| Service code | Service name | Price for Patient from Abroad (ILS) |
| 01996 | Day care management of epidural/subarachnoid continuous drug administration | 731.00 |
| 01999 | General anesthesia for ambulatory treatment, under anesthesiologist supervision | 1,880.00 |
| 10060 | Incision and drainage of abscess/cyst | 597.00 |
| 11100 | Biopsy, excluding breast | 288.00 |
| 11750 | Excision of ingrown nail | 459.00 |
| 11770 | Excision of cyst, eg, pilonidal | 915.00 |
| 11975 | Insertion, implantable contraceptive capsules (eg, Norplant), including the cost of contraceptive | 2,745.00 |
| 11976 | Removal, implantable contraceptive capsules | 257.00 |
| 12001 | Simple repair of superficial wounds | 216.00 |
| 16030 | Dressings and/or debridement, without anesthesia, large lesion | 555.00 |
| 17000 | Removal of skin lesions, any method | 288.00 |
| 17311 | Mohs micrographic technique | 13,061.00 |
| 17999 | Soft laser treatment, 1/2 level, per treatment | 288.00 |
| 19100 | Biopsy of breast; needle core, not using imaging guidance | 288.00 |
| 19101 | Biopsy of breast; open, incisional | 686.00 |
| 19102 | Biopsy of breast, using imaging guidance, excluding CT/MRI | 3,279.00 |
| 19499 | Breast examination | 0.00 |
| 20205 | Biopsy, muscle, including histological examinations | 1,629.00 |
| 20206 | Biopsy, muscle, including all tests, stains, EM | 4,575.00 |
| 20220 | Biopsy, bone, trocar/needle, superficial | 372.00 |
| 20520 | Foreign body removal, muscle/tendon, local anaesthesia | 201.00 |
| 20600 | Arthrocentesis, aspiration and/or injection; small joint or bursa (eg, fingers, toes) | 372.00 |
| 20605 | Arthrocentesis, aspiration and/or injection; intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa) | 372.00 |
| 20610 | Arthrocentesis, aspiration and/or injection; major joint or bursa (eg, shoulder, hip, knee joint, subacromial bursa) | 372.00 |
| 20902 | Harvesting of cortical bone, cartilage | 6,030.00 |
| 21310 | Closed treatment of nasal bone fracture | 372.00 |
| 28899 | Intra compartment pressure | 839.00 |
| 29035 | Application, body cast, shoulder to hips | 477.00 |
| 29065 | Application, cast; shoulder to hand (long arm) | 288.00 |
| 29075 | Application, cast, elbow to finger (short arm) | 201.00 |
| 29085 | Application, cast, hand and lower forearm (gauntlet) | 201.00 |
| 29345 | Application, cast, long leg (thigh to toes) | 288.00 |
| 29405 | Application, cast, short leg (below knee to toes) | 201.00 |
| 29700 | Cast removal | 170.00 |
| 29720 | Repair of spica, body cast or jacket | 0.00 |
| 29999 | Arthroscopy, diagnostic and/or surgical procedures, without using implants | 11,195.00 |
| 30110 | Excision, nasal polyp(s), simple | 372.00 |
| 30200 | Injection into turbinate(s) | 209.00 |
| 30300 | Foreign body removal, intranasal, superficial | 0.00 |
| 30801 | Cautery and/or ablation, mucosa of turbinates, unilateral/bilateral, any method | 372.00 |
| 31002 | Sinuses lavage | 209.00 |
| 31575 | Laryngoscopy, flexible fiberoptic, diagnostic | 138.00 |
| 31579 | Laryngoscopy, fiberoptic, with stroboscopy | 233.00 |
| 31622 | Bronchoscopy, diagnostic, with/without brushing/washing | 2,133.00 |
| 31636 | Bronchoscopy, rigid or flexible, with placement of bronchial stent(s) | 19,284.00 |
| 32000 | Thoracentesis, puncture of pleural cavity for aspiration | 372.00 |
| 36005 | Injection of contrast material, including radiology/fluoroscopy | 786.00 |
| 36468 | Injections of sclerosing solutions, spider veins (telangiectasia) | 170.00 |
| 36511 | Therapeutic apheresis, for white blood cells | 5,373.00 |
| 36513 | Therapeutic apheresis, for platelets | 4,334.00 |
| 36515 | Therapeutic apheresis; with extracorporeal immunoadsorption and plasma reinfusion | 14,159.00 |
| 36522 | Photopheresis, extracorporeal | 11,382.00 |
| 36590 | Removal of tunneled central venous access device, with subcutaneous port or pump, central or peripheral insertion | 530.00 |
| 36600 | Arterial blood sampling and diagnosis | 288.00 |
| 38220 | Bone marrow aspiration and smear | 594.00 |
| 38221 | Bone marrow biopsy and smear | 594.00 |
| 38505 | Biopsy or excision of lymph node(s); by needle, superficial | 288.00 |
| 40808 | Biopsy, vestibule of mouth | 264.00 |
| 40840 | Vestibuloplasty, anterior | 1,212.00 |
| 41010 | Incision of lingual frenum (frenotomy) | 888.00 |
| 42699 | Salivary glands endoscopy | 11,526.00 |
| 42700 | Incision and drainage of peritonsillar abscess | 372.00 |
| 42809 | Foreign body removal, pharynx, superficial | 0.00 |
| 43200 | Esophagoscopy, diagnostic | 434.00 |
| 43204 | Esophagoscopy, with injection sclerosis of esophageal varices | 5,328.00 |
| 43219 | Esophageal dilation and insertion of stent | 25,788.00 |
| 43235 | UGI endoscopy, with/without sampling | 1,793.00 |
| 43240 | Endoscopic drainage of pseudocyst of pancreas, using EUS guidance | 14,717.00 |
| 43259 | Upper gastrointestinal endoscopy; with endoscopic ultrasound examination | 2,166.00 |
| 43260 | ERCP (Endoscopic retrograde cholangiopancreatography), diagnostic | 5,777.00 |
| 43264 | ERCP (Endoscopic retrograde cholangiopancreatography), therapeutic | 9,812.00 |
| 43450 | Esophageal dilation, without using imaging guidance | 434.00 |
| 43750 | PEG (Percutaneous Endoscopic Gastrostomy) | 3,530.00 |
| 43760 | Replacement of PEG (Percutaneous Endoscopic Gastrostomy) | 1,943.00 |
| 44360 | Small intestinal endoscopy, enteroscopy, diagnostic, with/without collection of specimen(s) | 4,007.00 |
| 45300 | Proctosigmoidoscopy, diagnostic | 315.00 |
| 45331 | Sigmoidoscopy, flexible, with/without biopsy | 1,034.00 |
| 45378 | Colonoscopy, flexible; diagnostic, with/without collection of specimen(s), population at risk | 1,616.00 |
| 45383 | Colonoscopy, with excision of lesion | 3,311.00 |
| 45387 | Colonoscopy, with dilation and stent placement | 25,788.00 |
| 45905 | Dilation of anal sphincter | 492.00 |
| 46080 | Sphincterotomy, anal, division of sphincter under general/regional anesthesia | 3,116.00 |
| 46500 | Injection of sclerosing solution, hemorrhoids | 170.00 |
| 46600 | Anoscopy, diagnostic | 129.00 |
| 47999 | Extracorporeal shockwave lithotripsy, biliary tract, simple | 9,525.00 |
| 49321 | Laparoscopy, surgical, with biopsy (single or multiple) | 8,748.00 |
| 50040 | Nephrostomy, nephrotomy with drainage | 4,122.00 |
| 50398 | Repositioning/change of nephrostomy or pyelostomy tube | 2,459.00 |
| 50590 | Extracorporeal shockwave lithotripsy, kidney; simple | 9,879.00 |
| 51045 | Insertion of urethral or ureteral stent | 4,122.00 |
| 51700 | Bladder irrigation, simple, lavage and/or instillation | 201.00 |
| 51703 | Insertion of urethral catheter | 209.00 |
| 51720 | Bladder instillation of anticarcinogenic agent | 528.00 |
| 51726 | Cystometrogram | 786.00 |
| 51736 | Simple uroflowmetry (UFR) | 372.00 |
| 51741 | Complex uroflowmetry | 2,574.00 |
| 51772 | Urethral pressure profile studies (UPP) (urethral closure pressure profile) | 786.00 |
| 51784 | EMG of anal/urethral sphincter, any technique | 786.00 |
| 52000 | Cystourethroscopy | 768.00 |
| 52204 | Cystourethroscopy, with biopsy/other surgical procedure | 1,998.00 |
| 53000 | Urethrotomy or urethrostomy | 768.00 |
| 53850 | Destruction of prostate tissue by thermotherapy | 6,968.00 |
| 53899 | Cystoscopic injection of botulinum toxin, including cost of material | 4,809.00 |
| 54235 | Injection of corpora cavernosa | 141.00 |
| 54250 | Nocturnal penile tumescence and/or rigidity test | 1,013.00 |
| 55000 | Puncture aspiration of hydrocele, with/without injection of medication | 434.00 |
| 55700 | Biopsy, prostate; needle or punch, single or multiple, any approach | 2,753.00 |
| 55870 | Electroejaculation | 9,662.00 |
| 57452 | Colposcopy, vaginoscopy | 197.00 |
| 57510 | Cautery of cervix, any method | 201.00 |
| 58120 | Dilation and curettage, diagnostic and/or therapeutic, excluding induced abortion | 4,106.00 |
| 58300 | Insertion of intrauterine device (IUD) | 434.00 |
| 58301 | Removal of intrauterine device (IUD) | 201.00 |
| 58321 | Artificial insemination, intra-cervical | 201.00 |
| 58322 | Artificial insemination, intra-uterine | 278.00 |
| 58323 | Sperm washing for artificial insemination | 840.00 |
| 58345 | Fallopian tube dilation, catheterization, diagnostic/therapeutic | 6,084.00 |
| 58555 | Hysteroscopy | 768.00 |
| 58558 | Hysteroscopy, surgical, with biopsy/other surgical procedure | 1,401.00 |
| 58563 | Uterine thermal therapy | 8,985.00 |
| 58974 | Cryopreserved embryos transfer, intrauterine | 6,140.00 |
| 59000 | Amniocentesis | 380.00 |
| 59012 | Cordocentesis (intrauterine), any method | 4,319.00 |
| 59020 | Fetal contraction stress test | 1,106.00 |
| 59025 | Fetal NST (non stress test) | 521.00 |
| 59866 | Multifetal pregnancy reduction(s) (MPR), including US guidance | 4,106.00 |
| 59871 | Removal of cerclage suture | 288.00 |
| 62270 | Spinal puncture, lumbar, diagnostic | 1,046.00 |
| 62272 | Spinal puncture, therapeutic | 1,046.00 |
| 62310 | Injection, epidural/subarachnoid; cervical/thoracic | 731.00 |
| 62311 | Injection, epidural/subarachnoid; lumbar/sacral (caudal) | 731.00 |
| 64400 | Injection, anesthetic agent (eg, Lignocaine) | 360.00 |
| 64470 | Paravertebral injection | 209.00 |
| 64550 | Application of surface (transcutaneous) neurostimulator | 372.00 |
| 64612 | Botolinum Toxin, 10 units Botox administration | 396.00 |
| 65205 | Foreign body removal, external eye, superficial | 0.00 |
| 66984 | Extracapsular cataract removal with insertion of intraocular lens prosthesis, any methods, lens included | 8,223.00 |
| 66999 | Intracorneal rings for keratoconus treatment, Intacs | 10,770.00 |
| 67210 | Retinal photocoagulation, PDT, without material | 2,786.00 |
| 67912 | Implantation of upper eyelid gold weight | 7,116.00 |
| 68810 | Probing of nasolacrimal duct, with/without irrigation | 1,955.00 |
| 68811 | Probing of nasolacrimal duct, with/without irrigation; requiring general anesthesia | 5,267.00 |
| 69000 | Puncture/drainage external ear abscess/hematoma | 372.00 |
| 69200 | Foreign body removal, ear, superficial | 0.00 |
| 69210 | Removal impacted cerumen | 209.00 |
| 69420 | Myringotomy including puncture/aspiration | 372.00 |
| 69436 | Tympanostomy (requiring insertion of ventilating tube), general anesthesia | 2,252.00 |
| 70030 | Eye radiology, foreign body detection | 450.00 |
| 70100 | Mandible radiology, up to two views | 377.00 |
| 70120 | Mastoids radiology, up to two views | 201.00 |
| 70170 | Dacryocystography, radiological supervision and interpretation | 278.00 |
| 70200 | Orbits radiology, up to two views | 269.00 |
| 70210 | Paranasal sinuses radiology, up to two views | 266.00 |
| 70240 | Sella turcica radiology | 372.00 |
| 70250 | Skull radiology, up to two views | 186.00 |
| 70332 | TMJ arthrography, including injection and interpretation | 477.00 |
| 70336 | TMJ (temporomandibular joint(s)) MRI | 3,336.00 |
| 70360 | Neck, soft tissue radiology, trachea | 597.00 |
| 70390 | Salivary glands radiology, sialography | 564.00 |
| 70540 | Orbit, face and neck, without contrast material | 3,336.00 |
| 70544 | Brain MRA | 3,336.00 |
| 70547 | Head and/or neck MRA | 3,336.00 |
| 70551 | Brain/brain stem MRI, without contrast material | 3,336.00 |
| 71020 | Chest radiology, up to two views | 173.00 |
| 71023 | Chest radiology, up to two views, with fluoroscopy | 528.00 |
| 71100 | Ribs radiology, up to two views | 260.00 |
| 71120 | Sternum radiology, up to two views | 278.00 |
| 71550 | Thorax MRI, without contrast material | 3,224.00 |
| 71555 | Thoracic MRA, excluding myocardium | 3,224.00 |
| 72010 | Spine radiology, entire, up to two views | 269.00 |
| 72040 | Cervical spine radiology, up to two views | 186.00 |
| 72070 | Thoracic spine radiology, up to two views | 186.00 |
| 72080 | Thoracolumbar spine radiology, up to two views | 186.00 |
| 72100 | Lumbosacral spine radiology, up to two views | 186.00 |
| 72141 | Cervical spine, MRI, per patient | 3,336.00 |
| 72146 | Thoracic spine, MRI, per patient | 3,336.00 |
| 72148 | Lumbar spine, MRI, per patient | 3,336.00 |
| 72159 | Spinal canal and contents MRA | 3,336.00 |
| 72170 | Pelvis radiology, up to two views | 207.00 |
| 72198 | Pelvic MRA | 3,360.00 |
| 72200 | SIJ radiology, up to two views | 278.00 |
| 72270 | Myelography | 2,136.00 |
| 73000 | Clavicle radiology | 221.00 |
| 73010 | Scapula radiology | 221.00 |
| 73030 | Shoulder radiology, complete, one side, up to two views | 201.00 |
| 73040 | Shoulder arthrography, including injection and interpretation | 477.00 |
| 73060 | Humerus radiology, up to two views | 186.00 |
| 73070 | Elbow radiology, up to two views | 186.00 |
| 73085 | Elbow arthrography, including injection and interpretation | 477.00 |
| 73090 | Forearm radiology, up to two views | 186.00 |
| 73092 | Upper extremity radiology, infant, up to two views | 186.00 |
| 73100 | Wrist radiology, up to two views | 186.00 |
| 73115 | Wrist, arthrography, including injection and interpretation | 477.00 |
| 73120 | Hand radiology, up to two views | 186.00 |
| 73140 | Finger(s) radiology, up to two views | 186.00 |
| 73221 | Upper extremity joints MRI, without contrast material, per patient | 3,224.00 |
| 73225 | Upper extremity MRA | 3,224.00 |
| 73500 | Hip radiology, unilateral, one view | 186.00 |
| 73520 | Hip radiology, bilateral, including pelvis | 186.00 |
| 73525 | Hip arthrography, including injection and interpretation | 477.00 |
| 73542 | SIJ arthrography, including injection and interpretation | 477.00 |
| 73550 | Femur radiology, up to two views | 186.00 |
| 73560 | Knee radiology, up to two views, per side | 186.00 |
| 73562 | Knee radiology, third or more additional views | 201.00 |
| 73580 | Knee arthrography, including injection and interpretation | 477.00 |
| 73590 | Tibia and fibula radiology, up to two views | 186.00 |
| 73592 | Lower extremity radiology, infant, up to two views | 186.00 |
| 73610 | Ankle radiology, complete, one side | 186.00 |
| 73615 | Ankle arthrography, including injection and interpretation | 477.00 |
| 73620 | Foot radiology, up to two views | 186.00 |
| 73721 | Lower extremity joints MRI, without contrast material, per patient | 3,224.00 |
| 73725 | Lower extremity MRA | 3,224.00 |
| 74000 | Abdomen radiology, without contrast material | 266.00 |
| 74181 | Abdominal MRI, per patient | 3,336.00 |
| 74185 | Abdominal MRA | 3,336.00 |
| 74220 | Esophagus radiology | 660.00 |
| 74230 | Swallowing function, with cineradiography/videoradiography | 1,052.00 |
| 74241 | UGI fluoroscopy and/or radiology, with/without delayed films | 1,106.00 |
| 74245 | UGI fluoroscopy, including serial films | 1,365.00 |
| 74249 | Abdomen radiology, small intestine follow-through | 660.00 |
| 74270 | Barium enema | 786.00 |
| 74280 | Air barium enema, with/without glucagon | 1,263.00 |
| 74290 | Cholecystography, oral contrast | 657.00 |
| 74360 | Esophageal dilation, using imaging guidance | 8,778.00 |
| 74400 | IVP, with or without tomography | 972.00 |
| 74420 | Urography, retrograde | 800.00 |
| 74450 | Urethrocystography, retrograde, radiological supervision and interpretation | 620.00 |
| 74455 | Urethrocystography, radiological supervision and interpretation | 774.00 |
| 74740 | Hysterosalpingography, radiology | 806.00 |
| 75552 | MRI cardiac morphology, per patient | 8,889.00 |
| 75554 | Cardiac FMRI; with/without morphology, complete study, per patient | 8,889.00 |
| 75803 | Lymphangiography, extremities | 3,105.00 |
| 75822 | Phlebography, venography, including injection and imaging | 1,046.00 |
| 76000 | Fluoroscopy | 170.00 |
| 76120 | Cineradiography/videoradiography, video capsule | 7,896.00 |
| 76140 | Interpretation/consultation on imaging made elsewhere | 201.00 |
| 76390 | MRS,Magnetic resonance spectroscopy, per patient | 8,889.00 |
| 76512 | Ophthalmic US (ultrasound) | 260.00 |
| 76514 | Ophthalmic US, corneal pachymetry, determination of corneal thickness, per patient | 144.00 |
| 76536 | Head and neck soft tissues US, with image documentation | 521.00 |
| 76604 | Chest US, including mediastinum, with image documentation | 894.00 |
| 76645 | Breasts and chest wall US, with image documentation | 362.00 |
| 76700 | Abdomen US, with image documentation | 521.00 |
| 76805 | Fetal anatomic US, with image documentation | 1,338.00 |
| 76813 | Fetal nuchal translucency US, per one fetus, with image documentation | 548.00 |
| 76814 | Fetal nuchal translucency US, per each additional fetus, with image documentation | 362.00 |
| 76815 | Obstetric US, with image documentation | 731.00 |
| 76825 | Echocardiography, fetal, with image documentation | 1,530.00 |
| 76827 | Doppler echocardiography, fetal | 1,893.00 |
| 76830 | TVUS (Transvaginal Ultrasound) | 428.00 |
| 76831 | Uterus and fallopian tube sonography, with contrast material | 1,485.00 |
| 76857 | Gynecological US, follicles | 273.00 |
| 76870 | Scrotum US, with image documentation | 894.00 |
| 76872 | TRUS (transrectal ultrasound), with image documentation | 1,299.00 |
| 76942 | Biopsy/surgical procedure, US guidance | 4,121.00 |
| 77002 | Biopsy/surgical procedure, using fluoroscopic guidance | 4,121.00 |
| 77012 | Biopsy/surgical procedure, using CT guidance | 7,463.00 |
| 77021 | Biopsy/surgical procedure, using MRI guidance | 11,195.00 |
| 77031 | Stereotactic localization guidance for breast biopsy/needle placement, including biopsy, using imaging guidance (eg, mammography) | 7,460.00 |
| 77032 | Mammographic guidance for needle placement, breast (eg, for wire localization or for injection), each lesion, radiological supervision and interpretation | 1,133.00 |
| 77054 | Mammary ductogram/galactogram, including interpretation | 1,466.00 |
| 77056 | Mammography; bilateral | 365.00 |
| 77059 | MRI, breast, without and/or with contrast material(s); bilateral | 3,336.00 |
| 77073 | Bone length studies (orthoroentgenogram, scanogram) | 525.00 |
| 77080 | DXA, bone density study | 324.00 |
| 77261 | Therapeutic radiology treatment planning, radiotherapy | 854.00 |
| 77280 | Radiotherapy simulation | 3,395.00 |
| 77295 | Radiology simulation-aided field setting, three-dimensional | 4,248.00 |
| 77401 | Radiation treatment delivery, per field | 746.00 |
| 78000 | Thyroid uptake, single determination | 428.00 |
| 78001 | Thyroid uptake, multiple determinations | 728.00 |
| 78007 | Thyroid imaging, with uptake, multiple determinations | 1,455.00 |
| 78010 | Thyroid imaging | 947.00 |
| 78018 | Thyroid imaging; I-131, whole body | 4,394.00 |
| 78070 | Parathyroid imaging | 2,190.00 |
| 78104 | Bone marrow imaging, whole body | 4,097.00 |
| 78122 | Whole blood volume determination, radiopharmaceutical technique | 2,718.00 |
| 78130 | Red cell survival study | 4,638.00 |
| 78191 | Platelet survival study | 1,472.00 |
| 78195 | Lymphatics and lymph nodes imaging | 4,056.00 |
| 78205 | Liver and spleen imaging, SPECT | 1,281.00 |
| 78215 | Liver and spleen imaging, static | 1,133.00 |
| 78216 | Liver and spleen imaging, dynamic and static | 1,203.00 |
| 78223 | Hepatobiliary imaging, with/without pharmacologic intervention, with/without quantitative measurement of gallbladder function | 3,339.00 |
| 78231 | Salivary gland imaging, with serial images | 1,394.00 |
| 78258 | Esophageal motility, dynamic | 1,443.00 |
| 78262 | Gastroesophageal reflux study | 1,086.00 |
| 78264 | Gastric emptying study | 4,325.00 |
| 78270 | Vitamin B-12 absorption, without intrinsic factor | 1,041.00 |
| 78271 | Vitamin B-12 absorption, with intrinsic factor | 1,427.00 |
| 78278 | Acute GI bleeding imaging, dynamic and static | 4,215.00 |
| 78290 | Intestine imaging (eg, Meckel’s, ectopic gastric mucosa) | 2,088.00 |
| 78291 | Peritoneal-venous shunt patency test (eg, for LeVeen, Denver shunt) | 2,952.00 |
| 78300 | Bone and/or joint imaging, limited area | 1,761.00 |
| 78306 | Bone and/or joint imaging, whole body | 1,101.00 |
| 78315 | Bone and/or joint imaging, three phase | 3,551.00 |
| 78320 | Bone and/or joint imaging, SPECT | 1,241.00 |
| 78399 | Bone and/or joint imaging, whole body, 24 hours later | 506.00 |
| 78428 | Cardiac shunt detection, dynamic | 1,158.00 |
| 78445 | Vascular flow imaging, perfusion | 1,515.00 |
| 78458 | Venous thrombosis imaging, bilateral | 1,998.00 |
| 78461 | Myocardial perfusion imaging, at rest and/or stress, planar | 4,859.00 |
| 78465 | Myocardial perfusion imaging, rest and/or stress, SPECT | 5,508.00 |
| 78466 | Myocardial imaging, infarct, planar | 3,615.00 |
| 78468 | Myocardial imaging, infarct, planar first pass, EF | 4,290.00 |
| 78469 | Myocardial imaging, infarct, SPECT | 4,976.00 |
| 78472 | Cardiac BP imaging, gated planar, rest/stress, EF | 2,279.00 |
| 78473 | Cardiac BP imaging, gated, rest and stress, EF | 5,399.00 |
| 78478 | Myocardial perfusion imaging, with wall motion | 6,732.00 |
| 78480 | Myocardial perfusion study with EF | 7,037.00 |
| 78481 | Cardiac BP imaging, gated planar, rest/stress, first pass, EF | 2,249.00 |
| 78499 | Cardiac BP (pool imaging)imaging, static | 1,089.00 |
| 78580 | Pulmonary imaging, perfusion | 1,302.00 |
| 78585 | Pulmonary imaging, ventilation and perfusion, Xenon | 3,042.00 |
| 78587 | Pulmonary imaging, ventilation, aerosol | 2,505.00 |
| 78594 | Pulmonary imaging, ventilation, xenon | 2,607.00 |
| 78596 | Pulmonary imaging, ventilation and perfusion, quantitative differential function | 3,845.00 |
| 78605 | Brain imaging, static | 1,814.00 |
| 78606 | Brain imaging, dynamic and static | 2,439.00 |
| 78607 | Brain imaging, SPECT | 4,667.00 |
| 78610 | Brain imaging, dynamic | 1,689.00 |
| 78630 | CSF (Cerebrospinal fluid) imaging, cisternography | 7,001.00 |
| 78645 | CSF flow imaging, shunt evaluation | 1,439.00 |
| 78650 | CSF leakage detection and localization | 4,154.00 |
| 78660 | Radiopharmaceutical dacryocystography | 1,749.00 |
| 78699 | Brain tumor imaging, SPECT | 4,211.00 |
| 78700 | Kidney imaging, static | 2,151.00 |
| 78701 | Kidney imaging, dynamic, GFR | 2,439.00 |
| 78707 | Kidney imaging, dynamic, without pharmacological intervention | 1,659.00 |
| 78708 | Kidney imaging, dynamic, with pharmacological intervention | 1,977.00 |
| 78710 | Kidney imaging, SPECT | 2,126.00 |
| 78740 | Ureteral reflux imaging (cystogram) | 1,859.00 |
| 78761 | Testicular imaging, dynamic and static | 1,080.00 |
| 78802 | Tumor imaging, planar | 6,597.00 |
| 78803 | Tumor imaging, SPECT | 5,748.00 |
| 78805 | Inflammatory process imaging, limited area | 6,444.00 |
| 78806 | Inflammatory process imaging, whole body | 7,922.00 |
| 78807 | Inflammatory process imaging, SPECT | 5,748.00 |
| 78813 | FDG PET imaging | 6,567.00 |
| 78999 | Tumor imaging, monoclonal antibodies, SPECT | 12,155.00 |
| 79101 | Radiopharmaceutical therapy, polycythemia vera | 3,068.00 |
| 79403 | Radiopharmaceutical therapy, intravenous administration, Zevalin, 90Y-Ibritumomab tiuxetan | 2,607.00 |
| 79440 | Radiopharmaceutical therapy, by intra-articular administration | 8,424.00 |
| 80053 | Chemistry panel | 89.00 |
| 80061 | Lipids panel — blood: Cholesterol, TG, HDL, LDL | 71.00 |
| 80076 | Hepatic function panel | 99.00 |
| 80100 | Drug, qualitative — urine | 195.00 |
| 80101 | Drug, qualitative | 288.00 |
| 80162 | Digoxin | 138.00 |
| 80178 | Lithium | 209.00 |
| 80195 | Sirolimus | 474.00 |
| 80299 | Drug, quantitative | 288.00 |
| 80400 | ACTH stimulation, including blood hormones levels | 734.00 |
| 80420 | Dexamethasone suppression test, 48 hour, include: free cortisol, urine cortisol, volume measurement | 218.00 |
| 81000 | Urinalysis, with microscopy | 63.00 |
| 81002 | Urinalysis stick, manual — urine, panel billing code | 29.00 |
| 82010 | Acetone, quantitative | 129.00 |
| 82013 | Acetylcholinesterase — amniotic fluid | 806.00 |
| 82017 | Acylcarnitine, quantitative — blood/urine | 974.00 |
| 82030 | Cyclic AMP — blood and urine | 1,154.00 |
| 82040 | Albumin — serum | 26.00 |
| 82042 | Albumin, quantitative — urine/other source, excluding serum | 26.00 |
| 82043 | Microalbumin — urine / 24 hours | 138.00 |
| 82085 | Aldolase | 288.00 |
| 82088 | Aldosterone | 377.00 |
| 82103 | Alpha 1 antitrypsin, total | 434.00 |
| 82105 | Alpha-fetoprotein — serum | 53.00 |
| 82128 | Amino acids, qualitative | 180.00 |
| 82131 | Amino acids, quantitative | 513.00 |
| 82135 | Aminolevulinic acid (ALA), quantitative — urine | 495.00 |
| 82140 | Ammonia | 281.00 |
| 82150 | Amylase | 51.00 |
| 82154 | Androstenedione/androstenediol glucoronide | 311.00 |
| 82160 | Androsterone | 620.00 |
| 82172 | Apolipoprotein B1/A1 | 209.00 |
| 82180 | Vitamin C, ascorbic acid — blood | 201.00 |
| 82205 | Barbiturates, qualitative — urine | 288.00 |
| 82232 | Beta 2 microglobulin | 432.00 |
| 82239 | Bile acids degradation test | 437.00 |
| 82247 | Bilirubin, total | 26.00 |
| 82248 | Bilirubin, direct | 26.00 |
| 82261 | Biotinidase | 411.00 |
| 82270 | Occult blood — feces | 129.00 |
| 82306 | Calcifediol (25-OH Vitamin D-3) | 182.00 |
| 82307 | Calciferol (Vitamin D) | 182.00 |
| 82308 | Calcitonin | 377.00 |
| 82310 | Calcium, total, excluding urine | 26.00 |
| 82340 | Calcium — urine | 50.00 |
| 82360 | Calculus, quantitative and qualitative analysis | 1,529.00 |
| 82374 | Carbon dioxide (bicarbonate) | 170.00 |
| 82378 | CEA (Carcinoembryonic Ag), including dilution | 53.00 |
| 82380 | Carotene | 201.00 |
| 82382 | Catecholamines, total | 894.00 |
| 82390 | Ceruloplasmin | 288.00 |
| 82435 | Chloride — blood | 50.00 |
| 82436 | Chloride — urine | 50.00 |
| 82438 | Chloride — other source, excluding blood/urine | 50.00 |
| 82465 | Cholesterol, total — blood | 26.00 |
| 82480 | Cholinesterase — serum | 129.00 |
| 82486 | Chromatography, qualitative | 209.00 |
| 82492 | Chromatography, quantitative, any method | 209.00 |
| 82525 | Copper | 114.00 |
| 82533 | Cortisol, total | 63.00 |
| 82540 | Creatine | 129.00 |
| 82550 | CK (Creatine Kinase, CPK), total | 26.00 |
| 82552 | CK (Creatine Kinase, CPK) isoenzymes | 414.00 |
| 82565 | Creatinine — blood | 30.00 |
| 82570 | Creatinine — other fluids, excluding blood | 63.00 |
| 82575 | Creatinine clearance test | 87.00 |
| 82585 | Cryofibrinogen | 422.00 |
| 82595 | Cryoglobulin, qualitative or semi-quantitative (eg, cryocrit) | 209.00 |
| 82607 | Vitamin B-12, cyanocobalamin | 233.00 |
| 82608 | Vitamin B-12, cyanocobalamin, binding capacity | 83.00 |
| 82626 | Dehydroepiandrosterone (DHEA) | 99.00 |
| 82627 | Dehydroepiandrosterone-sulfate (DHEA-S) | 99.00 |
| 82652 | Vitamin D (Calciferol) 1,25-Dihydroxy | 734.00 |
| 82657 | Enzyme activity in blood cells, cultured cells, or tissue, each | 288.00 |
| 82670 | Estradiol | 99.00 |
| 82672 | Estrogens, total, all derivatives | 620.00 |
| 82677 | Estriol | 434.00 |
| 82679 | Estrone | 422.00 |
| 82705 | Fat, qualitative — feces | 201.00 |
| 82710 | Fat, quantitative — feces | 657.00 |
| 82726 | Very long chain fatty acids | 1,395.00 |
| 82728 | Ferritin | 48.00 |
| 82731 | Fetal fibronectin | 680.00 |
| 82746 | Folic acid — serum | 207.00 |
| 82757 | Fructose — seminal fluid | 434.00 |
| 82759 | Galactokinase | 1,223.00 |
| 82760 | Galactose | 422.00 |
| 82775 | Galactose 1 phosphate uridyl transferase, quantitative | 657.00 |
| 82787 | Gammaglobulin, immunoglobulin subclasses | 1,035.00 |
| 82800 | Gases, pH only — blood | 209.00 |
| 82803 | Gases — blood | 264.00 |
| 82941 | Gastrin | 377.00 |
| 82945 | Glucose — other fluids, excluding blood | 129.00 |
| 82947 | Glucose, quantitative — blood | 26.00 |
| 82951 | Glucose tolerance test (GTT) | 288.00 |
| 82955 | Glucose-6-phosphate dehydrogenase (G6PD), quantitative | 620.00 |
| 82960 | Glucose-6-phosphate dehydrogenase (G6PD), screen | 422.00 |
| 82977 | Gamma glutamyltransferase (GGT) | 48.00 |
| 82985 | Fructosamine/glycated protein | 620.00 |
| 83001 | Gonadotropin, FSH (Follicle stimulating hormone) | 48.00 |
| 83002 | Gonadotropin, LH (Luteinizing hormone) | 95.00 |
| 83003 | GH (Growth hormone), somatotropin | 99.00 |
| 83010 | Haptoglobin, quantitative | 477.00 |
| 83013 | Rapid urease test, helicobacter pylori — exhaled air | 71.00 |
| 83015 | Heavy metal (arsenic, barium, beryllium, bismuth, antimony, mercury, thallium), screen | 288.00 |
| 83020 | Hemoglobin, electrophoresis | 176.00 |
| 83036 | Hemoglobin; glycosylated (A1C) | 63.00 |
| 83045 | Hemoglobin, methemoglobin, qualitative | 620.00 |
| 83069 | Hemoglobin — urine | 360.00 |
| 83070 | Hemosiderin, qualitative — urine | 372.00 |
| 83071 | Hemosiderin, quantitative — urine | 372.00 |
| 83090 | Homocysteine | 387.00 |
| 83491 | Hydroxycorticosteroids, 17- (17-OHCS) | 476.00 |
| 83497 | Hydroxyindolacetic acid, 5-(HIAA) | 227.00 |
| 83525 | Insulin, total | 99.00 |
| 83540 | Iron | 63.00 |
| 83550 | Iron binding capacity | 288.00 |
| 83586 | Ketosteroids , total | 422.00 |
| 83593 | Ketosteroids, 17- (17-KS), fractionation | 2,331.00 |
| 83605 | Lactate (lactic acid) | 150.00 |
| 83615 | Lactate dehydrogenase (LD), (LDH) | 26.00 |
| 83625 | Lactate dehydrogenase (LD), (LDH), isoenzymes, total | 620.00 |
| 83655 | Lead | 138.00 |
| 83661 | Fetal lung maturity assessment, Lecithin/Sphingomyelin ratio — amniotic fluid | 786.00 |
| 83690 | Lipase | 51.00 |
| 83700 | Lipoprotein, electrophoresis — blood | 42.00 |
| 83718 | Lipoprotein, HDL cholesterol | 50.00 |
| 83719 | Lipoprotein, VLDL cholesterol | 50.00 |
| 83735 | Magnesium | 26.00 |
| 83825 | Mercury, quantitative | 288.00 |
| 83866 | Mucopolysaccharides, screen — urine, per patient | 450.00 |
| 83872 | Mucin/other material — synovial fluid, including biochemistry, cytology and culture | 450.00 |
| 83874 | Myoglobin | 389.00 |
| 83896 | Molecular diagnosis of hematologic malignancies | 1,986.00 |
| 83898 | RT-PCR, molecular diagnostics | 4,827.00 |
| 83918 | Organic acids, quantitative — urine | 912.00 |
| 83930 | Osmolality — blood | 129.00 |
| 83935 | Osmolality — urine | 129.00 |
| 83945 | Oxalate, qualitative/quantitative — urine | 521.00 |
| 83970 | Parathormone (parathyroid hormone) | 356.00 |
| 84060 | Acid phosphatase, total | 129.00 |
| 84061 | Acid phosphatase stain | 288.00 |
| 84066 | Acid phosphatase, prostatic | 201.00 |
| 84075 | Alkaline phosphatase | 26.00 |
| 84080 | Alkaline phosphatase isoenzymes | 620.00 |
| 84100 | Phosphorus — blood | 26.00 |
| 84105 | Phosphorus — urine | 26.00 |
| 84110 | Porphobilinogen, quantitative, collection — urine | 363.00 |
| 84119 | Porphobilinogen, quantitative — urine | 201.00 |
| 84127 | Porphyrins, qualitative — feces | 323.00 |
| 84132 | Potassium — blood | 26.00 |
| 84135 | Pregnanediol | 422.00 |
| 84138 | Pregnanetriol | 620.00 |
| 84144 | Progesterone | 99.00 |
| 84146 | Prolactin | 146.00 |
| 84153 | PSA (Prostate specific Ag), total | 63.00 |
| 84154 | PSA (Prostate specific Ag), free | 129.00 |
| 84155 | Protein, total — serum | 26.00 |
| 84156 | Protein, total — urine | 26.00 |
| 84165 | Protein electrophoretic | 138.00 |
| 84207 | Vitamin B-6 (pyridoxal phosphate) | 441.00 |
| 84210 | Phenylpyruvic acid — urine | 63.00 |
| 84233 | Receptor assay, estrogene | 969.00 |
| 84244 | Renin | 377.00 |
| 84260 | Serotonin | 227.00 |
| 84295 | Sodium — blood | 26.00 |
| 84375 | Sugars chromatography | 209.00 |
| 84376 | Sugars (mono-, di-, and oligosaccharides), qualitative — body fluids | 450.00 |
| 84402 | Testosterone, free | 201.00 |
| 84403 | Testosterone, total | 99.00 |
| 84432 | Thyroglobulin | 536.00 |
| 84436 | Thyroxine, total | 56.00 |
| 84443 | Thyroid stimulating hormone (TSH) | 56.00 |
| 84446 | Tocopherol alpha (Vitamin E) | 288.00 |
| 84450 | AST (GOT) Aspartate aminotransferase | 48.00 |
| 84460 | ALT (GPT) Alanine amino transferase | 48.00 |
| 84466 | Transferrin | 185.00 |
| 84478 | Triglycerides | 26.00 |
| 84479 | Thyroid hormone (T3/T4) uptake or binding ratio (THBR) | 116.00 |
| 84480 | Triiodothyronine T3, total (TT-3) | 116.00 |
| 84484 | Troponin, quantitative | 239.00 |
| 84490 | Chymotrypsin, quantitative — feces | 360.00 |
| 84520 | Urea, quantitative — blood | 26.00 |
| 84540 | Urea, quantitative — urine/other fluids, excluding blood | 63.00 |
| 84550 | Uric acid — blood | 26.00 |
| 84560 | Uric acid — body fluids, excluding blood | 63.00 |
| 84585 | Vanillylmandelic acid (VMA) — urine | 288.00 |
| 84588 | Vasopressin (antidiuretic hormone, ADH) | 734.00 |
| 84590 | Vitamin A | 201.00 |
| 84620 | Xylose absorption test — blood/urine | 209.00 |
| 84681 | C-peptide | 201.00 |
| 84702 | hCG (Human chorionic gonadotropin), qualitative/quantitative | 138.00 |
| 85002 | Bleeding time | 122.00 |
| 85007 | Manual differential | 60.00 |
| 85009 | Blood count, manual differential, buffy coat | 288.00 |
| 85025 | CBC (complete blood count) with differential | 42.00 |
| 85032 | Blood smear, manual test | 170.00 |
| 85044 | Reticulocytes manual count | 99.00 |
| 85049 | Platelet, thrombocyte | 108.00 |
| 85170 | Clot retraction | 170.00 |
| 85210 | Clotting, factor II, prothrombin | 321.00 |
| 85220 | Clotting, factor V (AcG or proaccelerin) | 422.00 |
| 85230 | Clotting, factor VII, proconvertin | 321.00 |
| 85244 | Clotting, factor VIII related antigen | 417.00 |
| 85245 | Clotting, factor VIII, ristocetin cofactor | 972.00 |
| 85250 | Clotting, factor IX | 467.00 |
| 85260 | Clotting, factor X (Stuart-Prower) | 321.00 |
| 85270 | Clotting, factor XI (PTA) | 321.00 |
| 85280 | Clotting, factor XII (Hageman) | 786.00 |
| 85290 | Clotting, factor XIII (fibrin stabilizing) | 422.00 |
| 85301 | Clotting anticoagulant, antithrombin III antigen | 461.00 |
| 85302 | Protein C, anticoagulant | 573.00 |
| 85305 | Protein S, anticoagulant | 477.00 |
| 85362 | Fibrinogen degradation (split) products (FDP) (FSP | 786.00 |
| 85384 | Fibrinogen activity | 138.00 |
| 85390 | Fibrinolysins or coagulopathy, screen | 620.00 |
| 85460 | HbF (Hemoglobin fetal) stain | 288.00 |
| 85475 | Hemolysin, acid, Ham test | 372.00 |
| 85540 | LAP (Leukocyte Alkaline Phosphatase) with count | 422.00 |
| 85549 | Muramidase | 734.00 |
| 85557 | Osmotic fragility | 422.00 |
| 85576 | Platelet aggregation | 657.00 |
| 85597 | Platelet neutralization | 806.00 |
| 85610 | PT (Prothrombin time) | 59.00 |
| 85635 | Reptilase test | 288.00 |
| 85651 | Sedimentation rate — blood | 29.00 |
| 85670 | TT (Thrombin time) — plasma | 129.00 |
| 85730 | PTT (Thromboplastin time) — plasma/blood | 63.00 |
| 85810 | Viscosity — blood | 422.00 |
| 86000 | Agglutinins, febrile, per test | 170.00 |
| 86021 | Leucocyte, Ab | 360.00 |
| 86022 | Platelet, Ab | 743.00 |
| 86038 | ANA (Antinuclear antibodies) | 380.00 |
| 86060 | ASL0 (Antistreptolysin 0), titer | 209.00 |
| 86140 | C-reactive protein | 75.00 |
| 86147 | Cardiolipin, Ab | 99.00 |
| 86155 | Chemotaxis assay | 1,982.00 |
| 86156 | Cold agglutinin, screen | 170.00 |
| 86157 | Cold agglutinin, quantitative | 170.00 |
| 86162 | Complement total hemolytic activity | 1,140.00 |
| 86171 | Complement fixation | 260.00 |
| 86225 | DNA, native or double stranded, Ab | 1,271.00 |
| 86235 | Extractable nuclear antigen, antibody to, any method (eg, nRNP, SS-A, SS-B, Sm, RNP, Sc170, J01), each antibody | 176.00 |
| 86255 | Fluorescent noninfectious agent Ab, not otherwise specified | 146.00 |
| 86300 | CA 15.3 tumor antigen | 71.00 |
| 86301 | CA 19.9, tumor antigen | 147.00 |
| 86304 | CA 125 tumor antigen | 63.00 |
| 86320 | Immunoelectrophoresis — serum | 447.00 |
| 86325 | Immunoelectrophoresis — body fluids, excluding serum, eg, urine, CSF | 129.00 |
| 86336 | Inhibin — serum | 344.00 |
| 86337 | Insulin, Ab | 411.00 |
| 86341 | Islet cell, Ab | 176.00 |
| 86344 | Leukocyte phagocytosis | 3,362.00 |
| 86353 | Lymphocyte transformation | 2,420.00 |
| 86359 | T and B cell count | 951.00 |
| 86360 | T cells absolute CD4 and CD8 count, including ratio | 2,978.00 |
| 86376 | Microsomal antibodies, eg, thyroid or liver-kidney | 405.00 |
| 86382 | Virus neutralization test | 488.00 |
| 86403 | Agglutination, screen (latex, Rose Waller) | 201.00 |
| 86406 | Agglutination, particle, titer, each Ab | 434.00 |
| 86431 | Rheumatoid factor, qualitative/quantitative | 170.00 |
| 86580 | Skin test; tuberculosis, intradermal | 92.00 |
| 86592 | Syphilis test, VDRL, RPR, TPHA, FTA, ELISA | 170.00 |
| 86619 | Borrelia (relapsing fever), Ab | 572.00 |
| 86644 | CMV (cytomegalovirus) Ab | 348.00 |
| 86648 | Diphtheria, Ab | 288.00 |
| 86677 | Helicobacter pylori, Ab — B | 71.00 |
| 86692 | Hepatitis delta, Ab | 147.00 |
| 86703 | HIV screening, central blood bank | 0.00 |
| 86704 | Hepatitis B core antibody (HBcAb), IgG and IgM | 87.00 |
| 86705 | Hepatitis B core Ab (HBcAb), IgM | 95.00 |
| 86706 | Hepatitis B surface Ab (HBsAb) | 48.00 |
| 86707 | Hepatitis Be Ab (HBeAb) | 120.00 |
| 86708 | Hepatitis A antibody (HAAb), total, IgG and IgM | 126.00 |
| 86709 | Hepatitis A Ab (HAAb), IgM or IgG | 153.00 |
| 86720 | Leptospira, Ab | 260.00 |
| 86738 | Mycoplasma, Ab | 360.00 |
| 86762 | Rubella virus IgG and IgM | 176.00 |
| 86778 | Toxoplasma IgM | 108.00 |
| 86789 | West Nile virus IgG and IgM | 560.00 |
| 86790 | Virus/bacteria Ab, not otherwise specified | 288.00 |
| 86800 | Thyroglobulin, Ab | 434.00 |
| 86803 | Hepatitis C, Ab | 53.00 |
| 86805 | Lymphocytotoxicity assay, visual crossmatch; with titration | 459.00 |
| 86813 | HLA typing, A, B, C | 2,360.00 |
| 86817 | HLA typing, DR/DQ | 3,053.00 |
| 86821 | HLA typing, MLC (mixed lymphocyte culture) | 3,053.00 |
| 86880 | DAT (Direct Antiglobulin Test) / Coombs | 209.00 |
| 86900 | Blood typing, including RH | 137.00 |
| 86901 | Rh test | 170.00 |
| 86903 | Blood typing and Rh, Ab, screen | 597.00 |
| 86904 | Blood typing and Rh, Ab | 1,185.00 |
| 86905 | Blood typing; RBC antigens, other than ABO or Rh (D) | 1,805.00 |
| 86940 | Hemolysins and agglutinins, screen | 620.00 |
| 87001 | Animal inoculation, eg, tuberculosis | 620.00 |
| 87040 | Blood culture and susceptibility | 129.00 |
| 87045 | Feces culture | 170.00 |
| 87070 | Culture, other source, excluding blood/urine/feces | 129.00 |
| 87081 | Urine culture, non quantitative | 170.00 |
| 87086 | Urine culture, quantitative | 347.00 |
| 87088 | Urine culture and susceptibility | 194.00 |
| 87106 | Fungi culture | 170.00 |
| 87109 | Mycoplasma culture | 260.00 |
| 87110 | Chlamydia culture | 528.00 |
| 87116 | Mycobacteria culture and identification | 564.00 |
| 87118 | Mycobacterial definitive identification, MTb | 285.00 |
| 87140 | Fluorescence or darkfield microscopy | 170.00 |
| 87177 | Ova and parasites, direct smear, identification — feces | 129.00 |
| 87181 | Susceptibility studies, antimicrobial agent, per agent | 170.00 |
| 87190 | Susceptibility studies, antimycobacterial agent, mycobacteria | 384.00 |
| 87205 | Smear interpretation, stain for bacteria, fungi, parasites or cell types | 129.00 |
| 87207 | Smear, special stain for parasites | 170.00 |
| 87250 | Virus isolation, including nucleic acid identification, polymerase chain reaction, PCR | 660.00 |
| 87252 | Virus isolation, tissue culture | 209.00 |
| 87253 | Virus isolation and identification, tissue culture, any method | 1,046.00 |
| 87278 | Legionella Ag — urine | 257.00 |
| 87299 | Immunofluorescent study; not otherwise specified | 360.00 |
| 87340 | Hepatitis B surface antigen (HBsAg), any method, including immunofluorescent study | 146.00 |
| 87350 | Hepatitis Be antigen (HBeAg), any method, including immunofluorescent study | 120.00 |
| 87389 | HIV Ab and P24 Ag, ELISA/EIA, at MOH recognized HIV laboratory | 36.00 |
| 87449 | Infectious agent antigen detection, not otherwise specified | 594.00 |
| 87472 | Bartonella henselae and Bartonella quintana, quantification | 455.00 |
| 87517 | Hepatitis B virus DNA/RNA, quantitative | 806.00 |
| 87522 | Hepatitis C virus DNA/RNA, quantitative | 1,497.00 |
| 87536 | HIV-1 DNA/RNA, quantitative | 2,094.00 |
| 87539 | HIV-2 DNA/RNA, quantitative | 2,094.00 |
| 87556 | Mycobacteria tuberculosis, AMTD | 720.00 |
| 87590 | Gonorrhoeae smear | 0.00 |
| 87620 | Papillomavirus (HPV) — tissue, including biopsy | 2,975.00 |
| 87622 | HPV (Human Papillomavirus) smear | 621.00 |
| 88036 | Necropsy (autopsy), limited, gross and/or microscopic; regional | 1,046.00 |
| 88130 | Sex chromatin identification, Barr bodies | 209.00 |
| 88141 | Pap smear, cervical/vaginal, cytopathology, including sampling | 177.00 |
| 88160 | Cytopathology examination and interpretation | 288.00 |
| 88230 | Karyotype, leukocyte culture | 1,809.00 |
| 88233 | Karyotype, tissue culture | 2,331.00 |
| 88240 | Cryopreservation of cells (eg, bone marrow), per year | 2,270.00 |
| 88299 | B &T cell receptor gene rearrangment analysis | 1,691.00 |
| 88305 | Histologic examination, microscopy and interpretation | 288.00 |
| 88313 | Bone marrow sampling and iron stain | 657.00 |
| 88319 | Histochemistry/cytochemistry stain for enzyme identification | 288.00 |
| 88346 | Immunofluorescent study, each antibody; direct method | 1,529.00 |
| 88347 | Immunofluorescent study, each antibody; indirect method | 1,529.00 |
| 88348 | EM (Electron microscopy), diagnostic | 5,120.00 |
| 89051 | Cell count — body fluids, eg, CSF, joint fluid, excluding blood | 201.00 |
| 89258 | Cryopreserved embryos storage for 5 years | 1,046.00 |
| 89259 | Cryopreservation, sperm, one year, up to 5 test tubes/straws | 1,152.00 |
| 89280 | Assisted oocyte fertilization, microtechnique | 6,930.00 |
| 89290 | Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis) | 14,928.00 |
| 89300 | Semen analysis; presence and/or motility of sperm including Huhner test (post coital) | 393.00 |
| 89320 | Semen analysis, complete (volume, count, motility, and differential) | 240.00 |
| 89325 | Sperm Ab | 384.00 |
| 90371 | HBIg (Hepatitis B immune globulin), IM | 6,603.00 |
| 90375 | Rlg (Rabies immune globulin), IM and/or subcutaneous | 4,514.00 |
| 90384 | Rho(D) immune globulin (Rhlg), Anti-D | 806.00 |
| 90585 | BCG (Bacillus Calmette-Guerin) vaccine for tuberculosis | 0.00 |
| 90586 | BCG vaccine for bladder, live, for intravesical use, per treatment, including material | 1,455.00 |
| 90749 | Immune globulin (Ig), not otherwise specified | 170.00 |
| 90772 | Subcutaneous/IM injection, therapeutic/prophylactic/diagnostic | 60.00 |
| 90862 | Pharmacological management/review, mental health | 176.00 |
| 90870 | Electroconvulsive therapy | 1,785.00 |
| 90880 | Hypnotherapy | 213.00 |
| 90882 | Psychosocial intervention — follow up | 206.00 |
| 90889 | Psychiatric medical opinion | 978.00 |
| 90901 | Biofeedback training | 638.00 |
| 90935 | Hemodialysis procedure, per treatment | 1,970.00 |
| 90945 | Dialysis procedure other than hemodialysis (eg, peritoneal dialysis) | 891.00 |
| 91010 | Esophageal motility (manometric study) | 1,767.00 |
| 91034 | Esophagus, acid reflux test, with intraluminal pH electrode for dection of gastroesophageal reflux; prolonged recording | 1,767.00 |
| 91065 | Breath hydrogen test (eg, for detection of lactase deficiency) | 324.00 |
| 91122 | Anorectal manometry | 1,767.00 |
| 92004 | Ophthalmological examination, initial | 786.00 |
| 92065 | Orthoptic evaluation and therapy | 170.00 |
| 92081 | Computerised visual field examination | 264.00 |
| 92083 | Visual field examination (eg, Goldmann visual fields) | 209.00 |
| 92230 | Fluorescein angioscopy, unilateral | 1,115.00 |
| 92235 | Fluorescein angioscopy, bilateral | 1,535.00 |
| 92240 | ICGI eye imaging, with interpretation and report | 2,816.00 |
| 92250 | Fundus photography, one eye | 336.00 |
| 92270 | Electro-oculography with interpretation and report | 528.00 |
| 92275 | Electroretinography with interpretation | 1,220.00 |
| 92283 | Color vision examination | 209.00 |
| 92284 | Dark adaptation examination with interpretation | 620.00 |
| 92285 | External eye photography, with interpretation and report | 660.00 |
| 92286 | Anterior segment photography, one eye | 528.00 |
| 92287 | Anterior segment photography, two eyes | 791.00 |
| 92310 | Contact lens fitting, including adjustment | 170.00 |
| 92355 | Fitting of telescopic lens system, age-related macular degeneration | 237.00 |
| 92506 | Evaluation of speech, language, voice | 209.00 |
| 92507 | Speech therapy, individual | 203.00 |
| 92508 | Speech therapy, group, per hour | 170.00 |
| 92512 | Rhinomanometry | 324.00 |
| 92526 | Feeding and swallowing therapy, per treatment | 194.00 |
| 92541 | Spontaneous nystagmus test, ENG (electronystagmography) | 786.00 |
| 92551 | Hearing test, screening | 48.00 |
| 92557 | Hearing test, comprehensive | 288.00 |
| 92567 | Tympanometry (impedance testing) | 126.00 |
| 92568 | Acoustic reflex testing | 278.00 |
| 92585 | Brain auditory evoked potentials, adult | 1,001.00 |
| 92588 | Brain evoked potentials, child | 1,361.00 |
| 92590 | Hearing aid fitting | 380.00 |
| 92593 | Hearing aid check/counselling, binaural | 288.00 |
| 92601 | Diagnostic analysis and programing of cochlear implant, binaural, under age 7 | 2,657.00 |
| 92602 | Diagnostic analysis and subsequent programing of cochlear implant, monaural, under age 7 | 864.00 |
| 92603 | Diagnostic analysis and programing of cochlear implant, binaural, age 7 or over | 2,657.00 |
| 92604 | Diagnostic analysis and subsequent programing of cochlear implant, monaural, age 7 or over | 864.00 |
| 92620 | Central auditory function test(s) | 566.00 |
| 92633 | Auditory rehabilitation following cochlear implant | 201.00 |
| 93000 | ECG (Electrocardiogram), with interpretation and report | 59.00 |
| 93012 | CardioBeeper device loan | 302.00 |
| 93015 | Cardiovascular stress test | 447.00 |
| 93224 | ECG monitoring for 24 hours (Holter) | 797.00 |
| 93307 | TTE (transthoracic echocardiography) | 674.00 |
| 93312 | TEE (transesophageal echocardiography) | 2,552.00 |
| 93350 | Effort or Dobutamine stress echocardiography (DSE) | 1,590.00 |
| 93720 | Pulmonary function tests, infant, plethysmography, with interpretation | 4,892.00 |
| 93784 | Blood pressure monitoring, for 24 hours | 705.00 |
| 93797 | Cardiac rehabilitation, per month | 1,314.00 |
| 93880 | Cervical arteries duplex, bilateral | 624.00 |
| 93923 | Extremities arteries duplex, stress and rest | 588.00 |
| 93925 | Extremity arteries/bypass grafts duplex | 624.00 |
| 93965 | Peripheral vessels flow study (eg, Doppler) | 260.00 |
| 93975 | Abdomen, pelvis and retroperitoneal vessels duplex | 588.00 |
| 93980 | Penile vessels duplex, per patient | 803.00 |
| 94010 | Spirometry, simple | 183.00 |
| 94060 | Spirometry with bronchodilator | 221.00 |
| 94070 | Prolonged bronchi evaluation, methacholine or other chemical agent | 1,302.00 |
| 94200 | Maximal voluntary ventilation | 89.00 |
| 94240 | Functional residual volume, noble gas | 935.00 |
| 94250 | Expired gas collection, quantitative | 465.00 |
| 94360 | Resistance to airflow, plethysmographic method | 797.00 |
| 94400 | Breathing response to CO2 (CO2 response curve) | 1,559.00 |
| 94620 | Pulmonary stress test, simple, including pre- and post-spirometry | 257.00 |
| 94621 | Pulmonary stress testing, complex | 1,970.00 |
| 94640 | Inhalation treatment | 60.00 |
| 94664 | Demonstration of an aerosol/inhaler use | 105.00 |
| 94667 | Physiotherapy, lung patient, per treatment | 203.00 |
| 94720 | Carbon monoxide diffusing capacity | 465.00 |
| 94760 | Noninvasive ear or pulse oximetry for oxygen saturation | 129.00 |
| 94762 | Oxygen saturation, overnight oximetry | 264.00 |
| 94772 | Pulmonary function tests, passive, child | 4,884.00 |
| 95004 | Aeroallergens/food, up to 10 allergens, screen | 201.00 |
| 95012 | Nitric oxide determination — exhaled air, per patient | 492.00 |
| 95028 | Aeroallergens/food, 11 or over allergens, extended test | 477.00 |
| 95044 | Patch or application skin alergy test | 258.00 |
| 95120 | Allergen immunotherapy, normal allergen | 285.00 |
| 95130 | Allergen immunotherapy, pure allergen | 579.00 |
| 95199 | Susceptibility studies, antimicrobial agent; lymphocyte and serum | 1,529.00 |
| 95810 | Polysomnography, including EEG | 1,722.00 |
| 95812 | EEG (Electroencephalogram) | 620.00 |
| 95813 | EEG (Electroencephalogram) extended monitoring | 1,338.00 |
| 95822 | EEG (Electroencephalogram), sleep | 1,013.00 |
| 95830 | EEG (Electroencephalogram), sphenoidal recording | 1,106.00 |
| 95857 | Tensilon test for myasthenia gravis | 278.00 |
| 95861 | EMG (electromyography) | 372.00 |
| 95872 | EMG (Electromyography) | 1,071.00 |
| 95900 | NCT (Nerve conduction test) | 854.00 |
| 95922 | Testing of autonomic nervous system function; vasomotor adrenergic innervation (sympathetic adrenergic function), including beat-to-beat blood pressure and R-R interval changes during Valsalva maneuver and at least five minutes of passive tilt | 744.00 |
| 95923 | Electrolyte concentration determination, sweat imprint | 209.00 |
| 95930 | VEP (visual evoked potential), adult | 1,001.00 |
| 95950 | EEG (electroencephalogram), 24 hours | 3,012.00 |
| 95990 | Refilling and maintenance of implantable pump or reservoir for drug delivery, spinal (intrathecal, epidural) or brain (intraventricular) | 1,364.00 |
| 96001 | Computerized three dimensional motion and walking analysis, per patient | 5,751.00 |
| 96567 | Photodynamic therapy (PDT), dermal lesions, non-melanoma/solar keratosis | 1,382.00 |
| 96910 | Phototherapy by UVB and tar/petrolatum | 207.00 |
| 96912 | Photochemotherapy by PUVA, including psoralens | 240.00 |
| 97001 | Physiotherapy, evaluation and treatment planning, adult | 323.00 |
| 97003 | Occupational therapy, evaluation and treatment planning, adult | 323.00 |
| 97113 | Aquatic physiotherapy/rehabilitation, individual, hydrotherapy | 314.00 |
| 97140 | Physiotherapy, individual | 203.00 |
| 97150 | Physiotherapy/rehabilitation, group, 4 or more individuals, including child, per individual | 60.00 |
| 97530 | Occupational therapy, individual | 203.00 |
| 97750 | Physical performance test or measurement (eg, musculoskeletal, functional capacity), with written report, eg, evaluation of pressure on sole | 951.00 |
| 97802 | Medical nutrition counselling and therapy | 201.00 |
| 97810 | Acupuncture | 288.00 |
| 99001 | Histopathology slides preparation for shipment | 455.00 |
| 99002 | Histopathology slides preparation in Israel | 657.00 |
| 99075 | Forensic medical opinion | 2,657.00 |
| 99080 | Medical opinion | 972.00 |
| 99183 | Elective hyperbaric oxygen therapy, per treatment, up to 2 hours | 1,365.00 |
| 99195 | Phlebotomy | 201.00 |
| 99212 | Follow up allergy testing after 95028 | 170.00 |
| 99214 | Post hospitalization examination | 0.00 |
| 99223 | Pre-operation evaluation, serial tests | 1,290.00 |
| 99242 | Physician examination, excluding tests with specific code | 372.00 |
| 99283 | ER visit, global payment | 1,208.00 |
| 99315 | Clinic nurse service, up to 30 minutes | 116.00 |
| 99316 | Clinic nurse service, over 30 minutes (eg, guidance for patient with stoma) | 246.00 |
| 99362 | Multidisciplinary team examination | 786.00 |
| 99371 | Telephonic consultation for poisoning/medication information/teratology | 312.00 |
| 99600 | Home visit, care worker | 270.00 |
| C0443 | Release of carpal tunnel, in surgical day care | 2,957.00 |
| C0449 | Peripheral nerve decompression/lysis of adhesions, excluding endoneurolysis, in surgical day care | 5,759.00 |
| C0460 | Peripheral nerve transposition, eg, ulnar nerve, in surgical day care | 5,759.00 |
| C0476 | Peripheral nerve repair, old traumatic injury, eg, ulnar nerve, in surgical day care | 5,759.00 |
| C0492 | Implantation/replacement of sacral nerve stimulation electrode/lead, in surgical day care, excluding device cost | 9,435.00 |
| C0670 | Excision of thyroglossal/branchial cleft cyst/sinus, in surgical day care | 5,759.00 |
| C0823 | Excision of lesion(s) and/or tissue of eyelid, excluding chalazion, in surgical day care | 5,759.00 |
| C0849 | Repair of eyelid position, excluding complex repair, in surgical day care | 5,759.00 |
| C0870 | Reconstruction of eyelid, in surgical day care | 5,759.00 |
| C0889 | Repair of eyelid position, complex, in surgical day care | 5,759.00 |
| C0920 | Lacrimal system operation, excluding fistulization, in surgical day care | 5,759.00 |
| C1000 | Conjunctiva operation, excluding removal of superficial foreign body, in surgical day care | 5,759.00 |
| C1139 | Excision of pterygium, without graft, in surgical day care | 5,759.00 |
| C1511 | Extraocular muscle(s) operation for strabismus repair, in surgical day care | 5,759.00 |
| C2169 | Turbinectomy, in surgical day care | 5,759.00 |
| C2189 | Nose operation/rhinoplasty, in surgical day care | 5,759.00 |
| C2220 | Intranasal antrotomy, excluding FESS, in surgical day care | 5,759.00 |
| C2840 | Excision of tonsil tag/lingual tonsil or adenoidectomy without tonsillectomy, in surgical day care | 7,818.00 |
| C3143 | Laryngoscopy with biopsy, in surgical day care | 5,759.00 |
| C3321 | Bronchoscopy through artificial stoma, in surgical day care | 5,759.00 |
| C3324 | Bronchoscopy with biopsy, in surgical day care | 5,759.00 |
| C4011 | Biopsy of lymphatic structure, in surgical day care | 5,759.00 |
| C4021 | Excision of lymph node(s), excluding internal mammary, in surgical day care | 5,759.00 |
| C4911 | Anal fistulotomy/fistulectomy under general anesthesia, in surgical day care | 5,759.00 |
| C4943 | Destruction of hemorrhoids by cauterization/cryotherapy, in surgical day care | 5,759.00 |
| C4945 | Ligation of hemorrhoids, in surgical day care | 10,266.00 |
| C5011 | Biopsy of liver, needle; percutaneous, not using CT/MRI guidance, in surgical day care | 5,759.00 |
| C5349 | Umbilical hernia repair, up to 5 years of age, in surgical day care | 5,759.00 |
| C5810 | Urethral meatotomy, in surgical day care | 5,759.00 |
| C5860 | Dilation of urethra, in surgical day care | 5,759.00 |
| C6120 | Excision of lesion(s) and/or hydrocele and/or varicocele of tunica vaginalis/spermatic cord, in surgical day care | 5,759.00 |
| C6250 | Orchiopexy, in surgical day care | 5,759.00 |
| C6420 | Excision/destruction of lesion(s) and/or tissue of penis under general anesthesia, in surgical day care | 5,759.00 |
| C6720 | Biopsy/conization of cervix, excluding by cauterization/cryosurgery, in surgical day care | 5,759.00 |
| C6739 | Excision of lesion(s) of cervix, including by cauterization/cryosurgery, in surgical day care | 5,759.00 |
| C6759 | Cerclage/repair of uterine cervix, in surgical day care | 5,759.00 |
| C7011 | Hymenotomy/hymenectomy, in surgical day care | 5,759.00 |
| C7024 | Biopsy/excision/destruction of lesion(s) of vagina, in surgical day care | 5,759.00 |
| C7129 | Bartholin’s gland/cyst operation under general anesthesia, in surgical day care | 5,759.00 |
| C7744 | Biopsy of bone/arthrotomy of hand/foot and finger(s)/toe(s), in surgical day care | 5,759.00 |
| C7751 | Bunion, eg, hallux valgus / hammer toe/claw operation, in surgical day care | 5,759.00 |
| C7860 | Removal of implanted device from bone, excluding face/hand/foot, in surgical day care | 5,759.00 |
| C8044 | Capsulotomy of hand/foot and finger(s)/toe(s), in surgical day care | 5,759.00 |
| C8201 | Tendon sheath incision, in surgical day care | 5,759.00 |
| C8313 | Tenotomy, excluding of hand, in surgical day care | 5,759.00 |
| C8331 | Excision of lesion(s) of tendon sheath, in surgical day care | 5,759.00 |
| C8350 | Excision of bursa, in surgical day care | 5,759.00 |
| C8611 | Biopsy of subcutaneous tissue under general anesthesia, in surgical day care | 5,759.00 |
| C8630 | Excision/destruction of lesions of skin and subcutaneous tissue, 4 or more, in surgical day care | 5,759.00 |
| C8660 | Free skin grafting, including excision of skin for autogenous graft, in surgical day care | 5,759.00 |
| C8689 | Repair and reconstruction of skin and subcutaneous tissue, in surgical day care | 5,759.00 |
| C8694 | Implantation/replacement of sacral nerve stimulation generator, in surgical day care, excluding device cost | 3,575.00 |
| C9802 | Esophagoscopy for removal of foreign body, in surgical day care | 5,759.00 |
| C999C | Surgical hospital day care, excluding procedures with specific code | 5,759.00 |
| D0210 | Intra oral radiograph — complete series | 539.00 |
| D0220 | Intraoral — periapical first radiographic image | 60.00 |
| D0230 | Intraoral — periapical each additional radiographic image | 60.00 |
| D0240 | Intraoral — occlusal radiographic image | 129.00 |
| D0330 | Panoramic radiographic image | 477.00 |
| D1201 | Application of fluoride, complete | 150.00 |
| D1351 | Sealant — per tooth | 221.00 |
| D1510 | Space maintainer, fixed | 1,116.00 |
| D2140 | Restoration — one surface, local anesthesia | 377.00 |
| D2150 | Restoration -2/more surfaces, any material | 477.00 |
| D2330 | Resin-based composite restoration — one surface, anterior | 642.00 |
| D2335 | Resin-based composite restoration, anterior | 794.00 |
| D2390 | Resin-based composite restoration — crown | 692.00 |
| D2752 | Crown — porcelain fused to noble metal | 4,062.00 |
| D2950 | Core build-up, including any pins | 1,310.00 |
| D2952 | Post and core in addition to crown | 1,914.00 |
| D2980 | Crown repair | 372.00 |
| D3220 | Pulpotomy, primary/permanent tooth | 348.00 |
| D3230 | Pulpal therapy, resorbable filling — primary tooth, excluding final restoration | 692.00 |
| D3310 | Root canal therapy — anterior, excluding final restoration | 1,418.00 |
| D3320 | Root canal therapy — bicuspid, excluding final restoration | 1,418.00 |
| D3330 | Root canal therapy — molar, excluding final restoration | 1,418.00 |
| D3351 | Apexification | 569.00 |
| D3410 | Apicoectomy, anterior, including placement of retrograde filling material | 1,421.00 |
| D3421 | Apicoectomy — bicuspid, including placement of retrograde filling material | 1,773.00 |
| D3425 | Apicoectomy — molar, including placement of retrograde filling material | 3,012.00 |
| D3450 | Root amputation | 1,773.00 |
| D3920 | Hemisection | 1,241.00 |
| D4240 | Gingival flap, with root planing, per quadrant | 1,217.00 |
| D4249 | Clinical crown lengthening | 1,134.00 |
| D4260 | Osseous surgery, including flap entry and closure, per quadrant | 1,565.00 |
| D4341 | Periodontal scaling and root planing, per meeting, 30 minutes | 209.00 |
| D5110 | Complete acrylic denture — pair | 11,880.00 |
| D5213 | Partial denture | 10,947.00 |
| D5730 | Reline denture (chairside) | 1,268.00 |
| D5750 | Reline denture — laboratory | 3,128.00 |
| D5951 | Feeding aid; feeding prosthesis | 981.00 |
| D5952 | Speech aid prosthesis, pediatric | 981.00 |
| D6010 | Surgical placement of dental implant body: endosteal implant, includes placement of healing cap | 5,462.00 |
| D6056 | Prefabricated abutment for dental implant | 3,411.00 |
| D7111 | Extraction, coronal remnants — deciduous tooth | 375.00 |
| D7140 | Extraction, erupted tooth or exposed root, single | 375.00 |
| D7141 | Extraction, erupted tooth or exposed root, second in the same session | 278.00 |
| D7142 | Extraction, erupted tooth or exposed root, each additional tooth in the same session | 186.00 |
| D7210 | Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth | 389.00 |
| D7220 | Removal of impacted tooth — soft tissue | 888.00 |
| D7230 | Removal of impacted tooth — partially bony | 1,241.00 |
| D7240 | Removal of impacted tooth — completely bony | 1,241.00 |
| D7270 | Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth and/or alveolus | 903.00 |
| D7280 | Exposure of impacted/unerupted tooth for orthodontic reasons, including orthodontic attachments | 1,241.00 |
| D7320 | Alveoloplasty not in conjunction with extractions — per quadrant | 915.00 |
| D7340 | Vestibuloplasty — ridge extension (secondary epithelialization) | 1,212.00 |
| D7450 | Removal of odontogenic cyst | 915.00 |
| D7950 | Bone graft to maxilla/mandible, unilateral | 15,587.00 |
| D7952 | Open sinus augmentation, including bone graft, unilateral | 7,376.00 |
| D7960 | Frenulectomy (frenectomy or frenotomy) | 888.00 |
| D7993 | Bone graft to maxilla/mandible, bilateral | 23,756.00 |
| D7994 | Open sinus augmentation, including bone graft, bilateral | 14,114.00 |
| D8050 | Interceptive orthodontic therapy, including chin cup | 2,385.00 |
| D8080 | Comprehensive orthodontic treatment of the adolescent dentition, for one year, up to 3 years | 6,323.00 |
| D8089 | Follow up code of D8080, established adolescent patient for comprehensive orthodontic treatment | 0.00 |
| D8210 | Removable dental appliance therapy | 1,268.00 |
| D8999 | Orthodontic preparation for orthognatic face mask | 2,385.00 |
| D9110 | Emergency treatment of dental pain | 264.00 |
| D9220 | Deep sedation/general anesthesia, for dental procedure — first hour | 1,880.00 |
| D9221 | Deep sedation/general anesthesia, for complex dental procedure — more than one hour | 2,126.00 |
| D9230 | Analgesia, including nitrous, excluding dental treatment | 347.00 |
| J0011 | Costeff syndrome, Methylglutaconic aciduria, molecular diagnostics, special case | 687.00 |
| J0021 | Adrenoleukodystrophy X-linked, molecular diagnostics, special case | 687.00 |
| J0031 | Canavan disease, molecular diagnostics, special case | 687.00 |
| J0041 | Carnitine Palmitoyl Tranferase, molecular diagnostics, special case | 687.00 |
| J0051 | Cystinuria, molecular diagnostics, special case | 687.00 |
| J0061 | Glycogen storage disease type 1, molecular diagnostics, special case | 687.00 |
| J0071 | Hyperglycinemia, nonketotic, molecular diagnostics, special case | 687.00 |
| J0081 | Hyperoxaluria, primary, type 1, molecular diagnostics, special case | 687.00 |
| J0091 | Isovalericacidemia, molecular diagnostics, special case | 687.00 |
| J0101 | Lipoamide Dehydrogenase Deficiency, molecular diagnostics, special case | 687.00 |
| J0111 | Maple syrup urine disease, molecular diagnostics, special case | 687.00 |
| J0121 | Methylmalonicaciduria, mutase deficiency, molecular diagnostics, special case | 687.00 |
| J0131 | Molybdenum cofactor deficiency, molecular diagnostics, special case | 687.00 |
| J0141 | Peroxysomal disorders, molecular diagnostics, special case | 687.00 |
| J0151 | Phenylketonuria, molecular diagnostics, special case | 687.00 |
| J0161 | Thiamine-responsive megaloblastic anemia, molecular diagnostics, special case | 687.00 |
| J0171 | Tyrosinemia, molecular diagnostics, special case | 687.00 |
| J0181 | VLCAD (Very Long Chain Acyl CoA Dehydrogenase) deficiency, molecular diagnostics, special case | 687.00 |
| J0191 | Wilson disease, molecular diagnostics, special case | 687.00 |
| J0201 | Xanthinuria, type I, molecular diagnostics, special case | 687.00 |
| J0211 | CTX (Cerebrotendinous xanthomatosis), molecular diagnostics, special case | 687.00 |
| J0221 | Hypercholesterolemia, familial, molecular diagnostics, special case | 687.00 |
| J0232 | Lysosomal acid phosphatase deficiency, biochemical diagnostics | 1,949.00 |
| J0241 | Aspartylglucosaminuria, molecular diagnostics, special case | 687.00 |
| J0242 | Aspartylglucosaminuria, biochemical diagnostics | 1,949.00 |
| J0251 | Ceroid lipofuscinosis, molecular diagnostics, special case | 687.00 |
| J0252 | Ceroid lipofuscinosis, biochemical diagnostics | 1,949.00 |
| J0262 | Cholesteryl ester storage disease, biochemical diagnostics | 1,949.00 |
| J0272 | Cystinosis, nephropathic, biochemical diagnostics | 1,949.00 |
| J0281 | Fabry disease, molecular diagnostics, special case | 687.00 |
| J0282 | Fabry disease, biochemical diagnostics | 1,949.00 |
| J0292 | Free sialic acid storage disease, biochemical diagnostics | 1,949.00 |
| J0302 | Fucosidosis, biochemical diagnostics | 1,949.00 |
| J0312 | GM1 gangliosidosis, biochemical diagnostics | 1,949.00 |
| J0322 | Galactosialidosis, biochemical diagnostics | 1,949.00 |
| J0331 | Gaucher disease, molecular diagnostics, special case | 885.00 |
| J0332 | Gaucher disease, biochemical diagnostics | 1,949.00 |
| J0341 | Glycogen storage disease type 2, Pompe, molecular diagnostics, special case | 687.00 |
| J0342 | Glycogen storage disease type 2, Pompe, biochemical diagnostics | 1,949.00 |
| J0351 | Ichthyosis, X-linked, molecular diagnostics, special case | 687.00 |
| J0352 | Ichthyosis, X-linked, biochemical diagnostics | 1,949.00 |
| J0361 | Krabbe disease, molecular diagnostics, special case | 687.00 |
| J0362 | Krabbe disease, biochemical diagnostics | 1,949.00 |
| J0372 | Mannosidosis, alpha, biochemical diagnostics | 1,949.00 |
| J0382 | Mannosidosis, beta, biochemical diagnostics | 1,949.00 |
| J0392 | Maroteaux-Lamy syndrome, biochemical diagnostics | 1,949.00 |
| J0400 | MLD (Metachromatic Leukodystrophy), pseudo deficiency, molecular diagnostics | 885.00 |
| J0401 | MLD (Metachromatic Leukodystrophy), molecular diagnostics, special case | 687.00 |
| J0402 | MLD (Metachromatic Leukodystrophy), biochemical diagnostics | 1,949.00 |
| J0412 | Mucolipidosis II, biochemical diagnostics | 4,433.00 |
| J0421 | Mucolipidosis III, molecular diagnostics, special case | 687.00 |
| J0422 | Mucolipidosis III, biochemical diagnostics | 4,433.00 |
| J0431 | Mucolipidosis IV, molecular diagnostics, special case | 687.00 |
| J0442 | Mucopolysaccharidosis II, biochemical diagnostics | 1,949.00 |
| J0452 | Mucopolysaccharidosis IV, biochemical diagnostics | 1,949.00 |
| J0462 | Mucopolysaccharidosis I, biochemical diagnostics | 1,949.00 |
| J0472 | Mucopolysaccharidosis VII, biochemical diagnostics | 1,949.00 |
| J0482 | Multiple sulfatase deficiency, biochemical diagnostics | 4,433.00 |
| J0491 | Niemann-Pick disease, molecular diagnostics, special case | 687.00 |
| J0492 | Niemann-Pick disease, biochemical diagnostics | 1,949.00 |
| J0501 | Niemann-Pick disease, type C, molecular diagnostics, special case | 687.00 |
| J0502 | Niemann-Pick disease, type C, biochemical diagnostics | 6,624.00 |
| J0511 | Pycnodysostosis, molecular diagnostics, special case | 687.00 |
| J0512 | Pycnodysostosis, biochemical diagnostics | 1,949.00 |
| J0522 | Salla disease, biochemical diagnostics | 1,949.00 |
| J0532 | Sanfilippo syndrome, biochemical diagnostics | 4,433.00 |
| J0542 | Schindler disease, biochemical diagnostics | 1,949.00 |
| J0552 | Sialidosis, biochemical diagnostics | 1,949.00 |
| J0561 | Tay Sachs, molecular diagnostics, special case | 687.00 |
| J0562 | Tay Sachs, biochemical diagnostics | 1,949.00 |
| J0572 | Wolman disease, biochemical diagnostics | 1,949.00 |
| J0581 | Mitochondrial disorder, molecular diagnostics, special case | 687.00 |
| J0582 | Mitochondrial disorder, biochemical diagnostics | |
| J0591 | Deafness, mitochondrial, molecular diagnostics, special case | 687.00 |
| J0600 | Kearns Sayre Syndrome, KSS, molecular diagnostics | 1,619.00 |
| J0610 | Leber Optic Atrophy, LHON, molecular diagnostics | 885.00 |
| J0621 | Leigh syndrome, molecular diagnostics, special case | 687.00 |
| J0622 | Leigh syndrome, biochemical diagnostics | |
| J0631 | Mitochondrial myopathy, Encephalopathy, Lactic Acidosis and Stroke-like episodes, MELAS, molecular diagnostics, special case | 885.00 |
| J0641 | Myoclonic Epilepsy with Ragged Red Fibers, MERFF, molecular diagnostics, special case | 1,619.00 |
| J0651 | Mitochondrial depletion syndrome, molecular diagnostics, special case | 687.00 |
| J0652 | Mitochondrial depletion syndrome, biochemical diagnostics | |
| J0661 | Alzheimer, early onset/familial, molecular diagnostics, special case | 687.00 |
| J0671 | Ataxia Telangiectasia, molecular diagnostics, special case | 687.00 |
| J0673 | Ataxia Telangiectasia, cytogenetic diagnostics | 4,998.00 |
| J0681 | Charcot-Marie-Tooth neuropathy, molecular diagnostics, special case | 1,400.00 |
| J0691 | Creutzfeldt-Jakob disease, familial, molecular diagnostics, special case | 687.00 |
| J0701 | Duchenne, Becker muscular dystrophy, molecular diagnostics, special case | 9,764.00 |
| J0710 | Familial dysautonomia, molecular diagnostics | 444.00 |
| J0720 | Dystonia, torsion, molecular diagnostics | 885.00 |
| J0730 | Facioscapulohumeral muscular dystrophy-1A, molecular diagnostics | 1,400.00 |
| J0740 | Hereditary Nerve Pressure Palsy, HNPP, molecular diagnostics | 1,619.00 |
| J0750 | Huntington disease, molecular diagnostics | 1,619.00 |
| J0761 | Inclusion body myopathy, autosomal recessive, molecular diagnostics, special case | 687.00 |
| J0771 | Insensitivity to pain, congenital, with anhidrosis, molecular diagnostics, special case | 687.00 |
| J0781 | LGMD (Limb girdle muscular dystrophy), dysferlin deficiency, molecular diagnostics, special case | 687.00 |
| J0790 | Myotonic dystrophy, molecular diagnostics | 1,619.00 |
| J0801 | Neurofibromatosis, type 1, molecular diagnostics, special case | 687.00 |
| J0810 | Oculopharyngeal muscular dystrophy, molecular diagnostics | 1,619.00 |
| J0820 | SMA (Spinal Muscular Atrophy), molecular diagnostics | 1,619.00 |
| J0830 | Spinocerebellar ataxia due to an expansion including Friedrich ataxia, molecular diagnostics | 1,619.00 |
| J0840 | Adenomatous polyposis coli, molecular diagnostics | 7,853.00 |
| J0841 | Adenomatous polyposis coli, molecular diagnostics, special case | 687.00 |
| J0850 | Multiple endocrine neoplasia 2A, molecular diagnostics | 1,767.00 |
| J0851 | Multiple endocrine neoplasia 2A, molecular diagnostics, special case | 687.00 |
| J0860 | Retinoblastoma, molecular diagnostics | 7,853.00 |
| J0861 | Retinoblastoma, molecular diagnostics, special case | 687.00 |
| J0870 | Von Hippel-Lindau, molecular diagnostics | 1,442.00 |
| J0871 | Von Hippel-Lindau, molecular diagnostics, special case | 687.00 |
| J0881 | Adrenal hyperplasia, congenital, 11-beta-hydroxylase deficiency, molecular diagnostics, special case | 687.00 |
| J0891 | Adrenal hyperplasia, congenital, 17-alpha-hydroxylase deficiency, molecular diagnostics, special case | 687.00 |
| J0901 | Adrenal hyperplasia, congenital, 21-hydroxylase deficiency, molecular diagnostics, special case | 687.00 |
| J0911 | Adrenal hypoplasia, congenital, molecular diagnostics, special case | 687.00 |
| J0921 | Pendred syndrome, molecular diagnostics, special case | 687.00 |
| J0931 | Persistent hyperinsulinemic hypoglycemia of infancy, molecular diagnostics, special case | 687.00 |
| J0941 | Combined factor V and VII deficiency, molecular diagnostics, special case | 687.00 |
| J0951 | Factor V deficiency, molecular diagnostics, special case | 687.00 |
| J0961 | Factor VII deficiency, molecular diagnostics, special case | 687.00 |
| J0971 | Factor XI deficiency, molecular diagnostics, special case | 687.00 |
| J0981 | Factor XIIIA deficiency, molecular diagnostics, special case | 687.00 |
| J0991 | Fanconi anemia, molecular diagnostics, special case | 687.00 |
| J0993 | Fanconi anemia, cytogenetic diagnostics | 4,998.00 |
| J1001 | Hemoglobinopathies alpha, alpha thalassemias, molecular diagnostics, special case | 2,079.00 |
| J1011 | Hemoglobinopathies beta, beta thalassemias, molecular diagnostics, special case | 2,079.00 |
| J1021 | Hemophilia A, factor VIII deficiency, molecular diagnostics, special case | 687.00 |
| J1031 | Hemophilia B, factor IX deficiency, molecular diagnostics, special case | 687.00 |
| J1040 | Achondroplasia/thanatophoric dwarfism, molecular diagnostics | 687.00 |
| J1051 | Achromatopsia, molecular diagnostics, special case | 687.00 |
| J1061 | Albinism, molecular diagnostics, special case | 687.00 |
| J1070 | Angelman syndrome/Prader Willi, molecular diagnostics | 1,400.00 |
| J1081 | Autoimmune polyglandular disease, type I, molecular diagnostics, special case | 687.00 |
| J1091 | Bardet-Biedl syndrome, molecular diagnostics, special case | 687.00 |
| J1100 | Beckwith-Wiedemann syndrome, molecular diagnostics | 1,400.00 |
| J1111 | Bloom syndrome, molecular diagnostics, special case | 444.00 |
| J1113 | Bloom syndrome, cytogenetic diagnostics | 4,998.00 |
| J1121 | Cockayne syndrome, molecular diagnostics, special case | 687.00 |
| J1122 | Cockayne syndrome, biochemical diagnostics | 6,624.00 |
| J1131 | Craniosynostosis, molecular diagnostics, special case | 687.00 |
| J1140 | Cystic fibrosis, molecular diagnostics | 885.00 |
| J1151 | Deafness, congenital, molecular diagnostics, special case | 687.00 |
| J1161 | Epidermolysis Bullosa, congenital, molecular diagnostics, special case | 687.00 |
| J1171 | Osteopetrosis, recessive, molecular diagnostics, special case | 687.00 |
| J1181 | Polycystic kidneys, dominant, molecular diagnostics, special case | 687.00 |
| J1191 | Polycystic kidneys, recessive, molecular diagnostics, special case | 687.00 |
| J1203 | Roberts syndrome, cytogenetic diagnostics | 4,998.00 |
| J1211 | Tuberous sclerosis, molecular diagnostics, special case | 687.00 |
| J1222 | Xeroderma pigmentosum, biochemical diagnostics | 6,624.00 |
| J1233 | DiGeorge/velocardiofacial syndrome, FISH, cytogenetic diagnostics | 2,094.00 |
| J1243 | Rubinstein-Taybi syndrome, FISH, cytogenetic diagnostics | 2,094.00 |
| J1253 | Smith-Magenis syndrome, FISH, cytogenetic diagnostics | 2,094.00 |
| J1263 | Williams syndrome, FISH, cytogenetic diagnostics | 2,094.00 |
| J1270 | Amplicon sequencing, price per each additional amplicon | 249.00 |
| J1271 | FMF, molecular diagnostics, special case | 885.00 |
| J1280 | Amplicon sequencing, price for single/first amplicon | 489.00 |
| J1311 | BRCA1/BRCA2 founder mutation analysis, breast/ovarian cancer, per patient | 825.00 |
| J3001 | Familial known mutation, molecular diagnostics | 687.00 |
| J8003 | Karyotype, cytogenetic diagnostics — chorionic villus | 3,131.00 |
| J8830 | Rapid aneuploidy detection, quantitative fluorescent PCR — amniotic fluid/chorionic villus | 1,536.00 |
| J8891 | Prenatal molecular diagnostics, basic | 2,258.00 |
| J9001 | Prenatal molecular diagnostics, complex | 3,305.00 |
| J9900 | Fragile X, molecular diagnostics | 816.00 |
| J9903 | Mental retardation, cytogenetic diagnostics | 1,241.00 |
| J9913 | Male infertility, cytogenetic diagnostics | 1,241.00 |
| J9941 | Y chromosome deletion, molecular diagnostics, special case | 1,340.00 |
| J9991 | Monogenic disease in family, molecular diagnostics, special case | 5,006.00 |
| L0005 | Long cast, local anesthesia | 422.00 |
| L0019 | Elastic bandage, elstoplast | 18.00 |
| L0020 | Needle aspiration, US guidance, including cytology | 773.00 |
| L0021 | Breast needle aspiration, US guidance, including cytology | 773.00 |
| L0022 | Thyroid needle aspiration, US guidance, including cytology, per patient | 2,276.00 |
| L0023 | Bandage placement or replacement | 122.00 |
| L0025 | Stitches | 0.00 |
| L0026 | Stitches removal | 65.00 |
| L0030 | Parotid needle aspiration, US guidance, including cytology, per patient | 2,073.00 |
| L0040 | Focused US ablation of uterine leiomyomata, MRI guidance | 24,114.00 |
| L0042 | Nephrostomy tube removal | 476.00 |
| L0062 | Vaginal smear, sampling, processing and interpretation | 288.00 |
| L0080 | Rehabilitation day care | 1,163.00 |
| L0100 | TMJ radiology, up to two views | 377.00 |
| L0106 | Radiology additional view, not elsewhere specified | 92.00 |
| L0107 | Jaw radiology, third or more additional views | 92.00 |
| L0108 | Mastoids radiology, third or more additional views | 92.00 |
| L0109 | Nasal bones radiology, third or more additional views | 92.00 |
| L0110 | Paranasal sinuses radiology, third or more additional views | 92.00 |
| L0111 | Skull radiology, third or more additional views | 92.00 |
| L0112 | Pelvis radiology, third or more additional views | 92.00 |
| L0113 | Shoulder radiology, complete, one side, third or more additional views | 92.00 |
| L0114 | Elbow radiology, third or more additional views | 92.00 |
| L0115 | Wrist radiology, third or more additional views | 92.00 |
| L0116 | Hand radiology, third or more additional views | 92.00 |
| L0117 | Hip radiology, unilateral, second or more additional views | 92.00 |
| L0118 | Ankle radiology, third or more additional views | 92.00 |
| L0119 | Abdomen radiology, second or more additional views | 92.00 |
| L0120 | TMJ radiology, third or more additional views | 92.00 |
| L0121 | Calcaneus radiology, third or more additional views | 92.00 |
| L0122 | Toe(s) radiology, third or more additional views | 92.00 |
| L0123 | Cervicothoracic spine radiology, Pawlow/Twining, up to two views | 92.00 |
| L0124 | Cervicothoracic spine radiology, Pawlow/Twining, third or more additional views | 92.00 |
| L0125 | Pelvis radiology, outlet | 92.00 |
| L0126 | Pelvis radiology, inlet | 92.00 |
| L0138 | Spine radiology, two parts, up to three views | 422.00 |
| L0151 | Arthrography, including injection and interpretation | 477.00 |
| L0160 | Chest radiology, third or more additional views | 170.00 |
| L0167 | Additional charge for device for insertion of left atrial appendage device | 36,267.00 |
| L0168 | Additional charge for device for implantation of diaphragmatic pacemaker for spinal cord injured patients | 163,350.00 |
| L0169 | Additional charge for device for implantation of diaphragmatic pacemaker for ALS patients | 142,079.00 |
| L0170 | Additional charge for programmable pump for chronic pain relief/spasticity treatment | 47,989.00 |
| L0171 | Additional charge for mechanical pump for pain relief | 32,691.00 |
| L0177 | Additional charge for vertical expandable prosthetic titanium rib system | 87,500.00 |
| L0178 | Additional charge for BAHA (Bone Anchored Hearing Aid), adult | 31,854.00 |
| L0179 | Additional charge for BAHA (Bone Anchored Hearing Aid), child | 33,806.00 |
| L0180 | Additional charge for VNS (Vagus Nerve Stimulator) kit for epilepsy treatment | 80,040.00 |
| L0182 | Additional charge for intracranial single array neurostimulator pulse generator kit, including leads, for movement disorders | 95,651.00 |
| L0183 | Additional charge for intracranial dual array neurostimulator pulse generators kit, including leads, for movement disorders | 110,501.00 |
| L0184 | Additional charge for rechargeable intracranial neurostimulator pulse generator kit for movement disorders | 162,912.00 |
| L0185 | Additional charge for leads of intracranial neurostimulator pulse generator, for movement disorders | 29,803.00 |
| L0187 | Additional charge for single/dual array neurostimulator pulse generator for intracranial stimulation, without leads, for movement disorders | 80,801.00 |
| L0188 | Additional charge for rechargeable neurostimulator pulse generator for intracranial stimulation, without leads, for movement disorders | 133,212.00 |
| L0194 | Large bandage, bandages & cotton | 372.00 |
| L0209 | Pregnancy termination approval committee | 585.00 |
| L0210 | Nasal bones radiology, up to two views | 266.00 |
| L0248 | Storage of corpse, 2 to 24 hours | 512.00 |
| L0268 | Spotting and copying patient records, first 10 pages | 141.00 |
| L0269 | Copying patient records, each 2 additional pages | 2.00 |
| L0280 | Additional charge for 90Y for SIRT (Selective Internal Radiation Therapy) for liver tumor, 90Y | 60,000.00 |
| L0300 | Additional charge for device for percutaneous mitral valve repair | 138,842.00 |
| L0372 | HBIg (Hepatitis B immune globulin), IV | 9,500.00 |
| L0396 | Varicella Zoster passive immunization, under 12 years of age, eg, varitect | 4,124.00 |
| L0397 | Varicella Zoster passive immunization, age 12 years or older, eg, varitect | 14,450.00 |
| L0409 | Small splints, occupational therapy, including cost of material and number of sessions | 303.00 |
| L0410 | Medium splints, static mouth splint, occupational therapy, including cost of material and number of sessions | 582.00 |
| L0411 | Medium splints, occupational therapy, including cost of material and number of sessions | 582.00 |
| L0412 | Complex medium splints, occupational therapy, including cost of material and number of sessions | 852.00 |
| L0413 | Big splints, occupational therapy, including cost of material and number of sessions | 1,148.00 |
| L0415 | JOBST suit measurement | 372.00 |
| L0416 | Complex medium splints, dynamic mouth splint, occupational therapy, including cost of material and number of sessions | 852.00 |
| L0438 | TRH (Thyrotropin releasing hormone) stimulation panel | 1,046.00 |
| L0444 | MRI (Magnetic resonance imaging), excluding tests with specific code | 3,395.00 |
| L0446 | MRI under general anesthesia, per test | 12,128.00 |
| L0486 | Geriatric hospital day care | 894.00 |
| L0487 | Cognitive geriatric hospital day care | 465.00 |
| L0491 | Cytotoxic capacity testing | 1,361.00 |
| L0534 | Orthoptic treatment, per treatment | 129.00 |
| L0546 | Auditory test for cochlear implant surgery candidate | 1,023.00 |
| L0554 | FMRI (functional magnetic resonance imaging) | 9,191.00 |
| L0560 | Internal hospital day care | 1,859.00 |
| L0561 | Rehabilitative hospital day care | 1,859.00 |
| L0564 | Histochemical staining including immunohistochemistry | 2,709.00 |
| L0574 | Breathing capability test | 129.00 |
| L0591 | Extracorporeal shockwave lithotripsy, kidney; complex | 31,023.00 |
| L0621 | Kit test | 1,472.00 |
| L0690 | Hotel care, per day, including medical supervision | 657.00 |
| L0692 | Home care, per day, including medical supervision | 984.00 |
| L0717 | Harvesting of cornea | 9,330.00 |
| L0749 | MRI, additional payment for gadolinum contrast | 375.00 |
| L0784 | IV (Intravenous) infusion of fluids | 372.00 |
| L0785 | IV (Intravenous) infusion of drugs | 372.00 |
| L0787 | Deflux injection, vesicoureteral reflux therapy, unilateral | 10,860.00 |
| L0788 | Deflux injection, vesicoureteral reflux therapy, bilateral | 19,184.00 |
| L0790 | Preparation of blood unit/blood product, price per preparation of one unit | 375.00 |
| L0791 | Blood unit/blood product, price per one unit | 370.00 |
| L0797 | Additional charge for pump for subcutaneous apomorphine injection | 10,000.00 |
| L0799 | IV (Intravenous) ileoprost | 1,751.00 |
| L0800 | Psychotherapy, individual, combined | 519.00 |
| L0801 | Psychiatric clinic evaluation | 249.00 |
| L0802 | Diagnostic interview/intake | 249.00 |
| L0803 | Home visit, member of psychiatric team | 213.00 |
| L0804 | Home visit, psychiatric team | 587.00 |
| L0805 | Comprehensive cognitive testing, 3 visits | 1,707.00 |
| L0806 | Multiprofessional evaluation for rehabilitation planning | 2,354.00 |
| L0807 | Psychological assessment for rehabilitation framework | 1,541.00 |
| L0808 | Psychodiagnostic assessment — full battery | 1,541.00 |
| L0809 | Psychodiagnostic assessment — partial battery | 791.00 |
| L0820 | Psychiatric hospital day care, adult, all hospitals | 591.00 |
| L0821 | Psychiatric hospital day care, children and adolescents, all hospitals | 633.00 |
| L0822 | Psychiatric community day care, adult | 639.00 |
| L0823 | Psychiatric community day care, children and adolescents | 689.00 |
| L0841 | Psychotherapy/counseling, individual | 374.00 |
| L0843 | Patient’s treatment framework assessment | 1,541.00 |
| L0846 | Family or conjoint therapy/counseling | 624.00 |
| L0849 | Psychotherapy, group, per session | 176.00 |
| L0885 | Psychotherapy/counselling, group, institutions/families/schools | 791.00 |
| L0886 | Guidance for other agencies, individual, within service site | 438.00 |
| L0887 | Guidance for other agencies, goup, within service site | 296.00 |
| L0888 | Guidance for other agencies, outside service site | 624.00 |
| L0899 | Psychosocial diagnosis and evaluation | 264.00 |
| L0911 | Hearing test, complete, anamnesis, child | 372.00 |
| L0914 | Biofeedback training, gastroenterology, single session | 512.00 |
| L0915 | Biofeedback training, gastroenterology, 6 sessions | 3,078.00 |
| L0934 | Circulating anticoagulants, eg, LAC | 528.00 |
| L0959 | Sexual counseling and therapy | 620.00 |
| L0962 | ER (Emergency room) medical examination | 432.00 |
| L0964 | ER (Emergency room) fee | 291.00 |
| L0969 | Collar or sling, including materials | 201.00 |
| L1015 | Enzymes activity with cells separation, six or more enzymes | 1,982.00 |
| L1028 | US (ultrasound), with image documentation | 521.00 |
| L1030 | FibroScan for assessment of liver fibrosis | 692.00 |
| L1031 | FibroTest — blood | 1,071.00 |
| L1039 | CT (Computed Tomography), excluding tests with specific code | 935.00 |
| L1040 | CTA / CT arthrography / CT urography, per patient, excluding thorax coronary arteries CTA | 1,680.00 |
| L1077 | Surgical obturator, assessment and preparation | 16,739.00 |
| L1079 | Interim obturator | 8,789.00 |
| L1080 | Definitive obturator | 24,068.00 |
| L1133 | Establishing paternity, per patient, including medical forensic opinion | 2,714.00 |
| L1139 | Pilot medical examination | 2,228.00 |
| L1275 | CTA chest, coronary arteries | 4,139.00 |
| L1611 | Initial insertion/replacement of speech prosthesis post laryngectomy | 4,247.00 |
| L1720 | Bladder instillation of Mitomycin, per treatment, including material | 1,593.00 |
| L1721 | Bladder hyperthermia and Mitomycin instillation, per treatment | 6,729.00 |
| L1922 | CT under general anesthesia | 2,718.00 |
| L1996 | Chronic pain control, infiltration | 450.00 |
| L1997 | Chronic pain control, nerves block, using fluoroscopic guidance, with contrast material | 2,253.00 |
| L1998 | Chronic pain control, nerves block, using fluoroscopic guidance, with neurolytic substance | 2,253.00 |
| L2001 | Radiofrequency treatment for pain control, per treatment | 7,172.00 |
| L2002 | Loading of pump for spasticity treatment, Baclofen | 5,198.00 |
| L2003 | Ozone treatment for skin ulcers, per day | 357.00 |
| L2004 | Negative pressure treatment for skin ulcers, per session | 924.00 |
| L2005 | Maggot debridement therapy, per session | 737.00 |
| L2013 | Acetylcholinesterase, Ab — serum | 588.00 |
| L2136 | OCT3 (Optical Coherence Tomography), per patient | 525.00 |
| L2196 | Pelvic/genitalia MRI, excluding prostate | 3,360.00 |
| L2197 | Prostate MRI | 6,716.00 |
| L2250 | Fundus photography, two eyes | 521.00 |
| L2340 | Optometry by an optometrist, per patient | 209.00 |
| L2498 | Corneal imaging | 275.00 |
| L2528 | Nasal potential difference measurements for cystic fibrosis diagnonsis | 2,316.00 |
| L2529 | Rectal biopsy sampling and testing for Cystic Fibrosis diagnosis, per patient | 2,316.00 |
| L2585 | Auditory screening test, OAE, infant | 0.00 |
| L2586 | Auditory screening test, AABR, infant | 0.00 |
| L2588 | OAE (Otoacoustic Emissions), diagnostic | 129.00 |
| L2589 | Auditory screening test, AABR, subsequent test, baby | 261.00 |
| L2699 | Extracorporeal shock wave lithotripsy, salivary glands | 7,575.00 |
| L2731 | Fibronectin | 680.00 |
| L2999 | Arthroscopy, complex and/or high skill surgical procedures, using implants | 22,388.00 |
| L3003 | ECG monitoring, Flecainide infusion, IV | 1,014.00 |
| L3013 | Rapid urease test, helicobacter pylori, child — exhaled air | 71.00 |
| L3239 | Biopsy, additional payment to EUS, excluding EUS (Endoscopic ultrasound) | 3,530.00 |
| L3250 | Endoscopic polyp marking, in addition to endoscopy, per patient | 1,259.00 |
| L3255 | Balloon enteroscopy | 16,416.00 |
| L3307 | TTE (transthoracic echocardiography), child | 674.00 |
| L3560 | Patella radiology, up to two views, per side | 186.00 |
| L3562 | Patella radiology, third or more additional views | 201.00 |
| L3620 | Toe(s) radiology, up to two views | 186.00 |
| L3621 | Calcaneus radiology, up to two views | 186.00 |
| L3711 | Apolipoprotein E, genotype | 642.00 |
| L3727 | Implantation of loop recorder system, including retrieval of recorded and stored ECG data, physician review and interpretation of retrieved ECG data, per ILR | 18,569.00 |
| L3795 | External Counter Pulsation Therapy (ECPT) / Enhanced External Counter Pulsation (EECP) therapy | 1,035.00 |
| L3799 | Rehabilitation workshop, lung diseases patients, per session | 108.00 |
| L3890 | Apolipoprotein E4, genotype | 1,529.00 |
| L3900 | Prenatal diagnosis, age 35-37, including US, amniocentesis and laboratory tests | 3,881.00 |
| L3902 | Prenatal diagnosis, over age 37, including US, amniocentesis and laboratory tests | 2,549.00 |
| L3903 | Prenatal diagnosis, younger than age 35, including US, amniocentesis and karyotype | 3,559.00 |
| L4110 | Porphobilinogen deaminase, quantitative — RBC | 671.00 |
| L4152 | Hospital circumcision, excluding newborn | 3,776.00 |
| L4233 | Her-2/neu, immunohistochemistry | 528.00 |
| L4234 | Her-2/neu, FISH method | 4,605.00 |
| L4283 | Enema | 39.00 |
| L4298 | Electrolytes, sodium and potassium | 38.00 |
| L4450 | Urethrocystography, retrograde, under sedation | 1,742.00 |
| L4581 | Additional charge for device for implantation/replacement of sacral nerve stimulation electrode/lead | 13,243.00 |
| L4583 | Additional charge for device for implantation/replacement of sacral nerve stimulation generator | 60,110.00 |
| L4612 | Botolinum Toxin, 30 units Dysport administration | 396.00 |
| L4705 | hCG and PAPP-A, quantitative — serum | 275.00 |
| L4793 | Ambulatory evaluaiton of TB suspected patient | 2,325.00 |
| L4794 | Basic evaluation of Mantoux positive patient | 284.00 |
| L4795 | Treatment of active TB patient, first 5 months | 11,121.00 |
| L4796 | Treatment of active TB patient, last month | 14,499.00 |
| L4797 | Evaluation of close contact of Tb patient | 924.00 |
| L4798 | Ambulatory treatment of close contact patient, prevention | 324.00 |
| L4799 | Ambulatory pharmacological treatment of close contact patient, last month | 434.00 |
| L4990 | Genotype characterization by caryotype analysis | 4,494.00 |
| L4991 | Malignancies genotype, FISH (Fluorescent in Situ Hybridization) | 2,010.00 |
| L4992 | Malignancies genotype, DNA index | 1,499.00 |
| L4999 | Orotic acid — urine | 128.00 |
| L5339 | Laser, additional payment to endoscopy, excluding endoscopy | 1,602.00 |
| L5378 | Colonoscopy, flexible; diagnostic, with/without collection of specimen(s) | 1,616.00 |
| L5400 | Endoscopic Argon laser treatment | 555.00 |
| L5441 | Femur head from bone bank | 2,394.00 |
| L5461 | Kappa or Lambda light chain, Ig, free — blood | 525.00 |
| L5799 | Angiography | 4,787.00 |
| L5810 | Polysomnography, including EEG, child | 1,722.00 |
| L5858 | Tensilon test for myasthenia gravis; with electromyographic recording | 786.00 |
| L5872 | Single fiber electromyography, per patient | 1,106.00 |
| L5925 | Sensory evoked potentials (SEP) study, per patient | 687.00 |
| L5990 | Minor ambulatory surgery, including foreign body removal, local anesthesia | 477.00 |
| L6002 | Cytokins | 432.00 |
| L6015 | Gliadin, Ab | 336.00 |
| L6030 | Intraocular injection, excluding material cost | 459.00 |
| L6031 | Intraocular injection of Bevacizumab (Avastin) | 1,007.00 |
| L6160 | KRAS mutation, per patient | 2,369.00 |
| L6171 | Additional charge for intraocular shunt, eg, Ex-PRESS, for trabeculectomy | 3,748.00 |
| L6312 | CA 72.4 tumor antigen | 200.00 |
| L6313 | NSE (Neuron specific enolase), tumor antigen | 200.00 |
| L6316 | Immunoassay for tumor antigen, quantitative; CA 21-1 | 179.00 |
| L6358 | Lymphocyte CD antigen determination, over 6 CD | 4,185.00 |
| L6375 | CT (Computed tomographic) virtual colonoscopy | 1,694.00 |
| L6414 | Hickman placement, angiography guidance | 4,646.00 |
| L6415 | Hickman placement under general anasthesia | 6,966.00 |
| L6416 | Portacath placement, angiography guidance | 6,737.00 |
| L6417 | Portacath placement under general anasthesia | 9,272.00 |
| L6418 | Declotting by thrombolytic agent of Hickman/portacath catheter | 257.00 |
| L6497 | Copying video, echo, catheterization, CD | 150.00 |
| L6498 | Copying of films from folder | 60.00 |
| L6499 | Copying of films from folder, each additional film | 29.00 |
| L6520 | Low density lipoprotein (LDL) apheresis | 14,928.00 |
| L6538 | HLA B57 | 759.00 |
| L6539 | HLA B5701 | 495.00 |
| L6550 | Oncological treatment, adult, with chemotherapeutic/biological medications, per patient per day | 2,120.00 |
| L6551 | Oncological treatment, child, with chemotherapeutic/biological medications, per patient per day | 2,753.00 |
| L6552 | Oncological/hematological treatment, adult, without chemotherapeutic/ biological medications, per patient per day | 1,272.00 |
| L6553 | Oncological/hematological treatment, child, without chemotherapeutic/ biological medications, per patient per day | 1,653.00 |
| L6611 | Bartonella henselae (Cat scratch) IgG — blood | 378.00 |
| L6612 | Bartonella henselae (Cat scratch) IgM — blood | 378.00 |
| L6689 | HIV or HTLV resistance to medication | 3,864.00 |
| L6705 | HBV, HCV and HIV-1 detection, NAT, at blood bank | 200.00 |
| L6707 | Hepatitis E, Ab | 377.00 |
| L6762 | Rubella virus IgG or IgM | 186.00 |
| L6776 | Toxoplasma, Sabin Feldman dye test | 332.00 |
| L6777 | Toxoplasmosis confirmation test | 860.00 |
| L6778 | Toxoplasma avidity testing | 459.00 |
| L6815 | Ultrasound, pregnant uterus, without image documentation | 476.00 |
| L6821 | Ophthalmic YAG laser treatment, per patient | 624.00 |
| L6822 | Ophthalmic Argon laser treatment, per patient | 485.00 |
| L6830 | Creation of arteriovenous fistula for renal dialysis, native or using graft | 19,593.00 |
| L6831 | Therapeutic catheterization of AV shunt for renal dialysis, native/with graft | 32,943.00 |
| L6849 | Interferon Ab | 498.00 |
| L6856 | Pelvis US, nonobstetric, with image documentation, complete | 521.00 |
| L6857 | Hips US | 521.00 |
| L6999 | Collagen corneal cross linking for keratoconus and keratectasia treatment | 4,701.00 |
| L7001 | Physiotherapy, evaluation and treatment planning, child | 579.00 |
| L7002 | Isokinetic assessment and treatment planning | 384.00 |
| L7003 | Occupational therapy, evaluation and treatment planning, child | 579.00 |
| L7004 | Isokinetic physiotherapeutic treatment | 318.00 |
| L7118 | NTM (Non Tuberculous Mycobacteria) identification | 615.00 |
| L7140 | Physiotherapy/rehabilitation, group, up to 4 individuals, including child, per individual | 126.00 |
| L7154 | Toxoplasma, molecular diagnostics — body fluids | 1,689.00 |
| L7204 | Spermatic veins embolization | 11,328.00 |
| L7210 | Photocoagulation, PDT, retina, including material | 16,532.00 |
| L7525 | Replacement/repositioning of biliary drain, percutaneous | 4,214.00 |
| L7619 | Malignant hyperthermia diagnosis test (muscle biopsy) | 12,915.00 |
| L7751 | Brachytherapy, gynecological | 15,861.00 |
| L7752 | Brachytherapy, lung cancer | 9,896.00 |
| L7753 | Brachytherapy, prostate cancer treatment | 63,437.00 |
| L7771 | Occupational therapy, group | 126.00 |
| L8074 | Adrenal imaging, medulla, I-123 MIBG, up to 7 years of age | 15,309.00 |
| L8075 | Adrenal imaging, medulla, I-123 MIBG, over 7 years of age | 26,571.00 |
| L8076 | Adrenal imaging, cortex | 15,611.00 |
| L8170 | Semen production from testis, surgical | 9,200.00 |
| L8180 | Chemotherapy resistance, Facs | 1,215.00 |
| L8181 | CD membrane antigen, up to 4 antigens | 1,749.00 |
| L8182 | Testes removal, for sperm isolation; cadaver, at the forensic medicine institute | 1,764.00 |
| L8183 | Pathological specimen, preparation of slides, at the forensic medicine institute | 144.00 |
| L8184 | DNA analysis in liquid blood, soft tissue, semen, at the forensic institute | 3,833.00 |
| L8186 | DNA analysis in dry blood, at the forensic institute | 4,037.00 |
| L8188 | DNA analysis in bone tissue, at the forensic institute | 14,084.00 |
| L8190 | Harvesting of cardiac valve (homograft bank) | 2,412.00 |
| L8213 | Aminolevulinic acid dehydratase (ALA-D), quantitative — RBC | 1,005.00 |
| L8242 | Allogeneic donor lymphocyte infusions, DLI | 5,372.00 |
| L8244 | Allogeneic lymphocyte proliferation | 8,084.00 |
| L8245 | Allogeneic lymphocyte activation | 51,135.00 |
| L8250 | Chromosome 1 and 19 analysis, per patient | 2,867.00 |
| L8252 | FLT3 and NPM1 internal random duplications, PCR | 1,185.00 |
| L8268 | Cholyl-14-C-Glycine breath test for bile salts deconjugation | |
| L8269 | C-13 urea test, helicobacter pylori — exhaled air | 239.00 |
| L8299 | Spleen imaging, with heated RBC (red blood cells) | 1,677.00 |
| L8307 | Examination of abortus for diagnosis of malformations | 8,894.00 |
| L8379 | EGFR (Epidermal Growth Factor Receptor) mutation, per patient | 1,593.00 |
| L8380 | ALK mutation, per patient | 4,149.00 |
| L8381 | BRAF mutation, per patient | 1,056.00 |
| L8400 | DNA extraction — whole blood | 129.00 |
| L8410 | Porphyrins, qualitative — plasma | 227.00 |
| L8411 | Porphyrins, chromatography — plasma | 854.00 |
| L8412 | Porphyrins, chromatography — urine | 789.00 |
| L8413 | Porphyrins, chromatography — feces | 903.00 |
| L8414 | Porphyrins, chromatography — RBC | 980.00 |
| L8599 | Pulmonary imaging, dynamic, mucociliary clearence | 5,459.00 |
| L8606 | DatScan brain imaging | 18,756.00 |
| L8738 | HIV Ab and P24 Ag, ELISA/EIA, at MOH recognized HIV clinic | 68.00 |
| L8739 | Delivering a non-negative HIV test result by a physician at MOH recognized HIV clinic | 180.00 |
| L8802 | Somatostatin receptor scintegraphy | 30,194.00 |
| L8970 | First stage IVF, including hormonal tests | 7,896.00 |
| L8971 | First stage IVF, excluding hormonal tests | 6,158.00 |
| L8972 | Second stage IVF, excluding hospitalization days | 9,524.00 |
| L8975 | Ovarian tissue cryopreservation | 7,847.00 |
| L8976 | Cryopreserved ovarian tissue storage for 5 years | 1,046.00 |
| L8977 | Oocyte retrieval and cryopreservation, eg, vitrification | 9,524.00 |
| L8978 | Cryopreserved oocytes storage for 5 years | 1,046.00 |
| L8979 | Cryopreserved oocytes transfer, intrauterine, including thawing and fertilization | 6,140.00 |
| L9000 | Radiopharmaceutical therapy, hyper-thyroidism | 2,423.00 |
| L9015 | Chorionic villus sampling, excluding laboratory processing and interpretation | 693.00 |
| L9030 | Radiopharmaceutical ablation of gland for thyroid carcinoma | 9,984.00 |
| L9035 | Radiopharmaceutical therapy for metastases of thyroid carcinoma | 15,846.00 |
| L9079 | Injection (eg, neurolytic substance) | 141.00 |
| L9080 | Medical opinion for appointment of legal guardian, including completion of form and reports | 974.00 |
| L9183 | Emergency hyperbaric oxygen therapy, excluding diving accidents | 16,733.00 |
| L9184 | Hyperbaric pretreatment assessment | 2,361.00 |
| L9201 | Physician consulation for a patient insured by another sick fund | 237.00 |
| L9211 | Fire arm license physician examination | 177.00 |
| L9212 | Driving license physician examination | 177.00 |
| L9215 | Fire arm license specialist examination | 521.00 |
| L9232 | Routine examinations for candidates for renal transplantation | 7,502.00 |
| L9241 | Perenatal genetic consultation | 825.00 |
| L9242 | Examination by medical specialist for appointment of legal guardian, for established patient | 372.00 |
| L9243 | Genetic consultation | 825.00 |
| L9244 | Physician examination, oncologist | 372.00 |
| L9245 | Physician examination, hematologist | 372.00 |
| L9246 | Physician examination, hemato-oncologist | 372.00 |
| L9247 | Physician examination, internal physician | 372.00 |
| L9248 | Physician examination, urologist | 372.00 |
| L9249 | Physician examination, orthopedic physician | 372.00 |
| L9250 | Stammering treatment, individual/group, per course | 12,978.00 |
| L9251 | Stammering treatment, individual/group, per patient/session | 248.00 |
| L9252 | Physician examination, alergologist | 372.00 |
| L9253 | Physician examination, endocrinologist | 372.00 |
| L9254 | Physician examination, otorhinolaryngologist | 372.00 |
| L9255 | Physician examination, obstetrician/gynecologist | 372.00 |
| L9256 | Physician examination, genetician | 372.00 |
| L9257 | Physician examination, gastroenterologist | 372.00 |
| L9258 | Physician examination, pediatrician | 372.00 |
| L9259 | Cryopreservation, sperm, any additional year, up to 5 test tubes/straws | 464.00 |
| L9260 | Physician examination, surgeon | 372.00 |
| L9261 | Physician examination, thoracic surgeon | 372.00 |
| L9262 | Physician examination, vascular surgeon | 372.00 |
| L9263 | Physician examination, hand surgeon | 372.00 |
| L9264 | Physician examination, maxillofacial surgeon | 372.00 |
| L9265 | Physician examination, proctologist surgeon | 372.00 |
| L9266 | Physician examination, breast surgeon | 372.00 |
| L9267 | Physician examination, plastic surgeon | 372.00 |
| L9268 | Physician examination, anesthesiologist | 372.00 |
| L9269 | Physician examination, neurosurgeon | 372.00 |
| L9270 | Physician examination, neurologist | 372.00 |
| L9271 | Consultation with a specialist | 620.00 |
| L9273 | Physician examination, nephrologist | 372.00 |
| L9274 | Physician examination, dermatologist | 372.00 |
| L9275 | Physician examination, ophthalmologist | 372.00 |
| L9276 | Physician examination, cardiologist | 372.00 |
| L9277 | Physician examination, rheumatologist | 372.00 |
| L9278 | Physician examination, pulmonologist | 372.00 |
| L9279 | Physician examination, rehabilitation physician | 372.00 |
| L9281 | Emergency physician consulation at sick fund clinic | 389.00 |
| L9301 | Clinic nurse evaluation for a patient insured by another sick fund | 168.00 |
| L9311 | Home visit, nurse | 209.00 |
| L9321 | Outpatient social treatment | 209.00 |
| L9331 | Rehabilitative day care center — long term | 405.00 |
| L9342 | Prosthesis extension | 377.00 |
| L9343 | Sheltered housing, per day | 51.00 |
| L9345 | Care hostel, per day | 188.00 |
| L9346 | Care hostel, extended, per day | 233.00 |
| L9347 | Short term treatment center, per day | 177.00 |
| L9348 | Club activity, per month, 8 visits at least, child | 504.00 |
| L9349 | Treatment boarding school services, per month | 10,290.00 |
| L9350 | Club activity, per month, 8 visits at least | 405.00 |
| L9351 | Occupational club activity, per day | 63.00 |
| L9352 | Sheltered factory, per day | 95.00 |
| L9353 | Occupational rehabilitation, extended, per day | 116.00 |
| L9354 | Sheltered housing, extended, per day | 128.00 |
| L9355 | School, per month, child/adolescent | 1,584.00 |
| L9359 | Medical evaluation based on documents | 176.00 |
| L9360 | Risk assessment of sex offenders | 5,069.00 |
| L9377 | Physician services in parent home | 377.00 |
| L9379 | Physician services in hostel | 201.00 |
| L9394 | Physician services in boarding school | 126.00 |
| L9413 | Medical records printout | 63.00 |
| L9420 | Calibration of instruments for measuring radiation | 1,022.00 |
| L9480 | Results reporting, free of charge | 0.00 |
| L9490 | Follow up service, free of charge | 0.00 |
| L9499 | Social worker services | 227.00 |
| L9500 | Medical examination, first visit — child development | 953.00 |
| L9501 | Medical examination, follow up — child development | 569.00 |
| L9502 | Psychological cognitive testing — child development | 1,175.00 |
| L9503 | Family workup and diagnosis — child development | 569.00 |
| L9504 | Psychoneurology assessment — child development | 1,610.00 |
| L9505 | Cognitive evaluation for rehabilitation — child development | 1,461.00 |
| L9506 | Learning disabilities evaluation — child development | 1,982.00 |
| L9507 | Multidisciplinary team for rehabilitation — child development | 1,998.00 |
| L9510 | Speech therapy, evaluation and treatment planning — child development | 579.00 |
| L9511 | Aquatic physiotherapy/rehabilitation, group, up to 4 individuals, inculding child, hydrotherapy | 225.00 |
| L9512 | Speech therapy, individual — child development | 297.00 |
| L9513 | Occupational therapy, individual — child development | 297.00 |
| L9514 | Physiotherapy, individual — child development | 323.00 |
| L9516 | Psycho/behavioral therapy — child development | 360.00 |
| L9517 | Developmental examination — nurse — child development | 258.00 |
| L9518 | Therapy/counseling, family/conjoint — child development | 791.00 |
| L9519 | Biofeedback training — child development | 638.00 |
| L9520 | Evaluation of supportive communication — child development | 2,108.00 |
| L9521 | Staff meeting with parents — child development | 710.00 |
| L9523 | Multiprofessional consulation for parents — child development | 221.00 |
| L9525 | Additional consulation — child development | 275.00 |
| L9528 | Physiotherapy, group — child development | 233.00 |
| L9529 | Speech therapy, group — child development | 233.00 |
| L9530 | Occupational therapy, group — child development | 233.00 |
| L9600 | Home visit, health care professional — child development | 417.00 |
| L9617 | Neuropsychological tests before epilepsy surgery | 1,887.00 |
| L9636 | Additional charge for Plerixafor (Mozobil), per ampoule | 32,985.00 |
| L9855 | Induced abortion, surgical, including curettage | 4,106.00 |
| L9856 | Induced abortion, pharmaceutical | 2,960.00 |
| L9857 | Induced abortion, surgical, following pharmaceutical abortion | 0.00 |
| L9899 | Prenatal course | 894.00 |
| L9900 | Provision of therapeutic radiopharmaceutical(s) | 1,229.00 |
| L9999 | Radiopharmaceutical therapy, pheochromocytoma/neuroblastoma; I-131-MIBG | 40,760.00 |
| G0018 | Transjugular intrahepatic portosystemic stent/shunt, TIPS | 32,904.00 |
| G0024 | Obstetric and neonatal hospitalization | 5,708.00 |
| G0026 | Preterm infant hospitalization | 5,708.00 |
| G0028 | Cryotherapy of prostatic cancer | 34,792.00 |
| G0031 | Insertion of stent to abdominal aortic aneurysm, stent graft | 111,948.00 |
| G0032 | Bone marrow transplantation, haploid, including stem cells separation | 539,870.00 |
| G0033 | Isolated limb perfusion in patient with sarcoma | 106,202.00 |
| G0035 | Interventional neuroradiology for intracranial aneurysm embolization/occlusion by catheterization, including use of stent, eg, SILK, and coils | 93,289.00 |
| G0036 | Insertion of intraocular lens, lens included | 8,223.00 |
| G0037 | Tension free vaging tape for incontinence (TVT) | 8,420.00 |
| G0045 | Mastectomy, bilateral | 25,761.00 |
| G0047 | Breast reconstruction, bilateral | 28,277.00 |
| G0048 | Breast reconstruction following mastectomy, bilateral | 49,508.00 |
| G0049 | Breast reconstruction following mastectomy, unilateral | 30,010.00 |
| G0050 | Breast reconstruction, unilateral, including nipple reconstruction | 24,877.00 |
| G0051 | Mastectomy, unilateral | 17,172.00 |
| G0054 | Lower extremities veins surgery, including varicose veins | 10,827.00 |
| G0055 | Blood vessels surgery, including nonautogenous graft | 60,724.00 |
| G0057 | Lung transplantation | 370,129.00 |
| G0058 | Heart-lung transplant | 518,185.00 |
| G0059 | Bone marrow transplantation; allogenic | 343,655.00 |
| G0060 | Bone marrow transplantation; autologous | 225,779.00 |
| G0061 | Renal and/or pancreas transplantation | 246,754.00 |
| G0062 | Heart transplantation | 370,129.00 |
| G0063 | Liver transplantation | 1,066,571.00 |
| G0064 | Corneal surgery, including cost of cornea | 21,145.00 |
| G0066 | Inguinal/femoral hernia repair, hospital day care | 5,630.00 |
| G0067 | Craniotomy | 68,866.00 |
| G0070 | Prostatectomy, open | 16,360.00 |
| G0074 | Therapeutic catheterization, excluding cardiac catheterization | 36,412.00 |
| G0075 | Hysterectomy | 16,076.00 |
| G0077 | Transurethral prostatectomy | 16,360.00 |
| G0078 | Hospital circumcision, excluding newborn | 3,776.00 |
| G0083 | Osteotomy of spine, including implants, diskectomy | 29,964.00 |
| G0084 | Osteotomy of spine, including implants — other surgeries | 55,026.00 |
| G0089 | Treatment of heavy burns | 209,807.00 |
| G0090 | Treatment of medium burns | 119,885.00 |
| G0096 | Gastric banding, laparoscopic, excluding band cost | 13,145.00 |
| G00A1 | Transcatheter placement of an intravascular stent graft, thoracic aorta | 180,263.00 |
| G00A2 | Hyperbaric chamber treatment of patients injured in diving accidents, up to 8 hours | 35,791.00 |
| G00A3 | Hyperbaric chamber treatment of patients injured in diving accidents, over 8 hours, and/or using a mixture of gases eg, Heliox | 48,547.00 |
| G00A4 | Spermatic veins embolization | 11,328.00 |
| G00A5 | Chemotherapy administration, inpatients, in addition to inpatient day charge | 4,479.00 |
| G00A6 | Open/closed reduction with internal fixation of fracture of neck of femur or internal fixation only of fracture of neck of femur | 27,628.00 |
| G00A8 | Insertion of biventricular cardiac pacemaker | 55,714.00 |
| G00A9 | Insertion of cardiac pacemaker/defibrillator, excluding machine cost | |
| G00B1 | Repair of cleft lip | 19,798.00 |
| G00B2 | Correction of cleft palate (including Push-Back palatoplasty) | 19,798.00 |
| G00B3 | Revision of cleft palate repair, velopharyngoplasty | 19,798.00 |
| G00B4 | Repair of cleft lip & limited rhinoplasty, for cleft palate | 19,798.00 |
| G00B5 | Closure of fistulae of mouth, for cleft palate | 13,417.00 |
| G00B6 | Bone graft to facial bone, for cleft palate | 23,516.00 |
| G00B7 | Jaw distraction osteogenesis, excluding device cost | 19,798.00 |
| G00B8 | Orthognatic surgery, excluding jaw distraction osteogenesis | 39,219.00 |
| G00C1 | Fallopian tube catheterization, diagnostic or therapeutic | 6,084.00 |
| G00C2 | Radiofrequency ablation of liver lesion(s) (tumor or metastases) | 15,133.00 |
| G00C3 | Esophageal dilation and insertion of stent | 25,788.00 |
| G00C5 | Local excision of lesion or tissue of bone (i.e. osteoid osteoma), using CT guidance | 9,406.00 |
| G00C6 | Intra-amniotic injection for late abortion | 3,403.00 |
| G00C7 | Arthroplasty with prosthetic replacement or implant of total or partial wrist (distal radius, carpocarpal or carpometacarpal joints) | 12,667.00 |
| G00C8 | Arthroplasty with prosthetic replacement or implant of foot or toe joint | 21,954.00 |
| G00D1 | Implantation or replacement of artificial urinary sphincter | 49,755.00 |
| G00D2 | Insertion of skin tissue expander(s), excluding breast | 21,127.00 |
| G00D3 | Closed (percutaneous) biopsy of brain, stereotactic method including burr holes | 15,906.00 |
| G00D4 | Orthopedic oncologic surgery, excision of soft tissues | 66,311.00 |
| G00D5 | Orthopedic oncologic surgery, revision of an artificial joint or implant | 211,042.00 |
| G00D6 | Orthopedic oncologic surgery, complex amputation or disarticulation | 76,342.00 |
| G00D7 | Orthopedic oncologic surgery, destructive and reconstructive surgery | 188,942.00 |
| G00D8 | Thoracic surgery | 40,951.00 |
| G00E1 | Intra-arterial administration of chemotherapy or chemoembolization, under angiography | 13,048.00 |
| G00E2 | Arthroscopy, diagnostic and/or surgical procedures, without using implants | 11,195.00 |
| G00E3 | Arthroscopy, complex and/or high skill surgical procedures, using implants | 22,388.00 |
| G00E4 | Arthroscopy, complex, unusual surgical procedures, including cartilage transplantation | 29,853.00 |
| G00E5 | Insertion (initial or replacement) of single/dual chamber cardiac pacemaker | 28,024.00 |
| G00E6 | Radical trachelectomy and lymphadenectomy | 17,397.00 |
| G00E7 | Brachytherapy for ocular tumors | 31,097.00 |
| G00E9 | Video and radio-telemetered electroencephalographic monitoring | 47,975.00 |
| G00F1 | Creation of arteriovenous fistula for renal dialysis, native or using graft | 19,593.00 |
| G00F2 | Gastric bypass, laparoscopic | 56,010.00 |
| G00F3 | Thoracic sympathectomy | 9,275.00 |
| G00F4 | Thyroidectomy, complete/partial | 16,793.00 |
| G00F5 | Gastrectomy, total/partial | 57,190.00 |
| G00F6 | Appendectomy, laparoscopic | 18,300.00 |
| G00F7 | Whipple operation (radical pancreatic duodenectomy or radical subtotal pancreatectomy) | 99,509.00 |
| G00F8 | Vertebroplasty | 9,954.00 |
| G00F9 | Wada test | 10,866.00 |
| G00G1 | Catheterization, insertion of umbrella like device for repair of cardial septal defects or patent ductus arteriosus (PDA) | 74,891.00 |
| G00G2 | Kyphoplasty | 47,178.00 |
| G00G3 | Mastectomy, partial (eg, lumpectomy), excludes biopsy of breast | 8,707.00 |
| G00G4 | Brachytherapy, prostate cancer treatment | 63,437.00 |
| G00G5 | Therapeutic catheterization of AV shunt for renal dialysis, native/with graft | 32,943.00 |
| G00G6 | Extracorporeal shockwave lithotripsy, salivary stones | 7,575.00 |
| G00G7 | Deflux injection, vesicoureteral reflux therapy, unilateral | 10,860.00 |
| G00G8 | Deflux injection, vesicoureteral reflux therapy, bilateral | 19,184.00 |
| G00G9 | Extracorporeal shockwave lithotripsy, kidney; simple | 9,879.00 |
| G00H2 | Inpatient, per day, up to 3 days in acute care hospital, excluding departments with specific code | 5,708.00 |
| G00H4 | Inpatient, per day, for fourth day or longer in acute care hospital, excluding departments with specific code | 4,964.00 |
| G00H5 | Inpatient, per day, Dermatology and Venereology Department in acute care hospital | 4,964.00 |
| G00H6 | Inpatient, per day, Ophthalmology and Pediatric Ophthalmology Departments in acute care hospital | 4,964.00 |
| G00H7 | Inpatient, per day, Rehabilitation Department in acute care hospital | 4,964.00 |
| G00J3 | Inpatient day, Acute Geriatric, Pulmonary and Tuberculosis Departments, geriatric hospitals and centers | 3,824.00 |
| G00J4 | Inpatient day, Geriatric Rehabilitation Department, geriatric hospitals and centers | 2,392.00 |
| G00J5 | Inpatient day, Complex Care Nursing Department, geriatric hospitals and centers | 1,442.00 |
| G00J7 | Inpatient day, Departments for the Independent, geriatric hospitals and centers | 528.00 |
| G00J8 | Inpatient day, Departments for the Frail, geriatric hospitals and centers | 842.00 |
| G00M1 | Inpatient day, Department of Internal Medicine in acute care hospital | 4,042.00 |
| G00M2 | Inpatient day, Rheumatology Department in acute care hospital | 4,042.00 |
| G00M3 | Inpatient day, Department of Pulmonary Medicine in acute care hospital | 4,042.00 |
| G00M4 | Inpatient day, Department of Geriatric Internal Medicine in acute care hospital | 4,042.00 |
| G00M5 | Inpatient day, Gastroenterology Department in acute care hospital | 4,042.00 |
| G00M6 | Inpatient day, Observation Department in acute care hospital | 4,042.00 |
| G00N1 | Inpatient day, General Intensive Care Department in acute care hospital | 4,964.00 |
| G00N3 | Inpatient day, Respiratory Intensive Care Department in acute care hospital | 4,964.00 |
| G00N5 | Inpatient day, Pediatric Intensive Care Department in acute care hospital | 4,964.00 |
| G00N7 | Inpatient day, Neurosurgical Intensive Care Department in acute care hospital | 4,964.00 |
| G00N9 | Additional inpatient day charge, up to 4, in Intensive Care Departments: General, Respirtory, Pediatric and Neurosurgical | 9,944.00 |
| G00P1 | Inpatient day, Acute geriatric Department in acute care hospital | 3,006.00 |
| G00P2 | Inpatient day, Geriatric Rehabilitation Department in acute care hospital | 3,006.00 |
| G00P3 | Inpatient day, Department of high Dependency Nursing in acute care hospital | 3,006.00 |
| G00Q1 | Acute inpatient day, psychiatric departments, all hospitals | 2,054.00 |
| G00Q2 | Long term inpatient day, psychiatric departments, all hospitals | 1,580.00 |
| G00Q3 | Inpatient day, children and adolescents, psychiatric departments, all hospitals | 2,470.00 |
| G00Q7 | Artificial liver therapy, eg, MARS, additional inpatient day charge | 39,419.00 |
| G00Q8 | Chronic artificial ventilation care, per day, all hospitals | 3,208.00 |
| G00R1 | Extracorporeal shockwave lithotripsy, kidney; complex | 31,023.00 |
| G00R2 | Closed percutaneous biopsy using CT guidance | 7,463.00 |
| G00R3 | Closed percutaneous biopsy using MRI guidance | 11,195.00 |
| G00R4 | Continuous intra-arterial administration of chemotherapeutic substance | 19,886.00 |
| G00R5 | Vertebral excision and fusion | 176,138.00 |
| G00R6 | Vertebral refusion | 211,042.00 |
| G00R7 | Secondary insertion of intraocular lens prosthesis | 3,489.00 |
| G00R8 | Single suture loop pupilloplasty | 5,582.00 |
| G00R9 | Vitrectomy | 15,121.00 |
| G00S1 | Bronchoscopy, rigid or flexible, with placement of bronchial stent(s) (including tracheal/bronchial dilation as required) | 19,284.00 |
| G00S2 | Partial/primary hip/shoulder replacement | 43,535.00 |
| G00S3 | Total joint replacement, including knee and shoulder replacement and revision surgery | 47,983.00 |
| G00S4 | Radical neck lymph nodes dissection, unilateral/bilateral | 27,526.00 |
| G00S5 | Lobectomy of liver | 81,492.00 |
| G00S6 | Partial hepatectomy | 45,614.00 |
| G00S7 | Maxillectomy/mandibulectomy, partial/total, including immediate insertion of surgical obturator | 39,198.00 |
| G00S8 | Stereotactic radiosurgery, brain | 48,833.00 |
| G00S9 | Implantation of heart assist system | 561,679.00 |
| G00T3 | Isolated limb perfusion in patient with melanoma | 106,202.00 |
| G00T4 | Colonoscopy, with dilation and stent placement | 25,788.00 |
| G00T5 | Removal of heart pacemaker lead(s) (electrodes) without replacement | 34,715.00 |
| G00T6 | Removal of heart pacemaker lead(s) (electrodes) with replacement of electrodes and pacemaker device | 48,730.00 |
| G00T7 | Scoliosis/kyphosis repair operation | 121,793.00 |
| G00T8 | Emergency coronary artery catheterization for removal of obstruction, including insertion of drug eluting stent(s) | 53,860.00 |
| G00T9 | Radical hysterectomy, abdominal/vaginal | 24,877.00 |
| G00U1 | Colorectal surgery | 49,851.00 |
| G00U2 | Surgical fistulization of lacrimal tract to nasal cavity using balloon dilatation, including dacryocystorhinostomy | 7,248.00 |
| G00U3 | Intravenous injection of rtPA, acute cerebrovascular stroke within 4.5 hours of stroke symptoms onset | 43,535.00 |
| G00U4 | Therapeutic catheterization, acute cerebrovascular stroke within 8 hours of stroke symptoms onset | 111,948.00 |
| G00U5 | Functional endoscopic nasal/sinus surgery (FESS), simple | 14,925.00 |
| G00U6 | Functional endoscopic nasal/sinus surgery (FESS), complex | 35,813.00 |
| G00U7 | Tonsillectomy without/with adenoidectomy | 5,212.00 |
| G00U9 | Enucleation of eyeball | 14,965.00 |
| G00V2 | Lengthening and adjustment of vertical expandable prosthetic titanium rib system | 24,227.00 |
| G00V3 | Replacement of vertical expandable prosthetic titanium rib system implants | 54,227.00 |
| G00V4 | Percutaneous pulmonary valve replacement, excluding valve cost | 40,916.00 |
| G00V5 | Percutaneous aortic valve replacement, excluding valve cost | 46,573.00 |
| G00V6 | Repair of inguinal/femoral hernia, unilateral, inpatient | 10,731.00 |
| G00V7 | Repair of inguinal/femoral hernia, bilateral, inpatient | 14,305.00 |
| G00V8 | Plastic surgery following significant weight loss | 34,091.00 |
| G00V9 | Bone graft to maxilla/mandible, autogenic graft from pelvis/scalp | 31,583.00 |
| G00W1 | Scleral buckling, with/without implant | 10,697.00 |
| G00W2 | Trabeculectomy | 5,177.00 |
| G00W3 | Intraocular valve implantation, eg, Ahmed, for glaucoma therapy | 14,162.00 |
| G00W4 | Repair of blepharoptosis, under 18 years, unilateral/bilateral | 8,260.00 |
| G00W5 | Repair of blepharoptosis, 18 years and older, unilateral/bilateral | 5,117.00 |
| G0100 | Additional charge for DRG in multiple trauma, admission from ER | 12,438.00 |
| G0101 | ORIF/CRIF of pelvis, closed/open fracture | 64,902.00 |
| G0102 | Arthroplasty with prosthetic replacement/implant of radial head, excluding open fracture | 37,939.00 |
| G0103 | Arthroplasty with prosthetic replacement/implant of radial head, open fracture | 62,410.00 |
| G0104 | ORIF of foot, closed fracture, excluding calcaneus | 41,018.00 |
| G0105 | ORIF of foot, open fracture, excluding calcaneus | 62,410.00 |
| G0106 | ORIF of calcaneus/operation on femur, excluding neck, closed fracture | 32,953.00 |
| G0107 | ORIF of calcaneus/operation on femur, excluding neck, open fracture | 51,612.00 |
| G0108 | Operation on clavicle/humerus/forearm, closed fracture, including closed dislocation of acromioclavicular joint, excluding distal humerus and shaft of radius/ulna, including bone graft | 28,225.00 |
| G0109 | Operation on clavicle/humerus/forearm, open fracture, including open dislocation of acromioclavicular joint, excluding distal humerus and shaft of radius/ulna | 42,032.00 |
| G0110 | ORIF/CRIF/EF of tibia and/or fibula, closed fracture | 38,058.00 |
| G0111 | ORIF/CRIF/EF of tibia and/or fibula, open fracture, including use of bone marrow aspiration concentrate | 65,516.00 |
| G0112 | ORIF of patella/ankle / CRIF of calcaneus, closed fracture | 23,114.00 |
| G0113 | ORIF of patella/ankle / CRIF of calcaneus, open fracture | 38,300.00 |
| G0114 | CRIF of ankle/foot, closed fracture, excluding calcaneus | 12,970.00 |
| G0115 | CRIF of ankle/foot, open fracture, excluding calcaneus | 24,409.00 |
| G0116 | Exploration of tendon/nerve of upper limb, including ganglion decompression/lysis of adhesions | 8,115.00 |
| G0117 | Suture of extensor tendons of hand, including delayed suture | 13,698.00 |
| G0118 | Suture of tendons/nerves of upper limb, including delayed suture, excluding extensor tendons of hand | 23,448.00 |
| G0120 | ORIF/EF of phalange of hand, closed fracture, including bone graft | 13,986.00 |
| G0121 | ORIF/EF of phalange of hand, open/complex fracture | 20,719.00 |
| G0122 | ORIF/EF of phalange of hand, with suture of tendons/nerves, closed/open fracture | 31,285.00 |
| G0123 | ORIF/EF of phalanges of hand, closed fractures, including bone graft | 20,348.00 |
| G0124 | ORIF/EF of phalanges of hand, open/complex fractures | 27,593.00 |
| G0125 | ORIF/EF of phalanges of hand, with suture of tendons/nerves, closed/open fractures | 38,161.00 |
| G0126 | ORIF/EF of metacarpal, closed fracture, including bone graft | 15,408.00 |
| G0127 | ORIF/EF of metacarpal, open/complex fracture | 22,254.00 |
| G0128 | ORIF/EF of metacarpal, with suture of tendons/nerves, closed/open fracture | 32,820.00 |
| G0129 | ORIF/EF of metacarpals, closed fractures, including bone graft | 23,955.00 |
| G0130 | ORIF/EF of metacarpals, open/complex fractures | 31,494.00 |
| G0131 | ORIF/EF of metacarpals, with suture of tendons/nerves, closed/open fractures | 42,062.00 |
| G0132 | ORIF of carpal(s), closed fracture, including bone graft | 20,388.00 |
| G0133 | ORIF of carpal(s), open/complex fracture, including bone graft | 27,637.00 |
| G0134 | ORIF of carpal(s), with suture of tendons/nerves, closed/open fracture, including bone graft | 38,205.00 |
| G0135 | CRIF of hand, with suture of tendons/nerves, closed/open fracture(s) | 34,974.00 |
| G0136 | Open reduction of closed dislocation of wrist | 23,955.00 |
| G0137 | Open reduction of open/complex dislocation of wrist | 31,494.00 |
| G0138 | Open reduction of dislocation of wrist, with suture of tendons/nerves | 42,062.00 |
| G0139 | Reattachment of any part of upper extremity | 71,538.00 |
| G0140 | Open/close reduction of fracture(s) of zygoma/maxilla/mandible, including internal fixation | 24,456.00 |
| G0141 | Open reduction of fractures of orbit/ Le Fort type 2 or 3 / TMJ fracture with dislocation, with insertion of synthetic implant/bone graft to facial bone | 37,978.00 |
| G0142 | Open reduction of comminuted fractures of facial bones, with insertion of synthetic implant/bone graft | 108,319.00 |
| G0144 | ORIF of distal humerus, closed fracture, including bone graft | 37,939.00 |
| G0145 | ORIF of distal humerus, open fracture | 62,410.00 |
| G0146 | ORIF/EF of shaft of radius/ulna, closed fracture, including bone graft | 21,378.00 |
| G0147 | ORIF/EF of shaft of radius/ulna, open fracture | 38,300.00 |
| G0148 | CRIF of distal humerus/forearm/hand, closed fracture, including bone graft | 11,998.00 |
| G0149 | CRIF of distal humerus/forearm/hand, open fracture, including complex fracture(s) of hand | 24,409.00 |
| G0150 | Removal of gastric band | 13,145.00 |
| G0151 | Sleeve gastrectomy | 45,398.00 |
| G0152 | Sleeve gastrectomy with removal of gastric band | 46,581.00 |
| G0153 | Sleeve gastrectomy with repair of diaphragmatic hernia | 46,581.00 |
| G0154 | Sleeve gastrectomy with total cholecystectomy | 48,027.00 |
| G0155 | Gastric bypass surgery with removal of gastric band | 57,196.00 |
| G0156 | Gastric bypass surgery with repair of diaphragmatic hernia | 57,196.00 |
| G0157 | Gastric bypass surgery with total cholecystectomy | 58,542.00 |
| G0158 | Ovarian tissue retrieval, laparoscopic | 7,077.00 |
| G0160 | Implantation/replacement/removal of cochlear prosthetic device, excluding device cost | 15,881.00 |
| G0161 | Repair of cystocele with graft/prosthesis | 11,543.00 |
| G0162 | Repair of rectocele with graft/prosthesis | 11,543.00 |
| G0163 | Repair of cystocele and rectocele with graft/prosthesis | 18,788.00 |
| G0164 | Repair of cystocele with graft/prosthesis and tension free vaging tape for incontinence | 17,113.00 |
| G0165 | Repair of rectocele with graft/prosthesis and tension free vaging tape for incontinence | 17,113.00 |
| G0166 | Repair of cystocele and rectocele with graft/prosthesis and tension free vaging tape for incontinence | 24,361.00 |
| G0167 | Percutaneous insertion of left atrial appendage device, excluding device cost | 13,130.00 |
| G0168 | Implantation of diaphragmatic pacemaker, excluding device cost | 16,961.00 |
| G0169 | Pump for spasticity treatment preimplantation assessment, Baclofen | 14,120.00 |
| G0170 | Implantation of pump for chronic pain relief/spasticity treatment, with drug loading, eg, Baclofen/Morphine, excluding pump cost | 14,588.00 |
| G0171 | Heart surgery, valves | 74,891.00 |
| G0172 | Heart surgery, bypass | 74,891.00 |
| G0173 | Heart surgery, valves and bypass | 74,891.00 |
| G0174 | Heart surgery, excluding valves and bypass surgery | 74,891.00 |
| G0175 | Cholecystectomy, open, partial/complete | 17,222.00 |
| G0176 | Cholecystectomy, laparoscopic, partial/complete | 17,222.00 |
| G0177 | Implantation of vertical expandable prosthetic titanium rib system, excluding system cost | 26,157.00 |
| G0178 | Implantation of BAHA (Bone Anchored Hearing Aid), excluding device cost | 10,237.00 |
| G0179 | Diagnostic catheterization, excluding cardiac catheterization | 14,486.00 |
| G0180 | Implantation of VNS (Vagus Nerve Stimulator) kit for epilepsy treatment, excluding device cost | 16,465.00 |
| G0181 | Diagnostic cardiac catheterization | 14,486.00 |
| G0182 | Implantation of intracranial neurostimulator pulse generator kit, including leads, or replacement of leads, for movement disorders, excluding devices cost | 32,930.00 |
| G0184 | Therapeutic cardiac catheterization, excision/destruction of lesion/tissue of heart | 40,710.00 |
| G0185 | Therapeutic cardiac catheterization, coronary arteries | 40,710.00 |
| G0186 | Percutaneous balloon valvuloplasty | 40,710.00 |
| G0187 | Replacement of neurostimulator pulse generator for intracranial stimulation, without leads, for movement disorders, excluding device cost | 16,465.00 |
| G0188 | Parathyroidectomy, partial | 19,150.00 |
| G0189 | Parathyroidectomy, complete | 19,150.00 |
| G0190 | Type 2/3 tympanoplasty, including replacement of auditory ossicles | 12,643.00 |
| G0191 | Simple mastoidectomy | 22,664.00 |
| G0192 | Radical mastoidectomy, including modified radical mastoidectomy | 28,454.00 |
| G0193 | Myringoplasty, including perforation closure | 14,044.00 |
| G0194 | Excision of salivary glands, excluding parotid, partial/complete | 15,441.00 |
| G0195 | Excision/destruction of vocal cord(s) lesion/tissue | 12,513.00 |
| G0196 | Excision of vocal cord(s) | 21,572.00 |
| G0197 | Maxillectomy/mandibulectomy with microsurgical reconstruction | 69,908.00 |
| G01H4 | Inpatient, per day, for fourth day or longer in acute care hospital, excluding departments with specific code — out of cap | 4,964.00 |
| G01H5 | Inpatient, per day, Dermatology and Venereology Department in acute care hospital — out of cap | 4,964.00 |
| G01H6 | Inpatient, per day, Ophthalmology and Pediatric Ophthalmology Departments in acute care hospital — out of cap | 4,964.00 |
| G01H7 | Inpatient, per day, Rehabilitation Department in acute care hospital — out of cap | 4,964.00 |
| G01M1 | Inpatient day, Department of Internal Medicine in acute care hospital — out of cap | 4,042.00 |
| G01M2 | Inpatient day, Rheumatology Department in acute care hospital — out of cap | 4,042.00 |
| G01M3 | Inpatient day, Department of Pulmonary Medicine in acute care hospital — out of cap | 4,042.00 |
| G01M4 | Inpatient day, Department of Geriatric Internal Medicine in acute care hospital — out of cap | 4,042.00 |
| G01M5 | Inpatient day, Gastroenterology Department in acute care hospital — out of cap | 4,042.00 |
| G01M6 | Inpatient day, Observation Department in acute care hospital — out of cap | 4,042.00 |
| G01N1 | Inpatient day, General Intensive Care Department in acute care hospital — out of cap | 4,964.00 |
| G01N3 | Inpatient day, Respiratory Intensive Care Department in acute care hospital — out of cap | 4,964.00 |
| G01N5 | Inpatient day, Pediatric Intensive Care Department in acute care hospital — out of cap | 4,964.00 |
| G01N7 | Inpatient day, Neurosurgical Intensive Care Department in acute care hospital — out of cap | 4,964.00 |
| G01P1 | Inpatient day, Acute geriatric Department in acute care hospital — out of cap | 3,006.00 |
| G01P2 | Inpatient day, Geriatric Rehabilitation Department in acute care hospital — out of cap | 3,006.00 |
| G01P3 | Inpatient day, Department of high Dependency Nursing in acute care hospital — out of cap | 3,006.00 |
| G01Q8 | Chronic artificial ventilation care, per day, all hospitals — out of cap | 3,208.00 |
| G0200 | POVH (Postoperative Ventral Hernia) repair, open | 28,268.00 |
| G0201 | POVH (Postoperative Ventral Hernia) repair, laparoscopic | 28,268.00 |
| G0202 | Anterior abdominal wall hernia repair, excluding POVH, open | 20,126.00 |
| G0203 | Anterior abdominal wall hernia repair, excluding POVH, laparoscopic | 20,126.00 |
| G0204 | Diaphragmatic hernia repair, laparoscopic | 26,252.00 |
| G0206 | Umbilical hernia repair, age 5 years or older, open | 12,887.00 |
| G0207 | Umbilical hernia repair, age 5 years or older, laparoscopic | 12,887.00 |
| G0208 | Esophagogastric sphincteric competence creation | 29,029.00 |
| G0210 | Percutaneous nephrostomy, including fragmentation | 37,178.00 |
| G0214 | Partial nephrectomy, open | 34,892.00 |
| G0215 | Partial nephrectomy, laparoscopic | 34,892.00 |
| G0216 | Complete nephrectomy, including ureterectomy, open | 36,943.00 |
| G0217 | Complete nephrectomy, including ureterectomy, laparoscopic | 36,943.00 |
| G0220 | Ureteroscopy, diagnostic, with/without biopsy | 11,835.00 |
| G0221 | Ureteroscopy, therapeutic, including RIRS | 18,172.00 |
| G0225 | Endoscopic excision of rectal tumor, transanal approach | 7,855.00 |
| G0229 | Excision of hemorrhoids | 5,108.00 |
| G0230 | Salpingectomy, laparoscopic, unilateral/bilateral | 13,995.00 |
| G0231 | Salpingo-oophorectomy, laparoscopic, unilateral/bilateral | 13,995.00 |
| G0240 | Reduction mammoplasty, female, excluding surgery following significant weight loss | 16,748.00 |
| G0241 | Reduction mammoplasty, male, excluding surgery following significant weight loss | 13,103.00 |
| G0250 | Corneal surgery with insertion of intraocular lens, including cost of cornea and lens | 24,161.00 |
| G0251 | Insertion of intraocular lens with trabeculectomy, including cost of lens | 7,082.00 |
| G0252 | Vitrectomy with insertion of intraocular lens, including cost of lens | 18,360.00 |
| G0253 | Vitrectomy with scleral buckling, with/without implant | 18,739.00 |
| G0254 | Single suture loop pupilloplasty with insertion of intraocular lens, including cost of lens | 9,173.00 |
| G0255 | Single suture loop pupilloplasty with secondary insertion of intraocular lens, including cost of lens | 8,267.00 |
| G0256 | Repair of corneal injury | 10,957.00 |
| G0257 | Repair of retinal detachment by injection of gas | 7,843.00 |
| G0258 | Foreign body removal from posterior segment of eye, with/ without use of magnet | 17,939.00 |
| G0259 | Diagnostic aspiration of vitreous | 13,265.00 |
| G0260 | Excision of lesion of orbit | 16,804.00 |
| G0270 | Radical prostatectomy, open | 29,473.00 |
| G0277 | Radical prostatectomy, laparoscopic | 29,473.00 |
| G0280 | SIRT (Selective Internal Radiation Therapy) for liver tumor, 90Y, excluding material cost | 45,690.00 |
| G0290 | Splenectomy, open, partial/complete | 27,575.00 |
| G0291 | Splenectomy, laparoscopic, partial/complete | 27,575.00 |
| G0292 | Partial pancreatectomy, open | 33,523.00 |
| G0293 | Partial pancreatectomy, laparoscopic | 33,523.00 |
| G0300 | Percutaneous mitral valve repair with implanted device, excluding device cost | 21,001.00 |
