Daman Published Rates

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Daman Published Rates as applicable for covered Health

Services in Non-Network Providers

Daman Published Rates

Non-Network Services Price List

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National Health Insurance Company – Daman (P.O. Box 128888, Abu Dhabi, U.A.E. Tel No. +97126149555 Fax No. +97126149550) Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 2 of 380

Daman Published Rates (Price List) is an integral part and shall be read and interpreted along with the Letter of Acceptance and the Schedule of Benefits detailing the prices as applicable for covered Health Services availed in Non-Network Providers. Content of this document shall be read and interpreted in conjunction with the applicable Policy terms and conditions.

How to read the Price List?

Following are the listed fields used across the Price List, alongwith their description for your easy reference:

Field Description

Type Code type:

SERVICE = Service Codes (used for Consultations, Room and Boarding)

CPT = Current Procedural Terminology (used for Inpatient and Outpatient Procedures)

HCPCS = Healthcare Common Procedure Coding System

Code Unique Alpha-numeric or Numeric code

Code Description Short description of the code

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 Pharmaceuticals: These benefits will be payable on Actuals, as per the Policy terms and

conditions

 All benefits and services with an undefined price list will be examined on case to case basis, according to Policy terms and conditions.

 Whereever insurance/Deductible applies to Non-Network Benefits; the amount of

Co-insurance/Deductible will be deducted from the amount reimbursable to the Eligible Person.

 For covered health services in Non-Network Providers, Daman will pay the lower of Claimed Amount or Benefit Payable under the terms of the Policy.

This has been illustrated below, for a case where 50% co-insurance applies for all covered services in Non-Network Provider:

Original Amount

After applying co-insurance

Maximum Benefit Payable Daman Published Rates: for

tonsillectomy services AED 1000 AED 500 AED 500

Scenario 1:

Claimed Amount AED 1428 AED 714 AED 500

Scenario 2 :

Claimed Amount AED 285 AED 142 AED 142

 Prices contained herein are subject to change by Daman. Any change to the Price List will be issued as an amendment and/or endorsement and will be communicated to the Policyholder. The Policyholder shall ensure that such amendments are communicated to the Daman members under the Policyholder’s Policy. No agent has the authority to change the Policy or waive any of its provisions.

How to obtain non-network benefits?

In case of Health Services that have been availed at Non-Network Provider, you will have to pay for the services provided. However, if such services are covered in your plan, you can apply for reimbursement.

All reimbursement claims, for Health Services availed at any Non-Network Provider within and/or outside the UAE, should be reported to Daman within 120 days from the date of service taken, and should be submitted with the following required documents:

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inpatient services only)

• Original drug prescription with a detailed pharmacy bill (itemized)

• Diagnostic (lab/radiology) investigation reports and invoices (if any), report of the results only if single investigation cost is more than AED 1,000

• Copy of Daman card

Reimbursement claims submission can be applied online through Daman’s web portal (www.damanhealth.ae) or through Daman’s interfaces, either in branches or service points. Reimbursement forms are available on Daman’s website.

Reimbursement of claims shall be subject to submission of all required documents, and will be settled as per Daman Published Rates and Policy terms and conditions within 15 working days from the date of receipt of the claim, and a cheque will be issued in the Policyholder’s/Principal’s name along with a detailed settlement report.

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TYPE CODE CODE DESCRIPTION PRICE (AED)

SERVICE 17-01 ROOM AND BOARD: SUITE 1,200

SERVICE 17-02 ROOM AND BOARD: VIP ROOM 1,000

SERVICE 17-03 ROOM AND BOARD: FIRST CLASS ROOM 750

SERVICE 17-04 ROOM AND BOARD: SHARED ROOM 550

SERVICE 17-05 ROOM AND BOARD: WARD 450

SERVICE 17-06 ROOM AND BOARD: ROYAL SUITE 2,000 SERVICE 17-10 ROOM AND BOARD: ISOLATION ROOM 700 SERVICE 29 SPECIAL CARE UNIT (SCU) OR ADULT SPECIAL-CARE UNIT (ASCU) 800

SERVICE 30 SPECIAL CARE BABY UNIT (SCBU) 900

SERVICE 32 NURSERY - GENERAL CLASSIFICATION 150

SERVICE 27 INTENSIVE CARE UNIT (ICU) 1,200

SERVICE 27-01 CORONARY CARE UNIT (CCU) 1,200

SERVICE 28 NEONATAL INTENSIVE CARE UNIT (NICU) 2,500 SERVICE 31 PAEDIATRIC INTENSIVE CARE UNIT (PICU) 1,500

SERVICE 17-21 EMERGENCY ROOM - HOURLY RATE 35

SERVICE 17-22 OBSERVATION OR TREATMENT ROOM - HOURLY RATE 50

SERVICE 17-23 RECOVERY ROOM - HOURLY RATE 150

SERVICE 17-24 OBSERVATION OR TREATMENT ROOM - DAILY RATE 200 SERVICE 17-25 DAY STAY (DAY CARE) ROOM - DAILY RATE 300 SERVICE 1 PERDIEM - WARD OR SHARED ROOM - DAILY RATE (DAY 1 TO 3) 1,300 SERVICE 2 PERDIEM - WARD OR SHARED ROOM - DAILY RATE (DAY 4 TO 8) 1,000 SERVICE 3 PERDIEM - WARD OR SHARED ROOM - DAILY RATE (DAY 8 AND

MORE) 800

SERVICE 3-01 PERDIEM - ROOM RATE DIFFERENCE - DAILY RATE (DAY 1 AND MORE ) - SUITE

700 SERVICE 3-02 PERDIEM - ROOM RATE DIFFERENCE - DAILY RATE (DAY 1 AND

MORE ) - VIP ROOM

500 SERVICE 3-03 PERDIEM - ROOM RATE DIFFERENCE - DAILY RATE (DAY 1 AND

MORE ) - FIRST CLASS ROOM 250

SERVICE 3-06 PERDIEM - ROOM RATE DIFFERENCE - DAILY RATE (DAY 1 AND

MORE ) - ROYAL SUITE 1,500

SERVICE 3-10 PERDIEM - ROOM RATE DIFFERENCE - DAILY RATE (DAY 1 AND

MORE ) - ISOLATION ROOM 200

SERVICE 4 PERDIEM - ICU/CCU - DAILY RATE (DAY 1 TO 7) 2,100 SERVICE 5 PERDIEM - NICU - DAILY RATE (DAY 1 TO 7) 4,000 SERVICE 6 PERDIEM - NICU - DAILY RATE (DAY 8 TO 14) 3,600 SERVICE 7 PERDIEM - NICU - DAILY RATE (DAY 15 TO 21) 3,200 SERVICE 8 PERDIEM - NICU - DAILY RATE (DAY 22 AND MORE) 2,800 SERVICE 17-07 PERDIEM - PICU - DAILY RATE (DAY 1 TO 7) 2,500 SERVICE

17-07-01 PERDIEM - PICU - DAILY RATE (DAY 8 TO 14) 2,250 SERVICE

17-07-02

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07-03

SERVICE 4-01 PERDIEM - ICU/CCU - DAILY RATE (DAY 8 TO 14) 1,900 SERVICE 4-02 PERDIEM - ICU/CCU - DAILY RATE (DAY 15 TO 21) 1,700 SERVICE 4-03 PERDIEM - ICU/CCU - DAILY RATE (DAY 22 AND MORE) 1,500 SERVICE 17-12 PERDIEM - NEW-BORN NURSERY - DAILY RATE (DAY 1 TO 3) 550 SERVICE 17-12

-02 PERDIEM - NEW-BORN NURSERY - DAILY RATE (DAY 9 AND MORE) 450 SERVICE

17-12-01 PERDIEM - NEW-BORN NURSERY - DAILY RATE (DAY 4 TO 8) 500 SERVICE 19 PERDIEM - SCBU - DAILY RATE (DAY 1 TO 3) 1,375 SERVICE 18 PERDIEM - SCU - DAILY RATE (DAY 1 TO 3) 1,400 SERVICE 18-01 PERDIEM - SCU - DAILY RATE (DAY 4 TO 8) 1,250 SERVICE 18-02 PERDIEM - SCU - DAILY RATE (DAY 9 AND MORE) 1,100 SERVICE 19-01 PERDIEM - SCBU - DAILY RATE (DAY 4 TO 8) 990 SERVICE 19-02 PERDIEM - SCBU - DAILY RATE (DAY 9 AND MORE) 1,200 SERVICE 17-13 PERDIEM - LONG TERM STAY - DAILY RATE - SIMPLE CASES 750 SERVICE 17-14 PERDIEM - LONG TERM STAY - DAILY RATE - INTERMEDIATE CASES 1,000 SERVICE 17-15 PERDIEM - LONG TERM STAY - DAILY RATE - INTENSIVE CASES 1,250 SERVICE 17-16 PERDIEM - LONG TERM STAY - DAILY RATE - SEVERE CASES 3,300 SERVICE 15 PERDIEM - TREATMENT OR OBSERVATION ROOM - NOT INCLUSIVE

OF LABORATORY AND RADIOLOGY 275

SERVICE 16 PERDIEM - DAY STAY (DAY CARE) ROOM - NOT INCLUSIVE OF

LABORATORY AND RADIOLOGY 550

SERVICE 24 PERDIEM - TREATMENT OR OBSERVATION ROOM - INCLUSIVE. 375 SERVICE 25 PERDIEM - DAY STAY (DAY CARE) - INCLUSIVE. 750 SERVICE 14-01 PERDIEM - HAEMODIALYSIS (HD) 1,500

SERVICE 9 CONSULTATION - GP 100

SERVICE 9.1 CONSULTATION - GP - FOLLOW UP WITHIN ONE WEEK 0

SERVICE 10 CONSULTATION - SPECIALIST 100

SERVICE 10.1 CONSULTATION - SPECIALIST - FOLLOW UP WITHIN ONE WEEK 0

SERVICE 11 CONSULTATION - CONSULTANT 100

SERVICE 11.1 CONSULTATION - CONSULTANT - FOLLOW UP WITHIN ONE WEEK 0 SERVICE 20 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2,050 SERVICE 20-01 OPERATING ROOM SERVICES - MINOR SURGERY 500 SERVICE 20-02 OPERATING ROOM SERVICES - FIRST HOUR 1,600 SERVICE 20-03 OPERATING ROOM SERVICES - EVERY ADDITIONAL 1/2 HR. 450

SERVICE 20-04 CATHETERIZATION LAB 1,600

SERVICE 20-05 DELIVERY ROOM 1,300

SERVICE 17-11 PERDIEM - NON- MEDICAL ESCORT ACCOMMODATION - DAILY RATE 100

SERVICE 26 PERDIEM COMPANION ACCOMMODATION 100

SERVICE 50-01 COMPREHENSIVE SCREENING EVALUATION AND MANAGEMENT BY CLINICIAN OF AN INDIVIDUAL, INCLUDING AN AGE AND GENDER APPROPRIATE HISTORY, QUESTIONNAIRE FILLING, EXAMINATION, AND ORDERING OF LABORATORY/DIAGNOSTIC PROCEDURES, NEW OR ESTABLISHED PATIENT; 30-40 MINUTES.

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AN INDIVIDUAL, INCLUDING VITAL SIGNS, AN AGE AND GENDER APPROPRIATE HISTORY, COORDINATION FOR ORDERING OF LABORATORY/DIAGNOSTIC PROCEDURES AND QUESTIONNAIRE FILLING, NEW OR ESTABLISHED PATIENT; 30-40 MINUTES.

SERVICE 99 OUTLIER PAYMENT USED

FOR OUTLIER BILLING ONLY

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Price List for Current Procedural Terminology

TYPE CODE CODE DESCRIPTION PRICE (AED)

CPT 0073T COMPENSATOR-BASED BEAM MODULATION TREATMENT DELIVERY OF INVERSE PLANNED TREATMENT USING THREE OR MORE HIGH

RESOLUTION (MILLED OR CAST) COMPENSATOR CONVERGENT BEAM MODULATED FIELDS, PER TREATMENT SESSION

1,674

CPT 10021 FINE NEEDLE ASPIRATION; WITHOUT IMAGING GUIDANCE 446 CPT 10022 FINE NEEDLE ASPIRATION; WITH IMAGING GUIDANCE 440 CPT 10040 ACNE SURGERY (E.G., MARSUPIALIZATION, OPENING OR REMOVAL OF

MULTIPLE MILIA, COMEDONES, CYSTS, PUSTULES)

323 CPT 10060 INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE

HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE

354 CPT 10061 INCISION AND DRAINAGE OF ABSCESS (E.G., CARBUNCLE, SUPPURATIVE

HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE

597 CPT 10080 INCISION AND DRAINAGE OF PILONIDAL CYST; SIMPLE 500 CPT 10081 INCISION AND DRAINAGE OF PILONIDAL CYST; COMPLICATED 780 CPT 10120 INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES;

SIMPLE

415 CPT 10121 INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES;

COMPLICATED 824

CPT 10140 INCISION AND DRAINAGE OF HEMATOMA, SEROMA OR FLUID COLLECTION 503 CPT 10160 PUNCTURE ASPIRATION OF ABSCESS, HEMATOMA, BULLA, OR CYST 404 CPT 10180 INCISION AND DRAINAGE, COMPLEX, POSTOPERATIVE WOUND INFECTION 738 CPT 11000 DEBRIDEMENT OF EXTENSIVE ECZEMATOUS OR INFECTED SKIN; UP TO

10% OF BODY SURFACE

174 CPT 11001 DEBRIDEMENT OF EXTENSIVE ECZEMATOUS OR INFECTED SKIN; EACH

ADDITIONAL 10% OF THE BODY SURFACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

71 CPT 11004 DEBRIDEMENT OF SKIN, SUBCUTANEOUS TISSUE, MUSCLE AND FASCIA

FOR NECROTIZING SOFT TISSUE INFECTION; EXTERNAL GENITALIA AND PERINEUM

1,847 CPT 11005 DEBRIDEMENT OF SKIN, SUBCUTANEOUS TISSUE, MUSCLE AND FASCIA

FOR NECROTIZING SOFT TISSUE INFECTION; ABDOMINAL WALL, WITH OR WITHOUT FASCIAL CLOSURE

2,389 CPT 11006 DEBRIDEMENT OF SKIN, SUBCUTANEOUS TISSUE, MUSCLE AND FASCIA

FOR NECROTIZING SOFT TISSUE INFECTION; EXTERNAL GENITALIA, PERINEUM AND ABDOMINAL WALL, WITH OR WITHOUT FASCIAL CLOSURE

2,308 CPT 11008 REMOVAL OF PROSTHETIC MATERIAL OR MESH, ABDOMINAL WALL FOR

INFECTION (E.G., FOR CHRONIC OR RECURRENT MESH INFECTION OR NECROTIZING SOFT TISSUE INFECTION) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

868

CPT 11010 DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL ASSOCIATED WITH OPEN FRACTURE(S) AND/OR DISLOCATION(S); SKIN AND

SUBCUTANEOUS TISSUES

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(AED)

CPT 11011 DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL ASSOCIATED WITH OPEN FRACTURE(S) AND/OR DISLOCATION(S); SKIN,

SUBCUTANEOUS TISSUE, MUSCLE FASCIA, AND MUSCLE

1,601 CPT 11012 DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL ASSOCIATED

WITH OPEN FRACTURE(S) AND/OR DISLOCATION(S); SKIN, SUBCUTANEOUS TISSUE, MUSCLE FASCIA, MUSCLE, AND BONE

2,144 CPT 11040 DEBRIDEMENT; SKIN, PARTIAL THICKNESS 156 CPT 11041 DEBRIDEMENT; SKIN, FULL THICKNESS 178 CPT 11042 DEBRIDEMENT; SKIN, AND SUBCUTANEOUS TISSUE 236 CPT 11043 DEBRIDEMENT; SKIN, SUBCUTANEOUS TISSUE, AND MUSCLE 864 CPT 11044 DEBRIDEMENT; SKIN, SUBCUTANEOUS TISSUE, MUSCLE, AND BONE 1,180 CPT 11055 PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (E.G., CORN

OR CALLUS); SINGLE LESION

162 CPT 11056 PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (E.G., CORN

OR CALLUS); 2 TO 4 LESIONS 196

CPT 11057 PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (E.G., CORN

OR CALLUS); MORE THAN 4 LESIONS 236

CPT 11100 BIOPSY OF SKIN, SUBCUTANEOUS TISSUE AND/OR MUCOUS MEMBRANE (INCLUDING SIMPLE CLOSURE), UNLESS OTHERWISE LISTED; SINGLE LESION

342 CPT 11101 BIOPSY OF SKIN, SUBCUTANEOUS TISSUE AND/OR MUCOUS MEMBRANE

(INCLUDING SIMPLE CLOSURE), UNLESS OTHERWISE LISTED; EACH SEPARATE/ADDITIONAL LESION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

105

CPT 11200 REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS

259 CPT 11201 REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA;

EACH ADDITIONAL 10 LESIONS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

59 CPT 11300 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK,

ARMS OR LEGS; LESION DIAMETER 0.5 CM OR LESS 217 CPT 11301 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK,

ARMS OR LEGS; LESION DIAMETER 0.6 TO 1.0 CM

ARMS OR LEGS; LESION DIAMETER 1.1 TO 2.0 CM

ARMS OR LEGS; LESION DIAMETER OVER 2.0 CM 420 CPT 11305 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP,

NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.5 CM OR LESS 227 CPT 11306 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP,

NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.6 TO 1.0 CM 313 CPT 11307 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP,

NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 1.1 TO 2.0 CM

366 CPT 11308 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP,

NECK, HANDS, FEET, GENITALIA; LESION DIAMETER OVER 2.0 CM

409 CPT 11310 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE,

EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 0.5 CM OR LESS

EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 0.6 TO 1.0 CM

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(AED)

CPT 11312 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 1.1 TO 2.0 CM

EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER OVER 2.0 CM

492 CPT 11400 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG

(UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.5 CM OR LESS

(UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM

(UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER OVER 4.0 CM

(UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS

(UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM

(UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 CM

1,015 CPT 11440 EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN

TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.5 CM OR LESS

390 CPT 11441 EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN

TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.6 TO 1.0 CM

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(AED)

CPT 11446 EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER OVER 4.0 CM

1,168 CPT 11450 EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS,

AXILLARY; WITH SIMPLE OR INTERMEDIATE REPAIR 1,083 CPT 11451 EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS,

AXILLARY; WITH COMPLEX REPAIR 1,417

CPT 11462 EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS,

INGUINAL; WITH SIMPLE OR INTERMEDIATE REPAIR 1,078 CPT 11463 EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS,

INGUINAL; WITH COMPLEX REPAIR

PERIANAL, PERINEAL, OR UMBILICAL; WITH SIMPLE OR INTERMEDIATE REPAIR

PERIANAL, PERINEAL, OR UMBILICAL; WITH COMPLEX REPAIR

1,497 CPT 11600 EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR

LEGS; EXCISED DIAMETER 0.5 CM OR LESS

556 CPT 11601 EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR

LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM 702 CPT 11602 EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR

LEGS; EXCISED DIAMETER OVER 4.0 CM

1,363 CPT 11620 EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK,

HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS

570 CPT 11621 EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK,

HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM 712 CPT 11622 EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK,

HANDS, FEET, GENITALIA; EXCISED DIAMETER 3.1 TO 4.0 CM

1,040 CPT 11626 EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK,

HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 CM

1,254 CPT 11640 EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS,

EYELIDS, NOSE, LIPS; EXCISED DIAMETER 0.5 CM OR LESS

602 CPT 11641 EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS,

EYELIDS, NOSE, LIPS; EXCISED DIAMETER 0.6 TO 1.0 CM 745 CPT 11642 EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS,

EYELIDS, NOSE, LIPS; EXCISED DIAMETER 1.1 TO 2.0 CM 855 CPT 11643 EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS,

EYELIDS, NOSE, LIPS; EXCISED DIAMETER 2.1 TO 3.0 CM

995 CPT 11644 EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS,

EYELIDS, NOSE, LIPS; EXCISED DIAMETER 3.1 TO 4.0 CM

1,224 CPT 11646 EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS,

EYELIDS, NOSE, LIPS; EXCISED DIAMETER OVER 4.0 CM

1,602 CPT 11719 TRIMMING OF NONDYSTROPHIC NAILS, ANY NUMBER 71 CPT 11720 DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); ONE TO FIVE 104

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(AED)

CPT 11721 DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); SIX OR MORE 146 CPT 11730 AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE 323 CPT 11732 AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; EACH

ADDITIONAL NAIL PLATE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

149

CPT 11740 EVACUATION OF SUBUNGUAL HEMATOMA 152

CPT 11750 EXCISION OF NAIL AND NAIL MATRIX, PARTIAL OR COMPLETE (E.G., INGROWN OR DEFORMED NAIL), FOR PERMANENT REMOVAL;

702 CPT 11752 EXCISION OF NAIL AND NAIL MATRIX, PARTIAL OR COMPLETE (E.G.,

INGROWN OR DEFORMED NAIL), FOR PERMANENT REMOVAL; WITH AMPUTATION OF TUFT OF DISTAL PHALANX

993 CPT 11755 BIOPSY OF NAIL UNIT (E.G., PLATE, BED, MATRIX, HYPONYCHIUM,

PROXIMAL AND LATERAL NAIL FOLDS) (SEPARATE PROCEDURE)

438

CPT 11760 REPAIR OF NAIL BED 655

CPT 11762 RECONSTRUCTION OF NAIL BED WITH GRAFT 877 CPT 11765 WEDGE EXCISION OF SKIN OF NAIL FOLD (E.G., FOR INGROWN TOENAIL) 435 CPT 11770 EXCISION OF PILONIDAL CYST OR SINUS; SIMPLE 808 CPT 11771 EXCISION OF PILONIDAL CYST OR SINUS; EXTENSIVE 1,681 CPT 11772 EXCISION OF PILONIDAL CYST OR SINUS; COMPLICATED 2,034 CPT 11900 INJECTION, INTRALESIONAL; UP TO AND INCLUDING 7 LESIONS 183 CPT 11901 INJECTION, INTRALESIONAL; MORE THAN 7 LESIONS 231 CPT 11920 TATTOOING, INTRADERMAL INTRODUCTION OF INSOLUBLE OPAQUE

PIGMENTS TO CORRECT COLOUR DEFECTS OF SKIN, INCLUDING MICROPIGMENTATION; 6.0 SQ. CM OR LESS

528 CPT 11921 TATTOOING, INTRADERMAL INTRODUCTION OF INSOLUBLE OPAQUE

PIGMENTS TO CORRECT COLOUR DEFECTS OF SKIN, INCLUDING MICROPIGMENTATION; 6.1 TO 20.0 SQ. CM

614 CPT 11922 TATTOOING, INTRADERMAL INTRODUCTION OF INSOLUBLE OPAQUE

PIGMENTS TO CORRECT COLOUR DEFECTS OF SKIN, INCLUDING

MICROPIGMENTATION; EACH ADDITIONAL 20.0 SQ. CM (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

186

CPT 11950 SUBCUTANEOUS INJECTION OF FILLING MATERIAL (E.G., COLLAGEN); 1 CC OR LESS

224 CPT 11951 SUBCUTANEOUS INJECTION OF FILLING MATERIAL (E.G., COLLAGEN); 1.1

TO 5.0 CC

276 CPT 11952 SUBCUTANEOUS INJECTION OF FILLING MATERIAL (E.G., COLLAGEN); 5.1

TO 10.0 CC 438

CPT 11954 SUBCUTANEOUS INJECTION OF FILLING MATERIAL (E.G., COLLAGEN);

OVER 10.0 CC 489

CPT 11960 INSERTION OF TISSUE EXPANDER(S) FOR OTHER THAN BREAST,

INCLUDING SUBSEQUENT EXPANSION 2,882

CPT 11970 REPLACEMENT OF TISSUE EXPANDER WITH PERMANENT PROSTHESIS 1,898 CPT 11971 REMOVAL OF TISSUE EXPANDER(S) WITHOUT INSERTION OF PROSTHESIS 1,375

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(AED)

CPT 11975 INSERTION, IMPLANTABLE CONTRACEPTIVE CAPSULES 401 CPT 11976 REMOVAL, IMPLANTABLE CONTRACEPTIVE CAPSULES 468 CPT 11977 REMOVAL WITH REINSERTION, IMPLANTABLE CONTRACEPTIVE CAPSULES 711 CPT 11980 SUBCUTANEOUS HORMONE PELLET IMPLANTATION (IMPLANTATION OF

ESTRADIOL AND/OR TESTOSTERONE PELLETS BENEATH THE SKIN) 337 CPT 11981 INSERTION, NON-BIODEGRADABLE DRUG DELIVERY IMPLANT 440 CPT 11982 REMOVAL, NON-BIODEGRADABLE DRUG DELIVERY IMPLANT 499 CPT 11983 REMOVAL WITH REINSERTION, NON-BIODEGRADABLE DRUG DELIVERY

IMPLANT 776

CPT 12001 SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS

453 CPT 12002 SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE,

EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM

EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); OVER 30.0 CM

999 CPT 12011 SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS,

NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS 484 CPT 12013 SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS,

NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM 536 CPT 12014 SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS,

NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM

NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM

NOSE, LIPS AND/OR MUCOUS MEMBRANES; OVER 30.0 CM 1,019 CPT 12020 TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; SIMPLE CLOSURE 834 CPT 12021 TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; WITH PACKING 497 CPT 12031 LAYER CLOSURE OF WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR

EXTREMITIES (EXCLUDING HANDS AND FEET); 2.5 CM OR LESS

785 CPT 12032 LAYER CLOSURE OF WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR

EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM 990 CPT 12034 LAYER CLOSURE OF WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR

(16)

(AED)

CPT 12035 LAYER CLOSURE OF WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR

EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM 1,149 CPT 12036 LAYER CLOSURE OF WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR

EXTREMITIES (EXCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM 1,261 CPT 12037 LAYER CLOSURE OF WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR

EXTREMITIES (EXCLUDING HANDS AND FEET); OVER 30.0 CM

1,426 CPT 12041 LAYER CLOSURE OF WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL

GENITALIA; 2.5 CM OR LESS

811 CPT 12042 LAYER CLOSURE OF WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL

GENITALIA; 2.6 CM TO 7.5 CM 935

CPT 12044 LAYER CLOSURE OF WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL

GENITALIA; 7.6 CM TO 12.5 CM 1,112

CPT 12045 LAYER CLOSURE OF WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL

GENITALIA; 12.6 CM TO 20.0 CM 1,144

CPT 12046 LAYER CLOSURE OF WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 20.1 CM TO 30.0 CM

1,316 CPT 12047 LAYER CLOSURE OF WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL

GENITALIA; OVER 30.0 CM

1,477 CPT 12051 LAYER CLOSURE OF WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS

AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS 855 CPT 12052 LAYER CLOSURE OF WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS

AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM 988 CPT 12053 LAYER CLOSURE OF WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS

AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM 1,102 CPT 12054 LAYER CLOSURE OF WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS

AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM 1,158 CPT 12055 LAYER CLOSURE OF WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS

AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM

AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM

AND/OR MUCOUS MEMBRANES; OVER 30.0 CM 1,798 CPT 13100 REPAIR, COMPLEX, TRUNK; 1.1 CM TO 2.5 CM 984 CPT 13101 REPAIR, COMPLEX, TRUNK; 2.6 CM TO 7.5 CM 1,276 CPT 13102 REPAIR, COMPLEX, TRUNK; EACH ADDITIONAL 5 CM OR LESS (LIST

SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 342 CPT 13120 REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 1.1 CM TO 2.5 CM 1,027 CPT 13121 REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM 1,426 CPT 13122 REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; EACH ADDITIONAL 5 CM

OR LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

372 CPT 13131 REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE,

GENITALIA, HANDS AND/OR FEET; 1.1 CM TO 2.5 CM

1,141 CPT 13132 REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE,

GENITALIA, HANDS AND/OR FEET; 2.6 CM TO 7.5 CM

1,849 CPT 13133 REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE,

GENITALIA, HANDS AND/OR FEET; EACH ADDITIONAL 5 CM OR LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

534 CPT 13150 REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; 1.0 CM OR LESS 1,117 CPT 13151 REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; 1.1 CM TO 2.5 CM 1,295

(17)

(AED)

CPT 13152 REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; 2.6 CM TO 7.5 CM 1,797 CPT 13153 REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; EACH

ADDITIONAL 5 CM OR LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

587 CPT 13160 SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE,

EXTENSIVE OR COMPLICATED

2,567 CPT 14000 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, TRUNK; DEFECT 10

SQ. CM OR LESS 2,060

CPT 14001 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, TRUNK; DEFECT 10.1

SQ. CM TO 30.0 SQ. CM 2,698

CPT 14020 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, SCALP, ARMS AND/OR

LEGS; DEFECT 10 SQ. CM OR LESS 2,308

CPT 14021 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, SCALP, ARMS AND/OR

LEGS; DEFECT 10.1 SQ. CM TO 30.0 SQ. CM 3,078 CPT 14040 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, FOREHEAD, CHEEKS,

CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; DEFECT 10 SQ. CM OR LESS

2,424 CPT 14041 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, FOREHEAD, CHEEKS,

CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; DEFECT 10.1 SQ. CM TO 30.0 SQ. CM

3,395 CPT 14060 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS, NOSE, EARS

AND/OR LIPS; DEFECT 10 SQ. CM OR LESS 2,446 CPT 14061 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS, NOSE, EARS

AND/OR LIPS; DEFECT 10.1 SQ. CM TO 30.0 SQ. CM 3,684 CPT 14300 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, MORE THAN 30 SQ.

CM, UNUSUAL OR COMPLICATED, ANY AREA 3,518 CPT 14350 FILLETED FINGER OR TOE FLAP, INCLUDING PREPARATION OF RECIPIENT

SITE

2,399 CPT 15002 SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION

OF OPEN WOUNDS, BURN ESCHAR, OR SCAR (INCLUDING SUBCUTANEOUS TISSUES), OR INCISIONAL RELEASE OF SCAR CONTRACTURE, TRUNK, ARMS, LEGS; FIRST 100 SQ. CM OR 1% OF BODY AREA OF INFANTS AND CHILDREN

1,052

CPT 15003 SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, BURN ESCHAR, OR SCAR (INCLUDING SUBCUTANEOUS TISSUES), OR INCISIONAL RELEASE OF SCAR CONTRACTURE, TRUNK, ARMS, LEGS; EACH ADDITIONAL 100 SQ. CM OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

227

CPT 15004 SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, BURN ESCHAR, OR SCAR (INCLUDING SUBCUTANEOUS TISSUES), OR INCISIONAL RELEASE OF SCAR CONTRACTURE, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET AND/OR MULTIPLE DIGITS; FIRST 100 SQ. CM OR 1% OF BODY AREA OF INFANTS AND CHILDREN

1,268

CPT 15005 SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, BURN ESCHAR, OR SCAR (INCLUDING SUBCUTANEOUS TISSUES), OR INCISIONAL RELEASE OF SCAR CONTRACTURE, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET AND/OR MULTIPLE DIGITS; EACH ADDITIONAL 100 SQ. CM OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

385

CPT 15040 HARVEST OF SKIN FOR TISSUE CULTURED SKIN AUTOGRAFT, 100 SQ. CM

OR LESS 777

CPT 15050 PINCH GRAFT, SINGLE OR MULTIPLE, TO COVER SMALL ULCER, TIP OF

(18)

(AED)

SIZE 2 CM DIAMETER

CPT 15100 SPLIT-THICKNESS AUTOGRAFT, TRUNK, ARMS, LEGS; FIRST 100 SQ. CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN (EXCEPT 15050)

2,616 CPT 15101 SPLIT-THICKNESS AUTOGRAFT, TRUNK, ARMS, LEGS; EACH ADDITIONAL

100 SQ. CM, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

557

CPT 15110 EPIDERMAL AUTOGRAFT, TRUNK, ARMS, LEGS; FIRST 100 SQ. CM OR

LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN 2,635 CPT 15111 EPIDERMAL AUTOGRAFT, TRUNK, ARMS, LEGS; EACH ADDITIONAL 100 SQ.

CM, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND

CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

375

CPT 15115 EPIDERMAL AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS; FIRST 100 SQ. CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN

2,715 CPT 15116 EPIDERMAL AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS,

ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS; EACH ADDITIONAL 100 SQ. CM, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

505

CPT 15120 SPLIT-THICKNESS AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS; FIRST 100 SQ. CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN (EXCEPT 15050)

2,954

CPT 15121 SPLIT-THICKNESS AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS; EACH ADDITIONAL 100 SQ. CM, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

814

CPT 15130 DERMAL AUTOGRAFT, TRUNK, ARMS, LEGS; FIRST 100 SQ. CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN

2,056 CPT 15131 DERMAL AUTOGRAFT, TRUNK, ARMS, LEGS; EACH ADDITIONAL 100 SQ.

CM, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND

CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

298

CPT 15135 DERMAL AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS; FIRST 100 SQ. CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN

2,722 CPT 15136 DERMAL AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS,

ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS; EACH ADDITIONAL 100 SQ. CM, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

297

CPT 15150 TISSUE CULTURED EPIDERMAL AUTOGRAFT, TRUNK, ARMS, LEGS; FIRST 25 SQ. CM OR LESS

2,201 CPT 15151 TISSUE CULTURED EPIDERMAL AUTOGRAFT, TRUNK, ARMS, LEGS;

ADDITIONAL 1 SQ. CM TO 75 SQ. CM (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

397 CPT 15152 TISSUE CULTURED EPIDERMAL AUTOGRAFT, TRUNK, ARMS, LEGS; EACH

ADDITIONAL 100 SQ. CM, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

490

CPT 15155 TISSUE CULTURED EPIDERMAL AUTOGRAFT, FACE, SCALP, EYELIDS,

(19)

(AED)

MULTIPLE DIGITS; FIRST 25 SQ. CM OR LESS

CPT 15156 TISSUE CULTURED EPIDERMAL AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS; ADDITIONAL 1 SQ. CM TO 75 SQ. CM (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

536

CPT 15157 TISSUE CULTURED EPIDERMAL AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR

MULTIPLE DIGITS; EACH ADDITIONAL 100 SQ. CM, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

595

CPT 15170 ACELLULAR DERMAL REPLACEMENT, TRUNK, ARMS, LEGS; FIRST 100 SQ.

CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN 1,327 CPT 15171 ACELLULAR DERMAL REPLACEMENT, TRUNK, ARMS, LEGS; EACH

ADDITIONAL 100 SQ. CM, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

294

CPT 15175 ACELLULAR DERMAL REPLACEMENT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS; FIRST 100 SQ. CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN

1,671

CPT 15176 ACELLULAR DERMAL REPLACEMENT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS; EACH ADDITIONAL 100 SQ. CM, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

475

CPT 15200 FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR

SITE, TRUNK; 20 SQ. CM OR LESS 2,499

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

444 CPT 15220 FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR

SITE, SCALP, ARMS, AND/OR LEGS; 20 SQ. CM OR LESS 2,424 CPT 15221 FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR

SITE, SCALP, ARMS, AND/OR LEGS; EACH ADDITIONAL 20 SQ. CM (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

421 CPT 15240 FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR

SITE, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS, AND/OR FEET; 20 SQ. CM OR LESS

2,908 CPT 15241 FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR

SITE, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS, AND/OR FEET; EACH ADDITIONAL 20 SQ. CM (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

582

CPT 15260 FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR

SITE, NOSE, EARS, EYELIDS, AND/OR LIPS; 20 SQ CM OR LESS 3,159 CPT 15261 FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR

SITE, NOSE, EARS, EYELIDS, AND/OR LIPS; EACH ADDITIONAL 20 SQ CM (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

682 CPT 15300 ALLOGRAFT SKIN FOR TEMPORARY WOUND CLOSURE, TRUNK, ARMS,

LEGS; FIRST 100 SQ CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN

1,079 CPT 15301 ALLOGRAFT SKIN FOR TEMPORARY WOUND CLOSURE, TRUNK, ARMS,

LEGS; EACH ADDITIONAL 100 SQ CM, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

201

CPT 15320 ALLOGRAFT SKIN FOR TEMPORARY WOUND CLOSURE, FACE, SCALP,

(20)

(AED)

AND/OR MULTIPLE DIGITS; FIRST 100 SQ CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN

CPT 15321 ALLOGRAFT SKIN FOR TEMPORARY WOUND CLOSURE, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS; EACH ADDITIONAL 100 SQ CM, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

302

CPT 15330 ACELLULAR DERMAL ALLOGRAFT, TRUNK, ARMS, LEGS; FIRST 100 SQ CM

OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN 1,004 CPT 15331 ACELLULAR DERMAL ALLOGRAFT, TRUNK, ARMS, LEGS; EACH ADDITIONAL

100 SQ CM, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

205

CPT 15335 ACELLULAR DERMAL ALLOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS; FIRST 100 SQ CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN

1,053

CPT 15336 ACELLULAR DERMAL ALLOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS; EACH ADDITIONAL 100 SQ CM, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

298

CPT 15340 TISSUE CULTURED ALLOGENEIC SKIN SUBSTITUTE; FIRST 25 SQ CM OR LESS

989 CPT 15341 TISSUE CULTURED ALLOGENEIC SKIN SUBSTITUTE; EACH ADDITIONAL 25

SQ CM 151

CPT 15360 TISSUE CULTURED ALLOGENEIC DERMAL SUBSTITUTE, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN

1,159 CPT 15361 TISSUE CULTURED ALLOGENEIC DERMAL SUBSTITUTE, TRUNK, ARMS,

LEGS; EACH ADDITIONAL 100 SQ CM, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

225

CPT 15365 TISSUE CULTURED ALLOGENEIC DERMAL SUBSTITUTE, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS; FIRST 100 SQ CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN

1,118

CPT 15366 TISSUE CULTURED ALLOGENEIC DERMAL SUBSTITUTE, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS; EACH ADDITIONAL 100 SQ CM, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

288

CPT 15400 XENOGRAFT, SKIN (DERMAL), FOR TEMPORARY WOUND CLOSURE, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN

1,239 CPT 15401 XENOGRAFT, SKIN (DERMAL), FOR TEMPORARY WOUND CLOSURE, TRUNK,

ARMS, LEGS; EACH ADDITIONAL 100 SQ CM, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

270

CPT 15420 XENOGRAFT SKIN (DERMAL), FOR TEMPORARY WOUND CLOSURE, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS; FIRST 100 SQ CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN

1,364

CPT 15421 XENOGRAFT SKIN (DERMAL), FOR TEMPORARY WOUND CLOSURE, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET,

(21)

(AED)

AND/OR MULTIPLE DIGITS; EACH ADDITIONAL 100 SQ CM, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

CPT 15430 ACELLULAR XENOGRAFT IMPLANT; FIRST 100 SQ CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN

1,661 CPT 15431 ACELLULAR XENOGRAFT IMPLANT; EACH ADDITIONAL 100 SQ CM, OR

EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

755

CPT 15570 FORMATION OF DIRECT OR TUBED PEDICLE, WITH OR WITHOUT

TRANSFER; TRUNK 2,697

CPT 15572 FORMATION OF DIRECT OR TUBED PEDICLE, WITH OR WITHOUT

TRANSFER; SCALP, ARMS, OR LEGS 2,634

CPT 15574 FORMATION OF DIRECT OR TUBED PEDICLE, WITH OR WITHOUT TRANSFER; FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS OR FEET

2,803 CPT 15576 FORMATION OF DIRECT OR TUBED PEDICLE, WITH OR WITHOUT

TRANSFER; EYELIDS, NOSE, EARS, LIPS, OR INTRAORAL 2,489 CPT 15600 DELAY OF FLAP OR SECTIONING OF FLAP (DIVISION AND INSET); AT

TRUNK

949 CPT 15610 DELAY OF FLAP OR SECTIONING OF FLAP (DIVISION AND INSET); AT

SCALP, ARMS, OR LEGS

1,054 CPT 15620 DELAY OF FLAP OR SECTIONING OF FLAP (DIVISION AND INSET); AT

FOREHEAD, CHEEKS, CHIN, NECK, AXILLAE, GENITALIA, HANDS, OR FEET

1,314 CPT 15630 DELAY OF FLAP OR SECTIONING OF FLAP (DIVISION AND INSET); AT

EYELIDS, NOSE, EARS, OR LIPS 1,431

CPT 15650 TRANSFER, INTERMEDIATE, OF ANY PEDICLE FLAP (EG, ABDOMEN TO

WRIST, WALKING TUBE), ANY LOCATION 1,553

CPT 15731 FOREHEAD FLAP WITH PRESERVATION OF VASCULAR PEDICLE (EG, AXIAL

PATTERN FLAP, PARAMEDIAN FOREHEAD FLAP) 3,436 CPT 15732 MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; HEAD AND NECK

(EG, TEMPORALIS, MASSETER MUSCLE, STERNOCLEIDOMASTOID, LEVATOR SCAPULAE)

4,576 CPT 15734 MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; TRUNK 4,775 CPT 15736 MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; UPPER

EXTREMITY 4,126

CPT 15738 MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; LOWER

EXTREMITY 4,450

CPT 15740 FLAP; ISLAND PEDICLE 3,244

CPT 15750 FLAP; NEUROVASCULAR PEDICLE 2,896

CPT 15756 FREE MUSCLE OR MYOCUTANEOUS FLAP WITH MICROVASCULAR ANASTOMOSIS

7,543 CPT 15757 FREE SKIN FLAP WITH MICROVASCULAR ANASTOMOSIS 7,391 CPT 15758 FREE FASCIAL FLAP WITH MICROVASCULAR ANASTOMOSIS 7,365 CPT 15760 GRAFT; COMPOSITE (EG, FULL THICKNESS OF EXTERNAL EAR OR NASAL

ALA), INCLUDING PRIMARY CLOSURE, DONOR AREA

2,636

CPT 15770 GRAFT; DERMA-FAT-FASCIA 2,066

(22)

(AED)

CPT 15776 PUNCH GRAFT FOR HAIR TRANSPLANT; MORE THAN 15 PUNCH GRAFTS 1,397 CPT 15780 DERMABRASION; TOTAL FACE (EG, FOR ACNE SCARRING, FINE

WRINKLING, RHYTIDS, GENERAL KERATOSIS)

2,569

CPT 15781 DERMABRASION; SEGMENTAL, FACE 1,753

CPT 15782 DERMABRASION; REGIONAL, OTHER THAN FACE 1,689 CPT 15783 DERMABRASION; SUPERFICIAL, ANY SITE (EG, TATTOO REMOVAL) 1,577 CPT 15786 ABRASION; SINGLE LESION (EG, KERATOSIS, SCAR) 762 CPT 15787 ABRASION; EACH ADDITIONAL FOUR LESIONS OR LESS (LIST SEPARATELY

IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 151 CPT 15788 CHEMICAL PEEL, FACIAL; EPIDERMAL 1,468

CPT 15789 CHEMICAL PEEL, FACIAL; DERMAL 1,830

CPT 15792 CHEMICAL PEEL, NONFACIAL; EPIDERMAL 1,380 CPT 15793 CHEMICAL PEEL, NONFACIAL; DERMAL 1,524

CPT 15819 CERVICOPLASTY 2,278

CPT 15820 BLEPHAROPLASTY, LOWER EYELID; 1,621

CPT 15821 BLEPHAROPLASTY, LOWER EYELID; WITH EXTENSIVE HERNIATED FAT PAD 1,721

CPT 15822 BLEPHAROPLASTY, UPPER EYELID; 1,272

CPT 15823 BLEPHAROPLASTY, UPPER EYELID; WITH EXCESSIVE SKIN WEIGHTING

DOWN LID 2,015

CPT 15824 RHYTIDECTOMY; FOREHEAD 3,441 CPT 15825 RHYTIDECTOMY; NECK WITH PLATYSMAL TIGHTENING (PLATYSMAL FLAP,

P-FLAP) 3,871

CPT 15826 RHYTIDECTOMY; GLABELLAR FROWN LINES 2,795 CPT 15828 RHYTIDECTOMY; CHEEK, CHIN, AND NECK 7,312 CPT 15829 RHYTIDECTOMY; SUPERFICIAL MUSCULOAPONEUROTIC SYSTEM (SMAS)

FLAP 8,172

CPT 15830 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); ABDOMEN, INFRAUMBILICAL PANNICULECTOMY

3,732 CPT 15832 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES

LIPECTOMY); THIGH 2,843

CPT 15833 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES

LIPECTOMY); LEG 2,604

LIPECTOMY); HIP 2,736

LIPECTOMY); BUTTOCK 2,800

CPT 15836 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); ARM

2,338 CPT 15837 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES

LIPECTOMY); FOREARM OR HAND

(23)

(AED)

LIPECTOMY); SUBMENTAL FAT PAD 1,774

LIPECTOMY); OTHER AREA 2,681

CPT 15840 GRAFT FOR FACIAL NERVE PARALYSIS; FREE FASCIA GRAFT (INCLUDING OBTAINING FASCIA)

3,148 CPT 15841 GRAFT FOR FACIAL NERVE PARALYSIS; FREE MUSCLE GRAFT (INCLUDING

OBTAINING GRAFT)

5,258 CPT 15842 GRAFT FOR FACIAL NERVE PARALYSIS; FREE MUSCLE FLAP BY

MICROSURGICAL TECHNIQUE 8,371

CPT 15845 GRAFT FOR FACIAL NERVE PARALYSIS; REGIONAL MUSCLE TRANSFER 2,921 CPT 15847 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES

LIPECTOMY), ABDOMEN (EG, ABDOMINOPLASTY) (INCLUDES UMBILICAL TRANSPOSITION AND FASCIAL PLICATION) (LIST SEPARATELY IN

ADDITION TO CODE FOR PRIMARY PROCEDURE)

1,506

CPT 15850 REMOVAL OF SUTURES UNDER ANESTHESIA (OTHER THAN LOCAL), SAME

SURGEON 255

CPT 15851 REMOVAL OF SUTURES UNDER ANESTHESIA (OTHER THAN LOCAL), OTHER

SURGEON 283

CPT 15852 DRESSING CHANGE (FOR OTHER THAN BURNS) UNDER ANESTHESIA (OTHER THAN LOCAL)

151 CPT 15860 INTRAVENOUS INJECTION OF AGENT (EG, FLUORESCEIN) TO TEST

VASCULAR FLOW IN FLAP OR GRAFT

359

CPT 15876 SUCTION ASSISTED LIPECTOMY; HEAD AND NECK N/A CPT 15877 SUCTION ASSISTED LIPECTOMY; TRUNK N/A CPT 15878 SUCTION ASSISTED LIPECTOMY; UPPER EXTREMITY N/A CPT 15879 SUCTION ASSISTED LIPECTOMY; LOWER EXTREMITY N/A CPT 15920 EXCISION, COCCYGEAL PRESSURE ULCER, WITH COCCYGECTOMY; WITH

PRIMARY SUTURE 1,830

CPT 15922 EXCISION, COCCYGEAL PRESSURE ULCER, WITH COCCYGECTOMY; WITH

FLAP CLOSURE 2,368

CPT 15931 EXCISION, SACRAL PRESSURE ULCER, WITH PRIMARY SUTURE; 2,110 CPT 15933 EXCISION, SACRAL PRESSURE ULCER, WITH PRIMARY SUTURE; WITH

OSTECTOMY 2,571

CPT 15934 EXCISION, SACRAL PRESSURE ULCER, WITH SKIN FLAP CLOSURE; 2,902 CPT 15935 EXCISION, SACRAL PRESSURE ULCER, WITH SKIN FLAP CLOSURE; WITH

OSTECTOMY 3,380

CPT 15936 EXCISION, SACRAL PRESSURE ULCER, IN PREPARATION FOR MUSCLE OR

MYOCUTANEOUS FLAP OR SKIN GRAFT CLOSURE; 2,798 CPT 15937 EXCISION, SACRAL PRESSURE ULCER, IN PREPARATION FOR MUSCLE OR

MYOCUTANEOUS FLAP OR SKIN GRAFT CLOSURE; WITH OSTECTOMY 3,273 CPT 15940 EXCISION, ISCHIAL PRESSURE ULCER, WITH PRIMARY SUTURE; 2,168 CPT 15941 EXCISION, ISCHIAL PRESSURE ULCER, WITH PRIMARY SUTURE; WITH

OSTECTOMY (ISCHIECTOMY) 2,810

CPT 15944 EXCISION, ISCHIAL PRESSURE ULCER, WITH SKIN FLAP CLOSURE; 2,776 CPT 15945 EXCISION, ISCHIAL PRESSURE ULCER, WITH SKIN FLAP CLOSURE; WITH

(24)

(AED)

CPT 15946 EXCISION, ISCHIAL PRESSURE ULCER, WITH OSTECTOMY, IN

PREPARATION FOR MUSCLE OR MYOCUTANEOUS FLAP OR SKIN GRAFT CLOSURE

5,120 CPT 15950 EXCISION, TROCHANTERIC PRESSURE ULCER, WITH PRIMARY SUTURE; 1,806 CPT 15951 EXCISION, TROCHANTERIC PRESSURE ULCER, WITH PRIMARY SUTURE;

WITH OSTECTOMY

2,547 CPT 15952 EXCISION, TROCHANTERIC PRESSURE ULCER, WITH SKIN FLAP CLOSURE; 2,668 CPT 15953 EXCISION, TROCHANTERIC PRESSURE ULCER, WITH SKIN FLAP CLOSURE;

WITH OSTECTOMY 2,947

CPT 15956 EXCISION, TROCHANTERIC PRESSURE ULCER, IN PREPARATION FOR MUSCLE OR MYOCUTANEOUS FLAP OR SKIN GRAFT CLOSURE;

3,569 CPT 15958 EXCISION, TROCHANTERIC PRESSURE ULCER, IN PREPARATION FOR

MUSCLE OR MYOCUTANEOUS FLAP OR SKIN GRAFT CLOSURE; WITH OSTECTOMY

3,680

CPT 15999 UNLISTED PROCEDURE, EXCISION PRESSURE ULCER N/A CPT 16000 INITIAL TREATMENT, FIRST DEGREE BURN, WHEN NO MORE THAN LOCAL

TREATMENT IS REQUIRED 212

CPT 16020 DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA)

250 CPT 16025 DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS,

INITIAL OR SUBSEQUENT; MEDIUM (EG, WHOLE FACE OR WHOLE EXTREMITY, OR 5% TO 10% TOTAL BODY SURFACE AREA)

454 CPT 16030 DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS,

INITIAL OR SUBSEQUENT; LARGE (EG, MORE THAN ONE EXTREMITY, OR GREATER THAN 10% TOTAL BODY SURFACE AREA)

553

CPT 16035 ESCHAROTOMY; INITIAL INCISION 682

CPT 16036 ESCHAROTOMY; EACH ADDITIONAL INCISION (LIST SEPARATELY IN

ADDITION TO CODE FOR PRIMARY PROCEDURE) 271 CPT 17000 DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY,

CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES); FIRST LESION

259 CPT 17003 DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY,

CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES); SECOND THROUGH 14 LESIONS, EACH (LIST SEPARATELY IN ADDITION TO CODE FOR FIRST LESION)

22

CPT 17004 DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES), 15 OR MORE LESIONS

550 CPT 17106 DESTRUCTION OF CUTANEOUS VASCULAR PROLIFERATIVE LESIONS (EG,

LASER TECHNIQUE); LESS THAN 10 SQ CM 1,215 CPT 17107 DESTRUCTION OF CUTANEOUS VASCULAR PROLIFERATIVE LESIONS (EG,

LASER TECHNIQUE); 10.0 TO 50.0 SQ CM

2,114 CPT 17108 DESTRUCTION OF CUTANEOUS VASCULAR PROLIFERATIVE LESIONS (EG,

LASER TECHNIQUE); OVER 50.0 SQ CM

2,848 CPT 17110 DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY,

CHEMOSURGERY, SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; UP TO 14 LESIONS

315

CPT 17111 DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; 15 OR MORE LESIONS

(25)

(AED)

CPT 17250 CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (PROUD FLESH,

SINUS OR FISTULA) 236

CPT 17260 DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), TRUNK, ARMS OR LEGS; LESION DIAMETER 0.5 CM OR LESS

299

CPT 17261 DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), TRUNK, ARMS OR LEGS; LESION DIAMETER 0.6 TO 1.0 CM

469

566

623

668

CPT 17266 DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL

CURETTEMENT), TRUNK, ARMS OR LEGS; LESION DIAMETER OVER 4.0 CM

748 CPT 17270 DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY,

ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.5 CM OR LESS

482

CPT 17271 DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.6 TO 1.0 CM

532

607

674

795

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

915

CURETTEMENT), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 0.5 CM OR LESS

453

CURETTEMENT), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 0.6 TO 1.0 CM

(26)

(AED)

664

796

922

CURETTEMENT), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER OVER 4.0 CM

1,149

CPT 17311 MOHS MICROGRAPHIC TECHNIQUE, INCLUDING REMOVAL OF ALL GROSS TUMOR, SURGICAL EXCISION OF TISSUE SPECIMENS, MAPPING, COLOR CODING OF SPECIMENS, MICROSCOPIC EXAMINATION OF SPECIMENS BY THE SURGEON, AND HISTOPATHOLOGIC PREPARATION INCLUDING ROUTINE STAIN(S) (EG, HEMATOXYLIN AND EOSIN, TOLUIDINE BLUE), HEAD, NECK, HANDS, FEET, GENITALIA, OR ANY LOCATION WITH SURGERY DIRECTLY INVOLVING MUSCLE, CARTILAGE, BONE, TENDON, MAJOR NERVES, OR VESSELS; FIRST STAGE, UP TO 5 TISSUE BLOCKS

2,158

CPT 17312 MOHS MICROGRAPHIC TECHNIQUE, INCLUDING REMOVAL OF ALL GROSS TUMOR, SURGICAL EXCISION OF TISSUE SPECIMENS, MAPPING, COLOR CODING OF SPECIMENS, MICROSCOPIC EXAMINATION OF SPECIMENS BY THE SURGEON, AND HISTOPATHOLOGIC PREPARATION INCLUDING ROUTINE STAIN(S) (EG, HEMATOXYLIN AND EOSIN, TOLUIDINE BLUE), HEAD, NECK, HANDS, FEET, GENITALIA, OR ANY LOCATION WITH SURGERY DIRECTLY INVOLVING MUSCLE, CARTILAGE, BONE, TENDON, MAJOR NERVES, OR VESSELS; EACH ADDITIONAL STAGE AFTER THE FIRST STAGE, UP TO 5 TISSUE BLOCKS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

1,298

CPT 17313 MOHS MICROGRAPHIC TECHNIQUE, INCLUDING REMOVAL OF ALL GROSS TUMOR, SURGICAL EXCISION OF TISSUE SPECIMENS, MAPPING, COLOR CODING OF SPECIMENS, MICROSCOPIC EXAMINATION OF SPECIMENS BY THE SURGEON, AND HISTOPATHOLOGIC PREPARATION INCLUDING

ROUTINE STAIN(S) (EG, HEMATOXYLIN AND EOSIN, TOLUIDINE BLUE), OF THE TRUNK, ARMS, OR LEGS; FIRST STAGE, UP TO 5 TISSUE BLOCKS

1,971

CPT 17314 MOHS MICROGRAPHIC TECHNIQUE, INCLUDING REMOVAL OF ALL GROSS TUMOR, SURGICAL EXCISION OF TISSUE SPECIMENS, MAPPING, COLOR CODING OF SPECIMENS, MICROSCOPIC EXAMINATION OF SPECIMENS BY THE SURGEON, AND HISTOPATHOLOGIC PREPARATION INCLUDING

ROUTINE STAIN(S) (EG, HEMATOXYLIN AND EOSIN, TOLUIDINE BLUE), OF THE TRUNK, ARMS, OR LEGS; EACH ADDITIONAL STAGE AFTER THE FIRST STAGE, UP TO 5 TISSUE BLOCKS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

1,202

CPT 17315 MOHS MICROGRAPHIC TECHNIQUE, INCLUDING REMOVAL OF ALL GROSS TUMOR, SURGICAL EXCISION OF TISSUE SPECIMENS, MAPPING, COLOR CODING OF SPECIMENS, MICROSCOPIC EXAMINATION OF SPECIMENS BY THE SURGEON, AND HISTOPATHOLOGIC PREPARATION INCLUDING ROUTINE STAIN(S) (EG, HEMATOXYLIN AND EOSIN, TOLUIDINE BLUE), EACH ADDITIONAL BLOCK AFTER THE FIRST 5 TISSUE BLOCKS, ANY STAGE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

(27)

(AED)

CPT 17340 CRYOTHERAPY (CO2 SLUSH, LIQUID N2) FOR ACNE 146 CPT 17360 CHEMICAL EXFOLIATION FOR ACNE (EG, ACNE PASTE, ACID) 422

CPT 17380 ELECTROLYSIS EPILATION, EACH 30 MINUTES 245 CPT 17999 UNLISTED PROCEDURE, SKIN, MUCOUS MEMBRANE AND SUBCUTANEOUS

TISSUE N/A CPT 19000 PUNCTURE ASPIRATION OF CYST OF BREAST; 356

CPT 19001 PUNCTURE ASPIRATION OF CYST OF BREAST; EACH ADDITIONAL CYST (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

90 CPT 19020 MASTOTOMY WITH EXPLORATION OR DRAINAGE OF ABSCESS, DEEP 1,361 CPT 19030 INJECTION PROCEDURE ONLY FOR MAMMARY DUCTOGRAM OR

GALACTOGRAM

539 CPT 19100 BIOPSY OF BREAST; PERCUTANEOUS, NEEDLE CORE, NOT USING IMAGING

GUIDANCE (SEPARATE PROCEDURE)

441 CPT 19101 BIOPSY OF BREAST; OPEN, INCISIONAL 1,001 CPT 19102 BIOPSY OF BREAST; PERCUTANEOUS, NEEDLE CORE, USING IMAGING

GUIDANCE

706 CPT 19103 BIOPSY OF BREAST; PERCUTANEOUS, AUTOMATED VACUUM ASSISTED OR

ROTATING BIOPSY DEVICE, USING IMAGING GUIDANCE

1,773 CPT 19105 ABLATION, CRYOSURGICAL, OF FIBROADENOMA, INCLUDING

ULTRASOUND GUIDANCE, EACH FIBROADENOMA 6,356 CPT 19110 NIPPLE EXPLORATION, WITH OR WITHOUT EXCISION OF A SOLITARY

LACTIFEROUS DUCT OR A PAPILLOMA LACTIFEROUS DUCT 1,383 CPT 19112 EXCISION OF LACTIFEROUS DUCT FISTULA 1,312 CPT 19120 EXCISION OF CYST, FIBROADENOMA, OR OTHER BENIGN OR MALIGNANT

TUMOR, ABERRANT BREAST TISSUE, DUCT LESION, NIPPLE OR AREOLAR LESION (EXCEPT 19300), OPEN, MALE OR FEMALE, ONE OR MORE LESIONS

1,467 CPT 19125 EXCISION OF BREAST LESION IDENTIFIED BY PREOPERATIVE PLACEMENT

OF RADIOLOGICAL MARKER, OPEN; SINGLE LESION

1,630 CPT 19126 EXCISION OF BREAST LESION IDENTIFIED BY PREOPERATIVE PLACEMENT

OF RADIOLOGICAL MARKER, OPEN; EACH ADDITIONAL LESION

SEPARATELY IDENTIFIED BY A PREOPERATIVE RADIOLOGICAL MARKER (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

511

CPT 19260 EXCISION OF CHEST WALL TUMOR INCLUDING RIBS 3,762 CPT 19271 EXCISION OF CHEST WALL TUMOR INVOLVING RIBS, WITH PLASTIC

RECONSTRUCTION; WITHOUT MEDIASTINAL LYMPHADENECTOMY 5,075 CPT 19272 EXCISION OF CHEST WALL TUMOR INVOLVING RIBS, WITH PLASTIC

RECONSTRUCTION; WITH MEDIASTINAL LYMPHADENECTOMY 5,637 CPT 19290 PREOPERATIVE PLACEMENT OF NEEDLE LOCALIZATION WIRE, BREAST; 532 CPT 19291 PREOPERATIVE PLACEMENT OF NEEDLE LOCALIZATION WIRE, BREAST;

EACH ADDITIONAL LESION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

227 CPT 19295 IMAGE GUIDED PLACEMENT, METALLIC LOCALIZATION CLIP,

PERCUTANEOUS, DURING BREAST BIOPSY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

288 CPT 19296 PLACEMENT OF RADIOTHERAPY AFTERLOADING BALLOON CATHETER INTO

THE BREAST FOR INTERSTITIAL RADIOELEMENT APPLICATION FOLLOWING PARTIAL MASTECTOMY, INCLUDES IMAGING GUIDANCE; ON DATE

SEPARATE FROM PARTIAL MASTECTOMY

Daman Published Rates