Pennsylvania Bulletin

PA Bulletin, Doc. No. 07-2316

NOTICES

DEPARTMENT OF PUBLIC WELFARE

Medical Assistance Program Fee Schedule Revisions

[37 Pa.B. 6610]
[Saturday, December 15, 2007]

   The Department of Public Welfare (Department) announces that it will revise the fees, or a component of the fee, on the Medical Assistance (MA) Program Fee Schedule for select medical, surgical, laboratory, durable medical equipment and radiological procedure codes effective January 1, 2008.

Fee Schedule Revisions

   The Pennsylvania Medicaid State Plan (State Plan) specifies that maximum fees for services covered under the MA Program are to be determined on the basis of the following: fees may not exceed the Medicare upper limit when applicable; fees must be consistent with efficiency, economy and quality of care and fees must be sufficient to assure the availability of services to recipients.

   The Department has determined that MA payment rates for approximately 2,100 medical, surgical, laboratory, durable medical equipment and radiological procedure codes or combinations of procedure codes and modifiers, are above the Medicare upper limit for the same procedure codes. The Department is adjusting the MA Program Fee Schedule payment rates for these combinations of procedure codes and modifiers to equal the Medicare upper limit. Revision of these fees is necessary to comply with the State Plan and to avoid a Federal disallowance. When adjusting the assistant surgeon fee rate (modifier 80), the Department followed the Medicare guidelines of paying 16% of the maximum allowable payment to a primary surgeon, as MA fees may not exceed the Medicare upper limit.

   In reviewing the MA payment rates for these procedure codes, the Department discovered several procedure codes that should not be billed with modifiers TC (technical component) and 26 (professional component). The Department will be removing the TC and 26 modifiers from the following procedure codes:

Procedure Code Procedure Code Description

77261 THERAPEUTIC RADIOLOGY TREATMENT PLANNING; SIMPLE

77262 THERAPEUTIC RADIOLOGY TREATMENT PLANNING; INTERMEDIATE

77263 THERAPEUTIC RADIOLOGY SIMULATION-AIDED FIELD SETTING; THREE-DIMENSIONAL

77336 CONTINUING MEDICAL PHYSICS CONSULTATION, INCLUDING ASSESSMENT OF TREATMENT PARAMETERS, QUALITY ASSURANCE OF DOSE DELIVERY AND REVIEW OF PATIENT TREATMENT DOCUMENTATION IN SUPPORT OF THE RADIATION ONCOLOGIST, REPORTED PER WEEK OF THERAPY

77417 THERAPEUTIC RADIOLOGY PORT FILM(S)

92516 FACIAL NERVE FUNCTION STUDIES (EG, ELECTRONEURONOGRAPHY)

92586 AUDITORY EVOKED POTENTIALS FOR EVOKED RESPONSE AUDIOMETRY AND/OR TESTING OF THE CENTRAL NERVOUS SYSTEM; LIMITED

94660 CONTINUOUS POSITIVE AIRWAY PRESSURE VENTILATION (CPAP), INITIATION AND MANAGEMENT

94662 CONTINUOUS NEGATIVE PRESSURE VENTILATION (CNP), INITIATION AND MANAGEMENT

   The Department has also determined that for the following procedure code, the sum of the professional and technical component rates did not equal the total component rate. The Department has adjusted the rates by decreasing the professional component fee to equal the Medicare rate and increasing the total component fee.

Procedure Code Procedure Code Description Fees

88318 DETERMINATIVE HISTOCHEMISTRY TO IDENTIFY CHEMICAL COMPONENTS (EG, COPPER, ZINC) $24.37 (Total Component Fee)
$20.83 (26--Professional Comp)
No Change (TC--Technical Comp)

   As set forth, the Department will revise the total fee (billed with no modifier) and, as applicable, the professional component fee (billed with modifier 26), the technical component fee (billed with modifier TC), the assistant surgeon fee (billed with modifier 80), the fee when billing with pricing modifiers U6, U7, U8, U9, SU and TH, or the fee when billing with modifiers NU (new) and RR (rental), for the following procedure codes:

Procedure Code Procedure Code Description Assistant Surgeon Fee Revision (Billing with Modifier 80) Professional Component Fee Revision (Billing with Modifier 26) Technical Component Fee Revision (Billing with Modifier TC) Billing with No Modifier or Pricing Modifiers U6, U7, U8, U9, SU or TH Billing with NU (New) or RR (Rental) Modifiers

10021 FINE NEEDLE ASPIRATION; WITHOUT IMAGING GUIDANCE N/A N/A N/A $63.41 N/A

10022 FINE NEEDLE ASPIRATION; WITH IMAGING GUIDANCE N/A N/A N/A $59.31 N/A

10180 INCISION AND DRAINAGE, COMPLEX, POSTOPERATIVE WOUND INFECTION N/A N/A N/A $154.29 N/A

11000 DEBRIDEMENT OF EXTENSIVE ECZEMATOUS OR INFECTED SKIN; UP TO 10% OF BODY SURFACE N/A N/A N/A $29.76 N/A

11001 DEBRIDEMENT OF EXTENSIVE ECZEMATOUS OR INFECTED SKIN; EACH ADDITIONAL 10% OF THE BODY SURFACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) N/A N/A N/A $14.86 N/A

11010 DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL ASSOCIATED WITH OPEN FRACTURE(S) AND/OR DISLOCATION(S); SKIN AND SUBCUTANEOUS TISSUES N/A N/A N/A $250.07 N/A

11011 DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL ASSOCIATED WITH OPEN FRACTURE(S) AND/OR DISLOCATION(S); SKIN, SUBCUTANEOUS TISSUE, MUSCLE FASCIA AND MUSCLE N/A N/A N/A $268.27 N/A

11012 DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL ASSOCIATED WITH OPEN FRACTURE(S) AND/OR DISLOCATION(S); SKIN, SUBCUTANEOUS TISSUE, MUSCLE FASCIA, MUSCLE AND BONE N/A N/A N/A $394.80 N/A

11057 PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); MORE THAN FOUR LESIONS N/A N/A N/A $39.51 N/A

11101 BIOPSY OF SKIN, SUBCUTANEOUS TISSUE AND/OR MUCOUS MEMBRANE (INCLUDING SIMPLE CLOSURE), UNLESS OTHERWISE LISTED (SEPARATE PROCEDURE); EACH SEPARATE/ADDITIONAL LESION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) N/A N/A N/A $21.47 N/A

11201 REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; EACH ADDITIONAL TEN LESIONS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) N/A N/A N/A $14.57 N/A

11471 EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, PERIANAL, PERINEAL OR UMBILICAL; WITH COMPLEX REPAIR N/A N/A N/A $278.14 N/A

11606 EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS OR LEGS; EXCISED DIAMETER OVER 4.0 CM N/A N/A N/A $246.00 N/A

11620 EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS N/A N/A N/A $91.50 N/A

11643 EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 2.1 TO 3.0 CM N/A N/A N/A $191.16 N/A

11720 DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); ONE TO FIVE N/A N/A N/A $15.96 N/A

11755 BIOPSY OF NAIL UNIT (EG, PLATE, BED, MATRIX, HYPONYCHIUM, PROXIMAL AND LATERAL NAIL FOLDS) (SEPARATE PROCEDURE) N/A N/A N/A $75.31 N/A

11770 EXCISION OF PILONIDAL CYST OR SINUS; SIMPLE N/A N/A N/A $151.47 N/A

11971 REMOVAL OF TISSUE EXPANDER(S) WITHOUT INSERTION OF PROSTHESIS N/A N/A N/A $251.72 N/A

11981 INSERTION, NON-BIODEGRADABLE DRUG DELIVERY IMPLANT N/A N/A N/A $76.62 N/A

11982 REMOVAL, NON-BIODEGRADABLE DRUG DELIVERY N/A N/A N/A $93.50 N/A

13121 REPAIR, COMPLEX, SCALP, ARMS AND/OR LEGS; 2.6 CM TO 7.5 CM N/A N/A N/A $259.53 N/A

15101 SPLIT GRAFT, TRUNK, ARMS, LEGS; EACH ADDITIONAL 100 SQ CM, OR EACH ADDITIONAL ONE PERCENT OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) $16.58 N/A N/A $103.64 N/A

15121 SPLIT GRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET AND/OR MULTIPLE DIGITS; EACH ADDITIONAL 100 SQ CM, OR EACH ADDITIONAL ONE PERCENT OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITIONTO CODE FOR PRIMARY PROCEDURE) $25.71 N/A N/A $160.70 N/A

15201 FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, TRUNK; EACH ADDITIONAL 20 SQ CM (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) N/A N/A N/A $71.71 N/A

15221 FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, SCALP, ARMS AND/OR LEGS; EACH ADDITIONAL 20 SQ CM (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) $10.27 N/A N/A $64.20 N/A

15241 FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; EACH ADDITIONAL 20 SQ CM (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) N/A N/A N/A $100.69 N/A

15261 FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, NOSE, EARS, EYELIDS, AND/OR LIPS; EACH ADDITIONAL 20 SQ CM (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) N/A N/A N/A $128.39 N/A

15400 XENOGRAFT, SKIN (DERMAL), FOR TEMPORARY WOUND CLOSURE; TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR LESS, OR ONE PERCENT OF BODY AREA OF INFANTS AND CHILDREN N/A N/A N/A $298.77 N/A

15570 FORMATION OF DIRECT OR TUBED PEDICLE, WITH OR WITHOUT TRANSFER; TRUNK $97.74 N/A N/A $610.85 N/A

15572 FORMATION OF DIRECT OR TUBED PEDICLE, WITH OR WITHOUT TRANSFER; SCALP, ARMS OR LEGS $95.77 N/A N/A $598.58 N/A

15574 FORMATION OF DIRECT OR TUBED PEDICLE, WITH OR WITHOUT TRANSFER; FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS OR FEET $104.79 N/A N/A $654.94 N/A

15576 FORMATION OF DIRECT OR TUBED PEDICLE, WITH OR WITHOUT TRANSFER; EYELIDS, NOSE, EARS, LIPS OR INTRAORAL $91.90 N/A N/A $574.38 N/A

15600 DELAY OF FLAP OR SECTIONING OF FLAP (DIVISION AND INSET); AT TRUNK N/A N/A N/A $176.53 N/A

15610 DELAY OF FLAP OR SECTIONING OF FLAP (DIVISION AND INSET); AT SCALP, ARMS OR LEGS N/A N/A N/A $208.36 N/A

15620 DELAY OF FLAP OR SECTIONING OF FLAP (DIVISION AND INSET); AT FOREHEAD, CHEEKS, CHIN, NECK, AXILLAE, GENITALIA, HANDS OR FEET N/A N/A N/A $266.99 N/A

15630 DELAY OF FLAP OR SECTIONING OF FLAP (DIVISION AND INSET); AT EYELIDS, NOSE, EARS OR LIPS N/A N/A N/A $288.30 N/A

15650 TRANSFER, INTERMEDIATE, OF ANY PEDICLE FLAP (EG, ABDOMEN TO WRIST, WALKING TUBE), ANY LOCATION $50.49 N/A N/A $315.57 N/A

15780 DERMABRASION; TOTAL FACE (EG, FOR ACNE SCARRING, FINE WRINKLING, RHYTIDS, GENERAL KERATOSIS) N/A N/A N/A $581.01 N/A

15786 ABRASION; SINGLE LESION (EG, KERATOSIS, SCAR) N/A N/A N/A $117.92 N/A

15787 ABRASION; EACH ADDITIONAL FOUR LESIONS OR LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) N/A N/A N/A $17.71 N/A

15822 BLEPHAROPLASTY, UPPER EYELID N/A N/A N/A $316.75 N/A

15936 EXCISION, SACRAL PRESSURE ULCER, IN PREPARATION FOR MUSCLE OR MYOCUTANEOUS FLAP OR SKIN GRAFT CLOSURE $123.87 N/A N/A $774.20 N/A

15937 EXCISION, SACRAL PRESSURE ULCER, IN PREPARATION FOR MUSCLE OR MYOCUTANEOUS FLAP OR SKIN GRAFT CLOSURE; WITH OSTECTOMY $144.65 N/A N/A $904.05 N/A

15952 EXCISION, TROCHANTERIC PRESSURE ULCER, WITH SKIN FLAP CLOSURE N/A N/A N/A $728.81 N/A

16025 DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; MEDIUM (EG, WHOLE FACE OR WHOLE EXTREMITY, OR 5% TO 10% TOTAL BODY SURFACE AREA) N/A N/A N/A $100.82 N/A

16030 DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; LARGE (EG, MORE THAN ONE EXTREMITY, OR GREATER THAN 10% TOTAL BODY SURFACE AREA) N/A N/A N/A $115.08 N/A

16035 ESCHAROTOMY; INITIAL INCISION N/A N/A N/A $192.89 N/A

17003 DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), ALL BENIGN OR PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES) OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; SECOND THROUGH 14 LESIONS N/A N/A N/A $4.63 N/A

17004 DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES), 15 OR MORE LESIONS N/A N/A N/A $118.22 N/A

17264 DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), TRUNK, ARMS OR LEGS; LESION DIAMETER 3.1 TO 4.0 CM N/A N/A N/A $110.56 N/A

17266 DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), TRUNK, ARMS OR LEGS; LESION DIAMETER OVER 4.0 CM N/A N/A N/A $128.61 N/A

17274 DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 3.1 TO 4.0 CM N/A N/A N/A $144.48 N/A

17276 DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER OVER 4.0 CM N/A N/A N/A $175.35 N/A

17282 DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 1.1 TO 2.0 CM N/A N/A N/A $117.39 N/A

17283 DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 2.1 TO 3.0 CM N/A N/A N/A $147.67 N/A

17284 DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 3.1 TO 4.0 CM N/A N/A N/A $177.23 N/A

17286 DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER OVER 4.0 CM N/A N/A N/A $242.78 N/A

19001 PUNCTURE ASPIRATION OF CYST OF BREAST; EACH ADDITIONAL CYST (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) N/A N/A N/A $20.40 N/A

19100 BIOPSY OF BREAST; PERCUTANEOUS, NEEDLE CORE, NOT USING IMAGING GUIDANCE (SEPARATE PROCEDURE) N/A N/A N/A $61.72 N/A

19102 BIOPSY OF BREAST; PERCUTANEOUS, NEEDLE CORE, USING IMAGING GUIDANCE N/A N/A N/A $94.35 N/A

19103 BIOPSY OF BREAST; PERCUTANEOUS, AUTOMATED VACUUM ASSISTED OR ROTATING BIOPSY DEVICE, USING IMAGING GUIDANCE N/A N/A N/A $175.26 N/A

19126 EXCISION OF BREAST LESION IDENTIFIED BY PREOPERATIVE PLACEMENT OF RADIOLOGICAL MARKER, OPEN; EACH ADDITIONAL LESION SEPARATELY IDENTIFIED BY A PREOPERATIVE RADIOLOGICAL MARKER (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) $22.99 N/A N/A $143.67 N/A

19291 PREOPERATIVE PLACEMENT OF NEEDLE LOCALIZATION WIRE, BREAST; EACH ADDITIONAL LESION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) N/A N/A N/A $29.66 N/A

19295 IMAGE GUIDED PLACEMENT, METALLIC LOCALIZATION CLIP, PERCUTANEOUS, DURING BREAST BIOPSY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) N/A N/A N/A $69.50 N/A

19296 PLACEMENT OF RADIOTHERAPY AFTERLOADING BALLOON CATHETER INTO THE BREAST FOR INTERSTITIAL RADIOELEMENT APPLICATION FOLLOWING PARTIAL MASTECTOMY, INCLUDES IMAGING GUIDANCE; ON DATE SEPARATE FROM PARTIAL MASTECTOMY N/A N/A N/A $184.04 N/A

19298 PLACEMENT OF RADIOTHERAPY AFTERLOADING BRACHYTHERAPY CATHETERS (MULTIPLE TUBE AND BUTTON TYPE) INTO THE BREAST FOR INTERSTITIAL RADIOELEMENT APPLICATION FOLLOWING (AT THE TIME OF OR SUBSEQUENT TO) PARTIAL MASTECTOMY, INCLUDES IMAGING GUIDANCE N/A N/A N/A $298.42 N/A

19325 MAMMAPLASTY, AUGMENTATION; WITH PROSTHETIC IMPLANT $88.75 N/A N/A $554.56 N/A

19340 IMMEDIATE INSERTION OF BREAST PROSTHESIS FOLLOWING MASTOPEXY, MASTECTOMY OR IN RECONSTRUCTION $56.37 N/A N/A $352.29 N/A

20100 EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE); NECK $85.50 N/A N/A $534.38 N/A

20101 EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE); CHEST $28.42 N/A N/A $177.60 N/A

20102 EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE); ABDOMEN/FLANK/BACK $34.24 N/A N/A $214.01 N/A

20103 EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE); EXTREMITY $50.30 N/A N/A $314.35 N/A

20150 BIOPSY, MUSCLE, PERCUTANEOUS NEEDLE $129.06 N/A N/A $806.60 N/A

20206 BIOPSY, MUSCLE, PERCUTANEOUS NEEDLE N/A N/A N/A $56.39 N/A

20551 INJECTION; TENDON ORGIN/INSERTION N/A N/A N/A $38.76 N/A

20552 INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), ONE OR TWO MUSCLE(S) N/A N/A N/A $31.06 N/A

20553 INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), THREE OR MORE MUSCLE(S) N/A N/A N/A $34.47 N/A

20612 ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION N/A N/A N/A $38.87 N/A

20615 ASPIRATION AND INJECTION FOR TREATMENT OF BONE CYST N/A N/A N/A $143.73 N/A

20650 INSERTION OF WIRE OR PIN WITH APPLICATION OF SKELETAL TRACTION, INCLUDING REMOVAL (SEPARATE PROCEDURE) N/A N/A N/A $138.63 N/A

20660 APPLICATION OF CRANIAL TONGS, CALIPER OR STEREOTACTIC FRAME, INCLUDING REMOVAL (SEPARATE PROCEDURE) N/A N/A N/A $157.85 N/A

20910 CARTILAGE GRAFT; COSTOCHONDRAL N/A N/A N/A $379.25 N/A

20912 CARTILAGE GRAFT; NASAL SEPTUM N/A N/A N/A $428.86 N/A

20920 FASCIA LATA GRAFT; BY STRIPPER $56.11 N/A N/A $350.68 N/A

20922 FASCIA LATA GRAFT; BY INCISION AND AREA EXPOSURE, COMPLEX OR SHEET $67.57 N/A N/A $422.32 N/A

20924 TENDON GRAFT, FROM A DISTANCE (EG, PALMARIS, TOE EXTENSOR, PLANTARIS) $72.04 N/A N/A $450.24 N/A

20926 TISSUE GRAFTS, OTHER (EG, PARATENON, FAT, DERMIS) N/A N/A N/A $380.55 N/A

20974 ELECTRICAL STIMULATION TO AID BONE HEALING; NONINVASIVE (NONOPERATIVE) N/A N/A N/A $42.69 N/A

20982 ABLATION, BONE TUMOR(S) (EG, OSTEOID OSTEOMA, METASTASIS) RADIOFREQUENCY, PERCUTANEOUS, INCLUDING COMPUTED TOMOGRAPHIC GUIDANCE $58.43 N/A N/A $365.20 N/A

21026 EXCISION OF BONE (EG, FOR OSTEOMYELITIS OR BONE ABSCESS); FACIAL BONE(S) N/A N/A N/A $419.51 N/A

21030 EXCISION OF BENIGN TUMOR OR CYST OF MAXILLA OR ZYGOMA BY ENUCLEATION AND CURETTAGE N/A N/A N/A $349.53 N/A

21120 GENIOPLASTY; AUGMENTATION (AUTOGRAFT, ALLOGRAFT, PROSTHETIC MATERIAL) $70.45 N/A N/A $440.34 N/A

21121 GENIOPLASTY; SLIDING OSTEOTOMY, SINGLE PIECE $88.88 N/A N/A $555.53 N/A

21122 GENIOPLASTY; SLIDING OSTEOTOMIES, TWO OR MORE OSTEOTOMIES (EG, WEDGE EXCISION OR BONE WEDGE REVERSAL FOR ASYMMETRICAL CHIN) $98.06 N/A N/A $612.88 N/A

21123 GENIOPLASTY; SLIDING, AUGMENTATION WITH INTERPOSITIONAL BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) $126.24 N/A N/A $788.98 N/A

21125 AUGMENTATION, MANDIBULAR BODY OR ANGLE; PROSTHETIC MATERIAL $106.09 N/A N/A $663.04 N/A

21127 AUGMENTATION, MANDIBULAR BODY OR ANGLE; WITH BONE GRAFT, ONLAY OR INTERPOSITIONAL (INCLUDES OBTAINING AUTOGRAFT) $123.90 N/A N/A $774.35 N/A

21137 REDUCTION FOREHEAD; CONTOURING ONLY $102.14 N/A N/A $638.40 N/A

21138 REDUCTION FOREHEAD; CONTOURING AND APPLICATION OF PROSTHETIC MATERIAL OR BONE GRAFT (INCLUDES OBTAINING AUTOGRAFT) $129.15 N/A N/A $807.19 N/A

21139 REDUCTION FOREHEAD; CONTOURING AND SETBACK OF ANTERIOR FRONTAL SINUS WALL $144.04 N/A N/A $900.27 N/A

21199 OSTEOTOMY, MANDIBLE, SEGMENTAL; WITH GENIOGLOSSUS ADVANCEMENT $144.31 N/A N/A $901.94 N/A

21206 OSTEOTOMY, MAXILLA, SEGMENTAL (EG, WASSMUND OR SCHUCHARD) $157.50 N/A N/A $984.38 N/A

21208 OSTEOPLASTY, FACIAL BONES; AUGMENTATION (AUTOGRAFT, ALLOGRAFT, OR PROSTHETIC IMPLANT) N/A N/A N/A $726.00 N/A

21209 OSTEOPLASTY, FACIAL BONES; REDUCTION $89.15 N/A N/A $557.18 N/A

21210 GRAFT, BONE; NASAL, MAXILLARY OR MALAR AREAS (INCLUDES OBTAINING GRAFT) $117.57 N/A N/A $734.82 N/A

21242 ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, WITH ALLOGRAFT $146.29 N/A N/A $914.3 N/A

21270 MALAR AUGMENTATION, PROSTHETIC MATERIAL N/A N/A N/A $617.91 N/A

21275 SECONDARY REVISION OF ORBITOCRANIOFACIAL RECONSTRUCTION $113.71 N/A N/A $710.69 N/A

21310 CLOSED TREATMENT OF NASAL BONE FRACTURE WITHOUT MANIPULATION N/A N/A N/A $26.01 N/A

21320 CLOSED TREATMENT OF NASAL BONE FRACTURE; WITH STABILIZATION N/A N/A N/A $121.12 N/A

21386 OPEN TREATMENT OF ORBITAL FLOOR BLOWOUT FRACTURE; PERIORBITAL APPROACH $93.37 N/A N/A $583.59 N/A

21387 OPEN TREATMENT OF ORBITAL FLOOR BLOWOUT FRACTURE; COMBINED APPROACH N/A N/A N/A $666.42 N/A

21390 OPEN TREATMENT OF ORBITAL FLOOR BLOWOUT FRACTURE; PERIORBITAL APPROACH, WITH ALLOPLASTIC OR OTHER IMPLANT $106.60 N/A N/A $666.25 N/A

21400 CLOSED TREATMENT OF FRACTURE OF ORBIT, EXCEPT BLOWOUT; WITHOUT MANIPULATION N/A N/A N/A $118.87 N/A

21401 CLOSED TREATMENT OF FRACTURE OF ORBIT, EXCEPT BLOWOUT; WITH MANIPULATION N/A N/A N/A $249.90 N/A

21406 OPEN TREATMENT OF FRACTURE OF ORBIT, EXCEPT BLOWOUT; WITHOUT IMPLANT N/A N/A N/A $471.34 N/A

21407 OPEN TREATMENT OF FRACTURE OF ORBIT, EXCEPT BLOWOUT; WITH IMPLANT $89.49 N/A N/A $559.29 N/A

21423 OPEN TREATMENT OF PALATAL OR MAXILLARY FRACTURE (LEFORT I TYPE); COMPLICATED (COMMINUTED OR INVOLVING CRANIAL NERVE FORAMINA), MULTIPLE APPROACHES $112.96 N/A N/A $705.97 N/A

21454 OPEN TREATMENT OF MANDIBULAR FRACTURE WITH EXTERNAL FIXATION N/A N/A N/A $479.43 N/A

21480 CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; INITIAL OR SUBSEQUENT N/A N/A N/A $29.16 N/A

21557 RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM), SOFT TISSUE OF NECK OR THORAX $81.88 N/A N/A $511.77 N/A

21720 DIVISION OF STERNOCLEIDOMASTOID FOR TORTICOLLIS, OPEN OPERATION; WITHOUT CAST APPLICATION N/A N/A N/A $322.86 N/A

21740 RECONSTRUCTIVE REPAIR OF PECTUS EXCAVATUM OR CARINATUM; OPEN $153.80 N/A N/A $961.22 N/A

22103 PARTIAL EXCISION OF POSTERIOR VERTEBRAL COMPONENT (EG, SPINOUS PROCESS, LAMINA OR FACET) FOR INTRINSIC BONY LESION, SINGLE VERTEBRAL SEGMENT; EACH ADDITIONAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) $21.04 N/A N/A $131.52 N/A

22116 PARTIAL EXCISION OF VERTEBRAL BODY, FOR INTRINSIC BONY LESION, WITHOUT DECOMPRESSION OF SPINAL CORD OR NERVE ROOT(S), SINGLE VERTEBRAL SEGMENT; EACH ADDITIONAL VERTEBRAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) $21.11 N/A N/A $131.92 N/A

22216 OSTEOTOMY OF SPINE, POSTERIOR OR POSTEROLATERAL APPROACH, ONE VERTEBRAL SEGMENT; EACH ADDITIONAL VERTEBRAL SEGMENT (LIST SEPARATELY IN ADDITION TO PRIMARY PROCEDURE) $55.24 N/A N/A $345.24 N/A

22226 OSTEOTOMY OF SPINE, INCLUDING DISKECTOMY, ANTERIOR APPROACH, SINGLE VERTEBRAL SEGMENT; EACH ADDITIONAL VERTEBRAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) $54.74 N/A N/A $342.15 N/A

22328 OPEN TREATMENT AND/OR REDUCTION OF VERTEBRAL FRACTURE(S) AND/ OR DISLOCATION(S), POSTERIOR APPROACH, ONE FRACTURED VERTEBRAE OR DISLOCATED SEGMENT; EACH ADDITIONAL FRACTURED VERTEBRAE OR DISLOCATED SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) $41.41 N/A N/A $258.80 N/A

22585 ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE, INCLUDING MINIMAL DISKECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) $50.45 N/A N/A $315.30 N/A

22614 ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE LEVEL; EACH ADDITIONAL VERTEBRAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) $58.95 N/A N/A $368.44 N/A

22632 ARTHRODESIS, POSTERIOR INTERBODY TECHNIQUE, INCLUDING LAMINECTOMY AND/OR DISKECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE; EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) $47.77 N/A N/A $298.59 N/A

22840 POSTERIOR NON-SEGMENTAL INSTRUMENTATION (EG, HARRINGTON ROD TECHNIQUE, PEDICLE FIXATION ACROSS ONE INTERSPACE, ATLANTOAXIAL TRANSARTICULAR SCREW FIXATION, SUBLAMINAR WIRING AT C1, FACET SCREW FIXATION) $115.13 N/A N/A $719.55 N/A

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Procedure Code	Procedure Code Description
77261	THERAPEUTIC RADIOLOGY TREATMENT PLANNING; SIMPLE
77262	THERAPEUTIC RADIOLOGY TREATMENT PLANNING; INTERMEDIATE
77263	THERAPEUTIC RADIOLOGY SIMULATION-AIDED FIELD SETTING; THREE-DIMENSIONAL
77336	CONTINUING MEDICAL PHYSICS CONSULTATION, INCLUDING ASSESSMENT OF TREATMENT PARAMETERS, QUALITY ASSURANCE OF DOSE DELIVERY AND REVIEW OF PATIENT TREATMENT DOCUMENTATION IN SUPPORT OF THE RADIATION ONCOLOGIST, REPORTED PER WEEK OF THERAPY
77417	THERAPEUTIC RADIOLOGY PORT FILM(S)
92516	FACIAL NERVE FUNCTION STUDIES (EG, ELECTRONEURONOGRAPHY)
92586	AUDITORY EVOKED POTENTIALS FOR EVOKED RESPONSE AUDIOMETRY AND/OR TESTING OF THE CENTRAL NERVOUS SYSTEM; LIMITED
94660	CONTINUOUS POSITIVE AIRWAY PRESSURE VENTILATION (CPAP), INITIATION AND MANAGEMENT
94662	CONTINUOUS NEGATIVE PRESSURE VENTILATION (CNP), INITIATION AND MANAGEMENT

Procedure Code	Procedure Code Description	Assistant Surgeon Fee Revision (Billing with Modifier 80)	Professional Component Fee Revision (Billing with Modifier 26)	Technical Component Fee Revision (Billing with Modifier TC)	Billing with No Modifier or Pricing Modifiers U6, U7, U8, U9, SU or TH	Billing with NU (New) or RR (Rental) Modifiers
10021	FINE NEEDLE ASPIRATION; WITHOUT IMAGING GUIDANCE	N/A	N/A	N/A	$63.41	N/A
10022	FINE NEEDLE ASPIRATION; WITH IMAGING GUIDANCE	N/A	N/A	N/A	$59.31	N/A
10180	INCISION AND DRAINAGE, COMPLEX, POSTOPERATIVE WOUND INFECTION	N/A	N/A	N/A	$154.29	N/A
11000	DEBRIDEMENT OF EXTENSIVE ECZEMATOUS OR INFECTED SKIN; UP TO 10% OF BODY SURFACE	N/A	N/A	N/A	$29.76	N/A
11001	DEBRIDEMENT OF EXTENSIVE ECZEMATOUS OR INFECTED SKIN; EACH ADDITIONAL 10% OF THE BODY SURFACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)	N/A	N/A	N/A	$14.86	N/A
11010	DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL ASSOCIATED WITH OPEN FRACTURE(S) AND/OR DISLOCATION(S); SKIN AND SUBCUTANEOUS TISSUES	N/A	N/A	N/A	$250.07	N/A
11011	DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL ASSOCIATED WITH OPEN FRACTURE(S) AND/OR DISLOCATION(S); SKIN, SUBCUTANEOUS TISSUE, MUSCLE FASCIA AND MUSCLE	N/A	N/A	N/A	$268.27	N/A
11012	DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL ASSOCIATED WITH OPEN FRACTURE(S) AND/OR DISLOCATION(S); SKIN, SUBCUTANEOUS TISSUE, MUSCLE FASCIA, MUSCLE AND BONE	N/A	N/A	N/A	$394.80	N/A
11057	PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); MORE THAN FOUR LESIONS	N/A	N/A	N/A	$39.51	N/A
11101	BIOPSY OF SKIN, SUBCUTANEOUS TISSUE AND/OR MUCOUS MEMBRANE (INCLUDING SIMPLE CLOSURE), UNLESS OTHERWISE LISTED (SEPARATE PROCEDURE); EACH SEPARATE/ADDITIONAL LESION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)	N/A	N/A	N/A	$21.47	N/A
11201	REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; EACH ADDITIONAL TEN LESIONS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)	N/A	N/A	N/A	$14.57	N/A
11471	EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, PERIANAL, PERINEAL OR UMBILICAL; WITH COMPLEX REPAIR	N/A	N/A	N/A	$278.14	N/A
11606	EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS OR LEGS; EXCISED DIAMETER OVER 4.0 CM	N/A	N/A	N/A	$246.00	N/A
11620	EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS	N/A	N/A	N/A	$91.50	N/A
11643	EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; EXCISED DIAMETER 2.1 TO 3.0 CM	N/A	N/A	N/A	$191.16	N/A
11720	DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); ONE TO FIVE	N/A	N/A	N/A	$15.96	N/A
11755	BIOPSY OF NAIL UNIT (EG, PLATE, BED, MATRIX, HYPONYCHIUM, PROXIMAL AND LATERAL NAIL FOLDS) (SEPARATE PROCEDURE)	N/A	N/A	N/A	$75.31	N/A
11770	EXCISION OF PILONIDAL CYST OR SINUS; SIMPLE	N/A	N/A	N/A	$151.47	N/A
11971	REMOVAL OF TISSUE EXPANDER(S) WITHOUT INSERTION OF PROSTHESIS	N/A	N/A	N/A	$251.72	N/A
11981	INSERTION, NON-BIODEGRADABLE DRUG DELIVERY IMPLANT	N/A	N/A	N/A	$76.62	N/A
11982	REMOVAL, NON-BIODEGRADABLE DRUG DELIVERY	N/A	N/A	N/A	$93.50	N/A
13121	REPAIR, COMPLEX, SCALP, ARMS AND/OR LEGS; 2.6 CM TO 7.5 CM	N/A	N/A	N/A	$259.53	N/A
15101	SPLIT GRAFT, TRUNK, ARMS, LEGS; EACH ADDITIONAL 100 SQ CM, OR EACH ADDITIONAL ONE PERCENT OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)	$16.58	N/A	N/A	$103.64	N/A
15121	SPLIT GRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET AND/OR MULTIPLE DIGITS; EACH ADDITIONAL 100 SQ CM, OR EACH ADDITIONAL ONE PERCENT OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITIONTO CODE FOR PRIMARY PROCEDURE)	$25.71	N/A	N/A	$160.70	N/A
15201	FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, TRUNK; EACH ADDITIONAL 20 SQ CM (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)	N/A	N/A	N/A	$71.71	N/A
15221	FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, SCALP, ARMS AND/OR LEGS; EACH ADDITIONAL 20 SQ CM (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)	$10.27	N/A	N/A	$64.20	N/A
15241	FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; EACH ADDITIONAL 20 SQ CM (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)	N/A	N/A	N/A	$100.69	N/A
15261	FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, NOSE, EARS, EYELIDS, AND/OR LIPS; EACH ADDITIONAL 20 SQ CM (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)	N/A	N/A	N/A	$128.39	N/A
15400	XENOGRAFT, SKIN (DERMAL), FOR TEMPORARY WOUND CLOSURE; TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR LESS, OR ONE PERCENT OF BODY AREA OF INFANTS AND CHILDREN	N/A	N/A	N/A	$298.77	N/A
15570	FORMATION OF DIRECT OR TUBED PEDICLE, WITH OR WITHOUT TRANSFER; TRUNK	$97.74	N/A	N/A	$610.85	N/A
15572	FORMATION OF DIRECT OR TUBED PEDICLE, WITH OR WITHOUT TRANSFER; SCALP, ARMS OR LEGS	$95.77	N/A	N/A	$598.58	N/A
15574	FORMATION OF DIRECT OR TUBED PEDICLE, WITH OR WITHOUT TRANSFER; FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS OR FEET	$104.79	N/A	N/A	$654.94	N/A
15576	FORMATION OF DIRECT OR TUBED PEDICLE, WITH OR WITHOUT TRANSFER; EYELIDS, NOSE, EARS, LIPS OR INTRAORAL	$91.90	N/A	N/A	$574.38	N/A
15600	DELAY OF FLAP OR SECTIONING OF FLAP (DIVISION AND INSET); AT TRUNK	N/A	N/A	N/A	$176.53	N/A
15610	DELAY OF FLAP OR SECTIONING OF FLAP (DIVISION AND INSET); AT SCALP, ARMS OR LEGS	N/A	N/A	N/A	$208.36	N/A
15620	DELAY OF FLAP OR SECTIONING OF FLAP (DIVISION AND INSET); AT FOREHEAD, CHEEKS, CHIN, NECK, AXILLAE, GENITALIA, HANDS OR FEET	N/A	N/A	N/A	$266.99	N/A
15630	DELAY OF FLAP OR SECTIONING OF FLAP (DIVISION AND INSET); AT EYELIDS, NOSE, EARS OR LIPS	N/A	N/A	N/A	$288.30	N/A
15650	TRANSFER, INTERMEDIATE, OF ANY PEDICLE FLAP (EG, ABDOMEN TO WRIST, WALKING TUBE), ANY LOCATION	$50.49	N/A	N/A	$315.57	N/A
15780	DERMABRASION; TOTAL FACE (EG, FOR ACNE SCARRING, FINE WRINKLING, RHYTIDS, GENERAL KERATOSIS)	N/A	N/A	N/A	$581.01	N/A
15786	ABRASION; SINGLE LESION (EG, KERATOSIS, SCAR)	N/A	N/A	N/A	$117.92	N/A
15787	ABRASION; EACH ADDITIONAL FOUR LESIONS OR LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)	N/A	N/A	N/A	$17.71	N/A
15822	BLEPHAROPLASTY, UPPER EYELID	N/A	N/A	N/A	$316.75	N/A
15936	EXCISION, SACRAL PRESSURE ULCER, IN PREPARATION FOR MUSCLE OR MYOCUTANEOUS FLAP OR SKIN GRAFT CLOSURE	$123.87	N/A	N/A	$774.20	N/A
15937	EXCISION, SACRAL PRESSURE ULCER, IN PREPARATION FOR MUSCLE OR MYOCUTANEOUS FLAP OR SKIN GRAFT CLOSURE; WITH OSTECTOMY	$144.65	N/A	N/A	$904.05	N/A
15952	EXCISION, TROCHANTERIC PRESSURE ULCER, WITH SKIN FLAP CLOSURE	N/A	N/A	N/A	$728.81	N/A
16025	DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; MEDIUM (EG, WHOLE FACE OR WHOLE EXTREMITY, OR 5% TO 10% TOTAL BODY SURFACE AREA)	N/A	N/A	N/A	$100.82	N/A
16030	DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; LARGE (EG, MORE THAN ONE EXTREMITY, OR GREATER THAN 10% TOTAL BODY SURFACE AREA)	N/A	N/A	N/A	$115.08	N/A
16035	ESCHAROTOMY; INITIAL INCISION	N/A	N/A	N/A	$192.89	N/A
17003	DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), ALL BENIGN OR PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES) OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; SECOND THROUGH 14 LESIONS	N/A	N/A	N/A	$4.63	N/A
17004	DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES), 15 OR MORE LESIONS	N/A	N/A	N/A	$118.22	N/A
17264	DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), TRUNK, ARMS OR LEGS; LESION DIAMETER 3.1 TO 4.0 CM	N/A	N/A	N/A	$110.56	N/A
17266	DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), TRUNK, ARMS OR LEGS; LESION DIAMETER OVER 4.0 CM	N/A	N/A	N/A	$128.61	N/A
17274	DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 3.1 TO 4.0 CM	N/A	N/A	N/A	$144.48	N/A
17276	DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER OVER 4.0 CM	N/A	N/A	N/A	$175.35	N/A
17282	DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 1.1 TO 2.0 CM	N/A	N/A	N/A	$117.39	N/A
17283	DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 2.1 TO 3.0 CM	N/A	N/A	N/A	$147.67	N/A
17284	DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 3.1 TO 4.0 CM	N/A	N/A	N/A	$177.23	N/A
17286	DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER OVER 4.0 CM	N/A	N/A	N/A	$242.78	N/A
19001	PUNCTURE ASPIRATION OF CYST OF BREAST; EACH ADDITIONAL CYST (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)	N/A	N/A	N/A	$20.40	N/A
19100	BIOPSY OF BREAST; PERCUTANEOUS, NEEDLE CORE, NOT USING IMAGING GUIDANCE (SEPARATE PROCEDURE)	N/A	N/A	N/A	$61.72	N/A
19102	BIOPSY OF BREAST; PERCUTANEOUS, NEEDLE CORE, USING IMAGING GUIDANCE	N/A	N/A	N/A	$94.35	N/A
19103	BIOPSY OF BREAST; PERCUTANEOUS, AUTOMATED VACUUM ASSISTED OR ROTATING BIOPSY DEVICE, USING IMAGING GUIDANCE	N/A	N/A	N/A	$175.26	N/A
19126	EXCISION OF BREAST LESION IDENTIFIED BY PREOPERATIVE PLACEMENT OF RADIOLOGICAL MARKER, OPEN; EACH ADDITIONAL LESION SEPARATELY IDENTIFIED BY A PREOPERATIVE RADIOLOGICAL MARKER (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)	$22.99	N/A	N/A	$143.67	N/A
19291	PREOPERATIVE PLACEMENT OF NEEDLE LOCALIZATION WIRE, BREAST; EACH ADDITIONAL LESION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)	N/A	N/A	N/A	$29.66	N/A
19295	IMAGE GUIDED PLACEMENT, METALLIC LOCALIZATION CLIP, PERCUTANEOUS, DURING BREAST BIOPSY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)	N/A	N/A	N/A	$69.50	N/A
19296	PLACEMENT OF RADIOTHERAPY AFTERLOADING BALLOON CATHETER INTO THE BREAST FOR INTERSTITIAL RADIOELEMENT APPLICATION FOLLOWING PARTIAL MASTECTOMY, INCLUDES IMAGING GUIDANCE; ON DATE SEPARATE FROM PARTIAL MASTECTOMY	N/A	N/A	N/A	$184.04	N/A
19298	PLACEMENT OF RADIOTHERAPY AFTERLOADING BRACHYTHERAPY CATHETERS (MULTIPLE TUBE AND BUTTON TYPE) INTO THE BREAST FOR INTERSTITIAL RADIOELEMENT APPLICATION FOLLOWING (AT THE TIME OF OR SUBSEQUENT TO) PARTIAL MASTECTOMY, INCLUDES IMAGING GUIDANCE	N/A	N/A	N/A	$298.42	N/A
19325	MAMMAPLASTY, AUGMENTATION; WITH PROSTHETIC IMPLANT	$88.75	N/A	N/A	$554.56	N/A
19340	IMMEDIATE INSERTION OF BREAST PROSTHESIS FOLLOWING MASTOPEXY, MASTECTOMY OR IN RECONSTRUCTION	$56.37	N/A	N/A	$352.29	N/A
20100	EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE); NECK	$85.50	N/A	N/A	$534.38	N/A
20101	EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE); CHEST	$28.42	N/A	N/A	$177.60	N/A
20102	EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE); ABDOMEN/FLANK/BACK	$34.24	N/A	N/A	$214.01	N/A
20103	EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE); EXTREMITY	$50.30	N/A	N/A	$314.35	N/A
20150	BIOPSY, MUSCLE, PERCUTANEOUS NEEDLE	$129.06	N/A	N/A	$806.60	N/A
20206	BIOPSY, MUSCLE, PERCUTANEOUS NEEDLE	N/A	N/A	N/A	$56.39	N/A
20551	INJECTION; TENDON ORGIN/INSERTION	N/A	N/A	N/A	$38.76	N/A
20552	INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), ONE OR TWO MUSCLE(S)	N/A	N/A	N/A	$31.06	N/A
20553	INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), THREE OR MORE MUSCLE(S)	N/A	N/A	N/A	$34.47	N/A
20612	ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION	N/A	N/A	N/A	$38.87	N/A
20615	ASPIRATION AND INJECTION FOR TREATMENT OF BONE CYST	N/A	N/A	N/A	$143.73	N/A
20650	INSERTION OF WIRE OR PIN WITH APPLICATION OF SKELETAL TRACTION, INCLUDING REMOVAL (SEPARATE PROCEDURE)	N/A	N/A	N/A	$138.63	N/A
20660	APPLICATION OF CRANIAL TONGS, CALIPER OR STEREOTACTIC FRAME, INCLUDING REMOVAL (SEPARATE PROCEDURE)	N/A	N/A	N/A	$157.85	N/A
20910	CARTILAGE GRAFT; COSTOCHONDRAL	N/A	N/A	N/A	$379.25	N/A
20912	CARTILAGE GRAFT; NASAL SEPTUM	N/A	N/A	N/A	$428.86	N/A
20920	FASCIA LATA GRAFT; BY STRIPPER	$56.11	N/A	N/A	$350.68	N/A
20922	FASCIA LATA GRAFT; BY INCISION AND AREA EXPOSURE, COMPLEX OR SHEET	$67.57	N/A	N/A	$422.32	N/A
20924	TENDON GRAFT, FROM A DISTANCE (EG, PALMARIS, TOE EXTENSOR, PLANTARIS)	$72.04	N/A	N/A	$450.24	N/A
20926	TISSUE GRAFTS, OTHER (EG, PARATENON, FAT, DERMIS)	N/A	N/A	N/A	$380.55	N/A
20974	ELECTRICAL STIMULATION TO AID BONE HEALING; NONINVASIVE (NONOPERATIVE)	N/A	N/A	N/A	$42.69	N/A
20982	ABLATION, BONE TUMOR(S) (EG, OSTEOID OSTEOMA, METASTASIS) RADIOFREQUENCY, PERCUTANEOUS, INCLUDING COMPUTED TOMOGRAPHIC GUIDANCE	$58.43	N/A	N/A	$365.20	N/A
21026	EXCISION OF BONE (EG, FOR OSTEOMYELITIS OR BONE ABSCESS); FACIAL BONE(S)	N/A	N/A	N/A	$419.51	N/A
21030	EXCISION OF BENIGN TUMOR OR CYST OF MAXILLA OR ZYGOMA BY ENUCLEATION AND CURETTAGE	N/A	N/A	N/A	$349.53	N/A
21120	GENIOPLASTY; AUGMENTATION (AUTOGRAFT, ALLOGRAFT, PROSTHETIC MATERIAL)	$70.45	N/A	N/A	$440.34	N/A
21121	GENIOPLASTY; SLIDING OSTEOTOMY, SINGLE PIECE	$88.88	N/A	N/A	$555.53	N/A
21122	GENIOPLASTY; SLIDING OSTEOTOMIES, TWO OR MORE OSTEOTOMIES (EG, WEDGE EXCISION OR BONE WEDGE REVERSAL FOR ASYMMETRICAL CHIN)	$98.06	N/A	N/A	$612.88	N/A
21123	GENIOPLASTY; SLIDING, AUGMENTATION WITH INTERPOSITIONAL BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS)	$126.24	N/A	N/A	$788.98	N/A
21125	AUGMENTATION, MANDIBULAR BODY OR ANGLE; PROSTHETIC MATERIAL	$106.09	N/A	N/A	$663.04	N/A
21127	AUGMENTATION, MANDIBULAR BODY OR ANGLE; WITH BONE GRAFT, ONLAY OR INTERPOSITIONAL (INCLUDES OBTAINING AUTOGRAFT)	$123.90	N/A	N/A	$774.35	N/A
21137	REDUCTION FOREHEAD; CONTOURING ONLY	$102.14	N/A	N/A	$638.40	N/A
21138	REDUCTION FOREHEAD; CONTOURING AND APPLICATION OF PROSTHETIC MATERIAL OR BONE GRAFT (INCLUDES OBTAINING AUTOGRAFT)	$129.15	N/A	N/A	$807.19	N/A
21139	REDUCTION FOREHEAD; CONTOURING AND SETBACK OF ANTERIOR FRONTAL SINUS WALL	$144.04	N/A	N/A	$900.27	N/A
21199	OSTEOTOMY, MANDIBLE, SEGMENTAL; WITH GENIOGLOSSUS ADVANCEMENT	$144.31	N/A	N/A	$901.94	N/A
21206	OSTEOTOMY, MAXILLA, SEGMENTAL (EG, WASSMUND OR SCHUCHARD)	$157.50	N/A	N/A	$984.38	N/A
21208	OSTEOPLASTY, FACIAL BONES; AUGMENTATION (AUTOGRAFT, ALLOGRAFT, OR PROSTHETIC IMPLANT)	N/A	N/A	N/A	$726.00	N/A
21209	OSTEOPLASTY, FACIAL BONES; REDUCTION	$89.15	N/A	N/A	$557.18	N/A
21210	GRAFT, BONE; NASAL, MAXILLARY OR MALAR AREAS (INCLUDES OBTAINING GRAFT)	$117.57	N/A	N/A	$734.82	N/A
21242	ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, WITH ALLOGRAFT	$146.29	N/A	N/A	$914.3	N/A
21270	MALAR AUGMENTATION, PROSTHETIC MATERIAL	N/A	N/A	N/A	$617.91	N/A
21275	SECONDARY REVISION OF ORBITOCRANIOFACIAL RECONSTRUCTION	$113.71	N/A	N/A	$710.69	N/A
21310	CLOSED TREATMENT OF NASAL BONE FRACTURE WITHOUT MANIPULATION	N/A	N/A	N/A	$26.01	N/A
21320	CLOSED TREATMENT OF NASAL BONE FRACTURE; WITH STABILIZATION	N/A	N/A	N/A	$121.12	N/A
21386	OPEN TREATMENT OF ORBITAL FLOOR BLOWOUT FRACTURE; PERIORBITAL APPROACH	$93.37	N/A	N/A	$583.59	N/A
21387	OPEN TREATMENT OF ORBITAL FLOOR BLOWOUT FRACTURE; COMBINED APPROACH	N/A	N/A	N/A	$666.42	N/A
21390	OPEN TREATMENT OF ORBITAL FLOOR BLOWOUT FRACTURE; PERIORBITAL APPROACH, WITH ALLOPLASTIC OR OTHER IMPLANT	$106.60	N/A	N/A	$666.25	N/A
21400	CLOSED TREATMENT OF FRACTURE OF ORBIT, EXCEPT BLOWOUT; WITHOUT MANIPULATION	N/A	N/A	N/A	$118.87	N/A
21401	CLOSED TREATMENT OF FRACTURE OF ORBIT, EXCEPT BLOWOUT; WITH MANIPULATION	N/A	N/A	N/A	$249.90	N/A
21406	OPEN TREATMENT OF FRACTURE OF ORBIT, EXCEPT BLOWOUT; WITHOUT IMPLANT	N/A	N/A	N/A	$471.34	N/A
21407	OPEN TREATMENT OF FRACTURE OF ORBIT, EXCEPT BLOWOUT; WITH IMPLANT	$89.49	N/A	N/A	$559.29	N/A
21423	OPEN TREATMENT OF PALATAL OR MAXILLARY FRACTURE (LEFORT I TYPE); COMPLICATED (COMMINUTED OR INVOLVING CRANIAL NERVE FORAMINA), MULTIPLE APPROACHES	$112.96	N/A	N/A	$705.97	N/A
21454	OPEN TREATMENT OF MANDIBULAR FRACTURE WITH EXTERNAL FIXATION	N/A	N/A	N/A	$479.43	N/A
21480	CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; INITIAL OR SUBSEQUENT	N/A	N/A	N/A	$29.16	N/A
21557	RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM), SOFT TISSUE OF NECK OR THORAX	$81.88	N/A	N/A	$511.77	N/A
21720	DIVISION OF STERNOCLEIDOMASTOID FOR TORTICOLLIS, OPEN OPERATION; WITHOUT CAST APPLICATION	N/A	N/A	N/A	$322.86	N/A
21740	RECONSTRUCTIVE REPAIR OF PECTUS EXCAVATUM OR CARINATUM; OPEN	$153.80	N/A	N/A	$961.22	N/A
22103	PARTIAL EXCISION OF POSTERIOR VERTEBRAL COMPONENT (EG, SPINOUS PROCESS, LAMINA OR FACET) FOR INTRINSIC BONY LESION, SINGLE VERTEBRAL SEGMENT; EACH ADDITIONAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)	$21.04	N/A	N/A	$131.52	N/A
22116	PARTIAL EXCISION OF VERTEBRAL BODY, FOR INTRINSIC BONY LESION, WITHOUT DECOMPRESSION OF SPINAL CORD OR NERVE ROOT(S), SINGLE VERTEBRAL SEGMENT; EACH ADDITIONAL VERTEBRAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)	$21.11	N/A	N/A	$131.92	N/A
22216	OSTEOTOMY OF SPINE, POSTERIOR OR POSTEROLATERAL APPROACH, ONE VERTEBRAL SEGMENT; EACH ADDITIONAL VERTEBRAL SEGMENT (LIST SEPARATELY IN ADDITION TO PRIMARY PROCEDURE)	$55.24	N/A	N/A	$345.24	N/A
22226	OSTEOTOMY OF SPINE, INCLUDING DISKECTOMY, ANTERIOR APPROACH, SINGLE VERTEBRAL SEGMENT; EACH ADDITIONAL VERTEBRAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)	$54.74	N/A	N/A	$342.15	N/A
22328	OPEN TREATMENT AND/OR REDUCTION OF VERTEBRAL FRACTURE(S) AND/ OR DISLOCATION(S), POSTERIOR APPROACH, ONE FRACTURED VERTEBRAE OR DISLOCATED SEGMENT; EACH ADDITIONAL FRACTURED VERTEBRAE OR DISLOCATED SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)	$41.41	N/A	N/A	$258.80	N/A
22585	ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE, INCLUDING MINIMAL DISKECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)	$50.45	N/A	N/A	$315.30	N/A
22614	ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE LEVEL; EACH ADDITIONAL VERTEBRAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)	$58.95	N/A	N/A	$368.44	N/A
22632	ARTHRODESIS, POSTERIOR INTERBODY TECHNIQUE, INCLUDING LAMINECTOMY AND/OR DISKECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE; EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)	$47.77	N/A	N/A	$298.59	N/A
22840	POSTERIOR NON-SEGMENTAL INSTRUMENTATION (EG, HARRINGTON ROD TECHNIQUE, PEDICLE FIXATION ACROSS ONE INTERSPACE, ATLANTOAXIAL TRANSARTICULAR SCREW FIXATION, SUBLAMINAR WIRING AT C1, FACET SCREW FIXATION)	$115.13	N/A	N/A	$719.55	N/A

NOTICES

DEPARTMENT OF PUBLIC WELFARE

Medical Assistance Program Fee Schedule Revisions

[37 Pa.B. 6610][Saturday, December 15, 2007]

[Continued on next Web Page]

[37 Pa.B. 6610]
[Saturday, December 15, 2007]