ราคากรมบัญชีกลาง

- 1
- 2
- 3
- 4
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- 6
- 7
- 8
- 9
- 10
- 11

- 12
- 13
- 16
:
ICU

.. 2547

1. (Labor Cost: LC)
50
2.
(Material Cost: MC)
3.

(Capital Cost: CC)

25
4. (Overhead Cost) 20 LC, MC
CC

( )

5. (Future Development Cost)
20-25 LC, MC, CC Overhead Cost (
)
(Mark up) (Step)

16
1
2
3
4
5
6
7
8
9
10
11

12
13
14
15
16

1. 1 2

(
)
2. 3 12 ( 11 )

2.1

2.2
2548

3. 11
2548
11-15
4. 13
( )
5.
8 14 15
16

( )
6.

7.
ICU ()

1,000

1. (Synonym, Acronym Eponym)

Anti-Scl-70
Anti-topoisomerase I

2. 1
(.)
( )
2548

2.1

2.2
.

3.

2548 .

.

1.
2. ( )
3. ( ..
)

I.C.U. 300-600
( )
I.C.U.

1.1
1.2
1.3
/
Ambulatory, one day
treatment (
)
300 21101
300
600 21201
600
100 -
21301

2
-

1.

1.1
1.2 13

13

2.

2.1
100
2.2
200

(.)

. 1 2548 18.00 .
3 2548 10.00 .
2
18.00 . 1
18.00 . 2 = 24 = 1
18.00 . 2 10.00 . 3 = 16 1
. 1 2548 9.00 .
3 2548 11.00 .
2
9.00 . 1
9.00 . 2 = 24 = 1
9.00 . 2 9.00 . 3 = 24 = 1
9.00
11.00 . 3 = 2
. 1 2548 10.00 .
17.00 .
1
10.00
17.00 . 1 = 7 1
. 1 2548 10.00 .
15.00 . = 5
100
2

0417/ 460 24 2547

10 (Vagal Nerve Stimulator)
( 1201)
900,000
-
0417/ 77 15 2548

10
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8 /
- 9
-

1.

2.

3.

0417/ 140 7 2548
3

1.
(.)
2.
2.1

0526.5/ 66 30
2542 0526.5/
65

2.2 .

2.3 .

()
0.01 0.20 0.50
0.21 0.50 1.00
0.50 1 1.50
1.01 10 1.50 + 125
% 1
10.01 100 1
3 + 120 % 10
100.01 1,000 1
26 + 115 % 100
1,000 1,1
61 + 110 % 1,000
10 0.25
10 100 0.50
100 0.50 0.50

2 1.50 + 1.25
X (2 1)
2.75
1.50 + 1.25 X (4 1)
5.25
1.50 + 1.25 X (8 1)
10.25
10
16
13 + 1.20 X (16 10)
20.20
20
32
13 + 1.20 X (32 10)
39.40
39.50
64
13 + 1.20 X (64 10)
77.80
78
128
126 + 1.15 X (128 100)
158.20
158
512
126 + 1.15 X (512 100)
599.80
600
1,024
1,161 + 1.10 X (1,024 1,000)
1,187.40
1,187
6,000
1,161 + 1.10 X (6,000 1,000)
6,661
11,000
1,161 + 1.10 X (11,000 1,000)
12,161

2

(

)

6

(Whole Blood) (Packed Red Cell)
(Fresh Plasma Fresh Frozen Plasma) (Platelet Concentrate)
(Plasma)

Blood Bank Section

6.1.1 Antibody identification (tube method)
6.1.2 Antibody identification (gel test)
6.1.3 Antibody screening, (Indirect
antiglobulin) (tube method)
6.1.4 Antibody screening, (Indirect
antiglobulin) (gel test)
6.1.5 Blood group (ABO) - Tube method
6.1.6 ABO Cell grouping
6.1.7 ABO Serum grouping
6.1.8 Rh. (D) Typing
6.1.9 Rh. Typing (Complete)
6.1.10 Direct antiglobulin test
6.1.11 Direct antiglobulin test (gel test)
6.1.12 Cross matching
6.1.13 Cross matching (gel test)
6.1
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
200 1)
400
50
100 2)
100
50
50 7 (
40 7.1.1.16 - 7.1.1.25)
350
45
100
80
150
22101
22102
22103
22104
22105
22106
22107
22108
22109
22110
22111
22114
22115

NAT Unit

6.2
Whole Blood
1)
6.2.1 Whole blood ()
720
23101
6.2.2 Leukocyte depleted whole blood
1,860
23102
(LD.WB) ()
6.2.3 Whole blood
700 23151
6.2.4 Whole blood (NAT)
1,200
23152
6.2.5 Autologous blood/whole blood
700 2)
23153
Packed Red Cell: PRC

6.3
6.3.1 PRC ()
580 Leukocyte
23201
6.3.2 Leukocyte poor PRC ()
660 depleted
23202
6.3.3 Leukocyte depleted PRC ()
1,710 filtration set 23203

6.3.4 Single donor PRC/unit ()
1,800 3) Leukocyte 23204

6.3.5 Leukocyte depleted single donor PRC/
2,640 depletion filter
23205

unit ()
6.3.6 Single donor red cell. (SDR)
1,800 Leukocyte depleted 23206

products
Non-Filter ()
6.3.7 Single donor red cell. (SDR) Filter
2,640 Leukocyte
23207
depleted products
()
6.3.8 PRC
480 4)
23251
6.3.9 PRC (NAT)
780
23252
6.3.10 Leukocyte poor PRC
550
23253
unit
6.3.11 Leukocyte poor PRC (NAT)
850
23254
NAT
6.3.12 Leukocyte depleted PRC
1,650
23255
6.3.13 Leukocyte depleted PRC (NAT)
1,950
23256
6.4
Platelet
6.4.1
Blood Bank Section
Random platelet conc. ()
400
23301
6.4.2
Blood Bank Section
Leukocyte poor pooled platelet conc.

()
6.4.3 Leukocyte depleted pooled platelet
conc. () (4units)
6.4.4 Single donor platelet conc., NonFiltered, close system ()
6.4.5 Single donor platelet conc., Filtered,
close system ()
6.4.6 Platelet concentrate
6.4.7 Leukocyte poor platelet conc. 4 units
6.4.8 Leukocyte depleted platelet conc.
4 units (filtration method)
6.4.9 Single donor platelet, open system
6.4.10 Single donor platelet, open system
(filtration method)
6.4.11 Single donor platelet, close system
6.4.12 Single donor platelet, close system
(filtration method)
6.5
Plasma, WBC
6.5.1 Fresh frozen plasma ()
6.5.2 Cryo-removed plasma ()
6.5.3 Cryoprecipitate ()
6.5.4 Fresh frozen plasma
6.5.5 Fresh frozen plasma (NAT)
6.5.6 Leucocyte depleted fresh frozen
plasma (LD.FFP)
6.5.7 Aged Plasma/cryo-removed plasma
6.5.8 Cryoprecipitate
6.5.9 Single donor granocyte
4,800
23302
5,520
23303
7,200
23304
9,000
23305
380
4,500
6,300
23351
23352
23353
7,000
8,500
23354
23355
7,500
9,500
23356
23357
400
330
330
370
670
695
23401
23402
23403
23451
23452
23453
400
370
7,000
23454
23455
23456
6.6
6.6.1
6.6.2
6.6.3
6.6.4
6.6.5
6.6.6
6.6.7
6.6.8
6.6.9
Blood Bank Section

( )
Leukapheresis
Blood exchange Apherresis
Plasma exchange Apherresis
Stem cell processing for Autologous
Bone marrow collection
Stem cell processing for Autologous
PBSC collection
Stem cell processing for Bone
marrow collection
Stem cell processing for Cord blood
collection
6.6.10

6.1-6.6

*NAT= Nucleic acid Amplification Technology
350
7,000
7,000
7,000
7,500
23501
23502
23503
23504
23505
7,500
23506
3,000
23507
7,500
23508
100
23509
100
2548
23510
23999
1. 2.
( Cross matching x ( Blood component

) +
x )
(1+2)

Whole blood (80 x 2) + 140 = 300 1 = 720
1 = 300 + 720
2 ()
2 = 1,440 = 1,020
2 = 300 + 1,440
= 1,740
Packed red (80 x 3) + 140 = 380 1 = 580
1 = 380 + 580
cell 3
2 = 1,160 = 960
()
2 = 380 + 960
= 1,540
Leukocyte 1 = 4 = 4,800 = 140 + 4,800
poor pooled
140
= 4,940
platelet
concentrate 1
()
7.1 Hematology
7.1.1
Blood Cells
7.1.1.1 CBC (+ diff. + RBC morphology + plt
count) by automation
7.1.1.2 CBC (+ diff. + RBC morphology, platelet
smear) - Manual
7.1.1.3 Reticulocyte count
7.1.1.4 Hct (Hematocrit)
7.1.1.5 ESR (Erythrocyte Sedimentation Rate)
7.1.1.6 Acid phosphatase with tartrate (hairy cell
leukemia)
7.1.1.7 Bone marrow stain (wright stain),
differential, interpretation
7.1.1.8 Bone marrow, iron stain, interpretation
7.1.1.9 Cytochemical profile stain ()
7.1.1.10 Buffy coat preparation, stain, interpretation
7.1.1.11 Heinz body
7.1.1.12 Hemosiderin test
7.1.1.13 Inclusion body
Test
90
30101
Test
60
30102
Test
Test
Test
Test
40
30
40
200
30103
30104
30105
30106
Test
185
30107
Test
Test
Test
Test
Test
Test
50
100
110
50
80
30
30108
30109
30110
30111
30112
30113

7.1.1.14
7.1.1.15
7.1.1.16
7.1.1.17
7.1.1.18
7.1.1.19
7.1.1.20
7.1.1.21
7.1.1.22
7.1.1.23
7.1.1.23
7.1.1.24
7.1.1.25
7.1.1.26
7.1.1.27
7.1.1.28
7.1.1.29
7.1.2
7.1.2.1
7.1.2.2
7.1.2.3
7.1.2.4
7.1.2.5
7.1.2.6
7.1.2.7
7.1.2.8
7.1.2.9
Sudan Black
LAP score
Antibody identification (tube method)
Antibody identification (gel test)
Antibody screening, (Indirect
antiglobulin) (tube method)
Antibody screening, (Indirect
antiglobulin) (gel test)
Blood group (ABO) Tube method
ABO Cell grouping
ABO Serum grouping
Rh. (D) Typing
Rh. Typing (complete)
Direct antiglobulin test
Direct antiglobulin test (gel test)
LE cell preparation, stain, examination
Osmotic fragility test, screening
Osmotic fragility test, quantitative
Malarial film
Coagulation
PT (Prothombin Time)
PTT (Partial Thomboplastin Time)
TT (Thrombin Time)
VCT (Venous Cloting Time)
Clot retraction time/Clot lysis time
ELT (Euglobulin Lysis Time)
FDP (Fibrin Degradation Product)
D-dimer
Von Willebrand factor
Test
Test
Test
Test
Test
100
550
200
400
50
30127
30114
30115
30128
30116
Test
100
30129
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
100
50
50
40
350
45
100
150
50
100
50
30118
30119
30120
30121
30130
30122
30131
30124
30125
30133
30126
Test
Test
Test
Test
Test
Test
Test
Test
Test
60
70
80
40
30
50
800
300
400
30201
30202
30203
30204
30205
30206
30207
30208
30209
7.1.2.10
7.1.2.11
7.1.2.12
7.1.2.13
Bleeding time
Ristocetin cofactor activity
Ristocetin induced agglutination
Dichlorophenol indophenol precipitation
test (DCIP)
Fibrinogen level
Factor assay - Factor II
Factor assay - Factor V
Factor assay - Factor V Leiden
Factor assay - Factor VII
Factor assay - Factor VIII
Factor assay - Factor VIII Inhibitor
Factor assay - Factor IX
Factor assay - Factor IX Inhibitor
Factor assay - Factor X
Factor assay - Factor XI
Factor assay - Factor XII
Platelet aggregration with ADP, Collagen,
Adrenaline, Ristocetin
Protein C (automate ACC)
Protein S (automate ACC)
Antithrombin III activity (chromogenic)
Heparin anti Xa
Alpha 2 antiplasmin
Lupus anticoagulant (screening)
Lupus anticoagulant (confirm), conc RW
Other Substances/Molecules/Tests
Red cell folate (chemiluminescent)
Serum iron
Test
Test
Test
Test
60
250
250
70
30210
30211
30212
30213
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
350
1,000
1,000
1,900
1,000
750
900
600
1,000
1,000
1,000
1,000
800
30214
30215
30216
30217
30218
30219
30220
30221
30222
30223
30224
30225
30226
Test
Test
Test
Test
Test
Test
Test
600
700
250
400
300
90
250
30227
30228
30229
30230
30231
30233
30234
Test
Test
250
80
30303
30304
7.1.2.14
7.1.2.15
7.1.2.16
7.1.2.17
7.1.2.18
7.1.2.19
7.1.2.20
7.1.2.21
7.1.2.22
7.1.2.23
7.1.2.24
7.1.2.25
7.1.2.26
7.1.2.27
7.1.2.28
7.1.2.29
7.1.2.30
7.1.2.31
7.1.2.32
7.1.2.33
7.1.3
7.1.3.1
7.1.3.2

7.1.3.3
7.1.3.4
7.1.3.5
7.1.3.6
7.1.3.7
7.1.3.8
7.1.3.9
7.1.3.10
7.1.3.11
7.1.3.12
7.1.3.13
7.1.4
7.1.4.1
7.1.4.2
7.1.4.3
7.1.4.4
7.1.4.5
7.1.5
7.1.5.1
7.1.5.2
7.1.5.3
7.1.5.4
TIBC
Ferritin
Transferrin
EPO (erythropoietin)
Fetal hemoglobin
G-6-PD
Homocystein
Hams test
Hb typing (Hemoglobin typing)
Serum viscosity
Haptoglobin
Chromosome/DNA
Chromosome study from blood/BM
Chromosome study from amniotic fluid/
chorionic villus
DNA index (ploidy) for ALL
DNA detection for , -thalassemia
gene
RT-PCR for BCR/ABL gene for diagnosis
of CML
Leukocyte Surface Antigens/Subpopulation
Flow cytometry for acute leukemia panel,
AML, ALL
Flow cytometry for Non Hodgkins
lymphoma panel
Flow cytometry for detection of DAF (CD55
and CD59) (blood)
Immunophenotyping for CD34 surface
antigen (blood, flow cytometry)
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
80
310
250
250
80
60
400
90
270
100
200
30305
30306
30307
30308
30309
30310
30311
30312
30313
30316
30317
Test
Test
1,500
2,500
30401
30402
Test
Test
1,600
1,200
30403
30404
Test
1,000
30405
Test
2,300
30501
Test
1,800
30502
Test
600
30503
Test
1,000
30504

7.1.5.5
7.1.5.6
7.1.5.7
7.1.5.8
7.1.5.9
7.1.5.10
7.1.5.11
7.1.5.12
7.1.6
7.1.6.1
7.1.6.2
7.1.6.3
7.1.6.4
7.1.6.5
7.1.6.6
7.1.6.7
7.1.6.8
7.1.6.9
7.1.6.10
Flow cytometry for minimal residual

disease, B-ALL panel
disease, T-ALL panel
disease, AML panel
CD3 Count
CD4 Count
CD8 Count
CD19 Count
CD56 Count
HLA
Test
1,800
30505
Test
1,600
30506
Test
1,600
30507
Test
Test
Test
Test
Test
1,000
500
500
1,000
1,000
30508
30509
30510
30511
30512
Disease association: HLA-B27 typing

Kidney/Bone marrow transplantation Autoantibody (T, B)
Kidney/Bone marrow transplantation Lymphocyte crossmatch T, B cell
Bone marrow transplantation - HLA-AB
common Ag typing
Bone marrow transplantation - HLA-ABC
complete typing
Bone marrow transplantation - HLA class
II DNA High Resolution
Transfusion reaction - HLA antibody
Transfusion reaction - Leukoagglutinin
Kidney transplantation - HLA-A, B DNA
typing
Kidney transplantation - Panel reactive
antibody (PRA)
Test
Test
500
1,500
30601
30602
Test
2,000
30603
Test
1,200
30604
Test
5,000
30605
Test
7,600
30606
Test
Test
Test
800
400
5,000
30607
30608
30609
Test
1,300
30610
7.1.6.11
Kidney transplantation - HLA-DRB, DQB

DNA typing
Stem cells
Test
4,500
30611
Test
Test
600
600
30701
30702
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
50
20
20
20
20
40
40
30
50
40
50
100
50
70
40
31001
31002
31003
31004
31005
31006
31007
31008
31009
31010
31011
31012
31013
31101
31102
Test
Test
Test
Test
Test
40
60
30
30
80
31201
31202
31203
31204
31205
7.1.7
7.1.7.1 Stem cell cuture for BFU-E number

7.1.7.2 Stem cell cuture for CFU-GM number
7.2. Clinical Microscopy
7.2.1
Urine examination
7.2.1.1 Urine Analysis
7.2.1.2 Specific gravity
7.2.1.3 pH
7.2.1.4 Albumin
7.2.1.5 Sugar
7.2.1.6 Bile
7.2.1.7 Ketone body
7.2.1.8 Phenyketonuria
7.2.1.9 Urobilinogen
7.2.1.10 Hemosiderin
7.2.1.11 Alkaptonuria
7.2.1.12 Urine Iodine
7.2.1.13 Melanin in urine
7.2.1.14 Pregnancy test
7.2.1.15 Bence-Jones protein
7.2.2
Stool examination
7.2.2.1 Routine direct smear
7.2.2.2 Routine concentration
7.2.2.3 Occult blood
7.2.2.4 Sudan stain (stool)
7.2.2.5 Stool fat
7.2.3
Other Examination
7.2.3.1 Body fluid examination

7.2.3.2 Giemsa stain for Virus or Parasite
7.2.3.3 Pneumocystis carinii
7.2.3.4 Semen analysis
7.2.3.5 Acid phosphatase and spermatozoa
7.2.3.6 Herpes virus DIF
7.2.3.7 Dark field for Treponema
7.2.3.8 Tzanks smear (wright stain)
7.3 Clinical Chemistry
7.3.1
Combined
7.3.1.1 Electrolyte (Na, K, Cl, CO2)
7.3.1.2 Blood gas analysis
7.3.1.3 Liver function test
7.3.1.4 Lipid profile (Cholesterol, HDL-chol,
LDL-chol, TG)
7.3.1.5 Lipoprotein electrophoresis
7.3.1.6 Protein electrophoresis
7.3.2
Inorganic
7.3.2.1 Serum osmolarity
7.3.2.2 Na
7.3.2.3 K
7.3.2.4 Cl
7.3.2.5 CO2
7.3.2.6 Calcium
7.3.2.7 Ionized calcium
7.3.2.8 Magnesium
7.3.2.9 Ionized magnesium
7.3.2.10 Zinc
7.3.2.11 Phosphorus
Test
Test
Test
Test
Test
Test
Test
Test
60
80
150
120
270
100
50
80
31301
31302
31303
31401
31402
31501
31502
31503
Test
Test
Test
Test
80
160
350
200
32001
32002
32003
32004
Test
Test
300
300
32005
32006
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
120
40
40
40
40
50
400
70
400
350
55
32101
32102
32103
32104
32105
32106
32110
32107
32111
32108
32109

7.3.3
7.3.3.1
7.3.3.2
7.3.3.3
7.3.3.4
7.3.3.5
7.3.3.6
7.3.3.7
7.3.3.8
7.3.3.9
7.3.3.10
7.3.4
7.3.4.1
7.3.4.2
7.3.4.3
7.3.4.4
7.3.4.5
7.3.4.6
7.3.4.7
7.3.4.8
7.3.4.9
7.3.4.10
7.3.4.11
7.3.4.12
7.3.4.13
7.3.4.14
7.3.4.15
Organic/Biochem
BUN (Blood Urea Nitrogen)
Creatinine
Glucose
OGTT (Oral Glucose Tolerance Test)

Uric acid
Fructosamine
Bilirubin, Direct
Bilirubin, Total
Bilirubin, Micro
Ammonia
Proteins Enzymes
Acid phosphatase, Total
Aldolase
Amylase (blood)
CPK
CK-MB
LDH
LDH isoenzyme
Troponin I
Troponin T
Alkaline phosphatase
SGOT (AST)
SGPT (ALT)
Gamma glutamyl transpeptidase
Lipase
Myoglobin
Test
Test
Test
Test
50
50
40
170
32201
32202
32203
32204
Test
Test
Test
Test
Test
Test
60
100
50
50
60
300
32205
32206
32207
32208
32209
32210
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
150
150
100
90
120
60
250
260
400
50
50
50
130
250
300
32301
32314
32303
32304
32305
32306
32315
32307
32308
32309
32310
32311
32312
32313
32316
7.3.5
7.3.5.1
7.3.5.2
7.3.5.3
7.3.5.4
7.3.5.5
7.3.5.6
7.3.5.7
7.3.5.8
7.3.5.9
7.3.5.10
7.3.5.11
7.3.5.12
7.3.5.13
7.3.6
7.3.6.1
7.3.6.2
7.3.6.3
7.3.6.4
7.3.6.5
7.3.6.6
7.3.6.7
Proteins - nonenzyme, Vitamins

Hb A1C
Protein, Total
Albumin
Ceruloplasmin
NT-pro BNP
Prealbumin
Vitamin A
Vitamin B1
Vitamin B12
Vitamin C
Vitamin E
Beta carotene
Folate
Lipid & Lipoproteins
Lipid - Cholesterol
Lipid - TG (Triglyceride)
Lipid - HDL-chol
Lipid - LDL-chol (direct)
Apo A
Apo B
Lipoprotein A
7.3.7
7.3.7.1
7.3.7.2
7.3.7.3
7.3.7.4
7.3.7.5
7.3.7.6
Hormones
ACTH (Immulite)
ACTH (IRMA)
Cortisol
17-Oxosteroids
17-Oxogenic steroids
Aldosterone
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
150
50
50
300
1,500
300
1,000
150
200
300
1,000
1,000
200
32401
32402
32403
32406
32407
32408
32409
32410
30311
32412
32413
32414
30315
Test
Test
Test
Test
Test
Test
Test
60
60
100
150
200
200
250
32501
32502
32503
32504
32505
32506
32507
Test
Test
Test
Test
Test
Test
350
700
300
200
250
600
32601
32602
32603
32628
32629
32604
7.3.7.7
7.3.7.8
7.3.7.9
7.3.7.10
Renin
17-OH-progesterone
DHEA-sulphate
Thyroid hormone - TSH (Thyroid
Stimulating Hormone)
Thyroid hormone - T4 (Thyroxine)
Thyroid hormone - Free T4 (Free Thyroxine)
Thyroid hormone - T3 (Tri - iodothyroxine)
Thyroid hormone - Free T3 (Free Tri iodothyroxine )
PTH (intact)
Osteocalcin
Calcitonin
FSH
LH
Estradiol
Progesterone
Testosterone
Free androgen index
Prolactin
Growth hormone
C-peptide
Insulin
Insulin - IG F1
Insulin - IGF BP3
Serum thyroglobulin (IRMA)
Serum anti-thyroglobulin antibody (IRMA)
Serum neonatal blood spots TSH (IRMA)
Drugs
Test
Test
Test
Test
800
250
300
200
32605
32606
32607
32608
Test
Test
Test
Test
180
200
200
200
32609
32610
32611
32612
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
200
250
500
250
250
300
250
250
450
300
600
350
250
600
400
400
400
50
32613
32614
32615
32616
32617
32618
32619
32620
32621
32622
32623
32624
32625
32626
32627
32630
32631
32632
7.3.7.11
7.3.7.12
7.3.7.13
7.3.7.14
7.3.7.15
7.3.7.16
7.3.7.17
7.3.7.18
7.3.7.19
7.3.7.20
7.3.7.21
7.3.7.22
7.3.7.23
7.3.7.24
7.3.7.25
7.3.7.26
7.3.7.27
7.3.7.28
7.3.7.29
7.3.7.30
7.3.7.31
7.3.7.32
7.3.8
7.3.8.1
7.3.8.2
7.3.8.3
7.3.8.4
7.3.8.5
7.3.8.6
7.3.8.7
7.3.8.8
7.3.8.9
7.3.8.10
Aminoglycoside
Isoniazid (INH) (HPLC)
Pyrazinamide (HPLC)
Rifampicin (HPLC)
Vancomycin
Carbamazepine (Tegretol)
Phenobarbital
Phenytoin (Dilantin)
Valproic acid/Sodium valproate (Depakin)
Benzodiazepine, Phenothiazine, Tricyclic
antidepressant
Chlorpromazine
Acetaminophen
Salicylate
Chlorpheniramine
Lithium (blood)
Cyclosporin (CSA)
Methotrexate
Tracolimus
Sirolimus
Theophyline
Digoxin
Hydrocortisone
Wafarin
Prednisolone
Dexamethasone
Toxicology
Metals
Aluminium (blood)
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
200
220
220
220
220
250
200
250
250
250
33001
33002
33003
33004
33005
33101
33102
33103
33104
33105
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
200
300
300
250
350
1,000
220
1,000
1,000
250
200
200
200
250
200
33106
33107
33108
33109
33110
33201
33202
33203
33204
33301
33302
33303
33304
33305
33306
Test
300
33501
7.3.8.11
7.3.8.12
7.3.8.13
7.3.8.14
7.3.8.15
7.3.8.16
7.3.8.17
7.3.8.18
7.3.8.19
7.3.8.20
7.3.8.21
7.3.8.22
7.3.8.23
7.3.8.24
7.3.8.25
7.3.9
7.3.9.1

7.3.9.2
7.3.9.3
7.3.9.4
7.3.9.5
7.3.9.6
7.3.9.7
7.3.9.8
7.3.9.10
7.3.9.11
7.3.9.12
7.3.9.13
7.3.9.14
7.3.9.15
7.3.9.16
7.3.9.17
7.3.9.18
7.3.9.19
7.3.9.20
7.3.9.21
7.3.9.22
7.3.9.23
7.3.9.24
7.3.9.25
7.3.9.26
7.3.9.27
7.3.9.28
7.3.9.29
Arsenic (gastric lavage)

Arsenic (blood, urine)
Cadmium (blood, urine)
Chromium (blood)
Copper (blood)
Copper (24 hours urine)
Lead (blood)
Lead (urine)
Manganese (blood)
Mercury (blood, urine)
Nickel (blood, urine)
Volatile Agents, Solvents
Acetone (urine)
Acetonitrite
Benzene (urine)
Butanol
Chloroform
Ethanol (Ethyl alcohol) (blood) GC
Isopropanol (urine)
Methanol (blood) GC-headspace
Thinner (urine)
Xylene (urine)
Other volatile agent
Pesticides
Carbamate
Carbamate (Gastric lavage)
Chlorinated hydrocarbon
Organophosphate (Gastric lavage)
Paraquat
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
100
350
350
350
350
350
200
300
200
350
350
33502
33503
33504
33505
33506
33507
33508
33510
33511
33512
33513
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
250
250
250
150
250
250
250
250
300
250
250
33550
33551
33552
33553
33554
33555
33556
33557
33558
33559
33560
Test
Test
Test
Test
Test
200
100
250
100
250
33601
33602
33603
33604
33605
7.3.9.30
7.3.9.31
Paraquate (urine)
Zinc Phosphide (Gastric lavage)
Drugs
Amphetamine (urine)
Cannabis (Urine)
Cocaine
Cocain (urine)
Marijuana (Cannabinoid) (urine)
(immunoassay)
Marijuana (urine) (HPLC)
Methadone, Confirm test
Methamphetamine (urine) (immunoassay)
Methamphetamine (urine), Confirm test
HPLC
Morphine, Confirm test
Pethidine, Confirm test
Urine organic acid
Opiate, Screening test (eg. Morphine,
Heroin, Codeine)
Screening for basic drugs and drugs
abuse (blood)(Automate HPLC: REMEDI)
Screening for basic drugs and drugs
abuse (urine) (Automate HPLC: REMEDI)
Screening for drugs and pesticide
(Paracetamol , Benzodizipine) (Gastric
larvage) ( GC-MS)
Bodys Molecules
Adenosine deaminase test (body fluid)
Acetylcholinesterase activity in RBC or
Test
Test
100
100
33606
33607
Test
Test
Test
Test
Test
300
300
700
300
120
33701
33702
33703
33704
33705
Test
Test
Test
Test
700
700
150
1,000
33706
33707
33708
33709
Test
Test
Test
Test
700
700
2,000
140
33710
33711
33712
33713
Test
1,300
33714
Test
1,000
33715
Test
1,300
33716
Test
Test
200
250
33801
33802
7.3.9.32
7.3.9.33
7.3.9.34
7.3.9.35
7.3.9.36
7.3.9.37
7.3.9.38
7.3.9.39
7.3.9.40
7.3.9.41
7.3.9.42
7.3.9.43
7.3.9.44
7.3.9.45
7.3.9.46
7.3.9.47
7.3.9.48
7.3.9.49
Plasma (Organophosphate)
7.3.9.50 Cholinesterase (plasma or red cell)
7.3.9.51 Carboxyhemoglobin
7.3.10
Urine Chemistry
7.3.10.1 Urine Osmolality
7.3.10.2 Urine Sodium
7.3.10.3 Urine Potassium
7.3.10.4 Urine Calcium
7.3.10.5 Urine Creatinine
7.3.10.6 Urine Creatinine (24 hours)
7.3.10.7 Urine Microalbumin
7.3.10.8 Urine Protein (Random)
7.3.10.9 Urine Protein (24 Hours)
7.3.10.10 Urine VMA
7.3.10.11 Urine VMA (HPLC)
7.3.10.12 Urine catecholamine
7.3.10.13 Urine metanephrine
7.3.10.14 Urine HVA
7.3.10.15 Urine HIAA (5-Hydroxyindoleacetic acid)
7.3.10.16 Urine free cortisol
7.3.10.17 Urine 17-KS
7.3.10.18 Urine 17-OHCS
7.3.10.19 Urine Amylase
7.3.10.20 Urine Porphyrin
7.3.11
Body Fluid Chemistry
7.3.11.1 Protein
7.3.11.2 Sugar
7.3.11.3 Chloride
7.4 Microbiology Section
Test
Test
360
250
33803
33804
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
120
40
40
50
50
90
270
50
90
300
600
800
1,000
600
600
250
250
250
100
100
34001
34002
34004
34006
34101
34102
34116
34103
34104
34105
34106
34107
34108
34109
34110
34111
34112
34113
34114
34115
Test
Test
Test
70
70
70
34301
34302
34303

7.4.1
7.4.2
7.4.3
7.4.4
7.4.5
7.4.6
7.4.7
7.4.8
7.4.9
7.4.10
7.4.11
7.4.12
7.4.13
7.4.14
AFB stain (Acid-Fast Bacilli stain)

Modified AFB
Gram stain
Gram chromotope stain for microsporidium
Indian ink preparation
KOH preparation
Wet smear
scabies
Routine aerobic culture and sensitivity
Anaerobic culture and sensitivity
Mycobacterium culture
Mycobacterial culture and sensitvity
Hemoculture and sensitivity, Manual
Hemoculture and sensitivity, Automate
7.4.15
Culture - Helicobacter culture (
)
7.4.16
Culture for fungus
7.4.17
Sensitivity Test
7.4.18
MIC
7.4.19
MBC
7.4.20
SBC
7.4.21
Mycobacteria: antimicrobial susceptibility
test for non-tuberculous mycobacteria
7.4.22
Fungi: antimicrobial susceptibility test
yeast
7.4.23
Urease test ( )
7.5 Immunological/Serology and Virology Section
7.5.1
Bacteria
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
60
70
65
100
55
60
50
50
200
400
200
400
220
290
35001
35005
35002
35006
35003
35004
35007
35008
35101
35102
35103
35110
35104
35105
Test
400
35106
Test
Test
Test
Test
Test
Test
110
130
150
150
150
200
35107
35108
35109
35111
35112
35113
Test
600
35114
Test
50
35201
7.5.1.1
7.5.1.2
7.5.1.3
7.5.1.4
7.5.1.5
7.5.1.6
7.5.1.7
7.5.1.8
7.5.1.9
7.5.1.10
7.5.1.11
7.5.1.12
7.5.1.13
7.5.1.14
7.5.1.15
7.5.1.16
7.5.1.17
7.5.1.18
7.5.1.19
7.5.1.20
7.5.1.21
7.5.1.22
7.5.1.23
7.5.1.24
7.5.2
7.5.2.1
7.5.2.2
7.5.2.3
7.5.2.4
ASO test - Latex

ASO test - Nephelometry
VDRL (RPR)
FTA-Abs
FTA-ABS Ig M
TPHA
Leptospira-Ab screening
S. pneumoniae Ag
Streptococcus gr B Ag
N. meningitidis ACYW 135 Ag
N. meningitidis B/E coli K 1 Ag
B. pseudomallei-Ab (Melloid titer)
H. influenzae type b Ag
Helicobacter pyroli/Ab
H. Pylori (CLO)
Mycoplasma pneumoniae-Ab IgG
Mycoplasma pneumoniae-Ab IgM
Mycoplasma pneumoniae-Ab
C. defficile toxin A
TB-DNA (PCR for TB)
Weil-felix test
Widals test
Bacterial Antigen
Brucella Ab
Fungal
Cryptococcus neoformans - Ag titer (LA)
Cryptococcus: DNA detection
Histoplasma
Toxoplasma, IgG/ IgM
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
110
250
50
200
200
100
200
250
250
250
250
80
200
500
300
250
350
250
500
1,500
100
100
800
100
36001
36002
36003
36004
36005
36006
36007
36008
36009
36010
36011
36012
36013
36014
36015
36016
36022
36023
36017
36018
36019
36020
36021
36024
Test
Test
Test
Test
270
650
180
250
36101
36104
36102
36103
7.5.2.5
7.5.2.7
7.5.2.8
7.5.3
7.5.3.1
7.5.3.2
7.5.3.3
7.5.4
7.5.4.1
7.5.4.2
7.5.4.3
7.5.4.4
7.5.4.5
7.5.4.6
7.5.4.7
7.5.4.8
7.5.4.9
7.5.4.10
7.5.4.11
Candida: DNA detection

Pythium antibody detection
Pythium antibody detection Western blot
Parasites
E. histolytica-Ab
PCP (Pneumocistis) - IFA
Cysticercosis Ab
Viruses: Hepatitis, HIV
Hepatitis - Anti HAV total (ELISA)
Hepatitis - Anti HAV IgM (ELISA)
Hepatitis - HAV RNA (PCR)
HBc-Ab - PHA
HBc-Ab - ELISA, MEIA, ECLIA
HBc-Ab (IgM)
HBe-Ag - PHA
HBe-Ag - ELISA, MEIA, ECLIA
HBe-Ab
HBs-Ab (Hepatitis B surface Ab) - PHA
HBs-Ab (Hepatitis B surface Ab) - ELISA,
MEIA, ECLIA
HBs-Ag (Hepatitis B surface antigen) PHA
HBs-Ag (Hepatitis B surface antigen) ELISA, MEIA, ECLIA
HBs-Ag (Hepatitis B surface antigen) PCR Qualitative
HBs-Ag (Hepatitis B surface antigen) Quantitative (Amplicor)
HBs-Ag (Hepatitis B surface antigen) -
Test
Test
Test
650
200
1,000
36105
36106
36107
Test
Test
Test
130
300
100
36201
36202
36203
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
500
500
1,700
140
230
300
150
300
350
100
180
36301
36302
36303
36310
36311
36312
36313
36314
36315
36316
36317
Test
80
36318
Test
130
36319
Test
1,700
36320
Test
2,200
36321
Test
3,000
36322
7.5.4.12
7.5.4.13
7.5.4.14
7.5.4.15
7.5.4.16

7.5.4.17
7.5.4.18
7.5.4.19
7.5.4.20
7.5.4.21
7.5.4.22
7.5.4.23
7.5.4.24
7.5.4.25
7.5.4.26
7.5.4.27
7.5.4.28
7.5.4.29
7.5.4.30
7.5.4.31
7.5.4.32
7.5.4.33
7.5.5
7.5.5.1
Quantitative (bDNA)
HBV Genotype, drug resistance (INNOLIPA)
HCV-Ab (Hepatitis C Antibody) - PHA
HCV-Ab (Hepatitis C Antibody) - ELISA,
MEIA, ECLIA
HCV-Ag - Qualitative PCR
HCV-Ag - Quantitative (Amplicor, bDNA)
HCV genotype (line-probe)
HIV-Ab (screening) - RAPID
HIV-Ab (screening) - GPA, ELISA, MEIA,
ECLIA
HIV-Ab (confirm) - WESTERN BLOT
Anti- HTLV-1
HIV-Ag
HIV - Qualitative RT-PCR
HIV - Quantitative, viral load standard
method
HIV-I genotype (3-DCR), reverse
transcriptase and protease inhibitors)
HIV-I genotype (3-DCR), reverse
transcriptase inhibitors
HIV-I genotype (3-DCR), protease
inhibitors
HIV-2, qualitative RT-PCR
Viruses: Others
Herpes (HSV, VZV, EBV,CMV,HHV)
HSV-1 and -2 (Herpes simplex virus type
1 and 2), direct FA smear sample (slide)
Test
3,200
36323
Test
Test
200
300
36330
36331
Test
Test
Test
Test
Test
1,700
2,500
3,800
250
140
36332
36333
36334
36350
36351
Test
Test
Test
Test
Test
1,000
150
160
1,700
2,000
36352
36353
36360
36361
36362
Test
8,000
36370
Test
4,700
36371
Test
4,700
36372
Test
1,600
36380
Test
250
36401
7.5.5.2
7.5.5.3
7.5.5.4
7.5.5.5
7.5.5.6
7.5.5.7
7.5.5.8
7.5.5.9
7.5.5.10
7.5.5.11
7.5.5.12
7.5.5.13
7.5.5.14
7.5.5.15
7.5.5.16
7.5.5.17
7.5.5.18
HSV-1 and -2 IgG (ELISA)

HSV-1 and -2 IgM (ELISA)
HSV-1 and -2, qualitative RT-PCR
HSV-1 and -2, viral load RT-PCR
HSV-1 and -2, isolation (culture)
HSV-2 Ag
VZV, IgG/IgM (Varicella-Zoster) (ELISA)
VZV, qualitative RT-PCR
VZV, viral load RT-PCR
EBV-IgG/IgM (Anti-Epstein Barr Virus)
EBV-IgA (Anti-Epstein Barr Virus)
EBV, qualitative RT-PCR
EBV, viral load RT-PCR
Cytomeglovirus-Ab
Cytomegalovirus (CMV), IgG/IgM (ELISA)
Cytomegalovirus (CMV) - Qualitative-PCR
Cytomegalovirus (CMV) - Viral load
(Amplicor)
HHV-6 (Human Herpesvirus type 6),
qualitative RT-PCR
HHV-7, qualitative RT-PCR
HHV-8, qualitative RT-PCR
Resp, GI viruses
Influenza virus-A, B, IgG/ IgM (ELISA)
Influenza virus, qualitative RT-PCR
Influenza virus, viral load RT-PCR
Avian influenza virus, qualitative RT-PCR
Avian influenza virus, viral load RT-PCR
Parainfluenza virus1,2,3 IgG/ IgM (ELISA)
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
300
300
1,600
1,600
500
300
300
1,600
1,600
300
250
1,600
1,600
250
300
1,600
2,500
36402
36403
36404
36405
36406
36415
36420
36421
36422
36430
36431
36432
36433
36440
36441
36442
36443
Test
1,600
36450
Test
Test
1,600
1,600
36451
36452
Test
Test
Test
Test
Test
Test
300
1,600
1,600
1,600
1,600
300
36501
36502
36503
36504
36505
36520
7.5.5.19
7.5.5.20
7.5.5.21
7.5.5.22
7.5.5.23
7.5.5.24
7.5.5.25
7.5.5.26
7.5.5.27
7.5.5.28
7.5.5.29
7.5.5.30
SARS corona virus-Qualitative

SARS corona virus-Viral load (PCR)
Respiratory syncytial virus IgG/IgM
(ELISA)
Adenovirus, Ig G/Ig M (ELISA)
Panenterovirus
Rota virus
Rotavirus (ds-RNA PAGE test)
Coxackie B Ab, neutralizing Ab (NT)
Arthropod - borne and other viruses
Chikungunya-Ab
Chikungunya, IgG (HAI)
Dengue virus-Ab
Dengue - IgG (HAI)
Dengue - IgM (ELISA)
Dengue virus, qualitative RT-PCR
Japanese Encephalitis virus Ab
West Nile virus
Nipah virus
Rabies Ab
Rabies virus Ag (FTA)
Rabies (NASBA)
Mumps, IgG/IgM (ELISA)
Measles, IgG/IgM (ELISA)
Rubella IgG
Rubella IgM antibody
JC Virus and BK Virus, qualitative RT-PCR
JC Virus and BK Virus, viral load RT-PCR
Parvo virus B19, IgG/IgM (ELISA)
Test
Test
Test
1,600
1,600
300
36530
36531
36540
Test
Test
Test
Test
Test
250
2,200
200
250
500
36550
36560
36570
36571
36580
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
250
150
310
200
300
800
250
1,500
1,500
400
250
1,500
250
250
200
300
1,600
1,600
300
36601
36602
36610
36611
36612
36613
36620
36630
36635
36640
36641
36642
36650
36655
36660
36661
36670
36671
36680
7.5.5.31
7.5.5.32
7.5.5.33
7.5.5.34
7.5.5.35
7.5.5.36
7.5.5.37
7.5.5.38
7.5.5.39
7.5.5.40
7.5.5.41
7.5.5.42
7.5.5.43
7.5.5.44
7.5.5.45
7.5.5.46
7.5.5.47
7.5.5.48
7.5.5.49
7.5.5.50
7.5.5.51
7.5.5.52
7.5.5.53
7.5.5.54
7.5.5.55
7.5.5.56
7.5.5.57
Parvo virus B19, qualitative RT-PCR

Parvo virus B19, viral load RT-PCR
HPV (Human papilomavirus) qualitative
RT-PCR, screen for high risk types
Immunology
Rheumatoid factor test - Latex
Rheumatoid factor test - Nephelometry
FANA
Anti-DNA
Anti-Sm
Anti-Sm (ELISA)
Anti-nRNP (Immunodiffusion)
Anti-nRNP (ELISA)
Anti-Ro (SS-A)
Anti-La (SS-B)
Anti-Scl 70
Anticentromere
Anti-MPO (Myeloperoxidase)
Anti-PR3 (Proteinase 3)
ANCA
Antimitrochondrial
Smooth muscle Ab
Anti-LKM (Liver-Kidney Microsome)
Thyroid antibody test
Anticardiolipin
Complement C3 level - Latex
Complement C3 level - Nephelometry
CRP (C-Reactive protein) - Latex
CRP (C-Reactive protein) - Nephelometry
Test
Test
Test
1,600
1,600
1,600
36681
36682
36690
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
80
200
450
200
90
350
90
350
400
400
150
250
550
550
300
300
300
300
200
400
50
250
110
170
37001
37002
37003
37004
37005
37006
37007
37008
37009
37010
37011
37012
37013
37014
37015
37016
37017
37018
37019
37020
37101
37102
37103
37104
7.5.6
7.5.6.1
7.5.6.2
7.5.6.3
7.5.6.4
7.5.6.5
7.5.6.6
7.5.6.7
7.5.6.8
7.5.6.9
7.5.6.10
7.5.6.11
7.5.6.12
7.5.6.13
7.5.6.14
7.5.6.15
7.5.6.16
7.5.6.17
7.5.6.18
7.5.6.19
7.5.6.20
7.5.6.21
7.5.6.22
7.5.6.23
7.5.6.24
7.5.6.25
7.5.6.26
7.5.6.27
7.5.6.28
7.5.6.29
7.5.6.30
7.5.6.31
7.5.7
7.5.7.1
7.5.7.2
CH50
Cold agglutinin
C4
Immunoglobulin level (IgG/IgA/IgM)
Heterophile-Ab test
Immunoelectrophoresis (3 antibodies)
Immunoelectrophoresis (5 antibodies )
Tumor markers
Alpha Fetoprotein (AFP) - PHA
Alpha Fetoprotein (AFP) - ELISA, MEIA,
ECLIA
Beta-HCG
Beta-2 microglobulin, serum/urine
HCG titer
CA 125
CA 19-9
CEA (Carcinoembryonic antigen)
PSA (Prostate-specific antigen)
Free PSA
TPS (Tissue polypeptide specific Antigen)
NSE (Neuro-specific enolase)
CA 153
Beta2 glycoprotein IgG (b2 Gp1)
IgE
IgE (total)
Specific IgE to mixture of food allergens
(screening test)
Specific IgE to mixture of food allergens
(screening test) plus total IgE
Test
Test
Test
Test
Test
Test
Test
150
40
300
350
200
800
1,200
37105
37106
37107
37201
37202
37203
37204
Test
Test
80
270
37301
37302
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
Test
270
400
300
600
600
300
300
400
400
500
400
300
37303
37304
37305
37306
37307
37308
37310
37311
37312
37313
37314
37315
Test
Test
400
450
37350
37351
Test
650
37352
7.5.7.3
7.5.7.4
7.5.7.5
7.5.7.6
7.5.7.7
7.5.7.8
7.5.7.9
7.5.7.10
7.5.7.11
7.5.7.12
7.5.7.13
7.5.7.14
7.5.8
7.5.8.1
7.5.8.2
7.5.8.3
Specific IgE to mixture of respiratory

(inhalant) allergens (screening test)
7.5.8.5 Specific IgE to mixture of respiratory
(inhalant) allergens (screening test) plus
total IgE
7.5.8.6 Specific IgE, quantitative (1 allergen)
7.5.8.7 Specific IgE, quantitative (1 allergen) plus
total IgE
7.5.8.8 Specific IgE, quantitative (3 allergens)
plus total IgE
plus total IgE
plus total IgE
7.6 Genetic testings
7.6.1
Metabolic screen
Test
350
37353
Test
550
37354
Test
Test
450
650
37355
37356
Test
Test
1,200
1,400
37357
37358
Test
Test
1,800
2,000
37359
37360
Test
Test
2,500
2,700
37361
37362
Test
37501
7.6.2
7.6.3
7.6.4
7.6.5
7.6.6
7.6.7
Test
Test
Test
Test
Test
Test
200
2,500
2,500
2,000
2,000
2,500
2,500
Test
Test
500
2,500
37508
37509
7.5.8.4
7.6.8
7.6.9
Quantitative plasma amino acid analysis

Urine organic acid analysis
Urine Thin layer chromatography for MPS
Carnitine/acylcarnitine analysis
Chromosome breakage study
Fluorescence in situ hybridization using
probe
PCR for SRY gene
PCR (methylation sensitive) for fragile X
syndrome
37502
37503
37504
37505
37506
37507

7.6.10
7.6.11
7.6.12
7.6.13
7.6.14
7.6.15
7.6.16
7.6.17
7.6.18
7.6.19
7.6.20
7.6.21
7.6.22
7.6.23
7.6.24
7.6.25
7.6.26
7.6.27
PCR (multiplex) for Duchenne/Becker

muscular dystrophy
MLPA test for Duchenne/Becker
muscular dystrophy
PCR (methylation sensitive) for
methylation analysis
PCR-RFLP for spinal muscular atrophy
PCR-RFLP for Hb E allele
PCR-ASA for common V37I GJB2
mutation in hearing loss
PCR-ASA for factor V Leiden
PCR-ASA for MTHFR C677T
PCR-ASA (multiplex) for thrombophilia
variants
PCR-Gap (multiplex) for deletional alpha
thalassemia
PCR-ASA (multiplex) for non-deletional
alpha thalassemia
Real time PCR for ApoE polymorphism
Real time PCR for Charcot - Marie-Tooth
type IA
Real time PCR for CYP450 2C9
Real time PCR Others
Long PCR for hemophilia A intron 22
inversion
Long PCR for glucocorticoid remediable
aldosteronism
Sequencing of triplet repeats
- Huntington disease
Test
2,500
37510
Test
2,500
37511
Test
2,500
37512
Test
Test
Test
1,000
500
500
37513
37514
37515
Test
Test
Test
500
500
1,000
37516
37517
37518
Test
500
37519
Test
500
37520
Test
Test
1,000
2,000
37521
37522
Test
Test
Test
1,000
2,000
1,000
37523
37524
37525
Test
1,000
37526
Test
2,500
37527

7.6.28
7.6.29
7.6.30
7.6.31
7.6.32
7.6.33
7.6.34
7.6.35
7.6.36
7.6.37
7.6.38
7.6.39
7.6.40
7.6.41
7.6.42
7.6.43
7.6.44
Sequencing of triplet repeats - OPMD

Sequencing of triplet repeats - SCA type
1, 2, 3
Sequencing of triplet repeats - Kennedy
disease
Sequencing of triplet repeats - Others
Whole gene sequencing - Beta
thalassemia
Whole gene sequencing - GJB2 in
hearing loss
Whole gene sequencing - Von Hippel
Lindau disease
Whole gene sequencing - Doparesponsive dystonia DYT1
Whole gene sequencing
- Hemochromatosis HFE
Whole gene sequencing - Idiopathic
pancreatitis PRSS1
Whole gene sequencing - Metachromatic
leukodystrophy
Whole gene sequencing - MECP2
Whole gene sequencing - ARX
Whole gene sequencing - X-linked
adrenoleukodystrophy
Whole gene sequencing - Wiskott Aldrich
syndrome
Whole gene sequencing - Peutz-Jeghers
syndrome
Whole gene sequencing - Cystinosis
Test
Test
2,000
2,500
37528
37529
Test
1,500
37530
Test
Test
2,500
2,500
37531
37532
Test
2,000
37533
Test
5,000
37534
Test
1,000
37535
Test
5,000
37536
Test
5,000
37537
Test
5,000
37538
Test
Test
Test
5,000
2,500
5,000
37539
37540
37541
Test
5,000
37542
Test
5,000
37543
Test
5,000
37544

7.6.45
7.6.46
7.6.47
7.6.48
7.6.49
7.6.50
7.6.51
7.6.52
7.6.53
7.6.54
7.6.55
7.6.56
7.6.57
7.6.58
7.6.59
7.6.60
7.6.61
7.6.62
Whole gene sequencing - Bruton

hypogammaglobulinemia
Whole gene sequencing - Chronic
granulomatous disease
Whole gene sequencing Methemoglobinemia (cyt b5R)
Whole gene sequencing Others
Whole gene mutation screening - Marfan
syndrome
Whole gene mutation screening - BRCA1, 2
Whole gene mutation screening - HNPCC
MSH2, MLH1
Whole gene mutation screening - ADPKD
Whole gene mutation screening - Wilson
disease
Whole gene mutation screening
- Hemophilia A
Whole gene mutation screening Dysferlinopathy
Whole gene mutation screening - DMRV
Whole gene mutation screening - FAP
Limited gene sequencing - CADASIL
Limited gene sequencing - FGFR related
conditions
Limited gene sequencing - RET related
conditions
Limited gene sequencing - Liddle's syndrome
Limited gene sequencing - Hereditary
pancreatitis SPINK1
Test
5,000
37545
Test
5,000
37546
Test
5,000
37547
Test
Test
5,000
10,000
37548
37549
Test
Test
10,000
10,000
37550
37551
Test
Test
10,000
5,000
37552
37553
Test
10,000
37554
Test
10,000
37555
Test
Test
Test
Test
5,000
5,000
1,000
3,000
37556
37557
37558
37559
Test
2,000
37560
Test
Test
2,000
1,000
37561
37562

7.6.63
7.6.64
7.6.65
7.6.66
7.6.67
7.6.68
7.6.69
Mitochondrial DNA analysis - Leber optic

atrophy
Mitochondrial DNA analysis - Kearns
Sayre/CPEO
Mitochondrial DNA analysis
- Encephalomyopathy
Test
2,500
37563
Test
3,500
37564
Test
2,500
37565
Microsatellite instability testing from

tissue specimen
Tumor clonality DNA study
Prenatal diagnosis using direct mutation
analysis
Prenatal diagnosis using linkage analysis

7.1-7.6

Test
3,000
37566
Test
Test
5,000
3,000
37567
37568
Test
Test
5,000
2548
37569
37999
7.7
7.7.1 (Surgical pathology)

( )
7.7.1.1 Biopsy
2 .
7.7.1.2 Biopsy
2 . 5 .
7.7.1.3 Biopsy
5 .
7.7.1.4

7.7.1.5

7.7.1.6 Excisional biopsy with margin
examination
7.7.1.7 Frozen section
( )
Neuro, Endocrine, Eye, Ear, Nose, Mouth
7.7.1.8 Nerve with resin study
Thyroidectomy (lobectomy or subtotal or
7.7.1.9
total)
7.7.1.10 Thyroidectomy with node dissection
7.7.1.11 Eye ball, enucleatiion
7.7.1.12 Eye ball, excenteration
240
38001
500
38002
1,000
38003
1,200
38004
2,400
38005
1,000
38006
1,160
38010
1,350
38020
38030
1,200
2,400
500
1,000
38031
38040
38041

7.7.1.13
7.7.1.14
7.7.1.15
7.7.1.16
7.7.1.17
7.7.1.18
7.7.1.19
7.7.1.20
7.7.1.21
7.7.1.22
7.7.1.23
7.7.1.24
7.7.1.25
7.7.1.26
7.7.1.27
Tonsil, each specimen
Respiratory, Cardivascular, Lymphatic

Lung, wedge biopsy
Lung, lobectomy
Lung, lobectomy with lymph node
Heart valve
Lymph node, radical dissection
Digestive
Esophagus, esophagectomy
Esophagus, esophagectomy with node
dissection
Stomach, gastrectomy
Stomach, gastrectomy with node
dissection
Small bowel, resection
Small bowel, resection with node
dissection
Appendix
Colon, colectomy
Colon, colectomy with node dissection
240
38060
1,000
1,200
2,400
1,000
1,200
38070
38071
38072
38080
38090
1,200
2,400
38100
38101
1,200
2,400
38102
38103
1,200
2,400
38104
38105
240
1,200
2,400
38106
38107
38108
7.7.1.28
7.7.1.29
7.7.1.30
7.7.1.31
7.7.1.32
7.7.1.33
7.7.1.34
7.7.1.35
Rectum
Rectum with node dissection
Whipple's specimen
Liver needle biopsy
Liver wedge biopsy
Liver resection
Gallbladder
Omentectomy
Urinary
Kidney needle biopsy
Kidney needle biopsy (with
immunohistochemical study)
Kidney, nephrectomy and partial
nephrectomy
Kidney, wedge biopsy
Urinary bladder, cystectomy
Urinary bladder, cystectomy with lymph
nodes dissection
Urinary bladder, cystoscopic biopsy
Urinary bladder, TUR-tumor
Male genital
Prostate, needle biopsy
Prostate gland, prostatic chips (TUR)
Prostate gland, prostatectomy for BPH
Prostate gland, prostatectomy with
radical node dissection
Testis, unilateral or bilateral orchidectomy
Vasectomy (unilateral or bilateral)
Female genital
7.7.1.36
7.7.1.37
7.7.1.38
7.7.1.39
7.7.1.40
7.7.1.41
7.7.1.42
7.7.1.43
7.7.1.44
7.7.1.45
7.7.1.46
7.7.1.47
7.7.1.48
7.7.1.49
1,200
2,400
2,400
500
500
1,200
500
500
38109
38110
38120
38121
38122
38123
38124
38130
750
2,350
38140
38141
1,200
38142
500
1,200
2,400
38143
38144
38145
240
500
38146
38147
1,000
1,450
1,000
2,400
38150
38151
38152
38153
500
240
38160
38161

7.7.1.50
7.7.1.51
7.7.1.52
7.7.1.53
7.7.1.54
7.7.1.55
7.7.1.56
7.7.1.57
7.7.1.58
7.7.1.59
7.7.1.60
7.7.1.61
7.7.1.62
7.7.1.63
7.7.1.64
7.7.1.65
7.7.1.66
7.7.1.67
7.7.1.68
7.7.1.69
7.7.1.70
7.7.1.71
Pelvic exenteration (uterus with urinary

bladder or colon and lymph node)
Wertheim's operation
Ovarian mass
Fallopian tube, Tubal steritization
Fallopian tube, tubal pregnancy
Uterus with cervical conization
3,000
38170
3,000
1,200
240
240
2,400
38171
38172
38173
38174
38176
Uterus with multiple groups of lymph

nodes
Uterus with ovarian tumor
Uterus, hysterectomy (TAH)
Uterus, hysterectomy with adnexa
Cervical conization, LEEP
Musculoskeletal
Bone (tumor : en bloc resection
pelvectomy, sacrectomy)
Bone marrow biopsy
Muscle biopsy
Muscle biopsy with special study
Extremities, amputation with tumor
Leg, amputation (AK, BK) for non-tumor
Skin and Breast
Breast (mass, excision, 2-5 cm)
Breast (mass, excision, > 5 cm)
Breast (mass, excision, less than 2 cm)
Breast (core needle biopsy, multiple
pieces)
Breast (simple mastectomy)
2,400
38177
2,400
1,000
1,200
1,200
38178
38179
38180
38181
2,400
38190
240
500
2,400
3,000
2,400
38191
38200
38201
38210
38211
500
1,000
240
1,200
38220
38221
38222
38223
1,200
38224

7.7.1.72
7.7.1.73
Breast, mastectomy (simple, radical,

modified radical) and axillary content
Skin biopsy (Dermatosis)
7.7.2 (Cytopathology)
7.7.2.1 - Non-Gynecological
specimen
7.7.2.2 - Gynecological
specimen (PAP smear)

7.7.3 (Electron microscopy)
7.7.3.1

(Transmission electron
microscopy)
7.7.3.2

(Scanning electron microscopy)
7.7.3.3 resin
Slide
7.7.4 (Special staining)
7.7.4.1
7.7.5
2,400
38225
500
38230
500
38301
100
38302
2,800
38330
3,400
38331
1,100
38332
60
38401

7.7.5.1
7.7.5.2
7.7.5.3
7.7.5.4
7.7.5.5
7.7.5.6
7.7.5.7
7.7.5.8
7.7.5.9
7.7.5.10
7.7.5.11
7.7.5.12
7.7.5.13
ACT
ACTH
Alpha-Actinin
AE1/AE3
AFP
ALK protein
Alpha-Inhibin
Amyloid A
Aromatase
AT
B-cell his X
Bcl-2
Bcl-6
270
420
1,320
300
290
420
390
540
480
270
300
360
420
38501
38502
38503
38504
38505
38506
38507
38508
38509
38510
38511
38512
38513

7.7.5.14
7.7.5.15
7.7.5.16
7.7.5.17
7.7.5.18
7.7.5.19
7.7.5.20
7.7.5.21
7.7.5.22
7.7.5.23
7.7.5.24
7.7.5.25
7.7.5.26
7.7.5.27
7.7.5.28
7.7.5.29
7.7.5.30
7.7.5.31
7.7.5.32
7.7.5.33
7.7.5.34
7.7.5.35
7.7.5.36
7.7.5.37
7.7.5.38
7.7.5.39
7.7.5.40
7.7.5.41
7.7.5.42
Bcl-10
Ber-EP 4
34-beta-E12
Beta2-Microglobulin
Beta-hCG
BLA-36
BM-2
BOB-1
C1q
C3c
Calcitonin
Caldesmon
Calponin
Calretinin
CAM 5.2
Cathepsin D
CD1a
CD3
CD4
CD5
CD8
CD10
CD15
CD20
CD21
CD23
CD30
CD31
CD34
320
290
350
280
290
310
380
540
280
280
440
340
340
390
330
330
720
430
420
400
480
430
300
360
300
490
330
320
390
38514
38515
38516
38517
38518
38519
38520
38521
38522
38523
38524
38525
38526
38527
38528
38529
38530
38531
38532
38533
38534
38535
38536
38537
38538
38539
38540
38541
38542

7.7.5.43
7.7.5.44
7.7.5.45
7.7.5.46
7.7.5.47
7.7.5.48
7.7.5.49
7.7.5.50
7.7.5.51
7.7.5.52
7.7.5.53
7.7.5.54
7.7.5.55
7.7.5.56
7.7.5.57
7.7.5.58
7.7.5.59
7.7.5.60
7.7.5.61
7.7.5.62
7.7.5.63
7.7.5.64
7.7.5.65
7.7.5.66
7.7.5.67
7.7.5.68
7.7.5.69
7.7.5.70
7.7.5.71
CD35
CD43
CD45
CD56
CD57
CD68
CD74
CD79a
CD99
CD117
CD138
CD141 (Thrombomodulin)
CD146 MCAM
CDW75
CDX-2
CEA
Chlamydia
Chromogranin A
CK-5/6
CK-7
CK-8
CK-19
CK-20
CMV
c-myc
Collagen IV
Collagen VI
Cryptosporidium
Cyclin D1
300
340
340
350
410
320
250
400
360
560
310
350
350
250
320
320
340
450
410
350
330
350
340
320
400
340
1,450
300
430
38543
38544
38545
38546
38547
38548
38549
38550
38551
38552
38553
38554
38555
38556
38557
38558
38559
38560
38561
38562
38563
38564
38565
38566
38567
38568
38569
38570
38571
7.7.5.72
7.7.5.73
7.7.5.74
7.7.5.75
7.7.5.76
7.7.5.77
7.7.5.78
7.7.5.79
7.7.5.80
7.7.5.81
7.7.5.82
7.7.5.83
7.7.5.84
7.7.5.85
7.7.5.86
7.7.5.87
7.7.5.88
7.7.5.89
7.7.5.90
7.7.5.91
7.7.5.92
7.7.5.93
7.7.5.94
7.7.5.95
7.7.5.96
7.7.5.97
7.7.5.98
7.7.5.99
7.7.5.100
Desmin
Dysferin
Dystrophin-1 (Rod domain)
Dystrophin-2 (C-terminus) / Dystrophin A
Dystrophin-3 (N-terminus)
EBV
E-cadherin
EGFR
EMA
Emerin
ER
Factor VIII
Fascin
FDRC Predilute
Fibrinogen
FSH
Gastrin
GCDFP 15
GFAP
Glucagon
Glycophorin A
Glycophorin C
Granzyme B
Growth hormone
H.pylori
HBcAg
HBsAg
HCV
Hemoglobin
340
1,550
490
490
490
250
360
460
280
1,450
570
310
350
480
250
320
400
400
330
340
380
320
430
350
320
300
340
450
220
38572
38573
38574
38575
38576
38577
38578
38579
38580
38581
38582
38583
38584
38585
38586
38587
38588
38589
38590
38591
38592
38593
38594
38595
38596
38597
38598
38599
38601

7.7.5.101
7.7.5.102
7.7.5.103
7.7.5.104
7.7.5.105
7.7.5.106
7.7.5.107
7.7.5.108
7.7.5.109
7.7.5.110
7.7.5.111
7.7.5.112
7.7.5.113
7.7.5.114
7.7.5.115
7.7.5.116
7.7.5.117
7.7.5.118
7.7.5.119
7.7.5.120
7.7.5.121
7.7.5.122
7.7.5.123
7.7.5.124
7.7.5.125
7.7.5.126
7.7.5.127
7.7.5.128
7.7.5.129
Hepatocyte
HER-2
HHF - 35
HLA class II
HMB - 45
hPL (Placental Lactogen)
HPV
HSV (type II)
IgA
IgD
IgG
IgM
Insulin
Kappa
Ker I (human)
Ker II (Bovine)
Ki-67 (MIB-1)
Lambda
LH
Lysozyme
Mac-387
MAK-6
Mast cell tryptase
Melan A
Merosin
MNF 116
MOC-31
MUC-2
MUC-5AC
370
740
340
290
360
260
260
270
280
280
280
250
370
280
220
210
390
300
320
260
280
250
320
400
1,440
310
380
640
640
38602
38603
38604
38605
38606
38607
38608
38609
38610
38611
38612
38613
38614
38615
38616
38617
38618
38619
38620
38621
38622
38623
38624
38625
38626
38627
38628
38629
38630

7.7.5.130
7.7.5.131
7.7.5.132
7.7.5.133
7.7.5.134
7.7.5.135
7.7.5.136
7.7.5.137
7.7.5.138
7.7.5.139
7.7.5.140
7.7.5.141
7.7.5.142
7.7.5.143
7.7.5.144
7.7.5.145
7.7.5.146
7.7.5.147
7.7.5.148
7.7.5.149
7.7.5.150
7.7.5.151
7.7.5.152
7.7.5.153
7.7.5.154
7.7.5.155
7.7.5.156
7.7.5.157
7.7.5.158
MUM-1
Myelin (MBP 88)
Myeloperoxidase
Myogenin
Myoglobin
Myosin
Neuroblastoma
Neurofilament
Neutrophil elastase
NSE
OCT-2
OCT-3/4
Osteocalcin
Osteonectin
P504
p53
p57
p63
Parathyroid hormone
Perforin
Peripherin
PGP 9.5
PIP
PLAP
Plasma cell
Plt. (GP IIIa)
Pneumocystis
PR
Prolactin
410
340
310
380
260
340
300
330
290
460
560
350
1,190
400
570
390
450
450
380
390
390
380
390
320
290
310
320
570
360
38631
38632
38633
38634
38635
38636
38637
38638
38639
38640
38641
38642
38643
38644
38645
38646
38647
38648
38649
38650
38651
38652
38653
38654
38655
38656
38657
38658
38659

7.7.5.159
7.7.5.160
7.7.5.161
7.7.5.161
7.7.5.162
7.7.5.163
7.7.5.164
7.7.5.166
7.7.5.167
7.7.5.168
7.7.5.169
7.7.5.170
7.7.5.171
7.7.5.172
7.7.5.173
7.7.5.174
7.7.5.175
7.7.5.176
7.7.5.177
7.7.5.178
7.7.5.179
7.7.5.180
7.7.5.181
7.7.5.182
7.7.5.183
7.7.5.184
7.7.5.185
7.7.5.186
7.7.5.187
PSA
PSAP
PTEN
Renal cell carcinoma
S-100
Alpha-Sarcoglycan
Beta-Sarcoglycan
Delta-Sarcoglycan
Gamma-Sarcoglycan
Sarcomeric actin
Serotonin
Smooth m.actin
Smooth muscle myosin heavy chain
Somatostatin
Spectrin
Surfactant
Synaptophysin
T-cell, UCHL-1
TdT 2
Testosterone
Thyroglobulins (TG)
TIA-1
TTF-1
Tyrosinase
Ulex B279
Ulex X921
VEGF
Villin
Vimentin
290
270
360
320
310
1,260
1,480
1,480
1,490
320
280
310
390
350
320
450
360
280
670
270
270
390
400
470
220
210
540
330
360
38660
38661
38662
38663
38664
38665
38666
38667
38668
38669
38670
38671
38672
38673
38674
38675
38676
38677
38678
38679
38680
38681
38682
38683
38684
38685
38686
38687
38688
7.7.5.188 Wilms' tumor

7.7

370
2548
38689
38999
X-ray, CT scan, Ultrasonography, MRI, Radionuclide scan

( )
monitor
( )
( 11)
(8.1 - 8.5)
Computerized tomography Ionic
contrast media Nonionic contrast media
Non contrast (NC) with contrast media (CM)
Nonionic contrast media

Gd-contrast

8.1
8.1.1
Plain X-ray

film
170
41001
8.1.2
Mobile X-Rays
film
300
41002
8.1.3
TM joint
film
130
41203
8.1.4
Panoramic/Cephalometry
film
300
41201
8.1.5
Dental film
film
80
41202
8.1.6
Mass chest (small film)
film
50
41301
8.1.7
220
41003
8.2
8.2.1
X-ray: Special
Fluoroscopic observation
8.2.2
Myelography one part

cervical/lumbar
Myelographycomplete/thoracic
Sialography
Dracyography
Venography
Mammography
Mammography with US
Barium swallowing
Esophagogram
BS with esophagogram
UGI
UGI with small bowel series
Barium enema, single CM
Barium enema, double CM
Transhepatic cholangiography
T-Tube cholangiography
Intraoperative cholangiography
Fistulography
IVP (Ionic contrast)
Retrograde Pyelography
VCUG/Cystogram
Urethrogram
Hysterosalpingography
Arthrography
8.2.3
8.2.4
8.2.5
8.2.6
8.2.7
8.2.8
8.2.9
8.2.10
8.2.11
8.2.12
8.2.13
8.2.14
8.2.15
8.2.16
8.2.17
8.2.18
8.2.19
8.2.20
8.2.21
8.2.22
8.2.23
8.2.24
8.2.25
600

2,000

(
2,550
1,150
1,150 catheter
1,800
1,200

1,700
1,350
)
1,350
1,350
1,400
1,700
1,750
2,300
2,050
1,300
450
1,300
1,950
1,500
1,800
1,500
1,850
1,750
42001
42101
42102
42201
42202
42010
42330
42331
42501
42502
42503
42504
42505
42506
42507
42508
42509
42510
42511
42601
42602
42603
42604
42605
42701
8.2.26
8.2.27
8.2.32
8.3
Bone density: X-rays 1 part

Bone density: X-Rays whole
body
Angiography, single shot
Angiography, selective
Angiography, each following
vessel
Splenoportography
(percutaneous)
Splenoportography (selective)
Ultrasound
8.3.1
8.3.2
8.3.3
8.2.28
8.2.29
8.2.30
8.2.31
8.3.4
8.3.5
8.3.6
8.3.7
8.3.8
8.3.9
8.3.10
8.3.11
1,000
2,900
4,000
17,000 set
5,000 catheter

42702
42703
42512
42513
42514
2,050
42515
18,000
42516
US Portable
1,050
43001
3-D Ultrasound
4-D Ultrasound, diagnostic of
fetal anomalies, breast biopsy
US Small part
US Doppler artery or vein
US Upper/lower abdomen
US Whole abdomen
US Endovaginal or endorectal
probe
Bone density: US
Fine needle aspiration under
U/S
800
2,500
43002
43003
650
1,000
650
850
850
43004
43005
43501
43502
43601
43701
43910
US guided for biopsy
650
1,000 set sterile

2,300 set semiautomatic
needle

43911

8.4
8.4.1
8.4.2
8.4.3
8.4.4
8.4.5
8.4.6
8.4.7
8.4.8
8.4.9
8.4.10
8.4.11
8.4.12
8.4.13
8.4.14
8.4.15
8.4.16
8.4.17
8.4.18
8.4.19
8.4.20
8.4.21
8.4.22
8.4.23
8.4.24
8.4.25
8.4.26
CT & CTA
CT 1 part + Multiphase CM
CT 1 part + 3D Navigator
3D CT scan
Additional surface 3D views
Additional multiphase
CTA 1 part
CTA Peripheral run off
CT Fistulogram
CT Brain NC
CT Brain with CM
CTA Brain
CT Sella
CT Pituitary gland 2 planes
CT Spine 1 part
CT Myelogram
CT Facial bone
CT Facial bone3 D
CT Orbits 2 planes
CT Temporal bone
CT IAC/Temporal bone
screening
CT IAC
CT Parotid gland
CT Nasal cavity
CT Nasopharynx 2 planes
CT PNS screening 1 plane
CT PNS 2 planes
6,800
14,500
8,000
350
1,000
12,000
12,000
6,000
3,100
4,600
12,000
4,000
5,000
5,350
5,800
4,000
6,000
5,000
5,000
3,100
44001
44002
44003
44004
44005
44010
44011
44020
44101
44102
44103
44110
44111
44140
44150
44201
44202
44210
44220
44221
5,000
5,700
4.000
5,700
2,500
5,000
44222
44223
44230
44231
44232
44233

8.4.27
8.4.28
8.4.29
8.4.30
8.4.31
8.4.32
8.4.33
8.4.34
8.4.35
8.4.36
8.4.37
8.4.38
8.4.39
8.4.40
8.4.41
8.4.42
8.4.43
8.4.44
8.4.45
8.4.46
8.4.47
8.4.48
8.4.49
8.4.50
44240
44241
44242
44243
44250
44251
44252
CT Oral cavity
CT Dental scan -maxilla
CT Dental scan - mandible
CT Oropharynx
CT Neck
CTA Neck
CT Neck, Thyroid and
Parathyroid
CT Larynx
CT Thyroid
CT Chest/Lungs CM
High resolution CT (Lungs)
5,700
5,000
5,000
5,700
5,700
12,000
5,700
44260
44261
44301
44302
CTA Chest
CTA for Pulmonary Emboli
Cardiac function graft full
cardiac function including
coronary artery angiogram
CTA Coronary artery
CTA Aorta (1 part)
CTA Whole aorta
CT Upper abdomen
CT Lower abdomen
CT Whole abdomen
CTA Liver donor
CT Pancreas spiral
CT Kidney spiral
CTA Renal artery
5,700
5,700
5,000
4,000
CT
12,000
12,000
18,000
13,000
12,000
16,000
5,000
5,000
9,500
12,000
5,000
5,000
12,000
44402
44420
44421
44501
44502
44503
44510
44511
44610
44611
44310
44311
44401

8.4.51
8.4.52
8.4.53
8.4.54
8.4.55
8.4.56
8.5
8.5.1
8.5.2
8.5.3
8.5.4
8.5.5
8.5.6
8.5.7
8.5.8
8.5.9
8.5.10
8.5.11
8.5.12
8.5.13
8.5.14
8.5.15
8.5.16
8.5.17
8.5.18
CT Adrenal
CT Extremity and joint per
part
Bone density: CT
CTA Arm
Using Nonionic CM add
Biopsy under CT guidance
MRI, MRA, MRV, MRCP
MRI 1 small part or small
organ
MRI Diffusion/Perfusion
Functional MRI
MR Spectroscopy
MRA (one part)
MRV (one part)
MRI + MRA (nonbrain)
MRA + MRV
MRI + MRA + MRV
MR SRT or SRS
MRI Brain
MRl Brain + MRA
MRl Brain + CSF flow
MRI Hippocampus
MRI Pituitary gland
MR Cisternography
MRI Base of skull
MRI Cavernous sinus
50 ml.
5,000
5,000
2,500
12,000
750
3,000 set sterile
set semiautomatic needle
44612
44701
44710
44750
44901
44910
4,000
45001
4,000
10,000
4,000
9,100
9,100
12,000
12,000
15,000
4,000
8,000
11,000
11,000
4,000
8,000
8,000
4,000
4,000
45003
45004
45005
45010
45011
45020
45021
45022
45030
45101
45102
45103
45104
45110
45111
45120
45121

8.5.19
8.5.20
8.5.21
8.5.22
8.5.33
8.5.24
8.5.25
8.5.26
8.5.27
8.5.28
8.5.29
8.5.30
8.5.31
8.5.32
8.5.33
8.5.34
8.5.35
8.5.36
8.5.37
8.5.38
8.5.39
8.5.40
8.5.41
8.5.42
8.5.43
8.5.44
8.5.45
8.5.46
MRI Cranial nerve

MRI Spine 1 part
MRI Whole spine
MRI Myelogram
MRI Brachial plexus
MRI LS Plexus
MRI Sacral plexus
MRI TM joint
MRI Orbits
MRI 3D IAC
MRI Nasopharynx
MRI PNS
MRI Oropharynx
MRA Carotid
MRI Larynx (Neck)
MRI Thyroid glands
MRI Chest
MRV Chest
MRA Pulmonary
MRI Mediastinum
MRI Breast (1 side)
MRI Breasts (2 sides)
MRI Guided breast biopsy
MRI Heart
MRI Heart + perfusion
MRI Heart CgHD/Cine
MRI Heart screening ASD
MRA Heart
4,000
8,000
16,000
8,000
13,500
8,000
4,000
8,000
8,000
4,000
8,000
8,000
8,000
12,000
8,000
8,000
8,000
12,000
12,000
4,000
8,000
12,000
8,000
8,000
12,000
12,000
4,000
12,000
45130
45140
45141
45150
45160
45161
45162
45201
45211
45220
45230
45231
45240
45250
45260
45261
45301
45302
45310
45320
45330
45331
45332
45401
45402
45403
45404
45410
8.5.47
8.5.48
8.5.49
8.5.50
8.5.51
8.5.52
8.5.53
8.5.54
8.5.55
8.5.56
8.5.57
8.5.58
8.5.59
8.5.60
8.5.61
8.5.62
8.5.63
8.5.64
8.5.65
8.5.66
8.5.67
MRA Aorta
MRI Upper/Lower abdomen
MRI Whole abdomen
MRA Upper/Lower abdomen
MRA Whole abdomen
MRV upper/lower abd.
MRI Pancrease
MRCP onIy
MRCP + Upper abdomen
MRV Portal v.
MRI Pelvic cavity
MRI Urography
MRI Kidney
MRI Adrenal gland
MRA Renal artery
MRI Prostate gland
MRS Prostate gland
MRI Prostate special coil
MRI Bone/Joint/Extremity 1 part
MR Arthrography
MRA Femoral artery/
Peripheral run off
MRV Femoral v.
Using Gd contrast medium
Using Ferucarbotran contrast
medium
12,000
8,000
16,000
12,000
16,000
12,000
4,000
4,000
12,000
12,000
4,000
4,000
4,000
4,000
12,000
8,000
4,000
12,000
8,000
8,000
12,000
45420
45501
45502
45503
45504
45505
45510
45511
45512
45513
45601
45602
45611
45612
45613
45640
45641
45602
45701
45710
45760
15 ml.
Vial
12,000
2,500
9,050
45761
45901
45902
8.5.68
8.5.69
8.5.70

8.1-8.5

2548
45999
(8.6 8.7)
8.6
8.6.1
8.6.2
8.6.3
8.6.4
8.6.5
8.6.6
8.6.7
8.6.8
8.6.9
8.6.10
8.6.11
8.6.12
:
Total Body scan l-131
Total Body scan MIBI
Tc-99m-WBC
Gallium scan (Ga-67-citrate)
Octreoscan (In-111 Pentetreotide)
Parotid scan
Parathyroid (MIBI)
Thyroid uptake
Thyroid scan pertechnetrate
Parathyroid (MIBI + Pertechnetate)
Lung scan
MUGA scan (Multiple Gated
Acquisition)
Heart SPECT MIBI TL-201
Venogram scan
Lymphatic scan (Dextrans)
Gl Bleeding (Phaytate)
Gl Bleeding (RBC)
Gl scan (Albumin)
Gastric emptying
Meckels scan
Liver scan (Phytate)
Liver scan (RBC)
Hepatobiliary (DISIDA)
Renal scan DMSA
8.6.13
8.6.14
8.6.15
8.6.16
8.6.17
8.6.18
8.6.19
8.6.20
8.6.21
8.6.22
8.6.23
8.6.24
2,900
4,100
8,000
13,500
59,000
2,800
4,000
500
800
4,200
5,800
3,000
47001
47002
47003
47004
47005
47201
47202
47203
47204
47205
47301
47401
8,300
1,000
7,400
2,300
4,700
7,600
3,200
4,000
2,100
3,500
5,800
3,500
47402
47403
47404
47501
47502
47503
47504
47505
47506
47507
47508
47601

8.6.25
8.6.26
8.6.27
8.6.28
8.7
8.7.1
8.7.2
Captopril renogram
Furosemide renogram
Testicular scan
Bone scan
:
Rx Sr-89 (Strontum Chloride Sr 89)
Rx Sm-153 50 mCi (Samarium Sm
153 lexidronam)
8.7.3 Rx Hyperthyroid I-131:1-10 mCi
8.7.6 Post treatment I131
8.7.7 Rx CA Thyroid with l-I31 (OPD)
8.7.8 Rx CA Thyroid with I-131 100 mCi
8.7.9 Rx CA Thyroid with l-131 150 mCi
8.7.10 Rx CA Thyroid with I-131 200 mCi

8.6-8.7

3,700
3,700
3,300
2,900
47602
47603
47604
47701
59,000
5,100
48001
48002
1,500
2,000
3,000
4,000
3,500
8,000
11,300
15,300
2548
48201
48206
48207
48208
48202
48203
48204
48205
48999
9

EKG, EMG, EEG,
Exercise stress test, Echocardiography, Audiometry

9.1
9.1.1
9.1.2
9.1.3
9.1.4
9.1.5
9.1.6
9.1.7
9.1.8
9.1.9
9.1.10
9.1.11
9.1.12
9.1.13
9.1.14
9.1.15
Scalp E.E.G. (16 )

Scalp & Sphenoid E.E.G. (16 )
Scalp & Sleep Record E.E.G. (16 )
Multiple sleep latency test (ICD-9-CM
89.18)
Scalp EEG 10-20 system (32 )
Scalp EEG & Nasopharynx (32 )
Scalp EEG & Sleep deprivation (32 )
Scalp EEG & VDO monitoring (4-8 hours)
Scalp EEG & VDO monitoring (24 hours)
Intra-Op Cortical EEG
Polysomnogram (ICD-9-CM 89.17)

Auditory brain stem response (ABR)
Brain stem evoked potential response
Long-Latency Auditory and Auditory
P300
Standard Pattern-Shift VER
900
1,500
1,500
5,500
51110
51111
51112
51113
1,800
2,000
2,000
4,200
4,800
3,000
7,000

51114
51115
51116
51117
51118
51119
51120
500
700
700
51130
51131
51132
700
51133
9.1.16
9.1.17
Flash VER
(Nerve
conduction velocity)
(Electro
myograghy)

(Somatosensory evoked potential)

A-scan (IOL measurement)
B-scan
Fundus fluorescein angiography
Refraction and strabismus examination
Routine hearing test (Audiogram)
Special hearing test (Tympanogram)
Speech evaluation
Speech therapy
Lung Function Test - Spirometry (Peak flow)

Lung Function Test - Spirometry
(Pulmonary Function Test)
Lung Function Test - Spirometry (Pre &
post Brochodilater PFT)
Lung Function Test - Lung Volume Study
(+ DLCO)
Lung Function Test - Cardiopulmonary
Exercise Test (CPET)
E.C.G. (Electrocardiography)
Stress Test Electrocardiography
limb
700
500
51134
51140
500
51141
700
51142
9.1.18
9.1.19
9.2
9.2.1
9.2.2
9.2.3
9.2.4
9.2.5
9.2.6
9.2.7
9.2.8
9.3
9.3.1
9.3.2
9.3.3
9.3.4
9.3.5
9.4
9.4.1
9.4.2
300
500
1,000 contrast
200
150
150
150
70
51210
51211
51212
51220
51230
51231
51240
51241
30
300
51310
51311
400
51312
1,000 CO
51313
1,500 Gas
51314
200 red dot

1,500
51410
51411
9.4.3
9.4.4
9.4.5
9.4.6
8.4.7
9.4.8
Holter Monitor
Echo-Transthoracic + color + Doppler
3 D Echocardiography
Transesophageal Echocardiogram
Dobutamine Echocardiography
Tilt table test

9.4.9 Transcranial Doppler Ultrasound
9.4.10 Carotid Duplex Scan

9.4.11 Ankle-Brachial index (A.B.I)
9.4.12 Toe-Brachial Index (T.B.I)
9.5

9.5.1 Uroflowmetry
9.5.2 Urometry
9.6
9.6.1
9.6.2
9.6.3
9.6.4
9.6.5
9.6.6
9.6.7
Standardized occupational therapy

assessment (DDST, reflex testing,
dexterity)
Non-standardized OT assessment
Group assessment (no later than 5 clients
per one OT)
2,000
2,000
3,000
2,000
4,000
2,000
51412
51420
51421
51422
51423
51430
2,000
1,500
51440
51441
500
700
51460
51461
200
1,000
51610
51611
200
200
300
200
51900
51901
51902
51903
100
51910
80
80
51911
51912

9.1-9.6

2548
51999
10

( ) monitor
set
10.1
10.1.1
10.1.2
10.1.3
Infant radiant warmer
10.1.4
10.1.5
Hypo-hyperthemia

- Multiplace Chamber
550
100
300
52010
52011
52012
200
1,250
52013
52020
1. CO poisoning
10.1.6

- Monoplace Chamber
1,600
10.1.7
12,000
10.2
2. Non diabetic - non

atherosclerotic leg ulcer,
(not include pressure
sore)
3. Diabetic ulcers for
Wagner gr III and IV
4. Osteoradionecrosis
52021
52022
10.2.1
Intracranial pressure monitoring
10.2.2
10.3.6
PCA (pain control

assistant)
- Pressure
control respirator
- Pressure
control respirator
- Volume control
respirator
- Volume control
respirator
- Bipap (non
invasive positive pressure)
10.3.7
10.4
10.4.1
10.4.2
EKG monitor

1
10.4.3
10.4.4
10.4.5
10.4.6
10.4.7
10.4.8
Monitoring of cardiac output

Swan-Gantz
Invasive blood pressure monitoring
Cental venous pressure
NIBP
O2 sat
10.3
10.3.1
10.3.2
10.3.3
10.3.4
10.3.5
<8 .
400
1103
180
52110
52120
650

1,000 Flexible tube,
Connector
1,000
52310
1,900
52313
1,000
52314
<8 .
<8 .
52311
52312
160
Canular Mask
450 T-tube
52320
300 Red dot

600 Monitor
3 BP, EKG,
O2 sat Red dot
1,000
200
200
200 Monitor
100
100
52410
52411
52321
52420
52430
52431
52432
52440
52441

10.4.9
10.4.10
10.5
10.5.1
10.6
10.6.1
10.6.2
10.6.3
10.6.4
10.6.5
10.7
10.7.1
10.8
10.8.1
Defibrillator
400
Intraaortic balloon pump
1,000
Intermittent NG suction
100
/ /
Electronic fetal monitoring
/
200
Continuous electronic fetal
200
monitoring
400
(1st level ultrasound for
pregnant woman)
Contraction stress test
/
200
Non stress test/ acoustic stimulation
200
test
40
(Infusion
180 Set infusion

pump)
pump

10.1-10.8
2548
52450
52460
52510
52610
52611
52612
52620
52621
52810
52910
52999
11

1. Bacteria filter
Monitor
Vital Signs (NIBP, EKG) red dot
Airway assisted intubation, Airway nasal or oral
2.

3. 3 -way, Extension tube,
Syringes

1.
2.
Monitor function Monitor
pressure 2-3 pressure, Monitor EKG 2 lead,
Monitor
1-2
3.
1
(Regional block)
1. Anesthetic machine stand by
2. Sterile Spinal block Epidural block,
Spinal
(IVA)
1. Anesthetic machine stand by
2.

15 ()

11.0.1
11.0.2
11.0.3
11.0.4
11.0.5
11.0.6
11.0.7
11.0.8
11.0.9
11.0.10
11.0.11
11.0.12
11.0.13
11.0.14
(GA)
(GA)
(GA)
(GA)
(IVA)
(RA)
(RA)

(LA with MAC)
Volatile anesthetic agents
Carbondioxide monitoring

jet ventilation
fiber optic
(infusion pump)
70110
70111
70112
70113
70120
70130
1,400
1,000
2,000
1,500
700
1,200
900
500
450
200
300
70201
70301
70310
500
1,000
60
70320
70330
70340
70140
1.

2.
-
- Lab
- IV Fluid, Plasma expander,
- unit dose

1.

2. Antiseptic
3.

( / )
11.1
11.1.1
11.2
11.2.1
11.3
11.3.1
11.3.2
11.3.3
Lumbar puncture

Remove eye FB
I & D /

Nasal packing, anterior
Nasal packing, anterior and

posterior
Nasal endoscope
Direct FOL laryngoscopy
Direct laryngoscopy with
remove FB
Microdirect laryngoscopy
with or without laser therapy
(Intubation/)
11.3.4
11.3.5
11.3.6
11.3.7
11.3.8
11.3.9
11.3.10
11.3.11
11.3.12
11.4
11.4.1
11.4.2
Rigid bronchoscope
900 -
Defibrillation
- ET tube
71011
200
71121
70
90
50
71210
71211
71220
100
120 Fiber optic
120
1,000 packing
71230
71240
71241
71242
800
120 Fiber optic
1,000
1,400
71250
71260
71270
71271
1,500
71272
180 - /
Airway
- ET tube
1,200
71310
71320

11.4.3
11.4.4
11.4.5
11.4.6
11.4.7
11.4.8
11.4.9
11.4.10
11.4.11
11.5
Rigid bronchoscope with FB

removal/ dilatation
Laryngo-esophagobronchoscope
FOL Bronchoscopy
FOL Bronchoscopy &
biopsy
FOL Bronchoscope with
remove FB
FOL Bronchoscopy &
treatment (laser, heat)
(Diagnostic
thoracocentesis)

(Chest Drain)
(Pleural
Biopsy)
1,400
71321
2,050
71322
1,800 - VDO
1,900 -
71330
71331
2,100
71332
2,600
71333
200
71340
400 chest drain

( 3101)
300
71341
71342
set
Thouhy bose, Indeflater, Needle pucture, Manifold, Connector, Dome,
Contrast media, Torguer device, etc. ( 2)
Introducer sheath, Guide wire, Balloon for PTCA, Guide wire for PTCA
4307, 4308, 4309, 4310, 4313, 4802
11.5.1
(Cut
down)
11.5.2
11.5.3
800 /
Cut down

400
350
71410
71411
71412

11.5.4
11.5.5
Double lumen
catheter
Permanent catheter
(Pulmonary
wedge pressure)

Myocardial biopsy
Coronary angiography
(CAG)
Percutaneous transluminal
coronary agiography and
stent implantation
11.5.12
Additional coronary arteries
11.5.13
11.5.14
11.5.15
11.5.16
11.5.17
11.5.18
Right & Left heart

catheterization
Ablation
PTMC
ASD
PDA
Temporary Pacemaker
11.5.19
Permanent Pacemaker
11.5.6
11.5.7
11.5.8
11.5.9
11.5.10
11.5.11
700 Set
450 Double
lumen cath
1,000
Permanent cath
900 Pulm wed
pressure
900 Monitor
3,000 Set Myotome

15,000
50,000 Stent

16,500 PTCA
stent
15,000 Lab
100,000
55,000
140,000
80,000
10,000
10,000
71413
71420
71421
71422
71430
71432
71440
71441
71442
71450
71451
71452
71453
71454
71460
71461
11.5.20
IABP
11.6
11.6.1

(Abdominal Paracentesis)
(Liver
Aspiration)

(Liver Biopsy)

(Peritoneoscopy)
Esophagoscopy
Esophagoscopy with
remove FB
Zengstaken
Intubation
Gastroduodenoscopy
Gastroduodenoscopy &
biopsy
Esophago-gastroscope with
banding
Gastroscope & adrenaline
injection
11.6.2
11.6.3
11.6.4
11.6.5
11.6.6
11.6.7
11.6.8
11.6.9
11.6.10
11.6.11
11.6.12
11.6.13
11.6.14
Gastroduodenoscopy &
sclerotherapy (laser, heat)
Endoscopic ultrasound
10,000 -
- 4424
71470
200
71510
250
71511
250
71512
700
71520
1,300 - VDO
1,400 -
71530
71531
450 71532
1,300 - VDO
1,500 -
71540
71541
1,900 Banding
71542
1,600 Adrenaline
71543
2,900 /
Probe
3,000
40
71544
71545
71550

11.6.15
11.6.16
11.6.17
11.6.18
11.6.19
11.6.20
11.7
11.7.1
11.7.2
11.7.3
(Proctoscopy)
(Proctosigmoidoscopy
fiberoptic)
Banding Hemorrhoid
Colonoscopy (
)
Colonoscopy & biopsy
Colonoscopy &
Polypectomy
Endoscopic
Retrograde Cholangio
Pancreatography (ERCP)
1,000
71551
250
2,300
71552
71560
2,500
3,300
71561
71562
6,500
catheter
GW
stent, brush,
balloon, sphincterostomy
71570
(Peritoneal Dialysis)
- Tro cath

-
24 (Manual)
900
71610
1,100 Tro cath

5603
71620
900
71621

- 24
(Machine)

(CAPD)
- Tenchkoff (CAPD)

(CAPD)
-

(Hemodialysis)
- Acute Hemodialysis
2,500
1,400 Tenchkoff
5604, 5605
71630
1,400

71631
71640
11.7.8
(Hemodialysis)
- Chronic Hemodialysis)
3,500

Blood line

monitor
2,000

31 .. 2548
11.8
11.8.1

(Vac/forcep)

Colposcopic examination
( )
1,000
71650
1,300
1,300
71651
71652
350
70
250
71653
71660
71661
11.7.4
11.7.5
11.7.6
11.7.7
11.8.2
11.8.3
11.8.4
11.8.5
11.8.6
71622
71641

11.8.7
11.8.8
11.8.9
11.8.13
11.8.14
11.8.15
11.8.16
11.8.17
11.8.18
11.9
11.9.1
11.9.2
Culdocentesis
Cryosurgery ( )
/
Podiphyllin Trichloacetic
acid
/Incission
and drain of Bartholin
abscess
Marsupialization of Bartholin
cyst
Endometrial biopsy
Artificial Insemination
11.10
11.10.1
11.10.2
11.10.3
11.10.4
11.10.5
Skin traction
Skeletal traction
(Finger splint)
11.8.10
11.8.11
11.8.12
170
160
250
71662
71670
71671
130
71672
300
71673
350
71674
150
0
0
0
0
0
71680
71681
71682
71683
71690
71691
150
120
71710
71711
100
300
300
900
100
1. AP Slab
Slab 2
anterior posterior
2. Volar slab, post. slab
slab 1
71720
71721
71722
71723
71724

11.10.6
11.10.7
11.10.8
11.10.9
11.10.10
11.10.11
11.10.12
11.10.13
11.10.14
11.10.15
11.10.16
11.10.17
11.10.18
11.10.19
11.10.20
11.10.21
11.10.22
11.10.23
11.10.24
11.10.25
11.10.26
11.10.27
11.10.28
11.10.29
11.10.30

Short arm AP slab
Short arm volar slab
Ulnar gutter
Radius gutter
Long arm AP slab
Long arm post. slab
U slab
Thumb spica slab
Short leg AP slab
Short leg post. slab
Long leg AP slab
Long leg post slab
Knee AP slab
Knee post. slab
Short arm cast
Long arm cast
Thumb spica cast
Short leg cast
Long leg cast
Short leg walking cast
Club foot cast (Long leg
cast )
Knee cast
PTB (Patella tension
banding) cast
Body jacket
300 3.

71725
250
180
220
220
380
340
380
220
500
400
850
750
650
550
250
380
250
420
800
500
250
71730
71731
71732
71733
71734
71735
71736
71737
71738
71739
71740
71741
71742
71743
71750
71751
71752
71753
71754
71755
71756
570
800
71757
71758
1,900
71760

11.10.31
11.10.32
11.10.33
11.10.34
11.10.35
11.10.36
11.10.37
11.10.38
11.10.39
11.10.40
11.10.41
11.10.42
11.10.13
11.10.44
11.10.45
11.10.46
11.10.47
11.11
11.11.1
11.11.2
11.11.3
1,500
1,800
1,300
2,000
71761
71762
71763
71764
260
750
500
420
1,100
680
71770
71771
71772
71773
71774
71775
670
1,350
1,750
3,300
1,750
2,650
71780
71781
71782
71783
71784
71785
4,000
71786
200
71810
100
71811
Single hip spica
Double hip spica
Shoulder spica
Minerva cast

Short arm volar slab
Short arm post. slab
Long arm post. slab
Thumb spica slab
Long leg post. slab
Knee slab

Short arm cast
Long arm cast
Short leg cast
Long leg cast
Knee cast
PTB (Patella tension
banding) cast
Body jacket

(Skin Biopsy)
(Patch test
7-10 )

(Intralesional
60
71820
injection)
11.11.4
Podophyllin
11.11.5
11.11.6
11.11.7
11.11.8 Sebaceous cyst
11.11.9
11.11.10
11.11.11
11.12
11.12.1 (Bone
marrow aspiration)
11.12.2 (Bone
marrow biopsy)
11.13
11.13.1
Unmodified
11.13.2
Modified
11.14
11.14.1
11.14.2
130
71821
250
350
300 1
500 ()
300
300
80
71822
71830
71831
71832
71833
71834
71835
300
71840
400
71841
100
71910
300
71911
: Non-vascular Intervention
PTBD ()
13,000 Set
introducer access
PTBD (
2)
PTBD with stent (
17,000 Stent
)
72610
72611

11.14.3
11.15
Stent implantation (
8,000 Stent
)
: Vascular Intervention and other interventions
72612
Vascular Intervention Non-vacular

Intervention
2
11.15.1
Fluoroscope
11.15.2
DSI
11.15.3
DSA 1 plane
11.15.4
DSA 2 planes

11.1-11.15

1,700 2
Set
5,000 Mask

12,000
18,000
2548
72940
72941
72942
72943
72999

2548
50

1.

2.
( ) Set

Suction

0417/77
gel foam

(Explore laparotomy and splenectomy (54.11 + 41.5)) Splenectomy 6,000
Explore laparotomy 3,150 Splenectomy (6,000 )
Explore laparotomy (3,150 ) Splenectomy (6,000 )

Operative fields
25
Cesarian section (4,100 )
Incidental appendectomy (2,550 ) Tubal ligation (1,600 )
(4,100 + (0.25 x 2,550) + (0.25 x 1,600))

Cosmetic blepharoplasty (08.36),
Augmentation rhinoplasty (21.85), Face lift (86.82)

PROCEDURES
ICD-9-CM
1. OPERATIONS ON THE NERVOUS SYSTEM (01-05)

Incision and excision of skull, brain, and cerebral meninges
01
Open biopsy of cerebral meninges
01.12
Open biopsy of brain

01.14
Biopsy of skull
01.15
2548
PROCEDURES
Incision and drainage of cranial sinus
Reopening of craniotomy site
Cranial decompression
Craniotomy with removal of epidural abscess
Craniotomy with removal of extradural hematoma
Craniotomy with removal of foreign body of skull
Burr hole with irrigation and drainage
Sequestrectomy of skull
Drainage of intracranial hygroma
Drainage of subarachnoid abscess (cerebral)
Drainage of subdural empyema
Drainage of subdural hematoma
Division of brain tissue (lobotomy)
Drainage of intracerebral hematoma
Decortication of (cerebral) meninges
Hemispherectomy
Lobectomy of brain
Curettage of brain
Debridement of brain
Marsupialization of brain cyst
Excision of brain tumor
Excision of lesion of skull
Other operations on skull, brain, and cerebral meninges
Opening of cranial suture
Decompression of skull fracture
Repair of skull with flap
Pericranial graft (autogenous) (heterogenous)
Insertion of skull plate
Revision of bone flap of skull
Removal of skull plate
ICD-9-CM
01.21
01.23
01.24
01.24
01.24
01.24
01.24
01.25
01.31
01.31
01.31
01.31
01.32
01.39
01.51
01.52
01.53
01.59
01.59
01.59
01.59
01.6
02
02.01
02.02
02.03
02.04
02.05
02.06
02.07
2548
PROCEDURES
ICD-9-CM
Simple suture of dura mater of brain

Closure of fistula of cerebrospinal fluid
Dural graft
Repair of encephalocele including synchronous cranioplasty
Subdural patch
Ligation of middle meningeal artery
Ventriculostomy
Extracranial ventricular shunt
Revision of ventriculoperitoneal shunt at ventricular site
Removal of ventricular shunt
Repair of brain
Operations on spinal cord and spinal canal structures
Decompression of spinal canal (laminectomy)
Exploration of spinal nerve root
Anterior decompression of spinal canal
Rhizotomy
Biopsy of spinal cord or spinal meninges
Excision or destruction of lesion of spinal cord or spinal
meninges
Repair of spinal meningocele
Repair of spinal myelomeningocele
Reduction of fracture of vertebrae
Lysis of adhesions of spinal cord and nerve roots
Operations on cranial and peripheral nerves
Suture of cranial and peripheral nerves
Decompression of facial nerve
Release of carpal tunnel
Cranial or peripheral nerve graft
Hypoglossal-facial anastomosis
Accessory-facial anastomosis
02.11
02.12
02.12
02.12
02.12
02.13
02.2
02.3 (1-5, 9)
02.42
02.43
02.92
03
03.09
03.09
03.09
03.1
03.32
03.4
03.51
03.52
03.53
03.6
04
04.3
04.42
04.43
04.5
04.71
04.72
2548
PROCEDURES
Repair of facial nerve
Repair of digital nerve
Operations on sympathetic nerves or ganglia
Biopsy of sympathetic nerve or ganglion
Cervical sympathectomy
Lumbar sympathectomy
ICD-9-CM
04.74
04.74
05
05.11
05.22
05.23
2. OPERATIONS ON THE ENDOCRINE SYSTEM (06-07)

Operations on thyroid and parathyroid glands
06
Reopening of wound of thyroid field for control of
06.02
(postoperative) hemorrhage
Exploration neck by incision
06.09
Open biopsy of thyroid gland

06.12
Biopsy of parathyroid gland

06.13
Complete removal of one lobe of thyroid (with removal of

06.2
isthmus or portion of other lobe)

Hemithyroidectomy
06.2
Excision of lesion of thyroid

06.31
Subtotal thyroidectomy
06.39
Complete thyroidectomy
06.4
Partial substernal thyroidectomy

06.51
Complete substernal thyroidectomy

06.52
Excision of thyroid by submental route

06.6
Excision of thyroid by transoral route

06.6
Excision of thyroglossal duct or tract

06.7
Complete parathyroidectomy
06.81
Partial parathyroidectomy
06.89
Division of thyroid isthmus

06.91
Ligation of thyroid vessels

06.92
Suture of thyroid gland

06.93
2548
2548
PROCEDURES
Autotransplantation of parathyroid tissue
Operations on other endocrine glands
Unilateral adrenalectomy
Bilateral adrenalectomy
Thymectomy by median sternotomy
Total excision of thymus
ICD-9-CM
06.95
07
07.22
07.3
07.80
07.82
3. OPERATIONS ON THE EYE (08-16)

Operations on eyelids
08
Incision of lid margin
08.01
Severing of blepharorrhaphy
08.02
Biopsy of eyelid
08.11
Excision of chalazion
08.21
Excision of minor lesion of eyelid
08.22
Excision involving one-fourth or more of lid margin, partial08.23
thickness
Excision involving one-fourth or more of lid margin, full08.24
thickness
Repair of blepharoptosis by frontalis muscle technique with
08.31
suture
Repair of blepharoptosis by frontalis muscle technique with
08.32
fascial sling
Repair of blepharoptosis by resection or advancement of
levator muscle or aponeurosis
Repair of blepharoptosis by other levator muscle techniques
Repair of blepharoptosis by tarsal technique
Corrective blepharoplasty
Cosmetic blepharoplasty
Reduction of overcorrection of ptosis
2548
08.33
08.34
08.35
08.36
08.36
08.37
2548
0
PROCEDURES
ICD-9-CM
Correction of lid retraction

Repair of entropion or ectropion by suture technique
Repair of entropion or ectropion with wedge resection
Repair of entropion or ectropion with lid reconstruction
Repair of entropion or ectropion 2
Canthotomy
Blepharorrhaphy
Canthorrhaphy
Tarsorrhaphy
Reconstruction of eyelid with skin flap or graft
Reconstruction of eyelid with mucous membrane flap or graft
Reconstruction of eyelid with hair follicle graft
Reconstruction of eyelid with tarsoconjunctival flap
Eyelid reconstruction, Z-plasty 1
Eyelid reconstruction, Z-plasty 2
Reconstruction of eyelid involving lid margin, partialthickness
Reconstruction of eyelid involving lid margin, full-thickness
Linear repair of laceration of eyelid or eyebrow
Repair of laceration involving lid margin, partial-thickness
Repair of laceration involving lid margin, full-thickness
Lower eyelid rhytidectomy
Upper eyelid rhytidectomy
Eletrolysis
Operations on lacrimal system
Incision of lacrimal cyst (with drainage)
Biopsy of lacrimal gland
Biopsy of lacrimal sac
Excision of lesion of lacrimal gland
Partial dacryoadenectomy
08.38
08.42
08.43
08.44
08.49
08.51
08.52
08.52
08.52
08.61
08.62
08.63
08.64
08.70
08.70
08.71
2548
08.73
08.81
08.82
08.84
08.86
08.87
08.91
09
09.0
09.11
09.12
09.21
09.22
2548
PROCEDURES
ICD-9-CM
Total dacryoadenectomy
Refixation of lacrimal gland
Probing of lacrimal punctum
Probing of lacrimal canaliculi
Probing of nasolacrimal duct
Dacryocystorhinostomy (DCR) with insertion of tube or stent
Repair of canaliculus and punctum with/without silicone
intubation
Incision of lacrimal punctum
Incision of lacrimal sac
Excision of lacrimal sac and passage
Repair of punctual ectropion 1
Repair of punctual ectropion 2
Repair of canaliculus
Dacryocystorhinostomy [DCR]
Conjunctivodacryocystorhinostomy [CDCR]
Obliteration of lacrimal punctum
Operations on conjunctiva
Removal of embedded foreign body from conjunctiva by incision
Biopsy of conjunctiva
Excision of lesion or tissue of conjunctiva
Repair of symblepharon with free graft
Repair fornixes with graft (Mucosa graft)
Repair fornixes with silicone rod
Lysis of adhesions of conjunctiva and eyelid
Repair of laceration of conjunctiva
Subconjunctival injection
Operations on cornea
Magnetic removal of embedded foreign body from cornea
Scraping of cornea for smear or culture
09.23
09.3
09.41
09.42
09.43
09.44
09.44
09.51
09.53
09.6
09.71
09.71
09.73
09.81
09.82
09.91
10
10.0
10.21
10.31
10.41
10.42
10.43
10.5
10.6
10.91
11
11.0
11.21
2548
PROCEDURES
ICD-9-CM
Biopsy of cornea
Excision of pterygium with corneal graft
Excision of pterygium
Suture of corneal laceration
Repair of corneal laceration or wound with conjunctival flap
Keratoplasty
Keratoprosthesis
Tattooing of cornea
Operations on iris, ciliary body, sclera, and anterior chamber
Removal of intraocular foreign body from anterior segment of
eye
Iridectomy (basal) (peripheral) (total)
Diagnostic aspiration of anterior chamber of eye
Lysis of goniosynechiae
Lysis of anterior synechiae by injection of air or liquid
Lysis of posterior synechiae
Lysis of corneovitreal adhesions
Excision of lesion of iris
Excision of lesion of ciliary body
Goniotomy without goniopuncture
Trabeculotomy ab externo
Cyclodialysis
Trephination of sclera with iridectomy
Iridencleisis and iridotasis
Trabeculectomy ab externo
Postoperative revision of scleral fistulization procedure
Cyclodiathermy
Cyclocryotherapy
Cyclophotocoagulation
Suture of laceration of sclera
11.22
11.32
11.39
11.51
11.53
11.60
11.73
11.91
12
12.0 (0-2)
12.14
12.21
12.31
12.32
12.33
12.34
12.42
12.44
12.52
12.54
12.55
12.61
12.63
12.64
12.66
12.71
12.72
12.73
12.81
2548
PROCEDURES
ICD-9-CM
Excision or destruction of lesion of sclera

Paracentesis of anterior chamber
Injection into anterior chamber
Removal or destruction of epithelial downgrowth from
anterior chamber
Operations on lens
Intracapsular extraction of lens
Extracapsular extraction of lens by linear extraction technique
Extracapsular extraction of lens by simple aspiration (and
irrigation) technique
Phacoemulsification and aspiration of cataract
Mechanical phacofragmentation and aspiration of cataract
by posterior route
Discission of secondary membrane [after cataract]
Excision of secondary membrane [after cataract]
Capsulectomy
Insertion of intraocular lens prosthesis at time of cataract
extraction, one-stage
Secondary insertion of intraocular lens prosthesis
Operations on retina, choroid, vitreous, and posterior chamber
Removal of foreign body from posterior segment of eye
Destruction of chorioretinal lesion by cryotherapy
Repair of retinal tear by cryotherapy
Scleral buckling with implant
Scleral buckling with vitrectomy
Repair of retinal detachment with cryotherapy
Removal of surgically implanted material from posterior
segment of eye
Removal of vitreous, anterior approach
Aspiration of vitreous by posterior sclerotomy
12.84
12.91
12.92
12.93
13
13.1 (1, 9)
13.2
13.3
13.41
13.42
13.64
13.65
13.71
13.72
14
14.0 (0-2)
14.22
14.32
14.41
14.49
14.52
14.6
14.71
14.72
2548
PROCEDURES
ICD-9-CM
Mechanical vitrectomy by anterior approach

Injection of vitreous substitute
Operations on extraocular muscles
Biopsy of extraocular muscle or tendon
Operations on one extraocular muscle involving temporary
detachment from globe
Lengthening procedure on one extraocular muscle
Shortening procedure on one extraocular muscle
Operations on two or more extraocular muscles involving
temporary detachment from globe, one or both eyes
Transposition of extraocular muscles
Revision of extraocular muscle surgery
Repair of injury of extraocular muscle
Operations on orbit and eyeball
Orbitotomy with bone flap
Diagnostic aspiration of orbit
Removal of ocular contents with synchronous implant into
scleral shell
Enucleation of eyeball with synchronous implant into Tenon's
capsule with attachment of muscles
Exenteration of orbit with removal of adjacent structures
Exenteration of orbit with therapeutic removal of orbital bone
Secondary insertion of ocular implant
Removal of ocular or orbital implant
Repair of wound of orbit
Repair of rupture of eyeball
Retrobulbar injection of therapeutic agent
Excision of lesion of orbit
14.73
14.75
15
15.01
15.1 (1-9)
15.21
15.22
15.3
15.5
15.6
15.7
16
16.01
16.22
16.31
16.41
16.51
16.52
16.61
16.7 (1-2)
16.81
16.82
16.91
16.92
4. OPERATIONS ON THE EAR (18-20)
2548
PROCEDURES
Operations on external ear
Excision of preauricular sinus
Excision of preauricular cyst
Excision of preauricular remnant [appendage]
Radical excision of lesion of external ear
Amputation of external ear
Suture of laceration of external ear
Surgical correction of prominent ear
Reattachment of amputated ear
Plastic repair of external ear ( )
Reconstructive operations on middle ear
Stapedectomy
Revision of stapedectomy
Myringoplasty
Type II tympanoplasty
Type III tympanoplasty
Type IV tympanoplasty
Type V tympanoplasty
Revision of tympanoplasty
Other operations on middle and inner ear
Myringotomy
Simple mastoidectomy
Radical mastoidectomy
Excision of lesion of middle ear
Fenestration of inner ear
Revision of mastoidectomy
ICD-9-CM
18
18.21
18.21
18.29
18.31
18.39
18.4
18.5
18.72
18.79
19
19.1 (1, 9)
19.2 (1, 9)
19.4
19.52
19.53
19.54
19.55
19.6
20
20.0 (0, 9)
20.41
20.42
20.51
20.6 (1, 2)
20.92
2548
2548
5. OPERATIONS ON THE NOSE, MOUTH, AND PHARYNX (21-29)

Operations on nose
21
Control of epistaxis by posterior (and anterior) packing

21.02

PROCEDURES
ICD-9-CM
Control of epistaxis by ligation of ethmoidal arteries

Control of epistaxis by (transantral) ligation of the maxillary
artery
Control of epistaxis by excision of nasal mucosa and skin
grafting of septum and lateral nasal wall
Biopsy of nose
Local excision or destruction of intranasal lesion
Nasal polypectomy
Local excision or destruction of skin lesion of nose
Submucous resection of nasal septum
Closed reduction of nasal fracture
Open reduction of nasal fracture
Suture of laceration of nose
Total nasal reconstruction
Revision rhinoplasty
Rhinoseptoplasty
Augmentation rhinoplasty
21.04
21.05
21.07
21.22
21.31
21.31
21.32
21.5
21.71
21.72
21.81
21.83
21.84
21.84
21.85
Other rhinoplasty ( )
Repair of septal perforation
Operations on nasal sinuses
Open biopsy of nasal sinus
Intranasal antrotomy
Radical maxillary antrotomy
Frontal sinusotomy
Frontal sinusectomy
Excision of lesion of maxillary sinus with Caldwell-Luc
approach
Ethmoidectomy
Sphenoidectomy
21.87
21.88
22
22.12
22.2
22.31
22.41
22.42
22.61
22.63
22.64
2548
2548
PROCEDURES
Closure of nasal sinus fistula
Other operations on teeth, gums, and alveoli
Apical alveolotomy
Biopsy of gum
Biopsy of alveolus
Gingivoplasty
Excision of lesion or tissue of gum
Suture of laceration of gum
Excision of dental lesion of jaw
Alveoloplasty
Exposure of tooth
Application, insertion, or fitting of arch bars
Removal of arch bars
Extension or deepening of buccolabial or lingual sulcus
Operations on tongue
Excision or destruction of lesion or tissue of tongue
Partial glossectomy
Complete glossectomy
Radical glossectomy
Suture of laceration of tongue
Lingual frenotomy
Lingual frenectomy
Lysis of adhesions of tongue
Operations on salivary glands and ducts
Incision of salivary gland or duct
Open biopsy of salivary gland or duct
Excision of lesion of salivary gland
Marsupialization of salivary gland cyst
Superficial parotidectomy
Total parotidectomy
ICD-9-CM
22.71
24
24.0
24.11
24.12
24.2
24.31
24.32
24.4
24.5
24.6
24.7
24.8
24.91
25
25.1
25.2
25.3
25.4
25.51
25.91
25.92
25.93
26
26.0
26.12
26.2
26.21
26.31
26.32
2548
PROCEDURES
ICD-9-CM
Maxillary gland resection

Submandibular gland resection
Suture of laceration of salivary gland
Repair of Stensen's duct
Probing of salivary duct
Other operations on mouth and face
Drainage of facial region (abscess)
Drainage of Ludwig's angina
Incision of palate
Biopsy of bony palate
Biopsy of uvula and soft palate
Biopsy of lip
Local excision or destruction of lesion or tissue of bony palate
Wide excision or destruction of lesion or tissue of bony palate
Labial frenectomy
Wide excision of lesion of lip
Suture of laceration of lip
Closure of fistula of mouth
Repair of cleft lip
Full-thickness skin graft to lip and mouth
Attachment of pedicle or flap graft to lip and mouth
Suture of laceration of palate
Correction of cleft palate
Correction of cleft palate by push-back operation
Revision of cleft palate repair
Repair of uvula
Labial frenotomy
Operations on tonsils and adenoids
Incision and drainage of tonsil and peritonsillar structures
Tonsillectomy without adenoidectomy
26.32
26.32
26.41
26.49
26.91
27
27.0
27.0
27.1
27.21
27.22
27.23
27.31
27.32
27.41
27.42
27.51
27.53
27.54
27.55
27.57
27.61
27.62
27.62
27.63
27.73
27.91
28
28.0
28.2
2548
PROCEDURES
ICD-9-CM
Tonsillectomy with adenoidectomy

Adenoidectomy without tonsillectomy
Control of hemorrhage after tonsillectomy and adenoidectomy
Removal of foreign body from tonsil and adenoid by incision
Excision of lesion of tonsil and adenoid
Operations on pharynx
Excision of branchial cleft cyst or vestige
Suture of laceration of pharynx
Closure of branchial cleft fistula
28.3
28.6
28.7
28.91
28.92
29
29.2
29.51
29.52
6. OPERATIONS ON THE RESPIRATORY SYSTEM (30-34)

Excision of larynx
30
Marsupialization of laryngeal cyst
30.01
Excision of lesion of vocal cords

30.09
Hemilaryngectomy
30.1
Complete laryngectomy
30.3
Radical laryngectomy
30.4
Other operations on larynx and trachea

31
Temporary tracheostomy
31.1
Mediastinal tracheostomy
31.21
Laryngoscopy and other tracheoscopy

31.42
Open biopsy of larynx or trachea

31.45
Suture of laceration of larynx

31.61
Suture of laceration of trachea

31.71
Tracheoesophageal fistulectomy
31.73
Revision of tracheostomy
31.74
Tracheoplasty with artificial larynx

31.75
Lysis of adhesions of trachea or larynx

31.92
Laryngoplasty
31.98
Excision of lung and bronchus

32
2548
2548
PROCEDURES
Thoracotomy with resection of thoracic tumor
Segmental resection of lung
Lobectomy
Complete pneumonectomy
Other operations on lung and bronchus
Fiber-optic bronchoscopy
Rigid bronchoscopy
Closed [endoscopic] biopsy of bronchus
Open biopsy of bronchus
V.A.T.S. with biopsy of lung
V.A.T.S. with bleb resection mass, lung biopsy
Open lung biopsy
Artificial pneumothorax for collapse of lung
Thoracoplasty
Suture of laceration of bronchus
Closure of bronchial fistula
Closure of laceration of lung
Thoracotomy, with Repair Bronchus
Unilateral lung transplantation
Bronchial dilation
Operations on chest wall, pleura, mediastinum, and diaphragm
Extrapleural drainage
Exploratory thoracotomy with or without biopsy
Thoracotomy
Video Assist Thoracic surgery (V.A.T.S.)
Revision of intercostal catheter (chest tube) (with lysis of
adhesions)
Insertion of intercostals catheter for drainage
Rib resection and drainage
Thoracotomy, with stop bleeding
ICD-9-CM
32.29
32.3
32.4
32.5
33
33.22
33.23
33.24
33.25
33.27
33.27
33.28
33.32
33.34
33.41
33.42
33.43
33.48
33.51
33.91
34
34.01
34.02
34.02
34.02
34.04
34.04
34.09
34.09
2548
PROCEDURES
Median sternotomy
V.A.T.S. (Video Assisted Thoracic Surgery)
Mediastinoscope
Biopsy of chest wall
V.A.T.S. With biopsy of chest wall, pleura, mediastinum,
diaphragm
V.A.T.S. with pleural biopsy
Open mediastinal biopsy
Biopsy of diaphragm
V.A.T.S. with biopsy of diaphragm
Excision or destruction of lesion or tissue of mediastinum
Excision or destruction of lesion of chest wall
V.A.T.S. with decortication of lung
V.A.T.S. with decortication of lung
Decortications
Suture of laceration of chest wall
Repair of pectus carinatum (with implant)
Repair of pectus excavatum (with implant)
Excision of lesion or tissue of diaphragm
Suture of laceration of diaphragm
Closure of fistula of diaphragm
Repair or plication of diaphragm
Repair diaphragm
Implantation of diaphragmatic pacemaker
V.A.T.S. with chemical pleurodesis
Repair of pleura
ICD-9-CM
34.1
34.21
34.22
34.23
34.23
34.24
34.26
34.27
34.27
34.3
34.4
34.5
34.51
34.51
34.71
34.74
34.74
34.81
34.82
34.83
34.84
34.84
34.85
34.92
34.93
7. OPERATIONS ON THE CARDIOVASCULAR SYSTEM (35-39)

Operations on valves and septa of heart
35
Closed mitral valvulotomy
35.02
2548
PROCEDURES
ICD-9-CM
Open heart valvuloplasty of aortic valve without replacement

Open heart valvuloplasty of mitral valve without replacement
Open heart valvuloplasty of pulmonary valve without
replacement
Open heart valvuloplasty of tricuspid valve without replacement
Repair of aortic valve with tissue graft (autograft)
(heterograft) (homograft)
Repair of aortic valve with replacement prosthetic (partial)
(synthetic) (total)
Repair of mitral valve with tissue graft (autograft)
Repair of mitral valve with replacement prosthetic (partial)
(synthetic) (total)
35.11
35.12
35.13
35.14
35.21
35.22
35.23
35.24
Repair of pulmonary valve with tissue graft (autograft)

Repair of pulmonary valve with replacement prosthetic
(partial) (synthetic) (total)
Repair of tricuspid valve with tissue graft (autograft)
Repair of tricuspid valve with replacement prosthetic (partial)
(synthetic) (total)
Single Valve Repair/Replacement
Redo Valve
Annuloplasty
Bentall's operation
Blalock operation
Correction of atrial septal defect with prosthesis
Repair of atrial septal defect with prosthesis, closed
technique
35.25
35.26
35.27
35.28
35.2 (1-8)
35.2 (1-8)
35.33
35.39
35.42
35.51
35.52
2548
2548
PROCEDURES
Repair of ventricular septal defect with prosthesis
Correction of ventricular septal defect with prosthesis
Repair of ventricular septal defect with tissue graft
Total repair of tetralogy of Fallot
TOF
Operations on vessels of heart
CABG (Coronary Artery Bypas Graft)
CABG x 4
Other operations on heart and pericardium
Pericardial window
Subxiphoid window
Pericardial biopsy
V.A.T.S. with pericardiectomy
Pericardiectomy
Repair of heart and pericardium
Heart transplantation
Pacemaker implantation (permanent) epicardium lead
Insertion or replacement of epicardial lead [electrode] into
epicardium
Open chest cardiac massage
Incision, excision, and occlusion of vessels
Embolectomy
Thrombectomy
Endarterectomy with embolectomy
Endarterectomy with patch graft
Endarterectomy with thrombectomy
Biopsy of blood vessel
Excision of blood vessel (lesion) with anastomosis, upper
limb vessels
Coarctation
ICD-9-CM
35.53
35.53
35.62
35.81
35.81
36
36.1 (0-9)
36.14
37
37.12
37.12
37.24
37.31
37.31
37.4
37.51
37.67
37.74
37.91
38
38.0 (0-9)
38.0 (0-9)
38.1(0-6,8)
38.1(0-6,8)
38.1(0-6,8)
38.21
38.33
38.34
2548
PROCEDURES
ICD-9-CM
Excision of blood vessel (lesion) with anastomosis, abdominal

arteries
Excision of blood vessel (lesion) with anastomosis, lower
limb arteries
Excision of aneurysm (arteriovenous) or blood vessel
(lesion) with replacement, upper limb vessels
Thoracic aortic aneurysm resection
Thoracoabdominal aortic aneurysm resection
Abdominal aortic aneurysm resection
Excision of aneurysm (arteriovenous) or blood vessel
(lesion) with replacement, lower limb arteries
Ligation and stripping of varicose veins
PA banding
PDA
Ligation of blood vessel, hepatic artery
Other operations on vessels
Blalock' s shunt
Anastomosis portacaval
Anastomosis splenic and renal veins
Aorta-subclavian-carotid bypass
Aorta-renal bypass
Aorta-iliac-femoral bypass
Bypass aortoceliac
Anastomosis for renal dialysis, forearm loop graft
Anastomosis for renal dialysis, forearm straight graft
Anastomosis for renal dialysis, arm straight graft
Formation of (peripheral) arteriovenous fistula for renal
[kidney] dialysis
Bypass (graft) axillary-brachial
Bypass (graft) axillary-femoral [axillofemoral] (superficial)
38.36
38.38
38.43
38.44
38.44
38.44
38.48
38.5 (0-9)
38.85
38.85
38.86
39
39.0
39.1
39.1
39.22
39.24
39.25
39.26
39.27
39.27
39.27
39.27
39.29
39.29
2548
PROCEDURES
ICD-9-CM
Bypass (graft) brachial

Bypass (graft) femoral-femoral
Bypass (graft) femoroperoneal
Bypass (graft) femoropopliteal (arteries)
Bypass (graft) femorotibial (anterior) (posterior)
Suture of artery
Suture of vein
Revision of arteriovenous shunt for renal dialysis
Removal of arteriovenous shunt for renal dialysis
Revision of anastomosis of blood vessel
Repair of arteriovenous fistula
Embolization of carotid cavernous fistula
Repair of arteriovenous fistula by clipping, intracranial
Repair of arteriovenous fistula by ligation and division, PDA
Fenestration of dissecting aneurysm of thoracic aorta
Repair of blood vessel with tissue patch graft
Repair of blood vessel with synthetic patch graft
39.29
39.29
39.29
39.29
39.29
39.31
39.32
39.42
39.43
39.49
39.53
39.53
39.53
39.53
39.54
39.56
39.57
8. OPERATIONS ON THE HEMIC AND LYMPHATIC SYSTEM (40-41)

Operations on lymphatic system
40
Biopsy of lymphatic structure
40.11
Excision of deep cervical lymph node

40.21
Excision of internal mammary lymph node

40.22
Excision of axillary lymph node

40.23
Excision of inguinal lymph node

40.24
Excision of cystic hygroma

40.29
Regional lymph node excision

40.3
Radical neck dissection, unilateral

40.41
Radical neck dissection, bilateral

40.42
Radical excision of axillary lymph nodes

40.51
2548
2548
PROCEDURES
Radical excision of periaortic lymph nodes
Radical excision of iliac lymph nodes
Radical groin dissection
Closure of fistula of thoracic duct
Ligation of thoracic duct
Operations on bone marrow and spleen
Open biopsy of spleen
Partial splenectomy
Total splenectomy
Splenorrhaphy
ICD-9-CM
40.52
40.53
40.54
40.63
40.64
41
41.33
41.43
41.5
41.95
9. OPERATIONS ON THE DIGESTIVE SYSTEM (42-54)

Operations on esophagus
42
Incision of esophageal web
42.01
Cervical esophagostomy
42.11
Open biopsy of esophagus

42.25
Local excision of esophageal diverticulum

42.31
Esophagogastrectomy
42.40
Partial esophagectomy
42.41
Total esophagectomy
42.42
Intrathoracic esophagoesophagostomy
42.51
Intrathoracic esophagogastrostomy
42.52
Intrathoracic esophageal anastomosis with interposition of

42.53
small bowel
Intrathoracic esophageal anastomosis with interposition of
42.55
colon
Antesternal esophagogastrostomy
42.62
Antethoracic esophagojejunostomy
42.64
Antethoracic esophagocolostomy
42.66
2548
PROCEDURES
Esophagomyotomy
Suture of laceration of esophagus
Closure of esophagostomy
Ligation of esophageal varices
Dilation of esophagus
Incision and excision of stomach
Gastrotomy
Gastrostomy
Pyloromyotomy
Proximal gastrectomy
Billroth I operation
Billroth II operation
Partial gastrectomy with jejunal transposition
Total gastrectomy
Radical gastrectomy
Other operations on stomach
Truncal vagotomy
Highly selective vagotomy
Intraoperative gastroscopy
Open biopsy of stomach
Pyloroplasty
High gastric bypass
Bypass gastroduodenostomy
Bypass gastrojejunostomy
Suture of gastric ulcer site
Suture of duodenal ulcer site
Closure of gastroduodenostomy
Closure of gastrojejunostomy
Suture of laceration of stomach
Closure of gastrostomy
ICD-9-CM
42.7
42.82
42.83
42.91
42.92
43
43.0
43.19
43.3
43.5
43.6
43.7
43.81
43.9 (1,9)
43.99
44
44.01
44.02
44.11
44.15
44.2 (1, 2, 9)
44.31
44.39
44.39
44.41
44.42
44.5
44.5
44.61
44.62
2548
PROCEDURES
Closure of gastrocolic fistula
Gastropexy
Nissen's fundoplication
Ligation of gastric varices
Reduction of gastric volvulus
Incision, excision, and anastomosis of intestine
Incision of small intestine
Incision of duodenum
Incision of large intestine
Esophagogastroduodenoscopy [EGD]
Open biopsy of small intestine
Flexible sigmoidoscopy
Rigid sigmoidoscopy
Open biopsy of large intestine
Meckel's diverticulectomy
Segmental resection for multiple traumatic lesions of small
intestine
Small bowel resection
Total removal of small intestine
Segmental resection for multiple traumatic lesions of large
intestine
Cecectomy
Right hemicolectomy
Resection of transverse colon
Left hemicolectomy
Sigmoidectomy
Total intra-abdominal colectomy
Small-to-small intestinal anastomosis
Duodenoduodenostomy
Anastomosis of small intestine to rectal stump
ICD-9-CM
44.63
44.64
44.66
44.91
44.92
45
45.00
45.01
45.03
45.13
45.15
45.24
45.24
45.26
45.33
45.61
45.62
45.63
45.71
45.72
45.73
45.74
45.75
45.76
45.8
45.91
45.91
45.92
2548
PROCEDURES
Large-to-large intestinal anastomosis
Formation of endorectal ileal pouch (H- pouch) (J-pouch)
(S-pouch) with anastomosis of small intestine to anus
Other operations on intestine
Loop ileostomy
Loop colostomy
Temporary colostomy
Permanent colostomy
Delayed opening of colostomy
Temporary ileostomy
Continent ileostomy
Delayed opening of ileostomy
Duodenostomy
Open feeding enterostomy
Revision of stoma of small intestine
Repair of pericolostomy hernia
Closure of stoma of small intestine
Closure or take-down of cecostomy
Closure or take-down of colostomy
Closure or take-down of sigmoidostomy
Cecocoloplicopexy
Sigmoidopexy (Moschowitz)
Suture of laceration of duodenum
Closure of fistula of duodenum
Suture of laceration of small intestine, except duodenum
Closure of fistula of small intestine, except duodenum
Suture of laceration of large intestine
Closure of fistula of large intestine
Correction of intestinal malrotation
Reduction of intestinal volvulus
ICD-9-CM
45.94
45.95
46
46.01
46.03
46.11
46.13
46.14
46.21
46.22
46.24
46.39
46.39
46.41
46.42
46.51
46.52
46.52
46.52
46.63
46.63
46.71
46.72
46.73
46.74
46.75
46.76
46.80
46.80
2548
PROCEDURES
Reduction of intussusception
Revision of anastomosis of small intestine
Revision of anastomosis of large intestine
Operations on appendix
Laparoscopic appendectomy
Appendectomy
Laparoscopic incidental appendectomy
Incidental appendectomy
Drainage of appendiceal abscess
Closure of appendiceal fistula
Operations on rectum, rectosigmoid and perirectal tissue
Decompression of imperforate anus
Panas' operation [linear proctotomy]
Proctosigmoidoscopy with biopsy
Open biopsy of rectum
Biopsy of perirectal tissue
Local excision of rectal lesion or tissue
[Endoscopic] polypectomy of rectum
Endorectal pull-through operation
Abdominoperineal pull-through
Abdominoperineal resection of rectum
Transsacral rectosigmoidectomy
Anterior resection of rectum with synchronous colostomy
Low anterior resection
Duhamel resection of rectum
Suture of laceration of rectum
Ripstein repair of rectal prolapse
Proctosigmoidopexy
Repair of old obstetric laceration of rectum
Excision of perirectal tissue
ICD-9-CM
46.80
46.93
46.94
47
47.01
47.09
47.11
47.19
47.2
47.92
48
48.0
48.0
48.24
48.25
48.26
48.35
48.36
48.41
48.49
48.5
48.61
48.62
48.63
48.65
48.71
48.75
48.76
48.79
48.82
2548
PROCEDURES
Anorectal myectomy
Posterior sagittal anorectoplasty
Operations on anus
Incision of perianal abscess
Excision of perianal skin tags
Anal fistulotomy
Anal fistulectomy
Biopsy of perianal tissue
Biopsy of anus
Reduction of hemorrhoids
Excision of hemorrhoids
Evacuation of thrombosed hemorrhoids
Left lateral anal sphincterotomy
Suture of laceration of anus
Gracilis muscle transplant for anal incontinence
Reduction of anal prolapse
Control of (postoperative) hemorrhage of anus
Perineal anoplasty
Operations on liver
Incision of abscess of liver
Open biopsy of liver
Marsupialization of lesion of liver
Wedge resection of liver
Enucleation of hepatic lesion
Lobectomy of liver
Liver transplant
Closure of laceration of liver
Operations on gallbladder and biliary tract
Open cholecystostomy
Open biopsy of gallbladder or bile ducts
ICD-9-CM
48.92
48.99
49
49.01
49.03
49.11
49.12
49.22
49.23
49.41
49.46
49.47
49.51
49.71
49.74
49.94
49.95
49.99
50
50.0
50.12
50.21
50.22
50.29
50.3
50.5 (1,9)
50.61
51
51.03
51.13
2548
PROCEDURES
ICD-9-CM
Intraoperative choledochoscopy
Cholecystectomy
Laparoscopic cholecystectomy
Anastomosis of gallbladder to intestine
Choledochoduodenostomy
Choledochojejunostomy
Kasai portoenterostomy
Hepaticojejunostomy
Common duct exploration for removal of calculus
Insertion of choledochohepatic tube for decompression
Exploration of common duct
Excision of ampulla of Vater (with reimplantation of common
duct)
Excision of Choledochal cyst
Simple suture of common bile duct
Pancreatic sphincterotomy
Transduodenal ampullary sphincteroplasty
Repair of laceration of gallbladder
Revision of anastomosis of biliary tract
Operations on pancreas
Drainage of pancreatic cyst by catheter
Open biopsy of pancreas
Pancreaticocystoduodenostomy
Pancreaticocystogastrostomy
Pancreaticocystojejunostomy
Distal pancreatectomy
Radical subtotal pancreatectomy
Total pancreatectomy
Whipple procedure
Simple suture of pancreas
51.19
51.22
51.23
51.32
51.36
51.36
51.37
51.37
51.41
51.43
51.51
51.62
51.63
51.71
51.82
51.83
51.91
51.94
52
52.01
52.12
52.4
52.4
52.4
52.52
52.53
52.6
52.7
52.95
2548
PROCEDURES
ICD-9-CM
Anastomosis of pancreas (duct) to jejunum

Repair of hernia
Herniotomy
Repair of direct inguinal hernia
Repair of indirect inguinal hernia
Repair of direct inguinal hernia with graft or prosthesis
Repair of indirect inguinal hernia with graft or prosthesis
Bilateral repair of direct inguinal hernia
Bilateral repair of indirect inguinal hernia
Bilateral repair of inguinal hernia, one direct and one indirect
Bilateral repair of direct inguinal hernia with graft or
prosthesis
Bilateral repair of indirect inguinal hernia with graft or
prosthesis
Bilateral repair of inguinal hernia, one direct and one
indirect, with graft or prosthesis
Unilateral repair of femoral hernia
Bilateral repair of femoral hernia
Repair of umbilical hernia
Incisional hernia repair
Repair of hernia ventral
Incisional hernia repair with prosthesis
Repair of diaphragmatic hernia, abdominal approach
Repair of diaphragmatic hernia, thoracic approach
Plication of the diaphragm
Repair of parasternal hernia
Repair of hernia obturator
Other operations on abdominal region
Drainage of abdominal wall
Drainage of extraperitoneal abscess
52.96
53
53.00
53.01
53.02
53.03
53.04
53.11
53.12
53.13
53.14
53.15
53.16
53.2 (1,9)
53.3 (1,9)
53.4 (1,9)
53.51
53.59
53.61
53.7
53.8
53.81
53.82
53.9
54
54.0
54.0
2548
PROCEDURES
ICD-9-CM
Drainage of retroperitoneal abscess

54.0
Exploratory laparotomy
54.11
Reopening of recent laparotomy site for control of
54.12
hemorrhage
Reopening of recent laparotomy site for exploration
54.12
Drainage of intraperitoneal abscess or hematoma
54.19
Staging laparotomy
54.19
Biopsy of abdominal wall or umbilicus
54.22
Biopsy of peritoneum
54.23
Biopsy of mesentery
54.23
Biopsy of omentum
54.23
Diagnostic peritoneal lavage
54.25
Debridement of abdominal wall
54.3
Excision of lesion of mesentery
54.4
Excision of lesion of omentum
54.4
Excision of lesion of peritoneum
54.4
Excision of retroperitoneal lesion
54.4
Laparoscopic lysis of peritoneal adhesions
54.51
Freeing of adhesions of intestines
54.59
Reclosure of postoperative disruption of abdominal wall
54.61
Delayed closure of granulating abdominal wound
54.62
Suture of laceration of abdominal wall
54.63
Repair of gastroschisis
54.71
Repair of omphalocele
54.72
Reduction of torsion of omentum
54.74
Removal of foreign body from peritoneal cavity
54.92
Ladd operation
54.95
10. OPERATIONS ON THE URINARY SYSTEM (55-59)
Operations on kidney
55
Nephrotomy
55.01
2548
PROCEDURES
Evacuation of renal cyst
Nephrolithotomy
Nephrostomy
Nephrostolithotomy, percutaneous (nephroscopic)
Percutaneous nephrostomy without fragmentation
Pyelotomy
Pyelolithotomy
Pyelostomy
Closed [percutaneous] [needle] biopsy of kidney
Partial nephrectomy
Nephroureterectomy
Total nephrectomy (unilateral)
Removal of transplanted or rejected kidney
Transplant of kidney
Nephropexy
Suture of laceration of kidney
Reduction of torsion of renal pedicle
Correction of ureteropelvic junction
Percutaneous aspiration of kidney (pelvis)
Replacement of nephrostomy tube
Bivalve renal calculi with hypothermia
Operations on ureter
URSL (Ureteroscopy with litholapaxy)
Ureteral meatotomy
Incision of ureter for removal of calculus
Ureteroscopy
Partial ureterectomy
Total ureterectomy
Ureteroneocystostomy
Ureteroureterostomy
ICD-9-CM
55.01
55.01
55.02
55.03
55.03
55.11
55.11
55.12
55.23
55.4
55.51
55.51
55.53
55.6 (1,9)
55.7
55.81
55.84
55.87
55.92
55.93
55.99
56
56.0
56.1
56.2
56.31
56.41
56.42
56.74
56.75
2548
0
2548
PROCEDURES
Lysis of intraluminal adhesions of ureter
Suture of laceration of ureter
Closure of ureterostomy
Ureteropexy
Dilation of ureteral meatus
Double J insertion
Operations on urinary bladder
Transurethral litholapexy
Percutaneous suprapubic cystostomy
Suprapubic cystostomy
Cystolithotomy
Vesicostomy
Revision or closure of vesicostomy
Transurethral cystoscopy
Closed [transurethral] biopsy of bladder
TUR bladder neck
TUR bladder tumor
Excision of urachus
Suprapubic excision of bladder lesion
Partial cystectomy
Total cystectomy
Radical cystectomy
Suture of laceration of bladder
Vaginovesical fistulectomy
V-Y plasty of bladder neck
Ileal bladder
Operations on urethra
Urethrotomy
Urethral meatotomy
Biopsy of urethra
ICD-9-CM
56.81
56.82
56.83
56.85
56.91
56.99
57
57.0
57.17
57.18
57.19
57.21
57.22
57.32
57.33
57.49
57.49
57.51
57.59
57.6
57.7
57.71
57.81
57.84
57.85
57.87
58
58.0
58.1
58.23
2548
PROCEDURES
Suture of laceration of urethra
Repair of hypospadias or epispadias
Urethral meatoplasty
Release of urethral stricture
Dilation of urethra
Other operations on urinary tract
Marshall-Marchetti-Krantz operation
Ureteral catheterization
Replacement of ureterostomy tube
Replacement of cystostomy tube
ICD-9-CM
58.41
58.45
58.47
58.5
58.6
59
59.5
59.8
59.93
59.94
11. OPERATIONS ON THE MALE GENITAL ORGANS (60-64)

Operations on prostate and seminal vesicles
60
Transurethral resection of prostate (TURP)
60.29
Suprapubic prostatectomy
60.3
Retropubic prostatectomy
60.4
Radical prostatectomy
60.5
Operations on scrotum and tunica vaginalis

61
Incision and drainage of scrotum and tunica vaginalis
61.0
Biopsy of scrotum or tunica vaginalis

61.11
Excision of hydrocele (of tunica vaginalis)

61.2
Excision or destruction of lesion or tissue of scrotum

61.3
Suture of laceration of scrotum and tunica vaginalis

61.41
Reconstruction with rotational or pedicle flaps

61.49
Excision of hematocele of tunica vaginalis

61.92
Operations on testes
62
Unilateral orchiectomy
62.3
Bilateral orchiectomy
62.4 (1,2)
Orchiopexy
62.5
Suture of laceration of testis

62.61
2548
2548
PROCEDURES
ICD-9-CM
Operations on spermatic cord, epididymis, and vas deferens

High ligation of spermatic vein
Hydrocelectomy of canal of Nuck
Varicocelectomy
Reduction of torsion of testis or spermatic cord
Vasectomy
Reconstruction of surgically divided vas deferens
Operations on penis
Circumcision
Biopsy of penis
Local excision or destruction of lesion of penis
Amputation of penis
Suture of laceration of penis
Reconstruction of penis
Reattachment of amputated penis
Dorsal or lateral slit of prepuce
63
63.1
63.1
63.1
63.52
63.73
63.82
64
64.0
64.11
64.2
64.3
64.41
64.44
64.45
64.91
12. OPERATIONS ON THE FEMALE GENITAL ORGANS (65-71)

Operations on ovary
65
Other biopsy of ovary
65.12
Other biopsy of ovary

65.12
Laparoscopic biopsy of ovary

65.13
Wedge resection of ovary

65.22
Laparoscopic wedge resection of ovary

65.24
Other laparoscopic local excision or destruction of ovary :

65.25
cauterization of endometriosis
Other local excision or destruction of ovary :Bisection,
65.29
Cauterization, Partial excision
Laparoscopic unilateral oophorectomy
65.31
2548
2548
PROCEDURES
ICD-9-CM
Unilateral oophorectomy
Laparoscopic unilateral salpingo-oophorectomy
Unilateral salpingo-oophorectomy
Bilateral oophorectomy
Other removal of remaining ovary
Laparoscopic removal of remaining ovary
Bilateral salpingo-oophorectomy
Other removal of remaining ovary and tube
Laparoscopic removal of both ovaries and tubes at same
operative episode
Laparoscopic removal of remaining ovary and tube
Other simple suture of ovary
Salpingo-oophoroplasty
Laparoscopic simple suture of ovary
Laparoscopic salpingo-oophoroplasty
Other repair of ovary: oophoropexy
Laparoscopic lysis adhesion of ovary and fallopian tube
Other lysis of adhesion of ovary and fallopian tube
Release of torsion of ovary
Operations on fallopian tubes
Salpingotomy
Salpingostomy: Conservative operation for ectopic pregnancy
Bilateral endoscopic ligation and crushing of fallopian tubes
Bilateral endoscopic ligation and division of fallopian tubes
Other bilateral endoscopic destruction or occlusion of
fallopian tubes
TR
Bilateral destruction or occlusion of fallopian tubes
Total unilateral salpingectomy
Total bilateral salpingectomy
65.39
65.41
65.49
65.5 (1,3)
65.52
65.54
65.6 (1, 3, 4)
65.62
65.63
65.64
65.71
65.73
65.74
65.76
65.79
65.81
65.89
65.95
66
66.01
66.02
66.21
66.22
66.29
66.32
66.39
66.4
66.51
2548
PROCEDURES
Removal of remaining of fallopian tube
Excision or destruction of lesion of fallopian tube
Salpingectomy with removal of tubal pregnancy
Bilateral partial salpingectomy, NOS.
Partial salpingectomy: exp. For Ectopic pregnancy
Simple suture of fallopian tube
Salpingo-salpingostomy
Salpingo-uterostomy
Other repair of fallopian tube: Graft of fallopian tube,
Reopening of devided fallopian tube, Salpingoplasty
Salpingoplasty
Insufflation of fallopian tube: with air, dye, gas, saline,
Rubins test
Unilateral destruction or occlusion of fallopian tube
Burying of fimbriae in uterine wall
Operations on cervix
Dilation of cervical canal
Conization of cervix
Destruction of lesion of cervix by cauterization
Destruction of lesion of cervix by cryosurgery
Other excision/destruction of lesion/tissue of cervix
Amputation of cervix: Cervicectomy with synchronous
colporrhaphy
Cerclage of isthmus uteri
Suture of laceration of cervix
Repair of fistula of cervix
Repair of fornix
Other incision and excision of uterus
Hysterotomy : with removal of hydatidiform mole/fetus
Hysteroscopy
ICD-9-CM
66.52
66.61
66.62
66.63
66.69
66.71
66.73
66.74
66.79
66.79
66.8
66.92
66.97
67
67.0
67.2
67.32
67.33
67.39
67.4
67.59
67.61
67.62
67.69
68
68.0
68.12
2548
PROCEDURES
ICD-9-CM
Open biopsy of uterus

Open biopsy of uterine ligament
Closed biopsy of uterine ligament: Laparoscopic
Closed biopsy of uterus: Laparoscopic, Hysteroscopic
Division of endometrial synechiae
Incision of excision of congenital septum of uterus
Dilation and curettage for destruction of lesion or tissue of
uterus
Uterine myomectomy
Laparoscopic excision or destruction of lesion or tissue of
uterus: Myomectomy
Subtotal abdominal hysterectomy
Subtotal abdominal hysterectomy: Supracervical
hysterectomy
Total abdominal hysterectomy
Total abdominal laparoscopic hysterectomy: TLH
Laparoscopically assisted vaginal hysterectomy (LAVH)
Vaginal hysterectomy
Vaginal hysterectomy with A-P repair
Radical abdominal hysterectomy
Radical vaginal hysterectomy
Pelvic evisceration: Removal of ovaries, tubes, uterus,
vagina, bladder and urethra (with removal of sigmoid colon
and rectum)
Other and unspecified hysterectomy
D and C for termination of pregnancy
D and C following delivery and abortion
Other dilatation and curettage: Diagnostic D&C, F/C
Other excision and destruction of uterus and supporting
structures
68.13
68.14
68.15
68.16
68.21
68.22
68.23
2548
68.29
68.29
68.3 (1,9)
68.39
68.4
68.4
68.51
68.59
68.59
68.6
68.7
68.8
68.9
69.01
69.02
69.09
69.19
PROCEDURES
Paracervical uterine denervation
Suture of laceration of uterus: esp.:-Ruptured uterus
Other repair of uterus: Repair of old obstetric laceration of
uterus
Aspiration curettage of uterus
Menstrual extraction or regulation
Manual replacement of inverted uterus
Removal of cerclage material from cervix
Other operation on supporting structures of uterus
Operations on vagina and cul-de-sac
Hymenotomy
Culdotomy
Lysis of intraluminal adhesion of vagina
Other vaginotomy: Devision of vaginal septum, Drainage of
hematoma of vaginal cuff
Hymenectomy
Excision or destruction of lesion of vagina
Obliteration and total excision of vagina: Vaginectomy
Repair of cystocele and rectocele
Repair of cystocele
Repair of cystocele/urethrocele: Anterior colporrhaphy
Repair of rectocele
Repair of rectocele: Posterior colporrhaphy
Vaginal construction
Vaginal reconstruction
Suture of laceration of vagina:- Repair of fornix
Repair of colovaginal fistula
Repair of rectovaginal fistula
Repair of other vaginoenteric fistula
Repair of other fistula of vagina
ICD-9-CM
69.3
69.41
69.49
69.5
69.6
69.94
69.96
69.98
70
70.11
70.12
70.13
70.14
70.31
70.33
70.4
70.50
70.51
70.51
70.52
70.52
70.61
70.62
70.71
70.72
70.73
70.74
70.75
2548
PROCEDURES
Hymenorrhaphy
Vaginal suspension and fixation
Other repair of vagina: Colpoperineoplasty, Repair of old
obstetric laceration of vagina
Obliteration of vaginal vault: LeFort operation
Operations on vulva and perineum
Lysis of vulvar adhesion
Other incision of vulva and perineum: Enlargement of
introitus NOS
Marsupialization of Bartholin's gland (cyst)
Excision or other destruction of Bartholins mass
Cauterization of condyloma
Female circumcision
Radical vulvectomy
Unilateral vulvectomy
Bilateral vulvectomy
Suture of laceration of vulva or perineum
Anterior-posterior repair of perineum
Posterior repair of perineum
ICD-9-CM
70.76
70.77
70.79
70.8
71
71.01
71.09
71.23
71.24
71.3
71.4
71.5
71.61
71.62
71.71
71.79
71.79
13. OBSTETRICAL PROCEDURES (72-75)

Cesarean section and removal of fetus
74
Classical cesarean section
74.0
Low cervical cesarean section
74.1
2548
2548
2548
14. OPERATIONS ON THE MUSCULOSKELETAL SYSTEM (76-84)

Operations on facial bones and joints
76
Sequestrectomy of facial bone

76.01

PROCEDURES
Biopsy of facial bone
Local excision or destruction of lesion of facial bone
Hemimandibulectomy
Hemimaxillectomy (with bone graft or prosthesis)
Total mandibulectomy with synchronous reconstruction
Total ostectomy of other facial bone with synchronous
reconstruction
Temporomandibular arthroplasty
Closed osteoplasty [osteotomy] of mandibular ramus
Open osteoplasty [osteotomy] of mandibular ramus
Osteoplasty [osteotomy] of body of mandible
Segmental or subapical osteotomy
Segmental osteoplasty [osteotomy] of maxilla
Total osteoplasty [osteotomy] of maxilla
Reduction genioplasty
Augmentation genioplasty
Closed reduction of malar and zygomatic fracture
Open reduction of malar and zygomatic fracture
Closed reduction of maxillary fracture
Open reduction of maxillary fracture
Closed reduction of mandibular fracture
Open reduction of mandibular fracture
Open reduction of alveolar fracture
Open reduction of orbit rim or wall
Bone graft to facial bone
Insertion of synthetic implant in facial bone
Closed reduction of temporomandibular dislocation
Open reduction of temporomandibular dislocation
Removal of internal fixation device from facial bone
Incision, excision, and division of other bones
ICD-9-CM
76.11
76.2
76.31
76.39
76.41
76.44
76.5
76.61
76.62
76.63
76.64
76.65
76.66
76.67
76.68
76.71
76.72
76.73
76.74
76.75
76.76
76.77
76.79
76.91
76.92
76.93
76.94
76.97
77
2548
2548
PROCEDURES
ICD-9-CM
Sequestrectomy
Wedge osteotomy
Biopsy of bone
Bunionectomy with soft tissue correction and osteotomy of
the first metatarsal
Rib resection
Local excision of lesion or tissue of bone, clavicle
Local excision of lesion or tissue of bone, humerus
Local excision of lesion or tissue of bone, femur
Local excision of lesion or tissue of bone, patella
Local excision of lesion or tissue of bone, tibia and fibula
Local excision of lesion or tissue of bone, tarsals and
metatarsals
Local excision of lesion or tissue of bone, pelvic bones
Local excision of lesion or tissue of bone, phalanges (of foot)
(of hand)
Excision of bone for graft
Condylectomy
Other operations on bones, except facial bones
Bone graft (autogenous) (heterogenous), humerus
Bone graft (autogenous) (heterogenous), radius and ulna
Bone graft (autogenous) (heterogenous), femur
Bone graft (autogenous) (heterogenous), tibia and fibula
Minifixator with insertion of pins/wires/screws into bone,
clavicle
humerus
radius and ulna
Minifixator with insertion of pins/wires/screws into bone, femur
77.0 (1-9)
77.2 (1-9)
77.4 (1-9)
77.51
77.61
77.61
77.62
77.65
77.66
77.67
77.68
77.69
77.69
77.7 (1-9)
77.8 (1-9)
78
78.02
78.03
78.05
78.07
78.11
78.12
78.13
78.15
2548
PROCEDURES
ICD-9-CM
Application of external fixation device, humerus

Application of external fixation device, radius and ulna
Application of external fixation device, femur
Application of external fixation device, tibia and fibula
Application of external fixation device, pelvic bones
Application of external fixation device, phalanges (of foot)
(of hand)
Epiphyseal stapling, femur
Limb lengthening procedures, femur
Removal of external fixator device, humerus
Removal of external fixator device, radius and ulna
Removal of external fixator device, tibia and fibula
Removal of internal fixation device, humerus
Removal of internal fixation device, radius and ulna
Removal of internal fixation device, carpals and metacarpals
Removal of internal fixation device, femur
Removal of internal fixation device, patella
Removal of internal fixation device, tibia and fibula
Removal of internal fixation device, tarsals and metatarsals
Removal of internal fixation device, phalanges (of foot)
(of hand)
Removal of internal fixation device, vertebrae
Reduction of fracture and dislocation
Closed reduction of fracture without internal fixation, humerus
Closed reduction of fracture without internal fixation, radius
and ulna
Closed reduction of fracture without internal fixation, carpals
and metacarpals
Closed reduction of fracture without internal fixation,
phalanges of hand
78.12
78.13
78.15
78.17
78.19
78.19
78.25
78.35
78.62
78.63
78.67
78.62
78.63
78.64
78.65
78.66
78.67
78.68
78.69
78.69
79
79.01
79.02
79.03
79.04
2548
PROCEDURES
ICD-9-CM
Closed reduction of fracture without internal fixation, femur

Closed reduction of fracture without internal fixation, tibia
and fibula
Closed reduction of fracture without internal fixation, tarsals
and metatarsals
Closed reduction of fracture without internal fixation,
phalanges of foot
Closed reduction of fracture with internal fixation, humerus
Closed reduction of fracture with internal fixation, radius and ulna
Closed reduction of fracture with internal fixation, carpals
and metacarpals
Closed reduction of fracture with internal fixation, phalanges
of hand
Closed reduction of fracture with internal fixation, femur
Closed reduction of fracture with internal fixation, tibia and
fibula
Closed reduction of fracture with internal fixation, tarsals and
metatarsals
Closed reduction of fracture with internal fixation, phalanges
of foot
Open reduction of fracture without internal fixation, humerus
Open reduction of fracture without internal fixation, radius
and ulna
Open reduction of fracture without internal fixation, carpals
and metacarpals
Open reduction of fracture without internal fixation,
phalanges of hand
Open reduction of fracture without internal fixation, femur
Open reduction of fracture without internal fixation, tibia and
fibula
79.05
79.06
79.07
79.08
79.11
79.12
79.13
79.14
79.15
79.16
79.17
79.18
79.21
79.22
79.23
79.24
79.25
79.26
2548
PROCEDURES
ICD-9-CM
Open reduction of fracture without internal fixation, tarsals

and metatarsals
Open reduction of fracture without internal fixation, phalanges
of foot
Open reduction of fracture with internal fixation, humerus
Open reduction of fracture with internal fixation, radius and ulna
Open reduction of fracture with internal fixation, carpals and
metacarpals
Open reduction of fracture with internal fixation, phalanges of
hand
Open reduction of fracture with internal fixation, neck of femur
Open reduction of fracture with internal fixation, femur
Open reduction of fracture with internal fixation, femuoral
condyle
Open reduction of fracture with internal fixation, tibia and
fibula
Open reduction of fracture with internal fixation, malleolar
Open reduction of fracture with internal fixation, tarsals and
metatarsals
Open reduction of fracture with internal fixation, phalanges of
foot
Open reduction of fracture with internal fixation, platella
Open reduction of fracture with internal fixation, clavicle
Closed reduction of separated epiphysis, humerus
Closed reduction of separated epiphysis, radius and ulna
Closed reduction of separated epiphysis, femur
Closed reduction of separated epiphysis, tibia and fibula
Open reduction of separated epiphysis, humerus
Open reduction of separated epiphysis, radius and ulna
Open reduction of separated epiphysis, femur
79.27
79.28
79.31
79.32
79.33
79.34
79.35
79.35
79.35
79.36
79.36
79.37
79.38
79.39
79.39
79.41
79.42
79.45
79.46
79.51
79.52
79.55
2548
PROCEDURES
ICD-9-CM
Open reduction of separated epiphysis, tibia and fibula

Debridement of compound fracture, humerus
Debridement of compound fracture, radius and ulna
Debridement of compound fracture, carpals and
metacarpals
Debridement of compound fracture, phalanges of hand
Debridement of compound fracture, femur
Debridement of compound fracture, tibia and fibula
Debridement of compound fracture, tarsals and metatarsals
Debridement of compound fracture, phalanges of foot
Closed reduction of dislocation of shoulder
Closed reduction of dislocation of elbow
Closed reduction of dislocation of wrist
Closed reduction of dislocation of hand and finger
Closed reduction of dislocation of hip
Closed reduction of dislocation of knee
Closed reduction of dislocation of ankle
Closed reduction of dislocation of foot and toe
Open reduction of dislocation of shoulder
Open reduction of dislocation of elbow
Open reduction of dislocation of wrist
Open reduction of dislocation of hand and finger
Open reduction of dislocation of hip
Open reduction of dislocation of knee
Open reduction of dislocation of ankle
Open reduction of dislocation of foot and toe
Incision and excision of joint structures
Arthrostomy, shoulder
Arthrostomy, elbow
Arthrostomy, knee
79.56
79.61
79.62
79.63
79.64
79.65
79.66
79.67
79.68
79.71
79.72
79.73
79.74
79.75
79.76
79.77
79.78
79.81
79.82
79.83
79.84
79.85
79.86
79.87
79.88
80
80.11
80.12
80.16
2548
PROCEDURES
Arthroscopy, shoulder
Arthroscopy, knee
Aspiration biopsy
Diskectomy
Excision of meniscus of knee
Synovectomy, carpals and metacarpals
Synovectomy, knee
Synovectomy, tarsals and metatarsals
Synovectomy, phalanges of foot
Repair and plastic operations on joint structures
Harrington rod fixation for fracture spine
Pedicular screws fixation of spine
Craniocervical fusion by anterior, transoral, or posterior
technique
Arthrodesis of C2 level or below anterior (interbody)
technique
Arthrodesis of C2 level or below anterolateral technique
Arthrodesis of C2 level or below posterior (interbody)
technique
Arthrodesis of C2 level or below posterolateral technique
Lumbar and lumbosacral fusion, posterior technique
Ankle fusion
Arthrodesis of hip
Arthrodesis of knee
Arthrodesis of shoulder
Arthrodesis of elbow
Interphalangeal fusion
ACL reconstruction
PCL reconstruction
Open reduction with screw fixation for PCL avulsion
ICD-9-CM
80.21
80.26
80.3 (1-9)
80.51
80.6
80.73
80.76
80.77
80.78
81
81.0 (0-9)
81.0 (0-9)
81.01
81.02
81.02
81.03
81.03
81.08
81.11
81.21
81.22
81.23
81.24
81.28
81.45
81.45
81.45
2548
PROCEDURES
ICD-9-CM
Total hip replacement

Femoral head replacement (hemiarthroplasty)
Bipolar endoprosthesis
Total knee replacement
Total ankle replacement
Total shoulder replacement
Suture of capsule or ligament of upper extremity
Suture of capsule or ligament of ankle and foot
Operations on muscle, tendon, and fascia of hand
Removal of rice bodies in tendon sheath of hand
Bursotomy of hand
Excision of lesion of tendon sheath of hand
Suture of tendon sheath of hand
Delayed suture of flexor tendon of hand
Suture of muscle or fascia of hand
Reattachment of tendon of hand
Digital transfer to act as thumb
Plastic operation on hand with graft of muscle or fascia
Repair of cleft hand
Operations on muscle, tendon, fascia, and bursa, except hand
Removal of rice bodies from tendon sheath
Fasciotomy
Release of Volkmann's contracture by fasciotomy
Division of muscle for torticollis
Muscle release
Myotomy for thoracic outlet decompression
Biopsy of soft tissue
Excision of ganglion of tendon sheath, except of hand
Excision of lesion of muscle
Excision of Baker's cyst
81.51
81.52
81.52
81.54
81.56
81.80
81.93
81.94
82
82.01
82.03
82.21
82.41
82.42
82.46
82.53
82.6 (1,9)
82.72
82.82
83
83.01
83.14
83.14
83.19
83.19
83.19
83.21
83.31
83.32
83.39
2548
PROCEDURES
Excision of tendon for graft
Excision of muscle or fascia for graft
Scalenectomy
Bursectomy
Suture of tendon sheath
Rotator cuff repair
Achillorrhaphy
Advancement of tendon
Recession of tendon
Reattachment of tendon
Reattachment of muscle
Tendon transfer or transplantation
Tendon graft
Graft of muscle or fascia
Tendon pulley reconstruction
Release of clubfoot
Teno achillis lengthening
Myotenoplasty
Other procedures on musculoskeletal system
Amputation and disarticulation of finger
Amputation and disarticulation of thumb
Amputation through hand
Disarticulation of wrist
Forearm amputation
Disarticulation of elbow
Upper arm amputation
Disarticulation of shoulder
Amputation of toe
Amputation through metatarsophalangeal joint
ICD-9-CM
83.41
83.43
83.45
83.5
83.61
83.63
83.64
83.71
83.72
83.73
83.74
83.75
83.81
83.82
83.83
83.84
83.85
83.88
84
84.01
84.02
84.03
84.04
84.05
84.06
84.07
84.08
84.11
84.11
2548
PROCEDURES
ICD-9-CM
Ray amputation of foot (disarticulation of the metatarsal head

of the toe extending across the forefoot just proximal to the
metatarsophalangeal crease)
Amputation through foot
Disarticulation of ankle
Amputation below knee
Disarticulation of knee
Amputation above knee
Disarticulation of hip
Thumb reattachment
Finger reattachment
Forearm, wrist, or hand reattachment
Upper arm reattachment
Reamputation of stump
Secondary closure of stump
Trimming of stump
84.11
84.12
84.13
84.15
84.16
84.17
84.18
84.21
84.22
84.23
84.24
84.3
84.3
84.3
15. OPERATIONS ON THE INTEGUMENTARY SYSTEM (85-86)

Operations on the breast
85
Open biopsy of breast
85.12
Local excision of lesion of breast

85.21
Resection of quadrant of breast

85.22
Excision of ectopic breast tissue

85.24
Excision of nipple
85.25
Unilateral reduction mammoplasty

85.31
Bilateral reduction mammoplasty

85.32
Removal of breast tissue with preservation of skin and nipple

85.34
Unilateral simple mastectomy

85.41
2548
0
0
PROCEDURES
ICD-9-CM
Bilateral simple mastectomy

Modified radical mastectomy
Unilateral radical mastectomy
Augmentation mammoplasty
Mastopexy
Total reconstruction of breast
Suture of laceration of breast
Split-thickness graft to breast
Full-thickness graft to breast
Pedicle graft to breast
Muscle flap graft to breast
Revision of implant of breast
Operations on skin and subcutaneous tissue
Incision with removal of foreign body from skin and
subcutaneous tissue
Removal of tissue expander(s) from skin or soft tissue other
than breast tissue
Escharotomy
Excisional debridement of wound, infection, or burn
Tangential excision of burn
Dermabrasion
Ligation of dermal appendage
Debridement of nail, nail bed, or nail fold
Scrub burn
Destruction of skin by laser beam
Wide excision of skin lesion involving underlying or adjacent
structure
Replantation of scalp
Closure of skin and subcutaneous tissue
Split-thickness skin graft
85.42
85.43
85.45
85.5 (0-4)
85.6
85.7
85.81
85.82
85.83
85.84
85.85
85.93
86
86.05
86.05
86.09
86.22
86.22
86.25
86.26
86.27
86.28
86.3
86.4
86.51
86.59
86.60
2548
0
2548
2548
PROCEDURES
Full-thickness skin graft to hand
Full-thickness skin graft to other sites
Cutting and preparation of pedicle grafts or flaps
Advancement of pedicle graft
Attachment of pedicle or flap graft to hand
Attachment of pedicle or flap graft to other sites
Revision of pedicle or flap graft
Repair for facial weakness
Face lift
Liposuction
Reduction of adipose tissue of abdominal wall (pendulous)
Relaxation of scar or web contracture of skin
Z-plasty of skin
Correction of syndactyly
Repair of facial wound
Scar revision
Insertion of tissue expander
ICD-9-CM
86.61
86.63
86.71
86.72
86.73
86.74
86.75
86.81
86.82
86.83
86.83
86.84
86.84
86.85
86.89
86.89
86.93
0
0
2548
16. MISCELLANEOUS DIAGNOSTIC AND THERAPEUTIC PROCEDURES (87-99)

Diagnostic Radiology
87
Intraoperative intravenous pyelogram
87.73
Intraoperative retrograde pyelogram

87.74
Intraoperative retrograde cystourethrogram

87.76
Physical therapy, respiratory therapy, rehabilitation, and

93
related procedures
Skeletal traction
93.44
2548
Adhesive tape traction
93.46
Nonoperative removal of foreign body or calculus

98
Removal of intraluminal foreign body from esophagus
98.02
without incision
PROCEDURES
Removal of intraluminal foreign body from larynx without
incision
Removal of intraluminal foreign body from trachea and
bronchus without incision
Removal of intraluminal foreign body from urethra without
incision
ESWL
ESWL
ICD-9-CM
98.14
98.15
98.19
98.51
98.51
: 0

Combination code
PROCEDURES
Thoracotomy with suture heart, repair vascular, suture lung
( 3 )
V.A.T.S. with chemical pleurodesis, pericardiectomy,

decorticate
Median sternotomy with suture heart, repair vascular
Aneurysm resection
ICD-9-CM
33.43
37.4
39.31
39.32
34.92 +
34.51 +
37.31
37.4
39.31
39.32
38.3 (4-6)
2548
PROCEDURES
Double Valve Repair/Replacement
Triple Valve Repair/Replacement
OMV, ASD
VSD, venticuloseptoplexy or ventriculoseptoplasty
Aneurysm with graft (By pass)
Bentall's operation
Redo CABG
CABG vein + internal mammary arterial graft
CABG vein + radial arterial graft
Single valve + CABG
Double Valve + CABG
Ross's operation
Total abdominal hysterectomy + radical excision of iliac
nodes + Omentectomy
Radical abdominal hysterectomy: Modified, Wertheims
operation with radical excision of iliac nodes
Radical vulvectomy With groin nodes dissection
ICD-9-CM
35.2 (0-8)
35.2 (0-8)
35.2 (0-8)
35.2 (0-8)
35.2 (0-8)
35.51
35.61
35.53
35.62
38.4 (4-6)
+ 39.61
36.10 +
38.34
36.1 (0-9)
36.15
36.16
36.1 (0-4)
38.13
35.2 (1-8) +
36.1 (0-9)
35.2 (1-8) +
36.1 (0-9)
35.21 +
35.13
68.4 +
40.53
68.6 +
40.53
71.5 +
40.54
2548
12

2
- ICU

/
Syringes
-

12.1
12.1.1 (IPD)
12.1.2
Semi ICU
12.1.3 ICU
12.1.4
12.1.5
12.1.6 (IPD)
12.1.7 (IPD)
12.2

300 -

500 12
Syringes
700 -

Suction
50 -

-
50

X-ray

0
0
55010
55011
55012
55020
55021
55090
55091
12.2.1 / (
)
12.2.2 ()
12.2.3
70 55210
40
55211
70
55212
12.2.4 /
12.3
70
55220
12.3.1
(Clear air way) (
)
12.3.2
( )
(visit)
80 Airway
55310
(visit)
12.3.3
( )
(visit)
50 - 55311
O2,
- Suction
50 -
55320
Syringe, Needle, O2, NSS
-
12.4
12.4.1
12.4.2
( )
12.4.3
12.4.4
70 NG
60

220
3-7
60
55510
55511
55512
55520
12.4.5
12.5

80 2
55521
12.5.1
90
55610
12.5.2
90
55611
12.5.3
130 3 55612
12.5.4
100
55620
12.5.5
200
55621
12.5.6
Perinium
12.6
( )/
12.6.1
12.6.2
12.6.3

(>15 )
12.6.4

()
12.6.5

()
12.6.6
IV (
)
IM (
)
(
)
12.6.7
12.6.8
60 Set flush
70 Set

5-7
140 Top dressing
3-7 Sterile glove,
Syringe
270 Top dressing 812 Sterile glove,
Syringe
100 - IV set, T-way,
extension, IV catheter
-
0 -

-
5
20
20
20
Syringe
55622
55810
55811
55812
55820
55821
55822
55823
55824
12.6.9
()
( 21301
)
12.6.10
12.6.11
12.7
160
55825
0
55830

0
55840

12.7.1
(<30 )
12.7.2
(>30 )

12.1-12.7

2548
55910
55911
55999
ICU

ICU 1,000
13

(
)

( )
1. LAB
LAB 10 (
)
2.

13.1
13.1.1

Extraction and Suture is needed
13.1.1.1
13.1.1.2 ( )
Surgical Extraction
13.1.1.3 (Surgical Removal of
Residual Tooth Root)
13.1.1.4 (Soft
Tissue Impaction)
13.1.1.5 (Bony
Impaction or Embedded Tooth) - Partial Bony
13.1.1.6 (Bony
Impaction or Embedded Tooth) - Complete Bony
170
350
62101
62102
350
62103
340
62104
470
62105
600
62106

13.1.1.7
13.1.1.8
13.1.1.9
13.1.1.10
13.1.1.11
13.1.2
13.1.2.1
13.1.2.2
Other Surgical Procedure

(Root resection) -
(Root resection) -
(Retrograde) -
(Retrograde) -
Root Amputation/Bicuspidization/Hemisection
( )
Marsupialization (under local anesthesia)
Oroantral Fistula Closure ( Soft Tissue
Graft) under local anesthesia
Excision of Pericoronal Gingiva
Biopsy of Oral Tissue (Hard/Soft)
Debridement and Suturing
Excision of Bone Tissue
(Alveolectomy/
Alveoloplasty)
Vestibuloplasty
(Ridge Augmentation)
Epulis, Fibrous Alveolar Ridge
Torectomy, Ostectomy ( stent)
Torectomy, Ostectomy ( stent)
Removal of Tumors, Cysts, Neoplasms
, (<1.5 cm)
, (>1.5 cm)
(<1.5cm)
(>1.5cm)
470
600
650
860
860
62107
62108
62109
62110
62111
540
490
62201
62202
170
280
280
62203
62204
62205
470
62206
Arch
Arch
600
750
450
670
520
62207
62208
62209
62210
62211
450
600
450
600
62212
62213
62214
62215
13.1.2.16
13.1.2.17 ( )
200
330
62216
62217
13.1.2.3
13.1.2.4
13.1.2.5
13.1.2.6
13.1.2.7
13.1.2.8
13.1.2.9
13.1.2.10
13.1.2.11
13.1.2.12
13.1.2.13
13.1.2.14
13.1.2.15
Surgical Incision
13.1.2.18 Sequestrectomy ( )
13.1.2.19 Maxillary Sinusotomy for Removal of Tooth
fragment or Foreign body (Cald Well Luc)

-
13.1.3
Treatment of Fracture ( /)
13.1.3.1
13.1.3.2
13.1.4
(Intra Arch) Subluxation
Fracture Mandible - Closed reduction (
)
Fracture Maxilla - Closed reduction (
)
Alveolar Fracture - Closed reduction ( Arch
)
Correction or Repair Procedure ( )
13.1.4.1
13.1.4.2
13.1.5
Frenectomy, Frenoplasty
Sialolithotomy ( )
Miscellaneous Procedures ()
13.1.5.1
13.1.5.2
13.1.5.3
13.1.5.4
13.1.5.5
13.1.5.6

Dry Socket
(Curettage)
Wound dressing with Coe-pack (without splint)
Wound dressing with Coe-pack (with splint)
Special procedure for Stop Bleeding (packing
with Avogel, gel foam in bleeding disorder)
Surgical stent, upper/lower
13.1.3.3
13.1.3.4
13.1.5.7
460 62218
980 62219
680
1,300
62301
62302
1,300
62303
680
62304
400
440
62401
62402
150
130
170
250
500
180
62501
62502
62503
62504
62505
62506
Arch
800
62507
200
270
370
370
67101
67201
67202
67203
13.2
13.2.1
13.2.2
13.2.3
13.2.4
/Pulp capping
Amalgam -
Amalgam - 2
Amalgam - 3
370 67204
300
67210
430
67211
430
67212
430
67213
300
390
67220
67221
540
Pulpotomy -
480
Pulpotomy -
580
Pulpectomy ( ) -
820
Pulpectomy ( ) -
970
-
1,750
- ( 1-3 )
2,180
- ( 1-4 )
2,900
Apexification/Recalcification
420
(Non-vital Bleaching)
340

X-ray
13.4
63101
63102
63103
63104
63105
63110
63111
63112
63120
63130
13.4.1
13.4.2
64101
64102
13.2.5
Amalgam -
4
Amalgam overlay
13.2.6
(Composite, GI, Flowable
composite) -
13.2.7
composite) - 2
13.2.8
composite) - 3
13.2.9
composite) -
4 Composite
onlay (direct)
13.2.10 (Band) -
13.2.11 (Band) -
13.3
13.3.1
13.3.2
13.3.3
13.3.4
13.3.5
13.3.6
13.3.7
13.3.8
13.3.9
13.3.10
Root planing/Curettage
Qualdant
280
340

13.4.3
13.4.4
13.4.5
13.4.6
64110
64111
64112
64120
Flap Operation
600
Osseous Surgery
780
Crown Lengthening
760
Mucogingival Surgery Periodontitis
860
- CPFP, APFP
13.4.7
1,290 64121
- FGG Stent
13.4.8
940 64122
- GTR ( Membrane
Bone graft)
13.4.9
(Periodontal Splint)
400 64130
13.4.10 -
240 64131
13.4.11 -
390 64132
13.4.12
170 64140
13.4.13 Periodontal Dressing
170 64141

13.5 Cleft
lip, Cleft palate,
13.5.1
Feeding Aid

800 60101
13.5.2
Speech Aid*

1,450 60102
13.5.3
140 61101
13.5.4
Tooth Reimplantation and/or Stabilization of
400 62112
Accidentally Avulsed or Displaced Tooth
(Splinting Composite wire or Arch bar)
13.5.5
Off Arch Bar
370 62310
13.5.6
Removal Suspension Wire
370 62311
13.5.7
Plate and Screw/Wire Removal -
500 62312
13.5.8
Obtulator prosthesis: Surgical

13.5.9
Obtulator prosthesis: Definitive*

* Lab

800 62410
1,600 62411
16

:

1. 35
1.1 Chest X-ray

- Film Chest ( 41001)
- Mass Chest ( 41301)
1.2 Urine Examination - Urine Analysis ( 31001)
1.3 Stool Examination - Routine direct smear ( 31201) Occult blood
( 31203)
1.4 Complete Blood Count: CBC Automation ( 30101)
1.5
- ( 55620)
- Pap Smear ( 38302)
2. 35
2.1 35 1.1-1.5
2.2 Blood Chemistry
- Glucose ( 32203)
- Cholesteral ( 32501)
- Triglyceride ( 32502)
- Blood Urea Nitrogen: BUN ( 32201)
- Creatinine ( 32202)
- SGOT (AST) ( 32310)
- SGPT (ALT) ( 32311)
- Alkaline Phosphatase ( 32309)
- Uric Acid ( 32205)
170
50
50
70
90
100
50
40
60
60
50
50
50
50
50
60
: ICU
Items
1
3
4
Facilities
1.1 Organ support
- Ventilator
- Hemodynamic monitoring
- Hemodialysis unit
- Liver dialysis unit
1.2 Monitor
Human resources
2.1 ICU
Requirements
ICU
1
2 - 1.2 1
Share facility ICU

Share facility ICU ()
ICU 8 6 = 1 4
2.2
2.3
1 1

4
4
1 (Optional)
Inter ICU Conference
Severity of Disease
APACHE score, SAP score
Priority
4.1
4.2
4.3
4.4
ICU

ICU outcome
Acute on top chronic disease
ICU
Septic shock, MI with shock

CHF, Post-intervention
CHF with CRF
/terminal disease

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- 1

13 + 1.20 X (16 10)

13 + 1.20 X (32 10)

13 + 1.20 X (64 10)

126 + 1.15 X (128 100)

126 + 1.15 X (512 100)

1,161 + 1.10 X (1,024 1,000)

1,161 + 1.10 X (6,000 1,000)

1,161 + 1.10 X (11,000 1,000)

Blood Bank Section

Packed Red Cell: PRC

1,710 filtration set 23203

1,800 3) Leukocyte 23204

1,800 Leukocyte depleted 23206

Blood Bank Section

Random platelet conc. ()

Blood Bank Section

Leukocyte poor pooled platelet conc.

Blood Bank Section

*NAT= Nucleic acid Amplification Technology

Flow cytometry for minimal residual

Disease association: HLA-B27 typing

Kidney transplantation - HLA-DRB, DQB

7.1.7.1 Stem cell cuture for BFU-E number

7.2.3.1 Body fluid examination

Proteins - nonenzyme, Vitamins

Arsenic (gastric lavage)

AFB stain (Acid-Fast Bacilli stain)

ASO test - Latex

Candida: DNA detection

HSV-1 and -2 IgG (ELISA)

SARS corona virus-Qualitative

Parvo virus B19, qualitative RT-PCR

Specific IgE to mixture of respiratory

Quantitative plasma amino acid analysis

PCR (multiplex) for Duchenne/Becker

Sequencing of triplet repeats - OPMD

Whole gene sequencing - Bruton

Mitochondrial DNA analysis - Leber optic

Microsatellite instability testing from

7.7.1 (Surgical pathology)

Tonsil, each specimen

Respiratory, Cardivascular, Lymphatic

Pelvic exenteration (uterus with urinary

Uterus with multiple groups of lymph

Breast, mastectomy (simple, radical,

specimen (PAP smear)

7.7.5.188 Wilms' tumor

X-ray, CT scan, Ultrasonography, MRI, Radionuclide scan

Mass chest (small film)

Myelography one part

Bone density: X-rays 1 part

US guided for biopsy

MRI Cranial nerve

Scalp E.E.G. (16 )

Brain stem evoked potential response

Long-Latency Auditory and Auditory

Lung Function Test - Spirometry (Peak flow)

200 red dot

Echo-Transthoracic + color + Doppler

Tilt table test

9.4.10 Carotid Duplex Scan

9.4.12 Toe-Brachial Index (T.B.I)

Standardized occupational therapy