Statutes, codes, and regulations
Wyoming Administrative Code
Agency 053 - Workforce Services, Department ofSubagency 0021 - Workers' Compensation Division
Chapter 9 - FEE SCHEDULES
Section 9-9 - Facility Fees

053-9 Wyo. Code R. § 9-9

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Current through April 27, 2019
Section 9-9 - Facility Fees

(a) Fees for Inpatient Hospital Services.

  • (i) Services or items shall be paid per usual and customary services pursuant to Chapter 9, Sections 1, 2, 4, 6, and 8 in addition to this section. Required documentation to support billed charges are as follows:
    • (A) Detailed itemization
    • (B) Anesthesia graphic
    • (C) Operative report
    • (D) History and physical
    • (E) Discharge summary
    • (F) Supplier's invoice for any single supply/implant charged at $1,000.00 or more.
      • (I) Such items shall be reimbursed at 130% of invoice amount. Shipping and handling charges shall not be reimbursed.
  • (ii) Bills shall be audited for unidentified and unrelated services and/or items.
  • (iii) The Division shall provide a copy of the audit upon request.
  • (iv) Hospital Room Rates. The Division shall pay inpatient hospital room rates based upon an annual survey conducted by the Division. The hospital room rates for a semi-private and intensive care unit bed shall be at the usual and customary rates charged to the general public. Such rates shall be effective automatically on the first day of each calendar year.

(b) Fees for Injections, Rhizotomies and IV Sedation. Injections services shall be paid per the listed reimbursement rates shown in Table A. Reimbursement allowables are all inclusive to each procedural code. See Chapter 9, Section 1 of these Rules for additional guidelines.

  • (i) Refer to Table A for procedures done with guidance and/or sedation.
  • (ii) The Division shall pay 25% of the facility reimbursement base value for any injection(s) in addition to a primary code from Table A or any code from Table B. Added level codes shall be paid at 100% of the base value listed on Table A.

(c) Fees for Surgery Centers Other than for Injections. Surgical services shall be paid per the listed reimbursement rates shown in Table B. Reimbursement allowables are all inclusive unless otherwise specifically noted. Providers may note specific bill(s) with a written request for an audit to elect payment under the hospital fee schedule. See Chapter 9, Section 9, (a), Fees for Inpatient Hospital Services for required documentation for such audit. See Chapter 9, Section 1 for additional guidelines.

  • (i) The highest value procedure shall be considered the primary procedure and be paid at 100% of the allowable listed on Table B. Additional procedures shall then be paid at 50% of the allowable.
  • (ii) Invoices. The Division has defined a group of procedures that require surgery centers to provide suppliers' or manufacturers' invoice(s) for maximum reimbursement. They are distinguished by an asterisk (*) In Table B. The following standards shall be applied:
    • (A) Maximum reimbursement for asterisked procedures shall be the facility reimbursement allowable listed in Table B plus 130% of invoice amount. Shipping and handling charges shall not be reimbursed.
    • (B) The Division shall not provide direct payment to suppliers or manufacturers.
    • (C) The Division shall reimburse invoiced costs of an implant/device for any code marked with an asterisk on Table B and not otherwise recognized for payment.
  • (iii) 23-Hour Stay. Code 19999 is recognized as a 23-hour stay. Documentation supporting the medical necessity for the stay is required for reimbursement. Reimbursement shall be based on half of the average Wyoming semi-private hospital room rate. See (a)(iv) for guidelines.

Table A - INJECTION PROCEDURES FEE SCHEDULE FOR FACILITY

See Chapter 9, Section 9(b), for additional guidelines on facility reimbursements and Chapter 9, Section 1 for general guidelines for fee schedules.

AA AB AC AD
CPT SHORT DESCRIPTOR WITHOUT GUIDANCE & WITHOUT IV SEDATION * WITHOUT GUIDANCE & WITH IV SEDATION WITH GUIDANCE & WITHOUT IV SEDATION * WITH GUIDANCE & WITH IV SEDATION*
20526 Ther injection, carp tunnel $237.55 $985.22 $321.04 $1,068.71
20550 Inj tendon sheath/ligament $237.55 $985.22 $321.04 $1,068.71
20551 Inj tendon origin/insertion $237.55 $985.22 $321.04 $1,068.71
20552 Inj trigger point, 1/2 muscl $237.55 $985.22 $321.04 $1,068.71
20553 Inject trigger points, =/> 3 $237.55 $985.22 $321.04 $1,068.71
20600 Drain/inject, joint/bursa $237.55 $985.22 $321.04 $1,068.71
20605 Drain/inject, joint/bursa $237.55 $985.22 $321.04 $1,068.71
20610 Drain/inject, joint/bursa $237.55 $985.22 $321.04 $1,068.71
20612 Aspirate/inj ganglion cyst $237.55 $985.22 $321.04 $1,068.71
27096 Inject sacroiliac joint w/ GUID $480.05 no code AB $647.04 $1,205.66
62264 Epidural lysis on single day no code AA no code AB $647.04 $1,205.66
62270 Spinal fluid tap, diagnostic $480.05 $1,038.67 $647.04 $1,205.66
62272 Drain cerebro spinal fluid $480.05 $1,038.67 $647.04 $1,205.66
62273 Inject epidural patch $480.05 $1,038.67 $647.04 $1,205.66
62280 Treat spinal cord lesion $480.05 $1,038.67 $647.04 $1,205.66
62281 Treat spinal cord lesion $480.05 $1,038.67 $647.04 $1,205.66
62282 Treat spinal canal lesion $480.05 $1,038.67 $647.04 $1,205.66
64400 N block inj, trigeminal $237.55 $985.22 $321.04 $1,068.71
64402 N block inj, facial $237.55 $985.22 $321.04 $1,068.71
64405 N block inj, occipital $354.56 $1,038.67 $438.05 $1,185.72
64408 N block inj, vagus $237.55 $985.22 $321.04 $1,068.71
64410 N block inj, phrenic $237.55 $985.22 $321.04 $1,068.71
64413 N block inj, cervical $354.56 $1,038.67 $438.05 $1,185.72
64415 N block brachial plexus, single $354.56 $1,038.67 $438.05 $1,185.72
64416 N block cont infuse, b plex $480.05 $1,038.67 $647.04 $1,205.66
64417 N block inj, axillary $354.56 $1,038.67 $438.05 $1,185.72
64418 N block inj, suprascapular $354.56 $1,038.67 $438.05 $1,185.72
64420 N block inj, intercost, sng $354.56 $1,038.67 $438.05 $1,185.72
64421 N block inj, intercost, mlt $480.05 $1,038.67 $647.04 $1,205.66
64425 N block inj, ilio-ing/hypogi $354.56 $1,038.67 $438.05 $1,185.72
64430 N block inj, pudendal $480.05 $1,038.67 $647.04 $1,205.66
64435 N block inj, paracervical $354.56 $1,038.67 $438.05 $1,185.72
64445 N block inj, sciatic, sng $480.05 $1,038.67 $647.04 $1,205.66
64447 N block inj fem, single $354.56 $1,038.67 $438.05 $1,185.72
64448 N block inj fem, cont inf $480.05 $1,038.67 $647.04 $1,205.66
64449 N block inj, lumbar plexus $480.05 $1,038.67 $647.04 $1,205.66
64450 N block, other peripheral $354.56 $1,038.67 $438.05 $1,185.72
64479 Inj foramen epidural c/t $480.05 $1,038.67 $647.04 $1,205.66
64480 Inj foramen added level $ 120.01 for added level no code AB no code AC no code AD
64483 Inj foramen epidural 1/s $480.05 $1,038.67 $647.04 $1,205.66
64484 Inj 1/s added level $ 120.01 for added level no code AB no code AC no code AD
64490 Inj paravertebral c/t - fluor / CT $120.01 for bilaterial sid no code AB $647.04 $1,205.66
64491 Inj paravertebral c/t - Fluor / CT added level $ 120.01 for added level no code AB no code AC no code AD
64492 Inj paravertebral c/t - Fluor / CT 3 levels or more $ 120.01 for added level no code AB no code AC no code AD
64493 Inj paravertebral 1/s - Fluor / CT $120.01 for bilaterial sid no code AB $647.04 $1,205.66
64494 Inj paravertebral 1/s- Fluor / CT added level $ 120.01 for added level no code AB no code AC no code AD
64495 Inj paravertebral 1/s- Fluor / CT 3 levels or more $ 120.01 for added level no code AB no code AC no code AD
64505 N block, spenopalatine gangl $237.55 $985.22 $321.04 $1,068.71
64508 N block, carotid sinus s/p $237.55 $985.22 $321.04 $1,068.71
64510 N block, stellate ganglion $480.05 no code AB $647.04 $1,205.66
64517 N block inj, hypogas plxs $480.05 $1,038.67 $647.04 $1,205.66
64520 N block, lumbar/thoracic $480.05 no code AB $647.04 $1,205.66
64530 N block inj, celiac pelus $480.05 no code AB $647.04 $1,205.66
64600 Injection treatment of nerve $341.86 $1,038.67 $425.35 $1,173.02
64612 Destroy nerve, face muscle $237.55 $985.22 $321.04 $1,068.71
64620 Injection treatment of nerve $341.86 $1,038.67 $425.35 $1,173.02
64630 Injection treatment of nerve $480.05 $1,038.67 $647.04 $1,205.66
64633 Destr paravertebrl nerve c/t $480.05 no code AB $647.04 $1,205.66
64634 Destr c/t added level $ 120.01 for added level no code AB no code AC no code AD
64635 Destr paravertebrl nerve l/s $480.05 $1,038.67 $647.04 $1,205.66
64636 Destr 1/s added level $ 120.01 for added level no code AB no code AC no code AD
64640 Injection treatment of nerve $480.05 $1,038.67 $647.04 $1,205.66
64680 Injection treatment of nerve $341.86 $1,038.67 $425.35 $1,173.02
64681 Injection treatment of nerve $341.86 $1,038.67 $425.35 $1,173.02
72285 X-ray cervical / thoracic spine disk - Discogram -under fluoroscopy. PER SURGICAL EPISODE no code AA no code AB $1,330.73 $2,078.40
72295 X-ray of lower spine disk -Discogram - under fluoroscopy. PER SURGICAL EPISODE no code AA no code AB $1,330.73 $2,078.40
0213T Inj paravertebral c/t ultrasound $120.01 for bilaterial side $1,038.67 $647.04 $1,205.66
0214T Inj paravertebral c/t ultrasound added level $ 120.01 for added level no code AB no code AC no code AD
0215T Inj paravertebral c/t ultrasound 3 levels or more $ 120.01 for added level no code AB no code AC no code AD
0216T Inj paravertebral l/s ultrasound $120.01 for bilaterial side $1,038.67 $647.04 $1,205.66
0217T Inj paravertebral l/s ultrasound added level $ 120.01 for added level no code AB no code AC no code AD
0218T Inj paravertebral l/s ultrasound 3 levels or more $ 120.01 for added level no code AB no code AC no code AD

* The Division shall pay 25% of the base value for each procedural code unless otherwise specified.

Table B - SURGERY CENTER PROCEDURES

See Chapter 9, Section 9(c), for additional information on facility reimbursements and Chapter 9, Section 1 for general guidelines.

B
CPT Short Descriptor Facility Reimbursement Invoice Required
10060 Drainage of skin abscess $129.33
10061 Drainage of skin abscess $129.33
10120 Remove foreign body $251.19
10121 Remove foreign body $1,546.95
10140 Drainage of hematoma/fluid $1,165.80
10180 Complex drainage wound $1,870.55
11010 Debride skin at fx site $400.06
11011 Debride skin musc at fx site $400.06
11012 Deb skin bone at fx site $400.06
11042 Deb subq tissue 20 sq cm/< $251.19
11043 Deb musc/fascia 20 sq cm/< $251.19
11044 Deb bone 20 sq cm/< $754.72
11400 Exc tr-ext b9+marg 0.5 < cm $400.06
11403 Exc tr-ext b9+marg 2.1-3 cm $754.72
11404 Exc tr-ext b9+marg 3.1-4 cm $1,546.95
11420 Exc h-f-nk-sp b9+marg 0.5 < $754.72
11421 Exc h-f-nk-sp b9+marg 0.6-1 $754.72
11422 Exc h-f-nk-sp b9+marg 1.1-2 $754.72
11423 Exc h-f-nk-sp b9+marg 2.1-3 $1,546.95
11440 Exc face-mm b9+marg 0.5 < cm $400.06
11720 Debride nail 1-5 $79.81
11730 Removal of nail plate $79.81
11750 Removal of nail bed $400.06
11760 Repair of nail bed $108.51
11762 Reconstruction of nail bed $1,526.43
12001 Repair superficial wound(s) $108.51
12020 Closure of split wound $448.46
12032 Intmd wnd repair s/a/t/ext $294.49
12034 Intmd wnd repair s/tr/ext $294.49
12041 Intmd wnd repair n-hf/genit $108.51
12042 Intmd wnd repair n-hf/genit $294.49
12051 Intmd wnd repair face/mm $294.49
13101 Repair of wound or lesion $448.46
13102 Repair wound/lesion add-on $294.49
13120 Repair of wound or lesion $294.49
13121 Repair of wound or lesion $294.49
13122 Repair wound/lesion add-on $108.51
13131 Repair of wound or lesion $294.49
13132 Repair of wound or lesion $448.46
13152 Repair of wound or lesion $448.46
13160 Late closure of wound $1,951.55
14000 Skin tissue rearrangement $1,526.43
14001 Skin tissue rearrangement $1,526.43
14021 Skin tissue rearrangement $1,526.43
14040 Skin tissue rearrangement $1,526.43
14041 Skin tissue rearrangement $1,526.43
15002 Wound prep trk/arm/leg $448.46
15003 Wound prep addl 100 cm $448.46
15004 Wound prep f/n/hf/g $294.49
15050 Skin pinch graft $294.49
15100 Skin splt grft trnk/arm/leg $1,951.55
15101 Skin splt grft t/a/l add-on $1,951.55
15120 Skin splt a-grft fac/nck/hf/g $1,951.55
15121 Skin splt a-grft f/n/hf/g add $1,951.55
15220 Skin full graft sclp/arm/leg $1,526.43
15240 Skin full grft face/genit/hf $1,526.43
15574 Form skin pedicle flap $1,951.55
15620 Skin graft $1,951.55
15760 Composite skin graft $1,951.55
15850 Removal of sutures $251.19
15851 Removal of sutures $251.19
15852 Dressing change not for burn $59.15
17111 Destruct lesion 15 or more $136.22
20100 Explore wound neck $679.14
20103 Explore wound extremity $1,165.80
20520 Removal of foreign body $400.06
20525 Removal of foreign body $2,117.45
20555 Place ndl musc/tis for rt $2,953.24
20670 Removal of support implant $1,546.95
20680 Removal of support implant $2,117.45
20690 Apply bone fixation device $2,953.24
20693 Adjust bone fixation device $2,953.24
20694 Remove bone fixation device $2,009.69
20900 Removal of bone for graft $2,953.24
20902 Removal of bone for graft $2,953.24
20912 Remove cartilage for graft $1,951.55
20924 Removal of tendon for graft $2,953.24
20930 Sp bone algrft morsel add-on invoice only *
20931 Sp bone algrft struct add-on invoice only *
20936 Sp bone agrft local add-on $2,953.24
20937 Sp bone agrft morsel add-on $2,953.24
20938 Sp bone agrft struct add-on $2,953.24
21320 Treatment of nose fracture $1,535.50
21325 Treatment of nose fracture $2,265.44
21330 Treatment of nose fracture $2,265.44
21335 Treatment of nose fracture $2,265.44
21356 Treat cheek bone fracture $2,265.44
21365 Treat cheek bone fracture $4,099.33
21385 Treat eye socket fracture $4,099.33
21390 Treat eye socket fracture $4,099.33
21407 Treat eye socket fracture $4,099.33
21408 Treat eye socket fracture $4,099.33
21462 Treat lower jaw fracture $4,099.33
21555 Exc neck les sc < 3 cm $1,546.95
21930 Exc back les sc < 3 cm $1,546.95
22100 Remove part of neck vertebra $4,617.84
22526 Idet single level $2,953.24
22527 Idet 1 or more levels $2,953.24
22551 Neck spine fuse&remov bel c2 $4,617.84
22552 Addl neck spine fusion $4,617.84
22554 Neck spine fusion $4,617.84
22556 Thorax spine fusion $4,617.84
22558 Lumbar spine fusion $4,617.84
22585 Additional spinal fusion $4,617.84
22600 Neck spine fusion $4,617.84
22610 Thorax spine fusion $4,617.84
22612 Lumbar spine fusion $4,617.84
22614 Spine fusion extra segment $4,617.84
22630 Lumbar spine fusion $4,617.84
22632 Spine fusion extra segment $4,617.84
22633 Lumbar spine fusion combined $6,926.76
22634 Spine fusion extra segment $6,926.76
22830 Exploration of spinal fusion $4,617.84
22840 Insert spine fixation device $4,617.84 *
22841 Insert spine fixation device $4,617.84 *
22842 Insert spine fixation device $4,617.84 *
22843 Insert spine fixation device $4,617.84 *
22844 Insert spine fixation device $4,617.84 *
22845 Insert spine fixation device $4,617.84 *
22846 Insert spine fixation device $4,617.84 *
22847 Insert spine fixation device $4,617.84 *
22848 Insert pelv fixation device $4,617.84 *
22849 Reinsert spinal fixation $4,617.84 *
22850 Remove spine fixation device $4,617.84
22852 Remove spine fixation device $4,617.84
22855 Remove spine fixation device $4,617.84
22856 Cerv artific diskectomy $4,617.84 *
22857 Lumbar artif diskectomy $4,617.84 *
23020 Release shoulder joint $2,953.24
23030 Drain shoulder lesion $1,870.55
23040 Exploratory shoulder surgery $2,953.24
23044 Exploratory shoulder surgery $2,953.24
23075 Exc shoulder les sc < 3 cm $1,546.95
23076 Exc shoulder tum deep < 5 cm $1,546.95
23100 Biopsy of shoulder joint $2,009.69
23101 Shoulder joint surgery $2,953.24
23105 Remove shoulder joint lining $2,953.24
23106 Incision of collarbone joint $2,953.24
23107 Explore treat shoulder joint $2,953.24
23120 Partial removal collar bone $2,953.24
23130 Remove shoulder bone part $4,323.74
23140 Removal of bone lesion $2,009.69
23145 Removal of bone lesion $2,953.24
23330 Remove shoulder foreign body $754.72
23405 Incision of tendon & muscle $2,953.24
23410 Repair rotator cuff acute $3,669.13 *
23412 Repair rotator cuff chronic $3,669.13 *
23415 Release of shoulder ligament $4,323.74
23420 Repair of shoulder $3,669.13 *
23430 Repair biceps tendon $4,323.74
23440 Remove/transplant tendon $2,953.24
23450 Repair shoulder capsule $6,159.04 *
23455 Repair shoulder capsule $6,159.04 *
23460 Repair shoulder capsule $6,159.04 *
23462 Repair shoulder capsule $4,323.74
23465 Repair shoulder capsule $6,159.04 *
23466 Repair shoulder capsule $4,323.74
23470 Reconstruct shoulder joint $4,646.69 *
23472 Reconstruct shoulder joint $4,646.69 *
23485 Revision of collar bone $6,159.04 *
23515 Treat clavicle fracture $6,200.31
23530 Treat clavicle dislocation $4,541.71
23532 Treat clavicle dislocation $2,377.46
23550 Treat clavicle dislocation $4,541.71
23552 Treat clavicle dislocation $4,541.71
23585 Treat scapula fracture $6,200.31
23630 Treat humerus fracture $6,200.31
23655 Treat shoulder dislocation $1,407.13
23700 Fixation of shoulder $1,407.13
23929 Shoulder surgery procedure $136.71
23930 Drainage of arm lesion $1,870.55
23931 Drainage of arm bursa $1,870.55
24000 Exploratory elbow surgery $2,953.24
24006 Release elbow joint $2,953.24
24101 Explore/treat elbow joint $2,953.24
24102 Remove elbow joint lining $2,953.24
24105 Removal of elbow bursa $2,009.69
24110 Remove humerus lesion $2,009.69
24120 Remove elbow lesion $2,009.69
24130 Removal of head of radius $2,953.24
24140 Partial removal of arm bone $2,953.24
24145 Partial removal of radius $2,953.24
24147 Partial removal of elbow $2,953.24
24164 Remove radius head implant $2,953.24
24200 Removal of arm foreign body $400.06
24201 Removal of arm foreign body $1,546.95
24300 Manipulate elbow w/anesth $1,407.13
24305 Arm tendon lengthening $2,953.24
24340 Repair of biceps tendon $4,323.74
24341 Repair arm tendon/muscle $4,323.74
24342 Repair of ruptured tendon $4,323.74
24343 Repr elbow lat ligmnt w/tiss $2,953.24
24344 Reconstruct elbow lat ligmnt $6,159.04 *
24345 Repr elbw med ligmnt w/tissu $2,953.24
24346 Reconstruct elbow med ligmnt $6,159.04 *
24357 Repair elbow perc $2,953.24
24358 Repair elbow w/deb open $2,953.24
24359 Repair elbow deb/attch open $2,953.24
24360 Reconstruct elbow joint $3,757.97
24365 Reconstruct head of radius $3,757.97
24366 Reconstruct head of radius $4,646.69 *
24400 Revision of humerus $6,159.04 *
24430 Repair of humerus $6,159.04 *
24435 Repair humerus with graft $6,159.04 *
24545 Treat humerus fracture $6,200.31
24546 Treat humerus fracture $6,200.31
24575 Treat humerus fracture $6,200.31
24579 Treat humerus fracture $6,200.31
24582 Treat humerus fracture $2,377.46
24586 Treat elbow fracture $6,200.31
24605 Treat elbow dislocation $1,407.13
24615 Treat elbow dislocation $6,200.31
24655 Treat radius fracture $459.23
24665 Treat radius fracture $4,541.71
24666 Treat radius fracture $6,200.31
24685 Treat ulnar fracture $4,541.71
24800 Fusion of elbow joint $4,323.74
25000 Incision of tendon sheath $2,009.69
25001 Incise flexor carpi radialis $2,009.69
25020 Decompress forearm 1 space $2,953.24
25023 Decompress forearm 1 space $2,953.24
25024 Decompress forearm 2 spaces $2,953.24
25025 Decompress forearm 2 spaces $2,953.24
25028 Drainage of forearm lesion $2,009.69
25031 Drainage of forearm bursa $2,009.69
25040 Explore/treat wrist joint $2,953.24
25066 Biopsy forearm soft tissues $2,117.45
25075 Exc forearm les sc < 3 cm $1,546.95
25076 Exc forearm tum deep < 3 cm $1,546.95
25085 Incision of wrist capsule $2,009.69
25100 Biopsy of wrist joint $2,009.69
25101 Explore/treat wrist joint $2,953.24
25105 Remove wrist joint lining $2,953.24
25107 Remove wrist joint cartilage $2,953.24
25110 Remove wrist tendon lesion $2,009.69
25111 Remove wrist tendon lesion $2,009.69
25112 Reremove wrist tendon lesion $2,009.69
25115 Remove wrist/forearm lesion $2,009.69
25116 Remove wrist/forearm lesion $2,009.69
25118 Excise wrist tendon sheath $2,953.24
25120 Removal of forearm lesion $2,953.24
25126 Remove/graft forearm lesion $2,953.24
25136 Remove & graft wrist lesion $2,953.24
25150 Partial removal of ulna $2,953.24
25151 Partial removal of radius $2,953.24
25210 Removal of wrist bone $2,953.24
25215 Removal of wrist bones $2,953.24
25230 Partial removal of radius $2,953.24
25240 Partial removal of ulna $2,953.24
25248 Remove forearm foreign body $2,009.69
25259 Manipulate wrist w/anesthes $1,724.73
25260 Repair forearm tendon/muscle $2,953.24
25263 Repair forearm tendon/muscle $2,953.24
25270 Repair forearm tendon/muscle $2,953.24
25272 Repair forearm tendon/muscle $2,953.24
25274 Repair forearm tendon/muscle $2,953.24
25275 Repair forearm tendon sheath $2,953.24
25280 Revise wrist/forearm tendon $2,953.24
25290 Incise wrist/forearm tendon $2,953.24
25295 Release wrist/forearm tendon $2,009.69
25300 Fusion of tendons at wrist $2,953.24
25301 Fusion of tendons at wrist $2,953.24
25310 Transplant forearm tendon $2,953.24
25312 Transplant forearm tendon $4,323.74
25320 Repair/revise wrist joint $4,323.74
25337 Reconstruct ulna/radioulnar $4,323.74
25360 Revision of ulna $4,323.74
25390 Shorten radius or ulna $4,323.74
25400 Repair radius or ulna $6,159.04 *
25405 Repair/graft radius or ulna $6,159.04 *
25415 Repair radius & ulna $6,159.04 *
25420 Repair/graft radius & ulna $6,159.04 *
25430 Vasc graft into carpal bone $4,323.74
25431 Repair nonunion carpal bone $4,323.74
25440 Repair/graft wrist bone $6,159.04 *
25447 Repair wrist joints $3,757.97
25515 Treat fracture of radius $4,541.71
25545 Treat fracture of ulna $4,541.71
25575 Treat fracture radius/ulna $6,200.31
25605 Treat fracture radius/ulna $459.23
25606 Treat fx distal radial $2,377.46
25607 Treat fx rad extra-articul $6,200.31
25608 Treat fx rad intra-articul $6,200.31
25609 Treat fx radial 3+ frag $6,200.31
25622 Treat wrist bone fracture $136.71
25628 Treat wrist bone fracture $4,541.71
25645 Treat wrist bone fracture $4,541.71
25651 Pin ulnar styloid fracture $2,377.46
25652 Treat fracture ulnar styloid $4,541.71
25660 Treat wrist dislocation $136.71
25670 Treat wrist dislocation $2,377.46
25671 Pin radioulnar dislocation $2,377.46
25676 Treat wrist dislocation $2,377.46
25685 Treat wrist fracture $2,377.46
25695 Treat wrist dislocation $2,377.46
25800 Fusion of wrist joint $6,159.04 *
25810 Fusion/graft of wrist joint $6,159.04 *
25820 Fusion of hand bones $4,323.74
25825 Fuse hand bones with graft $6,159.04 *
26011 Drainage of finger abscess $1,165.80
26020 Drain hand tendon sheath $1,564.65
26037 Decompress fingers/hand $1,564.65
26040 Release palm contracture $1,564.65
26055 Incise finger tendon sheath $1,564.65
26060 Incision of finger tendon $1,564.65
26070 Explore/treat hand joint $1,564.65
26075 Explore/treat finger joint $1,564.65
26080 Explore/treat finger joint $1,564.65
26100 Biopsy hand joint lining $1,564.65
26105 Biopsy finger joint lining $1,564.65
26110 Biopsy finger joint lining $1,564.65
26113 Exc hand tum deep 1.5 cm/> $2,117.45
26115 Exc hand les sc < 1.5 cm $1,546.95
26116 Exc hand tum deep < 1.5 cm $1,546.95
26121 Release palm contracture $2,627.06
26123 Release palm contracture $2,627.06
26125 Release palm contracture $1,564.65
26130 Remove wrist joint lining $1,564.65
26140 Revise finger joint each $1,564.65
26145 Tendon excision palm/finger $1,564.65
26160 Remove tendon sheath lesion $1,564.65
26170 Removal of palm tendon each $1,564.65
26180 Removal of finger tendon $1,564.65
26185 Remove finger bone $1,564.65
26200 Remove hand bone lesion $1,564.65
26230 Partial removal of hand bone $1,564.65
26235 Partial removal finger bone $1,564.65
26236 Partial removal finger bone $1,564.65
26320 Removal of implant from hand $1,546.95
26340 Manipulate finger w/anesth $459.23
26350 Repair finger/hand tendon $2,627.06
26352 Repair/graft hand tendon $2,627.06
26356 Repair finger/hand tendon $2,627.06
26357 Repair finger/hand tendon $2,627.06
26358 Repair/graft hand tendon $2,627.06
26370 Repair finger/hand tendon $2,627.06
26372 Repair/graft hand tendon $2,627.06
26373 Repair finger/hand tendon $2,627.06
26390 Revise hand/finger tendon $2,627.06
26392 Repair/graft hand tendon $2,627.06
26410 Repair hand tendon $1,564.65
26412 Repair/graft hand tendon $2,627.06
26418 Repair finger tendon $1,564.65
26420 Repair/graft finger tendon $2,627.06
26426 Repair finger/hand tendon $2,627.06
26428 Repair/graft finger tendon $2,627.06
26432 Repair finger tendon $1,564.65
26433 Repair finger tendon $1,564.65
26434 Repair/graft finger tendon $2,627.06
26437 Realignment of tendons $1,564.65
26440 Release palm/finger tendon $1,564.65
26442 Release palm & finger tendon $2,627.06
26445 Release hand/finger tendon $1,564.65
26449 Release forearm/hand tendon $2,627.06
26450 Incision of palm tendon $1,564.65
26455 Incision of finger tendon $1,564.65
26460 Incise hand/finger tendon $1,564.65
26471 Fusion of finger tendons $1,564.65
26474 Fusion of finger tendons $1,564.65
26476 Tendon lengthening $1,564.65
26477 Tendon shortening $1,564.65
26478 Lengthening of hand tendon $1,564.65
26479 Shortening of hand tendon $1,564.65
26480 Transplant hand tendon $2,627.06
26483 Transplant/graft hand tendon $2,627.06
26485 Transplant palm tendon $2,627.06
26489 Transplant/graft palm tendon $2,627.06
26500 Hand tendon reconstruction $1,564.65
26502 Hand tendon reconstruction $2,627.06
26508 Release thumb contracture $1,564.65
26516 Fusion of knuckle joint $2,627.06
26520 Release knuckle contracture $1,564.65
26525 Release finger contracture $1,564.65
26530 Revise knuckle joint $3,757.97
26535 Revise finger joint $3,757.97
26536 Revise/implant finger joint $3,348.85 *
26540 Repair hand joint $1,564.65
26541 Repair hand joint with graft $2,627.06
26542 Repair hand joint with graft $1,564.65
26545 Reconstruct finger joint $2,627.06
26546 Repair nonunion hand $2,627.06
26548 Reconstruct finger joint $2,627.06
26565 Correct metacarpal flaw $2,627.06
26593 Release muscles of hand $1,564.65
26605 Treat metacarpal fracture $136.71
26607 Treat metacarpal fracture $1,724.73
26608 Treat metacarpal fracture $2,377.46
26615 Treat metacarpal fracture $4,541.71
26650 Treat thumb fracture $2,377.46
26665 Treat thumb fracture $4,541.71
26676 Pin hand dislocation $2,377.46
26685 Treat hand dislocation $2,377.46
26705 Treat knuckle dislocation $136.71
26706 Pin knuckle dislocation $1,724.73
26715 Treat knuckle dislocation $2,377.46
26725 Treat finger fracture each $136.71
26727 Treat finger fracture each $2,377.46
26735 Treat finger fracture each $2,377.46
26742 Treat finger fracture each $136.71
26746 Treat finger fracture each $2,377.46
26755 Treat finger fracture each $136.71
26756 Pin finger fracture each $2,377.46
26765 Treat finger fracture each $2,377.46
26775 Treat finger dislocation $1,407.13
26776 Pin finger dislocation $2,377.46
26785 Treat finger dislocation $2,377.46
26841 Fusion of thumb $2,627.06
26842 Thumb fusion with graft $2,627.06
26843 Fusion of hand joint $2,627.06
26844 Fusion/graft of hand joint $2,627.06
26850 Fusion of knuckle $2,627.06
26852 Fusion of knuckle with graft $2,627.06
26860 Fusion of finger joint $2,627.06
26861 Fusion of finger jnt add-on $2,627.06
26862 Fusion/graft of finger joint $2,627.06
26863 Fuse/graft added joint $2,627.06
26910 Amputate metacarpal bone $2,627.06
26951 Amputation of finger/thumb $1,564.65
26952 Amputation of finger/thumb $1,564.65
26990 Drainage of pelvis lesion $2,009.69
27006 Incision of hip tendons $2,953.24
27062 Remove femur lesion/bursa $2,009.69
27065 Remove hip bone les super $2,009.69
27066 Remove hip bone les deep $2,953.24
27216 Treat pelvic ring fracture $2,953.24
27267 Cltx thigh fx $136.71
27275 Manipulation of hip joint $1,407.13
27280 Fusion of sacroiliac joint $4,617.84
27301 Drain thigh/knee lesion $1,870.55
27306 Incision of thigh tendon $2,009.69
27310 Exploration of knee joint $2,953.24
27324 Biopsy thigh soft tissues $2,117.45
27327 Exc thigh/knee les sc < 3 cm $2,117.45
27328 Exc thigh/knee tum deep < 5 cm $1,546.95
27331 Explore/treat knee joint $2,953.24
27332 Removal of knee cartilage $2,953.24
27333 Removal of knee cartilage $2,953.24
27334 Remove knee joint lining $2,953.24
27335 Remove knee joint lining $2,953.24
27340 Removal of kneecap bursa $2,009.69
27345 Removal of knee cyst $2,009.69
27347 Remove knee cyst $2,009.69
27350 Removal of kneecap $2,953.24
27360 Partial removal leg bone(s) $2,953.24
27372 Removal of foreign body $2,117.45
27380 Repair of kneecap tendon $2,953.24
27381 Repair/graft kneecap tendon $2,953.24
27385 Repair of thigh muscle $2,953.24
27386 Repair/graft of thigh muscle $2,953.24
27400 Revise thigh muscles/tendons $4,323.74
27403 Repair of knee cartilage $2,953.24
27405 Repair of knee ligament $4,323.74
27407 Repair of knee ligament $6,159.04 *
27409 Repair of knee ligaments $6,159.04 *
27415 Osteochondral knee allograft $6,159.04 *
27416 Osteochondral knee autograft $4,323.74
27418 Repair degenerated kneecap $4,323.74
27420 Revision of unstable kneecap $4,323.74
27422 Revision of unstable kneecap $4,323.74
27424 Revision/removal of kneecap $4,323.74
27425 Lat retinacular release open $2,953.24
27427 Reconstruction knee $6,159.04 *
27428 Reconstruction knee $6,159.04 *
27429 Reconstruction knee $6,159.04 *
27438 Revise kneecap with implant $3,348.85 *
27446 Revision of knee joint $4,646.69 *
27447 Total knee arthroplasty $4,646.69 *
27486 Revise/replace knee joint $4,646.69 *
27520 Treat kneecap fracture $136.71
27524 Treat kneecap fracture $4,541.71
27562 Treat kneecap dislocation $1,407.13
27570 Fixation of knee joint $1,407.13
27603 Drain lower leg lesion $1,870.55
27604 Drain lower leg bursa $2,953.24
27605 Incision of achilles tendon $2,011.21
27606 Incision of achilles tendon $2,009.69
27610 Explore/treat ankle joint $2,953.24
27612 Exploration of ankle joint $2,953.24
27618 Exc leg/ankle tum < 3 cm $1,546.95
27619 Exc leg/ankle tum deep < 5 cm $1,546.95
27620 Explore/treat ankle joint $2,953.24
27625 Remove ankle joint lining $2,953.24
27626 Remove ankle joint lining $2,953.24
27630 Removal of tendon lesion $2,009.69
27638 Remove/graft leg bone lesion $2,953.24
27640 Partial removal of tibia $2,953.24
27641 Partial removal of fibula $2,953.24
27650 Repair achilles tendon $4,323.74
27652 Repair/graft achilles tendon $6,159.04 *
27654 Repair of achilles tendon $4,323.74
27658 Repair of leg tendon each $2,009.69
27659 Repair of leg tendon each $2,009.69
27664 Repair of leg tendon each $2,953.24
27665 Repair of leg tendon each $2,953.24
27675 Repair lower leg tendons $2,009.69
27676 Repair lower leg tendons $2,953.24
27680 Release of lower leg tendon $2,953.24
27685 Revision of lower leg tendon $2,953.24
27687 Revision of calf tendon $2,953.24
27690 Revise lower leg tendon $4,323.74
27691 Revise lower leg tendon $4,323.74
27695 Repair of ankle ligament $2,953.24
27696 Repair of ankle ligaments $2,953.24
27698 Repair of ankle ligament $2,953.24
27700 Revision of ankle joint $3,757.97
27707 Incision of fibula $2,953.24
27720 Repair of tibia $4,541.71
27726 Repair fibula nonunion $4,541.71
27745 Reinforce tibia $6,159.04 *
27758 Treatment of tibia fracture $4,541.71
27762 Cltx med ankle fx w/mnpj $1,724.73
27766 Optx medial ankle fx $4,541.71
27767 Cltx post ankle fx $136.71
27768 Cltx post ankle fx w/mnpj $136.71
27769 Optx post ankle fx $4,541.71
27784 Treatment of fibula fracture $4,541.71
27792 Treatment of ankle fracture $4,541.71
27814 Treatment of ankle fracture $4,541.71
27818 Treatment of ankle fracture $459.23
27822 Treatment of ankle fracture $4,541.71
27823 Treatment of ankle fracture $6,200.31
27825 Treat lower leg fracture $1,724.73
27827 Treat lower leg fracture $6,200.31
27828 Treat lower leg fracture $6,200.31
27829 Treat lower leg joint $4,541.71
27842 Treat ankle dislocation $1,407.13
28035 Decompression of tibia nerve $1,719.56
28050 Biopsy of foot joint lining $2,011.21
28060 Partial removal foot fascia $2,011.21
28062 Removal of foot fascia $2,011.21
28070 Removal of foot joint lining $2,011.21
28072 Removal of foot joint lining $2,011.21
28080 Removal of foot lesion $2,011.21
28086 Excise foot tendon sheath $2,011.21
28088 Excise foot tendon sheath $2,011.21
28090 Removal of foot lesion $2,011.21
28092 Removal of toe lesions $2,011.21
28111 Part removal of metatarsal $2,011.21
28112 Part removal of metatarsal $2,011.21
28113 Part removal of metatarsal $2,011.21
28116 Revision of foot $2,011.21
28118 Removal of heel bone $2,011.21
28119 Removal of heel spur $2,011.21
28120 Part removal of ankle/heel $2,011.21
28122 Partial removal of foot bone $2,011.21
28124 Partial removal of toe $2,011.21
28200 Repair of foot tendon $2,011.21
28202 Repair/graft of foot tendon $2,011.21
28208 Repair of foot tendon $2,011.21
28210 Repair/graft of foot tendon $5,320.90
28220 Release of foot tendon $2,011.21
28222 Release of foot tendons $2,011.21
28225 Release of foot tendon $2,011.21
28226 Release of foot tendons $2,011.21
28230 Incision of foot tendon(s) $2,011.21
28232 Incision of toe tendon $2,011.21
28234 Incision of foot tendon $2,011.21
28238 Revision of foot tendon $5,320.90
28270 Release of foot contracture $2,011.21
28272 Release of toe joint each $2,011.21
28285 Repair of hammertoe $2,011.21
28289 Repair hallux rigidus $2,011.21
28297 Correction of bunion $2,978.74
28300 Incision of heel bone $5,320.90
28302 Incision of ankle bone $2,011.21
28304 Incision of midfoot bones $5,320.90
28305 Incise/graft midfoot bones $5,320.90
28306 Incision of metatarsal $2,011.21
28307 Incision of metatarsal $2,011.21
28308 Incision of metatarsal $2,011.21
28310 Revision of big toe $2,011.21
28315 Removal of sesamoid bone $2,011.21
28320 Repair of foot bones $5,320.90
28322 Repair of metatarsals $5,320.90
28415 Treat heel fracture $6,200.31
28446 Osteochondral talus autogrft $5,320.90
28450 Treat midfoot fracture each $136.71
28465 Treat midfoot fracture each $4,541.71
28470 Treat metatarsal fracture $136.71
28476 Treat metatarsal fracture $2,377.46
28485 Treat metatarsal fracture $4,541.71
28496 Treat big toe fracture $2,377.46
28505 Treat big toe fracture $2,377.46
28515 Treatment of toe fracture $136.71
28525 Treat toe fracture $2,377.46
28531 Treat sesamoid bone fracture $2,377.46
28546 Treat foot dislocation $2,377.46
28555 Repair foot dislocation $4,541.71
28576 Treat foot dislocation $2,377.46
28585 Repair foot dislocation $2,377.46
28606 Treat foot dislocation $2,377.46
28615 Repair foot dislocation $4,541.71
28636 Treat toe dislocation $2,377.46
28645 Repair toe dislocation $2,377.46
28666 Treat toe dislocation $2,377.46
28675 Repair of toe dislocation $2,377.46
28715 Fusion of foot bones $6,159.04 *
28725 Fusion of foot bones $5,320.90
28730 Fusion of foot bones $5,320.90
28740 Fusion of foot bones $5,320.90
28750 Fusion of big toe joint $5,320.90
28755 Fusion of big toe joint $2,011.21
28805 Amputation thru metatarsal $2,011.21
28820 Amputation of toe $2,011.21
28825 Partial amputation of toe $2,011.21
29581 Apply multlay comprs lwr leg $102.44
29584 Appl multlay comprs arm/hand $102.44
29800 Jaw arthroscopy/surgery $2,709.86
29804 Jaw arthroscopy/surgery $2,709.86
29805 Shoulder arthroscopy dx $2,709.86
29806 Shoulder arthroscopy/surgery $5,194.58
29807 Shoulder arthroscopy/surgery $5,194.58
29819 Shoulder arthroscopy/surgery $5,194.58
29820 Shoulder arthroscopy/surgery $5,194.58
29821 Shoulder arthroscopy/surgery $5,194.58
29822 Shoulder arthroscopy/surgery $2,709.86
29823 Shoulder arthroscopy/surgery $5,194.58
29824 Shoulder arthroscopy/surgery $2,709.86
29825 Shoulder arthroscopy/surgery $5,194.58
29826 Shoulder arthroscopy/surgery $2,709.86
29827 Arthroscop rotator cuff repr $4,546.81 *
29828 Arthroscopy biceps tenodesis $5,194.58
29830 Elbow arthroscopy $2,709.86
29834 Elbow arthroscopy/surgery $2,709.86
29835 Elbow arthroscopy/surgery $2,709.86
29836 Elbow arthroscopy/surgery $2,709.86
29837 Elbow arthroscopy/surgery $2,709.86
29838 Elbow arthroscopy/surgery $2,709.86
29840 Wrist arthroscopy $2,709.86
29843 Wrist arthroscopy/surgery $2,709.86
29844 Wrist arthroscopy/surgery $2,709.86
29845 Wrist arthroscopy/surgery $2,709.86
29846 Wrist arthroscopy/surgery $2,709.86
29847 Wrist arthroscopy/surgery $5,194.58
29848 Wrist endoscopy/surgery $2,709.86
29850 Knee arthroscopy/surgery $2,709.86
29851 Knee arthroscopy/surgery $5,194.58
29855 Tibial arthroscopy/surgery $5,194.58
29856 Tibial arthroscopy/surgery $5,194.58
29860 Hip arthroscopy dx $5,194.58
29861 Hip arthro w/fb removal $5,194.58
29862 Hip arthro w/debridement $5,194.58
29863 Hip arthro w/synovectomy $5,194.58
29866 Autgrft implnt knee w/scope $5,194.58
29867 Allgrft implnt knee w/scope $5,194.58
29868 Meniscal trnspl knee w/scpe $5,194.58
29870 Knee arthroscopy dx $2,709.86
29871 Knee arthroscopy/drainage $2,709.86
29873 Knee arthroscopy/surgery $2,709.86
29874 Knee arthroscopy/surgery $2,709.86
29875 Knee arthroscopy/surgery $2,709.86
29876 Knee arthroscopy/surgery $2,709.86
29877 Knee arthroscopy/surgery $2,709.86
29879 Knee arthroscopy/surgery $2,709.86
29880 Knee arthroscopy/surgery $2,709.86
29881 Knee arthroscopy/surgery $2,709.86
29882 Knee arthroscopy/surgery $2,709.86
29883 Knee arthroscopy/surgery $2,709.86
29884 Knee arthroscopy/surgery $2,709.86
29885 Knee arthroscopy/surgery $5,194.58
29886 Knee arthroscopy/surgery $2,709.86
29887 Knee arthroscopy/surgery $2,709.86
29888 Knee arthroscopy/surgery $6,159.04 *
29889 Knee arthroscopy/surgery $6,159.04 *
29891 Ankle arthroscopy/surgery $5,194.58
29892 Ankle arthroscopy/surgery $6,159.04 *
29893 Scope plantar fasciotomy $2,011.21
29894 Ankle arthroscopy/surgery $2,709.86
29895 Ankle arthroscopy/surgery $2,709.86
29897 Ankle arthroscopy/surgery $2,709.86
29898 Ankle arthroscopy/surgery $2,709.86
29904 Subtalar arthro w/fb rmvl $2,709.86
29905 Subtalar arthro w/exc $2,709.86
29906 Subtalar arthro w/deb $2,709.86
29907 Subtalar arthro w/fusion $5,194.58
30130 Excise inferior turbinate $1,535.50
30140 Resect inferior turbinate $2,265.44
30420 Reconstruction of nose $4,099.33
30465 Repair nasal stenosis $4,099.33
30520 Repair of nasal septum $2,265.44
30560 Release of nasal adhesions $283.53
30802 Ablate inf turbinate submuc $1,535.50
30930 Ther fx nasal inf turbinate $1,535.50
31254 Revision of ethmoid sinus $2,762.34
31256 Exploration maxillary sinus $2,762.34
31267 Endoscopy maxillary sinus $2,762.34
31505 Diagnostic laryngoscopy $97.66
31570 Laryngoscope w/vc inj $1,936.67
31571 Laryngoscop w/vc inj + scope $2,762.34
31575 Diagnostic laryngoscopy $169.69
35207 Repair blood vessel lesion $3,735.34
38230 Bone marrow harvest allogen $3,242.61
38500 Biopsy/removal lymph nodes $2,300.42
41899 Dental surgery procedure $97.47
42145 Repair palate pharynx/uvula $2,265.44
43235 Uppr gi endoscopy diagnosis $769.22
43239 Upper gi endoscopy biopsy $769.22
43248 Uppr gi endoscopy/guide wire $769.22
45330 Diagnostic sigmoidoscopy $566.19
45378 Diagnostic colonoscopy $852.79
45380 Colonoscopy and biopsy $852.79
45385 Lesion removal colonoscopy $852.79
46221 Ligation of hemorrhoid(s) $502.05
46260 Remove in/ex hem groups 2+ $2,224.36
46500 Injection into hemorrhoid(s) $502.05
49505 Prp i/hern init reduc > 5 yr $2,997.23
49507 Prp i/hern init block > 5 yr $2,997.23
49520 Rerepairing hernia reduce $2,997.23
49521 Rerepairing hernia blocked $2,997.23
49525 Repairing hernia sliding $2,997.23
49550 Rpr rem herniainit reduce $2,997.23
49553 Rpr fem hernia init blocked $2,997.23
49560 Rpr ventral hern init reduc $2,997.23
49561 Rpr ventral hern init block $2,997.23
49565 Rerepair ventrl hern reduce $2,997.23
49566 Rerepair ventrl hern block $2,997.23
49568 Hernia repair w/mesh $2,997.23
49570 Rpr epigastric hern reduce $2,997.23
49572 Rpr epigastric hern blocked $2,997.23
49585 Rpr umbil hern reduc > 5 yr $2,997.23
49587 Rpr umbil hern block > 5 yr $2,997.23
49650 Lap ing hernia repair init $4,363.44
49651 Lap ing hernia repair recur $4,363.44
49652 Lap vent/abd hernia repair $6,513.92
49653 Lap vent/abd hern proc comp $6,513.92
49654 Lap inc hernia repair $6,513.92
49655 Lap inc hern repair comp $6,513.92
49656 Lap inc hernia repair recur $6,513.92
49657 Lap inc hern recur comp $6,513.92
50590 Fragmenting of kidney stone $4,741.07
51040 Incise & drain bladder $2,393.58
51045 Incise bladder/drain ureter $616.53
51705 Change of bladder tube $177.48
51726 Complex cystometrogram $290.23
51741 Electro-uroflowmetry first $100.99
51784 Anal/urinary muscle study $100.99
51797 Intraabdominal pressure test $177.48
52000 Cystoscopy $616.53
52276 Cystoscopy and treatment $2,393.58
52281 Cystoscopy and treatment $1,590.26
52310 Cystoscopy and treatment $1,590.26
52332 Cystoscopy and treatment $2,393.58
54235 Penile injection $177.48
54415 Remove self-contd penis pros $3,149.92
54520 Removal of testis $2,143.10
55520 Removal of sperm cord lesion $2,143.10
55530 Revise spermatic cord veins $2,143.10
57240 Repair bladder & vagina $3,268.41
57267 Insert mesh/pelvic flr addon $3,268.41
61885 Insrt/redo neurostim 1 array $2,776.18 *
61886 Implant neurostim arrays $3,067.33 *
62287 Percutaneous diskectomy $3,288.46
62292 Injection into disk lesion $678.44
62350 Implant spinal canal cath $3,782.31
62351 Implant spinal canal cath $4,617.84
62355 Remove spinal canal catheter $1,165.02
62361 Implant spine infusion pump $3,284.05 *
62362 Implant spine infusion pump $3,284.05 *
62365 Remove spine infusion device $3,288.46
62367 Analyze spine infus pump $217.81
62368 Analyze sp inf pump w/reprog $217.81
63020 Neck spine disk surgery $4,617.84
63030 Low back disk surgery $4,617.84
63035 Spinal disk surgery add-on $4,617.84
63040 Laminotomy single cervical $4,617.84
63042 Laminotomy single lumbar $4,617.84
63044 Laminotomy addl lumbar $4,617.84
63045 Removal of spinal lamina $4,617.84
63046 Removal of spinal lamina $4,617.84
63047 Removal of spinal lamina $4,617.84
63048 Remove spinal lamina add-on $4,617.84
63056 Decompress spinal cord $4,617.84
63075 Neck spine disk surgery $4,617.84
63076 Neck spine disk surgery $4,617.84
63081 Removal of vertebral body $4,617.84
63267 Excise intraspinal lesion $4,617.84
63650 Implant neuroelectrodes $2,588.19 *
63655 Implant neuroelectrodes $2,883.18 *
63661 Remove spine eltrd perq aray $1,885.92
63662 Remove spine eltrd plate $1,885.92
63663 Revise spine eltrd perq aray $2,588.19 *
63664 Revise spine eltrd plate $2,588.19 *
63685 Insrt/redo spine n generator $2,776.18 *
63688 Revise/remove neuroreceiver $2,830.74
64555 Implant neuroelectrodes $2,588.19 *
64561 Implant neuroelectrodes $2,588.19 *
64575 Implant neuroelectrodes $2,883.18 *
64580 Implant neuroelectrodes $2,883.18 *
64581 Implant neuroelectrodes $2,883.18 *
64590 Insrt/redo pn/gastr stimul $2,776.18 *
64595 Revise/rmv pn/gastr stimul $2,830.74
64702 Revise finger/toe nerve $1,719.56
64704 Revise hand/foot nerve $1,719.56
64708 Revise arm/leg nerve $1,719.56
64712 Revision of sciatic nerve $1,719.56
64714 Revise low back nerve(s) $1,719.56
64718 Revise ulnar nerve at elbow $1,719.56
64719 Revise ulnar nerve at wrist $1,719.56
64721 Carpal tunnel surgery $1,719.56
64722 Relieve pressure on nerve(s) $1,719.56
64727 Internal nerve revision $1,719.56
64771 Sever cranial nerve $1,719.56
64772 Incision of spinal nerve $1,719.56
64776 Remove digit nerve lesion $1,719.56
64778 Digit nerve surgery add-on $1,719.56
64782 Remove limb nerve lesion $1,719.56
64783 Limb nerve surgery add-on $1,719.56
64784 Remove nerve lesion $1,719.56
64787 Implant nerve end $1,719.56
64790 Removal of nerve lesion $1,719.56
64831 Repair of digit nerve $3,288.46
64832 Repair nerve add-on $3,288.46
64834 Repair of hand or foot nerve $3,288.46
64836 Repair of hand or foot nerve $3,288.46
64837 Repair nerve add-on $3,288.46
64856 Repair/transpose nerve $3,288.46
64890 Nerve graft hand or foot $3,288.46
64898 Nerve graft arm or leg $3,288.46
64910 Nerve repair w/allograft $3,288.46
65210 Remove foreign body from eye $96.38
65222 Remove foreign body from eye $96.38
65235 Remove foreign body from eye $1,512.88
65260 Remove foreign body from eye $438.12
65280 Repair of eye wound $1,960.28
65285 Repair of eye wound $3,733.27
65400 Removal of eye lesion $1,512.88
65426 Removal of eye lesion $2,119.41
65435 Curette/treat cornea $696.90
65710 Corneal transplant $3,010.00 *
65730 Corneal transplant $3,010.00 *
65750 Corneal transplant $3,010.00 *
65755 Corneal transplant $3,010.00 *
65756 Corneal trnspl endothelial $3,010.00 *
65875 Incise inner eye adhesions $2,119.41
66180 Implant eye shunt $3,784.41
66250 Follow-up surgery of eye $1,512.88
66761 Revision of iris $492.60
66821 After cataract laser surgery $492.60
66825 Reposition intraocular lens $2,119.41
66830 Removal of lens lesion $657.07
66840 Removal of lens material $1,512.88
66852 Removal of lens material $2,820.30
66920 Extraction of lens $2,820.30
66930 Extraction of lens $2,820.30
66982 Cataract surgery complex $2,173.65
66983 Cataract surg w/iol 1 stage $2,173.65
66984 Cataract surg w/iol 1 stage $2,173.65
66985 Insert lens prosthesis $2,173.65
67036 Removal of inner eye fluid $3,733.27
67040 Laser treatment of retina $3,733.27
67110 Repair detached retina $1,960.28
67121 Remove eye implant material $3,733.27
67225 Eye photodynamic ther add-on $438.12
67314 Revise eye muscle $2,263.40
67332 Rerevise eye muscles add-on $2,263.40
67335 Eye suture during surgery $2,263.40
67399 Eye muscle surgery procedure $2,263.40
67820 Revise eyelashes $96.38
67875 Closure of eyelid by suture $696.90
67917 Repair eyelid defect $1,800.25
67950 Revision of eyelid $1,800.25
68320 Revise/graft eyelid lining $2,488.63
68360 Revise eyelid lining $2,119.41
68362 Revise eyelid lining $2,119.41
69310 Rebuild outer ear canal $4,099.33
69436 Create eardrum opening $1,535.50
69620 Repair of eardrum $2,265.44
69631 Repair eardrum structures $4,099.33

053-9 Wyo. Code R. § 9-9

Amended, Eff. 12/12/2017.

Amended, Eff. 5/23/2018.