFT Surgery Blank 8.08 8.15 8.15 Blank RBRVS

23150 Blank EXC/CURTG BONE CYST/BENIGN TUMOR PROX HUMERUS Surgery Blank 8.91 8.37 8.37 Blank RBRVS

23155 Blank EXC/CURTG BONE CYST/BENIGN TUM PROX HUM W/AGRFT Surgery Blank 10.86 9.78 9.78 Blank RBRVS

23156 Blank EXC/CURTG BONE CYST/BENIGN TUM PROX HUM W/ALGRFT Surgery Blank 9.11 8.56 8.56 Blank RBRVS

23170 Blank SEQUESTRECTOMY CLAVICLE Surgery Blank 7.21 7.45 7.45 Blank RBRVS

23172 Blank SEQUESTRECTOMY SCAPULA Surgery Blank 7.31 7.50 7.50 Blank RBRVS

23174 Blank SEQUESTRECTOMY HUMERAL HEAD SURGERY NECK Surgery Blank 10.05 9.75 9.75 Blank RBRVS

23180 Blank PARTIAL EXCISION BONE CLAVICLE Surgery Blank 8.99 8.01 8.01 Blank RBRVS

23182 Blank PARTIAL EXCISION BONE SCAPULA Surgery Blank 8.61 8.49 8.49 Blank RBRVS

23184 Blank PARTIAL EXCISION BONE PROXIMAL HUMERUS Surgery Blank 9.90 9.21 9.21 Blank RBRVS

23190 Blank OSTECTOMY SCAPULA PARTIAL Surgery Blank 7.47 7.47 7.47 Blank RBRVS

23195 Blank RESECTION HUMERAL HEAD Surgery Blank 10.36 9.30 9.30 Blank RBRVS

23200 Blank RADICAL RESECTION TUMOR CLAVICLE Surgery Blank 22.71 16.49 16.49 Blank RBRVS

23210 Blank RADICAL RESECTION TUMOR SCAPULA Surgery Blank 27.21 18.77 18.77 Blank RBRVS

23220 Blank RADICAL RESECTION BONE TUMOR PROXIMAL HUMERUS Surgery Blank 30.21 20.23 20.23 Blank RBRVS

23330 Blank REMOVAL FOREIGN BODY SHOULDER SUBCUTANEOUS Surgery Blank 1.90 2.51 5.55 Blank RBRVS

23333 Blank REMOVAL SHOULDER FOREIGN BODY DEEP SUBFASCIAL/IM Surgery Blank 6.00 6.31 6.31 Blank RBRVS

23334 Blank PROSTHESIS REMOVAL HUMERAL/GLENOID COMPONENT Surgery Blank 15.50 12.43 12.43 Blank RBRVS





PAGE 13 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

23335 Blank PROSTHESIS REMOVAL HUMERAL AND GLENOID COMPONENT Surgery Blank 19.00 14.17 14.17 Blank RBRVS

23350 Blank INJECTION SHOULDER ARTHROGRAPHY/ CT/MRI ARTHG Surgery Blank 1.00 0.38 2.61 Blank RBRVS

23395 Blank MUSCLE TRANSFER SHOULDER/UPPER ARM SINGLE Surgery Blank 18.54 14.88 14.88 Blank RBRVS

23397 Blank MUSCLE TRANSFER SHOULDER/UPPER ARM MULTIPLE Surgery Blank 16.76 12.59 12.59 Blank RBRVS

23400 Blank SCAPULOPEXY Surgery Blank 13.87 11.31 11.31 Blank RBRVS

23405 Blank TENOTOMY SHOULDER AREA 1 TENDON Surgery Blank 8.54 7.68 7.68 Blank RBRVS

23406 Blank TENOTOMY SHOULDER MULTIPLE THRU SAME INCISION Surgery Blank 11.01 9.13 9.13 Blank RBRVS

23410 Blank OPEN REPAIR OF ROTATOR CUFF ACUTE Surgery Blank 11.39 10.03 10.03 Blank RBRVS

23412 Blank OPEN REPAIR OF ROTATOR CUFF CHRONIC Surgery Blank 11.93 10.29 10.29 Blank RBRVS

23415 Blank CORACOACROMIAL LIGAMENT RELEAS W/WOACROMIOPLASTY Surgery Blank 9.23 8.98 8.98 Blank RBRVS

23420 Blank RECONSTRUCTION ROTATOR CUFF AVULSION CHRONIC Surgery Blank 13.54 11.73 11.73 Blank RBRVS

23430 Blank TENODESIS LONG TENDON BICEPS Surgery Blank 10.17 9.31 9.31 Blank RBRVS

23440 Blank RESECTION/TRANSPLANTATION LONG TENDON BICEPS Surgery Blank 10.64 9.01 9.01 Blank RBRVS

23450 Blank CAPSULORRHAPHY ANTERIOR PUTTI-PLATT/MAGNUSON Surgery Blank 13.70 10.88 10.88 Blank RBRVS

23455 Blank CAPSULORRHAPHY ANTERIOR W/LABRAL REPAIR Surgery Blank 14.67 11.24 11.24 Blank RBRVS

23460 Blank CAPSULORRHAPHY ANTERIOR WITH BONE BLOCK Surgery Blank 15.82 12.41 12.41 Blank RBRVS

23462 Blank CAPSULORRHAPHY ANTERIOR W/CORACOID PROCESS TR Surgery Blank 15.72 11.78 11.78 Blank RBRVS

23465 Blank CAPSULORRHAPHY GLENOHUMERAL JT PST W/WO BONE BLK Surgery Blank 16.30 12.65 12.65 Blank RBRVS

23466 Blank CAPSULORRHAPHY GLENOHUMRL JT MULTI-DIRIONAL INS Surgery Blank 15.80 13.42 13.42 Blank RBRVS

23470 Blank ARTHROPLASTY GLENOHUMRL JT HEMIARTHROPLASTY Surgery Blank 17.89 13.27 13.27 Blank RBRVS

23472 Blank ARTHROPLASTY GLENOHUMERAL JOINT TOTAL SHOULDER Surgery Blank 22.13 15.66 15.66 Blank RBRVS

23473 Blank REVIS SHOULDER ARTHRPLSTY HUMERAL/GLENOID COMPNT Surgery Blank 25.00 17.11 17.11 Blank RBRVS

23474 Blank REVIS SHOULDER ARTHRPLSTY HUMERAL&GLENOID COMPNT Surgery Blank 27.21 18.25 18.25 Blank RBRVS

23480 Blank OSTEOTOMY CLAVICLE W/WO INTERNAL FIXATION Surgery Blank 11.54 9.79 9.79 Blank RBRVS

23485 Blank OSTEOTOMY CLAV W/WO INT FIXJ W/BONE GRF NON/MAL Surgery Blank 13.91 10.82 10.82 Blank RBRVS

23490 Blank PROPH TX W/WO METHYLMETHACRYLATE CLAVICLE Surgery Blank 12.16 10.23 10.23 Blank RBRVS

23491 Blank PROPH TX W/WO METHYLMETHACRYLATE PROX HUMERUS Surgery Blank 14.54 11.77 11.77 Blank RBRVS

23500 Blank CLSD TX CLAVICULAR FRACTURE W/O MANIPULATION Surgery Blank 2.21 3.76 3.69 Blank RBRVS

23505 Blank CLSD TX CLAVICULAR FRACTURE W/MANIPULATION Surgery Blank 3.83 4.94 5.55 Blank RBRVS

23515 Blank OPEN TX CLAVICULAR FRACTURE INTERNAL FIXATION Surgery Blank 9.69 9.14 9.14 Blank RBRVS

23520 Blank CLSD TX STERNOCLAVICULAR DISLC W/O MANIPULATION Surgery Blank 2.29 3.97 3.90 Blank RBRVS

23525 Blank CLOSED TX STERNOCLAVICULAR DISLC W/MANIPULATION Surgery Blank 3.79 5.64 6.49 Blank RBRVS

23530 Blank OPEN TX STERNOCLAVICULAR DISLC ACUTE/CHRONIC Surgery Blank 7.48 7.47 7.47 Blank RBRVS

23532 Blank OPTX STRNCLAV DISLC ACUTE/CHRONIC W/FASCIAL GRF Surgery Blank 8.20 8.10 8.10 Blank RBRVS

23540 Blank CLSD TX ACROMIOCLAVICULAR DISLC W/O MANIPULATION Surgery Blank 2.36 3.77 3.70 Blank RBRVS

23545 Blank CLSD TX ACROMIOCLAVICULAR DISLC W/MANIPULATION Surgery Blank 3.43 4.89 5.82 Blank RBRVS

23550 Blank OPEN TX ACROMIOCLAVICULAR DISLC ACUTE/CHRONIC Surgery Blank 7.59 7.18 7.18 Blank RBRVS

23552 Blank OPTX ACROMCLAV DISLC ACUTE/CHRONIC W/FASCIAL GRF Surgery Blank 8.82 8.30 8.30 Blank RBRVS

23570 Blank CLOSED TX SCAPULAR FRACTURE W/O MANIPULATION Surgery Blank 2.36 4.04 3.87 Blank RBRVS

23575 Blank CLTX SCAPULAR FX W/MANJ W/WO SKELETAL TRACTION Surgery Blank 4.23 5.68 6.43 Blank RBRVS

23585 Blank OPEN TX SCAPULAR FX W/INTERNAL FIXATION IF PFRMD Surgery Blank 14.23 11.27 11.27 Blank RBRVS

23600 Blank CLTX PROXIMAL HUMERAL FRACTURE W/O MANIPULATION Surgery Blank 3.00 5.24 5.81 Blank RBRVS

23605 Blank CLTX PROX HUMRL FX W/MANJ W/WO SKELETAL TRACJ Surgery Blank 5.06 6.12 7.27 Blank RBRVS

23615 Blank OPEN TREATMENT PROXIMAL HUMERAL FRACTURE Surgery Blank 12.30 10.78 10.78 Blank RBRVS

23616 Blank OPEN PROX HUMERAL FRACTURE PROSTHETIC RPLCMT Surgery Blank 18.37 13.83 13.83 Blank RBRVS

23620 Blank CLTX GREATER HUMERAL TUBEROSITY FX W/O MANJ Surgery Blank 2.55 4.30 4.70 Blank RBRVS

23625 Blank CLTX GRTER HUMERAL TUBEROSITY FX W/MANIPULATION Surgery Blank 4.10 5.17 5.97 Blank RBRVS

23630 Blank OPEN TREATMENT GRTER HUMERAL TUBEROSITY FRACTURE Surgery Blank 10.57 9.84 9.84 Blank RBRVS

23650 Blank CLSD TX SHOULDER DISLC W/MANIPULATION W/O ANES Surgery Blank 3.53 4.18 4.96 Blank RBRVS

23655 Blank CLSD TX SHOULDER DISLC W/MANIPULATION REQ ANES Surgery Blank 4.76 5.85 5.85 Blank RBRVS

23660 Blank OPEN TX ACUTE SHOULDER DISLOCATION Surgery Blank 7.66 7.61 7.61 Blank RBRVS

23665 Blank CLTX SHOULDER DISLC W/FX HUMERAL TUBRST W/MANJ Surgery Blank 4.66 5.78 6.65 Blank RBRVS

23670 Blank OPEN TX SHOULDER DISLC W/HUMERAL TUBEROSITY FX Surgery Blank 12.28 10.53 10.53 Blank RBRVS

23675 Blank CLTX SHOULDER DISLC W/SURG/ANTMCL NECK FX W/MANJ Surgery Blank 6.27 6.83 8.27 Blank RBRVS

23680 Blank OPEN TX SHOULDER DISLOCATION W/NECK FRACTURE Surgery Blank 13.15 11.05 11.05 Blank RBRVS

23700 Blank MANJ W/ANES SHOULDER JOINT W/FIXATION APPARATUS Surgery Blank 2.57 2.57 2.57 Blank RBRVS

23800 Blank ARTHRODESIS GLENOHUMERAL JOINT Surgery Blank 14.73 11.86 11.86 Blank RBRVS

23802 Blank ARTHRODESIS GLENOHUMERAL JT W/AUTOGENOUS GRAFT Surgery Blank 18.42 14.89 14.89 Blank RBRVS

23900 Blank INTERTHORACOSCAPULAR AMPUTATION Surgery Blank 20.72 15.15 15.15 Blank RBRVS

23920 Blank DISARTICULATION SHOULDER Surgery Blank 16.23 13.01 13.01 Blank RBRVS

23921 Blank DISRTCJ SHOULDER SECONDARY CLSR/SCAR REVISION Surgery Blank 5.72 6.57 6.57 Blank RBRVS

23929 Blank UNLISTED PROCEDURE SHOULDER Surgery Blank Blank Blank Blank 17.12 Unlisted

23930 Blank I&D UPPER ARM/ELBOW DEEP ABSCESS/HEMATOMA Surgery Blank 2.99 2.64 6.66 Blank RBRVS

23931 Blank INCISION&DRAINAGE UPPER ARM/ELBOW BURSA Surgery Blank 1.84 2.43 6.12 Blank RBRVS

23935 Blank INC DEEP W/OPENING BONE CORTEX HUMERUS/ELBOW Surgery Blank 6.38 6.93 6.93 Blank RBRVS

24000 Blank ARTHRT ELBOW W/EXPLORATION DRAINAGE/REMOVAL FB Surgery Blank 6.08 6.46 6.46 Blank RBRVS

24006 Blank ARTHRT ELBOW CAPSULAR EXCISION CAPSULAR RLS SPX Surgery Blank 9.74 8.87 8.87 Blank RBRVS

24065 Blank BIOPSY SOFT TISSUE UPPER ARM/ELBOW SUPERFICIAL Surgery Blank 2.13 2.36 4.90 Blank RBRVS

24066 Blank BIOPSY SOFT TISSUE UPPER ARM/ELBOW AREA DEEP Surgery Blank 5.35 5.42 11.30 Blank RBRVS

24071 Blank EXC TUMOR SOFT TISSUE UPPER ARM/ELBOW SUBQ 3CM/> Surgery Blank 5.70 4.75 4.75 Blank RBRVS

24073 Blank EXC TUMOR SOFT TISS UPPER ARM/ELBW SUBFASC 5CM/> Surgery Blank 10.13 7.70 7.70 Blank RBRVS

24075 Blank EXC TUMOR SOFT TISS UPPER ARM/ELBOW SUBQ <3CM Surgery Blank 4.24 4.39 8.96 Blank RBRVS





PAGE 14 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

24076 Blank EXC TUMOR SOFT TISS UPR ARM/ELBOW SUBFASC <5CM Surgery Blank 7.41 6.73 6.73 Blank RBRVS

24077 Blank RAD RESECT TUMOR SOFT TISS UPPER ARM/ELBOW <5CM Surgery Blank 15.72 10.80 10.80 Blank RBRVS

24079 Blank RAD RESECT TUMOR SOFT TISS UPPER ARM/ELBOW 5CM/> Surgery Blank 20.61 13.37 13.37 Blank RBRVS

24100 Blank ARTHROTOMY ELBOW W/SYNOVIAL BIOPSY ONLY Surgery Blank 5.07 5.91 5.91 Blank RBRVS

24101 Blank ARTHRT ELBOW W/JNT EXPL W/WOBX W/WORMVL LOOSE/FB Surgery Blank 6.30 6.84 6.84 Blank RBRVS

24102 Blank ARTHROTOMY ELBOW W/SYNOVECTOMY Surgery Blank 8.26 7.91 7.91 Blank RBRVS

24105 Blank EXCISION OLECRANON BURSA Surgery Blank 3.78 5.54 5.54 Blank RBRVS

24110 Blank EXCISION/CURTG BONE CYST/BENIGN TUMOR HUMERUS Surgery Blank 7.58 7.75 7.75 Blank RBRVS

24115 Blank EXC/CURTG BONE CYST/BENIGN TUMOR HUMERUS W/AGRFT Surgery Blank 10.12 9.07 9.07 Blank RBRVS

24116 Blank EXC/CURTG BONE CYST/BENIGN TUM HUMERUS W/ALGRFT Surgery Blank 12.23 10.14 10.14 Blank RBRVS

24120 Blank EXC/CURTG BONE CYST/BENIGN TUMOR H/N RDS/OLECRN Surgery Blank 6.82 7.13 7.13 Blank RBRVS

24125 Blank EXC/CURTG BONE CST/B9 TUM H/N RDS/OLECRN W/AGRFT Surgery Blank 8.14 8.06 8.06 Blank RBRVS

24126 Blank EXC/CURTG BONE CST/B9 TUM H/N RDS/OLECRN W/ALGRT Surgery Blank 8.62 8.31 8.31 Blank RBRVS

24130 Blank EXCISION RADIAL HEAD Surgery Blank 6.42 6.95 6.95 Blank RBRVS

24134 Blank SEQUESTRECTOMY SHAFT/DISTAL HUMERUS Surgery Blank 10.22 9.23 9.23 Blank RBRVS

24136 Blank SEQUESTRECTOMY RADIAL HEAD OR NECK Surgery Blank 8.40 8.05 8.05 Blank RBRVS

24138 Blank SEQUESTRECTOMY OLECRANON PROCESS Surgery Blank 8.50 9.19 9.19 Blank RBRVS

24140 Blank PARTIAL EXCISION BONE HUMERUS Surgery Blank 9.55 8.84 8.84 Blank RBRVS

24145 Blank PARTIAL EXCISION BONE RADIAL HEAD/NECK Surgery Blank 7.81 7.64 7.64 Blank RBRVS

24147 Blank PARTIAL EXCISION BONE OLECRANON PROCESS Surgery Blank 7.84 8.52 8.52 Blank RBRVS

24149 Blank RAD RESCJ CAPSL TISS&HTRTPC BONE ELBW CONTRCT Surgery Blank 16.22 14.62 14.62 Blank RBRVS

24150 Blank RADICAL RESECTION TUMOR SHAFT/DISTAL HUMERUS Surgery Blank 23.46 16.75 16.75 Blank RBRVS

24152 Blank RADICAL RESECTION TUMOR RADIAL HEAD/NECK Surgery Blank 19.99 15.00 15.00 Blank RBRVS

24155 Blank RESECTION ELBOW JOINT ARTHRECTOMY Surgery Blank 12.09 10.06 10.06 Blank RBRVS

24160 Blank PROSTHESIS REMOVAL HUMERAL AND ULNAR COMPONENTS Surgery Blank 18.63 14.23 14.23 Blank RBRVS

24164 Blank PROSTHESIS REMOVAL RADIAL HEAD Surgery Blank 10.00 9.13 9.13 Blank RBRVS

24200 Blank RMVL FOREIGN BODY UPPER ARM/ELBOW SUBCUTANEOUS Surgery Blank 1.81 1.92 3.86 Blank RBRVS

24201 Blank REMOVAL FOREIGN BODY UPPER ARM/ELBOW DEEP Surgery Blank 4.70 4.77 10.12 Blank RBRVS

24220 Blank INJECTION ELBOW ARTHROGRAPHY Surgery Blank 1.31 0.53 3.03 Blank RBRVS

24300 Blank MANIPULATION ELBOW UNDER ANESTHESIA Surgery Blank 4.04 7.12 7.12 Blank RBRVS

24301 Blank MUSCLE/TENDON TRANSFER UPPER ARM/ELBOW SINGLE Surgery Blank 10.38 9.23 9.23 Blank RBRVS

24305 Blank TENDON LENGTHENING UPPER ARM/ELBOW EA TENDON Surgery Blank 7.62 7.63 7.63 Blank RBRVS

24310 Blank TENOTOMY OPEN ELBOW TO SHOULDER EACH TENDON Surgery Blank 6.12 6.31 6.31 Blank RBRVS

24320 Blank TENOPLASTY ELBOW TO SHOULDER SINGLE Surgery Blank 10.86 9.43 9.43 Blank RBRVS

24330 Blank FLEXOR-PLASTY ELBOW Surgery Blank 9.79 8.90 8.90 Blank RBRVS

24331 Blank FLEXOR-PLASTY ELBOW W/EXTENSOR ADVANCEMENT Surgery Blank 10.95 9.48 9.48 Blank RBRVS

24332 Blank TENOLYSIS TRICEPS Surgery Blank 7.91 8.11 8.11 Blank RBRVS

24340 Blank TENODESIS BICEPS TENDON ELBOW SEPARATE PROCEDURE Surgery Blank 8.08 8.01 8.01 Blank RBRVS

24341 Blank REPAIR TENDON/MUSCLE UPPER ARM/ELBOW EA Surgery Blank 9.49 10.12 10.12 Blank RBRVS

24342 Blank RINSJ RPTD BICEPS/TRICEPS TDN DSTL W/WO TDN GRF Surgery Blank 10.86 9.41 9.41 Blank RBRVS

24343 Blank REPAIR LATERAL COLLATERAL LIGAMENT ELBOW Surgery Blank 9.16 9.44 9.44 Blank RBRVS

24344 Blank RCNSTJ LAT COLTRL LIGM ELBOW W/TENDON GRAFT Surgery Blank 15.21 13.41 13.41 Blank RBRVS

24345 Blank REPAIR MEDIAL COLLATERAL LIGAMENT ELBOW Surgery Blank 9.16 9.31 9.31 Blank RBRVS

24346 Blank RCNSTJ MEDIAL COLTRL LIGM ELBW W/TDN GRF Surgery Blank 15.21 13.36 13.36 Blank RBRVS

24357 Blank TENOTOMY ELBOW LATERAL/MEDIAL PERCUTANEOUS Surgery Blank 5.44 5.79 5.79 Blank RBRVS

24358 Blank TNOT ELBOW LATERAL/MEDIAL DEBRIDE OPEN Surgery Blank 6.66 7.13 7.13 Blank RBRVS

24359 Blank TNOT ELBOW LATERAL/MEDIAL DEBRIDE OPEN TDN RPR Surgery Blank 8.98 8.32 8.32 Blank RBRVS

24360 Blank ARTHROPLASTY ELBOW W/MEMBRANE Surgery Blank 12.67 10.68 10.68 Blank RBRVS

24361 Blank ARTHROPLASTY ELBOW W/DISTAL HUMRL PROSTC RPLCMT Surgery Blank 14.41 11.68 11.68 Blank RBRVS

24362 Blank ARTHRP ELBOW W/IMPLT&FSCA LATA LIGAMENT RCNSTJ Surgery Blank 15.32 12.13 12.13 Blank RBRVS

24363 Blank ARTHRP ELBOW W/DISTAL HUM&PROX UR PROSTC RPLCM Surgery Blank 22.00 15.90 15.90 Blank RBRVS

24365 Blank ARTHROPLASTY RADIAL HEAD Surgery Blank 8.62 8.03 8.03 Blank RBRVS

24366 Blank ARTHROPLASTY RADIAL HEAD W/IMPLANT Surgery Blank 9.36 8.44 8.44 Blank RBRVS

24370 Blank REVIS ELBOW ARTHRPLSTY HUMERAL/ULNA COMPNT Surgery Blank 23.55 16.64 16.64 Blank RBRVS

24371 Blank REVIS ELBOW ARTHRPLSTY HUMERAL&ULNA COMPNT Surgery Blank 27.50 18.88 18.88 Blank RBRVS

24400 Blank OSTEOTOMY HUMERUS W/WO INTERNAL FIXATION Surgery Blank 11.33 10.06 10.06 Blank RBRVS

24410 Blank MLT OSTEOT W/RELIGNMT IMED ROD HUMERAL SHAFT Surgery Blank 15.11 12.30 12.30 Blank RBRVS

24420 Blank OSTEOPLASTY HUMERUS Surgery Blank 13.73 12.15 12.15 Blank RBRVS

24430 Blank REPAIR NON/MALUNION HUMERUS W/O GRAFT Surgery Blank 15.25 12.24 12.24 Blank RBRVS

24435 Blank REPAIR NON/MALUNION HUMERUS W/ILIAC/OTH AGRFT Surgery Blank 14.99 13.13 13.13 Blank RBRVS

24470 Blank HEMIEPIPHYSEAL ARREST Surgery Blank 8.93 8.58 8.58 Blank RBRVS

24495 Blank DECOMPRESSION FASCT F/ARM W/BRACH ART EXPL Surgery Blank 8.41 11.10 11.10 Blank RBRVS

24498 Blank PROPH TX W/WO METHYLMETHACRYLATE HUMERAL SHAFT Surgery Blank 12.28 10.17 10.17 Blank RBRVS

24500 Blank CLSD TX HUMERAL SHAFT FRACTURE W/O MANIPULATION Surgery Blank 3.41 5.30 6.25 Blank RBRVS

24505 Blank CLTX HUMERAL SHFT FX W/MANJ W/WO SKELETAL TRACJ Surgery Blank 5.39 6.42 7.82 Blank RBRVS

24515 Blank OPTX HUMERAL SHFT FX W/PLATE/SCREWS W/WOCERCLAGE Surgery Blank 12.12 10.75 10.75 Blank RBRVS

24516 Blank TX HUMRAL SHAFT FX W/INSJ IMED IMPLT W/W CERCLGE Surgery Blank 12.19 10.18 10.18 Blank RBRVS

24530 Blank CLTX SPRCNDYLR/TRANSCNDYLR HUMERAL FX W/WO MANJ Surgery Blank 3.69 5.48 6.53 Blank RBRVS

24535 Blank CLTX SPRCNDYLR/TRANSCNDYLR HUMERAL FX W/MANJ Surgery Blank 7.11 7.82 9.21 Blank RBRVS

24538 Blank PRQ SKEL FIXJ SPRCNDYLR/TRANSCNDYLR HUMERAL FX Surgery Blank 9.77 9.64 9.64 Blank RBRVS

24545 Blank OPEN TX HUMERAL SUPRACONDYLAR FRACTURE W/O XTN Surgery Blank 13.15 11.08 11.08 Blank RBRVS

24546 Blank OPEN TX HUMERAL SUPRACONDYLAR FRACTURE W/XTN Surgery Blank 14.91 12.17 12.17 Blank RBRVS





PAGE 15 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

24560 Blank CLTX HUMERAL EPICONDYLAR FX MEDIAL/LAT W/O MANJ Surgery Blank 2.98 4.74 5.73 Blank RBRVS

24565 Blank CLTX HUMERAL EPICONDYLAR FX MEDIAL/LAT W/MANJ Surgery Blank 5.78 7.08 8.36 Blank RBRVS

24566 Blank PRQ SKEL FIXJ HUMRL EPCNDYLR FX MEDIAL/LAT MANJ Surgery Blank 9.06 9.74 9.74 Blank RBRVS

24575 Blank OPEN TX HUMERAL EPICONDYLAR FRACTURE Surgery Blank 9.71 9.53 9.53 Blank RBRVS

24576 Blank CLTX HUMERAL CONDYLAR FX MEDIAL/LAT W/O MANJ Surgery Blank 3.06 5.13 6.16 Blank RBRVS

24577 Blank CLTX HUMERAL CONDYLAR FX MEDIAL/LATERAL W/MANJ Surgery Blank 6.01 7.20 8.55 Blank RBRVS

24579 Blank OPEN TREATMENT HUMERAL CONDYLAR FRACTURE Surgery Blank 11.44 10.41 10.41 Blank RBRVS

24582 Blank PRQ SKEL FIXJ HUMRL CNDYLR FX MEDIAL/LAT W/MANJ Surgery Blank 10.14 11.08 11.08 Blank RBRVS

24586 Blank OPTX PERIARTICULAR FRACTURE &/DISLOCATION ELBO Surgery Blank 15.78 12.45 12.45 Blank RBRVS

24587 Blank OPTX PRIARTICULAR FX&/DISLC ELBW W/IMPLT ARTHR Surgery Blank 15.79 12.52 12.52 Blank RBRVS

24600 Blank TREATMENT CLOSED ELBOW DISLOCATION W/O ANES Surgery Blank 4.37 4.49 5.41 Blank RBRVS

24605 Blank TREATMENT CLOSED ELBOW DISLOCATION REQ ANES Surgery Blank 5.64 6.76 6.76 Blank RBRVS

24615 Blank OPEN TX ACUTE/CHRONIC ELBOW DISLOCATION Surgery Blank 9.83 8.81 8.81 Blank RBRVS

24620 Blank CLOSED TX MONTEGGIA FX DISLOCATION ELBOW W/MANJ Surgery Blank 7.22 7.32 7.32 Blank RBRVS

24635 Blank OPEN TX MONTEGGIA FRACTURE DISLOCATION ELBOW Surgery Blank 8.80 8.88 8.88 Blank RBRVS

24640 Blank CLTX RDL HEAD SUBLXTJ CHLD NURSEMAID ELBW W/MANJ Surgery Blank 1.25 0.89 1.51 Blank RBRVS

24650 Blank CLOSED TX RADIAL HEAD/NECK FX W/O MANIPULATION Surgery Blank 2.31 4.15 4.80 Blank RBRVS

24655 Blank CLOSED TX RADIAL HEAD/NECK FX W/MANIPULATION Surgery Blank 4.62 5.96 7.12 Blank RBRVS

24665 Blank OPEN TX RADIAL HEAD/NECK FRACTURE Surgery Blank 8.36 8.84 8.84 Blank RBRVS

24666 Blank OPEN TX RADIAL HEAD/NECK FRACTURE PROSTHETIC Surgery Blank 9.86 9.36 9.36 Blank RBRVS

24670 Blank CLOSED TX ULNAR FRACTURE PROXIMAL END W/O MANJ Surgery Blank 2.69 4.33 5.17 Blank RBRVS

24675 Blank CLOSED TX ULNAR FRACTURE PROXIMAL END W/MANJ Surgery Blank 4.91 6.02 7.20 Blank RBRVS

24685 Blank OPEN TREATMENT ULNAR FRACTURE PROXIMAL END Surgery Blank 8.37 8.82 8.82 Blank RBRVS

24800 Blank ARTHRODESIS ELBOW JOINT LOCAL Surgery Blank 11.41 10.17 10.17 Blank RBRVS

24802 Blank ARTHRODESIS ELBOW JOINT W/AUTOGENOUS GRAFT Surgery Blank 14.32 11.65 11.65 Blank RBRVS

24900 Blank AMPUTATION ARM THRU HUMERUS W/PRIMARY CLOSURE Surgery Blank 10.18 9.07 9.07 Blank RBRVS

24920 Blank AMPUTATION ARM THRU HUMERUS OPEN CIRCULAR Surgery Blank 10.13 8.92 8.92 Blank RBRVS

24925 Blank AMP ARM THRU HUMERUS SECONDARY CLSR/SCAR REVJ Surgery Blank 7.30 7.33 7.33 Blank RBRVS

24930 Blank AMPUTATION ARM THRU HUMERUS RE-AMPUTATION Surgery Blank 10.83 9.27 9.27 Blank RBRVS

24931 Blank AMPUTATION ARM THRU HUMERUS W/IMPLANT Surgery Blank 13.44 10.74 10.74 Blank RBRVS

24935 Blank STUMP ELONGATION UPPER EXTREMITY Surgery Blank 16.45 13.43 13.43 Blank RBRVS

24940 Blank CINEPLASTY UPPER EXTREMITY COMPLETE PROCEDURE Surgery Blank Blank Blank Blank 27.65 ERBRVS

24999 Blank UNLISTED PROCEDURE HUMERUS/ELBOW Surgery Blank Blank Blank Blank 12.54 Unlisted

25000 Blank INCISION EXTENSOR TENDON SHEATH WRIST Surgery Blank 3.55 5.45 5.45 Blank RBRVS

25001 Blank INCISION FLEXOR TENDON SHEATH WRIST Surgery Blank 3.79 5.38 5.38 Blank RBRVS

25020 Blank DCMPRN FASCT F/ARM&WRST FLXR/XTNSR W/O DBRDMT Surgery Blank 6.06 9.28 9.28 Blank RBRVS

25023 Blank DCMPRN FASCT F/ARM&/WRST FLXR/XTNSR W/DBRDMT Surgery Blank 13.83 15.45 15.45 Blank RBRVS

25024 Blank DCMPRN FASCT F/ARM&/WRST FLXR&XTNSR W/O DB Surgery Blank 10.79 9.43 9.43 Blank RBRVS

25025 Blank DCMPRN FASCT F/ARM&/WRST FLXR&XTNSR DBRDMT Surgery Blank 17.94 13.39 13.39 Blank RBRVS

25028 Blank I&D FOREARM&/WRIST DEEP ABSCESS/HEMATOMA Surgery Blank 5.39 8.65 8.65 Blank RBRVS

25031 Blank INCISION & DRAINAGE FOREARM&/WRIST BURSA Surgery Blank 4.26 4.99 4.99 Blank RBRVS

25035 Blank INCISION DEEP BONE CORTEX FOREARM&/WRIST Surgery Blank 7.65 7.70 7.70 Blank RBRVS

25040 Blank ARTHRT RDCRPL/MIDCARPL JT W/EXPL DRG/RMVL FB Surgery Blank 7.50 7.30 7.30 Blank RBRVS

25065 Blank BIOPSY SOFT TISSUE FOREARM&/WRIST SUPERFICIAL Surgery Blank 2.04 2.34 4.93 Blank RBRVS

25066 Blank BIOPSY SOFT TISSUE FOREARM&/WRIST DEEP Surgery Blank 4.27 5.21 5.21 Blank RBRVS

25071 Blank EXC TUMOR SOFT TISS FOREARM AND/WRIST SUBQ 3CM/> Surgery Blank 5.91 5.08 5.08 Blank RBRVS

25073 Blank EXC TUMOR SFT TISS FOREARM&/WRIST SUBFASC 3CM/> Surgery Blank 7.13 6.80 6.80 Blank RBRVS

25075 Blank EXC TUMOR SOFT TISSUE FOREARM &/WRIST SUBQ <3CM Surgery Blank 3.96 4.35 8.95 Blank RBRVS

25076 Blank EXC TUMOR SOFT TISS FOREARM&/WRIST SUBFASC <3CM Surgery Blank 6.74 6.90 6.90 Blank RBRVS

25077 Blank RAD RESECT TUMOR SOFT TISS FOREARM&/WRIST <3 CM Surgery Blank 12.93 9.92 9.92 Blank RBRVS

25078 Blank RAD RESCJ TUM SOFT TISSUE FOREARM&/WRIST 3 CM/> Surgery Blank 17.69 12.29 12.29 Blank RBRVS

25085 Blank CAPSULOTOMY WRIST Surgery Blank 5.64 6.24 6.24 Blank RBRVS

25100 Blank ARTHROTOMY WRIST JOINT WITH BIOPSY Surgery Blank 4.02 5.10 5.10 Blank RBRVS

25101 Blank ARTHRT WRST W/JT EXPL W/WO BX W/WO RMVL LOOSE/FB Surgery Blank 4.83 5.87 5.87 Blank RBRVS

25105 Blank ARTHROTOMY WRIST JOINT WITH SYNOVECTOMY Surgery Blank 6.02 6.74 6.74 Blank RBRVS

25107 Blank ARTHROTOMY DSTL RADIOULNAR JOINT RPR CARTILAGE Surgery Blank 7.70 8.64 8.64 Blank RBRVS

25109 Blank EXC TENDON FOREARM&/WRIST FLEXOR/EXTENSOR EA Surgery Blank 6.94 7.29 7.29 Blank RBRVS

25110 Blank EXCISION LESION TENDON SHEATH FOREARM&/WRIST Surgery Blank 4.04 4.97 4.97 Blank RBRVS

25111 Blank EXCISION GANGLION WRIST DORSAL/VOLAR PRIMARY Surgery Blank 3.53 5.00 5.00 Blank RBRVS

25112 Blank EXCISION GANGLION WRIST DORSAL/VOLAR RECURRENT Surgery Blank 4.67 5.56 5.56 Blank RBRVS

25115 Blank RAD EXC BURSA SYNVA WRST/F/ARM TDN SHTHS FLXRS Surgery Blank 10.09 9.93 9.93 Blank RBRVS

25116 Blank RAD EXC BURSA SYNVA WRST/F/ARM TDN SHTHS XTNSRS Surgery Blank 7.56 8.36 8.36 Blank RBRVS

25118 Blank SYNOVECTOMY EXTENSOR TENDON SHTH WRIST 1 CMPRT Surgery Blank 4.51 5.62 5.62 Blank RBRVS

25119 Blank SYNVCT XTNSR TDN SHTH WRST 1 RESCJ DSTL ULNA Surgery Blank 6.21 6.86 6.86 Blank RBRVS

25120 Blank EXCISION/CURETTAGE CYST/TUMOR RADIUS/ULNA Surgery Blank 6.27 6.88 6.88 Blank RBRVS

25125 Blank EXC/CURTG CYST/TUMOR RADIUS/ULNA W/AUTOGRAFT Surgery Blank 7.67 7.82 7.82 Blank RBRVS

25126 Blank EXC/CURTG CYST/TUMOR RADIUS/ULNA W/ALLOGRAFT Surgery Blank 7.74 7.86 7.86 Blank RBRVS

25130 Blank EXCISION/CURETTAGE CYST/TUMOR CARPAL BONES Surgery Blank 5.43 6.45 6.45 Blank RBRVS

25135 Blank EXC/CURTG CYST/TUMOR CARPAL BONES W/AUTOGRAFT Surgery Blank 7.08 7.53 7.53 Blank RBRVS

25136 Blank EXC/CURTG CYST/TUMOR CARPAL BONES W/ALLOGRAFT Surgery Blank 6.14 6.78 6.78 Blank RBRVS

25145 Blank SEQUESTRECTOMY FOREARM &/WRIST Surgery Blank 6.54 6.99 6.99 Blank RBRVS

25150 Blank PARTIAL EXCISION BONE ULNA Surgery Blank 7.38 7.44 7.44 Blank RBRVS





PAGE 16 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

25151 Blank PARTIAL EXCISION BONE RADIUS Surgery Blank 7.68 7.68 7.68 Blank RBRVS

25170 Blank RADICAL RESECTION TUMOR RADIUS OR ULNA Surgery Blank 22.21 16.01 16.01 Blank RBRVS

25210 Blank CARPECTOMY 1 BONE Surgery Blank 6.12 6.83 6.83 Blank RBRVS

25215 Blank CARPECTOMY ALL BONES PROXIMAL ROW Surgery Blank 8.14 8.16 8.16 Blank RBRVS

25230 Blank RADICAL STYLOIDECTOMY SEPARATE PROCEDURE Surgery Blank 5.37 6.09 6.09 Blank RBRVS

25240 Blank EXCISION DISTAL ULNA PARTIAL/COMPLETE Surgery Blank 5.31 6.08 6.08 Blank RBRVS

25246 Blank INJECTION WRIST ARTHROGRAPHY Surgery Blank 1.45 0.57 3.00 Blank RBRVS

25248 Blank EXPL W/REMOVAL DEEP FOREIGN BODY FOREARM/WRIST Surgery Blank 5.31 5.48 5.48 Blank RBRVS

25250 Blank REMOVAL WRIST PROSTHESIS SEPARATE PROCEDURE Surgery Blank 6.77 7.10 7.10 Blank RBRVS

25251 Blank REMOVAL WRIST PROSTH COMPLICATED W/TOTAL WRIST Surgery Blank 9.82 8.90 8.90 Blank RBRVS

25259 Blank MANIPULATION WRIST UNDER ANESTHESIA Surgery Blank 4.04 7.15 7.15 Blank RBRVS

25260 Blank RPR TDN/MUSC FLXR F/ARM&/WRST PRIM 1 EA TDN/MU Surgery Blank 8.04 8.58 8.58 Blank RBRVS

25263 Blank RPR TDN/MUSC FLXR F/ARM&/WRIST SEC 1 EA TDN/MUS Surgery Blank 8.04 8.36 8.36 Blank RBRVS

25265 Blank RPR TDN/MUSC FLXR F/ARM&/WRISTSEC FR GRF EA Surgery Blank 10.10 9.63 9.63 Blank RBRVS

25270 Blank RPR TDN/MUSC XTNSR F/ARM&/WRIST PRIM 1 EA TDN Surgery Blank 6.17 6.81 6.81 Blank RBRVS

25272 Blank RPR TDN/MUSC XTNSR F/ARM&/WRIST SEC 1 EA TDN/MU Surgery Blank 7.21 7.33 7.33 Blank RBRVS

25274 Blank RPR TDN/MUSC XTNSR F/ARM&/WRST SEC FR GRF EA TDN Surgery Blank 8.94 8.61 8.61 Blank RBRVS

25275 Blank RPR TENDON SHEATH EXTENSOR F/ARM&/WRIST W/GRAFT Surgery Blank 8.96 8.75 8.75 Blank RBRVS

25280 Blank LNGTH/SHRT FLXR/XTNSR TDN F/ARM&/WRIST 1 EA TDN Surgery Blank 7.39 7.51 7.51 Blank RBRVS

25290 Blank TNOT FLXR/XTNSR TENDON FOREARM&/WRIST 1 EA Surgery Blank 5.43 6.13 6.13 Blank RBRVS

25295 Blank TNOLS FLXR/XTNSR TENDON FOREARM&/WRIST 1 EA Surgery Blank 6.72 7.13 7.13 Blank RBRVS

25300 Blank TENODESIS WRIST FLEXORS FINGERS Surgery Blank 9.02 9.00 9.00 Blank RBRVS

25301 Blank TENODESIS WRIST EXTENSORS FINGERS Surgery Blank 8.59 8.33 8.33 Blank RBRVS

25310 Blank TDN TRNSPLJ/TR FLXR/XTNSR F/ARM&/WRST 1 EA TDN Surgery Blank 8.08 8.29 8.29 Blank RBRVS

25312 Blank TDN TRNSPLJ/TR FLXR/XTNSR F/ARM&/WRST 1/TDN GR Surgery Blank 9.82 9.05 9.05 Blank RBRVS

25315 Blank FLEXOR ORIGIN SLIDE FOREARM &/WRIST Surgery Blank 10.68 9.34 9.34 Blank RBRVS

25316 Blank FLEXOR ORIGIN SLIDE F/ARM&/WRST TENDON TRANSFE Surgery Blank 12.90 10.81 10.81 Blank RBRVS

25320 Blank CAPSL-RHPHY/RCNSTJ WRST OPN CARPL INS Surgery Blank 12.75 13.35 13.35 Blank RBRVS

25332 Blank ARTHRP WRST W/WO INTERPOS W/WO XTRNL/INT FIXJ Surgery Blank 11.74 10.35 10.35 Blank RBRVS

25335 Blank CENTRALIZATION WRST ULNA Surgery Blank 13.39 11.06 11.06 Blank RBRVS

25337 Blank RCNSTJ STABLJ DSTL U/DSTL JT 2 SOFT TISS STABLJ Surgery Blank 11.73 11.81 11.81 Blank RBRVS

25350 Blank OSTEOTOMY RADIUS DISTAL THIRD Surgery Blank 9.09 8.67 8.67 Blank RBRVS

25355 Blank OSTEOTOMY RADIUS MIDDLE/PROXIMAL THIRD Surgery Blank 10.53 9.39 9.39 Blank RBRVS

25360 Blank OSTEOTOMY ULNA Surgery Blank 8.74 8.43 8.43 Blank RBRVS

25365 Blank OSTEOTOMY RADIUS & ULNA Surgery Blank 12.91 10.82 10.82 Blank RBRVS

25370 Blank MLT OSTEOTOMIES W/RELIGNMT IMED ROD RADIUS/ULNA Surgery Blank 14.10 12.03 12.03 Blank RBRVS

25375 Blank MLT OSTEOTOMIES W/RELIGNMT IMED ROD RADIUS&ULNA Surgery Blank 13.55 11.15 11.15 Blank RBRVS

25390 Blank OSTEOPLASTY RADIUS/ULNA SHORTENING Surgery Blank 10.70 9.54 9.54 Blank RBRVS

25391 Blank OSTEOPLASTY RADIUS/ULNA LENGTHENING W/AUTOGRAFT Surgery Blank 14.28 11.52 11.52 Blank RBRVS

25392 Blank OSTEOPLASTY RADIUS & ULNA SHORTENING Surgery Blank 14.58 11.67 11.67 Blank RBRVS

25393 Blank OSTEOPLASTY RADIUS&ULNA LENGTHENING W/AUTOGRAF Surgery Blank 16.56 12.67 12.67 Blank RBRVS

25394 Blank OSTEOPLASTY CARPAL BONE SHORTENING Surgery Blank 10.85 9.52 9.52 Blank RBRVS

25400 Blank RPR NONUNION/MALUNION RADIUS/ULNA W/O AUTOGRAFT Surgery Blank 11.28 9.76 9.76 Blank RBRVS

25405 Blank RPR NONUNION/MALUNION RADIUS/ULNA W/AUTOGRAFT Surgery Blank 15.01 12.07 12.07 Blank RBRVS

25415 Blank RPR NONUNION/MALUNION RADIUS&ULNA W/O AUTOGRAF Surgery Blank 13.80 11.27 11.27 Blank RBRVS

25420 Blank RPR NONUNION/MALUNION RADIUS&ULNA W/AUTOGRAFT Surgery Blank 17.04 13.18 13.18 Blank RBRVS

25425 Blank REPAIR DEFECT W/AUTOGRAFT RADIUS/ULNA Surgery Blank 13.72 11.23 11.23 Blank RBRVS

25426 Blank REPAIR DEFECT W/AUTOGRAFT RADIUS&ULNA Surgery Blank 16.45 12.61 12.61 Blank RBRVS

25430 Blank INSERTION VASCULAR PEDICLE CARPAL BONE Surgery Blank 9.71 9.37 9.37 Blank RBRVS

25431 Blank REPAIR NONUNION CARPAL BONE EACH BONE Surgery Blank 10.89 9.62 9.62 Blank RBRVS

25440 Blank RPR NONUNION SCAPHOID CARPAL BNE W/WO RDL STYLEC Surgery Blank 10.68 9.55 9.55 Blank RBRVS

25441 Blank ARTHROPLASTY W/PROSTHETIC RPLCMT DISTAL RADIUS Surgery Blank 13.29 10.99 10.99 Blank RBRVS

25442 Blank ARTHROPLASTY W/PROSTHETIC RPLCMT DISTAL ULNA Surgery Blank 11.12 10.13 10.13 Blank RBRVS

25443 Blank ARTHROPLASTY W/PROSTHETIC RPLCMT SCAPHOID CARPAL Surgery Blank 10.66 9.66 9.66 Blank RBRVS

25444 Blank ARTHROPLASTY W/PROSTHETIC REPLACEMENT LUNATE Surgery Blank 11.42 10.05 10.05 Blank RBRVS

25445 Blank ARTHROPLASTY W/PROSTHETIC REPLACEMENT TRAPEZIUM Surgery Blank 9.88 9.06 9.06 Blank RBRVS

25446 Blank ARTHRP W/PROSTC RPLCMT DSTL RDS&PRTL/CARPUS Surgery Blank 17.30 13.39 13.39 Blank RBRVS

25447 Blank ARTHRP INTERPOS INTERCARPAL/METACARPAL JOINTS Surgery Blank 11.14 10.69 10.69 Blank RBRVS

25449 Blank REVJ ARTHRP W/REMOVAL IMPLANT WRIST JOINT Surgery Blank 14.94 12.10 12.10 Blank RBRVS

25450 Blank EPIPHYSL ARRST EPIPHYSIOD/STAPLING DSTL RDS/U Surgery Blank 8.06 8.02 8.02 Blank RBRVS

25455 Blank EPIPHYSL ARRST EPIPHYSIOD/STAPLING DSTL RDS&ULNA Surgery Blank 9.71 9.19 9.19 Blank RBRVS

25490 Blank PROPH TX N/P/PLTWR W/WO METHYLACRYLATE RADIUS Surgery Blank 9.73 8.99 8.99 Blank RBRVS

25491 Blank PROPH TX N/P/PLTWR W/WO METHYLMETHACRYLATE ULNA Surgery Blank 10.15 9.09 9.09 Blank RBRVS

25492 Blank PROPH TX N/P/PLTWR W/WO METHYLMECRYLATE RAD&UL Surgery Blank 12.66 10.81 10.81 Blank RBRVS

25500 Blank CLOSED TX RADIAL SHAFT FRACTURE W/O MANIPULATION Surgery Blank 2.60 4.12 4.80 Blank RBRVS

25505 Blank CLOSED TX RADIAL SHAFT FRACTURE W/MANIPULATION Surgery Blank 5.45 6.63 7.87 Blank RBRVS

25515 Blank OPEN TREATMENT RADIAL SHAFT FRACTURE Surgery Blank 8.80 8.75 8.75 Blank RBRVS

25520 Blank CLTX RDL SHFT FX&CLTX DISLC DSTL RAD/ULN JT Surgery Blank 6.50 7.63 8.49 Blank RBRVS

25525 Blank OPEN RDL SHAFT FX CLOSED RAD/ULN JT DISLOCATE Surgery Blank 10.55 10.00 10.00 Blank RBRVS

25526 Blank OPEN RDL SHAFT FX OPEN RAD/ULN JT DISLOCATE Surgery Blank 13.15 11.69 11.69 Blank RBRVS

25530 Blank CLOSED TX ULNAR SHAFT FRACTURE W/O MANIPULATION Surgery Blank 2.24 4.15 4.90 Blank RBRVS

25535 Blank CLOSED TX ULNAR SHAFT FRACTURE W/MANIPULATION Surgery Blank 5.36 6.55 7.58 Blank RBRVS





PAGE 17 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

25545 Blank OPEN TREATMENT OF ULNAR SHAFT FRACTURE Surgery Blank 7.94 8.44 8.44 Blank RBRVS

25560 Blank CLOSED TX RADIAL&ULNAR SHAFT FRACTURES W/O MAN Surgery Blank 2.59 4.17 4.96 Blank RBRVS

25565 Blank CLOSED TX RADIAL&ULNAR SHAFT FRACTURES W/MANJ Surgery Blank 5.85 6.46 7.93 Blank RBRVS

25574 Blank OPEN TX RADIAL&ULNAR SHAFT FX W/FIXJ RADIUS/ULNA Surgery Blank 8.80 8.85 8.85 Blank RBRVS

25575 Blank OPEN TX RADIAL&ULNAR SHAFT FX W/FIXJ RADIUS&ULNA Surgery Blank 12.29 11.23 11.23 Blank RBRVS

25600 Blank CLTX DSTL RADIAL FX/EPIPHYSL SEP W/O MANJ Surgery Blank 2.78 5.60 6.14 Blank RBRVS

25605 Blank CLTX DSTL RDL FX/EPIPHYSL SEP W/MANJ WHEN PERF Surgery Blank 6.25 7.23 8.19 Blank RBRVS

25606 Blank PERQ SKEL FIXJ DISTAL RADIAL FX/EPIPHYSL SEP Surgery Blank 8.31 9.09 9.09 Blank RBRVS

25607 Blank OPTX DSTL RADL X-ARTIC FX/EPIPHYSL SEP Surgery Blank 9.56 9.75 9.75 Blank RBRVS

25608 Blank OPTX DSTL RADL I-ARTIC FX/EPIPHYSL SEP 2 FRAG Surgery Blank 11.07 10.54 10.54 Blank RBRVS

25609 Blank OPTX DSTL RADL I-ARTIC FX/EPIPHYSL SEP 3 FRAG Surgery Blank 14.38 13.08 13.08 Blank RBRVS

25622 Blank CLOSED TX CARPAL SCAPHOID FRACTURE W/O MANJ Surgery Blank 2.79 4.69 5.49 Blank RBRVS

25624 Blank CLOSED TX CARPAL SCAPHOID FRACTURE W/MANJ Surgery Blank 4.77 6.75 8.00 Blank RBRVS

25628 Blank OPEN TX CARPAL SCAPHOID NAVICULAR FRACTURE Surgery Blank 9.67 9.28 9.28 Blank RBRVS

25630 Blank CLTX CARPAL BONE FX W/O MANJ EACH BONE Surgery Blank 3.03 4.48 5.22 Blank RBRVS

25635 Blank CLTX CARPAL BONE FX W/MANJ EACH BONE Surgery Blank 4.61 6.37 7.54 Blank RBRVS

25645 Blank OPEN TX CARPAL BONE FRACTURE OTH/THN SCAPHOID EA Surgery Blank 7.42 7.44 7.44 Blank RBRVS

25650 Blank CLOSED TREATMENT ULNAR STYLOID FRACTURE Surgery Blank 3.23 4.80 5.40 Blank RBRVS

25651 Blank PRQ SKELETAL FIXATION ULNAR STYLOID FRACTURE Surgery Blank 5.82 7.06 7.06 Blank RBRVS

25652 Blank OPEN TREATMENT ULNAR STYLOID FRACTURE Surgery Blank 8.06 8.31 8.31 Blank RBRVS

25660 Blank CLTX RDCRPL/INTERCARPL DISLC 1/> BONES W/MANJ Surgery Blank 4.98 5.88 5.88 Blank RBRVS

25670 Blank OPEN TX RADIOCARPAL/INTERCARPAL DISLC 1/> BONES Surgery Blank 8.09 7.79 7.79 Blank RBRVS

25671 Blank PRQ SKELETAL FIXJ DISTAL RADIOULNAR DISLOCATION Surgery Blank 6.46 7.49 7.49 Blank RBRVS

25675 Blank CLOSED TX DISTAL RADIOULNAR DISLOCATION W/MANJ Surgery Blank 4.89 5.61 6.76 Blank RBRVS

25676 Blank OPEN TX DISTAL RADIOULNAR DISLC ACUTE/CHRONIC Surgery Blank 8.29 8.26 8.26 Blank RBRVS

25680 Blank CLTX TRANS-SCAPHOPRILUNAR TYP FX DISLC W/MANJ Surgery Blank 6.23 7.45 7.45 Blank RBRVS

25685 Blank OPEN TX TRANS-SCAPHOPERILUNAR FRACTURE DISLC Surgery Blank 10.09 9.05 9.05 Blank RBRVS

25690 Blank CLOSED TX LUNATE DISLOCATION W/MANIPULATION Surgery Blank 5.72 6.92 6.92 Blank RBRVS

25695 Blank OPEN TREATMENT LUNATE DISLOCATION Surgery Blank 8.51 7.98 7.98 Blank RBRVS

25800 Blank ARTHRODESIS WRIST COMPLETE W/O BONE GRAFT Surgery Blank 10.07 9.19 9.19 Blank RBRVS

25805 Blank ARTHRODESIS WRIST W/SLIDING GRAFT Surgery Blank 11.73 10.22 10.22 Blank RBRVS

25810 Blank ARTHRODESIS WRIST W/ILIAC/OTHER AUTOGRAFT Surgery Blank 11.95 10.91 10.91 Blank RBRVS

25820 Blank ARTHRODESIS WRIST LIMITED W/O BONE GRAFT Surgery Blank 7.64 8.70 8.70 Blank RBRVS

25825 Blank ARTHRODESIS WRIST LIMITED W/AUTOGRAFT Surgery Blank 9.69 10.41 10.41 Blank RBRVS

25830 Blank ARTHRD DSTL RAD/ULN JT SGMTL RSCJ ULNA W/WO BONE Surgery Blank 10.88 14.28 14.28 Blank RBRVS

25900 Blank AMPUTATION FOREARM THROUGH RADIUS & ULNA Surgery Blank 9.61 8.88 8.88 Blank RBRVS

25905 Blank AMP FOREARM THRU RADIUS & ULNA OPEN CIRCULAR Surgery Blank 9.59 8.65 8.65 Blank RBRVS

25907 Blank AMP F/ARM THRU RADIUS&ULNA SEC CLOSURE/SCAR RE Surgery Blank 8.09 7.89 7.89 Blank RBRVS

25909 Blank AMP FOREARM THRU RADIUS&ULNA RE-AMPUTATION Surgery Blank 9.31 8.51 8.51 Blank RBRVS

25915 Blank KRUKENBERG PROCEDURE Surgery Blank 17.52 12.73 12.73 Blank RBRVS

25920 Blank DISARTICULATION THROUGH WRIST Surgery Blank 9.03 9.18 9.18 Blank RBRVS

25922 Blank DISARTICULATION THRU WRIST SEC CLOSURE/SCAR REVJ Surgery Blank 7.65 8.37 8.37 Blank RBRVS

25924 Blank DISARTICULATION THRU WRIST RE-AMPUTATION Surgery Blank 8.81 8.96 8.96 Blank RBRVS

25927 Blank TRANSMETACARPAL AMPUTATION Surgery Blank 9.09 12.38 12.38 Blank RBRVS

25929 Blank TRANSMETACARPAL AMPUTATION SEC CLOSURE/SCAR REVJ Surgery Blank 7.82 7.75 7.75 Blank RBRVS

25931 Blank TRANSMETACARPAL AMPUTATION RE-AMPUTATION Surgery Blank 8.04 11.73 11.73 Blank RBRVS

25999 Blank UNLISTED PROCEDURE FOREARM/WRIST Surgery Blank Blank Blank Blank 14.80 Unlisted

26010 Blank DRAINAGE FINGER ABSCESS SIMPLE Surgery Blank 1.59 2.12 5.76 Blank RBRVS

26011 Blank DRAINAGE FINGER ABSCESS COMPLICATED Surgery Blank 2.24 2.69 8.56 Blank RBRVS

26020 Blank DRAINAGE TENDON SHEATH DIGIT&/PALM EACH Surgery Blank 5.08 6.42 6.42 Blank RBRVS

26025 Blank DRAINAGE OF PALMAR BURSA SINGLE BURSA Surgery Blank 5.08 6.09 6.09 Blank RBRVS

26030 Blank DRAINAGE OF PALMAR BURSA MULTIPLE BURSA Surgery Blank 6.25 6.76 6.76 Blank RBRVS

26034 Blank INCISION BONE CORTEX HAND/FINGER Surgery Blank 6.63 7.70 7.70 Blank RBRVS

26035 Blank DECOMPRESSION FINGERS&/HAND INJECTION INJURY Surgery Blank 11.37 11.01 11.01 Blank RBRVS

26037 Blank DECOMPRESSIVE FASCIOTOMY HAND Surgery Blank 7.57 7.34 7.34 Blank RBRVS

26040 Blank FASCIOTOMY PALMAR PERCUTANEOUS Surgery Blank 3.46 4.88 4.88 Blank RBRVS

26045 Blank FASCIOTOMY PALMAR OPEN PARTIAL Surgery Blank 5.73 6.59 6.59 Blank RBRVS

26055 Blank TENDON SHEATH INCISION Surgery Blank 3.11 5.21 12.28 Blank RBRVS

26060 Blank TENOTOMY PERCUTANEOUS SINGLE EACH DIGIT Surgery Blank 2.91 4.06 4.06 Blank RBRVS

26070 Blank ARTHRT EXPL DRG/RMVL LOOSE/FB CARP/MTCRPL JT Surgery Blank 3.81 4.69 4.69 Blank RBRVS

26075 Blank ARTHRT EXPL DRG/RMVL LOOSE/FB MTCARPHLNGL JT EA Surgery Blank 3.91 4.94 4.94 Blank RBRVS

26080 Blank ARTHRT EXPL DRG/RMVL LOOSE/FB IPHAL JT EA Surgery Blank 4.47 5.93 5.93 Blank RBRVS

26100 Blank ARTHROTOMY BIOPSY CARP/MTCRPL JOINT EACH Surgery Blank 3.79 5.06 5.06 Blank RBRVS

26105 Blank ARTHROTOMY BIOPSY MTCARPHLNGL JOINT EACH Surgery Blank 3.83 5.08 5.08 Blank RBRVS

26110 Blank ARTHROTOMY BIOPSY INTERPHALANGEAL JOINT EACH Surgery Blank 3.65 4.92 4.92 Blank RBRVS

26111 Blank EX TUM/VASC MALF SFT TISS HAND/FNGR SUBQ 1.5CM/> Surgery Blank 5.42 5.61 5.61 Blank RBRVS

26113 Blank EX TUM/VASC MAL SFT TIS HAND/FNGR SUBFSC 1.5CM/> Surgery Blank 7.13 7.36 7.36 Blank RBRVS

26115 Blank EXC TUM/VASC MAL SFT TISS HAND/FNGR SUBQ <1.5CM Surgery Blank 3.96 4.88 9.74 Blank RBRVS

26116 Blank EXC TUM/VAS MAL SFT TIS HAND/FNGR SUBFASC<1.5CM Surgery Blank 6.74 7.20 7.20 Blank RBRVS

26117 Blank RAD RESECT TUMOR SOFT TISSUE HAND/FINGER <3CM Surgery Blank 10.13 9.43 9.43 Blank RBRVS

26118 Blank RAD RESCJ TUM SOFT TISSUE HAND/FINGER 3 CM/> Surgery Blank 14.81 12.71 12.71 Blank RBRVS

26121 Blank FASCT PALM W/WO Z-PLASTY TISSUE REARGMT/SKN GRFT Surgery Blank 7.73 8.02 8.02 Blank RBRVS





PAGE 18 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

26123 Blank FASCT PRTL PALMAR 1 DGT PROX IPHAL JT W/WO RPR Surgery Blank 10.88 11.13 11.13 Blank RBRVS

26125 Blank FASCT PRTL PALMR ADDL DGT PROX IPHAL JT W/WO RPR Surgery Blank 4.60 2.49 2.49 Blank RBRVS

26130 Blank SYNOVECTOMY CARPOMETACARPAL JOINT Surgery Blank 5.59 6.49 6.49 Blank RBRVS

26135 Blank SYNVCT MTCARPHLNGL JT W/INTRNSC RLS&XTNSR HOOD Surgery Blank 7.13 7.42 7.42 Blank RBRVS

26140 Blank SYNVCT PROX IPHAL JT W/XTNSR RCNSTJ EA IPHAL JT Surgery Blank 6.34 6.99 6.99 Blank RBRVS

26145 Blank SYNVCT TDN SHTH RAD FLXR TDN PALM&/FNGR EA TDN Surgery Blank 6.49 7.03 7.03 Blank RBRVS

26160 Blank EXC LESION TDN SHTH/JT CAPSL HAND/FNGR Surgery Blank 3.57 5.36 12.21 Blank RBRVS

26170 Blank EXCISION TENDON PALM FLEXOR/EXTENSOR SINGLE EACH Surgery Blank 4.91 5.92 5.92 Blank RBRVS

26180 Blank EXCISION TENDON FINGER FLEXOR/EXTENSOR EACH Surgery Blank 5.35 6.48 6.48 Blank RBRVS

26185 Blank SESAMOIDECTOMY THUMB/FINGER SEPARATE PROCEDURE Surgery Blank 6.52 7.99 7.99 Blank RBRVS

26200 Blank EXCISION/CURETTAGE CYST/TUMOR METACARPAL Surgery Blank 5.65 6.26 6.26 Blank RBRVS

26205 Blank EXC/CURETTAGE CYST/TUMOR METACARPAL W/AUTOGRAFT Surgery Blank 7.93 7.77 7.77 Blank RBRVS

26210 Blank EXCISION/CURETTAGE CYST/TUMOR PHALANX FINGER Surgery Blank 5.32 6.42 6.42 Blank RBRVS

26215 Blank EXC/CURETTAGE CYST/TUMOR PHALANX FINGER W/AGRAFT Surgery Blank 7.27 7.44 7.44 Blank RBRVS

26230 Blank PARTIAL EXCISION BONE METACARPAL Surgery Blank 6.47 6.77 6.77 Blank RBRVS

26235 Blank PARTIAL EXCISION PROXIMAL/MIDDLE PHALANX FINGER Surgery Blank 6.33 6.72 6.72 Blank RBRVS

26236 Blank PARTIAL EXCISION DISTAL PHALANX FINGER Surgery Blank 5.46 6.22 6.22 Blank RBRVS

26250 Blank RADICAL RESECTION TUMOR METACARPAL Surgery Blank 15.21 12.58 12.58 Blank RBRVS

26260 Blank RAD RESECTION TUMOR PROX/MIDDLE PHALANX FINGER Surgery Blank 11.16 9.73 9.73 Blank RBRVS

26262 Blank RADICAL RESECTION TUMOR DISTAL PHALANX FINGER Surgery Blank 8.29 8.28 8.28 Blank RBRVS

26320 Blank REMOVAL IMPLANT FROM FINGER/HAND Surgery Blank 4.10 5.11 5.11 Blank RBRVS

26340 Blank MANIPULATION FINGER JOINT UNDER ANES EACH JOINT Surgery Blank 2.80 6.25 6.25 Blank RBRVS

26341 Blank MANIPLATN PALAR FASCIAL CRD POST INJ SINGLE CORD Surgery Blank 0.91 1.07 1.76 Blank RBRVS

26350 Blank RPR/ADVMNT FLXR TDN N/Z/2 W/O FR GRAFT EA TENDON Surgery Blank 6.21 12.83 12.83 Blank RBRVS

26352 Blank RPR/ADVMNT FLXR TDN N/Z/2 W/FR GRAFT EA TENDON Surgery Blank 7.87 13.73 13.73 Blank RBRVS

26356 Blank RPR/ADVMNT FLXR TDN ZONE 2 W/O FR GRFT EA TENDON Surgery Blank 9.56 11.52 11.52 Blank RBRVS

26357 Blank RPR/ADVMNT FLXR TDN ZONE 2 W/O FR GRFT EA TENDON Surgery Blank 11.00 12.28 12.28 Blank RBRVS

26358 Blank RPR/ADVMNT FLXR TDN ZONE 2 W/FR GRAFT EA TENDON Surgery Blank 12.60 13.10 13.10 Blank RBRVS

26370 Blank RPR/ADVMNT TDN W/NTC SUPFCIS TDN PRIM EA TDN Surgery Blank 7.28 12.89 12.89 Blank RBRVS

26372 Blank RPR/ADVMNT TDN W/NTC SUPFCIS TDN W/FREE GRAFT EA Surgery Blank 9.01 14.31 14.31 Blank RBRVS

26373 Blank RPR/ADVMNT TDN W/NTC SUPFCIS TDN W/O FREE GRF EA Surgery Blank 8.41 14.00 14.00 Blank RBRVS

26390 Blank EXC FLXR TDN W/IMPLTJ SYNTH ROD DLYD TDN GRF H/F Surgery Blank 9.43 12.43 12.43 Blank RBRVS

26392 Blank RMVL SYNTH ROD & INSJ FLXR TDN GRF H/F EA ROD Surgery Blank 10.50 15.06 15.06 Blank RBRVS

26410 Blank REPAIR EXTENSOR TENDON HAND W/O GRAFT EACH Surgery Blank 4.77 10.37 10.37 Blank RBRVS

26412 Blank REPAIR EXTENSOR TENDON HAND W/GRAFT EACH Surgery Blank 6.48 11.62 11.62 Blank RBRVS

26415 Blank EXC XTNSR TDN W/IMPLTJ SYNTH ROD DLYD GRF H/F EA Surgery Blank 8.51 12.88 12.88 Blank RBRVS

26416 Blank RMVL SYNTH ROD & INSJ XTNSR TDN GRF H/F EA ROD Surgery Blank 9.56 13.67 13.67 Blank RBRVS

26418 Blank REPAIR EXTENSOR TENDON FINGER W/O GRAFT EACH Surgery Blank 4.47 11.06 11.06 Blank RBRVS

26420 Blank REPAIR EXTENSOR TENDON FINGER W/GRAFT EACH Surgery Blank 6.94 11.92 11.92 Blank RBRVS

26426 Blank RPR XTNSR TDN CNTRL SLIP TISS W/LAT BAND EA FNGR Surgery Blank 6.32 6.91 6.91 Blank RBRVS

26428 Blank RPR XTNSR TDN CNTRL SLIP SEC W/FR GRFT EA FINGER Surgery Blank 7.40 12.58 12.58 Blank RBRVS

26432 Blank CLTX DSTL XTNSR TDN INSJ W/WO PERCUTAN PINNING Surgery Blank 4.16 9.20 9.20 Blank RBRVS

26433 Blank REPAIR EXTENSOR TENDON DISTAL INSERTION W/O GRF Surgery Blank 4.70 9.45 9.45 Blank RBRVS

26434 Blank REPAIR EXTENSOR TENDON DISTAL INSERTION W/GRAFT Surgery Blank 6.26 10.83 10.83 Blank RBRVS

26437 Blank REALIGNMENT EXTENSOR TENDON HAND EACH TENDON Surgery Blank 5.99 10.57 10.57 Blank RBRVS

26440 Blank TENOLYSIS FLEXOR TENDON PALM/FINGER EACH TENDON Surgery Blank 5.16 11.48 11.48 Blank RBRVS

26442 Blank TENOLYSIS FLEXOR TENDON PALM&FINGER EACH TENDO Surgery Blank 9.75 15.87 15.87 Blank RBRVS

26445 Blank TENOLYSIS EXTENSOR TENDON HAND/FINGER EACH Surgery Blank 4.45 11.08 11.08 Blank RBRVS

26449 Blank TENOLYSIS CPLX XTNSR TENDON FINGER W/FOREARM EA Surgery Blank 8.59 9.69 9.69 Blank RBRVS

26450 Blank TENOTOMY FLEXOR PALM OPEN EACH TENDON Surgery Blank 3.79 7.08 7.08 Blank RBRVS

26455 Blank TENOTOMY FLEXOR FINGER OPEN EACH TENDON Surgery Blank 3.76 7.02 7.02 Blank RBRVS

26460 Blank TENOTOMY EXTENSOR HAND/FINGER OPEN EACH TENDON Surgery Blank 3.58 6.96 6.96 Blank RBRVS

26471 Blank TENODESIS PROXIMAL INTERPHALANGEAL JOINT EACH Surgery Blank 5.90 10.54 10.54 Blank RBRVS

26474 Blank TENODESIS DISTAL JOINT EACH Surgery Blank 5.49 10.44 10.44 Blank RBRVS

26476 Blank LENGTHENING TENDON EXTENSOR HAND/FINGER EACH Surgery Blank 5.35 10.37 10.37 Blank RBRVS

26477 Blank SHORTENING TENDON EXTENSOR HAND/FINGER EACH Surgery Blank 5.32 10.19 10.19 Blank RBRVS

26478 Blank LENGTHENING TENDON FLEXOR HAND/FINGER EACH Surgery Blank 5.97 10.50 10.50 Blank RBRVS

26479 Blank SHORTENING TENDON FLEXOR HAND/FINGER EACH Surgery Blank 5.91 10.65 10.65 Blank RBRVS

26480 Blank TR/TRNSPL TDN CARP/MTCRPL HAND W/O FR GRF EA TDN Surgery Blank 6.90 13.26 13.26 Blank RBRVS

26483 Blank TENDON TRANSFER TRANSPLANT CARP/MTCRPL GRAFT Surgery Blank 8.48 13.91 13.91 Blank RBRVS

26485 Blank TRANSFER/TRANSPLANT TENDON PALMAR W/O GRAFT EACH Surgery Blank 7.89 13.56 13.56 Blank RBRVS

26489 Blank TRANSFER/TRANSPLANT TENDON PALMAR W/GRAFT EACH Surgery Blank 9.86 14.74 14.74 Blank RBRVS

26490 Blank OPPONENSPLASTY SUPFCIS TDN TR TYP EA TDN Surgery Blank 8.60 12.27 12.27 Blank RBRVS

26492 Blank OPPONENSPLASTY TDN TR W/GRF EA TDN Surgery Blank 9.84 13.25 13.25 Blank RBRVS

26494 Blank OPPONENSPLASTY HYPOTHENAR MUSC TR Surgery Blank 8.66 12.30 12.30 Blank RBRVS

26496 Blank OPPONENSPLASTY OTHER METHODS Surgery Blank 9.78 12.90 12.90 Blank RBRVS

26497 Blank TR TDN RESTORE INTRNSC FUNCJ RING&SM FNGR Surgery Blank 9.76 12.87 12.87 Blank RBRVS

26498 Blank TR TDN RESTORE INTRNSC FUNCJ ALL 4 FNGRS Surgery Blank 14.21 15.46 15.46 Blank RBRVS

26499 Blank CORRECTION CLAW FINGER OTHER METHODS Surgery Blank 9.17 12.56 12.56 Blank RBRVS

26500 Blank RCNSTJ TENDON PULLEY EACH W/LOCAL TISSUES SPX Surgery Blank 6.13 10.44 10.44 Blank RBRVS

26502 Blank RCNSTJ TDN PULLEY EA TDN W/TDN/FSCAL GRF SPX Surgery Blank 7.31 11.36 11.36 Blank RBRVS

26508 Blank RELEASE THENAR MUSCLE Surgery Blank 6.18 10.65 10.65 Blank RBRVS





PAGE 19 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

26510 Blank CROSS INTRINSIC TRANSFER EACH TENDON Surgery Blank 5.60 10.32 10.32 Blank RBRVS

26516 Blank CAPSULODESIS MTCARPHLNGL JOINT SINGLE DIGIT Surgery Blank 7.32 11.27 11.27 Blank RBRVS

26517 Blank CAPSULODESIS MTCARPHLNGL JOINT 2 DIGITS Surgery Blank 9.08 12.52 12.52 Blank RBRVS

26518 Blank CAPSULODESIS MTCARPHLNGL JOINT 3/4 DIGITS Surgery Blank 9.27 12.62 12.62 Blank RBRVS

26520 Blank CAPSULECTOMY/CAPSULOTOMY MTCARPHLNGL JOINT EACH Surgery Blank 5.47 11.94 11.94 Blank RBRVS

26525 Blank CAPSULECTOMY/CAPSULOTOMY IPHAL JOINT EACH Surgery Blank 5.50 11.96 11.96 Blank RBRVS

26530 Blank ARTHROPLASTY METACARPOPHALANGEAL JOINT EACH Surgery Blank 6.88 7.34 7.34 Blank RBRVS

26531 Blank ARTHRP MTCARPHLNGL JT W/PROSTC IMPLT EA JT Surgery Blank 8.13 8.37 8.37 Blank RBRVS

26535 Blank ARTHROPLASTY INTERPHALANGEAL JOINT EACH Surgery Blank 5.41 5.93 5.93 Blank RBRVS

26536 Blank ARTHROPLASTY INTERPHALANGEAL JT W/PROSTHETIC EA Surgery Blank 6.56 12.47 12.47 Blank RBRVS

26540 Blank RPR COLTRL LIGM MTCARPHLNGL/IPHAL JT Surgery Blank 6.60 10.85 10.85 Blank RBRVS

26541 Blank RCNSTJ COLTRL LIGM MTCARPHLNGL 1 W/TDN/FSCAL GRF Surgery Blank 8.81 12.31 12.31 Blank RBRVS

26542 Blank RCNSTJ COLTRL LIGM MTCARPHLNGL 1 W/LOCAL TISS Surgery Blank 6.95 11.02 11.02 Blank RBRVS

26545 Blank RCNSTJ COLTRL LIGM IPHAL JT 1 W/GRF EA JT Surgery Blank 7.11 11.28 11.28 Blank RBRVS

26546 Blank RPR NON-UNION MTCRPL/PHALANX Surgery Blank 10.83 15.44 15.44 Blank RBRVS

26548 Blank RPR & RCNSTJ FINGER VOLAR PLATE INTERPHALANGEAL Surgery Blank 8.22 11.92 11.92 Blank RBRVS

26550 Blank POLLICIZATION DIGIT Surgery Blank 21.68 20.90 20.90 Blank RBRVS

26551 Blank TR TOE-TO-HAND W/MVASC ANAST GRT TOE WRP/ARND Surgery Blank 48.48 36.42 36.42 Blank RBRVS

26553 Blank TR TOE-TO-HAND W/MVASC ANAST OTH/THN GRT TOE 1 Surgery Blank 48.17 36.15 36.15 Blank RBRVS

26554 Blank TR TOE-TO-HAND W/MVASC ANAST OTH/THN GRT TOE 2 Surgery Blank 57.01 41.23 41.23 Blank RBRVS

26555 Blank TR FNGR AXH POS W/O MVASC ANAST Surgery Blank 17.08 18.57 18.57 Blank RBRVS

26556 Blank TRANSFER FREE TOE JOINT W/MVASC ANASTOMOSIS Surgery Blank 49.75 37.92 37.92 Blank RBRVS

26560 Blank REPAIR SYNDACTYLY EACH SPACE W/SKIN FLAPS Surgery Blank 5.52 10.12 10.12 Blank RBRVS

26561 Blank REPAIR SYNDACTYLY EACH SPACE W/SKIN FLAPS&GRAFT Surgery Blank 11.10 13.54 13.54 Blank RBRVS

26562 Blank REPAIR SYNDACTYLY EACH SPACE COMPLEX Surgery Blank 16.68 18.22 18.22 Blank RBRVS

26565 Blank OSTEOTOMY METACARPAL EACH Surgery Blank 6.91 11.04 11.04 Blank RBRVS

26567 Blank OSTEOTOMY PHALANX FINGER EACH Surgery Blank 6.99 11.04 11.04 Blank RBRVS

26568 Blank OSTEOPLASTY LENGTHENING METACARPAL/PHALANX Surgery Blank 9.27 14.44 14.44 Blank RBRVS

26580 Blank REPAIR CLEFT HAND Surgery Blank 19.75 19.43 19.43 Blank RBRVS

26587 Blank RCNSTJ POLYDACTYLOUS DIGIT SOFT TISSUE & BONE Surgery Blank 14.50 12.47 12.47 Blank RBRVS

26590 Blank REPAIR MACRODACTYLIA EACH DIGIT Surgery Blank 18.67 17.73 17.73 Blank RBRVS

26591 Blank REPAIR INTRINSIC MUSCLES HAND EACH MUSCLE Surgery Blank 3.38 8.41 8.41 Blank RBRVS

26593 Blank RELEASE INTRINSIC MUSCLES HAND EACH MUSCLE Surgery Blank 5.50 10.54 10.54 Blank RBRVS

26596 Blank EXC CONSTRICTING RING FNGR W/MLT Z-PLASTIES Surgery Blank 9.14 10.73 10.73 Blank RBRVS

26600 Blank CLTX METACARPAL FX W/O MANIPULATION EACH BONE Surgery Blank 2.60 4.87 5.39 Blank RBRVS

26605 Blank CLTX METACARPAL FX W/MANIPULATION EACH BONE Surgery Blank 3.03 4.80 5.64 Blank RBRVS

26607 Blank CLTX METACARPAL FX W/MANJ W/XTRNL FIXJ EA BONE Surgery Blank 5.48 6.56 6.56 Blank RBRVS

26608 Blank PRQ SKELETAL FIXJ METACARPAL FX EACH BONE Surgery Blank 5.55 7.08 7.08 Blank RBRVS

26615 Blank OPEN TX METACARPAL FRACTURE SINGLE EA BONE Surgery Blank 7.07 8.16 8.16 Blank RBRVS

26641 Blank CLTX CARPO/METACARPAL DISLOCATION THUMB W/MANJ Surgery Blank 4.13 4.98 5.99 Blank RBRVS

26645 Blank CLTX CARPO/METACARPAL FX DISLC THUMB W/MANJ Surgery Blank 4.58 5.75 6.77 Blank RBRVS

26650 Blank PRQ SKELETAL FIX CARPO/METACARPAL FX DISLC THUMB Surgery Blank 5.35 7.32 7.32 Blank RBRVS

26665 Blank OPEN TX CARPOMETACARPAL FRACTURE DISLOCATE THUMB Surgery Blank 7.94 8.58 8.58 Blank RBRVS

26670 Blank CLTX CARPO/METACARPL DISLC THMB MANJ EA W/O ANES Surgery Blank 3.83 4.41 5.37 Blank RBRVS

26675 Blank CLTX CARPO/MTCRPL DISLC THUMB MANJ EA JT W/ANES Surgery Blank 4.83 6.17 7.24 Blank RBRVS

26676 Blank PRQ SKEL FIXJ CARPO/MTCRPL DISLC THMB MANJ EA JT Surgery Blank 5.74 7.57 7.57 Blank RBRVS

26685 Blank OPEN TX CARPOMETACARPAL DISLOCATE NOT THUMB Surgery Blank 7.07 8.18 8.18 Blank RBRVS

26686 Blank OPTX CARP/MTCRPL DISLC THMB CPLX MLT/DLYD RDCTJ Surgery Blank 8.17 8.10 8.10 Blank RBRVS

26700 Blank CLTX METACARPOPHALANGEAL DISLC W/MANJ W/O ANES Surgery Blank 3.83 4.26 4.86 Blank RBRVS

26705 Blank CLTX METACARPOPHALANGEAL DISLC W/MANJ W/ANES Surgery Blank 4.38 5.68 6.68 Blank RBRVS

26706 Blank PRQ SKEL FIXJ METACARPOPHALANGEAL DISLC W/MANJ Surgery Blank 5.31 6.34 6.34 Blank RBRVS

26715 Blank OPEN TREATMENT METACARPOPHALANGEAL DISLOCATION Surgery Blank 7.03 8.14 8.14 Blank RBRVS

26720 Blank CLTX PHLNGL FX PROX/MIDDLE PX/F/T W/O MANJ EA Surgery Blank 1.76 3.23 3.65 Blank RBRVS

26725 Blank CLTX PHLNGL FX PROX/MIDDLE PX/F/T W/MANJ EA Surgery Blank 3.48 4.59 5.56 Blank RBRVS

26727 Blank PRQ SKEL FIXJ PHLNGL SHFT FX PROX/MIDDLE PX/F/T Surgery Blank 5.42 7.04 7.04 Blank RBRVS

26735 Blank OPEN TX PHALANGEAL SHAFT FRACTURE PROX/MIDDLE EA Surgery Blank 7.42 8.33 8.33 Blank RBRVS

26740 Blank CLTX ARTCLR FX INVG MTCRPHLNGL/IPHAL JT W/O MANJ Surgery Blank 2.07 3.74 4.18 Blank RBRVS

26742 Blank CLTX ARTCLR FX INVG MTCARPHLNGL/IPHAL JT W/MANJ Surgery Blank 3.99 4.89 5.91 Blank RBRVS

26746 Blank OPEN TX ARTICULAR FRACTURE MCP/IP JOINT EA Surgery Blank 9.80 9.76 9.76 Blank RBRVS

26750 Blank CLTX DSTL PHLNGL FX FNGR/THMB W/O MANJ EA Surgery Blank 1.80 3.20 3.22 Blank RBRVS

26755 Blank CLTX DSTL PHLNGL FX FNGR/THMB W/MANJ EA Surgery Blank 3.23 4.05 5.26 Blank RBRVS

26756 Blank PRQ SKEL FIXJ DSTL PHLNGL FX FNGR/THMB EA Surgery Blank 4.58 6.54 6.54 Blank RBRVS

26765 Blank OPEN TX DISTAL PHALANGEAL FRACTURE EACH Surgery Blank 5.86 7.45 7.45 Blank RBRVS

26770 Blank CLTX IPHAL JT DISLC W/MANJ W/O ANES Surgery Blank 3.15 3.68 4.31 Blank RBRVS

26775 Blank CLTX IPHAL JT DISLC W/MANJ REQ ANES Surgery Blank 3.90 5.31 6.36 Blank RBRVS

26776 Blank PRQ SKEL FIXJ IPHAL JT DISLC W/MANJ Surgery Blank 4.99 6.80 6.80 Blank RBRVS

26785 Blank OPEN TX INTERPHALANGEAL JOINT DISLOCATION Surgery Blank 6.60 7.90 7.90 Blank RBRVS

26820 Blank FUSION OPPOSITION THUMB W/AUTOGENOUS GRAFT Surgery Blank 8.45 12.20 12.20 Blank RBRVS

26841 Blank ARTHRD CARPO/METACARPAL JT THUMB W/WO INT FIXJ Surgery Blank 7.35 11.89 11.89 Blank RBRVS

26842 Blank ARTHRD CRP/MTACRPL JT THMB W/WO INT FIXJ W/AGRFT Surgery Blank 8.49 12.18 12.18 Blank RBRVS

26843 Blank ARTHRD CARP/MTCRPL JT DGT OTHER THAN THUMB EACH Surgery Blank 7.78 11.60 11.60 Blank RBRVS

26844 Blank ARTHRD CARP/MTCRPL JT DGT OTH/THN THMB W/AGRFT Surgery Blank 8.98 12.47 12.47 Blank RBRVS





PAGE 20 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

26850 Blank ARTHRODESIS METACARPOPHALANGEAL JT W/WO INT FIXJ Surgery Blank 7.14 11.21 11.21 Blank RBRVS

26852 Blank ARTHRODESIS MTCRPL JT W/WO INT FIXJ W/AUTOGRAFT Surgery Blank 8.71 12.33 12.33 Blank RBRVS

26860 Blank ARTHRODESIS INTERPHALANGEAL JT W/WO INT FIXJ Surgery Blank 4.88 10.24 10.24 Blank RBRVS

26861 Blank ARTHRODESIS IPHAL JT W/WO INT FIXJ EA IPHAL JT Surgery Blank 1.74 0.93 0.93 Blank RBRVS

26862 Blank ARTHRODESIS IPHAL JT W/WO INT FIXJ W/AUTOGRAFT Surgery Blank 7.56 11.70 11.70 Blank RBRVS

26863 Blank ARTHRODESIS IPHAL JT W/WO INT FIXJ W/AGRFT EA JT Surgery Blank 3.89 1.97 1.97 Blank RBRVS

26910 Blank AMP MTCRPL W/FINGER/THUMB W/WO INTEROSS TRANSFER Surgery Blank 7.79 11.25 11.25 Blank RBRVS

26951 Blank AMP F/TH 1/2 JT/PHALANX W/NEURECT W/DIR CLSR Surgery Blank 6.04 11.30 11.30 Blank RBRVS

26952 Blank AMP F/TH 1/2 JT/PHALANX W/NEURECT LOCAL FLAP Surgery Blank 6.48 10.61 10.61 Blank RBRVS

26989 Blank UNLISTED PROCEDURE HANDS/FINGERS Surgery Blank Blank Blank Blank 10.08 Unlisted

26990 Blank I&D PELVIS/HIP JT AREA DEEP ABSCESS/HEMATOMA Surgery Blank 7.95 8.45 8.45 Blank RBRVS

26991 Blank I&D PELVIS/HIP JOINT AREA INFECTED BURSA Surgery Blank 7.06 6.67 11.90 Blank RBRVS

26992 Blank INCISION BONE CORTEX PELVIS&/HIP JOINT Surgery Blank 13.48 11.57 11.57 Blank RBRVS

27000 Blank TENOTOMY ADDUCTOR HIP PERCUTANEOUS SPX Surgery Blank 5.74 5.24 5.24 Blank RBRVS

27001 Blank TENOTOMY ADDUCTOR HIP OPEN Surgery Blank 7.14 6.95 6.95 Blank RBRVS

27003 Blank TX ADDUXOR SUBQ OPN W/OBTURATOR NEURECTOMY Surgery Blank 7.81 7.75 7.75 Blank RBRVS

27005 Blank TENOTOMY HIP FLEXOR OPEN SEPARATE PROCEDURE Surgery Blank 10.07 8.87 8.87 Blank RBRVS

27006 Blank TENOTOMY ABDUCTORS&/EXTENSOR HIP OPEN SPX Surgery Blank 10.11 9.09 9.09 Blank RBRVS

27025 Blank FASCIOTOMY HIP/THIGH ANY TYPE Surgery Blank 12.89 11.13 11.13 Blank RBRVS

27027 Blank DECOMPRESSION FASCIOTOMY PELVIC COMPARTMENT UNI Surgery Blank 13.04 9.96 9.96 Blank RBRVS

27030 Blank ARTHROTOMY HIP W/DRAINAGE Surgery Blank 13.65 10.66 10.66 Blank RBRVS

27033 Blank ARTHROTOMY HIP EXPLORATION/REMOVAL FOREIGN BODY Surgery Blank 14.11 11.10 11.10 Blank RBRVS

27035 Blank DNRVTJ HIP JT INTRAPEL/XTRPEL INTRA-ARTCLR BRNCH Surgery Blank 17.37 14.69 14.69 Blank RBRVS

27036 Blank CAPSLCTOMY/CAPSUL HIP W/RLS HIP FLXR MUSC Surgery Blank 14.38 11.95 11.95 Blank RBRVS

27040 Blank BIOPSY SOFT TISSUE PELVIS&HIP AREA SUPERFICIAL Surgery Blank 2.92 2.34 6.48 Blank RBRVS

27041 Blank BIOPSY SOFT TISSUE PELVIS&HIP DEEP/SUBFSCAL/IM Surgery Blank 10.18 7.92 7.92 Blank RBRVS

27043 Blank EXCISION TUMOR SOFT TISSUE PELVIS&HIP SUBQ 3CM/> Surgery Blank 6.88 5.10 5.10 Blank RBRVS

27045 Blank EXC TUMOR SOFT TISSUE PELVIS & HIP SUBFASC 5CM/> Surgery Blank 11.13 8.04 8.04 Blank RBRVS

27047 Blank EXC TUMOR SOFT TISSUE PELVIS & HIP SUBQ <3CM Surgery Blank 4.94 4.39 7.33 Blank RBRVS

27048 Blank EXC TUMOR SOFT TISSUE PELVIS & HIP SUBFASC <5CM Surgery Blank 8.85 6.85 6.85 Blank RBRVS

27049 Blank RAD RESECT TUMOR SOFT TISSUE PELVIS & HIP <5 CM Surgery Blank 21.55 12.71 12.71 Blank RBRVS

27050 Blank ARTHROTOMY W/BIOPSY SACROILIAC JOINT Surgery Blank 4.74 5.86 5.86 Blank RBRVS

27052 Blank ARTHROTOMY W/BIOPSY HIP JOINT Surgery Blank 7.42 7.75 7.75 Blank RBRVS

27054 Blank ARTHROTOMY W/SYNOVECTOMY HIP JOINT Surgery Blank 9.21 8.69 8.69 Blank RBRVS

27057 Blank DCMPRN FASCIOTOMY PELVIC CMPRT DBRDMT MUSCLE UNI Surgery Blank 14.91 11.33 11.33 Blank RBRVS

27059 Blank RAD RESECTION TUMOR SOFT TISS PELVIS&HIP 5 CM/> Surgery Blank 29.35 17.29 17.29 Blank RBRVS

27060 Blank EXCISION ISCHIAL BURSA Surgery Blank 5.87 6.32 6.32 Blank RBRVS

27062 Blank EXCISION TROCHANTERIC BURSA/CALCIFICATION Surgery Blank 5.75 6.19 6.19 Blank RBRVS

27065 Blank EXCISION BONE CYST/BNIGN TUMOR SUPERFICIAL Surgery Blank 6.55 7.06 7.06 Blank RBRVS

27066 Blank EXCISION BONE CYST/BENIGN TUMOR DEEP Surgery Blank 11.20 9.87 9.87 Blank RBRVS

27067 Blank EXC B1 CST/B9 TUM W/AGRFT REQ SEP INC Surgery Blank 14.72 12.11 12.11 Blank RBRVS

27070 Blank PARTIAL EXCISION SUPERFICIAL PELVIS Surgery Blank 11.56 10.56 10.56 Blank RBRVS

27071 Blank PARTIAL EXCISION DEEP PELVIS Surgery Blank 12.39 11.57 11.57 Blank RBRVS

27075 Blank RAD RESCT TUMOR WING OF ILIUM 1 PUBIC/ISCHIAL Surgery Blank 32.71 21.44 21.44 Blank RBRVS

27076 Blank RAD RESCT TUMOR ILIUM ACETABULUM BOTH PUBIC Surgery Blank 40.21 25.23 25.23 Blank RBRVS

27077 Blank RADICAL RESCTION TUMOR INNOMINATE BONE TOTAL Surgery Blank 45.21 27.76 27.76 Blank RBRVS

27078 Blank RAD RESCT TUMOR ISCHIAL TUBEROSITY&GRT TRCHNTR Surgery Blank 32.21 21.18 21.18 Blank RBRVS

27080 Blank COCCYGECTOMY PRIMARY Surgery Blank 6.89 6.32 6.32 Blank RBRVS

27086 Blank RMVL FOREIGN BODY PELVIS/HIP SUBCUTANEOUS TISS Surgery Blank 1.92 2.52 6.20 Blank RBRVS

27087 Blank REMOVAL FOREIGN BODY PELVIS/HIP DEEP Surgery Blank 8.83 7.11 7.11 Blank RBRVS

27090 Blank REMOVAL HIP PROSTHESIS SEPARATE PROCEDURE Surgery Blank 11.69 9.91 9.91 Blank RBRVS

27091 Blank RMVL HIP PROSTH COMP W/TOT HIP PROSTH MMA Surgery Blank 24.35 17.00 17.00 Blank RBRVS

27093 Blank INJECTION HIP ARTHROGRAPHY W/O ANESTHESIA Surgery Blank 1.30 0.58 3.89 Blank RBRVS

27095 Blank INJECTION HIP ARTHROGRAPHY W/ANESTHESIA Surgery Blank 1.50 0.70 5.30 Blank RBRVS

27096 Blank INJECT SI JOINT ARTHRGRPHY&/ANES/STEROID W/IMA Surgery Blank 1.48 0.80 2.93 Blank RBRVS

27097 Blank RELEASE/RECESSION HAMSTRING PROXIMAL Surgery Blank 9.27 8.48 8.48 Blank RBRVS

27098 Blank TRANSFER ADDUCTOR ISCHIUM Surgery Blank 9.32 8.77 8.77 Blank RBRVS

27100 Blank TR XTRNL OBLQ MUSC TRCHNTR W/FSCAL/TDN XTN GRF Surgery Blank 11.35 10.14 10.14 Blank RBRVS

27105 Blank TR PARASPI MUSC HIP FASC/TDN XTN GRF Surgery Blank 12.04 10.49 10.49 Blank RBRVS

27110 Blank TRANSFER ILIOPSOAS GREATER TROCHANTER FEMUR Surgery Blank 13.77 11.37 11.37 Blank RBRVS

27111 Blank TRANSFER ILIOPSOAS FEMORAL NECK Surgery Blank 12.60 10.77 10.77 Blank RBRVS

27120 Blank ACETABULOPLASTY Surgery Blank 19.25 14.39 14.39 Blank RBRVS

27122 Blank ACETABULOPLASTY RESECTION FEMORAL HEAD Surgery Blank 16.09 12.45 12.45 Blank RBRVS

27125 Blank HEMIARTHROPLASTY HIP PARTIAL Surgery Blank 16.64 12.78 12.78 Blank RBRVS

27130 Blank ARTHRP ACETBLR/PROX FEM PROSTC AGRFT/ALGRFT Surgery Blank 20.72 14.44 14.44 Blank RBRVS

27132 Blank CONV PREV HIP TOT HIP ARTHRP W/WO AGRFT/ALGRFT Surgery Blank 25.69 17.70 17.70 Blank RBRVS

27134 Blank REVJ TOT HIP ARTHRP BTH W/WO AGRFT/ALGRFT Surgery Blank 30.28 19.24 19.24 Blank RBRVS

27137 Blank REVJ TOT HIP ARTHRP ACTBLR W/WO AGRFT/ALGRFT Surgery Blank 22.70 15.43 15.43 Blank RBRVS

27138 Blank REVJ TOT HIP ARTHRP FEM ONLY W/WO ALGRFT Surgery Blank 23.70 15.92 15.92 Blank RBRVS

27140 Blank OSTEOTOMY&TRANSFER GREATER TROCHANTER SPX Surgery Blank 12.78 10.53 10.53 Blank RBRVS

27146 Blank OSTEOTOMY ILIAC ACETABULAR/INNOMINATE BONE Surgery Blank 18.92 14.22 14.22 Blank RBRVS

27147 Blank OSTEOTOMY ILIAC ACETABULAR/INNOMINATE HIP RDCTJ Surgery Blank 22.07 15.95 15.95 Blank RBRVS





PAGE 21 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

27151 Blank OSTEOTOMY ILIAC ACETABULAR/INNOMINATE FEM OSTEOT Surgery Blank 24.12 16.99 16.99 Blank RBRVS

27156 Blank OSTEOT ILIAC ACTBLR/INNOMINATE BONE OSTEOT RDCTJ Surgery Blank 26.23 18.05 18.05 Blank RBRVS

27158 Blank OSTEOTOMY PELVIS BILATERAL Surgery Blank 21.04 15.19 15.19 Blank RBRVS

27161 Blank OSTEOTOMY FEMORAL NECK SEPARATE PROCEDURE Surgery Blank 17.89 13.69 13.69 Blank RBRVS

27165 Blank OSTEOT INTERTRCHNTRIC/SUBTRCHNTRIC W/INT/XTRNL Surgery Blank 20.29 15.35 15.35 Blank RBRVS

27170 Blank B1 GRF FEM H/N INTERTRCHNTRIC/SUBTRCHNTRIC AREA Surgery Blank 17.61 12.86 12.86 Blank RBRVS

27175 Blank TX SLP FEMORAL EPIPHYSIS TRCJ W/O REDUCTION Surgery Blank 9.38 7.94 7.94 Blank RBRVS

27176 Blank TX SLP FEM EPIPHYSIS SINGLE/MULTIPL PINNING SITU Surgery Blank 12.92 10.93 10.93 Blank RBRVS

27177 Blank OPTX SLP FEM EPIPHYSIS SINGLE/MULT PIN/BONE GRFT Surgery Blank 16.09 12.80 12.80 Blank RBRVS

27178 Blank OPTX SLP FEM EPIPHYSIS CLSD MANJ SINGL/MLTPL PIN Surgery Blank 12.92 10.93 10.93 Blank RBRVS

27179 Blank OPTX SLP FEM EPIPHYSIS OSTPL FEM NCK HEYMAN PX Surgery Blank 13.97 11.35 11.35 Blank RBRVS

27181 Blank OPTX SLP FEM EPIPHYSIS OSTEOT&INT FIXJ Surgery Blank 16.18 12.97 12.97 Blank RBRVS

27185 Blank EPIPHYSL ARRST EPIPHYSIOD/STAPLING TRCHNTR FEMUR Surgery Blank 9.79 8.90 8.90 Blank RBRVS

27187 Blank PROPH TX N/P/PLTWR W/WO MMA FEM NCK & PROX FEMUR Surgery Blank 14.23 11.55 11.55 Blank RBRVS

27197 Blank CLSD TX PELVIC RING FX Surgery Blank 1.53 1.63 1.63 Blank RBRVS

27198 Blank CLSD TX PELVIC RING FX Surgery Blank 4.75 3.07 3.07 Blank RBRVS

27200 Blank CLOSED TREATMENT COCCYGEAL FRACTURE Surgery Blank 1.92 3.15 2.97 Blank RBRVS

27202 Blank OPEN TREATMENT COCCYGEAL FRACTURE Surgery Blank 7.31 6.55 6.55 Blank RBRVS

27215 Blank OPTX ILIAC TUBRST AVLS/WING FX FIXJ IF PRFRMD Surgery Blank 10.45 6.15 6.15 Blank RBRVS

27216 Blank PERQ SKELETAL FIXATION PST PELVIC BONE FX&/DIS Surgery Blank 15.73 8.85 8.85 Blank RBRVS

27217 Blank OPTX ANT PELVIC BONE FX&/DISLC INT FIXJ IF PFR Surgery Blank 14.65 8.43 8.43 Blank RBRVS

27218 Blank OPTX POST PEL BONE FX&/DISLC INT FIXJ IF PFRMD Surgery Blank 20.93 10.85 10.85 Blank RBRVS

27220 Blank CLTX ACETABULUM HIP/SOCKT FX W/O MANJ Surgery Blank 6.83 6.94 7.11 Blank RBRVS

27222 Blank CLTX ACETABULM HIP/SOCKT FX MANJ W/WO SKEL TRACJ Surgery Blank 14.11 11.19 11.19 Blank RBRVS

27226 Blank OPTX PST/ANT ACTBLR WALL FX W/INT FIXJ Surgery Blank 15.57 11.73 11.73 Blank RBRVS

27227 Blank OPTX ACTBLR FX INVG ANT/PST 1 COLUMN/FX W/INT Surgery Blank 25.41 17.51 17.51 Blank RBRVS

27228 Blank OPTX ACTBLR FX INVG ANT&POST 2 COLUMNS FX W/INT Surgery Blank 29.33 19.36 19.36 Blank RBRVS

27230 Blank CLTX FEM FX PROX END NCK W/O MANJ Surgery Blank 5.81 6.61 6.74 Blank RBRVS

27232 Blank CLTX FEM FX PROX END NCK W/MANJ W/WO SKEL TRACJ Surgery Blank 11.72 7.59 7.59 Blank RBRVS

27235 Blank PRQ SKEL FIXJ FEMORAL FX PROX END NECK Surgery Blank 13.00 10.60 10.60 Blank RBRVS

27236 Blank OPTX FEM FX PROX END NCK INT FIXJ/PROSTC RPLCMT Surgery Blank 17.61 13.44 13.44 Blank RBRVS

27238 Blank CLTX INTER/PERI/SUBTROCHANTERIC FEM FX W/O MANJ Surgery Blank 5.75 6.36 6.36 Blank RBRVS

27240 Blank CLTX INTR/PERI/SBTRCHNTC FEMORAL FX W/MANJ Surgery Blank 13.81 11.11 11.11 Blank RBRVS

27244 Blank TX INTER/PR/SUBTRCHNTRIC FEMORAL FX SCREW IMPLT Surgery Blank 18.18 13.76 13.76 Blank RBRVS

27245 Blank TX INTER/PR/SUBTRCHNTRIC FEM FX IMED IMPLTSCREW Surgery Blank 18.18 13.76 13.76 Blank RBRVS

27246 Blank CLTX GREATER TROCHANTERIC FX W/O MANJ Surgery Blank 4.83 5.33 5.31 Blank RBRVS

27248 Blank OPEN TREATMENT GREATER TROCHANTERIC FRACTURE Surgery Blank 10.78 8.53 8.53 Blank RBRVS

27250 Blank CLTX HIP DISLOCATION TRAUMATIC W/O ANESTHESIA Surgery Blank 3.82 0.78 0.78 Blank RBRVS

27252 Blank CLTX HIP DISLOCATION TRAUMATIC REQ ANESTHESIA Surgery Blank 11.03 8.62 8.62 Blank RBRVS

27253 Blank OPTX HIP DISLOCATION TRAUMATIC W/O INTERNAL FIXJ Surgery Blank 13.58 10.81 10.81 Blank RBRVS

27254 Blank OPTX HIP DISLC TRAUMTC W/ACTBLR WALL&FEM HEAD Surgery Blank 18.94 13.84 13.84 Blank RBRVS

27256 Blank TX SPONTAN HIP DISLC ABDCT SPLNT/TRCJ W/O ANES Surgery Blank 4.28 1.79 3.74 Blank RBRVS

27257 Blank TX SPON HIP DISLC ABDCT SPLNT/TRCJ W/MANJ ANES Surgery Blank 5.38 4.02 4.02 Blank RBRVS

27258 Blank OPTX SPON HIP DISLC RPLCMT FEM HEAD ACTBLM Surgery Blank 16.18 12.58 12.58 Blank RBRVS

27259 Blank OPTX SPON HIP DISLC RPLCMT FEM HEAD ACTBLM SHRT Surgery Blank 23.26 16.90 16.90 Blank RBRVS

27265 Blank CLTX POST HIP ARTHRP DISLC W/O ANES Surgery Blank 5.24 5.38 5.38 Blank RBRVS

27266 Blank CLTX POST HIP ARTHRP DISLC REQ ANES Surgery Blank 7.78 7.38 7.38 Blank RBRVS

27267 Blank CLOSED TX FEMORAL FRACTURE PROX HEAD W/O MANJ Surgery Blank 5.50 5.89 5.89 Blank RBRVS

27268 Blank CLOSED TX FEMORAL FRACTURE PROX HEAD W/MANJ Surgery Blank 7.12 6.93 6.93 Blank RBRVS

27269 Blank OPEN TX FEMORAL FRACTURE PROXIMAL END HEAD Surgery Blank 18.89 13.29 13.29 Blank RBRVS

27275 Blank MANIPULATION HIP JOINT GENERAL ANESTHESIA Surgery Blank 2.32 2.50 2.50 Blank RBRVS

27279 Blank ARTHRODESIS SACROILIAC JOINT PERCUTANEOUS Surgery Blank 9.03 8.47 8.47 Blank RBRVS

27280 Blank ARTHRODESIS SACROILIAC JOINT W/OBTAINING GRAFT Surgery Blank 20.00 13.91 13.91 Blank RBRVS

27282 Blank ARTHRODESIS SYMPHYSIS PUBIS W/OBTAINING GRAFT Surgery Blank 11.85 10.40 10.40 Blank RBRVS

27284 Blank ARTHRODESIS HIP JOINT W/OBTAINING GRAFT Surgery Blank 25.06 16.68 16.68 Blank RBRVS

27286 Blank ARTHRD HIP JT W/OBTG GRF W/SUBTRCHNTRIC OSTEOT Surgery Blank 25.17 17.52 17.52 Blank RBRVS

27290 Blank INTERPELVIABDOMINAL AMPUTATION Surgery Blank 24.55 17.43 17.43 Blank RBRVS

27295 Blank DISARTICULATION HIP Surgery Blank 19.66 12.93 12.93 Blank RBRVS

27299 Blank UNLISTED PROCEDURE PELVIS/HIP JOINT Surgery Blank Blank Blank Blank 3.72 Unlisted

27301 Blank I&D DEEP ABSC BURSA/HEMATOMA THIGH/KNEE REGION Surgery Blank 6.78 6.29 11.14 Blank RBRVS

27303 Blank INC DEEP W/OPNG BONE CORTEX FEMUR/KNEE Surgery Blank 8.63 8.03 8.03 Blank RBRVS

27305 Blank FASCIOTOMY ILIOTIBIAL OPEN Surgery Blank 6.18 6.42 6.42 Blank RBRVS

27306 Blank TENOTOMY PRQ ADDUCTOR/HAMSTRING 1 TENDON SPX Surgery Blank 4.74 4.63 4.63 Blank RBRVS

27307 Blank TENOTOMY PRQ ADDUCTOR/HAMSTRING MULTIPLE TENDON Surgery Blank 6.06 4.96 4.96 Blank RBRVS

27310 Blank ARTHRT KNE W/EXPL DRG/RMVL FB Surgery Blank 10.00 9.07 9.07 Blank RBRVS

27323 Blank BIOPSY SOFT TISSUE THIGH/KNEE AREA SUPERFICIAL Surgery Blank 2.33 2.41 5.07 Blank RBRVS

27324 Blank BIOPSY SOFT TISSUE THIGH/KNEE AREA DEEP Surgery Blank 5.04 5.36 5.36 Blank RBRVS

27325 Blank NEURECTOMY HAMSTRING MUSCLE Surgery Blank 7.20 7.37 7.37 Blank RBRVS

27326 Blank NEURECTOMY POPLITEAL Surgery Blank 6.47 7.00 7.00 Blank RBRVS

27327 Blank EXCISION TUMOR SOFT TISSUE THIGH/KNEE SUBQ <3CM Surgery Blank 3.96 4.22 8.34 Blank RBRVS

27328 Blank EXC TUMOR SOFT TISSUE THIGH/KNEE SUBFASC <5CM Surgery Blank 8.85 7.20 7.20 Blank RBRVS

27329 Blank RAD RESECT TUMOR SOFT TISSUE THIGH/KNEE <5CM Surgery Blank 15.72 10.84 10.84 Blank RBRVS





PAGE 22 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

27330 Blank ARTHROTOMY KNEE W/SYNOVIAL BIOPSY ONLY Surgery Blank 5.11 5.81 5.81 Blank RBRVS

27331 Blank ARTHRT KNE W/JT EXPL BX/RMVL LOOSE/FB Surgery Blank 6.02 6.43 6.43 Blank RBRVS

27332 Blank ARTHRT W/EXC SEMILUNAR CRTLG KNEE MEDIAL/LAT Surgery Blank 8.46 8.34 8.34 Blank RBRVS

27333 Blank ARTHRT W/EXC SEMILUNAR CRTLG KNEE MEDIAL&LAT Surgery Blank 7.55 7.76 7.76 Blank RBRVS

27334 Blank ARTHROTOMY W/SYNOVECTOMY KNEE ANTERIOR/POSTERIOR Surgery Blank 9.19 8.68 8.68 Blank RBRVS

27335 Blank ARTHRT W/SYNVCT KNE ANT&POST W/POP AREA Surgery Blank 10.55 9.37 9.37 Blank RBRVS

27337 Blank EXCISON TUMOR SOFT TISSUE THIGH/KNEE SUBQ 3 CM/> Surgery Blank 5.91 4.84 4.84 Blank RBRVS

27339 Blank EXC TUMOR SOFT TISSUE THIGH/KNEE SUBFASC 5 CM/> Surgery Blank 11.13 8.20 8.20 Blank RBRVS

27340 Blank EXCISION PREPATELLAR BURSA Surgery Blank 4.32 5.48 5.48 Blank RBRVS

27345 Blank EXCISION SYNOVIAL CYST POPLITEAL SPACE Surgery Blank 6.09 6.52 6.52 Blank RBRVS

27347 Blank EXCISION LESION MENISCUS/CAPSULE KNEE Surgery Blank 6.73 7.14 7.14 Blank RBRVS

27350 Blank PATELLECTOMY/HEMIPATELLECTOMY Surgery Blank 8.66 8.40 8.40 Blank RBRVS

27355 Blank EXCISION/CURETTAGE CYST/TUMOR FEMUR Surgery Blank 8.00 7.80 7.80 Blank RBRVS

27356 Blank EXCISION/CURETTAGE CYST/TUMOR FEMUR W/ALLOGRAFT Surgery Blank 10.09 9.16 9.16 Blank RBRVS

27357 Blank EXCISION/CURETTAGE CYST/TUMOR FEMUR W/AUTOGRAFT Surgery Blank 11.16 10.05 10.05 Blank RBRVS

27358 Blank EXCISION/CURETTAGE CYST/TUMOR FEMUR INT FIXATION Surgery Blank 4.73 2.39 2.39 Blank RBRVS

27360 Blank PRTL EXC BONE FEMUR PROX TIBIA&/FIBULA Surgery Blank 11.46 10.81 10.81 Blank RBRVS

27364 Blank RAD RESECTION TUMOR SOFT TIS THIGH/KNEE 5 CM/> Surgery Blank 24.49 15.60 15.60 Blank RBRVS

27365 Blank RADICAL RESECTION TUMOR FEMOR OR KNEE Surgery Blank 32.21 21.12 21.12 Blank RBRVS

27369 Blank NJX CNTRST KNE ARTHG/CT/MRI Surgery Blank 0.77 0.31 3.20 Blank RBRVS

27372 Blank REMOVAL FOREIGN BODY DEEP THIGH/KNEE Surgery Blank 5.21 5.22 10.82 Blank RBRVS

27380 Blank SUTURE INFRAPATELLAR TENDON PRIMARY Surgery Blank 7.45 8.13 8.13 Blank RBRVS

27381 Blank SUTR INFRAPATELLAR TDN 2 RCNSTJ W/FSCAL/TDN GRF Surgery Blank 10.76 10.10 10.10 Blank RBRVS

27385 Blank SUTURE QUADRICEPS/HAMSTRING RUPTURE PRIMARY Surgery Blank 6.93 8.22 8.22 Blank RBRVS

27386 Blank SUTR QUADRICEPS/HAMSTRING MUSC RPT RCNSTJ Surgery Blank 11.13 10.57 10.57 Blank RBRVS

27390 Blank TENOTOMY OPEN HAMSTRING KNEE HIP SINGLE TENDON Surgery Blank 5.53 6.25 6.25 Blank RBRVS

27391 Blank TENOTOMY OPN HAMSTRING KNEE HIP MULTIPLE 1 LEG Surgery Blank 7.49 7.47 7.47 Blank RBRVS

27392 Blank TENOTOMY OPEN HAMSTRING KNEE HIP MULTIPLE BI Surgery Blank 9.63 8.93 8.93 Blank RBRVS

27393 Blank LENGTHENING HAMSTRING TENDON SINGLE Surgery Blank 6.59 6.74 6.74 Blank RBRVS

27394 Blank LENGTHENING HAMSTRING TENDON MULTIPLE 1 LEG Surgery Blank 8.79 8.24 8.24 Blank RBRVS

27395 Blank LENGTHENING HAMSTRING TENDON MULTIPLE BILATERAL Surgery Blank 12.24 10.59 10.59 Blank RBRVS

27396 Blank TRANSPLANT/TRANSFER THIGH XTNSR TO FLXR 1 TENDON Surgery Blank 8.15 7.91 7.91 Blank RBRVS

27397 Blank TRANSPLANT/TRANSFER THIGH XTNSR TO FLXR MULT TDN Surgery Blank 12.66 11.19 11.19 Blank RBRVS

27400 Blank TRANSFER TENDON/MUSCLE HAMSTRINGS FEMUR Surgery Blank 9.33 8.78 8.78 Blank RBRVS

27403 Blank ARTHROTOMY W/MENISCUS REPAIR KNEE Surgery Blank 8.62 8.06 8.06 Blank RBRVS

27405 Blank RPR PRIMARY TORN LIGM&/CAPSULE KNEE COLLATERAL Surgery Blank 9.08 8.56 8.56 Blank RBRVS

27407 Blank REPAIR PRIMARY TORN LIGM&/CAPSULE KNEE CRUCIAT Surgery Blank 10.85 9.77 9.77 Blank RBRVS

27409 Blank RPR 1 TORN LIGM&/CAPSL KNE COLTRL&CRUCIATE Surgery Blank 13.71 11.34 11.34 Blank RBRVS

27412 Blank AUTOLOGOUS CHONDROCYTE IMPLANTATION KNEE Surgery Blank 24.74 18.05 18.05 Blank RBRVS

27415 Blank OSTEOCHONDRAL ALLOGRAFT KNEE OPEN Surgery Blank 20.00 15.27 15.27 Blank RBRVS

27416 Blank OSTEOCHONDRAL AUTOGRAFT KNEE OPEN MOSAICPLASTY Surgery Blank 14.16 11.26 11.26 Blank RBRVS

27418 Blank ANTERIOR TIBIAL TUBERCLEPLASTY Surgery Blank 11.60 9.92 9.92 Blank RBRVS

27420 Blank RCNSTJ DISLOCATING PATELLA Surgery Blank 10.26 9.13 9.13 Blank RBRVS

27422 Blank RCNSTJ DISLC PATELLA W/XTNSR RELIGNMT&/MUSC RL Surgery Blank 10.21 9.16 9.16 Blank RBRVS

27424 Blank RCNSTJ DISLC PATELLA W/PATELLECTOMY Surgery Blank 10.24 9.23 9.23 Blank RBRVS

27425 Blank LATERAL RETINACULAR RELEASE OPEN Surgery Blank 5.39 6.40 6.40 Blank RBRVS

27427 Blank LIGAMENTOUS RECONSTRUCTION KNEE EXTRA-ARTICULAR Surgery Blank 9.79 8.78 8.78 Blank RBRVS

27428 Blank LIGAMENTOUS RECONSTRUCTION KNEE INTRA-ARTICULAR Surgery Blank 15.58 13.45 13.45 Blank RBRVS

27429 Blank LIGMOUS RCNSTJ AGMNTJ KNE INTRA-ARTICULAR XTR Surgery Blank 17.54 14.72 14.72 Blank RBRVS

27430 Blank QUADRICEPSPLASTY Surgery Blank 10.16 9.17 9.17 Blank RBRVS

27435 Blank CAPSULOTOMY POSTERIOR CAPSULAR RELEASE KNEE Surgery Blank 10.88 10.24 10.24 Blank RBRVS

27437 Blank ARTHROPLASTY PATELLA W/O PROSTHESIS Surgery Blank 8.93 8.29 8.29 Blank RBRVS

27438 Blank ARTHROPLASTY PATELLA W/PROSTHESIS Surgery Blank 11.89 9.98 9.98 Blank RBRVS

27440 Blank ARTHROPLASTY KNEE TIBIAL PLATEAU Surgery Blank 11.09 9.66 9.66 Blank RBRVS

27441 Blank ARTHRP KNEE TIBIAL PLATEAU DBRDMT&PRTL SYNVCT Surgery Blank 11.54 9.89 9.89 Blank RBRVS

27442 Blank ARTHROPLASTY FEM CONDYLES/TIBIAL PLATEAU KNEE Surgery Blank 12.37 10.27 10.27 Blank RBRVS

27443 Blank ARTHRP FEM CONDYLES/TIBL PLATU KNE DBRDMT&PRTL Surgery Blank 11.41 9.68 9.68 Blank RBRVS

27445 Blank ARTHROPLASTY KNEE HINGE PROSTHESIS Surgery Blank 18.66 13.82 13.82 Blank RBRVS

27446 Blank ARTHRP KNEE CONDYLE&PLATEAU MEDIAL/LAT CMPRT Surgery Blank 17.48 12.60 12.60 Blank RBRVS

27447 Blank ARTHRP KNE CONDYLE&PLATU MEDIAL&LAT COMPARTMENTS Surgery Blank 20.72 14.41 14.41 Blank RBRVS

27448 Blank OSTEOTOMY FEMUR SHAFT/SUPRACONDYLAR W/O FIXATION Surgery Blank 11.60 8.85 8.85 Blank RBRVS

27450 Blank OSTEOTOMY FEMUR SHAFT/SUPRACONDYLAR W/FIXATION Surgery Blank 14.61 11.54 11.54 Blank RBRVS

27454 Blank OSTEOT MLT W/RELIGNMT IMED ROD FEM SHFT Surgery Blank 19.17 14.49 14.49 Blank RBRVS

27455 Blank OSTEOT PROX TIBIA FIB EXC/OSTEOT BEFORE EPIPHYSL Surgery Blank 13.36 11.09 11.09 Blank RBRVS

27457 Blank OSTEOT PROX TIBIA FIB EXC/OSTEOT AFTER EPIPHYSL Surgery Blank 14.03 10.54 10.54 Blank RBRVS

27465 Blank OSTEOPLASTY FEMUR SHORTENING EXCLUDING 64876 Surgery Blank 18.60 12.45 12.45 Blank RBRVS

27466 Blank OSTEOPLASTY FEMUR LENGTHENING Surgery Blank 17.28 13.40 13.40 Blank RBRVS

27468 Blank OSTPL FEMUR CMBN LNGTH&SHRT W/FEMORAL SGM TRNSFR Surgery Blank 19.97 14.76 14.76 Blank RBRVS

27470 Blank RPR NON/MAL FEMUR DSTL H/N W/O GRF Surgery Blank 17.14 13.44 13.44 Blank RBRVS

27472 Blank RPR NON/MAL FEMUR DSTL H/N W/ILIAC/AUTOG BONE Surgery Blank 18.72 14.03 14.03 Blank RBRVS

27475 Blank ARREST EPIPHYSEAL DISTAL FEMUR Surgery Blank 8.93 8.31 8.31 Blank RBRVS

27477 Blank ARREST EPIPHYSEAL TIBIA & FIBULA PROXIMAL Surgery Blank 10.14 8.93 8.93 Blank RBRVS





PAGE 23 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

27479 Blank ARRST EPIPHYSL CMBN DSTL FEMUR PROX TIBFIB Surgery Blank 13.16 10.71 10.71 Blank RBRVS

27485 Blank ARRST HEMIEPIPHYSL DSTL FEMUR/PROX TIBIA/FIBULA Surgery Blank 9.13 8.33 8.33 Blank RBRVS

27486 Blank REVJ TOTAL KNEE ARTHRP W/WO ALGRFT 1 COMPONENT Surgery Blank 21.12 15.41 15.41 Blank RBRVS

27487 Blank REVJ TOT KNEE ARTHRP FEM&ENTIRE TIBIAL COMPONE Surgery Blank 27.11 18.43 18.43 Blank RBRVS

27488 Blank RMVL PROSTH TOT KNEE PROSTH MMA W/WO INSJ SPACER Surgery Blank 17.60 13.62 13.62 Blank RBRVS

27495 Blank PROPH TX N/P/PLTWR W/WO METHYLMETHACRYLATE FEMUR Surgery Blank 16.54 12.65 12.65 Blank RBRVS

27496 Blank DECOMPRESSION FASCIOTOMY THIGH&/KNEE 1 COMPONENT Surgery Blank 6.78 7.49 7.49 Blank RBRVS

27497 Blank DCMPRN FASCT THIGH&/KNEE DBRDMT MUSCLE&/NERVE Surgery Blank 7.79 7.40 7.40 Blank RBRVS

27498 Blank DCMPRN FASCIOTOMY THIGH&/KNEE MLT COMPARTMENTS Surgery Blank 8.66 8.44 8.44 Blank RBRVS

27499 Blank DCMPRN FASCT THIGH&/KNEE MLT DBRDMT NV MUSC&NRVE Surgery Blank 9.43 8.83 8.83 Blank RBRVS

27500 Blank CLOSED TX FEMORAL SHAFT FX W/O MANIPULATION Surgery Blank 6.30 6.29 7.42 Blank RBRVS

27501 Blank CLTX SPRCNDYLR/TRNSCNDYLR FEM FX W/O MANJ Surgery Blank 6.45 6.60 6.76 Blank RBRVS

27502 Blank CLTX FEM SHFT FX W/MANJ W/WO SKIN/SKELETAL TRACJ Surgery Blank 11.36 8.39 8.39 Blank RBRVS

27503 Blank CLTX SPRCNDYLR/TRNSCNDYLR FEM FX W/MANJ Surgery Blank 11.27 9.60 9.60 Blank RBRVS

27506 Blank OPTX FEM SHFT FX W/INSJ IMED IMPLT W/WO SCREW Surgery Blank 19.65 15.08 15.08 Blank RBRVS

27507 Blank OPTX FEM SHFT FX W/PLATE/SCREWS W/WO CERCLAGE Surgery Blank 14.48 10.73 10.73 Blank RBRVS

27508 Blank CLTX FEM FX DSTL END MEDIAL/LAT CONDYLE W/O MANJ Surgery Blank 6.20 6.80 7.72 Blank RBRVS

27509 Blank PRQ SKELETAL FIXJ FEMORAL FX DISTAL END Surgery Blank 8.14 8.79 8.79 Blank RBRVS

27510 Blank CLTX FEM FX DSTL END MEDIAL/LAT CONDYLE W/MANJ Surgery Blank 9.80 8.03 8.03 Blank RBRVS

27511 Blank OPEN TX FEMORAL SUPRACONDYLAR FRACTURE W/O XTN Surgery Blank 15.11 10.68 10.68 Blank RBRVS

27513 Blank OPEN TX FEMORAL SUPRACONDYLAR FRACTURE W/XTN Surgery Blank 19.25 12.76 12.76 Blank RBRVS

27514 Blank OPEN TX FEMORAL FRACTURE DISTAL MED/LAT CONDYLE Surgery Blank 14.60 10.43 10.43 Blank RBRVS

27516 Blank CLTX DISTAL FEMORAL EPIPHYSL SEPARATION W/O MANJ Surgery Blank 5.59 6.99 7.86 Blank RBRVS

27517 Blank CLTX DSTL FEM EPIPHYSL SEP W/MANJ W/WO SKIN/SKEL Surgery Blank 9.12 8.77 8.77 Blank RBRVS

27519 Blank OPEN TX DISTAL FEMORAL EPIPHYSEAL SEPARATION Surgery Blank 13.25 9.80 9.80 Blank RBRVS

27520 Blank CLOSED TX PATELLAR FRACTURE W/O MANIPULATION Surgery Blank 3.04 4.84 5.68 Blank RBRVS

27524 Blank OPTX PATLLR FX W/INT FIXJ/PATLLC&SOFT TISS RPR Surgery Blank 10.37 9.25 9.25 Blank RBRVS

27530 Blank CLTX TIBIAL FX PROXIMAL W/O MANIPULATION Surgery Blank 2.65 4.88 5.53 Blank RBRVS

27532 Blank CLTX TIBIAL FX PROXIMAL W/WO MANJ W/SKEL TRACJ Surgery Blank 7.55 7.53 8.64 Blank RBRVS

27535 Blank OPEN TX TIBIAL FRACTURE PROXIMAL UNICONDYLAR Surgery Blank 13.41 9.82 9.82 Blank RBRVS

27536 Blank OPTX TIBIAL FX PROX BICONDYLAR W/WO INT FIXJ Surgery Blank 17.39 13.50 13.50 Blank RBRVS

27538 Blank CLTX INTERCONDYLAR SPI&/TUBRST FX KNE W/WO MAN Surgery Blank 5.09 6.65 7.55 Blank RBRVS

27540 Blank OPEN TX INTERCONDYLAR SPINE/TUBRST FRACTURE KNEE Surgery Blank 11.30 9.78 9.78 Blank RBRVS

27550 Blank CLOSED TX KNEE DISLOCATION W/O ANESTHESIA Surgery Blank 5.98 6.54 7.63 Blank RBRVS

27552 Blank CLOSED TX KNEE DISLOCATION W/ANESTHESIA Surgery Blank 8.18 8.15 8.15 Blank RBRVS

27556 Blank OPEN TX KNEE DISLOCATION W/O LIGAMENTOUS REPAIR Surgery Blank 13.00 9.67 9.67 Blank RBRVS

27557 Blank OPEN TX KNEE DISLOCATION W/LIGAMENTOUS REPAIR Surgery Blank 15.90 11.14 11.14 Blank RBRVS

27558 Blank OPEN TX KNEE DISLOCATION W/REPAIR/RECONSTRUCTION Surgery Blank 18.39 12.40 12.40 Blank RBRVS

27560 Blank CLOSED TX PATELLAR DISLOCATION W/O ANESTHESIA Surgery Blank 3.99 4.93 5.77 Blank RBRVS

27562 Blank CLOSED TX PATELLAR DISLOCATION W/ANESTHESIA Surgery Blank 5.98 6.71 6.71 Blank RBRVS

27566 Blank OPTX PATELLAR DISLC W/WO PRTL/TOT PATELLECTOMY Surgery Blank 12.71 10.50 10.50 Blank RBRVS

27570 Blank MANIPULATION KNEE JOINT UNDER GENERAL ANESTHESIA Surgery Blank 1.79 2.18 2.18 Blank RBRVS

27580 Blank ARTHRODESIS KNEE ANY TECHNIQUE Surgery Blank 21.10 16.23 16.23 Blank RBRVS

27590 Blank AMPUTATION THIGH THROUGH FEMUR ANY LEVEL Surgery Blank 13.47 6.57 6.57 Blank RBRVS

27591 Blank AMP THI THRU FEMUR LVL IMMT FITG TQ W/1ST CST Surgery Blank 13.94 11.12 11.12 Blank RBRVS

27592 Blank AMPUTATION THIGH THRU FEMUR OPEN CIRCULAR Surgery Blank 10.98 6.25 6.25 Blank RBRVS

27594 Blank AMP THIGH THRU FEMUR SEC CLOSURE/SCAR REVISION Surgery Blank 7.29 5.64 5.64 Blank RBRVS

27596 Blank AMPUTATION THIGH THROUGH FEMUR RE-AMPUTATION Surgery Blank 11.29 7.01 7.01 Blank RBRVS

27598 Blank DISARTICULATION KNEE Surgery Blank 11.22 7.01 7.01 Blank RBRVS

27599 Blank UNLISTED PROCEDURE FEMUR/KNEE Surgery Blank Blank Blank Blank 35.13 Unlisted

27600 Blank DCMPRN FASCT LEG ANT&/LAT COMPARTMENTS ONLY Surgery Blank 6.03 4.40 4.40 Blank RBRVS

27601 Blank DCMPRN FASCT LEG POST COMPARTMENT ONLY Surgery Blank 6.05 5.65 5.65 Blank RBRVS

27602 Blank DCMPRN FASCT LEG ANT&/LAT&PST CMPRT Surgery Blank 7.82 4.48 4.48 Blank RBRVS

27603 Blank INCISION & DRAINAGE LEG/ANKLE ABSCESS/HEMATOMA Surgery Blank 5.23 4.92 8.93 Blank RBRVS

27604 Blank INCISION & DRAINAGE LEG/ANKLE INFECTED BURSA Surgery Blank 4.59 4.38 8.44 Blank RBRVS

27605 Blank TENOTOMY PRQ ACHILLES TENDON SPX LOCAL ANES Surgery Blank 2.92 2.13 6.70 Blank RBRVS

27606 Blank TENOTOMY PRQ ACHILLES TENDON SPX GENERAL ANES Surgery Blank 4.18 3.22 3.22 Blank RBRVS

27607 Blank INCISION LEG/ANKLE Surgery Blank 8.62 7.30 7.30 Blank RBRVS

27610 Blank ARTHROTOMY ANKLE W/EXPL DRAINAGE/REMOVAL FB Surgery Blank 9.13 7.95 7.95 Blank RBRVS

27612 Blank ARTHRT PST CAPSUL RLS ANKLE W/WO ACHLL TDN LNGTH Surgery Blank 8.15 6.86 6.86 Blank RBRVS

27613 Blank BIOPSY SOFT TISSUE LEG/ANKLE AREA SUPERFICIAL Surgery Blank 2.22 2.17 4.76 Blank RBRVS

27614 Blank BIOPSY SOFT TISSUE LEG/ANKLE AREA DEEP Surgery Blank 5.80 4.98 9.94 Blank RBRVS

27615 Blank RAD RESECTION TUMOR SOFT TISSUE LEG/ANKLE <5CM Surgery Blank 15.72 10.72 10.72 Blank RBRVS

27616 Blank RAD RESECTION TUMOR SOFT TISSUE LEG/ANKLE 5 CM/> Surgery Blank 19.63 13.10 13.10 Blank RBRVS

27618 Blank EXC TUMOR SOFT TISSUE LEG/ANKLE SUBQ <3CM Surgery Blank 3.96 4.17 8.21 Blank RBRVS

27619 Blank EXC TUMOR SOFT TISSUE LEG/ANKLE SUBFASCIAL <5CM Surgery Blank 6.91 5.41 5.41 Blank RBRVS

27620 Blank ARTHRT ANKLE W/EXPL W/WO BX W/WO RMVL LOOSE/FB Surgery Blank 6.15 5.81 5.81 Blank RBRVS

27625 Blank ARTHROTOMY W/SYNOVECTOMY ANKLE Surgery Blank 8.49 6.92 6.92 Blank RBRVS

27626 Blank ARTHROTOMY W/SYNOVECTOMY ANKLE TENOSYNOVECTOMY Surgery Blank 9.10 6.97 6.97 Blank RBRVS

27630 Blank EXCISION LESION TENDON SHEATH/CAPSULE LEG&/ANK Surgery Blank 4.94 4.80 10.38 Blank RBRVS

27632 Blank EXCISION TUMOR SOFT TISSUE LEG/ANKLE SUBQ 3 CM/> Surgery Blank 5.91 4.82 4.82 Blank RBRVS

27634 Blank EXC TUMOR SOFT TISSUE LEG/ANKLE SUBFASC 5 CM/> Surgery Blank 10.13 7.54 7.54 Blank RBRVS





PAGE 24 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

27635 Blank EXCISION/CURETTAGE BONE CYST/TUMOR TIBIA/FIBULA Surgery Blank 8.03 7.37 7.37 Blank RBRVS

27637 Blank EXC/CURETTAGE CYST/TUMOR TIBIA/FIBULA W/AGRAFT Surgery Blank 10.31 9.62 9.62 Blank RBRVS

27638 Blank EXC/CURETTAGE CYST/TUMOR TIBIA/FIBULA W/ALGRAFT Surgery Blank 10.99 9.05 9.05 Blank RBRVS

27640 Blank PARTIAL EXCISION BONE TIBIA Surgery Blank 12.24 9.55 9.55 Blank RBRVS

27641 Blank PARTIAL EXCISION BONE FIBULA Surgery Blank 9.84 7.73 7.73 Blank RBRVS

27645 Blank RADICAL RESECTION OF TUMOR TIBIA Surgery Blank 27.21 18.77 18.77 Blank RBRVS

27646 Blank RADICAL RESECTION TUMOR BONE FIBULA Surgery Blank 23.21 16.74 16.74 Blank RBRVS

27647 Blank RADICAL RESECTION OF TUMOR TALUS OR CALCANEUS Surgery Blank 20.26 7.75 7.75 Blank RBRVS

27648 Blank INJECTION ANKLE ARTHROGRAPHY Surgery Blank 0.96 0.43 3.69 Blank RBRVS

27650 Blank REPAIR PRIMARY OPEN/PRQ RUPTURED ACHILLES TENDON Surgery Blank 9.21 8.31 8.31 Blank RBRVS

27652 Blank RPR PRIMARY OPEN/PRQ RUPTURED ACHILLES W/GRAFT Surgery Blank 10.78 7.35 7.35 Blank RBRVS

27654 Blank REPAIR SECONDARY ACHILLES TENDON W/WO GRAFT Surgery Blank 10.53 8.39 8.39 Blank RBRVS

27656 Blank REPAIR FASCIAL DEFECT LEG Surgery Blank 4.71 5.75 12.60 Blank RBRVS

27658 Blank REPAIR FLEXOR TENDON LEG PRIMARY W/O GRAFT EACH Surgery Blank 5.12 4.84 4.84 Blank RBRVS

27659 Blank RPR FLEXOR TENDON LEG SECONDARY W/O GRAFT EACH Surgery Blank 7.10 5.64 5.64 Blank RBRVS

27664 Blank RPR EXTENSOR TENDON LEG PRIMARY W/O GRAFT EACH Surgery Blank 4.73 4.96 4.96 Blank RBRVS

27665 Blank RPR EXTENSOR TENDON LEG SECONDRY W/WO GRAFT EACH Surgery Blank 5.57 5.49 5.49 Blank RBRVS

27675 Blank RPR DISLOC PERONEAL TENDON W/O FIBULAR OSTEOTOMY Surgery Blank 7.35 5.78 5.78 Blank RBRVS

27676 Blank REPAIR DISLOCATING PERONEAL TENDON W/FIB OSTEOT Surgery Blank 8.73 7.32 7.32 Blank RBRVS

27680 Blank TENOLYSIS FLXR/XTNSR TENDON LEG&/ANKLE 1 EACH Surgery Blank 5.88 5.45 5.45 Blank RBRVS

27681 Blank TNOLS FLXR/XTNSR TDN LEG&/ANKLE MLT TDN Surgery Blank 7.05 7.25 7.25 Blank RBRVS

27685 Blank LNGTH/SHRT TENDON LEG/ANKLE 1 TENDON SPX Surgery Blank 6.69 5.79 11.54 Blank RBRVS

27686 Blank LNGTH/SHRT TDN LEG/ANKLE MLT TDN SAME INC EA Surgery Blank 7.75 6.82 6.82 Blank RBRVS

27687 Blank GASTROCNEMIUS RECESSION Surgery Blank 6.41 5.70 5.70 Blank RBRVS

27690 Blank TR/TRNSPL 1 TDN W/MUSC REDIRION/REROUTING SUPFC Surgery Blank 9.17 7.84 7.84 Blank RBRVS

27691 Blank TR/TRNSPL 1 TDN W/MUSC REDIRION/REROUTING DP Surgery Blank 10.49 9.26 9.26 Blank RBRVS

27692 Blank TR/TRNSPL 1 TDN W/MUSC REDIRION/REROUTING EA TDN Surgery Blank 1.87 0.84 0.84 Blank RBRVS

27695 Blank RPR PRIMARY DISRUPTED LIGAMENT ANKLE COLLATERAL Surgery Blank 6.70 6.04 6.04 Blank RBRVS

27696 Blank RPR PRIM DISRUPTED LIGM ANKLE BTH COLTRL LIGMS Surgery Blank 8.58 6.39 6.39 Blank RBRVS

27698 Blank REPAIR SECONDARY DISRUPTED LIGAMENT ANKLE COLTRL Surgery Blank 9.61 7.39 7.39 Blank RBRVS

27700 Blank ARTHROPLASTY ANKLE Surgery Blank 9.66 6.56 6.56 Blank RBRVS

27702 Blank ARTHROPLASTY ANKLE W/IMPLANT Surgery Blank 14.42 10.75 10.75 Blank RBRVS

27703 Blank ARTHROPLASTY ANKLE REVISION TOTAL ANKLE Surgery Blank 16.94 12.05 12.05 Blank RBRVS

27704 Blank REMOVAL ANKLE IMPLANT Surgery Blank 7.81 7.22 7.22 Blank RBRVS

27705 Blank OSTEOTOMY TIBIA Surgery Blank 10.86 9.11 9.11 Blank RBRVS

27707 Blank OSTEOTOMY FIBULA Surgery Blank 4.78 5.80 5.80 Blank RBRVS

27709 Blank OSTEOTOMY TIBIA & FIBULA Surgery Blank 17.48 12.89 12.89 Blank RBRVS

27712 Blank OSTEOT MLT W/RELIGNMT IMED ROD Surgery Blank 15.87 12.82 12.82 Blank RBRVS

27715 Blank OSTEOPLASTY TIBIA & FIBULA LENGTHENING/SHORTENIN Surgery Blank 15.50 12.25 12.25 Blank RBRVS

27720 Blank REPAIR NONUNION/MALUNION TIBIA W/O GRAFT Surgery Blank 12.36 10.42 10.42 Blank RBRVS

27722 Blank REPAIR NONUNION/MALUNION TIBIA W/SLIDING GRAFT Surgery Blank 12.45 10.70 10.70 Blank RBRVS

27724 Blank RPR NON/MAL TIBIA W/ILIAC/OTH AGRFT Surgery Blank 19.31 13.43 13.43 Blank RBRVS

27725 Blank RPR NON/MAL TIBIA SYNOSTOSIS W/FIBULA ANY METH Surgery Blank 17.41 14.29 14.29 Blank RBRVS

27726 Blank REPAIR FIBULA NONUNION/MALUNION W/INT FIXATION Surgery Blank 14.34 10.64 10.64 Blank RBRVS

27727 Blank REPAIR CONGENITAL PSEUDARTHROSIS TIBIA Surgery Blank 14.84 12.06 12.06 Blank RBRVS

27730 Blank ARREST EPIPHYSEAL OPEN DISTAL TIBIA Surgery Blank 7.70 7.61 7.61 Blank RBRVS

27732 Blank ARREST EPIPHYSEAL OPEN DISTAL FIBULA Surgery Blank 5.46 6.31 6.31 Blank RBRVS

27734 Blank ARREST EPIPHYSEAL OPEN DISTAL TIBIA&FIBULA Surgery Blank 8.83 8.27 8.27 Blank RBRVS

27740 Blank ARREST EPIPHYSEAL ANY METHOD TIBIA & FIBULA Surgery Blank 9.61 8.84 8.84 Blank RBRVS

27742 Blank ARRST EPIPHYSL ANY METH TIBFIB&DSTL FEMUR Surgery Blank 10.63 9.64 9.64 Blank RBRVS

27745 Blank PROPH TX N/P/PLTWR W/WO METHYLMETHACRYLATE TIBIA Surgery Blank 10.49 9.25 9.25 Blank RBRVS

27750 Blank CLTX TIBIAL SHAFT FX W/O MANIPULATION Surgery Blank 3.37 5.10 5.95 Blank RBRVS

27752 Blank CLTX TIBIAL SHAFT FX W/MANJ W/WO SKEL TRACJ Surgery Blank 6.27 6.68 7.89 Blank RBRVS

27756 Blank PRQ SKELETAL FIXATION TIBIAL SHAFT FRACTURE Surgery Blank 7.45 7.76 7.76 Blank RBRVS

27758 Blank OPTX TIBIAL SHFT FX W/PLATE/SCREWS W/WO CERCLAGE Surgery Blank 12.54 10.67 10.67 Blank RBRVS

27759 Blank TX TIBL SHFT FX IMED IMPLT W/WO SCREWS&/CERCLA Surgery Blank 14.45 11.50 11.50 Blank RBRVS

27760 Blank CLTX MEDIAL MALLEOLUS FX W/O MANIPULATION Surgery Blank 3.21 4.96 5.83 Blank RBRVS

27762 Blank CLTX MEDIAL MALLS FX W/MANJ W/WO SKN/SKEL TRACJ Surgery Blank 5.47 5.88 7.11 Blank RBRVS

27766 Blank OPEN TREATMENT MEDIAL MALLEOLUS FRACTURE Surgery Blank 7.89 8.08 8.08 Blank RBRVS

27767 Blank CLOSED TREATMENT PST MALLEOLUS FRACTURE W/O MANJ Surgery Blank 2.64 4.99 4.94 Blank RBRVS

27768 Blank CLOSED TREATMENT PST MALLEOLUS FRACTURE W/MANJ Surgery Blank 5.14 6.47 6.47 Blank RBRVS

27769 Blank OPEN TREATMENT POSTERIOR MALLEOLUS FRACTURE Surgery Blank 10.14 8.91 8.91 Blank RBRVS

27780 Blank CLTX PROX FIBULA/SHFT FX W/O MANJ Surgery Blank 2.83 4.64 5.46 Blank RBRVS

27781 Blank CLTX PROX FIBULA/SHFT FX W/MANJ Surgery Blank 4.59 5.89 6.81 Blank RBRVS

27784 Blank OPEN TREATMENT PROXIMAL FIBULA/SHAFT FRACTURE Surgery Blank 9.67 8.96 8.96 Blank RBRVS

27786 Blank CLTX DSTL FIBULAR FX LAT MALLS W/O MANJ Surgery Blank 3.02 4.64 5.52 Blank RBRVS

27788 Blank CLTX DSTL FIBULAR FX LAT MALLS W/MANJ Surgery Blank 4.64 5.54 6.62 Blank RBRVS

27792 Blank OPEN TX DISTAL FIBULAR FRACTURE LAT MALLEOLUS Surgery Blank 8.75 8.31 8.31 Blank RBRVS

27808 Blank CLOSED TX BIMALLEOLAR ANKLE FRACTURE W/O MANJ Surgery Blank 3.03 5.01 6.02 Blank RBRVS

27810 Blank CLOSED TX BIMALLEOLAR ANKLE FRACTURE W/MANJ Surgery Blank 5.32 5.85 7.12 Blank RBRVS

27814 Blank OPEN TREATMENT BIMALLEOLAR ANKLE FRACTURE Surgery Blank 10.62 9.54 9.54 Blank RBRVS

27816 Blank CLTX TRIMALLEOLAR ANKLE FX W/O MANIPULATION Surgery Blank 3.07 4.67 5.65 Blank RBRVS





PAGE 25 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

27818 Blank CLTX TRIMALLEOLAR ANKLE FX W/MANIPULATION Surgery Blank 5.69 5.76 7.23 Blank RBRVS

27822 Blank OPEN TX TRIMALLEOLAR ANKLE FX W/O FIXJ PST LIP Surgery Blank 11.21 11.36 11.36 Blank RBRVS

27823 Blank OPEN TX TRIMALLEOLAR ANKLE FX W/FIXJ PST LIP Surgery Blank 13.16 12.33 12.33 Blank RBRVS

27824 Blank CLTX FX W8 BRG ARTCLR PRTN DSTL TIBIA W/O MANJ Surgery Blank 3.31 4.83 5.11 Blank RBRVS

27825 Blank CLTX FX W8 BRG ARTCLR PRTN DSTL TIB W/SKEL TRACJ Surgery Blank 6.69 6.30 7.77 Blank RBRVS

27826 Blank OPEN TREATMENT FRACTURE DISTAL TIBIA FIBULA Surgery Blank 11.10 11.17 11.17 Blank RBRVS

27827 Blank OPEN TREATMENT FRACTURE DISTAL TIBIA ONLY Surgery Blank 14.79 14.01 14.01 Blank RBRVS

27828 Blank OPEN TREATMENT FRACTURE DISTAL TIBIA & FIBULA Surgery Blank 18.43 15.84 15.84 Blank RBRVS

27829 Blank OPEN TX DISTAL TIBIOFIBULAR JOINT DISRUPTION Surgery Blank 8.80 9.56 9.56 Blank RBRVS

27830 Blank CLTX PROX TIBFIB JT DISLC W/O ANES Surgery Blank 3.96 5.43 6.22 Blank RBRVS

27831 Blank CLTX PROX TIBFIB JT DISLC REQ ANES Surgery Blank 4.73 5.82 5.82 Blank RBRVS

27832 Blank OPEN TX PROX TIBFIB JOINT DISLOCATE EXC PROX FIB Surgery Blank 10.17 9.57 9.57 Blank RBRVS

27840 Blank CLOSED TX ANKLE DISLOCATION W/O ANESTHESIA Surgery Blank 4.77 5.12 5.12 Blank RBRVS

27842 Blank CLTX ANKLE DISLC REQ ANES W/WO PRQ SKEL FIXJ Surgery Blank 6.46 6.52 6.52 Blank RBRVS

27846 Blank OPTX ANKLE DISLOCATION W/O REPAIR/INTERNAL FIXJ Surgery Blank 10.28 8.61 8.61 Blank RBRVS

27848 Blank OPTX ANKLE DISLOCATION W/REPAIR/INT/XTRNL FIXJ Surgery Blank 11.68 9.28 9.28 Blank RBRVS

27860 Blank MANIPULATION ANKLE UNDER GENERAL ANESTHESIA Surgery Blank 2.39 2.24 2.24 Blank RBRVS

27870 Blank ARTHRODESIS ANKLE OPEN Surgery Blank 15.41 11.56 11.56 Blank RBRVS

27871 Blank ARTHRODESIS TIBIOFIBULAR JOINT PROXIMAL/DISTAL Surgery Blank 9.54 8.42 8.42 Blank RBRVS

27880 Blank AMPUTATION LEG THROUGH TIBIA&FIBULA Surgery Blank 15.37 7.70 7.70 Blank RBRVS

27881 Blank AMP LEG THRU TIBFIB W/IMMT FITG TQ W/1ST CST Surgery Blank 13.47 8.67 8.67 Blank RBRVS

27882 Blank AMPUTATION LEG THRU TIBIA&FIBULA OPEN CIRCULAR Surgery Blank 9.79 5.35 5.35 Blank RBRVS

27884 Blank AMP LEG THRU TIBIA&FIBULA SEC CLOSURE/SCAR REV Surgery Blank 8.76 5.84 5.84 Blank RBRVS

27886 Blank AMP LEG THRU TIBIA&FIBULA RE-AMPUTATION Surgery Blank 10.02 6.76 6.76 Blank RBRVS

27888 Blank AMP ANKLE-MALLI TIBFIB W/PLSTC CLSR&RESCJ NRV Surgery Blank 10.37 7.13 7.13 Blank RBRVS

27889 Blank ANKLE DISARTICULATION Surgery Blank 10.86 5.51 5.51 Blank RBRVS

27892 Blank DCMPRN FASCT LEG ANT&/LAT W/DBRDMT MUSC&/NERVE Surgery Blank 7.94 6.65 6.65 Blank RBRVS

27893 Blank DCMPRN FASCT LEG PST W/DBRDMT MUSC&/NRV Surgery Blank 7.90 8.05 8.05 Blank RBRVS

27894 Blank DCMPRN FASCT LEG ANT&/LAT&PST W/DBRDMT MUS Surgery Blank 12.67 8.98 8.98 Blank RBRVS

27899 Blank UNLISTED PROCEDURE LEG/ANKLE Surgery Blank Blank Blank Blank 17.00 Unlisted

28001 Blank INCISION&DRAINAGE BURSA FOOT Surgery Blank 2.78 1.85 4.96 Blank RBRVS

28002 Blank I&D BELOW FASCIA FOOT 1 BURSAL SPACE Surgery Blank 5.34 3.28 6.87 Blank RBRVS

28003 Blank I&D BELOW FASCIA FOOT MULTIPLE AREAS Surgery Blank 9.06 6.15 10.22 Blank RBRVS

28005 Blank INCISION BONE CORTEX FOOT Surgery Blank 9.44 6.23 6.23 Blank RBRVS

28008 Blank FASCIOTOMY FOOT&/TOE Surgery Blank 4.59 3.47 7.52 Blank RBRVS

28010 Blank TENOTOMY PERCUTANEOUS TOE SINGLE TENDON Surgery Blank 2.97 2.78 3.45 Blank RBRVS

28011 Blank TENOTOMY PERCUTANEOUS TOE MULTIPLE TENDON Surgery Blank 4.28 3.54 4.52 Blank RBRVS

28020 Blank ARTHRT W/EXPL DRG/RMVL LOOSE/FB NTRTRSL/TARS JT Surgery Blank 5.15 4.62 9.83 Blank RBRVS

28022 Blank ARTHRT W/EXPL DRG/RMVL LOOSE/FB MTTARPHLNGL JT Surgery Blank 4.81 3.99 8.70 Blank RBRVS

28024 Blank ARTHRT W/EXPL DRG/RMVL LOOSE/FB IPHAL JT Surgery Blank 4.52 3.79 8.32 Blank RBRVS

28035 Blank RELEASE TARSAL TUNNEL Surgery Blank 5.23 4.42 9.46 Blank RBRVS

28039 Blank EXCISION TUMOR SOFT TIS FOOT/TOE SUBQ 1.5 CM/> Surgery Blank 5.42 3.97 8.57 Blank RBRVS

28041 Blank EXC TUMOR SOFT TISSUE FOOT/TOE SUBFASC 1.5 CM/> Surgery Blank 7.13 5.21 5.21 Blank RBRVS

28043 Blank EXCISION TUMOR SOFT TISSUE FOOT/TOE SUBQ <1.5CM Surgery Blank 3.96 3.26 7.28 Blank RBRVS

28045 Blank EXC TUMOR SOFT TISSUE FOOT/TOE SUBFASC <1.5CM Surgery Blank 5.45 4.10 8.43 Blank RBRVS

28046 Blank RAD RESECTION TUMOR SOFT TISSUE FOOT/TOE <3CM Surgery Blank 12.38 7.27 7.27 Blank RBRVS

28047 Blank RAD RESECTION TUMOR SOFT TISSUE FOOT/TOE 3 CM/> Surgery Blank 17.45 10.30 10.30 Blank RBRVS

28050 Blank ARTHRT W/BX INTERTARSAL/TARSOMETATARSAL JOINT Surgery Blank 4.39 3.36 7.57 Blank RBRVS

28052 Blank ARTHRTOMY W/BX METATARSOPHALANGEAL JOINT Surgery Blank 4.06 3.74 8.49 Blank RBRVS

28054 Blank ARTHRTOMY W/BX INTERPHALANGEAL JOINT Surgery Blank 3.57 2.95 7.03 Blank RBRVS

28055 Blank NEURECTOMY INTRINSIC MUSCULATURE OF FOOT Surgery Blank 6.29 4.12 4.12 Blank RBRVS

28060 Blank FASCIECTOMY PLANTAR FASCIA PARTIAL SPX Surgery Blank 5.40 4.34 9.07 Blank RBRVS

28062 Blank FASCIOTOMY PLANTAR FASCIA RADICAL SPX Surgery Blank 6.69 4.46 9.68 Blank RBRVS

28070 Blank SYNVCT INTERTARSAL/TARSOMETATARSAL JT EA SPX Surgery Blank 5.24 4.51 9.75 Blank RBRVS

28072 Blank SYNOVECTOMY METATARSOPHALANGEAL JOINT EACH Surgery Blank 4.72 4.24 9.33 Blank RBRVS

28080 Blank EXCISION INTERDIGITAL MORTON NEUROMA SINGLE EACH Surgery Blank 4.86 5.24 9.85 Blank RBRVS

28086 Blank SYNOVECTOMY TENDON SHEATH FOOT FLEXOR Surgery Blank 4.92 4.76 10.18 Blank RBRVS

28088 Blank SYNOVECTOMY TENDON SHEATH FOOT EXTENSOR Surgery Blank 3.98 3.72 8.53 Blank RBRVS

28090 Blank EXC LESION TENDON SHEATH/CAPSULE W/SYNVCT FOOT Surgery Blank 4.55 3.86 8.61 Blank RBRVS

28092 Blank EXC LESION TENDON SHEATH/CAPSULE W/SYNVCT TOE EA Surgery Blank 3.78 3.61 8.14 Blank RBRVS

28100 Blank EXCISION/CURETTAGE CYST/TUMOR TALUS/CALCANEUS Surgery Blank 5.83 5.37 11.12 Blank RBRVS

28102 Blank EXC/CURTG CST/B9 TUM TALUS/CLCNS W/ILIAC/AGRFT Surgery Blank 7.92 7.94 7.94 Blank RBRVS

28103 Blank EXC/CURETTAGE CYST/TUMOR TALUS/CALCANEUS ALGRFT Surgery Blank 6.67 4.12 4.12 Blank RBRVS

28104 Blank EXC/CURTG BONE CYST/B9 TUMORTARSAL/METATARSAL Surgery Blank 5.26 4.35 9.46 Blank RBRVS

28106 Blank EXC/CURTG CST/B9 TUM TARSAL/METAR W/ILIAC/AGRFT Surgery Blank 7.35 4.46 4.46 Blank RBRVS

28107 Blank EXC/CURTG CST/B9 TUM TARSAL/METAR W/ALGRFT Surgery Blank 5.73 3.89 8.78 Blank RBRVS

28108 Blank EXC/CURTG CST/B9 TUM PHALANGES FOOT Surgery Blank 4.30 3.63 8.07 Blank RBRVS

28110 Blank OSTECTOMY PRTL 5TH METAR HEAD SPX Surgery Blank 4.22 3.72 8.82 Blank RBRVS

28111 Blank OSTECTOMY COMPLETE 1ST METATARSAL HEAD Surgery Blank 5.15 3.66 8.52 Blank RBRVS

28112 Blank OSTECTOMY COMPLETE OTHER METATARSAL HEAD 2/3/4 Surgery Blank 4.63 3.88 9.02 Blank RBRVS

28113 Blank OSTECTOMY COMPLETE 5TH METATARSAL HEAD Surgery Blank 6.11 5.53 10.39 Blank RBRVS

28114 Blank OSTC COMPL ALL METAR HEADS W/PRTL PROX PHALANGC Surgery Blank 12.00 10.54 17.46 Blank RBRVS





PAGE 26 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

28116 Blank OSTECTOMY TARSAL COALITION Surgery Blank 9.14 6.61 12.20 Blank RBRVS

28118 Blank OSTECTOMY CALCANEUS Surgery Blank 6.13 5.06 10.38 Blank RBRVS

28119 Blank OSTECTOMY CALCANEUS SPUR W/WO PLNTAR FASCIAL RLS Surgery Blank 5.56 4.29 9.10 Blank RBRVS

28120 Blank PARTIAL EXCISION BONE TALUS/CALCANEUS Surgery Blank 7.31 6.09 11.34 Blank RBRVS

28122 Blank PRTL EXC B1 TARSAL/METAR B1 XCP TALUS/CALCANEUS Surgery Blank 6.76 5.24 9.89 Blank RBRVS

28124 Blank PARTICAL EXCISION BONE PHALANX TOE Surgery Blank 5.00 4.11 8.42 Blank RBRVS

28126 Blank RESECTION PARTIAL/COMPLETE PHALANGEAL BASE EACH Surgery Blank 3.64 3.20 7.50 Blank RBRVS

28130 Blank TALECTOMY ASTRAGALECTOMY Surgery Blank 9.50 9.59 9.59 Blank RBRVS

28140 Blank METATARSECTOMY Surgery Blank 7.14 4.65 9.24 Blank RBRVS

28150 Blank PHALANGECTOMY TOE EACH TOE Surgery Blank 4.23 3.43 7.66 Blank RBRVS

28153 Blank RESECTION CONDYLE DISTAL END PHALANX EACH TOE Surgery Blank 3.80 3.49 7.82 Blank RBRVS

28160 Blank HEMIPHALANGECTOMY/INTERPHALANGEAL JOINT EXC TOE Surgery Blank 3.88 3.49 7.86 Blank RBRVS

28171 Blank RAD RESCJ TUMOR TARSAL EXCEPT TALUS/CALCANEUS Surgery Blank 16.41 12.50 12.50 Blank RBRVS

28173 Blank RADICAL RESECTION TUMOR METATARSAL Surgery Blank 14.16 6.57 6.57 Blank RBRVS

28175 Blank RADICAL RESECTION TUMOR PHALANX OR TOE Surgery Blank 8.29 4.87 4.87 Blank RBRVS

28190 Blank REMOVAL FOREIGN BODY FOOT SUBCUTANEOUS Surgery Blank 2.01 1.67 5.28 Blank RBRVS

28192 Blank REMOVAL FOREIGN BODY FOOT DEEP Surgery Blank 4.78 3.78 8.32 Blank RBRVS

28193 Blank REMOVAL FOREIGN BODY FOOT COMPLICATED Surgery Blank 5.90 4.20 8.95 Blank RBRVS

28200 Blank RPR TDN FLXR FOOT 1/2 W/O FREE GRAFG EACH TENDON Surgery Blank 4.74 4.07 9.04 Blank RBRVS

28202 Blank RPR TENDON FLXR FOOT SEC W/FREE GRAFT EA TENDON Surgery Blank 7.07 4.63 9.66 Blank RBRVS

28208 Blank REPAIR TENDON EXTENSOR FOOT 1/2 EACH TENDON Surgery Blank 4.51 4.07 8.89 Blank RBRVS

28210 Blank RPR TENDON XTNSR FOOT SEC W/FREE GRAFT EA TENDON Surgery Blank 6.52 4.87 9.87 Blank RBRVS

28220 Blank TENOLYSIS FLEXOR FOOT SINGLE TENDON Surgery Blank 4.67 3.63 7.98 Blank RBRVS

28222 Blank TENOLYSIS FLEXOR FOOT MULTIPLE TENDONS Surgery Blank 5.76 3.88 8.53 Blank RBRVS

28225 Blank TENOLYSIS EXTENSOR FOOT SINGLE TENDON Surgery Blank 3.78 3.39 7.83 Blank RBRVS

28226 Blank TENOLYSIS EXTENSOR FOOT MULTIPLE TENDON Surgery Blank 4.67 5.73 12.08 Blank RBRVS

28230 Blank TX OPN TENDON FLEXOR FOOT SINGLE/MULT TENDON SPX Surgery Blank 4.36 3.42 7.85 Blank RBRVS

28232 Blank TX OPEN TENDON FLEXOR TOE 1 TENDON SPX Surgery Blank 3.51 3.18 7.39 Blank RBRVS

28234 Blank TENOTOMY OPEN EXTENSOR FOOT/TOE EACH TENDON Surgery Blank 3.54 3.70 7.92 Blank RBRVS

28238 Blank RCNSTJ PST TIBL TDN W/EXC ACCESSORY TARSL NAVCLR Surgery Blank 7.96 5.25 10.63 Blank RBRVS

28240 Blank TENOTOMY LENGTHENING/RLS ABDUCTOR HALLUCIS MUSC Surgery Blank 4.48 3.73 8.39 Blank RBRVS

28250 Blank DIVISION PLANTAR FASCIA & MUSCLE SPX Surgery Blank 6.06 4.87 10.03 Blank RBRVS

28260 Blank CAPSULOTOMY MIDFOOT MEDIAL RELEASE ONLY SPX Surgery Blank 8.19 5.59 10.76 Blank RBRVS

28261 Blank CAPSULOTOMY MIDFOOT W/TENDON LENGTHENING Surgery Blank 13.11 8.44 14.74 Blank RBRVS

28262 Blank CAPSUL MIDFOOT W/PST TALOTIBL CAPSUL&TDN LNGTH Surgery Blank 17.21 13.54 21.96 Blank RBRVS

28264 Blank CAPSULOTOMY MIDTARSAL Surgery Blank 10.65 9.36 16.39 Blank RBRVS

28270 Blank CAPSUL MTTARPHLNGL JT W/WO TENORRHAPHY EA JT SPX Surgery Blank 4.93 4.23 8.87 Blank RBRVS

28272 Blank CAPSULOTOMY IPHAL JOINT EACH JOINT SPX Surgery Blank 3.92 3.09 7.18 Blank RBRVS

28280 Blank SYNDACTYLIZATION TOES Surgery Blank 5.33 4.19 9.10 Blank RBRVS

28285 Blank CORRECTION HAMMERTOE Surgery Blank 5.62 4.74 9.35 Blank RBRVS

28286 Blank CORRECTION COCK-UP 5TH TOE W/PLASTIC CLOSURE Surgery Blank 4.70 3.55 8.01 Blank RBRVS

28288 Blank OSTC PRTL EXOSTC/CONDYLC METAR HEAD Surgery Blank 6.02 5.74 10.86 Blank RBRVS

28289 Blank HALLUX RIGIDUS CORRECT W/CHEILECTOMY 1ST MP JT Surgery Blank 6.90 5.67 13.87 Blank RBRVS

28291 Blank CORRJ HALUX RIGDUS W/IMPLT Surgery Blank 8.01 5.06 12.41 Blank RBRVS

28292 Blank KELLER/MCBRIDE/MAYO PROCEDURE Surgery Blank 7.44 5.87 13.61 Blank RBRVS

28295 Blank CORRECTION HALLUX VALGUS Surgery Blank 8.57 6.12 17.86 Blank RBRVS

28296 Blank CORRJ HALLUX VALGUS W/WO SESMDC W/METAR OSTEOT Surgery Blank 8.25 5.87 17.40 Blank RBRVS

28297 Blank CORRJ HALLUX VALGUS W/WO SESMDC LAPIDUS-TYP PX Surgery Blank 9.29 6.97 19.91 Blank RBRVS

28298 Blank CORRJ HALLUX VALGUS W/WO SESMDC PHALANX OSTEOT Surgery Blank 7.75 5.76 16.14 Blank RBRVS

28299 Blank CORRJ HALLUX VALGUS W/WO SESMDC 2 OSTEOT Surgery Blank 9.29 6.54 18.93 Blank RBRVS

28300 Blank OSTEOTOMY CALCANEUS W/WO INTERNAL FIXATION Surgery Blank 9.73 7.52 7.52 Blank RBRVS

28302 Blank OSTEOTOMY TALUS Surgery Blank 9.74 8.91 8.91 Blank RBRVS

28304 Blank OSTEOTOMY TARSAL BONES OTH/THN CALCANEUS/TALUS Surgery Blank 9.41 6.82 13.25 Blank RBRVS

28305 Blank OSTEOT TARSAL OTH/THN CALCANEUS/TALUS W/AGRFT Surgery Blank 10.77 7.17 7.17 Blank RBRVS

28306 Blank OSTEOT W/WO LNGTH SHRT/CORRJ 1ST METAR Surgery Blank 6.00 4.90 11.05 Blank RBRVS

28307 Blank OSTEOT W/WO LNGTH SHRT/CORRJ METAR XCP 1ST TOE Surgery Blank 6.50 5.07 11.44 Blank RBRVS

28308 Blank OSTEOT W/WO LNGTH SHRT/CORRJ METAR XCP 1ST EA Surgery Blank 5.48 4.82 10.36 Blank RBRVS

28309 Blank OSTEOT W/WO LNGTH SHRT/ANGULAR CORRJ METAR MLT Surgery Blank 14.16 9.58 9.58 Blank RBRVS

28310 Blank OSTEOT SHRT CORRJ PROX PHALANX 1ST TOE Surgery Blank 5.57 4.18 9.71 Blank RBRVS

28312 Blank OSTEOT SHRT CORRJ OTH PHALANGES ANY TOE Surgery Blank 4.69 3.97 9.49 Blank RBRVS

28313 Blank RCNSTJ ANGULAR DFRM TOE SOFT TISS PX ONLY Surgery Blank 5.15 4.45 9.35 Blank RBRVS

28315 Blank SESAMOIDECTOMY FIRST TOE SPX Surgery Blank 5.00 3.92 8.51 Blank RBRVS

28320 Blank REPAIR NONUNION/MALUNION TARSAL BONES Surgery Blank 9.37 6.90 6.90 Blank RBRVS

28322 Blank RPR NON/MALUNION METARSAL W/WO BONE GRAFT Surgery Blank 8.53 6.86 13.04 Blank RBRVS

28340 Blank RCNSTJ TOE MACRODACTYLY SOFT TISSUE RESECTION Surgery Blank 7.15 4.24 9.08 Blank RBRVS

28341 Blank RCNSTJ TOE MACRODACTYLY REQUIRING BONE RESECTION Surgery Blank 8.72 4.82 10.07 Blank RBRVS

28344 Blank RECONSTRUCTION TOE POLYDACTYLY Surgery Blank 4.40 3.62 8.36 Blank RBRVS

28345 Blank RCNSTJ TOE SYNDACTYLY W/WO SKIN GRAFT EACH WEB Surgery Blank 6.09 3.98 8.59 Blank RBRVS

28360 Blank RECONSTRUCTION CLEFT FOOT Surgery Blank 14.92 13.35 13.35 Blank RBRVS

28400 Blank CLOSED TX CALCANEAL FRACTURE W/O MANIPULATION Surgery Blank 2.31 3.86 4.50 Blank RBRVS

28405 Blank CLOSED TX CALCANEAL FRACTURE W/MANIPULATION Surgery Blank 4.74 4.77 5.83 Blank RBRVS

28406 Blank PRQ SKELETAL FIXJ CALCANEAL FRACTURE W/MANJ Surgery Blank 6.56 7.27 7.27 Blank RBRVS





PAGE 27 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

28415 Blank OPEN TREATMENT CALCANEAL FRACTURE Surgery Blank 16.19 13.36 13.36 Blank RBRVS

28420 Blank OPEN TREATMENT CALCANEAL FRACTURE W BONE GRAFT Surgery Blank 17.52 15.44 15.44 Blank RBRVS

28430 Blank CLOSED TX TALUS FRACTURE W/O MANIPULATION Surgery Blank 2.22 3.45 4.23 Blank RBRVS

28435 Blank CLOSED TX TALUS FRACTURE W/MANIPULATION Surgery Blank 3.54 5.01 6.15 Blank RBRVS

28436 Blank PRQ SKELETAL FIXATION TALUS FRACTURE W/MANJ Surgery Blank 4.90 7.05 7.05 Blank RBRVS

28445 Blank OPEN TREATMENT TALUS FRACTURE Surgery Blank 15.76 12.00 12.00 Blank RBRVS

28446 Blank OPEN OSTEOCHONDRAL AUTOGRAFT TALUS Surgery Blank 17.71 14.06 14.06 Blank RBRVS

28450 Blank TX TARSAL BONE FX XCP TALUS&CALCN W/O MANJ Surgery Blank 2.03 3.18 3.88 Blank RBRVS

28455 Blank TX TARSAL BONE FX XCP TALUS&CALCN W/MANJ Surgery Blank 3.24 3.81 4.67 Blank RBRVS

28456 Blank PRQ SKEL FIXJ TARSL FX XCP TALUS&CALCNS W/MANJ Surgery Blank 2.86 5.76 5.76 Blank RBRVS

28465 Blank OPEN TX TARSAL FRACTURE XCP TALUS & CALCANEUS EA Surgery Blank 8.80 8.11 8.11 Blank RBRVS

28470 Blank CLOSED TX METATARSAL FRACTURE W/O MANIPULATION Surgery Blank 2.03 3.53 3.98 Blank RBRVS

28475 Blank CLTX METAR FX W/MANJ Surgery Blank 3.01 3.12 3.96 Blank RBRVS

28476 Blank PRQ SKEL FIXJ METAR FX W/MANJ Surgery Blank 3.60 5.90 5.90 Blank RBRVS

28485 Blank OPEN TREATMENT METATARSAL FRACTURE EACH Surgery Blank 7.44 7.25 7.25 Blank RBRVS

28490 Blank CLTX FX GRT TOE PHLX/PHLG W/O MANJ Surgery Blank 1.17 2.27 2.89 Blank RBRVS

28495 Blank CLTX FX GRT TOE PHLX/PHLG W/MANJ Surgery Blank 1.68 2.42 3.26 Blank RBRVS

28496 Blank PRQ SKEL FIXJ FX GRT TOE PHLX/PHLG W/MANJ Surgery Blank 2.48 4.12 10.37 Blank RBRVS

28505 Blank OPEN TX FRACTURE GREAT TOE/PHALANX/PHALANGES Surgery Blank 7.44 6.05 10.95 Blank RBRVS

28510 Blank CLTX FX PHLX/PHLG OTH/THN GRT TOE W/O MANJ Surgery Blank 1.17 2.14 2.27 Blank RBRVS

28515 Blank CLTX FX PHLX/PHLG OTH/THN GRT TOE W/MANJ Surgery Blank 1.56 2.36 2.94 Blank RBRVS

28525 Blank OPEN TX FRACTURE PHALANX/PHALANGES NOT GREAT TOE Surgery Blank 5.62 5.23 10.18 Blank RBRVS

28530 Blank CLOSED TREATMENT SESAMOID FRACTURE Surgery Blank 1.11 1.75 2.13 Blank RBRVS

28531 Blank OPEN TX SESAMOID FRACTURE W/WO INTERNAL FIXATION Surgery Blank 2.57 2.49 7.16 Blank RBRVS

28540 Blank CLTX TARSAL DISLC OTH/THN TALOTARSAL W/O ANES Surgery Blank 2.19 2.65 3.18 Blank RBRVS

28545 Blank CLTX TARSAL DISLC OTH/THN TALOTARSAL W/ANES Surgery Blank 2.60 4.43 5.44 Blank RBRVS

28546 Blank PRQ SKEL FIXJ TARSL DISLC XCP TALOTARSAL W/MANJ Surgery Blank 3.40 5.70 12.63 Blank RBRVS

28555 Blank OPEN TREATMENT TARSAL BONE DISLOCATION Surgery Blank 9.65 7.89 13.99 Blank RBRVS

28570 Blank CLOSED TX TALOTARSAL JOINT DISLC W/O ANES Surgery Blank 1.76 3.39 4.40 Blank RBRVS

28575 Blank CLOSED TX TALOTARSAL JOINT DISLOCATION W/ANES Surgery Blank 3.49 5.31 6.35 Blank RBRVS

28576 Blank PRQ SKEL FIXJ TALOTARSAL JT DISLC W/MANJ Surgery Blank 4.60 5.88 5.88 Blank RBRVS

28585 Blank OPEN TREATMENT TALOTARSAL JOINT DISLOCATION Surgery Blank 11.13 7.23 12.69 Blank RBRVS

28600 Blank CLOSED TX TARSOMETATARSAL DISLOCATION W/O ANES Surgery Blank 2.02 3.07 3.98 Blank RBRVS

28605 Blank CLOSED TX TARSOMETATARSAL DISLOCATION W/ANES Surgery Blank 2.89 5.00 5.99 Blank RBRVS

28606 Blank PRQ SKEL FIXJ TARS JT DISLC W/MANJ Surgery Blank 5.09 5.59 5.59 Blank RBRVS

28615 Blank OPEN TREATMENT TARSOMETATARSAL JOINT DISLOCATION Surgery Blank 10.70 10.72 10.72 Blank RBRVS

28630 Blank CLTX METATARSOPHLNGL JT DISLC W/O ANES Surgery Blank 1.75 1.18 2.56 Blank RBRVS

28635 Blank CLTX METATARSOPHLNGL JT DISLC REQ ANES Surgery Blank 1.96 1.64 2.93 Blank RBRVS

28636 Blank PRQ SKEL FIXJ METATARSOPHLNGL JT DISLC W/MANJ Surgery Blank 2.77 2.74 6.08 Blank RBRVS

28645 Blank OPEN TX METATARSOPHALANGEAL JOINT DISLOCATION Surgery Blank 7.44 5.67 10.65 Blank RBRVS

28660 Blank CLTX INTERPHALANGEAL JOINT DISLOCATION W/O ANES Surgery Blank 1.28 1.09 1.89 Blank RBRVS

28665 Blank CLTX INTERPHALANGEAL JOINT DISLOCATION REQ ANES Surgery Blank 1.97 1.61 2.30 Blank RBRVS

28666 Blank PRQ SKEL FIXJ INTERPHALANGEAL JOINT DISLC W/MANJ Surgery Blank 2.66 2.32 2.32 Blank RBRVS

28675 Blank OPEN TREATMENT INTERPHALANGEAL JOINT DISLOCATION Surgery Blank 5.62 5.39 10.36 Blank RBRVS

28705 Blank ARTHRODESIS PANTALAR Surgery Blank 20.33 12.62 12.62 Blank RBRVS

28715 Blank ARTHRODESIS TRIPLE Surgery Blank 13.42 11.39 11.39 Blank RBRVS

28725 Blank ARTHRODESIS SUBTALAR Surgery Blank 11.22 9.42 9.42 Blank RBRVS

28730 Blank ARTHRD MIDTARSL/TARSOMETATARSAL MULT/TRANSVRS Surgery Blank 10.70 8.88 8.88 Blank RBRVS

28735 Blank ARTHRD MIDTARSL/TARS MLT/TRANSVRS W/OSTEOT Surgery Blank 12.23 8.63 8.63 Blank RBRVS

28737 Blank ARTHRD W/TDN LNGTH&ADVMNT TARSL NVCLR-CUNEIFOR Surgery Blank 11.03 7.66 7.66 Blank RBRVS

28740 Blank ARTHRODESIS MIDTARSOMETATARSAL SINGLE JOINT Surgery Blank 9.29 7.41 13.93 Blank RBRVS

28750 Blank ARTHRODESIS GREAT TOE METATARSOPHALANGEAL JOINT Surgery Blank 8.57 7.20 13.64 Blank RBRVS

28755 Blank ARTHRODESIS GREAT TOE INTERPHALANGEAL JOINT Surgery Blank 4.88 4.15 9.37 Blank RBRVS

28760 Blank ARTHRD W/XTNSR HALLUCIS LONGUS TR 1ST METAR NCK Surgery Blank 9.14 6.61 12.88 Blank RBRVS

28800 Blank AMPUTATION FOOT MIDTARSAL Surgery Blank 8.79 5.56 5.56 Blank RBRVS

28805 Blank AMPUTATION FOOT TRANSMETARSAL Surgery Blank 12.71 6.55 6.55 Blank RBRVS

28810 Blank AMPUTATION METATARSAL W/TOE SINGLE Surgery Blank 6.64 4.67 4.67 Blank RBRVS

28820 Blank AMPUTATION TOE METATARSOPHALANGEAL JOINT Surgery Blank 5.82 4.80 9.71 Blank RBRVS

28825 Blank AMPUTATION TOE INTERPHALANGEAL JOINT Surgery Blank 5.37 4.63 9.53 Blank RBRVS

28890 Blank ESWT HI NRG PHYS/QHP W/US GDN INVG PLNTAR FASCIA Surgery Blank 3.45 2.69 5.70 Blank RBRVS

28899 Blank UNLISTED PROCEDURE FOOT/TOES Surgery Blank Blank Blank Blank 10.76 Unlisted

29000 Blank APPLICATION HALO TYPE BODY CAST Surgery Blank 2.25 2.57 6.88 Blank RBRVS

29010 Blank APPLICATION RISSER JACKET LOCALIZER BODY ONLY Surgery Blank 2.06 2.18 5.39 Blank RBRVS

29015 Blank APPLICATION RISSER JACKET LOCALIZER BODY W/HEAD Surgery Blank 2.41 2.36 5.56 Blank RBRVS

29035 Blank APPLICATION BODY CAST SHOULDER HIPS Surgery Blank 1.77 2.04 5.24 Blank RBRVS

29040 Blank APPLICATION BODY CAST SHOULDER HIPS HEAD MINERVA Surgery Blank 2.22 2.36 5.77 Blank RBRVS

29044 Blank APPLICATION BODY CAST SHOULDER HIPS W/ONE THIGH Surgery Blank 2.12 2.31 5.72 Blank RBRVS

29046 Blank APPLICATION BODY CAST SHOULDER HIPS BOTH THIGHS Surgery Blank 2.41 2.56 6.17 Blank RBRVS

29049 Blank APPLICATION CAST FIGURE-OF-8 Surgery Blank 0.89 0.95 1.78 Blank RBRVS

29055 Blank APPLICATION CAST SHOULDER SPICA Surgery Blank 1.78 1.87 4.27 Blank RBRVS

29058 Blank APPLICATION CAST PLASTER VELPEAU Surgery Blank 1.31 1.16 2.00 Blank RBRVS

29065 Blank APPLICATION CAST SHOULDER HAND LONG ARM Surgery Blank 0.87 0.94 1.74 Blank RBRVS





PAGE 28 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

29075 Blank APPLICATION CAST ELBOW FINGER SHORT ARM Surgery Blank 0.77 0.89 1.59 Blank RBRVS

29085 Blank APPLICATION CAST HAND & LOWER FOREARM GAUNTLET Surgery Blank 0.87 0.93 1.73 Blank RBRVS

29086 Blank APPLICATION CAST FINGER Surgery Blank 0.62 0.79 1.59 Blank RBRVS

29105 Blank APPLICATION LONG ARM SPLINT SHOULDER HAND Surgery Blank 0.87 0.70 1.52 Blank RBRVS

29125 Blank APPLICATION SHORT ARM SPLINT FOREARM-HAND STATIC Surgery Blank 0.50 0.57 1.29 Blank RBRVS

29126 Blank APPLICATION SHORT ARM SPLINT DYNAMIC Surgery Blank 0.68 0.64 1.45 Blank RBRVS

29130 Blank APPLICATION FINGER SPLINT STATIC Surgery Blank 0.50 0.26 0.62 Blank RBRVS

29131 Blank APPLICATION FINGER SPLINT DYNAMIC Surgery Blank 0.55 0.35 0.87 Blank RBRVS

29200 Blank STRAPPING THORAX Surgery Blank 0.39 0.13 0.48 Blank RBRVS

29240 Blank STRAPPING SHOULDER Surgery Blank 0.39 0.13 0.45 Blank RBRVS

29260 Blank STRAPPING ELBOW/WRIST Surgery Blank 0.39 0.14 0.43 Blank RBRVS

29280 Blank STRAPPING HAND/FINGER Surgery Blank 0.39 0.16 0.44 Blank RBRVS

29305 Blank APPLICATION HIP SPICA CAST 1 LEG Surgery Blank 2.03 2.16 4.68 Blank RBRVS

29325 Blank APPL HIP SPICA CAST ONE&ONE-HALF SPICA/BOTH LEGS Surgery Blank 2.32 2.37 5.09 Blank RBRVS

29345 Blank APPLICATION LONG LEG CAST THIGH-TOE Surgery Blank 1.40 1.25 2.25 Blank RBRVS

29355 Blank APPLICATION LONG LEG CAST WALKER/AMBULATORY TYPE Surgery Blank 1.53 1.26 2.23 Blank RBRVS

29358 Blank APPLICATION LONG LEG CAST BRACE Surgery Blank 1.43 1.29 2.90 Blank RBRVS

29365 Blank APPLICATION CYLINDER CAST THIGH ANKLE Surgery Blank 1.18 1.13 2.13 Blank RBRVS

29405 Blank APPLICATION SHORT LEG CAST BELOW KNEE-TOE Surgery Blank 0.80 0.80 1.41 Blank RBRVS

29425 Blank APPLICATION SHORT LEG CAST WALKING/AMBULATORY Surgery Blank 0.80 0.72 1.34 Blank RBRVS

29435 Blank APPLICATION PATELLAR TENDON BEARING CAST Surgery Blank 1.18 1.02 2.00 Blank RBRVS

29440 Blank ADDING WALKER PREVIOUSLY APPLIED CAST Surgery Blank 0.57 0.22 0.64 Blank RBRVS

29445 Blank APPLICATION RIGID TOTAL CONTACT LEG CAST Surgery Blank 1.78 0.98 1.76 Blank RBRVS

29450 Blank APPL CLUBFOOT CAST MOLDING/MANJ LONG/SHORT LEG Surgery Blank 2.08 0.99 1.90 Blank RBRVS

29505 Blank APPLICATION LONG LEG SPLINT THIGH ANKLE/TOES Surgery Blank 0.69 0.67 1.66 Blank RBRVS

29515 Blank APPLICATION SHORT LEG SPLINT CALF FOOT Surgery Blank 0.73 0.61 1.24 Blank RBRVS

29520 Blank STRAPPING HIP Surgery Blank 0.39 0.14 0.53 Blank RBRVS

29530 Blank STRAPPING KNEE Surgery Blank 0.39 0.13 0.44 Blank RBRVS

29540 Blank STRAPPING ANKLE &/FOOT Surgery Blank 0.39 0.10 0.33 Blank RBRVS

29550 Blank STRAPPING TOES Surgery Blank 0.25 0.06 0.27 Blank RBRVS

29580 Blank STRAPPING UNNA BOOT Surgery Blank 0.55 0.21 1.13 Blank RBRVS

29581 Blank APPL MLTLAYR COMPRES LEG BELOW KNEE W/ANKLE FOOT Surgery Blank 0.60 0.18 1.80 Blank RBRVS

29584 Blank APPL MLTLAYR COMPRES SYS UPARM LWARM HAND&FING Surgery Blank 0.35 0.11 1.89 Blank RBRVS

29700 Blank REMOVAL/BIVALVING GAUNTLET BOOT/BODY CAST Surgery Blank 0.57 0.32 1.21 Blank RBRVS

29705 Blank REMOVAL/BIVALVING FULL ARM/FULL LEG CAST Surgery Blank 0.76 0.46 1.01 Blank RBRVS

29710 Blank RMVL/BIVALV SHO/HIP SPICA MINERVA/RISSER JACKET Surgery Blank 1.34 0.80 1.95 Blank RBRVS

29720 Blank REPAIR SPICA BODY CAST/JACKET Surgery Blank 0.68 0.46 1.63 Blank RBRVS

29730 Blank WINDOWING CAST Surgery Blank 0.75 0.41 0.95 Blank RBRVS

29740 Blank WEDGING CAST EXCEPT CLUBFOOT CASTS Surgery Blank 1.12 0.69 1.51 Blank RBRVS

29750 Blank WEDGING CLUBFOOT CAST Surgery Blank 1.26 0.75 1.58 Blank RBRVS

29799 Blank UNLISTED PROCEDURE CASTING/STRAPPING Surgery Blank Blank Blank Blank 1.57 Unlisted

29800 Blank ARTHRS TEMPOROMANDIBULR JT DX W/WO SYNVAL BX SPX Surgery Blank 6.84 6.98 6.98 Blank RBRVS

29804 Blank ARTHROSCOPY TEMPOROMANDIBULAR JOINT SURGICAL Surgery Blank 8.87 8.11 8.11 Blank RBRVS

29805 Blank ARTHROSCOPY SHOULDER DX W/WO SYNOVIAL BIOPSY SPX Surgery Blank 6.03 6.35 6.35 Blank RBRVS

29806 Blank ARTHROSCOPY SHOULDER SURGICAL CAPSULORRHAPHY Surgery Blank 15.14 12.43 12.43 Blank RBRVS

29807 Blank ARTHROSCOPY SHOULDER SURGICAL REPAIR SLAP LESION Surgery Blank 14.67 12.27 12.27 Blank RBRVS

29819 Blank ARTHROSCOPY SHOULDER SURGICAL REMOVAL LOOSE/FB Surgery Blank 7.79 7.49 7.49 Blank RBRVS

29820 Blank ARTHROSCOPY SHOULDER SURG SYNOVECTOMY PARTIAL Surgery Blank 7.21 6.92 6.92 Blank RBRVS

29821 Blank ARTHROSCOPY SHOULDER SURG SYNOVECTOMY COMPLETE Surgery Blank 7.89 7.61 7.61 Blank RBRVS

29822 Blank ARTHROSCOPY SHOULDER SURG DEBRIDEMENT LIMITED Surgery Blank 7.60 7.46 7.46 Blank RBRVS

29823 Blank ARTHROSCOPY SHOULDER SURG DEBRIDEMENT EXTENSIVE Surgery Blank 8.36 8.05 8.05 Blank RBRVS

29824 Blank ARTHROSCOPY SHOULDER DISTAL CLAVICULECTOMY Surgery Blank 8.98 8.73 8.73 Blank RBRVS

29825 Blank ARTHROSCOPY SHOULDER AHESIOLYSIS W/WO MANIPJ Surgery Blank 7.79 7.50 7.50 Blank RBRVS

29826 Blank ARTHROSCOPY SHOULDER W/CORACOACRM LIGMNT RELEASE Surgery Blank 3.00 1.51 1.51 Blank RBRVS

29827 Blank ARTHROSCOPY SHOULDER ROTATOR CUFF REPAIR Surgery Blank 15.59 12.26 12.26 Blank RBRVS

29828 Blank ARTHROSCOPY SHOULDER BICEPS TENODESIS Surgery Blank 13.16 10.82 10.82 Blank RBRVS

29830 Blank ARTHROSCOPY ELBOW DIAG W/WO SYNOVIAL BIOPSY SPX Surgery Blank 5.88 6.07 6.07 Blank RBRVS

29834 Blank ARTHROSCOPY ELBOW SURGICAL W/REMOVAL LOOSE/FB Surgery Blank 6.42 6.50 6.50 Blank RBRVS

29835 Blank ARTHROSCOPY ELBOW SURGICAL SYNOVECTOMY PARTIAL Surgery Blank 6.62 6.68 6.68 Blank RBRVS

29836 Blank ARTHROSCOPY ELBOW SURGICAL SYNOVECTOMY COMPLETE Surgery Blank 7.72 7.49 7.49 Blank RBRVS

29837 Blank ARTHROSCOPY ELBOW SURGICAL DEBRIDEMENT LIMITED Surgery Blank 7.01 6.87 6.87 Blank RBRVS

29838 Blank ARTHROSCOPY ELBOW SURGICAL DEBRIDEMENT EXTENSIVE Surgery Blank 7.88 7.61 7.61 Blank RBRVS

29840 Blank ARTHROSCOPY WRIST DIAG W/WO SYNOVIAL BIOPSY SPX Surgery Blank 5.68 6.18 6.18 Blank RBRVS

29843 Blank ARTHROSCOPY WRIST INFECTION LAVAGE&DRAINAGE Surgery Blank 6.15 6.55 6.55 Blank RBRVS

29844 Blank ARTHROSCOPY WRIST SURGICAL SYNOVECTOMY PARTIAL Surgery Blank 6.51 6.73 6.73 Blank RBRVS

29845 Blank ARTHROSCOPY WRIST SURGICAL SYNOVECTOMY COMPLETE Surgery Blank 7.69 7.64 7.64 Blank RBRVS

29846 Blank ARTHRS WRST EXC&/RPR TRIANG FIBROCART&/JOINT Surgery Blank 6.89 6.92 6.92 Blank RBRVS

29847 Blank ARTHROSCOPY WRIST SURG INT FIXJ FX/INSTABILITY Surgery Blank 7.22 6.98 6.98 Blank RBRVS

29848 Blank NDSC WRST SURG W/RLS TRANSVRS CARPL LIGM Surgery Blank 6.39 7.15 7.15 Blank RBRVS

29850 Blank ARTHROSCOPY AID TX SPINE&/FX KNEE W/O FIXJ Surgery Blank 8.27 8.05 8.05 Blank RBRVS

29851 Blank ARTHROSCOPY AID TX SPINE&/FX KNEE W/FIXJ Surgery Blank 13.26 10.97 10.97 Blank RBRVS

29855 Blank ARTHRS AID TIBIAL FRACTURE PROXIMAL UNICONDYLAR Surgery Blank 10.76 9.71 9.71 Blank RBRVS





PAGE 29 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

29856 Blank ARTHRS AID TIBIAL FX PROX UNICONDYLAR BICONDYLAR Surgery Blank 14.28 11.61 11.61 Blank RBRVS

29860 Blank ARTHROSCOPY HIP DIAGNOSTIC W/WO SYNOVIAL BYP SPX Surgery Blank 9.00 8.43 8.43 Blank RBRVS

29861 Blank ARTHROSCOPY HIP SURGICAL W/REMOVAL LOOSE/FB Surgery Blank 10.10 8.94 8.94 Blank RBRVS

29862 Blank ARTHRS HIP DEBRIDEMENT/SHAVING ARTICULAR CRTLG Surgery Blank 11.17 10.19 10.19 Blank RBRVS

29863 Blank ARTHROSCOPY HIP SURGICAL W/SYNOVECTOMY Surgery Blank 11.17 10.12 10.12 Blank RBRVS

29866 Blank ARTHROSCOPY KNEE OSTEOCHONDRAL AGRFT MOSAICPLAST Surgery Blank 14.67 12.66 12.66 Blank RBRVS

29867 Blank ARTHROSCOPY KNEE OSTEOCHONDRAL ALLOGRAFT Surgery Blank 18.39 14.83 14.83 Blank RBRVS

29868 Blank ARTHROSCOPY KNEE MENISCAL TRNSPLJ MED/LAT Surgery Blank 25.10 18.23 18.23 Blank RBRVS

29870 Blank ARTHROSCOPY KNEE DIAGNOSTIC W/WO SYNOVIAL BX SPX Surgery Blank 5.19 5.56 10.37 Blank RBRVS

29871 Blank ARTHROSCOPY KNEE INFECTION LAVAGE & DRAINAGE Surgery Blank 6.69 6.80 6.80 Blank RBRVS

29873 Blank ARTHROSCOPY KNEE LATERAL RELEASE Surgery Blank 6.24 7.62 7.62 Blank RBRVS

29874 Blank ARTHROSCOPY KNEE REMOVAL LOOSE/FOREIGN BODY Surgery Blank 7.19 6.87 6.87 Blank RBRVS

29875 Blank ARTHROSCOPY KNEE SYNOVECTOMY LIMITED SPX Surgery Blank 6.45 6.55 6.55 Blank RBRVS

29876 Blank ARTHROSCOPY KNEE SYNOVECTOMY 2/>COMPARTMENTS Surgery Blank 8.87 8.29 8.29 Blank RBRVS

29877 Blank ARTHRS KNEE DEBRIDEMENT/SHAVING ARTCLR CRTLG Surgery Blank 8.30 7.99 7.99 Blank RBRVS

29879 Blank ARTHRS KNEE ABRASION ARTHRP/MLT DRLG/MICROFX Surgery Blank 8.99 8.35 8.35 Blank RBRVS

29880 Blank ARTHRS KNEE W/MENISCECTOMY MED&LAT W/SHAVING Surgery Blank 7.39 7.38 7.38 Blank RBRVS

29881 Blank ARTHRS KNE SURG W/MENISCECTOMY MED/LAT W/SHVG Surgery Blank 7.03 7.20 7.20 Blank RBRVS

29882 Blank ARTHROSCOPY KNEE W/MENISCUS RPR MEDIAL/LATERAL Surgery Blank 9.60 8.64 8.64 Blank RBRVS

29883 Blank ARTHROSCOPY KNEE W/MENISCUS RPR MEDIAL&LATERAL Surgery Blank 11.77 10.20 10.20 Blank RBRVS

29884 Blank ARTHROSCOPY KNEE W/LYSIS ADHESIONS W/WO MANJ SPX Surgery Blank 8.28 7.95 7.95 Blank RBRVS

29885 Blank ARTHRS KNEE DRILL OSTEOCHONDRITIS DISSECANS GRFG Surgery Blank 10.21 9.46 9.46 Blank RBRVS

29886 Blank ARTHRS KNEE DRILLING OSTEOCHOND DISSECANS LESION Surgery Blank 8.49 8.17 8.17 Blank RBRVS

29887 Blank ARTHRS KNEE DRLG OSTEOCHOND DISSECANS INT FIXJ Surgery Blank 10.16 9.43 9.43 Blank RBRVS

29888 Blank ARTHRS AIDED ANT CRUCIATE LIGM RPR/AGMNTJ/RCNSTJ Surgery Blank 14.30 11.33 11.33 Blank RBRVS

29889 Blank ARTHRS AIDED PST CRUCIATE LIGM RPR/AGMNTJ/RCNSTJ Surgery Blank 17.41 14.41 14.41 Blank RBRVS

29891 Blank ARTHRS ANKLE EXC OSTCHNDRL DFCT W/DRLG DFCT Surgery Blank 9.67 8.17 8.17 Blank RBRVS

29892 Blank ARTHRS AID RPR LES/TALAR DOME FX/TIBL PLAFOND FX Surgery Blank 10.27 7.30 7.30 Blank RBRVS

29893 Blank ENDOSCOPIC PLANTAR FASCIOTOMY Surgery Blank 6.32 5.50 10.87 Blank RBRVS

29894 Blank ARTHROSCOPY ANKLE W/REMOVAL LOOSE/FOREIGN BODY Surgery Blank 7.35 5.75 5.75 Blank RBRVS

29895 Blank ARTHROSCOPY ANKLE SURGICAL SYNOVECTOMY PARTIAL Surgery Blank 7.13 5.45 5.45 Blank RBRVS

29897 Blank ARTHROSCOPY ANKLE SURGICAL DEBRIDEMENT LIMITED Surgery Blank 7.32 6.01 6.01 Blank RBRVS

29898 Blank ARTHROSCOPY ANKLE SURGICAL DEBRIDEMENT EXTENSIVE Surgery Blank 8.49 6.50 6.50 Blank RBRVS

29899 Blank ARTHROSCOPY ANKLE SURGICAL W/ANKLE ARTHRODESIS Surgery Blank 15.41 11.61 11.61 Blank RBRVS

29900 Blank ARTHROSCOPY METACARPOPHALANGEAL SYNOVIAL BIOPSY Surgery Blank 5.88 7.20 7.20 Blank RBRVS

29901 Blank ARTHRS METACARPOPHALANGEAL JOINT DEBRIDEMENT Surgery Blank 6.59 7.45 7.45 Blank RBRVS

29902 Blank ARTHRS MTCARPHLNGL JT W/RDCTJ UR COLTRL LIGM Surgery Blank 7.16 7.73 7.73 Blank RBRVS

29904 Blank ARTHRS SUBTALAR JOINT REMOVE LOOSE/FOREIGN BODY Surgery Blank 8.65 8.01 8.01 Blank RBRVS

29905 Blank ARTHROSCOPY SUBTALAR JOINT WITH SYNOVECTOMY Surgery Blank 9.18 6.03 6.03 Blank RBRVS

29906 Blank ARTHROSCOPY SUBTALAR JOINT WITH DEBRIDEMENT Surgery Blank 9.65 8.43 8.43 Blank RBRVS

29907 Blank ARTHROSCOPY SUBTALAR JOINT SUBTALAR ARTHRODESIS Surgery Blank 12.18 10.65 10.65 Blank RBRVS

29914 Blank ARTHROSCOPY HIP W/FEMOROPLASTY Surgery Blank 14.67 11.22 11.22 Blank RBRVS

29915 Blank ARTHROSCOPY HIP W/ACETABULOPLASTY Surgery Blank 15.00 11.59 11.59 Blank RBRVS

29916 Blank ARTHROSCOPY HIP W/LABRAL REPAIR Surgery Blank 15.00 11.75 11.75 Blank RBRVS

29999 Blank UNLISTED PROCEDURE ARTHROSCOPY Surgery Blank Blank Blank Blank 15.06 Unlisted

30000 Blank DRAINAGE ABSCESS/HEMATOMA NASAL INT APPROACH Surgery Blank 1.48 1.64 4.75 Blank RBRVS

30020 Blank DRAINAGE ABSCESS/HEMATOMA NASAL SEPTUM Surgery Blank 1.48 1.65 4.82 Blank RBRVS

30100 Blank BIOPSY INTRANASAL Surgery Blank 0.94 0.86 2.86 Blank RBRVS

30110 Blank EXCISION NASAL POLYP SIMPLE Surgery Blank 1.68 1.74 4.51 Blank RBRVS

30115 Blank EXCISION NASAL POLYP EXTENSIVE Surgery Blank 4.44 7.01 7.01 Blank RBRVS

30117 Blank EXCISION/DESTRUCTION INTRANASAL LESION INT APPR Surgery Blank 3.26 5.81 20.77 Blank RBRVS

30118 Blank EXCISION/DESTRUCTION INTRANASAL LESION XTRNL Surgery Blank 9.92 10.34 10.34 Blank RBRVS

30120 Blank EXCISION/SURGICAL PLANING SKIN NOSE RHINOPHYMA Surgery Blank 5.39 6.27 8.57 Blank RBRVS

30124 Blank EXCISION DERMOID CYST NOSE SIMPLE SUBCUTANEOUS Surgery Blank 3.20 4.32 4.32 Blank RBRVS

30125 Blank EXC DERMOID CYST NOSE COMPLEX UNDER BONE/CRTLG Surgery Blank 7.30 8.65 8.65 Blank RBRVS

30130 Blank EXCISION INFERIOR TURBINATE PARTIAL/COMPLETE Surgery Blank 3.47 6.72 6.72 Blank RBRVS

30140 Blank SUBMUCOUS RESCJ INFERIOR TURBINATE PRTL/COMPL Surgery Blank 3.00 1.68 4.37 Blank RBRVS

30150 Blank RHINECTOMY PARTIAL Surgery Blank 9.55 10.60 10.60 Blank RBRVS

30160 Blank RHINECTOMY TOTAL Surgery Blank 9.99 10.22 10.22 Blank RBRVS

30200 Blank INJECTION TURBINATE THERAPEUTIC Surgery Blank 0.78 0.77 2.26 Blank RBRVS

30210 Blank DISPLACEMENT THERAPY PROETZ TYPE Surgery Blank 1.13 1.50 2.92 Blank RBRVS

30220 Blank INSERTION NASAL SEPTAL PROSTHESIS BUTTON Surgery Blank 1.59 1.70 6.63 Blank RBRVS

30300 Blank REMOVAL FOREIGN BODY INTRANASAL OFFICE PROCEDURE Surgery Blank 1.09 1.77 3.79 Blank RBRVS

30310 Blank REMOVAL FOREIGN BODY INTRANASAL GENERAL ANES Surgery Blank 2.01 3.38 3.38 Blank RBRVS

30320 Blank RMVL FOREIGN BODY INTRANASAL LATERAL RHINOTOMY Surgery Blank 4.64 7.33 7.33 Blank RBRVS

30400 Blank RHINP PRIM LAT&ALAR CRTLGS&/ELVTN NASAL TI Surgery Blank 10.86 17.34 17.34 Blank RBRVS

30410 Blank RHINP PRIM COMPLETE XTRNL PARTS Surgery Blank 14.00 19.07 19.07 Blank RBRVS

30420 Blank RHINOPLASTY PRIMARY W/MAJOR SEPTAL REPAIR Surgery Blank 16.90 19.04 19.04 Blank RBRVS

30430 Blank RHINOPLASTY SECONDARY MINOR REVISION Surgery Blank 8.24 16.68 16.68 Blank RBRVS

30435 Blank RHINOPLASTY SECONDARY INTERMEDIATE REVISION Surgery Blank 12.73 18.25 18.25 Blank RBRVS

30450 Blank RHINOPLASTY SECONDARY MAJOR REVISION Surgery Blank 19.66 21.11 21.11 Blank RBRVS

30460 Blank RHINP DFRM W/COLUM LNGTH TIP ONLY Surgery Blank 10.32 11.25 11.25 Blank RBRVS





PAGE 30 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

30462 Blank RHINP DFRM COLUM LNGTH TIP SEPTUM OSTEOT Surgery Blank 20.28 21.02 21.02 Blank RBRVS

30465 Blank REPAIR NASAL VESTIBULAR STENOSIS Surgery Blank 12.36 13.31 13.31 Blank RBRVS

30520 Blank SEPTOPLASTY/SUBMUCOUS RESECJ W/WO CARTILAGE GRF Surgery Blank 7.01 9.42 9.42 Blank RBRVS

30540 Blank REPAIR CHOANAL ATRESIA INTRANASAL Surgery Blank 7.92 10.18 10.18 Blank RBRVS

30545 Blank REPAIR CHOANAL ATRESIA TRANSPALATINE Surgery Blank 11.62 13.05 13.05 Blank RBRVS

30560 Blank LYSIS INTRANASAL SYNECHIA Surgery Blank 1.31 2.34 5.98 Blank RBRVS

30580 Blank REPAIR FISTULA OROMAXILLARY Surgery Blank 6.88 6.51 10.45 Blank RBRVS

30600 Blank REPAIR FISTULA ORONASAL Surgery Blank 6.16 5.75 9.42 Blank RBRVS

30620 Blank SEPTAL/OTHER INTRANASAL DERMATOPLASTY Surgery Blank 6.16 10.40 10.40 Blank RBRVS

30630 Blank REPAIR NASAL SEPTAL PERFORATIONS Surgery Blank 7.29 9.09 9.09 Blank RBRVS

30801 Blank ABLTJ SOFT TIS INFERIOR TURBINATES UNI/BI SUPFC Surgery Blank 1.14 2.54 5.12 Blank RBRVS

30802 Blank ABLTJ SOF TISS INF TURBS UNI/BI SUPFC INTRAMURAL Surgery Blank 2.08 2.94 5.73 Blank RBRVS

30901 Blank CONTROL NASAL HEMORRHAGE ANTERIOR SIMPLE Surgery Blank 1.10 0.36 2.61 Blank RBRVS

30903 Blank CONTROL NASAL HEMORRHAGE ANTERIOR COMPLEX Surgery Blank 1.54 0.49 4.19 Blank RBRVS

30905 Blank CTRL NSL HEMRRG PST NASAL PACKS&/CAUTERY 1ST Surgery Blank 1.97 0.77 6.96 Blank RBRVS

30906 Blank CTRL NSL HEMRRG PST NASAL PACKS&/CAUTERY SUBSQ Surgery Blank 2.45 1.09 6.76 Blank RBRVS

30915 Blank LIGATION ARTERIES ETHMOIDAL Surgery Blank 7.44 7.61 7.61 Blank RBRVS

30920 Blank LIGATION ARTERIES INT MAXILLARY TRANSANTRAL Surgery Blank 11.14 10.64 10.64 Blank RBRVS

30930 Blank FRACTURE NASAL INFERIOR TURBINATE THERAPEUTIC Surgery Blank 1.31 1.97 1.97 Blank RBRVS

30999 Blank UNLISTED PROCEDURE NOSE Surgery Blank Blank Blank Blank 9.28 Unlisted

31000 Blank LAVAGE CANNULATION MAXILLARY SINUS Surgery Blank 1.20 1.62 3.78 Blank RBRVS

31002 Blank LAVAGE CANNULATION SPHENOID SINUS Surgery Blank 1.96 3.12 3.12 Blank RBRVS

31020 Blank SINUSOTOMY MAXILLARY ANTROTOMY INTRANASAL Surgery Blank 3.07 6.58 10.12 Blank RBRVS

31030 Blank SINUSOTOMY MAXILLARY RAD W/O RMVL ANTROCH POLYPS Surgery Blank 6.01 7.95 12.45 Blank RBRVS

31032 Blank SINUSOT MAX ANTRT RAD W/RMVL ANTROCH POLYPS Surgery Blank 6.69 8.46 8.46 Blank RBRVS

31040 Blank PTERYGOMAXILLARY FOSSA SURGERY ANY APPROACH Surgery Blank 9.77 10.28 10.28 Blank RBRVS

31050 Blank SINUSOTOMY SPHENOID W/WO BIOPSY Surgery Blank 5.37 7.41 7.41 Blank RBRVS

31051 Blank SINUSOT SPHENOID W/MUCOSAL STRIPPING/RMVL POLYP Surgery Blank 7.25 9.74 9.74 Blank RBRVS

31070 Blank SINUSOTOMY FRONTAL EXTERNAL SIMPLE Surgery Blank 4.40 7.23 7.23 Blank RBRVS

31075 Blank SINUSOTOMY FRONTAL TRANSORBITAL UNILATERAL Surgery Blank 9.51 10.98 10.98 Blank RBRVS

31080 Blank SINUSOTOMY FRNT OBLITERATIVE W/O FLAP BROW INC Surgery Blank 12.74 14.24 14.24 Blank RBRVS

31081 Blank SINUSOT FRNT OBLIT W/O OSTPL FLAP CORONAL INC Surgery Blank 14.19 18.23 18.23 Blank RBRVS

31084 Blank SINUSOT FRNT OBLIT W/OSTPL FLAP BROW INC Surgery Blank 14.95 15.16 15.16 Blank RBRVS

31085 Blank SINUSOT FRNT OBLIT W/OSTPL FLAP CORONAL INC Surgery Blank 15.64 18.89 18.89 Blank RBRVS

31086 Blank SINUSOT FRNT NONOBLIT W/OSTPL FLAP BROW INC Surgery Blank 14.36 14.91 14.91 Blank RBRVS

31087 Blank SINUSOT FRNT NONOBLIT W/OSTPL FLAP CORONAL INC Surgery Blank 14.57 13.60 13.60 Blank RBRVS

31090 Blank SINUSOT UNI 3/> PARANSL SINUSES Surgery Blank 11.17 16.06 16.06 Blank RBRVS

31200 Blank ETHMOIDECTOMY INTRANASAL ANTERIOR Surgery Blank 5.14 10.69 10.69 Blank RBRVS

31201 Blank ETHMOIDECTOMY INTRANASAL TOTAL Surgery Blank 8.60 11.05 11.05 Blank RBRVS

31205 Blank ETHMOIDECTOMY EXTRANASAL TOTAL Surgery Blank 10.58 14.16 14.16 Blank RBRVS

31225 Blank MAXILLECTOMY W/O ORBITAL EXENTERATION Surgery Blank 26.70 22.27 22.27 Blank RBRVS

31230 Blank MAXILLECTOMY W/ORBITAL EXENTERATION Surgery Blank 30.82 23.03 23.03 Blank RBRVS

31231 Blank NASAL ENDOSCOPY DIAGNOSTIC UNI/BI SPX Surgery Blank 1.10 0.59 4.70 Blank RBRVS

31233 Blank NASAL/SINUS ENDOSCOPY DX MAXILLARY SINUSOSCOPY Surgery Blank 2.18 1.37 4.84 Blank RBRVS

31235 Blank NASAL/SINUS ENDOSCOPY DX SPHENOID SINUSOSCOPY Surgery Blank 2.64 1.58 5.39 Blank RBRVS

31237 Blank NASAL/SINUS NDSC SURG W/BX POLYPECT/DBRDMT SPX Surgery Blank 2.60 1.59 4.46 Blank RBRVS

31238 Blank NASAL/SINUS NDSC SURG W/CONTROL NASAL HEMRRG Surgery Blank 2.74 1.65 4.29 Blank RBRVS

31239 Blank NASAL/SINUS NDSC SURG W/DACRYOCSTORHINOSTOMY Surgery Blank 9.04 7.59 7.59 Blank RBRVS

31240 Blank NASAL/SINUS NDSC SURG W/CONCHA BULLOSA RESECTION Surgery Blank 2.61 1.56 1.56 Blank RBRVS

31241 Blank NSL/SINS NDSC W/ARTERY LIG Surgery Blank 8.00 3.61 3.61 Blank RBRVS

31253 Blank NSL/SINS NDSC TOTAL Surgery Blank 9.00 4.08 4.08 Blank RBRVS

31254 Blank NASAL/SINUS ENDOSCOPY W/ETHMOIDECTOMY PARTIAL Surgery Blank 4.27 2.11 6.66 Blank RBRVS

31255 Blank NASAL/SINUS ENDOSCOPY W/ETHMOIDECTOMY TOTAL Surgery Blank 5.75 2.72 2.72 Blank RBRVS

31256 Blank NASAL/SINUS ENDOSCOPY W/MAXILLARY ANTROSTOMY Surgery Blank 3.11 1.61 1.61 Blank RBRVS

31257 Blank NSL/SINS NDSC TOT W/SPHENDT Surgery Blank 8.00 3.66 3.66 Blank RBRVS

31259 Blank NSL/SINS NDSC SPHN TISS RMVL Surgery Blank 8.48 3.87 3.87 Blank RBRVS

31267 Blank NSL/SINUS NDSC MAX ANTROST W/RMVL TISS MAX SINUS Surgery Blank 4.68 2.27 2.27 Blank RBRVS

31276 Blank NASAL/SINUS NDSC W/FRONTAL SINUS EXPLORATION Surgery Blank 6.75 3.14 3.14 Blank RBRVS

31287 Blank NASAL/SINUS ENDOSCOPY W/SPHENOIDOTOMY Surgery Blank 3.50 1.78 1.78 Blank RBRVS

31288 Blank NSL/SINUS NDSC SPHENDT RMVL TISS SPHENOID SINUS Surgery Blank 4.10 2.03 2.03 Blank RBRVS

31290 Blank NASAL/SINUS NDSC RPR CEREBRSP FLUID LEAK ETHMOID Surgery Blank 18.61 11.20 11.20 Blank RBRVS

31291 Blank NASAL/SINUS NDSC RPR CEREBSP FLUID LEAK SPHENOID Surgery Blank 19.56 11.94 11.94 Blank RBRVS

31292 Blank NSL/SINUS NDSC SURG W/MEDIAL/INF ORB WALL DCMPRN Surgery Blank 15.90 9.97 9.97 Blank RBRVS

31293 Blank NASAL/SINUS NDSC MEDIAL ORB&NF ORB WALL DCMPR Surgery Blank 17.47 10.58 10.58 Blank RBRVS

31294 Blank NASAL/SINUS NDSC SURG W/OPTIC NERVE DCMPRN Surgery Blank 20.31 11.78 11.78 Blank RBRVS

31295 Blank NASAL/SINUS NDSC SURG W/DILAT MAXILLARY SINUS Surgery Blank 2.70 1.44 53.99 Blank RBRVS

31296 Blank NASAL/SINUS NDSC SURG W/DILATION FRONTAL SINUS Surgery Blank 3.10 1.61 54.25 Blank RBRVS

31297 Blank NASAL/SINUS NDSC SURG W/DILATION SPHENOID SINUS Surgery Blank 2.44 1.33 53.89 Blank RBRVS

31298 Blank NSL/SINS NDSC W/SINS DILAT Surgery Blank 4.50 2.19 104.70 Blank RBRVS

31299 Blank UNLISTED PROCEDURE ACCESSORY SINUSES Surgery Blank Blank Blank Blank 5.57 Unlisted

31300 Blank LARYNGOTOMY W/RMVL TUMOR/LARYNGOCELE CORDECTOMY Surgery Blank 15.91 18.57 18.57 Blank RBRVS

31360 Blank LARYNGECTOMY TOTAL W/O RADICAL NECK DISSECTION Surgery Blank 29.91 25.47 25.47 Blank RBRVS





PAGE 31 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

31365 Blank LARYNGECTOMY TOTAL W/RADICAL NECK DISSECTION Surgery Blank 38.81 29.23 29.23 Blank RBRVS

31367 Blank LARYNGECTOMY STOT SUPRAGLOTTIC W/O RAD NECK DSJ Surgery Blank 30.57 28.23 28.23 Blank RBRVS

31368 Blank LARYNGECTOMY STOT SUPRAGLOTTIC W/RAD NCK DSJ Surgery Blank 34.19 31.13 31.13 Blank RBRVS

31370 Blank PARTIAL LARYNGECTOMY HEMILARYGECTOMY HORIZONTAL Surgery Blank 27.57 27.91 27.91 Blank RBRVS

31375 Blank PARTIAL LARYNGECTOMY HEMILARYNG LATEROVERTICAL Surgery Blank 26.07 26.53 26.53 Blank RBRVS

31380 Blank PARTIAL LARYNGECTOMY HEMILARYNG ANTEROVERTICAL Surgery Blank 25.57 26.32 26.32 Blank RBRVS

31382 Blank PARTIAL LARYNG HEMILARYNG ANTERO-LATERO-VERTICAL Surgery Blank 28.57 28.33 28.33 Blank RBRVS

31390 Blank PHARYNGOLARYNGECTOMY W/RAD NECK DSJ W/O RCNSTJ Surgery Blank 42.51 33.34 33.34 Blank RBRVS

31395 Blank PHARYNGOLARYNGECTOMY W/RAD NECK DSJ W/RCNSTJ Surgery Blank 43.80 36.65 36.65 Blank RBRVS

31400 Blank ARYTENOIDECTOMY/ARYTENOIDOPEXY XTRNL APPROACH Surgery Blank 11.60 14.66 14.66 Blank RBRVS

31420 Blank EPIGLOTTIDECTOMY Surgery Blank 11.43 10.36 10.36 Blank RBRVS

31500 Blank INTUBATION ENDOTRACHEAL EMERGENCY PROCEDURE Surgery Blank 3.00 0.71 0.71 Blank RBRVS

31502 Blank TRACHEOTOMY TUBE CHANGE PRIOR TO FISTULA TRACT Surgery Blank 0.65 0.27 0.27 Blank RBRVS

31505 Blank LARYNGOSCOPY INDIRECT DIAGNOSTIC SPX Surgery Blank 0.61 0.70 1.64 Blank RBRVS

31510 Blank LARYNGOSCOPY INDIRECT W/BIOPSY Surgery Blank 1.92 1.26 3.75 Blank RBRVS

31511 Blank LARYNGOSCOPY INDIRECT W/REMOVAL FOREIGN BODY Surgery Blank 2.16 1.27 3.50 Blank RBRVS

31512 Blank LARYNGOSCOPY INDIRECT W/REMOVAL LESION Surgery Blank 2.07 1.32 3.43 Blank RBRVS

31513 Blank LARYNGOSCOPY INDIRECT W/VOCAL CORD INJECTION Surgery Blank 2.10 1.34 1.34 Blank RBRVS

31515 Blank LARYNGOSCOPY W/WO TRACHEOSCOPY ASPIRATION Surgery Blank 1.80 1.11 3.74 Blank RBRVS

31520 Blank LARYNGOSCOPY W/WO TRACHEOSCOPY DX NEWBORN Surgery Blank 2.56 1.53 1.53 Blank RBRVS

31525 Blank LARYNGOSCOPY W/WO TRACHEOSCOPY DX EXCEPT NEWBORN Surgery Blank 2.63 1.56 4.11 Blank RBRVS

31526 Blank LARYNGOSCOPY W/WO TRACHEOSCOPY W/MICRO/TELESCOPE Surgery Blank 2.57 1.54 1.54 Blank RBRVS

31527 Blank LARYNGOSCOPY W/WO TRACHEOSCOPY INSERT OBTURATOR Surgery Blank 3.27 1.83 1.83 Blank RBRVS

31528 Blank LARYNGOSCOPY W/WO TRACHEOSCOPY W/DILATION IN Surgery Blank 2.37 1.40 1.40 Blank RBRVS

31529 Blank LARYNGOSCOPY W/WO TRACHEOSCOPY DILATION SUBSQ Surgery Blank 2.68 1.54 1.54 Blank RBRVS

31530 Blank LARYNGOSCOPY W/FOREIGN BODY REMOVAL Surgery Blank 3.38 1.82 1.82 Blank RBRVS

31531 Blank LARYNGOSCOPY FOREIGN BODY RMVL MICRO/TELESCOPE Surgery Blank 3.58 1.97 1.97 Blank RBRVS

31535 Blank LARYNGOSCOPY DIRECT OPERATIVE W/BIOPSY Surgery Blank 3.16 1.79 1.79 Blank RBRVS

31536 Blank LARYNGOSCOPY W/BIOPSY MICROSCOPE/TELESCOPE Surgery Blank 3.55 1.95 1.95 Blank RBRVS

31540 Blank LARYNGOSCOPY EXC TUM&/STRIPPING CORDS/EPIGLOTT Surgery Blank 4.12 2.18 2.18 Blank RBRVS

31541 Blank LARGSC EXC TUM&/STRPG CORDS/EPIGL MCRSCP/TLSCP Surgery Blank 4.52 2.35 2.35 Blank RBRVS

31545 Blank LARGSC MICRO/TELESCOPE RMVL LES VOCAL CORD FLAP Surgery Blank 6.30 3.14 3.14 Blank RBRVS

31546 Blank LARGSC MICRO/TELESCOPE RMVL LES VOCAL CORD GRAFT Surgery Blank 9.73 4.58 4.58 Blank RBRVS

31551 Blank LARYNGOPLASTY LARYNGEAL STEN Surgery Blank 21.50 16.57 16.57 Blank RBRVS




31560 Blank LARYNGOSCOPY DIRECT OPERATIVE W/ARYTENOIDECTOMY Surgery Blank 5.45 2.70 2.70 Blank RBRVS

31561 Blank LARGSC ARYTENOIDECTOMY MICROSCOPE/TELESCOPE Surgery Blank 5.99 2.92 2.92 Blank RBRVS

31570 Blank LARYNGOSCOPE INJECTION VOCAL CORD THERAPEUTIC Surgery Blank 3.86 2.10 5.07 Blank RBRVS

31571 Blank LARGSC W/NJX VOCAL CORD THER W/MICRO/TELESCOPE Surgery Blank 4.26 2.24 2.24 Blank RBRVS

31572 Blank LARGSC W/LASER DSTRJ LES Surgery Blank 3.01 1.71 10.56 Blank RBRVS

31573 Blank LARGSC W/THER INJECTION Surgery Blank 2.43 1.47 4.70 Blank RBRVS

31574 Blank LARGSC W/NJX AUGMENTATION Surgery Blank 2.43 1.47 26.03 Blank RBRVS

31575 Blank LARYNGOSCOPY FLEXIBLE FIBEROPTIC DIAGNOSTIC Surgery Blank 0.94 0.84 2.13 Blank RBRVS

31576 Blank LARYNGOSCOPY FLEXIBLE FIBEROPTIC W/BIOPSY Surgery Blank 1.89 1.23 5.34 Blank RBRVS

31577 Blank LARYNGOSCOPY FLX FIBEROPTIC RMVL FOREIGN BODY Surgery Blank 2.19 1.32 5.28 Blank RBRVS

31578 Blank LARYNGOSCOPY FLEXIBLE FIBEROPTIC REMOVAL LESION Surgery Blank 2.43 1.47 5.74 Blank RBRVS

31579 Blank LARYNGOSCOPY FLX/RGD FIBOPT W/STROBOSCOPY Surgery Blank 1.88 1.27 2.95 Blank RBRVS

31580 Blank LARYNGOPLASTY LARYN WEB 2 STG W/KEEL INSJ&RMVL Surgery Blank 14.60 18.65 18.65 Blank RBRVS

31584 Blank LARYNGOPLASTY W/OPEN REDUCTION FRACTURE Surgery Blank 17.58 19.06 19.06 Blank RBRVS

31587 Blank LARYNGOPLASTY CRICOID SPLIT Surgery Blank 15.27 15.23 15.23 Blank RBRVS

31590 Blank LARYNGEAL REINNERVATION NEUROMUSCULAR PEDICLE Surgery Blank 7.85 15.85 15.85 Blank RBRVS

31591 Blank LARYNGOPLASTY MEDIALIZATION Surgery Blank 13.56 14.09 14.09 Blank RBRVS

31592 Blank CRICOTRACHEAL RESECTION Surgery Blank 25.00 19.53 19.53 Blank RBRVS

31599 Blank UNLISTED PROCEDURE LARYNX Surgery Blank Blank Blank Blank 2.93 Unlisted

31600 Blank TRACHEOSTOMY PLANNED SEPARATE PROCEDURE Surgery Blank 5.56 2.68 2.68 Blank RBRVS

31601 Blank TRACHEOSTOMY PLANNED UNDER 2 YEARS SPX Surgery Blank 8.00 3.77 3.77 Blank RBRVS

31603 Blank TRACHEOSTOMY EMERGENCY PROCEDURE TRANSTRACHEAL Surgery Blank 6.00 2.25 2.25 Blank RBRVS

31605 Blank TRACHEOSTOMY EMERGENCY CRICOTHYROID MEMBRANE Surgery Blank 6.45 2.00 2.00 Blank RBRVS

31610 Blank TRACHEOSTOMY FENESTRATION W/SKIN FLAPS Surgery Blank 12.00 13.13 13.13 Blank RBRVS

31611 Blank CONSTJ TRACHEOESOPHGL FSTL&INSJ SP PROSTH Surgery Blank 6.00 8.28 8.28 Blank RBRVS

31612 Blank TRACHEAL PNXR PRQ W/TRANSTRACHEAL ASPIR&/NJX Surgery Blank 0.91 0.34 1.31 Blank RBRVS

31613 Blank TRACHEOSTOMA REVJ SMPL W/O FLAP ROTATION Surgery Blank 4.71 7.35 7.35 Blank RBRVS

31614 Blank TRACHEOSTOMA REVJ CPLX W/FLAP ROTATION Surgery Blank 8.63 11.30 11.30 Blank RBRVS

31615 Blank TRACHEOBRNCHSC THRU EST TRACHS INC Surgery Blank 1.84 1.19 2.67 Blank RBRVS

31622 Blank BRNCHSC INCL FLUOR GDNCE DX W/CELL WASHG SPX Surgery Blank 2.53 0.99 4.06 Blank RBRVS

31623 Blank BRNCHSC BRUSHING/PROTECTED BRUSHINGS Surgery Blank 2.63 1.01 4.90 Blank RBRVS

31624 Blank BRNCHSC W/BRNCL ALVEOLAR LAVAGE Surgery Blank 2.63 1.05 4.37 Blank RBRVS

31625 Blank BRONCHOSCOPY BRONCHIAL/ENDOBRNCL BX 1+ SITES Surgery Blank 3.11 1.13 6.07 Blank RBRVS

31626 Blank BRONCHOSCOPY W/PLMT FIDUCIAL MARKERS SINGLE/MULT Surgery Blank 3.91 1.40 19.76 Blank RBRVS

31627 Blank BRONCHOSCOPY W/CPTR-ASST IMAGE-GUIDED NAVIGATION Surgery Blank 2.00 0.60 37.70 Blank RBRVS





PAGE 32 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

31628 Blank BRONCHOSCOPY W/TRANSBRONCHIAL LUNG BX 1 LOBE Surgery Blank 3.55 1.25 6.21 Blank RBRVS

31629 Blank BRONCHOSCOPY NEEDLE BX TRACHEA MAIN STEM&/BRON Surgery Blank 3.75 1.32 8.32 Blank RBRVS

31630 Blank BRNCHSC W/TRACHEAL/BRONCHIAL DILAT/CLSD RDCTJ FX Surgery Blank 3.81 1.47 1.47 Blank RBRVS

31631 Blank BRONCHOSCOPY W/PLACEMENT TRACHEAL STENT Surgery Blank 4.36 1.66 1.66 Blank RBRVS

31632 Blank BRONCHOSCOPY W/TRANSBRONCHIAL LUNG BX EACH LOBE Surgery Blank 1.03 0.31 0.71 Blank RBRVS

31633 Blank BRONCHOSCOPY W/TRANSBRONCL NDL ASPIR BX EA LOBE Surgery Blank 1.32 0.40 0.86 Blank RBRVS

31634 Blank BRONCHOSCOPY BALLOON OCCLUSION Surgery Blank 3.75 1.41 46.67 Blank RBRVS

31635 Blank BRONCHOSCOPY W/REMOVAL FOREIGN BODY Surgery Blank 3.42 1.30 4.24 Blank RBRVS

31636 Blank BRNCHSC W/PLACEMENT BRNCL STENT 1ST BRONCHUS Surgery Blank 4.30 1.58 1.58 Blank RBRVS

31637 Blank BRONCHOSCOPY EACH MAJOR BRONCHUS STENTED Surgery Blank 1.58 0.44 0.44 Blank RBRVS

31638 Blank BRNCHSC REVJ TRACHEAL/BRNCL STENT INS PREV SESS Surgery Blank 4.88 1.77 1.77 Blank RBRVS

31640 Blank BRONCHOSCOPY W/EXCISION TUMOR Surgery Blank 4.93 1.78 1.78 Blank RBRVS

31641 Blank BRNCHSC W/DSTRJ TUM RELIEF STENOSIS OTH/THN EXC Surgery Blank 5.02 1.86 1.86 Blank RBRVS

31643 Blank BRNCHSC W/PLMT CATH INTRCV RADIOELMNT APPL Surgery Blank 3.49 1.32 1.32 Blank RBRVS

31645 Blank BRNCHSC W/THER ASPIR TRACHEOBRNCL TREE 1ST Surgery Blank 2.88 1.09 4.24 Blank RBRVS

31646 Blank BRNCHSC W/THER ASPIR TRACHEOBRNCL TREE SBSQ Surgery Blank 2.78 1.05 1.05 Blank RBRVS

31647 Blank BRNCHSC OCCLUSION&INSERT BRONCH VALVE INIT LOBE Surgery Blank 4.15 1.50 1.50 Blank RBRVS

31648 Blank BRNCHSC REMOVAL BRONCHIAL VALVE INITIAL Surgery Blank 3.95 1.38 1.38 Blank RBRVS

31649 Blank BRNCHSC REMOVAL BRONCHIAL VALVE EA ADDL Surgery Blank 1.44 0.40 0.40 Blank RBRVS

31651 Blank BRNCHSC OCCLUSION&INSERT BRONCH VALVE ADDL LOBE Surgery Blank 1.58 0.44 0.44 Blank RBRVS

31652 Blank BRNCHSC EBUS GUIDED SAMPL 1/2 NODE STATION/STRUX Surgery Blank 4.46 1.54 18.77 Blank RBRVS

31653 Blank BRNCHSC EBUS GUIDED SAMPL 3/> NODE STATION/STRUX Surgery Blank 4.96 1.69 19.57 Blank RBRVS

31654 Blank BRNSCHSC TNDSC EBUS DX/TX INTERVENTION PERPH LES Surgery Blank 1.40 0.43 2.06 Blank RBRVS

31660 Blank BRONCHOSCOPIC THERMOPLASTY ONE LOBE Surgery Blank 4.00 1.33 1.33 Blank RBRVS

31661 Blank BRONCHOSCOPIC THERMOPLASTY 2/> LOBES Surgery Blank 4.25 1.39 1.39 Blank RBRVS

31717 Blank CATHETERIZATION W/BRONCHIAL BRUSH BIOPSY Surgery Blank 2.12 0.89 5.36 Blank RBRVS

31720 Blank CATHETER ASPIRATION NASOTRACHEAL SPX Surgery Blank 1.06 0.29 0.29 Blank RBRVS

31725 Blank CATH ASPIR TRACHEOBRNCL FIBERSCOPE BEDSIDE SPX Surgery Blank 1.71 0.40 0.40 Blank RBRVS

31730 Blank TTRACH INTRO NDL WIRE DIL/STENT/TUBE O2 THER Surgery Blank 2.85 0.94 31.87 Blank RBRVS

31750 Blank TRACHEOPLASTY CERVICAL Surgery Blank 15.39 21.88 21.88 Blank RBRVS

31755 Blank TRACHEOPLASTY TRACHEOPHARYNGEAL FSTLJ EA STG Surgery Blank 17.54 30.15 30.15 Blank RBRVS

31760 Blank TRACHEOPLASTY INTRATHORACIC Surgery Blank 23.48 10.62 10.62 Blank RBRVS

31766 Blank CARINAL RECONSTRUCTION Surgery Blank 31.67 12.31 12.31 Blank RBRVS

31770 Blank BRONCHOPLASTY GRAFT REPAIR Surgery Blank 23.54 9.44 9.44 Blank RBRVS

31775 Blank BRONCHOPLASTY EXCISION STENOSIS & ANASTOMOSIS Surgery Blank 24.59 10.07 10.07 Blank RBRVS

31780 Blank EXCISION TRACHEAL STENOSIS&ANASTOMOSIS CERVICA Surgery Blank 19.84 11.30 11.30 Blank RBRVS

31781 Blank EXC TRACHEAL STENOSIS&ANAST CERVICOTHORACIC Surgery Blank 24.85 9.35 9.35 Blank RBRVS

31785 Blank EXCISION TRACHEAL TUMOR/CARCINOMA CERVICAL Surgery Blank 18.35 9.44 9.44 Blank RBRVS

31786 Blank EXCISION TRACHEAL TUMOR/CARCINOMA THORACIC Surgery Blank 25.42 10.30 10.30 Blank RBRVS

31800 Blank SUTURE TRACHEAL WOUND/INJURY CERVICAL Surgery Blank 8.18 11.35 11.35 Blank RBRVS

31805 Blank SUTURE TRACHEAL WOUND/INJURY INTRATHORACIC Surgery Blank 13.42 6.95 6.95 Blank RBRVS

31820 Blank SURG CLSR TRACHEOSTOMY/FISTULA W/O PLASTIC RPR Surgery Blank 4.64 3.93 6.90 Blank RBRVS

31825 Blank SURG CLSR TRACHEOSTOMY/FISTULA W/PLASTIC RPR Surgery Blank 7.07 5.45 8.82 Blank RBRVS

31830 Blank REVISION TRACHEOSTOMY SCAR Surgery Blank 4.62 4.36 7.15 Blank RBRVS

31899 Blank UNLISTED PROCEDURE TRACHEA BRONCHI Surgery Blank Blank Blank Blank 3.71 Unlisted

32035 Blank THORACOSTOMY W/RIB RESECTION EMPYEMA Surgery Blank 11.29 7.03 7.03 Blank RBRVS

32036 Blank THORACOSTOMY OPEN FLAP DRAINAGE EMPYEMA Surgery Blank 12.30 7.25 7.25 Blank RBRVS

32096 Blank THORACTOMY W/DX BX LUNG INFILTRATE UNILATERAL Surgery Blank 13.75 6.34 6.34 Blank RBRVS

32097 Blank THORACTOMY W/DX BX LUNG NODULE/MASS UNILATERAL Surgery Blank 13.75 6.33 6.33 Blank RBRVS

32098 Blank THORACOTOMY W/BIOPSY OF PLEURA Surgery Blank 12.91 6.20 6.20 Blank RBRVS

32100 Blank THORACOTOMY WITH EXPLORATION Surgery Blank 13.75 6.49 6.49 Blank RBRVS

32110 Blank THORCOM CTRL TRAUMTC HEMRRG&/RPR LNG TEAR Surgery Blank 25.28 11.29 11.29 Blank RBRVS

32120 Blank THORACOTOMY POSTOPERATIVE COMPLICATIONS Surgery Blank 14.39 7.49 7.49 Blank RBRVS

32124 Blank THORACOTOMY OPN INTRAPLEURAL PNEUMONOLYSIS Surgery Blank 15.45 7.76 7.76 Blank RBRVS

32140 Blank THORCOM W/REMOVAL OF CYST Surgery Blank 16.66 8.09 8.09 Blank RBRVS

32141 Blank THORACOTOMY W/RESECTION BULLAE Surgery Blank 27.18 10.67 10.67 Blank RBRVS

32150 Blank THORCOM W/RMVL INTRAPLEURAL FB/FIBRIN DEP Surgery Blank 16.82 8.35 8.35 Blank RBRVS

32151 Blank THORCOM W/RMVL IPUL FB Surgery Blank 16.94 8.17 8.17 Blank RBRVS

32160 Blank THORACOTOMY W/CARDIAC MASSAGE Surgery Blank 13.10 6.87 6.87 Blank RBRVS

32200 Blank PNEUMONOSTOMY W/OPEN DRAINAGE ABSCESS/CYST Surgery Blank 18.68 9.83 9.83 Blank RBRVS

32215 Blank PLEURAL SCARIFICATION REPEAT PNEUMOTHORAX Surgery Blank 13.05 7.11 7.11 Blank RBRVS

32220 Blank DECORTICATION PULMONARY TOTAL SEPARATE PROCEDURE Surgery Blank 26.65 13.00 13.00 Blank RBRVS

32225 Blank DECORTICATION PULMONARY PARTIAL SEPARATE PROC Surgery Blank 16.75 8.15 8.15 Blank RBRVS

32310 Blank PLEURECTOMY PARIETAL SEPARATE PROCEDURE Surgery Blank 15.28 7.63 7.63 Blank RBRVS

32320 Blank DECORTICATION & PARIETAL PLEURECTOMY Surgery Blank 27.25 12.58 12.58 Blank RBRVS

32400 Blank BIOPSY PLEURA PERCUTANEOUS NEEDLE Surgery Blank 1.76 0.59 2.37 Blank RBRVS

32405 Blank BIOPSY LUNG/MEDIASTINUM PERCUTANEOUS NEEDLE Surgery Blank 1.68 0.79 9.30 Blank RBRVS

32440 Blank REMOVAL OF LUNG PNEUMONECTOMY Surgery Blank 27.28 11.69 11.69 Blank RBRVS

32442 Blank REMOVAL LUNG PNEUMONECTOMY RESXN SGMNT TRACHEA Surgery Blank 56.47 19.01 19.01 Blank RBRVS

32445 Blank REMOVAL LUNG PNEUMONECTOMY EXTRAPLEURAL Surgery Blank 63.84 23.47 23.47 Blank RBRVS

32480 Blank RMVL LUNG OTHER THAN PNEUMONECTOMY 1 LOBE LOBECT Surgery Blank 25.82 10.96 10.96 Blank RBRVS

32482 Blank RMVL LUNG OTHER THAN PNEUMONECT 2 LOBES BILOBEC Surgery Blank 27.44 11.97 11.97 Blank RBRVS





PAGE 33 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

32484 Blank RMVL LUNG OTHER THAN PNEUMONECT 1 SEGMENTECTOMY Surgery Blank 25.38 10.22 10.22 Blank RBRVS

32486 Blank RMVL LUNG XCP TOT PNEUMONECTOMY SLEEVE LOBECTOMY Surgery Blank 42.88 15.27 15.27 Blank RBRVS

32488 Blank RMVL LUNG OTHER/THAN PNUMEC COMPLETION PNUMEC Surgery Blank 42.99 16.32 16.32 Blank RBRVS

32491 Blank RMVL LUNG OTH/THN PNUMEC RESXN-PLCTJ EMPHY LUNG Surgery Blank 25.24 11.12 11.12 Blank RBRVS

32501 Blank RESCJ&BRONCHOPLASTY PFRMD TM LOBEC/SGMECTOMY Surgery Blank 4.68 1.33 1.33 Blank RBRVS

32503 Blank RESCJ APICAL LUNG TUMOR W/O CHEST WALL RCNSTJ Surgery Blank 31.74 12.81 12.81 Blank RBRVS

32504 Blank RESCJ APICAL LUNG TUMOR W/CHEST WALL RCNSTJ Surgery Blank 36.54 14.15 14.15 Blank RBRVS

32505 Blank THORACOTOMY W/THERAPEUTIC WEDGE RESEXN INITIAL Surgery Blank 15.75 7.54 7.54 Blank RBRVS

32506 Blank THORACOTOMY W/THERAP WEDGE RESEXN ADDL IPSILATRL Surgery Blank 3.00 0.84 0.84 Blank RBRVS

32507 Blank THORACOTOMY W/DX WEDGE RESEXN & ANTOM LUNG RESE Surgery Blank 3.00 0.84 0.84 Blank RBRVS

32540 Blank EXTRAPLEURAL ENUCLEATION EMPYEMA EMPYEMECTOMY Surgery Blank 30.35 12.60 12.60 Blank RBRVS

32550 Blank INSERTION INDWELLING TUNNELED PLEURAL CATHETER Surgery Blank 3.92 1.53 15.73 Blank RBRVS

32551 Blank TUBE THORACOSTOMY INCLUDES WATER SEAL Surgery Blank 3.04 1.00 1.00 Blank RBRVS

32552 Blank RMVL NDWELLG TUNNELED PLEURAL CATHETER W/CUFF Surgery Blank 2.53 1.66 2.36 Blank RBRVS

32553 Blank PLMT NTRSTL DEV RADJ THX GID PRQ INTRATHRC 1/MLT Surgery Blank 3.55 1.34 11.01 Blank RBRVS

32554 Blank THORACENTESIS NEEDLE/CATH PLEURA W/O IMAGING Surgery Blank 1.82 0.58 3.77 Blank RBRVS

32555 Blank THORACENTESIS NEEDLE/CATH PLEURA W/IMAGING Surgery Blank 2.27 0.76 5.80 Blank RBRVS

32556 Blank PERQ DRAINAGE PLEURA INSERT CATH W/O IMAGING Surgery Blank 2.50 0.77 13.13 Blank RBRVS

32557 Blank PERQ DRAINAGE PLEURA INSERT CATH W/IMAGING Surgery Blank 3.12 1.01 11.16 Blank RBRVS

32560 Blank INSTLJ VIA CHEST TUBE/CATH AGENT FOR PLEURODESIS Surgery Blank 1.54 0.47 5.21 Blank RBRVS

32561 Blank INSTLJ VIA CH TUBE/CATH AGENT FBRNLYSIS 1ST DAY Surgery Blank 1.39 0.43 1.12 Blank RBRVS

32562 Blank INSTLJ CH TUBE/CATH AGENT FBRNLYSIS SBSQ DAY Surgery Blank 1.24 0.38 1.00 Blank RBRVS

32601 Blank THORSC DX LUNGS/PERICAR/MED/PLEURAL SPACE W/O BX Surgery Blank 5.50 2.19 2.19 Blank RBRVS

32604 Blank THORACOSCOPY DX PERICARDIAL SAC W/BIOPSY SPX Surgery Blank 8.77 3.12 3.12 Blank RBRVS

32606 Blank THORACOSCOPY DX MEDIASTINAL SPACE W/BIOPSY SPX Surgery Blank 8.39 3.08 3.08 Blank RBRVS

32607 Blank THORACOSCOPY W/DX BX OF LUNG INFILTRATE UNILATRL Surgery Blank 5.50 2.18 2.18 Blank RBRVS

32608 Blank THORACOSCOPY W/DX BX OF LUNG NODULES UNILATRL Surgery Blank 6.84 2.56 2.56 Blank RBRVS

32609 Blank THORACOSCOPY WITH BIOPSYIES OF PLEURA Surgery Blank 4.58 1.92 1.92 Blank RBRVS

32650 Blank THORACOSCOPY W/PLEURODESIS Surgery Blank 10.83 5.95 5.95 Blank RBRVS

32651 Blank THORACOSCOPY W/PARTIAL PULMONARY DECORTICATION Surgery Blank 18.78 8.52 8.52 Blank RBRVS

32652 Blank THRSC TOT PULM DCRTCTJ INTRAPLEURAL PNEUMONOLSS Surgery Blank 29.13 12.18 12.18 Blank RBRVS

32653 Blank THORACOSCOPY RMVL INTRAPLEURAL FB/FIBRIN DEPOSIT Surgery Blank 18.17 8.29 8.29 Blank RBRVS

32654 Blank THORACOSCOPY CONTROL TRAUMATIC HEMORRHAGE Surgery Blank 20.52 8.75 8.75 Blank RBRVS

32655 Blank THORACOSCOPY W/RESECTION BULLAE W/WO PLEURAL PX Surgery Blank 16.17 7.72 7.72 Blank RBRVS

32656 Blank THORACOSCOPY W/PARIETAL PLEURECTOMY Surgery Blank 13.26 6.82 6.82 Blank RBRVS

32658 Blank THORACOSCOPY W/RMVL CLOT/FB FROM PERICARDIAL SAC Surgery Blank 11.71 6.15 6.15 Blank RBRVS

32659 Blank THRSC CRTJ PRCRD WINDOW/PRTL RESCJ PRCRD SAC Surgery Blank 11.94 6.41 6.41 Blank RBRVS

32661 Blank THORACOSCOPY W/EXC PERICARDIAL CYST TUMOR/MASS Surgery Blank 13.33 6.60 6.60 Blank RBRVS

32662 Blank THORACOSCOPY W/EXC MEDIASTINAL CYST TUMOR/MASS Surgery Blank 14.99 7.31 7.31 Blank RBRVS

32663 Blank THORACOSCOPY W/LOBECTOMY SINGLE LOBE Surgery Blank 24.64 10.17 10.17 Blank RBRVS

32664 Blank THORACOSCOPY W/THORACIC SYMPATHECTOMY Surgery Blank 14.28 6.87 6.87 Blank RBRVS

32665 Blank THORACOSCOPY W/ESOPHAGOMYOTOMY HELLER TYPE Surgery Blank 21.53 9.08 9.08 Blank RBRVS

32666 Blank THORACOSCOPY W/THERA WEDGE RESEXN INITIAL UNILAT Surgery Blank 14.50 7.29 7.29 Blank RBRVS

32667 Blank THORACOSCOPY W/THERA WEDGE RESEXN ADDL IPSILATRL Surgery Blank 3.00 0.85 0.85 Blank RBRVS

32668 Blank THORACOSCOPY W/DX WEDGE RESEXN ANATO LUNG RESEXN Surgery Blank 3.00 0.85 0.85 Blank RBRVS

32669 Blank THORACOSCOPY W/SEGMENTECTOMY Surgery Blank 23.53 9.87 9.87 Blank RBRVS

32670 Blank THORACOSCOPY W/BILOBECTOMY Surgery Blank 28.52 11.39 11.39 Blank RBRVS

32671 Blank THORACOSCOPY W/PNEUMONECTOMY Surgery Blank 31.92 12.06 12.06 Blank RBRVS

32672 Blank THORACOSCOPY W/RESEXN-PLICAJ EMPHYSEMA LUNG UNIL Surgery Blank 27.00 10.82 10.82 Blank RBRVS

32673 Blank THORACOSCOPY RESEXN THYMUS UNI/BILATERAL Surgery Blank 21.13 9.21 9.21 Blank RBRVS

32674 Blank THORCOSCPY W/MEDIASTINL & REGIONL LYMPHDENECTOMY Surgery Blank 4.12 1.17 1.17 Blank RBRVS

32701 Blank THORAX STEREOTACTIC RADIATION TARGET W/TX COURSE Surgery Blank 4.18 1.22 1.22 Blank RBRVS

32800 Blank REPAIR LUNG HERNIA THROUGH CHEST WALL Surgery Blank 15.71 7.84 7.84 Blank RBRVS

32810 Blank CLSR CH WALL FLWG OPN FLAP DRG EMPYEMA Surgery Blank 14.95 7.58 7.58 Blank RBRVS

32815 Blank OPEN CLOSURE MAJOR BRONCHIAL FISTULA Surgery Blank 50.03 19.29 19.29 Blank RBRVS

32820 Blank MAJOR RECONSTRUCTION CHEST WALL POSTTRAUMATIC Surgery Blank 22.51 10.65 10.65 Blank RBRVS

32851 Blank LUNG TRANSPLANT 1 W/O CARDIOPULMONARY BYPASS Surgery Blank 59.64 21.70 21.70 Blank RBRVS

32852 Blank LUNG TRANSPLANT 1 W/CARDIOPULMONARY BYPASS Surgery Blank 65.50 22.83 22.83 Blank RBRVS

32853 Blank LUNG TRANSPLANT 2 W/O CARDIOPULMONARY BYPASS Surgery Blank 84.48 28.69 28.69 Blank RBRVS

32854 Blank LUNG TRANSPLANT 2 W/CARDIOPULMONARY BYPASS Surgery Blank 90.00 30.10 30.10 Blank RBRVS

32855 Blank BKBENCH PREPJ CADAVER DONOR LUNG ALLOGRAFT UNI Surgery Blank Blank Blank Blank 15.10 FAIR Health

32856 Blank BKBENCH PREPJ CADAVER DONOR LUNG ALLOGRAFT BI Surgery Blank Blank Blank Blank 20.42 FAIR Health

32900 Blank RESECTION RIBS EXTRAPLEURAL ALL STAGES Surgery Blank 23.81 11.73 11.73 Blank RBRVS

32905 Blank THORACOPLASTY SCHEDE TYPE/EXTRAPLEURAL Surgery Blank 23.29 9.91 9.91 Blank RBRVS

32906 Blank THORACOP SCHEDE TYP/XTRPLEURAL CLSR BRNCPLR FSTL Surgery Blank 29.30 11.58 11.58 Blank RBRVS

32940 Blank PNEUMONOLYSIS XTRPRIOSTEAL W/FILLING/PACKING PX Surgery Blank 21.34 9.36 9.36 Blank RBRVS

32960 Blank PNEUMOTHORAX THER INTRAPLEURAL INJECTION AIR Surgery Blank 1.84 0.66 1.64 Blank RBRVS

32994 Blank ABLATE PULM TUMOR PERQ CRYBL Surgery Blank 9.03 3.77 164.92 Blank RBRVS

32997 Blank TOTAL LUNG LAVAGE UNILATERAL Surgery Blank 7.31 2.01 2.01 Blank RBRVS

32998 Blank ABLATION PULMONARY TUMOR PERQ RADIOFREQUENCY UNI Surgery Blank 9.03 3.10 93.05 Blank RBRVS

32999 Blank UNLISTED PROCEDURE LUNGS & PLEURA Surgery Blank Blank Blank Blank 3.27 Unlisted

33010 Blank PERICARDIOCENTESIS INITIAL Surgery Blank 1.99 0.69 0.69 Blank RBRVS





PAGE 34 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

33011 Blank PERICARDIOCENTESIS SUBSEQUENT Surgery Blank 1.99 0.68 0.68 Blank RBRVS

33015 Blank TUBE PERICARDIOSTOMY Surgery Blank 8.52 4.54 4.54 Blank RBRVS

33020 Blank PERICARDIOTOMY REMOVAL CLOT/FOREIGN BODY PRIMARY Surgery Blank 14.95 7.11 7.11 Blank RBRVS

33025 Blank CRTJ PERICARDIAL WINDOW/PRTL RESECJ W/DRG/BX Surgery Blank 13.70 6.25 6.25 Blank RBRVS

33030 Blank PRICARDIECTOMY STOT/COMPL W/O CARDPULM BYPASS Surgery Blank 36.00 13.68 13.68 Blank RBRVS

33031 Blank PRICARDIECTOMY STOT/COMPL W/CARDPULM BYPASS Surgery Blank 45.00 16.45 16.45 Blank RBRVS

33050 Blank RESECTION PERICARDIAL CYST/TUMOR Surgery Blank 16.97 8.27 8.27 Blank RBRVS

33120 Blank EXC INTRACARDIAC TUMOR RESCJ CARDIOPULMONARY BYP Surgery Blank 38.45 13.57 13.57 Blank RBRVS

33130 Blank RESECTION EXTERNAL CARDIAC TUMOR Surgery Blank 24.17 10.01 10.01 Blank RBRVS

33140 Blank TRANSMYOCARDIAL LASER REVASCULAR THORACOTOMY SPX Surgery Blank 28.34 10.56 10.56 Blank RBRVS

33141 Blank TRANSMYOCRD LASER REVSC PFRMD TM OTH OPN CAR PX Surgery Blank 2.54 0.70 0.70 Blank RBRVS

33202 Blank INSERTION EPICARDIAL ELECTRODE OPEN Surgery Blank 13.20 6.17 6.17 Blank RBRVS

33203 Blank INSERTION EPICARDIAL ELECTRODE ENDOSCOPIC Surgery Blank 13.97 6.18 6.18 Blank RBRVS

33206 Blank INS NEW/RPLCMT PRM PACEMAKR W/TRANS ELTRD ATRIAL Surgery Blank 7.14 4.36 4.36 Blank RBRVS

33207 Blank INS NEW/RPLC PRM PACEMAKER W/TRANSV ELTRD VENTR Surgery Blank 7.80 4.37 4.37 Blank RBRVS

33208 Blank INS NEW/RPLCMT PRM PM W/TRANSV ELTRD ATRIAL&VENT Surgery Blank 8.52 4.67 4.67 Blank RBRVS

33210 Blank INSJ/RPLCMT TEMP TRANSVNS 1CHMBR ELTRD/PM CATH Surgery Blank 3.05 1.07 1.07 Blank RBRVS

33211 Blank INSJ/RPLCMT TEMP TRANSVNS 2CHMBR PACG ELTRDS SPX Surgery Blank 3.14 1.11 1.11 Blank RBRVS

33212 Blank INS PM PLS GEN W/EXIST SINGLE LEAD Surgery Blank 5.01 3.15 3.15 Blank RBRVS

33213 Blank INS PACEMAKER PULSE GEN ONLY W/EXIST DUAL LEADS Surgery Blank 5.28 3.24 3.24 Blank RBRVS

33214 Blank UPG PACEMAKER SYS CONVERT 1CHMBR SYS 2CHMBR SYS Surgery Blank 7.59 4.58 4.58 Blank RBRVS

33215 Blank RPSG PREV IMPLTED PM/DFB R ATR/R VENTR ELECTRODE Surgery Blank 4.92 2.97 2.97 Blank RBRVS

33216 Blank INSJ 1 TRANSVNS ELTRD PERM PACEMAKER/IMPLTBL DFB Surgery Blank 5.62 3.83 3.83 Blank RBRVS

33217 Blank INSJ 2 TRANSVNS ELTRD PERM PACEMAKER/IMPLTBL DFB Surgery Blank 5.59 3.69 3.69 Blank RBRVS

33218 Blank RPR 1 TRANSVNS ELTRD PRM PM/PACING IMPLNTBL DFB Surgery Blank 5.82 4.10 4.10 Blank RBRVS

33220 Blank RPR 2 TRANSVNS ELECTRODES PRM PM/IMPLANTABLE DFB Surgery Blank 5.90 4.07 4.07 Blank RBRVS

33221 Blank INS PACEMAKER PULSE GEN ONLY W/EXIST MULT LEADS Surgery Blank 5.55 3.62 3.62 Blank RBRVS

33222 Blank RELOCATION OF SKIN POCKET FOR PACEMAKER Surgery Blank 4.85 3.83 3.83 Blank RBRVS

33223 Blank RELOCATE SKIN POCKET IMPLANTABLE DEFIBRILLATOR Surgery Blank 6.30 4.11 4.11 Blank RBRVS

33224 Blank INSJ ELTRD CAR VEN SYS ATTCH PREV PM/DFB PLS GEN Surgery Blank 9.04 3.90 3.90 Blank RBRVS

33225 Blank INSJ ELTRD CAR VEN SYS TM INSJ DFB/PM PLS GEN Surgery Blank 8.33 3.44 3.44 Blank RBRVS

33226 Blank RPSG PREV IMPLTED CAR VEN SYS L VENTR ELTRD Surgery Blank 8.68 3.74 3.74 Blank RBRVS

33227 Blank REMVL PERM PM PLSE GEN W/REPL PLSE GEN SNGL LEAD Surgery Blank 5.25 3.35 3.35 Blank RBRVS

33228 Blank REMVL PERM PM PLS GEN W/REPL PLSE GEN 2 LEAD SYS Surgery Blank 5.52 3.47 3.47 Blank RBRVS

33229 Blank REMVL PERM PM PLS GEN W/REPL PLSE GEN MULT LEAD Surgery Blank 5.79 3.74 3.74 Blank RBRVS

33230 Blank INSJ IMPLNTBL DEFIB PULSE GEN W/EXIST DUAL LEADS Surgery Blank 6.07 3.63 3.63 Blank RBRVS

33231 Blank INSJ IMPLNTBL DEFIB PULSE GEN W/EXIST MULTILEADS Surgery Blank 6.34 3.85 3.85 Blank RBRVS

33233 Blank REMOVAL PERMANENT PACEMAKER PULSE GENERATOR ONLY Surgery Blank 3.14 2.81 2.81 Blank RBRVS

33234 Blank RMVL TRANSVNS PM ELTRD 1 LEAD SYS ATR/VENTR Surgery Blank 7.66 4.66 4.66 Blank RBRVS

33235 Blank RMVL TRANSVNS PM ELTRD DUAL LEAD SYS Surgery Blank 9.90 6.34 6.34 Blank RBRVS

33236 Blank RMVL PRM EPICAR PM&ELTRDS THORCOM 1 LEAD SYS Surgery Blank 12.73 6.94 6.94 Blank RBRVS

33237 Blank RMVL PRM EPICAR PM&ELTRDS THORCOM DUAL LEAD SY Surgery Blank 13.84 7.24 7.24 Blank RBRVS

33238 Blank RMVL PRM TRANSVENOUS ELECTRODE THORACOTOMY Surgery Blank 15.40 8.27 8.27 Blank RBRVS

33240 Blank INSJ IMPLNTBL DEFIB PULSE GEN W/1 EXISTING LD Surgery Blank 5.80 3.48 3.48 Blank RBRVS

33241 Blank REMOVAL IMPLANTABLE DEFIB PULSE GENERATOR ONLY Surgery Blank 3.04 2.50 2.50 Blank RBRVS

33243 Blank RMVL 1/DUAL CHAMBER DEFIB ELECTRODE BY THORACOM Surgery Blank 23.57 10.70 10.70 Blank RBRVS

33244 Blank RMVL1/DUAL CHMBR IMPLTBL DFB ELTRD TRANSVNS XTRJ Surgery Blank 13.74 8.07 8.07 Blank RBRVS

33249 Blank INSJ/RPLCMT PERM DFB W/TRNSVNS LDS 1/DUAL CHMBR Surgery Blank 14.92 8.29 8.29 Blank RBRVS

33250 Blank ABLATION ARRHYTHMOGENIC FOCI/PATHWAY W/O BYPASS Surgery Blank 25.90 10.49 10.49 Blank RBRVS

33251 Blank ABLATION ARRHYTHMOGENIC FOCI/PATHWAY W/BYPASS Surgery Blank 28.92 11.31 11.31 Blank RBRVS

33254 Blank ABLATION & RECONSTRUCTION ATRIA LIMITED Surgery Blank 23.71 10.18 10.18 Blank RBRVS

33255 Blank ABLATION & RCNSTJ ATRIA EXTNSV W/O BYPASS Surgery Blank 29.04 11.64 11.64 Blank RBRVS

33256 Blank ABLATION & RCNSTJ ATRIA EXTNSV W/BYPASS Surgery Blank 34.90 13.25 13.25 Blank RBRVS

33257 Blank ATRIA ABLATE & RCNSTJ W/OTHER PROCEDURE LIMITE Surgery Blank 9.63 5.05 5.05 Blank RBRVS

33258 Blank ATRIA ABLTJ & RCNSTJ W/OTHER PX EXTENSIV W/O BYP Surgery Blank 11.00 5.46 5.46 Blank RBRVS

33259 Blank ATRIA ABLTJ & RCNSTJ W/OTHER PX EXTEN W/BYPASS Surgery Blank 14.14 7.12 7.12 Blank RBRVS

33261 Blank OPRATIVE ABLTJ VENTR ARRHYTHMOGENIC FOC W/BYPASS Surgery Blank 28.92 11.32 11.32 Blank RBRVS

33262 Blank RMVL IMPLTBL DFB PLSE GEN W/REPL PLSE GEN 1 LEAD Surgery Blank 5.81 3.66 3.66 Blank RBRVS

33263 Blank RMVL IMPLTBL DFB PLSE GEN W/RPLCMT PLSE GEN 2 LD Surgery Blank 6.08 3.78 3.78 Blank RBRVS

33264 Blank RMVL IMPLTBL DFB PLS GEN W/RPLCMT PLS GEN MLT LD Surgery Blank 6.35 3.93 3.93 Blank RBRVS

33265 Blank NDSC ABLATION & RCNSTJ ATRIA LIMITED W/O BYPAS Surgery Blank 23.71 10.33 10.33 Blank RBRVS

33266 Blank NDSC ABLATION & RCNSTJ ATRIA EXTEN W/O BYPASS Surgery Blank 33.04 12.92 12.92 Blank RBRVS

33270 Blank INS/RPLCMNT PERM SUBQ IMPLTBL DFB W/SUBQ ELTRD Surgery Blank 9.10 5.33 5.33 Blank RBRVS

33271 Blank INSJ OF SUBQ IMPLANTABLE DEFIBRILLATOR ELECTRODE Surgery Blank 7.50 4.01 4.01 Blank RBRVS

33272 Blank RMVL OF SUBQ IMPLANTABLE DEFIBRILLATOR ELECTRODE Surgery Blank 5.42 3.50 3.50 Blank RBRVS

33273 Blank REPOS PREVIOUSLY IMPLANTED SUBQ IMPLANTABLE DFB Surgery Blank 6.50 3.67 3.67 Blank RBRVS

33274 Blank TCAT INSJ/RPL PERM LDLS PM Surgery Blank 7.80 4.60 4.60 Blank RBRVS

33275 Blank TCAT RMVL PERM LDLS PM Surgery Blank 8.59 4.48 4.48 Blank RBRVS

33285 Blank INSJ SUBQ CAR RHYTHM MNTR Surgery Blank 1.53 0.70 144.18 Blank RBRVS

33286 Blank RMVL SUBQ CAR RHYTHM MNTR Surgery Blank 1.50 0.69 1.95 Blank RBRVS

33289 Blank TCAT IMPL WRLS P-ART PRS SNR Surgery Blank 6.00 2.23 2.23 Blank RBRVS

33300 Blank REPAIR CARDIAC WOUND W/O BYPASS Surgery Blank 44.97 15.81 15.81 Blank RBRVS





PAGE 35 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

33305 Blank REPAIR CARDIAC WOUND W/CARDIOPULMONARY BYPASS Surgery Blank 76.93 24.59 24.59 Blank RBRVS

33310 Blank CARDIOT EXPL W/RMVL FB ATR/VENTR THRMB W/O BYP Surgery Blank 20.34 8.96 8.96 Blank RBRVS

33315 Blank CARDIOT EXPL RMVL FB ATR/VENTR THRMB CARD BYP Surgery Blank 35.00 12.49 12.49 Blank RBRVS

33320 Blank SUTR RPR AORTA/GRT VSL W/O SHUNT/CARD BYP Surgery Blank 18.54 7.86 7.86 Blank RBRVS

33321 Blank SUTR RPR AORTA/GREAT VESSEL W/SHUNT BYPASS Surgery Blank 20.81 8.93 8.93 Blank RBRVS

33322 Blank SUTURE REPAIR AORTA/GREAT VESSEL W/BYPASS Surgery Blank 24.42 10.29 10.29 Blank RBRVS

33330 Blank INSJ GRAFT AORTA/GREAT VESSEL W/O SHUNT/BYPASS Surgery Blank 25.29 10.32 10.32 Blank RBRVS

33335 Blank INSJ GRAFT AORTA/GREAT VESSEL W/BYPASS Surgery Blank 33.91 12.93 12.93 Blank RBRVS

33340 Blank PERQ CLSR TCAT L ATR APNDGE Surgery Blank 14.00 5.99 5.99 Blank RBRVS

33361 Blank REPLACE AORTIC VALVE PERQ FEMORAL ARTRY APPROACH Surgery Blank 25.13 8.55 8.55 Blank RBRVS

33362 Blank REPLACE AORTIC VALVE OPENFEMORAL ARTERY APPROACH Surgery Blank 27.52 9.21 9.21 Blank RBRVS

33363 Blank REPLACE AORTIC VALVE OPEN AXILLRY ARTRY APPROACH Surgery Blank 28.50 9.54 9.54 Blank RBRVS

33364 Blank REPLACE AORTIC VALVE OPEN ILIAC ARTERY APPROACH Surgery Blank 30.00 10.07 10.07 Blank RBRVS

33365 Blank REPLACE AORTIC VALVE OPEN TRANSAORTIC APPROACH Surgery Blank 33.12 11.00 11.00 Blank RBRVS

33366 Blank TRANSCATHETER TRANSAPICAL REPLACEMT AORTIC VALVE Surgery Blank 35.88 11.81 11.81 Blank RBRVS

33367 Blank REPLACE AORTIC VALVE W/BYP PRQ ART/VENOUS APPRCH Surgery Blank 11.88 3.61 3.61 Blank RBRVS

33368 Blank REPLACE AORTIC VALVE W/BYP OPEN ART/VENOUS APRCH Surgery Blank 14.39 3.95 3.95 Blank RBRVS

33369 Blank REPLACE AORTA VALVE W/BYP CNTRL ART/VENOUS APRCH Surgery Blank 19.00 5.22 5.22 Blank RBRVS

33390 Blank VALVULOPLASTY AORTIC VALVE Surgery Blank 35.00 12.94 12.94 Blank RBRVS

33391 Blank VALVULOPLASTY AORTIC VALVE Surgery Blank 41.50 15.32 15.32 Blank RBRVS

33404 Blank CONSTRUCTION APICAL-AORTIC CONDUIT Surgery Blank 31.37 12.30 12.30 Blank RBRVS

33405 Blank RPLCMT PROST AORTIC VALVE XCP HOMOGRF/STENT Surgery Blank 41.32 15.08 15.08 Blank RBRVS

33406 Blank RPLCMT AORTIC VALVE ALLOGRAFT VALVE FREEHAND Surgery Blank 52.68 18.70 18.70 Blank RBRVS

33410 Blank RPLCMT AORTIC VALVE W/STENTLESS TISSUE VALVE Surgery Blank 46.41 16.85 16.85 Blank RBRVS

33411 Blank RPLCMT AORTIC VALVE ANNULUS ENLGMENT NONC SINUS Surgery Blank 62.07 21.18 21.18 Blank RBRVS

33412 Blank REPLACEMENT AORTIC VALVE KONNO PROCEDURE Surgery Blank 59.00 19.29 19.29 Blank RBRVS

33413 Blank REPLACEMENT AORTIC&PULMON VALVES ROSS PROCEDUR Surgery Blank 59.87 20.32 20.32 Blank RBRVS

33414 Blank RPR VENTR O/F TRC OBSTRCJ PATCH ENLGMENT O/F TRC Surgery Blank 39.37 13.83 13.83 Blank RBRVS

33415 Blank RESECTION/INCISION SUBVALVULAR TISSUE Surgery Blank 37.27 13.51 13.51 Blank RBRVS

33416 Blank VENTRICULOMYOTOMY-MYECTOMY Surgery Blank 36.56 13.88 13.88 Blank RBRVS

33417 Blank AORTOPLASTY SUPRAVALVULAR STENOSIS Surgery Blank 29.33 12.16 12.16 Blank RBRVS

33418 Blank TCAT MITRAL VALVE REPAIR INITIAL PROSTHESIS Surgery Blank 32.25 12.98 12.98 Blank RBRVS

33419 Blank TCAT MITRAL VALVE REPAIR ADDL PROSTHESIS Surgery Blank 7.93 2.70 2.70 Blank RBRVS

33420 Blank VALVOTOMY MITRAL VALVE CLOSED HEART Surgery Blank 25.79 10.46 10.46 Blank RBRVS

33422 Blank VALVOTOMY MITRAL VALVE OPEN HEART W/BYPASS Surgery Blank 29.73 11.86 11.86 Blank RBRVS

33425 Blank VALVULOPLASTY MITRAL VALVE W/CARDIAC BYPASS Surgery Blank 49.96 18.00 18.00 Blank RBRVS

33426 Blank VLVP MITRAL VALVE W/CARD BYP W/PROSTC RING Surgery Blank 43.28 16.02 16.02 Blank RBRVS

33427 Blank VLVP MITRAL VALVE W/BYPASS RAD RCNSTJ W/WO RING Surgery Blank 44.83 15.94 15.94 Blank RBRVS

33430 Blank REPLACEMENT MITRAL VALVE W/CARDIOPULMONARY BYP Surgery Blank 50.93 18.62 18.62 Blank RBRVS

33440 Blank RPLCMT A-VALVE TLCJ AUTOL PV Surgery Blank 64.00 20.02 20.02 Blank RBRVS

33460 Blank VALVECTOMY TRICUSPID VALVE W/CARDIOPULMONARY BYP Surgery Blank 44.70 15.05 15.05 Blank RBRVS

33463 Blank VALVULOPLASTY TRICUSPID VALVE W/O RING INSERTION Surgery Blank 57.08 19.65 19.65 Blank RBRVS

33464 Blank VALVULOPLASTY TRICUSPID VALVE W/RING INSERTION Surgery Blank 44.62 16.18 16.18 Blank RBRVS

33465 Blank REPLACEMENT TRICUSPID VALVE W/CARD BYPASS Surgery Blank 50.72 17.62 17.62 Blank RBRVS

33468 Blank TRICUSPID VALVE RPSG&PLCTJ EBSTEIN ANOMALY Surgery Blank 45.13 15.48 15.48 Blank RBRVS

33470 Blank VALVOTOMY PULMONARY VALVE CLSD HEART TRANSVENTR Surgery Blank 21.54 9.29 9.29 Blank RBRVS

33471 Blank VALVOTOMY PULM VALVE CLSD HEART VIA PULM ARTERY Surgery Blank 22.96 10.04 10.04 Blank RBRVS

33474 Blank VALVOTOMY PULMONARY VALVE OPEN HEART W/BYPASS Surgery Blank 39.40 14.58 14.58 Blank RBRVS

33475 Blank REPLACEMENT PULMONARY VALVE Surgery Blank 42.40 15.49 15.49 Blank RBRVS

33476 Blank R VENTRIC RESCJ INFUND STEN W/WO COMMISSUROTOMY Surgery Blank 26.57 11.35 11.35 Blank RBRVS

33477 Blank TCAT PULMONARY VALVE IMPLANTATION PRQ APPROACH Surgery Blank 25.00 8.81 8.81 Blank RBRVS

33478 Blank OUTFLOW TRACT AGMNTJ W/WO COMMISSUR/INFUND RESCJ Surgery Blank 27.54 11.62 11.62 Blank RBRVS

33496 Blank RPR NON-STRUCT PROSTC VALVE DYSFUNCTION W/BYPASS Surgery Blank 29.84 11.74 11.74 Blank RBRVS

33500 Blank RPR CORONARY AV/ARTERIOCAR CHMBR FSTL W/BYPASS Surgery Blank 27.94 11.04 11.04 Blank RBRVS

33501 Blank RPR CORONARY AV/ARTERIOCAR CHMBR FSTL W/O BYPASS Surgery Blank 19.51 8.44 8.44 Blank RBRVS

33502 Blank RPR ANOM CORONARY ART PULM ART ORIGIN LIGATION Surgery Blank 21.85 10.03 10.03 Blank RBRVS

33503 Blank RPR ANOM CORONARY ARTERY PULM ART ORIGIN GRAFT Surgery Blank 22.51 10.67 10.67 Blank RBRVS

33504 Blank RPR ANOM CORONARY ART PULM ART ORIGIN GRF W/BYP Surgery Blank 25.46 11.09 11.09 Blank RBRVS

33505 Blank RPR ANOM CORON ART W/CONSTJ INTRAPULM ART TUNNEL Surgery Blank 38.40 12.52 12.52 Blank RBRVS

33506 Blank RPR ANOM CORONARY ART FROM PULM ART TO AORTA Surgery Blank 37.85 12.94 12.94 Blank RBRVS

33507 Blank RPR ANOM AORTIC ORIGIN CORONARY ART UNROOF/TLCJ Surgery Blank 31.40 11.29 11.29 Blank RBRVS

33508 Blank NDSC SURG W/VIDEO-ASSISTED HARVEST VEIN CABG Surgery Blank 0.31 0.09 0.09 Blank RBRVS

33510 Blank CORONARY ARTERY BYPASS 1 CORONARY VENOUS GRAFT Surgery Blank 34.98 13.13 13.13 Blank RBRVS

33511 Blank CORONARY ARTERY BYPASS 2 CORONARY VENOUS GRAFTS Surgery Blank 38.45 14.40 14.40 Blank RBRVS




33516 Blank CORONARY ARTERY BYPASS 6/+ CORONARY VENOUS GRAFT Surgery Blank 49.76 17.56 17.56 Blank RBRVS

33517 Blank CORONARY ARTERY BYP W/VEIN & ARTERY GRAFT 1 VEIN Surgery Blank 3.61 1.01 1.01 Blank RBRVS








PAGE 36 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3


33523 Blank CORONARY ARTERY BYP W/VEIN &ARTERY GRAFT 6 VEIN Surgery Blank 16.08 4.39 4.39 Blank RBRVS

33530 Blank ROPRTJ CAB/VALVE PX > 1 MO AFTER ORIGINAL OPERJ Surgery Blank 10.13 2.83 2.83 Blank RBRVS

33533 Blank CABG W/ARTERIAL GRAFT SINGLE ARTERIAL GRAFT Surgery Blank 33.75 12.78 12.78 Blank RBRVS

33534 Blank CABG W/ARTERIAL GRAFT TWO ARTERIAL GRAFTS Surgery Blank 39.88 14.78 14.78 Blank RBRVS

33535 Blank CABG W/ARTERIAL GRAFT THREE ARTERIAL GRAFTS Surgery Blank 44.75 16.16 16.16 Blank RBRVS

33536 Blank CABG W/ARTERIAL GRAFT FOUR/>ARTERIAL GRAFTS Surgery Blank 48.43 17.09 17.09 Blank RBRVS

33542 Blank MYOCARDIAL RESECTION Surgery Blank 48.21 16.97 16.97 Blank RBRVS

33545 Blank RPR POSTINFRCJ VENTRICULAR SEPTAL DEFECT Surgery Blank 57.06 19.23 19.23 Blank RBRVS

33548 Blank SURG VENTRICULAR RSTRJ PX W/PROSTC PATCH PFRMD Surgery Blank 54.14 19.43 19.43 Blank RBRVS

33572 Blank CORONARY ENDARTERCOMY OPEN ANY METHOD Surgery Blank 4.44 1.24 1.24 Blank RBRVS

33600 Blank CLOSURE ATRIOVENTRICULAR VALVE SUTURE/PATCH Surgery Blank 30.31 12.44 12.44 Blank RBRVS

33602 Blank CLOSURE SEMILUNAR VALVE AORTIC/PULM SUTURE/PATCH Surgery Blank 29.34 12.17 12.17 Blank RBRVS

33606 Blank ANAST PULMONARY ART AORTA DAMUS-KAYE-STANSEL PX Surgery Blank 31.53 12.66 12.66 Blank RBRVS

33608 Blank RPR CAR ANOMAL XCP PULM ATRESIA VENTR SEPTL DFCT Surgery Blank 31.88 12.88 12.88 Blank RBRVS

33610 Blank RPR CAR ANOMAL SURG ENLGMENT VENTR SEPTL DFCT Surgery Blank 31.40 12.74 12.74 Blank RBRVS

33611 Blank RPR 2 OUTLET R VNTRC W/INTRAVENTR TUNNEL RPR Surgery Blank 35.57 12.78 12.78 Blank RBRVS

33612 Blank RPR 2 OUTLET R VNTRC RPR R VENTR O/F TRC OBSTRCJ Surgery Blank 36.57 13.06 13.06 Blank RBRVS

33615 Blank RPR CAR ANOMAL CLSR SEPTL DFCT SMPL FONTAN PX Surgery Blank 35.89 13.65 13.65 Blank RBRVS

33617 Blank RPR COMPLEX CARDIAC ANOMALY MODIFIED FONTAN PX Surgery Blank 39.09 14.54 14.54 Blank RBRVS

33619 Blank RPR 1 VNTRC W/O/F OBSTRCJ&AORTIC ARCH HYPOPLAS Surgery Blank 48.76 18.93 18.93 Blank RBRVS

33620 Blank APPLICATION RIGHT & LEFT PULMONARY ARTERY BAND Surgery Blank 30.00 10.89 10.89 Blank RBRVS

33621 Blank TRANSTHORACIC CATHETER INSERTION FOR STENT PLMT Surgery Blank 16.18 7.04 7.04 Blank RBRVS

33622 Blank RECONSTRUCTION COMPLEX CARDIAC ANOMALY Surgery Blank 64.00 20.74 20.74 Blank RBRVS

33641 Blank RPR ATRIAL SEPTAL DFCT SECUNDUM W/BYP W/WO PATCH Surgery Blank 29.58 11.10 11.10 Blank RBRVS

33645 Blank DIR/PTCH CLS SINUS VENOSUS W/WO ANOM PUL VEN DRG Surgery Blank 31.30 11.62 11.62 Blank RBRVS

33647 Blank RPR ATRIAL & VENTRIC SEPTAL DFCT DIR/PATCH CLS Surgery Blank 33.00 12.05 12.05 Blank RBRVS

33660 Blank RPR INCPLT/PRTL AV CANAL W/WO AV VALVE RPR Surgery Blank 31.83 11.73 11.73 Blank RBRVS

33665 Blank RPR INTRM/TRANSJ AV CANAL W/WO AV VALVE RPR Surgery Blank 34.85 12.57 12.57 Blank RBRVS

33670 Blank RPR COMPL AV CANAL W/WO PROSTC VALVE Surgery Blank 36.63 12.11 12.11 Blank RBRVS

33675 Blank CLOSURE MULTIPLE VENTRICULAR SEPTAL DEFECTS Surgery Blank 35.95 12.92 12.92 Blank RBRVS

33676 Blank CLOSURE MULTIPLE VSD W/RESECTION Surgery Blank 36.95 13.20 13.20 Blank RBRVS

33677 Blank CLOSURE MULTIPLE VSD W/REMOVAL ARTERY BAND Surgery Blank 38.45 13.61 13.61 Blank RBRVS

33681 Blank CLSR 1 VENTRICULAR SEPTAL DEFECT W/WO PATCH Surgery Blank 32.34 13.44 13.44 Blank RBRVS

33684 Blank CLSR V-SEPTL DFCT W/PULM VLVT/INFUND RESCJ Surgery Blank 34.37 12.44 12.44 Blank RBRVS

33688 Blank CLSR V-SEPTAL DFCT W/RMVL P-ART BAND W/WO GUSSET Surgery Blank 34.75 11.85 11.85 Blank RBRVS

33690 Blank BANDING PULMONARY ARTERY Surgery Blank 20.36 9.66 9.66 Blank RBRVS

33692 Blank COMPL RPR TETRALOGY FALLOT W/O PULM ATRESIA Surgery Blank 36.15 12.23 12.23 Blank RBRVS

33694 Blank COMPL RPR T-FALLOT W/O PULM ATRESIA TANULR PATCH Surgery Blank 35.57 12.78 12.78 Blank RBRVS

33697 Blank COMPL RPR T-FALLOT W/PULM ATRESIA Surgery Blank 37.57 13.34 13.34 Blank RBRVS

33702 Blank RPR SINUS VALSALVA FISTULA Surgery Blank 27.24 11.23 11.23 Blank RBRVS

33710 Blank RPR SINUS VALSALVA FISTULA W/RPR V-SEPTAL DEFECT Surgery Blank 37.50 13.32 13.32 Blank RBRVS

33720 Blank RPR SINUS VALSALVA ANEURYSM Surgery Blank 27.26 11.24 11.24 Blank RBRVS

33722 Blank CLOSURE AORTICO-LEFT VENTRICULAR TUNNEL Surgery Blank 29.21 11.14 11.14 Blank RBRVS

33724 Blank REPAIR ISOLATED PARTIAL PULM VENOUS RETURN Surgery Blank 27.63 10.59 10.59 Blank RBRVS

33726 Blank REPAIR PULMONARY VENOUS STENOSIS Surgery Blank 37.12 13.25 13.25 Blank RBRVS

33730 Blank COMPLETE RPR ANOMALOUS PULMONARY VENOUS RETURN Surgery Blank 36.14 13.59 13.59 Blank RBRVS

33732 Blank RPR COR TRIATM/SUPVALVR RING RESCJ L ATRIAL MEMB Surgery Blank 28.96 12.06 12.06 Blank RBRVS

33735 Blank ATRIAL SEPTECTOMY/SEPTOSTOMY CLOSED HEART Surgery Blank 22.20 10.18 10.18 Blank RBRVS

33736 Blank ATRIAL SEPTECTOMY/SEPTOSTOMY OPEN HEART W/BYPASS Surgery Blank 24.32 10.76 10.76 Blank RBRVS

33737 Blank ATRIAL SEPTECT/SEPTOST OPN HRT W/INFL OCCLUSION Surgery Blank 22.47 9.90 9.90 Blank RBRVS

33750 Blank SHUNT SUBCLAVIAN PULMONARY ARTERY Surgery Blank 22.22 9.18 9.18 Blank RBRVS

33755 Blank SHUNT ASCENDING AORTA PULMONARY ARTERY Surgery Blank 22.60 10.29 10.29 Blank RBRVS

33762 Blank SHUNT DESCENDING AORTA PULMONARY ARTERY Surgery Blank 22.60 9.29 9.29 Blank RBRVS

33764 Blank SHUNT CENTRAL W/PROSTHETIC GRAFT Surgery Blank 22.60 10.29 10.29 Blank RBRVS

33766 Blank SHUNT SUPERIOR VENA CAVA PULMONARY ART 1 LUNG Surgery Blank 23.57 9.56 9.56 Blank RBRVS

33767 Blank SHUNT SUPERIOR VENA CAVA PULM ARTERY BOTH LUNGS Surgery Blank 25.30 10.05 10.05 Blank RBRVS

33768 Blank ANASTOMOSIS CAVOPULMARY 2ND SUPRIOR VENA CAVA Surgery Blank 8.00 2.23 2.23 Blank RBRVS

33770 Blank RPR TRPOS GREAT VSLS W/O ENLGMNT V-SEPTL DFCT Surgery Blank 39.07 13.28 13.28 Blank RBRVS

33771 Blank RPR TRPOS GREAT VSLS W/ENLGMNT V-SEPTL DFCT Surgery Blank 40.63 13.15 13.15 Blank RBRVS

33774 Blank RPR TRPOS GREAT VSLS ATRIAL BAFFLE PX W/BYPASS Surgery Blank 31.73 13.04 13.04 Blank RBRVS

33775 Blank RPR TRPOS GREAT VSLS ATR BAFFLE W/RMVL PULM BAND Surgery Blank 32.99 13.07 13.07 Blank RBRVS

33776 Blank RPR TRPOS GRT VSL ATR BAFFLE W/CLSR V-SEPTL DFCT Surgery Blank 34.75 13.97 13.97 Blank RBRVS

33777 Blank RPR TRPOS GRT VSL ATR BAFFLE W/BYP SBPULM OBSTRC Surgery Blank 34.17 12.73 12.73 Blank RBRVS

33778 Blank RPR TRPOS GRT VESSEL AORTIC PULMONARY ART RCNSTJ Surgery Blank 42.75 15.44 15.44 Blank RBRVS

33779 Blank RPR TGV AORTIC PULM ART RCNSTJ W/RMVL PULM BAND Surgery Blank 43.23 14.21 14.21 Blank RBRVS

33780 Blank RPR TGV AORTIC P-ART RCNSTJ W/CLSR V-SEPTL DFCT Surgery Blank 43.90 14.63 14.63 Blank RBRVS

33781 Blank RPR TGV AORTIC P-ART RCNSTJ RPR SBPULMC OBSTRCJ Surgery Blank 43.21 13.86 13.86 Blank RBRVS

33782 Blank A-ROOT TLCJ VSD PULM STNS RPR W/O C OST RIMPLTJ Surgery Blank 60.08 19.65 19.65 Blank RBRVS

33783 Blank A-ROOT TLCJ VSD PULM STNS RPR W/RIMPLTJ C OSTIA Surgery Blank 65.08 21.05 21.05 Blank RBRVS

33786 Blank TOTAL REPAIR TRUNCUS ARTERIOSUS Surgery Blank 41.87 14.42 14.42 Blank RBRVS

33788 Blank REIMPLANTATION ANOMALOUS PULMONARY ARTERY Surgery Blank 27.42 10.63 10.63 Blank RBRVS





PAGE 37 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

33800 Blank AORTIC SUSPENSION TRACHEAL DECOMPRESSION SPX Surgery Blank 17.28 7.32 7.32 Blank RBRVS

33802 Blank DIVISION ABERRANT VESSEL VASCULAR RING Surgery Blank 18.37 8.76 8.76 Blank RBRVS

33803 Blank DIVISION ABERRANT VESSEL W/REANASTOMOSIS Surgery Blank 20.31 8.31 8.31 Blank RBRVS

33813 Blank OBLTRJ AORTOPULMONARY SEPTAL DEFECT W/O BYPASS Surgery Blank 21.36 9.59 9.59 Blank RBRVS

33814 Blank OBLTRJ AORTOPULMONARY SEPTAL DEFECT W/BYPASS Surgery Blank 26.57 11.40 11.40 Blank RBRVS

33820 Blank REPAIR PATENT DUCTUS ARTERIOSUS LIGATION Surgery Blank 16.69 7.51 7.51 Blank RBRVS

33822 Blank RPR PATENT DUXUS ARTERIOSUS DIV UNDER 18 YR Surgery Blank 17.71 7.79 7.79 Blank RBRVS

33824 Blank RPR PATENT DUXUS ARTERIOSUS DIV 18 YR & OLDER Surgery Blank 20.23 9.23 9.23 Blank RBRVS

33840 Blank EXC COARCJ AORTA W/WO PDA W/DIRECT ANASTOMOSIS Surgery Blank 21.34 9.59 9.59 Blank RBRVS

33845 Blank EXCISION COARCTATION AORTA W/WO PDA W/GRAFT Surgery Blank 22.93 10.38 10.38 Blank RBRVS

33851 Blank EXC COARCJ AORTA W/L SUBCLAV ART/PROSTC GUSSET Surgery Blank 21.98 9.77 9.77 Blank RBRVS

33852 Blank RPR HYPOPLSTC A-ARCH W/AGRFT/PROSTC W/O BYPASS Surgery Blank 24.41 10.45 10.45 Blank RBRVS

33853 Blank RPR HYPOPLSTC A-ARCH W/AGRFT/PROSTC W/BYPASS Surgery Blank 32.51 13.06 13.06 Blank RBRVS

33860 Blank ASCENDING AORTA GRF W/CARD BYP & VALVE SSP Surgery Blank 59.46 20.21 20.21 Blank RBRVS

33863 Blank AS-AORT GRF W/CARD BYP & AORTIC ROOT RPLCMT Surgery Blank 58.79 19.25 19.25 Blank RBRVS

33864 Blank ASCENDING AORTA GRF VALVE SPARE ROOT REMODEL Surgery Blank 60.08 19.91 19.91 Blank RBRVS

33866 Blank AORTIC HEMIARCH GRAFT Surgery Blank 19.74 6.05 6.05 Blank RBRVS

33870 Blank TRANSVERSE ARCH GRAFT W/CARDIOPULMONARY BYPASS Surgery Blank 46.06 16.59 16.59 Blank RBRVS

33875 Blank DESCENDING THORACIC AORTA GRAFT W/WO BYPASS Surgery Blank 50.72 17.39 17.39 Blank RBRVS

33877 Blank RPR THORACOABDOMINAL AORTIC ANEURYS W/WO BYPASS Surgery Blank 69.03 20.32 20.32 Blank RBRVS

33880 Blank EVASC RPR DTA COVERAGE ART ORIGIN 1ST ENDOPROSTH Surgery Blank 34.58 9.92 9.92 Blank RBRVS

33881 Blank EVASC RPR DTA EXP COVERAGE W/O ART ORIGIN Surgery Blank 29.58 8.66 8.66 Blank RBRVS

33883 Blank PLMT PROX XTN PROSTH EVASC RPR DTA 1ST XTN Surgery Blank 21.09 6.90 6.90 Blank RBRVS

33884 Blank PLMT PROX XTN PROSTH EVASC RPR DTA EA PROX XTN Surgery Blank 8.20 2.01 2.01 Blank RBRVS

33886 Blank PLMT DSTL XTN PROSTH DLYD AFTER EVASC RPR DTA Surgery Blank 18.09 5.97 5.97 Blank RBRVS

33889 Blank OPN SUBCLA CRTD ART TRPOS NCK INC ULAT Surgery Blank 15.92 3.49 3.49 Blank RBRVS

33891 Blank BYP GRF W/DESCENDING THORACIC AORTA RPR NECK INC Surgery Blank 20.00 3.46 3.46 Blank RBRVS

33910 Blank PULMONARY ARTERY EMBOLECTOMY W/CARD BYPASS Surgery Blank 48.21 17.37 17.37 Blank RBRVS

33915 Blank PULMONARY ARTERY EMBOLECTOMY W/O CARD BYPASS Surgery Blank 24.95 9.38 9.38 Blank RBRVS

33916 Blank PULMONARY ENDARTERCOMY W/WO EMBOLECTOMY W/BYPASS Surgery Blank 78.00 26.62 26.62 Blank RBRVS

33917 Blank RPR PULMONARY ART STENOSIS RCNSTJ W/PATCH/GRAFT Surgery Blank 25.30 11.04 11.04 Blank RBRVS

33920 Blank RPR PULMONARY ATRESIA W/CONSTJ/RPLCMT CONDUIT Surgery Blank 32.74 12.12 12.12 Blank RBRVS

33922 Blank TRANSECTION PULMONARY ARTERY W/CARD BYPASS Surgery Blank 24.22 10.40 10.40 Blank RBRVS

33924 Blank LIG&TKDN SYSIC-TO-PULM ART SHUNT W/CGEN HEART Surgery Blank 5.49 1.53 1.53 Blank RBRVS

33925 Blank RPR P-ART ARBORIZJ ANOMAL UNIFCLIZJ W/O BYPASS Surgery Blank 31.30 11.26 11.26 Blank RBRVS

33926 Blank RPR P-ART ARBORIZJ ANOMAL UNIFCLIZJ W/BYPASS Surgery Blank 44.73 15.00 15.00 Blank RBRVS

33927 Blank IMPLTJ TOT RPLCMT HRT SYS Surgery Blank 49.00 13.45 13.45 Blank RBRVS

33935 Blank HEART-LUNG TRNSPL W/RECIPIENT CARDIECTOMY-PNUMEC Surgery Blank 91.78 32.44 32.44 Blank RBRVS

33940 Blank DONOR CARDIECTOMY Surgery Blank Blank Blank Blank 39.56 v3.23

33944 Blank BKBENCH PREPJ CADAVER DONOR HEART ALLOGRAFT Surgery Blank Blank Blank Blank 12.52 FAIR Health

33945 Blank HEART TRANSPLANT W/WO RECIPIENT CARDIECTOMY Surgery Blank 89.50 30.80 30.80 Blank RBRVS

33946 Blank ECMO/ECLS INITIATION VENO-VENOUS Surgery Blank 6.00 1.76 1.76 Blank RBRVS

33947 Blank ECMO/ECLS INITIATION VENO-ARTERIAL Surgery Blank 6.63 1.94 1.94 Blank RBRVS

33948 Blank ECMO/ECLS DAILY MANAGEMENT EACH DAY VENO-VENOUS Surgery Blank 4.73 1.45 1.45 Blank RBRVS

33949 Blank ECMO/ECLS DAILY MANAGEMENT EA DAY VENO-ARTERIAL Surgery Blank 4.60 1.34 1.34 Blank RBRVS

33951 Blank ECMO/ECLS INSJ OF PRPH CANNULA BIRTH-5 YRS PERQ Surgery Blank 8.15 2.34 2.34 Blank RBRVS

33952 Blank ECMO/ECLS INSJ OF PRPH CANNULA 6 YRS&OLDER PERQ Surgery Blank 8.15 2.47 2.47 Blank RBRVS

33953 Blank ECMO/ECLS INSJ OF PRPH CANNULA BIRTH-5 YRS OPEN Surgery Blank 9.11 2.60 2.60 Blank RBRVS

33954 Blank ECMO/ECLS INSJ OF PRPH CANNULA 6 YRS&OLDER OPEN Surgery Blank 9.11 2.72 2.72 Blank RBRVS

33955 Blank ECMO/ECLS INSJ OF CENTRAL CANNULA BIRTH-5 YRS Surgery Blank 16.00 4.50 4.50 Blank RBRVS

33956 Blank ECMO/ECLS INSJ OF CENTRAL CANNULA 6 YRS & OLDER Surgery Blank 16.00 4.64 4.64 Blank RBRVS

33957 Blank ECMO/ECLS REPOS PERIPH CANNULA PERQ BIRTH-5 YRS Surgery Blank 3.51 1.06 1.06 Blank RBRVS

33958 Blank ECMO/ECLS REPOS PERPH CANNULA PRQ 6 YRS & OLDER Surgery Blank 3.51 1.07 1.07 Blank RBRVS

33959 Blank ECMO/ECLS REPOS PERPH CANNULA OPEN BIRTH-5 YRS Surgery Blank 4.47 1.33 1.33 Blank RBRVS

33962 Blank ECMO/ECLS REPOS PERPH CANNULA OPEN 6 YRS & OLDER Surgery Blank 4.47 1.35 1.35 Blank RBRVS

33963 Blank ECMO/ECLS REPOS CENTRAL PERPH CANNULA BIRTH-5YRS Surgery Blank 9.00 2.57 2.57 Blank RBRVS

33964 Blank ECMO/ECLS ECLS REPOS CENTRAL CNULA 6YRS & OLDER Surgery Blank 9.50 2.71 2.71 Blank RBRVS

33965 Blank ECMO/ECLS RMVL OF PERPH CANNULA PERQ BIRTH-5 YRS Surgery Blank 3.51 1.06 1.06 Blank RBRVS

33966 Blank ECMO/ECLS RMVL OF PRPH CANNULA PRQ 6 YRS & OLDER Surgery Blank 4.50 1.40 1.40 Blank RBRVS

33967 Blank INSERTION INTRA-AORTIC BALLOON ASSIST DEV PERQ Surgery Blank 4.84 1.62 1.62 Blank RBRVS

33968 Blank REMOVAL INTRA-AORTIC BALLOON ASSIST DEVICE PRQ Surgery Blank 0.64 0.21 0.21 Blank RBRVS

33969 Blank ECMO/ECLS RMVL OF PERPH CANNULA OPEN BIRTH-5 YRS Surgery Blank 5.22 1.54 1.54 Blank RBRVS

33970 Blank INSJ INTRA-AORT BALO ASSIST DEV VIA FEM ART OPEN Surgery Blank 6.74 2.06 2.06 Blank RBRVS

33971 Blank RMVL I-AORT BALO ASST DEV W/RPR FEM ART W/WO GRF Surgery Blank 11.99 5.85 5.85 Blank RBRVS

33973 Blank INSJ I-AORT BALO ASSIST DEV VIA ASCENDING AORTA Surgery Blank 9.75 3.01 3.01 Blank RBRVS

33974 Blank RMVL ASCENDING-AORTA BALO DEV W/RPR ASCEND-AORTA Surgery Blank 15.03 7.28 7.28 Blank RBRVS

33975 Blank INSJ VENTRIC ASSIST DEV XTRCORP SINGLE VENTRICLE Surgery Blank 25.00 7.28 7.28 Blank RBRVS

33976 Blank INSJ VENTRIC ASSIST DEV XTRCORP BIVENTRICULAR Surgery Blank 30.75 8.45 8.45 Blank RBRVS

33977 Blank REMOVAL VENTR ASSIST DEVICE XTRCORP 1 VENTRICLE Surgery Blank 20.86 7.03 7.03 Blank RBRVS

33978 Blank REMOVAL VENTR ASSIST DEVICE XTRCORP BIVENTR Surgery Blank 25.00 8.08 8.08 Blank RBRVS

33979 Blank INSJ VENTR ASSIST DEV IMPLTABLE ICORP 1 VNTRC Surgery Blank 37.50 10.63 10.63 Blank RBRVS

33980 Blank RMVL VENTR ASSIST DEV IMPLTABLE ICORP 1 VNTRC Surgery Blank 33.50 10.64 10.64 Blank RBRVS





PAGE 38 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

33981 Blank RPLCMT XTRCORP VAD 1/BIVENTR PUMP 1/EA PUMP Surgery Blank 16.11 4.43 4.43 Blank RBRVS

33982 Blank PLCMT VAD PMP IMPLTBL ICORP 1 VENTR W/O BYPASS Surgery Blank 37.86 10.40 10.40 Blank RBRVS

33983 Blank RPLCMT VAD PMP IMPLTBL ICORP 1 VNTR W/BYPASS Surgery Blank 44.54 12.53 12.53 Blank RBRVS

33984 Blank ECMO/ECLS RMVL PRPH CANNULA OPEN 6 YRS & OLDER Surgery Blank 5.46 1.60 1.60 Blank RBRVS

33985 Blank ECMO/ECLS REMOVAL OF CENTRAL CANNULA BIRTH-5 YRS Surgery Blank 9.89 2.82 2.82 Blank RBRVS

33986 Blank ECMO/ECLS RMVL OF CENTRAL CANNULA 6 YRS & OLDER Surgery Blank 10.00 2.90 2.90 Blank RBRVS

33987 Blank ARTERY EXPOS/GRAFT ARTERY PERFUSION ECMO/ECLS Surgery Blank 4.04 1.11 1.11 Blank RBRVS

33988 Blank INSERT LEFT HEART VENT BY THORACIC INC ECMO/ECLS Surgery Blank 15.00 4.22 4.22 Blank RBRVS

33989 Blank RMVL LEFT HEART VENT BY THORACIC INCIS ECMO/ECLS Surgery Blank 9.50 2.71 2.71 Blank RBRVS

33990 Blank INSJ PERQ VAD W/IMAGING ARTERY ACCESS ONLY Surgery Blank 7.90 2.69 2.69 Blank RBRVS

33991 Blank INSJ PERQ VAD TRNSPTAL W/IMAGE ART&VENOUS ACCESS Surgery Blank 11.63 3.93 3.93 Blank RBRVS

33992 Blank REMOVAL PERCUTANEOUS VAD DIFFERENT SESSION Surgery Blank 3.75 1.22 1.22 Blank RBRVS

33993 Blank REPOSITION VAD W/IMAGING DIFFERENT SESSION Surgery Blank 3.26 1.10 1.10 Blank RBRVS

33999 Blank UNLISTED CARDIAC SURGERY Surgery Blank Blank Blank Blank 12.96 Unlisted

34001 Blank EMBLC/THRMBC CATH CRTD SUBCLA/INNOMINATE ART Surgery Blank 17.88 4.59 4.59 Blank RBRVS

34051 Blank EMBLC/THRMBC INNOMINATE SUBCLAVIAN ARTERY Surgery Blank 16.99 7.83 7.83 Blank RBRVS

34101 Blank EMBLC/THRMBC AX BRACH INNOMINATE SUBCLA ART Surgery Blank 10.93 4.01 4.01 Blank RBRVS

34111 Blank EMBLC/THRMBC W/WO CATH RADIAL/ULNAR ART ARM INC Surgery Blank 10.93 4.03 4.03 Blank RBRVS

34151 Blank EMBLC/THRMBC RNL CELIAC MESENTRY AORTO-ILIAC ART Surgery Blank 26.52 8.09 8.09 Blank RBRVS

34201 Blank EMBLC/THRMBC FEMORAL POPLITEAL AORTO-ILIAC ART Surgery Blank 19.48 6.03 6.03 Blank RBRVS

34203 Blank EMBLC/THRMBC POPLITEAL-TIBIO-PRONEAL ART LEG INC Surgery Blank 17.86 5.81 5.81 Blank RBRVS

34401 Blank THRMBC DIR/W/CATH VENA CAVA ILIAC VEIN ABDL INC Surgery Blank 26.52 10.23 10.23 Blank RBRVS

34421 Blank THRMBC DIR/W/CATH V/C ILIAC FEMPOP VEIN LEG INC Surgery Blank 13.37 4.97 4.97 Blank RBRVS

34451 Blank THRMBC DIR/W/CATH V/C ILIAC FEMPOP VEIN ABDL&LEG Surgery Blank 28.52 6.62 6.62 Blank RBRVS

34471 Blank THRMBC DIR/W/CATH SUBCLAVIAN VEIN NECK INC Surgery Blank 21.11 5.34 5.34 Blank RBRVS

34490 Blank THRMBC DIR/W/CATH AXILL&SUBCLAVIAN VEIN ARM IN Surgery Blank 10.91 4.52 4.52 Blank RBRVS

34501 Blank VALVULOPLASTY FEMORAL VEIN Surgery Blank 16.85 5.17 5.17 Blank RBRVS

34502 Blank RECONSTRUCTION VENA CAVA ANY METHOD Surgery Blank 28.07 10.72 10.72 Blank RBRVS

34510 Blank VENOUS VALVE TRANSPOSITION ANY VEIN DONOR Surgery Blank 19.91 5.14 5.14 Blank RBRVS

34520 Blank CROSS-OVER VEIN GRAFT VENOUS SYSTEM Surgery Blank 19.18 5.11 5.11 Blank RBRVS

34530 Blank SAPHENOPOPLITEAL VEIN ANASTOMOSIS Surgery Blank 17.93 5.17 5.17 Blank RBRVS

34701 Blank EVASC RPR A-AO NDGFT Surgery Blank 23.71 7.10 7.10 Blank RBRVS

34702 Blank EVASC RPR A-AO NDGFT RPT Surgery Blank 36.00 10.11 10.11 Blank RBRVS

34703 Blank EVASC RPR A-UNILAC NDGFT Surgery Blank 26.52 7.78 7.78 Blank RBRVS

34704 Blank EVASC RPR A-UNILAC NDGFT RPT Surgery Blank 45.00 12.23 12.23 Blank RBRVS

34705 Blank EVAC RPR A-BIILIAC NDGFT Surgery Blank 29.58 8.56 8.56 Blank RBRVS

34706 Blank EVASC RPR A-BIILIAC RPT Surgery Blank 45.00 12.34 12.34 Blank RBRVS

34707 Blank EVASC RPR ILIO-ILIAC NDGFT Surgery Blank 22.28 6.42 6.42 Blank RBRVS

34708 Blank EVASC RPR ILIO-ILIAC RPT Surgery Blank 36.50 9.69 9.69 Blank RBRVS

34709 Blank PLMT XTN PROSTH EVASC RPR Surgery Blank 6.50 1.49 1.49 Blank RBRVS

34710 Blank DLYD PLMT XTN PROSTH 1ST VSL Surgery Blank 15.00 5.08 5.08 Blank RBRVS

34711 Blank DLYD PLMT XTN PROSTH EA ADDL Surgery Blank 6.00 1.37 1.37 Blank RBRVS

34712 Blank TCAT DLVR ENHNCD FIXJ DEV Surgery Blank 12.00 5.49 5.49 Blank RBRVS

34713 Blank PERQ ACCESS & CLSR FEM ART Surgery Blank 2.50 0.73 0.73 Blank RBRVS

34714 Blank OPN FEM ART EXPOS CNDT CRTJ Surgery Blank 5.25 1.57 1.57 Blank RBRVS

34715 Blank OPN AX/SUBCLA ART EXPOS Surgery Blank 6.00 1.65 1.65 Blank RBRVS

34716 Blank OPN AX/SUBCLA ART EXPOS CNDT Surgery Blank 7.19 2.30 2.30 Blank RBRVS

34808 Blank EVASC PLACEMENT ILIAC ARTERY OCCLUSION DEVICE Surgery Blank 4.12 0.97 0.97 Blank RBRVS

34812 Blank OPN FEM ART EXPOS DLVR EVASC PROSTH UNI Surgery Blank 4.13 0.95 0.95 Blank RBRVS

34813 Blank PLMT FEM-FEM PROSTC GRF EVASC AORTIC ARYSM RPR Surgery Blank 4.79 1.00 1.00 Blank RBRVS

34820 Blank ILIAC ART EXPOS PROSTH/ILIAC OCCLS EVASC UNI Surgery Blank 7.00 1.67 1.67 Blank RBRVS

34830 Blank OPN RPR ARYSM RPR ARTL TRAUMA TUBE PROSTH Surgery Blank 35.23 7.87 7.87 Blank RBRVS

34831 Blank OPN RPR ARYSM RPR ARTL TRMA AORTOBIILIAC PROSTH Surgery Blank 37.98 9.46 9.46 Blank RBRVS

34832 Blank OPN RPR ARYSM RPR ARTL TRMA AORTO-BIFEM PROSTH Surgery Blank 37.98 8.35 8.35 Blank RBRVS

34833 Blank ILIAC ART EXPOS W/CRTJ CONDUIT UNI Surgery Blank 8.16 1.78 1.78 Blank RBRVS

34834 Blank BRACH ART EXPOS DPLMNT AORTIC/ILIAC PROSTH UNI Surgery Blank 2.65 0.54 0.54 Blank RBRVS

34841 Blank ENDOVASC VISCER AORTA REPAIR FENEST 1 ENDOGRAFT Surgery Blank Blank Blank Blank 15.50 v3.23



34844 Blank ENDOVASC VISCER AORTA REPR FENEST 4+ ENDOGRAFT Surgery Blank Blank Blank Blank 62.00 v3.23

34845 Blank VISCER AND INFRARENAL ABDOM AORTA 1 PROSTHESIS Surgery Blank Blank Blank Blank 21.51 v3.23

34846 Blank VISCER AND INFRARENAL ABDOM AORTA 2 PROSTHESIS Surgery Blank Blank Blank Blank 58.98 FAIR Health

34847 Blank VISCER AND INFRARENAL ABDOM AORTA 3 PROSTHESIS Surgery Blank Blank Blank Blank 79.93 FAIR Health

34848 Blank VISCER AND INFRARENAL ABDOM AORTA 4+ PROSTHESIS Surgery Blank Blank Blank Blank 85.56 FAIR Health

35001 Blank DIR RPR ANEURYSM CAROTID-SUBCLAVIAN ARTERY Surgery Blank 20.81 7.10 7.10 Blank RBRVS

35002 Blank DIR RPR RUPTD ANEURYSM CAROTID-SUBCLAVIAN ARTERY Surgery Blank 22.23 5.61 5.61 Blank RBRVS

35005 Blank DIR RPR ANEURYSM VERTEBRAL ARTERY Surgery Blank 19.29 5.10 5.10 Blank RBRVS

35011 Blank DIR RPR ANEURYSM AXIL-BRACHIAL ARM INCISION Surgery Blank 18.58 6.39 6.39 Blank RBRVS

35013 Blank DIR RPR RUPTD ANEURYSM AXIL-BRACHIAL ARM INCIS Surgery Blank 23.23 8.04 8.04 Blank RBRVS

35021 Blank DIR RPR ANEURYSM INNOMINATE/SUBCLAVIAN ARTERY Surgery Blank 22.17 9.25 9.25 Blank RBRVS

35022 Blank DIR RPR RUPTD ANEURYSM INNOMINATE/SUBCLAVIAN Surgery Blank 25.70 10.23 10.23 Blank RBRVS

35045 Blank DIR RPR RUPTD ANEURYSM RADIAL/ULNAR ARTERY Surgery Blank 18.01 6.66 6.66 Blank RBRVS





PAGE 39 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

35081 Blank DIR RPR ANEURYSM ABDOMINAL AORTA Surgery Blank 33.53 9.50 9.50 Blank RBRVS

35082 Blank DIR RPR RUPTD ANEURYSM ABDOMINAL AORTA Surgery Blank 42.09 12.09 12.09 Blank RBRVS

35091 Blank DIR RPR ANEURYSM ABDOM AORTA W/VISCERAL VESSELS Surgery Blank 35.35 8.61 8.61 Blank RBRVS

35092 Blank DIR RPR RUPTD ANEURSM ABDOM AORTA W/VISCERA VSLS Surgery Blank 50.97 12.96 12.96 Blank RBRVS

35102 Blank DIR RPR ANEURYSM ABDOM AORTA W/ILIAC VESSELS Surgery Blank 36.53 9.88 9.88 Blank RBRVS

35103 Blank DIR RPR RUPTD ANEURYSM ABDOM AORTA W/ILIAC VSLS Surgery Blank 43.62 11.64 11.64 Blank RBRVS

35111 Blank DIR RPR ANEURYSM SPLENIC ARTERY Surgery Blank 26.28 6.25 6.25 Blank RBRVS

35112 Blank DIR RPR RUPTD ANEURYSM SPLENIC ARTERY Surgery Blank 32.57 7.42 7.42 Blank RBRVS

35121 Blank DIR RPR ANEURYSM HEPATIC/CELIAC/RENAL/MESENTERIC Surgery Blank 31.52 9.31 9.31 Blank RBRVS

35122 Blank DIR RPR RUPTD ANEURSM HEPATIC/CELIAC/RENAL/MESEN Surgery Blank 37.89 8.33 8.33 Blank RBRVS

35131 Blank DIR RPR ANEURYSM & GRAFT ILIAC ARTERY Surgery Blank 26.40 8.11 8.11 Blank RBRVS

35132 Blank DIR RPR RUPTD ANEURYSM & GRAFT ILIAC ARTERY Surgery Blank 32.57 7.42 7.42 Blank RBRVS

35141 Blank DIR RPR ANEURYSM & GRAFT COMMON FEMORAL ARTERY Surgery Blank 20.91 6.49 6.49 Blank RBRVS

35142 Blank DIR RPR RUPTD ANEURYSM & GRF COMMON FEMORAL ART Surgery Blank 25.16 7.78 7.78 Blank RBRVS

35151 Blank DIR RPR ANEURYSM & GRAFT POPLITEAL ARTERY Surgery Blank 23.72 7.03 7.03 Blank RBRVS

35152 Blank DIR RPR RUPTD ANEURYSM & GRF POPLITEAL ARTERY Surgery Blank 27.66 6.56 6.56 Blank RBRVS

35180 Blank REPAIR CONGENITAL AV FISTULA HEAD & NECK Surgery Blank 15.10 6.73 6.73 Blank RBRVS

35182 Blank RPR CONGENITAL AV FISTULA THORAX & ABDOMEN Surgery Blank 31.71 12.69 12.69 Blank RBRVS

35184 Blank RPR CONGENITAL AV FISTULA EXTREMITIES Surgery Blank 18.82 4.83 4.83 Blank RBRVS

35188 Blank RPR/TRAUMATIC AV FISTULA HEAD & NECK Surgery Blank 18.00 12.30 12.30 Blank RBRVS

35189 Blank RPR/TRAUMATIC AV FISTULA THORAX & ABDOMEN Surgery Blank 29.98 6.96 6.96 Blank RBRVS

35190 Blank RPR/TRAUMATIC AV FISTULA EXTREMITIES Surgery Blank 13.42 5.68 5.68 Blank RBRVS

35201 Blank REPAIR BLOOD VESSEL DIRECT NECK Surgery Blank 16.93 6.57 6.57 Blank RBRVS

35206 Blank REPAIR BLOOD VESSEL DIRECT UPPER EXTREMITY Surgery Blank 13.84 5.81 5.81 Blank RBRVS

35207 Blank REPAIR BLOOD VESSEL DIRECT HAND FINGER Surgery Blank 10.94 8.97 8.97 Blank RBRVS

35211 Blank RPR BLOOD VESSEL DIRECT INTRATHORACIC W/BYPASS Surgery Blank 24.58 10.00 10.00 Blank RBRVS

35216 Blank RPR BLOOD VESSEL DIRECT INTRATHORACIC W/O BYPASS Surgery Blank 36.61 14.75 14.75 Blank RBRVS

35221 Blank RPR BLOOD VESSEL DIRECT INTRA-ABDOMINAL Surgery Blank 26.62 9.75 9.75 Blank RBRVS

35226 Blank RPR BLOOD VESSEL DIRECT LOWER EXTREMITY Surgery Blank 15.30 5.49 5.49 Blank RBRVS

35231 Blank REPAIR BLOOD VESSEL W/VEIN GRAFT NECK Surgery Blank 21.16 10.95 10.95 Blank RBRVS

35236 Blank REPAIR BLOOD VESSEL W/VEIN GRAFT UPPER EXTREMITY Surgery Blank 18.02 6.98 6.98 Blank RBRVS

35241 Blank RPR BLOOD VESSEL VEIN GRAFT INTRATHORACIC W/BYP Surgery Blank 25.58 10.53 10.53 Blank RBRVS

35246 Blank RPR BLOOD VESSEL VEIN GRF INTRATHORACIC W/O BYP Surgery Blank 28.23 10.78 10.78 Blank RBRVS

35251 Blank REPAIR BLOOD VESSEL VEIN GRAFT INTRA-ABDOMINAL Surgery Blank 31.91 11.10 11.10 Blank RBRVS

35256 Blank REPAIR BLOOD VESSEL VEIN GRAFT LOWER EXTREMITY Surgery Blank 19.06 6.43 6.43 Blank RBRVS

35261 Blank REPAIR BLOOD VESSEL W/GRAFT OTHER/THAN VEIN NECK Surgery Blank 18.96 7.35 7.35 Blank RBRVS

35266 Blank RPR BLOOD VSL GRF OTH/THN VEIN UPPER EXTREMITY Surgery Blank 15.83 5.69 5.69 Blank RBRVS

35271 Blank RPR BLOOD VSL GRF OTH/THN VEIN INTRATHRC W/BYP Surgery Blank 24.58 9.77 9.77 Blank RBRVS

35276 Blank RPR BLOOD VSL GRF OTH/THN VEIN INTRATHRC W/O BYP Surgery Blank 25.83 10.54 10.54 Blank RBRVS

35281 Blank RPR BLVSL W/GRFT OTHER/THAN VEIN INTRA-ABDOMINAL Surgery Blank 30.06 10.04 10.04 Blank RBRVS

35286 Blank RPR BLVSL W/GRF OTHER/THAN VEIN LOWER EXTREMITY Surgery Blank 17.19 5.99 5.99 Blank RBRVS

35301 Blank TEAEC W/PATCH GRF CAROTID VERTB SUBCLAV NECK INC Surgery Blank 21.16 6.92 6.92 Blank RBRVS

35302 Blank TEAEC W/GRAFT SUPERFICIAL FEMORAL ARTERY Surgery Blank 21.35 6.48 6.48 Blank RBRVS

35303 Blank TEAEC W/GRAFT POPLITEAL ARTERY Surgery Blank 23.60 7.16 7.16 Blank RBRVS

35304 Blank TEAEC W/GRAFT TIBIOPERONEAL TRUNK ARTERY Surgery Blank 24.60 7.19 7.19 Blank RBRVS

35305 Blank TEAEC W/GRAFT TIBIAL/PERONEAL ART 1ST VESSEL Surgery Blank 23.60 6.92 6.92 Blank RBRVS

35306 Blank TEAEC W/GRAFT EA ADDL TIBIAL/PERONEAL ART Surgery Blank 9.25 1.60 1.60 Blank RBRVS

35311 Blank TEAEC W/WO PATCH GRF SUBCLAV INNOM THORACIC INC Surgery Blank 28.60 10.13 10.13 Blank RBRVS

35321 Blank TEAEC W/WO PATCH GRF AXILLARY-BRACHIAL Surgery Blank 16.59 5.55 5.55 Blank RBRVS

35331 Blank TEAEC W/WO PATCH GRAFT ABDOMINAL AORTA Surgery Blank 27.72 8.25 8.25 Blank RBRVS

35341 Blank TEAEC W/WO PATCH GRAFT MESENTERIC CELIAC/RENAL Surgery Blank 26.21 7.81 7.81 Blank RBRVS

35351 Blank TEAEC W/WO PATCH GRAFT ILIAC Surgery Blank 24.61 7.13 7.13 Blank RBRVS

35355 Blank TEAEC W/WO PATCH GRAFT ILIOFEMORAL Surgery Blank 19.86 5.70 5.70 Blank RBRVS

35361 Blank TEAEC W/WO PATCH GRAFT COMBINED AORTOILIAC Surgery Blank 30.24 7.01 7.01 Blank RBRVS

35363 Blank TEAEC W/WO PATCH GRAFT COMBINED AORTOILIOFEMORAL Surgery Blank 32.35 11.48 11.48 Blank RBRVS

35371 Blank TEAEC W/WO PATCH GRAFT COMMON FEMORAL Surgery Blank 15.31 5.04 5.04 Blank RBRVS

35372 Blank TEAEC W/WO PATCH GRAFT DEEP PROFUNDA FEMORAL Surgery Blank 18.58 5.79 5.79 Blank RBRVS

35390 Blank ROPRTJ CRTD TEAEC > 1 MO AFTER ORIGINAL OPRATIO Surgery Blank 3.19 0.73 0.73 Blank RBRVS

35400 Blank ANGIOSCOPY NON-CORONARY VESSEL/GRAFTS THER IVNTJ Surgery Blank 3.00 0.66 0.66 Blank RBRVS

35500 Blank HARVEST UXTR VEIN 1 SGM LOWER EXTREMITY/CABG PX Surgery Blank 6.44 1.41 1.41 Blank RBRVS

35501 Blank BYPASS W/VEIN COMMON-IPSILATERAL CAROTID Surgery Blank 29.09 6.68 6.68 Blank RBRVS

35506 Blank BYPASS W/VEIN CAROTID-SUBCLV/SUBCLAVIAN CAROTID Surgery Blank 25.33 5.88 5.88 Blank RBRVS

35508 Blank BYPASS W/VEIN CAROTID-VERTEBRAL Surgery Blank 26.09 6.51 6.51 Blank RBRVS

35509 Blank BYPASS W/VEIN CAROTID-CONTRALATERAL CAROTID Surgery Blank 28.09 6.54 6.54 Blank RBRVS

35510 Blank BYPASS W/VEIN CAROTID-BRACHIAL Surgery Blank 24.39 5.76 5.76 Blank RBRVS

35511 Blank BYPASS W/VEIN SUBCLAVIAN-SUBCLAVIAN Surgery Blank 22.20 5.25 5.25 Blank RBRVS

35512 Blank BYPASS W/VEIN SUBCLAVIAN-BRACHIAL Surgery Blank 23.89 5.67 5.67 Blank RBRVS

35515 Blank BYPASS W/VEIN SUBCLAVIAN-VERTEBRAL Surgery Blank 26.09 6.51 6.51 Blank RBRVS

35516 Blank BYPASS W/VEIN SUBCLAVIAN-AXILLARY Surgery Blank 24.21 5.69 5.69 Blank RBRVS

35518 Blank BYPASS W/VEIN AXILLARY-AXILLARY Surgery Blank 22.65 5.33 5.33 Blank RBRVS

35521 Blank BYPASS W/VEIN AXILLARY-FEMORAL Surgery Blank 24.13 5.96 5.96 Blank RBRVS

35522 Blank BYPASS W/VEIN AXILLARY-BRACHIAL Surgery Blank 23.15 6.77 6.77 Blank RBRVS





PAGE 40 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

35523 Blank BYPASS W/VEIN BRACHIAL-ULNAR/-RADIAL Surgery Blank 24.13 7.45 7.45 Blank RBRVS

35525 Blank BYPASS W/VEIN BRACHIAL-BRACHIAL Surgery Blank 21.69 6.60 6.60 Blank RBRVS

35526 Blank BYPASS W/VEIN AORTOSUBCLAV/CAROTID/INNOMINATE Surgery Blank 31.55 11.57 11.57 Blank RBRVS

35531 Blank BYPASS W/VEIN AORTOCELIAC/AORTOMESENTERIC Surgery Blank 39.11 11.20 11.20 Blank RBRVS

35533 Blank BYPASS W/VEIN AXILLARY-FEMORAL-FEMORAL Surgery Blank 29.92 6.95 6.95 Blank RBRVS

35535 Blank BYPASS W/VEIN HEPATORENAL Surgery Blank 38.13 8.41 8.41 Blank RBRVS

35536 Blank BYPASS W/VEIN SPLENORENAL Surgery Blank 33.73 7.62 7.62 Blank RBRVS

35537 Blank BYPASS W/VEIN AORTOILIAC Surgery Blank 41.88 9.10 9.10 Blank RBRVS

35538 Blank BYPASS W/VEIN AORTOBI-ILIAC Surgery Blank 47.03 10.01 10.01 Blank RBRVS

35539 Blank BYPASS W/VEIN AORTOFEMORAL Surgery Blank 44.11 9.48 9.48 Blank RBRVS

35540 Blank BYPASS W/VEIN AORTOBIFEMORAL Surgery Blank 49.33 10.38 10.38 Blank RBRVS

35556 Blank BYPASS W/VEIN FEMORAL-POPLITEAL Surgery Blank 26.75 7.98 7.98 Blank RBRVS

35558 Blank BYPASS W/VEIN FEMORAL-FEMORAL Surgery Blank 23.13 7.48 7.48 Blank RBRVS

35560 Blank BYPASS W/VEIN AORTORENAL Surgery Blank 34.03 7.67 7.67 Blank RBRVS

35563 Blank BYPASS W/VEIN ILIOILIAC Surgery Blank 26.12 6.30 6.30 Blank RBRVS

35565 Blank BYPASS W/VEIN ILIOFEMORAL Surgery Blank 25.13 7.68 7.68 Blank RBRVS

35566 Blank BYP FEM-ANT TIBL PST TIBL PRONEAL ART/OTH DSTL Surgery Blank 32.35 8.98 8.98 Blank RBRVS

35570 Blank BYP TIBL-TIBL/PRONEAL-TIBL/TIBL/PRONEAL TRK-TIBL Surgery Blank 29.15 8.42 8.42 Blank RBRVS

35571 Blank BYP W/VEIN POP-TIBL-PRONEAL ART/OTH DSTL VSL Surgery Blank 25.52 7.30 7.30 Blank RBRVS

35572 Blank HARVEST FEMPOP VEIN 1 SGM VASC RCNSTJ PX Surgery Blank 6.81 1.73 1.73 Blank RBRVS

35583 Blank IN-SITU VEIN BYPASS FEMORAL-POPLITEAL Surgery Blank 27.75 8.06 8.06 Blank RBRVS

35585 Blank IN-SITU FEM-ANT TIBL PST TIBL/PRONEAL ART Surgery Blank 32.35 9.09 9.09 Blank RBRVS

35587 Blank IN-SITU VEIN BYP POP-TIBL PRONEAL Surgery Blank 26.21 7.71 7.71 Blank RBRVS

35600 Blank HARVEST UPPER EXTREMITY ARTERY 1 SEGMENT CABG Surgery Blank 4.94 1.37 1.37 Blank RBRVS

35601 Blank BYP OTH/THN VEIN COMMON-IPSILATERAL CAROTID Surgery Blank 27.09 7.54 7.54 Blank RBRVS

35606 Blank BYP OTH/THN VEIN CAROTID-SUBCLAVIAN Surgery Blank 22.46 6.61 6.61 Blank RBRVS

35612 Blank BYP OTH/THN VEIN SUBCLAVIAN-SUBCLAVIAN Surgery Blank 20.35 5.29 5.29 Blank RBRVS

35616 Blank BYP OTH/THN VEIN SUBCLAVIAN-AXILLARY Surgery Blank 21.82 5.19 5.19 Blank RBRVS

35621 Blank BYP OTH/THN VEIN AXILLARY-FEMORAL Surgery Blank 21.03 6.18 6.18 Blank RBRVS

35623 Blank BYP OTH/THN VEIN AXILLARY-POPLITEAL/-TIBIAL Surgery Blank 25.92 6.27 6.27 Blank RBRVS

35626 Blank BYPASS NOT VEIN AORTOSUBCLA/CAROTID/INNOMINATE Surgery Blank 29.14 10.21 10.21 Blank RBRVS

35631 Blank BYP OTH/THN VEIN AORTOCELIAC AORTOMSN AORTORNL Surgery Blank 36.03 9.66 9.66 Blank RBRVS

35632 Blank BYPASS GRAFT W/OTHER THAN VEIN ILIO-CELIAC Surgery Blank 36.13 8.07 8.07 Blank RBRVS

35633 Blank BYPASS GRAFT W/OTHER THAN VEIN ILIO-MESENTERIC Surgery Blank 39.11 10.16 10.16 Blank RBRVS

35634 Blank BYPASS GRAFT W/OTHER THAN VEIN ILIORENAL Surgery Blank 35.33 7.93 7.93 Blank RBRVS

35636 Blank BYP OTH/THN VEIN SPLENORENAL Surgery Blank 31.75 7.27 7.27 Blank RBRVS

35637 Blank BYP OTH/THN VEIN AORTOILIAC Surgery Blank 33.05 9.53 9.53 Blank RBRVS

35638 Blank BYP OTH/THN VEIN AORTOBI-ILIAC Surgery Blank 33.60 10.01 10.01 Blank RBRVS

35642 Blank BYP OTH/THN VEIN CAROTID-VERTEBRAL Surgery Blank 18.94 5.34 5.34 Blank RBRVS

35645 Blank BYP OTH/THN VEIN SUBCLAVIAN-VERTEBRAL Surgery Blank 18.43 4.80 4.80 Blank RBRVS

35646 Blank BYP OTH/THN VEIN AORTOBIFEMORAL Surgery Blank 32.98 9.55 9.55 Blank RBRVS

35647 Blank BYP OTH/THN VEIN AORTOFEMORAL Surgery Blank 29.73 8.79 8.79 Blank RBRVS

35650 Blank BYP OTH/THN VEIN AXILLARY-AXILLARY Surgery Blank 20.16 6.83 6.83 Blank RBRVS

35654 Blank BYP OTH/THN VEIN AXILLARY-FEMORAL-FEMORAL Surgery Blank 26.28 7.62 7.62 Blank RBRVS

35656 Blank BYP OTH/THN VEIN FEMORAL-POPLITEAL Surgery Blank 20.47 6.43 6.43 Blank RBRVS

35661 Blank BYP OTH/THN VEIN FEMORAL-FEMORAL Surgery Blank 20.35 6.63 6.63 Blank RBRVS

35663 Blank BYP OTH/THN VEIN ILIOILIAC Surgery Blank 23.93 5.92 5.92 Blank RBRVS

35665 Blank BYP OTH/THN VEIN ILIOFEMORAL Surgery Blank 22.35 6.80 6.80 Blank RBRVS

35666 Blank BYP OTH/THN VEIN FEM-ANT TIBL PST TIBL/PRONEAL Surgery Blank 23.66 7.81 7.81 Blank RBRVS

35671 Blank BYP OTH/THN VEIN POPLITEAL-TIBIAL/-PERONEAL ART Surgery Blank 20.77 7.02 7.02 Blank RBRVS

35681 Blank BYPASS COMPOSITE GRAFT PROSTHETIC & VEIN Surgery Blank 1.60 0.38 0.38 Blank RBRVS

35682 Blank BYP AUTOG COMPOSIT 2 SEG VEINS FROM 2 LOCATIONS Surgery Blank 7.19 1.48 1.48 Blank RBRVS

35683 Blank BYP AUTOG COMPOSIT 3/> SEG FROM 2/> LOCATION Surgery Blank 8.49 1.47 1.47 Blank RBRVS

35685 Blank PLMT VEIN PATCH/CUFF DSTL ANAST BYP CONDUIT Surgery Blank 4.04 0.82 0.82 Blank RBRVS

35686 Blank CRTJ DSTL ARVEN FSTL LXTR BYP SURG NON-HEMO Surgery Blank 3.34 0.58 0.58 Blank RBRVS

35691 Blank TRPOS&/RIMPLTJ VERTEBRAL CAROTID ART Surgery Blank 18.41 4.80 4.80 Blank RBRVS

35693 Blank TRPOS&/RIMPLTJ VERTEBRAL SUBCLAVIAN ART Surgery Blank 15.73 4.87 4.87 Blank RBRVS

35694 Blank TRPOS&/RIMPLTJ SUBCLAVIAN CAROTID ART Surgery Blank 19.28 4.94 4.94 Blank RBRVS

35695 Blank TRPOS&/RIMPLTJ CAROTID SUBCLAVIAN ART Surgery Blank 20.06 5.08 5.08 Blank RBRVS

35697 Blank RIMPLTJ VISC ART INFRARNL AORTIC PROSTH EA ART Surgery Blank 3.00 0.63 0.63 Blank RBRVS

35700 Blank ROPRTJ > 1 MO AFTER ORIGINAL OPRATION Surgery Blank 3.08 0.67 0.67 Blank RBRVS

35701 Blank EXPL N/FLWD SURG RPR W/WO LYSIS CAROTID ARTERY Surgery Blank 9.19 5.55 5.55 Blank RBRVS

35721 Blank EXPL N/FLWD SURG RPR W/WO LYSIS FEMORAL ARTERY Surgery Blank 7.72 3.88 3.88 Blank RBRVS

35741 Blank EXPL N/FLWD SURG RPR W/WO LYSIS POPLITEAL ARTERY Surgery Blank 8.69 4.44 4.44 Blank RBRVS

35761 Blank EXPL N/FLWD SURG RPR W/WO LYSIS OTHER ARTERY Surgery Blank 5.93 4.17 4.17 Blank RBRVS

35800 Blank EXPL PO HEMRRG THROMBOSIS/INFCTJ NCK Surgery Blank 12.00 6.40 6.40 Blank RBRVS

35820 Blank EXPL PO HEMRRG THROMBOSIS/INFCTJ CH Surgery Blank 36.89 13.17 13.17 Blank RBRVS

35840 Blank EXPL PO HEMRRG THROMBOSIS/INFCTJ ABD Surgery Blank 20.75 9.27 9.27 Blank RBRVS

35860 Blank EXPL PO HEMRRG THROMBOSIS/INFCTJ XTR Surgery Blank 15.25 5.70 5.70 Blank RBRVS

35870 Blank RPR GRF-ENTERIC FSTL Surgery Blank 24.50 6.01 6.01 Blank RBRVS

35875 Blank THRMBC ARTL/VEN GRF OTH/THN HEMO GRF/FSTL Surgery Blank 10.72 4.18 4.18 Blank RBRVS

35876 Blank THRMBC ARTL/VEN GRF XCP HEMO GRF/FSTL W/REVJ GRF Surgery Blank 17.82 5.82 5.82 Blank RBRVS





PAGE 41 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

35879 Blank REVJ LXTR ARTL BYP OPN VEIN PATCH ANGIOP Surgery Blank 17.41 5.66 5.66 Blank RBRVS

35881 Blank REVJ LXTR ARTL BYP OPN W/SGMTL VEIN INTERPOS Surgery Blank 19.35 5.98 5.98 Blank RBRVS

35883 Blank REVISION FEMORAL ANAST OPEN NONAUTOG GRAFT Surgery Blank 23.15 6.72 6.72 Blank RBRVS

35884 Blank REVISION FEMORAL ANAST OPEN W/AUTOG GRAFT Surgery Blank 24.65 5.74 5.74 Blank RBRVS

35901 Blank EXCISION INFECTED NECK GRAFT Surgery Blank 8.38 3.35 3.35 Blank RBRVS

35903 Blank EXCISION INFECTED GRAFT EXTREMITY Surgery Blank 9.53 4.67 4.67 Blank RBRVS

35905 Blank EXCISION INFECTED GRAFT THORAX Surgery Blank 33.52 7.58 7.58 Blank RBRVS

35907 Blank EXCISION INFECTED GRAFT ABDOMEN Surgery Blank 37.27 10.00 10.00 Blank RBRVS

36000 Blank INTRODUCTION NEEDLE/INTRACATHETER VEIN Surgery Blank 0.18 0.07 0.54 Blank RBRVS

36002 Blank INJECTION PX PRQ TX EXTREMITY PSEUDOANEURYSM Surgery Blank 1.96 0.82 2.34 Blank RBRVS

36005 Blank NJX PX XTR VNGRPH W/INTRO NDL/INTRACATH Surgery Blank 0.95 0.30 8.12 Blank RBRVS

36010 Blank INTRO CATHETER SUPERIOR/INFERIOR VENA CAVA Surgery Blank 2.18 0.64 11.13 Blank RBRVS

36011 Blank SLCTV CATH PLMT VEN SYS 1ST ORDER BRANCH Surgery Blank 3.14 0.95 19.91 Blank RBRVS

36012 Blank SLCTV CATH PLMT VEN SYS 2ND ORDER/> SLCTV BRANC Surgery Blank 3.51 1.00 20.08 Blank RBRVS

36013 Blank INTRO CATHETER RIGHT HEART/MAIN PULMONARY ARTERY Surgery Blank 2.52 0.71 18.94 Blank RBRVS

36014 Blank SLCTV CATHETER PLMT LEFT/RIGHT PULMONARY ARTERY Surgery Blank 3.02 0.94 19.11 Blank RBRVS

36015 Blank SLCTV CATH PLMT SEGMENTAL/SUBSEGMENTAL PULM ART Surgery Blank 3.51 1.07 20.60 Blank RBRVS

36100 Blank INTRO NEEDLE/INTRACATH CAROTID/VERTEBRAL ARTERY Surgery Blank 3.02 0.81 10.08 Blank RBRVS

36140 Blank INTRO NEEDLE/INTRACATH EXTREMITY ARTERY Surgery Blank 1.76 0.52 10.01 Blank RBRVS

36160 Blank INTRO NEEDLE/INTRACATH AORTIC TRANSLUMBAR Surgery Blank 2.52 0.78 11.16 Blank RBRVS

36200 Blank INTRODUCTION CATHETER AORTA Surgery Blank 2.77 0.70 12.54 Blank RBRVS

36215 Blank SLCTV CATHJ EA 1ST ORD THRC/BRCH/CPHLC BRNCH Surgery Blank 4.17 1.40 23.86 Blank RBRVS

36216 Blank SLCTV CATHJ 1ST 2ND ORD THRC/BRCH/CPHLC BRNCH Surgery Blank 5.27 1.71 24.82 Blank RBRVS

36217 Blank SLCTV CATHJ 3RD+ ORD SLCTV THRC/BRCH/CPHLC BRNCH Surgery Blank 6.29 2.02 45.28 Blank RBRVS

36218 Blank SLCTV CATHJ EA 2ND+ ORD THRC/BRCH/CPHLC BRNCH Surgery Blank 1.01 0.32 5.98 Blank RBRVS

36221 Blank NONSLCTV CATH THOR AORTA ANGIO INTR/XTRCRANL ART Surgery Blank 3.92 1.12 24.39 Blank RBRVS

36222 Blank SLCTV CATH CAROTID/INNOM ART ANGIO XTRCRANL ART Surgery Blank 5.28 1.75 27.82 Blank RBRVS

36223 Blank SLCTV CATH CAROTID/INNOM ART ANGIO INTRCRANL ART Surgery Blank 5.75 2.08 35.89 Blank RBRVS

36224 Blank SLCTV CATH INTRNL CAROTID ART ANGIO INTRCRNL ART Surgery Blank 6.25 2.53 46.72 Blank RBRVS

36225 Blank SLCTV CATH SUBCLAVIAN ART ANGIO VERTEBRAL ARTERY Surgery Blank 5.75 2.01 34.23 Blank RBRVS

36226 Blank SLCTV CATH VERTEBRAL ART ANGIO VERTEBRAL ARTERY Surgery Blank 6.25 2.48 45.10 Blank RBRVS

36227 Blank SLCTV CATH XTRNL CAROTID ANGIO XTRNL CAROTD CIRC Surgery Blank 2.09 0.78 4.71 Blank RBRVS

36228 Blank SLCTV CATH INTRCRNL BRNCH ANGIO INTRL CAROT/VERT Surgery Blank 4.25 1.64 32.22 Blank RBRVS

36245 Blank SLCTV CATHJ EA 1ST ORD ABDL PEL/LXTR ART BRNCH Surgery Blank 4.65 1.50 31.71 Blank RBRVS

36246 Blank SLCTV CATHJ 2ND ORDER ABDL PEL/LXTR ART BRNCH Surgery Blank 5.02 1.43 17.34 Blank RBRVS

36247 Blank SLCTV CATHJ 3RD+ ORD SLCTV ABDL PEL/LXTR BRNCH Surgery Blank 6.04 1.74 35.44 Blank RBRVS

36248 Blank SLCTV CATHJ EA 2ND+ ORD ABDL PEL/LXTR ART BRNCH Surgery Blank 1.01 0.30 3.21 Blank RBRVS

36251 Blank SLCTV CATH 1STORD W/WO ART PUNCT/FLUORO/S&I UN Surgery Blank 5.10 1.60 33.26 Blank RBRVS

36252 Blank SLCTV CATH 1STORD W/WO ART PUNCT/FLUOR/S&I BIL Surgery Blank 6.74 2.30 34.21 Blank RBRVS

36253 Blank SUPSLCTV CATH 2ND+ORD RENAL&ACCESSORY ARTERY/S&I Surgery Blank 7.30 2.32 54.53 Blank RBRVS

36254 Blank SUPSLCTV CATH 2ND+ORD RENAL&ACCESSORY ARTERY/S&I Surgery Blank 7.90 2.66 51.65 Blank RBRVS

36260 Blank INSJ IMPLANTABLE INTRA-ARTERIAL INFUSION PUM Surgery Blank 9.91 6.44 6.44 Blank RBRVS

36261 Blank REVJ IMPLANTED INTRA-ARTERIAL INFUSION PUMP Surgery Blank 5.63 4.60 4.60 Blank RBRVS

36262 Blank REMOVAL IMPLANTED INTRA-ARTERIAL INFUSION PUMP Surgery Blank 4.11 3.70 3.70 Blank RBRVS

36299 Blank UNLISTED PROCEDURE VASCULAR INJECTION Surgery Blank Blank Blank Blank 0.08 Unlisted

36400 Blank VNPNXR <3 YEARS PHY/QHP SKILL FEMRAL/JUGLAR VEIN Surgery Blank 0.38 0.13 0.35 Blank RBRVS

36405 Blank VNPNXR <3 YEARS PHYS/QHP SKILL SCALP VEIN Surgery Blank 0.31 0.11 0.33 Blank RBRVS

36406 Blank VNPNXR <3 YEARS PHYS/QHP SKILL OTHER VEIN Surgery Blank 0.18 0.06 0.28 Blank RBRVS

36410 Blank VNPNXR 3 YEARS/> PHYS/QHP SKILL Surgery Blank 0.18 0.07 0.28 Blank RBRVS

36416 Blank COLLECTION CAPILLARY BLOOD SPECIMEN Pathology Blank Blank Blank Blank 0.11 FAIR Health

36420 Blank VENIPUNCTURE CUTDOWN UNDER AGE 1 YR Surgery Blank 1.01 0.18 0.18 Blank RBRVS

36425 Blank VENIPUNCTURE CUTDOWN AGE 1 YR/> Surgery Blank 0.76 0.30 0.30 Blank RBRVS

36430 Blank TRANSFUSION BLOOD/BLOOD COMPONENTS Surgery Blank Blank 0.98 0.98 Blank RBRVS

36440 Blank PUSH TRANSFUSION BLOOD 2 YR/UNDER Surgery Blank 1.03 0.36 0.36 Blank RBRVS

36450 Blank EXCHNG TRANSFUSION BLOOD NEWBORN Surgery Blank 3.50 1.21 1.21 Blank RBRVS

36455 Blank EXCHNG TRANSFUSION BLOOD OTHER/THAN NEW BORN Surgery Blank 2.43 0.68 0.68 Blank RBRVS

36456 Blank PRTL EXCHANGE TRANSFUSE NB Surgery Blank 2.00 0.89 0.89 Blank RBRVS

36460 Blank TRANSFUSION INTRAUTERINE FETAL Surgery Blank 6.58 2.54 2.54 Blank RBRVS

36465 Blank NJX NONCMPND SCLRSNT 1 VEIN Surgery Blank 2.35 0.63 42.29 Blank RBRVS

36466 Blank NJX NONCMPND SCLRSNT MLT VN Surgery Blank 3.00 0.80 43.54 Blank RBRVS

36468 Blank 1/MLT NJXS SCLRSG SLNS SPIDER VEINS LIMB/TRUNK Surgery Blank Blank Blank Blank 2.31 FAIR Health

36470 Blank NJX SCLEROSING SOLUTION SINGLE VEIN Surgery Blank 0.75 0.22 2.11 Blank RBRVS

36471 Blank NJX SCLEROSING SOLUTION MULTIPLE VEINS SAME LEG Surgery Blank 1.50 0.45 3.63 Blank RBRVS

36473 Blank ENDOVENOUS MCHNCHEM 1ST VEIN Surgery Blank 3.50 0.93 38.62 Blank RBRVS

36474 Blank ENDOVENOUS MCHNCHEM ADD-ON Surgery Blank 1.75 0.47 5.77 Blank RBRVS

36475 Blank ENDOVEN ABLTJ INCMPTNT VEIN XTR RF 1ST VEIN Surgery Blank 5.30 1.76 36.66 Blank RBRVS

36476 Blank ENDOVEN ABLTJ INCMPTNT VEIN XTR RF 2ND+ VEINS Surgery Blank 2.65 0.74 5.15 Blank RBRVS

36478 Blank ENDOVEN ABLTJ INCMPTNT VEIN XTR LASER 1ST VEIN Surgery Blank 5.30 1.78 28.04 Blank RBRVS

36479 Blank ENDOVEN ABLTJ INCMPTNT VEIN XTR LASER 2ND+ VEINS Surgery Blank 2.65 0.80 5.67 Blank RBRVS

36481 Blank PRQ PORTAL VEIN CATHETERIZATION ANY METHOD Surgery Blank 6.73 2.32 48.36 Blank RBRVS

36482 Blank ENDOVEN THER CHEM ADHES 1ST Surgery Blank 3.50 0.93 55.86 Blank RBRVS

36483 Blank ENDOVEN THER CHEM ADHES SBSQ Surgery Blank 1.75 0.47 1.99 Blank RBRVS





PAGE 42 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

36500 Blank VEN CATHJ SLCTV ORGAN BLD SAMPLING Surgery Blank 3.51 1.20 1.20 Blank RBRVS

36510 Blank CATHJ UMBILICAL VEIN DX/THER NB Surgery Blank 1.09 0.38 1.16 Blank RBRVS

36511 Blank THERAPEUTIC APHERESIS WHITE BLOOD CELLS Surgery Blank 2.00 0.98 0.98 Blank RBRVS

36512 Blank THERAPEUTIC APHERESIS RED BLOOD CELLS Surgery Blank 2.00 0.99 0.99 Blank RBRVS

36513 Blank THERAPEUTIC APHERESIS PLATELETS Surgery Blank 2.00 0.94 0.94 Blank RBRVS

36514 Blank THERAPEUTIC APHERESIS PLASMA PHERESIS Surgery Blank 1.81 0.81 20.13 Blank RBRVS

36516 Blank THER APHRS XTRCORP SLCTV ADSRPJ/FILTRJ & REINFSJ Surgery Blank 1.56 0.63 60.14 Blank RBRVS

36522 Blank PHOTOPHERESIS EXTRACORPOREAL Surgery Blank 1.75 0.93 68.69 Blank RBRVS

36555 Blank INSJ NON-TUNNELED CENTRAL VENOUS CATH AGE < 5 Y Surgery Blank 1.93 0.41 3.19 Blank RBRVS

36556 Blank INSJ NON-TUNNELED CENTRAL VENOUS CATH AGE 5 YR/> Surgery Blank 1.75 0.87 4.02 Blank RBRVS

36557 Blank INSERT TUNNELED CVC W/O SUBQ PORT/PMP AGE <5 YR Surgery Blank 4.89 3.11 20.56 Blank RBRVS

36558 Blank INSJ TUNNELED CVC W/O SUBQ PORT/PMP AGE 5 YR/> Surgery Blank 4.59 2.39 15.11 Blank RBRVS

36560 Blank INSJ TUNNELED CTR VAD W/SUBQ PORT UNDER 5 YR Surgery Blank 6.04 3.53 29.62 Blank RBRVS

36561 Blank INSJ TUNNELED CTR VAD W/SUBQ PORT AGE 5 YR/> Surgery Blank 5.79 3.04 24.08 Blank RBRVS

36563 Blank INSJ TUNNELED CTR VAD W/SUBQ PUMP Surgery Blank 5.99 3.33 27.73 Blank RBRVS

36565 Blank INSJ TUN VAD REQ 2 CATH 2 SITS W/O SUBQ PORT/PMP Surgery Blank 5.79 2.63 18.12 Blank RBRVS

36566 Blank INSJ TUN VAD REQ 2 CATH 2 SITS W/SUBQ PORT Surgery Blank 6.29 3.09 138.86 Blank RBRVS

36568 Blank INSJ PRPH CVC W/O SUBQ PORT/PMP UNDER 5 YR Surgery Blank 1.67 0.31 4.38 Blank RBRVS

36569 Blank INSJ PRPH CVC W/O SUBQ PORT/PMP AGE 5 YR/> Surgery Blank 1.70 0.61 5.18 Blank RBRVS

36570 Blank INSJ PRPH CTR VAD W/SUBQ PORT UNDER 5 YR Surgery Blank 5.11 3.21 33.36 Blank RBRVS

36571 Blank INSJ PRPH CTR VAD W/SUBQ PORT AGE 5 YR/> Surgery Blank 5.09 2.94 28.74 Blank RBRVS

36572 Blank INSJ PICC RS&I <5 YR Surgery Blank 1.82 0.67 9.92 Blank RBRVS

36573 Blank INSJ PICC RS&I 5 YR+ Surgery Blank 1.70 0.57 9.32 Blank RBRVS

36575 Blank RPR TUN/NON-TUN CTR VAD CATH W/O SUBQ PORT/PMP Surgery Blank 0.67 0.25 3.93 Blank RBRVS

36576 Blank RPR CTR VAD W/SUBQ PORT/PMP CTR/PRPH INSJ SIT Surgery Blank 2.99 1.78 5.42 Blank RBRVS

36578 Blank RPLCMT CATH CTR VAD SUBQ PORT/PMP Surgery Blank 3.29 2.05 8.97 Blank RBRVS

36580 Blank RPLCMT COMPL NON-TUN CVC W/O SUBQ PORT/PMP Surgery Blank 1.31 0.46 4.63 Blank RBRVS

36581 Blank RPLCMT COMPL TUN CVC W/O SUBQ PORT/PMP Surgery Blank 3.23 1.68 16.43 Blank RBRVS

36582 Blank RPLCMT COMPL TUN CTR VAD W/SUBQ PORT Surgery Blank 4.99 2.59 22.71 Blank RBRVS

36583 Blank RPLCMT COMPL TUN CTR VAD W/SUBQ PMP Surgery Blank 5.04 3.18 29.79 Blank RBRVS

36584 Blank RPLCMT COMPL PRPH CVC W/O SUBQ PORT/PMP Surgery Blank 1.20 0.60 4.52 Blank RBRVS

36585 Blank RPLCMT COMPL PRPH CTR VAD W/SUBQ PORT Surgery Blank 4.59 2.47 24.73 Blank RBRVS

36589 Blank RMVL TUN CVC W/O SUBQ PORT/PMP Surgery Blank 2.28 1.36 2.09 Blank RBRVS

36590 Blank RMVL TUN CTR VAD W/SUBQ PORT/PMP CTR/PRPH INSJ Surgery Blank 3.10 1.86 2.68 Blank RBRVS

36591 Blank COLLECT BLOOD FROM IMPLANT VENOUS ACCESS DEVICE Surgery a Blank 0.67 0.67 Blank RBRVS

36592 Blank COLLECT BLOOD FROM CATHETER VENOUS NOS Surgery a Blank 0.75 0.75 Blank RBRVS

36593 Blank DECLOT BY THROMBOLYTIC AGENT IMPLANT DEVICE/CATH Surgery a Blank 0.88 0.88 Blank RBRVS

36595 Blank MCHNL RMVL PRICATH OBSTR CV DEV VIA VEN ACCESS Surgery Blank 3.59 1.34 12.80 Blank RBRVS

36596 Blank MCHNL RMVL INTRAL OBSTR CV DEV THRU DEV LUMEN Surgery Blank 0.75 0.44 2.88 Blank RBRVS

36597 Blank RPSG PREVIOUSLY PLACED CVC UNDER FLUOR GDNCE Surgery Blank 1.21 0.43 2.30 Blank RBRVS

36598 Blank CNTRST NJX RAD EVAL CTR VAD FLUOR IMG&REPRT Surgery Blank 0.74 0.25 2.37 Blank RBRVS

36600 Blank ARTERIAL PUNCTURE WITHDRAWAL BLOOD DX Surgery Blank 0.32 0.10 0.58 Blank RBRVS

36620 Blank ARTL CATHJ/CANNULJ MNTR/TRANSFUSION SPX PRQ Surgery Blank 1.00 0.19 0.19 Blank RBRVS

36625 Blank ARTL CATHJ/CANNULJ MNTR/TRANSFUSION SPX CUTDOWN Surgery Blank 2.11 0.60 0.60 Blank RBRVS

36640 Blank ARTL CATHJ PROLNG NFS THER CHEMOTX CUTDOWN Surgery Blank 2.10 1.06 1.06 Blank RBRVS

36660 Blank CATHETERIZATION UMBILICAL NEWBORN ART DX/THERAPY Surgery Blank 1.40 0.49 0.49 Blank RBRVS

36680 Blank PLACEMENT NEEDLE INTRAOSSEOUS INFUSION Surgery Blank 1.20 0.31 0.31 Blank RBRVS

36800 Blank INSJ CANNULA HEMO OTH PURPOSE SPX VEIN VEIN Surgery Blank 2.43 0.78 0.78 Blank RBRVS

36810 Blank INSJ CANNULA HEMO OTH PURPOSE SPX ARVEN XTRNL Surgery Blank 3.96 1.54 1.54 Blank RBRVS

36815 Blank INSJ CANNULA HEMO OTH SPX ARVEN XTRNL REVJ/CLSR Surgery Blank 2.62 0.72 0.72 Blank RBRVS

36818 Blank ARVEN ANAST OPN UPR ARM CEPHALIC VEIN TRPOS Surgery Blank 12.39 4.98 4.98 Blank RBRVS

36819 Blank ARVEN ANAST OPN UPR ARM BASILIC VEIN TRPOS Surgery Blank 13.29 4.96 4.96 Blank RBRVS

36820 Blank ARVEN ANAST OPN F/ARM VEIN TRPOS Surgery Blank 13.07 5.30 5.30 Blank RBRVS

36821 Blank ARTERIOVENOUS ANASTOMOSIS OPEN DIRECT Surgery Blank 11.90 4.71 4.71 Blank RBRVS

36823 Blank INSJ CNULA ISLTD XC-CIRCJ REG CHEMOTX XTR RMVL Surgery Blank 22.98 11.88 11.88 Blank RBRVS

36825 Blank CRTJ ARVEN FSTL XCP DIR ARVEN ANAST AUTOG GRF Surgery Blank 14.17 5.78 5.78 Blank RBRVS

36830 Blank CRTJ ARVEN FSTL XCP DIR ARVEN ANAST NONAUTOG GRF Surgery Blank 12.03 4.63 4.63 Blank RBRVS

36831 Blank THRMBC OPN ARVEN FSTL W/O REVJ DIAL GRF Surgery Blank 11.00 4.43 4.43 Blank RBRVS

36832 Blank REVJ OPN ARVEN FSTL W/O THRMBC DIAL GRF Surgery Blank 13.50 5.43 5.43 Blank RBRVS

36833 Blank REVJ OPN ARVEN FSTL W/THRMBC DIAL GRF Surgery Blank 14.50 5.81 5.81 Blank RBRVS

36835 Blank INSERTION THOMAS SHUNT SEPARATE PROCEDURE Surgery Blank 7.51 4.52 4.52 Blank RBRVS

36838 Blank DSTL REVSC&INTERVAL LIG UXTR HEMO ACCESS Surgery Blank 21.69 6.73 6.73 Blank RBRVS

36860 Blank XTRNL CANNULA DECLTNG SPX W/O BALO CATH Surgery Blank 2.01 0.96 3.80 Blank RBRVS

36861 Blank XTRNL CANNULA DECLTNG SPX W/BALO CATH Surgery Blank 2.52 0.89 0.89 Blank RBRVS

36901 Blank INTRO CATH DIALYSIS CIRCUIT Surgery Blank 3.36 1.06 13.14 Blank RBRVS



36904 Blank THRMBC/NFS DIALYSIS CIRCUIT Surgery Blank 7.50 2.24 42.82 Blank RBRVS



36907 Blank BALO ANGIOP CTR DIALYSIS SEG Surgery Blank 3.00 0.85 17.96 Blank RBRVS

36908 Blank STENT PLMT CTR DIALYSIS SEG Surgery Blank 4.25 1.19 71.84 Blank RBRVS





PAGE 43 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

36909 Blank DIALYSIS CIRCUIT EMBOLJ Surgery Blank 4.12 1.23 50.97 Blank RBRVS

37140 Blank VENOUS ANASTOMOSIS OPEN PORTOCAVAL Surgery Blank 40.00 17.61 17.61 Blank RBRVS

37145 Blank VENOUS ANASTOMOSIS OPEN RENOPORTAL Surgery Blank 37.00 16.45 16.45 Blank RBRVS

37160 Blank VENOUS ANASTOMOSIS OPEN CAVAL-MESENTERIC Surgery Blank 38.00 16.91 16.91 Blank RBRVS

37180 Blank VENOUS ANASTOMOSIS OPEN SPLENORENAL PROXIMAL Surgery Blank 36.50 16.33 16.33 Blank RBRVS

37181 Blank VENOUS ANASTOMOSIS OPEN SPLENORENAL DISTAL Surgery Blank 40.00 17.61 17.61 Blank RBRVS

37182 Blank INSJ TRANSVNS INTRAHEPATC PORTOSYSIC SHUNT Surgery Blank 16.97 5.46 5.46 Blank RBRVS

37183 Blank REVJ TRANSVNS INTRAHEPATIC PORTOSYSTEMIC SHUNT Surgery Blank 7.74 2.49 156.43 Blank RBRVS

37184 Blank PRIM PRQ TRLUML MCHNL THRMBC N-COR N-ICRA 1ST Surgery Blank 8.41 2.93 52.64 Blank RBRVS

37185 Blank PRIM PRQ TRLUML MCHNL THRMBC N-COR N-ICRA SBSQ Surgery Blank 3.28 0.93 16.00 Blank RBRVS

37186 Blank SEC PRQ TRLUML THRMBC N-CORONARY N-INTRACRANIAL Surgery Blank 4.92 1.27 31.93 Blank RBRVS

37187 Blank PRQ TRANSLUMINAL MECHANICAL THROMBECTOMY VEIN Surgery Blank 7.78 2.43 47.25 Blank RBRVS

37188 Blank PRQ TRLUML MCHNL THRMBC VEIN REPEAT TX Surgery Blank 5.46 1.85 41.16 Blank RBRVS

37191 Blank INS INTRVAS VC FILTR W/WO VAS ACS VSL SELXN RS&I Surgery Blank 4.46 1.45 67.64 Blank RBRVS

37192 Blank REPSNG INTRVAS VC FILTR W/WO ACS VSL SELXN RS& Surgery Blank 7.10 1.48 29.63 Blank RBRVS

37193 Blank RTRVL INTRVAS VC FILTR W/WO ACS VSL SELXN RS&I Surgery Blank 7.10 2.11 35.32 Blank RBRVS

37195 Blank THROMBOLYSIS CEREBRAL IV INFUSION Surgery Blank Blank Blank Blank 7.81 FAIR Health

37197 Blank PRQ TRANSCATHETER RTRVL INTRVAS FB WITH IMAGING Surgery Blank 6.04 1.80 34.17 Blank RBRVS

37200 Blank TRANSCATHETER BIOPSY Surgery Blank 4.55 1.37 1.37 Blank RBRVS

37211 Blank THROMBOLYSIS ARTERIAL INFUSION ICRA RS&I INIT TX Surgery Blank 7.75 2.14 2.14 Blank RBRVS

37212 Blank THROMBOLYSIS VENOUS INFUSION W/IMAGING INIT TX Surgery Blank 6.81 1.94 1.94 Blank RBRVS

37213 Blank THROMBOLYSIS ART/VENOUS INFSN W/IMAGE SUBSQ TX Surgery Blank 4.75 1.36 1.36 Blank RBRVS

37214 Blank CESSATION THROMBOLYTIC THER W/CATHETER REMOVAL Surgery Blank 2.49 0.70 0.70 Blank RBRVS

37215 Blank TCAT IV STENT CRV CRTD ART EMBOLIC PROTECJ Surgery Blank 17.75 7.26 7.26 Blank RBRVS

37216 Blank TCAT IV STENT CRV CRTD ART W/O EMBOLIC PROTECJ Surgery Blank 17.98 8.91 8.91 Blank RBRVS

37217 Blank TCATH STENT PLACEMT RETROGRAD CAROTID/INNOMINATE Surgery Blank 20.38 6.67 6.67 Blank RBRVS

37218 Blank TCATH STENT PLACEMT ANTEGRADE CAROTID/INNOMINATE Surgery Blank 14.75 5.69 5.69 Blank RBRVS

37220 Blank REVASCULARIZATION ILIAC ARTERY ANGIOP 1ST VSL Surgery Blank 7.90 2.13 77.12 Blank RBRVS

37221 Blank REVSC OPN/PRQ ILIAC ART W/STNT PLMT & ANGIOPLSTY Surgery Blank 9.75 2.67 116.84 Blank RBRVS

37222 Blank REVASCULARIZATION ILIAC ART ANGIOP EA IPSI VSL Surgery Blank 3.73 0.92 19.84 Blank RBRVS

37223 Blank REVSC OPN/PRQ ILIAC ART W/STNT & ANGIOP IPSILATL Surgery Blank 4.25 1.08 66.93 Blank RBRVS

37224 Blank REVSC OPN/PRG FEM/POP W/ANGIOPLASTY UNI Surgery Blank 8.75 2.41 94.73 Blank RBRVS

37225 Blank REVSC OPN/PRQ FEM/POP W/ATHRC/ANGIOP SM VSL Surgery Blank 11.75 3.41 294.90 Blank RBRVS

37226 Blank REVSC OPN/PRQ FEM/POP W/STNT/ANGIOP SM VSL Surgery Blank 10.24 2.83 240.35 Blank RBRVS

37227 Blank REVSC OPN/PRQ FEM/POP W/STNT/ATHRC/ANGIOP SM VSL Surgery Blank 14.25 3.98 401.10 Blank RBRVS

37228 Blank REVSC OPN/PRQ TIB/PERO W/ANGIOPLASTY UNI Surgery Blank 10.75 2.89 137.69 Blank RBRVS

37229 Blank REVSC OPN/PRQ TIB/PERO W/ATHRC/ANGIOP SM VSL Surgery Blank 13.80 3.94 288.21 Blank RBRVS

37230 Blank REVSC OPN/PRQ TIB/PERO W/STNT/ANGIOP SM VSL Surgery Blank 13.55 3.98 216.60 Blank RBRVS

37231 Blank REVSC OPN/PRQ TIB/PERO W/STNT/ATHR/ANGIOP SM VSL Surgery Blank 14.75 4.33 360.09 Blank RBRVS

37232 Blank REVSC OPN/PRQ TIB/PERO W/ANGIOPLASTY UNI EA VSL Surgery Blank 4.00 1.07 28.80 Blank RBRVS

37233 Blank REVSC OPN/PRQ TIB/PERO W/ATHRC/ANGIOP UNI EA VSL Surgery Blank 6.50 1.75 32.83 Blank RBRVS

37234 Blank REVSC OPN/PRQ TIB/PERO W/STNT/ANGIOP UNI EA VSL Surgery Blank 5.50 1.65 103.57 Blank RBRVS

37235 Blank REVSC OPN/PRQ TIB/PERO W/STNT/ATHR/ANGIOP EA VSL Surgery Blank 7.80 2.18 107.01 Blank RBRVS

37236 Blank OPEN/PERQ PLACEMENT INTRAVASCULAR STENT INITIAL Surgery Blank 8.75 2.50 98.48 Blank RBRVS

37237 Blank OPEN/PERQ PLACEMENT INTRAVASCULAR STENT EA ADDL Surgery Blank 4.25 1.09 63.45 Blank RBRVS

37238 Blank OPEN/PERQ PLACEMENT INTRAVASCULAR STENT SAME 1ST Surgery Blank 6.04 1.80 111.13 Blank RBRVS

37239 Blank OPEN/PERQ PLACEMENT INTRAVASC STENT SAME EA ADDL Surgery Blank 2.97 0.86 53.59 Blank RBRVS

37241 Blank VASCULAR EMBOLIZATION OR OCCLUSION VENOUS RS&I Surgery Blank 8.75 2.68 123.95 Blank RBRVS

37242 Blank VASCULAR EMBOLIZATION OR OCCLUSION ARTERIAL RS&I Surgery Blank 9.80 2.76 196.43 Blank RBRVS

37243 Blank VASCULAR EMBOLIZE/OCCLUDE ORGAN TUMOR INFARCT Surgery Blank 11.74 3.62 262.25 Blank RBRVS

37244 Blank VASCULAR EMBOLIZATION OR OCCLUSION HEMORRHAGE Surgery Blank 13.75 4.35 176.68 Blank RBRVS

37246 Blank TRLUML BALO ANGIOP 1ST ART Surgery Blank 7.00 2.07 52.54 Blank RBRVS

37247 Blank TRLUML BALO ANGIOP ADDL ART Surgery Blank 3.50 0.98 20.49 Blank RBRVS

37248 Blank TRLUML BALO ANGIOP 1ST VEIN Surgery Blank 6.00 1.81 35.18 Blank RBRVS

37249 Blank TRLUML BALO ANGIOP ADDL VEIN Surgery Blank 2.97 0.84 14.61 Blank RBRVS

37252 Blank INTRAVASCULAR US NONCORONARY RS&I INTIAL VESSEL Surgery Blank 1.80 0.48 36.65 Blank RBRVS

37253 Blank INTRAVASCULAR US NONCORONARY RS&I ADDL VESSEL Surgery Blank 1.44 0.39 4.11 Blank RBRVS

37500 Blank VASC ENDOSCOPY SURG W/LIG PERFORATOR VEINS SPX Surgery Blank 11.67 4.12 4.12 Blank RBRVS

37501 Blank UNLISTED VASCULAR ENDOSCOPY PROCEDURE Surgery Blank Blank Blank Blank 15.79 Unlisted

37565 Blank LIGATION INTERNAL JUGULAR VEIN Surgery Blank 12.05 7.20 7.20 Blank RBRVS

37600 Blank LIGATION EXTERNAL CAROTID ARTERY Surgery Blank 12.42 6.18 6.18 Blank RBRVS

37605 Blank LIGATION INTERNAL/COMMON CAROTID ARTERY Surgery Blank 14.28 3.88 3.88 Blank RBRVS

37606 Blank LIG INT/COMMON CAROTID ART W/GRADUAL OCCLUSION Surgery Blank 8.81 8.45 8.45 Blank RBRVS

37607 Blank LIG/BANDING ANGIOACCESS ARTERIOVENOUS FISTULA Surgery Blank 6.25 3.21 3.21 Blank RBRVS

37609 Blank LIGATION/BIOPSY TEMPORAL ARTERY Surgery Blank 3.05 2.31 5.17 Blank RBRVS

37615 Blank LIGATION MAJOR ARTERY NECK Surgery Blank 7.80 5.47 5.47 Blank RBRVS

37616 Blank LIGATION MAJOR ARTERY CHEST Surgery Blank 18.97 8.74 8.74 Blank RBRVS

37617 Blank LIGATION MAJOR ARTERY ABDOMEN Surgery Blank 23.79 9.79 9.79 Blank RBRVS

37618 Blank LIGATION MAJOR ARTERY EXTREMITY Surgery Blank 6.03 3.73 3.73 Blank RBRVS

37619 Blank INS INTRVAS VC FILTR W/WO VAS ACS VSL SELXN RS&I Surgery Blank 30.00 12.79 12.79 Blank RBRVS

37650 Blank REPSNG INTRVAS VC FILTR W/WO ACS VSL SELXN RS& Surgery Blank 8.49 2.89 2.89 Blank RBRVS

37660 Blank RTRVL INTRVAS VC FILTR W/WO ACS VSL SELXN RS&I Surgery Blank 22.28 10.49 10.49 Blank RBRVS





PAGE 44 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

37700 Blank LIG&DIV LONG SAPH VEIN SAPHFEM JUNCT/INTERRUPJ Surgery Blank 3.82 2.47 2.47 Blank RBRVS

37718 Blank LIGJ DIVJ & STRIPPING SHORT SAPHENOUS VEIN Surgery Blank 7.13 3.77 3.77 Blank RBRVS

37722 Blank LIGJ DIVJ&STRIP LONG SAPH SAPHFEM JUNCT KNE/BELW Surgery Blank 8.16 3.73 3.73 Blank RBRVS

37735 Blank LIGJ & DIVJ RADICAL STRIP LONG/SHORT SAPHENOUS Surgery Blank 10.90 3.45 3.45 Blank RBRVS

37760 Blank LIG PRFRATR VEIN SUBFSCAL RAD INCL SKN GRF 1 LEG Surgery Blank 10.78 4.68 4.68 Blank RBRVS

37761 Blank LIG PRFRATR VEIN SUBFSCAL OPEN INCL US GID 1 LEG Surgery Blank 9.13 4.64 4.64 Blank RBRVS

37765 Blank STAB PHLEBT VARICOSE VEINS 1 XTR 10-20 STAB INCS Surgery Blank 7.71 3.73 9.34 Blank RBRVS

37766 Blank STAB PHLEBT VARICOSE VEINS 1 XTR > 20 INCS Surgery Blank 9.66 4.28 10.53 Blank RBRVS

37780 Blank LIGJ & DIV SHORT SAPH VEIN SAPHENOPOP JUNCT SPX Surgery Blank 3.93 1.96 1.96 Blank RBRVS

37785 Blank LIGJ DIVJ &/EXCJ VARICOSE VEIN CLUSTER 1 LEG Surgery Blank 3.93 2.73 5.29 Blank RBRVS

37788 Blank PENILE REVASCULARIZATION ARTERY W/WO VEIN GRAFT Surgery Blank 23.33 10.74 10.74 Blank RBRVS

37790 Blank PENILE VENOUS OCCLUSIVE PROCEDURE Surgery Blank 8.43 4.78 4.78 Blank RBRVS

37799 Blank UNLISTED PROCEDURE VASCULAR SURGERY Surgery Blank Blank Blank Blank 0.11 Unlisted

38100 Blank SPLENECTOMY TOTAL SEPARATE PROCEDURE Surgery Blank 19.55 9.36 9.36 Blank RBRVS

38101 Blank SPLENECTOMY TOTAL EN BLOC W/OTHER PROCEDURE Surgery Blank 19.55 9.52 9.52 Blank RBRVS

38102 Blank SPLENC TOT EN BLOC EXTNSV DS CONJUNCT W/OTH PX Surgery Blank 4.79 1.77 1.77 Blank RBRVS

38115 Blank RPR RPTD SPLEEN SPLENORRHAPHY W/WO PRTL SPLENECT Surgery Blank 21.88 10.17 10.17 Blank RBRVS

38120 Blank LAPAROSCOPIC SURGICAL SPLENECTOMY Surgery Blank 17.07 9.40 9.40 Blank RBRVS

38129 Blank UNLISTED LAPAROSCOPY PROCEDURE SPLEEN Surgery Blank Blank Blank Blank 26.47 Unlisted

38200 Blank INJECTION PROCEDURE SPLENOPORTOGRAPY Surgery Blank 2.64 0.97 0.97 Blank RBRVS

38204 Blank MGMT RCP HEMATOP PROGENITOR CELL DONOR &ACQUISJ Surgery Blank 2.00 0.77 0.77 Blank RBRVS

38205 Blank BLD-DRV HEMATOP PROGEN CELL HRVG TRNSPLJ ALGNC Surgery Blank 1.50 0.81 0.81 Blank RBRVS

38206 Blank BLD-DRV HEMATOP PROGEN CELL HRVG TRNSPLJ AUTOL Surgery Blank 1.50 0.80 0.80 Blank RBRVS

38207 Blank TRNSPL PREPJ HEMATOP PROGEN CELLS CRYOPRSRV STOR Surgery Blank 0.89 0.35 0.35 Blank RBRVS

38208 Blank TRNSPL PREP HEMATOP PROGEN THAW PREV HRV PER DNR Surgery Blank 0.56 0.22 0.22 Blank RBRVS

38209 Blank TRNSP PREP HMATOP PROG THAW PREV HRV WSH PER DNR Surgery Blank 0.24 0.09 0.09 Blank RBRVS

38210 Blank TRNSPL PREPJ HEMATOP PROGEN DEPLJ IN HRV T-CELL Surgery Blank 1.57 0.61 0.61 Blank RBRVS

38211 Blank TRNSPL PREPJ HEMATOP PROGEN TUM CELL DEPLJ Surgery Blank 1.42 0.55 0.55 Blank RBRVS

38212 Blank TRNSPL PREPJ HEMATOP PROGEN RED BLD CELL RMVL Surgery Blank 0.94 0.37 0.37 Blank RBRVS

38213 Blank TRNSPL PREPJ HEMATOP PROGEN PLTLT DEPLJ Surgery Blank 0.24 0.09 0.09 Blank RBRVS

38214 Blank TRNSPL PREPJ HEMATOP PROGEN PLSM VOL DEPLJ Surgery Blank 0.81 0.32 0.32 Blank RBRVS

38215 Blank TRNSPL PREPJ HEMATOP PROGEN CONCENTRATION PLSM Surgery Blank 0.94 0.37 0.37 Blank RBRVS

38220 Blank MARROW ASPIRATION ONLY Surgery Blank 1.20 0.62 3.46 Blank RBRVS

38221 Blank BONE MARROW BIOPSY NEEDLE/TROCAR Surgery Blank 1.28 0.65 2.99 Blank RBRVS

38222 Blank DX BONE MARROW BX & ASPIR Surgery Blank 1.44 0.70 3.30 Blank RBRVS

38230 Blank BONE MARROW HARVEST TRANSPLANTATION ALLOGENEIC Surgery Blank 3.50 1.77 1.77 Blank RBRVS

38232 Blank BONE MARROW HARVEST TRANSPLANTATION AUTOLOGOUS Surgery Blank 3.50 1.76 1.76 Blank RBRVS

38240 Blank TRNSPLJ ALLOGENEIC HEMATOPOIETIC CELLS PER DONOR Surgery Blank 4.00 2.26 2.26 Blank RBRVS

38241 Blank TRNSPLJ AUTOLOGOUS HEMATOPOIETIC CELLS PER DONOR Surgery Blank 3.00 1.68 1.68 Blank RBRVS

38242 Blank ALLOGENEIC LYMPHOCYTE INFUSIONS Surgery Blank 2.11 1.20 1.20 Blank RBRVS

38243 Blank TRNSPLJ HEMATOPOIETIC CELL BOOST Surgery Blank 2.13 0.82 0.82 Blank RBRVS

38300 Blank DRG LYMPH NODE ABSC/LYMPHADENITIS SMPL Surgery Blank 2.36 2.90 6.11 Blank RBRVS

38305 Blank DRG LYMPH NODE ABSC/LYMPHADENITIS EXTNSV Surgery Blank 6.68 5.66 5.66 Blank RBRVS

38308 Blank LYMPHANGIOTOMY/OTH OPRATIONS LYMPHATIC CHANNELS Surgery Blank 6.81 4.54 4.54 Blank RBRVS

38380 Blank SUTR&/LIG THORACIC DUCT CERVICAL APPROACH Surgery Blank 8.46 6.46 6.46 Blank RBRVS

38381 Blank SUTR&/LIG THORACIC DUCT THORACIC APPROACH Surgery Blank 13.38 6.74 6.74 Blank RBRVS

38382 Blank SUTR&/LIG THORACIC DUCT ABDOMINAL APPROACH Surgery Blank 10.65 6.29 6.29 Blank RBRVS

38500 Blank BX/EXC LYMPH NODE OPEN SUPERFICIAL Surgery Blank 3.79 2.68 4.85 Blank RBRVS

38505 Blank BX/EXC LYMPH NODE NEEDLE SUPERFICIAL Surgery Blank 1.14 0.79 2.33 Blank RBRVS

38510 Blank BX/EXC LYMPH NODE OPEN DEEP CERVICAL NODE Surgery Blank 6.74 4.01 6.75 Blank RBRVS

38520 Blank BX/EXC LYMPH NODE OPN DP CRV NODE W/EXC FAT PAD Surgery Blank 7.03 4.84 4.84 Blank RBRVS

38525 Blank BX/EXC LYMPH NODE OPEN DEEP AXILLARY NODE Surgery Blank 6.43 4.66 4.66 Blank RBRVS

38530 Blank BX/EXC LYMPH NODE OPEN INT MAMMARY NODE Surgery Blank 8.34 6.03 6.03 Blank RBRVS

38531 Blank OPEN BX/EXC INGUINOFEM NODES Surgery Blank 6.74 4.60 4.60 Blank RBRVS

38542 Blank DISSECTION DEEP JUGULAR NODE Surgery Blank 7.95 5.51 5.51 Blank RBRVS

38550 Blank EXC CSTIC HYGROMA AX/CRV W/O DP NEUROVASC DSJ Surgery Blank 7.11 5.86 5.86 Blank RBRVS

38555 Blank EXC CSTIC HYGROMA AX/CRV W/DP NEUROVASC DSJ Surgery Blank 15.59 9.77 9.77 Blank RBRVS

38562 Blank LMTD LMPHADEC STAGING SPX PEL&PARA-AORTIC Surgery Blank 11.06 7.17 7.17 Blank RBRVS

38564 Blank LMTD LMPHADEC STAGING SPX RPR AORTIC&/SPLENIC Surgery Blank 11.38 6.53 6.53 Blank RBRVS

38570 Blank LAPS SURG RETROPERITONEAL LYMPH NODE BX 1/MLT Surgery Blank 8.49 4.74 4.74 Blank RBRVS

38571 Blank LAPS SURG BILATERAL TOTAL PELVIC LMPHADECTOMY Surgery Blank 12.00 5.81 5.81 Blank RBRVS

38572 Blank LAPS BI TOT PEL LMPHADEC & PRI-AORTIC LYMPH BX 1 Surgery Blank 15.60 8.37 8.37 Blank RBRVS

38573 Blank LAPS PELVIC LYMPHADEC Surgery Blank 20.00 10.12 10.12 Blank RBRVS

38589 Blank UNLISTED LAPAROSCOPY PX LYMPHATIC SYSTEM Surgery Blank Blank Blank Blank 17.81 Unlisted

38700 Blank SUPRAHYOID LYMPHADENECTOMY Surgery Blank 12.81 8.19 8.19 Blank RBRVS

38720 Blank CERVICAL LYMPHADENECTOMY Surgery Blank 21.95 12.78 12.78 Blank RBRVS

38724 Blank CERVICAL LYMPHADEC MODIFIED RADICAL NECK DSJ Surgery Blank 23.95 13.80 13.80 Blank RBRVS

38740 Blank AXILLARY LYMPHADENECTOMY SUPERFICIAL Surgery Blank 10.70 6.85 6.85 Blank RBRVS

38745 Blank AXILLARY LYMPHADENECTOMY COMPLETE Surgery Blank 13.87 8.22 8.22 Blank RBRVS

38746 Blank THORCOM THRC W/MEDSTNL & REGIONAL LMPHADEC Surgery Blank 4.12 1.17 1.17 Blank RBRVS

38747 Blank ABDL LMPHADEC REG CELIAC GSTR PORTAL PRIPNCRTC Surgery Blank 4.88 1.75 1.75 Blank RBRVS

38760 Blank INGUINOFEM LMPHADEC SUPFC W/CLOQUETS NODE SPX Surgery Blank 13.62 7.78 7.78 Blank RBRVS





PAGE 45 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

38765 Blank INGUINOFEM LMPHADEC SUPFC W/PEL LMPHADEC Surgery Blank 21.91 10.93 10.93 Blank RBRVS

38770 Blank PEL LMPHADEC W/XTRNL ILIAC HYPOGSTR&OBTURATOR Surgery Blank 14.06 7.25 7.25 Blank RBRVS

38780 Blank RPR TABDL LMPHADEC EXTNSV W/PEL AORTIC&RNL Surgery Blank 17.70 9.22 9.22 Blank RBRVS

38790 Blank INJECTION PROCEDURE LYMPHANGIOGRAPHY Surgery Blank 1.29 0.90 0.90 Blank RBRVS

38792 Blank INJ RADIOACTIVE TRACER FOR ID OF SENTINEL NODE Surgery Blank 0.52 0.56 0.56 Blank RBRVS

38794 Blank CANNULATION THORACIC DUCT Surgery Blank 4.62 3.61 3.61 Blank RBRVS

38900 Blank INTRAOP SENTINEL LYMPH NODE ID W/DYE INJECTION Surgery Blank 2.50 0.90 0.90 Blank RBRVS

38999 Blank UNLISTED PROCEDURE HEMIC OR LYMPHATIC SYSTEM Surgery Blank Blank Blank Blank 2.66 Unlisted

39000 Blank MEDIAST W/EXPL DRG RMVL FB/BX CRV APPR Surgery Blank 7.57 5.12 5.12 Blank RBRVS

39010 Blank MEDIAST W/EXPL DRG RMVL FB/BX TTHRC APPR Surgery Blank 13.19 6.54 6.54 Blank RBRVS

39200 Blank RESECTION OF MEDIASTINAL CYST Surgery Blank 15.09 6.67 6.67 Blank RBRVS

39220 Blank RESECTION MEDIASTINAL TUMOR Surgery Blank 19.55 8.98 8.98 Blank RBRVS

39401 Blank MEDIASTINOSCOPY INCLUDES MEDIASTINAL MASS BIOPSY Surgery Blank 5.44 2.27 2.27 Blank RBRVS

39402 Blank MEDIASTINOSCOPY WITH LYMPH NODE BIOPSY/IES Surgery Blank 7.25 2.80 2.80 Blank RBRVS

39499 Blank UNLISTED PROCEDURE MEDIASTINUM Surgery Blank Blank Blank Blank 10.05 Unlisted

39501 Blank REPAIR LACERATION DIAPHRAGM ANY APPROACH Surgery Blank 13.98 7.44 7.44 Blank RBRVS

39503 Blank RPR NEONATAL DIPHRG HERNIA W/WO CHEST TUBE INSJ Surgery Blank 108.91 34.60 34.60 Blank RBRVS

39540 Blank RPR DIPHRG HRNA OTH/THN NEONATAL TRAUMTC AQT Surgery Blank 14.57 7.20 7.20 Blank RBRVS

39541 Blank RPR DIPHRG HRNA OTH/THN NEONATAL TRAUMTC CHRNC Surgery Blank 15.75 7.82 7.82 Blank RBRVS

39545 Blank IMBRICATION DIAPHRAGM EVENTRATION Surgery Blank 14.67 7.76 7.76 Blank RBRVS

39560 Blank RESCJ DIAPHRAGM W/SIMPLE REPAIR Surgery Blank 13.06 7.08 7.08 Blank RBRVS

39561 Blank RESCJ DIAPHRAGM W/COMPLEX REPAIR Surgery Blank 19.99 11.32 11.32 Blank RBRVS

39599 Blank UNLISTED PROCEDURE DIAPHRAGM Surgery Blank Blank Blank Blank 21.77 Unlisted

40490 Blank BIOPSY OF LIP Surgery Blank 1.22 0.72 2.29 Blank RBRVS

40500 Blank VERMILIONECTOMY LIP SHV W/MUCOSAL ADVMNT Surgery Blank 4.47 5.29 9.30 Blank RBRVS

40510 Blank EXC LIP TRANSVRS WEDGE EXC W/PRIM CLSR Surgery Blank 4.82 4.62 8.22 Blank RBRVS

40520 Blank EXC LIP V-EXC W/PRIM DIR LINR CLSR Surgery Blank 4.79 4.73 8.43 Blank RBRVS

40525 Blank EXC LIP FULL THKNS RCNSTJ W/LOCAL FLAP Surgery Blank 7.72 6.89 6.89 Blank RBRVS

40527 Blank EXC LIP FULL THKNS RCNSTJ W/CROSS LIP FLAP Surgery Blank 9.32 6.89 6.89 Blank RBRVS

40530 Blank RESCJ LIP > ONE-FOURTH W/O RCNSTJ Surgery Blank 5.54 5.07 8.87 Blank RBRVS

40650 Blank RPR LIP FULL THICKNESS VERMILION ONLY Surgery Blank 3.78 4.28 8.27 Blank RBRVS

40652 Blank RPR LIP FULL THICKNESS HALF/< VERTICAL HEIGHT Surgery Blank 4.43 5.06 8.99 Blank RBRVS

40654 Blank RPR LIP FULL THKNS >ONE-HALF VERT HEIGHT/COMPLE Surgery Blank 5.48 5.92 10.04 Blank RBRVS

40700 Blank PLSTC RPR CL LIP/NSL DFRM PRIM PRTL/COMPL UNI Surgery Blank 14.17 12.60 12.60 Blank RBRVS

40701 Blank PLSTC RPR CL LIP/NSL DFRM PRIM BI 1 STG PX Surgery Blank 17.23 14.42 14.42 Blank RBRVS

40702 Blank PLSTC RPR CL LIP/NSL DFRM PRIM BI 1 2 STGS Surgery Blank 14.27 12.32 12.32 Blank RBRVS

40720 Blank PLSTC RPR CL LIP/NSL DFRM SEC RECRTJ DFCT & RECL Surgery Blank 14.72 12.59 12.59 Blank RBRVS

40761 Blank PLSTC RPR CL LIP/NSL DFRM W/CROSS LIP PEDCL FLAP Surgery Blank 15.84 12.92 12.92 Blank RBRVS

40799 Blank UNLISTED PROCEDURE LIPS Surgery Blank Blank Blank Blank 3.44 Unlisted

40800 Blank DRG ABSC CST HMTMA VESTIBULE MOUTH SMPL Surgery Blank 1.23 2.38 4.69 Blank RBRVS

40801 Blank DRG ABSC CST HMTMA VESTIBULE MOUTH COMP Surgery Blank 2.63 3.36 5.94 Blank RBRVS

40804 Blank RMVL EMBEDDED FB VESTIBULE MOUTH SMPL Surgery Blank 1.30 1.81 3.78 Blank RBRVS

40805 Blank RMVL EMBEDDED FB VESTIBULE MOUTH COMP Surgery Blank 2.79 3.42 5.92 Blank RBRVS

40806 Blank INCISION LABIAL FRENUM FRENOTOMY Surgery Blank 0.31 0.60 2.60 Blank RBRVS

40808 Blank BIOPSY VESTIBULE MOUTH Surgery Blank 1.01 1.95 4.18 Blank RBRVS

40810 Blank EXC LES MUCOSA & SBMCSL VESTIBULE MOUTH W/O RPR Surgery Blank 1.36 2.11 4.36 Blank RBRVS

40812 Blank EXC LESION MUCOSA & SBMCSL VESTIBULE SMPL RPR Surgery Blank 2.37 2.95 5.55 Blank RBRVS

40814 Blank EXC LESION MUCOSA & SBMCSL VESTIBULE CPLX RPR Surgery Blank 3.52 4.73 7.02 Blank RBRVS

40816 Blank EXC LESION MUCOSA&SBMCSL VESTIBULE CPLX EXC MUSC Surgery Blank 3.77 4.77 7.20 Blank RBRVS

40818 Blank EXC MUCOSA VESTIBULE MOUTH AS DON GRF Surgery Blank 2.83 4.76 7.24 Blank RBRVS

40819 Blank EXC FRENUM LABIAL/BUCCAL Surgery Blank 2.51 4.04 6.23 Blank RBRVS

40820 Blank DSTRJ LES/SCAR VESTIBULE MOUTH PHYSICAL METHS Surgery Blank 1.34 3.42 6.05 Blank RBRVS

40830 Blank CLOSURE LACERATION VESTIBULE MOUTH 2.5 CM/< Surgery Blank 1.82 2.76 5.68 Blank RBRVS

40831 Blank CLOSURE LACERATION VESTIBULE MOUTH > 2.5 CM/CPL Surgery Blank 2.57 3.59 6.84 Blank RBRVS

40840 Blank VESTIBULOPLASTY ANTERIOR Surgery Blank 9.15 7.46 12.69 Blank RBRVS

40842 Blank VESTIBULOPLASTY POSTERIOR UNILATERAL Surgery Blank 9.15 7.19 12.13 Blank RBRVS

40843 Blank VESTIBULOPLASTY POSTERIOR BILATERAL Surgery Blank 12.79 9.35 15.88 Blank RBRVS

40844 Blank VESTIBULOPLASTY ENTIRE ARCH Surgery Blank 16.80 11.98 18.87 Blank RBRVS

40845 Blank VESTIBULOPLASTY CPLX W/RIDGE XTN MUSC RPSG Surgery Blank 19.36 12.83 19.43 Blank RBRVS

40899 Blank UNLISTED PROCEDURE VESTIBULE MOUTH Surgery Blank Blank Blank Blank 5.48 Unlisted

41000 Blank INTRAORAL I&D TONGUE/FLOOR LINGUAL Surgery Blank 1.35 1.69 3.10 Blank RBRVS

41005 Blank INTRAORAL I&D TONGUE/FLOOR SUBLNGL SUPFC Surgery Blank 1.31 2.16 4.86 Blank RBRVS

41006 Blank INTRAORAL I&D TONGUE/FLOOR SUBLNGL DP SPRMLHYD Surgery Blank 3.34 3.73 6.48 Blank RBRVS

41007 Blank INTRAORAL I&D TONGUE/FLOOR SUBMENTAL SPACE Surgery Blank 3.20 3.65 6.44 Blank RBRVS

41008 Blank INTRAORAL I&D TONGUE/FLOOR SUBMNDBLR SPACE Surgery Blank 3.46 3.80 6.94 Blank RBRVS

41009 Blank INTRAORAL I&D TONGUE/FLOOR MASTICATOR SPACE Surgery Blank 3.71 4.20 7.36 Blank RBRVS

41010 Blank INCISION LINGUAL FRENUM FRENOTOMY Surgery Blank 1.11 1.83 4.50 Blank RBRVS

41015 Blank XTRORAL I&D ABSC CST/HMTMA FLOOR MOUTH SUBLNGL Surgery Blank 4.08 5.11 7.54 Blank RBRVS

41016 Blank XTRORAL I&D ABSC CST/HMTMA FLOOR MOUTH SUBMENT Surgery Blank 4.19 5.33 7.85 Blank RBRVS

41017 Blank XTRORAL I&D ABSC CST/HMTMA FLOOR MOUTH SUBMNDB Surgery Blank 4.19 5.42 8.04 Blank RBRVS

41018 Blank XTRORAL I&D FLOOR MASTICATOR SPACE Surgery Blank 5.22 5.93 8.58 Blank RBRVS

41019 Blank PLACEMENT NEEDLE HEAD/NECK RADIOELEMENT APPLICAT Surgery Blank 8.84 4.19 4.19 Blank RBRVS





PAGE 46 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

41100 Blank BIOPSY TONGUE ANTERIOR TWO-THIRDS Surgery Blank 1.42 1.46 3.20 Blank RBRVS

41105 Blank BIOPSY TONGUE POSTERIOR ONE-THIRD Surgery Blank 1.47 1.52 3.22 Blank RBRVS

41108 Blank BIOPSY FLOOR MOUTH Surgery Blank 1.10 1.33 2.99 Blank RBRVS

41110 Blank EXCISION LESION TONGUE W/O CLOSURE Surgery Blank 1.56 1.99 4.29 Blank RBRVS

41112 Blank EXC LESION TONGUE W/CLSR ANTERIOR TWO-THIRDS Surgery Blank 2.83 4.03 6.35 Blank RBRVS

41113 Blank EXC LESION TONGUE W/CLSR POSTERIOR ONE-THIRD Surgery Blank 3.29 4.29 6.73 Blank RBRVS

41114 Blank EXC LESION TONGUE W/CLSR W/LOCAL TONGUE FLAP Surgery Blank 8.82 8.05 8.05 Blank RBRVS

41115 Blank EXCISION LINGUAL FRENUM FRENECTOMY Surgery Blank 1.79 2.11 4.98 Blank RBRVS

41116 Blank EXCISION LESION FLOOR MOUTH Surgery Blank 2.52 3.44 6.61 Blank RBRVS

41120 Blank GLOSSECTOMY <ONE-HALF TONGUE Surgery Blank 11.14 18.23 18.23 Blank RBRVS

41130 Blank GLOSSECTOMY HEMIGLOSSECTOMY Surgery Blank 15.74 20.14 20.14 Blank RBRVS

41135 Blank GLOSSECTOMY PRTL W/UNI RADICAL NECK DSJ Surgery Blank 30.14 28.12 28.12 Blank RBRVS

41140 Blank GLSSC COMPL/TOT W/WOTRACHS W/O RAD NECK DSJ Surgery Blank 29.15 29.70 29.70 Blank RBRVS

41145 Blank GLSSC COMPL/TOT W/WO TRACHS W/UNI RAD NECK DSJ Surgery Blank 37.93 36.47 36.47 Blank RBRVS

41150 Blank GLSSC COMPOSIT W/RESCJ FLOOR & MANDIBULAR RESCJ Surgery Blank 29.86 29.23 29.23 Blank RBRVS

41153 Blank GLSSC COMPOSIT RESCJ FLOOR SUPRAHYOID NCK DSJ Surgery Blank 33.59 30.37 30.37 Blank RBRVS

41155 Blank GLSSC COMPOSIT RESCJ FLR MNDBLR RESCJ & RAD NECK Surgery Blank 44.30 36.26 36.26 Blank RBRVS

41250 Blank RPR LAC 2.5 CM/< MOUTH&/ANT TWO-THIRDS TONG Surgery Blank 1.96 2.24 5.51 Blank RBRVS

41251 Blank RPR LAC 2.5 CM/< PST ONE-THIRD TONGUE Surgery Blank 2.32 2.68 5.86 Blank RBRVS

41252 Blank RPR LAC TONGUE FLOOR MOUTH > 2.6 CM/CPLX Surgery Blank 3.02 2.62 5.58 Blank RBRVS

41510 Blank SUTURE TONGUE LIP MICROGNATHIA Surgery Blank 3.51 9.07 9.07 Blank RBRVS

41512 Blank TONGUE BASE SUSPENSION PERMANENT SUTURE TQ Surgery Blank 6.86 11.10 11.10 Blank RBRVS

41520 Blank FRENOPLASTY SURG REVJ FRENUM EG W/Z-PLASTY Surgery Blank 2.83 3.83 6.72 Blank RBRVS

41530 Blank SUBMUCOSAL ABLTJ TONGUE RF 1/> SITES PR SESSION Surgery Blank 3.50 6.73 23.72 Blank RBRVS

41599 Blank UNLISTED PROCEDURE TONGUE FLOOR MOUTH Surgery Blank Blank Blank Blank 4.48 Unlisted

41800 Blank DRG ABSC CST HMTMA FROM DENTOALVEOLAR STRUXS Surgery Blank 1.27 2.90 6.70 Blank RBRVS

41805 Blank RMVL EMBEDDED FB FROM DENTALVLR STRUXS SOFT TISS Surgery Blank 1.34 3.86 6.53 Blank RBRVS

41806 Blank RMVL EMBEDDED FB FROM DENTOALVEOLAR STRUXS BONE Surgery Blank 2.79 4.69 7.95 Blank RBRVS

41820 Blank GINGIVECTOMY EXC GINGIVA EACH QUADRANT Surgery Blank Blank Blank Blank 4.54 FAIR Health

41821 Blank OPRCULECTOMY EXC PRICORONAL TISSUE Surgery Blank Blank Blank Blank 2.02 FAIR Health

41822 Blank EXC FIBROUS TUBEROSITIES DENTOALVEOLAR STRUXS Surgery Blank 2.41 2.46 5.91 Blank RBRVS

41823 Blank EXC OSS TUBEROSITIES DENTOALVEOLAR STRUXS Surgery Blank 3.77 5.15 8.45 Blank RBRVS

41825 Blank EXC LESION/TUMOR DENTOALVEOLAR STRUX W/O RPR Surgery Blank 1.41 1.91 4.48 Blank RBRVS

41826 Blank EXC LESION/TUMOR DENTOALVEOLAR STRUX W/SMPL RPR Surgery Blank 2.41 3.39 6.32 Blank RBRVS

41827 Blank EXC LESION/TUMOR DENTALVEOLAR STRUX W/CMPLX RPR Surgery Blank 3.83 4.47 8.24 Blank RBRVS

41828 Blank EXC HYPRPLSTC ALVEOLAR MUCOSA EA QUADRANT SPEC Surgery Blank 3.14 2.46 5.41 Blank RBRVS

41830 Blank ALVEOLECTOMY W/CURTG OSTEITIS/SEQUESTRECTOMY Surgery Blank 3.45 4.21 7.60 Blank RBRVS

41850 Blank DESTRUCTION LESION DENTOALVEOLAR STRUCTURES Surgery Blank Blank Blank Blank 2.98 FAIR Health

41870 Blank PERIODONTAL MUCOSAL GRAFTING Surgery Blank Blank Blank Blank 6.00 FAIR Health

41872 Blank GINGIVOPLASTY EACH QUADRANT SPECIFY Surgery Blank 3.01 3.65 6.57 Blank RBRVS

41874 Blank ALVEOLOPLASTY EACH QUADRANT SPECIFY Surgery Blank 3.19 3.77 7.35 Blank RBRVS

41899 Blank UNLISTED PROCEDURE DENTOALVEOLAR STRUCTURES Surgery Blank Blank Blank Blank 9.46 Unlisted

42000 Blank DRAINAGE ABSCESS PALATE UVULA Surgery Blank 1.28 1.48 2.90 Blank RBRVS

42100 Blank BIOPSY PALATE UVULA Surgery Blank 1.36 1.59 2.72 Blank RBRVS

42104 Blank EXC LESION PALATE UVULA W/O CLOSURE Surgery Blank 1.69 2.06 4.21 Blank RBRVS

42106 Blank EXC LESION PALATE UVULA W/SMPL PRIM CLOSURE Surgery Blank 2.15 2.68 5.39 Blank RBRVS

42107 Blank EXC LESION PALATE UVULA W/LOCAL FLAP CLOSURE Surgery Blank 4.56 4.72 7.99 Blank RBRVS

42120 Blank RESCJ PALATE/EXTENSIVE RESCJ LESION Surgery Blank 11.86 15.56 15.56 Blank RBRVS

42140 Blank UVULECTOMY EXCISION UVULA Surgery Blank 1.70 2.47 5.25 Blank RBRVS

42145 Blank PALATOPHARYNGOPLASTY Surgery Blank 9.78 8.87 8.87 Blank RBRVS

42160 Blank DSTRJ LESION PALATE/UVULA THERMAL CRYO/CHEM Surgery Blank 1.85 2.11 4.50 Blank RBRVS

42180 Blank REPAIR LACERATION PALATE </2 CM Surgery Blank 2.55 2.32 4.00 Blank RBRVS

42182 Blank REPAIR LACERATION PALATE >2 CM/COMPLEX Surgery Blank 3.87 2.88 4.66 Blank RBRVS

42200 Blank PALATOP CL PALATE SOFT&/HARD PALATE ONLY Surgery Blank 12.53 12.92 12.92 Blank RBRVS

42205 Blank PALATOPLASTY W/CLSR ALVEOLAR RIDGE SOFT TISSUE Surgery Blank 13.66 12.76 12.76 Blank RBRVS

42210 Blank PALATOP CLSR ALVEOLAR RIDGE GRF ALVEOLAR RIDGE Surgery Blank 15.03 14.43 14.43 Blank RBRVS

42215 Blank PALATOPLASTY CLEFT PALATE MAJOR REVJ Surgery Blank 8.99 10.44 10.44 Blank RBRVS

42220 Blank PALATOPLASTY CLEFT PALATE SEC LNGTH PX Surgery Blank 7.16 8.92 8.92 Blank RBRVS

42225 Blank PALATOP CL PALATE ATTACHMENT PHARYNGEAL FLAP Surgery Blank 9.77 17.32 17.32 Blank RBRVS

42226 Blank LENGTHENING PALATE & PHARYNGEAL FLAP Surgery Blank 10.35 13.51 13.51 Blank RBRVS

42227 Blank LENGTHENING PALATE W/ISLAND FLAP Surgery Blank 9.90 12.46 12.46 Blank RBRVS

42235 Blank REPAIR ANTERIOR PALATE W/VOMER FLAP Surgery Blank 8.01 11.67 11.67 Blank RBRVS

42260 Blank REPAIR NASOLABIAL FISTULA Surgery Blank 10.22 7.09 11.35 Blank RBRVS

42280 Blank MAXILLARY IMPRESJ PALATAL PROSTHESIS Surgery Blank 1.59 1.33 3.17 Blank RBRVS

42281 Blank INSJ PIN-RETAINED PALATAL PROSTHESIS Surgery Blank 1.98 2.44 4.20 Blank RBRVS

42299 Blank UNLISTED PROCEDURE PALATE UVULA Surgery Blank Blank Blank Blank 5.38 Unlisted

42300 Blank DRAINAGE ABSCESS PAROTID SIMPLE Surgery Blank 1.98 2.10 3.68 Blank RBRVS

42305 Blank DRAINAGE ABSCESS PAROTID COMPLICATED Surgery Blank 6.31 5.07 5.07 Blank RBRVS

42310 Blank DRG ABSC SUBMAXILLARY/SUBLINGUAL INTRAORAL Surgery Blank 1.61 2.03 3.21 Blank RBRVS

42320 Blank DRAINAGE ABSCESS SUBMAXILLARY INTRAORAL Surgery Blank 2.40 2.25 4.33 Blank RBRVS

42330 Blank SIALOT SUBMNDBLR SUBLNGL/PRTD UNCOMP INTRAORAL Surgery Blank 2.26 2.12 4.02 Blank RBRVS

42335 Blank SIALOLITHOTOMY SUBMNDBLR SUBMAX COMP INTRAORAL Surgery Blank 3.41 3.45 6.75 Blank RBRVS





PAGE 47 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

42340 Blank SIALOLITHOTOMY PRTD XTRORAL/COMP INTRAORAL Surgery Blank 4.72 4.25 7.89 Blank RBRVS

42400 Blank BIOPSY SALIVARY GLAND NEEDLE Surgery Blank 0.78 0.70 2.12 Blank RBRVS

42405 Blank BIOPSY SALIVARY GLAND INCISIONAL Surgery Blank 3.34 2.64 4.67 Blank RBRVS

42408 Blank EXC SUBLINGUAL SALIVARY CYST RANULA Surgery Blank 4.66 4.77 8.85 Blank RBRVS

42409 Blank MARSUPIALIZATION SUBLNGL SALIVARY CST RANULA Surgery Blank 2.91 3.00 6.15 Blank RBRVS

42410 Blank EXC PRTD TUM/PRTD GLND LAT LOBE W/O NRV DSJ Surgery Blank 9.57 6.67 6.67 Blank RBRVS

42415 Blank EXC PRTD TUM/PRTD GLND LAT DSJ&PRSRV FACIAL NR Surgery Blank 17.16 10.42 10.42 Blank RBRVS

42420 Blank EXC PRTD TUM/PRTD GLND TOT DSJ&PRSRV FACIAL NR Surgery Blank 19.53 11.41 11.41 Blank RBRVS

42425 Blank EXCISION PAROTID TUMOR/GLAND TOTAL EN BLOC RMVL Surgery Blank 13.42 8.47 8.47 Blank RBRVS

42426 Blank EXC PRTD TUM/PRTD GLND TOT W/UNI RAD NCK DSJ Surgery Blank 22.66 12.47 12.47 Blank RBRVS

42440 Blank EXCISION SUBMANDIBULAR SUBMAXILLARY GLAND Surgery Blank 6.14 4.70 4.70 Blank RBRVS

42450 Blank EXISION OF SUBLINGUAL GLAND Surgery Blank 4.74 4.83 7.51 Blank RBRVS

42500 Blank PLSTC RPR SALIVARY DUX SIALODOCHOPLASTY PRIM Surgery Blank 4.42 4.71 7.29 Blank RBRVS

42505 Blank PLSTC RPR SALIVARY DUX SIALODOCHOPLASTY SEC/COMP Surgery Blank 6.32 5.70 8.59 Blank RBRVS

42507 Blank PAROTID DUCT DIVERSION BILATERAL WILKE PX Surgery Blank 6.25 7.43 7.43 Blank RBRVS

42509 Blank PAROTID DUCT DVRJ BI W/EXC BOTH SUBMNDBLR GLANDS Surgery Blank 11.76 10.59 10.59 Blank RBRVS

42510 Blank PAROTID DUCT DVRJ BILATERAL WITH LIG BOTH DUCTS Surgery Blank 8.35 8.31 8.31 Blank RBRVS

42550 Blank INJECTION PROCEDURE SIALOGRAPHY Surgery Blank 1.25 0.46 2.51 Blank RBRVS

42600 Blank CLOSURE SALIVARY FISTULA Surgery Blank 4.94 4.26 7.95 Blank RBRVS

42650 Blank DILATION SALIVARY DUCT Surgery Blank 0.77 0.78 1.49 Blank RBRVS

42660 Blank DILAT&CATHJ SALIVARY DUCT W/WO INJECTION Surgery Blank 1.13 1.13 2.25 Blank RBRVS

42665 Blank LIGATION SALIVARY DUCT INTRAORAL Surgery Blank 2.63 2.88 5.91 Blank RBRVS

42699 Blank UNLISTED PX SALIVARY GLANDS/DUCTS Surgery Blank Blank Blank Blank 16.24 Unlisted

42700 Blank I&D ABSCESS PERITONSILLAR Surgery Blank 1.67 1.97 3.48 Blank RBRVS

42720 Blank I&D ABSC RTRPHRNGL/PARAPHARYNGEAL INTRAORAL Surgery Blank 6.31 4.00 5.73 Blank RBRVS

42725 Blank I&D ABSC RTRPHRNGL/PARAPHARYNGEAL XTRNL APPR Surgery Blank 12.41 9.13 9.13 Blank RBRVS

42800 Blank BIOPSY OROPHARYNX Surgery Blank 1.44 1.54 2.84 Blank RBRVS

42804 Blank BIOPSY NASOPHARYNX VISIBLE LESION SIMPLE Surgery Blank 1.29 1.74 4.04 Blank RBRVS

42806 Blank BX NASOPHARYNX SURVEY UNKNOWN PRIMARY LESION Surgery Blank 1.63 1.90 4.35 Blank RBRVS

42808 Blank EXCISION/DESTRUCTION LESION PHARYNX ANY METHOD Surgery Blank 2.35 1.94 3.75 Blank RBRVS

42809 Blank REMOVAL FOREIGN BODY PHARYNX Surgery Blank 1.86 1.37 3.64 Blank RBRVS

42810 Blank EXC BRANCHIAL CLEFT CYST CONFINED SKN&SUBQ TIS Surgery Blank 3.38 4.37 7.16 Blank RBRVS

42815 Blank EXC BRANCHIAL CLEFT CYST BELOW SUBQ TISS&/PHRYNX Surgery Blank 7.31 7.51 7.51 Blank RBRVS

42820 Blank TONSILLECTOMY & ADENOIDECTOMY <AGE 12 Surgery Blank 4.22 3.43 3.43 Blank RBRVS

42821 Blank TONSILLECTOMY & ADENOIDECTOMY AGE 12/> Surgery Blank 4.36 3.58 3.58 Blank RBRVS

42825 Blank TONSILLECTOMY ONE-HALF <AGE 12 Surgery Blank 3.51 3.44 3.44 Blank RBRVS

42826 Blank TONSILLECTOMY ONE-HALF AGE 12/> Surgery Blank 3.45 3.21 3.21 Blank RBRVS

42830 Blank ADENOIDECTOMY PRIMARY <AGE 12 Surgery Blank 2.65 2.87 2.87 Blank RBRVS

42831 Blank ADENOIDECTOMY PRIMARY AGE 12/> Surgery Blank 2.81 3.15 3.15 Blank RBRVS

42835 Blank ADENOIDECTOMY SECONDARY<AGE 12 Surgery Blank 2.38 2.75 2.75 Blank RBRVS

42836 Blank ADENOIDECTOMY SECONDARY AGE 12/> Surgery Blank 3.26 3.12 3.12 Blank RBRVS

42842 Blank RADICAL RESECTION TONSIL W/O CLOSURE Surgery Blank 12.23 15.11 15.11 Blank RBRVS

42844 Blank RADICAL RESCJ TONSIL CLOSURE W/LOCAL FLAP Surgery Blank 17.78 19.73 19.73 Blank RBRVS

42845 Blank RADICAL RESCJ TONSIL CLOSURE W/OTHER FLAP Surgery Blank 32.56 27.15 27.15 Blank RBRVS

42860 Blank EXCISION TONSIL TAGS Surgery Blank 2.30 2.72 2.72 Blank RBRVS

42870 Blank EXC/DSTRJ LINGUAL TONSIL ANY METHOD SPX Surgery Blank 5.52 10.79 10.79 Blank RBRVS

42890 Blank LIMITED PHARYNGECTOMY Surgery Blank 19.13 19.43 19.43 Blank RBRVS

42892 Blank RESCJ LAT PHRNGL WALL/PYRIFORM SINUS DIR CLSR Surgery Blank 26.03 24.45 24.45 Blank RBRVS

42894 Blank RESCJ PHRNGL WALL CLSR W/FLP OR FLP W/MVASC ANAS Surgery Blank 33.92 29.59 29.59 Blank RBRVS

42900 Blank SUTURE PHARYNX WOUND/INJURY Surgery Blank 5.29 3.59 3.59 Blank RBRVS

42950 Blank PHARYNGOPLASTY PLSTC/RCNSTV OPRATION PHARYNX Surgery Blank 8.27 14.01 14.01 Blank RBRVS

42953 Blank PHARYNGOESOPHAGEAL REPAIR Surgery Blank 9.45 17.31 17.31 Blank RBRVS

42955 Blank PHARYNGOSTOMY FSTLJ PHARYNX XTRNL FEEDING Surgery Blank 8.01 13.01 13.01 Blank RBRVS

42960 Blank CONTROL OROPHARYNGEAL HEMORRHAGE SIMPLE Surgery Blank 2.38 2.12 2.12 Blank RBRVS

42961 Blank CTRL OROPHARYNGEAL HEMORRHAGE COMP REQ HOSPITJ Surgery Blank 5.77 5.40 5.40 Blank RBRVS

42962 Blank CTRL OROPHARYNGEAL HEMORRHAGE W/SEC SURG IVNTJ Surgery Blank 7.40 6.33 6.33 Blank RBRVS

42970 Blank CTRL NASOPHARYNGEAL HEMRRG SMPL W/PST NSL PACKS Surgery Blank 5.82 5.14 5.14 Blank RBRVS

42971 Blank CTRL NASOPHARYNGEAL HEMRRG COMP REQ HOSPIZATION Surgery Blank 6.60 5.47 5.47 Blank RBRVS

42972 Blank CTRL NASOPHARYNGEAL HEMORRHAGE W/SEC SURG IVNTJ Surgery Blank 7.59 5.89 5.89 Blank RBRVS

42999 Blank UNLISTED PROCEDURE PHARYNX ADENOIDS/TONSILS Surgery Blank Blank Blank Blank 6.66 Unlisted

43020 Blank ESOPHAGOTOMY CERVICAL APPR W/RMVL FB Surgery Blank 8.23 5.90 5.90 Blank RBRVS

43030 Blank CRICOPHARYNGEAL MYOTOMY Surgery Blank 7.99 5.57 5.57 Blank RBRVS

43045 Blank ESOPHAGOTOMY THORACIC APPR W/RMVL FB Surgery Blank 21.88 10.61 10.61 Blank RBRVS

43100 Blank EXC LESION ESOPHOGUS W/PRIM RPR CERVICAL APPR Surgery Blank 9.66 6.78 6.78 Blank RBRVS

43101 Blank EXC LESION ESOPHAGUS W/PRIM RPR THRC/ABDL APPR Surgery Blank 17.07 8.02 8.02 Blank RBRVS

43107 Blank TOT ESOPHAGECTOMY W/O THORCOM W/WO PYLOROPLASTY Surgery Blank 52.05 22.23 22.23 Blank RBRVS

43108 Blank TOT ESOPHG W/O THORCOM COLON NTRPSTJ/INT RCNSTJ Surgery Blank 82.87 26.92 26.92 Blank RBRVS

43112 Blank TOTAL ESOPHAGECTOMY W/THORCOM W/WO PYLORPLASTY Surgery Blank 62.00 24.76 24.76 Blank RBRVS

43113 Blank TOT ESOPHG W/THORCOM W/COLON NTRPSTJ/INT RCNSTJ Surgery Blank 80.06 27.39 27.39 Blank RBRVS

43116 Blank PRTL ESOPHAGECTOMY CERVICAL W/FREE INTSTINAL GRF Surgery Blank 92.99 29.74 29.74 Blank RBRVS

43117 Blank PRTL ESOPHECT DSTL W/WO PROX GASTRECT/PYLORPLSTY Surgery Blank 57.50 23.25 23.25 Blank RBRVS

43118 Blank PRTL ESOPH DSTL W/WO PROX GASTRC W/COLON NTRPSTJ Surgery Blank 67.07 22.51 22.51 Blank RBRVS





PAGE 48 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

43121 Blank PRTL ESOPHAGEC W/WO PROX GASTREC/PYLOROPLASTY Surgery Blank 51.43 19.35 19.35 Blank RBRVS

43122 Blank PRTL ESOPHG THORACOABD W/WO PROXGASTREC/PYLOROPL Surgery Blank 44.18 19.70 19.70 Blank RBRVS

43123 Blank PRTL ESPHG THORACOABDL/ABDL APPR NTRPSTJ/RCNSTJ Surgery Blank 83.12 28.24 28.24 Blank RBRVS

43124 Blank TOT/PRTL ESPHG W/O RCNSTJ W/CRV ESOPHAGOSTOMY Surgery Blank 69.09 25.11 25.11 Blank RBRVS

43130 Blank DIVERTICULECTOMY HYPOPHARYNX/ESOPH CRV APPR Surgery Blank 12.53 7.74 7.74 Blank RBRVS

43135 Blank DIVERTICULECTOMY HYPOPHARYNX/ESOPH THRC APPR Surgery Blank 26.17 10.85 10.85 Blank RBRVS

43180 Blank ESOPHAGOSCP RIG TRANSORAL HYPOPHARYNX CRV ESOPH Surgery Blank 9.03 5.29 5.29 Blank RBRVS

43191 Blank ESOPHAGOSCOPY RIGID TRANSORAL DIAGNOSTIC BRUSH Surgery Blank 2.49 1.60 1.60 Blank RBRVS

43192 Blank ESOPHAGOSCOPY RIGID TRANSORAL INJ SUBMUCOSAL Surgery Blank 2.79 1.67 1.67 Blank RBRVS

43193 Blank ESOPHAGOSCOPY RIGID TRANSORAL WITH BIOPSY Surgery Blank 2.79 1.67 1.67 Blank RBRVS

43194 Blank ESOPHAGOSCOPY RIG TRANSORAL REMOVAL FOREIGN BODY Surgery Blank 3.51 1.49 1.49 Blank RBRVS

43195 Blank ESOPHAGOSCOPY RIGID TRANSORAL BALLOON DILATION Surgery Blank 3.07 1.80 1.80 Blank RBRVS

43196 Blank ESOPHAGOSCOPY RIG TRANSORAL GUIDE WIRE DILATION Surgery Blank 3.31 1.86 1.86 Blank RBRVS

43197 Blank ESOPHAGOSCOPY FLEXIBLE TRANSNASAL DIAGNOSTIC Surgery Blank 1.52 0.63 3.69 Blank RBRVS

43198 Blank ESOPHAGOSCOPY FLEXIBLE TRANSNASAL WITH BIOPSY Surgery Blank 1.82 0.75 3.92 Blank RBRVS

43200 Blank ESOPHAGOSCOPY FLEXIBLE TRANSORAL DIAGNOSTIC Surgery Blank 1.42 0.90 4.49 Blank RBRVS

43201 Blank ESOPHAGOSCOPY FLEXIBLE TRANSORAL W SUBMUCOUS INJ Surgery Blank 1.72 1.03 4.29 Blank RBRVS

43202 Blank ESOPHAGOSCOPY FLEXIBLE TRANSORAL WITH BIOPSY Surgery Blank 1.72 1.04 6.77 Blank RBRVS

43204 Blank ESOPHAGOSCOPY FLEX TRANSORAL INJECTION VARICES Surgery Blank 2.33 1.35 1.35 Blank RBRVS

43205 Blank ESPHGOSCOPY FLEX W/BAND LIGATION ESOPHGL VARICES Surgery Blank 2.44 1.40 1.40 Blank RBRVS

43206 Blank ESOPHAGOSCOPY TRANSORAL W/OPTICAL ENDOMICROSCOPY Surgery Blank 2.29 1.33 5.02 Blank RBRVS

43210 Blank EGD PARTIAL/COMPL ESOPHAGOGASTRIC FUNDOPLASTY Surgery Blank 7.75 3.43 3.43 Blank RBRVS

43211 Blank ESOPHAGOSCOPY FLEXIBLE TRANSORAL MUCOSAL RESEXN Surgery Blank 4.20 2.11 2.11 Blank RBRVS

43212 Blank ESOPHAGOSCOPY TRANSORAL STENT PLACEMENT Surgery Blank 3.40 1.56 1.56 Blank RBRVS

43213 Blank ESOPHAGOSCOPY RETROGRADE DILATE BALLOON/OTHER Surgery Blank 4.63 2.26 27.40 Blank RBRVS

43214 Blank ESOPHAGOSCOPY DILATE ESOPHAGUS BALLOON 30 MM Surgery Blank 3.40 1.74 1.74 Blank RBRVS

43215 Blank ESOPHAGOSCOPY FLEXIBLE REMOVAL FOREIGN BODY Surgery Blank 2.44 1.31 7.43 Blank RBRVS

43216 Blank ESPHAGOSCOPY FLEX LESION REMOVAL HOT BX FORCEPS Surgery Blank 2.30 1.32 7.61 Blank RBRVS

43217 Blank ESOPHAGOSCOPY FLEXIB LESION REMOVAL TUMOR SNARE Surgery Blank 2.80 1.49 7.59 Blank RBRVS

43220 Blank ESOPHAGOSCOPY FLEX BALLOON DILAT <30 MM DIAM Surgery Blank 2.00 1.16 28.22 Blank RBRVS

43226 Blank ESOPHAGOSCOPY FLEXIBLE GUIDE WIRE DILATION Surgery Blank 2.24 1.22 6.44 Blank RBRVS

43227 Blank ESOPHAGOSCOPY FLEXIBLE W/BLEEDING CONTROL Surgery Blank 2.89 1.58 14.68 Blank RBRVS

43229 Blank ESOPHAGOSCOPY FLEX TRANSORAL LESION ABLATION Surgery Blank 3.49 1.83 14.50 Blank RBRVS

43231 Blank ESOPHAGOSCOPY FLEXIBLE TRANSORAL ULTRASOUND EXAM Surgery Blank 2.80 1.55 6.41 Blank RBRVS

43232 Blank ESOPHAGOSCOPY INTRA/TRANSMURAL NEEDLE ASPIRAT/BX Surgery Blank 3.59 1.83 7.56 Blank RBRVS

43233 Blank EGD ESOPHAGUS BALLOON DILATION 30 MM OR LARGER Surgery Blank 4.07 2.05 2.05 Blank RBRVS

43235 Blank ESOPHAGOGASTRODUODENOSCOPY TRANSORAL DIAGNOSTIC Surgery Blank 2.09 1.23 4.93 Blank RBRVS

43236 Blank ESOPHAGOGASTRODUODENOSCOPY SUBMUCOSAL INJECTION Surgery Blank 2.39 1.37 6.68 Blank RBRVS

43237 Blank ESOPHAGOGASTRODUODENOSCOPY US SCOPE W/ADJ STRXRS Surgery Blank 3.47 1.85 1.85 Blank RBRVS

43238 Blank EGD INTRMURAL US NEEDLE ASPIRATE/BIOPSY ESOPHAGS Surgery Blank 4.16 2.15 2.15 Blank RBRVS

43239 Blank EGD TRANSORAL BIOPSY SINGLE/MULTIPLE Surgery Blank 2.39 1.36 7.08 Blank RBRVS

43240 Blank EGD TRANSORAL TRANSMURAL DRAINAGE PSEUDOCYST Surgery Blank 7.15 3.47 3.47 Blank RBRVS

43241 Blank EGD INTRALUMINAL TUBE/CATHETER INSERTION Surgery Blank 2.49 1.35 1.35 Blank RBRVS

43242 Blank EGD INTRMURAL NEEDLE ASPIR/BIOP ALTERED ANATOMY Surgery Blank 4.73 2.41 2.41 Blank RBRVS

43243 Blank EGD INJECTION SCLEROSIS ESOPHGL/GASTRIC VARICES Surgery Blank 4.27 2.14 2.14 Blank RBRVS

43244 Blank EGD BAND LIGATION ESOPHGEAL/GASTRIC VARICES Surgery Blank 4.40 2.26 2.26 Blank RBRVS

43245 Blank EGD DILATION GASTRIC/DUODENAL STRICTURE Surgery Blank 3.08 1.62 12.23 Blank RBRVS

43246 Blank EGD PERCUTANEOUS PLACEMENT GASTROSTOMY TUBE Surgery Blank 3.56 1.77 1.77 Blank RBRVS

43247 Blank EGD FLEXIBLE FOREIGN BODY REMOVAL Surgery Blank 3.11 1.67 6.43 Blank RBRVS

43248 Blank EGD INSERT GUIDE WIRE DILATOR PASSAGE ESOPHAGUS Surgery Blank 2.91 1.60 6.70 Blank RBRVS

43249 Blank EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM Surgery Blank 2.67 1.48 26.01 Blank RBRVS

43250 Blank EGD FLEX REMOVAL LESION(S) BY HOT BIOPSY FORCEPS Surgery Blank 2.97 1.57 7.91 Blank RBRVS

43251 Blank EGD REMOVAL TUMOR POLYP/OTHER LESION SNARE TECH Surgery Blank 3.47 1.84 8.64 Blank RBRVS

43252 Blank EGD FLEX TRANSORAL W/OPTICAL ENDOMICROSCOPY Surgery Blank 2.96 1.58 5.28 Blank RBRVS

43253 Blank EGD US GUIDED TRANSMURAL INJXN/FIDUCIAL MARKER Surgery Blank 4.73 2.41 2.41 Blank RBRVS

43254 Blank EGD TRANSORAL ENDOSCOPIC MUCOSAL RESECTION Surgery Blank 4.87 2.46 2.46 Blank RBRVS

43255 Blank EGD TRANSORAL CONTROL BLEEDING ANY METHOD Surgery Blank 3.56 1.89 14.96 Blank RBRVS

43257 Blank EGD DELIVER THERMAL ENERGY SPHNCTR/CARDIA GERD Surgery Blank 4.15 2.10 2.10 Blank RBRVS

43259 Blank EDG US EXAM SURGICAL ALTER STOM DUODENUM/JEJUNUM Surgery Blank 4.04 2.11 2.11 Blank RBRVS

43260 Blank ERCP DX COLLECTION SPECIMEN BRUSHING/WASHING Surgery Blank 5.85 2.90 2.90 Blank RBRVS

43261 Blank ERCP W/BIOPSY SINGLE/MULTIPLE Surgery Blank 6.15 3.04 3.04 Blank RBRVS

43262 Blank ERCP W/SPHINCTEROTOMY/PAPILLOTOMY Surgery Blank 6.50 3.19 3.19 Blank RBRVS

43263 Blank ERCP W/PRESSURE MEASUREMENT SPHINCTER OF ODDI Surgery Blank 6.50 3.18 3.18 Blank RBRVS

43264 Blank ERCP REMOVE CALCULI/DEBRIS BILIARY/PANCREAS DUCT Surgery Blank 6.63 3.25 3.25 Blank RBRVS

43265 Blank ERCP DESTRUCTION/LITHOTRIPSY CALCULI ANY METHOD Surgery Blank 7.93 3.81 3.81 Blank RBRVS

43266 Blank EGD ENDOSCOPIC STENT PLACEMENT W/WIRE& DILATION Surgery Blank 3.92 1.94 1.94 Blank RBRVS

43270 Blank EGD ABLATE TUMOR POLYP/LESION W/DILATION& WIRE Surgery Blank 4.01 2.08 14.52 Blank RBRVS

43273 Blank ENDOSCOPIC PAPILLA CANNULATION BILE/PANCREATIC Surgery Blank 2.24 0.98 0.98 Blank RBRVS

43274 Blank ERCP STENT PLACEMENT BILIARY/PANCREATIC DUCT Surgery Blank 8.48 4.06 4.06 Blank RBRVS

43275 Blank ERCP REMOVE FOREIGN BODY/STENT BILIARY/PANC DUCT Surgery Blank 6.86 3.35 3.35 Blank RBRVS

43276 Blank ERCP BILIARY/PANC DUCT STENT EXCHANGE W/DIL&WIRE Surgery Blank 8.84 4.22 4.22 Blank RBRVS

43277 Blank ERCP BALLOON DILATE BILIARY/PANC DUCT/AMPULLA EA Surgery Blank 6.90 3.37 3.37 Blank RBRVS





PAGE 49 of 144

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HCPCS

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Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

43278 Blank ERCP TUMOR/POLYP/LESION ABLATION W/DILATION&WIRE Surgery Blank 7.92 3.81 3.81 Blank RBRVS

43279 Blank LAPS ESOPHAGOMYOTOMY W/FUNDOPLASTY IF PERFORMED Surgery Blank 22.10 10.10 10.10 Blank RBRVS

43280 Blank LAPS SURG ESOPG/GSTR FUNDOPLASTY Surgery Blank 18.10 8.99 8.99 Blank RBRVS

43281 Blank LAPS RPR PARAESPHGL HRNA INCL FUNDPLSTY W/O MESH Surgery Blank 26.60 11.95 11.95 Blank RBRVS

43282 Blank LAPS RPR PARAESPHGL HRNA INCL FUNDPLSTY W/MESH Surgery Blank 30.10 13.20 13.20 Blank RBRVS

43283 Blank LAPS ESOPHAGEAL LENGTHENING ADDL Surgery Blank 2.95 0.95 0.95 Blank RBRVS

43284 Blank LAPS ESOPHGL SPHNCTR AGMNTJ Surgery Blank 10.13 6.27 6.27 Blank RBRVS

43285 Blank RMVL ESOPHGL SPHNCTR DEV Surgery Blank 10.47 6.14 6.14 Blank RBRVS

43286 Blank ESPHG TOT W/LAPS MOBLJ Surgery Blank 55.00 25.32 25.32 Blank RBRVS

43287 Blank ESPHG DSTL 2/3 W/LAPS MOBLJ Surgery Blank 63.00 28.15 28.15 Blank RBRVS

43288 Blank ESPHG THRSC MOBLJ Surgery Blank 66.42 29.36 29.36 Blank RBRVS

43289 Blank UNLISTED LAPAROSCOPIC PROCEDURE ESOPHAGUS Surgery Blank Blank Blank Blank 38.55 Unlisted

43300 Blank ESPHGP CRV APPR W/O RPR TRACHEOESOPHGL FSTL Surgery Blank 9.33 6.83 6.83 Blank RBRVS

43305 Blank ESPHGP CRV APPR W/RPR TRACHEOESOPHGL FSTL Surgery Blank 18.10 10.37 10.37 Blank RBRVS

43310 Blank ESPHGP THRC APPR W/O RPR TRACHEOESOPHGL FSTL Surgery Blank 26.26 10.54 10.54 Blank RBRVS

43312 Blank ESPHGP THRC APPR W/RPR TRACHEOESOPHGL FSTL Surgery Blank 29.25 10.17 10.17 Blank RBRVS

43313 Blank ESPHGP CGEN DFCT THRC APPR W/O RPR FSTL Surgery Blank 48.45 19.34 19.34 Blank RBRVS

43314 Blank ESPHGP CGEN DFCT THRC APPR W/RPR FSTL Surgery Blank 53.43 19.26 19.26 Blank RBRVS

43320 Blank EGST W/WO VAGOTOMY&PYLOROPLASTY TABDL/TTHRC AP Surgery Blank 23.31 11.57 11.57 Blank RBRVS

43325 Blank ESOPG/GSTR FUNDOPLASTY W/FUNDIC PATCH Surgery Blank 22.60 11.32 11.32 Blank RBRVS

43327 Blank ESOPG/GSTR FUNDOPLASTY W/LAPAROTOMY Surgery Blank 13.35 7.29 7.29 Blank RBRVS

43328 Blank ESOPG/GSTR FUNDOPLASTY W/THORACOTOMY Surgery Blank 19.91 8.10 8.10 Blank RBRVS

43330 Blank ESOPHAGOMYOTOMY HELLER TYPE ABDOMINAL APPROACH Surgery Blank 22.19 11.17 11.17 Blank RBRVS

43331 Blank ESOPHAGOMYOTOMY HELLER TYPE THORACIC APPROACH Surgery Blank 23.06 10.34 10.34 Blank RBRVS

43332 Blank RPR PARAESOPH HIATAL HERNIA W/LAPT W/O MESH Surgery Blank 19.62 9.40 9.40 Blank RBRVS

43333 Blank LAPT RPR PARAESOPH HIATAL HERNIA W/MESH Surgery Blank 21.46 10.16 10.16 Blank RBRVS

43334 Blank RPR PARAESOPH HIATAL HERNIA W/THORCOM W/O MESH Surgery Blank 22.12 9.01 9.01 Blank RBRVS

43335 Blank RPR PARAESOPH HIATAL HERNIA W/THORCOM W/MESH Surgery Blank 23.97 9.23 9.23 Blank RBRVS

43336 Blank RPR PARAESOPH HIATAL HERNIA THORCOABDOM W/O MESH Surgery Blank 25.81 11.70 11.70 Blank RBRVS

43337 Blank RPR PARAESOPH HIATAL HERNIA THORCOABDOM W/MESH Surgery Blank 27.65 10.73 10.73 Blank RBRVS

43338 Blank ESOPHAGUS LENGTHENING Surgery Blank 2.21 0.65 0.65 Blank RBRVS

43340 Blank ESOPHAGOJEJUNOSTOMY W/O TOT GSTRCT ABDL APPR Surgery Blank 22.99 11.46 11.46 Blank RBRVS

43341 Blank ESOPHAGOJEJUNOSTOMY W/O TOT GSTRCT THRC APPR Surgery Blank 24.23 10.66 10.66 Blank RBRVS

43351 Blank ESOPHAGOSTOMY FSTLJ ESOPH XTRNL THRC APPR Surgery Blank 22.05 10.84 10.84 Blank RBRVS

43352 Blank ESOPHAGOSTOMY FSTLJ ESOPH XTRNL CRV APPR Surgery Blank 17.81 8.87 8.87 Blank RBRVS

43360 Blank GI RCNSTJ PREV ESPHG/EXCLUSION W/STOMACH Surgery Blank 40.11 15.80 15.80 Blank RBRVS

43361 Blank GI RCNSTJ PREV ESPHG/EXCLUSION W/COLON SM INT Surgery Blank 45.68 21.47 21.47 Blank RBRVS

43400 Blank LIGATION DIRECT ESOPHAGEAL VARICES Surgery Blank 25.60 12.38 12.38 Blank RBRVS

43401 Blank TRNSXJ ESOPH W/RPR ESOPHAGEAL VARICES Surgery Blank 26.49 12.70 12.70 Blank RBRVS

43405 Blank LIG/STAPLING G-ESOP JUNCT PRE-ESOPHGL PRF8J Surgery Blank 24.73 11.60 11.60 Blank RBRVS

43410 Blank SUTR ESOPHGL WND/INJ CRV APPR Surgery Blank 16.41 10.53 10.53 Blank RBRVS

43415 Blank SUTR ESOPHGL WND/INJ TTHRC/TABDL APPR Surgery Blank 44.88 19.65 19.65 Blank RBRVS

43420 Blank CLSR ESOPHAGOSTOMY/FSTL CRV APPR Surgery Blank 16.78 9.78 9.78 Blank RBRVS

43425 Blank CLSR ESOPHAGOSTOMY/FSTL TTHRC/TABDL APPR Surgery Blank 25.04 10.89 10.89 Blank RBRVS

43450 Blank DILATION ESOPH UNGUIDED SOUND/BOUGIE 1/MULT PASS Surgery Blank 1.28 0.88 3.03 Blank RBRVS

43453 Blank DILATION ESOPHAGUS GUIDE WIRE Surgery Blank 1.41 0.92 24.40 Blank RBRVS

43460 Blank ESOPG/GSTR TAMPONADE W/BALO SENGSTAKEN TYPE Surgery Blank 3.79 1.98 1.98 Blank RBRVS

43496 Blank FREE JEJUNUM TRSF W/MICROVASC ANASTOMOSIS Surgery Blank Blank Blank Blank 3.93 v3.23

43499 Blank UNLISTED PROCEDURE ESOPHAGUS Surgery Blank Blank Blank Blank 4.25 Unlisted

43500 Blank GASTROTOMY W/EXPLORATION/FOREIGN BODY REMOVAL Surgery Blank 12.79 7.00 7.00 Blank RBRVS

43501 Blank GASTROTOMY W/SUTURE REPAIR BLEEDING ULCER Surgery Blank 22.60 11.09 11.09 Blank RBRVS

43502 Blank GASTROTOMY W/SUTR RPR PRE-ESOPG/GASTRIC LAC Surgery Blank 25.69 12.36 12.36 Blank RBRVS

43510 Blank GSTRT W/ESOPHGL DILAT&INSJ PRM INTRAL TUBE Surgery Blank 15.14 8.61 8.61 Blank RBRVS

43520 Blank PYLOROMYOTOMY CUTTING PYLORIC MUSC Surgery Blank 11.29 6.01 6.01 Blank RBRVS

43605 Blank BIOPSY STOMACH LAPAROTOMY Surgery Blank 13.72 7.39 7.39 Blank RBRVS

43610 Blank EXC LOCAL ULCER/BENIGN TUMOR STOMACH Surgery Blank 16.34 8.23 8.23 Blank RBRVS

43611 Blank EXC LOCAL MALIGNANT TUMOR STOMACH Surgery Blank 20.38 10.32 10.32 Blank RBRVS

43620 Blank GSTRCT TOT W/ESOPHAGOENTEROSTOMY Surgery Blank 34.04 15.03 15.03 Blank RBRVS

43621 Blank GSTRCT TOT W/ROUX-EN-Y RCNSTJ Surgery Blank 39.53 16.95 16.95 Blank RBRVS

43622 Blank GSTRCT TOT W/FRMJ INTSTINAL POUCH ANY TYPE Surgery Blank 40.03 17.46 17.46 Blank RBRVS

43631 Blank GSTRCT PRTL DSTL W/GASTRODUODENOSTOMY Surgery Blank 24.51 11.75 11.75 Blank RBRVS

43632 Blank GSTRCT PRTL DSTL W/GASTROJEJUNOSTOMY Surgery Blank 35.14 15.53 15.53 Blank RBRVS

43633 Blank GSTRCT PRTL DSTL W/ROUX-EN-Y RCNSTJ Surgery Blank 33.14 14.80 14.80 Blank RBRVS

43634 Blank GSTRCT PRTL DSTL W/FRMJ INTSTINAL POUCH Surgery Blank 36.64 16.25 16.25 Blank RBRVS

43635 Blank VAGOTOMY PFRMD W/PRTL DSTL GSTRCT Surgery Blank 2.06 0.72 0.72 Blank RBRVS

43640 Blank VGTMY W/PYLORPLSTY W/WO GASTROST TRUNCAL/SLCTV Surgery Blank 19.56 10.06 10.06 Blank RBRVS

43641 Blank VGTMY W/PYLOROPLASTY W/WO GASTROST PARIETAL CELL Surgery Blank 19.81 10.27 10.27 Blank RBRVS

43644 Blank LAPS GSTR RSTCV PX W/BYP ROUX-EN-Y LIMB <150 CM Surgery Blank 29.40 13.95 13.95 Blank RBRVS

43645 Blank LAPS GSTR RSTCV PX W/BYP&SM INT RCNSTJ Surgery Blank 31.53 14.71 14.71 Blank RBRVS

43647 Blank LAPS IMPLTJ/RPLCMT GASTRIC NSTIM ELTRD ANTRUM Surgery Blank Blank Blank Blank 15.85 FAIR Health

43651 Blank LAPS SURG TRNSXJ VAGUS NRV TRUNCAL Surgery Blank 10.13 6.39 6.39 Blank RBRVS

43652 Blank LAPS SURG TRNSXJ VAGUS NRV SLCTV/HILY SLCTV Surgery Blank 12.13 7.10 7.10 Blank RBRVS





PAGE 50 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

43653 Blank LAPS SURG GASTROSTOMY W/O CONSTJ GSTR TUBE SPX Surgery Blank 8.48 6.11 6.11 Blank RBRVS

43659 Blank UNLISTED LAPAROSCOPIC PROCEDURE STOMACH Surgery Blank Blank Blank Blank 43.35 Unlisted

43752 Blank NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE Surgery Blank 0.81 0.29 0.29 Blank RBRVS

43753 Blank GASTRIC INTUBATJ & ASPIRAJ W/PHYS SKILL/LAVAGE Surgery Blank 0.45 0.12 0.12 Blank RBRVS

43754 Blank GASTRIC INTUBAT DX W/ASPIRATION SINGLE SPECIMEN Surgery Blank 0.45 0.54 3.31 Blank RBRVS

43755 Blank GASTRIC INTUBATION DX & ASPIRATJ MULTIPLE SPEC Surgery Blank 0.94 0.70 2.86 Blank RBRVS

43756 Blank DUODENAL INTUBAT W/IMAG GUIDED SINGLE SPECIMEN Surgery Blank 0.77 0.62 5.04 Blank RBRVS

43757 Blank DUODENAL INTUBAT W/IMAG GUIDED MULTIPLE SPECIMEN Surgery Blank 1.26 0.83 6.95 Blank RBRVS

43761 Blank REPOS NASO/ORO GASTRIC FEEDING TUBE THRU DUO Surgery Blank 2.01 0.73 1.12 Blank RBRVS

43762 Blank RPLC GTUBE NO REVJ TRC Surgery Blank 0.75 0.23 5.45 Blank RBRVS

43763 Blank RPLC GTUBE REVJ GSTRST TRC Surgery Blank 1.41 0.80 7.76 Blank RBRVS

43770 Blank LAPS GASTRIC RESTRICTIVE PROCEDURE PLACE DEVICE Surgery Blank 18.00 10.24 10.24 Blank RBRVS

43771 Blank LAPS GASTRIC RESTRICTIVE PX REVISION DEVICE Surgery Blank 20.79 11.15 11.15 Blank RBRVS

43772 Blank LAPS GASTRIC RESTRICTIVE PX REMOVE DEVICE Surgery Blank 15.70 8.14 8.14 Blank RBRVS

43773 Blank LAPS GASTRIC RESTRICTIVE PX REMOVE&RPLCMT DEVICE Surgery Blank 20.79 11.24 11.24 Blank RBRVS

43774 Blank LAPS GASTRIC RESTRICTIVE PX REMOVE DEVICE & PORT Surgery Blank 15.76 8.36 8.36 Blank RBRVS

43775 Blank LAPS GSTRC RSTRICTIV PX LONGITUDINAL GASTRECTOMY Surgery Blank 20.38 7.23 7.23 Blank RBRVS

43800 Blank PYLOROPLASTY Surgery Blank 15.43 7.89 7.89 Blank RBRVS

43810 Blank GASTRODUODENOSTOMY Surgery Blank 16.88 8.57 8.57 Blank RBRVS

43820 Blank GASTROJEJUNOSTOMY W/O VAGOTOMY Surgery Blank 22.53 11.08 11.08 Blank RBRVS

43825 Blank GASTROJEJUNOSTOMY W/VAGOTOMY ANY TYPE Surgery Blank 21.76 10.96 10.96 Blank RBRVS

43830 Blank GASTROSTOMY OPN W/O CONSTJ GSTR TUBE SPX Surgery Blank 10.85 6.91 6.91 Blank RBRVS

43831 Blank GASTROSTOMY OPN NEONATAL FEEDING Surgery Blank 8.49 6.68 6.68 Blank RBRVS

43832 Blank GASTROSTOMY OPN W/CONSTJ GSTR TUBE Surgery Blank 17.34 8.72 8.72 Blank RBRVS

43840 Blank GASTRORRHAPHY SUTR PRF8 DUOL/GSTR ULCER WND/INJ Surgery Blank 22.83 11.22 11.22 Blank RBRVS

43842 Blank GASTRIC RSTCV W/O BYP VERTICAL-BANDED GASTROPLY Surgery Blank 21.03 10.70 10.70 Blank RBRVS

43843 Blank GSTR RSTCV W/O BYP OTH/THN VER-BANDED GSTP Surgery Blank 21.21 10.81 10.81 Blank RBRVS

43845 Blank GASTRIC RSTCV W/PRTL GASTRECTOMY 50-100 CM Surgery Blank 33.30 15.70 15.70 Blank RBRVS

43846 Blank GASTRIC RSTCV W/BYP W/SHORT LIMB 150 CM/< Surgery Blank 27.41 13.19 13.19 Blank RBRVS

43847 Blank GASTRIC RSTCV W/BYP W/SM INT RCNSTJ LIMIT ABSRPJ Surgery Blank 30.28 14.72 14.72 Blank RBRVS

43848 Blank REVISION OPEN GASTRIC RESTRICTIVE PX NOT DEVICE Surgery Blank 32.75 15.44 15.44 Blank RBRVS

43850 Blank REVJ GASTRODUOL ANAST W/RCNSTJ W/O VAGOTOMY Surgery Blank 27.58 13.03 13.03 Blank RBRVS

43855 Blank REVJ GASTRODUOL ANAST W/RCNSTJ W/VGTMY Surgery Blank 28.69 13.42 13.42 Blank RBRVS

43860 Blank REVJ GSTR/JJ ANAST W/RCNSTJ W/O VGTMY Surgery Blank 27.89 13.08 13.08 Blank RBRVS

43865 Blank REVJ GSTR/JJ ANAST W/RCNSTJ W/VGTMY Surgery Blank 29.05 13.55 13.55 Blank RBRVS

43870 Blank CLOSURE GASTROSTOMY SURG Surgery Blank 11.44 6.55 6.55 Blank RBRVS

43880 Blank CLOSURE GASTROCOLIC FISTULA Surgery Blank 27.18 12.84 12.84 Blank RBRVS

43881 Blank IMPLTJ/RPLCMT GASTRIC NSTIM ELTRDE ANTRUM OPEN Surgery Blank Blank Blank Blank 16.98 FAIR Health

43886 Blank GSTR RSTCV PX OPN REVJ SUBQ PORT COMPONENT ONLY Surgery Blank 4.64 4.73 4.73 Blank RBRVS

43887 Blank GSTR RSTCV PX OPN RMVL SUBQ PORT COMPONENT ONLY Surgery Blank 4.32 4.10 4.10 Blank RBRVS

43888 Blank GSTR RSTCV OPN RMVL & RPLCMT SUBQ PORT Surgery Blank 6.44 5.36 5.36 Blank RBRVS

43999 Blank UNLISTED PROCEDURE STOMACH Surgery Blank Blank Blank Blank 5.96 Unlisted

44005 Blank ENTEROLSS FRING INTSTINAL ADHESION SPX Surgery Blank 18.46 9.02 9.02 Blank RBRVS

44010 Blank DUODENOTOMY EXPLORATION/BX/FOREIGN BODY REMOVAL Surgery Blank 14.26 7.82 7.82 Blank RBRVS

44015 Blank TUBE/NEEDLE CATH JEJUNOSTOMY ANY METHOD Surgery Blank 2.62 0.89 0.89 Blank RBRVS

44020 Blank ENTEROTOMY SM INT OTH/THN DUO EXPL BX/FB RMVL Surgery Blank 16.22 8.23 8.23 Blank RBRVS

44021 Blank ENTEROTOMY SM INT OTH/THN DUO DCMPRN Surgery Blank 16.31 8.26 8.26 Blank RBRVS

44025 Blank COLOTOMY EXPLORATION/BIOPSY/FOREIGN BODY REMOVAL Surgery Blank 16.51 8.35 8.35 Blank RBRVS

44050 Blank RDCTJ VOLVULUS INTUSSUSCEPTION INT HRNA LAPT Surgery Blank 15.52 7.98 7.98 Blank RBRVS

44055 Blank CORRJ MALROTATION BANDS&/RDCTJ VOLVULUS Surgery Blank 25.63 11.72 11.72 Blank RBRVS

44100 Blank BX INTESTINE CAPSULE TUBE PRORAL 1/> SPECIMENS Surgery Blank 2.01 0.86 0.86 Blank RBRVS

44110 Blank EXC 1/> SMALL/LARGE LESIONS INTESTINE ENTEROTOM Surgery Blank 14.04 7.52 7.52 Blank RBRVS

44111 Blank EXC 1/> SM/LG LESIONS INTESTNE MULT ENTEROTOMIE Surgery Blank 16.52 8.44 8.44 Blank RBRVS

44120 Blank ENTRC RESCJ SMALL INTESTINE 1 RESCJ & ANAST Surgery Blank 20.82 9.89 9.89 Blank RBRVS

44121 Blank ENTERECTOMY RESCJ SMALL INTESTINE EA RESCJ & ANA Surgery Blank 4.44 1.59 1.59 Blank RBRVS

44125 Blank ENTERECTOMY RESCJ SMALL INTESTINE W/ENTEROSTOMY Surgery Blank 20.03 9.75 9.75 Blank RBRVS

44126 Blank ENTRC RESCJ ATRESIA RESCJ & ANAST W/O TAPRING Surgery Blank 42.23 19.18 19.18 Blank RBRVS

44127 Blank ENTRC RESCJ ATRESIA RESCJ & ANAST SGM W/TAPRING Surgery Blank 49.30 21.60 21.60 Blank RBRVS

44128 Blank ENTRC RESCJ ATRESIA EA RESCJ & ANASTOMOSIS Surgery Blank 4.44 1.58 1.58 Blank RBRVS

44130 Blank ENTEROENTEROST ANAST INT W/WO CUTAN NTRSTM SPX Surgery Blank 22.11 10.97 10.97 Blank RBRVS

44139 Blank MOBLJ SPLENIC FLXR PFRMD CONJUNCT W/PRTL COLCT Surgery Blank 2.23 0.80 0.80 Blank RBRVS

44140 Blank COLECTOMY PARTIAL W/ANASTOMOSIS Surgery Blank 22.59 11.19 11.19 Blank RBRVS

44141 Blank COLECTOMY PRTL W/SKIN LEVEL CECOST/COLOSTOMY Surgery Blank 29.91 16.28 16.28 Blank RBRVS

44143 Blank COLECTOMY PRTL W/END COLOSTOMY & CLSR DSTL SGMT Surgery Blank 27.79 14.21 14.21 Blank RBRVS

44144 Blank COLECTOMY PRTL W/COLOST/ILEOST & MUCOFISTULA Surgery Blank 29.91 14.69 14.69 Blank RBRVS

44145 Blank COLECTOMY PRTL W/COLOPROCTOSTOMY Surgery Blank 28.58 13.42 13.42 Blank RBRVS

44146 Blank COLECTOMY PRTL W/COLOPROCTOSTOMY & COLOSTOMY Surgery Blank 35.30 18.72 18.72 Blank RBRVS

44147 Blank COLECTOMY PRTL ABDOMINAL & TRANSANAL APPROACH Surgery Blank 33.69 15.18 15.18 Blank RBRVS

44150 Blank COLCT TOT ABDL W/O PRCTECT W/ILEOST/ILEOPXTS Surgery Blank 30.18 17.47 17.47 Blank RBRVS

44151 Blank COLCT TOT ABDL W/O PRCTECT W/CONTINENT ILEOST Surgery Blank 34.92 19.34 19.34 Blank RBRVS

44155 Blank COLECTOMY TOT ABDL W/PROCTECTOMY W/ILEOSTOMY Surgery Blank 34.42 19.01 19.01 Blank RBRVS

44156 Blank COLECTOMY TOT ABDL W/PROCTECTOMY W/CONTNT ILEOST Surgery Blank 37.42 20.70 20.70 Blank RBRVS





PAGE 51 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

44157 Blank COLECTOMY TOT ABD W/PROCTECTOMY ILEOANAL ANAST Surgery Blank 35.70 19.34 19.34 Blank RBRVS

44158 Blank COLCT TTL ABD W/PRCTECT ILEOANAL ANAST & RSVR Surgery Blank 36.70 19.69 19.69 Blank RBRVS

44160 Blank COLECTOMY PRTL W/RMVL TERMINAL ILEUM & ILEOCOLOS Surgery Blank 20.89 10.45 10.45 Blank RBRVS

44180 Blank LAPAROSCOPY ENTEROLYSIS SEPARATE PROCEDURE Surgery Blank 15.27 7.91 7.91 Blank RBRVS

44186 Blank LAPAROSCOPY SURGICAL JEJUNOSTOMY Surgery Blank 10.38 6.01 6.01 Blank RBRVS

44187 Blank LAPAROSCOPY SURG ILEOSTOMY/JEJUNOSTOMY NON-TUBE Surgery Blank 17.40 11.20 11.20 Blank RBRVS

44188 Blank LAPAROSCOPY SURG COLOSTOMY/SKN LVL CECOSTOMY Surgery Blank 19.35 12.06 12.06 Blank RBRVS

44202 Blank LAPS ENTERECT RESCJ 1 SMALL INTEST RESCJ & ANA Surgery Blank 23.39 11.51 11.51 Blank RBRVS

44203 Blank LAPAROSCOPY SMALL INTESTINE RESCJ & ANASTOMOSIS Surgery Blank 4.44 1.59 1.59 Blank RBRVS

44204 Blank LAPAROSCOPY COLECTOMY PARTIAL W/ANASTOMOSIS Surgery Blank 26.42 12.61 12.61 Blank RBRVS

44205 Blank LAPS COLECTOMY PRTL W/RMVL TERMINAL ILEUM Surgery Blank 22.95 11.06 11.06 Blank RBRVS

44206 Blank LAPS COLECTOMY PRTL W/END CLST & CLSR DSTL SGM Surgery Blank 29.79 14.64 14.64 Blank RBRVS

44207 Blank LAPS COLECTOMY PRTL W/COLOPXTSTMY LW ANAST Surgery Blank 31.92 14.53 14.53 Blank RBRVS

44208 Blank LAPS COLECTMY PRTL W/COLOPXTSTMY LW ANAST W/CLST Surgery Blank 33.99 16.93 16.93 Blank RBRVS

44210 Blank LAPS COLECTOMY TOT W/O PRCTECT W/ILEOST/ILEOPXTS Surgery Blank 30.09 15.90 15.90 Blank RBRVS

44211 Blank LAPS COLCT TTL ABD W/PRCTECT ILEOANAL ANASTOMSIS Surgery Blank 37.08 19.64 19.64 Blank RBRVS

44212 Blank LAPS COLECTOMY ABDL W/PROCTECTOMY W/ILEOSTOMY Surgery Blank 34.58 18.64 18.64 Blank RBRVS

44213 Blank LAPS MOBLJ SPLENIC FLXR PFRMD W/PRTL COLECTOMY Surgery Blank 3.50 1.26 1.26 Blank RBRVS

44227 Blank LAPS CLSR NTRSTM LG/SM INT W/RESCJ & ANASTOMOSIS Surgery Blank 28.62 13.46 13.46 Blank RBRVS

44238 Blank UNLISTED LAPAROSCOPY PX INTESTINE XCP RECTUM Surgery Blank Blank Blank Blank 39.03 Unlisted

44300 Blank PLACEMENT ENTEROSTOMY/CECOSTOMY TUBE OPEN Surgery Blank 13.75 7.44 7.44 Blank RBRVS

44310 Blank ILEOSTOMY/JEJUNOSTOMY NON-TUBE Surgery Blank 17.59 8.96 8.96 Blank RBRVS

44312 Blank REVJ ILEOSTOMY SIMPLE RLS SUPERFICIAL SCAR SPX Surgery Blank 9.43 5.89 5.89 Blank RBRVS

44314 Blank REVJ ILEOSTOMY COMPLIC RCNSTJ IN-DEPTH SPX Surgery Blank 16.74 9.08 9.08 Blank RBRVS

44316 Blank CONTINENT ILEOSTOMY KOCK PROCEDURE SPX Surgery Blank 23.59 11.75 11.75 Blank RBRVS

44320 Blank COLOSTOMY/SKIN LEVEL CECOSTOMY Surgery Blank 19.91 10.53 10.53 Blank RBRVS

44322 Blank COLOSTOMY/SKN LVL CECOSTOMY W/MULT BXS SPX Surgery Blank 13.32 12.46 12.46 Blank RBRVS

44340 Blank REVJ COLOSTOMY SMPL RLS SUPFC SCAR SPX Surgery Blank 9.28 6.75 6.75 Blank RBRVS

44345 Blank REVJ COLOSTOMY COMP RCNSTJ IN-DEPTH SPX Surgery Blank 17.22 9.60 9.60 Blank RBRVS

44346 Blank REVJ COLOSTOMY W/RPR PARACLST HERNIA SPX Surgery Blank 19.63 10.50 10.50 Blank RBRVS

44360 Blank ENDOSCOPY UPPER SMALL INTESTINE Surgery Blank 2.49 1.42 1.42 Blank RBRVS

44361 Blank ENDOSCOPY UPPER SMALL INTESTINE W/BIOPSY Surgery Blank 2.77 1.54 1.54 Blank RBRVS

44363 Blank ENTEROSCOPY > 2ND PRTN W/RMVL FOREIGN BODY Surgery Blank 3.39 1.80 1.80 Blank RBRVS

44364 Blank ENTEROSCOPY > 2ND PRTN W/RMVL LESION SNARE Surgery Blank 3.63 1.92 1.92 Blank RBRVS

44365 Blank ENTEROSCOPY > 2ND PRTN W/RMVL LESION CAUTERY Surgery Blank 3.21 1.74 1.74 Blank RBRVS

44366 Blank ENTEROSCOPY > 2ND PRTN W/CONTROL BLEEDING Surgery Blank 4.30 2.22 2.22 Blank RBRVS

44369 Blank ENTEROSCOPY > 2ND PRTN ABLTJ LESION Surgery Blank 4.41 2.26 2.26 Blank RBRVS

44370 Blank ENTEROSCOPY > 2ND PRTN TNDSC STENT PLMT Surgery Blank 4.69 2.48 2.48 Blank RBRVS

44372 Blank ENTEROSCOPY > 2ND PRTN W/PLMT PRQ TUBE Surgery Blank 4.30 2.15 2.15 Blank RBRVS

44373 Blank ENTEROSCOPY > 2ND PRTN CONV GSTRST TUBE Surgery Blank 3.39 1.77 1.77 Blank RBRVS

44376 Blank ENTEROSC >2ND PRTN W/ILEUM W/WO COLLJ SPEC SPX Surgery Blank 5.15 2.53 2.53 Blank RBRVS

44377 Blank ENTEROSC >2ND PRTN W/ILEUM W/BX SINGLE/MULTIPLE Surgery Blank 5.42 2.68 2.68 Blank RBRVS

44378 Blank ENTEROSCOPY > 2ND PRTN ILEUM CONTROL BLEEDING Surgery Blank 7.02 3.42 3.42 Blank RBRVS

44379 Blank ENTEROSCOPY > 2ND PRTN W/ILEUM W/STENT PLMT Surgery Blank 7.36 3.73 3.73 Blank RBRVS

44380 Blank ILEOSCOPY THRU STOMA DX W/COLLJ SPEC WHEN PRFMD Surgery Blank 0.87 0.68 3.82 Blank RBRVS

44381 Blank ILEOSCOPY STOMA W/BALLOON DILATION Surgery Blank 1.38 0.90 24.76 Blank RBRVS

44382 Blank ILEOSCOPY STOMA W/BX SINGLE/MULTIPLE Surgery Blank 1.17 0.82 6.21 Blank RBRVS

44384 Blank ILEOSCOPY STOMA W/PLMT OF ENDOSCOPIC STENT Surgery Blank 2.85 1.31 1.31 Blank RBRVS

44385 Blank NDSC EVAL INTSTINAL POUCH DX W/COLLJ SPEC SPX Surgery Blank 1.20 0.74 4.11 Blank RBRVS

44386 Blank NDSC EVAL INTSTINAL POUCH W/BX SINGLE/MULTIPLE Surgery Blank 1.50 0.90 6.45 Blank RBRVS

44388 Blank COLONOSCOPY STOMA DX INCLUDING COLLJ SPEC SPX Surgery Blank 2.72 1.44 5.09 Blank RBRVS

44389 Blank COLONOSCOPY STOMA W/BIOPSY SINGLE/MULTIPLE Surgery Blank 3.02 1.60 7.37 Blank RBRVS

44390 Blank COLONOSCOPY STOMA W/RMVL FOREIGN BODY Surgery Blank 3.74 1.98 6.52 Blank RBRVS

44391 Blank COLONOSCOPY STOMA CONTROL BLEEDING Surgery Blank 4.12 2.11 15.15 Blank RBRVS

44392 Blank COLONOSCOPY STOMA RMVL LES BY HOT BIOPSY FORCEPS Surgery Blank 3.53 1.76 5.97 Blank RBRVS

44394 Blank COLONOSCOPY STOMA W/RMVL TUM POLYP/OTH LES SNARE Surgery Blank 4.03 2.03 6.93 Blank RBRVS

44401 Blank COLONOSCOPY STOMA ABLATION LESION Surgery Blank 4.34 2.16 86.08 Blank RBRVS

44402 Blank COLONOSCOPY STOMA W/ENDOSCOPIC STENT PLCMT Surgery Blank 4.70 2.40 2.40 Blank RBRVS

44403 Blank COLONOSCOPY STOMA W/ENDOSCOPIC MUCOSAL RESCJ Surgery Blank 5.50 2.73 2.73 Blank RBRVS

44404 Blank COLONOSCOPY STOMA W/SUBMUCOSAL INJECTION Surgery Blank 3.02 1.61 6.90 Blank RBRVS

44405 Blank COLONOSCOPY STOMA W/BALLOON DILATION Surgery Blank 3.23 1.75 11.68 Blank RBRVS

44406 Blank COLONOSCOPY STOMA W/ENDOSCOPIC ULTRASOUND EXAM Surgery Blank 4.10 2.13 2.13 Blank RBRVS

44407 Blank COLONOSCOPY STOMA W/US GID NDL ASPIR/BX Surgery Blank 4.96 2.51 2.51 Blank RBRVS

44408 Blank COLONOSCOPY THROUGH STOMA WITH DECOMPRESSION Surgery Blank 4.14 2.15 2.15 Blank RBRVS

44500 Blank INTRODUCTION LONG GI TUBE SEPARATE PROCEDURE Surgery Blank 0.39 0.14 0.14 Blank RBRVS

44602 Blank ENTERORRHAPHY 1PERFORATION Surgery Blank 24.72 10.59 10.59 Blank RBRVS

44603 Blank ENTERORRHAPHY MULTIPLE PERFORATIONS Surgery Blank 28.16 12.56 12.56 Blank RBRVS

44604 Blank SUTR LG INTESTINE 1/MULT PERFORAT W/O COLOSTOMY Surgery Blank 18.16 8.45 8.45 Blank RBRVS

44605 Blank SUTR LG INTESTINE 1/MULT PERFORAT W/COLOSTOMY Surgery Blank 22.08 10.84 10.84 Blank RBRVS

44615 Blank INTSTINAL STRICTUROPLASTY W/WO DILAT OBSTRCJ Surgery Blank 18.16 8.97 8.97 Blank RBRVS

44620 Blank CLOSURE ENTEROSTOMY LG/SMALL INTESTINE Surgery Blank 14.43 7.68 7.68 Blank RBRVS

44625 Blank CLSR NTRSTM LG/SM RESCJ & ANAST OTH/THN CLRCT Surgery Blank 17.28 8.74 8.74 Blank RBRVS





PAGE 52 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

44626 Blank CLSR NTRSTM LG/SM RESCJ & COLORECTAL ANASTOMOSIS Surgery Blank 27.90 12.47 12.47 Blank RBRVS

44640 Blank CLOSURE INTESTINAL CUTANEOUS FISTULA Surgery Blank 24.20 11.14 11.14 Blank RBRVS

44650 Blank CLSR ENTEROENTERIC/ENTEROCOLIC FSTL Surgery Blank 25.12 11.48 11.48 Blank RBRVS

44660 Blank CLSR ENTEROVES FSTL W/O INTSTINAL/BLADDER RESCJ Surgery Blank 23.91 10.70 10.70 Blank RBRVS

44661 Blank CLSR ENTEROVES FSTL W/INTESTINE&/BLADDER RESCJ Surgery Blank 27.35 12.14 12.14 Blank RBRVS

44680 Blank INTESTINAL PLICATION SEPARATE PROCEDURE Surgery Blank 17.96 8.79 8.79 Blank RBRVS

44700 Blank EXCLUSION SM INT FROM PELVIS MESH/PROSTH/TISS Surgery Blank 17.48 8.78 8.78 Blank RBRVS

44701 Blank INTRAOPERATIVE COLONIC LAVAGE Surgery Blank 3.10 1.11 1.11 Blank RBRVS

44705 Blank PREPARE FECAL MICROBIOTA FOR INSTILLATION Surgery Blank 1.42 0.55 1.65 Blank RBRVS

44720 Blank BKBENCH RCNSTJ INT ALGRFT VEN ANAST EA Surgery Blank 5.00 1.78 1.78 Blank RBRVS

44721 Blank BKBENCH RCNSTJ INT ALGRFT ARTL ANAST EA Surgery Blank 7.00 2.49 2.49 Blank RBRVS

44799 Blank UNLISTED PROCEDURE SMALL INTESTINE Surgery Blank Blank Blank Blank 30.71 Unlisted

44800 Blank EXC MECKEL'S DIVERTICULUM/OMPHALOMESENTERIC DUCT Surgery Blank 12.05 7.35 7.35 Blank RBRVS

44820 Blank EXCISION LESION MESENTERY SEPARATE PROCEDURE Surgery Blank 13.73 7.45 7.45 Blank RBRVS

44850 Blank SUTURE MESENTERY SEPARATE PROCEDURE Surgery Blank 12.11 6.85 6.85 Blank RBRVS

44899 Blank UNLISTED PX MECKEL'S DIVERTICULUM & MESENTERY Surgery Blank Blank Blank Blank 19.40 Unlisted

44900 Blank INCISION AND DRAINAGE APPENDICEAL ABSCESS OPEN Surgery Blank 12.57 6.86 6.86 Blank RBRVS

44950 Blank APPENDECTOMY Surgery Blank 10.60 5.53 5.53 Blank RBRVS

44955 Blank APPENDEC INDICATED PURPOSE OTH MAJOR PX NOT SPX Surgery Blank 1.53 0.58 0.58 Blank RBRVS

44960 Blank APPENDEC RPTD APPENDIX ABSC/PRITONITIS Surgery Blank 14.50 7.41 7.41 Blank RBRVS

44970 Blank LAPAROSCOPIC APPENDECTOMY Surgery Blank 9.45 5.74 5.74 Blank RBRVS

44979 Blank UNLISTED LAPAROSCOPY PROCEDURE APPENDIX Surgery Blank Blank Blank Blank 15.19 Unlisted

45000 Blank TRANSRECTAL DRAINAGE OF PELVIC ABSCESS Surgery Blank 6.30 4.88 4.88 Blank RBRVS

45005 Blank I&D SUBMUCOSAL ABSCESS RECTUM Surgery Blank 2.02 2.21 5.48 Blank RBRVS

45020 Blank I&D DP SUPRALEVATOR PELVIRCT/RETRORCT ABSC Surgery Blank 8.56 6.25 6.25 Blank RBRVS

45100 Blank BX ANORECTAL WALL ANAL APPROACH Surgery Blank 4.04 3.85 3.85 Blank RBRVS

45108 Blank ANORECTAL MYOMECTOMY Surgery Blank 5.12 4.33 4.33 Blank RBRVS

45110 Blank PRCTECT COMPL CMBN ABDOMINOPRNL W/CLST Surgery Blank 30.76 16.81 16.81 Blank RBRVS

45111 Blank PRCTECT PRTL RESCJ RECTUM TABDL APPR Surgery Blank 18.01 9.83 9.83 Blank RBRVS

45112 Blank PRCTECT CMBN ABDOMINOPRNL PULL-THRU PX Surgery Blank 33.18 15.22 15.22 Blank RBRVS

45113 Blank PRCTECT PRTL W/MUCOSEC ILEOANAL ANAST RSVR Surgery Blank 33.22 17.08 17.08 Blank RBRVS

45114 Blank PRCTECT PRTL W/ANAST ABDL & TRANSSAC APPROACH Surgery Blank 30.79 14.53 14.53 Blank RBRVS

45116 Blank PRCTECT PRTL W/ANAST TRANSSAC APPR ONLY Surgery Blank 27.72 13.63 13.63 Blank RBRVS

45119 Blank PRCTECT CMBN PULL-THRU W/RSVR W/NTRSTM Surgery Blank 33.48 16.99 16.99 Blank RBRVS

45120 Blank PRCTECT COMPL W/PULL-THRU PX & ANASTOMOSIS Surgery Blank 26.40 13.38 13.38 Blank RBRVS

45121 Blank PRCTECT COMPL W/STOT/TOT COLCT W/MLT BXS Surgery Blank 29.08 14.34 14.34 Blank RBRVS

45123 Blank PRCTECT PRTL W/O ANAST PRNL APPR Surgery Blank 18.86 10.33 10.33 Blank RBRVS

45126 Blank PELVIC EXENTERATION COLORECTAL MALIGNANCY Surgery Blank 49.10 23.40 23.40 Blank RBRVS

45130 Blank EXC RCT PROCIDENTIA W/ANAST PERINEAL APPROACH Surgery Blank 18.50 9.89 9.89 Blank RBRVS

45135 Blank EXC RCT PROCIDENTIA W/ANAST ABDL & PRNL APPROACH Surgery Blank 22.36 12.28 12.28 Blank RBRVS

45136 Blank EXC ILEOANAL RSVR W/ILEOSTOMY Surgery Blank 30.82 17.37 17.37 Blank RBRVS

45150 Blank DIVISION STRICTURE RECTUM Surgery Blank 5.85 4.73 4.73 Blank RBRVS

45160 Blank EXC RCT TUM PROCTOTOMY TRANSSAC/TRANSCOCCYGEAL Surgery Blank 16.33 9.37 9.37 Blank RBRVS

45171 Blank EXC RCT TUM NOT INCL MUSCULARIS PROPRIA Surgery Blank 8.13 7.70 7.70 Blank RBRVS

45172 Blank EXC RCT TUM INCL MUSCULARIS PROPRIA Surgery Blank 12.13 9.22 9.22 Blank RBRVS

45190 Blank DESTRUCTION RECTAL TUMOR TRANSANAL APPROACH Surgery Blank 10.42 7.96 7.96 Blank RBRVS

45300 Blank PROCTOSGMDSC RGD DX W/WO COLLJ SPEC BR/WA SPX Surgery Blank 0.80 0.64 2.65 Blank RBRVS

45303 Blank PROCTOSGMDSC RIGID W/DILATION Surgery Blank 1.40 0.86 24.06 Blank RBRVS

45305 Blank PROCTOSGMDSC RIGID W/BX SINGLE/MULTIPLE Surgery Blank 1.15 0.77 2.75 Blank RBRVS

45307 Blank PROCTOSGMDSC RIGID W/RMVL FOREIGN BODY Surgery Blank 1.60 0.93 2.88 Blank RBRVS

45308 Blank PROCTOSGMDSC RIGID RMVL 1 LESION CAUTERY Surgery Blank 1.30 0.82 3.00 Blank RBRVS

45309 Blank PROCTOSGMDSC RIGID RMVL 1 LESION SNARE TQ Surgery Blank 1.40 0.86 3.06 Blank RBRVS

45315 Blank PROCTOSGMDSC RIGID RMVL MULT TUMOR CAUTERY/SNARE Surgery Blank 1.70 0.96 3.19 Blank RBRVS

45317 Blank PROCTOSGMDSC RIGID CONTROL BLEEDING Surgery Blank 1.90 1.05 3.06 Blank RBRVS

45320 Blank PROCTOSGMDSC RIGID ABLATION LESION Surgery Blank 1.68 0.96 3.06 Blank RBRVS

45321 Blank PROCTOSGMDSC RIGID DCMPRN VOLVULUS Surgery Blank 1.65 0.95 0.95 Blank RBRVS

45327 Blank PROCTOSGMDSC RIGID TNDSC STENT PLMT Surgery Blank 1.90 1.04 1.04 Blank RBRVS

45330 Blank SIGMOIDOSCOPY FLX DX W/COLLJ SPEC BR/WA IF PFRMD Surgery Blank 0.84 0.68 3.85 Blank RBRVS

45331 Blank SIGMOIDOSCOPY FLX W/BIOPSY SINGLE/MULTIPLE Surgery Blank 1.14 0.81 6.07 Blank RBRVS

45332 Blank SIGMOIDOSCOPY FLX W/RMVL FOREIGN BODY Surgery Blank 1.76 1.06 5.17 Blank RBRVS

45333 Blank SIGMOIDOSCOPY FLX W/RMVL TUMOR BY HOT BX FORCEPS Surgery Blank 1.55 0.96 6.61 Blank RBRVS

45334 Blank SIGMOIDOSCOPY FLX CONTROL BLEEDING Surgery Blank 2.00 1.19 13.48 Blank RBRVS

45335 Blank SGMDSC FLX DIRED SBMCSL NJX ANY SBST Surgery Blank 1.04 0.75 5.50 Blank RBRVS

45337 Blank SGMDSC FLX W/DCMPRN W/PLMT DCMPRN TUBE Surgery Blank 2.10 0.98 0.98 Blank RBRVS

45338 Blank SGMDSC FLX RMVL TUM POLYP/OTH LES SNARE TQ Surgery Blank 2.05 1.20 5.34 Blank RBRVS

45340 Blank SIGMOIDOSCOPY FLX TNDSC BALO DILAT Surgery Blank 1.25 0.84 10.90 Blank RBRVS

45341 Blank SIGMOIDOSCOPY FLX NDSC US XM Surgery Blank 2.12 1.24 1.24 Blank RBRVS

45342 Blank SIGMOIDOSCOPY FLX TNDSC US GID NDL ASPIR/BX Surgery Blank 2.98 1.64 1.64 Blank RBRVS

45346 Blank SIGMOIDOSCOPY FLX ABLATION TUMOR POLYP/OTH LES Surgery Blank 2.81 1.53 84.28 Blank RBRVS

45347 Blank SIGMOIDOSCOPY FLX PLACEMENT OF ENDOSCOPIC STENT Surgery Blank 2.72 1.45 1.45 Blank RBRVS

45349 Blank SGMDSC FLX WITH ENDOSCOPIC MUCOSAL RESECTION Surgery Blank 3.52 1.86 1.86 Blank RBRVS

45350 Blank SIGMOIDOSCOPY FLX WITH WITH BAND LIGATION(S) Surgery Blank 1.68 1.04 13.14 Blank RBRVS





PAGE 53 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

45378 Blank COLONOSCOPY FLX DX W/COLLJ SPEC WHEN PFRMD Surgery Blank 3.26 1.71 5.29 Blank RBRVS

45379 Blank COLONOSCOPY FLX W/REMOVAL OF FOREIGN BODY(S) Surgery Blank 4.28 2.16 6.77 Blank RBRVS

45380 Blank COLONOSCOPY W/BIOPSY SINGLE/MULTIPLE Surgery Blank 3.56 1.87 7.51 Blank RBRVS

45381 Blank COLSC FLX WITH DIRECTED SUBMUCOSAL NJX ANY SBST Surgery Blank 3.56 1.87 7.01 Blank RBRVS

45382 Blank COLSC FLEXIBLE W/CONTROL BLEEDING ANY METHOD Surgery Blank 4.66 2.36 15.31 Blank RBRVS

45384 Blank COLSC FLX W/REMOVAL LESION BY HOT BX FORCEPS Surgery Blank 4.07 2.02 8.14 Blank RBRVS

45385 Blank COLSC FLX W/RMVL OF TUMOR POLYP LESION SNARE TQ Surgery Blank 4.57 2.30 6.95 Blank RBRVS

45386 Blank COLSC FLEXIBLE W/TRANSENDOSCOPIC BALLOON DILAT Surgery Blank 3.77 1.94 12.40 Blank RBRVS

45388 Blank COLONOSCOPY FLX ABLATION TUMOR POLYP/OTHER LES Surgery Blank 4.88 2.39 86.19 Blank RBRVS

45389 Blank COLONOSCOPY FLX WITH ENDOSCOPIC STENT PLACEMENT Surgery Blank 5.24 2.58 2.58 Blank RBRVS

45390 Blank COLONOSCOPY FLX W/ENDOSCOPIC MUCOSAL RESECTION Surgery Blank 6.04 2.98 2.98 Blank RBRVS

45391 Blank COLSC FLX W/NDSC US XM RCTM ET AL LMTD&ADJ STRUX Surgery Blank 4.64 2.35 2.35 Blank RBRVS

45392 Blank COLSC FLX W/US GUID NDL ASPIR/BX W/US RCTM ET AL Surgery Blank 5.50 2.73 2.73 Blank RBRVS

45393 Blank COLONOSCOPY FLEXIBLE WITH DECOMPRESSION Surgery Blank 4.68 2.09 2.09 Blank RBRVS

45395 Blank LAPS PROCTECTOMY ABDOMINOPERINEAL W/COLOSTOMY Surgery Blank 33.00 18.31 18.31 Blank RBRVS

45397 Blank LAPS PROCTECTOMY COMBINED PULL-THRU W/RESERVOIR Surgery Blank 36.50 19.72 19.72 Blank RBRVS

45398 Blank COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S) Surgery Blank 4.20 2.03 14.63 Blank RBRVS

45399 Blank UNLISTED PROCEDURE COLON Surgery Blank Blank Blank Blank 5.88 Unlisted

45400 Blank LAPAROSCOPY PROCTOPEXY PROLAPSE Surgery Blank 19.44 10.28 10.28 Blank RBRVS

45402 Blank LAPAROSCOPY PROCTOPEXY PROLAPSE SIGMOID RESCJ Surgery Blank 26.51 12.86 12.86 Blank RBRVS

45499 Blank UNLISTED LAPAROSCOPY PROCEDURE RECTUM Surgery Blank Blank Blank Blank 7.59 Unlisted

45500 Blank PROCTOPLASTY STENOSIS Surgery Blank 7.73 6.44 6.44 Blank RBRVS

45505 Blank PROCTOPLASTY PROLAPSE MUCOUS MEMBRANE Surgery Blank 8.36 7.22 7.22 Blank RBRVS

45520 Blank PERIRECTAL INJ SCLEROSING SOLUTION PROLAPSE Surgery Blank 0.55 0.54 3.84 Blank RBRVS

45540 Blank PROCTOPEXY ABDOMINAL APPROACH Surgery Blank 18.12 9.34 9.34 Blank RBRVS

45541 Blank PROCTOPEXY PERINEAL APPROACH Surgery Blank 14.85 9.45 9.45 Blank RBRVS

45550 Blank PROCTOPEXY W/SIGMOID RESCJ ABDL APPR Surgery Blank 24.80 13.04 13.04 Blank RBRVS

45560 Blank REPAIR RECTOCELE SEPARATE PROCEDURE Surgery Blank 11.50 6.82 6.82 Blank RBRVS

45562 Blank EXPL RPR & PRESACRAL DRG RECTAL INJURY Surgery Blank 17.98 10.82 10.82 Blank RBRVS

45563 Blank EXPL RPR & PRESACRAL DRG RECTAL INJ W/COLOSTOMY Surgery Blank 26.38 15.07 15.07 Blank RBRVS

45800 Blank CLOSURE RECTOVESICAL FISTULA Surgery Blank 20.31 10.89 10.89 Blank RBRVS

45805 Blank CLSR RECTOVESICAL FISTULA W/COLOSTOMY Surgery Blank 23.32 13.47 13.47 Blank RBRVS

45820 Blank CLOSURE RECTOURETHRAL FISTULA Surgery Blank 20.37 11.35 11.35 Blank RBRVS

45825 Blank CLOSURE RECTOURETHRAL FISTULA W/COLOSTOMY Surgery Blank 24.17 14.28 14.28 Blank RBRVS

45900 Blank RDCTJ PROCIDENTIA UNDER ANES SEPARATE PROCEDURE Surgery Blank 2.99 2.39 2.39 Blank RBRVS

45905 Blank DILAT ANAL SPHNCTR SPX UNDER ANES OTH/THN LOCAL Surgery Blank 2.35 2.11 2.11 Blank RBRVS

45910 Blank DILAT RCT STRIX SPX UNDER ANES OTH/THN LOCAL Surgery Blank 2.85 2.25 2.25 Blank RBRVS

45915 Blank RMVL FECAL IMPACTION/FB SPX UNDER ANES Surgery Blank 3.19 2.88 5.91 Blank RBRVS

45990 Blank ANRCT XM SURG REQ ANES GENERAL SPI/EDRL DX Surgery Blank 1.80 0.98 0.98 Blank RBRVS

45999 Blank UNLISTED PROCEDURE RECTUM Surgery Blank Blank Blank Blank 5.88 Unlisted

46020 Blank PLACEMENT SETON Surgery Blank 3.00 3.21 4.38 Blank RBRVS

46030 Blank REMOVAL ANAL SETON OTHER MARKER Surgery Blank 1.26 1.12 2.54 Blank RBRVS

46040 Blank I&D ISCHIORECTAL&/PERIRECTAL ABSCESS SPX Surgery Blank 5.37 5.50 8.96 Blank RBRVS

46045 Blank I&D INTRAMURAL IM/ABSC TRANSANAL ANES Surgery Blank 5.87 5.44 5.44 Blank RBRVS

46050 Blank I&D PERIANAL ABSCESS SUPERFICIAL Surgery Blank 1.24 1.34 4.36 Blank RBRVS

46060 Blank I&D ISCHIORCT/INTRAMURAL ABSC W/WO SETON Surgery Blank 6.37 6.18 6.18 Blank RBRVS

46070 Blank INCISION ANAL SEPTUM INFANT Surgery Blank 2.79 3.96 3.96 Blank RBRVS

46080 Blank SPHINCTEROTOMY ANAL DIVISION SPHINCTER SPX Surgery Blank 2.52 1.57 4.13 Blank RBRVS

46083 Blank INCISION THROMBOSED HEMORRHOID EXTERNAL Surgery Blank 1.45 1.39 3.43 Blank RBRVS

46200 Blank FISSURECTOMY INCL SPHINCTEROTOMY WHEN PERFORMED Surgery Blank 3.59 5.16 8.61 Blank RBRVS

46220 Blank EXCISION SINGLE EXTERNAL PAPILLA OR TAG ANUS Surgery Blank 1.61 1.51 4.03 Blank RBRVS

46221 Blank HEMORRHOIDECTOMY INTERNAL RUBBER BAND LIGATIONS Surgery Blank 2.36 2.77 5.00 Blank RBRVS

46230 Blank EXCISION MULTIPLE EXTERNAL PAPILLAE/TAGS ANUS Surgery Blank 2.62 1.89 4.76 Blank RBRVS

46250 Blank HEMORRHOIDECTOMY XTRNL 2/> COLUMN/GROUP Surgery Blank 4.25 4.01 8.25 Blank RBRVS

46255 Blank HEMORRHOIDECTOMY NTRNL & XTRNL 1 COLUMN/GROUP Surgery Blank 4.96 4.27 8.64 Blank RBRVS

46257 Blank HEMORRHOID NTRNL & XTRNL 1 COLUMN W/FISSURECTO Surgery Blank 5.76 5.36 5.36 Blank RBRVS

46258 Blank HRHC 1 COL/GRP W/FSTULECTMY INCL FSSRECTOMY Surgery Blank 6.41 5.50 5.50 Blank RBRVS

46260 Blank HEMORRHOIDECTOMY INT & XTRNL 2/> COLUMN/GRO Surgery Blank 6.73 5.67 5.67 Blank RBRVS

46261 Blank HRHC NTRNL & XTRNL 2/> COLUMN/GROUP W/FISSU Surgery Blank 7.76 5.94 5.94 Blank RBRVS

46262 Blank HRHC 2/> COL/GRP W/FSTULECTMY INCL FSSRECTMY Surgery Blank 7.91 6.61 6.61 Blank RBRVS

46270 Blank SURG TX ANAL FISTULA SUBQ Surgery Blank 4.92 5.39 8.71 Blank RBRVS

46275 Blank SURG TX ANAL FISTULA INTERSPHINCTERIC Surgery Blank 5.42 5.55 9.12 Blank RBRVS

46280 Blank TX ANAL FSTL TRANS/SUPRA/XTRASPHNCTRC INCL SETON Surgery Blank 6.39 6.04 6.04 Blank RBRVS

46285 Blank SURG TX ANAL FISTULA 2ND STAGE Surgery Blank 5.42 5.59 9.07 Blank RBRVS

46288 Blank CLSR ANAL FSTL W/RCT ADVMNT FLAP Surgery Blank 7.81 6.65 6.65 Blank RBRVS

46320 Blank EXC THROMBOSED HEMORRHOID XTRNL Surgery Blank 1.64 1.27 3.38 Blank RBRVS

46500 Blank INJECTION SCLEROSING SOLUTION HEMORRHOIDS Surgery Blank 1.74 3.10 6.21 Blank RBRVS

46505 Blank CHEMODENERVATION INTERNAL ANAL SPHINCTER Surgery Blank 3.18 3.15 4.48 Blank RBRVS

46600 Blank ANOSCOPY DX W/COLLJ SPEC BR/WA SPX WHEN PRFRMD Surgery Blank 0.55 0.55 1.91 Blank RBRVS

46601 Blank ANOSCOPY DX W/HRA &CHEM AGNTS ENHANCEMENT Surgery Blank 1.60 0.96 2.12 Blank RBRVS

46604 Blank ANOSCOPY W/DILATION Surgery Blank 1.03 0.73 16.66 Blank RBRVS

46606 Blank ANOSCOPY W/BX SINGLE/MULTIPLE Surgery Blank 1.20 0.80 5.13 Blank RBRVS





PAGE 54 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

46607 Blank ANOSCOPY DX W/HRA &CHEM AGNTS ENHANCEMENT W/BX Surgery Blank 2.20 1.21 3.02 Blank RBRVS

46608 Blank ANOSCOPY W/RMVL FOREIGN BODY Surgery Blank 1.30 0.82 5.24 Blank RBRVS

46610 Blank ANOSCOPY W/RMVL LESION CAUTERY Surgery Blank 1.28 0.81 5.05 Blank RBRVS

46611 Blank ANOSC RMVL 1 TUM POLYP/OTH LES SNARE TQ Surgery Blank 1.30 0.84 3.59 Blank RBRVS

46612 Blank ANOSC RMVL MULT TUMORS CAUTERY/SNARE Surgery Blank 1.50 0.89 6.06 Blank RBRVS

46614 Blank ANOSCOPY CONTROL BLEEDING Surgery Blank 1.00 0.71 2.56 Blank RBRVS

46615 Blank ANOSCOPY ABLATION LESION Surgery Blank 1.50 0.91 2.38 Blank RBRVS

46700 Blank ANOPLASTY PLASTIC OPERATION STRICTURE ADULT Surgery Blank 9.81 7.43 7.43 Blank RBRVS

46705 Blank ANOPLASTY PLASTIC OPERATION STRICTURE INFANT Surgery Blank 7.43 6.72 6.72 Blank RBRVS

46706 Blank REPAIR ANAL FISTULA W/FIBRIN GLUE Surgery Blank 2.44 2.06 2.06 Blank RBRVS

46707 Blank REPAIR ANORECTAL FISTULA PLUG Surgery Blank 6.39 6.02 6.02 Blank RBRVS

46710 Blank RPR ILEOANAL POUCH FSTL/POUCH ADVMNT TPRNL APPR Surgery Blank 17.14 10.76 10.76 Blank RBRVS

46712 Blank RPR ILEOANAL POUCH FSTL/POUCH ADVMNT CMBN APPR Surgery Blank 36.45 19.41 19.41 Blank RBRVS

46715 Blank RPR LW IMPERFORATE ANUS W/ANOPRNL FSTL CUT-BK Surgery Blank 7.62 6.19 6.19 Blank RBRVS

46716 Blank RPR LW IMPERFORATE ANUS W/TRPOS FISTULA Surgery Blank 17.54 13.17 13.17 Blank RBRVS

46730 Blank RPR HI IMPRF ANUS W/O FSTL PRNL/SACROPRNL APPR Surgery Blank 30.65 18.78 18.78 Blank RBRVS

46735 Blank RPR HI IMPRF ANUS W/O FISTULA CMBN APPR Surgery Blank 36.14 20.72 20.72 Blank RBRVS

46740 Blank RPR HI IMPRF ANUS W/FSTL PRNL/SACROPRNL APPR Surgery Blank 33.90 20.03 20.03 Blank RBRVS

46742 Blank RPR HI IMPRF ANUS W/FSTL TABDL & SACROPRNL Surgery Blank 40.14 22.14 22.14 Blank RBRVS

46744 Blank RPR CLOACAL ANOMALY SACROPERINEAL Surgery Blank 58.94 28.92 28.92 Blank RBRVS

46746 Blank RPR CLOACAL ANOMALY CMBN ABDL&SACROPRNL Surgery Blank 65.44 31.32 31.32 Blank RBRVS

46748 Blank RPR CLOACAL ANOMALY CMBN ABDL & SACROPRNL W/GRF Surgery Blank 71.42 33.44 33.44 Blank RBRVS

46750 Blank SPHNCTROP ANAL INCONTINENCE/PROLAPSE ADULT Surgery Blank 12.15 7.78 7.78 Blank RBRVS

46751 Blank SPHNCTROP ANAL INCONTINENCE/PROLAPSE CHLD Surgery Blank 9.30 7.29 7.29 Blank RBRVS

46753 Blank GRAFT THIERSCH RCT INCONTINENCE &/PROLAPSE Surgery Blank 8.89 6.61 6.61 Blank RBRVS

46754 Blank RMVL THIERSCH WIRE/SUTURE ANAL CANAL Surgery Blank 3.01 3.31 5.40 Blank RBRVS

46760 Blank SPHINCTEROPLASTY ANAL MUSCLE TRANSPLANT Surgery Blank 17.45 11.74 11.74 Blank RBRVS

46761 Blank SPHNCTROP ANAL LEVATOR MUSC IMBRCJ Surgery Blank 15.29 9.02 9.02 Blank RBRVS

46900 Blank DSTRJ LESION ANUS SIMPLE CHEMICAL Surgery Blank 1.91 1.76 4.77 Blank RBRVS

46910 Blank DSTRJ LESION ANUS SMPL ELTRDSICCATION Surgery Blank 1.91 1.66 5.19 Blank RBRVS

46916 Blank DSTRJ LESION ANUS SIMPLE CRYOSURGERY Surgery Blank 1.91 1.98 4.45 Blank RBRVS

46917 Blank DSTRJ LESION ANUS SIMPLE LASER SURG Surgery Blank 1.91 1.67 10.77 Blank RBRVS

46922 Blank DSTRJ LESION ANUS SIMPLE SURG EXCISION Surgery Blank 1.91 1.64 5.42 Blank RBRVS

46924 Blank DSTRJ LESION ANUS EXTENSIVE Surgery Blank 2.81 2.01 11.75 Blank RBRVS

46930 Blank DESTRUCTION INTERNAL HEMORRHOID THERMAL ENERGY Surgery Blank 1.61 2.42 4.12 Blank RBRVS

46940 Blank CURTG/CAUT ANAL FISSURE W/DILAT SPHNCTR SPX 1ST Surgery Blank 2.35 1.51 3.86 Blank RBRVS

46942 Blank CURTG/CAUT ANAL FISSURE W/DILAT SPHNCTR SPX SBSQ Surgery Blank 2.07 1.42 3.88 Blank RBRVS

46945 Blank HRHC NTRNL LIG OTH THAN RBBR BAND 1 COL/GRP Surgery Blank 2.21 3.89 6.28 Blank RBRVS

46946 Blank HRHC NTRNL LIG OTH THAN RBBR BAND 2/> COL/GRP Surgery Blank 2.63 3.41 5.94 Blank RBRVS

46947 Blank HEMORRHOIDOPEXY STAPLING Surgery Blank 5.57 4.29 4.29 Blank RBRVS

46999 Blank UNLISTED PROCEDURE ANUS Surgery Blank Blank Blank Blank 6.51 Unlisted

47000 Blank BIOPSY LIVER NEEDLE PERCUTANEOUS Surgery Blank 1.65 0.79 6.91 Blank RBRVS

47001 Blank BX LVR NDL DONE PURPOSE TM OTH MAJOR PX Surgery Blank 1.90 0.68 0.68 Blank RBRVS

47010 Blank HEPATOTOMY OPEN DRAINAGE ABSCESS/CYST 1/2 STAGES Surgery Blank 19.40 11.09 11.09 Blank RBRVS

47015 Blank LAPT W/ASPIR &/NJX HEPATC PARASITIC CYST/ABSCESS Surgery Blank 18.50 10.73 10.73 Blank RBRVS

47100 Blank BIOPSY LIVER WEDGE Surgery Blank 12.91 8.53 8.53 Blank RBRVS

47120 Blank HEPATECTOMY RESCJ PARTIAL LOBECTOMY Surgery Blank 39.01 19.29 19.29 Blank RBRVS

47122 Blank HEPATECTOMY RESCJ TRISEGMENTECTOMY Surgery Blank 59.48 25.91 25.91 Blank RBRVS

47125 Blank HEPATECTOMY RESCJ TOTAL LEFT LOBECTOMY Surgery Blank 53.04 23.77 23.77 Blank RBRVS

47130 Blank HEPATECTOMY RESCJ TOTAL RIGHT LOBECTOMY Surgery Blank 57.19 25.08 25.08 Blank RBRVS

47133 Blank DONOR HEPATECTOMY CADAVER DONOR Surgery Blank Blank Blank Blank 41.46 FAIR Health

47135 Blank LVR ALTRNSPLJ ORTHOTOPIC PRTL/WHL DON ANY AGE Surgery Blank 90.00 44.42 44.42 Blank RBRVS

47140 Blank DONOR HEPATECTOMY LIVING DONOR SEG II & III Surgery Blank 59.40 29.76 29.76 Blank RBRVS

47141 Blank DONOR HEPATECTOMY LIVING DONOR SEG II III & IV Surgery Blank 71.50 34.94 34.94 Blank RBRVS

47142 Blank DONOR HEPATECTOMY LIVING DONOR SEG V VI VII &VI Surgery Blank 79.44 37.76 37.76 Blank RBRVS

47143 Blank BKBENCH PREP CADAVER DONOR Surgery Blank Blank Blank Blank 20.20 FAIR Health

47146 Blank BKBENCH RCNSTJ LVR GRF VENOUS ANAST EA Surgery Blank 6.00 2.13 2.13 Blank RBRVS

47147 Blank BKBENCH RCNSTJ LVR GRF ARTL ANAST EA Surgery Blank 7.00 2.49 2.49 Blank RBRVS

47300 Blank MARSUPIALIZATION CST/ABSC LVR Surgery Blank 18.14 10.42 10.42 Blank RBRVS

47350 Blank MGMT LVR HEMRRG SMPL SUTR LVR WND/INJ Surgery Blank 22.49 12.03 12.03 Blank RBRVS

47360 Blank MGMT LVR HEMRRG CPLX SUTR WND/INJ Surgery Blank 31.31 15.58 15.58 Blank RBRVS

47361 Blank MGMT LVR HEMRRG EXPL WND DBRDMT COAGJ/SUTR Surgery Blank 52.60 23.16 23.16 Blank RBRVS

47362 Blank MGMT LVR HEMRRG RE-EXPL WND RMVL PACKING Surgery Blank 23.54 12.82 12.82 Blank RBRVS

47370 Blank LAPS SURG ABLTJ 1/> LVR TUM RF Surgery Blank 20.80 10.45 10.45 Blank RBRVS

47371 Blank LAPS SURG ABLTJ 1 > LVR TUM CRYOSURG Surgery Blank 20.80 10.61 10.61 Blank RBRVS

47379 Blank UNLIS LAPAROSCOPIC PROCEDURE LIVER Surgery Blank Blank Blank Blank 31.25 Unlisted

47380 Blank ABLTJ OPN 1/> LVR TUM RF Surgery Blank 24.56 11.67 11.67 Blank RBRVS

47381 Blank ABLTJ OPN 1/> LVR TUM CRYOSURG Surgery Blank 24.88 12.06 12.06 Blank RBRVS

47382 Blank ABLTJ 1/> LVR TUM PRQ RF Surgery Blank 14.97 5.38 121.10 Blank RBRVS

47383 Blank ABLATION 1/> LIVER TUMOR PERQ CRYOABLATION Surgery Blank 8.88 3.51 185.43 Blank RBRVS

47399 Blank UNLISTED PROCEDURE LIVER Surgery Blank Blank Blank Blank 2.71 Unlisted

47400 Blank HEPATCOTOMY/HEPATCOSTOMY W/EXPL DRG/RMVL ST1 Surgery Blank 36.36 17.38 17.38 Blank RBRVS





PAGE 55 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

47420 Blank CHOLEDOCHOT/OST W/O SPHNCTROTOMY/SPHNCTROP Surgery Blank 22.03 11.64 11.64 Blank RBRVS

47425 Blank CHOLEDOCHOT/OST W/SPHNCTROTOMY/SPHNCTROP Surgery Blank 22.31 11.94 11.94 Blank RBRVS

47460 Blank TRANSDUOL SPHINCTEROT/PLASTY W/WO RMVL CALCULUS Surgery Blank 20.52 11.30 11.30 Blank RBRVS

47480 Blank CHOLECSTOT/CHOLECSTOST W/EXPL DRG/RMVL ST1 SPX Surgery Blank 13.25 9.06 9.06 Blank RBRVS

47490 Blank CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT Surgery Blank 4.76 4.35 4.35 Blank RBRVS

47531 Blank NJX CHOLANGIO PRQ W/IMG GID RS&I EXISTING ACCESS Surgery Blank 1.30 0.65 7.58 Blank RBRVS

47532 Blank NJX CHOLANGIO PRQ W/IMG GID RS&I NEW ACCESS Surgery Blank 4.25 1.53 17.99 Blank RBRVS

47533 Blank PRQ PLMT BILIARY DRG CATH W/IMG GID RS&I EXTERNL Surgery Blank 5.38 1.90 29.14 Blank RBRVS

47534 Blank PRQ PLMT BILIARY DRG CATH W/IMG GID RS&I INT-EXT Surgery Blank 7.60 2.57 33.56 Blank RBRVS

47535 Blank CONV EXT BIL DRG CATH TO INT-EXT BIL DRG CATH Surgery Blank 3.95 1.47 24.59 Blank RBRVS

47536 Blank EXCHANGE BILIARY DRG CATHETER PRQ W/IMG GID RS&I Surgery Blank 2.61 1.02 16.75 Blank RBRVS

47537 Blank REMOVAL BILIARY DRG CATHETER REQ FLUOR GID RS&I Surgery Blank 1.84 0.80 8.42 Blank RBRVS

47538 Blank PLMT BILE DUCT STENT PRQ EXISTING ACCESS Surgery Blank 4.75 1.72 117.67 Blank RBRVS

47539 Blank PLMT BILE DUCT STENT PRQ NEW ACCESS W/O SEP CATH Surgery Blank 8.75 2.95 126.57 Blank RBRVS

47540 Blank PLMT BILE DUCT STENT PRQ NEW ACCESS W/SEP CATH Surgery Blank 9.03 3.05 129.24 Blank RBRVS

47541 Blank PLMT ACCESS THRU BILIARY TREE INTO SMALL BWL NEW Surgery Blank 6.75 2.34 26.01 Blank RBRVS

47542 Blank BALLOON DILAT BILIARY DUCT/AMPULLA PRQ EACH DUCT Surgery Blank 2.85 0.85 10.03 Blank RBRVS

47543 Blank ENDOLUMINAL BX BILIARY TREE PRQ ANY METH SNG/MLT Surgery Blank 3.00 0.94 10.29 Blank RBRVS

47544 Blank REMOVAL BILIARY DUCT &/GLBLDR CALCULI PERQ RS&I Surgery Blank 3.28 1.04 26.94 Blank RBRVS

47550 Blank BILIARY NDSC INTRAOPERATIVE Surgery Blank 3.02 1.07 1.07 Blank RBRVS

47552 Blank BILIARY ENDO PRQ T-TUBE DX W/COLLECT SPEC BRUSH Surgery Blank 6.03 2.39 2.39 Blank RBRVS

47553 Blank BILIARY NDSC PRQ T-TUBE W/BX SINGLE/MULTIPLE Surgery Blank 6.34 1.93 1.93 Blank RBRVS

47554 Blank BILIARY ENDOSCOPY PRQ VIA T-TUBE W/RMVL CALCULUS Surgery Blank 9.05 3.76 3.76 Blank RBRVS

47555 Blank BILIARY NDSC PRQ T-TUBE W/DIL DUCT W/O STENT Surgery Blank 7.55 1.23 1.23 Blank RBRVS

47556 Blank BILIARY NDSC PRQ T-TUBE DILAT STRIX W/STENT Surgery Blank 8.55 1.39 1.39 Blank RBRVS

47562 Blank LAPAROSCOPY SURG CHOLECYSTECTOMY Surgery Blank 10.47 6.12 6.12 Blank RBRVS

47563 Blank LAPS SURG CHOLECYSTECTOMY W/CHOLANGIOGRAPHY Surgery Blank 11.47 6.51 6.51 Blank RBRVS

47564 Blank LAPS SURG CHOLECSTC W/EXPL COMMON DUCT Surgery Blank 18.00 9.98 9.98 Blank RBRVS

47570 Blank LAPAROSCOPY SURG CHOLECYSTOENETEROSTOMY Surgery Blank 12.56 6.88 6.88 Blank RBRVS

47579 Blank UNLISTED LAPAROSCOPY PROCEDURE BILIARY TRACT Surgery Blank Blank Blank Blank 16.59 Unlisted

47600 Blank CHOLECYSTECTOMY Surgery Blank 17.48 9.35 9.35 Blank RBRVS

47605 Blank CHOLECYSTECTOMY W/CHOLANGIOGRAPHY Surgery Blank 18.48 9.72 9.72 Blank RBRVS

47610 Blank CHOLECYSTECTOMY W/EXPLORATION COMMON DUCT Surgery Blank 20.92 10.49 10.49 Blank RBRVS

47612 Blank CHOLECYSTECTOMY EXPL DUCT CHOLEDOCHOENTEROSTOMY Surgery Blank 21.21 10.54 10.54 Blank RBRVS

47620 Blank CHOLECSTC EXPL DUX SPHNCTROTOMY/SPHNCTROP Surgery Blank 23.07 11.35 11.35 Blank RBRVS

47700 Blank EXPL CONGENITAL ATRESIA BILE DUCTS Surgery Blank 16.50 10.01 10.01 Blank RBRVS

47701 Blank PORTOENETEROSTOMY Surgery Blank 28.73 14.65 14.65 Blank RBRVS

47711 Blank EXC BILE DUX TUM W/WO PRIM RPR XTRHEPATC Surgery Blank 25.90 13.19 13.19 Blank RBRVS

47712 Blank EXC BILE DUX TUM W/WO PRIM RPR INTRAHEPATC Surgery Blank 33.72 16.15 16.15 Blank RBRVS

47715 Blank EXCISION CHOLEDOCHAL CYST Surgery Blank 21.55 11.82 11.82 Blank RBRVS

47720 Blank CHOLECYSTOENTEROSTOMY DIRECT Surgery Blank 18.34 10.68 10.68 Blank RBRVS

47721 Blank CHOLECYSTOENTEROSTOMY W/GASTROENTEROSTOMY Surgery Blank 21.99 11.97 11.97 Blank RBRVS

47740 Blank CHOLECYSTOENTEROSTOMY ROUX-EN-Y Surgery Blank 21.23 11.71 11.71 Blank RBRVS

47741 Blank CHOLECSTONTRSTM ROUX-EN-Y W/GASTRONTRSTM Surgery Blank 24.21 12.77 12.77 Blank RBRVS

47760 Blank ANAST XTRHEPATC BILIARY DUCTS & GI TRACT Surgery Blank 38.32 18.05 18.05 Blank RBRVS

47765 Blank ANAST INTRAHEPATC DUCTS & GI TRACT Surgery Blank 52.19 23.44 23.44 Blank RBRVS

47780 Blank ANAST ROUX-EN-Y XTRHEPATC BILIARY DUCTS & GI Surgery Blank 42.32 19.49 19.49 Blank RBRVS

47785 Blank ANAST ROUX-EN-Y INTRAHEPATC BILIARY DUCTS & GI Surgery Blank 56.19 24.59 24.59 Blank RBRVS

47800 Blank RCNSTJ PLSTC BILIARY DUCTS W/END-TO-END ANAST Surgery Blank 26.17 13.52 13.52 Blank RBRVS

47801 Blank PLACEMENT CHOLEDOCHAL STENT Surgery Blank 17.60 9.13 9.13 Blank RBRVS

47802 Blank U-TUBE HEPATICOENTEROSTOMY Surgery Blank 24.93 13.32 13.32 Blank RBRVS

47900 Blank SUTURE EXTRAHEPATIC BILE DUCT PRE-EXIST INJURY Surgery Blank 22.44 11.96 11.96 Blank RBRVS

47999 Blank UNLISTED PROCEDURE BILIARY TRACT Surgery Blank Blank Blank Blank 16.59 Unlisted

48000 Blank PLACE DRAIN PERIPANCREATIC ACUTE PANCREATITIS Surgery Blank 31.95 15.10 15.10 Blank RBRVS

48001 Blank PLACE DRAIN PERIPANCREATIC W/CHOLECYSTOSTOMY Surgery Blank 39.69 17.75 17.75 Blank RBRVS

48020 Blank REMOVAL PANCREATIC CALCULUS Surgery Blank 19.09 10.44 10.44 Blank RBRVS

48100 Blank BIOPSY PANCREAS OPEN Surgery Blank 14.46 7.91 7.91 Blank RBRVS

48102 Blank BIOPSY PANCREA PERCUTANEOUS NEEDLE Surgery Blank 4.70 1.86 10.04 Blank RBRVS

48105 Blank RESECJ/DBRDMT PANCREAS NECROTIZING PANCREATITIS Surgery Blank 49.26 22.00 22.00 Blank RBRVS

48120 Blank EXCISION LESION PANCREAS Surgery Blank 18.41 9.33 9.33 Blank RBRVS

48140 Blank PNCRTECT DSTL STOT W/O PNCRTCOJEJUNOSTOMY Surgery Blank 26.32 12.79 12.79 Blank RBRVS

48145 Blank PNCRTECT DSTL STOT W/PNCRTCOJEJUNOSTOMY Surgery Blank 27.39 13.38 13.38 Blank RBRVS

48146 Blank PNCRTECT DSTL NR-TOT W/PRSRV DUO CHLD-TYP PX Surgery Blank 30.60 16.52 16.52 Blank RBRVS

48148 Blank EXCISION AMPULLA VATER Surgery Blank 20.39 10.90 10.90 Blank RBRVS

48150 Blank PNCRTECT PROX STOT W/PANCREATOJEJUNOSTOMY Surgery Blank 52.84 24.78 24.78 Blank RBRVS

48152 Blank PNCRTECT WHIPPLE W/O PANCREATOJEJUNOSTOMY Surgery Blank 48.65 23.37 23.37 Blank RBRVS

48153 Blank PNCRTECT W/PANCREATOJEJUNOSTOMY Surgery Blank 52.79 24.54 24.54 Blank RBRVS

48154 Blank PNCRTECT PROX STOT W/O PANCREATOJEJUNOSTOMY Surgery Blank 48.88 23.45 23.45 Blank RBRVS

48155 Blank PANCREATECTOMY TOTAL Surgery Blank 29.45 16.19 16.19 Blank RBRVS

48160 Blank PANCREATECTOMY W/TRNSPLJ PANCREAS/ISLET CELLS Surgery Blank Blank Blank Blank 43.93 FAIR Health

48400 Blank INJECTION INTRAOPERATIVE PANCREATOGRAPHY Surgery Blank 1.95 0.70 0.70 Blank RBRVS

48500 Blank MARSUPIALIZATION PANCREATIC CYST Surgery Blank 18.16 10.82 10.82 Blank RBRVS





PAGE 56 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

48510 Blank EXTERNAL DRAINAGE PSEUDOCYST OF PANCREAS OPEN Surgery Blank 17.19 10.48 10.48 Blank RBRVS

48520 Blank INT ANAST PANCREATIC CYST GI TRACT DIRECT Surgery Blank 18.15 9.30 9.30 Blank RBRVS

48540 Blank INT ANAST PANCREATIC CYST GI TRACT ROUX-EN-Y Surgery Blank 21.94 10.79 10.79 Blank RBRVS

48545 Blank PANCREATORRHAPHY INJURY Surgery Blank 22.23 11.43 11.43 Blank RBRVS

48547 Blank DUOL EXCLUSION W/GASTROJEJUNOSTOMY PNCRTC INJ Surgery Blank 30.38 14.33 14.33 Blank RBRVS

48548 Blank PANCREATICOJEJUNOSTOMY SIDE-TO-SIDE ANAST Surgery Blank 28.09 13.52 13.52 Blank RBRVS

48551 Blank BKBENCH PREPJ CADAVER DONOR PANCREAS ALLOGRAFT Surgery Blank Blank Blank Blank 17.88 FAIR Health

48552 Blank BKBENCH RCNSTJ CDVR PNCRS ALGRFT VEN ANAST EA Surgery Blank 4.30 1.53 1.53 Blank RBRVS

48554 Blank TRANSPLANTATION PANCREATIC ALLOGRAFT Surgery Blank 37.80 27.28 27.28 Blank RBRVS

48556 Blank RMVL TRANSPLANTED PANCREATIC ALLOGRAFT Surgery Blank 19.47 12.76 12.76 Blank RBRVS

48999 Blank UNLISTED PROCEDURE PANCREAS Surgery Blank Blank Blank Blank 60.67 Unlisted

49000 Blank EXPLORATORY LAPAROTOMY CELIOTOMY W/WO BIOPSY SPX Surgery Blank 12.54 6.94 6.94 Blank RBRVS

49002 Blank REOPENING RECENT LAPAROTOMY Surgery Blank 17.63 8.68 8.68 Blank RBRVS

49010 Blank EXPL RETROPERITONEUM W/WO BX SPX Surgery Blank 16.06 7.49 7.49 Blank RBRVS

49020 Blank DRAINAGE PERITON ABSCESS/LOCAL PERITONITIS OPEN Surgery Blank 26.67 13.42 13.42 Blank RBRVS

49040 Blank DRAINAGE SUBDIAPHRAGMATIC/SUBPHREN ABSCESS OPEN Surgery Blank 16.52 8.70 8.70 Blank RBRVS

49060 Blank DRAINAGE OF RETROPERITONEAL ABSCESS OPEN Surgery Blank 18.53 9.26 9.26 Blank RBRVS

49062 Blank DRG XTRAPERITONEAL LYMPHOCELE PERITON CAVITY OPN Surgery Blank 12.22 6.52 6.52 Blank RBRVS

49082 Blank ABDOM PARACENTESIS DX/THER W/O IMAGING GUIDANCE Surgery Blank 1.24 0.74 4.16 Blank RBRVS

49083 Blank ABDOM PARACENTESIS DX/THER W/IMAGING GUIDANCE Surgery Blank 2.00 0.95 6.22 Blank RBRVS

49084 Blank PERITONEAL LAVAGE W/WO IMAGING GUIDANCE Surgery Blank 2.00 0.71 0.71 Blank RBRVS

49180 Blank BX ABDL/RETROPERITONEAL MASS PRQ NEEDLE Surgery Blank 1.73 0.59 2.78 Blank RBRVS

49185 Blank SCLEROTHERAPY FLUID COLLECTION PRQ W/IMG GID Surgery Blank 2.35 0.92 24.36 Blank RBRVS

49203 Blank EXCISION/DESTRUCTION OPEN ABDOMINAL TUMOR 5 CM/< Surgery Blank 20.13 10.25 10.25 Blank RBRVS

49204 Blank EXC/DESTRUCTION OPEN ABDMNL TUMORS 5.1-10.0 CM Surgery Blank 26.13 12.64 12.64 Blank RBRVS

49205 Blank EXC/DESTRUCTION OPEN ABDOMINAL TUMORS >10.0 CM Surgery Blank 30.13 14.22 14.22 Blank RBRVS

49215 Blank EXC PRESAC/SACROCOCCYGEAL TUMOR Surgery Blank 37.81 18.71 18.71 Blank RBRVS

49220 Blank STAGING LAPAROTOMY HODGKINS DISEASE/LYMPHOMA Surgery Blank 15.79 8.54 8.54 Blank RBRVS

49250 Blank UMBILECTOMY OMPHALECTOMY EXC UMBILICUS SPX Surgery Blank 9.01 5.92 5.92 Blank RBRVS

49255 Blank OMNTC EPIPLOECTOMY RESCJ OMENTUM SPX Surgery Blank 12.56 7.64 7.64 Blank RBRVS

49320 Blank LAPS ABD PRTM&OMENTUM DX W/WO SPEC BR/WA SPX Surgery Blank 5.14 3.24 3.24 Blank RBRVS

49321 Blank LAPAROSCOPY SURG W/BX SINGLE/MULTIPLE Surgery Blank 5.44 3.39 3.39 Blank RBRVS

49322 Blank LAPS SURG W/ASPIR CAVITY/CYST SINGLE/MULTIPLE Surgery Blank 6.01 3.50 3.50 Blank RBRVS

49323 Blank LAPS SURG W/DRG LYMPHOCELE PRTL CAVITY Surgery Blank 10.23 6.17 6.17 Blank RBRVS

49324 Blank LAPS INSERTION TUNNELED INTRAPERITONEAL CATHETER Surgery Blank 6.32 3.50 3.50 Blank RBRVS

49325 Blank LAPS W/REVISION INTRAPERITONEAL CATHETER Surgery Blank 6.82 3.61 3.61 Blank RBRVS

49326 Blank LAPAROSCOPY W/OMENTOPEXY Surgery Blank 3.50 1.16 1.16 Blank RBRVS

49327 Blank LAPS W/INSERTION NTRSTL DEV W/IMG GUID 1/MLT Surgery Blank 2.38 0.84 0.84 Blank RBRVS

49329 Blank UNLISTED LAPAROSCOPIC PX ABD PERTONEUM & OMENTUM Surgery Blank Blank Blank Blank 8.83 Unlisted

49400 Blank INJECTION AIR/CONTRAST PERITONEAL CAVITY SPX Surgery Blank 1.88 0.59 1.75 Blank RBRVS

49402 Blank REMOVAL PERITONEAL FOREIGN BODY FROM CAVITY Surgery Blank 14.09 7.49 7.49 Blank RBRVS

49405 Blank IMAGE-GUIDE FLUID COLLXN DRAINAGE CATH VISC PERQ Surgery Blank 4.00 1.38 18.62 Blank RBRVS

49406 Blank IMG-GUIDE FLUID COLLXN DRAINAG CATH PERITON PERQ Surgery Blank 4.00 1.38 18.61 Blank RBRVS

49407 Blank IMAGE FLUID COLLXN DRAINAG CATH TRANSREC/VAGINAL Surgery Blank 4.25 1.42 13.90 Blank RBRVS

49411 Blank INTERSTITIAL DEV PLMT RADIATION THERAPY 1/MLT Surgery Blank 3.57 1.46 9.86 Blank RBRVS

49412 Blank PLACEMENT INTRSTL DEV OPN W/IMG GUID 1/MLT Surgery Blank 1.50 0.54 0.54 Blank RBRVS

49418 Blank INSJ INTRAPERITONEAL CATHETER W/IMG GUID Surgery Blank 3.96 1.55 34.36 Blank RBRVS

49419 Blank INSERTION TUNNEL INTRAPERITONEAL CATH SUBQ PORT Surgery Blank 7.08 4.32 4.32 Blank RBRVS

49421 Blank INSERTION TUNNEL INTRAPERITONEAL CATH DIAL OPEN Surgery Blank 4.21 1.50 1.50 Blank RBRVS

49422 Blank REMOVAL TUNNELED INTRAPERITONEAL CATHETER Surgery Blank 6.29 3.30 3.30 Blank RBRVS

49423 Blank EXCHNG ABSC/CST DRG CATH RAD GID SPX Surgery Blank 1.46 0.48 13.95 Blank RBRVS

49424 Blank CNTRST NJX ASSMT ABSC/CST VIA DRG CATH/TUBE SPX Surgery Blank 0.76 0.27 3.32 Blank RBRVS

49425 Blank INSERTION PERITONEAL-VENOUS SHUNT Surgery Blank 12.22 6.32 6.32 Blank RBRVS

49426 Blank REVIS PERITONEAL-VENOUS SHUNT Surgery Blank 10.41 5.16 5.16 Blank RBRVS

49427 Blank INJECT EVALUATE PREVIOUS PERITONEAL-VENOUS SHUNT Surgery Blank 0.89 0.31 0.31 Blank RBRVS

49428 Blank LIGATION PERITONEAL-VENOUS SHUNT Surgery Blank 6.87 3.99 3.99 Blank RBRVS

49429 Blank RMVL PERITONEAL-VENOUS SHUNT Surgery Blank 7.44 4.07 4.07 Blank RBRVS

49435 Blank INSJ SUBQ EXTENSION INTRAPERITONEAL CATHETER Surgery Blank 2.25 0.68 0.68 Blank RBRVS

49436 Blank DELAYED CREATION EXIT SITE EMBEDDED CATHETER Surgery Blank 2.72 2.02 2.02 Blank RBRVS

49440 Blank INSERT GASTROSTOMY TUBE PERCUTANEOUS Surgery Blank 3.93 1.69 23.19 Blank RBRVS

49441 Blank INSERT DUODENOSTOMY/JEJUNOSTOMY TUBE PERQ Surgery Blank 4.52 1.95 26.05 Blank RBRVS

49442 Blank INSERT CECOSTOMY/OTHER COLONIC TUBE PERCUTANEOUS Surgery Blank 3.75 1.97 21.78 Blank RBRVS

49446 Blank CONVERT GASTROSTOMY-GASTRO-JEJUNOSTOMY TUBE PERQ Surgery Blank 3.06 0.98 23.14 Blank RBRVS

49450 Blank REPLACE GASTROSTOMY/CECOSTOMY TUBE PERCUTANEOUS Surgery Blank 1.36 0.44 17.45 Blank RBRVS

49451 Blank REPLACE DUODENOSTOMY/JEJUNOSTOMY TUBE PERQ Surgery Blank 1.84 0.60 18.66 Blank RBRVS

49452 Blank REPLACEMENT GASTRO-JEJUNOSTOMY TUBE PERCUTANEOUS Surgery Blank 2.86 0.91 22.47 Blank RBRVS

49460 Blank OBSTRUCTIVE MATERIAL REMOVAL FROM GI TUBE Surgery Blank 0.96 0.33 19.92 Blank RBRVS

49465 Blank CONTRAST INJECTION PERQ RADIOLOGIC EVAL GI TUBE Surgery Blank 0.62 0.22 3.99 Blank RBRVS

49491 Blank RPR 1ST INGUN HRNA PRETERM INFT RDC Surgery Blank 12.53 7.42 7.42 Blank RBRVS

49492 Blank RPR 1ST INGUN HRNA PRETERM INFT INCARCERATED Surgery Blank 15.43 8.55 8.55 Blank RBRVS

49495 Blank RPR 1ST INGUN HRNA FULL TERM INFT <6 MO RDC Surgery Blank 6.20 4.17 4.17 Blank RBRVS

49496 Blank RPR 1ST INGUN HRNA FULL TERM INFT <6 MO INCARCER Surgery Blank 9.42 6.08 6.08 Blank RBRVS





PAGE 57 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

49500 Blank RPR 1ST INGUN HRNA AGE 6 MO-5 YRS REDUCIBLE Surgery Blank 5.84 4.65 4.65 Blank RBRVS

49501 Blank RPR 1ST INGUN HRNA AGE 6 MO-5 YRS INCARCERATED Surgery Blank 9.36 5.90 5.90 Blank RBRVS

49505 Blank RPR 1ST INGUN HRNA AGE 5 YRS/> REDUCIBLE Surgery Blank 7.96 5.23 5.23 Blank RBRVS

49507 Blank RPR 1ST INGUN HRNA AGE 5 YRS/> INCARCERATED Surgery Blank 9.09 5.72 5.72 Blank RBRVS

49520 Blank RPR RECRT INGUINAL HERNIA ANY AGE REDUCIBLE Surgery Blank 9.99 5.94 5.94 Blank RBRVS

49521 Blank RPR RECRT INGUN HERNIA ANY AGE INCARCERATED Surgery Blank 11.48 6.56 6.56 Blank RBRVS

49525 Blank RPR INGUN HERNIA SLIDING ANY AGE Surgery Blank 8.93 5.55 5.55 Blank RBRVS

49540 Blank REPAIR LUMBAR HERNIA Surgery Blank 10.74 6.20 6.20 Blank RBRVS

49550 Blank RPR 1ST FEM HRNA ANY AGE REDUCIBLE Surgery Blank 8.99 5.54 5.54 Blank RBRVS

49553 Blank RPR 1ST FEM HERNIA ANY AGE INCARCERATED Surgery Blank 9.92 6.01 6.01 Blank RBRVS

49555 Blank RPR RECRT FEM HERNIA REDUCIBLE Surgery Blank 9.39 5.76 5.76 Blank RBRVS

49557 Blank RPR RECRT FEM HRNA INCARCERATED Surgery Blank 11.62 6.58 6.58 Blank RBRVS

49560 Blank REPAIR FIRST ABDOMINAL WALL HERNIA Surgery Blank 11.92 6.67 6.67 Blank RBRVS

49561 Blank RPR 1ST INCAL/VNT HERNIA INCARCERATED Surgery Blank 15.38 7.95 7.95 Blank RBRVS

49565 Blank RPR RECRT INCAL/VNT HERNIA REDUCIBLE Surgery Blank 12.37 7.01 7.01 Blank RBRVS

49566 Blank RPR RECRT INCAL/VNT HERNIA INCARCERATED Surgery Blank 15.53 8.02 8.02 Blank RBRVS

49568 Blank IMPLANT MESH OPN HERNIA RPR/DEBRIDEMENT CLOSURE Surgery Blank 4.88 1.75 1.75 Blank RBRVS

49570 Blank RPR EPIGASTRIC HERNIA REDUCIBLE SPX Surgery Blank 6.05 4.59 4.59 Blank RBRVS

49572 Blank RPR EPIGASTRIC HERNIA INCARCERATED Surgery Blank 7.87 5.19 5.19 Blank RBRVS

49580 Blank RPR UMBILICAL HERNIA < 5 YRS REDUCIBLE Surgery Blank 4.47 4.06 4.06 Blank RBRVS

49582 Blank RPR UMBILICAL HERNIA < 5 YRS INCARCERATED Surgery Blank 7.13 5.10 5.10 Blank RBRVS

49585 Blank RPR UMBILICAL HRNA 5 YRS/> REDUCIBLE Surgery Blank 6.59 4.74 4.74 Blank RBRVS

49587 Blank RPR UMBILICAL HERNIA AGE 5 YRS/> INCARCERATED Surgery Blank 7.08 5.00 5.00 Blank RBRVS

49590 Blank RPR SPIGELIAN HERNIA Surgery Blank 8.90 5.56 5.56 Blank RBRVS

49600 Blank RPR SMALL OMPHALOCELE W/PRIMARY CLOSURE Surgery Blank 11.55 6.81 6.81 Blank RBRVS

49605 Blank RPR LG OMPHALOCELE/GASTROSCHISIS W/WO PROSTH Surgery Blank 87.09 35.19 35.19 Blank RBRVS

49606 Blank RPR LG OMPHALOCELE/GASTROSCHISIS RMVL PROSTH Surgery Blank 19.00 9.24 9.24 Blank RBRVS

49610 Blank RPR OMPHALOCELE GROSS TYP OPRATION 1ST STG Surgery Blank 10.91 6.36 6.36 Blank RBRVS

49611 Blank RPR OMPHALOCELE GROSS TYP OPRATION 2ND STG Surgery Blank 9.34 5.93 5.93 Blank RBRVS

49650 Blank LAPAROSCOPY SURG RPR INITIAL INGUINAL HERNIA Surgery Blank 6.36 4.54 4.54 Blank RBRVS

49651 Blank LAPS SURG RPR RECURRENT INGUINAL HERNIA Surgery Blank 8.38 5.74 5.74 Blank RBRVS

49652 Blank LAPS REPAIR HERNIA EXCEPT INCAL/INGUN REDUCIBLE Surgery Blank 11.92 6.83 6.83 Blank RBRVS

49653 Blank LAP RPR HRNA XCPT INCAL/INGUN NCRC8/STRANGULATED Surgery Blank 14.94 8.41 8.41 Blank RBRVS

49654 Blank LAPAROSCOPY REPAIR INCISIONAL HERNIA REDUCIBLE Surgery Blank 13.76 7.50 7.50 Blank RBRVS

49655 Blank LAPS RPR INCISIONAL HERNIA NCRC8/STRANGULATED Surgery Blank 16.84 9.10 9.10 Blank RBRVS

49656 Blank LAPS RPR RECURRENT INCISIONAL HERNIA REDUCIBLE Surgery Blank 15.08 7.98 7.98 Blank RBRVS

49657 Blank LAPS RPR RECURRENT INCAL HRNA NCRC8/STRANGULATED Surgery Blank 22.11 10.94 10.94 Blank RBRVS

49659 Blank UNLIS LAPS PX HRNAP HERNIORRHAPHY HERNIOTOMY Surgery Blank Blank Blank Blank 13.19 Unlisted

49900 Blank SEC ABDOMINAL WALL SUTURE EVISCERATION/DEHSN Surgery Blank 12.41 8.40 8.40 Blank RBRVS

49904 Blank OMENTAL FLAP EXTRA-ABDOMINAL Surgery Blank 22.35 14.00 14.00 Blank RBRVS

49905 Blank OMENTAL FLAP INTRA-ABDOMINAL Surgery Blank 6.54 2.32 2.32 Blank RBRVS

49906 Blank FREE OMENTAL FLAP W/MICROVASCULAR ANAST Surgery Blank Blank Blank Blank 36.70 FAIR Health

49999 Blank UNLISTED PROCEDURE ABDOMEN PERITONEUM & OMENTUM Surgery Blank Blank Blank Blank 5.75 Unlisted

50010 Blank RNL EXPL X NECESSITATING OTH SPEC PX Surgery Blank 12.28 7.03 7.03 Blank RBRVS

50020 Blank DRAINAGE PERIRENAL/RENAL ABSCESS OPEN Surgery Blank 18.08 9.27 9.27 Blank RBRVS

50040 Blank NEPHROSTOMY/NEPHROTOMY W/DRAINAGE Surgery Blank 16.68 8.28 8.28 Blank RBRVS

50045 Blank NEPHROTOMY W/EXPLORATION Surgery Blank 16.82 8.36 8.36 Blank RBRVS

50060 Blank NEPHROLITHOTOMY REMOVAL STAGE 1 Surgery Blank 20.95 9.80 9.80 Blank RBRVS

50065 Blank NEPHROLITHOTOMY SECONDARY FOR CALCULUS Surgery Blank 22.32 10.29 10.29 Blank RBRVS

50070 Blank NEPHROLITHOTOMY COMP CGEN KDN ABNORMALITY Surgery Blank 21.85 10.12 10.12 Blank RBRVS

50075 Blank NEPHROLITHOTOMY RMVL LG STAGHORN STAGE 1 Surgery Blank 27.09 12.19 12.19 Blank RBRVS

50080 Blank PRQ NEPHROSTOLITHOTOMY/PYELOSTOLITHOTOMY </2 CM Surgery Blank 15.74 7.73 7.73 Blank RBRVS

50081 Blank PRQ NEPHROSTOLITHOTOMY/PYELOSTOLITHOTOMY > 2 CM Surgery Blank 23.50 10.93 10.93 Blank RBRVS

50100 Blank TRNSXJ/REPOSITIONING ABERRANT RENAL VESSEL SPX Surgery Blank 17.45 9.58 9.58 Blank RBRVS

50120 Blank PYELOTOMY W/EXPLORATION Surgery Blank 17.21 8.42 8.42 Blank RBRVS

50125 Blank PYELOTOMY W/DRAINAGE PYELOSTOMY Surgery Blank 17.82 8.71 8.71 Blank RBRVS

50130 Blank PYELOTOMY W/REMOVAL CALCULUS Surgery Blank 18.82 9.06 9.06 Blank RBRVS

50135 Blank PYELOTOMY COMPLICATED Surgery Blank 20.59 9.68 9.68 Blank RBRVS

50200 Blank RENAL BIOPSY PRQ TROCAR/NEEDLE Surgery Blank 2.38 1.11 12.66 Blank RBRVS

50205 Blank RENAL BIOPSY SURG EXPOSURE KIDNEY Surgery Blank 12.29 6.84 6.84 Blank RBRVS

50220 Blank NEPHRECTOMY W/PRTL URETERECTOMY W/OPEN RIB RESCJ Surgery Blank 18.68 9.11 9.11 Blank RBRVS

50225 Blank NEPHRECTOMY W/PRTL URETERECT OPN RIB RESCJ COMPL Surgery Blank 21.88 10.16 10.16 Blank RBRVS

50230 Blank NEPHRECTOMY W/PRTL URETERECT OPEN RIB RESCJ RAD Surgery Blank 23.81 10.54 10.54 Blank RBRVS

50234 Blank NEPHRECTOMY W/TOT URETERECT&BLDR CUFF SAME INC Surgery Blank 24.05 10.90 10.90 Blank RBRVS

50236 Blank NEPHRECTOMY TOT URETEREC&BLDR CUFF SEPAR INCISN Surgery Blank 26.94 12.55 12.55 Blank RBRVS

50240 Blank NEPHRECTOMY PARTIAL Surgery Blank 24.21 11.44 11.44 Blank RBRVS

50250 Blank OPEN ABLATION RENAL MASS CRYOSURG ULTRASOUND Surgery Blank 22.22 10.60 10.60 Blank RBRVS

50280 Blank EXCISION/UNROOFING CYST KIDNEY Surgery Blank 17.09 8.49 8.49 Blank RBRVS

50290 Blank EXCISION PERINEPHRIC CYST Surgery Blank 16.15 8.12 8.12 Blank RBRVS

50300 Blank DONOR NEPHRECTOMY CADAVER DONOR UNI/BILATERAL Surgery Blank Blank Blank Blank 23.05 v3.23

50320 Blank DONOR NEPHRECTOMY OPEN LIVING DONOR Surgery Blank 22.43 15.65 15.65 Blank RBRVS

50323 Blank BKBENCH PREPJ CADAVER DONOR RENAL ALLOGRAFT Surgery Blank Blank Blank Blank 10.33 FAIR Health





PAGE 58 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

50325 Blank BKBENCH PREPJ LIVING RENAL DONOR ALLOGRAFT Surgery Blank Blank Blank Blank 12.49 FAIR Health

50327 Blank BKBENCH RCNSTJ RENAL ALGRFT VENOUS ANAST EA Surgery Blank 4.00 1.41 1.41 Blank RBRVS

50328 Blank BKBENCH RCNSTJ RENAL ALLOGRAFT ARTERIAL ANAST EA Surgery Blank 3.50 1.24 1.24 Blank RBRVS

50329 Blank BKBENCH RCNSTJ ALGRFT URETERAL ANAST EA Surgery Blank 3.34 1.18 1.18 Blank RBRVS

50340 Blank RECIPIENT NEPHRECTOMY SEPARATE PROCEDURE Surgery Blank 14.04 9.99 9.99 Blank RBRVS

50360 Blank RENAL ALTRNSPLJ IMPLTJ GRF W/O RCP NEPHRECTOMY Surgery Blank 39.88 21.10 21.10 Blank RBRVS

50365 Blank RENAL ALTRNSPLJ IMPLTJ GRF W/RCP NEPHRECTOMY Surgery Blank 46.13 26.34 26.34 Blank RBRVS

50370 Blank RMVL TRNSPLED RENAL ALLOGRAFT Surgery Blank 18.88 11.75 11.75 Blank RBRVS

50380 Blank RENAL AUTOTRNSPLJ REIMPLANTATION KIDNEY Surgery Blank 30.11 20.56 20.56 Blank RBRVS

50382 Blank RMVL & RPLCMT INTLY DWELLING URETERAL STENT PRQ Surgery Blank 5.25 1.74 25.90 Blank RBRVS

50384 Blank REMOVAL INDWELLING URETERAL STENT PRQ Surgery Blank 4.75 1.52 19.65 Blank RBRVS

50385 Blank REMOVE & REPLACE INDWELL URETERAL STENT TRURTHRL Surgery Blank 4.19 1.76 26.35 Blank RBRVS

50386 Blank REMOVE INT DWELL URETERAL STENT TRANSURETHRAL Surgery Blank 3.05 1.37 16.59 Blank RBRVS

50387 Blank RMVL & RPLCMT XTRNL ACCESSIBLE NEPHROURTRL CATH Surgery Blank 1.75 0.54 12.04 Blank RBRVS

50389 Blank RMVL NFROS TUBE REQ FLUORO GUIDANCE Surgery Blank 1.10 0.37 7.27 Blank RBRVS

50390 Blank ASPIR &/NJX RENAL CYST/PELVIS NEEDLE PRQ Surgery Blank 1.96 0.65 0.65 Blank RBRVS

50391 Blank INSTLJ THER AGENT RENAL PELVIS&/URETER VIA TUB Surgery Blank 1.96 0.69 1.35 Blank RBRVS

50396 Blank MANOMETRIC STDS THRU TUBE/NDWELLG URTRL CATH Surgery Blank 2.09 1.12 1.12 Blank RBRVS

50400 Blank PYELOPLASTY SIMPLE Surgery Blank 21.27 9.91 9.91 Blank RBRVS

50405 Blank PYELOPLASTY COMPLICATED Surgery Blank 25.86 11.77 11.77 Blank RBRVS

50430 Blank NJX PX ANTEGRDE NFROSGRM &/URTRGRM NEW ACCESS Surgery Blank 2.90 1.31 9.89 Blank RBRVS

50431 Blank NJX PX ANTEGRDE NFROSGRM &/URTRGRM EXSTNG ACESS Surgery Blank 1.10 0.71 3.44 Blank RBRVS

50432 Blank PLMT NEPHROSTOMY CATH PRQ NEW ACCESS RS&I Surgery Blank 4.00 1.65 17.62 Blank RBRVS

50433 Blank PLMT NEPHROURETERAL CATH PRQ NEW ACCESS RS&I Surgery Blank 5.05 1.98 24.53 Blank RBRVS

50434 Blank CONVERT NEPHROSTOMY CATH TO NEPHROURTRL CATH PRQ Surgery Blank 3.75 1.56 19.45 Blank RBRVS

50435 Blank EXCHANGE NEPHROSTOMY CATHETER PRQ W/IMG GID RS&I Surgery Blank 1.82 0.93 11.44 Blank RBRVS

50436 Blank DILAT XST TRC NDURLGC PX Surgery Blank 2.78 1.32 1.32 Blank RBRVS

50437 Blank DILAT XST TRC NEW ACCESS RCS Surgery Blank 4.85 1.99 1.99 Blank RBRVS

50500 Blank NEPHRORRHAPHY SUTURE KIDNEY WOUND/INJURY Surgery Blank 21.22 10.92 10.92 Blank RBRVS

50520 Blank CLOSURE NEPHROCUTANEOUS/PYELOCUTANEOUS FISTULA Surgery Blank 18.88 10.09 10.09 Blank RBRVS

50525 Blank CLSR NEPHROVISCERAL FISTULA W/VISC RPR ABDL APPR Surgery Blank 24.39 12.28 12.28 Blank RBRVS

50526 Blank CLSR NEPHROVISCERAL FISTULA W/VISC RPR THRC APPR Surgery Blank 26.31 12.96 12.96 Blank RBRVS

50540 Blank SYMPHYSIOTOMY HORSESHOE KDN W/WO PLOP UNI/BI Surgery Blank 21.10 9.86 9.86 Blank RBRVS

50541 Blank LAPAROSCOPY SURG ABLATION RENAL CYSTS Surgery Blank 16.86 7.90 7.90 Blank RBRVS

50542 Blank LAPS ABLTJ RENAL MASS LESION W/INTRAOP US Surgery Blank 21.36 10.09 10.09 Blank RBRVS

50543 Blank LAPAROSCOPY SURG PARTIAL NEPHRECTOMY Surgery Blank 27.41 12.71 12.71 Blank RBRVS

50544 Blank LAPAROSCOPY SURG PYELOPLASTY Surgery Blank 23.37 10.18 10.18 Blank RBRVS

50545 Blank LAPAROSCOPY RADICAL NEPHRECTOMY Surgery Blank 25.06 10.99 10.99 Blank RBRVS

50546 Blank LAPAROSCOPY NEPHRECTOMY W/PARTIAL URETERECT Surgery Blank 21.87 10.40 10.40 Blank RBRVS

50547 Blank LAPAROSCOPY DONOR NEPHRECTOMY LIVING DONOR Surgery Blank 26.34 14.79 14.79 Blank RBRVS

50548 Blank LAPAROSCOPY NEPHRECTOMY W/TOTAL URETERECTOMY Surgery Blank 25.36 10.88 10.88 Blank RBRVS

50549 Blank UNLISTED LAPAROSCOPY PROCEDURE RENAL Surgery Blank Blank Blank Blank 36.05 Unlisted

50551 Blank RENAL ENDOSCOPY NEPHROSTOMY W/WO IRRIGATION Surgery Blank 5.59 2.35 4.24 Blank RBRVS

50553 Blank RENAL NDSC NEPHROST W/URETERAL CATH W/WO DILA Surgery Blank 5.98 2.50 4.55 Blank RBRVS

50555 Blank RENAL NDSC NEPHROS/PYELOSTOMY BIOPSY Surgery Blank 6.52 2.68 4.72 Blank RBRVS

50557 Blank RENAL NDSC NEPHROS/PYELOSTOMY FULG&/INC W/WO BI Surgery Blank 6.61 2.71 4.82 Blank RBRVS

50561 Blank RENAL NDSC NEPHROS/PYELOSTOMY RMVL FB/CALCULUS Surgery Blank 7.58 3.04 5.37 Blank RBRVS

50562 Blank RENAL NDSC NEPHROS/PYELOSTOMY RESCJ TUMOR Surgery Blank 10.90 4.78 4.78 Blank RBRVS

50570 Blank RENAL NDSC NEPHROTOMY W/WO IRRIGATION Surgery Blank 9.53 3.70 3.70 Blank RBRVS

50572 Blank RNL NDSC NFROT W/URTRL CATHJ W/WO DILAT URETER Surgery Blank 10.33 3.98 3.98 Blank RBRVS

50574 Blank RENAL NDSC NEPHROTOMY W/BIOPSY Surgery Blank 11.00 4.22 4.22 Blank RBRVS

50575 Blank RNL NDSC NFROT/PLOT W/ENDOPYELOTOMY Surgery Blank 13.96 5.25 5.25 Blank RBRVS

50576 Blank RNL NDSC NFROT FULGURATION &/INCISION W/WO BX Surgery Blank 10.97 4.21 4.21 Blank RBRVS

50580 Blank RNL NDSC NFROT/PLOT W/RMVL FB/CALCULUS Surgery Blank 11.84 4.51 4.51 Blank RBRVS

50590 Blank LITHOTRIPSY XTRCORP SHOCK WAVE Surgery Blank 9.77 5.62 9.96 Blank RBRVS

50592 Blank ABLTJ 1/> RENAL TUMOR PRQ UNI RADIOFREQUENCY Surgery Blank 6.55 2.84 87.28 Blank RBRVS

50593 Blank ABLATION RENAL TUMOR UNILATERAL PERQ CRYOTHERAPY Surgery Blank 8.88 3.71 118.97 Blank RBRVS

50600 Blank URTROTOMY W/EXPL/DRG SEPARATE PROCEDURE Surgery Blank 17.17 8.17 8.17 Blank RBRVS

50605 Blank URETEROTOMY INSERTION INDWELLING STENT ALL TYPES Surgery Blank 16.79 8.59 8.59 Blank RBRVS

50606 Blank ENDOLUMINAL BX URTR &/RNL PELVIS NONENDOSCOPIC Surgery Blank 3.16 1.01 16.48 Blank RBRVS

50610 Blank URTROLITHOTOMY UPPER ONE-THIRD URETER Surgery Blank 17.25 8.27 8.27 Blank RBRVS

50620 Blank URTROLITHOTOMY MIDDLE ONE-THIRD URETER Surgery Blank 16.43 7.98 7.98 Blank RBRVS

50630 Blank URTROLITHOTOMY LOWER ONE-THIRD URETER Surgery Blank 16.21 7.90 7.90 Blank RBRVS

50650 Blank URETRECECTOMY W/BLADDER CUFF SEPARATE PROCEDURE Surgery Blank 18.82 9.10 9.10 Blank RBRVS

50660 Blank URETERECTOMY TOT ECTOPIC URETER CMBN APPR Surgery Blank 21.02 9.83 9.83 Blank RBRVS

50684 Blank INJ PX URETEROGRAPHY/URETEROPYLOGRAPHY CATH Surgery Blank 0.76 0.62 2.23 Blank RBRVS

50686 Blank MANOMETRIC STDS THRU URTROST/NDWELLG URTRL CATH Surgery Blank 1.51 0.89 2.49 Blank RBRVS

50688 Blank CHNG URTROST TUBE/XTRNLLY ACCESSIBLE STENT ILEAL Surgery Blank 1.20 0.97 0.97 Blank RBRVS

50690 Blank NJX VISUALIZATION ILEAL CONDUIT&/URETEROPYELOG Surgery Blank 1.16 0.76 1.58 Blank RBRVS

50693 Blank PLMT URTRL STENT PRQ PRE-EXISTING NFROS TRACT Surgery Blank 3.96 1.64 23.79 Blank RBRVS

50694 Blank PLMT URTRL STNT PRQ NEW ACESS W/O SEP NFROS CATH Surgery Blank 5.25 2.07 25.12 Blank RBRVS

50695 Blank PLMT URTRL STENT PRQ NEW ACCESS W/SEP NFROS CATH Surgery Blank 6.80 2.57 30.47 Blank RBRVS





PAGE 59 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

50700 Blank URETEROPLASTY PLASTIC OPERATION URETER Surgery Blank 16.69 8.31 8.31 Blank RBRVS

50705 Blank URETERAL EMBOLIZATION/OCCLUSION W/IMG GID RS&I Surgery Blank 4.03 1.30 50.51 Blank RBRVS

50706 Blank BALLOON DILAT URETERAL STRICTURE W/IMG GID RS&I Surgery Blank 3.80 1.20 23.95 Blank RBRVS

50715 Blank URETEROLYSIS W/WORPSG URETER RETROPERIT FIBROSIS Surgery Blank 20.64 10.80 10.80 Blank RBRVS

50722 Blank URETEROLYSIS FOR OVARIAN VEIN SYNDROME Surgery Blank 17.95 9.18 9.18 Blank RBRVS

50725 Blank URTROLSS RETROCAVAL URTR W/REANAST Surgery Blank 20.20 9.54 9.54 Blank RBRVS

50727 Blank REVJ URINARY-CUTANEOUS ANASTAMOSIS Surgery Blank 8.28 5.46 5.46 Blank RBRVS

50728 Blank REVJ UR-CUTAN ANAST RPR FSCAL DFCT & HERNIA Surgery Blank 12.18 6.73 6.73 Blank RBRVS

50740 Blank EXC URACHAL CYST/SINUS W/WO UMBILICAL HERNIA RPR Surgery Blank 20.07 10.52 10.52 Blank RBRVS

50750 Blank URETEROCALYCOSTOMY ANAST URETER RENAL CALYX Surgery Blank 21.22 9.90 9.90 Blank RBRVS

50760 Blank URETEROURETEROSTOMY Surgery Blank 20.07 9.67 9.67 Blank RBRVS

50770 Blank TRANSURETEROURETEROSTOMY ANAST URETER CLAT URTR Surgery Blank 21.22 9.90 9.90 Blank RBRVS

50780 Blank URETERONEOCYSTOSTOMY ANAST 1 URETER BLADDER Surgery Blank 19.95 9.58 9.58 Blank RBRVS

50782 Blank URETERONEOCYSTOSTOMY ANAST DUPLICATE URETER BLDR Surgery Blank 19.66 9.35 9.35 Blank RBRVS

50783 Blank URETERONEOCYSTOSTOMY W/URETERAL TAILORING Surgery Blank 20.70 9.72 9.72 Blank RBRVS

50785 Blank URTRONEOCSTOST W/VESICO-PSOAS HITCH/BLDR FLAP Surgery Blank 22.23 10.34 10.34 Blank RBRVS

50800 Blank URETEROENTEROSTOMY ANAST URETER INTESTINE Surgery Blank 16.41 8.48 8.48 Blank RBRVS

50810 Blank URETEROSIGMOIDOSTOMY W/SIGMOID BLADDER & COLOSTO Surgery Blank 22.61 12.40 12.40 Blank RBRVS

50815 Blank URETEROCOLON CONDUIT INTESTINE ANASTOMOSIS Surgery Blank 22.26 10.74 10.74 Blank RBRVS

50820 Blank URETEROILEAL CONDUIT W/INTESTINE ANASTOMOSIS Surgery Blank 24.07 11.20 11.20 Blank RBRVS

50825 Blank CONTINENT DVRJ W/INT ANAST ANY SGM SM&/LG INTSTN Surgery Blank 30.68 13.77 13.77 Blank RBRVS

50830 Blank URINARY UNIDIVERSION Surgery Blank 33.77 14.77 14.77 Blank RBRVS

50840 Blank RPLCMT ALL/PART URETER INTESTINE SGM W/ANAST Surgery Blank 22.39 10.78 10.78 Blank RBRVS

50845 Blank CUTANANEOUS APPENDICO-VESICOSTOMY Surgery Blank 22.46 11.29 11.29 Blank RBRVS

50860 Blank URETEROSTOMY TRANSPLANTATION URETER SKIN Surgery Blank 17.08 8.45 8.45 Blank RBRVS

50900 Blank URETERORRHAPHY SUTURE URETER SEPARATE PROCEDURE Surgery Blank 15.04 7.78 7.78 Blank RBRVS

50920 Blank CLOSURE URETEROCUTANEOUS FISTULA Surgery Blank 15.81 8.00 8.00 Blank RBRVS

50930 Blank CLOSURE URETEROCUTANEOUS FISTULA W/VISC RPR Surgery Blank 20.19 9.54 9.54 Blank RBRVS

50940 Blank DELIGATION URETER Surgery Blank 15.93 8.04 8.04 Blank RBRVS

50945 Blank LAPAROSCOPY URTROLITHOTOMY Surgery Blank 17.97 8.28 8.28 Blank RBRVS

50947 Blank LAPS URTRONEOCSTOST W/CSTSC&URTRL STENT PLMT Surgery Blank 25.78 11.52 11.52 Blank RBRVS

50948 Blank LAPS URTRONEOCSTOST W/O CSTSC&URTRL STENT PLMT Surgery Blank 23.82 10.54 10.54 Blank RBRVS

50949 Blank UNLISTED LAPAROSCOPY PROCEDURE URETER Surgery Blank Blank Blank Blank 37.30 Unlisted

50951 Blank URETERAL ENDOSCOPY VIA URETEROSTOMY Surgery Blank 5.83 2.43 4.42 Blank RBRVS

50953 Blank URETERAL ENDOSCOPY VIA URETEROST W/WO DIL URETER Surgery Blank 6.23 2.59 4.66 Blank RBRVS

50955 Blank URETERAL ENDOSCOPY VIA URETEROSTOMY W/BIOPSY Surgery Blank 6.74 2.76 4.85 Blank RBRVS

50957 Blank URETERAL ENDOSCOPY W/DEST&/INC W/WO BIOPSY Surgery Blank 6.78 2.77 4.92 Blank RBRVS

50961 Blank URETERAL ENDOSCOPY VIA URETEROST W/RMVL FB/STONE Surgery Blank 6.04 2.51 4.52 Blank RBRVS

50970 Blank URETERAL ENDOSCOPY VIA URETEROTOMY W/O IMAGING Surgery Blank 7.13 2.86 2.86 Blank RBRVS

50972 Blank NDSC URETEROTOMY URTRL CATHJ W/WO DILAT URETER Surgery Blank 6.88 2.77 2.77 Blank RBRVS

50974 Blank URETERAL ENDOSCOPY VIA URETEROT W/O IMAGING W/BX Surgery Blank 9.16 3.57 3.57 Blank RBRVS

50976 Blank URETERAL ENDOSC VIA URETEROT W/DEST&/INC W/WO BX Surgery Blank 9.03 3.52 3.52 Blank RBRVS

50980 Blank NDSC URETEROTOMY RMVL FB/CALCULUS Surgery Blank 6.84 2.76 2.76 Blank RBRVS

51020 Blank CYSTOTOMY/CYSTOSTOMY FULG&/INSJ RADACT MATRL Surgery Blank 7.69 5.06 5.06 Blank RBRVS

51030 Blank CSTOTOMY/CSTOST CRYOSURG DSTRJ INTRAVESICAL LES Surgery Blank 7.81 4.97 4.97 Blank RBRVS

51040 Blank CYSTOSTOMY CYSTOTOMY W/DRAINAGE Surgery Blank 4.49 3.40 3.40 Blank RBRVS

51045 Blank CYSTOTOMY W/INSJ URETERAL CATH/STENT SPX Surgery Blank 7.81 5.22 5.22 Blank RBRVS

51050 Blank CYSTOLITHOTOMY CYSTOTOMY W/RMVL CALCULUS Surgery Blank 7.97 4.85 4.85 Blank RBRVS

51060 Blank TRANSVESICAL URETROLITHOTOMY Surgery Blank 9.95 5.80 5.80 Blank RBRVS

51065 Blank CYSTOTOMY W/CALCULUS BASKET XTRJ&/FRAGMENTATIO Surgery Blank 9.95 5.73 5.73 Blank RBRVS

51080 Blank DRG PRIVESICAL/PREVESICAL SPACE ABSC Surgery Blank 6.71 4.40 4.40 Blank RBRVS

51100 Blank ASPIRATION BLADDER NEEDLE Surgery Blank 0.78 0.25 0.90 Blank RBRVS

51101 Blank ASPIRATION BLADDER TROCAR/INTRACATHETER Surgery Blank 1.02 0.37 2.41 Blank RBRVS

51102 Blank ASPIRATION BLADDER INSERT SUPRAPUBIC CATHETER Surgery Blank 2.70 1.19 3.52 Blank RBRVS

51500 Blank EXC URACHAL CYST/SINUS W/WO UMBILICAL HERNIA RPR Surgery Blank 11.05 6.19 6.19 Blank RBRVS

51520 Blank CYSTOTOMY SIMPLE EXCISION VESICAL NECK Surgery Blank 10.21 5.89 5.89 Blank RBRVS

51525 Blank CYSTOTOMY EXCISE BLADDER DIVERTICULUM 1/MULTIPLE Surgery Blank 15.42 7.73 7.73 Blank RBRVS

51530 Blank CYSTOTOMY EXCISION BLADDER TUMOR Surgery Blank 13.71 7.41 7.41 Blank RBRVS

51535 Blank CYSTOTOMY EXCISE/INCISE/REPAIR URETEROCELE Surgery Blank 13.90 7.18 7.18 Blank RBRVS

51550 Blank CYSTECTOMY PARTIAL SIMPLE Surgery Blank 17.23 8.48 8.48 Blank RBRVS

51555 Blank CYSTECTOMY PARTIAL COMPLICATED Surgery Blank 23.18 10.73 10.73 Blank RBRVS

51565 Blank CSTC PRTL W/RIMPLTJ URTR IN BLDR URTRONEOCSTOST Surgery Blank 23.68 11.11 11.11 Blank RBRVS

51570 Blank CYSTECTOMY COMPLETE SEPARATE PROCEDURE Surgery Blank 27.46 12.17 12.17 Blank RBRVS

51575 Blank CYSTECTOMY W/BI PELVIC LYMPHADENECTOMY Surgery Blank 34.18 14.81 14.81 Blank RBRVS

51580 Blank CYSTECTOMY W/URETEROSIGMOIDOSTOMY W/NODES Surgery Blank 35.37 15.71 15.71 Blank RBRVS

51585 Blank CYSTECTOMY W/URETEROSIGMOID BI PELV LYMPH NODES Surgery Blank 39.64 17.21 17.21 Blank RBRVS

51590 Blank CSTC COMPL W/URTROILEAL CONDUIT/BLDR W/INT ANAST Surgery Blank 36.33 15.62 15.62 Blank RBRVS

51595 Blank CSTC COMPL W/CONDUIT/SIGMOID BLDR PEL LMPHADEC Surgery Blank 41.32 17.56 17.56 Blank RBRVS

51596 Blank CSTC COMPL W/CONTINENT DVRJ OPN NEOBLDR Surgery Blank 44.26 19.05 19.05 Blank RBRVS

51597 Blank PELVIC EXENTERATION COMPLETE MALIGNANCY Surgery Blank 42.86 18.71 18.71 Blank RBRVS

51600 Blank NJX CSTOGRAPY/VOIDING URETHROCSTOGRAPY Surgery Blank 0.88 0.32 4.29 Blank RBRVS

51605 Blank NJX & PLACEMENT CHAIN CONTRAST&/URETHROCSTOGRAPY Surgery Blank 0.64 0.41 0.41 Blank RBRVS





PAGE 60 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

51610 Blank NJX RETROGRADE URETHROCSTOGRAPY Surgery Blank 1.05 0.70 1.91 Blank RBRVS

51700 Blank BLDR IRRIGATION SMPL LAVAGE &/INSTLJ Surgery Blank 0.60 0.22 1.45 Blank RBRVS

51701 Blank INSJ NON-NDWELLG BLADDER CATHETER Surgery Blank 0.50 0.18 0.79 Blank RBRVS

51702 Blank INSJ TEMP NDWELLG BLADDER CATHETER SIMPLE Surgery Blank 0.50 0.19 1.27 Blank RBRVS

51703 Blank INSJ TEMP NDWELLG BLADDER CATHETER COMPLICATED Surgery Blank 1.47 0.60 1.99 Blank RBRVS

51705 Blank CHANGE CYSTOSTOMY TUBE SIMPLE Surgery Blank 0.90 0.51 1.62 Blank RBRVS

51710 Blank CHANGE CYSTOSTOMY TUBE COMPLICATED Surgery Blank 1.35 0.82 2.20 Blank RBRVS

51715 Blank NDSC NJX IMPLT MATRL URT&/BLDR NCK Surgery Blank 3.73 1.64 4.22 Blank RBRVS

51720 Blank BLADDER INSTILLATION ANTICARCINOGENIC AGENT Surgery Blank 0.87 0.55 1.45 Blank RBRVS

51725 Blank SIMPLE CYSTOMETROGRAM Surgery a 1.51 3.72 3.72 Blank RBRVS

51725 26 SIMPLE CYSTOMETROGRAM Surgery Blank 1.51 0.56 0.56 Blank RBRVS

51725 TC SIMPLE CYSTOMETROGRAM Surgery a Blank 3.16 3.16 Blank RBRVS

51726 Blank BLADDER PRESSURE MEASUREMENT DURING FILLING Surgery a 1.71 5.72 5.72 Blank RBRVS

51726 26 BLADDER PRESSURE MEASUREMENT DURING FILLING Surgery Blank 1.71 0.61 0.61 Blank RBRVS

51726 TC BLADDER PRESSURE MEASUREMENT DURING FILLING Surgery a Blank 5.11 5.11 Blank RBRVS

51727 Blank COMPLEX CYSTOMETROGRAM URETHRAL PRESS PROFILE Surgery a 2.11 6.62 6.62 Blank RBRVS

51727 26 COMPLEX CYSTOMETROGRAM URETHRAL PRESS PROFILE Surgery Blank 2.11 0.78 0.78 Blank RBRVS

51727 TC COMPLEX CYSTOMETROGRAM URETHRAL PRESS PROFILE Surgery a Blank 5.84 5.84 Blank RBRVS

51728 Blank COMPLEX CYSTOMETROGRAM VOIDING PRESSURE STUDIES Surgery a 2.11 6.80 6.80 Blank RBRVS

51728 26 COMPLEX CYSTOMETROGRAM VOIDING PRESSURE STUDIES Surgery Blank 2.11 0.74 0.74 Blank RBRVS

51728 TC COMPLEX CYSTOMETROGRAM VOIDING PRESSURE STUDIES Surgery a Blank 6.06 6.06 Blank RBRVS

51729 Blank COMPLX CYSTOMETRO W/VOID PRESS & URETHRAL PROFIL Surgery a 2.51 7.03 7.03 Blank RBRVS

51729 26 COMPLX CYSTOMETRO W/VOID PRESS & URETHRAL PROFIL Surgery Blank 2.51 0.92 0.92 Blank RBRVS

51729 TC COMPLX CYSTOMETRO W/VOID PRESS & URETHRAL PROFIL Surgery a Blank 6.11 6.11 Blank RBRVS

51736 Blank SIMPLE UROFLOMETRY Surgery a 0.17 0.25 0.25 Blank RBRVS

51736 26 SIMPLE UROFLOMETRY Surgery Blank 0.17 0.06 0.06 Blank RBRVS

51736 TC SIMPLE UROFLOMETRY Surgery a Blank 0.19 0.19 Blank RBRVS

51741 Blank COMPLEX UROFLOMETRY Surgery a 0.17 0.26 0.26 Blank RBRVS

51741 26 COMPLEX UROFLOMETRY Surgery Blank 0.17 0.06 0.06 Blank RBRVS

51741 TC COMPLEX UROFLOMETRY Surgery a Blank 0.20 0.20 Blank RBRVS

51784 Blank EMG STDS ANAL/URTL SPHNCTR OTH/THN NDL Surgery a 0.75 1.16 1.16 Blank RBRVS

51784 26 EMG STDS ANAL/URTL SPHNCTR OTH/THN NDL Surgery Blank 0.75 0.27 0.27 Blank RBRVS

51784 TC EMG STDS ANAL/URTL SPHNCTR OTH/THN NDL Surgery a Blank 0.89 0.89 Blank RBRVS

51785 Blank NDL EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ Surgery a 1.53 5.88 5.88 Blank RBRVS

51785 26 NDL EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ Surgery Blank 1.53 0.65 0.65 Blank RBRVS

51785 TC NDL EMG STDS EMG ANAL/URTL SPHNCTR ANY TQ Surgery a Blank 5.23 5.23 Blank RBRVS

51792 Blank STIMULUS EVOKED RESPONSE Surgery a 1.10 4.88 4.88 Blank RBRVS

51792 26 STIMULUS EVOKED RESPONSE Surgery Blank 1.10 0.40 0.40 Blank RBRVS

51792 TC STIMULUS EVOKED RESPONSE Surgery a Blank 4.48 4.48 Blank RBRVS

51797 Blank VOID PRESSURE STUDIES INTRAABDOMINAL Surgery a 0.80 2.37 2.37 Blank RBRVS

51797 26 VOID PRESSURE STUDIES INTRAABDOMINAL Surgery Blank 0.80 0.29 0.29 Blank RBRVS

51797 TC VOID PRESSURE STUDIES INTRAABDOMINAL Surgery a Blank 2.08 2.08 Blank RBRVS

51798 Blank MEAS POST-VOIDING RESIDUAL URINE&/BLADDER CAP Surgery a Blank 0.44 0.44 Blank RBRVS

51800 Blank CSTOPLASTY/CSTOURTP PLSTC ANY Surgery Blank 18.89 9.20 9.20 Blank RBRVS

51820 Blank CSTOURTP W/UNI/BI URTRONEOCSTOST Surgery Blank 19.59 9.66 9.66 Blank RBRVS

51840 Blank ANT VESICOURETHROPEXY/URETHROPEXY SMPL Surgery Blank 11.36 6.26 6.26 Blank RBRVS

51841 Blank ANT VESICOURETHROPEXY/URETHROPEXY COMP Surgery Blank 13.68 6.96 6.96 Blank RBRVS

51845 Blank ABDOMINO-VAG VESICAL NCK SSP W/WO NDSC CTRL Surgery Blank 10.15 5.64 5.64 Blank RBRVS

51860 Blank CYSTORRHAPHY SUTR BLDR WND INJ/RPT SIMPLE Surgery Blank 12.60 7.11 7.11 Blank RBRVS

51865 Blank CYSTORRHAPHY SUTR BLDR WND INJ/RPT COMPLICATED Surgery Blank 15.80 8.09 8.09 Blank RBRVS

51880 Blank CLOSURE CYSTOSTOMY SEPARATE PROCEDURE Surgery Blank 7.87 4.66 4.66 Blank RBRVS

51900 Blank CLSR VESICOVAGINAL FISTUL AABDL APPROACH Surgery Blank 14.63 7.66 7.66 Blank RBRVS

51920 Blank CLOSURE VESICOUTERINE FISTULA Surgery Blank 13.41 7.24 7.24 Blank RBRVS

51925 Blank CLSR VESICOUTERINE FISTULA W/HYSTERECTOMY Surgery Blank 17.53 9.49 9.49 Blank RBRVS

51940 Blank CLOSURE EXSTROPHY BLADDER Surgery Blank 30.66 13.56 13.56 Blank RBRVS

51960 Blank ENTEROCYSTOPLASTY W/INTESTINAL ANASTOMOSIS Surgery Blank 25.40 11.99 11.99 Blank RBRVS

51980 Blank CUTANEOUS VESICOSTOMY Surgery Blank 12.57 6.72 6.72 Blank RBRVS

51990 Blank LAPAROSCOPY URETHRAL SUSPENSION STRESS INCONT Surgery Blank 13.36 6.80 6.80 Blank RBRVS

51992 Blank LAPAROSCOPY SLING OPERATION STRESS INCONT Surgery Blank 14.87 7.48 7.48 Blank RBRVS

51999 Blank UNLISTED LAPAROSCOPY PROCEDURE BLADDER Surgery Blank Blank Blank Blank 20.16 Unlisted

52000 Blank CYSTOURETHROSCOPY Surgery Blank 1.53 0.68 3.03 Blank RBRVS

52001 Blank CYSTO W/IRRIG & EVAC MULTPLE OBSTRUCTING CLOTS Surgery Blank 5.44 2.30 4.70 Blank RBRVS

52005 Blank CYSTO BLADDER W/URETERAL CATHETERIZATION Surgery Blank 2.37 1.23 5.04 Blank RBRVS

52007 Blank CYSTO W/URTRL CATHJ BRUSH BX URTR&/RENAL PELVIS Surgery Blank 3.02 1.45 9.44 Blank RBRVS

52010 Blank CYSTO W/EJACULATORY DUCT CATHETERIZATION Surgery Blank 3.02 1.46 7.25 Blank RBRVS

52204 Blank CYSTOURETHROSCOPY WITH BIOPSY Surgery Blank 2.59 1.23 7.76 Blank RBRVS

52214 Blank CYSTO W/DESTRUCTION OF LESIONS Surgery Blank 3.50 1.23 15.24 Blank RBRVS

52224 Blank CYSTO W/REMOVAL OF LESIONS SMALL Surgery Blank 4.05 1.42 15.47 Blank RBRVS

52234 Blank CYSTO W/REMOVAL OF TUMORS SMALL Surgery Blank 4.62 2.02 2.02 Blank RBRVS

52235 Blank CYSTOURETHROSCOPY W/DEST &/RMVL MED BLADDER TUM Surgery Blank 5.44 2.34 2.34 Blank RBRVS

52240 Blank CYSTOURETHROSCOPY W/DEST &/RMVL TUMOR LARGE Surgery Blank 7.50 3.06 3.06 Blank RBRVS

52250 Blank CYSTOURETHROSCOPY INSJ RADIOACT SBST W/WOBX/FULG Surgery Blank 4.49 1.97 1.97 Blank RBRVS





PAGE 61 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

52260 Blank CYSTOURETHROSCOPY W/DIL BLADDER GENERAL ANESTH Surgery Blank 3.91 1.76 1.76 Blank RBRVS

52265 Blank CYSTOURETHROSCOPY W/DIL BLADDER LOCAL ANESTHESIA Surgery Blank 2.94 1.43 7.22 Blank RBRVS

52270 Blank CYSTOURETHROSCOPY W/INTERNAL URETHROTOMY FEMALE Surgery Blank 3.36 1.55 6.54 Blank RBRVS

52275 Blank CYSTOURETHROSCOPY W/INTERNAL URETHROTOMY MALE Surgery Blank 4.69 2.02 8.64 Blank RBRVS

52276 Blank CYSTOURETHROSCOPY W/INTERNAL URETHROTOMY MALE Surgery Blank 4.99 2.14 2.14 Blank RBRVS

52277 Blank CYSTOURETHROSCOPY W/RESECJ EXTERNAL SPHINCTER Surgery Blank 6.16 2.55 2.55 Blank RBRVS

52281 Blank CYSTO CALIBRATION DILAT URTL STRIX/STENOSIS Surgery Blank 2.75 1.36 4.81 Blank RBRVS

52282 Blank CYSTOURETHROSCOPY INSERTION PERM URETHRAL STENT Surgery Blank 6.39 2.65 2.65 Blank RBRVS

52283 Blank CYSTOURETHROSCOPY W/STEROID INJECTION STRICTURE Surgery Blank 3.73 1.71 3.85 Blank RBRVS

52285 Blank CYSTOURETHROSCOPY TX FEMALE URETHRAL SYNDROME Surgery Blank 3.60 1.68 4.05 Blank RBRVS

52287 Blank CYSTOURETHROSCOPY INJ CHEMODENERVATION BLADDER Surgery Blank 3.20 1.35 5.42 Blank RBRVS

52290 Blank CYSTOURETHROSCOPY W/URETERAL MEATOTOMY UNI/BI Surgery Blank 4.58 2.01 2.01 Blank RBRVS

52300 Blank CYSTO W/RESCJ/FULG ORTHOPIC URETEROCELE UNI/BI Surgery Blank 5.30 2.26 2.26 Blank RBRVS

52301 Blank CYSTO W/RESECJ ECTOPIC URETEROCELE UNI/BI Surgery Blank 5.50 2.32 2.32 Blank RBRVS

52305 Blank CYSTO INC/RESCJ ORIFICE BLDR DIVERTICULUM 1/MLT Surgery Blank 5.30 2.20 2.20 Blank RBRVS

52310 Blank CYSTO W/SIMPLE REMOVAL STONE & STENT Surgery Blank 2.81 1.27 3.91 Blank RBRVS

52315 Blank CYSTO W/COMPLEX REMOVAL STONE & STENT Surgery Blank 5.20 2.19 6.15 Blank RBRVS

52317 Blank LITHOLAPAXY SMPL/SM <2.5 CM Surgery Blank 6.71 2.64 15.75 Blank RBRVS

52318 Blank LITHOLAPAXY COMP/LG > 2.5 CM Surgery Blank 9.18 3.56 3.56 Blank RBRVS

52320 Blank CYSTOURETHROSCOPY W/RMVL URETERAL CALCULUS Surgery Blank 4.69 1.96 1.96 Blank RBRVS

52325 Blank CYSTO FRAGMENTATION URETERAL STONE Surgery Blank 6.15 2.49 2.49 Blank RBRVS

52327 Blank CYSTO W/SUBURTRIC NJX IMPLT MATRL Surgery Blank 5.18 1.86 1.86 Blank RBRVS

52330 Blank CYSTO MANJ W/O RMVL URETERAL STONE Surgery Blank 5.03 2.08 8.67 Blank RBRVS

52332 Blank CYSTO W/INSERT URETERAL STENT Surgery Blank 2.82 1.39 10.98 Blank RBRVS

52334 Blank CYSTO INSJ URTRL GD WIRE PRQ NFROS RTRGR Surgery Blank 4.82 2.09 2.09 Blank RBRVS

52341 Blank CYSTO W/TX URETERAL STRICTURE Surgery Blank 5.35 2.31 2.31 Blank RBRVS

52342 Blank CYSTO W/TX URETEROPELVIC JUNCTION STRICTURE Surgery Blank 5.85 2.48 2.48 Blank RBRVS

52343 Blank CYSTO W/TX INTRA-RENAL STRICTURE Surgery Blank 6.55 2.73 2.73 Blank RBRVS

52344 Blank CYSTO W/URTROSCOPY W/TX URETERAL STRICTURE Surgery Blank 7.05 2.91 2.91 Blank RBRVS

52345 Blank CYSTO W/URTROSCOPY W/TX URTROPEL JUNCT STRIX Surgery Blank 7.55 3.08 3.08 Blank RBRVS

52346 Blank CYSTO W/URTROSCOPY W/TX INTRA-RENAL STRICTURE Surgery Blank 8.58 3.45 3.45 Blank RBRVS

52351 Blank CYSTO W/URTROSCOPY&/PYELOSCOPY DX Surgery Blank 5.75 2.41 2.41 Blank RBRVS

52352 Blank CYSTO W/URETEROSCOPY W/RMVL/MANJ STONES Surgery Blank 6.75 2.80 2.80 Blank RBRVS

52353 Blank CYSTO W/URETEROSCOPY W/LITHOTRIPSY Surgery Blank 7.50 3.06 3.06 Blank RBRVS

52354 Blank CYSTO/PYELOSCOPY BX&/FULGURATION PELIVC LESION Surgery Blank 8.00 3.24 3.24 Blank RBRVS

52355 Blank CYSTO/PYELOSCOPY RESCJ PELVIC TUMOR Surgery Blank 9.00 3.59 3.59 Blank RBRVS

52356 Blank CYSTO/URETERO W/LITHOTRIPSY &INDWELL STENT INSRT Surgery Blank 8.00 3.20 3.20 Blank RBRVS

52400 Blank CYSTO INC FULG/RESCJ URTL VALVES/FOLDS Surgery Blank 8.69 4.22 4.22 Blank RBRVS

52402 Blank CSTO W/TRURL RESCJ/INC EJACULATORY DUXS Surgery Blank 5.27 1.90 1.90 Blank RBRVS

52441 Blank CYSTO INSERTION TRANSPROSTATIC IMPLANT SINGLE Surgery Blank 4.50 1.58 30.77 Blank RBRVS

52442 Blank CYSTO INSERTION TRANSPROSTATIC IMPLANT EA ADDL Surgery Blank 1.20 0.42 26.07 Blank RBRVS

52450 Blank TRANSURETHRAL INCISION PROSTATE Surgery Blank 7.78 4.98 4.98 Blank RBRVS

52500 Blank TRANSURETHRAL RESECTION PROSTATE Surgery Blank 8.14 5.11 5.11 Blank RBRVS

52601 Blank TRURL ELECTROSURG RESCJ PROSTATE BLEED COMPLETE Surgery Blank 13.16 6.53 6.53 Blank RBRVS

52630 Blank TRURL RESCJ RESIDUAL/REGROWTH OBSTR PRSTATE TISS Surgery Blank 6.55 4.33 4.33 Blank RBRVS

52640 Blank TRURL RESCJ POSTOP BLADDER NECK CONTRACTURE Surgery Blank 4.79 3.83 3.83 Blank RBRVS

52647 Blank LASER COAGULATION OF PROSTATE FOR URINE FLOW Surgery Blank 11.30 6.23 38.82 Blank RBRVS

52648 Blank LASER VAPORIZATION OF PROSTATE FOR URINE FLOW Surgery Blank 12.15 6.52 39.35 Blank RBRVS

52649 Blank LASER ENUCLEATION PROSTATE W/MORCELLATION Surgery Blank 14.56 7.70 7.70 Blank RBRVS

52700 Blank TRURL DRAINAGE PROSTATIC ABSCESS Surgery Blank 7.49 4.47 4.47 Blank RBRVS

53000 Blank URTT/URTS XTRNL SPX PENDULOUS URETHRA Surgery Blank 2.33 1.71 1.71 Blank RBRVS

53010 Blank URETHROTOMY/URETHROSTOMY XT SPX PERINEAL URETHRA Surgery Blank 4.45 3.59 3.59 Blank RBRVS

53020 Blank MEATOTOMY CUTTING MEATUS SPX EXCEPT INFANT Surgery Blank 1.77 0.85 0.85 Blank RBRVS

53025 Blank MEATOTOMY CUTTING MEATUS SPX INFANT Surgery Blank 1.13 0.73 0.73 Blank RBRVS

53040 Blank DRAINAGE DEEP PERIURETHRAL ABSCESS Surgery Blank 6.55 4.11 4.11 Blank RBRVS

53060 Blank DRG OF SKENE'S GLAND ABSCESS OR CYST Surgery Blank 2.68 1.71 2.25 Blank RBRVS

53080 Blank DRG PERINEAL URINARY XTRVASATION UNCOMP SPX Surgery Blank 6.92 4.50 4.50 Blank RBRVS

53085 Blank DRG PERINEAL URINARY XTRVASATION COMPLIC Surgery Blank 11.18 6.40 6.40 Blank RBRVS

53200 Blank BIOPSY URETHRA Surgery Blank 2.59 1.23 1.64 Blank RBRVS

53210 Blank URETHRECTOMY TOT W/CYSTOST FEMALE Surgery Blank 13.72 7.09 7.09 Blank RBRVS

53215 Blank URETHRECTOMY TOT W/CYSTOST MALE Surgery Blank 16.85 8.19 8.19 Blank RBRVS

53220 Blank EXC/FULGURATION CARCINOMA URETHRA Surgery Blank 7.63 4.63 4.63 Blank RBRVS

53230 Blank EXC URETHRAL DIVERTICULUM SPX FEMALE Surgery Blank 10.44 5.93 5.93 Blank RBRVS

53235 Blank EXC URETHRAL DIVERTICULUM SPX MALE Surgery Blank 10.99 6.15 6.15 Blank RBRVS

53240 Blank MARSUPIALIZATION URTL DIVERTICULUM MALE/FEMALE Surgery Blank 7.08 4.46 4.46 Blank RBRVS

53250 Blank EXCISION OF BULBOURETHRAL GLAND Surgery Blank 6.52 4.23 4.23 Blank RBRVS

53260 Blank EXC/FULGURATION URETHRAL POLYP DSTL URETHRA Surgery Blank 3.03 1.82 2.43 Blank RBRVS

53265 Blank EXC/FULGURATION URETHRAL CARUNCLE Surgery Blank 3.17 1.86 2.78 Blank RBRVS

53270 Blank EXCISION OR FULGURATION SKENES GLANDS Surgery Blank 3.14 1.84 2.48 Blank RBRVS

53275 Blank EXCISION/FULGURATION URETHRAL PROLAPSE Surgery Blank 4.57 2.53 2.53 Blank RBRVS

53400 Blank URETHROPLASTY 1ST STG FISTULA/DIVERTICULUM/STRIX Surgery Blank 14.13 7.50 7.50 Blank RBRVS

53405 Blank URETHROPLASTY 2ND STAGE W/URINARY DIVERSION Surgery Blank 15.66 7.94 7.94 Blank RBRVS





PAGE 62 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

53410 Blank URETHROPLASTY 1 STG RECNST MALE ANTERIOR URETHRA Surgery Blank 17.68 8.74 8.74 Blank RBRVS

53415 Blank URTP TRANSPUBIC/PRNL 1 STG RCNSTJ/RPR URT Surgery Blank 20.70 9.80 9.80 Blank RBRVS

53420 Blank URTP 2-STG RCNSTJ/RPR PROSTAT/URETHRA 1ST STAGE Surgery Blank 15.17 7.55 7.55 Blank RBRVS

53425 Blank URTP 2-STG RCNSTJ/RPR PROSTAT/URETHRA 2ND STAGE Surgery Blank 17.07 8.21 8.21 Blank RBRVS

53430 Blank URETHROPLASTY RCNSTJ FEMALE URETHRA Surgery Blank 17.43 8.61 8.61 Blank RBRVS

53431 Blank URTP W/TUBULARIZATION POST URT&/LWR BLDR Surgery Blank 21.18 9.96 9.96 Blank RBRVS

53440 Blank SLING OPRATION CORRJ MALE URINARY INCONTINENCE Surgery Blank 13.36 7.00 7.00 Blank RBRVS

53442 Blank RMVL/REVJ SLING MALE URINARY INCONTINENCE Surgery Blank 13.49 7.72 7.72 Blank RBRVS

53444 Blank INSERTION TANDEM CUFF Surgery Blank 14.19 7.24 7.24 Blank RBRVS

53445 Blank INSJ INFLATABLE URETHRAL/BLADDER NECK SPHINCTER Surgery Blank 13.00 7.39 7.39 Blank RBRVS

53446 Blank REMVL INFLATABLE URETHRAL/BLADDER NECK SPHINCTER Surgery Blank 11.02 6.37 6.37 Blank RBRVS

53447 Blank RMVL & RPLCMT NFLTL URETHRAL/BLADDER NECK SPHINC Surgery Blank 14.28 7.59 7.59 Blank RBRVS

53448 Blank RMVL & RPLCMT NFLTBL NCK SPHNCTR THRU INFCT FLD Surgery Blank 23.44 11.11 11.11 Blank RBRVS

53449 Blank RPR NFLTBL URETHRAL/BLADDER NECK SPHINCTER Surgery Blank 10.56 6.00 6.00 Blank RBRVS

53450 Blank URETHROMEATOPLASTY W/MUCOSAL ADVANCEMENT Surgery Blank 6.77 4.33 4.33 Blank RBRVS

53460 Blank URETHROMEATOPLASTY W/PRTL EXC DSTL URTL SGM Surgery Blank 7.75 4.68 4.68 Blank RBRVS

53500 Blank URETHROLSS TRVG SEC OPN W/CSTO Surgery Blank 13.00 7.13 7.13 Blank RBRVS

53502 Blank URETHRORRHAPHY SUTR URETHRAL WOUND/INJ FEMALE Surgery Blank 8.26 4.93 4.93 Blank RBRVS

53505 Blank URETHRORRHAPHY SUTR URETHRAL WOUND/INJ PENILE Surgery Blank 8.26 4.92 4.92 Blank RBRVS

53510 Blank URETHRORRHAPHY SUTR URETHRAL WOUND/INJ PERINEAL Surgery Blank 10.96 6.14 6.14 Blank RBRVS

53515 Blank URTORR SUTR URETHRAL WND/INJ PROSTATOMEMBRANOUS Surgery Blank 14.22 7.28 7.28 Blank RBRVS

53520 Blank CLSR URETHROSTOMY/URETHROQ FSTL MALE SPX Surgery Blank 9.48 5.61 5.61 Blank RBRVS

53600 Blank DILAT URETHRAL STRIX DILATOR MALE 1ST Surgery Blank 1.21 0.51 1.05 Blank RBRVS

53601 Blank DILAT URETHRAL STRIX DILATOR MALE SBSQ Surgery Blank 0.98 0.47 1.25 Blank RBRVS

53605 Blank DILAT URETHRAL STRIX/VESICAL NCK DILAT MALE ANES Surgery Blank 1.28 0.45 0.45 Blank RBRVS

53620 Blank DILAT URETHRAL STRIX FILIFORM & FOLLWR MALE 1ST Surgery Blank 1.62 0.73 1.55 Blank RBRVS

53621 Blank DILAT URETHRAL STRIX FILIFORM & FOLLWR MALE SBSQ Surgery Blank 1.35 0.60 1.65 Blank RBRVS

53660 Blank DILAT FEMALE URETHRA W/SUPPOSITORY&/INSTLJ INI Surgery Blank 0.71 0.42 1.24 Blank RBRVS

53661 Blank DILAT FEMALE URT W/SUPPOSITORY&/INSTLJ SBSQ Surgery Blank 0.72 0.38 1.19 Blank RBRVS

53665 Blank DILAT FEMALE URETHRA GENERAL/CNDJ SPINAL ANES Surgery Blank 0.76 0.27 0.27 Blank RBRVS

53850 Blank TRURL DSTRJ PRSTATE TISS MICROWAVE THERMOTH Surgery Blank 10.08 6.40 48.55 Blank RBRVS

53852 Blank TRURL DSTRJ PRSTATE TISS RF THERMOTH Surgery Blank 10.83 6.03 43.11 Blank RBRVS

53854 Blank TRURL DSTRJ PRST8 TISS RF WV Surgery Blank 5.93 4.27 45.43 Blank RBRVS

53855 Blank INSERT TEMP PROSTATIC URETH STENT W/MEASUREMENT Surgery Blank 1.64 0.58 20.63 Blank RBRVS

53860 Blank TRURL RF FEMALE BLADDER NECK STRS URIN INCONT Surgery Blank 3.97 2.11 40.88 Blank RBRVS

53899 Blank UNLISTED PROCEDURE URINARY SYSTEM Surgery Blank Blank Blank Blank 2.97 Unlisted

54000 Blank SLITTING PREPUCE DORSAL/LATERAL SPX NEWBORN Surgery Blank 1.59 1.37 2.53 Blank RBRVS

54001 Blank SLITTING PREPUCE DORSAL/LAT SPX XCP NEWBORN Surgery Blank 2.24 1.53 2.85 Blank RBRVS

54015 Blank I&D PENIS DEEP Surgery Blank 5.36 2.95 2.95 Blank RBRVS

54050 Blank DSTRJ LESION PENIS SIMPLE CHEMICAL Surgery Blank 1.29 1.59 2.37 Blank RBRVS

54055 Blank DSTRJ LESION PENIS SIMPLE ELECTRODESICCATION Surgery Blank 1.25 1.27 2.03 Blank RBRVS

54056 Blank DSTRJ LESION PENIS SIMPLE CRYOSURGERY Surgery Blank 1.29 1.73 2.62 Blank RBRVS

54057 Blank DSTRJ LESION PENIS SIMPLE LASER Surgery Blank 1.29 1.34 2.56 Blank RBRVS

54060 Blank DSTRJ LESION PENIS SIMPLE SURG EXCISION Surgery Blank 1.98 1.56 2.98 Blank RBRVS

54065 Blank DSTRJ LESION PENIS EXTENSIVE Surgery Blank 2.47 2.18 3.51 Blank RBRVS

54100 Blank BIOPSY PENIS SEPARATE PROCEDURE Surgery Blank 1.90 1.48 3.55 Blank RBRVS

54105 Blank BIOPSY PENIS DEEP STRUCTURES Surgery Blank 3.54 2.24 3.71 Blank RBRVS

54110 Blank EXCISION OF PENILE PLAQUE Surgery Blank 10.92 5.98 5.98 Blank RBRVS

54111 Blank EXC PENILE PLAQUE GRAFT &/5 CM LENGTH Surgery Blank 14.42 7.21 7.21 Blank RBRVS

54112 Blank EXC PENILE PLAQUE GRAFT > 5 CM LENGTH Surgery Blank 16.98 8.34 8.34 Blank RBRVS

54115 Blank REMOVAL FOREIGN BODY DEEP PENILE TISSUE Surgery Blank 6.95 4.59 5.38 Blank RBRVS

54120 Blank AMPUTATION PENIS PARTIAL Surgery Blank 11.01 6.10 6.10 Blank RBRVS

54125 Blank AMPUTATION PENIS COMPLETE Surgery Blank 14.56 7.37 7.37 Blank RBRVS

54130 Blank AMPUTATION PENIS RADW/BI INGUINOFEMORAL LMPHADE Surgery Blank 21.84 10.36 10.36 Blank RBRVS

54135 Blank AMPUTATION PENIS RADICAL W/LYMPH NODES Surgery Blank 28.17 12.57 12.57 Blank RBRVS

54150 Blank CIRCUMCISION W/CLAMP/OTH DEV W/BLOCK Surgery Blank 1.90 0.70 2.34 Blank RBRVS

54160 Blank CIRCUMCISION NEONATE Surgery Blank 2.53 1.36 3.54 Blank RBRVS

54161 Blank CIRCUMCISION AGE >28 DAYS Surgery Blank 3.32 2.01 2.01 Blank RBRVS

54162 Blank LYSIS/EXCISION PENILE POSTCIRCUMCISION ADHESIONS Surgery Blank 3.32 2.09 3.75 Blank RBRVS

54163 Blank REPAIR INCOMPLETE CIRCUMCISION Surgery Blank 3.32 2.65 2.65 Blank RBRVS

54164 Blank FRENULOTOMY PENIS Surgery Blank 2.82 2.48 2.48 Blank RBRVS

54200 Blank INJECTION PEYRONIE DISEASE Surgery Blank 1.11 1.20 1.89 Blank RBRVS

54205 Blank NJX PEYRONIE W/SURG EXPOS PLAQUE Surgery Blank 8.97 5.48 5.48 Blank RBRVS

54220 Blank IRRIGATION CORPORA CAVERNOSA PRIAPISM Surgery Blank 2.42 1.17 3.22 Blank RBRVS

54230 Blank INJECTION CORPORA CAVERNOSOGRAPY Surgery Blank 1.34 0.83 1.33 Blank RBRVS

54231 Blank DYNAMIC CAVERNOSOMETRY NJX VASOACTIVE DRUGS Surgery Blank 2.04 1.11 1.81 Blank RBRVS

54235 Blank NJX C/P/A CAVERNOSA W/PHARMACOLOGIC AGT Surgery Blank 1.19 0.81 1.31 Blank RBRVS

54240 Blank PENILE PLETHYSMOGRAPHY Surgery a 1.31 1.48 1.48 Blank RBRVS

54240 26 PENILE PLETHYSMOGRAPHY Surgery Blank 1.31 0.45 0.45 Blank RBRVS

54240 TC PENILE PLETHYSMOGRAPHY Surgery a Blank 1.03 1.03 Blank RBRVS

54250 Blank NOCTURNAL PENILE TUMESCENCE &/RIGIDITY TEST Surgery a 2.22 1.08 1.08 Blank RBRVS

54250 26 NOCTURNAL PENILE TUMESCENCE &/RIGIDITY TEST Surgery Blank 2.22 0.77 0.77 Blank RBRVS





PAGE 63 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

54250 TC NOCTURNAL PENILE TUMESCENCE &/RIGIDITY TEST Surgery a Blank 0.31 0.31 Blank RBRVS

54300 Blank PENIS STRAIGHTENING CHORDEE Surgery Blank 11.20 6.18 6.18 Blank RBRVS

54304 Blank PENIS CORRJ CHORDEE/1ST STAGE HYPOSPADIAS RPR Surgery Blank 13.28 7.01 7.01 Blank RBRVS

54308 Blank URETHROPLASTY 2ND STAGE HYPOSPADIAS RPR <3 CM Surgery Blank 12.62 6.73 6.73 Blank RBRVS

54312 Blank URETHROPLASTY 2ND STAGE HYPOSPADIAS RPR > 3 CM Surgery Blank 14.51 7.62 7.62 Blank RBRVS

54316 Blank URETHROPLASTY 2ND STAGE HYPOSPADIAS RPR SKIN GRF Surgery Blank 18.05 8.91 8.91 Blank RBRVS

54318 Blank URETHROPLASTY 3RD STG HYPOSPADIAS RPR RLS PENIS Surgery Blank 12.43 6.82 6.82 Blank RBRVS

54322 Blank 1 STG DSTL HYPOSPADIAS RPR W/SMPL MEATAL ADVMNT Surgery Blank 13.98 7.12 7.12 Blank RBRVS

54324 Blank 1 STG DSTL HYPOSPADIAS RPR W/URTP SKIN FLAPS Surgery Blank 17.55 8.61 8.61 Blank RBRVS

54326 Blank 1 STG DSTL HYPOSPADIAS RPR URTP SKN FLAPS Surgery Blank 17.02 8.54 8.54 Blank RBRVS

54328 Blank 1 STAGE DSTL HYPOSPADIAS RPR W/EXTENSIVE DSJ Surgery Blank 16.89 8.50 8.50 Blank RBRVS

54332 Blank 1 STAGE PROX PENILE/PENOSCROTAL HYPOSPADIAS RPR Surgery Blank 18.37 9.02 9.02 Blank RBRVS

54336 Blank 1 STG PERINEAL HYPOSPADIAS RPR W/GRF&/FLAP Surgery Blank 21.62 10.50 10.50 Blank RBRVS

54340 Blank RPR HYPOSPADIAS COMPLCTJS CLSR INC/EXC SIMPLE Surgery Blank 9.71 5.75 5.75 Blank RBRVS

54344 Blank RPR HYPOSPADIAS COMPLCTJS MOBLJ FLAPS & URTP Surgery Blank 17.06 8.55 8.55 Blank RBRVS

54348 Blank RPR HYPOSPADIAS COMPLCTJS DSJ & URTP FLAP/GRF Surgery Blank 18.32 9.08 9.08 Blank RBRVS

54352 Blank RPR HYPOSPADIAS CRIPPLE W/DSJ & EXC & GRFS/FLAP Surgery Blank 26.13 12.07 12.07 Blank RBRVS

54360 Blank PLASTIC RPR PENIS CORRECT ANGULATION Surgery Blank 12.78 6.71 6.71 Blank RBRVS

54380 Blank PLASTIC RPR PENIS EPISPADIAS DSTL SPHNCTR Surgery Blank 14.18 7.43 7.43 Blank RBRVS

54385 Blank PLASTIC PENIS EPISPADIAS DSTL SPHNCTR W/INCONT Surgery Blank 16.56 8.53 8.53 Blank RBRVS

54390 Blank PLASTIC RPR PENIS EPISPADIAS W/EXSTROPHY BLADDER Surgery Blank 22.77 10.70 10.70 Blank RBRVS

54400 Blank INSJ PENILE PROSTHESIS NON-INFLATABLE SEMI-RIGID Surgery Blank 9.17 5.17 5.17 Blank RBRVS

54401 Blank INSJ PENILE PROSTHESOS INFLATABLE SELF-CONTAINED Surgery Blank 10.44 7.42 7.42 Blank RBRVS

54405 Blank INSJ MULTI-COMPONENT INFLATABLE PENILE PROSTH Surgery Blank 14.52 7.32 7.32 Blank RBRVS

54406 Blank RMVL INFLATABLE PENILE PROSTH W/O RPLCMT PROSTH Surgery Blank 12.89 6.86 6.86 Blank RBRVS

54408 Blank RPR COMPONENT INFLATABLE PENILE PROSTHESIS Surgery Blank 13.91 7.46 7.46 Blank RBRVS

54410 Blank RMVL & RPLCMT INFLATABLE PENILE PROSTH SAME SESS Surgery Blank 15.18 8.06 8.06 Blank RBRVS

54411 Blank RMVL & RPLCMT NFLTBL PENILE PROSTH INFECTED FIEL Surgery Blank 18.35 9.38 9.38 Blank RBRVS

54415 Blank RMVL NON-NFLTBL/NFLTBL PENILE PROSTH W/O RPLCMT Surgery Blank 8.88 5.46 5.46 Blank RBRVS

54416 Blank RMVL & RPLCMT NON-NFLTBL/NFLTBL PENILE PROSTHESI Surgery Blank 12.08 7.18 7.18 Blank RBRVS

54417 Blank RMVL & RPLCMT PENILE PROSTHESIS INFECTED FIELD Surgery Blank 16.10 8.19 8.19 Blank RBRVS

54420 Blank CORPORA CAVERNOSA-SAPHENOUS VEIN SHUNT UNI/BI Surgery Blank 12.39 6.68 6.68 Blank RBRVS

54430 Blank CORPORA CAVERNOSA-CORPUS SPONGIOSUM SHUNT UNI/BI Surgery Blank 11.06 6.29 6.29 Blank RBRVS

54435 Blank CORPORA CAVERNOSA-GLANS PENIS FSTLJ PRIAPISM Surgery Blank 6.81 4.53 4.53 Blank RBRVS

54437 Blank REPAIR OF TRAUMATIC CORPOREAL TEAR(S) Surgery Blank 11.50 6.76 6.76 Blank RBRVS

54438 Blank REPLANTATION PENIS COMP AMPUTATION W/URETH REP Surgery Blank 24.50 11.59 11.59 Blank RBRVS

54440 Blank PLASTIC OPERATION PENIS INJURY Surgery Blank Blank Blank Blank 15.67 FAIR Health

54450 Blank FORESKN MANJ W/LSS PREPUTIAL ADS&STRETCHING Surgery Blank 1.12 0.43 0.79 Blank RBRVS

54500 Blank BIOPSY TESTIS NEEDLE SEPARATE PROCEDURE Surgery Blank 1.31 0.71 0.71 Blank RBRVS

54505 Blank BIOPSY TESTIS INCISIONAL SEPARATE PROCEDURE Surgery Blank 3.50 2.20 2.20 Blank RBRVS

54512 Blank EXC XTRPARENCHYMAL LESION TESTIS Surgery Blank 9.33 5.25 5.25 Blank RBRVS

54520 Blank ORCHIECTOMY SIMPLE SCROTAL/INGUINAL APPROACH Surgery Blank 5.30 3.51 3.51 Blank RBRVS

54522 Blank ORCHIECTOMY PARTIAL Surgery Blank 10.25 5.74 5.74 Blank RBRVS

54530 Blank ORCHIECTOMY RADICAL TUMOR INGUINAL APPROACH Surgery Blank 8.46 5.23 5.23 Blank RBRVS

54535 Blank ORCHIECTOMY RADICAL TUMOR W/ABDOMINAL EXPL Surgery Blank 13.19 6.93 6.93 Blank RBRVS

54550 Blank EXPL UNDESCENDED TSTIS INGUN/SCROTAL AREA Surgery Blank 8.41 4.93 4.93 Blank RBRVS

54560 Blank EXPL UNDESCENDED TESTIS W/ABDOMINAL EXPL Surgery Blank 12.10 6.48 6.48 Blank RBRVS

54600 Blank RDCTJ TORSION TSTIS W/WO FIXJ CLAT TESTIS Surgery Blank 7.64 4.67 4.67 Blank RBRVS

54620 Blank FIXATION CONTRALATERAL TESTIS SEPARATE PROCEDURE Surgery Blank 5.21 2.91 2.91 Blank RBRVS

54640 Blank ORCHIOPEXY INGUINAL APPROACH W/WO HERNIA RPR Surgery Blank 7.73 5.20 5.20 Blank RBRVS

54650 Blank ORCHIOPEXY ABDL APPROACH INTRA-ABDOMINAL TESTIS Surgery Blank 12.39 6.88 6.88 Blank RBRVS

54660 Blank INSJ TESTICULAR PROSTH SEPARATE PROCEDURE Surgery Blank 5.74 3.99 3.99 Blank RBRVS

54670 Blank SUTURE/REPAIR TESTICULAR INJURY Surgery Blank 6.65 4.38 4.38 Blank RBRVS

54680 Blank TRANSPLANTATION TESTIS TO THIGH Surgery Blank 14.04 7.24 7.24 Blank RBRVS

54690 Blank LAPAROSCOPY SURGICAL ORCHIECTOMY Surgery Blank 11.70 6.08 6.08 Blank RBRVS

54692 Blank LAPAROSCOPY ORCHIOPEXY INTRA-ABDOMINAL TESTIS Surgery Blank 13.74 6.76 6.76 Blank RBRVS

54699 Blank UNLISTED LAPAROSCOPY PROCEDURE TESTIS Surgery Blank Blank Blank Blank 20.50 Unlisted

54700 Blank I&D EPIDIDYMIS TSTIS&/SCROTAL SPACE Surgery Blank 3.47 2.28 2.28 Blank RBRVS

54800 Blank BIOPSY EPIDIDYMIS NEEDLE Surgery Blank 2.33 1.07 1.07 Blank RBRVS

54830 Blank EXCISION LOCAL LESION EPIDIDYMIS Surgery Blank 6.01 4.11 4.11 Blank RBRVS

54840 Blank EXCISION SPERMATOCELE W/WO EPIDIDYMECTOMY Surgery Blank 5.27 3.46 3.46 Blank RBRVS

54860 Blank EPIDIDYMECTOMY UNILATERAL Surgery Blank 6.95 4.43 4.43 Blank RBRVS

54861 Blank EPIDIDYMECTOMY BILATERAL Surgery Blank 9.70 5.65 5.65 Blank RBRVS

54865 Blank EXPLORATION EPIDIDYMIS W/WO BIOPSY Surgery Blank 5.77 4.00 4.00 Blank RBRVS

54900 Blank EPIDIDYMOVASOSTOMY ANAST EPIDIDYMIS UNI Surgery Blank 14.20 7.45 7.45 Blank RBRVS

54901 Blank EPIDIDYMOVASOSTOMY ANAST EPIDIDYMIS BI Surgery Blank 19.10 9.42 9.42 Blank RBRVS

55000 Blank PNXR ASPIR HYDROCELE TUNICA VAGIS W/WO NJX MED Surgery Blank 1.43 0.86 1.81 Blank RBRVS

55040 Blank EXCISION HYDROCELE UNILATERAL Surgery Blank 5.45 3.70 3.70 Blank RBRVS

55041 Blank EXCISION HYDROCELE BILATERAL Surgery Blank 8.54 5.26 5.26 Blank RBRVS

55060 Blank RPR TUNICA VAGINALIS HYDROCELE BOTTLE TYPE Surgery Blank 6.15 4.17 4.17 Blank RBRVS

55100 Blank DRAINAGE SCROTAL WALL ABSCESS Surgery Blank 2.45 2.06 3.48 Blank RBRVS

55110 Blank SCROTAL EXPLORATION Surgery Blank 6.33 4.16 4.16 Blank RBRVS





PAGE 64 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

55120 Blank REMOVAL FOREIGN BODY SCROTUM Surgery Blank 5.72 3.91 3.91 Blank RBRVS

55150 Blank RESECTION SCROTUM Surgery Blank 8.14 5.14 5.14 Blank RBRVS

55175 Blank SCROTOPLASTY SIMPLE Surgery Blank 5.87 4.00 4.00 Blank RBRVS

55180 Blank SCROTOPLASTY COMPLICATED Surgery Blank 11.78 6.72 6.72 Blank RBRVS

55200 Blank VASOTOMY CANNULIZATION W/WO VAS INC UNI/BI SPX Surgery Blank 4.55 3.03 7.56 Blank RBRVS

55250 Blank VASECTOMY UNI/BI SPX W/POSTOP SEMEN EXAMS Surgery Blank 3.37 2.85 7.38 Blank RBRVS

55300 Blank VASOTOMY VASOGRAMS UNI/BI Surgery Blank 3.50 1.55 1.55 Blank RBRVS

55400 Blank VASOVASOSTOMY VASOVASORRHAPHY Surgery Blank 8.61 4.90 4.90 Blank RBRVS

55500 Blank EXC HYDROCELE SPRMATIC CORD UNI SPX Surgery Blank 6.22 4.31 4.31 Blank RBRVS

55520 Blank EXC LESION SPERMATIC CORD SEPARATE PROCEDURE Surgery Blank 6.66 4.94 4.94 Blank RBRVS

55530 Blank EXC VARICOCELE/LIGATION SPERMATIC VEINS SPX Surgery Blank 5.75 3.79 3.79 Blank RBRVS

55535 Blank EXC VARICOCELE/LIGATION SPERMATIC VEINS ABDL Surgery Blank 7.19 4.51 4.51 Blank RBRVS

55540 Blank EXC VARICOCELE/LIGATION VEINS W/HERNIA RPR Surgery Blank 8.30 5.68 5.68 Blank RBRVS

55550 Blank LAPS LIGATION SPERMATIC VEINS VARICOCELE Surgery Blank 7.20 4.44 4.44 Blank RBRVS

55559 Blank UNLISTED LAPROSCOPY PROCEDURE SPERMATIC CORD Surgery Blank Blank Blank Blank 11.64 Unlisted

55600 Blank VESICULOTOMY Surgery Blank 7.01 4.45 4.45 Blank RBRVS

55605 Blank VESICULOTOMY COMPLICATED Surgery Blank 8.76 5.39 5.39 Blank RBRVS

55650 Blank VESICULECTOMY ANY APPROACH Surgery Blank 12.65 6.75 6.75 Blank RBRVS

55680 Blank EXCISION MULLERIAN DUCT CYST Surgery Blank 5.67 3.75 3.75 Blank RBRVS

55700 Blank PROSTATE NEEDLE BIOPSY ANY APPROACH Surgery Blank 2.50 1.02 4.37 Blank RBRVS

55705 Blank BIOPSY PROSTATE INCISIONAL ANY APPROACH Surgery Blank 4.61 2.59 2.59 Blank RBRVS

55706 Blank BX PROSTATE STRTCTC SATURATION SAMPLING IMG GID Surgery Blank 6.28 3.84 3.84 Blank RBRVS

55720 Blank PROSTATOTOMY EXTERNAL DRG ABSCESS SIMPLE Surgery Blank 7.73 4.53 4.53 Blank RBRVS

55725 Blank PROSTATOTOMY EXTERNAL DRG ABSCESS COMPLICATED Surgery Blank 10.05 6.05 6.05 Blank RBRVS

55801 Blank PROSTATECTOMY PERINEAL SUBTOTAL Surgery Blank 19.80 9.73 9.73 Blank RBRVS

55810 Blank PROSTATECTOMY PERINEAL RADICAL Surgery Blank 24.29 11.04 11.04 Blank RBRVS

55812 Blank PROSTATECTOMY PERINEAL RADICAL W/LYMPH NODE BX Surgery Blank 29.89 13.48 13.48 Blank RBRVS

55815 Blank PROSTATECTOMY PERINEAL RAD W/BI PELVIC LYMPH EXC Surgery Blank 32.95 14.56 14.56 Blank RBRVS

55821 Blank PROSTATECTOMY SUPRAPUBIC SUBTOTAL 1/2 STAGES Surgery Blank 15.76 7.82 7.82 Blank RBRVS

55831 Blank PROSTATECTOMY RETROPUBIC SUBTOTAL Surgery Blank 17.19 8.33 8.33 Blank RBRVS

55840 Blank PROSTATECTOMY RETROPUBIC W/WO NERVE SPARING Surgery Blank 21.36 10.26 10.26 Blank RBRVS

55842 Blank PROSTECT RETROPUBIC RAD W/WO NRV SPAR W/LYMPH BX Surgery Blank 21.36 10.25 10.25 Blank RBRVS

55845 Blank PROSTECT RETROPUB RAD W/WO NRV SPAR & BI PLV LYM Surgery Blank 25.18 11.60 11.60 Blank RBRVS

55860 Blank EXPOS PROSTATE ANY APPROACH INSJ RADIOACT SUBST Surgery Blank 15.84 7.79 7.79 Blank RBRVS

55862 Blank EXPOS PROSTATE INSJ RADIOACT SBST W/LYMPH BX Surgery Blank 20.04 9.56 9.56 Blank RBRVS

55865 Blank EXPOS PROSTATE INSJ RADIOAC SBST W/BI PELV LYMPH Surgery Blank 24.57 11.42 11.42 Blank RBRVS

55866 Blank LAPS PROSTECT RETROPUBIC RAD W/NRV SPARING ROBOT Surgery Blank 26.80 12.14 12.14 Blank RBRVS

55870 Blank ELECTROEJACULATION Surgery Blank 2.58 1.26 2.20 Blank RBRVS

55873 Blank CRYOSURGICAL ABLATION PROSTATE W/US & MONITORI Surgery Blank 13.60 7.05 188.52 Blank RBRVS

55874 Blank TPRNL PLMT BIODEGRDABL MATRL Surgery Blank 3.03 1.39 102.06 Blank RBRVS

55875 Blank TRANSPERINEAL PLMT NDL/CATHS PROSTATE RADJ INSJ Surgery Blank 13.46 7.29 7.29 Blank RBRVS

55876 Blank PLMT INTERSTITIAL DEV RADIAT TX PROSTATE 1/MULT Surgery Blank 1.73 1.01 2.03 Blank RBRVS

55899 Blank UNLISTED PROCEDURE MALE GENITAL SYSTEM Surgery Blank Blank Blank Blank 5.87 Unlisted

55920 Blank PLACEMENT NEEDLE PELVIC ORGAN RADIOELEMENT APPL Surgery Blank 8.31 3.93 3.93 Blank RBRVS

56405 Blank I&D VULVA/PERINEAL ABSCESS Surgery Blank 1.49 1.40 1.42 Blank RBRVS

56420 Blank I&D OF BARTHOLINS GLAND ABSCESS Surgery Blank 1.44 0.96 1.85 Blank RBRVS

56440 Blank MARSUPIALIZATION BARTHOLINS GLAND CYST Surgery Blank 2.89 1.92 1.92 Blank RBRVS

56441 Blank LYSIS LABIAL ADHESIONS Surgery Blank 2.02 1.69 1.86 Blank RBRVS

56442 Blank HYMENOTOMY SIMPLE INCISION Surgery Blank 0.68 0.60 0.60 Blank RBRVS

56501 Blank DESTRUCTION LESIONS VULVA SIMPLE Surgery Blank 1.58 1.49 1.97 Blank RBRVS

56515 Blank DESTRUCTION LESIONS VULVA EXTENSIVE Surgery Blank 3.08 2.20 2.92 Blank RBRVS

56605 Blank BIOPSY VULVA/PERINEUM 1 LESION SPX Surgery Blank 1.10 0.48 1.09 Blank RBRVS

56606 Blank BIOPSY VULVA/PERINEUM EACH ADDL LESION Surgery Blank 0.55 0.22 0.45 Blank RBRVS

56620 Blank VULVECTOMY SIMPLE PARTIAL Surgery Blank 7.53 6.04 6.04 Blank RBRVS

56625 Blank VULVECTOMY SIMPLE COMPLETE Surgery Blank 9.68 6.54 6.54 Blank RBRVS

56630 Blank VULVECTOMY RADICAL PARTIAL Surgery Blank 14.80 8.93 8.93 Blank RBRVS

56631 Blank VULVECTOMY RAD PRTL UNI INGUINOFEM LMPHADECTOMY Surgery Blank 18.99 11.19 11.19 Blank RBRVS

56632 Blank VULVECTOMY RAD PRTL BI INGUINOFEM LMPHADECTOMY Surgery Blank 21.86 13.37 13.37 Blank RBRVS

56633 Blank VULVECTOMY RADICAL COMPLETE Surgery Blank 19.62 11.26 11.26 Blank RBRVS

56634 Blank VULVECTOMY RAD COMPL UNI INGUINOFEM LMPHADECTOMY Surgery Blank 20.66 12.24 12.24 Blank RBRVS

56637 Blank VULVECTOMY RAD COMPL BI INGUINOFEM LMPHADECTOMY Surgery Blank 24.75 13.59 13.59 Blank RBRVS

56640 Blank VULVECTOMY RAD COMPL ILIAC & PELVIC LMPHADECTOMY Surgery Blank 24.78 13.58 13.58 Blank RBRVS

56700 Blank PRTL HYMENECTOMY/REVJ HYMENAL RING Surgery Blank 2.84 2.10 2.10 Blank RBRVS

56740 Blank EXC BARTHOLINS GLAND/CYST Surgery Blank 4.88 2.96 2.96 Blank RBRVS

56800 Blank PLASTIC REPAIR INTROITUS Surgery Blank 3.93 2.40 2.40 Blank RBRVS

56805 Blank CLITOROPLASTY INTERSEX STATE Surgery Blank 19.88 10.02 10.02 Blank RBRVS

56810 Blank PERINEOPLASTY RPR PERINEUM NONOBSTETRICAL SPX Surgery Blank 4.29 2.55 2.55 Blank RBRVS

56820 Blank COLPOSCOPY VULVA Surgery Blank 1.50 0.73 1.46 Blank RBRVS

56821 Blank COLPOSCOPY VULVA W/BIOPSY Surgery Blank 2.05 0.95 1.86 Blank RBRVS

57000 Blank COLPOTOMY W/EXPLORATION Surgery Blank 3.02 1.96 1.96 Blank RBRVS

57010 Blank COLPOTOMY W/DRAINAGE PELVIC ABSCESS Surgery Blank 6.84 4.59 4.59 Blank RBRVS

57020 Blank COLPOCENTESIS SEPARATE PROCEDURE Surgery Blank 1.50 0.62 0.94 Blank RBRVS





PAGE 65 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

57022 Blank I&D VAGINAL HEMATOMA OBSTETRICAL/POSTPARTUM Surgery Blank 2.73 1.69 1.69 Blank RBRVS

57023 Blank I&D VAGINAL HEMATOMA NON-OBSTETRICAL Surgery Blank 5.18 2.96 2.96 Blank RBRVS

57061 Blank DESTRUCTION VAGINAL LESIONS SIMPLE Surgery Blank 1.30 1.32 1.77 Blank RBRVS

57065 Blank DESTRUCTION VAGINAL LESIONS EXTENSIVE Surgery Blank 2.66 1.90 2.49 Blank RBRVS

57100 Blank BIOPSY VAGINAL MUCOSA SIMPLE Surgery Blank 1.20 0.53 1.15 Blank RBRVS

57105 Blank BIOPSY VAGINAL MUCOSA EXTENSIVE Surgery Blank 1.74 1.61 1.88 Blank RBRVS

57106 Blank VAGINECTOMY PARTIAL REMOVAL VAGINAL WALL Surgery Blank 7.50 5.39 5.39 Blank RBRVS

57107 Blank VAGINECTOMY PRTL RMVL VAG WALL & PARAVAGINAL T Surgery Blank 24.56 12.52 12.52 Blank RBRVS

57109 Blank VAGNC PRTL RMVL VAG WALL W/BI TOT PEL LMPHADEC Surgery Blank 28.40 15.47 15.47 Blank RBRVS

57110 Blank VAGINECTOMY COMPLETE REMOVAL VAGINAL WALL Surgery Blank 15.48 7.93 7.93 Blank RBRVS

57111 Blank VAGINECTOMY COMPL RMVL VAG WALL & PARAVAG TISS Surgery Blank 28.40 15.47 15.47 Blank RBRVS

57112 Blank VAGNC COMPL RMVL VAG WALL TOT PEL LMPHADEC BX Surgery Blank 30.52 16.42 16.42 Blank RBRVS

57120 Blank COLPOCLEISIS LE FORT TYPE Surgery Blank 8.28 5.13 5.13 Blank RBRVS

57130 Blank EXCISION VAGINAL SEPTUM Surgery Blank 2.46 1.74 2.25 Blank RBRVS

57135 Blank EXCISION VAGINAL CYST/TUMOR Surgery Blank 2.70 1.87 2.41 Blank RBRVS

57150 Blank IRRIGATION VAGINA&/APPL MEDICAMENT TX DISEASE Surgery Blank 0.55 0.21 0.67 Blank RBRVS

57155 Blank INSERTION UTERINE TANDEM&/VAGINAL OVOIDS Surgery Blank 5.15 2.43 4.88 Blank RBRVS

57156 Blank INSERTION VAGINAL RADIATION DEVICE Surgery Blank 2.69 1.35 2.82 Blank RBRVS

57160 Blank FIT&INSJ PESSARY/OTH INTRAVAGINAL SUPPORT DEVI Surgery Blank 0.89 0.34 1.16 Blank RBRVS

57170 Blank DIAPHRAGM/CERVICAL CAP FITTING W/INSTRUCTIONS Surgery Blank 0.91 0.35 0.69 Blank RBRVS

57180 Blank INTRO ANY HEMOSTATIC AGENT/PACK VAG HEMRRG SPX Surgery Blank 1.63 1.15 2.15 Blank RBRVS

57200 Blank COLPORRHAPHY SUTURE INJURY VAGINA Surgery Blank 4.42 3.53 3.53 Blank RBRVS

57210 Blank COLPOPERINEORRHAPHY SUTURE INJ VAGINA&/PERINEU Surgery Blank 5.71 3.98 3.98 Blank RBRVS

57220 Blank PLASTIC URETHRAL SPHINCTER VAGINAL APPROACH Surgery Blank 4.85 3.60 3.60 Blank RBRVS

57230 Blank PLASTIC REPAIR URETHROCELE Surgery Blank 6.30 4.09 4.09 Blank RBRVS

57240 Blank ANT COLPORRHAPHY CYSTOCELE W/WO RPR URETHROCELE Surgery Blank 10.08 5.52 5.52 Blank RBRVS

57250 Blank POST COLPORRHAPHY RECTOCELE W/WO PERINEORRHAPHY Surgery Blank 10.08 5.57 5.57 Blank RBRVS

57260 Blank COMBINED ANTEROPOSTERIOR COLPORRHAPHY Surgery Blank 13.25 6.78 6.78 Blank RBRVS

57265 Blank CMBND ANTEROPOST COLPORRHAPHY W/ENTEROCELE RPR Surgery Blank 15.00 7.47 7.47 Blank RBRVS

57267 Blank INSJ MESH/PROSTH PELVIC FLOOR DEFECT EACH SITE Surgery Blank 4.88 1.84 1.84 Blank RBRVS

57268 Blank REPAIR ENTEROCELE VAGINAL APPROACH SPX Surgery Blank 7.57 5.19 5.19 Blank RBRVS

57270 Blank REPAIR ENTEROCELE ABDOMINAL APPROACH SPX Surgery Blank 13.67 7.27 7.27 Blank RBRVS

57280 Blank COLPOPEXY ABDOMINAL APPROACH Surgery Blank 16.72 8.33 8.33 Blank RBRVS

57282 Blank COLPOPEXY VAGINAL EXTRAPERITONEAL APPROACH Surgery Blank 7.97 5.29 5.29 Blank RBRVS

57283 Blank COLPOPEXY VAGINAL INTRAPERITONEAL APPROACH Surgery Blank 11.66 6.41 6.41 Blank RBRVS

57284 Blank PARAVAGINAL DEFECT REPAIR OPEN ABDOMINAL APPR Surgery Blank 14.33 7.14 7.14 Blank RBRVS

57285 Blank PARAVAGINAL DEFECT REPAIR VAGINAL APPROACH Surgery Blank 11.60 6.14 6.14 Blank RBRVS

57287 Blank RMVL/REVJ SLING STRESS INCONTINENCE Surgery Blank 11.15 7.00 7.00 Blank RBRVS

57288 Blank SLING OPERATION STRESS INCONTINENCE Surgery Blank 12.13 6.88 6.88 Blank RBRVS

57289 Blank PEREYRA PX W/ANTERIOR COLPORRHAPHY Surgery Blank 12.80 7.17 7.17 Blank RBRVS

57291 Blank CONSTRUCTION ARTIFICIAL VAGINA W/O GRAFT Surgery Blank 8.64 5.27 5.27 Blank RBRVS

57292 Blank CONSTRUCTION ARTIFICIAL VAGINA W/GRAFT Surgery Blank 14.01 7.35 7.35 Blank RBRVS

57295 Blank REVJ/RMVL PROSTHETIC VAGINAL GRAFT VAGINAL APP Surgery Blank 7.82 4.83 4.83 Blank RBRVS

57296 Blank REVJ W/RMVL PROSTHETIC VAGINAL GRAFT ABDML APPR Surgery Blank 16.56 8.10 8.10 Blank RBRVS

57300 Blank CLSR RECTOVAGINAL FISTULA VAGINAL/TRANSANAL APPR Surgery Blank 8.71 5.94 5.94 Blank RBRVS

57305 Blank CLSR RECTOVAGINAL FISTULA ABDOMINAL APPROACH Surgery Blank 15.35 8.54 8.54 Blank RBRVS

57307 Blank CLSR RECTOVAG FSTL ABDL APPR W/CONCOMITANT CLST Surgery Blank 17.17 9.75 9.75 Blank RBRVS

57308 Blank CLSR RECTOVAG FSTL TPRNL PRNL BDY RCNSTJ Surgery Blank 10.59 6.89 6.89 Blank RBRVS

57310 Blank CLOSURE URETHROVAGINAL FISTULA Surgery Blank 7.65 4.86 4.86 Blank RBRVS

57311 Blank CLSR URETHROVAG FSTL W/BULBOCAVERNOSUS TRNSPL Surgery Blank 8.91 5.30 5.30 Blank RBRVS

57320 Blank CLOSURE VESICOVAGINAL FISTULA VAGINAL APPROACH Surgery Blank 8.88 5.34 5.34 Blank RBRVS

57330 Blank CLSR VESICOVAG FSTL TRANSVESICAL&VAG APPR Surgery Blank 13.21 6.76 6.76 Blank RBRVS

57335 Blank VAGINOPLASTY INTERSEX STATE Surgery Blank 20.02 10.19 10.19 Blank RBRVS

57400 Blank DILATION VAGINA W/ANESTHESIA OTHER THAN LOCAL Surgery Blank 2.27 1.25 1.25 Blank RBRVS

57410 Blank PELVIC EXAMINATION W/ANESTHESIA OTHER THAN LOCAL Surgery Blank 1.75 1.08 1.08 Blank RBRVS

57415 Blank REMOVAL IMPACTED VAG FB SPX W/ANES OTH/THN LOCAL Surgery Blank 2.49 1.77 1.77 Blank RBRVS

57420 Blank COLPOSCOPY ENTIRE VAGINA W/CERVIX IF PRESENT Surgery Blank 1.60 0.77 1.50 Blank RBRVS

57421 Blank COLPOSCOPY ENTIRE VAGINA W/VAGINA/CERVIX BX Surgery Blank 2.20 1.01 1.95 Blank RBRVS

57423 Blank PARAVAGINAL DEFECT REPAIR LAPAROSCOPIC APPROACH Surgery Blank 16.08 7.86 7.86 Blank RBRVS

57425 Blank LAPAROSCOPY COLPOPEXY SUSPENSION VAGINAL APEX Surgery Blank 17.03 8.45 8.45 Blank RBRVS

57426 Blank REVISION PROSTHETIC VAGINAL GRAFT LAPAROSCOPIC Surgery Blank 14.30 7.81 7.81 Blank RBRVS

57452 Blank COLPOSCOPY CERVIX UPPER/ADJACENT VAGINA Surgery Blank 1.50 0.93 1.39 Blank RBRVS

57454 Blank COLPOSCOPY CERVIX BX CERVIX & ENDOCRV CURRETAGE Surgery Blank 2.33 1.24 1.71 Blank RBRVS

57455 Blank COLPOSCOPY CERVIX UPPR/ADJCNT VAGINA W/CERVIX BX Surgery Blank 1.99 0.90 1.80 Blank RBRVS

57456 Blank COLPOSCOPY CERVIX ENDOCERVICAL CURETTAGE Surgery Blank 1.85 0.84 1.73 Blank RBRVS

57460 Blank COLPOSCOPY CERVIX VAG LOOP ELTRD BX CERVIX Surgery Blank 2.83 1.43 4.80 Blank RBRVS

57461 Blank COLPOSCOPY CERVIX VAG ELTRD CONIZATION CERVIX Surgery Blank 3.43 1.46 5.16 Blank RBRVS

57500 Blank BIOPSY CERVIX SINGLE/MULT/EXCISION OF LESION SPX Surgery Blank 1.20 0.80 2.26 Blank RBRVS

57505 Blank ENDOCERVICAL CURETTAGE W/DILATION & CURETTAGE Surgery Blank 1.19 1.27 1.56 Blank RBRVS

57510 Blank CAUTERY CERVIX ELECTRO/THERMAL Surgery Blank 1.90 1.14 1.60 Blank RBRVS

57511 Blank CAUTERY CERVIX CRYOCAUTERY INITIAL/REPEAT Surgery Blank 1.95 1.55 1.94 Blank RBRVS

57513 Blank CAUTERY CERVIX LASER ABLATION Surgery Blank 1.95 1.59 1.92 Blank RBRVS





PAGE 66 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

57520 Blank CONIZATION CERVIX W/WO D&C RPR KNIFE/LASER Surgery Blank 4.11 3.14 4.05 Blank RBRVS

57522 Blank CONIZATION CERVIX W/WO D&C RPR ELTRD EXC Surgery Blank 3.67 2.76 3.33 Blank RBRVS

57530 Blank TRACHELECTOMY CERVICECTOMY AMP CERVIX SPX Surgery Blank 5.27 3.84 3.84 Blank RBRVS

57531 Blank RAD TRACHELECTOMY W/BI PEL LMPHADEC Surgery Blank 29.95 14.21 14.21 Blank RBRVS

57540 Blank EXCISION CERVICAL STUMP ABDOMINAL APPROACH Surgery Blank 13.29 7.08 7.08 Blank RBRVS

57545 Blank EXC CERVICAL STUMP ABDL APPR W/PELVIC FLOOR RPR Surgery Blank 14.10 7.39 7.39 Blank RBRVS

57550 Blank EXCISION CERVICAL STUMP VAGINAL APPROACH Surgery Blank 6.34 4.39 4.39 Blank RBRVS

57555 Blank EXC CRV STUMP VAG APPR W/ANT &/POST REPAIR Surgery Blank 9.94 5.82 5.82 Blank RBRVS

57556 Blank EXC CRV STUMP VAG APPR W/RPR NTRCL Surgery Blank 9.36 5.56 5.56 Blank RBRVS

57558 Blank DILATION & CURETTAGE CERVICAL STUMP Surgery Blank 1.72 1.28 1.59 Blank RBRVS

57700 Blank CERCLAGE UTERINE CERVIX NONOBSTETRICAL Surgery Blank 4.35 3.90 3.90 Blank RBRVS

57720 Blank TRACHELORRHAPHY PLSTC RPR UTERINE CERVIX VAG Surgery Blank 4.61 3.51 3.51 Blank RBRVS

57800 Blank DILATION CERVICAL CANAL INSTRUMENTAL SPX Surgery Blank 0.77 0.52 0.83 Blank RBRVS

58100 Blank ENDOMETRIAL BX W/WO ENDOCERVIX BX W/O DILAT SPX Surgery Blank 1.53 0.76 1.36 Blank RBRVS

58110 Blank ENDOMETRIAL BX CONJUNCT W/COLPOSCOPY Surgery Blank 0.77 0.30 0.50 Blank RBRVS

58120 Blank DILATION & CURETTAGE DX&/THER NONOBSTETRIC Surgery Blank 3.59 2.14 3.26 Blank RBRVS

58140 Blank MYOMECTOMY 1-4 MYOMAS W/250 GM/< ABDOMINAL APPR Surgery Blank 15.79 8.09 8.09 Blank RBRVS

58145 Blank MYOMECTOMY 1-4 MYOMAS 250 GM/< VAGINAL APPR Surgery Blank 8.91 5.44 5.44 Blank RBRVS

58146 Blank MYOMECTOMY 5/> MYOMAS &/>250 GM ABDOMINA Surgery Blank 20.34 9.73 9.73 Blank RBRVS

58150 Blank TOTAL ABDOMINAL HYSTERECT W/WO RMVL TUBE OVARY Surgery Blank 17.31 8.96 8.96 Blank RBRVS

58152 Blank TOT ABD HYST W/WO RMVL TUBE OVARY W/COLPURETHRXY Surgery Blank 21.86 10.71 10.71 Blank RBRVS

58180 Blank SUPRACERVICAL ABDL HYSTER W/WO RMVL TUBE OVARY Surgery Blank 16.60 8.47 8.47 Blank RBRVS

58200 Blank TOT ABD HYST W/PARAORTIC & PELVIC LYMPH NODE SAM Surgery Blank 23.10 11.92 11.92 Blank RBRVS

58210 Blank RAD ABDL HYSTERECTOMY W/BI PELVIC LMPHADENECTOMY Surgery Blank 30.91 15.95 15.95 Blank RBRVS

58240 Blank PEL EXNTJ GYNECOLOGIC MAL Surgery Blank 49.33 24.90 24.90 Blank RBRVS

58260 Blank VAGINAL HYSTERECTOMY UTERUS 250 GM/< Surgery Blank 14.15 7.48 7.48 Blank RBRVS

58262 Blank VAG HYST 250 GM/< W/RMVL TUBE&/OVARY Surgery Blank 15.94 8.14 8.14 Blank RBRVS

58263 Blank VAG HYST 250 GM/< W/RMVL TUBE OVARY W/RPR NTRCL Surgery Blank 17.23 8.63 8.63 Blank RBRVS

58267 Blank VAG HYST 250 GM/< W/COLPO-URTCSTOPEXY Surgery Blank 18.36 9.15 9.15 Blank RBRVS

58270 Blank VAGINAL HYSTERECTOMY 250 GM/< W/RPR ENTEROCELE Surgery Blank 15.30 7.75 7.75 Blank RBRVS

58275 Blank VAGINAL HYSTERECTOMY W/TOT/PRTL VAGINECTOMY Surgery Blank 17.03 8.65 8.65 Blank RBRVS

58280 Blank VAG HYSTER W/TOT/PRTL VAGINECT W/RPR ENTEROCELE Surgery Blank 18.33 9.11 9.11 Blank RBRVS

58285 Blank VAGINAL HYSTERECTOMY RADICAL SCHAUTA OPERATION Surgery Blank 23.38 12.42 12.42 Blank RBRVS

58290 Blank VAGINAL HYSTERECTOMY UTERUS > 250 GM Surgery Blank 20.27 9.77 9.77 Blank RBRVS

58291 Blank VAG HYST > 250 GM RMVL TUBE&/OVARY Surgery Blank 22.06 10.53 10.53 Blank RBRVS

58292 Blank VAG HYST > 250 GM RMVL TUBE&/OVARY W/RPR ENTRCLE Surgery Blank 23.35 10.88 10.88 Blank RBRVS

58293 Blank VAG HYST >250 GM COLPOURTCSTOPEXY W/WO NDSC CTR Surgery Blank 24.33 11.26 11.26 Blank RBRVS

58294 Blank VAGINAL HYSTERECTOMY >250 GM RPR ENTEROCELE Surgery Blank 21.55 10.19 10.19 Blank RBRVS

58300 Blank INSERTION INTRAUTERINE DEVICE IUD Surgery Blank 1.01 0.39 0.94 Blank RBRVS

58301 Blank REMOVAL INTRAUTERINE DEVICE IUD Surgery Blank 1.27 0.50 1.28 Blank RBRVS

58321 Blank ARTIFICIAL INSEMINATION INTRA-CERVICAL Surgery Blank 0.92 0.36 1.14 Blank RBRVS

58322 Blank ARTIFICIAL INSEMINATION INTRA-UTERINE Surgery Blank 1.10 0.43 1.21 Blank RBRVS

58323 Blank SPERM WASHING ARTIFICIAL INSEMINATION Surgery Blank 0.23 0.09 0.18 Blank RBRVS

58340 Blank CATH & SALINE/CONTRAST SONOHYSTER/HYSTEROSALPI Surgery Blank 0.88 0.68 2.42 Blank RBRVS

58345 Blank TRANSCERV FALLOPIAN TUBE CATH W/WO HYSTOSALPING Surgery Blank 4.70 2.60 2.60 Blank RBRVS

58346 Blank INSERTION HEYMAN CAPSULES CLINICAL BRACHYTHERAPY Surgery Blank 7.56 4.80 4.80 Blank RBRVS

58350 Blank CHROMOTUBATION OVIDUCT W/MATERIALS Surgery Blank 1.06 1.03 1.55 Blank RBRVS

58353 Blank ENDOMETRIAL ABLTJ THERMAL W/O HYSTEROSCOPIC GUID Surgery Blank 3.60 2.14 24.38 Blank RBRVS

58356 Blank ENDOMETRIAL CRYOABLATION W/US & ENDOMETRIAL CR Surgery Blank 6.41 2.57 45.77 Blank RBRVS

58400 Blank UTERINE SUSPENSION W/WO SHORTENING LIGAMENTS SPX Surgery Blank 7.14 4.50 4.50 Blank RBRVS

58410 Blank UTERINE SUSP W/WO SHORT LIGAMNTS W/SYMPATHECTOMY Surgery Blank 13.80 7.21 7.21 Blank RBRVS

58520 Blank HYSTERORRHAPHY REPAIR RUPT UTERUS NONOBSTETRICAL Surgery Blank 13.48 7.09 7.09 Blank RBRVS

58540 Blank HYSTEROPLASTY RPR UTERINE ANOMALY Surgery Blank 15.71 8.01 8.01 Blank RBRVS

58541 Blank LAPAROSCOPY SUPRACERVICAL HYSTERECTOMY 250 GM/< Surgery Blank 12.29 6.51 6.51 Blank RBRVS

58542 Blank LAPS SUPRACRV HYSTERECT 250 GM/< RMVL TUBE/OVAR Surgery Blank 14.16 7.24 7.24 Blank RBRVS

58543 Blank LAPS SUPRACERVICAL HYSTERECTOMY >250 Surgery Blank 14.39 7.31 7.31 Blank RBRVS

58544 Blank LAPS SUPRACRV HYSTEREC >250 G RMVL TUBE/OVARY Surgery Blank 15.60 7.86 7.86 Blank RBRVS

58545 Blank LAPS MYOMECTOMY EXC 1-4 MYOMAS 250 GM/< Surgery Blank 15.55 7.84 7.84 Blank RBRVS

58546 Blank LAPS MYOMECTOMY EXC 5/> MYOMAS >250 GRAMS Surgery Blank 19.94 9.38 9.38 Blank RBRVS

58548 Blank LAPS W/RAD HYST W/BILAT LMPHADEC RMVL TUBE/OVARY Surgery Blank 31.63 16.58 16.58 Blank RBRVS

58550 Blank LAPS VAGINAL HYSTERECTOMY UTERUS 250 GM/< Surgery Blank 15.10 7.97 7.97 Blank RBRVS

58552 Blank LAPS W/VAG HYSTERECT 250 GM/&RMVL TUBE&/OVARIES Surgery Blank 16.91 8.77 8.77 Blank RBRVS

58553 Blank LAPS W/VAGINAL HYSTERECTOMY > 250 GRAMS Surgery Blank 20.06 9.42 9.42 Blank RBRVS

58554 Blank LAPS VAGINAL HYSTERECT > 250 GM RMVL TUBE&/OVAR Surgery Blank 23.11 11.27 11.27 Blank RBRVS

58555 Blank HYSTEROSCOPY DIAGNOSTIC SEPARATE PROCEDURE Surgery Blank 2.65 1.40 4.63 Blank RBRVS

58558 Blank HYSTEROSCOPY BX ENDOMETRIUM&/POLYPC W/WO D&C Surgery Blank 4.17 1.99 33.84 Blank RBRVS

58559 Blank HYSTEROSCOPY LYSIS INTRAUTERINE ADHESIONS Surgery Blank 5.20 2.40 2.40 Blank RBRVS

58560 Blank HYSTEROSCOPY DIV/RESCJ INTRAUTERINE SEPTUM Surgery Blank 5.75 2.58 2.58 Blank RBRVS

58561 Blank HYSTEROSCOPY REMOVAL LEIOMYOMATA Surgery Blank 6.60 2.92 2.92 Blank RBRVS

58562 Blank HYSTEROSCOPY REMOVAL IMPACTED FOREIGN BODY Surgery Blank 4.00 1.92 5.14 Blank RBRVS

58563 Blank HYSTEROSCOPY ENDOMETRIAL ABLATION Surgery Blank 4.47 2.10 39.96 Blank RBRVS

58565 Blank HYSTEROSCOPY BI TUBE OCCLUSION W/PERM IMPLNTS Surgery Blank 7.12 4.25 44.74 Blank RBRVS





PAGE 67 of 144

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HCPCS

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Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

58570 Blank LAPAROSCOPY W TOTAL HYSTERECTOMY UTERUS 250 GM/< Surgery Blank 13.36 7.03 7.03 Blank RBRVS

58571 Blank LAPS TOTAL HYSTERECT 250 GM/< W/RMVL TUBE/OVARY Surgery Blank 15.00 8.03 8.03 Blank RBRVS

58572 Blank LAPAROSCOPY TOTAL HYSTERECTOMY UTERUS >250 GM Surgery Blank 17.71 8.87 8.87 Blank RBRVS

58573 Blank LAPAROSCOPY TOT HYSTERECTOMY >250 G W/TUBE/OVAR Surgery Blank 20.79 10.44 10.44 Blank RBRVS

58575 Blank LAPS TOT HYST RESJ MAL Surgery Blank 32.60 16.00 16.00 Blank RBRVS

58578 Blank UNLISTED LAPAROSCOPY PROCEDURE UTERUS Surgery Blank Blank Blank Blank 23.03 Unlisted

58579 Blank UNLISTED HYSTEROSCOPY PROCEDURE UTERUS Surgery Blank Blank Blank Blank 10.83 Unlisted

58600 Blank LIG/TRNSXJ FLP TUBE ABDL/VAG APPR UNI/BI Surgery Blank 5.91 3.65 3.65 Blank RBRVS

58605 Blank LIG/TRNSXJ FLP TUBE ABDL/VAG POSTPARTUM SPX Surgery Blank 5.28 3.38 3.38 Blank RBRVS

58611 Blank LIG/TRNSXJ FALOPIAN TUBE CESAREAN DEL/ABDML SURG Surgery Blank 1.45 0.56 0.56 Blank RBRVS

58615 Blank OCCLUSION FLP TUBE DEV VAG/SUPRAPUBIC APPR Surgery Blank 3.94 2.46 2.46 Blank RBRVS

58660 Blank LAPAROSCOPY W/LYSIS OF ADHESIONS Surgery Blank 11.59 5.91 5.91 Blank RBRVS

58661 Blank LAPAROSCOPY W/RMVL ADNEXAL STRUCTURES Surgery Blank 11.35 5.48 5.48 Blank RBRVS

58662 Blank LAPS FULG/EXC OVARY VISCERA/PERITONEAL SURFACE Surgery Blank 12.15 6.32 6.32 Blank RBRVS

58670 Blank LAPAROSCOPY FULGURATION OVIDUCTS Surgery Blank 5.91 3.67 3.67 Blank RBRVS

58671 Blank LAPAROSCOPY W/PLMT OCCLUSION DEVICE OVIDUCTS Surgery Blank 5.91 3.66 3.66 Blank RBRVS

58672 Blank LAPAROSCOPY FIMBRIOPLASTY Surgery Blank 12.91 6.27 6.27 Blank RBRVS

58673 Blank LAPAROSCOPY SALPINGOSTOMY Surgery Blank 14.04 6.80 6.80 Blank RBRVS

58674 Blank LAPS ABLTJ UTERINE FIBROIDS Surgery Blank 14.08 7.26 7.26 Blank RBRVS

58679 Blank UNLISTED LAPAROSCOPY PROCEDURE OVIDUCT/OVARY Surgery Blank Blank Blank Blank 16.83 Unlisted

58700 Blank SALPINGECTOMY COMPLETE/PARTIAL UNI/BI SPX Surgery Blank 12.95 7.16 7.16 Blank RBRVS

58720 Blank SALPINGO-OOPHORECTOMY COMPL/PRTL UNI/BI SPX Surgery Blank 12.16 6.83 6.83 Blank RBRVS

58740 Blank LYSIS OF ADHESIONS SALPINX/OVARY Surgery Blank 14.90 7.98 7.98 Blank RBRVS

58750 Blank TUBOTUBAL ANASTATOMOSIS Surgery Blank 15.64 7.88 7.88 Blank RBRVS

58752 Blank TUBOUTERINE IMPLANTATION Surgery Blank 15.64 7.81 7.81 Blank RBRVS

58760 Blank FIMBRIOPLASTY Surgery Blank 13.93 7.22 7.22 Blank RBRVS

58770 Blank SALPINGOSTOMY Surgery Blank 14.77 7.48 7.48 Blank RBRVS

58800 Blank DRAINAGE OVARIAN CYST UNI/BI SPX VAGINAL APPR Surgery Blank 4.62 3.25 3.81 Blank RBRVS

58805 Blank DRAINAGE OVARIAN CYST UNI/BI SPX ABDOMINAL Surgery Blank 6.42 4.21 4.21 Blank RBRVS

58820 Blank DRAINAGE OVARIAN ABSCESS VAGINAL APPR OPEN Surgery Blank 4.70 3.54 3.54 Blank RBRVS

58822 Blank DRAINAGE OVARIAN ABSCESS ABDOMINAL APPROACH Surgery Blank 11.81 6.50 6.50 Blank RBRVS

58825 Blank TRANSPOSITION OVARY Surgery Blank 11.78 6.39 6.39 Blank RBRVS

58900 Blank BIOPSY OVARY UNI/BI SEPARATE PROCEDURE Surgery Blank 6.59 4.28 4.28 Blank RBRVS

58920 Blank WEDGE RESCJ/BISCTJ OVARY UNI/BI Surgery Blank 11.95 6.35 6.35 Blank RBRVS

58925 Blank OVARIAN CYSTECTOMY UNI/BI Surgery Blank 12.43 6.89 6.89 Blank RBRVS

58940 Blank OOPHORECTOMY PARTIAL/TOTAL UNI/BI Surgery Blank 8.22 5.36 5.36 Blank RBRVS

58943 Blank OOPHORECTOMY PRTL/TOT UNI/BI OVARIAN MALIGNANCY Surgery Blank 19.52 10.40 10.40 Blank RBRVS

58950 Blank RESCJ OVARIAN/TUBAL/PERITONEAL MALIGNANCY W/BSO Surgery Blank 18.37 10.46 10.46 Blank RBRVS

58951 Blank RESCJ PRIM PRTL MAL W/BSO & OMNTC TAH & LMPHAD Surgery Blank 24.26 12.69 12.69 Blank RBRVS

58952 Blank RESCJ PRIM PRTL MAL W/BSO & OMNTC RAD DEBULKING Surgery Blank 27.29 14.45 14.45 Blank RBRVS

58953 Blank BSO W/OMENTECTOMY TAH&RAD DEBULKING DISSECTION Surgery Blank 34.13 17.49 17.49 Blank RBRVS

58954 Blank BSO W/OMENTECTOMY TAH DEBULKING W/LMPHADECTOMY Surgery Blank 37.13 18.86 18.86 Blank RBRVS

58956 Blank BSO W/TOT OMENTECTOMY & HYSTERECTOMY MALIGNANC Surgery Blank 22.80 12.42 12.42 Blank RBRVS

58957 Blank RESECJ RECUR OVARIAN/TUBAL/PERITONEAL MALIGNANCY Surgery Blank 26.22 14.04 14.04 Blank RBRVS

58958 Blank RESECTION RECRT MAL W/OMENTECTOMY PEL LMPHADEC Surgery Blank 29.22 15.20 15.20 Blank RBRVS

58960 Blank LAPT STG/RESTG OVARIAN TUBAL/PRIM MAL 2ND LOOK Surgery Blank 15.79 8.98 8.98 Blank RBRVS

58970 Blank FOLLICLE PUNCTURE OOCYTE RETRIEVAL ANY METHOD Surgery Blank 3.52 1.72 2.34 Blank RBRVS

58974 Blank EMBRYO TRANSFER INTRAUTERINE Surgery Blank Blank Blank Blank 6.88 FAIR Health

58976 Blank GAMETE ZYGOTE/EMBRYO FALLOPIAN TRANSFER ANY METH Surgery Blank 3.82 1.84 2.69 Blank RBRVS

58999 Blank UNLISTED PX FEMALE GENITAL SYSTEM NONOBSTETRICAL Surgery Blank Blank Blank Blank 2.90 Unlisted

59000 Blank AMNIOCENTESIS DIAGNOSIC Maternity - Non-Deliveries Blank 1.30 0.70 1.99 Blank RBRVS

59001 Blank AMNIOCENTESIS THER AMNIOTIC FLUID RDCTJ US GUID Maternity - Non-Deliveries Blank 3.00 1.41 1.41 Blank RBRVS

59012 Blank CORDOCENTESIS INTRAUTERINE Maternity - Non-Deliveries Blank 3.44 1.53 1.53 Blank RBRVS

59015 Blank CHORIONIC VILLUS SAMPLING Maternity - Non-Deliveries Blank 2.20 1.05 1.73 Blank RBRVS

59020 Blank FETAL CONTRACTION STRESS TEST Maternity - Non-Deliveries a 0.66 1.20 1.20 Blank RBRVS

59020 26 FETAL CONTRACTION STRESS TEST Maternity - Non-Deliveries Blank 0.66 0.26 0.26 Blank RBRVS

59020 TC FETAL CONTRACTION STRESS TEST Maternity - Non-Deliveries a Blank 0.94 0.94 Blank RBRVS

59025 Blank FETAL NONSTRESS TEST Maternity - Non-Deliveries a 0.53 0.72 0.72 Blank RBRVS

59025 26 FETAL NONSTRESS TEST Maternity - Non-Deliveries Blank 0.53 0.21 0.21 Blank RBRVS

59025 TC FETAL NONSTRESS TEST Maternity - Non-Deliveries a Blank 0.51 0.51 Blank RBRVS

59030 Blank FETAL SCALP BLOOD SAMPLING Maternity - Non-Deliveries Blank 1.99 0.76 0.76 Blank RBRVS

59050 Blank FETAL MONITORING LABOR PHYS WRITTEN REPORT Maternity - Non-Deliveries Blank 0.89 0.35 0.35 Blank RBRVS

59051 Blank FETAL MONITR LABOR PHYS WRTTN REPRT INTERPJ ONLY Maternity - Non-Deliveries Blank 0.74 0.29 0.29 Blank RBRVS

59070 Blank TRANSABDOMINAL AMNIOINFUSION W/ULTRSND GUIDANCE Maternity - Non-Deliveries Blank 5.24 2.38 5.06 Blank RBRVS

59072 Blank FETAL UMBILICAL CORD OCCLUSION W/ULTRSND GUIDNCE Maternity - Non-Deliveries Blank 8.99 3.83 3.83 Blank RBRVS

59074 Blank FETAL FLUID DRAINAGE W/ULTRASOUND GUIDANCE Maternity - Non-Deliveries Blank 5.24 2.38 4.65 Blank RBRVS

59076 Blank FETAL SHUNT PLACEMENT W/ULTRASOUND GUIDANCE Maternity - Non-Deliveries Blank 8.99 3.83 3.83 Blank RBRVS

59100 Blank HYSTEROTOMY ABDOMINAL Maternity - Non-Deliveries Blank 13.37 7.20 7.20 Blank RBRVS

59120 Blank TX ECTOPIC PREGNANCY ABDOMINAL/VAGINAL APPR Maternity - Non-Deliveries Blank 12.67 6.93 6.93 Blank RBRVS

59121 Blank TX ECTOPIC PREGNANCY W/O SALPING&/OOPHORECTOMY Maternity - Non-Deliveries Blank 12.74 6.87 6.87 Blank RBRVS

59130 Blank TX ECTOPIC PREGNANCY ABDL PREGNANCY Maternity - Non-Deliveries Blank 15.08 7.77 7.77 Blank RBRVS

59135 Blank TX ECTOPIC PREGNANCY NTRSTL REQ TOT HYST Maternity - Non-Deliveries Blank 14.92 7.65 7.65 Blank RBRVS





PAGE 68 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

59136 Blank TX ECTOPIC PREGNANCY NTRSTL PRTL RESCJ UTER Maternity - Non-Deliveries Blank 14.25 7.39 7.39 Blank RBRVS

59140 Blank TX ECTOPIC PREGNANCY CERVICAL W/EVACUATION Maternity - Non-Deliveries Blank 5.94 4.06 4.06 Blank RBRVS

59150 Blank LAPS TX ECTOPIC PREG W/O SALPING&/OOPHORECTOMY Maternity - Non-Deliveries Blank 12.29 6.70 6.70 Blank RBRVS

59151 Blank LAPS TX ECTOPIC PREG W/SALPING&/OOPHORECTOMY Maternity - Non-Deliveries Blank 12.11 6.32 6.32 Blank RBRVS

59160 Blank CURETTAGE POSTPARTUM Maternity - Non-Deliveries Blank 2.76 1.52 2.40 Blank RBRVS

59200 Blank INSERTION CERVICAL DILATOR SEPARATE PROCEDURE Maternity - Non-Deliveries Blank 0.79 0.31 1.09 Blank RBRVS

59300 Blank EPISIOTOMY/VAG RPR OTH/THN ATTENDING Maternity - Non-Deliveries Blank 2.41 1.26 2.53 Blank RBRVS

59320 Blank CERCLAGE CERVIX PREGNANCY VAGINAL Maternity - Non-Deliveries Blank 2.48 1.29 1.29 Blank RBRVS

59325 Blank CERCLAGE CERVIX PREGNANCY ABDOMINAL Maternity - Non-Deliveries Blank 4.06 1.90 1.90 Blank RBRVS

59350 Blank HYSTERORRHAPHY RUPTURED UTERUS Maternity - Non-Deliveries Blank 4.94 1.91 1.91 Blank RBRVS

59400 Blank OB CARE ANTEPARTUM VAG DLVR & POSTPARTUM Maternity - Normal Deliveries Blank 32.16 20.14 20.14 Blank RBRVS

59409 Blank VAGINAL DELIVERY ONLY Maternity - Normal Deliveries Blank 14.37 5.69 5.69 Blank RBRVS

59410 Blank VAGINAL DELIVERY ONLY W/POSTPARTUM CARE Maternity - Normal Deliveries Blank 18.01 7.63 7.63 Blank RBRVS

59412 Blank EXTERNAL CEPHALIC VERSION W/WO TOCOLYSIS Maternity - Normal Deliveries Blank 1.71 0.83 0.83 Blank RBRVS

59414 Blank DELIVERY PLACENTA SEPARATE PROCEDURE Maternity - Normal Deliveries Blank 1.61 0.63 0.63 Blank RBRVS

59425 Blank ANTEPARTUM CARE ONLY 4-6 VISITS Maternity - Normal Deliveries Blank 6.31 2.47 5.23 Blank RBRVS

59426 Blank ANTEPARTUM CARE ONLY 7/> VISITS Maternity - Normal Deliveries Blank 11.16 4.39 9.63 Blank RBRVS

59430 Blank POSTPARTUM CARE ONLY SEPARATE PROCEDURE Maternity - Normal Deliveries Blank 2.47 0.96 2.25 Blank RBRVS

59510 Blank OB ANTEPARTUM CARE CESAREAN DLVR & POSTPARTUM Maternity - Cesarean Deliveries Blank 35.64 21.83 21.83 Blank RBRVS

59514 Blank CESAREAN DELIVERY ONLY Maternity - Cesarean Deliveries Blank 16.13 6.32 6.32 Blank RBRVS

59515 Blank CESAREAN DELIVERY ONLY W/POSTPARTUM CARE Maternity - Cesarean Deliveries Blank 21.47 9.47 9.47 Blank RBRVS

59525 Blank STOT/TOT HYSTERECTOMY AFTER CESAREAN DELIVERY Surgery Blank 8.53 3.30 3.30 Blank RBRVS

59610 Blank ROUTINE OB CARE VAG DLVRY & POSTPARTUM CARE VB Maternity - Normal Deliveries Blank 33.87 20.60 20.60 Blank RBRVS

59612 Blank VAGINAL DELIVERY AFTER CESAREAN DELIVERY Maternity - Normal Deliveries Blank 16.09 6.22 6.22 Blank RBRVS

59614 Blank VAGINAL DELIVERY & POSTPARTUM CARE VBAC Maternity - Normal Deliveries Blank 19.73 8.08 8.08 Blank RBRVS

59618 Blank ROUTINE OBSTETRICAL CARE ATTEMPTED VBAC Maternity - Cesarean Deliveries Blank 36.16 21.97 21.97 Blank RBRVS

59620 Blank CESAREAN DELIVERY ATTEMPTED VBAC Maternity - Cesarean Deliveries Blank 16.66 6.43 6.43 Blank RBRVS

59622 Blank CESAREAN DLVRY & POSTPARTUM CARE ATTEMPTED VBA Maternity - Cesarean Deliveries Blank 22.00 9.69 9.69 Blank RBRVS

59812 Blank TX INCOMPLETE ABORTION ANY TRIMESTER SURGICAL Maternity - Non-Deliveries Blank 4.44 2.93 3.55 Blank RBRVS

59820 Blank TX MISSED ABORTION FIRST TRIMESTER SURGICAL Maternity - Non-Deliveries Blank 4.84 4.15 4.82 Blank RBRVS

59821 Blank TX MISSED ABORTION SECOND TRIMESTER SURGICAL Maternity - Non-Deliveries Blank 5.09 3.86 4.58 Blank RBRVS

59830 Blank TX SEPTIC ABORTION SURGICAL Maternity - Non-Deliveries Blank 6.59 4.26 4.26 Blank RBRVS

59840 Blank INDUCED ABORTION DILATION AND CURETTAGE Maternity - Non-Deliveries Blank 3.01 2.19 2.46 Blank RBRVS

59841 Blank INDUCED ABORTION DILATION & EVACUATION Maternity - Non-Deliveries Blank 5.65 3.31 3.94 Blank RBRVS

59850 Blank INDUCED ABORTION 1/> AMNIOTIC INJX W/D&C/EVACJ Maternity - Non-Deliveries Blank 5.90 3.51 3.51 Blank RBRVS

59851 Blank INDUCE ABORT 1/> AMNIOT NJXS DLVR FETUS D&C Maternity - Non-Deliveries Blank 5.92 4.01 4.01 Blank RBRVS

59852 Blank INDUCE ABORT 1/> AMNIOT NJXS DLVR FETUS HYSTOTM Maternity - Non-Deliveries Blank 8.23 5.73 5.73 Blank RBRVS

59855 Blank INDUCED ABORT 1/> VAG SUPPOSITORIES DLVR FETUS Maternity - Non-Deliveries Blank 6.43 3.86 3.86 Blank RBRVS

59856 Blank INDUCED ABORT 1/> VAG SUPP DLVR FETUS D&C &/EVAC Maternity - Non-Deliveries Blank 7.79 4.24 4.24 Blank RBRVS

59857 Blank INDUCED ABORT 1/> VAG SUPPOS DLVR FETUS HYSTOT Maternity - Non-Deliveries Blank 9.33 4.93 4.93 Blank RBRVS

59866 Blank MULTIFETAL PREGNANCY REDUCTION Maternity - Non-Deliveries Blank 3.99 1.97 1.97 Blank RBRVS

59870 Blank UTERINE EVACUATION & CURETTAGE HYDATIDIFORM MOLE Maternity - Non-Deliveries Blank 6.57 5.29 5.29 Blank RBRVS

59871 Blank REMOVAL CERCLAGE SUTURE UNDER ANESTHESIA Maternity - Non-Deliveries Blank 2.13 1.18 1.18 Blank RBRVS

59897 Blank UNLISTED FETAL INVASIVE PX W/ULTRASOUND Maternity - Non-Deliveries Blank Blank Blank Blank 1.25 Unlisted

59898 Blank UNLISTED LAPAROSCOPY PX MATERNITY CARE&DELIVERY Maternity - Non-Deliveries Blank Blank Blank Blank 18.43 Unlisted

59899 Blank UNLISTED PROCEDURE MATERNITY CARE & DELIVERY Maternity - Non-Deliveries Blank Blank Blank Blank 1.45 Unlisted

60000 Blank I&D THYROGLOSSAL DUCT CYST INFECTED Surgery Blank 1.81 2.25 2.74 Blank RBRVS

60100 Blank BIOPSY THYROID PERCUTANEOUS CORE NEEDLE Surgery Blank 1.56 0.56 1.50 Blank RBRVS

60200 Blank EXC CYST/ADENOMA THYROID/TRANSECTION ISTHMUS Surgery Blank 10.02 6.98 6.98 Blank RBRVS

60210 Blank PRTL THYROID LOBECTOMY UNI W/WO ISTHMUSECTOMY Surgery Blank 11.23 6.84 6.84 Blank RBRVS

60212 Blank PRTL THYROID LOBEC UNI W/CONTRATLAT STOT LOBEC Surgery Blank 16.43 9.33 9.33 Blank RBRVS

60220 Blank TOTAL THYROID LOBECTOMY UNI W/WO ISTHMUSECTOMY Surgery Blank 11.19 6.96 6.96 Blank RBRVS

60225 Blank TOTAL THYROID LOBEC UNI W/CONTRALAT STOT LOBEC Surgery Blank 14.79 9.06 9.06 Blank RBRVS

60240 Blank THYROIDECTOMY TOTAL/COMPLETE Surgery Blank 15.04 8.38 8.38 Blank RBRVS

60252 Blank THYROIDECTOMY TOTAL/SUBTOTAL LMTD NECK DISSECT Surgery Blank 22.01 11.61 11.61 Blank RBRVS

60254 Blank THYROIDECTOMY TOTAL/SUBTOTAL RAD NECK DISSECT Surgery Blank 28.42 14.27 14.27 Blank RBRVS

60260 Blank THYROIDECTOMY RMVL REMAINING TISS FLWG PRTL RMVL Surgery Blank 18.26 9.67 9.67 Blank RBRVS

60270 Blank THYROIDECT W/SUBSTERNAL SPLIT/TRANSTHORACIC Surgery Blank 23.20 11.54 11.54 Blank RBRVS

60271 Blank THYROIDECTOMY SUBSTERNAL CERVICAL APPROACH Surgery Blank 17.62 9.39 9.39 Blank RBRVS

60280 Blank EXCISION THYROGLOSSAL DUCT CYST/SINUS Surgery Blank 6.16 5.44 5.44 Blank RBRVS

60281 Blank EXCISION THYROGLOSSAL DUCT CYST/SINUS RECURRENT Surgery Blank 8.82 6.54 6.54 Blank RBRVS

60300 Blank ASPIRATION AND/OR INJECTION THYROID CYST Surgery Blank 0.97 0.36 2.28 Blank RBRVS

60500 Blank PARATHYROIDECTOMY/EXPLORATION PARATHYROIDS Surgery Blank 15.60 8.94 8.94 Blank RBRVS

60502 Blank PARATHYROIDECTOMY/EXPLOR PARATHYROIDS RE-EXPLOR Surgery Blank 21.15 11.48 11.48 Blank RBRVS

60505 Blank PARATHYRDEC/EXPL PARATHYR MEDSTNL STERNAL/TTHRC Surgery Blank 23.06 12.27 12.27 Blank RBRVS

60512 Blank PARATHYROID AUTOTRANSPLANTATION ADD-ON Surgery Blank 4.44 1.67 1.67 Blank RBRVS

60520 Blank THYMECTOMY PRTL/TOT TRANSCERVICAL APPR SPX Surgery Blank 17.16 9.12 9.12 Blank RBRVS

60521 Blank THYMECTOMY PRTL/TOT W/O RAD MEDSTNL DSJ SPX Surgery Blank 19.18 8.86 8.86 Blank RBRVS

60522 Blank THYMECTOMY PRTL/TOT RAD MEDSTNL DSJ SPX Surgery Blank 23.48 10.65 10.65 Blank RBRVS

60540 Blank ADRENALECTOMY W/EXPL W/WO BX ABDL/LMBR/DRSAL SPX Surgery Blank 18.02 9.29 9.29 Blank RBRVS

60545 Blank ADRENALECTOMY EXPL W/EXC RETROPERTINEAL TUMOR Surgery Blank 20.93 10.17 10.17 Blank RBRVS

60600 Blank EXC CAROTID BODY TUMOR W/O EXC CAROTID ARTERY Surgery Blank 25.09 9.45 9.45 Blank RBRVS





PAGE 69 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

60605 Blank EXC CAROTID BODY TUMOR W EXC CAROTID ARTERY Surgery Blank 31.96 9.01 9.01 Blank RBRVS

60650 Blank LAPAROSCOPY ADRENALECTOMY PRTL/COMPL TABDL Surgery Blank 20.73 9.72 9.72 Blank RBRVS

60659 Blank UNLISTED LAPAROSCOPY PROCEDURE ENDOCRINE SYSTEM Surgery Blank Blank Blank Blank 30.45 Unlisted

60699 Blank UNLISTED PROCEDURE ENDOCRINE SYSTEM Surgery Blank Blank Blank Blank 17.00 Unlisted

61000 Blank SUBDURAL TAP FONTANELLE/SUTUR INFANT UNI/BI INIT Surgery Blank 1.58 1.11 1.11 Blank RBRVS

61001 Blank SUBDURAL TAP FONTANELLE/SUTUR INFANT UNI/BI SBSQ Surgery Blank 1.49 1.07 1.07 Blank RBRVS

61020 Blank VENTRICULAR PUNCTURE PREVIOUS BURR HOLE W/O NJX Surgery Blank 1.51 1.01 1.01 Blank RBRVS

61026 Blank VENTRICULAR PUNCTURE PREVIOUS BURR HOLE W/INJ Surgery Blank 1.69 1.03 1.03 Blank RBRVS

61050 Blank CISTERNAL/LATERAL C1-C2 PUNCTURE W/O INJ SPX Surgery Blank 1.51 0.81 0.81 Blank RBRVS

61055 Blank CISTERNAL/LATERAL C1-C2 PUNCTURE W/INJECTION Surgery Blank 2.10 1.07 1.07 Blank RBRVS

61070 Blank PUNCTURE SHUNT TUBE/RESERVOIR ASPIRATION/INJ PX Surgery Blank 0.89 0.61 0.61 Blank RBRVS

61105 Blank TWIST DRILL HOLE SUBDURAL/VENTRICULAR PUNCTURE Surgery Blank 5.45 5.86 5.86 Blank RBRVS

61107 Blank TWIST DRILL HOLE IMPLT VENTRICULAR CATH/DEVICE Surgery Blank 4.99 2.29 2.29 Blank RBRVS

61108 Blank TWIST DRILL HOLE EVAC&/DRG SUBDURAL HEMATOMA Surgery Blank 11.64 10.17 10.17 Blank RBRVS

61120 Blank BURR HOLE VENTRICULAR PUNCTURE Surgery Blank 9.60 8.33 8.33 Blank RBRVS

61140 Blank BURR HOLE/TREPHINE W/BX BRAIN/INTRACRNIAL LESION Surgery Blank 17.23 12.85 12.85 Blank RBRVS

61150 Blank BURR HOLE/TREPHINE W/DRG BRAIN ABSCESS/CYST Surgery Blank 18.90 13.11 13.11 Blank RBRVS

61151 Blank BURR HOLE/TREPHINE W/SBSQ TAPPING ICRA ABSC/CST Surgery Blank 13.49 10.13 10.13 Blank RBRVS

61154 Blank BURR HOLE W/EVAC&/DRG HEMATOMA XDRL/SDRL Surgery Blank 17.07 13.26 13.26 Blank RBRVS

61156 Blank BURR HOLE W/ASPIR HEMATOMA/CYST INTRACEREBRAL Surgery Blank 17.45 11.95 11.95 Blank RBRVS

61210 Blank BURR HOLE IMPLANT VENTRICULAR CATH/OTHER DEVICE Surgery Blank 5.83 2.68 2.68 Blank RBRVS

61215 Blank INSJ SUBQ RSVR PUMP/INFUSION SYSTEM VENTRIC CATH Surgery Blank 5.85 6.56 6.56 Blank RBRVS

61250 Blank BURR HOLE/TREPHINE SUPRATENTORIAL W/O OTH SURG Surgery Blank 11.49 9.20 9.20 Blank RBRVS

61253 Blank BURR HOLE/TREPHINE INFRATENTORIAL UNI/BI Surgery Blank 13.49 10.13 10.13 Blank RBRVS

61304 Blank CRANIECTOMY/CRANIOTOMY EXPL SUPRATENTORIAL Surgery Blank 23.41 15.36 15.36 Blank RBRVS

61305 Blank CRANIECTOMY/CRANIOTOMY EXPL INFRATENTORIAL Surgery Blank 28.64 18.63 18.63 Blank RBRVS

61312 Blank CRANIECTOMY HMTMA SUPRATENTORIAL EXTRA/SUBDURAL Surgery Blank 30.17 18.71 18.71 Blank RBRVS

61313 Blank CRANIECTOMY HMTMA SUPRATENTORIAL INTRACEREBRAL Surgery Blank 28.09 18.77 18.77 Blank RBRVS

61314 Blank CRANIECTOMY HMTMA INFRATENTORIAL EXTRA/SUBDURAL Surgery Blank 25.90 17.33 17.33 Blank RBRVS

61315 Blank CRANIECTOMY HMTMA SUPRATENTORIAL INTRACEREBRAL Surgery Blank 29.65 19.02 19.02 Blank RBRVS

61316 Blank INCISION & SUBCUTANEOUS PLMT CRANIAL BONE GRAF Surgery Blank 1.39 0.64 0.64 Blank RBRVS

61320 Blank CRANIECTOMY/CRANIOTMY DRG ABSCESS SUPRATENTORIAL Surgery Blank 27.42 17.42 17.42 Blank RBRVS

61321 Blank CRANIECTOMY/CRANIOTMY DRG ABSCESS INFRATENTORIAL Surgery Blank 30.53 19.49 19.49 Blank RBRVS

61322 Blank CRANIECT/CRANIOT W/WO DURAPLASTY W/O LOBECTOMY Surgery Blank 34.26 21.57 21.57 Blank RBRVS

61323 Blank CRANIECT/CRANIOT W/WO DURAPLASTY W/LOBECTOMY Surgery Blank 35.06 21.00 21.00 Blank RBRVS

61330 Blank DECOMPRESSION ORBIT ONLY TRANSCRANIAL APPROACH Surgery Blank 25.30 17.02 17.02 Blank RBRVS

61333 Blank EXPL ORBIT TRANSCRANIAL APPROACH W/RMVL LESION Surgery Blank 29.27 18.28 18.28 Blank RBRVS

61340 Blank SUBTEMPORAL CRANIAL DECOMPRESSION Surgery Blank 20.11 14.06 14.06 Blank RBRVS

61343 Blank CRNEC SUBOCCIPITAL CRV LAM DCMPRN MEDULLA & CORD Surgery Blank 31.86 19.87 19.87 Blank RBRVS

61345 Blank OTHER CRANIAL DECOMPRESSION POSTERIOR FOSSA Surgery Blank 29.23 18.70 18.70 Blank RBRVS

61450 Blank CRNEC STPL SCTJ COMPRESSION/DCMPRN GANGLION Surgery Blank 27.69 17.44 17.44 Blank RBRVS

61458 Blank CRNEC SOPL EXPL/DCMPRN CRNL NRV Surgery Blank 28.84 18.47 18.47 Blank RBRVS

61460 Blank CRANIECTOMY SUBOCCIPITAL SECTION 1/> CRANIAL NR Surgery Blank 30.24 19.16 19.16 Blank RBRVS

61500 Blank CRANIECTOMY W/EXCISION TUMOR/LESION SKULL Surgery Blank 19.18 13.14 13.14 Blank RBRVS

61501 Blank CRANIECTOMY OSTEOMYELITIS Surgery Blank 16.35 11.95 11.95 Blank RBRVS

61510 Blank CRANIEC TREPHINE BONE FLP BRAIN TUMOR SUPRTENTOR Surgery Blank 30.83 20.81 20.81 Blank RBRVS

61512 Blank CRNEC TREPHINE BONE FLAP MENINGIOMA SUPRATENTOR Surgery Blank 37.14 22.73 22.73 Blank RBRVS

61514 Blank CRNEC TREPHINE BONE FLAP BRAIN ABSC SUPRATENTOR Surgery Blank 27.23 17.63 17.63 Blank RBRVS

61516 Blank CRNEC TREPHINE BONE FLAP FENEST CYST SUPRATENTOR Surgery Blank 26.58 17.47 17.47 Blank RBRVS

61517 Blank IMPLTJ BRAIN INTRACAVITARY CHEMOTHERAPY AGENT Surgery Blank 1.38 0.64 0.64 Blank RBRVS

61518 Blank CRNEC EXC BRAIN TUMOR INFRATENTORIAL/POST FOSSA Surgery Blank 39.89 24.96 24.96 Blank RBRVS

61519 Blank CRNEC EXC TUM INFRATENTOR/POST FOSSA MENINGIOMA Surgery Blank 43.43 25.56 25.56 Blank RBRVS

61520 Blank CRNEC TUM INFRATTL/POSTFOSSA CRBLOPNT ANGLE TUM Surgery Blank 57.09 31.86 31.86 Blank RBRVS

61521 Blank CRNEC TUM INFRATTL/PFOSSA MIDLINE TUM BASE SKULL Surgery Blank 46.99 27.35 27.35 Blank RBRVS

61522 Blank CRNEC INFRATNTORIAL/POST FOSSA EXC BRAIN ABSCESS Surgery Blank 31.54 19.76 19.76 Blank RBRVS

61524 Blank CRNEC INFRATNTOR/POSTFOSSA EXC/FENESTRATION CYST Surgery Blank 29.89 18.99 18.99 Blank RBRVS

61526 Blank CRNEC TRANSTEMPOR EXC CEREBELLOPONTINE ANGLE TUM Surgery Blank 54.08 28.10 28.10 Blank RBRVS

61530 Blank CRNEC EXC CEREBELLOPNTIN ANGLE TUM MID/POSTFOSSA Surgery Blank 45.56 26.22 26.22 Blank RBRVS

61531 Blank SUBDURAL IMPLTJ ELECTRODES SEIZURE MONITORING Surgery Blank 16.41 12.68 12.68 Blank RBRVS

61533 Blank CRANIOT SUBDURAL IMPLT ELCTRD SEIZURE MONITORING Surgery Blank 21.46 14.52 14.52 Blank RBRVS

61534 Blank CRANIOT EPILEPTOGENIC FOC W/O ELECTRCORTICOGRPHY Surgery Blank 23.01 15.83 15.83 Blank RBRVS

61535 Blank CRANIOT RMVL EPID/SUBDURL ELCTRD W/O EXC TIS SPX Surgery Blank 13.15 10.73 10.73 Blank RBRVS

61536 Blank CRANIOT EPILEPTOGENIC FOCUS W/ELECTROCORTCOGRPHY Surgery Blank 37.72 22.61 22.61 Blank RBRVS

61537 Blank CRANIOT TEMPORAL LOBE W/O ELECTROCORTICOGRAPHY Surgery Blank 36.45 21.23 21.23 Blank RBRVS

61538 Blank CRANIOT LOBEC TEMPORAL LOBE W/ELECTROCORTCOGRPHY Surgery Blank 39.45 22.86 22.86 Blank RBRVS

61539 Blank CRANIOT LOBECTOMY OTH/THN TEMPORAL LOBE W/ECOG Surgery Blank 34.28 21.02 21.02 Blank RBRVS

61540 Blank CRANIOT LOBECTOMY OTH/THN TEMPORAL LOBE W/O ECOG Surgery Blank 31.43 19.79 19.79 Blank RBRVS

61541 Blank CRANIOTOMY TRANSECTION CORPUS CALLOSUM Surgery Blank 30.94 19.48 19.48 Blank RBRVS

61543 Blank CRANIOTOMY PARTIAL/SUBTOTAL HEMISPHERECTOMY Surgery Blank 31.31 19.65 19.65 Blank RBRVS

61544 Blank CRANIOTOMY EXCISION/COAGULATION CHOROID PLEXUS Surgery Blank 27.36 17.29 17.29 Blank RBRVS

61545 Blank CRANIOTOMY EXCISION CRANIOPHARYNGIOMA Surgery Blank 46.43 28.11 28.11 Blank RBRVS

61546 Blank CRANIOT HYPOPHYSEC/EXC PITUITARY TUMOR ICRL APPR Surgery Blank 33.44 20.63 20.63 Blank RBRVS





PAGE 70 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

61548 Blank HYPOPHYSEC/EXC PITUITARY TUM TRANSNASAL/SEPTAL Surgery Blank 23.37 14.41 14.41 Blank RBRVS

61550 Blank CRANIECTOMY CRANIOSYNOSTOSIS 1 CRANIAL SUTURE Surgery Blank 15.59 12.72 12.72 Blank RBRVS

61552 Blank CRANIECT CRANIOSYNOSTOSIS MULT CRANIAL SUTURES Surgery Blank 20.40 14.63 14.63 Blank RBRVS

61556 Blank CRANIEC CRANIOSYNOSTOSIS FRONT/PARIET BONE FLAP Surgery Blank 24.09 16.04 16.04 Blank RBRVS

61557 Blank CRANIECTOMY CRANIOSYNOSTOSIS BIFRONTAL BONE FLAP Surgery Blank 23.31 16.43 16.43 Blank RBRVS

61558 Blank XTN CRANIECT MULTIPLE SUTURE CRANIOSYNOSTOSIS Surgery Blank 26.50 17.75 17.75 Blank RBRVS

61559 Blank XTN CRNEC MLT SUTR CRANIOSYNOSTOSIS W/BONE GRAFT Surgery Blank 34.02 22.23 22.23 Blank RBRVS

61563 Blank EXC BENIGN TUM CRANIAL BONE W/O OPTIC NRV DCMPRN Surgery Blank 28.44 18.04 18.04 Blank RBRVS

61564 Blank EXC BENIGN TUM CRANIAL BONE W/OPTIC NRV DCMPRN Surgery Blank 34.74 21.71 21.71 Blank RBRVS

61566 Blank CRANIOTOMY SELECTIVE AMYGDALOHIPPOCAMPECTOMY Surgery Blank 32.45 20.27 20.27 Blank RBRVS

61567 Blank CRANIOTOMY MULTIPLE SUBPIAL TRANSECTIONS W/ECOG Surgery Blank 37.00 23.10 23.10 Blank RBRVS

61570 Blank CRANIECTOMY/CRANIOTOMY EXC FOREIGN BODY BRAIN Surgery Blank 26.51 17.44 17.44 Blank RBRVS

61571 Blank CRANIECTOMY/CRANIOTOMY TX PENETRATNG WOUND BRAIN Surgery Blank 28.42 18.32 18.32 Blank RBRVS

61575 Blank TRNSRAL SKULL BSE/BR STEM/CORD BX/DCOMPR/EXC LES Surgery Blank 36.56 22.07 22.07 Blank RBRVS

61576 Blank TRNSRL SKUL BSE/BR STM/CORD BX/DCMP/ SPLT TONGUE Surgery Blank 55.31 45.20 45.20 Blank RBRVS

61580 Blank CRANIOFACIAL ANT CRANIAL FOSSA W/O ORBITAL EXNTJ Surgery Blank 34.51 28.24 28.24 Blank RBRVS

61581 Blank CRANIOFACIAL ANT CRANIAL FOSSA W/ORBITAL EXNTJ Surgery Blank 39.13 30.20 30.20 Blank RBRVS

61582 Blank CRANFCL ANT CRANIAL FOSSA UNI/BI CRANIOT/OSTEOT Surgery Blank 35.14 38.29 38.29 Blank RBRVS

61583 Blank CRANFCL ANT CRANIAL FOSSA UNI/BIFRNTL ELEV LOBE Surgery Blank 38.50 30.49 30.49 Blank RBRVS

61584 Blank ORBITOCRANIAL ANT CRANIAL FOSSA W/O ORBIT EXNTJ Surgery Blank 37.70 30.86 30.86 Blank RBRVS

61585 Blank ORBITOCRANIAL ANT CRANIAL FOSSA W/ORBITAL EXNTJ Surgery Blank 42.57 34.14 34.14 Blank RBRVS

61586 Blank BICORONAL TRANSZYGMTC&/LEFORT I W/O BONE GRFT Surgery Blank 27.48 31.76 31.76 Blank RBRVS

61590 Blank INFRATEMPORAL MID CRANIAL FOSSA W/WO DISARTICLTN Surgery Blank 47.04 31.08 31.08 Blank RBRVS

61591 Blank INFRATEMPO MID CRANIAL FOSSA W/WO DCOMPR&/MOBI Surgery Blank 47.02 31.04 31.04 Blank RBRVS

61592 Blank ORBITOCRNL APPR MID CRANIAL FOSSA TEMPORAL LOBE Surgery Blank 43.08 32.88 32.88 Blank RBRVS

61595 Blank TRANSTEMP APPR POST CRAN FOSSA DCOMPR SINUS/NRV Surgery Blank 33.74 25.59 25.59 Blank RBRVS

61596 Blank TRANSCOCHLR POST CRNL FOSSA W/WO MOBIL NRV/ART Surgery Blank 39.43 24.38 24.38 Blank RBRVS

61597 Blank TRNSCONDLR POST CRNL FOSSA DCOMPR ART W/WO MOBIL Surgery Blank 40.82 29.46 29.46 Blank RBRVS

61598 Blank TRANSPTRSAL POST CRNL FOSSA CLIVUS/FORAMN MAGNUM Surgery Blank 36.53 31.49 31.49 Blank RBRVS

61600 Blank RESCJ/EXC LES BASE ANT CRANIAL FOSSA EXTRADURAL Surgery Blank 30.01 24.48 24.48 Blank RBRVS

61601 Blank RESCJ/EXC LES BASE ANT CRNL FOSSA INDRL W/WO GRF Surgery Blank 31.14 26.96 26.96 Blank RBRVS

61605 Blank RESCJ/EXC LES INFRATEMPOR FOSSA SPACE APEX XDRL Surgery Blank 32.57 23.78 23.78 Blank RBRVS

61606 Blank RESCJ/EXC LES ITPRL FOSSA SPACE APEX IDRL W/RPR Surgery Blank 42.05 29.05 29.05 Blank RBRVS

61607 Blank RESCJ/EXC LES PARASELLAR SINUS CLIVUS/MSB XDRL Surgery Blank 40.93 26.13 26.13 Blank RBRVS

61608 Blank RESCJ/EXC LES PARASELLAR SINUS CLIVUS/MSB IDRL Surgery Blank 45.54 31.86 31.86 Blank RBRVS

61611 Blank TRNSXJ/LIG CAROTID ARTERY PETROUS CANAL W/O RPR Surgery Blank 7.41 3.42 3.42 Blank RBRVS

61613 Blank OBLTRJ CAROTID ARYSM ARTVEN CAROTID FISTULA DSJ Surgery Blank 45.03 32.78 32.78 Blank RBRVS

61615 Blank RESCJ/EXC LES BASE POST CRNL FOSSA JUG FRMN XDRL Surgery Blank 35.77 31.41 31.41 Blank RBRVS

61616 Blank RESCJ/EXC LES BASE PCF FORAMEN VRT BODIES IDRL Surgery Blank 46.74 33.60 33.60 Blank RBRVS

61618 Blank SECONDARY RPR DURA CSF LEAK FREE TISSUE GRAFT Surgery Blank 18.69 12.66 12.66 Blank RBRVS

61619 Blank SEC RPR DURA CSF LEAK LOCAL/REGIONALIZED FLAP Surgery Blank 22.10 13.38 13.38 Blank RBRVS

61623 Blank EVASC TEMP BALLOON ARTL OCCLUSION HEAD/NECK Surgery Blank 9.95 4.07 4.07 Blank RBRVS

61624 Blank TCAT PERMANENT OCCLUSION/EMBOLIZATION PRQ CNS Surgery Blank 20.12 7.97 7.97 Blank RBRVS

61626 Blank TCAT PERMANT OCCLUSION/EMBOLIZATION PRQ NON-CNS Surgery Blank 16.60 5.82 5.82 Blank RBRVS

61630 Blank BALLOON ANGIOPLASTY INTRACRANIAL PERCUTANEOUS Surgery Blank 22.07 11.39 11.39 Blank RBRVS

61635 Blank TCAT PLMT IV STENT ICRA W/BALO ANGIOP IF PFRMD Surgery Blank 24.28 11.85 11.85 Blank RBRVS

61640 Blank BALLOON DILAT INTRACRANIAL VASOSPASM PRQ INITIAL Surgery Blank 12.32 Blank Blank Blank RBRVS

61641 Blank BALLOON DILAT INCRNL VASOSPSM PRQ EA VESSEL Surgery Blank 4.33 Blank Blank Blank RBRVS

61642 Blank BALLOON DILAT INCRNL VASOSPSM PRQ EA VESSEL Surgery Blank 8.66 Blank Blank Blank RBRVS

61645 Blank PERQ ART TRLUML M-THROMBEC &/NFS INTRACRANIAL Surgery Blank 15.00 5.57 5.57 Blank RBRVS

61650 Blank EVASC INTRACRANIAL PROLNG ADMN RX AGENT ART 1ST Surgery Blank 10.00 3.32 3.32 Blank RBRVS

61651 Blank EVASC INTRACRANIAL PROLNG ADMN RX AGENT ART ADDL Surgery Blank 4.25 1.38 1.38 Blank RBRVS

61680 Blank INTRACRANIAL ARVEN MALFRMJ SUPRATENTRL SMPL Surgery Blank 32.55 20.37 20.37 Blank RBRVS

61682 Blank INTRACRANIAL ARVEN MALFRMJ SUPRATENTRL CMPL Surgery Blank 63.41 33.77 33.77 Blank RBRVS

61684 Blank INTRACRANIAL ARVEN MALFRMJ INFRATENTRL SMPL Surgery Blank 41.64 24.88 24.88 Blank RBRVS

61686 Blank INTRACRANIAL ARVEN MALFRMJ INFRATENTRL CMPL Surgery Blank 67.50 37.24 37.24 Blank RBRVS

61690 Blank INTRACRANIAL ARVEN MALFRMJ DURAL SMPL Surgery Blank 31.34 20.01 20.01 Blank RBRVS

61692 Blank INTRACRANIAL ARVEN MALFRMJ DURAL CMPL Surgery Blank 54.59 30.72 30.72 Blank RBRVS

61697 Blank COMPLX INTRACRANIAL ARYSM CAROTID CIRCULATION Surgery Blank 63.40 35.13 35.13 Blank RBRVS

61698 Blank CPLX INTRACRANIAL ARYSM VERTEBROBASILAR CRCJ Surgery Blank 69.63 38.23 38.23 Blank RBRVS

61700 Blank SIMPLE INTRACRANIAL ARYSM CAROTID CIRCULATION Surgery Blank 50.62 29.24 29.24 Blank RBRVS

61702 Blank SIMPLE INTRACRANIAL ARYSM VERTEBROBASILAR CRCJ Surgery Blank 60.04 33.81 33.81 Blank RBRVS

61703 Blank ICRA CRV APPL OCCLUDING CLAMP CRV CRTD ART Surgery Blank 18.80 13.34 13.34 Blank RBRVS

61705 Blank ARYSM VASC MALFRMJ/CRTD-OCCLUSION CRTD ART Surgery Blank 38.10 22.79 22.79 Blank RBRVS

61708 Blank ARYSM VASC MALFRMJ/ICRA ELECTROTHROMBOSIS Surgery Blank 37.20 22.37 22.37 Blank RBRVS

61710 Blank ARYSM VASC MALFRMJ IA EMBOLIZATION Surgery Blank 31.29 18.77 18.77 Blank RBRVS

61711 Blank ANAST ARTL EXTRACRANIAL-INTRACRANIAL ARTERIES Surgery Blank 38.23 22.54 22.54 Blank RBRVS

61720 Blank CRTJ LES STRTCTC BURR GLOBUS PALLIDUS/THALAMUS Surgery Blank 17.62 12.41 12.41 Blank RBRVS

61735 Blank CRTJ LES STRTCTC BURR SUBCORTICAL STRUX OTH/THN Surgery Blank 22.35 15.13 15.13 Blank RBRVS

61750 Blank STEREOTACTIC BX ASPIR/EXC BURR INTRACRANIAL LES Surgery Blank 19.83 13.41 13.41 Blank RBRVS

61751 Blank STRTCTC BX ASPIR/EXC BURR ICRA LESION W/CT&I/MR Surgery Blank 18.79 13.93 13.93 Blank RBRVS

61760 Blank STRTCTC IMPLTJ ELTRD CEREBRUM SEIZURE MONITORING Surgery Blank 22.39 14.68 14.68 Blank RBRVS





PAGE 71 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

61770 Blank STRTCTC LOCLZJ INSJ CATH/PRB PLMT RADJ SRC Surgery Blank 23.19 14.97 14.97 Blank RBRVS

61781 Blank STRTCTC CPTR ASSTD PX CRANIAL INTRADURAL Surgery Blank 3.75 1.72 1.72 Blank RBRVS

61782 Blank STRTCTC CPTR ASSTD PX EXTRADURAL CRANIAL Surgery Blank 3.18 1.34 1.34 Blank RBRVS

61783 Blank STEREOTACTIC COMPUTER ASSISTED PX SPINAL Surgery Blank 3.75 1.76 1.76 Blank RBRVS

61790 Blank CREATE LESION STRTCTC PRQ NEUROLYTIC GASSERIAN Surgery Blank 11.60 9.40 9.40 Blank RBRVS

61791 Blank CREATE LES STRTCTC PRQ NEUROLYTIC TRIGEMINAL TRC Surgery Blank 15.41 11.23 11.23 Blank RBRVS

61796 Blank STEREOTACTIC RADIOSURGERY 1 SIMPLE CRANIAL LES Surgery Blank 13.93 10.14 10.14 Blank RBRVS

61797 Blank STRTCTC RADIOSURGERY EA ADDL CRANIAL LES SIMPLE Surgery Blank 3.48 1.60 1.60 Blank RBRVS

61798 Blank STEREOTACTIC RADIOSURGERY 1 COMPLEX CRANIAL LES Surgery Blank 19.85 12.75 12.75 Blank RBRVS

61799 Blank STRTCTC RADIOSURGERY EA ADDL CRANIAL LES COMPLEX Surgery Blank 4.81 2.21 2.21 Blank RBRVS

61800 Blank APPL STRTCTC HEADFRAME STEREOTACTIC RADIOSURGERY Surgery Blank 2.25 1.37 1.37 Blank RBRVS

61850 Blank TWIST/BURR HOLE IMPLTJ NSTIM ELTRD CORTICAL Surgery Blank 13.34 9.97 9.97 Blank RBRVS

61860 Blank CRNEC/CRX IMPLTJ NSTIM ELTRD CERE CORTICAL Surgery Blank 22.26 14.55 14.55 Blank RBRVS

61863 Blank STRTCTC IMPLTJ NSTIM ELTRD W/O RECORD 1ST ARRAY Surgery Blank 20.71 14.87 14.87 Blank RBRVS

61864 Blank STRTCTC IMPLTJ NSTIM ELTRD W/O RECORD EA ARRAY Surgery Blank 4.49 2.07 2.07 Blank RBRVS

61867 Blank STRTCTC IMPLTJ NSTIM ELTRD W/RECORD 1ST ARRAY Surgery Blank 33.03 20.54 20.54 Blank RBRVS

61868 Blank STRTCTC IMPLTJ NSTIM ELTRD W/RECORD EA ARRAY Surgery Blank 7.91 3.64 3.64 Blank RBRVS

61870 Blank CRNEC IMPLTJ NSTIM ELTRD CEREBELLAR CORTICAL Surgery Blank 16.34 11.67 11.67 Blank RBRVS

61880 Blank REVJ/RMVL INTRACRANIAL NEUROSTIMULATOR ELTRDS Surgery Blank 6.95 6.90 6.90 Blank RBRVS

61885 Blank INSJ/RPLCMT CRANIAL NEUROSTIM PULSE GENERATOR Surgery Blank 6.05 6.65 6.65 Blank RBRVS

61886 Blank INSJ/RPLCMT CRANIAL NEUROSTIM GENER 2/> ELTRDS Surgery Blank 9.93 10.77 10.77 Blank RBRVS

61888 Blank REVJ/RMVL NEUROSTIMULATOR PULSE GENERATOR Surgery Blank 5.23 4.31 4.31 Blank RBRVS

62000 Blank ELEVATION DEPRESSED SKULL FX SIMPLE EXTRADURAL Surgery Blank 13.93 10.55 10.55 Blank RBRVS

62005 Blank ELVTN DEPRS SKL FX COMPOUND/COMMIND XDRL Surgery Blank 17.63 12.41 12.41 Blank RBRVS

62010 Blank ELVTN DEPRS SKL FX W/RPR DURA&/DBRDMT BRN Surgery Blank 21.43 14.72 14.72 Blank RBRVS

62100 Blank CRX RPR DURAL/CSF LEAK RHINORRHEA/OTORRHEA Surgery Blank 23.53 14.58 14.58 Blank RBRVS

62115 Blank RDCTJ CRANIOMEGALIC SKULL W/O GRAFT/CRANIOPLASTY Surgery Blank 22.91 16.72 16.72 Blank RBRVS

62117 Blank RDCTJ CRANIOMEGALIC CRANIO&RECNSTJ W/WO GRAFT Surgery Blank 28.35 17.66 17.66 Blank RBRVS

62120 Blank RPR ENCEPHALOCELE SKULL VAULT W/CRANIOPLASTY Surgery Blank 24.59 27.57 27.57 Blank RBRVS

62121 Blank CRANIOTOMY FOR ENCEPHALOCELE REPAIR SKULL BASE Surgery Blank 23.03 17.00 17.00 Blank RBRVS

62140 Blank CRANIOPLASTY SKULL DEFECT </5 CM DIAMETER Surgery Blank 14.55 10.32 10.32 Blank RBRVS

62141 Blank CRANIOPLASTY SKULL DEFECT >5 CM DIAMETER Surgery Blank 16.07 11.34 11.34 Blank RBRVS

62142 Blank RMVL BONE FLAP/PROSTHETIC PLATE SKULL Surgery Blank 11.83 9.51 9.51 Blank RBRVS

62143 Blank RPLCMT BONE FLAP/PROSTHETIC PLATE SKULL Surgery Blank 14.15 10.66 10.66 Blank RBRVS

62145 Blank CRANIOPLASTY SKULL DEFECT REPARATIVE BRAIN SURG Surgery Blank 20.09 13.41 13.41 Blank RBRVS

62146 Blank CRANIOPLASTY W/AUTOGRAFT </ 5 CM DIAMETER Surgery Blank 17.28 11.62 11.62 Blank RBRVS

62147 Blank CRANIOPLASTY W/AUTOGRAFT > 5 CM DIAMETER Surgery Blank 20.67 13.66 13.66 Blank RBRVS

62148 Blank INCISE&RETRIEVAL SUBQ CRANIOPLASTY BONE GRAFT Surgery Blank 2.00 0.92 0.92 Blank RBRVS

62160 Blank NUNDSC ICRA PLMT/RPLCMT VENTR CATH SHUNT SYS Surgery Blank 3.00 1.38 1.38 Blank RBRVS

62161 Blank NUNDSC ICRA DSJ ADS FENESTRATION SEPTUM CSTS Surgery Blank 21.23 14.52 14.52 Blank RBRVS

62162 Blank NUNDSC ICRA FENESTEXC CYST W/VENTRIC CATH DRG Surgery Blank 26.80 17.69 17.69 Blank RBRVS

62163 Blank NEUROENDOSCOPY ICRA W/RETRIEVAL FOREIGN BODY Surgery Blank 16.53 12.57 12.57 Blank RBRVS

62164 Blank NEUROENDOSCOPY ICRA W/RETRIEVAL FOREIGN BODY Surgery Blank 29.43 19.82 19.82 Blank RBRVS

62165 Blank NUNDSC ICRA EXC PITUITRY TUM TRNSNSL/SPHENOID Surgery Blank 23.23 14.31 14.31 Blank RBRVS

62180 Blank VENTRICULOCISTERNOSTOMY Surgery Blank 22.58 15.13 15.13 Blank RBRVS

62190 Blank CRTJ SHUNT SARACH/SDRL-ATR-JUG-AUR Surgery Blank 12.17 9.89 9.89 Blank RBRVS

62192 Blank CRTJ SHUNT SARACH/SDRL-PRTL-PLEURAL OTH Surgery Blank 13.35 10.10 10.10 Blank RBRVS

62194 Blank RPLCMT/IRRG SUBARACHNOID/SUBDURAL CATHETER Surgery Blank 5.78 6.06 6.06 Blank RBRVS

62200 Blank VENTRICULOCISTERNOSTOMY 3RD VENTRICLE Surgery Blank 19.29 13.18 13.18 Blank RBRVS

62201 Blank VENTRICULOCISTERNOSTOMY 3RD VNTRC NEURONDSC Surgery Blank 16.04 12.62 12.62 Blank RBRVS

62220 Blank CRTJ SHUNT VENTRICULO-ATR-JUG-AUR Surgery Blank 14.10 10.09 10.09 Blank RBRVS

62223 Blank CRTJ SHUNT VENTRICULO-PERITNEAL-PLEURAL TERMINUS Surgery Blank 14.05 11.10 11.10 Blank RBRVS

62225 Blank RPLCMT/IRRIGATION VENTRICULAR CATHETER Surgery Blank 6.19 6.53 6.53 Blank RBRVS

62230 Blank RPLCMT/REVJ CSF SHUNT VALVE/CATH SHUNT SYS Surgery Blank 11.43 8.71 8.71 Blank RBRVS

62252 Blank REPRGRMG PROGRAMMABLE CEREBROSPINAL SHUNT Surgery a 0.74 1.41 1.41 Blank RBRVS

62252 26 REPRGRMG PROGRAMMABLE CEREBROSPINAL SHUNT Surgery Blank 0.74 0.34 0.34 Blank RBRVS

62252 TC REPRGRMG PROGRAMMABLE CEREBROSPINAL SHUNT Surgery a Blank 1.07 1.07 Blank RBRVS

62256 Blank RMVL COMPL CSF SHUNT SYSTEM W/O RPLCMT SHUNT Surgery Blank 7.38 7.15 7.15 Blank RBRVS

62258 Blank RMVL COMPLETE CSF SHUNT SYSTEM W/RPLCMT SHUNT Surgery Blank 15.64 11.01 11.01 Blank RBRVS

62263 Blank PRQ LYSIS EPIDURAL ADHESIONS MULT SESS 2/> DAYS Surgery Blank 5.00 3.75 11.61 Blank RBRVS

62264 Blank PRQ LYSIS EPIDURAL ADHESIONS MULT SESSIONS 1 DAY Surgery Blank 4.42 2.05 7.17 Blank RBRVS

62267 Blank PRQ ASPIR PULPOSUS/INTERVERTEBRAL DISC/PVRT TISS Surgery Blank 3.00 1.29 3.81 Blank RBRVS

62268 Blank PERCUTANEOUS ASPIRATION SPINAL CORD CYST/SYRINX Surgery Blank 4.73 2.21 2.21 Blank RBRVS

62269 Blank BIOPSY SPINAL CORD PERCUTANEOUS NEEDLE Surgery Blank 5.01 2.09 2.09 Blank RBRVS

62270 Blank SPINAL PUNCTURE LUMBAR DIAGNOSTIC Surgery Blank 1.37 0.69 2.95 Blank RBRVS

62272 Blank SPINAL PUNCTURE THER DRAIN CEREBROSPINAL FLUID Surgery Blank 1.35 0.77 4.14 Blank RBRVS

62273 Blank INJECTION EPIDURAL BLOOD/CLOT PATCH Surgery Blank 2.15 0.92 2.61 Blank RBRVS

62280 Blank INJX/INFUSION NEUROLYTIC SUBSTANCE SUBARACHNOID Surgery Blank 2.63 1.74 5.91 Blank RBRVS

62281 Blank INJX/INFUS NEUROLYT SUBST EPIDURAL CERV/THORACIC Surgery Blank 2.66 1.62 3.93 Blank RBRVS

62282 Blank INJX/INFUS NEUROLYT SBST EPIDURAL LUMBAR/SACRAL Surgery Blank 2.33 1.59 5.69 Blank RBRVS

62284 Blank INJECTION PROCEDURE MYELOGRAPHY/CT LUMBAR Surgery Blank 1.54 0.79 3.67 Blank RBRVS

62287 Blank DCMPRN PERQ NUCLEUS PULPOSUS 1/> LEVELS LUMBAR Surgery Blank 9.03 6.37 6.37 Blank RBRVS





PAGE 72 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

62290 Blank INJECTION PX DISCOGRAPHY EACH LEVEL LUMBAR Surgery Blank 3.00 1.61 6.02 Blank RBRVS

62291 Blank INJECTION PX DISCOGRPHY EA LVL CERVICAL/THORACIC Surgery Blank 2.91 1.66 6.06 Blank RBRVS

62292 Blank INJECTION PX DISCOGRPHY EA LVL CERVICAL/THORACIC Surgery Blank 9.24 6.55 6.55 Blank RBRVS

62294 Blank NJX ARTERIAL OCCLUSION ARVEN MALFRMJ SPINAL Surgery Blank 12.87 9.67 9.67 Blank RBRVS

62302 Blank MYELOGRAPHY VIA LUMBAR INJECTION RS&I CERVICAL Radiology Blank 2.29 1.03 4.41 Blank RBRVS

62303 Blank MYELOGRAPHY VIA LUMBAR INJECTION RS&I THORACIC Radiology Blank 2.29 1.04 4.58 Blank RBRVS

62304 Blank MYELOGRAPHY VIA LUMBAR INJECT RS&I LUMBOSACRAL Radiology Blank 2.25 1.01 4.37 Blank RBRVS

62305 Blank MYELOGRAPHY VIA LUMBAR INJECTION RS&I 2+ REGIONS Radiology Blank 2.35 1.05 4.86 Blank RBRVS

62320 Blank NJX INTERLAMINAR CRV/THRC Surgery Blank 1.80 0.92 2.78 Blank RBRVS


62322 Blank NJX INTERLAMINAR LMBR/SAC Surgery Blank 1.55 0.80 2.75 Blank RBRVS






62350 Blank IMPLTJ REVJ/RPSG ITHCL/EDRL CATH PMP W/O LAM Surgery Blank 6.05 4.33 4.33 Blank RBRVS

62351 Blank IMPLTJ REVJ/RPSG ITHCL/EDRL CATH W/LAM Surgery Blank 11.66 9.87 9.87 Blank RBRVS

62355 Blank RMVL PREVIOUSLY IMPLTED ITHCL/EDRL CATH Surgery Blank 3.55 3.44 3.44 Blank RBRVS

62360 Blank IMPLTJ/RPLCMT ITHCL/EDRL DRUG NFS SUBQ RSVR Surgery Blank 4.33 3.71 3.71 Blank RBRVS

62361 Blank IMPLTJ/RPLCMT FS NON-PRGRBL PUMP Surgery Blank 5.00 5.42 5.42 Blank RBRVS

62362 Blank IMPLTJ/RPLCMT ITHCL/EDRL DRUG NFS PRGRBL PUMP Surgery Blank 5.60 4.28 4.28 Blank RBRVS

62365 Blank RMVL SUBQ RSVR/PUMP INTRATHECAL/EPIDURAL INFUS Surgery Blank 3.93 3.71 3.71 Blank RBRVS

62367 Blank ELECT ANLYS IMPLT ITHCL/EDRL PMP W/O REPRG/REFIL Surgery Blank 0.48 0.20 0.68 Blank RBRVS

62368 Blank ELECT ANALYS IMPLT ITHCL/EDRL PUMP W/REPRGRMG Surgery Blank 0.67 0.27 0.89 Blank RBRVS

62369 Blank ELECT ANLYS IMPLT ITHCL/EDRL PMP W/REPRG&REFIL Surgery Blank 0.67 0.27 2.67 Blank RBRVS

62370 Blank ELEC ANLYS IMPLT ITHCL/EDRL PMP W/REPR PHYS/QHP Surgery Blank 0.90 0.36 2.62 Blank RBRVS

62380 Blank NDSC DCMPRN 1 NTRSPC LUMBAR Surgery Blank Blank Blank Blank 33.28 FAIR Health

63001 Blank LAM W/O FACETEC FORAMOT/DSKC 1/2 VRT SEG CRV Surgery Blank 17.61 12.26 12.26 Blank RBRVS

63003 Blank LAMINECTOMY W/O FFD 1/2 VERT SEG THORACIC Surgery Blank 17.74 12.30 12.30 Blank RBRVS

63005 Blank LAMINECTOMY W/O FFD 1/2 VERT SEG LUMBAR Surgery Blank 16.43 12.43 12.43 Blank RBRVS

63011 Blank LAMINECTOMY W/O FFD 1/2 VERT SEG SACRAL Surgery Blank 15.91 11.56 11.56 Blank RBRVS

63012 Blank LAMINECTOMY W/RMVL ABNORMAL FACETS LUMBAR Surgery Blank 16.85 12.34 12.34 Blank RBRVS

63015 Blank LAMINECTOMY W/O FFD > 2 VERT SEG CERVICAL Surgery Blank 20.85 14.78 14.78 Blank RBRVS

63016 Blank LAMINECTOMY W/O FFD > 2 VERT SEG THORACIC Surgery Blank 22.03 14.86 14.86 Blank RBRVS

63017 Blank LAMINECTOMY W/O FFD > 2 VERT SEG LUMBAR Surgery Blank 17.33 13.06 13.06 Blank RBRVS

63020 Blank LAMNOTMY INCL W/DCMPRSN NRV ROOT 1 INTRSPC CERVC Surgery Blank 16.20 12.37 12.37 Blank RBRVS

63030 Blank LAMNOTMY INCL W/DCMPRSN NRV ROOT 1 INTRSPC LUMBR Surgery Blank 13.18 10.95 10.95 Blank RBRVS

63035 Blank LAMNOTMY W/DCMPRSN NRV EACH ADDL CRVCL/LMBR Surgery Blank 3.15 1.51 1.51 Blank RBRVS

63040 Blank LAMOT PRTL FFD EXC DISC REEXPL 1 NTRSPC CERVICAL Surgery Blank 20.31 13.97 13.97 Blank RBRVS

63042 Blank LAMOT PRTL FFD EXC DISC REEXPL 1 NTRSPC LUMBAR Surgery Blank 18.76 13.55 13.55 Blank RBRVS

63043 Blank LAMOT PRTL FFD EXC DISC REEXPL 1 NTRSPC EA CRV Surgery Blank Blank Blank Blank 13.89 FAIR Health

63044 Blank LAMOT W/PRTL FFD HRNA8 REEXPL 1 NTRSPC EA LMBR Surgery Blank Blank Blank Blank 17.85 FAIR Health

63045 Blank LAM FACETECTOMY & FORAMOTOMY 1 SEGMENT CERVICAL Surgery Blank 17.95 13.35 13.35 Blank RBRVS

63046 Blank LAM FACETECTOMY & FORAMOTOMY 1 SEGMENT THORACIC Surgery Blank 17.25 12.90 12.90 Blank RBRVS

63047 Blank LAM FACETECTOMY & FORAMOTOMY 1 SEGMENT LUMBAR Surgery Blank 15.37 11.97 11.97 Blank RBRVS

63048 Blank LAM FACETECTOMY&FORAMTOMY 1 SGM EA CRV THRC/LMBR Surgery Blank 3.47 1.67 1.67 Blank RBRVS

63050 Blank LAMOP CERVICAL W/DCMPRN SPI CORD 2/> VERT SEG Surgery Blank 22.01 14.98 14.98 Blank RBRVS

63051 Blank LAMOPLASTY CERVICAL DCMPRN CORD 2/> SEG RCNSTJ Surgery Blank 25.51 16.67 16.67 Blank RBRVS

63055 Blank TRANSPEDICULAR DCMPRN SPINAL CORD 1 SEG THORACIC Surgery Blank 23.55 15.54 15.54 Blank RBRVS

63056 Blank TRANSPEDICULAR DCMPRN SPINAL CORD 1 SEG LUMBAR Surgery Blank 21.86 14.64 14.64 Blank RBRVS

63057 Blank TRANSPEDICULAR DCMPRN 1 SEG EA THORACIC/LUMBAR Surgery Blank 5.25 2.51 2.51 Blank RBRVS

63064 Blank COSTOVERTEBRAL DCMPRN SPINAL CORD THORACIC 1 SEG Surgery Blank 26.22 16.77 16.77 Blank RBRVS

63066 Blank COSTOVERTEBRAL DCMPRN SPINE CORD THORACIC EA SEG Surgery Blank 3.26 1.50 1.50 Blank RBRVS

63075 Blank DISCECTOMY ANT DCMPRN CORD CERVICAL 1 NTRSPC Surgery Blank 19.60 13.67 13.67 Blank RBRVS

63076 Blank DISCECTOMY ANT DCMPRN CORD CERVICAL EA NTRSPC Surgery Blank 4.04 1.93 1.93 Blank RBRVS

63077 Blank DISCECTOMY ANT DCMPRN CORD THORACIC 1 NTRSPC Surgery Blank 22.88 13.94 13.94 Blank RBRVS

63078 Blank DISCECTOMY ANT DCMPRN CORD THORACIC EA NTRSPC Surgery Blank 3.28 1.51 1.51 Blank RBRVS

63081 Blank VERTEBRAL CORPECTOMY ANT DCMPRN CERVICAL 1 SEG Surgery Blank 26.10 17.01 17.01 Blank RBRVS

63082 Blank VERTEBRAL CORPECTOMY DCMPRN CERVICAL EA SEG Surgery Blank 4.36 2.09 2.09 Blank RBRVS

63085 Blank VERTEBRAL CORPECTOMY DCMPRN CORD THORACIC 1 SEG Surgery Blank 29.47 17.36 17.36 Blank RBRVS

63086 Blank VERTEBRAL CORPECTOMY DCMPRN CORD THORACIC EA SEG Surgery Blank 3.19 1.45 1.45 Blank RBRVS

63087 Blank VCRPEC THORACOLMBR DCMPRN LWR THRC/LMBR 1 SEG Surgery Blank 37.53 21.66 21.66 Blank RBRVS

63088 Blank VCRPEC THORACOLMBR DCMPRN LWR THRC/LMBR EA SEG Surgery Blank 4.32 2.01 2.01 Blank RBRVS

63090 Blank VCRPEC TRANSPRTL/RPR DCMPRN THRC LMBR/SAC 1 SEG Surgery Blank 30.93 18.48 18.48 Blank RBRVS

63091 Blank VCRPEC TRANSPRTL/RPR DCMPRN THRC LMBR/SAC EA SEG Surgery Blank 3.03 1.42 1.42 Blank RBRVS

63101 Blank VERTEB CORPECT LAT XTRCAVITARY DCMPRN THRC 1 SEG Surgery Blank 34.10 22.09 22.09 Blank RBRVS

63102 Blank VERTEB CORPECT LAT XTRCAVITARY DCMPRN LMBR 1 SEG Surgery Blank 34.10 21.97 21.97 Blank RBRVS

63103 Blank VCRPEC LAT XTRCAVITARY DCMPRN THRC/LMBR EA SEG Surgery Blank 4.82 2.30 2.30 Blank RBRVS

63170 Blank LAM W/MYELOTOMY CERVICAL/THORACIC/THORACOLUMBAR Surgery Blank 22.21 15.41 15.41 Blank RBRVS

63172 Blank LAM W/DRG INTRMEDULLARY CYST/SYRINX SUBARACHNOID Surgery Blank 19.76 13.53 13.53 Blank RBRVS

63173 Blank LAM W/DRG INTRMEDULRY CYST/SYRINX PRTL/PLEURAL Surgery Blank 24.31 16.37 16.37 Blank RBRVS





PAGE 73 of 144

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HCPCS

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Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

63180 Blank LAM&SCTJ DENTATE LIG W/WO DURAL GRF CRV 1/2 SEG Surgery Blank 20.53 14.64 14.64 Blank RBRVS

63182 Blank LAM&SCTJ DENTATE LIG W/WO DURAL GRF CRV >2 SEG Surgery Blank 22.82 15.69 15.69 Blank RBRVS

63185 Blank LAMINECTOMY W/RHIZOTOMY 1/2 SEGMENTS Surgery Blank 16.49 11.99 11.99 Blank RBRVS

63190 Blank LAMINECTOMY W/RHIZOTOMY > 2 SEGMENTS Surgery Blank 18.89 13.40 13.40 Blank RBRVS

63191 Blank LAMINECTOMY W/SECTION SPINAL ACCESSORY NERVE Surgery Blank 18.92 13.73 13.73 Blank RBRVS

63194 Blank LAM CORDOTOMY SCTJ 1 SPINOTHALMIC TRACT CERVICAL Surgery Blank 22.10 15.70 15.70 Blank RBRVS

63195 Blank LAM CORDOTOMY SCTJ 1 SPINOTHALMIC TRACT THORACIC Surgery Blank 21.64 14.60 14.60 Blank RBRVS

63196 Blank LAM CORDOTOMY SCTJ BOTH SPINOTHALMIC TRACTS CRV Surgery Blank 25.27 16.66 16.66 Blank RBRVS

63197 Blank LAM CORDOTOMY SCTJ BOTH SPINOTHALMIC TRACT THRC Surgery Blank 24.08 16.27 16.27 Blank RBRVS

63198 Blank LAM CORDOTOMY SCTJ BOTH TRACTS 2 STAGES CERVICAL Surgery Blank 29.90 19.26 19.26 Blank RBRVS

63199 Blank LAM CORDOTOMY SCTJ BOTH TRACTS 2 STAGES THORACIC Surgery Blank 31.47 19.99 19.99 Blank RBRVS

63200 Blank LAMINECTOMY RELEASE TETHERED SPINAL CORD LUMBAR Surgery Blank 21.44 15.02 15.02 Blank RBRVS

63250 Blank LAM EXC/OCCLUSION AVM SPINAL CORD CERVICAL Surgery Blank 43.86 25.44 25.44 Blank RBRVS

63251 Blank LAM EXC/OCCLUSION AVM SPINAL CORD THORACIC Surgery Blank 44.64 26.26 26.26 Blank RBRVS

63252 Blank LAM EXC/OCCLUSION AVM SPI CORD THORACOLUMBAR Surgery Blank 44.63 26.26 26.26 Blank RBRVS

63265 Blank LAM EXC/EVAC ISPI LES OTH/THN NEO XDRL CERVICAL Surgery Blank 23.82 16.07 16.07 Blank RBRVS

63266 Blank LAM EXC/EVAC ISPI LES OTH/THN NEO XDRL THORACIC Surgery Blank 24.68 16.42 16.42 Blank RBRVS

63267 Blank LAM EXC/EVAC ISPI LESION OTH/THN NEO XDRL LUMBAR Surgery Blank 19.45 13.89 13.89 Blank RBRVS

63268 Blank LAM EXC/EVAC ISPI LES OTH/THN NEO XDRL SACRAL Surgery Blank 20.02 14.01 14.01 Blank RBRVS

63270 Blank LAM EXC ISPI LES OTH/THN NEO IDRL CERVICAL Surgery Blank 29.80 18.96 18.96 Blank RBRVS

63271 Blank LAM EXC ISPI LES OTH/THN NEO IDRL THORACIC Surgery Blank 29.92 18.95 18.95 Blank RBRVS

63272 Blank LAM EXC ISPI LES OTH/THN NEO IDRL LUMBAR Surgery Blank 27.50 17.79 17.79 Blank RBRVS

63273 Blank LAM EXC ISPI LES OTH/THN NEO IDRL SACRAL Surgery Blank 26.47 17.43 17.43 Blank RBRVS

63275 Blank LAMINECTOMY BX/EXC ISPI NEO XDRL CERVICAL Surgery Blank 25.86 17.02 17.02 Blank RBRVS

63276 Blank LAMINECTOMY BX/EXC ISPI NEO XDRL THORACIC Surgery Blank 25.69 16.88 16.88 Blank RBRVS

63277 Blank LAMINECTOMY BX/EXC ISPI NEO XDRL LUMBAR Surgery Blank 22.39 15.32 15.32 Blank RBRVS

63278 Blank LAMINECTOMY BX/EXC ISPI NEO XDRL SACRAL Surgery Blank 22.12 15.42 15.42 Blank RBRVS

63280 Blank LAM BX/EXC ISPI NEO IDRL XMED CERVICAL Surgery Blank 30.29 19.58 19.58 Blank RBRVS

63281 Blank LAM BX/EXC ISPI NEO IDRL XMED THORACIC Surgery Blank 29.99 19.48 19.48 Blank RBRVS

63282 Blank LAM BX/EXC ISPI NEO IDRL XMED LUMBAR Surgery Blank 28.15 18.59 18.59 Blank RBRVS

63283 Blank LAM BX/EXC ISPI NEO IDRL SACRAL Surgery Blank 26.76 18.02 18.02 Blank RBRVS

63285 Blank LAM BX/EXC ISPI NEO IDRL IMED CERVICAL Surgery Blank 38.05 23.22 23.22 Blank RBRVS

63286 Blank LAM BX/EXC ISPI NEO IDRL IMED THORACIC Surgery Blank 37.62 22.87 22.87 Blank RBRVS

63287 Blank LAM BX/EXC ISPI NEO IDRL IMED THORACOLMBR Surgery Blank 40.08 24.17 24.17 Blank RBRVS

63290 Blank LAM BX/EXC ISPI NEO XDRL-IDRL LES ANY LVL Surgery Blank 40.82 24.51 24.51 Blank RBRVS

63295 Blank OSTPL RCNSTJ DORSAL SPI ELMNTS FLWG ISPI PX Surgery Blank 5.25 2.42 2.42 Blank RBRVS

63300 Blank VCRPEC LES 1 SGM XDRL CERVICAL Surgery Blank 26.80 17.30 17.30 Blank RBRVS

63301 Blank VCRPEC LES 1 SGM XDRL THORACIC TTHRC Surgery Blank 31.57 20.25 20.25 Blank RBRVS

63302 Blank VCRPEC LES 1 SEG XDRL THRC THORACOLMBR Surgery Blank 31.15 20.05 20.05 Blank RBRVS

63303 Blank VCRPEC LES 1 SEG XDRL LMBR/SAC TRANSPRTL/RPR Surgery Blank 33.55 20.68 20.68 Blank RBRVS

63304 Blank VERTEBRAL CORPECTOMY EXC LES 1 SEG IDRL CERVICAL Surgery Blank 33.85 21.29 21.29 Blank RBRVS

63305 Blank VERTEBRAL CORPECTOMY LES 1 SEG IDRL THRC TTHRC Surgery Blank 36.24 22.39 22.39 Blank RBRVS

63306 Blank VERTEBRL CORPECT LES 1 SEG IDRL THRC THORACOLMBR Surgery Blank 35.55 22.07 22.07 Blank RBRVS

63307 Blank VCRPEC LES 1 SEG IDRL LMBR/SAC TRANSPRTL/RPR Surgery Blank 34.96 21.42 21.42 Blank RBRVS

63308 Blank VERTEBRAL CORPECTOMY EXC INDRL LES EACH SEG Surgery Blank 5.24 2.40 2.40 Blank RBRVS

63600 Blank CREATION LES SPINAL CORD STEREOTACTIC METHOD PRQ Surgery Blank 15.12 9.09 9.09 Blank RBRVS

63610 Blank STRTCTC STIMJ SPI CORD PRQ SPX N/FLWD OTH SURG Surgery Blank 8.72 4.88 4.88 Blank RBRVS

63620 Blank STEREOTACTIC RADIOSURGERY 1 SPINAL LESION Surgery Blank 15.60 10.92 10.92 Blank RBRVS

63621 Blank STEREOTACTIC RADIOSURGERY EA ADDL SPINAL LESION Surgery Blank 4.00 1.85 1.85 Blank RBRVS

63650 Blank PRQ IMPLTJ NSTIM ELECTRODE ARRAY EPIDURAL Surgery Blank 7.15 4.00 29.76 Blank RBRVS

63655 Blank LAM IMPLTJ NSTIM ELTRDS PLATE/PADDLE EDRL Surgery Blank 10.92 9.52 9.52 Blank RBRVS

63661 Blank RMVL SPINAL NSTIM ELTRD PRQ ARRAY INCL FLUOR Surgery Blank 5.08 3.44 10.84 Blank RBRVS

63662 Blank RMVL SPINAL NSTIM ELTRD PLATE/PADDLE INCL FLUOR Surgery Blank 11.00 9.65 9.65 Blank RBRVS

63663 Blank REVJ INCL RPLCMT NSTIM ELTRD PRQ RA INCL FLUOR Surgery Blank 7.75 4.25 13.76 Blank RBRVS

63664 Blank REVJ INCL RPLCMT NSTIM ELTRD PLT/PDLE INCL FLUOR Surgery Blank 11.52 9.91 9.91 Blank RBRVS

63685 Blank INSJ/RPLCMT SPI NPGR DIR/INDUXIVE COUPLING Surgery Blank 5.19 4.19 4.19 Blank RBRVS

63688 Blank REVJ/RMVL IMPLANTED SPINAL NEUROSTIM GENERATOR Surgery Blank 5.30 4.29 4.29 Blank RBRVS

63700 Blank REPAIR MENINGOCELE < 5 CM DIAMETER Surgery Blank 17.47 13.40 13.40 Blank RBRVS

63702 Blank REPAIR MENINGOCELE > 5 CM DIAMETER Surgery Blank 19.41 14.30 14.30 Blank RBRVS

63704 Blank REPAIR MYELOMENINGOCELE < 5 CM DIAMETER Surgery Blank 22.43 16.71 16.71 Blank RBRVS

63706 Blank REPAIR MYELOMENINGOCELE > 5 CM DIAMETER Surgery Blank 25.35 18.05 18.05 Blank RBRVS

63707 Blank RPR DURAL/CEREBROSPINAL FLUID LEAK X REQ LAM Surgery Blank 12.65 10.19 10.19 Blank RBRVS

63709 Blank RPR DURAL/CSF LEAK/PSEUDOMENINGOCELE W/LAM Surgery Blank 15.65 11.64 11.64 Blank RBRVS

63710 Blank DURAL GRAFT SPINAL Surgery Blank 15.40 11.50 11.50 Blank RBRVS

63740 Blank CRTJ SHUNT LMBR SARACH-PRTL-PLEURAL/OTH W/LAM Surgery Blank 12.63 10.65 10.65 Blank RBRVS

63741 Blank CRTJ SHUNT LMBR SARACH-PRTL-PLEURAL PRQ X LAM Surgery Blank 9.12 7.49 7.49 Blank RBRVS

63744 Blank RPLCMT IRRIGATION/REVJ LUMBOSARACH SHUNT Surgery Blank 8.94 7.12 7.12 Blank RBRVS

63746 Blank RMVL ENTIRE LUMBOSARACH SHUNT SYS W/O RPLCMT Surgery Blank 7.33 7.20 7.20 Blank RBRVS

64400 Blank NJX ANES TRIGEMINAL NRV ANY DIV/BRANCH Surgery Blank 1.11 0.72 2.39 Blank RBRVS

64402 Blank INJECTION ANESTHETIC AGENT FACIAL NERVE Surgery Blank 1.25 0.81 2.45 Blank RBRVS

64405 Blank INJECTION ANESTHETIC AGENT GREATER OCCIPITAL NRV Surgery Blank 0.94 0.69 1.79 Blank RBRVS

64408 Blank INJECTION ANESTHETIC AGENT VAGUS NERVE Surgery Blank 1.41 0.95 1.79 Blank RBRVS





PAGE 74 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

64410 Blank INJECTION ANESTHETIC AGENT PHRENIC NERVE Surgery Blank 1.43 0.66 2.64 Blank RBRVS

64413 Blank INJECTION ANESTHETIC AGENT CERVICAL PLEXUS Surgery Blank 1.40 0.73 2.02 Blank RBRVS

64415 Blank SINGLE NERVE BLOCK INJECTION ARM NERVE Surgery Blank 1.48 0.27 1.77 Blank RBRVS

64416 Blank INJECTION ANES BRACHIAL PLEXUS CONT NFS CATH Surgery Blank 1.81 0.32 0.32 Blank RBRVS

64417 Blank INJECTION ANESTHETIC AGENT AXILLARY NERVE Surgery Blank 1.44 0.46 2.13 Blank RBRVS

64418 Blank INJECTION ANESTHETIC AGENT SUPRASCAPULAR NERVE Surgery Blank 1.10 0.56 2.12 Blank RBRVS

64420 Blank INJECTION ANESTHETIC AGENT 1 INTERCOSTAL NERVE Surgery Blank 1.18 0.64 1.89 Blank RBRVS

64421 Blank MULTIPLE NERVE BLOCK INJECTIONS RIB NERVES Surgery Blank 1.68 0.82 2.48 Blank RBRVS

64425 Blank INJECTION ANES ILIOINGUINAL ILIOHYPOGASTRIC NRVS Surgery Blank 1.75 0.77 1.90 Blank RBRVS

64430 Blank INJECTION ANESTHETIC AGENT PUDENDAL NERVE Surgery Blank 1.46 0.71 2.31 Blank RBRVS

64435 Blank INJECTION ANESTHETIC PARACERVICAL UTERINE NERVE Surgery Blank 1.45 0.73 2.27 Blank RBRVS

64445 Blank INJECTION ANESTHETIC AGENT SCIATIC NRV SINGLE Surgery Blank 1.48 0.46 2.28 Blank RBRVS

64446 Blank INJECTION ANES SCIATIC NERVE CONT INFUSION CATH Surgery Blank 1.81 0.32 0.32 Blank RBRVS

64447 Blank INJECTION ANESTHETIC AGENT FEMORAL NERVE SINGLE Surgery Blank 1.50 0.29 1.84 Blank RBRVS

64448 Blank INJECTION ANES FEMORAL NERVE CONT INFUSION CATH Surgery Blank 1.63 0.29 0.29 Blank RBRVS

64449 Blank INJECTION ANES LUMBAR PLEXUS POST CONT NFS CATH Surgery Blank 1.81 0.44 0.44 Blank RBRVS

64450 Blank INJECTION ANES OTHER PERIPHERAL NERVE/BRANCH Surgery Blank 0.75 0.48 1.46 Blank RBRVS

64455 Blank NJX ANES&/STEROID PLANTAR COMMON DIGITAL NERVE Surgery Blank 0.75 0.19 0.55 Blank RBRVS

64461 Blank PVB THORACIC SINGLE INJECTION SITE W/IMG GID Surgery Blank 1.75 0.56 2.28 Blank RBRVS

64462 Blank PVB THORACIC SECOND & ADDL INJ SITE W/IMG GID Surgery Blank 1.10 0.34 1.12 Blank RBRVS

64463 Blank PVB THORACIC CONT CATHETER INFUSION W/IMG GID Surgery Blank 1.90 0.42 2.46 Blank RBRVS

64479 Blank NJX ANES&/STRD W/IMG TFRML EDRL CRV/THRC 1 LVL Surgery Blank 2.29 1.29 4.19 Blank RBRVS

64480 Blank NJX ANES&/STRD W/IMG TFRML EDRL CRV/THRC EA LV Surgery Blank 1.20 0.49 1.90 Blank RBRVS

64483 Blank NJX ANES&/STRD W/IMG TFRML EDRL LMBR/SAC 1 LVL Surgery Blank 1.90 1.16 4.14 Blank RBRVS

64484 Blank NJX ANES&/STRD W/IMG TFRML EDRL LMBR/SAC EA LV Surgery Blank 1.00 0.41 1.54 Blank RBRVS

64486 Blank TAP BLOCK UNILATERAL BY INJECTION(S) Surgery Blank 1.27 0.33 1.94 Blank RBRVS

64487 Blank TAP BLOCK UNILATERAL BY CONTINUOUS INFUSION(S) Surgery Blank 1.48 0.31 2.20 Blank RBRVS

64488 Blank TAP BLOCK BILATERAL BY INJECTION(S) Surgery Blank 1.60 0.31 2.09 Blank RBRVS

64489 Blank TAP BLOCK BILATERAL BY CONTINUOUS INFUSION(S) Surgery Blank 1.80 0.34 3.25 Blank RBRVS

64490 Blank NJX DX/THER AGT PVRT FACET JT CRV/THRC 1 LEVEL Surgery Blank 1.82 1.06 3.40 Blank RBRVS

64491 Blank NJX DX/THER AGT PVRT FACET JT CRV/THRC 2ND LEVEL Surgery Blank 1.16 0.47 1.39 Blank RBRVS

64492 Blank NJX DX/THER AGT PVRT FACET JT CRV/THRC 3+ LEVEL Surgery Blank 1.16 0.49 1.41 Blank RBRVS

64493 Blank NJX DX/THER AGT PVRT FACET JT LMBR/SAC 1 LEVEL Surgery Blank 1.52 0.95 3.23 Blank RBRVS

64494 Blank NJX DX/THER AGT PVRT FACET JT LMBR/SAC 2ND LEVEL Surgery Blank 1.00 0.40 1.36 Blank RBRVS

64495 Blank NJX DX/THER AGT PVRT FACET JT LMBR/SAC 3+ LEVEL Surgery Blank 1.00 0.42 1.36 Blank RBRVS

64505 Blank INJECTION ANES AGENT SPHENOPALATINE GANGLION Surgery Blank 1.36 1.02 1.54 Blank RBRVS

64510 Blank NJX ANES STELLATE GANGLION CRV SYMPATHETIC Surgery Blank 1.22 0.79 2.30 Blank RBRVS

64517 Blank INJECTION ANES SUPERIOR HYPOGASTRIC PLEXUS Surgery Blank 2.20 1.24 3.04 Blank RBRVS

64520 Blank INJECTION ANES LMBR/THRC PARAVERTBRL SYMPATHETIC Surgery Blank 1.35 0.84 3.85 Blank RBRVS

64530 Blank INJX ANES CELIAC PLEXUS W/WO RADIOLOGIC MONITRNG Surgery Blank 1.58 0.90 3.65 Blank RBRVS

64553 Blank PRQ IMPLTJ NEUROSTIMULATOR ELTRD CRANIAL NERVE Surgery Blank 6.13 2.28 23.49 Blank RBRVS

64555 Blank PRQ IMPLTJ NEUROSTIMULATOR ELTRD PERIPHERAL NRV Surgery Blank 5.76 3.30 27.91 Blank RBRVS

64561 Blank PRQ IMPLTJ NEUROSTIM ELTRD SACRAL NRVE W/IMAGING Surgery Blank 5.44 2.70 17.63 Blank RBRVS

64566 Blank POST TIB NEUROSTIMULATION PRQ NEEDLE ELECTRODE Surgery Blank 0.60 0.22 3.02 Blank RBRVS

64568 Blank INC IMPLTJ CRNL NRV NSTIM ELTRDS & PULSE GENER Surgery Blank 9.00 6.83 6.83 Blank RBRVS

64569 Blank REVISION/REPLMT NEUROSTIMLATOR ELTRD CRANIAL NRV Surgery Blank 11.00 7.80 7.80 Blank RBRVS

64570 Blank REMOVAL CRNL NRV NSTIM ELTRDS & PULSE GENERATO Surgery Blank 9.10 8.63 8.63 Blank RBRVS

64575 Blank INC IMPLTJ PERIPH NERVE NEUROSTIMULATOR ELTRD Surgery Blank 4.42 3.93 3.93 Blank RBRVS

64580 Blank INC IMPLTJ NSTIM ELTRD NEUROMUSCULAR Surgery Blank 4.19 3.61 3.61 Blank RBRVS

64581 Blank INC IMPLTJ NEUROSTIMULATOR ELTRD SACRAL NERVE Surgery Blank 12.20 5.54 5.54 Blank RBRVS

64585 Blank REVJ/RMVL PERIPHERAL NEUROSTIMULATOR ELECTRODE Surgery Blank 2.11 1.76 4.63 Blank RBRVS

64590 Blank INSERTION/RPLCMT PERIPHERAL/GASTRIC NPGR Surgery Blank 2.45 1.89 4.86 Blank RBRVS

64595 Blank REVISION/RMVL PERIPHERAL/GASTRIC NPGR Surgery Blank 1.78 1.64 5.02 Blank RBRVS

64600 Blank DSTRJ TRIGEMINAL NRV SUPRAORB INFRAORB BRANCH Surgery Blank 3.49 2.31 7.38 Blank RBRVS

64605 Blank DSTRJ NEUROLYTIC TRIGEMINAL NRV 2/3 DIV BRANCH Surgery Blank 5.65 3.23 9.01 Blank RBRVS

64610 Blank DSTRJ NEURLYTIC TRIGEM NRV 2/3 DIV RADIO MONITOR Surgery Blank 7.20 4.60 11.64 Blank RBRVS

64611 Blank CHEMODENERV PAROTID&SUBMANDIBL SALIVARY GLNDS Surgery Blank 1.03 1.55 2.03 Blank RBRVS

64612 Blank CHEMODNRVTJ MUSC MUSC INNERVATED FACIAL NRV UNIL Surgery Blank 1.41 1.67 2.11 Blank RBRVS

64615 Blank CHEMODERVATE FACIAL/TRIGEM/CERV MUSC MIGRAINE Surgery Blank 1.85 1.13 1.74 Blank RBRVS

64616 Blank CHEMODENERVATION MUSCLE NECK UNILAT FOR DYSTONIA Surgery Blank 1.53 1.14 1.69 Blank RBRVS

64617 Blank CHEMODENERVATION MUSCLE LARYNX UNILAT W/EMG Surgery Blank 1.90 0.95 2.39 Blank RBRVS

64620 Blank DSTRJ NEUROLYTIC AGENT INTERCOSTAL NERVE Surgery Blank 2.89 1.81 2.71 Blank RBRVS

64630 Blank DSTRJ NEUROLYTIC AGENT PUDENDAL NERVE Surgery Blank 3.05 2.00 3.07 Blank RBRVS

64632 Blank DSTRJ NEUROLYTIC PLANTAR COMMON DIGITAL NERVE Surgery Blank 1.23 0.66 1.12 Blank RBRVS

64633 Blank DSTR NROLYTC AGNT PARVERTEB FCT SNGL CRVCL/THORA Surgery Blank 3.84 2.32 7.78 Blank RBRVS

64634 Blank DSTR NROLYTC AGNT PARVERTEB FCT ADDL CRVCL/THORA Surgery Blank 1.32 0.53 3.93 Blank RBRVS

64635 Blank DSTR NROLYTC AGNT PARVERTEB FCT SNGL LMBR/SACRAL Surgery Blank 3.78 2.30 7.72 Blank RBRVS

64636 Blank DSTR NROLYTC AGNT PARVERTEB FCT ADDL LMBR/SACRAL Surgery Blank 1.16 0.46 3.62 Blank RBRVS

64640 Blank DSTRJ NEUROLYTIC AGENT OTHER PERIPHERAL NERVE Surgery Blank 1.23 1.34 2.44 Blank RBRVS

64642 Blank CHEMODENERVATION ONE EXTREMITY 1-4 MUSCLE Surgery Blank 1.65 1.11 2.09 Blank RBRVS

64643 Blank CHEMODENERVATION 1 EXTREMITY EA ADDL 1-4 MUSCLE Surgery Blank 1.22 0.62 1.19 Blank RBRVS

64644 Blank CHEMODENERVATION 1 EXTREMITY 5 OR MORE MUSCLES Surgery Blank 1.82 1.20 2.49 Blank RBRVS





PAGE 75 of 144

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HCPCS

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Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

64645 Blank CHEMODENERVATION 1 EXTREMITY EA ADDL 5/> MUSCLES Surgery Blank 1.39 0.70 1.57 Blank RBRVS

64646 Blank CHEMODENERVATION OF TRUNK MUSCLE 1-5 MUSCLES Surgery Blank 1.80 1.12 2.06 Blank RBRVS

64647 Blank CHEMODENERVATION OF TRUNK 6 OR MORE MUSCLES Surgery Blank 2.11 1.26 2.37 Blank RBRVS

64650 Blank CHEMODENERVATION ECCRINE GLANDS BOTH AXILLAE Surgery Blank 0.70 0.39 1.40 Blank RBRVS

64653 Blank CHEMODENERVATION ECCRINE GLANDS OTH AREA PER DAY Surgery Blank 0.88 0.46 1.63 Blank RBRVS

64680 Blank DSTRJ NEUROLYTIC W/WO RAD MONITOR CELIAC PLEXUS Surgery Blank 2.67 1.77 5.69 Blank RBRVS

64681 Blank DSTRJ NULYT W/WORAD MNTR SUPRIOR HYPOGSTR PLEXUS Surgery Blank 3.78 2.94 10.72 Blank RBRVS

64702 Blank NEUROPLASTY DIGITAL 1/BOTH SAME DIGIT Surgery Blank 6.26 7.06 7.06 Blank RBRVS

64704 Blank NEUROPLASTY NERVE HAND/FOOT Surgery Blank 4.69 3.98 3.98 Blank RBRVS

64708 Blank NEURP MAJOR PRPH NRV ARM/LEG OPN OTH/THN SPEC Surgery Blank 6.36 6.79 6.79 Blank RBRVS

64712 Blank NEURP MAJOR PRPH NRV OPN ARM/LEG SCIATIC NRV Surgery Blank 8.07 7.03 7.03 Blank RBRVS

64713 Blank NEURP MAJOR PRPH NRV OPN ARM/LEG BRACH PLEXUS Surgery Blank 11.40 8.40 8.40 Blank RBRVS

64714 Blank NEURP MAJOR PRPH NRV OPN ARM/LEG LMBR PLEXUS Surgery Blank 10.55 8.10 8.10 Blank RBRVS

64716 Blank NEUROPLASTY &/TRANSPOSITION CRANIAL NERVE Surgery Blank 6.99 7.03 7.03 Blank RBRVS

64718 Blank NEUROPLASTY &/TRANSPOSITION ULNAR NERVE ELBOW Surgery Blank 7.26 8.33 8.33 Blank RBRVS

64719 Blank NEUROPLASTY &/TRANSPOSITION ULNAR NERVE WRIST Surgery Blank 4.97 5.59 5.59 Blank RBRVS

64721 Blank NEUROPLASTY &/TRANSPOS MEDIAN NRV CARPAL TUNNE Surgery Blank 4.97 6.31 6.38 Blank RBRVS

64722 Blank DECOMPRESSION UNSPECIFIED NERVE Surgery Blank 4.82 4.62 4.62 Blank RBRVS

64726 Blank DECOMPRESSION PLANTAR DIGITAL NERVE Surgery Blank 4.27 3.16 3.16 Blank RBRVS

64727 Blank INTERNAL NEUROLYSIS REQ OPERATING MICROSCOPE Surgery Blank 3.10 1.59 1.59 Blank RBRVS

64732 Blank TRANSECTION/AVULSION SUPRAORBITAL NERVE Surgery Blank 4.89 5.92 5.92 Blank RBRVS

64734 Blank TRANSECTION/AVULSION INFRAORBITAL NERVE Surgery Blank 5.55 6.69 6.69 Blank RBRVS

64736 Blank TRANSECTION/AVULSION MENTAL NERVE Surgery Blank 5.23 5.03 5.03 Blank RBRVS

64738 Blank TRANSECTION/AVULSION INF ALVEOLAR NRV W/OSTEO Surgery Blank 6.36 5.91 5.91 Blank RBRVS

64740 Blank TRANSECTION/AVULSION LINGUAL NERVE Surgery Blank 6.22 6.91 6.91 Blank RBRVS

64742 Blank TRANSECTION/AVULSION FACIAL NRV DIFFERENT/CMPL Surgery Blank 6.85 6.79 6.79 Blank RBRVS

64744 Blank TRANSECTION/AVULSION GREATER OCCIPITAL NERVE Surgery Blank 5.72 6.30 6.30 Blank RBRVS

64746 Blank TRANSECTION/AVULSION PHRENIC NERVE Surgery Blank 6.56 4.29 4.29 Blank RBRVS

64755 Blank TRANSECTION/AVULSION VAGUS NERVES Surgery Blank 15.05 7.94 7.94 Blank RBRVS

64760 Blank TRANSECTION/AVULSION VAGUS NERVE ABDOMINAL Surgery Blank 7.59 5.44 5.44 Blank RBRVS

64763 Blank TRNSXJ/AVLSN OBTURAT NRV XPELV W/WO TENOTOMY Surgery Blank 7.56 5.33 5.33 Blank RBRVS

64766 Blank TRNSXJ/AVLSN OBTURAT NRV INPELV W/WO TENOTOMY Surgery Blank 9.47 6.36 6.36 Blank RBRVS

64771 Blank TRANSECTION/AVULSION OTH CRANIAL NRV XDRL Surgery Blank 8.15 7.56 7.56 Blank RBRVS

64772 Blank TRANSECTION/AVULSION OTH SPINAL NRV XDRL Surgery Blank 7.84 6.84 6.84 Blank RBRVS

64774 Blank EXC NEUROMA CUTAN NRV SURGLY IDENTIFIABLE Surgery Blank 5.80 5.06 5.06 Blank RBRVS

64776 Blank EXC NEUROMA DIGITAL NERVE 1 OR BOTH SAME DIGIT Surgery Blank 5.60 4.83 4.83 Blank RBRVS

64778 Blank EXCISION NEUROMA DIGITAL NRV EA ADDL DIGIT Surgery Blank 3.11 1.57 1.57 Blank RBRVS

64782 Blank EXC NEUROMA HAND/FOOT XCP DIGITAL NERVE Surgery Blank 6.86 5.34 5.34 Blank RBRVS

64783 Blank EXC NEUROMA HAND/FOOT EA NRV XCP SM DGT Surgery Blank 3.71 1.88 1.88 Blank RBRVS

64784 Blank EXC NEUROMA MAJOR PERIPHERAL NRV XCP SCIATIC Surgery Blank 10.62 8.41 8.41 Blank RBRVS

64786 Blank EXCISION NEUROMA SCIATIC NERVE Surgery Blank 16.25 8.77 8.77 Blank RBRVS

64787 Blank IMPLANTATION NERVE END BONE/MUSCLE Surgery Blank 4.29 2.02 2.02 Blank RBRVS

64788 Blank EXC NEUROFIBROMA/NEUROLEMMOMA CUTAN NRV Surgery Blank 5.24 5.10 5.10 Blank RBRVS

64790 Blank EXC NEUROFIBROMA/NEUROLEMMOMA MAJOR PRPH NRV Surgery Blank 12.10 9.21 9.21 Blank RBRVS

64792 Blank EXC NEUROFIBROMA/NEUROLEMMOMA EXTNSV Surgery Blank 15.86 12.44 12.44 Blank RBRVS

64795 Blank BIOPSY NERVE Surgery Blank 3.01 1.82 1.82 Blank RBRVS

64802 Blank SYMPATHECTOMY CERVICAL Surgery Blank 10.37 9.61 9.61 Blank RBRVS

64804 Blank SYMPATHECTOMY CERVICOTHORACIC Surgery Blank 15.91 12.16 12.16 Blank RBRVS

64809 Blank SYMPATHECTOMY THORACOLUMBAR Surgery Blank 14.71 11.06 11.06 Blank RBRVS

64818 Blank SYMPATHECTOMY LUMBAR Surgery Blank 11.34 4.53 4.53 Blank RBRVS

64820 Blank SYMPATHECTOMY DIGITAL ARTERIES EACH DIGIT Surgery Blank 10.74 8.17 8.17 Blank RBRVS

64821 Blank SYMPATHECTOMY RADIAL ARTERY Surgery Blank 9.33 8.75 8.75 Blank RBRVS

64822 Blank SYMPATHECTOMY ULNAR ARTERY Surgery Blank 9.33 8.75 8.75 Blank RBRVS

64823 Blank SYMPATHECTOMY SUPERFICIAL PALMAR ARCH Surgery Blank 10.94 9.56 9.56 Blank RBRVS

64831 Blank SUTURE DIGITAL NERVE HAND/FOOT 1 NERVE Surgery Blank 9.16 8.97 8.97 Blank RBRVS

64832 Blank SUTR DIGITAL NRV HAND/FOOT EA DGTAL NRV Surgery Blank 5.65 3.13 3.13 Blank RBRVS

64834 Blank SUTURE 1 NERVE HAND/FOOT COMMON SENSORY NERVE Surgery Blank 10.81 8.65 8.65 Blank RBRVS

64835 Blank SUTURE 1 NERVE MEDIAN MOTOR THENAR Surgery Blank 11.73 9.41 9.41 Blank RBRVS

64836 Blank SUTURE 1 NERVE ULNAR MOTOR Surgery Blank 11.73 9.41 9.41 Blank RBRVS

64837 Blank SUTURE EACH ADDITIONAL NERVE HAND/FOOT Surgery Blank 6.25 3.16 3.16 Blank RBRVS

64840 Blank SUTURE POSTERIOR TIBIAL NERVE Surgery Blank 14.02 10.92 10.92 Blank RBRVS

64856 Blank SUTR PRPH NRV ARM/LEG XCP SCIATIC W/TRPOS Surgery Blank 15.07 11.32 11.32 Blank RBRVS

64857 Blank SUTR PRPH NRV ARM/LEG XCP SCIATIC W/O TRPOS Surgery Blank 15.82 11.85 11.85 Blank RBRVS

64858 Blank SUTURE SCIATIC NERVE Surgery Blank 17.82 12.61 12.61 Blank RBRVS

64859 Blank SUTURE EACH ADDITIONAL PERIPHERAL NERVE Surgery Blank 4.25 2.15 2.15 Blank RBRVS

64861 Blank SUTURE BRACHIAL PLEXUS Surgery Blank 20.89 14.93 14.93 Blank RBRVS

64862 Blank SUTURE LUMBAR PLEXUS Surgery Blank 21.09 14.50 14.50 Blank RBRVS

64864 Blank SUTURE FACIAL NERVE EXTRACRANIAL Surgery Blank 13.41 9.67 9.67 Blank RBRVS

64865 Blank SUTURE FACIAL NERVE INFRATEMPORAL W/WO GRAFT Surgery Blank 16.09 12.99 12.99 Blank RBRVS

64866 Blank ANASTOMOSIS FACIAL-SPINAL ACCESSORY Surgery Blank 16.83 17.43 17.43 Blank RBRVS

64868 Blank ANASTOMOSIS FACIAL HYPOGLOSSAL Surgery Blank 14.90 11.71 11.71 Blank RBRVS

64872 Blank SUTURE NERVE REQ SECONDARY/DELAYED SUTURE Surgery Blank 1.99 1.00 1.00 Blank RBRVS





PAGE 76 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

64874 Blank SUTURE NERVE REQ XTNSV MOBIL/TRPOS NERVE Surgery Blank 2.98 1.51 1.51 Blank RBRVS

64876 Blank SUTURE NERVE REQ SHORTENING BONE EXTREMITY Surgery Blank 3.37 1.71 1.71 Blank RBRVS

64885 Blank NERVE GRAFT HEAD/NECK </ 4 CM Surgery Blank 17.60 12.13 12.13 Blank RBRVS

64886 Blank NERVE GRAFT HEAD/NECK >4 CM Surgery Blank 20.82 13.19 13.19 Blank RBRVS

64890 Blank NERVE GRAFT 1 STRAND HAND/FOOT </4 CM Surgery Blank 16.24 11.70 11.70 Blank RBRVS

64891 Blank NRV GRF 1 STRAND HAND/FOOT >4 CM Surgery Blank 17.35 12.37 12.37 Blank RBRVS

64892 Blank NERVE GRAFT 1 STRAND ARM/LEG <4 CM Surgery Blank 15.74 11.44 11.44 Blank RBRVS

64893 Blank NERVE GRAFT 1 STRAND ARM/LEG >4 CM Surgery Blank 16.87 12.13 12.13 Blank RBRVS

64895 Blank NERVE GRAFT MLT STRANDS HAND/FOOT </4 CM Surgery Blank 20.39 13.91 13.91 Blank RBRVS

64896 Blank NERVE GRAFT MLT STRANDS HAND/FOOT > 4 CM Surgery Blank 21.96 15.05 15.05 Blank RBRVS

64897 Blank NERVE GRAFT MLT STRANDS ARM/LEG </4 CM Surgery Blank 19.38 13.40 13.40 Blank RBRVS

64898 Blank NERVE GRAFT MLT STRANDS ARM/LEG >4 CM Surgery Blank 20.97 14.56 14.56 Blank RBRVS

64901 Blank NERVE GRAFT EACH NERVE 1 STRAND Surgery Blank 10.20 5.16 5.16 Blank RBRVS

64902 Blank NERVE GRAFT EACH NERVE MULTIPLE STRANDS Surgery Blank 11.81 5.98 5.98 Blank RBRVS

64905 Blank NERVE PEDICLE TRANSFER FIRST STAGE Surgery Blank 15.11 11.12 11.12 Blank RBRVS

64907 Blank NERVE PEDICAL TRANSFER SECOND STAGE Surgery Blank 20.03 13.61 13.61 Blank RBRVS

64910 Blank NERVE REPAIR W/CONDUIT EACH NERVE Surgery Blank 10.52 10.77 10.77 Blank RBRVS

64911 Blank NERVE REPAIR W/AUTOGENOUS VEIN GRAFT EA NERVE Surgery Blank 14.00 12.78 12.78 Blank RBRVS

64912 Blank NRV RPR W/NRV ALGRFT 1ST Surgery Blank 12.00 8.63 8.63 Blank RBRVS

64913 Blank NRV RPR W/NRV ALGRFT EA ADDL Surgery Blank 3.00 1.08 1.08 Blank RBRVS

64999 Blank UNLISTED PROCEDURE NERVOUS SYSTEM Surgery Blank Blank Blank Blank 3.54 Unlisted

65091 Blank EVISCERATION OCULAR CONTENTS W/O IMPLANT Surgery Blank 7.26 10.31 10.31 Blank RBRVS

65093 Blank EVISCERATION OCULAR CONTENTS W/IMPLANT Surgery Blank 7.04 10.33 10.33 Blank RBRVS

65101 Blank ENUCLEATION OF EYE W/O IMPLANT Surgery Blank 8.30 12.12 12.12 Blank RBRVS

65103 Blank ENUCLEATION EYE IMPLT MUSC X ATTACHED IMPLT Surgery Blank 8.84 12.46 12.46 Blank RBRVS

65105 Blank ENUCLEATION EYE IMPLT MUSC ATTACHED IMPLT Surgery Blank 9.93 13.52 13.52 Blank RBRVS

65110 Blank EXENTERATION ORBIT REMVL ORBITAL CONTENTS ONLY Surgery Blank 15.70 17.94 17.94 Blank RBRVS

65112 Blank EXENTERATION ORBIT RMVL ORBIT CONTENTS & BONE Surgery Blank 18.51 20.48 20.48 Blank RBRVS

65114 Blank EXNTJ ORBIT RMVL ORB CNTS W/MUSC/MYOQ FLAP Surgery Blank 19.65 21.21 21.21 Blank RBRVS

65125 Blank MODIFICAJ OC IMPLT W/PLMT/RPLCMT PEGS SPX Surgery Blank 3.27 4.84 9.56 Blank RBRVS

65130 Blank INSJ OC IMPLT SEC AFTER EVSC SCLL SHELL Surgery Blank 8.42 11.82 11.82 Blank RBRVS

65135 Blank INSJ OC IMPLT AFTER ENCL MUSC X ATTACHED Surgery Blank 8.60 11.93 11.93 Blank RBRVS

65140 Blank INSJ OC IMPLT AFTER ENCL MUSC ATTACHED Surgery Blank 9.46 12.85 12.85 Blank RBRVS

65150 Blank REINSERTION OCULAR IMPLT W/WO CONJUNCTIVAL GRAFT Surgery Blank 6.43 9.56 9.56 Blank RBRVS

65155 Blank REINSERTION OCULAR IMPLT RNFCMT &/ ATTACH MUSCLE Surgery Blank 10.10 13.26 13.26 Blank RBRVS

65175 Blank REMOVAL OCULAR IMPLANT Surgery Blank 7.40 10.76 10.76 Blank RBRVS

65205 Blank REMOVAL FB EYE CONJUNCTIVAL SUPERFICIAL Surgery Blank 0.71 0.51 0.87 Blank RBRVS

65210 Blank RMVL FB XTRNL EYE EMBED SCJNCL/SCLERAL NONPERFOR Surgery Blank 0.84 0.62 1.08 Blank RBRVS

65220 Blank RMVL FB XTRNL EYE CORNEAL W/O SLIT LAMP Surgery Blank 0.71 0.42 0.90 Blank RBRVS

65222 Blank RMVL FB XTRNL EYE CORNEAL W/SLIT LAMP Surgery Blank 0.84 0.60 1.04 Blank RBRVS

65235 Blank RMVL FB INTRAOCULAR ANT CHAMBER EYE/LENS Surgery Blank 9.01 10.57 10.57 Blank RBRVS

65260 Blank RMVL FB IO FROM POST SEG MAG XTRJ ANT/POST ROUTE Surgery Blank 12.54 13.93 13.93 Blank RBRVS

65265 Blank RMVL FB IO FROM POST SEG NONMAGNETIC XTRJ Surgery Blank 14.34 15.35 15.35 Blank RBRVS

65270 Blank RPR LAC CJNC W/WO NONPERFOR LAC SCLERA DIR CLSR Surgery Blank 1.95 1.94 5.56 Blank RBRVS

65272 Blank RPR LAC CJNC MOBLJ& REARGMT W/O HOSPITALIZATION Surgery Blank 4.62 5.05 9.40 Blank RBRVS

65273 Blank RPR LAC CJNC MOBLJ & REARGMT W/HOSPIZATION Surgery Blank 5.16 5.32 5.32 Blank RBRVS

65275 Blank RPR LAC CORNEA NONPERFOR W/WO RMVL FOREIGN BODY Surgery Blank 6.29 6.43 9.76 Blank RBRVS

65280 Blank RPR LAC CORNEA&/SCLERA PERFOR X INVG UVEAL TIS Surgery Blank 9.10 9.39 9.39 Blank RBRVS

65285 Blank RPR LAC CORN&/SCLRA PERF W/REPOS/RESCJ UVEAL T Surgery Blank 15.36 15.13 15.13 Blank RBRVS

65286 Blank RPR LAC APPL TISSUE GLUE WOUND CORNEA&/SCLERA Surgery Blank 6.63 7.02 13.00 Blank RBRVS

65290 Blank RPR WND EXTRAOCULAR MUSCLE TENDON&/TENON CAPSU Surgery Blank 6.53 6.98 6.98 Blank RBRVS

65400 Blank EXCISION LESION CORNEA XCP PTERYGIUM Surgery Blank 7.50 9.16 11.36 Blank RBRVS

65410 Blank BIOPSY CORNEA Surgery Blank 1.47 1.40 2.53 Blank RBRVS

65420 Blank EXCISION/TRANSPOSITION PTERYGIUM W/O GRAFT Surgery Blank 4.36 6.10 10.09 Blank RBRVS

65426 Blank EXCISION/TRANSPOSITION PTERYGIUM W/GRAFG Surgery Blank 6.05 7.17 12.13 Blank RBRVS

65430 Blank CORNEA SCRAPING DIAGNOSTIC SMEAR &/CULTURE Surgery Blank 1.47 1.38 1.73 Blank RBRVS

65435 Blank RMVL CORNEAL EPITHELIUM W/WO CHEMOCAUTERIZATION Surgery Blank 0.92 1.01 1.34 Blank RBRVS

65436 Blank RMVL CORNEAL EPITHELIUM W/APPL CHELATING AGENT Surgery Blank 4.82 5.43 5.91 Blank RBRVS

65450 Blank DSTRJ LESION CRYOTHER PHOTO/THERMOCAUTZATION Surgery Blank 3.47 5.46 5.58 Blank RBRVS

65600 Blank MULTIPLE PUNCTURES ANTERIOR CORNEA Surgery Blank 4.20 5.31 6.76 Blank RBRVS

65710 Blank KERATOPLASTY ANTERIOR LAMELLAR Surgery Blank 14.45 16.01 16.01 Blank RBRVS

65730 Blank KERATOPLASTY PENTRG EXCEPT APHAKIA/PSEUDOPHAKIA Surgery Blank 16.35 17.44 17.44 Blank RBRVS

65750 Blank KERATOPLASTY PENETRAING APHAKIA Surgery Blank 16.90 17.02 17.02 Blank RBRVS

65755 Blank KERATOPLASTY PENETRATING PSEUDOPHAKIA Surgery Blank 16.79 16.96 16.96 Blank RBRVS

65756 Blank KERATOPLASTY ENDOTHELIAL Surgery Blank 16.84 15.70 15.70 Blank RBRVS

65757 Blank BACKBENCH PREPJ CORNEAL ENDOTHELIAL ALLOGRAFT Surgery Blank Blank Blank Blank 5.95 FAIR Health

65760 Blank KERATOMILEUSIS Surgery Blank Blank Blank Blank 18.11 FAIR Health

65765 Blank KERATOPHAKIA Surgery Blank Blank Blank Blank 43.34 ERBRVS

65767 Blank EPIKERATOPLASTY Surgery Blank Blank Blank Blank 40.36 ERBRVS

65770 Blank KERATOPROSTHESIS Surgery Blank 19.74 18.76 18.76 Blank RBRVS

65771 Blank RADIAL KERATOTOMY Surgery Blank Blank Blank Blank 10.51 FAIR Health

65772 Blank CRNL RELAXING INC CORRJ INDUCED ASTIGMATISM Surgery Blank 5.09 6.14 7.43 Blank RBRVS





PAGE 77 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

65775 Blank CRNL WEDGE RESCJ CORRJ INDUCED ASTIGMATISM Surgery Blank 6.91 8.31 8.31 Blank RBRVS

65778 Blank PLACE AMNIOTIC MEMBRA OCULAR SURFACE W/O SUTURES Surgery Blank 1.00 0.54 39.15 Blank RBRVS

65779 Blank PLACE AMNIOTIC MEMBRANE OCULAR SURFACE SUTURED Surgery Blank 2.50 1.66 31.77 Blank RBRVS

65780 Blank OCULAR SURFACE RECONSTRUCTION AMNIOTIC MEMBRANE Surgery Blank 7.81 10.63 10.63 Blank RBRVS

65781 Blank OCULAR SURFACE RECONSTRUCTION LIMBAL ALLOGRAFT Surgery Blank 18.14 18.56 18.56 Blank RBRVS

65782 Blank OCCULAR SURFACE RECONSTRUCTION LIMBAL AUTOGRAFT Surgery Blank 15.43 16.26 16.26 Blank RBRVS

65785 Blank IMPLANTATION INTRASTROMAL CORNEAL RING SEGMENTS Surgery Blank 5.39 6.84 65.69 Blank RBRVS

65800 Blank PARACENTSIS ANT CHAMB EYE ASPIR AQUEOUS SPX Surgery Blank 1.53 0.97 1.78 Blank RBRVS

65810 Blank PARACENTSIS ANT CHAM RMVL VITREOUS W/WO AIR INJX Surgery Blank 5.82 7.02 7.02 Blank RBRVS

65815 Blank PARACEN ANT CHAM RMVL BLOOD W/WO IRRIG&/AIR IN Surgery Blank 6.00 7.19 11.79 Blank RBRVS

65820 Blank GONIOTOMY Surgery Blank 8.91 11.80 11.80 Blank RBRVS

65850 Blank TRABECULOTOMY AB EXTERNO Surgery Blank 11.39 11.72 11.72 Blank RBRVS

65855 Blank TRABECULOPLASTY BY LASER SURGERY Surgery Blank 3.00 2.71 3.78 Blank RBRVS

65860 Blank SEVERING ADHESIONS ANTERIOR SEGMENT LASER SPX Surgery Blank 3.59 3.38 4.98 Blank RBRVS

65865 Blank SEVERING ADS ANT SEG INCAL TQ SPX GONIOSYNECHIAE Surgery Blank 5.77 7.30 7.30 Blank RBRVS

65870 Blank SEVERING ADS ANT SEG INCAL SPX ANT SYNECHIAE Surgery Blank 7.39 8.92 8.92 Blank RBRVS

65875 Blank SEVERING ADS ANT SEG INCAL SPX POST SYNECHIAE Surgery Blank 7.81 9.60 9.60 Blank RBRVS

65880 Blank SEVERING ADS ANT SEG INCAL SPX CORNEOVITREAL Surgery Blank 8.36 9.95 9.95 Blank RBRVS

65900 Blank RMVL EPITHELIAL DOWNGROWTH ANT CHAMBER EYE Surgery Blank 12.51 14.05 14.05 Blank RBRVS

65920 Blank RMVL IMPLANTED MATERIAL ANTERIO SEGMENT EYE Surgery Blank 9.99 11.75 11.75 Blank RBRVS

65930 Blank RMVL BLOOD CLOT ANTERIOR SEGMENT EYE Surgery Blank 8.39 9.16 9.16 Blank RBRVS

66020 Blank INJX ANTERIOR CHAMBER EYE AIR/LIQUID SPX Surgery Blank 1.64 1.99 3.58 Blank RBRVS

66030 Blank INJX ANTERIOR CHAMBER EYE MEDICATION SPX Surgery Blank 1.30 1.78 3.37 Blank RBRVS

66130 Blank EXCISION LESION SCLERA Surgery Blank 7.83 7.82 11.48 Blank RBRVS

66150 Blank FSTLJ SCLERA GLAUCOMA TREPHIN W/IRIDECTOMY Surgery Blank 10.53 13.70 13.70 Blank RBRVS

66155 Blank FSTLJ SCLERA GLAUCOMA THERMOCAUT IRRIDEC Surgery Blank 10.52 13.69 13.69 Blank RBRVS

66160 Blank FSTLJ SCLERA SCLERECTOMY PUNCH/SCISSORS IRIDECT Surgery Blank 12.39 14.87 14.87 Blank RBRVS

66170 Blank FSTLJ SCLERA GLAUCOMA TRABECULECT AB EXTERNO Surgery Blank 13.94 16.24 16.24 Blank RBRVS

66172 Blank FSTLJ SCLERA GLC TRBEC AB EXTERNO SCARRING Surgery Blank 14.84 18.05 18.05 Blank RBRVS

66174 Blank TRLUML DILAT AQUEOUS CANAL W/O DEVICE/STENT Surgery Blank 12.85 13.24 13.24 Blank RBRVS

66175 Blank TRLUML DILAT AQUEOUS CANAL W/DEVICE/STENT Surgery Blank 13.60 13.70 13.70 Blank RBRVS

66179 Blank AQUEOUS SHUNT EXTRAOCULAR RESERVOIR W/O GRAFT Surgery Blank 14.00 15.71 15.71 Blank RBRVS

66180 Blank AQUEOUS SHUNT EXTRAOC EQUAT PLATE RSVR W/GRAFT Surgery Blank 15.00 16.33 16.33 Blank RBRVS

66183 Blank INSERT ANTER DRAINAGE DEV W/O EXTRAOC RESERVOIR Surgery Blank 13.20 15.21 15.21 Blank RBRVS

66184 Blank REVJ SHUNT EXTRAOCULAR RESERVOIR W/O GRAFT Surgery Blank 9.58 12.11 12.11 Blank RBRVS

66185 Blank REVJ AQUEOUS SHUNT EXTRAOCULAR RESERVOIR W/GRAFT Surgery Blank 10.58 12.73 12.73 Blank RBRVS

66225 Blank REPAIR SCLERAL STAPHYLOMA W/GRAFT Surgery Blank 12.63 13.02 13.02 Blank RBRVS

66250 Blank REVJ/RPR OPRATIVE WOUND ANTERIOR SEGMENT Surgery Blank 7.10 8.28 13.77 Blank RBRVS

66500 Blank IRIDOTOMY STAB INC SPX XCP TRANSFIXION Surgery Blank 3.83 5.98 5.98 Blank RBRVS

66505 Blank IRIDOTOMY STAB INC SPX TRANSFIXION Surgery Blank 4.22 6.54 6.54 Blank RBRVS

66600 Blank IRDEC CRNLSCLRL/CRNL SCTJ RMVL LES Surgery Blank 10.12 12.89 12.89 Blank RBRVS

66605 Blank IRDEC CRNLSCLRL/CRNL SCTJ CYCLECTOMY Surgery Blank 14.22 14.85 14.85 Blank RBRVS

66625 Blank IRDEC CRNLSCLRL/CRNL SCTJ PRPH GLC SPX Surgery Blank 5.30 6.56 6.56 Blank RBRVS

66630 Blank IRDEC CRNLSCLRL/CRNL SCTJ SECTOR GLC SPX Surgery Blank 7.28 8.43 8.43 Blank RBRVS

66635 Blank IRDEC CRNLSCLRL/CRNL SCTJ OPTICAL SPX Surgery Blank 7.37 8.49 8.49 Blank RBRVS

66680 Blank REPAIR IRIS CILIARY BODY Surgery Blank 6.39 7.89 7.89 Blank RBRVS

66682 Blank SUTURE IRIS CILIARY BODY SPX RETRIEVAL SUTURE Surgery Blank 7.33 10.33 10.33 Blank RBRVS

66700 Blank CILIARY BODY DESTRUCTION DIATHERMY Surgery Blank 5.14 5.71 7.37 Blank RBRVS

66710 Blank CILIARY BODY DSTRJ CYCLOPHOTOCOAG TRANSSCERAL Surgery Blank 5.14 5.70 7.09 Blank RBRVS

66711 Blank CILIARY BODY DSTRJ CYCLOPHOTOCOAG ENDOSCOPIC Surgery Blank 7.93 9.83 9.83 Blank RBRVS

66720 Blank CILIARY BODY DESTRUCTION CRYOTHERAPY Surgery Blank 4.75 6.58 8.06 Blank RBRVS

66740 Blank CILIARY BODY DESTRUCTION CYCLODIAL Surgery Blank 5.14 5.71 7.00 Blank RBRVS

66761 Blank IRIDOTOMY/IRRIDECTOMY LASER SURG PER SESSION Surgery Blank 3.00 3.51 5.26 Blank RBRVS

66762 Blank IRIDOPLASTY PHOTOCOAGULATION 1/> SESSIONS Surgery Blank 5.38 6.39 7.82 Blank RBRVS

66770 Blank DSTRJ CYST/LESION IRIS/CILIARY BODY Surgery Blank 6.13 7.19 8.50 Blank RBRVS

66820 Blank DISCISSION SECONDARY MEMBRANOUS CATARACT Surgery Blank 4.01 6.96 6.96 Blank RBRVS

66821 Blank POST-CATARACT LASER SURGERY Surgery Blank 3.42 5.20 5.73 Blank RBRVS

66825 Blank REPOSITIONING IO LENS PROSTHESIS REQ INC SPX Surgery Blank 9.01 11.99 11.99 Blank RBRVS

66830 Blank RMVL SEC MEMBRANOUS CTRC CORNEO-SCLL SCTJ Surgery Blank 9.47 10.14 10.14 Blank RBRVS

66840 Blank RMVL LENS MATERIAL ASPIR TQ 1/> STAGES Surgery Blank 9.18 10.02 10.02 Blank RBRVS

66850 Blank RMVL LENS MATERIAL PHACOFRAGMENTATION ASPIR Surgery Blank 10.55 11.29 11.29 Blank RBRVS

66852 Blank RMVL LENS MATERIAL PARS PLANA W/WO VITRECTOMY Surgery Blank 11.41 11.84 11.84 Blank RBRVS

66920 Blank RMVL LENS MATERIAL INTRACAPSULAR Surgery Blank 10.13 10.63 10.63 Blank RBRVS

66930 Blank REMOVAL LENS MATRL INTRACAPSULAR DISLOCATED LENS Surgery Blank 11.61 11.97 11.97 Blank RBRVS

66940 Blank REMOVAL LENS MATERIAL EXTRACAPSULAR Surgery Blank 10.37 11.18 11.18 Blank RBRVS

66982 Blank XCAPSULAR CATARACT RMVL INSJ LENS PROSTH 1 STG Surgery Blank 11.08 10.78 10.78 Blank RBRVS

66983 Blank ICAPSULAR CATARACT XTRJ INSJ IO LENS PRSTH 1 STG Surgery Blank 10.43 10.06 10.06 Blank RBRVS

66984 Blank CATARACT REMOVAL INSERTION OF LENS Surgery Blank 8.52 9.11 9.11 Blank RBRVS

66985 Blank INSJ IO LENS PROSTHESIS NOT W/CONCURRENT RMVL Surgery Blank 9.98 11.27 11.27 Blank RBRVS

66986 Blank EXCHANGE INTRAOCULAR LENS Surgery Blank 12.26 12.76 12.76 Blank RBRVS

66990 Blank USE OPHTHALMIC ENDOSCOPE Surgery Blank 1.51 0.95 0.95 Blank RBRVS

66999 Blank UNLISTED PROCEDURE ANTERIOR SEGMENT EYE Surgery Blank Blank Blank Blank 17.63 Unlisted





PAGE 78 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

67005 Blank RMVL VITREOUS ANT APPR PARTIAL REMOVAL Surgery Blank 5.89 7.15 7.15 Blank RBRVS

67010 Blank RMVL VITREOUS ANT APPR SUBTOT RMVL MECH VITRECT Surgery Blank 7.06 7.90 7.90 Blank RBRVS

67015 Blank ASPIRATION/RELEASE VITREOUS SUBRETINAL/CHOROIDAL Surgery Blank 7.14 8.89 8.89 Blank RBRVS

67025 Blank INJ SUBSTITUTE PARS PLANA/LIMBL W/WO ASPIR SPX Surgery Blank 8.11 9.35 12.03 Blank RBRVS

67027 Blank IMPLTJ INTRAVITREAL DRUG DLVR SYS RMVL VTS Surgery Blank 11.62 11.84 11.84 Blank RBRVS

67028 Blank INTRAVITREAL NJX PHARMACOLOGIC AGT SPX Surgery Blank 1.44 1.31 1.35 Blank RBRVS

67030 Blank DISCISSION VITREOUS STRANS PARS PLANA APPROACH Surgery Blank 6.11 8.63 8.63 Blank RBRVS

67031 Blank SEVERING VITREOUS STRANS LASER 1/> STAGES Surgery Blank 4.47 5.37 6.32 Blank RBRVS

67036 Blank VITRECTOMY MECHANICAL PARS PLANA Surgery Blank 12.13 12.69 12.69 Blank RBRVS

67039 Blank VITRECTOMY MCHNL PARS PLNA FOCAL ENDOLASER PC Surgery Blank 13.20 13.36 13.36 Blank RBRVS

67040 Blank VTRECTOMY MCHNL PARS PLNA ENDOLASER PANRTA PC Surgery Blank 14.50 14.19 14.19 Blank RBRVS

67041 Blank VITRECTOMY PARS PLANA REMOVE PRERETINAL MEMBRANE Surgery Blank 16.33 15.34 15.34 Blank RBRVS

67042 Blank VITRECTOMY PARS PLANA REMOVE INT MEMB RETINA Surgery Blank 16.33 15.34 15.34 Blank RBRVS

67043 Blank VITRECTOMY PARS PLANA REMOVE SUBRETINAL MEMBRANE Surgery Blank 17.40 16.04 16.04 Blank RBRVS

67101 Blank RPR RETINAL DTCHMNT 1/>SES CRYOTX/DTHRM INCL DRG Surgery Blank 3.50 4.37 5.60 Blank RBRVS

67105 Blank RPR RETINAL DTCHMNT 1/> SES PC INCL SUBRETI DRG Surgery Blank 3.39 4.21 4.82 Blank RBRVS

67107 Blank REPAIR RETINAL DETACHMENT SCLERAL BUCKLING Surgery Blank 16.00 15.12 15.12 Blank RBRVS

67108 Blank RPR RETINAL DTCHMNT W/VITRECTOMY ANY METH Surgery Blank 17.13 15.85 15.85 Blank RBRVS

67110 Blank RPR RETINAL DTCHMNT INJECTION AIR/OTHER GAS Surgery Blank 10.25 12.20 14.00 Blank RBRVS

67113 Blank RPR COMPLEX RETINA DETACH VITRECT &MEMBRANE PEEL Surgery Blank 19.00 17.82 17.82 Blank RBRVS

67115 Blank RELEASE ENCIRCLING MATERIAL POSTERIOR SEGMENT Surgery Blank 6.11 7.69 7.69 Blank RBRVS

67120 Blank RMVL IMPLNT MATL POSTERIOR SEGMENT EXTRAOCULAR Surgery Blank 7.10 8.27 11.10 Blank RBRVS

67121 Blank RMVL IMPLT MATRL POSTERIOR SEGMENT INTRAOCULAR Surgery Blank 12.25 12.76 12.76 Blank RBRVS

67141 Blank PROPH RTA DTCHMNT W/O DRG 1/> SESS CRTX DTHRM Surgery Blank 6.15 7.32 8.36 Blank RBRVS

67145 Blank PROPH RTA DTCHMNT W/O DRG 1/> SESS Surgery Blank 6.32 7.43 8.28 Blank RBRVS

67208 Blank DSTRJ LOCLZD LESION RETINA 1/> SESS CRTX DTHRM Surgery Blank 7.65 8.28 8.88 Blank RBRVS

67210 Blank DSTRJ LOCLZD LESION RETINA 1/> SESS PC Surgery Blank 6.36 7.45 7.94 Blank RBRVS

67218 Blank DSTRJ LESION RETINA 1/> SESS RADJ IMPLTJ Surgery Blank 20.36 17.58 17.58 Blank RBRVS

67220 Blank DSTRJ LESION CHOROID PC 1/> SESS Surgery Blank 6.36 7.45 8.40 Blank RBRVS

67221 Blank DSTRJ LESION CHOROID PHOTODYNAMIC THERAPY Surgery Blank 3.45 2.39 4.47 Blank RBRVS

67225 Blank DSTRJ LESION CHOROID PDT 2ND EYE 1 SESSION Surgery Blank 0.47 0.30 0.35 Blank RBRVS

67227 Blank DESTRUCTION RETINOPATHY CRYOTHERAPY DIATHERMY Surgery Blank 3.50 3.57 4.55 Blank RBRVS

67228 Blank TREATMENT EXTENSIVE RETINOPATHY PHOTOCOAGULATION Surgery Blank 4.39 4.05 5.05 Blank RBRVS

67229 Blank EXTENSIVE RETINOPATHY 1/> SESS PRETERM INFANT Surgery Blank 16.30 15.75 15.75 Blank RBRVS

67250 Blank SCLERAL REINFORCEMENT SPX W/O GRAFT Surgery Blank 9.61 11.95 11.95 Blank RBRVS

67255 Blank SCLERAL REINFORCEMENT SPX W/GRAFT Surgery Blank 8.38 10.50 10.50 Blank RBRVS

67299 Blank UNLISTED PROCEDURE POSTERIOR SEGMENT Surgery Blank Blank Blank Blank 2.79 Unlisted

67311 Blank STRABISMUS RECESSION/RESCJ 1 HRZNTL MUSC Surgery Blank 7.77 8.70 8.70 Blank RBRVS

67312 Blank STRABISMUS RECESSION/RESCJ 2 HRZNTL MUSC Surgery Blank 9.66 9.91 9.91 Blank RBRVS

67314 Blank STRABISMUS RECESSION/RESCJ 1 VER MUSC Surgery Blank 8.79 9.73 9.73 Blank RBRVS

67316 Blank STRABISMUS RECESSION/RESCJ 2/MORE VER MUSC Surgery Blank 10.93 11.15 11.15 Blank RBRVS

67318 Blank STRABISMUS ANY SUPERIOR OBLIQUE MUSCLE Surgery Blank 9.12 10.34 10.34 Blank RBRVS

67320 Blank TRANSPOSITION PROCEDURE EXTRAOCULAR MUSC Surgery Blank 5.40 3.42 3.42 Blank RBRVS

67331 Blank STRABISMUS PREVIOUS EYE X INVOLVE EO MUSC Surgery Blank 5.13 3.23 3.23 Blank RBRVS

67332 Blank STRABISMUS SCARRING EO MUSC/RSTCV MYOPATHY Surgery Blank 5.56 3.51 3.51 Blank RBRVS

67334 Blank STRABISMUS POST FIXJ SUTR TQ W/WO MUSC RECESSION Surgery Blank 5.05 3.20 3.20 Blank RBRVS

67335 Blank PLACEMENT ADJUSTABLE SUTURE STRABISMUS Surgery Blank 2.49 1.56 1.56 Blank RBRVS

67340 Blank STRABISMUS EXPL&/RPR DETACHED EXTROCULAR MUSC Surgery Blank 6.00 3.80 3.80 Blank RBRVS

67343 Blank RLS XTNSV SCAR TISS W/O DETACHING EO MUSC SPX Surgery Blank 8.47 9.44 9.44 Blank RBRVS

67345 Blank CHEMODENERVATION EXTRAOCULAR MUSCLE Surgery Blank 3.01 2.82 3.54 Blank RBRVS

67346 Blank BIOPSY EXTRAOCULAR MUSCLE Surgery Blank 2.87 2.46 2.46 Blank RBRVS

67399 Blank UNLISTED PROCEDURE EXTRAOCULAR MUSCLE Surgery Blank Blank Blank Blank 16.47 Unlisted

67400 Blank ORBITOTOMY W/O BONE FLAP EXPL W/WO BIOPSY Surgery Blank 11.20 14.47 14.47 Blank RBRVS

67405 Blank ORBITOTOMY W/O BONE FLAP EXPL W/DRAINAGE ONLY Surgery Blank 9.20 12.52 12.52 Blank RBRVS

67412 Blank ORBITOTOMY W/O BONE FLAP W/REMOVAL LESION Surgery Blank 10.30 13.17 13.17 Blank RBRVS

67413 Blank ORBITOTOMY W/O BONE FLAP W/RMVL FOREIGN BODY Surgery Blank 10.24 13.33 13.33 Blank RBRVS

67414 Blank ORBITOTOMY W/O BONE FLAP W/RMVL BONE DCMPRN Surgery Blank 17.94 18.41 18.41 Blank RBRVS

67415 Blank FINE NEEDLE ASPIRATION ORBITAL CONTENTS Surgery Blank 1.76 1.10 1.10 Blank RBRVS

67420 Blank ORBITOTOMY BONE FLAP/WINDOW LAT RMVL LESION Surgery Blank 21.87 22.32 22.32 Blank RBRVS

67430 Blank ORBITOTOMY BONE FLAP/WINDOW LATERAL RMVL FB Surgery Blank 15.29 19.13 19.13 Blank RBRVS

67440 Blank ORBITOTOMY BONE FLAP/WINDOW LATERAL W/DRG Surgery Blank 14.84 18.45 18.45 Blank RBRVS

67445 Blank ORBITOTOMY BONE FLAP/WINDOW LAT RMVL BONE DCMPRN Surgery Blank 19.12 19.32 19.32 Blank RBRVS

67450 Blank ORBITOTOMY BONE FLAP/WINDOW LAT EXPL W/WO BX Surgery Blank 15.41 19.21 19.21 Blank RBRVS

67500 Blank RETROBULBAR INJECTION MEDICATION SPX Surgery Blank 1.44 0.55 0.72 Blank RBRVS

67505 Blank RETROBULBAR INJECTION ALCOHOL Surgery Blank 1.27 0.92 1.13 Blank RBRVS

67515 Blank INJECTION MEDICATION/OTHER SUBST TENON CAPSULE Surgery Blank 1.40 1.04 1.26 Blank RBRVS

67550 Blank ORBITAL IMPLANT INSERTION Surgery Blank 11.77 14.81 14.81 Blank RBRVS

67560 Blank ORBITAL IMPLANT REMOVAL/REVISION Surgery Blank 12.18 15.05 15.05 Blank RBRVS

67570 Blank OPTIC NERVE DECOMPRESSION Surgery Blank 14.40 16.86 16.86 Blank RBRVS

67599 Blank UNLISTED PROCEDURE ORBIT Surgery Blank Blank Blank Blank 2.64 Unlisted

67700 Blank BLEPHAROTOMY DRAINAGE ABSCESS EYELID Surgery Blank 1.40 1.82 6.17 Blank RBRVS

67710 Blank SEVERING TARSORRHAPHY Surgery Blank 1.07 1.63 5.25 Blank RBRVS





PAGE 79 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

67715 Blank CANTHOTOMY SEPARATE PROCEDURE Surgery Blank 1.27 1.69 5.47 Blank RBRVS

67800 Blank EXCISION CHALAZION SINGLE Surgery Blank 1.41 1.44 2.13 Blank RBRVS

67801 Blank EXCISION CHALAZION MULTIPLE SAME LID Surgery Blank 1.91 1.76 2.59 Blank RBRVS

67805 Blank EXCISION CHALAZION MULTIPLE DIFFERENT LIDS Surgery Blank 2.27 2.25 3.33 Blank RBRVS

67808 Blank EXC CHALAZION ANES REQ HOSPIZATION SINGLE/MULT Surgery Blank 4.60 5.56 5.56 Blank RBRVS

67810 Blank INCISIONAL BIOPSY EYELID SKIN & LID MARGIN Surgery Blank 1.18 0.72 3.56 Blank RBRVS

67820 Blank CORRECTION TRICHIASIS EPILATION FORCEPS ONLY Surgery Blank 0.32 0.88 0.81 Blank RBRVS

67825 Blank CORRECTION TRICHIASIS EPILATION OTH/THAN FORCEPS Surgery Blank 1.43 1.94 2.13 Blank RBRVS

67830 Blank CORRECTION TRICHIASIS INCCISION LID MARGIN Surgery Blank 1.75 2.06 5.73 Blank RBRVS

67835 Blank CORRJ TRICHIASIS INC LID MRGN W/FR MUC MEMB GRF Surgery Blank 5.70 6.40 6.40 Blank RBRVS

67840 Blank EXC LESION EYELID W/O CLSR/W/SIMPLE DIR CLOSURE Surgery Blank 2.09 2.26 5.62 Blank RBRVS

67850 Blank DESTRUCTION LESION LID MARGIN </ 1 CM Surgery Blank 1.74 1.95 4.19 Blank RBRVS

67875 Blank TEMPORARY CLOSURE EYELIDS SUTURE Surgery Blank 1.35 1.32 3.47 Blank RBRVS

67880 Blank CONSTJ INTERMARGIN ADHES/TARSORRH/CANTHORRHAPY Surgery Blank 4.60 5.56 8.14 Blank RBRVS

67882 Blank CONSTJ INTERMARGIN ADHES/TARSOR/CANTHOR W/TRPOS Surgery Blank 6.02 7.01 9.63 Blank RBRVS

67900 Blank REPAIR BROW PTOSIS Surgery Blank 6.82 7.11 10.83 Blank RBRVS

67901 Blank RPR BLEPHAROPTOSIS FRONTALIS MUSC SUTR/OTH MATRL Surgery Blank 7.59 8.25 13.37 Blank RBRVS

67902 Blank RPR BLEPHAROPT FRONTALIS MUSC AUTOL FASCAL SLING Surgery Blank 9.82 10.01 10.01 Blank RBRVS

67903 Blank RPR BLEPHAROPTOSIS LEVATOR RESCJ/ADVMNT INTERNAL Surgery Blank 6.51 6.78 9.91 Blank RBRVS

67904 Blank RPR BLEPHAROPTOSIS LEVATOR RESCJ/ADVMNT XTRNL Surgery Blank 7.97 8.45 12.29 Blank RBRVS

67906 Blank RPR BLEPHAROPTOSIS SUPERIOR RECTUS FASCIAL SLING Surgery Blank 6.93 7.06 7.06 Blank RBRVS

67908 Blank RPR BLPOS CONJUNCTIVO-TARSO-MUSC-LEVATOR RESCJ Surgery Blank 5.30 6.42 8.39 Blank RBRVS

67909 Blank REDUCTION OVERCORRECTION PTOSIS Surgery Blank 5.57 6.49 9.28 Blank RBRVS

67911 Blank CORRECTION LID RETRACTION Surgery Blank 7.50 7.96 7.96 Blank RBRVS

67912 Blank CORRJ LAGOPHTHALMOS IMPLTJ UPR EYELID LID LOAD Surgery Blank 6.36 6.93 18.00 Blank RBRVS

67914 Blank REPAIR ECTROPION SUTURE Surgery Blank 3.75 5.30 9.35 Blank RBRVS

67915 Blank REPAIR ECTROPION THERMOCAUTERIZATION Surgery Blank 2.03 3.48 6.19 Blank RBRVS

67916 Blank REPAIR ECTROPION EXCISION TARSAL WEDGE Surgery Blank 5.48 6.38 10.96 Blank RBRVS

67917 Blank REPAIR ECTROPION EXTENSIVE Surgery Blank 5.93 6.67 10.80 Blank RBRVS

67921 Blank REPAIR ENTROPION SUTURE Surgery Blank 3.47 5.13 9.41 Blank RBRVS

67922 Blank REPAIR ENTROPION THERMOCAUTERIZATION Surgery Blank 2.03 3.46 6.11 Blank RBRVS

67923 Blank REPAIR ENTROPION EXCISION TARSAL WEDGE Surgery Blank 5.48 6.40 10.98 Blank RBRVS

67924 Blank REPAIR ENTROPION EXTENSIVE Surgery Blank 5.93 6.69 11.61 Blank RBRVS

67930 Blank SUTR WND EYELID/MARGIN/TARSUS/CONJUNC PRTL THICK Surgery Blank 3.65 2.92 6.46 Blank RBRVS

67935 Blank SUTR WND EYELID/MARGIN/TARSUS/CONJUNC FULL THICK Surgery Blank 6.36 5.70 10.03 Blank RBRVS

67938 Blank REMOVAL EMBEDDED FOREIGN BODY EYELID Surgery Blank 1.38 1.86 5.51 Blank RBRVS

67950 Blank CANTHOPLASTY Surgery Blank 5.99 6.73 9.84 Blank RBRVS

67961 Blank EXCISION & REPAIR EYELID > ONE-FOURTH LID MARGIN Surgery Blank 5.86 6.67 10.09 Blank RBRVS

67966 Blank EXCISION & REPAIR EYELID ONE-FOURTH LID MARGIN Surgery Blank 8.97 9.08 12.23 Blank RBRVS

67971 Blank RCNSTJ EYELID FULL THICKNESS </TWO-THIRDS 1 STG Surgery Blank 10.01 9.85 9.85 Blank RBRVS

67973 Blank RCNSTJ EYELID FULL THICKNESS LOWER EYELID 1 STG Surgery Blank 13.13 12.41 12.41 Blank RBRVS

67974 Blank RCNSTJ EYELID FULL THICKNESS UPPER EYELID 1 STG Surgery Blank 13.10 12.40 12.40 Blank RBRVS

67975 Blank RCNSTJ EYELID FULL THICKNESS SECOND STAGE Surgery Blank 9.35 9.44 9.44 Blank RBRVS

67999 Blank UNLISTED PROCEDURE EYELIDS Surgery Blank Blank Blank Blank 7.34 Unlisted

68020 Blank INCISION CONJUNCTIVA DRAINAGE OF CYST Surgery Blank 1.42 1.63 1.92 Blank RBRVS

68040 Blank EXPRESSION CONJUNCTIVAL FOLLICLES Surgery Blank 0.85 0.52 0.88 Blank RBRVS

68100 Blank BIOPSY CONJUNCTIVA Surgery Blank 1.35 1.33 3.43 Blank RBRVS

68110 Blank EXCISION LESION CONJUNCTIVA </1 CM Surgery Blank 1.82 2.29 4.50 Blank RBRVS

68115 Blank EXCISION LESION CONJUNCTIVA > 1 CM Surgery Blank 2.41 2.66 6.31 Blank RBRVS

68130 Blank EXCISION LESION CONJUNCTIVA ADJACENT SCLERA Surgery Blank 5.10 6.29 9.90 Blank RBRVS

68135 Blank DESTRUCTION LESION CONJUNCTIVA Surgery Blank 1.89 2.28 2.46 Blank RBRVS

68200 Blank SUBCONJUNCTIVAL INJECTION Surgery Blank 0.49 0.47 0.65 Blank RBRVS

68320 Blank CONJUNCTIVOPLASTY W/GRF/XTNSV REARRANGEMENT Surgery Blank 6.64 8.25 13.53 Blank RBRVS

68325 Blank CONJUNCTIVOPLASTY W/BUCCAL MUC MEMB GRAFT Surgery Blank 8.63 9.51 9.51 Blank RBRVS

68326 Blank CJP RCNSTJ CUL-DE-SAC BUCCAL GRF/XTNSV REARRGMT Surgery Blank 8.42 9.37 9.37 Blank RBRVS

68328 Blank CONJUNCTPL CUL-DE-SAC W/BUCCAL MUC MEMB GRAFT Surgery Blank 9.45 10.01 10.01 Blank RBRVS

68330 Blank RPR SYMBLEPHARON CONJUNCTIVOPLASTY W/O GRAFT Surgery Blank 5.78 6.95 11.04 Blank RBRVS

68335 Blank RPR SYMBLEPHARON FR GRF CJNC/BUCCAL MUC MEMB Surgery Blank 8.46 9.40 9.40 Blank RBRVS

68340 Blank RPR & DIV SYMBLEPHARON W/WO CONFORM/CONTACT LE Surgery Blank 4.97 6.06 10.22 Blank RBRVS

68360 Blank CONJUNCTIVAL FLAP BRIDGE/PARTIAL SPX Surgery Blank 5.17 6.20 9.60 Blank RBRVS

68362 Blank CONJUNCTIVAL FLAP TOTAL Surgery Blank 8.61 9.49 9.49 Blank RBRVS

68371 Blank HARVESTING CONJUNCIVAL ALLOGRAPHY LIVING DONOR Surgery Blank 5.09 6.32 6.32 Blank RBRVS

68399 Blank UNLISTED PROCEDURE CONJUNCTIVA Surgery Blank Blank Blank Blank 3.33 Unlisted

68400 Blank INCISION DRAINAGE LACRIMAL GLAND Surgery Blank 1.74 1.90 6.25 Blank RBRVS

68420 Blank INCISION DRAINAGE LACRIMAL SAC Surgery Blank 2.35 2.27 6.64 Blank RBRVS

68440 Blank SNIP INCISION LACRIMAL PUNCTUM Surgery Blank 0.99 1.77 1.85 Blank RBRVS

68500 Blank EXCISION LACRIMAL GLAND XCPT TUMOR TOTAL Surgery Blank 12.77 14.11 14.11 Blank RBRVS

68505 Blank EXCISION LACRIMAL GLAND XCPT TUMOR PRTL Surgery Blank 12.69 14.06 14.06 Blank RBRVS

68510 Blank BIOPSY LACRIMAL GLAND Surgery Blank 4.60 3.36 7.74 Blank RBRVS

68520 Blank EXCISION LACRIMAL SAC Surgery Blank 8.78 10.11 10.11 Blank RBRVS

68525 Blank BIOPSY LACRIMAL SAC Surgery Blank 4.42 2.78 2.78 Blank RBRVS

68530 Blank RMVL FB/DACRYOLITH LACRIMAL PASSAGES Surgery Blank 3.70 3.37 8.22 Blank RBRVS





PAGE 80 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

68540 Blank EXC LACRIMAL GLAND TUMOR FRONTAL APPROACH Surgery Blank 12.18 13.42 13.42 Blank RBRVS

68550 Blank EXC LACRIMAL GLAND TUMOR W/OSTEOTOMY Surgery Blank 15.16 16.20 16.20 Blank RBRVS

68700 Blank PLASTIC REPAIR CANALICULI Surgery Blank 7.87 8.78 8.78 Blank RBRVS

68705 Blank CORRECTION EVERTED PUNCTUM CAUTERY Surgery Blank 2.11 2.47 4.50 Blank RBRVS

68720 Blank DACRYOCSTORHINOSTOMY Surgery Blank 9.96 10.84 10.84 Blank RBRVS

68745 Blank CONJUNCTIVORHINOSTOMY W/O TUBE Surgery Blank 9.90 11.05 11.05 Blank RBRVS

68750 Blank CONJUNCTIVORHINOSTOMY INSJ TUBE/STENT Surgery Blank 10.10 11.54 11.54 Blank RBRVS

68760 Blank CLSR LACRIMAL PUNCTUM THERMOCAUT LIG/LASER Surgery Blank 1.78 2.26 3.85 Blank RBRVS

68761 Blank CLSR LACRIMAL PUNCTUM PLUG EACH Surgery Blank 1.41 1.90 2.73 Blank RBRVS

68770 Blank CLOSURE LACRIMAL FISTULA SPX Surgery Blank 8.29 9.05 9.05 Blank RBRVS

68801 Blank DILATION LACRIMAL PUNCTUM W/WO IRRGATION Surgery Blank 0.82 1.37 1.65 Blank RBRVS

68810 Blank PROBE NASOLACRIMAL DUCT W/WO IRRIGATION Surgery Blank 1.54 2.01 2.76 Blank RBRVS

68811 Blank PROBE NASOLACRIMAL DUCT W/WO IRRIG REQ GEN ANES Surgery Blank 1.74 2.01 2.01 Blank RBRVS

68815 Blank PROBE NASOLACRIMAL DUCT W/WO IRRG INSJ TUBE/STNT Surgery Blank 2.70 3.42 8.42 Blank RBRVS

68816 Blank PROBE NASOLACRIMAL DUCT WITH CATHETER DILATION Surgery Blank 2.10 2.24 16.21 Blank RBRVS

68840 Blank PROBE LACRIMAL CANALICULI W/WO IRRIGATION Surgery Blank 1.30 1.93 2.27 Blank RBRVS

68850 Blank INJECTION CONTRAST MEDIUM DACRYOCYSTOGRAPY Surgery Blank 0.80 0.73 0.91 Blank RBRVS

68899 Blank UNLISTED PROCEDURE LACRIMAL SYSTEM Surgery Blank Blank Blank Blank 4.13 Unlisted

69000 Blank DRAINAGE EXTERNAL EAR ABSCESS/HEMATOMA SIMPLE Surgery Blank 1.50 1.70 3.61 Blank RBRVS

69005 Blank DRAINAGE EXTERNAL EAR ABSCESS/HEMATOMA CMPLX Surgery Blank 2.16 1.97 3.56 Blank RBRVS

69020 Blank DRAINAGE EXTERNAL AUDITORY CANAL ABSCESS Surgery Blank 1.53 2.26 4.76 Blank RBRVS

69090 Blank EAR PIERCING Miscellaneous Medical Blank Blank Blank Blank 0.69 FAIR Health

69100 Blank BIOPSY EXTERNAL EAR Surgery Blank 0.81 0.49 1.95 Blank RBRVS

69105 Blank BIOPSY EXTERNAL AUDITORY CANAL Surgery Blank 0.85 0.83 2.96 Blank RBRVS

69110 Blank EXCISION EXTERNAL EAR PARTIAL SIMPLE REPAIR Surgery Blank 3.53 5.14 8.91 Blank RBRVS

69120 Blank EXCISION EXTERNAL EAR COMPLETE AMPUTATION Surgery Blank 4.14 6.76 6.76 Blank RBRVS

69140 Blank EXCISION EXOSTOSIS EXTERNAL AUDITORY CANAL Surgery Blank 8.14 15.41 15.41 Blank RBRVS

69145 Blank EXCISION SOFT TIS LESION EXTERNAL AUDITORY CANAL Surgery Blank 2.70 3.94 8.03 Blank RBRVS

69150 Blank RAD EXC XTRNL AUDITORY CANAL LES W/O NCK DSJ Surgery Blank 13.61 13.87 13.87 Blank RBRVS

69155 Blank RAD EXC XTRNL AUDITORY CANAL LES NCK DSJ Surgery Blank 23.35 20.28 20.28 Blank RBRVS

69200 Blank RMVL FB XTRNL AUDITORY CANAL W/O ANES Surgery Blank 0.77 0.48 1.46 Blank RBRVS

69205 Blank RMVL FB XTRNL AUDITORY CANAL ANES Surgery Blank 1.21 1.48 1.48 Blank RBRVS

69209 Blank REMOVAL IMPACTED CERUMEN IRRIGATION/LVG UNILAT Surgery Blank Blank 0.39 0.39 Blank RBRVS

69210 Blank REMOVAL IMPACTED CERUMEN INSTRUMENTATION UNILAT Surgery Blank 0.61 0.26 0.70 Blank RBRVS

69220 Blank DEBRIDEMENT MASTOIDECTOMY CAVITY SIMPLE Surgery Blank 0.83 0.52 1.37 Blank RBRVS

69222 Blank DEBRIDEMENT MASTOIDECTOMY CAVITY CMPLX Surgery Blank 1.45 2.19 4.47 Blank RBRVS

69300 Blank OTOPLASTY PROTRUDING EAR W/WO SIZE RDCTJ Surgery Blank 6.44 6.39 10.39 Blank RBRVS

69310 Blank RECONSTRUCTION EXTERNAL AUDITORY CANAL SPX Surgery Blank 10.97 18.16 18.16 Blank RBRVS

69320 Blank RCNSTJ XTRNL AUD CANAL CONGENITAL ATRESIA 1 STG Surgery Blank 17.18 23.47 23.47 Blank RBRVS

69399 Blank UNLISTED PROCEDURE EXTERNAL EAR Surgery Blank Blank Blank Blank 1.30 Unlisted

69420 Blank MYRINGOTOMY ASPIR&/EUSTACHIAN TUBE NFLTJ Surgery Blank 1.38 1.82 3.81 Blank RBRVS

69421 Blank MYRINGOTOMY ASPIR&/EUSTACHIAN TUBE NFLTJ ANES Surgery Blank 1.78 2.16 2.16 Blank RBRVS

69424 Blank VENTILATING TUBE RMVL REQUIRING GENERAL ANES Surgery Blank 0.85 0.78 2.63 Blank RBRVS

69433 Blank TYMPANOSTOMY LOCAL/TOPICAL ANESTHESIA Surgery Blank 1.57 1.94 3.89 Blank RBRVS

69436 Blank TYMPANOSTOMY GENERAL ANESTHESIA Surgery Blank 2.01 2.22 2.22 Blank RBRVS

69440 Blank MIDDLE EAR EXPL THRU POSTAUR/EAR CANAL INC Surgery Blank 7.71 10.59 10.59 Blank RBRVS

69450 Blank TYMPANOLYSIS TRANSCANAL Surgery Blank 5.69 8.89 8.89 Blank RBRVS

69501 Blank TRANSMASTOID ANTROTOMY Surgery Blank 9.21 10.13 10.13 Blank RBRVS

69502 Blank MASTOIDECTOMY COMPLETE Surgery Blank 12.56 13.07 13.07 Blank RBRVS

69505 Blank MASTOIDECTOMY MODIFIED RADICAL Surgery Blank 13.17 18.90 18.90 Blank RBRVS

69511 Blank MASTOIDECTOMY RADICAL Surgery Blank 13.70 19.12 19.12 Blank RBRVS

69530 Blank PETROUS APICECTOMY RADICAL MASTOIDECTOMY Surgery Blank 20.38 23.37 23.37 Blank RBRVS

69535 Blank RESCJ TEMPORAL BONE EXTERNAL APPROACH Surgery Blank 37.42 33.05 33.05 Blank RBRVS

69540 Blank EXCISION AURAL POLYP Surgery Blank 1.25 2.15 4.42 Blank RBRVS

69550 Blank EXCISION AURAL GLOMUS TUMOR TRANSCANAL Surgery Blank 11.15 16.61 16.61 Blank RBRVS

69552 Blank EXCISION AURAL GLOMUS TUMOR TRANSMASTOID Surgery Blank 19.81 21.69 21.69 Blank RBRVS

69554 Blank EXCISION AURAL GLOMUS TUMOR EXTENDED Surgery Blank 35.97 30.16 30.16 Blank RBRVS

69601 Blank REVJ MASTOIDECTOMY RSLTG COMPL MASTOIDECTOMY Surgery Blank 13.45 14.17 14.17 Blank RBRVS

69602 Blank REVJ MASTOIDECTOMY RSLTG MODF RAD MSTDC Surgery Blank 13.76 14.98 14.98 Blank RBRVS

69603 Blank REVJ MASTOIDECTOMY RSLTG RAD MASTOIDECTOMY Surgery Blank 14.20 19.33 19.33 Blank RBRVS

69604 Blank REVJ MASTOIDECTOMY RSLTG TYMPANOPLASTY Surgery Blank 14.20 15.17 15.17 Blank RBRVS

69605 Blank REVJ MASTOIDECTOMY W/APICECTOMY Surgery Blank 18.69 22.67 22.67 Blank RBRVS

69610 Blank TYMPANIC MEMB RPR W/WO PREPJ PERFOR PATCH Surgery Blank 4.47 3.13 5.72 Blank RBRVS

69620 Blank MYRINGOPLASTY Surgery Blank 6.03 6.89 12.57 Blank RBRVS

69631 Blank TYMPANOPLASTY W/O MASTOIDECT W/O OSSICLE RECNSTJ Surgery Blank 10.05 13.44 13.44 Blank RBRVS

69632 Blank TYMPNOPLSTY W/O MSTDC 1ST/REVJ W/OSICLE RECNSTJ Surgery Blank 12.96 15.60 15.60 Blank RBRVS

69633 Blank TYMPANOPLASTY W/O MASTOIDEC 1ST/REVJ PROSTH TORP Surgery Blank 12.31 15.37 15.37 Blank RBRVS

69635 Blank TYMPP ANTRT/MASTOID W/O OSSICULAR CHAIN RECNSTJ Surgery Blank 13.51 19.34 19.34 Blank RBRVS

69636 Blank TYMPP ANTRT/MASTOID W/OSSICULAR CHAIN RECNSTJ Surgery Blank 15.43 21.30 21.30 Blank RBRVS

69637 Blank TMPP ANTRT/MASTOIDOTOMY PROSTHESIS TORP Surgery Blank 15.32 21.78 21.78 Blank RBRVS

69641 Blank TMPP MASTOIDECTOMY W/O OSSICULAR CHAIN RECNSTJ Surgery Blank 12.89 14.66 14.66 Blank RBRVS

69642 Blank TMPP MASTOIDECTOMY W/OSSICULAR CHAIN RECNSTJ Surgery Blank 17.06 18.22 18.22 Blank RBRVS





PAGE 81 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

69643 Blank TMPP MASTOIDECT NTC/RCNSTED WALL W/O OCR Surgery Blank 15.59 16.71 16.71 Blank RBRVS

69644 Blank TMPP MASTOIDECT NTC/RCNSTED CANAL WALL OCR Surgery Blank 17.23 22.02 22.02 Blank RBRVS

69645 Blank TYMPANOPLASTY MASTOIDECTOMY RAD/COMPL W/O OCR Surgery Blank 16.71 21.82 21.82 Blank RBRVS

69646 Blank TYMPANOPLASTY MASTOIDECTOMY RAD/COMPL W/OCR Surgery Blank 18.37 22.64 22.64 Blank RBRVS

69650 Blank STAPES MOBILIZATION Surgery Blank 9.80 11.48 11.48 Blank RBRVS

69660 Blank STAPEDECTOMY/STAPEDOTOMY Surgery Blank 12.03 12.42 12.42 Blank RBRVS

69661 Blank STAPEDECTOMY/STAPEDOTOMY W/FOOTPLATE DRILL OUT Surgery Blank 15.92 15.90 15.90 Blank RBRVS

69662 Blank REVISION STAPEDECTOMY/STAPEDOTOMY Surgery Blank 15.60 14.87 14.87 Blank RBRVS

69666 Blank REPAIR OVAL WINDOW FISTULA Surgery Blank 9.89 11.56 11.56 Blank RBRVS

69667 Blank REPAIR ROUND WINDOW FISTULA Surgery Blank 9.90 11.58 11.58 Blank RBRVS

69670 Blank MASTOID OBLITERATION SEPARATE PROCEDURE Surgery Blank 11.73 13.38 13.38 Blank RBRVS

69676 Blank TYMPANIC NEURECTOMY Surgery Blank 9.69 12.36 12.36 Blank RBRVS

69700 Blank CLOSURE POSTAURICULAR FISTULA MASTOID SPX Surgery Blank 8.37 9.77 9.77 Blank RBRVS

69710 Blank IMPLTJ/RPLCMT EMGNT BONE CNDJ DEV TEMPORAL BONE Surgery Blank Blank Blank Blank 15.23 FAIR Health

69711 Blank RMVL/RPR EMGNT BONE CNDJ DEV TEMPORAL BONE Surgery Blank 10.62 12.19 12.19 Blank RBRVS

69714 Blank IMPLTJ OSSEOINTEGRATED TEMPORAL BONE W/MASTOID Surgery Blank 14.45 13.91 13.91 Blank RBRVS

69715 Blank IMPLJ OSSEOINTEGRATED TEMPORAL BONE W/O MASTOID Surgery Blank 18.96 15.90 15.90 Blank RBRVS

69717 Blank RPLMCT OSSEOINTEGRATE IMPLNT W/O MASTOIDECTOMY Surgery Blank 15.43 14.28 14.28 Blank RBRVS

69718 Blank RPLMCT OSSEOINTEGRATE IMPLNT W/MASTOIDECTOMY Surgery Blank 19.21 16.01 16.01 Blank RBRVS

69720 Blank DCMPRN FACIAL NRV INTRATEMPORAL LAT GANGLION Surgery Blank 14.71 17.14 17.14 Blank RBRVS

69725 Blank DCMPRN NRV INTRATEMPORAL MEDIAL GENICULATE Surgery Blank 27.64 21.60 21.60 Blank RBRVS

69740 Blank SUTR NRV ITPRL W/WO GRF/DCMPRN LAT GENICULATE Surgery Blank 16.27 14.40 14.40 Blank RBRVS

69745 Blank SUTR NRV ITPRL W/WO GRF/DCMPRN MEDIAL GENICULATE Surgery Blank 17.02 15.65 15.65 Blank RBRVS

69799 Blank UNLISTED PROCEDURE MIDDLE EAR Surgery Blank Blank Blank Blank 5.35 Unlisted

69801 Blank LABYRINTHOTOMY TRANSCANAL Surgery Blank 2.06 1.21 3.16 Blank RBRVS

69805 Blank ENDOLYMPHATIC SAC W/O SHUNT Surgery Blank 14.71 12.99 12.99 Blank RBRVS

69806 Blank ENDOLYMPHATIC SAC SHUNT Surgery Blank 12.63 12.25 12.25 Blank RBRVS

69905 Blank LABYRINTHECTOMY TRANSCANAL Surgery Blank 11.26 13.02 13.02 Blank RBRVS

69910 Blank LABYRINTHECTOMY W/MASTOIDECTOMY Surgery Blank 13.91 12.85 12.85 Blank RBRVS

69915 Blank VESTIBULAR NRV SECTION TRANSLABYRINTHINE APPR Surgery Blank 22.77 17.51 17.51 Blank RBRVS

69930 Blank COCHLEAR DEVICE IMPLANTATION W/WO MASTOIDECTOMY Surgery Blank 17.73 14.36 14.36 Blank RBRVS

69949 Blank UNLISTED PROCEDURE INNER EAR Surgery Blank Blank Blank Blank 27.70 Unlisted

69950 Blank VESTIBULAR NRV SECTION TRANSCRANIAL APPROACH Surgery Blank 27.63 18.89 18.89 Blank RBRVS

69955 Blank TOTAL FACIAL NERVE DECOMPRESSION &/REPAIR Surgery Blank 29.42 22.36 22.36 Blank RBRVS

69960 Blank DECOMPRESSION INTERNAL AUDITORY CANAL Surgery Blank 29.42 20.86 20.86 Blank RBRVS

69970 Blank REMOVAL TUMOR TEMPORAL BONE Surgery Blank 32.41 23.60 23.60 Blank RBRVS

69979 Blank UNLISTED PROCEDURE TEMPORAL BONE MIDDLE FOSSA Surgery Blank Blank Blank Blank 50.28 Unlisted

69990 Blank MICROSURG TQS REQ USE OPERATING MICROSCOPE Surgery Blank 3.46 1.60 1.60 Blank RBRVS

70010 Blank MYELOGRAPY POST FOSSA RS&I Radiology a Blank Blank Blank 1.63 Global/TC/26

70010 26 MYELOGRAPY POST FOSSA RS&I Radiology Blank Blank Blank Blank 0.42 Global/TC/26

70010 TC MYELOGRAPY POST FOSSA RS&I Radiology a Blank Blank Blank 1.21 Global/TC/26

70015 Blank CISTERNOGRAPHY POSITIVE CONTRAST RS&I Radiology a 1.19 2.82 2.82 Blank RBRVS

70015 26 CISTERNOGRAPHY POSITIVE CONTRAST RS&I Radiology Blank 1.19 0.44 0.44 Blank RBRVS

70015 TC CISTERNOGRAPHY POSITIVE CONTRAST RS&I Radiology a Blank 2.38 2.38 Blank RBRVS

70030 Blank RADIOLOGIC EXAMINATION EYE DETECT FOREIGN BODY Radiology a 0.17 0.60 0.60 Blank RBRVS

70030 26 RADIOLOGIC EXAMINATION EYE DETECT FOREIGN BODY Radiology Blank 0.17 0.06 0.06 Blank RBRVS

70030 TC RADIOLOGIC EXAMINATION EYE DETECT FOREIGN BODY Radiology a Blank 0.54 0.54 Blank RBRVS

70100 Blank RADIOLOGIC EXAMINATION MANDIPLE PRTL <4 VIEWS Radiology a 0.18 0.73 0.73 Blank RBRVS

70100 26 RADIOLOGIC EXAMINATION MANDIPLE PRTL <4 VIEWS Radiology Blank 0.18 0.07 0.07 Blank RBRVS

70100 TC RADIOLOGIC EXAMINATION MANDIPLE PRTL <4 VIEWS Radiology a Blank 0.66 0.66 Blank RBRVS

70110 Blank RADIOLOG EXAM MANDIBLE COMPL MINIMUM 4 VIEWS Radiology a 0.25 0.80 0.80 Blank RBRVS

70110 26 RADIOLOG EXAM MANDIBLE COMPL MINIMUM 4 VIEWS Radiology Blank 0.25 0.10 0.10 Blank RBRVS

70110 TC RADIOLOG EXAM MANDIBLE COMPL MINIMUM 4 VIEWS Radiology a Blank 0.70 0.70 Blank RBRVS

70120 Blank RADIOLOGIC EXAM MASTOIDS < 3 VIEWS PER SIDE Radiology a 0.18 0.74 0.74 Blank RBRVS

70120 26 RADIOLOGIC EXAM MASTOIDS < 3 VIEWS PER SIDE Radiology Blank 0.18 0.07 0.07 Blank RBRVS

70120 TC RADIOLOGIC EXAM MASTOIDS < 3 VIEWS PER SIDE Radiology a Blank 0.67 0.67 Blank RBRVS

70130 Blank RADEX MASTOIDS COMPL MINIMUM 3 VIEWS PR SIDE Radiology a 0.34 1.16 1.16 Blank RBRVS

70130 26 RADEX MASTOIDS COMPL MINIMUM 3 VIEWS PR SIDE Radiology Blank 0.34 0.13 0.13 Blank RBRVS

70130 TC RADEX MASTOIDS COMPL MINIMUM 3 VIEWS PR SIDE Radiology a Blank 1.03 1.03 Blank RBRVS

70134 Blank RADEX INTERNAL AUDITORY MEATI COMPLETE Radiology a 0.34 1.05 1.05 Blank RBRVS

70134 26 RADEX INTERNAL AUDITORY MEATI COMPLETE Radiology Blank 0.34 0.14 0.14 Blank RBRVS

70134 TC RADEX INTERNAL AUDITORY MEATI COMPLETE Radiology a Blank 0.91 0.91 Blank RBRVS

70140 Blank RADEX FACIAL BONES < 3 VIEWS Radiology a 0.19 0.63 0.63 Blank RBRVS

70140 26 RADEX FACIAL BONES < 3 VIEWS Radiology Blank 0.19 0.10 0.10 Blank RBRVS

70140 TC RADEX FACIAL BONES < 3 VIEWS Radiology a Blank 0.53 0.53 Blank RBRVS

70150 Blank RADEX FACIAL BONES COMPLETE MINIMUM 3 VIEWS Radiology a 0.26 0.89 0.89 Blank RBRVS

70150 26 RADEX FACIAL BONES COMPLETE MINIMUM 3 VIEWS Radiology Blank 0.26 0.11 0.11 Blank RBRVS

70150 TC RADEX FACIAL BONES COMPLETE MINIMUM 3 VIEWS Radiology a Blank 0.78 0.78 Blank RBRVS

70160 Blank RADEX NASAL BONES COMPLETE MINIMUM 3 VIEWS Radiology a 0.17 0.74 0.74 Blank RBRVS

70160 26 RADEX NASAL BONES COMPLETE MINIMUM 3 VIEWS Radiology Blank 0.17 0.07 0.07 Blank RBRVS

70160 TC RADEX NASAL BONES COMPLETE MINIMUM 3 VIEWS Radiology a Blank 0.67 0.67 Blank RBRVS

70170 Blank DACRYOCSTOGRAPY NASOLACRIMAL DUCT RS&I Radiology a Blank Blank Blank 1.03 Global/TC/26





PAGE 82 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

70170 26 DACRYOCSTOGRAPY NASOLACRIMAL DUCT RS&I Radiology Blank Blank Blank Blank 0.41 Global/TC/26

70170 TC DACRYOCSTOGRAPY NASOLACRIMAL DUCT RS&I Radiology a Blank Blank Blank 0.62 Global/TC/26

70190 Blank RADEX OPTIC FORAMINA Radiology a 0.21 0.78 0.78 Blank RBRVS

70190 26 RADEX OPTIC FORAMINA Radiology Blank 0.21 0.10 0.10 Blank RBRVS

70190 TC RADEX OPTIC FORAMINA Radiology a Blank 0.68 0.68 Blank RBRVS

70200 Blank RADEX ORBITS COMPLETE MINIMUM 4 VIEWS Radiology a 0.28 0.90 0.90 Blank RBRVS

70200 26 RADEX ORBITS COMPLETE MINIMUM 4 VIEWS Radiology Blank 0.28 0.12 0.12 Blank RBRVS

70200 TC RADEX ORBITS COMPLETE MINIMUM 4 VIEWS Radiology a Blank 0.78 0.78 Blank RBRVS

70210 Blank RADEX SINUSES PARANASAL <3 VIEWS Radiology a 0.17 0.65 0.65 Blank RBRVS

70210 26 RADEX SINUSES PARANASAL <3 VIEWS Radiology Blank 0.17 0.07 0.07 Blank RBRVS

70210 TC RADEX SINUSES PARANASAL <3 VIEWS Radiology a Blank 0.58 0.58 Blank RBRVS

70220 Blank RADEX SINUSES PARANASAL COMPL MINIMUM 3 VIEWS Radiology a 0.25 0.79 0.79 Blank RBRVS

70220 26 RADEX SINUSES PARANASAL COMPL MINIMUM 3 VIEWS Radiology Blank 0.25 0.10 0.10 Blank RBRVS

70220 TC RADEX SINUSES PARANASAL COMPL MINIMUM 3 VIEWS Radiology a Blank 0.69 0.69 Blank RBRVS

70240 Blank RADIOLOGIC EXAMINATION SELLA TURCICA Radiology a 0.19 0.66 0.66 Blank RBRVS

70240 26 RADIOLOGIC EXAMINATION SELLA TURCICA Radiology Blank 0.19 0.08 0.08 Blank RBRVS

70240 TC RADIOLOGIC EXAMINATION SELLA TURCICA Radiology a Blank 0.58 0.58 Blank RBRVS

70250 Blank RADIOLOGIC EXAMINATION SKULL 4/> VIEWS Radiology a 0.24 0.77 0.77 Blank RBRVS

70250 26 RADIOLOGIC EXAMINATION SKULL 4/> VIEWS Radiology Blank 0.24 0.11 0.11 Blank RBRVS

70250 TC RADIOLOGIC EXAMINATION SKULL 4/> VIEWS Radiology a Blank 0.66 0.66 Blank RBRVS

70260 Blank RADIOLOGIC EXAM SKULL COMPLETE MINIMUM 4 VIEWS Radiology a 0.34 0.92 0.92 Blank RBRVS

70260 26 RADIOLOGIC EXAM SKULL COMPLETE MINIMUM 4 VIEWS Radiology Blank 0.34 0.14 0.14 Blank RBRVS

70260 TC RADIOLOGIC EXAM SKULL COMPLETE MINIMUM 4 VIEWS Radiology a Blank 0.78 0.78 Blank RBRVS

70300 Blank RADIOLOGIC EXAMINATION TEETH 1 VIEW Radiology a 0.10 0.30 0.30 Blank RBRVS

70300 26 RADIOLOGIC EXAMINATION TEETH 1 VIEW Radiology Blank 0.10 0.06 0.06 Blank RBRVS

70300 TC RADIOLOGIC EXAMINATION TEETH 1 VIEW Radiology a Blank 0.24 0.24 Blank RBRVS

70310 Blank RADIOLOGIC EXAM TEETH PRTL EXAM < FULL MOUTH Radiology a 0.16 0.87 0.87 Blank RBRVS

70310 26 RADIOLOGIC EXAM TEETH PRTL EXAM < FULL MOUTH Radiology Blank 0.16 0.06 0.06 Blank RBRVS

70310 TC RADIOLOGIC EXAM TEETH PRTL EXAM < FULL MOUTH Radiology a Blank 0.81 0.81 Blank RBRVS

70320 Blank RADIOLOGIC EXAM TEETH COMPLETE FULL MOUTH Radiology a 0.22 1.24 1.24 Blank RBRVS

70320 26 RADIOLOGIC EXAM TEETH COMPLETE FULL MOUTH Radiology Blank 0.22 0.11 0.11 Blank RBRVS

70320 TC RADIOLOGIC EXAM TEETH COMPLETE FULL MOUTH Radiology a Blank 1.13 1.13 Blank RBRVS

70328 Blank RADEX TEMPOROMANDBLE JT OPN & CLSD MOUTH UNILAT Radiology a 0.18 0.66 0.66 Blank RBRVS

70328 26 RADEX TEMPOROMANDBLE JT OPN & CLSD MOUTH UNILAT Radiology Blank 0.18 0.07 0.07 Blank RBRVS

70328 TC RADEX TEMPOROMANDBLE JT OPN & CLSD MOUTH UNILAT Radiology a Blank 0.59 0.59 Blank RBRVS

70330 Blank RADEX TEMPOROMANDBLE JT OPN & CLSD MOUTH BILAT Radiology a 0.24 1.07 1.07 Blank RBRVS

70330 26 RADEX TEMPOROMANDBLE JT OPN & CLSD MOUTH BILAT Radiology Blank 0.24 0.10 0.10 Blank RBRVS

70330 TC RADEX TEMPOROMANDBLE JT OPN & CLSD MOUTH BILAT Radiology a Blank 0.97 0.97 Blank RBRVS

70332 Blank TEMPOROMANDBLE JT ARTHROGRAPHY RS&I Radiology a 0.54 1.42 1.42 Blank RBRVS

70332 26 TEMPOROMANDBLE JT ARTHROGRAPHY RS&I Radiology Blank 0.54 0.20 0.20 Blank RBRVS

70332 TC TEMPOROMANDBLE JT ARTHROGRAPHY RS&I Radiology a Blank 1.22 1.22 Blank RBRVS

70336 Blank MRI TEMPOROMANDIBULAR JOINT Radiology a 1.48 7.54 7.54 Blank RBRVS

70336 26 MRI TEMPOROMANDIBULAR JOINT Radiology Blank 1.48 0.53 0.53 Blank RBRVS

70336 TC MRI TEMPOROMANDIBULAR JOINT Radiology a Blank 7.01 7.01 Blank RBRVS

70350 Blank CEPHALOGRAM ORTHODONTIC Radiology a 0.17 0.35 0.35 Blank RBRVS

70350 26 CEPHALOGRAM ORTHODONTIC Radiology Blank 0.17 0.09 0.09 Blank RBRVS

70350 TC CEPHALOGRAM ORTHODONTIC Radiology a Blank 0.26 0.26 Blank RBRVS

70355 Blank ORTHOPANTOGRAM Radiology a 0.20 0.36 0.36 Blank RBRVS

70355 26 ORTHOPANTOGRAM Radiology Blank 0.20 0.10 0.10 Blank RBRVS

70355 TC ORTHOPANTOGRAM Radiology a Blank 0.26 0.26 Blank RBRVS

70360 Blank RADIOLOGIC EXAMINATION NECK SOFT TISSUE Radiology a 0.17 0.61 0.61 Blank RBRVS

70360 26 RADIOLOGIC EXAMINATION NECK SOFT TISSUE Radiology Blank 0.17 0.06 0.06 Blank RBRVS

70360 TC RADIOLOGIC EXAMINATION NECK SOFT TISSUE Radiology a Blank 0.55 0.55 Blank RBRVS

70370 Blank RADEX PHARYNX/LARX W/FLUOR&/MAGNIFICATION TQ Radiology a 0.32 1.69 1.69 Blank RBRVS

70370 26 RADEX PHARYNX/LARX W/FLUOR&/MAGNIFICATION TQ Radiology Blank 0.32 0.12 0.12 Blank RBRVS

70370 TC RADEX PHARYNX/LARX W/FLUOR&/MAGNIFICATION TQ Radiology a Blank 1.57 1.57 Blank RBRVS

70371 Blank CPLX DYNAMIC PHARYNGEAL&SP EVAL C/V REC Radiology a 0.84 1.62 1.62 Blank RBRVS

70371 26 CPLX DYNAMIC PHARYNGEAL&SP EVAL C/V REC Radiology Blank 0.84 0.30 0.30 Blank RBRVS

70371 TC CPLX DYNAMIC PHARYNGEAL&SP EVAL C/V REC Radiology a Blank 1.32 1.32 Blank RBRVS

70380 Blank RADIOLOGIC EXAMINATION SALIVARY GLAND CALCULUS Radiology a 0.17 0.72 0.72 Blank RBRVS

70380 26 RADIOLOGIC EXAMINATION SALIVARY GLAND CALCULUS Radiology Blank 0.17 0.06 0.06 Blank RBRVS

70380 TC RADIOLOGIC EXAMINATION SALIVARY GLAND CALCULUS Radiology a Blank 0.66 0.66 Blank RBRVS

70390 Blank SIALOGRAPHY RS&I Radiology a 0.38 2.25 2.25 Blank RBRVS

70390 26 SIALOGRAPHY RS&I Radiology Blank 0.38 0.14 0.14 Blank RBRVS

70390 TC SIALOGRAPHY RS&I Radiology a Blank 2.11 2.11 Blank RBRVS

70450 Blank CT HEAD/BRAIN W/O CONTRAST MATERIAL Radiology a 0.85 2.37 2.37 Blank RBRVS

70450 26 CT HEAD/BRAIN W/O CONTRAST MATERIAL Radiology Blank 0.85 0.31 0.31 Blank RBRVS

70450 TC CT HEAD/BRAIN W/O CONTRAST MATERIAL Radiology a Blank 2.06 2.06 Blank RBRVS

70460 Blank CT HEAD/BRAIN W/CONTRAST MATERIAL Radiology a 1.13 3.41 3.41 Blank RBRVS

70460 26 CT HEAD/BRAIN W/CONTRAST MATERIAL Radiology Blank 1.13 0.42 0.42 Blank RBRVS

70460 TC CT HEAD/BRAIN W/CONTRAST MATERIAL Radiology a Blank 2.99 2.99 Blank RBRVS

70470 Blank CT HEAD/BRAIN W/O & W/CONTRAST MATERIAL Radiology a 1.27 4.07 4.07 Blank RBRVS





PAGE 83 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

70470 26 CT HEAD/BRAIN W/O & W/CONTRAST MATERIAL Radiology Blank 1.27 0.47 0.47 Blank RBRVS

70470 TC CT HEAD/BRAIN W/O & W/CONTRAST MATERIAL Radiology a Blank 3.60 3.60 Blank RBRVS

70480 Blank CT ORBIT SELLA/POST FOSSA/EAR W/O CONTRAST MATRL Radiology a 1.28 5.23 5.23 Blank RBRVS

70480 26 CT ORBIT SELLA/POST FOSSA/EAR W/O CONTRAST MATRL Radiology Blank 1.28 0.47 0.47 Blank RBRVS

70480 TC CT ORBIT SELLA/POST FOSSA/EAR W/O CONTRAST MATRL Radiology a Blank 4.76 4.76 Blank RBRVS

70481 Blank CT ORBIT SELLA/POST FOSSA/EAR W/CONTRAST MATRL Radiology a 1.38 6.33 6.33 Blank RBRVS

70481 26 CT ORBIT SELLA/POST FOSSA/EAR W/CONTRAST MATRL Radiology Blank 1.38 0.51 0.51 Blank RBRVS

70481 TC CT ORBIT SELLA/POST FOSSA/EAR W/CONTRAST MATRL Radiology a Blank 5.82 5.82 Blank RBRVS

70482 Blank CT ORBIT SELLA/POST FOSSA/EAR W/O & W/CONTR MATR Radiology a 1.45 6.95 6.95 Blank RBRVS

70482 26 CT ORBIT SELLA/POST FOSSA/EAR W/O & W/CONTR MATR Radiology Blank 1.45 0.53 0.53 Blank RBRVS

70482 TC CT ORBIT SELLA/POST FOSSA/EAR W/O & W/CONTR MATR Radiology a Blank 6.42 6.42 Blank RBRVS

70486 Blank CT MAXILLOFACIAL W/O CONTRAST MATERIAL Radiology a 0.85 3.03 3.03 Blank RBRVS

70486 26 CT MAXILLOFACIAL W/O CONTRAST MATERIAL Radiology Blank 0.85 0.32 0.32 Blank RBRVS

70486 TC CT MAXILLOFACIAL W/O CONTRAST MATERIAL Radiology a Blank 2.71 2.71 Blank RBRVS

70487 Blank CT MAXILLOFACIAL W/CONTRAST MATERIAL Radiology a 1.13 3.54 3.54 Blank RBRVS

70487 26 CT MAXILLOFACIAL W/CONTRAST MATERIAL Radiology Blank 1.13 0.41 0.41 Blank RBRVS

70487 TC CT MAXILLOFACIAL W/CONTRAST MATERIAL Radiology a Blank 3.13 3.13 Blank RBRVS

70488 Blank CT MAXILLOFACIAL W/O & W/CONTRAST MATERIAL Radiology a 1.27 4.43 4.43 Blank RBRVS

70488 26 CT MAXILLOFACIAL W/O & W/CONTRAST MATERIAL Radiology Blank 1.27 0.47 0.47 Blank RBRVS

70488 TC CT MAXILLOFACIAL W/O & W/CONTRAST MATERIAL Radiology a Blank 3.96 3.96 Blank RBRVS

70490 Blank CT SOFT TISSUE NECK W/O CONTRAST MATERIAL Radiology a 1.28 3.40 3.40 Blank RBRVS

70490 26 CT SOFT TISSUE NECK W/O CONTRAST MATERIAL Radiology Blank 1.28 0.48 0.48 Blank RBRVS

70490 TC CT SOFT TISSUE NECK W/O CONTRAST MATERIAL Radiology a Blank 2.92 2.92 Blank RBRVS

70491 Blank CT SOFT TISSUE NECK W/CONTRAST MATERIAL Radiology a 1.38 4.28 4.28 Blank RBRVS

70491 26 CT SOFT TISSUE NECK W/CONTRAST MATERIAL Radiology Blank 1.38 0.51 0.51 Blank RBRVS

70491 TC CT SOFT TISSUE NECK W/CONTRAST MATERIAL Radiology a Blank 3.77 3.77 Blank RBRVS

70492 Blank CT SOFT TISSUE NECK W/O & W/CONTRAST MATERIAL Radiology a 1.62 5.21 5.21 Blank RBRVS

70492 26 CT SOFT TISSUE NECK W/O & W/CONTRAST MATERIAL Radiology Blank 1.62 0.60 0.60 Blank RBRVS

70492 TC CT SOFT TISSUE NECK W/O & W/CONTRAST MATERIAL Radiology a Blank 4.61 4.61 Blank RBRVS

70496 Blank CT ANGIOGRAPHY HEAD W/CONTRAST/NONCONTRAST Radiology a 1.75 6.42 6.42 Blank RBRVS

70496 26 CT ANGIOGRAPHY HEAD W/CONTRAST/NONCONTRAST Radiology Blank 1.75 0.64 0.64 Blank RBRVS

70496 TC CT ANGIOGRAPHY HEAD W/CONTRAST/NONCONTRAST Radiology a Blank 5.78 5.78 Blank RBRVS

70498 Blank CT ANGIOGRAPHY NECK W/CONTRAST/NONCONTRAST Radiology a 1.75 6.40 6.40 Blank RBRVS

70498 26 CT ANGIOGRAPHY NECK W/CONTRAST/NONCONTRAST Radiology Blank 1.75 0.64 0.64 Blank RBRVS

70498 TC CT ANGIOGRAPHY NECK W/CONTRAST/NONCONTRAST Radiology a Blank 5.76 5.76 Blank RBRVS

70540 Blank MRI ORBIT FACE &/NECK W/O CONTRAST Radiology a 1.35 6.24 6.24 Blank RBRVS

70540 26 MRI ORBIT FACE &/NECK W/O CONTRAST Radiology Blank 1.35 0.49 0.49 Blank RBRVS

70540 TC MRI ORBIT FACE &/NECK W/O CONTRAST Radiology a Blank 5.75 5.75 Blank RBRVS

70542 Blank MRI ORBIT FACE & NECK W/CONTRAST MATERIAL Radiology a 1.62 7.38 7.38 Blank RBRVS

70542 26 MRI ORBIT FACE & NECK W/CONTRAST MATERIAL Radiology Blank 1.62 0.60 0.60 Blank RBRVS

70542 TC MRI ORBIT FACE & NECK W/CONTRAST MATERIAL Radiology a Blank 6.78 6.78 Blank RBRVS

70543 Blank MRI ORBIT FACE & NECK W/O & W/CONTRAST MATRL Radiology a 2.15 9.15 9.15 Blank RBRVS

70543 26 MRI ORBIT FACE & NECK W/O & W/CONTRAST MATRL Radiology Blank 2.15 0.77 0.77 Blank RBRVS

70543 TC MRI ORBIT FACE & NECK W/O & W/CONTRAST MATRL Radiology a Blank 8.38 8.38 Blank RBRVS

70544 Blank MRA HEAD W/O CONTRST MATERIAL Radiology a 1.20 7.99 7.99 Blank RBRVS

70544 26 MRA HEAD W/O CONTRST MATERIAL Radiology Blank 1.20 0.44 0.44 Blank RBRVS

70544 TC MRA HEAD W/O CONTRST MATERIAL Radiology a Blank 7.55 7.55 Blank RBRVS

70545 Blank MRA HEAD W/CONTRAST MATERIAL Radiology a 1.20 7.91 7.91 Blank RBRVS

70545 26 MRA HEAD W/CONTRAST MATERIAL Radiology Blank 1.20 0.44 0.44 Blank RBRVS

70545 TC MRA HEAD W/CONTRAST MATERIAL Radiology a Blank 7.47 7.47 Blank RBRVS

70546 Blank MRA HEAD W/O & W/CONTRAST MATERIAL Radiology a 1.48 12.11 12.11 Blank RBRVS

70546 26 MRA HEAD W/O & W/CONTRAST MATERIAL Radiology Blank 1.48 0.54 0.54 Blank RBRVS

70546 TC MRA HEAD W/O & W/CONTRAST MATERIAL Radiology a Blank 11.57 11.57 Blank RBRVS

70547 Blank MRA NECK W/O CONTRST MATERIAL Radiology a 1.20 8.04 8.04 Blank RBRVS

70547 26 MRA NECK W/O CONTRST MATERIAL Radiology Blank 1.20 0.45 0.45 Blank RBRVS

70547 TC MRA NECK W/O CONTRST MATERIAL Radiology a Blank 7.59 7.59 Blank RBRVS

70548 Blank MRA NECK W/CONTRAST MATERIAL Radiology a 1.50 8.58 8.58 Blank RBRVS

70548 26 MRA NECK W/CONTRAST MATERIAL Radiology Blank 1.50 0.55 0.55 Blank RBRVS

70548 TC MRA NECK W/CONTRAST MATERIAL Radiology a Blank 8.03 8.03 Blank RBRVS

70549 Blank MRA NECK W/O &W/CONTRAST MATERIAL Radiology a 1.80 12.31 12.31 Blank RBRVS

70549 26 MRA NECK W/O &W/CONTRAST MATERIAL Radiology Blank 1.80 0.66 0.66 Blank RBRVS

70549 TC MRA NECK W/O &W/CONTRAST MATERIAL Radiology a Blank 11.65 11.65 Blank RBRVS

70551 Blank MRI BRAIN BRAIN STEM W/O CONTRAST MATERIAL Radiology a 1.48 4.97 4.97 Blank RBRVS

70551 26 MRI BRAIN BRAIN STEM W/O CONTRAST MATERIAL Radiology Blank 1.48 0.55 0.55 Blank RBRVS

70551 TC MRI BRAIN BRAIN STEM W/O CONTRAST MATERIAL Radiology a Blank 4.42 4.42 Blank RBRVS

70552 Blank MRI BRAIN BRAIN STEM W/CONTRAST MATERIAL Radiology a 1.78 7.18 7.18 Blank RBRVS

70552 26 MRI BRAIN BRAIN STEM W/CONTRAST MATERIAL Radiology Blank 1.78 0.66 0.66 Blank RBRVS

70552 TC MRI BRAIN BRAIN STEM W/CONTRAST MATERIAL Radiology a Blank 6.52 6.52 Blank RBRVS

70553 Blank MRI BRAIN BRAIN STEM W/O W/CONTRAST MATERIAL Radiology a 2.29 8.27 8.27 Blank RBRVS

70553 26 MRI BRAIN BRAIN STEM W/O W/CONTRAST MATERIAL Radiology Blank 2.29 0.83 0.83 Blank RBRVS

70553 TC MRI BRAIN BRAIN STEM W/O W/CONTRAST MATERIAL Radiology a Blank 7.44 7.44 Blank RBRVS

70554 Blank MRI BRAIN FUNCTIONAL W/O PHYSICIAN ADMNISTRATION Radiology a 2.11 10.48 10.48 Blank RBRVS





PAGE 84 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

70554 26 MRI BRAIN FUNCTIONAL W/O PHYSICIAN ADMNISTRATION Radiology Blank 2.11 0.78 0.78 Blank RBRVS

70554 TC MRI BRAIN FUNCTIONAL W/O PHYSICIAN ADMNISTRATION Radiology a Blank 9.70 9.70 Blank RBRVS

70555 Blank MRI BRAIN FUNCTIONAL W/PHYSICIAN ADMNISTRATION Radiology a Blank Blank Blank 21.05 Global/TC/26

70555 26 MRI BRAIN FUNCTIONAL W/PHYSICIAN ADMNISTRATION Radiology Blank Blank Blank Blank 3.43 Global/TC/26

70555 TC MRI BRAIN FUNCTIONAL W/PHYSICIAN ADMNISTRATION Radiology a Blank Blank Blank 17.62 Global/TC/26

70557 Blank MRI BRAIN OPEN INTRACRANIAL PX W/O CONTRAST MATL Radiology a Blank Blank Blank 37.62 Global/TC/26

70557 26 MRI BRAIN OPEN INTRACRANIAL PX W/O CONTRAST MATL Radiology Blank Blank Blank Blank 4.05 Global/TC/26

70557 TC MRI BRAIN OPEN INTRACRANIAL PX W/O CONTRAST MATL Radiology a Blank Blank Blank 33.57 Global/TC/26

70558 Blank MRI BRAIN OPEN INTRACRANIAL PX W/CONTRAST MATL Radiology a Blank Blank Blank 41.09 Global/TC/26

70558 26 MRI BRAIN OPEN INTRACRANIAL PX W/CONTRAST MATL Radiology Blank Blank Blank Blank 4.46 Global/TC/26

70558 TC MRI BRAIN OPEN INTRACRANIAL PX W/CONTRAST MATL Radiology a Blank Blank Blank 36.63 Global/TC/26

70559 Blank MRI BRAIN OPEN INTRACRANIAL PX W/O & W/CONTRAST Radiology a Blank Blank Blank 51.69 Global/TC/26

70559 26 MRI BRAIN OPEN INTRACRANIAL PX W/O & W/CONTRAST Radiology Blank Blank Blank Blank 4.40 Global/TC/26

70559 TC MRI BRAIN OPEN INTRACRANIAL PX W/O & W/CONTRAST Radiology a Blank Blank Blank 47.29 Global/TC/26

71045 Blank X-RAY EXAM CHEST 1 VIEW Radiology a 0.18 0.42 0.42 Blank RBRVS

71045 26 X-RAY EXAM CHEST 1 VIEW Radiology Blank 0.18 0.07 0.07 Blank RBRVS

71045 TC X-RAY EXAM CHEST 1 VIEW Radiology a Blank 0.35 0.35 Blank RBRVS

71046 Blank X-RAY EXAM CHEST 2 VIEWS Radiology a 0.22 0.62 0.62 Blank RBRVS

71046 26 X-RAY EXAM CHEST 2 VIEWS Radiology Blank 0.22 0.08 0.08 Blank RBRVS

71046 TC X-RAY EXAM CHEST 2 VIEWS Radiology a Blank 0.54 0.54 Blank RBRVS

71047 Blank X-RAY EXAM CHEST 3 VIEWS Radiology a 0.27 0.81 0.81 Blank RBRVS

71047 26 X-RAY EXAM CHEST 3 VIEWS Radiology Blank 0.27 0.12 0.12 Blank RBRVS

71047 TC X-RAY EXAM CHEST 3 VIEWS Radiology a Blank 0.69 0.69 Blank RBRVS

71048 Blank X-RAY EXAM CHEST 4+ VIEWS Radiology a 0.31 0.85 0.85 Blank RBRVS

71048 26 X-RAY EXAM CHEST 4+ VIEWS Radiology Blank 0.31 0.14 0.14 Blank RBRVS

71048 TC X-RAY EXAM CHEST 4+ VIEWS Radiology a Blank 0.71 0.71 Blank RBRVS

71100 Blank RADEX RIBS UNILATERAL 2 VIEWS Radiology a 0.22 0.70 0.70 Blank RBRVS

71100 26 RADEX RIBS UNILATERAL 2 VIEWS Radiology Blank 0.22 0.09 0.09 Blank RBRVS

71100 TC RADEX RIBS UNILATERAL 2 VIEWS Radiology a Blank 0.61 0.61 Blank RBRVS

71101 Blank RADEX RIBS UNI W/POSTEROANT CH MINIMUM 3 VIEWS Radiology a 0.27 0.78 0.78 Blank RBRVS

71101 26 RADEX RIBS UNI W/POSTEROANT CH MINIMUM 3 VIEWS Radiology Blank 0.27 0.10 0.10 Blank RBRVS

71101 TC RADEX RIBS UNI W/POSTEROANT CH MINIMUM 3 VIEWS Radiology a Blank 0.68 0.68 Blank RBRVS

71110 Blank RADEX RIBS BILATERAL 3 VIEWS Radiology a 0.29 0.82 0.82 Blank RBRVS

71110 26 RADEX RIBS BILATERAL 3 VIEWS Radiology Blank 0.29 0.12 0.12 Blank RBRVS

71110 TC RADEX RIBS BILATERAL 3 VIEWS Radiology a Blank 0.70 0.70 Blank RBRVS

71111 Blank RADEX RIBS BI W/POSTEROANT CH MINIMUM 4 VIEWS Radiology a 0.32 0.98 0.98 Blank RBRVS

71111 26 RADEX RIBS BI W/POSTEROANT CH MINIMUM 4 VIEWS Radiology Blank 0.32 0.13 0.13 Blank RBRVS

71111 TC RADEX RIBS BI W/POSTEROANT CH MINIMUM 4 VIEWS Radiology a Blank 0.85 0.85 Blank RBRVS

71120 Blank RADEX STERNUM MINIMUM 2 VIEWS Radiology a 0.20 0.62 0.62 Blank RBRVS

71120 26 RADEX STERNUM MINIMUM 2 VIEWS Radiology Blank 0.20 0.08 0.08 Blank RBRVS

71120 TC RADEX STERNUM MINIMUM 2 VIEWS Radiology a Blank 0.54 0.54 Blank RBRVS

71130 Blank RADEX STERNOCLAVICULAR JT/JTS MINIMUM 3 VIEWS Radiology a 0.22 0.78 0.78 Blank RBRVS

71130 26 RADEX STERNOCLAVICULAR JT/JTS MINIMUM 3 VIEWS Radiology Blank 0.22 0.09 0.09 Blank RBRVS

71130 TC RADEX STERNOCLAVICULAR JT/JTS MINIMUM 3 VIEWS Radiology a Blank 0.69 0.69 Blank RBRVS

71250 Blank CT THORAX W/O CONTRAST MATERIAL Radiology a 1.16 3.37 3.37 Blank RBRVS

71250 26 CT THORAX W/O CONTRAST MATERIAL Radiology Blank 1.16 0.43 0.43 Blank RBRVS

71250 TC CT THORAX W/O CONTRAST MATERIAL Radiology a Blank 2.94 2.94 Blank RBRVS

71260 Blank CT THORAX W/CONTRAST MATERIAL Radiology a 1.24 4.24 4.24 Blank RBRVS

71260 26 CT THORAX W/CONTRAST MATERIAL Radiology Blank 1.24 0.46 0.46 Blank RBRVS

71260 TC CT THORAX W/CONTRAST MATERIAL Radiology a Blank 3.78 3.78 Blank RBRVS

71270 Blank CT THORAX W/O & W/CONTRAST MATERIAL Radiology a 1.38 5.19 5.19 Blank RBRVS

71270 26 CT THORAX W/O & W/CONTRAST MATERIAL Radiology Blank 1.38 0.51 0.51 Blank RBRVS

71270 TC CT THORAX W/O & W/CONTRAST MATERIAL Radiology a Blank 4.68 4.68 Blank RBRVS

71275 Blank CT ANGIOGRAPHY CHEST W/CONTRAST/NONCONTRAST Radiology a 1.82 6.55 6.55 Blank RBRVS

71275 26 CT ANGIOGRAPHY CHEST W/CONTRAST/NONCONTRAST Radiology Blank 1.82 0.67 0.67 Blank RBRVS

71275 TC CT ANGIOGRAPHY CHEST W/CONTRAST/NONCONTRAST Radiology a Blank 5.88 5.88 Blank RBRVS

71550 Blank MRI CHEST W/O CONTRAST MATERIAL Radiology a 1.46 10.20 10.20 Blank RBRVS

71550 26 MRI CHEST W/O CONTRAST MATERIAL Radiology Blank 1.46 0.54 0.54 Blank RBRVS

71550 TC MRI CHEST W/O CONTRAST MATERIAL Radiology a Blank 9.66 9.66 Blank RBRVS

71551 Blank MRI CHEST W/CONTRAST MATERIAL Radiology a 1.73 11.10 11.10 Blank RBRVS

71551 26 MRI CHEST W/CONTRAST MATERIAL Radiology Blank 1.73 0.63 0.63 Blank RBRVS

71551 TC MRI CHEST W/CONTRAST MATERIAL Radiology a Blank 10.47 10.47 Blank RBRVS

71552 Blank MRI CHEST W/O & W/CONTRAST MATERIAL Radiology a 2.26 13.99 13.99 Blank RBRVS

71552 26 MRI CHEST W/O & W/CONTRAST MATERIAL Radiology Blank 2.26 0.82 0.82 Blank RBRVS

71552 TC MRI CHEST W/O & W/CONTRAST MATERIAL Radiology a Blank 13.17 13.17 Blank RBRVS

71555 Blank MRA CHEST W/O & W/CONTRAST MATERIAL Radiology a 1.81 9.40 9.40 Blank RBRVS

71555 26 MRA CHEST W/O & W/CONTRAST MATERIAL Radiology Blank 1.81 0.65 0.65 Blank RBRVS

71555 TC MRA CHEST W/O & W/CONTRAST MATERIAL Radiology a Blank 8.75 8.75 Blank RBRVS

72020 Blank RADEX SPINE 1 VIEW SPECIFY LEVEL Radiology a 0.15 0.46 0.46 Blank RBRVS

72020 26 RADEX SPINE 1 VIEW SPECIFY LEVEL Radiology Blank 0.15 0.06 0.06 Blank RBRVS

72020 TC RADEX SPINE 1 VIEW SPECIFY LEVEL Radiology a Blank 0.40 0.40 Blank RBRVS

72040 Blank RADEX SPINE CERVICAL 2 OR 3 VIEWS Radiology a 0.22 0.70 0.70 Blank RBRVS





PAGE 85 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

72040 26 RADEX SPINE CERVICAL 2 OR 3 VIEWS Radiology Blank 0.22 0.09 0.09 Blank RBRVS

72040 TC RADEX SPINE CERVICAL 2 OR 3 VIEWS Radiology a Blank 0.61 0.61 Blank RBRVS

72050 Blank RADEX SPINE CERVICAL 4 OR 5 VIEWS Radiology a 0.31 0.94 0.94 Blank RBRVS

72050 26 RADEX SPINE CERVICAL 4 OR 5 VIEWS Radiology Blank 0.31 0.12 0.12 Blank RBRVS

72050 TC RADEX SPINE CERVICAL 4 OR 5 VIEWS Radiology a Blank 0.82 0.82 Blank RBRVS

72052 Blank RADEX SPINE CERVICAL 6 OR MORE VIEWS Radiology a 0.36 1.19 1.19 Blank RBRVS

72052 26 RADEX SPINE CERVICAL 6 OR MORE VIEWS Radiology Blank 0.36 0.14 0.14 Blank RBRVS

72052 TC RADEX SPINE CERVICAL 6 OR MORE VIEWS Radiology a Blank 1.05 1.05 Blank RBRVS

72070 Blank RADEX SPINE THORACIC 2 VIEWS Radiology a 0.22 0.72 0.72 Blank RBRVS

72070 26 RADEX SPINE THORACIC 2 VIEWS Radiology Blank 0.22 0.09 0.09 Blank RBRVS

72070 TC RADEX SPINE THORACIC 2 VIEWS Radiology a Blank 0.63 0.63 Blank RBRVS

72072 Blank RADEX SPINE THORACIC 3 VIEWS Radiology a 0.22 0.74 0.74 Blank RBRVS

72072 26 RADEX SPINE THORACIC 3 VIEWS Radiology Blank 0.22 0.08 0.08 Blank RBRVS

72072 TC RADEX SPINE THORACIC 3 VIEWS Radiology a Blank 0.66 0.66 Blank RBRVS

72074 Blank RADEX SPINE THORACIC MINIMUM 4 VIEWS Radiology a 0.22 0.86 0.86 Blank RBRVS

72074 26 RADEX SPINE THORACIC MINIMUM 4 VIEWS Radiology Blank 0.22 0.08 0.08 Blank RBRVS

72074 TC RADEX SPINE THORACIC MINIMUM 4 VIEWS Radiology a Blank 0.78 0.78 Blank RBRVS

72080 Blank RADEX SPINE THORACOLUMBAR JUNCTION MIN 2 VIEWS Radiology a 0.22 0.71 0.71 Blank RBRVS

72080 26 RADEX SPINE THORACOLUMBAR JUNCTION MIN 2 VIEWS Radiology Blank 0.22 0.09 0.09 Blank RBRVS

72080 TC RADEX SPINE THORACOLUMBAR JUNCTION MIN 2 VIEWS Radiology a Blank 0.62 0.62 Blank RBRVS

72081 Blank RADEX ENTIR THRC LMBR CRV SAC SPI W/SKULL 1 VW Radiology a 0.26 0.80 0.80 Blank RBRVS

72081 26 RADEX ENTIR THRC LMBR CRV SAC SPI W/SKULL 1 VW Radiology Blank 0.26 0.10 0.10 Blank RBRVS

72081 TC RADEX ENTIR THRC LMBR CRV SAC SPI W/SKULL 1 VW Radiology a Blank 0.70 0.70 Blank RBRVS

72082 Blank RADEX ENTIR THRC LMBR CRV SAC SPI W/SKULL 2/3 VW Radiology a 0.31 1.42 1.42 Blank RBRVS

72082 26 RADEX ENTIR THRC LMBR CRV SAC SPI W/SKULL 2/3 VW Radiology Blank 0.31 0.13 0.13 Blank RBRVS

72082 TC RADEX ENTIR THRC LMBR CRV SAC SPI W/SKULL 2/3 VW Radiology a Blank 1.29 1.29 Blank RBRVS

72083 Blank RADEX ENTIR THRC LMBR CRV SAC SPI W/SKULL 4/5 VW Radiology a 0.35 1.74 1.74 Blank RBRVS

72083 26 RADEX ENTIR THRC LMBR CRV SAC SPI W/SKULL 4/5 VW Radiology Blank 0.35 0.15 0.15 Blank RBRVS

72083 TC RADEX ENTIR THRC LMBR CRV SAC SPI W/SKULL 4/5 VW Radiology a Blank 1.59 1.59 Blank RBRVS

72084 Blank RADEX ENTIR THRC LMBR CRV SAC SPI W/SKULL 6/> VW Radiology a 0.41 2.02 2.02 Blank RBRVS

72084 26 RADEX ENTIR THRC LMBR CRV SAC SPI W/SKULL 6/> VW Radiology Blank 0.41 0.17 0.17 Blank RBRVS

72084 TC RADEX ENTIR THRC LMBR CRV SAC SPI W/SKULL 6/> VW Radiology a Blank 1.85 1.85 Blank RBRVS

72100 Blank RADEX SPINE LUMBOSACRAL 2/3 VIEWS Radiology a 0.22 0.75 0.75 Blank RBRVS

72100 26 RADEX SPINE LUMBOSACRAL 2/3 VIEWS Radiology Blank 0.22 0.09 0.09 Blank RBRVS

72100 TC RADEX SPINE LUMBOSACRAL 2/3 VIEWS Radiology a Blank 0.66 0.66 Blank RBRVS

72110 Blank RADEX SPINE LUMBOSACRAL MINIMUM 4 VIEWS Radiology a 0.31 1.04 1.04 Blank RBRVS

72110 26 RADEX SPINE LUMBOSACRAL MINIMUM 4 VIEWS Radiology Blank 0.31 0.12 0.12 Blank RBRVS

72110 TC RADEX SPINE LUMBOSACRAL MINIMUM 4 VIEWS Radiology a Blank 0.92 0.92 Blank RBRVS

72114 Blank RADEX SPINE LUMBSCRL COMPL W/BENDING VIEWS MIN 6 Radiology a 0.32 1.39 1.39 Blank RBRVS

72114 26 RADEX SPINE LUMBSCRL COMPL W/BENDING VIEWS MIN 6 Radiology Blank 0.32 0.13 0.13 Blank RBRVS

72114 TC RADEX SPINE LUMBSCRL COMPL W/BENDING VIEWS MIN 6 Radiology a Blank 1.26 1.26 Blank RBRVS

72120 Blank RADEX SPINE LUMBOSACRAL ONLY BENDING 2/3 VIEWS Radiology a 0.22 0.91 0.91 Blank RBRVS

72120 26 RADEX SPINE LUMBOSACRAL ONLY BENDING 2/3 VIEWS Radiology Blank 0.22 0.09 0.09 Blank RBRVS

72120 TC RADEX SPINE LUMBOSACRAL ONLY BENDING 2/3 VIEWS Radiology a Blank 0.82 0.82 Blank RBRVS

72125 Blank CT CERVICAL SPINE W/O CONTRAST MATERIAL Radiology a 1.07 4.08 4.08 Blank RBRVS

72125 26 CT CERVICAL SPINE W/O CONTRAST MATERIAL Radiology Blank 1.07 0.39 0.39 Blank RBRVS

72125 TC CT CERVICAL SPINE W/O CONTRAST MATERIAL Radiology a Blank 3.69 3.69 Blank RBRVS

72126 Blank CT CERVICAL SPINE W/CONTRAST MATERIAL Radiology a 1.22 5.15 5.15 Blank RBRVS

72126 26 CT CERVICAL SPINE W/CONTRAST MATERIAL Radiology Blank 1.22 0.45 0.45 Blank RBRVS

72126 TC CT CERVICAL SPINE W/CONTRAST MATERIAL Radiology a Blank 4.70 4.70 Blank RBRVS

72127 Blank CT CERVICAL SPINE W/O &W/CONTRAST MATERIAL Radiology a 1.27 6.29 6.29 Blank RBRVS

72127 26 CT CERVICAL SPINE W/O &W/CONTRAST MATERIAL Radiology Blank 1.27 0.46 0.46 Blank RBRVS

72127 TC CT CERVICAL SPINE W/O &W/CONTRAST MATERIAL Radiology a Blank 5.83 5.83 Blank RBRVS

72128 Blank CT THORACIC SPINE W/O CONTRAST MATERIAL Radiology a 1.00 4.04 4.04 Blank RBRVS

72128 26 CT THORACIC SPINE W/O CONTRAST MATERIAL Radiology Blank 1.00 0.37 0.37 Blank RBRVS

72128 TC CT THORACIC SPINE W/O CONTRAST MATERIAL Radiology a Blank 3.67 3.67 Blank RBRVS

72129 Blank CT THORACIC SPINE W/CONTRAST MATERIAL Radiology a 1.22 5.18 5.18 Blank RBRVS

72129 26 CT THORACIC SPINE W/CONTRAST MATERIAL Radiology Blank 1.22 0.45 0.45 Blank RBRVS

72129 TC CT THORACIC SPINE W/CONTRAST MATERIAL Radiology a Blank 4.73 4.73 Blank RBRVS

72130 Blank CT THORACIC SPINE W/O & W/CONTRAST MATERIAL Radiology a 1.27 6.34 6.34 Blank RBRVS

72130 26 CT THORACIC SPINE W/O & W/CONTRAST MATERIAL Radiology Blank 1.27 0.47 0.47 Blank RBRVS

72130 TC CT THORACIC SPINE W/O & W/CONTRAST MATERIAL Radiology a Blank 5.87 5.87 Blank RBRVS

72131 Blank CT LUMBAR SPINE W/O CONTRAST MATERIAL Radiology a 1.00 4.02 4.02 Blank RBRVS

72131 26 CT LUMBAR SPINE W/O CONTRAST MATERIAL Radiology Blank 1.00 0.37 0.37 Blank RBRVS

72131 TC CT LUMBAR SPINE W/O CONTRAST MATERIAL Radiology a Blank 3.65 3.65 Blank RBRVS

72132 Blank CT LUMBAR SPINE W/CONTRAST MATERIAL Radiology a 1.22 5.15 5.15 Blank RBRVS

72132 26 CT LUMBAR SPINE W/CONTRAST MATERIAL Radiology Blank 1.22 0.45 0.45 Blank RBRVS

72132 TC CT LUMBAR SPINE W/CONTRAST MATERIAL Radiology a Blank 4.70 4.70 Blank RBRVS

72133 Blank CT LUMBAR SPINE W/O & W/CONTRAST MATERIAL Radiology a 1.27 6.26 6.26 Blank RBRVS

72133 26 CT LUMBAR SPINE W/O & W/CONTRAST MATERIAL Radiology Blank 1.27 0.46 0.46 Blank RBRVS

72133 TC CT LUMBAR SPINE W/O & W/CONTRAST MATERIAL Radiology a Blank 5.80 5.80 Blank RBRVS

72141 Blank MRI SPINAL CANAL CERVICAL W/O CONTRAST MATRL Radiology a 1.48 4.79 4.79 Blank RBRVS





PAGE 86 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

72141 26 MRI SPINAL CANAL CERVICAL W/O CONTRAST MATRL Radiology Blank 1.48 0.55 0.55 Blank RBRVS

72141 TC MRI SPINAL CANAL CERVICAL W/O CONTRAST MATRL Radiology a Blank 4.24 4.24 Blank RBRVS

72142 Blank MRI SPINAL CANAL CERVICAL W/CONTRAST MATRL Radiology a 1.78 7.35 7.35 Blank RBRVS

72142 26 MRI SPINAL CANAL CERVICAL W/CONTRAST MATRL Radiology Blank 1.78 0.67 0.67 Blank RBRVS

72142 TC MRI SPINAL CANAL CERVICAL W/CONTRAST MATRL Radiology a Blank 6.68 6.68 Blank RBRVS

72146 Blank MRI SPINAL CANAL THORACIC W/O CONTRAST MATRL Radiology a 1.48 4.80 4.80 Blank RBRVS

72146 26 MRI SPINAL CANAL THORACIC W/O CONTRAST MATRL Radiology Blank 1.48 0.55 0.55 Blank RBRVS

72146 TC MRI SPINAL CANAL THORACIC W/O CONTRAST MATRL Radiology a Blank 4.25 4.25 Blank RBRVS

72147 Blank MRI SPINAL CANAL THORACIC W/CONTRAST MATRL Radiology a 1.78 7.28 7.28 Blank RBRVS

72147 26 MRI SPINAL CANAL THORACIC W/CONTRAST MATRL Radiology Blank 1.78 0.66 0.66 Blank RBRVS

72147 TC MRI SPINAL CANAL THORACIC W/CONTRAST MATRL Radiology a Blank 6.62 6.62 Blank RBRVS

72148 Blank MRI SPINAL CANAL LUMBAR W/O CONTRAST MATERIAL Radiology a 1.48 4.79 4.79 Blank RBRVS

72148 26 MRI SPINAL CANAL LUMBAR W/O CONTRAST MATERIAL Radiology Blank 1.48 0.55 0.55 Blank RBRVS

72148 TC MRI SPINAL CANAL LUMBAR W/O CONTRAST MATERIAL Radiology a Blank 4.24 4.24 Blank RBRVS

72149 Blank MRI SPINAL CANAL LUMBAR W/CONTRAST MATERIAL Radiology a 1.78 7.22 7.22 Blank RBRVS

72149 26 MRI SPINAL CANAL LUMBAR W/CONTRAST MATERIAL Radiology Blank 1.78 0.66 0.66 Blank RBRVS

72149 TC MRI SPINAL CANAL LUMBAR W/CONTRAST MATERIAL Radiology a Blank 6.56 6.56 Blank RBRVS

72156 Blank MRI SPINAL CANAL CERVICAL W/O & W/CONTR MATRL Radiology a 2.29 8.33 8.33 Blank RBRVS

72156 26 MRI SPINAL CANAL CERVICAL W/O & W/CONTR MATRL Radiology Blank 2.29 0.83 0.83 Blank RBRVS

72156 TC MRI SPINAL CANAL CERVICAL W/O & W/CONTR MATRL Radiology a Blank 7.50 7.50 Blank RBRVS

72157 Blank MRI SPINAL CANAL THORACIC W/O & W/CONTR MATRL Radiology a 2.29 8.35 8.35 Blank RBRVS

72157 26 MRI SPINAL CANAL THORACIC W/O & W/CONTR MATRL Radiology Blank 2.29 0.83 0.83 Blank RBRVS

72157 TC MRI SPINAL CANAL THORACIC W/O & W/CONTR MATRL Radiology a Blank 7.52 7.52 Blank RBRVS

72158 Blank MRI SPINAL CANAL LUMBAR W/O & W/CONTR MATRL Radiology a 2.29 8.31 8.31 Blank RBRVS

72158 26 MRI SPINAL CANAL LUMBAR W/O & W/CONTR MATRL Radiology Blank 2.29 0.84 0.84 Blank RBRVS

72158 TC MRI SPINAL CANAL LUMBAR W/O & W/CONTR MATRL Radiology a Blank 7.47 7.47 Blank RBRVS

72159 Blank MRA SPINAL CANAL W/WO CONTRAST MATERIAL Radiology a 1.80 9.65 9.65 Blank RBRVS

72159 26 MRA SPINAL CANAL W/WO CONTRAST MATERIAL Radiology Blank 1.80 0.65 0.65 Blank RBRVS

72159 TC MRA SPINAL CANAL W/WO CONTRAST MATERIAL Radiology a Blank 9.00 9.00 Blank RBRVS

72170 Blank RADIOLOGIC EXAMINATION PELVIS 1/2 VIEWS Radiology a 0.17 0.71 0.71 Blank RBRVS

72170 26 RADIOLOGIC EXAMINATION PELVIS 1/2 VIEWS Radiology Blank 0.17 0.07 0.07 Blank RBRVS

72170 TC RADIOLOGIC EXAMINATION PELVIS 1/2 VIEWS Radiology a Blank 0.64 0.64 Blank RBRVS

72190 Blank RADIOLOGIC EXAM PELVIS COMPL MINIMUM 3 VIEWS Radiology a 0.21 0.84 0.84 Blank RBRVS

72190 26 RADIOLOGIC EXAM PELVIS COMPL MINIMUM 3 VIEWS Radiology Blank 0.21 0.09 0.09 Blank RBRVS

72190 TC RADIOLOGIC EXAM PELVIS COMPL MINIMUM 3 VIEWS Radiology a Blank 0.75 0.75 Blank RBRVS

72191 Blank CT ANGIOGRAPHY PELVIS W/CONTRAST/NONCONTRAST Radiology a 1.81 6.71 6.71 Blank RBRVS

72191 26 CT ANGIOGRAPHY PELVIS W/CONTRAST/NONCONTRAST Radiology Blank 1.81 0.64 0.64 Blank RBRVS

72191 TC CT ANGIOGRAPHY PELVIS W/CONTRAST/NONCONTRAST Radiology a Blank 6.07 6.07 Blank RBRVS

72192 Blank CT PELVIS W/O CONTRAST MATERIAL Radiology a 1.09 2.97 2.97 Blank RBRVS

72192 26 CT PELVIS W/O CONTRAST MATERIAL Radiology Blank 1.09 0.40 0.40 Blank RBRVS

72192 TC CT PELVIS W/O CONTRAST MATERIAL Radiology a Blank 2.57 2.57 Blank RBRVS

72193 Blank CT PELVIS W/CONTRAST MATERIAL Radiology a 1.16 5.15 5.15 Blank RBRVS

72193 26 CT PELVIS W/CONTRAST MATERIAL Radiology Blank 1.16 0.43 0.43 Blank RBRVS

72193 TC CT PELVIS W/CONTRAST MATERIAL Radiology a Blank 4.72 4.72 Blank RBRVS

72194 Blank CT PELVIS W/O & W/CONTRAST MATERIAL Radiology a 1.22 6.06 6.06 Blank RBRVS

72194 26 CT PELVIS W/O & W/CONTRAST MATERIAL Radiology Blank 1.22 0.45 0.45 Blank RBRVS

72194 TC CT PELVIS W/O & W/CONTRAST MATERIAL Radiology a Blank 5.61 5.61 Blank RBRVS

72195 Blank MRI PELVIS W/O CONTRAST MATERIAL Radiology a 1.46 7.42 7.42 Blank RBRVS

72195 26 MRI PELVIS W/O CONTRAST MATERIAL Radiology Blank 1.46 0.54 0.54 Blank RBRVS

72195 TC MRI PELVIS W/O CONTRAST MATERIAL Radiology a Blank 6.88 6.88 Blank RBRVS

72196 Blank MRI PELVIS W/CONTRAST MATERIAL Radiology a 1.73 8.00 8.00 Blank RBRVS

72196 26 MRI PELVIS W/CONTRAST MATERIAL Radiology Blank 1.73 0.64 0.64 Blank RBRVS

72196 TC MRI PELVIS W/CONTRAST MATERIAL Radiology a Blank 7.36 7.36 Blank RBRVS

72197 Blank MRI PELVIS W/O & W/CONTRAST MATERIAL Radiology a 2.20 9.72 9.72 Blank RBRVS

72197 26 MRI PELVIS W/O & W/CONTRAST MATERIAL Radiology Blank 2.20 0.80 0.80 Blank RBRVS

72197 TC MRI PELVIS W/O & W/CONTRAST MATERIAL Radiology a Blank 8.92 8.92 Blank RBRVS

72198 Blank MRA PELVIS W/WO CONTRAST MATERIAL Radiology a 1.80 9.43 9.43 Blank RBRVS

72198 26 MRA PELVIS W/WO CONTRAST MATERIAL Radiology Blank 1.80 0.63 0.63 Blank RBRVS

72198 TC MRA PELVIS W/WO CONTRAST MATERIAL Radiology a Blank 8.80 8.80 Blank RBRVS

72200 Blank RADIOLOGIC EXAMINATION SACROILIAC JNTS <3 VIEWS Radiology a 0.17 0.61 0.61 Blank RBRVS

72200 26 RADIOLOGIC EXAMINATION SACROILIAC JNTS <3 VIEWS Radiology Blank 0.17 0.07 0.07 Blank RBRVS

72200 TC RADIOLOGIC EXAMINATION SACROILIAC JNTS <3 VIEWS Radiology a Blank 0.54 0.54 Blank RBRVS

72202 Blank RADIOLOGIC EXAM SACROILIAC JOINTS 3/MORE VIEWS Radiology a 0.19 0.72 0.72 Blank RBRVS

72202 26 RADIOLOGIC EXAM SACROILIAC JOINTS 3/MORE VIEWS Radiology Blank 0.19 0.07 0.07 Blank RBRVS

72202 TC RADIOLOGIC EXAM SACROILIAC JOINTS 3/MORE VIEWS Radiology a Blank 0.65 0.65 Blank RBRVS

72220 Blank RADEX SACRUM & COCCYX MINIMUM 2 VIEWS Radiology a 0.17 0.61 0.61 Blank RBRVS

72220 26 RADEX SACRUM & COCCYX MINIMUM 2 VIEWS Radiology Blank 0.17 0.07 0.07 Blank RBRVS

72220 TC RADEX SACRUM & COCCYX MINIMUM 2 VIEWS Radiology a Blank 0.54 0.54 Blank RBRVS

72240 Blank MYELOGRAPHY CERVICAL RS&I Radiology a 0.91 1.80 1.80 Blank RBRVS

72240 26 MYELOGRAPHY CERVICAL RS&I Radiology Blank 0.91 0.33 0.33 Blank RBRVS

72240 TC MYELOGRAPHY CERVICAL RS&I Radiology a Blank 1.47 1.47 Blank RBRVS

72255 Blank MYELOGRAPHY THORACIC RS&I Radiology a 0.91 1.80 1.80 Blank RBRVS





PAGE 87 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

72255 26 MYELOGRAPHY THORACIC RS&I Radiology Blank 0.91 0.35 0.35 Blank RBRVS

72255 TC MYELOGRAPHY THORACIC RS&I Radiology a Blank 1.45 1.45 Blank RBRVS

72265 Blank MYELOGRAPY LUMBOSACRAL RS&I Radiology a 0.83 1.71 1.71 Blank RBRVS

72265 26 MYELOGRAPY LUMBOSACRAL RS&I Radiology Blank 0.83 0.29 0.29 Blank RBRVS

72265 TC MYELOGRAPY LUMBOSACRAL RS&I Radiology a Blank 1.42 1.42 Blank RBRVS

72270 Blank MYELOGRAPY 2/MORE REGIONS RS&I Radiology a 1.33 2.20 2.20 Blank RBRVS

72270 26 MYELOGRAPY 2/MORE REGIONS RS&I Radiology Blank 1.33 0.51 0.51 Blank RBRVS

72270 TC MYELOGRAPY 2/MORE REGIONS RS&I Radiology a Blank 1.69 1.69 Blank RBRVS

72275 Blank EPIDUROGRAPY RS&I Radiology a 0.76 2.46 2.46 Blank RBRVS

72275 26 EPIDUROGRAPY RS&I Radiology Blank 0.76 0.31 0.31 Blank RBRVS

72275 TC EPIDUROGRAPY RS&I Radiology a Blank 2.15 2.15 Blank RBRVS

72285 Blank DISKOGRAPY CERVICAL/THORACIC RS&I Radiology a 1.16 1.93 1.93 Blank RBRVS

72285 26 DISKOGRAPY CERVICAL/THORACIC RS&I Radiology Blank 1.16 0.47 0.47 Blank RBRVS

72285 TC DISKOGRAPY CERVICAL/THORACIC RS&I Radiology a Blank 1.46 1.46 Blank RBRVS

72295 Blank DISKOGRAPY LUMBAR RS&I Radiology a 0.83 1.85 1.85 Blank RBRVS

72295 26 DISKOGRAPY LUMBAR RS&I Radiology Blank 0.83 0.34 0.34 Blank RBRVS

72295 TC DISKOGRAPY LUMBAR RS&I Radiology a Blank 1.51 1.51 Blank RBRVS

73000 Blank RADEX CLAVICLE COMPLETE Radiology a 0.16 0.61 0.61 Blank RBRVS

73000 26 RADEX CLAVICLE COMPLETE Radiology Blank 0.16 0.07 0.07 Blank RBRVS

73000 TC RADEX CLAVICLE COMPLETE Radiology a Blank 0.54 0.54 Blank RBRVS

73010 Blank RADEX SCAPULA COMPLETE Radiology a 0.17 0.67 0.67 Blank RBRVS

73010 26 RADEX SCAPULA COMPLETE Radiology Blank 0.17 0.08 0.08 Blank RBRVS

73010 TC RADEX SCAPULA COMPLETE Radiology a Blank 0.59 0.59 Blank RBRVS

73020 Blank RADEX SHOULDER 1 VIEW Radiology a 0.15 0.48 0.48 Blank RBRVS

73020 26 RADEX SHOULDER 1 VIEW Radiology Blank 0.15 0.07 0.07 Blank RBRVS

73020 TC RADEX SHOULDER 1 VIEW Radiology a Blank 0.41 0.41 Blank RBRVS

73030 Blank RADEX SHOULDER COMPLETE MINIMUM 2 VIEWS Radiology a 0.18 0.63 0.63 Blank RBRVS

73030 26 RADEX SHOULDER COMPLETE MINIMUM 2 VIEWS Radiology Blank 0.18 0.08 0.08 Blank RBRVS

73030 TC RADEX SHOULDER COMPLETE MINIMUM 2 VIEWS Radiology a Blank 0.55 0.55 Blank RBRVS

73040 Blank RADEX SHOULDER ARTHROGRAPHY RS&I Radiology a 0.54 2.28 2.28 Blank RBRVS

73040 26 RADEX SHOULDER ARTHROGRAPHY RS&I Radiology Blank 0.54 0.21 0.21 Blank RBRVS

73040 TC RADEX SHOULDER ARTHROGRAPHY RS&I Radiology a Blank 2.07 2.07 Blank RBRVS

73050 Blank RADEX A-C JOINTS BI W/WO WEIGHTED DISTRCJ Radiology a 0.20 0.79 0.79 Blank RBRVS

73050 26 RADEX A-C JOINTS BI W/WO WEIGHTED DISTRCJ Radiology Blank 0.20 0.09 0.09 Blank RBRVS

73050 TC RADEX A-C JOINTS BI W/WO WEIGHTED DISTRCJ Radiology a Blank 0.70 0.70 Blank RBRVS

73060 Blank RADEX HUMERUS MINIMUM 2 VIEWS Radiology a 0.16 0.64 0.64 Blank RBRVS

73060 26 RADEX HUMERUS MINIMUM 2 VIEWS Radiology Blank 0.16 0.07 0.07 Blank RBRVS

73060 TC RADEX HUMERUS MINIMUM 2 VIEWS Radiology a Blank 0.57 0.57 Blank RBRVS

73070 Blank RADEX ELBOW 2 VIEWS Radiology a 0.15 0.60 0.60 Blank RBRVS

73070 26 RADEX ELBOW 2 VIEWS Radiology Blank 0.15 0.07 0.07 Blank RBRVS

73070 TC RADEX ELBOW 2 VIEWS Radiology a Blank 0.53 0.53 Blank RBRVS

73080 Blank RADEX ELBOW COMPLETE MINIMUM 3 VIEWS Radiology a 0.17 0.70 0.70 Blank RBRVS

73080 26 RADEX ELBOW COMPLETE MINIMUM 3 VIEWS Radiology Blank 0.17 0.07 0.07 Blank RBRVS

73080 TC RADEX ELBOW COMPLETE MINIMUM 3 VIEWS Radiology a Blank 0.63 0.63 Blank RBRVS

73085 Blank RADEX ELBOW ARTHROGRAPHY RS&I Radiology a 0.54 2.12 2.12 Blank RBRVS

73085 26 RADEX ELBOW ARTHROGRAPHY RS&I Radiology Blank 0.54 0.24 0.24 Blank RBRVS

73085 TC RADEX ELBOW ARTHROGRAPHY RS&I Radiology a Blank 1.88 1.88 Blank RBRVS

73090 Blank RADEX FOREARM 2 VIEWS Radiology a 0.16 0.55 0.55 Blank RBRVS

73090 26 RADEX FOREARM 2 VIEWS Radiology Blank 0.16 0.07 0.07 Blank RBRVS

73090 TC RADEX FOREARM 2 VIEWS Radiology a Blank 0.48 0.48 Blank RBRVS

73092 Blank RADEX UPPER EXTREMITY INFANT MINIMUM 2 VIEWS Radiology a 0.16 0.59 0.59 Blank RBRVS

73092 26 RADEX UPPER EXTREMITY INFANT MINIMUM 2 VIEWS Radiology Blank 0.16 0.06 0.06 Blank RBRVS

73092 TC RADEX UPPER EXTREMITY INFANT MINIMUM 2 VIEWS Radiology a Blank 0.53 0.53 Blank RBRVS

73100 Blank RADEX WRIST 2 VIEWS Radiology a 0.16 0.71 0.71 Blank RBRVS

73100 26 RADEX WRIST 2 VIEWS Radiology Blank 0.16 0.08 0.08 Blank RBRVS

73100 TC RADEX WRIST 2 VIEWS Radiology a Blank 0.63 0.63 Blank RBRVS

73110 Blank RADEX WRIST COMPLETE MINIMUM 3 VIEWS Radiology a 0.17 0.80 0.80 Blank RBRVS

73110 26 RADEX WRIST COMPLETE MINIMUM 3 VIEWS Radiology Blank 0.17 0.07 0.07 Blank RBRVS

73110 TC RADEX WRIST COMPLETE MINIMUM 3 VIEWS Radiology a Blank 0.73 0.73 Blank RBRVS

73115 Blank RADEX WRIST ARTHROGRAPHY RS&I Radiology a 0.54 2.43 2.43 Blank RBRVS

73115 26 RADEX WRIST ARTHROGRAPHY RS&I Radiology Blank 0.54 0.23 0.23 Blank RBRVS

73115 TC RADEX WRIST ARTHROGRAPHY RS&I Radiology a Blank 2.20 2.20 Blank RBRVS

73120 Blank RADEX HAND 2 VIEWS Radiology a 0.16 0.62 0.62 Blank RBRVS

73120 26 RADEX HAND 2 VIEWS Radiology Blank 0.16 0.07 0.07 Blank RBRVS

73120 TC RADEX HAND 2 VIEWS Radiology a Blank 0.55 0.55 Blank RBRVS

73130 Blank RADEX HAND MINIMUM 3 VIEWS Radiology a 0.17 0.71 0.71 Blank RBRVS

73130 26 RADEX HAND MINIMUM 3 VIEWS Radiology Blank 0.17 0.07 0.07 Blank RBRVS

73130 TC RADEX HAND MINIMUM 3 VIEWS Radiology a Blank 0.64 0.64 Blank RBRVS

73140 Blank RADEX FINGR MINIMUM 2 VIEWS Radiology a 0.13 0.76 0.76 Blank RBRVS

73140 26 RADEX FINGR MINIMUM 2 VIEWS Radiology Blank 0.13 0.06 0.06 Blank RBRVS

73140 TC RADEX FINGR MINIMUM 2 VIEWS Radiology a Blank 0.70 0.70 Blank RBRVS

73200 Blank CT UPPER EXTREMITY W/O CONTRAST MATERIAL Radiology a 1.00 4.01 4.01 Blank RBRVS





PAGE 88 of 144

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HCPCS

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Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

73200 26 CT UPPER EXTREMITY W/O CONTRAST MATERIAL Radiology Blank 1.00 0.37 0.37 Blank RBRVS

73200 TC CT UPPER EXTREMITY W/O CONTRAST MATERIAL Radiology a Blank 3.64 3.64 Blank RBRVS

73201 Blank CT UPPER EXTREMITY W/CONTRAST MATERIAL Radiology a 1.16 5.06 5.06 Blank RBRVS

73201 26 CT UPPER EXTREMITY W/CONTRAST MATERIAL Radiology Blank 1.16 0.43 0.43 Blank RBRVS

73201 TC CT UPPER EXTREMITY W/CONTRAST MATERIAL Radiology a Blank 4.63 4.63 Blank RBRVS

73202 Blank CT UPPER EXTREMITY W/O & W/CONTRAST MATERIAL Radiology a 1.22 6.56 6.56 Blank RBRVS

73202 26 CT UPPER EXTREMITY W/O & W/CONTRAST MATERIAL Radiology Blank 1.22 0.45 0.45 Blank RBRVS

73202 TC CT UPPER EXTREMITY W/O & W/CONTRAST MATERIAL Radiology a Blank 6.11 6.11 Blank RBRVS

73206 Blank CT ANGIOGRAPHY UPPER EXTREMITY Radiology a 1.81 7.35 7.35 Blank RBRVS

73206 26 CT ANGIOGRAPHY UPPER EXTREMITY Radiology Blank 1.81 0.64 0.64 Blank RBRVS

73206 TC CT ANGIOGRAPHY UPPER EXTREMITY Radiology a Blank 6.71 6.71 Blank RBRVS

73218 Blank MRI UPPER EXTREMITY OTH THAN JT W/O CONTR MATRL Radiology a 1.35 8.94 8.94 Blank RBRVS

73218 26 MRI UPPER EXTREMITY OTH THAN JT W/O CONTR MATRL Radiology Blank 1.35 0.50 0.50 Blank RBRVS

73218 TC MRI UPPER EXTREMITY OTH THAN JT W/O CONTR MATRL Radiology a Blank 8.44 8.44 Blank RBRVS

73219 Blank MRI UPPER EXTREMITY OTH THAN JT W/CONTR MATRL Radiology a 1.62 9.69 9.69 Blank RBRVS

73219 26 MRI UPPER EXTREMITY OTH THAN JT W/CONTR MATRL Radiology Blank 1.62 0.60 0.60 Blank RBRVS

73219 TC MRI UPPER EXTREMITY OTH THAN JT W/CONTR MATRL Radiology a Blank 9.09 9.09 Blank RBRVS

73220 Blank MRI UPPER EXTREM OTHER THAN JT W/O & W/CONTRAS Radiology a 2.15 11.87 11.87 Blank RBRVS

73220 26 MRI UPPER EXTREM OTHER THAN JT W/O & W/CONTRAS Radiology Blank 2.15 0.79 0.79 Blank RBRVS

73220 TC MRI UPPER EXTREM OTHER THAN JT W/O & W/CONTRAS Radiology a Blank 11.08 11.08 Blank RBRVS

73221 Blank MRI ANY JT UPPER EXTREMITY W/O CONTRAST MATRL Radiology a 1.35 5.28 5.28 Blank RBRVS

73221 26 MRI ANY JT UPPER EXTREMITY W/O CONTRAST MATRL Radiology Blank 1.35 0.51 0.51 Blank RBRVS

73221 TC MRI ANY JT UPPER EXTREMITY W/O CONTRAST MATRL Radiology a Blank 4.77 4.77 Blank RBRVS

73222 Blank MRI ANY JT UPPER EXTREMITY W/CONTRAST MATRL Radiology a 1.62 9.02 9.02 Blank RBRVS

73222 26 MRI ANY JT UPPER EXTREMITY W/CONTRAST MATRL Radiology Blank 1.62 0.61 0.61 Blank RBRVS

73222 TC MRI ANY JT UPPER EXTREMITY W/CONTRAST MATRL Radiology a Blank 8.41 8.41 Blank RBRVS

73223 Blank MRI ANY JT UPPER EXTREMITY W/O & W/CONTR MATRL Radiology a 2.15 11.04 11.04 Blank RBRVS

73223 26 MRI ANY JT UPPER EXTREMITY W/O & W/CONTR MATRL Radiology Blank 2.15 0.79 0.79 Blank RBRVS

73223 TC MRI ANY JT UPPER EXTREMITY W/O & W/CONTR MATRL Radiology a Blank 10.25 10.25 Blank RBRVS

73225 Blank MRA UPPER EXTREMITY W/WO CONTRAST MATERIAL Radiology a 1.73 9.71 9.71 Blank RBRVS

73225 26 MRA UPPER EXTREMITY W/WO CONTRAST MATERIAL Radiology Blank 1.73 0.61 0.61 Blank RBRVS

73225 TC MRA UPPER EXTREMITY W/WO CONTRAST MATERIAL Radiology a Blank 9.10 9.10 Blank RBRVS

73501 Blank RADEX HIP UNILATERAL WITH PELVIS 1 VIEW Radiology a 0.18 0.65 0.65 Blank RBRVS

73501 26 RADEX HIP UNILATERAL WITH PELVIS 1 VIEW Radiology Blank 0.18 0.08 0.08 Blank RBRVS

73501 TC RADEX HIP UNILATERAL WITH PELVIS 1 VIEW Radiology a Blank 0.57 0.57 Blank RBRVS

73502 Blank RADEX HIP UNILATERAL WITH PELVIS 2-3 VIEWS Radiology a 0.22 0.93 0.93 Blank RBRVS

73502 26 RADEX HIP UNILATERAL WITH PELVIS 2-3 VIEWS Radiology Blank 0.22 0.09 0.09 Blank RBRVS

73502 TC RADEX HIP UNILATERAL WITH PELVIS 2-3 VIEWS Radiology a Blank 0.84 0.84 Blank RBRVS

73503 Blank RADEX HIP UNILATERAL WITH PELVIS MINIMUM 4 VIEWS Radiology a 0.27 1.16 1.16 Blank RBRVS

73503 26 RADEX HIP UNILATERAL WITH PELVIS MINIMUM 4 VIEWS Radiology Blank 0.27 0.12 0.12 Blank RBRVS

73503 TC RADEX HIP UNILATERAL WITH PELVIS MINIMUM 4 VIEWS Radiology a Blank 1.04 1.04 Blank RBRVS

73521 Blank RADEX HIPS BILATERAL WITH PELVIS 2 VIEWS Radiology a 0.22 0.82 0.82 Blank RBRVS

73521 26 RADEX HIPS BILATERAL WITH PELVIS 2 VIEWS Radiology Blank 0.22 0.09 0.09 Blank RBRVS

73521 TC RADEX HIPS BILATERAL WITH PELVIS 2 VIEWS Radiology a Blank 0.73 0.73 Blank RBRVS

73522 Blank RADEX HIPS BILATERAL WITH PELVIS 3-4 VIEWS Radiology a 0.29 1.06 1.06 Blank RBRVS

73522 26 RADEX HIPS BILATERAL WITH PELVIS 3-4 VIEWS Radiology Blank 0.29 0.12 0.12 Blank RBRVS

73522 TC RADEX HIPS BILATERAL WITH PELVIS 3-4 VIEWS Radiology a Blank 0.94 0.94 Blank RBRVS

73523 Blank RADEX HIPS BILATERAL WITH PELVIS MINIMUM 5 VIEWS Radiology a 0.31 1.26 1.26 Blank RBRVS

73523 26 RADEX HIPS BILATERAL WITH PELVIS MINIMUM 5 VIEWS Radiology Blank 0.31 0.13 0.13 Blank RBRVS

73523 TC RADEX HIPS BILATERAL WITH PELVIS MINIMUM 5 VIEWS Radiology a Blank 1.13 1.13 Blank RBRVS

73525 Blank RADEX HIP ARTHROGRAPHY RS&I Radiology a 0.54 2.32 2.32 Blank RBRVS

73525 26 RADEX HIP ARTHROGRAPHY RS&I Radiology Blank 0.54 0.24 0.24 Blank RBRVS

73525 TC RADEX HIP ARTHROGRAPHY RS&I Radiology a Blank 2.08 2.08 Blank RBRVS

73551 Blank RADIOLOGIC EXAMINATION FEMUR 1 VIEW Radiology a 0.16 0.61 0.61 Blank RBRVS

73551 26 RADIOLOGIC EXAMINATION FEMUR 1 VIEW Radiology Blank 0.16 0.07 0.07 Blank RBRVS

73551 TC RADIOLOGIC EXAMINATION FEMUR 1 VIEW Radiology a Blank 0.54 0.54 Blank RBRVS

73552 Blank RADIOLOGIC EXAMINATION FEMUR MINIMUM 2 VIEWS Radiology a 0.18 0.73 0.73 Blank RBRVS

73552 26 RADIOLOGIC EXAMINATION FEMUR MINIMUM 2 VIEWS Radiology Blank 0.18 0.08 0.08 Blank RBRVS

73552 TC RADIOLOGIC EXAMINATION FEMUR MINIMUM 2 VIEWS Radiology a Blank 0.65 0.65 Blank RBRVS

73560 Blank RADIOLOGIC EXAMINATION KNEE 1/2 VIEWS Radiology a 0.16 0.70 0.70 Blank RBRVS

73560 26 RADIOLOGIC EXAMINATION KNEE 1/2 VIEWS Radiology Blank 0.16 0.07 0.07 Blank RBRVS

73560 TC RADIOLOGIC EXAMINATION KNEE 1/2 VIEWS Radiology a Blank 0.63 0.63 Blank RBRVS

73562 Blank RADIOLOGIC EXAMINATION KNEE 3 VIEWS Radiology a 0.18 0.81 0.81 Blank RBRVS

73562 26 RADIOLOGIC EXAMINATION KNEE 3 VIEWS Radiology Blank 0.18 0.08 0.08 Blank RBRVS

73562 TC RADIOLOGIC EXAMINATION KNEE 3 VIEWS Radiology a Blank 0.73 0.73 Blank RBRVS

73564 Blank RADIOLOGIC EXAM KNEE COMPLETE 4/MORE VIEWS Radiology a 0.22 0.88 0.88 Blank RBRVS

73564 26 RADIOLOGIC EXAM KNEE COMPLETE 4/MORE VIEWS Radiology Blank 0.22 0.09 0.09 Blank RBRVS

73564 TC RADIOLOGIC EXAM KNEE COMPLETE 4/MORE VIEWS Radiology a Blank 0.79 0.79 Blank RBRVS

73565 Blank RADIOLOGIC EXAM BOTH KNEES STANDING ANTEROPOST Radiology a 0.16 0.83 0.83 Blank RBRVS

73565 26 RADIOLOGIC EXAM BOTH KNEES STANDING ANTEROPOST Radiology Blank 0.16 0.08 0.08 Blank RBRVS

73565 TC RADIOLOGIC EXAM BOTH KNEES STANDING ANTEROPOST Radiology a Blank 0.75 0.75 Blank RBRVS

73580 Blank RADIOLOGIC EXAM KNEE ARTHROGRAPHY RS&I Radiology a 0.54 2.71 2.71 Blank RBRVS





PAGE 89 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

73580 26 RADIOLOGIC EXAM KNEE ARTHROGRAPHY RS&I Radiology Blank 0.54 0.23 0.23 Blank RBRVS

73580 TC RADIOLOGIC EXAM KNEE ARTHROGRAPHY RS&I Radiology a Blank 2.48 2.48 Blank RBRVS

73590 Blank RADIOLOGIC EXAMINATION TIBIA & FIBULA 2 VIEWS Radiology a 0.16 0.63 0.63 Blank RBRVS

73590 26 RADIOLOGIC EXAMINATION TIBIA & FIBULA 2 VIEWS Radiology Blank 0.16 0.07 0.07 Blank RBRVS

73590 TC RADIOLOGIC EXAMINATION TIBIA & FIBULA 2 VIEWS Radiology a Blank 0.56 0.56 Blank RBRVS

73592 Blank RADEX LOWER EXTREMITY INFANT MINIMUM 2 VIEWS Radiology a 0.16 0.59 0.59 Blank RBRVS

73592 26 RADEX LOWER EXTREMITY INFANT MINIMUM 2 VIEWS Radiology Blank 0.16 0.06 0.06 Blank RBRVS

73592 TC RADEX LOWER EXTREMITY INFANT MINIMUM 2 VIEWS Radiology a Blank 0.53 0.53 Blank RBRVS

73600 Blank RADIOLOGIC EXAMINATION ANKLE 2 VIEWS Radiology a 0.16 0.66 0.66 Blank RBRVS

73600 26 RADIOLOGIC EXAMINATION ANKLE 2 VIEWS Radiology Blank 0.16 0.07 0.07 Blank RBRVS

73600 TC RADIOLOGIC EXAMINATION ANKLE 2 VIEWS Radiology a Blank 0.59 0.59 Blank RBRVS

73610 Blank RADEX ANKLE COMPLETE MINIMUM 3 VIEWS Radiology a 0.17 0.70 0.70 Blank RBRVS

73610 26 RADEX ANKLE COMPLETE MINIMUM 3 VIEWS Radiology Blank 0.17 0.07 0.07 Blank RBRVS

73610 TC RADEX ANKLE COMPLETE MINIMUM 3 VIEWS Radiology a Blank 0.63 0.63 Blank RBRVS

73615 Blank RADEX ANKLE ARTHROGRAPHY RS&I Radiology a 0.54 2.43 2.43 Blank RBRVS

73615 26 RADEX ANKLE ARTHROGRAPHY RS&I Radiology Blank 0.54 0.24 0.24 Blank RBRVS

73615 TC RADEX ANKLE ARTHROGRAPHY RS&I Radiology a Blank 2.19 2.19 Blank RBRVS

73620 Blank RADIOLOGIC EXAMINATION FOOT 2 VIEWS Radiology a 0.16 0.56 0.56 Blank RBRVS

73620 26 RADIOLOGIC EXAMINATION FOOT 2 VIEWS Radiology Blank 0.16 0.05 0.05 Blank RBRVS

73620 TC RADIOLOGIC EXAMINATION FOOT 2 VIEWS Radiology a Blank 0.51 0.51 Blank RBRVS

73630 Blank RADEX FOOT COMPLETE MINIMUM 3 VIEWS Radiology a 0.17 0.64 0.64 Blank RBRVS

73630 26 RADEX FOOT COMPLETE MINIMUM 3 VIEWS Radiology Blank 0.17 0.06 0.06 Blank RBRVS

73630 TC RADEX FOOT COMPLETE MINIMUM 3 VIEWS Radiology a Blank 0.58 0.58 Blank RBRVS

73650 Blank RADEX CALCANEUS MINIMUM 2 VIEWS Radiology a 0.16 0.59 0.59 Blank RBRVS

73650 26 RADEX CALCANEUS MINIMUM 2 VIEWS Radiology Blank 0.16 0.06 0.06 Blank RBRVS

73650 TC RADEX CALCANEUS MINIMUM 2 VIEWS Radiology a Blank 0.53 0.53 Blank RBRVS

73660 Blank RADEX TOE MINIMUM 2 VIEWS Radiology a 0.13 0.65 0.65 Blank RBRVS

73660 26 RADEX TOE MINIMUM 2 VIEWS Radiology Blank 0.13 0.05 0.05 Blank RBRVS

73660 TC RADEX TOE MINIMUM 2 VIEWS Radiology a Blank 0.60 0.60 Blank RBRVS

73700 Blank CT LOWER EXTREMITY W/O CONTRAST MATERIAL Radiology a 1.00 4.02 4.02 Blank RBRVS

73700 26 CT LOWER EXTREMITY W/O CONTRAST MATERIAL Radiology Blank 1.00 0.37 0.37 Blank RBRVS

73700 TC CT LOWER EXTREMITY W/O CONTRAST MATERIAL Radiology a Blank 3.65 3.65 Blank RBRVS

73701 Blank CT LOWER EXTREMITY W/CONTRAST MATERIAL Radiology a 1.16 5.15 5.15 Blank RBRVS

73701 26 CT LOWER EXTREMITY W/CONTRAST MATERIAL Radiology Blank 1.16 0.43 0.43 Blank RBRVS

73701 TC CT LOWER EXTREMITY W/CONTRAST MATERIAL Radiology a Blank 4.72 4.72 Blank RBRVS

73702 Blank CT LOWER EXTREMITY W/O & W/CONTRAST MATRL Radiology a 1.22 6.46 6.46 Blank RBRVS

73702 26 CT LOWER EXTREMITY W/O & W/CONTRAST MATRL Radiology Blank 1.22 0.44 0.44 Blank RBRVS

73702 TC CT LOWER EXTREMITY W/O & W/CONTRAST MATRL Radiology a Blank 6.02 6.02 Blank RBRVS

73706 Blank CT ANGIOGRAPHY LOWER EXTREMITY Radiology a 1.90 8.02 8.02 Blank RBRVS

73706 26 CT ANGIOGRAPHY LOWER EXTREMITY Radiology Blank 1.90 0.68 0.68 Blank RBRVS

73706 TC CT ANGIOGRAPHY LOWER EXTREMITY Radiology a Blank 7.34 7.34 Blank RBRVS

73718 Blank MRI LOWER EXTREM OTH/THN JT W/O CONTR MATRL Radiology a 1.35 7.26 7.26 Blank RBRVS

73718 26 MRI LOWER EXTREM OTH/THN JT W/O CONTR MATRL Radiology Blank 1.35 0.50 0.50 Blank RBRVS

73718 TC MRI LOWER EXTREM OTH/THN JT W/O CONTR MATRL Radiology a Blank 6.76 6.76 Blank RBRVS

73719 Blank MRI LOWER EXTREM OTH/THN JT W/CONTRAST MATRL Radiology a 1.62 7.96 7.96 Blank RBRVS

73719 26 MRI LOWER EXTREM OTH/THN JT W/CONTRAST MATRL Radiology Blank 1.62 0.60 0.60 Blank RBRVS

73719 TC MRI LOWER EXTREM OTH/THN JT W/CONTRAST MATRL Radiology a Blank 7.36 7.36 Blank RBRVS

73720 Blank MRI LOWER EXTREM OTH/THN JT W/O & W/CONTR MATR Radiology a 2.15 9.76 9.76 Blank RBRVS

73720 26 MRI LOWER EXTREM OTH/THN JT W/O & W/CONTR MATR Radiology Blank 2.15 0.78 0.78 Blank RBRVS

73720 TC MRI LOWER EXTREM OTH/THN JT W/O & W/CONTR MATR Radiology a Blank 8.98 8.98 Blank RBRVS

73721 Blank MRI ANY JT LOWER EXTREM W/O CONTRAST MATRL Radiology a 1.35 5.28 5.28 Blank RBRVS

73721 26 MRI ANY JT LOWER EXTREM W/O CONTRAST MATRL Radiology Blank 1.35 0.51 0.51 Blank RBRVS

73721 TC MRI ANY JT LOWER EXTREM W/O CONTRAST MATRL Radiology a Blank 4.77 4.77 Blank RBRVS

73722 Blank MRI ANY JT LOWER EXTREM W/CONTRAST MATERIAL Radiology a 1.62 9.09 9.09 Blank RBRVS

73722 26 MRI ANY JT LOWER EXTREM W/CONTRAST MATERIAL Radiology Blank 1.62 0.61 0.61 Blank RBRVS

73722 TC MRI ANY JT LOWER EXTREM W/CONTRAST MATERIAL Radiology a Blank 8.48 8.48 Blank RBRVS

73723 Blank MRI ANY JT LOWER EXTREM W/O & W/CONTRAST MATRL Radiology a 2.15 11.02 11.02 Blank RBRVS

73723 26 MRI ANY JT LOWER EXTREM W/O & W/CONTRAST MATRL Radiology Blank 2.15 0.78 0.78 Blank RBRVS

73723 TC MRI ANY JT LOWER EXTREM W/O & W/CONTRAST MATRL Radiology a Blank 10.24 10.24 Blank RBRVS

73725 Blank MRA LOWER EXTREMITY W/WO CONTRAST MATERIAL Radiology a 1.82 9.42 9.42 Blank RBRVS

73725 26 MRA LOWER EXTREMITY W/WO CONTRAST MATERIAL Radiology Blank 1.82 0.64 0.64 Blank RBRVS

73725 TC MRA LOWER EXTREMITY W/WO CONTRAST MATERIAL Radiology a Blank 8.78 8.78 Blank RBRVS

74018 Blank X-RAY EXAM ABDOMEN 1 VIEW Radiology a 0.18 0.57 0.57 Blank RBRVS

74018 26 X-RAY EXAM ABDOMEN 1 VIEW Radiology Blank 0.18 0.07 0.07 Blank RBRVS

74018 TC X-RAY EXAM ABDOMEN 1 VIEW Radiology a Blank 0.50 0.50 Blank RBRVS

74019 Blank X-RAY EXAM ABDOMEN 2 VIEWS Radiology a 0.23 0.69 0.69 Blank RBRVS

74019 26 X-RAY EXAM ABDOMEN 2 VIEWS Radiology Blank 0.23 0.09 0.09 Blank RBRVS

74019 TC X-RAY EXAM ABDOMEN 2 VIEWS Radiology a Blank 0.60 0.60 Blank RBRVS

74021 Blank X-RAY EXAM ABDOMEN 3+ VIEWS Radiology a 0.27 0.80 0.80 Blank RBRVS

74021 26 X-RAY EXAM ABDOMEN 3+ VIEWS Radiology Blank 0.27 0.10 0.10 Blank RBRVS

74021 TC X-RAY EXAM ABDOMEN 3+ VIEWS Radiology a Blank 0.70 0.70 Blank RBRVS

74022 Blank RADEX ABD COMPL AQT ABD W/S/E/D VIEWS 1 VIEW CH Radiology a 0.32 0.91 0.91 Blank RBRVS





PAGE 90 of 144

CPT/

HCPCS

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Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

74022 26 RADEX ABD COMPL AQT ABD W/S/E/D VIEWS 1 VIEW CH Radiology Blank 0.32 0.12 0.12 Blank RBRVS

74022 TC RADEX ABD COMPL AQT ABD W/S/E/D VIEWS 1 VIEW CH Radiology a Blank 0.79 0.79 Blank RBRVS

74150 Blank CT ABDOMEN W/O CONTRAST MATERIAL Radiology a 1.19 2.97 2.97 Blank RBRVS

74150 26 CT ABDOMEN W/O CONTRAST MATERIAL Radiology Blank 1.19 0.44 0.44 Blank RBRVS

74150 TC CT ABDOMEN W/O CONTRAST MATERIAL Radiology a Blank 2.53 2.53 Blank RBRVS

74160 Blank CT ABDOMEN W/CONTRAST MATERIAL Radiology a 1.27 5.18 5.18 Blank RBRVS

74160 26 CT ABDOMEN W/CONTRAST MATERIAL Radiology Blank 1.27 0.47 0.47 Blank RBRVS

74160 TC CT ABDOMEN W/CONTRAST MATERIAL Radiology a Blank 4.71 4.71 Blank RBRVS

74170 Blank CT ABDOMEN W/O & W/CONTRAST MATERIAL Radiology a 1.40 5.94 5.94 Blank RBRVS

74170 26 CT ABDOMEN W/O & W/CONTRAST MATERIAL Radiology Blank 1.40 0.52 0.52 Blank RBRVS

74170 TC CT ABDOMEN W/O & W/CONTRAST MATERIAL Radiology a Blank 5.42 5.42 Blank RBRVS

74174 Blank CT ANGIO ABD&PLVIS CNTRST MTRL W/WO CNTRST IMG Radiology a 2.20 8.63 8.63 Blank RBRVS

74174 26 CT ANGIO ABD&PLVIS CNTRST MTRL W/WO CNTRST IMG Radiology Blank 2.20 0.77 0.77 Blank RBRVS

74174 TC CT ANGIO ABD&PLVIS CNTRST MTRL W/WO CNTRST IMG Radiology a Blank 7.86 7.86 Blank RBRVS

74175 Blank CT ANGIOGRAPHY ABDOMEN W/CONTRAST/NONCONTRAST Radiology a 1.82 6.75 6.75 Blank RBRVS

74175 26 CT ANGIOGRAPHY ABDOMEN W/CONTRAST/NONCONTRAST Radiology Blank 1.82 0.65 0.65 Blank RBRVS

74175 TC CT ANGIOGRAPHY ABDOMEN W/CONTRAST/NONCONTRAST Radiology a Blank 6.10 6.10 Blank RBRVS

74176 Blank CT ABDOMEN & PELVIS W/O CONTRAST MATERIAL Radiology a 1.74 3.83 3.83 Blank RBRVS

74176 26 CT ABDOMEN & PELVIS W/O CONTRAST MATERIAL Radiology Blank 1.74 0.64 0.64 Blank RBRVS

74176 TC CT ABDOMEN & PELVIS W/O CONTRAST MATERIAL Radiology a Blank 3.19 3.19 Blank RBRVS

74177 Blank CT ABDOMEN & PELVIS W/CONTRAST MATERIAL Radiology a 1.82 6.89 6.89 Blank RBRVS

74177 26 CT ABDOMEN & PELVIS W/CONTRAST MATERIAL Radiology Blank 1.82 0.68 0.68 Blank RBRVS

74177 TC CT ABDOMEN & PELVIS W/CONTRAST MATERIAL Radiology a Blank 6.21 6.21 Blank RBRVS

74178 Blank CT ABDOMEN & PELVIS W/O CONTRST 1/> BODY RE Radiology a 2.01 7.85 7.85 Blank RBRVS

74178 26 CT ABDOMEN & PELVIS W/O CONTRST 1/> BODY RE Radiology Blank 2.01 0.73 0.73 Blank RBRVS

74178 TC CT ABDOMEN & PELVIS W/O CONTRST 1/> BODY RE Radiology a Blank 7.12 7.12 Blank RBRVS

74181 Blank MRI ABDOMEN W/O CONTRAST MATERIAL Radiology a 1.46 6.45 6.45 Blank RBRVS

74181 26 MRI ABDOMEN W/O CONTRAST MATERIAL Radiology Blank 1.46 0.54 0.54 Blank RBRVS

74181 TC MRI ABDOMEN W/O CONTRAST MATERIAL Radiology a Blank 5.91 5.91 Blank RBRVS

74182 Blank MRI ABDOMEN W/CONTRAST MATERIAL Radiology a 1.73 9.00 9.00 Blank RBRVS

74182 26 MRI ABDOMEN W/CONTRAST MATERIAL Radiology Blank 1.73 0.64 0.64 Blank RBRVS

74182 TC MRI ABDOMEN W/CONTRAST MATERIAL Radiology a Blank 8.36 8.36 Blank RBRVS

74183 Blank MRI ABDOMEN W/O & W/CONTRAST MATERIAL Radiology a 2.20 9.75 9.75 Blank RBRVS

74183 26 MRI ABDOMEN W/O & W/CONTRAST MATERIAL Radiology Blank 2.20 0.80 0.80 Blank RBRVS

74183 TC MRI ABDOMEN W/O & W/CONTRAST MATERIAL Radiology a Blank 8.95 8.95 Blank RBRVS

74185 Blank MRA ABDOMEN W/WO CONTRAST MATERIAL Radiology a 1.80 9.50 9.50 Blank RBRVS

74185 26 MRA ABDOMEN W/WO CONTRAST MATERIAL Radiology Blank 1.80 0.64 0.64 Blank RBRVS

74185 TC MRA ABDOMEN W/WO CONTRAST MATERIAL Radiology a Blank 8.86 8.86 Blank RBRVS

74190 Blank PERITONEOGRAM RS&I Radiology a Blank Blank Blank 1.37 Global/TC/26

74190 26 PERITONEOGRAM RS&I Radiology Blank Blank Blank Blank 0.64 Global/TC/26

74190 TC PERITONEOGRAM RS&I Radiology a Blank Blank Blank 0.73 Global/TC/26

74210 Blank RADEX PHARYNX&/CERVICAL ESOPHAGUS Radiology a 0.36 1.81 1.81 Blank RBRVS

74210 26 RADEX PHARYNX&/CERVICAL ESOPHAGUS Radiology Blank 0.36 0.13 0.13 Blank RBRVS

74210 TC RADEX PHARYNX&/CERVICAL ESOPHAGUS Radiology a Blank 1.68 1.68 Blank RBRVS

74220 Blank RADEX ESOPHAGUS Radiology a 0.46 2.00 2.00 Blank RBRVS

74220 26 RADEX ESOPHAGUS Radiology Blank 0.46 0.17 0.17 Blank RBRVS

74220 TC RADEX ESOPHAGUS Radiology a Blank 1.83 1.83 Blank RBRVS

74230 Blank SWALLOWING FUNCJ W/CINERADIOGRAPY/VIDRADIOG Radiology a 0.53 3.08 3.08 Blank RBRVS

74230 26 SWALLOWING FUNCJ W/CINERADIOGRAPY/VIDRADIOG Radiology Blank 0.53 0.20 0.20 Blank RBRVS

74230 TC SWALLOWING FUNCJ W/CINERADIOGRAPY/VIDRADIOG Radiology a Blank 2.88 2.88 Blank RBRVS

74235 Blank RMVL FB ESOPHAGEAL W/USE BALLOON CATH RS&I Radiology a Blank Blank Blank 4.81 Global/TC/26

74235 26 RMVL FB ESOPHAGEAL W/USE BALLOON CATH RS&I Radiology Blank Blank Blank Blank 1.67 Global/TC/26

74235 TC RMVL FB ESOPHAGEAL W/USE BALLOON CATH RS&I Radiology a Blank Blank Blank 3.14 Global/TC/26

74240 Blank RADEX GI TRACT UPPER W/WO DELAYED IMAGES W/O KUB Radiology a 0.69 2.45 2.45 Blank RBRVS

74240 26 RADEX GI TRACT UPPER W/WO DELAYED IMAGES W/O KUB Radiology Blank 0.69 0.26 0.26 Blank RBRVS

74240 TC RADEX GI TRACT UPPER W/WO DELAYED IMAGES W/O KUB Radiology a Blank 2.19 2.19 Blank RBRVS

74241 Blank RADEX GI TRACT UPPER W/WO DELAYED IMAGES W/KUB Radiology a 0.69 2.57 2.57 Blank RBRVS

74241 26 RADEX GI TRACT UPPER W/WO DELAYED IMAGES W/KUB Radiology Blank 0.69 0.25 0.25 Blank RBRVS

74241 TC RADEX GI TRACT UPPER W/WO DELAYED IMAGES W/KUB Radiology a Blank 2.32 2.32 Blank RBRVS

74245 Blank RADEX GI TRACT UPR W/SM INT W/MULT SERIAL IMAGES Radiology a 0.91 3.86 3.86 Blank RBRVS

74245 26 RADEX GI TRACT UPR W/SM INT W/MULT SERIAL IMAGES Radiology Blank 0.91 0.34 0.34 Blank RBRVS

74245 TC RADEX GI TRACT UPR W/SM INT W/MULT SERIAL IMAGES Radiology a Blank 3.52 3.52 Blank RBRVS

74246 Blank RADEX UPPER GI W/WO GLUCAGON/DELAY IMGES W/O KUB Radiology a 0.69 2.83 2.83 Blank RBRVS

74246 26 RADEX UPPER GI W/WO GLUCAGON/DELAY IMGES W/O KUB Radiology Blank 0.69 0.25 0.25 Blank RBRVS

74246 TC RADEX UPPER GI W/WO GLUCAGON/DELAY IMGES W/O KUB Radiology a Blank 2.58 2.58 Blank RBRVS

74247 Blank RADEX UPPER GI W/WO GLUCAGON/DELAY IMAGES W/KUB Radiology a 0.69 3.25 3.25 Blank RBRVS

74247 26 RADEX UPPER GI W/WO GLUCAGON/DELAY IMAGES W/KUB Radiology Blank 0.69 0.25 0.25 Blank RBRVS

74247 TC RADEX UPPER GI W/WO GLUCAGON/DELAY IMAGES W/KUB Radiology a Blank 3.00 3.00 Blank RBRVS

74249 Blank RADEX GI UPR W/WO GLUCOSE W/SM INTEST FOLLW-THRU Radiology a 0.91 4.21 4.21 Blank RBRVS

74249 26 RADEX GI UPR W/WO GLUCOSE W/SM INTEST FOLLW-THRU Radiology Blank 0.91 0.34 0.34 Blank RBRVS

74249 TC RADEX GI UPR W/WO GLUCOSE W/SM INTEST FOLLW-THRU Radiology a Blank 3.87 3.87 Blank RBRVS

74250 Blank RADEX SMALL INTESTINE W/MULTIPLE SERIAL IMAGES Radiology a 0.47 2.41 2.41 Blank RBRVS





PAGE 91 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

74250 26 RADEX SMALL INTESTINE W/MULTIPLE SERIAL IMAGES Radiology Blank 0.47 0.17 0.17 Blank RBRVS

74250 TC RADEX SMALL INTESTINE W/MULTIPLE SERIAL IMAGES Radiology a Blank 2.24 2.24 Blank RBRVS

74251 Blank RADEX SM INT W/MLT SRL IMGES VIA ENTEROCLSS TUBE Radiology a 0.69 11.09 11.09 Blank RBRVS

74251 26 RADEX SM INT W/MLT SRL IMGES VIA ENTEROCLSS TUBE Radiology Blank 0.69 0.25 0.25 Blank RBRVS

74251 TC RADEX SM INT W/MLT SRL IMGES VIA ENTEROCLSS TUBE Radiology a Blank 10.84 10.84 Blank RBRVS

74260 Blank DUODENOGRAPY HYPOTONIC Radiology a 0.50 9.29 9.29 Blank RBRVS

74260 26 DUODENOGRAPY HYPOTONIC Radiology Blank 0.50 0.19 0.19 Blank RBRVS

74260 TC DUODENOGRAPY HYPOTONIC Radiology a Blank 9.10 9.10 Blank RBRVS

74261 Blank CT COLONOGRPHY DX IMAGE POSTPROCESS W/O CONTRAST Radiology a 2.40 11.20 11.20 Blank RBRVS

74261 26 CT COLONOGRPHY DX IMAGE POSTPROCESS W/O CONTRAST Radiology Blank 2.40 0.88 0.88 Blank RBRVS

74261 TC CT COLONOGRPHY DX IMAGE POSTPROCESS W/O CONTRAST Radiology a Blank 10.32 10.32 Blank RBRVS

74262 Blank CT COLONOGRPHY DX IMAGE POSTPROCESS W/CONTRAST Radiology a 2.50 12.75 12.75 Blank RBRVS

74262 26 CT COLONOGRPHY DX IMAGE POSTPROCESS W/CONTRAST Radiology Blank 2.50 0.92 0.92 Blank RBRVS

74262 TC CT COLONOGRPHY DX IMAGE POSTPROCESS W/CONTRAST Radiology a Blank 11.83 11.83 Blank RBRVS

74263 Blank CT COLONOGRAPHY SCREENING IMAGE POSTPROCESSING Radiology a 2.28 19.20 19.20 Blank RBRVS

74263 26 CT COLONOGRAPHY SCREENING IMAGE POSTPROCESSING Radiology Blank 2.28 0.88 0.88 Blank RBRVS

74263 TC CT COLONOGRAPHY SCREENING IMAGE POSTPROCESSING Radiology a Blank 18.32 18.32 Blank RBRVS

74270 Blank RADEX COLON BARIUM ENEMA W/WO KUB Radiology a 0.69 3.50 3.50 Blank RBRVS

74270 26 RADEX COLON BARIUM ENEMA W/WO KUB Radiology Blank 0.69 0.25 0.25 Blank RBRVS

74270 TC RADEX COLON BARIUM ENEMA W/WO KUB Radiology a Blank 3.25 3.25 Blank RBRVS

74280 Blank RADEX COLON W/SPEC HI DNS BARIUM W/WO GLUCAGON Radiology a 0.99 4.96 4.96 Blank RBRVS

74280 26 RADEX COLON W/SPEC HI DNS BARIUM W/WO GLUCAGON Radiology Blank 0.99 0.36 0.36 Blank RBRVS

74280 TC RADEX COLON W/SPEC HI DNS BARIUM W/WO GLUCAGON Radiology a Blank 4.60 4.60 Blank RBRVS

74283 Blank THERAPEUTIC ENEMA RDCTJ INTUSSUSCEPTION/OBSTRCJ Radiology a 2.02 3.79 3.79 Blank RBRVS

74283 26 THERAPEUTIC ENEMA RDCTJ INTUSSUSCEPTION/OBSTRCJ Radiology Blank 2.02 0.79 0.79 Blank RBRVS

74283 TC THERAPEUTIC ENEMA RDCTJ INTUSSUSCEPTION/OBSTRCJ Radiology a Blank 3.00 3.00 Blank RBRVS

74290 Blank CHOLECYSTOGRAPHY ORAL CONTRST Radiology a 0.32 1.62 1.62 Blank RBRVS

74290 26 CHOLECYSTOGRAPHY ORAL CONTRST Radiology Blank 0.32 0.12 0.12 Blank RBRVS

74290 TC CHOLECYSTOGRAPHY ORAL CONTRST Radiology a Blank 1.50 1.50 Blank RBRVS

74300 Blank CHOLANGIOGRAPHY&/PANCREATOGRAPHY NTRAOP RS&I Radiology a Blank Blank Blank 1.54 Global/TC/26

74300 26 CHOLANGIOGRAPHY&/PANCREATOGRAPHY NTRAOP RS&I Radiology Blank Blank Blank Blank 0.49 Global/TC/26

74300 TC CHOLANGIOGRAPHY&/PANCREATOGRAPHY NTRAOP RS&I Radiology a Blank Blank Blank 1.05 Global/TC/26

74301 Blank CHOLANGIO&/PANCREATOGRAPHY ADDL SET INTRAOP RS Radiology a Blank Blank Blank 1.05 Global/TC/26

74301 26 CHOLANGIO&/PANCREATOGRAPHY ADDL SET INTRAOP RS Radiology Blank Blank Blank Blank 0.28 Global/TC/26

74301 TC CHOLANGIO&/PANCREATOGRAPHY ADDL SET INTRAOP RS Radiology a Blank Blank Blank 0.77 Global/TC/26

74328 Blank ENDOSCOPIC CATHJ BILIARY DUCTAL SYSTEM RS&I Radiology a Blank Blank Blank 3.62 Global/TC/26

74328 26 ENDOSCOPIC CATHJ BILIARY DUCTAL SYSTEM RS&I Radiology Blank Blank Blank Blank 0.97 Global/TC/26

74328 TC ENDOSCOPIC CATHJ BILIARY DUCTAL SYSTEM RS&I Radiology a Blank Blank Blank 2.65 Global/TC/26

74329 Blank ENDOSCOPIC CATHJ PANCREATIC DUCTAL SYS RS&I Radiology a Blank Blank Blank 2.98 Global/TC/26

74329 26 ENDOSCOPIC CATHJ PANCREATIC DUCTAL SYS RS&I Radiology Blank Blank Blank Blank 0.98 Global/TC/26

74329 TC ENDOSCOPIC CATHJ PANCREATIC DUCTAL SYS RS&I Radiology a Blank Blank Blank 2.00 Global/TC/26

74330 Blank CMBN NDSC CATHJ BILIARY&PNCRTC DUCTAL SYS RS&I Radiology a Blank Blank Blank 4.47 Global/TC/26

74330 26 CMBN NDSC CATHJ BILIARY&PNCRTC DUCTAL SYS RS&I Radiology Blank Blank Blank Blank 1.25 Global/TC/26

74330 TC CMBN NDSC CATHJ BILIARY&PNCRTC DUCTAL SYS RS&I Radiology a Blank Blank Blank 3.22 Global/TC/26

74340 Blank INTRO LONG GI TUBE W/MULT FLUORO & IMAGES RS&I Radiology a Blank Blank Blank 2.17 Global/TC/26

74340 26 INTRO LONG GI TUBE W/MULT FLUORO & IMAGES RS&I Radiology Blank Blank Blank Blank 0.74 Global/TC/26

74340 TC INTRO LONG GI TUBE W/MULT FLUORO & IMAGES RS&I Radiology a Blank Blank Blank 1.43 Global/TC/26

74355 Blank PERCUTANEOUS PLACEMENT ENTEROCLYSIS TUBE RS&I Radiology a Blank Blank Blank 3.93 Global/TC/26

74355 26 PERCUTANEOUS PLACEMENT ENTEROCLYSIS TUBE RS&I Radiology Blank Blank Blank Blank 1.05 Global/TC/26

74355 TC PERCUTANEOUS PLACEMENT ENTEROCLYSIS TUBE RS&I Radiology a Blank Blank Blank 2.88 Global/TC/26

74360 Blank INTRALUMINAL DILATION STRICTURES&/OBSTRCJS RS&I Radiology a Blank Blank Blank 3.28 Global/TC/26

74360 26 INTRALUMINAL DILATION STRICTURES&/OBSTRCJS RS&I Radiology Blank Blank Blank Blank 0.75 Global/TC/26

74360 TC INTRALUMINAL DILATION STRICTURES&/OBSTRCJS RS&I Radiology a Blank Blank Blank 2.53 Global/TC/26

74363 Blank PRQ TRANSHEPATC DILAT BILIARY DUCT STRICTRE RS&I Radiology a Blank Blank Blank 3.14 Global/TC/26

74363 26 PRQ TRANSHEPATC DILAT BILIARY DUCT STRICTRE RS&I Radiology Blank Blank Blank Blank 1.16 Global/TC/26

74363 TC PRQ TRANSHEPATC DILAT BILIARY DUCT STRICTRE RS&I Radiology a Blank Blank Blank 1.98 Global/TC/26

74400 Blank UROGRAPHY IV W/WO KUB W/WO TOMOGRAPHY Radiology a 0.49 2.57 2.57 Blank RBRVS

74400 26 UROGRAPHY IV W/WO KUB W/WO TOMOGRAPHY Radiology Blank 0.49 0.18 0.18 Blank RBRVS

74400 TC UROGRAPHY IV W/WO KUB W/WO TOMOGRAPHY Radiology a Blank 2.39 2.39 Blank RBRVS

74410 Blank UROGRAPHY INFUSION DRIP &/BOLUS TECHNIQUE Radiology a 0.49 2.61 2.61 Blank RBRVS

74410 26 UROGRAPHY INFUSION DRIP &/BOLUS TECHNIQUE Radiology Blank 0.49 0.18 0.18 Blank RBRVS

74410 TC UROGRAPHY INFUSION DRIP &/BOLUS TECHNIQUE Radiology a Blank 2.43 2.43 Blank RBRVS

74415 Blank UROGRAPY INFUSION DRIP &/BOLUS TECHQ W/WO TOMO Radiology a 0.49 3.32 3.32 Blank RBRVS

74415 26 UROGRAPY INFUSION DRIP &/BOLUS TECHQ W/WO TOMO Radiology Blank 0.49 0.18 0.18 Blank RBRVS

74415 TC UROGRAPY INFUSION DRIP &/BOLUS TECHQ W/WO TOMO Radiology a Blank 3.14 3.14 Blank RBRVS

74420 Blank X-RAY URINARY TRACT EXAM WITH CONTRAST MATERIAL Radiology a Blank Blank Blank 2.53 Global/TC/26

74420 26 X-RAY URINARY TRACT EXAM WITH CONTRAST MATERIAL Radiology Blank Blank Blank Blank 0.49 Global/TC/26

74420 TC X-RAY URINARY TRACT EXAM WITH CONTRAST MATERIAL Radiology a Blank Blank Blank 2.04 Global/TC/26

74425 Blank UROGRAPHY ANTEGRADE RS&I Radiology a Blank Blank Blank 1.83 Global/TC/26

74425 26 UROGRAPHY ANTEGRADE RS&I Radiology Blank Blank Blank Blank 0.48 Global/TC/26

74425 TC UROGRAPHY ANTEGRADE RS&I Radiology a Blank Blank Blank 1.35 Global/TC/26

74430 Blank CYSTOGRAPHY MINIMUM 3 VIEWS RS&I Radiology a 0.32 0.73 0.73 Blank RBRVS





PAGE 92 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

74430 26 CYSTOGRAPHY MINIMUM 3 VIEWS RS&I Radiology Blank 0.32 0.12 0.12 Blank RBRVS

74430 TC CYSTOGRAPHY MINIMUM 3 VIEWS RS&I Radiology a Blank 0.61 0.61 Blank RBRVS

74440 Blank VASOGRAPY VESICULOGRAPY/EPIDIDYMOGRAPY RS&I Radiology a 0.38 1.87 1.87 Blank RBRVS

74440 26 VASOGRAPY VESICULOGRAPY/EPIDIDYMOGRAPY RS&I Radiology Blank 0.38 0.13 0.13 Blank RBRVS

74440 TC VASOGRAPY VESICULOGRAPY/EPIDIDYMOGRAPY RS&I Radiology a Blank 1.74 1.74 Blank RBRVS

74445 Blank CORPORA CAVERNOSOGRAPY RS&I Radiology a Blank Blank Blank 2.97 Global/TC/26

74445 26 CORPORA CAVERNOSOGRAPY RS&I Radiology Blank Blank Blank Blank 1.55 Global/TC/26

74445 TC CORPORA CAVERNOSOGRAPY RS&I Radiology a Blank Blank Blank 1.42 Global/TC/26

74450 Blank URETHROCYSTOGRAPHY RETROGRADE RS&I Radiology a Blank Blank Blank 2.06 Global/TC/26

74450 26 URETHROCYSTOGRAPHY RETROGRADE RS&I Radiology Blank Blank Blank Blank 0.45 Global/TC/26

74450 TC URETHROCYSTOGRAPHY RETROGRADE RS&I Radiology a Blank Blank Blank 1.61 Global/TC/26

74455 Blank URETHROCYSTOGRAPHY VOIDING RS&I Radiology a 0.33 1.97 1.97 Blank RBRVS

74455 26 URETHROCYSTOGRAPHY VOIDING RS&I Radiology Blank 0.33 0.12 0.12 Blank RBRVS

74455 TC URETHROCYSTOGRAPHY VOIDING RS&I Radiology a Blank 1.85 1.85 Blank RBRVS

74470 Blank RADEX RENAL CYST STUDY TRANSLUMBAR RS&I Radiology a Blank Blank Blank 2.51 Global/TC/26

74470 26 RADEX RENAL CYST STUDY TRANSLUMBAR RS&I Radiology Blank Blank Blank Blank 0.72 Global/TC/26

74470 TC RADEX RENAL CYST STUDY TRANSLUMBAR RS&I Radiology a Blank Blank Blank 1.79 Global/TC/26

74485 Blank DILATION NEPHROSTOMY/URETER/URETHRA RS&I Radiology a 0.54 2.05 2.05 Blank RBRVS

74485 26 DILATION NEPHROSTOMY/URETER/URETHRA RS&I Radiology Blank 0.54 0.18 0.18 Blank RBRVS

74485 TC DILATION NEPHROSTOMY/URETER/URETHRA RS&I Radiology a Blank 1.87 1.87 Blank RBRVS

74710 Blank PELVIMETRY W/WOPLACENTAL LOCALIZATION Radiology a 0.34 0.66 0.66 Blank RBRVS

74710 26 PELVIMETRY W/WOPLACENTAL LOCALIZATION Radiology Blank 0.34 0.13 0.13 Blank RBRVS

74710 TC PELVIMETRY W/WOPLACENTAL LOCALIZATION Radiology a Blank 0.53 0.53 Blank RBRVS

74712 Blank FETAL MRI W/PLACNTL MATRNL PLVC IMG SING/1ST GES Radiology a 3.00 10.77 10.77 Blank RBRVS

74712 26 FETAL MRI W/PLACNTL MATRNL PLVC IMG SING/1ST GES Radiology Blank 3.00 1.11 1.11 Blank RBRVS

74712 TC FETAL MRI W/PLACNTL MATRNL PLVC IMG SING/1ST GES Radiology a Blank 9.66 9.66 Blank RBRVS

74713 Blank FETAL MRI W/PLACNTL MATRNL PLVC IMG EA ADDL GES Radiology a 1.85 4.78 4.78 Blank RBRVS

74713 26 FETAL MRI W/PLACNTL MATRNL PLVC IMG EA ADDL GES Radiology Blank 1.85 0.69 0.69 Blank RBRVS

74713 TC FETAL MRI W/PLACNTL MATRNL PLVC IMG EA ADDL GES Radiology a Blank 4.09 4.09 Blank RBRVS

74740 Blank HYSTEROSALPINGOGRAPHY RS&I Radiology a 0.38 1.70 1.70 Blank RBRVS

74740 26 HYSTEROSALPINGOGRAPHY RS&I Radiology Blank 0.38 0.14 0.14 Blank RBRVS

74740 TC HYSTEROSALPINGOGRAPHY RS&I Radiology a Blank 1.56 1.56 Blank RBRVS

74742 Blank TRANSCERVICAL CATHJ FALLOPIAN TUBE RS&I Radiology a Blank Blank Blank 3.06 Global/TC/26

74742 26 TRANSCERVICAL CATHJ FALLOPIAN TUBE RS&I Radiology Blank Blank Blank Blank 0.84 Global/TC/26

74742 TC TRANSCERVICAL CATHJ FALLOPIAN TUBE RS&I Radiology a Blank Blank Blank 2.22 Global/TC/26

74775 Blank PERINEOGRAM Radiology a Blank Blank Blank 3.38 Global/TC/26

74775 26 PERINEOGRAM Radiology Blank Blank Blank Blank 0.85 Global/TC/26

74775 TC PERINEOGRAM Radiology a Blank Blank Blank 2.53 Global/TC/26

75557 Blank CARDIAC MRI MORPHOLOGY & FUNCTION W/O CONTRAST Radiology a 2.35 6.86 6.86 Blank RBRVS

75557 26 CARDIAC MRI MORPHOLOGY & FUNCTION W/O CONTRAST Radiology Blank 2.35 0.83 0.83 Blank RBRVS

75557 TC CARDIAC MRI MORPHOLOGY & FUNCTION W/O CONTRAST Radiology a Blank 6.03 6.03 Blank RBRVS

75559 Blank CARDIAC MRI W/O CONTRAST W/STRESS IMAGING Radiology a 2.95 9.51 9.51 Blank RBRVS

75559 26 CARDIAC MRI W/O CONTRAST W/STRESS IMAGING Radiology Blank 2.95 1.00 1.00 Blank RBRVS

75559 TC CARDIAC MRI W/O CONTRAST W/STRESS IMAGING Radiology a Blank 8.51 8.51 Blank RBRVS

75561 Blank CARDIAC MRI W/WO CONTRAST & FURTHER SEQ Radiology a 2.60 9.55 9.55 Blank RBRVS

75561 26 CARDIAC MRI W/WO CONTRAST & FURTHER SEQ Radiology Blank 2.60 0.91 0.91 Blank RBRVS

75561 TC CARDIAC MRI W/WO CONTRAST & FURTHER SEQ Radiology a Blank 8.64 8.64 Blank RBRVS

75563 Blank CARDIAC MRI W/W/O CONTRAST W/STRESS Radiology a 3.00 11.48 11.48 Blank RBRVS

75563 26 CARDIAC MRI W/W/O CONTRAST W/STRESS Radiology Blank 3.00 1.05 1.05 Blank RBRVS

75563 TC CARDIAC MRI W/W/O CONTRAST W/STRESS Radiology a Blank 10.43 10.43 Blank RBRVS

75565 Blank CARDIAC MRI FOR VELOCITY FLOW MAPPING Radiology a 0.25 1.29 1.29 Blank RBRVS

75565 26 CARDIAC MRI FOR VELOCITY FLOW MAPPING Radiology Blank 0.25 0.09 0.09 Blank RBRVS

75565 TC CARDIAC MRI FOR VELOCITY FLOW MAPPING Radiology a Blank 1.20 1.20 Blank RBRVS

75571 Blank CT HEART NO CONTRAST QUANT EVAL CORONRY CALCIUM Radiology a 0.58 2.30 2.30 Blank RBRVS

75571 26 CT HEART NO CONTRAST QUANT EVAL CORONRY CALCIUM Radiology Blank 0.58 0.21 0.21 Blank RBRVS

75571 TC CT HEART NO CONTRAST QUANT EVAL CORONRY CALCIUM Radiology a Blank 2.09 2.09 Blank RBRVS

75572 Blank CT HEART CONTRAST EVAL CARDIAC STRUCTURE&MORPH Radiology a 1.75 6.22 6.22 Blank RBRVS

75572 26 CT HEART CONTRAST EVAL CARDIAC STRUCTURE&MORPH Radiology Blank 1.75 0.63 0.63 Blank RBRVS

75572 TC CT HEART CONTRAST EVAL CARDIAC STRUCTURE&MORPH Radiology a Blank 5.59 5.59 Blank RBRVS

75573 Blank CT HRT CONTRST CARDIAC STRUCT&MORPH CONG HRT D Radiology a 2.55 8.33 8.33 Blank RBRVS

75573 26 CT HRT CONTRST CARDIAC STRUCT&MORPH CONG HRT D Radiology Blank 2.55 0.91 0.91 Blank RBRVS

75573 TC CT HRT CONTRST CARDIAC STRUCT&MORPH CONG HRT D Radiology a Blank 7.42 7.42 Blank RBRVS

75574 Blank CTA HRT CORNRY ART/BYPASS GRFTS CONTRST 3D POST Radiology a 2.40 9.46 9.46 Blank RBRVS

75574 26 CTA HRT CORNRY ART/BYPASS GRFTS CONTRST 3D POST Radiology Blank 2.40 0.84 0.84 Blank RBRVS

75574 TC CTA HRT CORNRY ART/BYPASS GRFTS CONTRST 3D POST Radiology a Blank 8.62 8.62 Blank RBRVS

75600 Blank AORTOGRAPHY THORACIC W/O SERIALOGRAPHY RS&I Radiology a 0.49 5.12 5.12 Blank RBRVS

75600 26 AORTOGRAPHY THORACIC W/O SERIALOGRAPHY RS&I Radiology Blank 0.49 0.15 0.15 Blank RBRVS

75600 TC AORTOGRAPHY THORACIC W/O SERIALOGRAPHY RS&I Radiology a Blank 4.97 4.97 Blank RBRVS

75605 Blank AORTOGRAPHY THORACIC SERIALOGRAPHY RS&I Radiology a 1.14 2.65 2.65 Blank RBRVS

75605 26 AORTOGRAPHY THORACIC SERIALOGRAPHY RS&I Radiology Blank 1.14 0.34 0.34 Blank RBRVS

75605 TC AORTOGRAPHY THORACIC SERIALOGRAPHY RS&I Radiology a Blank 2.31 2.31 Blank RBRVS

75625 Blank AORTOGRAPHY ABDOMINAL SERIALOGRAPHY RS&I Radiology a 1.14 2.59 2.59 Blank RBRVS





PAGE 93 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

75625 26 AORTOGRAPHY ABDOMINAL SERIALOGRAPHY RS&I Radiology Blank 1.14 0.31 0.31 Blank RBRVS

75625 TC AORTOGRAPHY ABDOMINAL SERIALOGRAPHY RS&I Radiology a Blank 2.28 2.28 Blank RBRVS

75630 Blank AORTOGRAPHY ABDL BI ILIOFEM LOW EXTREM CATH RS&I Radiology a 1.79 2.84 2.84 Blank RBRVS

75630 26 AORTOGRAPHY ABDL BI ILIOFEM LOW EXTREM CATH RS&I Radiology Blank 1.79 0.53 0.53 Blank RBRVS

75630 TC AORTOGRAPHY ABDL BI ILIOFEM LOW EXTREM CATH RS&I Radiology a Blank 2.31 2.31 Blank RBRVS

75635 Blank CTA ABDL AORTA&BI ILIOFEM W/CONTRAST&POSTP Radiology a 2.40 9.91 9.91 Blank RBRVS

75635 26 CTA ABDL AORTA&BI ILIOFEM W/CONTRAST&POSTP Radiology Blank 2.40 0.83 0.83 Blank RBRVS

75635 TC CTA ABDL AORTA&BI ILIOFEM W/CONTRAST&POSTP Radiology a Blank 9.08 9.08 Blank RBRVS

75705 Blank ANGIOGRAPHY SPINAL SELECTIVE RS&I Radiology a 2.18 4.64 4.64 Blank RBRVS

75705 26 ANGIOGRAPHY SPINAL SELECTIVE RS&I Radiology Blank 2.18 0.77 0.77 Blank RBRVS

75705 TC ANGIOGRAPHY SPINAL SELECTIVE RS&I Radiology a Blank 3.87 3.87 Blank RBRVS

75710 Blank ANGIOGRAPHY EXTREMITY UNILATERAL RS&I Radiology a 1.75 2.90 2.90 Blank RBRVS

75710 26 ANGIOGRAPHY EXTREMITY UNILATERAL RS&I Radiology Blank 1.75 0.49 0.49 Blank RBRVS

75710 TC ANGIOGRAPHY EXTREMITY UNILATERAL RS&I Radiology a Blank 2.41 2.41 Blank RBRVS

75716 Blank ANGIOGRAPHY EXTREMITY BILATERAL RS&I Radiology a 1.97 3.35 3.35 Blank RBRVS

75716 26 ANGIOGRAPHY EXTREMITY BILATERAL RS&I Radiology Blank 1.97 0.57 0.57 Blank RBRVS

75716 TC ANGIOGRAPHY EXTREMITY BILATERAL RS&I Radiology a Blank 2.78 2.78 Blank RBRVS

75726 Blank ANGIOGRAPHY VISCERAL SLCTV/SUPRASLCTV RS&I Radiology a 1.14 2.99 2.99 Blank RBRVS

75726 26 ANGIOGRAPHY VISCERAL SLCTV/SUPRASLCTV RS&I Radiology Blank 1.14 0.35 0.35 Blank RBRVS

75726 TC ANGIOGRAPHY VISCERAL SLCTV/SUPRASLCTV RS&I Radiology a Blank 2.64 2.64 Blank RBRVS

75731 Blank ANGIOGRAPHY ADRENAL UNILATERAL SLCTV RS&I Radiology a 1.14 3.64 3.64 Blank RBRVS

75731 26 ANGIOGRAPHY ADRENAL UNILATERAL SLCTV RS&I Radiology Blank 1.14 0.42 0.42 Blank RBRVS

75731 TC ANGIOGRAPHY ADRENAL UNILATERAL SLCTV RS&I Radiology a Blank 3.22 3.22 Blank RBRVS

75733 Blank ANGIOGRAPHY ADRENAL BILATERAL SLCTV RS&I Radiology a 1.31 3.84 3.84 Blank RBRVS

75733 26 ANGIOGRAPHY ADRENAL BILATERAL SLCTV RS&I Radiology Blank 1.31 0.45 0.45 Blank RBRVS

75733 TC ANGIOGRAPHY ADRENAL BILATERAL SLCTV RS&I Radiology a Blank 3.39 3.39 Blank RBRVS

75736 Blank ANGIOGRAPHY PELVIC SLCTV/SUPRASLCTV RS&I Radiology a 1.14 3.26 3.26 Blank RBRVS

75736 26 ANGIOGRAPHY PELVIC SLCTV/SUPRASLCTV RS&I Radiology Blank 1.14 0.32 0.32 Blank RBRVS

75736 TC ANGIOGRAPHY PELVIC SLCTV/SUPRASLCTV RS&I Radiology a Blank 2.94 2.94 Blank RBRVS

75741 Blank ANGIOGRAPHY PULMONARY UNILATERAL SLCTV RS&I Radiology a 1.31 2.84 2.84 Blank RBRVS

75741 26 ANGIOGRAPHY PULMONARY UNILATERAL SLCTV RS&I Radiology Blank 1.31 0.40 0.40 Blank RBRVS

75741 TC ANGIOGRAPHY PULMONARY UNILATERAL SLCTV RS&I Radiology a Blank 2.44 2.44 Blank RBRVS

75743 Blank ANGIOGRAPHY PULMONARY BILATERAL SLCTV RS&I Radiology a 1.66 2.98 2.98 Blank RBRVS

75743 26 ANGIOGRAPHY PULMONARY BILATERAL SLCTV RS&I Radiology Blank 1.66 0.51 0.51 Blank RBRVS

75743 TC ANGIOGRAPHY PULMONARY BILATERAL SLCTV RS&I Radiology a Blank 2.47 2.47 Blank RBRVS

75746 Blank ANGRPH PULMONARY NONSLCTV CATH/VEN NJX RS&I Radiology a 1.14 3.06 3.06 Blank RBRVS

75746 26 ANGRPH PULMONARY NONSLCTV CATH/VEN NJX RS&I Radiology Blank 1.14 0.37 0.37 Blank RBRVS

75746 TC ANGRPH PULMONARY NONSLCTV CATH/VEN NJX RS&I Radiology a Blank 2.69 2.69 Blank RBRVS

75756 Blank ANGIOGRAPHY INTERNAL MAMMARY RS&I Radiology a 1.14 3.57 3.57 Blank RBRVS

75756 26 ANGIOGRAPHY INTERNAL MAMMARY RS&I Radiology Blank 1.14 0.33 0.33 Blank RBRVS

75756 TC ANGIOGRAPHY INTERNAL MAMMARY RS&I Radiology a Blank 3.24 3.24 Blank RBRVS

75774 Blank ANGRPH SLCTV EA VSL STUDIED AFTER BASIC XM RS&I Radiology a 0.36 2.05 2.05 Blank RBRVS

75774 26 ANGRPH SLCTV EA VSL STUDIED AFTER BASIC XM RS&I Radiology Blank 0.36 0.10 0.10 Blank RBRVS

75774 TC ANGRPH SLCTV EA VSL STUDIED AFTER BASIC XM RS&I Radiology a Blank 1.95 1.95 Blank RBRVS

75801 Blank LYMPHANGIOGRAPHY EXTREMITY ONLY UNILATERAL RS&I Radiology a Blank Blank Blank 7.18 Global/TC/26

75801 26 LYMPHANGIOGRAPHY EXTREMITY ONLY UNILATERAL RS&I Radiology Blank Blank Blank Blank 1.13 Global/TC/26

75801 TC LYMPHANGIOGRAPHY EXTREMITY ONLY UNILATERAL RS&I Radiology a Blank Blank Blank 6.05 Global/TC/26

75803 Blank LYMPHANGIOGRAPHY EXTREMITY ONLY BILATERAL RS&I Radiology a Blank Blank Blank 7.41 Global/TC/26

75803 26 LYMPHANGIOGRAPHY EXTREMITY ONLY BILATERAL RS&I Radiology Blank Blank Blank Blank 1.61 Global/TC/26

75803 TC LYMPHANGIOGRAPHY EXTREMITY ONLY BILATERAL RS&I Radiology a Blank Blank Blank 5.80 Global/TC/26

75805 Blank LYMPHANGIOGRAPHY PELVIC/ABDOMINAL UNILAT RS&I Radiology a Blank Blank Blank 7.20 Global/TC/26

75805 26 LYMPHANGIOGRAPHY PELVIC/ABDOMINAL UNILAT RS&I Radiology Blank Blank Blank Blank 1.07 Global/TC/26

75805 TC LYMPHANGIOGRAPHY PELVIC/ABDOMINAL UNILAT RS&I Radiology a Blank Blank Blank 6.13 Global/TC/26

75807 Blank LYMPHANGIOGRAPHY PELVIC/ABDOMINAL BILATERAL RS&I Radiology a Blank Blank Blank 7.76 Global/TC/26

75807 26 LYMPHANGIOGRAPHY PELVIC/ABDOMINAL BILATERAL RS&I Radiology Blank Blank Blank Blank 1.54 Global/TC/26

75807 TC LYMPHANGIOGRAPHY PELVIC/ABDOMINAL BILATERAL RS&I Radiology a Blank Blank Blank 6.22 Global/TC/26

75809 Blank SHUNTOGRAM INDWELLING NONVASCULAR SHUNT RS&I Radiology a 0.47 2.29 2.29 Blank RBRVS

75809 26 SHUNTOGRAM INDWELLING NONVASCULAR SHUNT RS&I Radiology Blank 0.47 0.18 0.18 Blank RBRVS

75809 TC SHUNTOGRAM INDWELLING NONVASCULAR SHUNT RS&I Radiology a Blank 2.11 2.11 Blank RBRVS

75810 Blank SPLENOPORTOGRAPY RS&I Radiology a Blank Blank Blank 13.65 Global/TC/26

75810 26 SPLENOPORTOGRAPY RS&I Radiology Blank Blank Blank Blank 1.48 Global/TC/26

75810 TC SPLENOPORTOGRAPY RS&I Radiology a Blank Blank Blank 12.17 Global/TC/26

75820 Blank VENOGRAPHY EXTREMITY UNILATERAL RS&I Radiology a 0.70 2.50 2.50 Blank RBRVS

75820 26 VENOGRAPHY EXTREMITY UNILATERAL RS&I Radiology Blank 0.70 0.23 0.23 Blank RBRVS

75820 TC VENOGRAPHY EXTREMITY UNILATERAL RS&I Radiology a Blank 2.27 2.27 Blank RBRVS

75822 Blank VENOGRAPHY EXTREMITY BILATERAL RS&I Radiology a 1.06 2.68 2.68 Blank RBRVS

75822 26 VENOGRAPHY EXTREMITY BILATERAL RS&I Radiology Blank 1.06 0.33 0.33 Blank RBRVS

75822 TC VENOGRAPHY EXTREMITY BILATERAL RS&I Radiology a Blank 2.35 2.35 Blank RBRVS

75825 Blank VENOGRAPHY CAVAL INFERIOR SERIALOGRAPHY RS&I Radiology a 1.14 2.53 2.53 Blank RBRVS

75825 26 VENOGRAPHY CAVAL INFERIOR SERIALOGRAPHY RS&I Radiology Blank 1.14 0.32 0.32 Blank RBRVS

75825 TC VENOGRAPHY CAVAL INFERIOR SERIALOGRAPHY RS&I Radiology a Blank 2.21 2.21 Blank RBRVS

75827 Blank VENOGRAPHY CAVAL SUPERIOR SERIALOGRAPHY RS&I Radiology a 1.14 2.64 2.64 Blank RBRVS





PAGE 94 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

75827 26 VENOGRAPHY CAVAL SUPERIOR SERIALOGRAPHY RS&I Radiology Blank 1.14 0.32 0.32 Blank RBRVS

75827 TC VENOGRAPHY CAVAL SUPERIOR SERIALOGRAPHY RS&I Radiology a Blank 2.32 2.32 Blank RBRVS

75831 Blank VENOGRAPHY RENAL UNILATERAL SELECTIVE RS&I Radiology a 1.14 2.72 2.72 Blank RBRVS

75831 26 VENOGRAPHY RENAL UNILATERAL SELECTIVE RS&I Radiology Blank 1.14 0.33 0.33 Blank RBRVS

75831 TC VENOGRAPHY RENAL UNILATERAL SELECTIVE RS&I Radiology a Blank 2.39 2.39 Blank RBRVS

75833 Blank VENOGRAPHY RENAL BILATERAL SELECTIVE RS&I Radiology a 1.49 3.00 3.00 Blank RBRVS

75833 26 VENOGRAPHY RENAL BILATERAL SELECTIVE RS&I Radiology Blank 1.49 0.39 0.39 Blank RBRVS

75833 TC VENOGRAPHY RENAL BILATERAL SELECTIVE RS&I Radiology a Blank 2.61 2.61 Blank RBRVS

75840 Blank VENOGRAPHY ADRENAL UNILATERAL SELECTIVE RS&I Radiology a 1.14 2.98 2.98 Blank RBRVS

75840 26 VENOGRAPHY ADRENAL UNILATERAL SELECTIVE RS&I Radiology Blank 1.14 0.42 0.42 Blank RBRVS

75840 TC VENOGRAPHY ADRENAL UNILATERAL SELECTIVE RS&I Radiology a Blank 2.56 2.56 Blank RBRVS

75842 Blank VENOGRAPHY ADRENAL BILATERAL SELECTIVE RS&I Radiology a 1.49 3.43 3.43 Blank RBRVS

75842 26 VENOGRAPHY ADRENAL BILATERAL SELECTIVE RS&I Radiology Blank 1.49 0.55 0.55 Blank RBRVS

75842 TC VENOGRAPHY ADRENAL BILATERAL SELECTIVE RS&I Radiology a Blank 2.88 2.88 Blank RBRVS

75860 Blank VENOGRAPHY VENOUS SINUS/JUGULAR CATH RS&I Radiology a 1.14 2.83 2.83 Blank RBRVS

75860 26 VENOGRAPHY VENOUS SINUS/JUGULAR CATH RS&I Radiology Blank 1.14 0.35 0.35 Blank RBRVS

75860 TC VENOGRAPHY VENOUS SINUS/JUGULAR CATH RS&I Radiology a Blank 2.48 2.48 Blank RBRVS

75870 Blank VENOGRAPHY SUPERIOR SAGITTAL SINUS RS&I Radiology a 1.14 2.98 2.98 Blank RBRVS

75870 26 VENOGRAPHY SUPERIOR SAGITTAL SINUS RS&I Radiology Blank 1.14 0.42 0.42 Blank RBRVS

75870 TC VENOGRAPHY SUPERIOR SAGITTAL SINUS RS&I Radiology a Blank 2.56 2.56 Blank RBRVS

75872 Blank VENOGRAPHY EPIDURAL RS&I Radiology a 1.14 2.98 2.98 Blank RBRVS

75872 26 VENOGRAPHY EPIDURAL RS&I Radiology Blank 1.14 0.42 0.42 Blank RBRVS

75872 TC VENOGRAPHY EPIDURAL RS&I Radiology a Blank 2.56 2.56 Blank RBRVS

75880 Blank VENOGRAPHY ORBITAL RS&I Radiology a 0.70 2.81 2.81 Blank RBRVS

75880 26 VENOGRAPHY ORBITAL RS&I Radiology Blank 0.70 0.26 0.26 Blank RBRVS

75880 TC VENOGRAPHY ORBITAL RS&I Radiology a Blank 2.55 2.55 Blank RBRVS

75885 Blank PRQ TRANSHEPATC PORTOGRAPY HEMODYN EVAL RS&I Radiology a 1.44 2.89 2.89 Blank RBRVS

75885 26 PRQ TRANSHEPATC PORTOGRAPY HEMODYN EVAL RS&I Radiology Blank 1.44 0.41 0.41 Blank RBRVS

75885 TC PRQ TRANSHEPATC PORTOGRAPY HEMODYN EVAL RS&I Radiology a Blank 2.48 2.48 Blank RBRVS

75887 Blank PRQ TRANSHEPATC PORTOGRAPY W/O HEMODYN EVL INTRP Radiology a 1.44 2.91 2.91 Blank RBRVS

75887 26 PRQ TRANSHEPATC PORTOGRAPY W/O HEMODYN EVL INTRP Radiology Blank 1.44 0.42 0.42 Blank RBRVS

75887 TC PRQ TRANSHEPATC PORTOGRAPY W/O HEMODYN EVL INTRP Radiology a Blank 2.49 2.49 Blank RBRVS

75889 Blank HEPATC VNGRPH WDG/FR HEMODYN EVAL RS&I Radiology a 1.14 2.84 2.84 Blank RBRVS

75889 26 HEPATC VNGRPH WDG/FR HEMODYN EVAL RS&I Radiology Blank 1.14 0.34 0.34 Blank RBRVS

75889 TC HEPATC VNGRPH WDG/FR HEMODYN EVAL RS&I Radiology a Blank 2.50 2.50 Blank RBRVS

75891 Blank HEPATC VNGRPH WDG/FR W/O HEMODYN EVAL RS&I Radiology a 1.14 2.87 2.87 Blank RBRVS

75891 26 HEPATC VNGRPH WDG/FR W/O HEMODYN EVAL RS&I Radiology Blank 1.14 0.36 0.36 Blank RBRVS

75891 TC HEPATC VNGRPH WDG/FR W/O HEMODYN EVAL RS&I Radiology a Blank 2.51 2.51 Blank RBRVS

75893 Blank VENOUS SAMPLING THRU CATH W/WO ANGIOGRAPHY RS& Radiology a 0.54 2.81 2.81 Blank RBRVS

75893 26 VENOUS SAMPLING THRU CATH W/WO ANGIOGRAPHY RS& Radiology Blank 0.54 0.19 0.19 Blank RBRVS

75893 TC VENOUS SAMPLING THRU CATH W/WO ANGIOGRAPHY RS& Radiology a Blank 2.62 2.62 Blank RBRVS

75894 Blank TRANSCATHETER EMBOLIZATION ANY METH RS&I Radiology a Blank Blank Blank 27.43 Global/TC/26

75894 26 TRANSCATHETER EMBOLIZATION ANY METH RS&I Radiology Blank Blank Blank Blank 1.81 Global/TC/26

75894 TC TRANSCATHETER EMBOLIZATION ANY METH RS&I Radiology a Blank Blank Blank 25.62 Global/TC/26

75898 Blank ANGRPH CATH F-UP STD TCAT OTHER THAN THROMBYLSIS Radiology a Blank Blank Blank 3.67 Global/TC/26

75898 26 ANGRPH CATH F-UP STD TCAT OTHER THAN THROMBYLSIS Radiology Blank Blank Blank Blank 2.27 Global/TC/26

75898 TC ANGRPH CATH F-UP STD TCAT OTHER THAN THROMBYLSIS Radiology a Blank Blank Blank 1.40 Global/TC/26

75901 Blank MECHANICAL RMVL PERICATHETER OBSTR MATRL RS&I Radiology a 0.49 4.54 4.54 Blank RBRVS

75901 26 MECHANICAL RMVL PERICATHETER OBSTR MATRL RS&I Radiology Blank 0.49 0.15 0.15 Blank RBRVS

75901 TC MECHANICAL RMVL PERICATHETER OBSTR MATRL RS&I Radiology a Blank 4.39 4.39 Blank RBRVS

75902 Blank MECHANICAL RMVL INTRALUMINAL OBSTR MATRL RS&I Radiology a 0.39 1.61 1.61 Blank RBRVS

75902 26 MECHANICAL RMVL INTRALUMINAL OBSTR MATRL RS&I Radiology Blank 0.39 0.12 0.12 Blank RBRVS

75902 TC MECHANICAL RMVL INTRALUMINAL OBSTR MATRL RS&I Radiology a Blank 1.49 1.49 Blank RBRVS

75956 Blank EVASC RPR DESCND THORCIC AORTA SUBCLAV ORIG RS&I Radiology Blank Blank Blank Blank 10.31 Global/TC/26

75956 26 EVASC RPR DESCND THORCIC AORTA SUBCLAV ORIG RS&I Radiology Blank 7.00 1.60 1.60 Blank RBRVS

75956 TC EVASC RPR DESCND THORCIC AORTA SUBCLAV ORIG RS&I Radiology Blank Blank Blank Blank 1.71 FAIR Health

75957 Blank EVASC RPR DESCND THORCIC AORTA CELIAC ORIG RS&I Radiology Blank Blank Blank Blank 10.72 Global/TC/26

75957 26 EVASC RPR DESCND THORCIC AORTA CELIAC ORIG RS&I Radiology Blank 6.00 1.38 1.38 Blank RBRVS

75957 TC EVASC RPR DESCND THORCIC AORTA CELIAC ORIG RS&I Radiology Blank Blank Blank Blank 3.34 FAIR Health

75958 Blank PLMT PROX XTN PRSTH EVASC DESC THORAC AORTA RS&I Radiology Blank Blank Blank Blank 7.25 Global/TC/26

75958 26 PLMT PROX XTN PRSTH EVASC DESC THORAC AORTA RS&I Radiology Blank 4.00 0.92 0.92 Blank RBRVS

75958 TC PLMT PROX XTN PRSTH EVASC DESC THORAC AORTA RS&I Radiology Blank Blank Blank Blank 2.33 FAIR Health

75959 Blank PLMT DSTL XTN PRSTH EVASC DESC THORAC AORTA RS&I Radiology Blank Blank Blank Blank 6.43 Global/TC/26

75959 26 PLMT DSTL XTN PRSTH EVASC DESC THORAC AORTA RS&I Radiology Blank 3.50 0.80 0.80 Blank RBRVS

75959 TC PLMT DSTL XTN PRSTH EVASC DESC THORAC AORTA RS&I Radiology Blank Blank Blank Blank 2.13 FAIR Health

75970 Blank TRANSCATHETER BIOPSY RS&I Radiology a Blank Blank Blank 13.66 Global/TC/26

75970 26 TRANSCATHETER BIOPSY RS&I Radiology Blank Blank Blank Blank 1.08 Global/TC/26

75970 TC TRANSCATHETER BIOPSY RS&I Radiology a Blank Blank Blank 12.58 Global/TC/26

75984 Blank CHANGE PRQ TUBE/DRAINAGE CATH W CONTRAST RS&I Radiology a 0.72 2.23 2.23 Blank RBRVS

75984 26 CHANGE PRQ TUBE/DRAINAGE CATH W CONTRAST RS&I Radiology Blank 0.72 0.23 0.23 Blank RBRVS

75984 TC CHANGE PRQ TUBE/DRAINAGE CATH W CONTRAST RS&I Radiology a Blank 2.00 2.00 Blank RBRVS

75989 Blank RADIOLOGICAL GUIDANCE PRQ DRG W/PLMT CATH RS&I Radiology a 1.19 2.16 2.16 Blank RBRVS





PAGE 95 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

75989 26 RADIOLOGICAL GUIDANCE PRQ DRG W/PLMT CATH RS&I Radiology Blank 1.19 0.39 0.39 Blank RBRVS

75989 TC RADIOLOGICAL GUIDANCE PRQ DRG W/PLMT CATH RS&I Radiology a Blank 1.77 1.77 Blank RBRVS

76000 Blank FLUOROSCOPY SPX UP TO 1 HOUR PHYS/QHP TIME Radiology a 0.17 1.15 1.15 Blank RBRVS

76000 26 FLUOROSCOPY SPX UP TO 1 HOUR PHYS/QHP TIME Radiology Blank 0.17 0.06 0.06 Blank RBRVS

76000 TC FLUOROSCOPY SPX UP TO 1 HOUR PHYS/QHP TIME Radiology a Blank 1.09 1.09 Blank RBRVS

76010 Blank RADEX FROM NOSE RECTUM FOREIGN BODY 1 VIEW CHLD Radiology a 0.18 0.54 0.54 Blank RBRVS

76010 26 RADEX FROM NOSE RECTUM FOREIGN BODY 1 VIEW CHLD Radiology Blank 0.18 0.07 0.07 Blank RBRVS

76010 TC RADEX FROM NOSE RECTUM FOREIGN BODY 1 VIEW CHLD Radiology a Blank 0.47 0.47 Blank RBRVS

76080 Blank RADEX ABSCESS/FISTULA/SINUS TRACT RS&I Radiology a 0.54 0.97 0.97 Blank RBRVS

76080 26 RADEX ABSCESS/FISTULA/SINUS TRACT RS&I Radiology Blank 0.54 0.17 0.17 Blank RBRVS

76080 TC RADEX ABSCESS/FISTULA/SINUS TRACT RS&I Radiology a Blank 0.80 0.80 Blank RBRVS

76098 Blank RADIOLOGICAL EXAMINATION SURGICAL SPECIMEN Radiology a 0.16 0.30 0.30 Blank RBRVS

76098 26 RADIOLOGICAL EXAMINATION SURGICAL SPECIMEN Radiology Blank 0.16 0.06 0.06 Blank RBRVS

76098 TC RADIOLOGICAL EXAMINATION SURGICAL SPECIMEN Radiology a Blank 0.24 0.24 Blank RBRVS

76100 Blank RADEX 1 PLNE BODY SECTION OTH/THN W/UROGRAPY Radiology a 0.58 1.95 1.95 Blank RBRVS

76100 26 RADEX 1 PLNE BODY SECTION OTH/THN W/UROGRAPY Radiology Blank 0.58 0.27 0.27 Blank RBRVS

76100 TC RADEX 1 PLNE BODY SECTION OTH/THN W/UROGRAPY Radiology a Blank 1.68 1.68 Blank RBRVS

76101 Blank RADEX CPLX MOTION BDY SCTJ OTH/THN UROGRAPY UNI Radiology a 0.58 2.30 2.30 Blank RBRVS

76101 26 RADEX CPLX MOTION BDY SCTJ OTH/THN UROGRAPY UNI Radiology Blank 0.58 0.11 0.11 Blank RBRVS

76101 TC RADEX CPLX MOTION BDY SCTJ OTH/THN UROGRAPY UNI Radiology a Blank 2.19 2.19 Blank RBRVS

76102 Blank RADEX CPLX MOTION BDY SCTJ OTH/THN UROGRAPY BI Radiology a 0.58 4.14 4.14 Blank RBRVS

76102 26 RADEX CPLX MOTION BDY SCTJ OTH/THN UROGRAPY BI Radiology Blank 0.58 0.33 0.33 Blank RBRVS

76102 TC RADEX CPLX MOTION BDY SCTJ OTH/THN UROGRAPY BI Radiology a Blank 3.81 3.81 Blank RBRVS

76120 Blank CINERADIOGRAPY/VIDRADIOGRAPY XCPT WHERE SPEC Radiology a 0.38 2.21 2.21 Blank RBRVS

76120 26 CINERADIOGRAPY/VIDRADIOGRAPY XCPT WHERE SPEC Radiology Blank 0.38 0.11 0.11 Blank RBRVS

76120 TC CINERADIOGRAPY/VIDRADIOGRAPY XCPT WHERE SPEC Radiology a Blank 2.10 2.10 Blank RBRVS

76125 Blank CINERADIOGRAPY/VIDRADIOGRAPY ROUTINE EXAMINATION Radiology a Blank Blank Blank 1.16 Global/TC/26

76125 26 CINERADIOGRAPY/VIDRADIOGRAPY ROUTINE EXAMINATION Radiology Blank Blank Blank Blank 0.38 Global/TC/26

76125 TC CINERADIOGRAPY/VIDRADIOGRAPY ROUTINE EXAMINATION Radiology a Blank Blank Blank 0.78 Global/TC/26

76140 Blank CONSLTJ X-RAY XM MADE ELSEWHERE WRTTN REPRT Radiology Blank Blank Blank Blank 0.71 FAIR Health

76376 Blank 3D RENDERING W/INTERP & POSTPROCESS SUPERVISION Radiology a 0.20 0.44 0.44 Blank RBRVS

76376 26 3D RENDERING W/INTERP & POSTPROCESS SUPERVISION Radiology Blank 0.20 0.07 0.07 Blank RBRVS

76376 TC 3D RENDERING W/INTERP & POSTPROCESS SUPERVISION Radiology a Blank 0.37 0.37 Blank RBRVS

76377 Blank 3D RENDERING W/INTERP&POSTPROC DIFF WORK STATION Radiology a 0.79 1.16 1.16 Blank RBRVS

76377 26 3D RENDERING W/INTERP&POSTPROC DIFF WORK STATION Radiology Blank 0.79 0.29 0.29 Blank RBRVS

76377 TC 3D RENDERING W/INTERP&POSTPROC DIFF WORK STATION Radiology a Blank 0.87 0.87 Blank RBRVS

76380 Blank CT LIMITED/LOCALIZED FOLLOW UP STUDY Radiology a 0.98 3.06 3.06 Blank RBRVS

76380 26 CT LIMITED/LOCALIZED FOLLOW UP STUDY Radiology Blank 0.98 0.35 0.35 Blank RBRVS

76380 TC CT LIMITED/LOCALIZED FOLLOW UP STUDY Radiology a Blank 2.71 2.71 Blank RBRVS

76390 Blank MRI SPECTROSCOPY Radiology a 1.40 11.27 11.27 Blank RBRVS

76390 26 MRI SPECTROSCOPY Radiology Blank 1.40 0.55 0.55 Blank RBRVS

76390 TC MRI SPECTROSCOPY Radiology a Blank 10.72 10.72 Blank RBRVS

76391 Blank MR ELASTOGRAPHY Radiology Blank 1.10 5.49 5.49 Blank RBRVS

76391 26 MR ELASTOGRAPHY Radiology Blank 1.10 0.42 0.42 Blank RBRVS

76391 TC MR ELASTOGRAPHY Radiology Blank Blank 5.07 5.07 Blank RBRVS

76496 Blank UNLISTED FLUOROSCOPIC PROCEDURE Radiology a Blank Blank Blank 2.11 Unlisted

76496 26 UNLISTED FLUOROSCOPIC PROCEDURE Radiology Blank Blank Blank Blank 0.62 Unlisted

76496 TC UNLISTED FLUOROSCOPIC PROCEDURE Radiology a Blank Blank Blank 1.49 Unlisted

76497 Blank UNLISTED COMPUTED TOMOGRAPHY PROCEDURE Radiology a Blank Blank Blank 4.82 Unlisted

76497 26 UNLISTED COMPUTED TOMOGRAPHY PROCEDURE Radiology Blank Blank Blank Blank 1.63 Unlisted

76497 TC UNLISTED COMPUTED TOMOGRAPHY PROCEDURE Radiology a Blank Blank Blank 3.19 Unlisted

76498 Blank UNLISTED MAGNETIC RESONANCE PROCEDURE Radiology a Blank Blank Blank 6.80 Unlisted

76498 26 UNLISTED MAGNETIC RESONANCE PROCEDURE Radiology Blank Blank Blank Blank 2.03 Unlisted

76498 TC UNLISTED MAGNETIC RESONANCE PROCEDURE Radiology a Blank Blank Blank 4.77 Unlisted

76499 Blank UNLISTED DIAGNOSTIC RADIOGRAPHIC PROCEDURE Radiology a Blank Blank Blank 2.11 Unlisted

76499 26 UNLISTED DIAGNOSTIC RADIOGRAPHIC PROCEDURE Radiology Blank Blank Blank Blank 0.68 Unlisted

76499 TC UNLISTED DIAGNOSTIC RADIOGRAPHIC PROCEDURE Radiology a Blank Blank Blank 1.43 Unlisted

76506 Blank ECHOENCEPHALOGRAPHY REAL TIME IMAGING Radiology a 0.63 2.65 2.65 Blank RBRVS

76506 26 ECHOENCEPHALOGRAPHY REAL TIME IMAGING Radiology Blank 0.63 0.23 0.23 Blank RBRVS

76506 TC ECHOENCEPHALOGRAPHY REAL TIME IMAGING Radiology a Blank 2.42 2.42 Blank RBRVS

76510 Blank OPH US DX B-SCAN&QUAN A-SCAN SM PT ENCTR Radiology a 0.70 3.17 3.17 Blank RBRVS

76510 26 OPH US DX B-SCAN&QUAN A-SCAN SM PT ENCTR Radiology Blank 0.70 1.33 1.33 Blank RBRVS

76510 TC OPH US DX B-SCAN&QUAN A-SCAN SM PT ENCTR Radiology a Blank 1.84 1.84 Blank RBRVS

76511 Blank OPHTHALMIC ULTRASOUND DX QUAN A-SCAN ONLY Radiology a 0.64 1.67 1.67 Blank RBRVS

76511 26 OPHTHALMIC ULTRASOUND DX QUAN A-SCAN ONLY Radiology Blank 0.64 0.57 0.57 Blank RBRVS

76511 TC OPHTHALMIC ULTRASOUND DX QUAN A-SCAN ONLY Radiology a Blank 1.10 1.10 Blank RBRVS

76512 Blank OPHTHALMIC ULTRASOUND DX B-SCAN W/WO A-SCAN Radiology a 0.56 1.55 1.55 Blank RBRVS

76512 26 OPHTHALMIC ULTRASOUND DX B-SCAN W/WO A-SCAN Radiology Blank 0.56 0.65 0.65 Blank RBRVS

76512 TC OPHTHALMIC ULTRASOUND DX B-SCAN W/WO A-SCAN Radiology a Blank 0.90 0.90 Blank RBRVS

76513 Blank OPH US DX ANT SGM US IMMERSION B-SCAN/HR BIOM Radiology a 0.66 2.04 2.04 Blank RBRVS

76513 26 OPH US DX ANT SGM US IMMERSION B-SCAN/HR BIOM Radiology Blank 0.66 0.35 0.35 Blank RBRVS

76513 TC OPH US DX ANT SGM US IMMERSION B-SCAN/HR BIOM Radiology a Blank 1.69 1.69 Blank RBRVS





PAGE 96 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

76514 Blank OPHTHALMIC US DX CORNEAL PACHYMETRY UNI/BI Radiology a 0.17 0.25 0.25 Blank RBRVS

76514 26 OPHTHALMIC US DX CORNEAL PACHYMETRY UNI/BI Radiology Blank 0.17 0.10 0.10 Blank RBRVS

76514 TC OPHTHALMIC US DX CORNEAL PACHYMETRY UNI/BI Radiology a Blank 0.15 0.15 Blank RBRVS

76516 Blank OPHTHALMIC BIOMETRY US ECHOGRAPY A-SCAN Radiology a 0.40 1.38 1.38 Blank RBRVS

76516 26 OPHTHALMIC BIOMETRY US ECHOGRAPY A-SCAN Radiology Blank 0.40 0.30 0.30 Blank RBRVS

76516 TC OPHTHALMIC BIOMETRY US ECHOGRAPY A-SCAN Radiology a Blank 1.08 1.08 Blank RBRVS

76519 Blank OPH BMTRY US ECHOGRAPY A-SCAN IO LENS PWR CAL Radiology a 0.54 1.55 1.55 Blank RBRVS

76519 26 OPH BMTRY US ECHOGRAPY A-SCAN IO LENS PWR CAL Radiology Blank 0.54 0.34 0.34 Blank RBRVS

76519 TC OPH BMTRY US ECHOGRAPY A-SCAN IO LENS PWR CAL Radiology a Blank 1.21 1.21 Blank RBRVS

76529 Blank OPHTHALMIC ULTRASONIC FOREIGN BODY LOCALIZATION Radiology a 0.57 1.69 1.69 Blank RBRVS

76529 26 OPHTHALMIC ULTRASONIC FOREIGN BODY LOCALIZATION Radiology Blank 0.57 0.36 0.36 Blank RBRVS

76529 TC OPHTHALMIC ULTRASONIC FOREIGN BODY LOCALIZATION Radiology a Blank 1.33 1.33 Blank RBRVS

76536 Blank US SOFT TISSUE HEAD & NECK REAL TIME IMGE DOCM Radiology a 0.56 2.72 2.72 Blank RBRVS

76536 26 US SOFT TISSUE HEAD & NECK REAL TIME IMGE DOCM Radiology Blank 0.56 0.21 0.21 Blank RBRVS

76536 TC US SOFT TISSUE HEAD & NECK REAL TIME IMGE DOCM Radiology a Blank 2.51 2.51 Blank RBRVS

76604 Blank US CHEST REAL TIME W/IMAGE DOCUMENTATION Radiology a 0.55 1.95 1.95 Blank RBRVS

76604 26 US CHEST REAL TIME W/IMAGE DOCUMENTATION Radiology Blank 0.55 0.19 0.19 Blank RBRVS

76604 TC US CHEST REAL TIME W/IMAGE DOCUMENTATION Radiology a Blank 1.76 1.76 Blank RBRVS

76641 Blank US BREAST UNI REAL TIME WITH IMAGE COMPLETE Radiology a 0.73 2.28 2.28 Blank RBRVS

76641 26 US BREAST UNI REAL TIME WITH IMAGE COMPLETE Radiology Blank 0.73 0.27 0.27 Blank RBRVS

76641 TC US BREAST UNI REAL TIME WITH IMAGE COMPLETE Radiology a Blank 2.01 2.01 Blank RBRVS

76642 Blank US BREAST UNI REAL TIME WITH IMAGE LIMITED Radiology a 0.68 1.78 1.78 Blank RBRVS

76642 26 US BREAST UNI REAL TIME WITH IMAGE LIMITED Radiology Blank 0.68 0.25 0.25 Blank RBRVS

76642 TC US BREAST UNI REAL TIME WITH IMAGE LIMITED Radiology a Blank 1.53 1.53 Blank RBRVS

76700 Blank US ABDOMINAL REAL TIME W/IMAGE DOCUMENTATION Radiology a 0.81 2.63 2.63 Blank RBRVS

76700 26 US ABDOMINAL REAL TIME W/IMAGE DOCUMENTATION Radiology Blank 0.81 0.30 0.30 Blank RBRVS

76700 TC US ABDOMINAL REAL TIME W/IMAGE DOCUMENTATION Radiology a Blank 2.33 2.33 Blank RBRVS

76705 Blank US ABDOMINAL REAL TIME W/IMAGE LIMITED Radiology a 0.59 1.98 1.98 Blank RBRVS

76705 26 US ABDOMINAL REAL TIME W/IMAGE LIMITED Radiology Blank 0.59 0.22 0.22 Blank RBRVS

76705 TC US ABDOMINAL REAL TIME W/IMAGE LIMITED Radiology a Blank 1.76 1.76 Blank RBRVS

76706 Blank US ABDL AORTA SCREEN AAA Radiology a 0.55 2.09 2.09 Blank RBRVS

76706 26 US ABDL AORTA SCREEN AAA Radiology Blank 0.55 0.20 0.20 Blank RBRVS

76706 TC US ABDL AORTA SCREEN AAA Radiology a Blank 1.89 1.89 Blank RBRVS

76770 Blank US RETROPERITONEAL REAL TIME W/IMAGE COMPLETE Radiology a 0.74 2.44 2.44 Blank RBRVS

76770 26 US RETROPERITONEAL REAL TIME W/IMAGE COMPLETE Radiology Blank 0.74 0.27 0.27 Blank RBRVS

76770 TC US RETROPERITONEAL REAL TIME W/IMAGE COMPLETE Radiology a Blank 2.17 2.17 Blank RBRVS

76775 Blank US RETROPERITONEAL REAL TIME W/IMAGE LIMITED Radiology a 0.58 1.03 1.03 Blank RBRVS

76775 26 US RETROPERITONEAL REAL TIME W/IMAGE LIMITED Radiology Blank 0.58 0.21 0.21 Blank RBRVS

76775 TC US RETROPERITONEAL REAL TIME W/IMAGE LIMITED Radiology a Blank 0.82 0.82 Blank RBRVS

76776 Blank US TRNSPLNT KIDNEY REAL TIME W/IMAGE DOCMTN Radiology a 0.76 3.66 3.66 Blank RBRVS

76776 26 US TRNSPLNT KIDNEY REAL TIME W/IMAGE DOCMTN Radiology Blank 0.76 0.28 0.28 Blank RBRVS

76776 TC US TRNSPLNT KIDNEY REAL TIME W/IMAGE DOCMTN Radiology a Blank 3.38 3.38 Blank RBRVS

76800 Blank ULTRASOUND SPINAL CANAL & CONTENTS Radiology a 1.13 2.85 2.85 Blank RBRVS

76800 26 ULTRASOUND SPINAL CANAL & CONTENTS Radiology Blank 1.13 0.41 0.41 Blank RBRVS

76800 TC ULTRASOUND SPINAL CANAL & CONTENTS Radiology a Blank 2.44 2.44 Blank RBRVS

76801 Blank US PREGNANT UTERUS 14 WK TRANSABDL 1/1ST GESTAT Radiology a 0.99 2.46 2.46 Blank RBRVS

76801 26 US PREGNANT UTERUS 14 WK TRANSABDL 1/1ST GESTAT Radiology Blank 0.99 0.37 0.37 Blank RBRVS

76801 TC US PREGNANT UTERUS 14 WK TRANSABDL 1/1ST GESTAT Radiology a Blank 2.09 2.09 Blank RBRVS

76802 Blank US PREG UTERUS 14 WK TRANSABDL EACH GESTATION Radiology a 0.83 0.96 0.96 Blank RBRVS

76802 26 US PREG UTERUS 14 WK TRANSABDL EACH GESTATION Radiology Blank 0.83 0.32 0.32 Blank RBRVS

76802 TC US PREG UTERUS 14 WK TRANSABDL EACH GESTATION Radiology a Blank 0.64 0.64 Blank RBRVS

76805 Blank US PREG UTERUS AFTER 1ST TRIMEST 1/1ST GESTATION Radiology a 0.99 2.99 2.99 Blank RBRVS

76805 26 US PREG UTERUS AFTER 1ST TRIMEST 1/1ST GESTATION Radiology Blank 0.99 0.38 0.38 Blank RBRVS

76805 TC US PREG UTERUS AFTER 1ST TRIMEST 1/1ST GESTATION Radiology a Blank 2.61 2.61 Blank RBRVS

76810 Blank US PREG UTERUS > 1ST TRIMESTER ABDL EA GESTATIO Radiology a 0.98 1.61 1.61 Blank RBRVS

76810 26 US PREG UTERUS > 1ST TRIMESTER ABDL EA GESTATIO Radiology Blank 0.98 0.38 0.38 Blank RBRVS

76810 TC US PREG UTERUS > 1ST TRIMESTER ABDL EA GESTATIO Radiology a Blank 1.23 1.23 Blank RBRVS

76811 Blank US PREG UTERUS W/DETAIL FETAL ANAT 1ST GESTATION Radiology a 1.90 3.14 3.14 Blank RBRVS

76811 26 US PREG UTERUS W/DETAIL FETAL ANAT 1ST GESTATION Radiology Blank 1.90 0.73 0.73 Blank RBRVS

76811 TC US PREG UTERUS W/DETAIL FETAL ANAT 1ST GESTATION Radiology a Blank 2.41 2.41 Blank RBRVS

76812 Blank US PREG UTERUS DETAIL FETAL ANAT EXAM EA GESTAT Radiology a 1.78 3.89 3.89 Blank RBRVS

76812 26 US PREG UTERUS DETAIL FETAL ANAT EXAM EA GESTAT Radiology Blank 1.78 0.69 0.69 Blank RBRVS

76812 TC US PREG UTERUS DETAIL FETAL ANAT EXAM EA GESTAT Radiology a Blank 3.20 3.20 Blank RBRVS

76813 Blank US FETAL NUCHAL TRANSLUCENCY 1ST GESTATION Radiology a 1.18 2.19 2.19 Blank RBRVS

76813 26 US FETAL NUCHAL TRANSLUCENCY 1ST GESTATION Radiology Blank 1.18 0.45 0.45 Blank RBRVS

76813 TC US FETAL NUCHAL TRANSLUCENCY 1ST GESTATION Radiology a Blank 1.74 1.74 Blank RBRVS

76814 Blank US FETAL NUCHAL TRANSLUCENCY EA ADDL GESTATION Radiology a 0.99 1.22 1.22 Blank RBRVS

76814 26 US FETAL NUCHAL TRANSLUCENCY EA ADDL GESTATION Radiology Blank 0.99 0.39 0.39 Blank RBRVS

76814 TC US FETAL NUCHAL TRANSLUCENCY EA ADDL GESTATION Radiology a Blank 0.83 0.83 Blank RBRVS

76815 Blank US PREGNANT UTERUS LIMITED 1/> FETUSES Radiology a 0.65 1.71 1.71 Blank RBRVS

76815 26 US PREGNANT UTERUS LIMITED 1/> FETUSES Radiology Blank 0.65 0.24 0.24 Blank RBRVS

76815 TC US PREGNANT UTERUS LIMITED 1/> FETUSES Radiology a Blank 1.47 1.47 Blank RBRVS





PAGE 97 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

76816 Blank US PREG UTERUS REAL TIME F/U TRNSABDL PER FETUS Radiology a 0.85 2.37 2.37 Blank RBRVS

76816 26 US PREG UTERUS REAL TIME F/U TRNSABDL PER FETUS Radiology Blank 0.85 0.33 0.33 Blank RBRVS

76816 TC US PREG UTERUS REAL TIME F/U TRNSABDL PER FETUS Radiology a Blank 2.04 2.04 Blank RBRVS

76817 Blank US PREG UTERUS REAL TIME W/IMAGE DCMTN TRANSVAG Radiology a 0.75 1.96 1.96 Blank RBRVS

76817 26 US PREG UTERUS REAL TIME W/IMAGE DCMTN TRANSVAG Radiology Blank 0.75 0.28 0.28 Blank RBRVS

76817 TC US PREG UTERUS REAL TIME W/IMAGE DCMTN TRANSVAG Radiology a Blank 1.68 1.68 Blank RBRVS

76818 Blank FETAL BIOPHYSICAL PROFILE NON-STRESS TESTING Radiology a 1.05 2.36 2.36 Blank RBRVS

76818 26 FETAL BIOPHYSICAL PROFILE NON-STRESS TESTING Radiology Blank 1.05 0.41 0.41 Blank RBRVS

76818 TC FETAL BIOPHYSICAL PROFILE NON-STRESS TESTING Radiology a Blank 1.95 1.95 Blank RBRVS

76819 Blank FETAL BIOPHYSICAL PROFILE W/O NON-STRESS TESTING Radiology a 0.77 1.72 1.72 Blank RBRVS

76819 26 FETAL BIOPHYSICAL PROFILE W/O NON-STRESS TESTING Radiology Blank 0.77 0.29 0.29 Blank RBRVS

76819 TC FETAL BIOPHYSICAL PROFILE W/O NON-STRESS TESTING Radiology a Blank 1.43 1.43 Blank RBRVS

76820 Blank DOPPLER VELOCIMETRY FETAL UMBILICAL ARTERY Radiology a 0.50 0.82 0.82 Blank RBRVS

76820 26 DOPPLER VELOCIMETRY FETAL UMBILICAL ARTERY Radiology Blank 0.50 0.19 0.19 Blank RBRVS

76820 TC DOPPLER VELOCIMETRY FETAL UMBILICAL ARTERY Radiology a Blank 0.63 0.63 Blank RBRVS

76821 Blank DOPPLER VELOCIMETRY FETAL MIDDLE CEREBRAL ART Radiology a 0.70 1.89 1.89 Blank RBRVS

76821 26 DOPPLER VELOCIMETRY FETAL MIDDLE CEREBRAL ART Radiology Blank 0.70 0.27 0.27 Blank RBRVS

76821 TC DOPPLER VELOCIMETRY FETAL MIDDLE CEREBRAL ART Radiology a Blank 1.62 1.62 Blank RBRVS

76825 Blank ECHO FETAL CARDIOVASC W/WO M-MODE RECORDING Radiology a 1.67 6.14 6.14 Blank RBRVS

76825 26 ECHO FETAL CARDIOVASC W/WO M-MODE RECORDING Radiology Blank 1.67 0.62 0.62 Blank RBRVS

76825 TC ECHO FETAL CARDIOVASC W/WO M-MODE RECORDING Radiology a Blank 5.52 5.52 Blank RBRVS

76826 Blank ECHO FETAL CARDIOVASC W/WO M-MODE REPEAT STD Radiology a 0.83 3.80 3.80 Blank RBRVS

76826 26 ECHO FETAL CARDIOVASC W/WO M-MODE REPEAT STD Radiology Blank 0.83 0.31 0.31 Blank RBRVS

76826 TC ECHO FETAL CARDIOVASC W/WO M-MODE REPEAT STD Radiology a Blank 3.49 3.49 Blank RBRVS

76827 Blank DOPPLER ECHO FETAL SPECTRAL DISPLAY COMPLETE Radiology a 0.58 1.53 1.53 Blank RBRVS

76827 26 DOPPLER ECHO FETAL SPECTRAL DISPLAY COMPLETE Radiology Blank 0.58 0.21 0.21 Blank RBRVS

76827 TC DOPPLER ECHO FETAL SPECTRAL DISPLAY COMPLETE Radiology a Blank 1.32 1.32 Blank RBRVS

76828 Blank DOPPLER ECHO FETAL PULS SPECTRAL F/U/REPEAT Radiology a 0.56 0.91 0.91 Blank RBRVS

76828 26 DOPPLER ECHO FETAL PULS SPECTRAL F/U/REPEAT Radiology Blank 0.56 0.21 0.21 Blank RBRVS

76828 TC DOPPLER ECHO FETAL PULS SPECTRAL F/U/REPEAT Radiology a Blank 0.70 0.70 Blank RBRVS

76830 Blank US TRANSVAGINAL Radiology a 0.69 2.74 2.74 Blank RBRVS

76830 26 US TRANSVAGINAL Radiology Blank 0.69 0.26 0.26 Blank RBRVS

76830 TC US TRANSVAGINAL Radiology a Blank 2.48 2.48 Blank RBRVS

76831 Blank SALINE INFUS SONOHYSTEROGRAPHY W/COLOR DOPPLER Radiology a 0.72 2.63 2.63 Blank RBRVS

76831 26 SALINE INFUS SONOHYSTEROGRAPHY W/COLOR DOPPLER Radiology Blank 0.72 0.28 0.28 Blank RBRVS

76831 TC SALINE INFUS SONOHYSTEROGRAPHY W/COLOR DOPPLER Radiology a Blank 2.35 2.35 Blank RBRVS

76856 Blank US PELVIC NONOBSTETRIC REAL-TIME IMAGE COMPLETE Radiology a 0.69 2.40 2.40 Blank RBRVS

76856 26 US PELVIC NONOBSTETRIC REAL-TIME IMAGE COMPLETE Radiology Blank 0.69 0.25 0.25 Blank RBRVS

76856 TC US PELVIC NONOBSTETRIC REAL-TIME IMAGE COMPLETE Radiology a Blank 2.15 2.15 Blank RBRVS

76857 Blank US PELVIC NONOBSTETRIC IMAGE DCMTN LIMITED/F/U Radiology a 0.50 0.84 0.84 Blank RBRVS

76857 26 US PELVIC NONOBSTETRIC IMAGE DCMTN LIMITED/F/U Radiology Blank 0.50 0.18 0.18 Blank RBRVS

76857 TC US PELVIC NONOBSTETRIC IMAGE DCMTN LIMITED/F/U Radiology a Blank 0.66 0.66 Blank RBRVS

76870 Blank US SCROTUM & CONTENTS Radiology a 0.64 1.24 1.24 Blank RBRVS

76870 26 US SCROTUM & CONTENTS Radiology Blank 0.64 0.23 0.23 Blank RBRVS

76870 TC US SCROTUM & CONTENTS Radiology a Blank 1.01 1.01 Blank RBRVS

76872 Blank US TRANSRECTAL Radiology a 0.69 2.03 2.03 Blank RBRVS

76872 26 US TRANSRECTAL Radiology Blank 0.69 0.25 0.25 Blank RBRVS

76872 TC US TRANSRECTAL Radiology a Blank 1.78 1.78 Blank RBRVS

76873 Blank US TRANSRCT PRSTATE VOL BRACHYTX PLNNING SPX Radiology a 1.55 3.31 3.31 Blank RBRVS

76873 26 US TRANSRCT PRSTATE VOL BRACHYTX PLNNING SPX Radiology Blank 1.55 0.61 0.61 Blank RBRVS

76873 TC US TRANSRCT PRSTATE VOL BRACHYTX PLNNING SPX Radiology a Blank 2.70 2.70 Blank RBRVS

76881 Blank US EXTREMITY NON-VASC REAL-TIME IMG COMPL Radiology a 0.63 2.22 2.22 Blank RBRVS

76881 26 US EXTREMITY NON-VASC REAL-TIME IMG COMPL Radiology Blank 0.63 0.24 0.24 Blank RBRVS

76881 TC US EXTREMITY NON-VASC REAL-TIME IMG COMPL Radiology a Blank 1.98 1.98 Blank RBRVS

76882 Blank US EXTREMITY NON-VASC REAL-TIME IMG LMTD Radiology a 0.49 1.11 1.11 Blank RBRVS

76882 26 US EXTREMITY NON-VASC REAL-TIME IMG LMTD Radiology Blank 0.49 0.18 0.18 Blank RBRVS

76882 TC US EXTREMITY NON-VASC REAL-TIME IMG LMTD Radiology a Blank 0.93 0.93 Blank RBRVS

76885 Blank US INFT HIPS R-T IMG DYNAMIC REQ PHYS/QHP MANJ Radiology a 0.74 3.33 3.33 Blank RBRVS

76885 26 US INFT HIPS R-T IMG DYNAMIC REQ PHYS/QHP MANJ Radiology Blank 0.74 0.28 0.28 Blank RBRVS

76885 TC US INFT HIPS R-T IMG DYNAMIC REQ PHYS/QHP MANJ Radiology a Blank 3.05 3.05 Blank RBRVS

76886 Blank US INFT HIPS R-T IMG LMTD STATIC PHYS/QHP MANJ Radiology a 0.62 2.34 2.34 Blank RBRVS

76886 26 US INFT HIPS R-T IMG LMTD STATIC PHYS/QHP MANJ Radiology Blank 0.62 0.23 0.23 Blank RBRVS

76886 TC US INFT HIPS R-T IMG LMTD STATIC PHYS/QHP MANJ Radiology a Blank 2.11 2.11 Blank RBRVS

76930 Blank US GUIDANCE PERICARDIOCENTESIS RS&I Radiology a Blank Blank Blank 2.37 Global/TC/26

76930 26 US GUIDANCE PERICARDIOCENTESIS RS&I Radiology Blank Blank Blank Blank 0.91 Global/TC/26

76930 TC US GUIDANCE PERICARDIOCENTESIS RS&I Radiology a Blank Blank Blank 1.46 Global/TC/26

76932 Blank US ENDOMYOCARDIAL BIOPSY RS&I Radiology a Blank Blank Blank 2.46 Global/TC/26

76932 26 US ENDOMYOCARDIAL BIOPSY RS&I Radiology Blank Blank Blank Blank 0.90 Global/TC/26

76932 TC US ENDOMYOCARDIAL BIOPSY RS&I Radiology a Blank Blank Blank 1.56 Global/TC/26

76936 Blank US CMPRN RPR ARTL PSEUDOARYSM/ARVEN FSTL Radiology a 1.99 5.49 5.49 Blank RBRVS

76936 26 US CMPRN RPR ARTL PSEUDOARYSM/ARVEN FSTL Radiology Blank 1.99 0.55 0.55 Blank RBRVS

76936 TC US CMPRN RPR ARTL PSEUDOARYSM/ARVEN FSTL Radiology a Blank 4.94 4.94 Blank RBRVS





PAGE 98 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

76937 Blank US VASC ACCESS SITS VSL PATENCY NDL ENTRY Radiology a 0.30 0.57 0.57 Blank RBRVS

76937 26 US VASC ACCESS SITS VSL PATENCY NDL ENTRY Radiology Blank 0.30 0.09 0.09 Blank RBRVS

76937 TC US VASC ACCESS SITS VSL PATENCY NDL ENTRY Radiology a Blank 0.48 0.48 Blank RBRVS

76940 Blank US &MNTR PARENCHYMAL TISSUE ABLATION Radiology a Blank Blank Blank 4.33 Global/TC/26

76940 26 US &MNTR PARENCHYMAL TISSUE ABLATION Radiology Blank Blank Blank Blank 2.70 Global/TC/26

76940 TC US &MNTR PARENCHYMAL TISSUE ABLATION Radiology a Blank Blank Blank 1.63 Global/TC/26

76941 Blank US INTRAUTERINE FTL TFUJ/CORDOCNTS IMG S&I Radiology a Blank Blank Blank 2.88 Global/TC/26

76941 26 US INTRAUTERINE FTL TFUJ/CORDOCNTS IMG S&I Radiology Blank Blank Blank Blank 1.85 Global/TC/26

76941 TC US INTRAUTERINE FTL TFUJ/CORDOCNTS IMG S&I Radiology a Blank Blank Blank 1.03 Global/TC/26

76942 Blank US GUIDANCE NEEDLE PLACEMENT IMG S&I Radiology a 0.67 0.99 0.99 Blank RBRVS

76942 26 US GUIDANCE NEEDLE PLACEMENT IMG S&I Radiology Blank 0.67 0.22 0.22 Blank RBRVS

76942 TC US GUIDANCE NEEDLE PLACEMENT IMG S&I Radiology a Blank 0.77 0.77 Blank RBRVS

76945 Blank US GUIDANCE CHORIONIC VILLUS SAMPLING IMG S&I Radiology a Blank Blank Blank 2.59 Global/TC/26

76945 26 US GUIDANCE CHORIONIC VILLUS SAMPLING IMG S&I Radiology Blank Blank Blank Blank 0.92 Global/TC/26

76945 TC US GUIDANCE CHORIONIC VILLUS SAMPLING IMG S&I Radiology a Blank Blank Blank 1.67 Global/TC/26

76946 Blank US GUIDANCE AMNIOCENTESIS IMG S&I Radiology a 0.38 0.51 0.51 Blank RBRVS

76946 26 US GUIDANCE AMNIOCENTESIS IMG S&I Radiology Blank 0.38 0.15 0.15 Blank RBRVS

76946 TC US GUIDANCE AMNIOCENTESIS IMG S&I Radiology a Blank 0.36 0.36 Blank RBRVS

76948 Blank US GUIDANCE ASPIRATION OVA IMG S&I Radiology a 0.67 1.29 1.29 Blank RBRVS

76948 26 US GUIDANCE ASPIRATION OVA IMG S&I Radiology Blank 0.67 0.26 0.26 Blank RBRVS

76948 TC US GUIDANCE ASPIRATION OVA IMG S&I Radiology a Blank 1.03 1.03 Blank RBRVS

76965 Blank US GUIDANCE INTERSTITIAL RADIOELMENT APPLICATION Radiology a 1.34 1.21 1.21 Blank RBRVS

76965 26 US GUIDANCE INTERSTITIAL RADIOELMENT APPLICATION Radiology Blank 1.34 0.53 0.53 Blank RBRVS

76965 TC US GUIDANCE INTERSTITIAL RADIOELMENT APPLICATION Radiology a Blank 0.68 0.68 Blank RBRVS

76970 Blank US STUDY FOLLOW UP Radiology a 0.40 2.19 2.19 Blank RBRVS

76970 26 US STUDY FOLLOW UP Radiology Blank 0.40 0.12 0.12 Blank RBRVS

76970 TC US STUDY FOLLOW UP Radiology a Blank 2.07 2.07 Blank RBRVS

76975 Blank GI ENDOSCOPIC US S&I Radiology a Blank Blank Blank 4.35 Global/TC/26

76975 26 GI ENDOSCOPIC US S&I Radiology Blank Blank Blank Blank 1.15 Global/TC/26

76975 TC GI ENDOSCOPIC US S&I Radiology a Blank Blank Blank 3.20 Global/TC/26

76977 Blank US BONE DENSITY MEAS & INTERP PERIPH ANY METHO Radiology a 0.05 0.14 0.14 Blank RBRVS

76977 26 US BONE DENSITY MEAS & INTERP PERIPH ANY METHO Radiology Blank 0.05 0.02 0.02 Blank RBRVS

76977 TC US BONE DENSITY MEAS & INTERP PERIPH ANY METHO Radiology a Blank 0.12 0.12 Blank RBRVS

76978 Blank US TRGT DYN MBUBB 1ST LES Radiology Blank 1.62 7.45 7.45 Blank RBRVS

76978 26 US TRGT DYN MBUBB 1ST LES Radiology Blank 1.62 0.58 0.58 Blank RBRVS

76978 TC US TRGT DYN MBUBB 1ST LES Radiology Blank Blank 6.87 6.87 Blank RBRVS

76979 Blank US TRGT DYN MBUBB EA ADDL Radiology Blank 0.85 5.33 5.33 Blank RBRVS

76979 26 US TRGT DYN MBUBB EA ADDL Radiology Blank 0.85 0.31 0.31 Blank RBRVS

76979 TC US TRGT DYN MBUBB EA ADDL Radiology Blank Blank 5.02 5.02 Blank RBRVS

76981 Blank USE PARENCHYMA Radiology Blank 0.59 2.40 2.40 Blank RBRVS

76981 26 USE PARENCHYMA Radiology Blank 0.59 0.22 0.22 Blank RBRVS

76981 TC USE PARENCHYMA Radiology Blank Blank 2.18 2.18 Blank RBRVS

76982 Blank USE 1ST TARGET LESION Radiology Blank 0.59 2.08 2.08 Blank RBRVS

76982 26 USE 1ST TARGET LESION Radiology Blank 0.59 0.22 0.22 Blank RBRVS

76982 TC USE 1ST TARGET LESION Radiology Blank Blank 1.86 1.86 Blank RBRVS

76983 Blank USE EA ADDL TARGET LESION Radiology Blank 0.50 1.14 1.14 Blank RBRVS

76983 26 USE EA ADDL TARGET LESION Radiology Blank 0.50 0.19 0.19 Blank RBRVS

76983 TC USE EA ADDL TARGET LESION Radiology Blank Blank 0.95 0.95 Blank RBRVS

76998 Blank ULTRASONIC GUIDANCE INTRAOPERATIVE Radiology a Blank Blank Blank 3.01 Global/TC/26

76998 26 ULTRASONIC GUIDANCE INTRAOPERATIVE Radiology Blank Blank Blank Blank 1.59 Global/TC/26

76998 TC ULTRASONIC GUIDANCE INTRAOPERATIVE Radiology a Blank Blank Blank 1.42 Global/TC/26

76999 Blank UNLISTED US PROCEDURE Radiology a Blank Blank Blank 2.57 Unlisted

76999 26 UNLISTED US PROCEDURE Radiology Blank Blank Blank Blank 0.81 Unlisted

76999 TC UNLISTED US PROCEDURE Radiology a Blank Blank Blank 1.76 Unlisted

77001 Blank FLUORO CENTRAL VENOUS ACCESS DEV PLACEMENT Radiology a 0.38 1.96 1.96 Blank RBRVS

77001 26 FLUORO CENTRAL VENOUS ACCESS DEV PLACEMENT Radiology Blank 0.38 0.12 0.12 Blank RBRVS

77001 TC FLUORO CENTRAL VENOUS ACCESS DEV PLACEMENT Radiology a Blank 1.84 1.84 Blank RBRVS

77002 Blank FLUOROSCOPIC GUIDANCE NEEDLE PLACEMENT Radiology a 0.54 2.08 2.08 Blank RBRVS

77002 26 FLUOROSCOPIC GUIDANCE NEEDLE PLACEMENT Radiology Blank 0.54 0.22 0.22 Blank RBRVS

77002 TC FLUOROSCOPIC GUIDANCE NEEDLE PLACEMENT Radiology a Blank 1.86 1.86 Blank RBRVS

77003 Blank FLUORO NEEDLE/CATH SPINE/PARASPINAL DX/THER Radiology a 0.60 2.03 2.03 Blank RBRVS

77003 26 FLUORO NEEDLE/CATH SPINE/PARASPINAL DX/THER Radiology Blank 0.60 0.22 0.22 Blank RBRVS

77003 TC FLUORO NEEDLE/CATH SPINE/PARASPINAL DX/THER Radiology a Blank 1.81 1.81 Blank RBRVS

77011 Blank CT GUIDANCE STEREOTACTIC LOCALIZATION Radiology a 1.21 5.11 5.11 Blank RBRVS

77011 26 CT GUIDANCE STEREOTACTIC LOCALIZATION Radiology Blank 1.21 0.49 0.49 Blank RBRVS

77011 TC CT GUIDANCE STEREOTACTIC LOCALIZATION Radiology a Blank 4.62 4.62 Blank RBRVS

77012 Blank CT GUIDANCE NEEDLE PLACEMENT Radiology a 1.16 2.29 2.29 Blank RBRVS

77012 26 CT GUIDANCE NEEDLE PLACEMENT Radiology Blank 1.16 0.40 0.40 Blank RBRVS

77012 TC CT GUIDANCE NEEDLE PLACEMENT Radiology a Blank 1.89 1.89 Blank RBRVS

77013 Blank CT GUIDANCE &MONITORING VISC TISS ABLATION Radiology a Blank Blank Blank 22.81 Global/TC/26

77013 26 CT GUIDANCE &MONITORING VISC TISS ABLATION Radiology Blank Blank Blank Blank 5.25 Global/TC/26

77013 TC CT GUIDANCE &MONITORING VISC TISS ABLATION Radiology a Blank Blank Blank 17.56 Global/TC/26





PAGE 99 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

77014 Blank CT GUIDANCE RADIATION THERAPY FLDS PLACEMENT Radiology a 0.85 2.50 2.50 Blank RBRVS

77014 26 CT GUIDANCE RADIATION THERAPY FLDS PLACEMENT Radiology Blank 0.85 0.37 0.37 Blank RBRVS

77014 TC CT GUIDANCE RADIATION THERAPY FLDS PLACEMENT Radiology a Blank 2.13 2.13 Blank RBRVS

77021 Blank MR GUIDANCE NEEDLE PLACEMENT Radiology a 1.50 9.47 9.47 Blank RBRVS

77021 26 MR GUIDANCE NEEDLE PLACEMENT Radiology Blank 1.50 0.51 0.51 Blank RBRVS

77021 TC MR GUIDANCE NEEDLE PLACEMENT Radiology a Blank 8.96 8.96 Blank RBRVS

77022 Blank MR GUIDANCE &MONITORING TISSUE ABLATION Radiology a Blank Blank Blank 29.37 Global/TC/26

77022 26 MR GUIDANCE &MONITORING TISSUE ABLATION Radiology Blank Blank Blank Blank 5.91 Global/TC/26

77022 TC MR GUIDANCE &MONITORING TISSUE ABLATION Radiology a Blank Blank Blank 23.46 Global/TC/26

77046 Blank MRI BREAST C- UNILATERAL Radiology a 1.45 5.48 5.48 Blank RBRVS

77046 26 MRI BREAST C- UNILATERAL Radiology Blank 1.45 0.53 0.53 Blank RBRVS

77046 TC MRI BREAST C- UNILATERAL Radiology a Blank 4.95 4.95 Blank RBRVS

77047 Blank MRI BREAST C- BILATERAL Radiology a 1.60 5.51 5.51 Blank RBRVS

77047 26 MRI BREAST C- BILATERAL Radiology Blank 1.60 0.59 0.59 Blank RBRVS

77047 TC MRI BREAST C- BILATERAL Radiology a Blank 4.92 4.92 Blank RBRVS

77048 Blank MRI BREAST C-+ W/CAD UNI Radiology a 2.10 8.91 8.91 Blank RBRVS

77048 26 MRI BREAST C-+ W/CAD UNI Radiology Blank 2.10 0.76 0.76 Blank RBRVS

77048 TC MRI BREAST C-+ W/CAD UNI Radiology a Blank 8.15 8.15 Blank RBRVS

77049 Blank MRI BREAST C-+ W/CAD BI Radiology a 2.30 8.94 8.94 Blank RBRVS

77049 26 MRI BREAST C-+ W/CAD BI Radiology Blank 2.30 0.83 0.83 Blank RBRVS

77049 TC MRI BREAST C-+ W/CAD BI Radiology a Blank 8.11 8.11 Blank RBRVS

77053 Blank MAMMARY DUCTOGRAM OR GALACTOGRAM SINGLE Radiology a 0.36 1.26 1.26 Blank RBRVS

77053 26 MAMMARY DUCTOGRAM OR GALACTOGRAM SINGLE Radiology Blank 0.36 0.13 0.13 Blank RBRVS

77053 TC MAMMARY DUCTOGRAM OR GALACTOGRAM SINGLE Radiology a Blank 1.13 1.13 Blank RBRVS

77054 Blank MAMMARY DUCTOGRAM OR GALACTOGRAM MULTIPLE Radiology a 0.45 1.67 1.67 Blank RBRVS

77054 26 MAMMARY DUCTOGRAM OR GALACTOGRAM MULTIPLE Radiology Blank 0.45 0.17 0.17 Blank RBRVS

77054 TC MAMMARY DUCTOGRAM OR GALACTOGRAM MULTIPLE Radiology a Blank 1.50 1.50 Blank RBRVS

77061 Blank DIGITAL BREAST TOMOSYNTHESIS UNILATERAL Radiology a Blank Blank Blank 3.05 FAIR Health

77061 26 DIGITAL BREAST TOMOSYNTHESIS UNILATERAL Radiology Blank Blank Blank Blank 1.84 5% Sample

77061 TC DIGITAL BREAST TOMOSYNTHESIS UNILATERAL Radiology a Blank Blank Blank 1.21 Global/TC/26

77062 Blank DIGITAL BREAST TOMOSYNTHESIS BILATERAL Radiology a Blank Blank Blank 3.87 FAIR Health

77062 26 DIGITAL BREAST TOMOSYNTHESIS BILATERAL Radiology Blank Blank Blank Blank 2.58 5% Sample

77062 TC DIGITAL BREAST TOMOSYNTHESIS BILATERAL Radiology a Blank Blank Blank 1.29 Global/TC/26

77063 Blank SCREENING DIGITAL BREAST TOMOSYNTHESIS BI Radiology Blank 0.60 0.93 0.93 Blank RBRVS

77063 26 SCREENING DIGITAL BREAST TOMOSYNTHESIS BI Radiology Blank 0.60 0.22 0.22 Blank RBRVS

77063 TC SCREENING DIGITAL BREAST TOMOSYNTHESIS BI Radiology Blank Blank 0.71 0.71 Blank RBRVS

77065 Blank DX MAMMO INCL CAD UNI Radiology a 0.81 2.96 2.96 Blank RBRVS

77065 26 DX MAMMO INCL CAD UNI Radiology Blank 0.81 0.30 0.30 Blank RBRVS

77065 TC DX MAMMO INCL CAD UNI Radiology a Blank 2.66 2.66 Blank RBRVS

77066 Blank DX MAMMO INCL CAD BI Radiology a 1.00 3.77 3.77 Blank RBRVS

77066 26 DX MAMMO INCL CAD BI Radiology Blank 1.00 0.37 0.37 Blank RBRVS

77066 TC DX MAMMO INCL CAD BI Radiology a Blank 3.40 3.40 Blank RBRVS

77067 Blank SCR MAMMO BI INCL CAD Radiology a 0.76 3.09 3.09 Blank RBRVS

77067 26 SCR MAMMO BI INCL CAD Radiology Blank 0.76 0.28 0.28 Blank RBRVS

77067 TC SCR MAMMO BI INCL CAD Radiology a Blank 2.81 2.81 Blank RBRVS

77071 Blank MANUAL APPL STRESS PFRMD PHYS/QHP JOINT FILMS Radiology Blank 0.41 0.89 0.89 Blank RBRVS

77072 Blank BONE AGE STUDIES Radiology a 0.19 0.44 0.44 Blank RBRVS

77072 26 BONE AGE STUDIES Radiology Blank 0.19 0.07 0.07 Blank RBRVS

77072 TC BONE AGE STUDIES Radiology a Blank 0.37 0.37 Blank RBRVS

77073 Blank BONE LENGTH STUDIES Radiology a 0.27 0.72 0.72 Blank RBRVS

77073 26 BONE LENGTH STUDIES Radiology Blank 0.27 0.12 0.12 Blank RBRVS

77073 TC BONE LENGTH STUDIES Radiology a Blank 0.60 0.60 Blank RBRVS

77074 Blank RADIOLOGIC EXAMINATION OSSEOUS SURVEY LIMITED Radiology a 0.45 1.33 1.33 Blank RBRVS

77074 26 RADIOLOGIC EXAMINATION OSSEOUS SURVEY LIMITED Radiology Blank 0.45 0.17 0.17 Blank RBRVS

77074 TC RADIOLOGIC EXAMINATION OSSEOUS SURVEY LIMITED Radiology a Blank 1.16 1.16 Blank RBRVS

77075 Blank RADIOLOGIC EXAMINATION OSSEOUS SURVEY COMPL Radiology a 0.54 1.89 1.89 Blank RBRVS

77075 26 RADIOLOGIC EXAMINATION OSSEOUS SURVEY COMPL Radiology Blank 0.54 0.20 0.20 Blank RBRVS

77075 TC RADIOLOGIC EXAMINATION OSSEOUS SURVEY COMPL Radiology a Blank 1.69 1.69 Blank RBRVS

77076 Blank RADIOLOGIC EXAMINATION OSSEOUS SURVEY INFANT Radiology a 0.70 1.96 1.96 Blank RBRVS

77076 26 RADIOLOGIC EXAMINATION OSSEOUS SURVEY INFANT Radiology Blank 0.70 0.26 0.26 Blank RBRVS

77076 TC RADIOLOGIC EXAMINATION OSSEOUS SURVEY INFANT Radiology a Blank 1.70 1.70 Blank RBRVS

77077 Blank JOINT SURVEY SINGLE VIEW 2 OR MORE JOINTS Radiology a 0.31 0.71 0.71 Blank RBRVS

77077 26 JOINT SURVEY SINGLE VIEW 2 OR MORE JOINTS Radiology Blank 0.31 0.13 0.13 Blank RBRVS

77077 TC JOINT SURVEY SINGLE VIEW 2 OR MORE JOINTS Radiology a Blank 0.58 0.58 Blank RBRVS

77078 Blank CT BONE MINERL DENSITY STUDY 1/> SITS AXIAL SKE Radiology a 0.25 2.99 2.99 Blank RBRVS

77078 26 CT BONE MINERL DENSITY STUDY 1/> SITS AXIAL SKE Radiology Blank 0.25 0.09 0.09 Blank RBRVS

77078 TC CT BONE MINERL DENSITY STUDY 1/> SITS AXIAL SKE Radiology a Blank 2.90 2.90 Blank RBRVS

77080 Blank DXA BONE DENSITY STUDY 1/> SITES AXIAL SKEL Radiology a 0.20 0.97 0.97 Blank RBRVS

77080 26 DXA BONE DENSITY STUDY 1/> SITES AXIAL SKEL Radiology Blank 0.20 0.08 0.08 Blank RBRVS

77080 TC DXA BONE DENSITY STUDY 1/> SITES AXIAL SKEL Radiology a Blank 0.89 0.89 Blank RBRVS

77081 Blank DXA BONE DENSITY STUDY 1/>SITES APPENDICLR SKEL Radiology a 0.22 0.56 0.56 Blank RBRVS

77081 26 DXA BONE DENSITY STUDY 1/>SITES APPENDICLR SKEL Radiology Blank 0.22 0.08 0.08 Blank RBRVS





PAGE 100 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

77081 TC DXA BONE DENSITY STUDY 1/>SITES APPENDICLR SKEL Radiology a Blank 0.48 0.48 Blank RBRVS

77084 Blank BONE MARROW BLOOD SUPPLY Radiology a 1.60 9.32 9.32 Blank RBRVS

77084 26 BONE MARROW BLOOD SUPPLY Radiology Blank 1.60 0.60 0.60 Blank RBRVS

77084 TC BONE MARROW BLOOD SUPPLY Radiology a Blank 8.72 8.72 Blank RBRVS

77085 Blank DXA BONE DENSITY STUDY AXIAL SKELETON Radiology a 0.30 1.28 1.28 Blank RBRVS

77085 26 DXA BONE DENSITY STUDY AXIAL SKELETON Radiology Blank 0.30 0.11 0.11 Blank RBRVS

77085 TC DXA BONE DENSITY STUDY AXIAL SKELETON Radiology a Blank 1.17 1.17 Blank RBRVS

77086 Blank VERTEBRAL FRACTURE ASSESSMENT VIA DXA Radiology a 0.17 0.84 0.84 Blank RBRVS

77086 26 VERTEBRAL FRACTURE ASSESSMENT VIA DXA Radiology Blank 0.17 0.07 0.07 Blank RBRVS

77086 TC VERTEBRAL FRACTURE ASSESSMENT VIA DXA Radiology a Blank 0.77 0.77 Blank RBRVS

77261 Blank THERAPEUTIC RADIOLOGY TX PLANNING SIMPLE Radiology Blank 1.30 0.64 0.64 Blank RBRVS

77262 Blank THERAPEUTIC RADIOLOGY TX PLANNING INTERMEDIATE Radiology Blank 2.00 0.92 0.92 Blank RBRVS

77263 Blank THERAPEUTIC RADIOLOGY TX PLANNING COMPLEX Radiology Blank 3.14 1.37 1.37 Blank RBRVS

77280 Blank THER RAD SIMULAJ-AIDED FIELD SETTING SIMPLE Radiology a 0.70 7.24 7.24 Blank RBRVS

77280 26 THER RAD SIMULAJ-AIDED FIELD SETTING SIMPLE Radiology Blank 0.70 0.31 0.31 Blank RBRVS

77280 TC THER RAD SIMULAJ-AIDED FIELD SETTING SIMPLE Radiology a Blank 6.93 6.93 Blank RBRVS

77285 Blank THER RAD SIMULAJ-AIDED FIELD SETTING INTERMED Radiology a 1.05 11.92 11.92 Blank RBRVS

77285 26 THER RAD SIMULAJ-AIDED FIELD SETTING INTERMED Radiology Blank 1.05 0.49 0.49 Blank RBRVS

77285 TC THER RAD SIMULAJ-AIDED FIELD SETTING INTERMED Radiology a Blank 11.43 11.43 Blank RBRVS

77290 Blank THER RAD SIMULAJ-AIDED FIELD SETTING COMPLEX Radiology a 1.56 13.31 13.31 Blank RBRVS

77290 26 THER RAD SIMULAJ-AIDED FIELD SETTING COMPLEX Radiology Blank 1.56 0.69 0.69 Blank RBRVS

77290 TC THER RAD SIMULAJ-AIDED FIELD SETTING COMPLEX Radiology a Blank 12.62 12.62 Blank RBRVS

77293 Blank RESPIRATORY MOTION MANAGEMENT SIMULATION Radiology a 2.00 11.36 11.36 Blank RBRVS

77293 26 RESPIRATORY MOTION MANAGEMENT SIMULATION Radiology Blank 2.00 0.87 0.87 Blank RBRVS

77293 TC RESPIRATORY MOTION MANAGEMENT SIMULATION Radiology a Blank 10.49 10.49 Blank RBRVS

77295 Blank 3-D RADIOTHERAPY PLAN DOSE-VOLUME HISTOGRAMS Radiology a 4.29 9.62 9.62 Blank RBRVS

77295 26 3-D RADIOTHERAPY PLAN DOSE-VOLUME HISTOGRAMS Radiology Blank 4.29 1.88 1.88 Blank RBRVS

77295 TC 3-D RADIOTHERAPY PLAN DOSE-VOLUME HISTOGRAMS Radiology a Blank 7.74 7.74 Blank RBRVS

77299 Blank UNLIS PX THER RADIOL CLINICAL TX PLANNING Radiology a Blank Blank Blank 9.99 Unlisted

77299 26 UNLIS PX THER RADIOL CLINICAL TX PLANNING Radiology Blank Blank Blank Blank 2.25 Unlisted

77299 TC UNLIS PX THER RADIOL CLINICAL TX PLANNING Radiology a Blank Blank Blank 7.74 Unlisted

77300 Blank BASIC RADIATION DOSIMETRY CALCULATION Radiology a 0.62 1.25 1.25 Blank RBRVS

77300 26 BASIC RADIATION DOSIMETRY CALCULATION Radiology Blank 0.62 0.27 0.27 Blank RBRVS

77300 TC BASIC RADIATION DOSIMETRY CALCULATION Radiology a Blank 0.98 0.98 Blank RBRVS

77301 Blank NTSTY MODUL RADTHX PLN DOSE-VOL HISTOS Radiology a 7.99 47.91 47.91 Blank RBRVS

77301 26 NTSTY MODUL RADTHX PLN DOSE-VOL HISTOS Radiology Blank 7.99 3.49 3.49 Blank RBRVS

77301 TC NTSTY MODUL RADTHX PLN DOSE-VOL HISTOS Radiology a Blank 44.42 44.42 Blank RBRVS

77306 Blank TELETHX ISODOSE PLN SMPL W/DOSIMETRY CALCULATION Radiology a 1.40 2.83 2.83 Blank RBRVS

77306 26 TELETHX ISODOSE PLN SMPL W/DOSIMETRY CALCULATION Radiology Blank 1.40 0.62 0.62 Blank RBRVS

77306 TC TELETHX ISODOSE PLN SMPL W/DOSIMETRY CALCULATION Radiology a Blank 2.21 2.21 Blank RBRVS

77307 Blank TELETHX ISODOSE PLN CPLX W/BASIC DOSIMETRY Radiology a 2.90 5.26 5.26 Blank RBRVS

77307 26 TELETHX ISODOSE PLN CPLX W/BASIC DOSIMETRY Radiology Blank 2.90 1.26 1.26 Blank RBRVS

77307 TC TELETHX ISODOSE PLN CPLX W/BASIC DOSIMETRY Radiology a Blank 4.00 4.00 Blank RBRVS

77316 Blank BRACHYTX ISODOSE PLN SMPL W/DOSIMETRY CAL Radiology a 1.40 3.94 3.94 Blank RBRVS

77316 26 BRACHYTX ISODOSE PLN SMPL W/DOSIMETRY CAL Radiology Blank 1.40 0.62 0.62 Blank RBRVS

77316 TC BRACHYTX ISODOSE PLN SMPL W/DOSIMETRY CAL Radiology a Blank 3.32 3.32 Blank RBRVS

77317 Blank BRACHYTX ISODOSE PLN INTERMED W/DOSIMETRY CAL Radiology a 1.83 5.13 5.13 Blank RBRVS

77317 26 BRACHYTX ISODOSE PLN INTERMED W/DOSIMETRY CAL Radiology Blank 1.83 0.79 0.79 Blank RBRVS

77317 TC BRACHYTX ISODOSE PLN INTERMED W/DOSIMETRY CAL Radiology a Blank 4.34 4.34 Blank RBRVS

77318 Blank BRACHYTX ISODOSE PLN CPLX W/DOSIMETRY CAL Radiology a 2.90 7.15 7.15 Blank RBRVS

77318 26 BRACHYTX ISODOSE PLN CPLX W/DOSIMETRY CAL Radiology Blank 2.90 1.26 1.26 Blank RBRVS

77318 TC BRACHYTX ISODOSE PLN CPLX W/DOSIMETRY CAL Radiology a Blank 5.89 5.89 Blank RBRVS

77321 Blank SPEC TELETHX PORT PLN PARTS HEMIBDY TOT BDY Radiology a 0.95 1.68 1.68 Blank RBRVS

77321 26 SPEC TELETHX PORT PLN PARTS HEMIBDY TOT BDY Radiology Blank 0.95 0.42 0.42 Blank RBRVS

77321 TC SPEC TELETHX PORT PLN PARTS HEMIBDY TOT BDY Radiology a Blank 1.26 1.26 Blank RBRVS

77331 Blank SPEC DOSIM ONLY PRESCRIBED TREATING PHYS Radiology a 0.87 0.92 0.92 Blank RBRVS

77331 26 SPEC DOSIM ONLY PRESCRIBED TREATING PHYS Radiology Blank 0.87 0.38 0.38 Blank RBRVS

77331 TC SPEC DOSIM ONLY PRESCRIBED TREATING PHYS Radiology a Blank 0.54 0.54 Blank RBRVS

77332 Blank TX DEVICES DESIGN & CONSTRUCTION SIMPLE Radiology a 0.45 1.20 1.20 Blank RBRVS

77332 26 TX DEVICES DESIGN & CONSTRUCTION SIMPLE Radiology Blank 0.45 0.21 0.21 Blank RBRVS

77332 TC TX DEVICES DESIGN & CONSTRUCTION SIMPLE Radiology a Blank 0.99 0.99 Blank RBRVS

77333 Blank TX DEVICES DESIGN & CONSTRUCTION INTERMEDIATE Radiology a 0.75 2.00 2.00 Blank RBRVS

77333 26 TX DEVICES DESIGN & CONSTRUCTION INTERMEDIATE Radiology Blank 0.75 0.33 0.33 Blank RBRVS

77333 TC TX DEVICES DESIGN & CONSTRUCTION INTERMEDIATE Radiology a Blank 1.67 1.67 Blank RBRVS

77334 Blank TX DEVICES DESIGN & CONSTRUCTION COMPLEX Radiology a 1.15 2.48 2.48 Blank RBRVS

77334 26 TX DEVICES DESIGN & CONSTRUCTION COMPLEX Radiology Blank 1.15 0.51 0.51 Blank RBRVS

77334 TC TX DEVICES DESIGN & CONSTRUCTION COMPLEX Radiology a Blank 1.97 1.97 Blank RBRVS

77336 Blank CONTINUING MEDICAL PHYSICS CONSLTJ PR WK Radiology a Blank 2.23 2.23 Blank RBRVS

77338 Blank MLC IMRT DESIGN & CONSTRUCTION PER IMRT PLAN Radiology a 4.29 10.12 10.12 Blank RBRVS

77338 26 MLC IMRT DESIGN & CONSTRUCTION PER IMRT PLAN Radiology Blank 4.29 1.88 1.88 Blank RBRVS

77338 TC MLC IMRT DESIGN & CONSTRUCTION PER IMRT PLAN Radiology a Blank 8.24 8.24 Blank RBRVS

77370 Blank SPEC MEDICAL RADJ PHYSICS CONSLTJ Radiology a Blank 3.42 3.42 Blank RBRVS





PAGE 101 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

77371 Blank RADIATION DELIVERY STEREOTACTIC CRANIAL COBALT Radiology a Blank Blank Blank 30.48 ERBRVS

77372 Blank RADIATION DELIVERY STEREOTACTIC CRANIAL LINEAR Radiology a Blank 30.91 30.91 Blank RBRVS

77373 Blank STEREOTACTIC BODY RADIATION DELIVERY Radiology a Blank 39.32 39.32 Blank RBRVS

77385 Blank INTENSITY MODULATED RADIATION TX DLVR SIMPLE Radiology a Blank Blank Blank 11.30 FAIR Health

77386 Blank INTENSITY MODULATED RADIATION TX DLVR COMPLEX Radiology a Blank Blank Blank 12.64 FAIR Health

77387 Blank GUIDANCE FOR LOC OF TARGET VOL RADIAJ TX DLVR Radiology a Blank Blank Blank 2.04 Global/TC/26

77387 26 GUIDANCE FOR LOC OF TARGET VOL RADIAJ TX DLVR Radiology Blank Blank Blank Blank 0.79 Global/TC/26

77387 TC GUIDANCE FOR LOC OF TARGET VOL RADIAJ TX DLVR Radiology a Blank Blank Blank 1.25 Global/TC/26

77399 Blank UNLIS MEDICAL RADJ DOSIM TX DEV SPEC SVCS Radiology a Blank Blank Blank 2.14 Unlisted

77399 26 UNLIS MEDICAL RADJ DOSIM TX DEV SPEC SVCS Radiology Blank Blank Blank Blank 0.89 Unlisted

77399 TC UNLIS MEDICAL RADJ DOSIM TX DEV SPEC SVCS Radiology a Blank Blank Blank 1.25 Unlisted

77401 Blank RADIATION TX DELIVERY SUPERFICIAL&/ORTHO VOLTA Radiology a Blank 0.70 0.70 Blank RBRVS

77402 Blank RADIATION TREATMENT DELIVERY 1 MEV >= SIMPLE Radiology a Blank Blank Blank 2.76 FAIR Health

77407 Blank RADIATION TX DELIVERY 1 MEV >= INTERMEDIATE Radiology a Blank Blank Blank 2.66 Other

77412 Blank RADIATION TREATMENT DELIVERY 1 MEV >= COMPLEX Radiology a Blank Blank Blank 3.45 FAIR Health

77417 Blank THERAPEUTIC RADIOLOGY PORT IMAGES(S) Radiology a Blank 0.31 0.31 Blank RBRVS

77423 Blank HIGH ENERGY NEUTRON RADJ TX DLVR 1/> ISOCENTER Radiology a Blank Blank Blank 2.74 ERBRVS

77427 Blank RADIATION TREATMENT MANAGEMENT 5 TREATMENTS Radiology Blank 3.37 1.70 1.70 Blank RBRVS

77431 Blank RADIATION THERAPY MGMT 1/2 FRACTIONS ONLY Radiology Blank 1.81 0.98 0.98 Blank RBRVS

77432 Blank STERETCTC RADIATION TX MANAGEMENT CRANIAL LESION Radiology Blank 7.92 3.46 3.46 Blank RBRVS

77435 Blank STEREOTACTIC BODY RADIATION MANAGEMENT Radiology Blank 11.87 5.30 5.30 Blank RBRVS

77469 Blank INTRAOPERATIVE RADIATION TREATMENT MANAGEMENT Radiology Blank 5.75 2.96 2.96 Blank RBRVS

77470 Blank SPECIAL TREATMENT PROCEDURE Radiology a 2.03 1.76 1.76 Blank RBRVS

77470 26 SPECIAL TREATMENT PROCEDURE Radiology Blank 2.03 0.88 0.88 Blank RBRVS

77470 TC SPECIAL TREATMENT PROCEDURE Radiology a Blank 0.88 0.88 Blank RBRVS

77499 Blank UNLISTED PROCEDURE THERAPEUTIC RADIOLOGY TX MGMT Radiology a Blank Blank Blank 3.79 Unlisted

77499 26 UNLISTED PROCEDURE THERAPEUTIC RADIOLOGY TX MGMT Radiology Blank Blank Blank Blank 2.91 Unlisted

77499 TC UNLISTED PROCEDURE THERAPEUTIC RADIOLOGY TX MGMT Radiology a Blank Blank Blank 0.88 Unlisted

77520 Blank PROTON TX DELIVERY SIMPLE W/O COMPENSATION Radiology a Blank Blank Blank 22.35 FAIR Health

77522 Blank PROTON TX DELIVERY SIMPLE W/COMPENSATION Radiology a Blank Blank Blank 31.35 FAIR Health

77523 Blank PROTON TX DELIVERY INTERMEDIATE Radiology a Blank Blank Blank 28.36 FAIR Health

77525 Blank PROTON TX DELIVERY COMPLEX Radiology a Blank Blank Blank 37.07 FAIR Health

77600 Blank HYPERTHERMIA EXTERNAL GENERATED SUPERFICIAL Radiology a 1.31 10.87 10.87 Blank RBRVS

77600 26 HYPERTHERMIA EXTERNAL GENERATED SUPERFICIAL Radiology Blank 1.31 0.63 0.63 Blank RBRVS

77600 TC HYPERTHERMIA EXTERNAL GENERATED SUPERFICIAL Radiology a Blank 10.24 10.24 Blank RBRVS

77605 Blank HYPERTHERMIA EXTERNAL GENERATED DEEP Radiology a 1.84 19.47 19.47 Blank RBRVS

77605 26 HYPERTHERMIA EXTERNAL GENERATED DEEP Radiology Blank 1.84 0.74 0.74 Blank RBRVS

77605 TC HYPERTHERMIA EXTERNAL GENERATED DEEP Radiology a Blank 18.73 18.73 Blank RBRVS

77610 Blank HYPERTHERMIA INTERSTITIAL PROBE 5/< APPLICATORS Radiology a 1.31 20.40 20.40 Blank RBRVS

77610 26 HYPERTHERMIA INTERSTITIAL PROBE 5/< APPLICATORS Radiology Blank 1.31 0.53 0.53 Blank RBRVS

77610 TC HYPERTHERMIA INTERSTITIAL PROBE 5/< APPLICATORS Radiology a Blank 19.87 19.87 Blank RBRVS

77615 Blank HYPERTHERMIA INTERSTIAL PROBE 5/> APPLICATORS Radiology a 1.84 27.68 27.68 Blank RBRVS

77615 26 HYPERTHERMIA INTERSTIAL PROBE 5/> APPLICATORS Radiology Blank 1.84 0.79 0.79 Blank RBRVS

77615 TC HYPERTHERMIA INTERSTIAL PROBE 5/> APPLICATORS Radiology a Blank 26.89 26.89 Blank RBRVS

77620 Blank HYPERTHERMIA INTRACAVITARY PROBES Radiology a 1.56 11.56 11.56 Blank RBRVS

77620 26 HYPERTHERMIA INTRACAVITARY PROBES Radiology Blank 1.56 0.59 0.59 Blank RBRVS

77620 TC HYPERTHERMIA INTRACAVITARY PROBES Radiology a Blank 10.97 10.97 Blank RBRVS

77750 Blank NFS/INSTLJ RADIOELMNT SLN 3 MO FOLLOW-UP CARE Radiology a 5.00 5.43 5.43 Blank RBRVS

77750 26 NFS/INSTLJ RADIOELMNT SLN 3 MO FOLLOW-UP CARE Radiology Blank 5.00 2.18 2.18 Blank RBRVS

77750 TC NFS/INSTLJ RADIOELMNT SLN 3 MO FOLLOW-UP CARE Radiology a Blank 3.25 3.25 Blank RBRVS

77761 Blank INTRACAVITARY RADIATION SOURCE APPLIC SIMPLE Radiology a 3.85 7.19 7.19 Blank RBRVS

77761 26 INTRACAVITARY RADIATION SOURCE APPLIC SIMPLE Radiology Blank 3.85 1.69 1.69 Blank RBRVS

77761 TC INTRACAVITARY RADIATION SOURCE APPLIC SIMPLE Radiology a Blank 5.50 5.50 Blank RBRVS

77762 Blank INTRACAVITARY RADIATION SOURCE APPLIC INTERMED Radiology a 5.76 8.84 8.84 Blank RBRVS

77762 26 INTRACAVITARY RADIATION SOURCE APPLIC INTERMED Radiology Blank 5.76 2.52 2.52 Blank RBRVS

77762 TC INTRACAVITARY RADIATION SOURCE APPLIC INTERMED Radiology a Blank 6.32 6.32 Blank RBRVS

77763 Blank INTRACAVITARY RADIATION SOURCE APPLIC COMPLEX Radiology a 8.66 12.13 12.13 Blank RBRVS

77763 26 INTRACAVITARY RADIATION SOURCE APPLIC COMPLEX Radiology Blank 8.66 3.78 3.78 Blank RBRVS

77763 TC INTRACAVITARY RADIATION SOURCE APPLIC COMPLEX Radiology a Blank 8.35 8.35 Blank RBRVS

77767 Blank HDR RDNCL SKN SURF BRACHYTX LES </2CM/1 CHAN Radiology a 1.05 5.37 5.37 Blank RBRVS

77767 26 HDR RDNCL SKN SURF BRACHYTX LES </2CM/1 CHAN Radiology Blank 1.05 0.46 0.46 Blank RBRVS

77767 TC HDR RDNCL SKN SURF BRACHYTX LES </2CM/1 CHAN Radiology a Blank 4.91 4.91 Blank RBRVS

77768 Blank HDR RDNCL SK SRF BRCHYTX LES >2CM&2CHAN/MLT LES Radiology a 1.40 8.68 8.68 Blank RBRVS

77768 26 HDR RDNCL SK SRF BRCHYTX LES >2CM&2CHAN/MLT LES Radiology Blank 1.40 0.62 0.62 Blank RBRVS

77768 TC HDR RDNCL SK SRF BRCHYTX LES >2CM&2CHAN/MLT LES Radiology a Blank 8.06 8.06 Blank RBRVS

77770 Blank HDR RDNCL NTRSTL/INTRCAV BRACHYTX 1 CHANNEL Radiology a 1.95 7.22 7.22 Blank RBRVS

77770 26 HDR RDNCL NTRSTL/INTRCAV BRACHYTX 1 CHANNEL Radiology Blank 1.95 0.85 0.85 Blank RBRVS

77770 TC HDR RDNCL NTRSTL/INTRCAV BRACHYTX 1 CHANNEL Radiology a Blank 6.37 6.37 Blank RBRVS

77771 Blank HDR RDNCL NTRSTL/INTRCAV BRACHYTX 2-12 CHANNEL Radiology a 3.80 13.24 13.24 Blank RBRVS

77771 26 HDR RDNCL NTRSTL/INTRCAV BRACHYTX 2-12 CHANNEL Radiology Blank 3.80 1.67 1.67 Blank RBRVS

77771 TC HDR RDNCL NTRSTL/INTRCAV BRACHYTX 2-12 CHANNEL Radiology a Blank 11.57 11.57 Blank RBRVS

77772 Blank HDR RDNCL NTRSTL/INTRCAV BRACHYTX >12 CHANNELS Radiology a 5.40 20.60 20.60 Blank RBRVS





PAGE 102 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

77772 26 HDR RDNCL NTRSTL/INTRCAV BRACHYTX >12 CHANNELS Radiology Blank 5.40 2.34 2.34 Blank RBRVS

77772 TC HDR RDNCL NTRSTL/INTRCAV BRACHYTX >12 CHANNELS Radiology a Blank 18.26 18.26 Blank RBRVS

77778 Blank INTERSTITIAL RADIATION SOURCE APPLIC COMPLEX Radiology a 8.78 14.35 14.35 Blank RBRVS

77778 26 INTERSTITIAL RADIATION SOURCE APPLIC COMPLEX Radiology Blank 8.78 3.79 3.79 Blank RBRVS

77778 TC INTERSTITIAL RADIATION SOURCE APPLIC COMPLEX Radiology a Blank 10.56 10.56 Blank RBRVS

77789 Blank SURFACE APPLIC LOW DOSE RATE RADIONUCLIDE SOURCE Radiology a 1.14 2.27 2.27 Blank RBRVS

77789 26 SURFACE APPLIC LOW DOSE RATE RADIONUCLIDE SOURCE Radiology Blank 1.14 0.51 0.51 Blank RBRVS

77789 TC SURFACE APPLIC LOW DOSE RATE RADIONUCLIDE SOURCE Radiology a Blank 1.76 1.76 Blank RBRVS

77790 Blank SUPERVISION HANDLING LOADING RADIATION SOURCE Radiology a Blank Blank Blank 0.42 Global/TC/26

77790 26 SUPERVISION HANDLING LOADING RADIATION SOURCE Radiology Blank Blank Blank Blank 0.24 Global/TC/26

77790 TC SUPERVISION HANDLING LOADING RADIATION SOURCE Radiology a Blank Blank Blank 0.18 Global/TC/26

77799 Blank UNLISTED PROCEDURE CLINICAL BRACHYTHERAPY Radiology a Blank Blank Blank 18.30 Unlisted

77799 26 UNLISTED PROCEDURE CLINICAL BRACHYTHERAPY Radiology Blank Blank Blank Blank 7.74 Unlisted

77799 TC UNLISTED PROCEDURE CLINICAL BRACHYTHERAPY Radiology a Blank Blank Blank 10.56 Unlisted

78012 Blank THYROID UPTAKE SINGLE/MULTIPLE QUANT MEASUREMENT Radiology a 0.19 2.15 2.15 Blank RBRVS

78012 26 THYROID UPTAKE SINGLE/MULTIPLE QUANT MEASUREMENT Radiology Blank 0.19 0.07 0.07 Blank RBRVS

78012 TC THYROID UPTAKE SINGLE/MULTIPLE QUANT MEASUREMENT Radiology a Blank 2.08 2.08 Blank RBRVS

78013 Blank THYROID IMAGING WITH VASCULAR FLOW Radiology a 0.37 5.21 5.21 Blank RBRVS

78013 26 THYROID IMAGING WITH VASCULAR FLOW Radiology Blank 0.37 0.13 0.13 Blank RBRVS

78013 TC THYROID IMAGING WITH VASCULAR FLOW Radiology a Blank 5.08 5.08 Blank RBRVS

78014 Blank THYROID UPTAKE W/BLOOD FLOW SNGLE/MULT QUAN MEAS Radiology a 0.50 6.52 6.52 Blank RBRVS

78014 26 THYROID UPTAKE W/BLOOD FLOW SNGLE/MULT QUAN MEAS Radiology Blank 0.50 0.17 0.17 Blank RBRVS

78014 TC THYROID UPTAKE W/BLOOD FLOW SNGLE/MULT QUAN MEAS Radiology a Blank 6.35 6.35 Blank RBRVS

78015 Blank THYROID CARCINOMA METASTASES IMG LMTD AREA Radiology a 0.67 5.79 5.79 Blank RBRVS

78015 26 THYROID CARCINOMA METASTASES IMG LMTD AREA Radiology Blank 0.67 0.23 0.23 Blank RBRVS

78015 TC THYROID CARCINOMA METASTASES IMG LMTD AREA Radiology a Blank 5.56 5.56 Blank RBRVS

78016 Blank THYROID CARCINOMA METASTASES IMG ADDL STUDY Radiology a 0.82 7.39 7.39 Blank RBRVS

78016 26 THYROID CARCINOMA METASTASES IMG ADDL STUDY Radiology Blank 0.82 0.14 0.14 Blank RBRVS

78016 TC THYROID CARCINOMA METASTASES IMG ADDL STUDY Radiology a Blank 7.25 7.25 Blank RBRVS

78018 Blank THYROID CARCINOMA METASTASES IMG WHOLE BODY Radiology a 0.86 8.23 8.23 Blank RBRVS

78018 26 THYROID CARCINOMA METASTASES IMG WHOLE BODY Radiology Blank 0.86 0.27 0.27 Blank RBRVS

78018 TC THYROID CARCINOMA METASTASES IMG WHOLE BODY Radiology a Blank 7.96 7.96 Blank RBRVS

78020 Blank THYROID CARCINOMA METASTASES UPTAKE Radiology a 0.60 1.81 1.81 Blank RBRVS

78020 26 THYROID CARCINOMA METASTASES UPTAKE Radiology Blank 0.60 0.17 0.17 Blank RBRVS

78020 TC THYROID CARCINOMA METASTASES UPTAKE Radiology a Blank 1.64 1.64 Blank RBRVS

78070 Blank PARATHYROID PLANAR IMAGING Radiology a 0.80 7.93 7.93 Blank RBRVS

78070 26 PARATHYROID PLANAR IMAGING Radiology Blank 0.80 0.27 0.27 Blank RBRVS

78070 TC PARATHYROID PLANAR IMAGING Radiology a Blank 7.66 7.66 Blank RBRVS

78071 Blank PARATHYROID PLANAR IMAGING W/WO SUBTRACTION Radiology a 1.20 9.18 9.18 Blank RBRVS

78071 26 PARATHYROID PLANAR IMAGING W/WO SUBTRACTION Radiology Blank 1.20 0.41 0.41 Blank RBRVS

78071 TC PARATHYROID PLANAR IMAGING W/WO SUBTRACTION Radiology a Blank 8.77 8.77 Blank RBRVS

78072 Blank PARATHYROID IMAGING W/TOMOGRAPHIC SPECT & CT Radiology a 1.60 10.42 10.42 Blank RBRVS

78072 26 PARATHYROID IMAGING W/TOMOGRAPHIC SPECT & CT Radiology Blank 1.60 0.51 0.51 Blank RBRVS

78072 TC PARATHYROID IMAGING W/TOMOGRAPHIC SPECT & CT Radiology a Blank 9.91 9.91 Blank RBRVS

78075 Blank ADRENAL IMAGING CORTEX &/MEDULLA Radiology a 0.74 12.44 12.44 Blank RBRVS

78075 26 ADRENAL IMAGING CORTEX &/MEDULLA Radiology Blank 0.74 0.28 0.28 Blank RBRVS

78075 TC ADRENAL IMAGING CORTEX &/MEDULLA Radiology a Blank 12.16 12.16 Blank RBRVS

78099 Blank UNLISTED ENDOCRINE PX DX NUCLEAR MEDICINE Radiology a Blank Blank Blank 7.02 Unlisted

78099 26 UNLISTED ENDOCRINE PX DX NUCLEAR MEDICINE Radiology Blank Blank Blank Blank 0.67 Unlisted

78099 TC UNLISTED ENDOCRINE PX DX NUCLEAR MEDICINE Radiology a Blank Blank Blank 6.35 Unlisted

78102 Blank BONE MARROW IMAGING LIMITED AREA Radiology a 0.55 4.35 4.35 Blank RBRVS

78102 26 BONE MARROW IMAGING LIMITED AREA Radiology Blank 0.55 0.17 0.17 Blank RBRVS

78102 TC BONE MARROW IMAGING LIMITED AREA Radiology a Blank 4.18 4.18 Blank RBRVS

78103 Blank BONE MARROW IMAGING MULTIPLE AREAS Radiology a 0.75 5.53 5.53 Blank RBRVS

78103 26 BONE MARROW IMAGING MULTIPLE AREAS Radiology Blank 0.75 0.22 0.22 Blank RBRVS

78103 TC BONE MARROW IMAGING MULTIPLE AREAS Radiology a Blank 5.31 5.31 Blank RBRVS

78104 Blank BONE MARROW IMAGING WHOLE BODY Radiology a 0.80 6.37 6.37 Blank RBRVS

78104 26 BONE MARROW IMAGING WHOLE BODY Radiology Blank 0.80 0.26 0.26 Blank RBRVS

78104 TC BONE MARROW IMAGING WHOLE BODY Radiology a Blank 6.11 6.11 Blank RBRVS

78110 Blank PLASMA VOL RADIOPHARM VOL DILUTION SPX 1 SAMPLE Radiology a 0.19 2.14 2.14 Blank RBRVS

78110 26 PLASMA VOL RADIOPHARM VOL DILUTION SPX 1 SAMPLE Radiology Blank 0.19 0.03 0.03 Blank RBRVS

78110 TC PLASMA VOL RADIOPHARM VOL DILUTION SPX 1 SAMPLE Radiology a Blank 2.11 2.11 Blank RBRVS

78111 Blank PLASMA VOL RADIOPHARM VOL DILUTE SPX MULT SMPLES Radiology a 0.22 2.01 2.01 Blank RBRVS

78111 26 PLASMA VOL RADIOPHARM VOL DILUTE SPX MULT SMPLES Radiology Blank 0.22 0.04 0.04 Blank RBRVS

78111 TC PLASMA VOL RADIOPHARM VOL DILUTE SPX MULT SMPLES Radiology a Blank 1.97 1.97 Blank RBRVS

78120 Blank RED CELL VOLUME DETERMINATION SPX 1 SAMPLING Radiology a 0.23 1.96 1.96 Blank RBRVS

78120 26 RED CELL VOLUME DETERMINATION SPX 1 SAMPLING Radiology Blank 0.23 0.04 0.04 Blank RBRVS

78120 TC RED CELL VOLUME DETERMINATION SPX 1 SAMPLING Radiology a Blank 1.92 1.92 Blank RBRVS

78121 Blank RED CELL VOLUME DETERMINATION SPX MULT SAMPLINGS Radiology a 0.32 2.12 2.12 Blank RBRVS

78121 26 RED CELL VOLUME DETERMINATION SPX MULT SAMPLINGS Radiology Blank 0.32 0.05 0.05 Blank RBRVS

78121 TC RED CELL VOLUME DETERMINATION SPX MULT SAMPLINGS Radiology a Blank 2.07 2.07 Blank RBRVS

78122 Blank WHOLE BLOOD VOLUME DETERM PLASMA&RED CELL VOLU Radiology a 0.45 2.29 2.29 Blank RBRVS





PAGE 103 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

78122 26 WHOLE BLOOD VOLUME DETERM PLASMA&RED CELL VOLU Radiology Blank 0.45 0.13 0.13 Blank RBRVS

78122 TC WHOLE BLOOD VOLUME DETERM PLASMA&RED CELL VOLU Radiology a Blank 2.16 2.16 Blank RBRVS

78130 Blank RED CELL SURVIVAL STUDY Radiology a 0.61 3.32 3.32 Blank RBRVS

78130 26 RED CELL SURVIVAL STUDY Radiology Blank 0.61 0.10 0.10 Blank RBRVS

78130 TC RED CELL SURVIVAL STUDY Radiology a Blank 3.22 3.22 Blank RBRVS

78135 Blank RBC SURVIVAL STUDY DIFFERNTL ORGAN/TISS KINETICS Radiology a 0.64 7.68 7.68 Blank RBRVS

78135 26 RBC SURVIVAL STUDY DIFFERNTL ORGAN/TISS KINETICS Radiology Blank 0.64 0.11 0.11 Blank RBRVS

78135 TC RBC SURVIVAL STUDY DIFFERNTL ORGAN/TISS KINETICS Radiology a Blank 7.57 7.57 Blank RBRVS

78140 Blank LABELED RBC SEQUESTRATION DIFFERNTL ORGAN/TISSUE Radiology a 0.61 2.64 2.64 Blank RBRVS

78140 26 LABELED RBC SEQUESTRATION DIFFERNTL ORGAN/TISSUE Radiology Blank 0.61 0.10 0.10 Blank RBRVS

78140 TC LABELED RBC SEQUESTRATION DIFFERNTL ORGAN/TISSUE Radiology a Blank 2.54 2.54 Blank RBRVS

78185 Blank SPLEEN IMAGING ONLY W/WO VASCULAR FLOW Radiology a 0.40 4.58 4.58 Blank RBRVS

78185 26 SPLEEN IMAGING ONLY W/WO VASCULAR FLOW Radiology Blank 0.40 0.07 0.07 Blank RBRVS

78185 TC SPLEEN IMAGING ONLY W/WO VASCULAR FLOW Radiology a Blank 4.51 4.51 Blank RBRVS

78191 Blank PLATELET SURVIVAL STUDY Radiology a 0.61 3.32 3.32 Blank RBRVS

78191 26 PLATELET SURVIVAL STUDY Radiology Blank 0.61 0.10 0.10 Blank RBRVS

78191 TC PLATELET SURVIVAL STUDY Radiology a Blank 3.22 3.22 Blank RBRVS

78195 Blank LYMPHATICS & LYMPH NODES IMAGING Radiology a 1.20 9.13 9.13 Blank RBRVS

78195 26 LYMPHATICS & LYMPH NODES IMAGING Radiology Blank 1.20 0.40 0.40 Blank RBRVS

78195 TC LYMPHATICS & LYMPH NODES IMAGING Radiology a Blank 8.73 8.73 Blank RBRVS

78199 Blank UNLIS HEMATOP RET/ENDO&LYMPHATIC DX NUC MED Radiology a Blank Blank Blank 10.33 Unlisted

78199 26 UNLIS HEMATOP RET/ENDO&LYMPHATIC DX NUC MED Radiology Blank Blank Blank Blank 1.60 Unlisted

78199 TC UNLIS HEMATOP RET/ENDO&LYMPHATIC DX NUC MED Radiology a Blank Blank Blank 8.73 Unlisted

78201 Blank LIVER IMAGING STATIC ONLY Radiology a 0.44 5.06 5.06 Blank RBRVS

78201 26 LIVER IMAGING STATIC ONLY Radiology Blank 0.44 0.14 0.14 Blank RBRVS

78201 TC LIVER IMAGING STATIC ONLY Radiology a Blank 4.92 4.92 Blank RBRVS

78202 Blank LIVER IMAGING W/VASCULAR FLOW Radiology a 0.51 5.29 5.29 Blank RBRVS

78202 26 LIVER IMAGING W/VASCULAR FLOW Radiology Blank 0.51 0.14 0.14 Blank RBRVS

78202 TC LIVER IMAGING W/VASCULAR FLOW Radiology a Blank 5.15 5.15 Blank RBRVS

78205 Blank LIVER IMAGING SPECT Radiology a 0.71 5.41 5.41 Blank RBRVS

78205 26 LIVER IMAGING SPECT Radiology Blank 0.71 0.21 0.21 Blank RBRVS

78205 TC LIVER IMAGING SPECT Radiology a Blank 5.20 5.20 Blank RBRVS

78206 Blank LIVER IMAGING SPECT W/VASCULAR FLOW Radiology a 0.96 9.04 9.04 Blank RBRVS

78206 26 LIVER IMAGING SPECT W/VASCULAR FLOW Radiology Blank 0.96 0.32 0.32 Blank RBRVS

78206 TC LIVER IMAGING SPECT W/VASCULAR FLOW Radiology a Blank 8.72 8.72 Blank RBRVS

78215 Blank LIVER & SPLEEN IMAGING STATIC ONLY Radiology a 0.49 5.15 5.15 Blank RBRVS

78215 26 LIVER & SPLEEN IMAGING STATIC ONLY Radiology Blank 0.49 0.17 0.17 Blank RBRVS

78215 TC LIVER & SPLEEN IMAGING STATIC ONLY Radiology a Blank 4.98 4.98 Blank RBRVS

78216 Blank LIVER & SPLEEN IMAGING W/VASCULAR FLOW Radiology a 0.57 3.07 3.07 Blank RBRVS

78216 26 LIVER & SPLEEN IMAGING W/VASCULAR FLOW Radiology Blank 0.57 0.18 0.18 Blank RBRVS

78216 TC LIVER & SPLEEN IMAGING W/VASCULAR FLOW Radiology a Blank 2.89 2.89 Blank RBRVS

78226 Blank HEPATOBILIARY SYST IMAGING INCLUDING GALLBLADDER Radiology a 0.74 8.89 8.89 Blank RBRVS

78226 26 HEPATOBILIARY SYST IMAGING INCLUDING GALLBLADDER Radiology Blank 0.74 0.26 0.26 Blank RBRVS

78226 TC HEPATOBILIARY SYST IMAGING INCLUDING GALLBLADDER Radiology a Blank 8.63 8.63 Blank RBRVS

78227 Blank HEPATOBIL SYST IMAG INC GB W/PHARMA INTERVENJ Radiology a 0.90 12.16 12.16 Blank RBRVS

78227 26 HEPATOBIL SYST IMAG INC GB W/PHARMA INTERVENJ Radiology Blank 0.90 0.32 0.32 Blank RBRVS

78227 TC HEPATOBIL SYST IMAG INC GB W/PHARMA INTERVENJ Radiology a Blank 11.84 11.84 Blank RBRVS

78230 Blank SALIVARY GLAND IMAGING Radiology a 0.45 4.59 4.59 Blank RBRVS

78230 26 SALIVARY GLAND IMAGING Radiology Blank 0.45 0.17 0.17 Blank RBRVS

78230 TC SALIVARY GLAND IMAGING Radiology a Blank 4.42 4.42 Blank RBRVS

78231 Blank SALIVARY GLAND IMAGING SERIAL IMAGES Radiology a 0.52 2.51 2.51 Blank RBRVS

78231 26 SALIVARY GLAND IMAGING SERIAL IMAGES Radiology Blank 0.52 0.09 0.09 Blank RBRVS

78231 TC SALIVARY GLAND IMAGING SERIAL IMAGES Radiology a Blank 2.42 2.42 Blank RBRVS

78232 Blank SALIVARY GLAND FUNCTION STUDY Radiology a 0.47 2.42 2.42 Blank RBRVS

78232 26 SALIVARY GLAND FUNCTION STUDY Radiology Blank 0.47 0.08 0.08 Blank RBRVS

78232 TC SALIVARY GLAND FUNCTION STUDY Radiology a Blank 2.34 2.34 Blank RBRVS

78258 Blank ESOPHAGEAL MOTILITY Radiology a 0.74 5.78 5.78 Blank RBRVS

78258 26 ESOPHAGEAL MOTILITY Radiology Blank 0.74 0.26 0.26 Blank RBRVS

78258 TC ESOPHAGEAL MOTILITY Radiology a Blank 5.52 5.52 Blank RBRVS

78261 Blank GASTRIC MUCOSA IMAGING Radiology a 0.69 5.18 5.18 Blank RBRVS

78261 26 GASTRIC MUCOSA IMAGING Radiology Blank 0.69 0.12 0.12 Blank RBRVS

78261 TC GASTRIC MUCOSA IMAGING Radiology a Blank 5.06 5.06 Blank RBRVS

78262 Blank GASTROESOPHAGEAL REFLUX STUDY Radiology a 0.68 6.33 6.33 Blank RBRVS

78262 26 GASTROESOPHAGEAL REFLUX STUDY Radiology Blank 0.68 0.23 0.23 Blank RBRVS

78262 TC GASTROESOPHAGEAL REFLUX STUDY Radiology a Blank 6.10 6.10 Blank RBRVS

78264 Blank GASTRIC EMPTYING IMAGING STUDY Radiology a 0.79 8.98 8.98 Blank RBRVS

78264 26 GASTRIC EMPTYING IMAGING STUDY Radiology Blank 0.79 0.27 0.27 Blank RBRVS

78264 TC GASTRIC EMPTYING IMAGING STUDY Radiology a Blank 8.71 8.71 Blank RBRVS

78265 Blank GASTRIC EMPTYNG IMAG STD W/SM BWL TRANSIT Radiology a 0.98 10.61 10.61 Blank RBRVS

78265 26 GASTRIC EMPTYNG IMAG STD W/SM BWL TRANSIT Radiology Blank 0.98 0.34 0.34 Blank RBRVS

78265 TC GASTRIC EMPTYNG IMAG STD W/SM BWL TRANSIT Radiology a Blank 10.27 10.27 Blank RBRVS

78266 Blank GSTRC EMPTNG IMAG STD W/SM BWL COL TRNST MLT DAY Radiology a 1.08 12.74 12.74 Blank RBRVS





PAGE 104 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

78266 26 GSTRC EMPTNG IMAG STD W/SM BWL COL TRNST MLT DAY Radiology Blank 1.08 0.38 0.38 Blank RBRVS

78266 TC GSTRC EMPTNG IMAG STD W/SM BWL COL TRNST MLT DAY Radiology a Blank 12.36 12.36 Blank RBRVS

78278 Blank ACUTE GASTROINTESTINAL BLOOD LOSS IMAGING Radiology a 0.99 9.15 9.15 Blank RBRVS

78278 26 ACUTE GASTROINTESTINAL BLOOD LOSS IMAGING Radiology Blank 0.99 0.35 0.35 Blank RBRVS

78278 TC ACUTE GASTROINTESTINAL BLOOD LOSS IMAGING Radiology a Blank 8.80 8.80 Blank RBRVS

78282 Blank GASTROINTESTINAL PROTEIN LOSS Radiology a Blank Blank Blank 2.09 Global/TC/26

78282 26 GASTROINTESTINAL PROTEIN LOSS Radiology Blank Blank Blank Blank 0.52 Global/TC/26

78282 TC GASTROINTESTINAL PROTEIN LOSS Radiology a Blank Blank Blank 1.57 Global/TC/26

78290 Blank INTESTINE IMAGING Radiology a 0.68 8.95 8.95 Blank RBRVS

78290 26 INTESTINE IMAGING Radiology Blank 0.68 0.23 0.23 Blank RBRVS

78290 TC INTESTINE IMAGING Radiology a Blank 8.72 8.72 Blank RBRVS

78291 Blank PERITONEAL-VENOUS SHUNT PATENCY TEST Radiology a 0.88 6.56 6.56 Blank RBRVS

78291 26 PERITONEAL-VENOUS SHUNT PATENCY TEST Radiology Blank 0.88 0.29 0.29 Blank RBRVS

78291 TC PERITONEAL-VENOUS SHUNT PATENCY TEST Radiology a Blank 6.27 6.27 Blank RBRVS

78299 Blank UNLISTED GASTROINTESTINAL PX DX NUCLEAR MEDICINE Radiology a Blank Blank Blank 9.77 Unlisted

78299 26 UNLISTED GASTROINTESTINAL PX DX NUCLEAR MEDICINE Radiology Blank Blank Blank Blank 1.06 Unlisted

78299 TC UNLISTED GASTROINTESTINAL PX DX NUCLEAR MEDICINE Radiology a Blank Blank Blank 8.71 Unlisted

78300 Blank BONE &/JOINT IMAGING LIMITED AREA Radiology a 0.62 6.09 6.09 Blank RBRVS

78300 26 BONE &/JOINT IMAGING LIMITED AREA Radiology Blank 0.62 0.23 0.23 Blank RBRVS

78300 TC BONE &/JOINT IMAGING LIMITED AREA Radiology a Blank 5.86 5.86 Blank RBRVS

78305 Blank BONE &/JOINT IMAGING MULTIPLE AREAS Radiology a 0.83 7.34 7.34 Blank RBRVS

78305 26 BONE &/JOINT IMAGING MULTIPLE AREAS Radiology Blank 0.83 0.29 0.29 Blank RBRVS

78305 TC BONE &/JOINT IMAGING MULTIPLE AREAS Radiology a Blank 7.05 7.05 Blank RBRVS

78306 Blank BONE &/JOINT IMAGING WHOLE BODY Radiology a 0.86 7.96 7.96 Blank RBRVS

78306 26 BONE &/JOINT IMAGING WHOLE BODY Radiology Blank 0.86 0.30 0.30 Blank RBRVS

78306 TC BONE &/JOINT IMAGING WHOLE BODY Radiology a Blank 7.66 7.66 Blank RBRVS

78315 Blank BONE &/JOINT IMAGING 3 PHASE STUDY Radiology a 1.02 9.04 9.04 Blank RBRVS

78315 26 BONE &/JOINT IMAGING 3 PHASE STUDY Radiology Blank 1.02 0.35 0.35 Blank RBRVS

78315 TC BONE &/JOINT IMAGING 3 PHASE STUDY Radiology a Blank 8.69 8.69 Blank RBRVS

78320 Blank BONE &/JOINT IMAGING TOMOGRAPHIC SPECT Radiology a 1.04 5.57 5.57 Blank RBRVS

78320 26 BONE &/JOINT IMAGING TOMOGRAPHIC SPECT Radiology Blank 1.04 0.34 0.34 Blank RBRVS

78320 TC BONE &/JOINT IMAGING TOMOGRAPHIC SPECT Radiology a Blank 5.23 5.23 Blank RBRVS

78350 Blank BONE DENSITY 1/> SITES 1 PHOTON ABSORPTIOMETRY Radiology a 0.22 0.71 0.71 Blank RBRVS

78350 26 BONE DENSITY 1/> SITES 1 PHOTON ABSORPTIOMETRY Radiology Blank 0.22 0.09 0.09 Blank RBRVS

78350 TC BONE DENSITY 1/> SITES 1 PHOTON ABSORPTIOMETRY Radiology a Blank 0.62 0.62 Blank RBRVS

78351 Blank BONE DENSTY 1/> SITES DUAL PHOTON ABSORPTIOMETR Radiology Blank 0.30 0.12 0.12 Blank RBRVS

78399 Blank UNLISTED MUSCULOSKELETAL PX DX NUCLEAR MEDICINE Radiology a Blank Blank Blank 8.82 Unlisted

78399 26 UNLISTED MUSCULOSKELETAL PX DX NUCLEAR MEDICINE Radiology Blank Blank Blank Blank 1.16 Unlisted

78399 TC UNLISTED MUSCULOSKELETAL PX DX NUCLEAR MEDICINE Radiology a Blank Blank Blank 7.66 Unlisted

78414 Blank CARD-VASC HEMODYNAM W/WO PHARM/EXER 1/MLT DETERM Radiology a Blank Blank Blank 2.03 Global/TC/26

78414 26 CARD-VASC HEMODYNAM W/WO PHARM/EXER 1/MLT DETERM Radiology Blank Blank Blank Blank 0.61 Global/TC/26

78414 TC CARD-VASC HEMODYNAM W/WO PHARM/EXER 1/MLT DETERM Radiology a Blank Blank Blank 1.42 Global/TC/26

78428 Blank CARDIAC SHUNT DETECTION Radiology a 0.78 4.50 4.50 Blank RBRVS

78428 26 CARDIAC SHUNT DETECTION Radiology Blank 0.78 0.26 0.26 Blank RBRVS

78428 TC CARDIAC SHUNT DETECTION Radiology a Blank 4.24 4.24 Blank RBRVS

78445 Blank NONCARDIAC VASCULAR FLOW IMAGING Radiology a 0.49 4.91 4.91 Blank RBRVS

78445 26 NONCARDIAC VASCULAR FLOW IMAGING Radiology Blank 0.49 0.17 0.17 Blank RBRVS

78445 TC NONCARDIAC VASCULAR FLOW IMAGING Radiology a Blank 4.74 4.74 Blank RBRVS

78451 Blank MYOCARDIAL SPECT SINGLE STUDY AT REST OR STRESS Radiology a 1.38 8.50 8.50 Blank RBRVS

78451 26 MYOCARDIAL SPECT SINGLE STUDY AT REST OR STRESS Radiology Blank 1.38 0.47 0.47 Blank RBRVS

78451 TC MYOCARDIAL SPECT SINGLE STUDY AT REST OR STRESS Radiology a Blank 8.03 8.03 Blank RBRVS

78452 Blank MYOCARDIAL SPECT MULTIPLE STUDIES Radiology a 1.62 12.15 12.15 Blank RBRVS

78452 26 MYOCARDIAL SPECT MULTIPLE STUDIES Radiology Blank 1.62 0.56 0.56 Blank RBRVS

78452 TC MYOCARDIAL SPECT MULTIPLE STUDIES Radiology a Blank 11.59 11.59 Blank RBRVS

78453 Blank MYOCARDIAL PERFUSION PLANAR 1 STUDY REST/STRESS Radiology a 1.00 7.82 7.82 Blank RBRVS

78453 26 MYOCARDIAL PERFUSION PLANAR 1 STUDY REST/STRESS Radiology Blank 1.00 0.35 0.35 Blank RBRVS

78453 TC MYOCARDIAL PERFUSION PLANAR 1 STUDY REST/STRESS Radiology a Blank 7.47 7.47 Blank RBRVS

78454 Blank MYOCARDIAL PERFUSION PLANAR MULTIPLE STUDIES Radiology a 1.34 11.35 11.35 Blank RBRVS

78454 26 MYOCARDIAL PERFUSION PLANAR MULTIPLE STUDIES Radiology Blank 1.34 0.48 0.48 Blank RBRVS

78454 TC MYOCARDIAL PERFUSION PLANAR MULTIPLE STUDIES Radiology a Blank 10.87 10.87 Blank RBRVS

78456 Blank ACUTE VENOUS THROMBOSIS IMAGING PEPTIDE Radiology a 1.00 8.00 8.00 Blank RBRVS

78456 26 ACUTE VENOUS THROMBOSIS IMAGING PEPTIDE Radiology Blank 1.00 0.34 0.34 Blank RBRVS

78456 TC ACUTE VENOUS THROMBOSIS IMAGING PEPTIDE Radiology a Blank 7.66 7.66 Blank RBRVS

78457 Blank VENOUS THROMBOSIS IMAGING VENOGRAM UNILATERAL Radiology a 0.77 4.79 4.79 Blank RBRVS

78457 26 VENOUS THROMBOSIS IMAGING VENOGRAM UNILATERAL Radiology Blank 0.77 0.27 0.27 Blank RBRVS

78457 TC VENOUS THROMBOSIS IMAGING VENOGRAM UNILATERAL Radiology a Blank 4.52 4.52 Blank RBRVS

78458 Blank VENOUS THROMBOSIS IMAGING VENOGRAM BILATERAL Radiology a 0.90 5.00 5.00 Blank RBRVS

78458 26 VENOUS THROMBOSIS IMAGING VENOGRAM BILATERAL Radiology Blank 0.90 0.33 0.33 Blank RBRVS

78458 TC VENOUS THROMBOSIS IMAGING VENOGRAM BILATERAL Radiology a Blank 4.67 4.67 Blank RBRVS

78459 Blank MYOCARDIAL IMAGING PET METABOLIC EVALUATION Radiology a Blank Blank Blank 9.56 Global/TC/26

78459 26 MYOCARDIAL IMAGING PET METABOLIC EVALUATION Radiology Blank Blank Blank Blank 1.95 Global/TC/26

78459 TC MYOCARDIAL IMAGING PET METABOLIC EVALUATION Radiology a Blank Blank Blank 7.61 Global/TC/26





PAGE 105 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

78466 Blank MYOCARDIAL IMAGING INFARCT AVID PLANAR QUAL/QUAN Radiology a 0.69 5.03 5.03 Blank RBRVS

78466 26 MYOCARDIAL IMAGING INFARCT AVID PLANAR QUAL/QUAN Radiology Blank 0.69 0.28 0.28 Blank RBRVS

78466 TC MYOCARDIAL IMAGING INFARCT AVID PLANAR QUAL/QUAN Radiology a Blank 4.75 4.75 Blank RBRVS

78468 Blank MYOCRD IMG INFARCT AVID PLNR EJEC FXJ 1ST PS TQ Radiology a 0.80 4.78 4.78 Blank RBRVS

78468 26 MYOCRD IMG INFARCT AVID PLNR EJEC FXJ 1ST PS TQ Radiology Blank 0.80 0.27 0.27 Blank RBRVS

78468 TC MYOCRD IMG INFARCT AVID PLNR EJEC FXJ 1ST PS TQ Radiology a Blank 4.51 4.51 Blank RBRVS

78469 Blank MYOCRD INFARCT AVID PLNR TOMOG SPECT W/WO QUANTJ Radiology a 0.92 5.73 5.73 Blank RBRVS

78469 26 MYOCRD INFARCT AVID PLNR TOMOG SPECT W/WO QUANTJ Radiology Blank 0.92 0.33 0.33 Blank RBRVS

78469 TC MYOCRD INFARCT AVID PLNR TOMOG SPECT W/WO QUANTJ Radiology a Blank 5.40 5.40 Blank RBRVS

78472 Blank CARD BLOOD POOL GATED PLANAR 1 STUDY REST/STRESS Radiology a 0.98 5.65 5.65 Blank RBRVS

78472 26 CARD BLOOD POOL GATED PLANAR 1 STUDY REST/STRESS Radiology Blank 0.98 0.34 0.34 Blank RBRVS

78472 TC CARD BLOOD POOL GATED PLANAR 1 STUDY REST/STRESS Radiology a Blank 5.31 5.31 Blank RBRVS

78473 Blank CARD BL POOL GATED MLT STDY WAL MOTN EJECT FRACT Radiology a 1.47 6.89 6.89 Blank RBRVS

78473 26 CARD BL POOL GATED MLT STDY WAL MOTN EJECT FRACT Radiology Blank 1.47 0.49 0.49 Blank RBRVS

78473 TC CARD BL POOL GATED MLT STDY WAL MOTN EJECT FRACT Radiology a Blank 6.40 6.40 Blank RBRVS

78481 Blank CARD BL POOL PLANAR 1 STDY WAL MOTN EJECT FRACT Radiology a 0.98 4.08 4.08 Blank RBRVS

78481 26 CARD BL POOL PLANAR 1 STDY WAL MOTN EJECT FRACT Radiology Blank 0.98 0.34 0.34 Blank RBRVS

78481 TC CARD BL POOL PLANAR 1 STDY WAL MOTN EJECT FRACT Radiology a Blank 3.74 3.74 Blank RBRVS

78483 Blank CARD BL POOL PLNR MLT STDY WAL MOTN EJECT FRACT Radiology a 1.47 5.50 5.50 Blank RBRVS

78483 26 CARD BL POOL PLNR MLT STDY WAL MOTN EJECT FRACT Radiology Blank 1.47 0.49 0.49 Blank RBRVS

78483 TC CARD BL POOL PLNR MLT STDY WAL MOTN EJECT FRACT Radiology a Blank 5.01 5.01 Blank RBRVS

78491 Blank MYOCRD IMAGE PET PERFUS SINGLE STUDY REST/STRESS Radiology a Blank Blank Blank 9.88 Global/TC/26

78491 26 MYOCRD IMAGE PET PERFUS SINGLE STUDY REST/STRESS Radiology Blank Blank Blank Blank 1.96 Global/TC/26

78491 TC MYOCRD IMAGE PET PERFUS SINGLE STUDY REST/STRESS Radiology a Blank Blank Blank 7.92 Global/TC/26

78492 Blank MYOCRD IMAGE PET PERFUS MULTPL STUDY REST/STRESS Radiology a Blank Blank Blank 12.51 Global/TC/26

78492 26 MYOCRD IMAGE PET PERFUS MULTPL STUDY REST/STRESS Radiology Blank Blank Blank Blank 2.48 Global/TC/26

78492 TC MYOCRD IMAGE PET PERFUS MULTPL STUDY REST/STRESS Radiology a Blank Blank Blank 10.03 Global/TC/26

78494 Blank CARD BL POOL GATED SPECT REST WAL MOTN EJCT FRCT Radiology a 1.19 5.32 5.32 Blank RBRVS

78494 26 CARD BL POOL GATED SPECT REST WAL MOTN EJCT FRCT Radiology Blank 1.19 0.41 0.41 Blank RBRVS

78494 TC CARD BL POOL GATED SPECT REST WAL MOTN EJCT FRCT Radiology a Blank 4.91 4.91 Blank RBRVS

78496 Blank CARD BL POOL GATED 1 STDY REST RT VENT EJCT FRCT Radiology a 0.50 0.74 0.74 Blank RBRVS

78496 26 CARD BL POOL GATED 1 STDY REST RT VENT EJCT FRCT Radiology Blank 0.50 0.17 0.17 Blank RBRVS

78496 TC CARD BL POOL GATED 1 STDY REST RT VENT EJCT FRCT Radiology a Blank 0.57 0.57 Blank RBRVS

78499 Blank UNLISTED CARDIOVASCULAR PX DX NUCLEAR MEDICINE Radiology a Blank Blank Blank 13.77 Unlisted

78499 26 UNLISTED CARDIOVASCULAR PX DX NUCLEAR MEDICINE Radiology Blank Blank Blank Blank 2.18 Unlisted

78499 TC UNLISTED CARDIOVASCULAR PX DX NUCLEAR MEDICINE Radiology a Blank Blank Blank 11.59 Unlisted

78579 Blank PULMONARY VENTILATION IMAGING Radiology a 0.49 4.94 4.94 Blank RBRVS

78579 26 PULMONARY VENTILATION IMAGING Radiology Blank 0.49 0.17 0.17 Blank RBRVS

78579 TC PULMONARY VENTILATION IMAGING Radiology a Blank 4.77 4.77 Blank RBRVS

78580 Blank PULMONARY PERFUSION IMAGING PARTICULATE Radiology a 0.74 6.19 6.19 Blank RBRVS

78580 26 PULMONARY PERFUSION IMAGING PARTICULATE Radiology Blank 0.74 0.26 0.26 Blank RBRVS

78580 TC PULMONARY PERFUSION IMAGING PARTICULATE Radiology a Blank 5.93 5.93 Blank RBRVS

78582 Blank PULMONARY VENTILATION & PERFUSION IMAGING Radiology a 1.07 8.63 8.63 Blank RBRVS

78582 26 PULMONARY VENTILATION & PERFUSION IMAGING Radiology Blank 1.07 0.37 0.37 Blank RBRVS

78582 TC PULMONARY VENTILATION & PERFUSION IMAGING Radiology a Blank 8.26 8.26 Blank RBRVS

78597 Blank QUANT DIFFERENTIAL PULM PERFUSION W/WO IMAGING Radiology a 0.75 5.14 5.14 Blank RBRVS

78597 26 QUANT DIFFERENTIAL PULM PERFUSION W/WO IMAGING Radiology Blank 0.75 0.23 0.23 Blank RBRVS

78597 TC QUANT DIFFERENTIAL PULM PERFUSION W/WO IMAGING Radiology a Blank 4.91 4.91 Blank RBRVS

78598 Blank QUANT DIFF PULM PRFUSION & VENTLAJ W/WO IMAGIN Radiology a 0.85 8.01 8.01 Blank RBRVS

78598 26 QUANT DIFF PULM PRFUSION & VENTLAJ W/WO IMAGIN Radiology Blank 0.85 0.28 0.28 Blank RBRVS

78598 TC QUANT DIFF PULM PRFUSION & VENTLAJ W/WO IMAGIN Radiology a Blank 7.73 7.73 Blank RBRVS

78599 Blank UNLISTED RESPIRATORY PX DX NUCLEAR MEDICINE Radiology a Blank Blank Blank 9.70 Unlisted

78599 26 UNLISTED RESPIRATORY PX DX NUCLEAR MEDICINE Radiology Blank Blank Blank Blank 1.44 Unlisted

78599 TC UNLISTED RESPIRATORY PX DX NUCLEAR MEDICINE Radiology a Blank Blank Blank 8.26 Unlisted

78600 Blank BRAIN IMAGING <4 STATIC VIEWS Radiology a 0.44 4.91 4.91 Blank RBRVS

78600 26 BRAIN IMAGING <4 STATIC VIEWS Radiology Blank 0.44 0.16 0.16 Blank RBRVS

78600 TC BRAIN IMAGING <4 STATIC VIEWS Radiology a Blank 4.75 4.75 Blank RBRVS

78601 Blank BRAIN IMAGING <4 STATIC VIEWS W/VASCULAR FLOW Radiology a 0.51 5.72 5.72 Blank RBRVS

78601 26 BRAIN IMAGING <4 STATIC VIEWS W/VASCULAR FLOW Radiology Blank 0.51 0.17 0.17 Blank RBRVS

78601 TC BRAIN IMAGING <4 STATIC VIEWS W/VASCULAR FLOW Radiology a Blank 5.55 5.55 Blank RBRVS

78605 Blank BRAIN IMAGING MINIMUM 4 STATIC VIEWS Radiology a 0.53 5.24 5.24 Blank RBRVS

78605 26 BRAIN IMAGING MINIMUM 4 STATIC VIEWS Radiology Blank 0.53 0.20 0.20 Blank RBRVS

78605 TC BRAIN IMAGING MINIMUM 4 STATIC VIEWS Radiology a Blank 5.04 5.04 Blank RBRVS

78606 Blank BRAIN IMAGING MIN 4 STATIC VIEWS W VASCULAR FLOW Radiology a 0.64 8.95 8.95 Blank RBRVS

78606 26 BRAIN IMAGING MIN 4 STATIC VIEWS W VASCULAR FLOW Radiology Blank 0.64 0.22 0.22 Blank RBRVS

78606 TC BRAIN IMAGING MIN 4 STATIC VIEWS W VASCULAR FLOW Radiology a Blank 8.73 8.73 Blank RBRVS

78607 Blank BRAIN IMAGING TOMOGRAPHIC SPECT Radiology a 1.23 8.94 8.94 Blank RBRVS

78607 26 BRAIN IMAGING TOMOGRAPHIC SPECT Radiology Blank 1.23 0.39 0.39 Blank RBRVS

78607 TC BRAIN IMAGING TOMOGRAPHIC SPECT Radiology a Blank 8.55 8.55 Blank RBRVS

78608 Blank BRAIN IMAGING PET METABOLIC EVALUATION Radiology a Blank Blank Blank 12.48 Global/TC/26

78608 26 BRAIN IMAGING PET METABOLIC EVALUATION Radiology Blank Blank Blank Blank 1.97 Global/TC/26

78608 TC BRAIN IMAGING PET METABOLIC EVALUATION Radiology a Blank Blank Blank 10.51 Global/TC/26





PAGE 106 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

78609 Blank BRAIN IMAGING PET PERFUSION EVALUATION Radiology a Blank Blank Blank 4.64 Global/TC/26

78609 26 BRAIN IMAGING PET PERFUSION EVALUATION Radiology Blank 1.50 0.58 0.58 Blank RBRVS

78609 TC BRAIN IMAGING PET PERFUSION EVALUATION Radiology a Blank Blank Blank 2.56 Global/TC/26

78610 Blank BRAIN IMAGING VASCULAR FLOW ONLY Radiology a 0.30 4.78 4.78 Blank RBRVS

78610 26 BRAIN IMAGING VASCULAR FLOW ONLY Radiology Blank 0.30 0.11 0.11 Blank RBRVS

78610 TC BRAIN IMAGING VASCULAR FLOW ONLY Radiology a Blank 4.67 4.67 Blank RBRVS

78630 Blank CEREBROSPINAL FLUID FLOW W/O MATL CISTERNOGRAPHY Radiology a 0.68 9.17 9.17 Blank RBRVS

78630 26 CEREBROSPINAL FLUID FLOW W/O MATL CISTERNOGRAPHY Radiology Blank 0.68 0.24 0.24 Blank RBRVS

78630 TC CEREBROSPINAL FLUID FLOW W/O MATL CISTERNOGRAPHY Radiology a Blank 8.93 8.93 Blank RBRVS

78635 Blank CEREBROSPINAL FLUID FLOW W/O MATL VENTRICLGRAPHY Radiology a 0.61 9.25 9.25 Blank RBRVS

78635 26 CEREBROSPINAL FLUID FLOW W/O MATL VENTRICLGRAPHY Radiology Blank 0.61 0.23 0.23 Blank RBRVS

78635 TC CEREBROSPINAL FLUID FLOW W/O MATL VENTRICLGRAPHY Radiology a Blank 9.02 9.02 Blank RBRVS

78645 Blank CEREBROSPINAL FLUID FLOW W/O MATL SHUNT EVALTJ Radiology a 0.57 8.90 8.90 Blank RBRVS

78645 26 CEREBROSPINAL FLUID FLOW W/O MATL SHUNT EVALTJ Radiology Blank 0.57 0.19 0.19 Blank RBRVS

78645 TC CEREBROSPINAL FLUID FLOW W/O MATL SHUNT EVALTJ Radiology a Blank 8.71 8.71 Blank RBRVS

78647 Blank CEREBROSPINAL FLUID FLOW W/O MATL TOMOG SPECT Radiology a 0.90 9.31 9.31 Blank RBRVS

78647 26 CEREBROSPINAL FLUID FLOW W/O MATL TOMOG SPECT Radiology Blank 0.90 0.34 0.34 Blank RBRVS

78647 TC CEREBROSPINAL FLUID FLOW W/O MATL TOMOG SPECT Radiology a Blank 8.97 8.97 Blank RBRVS

78650 Blank CEREBROSPINAL FLUID LEAK DETECTION&LOCALIZATIO Radiology a 0.61 7.33 7.33 Blank RBRVS

78650 26 CEREBROSPINAL FLUID LEAK DETECTION&LOCALIZATIO Radiology Blank 0.61 0.10 0.10 Blank RBRVS

78650 TC CEREBROSPINAL FLUID LEAK DETECTION&LOCALIZATIO Radiology a Blank 7.23 7.23 Blank RBRVS

78660 Blank RADIOPHARMACEUTICAL DACRYOCYSTOGRAPHY Radiology a 0.53 4.70 4.70 Blank RBRVS

78660 26 RADIOPHARMACEUTICAL DACRYOCYSTOGRAPHY Radiology Blank 0.53 0.19 0.19 Blank RBRVS

78660 TC RADIOPHARMACEUTICAL DACRYOCYSTOGRAPHY Radiology a Blank 4.51 4.51 Blank RBRVS

78699 Blank UNLISTED NERVOUS SYSTEM PX DX NUCLEAR MEDICINE Radiology a Blank Blank Blank 10.33 Unlisted

78699 26 UNLISTED NERVOUS SYSTEM PX DX NUCLEAR MEDICINE Radiology Blank Blank Blank Blank 1.62 Unlisted

78699 TC UNLISTED NERVOUS SYSTEM PX DX NUCLEAR MEDICINE Radiology a Blank Blank Blank 8.71 Unlisted

78700 Blank KIDNEY IMAGING MORPHOLOGY Radiology a 0.45 4.55 4.55 Blank RBRVS

78700 26 KIDNEY IMAGING MORPHOLOGY Radiology Blank 0.45 0.16 0.16 Blank RBRVS

78700 TC KIDNEY IMAGING MORPHOLOGY Radiology a Blank 4.39 4.39 Blank RBRVS

78701 Blank KIDNEY IMAGING MORPHOOGY W/VASCULAR FLOW Radiology a 0.49 5.75 5.75 Blank RBRVS

78701 26 KIDNEY IMAGING MORPHOOGY W/VASCULAR FLOW Radiology Blank 0.49 0.17 0.17 Blank RBRVS

78701 TC KIDNEY IMAGING MORPHOOGY W/VASCULAR FLOW Radiology a Blank 5.58 5.58 Blank RBRVS

78707 Blank KIDNEY IMG MORPHOLOGY VASCULAR FLOW 1 W/O RX Radiology a 0.96 5.77 5.77 Blank RBRVS

78707 26 KIDNEY IMG MORPHOLOGY VASCULAR FLOW 1 W/O RX Radiology Blank 0.96 0.31 0.31 Blank RBRVS

78707 TC KIDNEY IMG MORPHOLOGY VASCULAR FLOW 1 W/O RX Radiology a Blank 5.46 5.46 Blank RBRVS

78708 Blank KIDNEY IMG MORPHOLOGY VASCULAR FLOW 1 W/RX Radiology a 1.21 3.82 3.82 Blank RBRVS

78708 26 KIDNEY IMG MORPHOLOGY VASCULAR FLOW 1 W/RX Radiology Blank 1.21 0.41 0.41 Blank RBRVS

78708 TC KIDNEY IMG MORPHOLOGY VASCULAR FLOW 1 W/RX Radiology a Blank 3.41 3.41 Blank RBRVS

78709 Blank KIDNEY IMG MORPHOLOGY VASCULAR FLOW MULTIPLE Radiology a 1.41 9.22 9.22 Blank RBRVS

78709 26 KIDNEY IMG MORPHOLOGY VASCULAR FLOW MULTIPLE Radiology Blank 1.41 0.46 0.46 Blank RBRVS

78709 TC KIDNEY IMG MORPHOLOGY VASCULAR FLOW MULTIPLE Radiology a Blank 8.76 8.76 Blank RBRVS

78710 Blank KIDNEY IMAGING MORPHOLOGY TOMOGRAPHIC Radiology a 0.66 5.21 5.21 Blank RBRVS

78710 26 KIDNEY IMAGING MORPHOLOGY TOMOGRAPHIC Radiology Blank 0.66 0.18 0.18 Blank RBRVS

78710 TC KIDNEY IMAGING MORPHOLOGY TOMOGRAPHIC Radiology a Blank 5.03 5.03 Blank RBRVS

78725 Blank KIDNEY FUNCJ STUDY NON-IMG RADIOISOTOPIC STUDY Radiology a 0.38 2.70 2.70 Blank RBRVS

78725 26 KIDNEY FUNCJ STUDY NON-IMG RADIOISOTOPIC STUDY Radiology Blank 0.38 0.12 0.12 Blank RBRVS

78725 TC KIDNEY FUNCJ STUDY NON-IMG RADIOISOTOPIC STUDY Radiology a Blank 2.58 2.58 Blank RBRVS

78730 Blank URINARY BLADDER RESIDUAL STUDY Radiology a 0.15 2.12 2.12 Blank RBRVS

78730 26 URINARY BLADDER RESIDUAL STUDY Radiology Blank 0.15 0.07 0.07 Blank RBRVS

78730 TC URINARY BLADDER RESIDUAL STUDY Radiology a Blank 2.05 2.05 Blank RBRVS

78740 Blank URETERAL REFLUX STUDY RP VOIDING CYSTOGRAM Radiology a 0.57 5.77 5.77 Blank RBRVS

78740 26 URETERAL REFLUX STUDY RP VOIDING CYSTOGRAM Radiology Blank 0.57 0.19 0.19 Blank RBRVS

78740 TC URETERAL REFLUX STUDY RP VOIDING CYSTOGRAM Radiology a Blank 5.58 5.58 Blank RBRVS

78761 Blank TESTICULAR IMAGING WITH VASCULAR FLOW Radiology a 0.71 5.39 5.39 Blank RBRVS

78761 26 TESTICULAR IMAGING WITH VASCULAR FLOW Radiology Blank 0.71 0.26 0.26 Blank RBRVS

78761 TC TESTICULAR IMAGING WITH VASCULAR FLOW Radiology a Blank 5.13 5.13 Blank RBRVS

78799 Blank UNLISTED GENITOURINARY PX DX NUCLEAR MEDICINE Radiology a Blank Blank Blank 5.66 Unlisted

78799 26 UNLISTED GENITOURINARY PX DX NUCLEAR MEDICINE Radiology Blank Blank Blank Blank 1.27 Unlisted

78799 TC UNLISTED GENITOURINARY PX DX NUCLEAR MEDICINE Radiology a Blank Blank Blank 4.39 Unlisted

78800 Blank RP LOCLZJ TUMOR/DSTRBJ AGENT LIMITED AREA Radiology a 0.66 4.90 4.90 Blank RBRVS

78800 26 RP LOCLZJ TUMOR/DSTRBJ AGENT LIMITED AREA Radiology Blank 0.66 0.24 0.24 Blank RBRVS

78800 TC RP LOCLZJ TUMOR/DSTRBJ AGENT LIMITED AREA Radiology a Blank 4.66 4.66 Blank RBRVS

78801 Blank RP LOCLZJ TUMOR/DSTRBJ AGENT MULTIPLE AREAS Radiology a 0.79 6.73 6.73 Blank RBRVS

78801 26 RP LOCLZJ TUMOR/DSTRBJ AGENT MULTIPLE AREAS Radiology Blank 0.79 0.27 0.27 Blank RBRVS

78801 TC RP LOCLZJ TUMOR/DSTRBJ AGENT MULTIPLE AREAS Radiology a Blank 6.46 6.46 Blank RBRVS

78802 Blank RP LOCLZJ TUMOR/DSTRBJ AGENT WHOLE BDY 1 DAY Radiology a 0.86 8.55 8.55 Blank RBRVS

78802 26 RP LOCLZJ TUMOR/DSTRBJ AGENT WHOLE BDY 1 DAY Radiology Blank 0.86 0.28 0.28 Blank RBRVS

78802 TC RP LOCLZJ TUMOR/DSTRBJ AGENT WHOLE BDY 1 DAY Radiology a Blank 8.27 8.27 Blank RBRVS

78803 Blank RP LOCLZJ TUMOR/DSTRBJ AGENT TOMOG SPECT Radiology a 1.09 8.86 8.86 Blank RBRVS

78803 26 RP LOCLZJ TUMOR/DSTRBJ AGENT TOMOG SPECT Radiology Blank 1.09 0.33 0.33 Blank RBRVS

78803 TC RP LOCLZJ TUMOR/DSTRBJ AGENT TOMOG SPECT Radiology a Blank 8.53 8.53 Blank RBRVS





PAGE 107 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

78804 Blank RP LOCLZJ TUMOR/DSTRBJ AGT WHOL BDY REQ 2/> DAY Radiology a 1.07 15.46 15.46 Blank RBRVS

78804 26 RP LOCLZJ TUMOR/DSTRBJ AGT WHOL BDY REQ 2/> DAY Radiology Blank 1.07 0.36 0.36 Blank RBRVS

78804 TC RP LOCLZJ TUMOR/DSTRBJ AGT WHOL BDY REQ 2/> DAY Radiology a Blank 15.10 15.10 Blank RBRVS

78805 Blank RP LOCLZJ INFLAMMATORY PROCESS LIMITED AREA Radiology a 0.73 4.56 4.56 Blank RBRVS

78805 26 RP LOCLZJ INFLAMMATORY PROCESS LIMITED AREA Radiology Blank 0.73 0.25 0.25 Blank RBRVS

78805 TC RP LOCLZJ INFLAMMATORY PROCESS LIMITED AREA Radiology a Blank 4.31 4.31 Blank RBRVS

78806 Blank RP LOCLZJ INFLAMMATORY PROCESS WHOLE BODY Radiology a 0.86 8.85 8.85 Blank RBRVS

78806 26 RP LOCLZJ INFLAMMATORY PROCESS WHOLE BODY Radiology Blank 0.86 0.29 0.29 Blank RBRVS

78806 TC RP LOCLZJ INFLAMMATORY PROCESS WHOLE BODY Radiology a Blank 8.56 8.56 Blank RBRVS

78807 Blank RP LOCLZJ INFLAMMATORY PROCESS TOMOG SPECT Radiology a 1.09 8.88 8.88 Blank RBRVS

78807 26 RP LOCLZJ INFLAMMATORY PROCESS TOMOG SPECT Radiology Blank 1.09 0.34 0.34 Blank RBRVS

78807 TC RP LOCLZJ INFLAMMATORY PROCESS TOMOG SPECT Radiology a Blank 8.54 8.54 Blank RBRVS

78808 Blank NJX RP LOCLZJ NON-IMG PROBE STUDY INTRAVENOUS Radiology Blank 0.18 0.92 0.92 Blank RBRVS

78811 Blank PET IMAGING LIMITED AREA CHEST HEAD/NECK Radiology a Blank Blank Blank 16.79 Global/TC/26

78811 26 PET IMAGING LIMITED AREA CHEST HEAD/NECK Radiology Blank Blank Blank Blank 2.09 Global/TC/26

78811 TC PET IMAGING LIMITED AREA CHEST HEAD/NECK Radiology a Blank Blank Blank 14.70 Global/TC/26

78812 Blank PET IMAGING SKULL BASE TO MID-THIGH Radiology a Blank Blank Blank 20.39 Global/TC/26

78812 26 PET IMAGING SKULL BASE TO MID-THIGH Radiology Blank Blank Blank Blank 2.56 Global/TC/26

78812 TC PET IMAGING SKULL BASE TO MID-THIGH Radiology a Blank Blank Blank 17.83 Global/TC/26

78813 Blank PET IMAGING WHOLE BODY Radiology a Blank Blank Blank 21.02 Global/TC/26

78813 26 PET IMAGING WHOLE BODY Radiology Blank Blank Blank Blank 2.65 Global/TC/26

78813 TC PET IMAGING WHOLE BODY Radiology a Blank Blank Blank 18.37 Global/TC/26

78814 Blank PET IMAGING CT FOR ATTENUATION LIMITED AREA Radiology a Blank Blank Blank 23.41 Global/TC/26

78814 26 PET IMAGING CT FOR ATTENUATION LIMITED AREA Radiology Blank Blank Blank Blank 2.94 Global/TC/26

78814 TC PET IMAGING CT FOR ATTENUATION LIMITED AREA Radiology a Blank Blank Blank 20.47 Global/TC/26

78815 Blank PET IMAGING CT ATTENUATION SKULL BASE MID-THIGH Radiology a Blank Blank Blank 25.66 Global/TC/26

78815 26 PET IMAGING CT ATTENUATION SKULL BASE MID-THIGH Radiology Blank Blank Blank Blank 3.26 Global/TC/26

78815 TC PET IMAGING CT ATTENUATION SKULL BASE MID-THIGH Radiology a Blank Blank Blank 22.40 Global/TC/26

78816 Blank PET IMAGING FOR CT ATTENUATION WHOLE BODY Radiology a Blank Blank Blank 26.22 Global/TC/26

78816 26 PET IMAGING FOR CT ATTENUATION WHOLE BODY Radiology Blank Blank Blank Blank 3.30 Global/TC/26

78816 TC PET IMAGING FOR CT ATTENUATION WHOLE BODY Radiology a Blank Blank Blank 22.92 Global/TC/26

78999 Blank UNLISTED MISCELLANEOUS PX DX NUCLEAR MEDICINE Radiology a Blank Blank Blank 25.66 Unlisted

78999 26 UNLISTED MISCELLANEOUS PX DX NUCLEAR MEDICINE Radiology Blank Blank Blank Blank 3.26 Unlisted

78999 TC UNLISTED MISCELLANEOUS PX DX NUCLEAR MEDICINE Radiology a Blank Blank Blank 22.40 Unlisted

79005 Blank RP THERAPY ORAL ADMINISTRATION Radiology a 1.80 2.00 2.00 Blank RBRVS

79005 26 RP THERAPY ORAL ADMINISTRATION Radiology Blank 1.80 0.62 0.62 Blank RBRVS

79005 TC RP THERAPY ORAL ADMINISTRATION Radiology a Blank 1.38 1.38 Blank RBRVS

79101 Blank RP THERAPY INTRAVENOUS ADMINISTRATION Radiology a 1.96 2.07 2.07 Blank RBRVS

79101 26 RP THERAPY INTRAVENOUS ADMINISTRATION Radiology Blank 1.96 0.70 0.70 Blank RBRVS

79101 TC RP THERAPY INTRAVENOUS ADMINISTRATION Radiology a Blank 1.37 1.37 Blank RBRVS

79200 Blank RP THERAPY INRACAVITARY ADMINISTRATION Radiology a 1.99 1.77 1.77 Blank RBRVS

79200 26 RP THERAPY INRACAVITARY ADMINISTRATION Radiology Blank 1.99 0.34 0.34 Blank RBRVS

79200 TC RP THERAPY INRACAVITARY ADMINISTRATION Radiology a Blank 1.43 1.43 Blank RBRVS

79300 Blank RP THERAPY INTERSTITIAL RADIOACTIVE COLLOID ADMN Radiology a Blank Blank Blank 3.64 Global/TC/26

79300 26 RP THERAPY INTERSTITIAL RADIOACTIVE COLLOID ADMN Radiology Blank Blank Blank Blank 2.20 Global/TC/26

79300 TC RP THERAPY INTERSTITIAL RADIOACTIVE COLLOID ADMN Radiology a Blank Blank Blank 1.44 Global/TC/26

79403 Blank RP THER RADIOLBLD MONOCLONAL ANTIBODY IV INFUS Radiology a 2.25 3.11 3.11 Blank RBRVS

79403 26 RP THER RADIOLBLD MONOCLONAL ANTIBODY IV INFUS Radiology Blank 2.25 0.77 0.77 Blank RBRVS

79403 TC RP THER RADIOLBLD MONOCLONAL ANTIBODY IV INFUS Radiology a Blank 2.34 2.34 Blank RBRVS

79440 Blank RP THERAPY INTRA-ARTICULAR ADMINISTRATION Radiology a 1.99 1.50 1.50 Blank RBRVS

79440 26 RP THERAPY INTRA-ARTICULAR ADMINISTRATION Radiology Blank 1.99 0.34 0.34 Blank RBRVS

79440 TC RP THERAPY INTRA-ARTICULAR ADMINISTRATION Radiology a Blank 1.16 1.16 Blank RBRVS

79445 Blank RP THERAPY INTRA-ARTERIAL PARTICULATE ADMN Radiology a Blank Blank Blank 9.49 Global/TC/26

79445 26 RP THERAPY INTRA-ARTERIAL PARTICULATE ADMN Radiology Blank Blank Blank Blank 3.14 Global/TC/26

79445 TC RP THERAPY INTRA-ARTERIAL PARTICULATE ADMN Radiology a Blank Blank Blank 6.35 Global/TC/26

79999 Blank RP THERAPY UNLISTED PROCEDURE Radiology a Blank Blank Blank 4.03 Unlisted

79999 26 RP THERAPY UNLISTED PROCEDURE Radiology Blank Blank Blank Blank 2.66 Unlisted

79999 TC RP THERAPY UNLISTED PROCEDURE Radiology a Blank Blank Blank 1.38 Unlisted

80500 Blank CLINICAL PATHOLOGY CONSULTATION LIMITED Pathology Blank 0.37 0.17 0.27 Blank RBRVS

80502 Blank CLINICAL PATHOLOGY CONSULTATION COMPREHENSIVE Pathology Blank 1.33 0.62 0.70 Blank RBRVS

83020 26 HEMOGLOBIN FRACTJ/QUANTJ ELECTROPHORESIS Pathology Blank 0.37 0.14 0.14 Blank RBRVS

84165 26 PROTEIN ELECTROPHORETIC FRACTJ&QUANTJ SERUM Pathology Blank 0.37 0.14 0.14 Blank RBRVS

84166 26 PROTEIN ELECTROP FXJ&QUAN OTH FLUS CONCENTRATI Pathology Blank 0.37 0.14 0.14 Blank RBRVS

84181 26 PROTEIN WESTRN BLOT I&R BLOOD/OTHER FLUID Pathology Blank 0.37 0.14 0.14 Blank RBRVS

84182 26 PROTEIN WESTRN BLOT BLOOD/OTH FLU IMMUNOLOGICAL Pathology Blank 0.37 0.14 0.14 Blank RBRVS

85060 Blank BLOOD SMEAR PERIPHERAL INTERP PHYS W/WRIT REPORT Pathology Blank 0.45 0.24 0.24 Blank RBRVS

85097 Blank BONE MARROW SMEAR INTERPRETATION Pathology Blank 0.94 0.44 1.61 Blank RBRVS

85390 26 FIBRINOLYSINS/COAGULOPATHY SCREEN INTERP&REPOR Pathology Blank 0.37 0.14 0.14 Blank RBRVS

85396 Blank COAGJ/FBRNLYS ASSAY WHOLE BLOOD ADDITIVE PER DAY Pathology Blank 0.37 0.20 0.20 Blank RBRVS

85576 26 PLATELET AGGREGATION IN VITRO EACH AGENT Pathology Blank 0.37 0.14 0.14 Blank RBRVS

86077 Blank BLD BANK PHYS SVCS DIFFC CROSS MATCH&/EVAL REP Pathology Blank 0.94 0.50 0.61 Blank RBRVS

86078 Blank BLD BANK PHYS SVCS INVSTGJ TFUJ RXN REPRT Pathology Blank 0.94 0.50 0.61 Blank RBRVS





PAGE 108 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

86079 Blank BLD BANK PHYS SVCS AUTHJ DEVIJ STANDARD REPRT Pathology Blank 0.94 0.49 0.60 Blank RBRVS

86153 26 CELL ENUMERATION IMMUNE SELECTJ & ID PHYS INTERP Pathology Blank 0.69 0.27 0.27 Blank RBRVS

86255 26 FLUORESCENT NONNFCT AGT ANTB SCREEN EA ANTIBODY Pathology Blank 0.37 0.14 0.14 Blank RBRVS

86256 26 FLUORESCENT NONNFCT AGT ANTB TITER EA ANTIBODY Pathology Blank 0.37 0.14 0.14 Blank RBRVS

86320 26 IMMUNOELECTROPHORESIS SERUM Pathology Blank 0.37 0.14 0.14 Blank RBRVS

86325 26 IMMUNOELECTROPHORESIS OTHER FLUIDS CONCENTRATION Pathology Blank 0.37 0.14 0.14 Blank RBRVS

86327 26 IMMUNOELECTROPHORESIS CROSSED Pathology Blank 0.42 0.16 0.16 Blank RBRVS

86334 26 IMMUNOFIXJ ELECTROPHORESIS SERUM Pathology Blank 0.37 0.14 0.14 Blank RBRVS

86335 26 IMMUNOFIXJ ELECTROPHORESIS OTHER FLUIDS Pathology Blank 0.37 0.14 0.14 Blank RBRVS

86486 Blank SKIN TEST UNLISTED ANTIGEN EACH Pathology a Blank 0.13 0.13 Blank RBRVS

86490 Blank SKIN TEST COCCIDIOIDOMYCOSIS Pathology a Blank 2.53 2.53 Blank RBRVS

86510 Blank SKIN TEST HISTOPLASMOSIS Pathology a Blank 0.17 0.17 Blank RBRVS

86580 Blank SKIN TEST TUBERCULOSIS INTRADERMAL Pathology a Blank 0.22 0.22 Blank RBRVS

87164 26 DARK FIELD EXAM ANY SOURCE W/SPECIMEN COLLECTION Pathology Blank 0.37 0.14 0.14 Blank RBRVS

87207 26 SMR PRIM SRC SPEC STAIN BODIES/PARASITS Pathology Blank 0.37 0.14 0.14 Blank RBRVS

88104 Blank CYTP FLU WASHGS/BRUSHINGS XCPT C/V SMRS INTERPJ Pathology a 0.56 1.48 1.48 Blank RBRVS

88104 26 CYTP FLU WASHGS/BRUSHINGS XCPT C/V SMRS INTERPJ Pathology Blank 0.56 0.26 0.26 Blank RBRVS

88104 TC CYTP FLU WASHGS/BRUSHINGS XCPT C/V SMRS INTERPJ Pathology a Blank 1.22 1.22 Blank RBRVS

88106 Blank CYTP FLU BR/WA XCPT C/V FILTER METH ONLY INTERPJ Pathology a 0.37 1.44 1.44 Blank RBRVS

88106 26 CYTP FLU BR/WA XCPT C/V FILTER METH ONLY INTERPJ Pathology Blank 0.37 0.19 0.19 Blank RBRVS

88106 TC CYTP FLU BR/WA XCPT C/V FILTER METH ONLY INTERPJ Pathology a Blank 1.25 1.25 Blank RBRVS

88108 Blank CYTP CONCENTRATION SMEARS & INTERPRETATION Pathology a 0.44 1.27 1.27 Blank RBRVS

88108 26 CYTP CONCENTRATION SMEARS & INTERPRETATION Pathology Blank 0.44 0.21 0.21 Blank RBRVS

88108 TC CYTP CONCENTRATION SMEARS & INTERPRETATION Pathology a Blank 1.06 1.06 Blank RBRVS

88112 Blank CYTP SLCTV CELL ENHANCEMENT INTERPJ XCPT C/V Pathology a 0.56 1.37 1.37 Blank RBRVS

88112 26 CYTP SLCTV CELL ENHANCEMENT INTERPJ XCPT C/V Pathology Blank 0.56 0.25 0.25 Blank RBRVS

88112 TC CYTP SLCTV CELL ENHANCEMENT INTERPJ XCPT C/V Pathology a Blank 1.12 1.12 Blank RBRVS

88120 Blank CYTP INSITU HYBRID URINE SPEC 3-5 PROBES EA MNL Pathology a 1.20 16.80 16.80 Blank RBRVS

88120 26 CYTP INSITU HYBRID URINE SPEC 3-5 PROBES EA MNL Pathology Blank 1.20 0.46 0.46 Blank RBRVS

88120 TC CYTP INSITU HYBRID URINE SPEC 3-5 PROBES EA MNL Pathology a Blank 16.34 16.34 Blank RBRVS

88121 Blank CYTP INSITU HYBRID URNE SPEC 3-5 PROBES CPTR EA Pathology a 1.00 14.02 14.02 Blank RBRVS

88121 26 CYTP INSITU HYBRID URNE SPEC 3-5 PROBES CPTR EA Pathology Blank 1.00 0.43 0.43 Blank RBRVS

88121 TC CYTP INSITU HYBRID URNE SPEC 3-5 PROBES CPTR EA Pathology a Blank 13.59 13.59 Blank RBRVS

88125 Blank CYTOPATHOLOGY FORENSIC Pathology a 0.26 0.48 0.48 Blank RBRVS

88125 26 CYTOPATHOLOGY FORENSIC Pathology Blank 0.26 0.14 0.14 Blank RBRVS

88125 TC CYTOPATHOLOGY FORENSIC Pathology a Blank 0.34 0.34 Blank RBRVS

88141 Blank CYTP CERVICAL/VAGINAL REQ INTERP PHYSICIAN Pathology Blank 0.42 0.48 0.48 Blank RBRVS

88160 Blank CYTP SMRS ANY OTH SRC SCR&INTERPJ Pathology a 0.50 1.54 1.54 Blank RBRVS

88160 26 CYTP SMRS ANY OTH SRC SCR&INTERPJ Pathology Blank 0.50 0.25 0.25 Blank RBRVS

88160 TC CYTP SMRS ANY OTH SRC SCR&INTERPJ Pathology a Blank 1.29 1.29 Blank RBRVS

88161 Blank CYTP SMRS ANY OTH SRC PREPJ SCR&INTERPJ Pathology a 0.50 1.35 1.35 Blank RBRVS

88161 26 CYTP SMRS ANY OTH SRC PREPJ SCR&INTERPJ Pathology Blank 0.50 0.22 0.22 Blank RBRVS

88161 TC CYTP SMRS ANY OTH SRC PREPJ SCR&INTERPJ Pathology a Blank 1.13 1.13 Blank RBRVS

88162 Blank CYTP SMRS ANY OTH SRC EXTND STD > 5 SLIDES Pathology a 0.76 1.95 1.95 Blank RBRVS

88162 26 CYTP SMRS ANY OTH SRC EXTND STD > 5 SLIDES Pathology Blank 0.76 0.35 0.35 Blank RBRVS

88162 TC CYTP SMRS ANY OTH SRC EXTND STD > 5 SLIDES Pathology a Blank 1.60 1.60 Blank RBRVS

88172 Blank CYTP FINE NDL ASPIRATE IMMT CYTOHIST STD DX 1ST Pathology a 0.69 0.92 0.92 Blank RBRVS

88172 26 CYTP FINE NDL ASPIRATE IMMT CYTOHIST STD DX 1ST Pathology Blank 0.69 0.35 0.35 Blank RBRVS

88172 TC CYTP FINE NDL ASPIRATE IMMT CYTOHIST STD DX 1ST Pathology a Blank 0.57 0.57 Blank RBRVS

88173 Blank CYTP EVAL FINE NEEDLE ASPIRATE INTERP & REPORT Pathology a 1.39 2.95 2.95 Blank RBRVS

88173 26 CYTP EVAL FINE NEEDLE ASPIRATE INTERP & REPORT Pathology Blank 1.39 0.66 0.66 Blank RBRVS

88173 TC CYTP EVAL FINE NEEDLE ASPIRATE INTERP & REPORT Pathology a Blank 2.29 2.29 Blank RBRVS

88177 Blank CYTP FINE NDL ASPIRATE IMMT CYTOHIST STD EA EVAL Pathology a 0.42 0.44 0.44 Blank RBRVS

88177 26 CYTP FINE NDL ASPIRATE IMMT CYTOHIST STD EA EVAL Pathology Blank 0.42 0.22 0.22 Blank RBRVS

88177 TC CYTP FINE NDL ASPIRATE IMMT CYTOHIST STD EA EVAL Pathology a Blank 0.22 0.22 Blank RBRVS

88182 Blank FLOW CYTOMETRY CELL CYCLE/DNA ANALYSIS Pathology a 0.77 2.90 2.90 Blank RBRVS

88182 26 FLOW CYTOMETRY CELL CYCLE/DNA ANALYSIS Pathology Blank 0.77 0.34 0.34 Blank RBRVS

88182 TC FLOW CYTOMETRY CELL CYCLE/DNA ANALYSIS Pathology a Blank 2.56 2.56 Blank RBRVS

88184 Blank FLOW CYTOMETRY CELL SURF MARKER TECHL ONLY 1ST Pathology a Blank 1.87 1.87 Blank RBRVS

88185 Blank FLOW CYTOMETRY CELL SURF MARKER TECHL ONLY EA Pathology a Blank 0.85 0.85 Blank RBRVS

88187 Blank FLOW CYTOMETRY INTERPJ 2-8 MARKERS Pathology Blank 0.74 0.56 0.56 Blank RBRVS

88188 Blank FLOW CYTOMETRY INTERPJ 9-15 MARKERS Pathology Blank 1.20 0.59 0.59 Blank RBRVS

88189 Blank FLOW CYTOMETRY INTERPRETATION 16/> MARKERS Pathology Blank 1.70 0.69 0.69 Blank RBRVS

88291 Blank CYTOGENETICS&MOLEC CYTOGENETICS INTERP&REP Pathology Blank 0.52 0.40 0.40 Blank RBRVS

88300 Blank LEVEL I SURG PATHOLOGY GROSS EXAMINATION ONLY Pathology a 0.08 0.37 0.37 Blank RBRVS

88300 26 LEVEL I SURG PATHOLOGY GROSS EXAMINATION ONLY Pathology Blank 0.08 0.04 0.04 Blank RBRVS

88300 TC LEVEL I SURG PATHOLOGY GROSS EXAMINATION ONLY Pathology a Blank 0.33 0.33 Blank RBRVS

88302 Blank LEVEL II SURG PATHOLOGY GROSS&MICROSCOPIC EXAM Pathology a 0.13 0.73 0.73 Blank RBRVS

88302 26 LEVEL II SURG PATHOLOGY GROSS&MICROSCOPIC EXAM Pathology Blank 0.13 0.07 0.07 Blank RBRVS

88302 TC LEVEL II SURG PATHOLOGY GROSS&MICROSCOPIC EXAM Pathology a Blank 0.66 0.66 Blank RBRVS

88304 Blank LEVEL III SURG PATHOLOGY GROSS&MICROSCOPIC EXAM Pathology a 0.22 0.92 0.92 Blank RBRVS

88304 26 LEVEL III SURG PATHOLOGY GROSS&MICROSCOPIC EXAM Pathology Blank 0.22 0.11 0.11 Blank RBRVS





PAGE 109 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

88304 TC LEVEL III SURG PATHOLOGY GROSS&MICROSCOPIC EXAM Pathology a Blank 0.81 0.81 Blank RBRVS

88305 Blank LEVEL IV SURG PATHOLOGY GROSS&MICROSCOPIC EXAM Pathology a 0.75 1.17 1.17 Blank RBRVS

88305 26 LEVEL IV SURG PATHOLOGY GROSS&MICROSCOPIC EXAM Pathology Blank 0.75 0.34 0.34 Blank RBRVS

88305 TC LEVEL IV SURG PATHOLOGY GROSS&MICROSCOPIC EXAM Pathology a Blank 0.83 0.83 Blank RBRVS

88307 Blank LEVEL V SURG PATHOLOGY GROSS&MICROSCOPIC EXAM Pathology a 1.59 5.85 5.85 Blank RBRVS

88307 26 LEVEL V SURG PATHOLOGY GROSS&MICROSCOPIC EXAM Pathology Blank 1.59 0.81 0.81 Blank RBRVS

88307 TC LEVEL V SURG PATHOLOGY GROSS&MICROSCOPIC EXAM Pathology a Blank 5.04 5.04 Blank RBRVS

88309 Blank LEVEL VI SURG PATHOLOGY GROSS&MICROSCOPIC EXAM Pathology a 2.80 8.49 8.49 Blank RBRVS

88309 26 LEVEL VI SURG PATHOLOGY GROSS&MICROSCOPIC EXAM Pathology Blank 2.80 1.46 1.46 Blank RBRVS

88309 TC LEVEL VI SURG PATHOLOGY GROSS&MICROSCOPIC EXAM Pathology a Blank 7.03 7.03 Blank RBRVS

88311 Blank DECALCIFICATION PROCEDURE Pathology a 0.24 0.37 0.37 Blank RBRVS

88311 26 DECALCIFICATION PROCEDURE Pathology Blank 0.24 0.12 0.12 Blank RBRVS

88311 TC DECALCIFICATION PROCEDURE Pathology a Blank 0.25 0.25 Blank RBRVS

88312 Blank SPECIAL STAIN GROUP 1 MICROORGANISMS I&R Pathology a 0.54 2.20 2.20 Blank RBRVS

88312 26 SPECIAL STAIN GROUP 1 MICROORGANISMS I&R Pathology Blank 0.54 0.23 0.23 Blank RBRVS

88312 TC SPECIAL STAIN GROUP 1 MICROORGANISMS I&R Pathology a Blank 1.97 1.97 Blank RBRVS

88313 Blank SPCL STN 2 I&R EXCPT MICROORG/ENZYME/IMCYT Pathology a 0.24 1.74 1.74 Blank RBRVS

88313 26 SPCL STN 2 I&R EXCPT MICROORG/ENZYME/IMCYT Pathology Blank 0.24 0.10 0.10 Blank RBRVS

88313 TC SPCL STN 2 I&R EXCPT MICROORG/ENZYME/IMCYT Pathology a Blank 1.64 1.64 Blank RBRVS

88314 Blank SPECIAL STAIN I&R HISTOCHEMICAL W/FROZEN TISSU Pathology a 0.45 1.95 1.95 Blank RBRVS

88314 26 SPECIAL STAIN I&R HISTOCHEMICAL W/FROZEN TISSU Pathology Blank 0.45 0.20 0.20 Blank RBRVS

88314 TC SPECIAL STAIN I&R HISTOCHEMICAL W/FROZEN TISSU Pathology a Blank 1.75 1.75 Blank RBRVS

88319 Blank SPECIAL STAIN I&R GROUP III ENZYME CONSITUENTS Pathology a 0.53 1.95 1.95 Blank RBRVS

88319 26 SPECIAL STAIN I&R GROUP III ENZYME CONSITUENTS Pathology Blank 0.53 0.24 0.24 Blank RBRVS

88319 TC SPECIAL STAIN I&R GROUP III ENZYME CONSITUENTS Pathology a Blank 1.71 1.71 Blank RBRVS

88321 Blank CONSLTJ&REPRT SLIDES PREPARED ELSEWHERE Pathology Blank 1.63 0.74 1.21 Blank RBRVS

88323 Blank CONSLTJ&REPRT MATERIAL REQUIRING PREPJ SLIDES Pathology a 1.83 1.60 1.60 Blank RBRVS

88323 26 CONSLTJ&REPRT MATERIAL REQUIRING PREPJ SLIDES Pathology Blank 1.83 0.68 0.68 Blank RBRVS

88323 TC CONSLTJ&REPRT MATERIAL REQUIRING PREPJ SLIDES Pathology a Blank 0.92 0.92 Blank RBRVS

88325 Blank CONSLTJ COMPRE REVIEW REPRT REFERRED MATRL Pathology Blank 2.85 1.38 2.28 Blank RBRVS

88329 Blank PATHOLOGY CONSULTATION DURING SURGERY Pathology Blank 0.67 0.35 0.77 Blank RBRVS

88331 Blank PATH CONSLTJ SURG 1ST BLK FROZEN SCTJ 1 SPEC Pathology a 1.19 1.54 1.54 Blank RBRVS

88331 26 PATH CONSLTJ SURG 1ST BLK FROZEN SCTJ 1 SPEC Pathology Blank 1.19 0.63 0.63 Blank RBRVS

88331 TC PATH CONSLTJ SURG 1ST BLK FROZEN SCTJ 1 SPEC Pathology a Blank 0.91 0.91 Blank RBRVS

88332 Blank PATH CONSLTJ SURG EA ADDL BLK FROZEN SECTION Pathology a 0.59 0.90 0.90 Blank RBRVS

88332 26 PATH CONSLTJ SURG EA ADDL BLK FROZEN SECTION Pathology Blank 0.59 0.31 0.31 Blank RBRVS

88332 TC PATH CONSLTJ SURG EA ADDL BLK FROZEN SECTION Pathology a Blank 0.59 0.59 Blank RBRVS

88333 Blank PATH CONSLTJ SURG CYTOLOGIC EXAM INITIAL SITE Pathology a 1.20 1.31 1.31 Blank RBRVS

88333 26 PATH CONSLTJ SURG CYTOLOGIC EXAM INITIAL SITE Pathology Blank 1.20 0.62 0.62 Blank RBRVS

88333 TC PATH CONSLTJ SURG CYTOLOGIC EXAM INITIAL SITE Pathology a Blank 0.69 0.69 Blank RBRVS

88334 Blank PATH CONSLTJ SURG CYTOLOGIC EXAM ADDL SITE Pathology a 0.73 0.83 0.83 Blank RBRVS

88334 26 PATH CONSLTJ SURG CYTOLOGIC EXAM ADDL SITE Pathology Blank 0.73 0.38 0.38 Blank RBRVS

88334 TC PATH CONSLTJ SURG CYTOLOGIC EXAM ADDL SITE Pathology a Blank 0.45 0.45 Blank RBRVS

88341 Blank IMHISTOCHEM/CYTCHM EA ADDL ANTIBODY SLIDE Pathology a 0.56 2.06 2.06 Blank RBRVS

88341 26 IMHISTOCHEM/CYTCHM EA ADDL ANTIBODY SLIDE Pathology Blank 0.56 0.26 0.26 Blank RBRVS

88341 TC IMHISTOCHEM/CYTCHM EA ADDL ANTIBODY SLIDE Pathology a Blank 1.80 1.80 Blank RBRVS

88342 Blank IMHISTOCHEM/CYTCHM 1ST ANTIBODY STAIN PROCEDURE Pathology a 0.70 2.37 2.37 Blank RBRVS

88342 26 IMHISTOCHEM/CYTCHM 1ST ANTIBODY STAIN PROCEDURE Pathology Blank 0.70 0.32 0.32 Blank RBRVS

88342 TC IMHISTOCHEM/CYTCHM 1ST ANTIBODY STAIN PROCEDURE Pathology a Blank 2.05 2.05 Blank RBRVS

88344 Blank IMHISTOCHEM/CYTCHM EA MULTIPLEX ANTIBODY SLIDE Pathology a 0.77 4.16 4.16 Blank RBRVS

88344 26 IMHISTOCHEM/CYTCHM EA MULTIPLEX ANTIBODY SLIDE Pathology Blank 0.77 0.35 0.35 Blank RBRVS

88344 TC IMHISTOCHEM/CYTCHM EA MULTIPLEX ANTIBODY SLIDE Pathology a Blank 3.81 3.81 Blank RBRVS

88346 Blank IMMUNOFLUORESCENCE PER SPEC 1ST SINGL ANTB STAIN Pathology a 0.74 1.90 1.90 Blank RBRVS

88346 26 IMMUNOFLUORESCENCE PER SPEC 1ST SINGL ANTB STAIN Pathology Blank 0.74 0.30 0.30 Blank RBRVS

88346 TC IMMUNOFLUORESCENCE PER SPEC 1ST SINGL ANTB STAIN Pathology a Blank 1.60 1.60 Blank RBRVS

88348 Blank ELECTRON MICROSCOPY DIAGNOSTIC Pathology a 1.51 8.25 8.25 Blank RBRVS

88348 26 ELECTRON MICROSCOPY DIAGNOSTIC Pathology Blank 1.51 0.68 0.68 Blank RBRVS

88348 TC ELECTRON MICROSCOPY DIAGNOSTIC Pathology a Blank 7.57 7.57 Blank RBRVS

88350 Blank IMMUNOFLUORESCENCE PER SPEC ADD SINGL ANTB STAIN Pathology a 0.59 1.45 1.45 Blank RBRVS

88350 26 IMMUNOFLUORESCENCE PER SPEC ADD SINGL ANTB STAIN Pathology Blank 0.59 0.24 0.24 Blank RBRVS

88350 TC IMMUNOFLUORESCENCE PER SPEC ADD SINGL ANTB STAIN Pathology a Blank 1.21 1.21 Blank RBRVS

88355 Blank MORPHOMETRIC ANALYSIS SKELETAL MUSCLE Pathology a 1.85 1.86 1.86 Blank RBRVS

88355 26 MORPHOMETRIC ANALYSIS SKELETAL MUSCLE Pathology Blank 1.85 0.52 0.52 Blank RBRVS

88355 TC MORPHOMETRIC ANALYSIS SKELETAL MUSCLE Pathology a Blank 1.34 1.34 Blank RBRVS

88356 Blank MORPHOMETRIC ANALYSIS NERVE Pathology a 2.80 3.38 3.38 Blank RBRVS

88356 26 MORPHOMETRIC ANALYSIS NERVE Pathology Blank 2.80 0.75 0.75 Blank RBRVS

88356 TC MORPHOMETRIC ANALYSIS NERVE Pathology a Blank 2.63 2.63 Blank RBRVS

88358 Blank MORPHOMETRIC ANALYSIS TUMOR Pathology a 0.95 1.71 1.71 Blank RBRVS

88358 26 MORPHOMETRIC ANALYSIS TUMOR Pathology Blank 0.95 0.39 0.39 Blank RBRVS

88358 TC MORPHOMETRIC ANALYSIS TUMOR Pathology a Blank 1.32 1.32 Blank RBRVS

88360 Blank M/PHMTRC ALYS TUMOR IMHCHEM EA ANTIBODY MANUAL Pathology a 0.85 2.91 2.91 Blank RBRVS

88360 26 M/PHMTRC ALYS TUMOR IMHCHEM EA ANTIBODY MANUAL Pathology Blank 0.85 0.43 0.43 Blank RBRVS





PAGE 110 of 144

CPT/

HCPCS

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Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

88360 TC M/PHMTRC ALYS TUMOR IMHCHEM EA ANTIBODY MANUAL Pathology a Blank 2.48 2.48 Blank RBRVS

88361 Blank M/PHMTRC ALYS TUMOR IMHCHEM EA ANTBDY CMPTR ASST Pathology a 0.95 3.14 3.14 Blank RBRVS

88361 26 M/PHMTRC ALYS TUMOR IMHCHEM EA ANTBDY CMPTR ASST Pathology Blank 0.95 0.41 0.41 Blank RBRVS

88361 TC M/PHMTRC ALYS TUMOR IMHCHEM EA ANTBDY CMPTR ASST Pathology a Blank 2.73 2.73 Blank RBRVS

88362 Blank NERVE TEASING PREPARATIONS Pathology a 2.17 3.67 3.67 Blank RBRVS

88362 26 NERVE TEASING PREPARATIONS Pathology Blank 2.17 0.98 0.98 Blank RBRVS

88362 TC NERVE TEASING PREPARATIONS Pathology a Blank 2.69 2.69 Blank RBRVS

88363 Blank EXAM & SELECT ARCHIVE TISSUE MOLECULAR ANALYSI Pathology Blank 0.37 0.19 0.29 Blank RBRVS

88364 Blank IN SITU HYBRIDIZATION EA ADDL PROBE STAIN Pathology a 0.70 3.02 3.02 Blank RBRVS

88364 26 IN SITU HYBRIDIZATION EA ADDL PROBE STAIN Pathology Blank 0.70 0.30 0.30 Blank RBRVS

88364 TC IN SITU HYBRIDIZATION EA ADDL PROBE STAIN Pathology a Blank 2.72 2.72 Blank RBRVS

88365 Blank IN SITU HYBRIDIZATION 1ST PROBE STAIN Pathology a 0.88 4.19 4.19 Blank RBRVS

88365 26 IN SITU HYBRIDIZATION 1ST PROBE STAIN Pathology Blank 0.88 0.39 0.39 Blank RBRVS

88365 TC IN SITU HYBRIDIZATION 1ST PROBE STAIN Pathology a Blank 3.80 3.80 Blank RBRVS

88366 Blank IN SITU HYBRIDIZATION EA MULTIPLEX PROBE STAIN Pathology a 1.24 6.17 6.17 Blank RBRVS

88366 26 IN SITU HYBRIDIZATION EA MULTIPLEX PROBE STAIN Pathology Blank 1.24 0.55 0.55 Blank RBRVS

88366 TC IN SITU HYBRIDIZATION EA MULTIPLEX PROBE STAIN Pathology a Blank 5.62 5.62 Blank RBRVS

88367 Blank M/PHMTRC ALYS ISH CPTR-ASST TECH 1ST PROBE STAIN Pathology a 0.73 2.29 2.29 Blank RBRVS

88367 26 M/PHMTRC ALYS ISH CPTR-ASST TECH 1ST PROBE STAIN Pathology Blank 0.73 0.27 0.27 Blank RBRVS

88367 TC M/PHMTRC ALYS ISH CPTR-ASST TECH 1ST PROBE STAIN Pathology a Blank 2.02 2.02 Blank RBRVS

88368 Blank M/PHMTRC ALYS IN SITU HYBRIDIZATION EA PROBE MNL Pathology a 0.88 2.52 2.52 Blank RBRVS

88368 26 M/PHMTRC ALYS IN SITU HYBRIDIZATION EA PROBE MNL Pathology Blank 0.88 0.31 0.31 Blank RBRVS

88368 TC M/PHMTRC ALYS IN SITU HYBRIDIZATION EA PROBE MNL Pathology a Blank 2.21 2.21 Blank RBRVS

88369 Blank M/PHMTRC ALYS ISH QUANT/SEMIQ MNL PER SPEC EACH Pathology a 0.70 2.38 2.38 Blank RBRVS

88369 26 M/PHMTRC ALYS ISH QUANT/SEMIQ MNL PER SPEC EACH Pathology Blank 0.70 0.23 0.23 Blank RBRVS

88369 TC M/PHMTRC ALYS ISH QUANT/SEMIQ MNL PER SPEC EACH Pathology a Blank 2.15 2.15 Blank RBRVS

88371 26 PROTEIN ANAL TISSUE WESTERN BLOT W/INTERP&REPO Pathology Blank 0.37 0.14 0.14 Blank RBRVS

88372 26 PROTEIN ALYS WSTRN BLOT I&R IMMUNOLOGICAL EA Pathology Blank 0.37 0.14 0.14 Blank RBRVS

88373 Blank M/PHMTRC ALYS ISH QUANT/SEMIQ CPTR PER SPEC EACH Pathology a 0.58 1.64 1.64 Blank RBRVS

88373 26 M/PHMTRC ALYS ISH QUANT/SEMIQ CPTR PER SPEC EACH Pathology Blank 0.58 0.21 0.21 Blank RBRVS

88373 TC M/PHMTRC ALYS ISH QUANT/SEMIQ CPTR PER SPEC EACH Pathology a Blank 1.43 1.43 Blank RBRVS

88374 Blank M/PHMTRC ALYS ISH QUANT/SEMIQ CPTR EACH MULTIPRB Pathology a 0.93 8.81 8.81 Blank RBRVS

88374 26 M/PHMTRC ALYS ISH QUANT/SEMIQ CPTR EACH MULTIPRB Pathology Blank 0.93 0.34 0.34 Blank RBRVS

88374 TC M/PHMTRC ALYS ISH QUANT/SEMIQ CPTR EACH MULTIPRB Pathology a Blank 8.47 8.47 Blank RBRVS

88377 Blank M/PHMTRC ALYS ISH QUANT/SEMIQ MNL EACH MULTIPRB Pathology a 1.40 10.16 10.16 Blank RBRVS

88377 26 M/PHMTRC ALYS ISH QUANT/SEMIQ MNL EACH MULTIPRB Pathology Blank 1.40 0.44 0.44 Blank RBRVS

88377 TC M/PHMTRC ALYS ISH QUANT/SEMIQ MNL EACH MULTIPRB Pathology a Blank 9.72 9.72 Blank RBRVS

88380 Blank MICRODISSECTION PREP IDENTIFIED TARGET LASER Pathology a 1.14 2.71 2.71 Blank RBRVS

88380 26 MICRODISSECTION PREP IDENTIFIED TARGET LASER Pathology Blank 1.14 0.44 0.44 Blank RBRVS

88380 TC MICRODISSECTION PREP IDENTIFIED TARGET LASER Pathology a Blank 2.27 2.27 Blank RBRVS

88381 Blank MICRODISSECTION PREP IDENTIFIED TARGET MANUAL Pathology a 0.53 2.91 2.91 Blank RBRVS

88381 26 MICRODISSECTION PREP IDENTIFIED TARGET MANUAL Pathology Blank 0.53 0.19 0.19 Blank RBRVS

88381 TC MICRODISSECTION PREP IDENTIFIED TARGET MANUAL Pathology a Blank 2.72 2.72 Blank RBRVS

88387 Blank MACRO EXAM DISSECT&PREP TISS NONMICRO STD EA Pathology a 0.62 0.34 0.34 Blank RBRVS

88387 26 MACRO EXAM DISSECT&PREP TISS NONMICRO STD EA Pathology Blank 0.62 0.18 0.18 Blank RBRVS

88387 TC MACRO EXAM DISSECT&PREP TISS NONMICRO STD EA Pathology a Blank 0.16 0.16 Blank RBRVS

88388 Blank MACR EXM DISS&PRP NONMICR IMPRNT/CONSLT/FRZ SE Pathology a 0.45 0.51 0.51 Blank RBRVS

88388 26 MACR EXM DISS&PRP NONMICR IMPRNT/CONSLT/FRZ SE Pathology Blank 0.45 0.24 0.24 Blank RBRVS

88388 TC MACR EXM DISS&PRP NONMICR IMPRNT/CONSLT/FRZ SE Pathology a Blank 0.27 0.27 Blank RBRVS

89049 Blank CAFFEINE HALOTHANE CONTRACTURE TEST Pathology Blank 1.40 0.24 5.36 Blank RBRVS

89060 26 CRYSTAL ID LIGHT MICROSCOPY ALYS TISS/ANY FLUID Pathology Blank 0.37 0.14 0.14 Blank RBRVS

89220 Blank SPUTUM OBTAINING SPEC AEROSOL INDUCED TX SPX Pathology a Blank 0.45 0.45 Blank RBRVS

89230 Blank SWEAT COLLECTION IONTOPHORESIS Pathology a Blank 0.09 0.09 Blank RBRVS

90281 Blank IMMUNE GLOBULIN IG HUMAN IM USE Therapeutic Injections Blank Blank Blank Blank 0.59 FAIR Health

90283 Blank IMMUNE GLOBULIN IGIV HUMAN IV USE Therapeutic Injections Blank Blank Blank Blank 1.36 FAIR Health

90284 Blank IMMUNE GLOBULIN HUMAN SUBQ INFUSION 100 MG EA Therapeutic Injections Blank Blank Blank Blank 0.28 v3.23

90287 Blank BOTULINUM ANTITOXIN EQUINE ANY ROUTE Therapeutic Injections Blank Blank Blank Blank 0.16 v3.23

90291 Blank CYTOMEGALOVIRUS IMMUNE GLOBULIN HUMAN IV Therapeutic Injections Blank Blank Blank Blank 1.26 FAIR Health

90296 Blank DIPHTHERIA ANTITOXIN EQUINE ANY ROUTE Therapeutic Injections Blank Blank Blank Blank 0.45 v3.23

90371 Blank HEPATITIS B IMMUNE GLOBULIN HBIG HUMAN IM Therapeutic Injections Blank Blank Blank Blank 3.18 FAIR Health

90375 Blank RABIES IMMUNE GLOBULIN RIG HUMAN IM/SUBQ Therapeutic Injections Blank Blank Blank Blank 4.59 FAIR Health

90376 Blank RABIES IG HEAT-TREATED HUMAN IM/SUBQ Therapeutic Injections Blank Blank Blank Blank 3.54 FAIR Health

90378 Blank RESPIRATORY SYNCYTIAL VIRUS IG IM 50 MG E Therapeutic Injections Blank Blank Blank Blank 20.24 FAIR Health

90384 Blank RHO(D) IMMUNE GLOBULIN HUMAN FULL-DOSE IM Therapeutic Injections Blank Blank Blank Blank 1.64 FAIR Health

90385 Blank RHO(D) IMMUNE GLOBULIN HUMAN MINI-DOSE IM Therapeutic Injections Blank Blank Blank Blank 0.69 FAIR Health

90386 Blank RHO(D) IMMUNE GLOBULIN HUMAN IV Therapeutic Injections Blank Blank Blank Blank 2.03 FAIR Health

90389 Blank TETANUS IMMUNE GLOBULIN TIG HUMAN IM Therapeutic Injections Blank Blank Blank Blank 1.29 FAIR Health

90396 Blank VARICELLA-ZOSTER IMMUNE GLOBULIN HUMAN IM Therapeutic Injections Blank Blank Blank Blank 2.99 FAIR Health

90399 Blank UNLISTED IMMUNE GLOBULIN Therapeutic Injections Blank Blank Blank Blank 1.36 Unlisted

90460 Blank IM ADM THRU 18YR ANY RTE 1ST/ONLY COMPT VAC/TOX Immunizations Blank 0.17 0.40 0.40 Blank RBRVS

90461 Blank IM ADM THRU 18YR ANY RTE ADDL VAC/TOX COMPT Immunizations Blank 0.15 0.20 0.20 Blank RBRVS

90471 Blank IM ADM PRQ ID SUBQ/IM NJXS 1 VACCINE Immunizations Blank 0.17 0.40 0.40 Blank RBRVS





PAGE 111 of 144

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Work

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Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

90472 Blank IM ADM PRQ ID SUBQ/IM NJXS EA VACCINE Immunizations Blank 0.15 0.20 0.20 Blank RBRVS

90473 Blank IM ADM INTRANSL/ORAL 1 VACCINE Immunizations Blank 0.17 0.40 0.40 Blank RBRVS

90474 Blank IM ADM INTRANSL/ORAL EA VACCINE Immunizations Blank 0.15 0.20 0.20 Blank RBRVS

90476 Blank ADENOVIRUS VACCINE TYPE 4 LIVE ORAL Immunizations Blank Blank Blank Blank 0.40 FAIR Health

90477 Blank ADENOVIRUS VACCINE TYPE 7 LIVE FOR ORAL Immunizations Blank Blank Blank Blank 0.25 v3.23

90581 Blank ANTHRAX VACCINE SUBCUTANEOUS/IM USE Immunizations Blank Blank Blank Blank 3.50 ERBRVS

90585 Blank BACILLUS CALMETTE-GUERIN VACC FOR TB LIVE PERQ Immunizations Blank Blank Blank Blank 3.11 FAIR Health

90586 Blank BACILLUS CALMETTE-GUERIN VACCINE INTRAVESICAL Immunizations Blank Blank Blank Blank 3.84 FAIR Health

90620 Blank MENB RECOMBINANT PROT W/OUT MEMBR VESIC VACC IM Immunizations Blank Blank Blank Blank 3.62 FAIR Health

90621 Blank MENB RECOMBINANT LIPOPROTEIN VACCINE IM Immunizations Blank Blank Blank Blank 2.74 FAIR Health

90625 Blank CHOLERA VACCINE ADULT 1 DOSE LIVE FOR ORAL USE Immunizations Blank Blank Blank Blank 4.06 FAIR Health

90630 Blank INFLUENZA VACC IIV4 SPLIT VIRUS PRSRV FREE ID Immunizations Blank Blank Blank Blank 0.89 FAIR Health

90632 Blank HEPA VACCINE ADULT DOSE FOR INTRAMUSCULAR USE Immunizations Blank Blank Blank Blank 1.41 FAIR Health

90633 Blank HEPA VACCINE 2 DOSE SCHEDULE PED/ADOLESC IM USE Immunizations Blank Blank Blank Blank 0.86 FAIR Health

90634 Blank HEPA VACCINE 3 DOSE SCHEDULE PED/ADOLESC IM USE Immunizations Blank Blank Blank Blank 1.04 FAIR Health

90636 Blank HEPATITIS A & B VACCINE HEPA-HEPB ADULT IM Immunizations Blank Blank Blank Blank 2.07 FAIR Health

90644 Blank HIB-MENCY VACC 4 DOSE SCHEDULE 2-18 MONTHS IM Immunizations Blank Blank Blank Blank 1.09 FAIR Health

90647 Blank HIB PRP-OMP VACCINE 3 DOSE SCHEDULE IM USE Immunizations Blank Blank Blank Blank 0.72 FAIR Health

90648 Blank HIB PRP-T VACCINE 4 DOSE SCHEDULE IM USE Immunizations Blank Blank Blank Blank 0.69 FAIR Health

90649 Blank 4VHPV VACCINE 3 DOSE SCHEDULE FOR IM USE Immunizations Blank Blank Blank Blank 3.02 FAIR Health



90653 Blank IIV ADJUVANTED VACCINE FOR INTRAMUSCULAR USE Immunizations Blank Blank Blank Blank 0.73 FAIR Health

90654 Blank INFLUENZA VACC IIV3 SPLIT VIRUS PRSRV FREE ID Immunizations Blank Blank Blank Blank 0.46 FAIR Health

90655 Blank IIV3 VACC PRESRV FREE CHILD 6-35 MONTHS IM USE Immunizations Blank Blank Blank Blank 0.44 FAIR Health

90656 Blank IIV3 VACC PRESERVATIVE FREE 3 YRS & OLDER IM USE Immunizations Blank Blank Blank Blank 0.34 FAIR Health

90657 Blank IIV3 VACCINE TO CHILD 6-35 MONTHS FOR IM USE Immunizations Blank Blank Blank Blank 0.39 FAIR Health

90658 Blank IIV3 VACCINE 3 YRS & OLDER FOR IM USE Immunizations Blank Blank Blank Blank 0.37 FAIR Health

90660 Blank LAIV3 VACCINE LIVE FOR INTRANASAL USE Immunizations Blank Blank Blank Blank 0.61 FAIR Health

90661 Blank CCIIV3 VACCINE PRESERVATIVE FREE FOR IM USE Immunizations Blank Blank Blank Blank 0.51 FAIR Health

90662 Blank IIV VACCINE PRESERV FREE INCREASED AG COUNT IM Immunizations Blank Blank Blank Blank 0.74 FAIR Health

90664 Blank LAIV VACCINE PANDEMIC FORMULA FOR INTRANASAL USE Immunizations Blank Blank Blank Blank 0.70 v3.23

90666 Blank INFLUENZA VACCINE PANDEMIC SPLT PRSRV FREE IM Immunizations Blank Blank Blank Blank 0.61 FAIR Health

90667 Blank IIV VACCINE PANDEMIC ADJUVANT FOR IM USE Immunizations Blank Blank Blank Blank 0.44 v3.23

90668 Blank IIV VACCINE PANDEMIC FOR INTRAMUSCULAR USE Immunizations Blank Blank Blank Blank 0.49 FAIR Health

90670 Blank PCV13 VACCINE FOR INTRAMUSCULAR USE Immunizations Blank Blank Blank Blank 3.09 FAIR Health

90672 Blank LAIV4 VACCINE FOR INTRANASAL USE Immunizations Blank Blank Blank Blank 0.73 FAIR Health

90673 Blank RIV3 VACCINE PRESERVATIVE FREE FOR IM USE Immunizations Blank Blank Blank Blank 0.72 FAIR Health

90674 Blank CCIIV4 VAC NO PRSV 0.5 ML IM Immunizations Blank Blank Blank Blank 0.45 FAIR Health

90675 Blank RABIES VACCINE INTRAMUSCULAR Immunizations Blank Blank Blank Blank 4.48 FAIR Health

90676 Blank RABIES VACCINE INTRADERMAL Immunizations Blank Blank Blank Blank 3.47 FAIR Health

90680 Blank RV5 VACCINE 3 DOSE SCHEDULE LIVE FOR ORAL USE Immunizations Blank Blank Blank Blank 1.62 FAIR Health

90681 Blank RV1 VACCINE 2 DOSE SCHEDULE LIVE FOR ORAL USE Immunizations Blank Blank Blank Blank 2.15 FAIR Health

90682 Blank RIV4 VACC RECOMBINANT DNA IM Immunizations Blank Blank Blank Blank 0.80 FAIR Health

90685 Blank IIV4 PRESRV FREE VACC CHILD 6-35 MO FOR IM USE Immunizations Blank Blank Blank Blank 0.51 FAIR Health

90686 Blank IIV4 VACC PRESRV FREE 3 YRS & OLDER IM USE Immunizations Blank Blank Blank Blank 0.46 FAIR Health

90687 Blank IIV4 VACCINE CHILD 6-35 MO FOR IM USE Immunizations Blank Blank Blank Blank 0.42 FAIR Health

90688 Blank IIV4 VACCINE 3 YRS & OLDER FOR IM USE Immunizations Blank Blank Blank Blank 0.43 FAIR Health

90690 Blank TYPHOID VACCINE LIVE ORAL Immunizations Blank Blank Blank Blank 1.00 FAIR Health

90691 Blank TYPHOID VACCINE VI CAPSULAR POLYSACCHARIDE IM Immunizations Blank Blank Blank Blank 1.46 FAIR Health

90696 Blank DTAP-IPV VACCINE CHILD 4-6 YRS FOR IM USE Immunizations Blank Blank Blank Blank 1.27 FAIR Health

90697 Blank DTAP-IPV-HIB-HEPB VACCINE INTRAMUSCULAR Immunizations Blank Blank Blank Blank 1.36 FAIR Health

90698 Blank DTAP-IPV/HIB VACCINE FOR INTRAMUSCULAR USE Immunizations Blank Blank Blank Blank 1.73 FAIR Health

90700 Blank DIPHTH TETANUS TOX ACELL PERTUSSIS VACC<7 YR IM Immunizations Blank Blank Blank Blank 0.70 FAIR Health

90702 Blank DT VACCINE YOUNGER THAN 7 YRS FOR IM USE Immunizations Blank Blank Blank Blank 0.61 FAIR Health

90707 Blank MEASLES MUMPS RUBELLA VIRUS VACCINE LIVE SUBQ Immunizations Blank Blank Blank Blank 1.21 FAIR Health

90710 Blank MEASLES MUMPS RUBELLA VARICELLA VACC LIVE SUBQ Immunizations Blank Blank Blank Blank 3.18 FAIR Health

90713 Blank POLIOVIRUS VACCINE INACTIVATED SUBQ/IM Immunizations Blank Blank Blank Blank 0.72 FAIR Health

90714 Blank TD VACCINE PRSRV FREE 7 YRS OR OLDER FOR IM USE Immunizations Blank Blank Blank Blank 0.61 FAIR Health

90715 Blank TDAP VACCINE 7 YRS/> IM Immunizations Blank Blank Blank Blank 0.94 FAIR Health

90716 Blank VAR VACCINE LIVE FOR SUBCUTANEOUS USE Immunizations Blank Blank Blank Blank 1.94 FAIR Health

90717 Blank YELLOW FEVER VACCINE LIVE SUBQ Immunizations Blank Blank Blank Blank 2.19 FAIR Health

90723 Blank DTAP-HEPB-IPV VACCINE INTRAMUSCULAR Immunizations Blank Blank Blank Blank 1.72 FAIR Health

90732 Blank PPSV23 VACCINE 2 YRS OR OLDER FOR SUBQ/IM USE Immunizations Blank Blank Blank Blank 1.58 FAIR Health

90733 Blank MPSV4 VACCINE GROUPS ACYW-135 SUBQ USE Immunizations Blank Blank Blank Blank 2.25 FAIR Health

90734 Blank MENACWY CONJUGATE VACCINE GROUPS ACYW-135 IM USE Immunizations Blank Blank Blank Blank 2.20 FAIR Health

90736 Blank ZOSTER VACCINE HZV LIVE FOR SUBCUTANEOUS USE Immunizations Blank Blank Blank Blank 3.50 FAIR Health

90738 Blank JAPANESE ENCEPHALITIS VACCINE INACTIVATED IM Immunizations Blank Blank Blank Blank 3.94 FAIR Health

90739 Blank HEPB VACCINE ADULT 2 DOSE SCHEDULE FOR IM USE Immunizations Blank Blank Blank Blank 1.40 FAIR Health

90740 Blank HEPB VACCINE DIALYSIS/IMMUNSUP PAT 3 DOSE IM Immunizations Blank Blank Blank Blank 4.25 FAIR Health

90743 Blank HEPB VACCINE ADOLESCENT 2 DOSE SCHEDULE IM Immunizations Blank Blank Blank Blank 1.14 FAIR Health

90744 Blank HEPB VACCINE PED/ADOLESC 3 DOSE SCHEDULE IM Immunizations Blank Blank Blank Blank 0.78 FAIR Health





PAGE 112 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

90746 Blank HEPB VACCINE ADULT 3 DOSE SCHEDULE FOR IM USE Immunizations Blank Blank Blank Blank 1.43 FAIR Health

90747 Blank HEPB VACCINE DIALYSIS/IMMUNSUP PAT 4 DOSE IM Immunizations Blank Blank Blank Blank 5.57 FAIR Health

90748 Blank HIB-HEPB VACCINE FOR INTRAMUSCULAR USE Immunizations Blank Blank Blank Blank 1.21 FAIR Health

90749 Blank UNLISTED VACCINE/TOXOID Immunizations Blank Blank Blank Blank 0.57 Unlisted

90750 Blank HZV VACC RECOMBINANT IM Immunizations Blank Blank Blank Blank 2.75 FAIR Health

90756 Blank CCIIV4 VACC ABX FREE IM Immunizations Blank Blank Blank Blank 0.52 FAIR Health

90785 Blank PSYCHOTHERAPY COMPLEX INTERACTIVE OP Psych./Alc. & Drug Abuse Blank 0.33 0.05 0.07 Blank RBRVS

90791 Blank PSYCHIATRIC DIAGNOSTIC EVALUATION OP Psych./Alc. & Drug Abuse Blank 3.00 0.45 0.68 Blank RBRVS

90792 Blank PSYCHIATRIC DIAGNOSTIC EVAL W/MEDICAL SERVICES OP Psych./Alc. & Drug Abuse Blank 3.25 0.61 0.84 Blank RBRVS

90832 Blank PSYCHOTHERAPY PATIENT &/ FAMILY 30 MINUTES OP Psych./Alc. & Drug Abuse Blank 1.50 0.22 0.29 Blank RBRVS

90833 Blank PSYCHOTHERAPY PT&/FAMILY W/E&M SRVCS 30 MIN OP Psych./Alc. & Drug Abuse Blank 1.50 0.28 0.35 Blank RBRVS





90839 Blank PSYCHOTHERAPY FOR CRISIS INITIAL 60 MINUTES OP Psych./Alc. & Drug Abuse Blank 3.13 0.46 0.61 Blank RBRVS

90840 Blank PSYCHOTHERAPY FOR CRISIS EACH ADDL 30 MINUTES OP Psych./Alc. & Drug Abuse Blank 1.50 0.22 0.29 Blank RBRVS

90845 Blank PSYCHOANALYSIS OP Psych./Alc. & Drug Abuse Blank 2.10 0.36 0.46 Blank RBRVS

90846 Blank FAMILY PSYCHOTHERAPY W/O PATIENT PRESENT OP Psych./Alc. & Drug Abuse Blank 2.40 0.37 0.48 Blank RBRVS

90847 Blank FAMILY PSYCHOTHERAPY W/PATIENT PRESENT OP Psych./Alc. & Drug Abuse Blank 2.50 0.39 0.50 Blank RBRVS

90849 Blank MULTIPLE FAMILY GROUP PSYCHOTHERAPY OP Psych./Alc. & Drug Abuse Blank 0.59 0.27 0.42 Blank RBRVS

90853 Blank GROUP PSYCHOTHERAPY OP Psych./Alc. & Drug Abuse Blank 0.59 0.09 0.13 Blank RBRVS

90863 Blank PHARMACOLOGIC MANAGEMENT W/PSYCHOTHERAPY OP Psych./Alc. & Drug Abuse Blank 0.48 0.19 0.23 Blank RBRVS

90865 Blank NARCOSYNTHESIS PSYC DX&THER PURPOSES OP Psych./Alc. & Drug Abuse Blank 2.84 0.67 1.79 Blank RBRVS

90867 Blank REPET TMS TX INITIAL W/MAP/MOTR THRESHLD/DEL&M OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 7.73 FAIR Health

90868 Blank THERAP REPETITIVE TMS TX SUBSEQ DELIVERY & MNG OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 6.03 FAIR Health

90869 Blank REPET TMS TX SUBSEQ MOTR THRESHLD W/DELIV & MN OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 8.67 FAIR Health

90870 Blank ELECTROCONVULSIVE THERAPY OP Psych./Alc. & Drug Abuse Blank 2.50 0.53 2.36 Blank RBRVS

90875 Blank INDIV PSYCHOPHYS BIOFEED TRAIN W/PSYTX 30 MIN OP Psych./Alc. & Drug Abuse Blank 1.20 0.47 0.50 Blank RBRVS

90876 Blank INDIV PSYCHOPHYS BIOFEED TRAIN W/PSYTX 45 MIN OP Psych./Alc. & Drug Abuse Blank 1.90 0.73 1.06 Blank RBRVS

90880 Blank HYPNOTHERAPY OP Psych./Alc. & Drug Abuse Blank 2.19 0.33 0.66 Blank RBRVS

90882 Blank ENVIRONMENTAL IVNTJ MGMT PURPOSES PSYC PT OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 1.16 FAIR Health

90885 Blank PSYCHIATRIC EVAL HOSPITAL RECORDS DX PURPOSES OP Psych./Alc. & Drug Abuse Blank 0.97 0.38 0.38 Blank RBRVS

90887 Blank INTERPJ/EXPLNAJ RESULTS PSYCHIATRIC EXAM FAMILY OP Psych./Alc. & Drug Abuse Blank 1.48 0.58 0.93 Blank RBRVS

90889 Blank PREP REPORT PT PSYCH STATUS AGENCY/PAYER OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 1.60 FAIR Health

90899 Blank UNLISTED PSYCHIATRIC SERVICE/PROCEDURE OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 1.85 Unlisted

90901 Blank BIOFEEDBACK TRAINING ANY MODALITY Miscellaneous Medical Blank 0.41 0.13 0.69 Blank RBRVS

90911 Blank BIOFDBK TRNG PERINL MUSC ANORECT/URO SPHX W/EMG Miscellaneous Medical Blank 0.89 0.32 1.51 Blank RBRVS

90935 Blank HEMODIALYSIS PROCEDURE W/ PHYS/QHP EVALUATION Miscellaneous Medical Blank 1.48 0.49 0.49 Blank RBRVS

90937 Blank HEMODIALYSIS PX REPEAT EVAL W/WO REVJ DIALYS RX Miscellaneous Medical Blank 2.11 0.71 0.71 Blank RBRVS

90940 Blank HEMODIALYSIS ACCESS FLOW STUDY Miscellaneous Medical Blank Blank Blank Blank 0.77 FAIR Health

90945 Blank DIALYSIS OTHER/THAN HEMODIALYSIS 1 PHYS/QHP EVAL Miscellaneous Medical Blank 1.56 0.77 0.77 Blank RBRVS

90947 Blank DIALYSIS OTH/THN HEMODIALY REPEAT PHYS/QHP EVALS Miscellaneous Medical Blank 2.52 0.83 0.83 Blank RBRVS

90951 Blank ESRD RELATED SVC MONTHLY & <2 YR OLD 4/> VISITS Miscellaneous Medical Blank 18.46 7.06 7.06 Blank RBRVS

90952 Blank ESRD RELATED SVC MONTHLY <2 YR OLD 2/3 VISITS Miscellaneous Medical Blank Blank Blank Blank 19.81 ERBRVS

90953 Blank ESRD RELATED SVC MONTHLY <2 YR OLD 1 VISIT Miscellaneous Medical Blank Blank Blank Blank 13.21 ERBRVS

90954 Blank ESRD RELATED SVC MONTHLY 2-11 YR OLD 4/> VISITS Miscellaneous Medical Blank 15.98 6.05 6.05 Blank RBRVS

90955 Blank ESRD RELATED SVC MONTHLY 2-11 YR OLD 2/3 VISITS Miscellaneous Medical Blank 8.79 3.61 3.61 Blank RBRVS

90956 Blank ESRD RELATED SVC MONTHLY 2-11 YR OLD 1 VISIT Miscellaneous Medical Blank 5.95 2.68 2.68 Blank RBRVS

90957 Blank ESRD RELATED SVC MONTHLY 12-19 YR OLD 4/> VISITS Miscellaneous Medical Blank 12.52 4.92 4.92 Blank RBRVS

90958 Blank ESRD RELATED SVC MONTHLY 12-19 YR OLD 2/3 VISITS Miscellaneous Medical Blank 8.34 3.51 3.51 Blank RBRVS

90959 Blank ESRD RELATED SVC MONTHLY 12-19 YR OLD 1 VISIT Miscellaneous Medical Blank 5.50 2.56 2.56 Blank RBRVS

90960 Blank ESRD RELATED SVC MONTHLY 20&/> YR OLD 4/> VISITS Miscellaneous Medical Blank 5.18 2.54 2.54 Blank RBRVS

90961 Blank ESRD RELATED SVC MONTHLY 20/>YR OLD 2/3 VISITS Miscellaneous Medical Blank 4.26 2.23 2.23 Blank RBRVS

90962 Blank ESRD RELATED SVC MONTHLY 20&/>YR OLD 1 VISIT Miscellaneous Medical Blank 3.15 1.88 1.88 Blank RBRVS

90963 Blank ESRD SVC HOME DIALYSIS FULL MONTH <2YR OLD Miscellaneous Medical Blank 10.56 4.24 4.24 Blank RBRVS

90964 Blank ESRD SVC HOME DIALYSIS FULL MONTH 2-11 YR OLD Miscellaneous Medical Blank 9.14 3.78 3.78 Blank RBRVS

90965 Blank ESRD SVC HOME DIALYSIS FULL MONTH 12-19 YR OLD Miscellaneous Medical Blank 8.69 3.61 3.61 Blank RBRVS

90966 Blank ESRD SVC HOME DIALYSIS FULL MONTH 20 YR OLD Miscellaneous Medical Blank 4.26 2.22 2.22 Blank RBRVS

90967 Blank ESRD RELATED SVC <FULL MONTH <2 YR OLD Miscellaneous Medical Blank 0.35 0.14 0.14 Blank RBRVS

90968 Blank ESRD RELATED SVC <FULL MONTH 2-11 YR OLD Miscellaneous Medical Blank 0.30 0.12 0.12 Blank RBRVS

90969 Blank ESRD RELATED SVC <FULL MONTH 12-19 YR OLD Miscellaneous Medical Blank 0.29 0.12 0.12 Blank RBRVS

90970 Blank ESRD RELATED SVC <FULL MONTH 20/>YR OLD Miscellaneous Medical Blank 0.14 0.07 0.07 Blank RBRVS

90989 Blank DIALYSIS TRAINING PATIENT COMPLETED COURSE Miscellaneous Medical Blank Blank Blank Blank 10.40 FAIR Health

90993 Blank DIALYSIS TRAINING PATIENT PER TRAINING SESSION Miscellaneous Medical Blank Blank Blank Blank 6.64 FAIR Health

90997 Blank HEMOPERFUSION Miscellaneous Medical Blank 1.84 0.58 0.58 Blank RBRVS

90999 Blank UNLISTED DIALYSIS PROCEDURE INPATIENT/OUTPATIENT Miscellaneous Medical Blank Blank Blank Blank 2.68 Unlisted

91010 Blank ESOPHAGEAL MOTILITY STUDY W/INTERP&RPT Miscellaneous Medical a 1.28 3.66 3.66 Blank RBRVS

91010 26 ESOPHAGEAL MOTILITY STUDY W/INTERP&RPT Miscellaneous Medical Blank 1.28 0.55 0.55 Blank RBRVS

91010 TC ESOPHAGEAL MOTILITY STUDY W/INTERP&RPT Miscellaneous Medical a Blank 3.11 3.11 Blank RBRVS

91013 Blank ESOPHAGEAL MOTILITY STD W/I&R STIM/PERFUSION Miscellaneous Medical a 0.18 0.53 0.53 Blank RBRVS

91013 26 ESOPHAGEAL MOTILITY STD W/I&R STIM/PERFUSION Miscellaneous Medical Blank 0.18 0.08 0.08 Blank RBRVS





PAGE 113 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

91013 TC ESOPHAGEAL MOTILITY STD W/I&R STIM/PERFUSION Miscellaneous Medical a Blank 0.45 0.45 Blank RBRVS

91020 Blank GASTRIC MOTILITY MANOMETRIC STUDIES Miscellaneous Medical a 1.44 5.18 5.18 Blank RBRVS

91020 26 GASTRIC MOTILITY MANOMETRIC STUDIES Miscellaneous Medical Blank 1.44 0.64 0.64 Blank RBRVS

91020 TC GASTRIC MOTILITY MANOMETRIC STUDIES Miscellaneous Medical a Blank 4.54 4.54 Blank RBRVS

91022 Blank DUODENAL MOTILITY MANOMETRIC STUDY Miscellaneous Medical a 1.44 3.30 3.30 Blank RBRVS

91022 26 DUODENAL MOTILITY MANOMETRIC STUDY Miscellaneous Medical Blank 1.44 0.64 0.64 Blank RBRVS

91022 TC DUODENAL MOTILITY MANOMETRIC STUDY Miscellaneous Medical a Blank 2.66 2.66 Blank RBRVS

91030 Blank ESOPHAGUS ACID PERFUSION TEST ESOPHAGITIS Miscellaneous Medical a 0.91 2.94 2.94 Blank RBRVS

91030 26 ESOPHAGUS ACID PERFUSION TEST ESOPHAGITIS Miscellaneous Medical Blank 0.91 0.41 0.41 Blank RBRVS

91030 TC ESOPHAGUS ACID PERFUSION TEST ESOPHAGITIS Miscellaneous Medical a Blank 2.53 2.53 Blank RBRVS

91034 Blank GASTROESOPHAG REFLX TEST W/CATH PH ELTRD PLCMT Miscellaneous Medical a 0.97 4.30 4.30 Blank RBRVS

91034 26 GASTROESOPHAG REFLX TEST W/CATH PH ELTRD PLCMT Miscellaneous Medical Blank 0.97 0.41 0.41 Blank RBRVS

91034 TC GASTROESOPHAG REFLX TEST W/CATH PH ELTRD PLCMT Miscellaneous Medical a Blank 3.89 3.89 Blank RBRVS

91035 Blank GASTROESOPHAG REFLX TEST W/TELEMTRY PH ELTRD Miscellaneous Medical a 1.59 11.99 11.99 Blank RBRVS

91035 26 GASTROESOPHAG REFLX TEST W/TELEMTRY PH ELTRD Miscellaneous Medical Blank 1.59 0.68 0.68 Blank RBRVS

91035 TC GASTROESOPHAG REFLX TEST W/TELEMTRY PH ELTRD Miscellaneous Medical a Blank 11.31 11.31 Blank RBRVS

91037 Blank GASTROESOPHAG REFLX TEST W/INTRLUML IMPED ELTRD Miscellaneous Medical a 0.97 3.56 3.56 Blank RBRVS

91037 26 GASTROESOPHAG REFLX TEST W/INTRLUML IMPED ELTRD Miscellaneous Medical Blank 0.97 0.42 0.42 Blank RBRVS

91037 TC GASTROESOPHAG REFLX TEST W/INTRLUML IMPED ELTRD Miscellaneous Medical a Blank 3.14 3.14 Blank RBRVS

91038 Blank ESOPHGL FUNCJ G-ESOP RFLX IMPD ELTRD PROLNG Miscellaneous Medical a 1.10 11.59 11.59 Blank RBRVS

91038 26 ESOPHGL FUNCJ G-ESOP RFLX IMPD ELTRD PROLNG Miscellaneous Medical Blank 1.10 0.48 0.48 Blank RBRVS

91038 TC ESOPHGL FUNCJ G-ESOP RFLX IMPD ELTRD PROLNG Miscellaneous Medical a Blank 11.11 11.11 Blank RBRVS

91040 Blank ESOPHGL BALO DISTENSION DX STD W/PROVOCATION Miscellaneous Medical a 0.97 11.72 11.72 Blank RBRVS

91040 26 ESOPHGL BALO DISTENSION DX STD W/PROVOCATION Miscellaneous Medical Blank 0.97 0.38 0.38 Blank RBRVS

91040 TC ESOPHGL BALO DISTENSION DX STD W/PROVOCATION Miscellaneous Medical a Blank 11.34 11.34 Blank RBRVS

91065 Blank BREATH HYDROGEN/METHANE TEST Miscellaneous Medical a 0.20 1.83 1.83 Blank RBRVS

91065 26 BREATH HYDROGEN/METHANE TEST Miscellaneous Medical Blank 0.20 0.08 0.08 Blank RBRVS

91065 TC BREATH HYDROGEN/METHANE TEST Miscellaneous Medical a Blank 1.75 1.75 Blank RBRVS

91110 Blank GI IMAG INTRALUMINAL ESOPHAGUS-ILEUM W/I&R Miscellaneous Medical a 2.49 23.12 23.12 Blank RBRVS

91110 26 GI IMAG INTRALUMINAL ESOPHAGUS-ILEUM W/I&R Miscellaneous Medical Blank 2.49 1.09 1.09 Blank RBRVS

91110 TC GI IMAG INTRALUMINAL ESOPHAGUS-ILEUM W/I&R Miscellaneous Medical a Blank 22.03 22.03 Blank RBRVS

91111 Blank GASTROINTESTINAL TRACT IMAGING ESOPHAGUS W/I&R Miscellaneous Medical a 1.00 20.14 20.14 Blank RBRVS

91111 26 GASTROINTESTINAL TRACT IMAGING ESOPHAGUS W/I&R Miscellaneous Medical Blank 1.00 0.44 0.44 Blank RBRVS

91111 TC GASTROINTESTINAL TRACT IMAGING ESOPHAGUS W/I&R Miscellaneous Medical a Blank 19.70 19.70 Blank RBRVS

91112 Blank GI TRANSIT & PRES MEAS WIRELESS CAPSULE W/INTERP Miscellaneous Medical a 2.10 28.32 28.32 Blank RBRVS

91112 26 GI TRANSIT & PRES MEAS WIRELESS CAPSULE W/INTERP Miscellaneous Medical Blank 2.10 0.92 0.92 Blank RBRVS

91112 TC GI TRANSIT & PRES MEAS WIRELESS CAPSULE W/INTERP Miscellaneous Medical a Blank 27.40 27.40 Blank RBRVS

91117 Blank COLON MOTILITY STDY MIN 6 HR CONT RECORD W/I&R Miscellaneous Medical Blank 2.45 1.36 1.36 Blank RBRVS

91120 Blank RECTAL SESATION TONE & COMPLIANCE TEST Miscellaneous Medical a 0.97 11.06 11.06 Blank RBRVS

91120 26 RECTAL SESATION TONE & COMPLIANCE TEST Miscellaneous Medical Blank 0.97 0.39 0.39 Blank RBRVS

91120 TC RECTAL SESATION TONE & COMPLIANCE TEST Miscellaneous Medical a Blank 10.67 10.67 Blank RBRVS

91122 Blank ANORECTAL MANOMETRY Miscellaneous Medical a 1.77 4.64 4.64 Blank RBRVS

91122 26 ANORECTAL MANOMETRY Miscellaneous Medical Blank 1.77 0.69 0.69 Blank RBRVS

91122 TC ANORECTAL MANOMETRY Miscellaneous Medical a Blank 3.95 3.95 Blank RBRVS

91132 Blank ELECTROGASTROGRAPHY DX TRANSCUTANEOUS Miscellaneous Medical a 0.52 3.73 3.73 Blank RBRVS

91132 26 ELECTROGASTROGRAPHY DX TRANSCUTANEOUS Miscellaneous Medical Blank 0.52 0.23 0.23 Blank RBRVS

91132 TC ELECTROGASTROGRAPHY DX TRANSCUTANEOUS Miscellaneous Medical a Blank 3.50 3.50 Blank RBRVS

91133 Blank ELECTROGASTROGRAPHY DX TRANSCUT W/PROVOCTVE TSTG Miscellaneous Medical a 0.66 4.22 4.22 Blank RBRVS

91133 26 ELECTROGASTROGRAPHY DX TRANSCUT W/PROVOCTVE TSTG Miscellaneous Medical Blank 0.66 0.29 0.29 Blank RBRVS

91133 TC ELECTROGASTROGRAPHY DX TRANSCUT W/PROVOCTVE TSTG Miscellaneous Medical a Blank 3.93 3.93 Blank RBRVS

91200 Blank LIVER ELASTOGRAPHY W/O IMAG W/I&R Radiology a 0.27 0.85 0.85 Blank RBRVS

91200 26 LIVER ELASTOGRAPHY W/O IMAG W/I&R Radiology Blank 0.27 0.12 0.12 Blank RBRVS

91200 TC LIVER ELASTOGRAPHY W/O IMAG W/I&R Radiology a Blank 0.73 0.73 Blank RBRVS

91299 Blank UNLISTED DIAGNOSTIC GASTROENTEROLOGY PROCEDURE Miscellaneous Medical a Blank Blank Blank 2.44 Unlisted

91299 26 UNLISTED DIAGNOSTIC GASTROENTEROLOGY PROCEDURE Miscellaneous Medical Blank Blank Blank Blank 0.69 Unlisted

91299 TC UNLISTED DIAGNOSTIC GASTROENTEROLOGY PROCEDURE Miscellaneous Medical a Blank Blank Blank 1.75 Unlisted

92002 Blank OPHTH MEDICAL XM&EVAL INTERMEDIATE NEW PT Vision Exams Blank 0.88 0.45 1.45 Blank RBRVS

92004 Blank OPHTH MEDICAL XM&EVAL COMPRE NEW PT 1/> VST Vision Exams Blank 1.82 0.93 2.38 Blank RBRVS

92012 Blank OPHTH MEDICAL XM&EVAL INTERMEDIATE ESTAB PT Vision Exams Blank 0.92 0.54 1.52 Blank RBRVS

92014 Blank OPHTH MEDICAL XM&EVAL COMPRHNSV ESTAB PT 1/> Vision Exams Blank 1.42 0.78 2.09 Blank RBRVS

92015 Blank DETERMINATION REFRACTIVE STATE Vision Exams Blank 0.38 0.15 0.16 Blank RBRVS

92018 Blank OPHTH XM&EVAL ANES W/WO MANJ GLOBE COMPL Miscellaneous Medical Blank 2.50 1.52 1.52 Blank RBRVS

92019 Blank OPHTH XM&EVAL ANES W/WO MANJ GLOBE LMTD Miscellaneous Medical Blank 1.31 0.70 0.70 Blank RBRVS

92020 Blank GONIOSCOPY SEPARATE PROCEDURE Miscellaneous Medical Blank 0.37 0.22 0.38 Blank RBRVS

92025 Blank COMPUTERIZED CORNEAL TOPOGRAPHY UNI/BI Miscellaneous Medical a 0.35 0.71 0.71 Blank RBRVS

92025 26 COMPUTERIZED CORNEAL TOPOGRAPHY UNI/BI Miscellaneous Medical Blank 0.35 0.21 0.21 Blank RBRVS

92025 TC COMPUTERIZED CORNEAL TOPOGRAPHY UNI/BI Miscellaneous Medical a Blank 0.50 0.50 Blank RBRVS

92060 Blank SENSORMOTOR XM W/MLT MEAS OCULAR DEVIJ W/I&R SPX Miscellaneous Medical a 0.69 1.13 1.13 Blank RBRVS

92060 26 SENSORMOTOR XM W/MLT MEAS OCULAR DEVIJ W/I&R SPX Miscellaneous Medical Blank 0.69 0.39 0.39 Blank RBRVS

92060 TC SENSORMOTOR XM W/MLT MEAS OCULAR DEVIJ W/I&R SPX Miscellaneous Medical a Blank 0.74 0.74 Blank RBRVS

92065 Blank ORTHOPTIC &/PLEOPTIC TRAINING W/MEDICAL DIRECTJ Miscellaneous Medical a 0.37 1.14 1.14 Blank RBRVS

92065 26 ORTHOPTIC &/PLEOPTIC TRAINING W/MEDICAL DIRECTJ Miscellaneous Medical Blank 0.37 0.13 0.13 Blank RBRVS





PAGE 114 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

92065 TC ORTHOPTIC &/PLEOPTIC TRAINING W/MEDICAL DIRECTJ Miscellaneous Medical a Blank 1.01 1.01 Blank RBRVS

92071 Blank FIT CONTACT LENS TX OCULAR SURFACE DISEASE Miscellaneous Medical Blank 0.61 0.33 0.44 Blank RBRVS

92072 Blank FITTING CONTACT LENS FOR MNGT OF KERATOCONUS Miscellaneous Medical Blank 1.97 0.83 1.73 Blank RBRVS

92081 Blank VISUAL FIELD XM UNI/BI W/INTERPRETJ LIMITED EXAM Miscellaneous Medical a 0.30 0.66 0.66 Blank RBRVS

92081 26 VISUAL FIELD XM UNI/BI W/INTERPRETJ LIMITED EXAM Miscellaneous Medical Blank 0.30 0.16 0.16 Blank RBRVS

92081 TC VISUAL FIELD XM UNI/BI W/INTERPRETJ LIMITED EXAM Miscellaneous Medical a Blank 0.50 0.50 Blank RBRVS

92082 Blank VISUAL FIELD XM UNI/BI W/INTERP INTERMED EXAM Miscellaneous Medical a 0.40 0.95 0.95 Blank RBRVS

92082 26 VISUAL FIELD XM UNI/BI W/INTERP INTERMED EXAM Miscellaneous Medical Blank 0.40 0.21 0.21 Blank RBRVS

92082 TC VISUAL FIELD XM UNI/BI W/INTERP INTERMED EXAM Miscellaneous Medical a Blank 0.74 0.74 Blank RBRVS

92083 Blank VISUAL FIELD XM UNI/BI W/INTERP EXTENDED EXAM Miscellaneous Medical a 0.50 1.30 1.30 Blank RBRVS

92083 26 VISUAL FIELD XM UNI/BI W/INTERP EXTENDED EXAM Miscellaneous Medical Blank 0.50 0.28 0.28 Blank RBRVS

92083 TC VISUAL FIELD XM UNI/BI W/INTERP EXTENDED EXAM Miscellaneous Medical a Blank 1.02 1.02 Blank RBRVS

92100 Blank SERIAL TONOMETRY SPX W/MLT MEAS INTRAOCULAR PRES Miscellaneous Medical Blank 0.61 0.34 1.67 Blank RBRVS

92132 Blank CMPTR OPHTHALMIC DX IMG ANT SEGMT W/I&R UNI/BI Miscellaneous Medical a 0.30 0.57 0.57 Blank RBRVS

92132 26 CMPTR OPHTHALMIC DX IMG ANT SEGMT W/I&R UNI/BI Miscellaneous Medical Blank 0.30 0.16 0.16 Blank RBRVS

92132 TC CMPTR OPHTHALMIC DX IMG ANT SEGMT W/I&R UNI/BI Miscellaneous Medical a Blank 0.41 0.41 Blank RBRVS

92133 Blank COMPUTERIZED OPHTHALMIC IMAGING OPTIC NERVE Miscellaneous Medical a 0.40 0.65 0.65 Blank RBRVS

92133 26 COMPUTERIZED OPHTHALMIC IMAGING OPTIC NERVE Miscellaneous Medical Blank 0.40 0.23 0.23 Blank RBRVS

92133 TC COMPUTERIZED OPHTHALMIC IMAGING OPTIC NERVE Miscellaneous Medical a Blank 0.42 0.42 Blank RBRVS

92134 Blank COMPUTERIZED OPHTHALMIC IMAGING RETINA Miscellaneous Medical a 0.45 0.71 0.71 Blank RBRVS

92134 26 COMPUTERIZED OPHTHALMIC IMAGING RETINA Miscellaneous Medical Blank 0.45 0.28 0.28 Blank RBRVS

92134 TC COMPUTERIZED OPHTHALMIC IMAGING RETINA Miscellaneous Medical a Blank 0.43 0.43 Blank RBRVS

92136 Blank OPH BMTRY PRTL COHER INTRFRMTRY IO LENS PWR CAL Miscellaneous Medical a 0.54 1.67 1.67 Blank RBRVS

92136 26 OPH BMTRY PRTL COHER INTRFRMTRY IO LENS PWR CAL Miscellaneous Medical Blank 0.54 0.34 0.34 Blank RBRVS

92136 TC OPH BMTRY PRTL COHER INTRFRMTRY IO LENS PWR CAL Miscellaneous Medical a Blank 1.33 1.33 Blank RBRVS

92145 Blank CORNEA HYSTERESIS DETERMIN IMPULSE STIMJ UNI/BI Miscellaneous Medical a 0.17 0.31 0.31 Blank RBRVS

92145 26 CORNEA HYSTERESIS DETERMIN IMPULSE STIMJ UNI/BI Miscellaneous Medical Blank 0.17 0.09 0.09 Blank RBRVS

92145 TC CORNEA HYSTERESIS DETERMIN IMPULSE STIMJ UNI/BI Miscellaneous Medical a Blank 0.22 0.22 Blank RBRVS

92225 Blank OPHTHALMOSCPY EXTENDED RETINAL DRAWING I&R 1ST Miscellaneous Medical Blank 0.38 0.22 0.38 Blank RBRVS

92226 Blank OPHTHALMOSCPY EXTENDED RETINAL DRAWING I&R SBS Miscellaneous Medical Blank 0.33 0.20 0.37 Blank RBRVS

92227 Blank REMOTE IMG DX RETINL DIS W/ALYS & REPORT UNI/B Miscellaneous Medical a Blank 0.41 0.41 Blank RBRVS

92228 Blank REMOTE IMAGING MGT RETINAL DISEASE W/I&R UNI/B Miscellaneous Medical a 0.37 0.57 0.57 Blank RBRVS

92228 26 REMOTE IMAGING MGT RETINAL DISEASE W/I&R UNI/B Miscellaneous Medical Blank 0.37 0.20 0.20 Blank RBRVS

92228 TC REMOTE IMAGING MGT RETINAL DISEASE W/I&R UNI/B Miscellaneous Medical a Blank 0.37 0.37 Blank RBRVS

92230 Blank FLUORESCEIN ANGIOSCOPY INTERPRETATION & REPORT Miscellaneous Medical Blank 0.60 0.31 1.01 Blank RBRVS

92235 Blank FLUORESCEIN ANGIOSCOPY INTERPRETATION & REPORT Miscellaneous Medical a 0.75 1.67 1.67 Blank RBRVS

92235 26 FLUORESCEIN ANGIOSCOPY INTERPRETATION & REPORT Miscellaneous Medical Blank 0.75 0.48 0.48 Blank RBRVS

92235 TC FLUORESCEIN ANGIOSCOPY INTERPRETATION & REPORT Miscellaneous Medical a Blank 1.19 1.19 Blank RBRVS

92240 Blank INDOCYANINE GREEN ANGIOGRAPHY W/INTERP & REPOR Miscellaneous Medical a 0.80 5.12 5.12 Blank RBRVS

92240 26 INDOCYANINE GREEN ANGIOGRAPHY W/INTERP & REPOR Miscellaneous Medical Blank 0.80 0.51 0.51 Blank RBRVS

92240 TC INDOCYANINE GREEN ANGIOGRAPHY W/INTERP & REPOR Miscellaneous Medical a Blank 4.61 4.61 Blank RBRVS

92242 Blank FLUORESCEIN ICG ANGIOGRAPHY Miscellaneous Medical a 0.95 5.51 5.51 Blank RBRVS

92242 26 FLUORESCEIN ICG ANGIOGRAPHY Miscellaneous Medical Blank 0.95 0.60 0.60 Blank RBRVS

92242 TC FLUORESCEIN ICG ANGIOGRAPHY Miscellaneous Medical a Blank 4.91 4.91 Blank RBRVS

92250 Blank FUNDUS PHOTOGRAPHY W/INTERPRETATION & REPORT Miscellaneous Medical a 0.40 1.20 1.20 Blank RBRVS

92250 26 FUNDUS PHOTOGRAPHY W/INTERPRETATION & REPORT Miscellaneous Medical Blank 0.40 0.21 0.21 Blank RBRVS

92250 TC FUNDUS PHOTOGRAPHY W/INTERPRETATION & REPORT Miscellaneous Medical a Blank 0.99 0.99 Blank RBRVS

92260 Blank OPHTHALMODYNAMOMETRY Miscellaneous Medical Blank 0.20 0.10 0.31 Blank RBRVS

92265 Blank NEEDLE OCULOGRAPHY 1/ XOC MUSC 1/BOTH EYE W/I&R Miscellaneous Medical a 0.81 1.67 1.67 Blank RBRVS

92265 26 NEEDLE OCULOGRAPHY 1/ XOC MUSC 1/BOTH EYE W/I&R Miscellaneous Medical Blank 0.81 0.52 0.52 Blank RBRVS

92265 TC NEEDLE OCULOGRAPHY 1/ XOC MUSC 1/BOTH EYE W/I&R Miscellaneous Medical a Blank 1.15 1.15 Blank RBRVS

92270 Blank ELECTRO-OCULOGRAPY W/INTERPRETATION & REPORT Miscellaneous Medical a 0.81 1.80 1.80 Blank RBRVS

92270 26 ELECTRO-OCULOGRAPY W/INTERPRETATION & REPORT Miscellaneous Medical Blank 0.81 0.34 0.34 Blank RBRVS

92270 TC ELECTRO-OCULOGRAPY W/INTERPRETATION & REPORT Miscellaneous Medical a Blank 1.46 1.46 Blank RBRVS

92273 Blank FULL FIELD ERG W/I&R Miscellaneous Medical a 0.69 3.07 3.07 Blank RBRVS

92273 26 FULL FIELD ERG W/I&R Miscellaneous Medical Blank 0.69 0.36 0.36 Blank RBRVS

92273 TC FULL FIELD ERG W/I&R Miscellaneous Medical a Blank 2.71 2.71 Blank RBRVS

92274 Blank MULTIFOCAL ERG W/I&R Miscellaneous Medical a 0.61 1.93 1.93 Blank RBRVS

92274 26 MULTIFOCAL ERG W/I&R Miscellaneous Medical Blank 0.61 0.32 0.32 Blank RBRVS

92274 TC MULTIFOCAL ERG W/I&R Miscellaneous Medical a Blank 1.61 1.61 Blank RBRVS

92283 Blank COLOR VISION XM EXTENDED ANOMALOSCOPE/EQUIV Miscellaneous Medical a 0.17 1.37 1.37 Blank RBRVS

92283 26 COLOR VISION XM EXTENDED ANOMALOSCOPE/EQUIV Miscellaneous Medical Blank 0.17 0.08 0.08 Blank RBRVS

92283 TC COLOR VISION XM EXTENDED ANOMALOSCOPE/EQUIV Miscellaneous Medical a Blank 1.29 1.29 Blank RBRVS

92284 Blank DARK ADAPTATION XM W/INTERPRETATION & REPORT Miscellaneous Medical a 0.24 1.52 1.52 Blank RBRVS

92284 26 DARK ADAPTATION XM W/INTERPRETATION & REPORT Miscellaneous Medical Blank 0.24 0.11 0.11 Blank RBRVS

92284 TC DARK ADAPTATION XM W/INTERPRETATION & REPORT Miscellaneous Medical a Blank 1.41 1.41 Blank RBRVS

92285 Blank XTRNL OCULAR PHOTOG W/I&R DOCMT MEDICAL PROGRE Miscellaneous Medical a 0.05 0.52 0.52 Blank RBRVS

92285 26 XTRNL OCULAR PHOTOG W/I&R DOCMT MEDICAL PROGRE Miscellaneous Medical Blank 0.05 0.03 0.03 Blank RBRVS

92285 TC XTRNL OCULAR PHOTOG W/I&R DOCMT MEDICAL PROGRE Miscellaneous Medical a Blank 0.49 0.49 Blank RBRVS

92286 Blank ANT SGM IMAGING W/MICROSCOPY ENDOTHELIAL ANALY Miscellaneous Medical a 0.40 0.67 0.67 Blank RBRVS

92286 26 ANT SGM IMAGING W/MICROSCOPY ENDOTHELIAL ANALY Miscellaneous Medical Blank 0.40 0.22 0.22 Blank RBRVS

92286 TC ANT SGM IMAGING W/MICROSCOPY ENDOTHELIAL ANALY Miscellaneous Medical a Blank 0.45 0.45 Blank RBRVS





PAGE 115 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

92287 Blank ANT SGM IMAGING W/FLUOROSCEIN ANGIO & I&R Miscellaneous Medical a 0.81 3.09 3.09 Blank RBRVS

92287 26 ANT SGM IMAGING W/FLUOROSCEIN ANGIO & I&R Miscellaneous Medical Blank 0.81 0.51 0.51 Blank RBRVS

92287 TC ANT SGM IMAGING W/FLUOROSCEIN ANGIO & I&R Miscellaneous Medical a Blank 2.58 2.58 Blank RBRVS

92310 Blank RX&FITG C-LENS SUPVJ CRNL LENS OU XCPT APHK Vision Exams Blank 1.17 0.46 1.52 Blank RBRVS

92311 Blank RX&FITG CONTACT CORNEAL LENS APHAKIA 1 EYE Miscellaneous Medical Blank 1.08 0.45 1.77 Blank RBRVS

92312 Blank RX&FITG CONTACT CORNEAL LENS APHAKIA BOTH EYES Miscellaneous Medical Blank 1.26 0.51 2.05 Blank RBRVS

92313 Blank RX&FITG CORNEOSCLERAL LENS Miscellaneous Medical Blank 0.92 0.37 1.79 Blank RBRVS

92314 Blank RX&FTG CONTACT CORNEAL LENS EYES XCPT APHAKIA Vision Exams Blank 0.69 0.27 1.57 Blank RBRVS

92315 Blank RX CONTACT CORNEAL LENS APHAKIA 1 EYE Miscellaneous Medical Blank 0.45 0.16 1.66 Blank RBRVS

92316 Blank RX CONTACT CORNEAL LENS APHAKIA BOTH EYES Miscellaneous Medical Blank 0.68 0.24 1.96 Blank RBRVS

92317 Blank RX CONTACT CORNEOSCLERAL LENS Miscellaneous Medical Blank 0.45 0.16 1.76 Blank RBRVS

92325 Blank MODIFICAJ CONTACT LENX SPX SUPVJ ADAPTATION Miscellaneous Medical Blank Blank 1.22 1.22 Blank RBRVS

92326 Blank REPLACEMENT CONTACT LENS Miscellaneous Medical Blank Blank 1.03 1.03 Blank RBRVS

92340 Blank FITTING SPECTACLES XCPT APHAKIA MONOFOCAL Miscellaneous Medical Blank 0.37 0.14 0.62 Blank RBRVS

92341 Blank FITTING SPECTACLES XCPT APHAKIA BIFOCAL Miscellaneous Medical Blank 0.47 0.18 0.66 Blank RBRVS

92342 Blank FITTING SPECTACLES XCPT APHAKIA MULTIFOCAL Miscellaneous Medical Blank 0.53 0.21 0.68 Blank RBRVS

92352 Blank FITTING SPECTACLE PROSTH APHAKIA MONOFOCAL Miscellaneous Medical Blank 0.37 0.14 0.76 Blank RBRVS

92353 Blank FITTING SPECTACLE PROSTH APHAKIA MULTIFOCAL Miscellaneous Medical Blank 0.50 0.19 0.81 Blank RBRVS

92354 Blank FITTING SPECTACLE MOUNTED LW VIS AID 1 ELMNT Miscellaneous Medical Blank Blank 0.38 0.38 Blank RBRVS

92355 Blank FITTING SPECTACLE MOUNTED LW VIS AID TLSCP Miscellaneous Medical Blank Blank 0.59 0.59 Blank RBRVS

92358 Blank PROSTHESIS SERVICE APHAKIA TEMPORARY Miscellaneous Medical Blank Blank 0.32 0.32 Blank RBRVS

92370 Blank RPR&REFITG SPECTACLES EXCEPT APHAKIA Miscellaneous Medical Blank 0.32 0.12 0.54 Blank RBRVS

92371 Blank RPR&REFITG SPECTACLE PROSTHESIS APHAKIA Miscellaneous Medical Blank Blank 0.32 0.32 Blank RBRVS

92499 Blank UNLIVSTED OPHTHALMOLOGICAL SERVICE/PROCEDURE Miscellaneous Medical a Blank Blank Blank 1.62 Unlisted

92499 26 UNLIVSTED OPHTHALMOLOGICAL SERVICE/PROCEDURE Miscellaneous Medical Blank Blank Blank Blank 0.63 Unlisted

92499 TC UNLIVSTED OPHTHALMOLOGICAL SERVICE/PROCEDURE Miscellaneous Medical a Blank Blank Blank 0.99 Unlisted

92502 Blank OTOLARYNGOLOGIC EXAM UNDER GENERAL ANESTHESIA Miscellaneous Medical Blank 1.51 1.12 1.12 Blank RBRVS

92504 Blank BINOCULAR MICROSCOPY SEPARATE DX PROCEDURE Miscellaneous Medical Blank 0.18 0.08 0.64 Blank RBRVS

92507 Blank TX SPEECH LANG VOICE COMMJ &/AUDITORY PROC IND Hearing/Speech Exams Blank 1.30 0.87 0.87 Blank RBRVS

92508 Blank TX SPEECH LANGUAGE VOICE COMMJ AUDITRY 2/>INDIV Hearing/Speech Exams Blank 0.33 0.31 0.31 Blank RBRVS

92511 Blank NASOPHARYNGOSCOPY W/ENDOSCOPE SPX Miscellaneous Medical Blank 0.61 0.42 2.44 Blank RBRVS

92512 Blank NASAL FUNCTION STUDIES Miscellaneous Medical Blank 0.55 0.22 1.09 Blank RBRVS

92516 Blank FACIAL NERVE FUNCTION STUDIES Miscellaneous Medical Blank 0.43 0.19 1.48 Blank RBRVS

92520 Blank LARYNGEAL FUNCTION STUDIES Miscellaneous Medical Blank 0.75 0.36 1.38 Blank RBRVS

92521 Blank EVALUATION OF SPEECH FLUENCY (STUTTER CLUTTER) Hearing/Speech Exams Blank 1.75 1.41 1.41 Blank RBRVS

92522 Blank EVALUATION OF SPEECH SOUND PRODUCTION ARTICULATE Hearing/Speech Exams Blank 1.50 1.02 1.02 Blank RBRVS

92523 Blank EVAL SPEECH SOUND PRODUCT LANGUAGE COMPREHENSION Hearing/Speech Exams Blank 3.00 2.49 2.49 Blank RBRVS

92524 Blank BEHAVIORAL & QUALIT ANALYSIS VOICE AND RESONANCE Hearing/Speech Exams Blank 1.50 0.92 0.92 Blank RBRVS

92526 Blank TX SWALLOWING DYSFUNCTION&/ORAL FUNCJ FEEDING Miscellaneous Medical Blank 1.34 1.04 1.04 Blank RBRVS

92531 Blank SPONTANEOUS NYSTAGMUS W/GAZE Miscellaneous Medical Blank Blank Blank Blank 0.58 FAIR Health

92532 Blank POSITIONAL NYSTAGMUS TEST Miscellaneous Medical Blank Blank Blank Blank 0.78 FAIR Health

92533 Blank CALORIC VESTIBULAR TEST EACH IRRIGATION Miscellaneous Medical Blank Blank Blank Blank 1.34 FAIR Health

92534 Blank OPTOKINETIC NYSTAGMUS TEST Miscellaneous Medical Blank Blank Blank Blank 0.70 FAIR Health

92537 Blank CALORIC VESTIBULAR TEST W/REC BI BITHERMAL Miscellaneous Medical a 0.60 0.52 0.52 Blank RBRVS

92537 26 CALORIC VESTIBULAR TEST W/REC BI BITHERMAL Miscellaneous Medical Blank 0.60 0.28 0.28 Blank RBRVS

92537 TC CALORIC VESTIBULAR TEST W/REC BI BITHERMAL Miscellaneous Medical a Blank 0.24 0.24 Blank RBRVS

92538 Blank CALORIC VESTIBULAR TEST W/REC BI MONOTHERMAL Miscellaneous Medical a 0.30 0.27 0.27 Blank RBRVS

92538 26 CALORIC VESTIBULAR TEST W/REC BI MONOTHERMAL Miscellaneous Medical Blank 0.30 0.14 0.14 Blank RBRVS

92538 TC CALORIC VESTIBULAR TEST W/REC BI MONOTHERMAL Miscellaneous Medical a Blank 0.13 0.13 Blank RBRVS

92540 Blank VSTBLR FUNCJ NYSTAG FOVL&PERPH STIMJ OSCIL TRK Miscellaneous Medical a 1.50 1.31 1.31 Blank RBRVS

92540 26 VSTBLR FUNCJ NYSTAG FOVL&PERPH STIMJ OSCIL TRK Miscellaneous Medical Blank 1.50 0.70 0.70 Blank RBRVS

92540 TC VSTBLR FUNCJ NYSTAG FOVL&PERPH STIMJ OSCIL TRK Miscellaneous Medical a Blank 0.61 0.61 Blank RBRVS

92541 Blank SPONTANEOUS NYSTAGMUS TEST Miscellaneous Medical a 0.40 0.28 0.28 Blank RBRVS

92541 26 SPONTANEOUS NYSTAGMUS TEST Miscellaneous Medical Blank 0.40 0.19 0.19 Blank RBRVS

92541 TC SPONTANEOUS NYSTAGMUS TEST Miscellaneous Medical a Blank 0.09 0.09 Blank RBRVS

92542 Blank POSITIONAL NYSTAGMUS TEST Miscellaneous Medical a 0.48 0.29 0.29 Blank RBRVS

92542 26 POSITIONAL NYSTAGMUS TEST Miscellaneous Medical Blank 0.48 0.21 0.21 Blank RBRVS

92542 TC POSITIONAL NYSTAGMUS TEST Miscellaneous Medical a Blank 0.08 0.08 Blank RBRVS

92544 Blank OPTKINETIC NYSTAG BIDIR/FOVEAL/PERIPH STIM W/REC Miscellaneous Medical a 0.27 0.19 0.19 Blank RBRVS

92544 26 OPTKINETIC NYSTAG BIDIR/FOVEAL/PERIPH STIM W/REC Miscellaneous Medical Blank 0.27 0.13 0.13 Blank RBRVS

92544 TC OPTKINETIC NYSTAG BIDIR/FOVEAL/PERIPH STIM W/REC Miscellaneous Medical a Blank 0.06 0.06 Blank RBRVS

92545 Blank OSCILLATING TRACKING TEST W/RECORDING Miscellaneous Medical a 0.25 0.18 0.18 Blank RBRVS

92545 26 OSCILLATING TRACKING TEST W/RECORDING Miscellaneous Medical Blank 0.25 0.12 0.12 Blank RBRVS

92545 TC OSCILLATING TRACKING TEST W/RECORDING Miscellaneous Medical a Blank 0.06 0.06 Blank RBRVS

92546 Blank SINUSOIDAL VERTICAL AXIS ROTATIONAL TESTING Miscellaneous Medical a 0.29 2.64 2.64 Blank RBRVS

92546 26 SINUSOIDAL VERTICAL AXIS ROTATIONAL TESTING Miscellaneous Medical Blank 0.29 0.13 0.13 Blank RBRVS

92546 TC SINUSOIDAL VERTICAL AXIS ROTATIONAL TESTING Miscellaneous Medical a Blank 2.51 2.51 Blank RBRVS

92547 Blank USE VERTICAL ELECTRODES Miscellaneous Medical a Blank 0.17 0.17 Blank RBRVS

92548 Blank COMPUTERIZED DYNAMIC POSTUROGRAPY Miscellaneous Medical a 0.50 2.27 2.27 Blank RBRVS

92548 26 COMPUTERIZED DYNAMIC POSTUROGRAPY Miscellaneous Medical Blank 0.50 0.22 0.22 Blank RBRVS

92548 TC COMPUTERIZED DYNAMIC POSTUROGRAPY Miscellaneous Medical a Blank 2.05 2.05 Blank RBRVS

92550 Blank TYMPANOMETRY AND REFLEX THRESHOLD MEASUREMENTS Hearing/Speech Exams Blank 0.35 0.24 0.24 Blank RBRVS





PAGE 116 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

92551 Blank SCREENING TEST PURE TONE AIR ONLY Hearing/Speech Exams Blank Blank 0.34 0.34 Blank RBRVS

92552 Blank PURE TONE AUDIOMETRY AIR ONLY Hearing/Speech Exams a Blank 0.89 0.89 Blank RBRVS

92553 Blank PURE TONE AUDIOMETRY AIR & BONE Hearing/Speech Exams a Blank 1.07 1.07 Blank RBRVS

92555 Blank SPEECH AUDIOMETRY THRESHOLD Hearing/Speech Exams a Blank 0.67 0.67 Blank RBRVS

92556 Blank SPEECH AUDIOMETRY THRESHOLD SPEECH RECOGNIJ Hearing/Speech Exams a Blank 1.07 1.07 Blank RBRVS

92557 Blank COMPRE AUDIOMETRY THRESHOLD EVAL SP RECOGNIJ Hearing/Speech Exams Blank 0.60 0.30 0.44 Blank RBRVS

92558 Blank EVOKED OTOACOUSTIC EMISSIONS SCREEN AUTO ANALYS Hearing/Speech Exams Blank 0.17 0.07 0.10 Blank RBRVS

92559 Blank AUDIOMETRIC TESTING GROUPS Hearing/Speech Exams Blank Blank Blank Blank 0.59 FAIR Health

92560 Blank BEKESY AUDIOMETRY SCREENING Hearing/Speech Exams Blank Blank Blank Blank 0.82 FAIR Health

92561 Blank BEKESY AUDIOMETRY DIAGNOSTIC Hearing/Speech Exams a Blank 1.09 1.09 Blank RBRVS

92562 Blank LOUDNESS BALANCE BINAURAL/MONAURAL Hearing/Speech Exams a Blank 1.31 1.31 Blank RBRVS

92563 Blank TONE DECAY TEST Hearing/Speech Exams a Blank 0.87 0.87 Blank RBRVS

92564 Blank SHORT INCREMENT SENSITIVITY INDEX Hearing/Speech Exams a Blank 0.73 0.73 Blank RBRVS

92565 Blank STENGER TEST PURE TONE Hearing/Speech Exams a Blank 0.43 0.43 Blank RBRVS

92567 Blank TYMPANOMETRY Hearing/Speech Exams Blank 0.20 0.10 0.20 Blank RBRVS

92568 Blank ACOUSTIC REFLEX THRESHOLD Hearing/Speech Exams Blank 0.29 0.13 0.14 Blank RBRVS

92570 Blank ACOUSTIC IMMIT TEST TYMPANOM/ACOUST REFLX/DECAY Hearing/Speech Exams Blank 0.55 0.27 0.33 Blank RBRVS

92571 Blank FILTERED SPEECH TEST Hearing/Speech Exams a Blank 0.77 0.77 Blank RBRVS

92572 Blank STAGGERED SPONDAIC WORD Hearing/Speech Exams a Blank 1.49 1.49 Blank RBRVS

92575 Blank SENSORINEURAL ACUITY LEVEL Hearing/Speech Exams a Blank 1.32 1.32 Blank RBRVS

92576 Blank SYNTHETIC SENTENCE IDENTIFICATION TEST Hearing/Speech Exams a Blank 1.06 1.06 Blank RBRVS

92577 Blank STENGER TEST SPEECH Hearing/Speech Exams a Blank 0.40 0.40 Blank RBRVS

92579 Blank VISUAL REINFORCEMENT AUDIOMETRY Hearing/Speech Exams Blank 0.70 0.36 0.57 Blank RBRVS

92582 Blank CONDITIONING PLAY AUDIOMETRY Hearing/Speech Exams a Blank 1.91 1.91 Blank RBRVS

92583 Blank SELECT PICTURE AUDIOMETRY Hearing/Speech Exams a Blank 1.39 1.39 Blank RBRVS

92584 Blank ELECTROCOCHLEOGRAPHY Hearing/Speech Exams a Blank 2.08 2.08 Blank RBRVS

92585 Blank AUDITORY EVOKED POTENTIALS COMPREHENSIVE Hearing/Speech Exams a 0.50 3.30 3.30 Blank RBRVS

92585 26 AUDITORY EVOKED POTENTIALS COMPREHENSIVE Hearing/Speech Exams Blank 0.50 0.24 0.24 Blank RBRVS

92585 TC AUDITORY EVOKED POTENTIALS COMPREHENSIVE Hearing/Speech Exams a Blank 3.06 3.06 Blank RBRVS

92586 Blank AUDITORY EVOKED POTENTIALS LIMITED Hearing/Speech Exams a Blank 2.51 2.51 Blank RBRVS

92587 Blank DISTORT PRODUCT EVOKED OTOACOUSTIC EMISNS LIMITD Hearing/Speech Exams a 0.35 0.24 0.24 Blank RBRVS

92587 26 DISTORT PRODUCT EVOKED OTOACOUSTIC EMISNS LIMITD Hearing/Speech Exams Blank 0.35 0.16 0.16 Blank RBRVS

92587 TC DISTORT PRODUCT EVOKED OTOACOUSTIC EMISNS LIMITD Hearing/Speech Exams a Blank 0.08 0.08 Blank RBRVS

92588 Blank DISTRT PROD EVOKD OTOACOUSTIC EMSNS COMP/DX EVAL Hearing/Speech Exams a 0.55 0.36 0.36 Blank RBRVS

92588 26 DISTRT PROD EVOKD OTOACOUSTIC EMSNS COMP/DX EVAL Hearing/Speech Exams Blank 0.55 0.26 0.26 Blank RBRVS

92588 TC DISTRT PROD EVOKD OTOACOUSTIC EMSNS COMP/DX EVAL Hearing/Speech Exams a Blank 0.10 0.10 Blank RBRVS

92590 Blank HEARING AID EXAMINATION & SELECTION MONAURAL Hearing/Speech Exams Blank Blank Blank Blank 1.68 FAIR Health

92591 Blank HEARING AID EXAMINATION & SELECTION BINAURAL Hearing/Speech Exams Blank Blank Blank Blank 2.14 FAIR Health

92592 Blank HEARING AID CHECK MONAURAL Hearing/Speech Exams Blank Blank Blank Blank 0.87 FAIR Health

92593 Blank HEARING AID CHECK BINAURAL Hearing/Speech Exams Blank Blank Blank Blank 1.14 FAIR Health

92594 Blank ELECTROACOUS EVAL HEARING AID MONAURAL Hearing/Speech Exams Blank Blank Blank Blank 0.88 FAIR Health

92595 Blank ELECTROACOUS EVAL HEARING AID BINAURAL Hearing/Speech Exams Blank Blank Blank Blank 1.27 FAIR Health

92596 Blank EAR PROTECTOR ATTENUATION MEASUREMENTS Hearing/Speech Exams a Blank 1.93 1.93 Blank RBRVS

92597 Blank EVAL&/FITG VOICE PROSTC DEV SUPLMNT ORAL SPEEC Hearing/Speech Exams Blank 1.26 0.71 0.71 Blank RBRVS

92601 Blank ANALYSIS COCHLEAR IMPLT PT <7 YR PRGRMG Miscellaneous Medical Blank 2.30 1.20 2.30 Blank RBRVS

92602 Blank ANALYSIS COCHLEAR IMPLT PT <7 YR SBSQ REPRGRMG Miscellaneous Medical Blank 1.30 0.69 1.56 Blank RBRVS

92603 Blank ANALYSIS COCHLEAR IMPLT 7 YR/> PRGRMG Miscellaneous Medical Blank 2.25 1.13 2.00 Blank RBRVS

92604 Blank ANALYSIS COCHLEAR IMPLT 7 YR/> SBSQ REPRGRMG Miscellaneous Medical Blank 1.25 0.64 1.27 Blank RBRVS

92605 Blank EVAL RX N-SP-GEN AUGMT ALT COMMUN DEV F2F 1ST HR Miscellaneous Medical Blank 1.75 0.68 0.79 Blank RBRVS

92606 Blank THER SVC N-SP-GENRATJ DEV PRGRMG&MODIFICAJ Miscellaneous Medical Blank 1.40 0.55 0.87 Blank RBRVS

92607 Blank RX SP-GENRATJ AUGMNT&COMUNICAJ DEV 1ST HR Miscellaneous Medical Blank 1.85 1.79 1.79 Blank RBRVS

92608 Blank RX SP-GENRATJ AUGMNT&COMUNICAJ DEV EA 30 MIN Miscellaneous Medical Blank 0.70 0.77 0.77 Blank RBRVS

92609 Blank THER SP-GENRATJ DEV PRGRMG&MODIFICAJ Miscellaneous Medical Blank 1.50 1.56 1.56 Blank RBRVS

92610 Blank EVAL ORAL&PHARYNGEAL SWLNG FUNCJ Miscellaneous Medical Blank 1.30 0.70 1.07 Blank RBRVS

92611 Blank MOTION FLUOR EVAL SWLNG FUNCJ C/V REC Miscellaneous Medical Blank 1.34 1.06 1.06 Blank RBRVS

92612 Blank FLX FIBOPT NDSC EVAL SWLNG C/V REC Miscellaneous Medical Blank 1.27 0.59 4.07 Blank RBRVS

92613 Blank FLX FIBOPT NDSC EVAL SWLNG C/V REC PHYS I&R Miscellaneous Medical Blank 0.71 0.32 0.32 Blank RBRVS

92614 Blank FLX FIBOPT NDSC EVAL LARYN SENS C/V REC Miscellaneous Medical Blank 1.27 0.54 2.74 Blank RBRVS

92615 Blank FLX FIBOPT NDSC EVAL LARYN SENS PHYS I&R Miscellaneous Medical Blank 0.63 0.27 0.27 Blank RBRVS

92616 Blank FLX FIBOPT NDSC EVAL SWLNG&LARYN SENS C/V REC Miscellaneous Medical Blank 1.88 0.83 3.86 Blank RBRVS

92617 Blank FLX FIBOPT NDSC EVAL SWLNG&LARYN SENS PHYS I&R Miscellaneous Medical Blank 0.79 0.33 0.34 Blank RBRVS

92618 Blank EVAL RX N-SP-GEN AUGMT ALT COMMUN DEV ADD 30 MIN Miscellaneous Medical Blank 0.65 0.25 0.27 Blank RBRVS

92620 Blank EVAL CENTRAL AUDITORY FUNCJ W/REPRT 1ST 60 MIN Miscellaneous Medical Blank 1.50 0.78 1.12 Blank RBRVS

92621 Blank EVAL CENTRAL AUDITORY FUNCJ W/REPRT EA 15 MIN Miscellaneous Medical Blank 0.35 0.18 0.28 Blank RBRVS

92625 Blank ASSESSMENT TINNITUS Miscellaneous Medical Blank 1.15 0.58 0.79 Blank RBRVS

92626 Blank EVALUATION AUDITORY REHAB STATUS 1ST HR Miscellaneous Medical Blank 1.40 0.71 1.10 Blank RBRVS

92627 Blank EVALUATION AUDITORY REHAB STATUS EA 15 MIN Miscellaneous Medical Blank 0.33 0.17 0.30 Blank RBRVS

92630 Blank AUDITORY REHABILITATION PRELINGUAL HEARING LOSS Miscellaneous Medical Blank Blank Blank Blank 1.90 FAIR Health

92633 Blank AUDITORY REHABILITATION POSTLINGUAL HEARING LOSS Miscellaneous Medical Blank Blank Blank Blank 1.61 FAIR Health

92640 Blank ANALYSIS W/PRGRMG AUD BRAINSTEM IMPLANT PR HR Miscellaneous Medical Blank 1.76 0.92 1.44 Blank RBRVS

92700 Blank UNLISTED OTORHINOLARYNGOLOGICAL SERVICE Miscellaneous Medical Blank Blank Blank Blank 0.98 Unlisted

92920 Blank PRQ TRLUML CORONARY ANGIOPLASTY ONE ART/BRANCH Surgery Blank 9.85 3.39 3.39 Blank RBRVS





PAGE 117 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

92921 Blank PRQ TRLUML CORONARY ANGIOPLASTY ADDL BRANCH Surgery Blank Blank Blank Blank 5.16 FAIR Health

92924 Blank PRQ TRLUML CORONARY ANGIO/ATHERECT ONE ART/BRNCH Surgery Blank 11.74 4.02 4.02 Blank RBRVS

92925 Blank PRQ TRLUML CORONARY ANGIO/ATHEREC ADDL ART/BRNCH Surgery Blank Blank Blank Blank 4.64 FAIR Health

92928 Blank PRQ TRLUML CORONARY STENT W/ANGIO ONE ART/BRNCH Surgery Blank 10.96 3.76 3.76 Blank RBRVS

92929 Blank PRQ TRLUML CORONARY STENT W/ANGIO ADDL ART/BRNCH Surgery Blank Blank Blank Blank 5.23 FAIR Health

92933 Blank PRQ TRLUML CORONRY STENT/ATH/ANGIO ONE ART/BRNCH Surgery Blank 12.29 4.21 4.21 Blank RBRVS

92934 Blank PRQ TRLUML CORONARY STENT/ATH/ANGIO ADDL BRANCH Surgery Blank Blank Blank Blank 4.76 FAIR Health

92937 Blank PRQ TRLUML CORONARY BYP GRFT REVASC ONE VESSEL Surgery Blank 10.95 3.75 3.75 Blank RBRVS

92938 Blank PRQ TRLUML CORONARY BYP GRFT REVASC ADDL VESSEL Surgery Blank Blank Blank Blank 6.56 FAIR Health

92941 Blank PRQ TRLUML CORONRY TOT OCCLUS REVASC MI ONE VSL Surgery Blank 12.31 4.22 4.22 Blank RBRVS

92943 Blank PRQ TRLUML CORONRY CHRONIC OCCLUS REVASC ONE VSL Surgery Blank 12.31 4.23 4.23 Blank RBRVS

92944 Blank PRQ TRLUML CORONRY CHRNIC OCCLUS REVASC ADDL VSL Surgery Blank Blank Blank Blank 7.17 FAIR Health

92950 Blank CARDIOPULMONARY RESUSCITATION Cardiovascular Blank 4.00 0.99 4.29 Blank RBRVS

92953 Blank TEMPORARY TRANSCUTANEOUS PACING Cardiovascular Blank 0.01 0.01 0.01 Blank RBRVS

92960 Blank CARDIOVERSION ELECTIVE ARRHYTHMIA EXTERNAL Cardiovascular Blank 2.00 1.00 2.39 Blank RBRVS

92961 Blank CARDIOVERSION ELECTIVE ARRHYTHMIA INTERNAL SPX Cardiovascular Blank 4.34 1.95 1.95 Blank RBRVS

92970 Blank CARDIOASSIST-METH CIRCULATORY ASSIST INTERNAL Cardiovascular Blank 3.51 1.41 1.41 Blank RBRVS

92971 Blank CARDIOASSIST-METH CIRCULATORY ASSIST EXTERNAL Cardiovascular Blank 1.77 0.75 0.75 Blank RBRVS

92973 Blank PRQ TRANSLUMINAL CORONARY MECHANICL THROMBECTOMY Surgery Blank 3.28 1.12 1.12 Blank RBRVS

92974 Blank TCAT PLACEMENT RADJ DLVR DEV SBSQ C IV BRACHYTX Surgery Blank 3.00 1.02 1.02 Blank RBRVS

92975 Blank THROMBOLYSIS INTRACORONARY NFS SLCTV ANGRPH Cardiovascular Blank 6.99 2.41 2.41 Blank RBRVS

92977 Blank THROMBOLYSIS CORONARY INTRAVENOUS INFUSION Cardiovascular Blank Blank 1.52 1.52 Blank RBRVS

92978 Blank INTRAVASC US CORONARY INTERP&RPT INITIAL VESSE Cardiovascular a Blank Blank Blank 7.45 Global/TC/26

92978 26 INTRAVASC US CORONARY INTERP&RPT INITIAL VESSE Cardiovascular Blank Blank Blank Blank 2.42 Global/TC/26

92978 TC INTRAVASC US CORONARY INTERP&RPT INITIAL VESSE Cardiovascular a Blank Blank Blank 5.03 Global/TC/26

92979 Blank INTRAVASC US CORONARY INTERP&RPT ADDL VESSEL Cardiovascular a Blank Blank Blank 3.99 Global/TC/26

92979 26 INTRAVASC US CORONARY INTERP&RPT ADDL VESSEL Cardiovascular Blank Blank Blank Blank 1.94 Global/TC/26

92979 TC INTRAVASC US CORONARY INTERP&RPT ADDL VESSEL Cardiovascular a Blank Blank Blank 2.05 Global/TC/26

92986 Blank PRQ BALLOON VALVULOPLASTY AORTIC VALVE Surgery Blank 22.60 10.58 10.58 Blank RBRVS

92987 Blank PRQ BALLOON VALVULOPLASTY MITRAL VALVE Surgery Blank 23.38 10.87 10.87 Blank RBRVS

92990 Blank PRQ BALLOON VALVULOPLASTY PULMONARY VALVE Surgery Blank 18.27 9.04 9.04 Blank RBRVS

92992 Blank ATRIAL SEPTECT/SEPTOST TRANSVENOUS BALLOON Surgery Blank Blank Blank Blank 37.72 FAIR Health

92993 Blank ATRIAL SEPTECT/SEPTOSTOMY BLADE METHOD Surgery Blank Blank Blank Blank 23.52 ERBRVS

92997 Blank PRQ TRLUML PULMONARY ART BALLOON ANGIOP 1 VSL Surgery Blank 11.98 4.27 4.27 Blank RBRVS

92998 Blank PRQ TRLUML PULMONARY ART BALLOON ANGIOP EA VSL Surgery Blank 5.99 2.04 2.04 Blank RBRVS

93000 Blank ECG ROUTINE ECG W/LEAST 12 LDS W/I&R Cardiovascular Blank 0.17 0.29 0.29 Blank RBRVS

93005 Blank ECG ROUTINE ECG W/LEAST 12 LDS TRCG ONLY W/O I&R Cardiovascular a Blank 0.23 0.23 Blank RBRVS

93010 Blank ECG ROUTINE ECG W/LEAST 12 LDS I&R ONLY Cardiovascular Blank 0.17 0.06 0.06 Blank RBRVS

93015 Blank CV STRS TST XERS&/OR RX CONT ECG W/SI&R Cardiovascular Blank 0.75 1.23 1.23 Blank RBRVS

93016 Blank CV STRS TST XERS&/OR RX CONT ECG W/O I&R Cardiovascular Blank 0.45 0.16 0.16 Blank RBRVS

93017 Blank CV STRS TST XERS&/OR RX CONT ECG TRCG ONLY Cardiovascular a Blank 0.96 0.96 Blank RBRVS

93018 Blank CV STRS TST XERS&/OR RX CONT ECG I&R ONLY Cardiovascular Blank 0.30 0.11 0.11 Blank RBRVS

93024 Blank ERGONOVINE PROVOCATION TST Cardiovascular a 1.17 1.93 1.93 Blank RBRVS

93024 26 ERGONOVINE PROVOCATION TST Cardiovascular Blank 1.17 0.41 0.41 Blank RBRVS

93024 TC ERGONOVINE PROVOCATION TST Cardiovascular a Blank 1.52 1.52 Blank RBRVS

93025 Blank MICROVOLT T-WAVE ASSESS VENTRICULAR ARRHYTHMIAS Cardiovascular a 0.75 3.84 3.84 Blank RBRVS

93025 26 MICROVOLT T-WAVE ASSESS VENTRICULAR ARRHYTHMIAS Cardiovascular Blank 0.75 0.27 0.27 Blank RBRVS

93025 TC MICROVOLT T-WAVE ASSESS VENTRICULAR ARRHYTHMIAS Cardiovascular a Blank 3.57 3.57 Blank RBRVS

93040 Blank RHYTHM ECG 1-3 LEADS W/INTERPRETATION & REPORT Cardiovascular Blank 0.15 0.19 0.19 Blank RBRVS

93041 Blank RHYTHM ECG 1-3 LEADS TRACING ONLY W/O I&R Cardiovascular a Blank 0.15 0.15 Blank RBRVS

93042 Blank RHYTHM ECG 1-3 LEADS INTERPRETATION & REPRT ON Cardiovascular Blank 0.15 0.04 0.04 Blank RBRVS

93050 Blank ART PRESS WAVEFORM ANALYS CENTRAL ART PRESSURE Cardiovascular a 0.17 0.28 0.28 Blank RBRVS

93050 26 ART PRESS WAVEFORM ANALYS CENTRAL ART PRESSURE Cardiovascular Blank 0.17 0.06 0.06 Blank RBRVS

93050 TC ART PRESS WAVEFORM ANALYS CENTRAL ART PRESSURE Cardiovascular a Blank 0.22 0.22 Blank RBRVS

93224 Blank XTRNL ECG & 48 HR RECORD SCAN STOR W/R&I Cardiovascular Blank 0.52 2.02 2.02 Blank RBRVS

93225 Blank XTRNL ECG & 48 HR RECORDING Cardiovascular a Blank 0.74 0.74 Blank RBRVS

93226 Blank EXTERNAL ECG SCANNING ANALYSIS REPORT Cardiovascular a Blank 1.06 1.06 Blank RBRVS

93227 Blank XTRNL ECG CONTINUOUS RHYTHM W/I&R UP TO 48 HRS Cardiovascular Blank 0.52 0.22 0.22 Blank RBRVS

93228 Blank XTRNL MOBILE CV TELEMETRY W/I&REPORT 30 DAYS Cardiovascular Blank 0.52 0.19 0.19 Blank RBRVS

93229 Blank XTRNL MOBILE CV TELEMETRY W/TECHNICAL SUPPORT Cardiovascular a Blank 20.59 20.59 Blank RBRVS

93260 Blank PRGRMG DEV EVAL IMPLANTABLE SUBQ LEAD DFB SYSTEM Cardiovascular a 0.85 0.96 0.96 Blank RBRVS

93260 26 PRGRMG DEV EVAL IMPLANTABLE SUBQ LEAD DFB SYSTEM Cardiovascular Blank 0.85 0.35 0.35 Blank RBRVS

93260 TC PRGRMG DEV EVAL IMPLANTABLE SUBQ LEAD DFB SYSTEM Cardiovascular a Blank 0.61 0.61 Blank RBRVS

93261 Blank INTERROGATION EVAL F2F IMPLANT SUBQ LEAD DEFIB Cardiovascular a 0.74 0.90 0.90 Blank RBRVS

93261 26 INTERROGATION EVAL F2F IMPLANT SUBQ LEAD DEFIB Cardiovascular Blank 0.74 0.30 0.30 Blank RBRVS

93261 TC INTERROGATION EVAL F2F IMPLANT SUBQ LEAD DEFIB Cardiovascular a Blank 0.60 0.60 Blank RBRVS

93264 Blank REM MNTR WRLS P-ART PRS SNR Miscellaneous Medical Blank 0.70 0.27 0.69 Blank RBRVS

93268 Blank XTRNL PT ACTIV ECG TRANSMIS W/R&I </30 DAYS Cardiovascular Blank 0.52 5.27 5.27 Blank RBRVS

93270 Blank XTRNL PT ACTIVATED ECG RECORD MONITOR 30 DAYS Cardiovascular a Blank 0.25 0.25 Blank RBRVS

93271 Blank XTRNL PT ACTIVATED ECG REC DWNLD 30 DAYS Cardiovascular a Blank 4.84 4.84 Blank RBRVS

93272 Blank XTRNL PT ACTIVTD ECG DWNLD W/R&I </30 DAYS Cardiovascular Blank 0.52 0.18 0.18 Blank RBRVS

93278 Blank SIGNAL AVERAGED ELECTROCARDIOGRAPHY W/WO ECG Cardiovascular a 0.25 0.61 0.61 Blank RBRVS





PAGE 118 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

93278 26 SIGNAL AVERAGED ELECTROCARDIOGRAPHY W/WO ECG Cardiovascular Blank 0.25 0.10 0.10 Blank RBRVS

93278 TC SIGNAL AVERAGED ELECTROCARDIOGRAPHY W/WO ECG Cardiovascular a Blank 0.51 0.51 Blank RBRVS

93279 Blank PROGRAM EVAL IMPLANTABLE IN PRSN 1 LD PACEMAKER Cardiovascular a 0.65 0.72 0.72 Blank RBRVS

93279 26 PROGRAM EVAL IMPLANTABLE IN PRSN 1 LD PACEMAKER Cardiovascular Blank 0.65 0.25 0.25 Blank RBRVS

93279 TC PROGRAM EVAL IMPLANTABLE IN PRSN 1 LD PACEMAKER Cardiovascular a Blank 0.47 0.47 Blank RBRVS

93280 Blank PROGRAM EVAL IMPLANTABLE IN PERSN DUAL LD PACER Cardiovascular a 0.77 0.84 0.84 Blank RBRVS

93280 26 PROGRAM EVAL IMPLANTABLE IN PERSN DUAL LD PACER Cardiovascular Blank 0.77 0.29 0.29 Blank RBRVS

93280 TC PROGRAM EVAL IMPLANTABLE IN PERSN DUAL LD PACER Cardiovascular a Blank 0.55 0.55 Blank RBRVS

93281 Blank PROGRAM EVAL IMPLANTABLE IN PRSN MULTI LD PACER Cardiovascular a 0.85 0.90 0.90 Blank RBRVS

93281 26 PROGRAM EVAL IMPLANTABLE IN PRSN MULTI LD PACER Cardiovascular Blank 0.85 0.34 0.34 Blank RBRVS

93281 TC PROGRAM EVAL IMPLANTABLE IN PRSN MULTI LD PACER Cardiovascular a Blank 0.56 0.56 Blank RBRVS

93282 Blank PRGRMNG DEV EVAL IMPLANTABLE IN PERSN 1 LD DFB Cardiovascular a 0.85 0.84 0.84 Blank RBRVS

93282 26 PRGRMNG DEV EVAL IMPLANTABLE IN PERSN 1 LD DFB Cardiovascular Blank 0.85 0.33 0.33 Blank RBRVS

93282 TC PRGRMNG DEV EVAL IMPLANTABLE IN PERSN 1 LD DFB Cardiovascular a Blank 0.51 0.51 Blank RBRVS

93283 Blank PRGRMG EVAL IMPLANTABLE IN PRSN DUAL LEAD DFB Cardiovascular a 1.15 1.01 1.01 Blank RBRVS

93283 26 PRGRMG EVAL IMPLANTABLE IN PRSN DUAL LEAD DFB Cardiovascular Blank 1.15 0.45 0.45 Blank RBRVS

93283 TC PRGRMG EVAL IMPLANTABLE IN PRSN DUAL LEAD DFB Cardiovascular a Blank 0.56 0.56 Blank RBRVS

93284 Blank PRGRMG EVAL IMPLANTABLE IN PERSON MULTI LEAD DFB Cardiovascular a 1.25 1.10 1.10 Blank RBRVS

93284 26 PRGRMG EVAL IMPLANTABLE IN PERSON MULTI LEAD DFB Cardiovascular Blank 1.25 0.49 0.49 Blank RBRVS

93284 TC PRGRMG EVAL IMPLANTABLE IN PERSON MULTI LEAD DFB Cardiovascular a Blank 0.61 0.61 Blank RBRVS

93285 Blank PROGRAM EVAL IMPLANTABLE DEV IN PRSN ILR SYSTEM Cardiovascular a 0.52 0.66 0.66 Blank RBRVS

93285 26 PROGRAM EVAL IMPLANTABLE DEV IN PRSN ILR SYSTEM Cardiovascular Blank 0.52 0.21 0.21 Blank RBRVS

93285 TC PROGRAM EVAL IMPLANTABLE DEV IN PRSN ILR SYSTEM Cardiovascular a Blank 0.45 0.45 Blank RBRVS

93286 Blank PERI-PX EVAL&PROGRAM IN PRSN PACEMAKER SYSTEM Cardiovascular a 0.30 0.53 0.53 Blank RBRVS

93286 26 PERI-PX EVAL&PROGRAM IN PRSN PACEMAKER SYSTEM Cardiovascular Blank 0.30 0.12 0.12 Blank RBRVS

93286 TC PERI-PX EVAL&PROGRAM IN PRSN PACEMAKER SYSTEM Cardiovascular a Blank 0.41 0.41 Blank RBRVS

93287 Blank PERI-PX DEV EVAL & PROG SING/DUAL/MULTI LEAD DFB Cardiovascular a 0.45 0.60 0.60 Blank RBRVS

93287 26 PERI-PX DEV EVAL & PROG SING/DUAL/MULTI LEAD DFB Cardiovascular Blank 0.45 0.19 0.19 Blank RBRVS

93287 TC PERI-PX DEV EVAL & PROG SING/DUAL/MULTI LEAD DFB Cardiovascular a Blank 0.41 0.41 Blank RBRVS

93288 Blank INTERROGATION EVAL IN PERSON 1/DUAL/MLT LEAD PM Cardiovascular a 0.43 0.63 0.63 Blank RBRVS

93288 26 INTERROGATION EVAL IN PERSON 1/DUAL/MLT LEAD PM Cardiovascular Blank 0.43 0.16 0.16 Blank RBRVS

93288 TC INTERROGATION EVAL IN PERSON 1/DUAL/MLT LEAD PM Cardiovascular a Blank 0.47 0.47 Blank RBRVS

93289 Blank INTERROG EVAL F2F 1/DUAL/MLT LEADS IMPLTBL DFB Cardiovascular a 0.75 0.75 0.75 Blank RBRVS

93289 26 INTERROG EVAL F2F 1/DUAL/MLT LEADS IMPLTBL DFB Cardiovascular Blank 0.75 0.28 0.28 Blank RBRVS

93289 TC INTERROG EVAL F2F 1/DUAL/MLT LEADS IMPLTBL DFB Cardiovascular a Blank 0.47 0.47 Blank RBRVS

93290 Blank INTERROGATION EVAL F2F IMPLANTABLE CV MNTR SYS Cardiovascular a 0.43 0.58 0.58 Blank RBRVS

93290 26 INTERROGATION EVAL F2F IMPLANTABLE CV MNTR SYS Cardiovascular Blank 0.43 0.17 0.17 Blank RBRVS

93290 TC INTERROGATION EVAL F2F IMPLANTABLE CV MNTR SYS Cardiovascular a Blank 0.41 0.41 Blank RBRVS

93291 Blank INTERROGATION EVALUATION IN PERSON ILR SYSTEM Cardiovascular a 0.37 0.54 0.54 Blank RBRVS

93291 26 INTERROGATION EVALUATION IN PERSON ILR SYSTEM Cardiovascular Blank 0.37 0.14 0.14 Blank RBRVS

93291 TC INTERROGATION EVALUATION IN PERSON ILR SYSTEM Cardiovascular a Blank 0.40 0.40 Blank RBRVS

93292 Blank INTERROGATION EVAL IN PERSON WR DEFIBRILLATOR Cardiovascular a 0.43 0.58 0.58 Blank RBRVS

93292 26 INTERROGATION EVAL IN PERSON WR DEFIBRILLATOR Cardiovascular Blank 0.43 0.16 0.16 Blank RBRVS

93292 TC INTERROGATION EVAL IN PERSON WR DEFIBRILLATOR Cardiovascular a Blank 0.42 0.42 Blank RBRVS

93293 Blank TRANSTELEPHONIC RHYTHM STRIP PACEMAKER EVAL Cardiovascular a 0.31 1.18 1.18 Blank RBRVS

93293 26 TRANSTELEPHONIC RHYTHM STRIP PACEMAKER EVAL Cardiovascular Blank 0.31 0.11 0.11 Blank RBRVS

93293 TC TRANSTELEPHONIC RHYTHM STRIP PACEMAKER EVAL Cardiovascular a Blank 1.07 1.07 Blank RBRVS

93294 Blank INTERROGATION EVAL REMOTE </90 D 1/2/MLT LEAD PM Cardiovascular Blank 0.60 0.23 0.23 Blank RBRVS

93295 Blank INTERROGATION EVAL REMOTE </90 D 1/2/MLT LD DFB Cardiovascular Blank 0.74 0.77 0.77 Blank RBRVS

93296 Blank INTERROGATION REMOTE </90 D TECHNICIAN REVIEW Cardiovascular a Blank 0.74 0.74 Blank RBRVS

93297 Blank INTERROGATION EVAL REMOTE </30 D CV MNTR SYS Cardiovascular Blank 0.52 0.20 0.20 Blank RBRVS

93298 Blank INTERROGATION EVALUATION REMOTE </30 D ILR SYS Cardiovascular Blank 0.52 0.21 0.21 Blank RBRVS

93299 Blank INTERROGATION EVAL REMOTE </30 D TECH REVIEW Cardiovascular a Blank Blank Blank 1.18 FAIR Health

93303 Blank COMPLETE TTHRC ECHO CONGENITAL CARDIAC ANOMALY Cardiovascular a 1.30 5.48 5.48 Blank RBRVS

93303 26 COMPLETE TTHRC ECHO CONGENITAL CARDIAC ANOMALY Cardiovascular Blank 1.30 0.46 0.46 Blank RBRVS

93303 TC COMPLETE TTHRC ECHO CONGENITAL CARDIAC ANOMALY Cardiovascular a Blank 5.02 5.02 Blank RBRVS

93304 Blank F-UP/LIMITED TTHRC ECHO CONGENITAL CAR ANOMALY Cardiovascular a 0.75 3.77 3.77 Blank RBRVS

93304 26 F-UP/LIMITED TTHRC ECHO CONGENITAL CAR ANOMALY Cardiovascular Blank 0.75 0.26 0.26 Blank RBRVS

93304 TC F-UP/LIMITED TTHRC ECHO CONGENITAL CAR ANOMALY Cardiovascular a Blank 3.51 3.51 Blank RBRVS

93306 Blank ECHO TTHRC R-T 2D W/WOM-MODE COMPL SPEC&COLR D Cardiovascular a 1.50 4.37 4.37 Blank RBRVS

93306 26 ECHO TTHRC R-T 2D W/WOM-MODE COMPL SPEC&COLR D Cardiovascular Blank 1.50 0.53 0.53 Blank RBRVS

93306 TC ECHO TTHRC R-T 2D W/WOM-MODE COMPL SPEC&COLR D Cardiovascular a Blank 3.84 3.84 Blank RBRVS

93307 Blank ECHO TRANSTHORAC R-T 2D W/WO M-MODE REC COMP Cardiovascular a 0.92 3.08 3.08 Blank RBRVS

93307 26 ECHO TRANSTHORAC R-T 2D W/WO M-MODE REC COMP Cardiovascular Blank 0.92 0.33 0.33 Blank RBRVS

93307 TC ECHO TRANSTHORAC R-T 2D W/WO M-MODE REC COMP Cardiovascular a Blank 2.75 2.75 Blank RBRVS

93308 Blank ECHO TRANSTHORC R-T 2D W/WO M-MODE REC F-UP/LMTD Cardiovascular a 0.53 2.44 2.44 Blank RBRVS

93308 26 ECHO TRANSTHORC R-T 2D W/WO M-MODE REC F-UP/LMTD Cardiovascular Blank 0.53 0.18 0.18 Blank RBRVS

93308 TC ECHO TRANSTHORC R-T 2D W/WO M-MODE REC F-UP/LMTD Cardiovascular a Blank 2.26 2.26 Blank RBRVS

93312 Blank ECHO TRANSESOPHAG R-T 2D W/PRB IMG ACQUISJ I&R Cardiovascular a 2.30 4.62 4.62 Blank RBRVS

93312 26 ECHO TRANSESOPHAG R-T 2D W/PRB IMG ACQUISJ I&R Cardiovascular Blank 2.30 0.72 0.72 Blank RBRVS

93312 TC ECHO TRANSESOPHAG R-T 2D W/PRB IMG ACQUISJ I&R Cardiovascular a Blank 3.90 3.90 Blank RBRVS

93313 Blank ECHO R-T 2D W/PROBE PLACEMENT ONLY Cardiovascular Blank 0.26 0.05 0.05 Blank RBRVS





PAGE 119 of 144

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HCPCS

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Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

93314 Blank ECHO TRANSESOPHAG R-T 2D IMG ACQUISJ I&R ONLY Cardiovascular a 1.85 4.75 4.75 Blank RBRVS

93314 26 ECHO TRANSESOPHAG R-T 2D IMG ACQUISJ I&R ONLY Cardiovascular Blank 1.85 0.59 0.59 Blank RBRVS

93314 TC ECHO TRANSESOPHAG R-T 2D IMG ACQUISJ I&R ONLY Cardiovascular a Blank 4.16 4.16 Blank RBRVS

93315 Blank ECHO TRANSESOPHAG CONGEN PROBE PLCMT IMGNG I&R Cardiovascular a Blank Blank Blank 6.15 Global/TC/26

93315 26 ECHO TRANSESOPHAG CONGEN PROBE PLCMT IMGNG I&R Cardiovascular Blank Blank Blank Blank 3.56 Global/TC/26

93315 TC ECHO TRANSESOPHAG CONGEN PROBE PLCMT IMGNG I&R Cardiovascular a Blank Blank Blank 2.59 Global/TC/26

93316 Blank ECHO TRANSESOPHAG CONGEN PROBE PLCMT ONLY Cardiovascular Blank 0.60 0.13 0.13 Blank RBRVS

93317 Blank ECHO TRANSESOPHAG IMAGE ACQUISJ INTERP&REPORT Cardiovascular a Blank Blank Blank 4.35 Global/TC/26

93317 26 ECHO TRANSESOPHAG IMAGE ACQUISJ INTERP&REPORT Cardiovascular Blank Blank Blank Blank 2.48 Global/TC/26

93317 TC ECHO TRANSESOPHAG IMAGE ACQUISJ INTERP&REPORT Cardiovascular a Blank Blank Blank 1.87 Global/TC/26

93318 Blank ECHO TRANSESOPHAG MONTR CARDIAC PUMP FUNCTJ Cardiovascular a Blank Blank Blank 4.90 Global/TC/26

93318 26 ECHO TRANSESOPHAG MONTR CARDIAC PUMP FUNCTJ Cardiovascular Blank Blank Blank Blank 2.83 Global/TC/26

93318 TC ECHO TRANSESOPHAG MONTR CARDIAC PUMP FUNCTJ Cardiovascular a Blank Blank Blank 2.07 Global/TC/26

93320 Blank DOPPLER ECHOCARD PULSE WAVE W/SPECTRAL DISPLAY Cardiovascular a 0.38 1.15 1.15 Blank RBRVS

93320 26 DOPPLER ECHOCARD PULSE WAVE W/SPECTRAL DISPLAY Cardiovascular Blank 0.38 0.13 0.13 Blank RBRVS

93320 TC DOPPLER ECHOCARD PULSE WAVE W/SPECTRAL DISPLAY Cardiovascular a Blank 1.02 1.02 Blank RBRVS

93321 Blank DOP ECHOCARD PULSE WAVE W/SPECTRAL F-UP/LMTD STD Cardiovascular a 0.15 0.62 0.62 Blank RBRVS

93321 26 DOP ECHOCARD PULSE WAVE W/SPECTRAL F-UP/LMTD STD Cardiovascular Blank 0.15 0.05 0.05 Blank RBRVS

93321 TC DOP ECHOCARD PULSE WAVE W/SPECTRAL F-UP/LMTD STD Cardiovascular a Blank 0.57 0.57 Blank RBRVS

93325 Blank DOP ECHOCARD COLOR FLOW VELOCITY MAPPING Cardiovascular a 0.07 0.66 0.66 Blank RBRVS

93325 26 DOP ECHOCARD COLOR FLOW VELOCITY MAPPING Cardiovascular Blank 0.07 0.02 0.02 Blank RBRVS

93325 TC DOP ECHOCARD COLOR FLOW VELOCITY MAPPING Cardiovascular a Blank 0.64 0.64 Blank RBRVS

93350 Blank ECHO TTHRC R-T 2D W/WO M-MODE COMPLETE REST&ST Cardiovascular a 1.46 4.36 4.36 Blank RBRVS

93350 26 ECHO TTHRC R-T 2D W/WO M-MODE COMPLETE REST&ST Cardiovascular Blank 1.46 0.51 0.51 Blank RBRVS

93350 TC ECHO TTHRC R-T 2D W/WO M-MODE COMPLETE REST&ST Cardiovascular a Blank 3.85 3.85 Blank RBRVS

93351 Blank ECHO TTHRC R-T 2D W/WO M-MODE REST&STRS CONT ECG Cardiovascular a 1.75 4.80 4.80 Blank RBRVS

93351 26 ECHO TTHRC R-T 2D W/WO M-MODE REST&STRS CONT ECG Cardiovascular Blank 1.75 0.61 0.61 Blank RBRVS

93351 TC ECHO TTHRC R-T 2D W/WO M-MODE REST&STRS CONT ECG Cardiovascular a Blank 4.19 4.19 Blank RBRVS

93352 Blank USE OF ECHO CONTRAST AGENT DURING STRESS ECHO Cardiovascular Blank 0.19 0.75 0.75 Blank RBRVS

93355 Blank ECHO TEE GUID TCAT ICAR/VESSEL STRUCTURAL INTVN Cardiovascular Blank 4.66 1.52 1.52 Blank RBRVS

93451 Blank RIGHT HEART CATH O2 SATURATION & CARDIAC OUTPUT Surgery a 2.47 17.72 17.72 Blank RBRVS

93451 26 RIGHT HEART CATH O2 SATURATION & CARDIAC OUTPUT Surgery Blank 2.47 0.84 0.84 Blank RBRVS

93451 TC RIGHT HEART CATH O2 SATURATION & CARDIAC OUTPUT Surgery a Blank 16.88 16.88 Blank RBRVS

93452 Blank L HRT CATH W/NJX L VENTRICULOGRAPHY IMG S&I Surgery a 4.50 18.15 18.15 Blank RBRVS

93452 26 L HRT CATH W/NJX L VENTRICULOGRAPHY IMG S&I Surgery Blank 4.50 1.57 1.57 Blank RBRVS

93452 TC L HRT CATH W/NJX L VENTRICULOGRAPHY IMG S&I Surgery a Blank 16.58 16.58 Blank RBRVS

93453 Blank R & L HRT CATH W/NJX L VENTRICULOG IMG S&I Surgery a 5.99 23.36 23.36 Blank RBRVS

93453 26 R & L HRT CATH W/NJX L VENTRICULOG IMG S&I Surgery Blank 5.99 2.08 2.08 Blank RBRVS

93453 TC R & L HRT CATH W/NJX L VENTRICULOG IMG S&I Surgery a Blank 21.28 21.28 Blank RBRVS

93454 Blank CATH PLACEMENT & NJX CORONARY ART ANGIO IMG S&I Surgery a 4.54 18.41 18.41 Blank RBRVS

93454 26 CATH PLACEMENT & NJX CORONARY ART ANGIO IMG S&I Surgery Blank 4.54 1.56 1.56 Blank RBRVS

93454 TC CATH PLACEMENT & NJX CORONARY ART ANGIO IMG S&I Surgery a Blank 16.85 16.85 Blank RBRVS

93455 Blank CATH PLMT & NJX CORONARY ART/GRFT ANGIO IMG S&I Surgery a 5.29 21.57 21.57 Blank RBRVS

93455 26 CATH PLMT & NJX CORONARY ART/GRFT ANGIO IMG S&I Surgery Blank 5.29 1.82 1.82 Blank RBRVS

93455 TC CATH PLMT & NJX CORONARY ART/GRFT ANGIO IMG S&I Surgery a Blank 19.75 19.75 Blank RBRVS

93456 Blank CATH PLMT R HRT & ARTS W/NJX & ANGIO IMG S&I Surgery a 5.90 23.13 23.13 Blank RBRVS

93456 26 CATH PLMT R HRT & ARTS W/NJX & ANGIO IMG S&I Surgery Blank 5.90 2.04 2.04 Blank RBRVS

93456 TC CATH PLMT R HRT & ARTS W/NJX & ANGIO IMG S&I Surgery a Blank 21.09 21.09 Blank RBRVS

93457 Blank CATH PLMT R HRT/ARTS/GRFTS W/NJX& ANGIO IMG S&I Surgery a 6.64 26.22 26.22 Blank RBRVS

93457 26 CATH PLMT R HRT/ARTS/GRFTS W/NJX& ANGIO IMG S&I Surgery Blank 6.64 2.28 2.28 Blank RBRVS

93457 TC CATH PLMT R HRT/ARTS/GRFTS W/NJX& ANGIO IMG S&I Surgery a Blank 23.94 23.94 Blank RBRVS

93458 Blank CATH PLMT L HRT & ARTS W/NJX & ANGIO IMG S&I Surgery a 5.60 22.03 22.03 Blank RBRVS

93458 26 CATH PLMT L HRT & ARTS W/NJX & ANGIO IMG S&I Surgery Blank 5.60 1.93 1.93 Blank RBRVS

93458 TC CATH PLMT L HRT & ARTS W/NJX & ANGIO IMG S&I Surgery a Blank 20.10 20.10 Blank RBRVS

93459 Blank CATH PLMT L HRT/ARTS/GRFTS WNJX & ANGIO IMG S&I Surgery a 6.35 24.23 24.23 Blank RBRVS

93459 26 CATH PLMT L HRT/ARTS/GRFTS WNJX & ANGIO IMG S&I Surgery Blank 6.35 2.17 2.17 Blank RBRVS

93459 TC CATH PLMT L HRT/ARTS/GRFTS WNJX & ANGIO IMG S&I Surgery a Blank 22.06 22.06 Blank RBRVS

93460 Blank R & L HRT CATH WINJX HRT ART& L VENTR IMG Surgery a 7.10 25.80 25.80 Blank RBRVS

93460 26 R & L HRT CATH WINJX HRT ART& L VENTR IMG Surgery Blank 7.10 2.44 2.44 Blank RBRVS

93460 TC R & L HRT CATH WINJX HRT ART& L VENTR IMG Surgery a Blank 23.36 23.36 Blank RBRVS

93461 Blank R& L HRT CATH W/INJEC HRT ART/GRFT& L VENT I Surgery a 7.85 29.89 29.89 Blank RBRVS

93461 26 R& L HRT CATH W/INJEC HRT ART/GRFT& L VENT I Surgery Blank 7.85 2.70 2.70 Blank RBRVS

93461 TC R& L HRT CATH W/INJEC HRT ART/GRFT& L VENT I Surgery a Blank 27.19 27.19 Blank RBRVS

93462 Blank LEFT HEART CATH BY TRANSEPTAL PUNCTURE Surgery Blank 3.73 1.52 1.52 Blank RBRVS

93463 Blank MEDICATION ADMIN & HEMODYNAMIC MEASURMENT Surgery Blank 2.00 0.68 0.68 Blank RBRVS

93464 Blank PHYSIOLOGIC EXERCISE STUDY & HEMODYNAMIC MEASU Surgery a 1.80 5.38 5.38 Blank RBRVS

93464 26 PHYSIOLOGIC EXERCISE STUDY & HEMODYNAMIC MEASU Surgery Blank 1.80 0.62 0.62 Blank RBRVS

93464 TC PHYSIOLOGIC EXERCISE STUDY & HEMODYNAMIC MEASU Surgery a Blank 4.76 4.76 Blank RBRVS

93503 Blank INSERTION FLOW DIRECTED CATHETER FOR MONITORING Surgery Blank 2.00 0.82 0.82 Blank RBRVS

93505 Blank ENDOMYOCARDIAL BIOPSY Surgery a 4.12 15.04 15.04 Blank RBRVS

93505 26 ENDOMYOCARDIAL BIOPSY Surgery Blank 4.12 1.42 1.42 Blank RBRVS

93505 TC ENDOMYOCARDIAL BIOPSY Surgery a Blank 13.62 13.62 Blank RBRVS





PAGE 120 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

93530 Blank R HRT CATHETERIZATION CONGENITAL CARDIAC ANOMALY Surgery a Blank Blank Blank 32.31 Global/TC/26

93530 26 R HRT CATHETERIZATION CONGENITAL CARDIAC ANOMALY Surgery Blank Blank Blank Blank 5.37 Global/TC/26

93530 TC R HRT CATHETERIZATION CONGENITAL CARDIAC ANOMALY Surgery a Blank Blank Blank 26.94 Global/TC/26

93531 Blank CMBN R HRT & RETROGRADE L HRT CATHJ CGEN ANOMA Surgery a Blank Blank Blank 89.92 Global/TC/26

93531 26 CMBN R HRT & RETROGRADE L HRT CATHJ CGEN ANOMA Surgery Blank Blank Blank Blank 11.21 Global/TC/26

93531 TC CMBN R HRT & RETROGRADE L HRT CATHJ CGEN ANOMA Surgery a Blank Blank Blank 78.71 Global/TC/26

93532 Blank CMBN R HRT T-SEPTAL L HRT CATHJ NTC SEPTUM CGEN Surgery a Blank Blank Blank 96.60 Global/TC/26

93532 26 CMBN R HRT T-SEPTAL L HRT CATHJ NTC SEPTUM CGEN Surgery Blank Blank Blank Blank 13.43 Global/TC/26

93532 TC CMBN R HRT T-SEPTAL L HRT CATHJ NTC SEPTUM CGEN Surgery a Blank Blank Blank 83.17 Global/TC/26

93533 Blank CMBN R HRT T-SEPTAL L HRT CATHJ SEPTAL OPNG CGEN Surgery a Blank Blank Blank 90.94 Global/TC/26

93533 26 CMBN R HRT T-SEPTAL L HRT CATHJ SEPTAL OPNG CGEN Surgery Blank Blank Blank Blank 8.99 Global/TC/26

93533 TC CMBN R HRT T-SEPTAL L HRT CATHJ SEPTAL OPNG CGEN Surgery a Blank Blank Blank 81.95 Global/TC/26

93561 Blank INDIC DIL STD ARTL&/OR VEN CATHJ W/OUTP MEAS Cardiovascular a Blank Blank Blank 1.64 Global/TC/26

93561 26 INDIC DIL STD ARTL&/OR VEN CATHJ W/OUTP MEAS Cardiovascular Blank 0.95 0.33 0.33 Blank RBRVS

93561 TC INDIC DIL STD ARTL&/OR VEN CATHJ W/OUTP MEAS Cardiovascular a Blank Blank Blank 0.36 FAIR Health

93562 Blank INDIC DIL STD ARTL&/OR VEN CATHJ SBSQ OUTP MEA Cardiovascular a Blank Blank Blank 1.34 Global/TC/26

93562 26 INDIC DIL STD ARTL&/OR VEN CATHJ SBSQ OUTP MEA Cardiovascular Blank 0.77 0.26 0.26 Blank RBRVS

93562 TC INDIC DIL STD ARTL&/OR VEN CATHJ SBSQ OUTP MEA Cardiovascular a Blank Blank Blank 0.31 FAIR Health

93563 Blank NJX SEL HRT ART CONGENITAL HRT CATH W/S&I Cardiovascular Blank 1.11 0.38 0.38 Blank RBRVS

93564 Blank NJX SEL HRT ART/GRFT CONGENITAL HRT CATH W/S&I Cardiovascular Blank 1.13 0.39 0.39 Blank RBRVS

93565 Blank NJX SEL L VENT/ATRIAL ANGIO HRT CATH W/S&I Cardiovascular Blank 0.86 0.30 0.30 Blank RBRVS

93566 Blank NJX SEL R VENT/ATRIAL ANGIO HRT CATH W/S&I Cardiovascular Blank 0.86 0.30 3.57 Blank RBRVS

93567 Blank NJX SUPRAVALV AORTOG HRT CATH W/S&I Cardiovascular Blank 0.97 0.34 2.70 Blank RBRVS

93568 Blank NJX PULMONARY ANGIO HRT CATH W/S&I Cardiovascular Blank 0.88 0.31 3.06 Blank RBRVS

93571 Blank IV DOP VEL&/OR PRESS C/FLO RSRV MEAS 1ST VSL Cardiovascular a Blank Blank Blank 8.26 Global/TC/26

93571 26 IV DOP VEL&/OR PRESS C/FLO RSRV MEAS 1ST VSL Cardiovascular Blank Blank Blank Blank 2.42 Global/TC/26

93571 TC IV DOP VEL&/OR PRESS C/FLO RSRV MEAS 1ST VSL Cardiovascular a Blank Blank Blank 5.84 Global/TC/26

93572 Blank IV DOP VEL&/OR PRESS C/FLO RSRV MEAS ADDL VSL Cardiovascular a Blank Blank Blank 5.13 Global/TC/26

93572 26 IV DOP VEL&/OR PRESS C/FLO RSRV MEAS ADDL VSL Cardiovascular Blank Blank Blank Blank 1.94 Global/TC/26

93572 TC IV DOP VEL&/OR PRESS C/FLO RSRV MEAS ADDL VSL Cardiovascular a Blank Blank Blank 3.19 Global/TC/26

93580 Blank PRQ TCAT CLSR CGEN INTRATRL COMUNICAJ W/IMPLT Surgery Blank 17.97 6.53 6.53 Blank RBRVS

93581 Blank PRQ TCAT CLSR CGEN VENTR SEPTAL DFCT W/IMPLT Surgery Blank 24.39 8.64 8.64 Blank RBRVS

93582 Blank PERCUTAN TRANSCATH CLOSURE PAT DUCT ARTERIOSUS Surgery Blank 12.31 4.19 4.19 Blank RBRVS

93583 Blank PERCUTANEOUS TRANSCATHETER SEPTAL REDUCTION THER Surgery Blank 13.75 4.77 4.77 Blank RBRVS

93590 Blank PERQ TRANSCATH CLS MITRAL Surgery Blank 21.70 7.89 7.89 Blank RBRVS

93591 Blank PERQ TRANSCATH CLS AORTIC Surgery Blank 17.97 6.59 6.59 Blank RBRVS

93592 Blank PERQ TRANSCATH CLOSURE EACH Surgery Blank 8.00 2.79 2.79 Blank RBRVS

93600 Blank BUNDLE OF HIS RECORDING Cardiovascular a Blank Blank Blank 3.28 Global/TC/26

93600 26 BUNDLE OF HIS RECORDING Cardiovascular Blank 2.12 0.90 0.90 Blank RBRVS

93600 TC BUNDLE OF HIS RECORDING Cardiovascular a Blank Blank Blank 0.26 FAIR Health

93602 Blank INTRA-ATRIAL RECORDING Cardiovascular a Blank Blank Blank 4.10 Global/TC/26

93602 26 INTRA-ATRIAL RECORDING Cardiovascular Blank 2.12 0.83 0.83 Blank RBRVS

93602 TC INTRA-ATRIAL RECORDING Cardiovascular a Blank Blank Blank 1.15 Global/TC/26

93603 Blank RIGHT VENTRICULAR RECORDING Cardiovascular a Blank Blank Blank 4.00 Global/TC/26

93603 26 RIGHT VENTRICULAR RECORDING Cardiovascular Blank Blank Blank Blank 2.95 Global/TC/26

93603 TC RIGHT VENTRICULAR RECORDING Cardiovascular a Blank Blank Blank 1.05 Global/TC/26

93609 Blank INTRA-VENTRIC&/ATRIAL MAPG TACHYCARD W/CATH MA Cardiovascular a Blank Blank Blank 9.25 Global/TC/26

93609 26 INTRA-VENTRIC&/ATRIAL MAPG TACHYCARD W/CATH MA Cardiovascular Blank Blank Blank Blank 7.08 Global/TC/26

93609 TC INTRA-VENTRIC&/ATRIAL MAPG TACHYCARD W/CATH MA Cardiovascular a Blank Blank Blank 2.17 Global/TC/26

93610 Blank INTRA-ATRIAL PACING Cardiovascular a Blank Blank Blank 4.23 Global/TC/26

93610 26 INTRA-ATRIAL PACING Cardiovascular Blank 3.02 1.15 1.15 Blank RBRVS

93610 TC INTRA-ATRIAL PACING Cardiovascular a Blank Blank Blank 0.06 Global/TC/26

93612 Blank INTRAVENTRICULAR PACING Cardiovascular a Blank Blank Blank 5.17 Global/TC/26

93612 26 INTRAVENTRICULAR PACING Cardiovascular Blank 3.02 1.13 1.13 Blank RBRVS

93612 TC INTRAVENTRICULAR PACING Cardiovascular a Blank Blank Blank 1.02 Global/TC/26

93613 Blank INTRACARDIAC ELECTROPHYSIOLOGIC 3D MAPPING Cardiovascular Blank 5.23 2.94 2.94 Blank RBRVS

93615 Blank ESOPHGL REC ATRIAL W/WO VENTRICULAR ELECTROGRAMS Cardiovascular a Blank Blank Blank 1.36 Global/TC/26

93615 26 ESOPHGL REC ATRIAL W/WO VENTRICULAR ELECTROGRAMS Cardiovascular Blank Blank Blank Blank 1.07 Global/TC/26

93615 TC ESOPHGL REC ATRIAL W/WO VENTRICULAR ELECTROGRAMS Cardiovascular a Blank Blank Blank 0.29 Global/TC/26

93616 Blank ESOPHGL REC ATRIAL W/WO VENTR ELECTRGRAMS W/PACG Cardiovascular a Blank Blank Blank 1.86 Global/TC/26

93616 26 ESOPHGL REC ATRIAL W/WO VENTR ELECTRGRAMS W/PACG Cardiovascular Blank 1.24 0.48 0.48 Blank RBRVS

93616 TC ESOPHGL REC ATRIAL W/WO VENTR ELECTRGRAMS W/PACG Cardiovascular a Blank Blank Blank 0.14 FAIR Health

93618 Blank INDUCTION ARRHYTHMIA ELECTRICAL PACING Cardiovascular a Blank Blank Blank 6.10 Global/TC/26

93618 26 INDUCTION ARRHYTHMIA ELECTRICAL PACING Cardiovascular Blank 4.00 1.64 1.64 Blank RBRVS

93618 TC INDUCTION ARRHYTHMIA ELECTRICAL PACING Cardiovascular a Blank Blank Blank 0.46 FAIR Health

93619 Blank COMPRE ELECTROPHYSIOLOGIC W/O ARRHYT INDUCTION Cardiovascular a Blank Blank Blank 11.10 Global/TC/26

93619 26 COMPRE ELECTROPHYSIOLOGIC W/O ARRHYT INDUCTION Cardiovascular Blank 7.06 2.88 2.88 Blank RBRVS

93619 TC COMPRE ELECTROPHYSIOLOGIC W/O ARRHYT INDUCTION Cardiovascular a Blank Blank Blank 1.16 FAIR Health

93620 Blank COMPRE ELECTROPHYSIOLOGIC ARRHYTHMIA INDUCTION Cardiovascular a Blank Blank Blank 19.16 Global/TC/26

93620 26 COMPRE ELECTROPHYSIOLOGIC ARRHYTHMIA INDUCTION Cardiovascular Blank Blank Blank Blank 15.99 Global/TC/26

93620 TC COMPRE ELECTROPHYSIOLOGIC ARRHYTHMIA INDUCTION Cardiovascular a Blank Blank Blank 3.17 Global/TC/26

93621 Blank COMPRE ELECTROPHYSIOL XM W/LEFT ATRIAL PACNG/REC Cardiovascular a Blank Blank Blank 4.86 Global/TC/26





PAGE 121 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

93621 26 COMPRE ELECTROPHYSIOL XM W/LEFT ATRIAL PACNG/REC Cardiovascular Blank Blank Blank Blank 2.98 Global/TC/26

93621 TC COMPRE ELECTROPHYSIOL XM W/LEFT ATRIAL PACNG/REC Cardiovascular a Blank Blank Blank 1.88 Global/TC/26

93622 Blank COMPRE ELECTROPHYSIOL XM W/LEFT VENTR PACNG/REC Cardiovascular a Blank Blank Blank 5.85 Global/TC/26

93622 26 COMPRE ELECTROPHYSIOL XM W/LEFT VENTR PACNG/REC Cardiovascular Blank Blank Blank Blank 4.39 Global/TC/26

93622 TC COMPRE ELECTROPHYSIOL XM W/LEFT VENTR PACNG/REC Cardiovascular a Blank Blank Blank 1.46 Global/TC/26

93623 Blank PROGRAMMED STIMJ & PACG AFTER IV DRUG NFS Cardiovascular a Blank Blank Blank 5.40 Global/TC/26

93623 26 PROGRAMMED STIMJ & PACG AFTER IV DRUG NFS Cardiovascular Blank Blank Blank Blank 4.05 Global/TC/26

93623 TC PROGRAMMED STIMJ & PACG AFTER IV DRUG NFS Cardiovascular a Blank Blank Blank 1.35 Global/TC/26

93624 Blank ELECTROPHYSIOLOGIC FOLLOW-UP W/PAC/REC W/ARRHYT Cardiovascular a Blank Blank Blank 7.85 Global/TC/26

93624 26 ELECTROPHYSIOLOGIC FOLLOW-UP W/PAC/REC W/ARRHYT Cardiovascular Blank 4.55 1.79 1.79 Blank RBRVS

93624 TC ELECTROPHYSIOLOGIC FOLLOW-UP W/PAC/REC W/ARRHYT Cardiovascular a Blank Blank Blank 1.51 Global/TC/26

93631 Blank INTRAOP EPICAR& ENDOCAR PACG& MAPG Cardiovascular a Blank Blank Blank 12.37 Global/TC/26

93631 26 INTRAOP EPICAR& ENDOCAR PACG& MAPG Cardiovascular Blank 7.59 2.37 2.37 Blank RBRVS

93631 TC INTRAOP EPICAR& ENDOCAR PACG& MAPG Cardiovascular a Blank Blank Blank 2.41 FAIR Health

93640 Blank EPHYS EVAL PACG CVDFB LDS INITIAL IMPLAN/REPLACE Cardiovascular a Blank Blank Blank 11.13 Global/TC/26

93640 26 EPHYS EVAL PACG CVDFB LDS INITIAL IMPLAN/REPLACE Cardiovascular Blank Blank Blank Blank 4.55 Global/TC/26

93640 TC EPHYS EVAL PACG CVDFB LDS INITIAL IMPLAN/REPLACE Cardiovascular a Blank Blank Blank 6.58 Global/TC/26

93641 Blank EPHYS EVAL PACG CVDFB LDS W/TSTG OF PULSE GEN Cardiovascular a Blank Blank Blank 13.24 Global/TC/26

93641 26 EPHYS EVAL PACG CVDFB LDS W/TSTG OF PULSE GEN Cardiovascular Blank Blank Blank Blank 7.95 Global/TC/26

93641 TC EPHYS EVAL PACG CVDFB LDS W/TSTG OF PULSE GEN Cardiovascular a Blank Blank Blank 5.29 Global/TC/26

93642 Blank EPHYS EVAL PACG CVDFB PRGRMG/REPRGRMG PARAMETERS Cardiovascular a 4.63 4.24 4.24 Blank RBRVS

93642 26 EPHYS EVAL PACG CVDFB PRGRMG/REPRGRMG PARAMETERS Cardiovascular Blank 4.63 1.90 1.90 Blank RBRVS

93642 TC EPHYS EVAL PACG CVDFB PRGRMG/REPRGRMG PARAMETERS Cardiovascular a Blank 2.34 2.34 Blank RBRVS

93644 Blank EPHYS EVAL SUBQ IMPLANTABLE DEFIBRILLATOR Cardiovascular a 3.04 2.65 2.65 Blank RBRVS

93644 26 EPHYS EVAL SUBQ IMPLANTABLE DEFIBRILLATOR Cardiovascular Blank 3.04 1.12 1.12 Blank RBRVS

93644 TC EPHYS EVAL SUBQ IMPLANTABLE DEFIBRILLATOR Cardiovascular a Blank 1.53 1.53 Blank RBRVS

93650 Blank ICAR CATHETER ABLATION ATRIOVENTR NODE FUNCTION Cardiovascular Blank 10.24 4.62 4.62 Blank RBRVS

93653 Blank EPHYS EVAL W/ABLATION SUPRAVENT ARRHYTHMIA Cardiovascular Blank 14.75 6.20 6.20 Blank RBRVS

93654 Blank EPHYS EVAL W/ABLATION VENTRICULAR TACHYCARDIA Cardiovascular Blank 19.75 8.32 8.32 Blank RBRVS

93655 Blank ICAR CATHETER ABLATION ARRHYTHMIA ADD ON Cardiovascular Blank 7.50 3.17 3.17 Blank RBRVS

93656 Blank EPHYS EVL TRNSPTL TX ATRIAL FIB ISOLAT PULM VEIN Cardiovascular Blank 19.77 8.38 8.38 Blank RBRVS

93657 Blank ABLATE L/R ATRIAL FIBRIL W/ISOLATED PULM VEIN Cardiovascular Blank 7.50 3.15 3.15 Blank RBRVS

93660 Blank CARDIOVASCULAR FUNCTION EVAL W/TILT TABLE W/MNTR Cardiovascular a 1.89 2.56 2.56 Blank RBRVS

93660 26 CARDIOVASCULAR FUNCTION EVAL W/TILT TABLE W/MNTR Cardiovascular Blank 1.89 0.71 0.71 Blank RBRVS

93660 TC CARDIOVASCULAR FUNCTION EVAL W/TILT TABLE W/MNTR Cardiovascular a Blank 1.85 1.85 Blank RBRVS

93662 Blank INTRACARD ECHOCARD W/THER/DX IVNTJ INCL IMG S&I Cardiovascular a Blank Blank Blank 5.41 Global/TC/26

93662 26 INTRACARD ECHOCARD W/THER/DX IVNTJ INCL IMG S&I Cardiovascular Blank Blank Blank Blank 3.98 Global/TC/26

93662 TC INTRACARD ECHOCARD W/THER/DX IVNTJ INCL IMG S&I Cardiovascular a Blank Blank Blank 1.43 Global/TC/26

93668 Blank PERIPHERAL ARTERIAL DISEASE REHAB PER SESSION Cardiovascular a Blank 0.54 0.54 Blank RBRVS

93701 Blank BIOMPEDANCE-DERIVED PHYSIOLOGIC CV ANALYSIS Cardiovascular a Blank Blank Blank 0.68 Global/TC/26

93701 26 BIOMPEDANCE-DERIVED PHYSIOLOGIC CV ANALYSIS Cardiovascular Blank Blank Blank Blank 0.18 Global/TC/26

93701 TC BIOMPEDANCE-DERIVED PHYSIOLOGIC CV ANALYSIS Cardiovascular a Blank Blank Blank 0.50 Global/TC/26

93702 Blank BIS EXTRACELLULAR FLUID ALYS LYMPHEDEMA ASSMNT Radiology a Blank 3.48 3.48 Blank RBRVS

93724 Blank ELECTRONIC ANALYSIS ANTITACHY PACEMAKER SYSTEM Cardiovascular a 4.88 2.66 2.66 Blank RBRVS

93724 26 ELECTRONIC ANALYSIS ANTITACHY PACEMAKER SYSTEM Cardiovascular Blank 4.88 1.85 1.85 Blank RBRVS

93724 TC ELECTRONIC ANALYSIS ANTITACHY PACEMAKER SYSTEM Cardiovascular a Blank 0.81 0.81 Blank RBRVS

93740 Blank TEMPRATURE GRADIENT STUDY Cardiovascular a Blank Blank Blank 0.22 Global/TC/26

93740 26 TEMPRATURE GRADIENT STUDY Cardiovascular Blank Blank Blank Blank 0.18 Global/TC/26

93740 TC TEMPRATURE GRADIENT STUDY Cardiovascular a Blank Blank Blank 0.04 Global/TC/26

93750 Blank INTERROGATION VAD IN PRSON W/PHYS/QHP ANALYSIS Cardiovascular Blank 0.92 0.31 0.57 Blank RBRVS

93770 Blank DERMINATION OF VENOUS PRESSUE Cardiovascular a Blank Blank Blank 0.22 Global/TC/26

93770 26 DERMINATION OF VENOUS PRESSUE Cardiovascular Blank Blank Blank Blank 0.20 Global/TC/26

93770 TC DERMINATION OF VENOUS PRESSUE Cardiovascular a Blank Blank Blank 0.02 Global/TC/26

93784 Blank AMBL BLD PRESS W/TAPE&/DISK 24/> HR ALYS I&R Cardiovascular Blank 0.38 1.11 1.11 Blank RBRVS

93786 Blank BL BLD PRESS W/TAPE&/DISK 24/> HR REC ONL Cardiovascular a Blank 0.83 0.83 Blank RBRVS

93788 Blank AMBL BLD PRESS W/TAPE/DISK 24/>HR ALYS W/REPRT Cardiovascular a Blank 0.14 0.14 Blank RBRVS

93790 Blank AMBL BLD PRESS TAPE&/DISK 24/> HR REVIEW Cardiovascular Blank 0.38 0.14 0.14 Blank RBRVS

93792 Blank PT/CAREGIVER TRAINJ HOME INR Miscellaneous Medical a Blank 1.51 1.51 Blank RBRVS

93793 Blank ANTICOAG MGMT PT WARFARIN Miscellaneous Medical Blank 0.18 0.15 0.15 Blank RBRVS

93797 Blank OUTPATIENT CARDIAC REHAB W/O CONT ECG MONITOR Cardiovascular Blank 0.18 0.06 0.27 Blank RBRVS

93798 Blank OUTPATIENT CARDIAC REHAB W/CONT ECG MONITORING Cardiovascular Blank 0.28 0.10 0.41 Blank RBRVS

93799 Blank UNLISTED CARDIOVASCULAR SERVICE/PROCEDURE Cardiovascular a Blank Blank Blank 5.87 Unlisted

93799 26 UNLISTED CARDIOVASCULAR SERVICE/PROCEDURE Cardiovascular Blank Blank Blank Blank 2.03 Unlisted

93799 TC UNLISTED CARDIOVASCULAR SERVICE/PROCEDURE Cardiovascular a Blank Blank Blank 3.84 Unlisted

93880 Blank DUPLEX SCAN EXTRACRANIAL ART COMPL BI STUDY Miscellaneous Medical a 0.80 4.92 4.92 Blank RBRVS

93880 26 DUPLEX SCAN EXTRACRANIAL ART COMPL BI STUDY Miscellaneous Medical Blank 0.80 0.27 0.27 Blank RBRVS

93880 TC DUPLEX SCAN EXTRACRANIAL ART COMPL BI STUDY Miscellaneous Medical a Blank 4.65 4.65 Blank RBRVS

93882 Blank DUPLEX SCAN EXTRACRANIAL ART UNI/LMTD STUDY Miscellaneous Medical a 0.50 3.14 3.14 Blank RBRVS

93882 26 DUPLEX SCAN EXTRACRANIAL ART UNI/LMTD STUDY Miscellaneous Medical Blank 0.50 0.15 0.15 Blank RBRVS

93882 TC DUPLEX SCAN EXTRACRANIAL ART UNI/LMTD STUDY Miscellaneous Medical a Blank 2.99 2.99 Blank RBRVS

93886 Blank TRANSCRANIAL DOPPLER STDY INTRACRANIAL ART COMPL Miscellaneous Medical a 0.91 6.79 6.79 Blank RBRVS

93886 26 TRANSCRANIAL DOPPLER STDY INTRACRANIAL ART COMPL Miscellaneous Medical Blank 0.91 0.37 0.37 Blank RBRVS





PAGE 122 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

93886 TC TRANSCRANIAL DOPPLER STDY INTRACRANIAL ART COMPL Miscellaneous Medical a Blank 6.42 6.42 Blank RBRVS

93888 Blank TRANSCRANIAL DOPPLER STDY INTRACRANIAL ART LMTD Miscellaneous Medical a 0.50 3.86 3.86 Blank RBRVS

93888 26 TRANSCRANIAL DOPPLER STDY INTRACRANIAL ART LMTD Miscellaneous Medical Blank 0.50 0.19 0.19 Blank RBRVS

93888 TC TRANSCRANIAL DOPPLER STDY INTRACRANIAL ART LMTD Miscellaneous Medical a Blank 3.67 3.67 Blank RBRVS

93890 Blank TRANSCRANIAL DOPPLER INTRACRAN ART VASOREAC STDY Miscellaneous Medical a 1.00 6.88 6.88 Blank RBRVS

93890 26 TRANSCRANIAL DOPPLER INTRACRAN ART VASOREAC STDY Miscellaneous Medical Blank 1.00 0.40 0.40 Blank RBRVS

93890 TC TRANSCRANIAL DOPPLER INTRACRAN ART VASOREAC STDY Miscellaneous Medical a Blank 6.48 6.48 Blank RBRVS

93892 Blank TRANSCRANIAL DOPPLER INTRACRAN ART EMBOLI DETECT Miscellaneous Medical a 1.15 7.87 7.87 Blank RBRVS

93892 26 TRANSCRANIAL DOPPLER INTRACRAN ART EMBOLI DETECT Miscellaneous Medical Blank 1.15 0.47 0.47 Blank RBRVS

93892 TC TRANSCRANIAL DOPPLER INTRACRAN ART EMBOLI DETECT Miscellaneous Medical a Blank 7.40 7.40 Blank RBRVS

93893 Blank TRANSCRAN DOPPLER INTRACRAN ART MICROBUBBLE INJ Miscellaneous Medical a 1.15 8.66 8.66 Blank RBRVS

93893 26 TRANSCRAN DOPPLER INTRACRAN ART MICROBUBBLE INJ Miscellaneous Medical Blank 1.15 0.48 0.48 Blank RBRVS

93893 TC TRANSCRAN DOPPLER INTRACRAN ART MICROBUBBLE INJ Miscellaneous Medical a Blank 8.18 8.18 Blank RBRVS

93895 Blank CAROTID INTIMA MEDIA & CAROTID ATHEROMA EVAL BI Cardiovascular Blank Blank Blank Blank 1.59 FAIR Health

93922 Blank NON-INVAS PHYSIOLOGIC STD EXTREMITY ART 2 LEVEL Miscellaneous Medical a 0.25 2.22 2.22 Blank RBRVS

93922 26 NON-INVAS PHYSIOLOGIC STD EXTREMITY ART 2 LEVEL Miscellaneous Medical Blank 0.25 0.08 0.08 Blank RBRVS

93922 TC NON-INVAS PHYSIOLOGIC STD EXTREMITY ART 2 LEVEL Miscellaneous Medical a Blank 2.14 2.14 Blank RBRVS

93923 Blank NON-INVASIVE PHYSIOLOGIC STUDY EXTREMITY 3 LEVLS Miscellaneous Medical a 0.45 3.37 3.37 Blank RBRVS

93923 26 NON-INVASIVE PHYSIOLOGIC STUDY EXTREMITY 3 LEVLS Miscellaneous Medical Blank 0.45 0.13 0.13 Blank RBRVS

93923 TC NON-INVASIVE PHYSIOLOGIC STUDY EXTREMITY 3 LEVLS Miscellaneous Medical a Blank 3.24 3.24 Blank RBRVS

93924 Blank N-INVAS PHYSIOLOGIC STD LXTR ART COMPL BI Miscellaneous Medical a 0.50 4.27 4.27 Blank RBRVS

93924 26 N-INVAS PHYSIOLOGIC STD LXTR ART COMPL BI Miscellaneous Medical Blank 0.50 0.15 0.15 Blank RBRVS

93924 TC N-INVAS PHYSIOLOGIC STD LXTR ART COMPL BI Miscellaneous Medical a Blank 4.12 4.12 Blank RBRVS

93925 Blank DUP-SCAN LXTR ART/ARTL BPGS COMPL BI STUDY Miscellaneous Medical a 0.80 6.55 6.55 Blank RBRVS

93925 26 DUP-SCAN LXTR ART/ARTL BPGS COMPL BI STUDY Miscellaneous Medical Blank 0.80 0.26 0.26 Blank RBRVS

93925 TC DUP-SCAN LXTR ART/ARTL BPGS COMPL BI STUDY Miscellaneous Medical a Blank 6.29 6.29 Blank RBRVS

93926 Blank DUP-SCAN LXTR ART/ARTL BPGS UNI/LMTD STUDY Miscellaneous Medical a 0.50 3.79 3.79 Blank RBRVS

93926 26 DUP-SCAN LXTR ART/ARTL BPGS UNI/LMTD STUDY Miscellaneous Medical Blank 0.50 0.14 0.14 Blank RBRVS

93926 TC DUP-SCAN LXTR ART/ARTL BPGS UNI/LMTD STUDY Miscellaneous Medical a Blank 3.65 3.65 Blank RBRVS

93930 Blank DUP-SCAN UXTR ART/ARTL BPGS COMPL BI STUDY Miscellaneous Medical a 0.80 5.07 5.07 Blank RBRVS

93930 26 DUP-SCAN UXTR ART/ARTL BPGS COMPL BI STUDY Miscellaneous Medical Blank 0.80 0.26 0.26 Blank RBRVS

93930 TC DUP-SCAN UXTR ART/ARTL BPGS COMPL BI STUDY Miscellaneous Medical a Blank 4.81 4.81 Blank RBRVS

93931 Blank DUP-SCAN UXTR ART/ARTL BPGS UNI/LMTD STUDY Miscellaneous Medical a 0.50 3.15 3.15 Blank RBRVS

93931 26 DUP-SCAN UXTR ART/ARTL BPGS UNI/LMTD STUDY Miscellaneous Medical Blank 0.50 0.15 0.15 Blank RBRVS

93931 TC DUP-SCAN UXTR ART/ARTL BPGS UNI/LMTD STUDY Miscellaneous Medical a Blank 3.00 3.00 Blank RBRVS

93970 Blank DUP-SCAN XTR VEINS COMPLETE BILATERAL STUDY Miscellaneous Medical a 0.70 4.83 4.83 Blank RBRVS

93970 26 DUP-SCAN XTR VEINS COMPLETE BILATERAL STUDY Miscellaneous Medical Blank 0.70 0.22 0.22 Blank RBRVS

93970 TC DUP-SCAN XTR VEINS COMPLETE BILATERAL STUDY Miscellaneous Medical a Blank 4.61 4.61 Blank RBRVS

93971 Blank DUP-SCAN XTR VEINS UNILATERAL/LIMITED STUDY Miscellaneous Medical a 0.45 2.94 2.94 Blank RBRVS

93971 26 DUP-SCAN XTR VEINS UNILATERAL/LIMITED STUDY Miscellaneous Medical Blank 0.45 0.15 0.15 Blank RBRVS

93971 TC DUP-SCAN XTR VEINS UNILATERAL/LIMITED STUDY Miscellaneous Medical a Blank 2.79 2.79 Blank RBRVS

93975 Blank DUP-SCAN ARTL FLO ABDL/PEL/SCROT&/RPR ORGN COM Miscellaneous Medical a 1.16 6.79 6.79 Blank RBRVS

93975 26 DUP-SCAN ARTL FLO ABDL/PEL/SCROT&/RPR ORGN COM Miscellaneous Medical Blank 1.16 0.39 0.39 Blank RBRVS

93975 TC DUP-SCAN ARTL FLO ABDL/PEL/SCROT&/RPR ORGN COM Miscellaneous Medical a Blank 6.40 6.40 Blank RBRVS

93976 Blank DUP-SCAN ARTL FLO ABDL/PEL/SCROT&/RPR ORGN LMT Miscellaneous Medical a 0.80 3.84 3.84 Blank RBRVS

93976 26 DUP-SCAN ARTL FLO ABDL/PEL/SCROT&/RPR ORGN LMT Miscellaneous Medical Blank 0.80 0.28 0.28 Blank RBRVS

93976 TC DUP-SCAN ARTL FLO ABDL/PEL/SCROT&/RPR ORGN LMT Miscellaneous Medical a Blank 3.56 3.56 Blank RBRVS

93978 Blank DUP-SCAN AORTA IVC ILIAC VASCL/BPGS COMPLETE Miscellaneous Medical a 0.80 4.57 4.57 Blank RBRVS

93978 26 DUP-SCAN AORTA IVC ILIAC VASCL/BPGS COMPLETE Miscellaneous Medical Blank 0.80 0.24 0.24 Blank RBRVS

93978 TC DUP-SCAN AORTA IVC ILIAC VASCL/BPGS COMPLETE Miscellaneous Medical a Blank 4.33 4.33 Blank RBRVS

93979 Blank DUP-SCAN AORTA IVC ILIAC VASCL/BPGS UNI/LMTD Miscellaneous Medical a 0.50 2.89 2.89 Blank RBRVS

93979 26 DUP-SCAN AORTA IVC ILIAC VASCL/BPGS UNI/LMTD Miscellaneous Medical Blank 0.50 0.15 0.15 Blank RBRVS

93979 TC DUP-SCAN AORTA IVC ILIAC VASCL/BPGS UNI/LMTD Miscellaneous Medical a Blank 2.74 2.74 Blank RBRVS

93980 Blank DUP-SCAN ARTL INFL&VEN O/F PEN VSL COMPL Miscellaneous Medical a 1.25 2.28 2.28 Blank RBRVS

93980 26 DUP-SCAN ARTL INFL&VEN O/F PEN VSL COMPL Miscellaneous Medical Blank 1.25 0.46 0.46 Blank RBRVS

93980 TC DUP-SCAN ARTL INFL&VEN O/F PEN VSL COMPL Miscellaneous Medical a Blank 1.82 1.82 Blank RBRVS

93981 Blank DUP-SCAN ARTL INFL&VEN O/F PEN VSL F-UP/LMTD STD Miscellaneous Medical a 0.44 1.71 1.71 Blank RBRVS

93981 26 DUP-SCAN ARTL INFL&VEN O/F PEN VSL F-UP/LMTD STD Miscellaneous Medical Blank 0.44 0.15 0.15 Blank RBRVS

93981 TC DUP-SCAN ARTL INFL&VEN O/F PEN VSL F-UP/LMTD STD Miscellaneous Medical a Blank 1.56 1.56 Blank RBRVS

93990 Blank DUPLEX SCAN HEMODIALYSIS ACCESS Miscellaneous Medical a 0.50 3.95 3.95 Blank RBRVS

93990 26 DUPLEX SCAN HEMODIALYSIS ACCESS Miscellaneous Medical Blank 0.50 0.12 0.12 Blank RBRVS

93990 TC DUPLEX SCAN HEMODIALYSIS ACCESS Miscellaneous Medical a Blank 3.83 3.83 Blank RBRVS

93998 Blank UNLISTED NONINVASIVE VASCULAR DIAGNOSTIC STUDY Miscellaneous Medical Blank Blank Blank Blank 5.37 Unlisted

94002 Blank VENTILATION ASSIST & MGMT INPATIENT 1ST DAY Miscellaneous Medical Blank 1.99 0.48 0.48 Blank RBRVS

94003 Blank VENTILATION ASSIST & MGMT INPATIENT EA SBSQ DA Miscellaneous Medical Blank 1.37 0.42 0.42 Blank RBRVS

94004 Blank VENTILATION ASSIST & MGMT NURSING FAC PR DAY Miscellaneous Medical Blank 1.00 0.32 0.32 Blank RBRVS

94005 Blank HOME VENTILATOR MGMT CARE OVERSIGHT 30 MIN/> Miscellaneous Medical Blank 1.50 1.04 1.04 Blank RBRVS

94010 Blank SPMTRY W/VC EXPIRATORY FLO W/WO MXML VOL VNTJ Miscellaneous Medical a 0.17 0.83 0.83 Blank RBRVS

94010 26 SPMTRY W/VC EXPIRATORY FLO W/WO MXML VOL VNTJ Miscellaneous Medical Blank 0.17 0.06 0.06 Blank RBRVS

94010 TC SPMTRY W/VC EXPIRATORY FLO W/WO MXML VOL VNTJ Miscellaneous Medical a Blank 0.77 0.77 Blank RBRVS

94011 Blank MEAS SPIROMTRC FORCD EXPIRATORY FLO INFANT&/2 Y Miscellaneous Medical Blank 1.75 0.61 0.61 Blank RBRVS

94012 Blank MEAS SPIRO FRCD EXP FLO PRE&POST BRONCH INF/2YRS Miscellaneous Medical Blank 2.85 0.99 0.99 Blank RBRVS





PAGE 123 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

94013 Blank MEASUREMENT LUNG VOLUMES INFANT/CHILD/2 YRS Miscellaneous Medical Blank 0.41 0.11 0.11 Blank RBRVS

94014 Blank PT-INITIATE SPIROMETRIC RECORDING PHYS/QHP R&I Miscellaneous Medical Blank 0.52 1.05 1.05 Blank RBRVS

94015 Blank PATIENT-INITIATED SPIROMETRIC RECORDING Miscellaneous Medical a Blank 0.87 0.87 Blank RBRVS

94016 Blank PATIENT-INITIATED SPIROMETRIC PHYS/QHP R&I ONLY Miscellaneous Medical Blank 0.52 0.18 0.18 Blank RBRVS

94060 Blank BRNCDILAT RSPSE SPMTRY PRE&POST-BRNCDILAT ADMN Miscellaneous Medical a 0.27 1.43 1.43 Blank RBRVS

94060 26 BRNCDILAT RSPSE SPMTRY PRE&POST-BRNCDILAT ADMN Miscellaneous Medical Blank 0.27 0.09 0.09 Blank RBRVS

94060 TC BRNCDILAT RSPSE SPMTRY PRE&POST-BRNCDILAT ADMN Miscellaneous Medical a Blank 1.34 1.34 Blank RBRVS

94070 Blank BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT Miscellaneous Medical a 0.60 1.08 1.08 Blank RBRVS

94070 26 BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT Miscellaneous Medical Blank 0.60 0.19 0.19 Blank RBRVS

94070 TC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT Miscellaneous Medical a Blank 0.89 0.89 Blank RBRVS

94150 Blank VITAL CAPACITY TOTAL SEPARATE PROCEDURE Miscellaneous Medical a 0.07 0.64 0.64 Blank RBRVS

94150 26 VITAL CAPACITY TOTAL SEPARATE PROCEDURE Miscellaneous Medical Blank 0.07 0.03 0.03 Blank RBRVS

94150 TC VITAL CAPACITY TOTAL SEPARATE PROCEDURE Miscellaneous Medical a Blank 0.61 0.61 Blank RBRVS

94200 Blank MAX BREATHING CAPACITY MAXIMAL VOLUNTARY VENTJ Miscellaneous Medical a 0.11 0.65 0.65 Blank RBRVS

94200 26 MAX BREATHING CAPACITY MAXIMAL VOLUNTARY VENTJ Miscellaneous Medical Blank 0.11 0.04 0.04 Blank RBRVS

94200 TC MAX BREATHING CAPACITY MAXIMAL VOLUNTARY VENTJ Miscellaneous Medical a Blank 0.61 0.61 Blank RBRVS

94250 Blank EXPIRED GAS COLLECTION QUANT 1 PROCEDURE SPX Miscellaneous Medical a 0.11 0.67 0.67 Blank RBRVS

94250 26 EXPIRED GAS COLLECTION QUANT 1 PROCEDURE SPX Miscellaneous Medical Blank 0.11 0.04 0.04 Blank RBRVS

94250 TC EXPIRED GAS COLLECTION QUANT 1 PROCEDURE SPX Miscellaneous Medical a Blank 0.63 0.63 Blank RBRVS

94375 Blank RESPIRATORY FLOW VOLUME LOOP Miscellaneous Medical a 0.31 0.80 0.80 Blank RBRVS

94375 26 RESPIRATORY FLOW VOLUME LOOP Miscellaneous Medical Blank 0.31 0.10 0.10 Blank RBRVS

94375 TC RESPIRATORY FLOW VOLUME LOOP Miscellaneous Medical a Blank 0.70 0.70 Blank RBRVS

94400 Blank BREATHING RESPONSE TO CO2 Miscellaneous Medical a 0.40 1.21 1.21 Blank RBRVS

94400 26 BREATHING RESPONSE TO CO2 Miscellaneous Medical Blank 0.40 0.14 0.14 Blank RBRVS

94400 TC BREATHING RESPONSE TO CO2 Miscellaneous Medical a Blank 1.07 1.07 Blank RBRVS

94450 Blank BREATHING RESPONSE TO HYPOXIA Miscellaneous Medical a 0.40 1.59 1.59 Blank RBRVS

94450 26 BREATHING RESPONSE TO HYPOXIA Miscellaneous Medical Blank 0.40 0.15 0.15 Blank RBRVS

94450 TC BREATHING RESPONSE TO HYPOXIA Miscellaneous Medical a Blank 1.44 1.44 Blank RBRVS

94452 Blank HIGH ALTITUDE SIMULATJ TEST W/PHYS INTERP&REPORT Miscellaneous Medical a 0.31 1.31 1.31 Blank RBRVS

94452 26 HIGH ALTITUDE SIMULATJ TEST W/PHYS INTERP&REPORT Miscellaneous Medical Blank 0.31 0.09 0.09 Blank RBRVS

94452 TC HIGH ALTITUDE SIMULATJ TEST W/PHYS INTERP&REPORT Miscellaneous Medical a Blank 1.22 1.22 Blank RBRVS

94453 Blank HIGH ALTITUDE SIMULATJ W/PHYS I&R W/O2 TITRATION Miscellaneous Medical a 0.40 1.84 1.84 Blank RBRVS

94453 26 HIGH ALTITUDE SIMULATJ W/PHYS I&R W/O2 TITRATION Miscellaneous Medical Blank 0.40 0.12 0.12 Blank RBRVS

94453 TC HIGH ALTITUDE SIMULATJ W/PHYS I&R W/O2 TITRATION Miscellaneous Medical a Blank 1.72 1.72 Blank RBRVS

94610 Blank INTRAPULMONARY SURFACTANT ADMINISTJ PHYS/QHP Miscellaneous Medical Blank 1.16 0.34 0.34 Blank RBRVS

94617 Blank EXERCISE TST BRNCSPSM Miscellaneous Medical a 0.70 1.95 1.95 Blank RBRVS

94617 26 EXERCISE TST BRNCSPSM Miscellaneous Medical Blank 0.70 0.22 0.22 Blank RBRVS

94617 TC EXERCISE TST BRNCSPSM Miscellaneous Medical a Blank 1.73 1.73 Blank RBRVS

94618 Blank PULMONARY STRESS TESTING Miscellaneous Medical a 0.48 0.46 0.46 Blank RBRVS

94618 26 PULMONARY STRESS TESTING Miscellaneous Medical Blank 0.48 0.15 0.15 Blank RBRVS

94618 TC PULMONARY STRESS TESTING Miscellaneous Medical a Blank 0.31 0.31 Blank RBRVS

94621 Blank PULMONARY STRESS TESTING COMPLEX Miscellaneous Medical a 1.42 3.18 3.18 Blank RBRVS

94621 26 PULMONARY STRESS TESTING COMPLEX Miscellaneous Medical Blank 1.42 0.48 0.48 Blank RBRVS

94621 TC PULMONARY STRESS TESTING COMPLEX Miscellaneous Medical a Blank 2.70 2.70 Blank RBRVS

94640 Blank PRESSURIZED/NONPRESSURIZED INHALATION TREATMENT Miscellaneous Medical Blank Blank 0.52 0.52 Blank RBRVS

94642 Blank PENTAMIDINE AERSL INHALATION PNEUMOCYSTIS/PROPH Miscellaneous Medical Blank Blank Blank Blank 1.26 FAIR Health

94644 Blank CONTINUOUS INHALATION TREATMENT 1ST HR Miscellaneous Medical Blank Blank 1.27 1.27 Blank RBRVS

94645 Blank CONTINUOUS INHALATION TREATMENT EA ADDL HR Miscellaneous Medical Blank Blank 0.45 0.45 Blank RBRVS

94660 Blank CPAP VENTILATION CPAP INITIATION&MGMT Miscellaneous Medical Blank 0.76 0.27 1.02 Blank RBRVS

94662 Blank CONTINUOUS NEGATIVE PRESSURE VENTJ INITIAT&MGM Miscellaneous Medical Blank 0.76 0.21 0.21 Blank RBRVS

94664 Blank DEMO&/EVAL OF PT UTILIZ AERSL GEN/NEB/INHLR/IP Miscellaneous Medical Blank Blank 0.48 0.48 Blank RBRVS

94667 Blank MANJ CH WALL FACILITATE LNG FUNCJ 1 DEMO&/EVAL Miscellaneous Medical Blank Blank 0.74 0.74 Blank RBRVS

94668 Blank MANJ CHEST WALL FACILITATE LUNG FUNCTION SUBSQ Miscellaneous Medical Blank Blank 0.89 0.89 Blank RBRVS

94669 Blank MECHANICAL CHEST WALL OSCILLATION LUNG FUNCTION Miscellaneous Medical Blank Blank 0.90 0.90 Blank RBRVS

94680 Blank O2 UPTK EXP GAS ANALYSIS REST&XERS DIRECT SIMP Miscellaneous Medical a 0.26 1.38 1.38 Blank RBRVS

94680 26 O2 UPTK EXP GAS ANALYSIS REST&XERS DIRECT SIMP Miscellaneous Medical Blank 0.26 0.09 0.09 Blank RBRVS

94680 TC O2 UPTK EXP GAS ANALYSIS REST&XERS DIRECT SIMP Miscellaneous Medical a Blank 1.29 1.29 Blank RBRVS

94681 Blank O2 UPTK EXP GAS ALYS W/CO2 OUTPUT % O2 XTRC Miscellaneous Medical a 0.20 1.40 1.40 Blank RBRVS

94681 26 O2 UPTK EXP GAS ALYS W/CO2 OUTPUT % O2 XTRC Miscellaneous Medical Blank 0.20 0.08 0.08 Blank RBRVS

94681 TC O2 UPTK EXP GAS ALYS W/CO2 OUTPUT % O2 XTRC Miscellaneous Medical a Blank 1.32 1.32 Blank RBRVS

94690 Blank O2 UPTAKE EXP GAS ANALYSIS REST INDIRECT SPX Miscellaneous Medical a 0.07 1.49 1.49 Blank RBRVS

94690 26 O2 UPTAKE EXP GAS ANALYSIS REST INDIRECT SPX Miscellaneous Medical Blank 0.07 0.03 0.03 Blank RBRVS

94690 TC O2 UPTAKE EXP GAS ANALYSIS REST INDIRECT SPX Miscellaneous Medical a Blank 1.46 1.46 Blank RBRVS

94726 Blank PLETHYSMOGRAPHY LUNG VOLUMES W/WO AIRWAY RESIST Miscellaneous Medical a 0.26 1.28 1.28 Blank RBRVS

94726 26 PLETHYSMOGRAPHY LUNG VOLUMES W/WO AIRWAY RESIST Miscellaneous Medical Blank 0.26 0.08 0.08 Blank RBRVS

94726 TC PLETHYSMOGRAPHY LUNG VOLUMES W/WO AIRWAY RESIST Miscellaneous Medical a Blank 1.20 1.20 Blank RBRVS

94727 Blank GAS DILUT/WASHOUT LUNG VOL W/WO DISTRIB VENT&V Miscellaneous Medical a 0.26 0.97 0.97 Blank RBRVS

94727 26 GAS DILUT/WASHOUT LUNG VOL W/WO DISTRIB VENT&V Miscellaneous Medical Blank 0.26 0.08 0.08 Blank RBRVS

94727 TC GAS DILUT/WASHOUT LUNG VOL W/WO DISTRIB VENT&V Miscellaneous Medical a Blank 0.89 0.89 Blank RBRVS

94728 Blank AIRWAY RESISTANCE BY IMPULSE OSCILLOMETRY Miscellaneous Medical a 0.26 0.89 0.89 Blank RBRVS

94728 26 AIRWAY RESISTANCE BY IMPULSE OSCILLOMETRY Miscellaneous Medical Blank 0.26 0.09 0.09 Blank RBRVS

94728 TC AIRWAY RESISTANCE BY IMPULSE OSCILLOMETRY Miscellaneous Medical a Blank 0.80 0.80 Blank RBRVS





PAGE 124 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

94729 Blank CO DIFFUSING CAPACITY Miscellaneous Medical a 0.19 1.34 1.34 Blank RBRVS

94729 26 CO DIFFUSING CAPACITY Miscellaneous Medical Blank 0.19 0.06 0.06 Blank RBRVS

94729 TC CO DIFFUSING CAPACITY Miscellaneous Medical a Blank 1.28 1.28 Blank RBRVS

94750 Blank PULMONARY COMPLIANCE STUDY Miscellaneous Medical a 0.23 2.09 2.09 Blank RBRVS

94750 26 PULMONARY COMPLIANCE STUDY Miscellaneous Medical Blank 0.23 0.07 0.07 Blank RBRVS

94750 TC PULMONARY COMPLIANCE STUDY Miscellaneous Medical a Blank 2.02 2.02 Blank RBRVS

94760 Blank NONINVASIVE EAR/PULSE OXIMETRY SINGLE DETER Miscellaneous Medical a Blank 0.07 0.07 Blank RBRVS

94761 Blank NONINVASIVE EAR/PULSE OXIMETRY MULTIPLE DETER Miscellaneous Medical a Blank 0.12 0.12 Blank RBRVS

94762 Blank NONINVASIVE EAR/PULSE OXIMETRY OVERNIGHT MONITOR Miscellaneous Medical a Blank 0.69 0.69 Blank RBRVS

94770 Blank CARBON DIOXIDE EXP GAS DETER INFRARED ANALYZER Miscellaneous Medical a Blank Blank Blank 0.20 Global/TC/26

94770 26 CARBON DIOXIDE EXP GAS DETER INFRARED ANALYZER Miscellaneous Medical Blank Blank Blank Blank 0.04 Global/TC/26

94770 TC CARBON DIOXIDE EXP GAS DETER INFRARED ANALYZER Miscellaneous Medical a Blank Blank Blank 0.16 Global/TC/26

94772 Blank CIRCADIAN RESPIRATRY PATTERN REC 12-24 HR INFANT Miscellaneous Medical a Blank Blank Blank 2.45 FAIR Health

94772 26 CIRCADIAN RESPIRATRY PATTERN REC 12-24 HR INFANT Miscellaneous Medical Blank Blank Blank Blank 1.53 FAIR Health

94772 TC CIRCADIAN RESPIRATRY PATTERN REC 12-24 HR INFANT Miscellaneous Medical a Blank Blank Blank 0.92 FAIR Health

94774 Blank PEDIATRIC APNEA MONITOR ATTACHMENT PHYS I&R Miscellaneous Medical Blank Blank Blank Blank 3.97 FAIR Health

94776 Blank PEDIATRIC APNEA MONITOR ANALYSES COMPUTER Miscellaneous Medical a Blank Blank Blank 4.33 FAIR Health

94777 Blank PEDIATRIC APNEA MONITOR PHYS/QHP REVIEW Miscellaneous Medical Blank Blank Blank Blank 2.65 FAIR Health

94780 Blank CAR SEAT/BED TESTING W/INTERP & REPORT 60 MIN Miscellaneous Medical Blank 0.48 0.17 0.97 Blank RBRVS

94781 Blank CAR SEAT/BED TESTNG W/INTERP & REPORT ADDL 30MIN Miscellaneous Medical Blank 0.17 0.06 0.41 Blank RBRVS

94799 Blank UNLISTED PULMONARY SERVICE/PROCEDURE Miscellaneous Medical a Blank Blank Blank 1.50 Unlisted

94799 26 UNLISTED PULMONARY SERVICE/PROCEDURE Miscellaneous Medical Blank Blank Blank Blank 0.30 Unlisted

94799 TC UNLISTED PULMONARY SERVICE/PROCEDURE Miscellaneous Medical a Blank Blank Blank 1.20 Unlisted

95004 Blank PERCUTANEOUS TESTS W/ALLERGENIC EXTRACTS Allergy Testing Blank 0.01 0.13 0.13 Blank RBRVS

95012 Blank NITRIC OXIDE EXPIRED GAS DETERMINATION Allergy Testing Blank Blank 0.56 0.56 Blank RBRVS

95017 Blank ALLG TSTG PERQ & IC VENOMS IMMED REACT W/I&R Allergy Testing Blank 0.07 0.03 0.14 Blank RBRVS

95018 Blank ALLG TEST PERQ & IC DRUG/BIOL IMMED REACT W/I&R Allergy Testing Blank 0.14 0.05 0.45 Blank RBRVS

95024 Blank INTRACUTANEOUS TESTS W/ALLERGENIC EXTRACTS Allergy Testing Blank 0.01 0.01 0.21 Blank RBRVS

95027 Blank INTRACUTANEOUS TESTS W/ALLERGENIC XTRCS AIRBORNE Allergy Testing Blank 0.01 0.11 0.11 Blank RBRVS

95028 Blank IC TSTS W/ALLGIC XTRCS DLYD TYP RXN W/READING Allergy Testing a Blank 0.36 0.36 Blank RBRVS

95044 Blank PATCH/APPLICATION TEST SPECIFY NUMBER TESTS Allergy Testing Blank Blank 0.15 0.15 Blank RBRVS

95052 Blank PHOTO PATCH TEST SPECIFY NUMBER TSTS Allergy Testing Blank Blank 0.18 0.18 Blank RBRVS

95056 Blank PHOTO TESTS Allergy Testing Blank Blank 1.28 1.28 Blank RBRVS

95060 Blank OPHTHALMIC MUCOUS MEMBRANE TESTS Allergy Testing a Blank 0.99 0.99 Blank RBRVS

95065 Blank DIRECT NASAL MUCOUS MEMBRANE TEST Allergy Testing a Blank 0.70 0.70 Blank RBRVS

95070 Blank INHLJ BRNCL CHALLENGE TSTG W/HISTAM/METHACHOL Allergy Testing a Blank 0.86 0.86 Blank RBRVS

95071 Blank INHLJ BRNCL CHALLENGE TSTG W/AGS/GASES Allergy Testing a Blank 0.99 0.99 Blank RBRVS

95076 Blank INGESTION CHALLENGE TEST INITIAL 120 MINUTES Allergy Testing Blank 1.50 0.55 1.83 Blank RBRVS

95079 Blank INGESTION CHALLENGE TEST EACH ADDL 60 MINUTES Allergy Testing Blank 1.38 0.50 0.95 Blank RBRVS

95115 Blank PROF SVCS ALLG IMMNTX X W/PRV ALLGIC XTRCS 1 NJX Allergy Immunotherapy Blank Blank 0.24 0.24 Blank RBRVS

95117 Blank PROF SVCS ALLG IMMNTX X W/PRV ALLGIC XTRCS NJXS Allergy Immunotherapy Blank Blank 0.28 0.28 Blank RBRVS

95120 Blank PROF SVCS ALLG IMMNTX W/PRV ALLGIC XTRC 1 NJX Allergy Immunotherapy Blank Blank Blank Blank 0.47 FAIR Health

95125 Blank PROF SVCS ALLG IMMNTX W/PRV ALLGIC XTRC 2/> NJX Allergy Immunotherapy Blank Blank Blank Blank 0.51 FAIR Health

95130 Blank PROF SVCS ALLG IMMNTX W/PRV XTRC 1 STING INSECT Allergy Immunotherapy Blank Blank Blank Blank 0.53 FAIR Health





95144 Blank PREPJ& ANTIGEN PRV ALLERGEN IMMUNOTHERAPY 1 DO Allergy Immunotherapy Blank 0.06 0.02 0.31 Blank RBRVS

95145 Blank PREPJ& ANTIGEN ALLERGEN IMMUNOTHERAPY 1 INSECT Allergy Immunotherapy Blank 0.06 0.02 0.66 Blank RBRVS





95165 Blank PREPJ& ALLERGEN IMMUNOTHERAPY 1/MLT ANTIGEN Allergy Immunotherapy Blank 0.06 0.02 0.30 Blank RBRVS

95170 Blank PREPJ& ANTIGEN ALLERGEN IMMUNOTHERAPY WHL INSE Allergy Immunotherapy Blank 0.06 0.02 0.21 Blank RBRVS

95180 Blank RAPID DESENSITIZATION PROCEDURE EACH HOUR Allergy Immunotherapy Blank 2.01 0.82 1.77 Blank RBRVS

95199 Blank UNLISTED ALLERGY/CLINICAL IMMUNOLOGIC SRVC/PX Allergy Immunotherapy Blank Blank Blank Blank 0.28 Unlisted

95249 Blank CONT GLUC MNTR PT PROV EQP Miscellaneous Medical a Blank 1.53 1.53 Blank RBRVS

95250 Blank GLUC MNTR CONT REC FROM INTERSTITIAL TISS FLUID Miscellaneous Medical a Blank 4.31 4.31 Blank RBRVS

95251 Blank GLUC MNTR CONT REC FROM NTRSTL TISS FLU I&R Miscellaneous Medical Blank 0.70 0.28 0.28 Blank RBRVS

95782 Blank POLYSOM <6 YRS SLEEP STAGE 4/> ADDL PARAM ATTND Miscellaneous Medical a 2.60 23.13 23.13 Blank RBRVS

95782 26 POLYSOM <6 YRS SLEEP STAGE 4/> ADDL PARAM ATTND Miscellaneous Medical Blank 2.60 0.90 0.90 Blank RBRVS

95782 TC POLYSOM <6 YRS SLEEP STAGE 4/> ADDL PARAM ATTND Miscellaneous Medical a Blank 22.23 22.23 Blank RBRVS

95783 Blank POLYSOM <6 YRS SLEEP W/CPAP/BILVL VENT 4/> PARAM Miscellaneous Medical a 2.83 24.61 24.61 Blank RBRVS

95783 26 POLYSOM <6 YRS SLEEP W/CPAP/BILVL VENT 4/> PARAM Miscellaneous Medical Blank 2.83 0.98 0.98 Blank RBRVS

95783 TC POLYSOM <6 YRS SLEEP W/CPAP/BILVL VENT 4/> PARAM Miscellaneous Medical a Blank 23.63 23.63 Blank RBRVS

95800 Blank SLP STDY UNATND W/HRT RATE/O2 SAT/RESP/SLP TIME Miscellaneous Medical a 1.05 3.91 3.91 Blank RBRVS

95800 26 SLP STDY UNATND W/HRT RATE/O2 SAT/RESP/SLP TIME Miscellaneous Medical Blank 1.05 0.38 0.38 Blank RBRVS

95800 TC SLP STDY UNATND W/HRT RATE/O2 SAT/RESP/SLP TIME Miscellaneous Medical a Blank 3.53 3.53 Blank RBRVS

95801 Blank SLP STDY UNATND W/MIN HRT RATE/O2 SAT/RESP ANAL Miscellaneous Medical a 1.00 1.52 1.52 Blank RBRVS

95801 26 SLP STDY UNATND W/MIN HRT RATE/O2 SAT/RESP ANAL Miscellaneous Medical Blank 1.00 0.36 0.36 Blank RBRVS





PAGE 125 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

95801 TC SLP STDY UNATND W/MIN HRT RATE/O2 SAT/RESP ANAL Miscellaneous Medical a Blank 1.16 1.16 Blank RBRVS

95803 Blank ACTIGRAPHY TESTING RECORDING ANALYSIS I&R Miscellaneous Medical a 0.90 3.11 3.11 Blank RBRVS

95803 26 ACTIGRAPHY TESTING RECORDING ANALYSIS I&R Miscellaneous Medical Blank 0.90 0.31 0.31 Blank RBRVS

95803 TC ACTIGRAPHY TESTING RECORDING ANALYSIS I&R Miscellaneous Medical a Blank 2.80 2.80 Blank RBRVS

95805 Blank MLT SLEEP LATENCY/MAINT OF WAKEFULNESS TSTG Miscellaneous Medical a 1.20 10.92 10.92 Blank RBRVS

95805 26 MLT SLEEP LATENCY/MAINT OF WAKEFULNESS TSTG Miscellaneous Medical Blank 1.20 0.43 0.43 Blank RBRVS

95805 TC MLT SLEEP LATENCY/MAINT OF WAKEFULNESS TSTG Miscellaneous Medical a Blank 10.49 10.49 Blank RBRVS

95806 Blank SLEEP STD AIRFLOW HRT RATE&O2 SAT EFFORT UNATT Miscellaneous Medical a 1.25 3.51 3.51 Blank RBRVS

95806 26 SLEEP STD AIRFLOW HRT RATE&O2 SAT EFFORT UNATT Miscellaneous Medical Blank 1.25 0.44 0.44 Blank RBRVS

95806 TC SLEEP STD AIRFLOW HRT RATE&O2 SAT EFFORT UNATT Miscellaneous Medical a Blank 3.07 3.07 Blank RBRVS

95807 Blank SLEEP STD REC VNTJ RESPIR ECG/HRT RATE&O2 ATTN Miscellaneous Medical a 1.28 11.64 11.64 Blank RBRVS

95807 26 SLEEP STD REC VNTJ RESPIR ECG/HRT RATE&O2 ATTN Miscellaneous Medical Blank 1.28 0.43 0.43 Blank RBRVS

95807 TC SLEEP STD REC VNTJ RESPIR ECG/HRT RATE&O2 ATTN Miscellaneous Medical a Blank 11.21 11.21 Blank RBRVS

95808 Blank POLYSOM ANY AGE SLEEP STAGE 1-3 ADDL PARAM ATTND Miscellaneous Medical a 1.74 17.96 17.96 Blank RBRVS

95808 26 POLYSOM ANY AGE SLEEP STAGE 1-3 ADDL PARAM ATTND Miscellaneous Medical Blank 1.74 0.70 0.70 Blank RBRVS

95808 TC POLYSOM ANY AGE SLEEP STAGE 1-3 ADDL PARAM ATTND Miscellaneous Medical a Blank 17.26 17.26 Blank RBRVS

95810 Blank POLYSOM 6/>YRS SLEEP 4/> ADDL PARAM ATTND Miscellaneous Medical a 2.50 15.04 15.04 Blank RBRVS

95810 26 POLYSOM 6/>YRS SLEEP 4/> ADDL PARAM ATTND Miscellaneous Medical Blank 2.50 0.85 0.85 Blank RBRVS

95810 TC POLYSOM 6/>YRS SLEEP 4/> ADDL PARAM ATTND Miscellaneous Medical a Blank 14.19 14.19 Blank RBRVS

95811 Blank POLYSOM 6/>YRS SLEEP W/CPAP 4/> ADDL PARAM ATTND Miscellaneous Medical a 2.60 15.82 15.82 Blank RBRVS

95811 26 POLYSOM 6/>YRS SLEEP W/CPAP 4/> ADDL PARAM ATTND Miscellaneous Medical Blank 2.60 0.88 0.88 Blank RBRVS

95811 TC POLYSOM 6/>YRS SLEEP W/CPAP 4/> ADDL PARAM ATTND Miscellaneous Medical a Blank 14.94 14.94 Blank RBRVS

95812 Blank ELECTROENCEPHALOGRAM EXTEND MONITORING 41-60 MIN Miscellaneous Medical a 1.08 8.00 8.00 Blank RBRVS

95812 26 ELECTROENCEPHALOGRAM EXTEND MONITORING 41-60 MIN Miscellaneous Medical Blank 1.08 0.51 0.51 Blank RBRVS

95812 TC ELECTROENCEPHALOGRAM EXTEND MONITORING 41-60 MIN Miscellaneous Medical a Blank 7.49 7.49 Blank RBRVS

95813 Blank ELECTROENCEPHALOGRAM EXTND MNTR >1 HR Miscellaneous Medical a 1.63 9.76 9.76 Blank RBRVS

95813 26 ELECTROENCEPHALOGRAM EXTND MNTR >1 HR Miscellaneous Medical Blank 1.63 0.75 0.75 Blank RBRVS

95813 TC ELECTROENCEPHALOGRAM EXTND MNTR >1 HR Miscellaneous Medical a Blank 9.01 9.01 Blank RBRVS

95816 Blank ELECTROENCEPHALOGRAM W/REC AWAKE&DROWSY Miscellaneous Medical a 1.08 9.16 9.16 Blank RBRVS

95816 26 ELECTROENCEPHALOGRAM W/REC AWAKE&DROWSY Miscellaneous Medical Blank 1.08 0.51 0.51 Blank RBRVS

95816 TC ELECTROENCEPHALOGRAM W/REC AWAKE&DROWSY Miscellaneous Medical a Blank 8.65 8.65 Blank RBRVS

95819 Blank ELECTROENCEPHALOGRAM W/REC AWAKE&ASLEEP Miscellaneous Medical a 1.08 10.83 10.83 Blank RBRVS

95819 26 ELECTROENCEPHALOGRAM W/REC AWAKE&ASLEEP Miscellaneous Medical Blank 1.08 0.51 0.51 Blank RBRVS

95819 TC ELECTROENCEPHALOGRAM W/REC AWAKE&ASLEEP Miscellaneous Medical a Blank 10.32 10.32 Blank RBRVS

95822 Blank ELECTROENCEPHALOGRAM REC COMA/SLEEP ONLY Miscellaneous Medical a 1.08 9.65 9.65 Blank RBRVS

95822 26 ELECTROENCEPHALOGRAM REC COMA/SLEEP ONLY Miscellaneous Medical Blank 1.08 0.51 0.51 Blank RBRVS

95822 TC ELECTROENCEPHALOGRAM REC COMA/SLEEP ONLY Miscellaneous Medical a Blank 9.14 9.14 Blank RBRVS

95824 Blank ELECTROENCEPHALOGRAM CERE DEATH EVAL ONLY Miscellaneous Medical a Blank Blank Blank 2.79 Global/TC/26

95824 26 ELECTROENCEPHALOGRAM CERE DEATH EVAL ONLY Miscellaneous Medical Blank Blank Blank Blank 1.09 Global/TC/26

95824 TC ELECTROENCEPHALOGRAM CERE DEATH EVAL ONLY Miscellaneous Medical a Blank Blank Blank 1.70 Global/TC/26

95827 Blank ELECTROENCEPHALOGRAM ALL NIGHT RECORDING Miscellaneous Medical a 1.08 16.54 16.54 Blank RBRVS

95827 26 ELECTROENCEPHALOGRAM ALL NIGHT RECORDING Miscellaneous Medical Blank 1.08 0.47 0.47 Blank RBRVS

95827 TC ELECTROENCEPHALOGRAM ALL NIGHT RECORDING Miscellaneous Medical a Blank 16.07 16.07 Blank RBRVS

95829 Blank ELECTROCORTICOGRAM SURGERY SPX Miscellaneous Medical a 6.20 47.47 47.47 Blank RBRVS

95829 26 ELECTROCORTICOGRAM SURGERY SPX Miscellaneous Medical Blank 6.20 2.89 2.89 Blank RBRVS

95829 TC ELECTROCORTICOGRAM SURGERY SPX Miscellaneous Medical a Blank 44.58 44.58 Blank RBRVS

95830 Blank INSERTION SPHENOIDAL ELECTRODES EEG PHYS/QHP Miscellaneous Medical Blank 1.70 0.79 4.81 Blank RBRVS

95831 Blank MUSC TSTG MNL W/REPRT XTR EX HAND/TRNK Miscellaneous Medical Blank 0.28 0.13 0.62 Blank RBRVS

95832 Blank MUSC TSTG MNL W/REPRT HAND W/WO CMPRSN NRML SIDE Miscellaneous Medical Blank 0.29 0.14 0.58 Blank RBRVS

95833 Blank MUSC TSTG MNL W/REPRT TOTAL EVAL BODY EX HANDS Miscellaneous Medical Blank 0.47 0.14 0.67 Blank RBRVS

95834 Blank MUSC TSTG MNL W/REPRT TOTAL EVAL BODY W/HANDS Miscellaneous Medical Blank 0.60 0.26 0.90 Blank RBRVS

95836 Blank ECOG IMPLTD BRN NPGT </30 D Miscellaneous Medical Blank 1.98 0.84 0.84 Blank RBRVS

95851 Blank ROM MEAS&REPRT EA XTR EX HAND/EA TRNK SCTJ SPI Miscellaneous Medical Blank 0.16 0.05 0.40 Blank RBRVS

95852 Blank ROM MEAS&REPRT HAND W/WO COMPARISON NORMAL SID Miscellaneous Medical Blank 0.11 0.05 0.40 Blank RBRVS

95857 Blank CHOLINESTERASE INHIBITOR CHALLENGE TEST Miscellaneous Medical Blank 0.53 0.28 0.96 Blank RBRVS

95860 Blank NDL EMG 1 XTR W/WO RELATED PARASPINAL AREAS Miscellaneous Medical a 0.96 2.49 2.49 Blank RBRVS

95860 26 NDL EMG 1 XTR W/WO RELATED PARASPINAL AREAS Miscellaneous Medical Blank 0.96 0.48 0.48 Blank RBRVS

95860 TC NDL EMG 1 XTR W/WO RELATED PARASPINAL AREAS Miscellaneous Medical a Blank 2.01 2.01 Blank RBRVS










95865 Blank NEEDLE ELECTROMYOGRAPHY LARYNX Miscellaneous Medical a 1.57 2.51 2.51 Blank RBRVS

95865 26 NEEDLE ELECTROMYOGRAPHY LARYNX Miscellaneous Medical Blank 1.57 0.73 0.73 Blank RBRVS

95865 TC NEEDLE ELECTROMYOGRAPHY LARYNX Miscellaneous Medical a Blank 1.78 1.78 Blank RBRVS

95866 Blank NEEDLE ELECTROMYOGRAPHY HEMIDIAPHRAGM Miscellaneous Medical a 1.25 2.52 2.52 Blank RBRVS

95866 26 NEEDLE ELECTROMYOGRAPHY HEMIDIAPHRAGM Miscellaneous Medical Blank 1.25 0.62 0.62 Blank RBRVS





PAGE 126 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

95866 TC NEEDLE ELECTROMYOGRAPHY HEMIDIAPHRAGM Miscellaneous Medical a Blank 1.90 1.90 Blank RBRVS

95867 Blank NEEDLE ELECTROMYOGRAPHY CRANIAL NRV MUSCLE UNI Miscellaneous Medical a 0.79 2.04 2.04 Blank RBRVS

95867 26 NEEDLE ELECTROMYOGRAPHY CRANIAL NRV MUSCLE UNI Miscellaneous Medical Blank 0.79 0.37 0.37 Blank RBRVS

95867 TC NEEDLE ELECTROMYOGRAPHY CRANIAL NRV MUSCLE UNI Miscellaneous Medical a Blank 1.67 1.67 Blank RBRVS

95868 Blank NEEDLE ELECTROMYOGRAPHY CRANIAL NRV MUSCLE BI Miscellaneous Medical a 1.18 2.60 2.60 Blank RBRVS

95868 26 NEEDLE ELECTROMYOGRAPHY CRANIAL NRV MUSCLE BI Miscellaneous Medical Blank 1.18 0.56 0.56 Blank RBRVS

95868 TC NEEDLE ELECTROMYOGRAPHY CRANIAL NRV MUSCLE BI Miscellaneous Medical a Blank 2.04 2.04 Blank RBRVS

95869 Blank NEEDLE EMG THRC PARASPI MUSC EXCLUDING T1/T12 Miscellaneous Medical a 0.37 2.26 2.26 Blank RBRVS

95869 26 NEEDLE EMG THRC PARASPI MUSC EXCLUDING T1/T12 Miscellaneous Medical Blank 0.37 0.18 0.18 Blank RBRVS

95869 TC NEEDLE EMG THRC PARASPI MUSC EXCLUDING T1/T12 Miscellaneous Medical a Blank 2.08 2.08 Blank RBRVS

95870 Blank NEEDLE EMG LMTD STD MUSC 1 XTR/NON-LIMB UNI/BI Miscellaneous Medical a 0.37 2.30 2.30 Blank RBRVS

95870 26 NEEDLE EMG LMTD STD MUSC 1 XTR/NON-LIMB UNI/BI Miscellaneous Medical Blank 0.37 0.18 0.18 Blank RBRVS

95870 TC NEEDLE EMG LMTD STD MUSC 1 XTR/NON-LIMB UNI/BI Miscellaneous Medical a Blank 2.12 2.12 Blank RBRVS

95872 Blank NEEDLE EMG W/1 FIBER ELECTRODE QUAN MEAS JITTER Miscellaneous Medical a 2.88 2.53 2.53 Blank RBRVS

95872 26 NEEDLE EMG W/1 FIBER ELECTRODE QUAN MEAS JITTER Miscellaneous Medical Blank 2.88 1.34 1.34 Blank RBRVS

95872 TC NEEDLE EMG W/1 FIBER ELECTRODE QUAN MEAS JITTER Miscellaneous Medical a Blank 1.19 1.19 Blank RBRVS

95873 Blank ELECTRICAL STIMULATION GUID W/CHEMODENERVATION Miscellaneous Medical a 0.37 1.71 1.71 Blank RBRVS

95873 26 ELECTRICAL STIMULATION GUID W/CHEMODENERVATION Miscellaneous Medical Blank 0.37 0.19 0.19 Blank RBRVS

95873 TC ELECTRICAL STIMULATION GUID W/CHEMODENERVATION Miscellaneous Medical a Blank 1.52 1.52 Blank RBRVS

95874 Blank NEEDLE EMG GUID W/CHEMODENERVATION Miscellaneous Medical a 0.37 1.74 1.74 Blank RBRVS

95874 26 NEEDLE EMG GUID W/CHEMODENERVATION Miscellaneous Medical Blank 0.37 0.18 0.18 Blank RBRVS

95874 TC NEEDLE EMG GUID W/CHEMODENERVATION Miscellaneous Medical a Blank 1.56 1.56 Blank RBRVS

95875 Blank ISCHEMIC LIMB XERS TST SPEC ACQUISJ METAB Miscellaneous Medical a 1.10 2.54 2.54 Blank RBRVS

95875 26 ISCHEMIC LIMB XERS TST SPEC ACQUISJ METAB Miscellaneous Medical Blank 1.10 0.53 0.53 Blank RBRVS

95875 TC ISCHEMIC LIMB XERS TST SPEC ACQUISJ METAB Miscellaneous Medical a Blank 2.01 2.01 Blank RBRVS

95885 Blank NEEDLE EMG EA EXTREMITY W/PARASPINL AREA LIMITED Miscellaneous Medical a 0.35 1.31 1.31 Blank RBRVS

95885 26 NEEDLE EMG EA EXTREMITY W/PARASPINL AREA LIMITED Miscellaneous Medical Blank 0.35 0.17 0.17 Blank RBRVS

95885 TC NEEDLE EMG EA EXTREMITY W/PARASPINL AREA LIMITED Miscellaneous Medical a Blank 1.14 1.14 Blank RBRVS

95886 Blank NEEDLE EMG EA EXTREMTY W/PARASPINL AREA COMPLETE Miscellaneous Medical a 0.86 1.70 1.70 Blank RBRVS

95886 26 NEEDLE EMG EA EXTREMTY W/PARASPINL AREA COMPLETE Miscellaneous Medical Blank 0.86 0.42 0.42 Blank RBRVS

95886 TC NEEDLE EMG EA EXTREMTY W/PARASPINL AREA COMPLETE Miscellaneous Medical a Blank 1.28 1.28 Blank RBRVS

95887 Blank NEEDLE EMG NONEXTREMTY MSCLES W/NERVE CONDUCTION Miscellaneous Medical a 0.71 1.55 1.55 Blank RBRVS

95887 26 NEEDLE EMG NONEXTREMTY MSCLES W/NERVE CONDUCTION Miscellaneous Medical Blank 0.71 0.34 0.34 Blank RBRVS

95887 TC NEEDLE EMG NONEXTREMTY MSCLES W/NERVE CONDUCTION Miscellaneous Medical a Blank 1.21 1.21 Blank RBRVS

95905 Blank MOTOR &/SENS NRV CNDJ PRECONF ELTRD ARRAY LIMB Miscellaneous Medical a 0.05 1.99 1.99 Blank RBRVS

95905 26 MOTOR &/SENS NRV CNDJ PRECONF ELTRD ARRAY LIMB Miscellaneous Medical Blank 0.05 0.02 0.02 Blank RBRVS

95905 TC MOTOR &/SENS NRV CNDJ PRECONF ELTRD ARRAY LIMB Miscellaneous Medical a Blank 1.97 1.97 Blank RBRVS

95907 Blank NERVE CONDUCTION STUDIES 1-2 STUDIES Miscellaneous Medical a 1.00 1.72 1.72 Blank RBRVS

95907 26 NERVE CONDUCTION STUDIES 1-2 STUDIES Miscellaneous Medical Blank 1.00 0.48 0.48 Blank RBRVS

95907 TC NERVE CONDUCTION STUDIES 1-2 STUDIES Miscellaneous Medical a Blank 1.24 1.24 Blank RBRVS
















95913 Blank NERVE CONDUCTION STUDIES 13/> STUDIES Miscellaneous Medical a 3.56 4.88 4.88 Blank RBRVS

95913 26 NERVE CONDUCTION STUDIES 13/> STUDIES Miscellaneous Medical Blank 3.56 1.65 1.65 Blank RBRVS

95913 TC NERVE CONDUCTION STUDIES 13/> STUDIES Miscellaneous Medical a Blank 3.23 3.23 Blank RBRVS

95921 Blank TSTG ANS FUNCJ CARDIOVAGAL INNERVAJ PARASYMP Miscellaneous Medical a 0.90 1.42 1.42 Blank RBRVS

95921 26 TSTG ANS FUNCJ CARDIOVAGAL INNERVAJ PARASYMP Miscellaneous Medical Blank 0.90 0.35 0.35 Blank RBRVS

95921 TC TSTG ANS FUNCJ CARDIOVAGAL INNERVAJ PARASYMP Miscellaneous Medical a Blank 1.07 1.07 Blank RBRVS

95922 Blank TSTG ANS FUNCJ VASOMOTOR ADRENERGIC INNERVAJ Miscellaneous Medical a 0.96 1.76 1.76 Blank RBRVS

95922 26 TSTG ANS FUNCJ VASOMOTOR ADRENERGIC INNERVAJ Miscellaneous Medical Blank 0.96 0.38 0.38 Blank RBRVS

95922 TC TSTG ANS FUNCJ VASOMOTOR ADRENERGIC INNERVAJ Miscellaneous Medical a Blank 1.38 1.38 Blank RBRVS

95923 Blank TESTING AUTONOMIC NERVOUS SYSTEM FUNCTION Miscellaneous Medical a 0.90 2.73 2.73 Blank RBRVS

95923 26 TESTING AUTONOMIC NERVOUS SYSTEM FUNCTION Miscellaneous Medical Blank 0.90 0.36 0.36 Blank RBRVS

95923 TC TESTING AUTONOMIC NERVOUS SYSTEM FUNCTION Miscellaneous Medical a Blank 2.37 2.37 Blank RBRVS

95924 Blank TSTG ANS FUNCJ PARASYMP&SYMP W/5 MIN PASIVE TILT Miscellaneous Medical a 1.73 2.44 2.44 Blank RBRVS

95924 26 TSTG ANS FUNCJ PARASYMP&SYMP W/5 MIN PASIVE TILT Miscellaneous Medical Blank 1.73 0.70 0.70 Blank RBRVS

95924 TC TSTG ANS FUNCJ PARASYMP&SYMP W/5 MIN PASIVE TILT Miscellaneous Medical a Blank 1.74 1.74 Blank RBRVS

95925 Blank SHORT-LATENCY SOMATOSENS EP STD UPR LIMBS Miscellaneous Medical a 0.54 3.17 3.17 Blank RBRVS

95925 26 SHORT-LATENCY SOMATOSENS EP STD UPR LIMBS Miscellaneous Medical Blank 0.54 0.22 0.22 Blank RBRVS





PAGE 127 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

95925 TC SHORT-LATENCY SOMATOSENS EP STD UPR LIMBS Miscellaneous Medical a Blank 2.95 2.95 Blank RBRVS

95926 Blank SHORT-LATENCY SOMATOSENS EP STD LWR LIMBS Miscellaneous Medical a 0.54 3.10 3.10 Blank RBRVS

95926 26 SHORT-LATENCY SOMATOSENS EP STD LWR LIMBS Miscellaneous Medical Blank 0.54 0.21 0.21 Blank RBRVS

95926 TC SHORT-LATENCY SOMATOSENS EP STD LWR LIMBS Miscellaneous Medical a Blank 2.89 2.89 Blank RBRVS

95927 Blank SHORT-LATENCY SOMATOSENS EP STD TRNK/HEAD Miscellaneous Medical a 0.54 3.27 3.27 Blank RBRVS

95927 26 SHORT-LATENCY SOMATOSENS EP STD TRNK/HEAD Miscellaneous Medical Blank 0.54 0.21 0.21 Blank RBRVS

95927 TC SHORT-LATENCY SOMATOSENS EP STD TRNK/HEAD Miscellaneous Medical a Blank 3.06 3.06 Blank RBRVS

95928 Blank CTR MOTOR EP STD TRANSCRNL MOTOR STIMJ UPR LIMBS Miscellaneous Medical a 1.50 4.46 4.46 Blank RBRVS

95928 26 CTR MOTOR EP STD TRANSCRNL MOTOR STIMJ UPR LIMBS Miscellaneous Medical Blank 1.50 0.70 0.70 Blank RBRVS

95928 TC CTR MOTOR EP STD TRANSCRNL MOTOR STIMJ UPR LIMBS Miscellaneous Medical a Blank 3.76 3.76 Blank RBRVS

95929 Blank CTR MOTOR EP STD TRANSCRNL MOTOR STIMJ LWR LIMBS Miscellaneous Medical a 1.50 4.63 4.63 Blank RBRVS

95929 26 CTR MOTOR EP STD TRANSCRNL MOTOR STIMJ LWR LIMBS Miscellaneous Medical Blank 1.50 0.72 0.72 Blank RBRVS

95929 TC CTR MOTOR EP STD TRANSCRNL MOTOR STIMJ LWR LIMBS Miscellaneous Medical a Blank 3.91 3.91 Blank RBRVS

95930 Blank VISUAL EP TSTG CNS CHECKERBOARD/FLASH Miscellaneous Medical a 0.35 1.61 1.61 Blank RBRVS

95930 26 VISUAL EP TSTG CNS CHECKERBOARD/FLASH Miscellaneous Medical Blank 0.35 0.18 0.18 Blank RBRVS

95930 TC VISUAL EP TSTG CNS CHECKERBOARD/FLASH Miscellaneous Medical a Blank 1.43 1.43 Blank RBRVS

95933 Blank ORBICULARIS OCULI REFLX ELECTRODIAGNOSTIC TEST Miscellaneous Medical a 0.59 1.59 1.59 Blank RBRVS

95933 26 ORBICULARIS OCULI REFLX ELECTRODIAGNOSTIC TEST Miscellaneous Medical Blank 0.59 0.28 0.28 Blank RBRVS

95933 TC ORBICULARIS OCULI REFLX ELECTRODIAGNOSTIC TEST Miscellaneous Medical a Blank 1.31 1.31 Blank RBRVS

95937 Blank NEUROMUSCULAR JUNCT TSTG EA NRV ANY 1 METH Miscellaneous Medical a 0.65 1.64 1.64 Blank RBRVS

95937 26 NEUROMUSCULAR JUNCT TSTG EA NRV ANY 1 METH Miscellaneous Medical Blank 0.65 0.30 0.30 Blank RBRVS

95937 TC NEUROMUSCULAR JUNCT TSTG EA NRV ANY 1 METH Miscellaneous Medical a Blank 1.34 1.34 Blank RBRVS

95938 Blank SHORT-LATENCY SOMATOSENS EP STD UPR & LOW LIMB Miscellaneous Medical a 0.86 8.86 8.86 Blank RBRVS

95938 26 SHORT-LATENCY SOMATOSENS EP STD UPR & LOW LIMB Miscellaneous Medical Blank 0.86 0.41 0.41 Blank RBRVS

95938 TC SHORT-LATENCY SOMATOSENS EP STD UPR & LOW LIMB Miscellaneous Medical a Blank 8.45 8.45 Blank RBRVS

95939 Blank CTR MOTR EP STD TRANSCRNL MOTR STIM UPR&LOW LI Miscellaneous Medical a 2.25 11.99 11.99 Blank RBRVS

95939 26 CTR MOTR EP STD TRANSCRNL MOTR STIM UPR&LOW LI Miscellaneous Medical Blank 2.25 1.05 1.05 Blank RBRVS

95939 TC CTR MOTR EP STD TRANSCRNL MOTR STIM UPR&LOW LI Miscellaneous Medical a Blank 10.94 10.94 Blank RBRVS

95940 Blank IONM 1 ON 1 IN OR W/ATTENDANCE EACH 15 MINUTES Miscellaneous Medical Blank 0.60 0.28 0.28 Blank RBRVS

95941 Blank IONM REMOTE/NEARBY/>1 PATIENT IN OR PER HOUR Miscellaneous Medical Blank Blank Blank Blank 8.89 FAIR Health

95943 Blank PARASYMP & SYMP NRV FUNCJ HRT RATE VARIABILITY Miscellaneous Medical a Blank Blank Blank 4.70 FAIR Health

95943 26 PARASYMP & SYMP NRV FUNCJ HRT RATE VARIABILITY Miscellaneous Medical Blank Blank Blank Blank 4.51 FAIR Health

95943 TC PARASYMP & SYMP NRV FUNCJ HRT RATE VARIABILITY Miscellaneous Medical a Blank Blank Blank 0.18 FAIR Health

95950 Blank MONITOR ID& LATERALIZATION SEIZURE FOCUS EEG Miscellaneous Medical a 1.51 8.11 8.11 Blank RBRVS

95950 26 MONITOR ID& LATERALIZATION SEIZURE FOCUS EEG Miscellaneous Medical Blank 1.51 0.70 0.70 Blank RBRVS

95950 TC MONITOR ID& LATERALIZATION SEIZURE FOCUS EEG Miscellaneous Medical a Blank 7.41 7.41 Blank RBRVS

95951 Blank LOCALIZE CEREBRAL SEIZURE CABLE/RADIO EEG/VIDEO Miscellaneous Medical a Blank Blank Blank 15.73 Global/TC/26

95951 26 LOCALIZE CEREBRAL SEIZURE CABLE/RADIO EEG/VIDEO Miscellaneous Medical Blank Blank Blank Blank 8.81 Global/TC/26

95951 TC LOCALIZE CEREBRAL SEIZURE CABLE/RADIO EEG/VIDEO Miscellaneous Medical a Blank Blank Blank 6.92 Global/TC/26

95953 Blank LOCALIZE CEREBRAL SEIZURE CPTR PORTABLE EEG Miscellaneous Medical a 3.08 9.02 9.02 Blank RBRVS

95953 26 LOCALIZE CEREBRAL SEIZURE CPTR PORTABLE EEG Miscellaneous Medical Blank 3.08 1.43 1.43 Blank RBRVS

95953 TC LOCALIZE CEREBRAL SEIZURE CPTR PORTABLE EEG Miscellaneous Medical a Blank 7.59 7.59 Blank RBRVS

95954 Blank RX/PHYSICAL EEG ACTIVAJ PHYS/QHP ATTENDANCE Miscellaneous Medical a 2.45 9.49 9.49 Blank RBRVS

95954 26 RX/PHYSICAL EEG ACTIVAJ PHYS/QHP ATTENDANCE Miscellaneous Medical Blank 2.45 0.86 0.86 Blank RBRVS

95954 TC RX/PHYSICAL EEG ACTIVAJ PHYS/QHP ATTENDANCE Miscellaneous Medical a Blank 8.63 8.63 Blank RBRVS

95955 Blank EEG NONINTRACRANIAL SURGERY Miscellaneous Medical a 1.01 5.02 5.02 Blank RBRVS

95955 26 EEG NONINTRACRANIAL SURGERY Miscellaneous Medical Blank 1.01 0.48 0.48 Blank RBRVS

95955 TC EEG NONINTRACRANIAL SURGERY Miscellaneous Medical a Blank 4.54 4.54 Blank RBRVS

95956 Blank MNTR SEIZURE CMPTR 16CHAN EEG ATND EA 24 HR Miscellaneous Medical a 3.61 41.22 41.22 Blank RBRVS

95956 26 MNTR SEIZURE CMPTR 16CHAN EEG ATND EA 24 HR Miscellaneous Medical Blank 3.61 1.63 1.63 Blank RBRVS

95956 TC MNTR SEIZURE CMPTR 16CHAN EEG ATND EA 24 HR Miscellaneous Medical a Blank 39.59 39.59 Blank RBRVS

95957 Blank DIGITAL ANALYSIS ELECTROENCEPHALOGRAM Miscellaneous Medical a 1.98 6.05 6.05 Blank RBRVS

95957 26 DIGITAL ANALYSIS ELECTROENCEPHALOGRAM Miscellaneous Medical Blank 1.98 0.88 0.88 Blank RBRVS

95957 TC DIGITAL ANALYSIS ELECTROENCEPHALOGRAM Miscellaneous Medical a Blank 5.17 5.17 Blank RBRVS

95958 Blank WADA ACTIVATION TEST HEMISPHERIC FUNCTION W/EEG Miscellaneous Medical a 4.24 11.91 11.91 Blank RBRVS

95958 26 WADA ACTIVATION TEST HEMISPHERIC FUNCTION W/EEG Miscellaneous Medical Blank 4.24 1.94 1.94 Blank RBRVS

95958 TC WADA ACTIVATION TEST HEMISPHERIC FUNCTION W/EEG Miscellaneous Medical a Blank 9.97 9.97 Blank RBRVS

95961 Blank FUNCJAL CORT&SUBCORT MAPG PHYS/QHP ATTND INIT HR Miscellaneous Medical a 2.97 5.41 5.41 Blank RBRVS

95961 26 FUNCJAL CORT&SUBCORT MAPG PHYS/QHP ATTND INIT HR Miscellaneous Medical Blank 2.97 1.38 1.38 Blank RBRVS

95961 TC FUNCJAL CORT&SUBCORT MAPG PHYS/QHP ATTND INIT HR Miscellaneous Medical a Blank 4.03 4.03 Blank RBRVS

95962 Blank FUNCJAL CORT&SUBCORT MAPG PHYS/QHP ATTND ADDL HR Miscellaneous Medical a 3.21 4.02 4.02 Blank RBRVS

95962 26 FUNCJAL CORT&SUBCORT MAPG PHYS/QHP ATTND ADDL HR Miscellaneous Medical Blank 3.21 1.51 1.51 Blank RBRVS

95962 TC FUNCJAL CORT&SUBCORT MAPG PHYS/QHP ATTND ADDL HR Miscellaneous Medical a Blank 2.51 2.51 Blank RBRVS

95965 Blank MAGNETOENCEPHALOGRAPHY SPON BRAIN ACTIVITY Miscellaneous Medical a Blank Blank Blank 58.54 Global/TC/26

95965 26 MAGNETOENCEPHALOGRAPHY SPON BRAIN ACTIVITY Miscellaneous Medical Blank Blank Blank Blank 11.63 Global/TC/26

95965 TC MAGNETOENCEPHALOGRAPHY SPON BRAIN ACTIVITY Miscellaneous Medical a Blank Blank Blank 46.91 Global/TC/26

95966 Blank MAGNETOENCEPHALOGRAPY EVOKED FIELDS 1 MODALITY Miscellaneous Medical a Blank Blank Blank 28.87 Global/TC/26

95966 26 MAGNETOENCEPHALOGRAPY EVOKED FIELDS 1 MODALITY Miscellaneous Medical Blank Blank Blank Blank 5.75 Global/TC/26

95966 TC MAGNETOENCEPHALOGRAPY EVOKED FIELDS 1 MODALITY Miscellaneous Medical a Blank Blank Blank 23.12 Global/TC/26

95967 Blank MAGNETOENCEPHALOGRAPY EVOKED FIELDS EACH ADDL Miscellaneous Medical a Blank Blank Blank 24.97 Global/TC/26

95967 26 MAGNETOENCEPHALOGRAPY EVOKED FIELDS EACH ADDL Miscellaneous Medical Blank Blank Blank Blank 4.97 Global/TC/26

95967 TC MAGNETOENCEPHALOGRAPY EVOKED FIELDS EACH ADDL Miscellaneous Medical a Blank Blank Blank 20.00 Global/TC/26





PAGE 128 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

95970 Blank ELEC ALYS NSTIM PLS GEN BRN/SC/PERPH W/O REPRGRM Miscellaneous Medical Blank 0.45 0.20 1.48 Blank RBRVS

95971 Blank ELEC ALYS NSTIM PLS GEN SMPL SC/PERPH W/PRGRMG Miscellaneous Medical Blank 0.78 0.32 0.60 Blank RBRVS

95972 Blank ELEC ALYS NSTIM PLS GEN CPLX SC/PERPH W/PRGRMG Miscellaneous Medical Blank 0.80 0.31 0.79 Blank RBRVS

95976 Blank ALYS SMPL CN NPGT PRGRMG Miscellaneous Medical Blank 0.73 0.34 0.36 Blank RBRVS

95977 Blank ALYS CPLX CN NPGT PRGRMG Miscellaneous Medical Blank 0.97 0.46 0.48 Blank RBRVS

95980 Blank ELEC ALYS NSTIM PLS GEN GASTRIC INTRAOP W/PRGRMG Miscellaneous Medical Blank 0.80 0.35 0.35 Blank RBRVS

95981 Blank ELEC ALYS NSTIM GEN GASTRIC SBSQ W/O REPRGRMG Miscellaneous Medical Blank 0.30 0.17 0.61 Blank RBRVS

95982 Blank ELEC ALYS NSTIM PLS GEN GASTRIC SBSQ W/REPRGRMG Miscellaneous Medical Blank 0.65 0.31 0.79 Blank RBRVS

95983 Blank ALYS BRN NPGT PRGRMG 15 MIN Miscellaneous Medical Blank 0.91 0.43 0.45 Blank RBRVS

95984 Blank ALYS BRN NPGT PRGRMG ADDL 15 Miscellaneous Medical Blank 0.80 0.38 0.39 Blank RBRVS

95990 Blank REFILL&MAINTENANCE PUMP DRUG DLVR SPINAL/BRAIN Miscellaneous Medical Blank Blank 2.62 2.62 Blank RBRVS

95991 Blank RFL&MAIN IMPLT PMP/RSVR DLVR SPI/BRN PHY/QHP Miscellaneous Medical Blank 0.77 0.30 2.56 Blank RBRVS

95992 Blank CANALITH REPOSITIONING PROCEDURE Miscellaneous Medical Blank 0.75 0.28 0.44 Blank RBRVS

95999 Blank UNLIS NEUROLOGICAL/NEUROMUSCULAR DX PX Miscellaneous Medical Blank Blank Blank Blank 5.54 Unlisted

96000 Blank COMPRE CPTR MTN ALYS VIDEO TAPING 3D KINEMATICS Miscellaneous Medical Blank 1.80 0.83 0.83 Blank RBRVS

96001 Blank COMPRE CPTR MTN ALYS W/DYN PLNTR PRES MEAS WALKG Miscellaneous Medical Blank 2.15 1.09 1.09 Blank RBRVS

96002 Blank DYN SURF EMG WALKG/FUNCJAL ACTV 1-12 MUSC Miscellaneous Medical Blank 0.41 0.19 0.19 Blank RBRVS

96003 Blank DYN FINE WIRE EMG WALKG/FUNCJAL ACTV 1 MUSC Miscellaneous Medical Blank 0.37 0.11 0.11 Blank RBRVS

96004 Blank PHYS/QHP R&I CPTR MTN ALYS WALK/FUNCJL ACTV REPR Miscellaneous Medical Blank 2.14 0.96 0.96 Blank RBRVS

96020 Blank TEST SELECT & ADMN FUNCTL BRAIN MAP PHYS/QHP Miscellaneous Medical a Blank Blank Blank 6.95 Global/TC/26

96020 26 TEST SELECT & ADMN FUNCTL BRAIN MAP PHYS/QHP Miscellaneous Medical Blank Blank Blank Blank 4.46 Global/TC/26

96020 TC TEST SELECT & ADMN FUNCTL BRAIN MAP PHYS/QHP Miscellaneous Medical a Blank Blank Blank 2.49 Global/TC/26

96040 Blank MEDICAL GENETICS COUNSELING EACH 30 MINUTES Miscellaneous Medical Blank Blank 1.31 1.31 Blank RBRVS

96105 Blank ASSESSMENT APHASIA W/INTERP & REPORT PER HOUR OP Psych./Alc. & Drug Abuse Blank 1.75 1.25 1.25 Blank RBRVS

96110 Blank DEVELOPMENTAL SCREEN W/SCORING & DOC STD INSTRM OP Psych./Alc. & Drug Abuse Blank Blank 0.28 0.28 Blank RBRVS

96112 Blank DEVEL TST PHYS/QHP 1ST HR Miscellaneous Medical Blank 2.56 0.91 1.13 Blank RBRVS

96113 Blank DEVEL TST PHYS/QHP EA ADDL Miscellaneous Medical Blank 1.16 0.42 0.48 Blank RBRVS

96116 Blank NUBHVL STATUS XM PR HR W/PT INTERPJ&PREPJ OP Psych./Alc. & Drug Abuse Blank 1.86 0.47 0.70 Blank RBRVS

96121 Blank NUBHVL XM PHY/QHP EA ADDL HR OP Psych./Alc. & Drug Abuse Blank 1.71 0.42 0.53 Blank RBRVS

96125 Blank STANDARDIZED COGNITIVE PERFORMANCE TESTING OP Psych./Alc. & Drug Abuse Blank 1.70 1.59 1.59 Blank RBRVS

96127 Blank BEHAV ASSMT W/SCORE & DOCD/STAND INSTRUMENT OP Psych./Alc. & Drug Abuse a Blank 0.17 0.17 Blank RBRVS

96130 Blank PSYCL TST EVAL PHYS/QHP 1ST OP Psych./Alc. & Drug Abuse Blank 2.56 0.44 0.64 Blank RBRVS

96131 Blank PSYCL TST EVAL PHYS/QHP EA OP Psych./Alc. & Drug Abuse Blank 1.96 0.33 0.48 Blank RBRVS

96132 Blank NRPSYC TST EVAL PHYS/QHP 1ST OP Psych./Alc. & Drug Abuse Blank 2.56 0.39 1.06 Blank RBRVS

96133 Blank NRPSYC TST EVAL PHYS/QHP EA OP Psych./Alc. & Drug Abuse Blank 1.96 0.30 0.80 Blank RBRVS

96136 Blank PSYCL/NRPSYC TST PHY/QHP 1ST OP Psych./Alc. & Drug Abuse Blank 0.55 0.12 0.75 Blank RBRVS

96137 Blank PSYCL/NRPSYC TST PHY/QHP EA OP Psych./Alc. & Drug Abuse Blank 0.46 0.07 0.75 Blank RBRVS

96138 Blank PSYCL/NRPSYC TECH 1ST OP Psych./Alc. & Drug Abuse Blank Blank 1.07 1.07 Blank RBRVS

96139 Blank PSYCL/NRPSYC TST TECH EA OP Psych./Alc. & Drug Abuse Blank Blank 1.07 1.07 Blank RBRVS

96146 Blank PSYCL/NRPSYC TST AUTO RESULT OP Psych./Alc. & Drug Abuse Blank Blank 0.05 0.05 Blank RBRVS

96150 Blank HLTH&BEHAVIOR ASSMT EA 15 MIN W/PT 1ST ASSMT OP Psych./Alc. & Drug Abuse Blank 0.50 0.08 0.11 Blank RBRVS

96151 Blank HLTH&BEHAVIOR ASSMT EA 15 MIN W/PT RE-ASSMT OP Psych./Alc. & Drug Abuse Blank 0.48 0.08 0.11 Blank RBRVS

96152 Blank HLTH&BEHAVIOR IVNTJ EA 15 MIN INDIV OP Psych./Alc. & Drug Abuse Blank 0.46 0.07 0.10 Blank RBRVS

96153 Blank HLTH&BEHAVIOR IVNTJ EA 15 MIN GRP 2/>PTS OP Psych./Alc. & Drug Abuse Blank 0.10 0.01 0.02 Blank RBRVS

96154 Blank HLTH&BEHAVIOR IVNTJ EA 15 MIN FAM W/PT OP Psych./Alc. & Drug Abuse Blank 0.45 0.06 0.09 Blank RBRVS

96155 Blank HLTH&BEHAVIOR IVNTJ EA 15 MIN FAM W/O PT OP Psych./Alc. & Drug Abuse Blank 0.44 0.17 0.17 Blank RBRVS

96160 Blank PT-FOCUSED HLTH RISK ASSMT Physical Exams Blank Blank 0.11 0.11 Blank RBRVS

96161 Blank CAREGIVER HEALTH RISK ASSMT Physical Exams Blank Blank 0.11 0.11 Blank RBRVS

96360 Blank IV INFUSION HYDRATION INITIAL 31 MIN-1 HOUR Therapeutic Injections Blank 0.17 1.13 1.13 Blank RBRVS

96361 Blank IV INFUSION HYDRATION EACH ADDITIONAL HOUR Therapeutic Injections Blank 0.09 0.29 0.29 Blank RBRVS

96365 Blank IV INFUSION THERAPY/PROPHYLAXIS /DX 1ST TO 1 HR Therapeutic Injections Blank 0.21 1.81 1.81 Blank RBRVS

96366 Blank IV INFUSION THERAPY PROPHYLAXIS/DX EA HOUR Therapeutic Injections Blank 0.18 0.43 0.43 Blank RBRVS

96367 Blank IV INFUSION THER PROPH ADDL SEQUENTIAL TO 1 HR Therapeutic Injections Blank 0.19 0.68 0.68 Blank RBRVS

96368 Blank IV NFS THERAPY PROPHYLAXIS/DX CONCURRENT NFS Therapeutic Injections Blank 0.17 0.41 0.41 Blank RBRVS

96369 Blank SUBCUTANEOUS INFUSION INITIAL 1 HR W/PUMP SET-UP Therapeutic Injections Blank 0.21 4.67 4.67 Blank RBRVS

96370 Blank SUBCUTANEOUS INFUSION EACH ADDITIONAL HOUR Therapeutic Injections Blank 0.18 0.25 0.25 Blank RBRVS

96371 Blank SUBQ INFUSION ADDITIONAL PUMP INFUSION SITE Therapeutic Injections Blank Blank 1.80 1.80 Blank RBRVS

96372 Blank THERAPEUTIC PROPHYLACTIC/DX INJECTION SUBQ/IM Therapeutic Injections Blank 0.17 0.40 0.40 Blank RBRVS

96373 Blank THERAPEUTIC PROPHYLACTIC/DX NJX INTRA-ARTERIAL Therapeutic Injections Blank 0.17 0.36 0.36 Blank RBRVS

96374 Blank THER PROPH/DX NJX IV PUSH SINGLE/1ST SBST/DRUG Therapeutic Injections Blank 0.18 1.11 1.11 Blank RBRVS

96375 Blank THERAPEUTIC INJECTION IV PUSH EACH NEW DRUG Therapeutic Injections Blank 0.10 0.40 0.40 Blank RBRVS

96376 Blank THER PROPH/DX NJX EA SEQL IV PUSH SBST/DRUG FAC Therapeutic Injections Blank Blank Blank Blank 1.34 FAIR Health

96377 Blank APPLICATON ON-BODY INJECTOR Miscellaneous Medical Blank 0.17 0.40 0.40 Blank RBRVS

96379 Blank UNLISTED THERAPEUTIC PROPH/DX IV/IA NJX/NFS Therapeutic Injections Blank Blank Blank Blank 0.57 Unlisted

96401 Blank CHEMOTX ADMN SUBQ/IM NON-HORMONAL ANTI-NEO Miscellaneous Medical Blank 0.21 2.01 2.01 Blank RBRVS

96402 Blank CHEMOTX ADMN SUBQ/IM HORMONAL ANTI-NEO Miscellaneous Medical Blank 0.19 0.67 0.67 Blank RBRVS

96405 Blank CHEMOTHERAPY ADMINISTRATION INTRALESIONAL </7 Miscellaneous Medical Blank 0.52 0.30 1.74 Blank RBRVS

96406 Blank CHEMOTHERAPY ADMINISTRATION INTRALESIONAL >7 Miscellaneous Medical Blank 0.80 0.46 2.50 Blank RBRVS

96409 Blank CHEMOTX ADMN IV PUSH TQ 1/1ST SBST/DRUG Miscellaneous Medical Blank 0.24 2.79 2.79 Blank RBRVS

96411 Blank CHEMOTX ADMN IV PUSH TQ EA SBST/DRUG Miscellaneous Medical Blank 0.20 1.43 1.43 Blank RBRVS

96413 Blank CHEMOTX ADMN IV NFS TQ UP 1 HR 1/1ST SBST/DRUG Miscellaneous Medical Blank 0.28 3.66 3.66 Blank RBRVS

96415 Blank CHEMOTHERAPY ADMN IV INFUSION TQ EA HR Miscellaneous Medical Blank 0.19 0.67 0.67 Blank RBRVS





PAGE 129 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

96416 Blank CHEMOTX ADMN TQ INIT PROLNG CHEMOTX NFUS PMP Miscellaneous Medical Blank 0.21 3.80 3.80 Blank RBRVS

96417 Blank CHEMOTX ADMN IV NFS TQ EA SEQL NFS TO 1 HR Miscellaneous Medical Blank 0.21 1.68 1.68 Blank RBRVS

96420 Blank CHEMOTHERAPY ADMIN INTRA-ARTERIAL PUSH TQ Miscellaneous Medical Blank 0.17 2.75 2.75 Blank RBRVS

96422 Blank CHEMOTHERAPY ADMIN INTRA-ARTERIAL INFUS </1 HR Miscellaneous Medical Blank 0.17 4.95 4.95 Blank RBRVS

96423 Blank CHEMOTHERAPY ADMN INTRAARTERIAL INFUSION EA HR Miscellaneous Medical Blank 0.17 2.15 2.15 Blank RBRVS

96425 Blank CHEMOTX ADMN IA NFS >8 HR PRTBLE IMPLTBL PMP Miscellaneous Medical Blank 0.17 5.17 5.17 Blank RBRVS

96440 Blank CHEMOTX ADMN PLEURAL CAVITY REQ&W/THORACNTS Miscellaneous Medical Blank 2.12 0.97 19.71 Blank RBRVS

96446 Blank CHEMOTX ADMN PRTL CAVITY PORT/CATH Miscellaneous Medical Blank 0.37 0.19 5.26 Blank RBRVS

96450 Blank CHEMOTX ADMN CNS REQ SPINAL PUNCTURE Miscellaneous Medical Blank 1.53 0.64 3.54 Blank RBRVS

96521 Blank REFILLING & MAINTENANCE PORTABLE PUMP Miscellaneous Medical Blank 0.21 3.88 3.88 Blank RBRVS

96522 Blank REFILL&MAINTENANCE PUMP DRUG DLVR SYSTEMIC Miscellaneous Medical Blank 0.21 3.08 3.08 Blank RBRVS

96523 Blank IRRIGAJ IMPLNTD VENOUS ACCESS DRUG DELIVERY SYST Miscellaneous Medical Blank 0.04 0.73 0.73 Blank RBRVS

96542 Blank CHEMOTX NJX SUBARACHND/INTRAVENTR RSVR 1/MULT Miscellaneous Medical Blank 0.75 0.38 2.97 Blank RBRVS

96549 Blank UNLISTED CHEMOTHERAPY PROCEDURE Miscellaneous Medical Blank Blank Blank Blank 2.22 Unlisted

96567 Blank PDT XTRNL APPL LIGHT DSTR LES SKN BY ACTIVJ RX Miscellaneous Medical Blank Blank 3.23 3.23 Blank RBRVS

96570 Blank PDT NDSC ABL ABNOR TISS VIA ACTIVJ RX 30 MIN Miscellaneous Medical Blank 1.10 0.30 0.30 Blank RBRVS

96571 Blank PDT NDSC ABL ABNOR TISS VIA ACTIVJ RX A 15 MIN Miscellaneous Medical Blank 0.55 0.25 0.25 Blank RBRVS

96573 Blank PDT DSTR PRMLG LES PHYS/QHP Miscellaneous Medical Blank 0.48 4.86 4.86 Blank RBRVS

96574 Blank DBRDMT PRMLG LES W/PDT Miscellaneous Medical Blank 1.01 5.86 5.86 Blank RBRVS

96900 Blank ACTINOTHERAPY ULTRAVIOLET LIGHT Miscellaneous Medical Blank Blank 0.58 0.58 Blank RBRVS

96902 Blank MCRSCP XM HAIR PLUCK/CLIP FOR CNTS/STRUCT ABNORM Miscellaneous Medical Blank 0.41 0.16 0.18 Blank RBRVS

96904 Blank WHOLE BODY INTEGUMENTARY PHOTOGRAPHY Miscellaneous Medical Blank Blank 1.75 1.75 Blank RBRVS

96910 Blank PHOTOCHEMOTX TAR&UVB/PETROLATUM/UVB Miscellaneous Medical Blank Blank 3.19 3.19 Blank RBRVS

96912 Blank PHOTOCHEMOTX PSORALENS&ULTRAVIOLET PUVA Miscellaneous Medical Blank Blank 2.69 2.69 Blank RBRVS

96913 Blank PHOTOCHEMOTHERAPY DERMATOSES 4-8 HRS SUPERVISION Miscellaneous Medical Blank Blank 3.75 3.75 Blank RBRVS

96920 Blank LASER SKIN DISEASE PSORIASIS TOT AREA <250 SQ CM Miscellaneous Medical Blank 1.15 0.70 3.46 Blank RBRVS

96921 Blank LASER SKIN DISEASE PSORIASIS 250-500 SQ CM Miscellaneous Medical Blank 1.30 0.78 3.75 Blank RBRVS

96922 Blank LASER SKIN DISEASE PSORIASIS >500 SQ CM Miscellaneous Medical Blank 2.10 1.25 4.76 Blank RBRVS

96931 Blank RCM CELULR & SUBCELULR SKN IMGNG IMG ACQ I&R 1ST Miscellaneous Medical Blank 0.80 3.93 3.93 Blank RBRVS

96932 Blank RCM CELULR & SUBCELULR SKN IMGNG IMG ACQUISITION Miscellaneous Medical a Blank 3.45 3.45 Blank RBRVS

96933 Blank RCM CELULR & SUBCELULR SKN IMGNG I&R 1ST LES Miscellaneous Medical Blank 0.80 0.31 0.31 Blank RBRVS

96934 Blank RCM CELULR & SUBCELULR SKN IMGNG IMG ACQ I&R ADD Miscellaneous Medical Blank 0.76 1.29 1.29 Blank RBRVS

96935 Blank RCM CELULR & SUBCELULR SKN IMGNG IMG ACQ EA ADDL Miscellaneous Medical Blank Blank 0.98 0.98 Blank RBRVS

96936 Blank RCM CELULR & SUBCELULR SKN IMGNG I&R EA ADDL Miscellaneous Medical Blank 0.76 0.30 0.30 Blank RBRVS

96999 Blank UNLISTED SPECIAL DERMATOLOGICAL SERVICE/PROCED Miscellaneous Medical Blank Blank Blank Blank 2.69 Unlisted

97010 Blank APPLICATION MODALITY 1/> AREAS HOT/COLD PACKS Physical Medicine Blank 0.06 0.11 0.11 Blank RBRVS

97012 Blank APPL MODALITY 1/> AREAS TRACTION MECHANICAL Physical Medicine Blank 0.25 0.16 0.16 Blank RBRVS

97014 Blank APPL MODALITY 1/> AREAS ELEC STIMJ UNATTENDED Physical Medicine Blank 0.18 0.25 0.25 Blank RBRVS

97016 Blank APPL MODALITY 1/> AREAS VASOPNEUMATIC DEVICES Physical Medicine Blank 0.18 0.26 0.26 Blank RBRVS

97018 Blank APPL MODALITY 1/> AREAS PARAFFIN BATH Physical Medicine Blank 0.06 0.18 0.18 Blank RBRVS

97022 Blank APPLICATION MODALITY 1/> AREAS WHIRLPOOL Physical Medicine Blank 0.17 0.36 0.36 Blank RBRVS

97024 Blank APPLICATION MODALITY 1/> AREAS DIATHERMY Physical Medicine Blank 0.06 0.13 0.13 Blank RBRVS

97026 Blank APPLICATION MODALITY 1/> AREAS INFRARED Physical Medicine Blank 0.06 0.11 0.11 Blank RBRVS

97028 Blank APPL MODALITY 1/> AREAS ULTRAVIOLET Physical Medicine Blank 0.08 0.14 0.14 Blank RBRVS

97032 Blank APPL MODALITY 1/> AREAS ELEC STIMJ EA 15 MIN Physical Medicine Blank 0.25 0.18 0.18 Blank RBRVS

97033 Blank APPL MODALITY 1/> AREAS IONTOPHORESIS EA 15 MIN Physical Medicine Blank 0.26 0.32 0.32 Blank RBRVS

97034 Blank APPL MODALITY 1/> AREAS CONTRAST BATHS EA 15 MIN Physical Medicine Blank 0.21 0.21 0.21 Blank RBRVS

97035 Blank APPL MODALITY 1/> AREAS ULTRASOUND EA 15 MIN Physical Medicine Blank 0.21 0.16 0.16 Blank RBRVS

97036 Blank APPL MODALITY 1/> AREAS HUBBARD TANK EA 15 MIN Physical Medicine Blank 0.28 0.72 0.72 Blank RBRVS

97039 Blank UNLIST MODALITY SPEC TYPE&TIME CONSTANT ATTEND Physical Medicine Blank Blank Blank Blank 0.37 Unlisted

97110 Blank THERAPEUTIC PX 1/> AREAS EACH 15 MIN EXERCISES Physical Medicine Blank 0.45 0.40 0.40 Blank RBRVS

97112 Blank THER PX 1/> AREAS EACH 15 MIN NEUROMUSC REEDUCA Physical Medicine Blank 0.50 0.47 0.47 Blank RBRVS

97113 Blank THER PX 1/> AREAS EACH 15 MIN AQUA THER W/XERSS Physical Medicine Blank 0.48 0.61 0.61 Blank RBRVS

97116 Blank THER PX 1/> AREAS EA 15 MIN GAIT TRAINJ W/STAIR Physical Medicine Blank 0.45 0.39 0.39 Blank RBRVS

97124 Blank THER PX 1/> AREAS EACH 15 MINUTES MASSAGE Physical Medicine Blank 0.35 0.51 0.51 Blank RBRVS

97127 Blank THER IVNTJ W/FOCUS COG FUNCJ Physical Medicine Blank Blank Blank Blank 0.95 FAIR Health

97139 Blank UNLISTED THERAPEUTIC PROCEDURE SPECIFY Physical Medicine Blank Blank Blank Blank 0.85 Unlisted

97140 Blank MANUAL THERAPY TQS 1/> REGIONS EACH 15 MINUTES Physical Medicine Blank 0.43 0.35 0.35 Blank RBRVS

97150 Blank THERAPEUTIC PROCEDURES GROUP 2/> INDIVIDUALS Physical Medicine Blank 0.29 0.22 0.22 Blank RBRVS

97161 Blank PT EVAL LOW COMPLEX 20 MIN Physical Medicine Blank 1.20 1.13 1.13 Blank RBRVS

97162 Blank PT EVAL MOD COMPLEX 30 MIN Physical Medicine Blank 1.20 1.13 1.13 Blank RBRVS

97163 Blank PT EVAL HIGH COMPLEX 45 MIN Physical Medicine Blank 1.20 1.13 1.13 Blank RBRVS

97164 Blank PT RE-EVAL EST PLAN CARE Physical Medicine Blank 0.75 0.83 0.83 Blank RBRVS

97165 Blank OT EVAL LOW COMPLEX 30 MIN Physical Medicine Blank 1.20 1.32 1.32 Blank RBRVS

97166 Blank OT EVAL MOD COMPLEX 45 MIN Physical Medicine Blank 1.20 1.32 1.32 Blank RBRVS

97167 Blank OT EVAL HIGH COMPLEX 60 MIN Physical Medicine Blank 1.20 1.32 1.32 Blank RBRVS

97168 Blank OT RE-EVAL EST PLAN CARE Physical Medicine Blank 0.75 0.97 0.97 Blank RBRVS

97169 Blank ATHLETIC TRN EVAL LOW CMPLX Physical Medicine Blank Blank Blank Blank 1.81 FAIR Health

97170 Blank ATHLETIC TRN EVAL MOD CMPLX Physical Medicine Blank Blank Blank Blank 1.90 FAIR Health

97171 Blank ATHLETIC TRN EVAL HIGH CMPLX Physical Medicine Blank Blank Blank Blank 1.90 FAIR Health

97172 Blank ATHLETIC TRN RE-EVAL PLAN CR Physical Medicine Blank Blank Blank Blank 2.06 FAIR Health

97530 Blank THERAPEUT ACTVITY DIRECT PT CONTACT EACH 15 MIN Physical Medicine Blank 0.44 0.69 0.69 Blank RBRVS





PAGE 130 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

97533 Blank SENSORY INTEGRATIVE TECHNIQUES EACH 15 MINUTES Physical Medicine Blank 0.48 0.47 0.47 Blank RBRVS

97535 Blank SELF-CARE/HOME MGMT TRAINING EACH 15 MINUTES Physical Medicine Blank 0.45 0.51 0.51 Blank RBRVS

97537 Blank COMMUNITY/WORK REINTEGRATION TRAINJ EA 15 MIN Physical Medicine Blank 0.48 0.44 0.44 Blank RBRVS

97542 Blank WHEELCHAIR MGMT EA 15 MIN Physical Medicine Blank 0.48 0.45 0.45 Blank RBRVS

97545 Blank WORK HARDENING/CONDITIONING 1ST 2 HR Physical Medicine Blank Blank Blank Blank 3.27 FAIR Health

97546 Blank WORK HARDENING/CONDITIONING EACH HOUR Physical Medicine Blank Blank Blank Blank 1.53 FAIR Health

97597 Blank DEBRIDEMENT OPEN WOUND 20 SQ CM/< Miscellaneous Medical Blank 0.51 0.15 1.84 Blank RBRVS

97598 Blank DEBRIDEMENT OPEN WOUND EACH ADDITIONAL 20 SQ CM Miscellaneous Medical Blank 0.24 0.07 0.54 Blank RBRVS

97602 Blank RMVL DEVITAL TISS N-SLCTV DBRDMT W/O ANES 1 SESS Miscellaneous Medical Blank Blank Blank Blank 1.06 FAIR Health

97605 Blank NEGATIVE PRESSURE WOUND THERAPY DME </= 50 SQ CM Miscellaneous Medical Blank 0.55 0.17 0.68 Blank RBRVS

97606 Blank NEGATIVE PRESSURE WOUND THERAPY DME >50 SQ CM Miscellaneous Medical Blank 0.60 0.18 0.86 Blank RBRVS

97607 Blank NEG PRESSURE WOUND THERAPY NON DME </= 50 SQ CM Miscellaneous Medical Blank Blank Blank Blank 2.41 FAIR Health

97608 Blank NEG PRESSURE WOUND THERAPY NON DME >50 SQ CM Miscellaneous Medical Blank Blank Blank Blank 2.68 FAIR Health

97610 Blank LOW FREQUENCY NON-THERMAL ULTRASOUND PER DAY Physical Medicine Blank 0.35 0.11 3.42 Blank RBRVS

97750 Blank PHYSICAL PERFORMANCE TEST/MEAS W/REPRT EA 15 MIN Physical Medicine Blank 0.45 0.60 0.60 Blank RBRVS

97755 Blank ASSTV TECHNOL ASSMT DIR CNTCT W/REPRT EA 15 MIN Physical Medicine Blank 0.62 0.47 0.47 Blank RBRVS

97760 Blank ORTHOTIC MGMT&TRAINJ UXTR LXTR&/TRNK EA 15 Physical Medicine Blank 0.50 0.81 0.81 Blank RBRVS

97761 Blank PROSTHETIC TRAINING UPPR&/LOWER EXTREM EA 15 M Physical Medicine Blank 0.50 0.63 0.63 Blank RBRVS

97763 Blank ORTHC/PROSTC MGMT SBSQ ENC Physical Medicine Blank 0.48 0.87 0.87 Blank RBRVS

97799 Blank UNLISTED PHYSICAL MEDICINE/REHAB SERVICE/PROC Physical Medicine Blank Blank Blank Blank 0.85 Unlisted

97802 Blank MEDICAL NUTRITION ASSMT&IVNTJ INDIV EACH 15 MI Miscellaneous Medical Blank 0.53 0.37 0.43 Blank RBRVS

97803 Blank MEDICAL NUTRITION RE-ASSMT&IVNTJ INDIV EA 15 M Miscellaneous Medical Blank 0.45 0.31 0.38 Blank RBRVS

97804 Blank MEDICAL NUTRITION THERAPY GRP2/ INDIV EA 30 MI Miscellaneous Medical Blank 0.25 0.17 0.19 Blank RBRVS

97810 Blank ACUPUNCTURE 1/> NDLES W/O ELEC STIMJ INIT 15 MIN Miscellaneous Medical Blank 0.60 0.23 0.39 Blank RBRVS

97811 Blank ACUPUNCTURE 1/> NDLS W/O ELEC STIMJ EA 15 MIN Miscellaneous Medical Blank 0.50 0.19 0.25 Blank RBRVS

97813 Blank ACUPUNCTURE 1/> NDLS W/ELEC STIMJ 1ST 15 MIN Miscellaneous Medical Blank 0.65 0.25 0.41 Blank RBRVS

97814 Blank ACUP 1/> NDLS W/ELEC STIMJ EA 15 MIN W/RE-INSJ Miscellaneous Medical Blank 0.55 0.21 0.30 Blank RBRVS

98925 Blank OSTEOPATHIC MANIPULATIVE TX 1-2 BODY REGIONS Physical Medicine Blank 0.46 0.19 0.41 Blank RBRVS





98940 Blank CHIROPRACTIC MANIPULATIVE TX SPINAL 1-2 REGIONS Chiropractor Blank 0.46 0.16 0.33 Blank RBRVS

98941 Blank CHIROPRACTIC MANIPULATIVE TX SPINAL 3-4 REGIONS Chiropractor Blank 0.71 0.25 0.43 Blank RBRVS

98942 Blank CHIROPRACTIC MANIPULATIVE TX SPINAL 5 REGIONS Chiropractor Blank 0.96 0.34 0.52 Blank RBRVS

98943 Blank CHIROPRACTIC MANIPLTV TX EXTRASPINAL 1/> REGION Chiropractor Blank 0.46 0.18 0.29 Blank RBRVS

98960 Blank EDUCATION&TRAINING SELF-MGMT NONPHYS 1 PT Miscellaneous Medical Blank Blank 0.77 0.77 Blank RBRVS

98961 Blank EDUCATION&TRAINING SELF-MGMT NONPHYS 2-4 PTS Miscellaneous Medical Blank Blank 0.38 0.38 Blank RBRVS

98962 Blank EDUCATION&TRAINING SELF-MGMT NONPHYS 5-8 PTS Miscellaneous Medical Blank Blank 0.27 0.27 Blank RBRVS

98966 Blank NONPHYSICIAN TELEPHONE ASSESSMENT 5-10 MIN Office/Home/Urgent Care Visits Blank 0.25 0.10 0.14 Blank RBRVS



98969 Blank NONPHYSICIAN ONLINE ASSESSMENT AND MANAGEMENT Office/Home/Urgent Care Visits Blank Blank Blank Blank 1.36 FAIR Health

99000 Blank HANDLG&/OR CONVEY OF SPEC FOR TR OFFICE TO LAB Miscellaneous Medical Blank Blank Blank Blank 0.23 FAIR Health

99001 Blank HANDLG&/OR CONVEY OF SPEC FOR TR FROM PT TO LAB Miscellaneous Medical Blank Blank Blank Blank 0.34 FAIR Health

99002 Blank HANDLE/CONVEY/ANY OTH SVC DEVICE FIT PHYS/QHP Miscellaneous Medical Blank Blank Blank Blank 0.45 FAIR Health

99024 Blank POSTOP FOLLOW UP VISIT RELATED TO ORIGINAL PX Miscellaneous Medical Blank Blank Blank Blank 0.99 FAIR Health

99026 Blank HOSPITAL MANDATED CALL SERVICE IN-HOSPITAL EA HR Miscellaneous Medical Blank Blank Blank Blank 1.22 FAIR Health

99027 Blank HOSPITAL MANDATED CALL SVC OUT-OF-HOSPITAL EA HR Miscellaneous Medical Blank Blank Blank Blank 0.19 v3.23

99050 Blank SERVICES PROVIDED OFFICE OTH/THN REG SCHED HOURS Office/Home/Urgent Care Visits Blank Blank Blank Blank 0.74 FAIR Health

99051 Blank SVC PRV OFFICE REG SCHEDD EVN WKEND/HOLIDAY HRS Office/Home/Urgent Care Visits Blank Blank Blank Blank 0.62 FAIR Health

99053 Blank SERVICES PROVIDED BTW 10 PM&8 AM AT 24-HR FACI Office/Home/Urgent Care Visits Blank Blank Blank Blank 0.81 FAIR Health

99056 Blank SVC TYPICAL PRV OFFICE PRV OUT OFFICE REQUEST PT Office/Home/Urgent Care Visits Blank Blank Blank Blank 0.52 FAIR Health

99058 Blank SVC PRV EMER BASIS IN OFFICE DISRUPTING SVCS Office/Home/Urgent Care Visits Blank Blank Blank Blank 0.94 FAIR Health

99060 Blank SVC PRV EMER OUT OFFICE DISRUPTS OFFICE SVC Office/Home/Urgent Care Visits Blank Blank Blank Blank 2.23 FAIR Health

99070 Blank SUPPLIES&MATERIALS ABOVE/BEYOND PROV BY PHYS/QHP Miscellaneous Medical Blank Blank Blank Blank 0.56 5% Sample

99071 Blank EDUCATIONAL SUPPLIES PRV BY THE PHYS AT COST Miscellaneous Medical Blank Blank Blank Blank 0.23 5% Sample

99075 Blank MEDICAL TESTIMONY Miscellaneous Medical Blank Blank Blank Blank 1.91 v3.23

99078 Blank PHYS/QHP EDUCATION SVCS RENDERED PTS GRP SETTING Miscellaneous Medical Blank Blank Blank Blank 0.70 5% Sample

99080 Blank SPEC REPORTS > USUAL MED COMUNICAJ/STAND RPRTG Miscellaneous Medical Blank Blank Blank Blank 0.38 5% Sample

99082 Blank UNUSUAL TRAVEL Miscellaneous Medical Blank Blank Blank Blank 0.41 5% Sample

99091 Blank COLLJ&INTERPJ PHYS/QHP PHYSIO COMPUTR DATA 30 MI Miscellaneous Medical Blank 1.10 0.46 0.46 Blank RBRVS

99100 Blank ANESTHESIA EXTREME AGE PATIENT UNDER 1 YR/< Miscellaneous Medical Blank Blank Blank Blank 1.57 5% Sample

99116 Blank ANES COMPLICJ UTILIZATION TOTAL BODY HYPOTHERMIA Miscellaneous Medical Blank Blank Blank Blank 4.95 v3.23

99135 Blank ANES COMPLICJ UTILIZATION CONTROLLED HYPOTENSION Miscellaneous Medical Blank Blank Blank Blank 7.11 5% Sample

99140 Blank ANES COMPLICJ EMERGENCY CONDITIONS SPECIFY Miscellaneous Medical Blank Blank Blank Blank 2.53 5% Sample

99151 Blank MOD SED SAME PHYS/QHP <5 YRS Miscellaneous Medical Blank 0.50 0.15 1.65 Blank RBRVS

99152 Blank MOD SED SAME PHYS/QHP 5/>YRS Miscellaneous Medical Blank 0.25 0.08 1.18 Blank RBRVS

99153 Blank MOD SED SAME PHYS/QHP EA Miscellaneous Medical a Blank 0.30 0.30 Blank RBRVS

99155 Blank MOD SED OTH PHYS/QHP <5 YRS Miscellaneous Medical Blank 1.90 0.70 0.70 Blank RBRVS

99156 Blank MOD SED OTH PHYS/QHP 5/>YRS Miscellaneous Medical Blank 1.65 0.35 0.35 Blank RBRVS

99157 Blank MOD SED OTHER PHYS/QHP EA Miscellaneous Medical Blank 1.25 0.28 0.28 Blank RBRVS





PAGE 131 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

99170 Blank ANOGENITAL XM MAGNIFY CHILD/SUSPECT TRAUMA W IMG Miscellaneous Medical Blank 1.75 0.61 2.63 Blank RBRVS

99172 Blank VISUAL FUNCT SCRNG AUTO SEMI-AUTO BI QUAN DETERM Vision Exams a Blank Blank Blank 0.77 Global/TC/26

99172 26 VISUAL FUNCT SCRNG AUTO SEMI-AUTO BI QUAN DETERM Vision Exams Blank Blank Blank Blank 0.16 Global/TC/26

99172 TC VISUAL FUNCT SCRNG AUTO SEMI-AUTO BI QUAN DETERM Vision Exams a Blank Blank Blank 0.61 Global/TC/26

99173 Blank SCREENING TEST VISUAL ACUITY QUANTITATIVE BILAT Vision Exams Blank Blank 0.08 0.08 Blank RBRVS

99174 Blank INSTRUMENT BASED OCULAR SCR BI W/RMT ANAL & RPT Vision Exams a Blank Blank Blank 0.60 Global/TC/26

99174 26 INSTRUMENT BASED OCULAR SCR BI W/RMT ANAL & RPT Vision Exams Blank Blank Blank Blank 0.30 Global/TC/26

99174 TC INSTRUMENT BASED OCULAR SCR BI W/RMT ANAL & RPT Vision Exams a Blank Blank Blank 0.30 Global/TC/26

99175 Blank IPECAC/SIMILAR ADMN EMESIS&OBS STOMACH EMPTIED Miscellaneous Medical Blank Blank 0.72 0.72 Blank RBRVS

99177 Blank INSTRUMENT BASED OCULAR SCR BI W/ONSITE ANALYSIS Vision Exams Blank Blank 0.13 0.13 Blank RBRVS

99183 Blank PHYS/QHP ATTN&SUPVJ HYPRBARIC OXYGEN TX/SESSION Miscellaneous Medical Blank 2.11 0.77 0.77 Blank RBRVS

99184 Blank INITIAT SELECTIVE HEAD/BODY HYPOTHERMIA NEONATE Inpatient Visits Blank 4.50 1.53 1.53 Blank RBRVS

99188 Blank APPLICATION TOPICAL FLUORIDE VARNISH BY PHS/QHP Miscellaneous Medical Blank 0.20 0.08 0.14 Blank RBRVS

99190 Blank ASSEMBLY&OPERJ PUMP OXYGENATOR/HEAT EXCH EA HR Miscellaneous Medical Blank Blank Blank Blank 8.54 FAIR Health

99191 Blank ASSEMBLY&OPERJ PUMP OXYGENATOR/HEAT EXCH 45 MI Miscellaneous Medical Blank Blank Blank Blank 6.55 FAIR Health

99192 Blank ASSEMBLY&OPERJ PUMP OXYGENATOR/HEAT EXCH 30 MI Miscellaneous Medical Blank Blank Blank Blank 4.66 FAIR Health

99195 Blank PHLEBOTOMY THERAPEUTIC SEPARATE PROCEDURE Miscellaneous Medical Blank Blank 2.83 2.83 Blank RBRVS

99199 Blank UNLISTED SPECIAL SERVICE PROCEDURE/REPORT Miscellaneous Medical Blank Blank Blank Blank 0.70 Unlisted

99201 Blank OFFICE OUTPATIENT NEW 10 MINUTES Office/Home/Urgent Care Visits Blank 0.48 0.23 0.73 Blank RBRVS





99211 Blank OFFICE OUTPATIENT VISIT 5 MINUTES Office/Home/Urgent Care Visits Blank 0.18 0.07 0.42 Blank RBRVS





99217 Blank OBSERVATION CARE DISCHARGE MANAGEMENT Inpatient Visits Blank 1.28 0.70 0.70 Blank RBRVS

99218 Blank INITIAL OBSERVATION CARE/DAY 30 MINUTES Inpatient Visits Blank 1.92 0.75 0.75 Blank RBRVS



99221 Blank INITIAL HOSPITAL CARE/DAY 30 MINUTES Inpatient Visits Blank 1.92 0.76 0.76 Blank RBRVS



99224 Blank SBSQ OBSERVATION CARE/DAY 15 MINUTES Inpatient Visits Blank 0.76 0.31 0.31 Blank RBRVS



99231 Blank SBSQ HOSPITAL CARE/DAY 15 MINUTES Inpatient Visits Blank 0.76 0.29 0.29 Blank RBRVS



99234 Blank OBSERVATION/INPATIENT HOSPITAL CARE 40 MINUTES Inpatient Visits Blank 2.56 1.01 1.01 Blank RBRVS



99238 Blank HOSPITAL DISCHARGE DAY MANAGEMENT 30 MIN/< Inpatient Visits Blank 1.28 0.70 0.70 Blank RBRVS

99239 Blank HOSPITAL DISCHARGE DAY MANAGEMENT > 30 MIN Inpatient Visits Blank 1.90 1.03 1.03 Blank RBRVS

99241 Blank OFFICE CONSULTATION NEW/ESTAB PATIENT 15 MIN Consults Blank 0.64 0.24 0.66 Blank RBRVS





99251 Blank INITIAL INPATIENT CONSULT NEW/ESTAB PT 20 MIN Consults Blank 1.00 0.32 0.32 Blank RBRVS





99281 Blank EMERGENCY DEPARTMENT VISIT LIMITED/MINOR PROB Emergency Room Visits Blank 0.45 0.11 0.11 Blank RBRVS

99282 Blank EMERGENCY DEPARTMENT VISIT LOW/MODER SEVERITY Emergency Room Visits Blank 0.88 0.21 0.21 Blank RBRVS

99283 Blank EMERGENCY DEPARTMENT VISIT MODERATE SEVERITY Emergency Room Visits Blank 1.34 0.29 0.29 Blank RBRVS

99284 Blank EMERGENCY DEPARTMENT VISIT HIGH/URGENT SEVERITY Emergency Room Visits Blank 2.56 0.53 0.53 Blank RBRVS

99285 Blank EMERGENCY DEPT VISIT HIGH SEVERITY&THREAT FUNCJ Emergency Room Visits Blank 3.80 0.75 0.75 Blank RBRVS

99288 Blank PHYS/QHP DIRECTION EMERGENCY MEDICAL SYSTEMS Emergency Room Visits Blank Blank Blank Blank 0.65 5% Sample

99291 Blank CRITICAL CARE ILL/INJURED PATIENT INIT 30-74 MIN Inpatient Visits Blank 4.50 1.42 2.88 Blank RBRVS

99292 Blank CRITICAL CARE ILL/INJURED PATIENT ADDL 30 MIN Inpatient Visits Blank 2.25 0.71 1.02 Blank RBRVS

99304 Blank INITIAL NURSING FACILITY CARE/DAY 25 MINUTES Inpatient Visits Blank 1.64 0.83 0.83 Blank RBRVS



99307 Blank SBSQ NURSING FACILITY CARE/DAY E/M STABLE 10 MIN Inpatient Visits Blank 0.76 0.45 0.45 Blank RBRVS

99308 Blank SBSQ NURSING FACIL CARE/DAY MINOR COMPLJ 15 MIN Inpatient Visits Blank 1.16 0.72 0.72 Blank RBRVS

99309 Blank SBSQ NURSING FACIL CARE/DAY NEW PROBLEM 25 MIN Inpatient Visits Blank 1.55 0.93 0.93 Blank RBRVS

99310 Blank SBSQ NURS FACIL CARE/DAY UNSTABL/NEW PROB 35 MIN Inpatient Visits Blank 2.35 1.34 1.34 Blank RBRVS

99315 Blank NURSING FACILITY DISCHARGE MANAGEMENT 30 MINUTES Inpatient Visits Blank 1.28 0.70 0.70 Blank RBRVS





PAGE 132 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

99316 Blank NURSING FACILITY DISCHARGE MANAGEMENT 30 MINUTES Inpatient Visits Blank 1.90 0.97 0.97 Blank RBRVS

99318 Blank E/M ANNUAL NURSING FACILITY ASSESS STABLE 30 MIN Inpatient Visits Blank 1.71 0.90 0.90 Blank RBRVS

99324 Blank DOMICIL/REST HOME NEW PT VISIT LOW SEVER 20 MIN Office/Home/Urgent Care Visits Blank 1.01 0.48 0.48 Blank RBRVS

99325 Blank DOMICIL/REST HOME NEW PT VISIT MOD SEVER 30 MIN Office/Home/Urgent Care Visits Blank 1.52 0.65 0.65 Blank RBRVS

99326 Blank DOMICIL/REST HOME NEW PT HI-MOD SEVER 45 MINUTES Office/Home/Urgent Care Visits Blank 2.63 1.14 1.14 Blank RBRVS

99327 Blank DOMICIL/REST HOME NEW PT VISIT HI SEVER 60 MIN Office/Home/Urgent Care Visits Blank 3.46 1.58 1.58 Blank RBRVS

99328 Blank DOM/R-HOME E/M NEW PT SIGNIF NEW PROB 75 MINUTES Office/Home/Urgent Care Visits Blank 4.09 1.82 1.82 Blank RBRVS

99334 Blank DOM/R-HOME E/M EST PT SELF-LMTD/MINOR 15 MINUTES Office/Home/Urgent Care Visits Blank 1.07 0.56 0.56 Blank RBRVS

99335 Blank DOM/R-HOME E/M EST PT LW MOD SEVERITY 25 MINUTES Office/Home/Urgent Care Visits Blank 1.72 0.85 0.85 Blank RBRVS

99336 Blank DOM/R-HOME E/M EST PT MOD HI SEVERITY 40 MINUTES Office/Home/Urgent Care Visits Blank 2.46 1.20 1.20 Blank RBRVS

99337 Blank DOM/R-HOME E/M EST PT SIGNIF NEW PROB 60 MINUTES Office/Home/Urgent Care Visits Blank 3.58 1.65 1.65 Blank RBRVS

99339 Blank INDIV PHYS SUPVJ HOME/DOM/R-HOME MO 15-29 MIN Office/Home/Urgent Care Visits Blank 1.25 0.87 0.87 Blank RBRVS

99340 Blank INDIV PHYS SUPVJ HOME/DOM/R-HOME MO 30 MIN/> Office/Home/Urgent Care Visits Blank 1.80 1.16 1.16 Blank RBRVS

99341 Blank HOME VISIT NEW PATIENT LOW SEVERITY 20 MINUTES Office/Home/Urgent Care Visits Blank 1.01 0.47 0.47 Blank RBRVS

99342 Blank HOME VISIT NEW PATIENT MOD SEVERITY 30 MINUTES Office/Home/Urgent Care Visits Blank 1.52 0.62 0.62 Blank RBRVS

99343 Blank HOME VST NEW PATIENT MOD-HI SEVERITY 45 MINUTES Office/Home/Urgent Care Visits Blank 2.53 0.98 0.98 Blank RBRVS

99344 Blank HOME VISIT NEW PATIENT HI SEVERITY 60 MINUTES Office/Home/Urgent Care Visits Blank 3.38 1.56 1.56 Blank RBRVS

99345 Blank HOME VISIT NEW PT UNSTABL/SIGNIF NEW PROB 75 MIN Office/Home/Urgent Care Visits Blank 4.09 1.90 1.90 Blank RBRVS

99347 Blank HOME VISIT EST PT SELF LIMITED/MINOR 15 MINUTES Office/Home/Urgent Care Visits Blank 1.00 0.49 0.49 Blank RBRVS

99348 Blank HOME VISIT EST PT LOW-MOD SEVERITY 25 MINUTES Office/Home/Urgent Care Visits Blank 1.56 0.71 0.71 Blank RBRVS

99349 Blank HOME VISIT EST PT MOD-HI SEVERITY 40 MINUTES Office/Home/Urgent Care Visits Blank 2.33 1.15 1.15 Blank RBRVS

99350 Blank HOME VST EST PT UNSTABLE/SIGNIF NEW PROB 60 MINS Office/Home/Urgent Care Visits Blank 3.28 1.55 1.55 Blank RBRVS

99354 Blank PROLNG E&M/PSYCTX SVC OFFICE O/P DIR CON 1ST HR Office/Home/Urgent Care Visits Blank 2.33 0.96 1.20 Blank RBRVS

99355 Blank PROLNG E&M/PSYCTX SVC OFFICE O/P DIR CON ADDL 30 Office/Home/Urgent Care Visits Blank 1.77 0.70 0.90 Blank RBRVS

99356 Blank PROLONGED SERVICE I/P REQ UNIT/FLOOR TIME 1ST HR Inpatient Visits Blank 1.71 0.79 0.79 Blank RBRVS

99357 Blank PROLONGED SVC I/P REQ UNIT/FLOOR TIME EA 30 MIN Inpatient Visits Blank 1.71 0.80 0.80 Blank RBRVS

99358 Blank PROLNG E/M SVC BEFORE&/AFTER DIR PT CARE 1ST HR Office/Home/Urgent Care Visits Blank 2.10 0.91 0.91 Blank RBRVS

99359 Blank PROLNG E/M BEFORE&/AFTER DIR CARE EA 30 MINUTES Office/Home/Urgent Care Visits Blank 1.00 0.45 0.45 Blank RBRVS

99360 Blank PHYS STANDBY SVC PROLNG PHYS ATTN EA 30 MINUTES Miscellaneous Medical Blank 1.20 0.47 0.47 Blank RBRVS

99366 Blank TEAM CONFERENCE FACE-TO-FACE NONPHYSICIAN Office/Home/Urgent Care Visits Blank 0.82 0.32 0.34 Blank RBRVS

99367 Blank TEAM CONFERENCE NON-FACE-TO-FACE PHYSICIAN Office/Home/Urgent Care Visits Blank 1.10 0.43 0.43 Blank RBRVS

99368 Blank TEAM CONFERENCE NON-FACE-TO-FACE NONPHYSICIAN Office/Home/Urgent Care Visits Blank 0.72 0.28 0.28 Blank RBRVS

99374 Blank SUPVJ PT HOME HEALTH AGENCY MO 15-29 MINUTES Office/Home/Urgent Care Visits Blank 1.10 0.43 0.81 Blank RBRVS

99375 Blank SUPERVISION PT HOME HEALTH AGENCY MONTH 30 MIN/> Office/Home/Urgent Care Visits Blank 1.73 0.67 1.13 Blank RBRVS

99377 Blank SUPERVISION HOSPICE PATIENT/MONTH 15-29 MIN Office/Home/Urgent Care Visits Blank 1.10 0.43 0.81 Blank RBRVS

99378 Blank SUPERVISION HOSPICE PATIENT/MONTH 30 MINUTES/> Office/Home/Urgent Care Visits Blank 1.73 0.67 1.13 Blank RBRVS

99379 Blank SUPERVISION NURS FACILITY PATIENT MO 15-29 MIN Office/Home/Urgent Care Visits Blank 1.10 0.43 0.81 Blank RBRVS

99380 Blank SUPERVISION NURS FACILITY PATIENT MONTH 30 MIN/> Office/Home/Urgent Care Visits Blank 1.73 0.67 1.13 Blank RBRVS

99381 Blank INITIAL PREVENTIVE MEDICINE NEW PATIENT <1YEAR Well Baby Exams Blank 1.50 0.58 1.54 Blank RBRVS

99382 Blank INITIAL PREVENTIVE MEDICINE NEW PT AGE 1-4 YRS Well Baby Exams Blank 1.60 0.62 1.57 Blank RBRVS

99383 Blank INITIAL PREVENTIVE MEDICINE NEW PT AGE 5-11 YRS Physical Exams Blank 1.70 0.66 1.60 Blank RBRVS

99384 Blank INITIAL PREVENTIVE MEDICINE NEW PT AGE 12-17 YR Physical Exams Blank 2.00 0.77 1.72 Blank RBRVS

99385 Blank INITIAL PREVENTIVE MEDICINE NEW PT AGE 18-39YRS Physical Exams Blank 1.92 0.74 1.69 Blank RBRVS

99386 Blank INITIAL PREVENTIVE MEDICINE NEW PATIENT 40-64YRS Physical Exams Blank 2.33 0.90 1.85 Blank RBRVS

99387 Blank INITIAL PREVENTIVE MEDICINE NEW PATIENT 65YRS&> Physical Exams Blank 2.50 0.96 2.03 Blank RBRVS

99391 Blank PERIODIC PREVENTIVE MED ESTABLISHED PATIENT <1Y Well Baby Exams Blank 1.37 0.53 1.36 Blank RBRVS

99392 Blank PERIODIC PREVENTIVE MED EST PATIENT 1-4YRS Well Baby Exams Blank 1.50 0.58 1.41 Blank RBRVS

99393 Blank PERIODIC PREVENTIVE MED EST PATIENT 5-11YRS Physical Exams Blank 1.50 0.58 1.40 Blank RBRVS


99395 Blank PERIODIC PREVENTIVE MED EST PATIENT 18-39 YRS Physical Exams Blank 1.75 0.68 1.50 Blank RBRVS


99397 Blank PERIODIC PREVENTIVE MED EST PATIENT 65YRS& OLDER Physical Exams Blank 2.00 0.77 1.73 Blank RBRVS

99401 Blank PREVENT MED COUNSEL&/RISK FACTOR REDJ SPX 15 MIN Physical Exams Blank 0.48 0.19 0.56 Blank RBRVS




99406 Blank TOBACCO USE CESSATION INTERMEDIATE 3-10 MINUTES Miscellaneous Medical Blank 0.24 0.09 0.15 Blank RBRVS

99407 Blank TOBACCO USE CESSATION INTENSIVE >10 MINUTES Miscellaneous Medical Blank 0.50 0.19 0.25 Blank RBRVS

99408 Blank ALCOHOL/SUBSTANCE SCREEN & INTERVEN 15-30 MIN OP Psych./Alc. & Drug Abuse Blank 0.65 0.25 0.31 Blank RBRVS

99409 Blank ALCOHOL/SUBSTANCE SCREEN & INTERVENTION >30 MIN OP Psych./Alc. & Drug Abuse Blank 1.30 0.51 0.56 Blank RBRVS

99411 Blank PREV MED COUNSEL & RISK FACTOR REDJ GRP SPX 30 M Physical Exams Blank 0.15 0.06 0.35 Blank RBRVS

99412 Blank PREV MED COUNSEL & RISK FACTOR REDJ GRP SPX 60 M Physical Exams Blank 0.25 0.10 0.38 Blank RBRVS

99415 Blank PROLNG CLINCL STAFF SVC DURING O/P E/M 1ST HR Office/Home/Urgent Care Visits Blank Blank 0.27 0.27 Blank RBRVS

99416 Blank PROLNG CLINCL STAFF SVC DURING O/P E/M EA 30 MIN Office/Home/Urgent Care Visits Blank Blank 0.13 0.13 Blank RBRVS

99429 Blank UNLISTED PREVENTIVE MEDICINE SERVICE Physical Exams Blank Blank Blank Blank 3.44 Unlisted

99441 Blank PHYS/QHP TELEPHONE EVALUATION 5-10 MIN Office/Home/Urgent Care Visits Blank 0.25 0.10 0.14 Blank RBRVS



99444 Blank PHYS/QHP ONLINE EVALUATION & MANAGEMENT SERVICE Office/Home/Urgent Care Visits Blank Blank Blank Blank 0.61 FAIR Health

99446 Blank INTERPROF PHONE/INTERNET ASSESS/MANAGE 5-10 Office/Home/Urgent Care Visits Blank 0.35 0.14 0.14 Blank RBRVS







PAGE 133 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

99449 Blank INTERPROF PHONE/INTERNET ASSESS/MANAGE 31/> Office/Home/Urgent Care Visits Blank 1.40 0.55 0.55 Blank RBRVS

99450 Blank BASIC LIFE AND/OR DISABILITY EXAMINATION Miscellaneous Medical Blank Blank Blank Blank 1.34 FAIR Health

99451 Blank NTRPROF PH1/NTRNET/EHR 5/> Office/Home/Urgent Care Visits Blank 0.70 0.29 0.29 Blank RBRVS

99452 Blank NTRPROF PH1/NTRNET/EHR RFRL Office/Home/Urgent Care Visits Blank 0.70 0.29 0.29 Blank RBRVS

99453 Blank REM MNTR PHYSIOL PARAM SETUP Miscellaneous Medical Blank Blank 0.53 0.53 Blank RBRVS

99454 Blank REM MNTR PHYSIOL PARAM DEV Miscellaneous Medical Blank Blank 1.77 1.77 Blank RBRVS

99455 Blank WORK RELATED/MED DBLT XM TREATING PHYS Miscellaneous Medical Blank Blank Blank Blank 2.69 FAIR Health

99456 Blank WORK RELATED/MED DBLT XM OTH/THN TREATING PHYS Miscellaneous Medical Blank Blank Blank Blank 7.32 FAIR Health

99457 Blank REM PHYSIOL MNTR 20 MIN MO Miscellaneous Medical Blank 0.61 0.25 0.78 Blank RBRVS

99460 Blank 1ST HOSP/BIRTHING CENTER CARE PER DAY NML NB Inpatient Visits Blank 1.92 0.67 0.67 Blank RBRVS

99461 Blank 1ST CARE PR DAY NML NB XCPT HOSP/BIRTHING CENTER Well Baby Exams Blank 1.26 0.44 1.23 Blank RBRVS

99462 Blank SUBQ HOSPITAL CARE PER DAY E/M NORMAL NEWBORN Inpatient Visits Blank 0.84 0.29 0.29 Blank RBRVS

99463 Blank 1ST HOSP/BIRTHING CENTER NB ADMIT & DSCHG SM DAT Inpatient Visits Blank 2.13 0.87 0.87 Blank RBRVS

99464 Blank ATTN AT DELIVERY 1ST STABILIZATION OF NEWBORN Inpatient Visits Blank 1.50 0.52 0.52 Blank RBRVS

99465 Blank DELIVERY/BIRTHING ROOM RESUSCITATION Inpatient Visits Blank 2.93 1.01 1.01 Blank RBRVS

99466 Blank CRITICAL CARE INTERFACILITY TRANSPORT 30-74 MIN Inpatient Visits Blank 4.79 1.67 1.67 Blank RBRVS

99467 Blank CRITICAL CARE INTERFACILITY TRANSPORT EA 30 MIN Inpatient Visits Blank 2.40 0.83 0.83 Blank RBRVS

99468 Blank 1ST INPATIENT CRITICAL CARE PR DAY AGE 28 DAYS/< Inpatient Visits Blank 18.46 6.41 6.41 Blank RBRVS

99469 Blank SUBQ I/P CRITICAL CARE PR DAY AGE 28 DAYS/< Inpatient Visits Blank 7.99 2.77 2.77 Blank RBRVS

99471 Blank INITIAL PED CRITICAL CARE 29 DAYS THRU 24 MONTHS Inpatient Visits Blank 15.98 5.55 5.55 Blank RBRVS

99472 Blank SUBSQ PED CRITICAL CARE 29 DAYS THRU 24 MO Inpatient Visits Blank 7.99 2.99 2.99 Blank RBRVS

99475 Blank INITIAL PED CRITICAL CARE 2 THRU 5 YEARS Inpatient Visits Blank 11.25 3.90 3.90 Blank RBRVS

99476 Blank SUBSEQUENT PED CRITICAL CARE 2 THRU 5 YEARS Inpatient Visits Blank 6.75 2.50 2.50 Blank RBRVS

99477 Blank INITIAL HOSP NEONATE 28 D/< NOT CRITICALLY ILL Inpatient Visits Blank 7.00 2.43 2.43 Blank RBRVS

99478 Blank SUBSEQUENT INTENSIVE CARE INFANT < 1500 GRAMS Inpatient Visits Blank 2.75 0.95 0.95 Blank RBRVS

99479 Blank SUBSEQUENT INTENSIVE CARE INFANT 1500-2500 GRAMS Inpatient Visits Blank 2.50 0.86 0.86 Blank RBRVS

99480 Blank SUBSEQUENT INTENSIVE CARE INFANT 2501-5000 GRAMS Inpatient Visits Blank 2.40 0.84 0.84 Blank RBRVS

99483 Blank ASSMT & CARE PLN PT COG IMP OP Psych./Alc. & Drug Abuse Blank 3.44 1.33 3.08 Blank RBRVS

99484 Blank CARE MGMT SVC BHVL HLTH COND OP Psych./Alc. & Drug Abuse Blank 0.61 0.26 0.70 Blank RBRVS

99485 Blank SUPERVISION INTERFACILITY TRANSPORT INIT 30 MIN Inpatient Visits Blank 1.50 0.58 0.58 Blank RBRVS

99486 Blank SUPERVISION INTERFACILITY TRANSPORT ADDL 30 MIN Inpatient Visits Blank 1.30 0.51 0.51 Blank RBRVS

99487 Blank CMPLX CHRON CARE MGMT W/O PT VST 1ST HR PER MO Miscellaneous Medical Blank 1.00 0.42 1.57 Blank RBRVS

99489 Blank CMPLX CHRON CARE MGMT EA ADDL 30 MIN PER MONTH Miscellaneous Medical Blank 0.50 0.21 0.78 Blank RBRVS

99490 Blank CHRON CARE MANAGEMENT SRVC 20 MIN PER MONTH Miscellaneous Medical Blank 0.61 0.26 0.54 Blank RBRVS

99491 Blank CHRNC CARE MGMT SVC 30 MIN Miscellaneous Medical Blank 1.45 0.79 0.79 Blank RBRVS

99492 Blank 1ST PSYC COLLAB CARE MGMT OP Psych./Alc. & Drug Abuse Blank 1.70 0.70 2.67 Blank RBRVS

99493 Blank SBSQ PSYC COLLAB CARE MGMT OP Psych./Alc. & Drug Abuse Blank 1.53 0.64 1.95 Blank RBRVS

99494 Blank 1ST/SBSQ PSYC COLLAB CARE OP Psych./Alc. & Drug Abuse Blank 0.82 0.34 0.98 Blank RBRVS

99495 Blank TRANSITIONAL CARE MANAGE SRVC 14 DAY DISCHARGE Miscellaneous Medical Blank 2.11 0.88 2.40 Blank RBRVS

99496 Blank TRANSITIONAL CARE MANAGE SRVC 7 DAY DISCHARGE Miscellaneous Medical Blank 3.05 1.28 3.32 Blank RBRVS

99497 Blank ADVANCE CARE PLANNING FIRST 30 MINS Miscellaneous Medical Blank 1.50 0.64 0.79 Blank RBRVS

99498 Blank ADVANCE CARE PLANNING EA ADDL 30 MINS Miscellaneous Medical Blank 1.40 0.61 0.62 Blank RBRVS

99499 Blank UNLISTED EVALUATION AND MANAGEMENT SERVICE Office/Home/Urgent Care Visits Blank Blank Blank Blank 1.97 Unlisted

99500 Blank HOME VISIT PRENATAL MONITORING & ASSESSMENT Miscellaneous Medical Blank Blank Blank Blank 2.21 FAIR Health

99501 Blank HOME VISIT POSTNATAL ASSMT&F-UP CARE Miscellaneous Medical Blank Blank Blank Blank 2.02 FAIR Health

99502 Blank HOME VISIT NEWBORN CARE & ASSESSMENT Miscellaneous Medical Blank Blank Blank Blank 2.21 FAIR Health

99503 Blank HOME VISIT RESPIRATORY THERAPY CARE Miscellaneous Medical Blank Blank Blank Blank 1.70 FAIR Health

99504 Blank HOME VISIT MECHANICAL VENTILATION CARE Miscellaneous Medical Blank Blank Blank Blank 2.38 FAIR Health

99505 Blank HOME VISIT STOMA CARE&MAINT CLST&CSTOST Miscellaneous Medical Blank Blank Blank Blank 0.89 v3.23

99506 Blank HOME VISIT INTRAMUSCULAR INJECTIONS Miscellaneous Medical Blank Blank Blank Blank 2.03 FAIR Health

99507 Blank HOME VISIT CARE&MAINT CATH Miscellaneous Medical Blank Blank Blank Blank 0.94 FAIR Health

99509 Blank HOME VISIT ASSISTANCE DAILY LIV&PRSONAL CARE Miscellaneous Medical Blank Blank Blank Blank 0.80 FAIR Health

99510 Blank HOME VISIT INDIV FAM/MARRIAGE COUNSELING Miscellaneous Medical Blank Blank Blank Blank 1.34 FAIR Health

99511 Blank HOME VISIT FECAL IMPACTION MGMT&ENEMA ADMN Miscellaneous Medical Blank Blank Blank Blank 0.99 v3.23

99512 Blank HOME VISIT HEMODIALYSIS Miscellaneous Medical Blank Blank Blank Blank 29.80 FAIR Health

99600 Blank UNLISTED HOME VISIT SERVICE/PROCEDURE Miscellaneous Medical Blank Blank Blank Blank 0.80 Unlisted

99601 Blank HOME NFS/SPECTY DRUG ADMN PR VST </2 HR Miscellaneous Medical Blank Blank Blank Blank 2.79 FAIR Health

99602 Blank HOME NFS/SPECTY DRUG ADMN PR VST </2 HR EA HR Miscellaneous Medical Blank Blank Blank Blank 1.58 FAIR Health

99605 Blank MEDICATION THERAPY INITIAL 15 MIN NEW PATIENT Miscellaneous Medical Blank Blank Blank Blank 1.05 FAIR Health

99606 Blank MEDICATION THERAPY INITIAL 15 MIN ESTABLISHED PT Miscellaneous Medical Blank Blank Blank Blank 0.68 FAIR Health

99607 Blank MEDICATION THERAPY EACH ADDITIONAL 15 MIN Miscellaneous Medical Blank Blank Blank Blank 0.79 FAIR Health

0042T Blank CEREBRAL PERFUSION ANALYS CT W/BLOOD FLOW&VOLUME Radiology Blank Blank Blank Blank 3.11 5% Sample

0054T Blank CPTR-ASST MUSCSKEL NAVIGJ ORTHO FLUOR IMAGES Surgery Blank Blank Blank Blank 4.35 ERBRVS

0055T Blank CPTR-ASST MUSCSKEL NAVIGJ ORTHO CT/MRI Surgery Blank Blank Blank Blank 4.63 5% Sample

0075T Blank TCAT PLMT XTRC VRT CRTD STENT RS&I PRQ 1ST VSL Surgery Blank Blank Blank Blank 14.77 v3.23

0075T 26 TCAT PLMT XTRC VRT CRTD STENT RS&I PRQ 1ST VSL Surgery Blank Blank Blank Blank 0.92 v3.23

0075T TC TCAT PLMT XTRC VRT CRTD STENT RS&I PRQ 1ST VSL Surgery Blank Blank Blank Blank 13.85 v3.23

0095T Blank RMVL TOT DISC ARTHRP ANT APPR CRV EA NTRSPC Surgery Blank 4.04 1.52 1.52 Blank v3.23

0098T Blank REVJ TOT DISC ARTHRP ANT APPR CRV EA NTRSPC Surgery Blank 4.04 1.52 1.52 Blank v3.23

0100T Blank PLMT SCJNCL RTA PROSTH&PLS&IMPLTJ INTRA-OC RTA Surgery Blank Blank Blank Blank 16.74 ERBRVS

0101T Blank EXTRCORPL SHOCK WAVE MUSCSKELE NOS HIGH ENERGY Surgery Blank Blank Blank Blank 6.48 ERBRVS

0102T Blank EXTRCRPL SHOCK WAVE W/ANES LAT HUMERL EPICONDYLE Surgery Blank Blank Blank Blank 6.48 ERBRVS





PAGE 134 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

0106T Blank QUANT SENSORY TEST&INTERPJ/XTR W/TOUCH STIMULI Miscellaneous Medical Blank Blank Blank Blank 0.71 v3.23

0107T Blank QUANT SENSORY TEST&INTERPJ/XTR W/VIBRJ STIMULI Miscellaneous Medical Blank Blank Blank Blank 2.14 v3.23

0108T Blank QUANT SENSORY TEST&INTERPJ/XTR W/COOL STIMULI Miscellaneous Medical Blank Blank Blank Blank 2.14 v3.23

0110T Blank QUANT SENSORY TEST&INTERPJ/XTR OTHER STIMULI Miscellaneous Medical Blank Blank Blank Blank 0.09 5% Sample

0111T Blank LONG-CHAIN OMEGA-3 FATTY ACIDS RBC MEMBS Pathology Blank Blank Blank Blank 0.70 v3.23

0126T Blank COMMON CAROTID INTIMA MEDIA THICKNESS STUDY Cardiovascular Blank Blank Blank Blank 1.56 v3.23

0163T Blank TOT DISC ARTHRP ANT APPR DSKC PREP LMBR EA Surgery Blank Blank Blank Blank 45.67 ERBRVS

0164T Blank RMVL TOT DISC ARTHRP ANT APPR LMBR EA NTRSPC Surgery Blank Blank Blank Blank 12.09 ERBRVS

0165T Blank REVJ TOT DISC ARTHRP ANT APPR LMBR EA NTRSPC Surgery Blank Blank Blank Blank 11.03 ERBRVS

0174T Blank CAD CHEST RADIOGRAPH CONCURRENT W/INTERPRETATION Radiology Blank Blank Blank Blank 0.37 5% Sample

0175T Blank CAD CHEST RADIOGRAPH REMOTE FROM PRIMARY INTERPJ Radiology Blank Blank Blank Blank 0.41 ERBRVS

0184T Blank RECTAL TUMOR EXCISION TRANSANAL ENDOSCOPIC Surgery Blank Blank Blank Blank 19.17 ERBRVS

0191T Blank ANT SEGMENT INSERTION DRAINAGE W/O RESERVOIR INT Surgery Blank Blank Blank Blank 25.59 5% Sample

0198T Blank MEAS OCULAR BLOOD FLOW REPEAT IO PRES SAMP W/I&R Radiology Blank Blank Blank Blank 1.17 ERBRVS

0200T Blank PERQ SAC AGMNTJ UNI W/WO BALO/MCHNL DEV 1/> NDL Radiology Blank Blank Blank Blank 24.24 ERBRVS

0201T Blank PERQ SAC AGMNTJ BI W/WO BALO/MCHNL DEV 2/> NDLS Radiology Blank Blank Blank Blank 15.22 5% Sample

0202T Blank POST VERT ARTHRPLSTY W/WO BONE CEMENT 1 LUMB LVL Surgery Blank Blank Blank Blank 55.14 ERBRVS

0205T Blank IV CATH CORONARY VESSEL/GRAFT SPECTROSCPY EA VSL Radiology Blank Blank Blank Blank 2.15 ERBRVS

0206T Blank CPTR DBS ALYS MLT CYCLS CAR ELEC DTA 2/> ECG LDS Miscellaneous Medical a Blank Blank Blank 4.43 ERBRVS

0207T Blank EVAC MEIBOMIAN GLNDS AUTO HT& INTMT PRESS UNI Miscellaneous Medical Blank Blank Blank Blank 0.50 ERBRVS

0208T Blank PURE TONE AUDIOMETRY AUTOMATED AIR ONLY Hearing/Speech Exams a Blank Blank Blank 0.72 ERBRVS

0209T Blank PURE TONE AUDIOMETRY AUTOMATED AIR & BONE Hearing/Speech Exams a Blank Blank Blank 1.34 ERBRVS

0210T Blank SPEECH AUDIOMETRY THRESHOLD AUTOMATED Hearing/Speech Exams a Blank Blank Blank 0.89 ERBRVS

0212T Blank COMPRE AUDIOM THRESHOLD EVAL & SPEECH RECOG Hearing/Speech Exams a Blank Blank Blank 1.12 ERBRVS

0213T Blank NJX DX/THER PARAVER FCT JT W/US CER/THOR 1 LVL Surgery Blank Blank Blank Blank 4.28 ERBRVS

0214T Blank NJX DX/THER PARAVER FCT JT W/US CER/THOR 2ND LVL Surgery Blank Blank Blank Blank 2.06 ERBRVS

0215T Blank NJX PARAVERTBRL FACET JT W/US CER/THOR 3RD&> LVL Surgery Blank Blank Blank Blank 2.48 ERBRVS

0216T Blank NJX DX/THER PARAVER FCT JT W/US LUMB/SAC 1 LVL Surgery Blank Blank Blank Blank 2.77 5% Sample

0217T Blank NJX DX/THER PARAVER FCT JT W/US LUMB/SAC LVL 2 Surgery Blank Blank Blank Blank 2.22 ERBRVS

0218T Blank NJX PARAVERTBRL FCT JT W/US LUMB/SAC 3RD&> LVL Surgery Blank Blank Blank Blank 2.26 ERBRVS

0228T Blank NJX ANES/STEROID TFRML EDRL W/US CER/THOR 1 LVL Surgery Blank Blank Blank Blank 5.51 ERBRVS

0229T Blank NJX ANES/STERD TFRML EDRL W/US CER/THOR EA ADDL Surgery Blank Blank Blank Blank 2.74 ERBRVS

0230T Blank NJX ANES/STEROID TFRML EDRL W/US LUM/SAC 1 LVL Surgery Blank Blank Blank Blank 5.36 ERBRVS

0231T Blank NJX ANES/STEROID TFRML EDRL W/US LUM/SAC EA ADDL Surgery Blank Blank Blank Blank 2.71 ERBRVS

0232T Blank NJX PLTLT PLASMA W/IMG HARVEST/PREPARATION Miscellaneous Medical Blank Blank Blank Blank 12.16 5% Sample

0234T Blank TRLUML PERIPHERAL ATHERECTOMY RENAL ARTERY EA Surgery Blank Blank Blank Blank 10.45 ERBRVS

0235T Blank TRLUML PERIPHERAL ATHERECTOMY VISCERAL ARTERY EA Surgery Blank Blank Blank Blank 10.45 ERBRVS

0236T Blank TRLUML PERIPH ATHRC W/RS&I ABDOM AORTA Surgery Blank Blank Blank Blank 13.97 ERBRVS

0237T Blank TRLUML PERIPH ATHRC W/RS&I BRCHIOCPHL EA VSL Surgery Blank Blank Blank Blank 16.29 ERBRVS

0238T Blank TRLUML PERIPHERAL ATHERECTOMY ILIAC ARTERY EA Surgery Blank Blank Blank Blank 14.17 5% Sample

0249T Blank LIGATION HEMORRHOID BUNDLE W/US Surgery Blank Blank Blank Blank 8.62 ERBRVS

0253T Blank INSERT ANT SGM DRAINAGE DEV W/O RESERVR INT APPR Surgery Blank Blank Blank Blank 24.24 ERBRVS

0254T Blank EVASC ILIAC ART BIFURC W/ENDOPROSTH UNI Surgery Blank Blank Blank Blank 24.85 ERBRVS

0263T Blank AUTO BONE MARRW CELL RX COMPLT BONE MARRW HARVST Surgery Blank Blank Blank Blank 1.47 ERBRVS

0264T Blank AUTO BONE MARRW CELL RX COMP W/O BONE MAR HARVST Surgery Blank Blank Blank Blank 3.75 ERBRVS

0265T Blank BONE MAR HARVST ONLY FOR INTMUSC AUTOLO CELL RX Surgery Blank Blank Blank Blank 7.43 ERBRVS

0266T Blank IM/REPL CARTD SINUS BAROREFLX ACTIV DEV TOT SYST Surgery Blank Blank Blank Blank 2.89 ERBRVS

0267T Blank IM/REPL CARTD SINS BAROREFLX ACTIV DEV LEAD ONLY Surgery Blank Blank Blank Blank 2.89 ERBRVS

0275T Blank PERC LAMINO-/LAMINECTOMY INDIR IMAG GUIDE LUMBAR Surgery Blank Blank Blank Blank 43.13 v3.23

0278T Blank TRNSCUT ELECT MODLATION PAIN REPROCES EA TX SESS Miscellaneous Medical Blank Blank Blank Blank 2.57 5% Sample

0290T Blank CORNEA INCISNS RECIPIENT CORNEA W/LASR KERTPLSTY Surgery Blank Blank Blank Blank 3.26 v3.23

0295T Blank EXT ECG > 48HR TO 21 DAY RCRD SCAN ANLYS REP R&I Cardiovascular Blank Blank Blank Blank 5.27 5% Sample

0296T Blank EXT ECG > 48HR TO 21 DAY RCRD W/CONECT INTL RCRD Cardiovascular Blank Blank Blank Blank 1.02 5% Sample

0297T Blank EXT ECG > 48HR TO 21 DAY SCAN ANALYSIS W/REPORT Cardiovascular Blank Blank Blank Blank 2.19 5% Sample

0298T Blank EXT ECG > 48HR TO 21 DAY REVIEW AND INTERPRETATN Cardiovascular Blank Blank Blank Blank 0.95 5% Sample

0308T Blank INSJ OC TLSCP PROSTH RMVL CRYSTALLINE/IO LENS Surgery Blank Blank Blank Blank 37.61 ERBRVS

0330T Blank TEAR FILM IMAGING UNILATERAL OR BILATERAL W/I&R Miscellaneous Medical Blank Blank Blank Blank 0.47 5% Sample

0331T Blank MYOCRD SYMPATHETIC INNERVAJ IMG PLNR QUAL&QUANT Radiology Blank Blank Blank Blank 3.78 v3.23

0332T Blank MYOCRD SYMP INNERVAJ IMG PLNR QUAL&QUANT W/SPECT Radiology Blank Blank Blank Blank 5.25 v3.23

0333T Blank VISUAL EVOKED POTENTIAL ACUITY SCREENING AUTO Miscellaneous Medical Blank Blank Blank Blank 3.72 v3.23

0338T Blank TRANSCATHETER RENAL SYMPATH DENERVATION UNILAT Surgery Blank Blank Blank Blank 26.67 ERBRVS

0339T Blank TRANSCATHETER RENAL SYMPATH DENERVATION BILAT Surgery Blank Blank Blank Blank 32.04 ERBRVS

0345T Blank TRANSCATH MITRAL VALVE REPAIR VIA CORONARY SINUS Surgery Blank Blank Blank Blank 37.20 ERBRVS

0355T Blank GI TRACT IMAGING INTRALUMINAL COLON WITH I&R Miscellaneous Medical Blank Blank Blank Blank 22.19 ERBRVS

0358T Blank BIA WHOLE BODY COMPOSITION ASSESSMENT W/I&R Radiology Blank Blank Blank Blank 0.79 5% Sample

0375T Blank TOTAL DISC ARTHRP ANT APPR W/DISCECTOMY CRV 3+ Surgery Blank 10.08 4.20 4.20 Blank v3.23

0379T Blank VISUAL FIELD ASSESSMENT TECH SUPPORT W/INSTRUCT Miscellaneous Medical Blank Blank Blank Blank 0.70 5% Sample

0394T Blank HDR ELECTRONIC BRACHYTHERAPY SKIN SURFACE Radiology Blank Blank Blank Blank 17.75 5% Sample

0395T Blank HDR ELECTRONIC BRACHYTHERAPY NTRSTL/INTRCAV Radiology Blank Blank Blank Blank 17.75 ERBRVS

0399T Blank MYOCARDIAL STRAIN IMAGING QUAN ASSMT Radiology Blank Blank Blank Blank 1.06 5% Sample

0509T Blank PATTERN ERG W/I&R Miscellaneous Medical a 0.40 1.82 1.82 Blank RBRVS

0509T 26 PATTERN ERG W/I&R Miscellaneous Medical Blank 0.40 0.21 0.21 Blank RBRVS





PAGE 135 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

0509T TC PATTERN ERG W/I&R Miscellaneous Medical a Blank 1.61 1.61 Blank RBRVS

C8900 Blank MRA W/CONT, ABD Radiology Blank Blank Blank Blank 2.59 FAIR Health

C8901 Blank MRA W/O CONT, ABD Radiology Blank Blank Blank Blank 2.20 FAIR Health

C8902 Blank MRA W/O FOL W/CONT, ABD Radiology Blank Blank Blank Blank 4.16 FAIR Health

C8903 Blank MRI W/CONT, BREAST, UNI Radiology Blank Blank Blank Blank 2.59 FAIR Health

C8905 Blank MRI W/O FOL W/CONT, BRST, UN Radiology Blank Blank Blank Blank 4.16 FAIR Health

C8906 Blank MRI W/CONT, BREAST, BI Radiology Blank Blank Blank Blank 4.16 FAIR Health

C8908 Blank MRI W/O FOL W/CONT, BREAST, Radiology Blank Blank Blank Blank 16.38 v3.23

C8909 Blank MRA W/CONT, CHEST Radiology Blank Blank Blank Blank 2.59 FAIR Health

C8910 Blank MRA W/O CONT, CHEST Radiology Blank Blank Blank Blank 2.20 FAIR Health

C8911 Blank MRA W/O FOL W/CONT, CHEST Radiology Blank Blank Blank Blank 4.16 FAIR Health

C8912 Blank MRA W/CONT, LWR EXT Radiology Blank Blank Blank Blank 4.16 FAIR Health

C8913 Blank MRA W/O CONT, LWR EXT Radiology Blank Blank Blank Blank 2.20 FAIR Health

C8914 Blank MRA W/O FOL W/CONT, LWR EXT Radiology Blank Blank Blank Blank 4.16 FAIR Health

C8918 Blank MRA W/CONT, PELVIS Radiology Blank Blank Blank Blank 2.59 FAIR Health

C8919 Blank MRA W/O CONT, PELVIS Radiology Blank Blank Blank Blank 2.20 FAIR Health

C8920 Blank MRA W/O FOL W/CONT, PELVIS Radiology Blank Blank Blank Blank 4.16 FAIR Health

C8921 Blank TTE W OR W/O FOL W/CONT, COM Cardiovascular Blank Blank Blank Blank 6.71 FAIR Health

C8922 Blank TTE W OR W/O FOL W/CONT, F/U Cardiovascular Blank Blank Blank Blank 6.71 FAIR Health

C8923 Blank 2D TTE W OR W/O FOL W/CON,CO Cardiovascular Blank Blank Blank Blank 6.71 FAIR Health

C8924 Blank 2D TTE W OR W/O FOL W/CON,FU Cardiovascular Blank Blank Blank Blank 4.36 FAIR Health

C8925 Blank 2D TEE W OR W/O FOL W/CON,IN Cardiovascular Blank Blank Blank Blank 6.71 FAIR Health

C8926 Blank TEE W OR W/O FOL W/CONT,CONG Cardiovascular Blank Blank Blank Blank 6.71 FAIR Health

C8927 Blank TEE W OR W/O FOL W/CONT, MON Cardiovascular Blank Blank Blank Blank 6.71 FAIR Health

C8928 Blank TTE W OR W/O FOL W/CON,STRES Cardiovascular Blank Blank Blank Blank 20.36 FAIR Health

C8929 Blank TTE W OR WO FOL WCON,DOPPLER Cardiovascular Blank Blank Blank Blank 22.43 FAIR Health

C8930 Blank TTE W OR W/O CONTR, CONT ECG Cardiovascular Blank Blank Blank Blank 26.18 FAIR Health

C8931 Blank MRA, W/DYE, SPINAL CANAL Radiology Blank Blank Blank Blank 4.16 FAIR Health

C8932 Blank MRA, W/O DYE, SPINAL CANAL Radiology Blank Blank Blank Blank 2.20 FAIR Health

C8933 Blank MRA, W/O&W/DYE, SPINAL CANAL Radiology Blank Blank Blank Blank 4.16 FAIR Health

C8934 Blank MRA, W/DYE, UPPER EXTREMITY Radiology Blank Blank Blank Blank 2.59 FAIR Health

C8935 Blank MRA, W/O DYE, UPPER EXTR Radiology Blank Blank Blank Blank 2.20 FAIR Health

C8936 Blank MRA, W/O&W/DYE, UPPER EXTR Radiology Blank Blank Blank Blank 4.16 FAIR Health

C8957 Blank PROLONGED IV INF, REQ PUMP Miscellaneous Medical Blank Blank Blank Blank 5.59 FAIR Health

C9725 Blank PLACE ENDORECTAL APP Surgery Blank Blank Blank Blank 6.99 FAIR Health

C9727 Blank INSERT PALATE IMPLANTS Surgery Blank Blank Blank Blank 10.88 FAIR Health

C9728 Blank PLACE DEVICE/MARKER, NON PRO Surgery Blank Blank Blank Blank 11.17 FAIR Health

C9733 Blank NON-OPHTHALMIC FVA Radiology Blank Blank Blank Blank 4.06 FAIR Health

C9734 Blank U/S TRTMT, NOT LEIOMYOMATA Miscellaneous Medical Blank Blank Blank Blank 133.08 v3.23

C9739 Blank CYSTOSCOPY PROSTATIC IMP 1-3 Surgery Blank Blank Blank Blank 36.49 FAIR Health

C9740 Blank CYSTO IMPL 4 OR MORE Surgery Blank Blank Blank Blank 81.89 5% Sample

G0008 Blank ADMIN INFLUENZA VIRUS VAC Immunizations Blank Blank Blank Blank 0.54 FAIR Health

G0009 Blank ADMIN PNEUMOCOCCAL VACCINE Immunizations Blank Blank Blank Blank 0.54 FAIR Health

G0010 Blank ADMIN HEPATITIS B VACCINE Immunizations Blank Blank Blank Blank 0.54 FAIR Health

G0071 Blank COMM SVCS BY RHC/FQHC 5 MIN Office/Home/Urgent Care Visits Blank 0.22 0.09 0.15 Blank RBRVS

G0076 Blank CARE MANAG H VST NEW PT 20 M Office/Home/Urgent Care Visits Blank 1.01 0.48 0.48 Blank RBRVS





G0081 Blank CARE MAN H V EXT PT 20 MI Office/Home/Urgent Care Visits Blank 1.00 0.49 0.49 Blank RBRVS

G0082 Blank CARE MAN H V EXT PT 30 M Office/Home/Urgent Care Visits Blank 1.56 0.70 0.70 Blank RBRVS




G0086 Blank CARE MAN HOME CARE PLAN 30 M Office/Home/Urgent Care Visits Blank 1.25 0.85 0.85 Blank RBRVS

G0087 Blank CARE MAN HOME CARE PLAN 60 M Office/Home/Urgent Care Visits Blank 1.80 1.14 1.14 Blank RBRVS

G0101 Blank CA SCREEN;PELVIC/BREAST EXAM Physical Exams Blank 0.45 0.29 0.58 Blank RBRVS

G0102 Blank PROSTATE CA SCREENING; DRE Physical Exams Blank 0.17 0.07 0.42 Blank RBRVS

G0104 Blank CA SCREEN;FLEXI SIGMOIDSCOPE Surgery Blank 0.84 0.68 3.85 Blank RBRVS

G0105 Blank COLORECTAL SCRN; HI RISK IND Surgery Blank 3.26 1.71 5.29 Blank RBRVS

G0106 Blank COLON CA SCREEN;BARIUM ENEMA Radiology a 0.99 4.96 4.96 Blank RBRVS

G0106 26 COLON CA SCREEN;BARIUM ENEMA Radiology Blank 0.99 0.36 0.36 Blank RBRVS

G0106 TC COLON CA SCREEN;BARIUM ENEMA Radiology a Blank 4.60 4.60 Blank RBRVS

G0108 Blank DIAB MANAGE TRN PER INDIV Miscellaneous Medical Blank 0.90 0.57 0.57 Blank RBRVS

G0109 Blank DIAB MANAGE TRN IND/GROUP Miscellaneous Medical Blank 0.25 0.15 0.15 Blank RBRVS

G0117 Blank GLAUCOMA SCRN HGH RISK DIREC Miscellaneous Medical Blank 0.45 1.06 1.06 Blank RBRVS

G0118 Blank GLAUCOMA SCRN HGH RISK DIREC Miscellaneous Medical Blank 0.17 1.04 1.04 Blank RBRVS

G0120 Blank COLON CA SCRN; BARIUM ENEMA Radiology a 0.99 4.96 4.96 Blank RBRVS

G0120 26 COLON CA SCRN; BARIUM ENEMA Radiology Blank 0.99 0.36 0.36 Blank RBRVS

G0120 TC COLON CA SCRN; BARIUM ENEMA Radiology a Blank 4.60 4.60 Blank RBRVS

G0121 Blank COLON CA SCRN NOT HI RSK IND Surgery Blank 3.26 1.71 5.29 Blank RBRVS





PAGE 136 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

G0122 Blank COLON CA SCRN; BARIUM ENEMA Radiology Blank 0.99 6.61 6.61 Blank RBRVS

G0122 26 COLON CA SCRN; BARIUM ENEMA Radiology Blank 0.99 0.39 0.39 Blank RBRVS

G0122 TC COLON CA SCRN; BARIUM ENEMA Radiology Blank Blank 6.22 6.22 Blank RBRVS

G0124 Blank SCREEN C/V THIN LAYER BY MD Pathology Blank 0.42 0.48 0.48 Blank RBRVS

G0127 Blank TRIM NAIL(S) Surgery Blank 0.17 0.04 0.51 Blank RBRVS

G0128 Blank CORF SKILLED NURSING SERVICE Miscellaneous Medical a Blank 0.21 0.21 Blank RBRVS

G0130 Blank SINGLE ENERGY X-RAY STUDY Radiology a 0.22 0.75 0.75 Blank RBRVS

G0130 26 SINGLE ENERGY X-RAY STUDY Radiology Blank 0.22 0.09 0.09 Blank RBRVS

G0130 TC SINGLE ENERGY X-RAY STUDY Radiology a Blank 0.66 0.66 Blank RBRVS

G0141 Blank SCR C/V CYTO,AUTOSYS AND MD Pathology Blank 0.42 0.48 0.48 Blank RBRVS

G0151 Blank HHCP-SERV OF PT,EA 15 MIN Miscellaneous Medical Blank Blank Blank Blank 1.38 FAIR Health

G0152 Blank HHCP-SERV OF OT,EA 15 MIN Miscellaneous Medical Blank Blank Blank Blank 1.48 FAIR Health

G0153 Blank HHCP-SVS OF S/L PATH,EA 15MN Miscellaneous Medical Blank Blank Blank Blank 1.42 FAIR Health

G0155 Blank HHCP-SVS OF CSW,EA 15 MIN Miscellaneous Medical Blank Blank Blank Blank 1.91 FAIR Health

G0156 Blank HHCP-SVS OF AIDE,EA 15 MIN Miscellaneous Medical Blank Blank Blank Blank 0.08 FAIR Health

G0157 Blank HHC PT ASSISTANT EA 15 Miscellaneous Medical Blank Blank Blank Blank 0.17 v3.23

G0158 Blank HHC OT ASSISTANT EA 15 Miscellaneous Medical Blank Blank Blank Blank 0.28 v3.23

G0159 Blank HHC PT MAINT EA 15 MIN Miscellaneous Medical Blank Blank Blank Blank 0.17 v3.23

G0160 Blank HHC OCCUP THERAPY EA 15 Miscellaneous Medical Blank Blank Blank Blank 0.28 v3.23

G0161 Blank HHC SLP EA 15 MIN Miscellaneous Medical Blank Blank Blank Blank 0.24 v3.23

G0162 Blank HHC RN E&M PLAN SVS, 15 MIN Miscellaneous Medical Blank Blank Blank Blank 0.33 v3.23

G0166 Blank EXTRNL COUNTERPULSE, PER TX Miscellaneous Medical Blank 0.07 3.86 3.86 Blank RBRVS

G0168 Blank WOUND CLOSURE BY ADHESIVE Surgery Blank 0.45 0.30 2.43 Blank RBRVS

G0175 Blank OPPS SERVICE,SCHED TEAM CONF Miscellaneous Medical Blank Blank Blank Blank 0.17 v3.23

G0176 Blank OPPS/PHP;ACTIVITY THERAPY OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 2.08 FAIR Health

G0177 Blank OPPS/PHP; TRAIN & EDUC SERV OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 1.33 FAIR Health

G0179 Blank MD RECERTIFICATION HHA PT Office/Home/Urgent Care Visits Blank 0.45 0.70 0.70 Blank RBRVS

G0180 Blank MD CERTIFICATION HHA PATIENT Office/Home/Urgent Care Visits Blank 0.67 0.80 0.80 Blank RBRVS

G0181 Blank HOME HEALTH CARE SUPERVISION Office/Home/Urgent Care Visits Blank 1.73 1.21 1.21 Blank RBRVS

G0182 Blank HOSPICE CARE SUPERVISION Office/Home/Urgent Care Visits Blank 1.73 1.23 1.23 Blank RBRVS

G0186 Blank DSTRY EYE LESN,FDR VSSL TECH Miscellaneous Medical Blank Blank Blank Blank 9.21 v3.23

G0219 Blank PET IMG WHOLBOD MELANO NONCO Radiology a Blank Blank Blank 28.08 v3.23

G0219 26 PET IMG WHOLBOD MELANO NONCO Radiology Blank Blank Blank Blank 1.96 v3.23

G0219 TC PET IMG WHOLBOD MELANO NONCO Radiology a Blank Blank Blank 26.12 v3.23

G0235 Blank PET NOT OTHERWISE SPECIFIED Radiology a Blank Blank Blank 25.66 Unlisted

G0235 26 PET NOT OTHERWISE SPECIFIED Radiology Blank Blank Blank Blank 3.26 Unlisted

G0235 TC PET NOT OTHERWISE SPECIFIED Radiology a Blank Blank Blank 22.40 Unlisted

G0237 Blank THERAPEUTIC PROCD STRG ENDUR Miscellaneous Medical Blank Blank 0.27 0.27 Blank RBRVS

G0238 Blank OTH RESP PROC, INDIV Miscellaneous Medical Blank Blank 0.28 0.28 Blank RBRVS

G0239 Blank OTH RESP PROC, GROUP Miscellaneous Medical Blank Blank 0.36 0.36 Blank RBRVS

G0245 Blank INITIAL FOOT EXAM PT LOPS Office/Home/Urgent Care Visits Blank 0.88 0.28 0.92 Blank RBRVS

G0246 Blank FOLLOWUP EVAL OF FOOT PT LOP Office/Home/Urgent Care Visits Blank 0.45 0.13 0.61 Blank RBRVS

G0247 Blank ROUTINE FOOTCARE PT W LOPS Office/Home/Urgent Care Visits Blank 0.50 0.13 1.52 Blank RBRVS

G0248 Blank DEMONSTRATE USE HOME INR MON Miscellaneous Medical a Blank 2.48 2.48 Blank RBRVS

G0249 Blank PROVIDE INR TEST MATER/EQUIP Miscellaneous Medical a Blank 2.50 2.50 Blank RBRVS

G0250 Blank MD INR TEST REVIE INTER MGMT Cardiovascular Blank 0.18 0.07 0.07 Blank RBRVS

G0252 Blank PET IMAGING INITIAL DX Radiology Blank Blank Blank Blank 2.08 ERBRVS

G0252 26 PET IMAGING INITIAL DX Radiology Blank 1.50 0.58 0.58 Blank RBRVS

G0255 Blank CURRENT PERCEP THRESHOLD TST Miscellaneous Medical Blank Blank Blank Blank 1.35 FAIR Health

G0255 26 CURRENT PERCEP THRESHOLD TST Miscellaneous Medical Blank Blank Blank Blank 0.39 Global/TC/26

G0255 TC CURRENT PERCEP THRESHOLD TST Miscellaneous Medical Blank Blank Blank Blank 0.96 Global/TC/26

G0257 Blank UNSCHED DIALYSIS ESRD PT HOS Miscellaneous Medical Blank Blank Blank Blank 7.20 v3.23

G0259 Blank INJECT FOR SACROILIAC JOINT Surgery Blank Blank Blank Blank 4.77 v3.23

G0260 Blank INJ FOR SACROILIAC JT ANESTH Surgery Blank Blank Blank Blank 6.26 FAIR Health

G0268 Blank REMOVAL OF IMPACTED WAX MD Miscellaneous Medical Blank 0.61 0.26 0.78 Blank RBRVS

G0269 Blank OCCLUSIVE DEVICE IN VEIN ART Surgery Blank Blank Blank Blank 4.72 5% Sample

G0270 Blank MNT SUBS TX FOR CHANGE DX Miscellaneous Medical Blank 0.45 0.31 0.38 Blank RBRVS

G0271 Blank GROUP MNT 2 OR MORE 30 MINS Miscellaneous Medical Blank 0.25 0.17 0.19 Blank RBRVS

G0276 Blank PILD/PLACEBO CONTROL CLIN TR Miscellaneous Medical Blank 7.17 3.03 3.03 Blank RBRVS

G0277 Blank HBOT, FULL BODY CHAMBER, 30M Miscellaneous Medical a Blank 2.37 2.37 Blank RBRVS

G0278 Blank ILIAC ART ANGIO,CARDIAC CATH Radiology Blank 0.25 0.09 0.09 Blank RBRVS

G0279 Blank TOMOSYNTHESIS, MAMMO Radiology Blank 0.60 0.93 0.93 Blank RBRVS

G0279 26 TOMOSYNTHESIS, MAMMO Radiology Blank 0.60 0.22 0.22 Blank RBRVS

G0279 TC TOMOSYNTHESIS, MAMMO Radiology Blank Blank 0.71 0.71 Blank RBRVS

G0281 Blank ELEC STIM UNATTEND FOR PRESS Physical Medicine Blank 0.18 0.23 0.23 Blank RBRVS

G0282 Blank ELECT STIM WOUND CARE NOT PD Physical Medicine Blank Blank Blank Blank 0.61 v3.23

G0283 Blank ELEC STIM OTHER THAN WOUND Physical Medicine Blank 0.18 0.23 0.23 Blank RBRVS

G0288 Blank RECON, CTA FOR SURG PLAN Radiology a Blank 0.93 0.93 Blank RBRVS

G0289 Blank ARTHRO, LOOSE BODY + CHONDRO Surgery Blank 1.48 0.74 0.74 Blank RBRVS

G0293 Blank NON-COV SURG PROC,CLIN TRIAL Miscellaneous Medical Blank Blank Blank Blank 0.24 v3.23

G0295 Blank ELECTROMAGNETIC THERAPY ONC Physical Medicine Blank Blank Blank Blank 0.43 v3.23

G0296 Blank VISIT TO DETERM LDCT ELIG Radiology Blank 0.52 0.20 0.26 Blank RBRVS





PAGE 137 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

G0297 Blank LDCT FOR LUNG CA SCREEN Surgery a 1.02 5.64 5.64 Blank RBRVS

G0297 26 LDCT FOR LUNG CA SCREEN Surgery Blank 1.02 0.38 0.38 Blank RBRVS

G0297 TC LDCT FOR LUNG CA SCREEN Surgery a Blank 5.26 5.26 Blank RBRVS

G0299 Blank HHS/HOSPICE OF RN EA 15 MIN Surgery Blank Blank Blank Blank 0.57 FAIR Health

G0300 Blank HHS/HOSPICE OF LPN EA 15 MIN Surgery Blank Blank Blank Blank 0.47 FAIR Health

G0329 Blank ELECTROMAGNTIC TX FOR ULCERS Physical Medicine Blank 0.06 0.24 0.24 Blank RBRVS

G0337 Blank HOSPICE EVALUATION PREELECTI Office/Home/Urgent Care Visits Blank 1.42 0.55 0.55 Blank RBRVS

G0339 Blank ROBOT LIN-RADSURG COM, FIRST Surgery Blank Blank Blank Blank 113.73 5% Sample

G0340 Blank ROBT LIN-RADSURG FRACTX 2-5 Surgery Blank Blank Blank Blank 73.93 5% Sample

G0341 Blank PERCUTANEOUS ISLET CELLTRANS Surgery Blank 6.98 2.87 51.47 Blank RBRVS

G0342 Blank LAPAROSCOPY ISLET CELL TRANS Surgery Blank 11.92 6.71 6.71 Blank RBRVS

G0343 Blank LAPAROTOMY ISLET CELL TRANSP Surgery Blank 19.85 10.85 10.85 Blank RBRVS

G0365 Blank VESSEL MAPPING HEMO ACCESS Miscellaneous Medical a 0.25 5.29 5.29 Blank RBRVS

G0365 26 VESSEL MAPPING HEMO ACCESS Miscellaneous Medical Blank 0.25 0.07 0.07 Blank RBRVS

G0365 TC VESSEL MAPPING HEMO ACCESS Miscellaneous Medical a Blank 5.22 5.22 Blank RBRVS

G0372 Blank MD SERVICE REQUIRED FOR PMD Miscellaneous Medical Blank 0.17 0.08 0.08 Blank RBRVS

G0378 Blank HOSPITAL OBSERVATION PER HR Inpatient Visits Blank Blank Blank Blank 0.50 v3.23

G0382 Blank LEV 3 HOSP TYPE B ED VISIT Emergency Room Visits Blank Blank Blank Blank 0.70 v3.23

G0396 Blank ALCOHOL/SUBS INTERV 15-30MN OP Psych./Alc. & Drug Abuse Blank 0.65 0.25 0.31 Blank RBRVS

G0397 Blank ALCOHOL/SUBS INTERV >30 MIN OP Psych./Alc. & Drug Abuse Blank 1.30 0.50 0.56 Blank RBRVS

G0398 Blank HOME SLEEP TEST/TYPE 2 PORTA Miscellaneous Medical a Blank Blank Blank 6.01 FAIR Health

G0398 26 HOME SLEEP TEST/TYPE 2 PORTA Miscellaneous Medical Blank Blank Blank Blank 1.81 Global/TC/26

G0398 TC HOME SLEEP TEST/TYPE 2 PORTA Miscellaneous Medical a Blank Blank Blank 4.21 Global/TC/26

G0399 Blank HOME SLEEP TEST/TYPE 3 PORTA Miscellaneous Medical a Blank Blank Blank 4.68 Global/TC/26



G0400 Blank HOME SLEEP TEST/TYPE 4 PORTA Miscellaneous Medical a Blank Blank Blank 4.21 Global/TC/26



G0402 Blank INITIAL PREVENTIVE EXAM Physical Exams Blank 2.43 1.02 2.14 Blank RBRVS

G0403 Blank EKG FOR INITIAL PREVENT EXAM Physical Exams Blank 0.17 0.29 0.29 Blank RBRVS

G0404 Blank EKG TRACING FOR INITIAL PREV Physical Exams a Blank 0.23 0.23 Blank RBRVS

G0405 Blank EKG INTERPRET & REPORT PREVE Physical Exams Blank 0.17 0.06 0.06 Blank RBRVS

G0406 Blank INPT/TELE FOLLOW UP 15 Consults Blank 0.76 0.29 0.29 Blank RBRVS



G0409 Blank CORF RELATED SERV 15 MINS EA OP Psych./Alc. & Drug Abuse Blank Blank 0.56 0.56 Blank RBRVS

G0410 Blank GRP PSYCH PARTIAL HOSP 45-50 OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 0.81 v3.23

G0412 Blank OPEN TX ILIAC SPINE UNI/BIL Surgery Blank 10.45 8.28 8.28 Blank RBRVS

G0413 Blank PELVIC RING FRACTURE UNI/BIL Surgery Blank 15.73 11.87 11.87 Blank RBRVS

G0414 Blank PELVIC RING FX TREAT INT FIX Surgery Blank 14.65 11.34 11.34 Blank RBRVS

G0415 Blank OPEN TX POST PELVIC FXCTURE Surgery Blank 20.93 14.47 14.47 Blank RBRVS

G0416 Blank PROSTATE BIOPSY, ANY MTHD Pathology a 3.60 8.36 8.36 Blank RBRVS

G0416 26 PROSTATE BIOPSY, ANY MTHD Pathology Blank 3.60 1.51 1.51 Blank RBRVS

G0416 TC PROSTATE BIOPSY, ANY MTHD Pathology a Blank 6.85 6.85 Blank RBRVS

G0420 Blank ED SVC CKD IND PER SESSION Miscellaneous Medical Blank 2.12 0.83 0.83 Blank RBRVS

G0421 Blank ED SVC CKD GRP PER SESSION Miscellaneous Medical Blank 0.50 0.18 0.18 Blank RBRVS

G0422 Blank INTENS CARDIAC REHAB W/EXERC Cardiovascular Blank 1.75 1.39 1.39 Blank RBRVS

G0423 Blank INTENS CARDIAC REHAB NO EXER Cardiovascular Blank 1.75 1.39 1.39 Blank RBRVS

G0424 Blank PULMONARY REHAB W EXER Miscellaneous Medical Blank 0.28 0.10 0.55 Blank RBRVS

G0425 Blank INPT/ED TELECONSULT30 Consults Blank 1.92 0.76 0.76 Blank RBRVS



G0429 Blank DERMAL FILLER INJECTION(S) Miscellaneous Medical Blank 1.19 0.69 1.45 Blank RBRVS

G0438 Blank PPPS, INITIAL VISIT Office/Home/Urgent Care Visits Blank 2.43 2.28 2.28 Blank RBRVS

G0439 Blank PPPS, SUBSEQ VISIT Office/Home/Urgent Care Visits Blank 1.50 1.71 1.71 Blank RBRVS

G0442 Blank ANNUAL ALCOHOL SCREEN 15 MIN OP Psych./Alc. & Drug Abuse Blank 0.18 0.08 0.33 Blank RBRVS

G0443 Blank BRIEF ALCOHOL MISUSE COUNSEL OP Psych./Alc. & Drug Abuse Blank 0.45 0.19 0.25 Blank RBRVS

G0444 Blank DEPRESSION SCREEN ANNUAL OP Psych./Alc. & Drug Abuse Blank 0.18 0.08 0.32 Blank RBRVS

G0445 Blank HIGH INTEN BEH COUNS STD 30M OP Psych./Alc. & Drug Abuse Blank 0.45 0.19 0.29 Blank RBRVS

G0446 Blank INTENS BEHAVE THER CARDIO DX OP Psych./Alc. & Drug Abuse Blank 0.45 0.19 0.25 Blank RBRVS

G0447 Blank BEHAVIOR COUNSEL OBESITY 15M OP Psych./Alc. & Drug Abuse Blank 0.45 0.19 0.25 Blank RBRVS

G0451 Blank DEVLOPMENT TEST INTERPT&REP Pathology Blank Blank 0.28 0.28 Blank RBRVS

G0452 Blank MOLECULAR PATHOLOGY INTERPR Pathology Blank Blank Blank Blank 0.51 ERBRVS

G0452 26 MOLECULAR PATHOLOGY INTERPR Pathology Blank 0.37 0.14 0.14 Blank RBRVS

G0453 Blank CONT INTRAOP NEURO MONITOR Miscellaneous Medical Blank 0.60 0.28 0.28 Blank RBRVS

G0454 Blank MD DOCUMENT VISIT BY NPP Miscellaneous Medical Blank 0.18 0.07 0.07 Blank RBRVS

G0455 Blank FECAL MICROBIOTA PREP INSTIL Surgery Blank 1.34 0.61 2.15 Blank RBRVS

G0459 Blank TELEHEALTH INPT PHARM MGMT Miscellaneous Medical Blank 0.95 0.17 0.17 Blank RBRVS

G0460 Blank AUTOLOGOUS PRP FOR ULCERS Miscellaneous Medical Blank 2.25 0.94 2.89 Blank RBRVS

G0466 Blank FQHC VISIT NEW PATIENT Office/Home/Urgent Care Visits Blank Blank Blank Blank 3.25 5% Sample

G0467 Blank FQHC VISIT, ESTAB PT Office/Home/Urgent Care Visits Blank Blank Blank Blank 2.04 5% Sample





PAGE 138 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

G0469 Blank FQHC VISIT, MH NEW PT OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 2.55 v3.23

G0470 Blank FQHC VISIT, MH ESTAB PT OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 2.42 v3.23

G0473 Blank GROUP BEHAVE COUNS 2-10 OP Psych./Alc. & Drug Abuse Blank 0.23 0.09 0.12 Blank RBRVS

G0493 Blank RN CARE EA 15 MIN HH/HOSPICE Miscellaneous Medical Blank Blank Blank Blank 0.38 v3.23

G0494 Blank LPN CARE EA 15MIN HH/HOSPICE Miscellaneous Medical Blank Blank Blank Blank 0.27 v3.23

G0495 Blank RN CARE TRAIN/EDU IN HH Miscellaneous Medical Blank Blank Blank Blank 0.38 v3.23

G0496 Blank LPN CARE TRAIN/EDU IN HH Miscellaneous Medical Blank Blank Blank Blank 0.27 v3.23

G0498 Blank CHEMO EXTEND IV INFUS W/PUMP Miscellaneous Medical Blank Blank Blank Blank 11.56 FAIR Health

G0499 Blank HEPB SCREEN HIGH RISK INDIV Pathology Blank Blank Blank Blank 0.97 ERBRVS

G0500 Blank MOD SEDAT ENDO SERVICE >5YRS Miscellaneous Medical Blank 0.10 0.04 1.54 Blank RBRVS

G0506 Blank COMP ASSES CARE PLAN CCM SVC Miscellaneous Medical Blank 0.87 0.36 0.86 Blank RBRVS

G0508 Blank CRIT CARE TELEHEA CONSULT 60 Consults Blank 4.00 1.41 1.41 Blank RBRVS

G0509 Blank CRIT CARE TELEHEA CONSULT 50 Consults Blank 3.86 1.36 1.36 Blank RBRVS

G0511 Blank CCM/BHI BY RHC/FQHC 20MIN MO OP Psych./Alc. & Drug Abuse Blank 0.74 Blank 0.94 Blank RBRVS

G0512 Blank COCM BY RHC/FQHC 60 MIN MO OP Psych./Alc. & Drug Abuse Blank 1.62 Blank 2.31 Blank RBRVS

G0513 Blank PROLONG PREV SVCS, FIRST 30M Physical Exams Blank 1.17 0.47 0.58 Blank RBRVS

G0514 Blank PROLONG PREV SVCS, ADDL 30M Physical Exams Blank 1.17 0.47 0.58 Blank RBRVS

G0515 Blank COGNITIVE SKILLS DEVELOPMENT Physical Medicine Blank 0.44 0.35 0.35 Blank RBRVS

G0516 Blank INSERT DRUG DEL IMPLANT, >=4 Surgery Blank 1.82 1.02 4.58 Blank RBRVS

G0517 Blank REMOVE DRUG IMPLANT Surgery Blank 2.10 1.15 4.95 Blank RBRVS

G0518 Blank REMOVE W INSERT DRUG IMPLANT Surgery Blank 3.55 1.67 8.60 Blank RBRVS

G2010 Blank REMOT IMAGE SUBMIT BY PT Office/Home/Urgent Care Visits Blank 0.18 0.07 0.16 Blank RBRVS

G2011 Blank ALCOHOL/SUB ABUSE ASSESS OP Psych./Alc. & Drug Abuse Blank 0.33 0.12 0.12 Blank RBRVS

G2012 Blank BRIEF CHECK IN BY MD/QHP Office/Home/Urgent Care Visits Blank 0.25 0.10 0.14 Blank RBRVS

G6001 Blank ECHO GUIDANCE RADIOTHERAPY Radiology a 0.58 0.91 0.91 Blank RBRVS

G6001 26 ECHO GUIDANCE RADIOTHERAPY Radiology Blank 0.58 0.26 0.26 Blank RBRVS

G6001 TC ECHO GUIDANCE RADIOTHERAPY Radiology a Blank 0.65 0.65 Blank RBRVS

G6002 Blank STEREOSCOPIC X-RAY GUIDANCE Radiology a 0.39 1.76 1.76 Blank RBRVS

G6002 26 STEREOSCOPIC X-RAY GUIDANCE Radiology Blank 0.39 0.17 0.17 Blank RBRVS

G6002 TC STEREOSCOPIC X-RAY GUIDANCE Radiology a Blank 1.59 1.59 Blank RBRVS

G6003 Blank RADIATION TREATMENT DELIVERY Radiology a Blank 5.61 5.61 Blank RBRVS












G6015 Blank RADIATION TX DELIVERY IMRT Radiology a Blank 9.92 9.92 Blank RBRVS

G6016 Blank DELIVERY COMP IMRT Radiology a Blank 9.92 9.92 Blank RBRVS

G6017 Blank INTRAFRACTION TRACK MOTION Radiology Blank Blank Blank Blank 2.50 5% Sample

G9148 Blank MEDICAL HOME LEVEL 1 Miscellaneous Medical Blank Blank Blank Blank 0.02 v3.23

G9149 Blank MEDICAL HOME LEVEL II Miscellaneous Medical Blank Blank Blank Blank 0.02 v3.23

G9150 Blank MEDICAL HOME LEVEL III Miscellaneous Medical Blank Blank Blank Blank 0.03 v3.23

G9152 Blank MAPCP DEMO COMMUNITY Miscellaneous Medical Blank Blank Blank Blank 0.06 5% Sample

G9153 Blank MAPCP DEMO PHYSICIAN Miscellaneous Medical Blank Blank Blank Blank 0.03 5% Sample

G9157 Blank TRANSESOPH DOPPL CARDIAC MON Cardiovascular Blank 2.20 0.38 0.38 Blank RBRVS

G9187 Blank BPCI HOME VISIT Office/Home/Urgent Care Visits Blank 0.18 1.06 1.06 Blank RBRVS

G9481 Blank REMOTE E/M NEW PT 10MINS Office/Home/Urgent Care Visits Blank 0.48 Blank Blank Blank RBRVS





G9486 Blank REMOTE E/M EST. PT 10MINS Office/Home/Urgent Care Visits Blank 0.48 Blank Blank Blank RBRVS




G9490 Blank CMMI MOD HOME VISIT Office/Home/Urgent Care Visits Blank 0.18 1.06 1.06 Blank RBRVS

G9678 Blank ONCOLOGY CARE MODEL SERVICE Miscellaneous Medical Blank Blank Blank Blank 1.87 5% Sample

G9685 Blank ACUTE NURSING FACILITY CARE Inpatient Visits Blank 3.86 1.59 1.59 Blank RBRVS

G9868 Blank NEXT GEN ACO MODEL <10MIN Miscellaneous Medical Blank 0.80 Blank Blank Blank RBRVS

G9869 Blank NEXT GEN ACO MODEL 10-20MIN Miscellaneous Medical Blank 1.07 Blank Blank Blank RBRVS

G9870 Blank NEXT GEN ACO MODEL >20MIN Miscellaneous Medical Blank 1.34 Blank Blank Blank RBRVS

G9873 Blank 1 EM CORE SESSION Miscellaneous Medical Blank Blank Blank Blank 0.69 Other

G9874 Blank 4 EM CORE SESSIONS Miscellaneous Medical Blank Blank Blank Blank 1.39 Other

G9875 Blank 9 EM CORE SESSIONS Miscellaneous Medical Blank Blank Blank Blank 2.50 Other

G9876 Blank 2 EM CORE MS MO 7-9 NO WL Miscellaneous Medical Blank Blank Blank Blank 0.42 Other

G9877 Blank 2 EM CORE MS MO 10-12 NO WL Miscellaneous Medical Blank Blank Blank Blank 0.42 Other





PAGE 139 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

G9878 Blank 2 EM CORE MS MO 7-9 WL Miscellaneous Medical Blank Blank Blank Blank 1.67 Other

G9879 Blank 2 EM CORE MS MO 10-12 WL Miscellaneous Medical Blank Blank Blank Blank 1.67 Other

G9880 Blank EM 5 PERCENT WL Miscellaneous Medical Blank Blank Blank Blank 4.44 Other

G9881 Blank EM 9 PERCENT WL Miscellaneous Medical Blank Blank Blank Blank 0.69 Other

G9882 Blank 2 EM ONGOING MS MO 13-15 WL Miscellaneous Medical Blank Blank Blank Blank 1.39 Other




G9978 Blank REMOTE E/M NEW PT 10MINS Office/Home/Urgent Care Visits Blank 0.48 0.23 0.23 Blank RBRVS


G9980 Blank REMOTE E/M NEW PT 30 MINS Office/Home/Urgent Care Visits Blank 1.42 0.60 0.60 Blank RBRVS



G9983 Blank REMOTE E/M EST. PT 10MINS Office/Home/Urgent Care Visits Blank 0.48 0.20 0.20 Blank RBRVS




G9987 Blank BPCI ADVANCED IN HOME VISIT Office/Home/Urgent Care Visits Blank 0.18 1.06 1.06 Blank RBRVS

H0001 Blank ALCOHOL AND/OR DRUG ASSESS OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 1.14 v3.23

H0002 Blank ALCOHOL AND/OR DRUG SCREENIN OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 2.71 v3.23

H0003 Blank ALCOHOL AND/OR DRUG SCREENIN OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 0.51 v3.23

H0004 Blank ALCOHOL AND/OR DRUG SERVICES OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 0.54 5% Sample


H0006 Blank ALCOHOL AND/OR DRUG SERVICES OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 0.60 v3.23










H0022 Blank ALCOHOL AND/OR DRUG INTERVEN OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 0.66 v3.23

H0024 Blank ALCOHOL AND/OR DRUG PREVENTI OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 0.15 v3.23

H0025 Blank ALCOHOL AND/OR DRUG PREVENTI OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 0.11 v3.23

H0031 Blank MH HEALTH ASSESS BY NON-MD OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 1.69 5% Sample

H0032 Blank MH SVC PLAN DEV BY NON-MD OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 0.32 v3.23

H0033 Blank ORAL MED ADM DIRECT OBSERVE OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 2.18 v3.23

H0034 Blank MED TRNG & SUPPORT PER 15MIN OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 0.61 v3.23

H0035 Blank MH PARTIAL HOSP TX UNDER 24H OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 2.48 v3.23

H0036 Blank COMM PSY FACE-FACE PER 15MIN OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 0.19 v3.23

H0037 Blank COMM PSY SUP TX PGM PER DIEM OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 2.21 v3.23

H0038 Blank SELF-HELP/PEER SVC PER 15MIN OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 0.15 v3.23

H0039 Blank ASSER COM TX FACE-FACE/15MIN OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 0.79 v3.23

H0040 Blank ASSERT COMM TX PGM PER DIEM OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 1.35 v3.23

H0041 Blank FOS C CHLD NON-THER PER DIEM OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 1.54 v3.23

H0043 Blank SUPPORTED HOUSING, PER DIEM OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 0.56 v3.23

H0044 Blank SUPPORTED HOUSING, PER MONTH OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 9.57 v3.23

H0045 Blank RESPITE NOT-IN-HOME PER DIEM OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 2.29 v3.23

H0046 Blank MENTAL HEALTH SERVICE, NOS OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 0.41 Unlisted

H0047 Blank ALCOHOL/DRUG ABUSE SVC NOS OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 0.64 Unlisted

H0048 Blank SPEC COLL NON-BLOOD:A/D TEST OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 0.17 v3.23

H0050 Blank ALCOHOL/DRUG SERVICE 15 MIN OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 0.67 v3.23

H1000 Blank PRENATAL CARE ATRISK ASSESSM OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 1.06 v3.23

H1001 Blank ANTEPARTUM MANAGEMENT OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 2.30 v3.23

H1002 Blank CARECOORDINATION PRENATAL OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 0.53 v3.23

H1003 Blank PRENATAL AT RISK EDUCATION OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 0.28 v3.23

H1004 Blank FOLLOW UP HOME VISIT/PRENTAL OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 0.87 v3.23

H1005 Blank PRENATALCARE ENHANCED SRV PK OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 1.96 v3.23

H2000 Blank COMP MULTIDISIPLN EVALUATION OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 1.94 v3.23

H2010 Blank COMPREHENSIVE MED SVC 15 MIN OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 1.21 5% Sample

H2011 Blank CRISIS INTERVEN SVC, 15 MIN OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 0.96 5% Sample

H2012 Blank BEHAV HLTH DAY TREAT, PER HR OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 1.38 5% Sample

H2013 Blank PSYCH HLTH FAC SVC, PER DIEM OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 2.33 v3.23

H2014 Blank SKILLS TRAIN AND DEV, 15 MIN OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 1.54 v3.23

H2015 Blank COMP COMM SUPP SVC, 15 MIN OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 0.38 v3.23

H2017 Blank PSYSOC REHAB SVC, PER 15 MIN OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 0.30 5% Sample

H2018 Blank PSYSOC REHAB SVC, PER DIEM OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 1.76 v3.23

H2019 Blank THER BEHAV SVC, PER 15 MIN OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 0.45 5% Sample

H2020 Blank THER BEHAV SVC, PER DIEM OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 1.56 v3.23

H2021 Blank COM WRAP-AROUND SV, 15 MIN OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 0.21 v3.23





PAGE 140 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

H2022 Blank COM WRAP-AROUND SV, PER DIEM OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 3.13 v3.23

H2023 Blank SUPPORTED EMPLOY, PER 15 MIN OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 0.09 v3.23

H2024 Blank SUPPORTED EMPLOY, PER DIEM OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 0.72 v3.23

H2026 Blank SUPP MAINT EMPLOY, PER DIEM OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 0.63 v3.23

H2027 Blank PSYCHOED SVC, PER 15 MIN OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 0.33 v3.23

H2029 Blank SEX OFFEND TX SVC, PER DIEM OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 1.20 v3.23

H2032 Blank ACTIVITY THERAPY, PER 15 MIN OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 0.13 v3.23

H2033 Blank MULTISYS THER/JUVENILE 15MIN OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 0.50 v3.23

H2035 Blank A/D TX PROGRAM, PER HOUR OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 1.10 v3.23

H2036 Blank A/D TX PROGRAM, PER DIEM OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 1.36 v3.23

M0076 Blank PROLOTHERAPY Miscellaneous Medical Blank Blank Blank Blank 2.14 5% Sample

M0300 Blank IV CHELATIONTHERAPY Cardiovascular Blank Blank Blank Blank 0.64 v3.23

P3001 Blank SCREENING PAP SMEAR BY PHYS Pathology Blank 0.42 0.48 0.48 Blank RBRVS

P9010 Blank WHOLE BLOOD FOR TRANSFUSION Miscellaneous Medical Blank Blank Blank Blank 1.92 FAIR Health

P9011 Blank BLOOD SPLIT UNIT Miscellaneous Medical Blank Blank Blank Blank 2.74 FAIR Health

P9012 Blank CRYOPRECIPITATE EACH UNIT Miscellaneous Medical Blank Blank Blank Blank 0.55 v3.23

P9016 Blank RBC LEUKOCYTES REDUCED Miscellaneous Medical Blank Blank Blank Blank 6.37 FAIR Health

P9017 Blank PLASMA 1 DONOR FRZ W/IN 8 HR Miscellaneous Medical Blank Blank Blank Blank 0.10 v3.23

P9019 Blank PLATELETS, EACH UNIT Miscellaneous Medical Blank Blank Blank Blank 0.87 v3.23

P9020 Blank PLAELET RICH PLASMA UNIT Miscellaneous Medical Blank Blank Blank Blank 5.13 FAIR Health

P9021 Blank RED BLOOD CELLS UNIT Miscellaneous Medical Blank Blank Blank Blank 6.04 FAIR Health

P9022 Blank WASHED RED BLOOD CELLS UNIT Miscellaneous Medical Blank Blank Blank Blank 6.95 FAIR Health

P9031 Blank PLATELETS LEUKOCYTES REDUCED Miscellaneous Medical Blank Blank Blank Blank 1.95 v3.23

P9032 Blank PLATELETS, IRRADIATED Miscellaneous Medical Blank Blank Blank Blank 1.38 v3.23

P9033 Blank PLATELETS LEUKOREDUCED IRRAD Miscellaneous Medical Blank Blank Blank Blank 11.57 FAIR Health

P9034 Blank PLATELETS, PHERESIS Miscellaneous Medical Blank Blank Blank Blank 6.94 v3.23

P9035 Blank PLATELET PHERES LEUKOREDUCED Miscellaneous Medical Blank Blank Blank Blank 14.35 FAIR Health

P9037 Blank PLATE PHERES LEUKOREDU IRRAD Miscellaneous Medical Blank Blank Blank Blank 16.71 FAIR Health

P9040 Blank RBC LEUKOREDUCED IRRADIATED Miscellaneous Medical Blank Blank Blank Blank 7.92 FAIR Health

P9041 Blank ALBUMIN (HUMAN),5%, 50ML Miscellaneous Medical Blank Blank Blank Blank 0.65 FAIR Health

P9043 Blank PLASMA PROTEIN FRACT,5%,50ML Miscellaneous Medical Blank Blank Blank Blank 0.64 FAIR Health

P9045 Blank ALBUMIN (HUMAN), 5%, 250 ML Miscellaneous Medical Blank Blank Blank Blank 3.24 FAIR Health

P9046 Blank ALBUMIN (HUMAN), 25%, 20 ML Miscellaneous Medical Blank Blank Blank Blank 1.06 FAIR Health

P9047 Blank ALBUMIN (HUMAN), 25%, 50ML Miscellaneous Medical Blank Blank Blank Blank 2.64 FAIR Health

P9048 Blank PLASMAPROTEIN FRACT,5%,250ML Miscellaneous Medical Blank Blank Blank Blank 1.27 FAIR Health

P9053 Blank PLT, PHER, L/R CMV-NEG, IRR Miscellaneous Medical Blank Blank Blank Blank 14.03 v3.23

P9058 Blank RBC, L/R, CMV-NEG, IRRAD Miscellaneous Medical Blank Blank Blank Blank 7.51 v3.23

P9059 Blank PLASMA, FRZ BETWEEN 8-24HOUR Miscellaneous Medical Blank Blank Blank Blank 0.83 v3.23

P9070 Blank PATHOGEN REDUCED PLASMA POOL Miscellaneous Medical Blank Blank Blank Blank 0.83 v3.23

P9071 Blank PATHOGEN REDUCED PLASMA SING Miscellaneous Medical Blank Blank Blank Blank 0.27 v3.23

Q0035 Blank CARDIOKYMOGRAPHY Cardiovascular a 0.17 0.36 0.36 Blank RBRVS

Q0035 26 CARDIOKYMOGRAPHY Cardiovascular Blank 0.17 0.07 0.07 Blank RBRVS

Q0035 TC CARDIOKYMOGRAPHY Cardiovascular a Blank 0.29 0.29 Blank RBRVS

Q0081 Blank INFUSION THER OTHER THAN CHE Therapeutic Injections Blank Blank Blank Blank 1.62 FAIR Health

Q0083 Blank CHEMO BY OTHER THAN INFUSION Miscellaneous Medical Blank Blank Blank Blank 0.91 v3.23

Q0084 Blank CHEMOTHERAPY BY INFUSION Miscellaneous Medical Blank Blank Blank Blank 1.59 FAIR Health

Q0085 Blank CHEMO BY BOTH INFUSION AND O Miscellaneous Medical Blank Blank Blank Blank 6.14 v3.23

Q0091 Blank OBTAINING SCREEN PAP SMEAR Pathology Blank 0.37 0.15 0.85 Blank RBRVS

Q0092 Blank SET UP PORT XRAY EQUIPMENT Radiology a Blank 0.71 0.71 Blank RBRVS

Q2026 Blank RADIESSE INJECTION Miscellaneous Medical Blank Blank Blank Blank 1.83 FAIR Health

Q2028 Blank INJ, SCULPTRA, 0.5MG Miscellaneous Medical Blank Blank Blank Blank 0.10 FAIR Health

Q2035 Blank AFLURIA VACC, 3 YRS & >, IM Immunizations Blank Blank Blank Blank 0.52 FAIR Health

Q2036 Blank FLULAVAL VACC, 3 YRS & >, IM Immunizations Blank Blank Blank Blank 0.33 FAIR Health

Q2037 Blank FLUVIRIN VACC, 3 YRS & >, IM Immunizations Blank Blank Blank Blank 0.55 FAIR Health

Q2038 Blank FLUZONE VACC, 3 YRS & >, IM Immunizations Blank Blank Blank Blank 0.47 FAIR Health

Q2039 Blank INFLUENZA VIRUS VACCINE, NOS Immunizations Blank Blank Blank Blank 0.55 Unlisted

Q3014 Blank TELEHEALTH FACILITY FEE Miscellaneous Medical Blank Blank Blank Blank 0.38 5% Sample

Q5001 Blank HOSPICE OR HOME HLTH IN HOME Miscellaneous Medical Blank Blank Blank Blank 1.35 v3.23

Q5002 Blank HOSPICE/HOME HLTH IN ASST LV Miscellaneous Medical Blank Blank Blank Blank 1.61 v3.23

Q5003 Blank HOSPICE IN LT/NON-SKILLED NF Miscellaneous Medical Blank Blank Blank Blank 0.06 v3.23

Q5004 Blank HOSPICE IN SNF Miscellaneous Medical Blank Blank Blank Blank 1.52 v3.23

Q5005 Blank HOSPICE, INPATIENT HOSPITAL Miscellaneous Medical Blank Blank Blank Blank 5.03 v3.23

Q5006 Blank HOSPICE IN HOSPICE FACILITY Miscellaneous Medical Blank Blank Blank Blank 6.27 v3.23

Q5009 Blank HOSPICE/HOME HLTH, PLACE NOS Miscellaneous Medical Blank Blank Blank Blank 1.35 Unlisted

Q5010 Blank HOSPICE HOME CARE IN HOSPICE Miscellaneous Medical Blank Blank Blank Blank 6.27 v3.23

R0070 Blank TRANSPORT PORTABLE X-RAY Radiology a Blank Blank Blank 1.76 FAIR Health

R0075 Blank TRANSPORT PORT X-RAY MULTIPL Radiology a Blank Blank Blank 1.12 5% Sample

R0076 Blank TRANSPORT PORTABLE EKG Radiology Blank Blank Blank Blank 0.78 FAIR Health

S0199 Blank MED ABORTION INC ALL EX DRUG Maternity - Non-Deliveries Blank Blank Blank Blank 4.65 v3.23

S0201 Blank PARTIAL HOSPITALIZATION SERV Miscellaneous Medical Blank Blank Blank Blank 0.66 FAIR Health

S0207 Blank PARAMEDICINTERCEP NONHOSPALS Miscellaneous Medical Blank Blank Blank Blank 8.49 FAIR Health

S0208 Blank PARAMED INTRCEPT NONVOL Miscellaneous Medical Blank Blank Blank Blank 6.23 FAIR Health





PAGE 141 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

S0209 Blank WC VAN MILEAGE PER MI Miscellaneous Medical Blank Blank Blank Blank 0.03 FAIR Health

S0220 Blank MEDICAL CONFERENCE BY PHYSIC Office/Home/Urgent Care Visits Blank Blank Blank Blank 2.81 v3.23

S0221 Blank MEDICAL CONFERENCE, 60 MIN Office/Home/Urgent Care Visits Blank 1.42 0.44 1.10 Blank v3.23

S0255 Blank HOSPICE REFER VISIT NONMD Office/Home/Urgent Care Visits Blank 0.48 0.11 0.36 Blank v3.23

S0257 Blank END OF LIFE COUNSELING Office/Home/Urgent Care Visits Blank Blank Blank Blank 0.46 FAIR Health

S0260 Blank H&P FOR SURGERY Office/Home/Urgent Care Visits Blank Blank Blank Blank 4.88 v3.23

S0265 Blank GENETIC COUNSEL 15 MINS Miscellaneous Medical Blank Blank Blank Blank 0.69 FAIR Health

S0280 Blank MEDICAL HOME, INITIAL PLAN Miscellaneous Medical Blank Blank Blank Blank 0.56 FAIR Health

S0281 Blank MEDICAL HOME, MAINTENANCE Miscellaneous Medical Blank Blank Blank Blank 0.47 v3.23

S0302 Blank COMPLETED EPSDT Physical Exams Blank Blank Blank Blank 0.25 FAIR Health

S0310 Blank HOSPITALIST VISIT Inpatient Visits Blank Blank Blank Blank 1.00 FAIR Health

S0315 Blank DISEASE MANAGEMENT PROGRAM Miscellaneous Medical Blank Blank Blank Blank 1.12 v3.23

S0316 Blank FOLLOW-UP/REASSESSMENT Miscellaneous Medical Blank Blank Blank Blank 0.83 v3.23

S0317 Blank DISEASE MGMT PER DIEM Miscellaneous Medical Blank Blank Blank Blank 1.47 v3.23

S0390 Blank ROUT FOOT CARE PER VISIT Miscellaneous Medical Blank Blank Blank Blank 0.67 FAIR Health

S0400 Blank GLOBAL ESWL KIDNEY Surgery Blank 9.64 6.13 17.10 Blank v3.23

S0592 Blank COMP CONT LENS EVAL Vision Exams Blank Blank Blank Blank 0.92 FAIR Health

S0601 Blank SCREENING PROCTOSCOPY Surgery Blank 0.55 0.38 1.37 Blank v3.23

S0610 Blank ANNUAL GYNECOLOGICAL EXAMINA Physical Exams Blank Blank Blank Blank 3.67 FAIR Health

S0612 Blank ANNUAL GYNECOLOGICAL EXAMINA Physical Exams Blank Blank Blank Blank 2.57 FAIR Health

S0613 Blank ANN BREAST EXAM Physical Exams Blank Blank Blank Blank 1.22 FAIR Health

S0618 Blank AUDIOMETRY FOR HEARING AID Hearing/Speech Exams Blank Blank Blank Blank 1.26 FAIR Health

S0620 Blank ROUTINE OPHTHALMOLOGICAL EXA Vision Exams Blank Blank Blank Blank 0.95 FAIR Health

S0621 Blank ROUTINE OPHTHALMOLOGICAL EXA Vision Exams Blank Blank Blank Blank 1.06 FAIR Health

S0622 Blank PHYS EXAM FOR COLLEGE Miscellaneous Medical Blank Blank Blank Blank 0.56 FAIR Health

S0630 Blank REMOVAL OF SUTURES Miscellaneous Medical Blank Blank Blank Blank 1.54 FAIR Health

S0800 Blank LASER IN SITU KERATOMILEUSIS Miscellaneous Medical Blank Blank Blank Blank 21.12 FAIR Health

S0810 Blank PHOTOREFRACTIVE KERATECTOMY Miscellaneous Medical Blank Blank Blank Blank 21.98 FAIR Health

S0812 Blank PHOTOTHERAP KERATECT Miscellaneous Medical Blank Blank Blank Blank 2.28 FAIR Health

S2053 Blank TRANSPLANTATION OF SMALL INT Surgery Blank 83.29 27.76 27.76 Blank v3.23

S2054 Blank TRANSPLANTATION OF MULTIVISC Surgery Blank 61.68 22.96 22.96 Blank v3.23

S2055 Blank HARVESTING OF DONOR MULTIVIS Surgery Blank 61.68 22.96 22.96 Blank v3.23

S2060 Blank LOBAR LUNG TRANSPLANTATION Surgery Blank 40.94 20.19 20.19 Blank v3.23

S2065 Blank SIMULT PANC KIDN TRANS Surgery Blank 61.68 22.96 22.96 Blank v3.23

S2068 Blank BREAST DIEP OR SIEA FLAP Surgery Blank Blank Blank Blank 211.74 v3.23

S2070 Blank CYSTO LASER TX URETERAL CALC Surgery Blank 6.87 3.46 3.46 Blank v3.23

S2080 Blank LAUP Surgery Blank 9.63 7.49 7.49 Blank v3.23

S2083 Blank ADJUSTMENT GASTRIC BAND Surgery Blank Blank Blank Blank 2.99 FAIR Health

S2095 Blank TRANSCATH EMBOLIZ MICROSPHER Surgery Blank 18.11 6.24 6.24 Blank v3.23

S2102 Blank ISLET CELL TISSUE TRANSPLANT Surgery Blank Blank Blank Blank 48.84 v3.23

S2115 Blank PERIACETABULAR OSTEOTOMY Surgery Blank 21.87 12.02 12.02 Blank v3.23

S2120 Blank LOW DENSITY LIPOPROTEIN(LDL) Pathology Blank Blank Blank Blank 41.06 v3.23

S2140 Blank CORD BLOOD HARVESTING Surgery Blank Blank Blank Blank 2.41 FAIR Health

S2142 Blank CORD BLOOD-DERIVED STEM-CELL Surgery Blank Blank Blank Blank 1.62 v3.23

S2150 Blank BMT HARV/TRANSPL 28D PKG Surgery Blank 2.24 0.94 0.94 Blank v3.23

S2202 Blank ECHOSCLEROTHERAPY Miscellaneous Medical Blank Blank Blank Blank 4.78 FAIR Health

S2205 Blank MINIMALLY INVASIVE DIRECT CO Surgery Blank 33.64 12.57 12.57 Blank v3.23



S2225 Blank MYRINGOTOMY LASER-ASSIST Surgery Blank 1.35 1.56 3.32 Blank v3.23

S2230 Blank IMPLANT SEMI-IMP HEAR Surgery Blank Blank Blank Blank 15.48 v3.23

S2235 Blank IMPLANT AUDITORY BRAIN IMP Surgery Blank 0.73 8.52 8.52 Blank v3.23

S2260 Blank INDUCED ABORTION 17-24 WEEKS Maternity - Non-Deliveries Blank 5.90 2.46 2.46 Blank v3.23

S2265 Blank INDUCED ABORTION 25-28 WKS Maternity - Non-Deliveries Blank 5.90 2.46 2.46 Blank v3.23

S2266 Blank INDUCED ABORTION 29-31 WKS Maternity - Non-Deliveries Blank 5.90 2.46 2.46 Blank v3.23

S2267 Blank INDUCED ABORTION 32 OR MORE Maternity - Non-Deliveries Blank 5.90 2.46 2.46 Blank v3.23

S2300 Blank ARTHROSCOPY, SHOULDER, SURGI Surgery Blank Blank Blank Blank 12.49 v3.23

S2325 Blank HIP CORE DECOMPRESSION Surgery Blank Blank Blank Blank 25.67 FAIR Health

S2340 Blank CHEMODENERVATION OF ABDUCTOR Surgery Blank 3.86 1.65 4.26 Blank v3.23

S2341 Blank CHEMODENERV ADDUCT VOCAL Surgery Blank 3.86 1.65 4.26 Blank v3.23

S2342 Blank NASAL ENDOSCOP PO DEBRID Surgery Blank Blank Blank Blank 6.12 FAIR Health

S2348 Blank DECOMPRESS DISC RF LUMBAR Surgery Blank 8.88 4.30 4.30 Blank v3.23

S2350 Blank DISKECTOMY, ANTERIOR, WITH D Surgery Blank Blank Blank Blank 43.83 FAIR Health

S2351 Blank DISKECTOMY, ANTERIOR, WITH D Surgery Blank 3.28 1.21 1.21 Blank v3.23

S2404 Blank FETAL SURG MYELOMENINGO Surgery Blank Blank Blank Blank 102.72 FAIR Health

S2411 Blank FETOSCOP LASER THER TTTS Surgery Blank Blank Blank Blank 72.75 FAIR Health

S2900 Blank ROBOTIC SURGICAL SYSTEM Surgery Blank Blank Blank Blank 13.65 FAIR Health

S3000 Blank BILAT DIL RETINAL EXAM Vision Exams Blank 0.88 0.45 1.38 Blank v3.23

S3005 Blank EVAL SELF-ASSESS DEPRESSION OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 1.02 v3.23

S3870 Blank CGH TEST DEVELOPMENTAL DELAY Pathology Blank Blank Blank Blank 24.01 FAIR Health

S4005 Blank INTERIM LABOR FACILITY GLOBA Maternity - Non-Deliveries Blank Blank Blank Blank 16.78 FAIR Health

S4011 Blank IVF PACKAGE Miscellaneous Medical Blank Blank Blank Blank 90.66 FAIR Health





PAGE 142 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

S4015 Blank COMPLETE IVF NOS CASE RATE Miscellaneous Medical Blank Blank Blank Blank 97.97 FAIR Health

S4016 Blank FROZEN IVF CASE RATE Miscellaneous Medical Blank Blank Blank Blank 28.50 FAIR Health

S4017 Blank IVF CANC A STIM CASE RATE Miscellaneous Medical Blank Blank Blank Blank 10.55 FAIR Health

S4018 Blank F EMB TRNS CANC CASE RATE Miscellaneous Medical Blank Blank Blank Blank 9.49 FAIR Health

S4020 Blank IVF CANC A ASPIR CASE RATE Miscellaneous Medical Blank Blank Blank Blank 23.95 FAIR Health

S4021 Blank IVF CANC P ASPIR CASE RATE Miscellaneous Medical Blank Blank Blank Blank 77.47 FAIR Health

S4022 Blank ASST OOCYTE FERT CASE RATE Miscellaneous Medical Blank Blank Blank Blank 20.05 FAIR Health

S4023 Blank INCOMPL DONOR EGG CASE RATE Miscellaneous Medical Blank Blank Blank Blank 112.66 FAIR Health

S4026 Blank PROCURE DONOR SPERM Miscellaneous Medical Blank Blank Blank Blank 9.86 FAIR Health

S4027 Blank STORE PREV FROZ EMBRYOS Miscellaneous Medical Blank Blank Blank Blank 0.63 FAIR Health

S4035 Blank STIMULATED IUI CASE RATE Miscellaneous Medical Blank Blank Blank Blank 24.18 FAIR Health

S4037 Blank CRYO EMBRYO TRANSF CASE RATE Miscellaneous Medical Blank Blank Blank Blank 35.23 FAIR Health

S4040 Blank MONIT STORE CRYO EMBRYO 30 D Miscellaneous Medical Blank Blank Blank Blank 1.07 FAIR Health

S4042 Blank OVULATION MGMT PER CYCLE Miscellaneous Medical Blank Blank Blank Blank 5.05 FAIR Health

S4981 Blank INSERT LEVONORGESTREL IUS Miscellaneous Medical Blank Blank Blank Blank 2.38 FAIR Health

S5035 Blank HIT ROUTINE DEVICE MAINT Miscellaneous Medical Blank 0.18 0.37 0.37 Blank v3.23

S5100 Blank ADULT DAYCARE SERVICES 15MIN Miscellaneous Medical Blank Blank Blank Blank 0.03 FAIR Health

S5101 Blank ADULT DAY CARE PER HALF DAY Miscellaneous Medical Blank Blank Blank Blank 0.23 FAIR Health

S5105 Blank CENTERBASED DAY CARE PERDIEM Miscellaneous Medical Blank Blank Blank Blank 0.87 FAIR Health

S5108 Blank HOMECARE TRAIN PT 15 MIN Miscellaneous Medical Blank Blank Blank Blank 0.67 FAIR Health

S5109 Blank HOMECARE TRAIN PT SESSION Miscellaneous Medical Blank Blank Blank Blank 1.48 FAIR Health

S5110 Blank FAMILY HOMECARE TRAINING 15M Miscellaneous Medical Blank Blank Blank Blank 0.12 FAIR Health

S5111 Blank FAMILY HOMECARE TRAIN/SESSIO Miscellaneous Medical Blank Blank Blank Blank 1.68 v3.23

S5115 Blank NONFAMILY HOMECARE TRAIN/15M Miscellaneous Medical Blank Blank Blank Blank 1.68 v3.23

S5116 Blank NONFAMILY HC TRAIN/SESSION Miscellaneous Medical Blank Blank Blank Blank 1.38 FAIR Health

S5125 Blank ATTENDANT CARE SERVICE /15M Miscellaneous Medical Blank Blank Blank Blank 0.06 FAIR Health

S5126 Blank ATTENDANT CARE SERVICE /DIEM Miscellaneous Medical Blank Blank Blank Blank 0.26 v3.23

S5135 Blank ADULT COMPANIONCARE PER 15M Miscellaneous Medical Blank Blank Blank Blank 0.05 FAIR Health

S5136 Blank ADULT COMPANIONCARE PER DIEM Miscellaneous Medical Blank Blank Blank Blank 0.58 v3.23

S5140 Blank ADULT FOSTER CARE PER DIEM Miscellaneous Medical Blank Blank Blank Blank 0.51 v3.23

S5145 Blank CHILD FOSTERCARE TH PER DIEM Miscellaneous Medical Blank Blank Blank Blank 1.46 FAIR Health

S5150 Blank UNSKILLED RESPITE CARE /15M Miscellaneous Medical Blank Blank Blank Blank 0.07 FAIR Health

S5151 Blank UNSKILLED RESPITECARE /DIEM Miscellaneous Medical Blank Blank Blank Blank 2.12 FAIR Health

S5160 Blank EMER RESPONSE SYS INSTAL&TST Miscellaneous Medical Blank Blank Blank Blank 0.43 FAIR Health

S5161 Blank EMER RSPNS SYS SERV PERMONTH Miscellaneous Medical Blank Blank Blank Blank 0.37 FAIR Health

S5165 Blank HOME MODIFICATIONS PER SERV Miscellaneous Medical Blank Blank Blank Blank 21.14 FAIR Health

S5170 Blank HOMEDELIVERED PREPARED MEAL Miscellaneous Medical Blank Blank Blank Blank 0.10 FAIR Health

S5180 Blank HH RESPIRATORY THRPY IN EVAL Miscellaneous Medical Blank Blank Blank Blank 2.01 FAIR Health

S5181 Blank HH RESPIRATORY THRPY NOS/DAY Miscellaneous Medical Blank Blank Blank Blank 1.47 v3.23

S5190 Blank WELLNESS ASSESSMENT BY NONPH Miscellaneous Medical Blank Blank Blank Blank 0.57 FAIR Health

S5522 Blank HIT PICC INSERT NO SUPP Miscellaneous Medical Blank Blank Blank Blank 1.45 v3.23

S5523 Blank HIP MIDLINE CATH INSERT KIT Miscellaneous Medical Blank Blank Blank Blank 2.09 FAIR Health

S8030 Blank TANTALUM RING APPLICATION Radiology Blank 9.46 7.66 7.66 Blank v3.23

S8037 Blank MRCP Radiology Blank Blank Blank Blank 7.57 FAIR Health

S8040 Blank TOPOGRAPHIC BRAIN MAPPING Miscellaneous Medical Blank 2.97 3.05 3.05 Blank v3.23

S8080 Blank SCINTIMAMMOGRAPHY Radiology Blank Blank Blank Blank 3.57 v3.23

S8085 Blank FLUORINE-18 FLUORODEOXYGLUCO Radiology Blank Blank Blank Blank 2.91 v3.23

S8092 Blank ELECTRON BEAM COMPUTED TOMOG Radiology Blank Blank Blank Blank 2.28 v3.23

S8110 Blank PEAK EXPIRATORY FLOW RATE (P Miscellaneous Medical Blank Blank Blank Blank 0.33 FAIR Health

S8120 Blank O2 CONTENTS GAS CUBIC FT Miscellaneous Medical Blank Blank Blank Blank 0.03 FAIR Health

S8121 Blank O2 CONTENTS LIQUID LB Miscellaneous Medical Blank Blank Blank Blank 0.03 FAIR Health

S8930 Blank AURICULAR ELECTROSTIMULATION Miscellaneous Medical Blank Blank Blank Blank 0.93 FAIR Health

S8940 Blank HIPPOTHERAPY PER SESSION Physical Medicine Blank Blank Blank Blank 0.25 v3.23

S8948 Blank LOW-LEVEL LASER TRMT 15 MIN Miscellaneous Medical Blank Blank Blank Blank 0.63 FAIR Health

S8950 Blank COMPLEX LYMPHEDEMA THERAPY, Miscellaneous Medical Blank Blank Blank Blank 0.82 FAIR Health

S8990 Blank PT OR MANIP FOR MAINT Physical Medicine Blank Blank Blank Blank 0.71 FAIR Health

S9024 Blank PARANASAL SINUS ULTRASOUND Radiology Blank Blank Blank Blank 2.17 v3.23

S9034 Blank ESWL FOR GALLSTONES Surgery Blank 9.64 6.13 17.10 Blank v3.23

S9083 Blank URGENT CARE CENTER GLOBAL Office/Home/Urgent Care Visits Blank Blank Blank Blank 4.12 5% Sample

S9088 Blank SERVICES PROVIDED IN URGENT Office/Home/Urgent Care Visits Blank Blank Blank Blank 0.81 5% Sample

S9090 Blank VERTEBRAL AXIAL DECOMPRESSIO Miscellaneous Medical Blank Blank Blank Blank 0.82 FAIR Health

S9097 Blank HOME VISIT WOUND CARE Miscellaneous Medical Blank Blank Blank Blank 1.57 FAIR Health

S9098 Blank HOME PHOTOTHERAPY VISIT Miscellaneous Medical Blank Blank Blank Blank 2.58 FAIR Health

S9117 Blank BACK SCHOOL VISIT Miscellaneous Medical Blank 0.17 0.06 0.32 Blank v3.23

S9122 Blank HOME HEALTH AIDE OR CERTIFIE Miscellaneous Medical Blank Blank Blank Blank 0.36 FAIR Health

S9123 Blank NURSING CARE IN HOME RN Miscellaneous Medical Blank Blank Blank Blank 0.99 FAIR Health

S9124 Blank NURSING CARE, IN THE HOME; B Miscellaneous Medical Blank Blank Blank Blank 0.67 FAIR Health

S9125 Blank RESPITE CARE, IN THE HOME, P Miscellaneous Medical Blank Blank Blank Blank 0.43 FAIR Health

S9126 Blank HOSPICE CARE, IN THE HOME, P Miscellaneous Medical Blank Blank Blank Blank 1.88 FAIR Health

S9127 Blank SOCIAL WORK VISIT, IN THE HO Miscellaneous Medical Blank Blank Blank Blank 2.24 FAIR Health

S9128 Blank SPEECH THERAPY, IN THE HOME, Miscellaneous Medical Blank Blank Blank Blank 1.65 FAIR Health

S9129 Blank OCCUPATIONAL THERAPY, IN THE Miscellaneous Medical Blank Blank Blank Blank 1.63 FAIR Health





PAGE 143 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

S9131 Blank PT IN THE HOME PER DIEM Miscellaneous Medical Blank Blank Blank Blank 1.64 FAIR Health

S9140 Blank DIABETIC MANAGEMENT PROGRAM, Miscellaneous Medical Blank Blank Blank Blank 1.36 v3.23

S9141 Blank DIABETIC MANAGEMENT PROGRAM, Miscellaneous Medical Blank Blank Blank Blank 0.81 FAIR Health

S9145 Blank INSULIN PUMP INITIATION Miscellaneous Medical Blank Blank Blank Blank 3.81 v3.23

S9152 Blank SPEECH THERAPY, RE-EVAL Hearing/Speech Exams Blank Blank Blank Blank 3.58 FAIR Health

S9401 Blank ANTICOAG CLINIC PER SESSION Miscellaneous Medical Blank Blank Blank Blank 0.36 FAIR Health

S9430 Blank PHARMACY COMP/DISP SERV Miscellaneous Medical Blank Blank Blank Blank 0.66 v3.23

S9436 Blank LAMAZE CLASS Miscellaneous Medical Blank Blank Blank Blank 1.06 v3.23

S9441 Blank ASTHMA EDUCATION Miscellaneous Medical Blank Blank Blank Blank 0.55 FAIR Health

S9442 Blank BIRTHING CLASS Miscellaneous Medical Blank Blank Blank Blank 0.43 FAIR Health

S9443 Blank LACTATION CLASS Miscellaneous Medical Blank Blank Blank Blank 0.48 v3.23

S9449 Blank WEIGHT MGMT CLASS Miscellaneous Medical Blank Blank Blank Blank 0.53 FAIR Health

S9451 Blank EXERCISE CLASS Miscellaneous Medical Blank Blank Blank Blank 0.33 FAIR Health

S9452 Blank NUTRITION CLASS Miscellaneous Medical Blank Blank Blank Blank 0.16 FAIR Health

S9453 Blank SMOKING CESSATION CLASS Miscellaneous Medical Blank Blank Blank Blank 1.53 v3.23

S9455 Blank DIABETIC MANAGEMENT PROGRAM, Miscellaneous Medical Blank Blank Blank Blank 0.55 FAIR Health



S9470 Blank NUTRITIONAL COUNSELING, DIET Miscellaneous Medical Blank Blank Blank Blank 1.06 FAIR Health

S9472 Blank CARDIAC REHABILITATION PROGR Cardiovascular Blank Blank Blank Blank 0.63 FAIR Health

S9474 Blank ENTEROSTOMAL THERAPY BY A RE Miscellaneous Medical Blank Blank Blank Blank 0.67 v3.23

S9475 Blank AMBULATORY SETTING SUBSTANCE OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 1.79 v3.23

S9476 Blank VESTIBULAR REHAB PER DIEM Miscellaneous Medical Blank Blank Blank Blank 4.56 FAIR Health

S9480 Blank INTENSIVE OUTPATIENT PSYCHIA OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 4.98 FAIR Health

S9482 Blank FAMILY STABILIZATION 15 MIN OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 0.17 FAIR Health

S9484 Blank CRISIS INTERVENTION PER HOUR OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 0.39 FAIR Health

S9485 Blank CRISIS INTERVENTION MENTAL H OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 5.87 FAIR Health

S9900 Blank CHRISTIAN SCI PRACT VISIT Miscellaneous Medical Blank Blank Blank Blank 0.08 v3.23

S9970 Blank HEALTH CLUB MEMBERSHIP YR Miscellaneous Medical Blank Blank Blank Blank 1.17 FAIR Health

S9975 Blank TRANSPLANT RELATED PER DIEM Miscellaneous Medical Blank Blank Blank Blank 0.69 FAIR Health

S9981 Blank MED RECORD COPY ADMIN Miscellaneous Medical Blank Blank Blank Blank 0.30 FAIR Health

S9982 Blank MED RECORD COPY PER PAGE Miscellaneous Medical Blank Blank Blank Blank 0.02 FAIR Health

S9986 Blank NOT MEDICALLY NECESSARY SVC Miscellaneous Medical Blank Blank Blank Blank 8.84 FAIR Health

S9988 Blank SERV PART OF PHASE I TRIAL Miscellaneous Medical Blank Blank Blank Blank 0.06 v3.23

S9990 Blank SERVICES PROVIDED AS PART OF Miscellaneous Medical Blank Blank Blank Blank 1.04 v3.23

S9999 Blank SALES TAX Miscellaneous Medical Blank Blank Blank Blank 0.86 5% Sample

T1000 Blank PRIVATE DUTY/INDEPENDENT NSG Office/Home/Urgent Care Visits Blank Blank Blank Blank 0.21 v3.23

T1001 Blank NURSING ASSESSMENT/EVALUATN Office/Home/Urgent Care Visits Blank Blank Blank Blank 0.65 5% Sample

T1002 Blank RN SERVICES UP TO 15 MINUTES Office/Home/Urgent Care Visits Blank Blank Blank Blank 0.74 v3.23

T1003 Blank LPN/LVN SERVICES UP TO 15MIN Office/Home/Urgent Care Visits Blank Blank Blank Blank 0.53 v3.23

T1004 Blank NSG AIDE SERVICE UP TO 15MIN Office/Home/Urgent Care Visits Blank Blank Blank Blank 0.25 v3.23

T1005 Blank RESPITE CARE SERVICE 15 MIN Office/Home/Urgent Care Visits Blank Blank Blank Blank 0.14 v3.23

T1006 Blank FAMILY/COUPLE COUNSELING OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 0.47 v3.23

T1007 Blank TREATMENT PLAN DEVELOPMENT OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 3.02 v3.23

T1009 Blank CHILD SITTING SERVICES Miscellaneous Medical Blank Blank Blank Blank 0.06 v3.23

T1012 Blank ALCOHOL/SUBSTANCE ABUSE SKIL OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 0.13 v3.23

T1013 Blank SIGN LANG/ORAL INTERPRETER Miscellaneous Medical Blank Blank Blank Blank 0.26 5% Sample

T1015 Blank CLINIC SERVICE Office/Home/Urgent Care Visits Blank Blank Blank Blank 1.62 5% Sample

T1016 Blank CASE MANAGEMENT Office/Home/Urgent Care Visits Blank Blank Blank Blank 0.80 5% Sample

T1019 Blank PERSONAL CARE SER PER 15 MIN Office/Home/Urgent Care Visits Blank Blank Blank Blank 0.09 v3.23

T1020 Blank PERSONAL CARE SER PER DIEM Office/Home/Urgent Care Visits Blank Blank Blank Blank 1.88 v3.23

T1021 Blank HH AIDE OR CN AIDE PER VISIT Office/Home/Urgent Care Visits Blank Blank Blank Blank 0.79 v3.23

T1023 Blank PROGRAM INTAKE ASSESSMENT Office/Home/Urgent Care Visits Blank Blank Blank Blank 0.82 v3.23

T1024 Blank TEAM EVALUATION & MANAGEMENT Office/Home/Urgent Care Visits Blank Blank Blank Blank 0.32 v3.23

T1026 Blank PED COMPR CARE PKG, PER HOUR Office/Home/Urgent Care Visits Blank Blank Blank Blank 0.81 v3.23

T1027 Blank FAMILY TRAINING & COUNSELING OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 0.14 v3.23

T1028 Blank HOME ENVIRONMENT ASSESSMENT OP Psych./Alc. & Drug Abuse Blank Blank Blank Blank 0.26 v3.23

T1030 Blank RN HOME CARE PER DIEM Office/Home/Urgent Care Visits Blank Blank Blank Blank 1.99 v3.23

T1031 Blank LPN HOME CARE PER DIEM Office/Home/Urgent Care Visits Blank Blank Blank Blank 0.64 v3.23

T1502 Blank MEDICATION ADMIN VISIT Office/Home/Urgent Care Visits Blank Blank Blank Blank 0.25 v3.23

T2001 Blank N-ET; PATIENT ATTEND/ESCORT Miscellaneous Medical Blank Blank Blank Blank 0.18 v3.23

T2002 Blank N-ET; PER DIEM Miscellaneous Medical Blank Blank Blank Blank 0.11 v3.23

T2003 Blank N-ET; ENCOUNTER/TRIP Miscellaneous Medical Blank Blank Blank Blank 0.50 v3.23

T2004 Blank N-ET; COMMERC CARRIER PASS Miscellaneous Medical Blank Blank Blank Blank 0.07 v3.23

T2005 Blank N-ET; STRETCHER VAN Miscellaneous Medical Blank Blank Blank Blank 0.13 v3.23

T2007 Blank NON-EMER TRANSPORT WAIT TIME Miscellaneous Medical Blank Blank Blank Blank 0.26 v3.23

T2013 Blank HABIL ED WAIVER PER HOUR Miscellaneous Medical Blank Blank Blank Blank 0.52 v3.23

T2014 Blank HABIL PREVOC WAIVER, PER D Miscellaneous Medical Blank Blank Blank Blank 0.57 v3.23

T2016 Blank HABIL RES WAIVER PER DIEM Miscellaneous Medical Blank Blank Blank Blank 1.82 v3.23

T2017 Blank HABIL RES WAIVER 15 MIN Miscellaneous Medical Blank Blank Blank Blank 0.11 v3.23

T2018 Blank HABIL SUP EMPL WAIVER/DIEM Miscellaneous Medical Blank Blank Blank Blank 1.82 v3.23

T2020 Blank DAY HABIL WAIVER PER DIEM Miscellaneous Medical Blank Blank Blank Blank 1.05 v3.23





PAGE 144 of 144

CPT/

HCPCS

Code


Status/

Usage

Indicator 2

Work

Expense

RVUs

Facility

Practice

Expense RVUs

Non-Facility

Practice

Expense

RVUs

Total

Expense

RVUs

Charge

Methodology 3

T2022 Blank CASE MANAGEMENT, PER MONTH Miscellaneous Medical Blank Blank Blank Blank 0.63 v3.23

T2023 Blank TARGETED CASE MGMT PER MONTH Miscellaneous Medical Blank Blank Blank Blank 1.51 v3.23

T2025 Blank WAIVER SERVICE, NOS Miscellaneous Medical Blank Blank Blank Blank 0.18 v3.23

T2031 Blank ASSIST LIVING WAIVER/DIEM Miscellaneous Medical Blank Blank Blank Blank 2.47 v3.23

T2032 Blank RES CARE, NOS WAIVER/MONTH Miscellaneous Medical Blank Blank Blank Blank 2.48 v3.23

T2033 Blank RES, NOS WAIVER PER DIEM Miscellaneous Medical Blank Blank Blank Blank 1.65 v3.23

T2040 Blank FINANCIAL MGT WAIVER/15MIN Miscellaneous Medical Blank Blank Blank Blank 0.13 v3.23

T2042 Blank HOSPICE ROUTINE HOME CARE Miscellaneous Medical Blank Blank Blank Blank 1.20 v3.23

T2043 Blank HOSPICE CONTINUOUS HOME CARE Miscellaneous Medical Blank Blank Blank Blank 0.28 v3.23

T2045 Blank HOSPICE GENERAL CARE Miscellaneous Medical Blank Blank Blank Blank 5.70 v3.23

T2046 Blank HOSPICE LONG TERM CARE, R&B Miscellaneous Medical Blank Blank Blank Blank 1.37 v3.23

T2048 Blank BH LTC RES R&B, PER DIEM Miscellaneous Medical Blank Blank Blank Blank 2.28 5% Sample

T2049 Blank N-ET; STRETCHER VAN, MILEAGE Miscellaneous Medical Blank Blank Blank Blank 0.10 v3.23

V5008 Blank HEARING SCREENING Hearing/Speech Exams Blank Blank Blank Blank 1.40 FAIR Health

V5010 Blank ASSESSMENT FOR HEARING AID Hearing/Speech Exams Blank Blank Blank Blank 1.84 FAIR Health

V5362 Blank SPEECH SCREENING Hearing/Speech Exams Blank 0.86 0.28 3.50 Blank v3.23

V5363 Blank LANGUAGE SCREENING Hearing/Speech Exams Blank 0.86 0.28 3.50 Blank v3.23

V5364 Blank DYSPHAGIA SCREENING Hearing/Speech Exams Blank Blank 1.70 1.70 Blank v3.231 Key to Modifier:

TC: Represents the technical component of a service or procedure.

26: Represents the professional component of a service or procedure.

2 Key to Status/Usage Indicator:

a: Cannot be billed by VA Hospital Outpatient and Provider-Based Clinics (because the service or a service component is separately priced as outpatient facility charges - see Table F).

3 Charge Methodology:

5% Sample: RVUs based on the Medicare 5% Sample Part B database.

ERBRVS: RVUs based on Essential RBRVS RVUs.

FAIR Health: Charge developed from FAIR Health database.

Global/TC/26: RVUs were adjusted to ensure consistency between global, -26, and -TC services.

RBRVS: Based on the RBRVS fee schedule.

Unlisted: Developed based on the weighted median of the total RVUs of CPT/HCPCS codes within the series in which the unlisted procedure occurs. v3.23: RVUs from v3.23 were adopted for v3.25.

Other: RVUs based on methods not specified above, including crosswalks from similar code charges.



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