GUAM MEMORIAL HOSPITAL AUTHORITY PHYSICIAN CPT CODES AND FEES - Revision #2 SEPTEMBER 2013

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1 10021 Fine needle aspiration; without imaging guidance $ $ % Fine needle aspiration; with imaging guidance $ $ % Acne surgery (eg, marsupialization, opening or removal of m $ $ % Incision and drainage of abscess (eg, carbuncle, suppurativ $ $ % Incision and drainage of abscess (eg, carbuncle, suppurativ $ $ % Incision and drainage of pilonidal cyst; simple $ $ % Incision and drainage of pilonidal cyst; complicated $ $ % Incision and removal of foreign body, subcutaneous tissues; $ $ % Incision and removal of foreign body, subcutaneous tissues; $ $ % Incision and drainage of hematoma, seroma or fluid collectio $ $ % Puncture aspiration of abscess, hematoma, bulla, or cyst $ $ % Incision and drainage, complex, postoperative wound infecti $ $ % Debridement of extensive eczematous or infected skin; up to $ $ % Debridement of extensive eczematous or infected skin; each $89.00 $ % Debridement of skin, subcutaneous tissue, muscle and fasci $1, $1, % Debridement of skin, subcutaneous tissue, muscle and fasc $2, $2, % Debridement of skin, subcutaneous tissue, muscle and fasci $2, $2, % Removal of prosthetic material or mesh, abdominal wall for i $ $1, % Debridement including removal of foreign material at the site $1, $1, % Debridement including removal of foreign material at the site $1, $1, % Debridement including removal of foreign material at the site $1, $2, % Debridement, subcutaneous tissue (includes epidermis and $ $ % Debridement, muscle and/or fascia (includes epidermis, der $ $ % Debridement, bone (includes epidermis, dermis, subcutaneo $ $1, % Debridement, subcutaneous tissue (includes epidermis and $96.00 $ % Debridement, muscle and/or fascia (includes epidermis, derm $ $ % Debridement, bone (includes epidermis, dermis, subcutaneo $ $ % Paring or cutting of benign hyperkeratotic lesion (eg, corn or $71.00 $ % Paring or cutting of benign hyperkeratotic lesion (eg, corn or $80.00 $ % Paring or cutting of benign hyperkeratotic lesion (eg, corn or $ $ % Biopsy of skin, subcutaneous tissue and/or mucous membra $ $ % Biopsy of skin, subcutaneous tissue and/or mucous membra $94.00 $ % Removal of skin tags, multiple fibrocutaneous tags, any area $ $ % Removal of skin tags, multiple fibrocutaneous tags, any area $91.00 $ % Shaving of epidermal or dermal lesion, single lesion, trunk, a $ $ % Shaving of epidermal or dermal lesion, single lesion, trunk, a $ $ % Shaving of epidermal or dermal lesion, single lesion, trunk, a $ $ % Shaving of epidermal or dermal lesion, single lesion, trunk, a $ $ % Shaving of epidermal or dermal lesion, single lesion, scalp, n $ $ % Shaving of epidermal or dermal lesion, single lesion, scalp, n $ $ % Shaving of epidermal or dermal lesion, single lesion, scalp, n $ $ % Shaving of epidermal or dermal lesion, single lesion, scalp, n $ $ % Shaving of epidermal or dermal lesion, single lesion, face, e $ $ % Shaving of epidermal or dermal lesion, single lesion, face, e $ $ % Shaving of epidermal or dermal lesion, single lesion, face, e $ $ % Shaving of epidermal or dermal lesion, single lesion, face, e $ $ % Excision, benign lesion including margins, except skin tag (u $ $ % Excision, benign lesion including margins, except skin tag (u $ $ % Excision, benign lesion including margins, except skin tag (u $ $ % Excision, benign lesion including margins, except skin tag (u $ $ % Excision, benign lesion including margins, except skin tag (u $ $ % Excision, benign lesion including margins, except skin tag (u $ $ % Excision, benign lesion including margins, except skin tag (u $ $ % Excision, benign lesion including margins, except skin tag (u $ $ % Excision, benign lesion including margins, except skin tag (u $ $ % Excision, benign lesion including margins, except skin tag (u $ $ % Excision, benign lesion including margins, except skin tag (u $ $ % Excision, benign lesion including margins, except skin tag (u $ $ % Excision, other benign lesion including margins, except skin $ $ % Excision, other benign lesion including margins, except skin $ $ % Excision, other benign lesion including margins, except skin $ $ % Excision, other benign lesion including margins, except skin $ $ % Excision, other benign lesion including margins, except skin $ $ % Excision, other benign lesion including margins, except skin $ $1, % Effective 09/19/ of 153

2 11450 Excision of skin and subcutaneous tissue for hidradenitis, ax $ $1, % Excision of skin and subcutaneous tissue for hidradenitis, ax $ $1, % Excision of skin and subcutaneous tissue for hidradenitis, ing $ $1, % Excision of skin and subcutaneous tissue for hidradenitis, ing $1, $1, % Excision of skin and subcutaneous tissue for hidradenitis, pe $ $1, % Excision of skin and subcutaneous tissue for hidradenitis, pe $1, $1, % Excision, malignant lesion including margins, trunk, arms, or $ $ % Excision, malignant lesion including margins, trunk, arms, or $ $ % Excision, malignant lesion including margins, trunk, arms, or $ $ % Excision, malignant lesion including margins, trunk, arms, or $ $ % Excision, malignant lesion including margins, trunk, arms, or $ $ % Excision, malignant lesion including margins, trunk, arms, or $ $1, % Excision, malignant lesion including margins, scalp, neck, ha $ $ % Excision, malignant lesion including margins, scalp, neck, ha $ $ % Excision, malignant lesion including margins, scalp, neck, ha $ $ % Excision, malignant lesion including margins, scalp, neck, ha $ $ % Excision, malignant lesion including margins, scalp, neck, ha $ $1, % Excision, malignant lesion including margins, scalp, neck, ha $ $1, % Excision, malignant lesion including margins, face, ears, eye $ $ % Excision, malignant lesion including margins, face, ears, eye $ $ % Excision, malignant lesion including margins, face, ears, eye $ $ % Excision, malignant lesion including margins, face, ears, eye $ $1, % Excision, malignant lesion including margins, face, ears, eye $ $1, % Excision, malignant lesion including margins, face, ears, eye $1, $1, % Trimming of nondystrophic nails, any number $41.00 $ % Debridement of nail(s) by any method(s); 1 to 5 $57.00 $ % Debridement of nail(s) by any method(s); 6 or more $87.00 $ % Avulsion of nail plate, partial or complete, simple; single $ $ % Avulsion of nail plate, partial or complete, simple; each addit $81.00 $ % Evacuation of subungual hematoma $81.00 $ % Excision of nail and nail matrix, partial or complete (eg, ingro $ $ % Excision of nail and nail matrix, partial or complete (eg, ingro $ $ % Biopsy of nail unit (eg, plate, bed, matrix, hyponychium, prox $ $ % Repair of nail bed $ $ % Reconstruction of nail bed with graft $ $ % Wedge excision of skin of nail fold (eg, for ingrown toenail) $ $ % Excision of pilonidal cyst or sinus; simple $ $ % Excision of pilonidal cyst or sinus; extensive $1, $1, % Excision of pilonidal cyst or sinus; complicated $1, $1, % Injection, intralesional; up to and including 7 lesions $ $ % Injection, intralesional; more than 7 lesions $ $ % Tattooing, intradermal introduction of insoluble opaque pigm $ $ % Tattooing, intradermal introduction of insoluble opaque pigm $ $1, % Tattooing, intradermal introduction of insoluble opaque pigm $ $ % Subcutaneous injection of filling material (eg, collagen); 1 cc $ $ % Subcutaneous injection of filling material (eg, collagen); 1.1 $ $ % Subcutaneous injection of filling material (eg, collagen); 5.1 $ $ % Subcutaneous injection of filling material (eg, collagen); over $ $1, % Insertion of tissue expander(s) for other than breast, includin $2, $3, % Replacement of tissue expander with permanent prosthesis $2, $3, % Removal of tissue expander(s) without insertion of prosthesi $1, $1, % Removal, implantable contraceptive capsules $ $ % Subcutaneous hormone pellet implantation (implantation of $ $ % Insertion, non-biodegradable drug delivery implant $ $ % Removal, non-biodegradable drug delivery implant $ $ % Removal with reinsertion, non-biodegradable drug delivery im $ $ % Simple repair of superficial wounds of scalp, neck, axillae, e $ $ % Simple repair of superficial wounds of scalp, neck, axillae, e $ $ % Simple repair of superficial wounds of scalp, neck, axillae, e $ $ % Simple repair of superficial wounds of scalp, neck, axillae, e $ $ % Simple repair of superficial wounds of scalp, neck, axillae, e $ $ % Simple repair of superficial wounds of scalp, neck, axillae, ex $ $ % Simple repair of superficial wounds of face, ears, eyelids, no $ $ % Simple repair of superficial wounds of face, ears, eyelids, no $ $ % Effective 09/19/ of 153

3 12014 Simple repair of superficial wounds of face, ears, eyelids, no Simple repair of superficial wounds of face, ears, eyelids, no Simple repair of superficial wounds of face, ears, eyelids, no Simple repair of superficial wounds of face, ears, eyelids, no Simple repair of superficial wounds of face, ears, eyelids, no Treatment of superficial wound dehiscence; simple closure Treatment of superficial wound dehiscence; with packing Repair, intermediate, wounds of scalp, axillae, trunk and/or e Repair, intermediate, wounds of scalp, axillae, trunk and/or e Repair, intermediate, wounds of scalp, axillae, trunk and/or e Repair, intermediate, wounds of scalp, axillae, trunk and/or e Repair, intermediate, wounds of scalp, axillae, trunk and/or e Repair, intermediate, wounds of scalp, axillae, trunk and/or e Repair, intermediate, wounds of neck, hands, feet and/or ex Repair, intermediate, wounds of neck, hands, feet and/or ex Repair, intermediate, wounds of neck, hands, feet and/or ex Repair, intermediate, wounds of neck, hands, feet and/or ex Repair, intermediate, wounds of neck, hands, feet and/or ex Repair, intermediate, wounds of neck, hands, feet and/or ex Repair, intermediate, wounds of face, ears, eyelids, nose, lip Repair, intermediate, wounds of face, ears, eyelids, nose, lip Repair, intermediate, wounds of face, ears, eyelids, nose, lip Repair, intermediate, wounds of face, ears, eyelids, nose, lip Repair, intermediate, wounds of face, ears, eyelids, nose, lip Repair, intermediate, wounds of face, ears, eyelids, nose, lip Repair, intermediate, wounds of face, ears, eyelids, nose, lip Repair, complex, trunk; 1.1 cm to 2.5 cm Repair, complex, trunk; 2.6 cm to 7.5 cm Repair, complex, trunk; each additional 5 cm or less (List se Repair, complex, scalp, arms, and/or legs; 1.1 cm to 2.5 cm Repair, complex, scalp, arms, and/or legs; 2.6 cm to 7.5 cm Repair, complex, scalp, arms, and/or legs; each additional Repair, complex, forehead, cheeks, chin, mouth, neck, axilla Repair, complex, forehead, cheeks, chin, mouth, neck, axilla Repair, complex, forehead, cheeks, chin, mouth, neck, axilla Repair, complex, eyelids, nose, ears and/or lips; 1.0 cm or le Repair, complex, eyelids, nose, ears and/or lips; 1.1 cm to Repair, complex, eyelids, nose, ears and/or lips; 2.6 cm to Repair, complex, eyelids, nose, ears and/or lips; each additi Secondary closure of surgical wound or dehiscence, extensi Adjacent tissue transfer or rearrangement, trunk; defect 10 s Adjacent tissue transfer or rearrangement, trunk; defect Adjacent tissue transfer or rearrangement, scalp, arms and/o Adjacent tissue transfer or rearrangement, scalp, arms and/o Adjacent tissue transfer or rearrangement, forehead, cheeks Adjacent tissue transfer or rearrangement, forehead, cheeks Adjacent tissue transfer or rearrangement, eyelids, nose, ea Adjacent tissue transfer or rearrangement, eyelids, nose, ea Adjacent tissue transfer or rearrangement, any area; defect Adjacent tissue transfer or rearrangement, any area; each a Filleted finger or toe flap, including preparation of recipient s Surgical preparation or creation of recipient site by excision o Surgical preparation or creation of recipient site by excision o Surgical preparation or creation of recipient site by excision Surgical preparation or creation of recipient site by excision o Harvest of skin for tissue cultured skin autograft, 100 sq cm Pinch graft, single or multiple, to cover small ulcer, tip of digi Split-thickness autograft, trunk, arms, legs; first 100 sq cm o Split-thickness autograft, trunk, arms, legs; each additional Epidermal autograft, trunk, arms, legs; first 100 sq cm or les Epidermal autograft, trunk, arms, legs; each additional 100 s Epidermal autograft, face, scalp, eyelids, mouth, neck, ears, Epidermal autograft, face, scalp, eyelids, mouth, neck, ears, Split-thickness autograft, face, scalp, eyelids, mouth, neck, e $ $ % $ $ % $ $1, % $ $1, % $1, $1, % $ $ % $ $ % $ $ % $ $ % $ $ % $ $ % $ $1, % $1, $1, % $ $ % $ $ % $ $ % $ $1, % $ $1, % $ $1, % $ $ % $ $ % $ $ % $ $1, % $ $1, % $1, $1, % $1, $1, % $ $ % $ $ % $ $ % $ $ % $ $ % $ $ % $ $ % $ $1, % $ $ % $ $ % $ $1, % $1, $1, % $ $ % $1, $2, % $1, $1, % $1, $2, % $1, $1, % $1, $2, % $1, $2, % $1, $2, % $1, $2, % $2, $3, % $2, $3, % $ $ % $1, $2, % $ $1, % $ $ % $ $1, % $ $ % $ $ % $1, $1, % $1, $2, % $ $1, % $2, $2, % $ $ % $2, $2, % $ $ % $2, $3, % Effective 09/19/ of 153

4 15121 Split-thickness autograft, face, scalp, eyelids, mouth, neck, e Dermal autograft, trunk, arms, legs; first 100 sq cm or less, o Dermal autograft, trunk, arms, legs; each additional 100 sq c Dermal autograft, face, scalp, eyelids, mouth, neck, ears, or Dermal autograft, face, scalp, eyelids, mouth, neck, ears, or Tissue cultured skin autograft, trunk, arms, legs; first 25 sq c Tissue cultured skin autograft, trunk, arms, legs; additional Tissue cultured skin autograft, trunk, arms, legs; each additi Tissue cultured skin autograft, face, scalp, eyelids, mouth, n Tissue cultured skin autograft, face, scalp, eyelids, mouth, n Tissue cultured skin autograft, face, scalp, eyelids, mouth, n Full thickness graft, free, including direct closure of donor sit Full thickness graft, free, including direct closure of donor sit Full thickness graft, free, including direct closure of donor sit Full thickness graft, free, including direct closure of donor sit Full thickness graft, free, including direct closure of donor sit Full thickness graft, free, including direct closure of donor sit Full thickness graft, free, including direct closure of donor sit Full thickness graft, free, including direct closure of donor sit Application of skin substitute graft to trunk, arms, legs, total Application of skin substitute graft to trunk, arms, legs, total Application of skin substitute graft to trunk, arms, legs, total Application of skin substitute graft to trunk, arms, legs, total Application of skin substitute graft to face, scalp, eyelids, mo Application of skin substitute graft to face, scalp, eyelids, mo Application of skin substitute graft to face, scalp, eyelids, mo Application of skin substitute graft to face, scalp, eyelids, mo Formation of direct or tubed pedicle, with or without transfer; Formation of direct or tubed pedicle, with or without transfer; Formation of direct or tubed pedicle, with or without transfer; Formation of direct or tubed pedicle, with or without transfer; Delay of flap or sectioning of flap (division and inset); at trun Delay of flap or sectioning of flap (division and inset); at scal Delay of flap or sectioning of flap (division and inset); at fore Delay of flap or sectioning of flap (division and inset); at eyel Transfer, intermediate, of any pedicle flap (eg, abdomen to w Forehead flap with preservation of vascular pedicle (eg, axia Muscle, myocutaneous, or fasciocutaneous flap; head and n Muscle, myocutaneous, or fasciocutaneous flap; trunk Muscle, myocutaneous, or fasciocutaneous flap; upper extre Muscle, myocutaneous, or fasciocutaneous flap; lower extre Flap; island pedicle requiring identification and dissection of Flap; neurovascular pedicle Free muscle or myocutaneous flap with microvascular anast Free skin flap with microvascular anastomosis Free fascial flap with microvascular anastomosis Graft; composite (eg, full thickness of external ear or nasal a Graft; derma-fat-fascia Punch graft for hair transplant; 1 to 15 punch grafts Punch graft for hair transplant; more than 15 punch grafts Implantation of biologic implant (eg, acellular dermal matrix) Dermabrasion; total face (eg, for acne scarring, fine wrinkling Dermabrasion; segmental, face Dermabrasion; regional, other than face Dermabrasion; superficial, any site (eg, tattoo removal) Abrasion; single lesion (eg, keratosis, scar) Abrasion; each additional 4 lesions or less (List separately in Chemical peel, facial; epidermal Chemical peel, facial; dermal Chemical peel, nonfacial; epidermal Chemical peel, nonfacial; dermal Cervicoplasty Blepharoplasty, lower eyelid; Blepharoplasty, lower eyelid; with extensive herniated fat pa $1, $1, % $1, $2, % $ $ % $2, $2, % $ $ % $1, $2, % $ $ % $ $ % $1, $2, % $ $ % $ $ % $1, $2, % $ $ % $1, $2, % $ $ % $1, $2, % $ $1, % $2, $2, % $ $1, % $ $ % $25.92 #DIV/0! $ $ % $63.24 #DIV/0! $ $ % $39.44 #DIV/0! $ $ % $79.83 #DIV/0! $3, #DIV/0! $2, $2, % $2, $3, % $2, $3, % $1, $1, % $1, $1, % $1, $2, % $1, $2, % $1, $1, % $3, $4, % $4, $5, % $4, $7, % $4, $6, % $4, $6, % $2, $3, % $2, $3, % $8, $11, % $8, $12, % $8, $11, % $2, $3, % $2, $2, % $ $ % $ $ % $ #DIV/0! $2, $3, % $1, $1, % $ $1, % $ $1, % $ $ % $ $ % $ $1, % $1, $2, % $ $ % $ $1, % $2, $2, % $1, $2, % $1, $2, % Effective 09/19/ of 153

5 15822 Blepharoplasty, upper eyelid; $1, $3, % Blepharoplasty, upper eyelid; with excessive skin weighting $1, $2, % Rhytidectomy; forehead $2, $3, % Rhytidectomy; neck with platysmal tightening (platysmal flap $3, $4, % Rhytidectomy; glabellar frown lines $1, $2, % Rhytidectomy; cheek, chin, and neck $5, $9, % Rhytidectomy; superficial musculoaponeurotic system (SMA $5, $7, % Excision, excessive skin and subcutaneous tissue (includes $4, $5, % Excision, excessive skin and subcutaneous tissue (includes $4, $5, % Excision, excessive skin and subcutaneous tissue (includes $3, $4, % Excision, excessive skin and subcutaneous tissue (includes $3, $4, % Excision, excessive skin and subcutaneous tissue (includes $4, $6, % Excision, excessive skin and subcutaneous tissue (includes $3, $4, % Excision, excessive skin and subcutaneous tissue (includes $2, $3, % Excision, excessive skin and subcutaneous tissue (includes $1, $2, % Excision, excessive skin and subcutaneous tissue (includes $1, $2, % Graft for facial nerve paralysis; free fascia graft (including ob $3, $5, % Graft for facial nerve paralysis; free muscle graft (including o $4, $5, % Graft for facial nerve paralysis; free muscle flap by microsurg $6, $8, % Graft for facial nerve paralysis; regional muscle transfer $3, $4, % Excision, excessive skin and subcutaneous tissue (includes $1, $2, % Removal of sutures under anesthesia (other than local), sam $ $ % Removal of sutures under anesthesia (other than local), othe $ $ % Dressing change (for other than burns) under anesthesia (ot $ $ % Intravenous injection of agent (eg, fluorescein) to test vascu $ $ % Suction assisted lipectomy; head and neck $1, $2, % Suction assisted lipectomy; trunk $2, $3, % Suction assisted lipectomy; upper extremity $1, $2, % Suction assisted lipectomy; lower extremity $2, $3, % Excision, coccygeal pressure ulcer, with coccygectomy; with $1, $1, % Excision, coccygeal pressure ulcer, with coccygectomy; with $2, $2, % Excision, sacral pressure ulcer, with primary suture; $1, $2, % Excision, sacral pressure ulcer, with primary suture; with ost $2, $2, % Excision, sacral pressure ulcer, with skin flap closure; $2, $3, % Excision, sacral pressure ulcer, with skin flap closure; with o $2, $3, % Excision, sacral pressure ulcer, in preparation for muscle or $2, $3, % Excision, sacral pressure ulcer, in preparation for muscle or $3, $4, % Excision, ischial pressure ulcer, with primary suture; $1, $2, % Excision, ischial pressure ulcer, with primary suture; with ost $2, $2, % Excision, ischial pressure ulcer, with skin flap closure; $2, $2, % Excision, ischial pressure ulcer, with skin flap closure; with o $2, $3, % Excision, ischial pressure ulcer, with ostectomy, in preparatio $3, $5, % Excision, trochanteric pressure ulcer, with primary suture; $1, $2, % Excision, trochanteric pressure ulcer, with primary suture; wi $2, $2, % Excision, trochanteric pressure ulcer, with skin flap closure; $2, $2, % Excision, trochanteric pressure ulcer, with skin flap closure; w $2, $3, % Excision, trochanteric pressure ulcer, in preparation for musc $3, $4, % Excision, trochanteric pressure ulcer, in preparation for musc $3, $4, % Unlisted procedure, excision pressure ulcer Initial treatment, first degree burn, when no more than local $ $ % Dressings and/or debridement of partial-thickness burns, init $ $ % Dressings and/or debridement of partial-thickness burns, init $ $ % Dressings and/or debridement of partial-thickness burns, init $ $ % Escharotomy; initial incision $ $ % Escharotomy; each additional incision (List separately in add $ $ % Destruction (eg, laser surgery, electrosurgery, cryosurgery, c $ $ % Destruction (eg, laser surgery, electrosurgery, cryosurgery, c $56.00 $ % Destruction (eg, laser surgery, electrosurgery, cryosurgery, c $ $ % Destruction of cutaneous vascular proliferative lesions (eg, la $ $ % Destruction of cutaneous vascular proliferative lesions (eg, la $1, $1, % Destruction of cutaneous vascular proliferative lesions (eg, la $1, $2, % Destruction (eg, laser surgery, electrosurgery, cryosurgery, c $ $ % Destruction (eg, laser surgery, electrosurgery, cryosurgery, c $ $ % Chemical cauterization of granulation tissue (proud flesh, sin $ $ % Effective 09/19/ of 153

6 17260 Destruction, malignant lesion (eg, laser surgery, electrosurge Destruction, malignant lesion (eg, laser surgery, electrosurge Destruction, malignant lesion (eg, laser surgery, electrosurge Destruction, malignant lesion (eg, laser surgery, electrosurge Destruction, malignant lesion (eg, laser surgery, electrosurge Destruction, malignant lesion (eg, laser surgery, electrosurge Destruction, malignant lesion (eg, laser surgery, electrosurge Destruction, malignant lesion (eg, laser surgery, electrosurge Destruction, malignant lesion (eg, laser surgery, electrosurge Destruction, malignant lesion (eg, laser surgery, electrosurge Destruction, malignant lesion (eg, laser surgery, electrosurge Destruction, malignant lesion (eg, laser surgery, electrosurge Destruction, malignant lesion (eg, laser surgery, electrosurge Destruction, malignant lesion (eg, laser surgery, electrosurge Destruction, malignant lesion (eg, laser surgery, electrosurge Destruction, malignant lesion (eg, laser surgery, electrosurge Destruction, malignant lesion (eg, laser surgery, electrosurge Destruction, malignant lesion (eg, laser surgery, electrosurge Mohs micrographic technique, including removal of all gross Mohs micrographic technique, including removal of all gross Mohs micrographic technique, including removal of all gross Mohs micrographic technique, including removal of all gross Mohs micrographic technique, including removal of all gross Cryotherapy (CO2 slush, liquid N2) for acne Chemical exfoliation for acne (eg, acne paste, acid) Electrolysis epilation, each 30 minutes Unlisted procedure, skin, mucous membrane and subcutane Puncture aspiration of cyst of breast; Puncture aspiration of cyst of breast; each additional cyst (Li Mastotomy with exploration or drainage of abscess, deep Injection procedure only for mammary ductogram or galacto Biopsy of breast; percutaneous, needle core, not using imag Biopsy of breast; open, incisional Biopsy of breast; percutaneous, needle core, using imaging Biopsy of breast; percutaneous, automated vacuum assisted Ablation, cryosurgical, of fibroadenoma, including ultrasound Nipple exploration, with or without excision of a solitary lactif Excision of lactiferous duct fistula Excision of cyst, fibroadenoma, or other benign or malignant Excision of breast lesion identified by preoperative placemen Excision of breast lesion identified by preoperative placemen Excision of chest wall tumor including ribs Excision of chest wall tumor involving ribs, with plastic recon Excision of chest wall tumor involving ribs, with plastic recon Preoperative placement of needle localization wire, breast; Preoperative placement of needle localization wire, breast; e Image guided placement, metallic localization clip, percutane Placement of radiotherapy afterloading expandable catheter Placement of radiotherapy afterloading expandable catheter Placement of radiotherapy afterloading brachytherapy cathe Mastectomy for gynecomastia Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantec Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantec Mastectomy, simple, complete Mastectomy, subcutaneous Mastectomy, radical, including pectoral muscles, axillary lym Mastectomy, radical, including pectoral muscles, axillary and Mastectomy, modified radical, including axillary lymph nodes Mastopexy Reduction mammaplasty Mammaplasty, augmentation; without prosthetic implant Mammaplasty, augmentation; with prosthetic implant Removal of intact mammary implant Removal of mammary implant material $ $ % $ $ % $ $ % $ $ % $ $ % $ $ % $ $ % $ $ % $ $ % $ $ % $ $ % $ $ % $ $ % $ $ % $ $ % $ $ % $ $ % $ $1, % $1, $1, % $ $1, % $1, $1, % $ $1, % $ $ % $89.00 $ % $ $ % $ $ % $ $ % $ $ % $ $1, % $ $ % $ $ % $ $1, % $ $ % $1, $1, % $4, $6, % $1, $1, % $1, $1, % $1, $1, % $1, $1, % $ $ % $3, $4, % $4, $5, % $4, $6, % $ $ % $ $ % $ $ % $11, $15, % $ $ % $4, $6, % $1, $2, % $1, $2, % $2, $3, % $2, $3, % $1, $2, % $3, $4, % $3, $4, % $3, $4, % $3, $4, % $4, $6, % $1, $2, % $2, $4, % $1, $2, % $2, $2, % Effective 09/19/ of 153

7 19340 Immediate insertion of breast prosthesis following mastopex $2, $3, % Delayed insertion of breast prosthesis following mastopexy, $3, $4, % Nipple/areola reconstruction $2, $3, % Correction of inverted nipples $1, $2, % Breast reconstruction, immediate or delayed, with tissue exp $4, $6, % Breast reconstruction with latissimus dorsi flap, without pros $5, $8, % Breast reconstruction with free flap $10, $15, % Breast reconstruction with other technique $5, $7, % Breast reconstruction with transverse rectus abdominis myo $6, $10, % Breast reconstruction with transverse rectus abdominis myo $8, $11, % Breast reconstruction with transverse rectus abdominis myo $8, $10, % Open periprosthetic capsulotomy, breast $2, $3, % Periprosthetic capsulectomy, breast $2, $4, % Revision of reconstructed breast $2, $4, % Preparation of moulage for custom breast implant $ $ % Unlisted procedure, breast Incision and drainage of soft tissue abscess, subfascial (ie, i $ $1, % Exploration of penetrating wound (separate procedure); neck $1, $2, % Exploration of penetrating wound (separate procedure); ches $1, $1, % Exploration of penetrating wound (separate procedure); abd $1, $2, % Exploration of penetrating wound (separate procedure); extr $1, $1, % Excision of epiphyseal bar, with or without autogenous soft t $2, $2, % Biopsy, muscle; superficial $ $ % Biopsy, muscle; deep $ $ % Biopsy, muscle, percutaneous needle $ $ % Biopsy, bone, trocar, or needle; superficial (eg, ilium, sternum $ $ % Biopsy, bone, trocar, or needle; deep (eg, vertebral body, fe $ $1, % Biopsy, bone, open; superficial (eg, ilium, sternum, spinous p $ $ % Biopsy, bone, open; deep (eg, humerus, ischium, femur) $1, $2, % Biopsy, vertebral body, open; thoracic $1, $2, % Biopsy, vertebral body, open; lumbar or cervical $2, $2, % Injection of sinus tract; therapeutic (separate procedure) $ $ % Injection of sinus tract; diagnostic (sinogram) $ $ % Removal of foreign body in muscle or tendon sheath; simple $ $ % Removal of foreign body in muscle or tendon sheath; deep o $1, $1, % Injection, therapeutic (eg, local anesthetic, corticosteroid), ca $ $ % Injection, enzyme (eg, collagenase), palmar fascial cord (ie, $ $ % Injection(s); single tendon sheath, or ligament, aponeurosis $ $ % Injection(s); single tendon origin/insertion $ $ % Injection(s); single or multiple trigger point(s), 1 or 2 muscle( $ $ % Injection(s); single or multiple trigger point(s), 3 or more mus $ $ % Placement of needles or catheters into muscle and/or soft tis $ $ % Arthrocentesis, aspiration and/or injection; small joint or burs $ $ % Arthrocentesis, aspiration and/or injection; intermediate joint $ $ % Arthrocentesis, aspiration and/or injection; major joint or bur $ $ % Aspiration and/or injection of ganglion cyst(s) any location $ $ % Aspiration and injection for treatment of bone cyst $ $ % Insertion of wire or pin with application of skeletal traction, in $ $ % Application of cranial tongs, caliper, or stereotactic frame, in $ $1, % Application of halo, including removal; cranial $1, $1, % Application of halo, including removal; pelvic $1, $1, % Application of halo, including removal; femoral $ $1, % Application of halo, including removal, cranial, 6 or more pin $1, $2, % Removal of tongs or halo applied by another individual $ $ % Removal of implant; superficial (eg, buried wire, pin or rod) ( $ $1, % Removal of implant; deep (eg, buried wire, pin, screw, meta $1, $1, % Application of a uniplane (pins or wires in 1 plane), unilatera $1, $1, % Application of a multiplane (pins or wires in more than 1 plan $2, $3, % Adjustment or revision of external fixation system requiring a $1, $1, % Removal, under anesthesia, of external fixation system $1, $1, % Application of multiplane (pins or wires in more than 1 plane $2, $3, % Application of multiplane (pins or wires in more than 1 plane $3, $4, % Replantation, arm (includes surgical neck of humerus throug $10, $13, % Replantation, forearm (includes radius and ulna to radial car $12, $15, % Effective 09/19/ of 153

8 20808 Replantation, hand (includes hand through metacarpophalan $14, $17, % Replantation, digit, excluding thumb (includes metacarpopha $7, $9, % Replantation, digit, excluding thumb (includes distal tip to su $6, $8, % Replantation, thumb (includes carpometacarpal joint to MP j $7, $10, % Replantation, thumb (includes distal tip to MP joint), complet $6, $8, % Replantation, foot, complete amputation $12, $13, % Bone graft, any donor area; minor or small (eg, dowel or but $1, $1, % Bone graft, any donor area; major or large $1, $2, % Cartilage graft; costochondral $1, $1, % Cartilage graft; nasal septum $1, $1, % Fascia lata graft; by stripper $ $1, % Fascia lata graft; by incision and area exposure, complex or $1, $1, % Tendon graft, from a distance (eg, palmaris, toe extensor, pl $1, $1, % Tissue grafts, other (eg, paratenon, fat, dermis) $1, $1, % Allograft, morselized, or placement of osteopromotive mater $ $ % Allograft, structural, for spine surgery only (List separately in $ $ % Autograft for spine surgery only (includes harvesting the graf $ $1, % Autograft for spine surgery only (includes harvesting the graf $1, $1, % Autograft for spine surgery only (includes harvesting the graf $1, $1, % Monitoring of interstitial fluid pressure (includes insertion of d $ $ % Bone graft with microvascular anastomosis; fibula $9, $13, % Bone graft with microvascular anastomosis; iliac crest $7, $11, % Bone graft with microvascular anastomosis; metatarsal $7, $10, % Bone graft with microvascular anastomosis; other than fibula $7, $9, % Free osteocutaneous flap with microvascular anastomosis; o $8, $12, % Free osteocutaneous flap with microvascular anastomosis; i $8, $12, % Free osteocutaneous flap with microvascular anastomosis; m $7, $10, % Free osteocutaneous flap with microvascular anastomosis; g $8, $11, % Electrical stimulation to aid bone healing; noninvasive (nono $ $1, % Electrical stimulation to aid bone healing; invasive (operative $1, $1, % Low intensity ultrasound stimulation to aid bone healing, non $ $ % Ablation, bone tumor(s) (eg, osteoid osteoma, metastasis) ra $7, #DIV/0! Computer-assisted surgical navigational procedure for musc $ $1, % Unlisted procedure, musculoskeletal system, general Arthrotomy, temporomandibular joint $2, $3, % Excision, tumor, soft tissue of face or scalp, subcutaneous; l $ $1, % Excision, tumor, soft tissue of face or scalp, subcutaneous; 2 $ $1, % Excision, tumor, soft tissue of face and scalp, subfascial (eg $1, $1, % Excision, tumor, soft tissue of face and scalp, subfascial (eg $1, $1, % Radical resection of tumor (eg, malignant neoplasm), soft tis $1, $2, % Radical resection of tumor (eg, malignant neoplasm), soft tis $2, $3, % Excision of bone (eg, for osteomyelitis or bone abscess); ma $1, $2, % Excision of bone (eg, for osteomyelitis or bone abscess); fac $1, $2, % Removal by contouring of benign tumor of facial bone (eg, fi $2, $3, % Excision of benign tumor or cyst of maxilla or zygoma by enu $1, $2, % Excision of torus mandibularis $ $ % Excision of maxillary torus palatinus $ $1, % Excision of malignant tumor of maxilla or zygoma $3, $4, % Excision of benign tumor or cyst of mandible, by enucleation $1, $1, % Excision of malignant tumor of mandible; $2, $4, % Excision of malignant tumor of mandible; radical resection $4, $6, % Excision of benign tumor or cyst of mandible; requiring intra- $3, $4, % Excision of benign tumor or cyst of mandible; requiring extra $4, $5, % Excision of benign tumor or cyst of maxilla; requiring intra-or $3, $4, % Excision of benign tumor or cyst of maxilla; requiring extra-o $4, $5, % Condylectomy, temporomandibular joint (separate procedure $3, $4, % Meniscectomy, partial or complete, temporomandibular joint $3, $4, % Coronoidectomy (separate procedure) $2, $3, % Manipulation of temporomandibular joint(s) (TMJ), therapeut $1, $1, % Impression and custom preparation; surgical obturator prost $2, $3, % Impression and custom preparation; orbital prosthesis $6, $8, % Impression and custom preparation; interim obturator prosth $4, $6, % Impression and custom preparation; definitive obturator pros $4, $7, % Impression and custom preparation; mandibular resection pr $4, $6, % Effective 09/19/ of 153

9 21082 Impression and custom preparation; palatal augmentation p Impression and custom preparation; palatal lift prosthesis Impression and custom preparation; speech aid prosthesis Impression and custom preparation; oral surgical splint Impression and custom preparation; auricular prosthesis Impression and custom preparation; nasal prosthesis Impression and custom preparation; facial prosthesis Unlisted maxillofacial prosthetic procedure Application of halo type appliance for maxillofacial fixation, in Application of interdental fixation device for conditions other Injection procedure for temporomandibular joint arthrograph Genioplasty; augmentation (autograft, allograft, prosthetic m Genioplasty; sliding osteotomy, single piece Genioplasty; sliding osteotomies, 2 or more osteotomies (eg Genioplasty; sliding, augmentation with interpositional bone Augmentation, mandibular body or angle; prosthetic materia Augmentation, mandibular body or angle; with bone graft, on Reduction forehead; contouring only Reduction forehead; contouring and application of prosthetic Reduction forehead; contouring and setback of anterior fron Reconstruction midface, LeFort I; single piece, segment mov Reconstruction midface, LeFort I; 2 pieces, segment movem Reconstruction midface, LeFort I; 3 or more pieces, segmen Reconstruction midface, LeFort I; single piece, segment mov Reconstruction midface, LeFort I; 2 pieces, segment movem Reconstruction midface, LeFort I; 3 or more pieces, segmen Reconstruction midface, LeFort II; anterior intrusion (eg, Tre Reconstruction midface, LeFort II; any direction, requiring bo Reconstruction midface, LeFort III (extracranial), any type, re Reconstruction midface, LeFort III (extracranial), any type, re Reconstruction midface, LeFort III (extra and intracranial) wi Reconstruction midface, LeFort III (extra and intracranial) wi Reconstruction superior-lateral orbital rim and lower forehea Reconstruction, bifrontal, superior-lateral orbital rims and low Reconstruction, entire or majority of forehead and/or suprao Reconstruction, entire or majority of forehead and/or suprao Reconstruction by contouring of benign tumor of cranial bon Reconstruction of orbital walls, rims, forehead, nasoethmoid Reconstruction of orbital walls, rims, forehead, nasoethmoid Reconstruction of orbital walls, rims, forehead, nasoethmoid Reconstruction midface, osteotomies (other than LeFort type Reconstruction of mandibular rami, horizontal, vertical, C, or Reconstruction of mandibular rami, horizontal, vertical, C, or Reconstruction of mandibular rami and/or body, sagittal split Reconstruction of mandibular rami and/or body, sagittal split Osteotomy, mandible, segmental; Osteotomy, mandible, segmental; with genioglossus advanc Osteotomy, maxilla, segmental (eg, Wassmund or Schuchar Osteoplasty, facial bones; augmentation (autograft, allograft Osteoplasty, facial bones; reduction Graft, bone; nasal, maxillary or malar areas (includes obtain Graft, bone; mandible (includes obtaining graft) Graft; rib cartilage, autogenous, to face, chin, nose or ear (in Graft; ear cartilage, autogenous, to nose or ear (includes ob Arthroplasty, temporomandibular joint, with or without autogr Arthroplasty, temporomandibular joint, with allograft Arthroplasty, temporomandibular joint, with prosthetic joint re Reconstruction of mandible, extraoral, with transosteal bone Reconstruction of mandible or maxilla, subperiosteal implant Reconstruction of mandible or maxilla, subperiosteal implant Reconstruction of mandibular condyle with bone and cartilag Reconstruction of mandible or maxilla, endosteal implant (eg Reconstruction of mandible or maxilla, endosteal implant (eg Reconstruction of zygomatic arch and glenoid fossa with bon $4, $6, % $3, $4, % $4, $6, % $1, $2, % $5, $7, % $4, $7, % $2, $3, % $ $1, % $1, $1, % $ $ % $2, $2, % $2, $3, % $2, $3, % $3, $4, % $2, $4, % $3, $4, % $2, $3, % $3, $4, % $3, $5, % $5, $7, % $5, $7, % $5, $7, % $6, $8, % $6, $8, % $7, $8, % $6, $8, % $8, $9, % $8, $10, % $9, $11, % $11, $14, % $12, $15, % $7, $10, % $9, $12, % $6, $8, % $7, $9, % $2, $3, % $8, $10, % $9, $11, % $9, $12, % $6, $8, % $5, $6, % $6, $8, % $5, $7, % $5, $8, % $3, $4, % $4, $5, % $4, $6, % $3, $4, % $3, #DIV/0! $3, $4, % $3, $5, % $3, $4, % $2, $3, % $4, $6, % $4, $6, % $6, $8, % $4, $6, % $4, $6, % $5, $8, % $5, $7, % $4, $6, % $6, $7, % $5, $7, % Effective 09/19/ of 153

10 21256 Reconstruction of orbit with osteotomies (extracranial) and w $6, $8, % Periorbital osteotomies for orbital hypertelorism, with bone g $6, $8, % Periorbital osteotomies for orbital hypertelorism, with bone g $8, $11, % Periorbital osteotomies for orbital hypertelorism, with bone g $10, $12, % Orbital repositioning, periorbital osteotomies, unilateral, with $8, $11, % Orbital repositioning, periorbital osteotomies, unilateral, with $11, $15, % Malar augmentation, prosthetic material $3, $4, % Secondary revision of orbitocraniofacial reconstruction $5, $8, % Medial canthopexy (separate procedure) $2, $2, % Lateral canthopexy $1, $2, % Reduction of masseter muscle and bone (eg, for treatment o $2, $2, % Reduction of masseter muscle and bone (eg, for treatment o $2, $3, % Unlisted craniofacial and maxillofacial procedure Closed treatment of nasal bone fracture without manipulatio $ $ % Closed treatment of nasal bone fracture; without stabilization $ $ % Closed treatment of nasal bone fracture; with stabilization $ $1, % Open treatment of nasal fracture; uncomplicated $1, $2, % Open treatment of nasal fracture; complicated, with internal $2, $3, % Open treatment of nasal fracture; with concomitant open trea $3, $4, % Open treatment of nasal septal fracture, with or without stab $1, $2, % Closed treatment of nasal septal fracture, with or without sta $ $1, % Open treatment of nasoethmoid fracture; without external fix $2, $3, % Open treatment of nasoethmoid fracture; with external fixatio $2, $3, % Percutaneous treatment of nasoethmoid complex fracture, w $3, $4, % Open treatment of depressed frontal sinus fracture $3, $4, % Open treatment of complicated (eg, comminuted or involving $4, $6, % Closed treatment of nasomaxillary complex fracture (LeFort $2, $3, % Open treatment of nasomaxillary complex fracture (LeFort II $3, $5, % Open treatment of nasomaxillary complex fracture (LeFort II $4, $5, % Open treatment of nasomaxillary complex fracture (LeFort II $4, $5, % Percutaneous treatment of fracture of malar area, including $1, $1, % Open treatment of depressed zygomatic arch fracture (eg, G $1, $2, % Open treatment of depressed malar fracture, including zygom $2, $2, % Open treatment of complicated (eg, comminuted or involving $3, $5, % Open treatment of complicated (eg, comminuted or involving $4, $5, % Open treatment of orbital floor blowout fracture; transantral a $2, $3, % Open treatment of orbital floor blowout fracture; periorbital a $2, $3, % Open treatment of orbital floor blowout fracture; combined a $3, $4, % Open treatment of orbital floor blowout fracture; periorbital a $3, $4, % Open treatment of orbital floor blowout fracture; periorbital a $3, $5, % Closed treatment of fracture of orbit, except blowout; without $ $ % Closed treatment of fracture of orbit, except blowout; with m $1, $2, % Open treatment of fracture of orbit, except blowout; without i $2, $3, % Open treatment of fracture of orbit, except blowout; with imp $2, $4, % Open treatment of fracture of orbit, except blowout; with bon $3, $4, % Closed treatment of palatal or maxillary fracture (LeFort I typ $2, $3, % Open treatment of palatal or maxillary fracture (LeFort I type $2, $3, % Open treatment of palatal or maxillary fracture (LeFort I type $3, $4, % Closed treatment of craniofacial separation (LeFort III type) u $2, $3, % Open treatment of craniofacial separation (LeFort III type); w $3, $4, % Open treatment of craniofacial separation (LeFort III type); c $5, $7, % Open treatment of craniofacial separation (LeFort III type); c $5, $7, % Open treatment of craniofacial separation (LeFort III type); c $6, $8, % Closed treatment of mandibular or maxillary alveolar ridge fr $1, $2, % Open treatment of mandibular or maxillary alveolar ridge frac $1, $2, % Closed treatment of mandibular fracture; without manipulatio $1, $1, % Closed treatment of mandibular fracture; with manipulation $2, $2, % Percutaneous treatment of mandibular fracture, with externa $1, $2, % Closed treatment of mandibular fracture with interdental fixa $2, $3, % Open treatment of mandibular fracture with external fixation $2, $3, % Open treatment of mandibular fracture; without interdental fi $3, $4, % Open treatment of mandibular fracture; with interdental fixati $3, $5, % Open treatment of mandibular condylar fracture $3, $4, % Open treatment of complicated mandibular fracture by multip $4, $6, % Effective 09/19/ of 153

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