Gazette No. 60 dated 15 August, 2014. CHARGE MASTER

CAYMAN ISLANDS Supplement No. 1 published with Extraordinary Gazette No. 60 dated 15 August, 2014. CAYMAN ISLANDS HEALTH SERVICES AUTHORITY CHARGE MASTER Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifier CPT-4 HCPCS CPT/HCPCS Long Description Price 1 00100 00100 Anesthesia for procedures on salivary glands, including biopsy $ 192.50 2 00102 00102 Anesthesia for procedures involving plastic repair of cleft lip $ 273.00 Anesthesia for reconstructive procedures of eyelid (eg, 3 00103 00103 blepharoplasty, ptosis surgery) $ 385.00 4 00104 00104 Anesthesia for electroconvulsive therapy $ 273.00 Anesthesia for procedures on external, middle, and inner ear 5 00120 00120 including biopsy; not otherwise specified $ 192.50 Anesthesia for procedures on external, middle, and inner ear 6 00124 00124 including biopsy; otoscopy $ 273.00 Anesthesia for procedures on external, middle, and inner ear 7 00126 00126 including biopsy; tympanotomy $ 192.50 8 00140 00140 Anesthesia for procedures on eye; not otherwise specified $ 192.50 9 00142 00142 Anesthesia for procedures on eye; lens surgery $ 385.00 10 00144 00144 Anesthesia for procedures on eye; corneal transplant $ 385.00 11 00145 00145 Anesthesia for procedures on eye; vitreoretinal surgery $ 385.00 12 00147 00147 Anesthesia for procedures on eye; iridectomy $ 192.50 13 00148 00148 Anesthesia for procedures on eye; ophthalmoscopy $ 273.00 Anesthesia for procedures on nose and accessory sinuses; not 14 00160 00160 otherwise specified $ 192.50 Anesthesia for procedures on nose and accessory sinuses; radical 15 00162 00162 surgery $ 385.00 Anesthesia for procedures on nose and accessory sinuses; biopsy, 16 00164 00164 soft tissue $ 273.00 Anesthesia for intraoral procedures, including biopsy; not otherwise 17 00170 00170 specified $ 192.50 Anesthesia for intraoral procedures, including biopsy; repair of cleft 18 00172 00172 palate $ 273.00 Anesthesia for intraoral procedures, including biopsy; excision of 19 00174 00174 retropharyngeal tumor $ 273.00 Anesthesia for intraoral procedures, including biopsy; radical 20 00176 00176 surgery $ 273.00 Anesthesia for procedures on facial bones or skull; not otherwise 21 00190 00190 specified $ 385.00 Anesthesia for procedures on facial bones or skull; radical surgery 22 00192 00192 (including prognathism) $ 273.00 23 00210 00210 Anesthesia for intracranial procedures; not otherwise specified $ 385.00 Anesthesia for intracranial procedures; craniotomy or craniectomy 24 00211 00211 for evacuation of hematoma $ 286.00 Anesthesia for intracranial procedures; burr holes, including 25 00214 00214 ventriculography $ 385.00 Anesthesia for intracranial procedures; cranioplasty or elevation of 26 00215 00215 depressed skull fracture, extradural (simple or compound) $ 286.00 Anesthesia for intracranial procedures; procedures in sitting 27 00218 00218 position $ 286.00 Anesthesia for all procedures on the integumentary system, muscles and nerves of head, neck, and posterior trunk, not otherwise 28 00300 00300 specified $ 273.00 Anesthesia for all procedures on esophagus, thyroid, larynx, trachea and lymphatic system of neck; not otherwise specified, age 1 year 29 00320 00320 or older $ 385.00 Anesthesia for all procedures on esophagus, thyroid, larynx, trachea 30 00322 00322 and lymphatic system of neck; needle biopsy of thyroid $ 273.00 Anesthesia for all procedures on the larynx and trachea in children 31 00326 00326 younger than 1 year of age $ 273.00 Anesthesia for procedures on major vessels of neck; not otherwise 32 00350 00350 specified $ 273.00 33 00352 00352 Anesthesia for procedures on major vessels of neck; simple ligation $ 273.00 Anesthesia for procedures on the integumentary system on the 34 00400 00400 extremities, anterior trunk and perineum; not otherwise specified $ 385.00 Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; reconstructive procedures on breast (eg, reduction or augmentation 35 00402 00402 mammoplasty, muscle flaps) $ 385.00 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifier CPT-4 HCPCS CPT/HCPCS Long Description Price Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; radical or modified 36 00404 00404 radical procedures on breast $ 385.00 Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; radical or modified radical procedures on breast with internal mammary node 37 00406 00406 dissection $ 385.00 Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; electrical conversion of 38 00410 00410 arrhythmias $ 192.50 Cerebral perfusion analysis using computed tomography with contrast administration, including post-processing of parametric maps with determination of cerebral blood flow, cerebral blood 39 0042T 0042T volume, and mean transit time $ 1,133.10 Anesthesia for procedures on clavicle and scapula; not otherwise 40 00450 00450 specified $ 273.00 41 00452 00452 Anesthesia for procedures on clavicle and scapula; radical surgery $ 273.00 42 00454 00454 Anesthesia for procedures on clavicle and scapula; biopsy of clavicle $ 273.00 43 00500 00500 Anesthesia for all procedures on esophagus $ 192.50 Anesthesia for closed chest procedures; (including bronchoscopy) 44 00520 00520 not otherwise specified $ 192.50 45 00524 00524 Anesthesia for closed chest procedures; pneumocentesis $ 273.00 46 00530 00530 Anesthesia for permanent transvenous pacemaker insertion $ 273.00 47 00532 00532 Anesthesia for access to central venous circulation $ 273.00 Anesthesia for transvenous insertion or replacement of pacing 48 00534 00534 cardioverter-defibrillator $ 273.00 Anesthesia for thoracotomy procedures involving lungs, pleura, diaphragm, and mediastinum (including surgical thoracoscopy); not 49 00540 00540 otherwise specified $ 385.00 Anesthesia for thoracotomy procedures involving lungs, pleura, diaphragm, and mediastinum (including surgical thoracoscopy); 50 00541 00541 utilizing 1 lung ventilation $ 273.00 Anesthesia for thoracotomy procedures involving lungs, pleura, diaphragm, and mediastinum (including surgical thoracoscopy); 51 00542 00542 decortication $ 273.00 Anesthesia for thoracotomy procedures involving lungs, pleura, diaphragm, and mediastinum (including surgical thoracoscopy); 52 00546 00546 pulmonary resection with thoracoplasty $ 273.00 Anesthesia for thoracotomy procedures involving lungs, pleura, diaphragm, and mediastinum (including surgical thoracoscopy); 53 00548 00548 intrathoracic procedures on the trachea and bronchi $ 273.00 54 00550 00550 Anesthesia for sternal debridement $ 273.00 Anesthesia for procedures on heart, pericardial sac, and great 55 00560 00560 vessels of chest; without pump oxygenator $ 273.00 Anesthesia for procedures on heart, pericardial sac, and great 56 00561 00561 vessels of chest; with pump oxygenator, younger than 1 year of age $ 273.00 Anesthesia for procedures on heart, pericardial sac, and great vessels of chest; with pump oxygenator, age 1 year or older, for all non-coronary bypass procedures (eg, valve procedures) or for re- 57 00562 00562 operation for coronary bypass more than 1 month after origi $ 273.00 Anesthesia for procedures on heart, pericardial sac, and great vessels of chest; with pump oxygenator with hypothermic 58 00563 00563 circulatory arrest $ 273.00 Anesthesia for direct coronary artery bypass grafting; without pump 59 00566 00566 oxygenator $ 273.00 Anesthesia for direct coronary artery bypass grafting; with pump 60 00567 00567 oxygenator $ 273.00 61 00580 00580 Anesthesia for heart transplant or heart/lung transplant $ 273.00 Anesthesia for procedures on cervical spine and cord; not otherwise 62 00600 00600 specified $ 88.00 Anesthesia for procedures on cervical spine and cord; procedures 63 00604 00604 with patient in the sitting position $ 273.00 Anesthesia for procedures on thoracic spine and cord; not 64 00620 00620 otherwise specified $ 273.00 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifier CPT-4 HCPCS CPT/HCPCS Long Description Price Anesthesia for procedures on thoracic spine and cord; 65 00622 00622 thoracolumbar sympathectomy $ 273.00 Anesthesia for procedures on the thoracic spine and cord, via an 66 00625 00625 anterior transthoracic approach; not utilizing 1 lung ventilation $ 273.00 Anesthesia for procedures on the thoracic spine and cord, via an 67 00626 00626 anterior transthoracic approach; utilizing 1 lung ventilation $ 273.00 68 00630 00630 Anesthesia for procedures in lumbar region; not otherwise specified $ 385.00 Anesthesia for procedures in lumbar region; lumbar 69 00632 00632 sympathectomy $ 273.00 70 00634 00634 Anesthesia for procedures in lumbar region; chemonucleolysis $ 273.00 Anesthesia for procedures in lumbar region; diagnostic or 71 00635 00635 therapeutic lumbar puncture $ 273.00 Anesthesia for manipulation of the spine or for closed procedures 72 00640 00640 on the cervical, thoracic or lumbar spine $ 273.00 Anesthesia for extensive spine and spinal cord procedures (eg, 73 00670 00670 spinal instrumentation or vascular procedures) $ 273.00 Anesthesia for procedures on upper anterior abdominal wall; not 74 00700 00700 otherwise specified $ 273.00 Anesthesia for procedures on upper anterior abdominal wall; 75 00702 00702 percutaneous liver biopsy $ 273.00 76 00730 00730 Anesthesia for procedures on upper posterior abdominal wall $ 273.00 Anesthesia for upper gastrointestinal endoscopic procedures, 77 00740 00740 endoscope introduced proximal to duodenum $ 192.50 Anesthesia for hernia repairs in upper abdomen; not otherwise 78 00750 00750 specified $ 273.00 Anesthesia for hernia repairs in upper abdomen; lumbar and ventral 79 00752 00752 (incisional) hernias and/or wound dehiscence $ 273.00 80 00754 00754 Anesthesia for hernia repairs in upper abdomen; omphalocele $ 273.00 Anesthesia for hernia repairs in upper abdomen; transabdominal 81 00756 00756 repair of diaphragmatic hernia $ 273.00 82 00770 00770 Anesthesia for all procedures on major abdominal blood vessels $ 385.00 Anesthesia for intraperitoneal procedures in upper abdomen 83 00790 00790 including laparoscopy; not otherwise specified $ 385.00 Anesthesia for intraperitoneal procedures in upper abdomen including laparoscopy; partial hepatectomy or management of liver 84 00792 00792 hemorrhage (excluding liver biopsy) $ 385.00 Anesthesia for intraperitoneal procedures in upper abdomen including laparoscopy; pancreatectomy, partial or total (eg, Whipple 85 00794 00794 procedure) $ 273.00 Anesthesia for intraperitoneal procedures in upper abdomen 86 00796 00796 including laparoscopy; liver transplant (recipient) $ 273.00 Anesthesia for intraperitoneal procedures in upper abdomen including laparoscopy; gastric restrictive procedure for morbid 87 00797 00797 obesity $ 273.00 Anesthesia for procedures on lower anterior abdominal wall; not 88 00800 00800 otherwise specified $ 273.00 Anesthesia for procedures on lower anterior abdominal wall; 89 00802 00802 panniculectomy $ 273.00 Anesthesia for lower intestinal endoscopic procedures, endoscope 90 00810 00810 introduced distal to duodenum $ 385.00 91 00820 00820 Anesthesia for procedures on lower posterior abdominal wall $ 273.00 Anesthesia for hernia repairs in lower abdomen; not otherwise 92 00830 00830 specified $ 385.00 Anesthesia for hernia repairs in lower abdomen; ventral and 93 00832 00832 incisional hernias $ 385.00 Anesthesia for hernia repairs in the lower abdomen not otherwise 94 00834 00834 specified, younger than 1 year of age $ 273.00 Anesthesia for hernia repairs in the lower abdomen not otherwise specified, infants younger than 37 weeks gestational age at birth 95 00836 00836 and younger than 50 weeks gestational age at time of surgery $ 273.00 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifier CPT-4 HCPCS CPT/HCPCS Long Description Price Anesthesia for intraperitoneal procedures in lower abdomen 96 00840 00840 including laparoscopy; not otherwise specified $ 385.00 Anesthesia for intraperitoneal procedures in lower abdomen 97 00842 00842 including laparoscopy; amniocentesis $ 273.00 Anesthesia for intraperitoneal procedures in lower abdomen 98 00844 00844 including laparoscopy; abdominoperineal resection $ 385.00 Anesthesia for intraperitoneal procedures in lower abdomen 99 00846 00846 including laparoscopy; radical hysterectomy $ 273.00 Anesthesia for intraperitoneal procedures in lower abdomen 100 00848 00848 including laparoscopy; pelvic exenteration $ 273.00 Anesthesia for intraperitoneal procedures in lower abdomen 101 00851 00851 including laparoscopy; tubal ligation/transection $ 192.50 Anesthesia for extraperitoneal procedures in lower abdomen, 102 00860 00860 including urinary tract; not otherwise specified $ 273.00 Anesthesia for extraperitoneal procedures in lower abdomen, including urinary tract; renal procedures, including upper one-third 103 00862 00862 of ureter, or donor nephrectomy $ 385.00 Anesthesia for extraperitoneal procedures in lower abdomen, 104 00864 00864 including urinary tract; total cystectomy $ 273.00 Anesthesia for extraperitoneal procedures in lower abdomen, including urinary tract; radical prostatectomy (suprapubic, 105 00865 00865 retropubic) $ 385.00 Anesthesia for extraperitoneal procedures in lower abdomen, 106 00866 00866 including urinary tract; adrenalectomy $ 273.00 Anesthesia for extraperitoneal procedures in lower abdomen, 107 00868 00868 including urinary tract; renal transplant (recipient) $ 273.00 Anesthesia for procedures on male genitalia (including open 108 00869 00869 urethral procedures); vasectomy, unilateral or bilateral $ 385.00 Anesthesia for extraperitoneal procedures in lower abdomen, 109 00870 00870 including urinary tract; cystolithotomy $ 385.00 Anesthesia for lithotripsy, extracorporeal shock wave; with water 110 00872 00872 bath $ 273.00 Anesthesia for lithotripsy, extracorporeal shock wave; without 111 00873 00873 water bath $ 385.00 Anesthesia for procedures on major lower abdominal vessels; not 112 00880 00880 otherwise specified $ 273.00 Anesthesia for procedures on major lower abdominal vessels; 113 00882 00882 inferior vena cava ligation $ 273.00 114 00902 00902 Anesthesia for; anorectal procedure $ 192.50 115 00904 00904 Anesthesia for; radical perineal procedure $ 273.00 116 00906 00906 Anesthesia for; vulvectomy $ 273.00 117 00908 00908 Anesthesia for; perineal prostatectomy $ 273.00 Anesthesia for transurethral procedures (including 118 00910 00910 urethrocystoscopy); not otherwise specified $ 192.50 Anesthesia for transurethral procedures (including 119 00912 00912 urethrocystoscopy); transurethral resection of bladder tumor(s) $ 192.50 Anesthesia for transurethral procedures (including 120 00914 00914 urethrocystoscopy); transurethral resection of prostate $ 385.00 Anesthesia for transurethral procedures (including 121 00916 00916 urethrocystoscopy); post-transurethral resection bleeding $ 273.00 Anesthesia for transurethral procedures (including urethrocystoscopy); with fragmentation, manipulation and/or 122 00918 00918 removal of ureteral calculus $ 192.50 Anesthesia for procedures on male genitalia (including open 123 00920 00920 urethral procedures); not otherwise specified $ 192.50 Anesthesia for procedures on male genitalia (including open 124 00921 00921 urethral procedures); vasectomy, unilateral or bilateral $ 273.00 Anesthesia for procedures on male genitalia (including open 125 00922 00922 urethral procedures); seminal vesicles $ 273.00 Anesthesia for procedures on male genitalia (including open 126 00924 00924 urethral procedures); undescended testis, unilateral or bilateral $ 192.50 Anesthesia for procedures on male genitalia (including open 127 00926 00926 urethral procedures); radical orchiectomy, inguinal $ 192.50 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifier CPT-4 HCPCS CPT/HCPCS Long Description Price Anesthesia for procedures on male genitalia (including open 128 00928 00928 urethral procedures); radical orchiectomy, abdominal $ 273.00 Anesthesia for procedures on male genitalia (including open 129 00930 00930 urethral procedures); orchiopexy, unilateral or bilateral $ 192.50 Anesthesia for procedures on male genitalia (including open 130 00932 00932 urethral procedures); complete amputation of penis $ 273.00 Anesthesia for procedures on male genitalia (including open urethral procedures); radical amputation of penis with bilateral 131 00934 00934 inguinal lymphadenectomy $ 273.00 Anesthesia for procedures on male genitalia (including open urethral procedures); radical amputation of penis with bilateral 132 00936 00936 inguinal and iliac lymphadenectomy $ 273.00 Anesthesia for procedures on male genitalia (including open urethral procedures); insertion of penile prosthesis (perineal 133 00938 00938 approach) $ 273.00 Anesthesia for vaginal procedures (including biopsy of labia, vagina, 134 00940 00940 cervix or endometrium); not otherwise specified $ 192.50 Anesthesia for vaginal procedures (including biopsy of labia, vagina, cervix or endometrium); colpotomy, vaginectomy, colporrhaphy, 135 00942 00942 and open urethral procedures $ 192.50 Anesthesia for vaginal procedures (including biopsy of labia, vagina, 136 00944 00944 cervix or endometrium); vaginal hysterectomy $ 385.00 Anesthesia for vaginal procedures (including biopsy of labia, vagina, 137 00948 00948 cervix or endometrium); cervical cerclage $ 192.50 Anesthesia for vaginal procedures (including biopsy of labia, vagina, 138 00950 00950 cervix or endometrium); culdoscopy $ 273.00 Anesthesia for vaginal procedures (including biopsy of labia, vagina, cervix or endometrium); hysteroscopy and/or 139 00952 00952 hysterosalpingography $ 192.50 Anesthesia for bone marrow aspiration and/or biopsy, anterior or 140 01112 01112 posterior iliac crest $ 273.00 141 01120 01120 Anesthesia for procedures on bony pelvis $ 273.00 142 01130 01130 Anesthesia for body cast application or revision $ 192.50 143 01140 01140 Anesthesia for interpelviabdominal (hindquarter) amputation $ 273.00 Anesthesia for radical procedures for tumor of pelvis, except 144 01150 01150 hindquarter amputation $ 273.00 Anesthesia for closed procedures involving symphysis pubis or 145 01160 01160 sacroiliac joint $ 273.00 Anesthesia for open procedures involving symphysis pubis or 146 01170 01170 sacroiliac joint $ 273.00 Anesthesia for open repair of fracture disruption of pelvis or column 147 01173 01173 fracture involving acetabulum $ 273.00 148 01180 01180 Anesthesia for obturator neurectomy; extrapelvic $ 273.00 149 01190 01190 Anesthesia for obturator neurectomy; intrapelvic $ 273.00 150 01200 01200 Anesthesia for all closed procedures involving hip joint $ 192.50 151 01202 01202 Anesthesia for arthroscopic procedures of hip joint $ 273.00 Anesthesia for open procedures involving hip joint; not otherwise 152 01210 01210 specified $ 385.00 Anesthesia for open procedures involving hip joint; hip 153 01212 01212 disarticulation $ 273.00 Anesthesia for open procedures involving hip joint; total hip 154 01214 01214 arthroplasty $ 385.00 Anesthesia for open procedures involving hip joint; revision of total 155 01215 01215 hip arthroplasty $ 385.00 Anesthesia for all closed procedures involving upper two-thirds of 156 01220 01220 femur $ 273.00 Anesthesia for open procedures involving upper two-thirds of 157 01230 01230 femur; not otherwise specified $ 385.00 Anesthesia for open procedures involving upper two-thirds of 158 01232 01232 femur; amputation $ 273.00 Anesthesia for open procedures involving upper two-thirds of 159 01234 01234 femur; radical resection $ 273.00 Anesthesia for all procedures on nerves, muscles, tendons, fascia, 160 01250 01250 and bursae of upper leg $ 385.00 Anesthesia for all procedures involving veins of upper leg, including 161 01260 01260 exploration $ 385.00 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifier CPT-4 HCPCS CPT/HCPCS Long Description Price Anesthesia for procedures involving arteries of upper leg, including 162 01270 01270 bypass graft; not otherwise specified $ 385.00 Anesthesia for procedures involving arteries of upper leg, including 163 01272 01272 bypass graft; femoral artery ligation $ 273.00 Anesthesia for procedures involving arteries of upper leg, including 164 01274 01274 bypass graft; femoral artery embolectomy $ 273.00 Anesthesia for all procedures on nerves, muscles, tendons, fascia, 165 01320 01320 and bursae of knee and/or popliteal area $ 385.00 166 01340 01340 Anesthesia for all closed procedures on lower one-third of femur $ 273.00 167 01360 01360 Anesthesia for all open procedures on lower one-third of femur $ 273.00 168 01380 01380 Anesthesia for all closed procedures on knee joint $ 273.00 169 01382 01382 Anesthesia for diagnostic arthroscopic procedures of knee joint $ 385.00 Anesthesia for all closed procedures on upper ends of tibia, fibula, 170 01390 01390 and/or patella $ 273.00 Anesthesia for all open procedures on upper ends of tibia, fibula, 171 01392 01392 and/or patella $ 385.00 Anesthesia for open or surgical arthroscopic procedures on knee 172 01400 01400 joint; not otherwise specified $ 385.00 Anesthesia for open or surgical arthroscopic procedures on knee 173 01402 01402 joint; total knee arthroplasty $ 385.00 Anesthesia for open or surgical arthroscopic procedures on knee 174 01404 01404 joint; disarticulation at knee $ 273.00 Anesthesia for all cast applications, removal, or repair involving 175 01420 01420 knee joint $ 273.00 Anesthesia for procedures on veins of knee and popliteal area; not 176 01430 01430 otherwise specified $ 273.00 Anesthesia for procedures on veins of knee and popliteal area; 177 01432 01432 arteriovenous fistula $ 273.00 Anesthesia for procedures on arteries of knee and popliteal area; 178 01440 01440 not otherwise specified $ 273.00 Anesthesia for procedures on arteries of knee and popliteal area; 179 01442 01442 popliteal thromboendarterectomy, with or without patch graft $ 273.00 Anesthesia for procedures on arteries of knee and popliteal area; 180 01444 01444 popliteal excision and graft or repair for occlusion or aneurysm $ 273.00 181 01462 01462 Anesthesia for all closed procedures on lower leg, ankle, and foot $ 192.50 182 01464 01464 Anesthesia for arthroscopic procedures of ankle and/or foot $ 273.00 Anesthesia for procedures on nerves, muscles, tendons, and fascia 183 01470 01470 of lower leg, ankle, and foot; not otherwise specified $ 385.00 Anesthesia for procedures on nerves, muscles, tendons, and fascia of lower leg, ankle, and foot; repair of ruptured Achilles tendon, 184 01472 01472 with or without graft $ 385.00 Anesthesia for procedures on nerves, muscles, tendons, and fascia of lower leg, ankle, and foot; gastrocnemius recession (eg, Strayer 185 01474 01474 procedure) $ 273.00 Anesthesia for open procedures on bones of lower leg, ankle, and 186 01480 01480 foot; not otherwise specified $ 385.00 Anesthesia for open procedures on bones of lower leg, ankle, and 187 01482 01482 foot; radical resection (including below knee amputation) $ 273.00 Anesthesia for open procedures on bones of lower leg, ankle, and 188 01484 01484 foot; osteotomy or osteoplasty of tibia and/or fibula $ 273.00 Anesthesia for open procedures on bones of lower leg, ankle, and 189 01486 01486 foot; total ankle replacement $ 273.00 190 01490 01490 Anesthesia for lower leg cast application, removal, or repair $ 192.50 Anesthesia for procedures on arteries of lower leg, including bypass 191 01500 01500 graft; not otherwise specified $ 273.00 Anesthesia for procedures on arteries of lower leg, including bypass 192 01502 01502 graft; embolectomy, direct or with catheter $ 273.00 Anesthesia for procedures on veins of lower leg; not otherwise 193 01520 01520 specified $ 273.00 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Anesthesia for procedures on veins of lower leg; venous 194 01522 01522 thrombectomy, direct or with catheter $ 385.00 Anesthesia for all procedures on nerves, muscles, tendons, fascia, 195 01610 01610 and bursae of shoulder and axilla $ 385.00 Anesthesia for all closed procedures on humeral head and neck, 196 01620 01620 sternoclavicular joint, acromioclavicular joint, and shoulder joint $ 273.00 197 01622 01622 Anesthesia for diagnostic arthroscopic procedures of shoulder joint $ 385.00 Anesthesia for open or surgical arthroscopic procedures on humeral head and neck, sternoclavicular joint, acromioclavicular joint, and 198 01630 01630 shoulder joint; not otherwise specified $ 385.00 Anesthesia for open or surgical arthroscopic procedures on humeral head and neck, sternoclavicular joint, acromioclavicular joint, and 199 01634 01634 shoulder joint; shoulder disarticulation $ 273.00 Anesthesia for open or surgical arthroscopic procedures on humeral head and neck, sternoclavicular joint, acromioclavicular joint, and 200 01636 01636 shoulder joint; interthoracoscapular (forequarter) amputation $ 273.00 Anesthesia for open or surgical arthroscopic procedures on humeral head and neck, sternoclavicular joint, acromioclavicular joint, and 201 01638 01638 shoulder joint; total shoulder replacement $ 273.00 Anesthesia for procedures on arteries of shoulder and axilla; not 202 01650 01650 otherwise specified $ 273.00 Anesthesia for procedures on arteries of shoulder and axilla; axillary- 203 01652 01652 brachial aneurysm $ 273.00 Anesthesia for procedures on arteries of shoulder and axilla; bypass 204 01654 01654 graft $ 273.00 Anesthesia for procedures on arteries of shoulder and axilla; axillary- 205 01656 01656 femoral bypass graft $ 273.00 206 01670 01670 Anesthesia for all procedures on veins of shoulder and axilla $ 273.00 Anesthesia for shoulder cast application, removal or repair; not 207 01680 01680 otherwise specified $ 273.00 Anesthesia for shoulder cast application, removal or repair; 208 01682 01682 shoulder spica $ 273.00 Anesthesia for procedures on nerves, muscles, tendons, fascia, and 209 01710 01710 bursae of upper arm and elbow; not otherwise specified $ 385.00 Anesthesia for procedures on nerves, muscles, tendons, fascia, and 210 01712 01712 bursae of upper arm and elbow; tenotomy, elbow to shoulder, open $ 273.00 Anesthesia for procedures on nerves, muscles, tendons, fascia, and 211 01714 01714 bursae of upper arm and elbow; tenoplasty, elbow to shoulder $ 273.00 Anesthesia for procedures on nerves, muscles, tendons, fascia, and bursae of upper arm and elbow; tenodesis, rupture of long tendon 212 01716 01716 of biceps $ 385.00 213 01730 01730 Anesthesia for all closed procedures on humerus and elbow $ 192.50 214 01732 01732 Anesthesia for diagnostic arthroscopic procedures of elbow joint $ 273.00 Anesthesia for open or surgical arthroscopic procedures of the 215 01740 01740 elbow; not otherwise specified $ 385.00 Anesthesia for open or surgical arthroscopic procedures of the 216 01742 01742 elbow; osteotomy of humerus $ 273.00 Anesthesia for open or surgical arthroscopic procedures of the 217 01744 01744 elbow; repair of nonunion or malunion of humerus $ 273.00 Anesthesia for open or surgical arthroscopic procedures of the 218 01756 01756 elbow; radical procedures $ 273.00 Anesthesia for open or surgical arthroscopic procedures of the 219 01758 01758 elbow; excision of cyst or tumor of humerus $ 273.00 Anesthesia for open or surgical arthroscopic procedures of the 220 01760 01760 elbow; total elbow replacement $ 273.00 Anesthesia for procedures on arteries of upper arm and elbow; not 221 01770 01770 otherwise specified $ 273.00 Anesthesia for procedures on arteries of upper arm and elbow; 222 01772 01772 embolectomy $ 273.00 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Anesthesia for procedures on veins of upper arm and elbow; not 223 01780 01780 otherwise specified $ 273.00 Anesthesia for procedures on veins of upper arm and elbow; 224 01782 01782 phleborrhaphy $ 273.00 Anesthesia for all procedures on nerves, muscles, tendons, fascia, 225 01810 01810 and bursae of forearm, wrist, and hand $ 385.00 Anesthesia for all closed procedures on radius, ulna, wrist, or hand 226 01820 01820 bones $ 192.50 227 01829 01829 Anesthesia for diagnostic arthroscopic procedures on the wrist $ 273.00 Anesthesia for open or surgical arthroscopic/endoscopic procedures on distal radius, distal ulna, wrist, or hand joints; not otherwise 228 01830 01830 specified $ 385.00 Anesthesia for open or surgical arthroscopic/endoscopic procedures on distal radius, distal ulna, wrist, or hand joints; total wrist 229 01832 01832 replacement $ 273.00 Anesthesia for procedures on arteries of forearm, wrist, and hand; 230 01840 01840 not otherwise specified $ 273.00 Anesthesia for procedures on arteries of forearm, wrist, and hand; 231 01842 01842 embolectomy $ 385.00 Anesthesia for vascular shunt, or shunt revision, any type (eg, 232 01844 01844 dialysis) $ 385.00 Anesthesia for procedures on veins of forearm, wrist, and hand; not 233 01850 01850 otherwise specified $ 273.00 Anesthesia for procedures on veins of forearm, wrist, and hand; 234 01852 01852 phleborrhaphy $ 273.00 Anesthesia for forearm, wrist, or hand cast application, removal, or 235 01860 01860 repair $ 192.50 236 01916 01916 Anesthesia for diagnostic arteriography/venography $ 273.00 Anesthesia for cardiac catheterization including coronary angiography and ventriculography (not to include Swan-Ganz 237 01920 01920 catheter) $ 273.00 238 01922 01922 Anesthesia for non-invasive imaging or radiation therapy $ 192.50 Anesthesia for therapeutic interventional radiological procedures 239 01924 01924 involving the arterial system; not otherwise specified $ 273.00 Anesthesia for therapeutic interventional radiological procedures 240 01925 01925 involving the arterial system; carotid or coronary $ 273.00 Anesthesia for therapeutic interventional radiological procedures 241 01926 01926 involving the arterial system; intracranial, intracardiac, or aortic $ 273.00 Anesthesia for therapeutic interventional radiological procedures involving the venous/lymphatic system (not to include access to the 242 01930 01930 central circulation); not otherwise specified $ 273.00 Anesthesia for therapeutic interventional radiological procedures involving the venous/lymphatic system (not to include access to the central circulation); intrahepatic or portal circulation (eg, 243 01931 01931 transvenous intrahepatic portosystemic shunt[s] [TIPS]) $ 273.00 Anesthesia for therapeutic interventional radiological procedures involving the venous/lymphatic system (not to include access to the 244 01932 01932 central circulation); intrathoracic or jugular $ 273.00 Anesthesia for therapeutic interventional radiological procedures involving the venous/lymphatic system (not to include access to the 245 01933 01933 central circulation); intracranial $ 273.00 Anesthesia for percutaneous image guided procedures on the spine 246 01935 01935 and spinal cord; diagnostic $ 273.00 Anesthesia for percutaneous image guided procedures on the spine 247 01936 01936 and spinal cord; therapeutic $ 273.00 Anesthesia for second- and third-degree burn excision or debridement with or without skin grafting, any site, for total body surface area (TBSA) treated during anesthesia and surgery; less than 248 01951 01951 4% total body surface area $ 273.00 Anesthesia for second- and third-degree burn excision or debridement with or without skin grafting, any site, for total body surface area (TBSA) treated during anesthesia and surgery; between 249 01952 01952 4% and 9% of total body surface area $ 273.00 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Anesthesia for second- and third-degree burn excision or debridement with or without skin grafting, any site, for total body surface area (TBSA) treated during anesthesia and surgery; each 250 01953 01953 additional 9% total body surface area or part thereof (List separa $ 273.00 251 01958 01958 Anesthesia for external cephalic version procedure $ 273.00 252 01960 01960 Anesthesia for vaginal delivery only $ 273.00 253 01961 01961 Anesthesia for cesarean delivery only $ 214.50 254 01962 01962 Anesthesia for urgent hysterectomy following delivery $ 273.00 Anesthesia for cesarean hysterectomy without any labor 255 01963 01963 analgesia/anesthesia care $ 273.00 256 01965 01965 Anesthesia for incomplete or missed abortion procedures $ 273.00 257 01966 01966 Anesthesia for induced abortion procedures $ 273.00 Neuraxial labor analgesia/anesthesia for planned vaginal delivery (this includes any repeat subarachnoid needle placement and drug injection and/or any necessary replacement of an epidural catheter 258 01967 01967 during labor) $ 273.00 Anesthesia for cesarean delivery following neuraxial labor analgesia/anesthesia (List separately in addition to code for primary 259 01968 01968 procedure performed) $ 273.00 Anesthesia for cesarean hysterectomy following neuraxial labor analgesia/anesthesia (List separately in addition to code for primary 260 01969 01969 procedure performed) $ 286.00 Physiological support for harvesting of organ(s) from brain-dead 261 01990 01990 patient $ 273.00 Anesthesia for diagnostic or therapeutic nerve blocks and injections (when block or injection is performed by a different physician or other qualified health care professional); other than the prone 262 01991 01991 position $ 286.00 Anesthesia for diagnostic or therapeutic nerve blocks and injections (when block or injection is performed by a different physician or 263 01992 01992 other qualified health care professional); prone position $ 286.00 Daily hospital management of epidural or subarachnoid continuous 264 01996 01996 drug administration $ 88.00 265 01999 01999 Unlisted anesthesia procedure(s) $ 286.00 Transluminal peripheral atherectomy, open or percutaneous, 266 0234T 0234T including radiological supervision and interpretation; renal artery $ 8,842.66 Transluminal peripheral atherectomy, open or percutaneous, including radiological supervision and interpretation; visceral artery 267 0235T 0235T (except renal), each vessel $ 2,580.30 Transluminal peripheral atherectomy, open or percutaneous, including radiological supervision and interpretation; 268 0237T 0237T brachiocephalic trunk and branches, each vessel $ 8,842.66 Transluminal peripheral atherectomy, open or percutaneous, including radiological supervision and interpretation; iliac artery, 269 0238T 0238T each vessel $ 8,842.66 270 10021 10021 Fine needle aspiration; without imaging guidance $ 196.46 271 10022 10022 Fine needle aspiration; with imaging guidance $ 215.09 Acne surgery (eg, marsupialization, opening or removal of multiple 272 10040 10040 milia, comedones, cysts, pustules) $ 122.40 Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or 273 10060 10060 paronychia); simple or single $ 134.44 Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or 274 10061 10061 paronychia); complicated or multiple $ 358.05 275 10080 10080 Incision and drainage of pilonidal cyst; simple $ 190.80 276 10081 10081 Incision and drainage of pilonidal cyst; complicated $ 450.90 277 10120 10120 Incision and removal of foreign body, subcutaneous tissues; simple $ 149.67 Incision and removal of foreign body, subcutaneous tissues; 278 10121 10121 complicated $ 413.45 279 10140 10140 Incision and drainage of hematoma, seroma or fluid collection $ 183.32 280 10160 10160 Puncture aspiration of abscess, hematoma, bulla, or cyst $ 125.34 281 10180 10180 Incision and drainage, complex, postoperative wound infection $ 560.32 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Debridement of skin, subcutaneous tissue, muscle and fascia for 282 11004 11004 necrotizing soft tissue infection; external genitalia and perineum $ 756.94 Debridement of skin, subcutaneous tissue, muscle and fascia for necrotizing soft tissue infection; abdominal wall, with or without 283 11005 11005 fascial closure $ 1,068.79 Debridement of skin, subcutaneous tissue, muscle and fascia for necrotizing soft tissue infection; external genitalia, perineum and 284 11006 11006 abdominal wall, with or without fascial closure $ 973.26 Removal of prosthetic material or mesh, abdominal wall for infection (eg, for chronic or recurrent mesh infection or necrotizing soft tissue infection) (List separately in addition to code for primary 285 11008 11008 procedure) $ 437.12 Debridement, bone (includes epidermis, dermis, subcutaneous 286 11044 11044 tissue, muscle and/or fascia, if performed); first 20 sq cm or less $ 846.90 Biopsy of skin, subcutaneous tissue and/or mucous membrane 287 11100 11100 (including simple closure), unless otherwise listed; single lesion $ 134.31 Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed; each separate/additional lesion (List separately in addition to code for 288 11101 11101 primary procedure) $ 77.57 Removal of skin tags, multiple fibrocutaneous tags, any area; up to 289 11200 11200 and including 15 lesions $ 130.55 Removal of skin tags, multiple fibrocutaneous tags, any area; each additional 10 lesions, or part thereof (List separately in addition to 290 11201 11201 code for primary procedure) $ 94.70 Shaving of epidermal or dermal lesion, single lesion, trunk, arms or 291 11300 11300 legs; lesion diameter 0.5 cm or less $ 113.80 Shaving of epidermal or dermal lesion, single lesion, trunk, arms or 292 11301 11301 legs; lesion diameter 0.6 to 1.0 cm $ 142.45 Shaving of epidermal or dermal lesion, single lesion, trunk, arms or 293 11302 11302 legs; lesion diameter 1.1 to 2.0 cm $ 178.74 Shaving of epidermal or dermal lesion, single lesion, trunk, arms or 294 11303 11303 legs; lesion diameter over 2.0 cm $ 289.80 Shaving of epidermal or dermal lesion, single lesion, scalp, neck, 295 11305 11305 hands, feet, genitalia; lesion diameter 0.5 cm or less $ 125.15 Shaving of epidermal or dermal lesion, single lesion, scalp, neck, 296 11306 11306 hands, feet, genitalia; lesion diameter 0.6 to 1.0 cm $ 166.40 Shaving of epidermal or dermal lesion, single lesion, scalp, neck, 297 11307 11307 hands, feet, genitalia; lesion diameter 1.1 to 2.0 cm $ 232.20 Shaving of epidermal or dermal lesion, single lesion, scalp, neck, 298 11308 11308 hands, feet, genitalia; lesion diameter over 2.0 cm $ 261.50 Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.5 cm or 299 11310 11310 less $ 141.10 Shaving of epidermal or dermal lesion, single lesion, face, ears, 300 11311 11311 eyelids, nose, lips, mucous membrane; lesion diameter 0.6 to 1.0 cm $ 216.00 Shaving of epidermal or dermal lesion, single lesion, face, ears, 301 11312 11312 eyelids, nose, lips, mucous membrane; lesion diameter 1.1 to 2.0 cm $ 252.00 Shaving of epidermal or dermal lesion, single lesion, face, ears, 302 11313 11313 eyelids, nose, lips, mucous membrane; lesion diameter over 2.0 cm $ 283.29 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.5 cm or 303 11400 11400 less $ 151.78 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 1.1 to 2.0 304 11402 11402 cm $ 304.20 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 2.1 to 3.0 305 11403 11403 cm $ 323.56 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 3.1 to 4.0 306 11404 11404 cm $ 435.46 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous 307 11441 11441 membrane; excised diameter 0.6 to 1.0 cm $ 262.16 Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous 308 11442 11442 membrane; excised diameter 1.1 to 2.0 cm $ 345.79 Excision, malignant lesion including margins, trunk, arms, or legs; 309 11604 11604 excised diameter 3.1 to 4.0 cm $ 582.43 Excision, malignant lesion including margins, trunk, arms, or legs; 310 11606 11606 excised diameter over 4.0 cm $ 780.74 Excision, malignant lesion including margins, scalp, neck, hands, 311 11623 11623 feet, genitalia; excised diameter 2.1 to 3.0 cm $ 568.31 Excision, malignant lesion including margins, scalp, neck, hands, 312 11624 11624 feet, genitalia; excised diameter 3.1 to 4.0 cm $ 820.80 Excision, malignant lesion including margins, scalp, neck, hands, 313 11626 11626 feet, genitalia; excised diameter over 4.0 cm $ 990.00 314 11719 11719 Trimming of nondystrophic nails, any number $ 39.46 315 11720 11720 Debridement of nail(s) by any method(s); 1 to 5 $ 87.30 316 11721 11721 Debridement of nail(s) by any method(s); 6 or more $ 122.40 317 11740 11740 Evacuation of subungual hematoma $ 117.00 Excision of nail and nail matrix, partial or complete (eg, ingrown or 318 11750 11750 deformed nail), for permanent removal; $ 341.38 319 11765 11765 Wedge excision of skin of nail fold (eg, for ingrown toenail) $ 226.39 320 11900 11900 Injection, intralesional; up to and including 7 lesions $ 68.38 321 11901 11901 Injection, intralesional; more than 7 lesions $ 103.02 322 11950 11950 Subcutaneous injection of filling material (eg, collagen); 1 cc or less $ 348.30 323 11951 11951 Subcutaneous injection of filling material (eg, collagen); 1.1 to 5.0 cc $ 549.90 Subcutaneous injection of filling material (eg, collagen); 5.1 to 10.0 324 11952 11952 cc $ 899.10 325 11954 11954 Subcutaneous injection of filling material (eg, collagen); over 10.0 cc $ 1,215.90 326 11976 11976 Removal, implantable contraceptive capsules $ 318.60 Subcutaneous hormone pellet implantation (implantation of 327 11980 11980 estradiol and/or testosterone pellets beneath the skin) $ 430.20 328 11981 11981 Insertion, non-biodegradable drug delivery implant $ 162.00 329 11982 11982 Removal, non-biodegradable drug delivery implant $ 165.40 330 11983 11983 Removal with reinsertion, non-biodegradable drug delivery implant $ 193.58 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 331 12001 12001 cm or less $ 179.15 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.6 332 12002 12002 cm to 7.5 cm $ 230.42 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 7.6 333 12004 12004 cm to 12.5 cm $ 327.60 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 12.6 334 12005 12005 cm to 20.0 cm $ 421.20 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 20.1 335 12006 12006 cm to 30.0 cm $ 487.80 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); over 336 12007 12007 30.0 cm $ 675.90 Simple repair of superficial wounds of face, ears, eyelids, nose, lips 337 12011 12011 and/or mucous membranes; 2.5 cm or less $ 222.77 Simple repair of superficial wounds of face, ears, eyelids, nose, lips 338 12013 12013 and/or mucous membranes; 2.6 cm to 5.0 cm $ 288.43 Simple repair of superficial wounds of face, ears, eyelids, nose, lips 339 12014 12014 and/or mucous membranes; 5.1 cm to 7.5 cm $ 363.06 Simple repair of superficial wounds of face, ears, eyelids, nose, lips 340 12015 12015 and/or mucous membranes; 7.6 cm to 12.5 cm $ 477.90 Simple repair of superficial wounds of face, ears, eyelids, nose, lips 341 12016 12016 and/or mucous membranes; 12.6 cm to 20.0 cm $ 629.10 Simple repair of superficial wounds of face, ears, eyelids, nose, lips 342 12017 12017 and/or mucous membranes; 20.1 cm to 30.0 cm $ 779.40 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Simple repair of superficial wounds of face, ears, eyelids, nose, lips 343 12018 12018 and/or mucous membranes; over 30.0 cm $ 1,124.10 344 12020 12020 Treatment of superficial wound dehiscence; simple closure $ 388.79 Repair, intermediate, wounds of scalp, axillae, trunk and/or 345 12031 12031 extremities (excluding hands and feet); 2.5 cm or less $ 255.60 Repair, intermediate, wounds of scalp, axillae, trunk and/or 346 12032 12032 extremities (excluding hands and feet); 2.6 cm to 7.5 cm $ 343.80 Repair, intermediate, wounds of scalp, axillae, trunk and/or 347 12034 12034 extremities (excluding hands and feet); 7.6 cm to 12.5 cm $ 423.00 Repair, intermediate, wounds of scalp, axillae, trunk and/or 348 12035 12035 extremities (excluding hands and feet); 12.6 cm to 20.0 cm $ 555.30 Repair, intermediate, wounds of scalp, axillae, trunk and/or 349 12036 12036 extremities (excluding hands and feet); 20.1 cm to 30.0 cm $ 719.10 Repair, intermediate, wounds of scalp, axillae, trunk and/or 350 12037 12037 extremities (excluding hands and feet); over 30.0 cm $ 922.50 Repair, intermediate, wounds of neck, hands, feet and/or external 351 12041 12041 genitalia; 2.5 cm or less $ 291.60 Repair, intermediate, wounds of neck, hands, feet and/or external 352 12042 12042 genitalia; 2.6 cm to 7.5 cm $ 352.09 Repair, intermediate, wounds of neck, hands, feet and/or external 353 12044 12044 genitalia; 7.6 cm to 12.5 cm $ 468.90 Repair, intermediate, wounds of neck, hands, feet and/or external 354 12045 12045 genitalia; 12.6 cm to 20.0 cm $ 579.60 Repair, intermediate, wounds of neck, hands, feet and/or external 355 12046 12046 genitalia; 20.1 cm to 30.0 cm $ 812.70 Repair, intermediate, wounds of neck, hands, feet and/or external 356 12047 12047 genitalia; over 30.0 cm $ 963.00 Repair, intermediate, wounds of face, ears, eyelids, nose, lips 357 12051 12051 and/or mucous membranes; 2.5 cm or less $ 350.10 Repair, intermediate, wounds of face, ears, eyelids, nose, lips 358 12052 12052 and/or mucous membranes; 2.6 cm to 5.0 cm $ 470.70 Repair, intermediate, wounds of face, ears, eyelids, nose, lips 359 12053 12053 and/or mucous membranes; 5.1 cm to 7.5 cm $ 549.00 Repair, intermediate, wounds of face, ears, eyelids, nose, lips 360 12054 12054 and/or mucous membranes; 7.6 cm to 12.5 cm $ 704.70 Repair, intermediate, wounds of face, ears, eyelids, nose, lips 361 12055 12055 and/or mucous membranes; 12.6 cm to 20.0 cm $ 942.30 Repair, intermediate, wounds of face, ears, eyelids, nose, lips 362 12056 12056 and/or mucous membranes; 20.1 cm to 30.0 cm $ 1,141.20 Repair, intermediate, wounds of face, ears, eyelids, nose, lips 363 12057 12057 and/or mucous membranes; over 30.0 cm $ 1,338.30 Secondary closure of surgical wound or dehiscence, extensive or 364 13160 13160 complicated $ 1,059.69 Adjacent tissue transfer or rearrangement, trunk; defect 10 sq cm 365 14000 14000 or less $ 1,088.10 Adjacent tissue transfer or rearrangement, any area;

defect 30.1 sq 366 14301 14301 cm to 60.0 sq cm $ 2,113.30 Adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq cm, or part thereof (list separately in addition to 367 14302 14302 code for primary procedure) $ 480.88 Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, 368 15005 15005 neck, ears, orbits, genitalia, hands, feet and/or $ 265.38 369 15040 15040 Harvest of skin for tissue cultured skin autograft, 100 sq cm or less $ 563.25 Epidermal autograft, trunk, arms, legs; first 100 sq cm or less, or 1% 370 15110 15110 of body area of infants and children $ 1,887.78 Epidermal autograft, trunk, arms, legs; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part 371 15111 15111 thereof (List separately in addition to code for primary procedure) $ 294.39 Epidermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; each additional 100 sq cm, or each additional 1% of body area of infants and children, or 372 15116 15116 part thereof (List separately in addition to co $ 402.77 Dermal autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of 373 15130 15130 body area of infants and children $ 1,469.33 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Dermal autograft, trunk, arms, legs; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part 374 15131 15131 thereof (List separately in addition to code for primary procedure) $ 246.06 Dermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, 375 15135 15135 or 1% of body area of infants and children $ 1,861.86 Dermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; each additional 100 sq cm, or each additional 1% of body area of infants and children, or 376 15136 15136 part thereof (List separately in addition to code $ 227.31 Tissue cultured skin autograft, trunk, arms, legs; first 25 sq cm or 377 15150 15150 less $ 1,481.15 Tissue cultured skin autograft, trunk, arms, legs; additional 1 sq cm to 75 sq cm (List separately in addition to code for primary 378 15151 15151 procedure) $ 297.75 Tissue cultured skin autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 25 sq 379 15155 15155 cm or less $ 1,472.04 Tissue cultured skin autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; additional 1 sq cm to 75 sq cm (List separately in addition to code for primary 380 15156 15156 procedure) $ 424.98 Tissue cultured skin autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; each additional 100 sq cm, or each additional 1% of body area of infants 381 15157 15157 and children, or part thereof (List separately in add $ 481.51 Full thickness graft, free, including direct closure of donor site, 382 15200 15200 trunk; 20 sq cm or less $ 1,299.60 383 15738 15738 Muscle, myocutaneous, or fasciocutaneous flap; lower extremity $ 5,279.40 Dermabrasion; total face (eg, for acne scarring, fine wrinkling, 384 15780 15780 rhytids, general keratosis) $ 2,763.90 385 15781 15781 Dermabrasion; segmental, face $ 1,148.40 386 15782 15782 Dermabrasion; regional, other than face $ 772.20 387 15783 15783 Dermabrasion; superficial, any site (eg, tattoo removal) $ 772.20 388 15786 15786 Abrasion; single lesion (eg, keratosis, scar) $ 412.20 Abrasion; each additional 4 lesions or less (List separately in 389 15787 15787 addition to code for primary procedure) $ 207.90 390 15788 15788 Chemical peel, facial; epidermal $ 1,545.30 391 15789 15789 Chemical peel, facial; dermal $ 1,901.70 392 15792 15792 Chemical peel, nonfacial; epidermal $ 544.50 393 15793 15793 Chemical peel, nonfacial; dermal $ 849.60 394 15820 15820 Blepharoplasty, lower eyelid; $ 2,253.60 395 15822 15822 Blepharoplasty, upper eyelid; $ 2,542.50 Excision, excessive skin and subcutaneous tissue (includes 396 15830 15830 lipectomy); abdomen, infraumbilical panniculectomy $ 1,777.49 Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (eg, abdominoplasty) (includes umbilical transposition and fascial plication) (List separately in addition to 397 15847 15847 code for primary procedure) $ 715.00 Removal of sutures under anesthesia (other than local), other 398 15851 15851 surgeon $ 259.49 Dressing change (for other than burns) under anesthesia (other 399 15852 15852 than local) $ 373.50 400 15877 15877 Suction assisted lipectomy; trunk $ 2,446.20 401 15878 15878 Suction assisted lipectomy; upper extremity $ 2,060.10 402 15879 15879 Suction assisted lipectomy; lower extremity $ 2,292.30 403 15999 15999 Unlisted procedure, excision pressure ulcer Cost Initial treatment, first degree burn, when no more than local 404 16000 16000 treatment is required $ 104.40 Dressings and/or debridement of partial-thickness burns, initial or 405 16020 16020 subsequent; small (less than 5% total body surface area) $ 115.89 Dressings and/or debridement of partial-thickness burns, initial or subsequent; medium (eg, whole face or whole extremity, or 5% to 406 16025 16025 10% total body surface area) $ 217.86 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Dressings and/or debridement of partial-thickness burns, initial or subsequent; large (eg, more than 1 extremity, or greater than 10% 407 16030 16030 total body surface area) $ 363.34 Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, 408 17000 17000 actinic keratoses); first lesion $ 97.34 Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses); second through 14 lesions, each (List separately 409 17003 17003 in addition to code for first lesion) $ 37.26 Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, 410 17004 17004 actinic keratoses), 15 or more lesions $ 540.00 Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than 411 17110 17110 skin tags or cutaneous vascular proliferative lesions; up to 14 lesions $ 110.03 Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; 15 or more 412 17111 17111 lesions $ 178.20 Chemical cauterization of granulation tissue (proud flesh, sinus or 413 17250 17250 fistula) $ 152.10 414 17340 17340 Cryotherapy (CO2 slush, liquid N2) for acne $ 74.83 415 17380 17380 Electrolysis epilation, each 30 minutes $ 134.10 Biopsy of breast; percutaneous, needle core, not using imaging 416 19100 19100 guidance (separate procedure) $ 257.40 Ablation, cryosurgical, of fibroadenoma, including ultrasound 417 19105 19105 guidance, each fibroadenoma $ 3,171.04 Nipple exploration, with or without excision of a solitary lactiferous 418 19110 19110 duct or a papilloma lactiferous duct $ 1,235.70 Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion (except 419 19120 19120 19300), open, male or female, 1 or more lesions $ 1,105.37 Excision of breast lesion identified by preoperative placement of 420 19125 19125 radiological marker, open; single lesion $ 1,289.70 Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; first lesion, including 421 19281 19281 mammographic guidance $98.25 Placement of radiotherapy afterloading expandable catheter (single or multichannel) into the breast for interstitial radioelement application following partial mastectomy, includes imaging 422 19296 19296 guidance; on date separate from partial mastectomy $ 9,940.72 Placement of radiotherapy afterloading expandable catheter (single or multichannel) into the breast for interstitial radioelement application following partial mastectomy, includes imaging 423 19297 19297 guidance; concurrent with partial mastectomy (List separately in a $ 218.27 Placement of radiotherapy afterloading brachytherapy catheters (multiple tube and button type) into the breast for interstitial radioelement application following (at the time of or subsequent to) 424 19298 19298 partial mastectomy, includes imaging guidance $ 3,605.44 Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, 425 19301 19301 segmentectomy); $ 933.84 426 19303 19303 Mastectomy, simple, complete $ 1,597.79 427 19304 19304 Mastectomy, subcutaneous $ 1,169.33 Mastectomy, radical, including pectoral muscles, axillary lymph 428 19305 19305 nodes $ 2,032.87 Mastectomy, radical, including pectoral muscles, axillary and 429 19306 19306 internal mammary lymph nodes (Urban type operation) $ 2,299.98 430 19318 19318 Reduction mammaplasty $ 4,137.80 431 19325 19325 Mammaplasty, augmentation; with prosthetic implant $ 2,711.70 432 19328 19328 Removal of intact mammary implant $ 1,848.60 Delayed insertion of breast prosthesis following mastopexy, 433 19342 19342 mastectomy or in reconstruction $ 2,786.40 Breast reconstruction with latissimus dorsi flap, without prosthetic 434 19361 19361 implant $ 5,408.10 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), single pedicle, including closure of 435 19368 19368 donor site; with microvascular anastomosis (supercharging) $ 6,352.72 Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), double pedicle, including closure of 436 19369 19369 donor site $ 5,552.58 437 19499 19499 Unlisted procedure, breast Cost Incision and drainage of soft tissue abscess, subfascial (ie, involves 438 20005 20005 the soft tissue below the deep fascia) $ 664.63 439 20100 20100 Exploration of penetrating wound (separate procedure); neck $ 1,610.10 440 20101 20101 Exploration of penetrating wound (separate procedure); chest $ 675.00 Exploration of penetrating wound (separate procedure); 441 20102 20102 abdomen/flank/back $ 798.30 442 20103 20103 Exploration of penetrating wound (separate procedure); extremity $ 1,134.00 Excision of epiphyseal bar, with or without autogenous soft tissue 443 20150 20150 graft obtained through same fascial incision $ 2,912.40 444 20200 20200 Biopsy, muscle; superficial $ 412.20 445 20205 20205 Biopsy, muscle; deep $ 617.40 446 20206 20206 Biopsy, muscle, percutaneous needle $ 272.70 Biopsy, bone, trocar, or needle; superficial (eg, ilium, sternum, 447 20220 20220 spinous process, ribs) $ 360.90 448 20225 20225 Biopsy, bone, trocar, or needle; deep (eg, vertebral body, femur) $ 814.50 Biopsy, bone, open; superficial (eg, ilium, sternum, spinous process, 449 20240 20240 ribs, trochanter of femur) $ 654.30 450 20245 20245 Biopsy, bone, open; deep (eg, humerus, ischium, femur) $ 1,028.70 451 20250 20250 Biopsy, vertebral body, open; thoracic $ 3,141.00 452 20251 20251 Biopsy, vertebral body, open; lumbar or cervical $ 2,589.30 453 20500 20500 Injection of sinus tract; therapeutic (separate procedure) $ 114.30 454 20501 20501 Injection of sinus tract; diagnostic (sinogram) $ 147.60 455 20520 20520 Removal of foreign body in muscle or tendon sheath; simple $ 307.46 Removal of foreign body in muscle or tendon sheath; deep or 456 20525 20525 complicated $ 720.90 Injection, therapeutic (eg, local anesthetic, corticosteroid), carpal 457 20526 20526 tunnel $ 135.84 Injection(s); single tendon sheath, or ligament, aponeurosis (eg, 458 20550 20550 plantar 'fascia') $ 108.18 459 20551 20551 Injection(s); single tendon origin/insertion $ 104.87 460 20552 20552 Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s) $ 103.78 461 20553 20553 Injection(s); single or multiple trigger point(s), 3 or more muscle(s) $ 121.48 Placement of needles or catheters into muscle and/or soft tissue for subsequent interstitial radioelement application (at the time of or 462 20555 20555 subsequent to the procedure) $ 582.66 Arthrocentesis, aspiration and/or injection; small joint or bursa (eg, 463 20600 20600 fingers, toes) $ 94.96 Arthrocentesis, aspiration and/or injection; intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or 464 20605 20605 ankle, olecranon bursa) $ 107.28 Arthrocentesis, aspiration and/or injection; major joint or bursa (eg, 465 20610 20610 shoulder, hip, knee joint, subacromial bursa) $ 135.03 466 20612 20612 Aspiration and/or injection of ganglion cyst(s) any location $ 105.01 467 20615 20615 Aspiration and injection for treatment of bone cyst $ 527.40 Insertion of wire or pin with application of skeletal traction, 468 20650 20650 including removal (separate procedure) $ 468.90 Application of cranial tongs, caliper, or stereotactic frame, including 469 20660 20660 removal (separate procedure) $ 853.20 470 20661 20661 Application of halo, including removal; cranial $ 1,326.60 471 20662 20662 Application of halo, including removal; pelvic $ 902.70 472 20663 20663 Application of halo, including removal; femoral $ 765.00 Application of halo, including removal, cranial, 6 or more pins placed, for thin skull osteology (eg, pediatric patients, 473 20664 20664 hydrocephalus, osteogenesis imperfecta) $ 1,032.30 474 20665 20665 Removal of tongs or halo applied by another individual $ 234.90 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Removal of implant; superficial (eg, buried wire, pin or rod) 475 20670 20670 (separate procedure) $ 463.50 Removal of implant; deep (eg, buried wire, pin, screw, metal band, 476 20680 20680 nail, rod or plate) $ 857.90 Application of a uniplane (pins or wires in 1 plane), unilateral, 477 20690 20690 external fixation system $ 1,138.50 Application of a multiplane (pins or wires in more than 1 plane), 478 20692 20692 unilateral, external fixation system (eg, Ilizarov, Monticelli type) $ 1,752.30 Adjustment or revision of external fixation system requiring 479 20693 20693 anesthesia (eg, new pin[s] or wire[s] and/or new ring[s] or bar[s]) $ 908.10 480 20694 20694 Removal, under anesthesia, of external fixation system $ 824.40 Application of multiplane (pins or wires in more than 1 plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and 481 20696 20696 subsequent alignment(s), assessment(s), and computation(s) of $ 1,752.70 Application of multiplane (pins or wires in more than 1 plane), unilateral, external fixation with stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; exchange (ie, 482 20697 20697 removal and replacement) of strut, each $ 2,193.99 Replantation, arm (includes surgical neck of humerus through elbow 483 20802 20802 joint), complete amputation $ 9,720.90 Replantation, forearm (includes radius and ulna to radial carpal 484 20805 20805 joint), complete amputation $ 10,085.40 Replantation, hand (includes hand through metacarpophalangeal 485 20808 20808 joints), complete amputation $ 11,040.30 Replantation, digit, excluding thumb (includes metacarpophalangeal 486 20816 20816 joint to insertion of flexor sublimis tendon), complete amputation $ 5,793.30 Replantation, digit, excluding thumb (includes distal tip to sublimis 487 20822 20822 tendon insertion), complete amputation $ 5,794.20 Replantation, thumb (includes carpometacarpal joint to MP joint), 488 20824 20824 complete amputation $ 6,571.80 Replantation, thumb (includes distal tip to MP joint), complete 489 20827 20827 amputation $ 5,047.20 490 20838 20838 Replantation, foot, complete amputation $ 9,888.30 491 20900 20900 Bone graft, any donor area; minor or small (eg, dowel or button) $ 947.70 492 20902 20902 Bone graft, any donor area; major or large $ 1,587.60 493 20910 20910 Cartilage graft; costochondral $ 1,491.30 494 20912 20912 Cartilage graft; nasal septum $ 1,467.90 495 20920 20920 Fascia lata graft; by stripper $ 885.60 496 20922 20922 Fascia lata graft; by incision and area exposure, complex or sheet $ 1,241.10 497 20924 20924 Tendon graft, from a distance (eg, palmaris, toe extensor, plantaris) $ 1,360.80 498 20926 20926 Tissue grafts, other (eg, paratenon, fat, dermis) $ 1,014.30 Allograft, morselized, or placement of osteopromotive material, for spine surgery only (List separately in addition to code for primary 499 20930 20930 procedure) $ 978.30 Allograft, structural, for spine surgery only (List separately in 500 20931 20931 addition to code for primary procedure) $ 618.30 Autograft for spine surgery only (includes harvesting the graft); local (eg, ribs, spinous process, or laminar fragments) obtained from same incision (List separately in addition to code for primary 501 20936 20936 procedure) $ 1,545.30 Autograft for spine surgery only (includes harvesting the graft); morselized (through separate skin or fascial incision) (List separately 502 20937 20937 in addition to code for primary procedure) $ 1,235.70 Autograft for spine surgery only (includes harvesting the graft); structural, bicortical or tricortical (through separate skin or fascial 503 20938 20938 incision) (List separately in addition to code for primary procedure) $ 1,506.60 Monitoring of interstitial fluid pressure (includes insertion of device, eg, wick catheter technique, needle manometer technique) in 504 20950 20950 detection of muscle compartment syndrome $ 293.40 505 20955 20955 Bone graft with microvascular anastomosis; fibula $ 10,791.90 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price 506 20956 20956 Bone graft with microvascular anastomosis; iliac crest $ 8,655.30 507 20957 20957 Bone graft with microvascular anastomosis; metatarsal $ 8,967.60 Bone graft with microvascular anastomosis; other than fibula, iliac 508 20962 20962 crest, or metatarsal $ 8,168.40 Free osteocutaneous flap with microvascular anastomosis; other 509 20969 20969 than iliac crest, metatarsal, or great toe $ 7,750.80 510 20970 20970 Free osteocutaneous flap with microvascular anastomosis; iliac crest $ 9,907.20 Free osteocutaneous flap with microvascular anastomosis; 511 20972 20972 metatarsal $ 8,745.30 Free osteocutaneous flap with microvascular anastomosis; great toe 512 20973 20973 with web space $ 8,745.30 Electrical stimulation to aid bone healing; noninvasive 513 20974 20974 (nonoperative) $ 915.30 514 20975 20975 Electrical stimulation to aid bone healing; invasive (operative) $ 1,344.60 Low intensity ultrasound stimulation to aid bone healing, 515 20979 20979 noninvasive (nonoperative) $ 124.20 Ablation, bone tumor(s) (eg, osteoid osteoma, metastasis) radiofrequency, percutaneous, including computed tomographic 516 20982 20982 guidance $ 8,951.44 Computer-assisted surgical navigational procedure for musculoskeletal procedures, image-less (List separately in addition 517 20985 20985 to code for primary procedure) $ 207.47 518 20999 20999 Unlisted procedure, musculoskeletal system, general Cost 519 21010 21010 Arthrotomy, temporomandibular joint $ 2,836.80 Excision, tumor, soft tissue of face or scalp, subcutaneous; less than 520 21011 21011 2 cm $ 441.95 Excision, tumor, soft tissue of face or scalp, subcutaneous; 2 cm or 521 21012 21012 greater $ 465.84 Excision, tumor, soft tissue of face and scalp, subfascial (eg, 522 21013 21013 subgaleal, intramuscular); less than 2 cm $ 767.09 Excision, tumor, soft tissue of face and scalp, subfascial (eg, 523 21014 21014 subgaleal, intramuscular); 2 cm or greater $ 813.32 Radical resection of tumor (eg, sarcoma), soft tissue of face or scalp; 524 21015 21015 less than 2 cm $ 1,773.90 Radical resection of tumor (eg, sarcoma), soft tissue of face or scalp; 525 21016 21016 2 cm or greater $ 1,706.33 526 21025 21025 Excision of bone (eg, for osteomyelitis or bone abscess); mandible $ 1,602.00 Excision of bone (eg, for osteomyelitis or bone abscess); facial 527 21026 21026 bone(s) $ 1,498.50 Removal by contouring of benign tumor of facial bone (eg, fibrous 528 21029 21029 dysplasia) $ 1,532.70 Excision of benign tumor or cyst of maxilla or zygoma by 529 21030 21030 enucleation and curettage $ 2,193.30 530 21031 21031 Excision of torus mandibularis $ 696.60 531 21032 21032 Excision of maxillary torus palatinus $ 1,056.60 532 21034 21034 Excision of malignant tumor of maxilla or zygoma $ 3,169.80 Excision of benign tumor or cyst of mandible, by enucleation and/or 533 21040 21040 curettage $ 1,246.50 534 21044 21044 Excision of malignant tumor of mandible; $ 2,851.20 535 21045 21045 Excision of malignant tumor of mandible; radical resection $ 5,918.40 Excision of benign tumor or cyst of mandible; requiring intra-oral 536 21046 21046 osteotomy (eg, locally aggressive or destructive lesion(s)) $ 1,872.04 Excision of benign tumor or cyst of mandible; requiring extra-oral osteotomy and partial mandibulectomy (eg, locally aggressive or 537 21047 21047 destructive lesion(s)) $ 2,304.17 Excision of benign tumor or cyst of maxilla; requiring intra-oral 538 21048 21048 osteotomy (eg, locally aggressive or destructive lesion(s)) $ 1,918.12 Excision of benign tumor or cyst of maxilla; requiring extra-oral osteotomy and partial maxillectomy (eg, locally aggressive or 539 21049 21049 destructive lesion(s)) $ 2,210.72 540 21050 21050 Condylectomy, temporomandibular joint (separate procedure) $ 3,355.20 Meniscectomy, partial or complete, temporomandibular joint 541 21060 21060 (separate procedure) $ 3,330.00 542 21070 21070 Coronoidectomy (separate procedure) $ 2,724.30 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Manipulation of temporomandibular joint(s) (TMJ), therapeutic, requiring an anesthesia service (ie, general or monitored anesthesia 543 21073 21073 care) $ 524.35 544 21076 21076 Impression and custom preparation; surgical obturator prosthesis $ 1,781.92 545 21077 21077 Impression and custom preparation; orbital prosthesis $ 4,473.18 546 21079 21079 Impression and custom preparation; interim obturator prosthesis $ 2,974.29 547 21080 21080 Impression and custom preparation; definitive obturator prosthesis $ 3,342.10 Impression and custom preparation; mandibular resection 548 21081 21081 prosthesis $ 3,048.99 549 21083 21083 Impression and custom preparation; palatal lift prosthesis $ 2,579.92 550 21084 21084 Impression and custom preparation; speech aid prosthesis $ 3,019.99 551 21085 21085 Impression and custom preparation; oral surgical splint $ 398.70 552 21086 21086 Impression and custom preparation; auricular prosthesis $ 3,303.10 553 21087 21087 Impression and custom preparation; nasal prosthesis $ 3,302.27 554 21088 21088 Impression and custom preparation; facial prosthesis 555 21089 21089 Unlisted maxillofacial prosthetic procedure Cost Application of halo type appliance for maxillofacial fixation, includes 556 21100 21100 removal (separate procedure) $ 566.10 Application of interdental fixation device for conditions other than 557 21110 21110 fracture or dislocation, includes removal $ 1,364.40 558 21116 21116 Injection procedure for temporomandibular joint arthrography $ 178.20 Genioplasty; augmentation (autograft, allograft, prosthetic 559 21120 21120 material) $ 2,880.90 560 21121 21121 Genioplasty; sliding osteotomy, single piece $ 2,574.90 Genioplasty; sliding osteotomies, 2 or more osteotomies (eg, wedge 561 21122 21122 excision or bone wedge reversal for asymmetrical chin) $ 2,385.00 Genioplasty; sliding, augmentation with interpositional bone grafts 562 21123 21123 (includes obtaining autografts) $ 2,490.30 563 21125 21125 Augmentation, mandibular body or angle; prosthetic material $ 2,394.90 Augmentation, mandibular body or angle; with bone graft, onlay or 564 21127 21127 interpositional (includes obtaining autograft) $ 2,266.20 565 21137 21137 Reduction forehead; contouring only $ 2,266.20 Reduction forehead; contouring and application of prosthetic 566 21138 21138 material or bone graft (includes obtaining autograft) $ 2,652.30 Reduction forehead; contouring and setback of anterior frontal 567 21139 21139 sinus wall $ 3,278.60 Reconstruction midface, LeFort I; single piece, segment movement 568 21141 21141 in any direction (eg, for Long Face Syndrome), without bone graft $ 4,120.20 Reconstruction midface, LeFort I; 2 pieces, segment movement in 569 21142 21142 any direction, without bone graft $ 4,326.30 Reconstruction midface, LeFort I; 3 or more pieces, segment 570 21143 21143 movement in any direction, without bone graft $ 4,428.90 Reconstruction midface, LeFort I; single piece, segment movement in any direction, requiring bone grafts (includes obtaining 571 21145 21145 autografts) $ 4,496.20 Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) 572 21146 21146 (eg, ungrafted unilateral alveolar cleft) $ 5,983.20 Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, requiring bone grafts (includes obtaining autografts) (eg, ungrafted bilateral alveolar cleft or 573 21147 21147 multiple osteotomies) $ 6,391.80 Reconstruction midface, LeFort II; anterior intrusion (eg, Treacher- 574 21150 21150 Collins Syndrome) $ 5,568.30 Reconstruction midface, LeFort II; any direction, requiring bone 575 21151 21151 grafts (includes obtaining autografts) $ 6,695.10 Reconstruction midface, LeFort III (extracranial), any type, requiring 576 21154 21154 bone grafts (includes obtaining autografts); without LeFort I $ 6,677.10 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Reconstruction midface, LeFort III (extracranial), any type, requiring 577 21155 21155 bone grafts (includes obtaining autografts); with LeFort I $ 6,431.40 Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (eg, mono bloc), requiring bone grafts 578 21159 21159 (includes obtaining autografts); without LeFort I $ 9,682.20 Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (eg, mono bloc), requiring bone grafts 579 21160 21160 (includes obtaining autografts); with LeFort I $ 10,815.30 Reconstruction superior-lateral orbital rim and lower forehead, advancement or alteration, with or without grafts (includes 580 21172 21172 obtaining autografts) $ 8,767.80 Reconstruction, bifrontal, superior-lateral orbital rims and lower forehead, advancement or alteration (eg, plagiocephaly, trigonocephaly, brachycephaly), with or without grafts (includes 581 21175 21175 obtaining autografts) $ 9,409.50 Reconstruction, entire or majority of forehead and/or supraorbital 582 21179 21179 rims; with grafts (allograft or prosthetic material) $ 7,056.00 Reconstruction, entire or majority of forehead and/or supraorbital 583 21180 21180 rims; with autograft (includes obtaining grafts) $ 6,390.00 Reconstruction by contouring of benign tumor of cranial bones (eg, 584 21181 21181 fibrous dysplasia), extracranial $ 1,539.90 Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following intra- and extracranial excision of benign tumor of cranial bone (eg, fibrous dysplasia), with multiple autografts 585 21182 21182 (includes obtaining grafts); total area of bone grafting less $ 6,723.90 Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following intra- and extracranial excision of benign tumor of cranial bone (eg, fibrous dysplasia), with multiple autografts 586 21183 21183 (includes obtaining grafts); total area of bone grafting grea $ 7,144.20 Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following intra- and extracranial excision of benign tumor of cranial bone (eg, fibrous dysplasia), with multiple autografts 587 21184 21184 (includes obtaining grafts); total area of bone grafting grea $ 7,754.40 Reconstruction midface, osteotomies (other than LeFort type) and 588 21188 21188 bone grafts (includes obtaining autografts) $ 4,563.00 Reconstruction of mandibular rami, horizontal, vertical, C, or L 589 21193 21193 osteotomy; without bone graft $ 4,586.40 Reconstruction of mandibular rami, horizontal, vertical, C, or L 590 21194 21194 osteotomy; with bone graft (includes obtaining graft) $ 5,648.40 Reconstruction of mandibular rami and/or body, sagittal split; 591 21195 21195 without internal rigid fixation $ 4,891.50 Reconstruction of mandibular rami and/or body, sagittal split; with 592 21196 21196 internal rigid fixation $ 5,547.60 593 21198 21198 Osteotomy, mandible, segmental; $ 3,804.30 594 21199 21199 Osteotomy, mandible, segmental; with genioglossus advancement $ 3,879.00 595 21206 21206 Osteotomy, maxilla, segmental (eg, Wassmund or Schuchard) $ 4,425.30 Osteoplasty, facial bones; augmentation (autograft, allograft, or 596 21208 21208 prosthetic implant) $ 2,608.20 597 21209 21209 Osteoplasty, facial bones; reduction $ 2,713.50 Graft, bone; nasal, maxillary or malar areas (includes obtaining 598 21210 21210 graft) $ 3,510.00 599 21215 21215 Graft, bone; mandible (includes obtaining graft) $ 3,878.10 Graft; rib cartilage, autogenous, to face, chin, nose or ear (includes 600 21230 21230 obtaining graft) $ 4,305.60 Graft; ear cartilage, autogenous, to nose or ear (includes obtaining 601 21235 21235 graft) $ 2,547.90 Arthroplasty, temporomandibular joint, with or without autograft 602 21240 21240 (includes obtaining graft) $ 4,120.20 603 21242 21242 Arthroplasty, temporomandibular joint, with allograft $ 3,933.00 Arthroplasty, temporomandibular joint, with prosthetic joint 604 21243 21243 replacement $ 5,049.90 Reconstruction of mandible, extraoral, with transosteal bone plate 605 21244 21244 (eg, mandibular staple bone plate) $ 4,204.80 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Reconstruction of mandible or maxilla, subperiosteal implant; 606 21245 21245 partial $ 3,759.30 Reconstruction of mandible or maxilla, subperiosteal implant; 607 21246 21246 complete $ 5,781.60 Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial 608 21247 21247 microsomia) $ 5,665.50 Reconstruction of mandible or maxilla, endosteal implant (eg, blade, 609 21248 21248 cylinder); partial $ 3,985.20 Reconstruction of mandible or maxilla, endosteal implant (eg, blade, 610 21249 21249 cylinder); complete $ 7,416.00 Reconstruction of zygomatic arch and glenoid fossa with bone and 611 21255 21255 cartilage (includes obtaining autografts) $ 5,665.50 Reconstruction of orbit with osteotomies (extracranial) and with 612 21256 21256 bone grafts (includes obtaining autografts) (eg, micro-ophthalmia) $ 5,800.50 Periorbital osteotomies for orbital hypertelorism, with bone grafts; 613 21260 21260 extracranial approach $ 6,687.00 Periorbital osteotomies for orbital hypertelorism, with bone grafts; 614 21261 21261 combined intra- and extracranial approach $ 8,191.80 Orbital repositioning, periorbital osteotomies, unilateral, with bone 615 21267 21267 grafts; extracranial approach $ 6,246.90 Orbital repositioning, periorbital osteotomies, unilateral, with bone 616 21268 21268 grafts; combined intra- and extracranial approach $ 9,558.90 617 21270 21270 Malar augmentation, prosthetic material $ 4,648.50 618 21275 21275 Secondary revision of orbitocraniofacial reconstruction $ 6,386.40 619 21280 21280 Medial canthopexy (separate procedure) $ 2,368.80 620 21282 21282 Lateral canthopexy $ 1,957.50 Reduction of masseter muscle and bone (eg, for treatment of 621 21295 21295 benign masseteric hypertrophy); extraoral approach $ 2,487.73 Reduction of masseter muscle and bone (eg, for treatment of 622 21296 21296 benign masseteric hypertrophy); intraoral approach $ 2,095.08 623 21299 21299 Unlisted craniofacial and maxillofacial procedure Cost 624 21310 21310 Closed treatment of nasal bone fracture without manipulation $ 396.90 625 21315 21315 Closed treatment of nasal bone fracture; without stabilization $ 489.60 626 21320 21320 Closed treatment of nasal bone fracture; with stabilization $ 828.90 627 21325 21325 Open treatment of nasal fracture; uncomplicated $ 1,708.20 Open treatment of nasal fracture; complicated, with internal and/or 628 21330 21330 external skeletal fixation $ 2,563.20 Open treatment of nasal fracture; with concomitant open 629 21335 21335 treatment of fractured septum $ 2,959.20 Open treatment of nasal septal fracture, with or without 630 21336 21336 stabilization $ 1,738.80 Closed treatment of nasal septal fracture, with or without 631 21337 21337 stabilization $ 1,325.70 632 21338 21338 Open treatment of nasoethmoid fracture; without external fixation $ 2,750.40 633 21339 21339 Open treatment of nasoethmoid fracture; with external fixation $ 3,019.50 Percutaneous treatment of nasoethmoid complex fracture, with splint, wire or headcap fixation, including repair of canthal 634 21340 21340 ligaments and/or the nasolacrimal apparatus $ 3,490.20 635 21343 21343 Open treatment of depressed frontal sinus fracture $ 3,550.50 Open treatment of complicated (eg, comminuted or involving posterior wall) frontal sinus fracture, via coronal or multiple 636 21344 21344 approaches $ 3,872.70 Closed treatment of nasomaxillary complex fracture (LeFort II type), 637 21345 21345 with interdental wire fixation or fixation of denture or splint $ 3,108.60 Open treatment of nasomaxillary complex fracture (LeFort II type); 638 21346 21346 with wiring and/or local fixation $ 3,837.60 Open treatment of nasomaxillary complex fracture (LeFort II type); 639 21347 21347 requiring multiple open approaches $ 4,275.00 Open treatment of nasomaxillary complex fracture (LeFort II type); 640 21348 21348 with bone grafting (includes obtaining graft) $ 3,829.50 Percutaneous treatment of fracture of malar area, including 641 21355 21355 zygomatic arch and malar tripod, with manipulation $ 2,138.40 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Open treatment of depressed zygomatic arch fracture (eg, Gillies 642 21356 21356 approach) $ 1,796.40 Open treatment of depressed malar fracture, including zygomatic 643 21360 21360 arch and malar tripod $ 2,407.50 Open treatment of complicated (eg, comminuted or involving cranial nerve foramina) fracture(s) of malar area, including zygomatic arch and malar tripod; with internal fixation and multiple 644 21365 21365 surgical approaches $ 3,566.70 Open treatment of complicated (eg, comminuted or involving cranial nerve foramina) fracture(s) of malar area, including zygomatic arch and malar tripod; with bone grafting (includes 645 21366 21366 obtaining graft) $ 3,804.30 Open treatment of orbital floor blowout fracture; transantral 646 21385 21385 approach (Caldwell-Luc type operation) $ 2,743.20 Open treatment of orbital floor blowout fracture; periorbital 647 21386 21386 approach $ 2,984.40 Open treatment of orbital floor blowout fracture; combined 648 21387 21387 approach $ 3,267.00 Open treatment of orbital floor blowout fracture; periorbital 649 21390 21390 approach, with alloplastic or other implant $ 3,502.80 Open treatment of orbital floor blowout fracture; periorbital 650 21395 21395 approach with bone graft (includes obtaining graft) $ 3,692.70 Closed treatment of fracture of orbit, except blowout; without 651 21400 21400 manipulation $ 879.30 Closed treatment of fracture of orbit, except blowout; with 652 21401 21401 manipulation $ 2,475.90 Open treatment of fracture of orbit, except blowout; without 653 21406 21406 implant $ 2,877.30 654 21407 21407 Open treatment of fracture of orbit, except blowout; with implant $ 3,400.20 Open treatment of fracture of orbit, except blowout; with bone 655 21408 21408 grafting (includes obtaining graft) $ 3,346.20 Closed treatment of palatal or maxillary fracture (LeFort I type), 656 21421 21421 with interdental wire fixation or fixation of denture or splint $ 2,632.50 657 21422 21422 Open treatment of palatal or maxillary fracture (LeFort I type); $ 3,348.90 Open treatment of palatal or maxillary fracture (LeFort I type); complicated (comminuted or involving cranial nerve foramina), 658 21423 21423 multiple approaches $ 2,865.60 Closed treatment of craniofacial separation (LeFort III type) using 659 21431 21431 interdental wire fixation of denture or splint $ 2,807.10 Open treatment of craniofacial separation (LeFort III type); with 660 21432 21432 wiring and/or internal fixation $ 3,594.60 Open treatment of craniofacial separation (LeFort III type); complicated (eg, comminuted or involving cranial nerve foramina), 661 21433 21433 multiple surgical approaches $ 5,049.90 Open treatment of craniofacial separation (LeFort III type); complicated, utilizing internal and/or external fixation techniques 662 21435 21435 (eg, head cap, halo device, and/or intermaxillary fixation) $ 4,278.60 Open treatment of craniofacial separation (LeFort III type); complicated, multiple surgical approaches, internal fixation, with 663 21436 21436 bone grafting (includes obtaining graft) $ 5,112.00 Closed treatment of mandibular or maxillary alveolar ridge fracture 664 21440 21440 (separate procedure) $ 1,808.10 Open treatment of mandibular or maxillary alveolar ridge fracture 665 21445 21445 (separate procedure) $ 2,088.00 666 21450 21450 Closed treatment of mandibular fracture; without manipulation $ 812.70 667 21451 21451 Closed treatment of mandibular fracture; with manipulation $ 2,193.30 Percutaneous treatment of mandibular fracture, with external 668 21452 21452 fixation $ 1,540.80 669 21453 21453 Closed treatment of mandibular fracture with interdental fixation $ 2,735.10 670 21454 21454 Open treatment of mandibular fracture with external fixation $ 2,820.60 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Open treatment of mandibular fracture; without interdental 671 21461 21461 fixation $ 2,774.70 672 21462 21462 Open treatment of mandibular fracture; with interdental fixation $ 3,288.60 673 21465 21465 Open treatment of mandibular condylar fracture $ 2,871.00 Open treatment of complicated mandibular fracture by multiple surgical approaches including internal fixation, interdental fixation, 674 21470 21470 and/or wiring of dentures or splints $ 4,006.80 Closed treatment of temporomandibular dislocation; initial or 675 21480 21480 subsequent $ 385.20 Closed treatment of temporomandibular dislocation; complicated (eg, recurrent requiring intermaxillary fixation or splinting), initial or 676 21485 21485 subsequent $ 903.60 677 21490 21490 Open treatment of temporomandibular dislocation $ 2,578.50 678 21495 21495 Open treatment of hyoid fracture $ 2,726.10 679 21497 21497 Interdental wiring, for condition other than fracture $ 2,046.60 680 21499 21499 Unlisted musculoskeletal procedure, head Cost Incision and drainage, deep abscess or hematoma, soft tissues of 681 21501 21501 neck or thorax; $ 779.40 Incision and drainage, deep abscess or hematoma, soft tissues of 682 21502 21502 neck or thorax; with partial rib ostectomy $ 946.80 Incision, deep, with opening of bone cortex (eg, for osteomyelitis or 683 21510 21510 bone abscess), thorax $ 1,161.90 684 21550 21550 Biopsy, soft tissue of neck or thorax $ 405.00 Excision, tumor, soft tissue of neck or anterior thorax, 685 21552 21552 subcutaneous; 3 cm or greater $ 791.93 Excision, tumor, soft tissue of neck or anterior thorax, subfascial 686 21554 21554 (eg, intramuscular); 5 cm or greater $ 1,366.14 Excision, tumor, soft tissue of neck or anterior thorax, 687 21555 21555 subcutaneous; less than 3 cm $ 632.14 Excision, tumor, soft tissue of neck or anterior thorax, subfascial 688 21556 21556 (eg, intramuscular); less than 5 cm $ 1,127.30 Radical resection of tumor (eg, sarcoma), soft tissue of neck or 689 21557 21557 anterior thorax; less than 5 cm $ 3,090.60 Radical resection of tumor (eg, sarcoma), soft tissue of neck or 690 21558 21558 anterior thorax; 5 cm or greater $ 2,439.66 691 21600 21600 Excision of rib, partial $ 1,256.40 692 21610 21610 Costotransversectomy (separate procedure) $ 3,476.70 693 21615 21615 Excision first and/or cervical rib; $ 3,032.10 694 21616 21616 Excision first and/or cervical rib; with sympathectomy $ 2,896.20 695 21620 21620 Ostectomy of sternum, partial $ 3,269.70 696 21627 21627 Sternal debridement $ 1,960.20 697 21630 21630 Radical resection of sternum; $ 3,826.80 698 21632 21632 Radical resection of sternum; with mediastinal lymphadenectomy $ 4,892.40 699 21685 21685 Hyoid myotomy and suspension $ 2,168.29 700 21700 21700 Division of scalenus anticus; without resection of cervical rib $ 1,647.90 701 21705 21705 Division of scalenus anticus; with resection of cervical rib $ 2,286.90 Division of sternocleidomastoid for torticollis, open operation; 702 21720 21720 without cast application $ 1,333.80 Division of sternocleidomastoid for torticollis, open operation; with 703 21725 21725 cast application $ 1,486.80 704 21740 21740 Reconstructive repair of pectus excavatum or carinatum; open $ 3,577.50 Reconstructive repair of pectus excavatum or carinatum; minimally 705 21742 21742 invasive approach (Nuss procedure), without thoracoscopy Reconstructive repair of pectus excavatum or carinatum; minimally 706 21743 21743 invasive approach (Nuss procedure), with thoracoscopy Closure of median sternotomy separation with or without 707 21750 21750 debridement (separate procedure) $ 2,729.70 708 21800 21800 Closed treatment of rib fracture, uncomplicated, each $ 219.60 709 21805 21805 Open treatment of rib fracture without fixation, each $ 1,426.50 710 21810 21810 Treatment of rib fracture requiring external fixation (flail chest) $ 3,409.20 711 21820 21820 Closed treatment of sternum fracture $ 456.30 Open treatment of sternum fracture with or without skeletal 712 21825 21825 fixation $ 1,791.90 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price 713 21899 21899 Unlisted procedure, neck or thorax Cost 714 21920 21920 Biopsy, soft tissue of back or flank; superficial $ 466.20 715 21925 21925 Biopsy, soft tissue of back or flank; deep $ 796.50 Excision, tumor, soft tissue of back or flank, subcutaneous; less than 716 21930 21930 3 cm $ 1,846.80 Excision, tumor, soft tissue of back or flank, subcutaneous; 3 cm or 717 21931 21931 greater $ 1,124.11 Excision, tumor, soft tissue of back or flank, subfascial (eg, 718 21932 21932 intramuscular); less than 5 cm $ 1,469.92 Excision, tumor, soft tissue of back or flank, subfascial (eg, 719 21933 21933 intramuscular); 5 cm or greater $ 1,605.17 Radical resection of tumor (eg, sarcoma), soft tissue of back or 720 21935 21935 flank; less than 5 cm $ 3,547.80 Radical resection of tumor (eg, sarcoma), soft tissue of back or 721 21936 21936 flank; 5 cm or greater $ 3,109.09 Incision and drainage, open, of deep abscess (subfascial), posterior 722 22010 22010 spine; cervical, thoracic, or cervicothoracic $ 1,829.44 Incision and drainage, open, of deep abscess (subfascial), posterior 723 22015 22015 spine; lumbar, sacral, or lumbosacral $ 1,795.54 Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony lesion, single vertebral 724 22100 22100 segment; cervical $ 1,579.50 Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony lesion, single vertebral 725 22101 22101 segment; thoracic $ 1,560.60 Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony lesion, single vertebral 726 22102 22102 segment; lumbar $ 1,827.00 Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; each additional segment (List separately in addition to 727 22103 22103 code for primary procedure) $ 421.75 Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal cord or nerve root(s), single vertebral 728 22110 22110 segment; cervical $ 2,437.20 Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal cord or nerve root(s), single vertebral 729 22112 22112 segment; thoracic $ 2,290.50 Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal cord or nerve root(s), single vertebral 730 22114 22114 segment; lumbar $ 1,809.90 Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal cord or nerve root(s), single vertebral segment; each additional vertebral segment (List separately in 731 22116 22116 addition to code for primary procedure) $ 510.03 Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment (eg, pedicle/vertebral body 732 22206 22206 subtraction); thoracic $ 8,139.79 Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment (eg, pedicle/vertebral body 733 22207 22207 subtraction); lumbar $ 7,918.14 Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment (eg, pedicle/vertebral body subtraction); each additional vertebral segment (List separately in 734 22208 22208 addition to code for primary procedure) $ 2,343.90 Osteotomy of spine, posterior or posterolateral approach, 1 735 22210 22210 vertebral segment; cervical $ 5,474.70 Osteotomy of spine, posterior or posterolateral approach, 1 736 22212 22212 vertebral segment; thoracic $ 5,826.60 Osteotomy of spine, posterior or posterolateral approach, 1 737 22214 22214 vertebral segment; lumbar $ 5,076.00 Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; each additional vertebral segment (List 738 22216 22216 separately in addition to primary procedure) $ 1,650.31 Osteotomy of spine, including discectomy, anterior approach, single 739 22220 22220 vertebral segment; cervical $ 5,062.50 Osteotomy of spine, including discectomy, anterior approach, single 740 22222 22222 vertebral segment; thoracic $ 4,892.40 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Osteotomy of spine, including discectomy, anterior approach, single 741 22224 22224 vertebral segment; lumbar $ 4,738.50 Osteotomy of spine, including discectomy, anterior approach, single vertebral segment;

each additional vertebral segment (List 742 22226 22226 separately in addition to code for primary procedure) $ 1,576.45 743 22305 22305 Closed treatment of vertebral process fracture(s) $ 646.20 Closed treatment of vertebral body fracture(s), without 744 22310 22310 manipulation, requiring and including casting or bracing $ 1,089.00 Closed treatment of vertebral fracture(s) and/or dislocation(s) requiring casting or bracing, with and including casting and/or 745 22315 22315 bracing by manipulation or traction $ 1,676.70 Open treatment and/or reduction of odontoid fracture(s) and or dislocation(s) (including os odontoideum), anterior approach, 746 22318 22318 including placement of internal fixation; without grafting $ 4,835.70 Open treatment and/or reduction of odontoid fracture(s) and or dislocation(s) (including os odontoideum), anterior approach, 747 22319 22319 including placement of internal fixation; with grafting $ 5,462.10 Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, 1 fractured vertebra or 748 22325 22325 dislocated segment; lumbar $ 3,702.60 Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, 1 fractured vertebra or 749 22326 22326 dislocated segment; cervical $ 4,303.80 Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, 1 fractured vertebra or 750 22327 22327 dislocated segment; thoracic $ 3,861.00 Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, 1 fractured vertebra or dislocated segment; each additional fractured vertebra or dislocated segment (List separately in addition to code for primary 751 22328 22328 proce $ 1,339.20 752 22505 22505 Manipulation of spine requiring anesthesia, any region $ 594.00 Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection; 753 22520 22520 thoracic $ 10,247.30 Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection; 754 22521 22521 lumbar $ 4,183.34 Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection; each additional thoracic or lumbar vertebral body (List separately in 755 22522 22522 addition to code for primary procedure) $ 499.51 Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device, 1 vertebral body, unilateral or bilateral 756 22523 cannulation (eg, kyphoplasty); thoracic $ 1,477.34 Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device, 1 vertebral body, unilateral or bilateral 757 22524 22524 cannulation (eg, kyphoplasty); lumbar $ 1,382.74 Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device, 1 vertebral body, unilateral or bilateral 758 22525 22525 cannulation (eg, kyphoplasty); each additional thoracic or lumba $ 716.85 Percutaneous intradiscal electrothermal annuloplasty, unilateral or 759 22526 22526 bilateral including fluoroscopic guidance; single level $ 3,625.48 Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; 1 or more additional levels 760 22527 22527 (List separately in addition to code for primary procedure) $ 2,933.60 Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); 761 22532 22532 thoracic $ 7,248.19 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); 762 22533 22533 lumbar $ 6,841.56 Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic or lumbar, each additional vertebral segment (List 763 22534 22534 separately in addition to code for primary procedure) $ 1,793.42 Arthrodesis, anterior transoral or extraoral technique, clivus-C1-C2 764 22548 22548 (atlas-axis), with or without excision of odontoid process $ 4,671.90 Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); 765 22554 22554 cervical below C2 $ 5,047.20 Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); 766 22556 22556 thoracic $ 5,232.60 Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); 767 22558 22558 lumbar $ 4,895.10 Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); each additional interspace (List separately in addition to code for 768 22585 22585 primary procedure) $ 2,109.60 769 22590 22590 Arthrodesis, posterior technique, craniocervical (occiput-C2) $ 6,695.10 770 22595 22595 Arthrodesis, posterior technique, atlas-axis (C1-C2) $ 5,839.20 Arthrodesis, posterior or posterolateral technique, single level; 771 22600 22600 cervical below C2 segment $ 4,428.90 Arthrodesis, posterior or posterolateral technique, single level; 772 22610 22610 thoracic (with lateral transverse technique, when performed) $ 4,143.60 Arthrodesis, posterior or posterolateral technique, single level; 773 22612 22612 lumbar (with lateral transverse technique, when performed) $ 4,961.70 Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment (List separately in addition to code for 774 22614 22614 primary procedure) $ 1,858.50 Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for 775 22630 22630 decompression), single interspace; lumbar $ 4,412.70 Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; each additional interspace (List 776 22632 22632 separately in addition to code for primary procedure) $ 1,555.20 Arthrodesis, posterior, for spinal deformity, with or without cast; up 777 22800 22800 to 6 vertebral segments $ 4,953.60 Arthrodesis, posterior, for spinal deformity, with or without cast; 7 778 22802 22802 to 12 vertebral segments $ 6,030.00 Arthrodesis, posterior, for spinal deformity, with or without cast; 13 779 22804 22804 or more vertebral segments $ 6,646.50 Arthrodesis, anterior, for spinal deformity, with or without cast; 2 to 780 22808 22808 3 vertebral segments $ 4,555.80 Arthrodesis, anterior, for spinal deformity, with or without cast; 4 to 781 22810 22810 7 vertebral segments $ 4,892.40 Arthrodesis, anterior, for spinal deformity, with or without cast; 8 or 782 22812 22812 more vertebral segments $ 5,985.90 Kyphectomy, circumferential exposure of spine and resection of vertebral segment(s) (including body and posterior elements); 783 22818 22818 single or 2 segments $ 6,687.90 Kyphectomy, circumferential exposure of spine and resection of vertebral segment(s) (including body and posterior elements); 3 or 784 22819 22819 more segments $ 7,163.10 785 22830 22830 Exploration of spinal fusion $ 4,411.80 Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across 1 interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw 786 22840 22840 fixation) (List separately in addition to code for primary proced $ 5,926.50 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Internal spinal fixation by wiring of spinous processes (List 787 22841 22841 separately in addition to code for primary procedure) $ 3,862.80 Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 vertebral 788 22842 22842 segments (List separately in addition to code for primary procedure) $ 6,488.10 Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 7 to 12 vertebral 789 22843 22843 segments (List separately in addition to code for primary procedure) $ 2,050.20 Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 13 or more vertebral 790 22844 22844 segments (List separately in addition to code for primary procedure) $ 2,503.80 Anterior instrumentation; 2 to 3 vertebral segments (List separately 791 22845 22845 in addition to code for primary procedure) $ 6,088.50 Anterior instrumentation; 4 to 7 vertebral segments (List separately 792 22846 22846 in addition to code for primary procedure) $ 6,129.00 Anterior instrumentation; 8 or more vertebral segments (List 793 22847 22847 separately in addition to code for primary procedure) $ 4,006.54 Pelvic fixation (attachment of caudal end of instrumentation to pelvic bony structures) other than sacrum (List separately in 794 22848 22848 addition to code for primary procedure) $ 1,716.14 795 22849 22849 Reinsertion of spinal fixation device $ 3,637.80 Removal of posterior nonsegmental instrumentation (eg, 796 22850 22850 Harrington rod) $ 2,196.90 Application of intervertebral biomechanical device(s) (eg, synthetic cage(s), methylmethacrylate) to vertebral defect or interspace (List 797 22851 22851 separately in addition to code for primary procedure) $ 2,188.80 798 22852 22852 Removal of posterior segmental instrumentation $ 2,578.50 799 22855 22855 Removal of anterior instrumentation $ 3,174.30 Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection), 800 22856 22856 single interspace, cervical $ 7,409.11 Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), 801 22857 22857 single interspace, lumbar $ 7,481.77 Revision including replacement of total disc arthroplasty (artificial 802 22861 22861 disc), anterior approach, single interspace; cervical $ 9,122.80 Revision including replacement of total disc arthroplasty (artificial 803 22862 22862 disc), anterior approach, single interspace; lumbar $ 8,973.95 Removal of total disc arthroplasty (artificial disc), anterior approach, 804 22864 22864 single interspace; cervical $ 8,487.18 Removal of total disc arthroplasty (artificial disc), anterior approach, 805 22865 22865 single interspace; lumbar $ 9,570.92 806 22899 22899 Unlisted procedure, spine $ 1,613.81 Excision, tumor, soft tissue of abdominal wall, subfascial (eg, 807 22900 22900 intramuscular); less than 5 cm $ 1,592.10 Excision, tumor, soft tissue of abdominal wall, subfascial (eg, 808 22901 22901 intramuscular); 5 cm or greater $ 1,370.05 Excision, tumor, soft tissue of abdominal wall, subcutaneous; less 809 22902 22902 than 3 cm $ 861.30 Excision, tumor, soft tissue of abdominal wall, subcutaneous; 3 cm 810 22903 22903 or greater $ 901.22 Radical resection of tumor (eg, sarcoma), soft tissue of abdominal 811 22904 22904 wall; less than 5 cm $ 2,178.75 Radical resection of tumor (eg, sarcoma), soft tissue of abdominal 812 22905 22905 wall; 5 cm or greater $ 2,821.24 813 22999 22999 Unlisted procedure, abdomen, musculoskeletal system Cost 814 23000 23000 Removal of subdeltoid calcareous deposits, open $ 1,048.50 815 23020 23020 Capsular contracture release (eg, Sever type procedure) $ 1,676.70 816 23030 23030 Incision and drainage, shoulder area; deep abscess or hematoma $ 643.50 817 23031 23031 Incision and drainage, shoulder area; infected bursa $ 513.00 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Incision, bone cortex (eg, osteomyelitis or bone abscess), shoulder 818 23035 23035 area $ 1,620.00 Arthrotomy, glenohumeral joint, including exploration, drainage, or 819 23040 23040 removal of foreign body $ 1,976.40 Arthrotomy, acromioclavicular, sternoclavicular joint, including 820 23044 23044 exploration, drainage, or removal of foreign body $ 1,288.80 821 23065 23065 Biopsy, soft tissue of shoulder area; superficial $ 429.30 822 23066 23066 Biopsy, soft tissue of shoulder area; deep $ 772.20 Excision, tumor, soft tissue of shoulder area, subfascial (eg, 823 23073 23073 intramuscular); 5 cm or greater $ 1,601.52 Excision, tumor, soft tissue of shoulder area, subcutaneous; less 824 23075 23075 than 3 cm $ 690.30 Excision, tumor, soft tissue of shoulder area, subfascial (eg, 825 23076 23076 intramuscular); less than 5 cm $ 972.00 Radical resection of tumor (eg, sarcoma), soft tissue of shoulder 826 23077 23077 area; less than 5 cm $ 3,457.80 827 23100 23100 Arthrotomy, glenohumeral joint, including biopsy $ 1,900.80 Arthrotomy, acromioclavicular joint or sternoclavicular joint, 828 23101 23101 including biopsy and/or excision of torn cartilage $ 1,510.20 Arthrotomy; glenohumeral joint, with synovectomy, with or without 829 23105 23105 biopsy $ 2,547.90 Arthrotomy; sternoclavicular joint, with synovectomy, with or 830 23106 23106 without biopsy $ 1,841.40 Arthrotomy, glenohumeral joint, with joint exploration, with or 831 23107 23107 without removal of loose or foreign body $ 2,521.80 832 23120 23120 Claviculectomy; partial $ 1,359.90 833 23125 23125 Claviculectomy; total $ 2,212.20 Acromioplasty or acromionectomy, partial, with or without 834 23130 23130 coracoacromial ligament release $ 1,876.50 Excision or curettage of bone cyst or benign tumor of clavicle or 835 23140 23140 scapula; $ 1,152.90 Excision or curettage of bone cyst or benign tumor of clavicle or 836 23145 23145 scapula; with autograft (includes obtaining graft) $ 1,894.50 Excision or curettage of bone cyst or benign tumor of clavicle or 837 23146 23146 scapula; with allograft $ 1,276.20 Excision or curettage of bone cyst or benign tumor of proximal 838 23150 23150 humerus; $ 1,902.60 Excision or curettage of bone cyst or benign tumor of proximal 839 23155 23155 humerus; with autograft (includes obtaining graft) $ 2,513.70 Excision or curettage of bone cyst or benign tumor of proximal 840 23156 23156 humerus; with allograft $ 2,136.60 841 23170 23170 Sequestrectomy (eg, for osteomyelitis or bone abscess), clavicle $ 1,133.10 842 23172 23172 Sequestrectomy (eg, for osteomyelitis or bone abscess), scapula $ 1,035.00 Sequestrectomy (eg, for osteomyelitis or bone abscess), humeral 843 23174 23174 head to surgical neck $ 2,029.50 Partial excision (craterization, saucerization, or diaphysectomy) 844 23180 23180 bone (eg, osteomyelitis), clavicle $ 1,142.10 Partial excision (craterization, saucerization, or diaphysectomy) 845 23182 23182 bone (eg, osteomyelitis), scapula $ 1,146.60 Partial excision (craterization, saucerization, or diaphysectomy) 846 23184 23184 bone (eg, osteomyelitis), proximal humerus $ 1,805.40 847 23190 23190 Ostectomy of scapula, partial (eg, superior medial angle) $ 1,415.70 848 23195 23195 Resection, humeral head $ 2,023.20 849 23200 23200 Radical resection of tumor; clavicle $ 1,987.20 850 23210 23210 Radical resection of tumor; scapula $ 2,709.00 851 23220 23220 Radical resection of tumor, proximal humerus $ 2,718.90 852 23330 23330 Removal of foreign body, shoulder; subcutaneous $ 747.00 Removal of foreign body, shoulder; deep (subfascial or 853 23333 23333 intramuscular) $640.91 Injection procedure for shoulder arthrography or enhanced CT/MRI 854 23350 23350 shoulder arthrography $ 177.30 855 23395 23395 Muscle transfer, any type, shoulder or upper arm; single $ 2,472.30 856 23397 23397 Muscle transfer, any type, shoulder or upper arm; multiple $ 2,657.70 857 23400 23400 Scapulopexy (eg, Sprengels deformity or for paralysis) $ 2,549.70 858 23405 23405 Tenotomy, shoulder area; single tendon $ 1,497.60 859 23406 23406 Tenotomy, shoulder area; multiple tendons through same incision $ 2,154.60 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; 860 23410 23410 acute $ 2,492.10 Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; 861 23412 23412 chronic $ 3,027.60 862 23415 23415 Coracoacromial ligament release, with or without acromioplasty $ 1,882.80 Reconstruction of complete shoulder (rotator) cuff avulsion, chronic 863 23420 23420 (includes acromioplasty) $ 3,345.30 864 23430 23430 Tenodesis of long tendon of biceps $ 1,865.70 865 23440 23440 Resection or transplantation of long tendon of biceps $ 1,823.40 Capsulorrhaphy, anterior; Putti-Platt procedure or Magnuson type 866 23450 23450 operation $ 3,331.80 867 23455 23455 Capsulorrhaphy, anterior; with labral repair (eg, Bankart procedure) $ 3,392.10 868 23460 23460 Capsulorrhaphy, anterior, any type; with bone block $ 3,116.70 869 23462 23462 Capsulorrhaphy, anterior, any type; with coracoid process transfer $ 3,337.20 Capsulorrhaphy, glenohumeral joint, posterior, with or without 870 23465 23465 bone block $ 2,945.70 Capsulorrhaphy, glenohumeral joint, any type multi-directional 871 23466 23466 instability $ 3,508.20 872 23470 23470 Arthroplasty, glenohumeral joint; hemiarthroplasty $ 3,598.20 Arthroplasty, glenohumeral joint; total shoulder (glenoid and 873 23472 23472 proximal humeral replacement (eg, total shoulder)) $ 5,374.80 874 23480 23480 Osteotomy, clavicle, with or without internal fixation; $ 1,863.00 Osteotomy, clavicle, with or without internal fixation; with bone graft for nonunion or malunion (includes obtaining graft and/or 875 23485 23485 necessary fixation) $ 2,413.80 Prophylactic treatment (nailing, pinning, plating or wiring) with or 876 23490 23490 without methylmethacrylate; clavicle $ 2,123.10 Prophylactic treatment (nailing, pinning, plating or wiring) with or 877 23491 23491 without methylmethacrylate; proximal humerus $ 2,097.00 878 23500 23500 Closed treatment of clavicular fracture; without manipulation $ 342.90 879 23505 23505 Closed treatment of clavicular fracture; with manipulation $ 586.80 Open treatment of clavicular fracture, includes internal fixation, 880 23515 23515 when performed $ 1,595.70 Closed treatment of sternoclavicular dislocation; without 881 23520 23520 manipulation $ 387.90 882 23525 23525 Closed treatment of sternoclavicular dislocation; with manipulation $ 556.20 883 23530 23530 Open treatment of sternoclavicular dislocation, acute or chronic; $ 1,455.30 Open treatment of sternoclavicular dislocation, acute or chronic; 884 23532 23532 with fascial graft (includes obtaining graft) $ 1,701.90 Closed treatment of acromioclavicular dislocation; without 885 23540 23540 manipulation $ 418.50 Closed treatment of acromioclavicular dislocation; with 886 23545 23545 manipulation $ 565.20 887 23550 23550 Open treatment of acromioclavicular dislocation, acute or chronic; $ 1,890.00 Open treatment of acromioclavicular dislocation, acute or chronic; 888 23552 23552 with fascial graft (includes obtaining graft) $ 2,283.30 889 23570 23570 Closed treatment of scapular fracture; without manipulation $ 372.60 Closed treatment of scapular fracture; with manipulation, with or without skeletal traction (with or without shoulder joint 890 23575 23575 involvement) $ 533.70 Open treatment of scapular fracture (body, glenoid or acromion) 891 23585 23585 includes internal fixation, when performed $ 2,152.80 Closed treatment of proximal humeral (surgical or anatomical neck) 892 23600 23600 fracture; without manipulation $ 537.30 Closed treatment of proximal humeral (surgical or anatomical neck) 893 23605 23605 fracture; with manipulation, with or without skeletal traction $ 871.20 Open treatment of proximal humeral (surgical or anatomical neck) fracture, includes internal fixation, when performed, includes repair 894 23615 23615 of tuberosity(s), when performed; $ 2,034.00 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Open treatment of proximal humeral (surgical or anatomical neck) fracture, includes internal fixation, when performed, includes repair of tuberosity(s), when performed; with proximal humeral prosthetic 895 23616 23616 replacement $ 3,965.40 Closed treatment of greater humeral tuberosity fracture; without 896 23620 23620 manipulation $ 471.60 Closed treatment of greater humeral tuberosity fracture; with 897 23625 23625 manipulation $ 744.30 Open treatment of greater humeral tuberosity fracture, includes 898 23630 23630 internal fixation, when performed $ 1,616.40 Closed treatment of shoulder dislocation, with manipulation; 899 23650 23650 without anesthesia $ 457.20 Closed treatment of shoulder dislocation, with manipulation; 900 23655 23655 requiring anesthesia $ 669.60 901 23660 23660 Open treatment of acute shoulder dislocation $ 1,996.20 Closed treatment of shoulder dislocation, with fracture of greater 902 23665 23665 humeral tuberosity, with manipulation $ 749.70 Open treatment of shoulder dislocation, with fracture of greater 903 23670 23670 humeral tuberosity, includes internal fixation, when performed $ 1,975.50 Closed treatment of shoulder dislocation, with surgical or 904 23675 23675 anatomical neck fracture, with manipulation $ 888.30 Open treatment of shoulder dislocation, with surgical or anatomical 905 23680 23680 neck fracture, includes internal fixation, when performed $ 2,415.60 Manipulation under anesthesia, shoulder joint, including application 906 23700 23700 of fixation apparatus (dislocation excluded) $ 625.50 907 23800 23800 Arthrodesis, glenohumeral joint; $ 3,604.50 Arthrodesis, glenohumeral joint; with autogenous graft (includes 908 23802 23802 obtaining graft) $ 3,445.20 909 23900 23900 Interthoracoscapular amputation (forequarter) $ 4,063.50 910 23920 23920 Disarticulation of shoulder; $ 3,162.60 911 23921 23921 Disarticulation of shoulder; secondary closure or scar revision $ 909.90 912 23929 23929 Unlisted procedure, shoulder Cost Incision and drainage, upper arm or elbow area; deep abscess or 913 23930 23930 hematoma $ 819.90 914 23931 23931 Incision and drainage, upper arm or elbow area; bursa $ 675.90 Incision, deep, with opening of bone cortex (eg, for osteomyelitis or 915 23935 23935 bone abscess), humerus or elbow $ 1,374.30 Arthrotomy, elbow, including exploration, drainage, or removal of 916 24000 24000 foreign body $ 1,805.40 Arthrotomy of the elbow, with capsular excision for capsular release 917 24006 24006 (separate procedure) $ 1,784.70 918 24065 24065 Biopsy, soft tissue of upper arm or elbow area; superficial $ 385.20 Biopsy, soft tissue of upper arm or elbow area; deep (subfascial or 919 24066 24066 intramuscular) $ 707.89 Excision, tumor, soft tissue of upper arm or elbow area, 920 24071 24071 subcutaneous; 3 cm or greater $ 972.78 Excision, tumor, soft tissue of upper arm or elbow area, subfascial 921 24073 24073 (eg, intramuscular); 5 cm or greater $ 1,396.93 Excision, tumor, soft tissue of upper arm or elbow area, 922 24075 24075 subcutaneous; less than 3 cm $ 686.70 Excision, tumor, soft tissue of upper arm or elbow area, subfascial 923 24076 24076 (eg, intramuscular); less than 5 cm $ 1,179.00 Radical resection of tumor (eg, sarcoma), soft tissue of upper arm or 924 24077 24077 elbow area; less than 5 cm $ 2,430.90 Radical resection of tumor (eg, sarcoma), soft tissue of upper arm or 925 24079 24079 elbow area; 5 cm or greater $ 2,604.12 926 24100 24100 Arthrotomy, elbow; with synovial biopsy only $ 1,082.70 Arthrotomy, elbow; with joint exploration, with or without biopsy, 927 24101 24101 with or without removal of loose or foreign body $ 1,861.20 928 24102 24102 Arthrotomy, elbow; with synovectomy $ 2,224.80 929 24105 24105 Excision, olecranon bursa $ 898.20 930 24110 24110 Excision or curettage of bone cyst or benign tumor, humerus; $ 1,581.30 Excision or curettage of bone cyst or benign tumor, humerus; with 931 24115 24115 autograft (includes obtaining graft) $ 1,887.30 Excision or curettage of bone cyst or benign tumor, humerus; with 932 24116 24116 allograft $ 1,841.40 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Excision or curettage of bone cyst or benign tumor of head or neck 933 24120 24120 of radius or olecranon process; $ 1,485.00 Excision or curettage of bone cyst or benign tumor of head or neck of radius or olecranon process; with autograft (includes obtaining 934 24125 24125 graft) $ 1,740.60 Excision or curettage of bone cyst or benign tumor of head or neck 935 24126 24126 of radius or olecranon process; with allograft $ 1,524.60 936 24130 24130 Excision, radial head $ 1,459.80 Sequestrectomy (eg, for osteomyelitis or bone abscess), shaft or 937 24134 24134 distal humerus $ 1,854.00 Sequestrectomy (eg, for osteomyelitis or bone abscess), radial head 938 24136 24136 or neck $ 1,654.20 Sequestrectomy (eg, for osteomyelitis or bone abscess), olecranon 939 24138 24138 process $ 1,622.70 Partial excision (craterization, saucerization, or diaphysectomy) 940 24140 24140 bone (eg, osteomyelitis), humerus $ 2,168.10 Partial excision (craterization, saucerization, or diaphysectomy) 941 24145 24145 bone (eg, osteomyelitis), radial head or neck $ 1,442.70 Partial excision (craterization, saucerization, or diaphysectomy) 942 24147 24147 bone (eg, osteomyelitis), olecranon process $ 1,296.00 Radical resection of capsule, soft tissue, and heterotopic bone, 943 24149 24149 elbow, with contracture release (separate procedure) $ 2,652.30 944 24150 24150 Radical resection of tumor, shaft or distal humerus $ 2,443.50 945 24152 24152 Radical resection of tumor, radial head or neck $ 2,158.20 946 24155 24155 Resection of elbow joint (arthrectomy) $ 2,199.60 Removal of prosthesis, includes debridement and synovectomy 947 24160 24160 when performed; humeral and ulnar components $ 1,489.50 Removal of prosthesis, includes debridement and synovectomy 948 24164 24164 when performed; radial head $ 1,359.90 949 24200 24200 Removal of foreign body, upper arm or elbow area; subcutaneous $ 368.10 Removal of foreign body, upper arm or elbow area; deep (subfascial 950 24201 24201 or intramuscular) $ 962.10 951 24220 24220 Injection procedure for elbow arthrography $ 177.30 952 24300 24300 Manipulation, elbow, under anesthesia $ 777.16 Muscle or tendon transfer, any type, upper arm or elbow, single 953 24301 24301 (excluding 24320-24331) $ 1,998.00 954 24305 24305 Tendon lengthening, upper arm or elbow, each tendon $ 900.90 955 24310 24310 Tenotomy, open, elbow to shoulder, each tendon $ 955.80 Tenoplasty, with muscle transfer, with or without free graft, elbow 956 24320 24320 to shoulder, single (Seddon-Brookes type procedure) $ 2,311.20 957 24330 24330 Flexor-plasty, elbow (eg, Steindler type advancement); $ 2,269.80 Flexor-plasty, elbow (eg, Steindler type advancement); with 958 24331 24331 extensor advancement $ 2,086.20 959 24332 24332 Tenolysis, triceps $ 1,181.38 960 24340 24340 Tenodesis of biceps tendon at elbow (separate procedure) $ 1,922.40 Repair, tendon or muscle, upper arm or elbow, each tendon or 961 24341 24341 muscle, primary or secondary (excludes rotator cuff) $ 1,816.20 Reinsertion of ruptured biceps or triceps tendon, distal, with or 962 24342 24342 without tendon graft $ 2,416.50 963 24343 24343 Repair lateral collateral ligament, elbow, with local tissue $ 1,858.95 Reconstruction lateral collateral ligament, elbow, with tendon graft 964 24344 24344 (includes harvesting of graft) $ 2,485.31 965 24345 24345 Repair medial collateral ligament, elbow, with local tissue $ 1,857.96 Tenotomy, elbow, lateral or medial (eg, epicondylitis, tennis elbow, 966 24357 24357 golfer's elbow); percutaneous $ 1,115.21 Tenotomy, elbow, lateral or medial (eg, epicondylitis, tennis elbow, 967 24358 24358 golfer's elbow); debridement, soft tissue and/or bone, open $ 1,270.13 Tenotomy, elbow, lateral or medial (eg, epicondylitis, tennis elbow, golfer's elbow); debridement, soft tissue and/or bone, open with 968 24359 24359 tendon repair or reattachment $ 1,520.03 969 24360 24360 Arthroplasty, elbow; with membrane (eg, fascial) $ 3,267.00 970 24361 24361 Arthroplasty, elbow; with distal humeral prosthetic replacement $ 2,970.00 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifier CPT-4 HCPCS CPT/HCPCS Long Description Price Arthroplasty, elbow; with implant and fascia lata ligament 971 24362 24362 reconstruction $ 3,446.10 Arthroplasty, elbow; with distal humerus and proximal ulnar 972 24363 24363 prosthetic replacement (eg, total elbow) $ 4,614.30 973 24365 24365 Arthroplasty, radial head; $ 1,601.10 974 24366 24366 Arthroplasty, radial head; with implant $ 2,054.70 975 24400 24400 Osteotomy, humerus, with or without internal fixation $ 2,451.60 Multiple osteotomies with realignment on intramedullary rod, 976 24410 24410 humeral shaft (Sofield type procedure) $ 2,646.90 Osteoplasty, humerus (eg, shortening or lengthening) (excluding 977 24420 24420 64876) $ 2,397.60 Repair of nonunion or malunion, humerus; without graft (eg, 978 24430 24430 compression technique) $ 2,629.80 Repair of nonunion or malunion, humerus; with iliac or other 979 24435 24435 autograft (includes obtaining graft) $ 3,298.50 980 24470 24470 Hemiepiphyseal arrest (eg, cubitus varus or valgus, distal humerus) $ 1,476.00 Decompression fasciotomy, forearm, with brachial artery 981 24495 24495 exploration $ 2,070.00 Prophylactic treatment (nailing, pinning, plating or wiring), with or 982 24498 24498 without methylmethacrylate, humeral shaft $ 1,984.50 983 24500 24500 Closed treatment of humeral shaft fracture; without manipulation $ 503.10 Closed treatment of humeral shaft fracture; with manipulation, with 984 24505 24505 or without skeletal traction $ 1,046.70 Open treatment of humeral shaft fracture with plate/screws, with 985 24515 24515 or without cerclage $ 2,314.80 Treatment of humeral shaft fracture, with insertion of intramedullary implant, with or without cerclage and/or locking 986 24516 24516 screws $ 2,646.90 Closed treatment of supracondylar or transcondylar humeral fracture, with or without intercondylar extension; without 987 24530 24530 manipulation $ 612.20 Closed treatment of supracondylar or transcondylar humeral fracture, with or without intercondylar extension; with 988 24535 24535 manipulation, with or without skin or skeletal traction $ 1,064.70 Percutaneous skeletal fixation of supracondylar or transcondylar 989 24538 24538 humeral fracture, with or without intercondylar extension $ 1,833.30 Open treatment of humeral supracondylar or transcondylar fracture, includes internal fixation, when performed; without 990 24545 24545 intercondylar extension $ 2,343.60 Open treatment of humeral supracondylar or transcondylar fracture, includes internal fixation, when performed; with 991 24546 24546 intercondylar extension $ 2,875.50 Closed treatment of humeral epicondylar fracture, medial or lateral; 992 24560 24560 without manipulation $ 535.50 Closed treatment of humeral epicondylar fracture, medial or lateral; 993 24565 24565 with manipulation $ 788.40 Percutaneous skeletal fixation of humeral epicondylar fracture, 994 24566 24566 medial or lateral, with manipulation $ 1,277.10 Open treatment of humeral epicondylar fracture, medial or lateral, 995 24575 24575 includes internal fixation, when performed $ 1,759.50 Closed treatment of humeral condylar fracture, medial or lateral; 996 24576 24576 without manipulation $ 549.90 Closed treatment of humeral condylar fracture, medial or lateral; 997 24577 24577 with manipulation $ 991.80 Open treatment of humeral condylar fracture, medial or lateral, 998 24579 24579 includes internal fixation, when performed $ 1,859.40 Percutaneous skeletal fixation of humeral condylar fracture, medial 999 24582 24582 or lateral, with manipulation $ 1,494.00 Open treatment of periarticular fracture and/or dislocation of the elbow (fracture distal humerus and proximal ulna and/or proximal 1000 24586 24586 radius); $ 2,680.20 Open treatment of periarticular fracture and/or dislocation of the elbow (fracture distal humerus and proximal ulna and/or proximal 1001 24587 24587 radius); with implant arthroplasty $ 3,429.00 1002 24600 24600 Treatment of closed elbow dislocation; without anesthesia $ 462.60 1003 24605 24605 Treatment of closed elbow dislocation; requiring anesthesia $ 753.30 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price 1004 24615 24615 Open treatment of acute or chronic elbow dislocation $ 1,831.50 Closed treatment of Monteggia type of fracture dislocation at elbow (fracture proximal end of ulna with dislocation of radial 1005 24620 24620 head), with manipulation $ 952.20 Open treatment of Monteggia type of fracture dislocation at elbow (fracture proximal end of ulna with dislocation of radial head), 1006 24635 24635 includes internal fixation, when performed $ 2,043.00 Closed treatment of radial head subluxation in child, nursemaid 1007 24640 24640 elbow, with manipulation $ 280.80 Closed treatment of radial head or neck fracture; without 1008 24650 24650 manipulation $ 413.10 1009 24655 24655 Closed treatment of radial head or neck fracture; with manipulation $ 778.50 Open treatment of radial head or neck fracture, includes internal 1010 24665 24665 fixation or radial head excision, when performed; $ 1,544.40 Open treatment of radial head or neck fracture, includes internal fixation or radial head excision, when performed; with radial head 1011 24666 24666 prosthetic replacement $ 1,931.40 Closed treatment of ulnar fracture, proximal end (eg, olecranon or 1012 24670 24670 coronoid process[es]); without manipulation $ 478.80 Closed treatment of ulnar fracture, proximal end (eg, olecranon or 1013 24675 24675 coronoid process[es]); with manipulation $ 801.00 Open treatment of ulnar fracture, proximal end (eg, olecranon or 1014 24685 24685 coronoid process[es]), includes internal fixation, when performed $ 1,825.20 1015 24800 24800 Arthrodesis, elbow joint; local $ 2,271.60 Arthrodesis, elbow joint; with autogenous graft (includes obtaining 1016 24802 24802 graft) $ 2,788.20 1017 24900 24900 Amputation, arm through humerus; with primary closure $ 1,834.20 1018 24920 24920 Amputation, arm through humerus; open, circular (guillotine) $ 1,599.30 Amputation, arm through humerus; secondary closure or scar 1019 24925 24925 revision $ 774.90 1020 24930 24930 Amputation, arm through humerus; re-amputation $ 1,470.60 1021 24931 24931 Amputation, arm through humerus; with implant $ 1,900.80 1022 24935 24935 Stump elongation, upper extremity $ 2,499.30 1023 24940 24940 Cineplasty, upper extremity, complete procedure $ 2,632.50 1024 24999 24999 Unlisted procedure, humerus or elbow Cost 1025 25000 25000 Incision, extensor tendon sheath, wrist (eg, deQuervains disease) $ 1,080.90 1026 25001 25001 Incision, flexor tendon sheath, wrist (eg, flexor carpi radialis) $ 963.51 Decompression fasciotomy, forearm and/or wrist, flexor OR extensor compartment; without debridement of nonviable muscle 1027 25020 25020 and/or nerve $ 1,390.50 Decompression fasciotomy, forearm and/or wrist, flexor OR extensor compartment; with debridement of nonviable muscle 1028 25023 25023 and/or nerve $ 1,751.40 Decompression fasciotomy, forearm and/or wrist, flexor AND extensor compartment; without debridement of nonviable muscle 1029 25024 25024 and/or nerve $ 1,555.24 Decompression fasciotomy, forearm and/or wrist, flexor AND extensor compartment; with debridement of nonviable muscle 1030 25025 25025 and/or nerve $ 2,070.11 Incision and drainage, forearm and/or wrist; deep abscess or 1031 25028 25028 hematoma $ 981.00 1032 25031 25031 Incision and drainage, forearm and/or wrist; bursa $ 586.80 Incision, deep, bone cortex, forearm and/or wrist (eg, osteomyelitis 1033 25035 25035 or bone abscess) $ 1,416.60 Arthrotomy, radiocarpal or midcarpal joint, with exploration, 1034 25040 25040 drainage, or removal of foreign body $ 1,479.60 1035 25065 25065 Biopsy, soft tissue of forearm and/or wrist; superficial $ 434.70 Biopsy, soft tissue of forearm and/or wrist; deep (subfascial or 1036 25066 25066 intramuscular) $ 710.10 Excision, tumor, soft tissue of forearm and/or wrist area, subfascial 1037 25073 25073 (eg, intramuscular); 3 cm or greater $ 1,806.54 Excision, tumor, soft tissue of forearm and/or wrist area, 1038 25075 25075 subcutaneous; less than 3 cm $ 650.70 Excision, tumor, soft tissue of forearm and/or wrist area, subfascial 1039 25076 25076 (eg, intramuscular); less than 3 cm $ 1,148.40 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Radical resection of tumor (eg, sarcoma), soft tissue of forearm 1040 25077 25077 and/or wrist area; less than 3 cm $ 2,590.20 1041 25085 25085 Capsulotomy, wrist (eg, contracture) $ 1,601.10 1042 25100 25100 Arthrotomy, wrist joint; with biopsy $ 1,330.20 Arthrotomy, wrist joint; with joint exploration, with or without 1043 25101 25101 biopsy, with or without removal of loose or foreign body $ 1,323.00 1044 25105 25105 Arthrotomy, wrist joint; with synovectomy $ 1,722.60 Arthrotomy, distal radioulnar joint including repair of triangular 1045 25107 25107 cartilage, complex $ 1,453.50 1046 25109 25109 Excision of tendon, forearm and/or wrist, flexor or extensor, each $ 1,481.65 1047 25110 25110 Excision, lesion of tendon sheath, forearm and/or wrist $ 801.00 1048 25111 25111 Excision of ganglion, wrist (dorsal or volar); primary $ 943.10 1049 25112 25112 Excision of ganglion, wrist (dorsal or volar); recurrent $ 1,357.20 Radical excision of bursa, synovia of wrist, or forearm tendon sheaths (eg, tenosynovitis, fungus, Tbc, or other granulomas, 1050 25115 25115 rheumatoid arthritis); flexors $ 2,098.80 Radical excision of bursa, synovia of wrist, or forearm tendon sheaths (eg, tenosynovitis, fungus, Tbc, or other granulomas, rheumatoid arthritis); extensors, with or without transposition of 1051 25116 25116 dorsal retinaculum $ 2,058.30 1052 25118 25118 Synovectomy, extensor tendon sheath, wrist, single compartment; $ 1,926.00 Synovectomy, extensor tendon sheath, wrist, single compartment; 1053 25119 25119 with resection of distal ulna $ 1,556.10 Excision or curettage of bone cyst or benign tumor of radius or ulna 1054 25120 25120 (excluding head or neck of radius and olecranon process); $ 1,530.90 Excision or curettage of bone cyst or benign tumor of radius or ulna (excluding head or neck of radius and olecranon process); with 1055 25125 25125 autograft (includes obtaining graft) $ 1,812.60 Excision or curettage of bone cyst or benign tumor of radius or ulna (excluding head or neck of radius and olecranon process); with 1056 25126 25126 allograft $ 1,601.10 1057 25130 25130 Excision or curettage of bone cyst or benign tumor of carpal bones; $ 1,552.50 Excision or curettage of bone cyst or benign tumor of carpal bones; 1058 25135 25135 with autograft (includes obtaining graft) $ 1,781.10 Excision or curettage of bone cyst or benign tumor of carpal bones; 1059 25136 25136 with allograft $ 1,669.50 Sequestrectomy (eg, for osteomyelitis or bone abscess), forearm 1060 25145 25145 and/or wrist $ 1,837.80 Partial excision (craterization, saucerization, or diaphysectomy) of 1061 25150 25150 bone (eg, for osteomyelitis); ulna $ 1,599.30 Partial excision (craterization, saucerization, or diaphysectomy) of 1062 25151 25151 bone (eg, for osteomyelitis); radius $ 1,522.80 1063 25170 25170 Radical resection of tumor, radius or ulna $ 2,446.20 1064 25210 25210 Carpectomy; 1 bone $ 1,483.20 1065 25215 25215 Carpectomy; all bones of proximal row $ 2,278.80 1066 25230 25230 Radial styloidectomy (separate procedure) $ 1,163.70 Excision distal ulna partial or complete (eg, Darrach type or 1067 25240 25240 matched resection) $ 1,516.50 1068 25246 25246 Injection procedure for wrist arthrography $ 223.20 1069 25248 25248 Exploration with removal of deep foreign body, forearm or wrist $ 1,003.50 1070 25250 25250 Removal of wrist prosthesis; (separate procedure) $ 1,647.90 1071 25251 25251 Removal of wrist prosthesis; complicated, including total wrist $ 2,194.20 1072 25259 25259 Manipulation, wrist, under anesthesia $ 1,033.88 Repair, tendon or muscle, flexor, forearm and/or wrist; primary, 1073 25260 25260 single, each tendon or muscle $ 1,475.10 Repair, tendon or muscle, flexor, forearm and/or wrist; secondary, 1074 25263 25263 single, each tendon or muscle $ 1,476.00 Repair, tendon or muscle, flexor, forearm and/or wrist; secondary, 1075 25265 25265 with free graft (includes obtaining graft), each tendon or muscle $ 1,890.00 Repair, tendon or muscle, extensor, forearm and/or wrist; primary, 1076 25270 25270 single, each tendon or muscle $ 1,206.90 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Repair, tendon or muscle, extensor, forearm and/or wrist; 1077 25272 25272 secondary, single, each tendon or muscle $ 1,325.70 Repair, tendon or muscle, extensor, forearm and/or wrist; secondary, with free graft (includes obtaining graft), each tendon or 1078 25274 25274 muscle $ 2,003.40 Repair, tendon sheath, extensor, forearm and/or wrist, with free graft (includes obtaining graft) (eg, for extensor carpi ulnaris 1079 25275 25275 subluxation) $ 1,683.67 Lengthening or shortening of flexor or extensor tendon, forearm 1080 25280 25280 and/or wrist, single, each tendon $ 1,415.70 Tenotomy, open, flexor or extensor tendon, forearm and/or wrist, 1081 25290 25290 single, each tendon $ 943.20 Tenolysis, flexor or extensor tendon, forearm and/or wrist, single, 1082 25295 25295 each tendon $ 1,387.80 1083 25300 25300 Tenodesis at wrist; flexors of fingers $ 1,893.60 1084 25301 25301 Tenodesis at wrist; extensors of fingers $ 1,581.30 Tendon transplantation or transfer, flexor or extensor, forearm 1085 25310 25310 and/or wrist, single; each tendon $ 1,870.20 Tendon transplantation or transfer, flexor or extensor, forearm and/or wrist, single; with tendon graft(s) (includes obtaining graft), 1086 25312 25312 each tendon $ 2,202.30 Flexor origin slide (eg, for cerebral palsy, Volkmann contracture), 1087 25315 25315 forearm and/or wrist; $ 2,035.80 Flexor origin slide (eg, for cerebral palsy, Volkmann contracture), 1088 25316 25316 forearm and/or wrist; with tendon(s) transfer $ 2,677.50 Capsulorrhaphy or reconstruction, wrist, open (eg, capsulodesis, ligament repair, tendon transfer or graft) (includes synovectomy, 1089 25320 25320 capsulotomy and open reduction) for carpal instability $ 3,002.40 Arthroplasty, wrist, with or without interposition, with or without 1090 25332 25332 external or internal fixation $ 2,537.10 1091 25335 25335 Centralization of wrist on ulna (eg, radial club hand) $ 3,493.80 Reconstruction for stabilization of unstable distal ulna or distal radioulnar joint, secondary by soft tissue stabilization (eg, tendon transfer, tendon graft or weave, or tenodesis) with or without open 1092 25337 25337 reduction of distal radioulnar joint $ 1,961.10 1093 25350 25350 Osteotomy, radius; distal third $ 1,881.90 1094 25355 25355 Osteotomy, radius; middle or proximal third $ 1,962.90 1095 25360 25360 Osteotomy; ulna $ 1,773.00 1096 25365 25365 Osteotomy; radius AND ulna $ 2,209.50 Multiple osteotomies, with realignment on intramedullary rod 1097 25370 25370 (Sofield type procedure); radius OR ulna $ 2,259.00 Multiple osteotomies, with realignment on intramedullary rod 1098 25375 25375 (Sofield type procedure); radius AND ulna $ 3,060.90 1099 25390 25390 Osteoplasty, radius OR ulna; shortening $ 2,204.10 1100 25391 25391 Osteoplasty, radius OR ulna; lengthening with autograft $ 2,938.50 1101 25392 25392 Osteoplasty, radius AND ulna; shortening (excluding 64876) $ 2,710.80 1102 25393 25393 Osteoplasty, radius AND ulna; lengthening with autograft $ 3,029.40 1103 25394 25394 Osteoplasty, carpal bone, shortening $ 1,709.09 Repair of nonunion or malunion, radius OR ulna; without graft (eg, 1104 25400 25400 compression technique) $ 1,773.90 Repair of nonunion or malunion, radius OR ulna; with autograft 1105 25405 25405 (includes obtaining graft) $ 2,500.20 Repair of nonunion or malunion, radius AND ulna; without graft (eg, 1106 25415 25415 compression technique) $ 2,615.40 Repair of nonunion or malunion, radius AND ulna; with autograft 1107 25420 25420 (includes obtaining graft) $ 2,688.30 1108 25425 25425 Repair of defect with autograft; radius OR ulna $ 2,207.70 1109 25426 25426 Repair of defect with autograft; radius AND ulna $ 3,141.00 1110 25430 25430 Insertion of vascular pedicle into carpal bone (eg, Hori procedure) $ 1,713.16 Repair of nonunion of carpal bone (excluding carpal scaphoid (navicular)) (includes obtaining graft and necessary fixation), each 1111 25431 25431 bone $ 2,472.29 Repair of nonunion, scaphoid carpal (navicular) bone, with or without radial styloidectomy (includes obtaining graft and necessary 1112 25440 25440 fixation) $ 2,318.40 1113 25441 25441 Arthroplasty with prosthetic replacement; distal radius $ 2,338.20 1114 25442 25442 Arthroplasty with prosthetic replacement; distal ulna $ 1,840.50 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Arthroplasty with prosthetic replacement; scaphoid carpal 1115 25443 25443 (navicular) $ 2,010.60 1116 25444 25444 Arthroplasty with prosthetic replacement; lunate $ 2,404.80 1117 25445 25445 Arthroplasty with prosthetic replacement; trapezium $ 2,321.10 Arthroplasty with prosthetic replacement; distal radius and partial 1118 25446 25446 or entire carpus (total wrist) $ 3,823.20 1119 25447 25447 Arthroplasty, interposition, intercarpal or carpometacarpal joints $ 2,806.20 1120 25449 25449 Revision of arthroplasty, including removal of implant, wrist joint $ 1,763.10 1121 25450 25450 Epiphyseal arrest by epiphysiodesis or stapling; distal radius OR ulna $ 1,053.00 Epiphyseal arrest by epiphysiodesis or stapling; distal radius AND 1122 25455 25455 ulna $ 1,548.00 Prophylactic treatment (nailing, pinning, plating or wiring) with or 1123 25490 25490 without methylmethacrylate; radius $ 1,586.70 Prophylactic treatment (nailing, pinning, plating or wiring) with or 1124 25491 25491 without methylmethacrylate; ulna $ 1,681.20 Prophylactic treatment (nailing, pinning, plating or wiring) with or 1125 25492 25492 without methylmethacrylate; radius AND ulna $ 1,881.90 1126 25500 25500 Closed treatment of radial shaft fracture; without manipulation $ 513.00 1127 25505 25505 Closed treatment of radial shaft fracture;

with manipulation $ 775.80 Open treatment of radial shaft fracture, includes internal fixation, 1128 25515 25515 when performed $ 1,587.60 Closed treatment of radial shaft fracture and closed treatment of 1129 25520 25520 dislocation of distal radioulnar joint (Galeazzi fracture/dislocation) $ 1,447.20 Open treatment of radial shaft fracture, includes internal fixation, when performed, and closed treatment of distal radioulnar joint dislocation (Galeazzi fracture/dislocation), includes percutaneous 1130 25525 25525 skeletal fixation, when performed $ 2,566.80 Open treatment of radial shaft fracture, includes internal fixation, when performed, and open treatment of distal radioulnar joint dislocation (Galeazzi fracture/dislocation), includes internal fixation, 1131 25526 25526 when performed, includes repair of triangular fibro $ 2,663.10 1132 25530 25530 Closed treatment of ulnar shaft fracture; without manipulation $ 475.20 1133 25535 25535 Closed treatment of ulnar shaft fracture; with manipulation $ 811.80 Open treatment of ulnar shaft fracture, includes internal fixation, 1134 25545 25545 when performed $ 1,704.60 Closed treatment of radial and ulnar shaft fractures; without 1135 25560 25560 manipulation $ 612.90 Closed treatment of radial and ulnar shaft fractures; with 1136 25565 25565 manipulation $ 1,008.00 Open treatment of radial AND ulnar shaft fractures, with internal 1137 25574 25574 fixation, when performed; of radius OR ulna $ 2,353.50 Open treatment of radial AND ulnar shaft fractures, with internal 1138 25575 25575 fixation, when performed; of radius AND ulna $ 2,425.50 Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of 1139 25600 25600 ulnar styloid, when performed; without manipulation $ 550.80 Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of 1140 25605 25605 ulnar styloid, when performed; with manipulation $ 796.50 Percutaneous skeletal fixation of distal radial fracture or epiphyseal 1141 25606 25606 separation $ 1,524.64 Open treatment of distal radial extra-articular fracture or 1142 25607 25607 epiphyseal separation, with internal fixation $ 1,539.22 Closed treatment of carpal scaphoid (navicular) fracture; without 1143 25622 25622 manipulation $ 612.90 Closed treatment of carpal scaphoid (navicular) fracture; with 1144 25624 25624 manipulation $ 808.20 Open treatment of carpal scaphoid (navicular) fracture, includes 1145 25628 25628 internal fixation, when performed $ 1,751.40 Closed treatment of carpal bone fracture (excluding carpal scaphoid 1146 25630 25630 [navicular]); without manipulation, each bone $ 506.70 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Closed treatment of carpal bone fracture (excluding carpal scaphoid 1147 25635 25635 [navicular]); with manipulation, each bone $ 699.30 Open treatment of carpal bone fracture (other than carpal scaphoid 1148 25645 25645 [navicular]), each bone $ 1,376.10 1149 25650 25650 Closed treatment of ulnar styloid fracture $ 758.70 1150 25651 25651 Percutaneous skeletal fixation of ulnar styloid fracture $ 1,006.20 1151 25652 25652 Open treatment of ulnar styloid fracture $ 1,318.22 Closed treatment of radiocarpal or intercarpal dislocation, 1 or 1152 25660 25660 more bones, with manipulation $ 781.20 Open treatment of radiocarpal or intercarpal dislocation, 1 or more 1153 25670 25670 bones $ 1,624.50 1154 25671 25671 Percutaneous skeletal fixation of distal radioulnar dislocation $ 1,128.99 1155 25675 25675 Closed treatment of distal radioulnar dislocation with manipulation $ 776.70 1156 25676 25676 Open treatment of distal radioulnar dislocation, acute or chronic $ 1,699.20 Closed treatment of trans-scaphoperilunar type of fracture 1157 25680 25680 dislocation, with manipulation $ 1,107.90 Open treatment of trans-scaphoperilunar type of fracture 1158 25685 25685 dislocation $ 2,005.20 1159 25690 25690 Closed treatment of lunate dislocation, with manipulation $ 1,141.20 1160 25695 25695 Open treatment of lunate dislocation $ 1,864.80 Arthrodesis, wrist; complete, without bone graft (includes 1161 25800 25800 radiocarpal and/or intercarpal and/or carpometacarpal joints) $ 2,785.50 1162 25805 25805 Arthrodesis, wrist; with sliding graft $ 2,888.10 Arthrodesis, wrist; with iliac or other autograft (includes obtaining 1163 25810 25810 graft) $ 3,366.00 Arthrodesis, wrist; limited, without bone graft (eg, intercarpal or 1164 25820 25820 radiocarpal) $ 2,223.00 1165 25825 25825 Arthrodesis, wrist; with autograft (includes obtaining graft) $ 2,680.20 Arthrodesis, distal radioulnar joint with segmental resection of ulna, 1166 25830 25830 with or without bone graft (eg, Sauve-Kapandji procedure) $ 2,169.90 1167 25900 25900 Amputation, forearm, through radius and ulna; $ 1,926.00 Amputation, forearm, through radius and ulna; open, circular 1168 25905 25905 (guillotine) $ 1,746.00 Amputation, forearm, through radius and ulna; secondary closure 1169 25907 25907 or scar revision $ 837.00 1170 25909 25909 Amputation, forearm, through radius and ulna; re-amputation $ 1,625.40 1171 25915 25915 Krukenberg procedure $ 2,570.40 1172 25920 25920 Disarticulation through wrist; $ 1,611.90 1173 25922 25922 Disarticulation through wrist; secondary closure or scar revision $ 945.90 1174 25924 25924 Disarticulation through wrist; re-amputation $ 1,646.10 1175 25927 25927 Transmetacarpal amputation; $ 1,952.10 1176 25929 25929 Transmetacarpal amputation; secondary closure or scar revision $ 870.30 1177 25931 25931 Transmetacarpal amputation; re-amputation $ 1,794.60 1178 25999 25999 Unlisted procedure, forearm or wrist Cost 1179 26010 26010 Drainage of finger abscess; simple $ 293.40 1180 26011 26011 Drainage of finger abscess; complicated (eg, felon) $ 568.80 1181 26020 26020 Drainage of tendon sheath, digit and/or palm, each $ 1,313.10 1182 26025 26025 Drainage of palmar bursa; single, bursa $ 1,323.90 1183 26030 26030 Drainage of palmar bursa; multiple bursa $ 1,913.40 Incision, bone cortex, hand or finger (eg, osteomyelitis or bone 1184 26034 26034 abscess) $ 1,782.00 Decompression fingers and/or hand, injection injury (eg, grease 1185 26035 26035 gun) $ 2,395.80 1186 26037 26037 Decompressive fasciotomy, hand (excludes 26035) $ 2,175.30 1187 26040 26040 Fasciotomy, palmar (eg, Dupuytren's contracture); percutaneous $ 1,008.00 1188 26045 26045 Fasciotomy, palmar (eg, Dupuytren's contracture); open, partial $ 1,457.10 1189 26055 26055 Tendon sheath incision (eg, for trigger finger) $ 931.88 1190 26060 26060 Tenotomy, percutaneous, single, each digit $ 499.50 Arthrotomy, with exploration, drainage, or removal of loose or 1191 26070 26070 foreign body; carpometacarpal joint $ 841.50 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Arthrotomy, with exploration, drainage, or removal of loose or 1192 26075 26075 foreign body; metacarpophalangeal joint, each $ 1,145.70 Arthrotomy, with exploration, drainage, or removal of loose or 1193 26080 26080 foreign body; interphalangeal joint, each $ 895.50 1194 26100 26100 Arthrotomy with biopsy; carpometacarpal joint, each $ 920.70 1195 26105 26105 Arthrotomy with biopsy; metacarpophalangeal joint, each $ 1,050.30 1196 26110 26110 Arthrotomy with biopsy; interphalangeal joint, each $ 842.40 Excision, tumor or vascular malformation, soft tissue of hand or 1197 26111 26111 finger, subcutaneous; 1.5 cm or greater $ 1,075.54 Excision, tumor, soft tissue, or vascular malformation, of hand or 1198 26113 26113 finger, subfascial (eg, intramuscular); 1.5 cm or greater $ 1,621.65 Excision, tumor or vascular malformation, soft tissue of hand or 1199 26115 26115 finger, subcutaneous; less than 1.5 cm $ 927.00 Excision, tumor, soft tissue, or vascular malformation, of hand or 1200 26116 26116 finger, subfascial (eg, intramuscular); less than 1.5 cm $ 1,284.30 Radical resection of tumor (eg, sarcoma), soft tissue of hand or 1201 26117 26117 finger; less than 3 cm $ 2,445.30 Radical resection of tumor (eg, sarcoma), soft tissue of hand or 1202 26118 26118 finger; 3 cm or greater $ 3,201.59 Fasciectomy, palm only, with or without Z-plasty, other local tissue 1203 26121 26121 rearrangement, or skin grafting (includes obtaining graft) $ 2,585.70 Fasciectomy, partial palmar with release of single digit including proximal interphalangeal joint, with or without Z-plasty, other local 1204 26123 26123 tissue rearrangement, or skin grafting (includes obtaining graft); $ 2,606.40 Fasciectomy, partial palmar with release of single digit including proximal interphalangeal joint, with or without Z-plasty, other local tissue rearrangement, or skin grafting (includes obtaining graft); 1205 26125 26125 each additional digit (List separately in addition $ 2,230.20 1206 26130 26130 Synovectomy, carpometacarpal joint $ 1,566.00 Synovectomy, metacarpophalangeal joint including intrinsic release 1207 26135 26135 and extensor hood reconstruction, each digit $ 1,762.20 Synovectomy, proximal interphalangeal joint, including extensor 1208 26140 26140 reconstruction, each interphalangeal joint $ 1,708.20 Synovectomy, tendon sheath, radical (tenosynovectomy), flexor 1209 26145 26145 tendon, palm and/or finger, each tendon $ 1,744.20 Excision of lesion of tendon sheath or joint capsule (eg, cyst, 1210 26160 26160 mucous cyst, or ganglion), hand or finger $ 913.50 1211 26170 26170 Excision of tendon, palm, flexor or extensor, single, each tendon $ 945.90 1212 26180 26180 Excision of tendon, finger, flexor or extensor, each tendon $ 834.30 1213 26185 26185 Sesamoidectomy, thumb or finger (separate procedure) $ 929.70 1214 26200 26200 Excision or curettage of bone cyst or benign tumor of metacarpal; $ 1,137.60 Excision or curettage of bone cyst or benign tumor of metacarpal; 1215 26205 26205 with autograft (includes obtaining graft) $ 1,695.60 Excision or curettage of bone cyst or benign tumor of proximal, 1216 26210 26210 middle, or distal phalanx of finger; $ 1,234.80 Excision or curettage of bone cyst or benign tumor of proximal, middle, or distal phalanx of finger; with autograft (includes 1217 26215 26215 obtaining graft) $ 1,538.10 Partial excision (craterization, saucerization, or diaphysectomy) 1218 26230 26230 bone (eg, osteomyelitis); metacarpal $ 1,121.40 Partial excision (craterization, saucerization, or diaphysectomy) 1219 26235 26235 bone (eg, osteomyelitis); proximal or middle phalanx of finger $ 1,081.80 Partial excision (craterization, saucerization, or diaphysectomy) 1220 26236 26236 bone (eg, osteomyelitis); distal phalanx of finger $ 931.50 1221 26250 26250 Radical resection of tumor, metacarpal $ 1,561.50 1222 26260 26260 Radical resection of tumor, proximal or middle phalanx of finger $ 1,692.00 1223 26262 26262 Radical resection of tumor, distal phalanx of finger $ 1,568.70 1224 26320 26320 Removal of implant from finger or hand $ 956.70 1225 26340 26340 Manipulation, finger joint, under anesthesia, each joint $ 841.74 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Repair or advancement, flexor tendon, not in zone 2 digital flexor tendon sheath (eg, no man's land); primary or secondary without 1226 26350 26350 free graft, each tendon $ 2,094.30 Repair or advancement, flexor tendon, not in zone 2 digital flexor tendon sheath (eg, no man's land); secondary with free graft 1227 26352 26352 (includes obtaining graft), each tendon $ 2,346.30 Repair or advancement, flexor tendon, in zone 2 digital flexor tendon sheath (eg, no man's land); primary, without free graft, each 1228 26356 26356 tendon $ 2,266.20 Repair or advancement, flexor tendon, in zone 2 digital flexor tendon sheath (eg, no man's land); secondary, without free graft, 1229 26357 26357 each tendon $ 2,317.50 Repair or advancement, flexor tendon, in zone 2 digital flexor tendon sheath (eg, no man's land); secondary, with free graft 1230 26358 26358 (includes obtaining graft), each tendon $ 2,396.70 Repair or advancement of profundus tendon, with intact 1231 26370 26370 superficialis tendon; primary, each tendon $ 1,900.80 Repair or advancement of profundus tendon, with intact superficialis tendon; secondary with free graft (includes obtaining 1232 26372 26372 graft), each tendon $ 1,975.50 Repair or advancement of profundus tendon, with intact 1233 26373 26373 superficialis tendon; secondary without free graft, each tendon $ 1,825.20 Excision flexor tendon, with implantation of synthetic rod for 1234 26390 26390 delayed tendon graft, hand or finger, each rod $ 1,753.20 Removal of synthetic rod and insertion of flexor tendon graft, hand 1235 26392 26392 or finger (includes obtaining graft), each rod $ 2,260.80 Repair, extensor tendon, hand, primary or secondary; without free 1236 26410 26410 graft, each tendon $ 1,064.70 Repair, extensor tendon, hand, primary or secondary; with free 1237 26412 26412 graft (includes obtaining graft), each tendon $ 1,515.60 Excision of extensor tendon, with implantation of synthetic rod for 1238 26415 26415 delayed tendon graft, hand or finger, each rod $ 1,444.50 Removal of synthetic rod and insertion of extensor tendon graft 1239 26416 26416 (includes obtaining graft), hand or finger, each rod $ 1,515.60 Repair, extensor tendon, finger, primary or secondary; without free 1240 26418 26418 graft, each tendon $ 1,251.90 Repair, extensor tendon, finger, primary or secondary; with free 1241 26420 26420 graft (includes obtaining graft) each tendon $ 1,416.60 Repair of extensor tendon, central slip, secondary (eg, boutonniere deformity); using local tissue(s), including lateral band(s), each 1242 26426 26426 finger $ 1,654.20 Repair of extensor tendon, central slip, secondary (eg, boutonniere 1243 26428 26428 deformity); with free graft (includes obtaining graft), each finger $ 1,773.00 Closed treatment of distal extensor tendon insertion, with or 1244 26432 26432 without percutaneous pinning (eg, mallet finger) $ 1,139.40 Repair of extensor tendon, distal insertion, primary or secondary; 1245 26433 26433 without graft (eg, mallet finger) $ 1,485.00 Repair of extensor tendon, distal insertion, primary or secondary; 1246 26434 26434 with free graft (includes obtaining graft) $ 1,368.00 1247 26437 26437 Realignment of extensor tendon, hand, each tendon $ 1,484.10 1248 26440 26440 Tenolysis, flexor tendon; palm OR finger, each tendon $ 1,247.40 1249 26442 26442 Tenolysis, flexor tendon; palm AND finger, each tendon $ 1,440.90 1250 26445 26445 Tenolysis, extensor tendon, hand OR finger, each tendon $ 1,212.30 Tenolysis, complex, extensor tendon, finger, including forearm, each 1251 26449 26449 tendon $ 1,699.20 1252 26450 26450 Tenotomy, flexor, palm, open, each tendon $ 733.50 1253 26455 26455 Tenotomy, flexor, finger, open, each tendon $ 847.80 1254 26460 26460 Tenotomy, extensor, hand or finger, open, each tendon $ 849.60 1255 26471 26471 Tenodesis; of proximal interphalangeal joint, each joint $ 1,384.20 1256 26474 26474 Tenodesis; of distal joint, each joint $ 981.00 1257 26476 26476 Lengthening of tendon, extensor, hand or finger, each tendon $ 1,012.50 1258 26477 26477 Shortening of tendon, extensor, hand or finger, each tendon $ 1,078.20 1259 26478 26478 Lengthening of tendon, flexor, hand or finger, each tendon $ 1,345.50 1260 26479 26479 Shortening of tendon, flexor, hand or finger, each tendon $ 1,348.20 Transfer or transplant of tendon, carpometacarpal area or dorsum 1261 26480 26480 of hand; without free graft, each tendon $ 1,838.70 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Transfer or transplant of tendon, carpometacarpal area or dorsum of hand; with free tendon graft (includes obtaining graft), each 1262 26483 26483 tendon $ 2,086.20 Transfer or transplant of tendon, palmar; without free tendon graft, 1263 26485 26485 each tendon $ 1,926.90 Transfer or transplant of tendon, palmar; with free tendon graft 1264 26489 26489 (includes obtaining graft), each tendon $ 2,232.90 1265 26490 26490 Opponensplasty; superficialis tendon transfer type, each tendon $ 2,045.70 Opponensplasty; tendon transfer with graft (includes obtaining 1266 26492 26492 graft), each tendon $ 2,237.40 1267 26494 26494 Opponensplasty; hypothenar muscle transfer $ 2,032.20 1268 26496 26496 Opponensplasty; other methods $ 2,317.50 Transfer of tendon to restore intrinsic function; ring and small 1269 26497 26497 finger $ 2,201.40 1270 26498 26498 Transfer of tendon to restore intrinsic function; all 4 fingers $ 2,544.30 1271 26499 26499 Correction claw finger, other methods $ 2,403.90 Reconstruction of tendon pulley, each tendon; with local tissues 1272 26500 26500 (separate procedure) $ 1,257.30 Reconstruction of tendon pulley, each tendon; with tendon or 1273 26502 26502 fascial graft (includes obtaining graft) (separate procedure) $ 1,802.70 1274 26508 26508 Release of thenar muscle(s) (eg, thumb contracture) $ 1,460.70 1275 26510 26510 Cross intrinsic transfer, each tendon $ 1,870.20 1276 26516 26516 Capsulodesis, metacarpophalangeal joint; single digit $ 1,593.90 1277 26517 26517 Capsulodesis, metacarpophalangeal joint; 2 digits $ 1,629.90 1278 26518 26518 Capsulodesis, metacarpophalangeal joint; 3 or 4 digits $ 2,031.30 Capsulectomy or capsulotomy; metacarpophalangeal joint, each 1279 26520 26520 joint $ 1,548.00 1280 26525 26525 Capsulectomy or capsulotomy; interphalangeal joint, each joint $ 1,649.70 1281 26530 26530 Arthroplasty, metacarpophalangeal joint; each joint $ 1,611.90 Arthroplasty, metacarpophalangeal joint; with prosthetic implant, 1282 26531 26531 each joint $ 1,847.70 1283 26535 26535 Arthroplasty, interphalangeal joint; each joint $ 1,657.80 Arthroplasty, interphalangeal joint; with prosthetic implant, each 1284 26536 26536 joint $ 1,911.60 Repair of collateral ligament, metacarpophalangeal or 1285 26540 26540 interphalangeal joint $ 1,791.00 Reconstruction, collateral ligament, metacarpophalangeal joint, 1286 26541 26541 single; with tendon or fascial graft (includes obtaining graft) $ 2,261.70 Reconstruction, collateral ligament, metacarpophalangeal joint, 1287 26542 26542 single; with local tissue (eg, adductor advancement) $ 2,025.00 Reconstruction, collateral ligament, interphalangeal joint, single, 1288 26545 26545 including graft, each joint $ 1,589.40 Repair non-union, metacarpal or phalanx (includes obtaining bone 1289 26546 26546 graft with or without external or internal fixation) $ 1,758.60 1290 26548 26548 Repair and reconstruction, finger, volar plate, interphalangeal joint $ 1,946.70 1291 26550 26550 Pollicization of a digit $ 3,405.60 Transfer, toe-to-hand with microvascular anastomosis; great toe 1292 26551 26551 wrap-around with bone graft $ 9,160.20 Transfer, toe-to-hand with microvascular anastomosis; other than 1293 26553 26553 great toe, single $ 9,096.30 Transfer, toe-to-hand with microvascular anastomosis; other than 1294 26554 26554 great toe, double $ 10,847.70 Transfer, finger to another position without microvascular 1295 26555 26555 anastomosis $ 2,587.50 1296 26556 26556 Transfer, free toe joint, with microvascular anastomosis $ 9,251.10 1297 26560 26560 Repair of syndactyly (web finger) each web space; with skin flaps $ 1,658.70 Repair of syndactyly (web finger) each web space; with skin flaps 1298 26561 26561 and grafts $ 2,214.90 Repair of syndactyly (web finger) each web space; complex (eg, 1299 26562 26562 involving bone, nails) $ 2,721.60 1300 26565 26565 Osteotomy; metacarpal, each $ 1,844.10 1301 26567 26567 Osteotomy; phalanx of finger, each $ 1,483.20 1302 26568 26568 Osteoplasty, lengthening, metacarpal or phalanx $ 2,240.10 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price 1303 26580 26580 Repair cleft hand $ 3,350.70 1304 26587 26587 Reconstruction of polydactylous digit, soft tissue and bone $ 1,975.50 1305 26590 26590 Repair macrodactylia, each digit $ 2,241.00 1306 26591 26591 Repair, intrinsic muscles of hand, each muscle $ 1,861.20 1307 26593 26593 Release, intrinsic muscles of hand, each muscle $ 1,684.80 1308 26596 26596 Excision of constricting ring of finger, with multiple Z-plasties $ 1,884.60 Closed treatment of metacarpal fracture, single; without 1309 26600 26600 manipulation, each bone $ 341.10 Closed treatment of metacarpal fracture, single; with manipulation, 1310 26605 26605 each bone $ 504.00 Closed treatment of metacarpal fracture, with manipulation, with 1311 26607 26607 external fixation, each bone $ 983.70 1312 26608 26608 Percutaneous skeletal fixation of metacarpal fracture, each bone $ 1,079.10 Open treatment of metacarpal fracture, single, includes internal 1313 26615 26615 fixation, when performed, each bone $ 1,511.10 Closed treatment of carpometacarpal dislocation, thumb, with 1314 26641 26641 manipulation $ 526.50 Closed treatment of carpometacarpal fracture dislocation, thumb 1315 26645 26645 (Bennett fracture), with manipulation $ 703.80 Percutaneous skeletal fixation of carpometacarpal fracture 1316 26650 26650 dislocation, thumb (Bennett fracture), with manipulation $ 1,207.80 Open treatment of carpometacarpal fracture dislocation, thumb 1317 26665 26665 (Bennett fracture), includes internal fixation, when performed $ 1,818.90 Closed treatment of carpometacarpal dislocation, other than 1318 26670 26670 thumb, with manipulation, each joint; without anesthesia $ 373.50 Closed treatment of carpometacarpal dislocation, other than 1319 26675 26675 thumb, with manipulation, each joint; requiring anesthesia $ 617.66 Percutaneous skeletal fixation of carpometacarpal dislocation, other 1320 26676 26676 than thumb, with manipulation, each joint $ 885.60 Open treatment of carpometacarpal dislocation, other than thumb; 1321 26685 26685 includes internal fixation, when performed, each joint $ 1,269.00 Open treatment of carpometacarpal dislocation, other than thumb; 1322 26686 26686 complex, multiple, or delayed reduction $ 1,341.00 Closed treatment of metacarpophalangeal dislocation, single, with 1323 26700 26700 manipulation; without anesthesia $ 340.20 Closed treatment of metacarpophalangeal dislocation, single, with 1324 26705 26705 manipulation; requiring anesthesia $ 525.60 Percutaneous skeletal fixation of metacarpophalangeal dislocation, 1325 26706 26706 single, with manipulation $ 847.80 Open treatment of metacarpophalangeal dislocation, single, 1326 26715 26715 includes internal fixation, when performed $ 1,225.80 Closed treatment of phalangeal shaft fracture, proximal or middle 1327 26720 26720 phalanx, finger or thumb; without manipulation, each $ 278.10 Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; with manipulation, with or without skin 1328 26725 26725 or skeletal traction, each $ 462.60 Percutaneous skeletal fixation of unstable phalangeal shaft fracture, proximal or middle phalanx, finger or thumb, with manipulation, 1329 26727 26727 each $ 967.50 Open treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb, includes internal fixation, when 1330 26735 26735 performed, each $ 1,345.50 Closed treatment of articular fracture, involving metacarpophalangeal or interphalangeal joint; without 1331 26740 26740 manipulation, each $ 492.30 Closed treatment of articular fracture, involving metacarpophalangeal or interphalangeal joint; with manipulation, 1332 26742 26742 each $ 647.10 Open treatment of articular fracture, involving metacarpophalangeal or interphalangeal joint, includes internal 1333 26746 26746 fixation, when performed, each $ 1,380.60 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Closed treatment of distal phalangeal fracture, finger or thumb; 1334 26750 26750 without manipulation, each $ 227.70 Closed treatment of distal phalangeal fracture, finger or thumb; 1335 26755 26755 with manipulation, each $ 368.40 Percutaneous skeletal fixation of distal phalangeal fracture, finger 1336 26756 26756 or thumb, each $ 751.50 Open treatment of distal phalangeal fracture, finger or thumb, 1337 26765 26765 includes internal fixation, when performed, each $ 889.20 Closed treatment of interphalangeal joint dislocation, single, with 1338 26770 26770 manipulation; without anesthesia $ 244.56 Closed treatment of interphalangeal joint dislocation, single, with 1339 26775 26775 manipulation; requiring anesthesia $ 448.20 Percutaneous skeletal fixation of interphalangeal joint dislocation, 1340 26776 26776 single, with manipulation $ 712.80 Open treatment of interphalangeal joint dislocation, includes 1341 26785 26785 internal fixation, when performed, single $ 990.90 Fusion in opposition, thumb, with autogenous graft (includes 1342 26820 26820 obtaining graft) $ 1,808.10 Arthrodesis, carpometacarpal joint, thumb, with or without internal 1343 26841 26841 fixation; $ 1,699.20 Arthrodesis, carpometacarpal joint, thumb, with or without internal 1344 26842 26842 fixation; with autograft (includes obtaining graft) $ 1,946.70 1345 26843 26843 Arthrodesis, carpometacarpal joint, digit, other than thumb, each; $ 1,415.70 Arthrodesis, carpometacarpal joint, digit, other than thumb, each; 1346 26844 26844 with autograft (includes obtaining graft) $ 1,545.30 Arthrodesis, metacarpophalangeal joint, with or without internal 1347 26850 26850 fixation; $ 1,919.70 Arthrodesis, metacarpophalangeal joint, with or without internal 1348 26852 26852 fixation; with autograft (includes obtaining graft) $ 1,494.00 1349 26860 26860 Arthrodesis, interphalangeal joint, with or without internal fixation; $ 1,250.10 Arthrodesis, interphalangeal joint, with or without internal fixation; each additional interphalangeal joint (List separately in addition to 1350 26861 26861 code for primary procedure) $ 540.90 Arthrodesis, interphalangeal joint, with or without internal fixation; 1351 26862 26862 with autograft (includes obtaining graft) $ 1,629.90 Arthrodesis, interphalangeal joint, with or without internal fixation; with autograft (includes obtaining graft), each additional joint (List 1352 26863 26863 separately in addition to code for primary procedure) $ 646.20 Amputation, metacarpal, with finger or thumb (ray amputation), 1353 26910 26910 single, with or without interosseous transfer $ 1,870.20 Amputation, finger or thumb, primary or secondary, any joint or 1354 26951 26951 phalanx, single, including neurectomies; with direct closure $ 910.80 Amputation, finger or thumb, primary or secondary, any joint or phalanx, single, including neurectomies; with local advancement 1355 26952 26952 flaps (V-Y, hood) $ 1,376.10 1356 26989 26989 Unlisted procedure, hands or fingers $ 658.80 Incision and drainage, pelvis or hip joint area; deep abscess or 1357 26990 26990 hematoma $ 900.90 1358 26991 26991 Incision and drainage, pelvis or hip joint area; infected bursa $ 772.20 Incision, bone cortex, pelvis and/or hip joint (eg, osteomyelitis or 1359 26992 26992 bone abscess) $ 1,793.70 1360 27000 27000 Tenotomy, adductor of hip, percutaneous (separate procedure) $ 498.60 1361 27001 27001 Tenotomy, adductor of hip, open $ 912.60 Tenotomy, adductor, subcutaneous, open, with obturator 1362 27003 27003 neurectomy $ 1,064.70 1363 27005 27005 Tenotomy, hip flexor(s), open (separate procedure) $ 1,452.60 Tenotomy, abductors and/or extensor(s) of hip, open (separate 1364 27006 27006 procedure) $ 1,012.50 1365 27025 27025 Fasciotomy, hip or thigh, any type $ 1,698.30 Decompression fasciotomy(ies), pelvic (buttock) compartment(s) (eg, gluteus medius-minimus, gluteus maximus, iliopsoas, and/or 1366 27027 27027 tensor fascia lata muscle), unilateral $ 1,637.28 1367 27030 27030 Arthrotomy, hip, with drainage (eg, infection) $ 2,173.50 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Arthrotomy, hip, including exploration or removal of loose or 1368 27033 27033 foreign body $ 2,332.80 Denervation, hip joint, intrapelvic or extrapelvic intra-articular 1369 27035 27035 branches of sciatic, femoral, or obturator nerves $ 2,578.50 Capsulectomy or capsulotomy, hip, with or without excision of heterotopic bone, with release of hip flexor muscles (ie, gluteus medius, gluteus minimus, tensor fascia latae, rectus femoris, 1370 27036 27036 sartorius, iliopsoas) $ 2,480.40 1371 27040 27040 Biopsy, soft tissue of pelvis and hip area; superficial $ 462.60 Biopsy, soft tissue of pelvis and hip area; deep, subfascial or 1372 27041 27041 intramuscular $ 767.70 Excision, tumor, soft tissue of pelvis and hip area, subcutaneous; 3 1373 27043 27043 cm or greater $ 877.66 Excision, tumor, soft tissue of pelvis and hip area, subfascial (eg, 1374 27045 27045 intramuscular); 5 cm or greater $ 1,380.69 Excision, tumor, soft tissue of pelvis and hip area, subcutaneous; 1375 27047 27047 less than 3 cm $ 697.50 Excision, tumor, soft tissue of pelvis and hip area, subfascial (eg, 1376 27048 27048 intramuscular); less than 5 cm $ 1,323.00 Radical resection of tumor (eg, sarcoma), soft tissue of pelvis and 1377 27049 27049 hip area; less than 5 cm $ 3,126.60 1378 27050 27050 Arthrotomy, with biopsy; sacroiliac joint $ 1,007.10 1379 27052 27052 Arthrotomy, with biopsy; hip joint $ 2,218.50 1380 27054 27054 Arthrotomy with synovectomy, hip joint $ 2,638.80 Decompression fasciotomy(ies), pelvic (buttock) compartment(s) (eg, gluteus medius-minimus, gluteus maximus, iliopsoas, and/or tensor fascia lata muscle) with debridement of nonviable muscle, 1381 27057 27057 unilateral $ 1,660.89 Radical resection of tumor (eg, sarcoma), soft tissue of pelvis and 1382 27059 27059 hip area; 5 cm or greater $ 3,359.14 1383 27060 27060 Excision; ischial bursa $ 999.90 1384 27062 27062 Excision; trochanteric bursa or calcification $ 904.50 Excision of bone cyst or benign tumor, wing of ilium, symphysis pubis, or greater trochanter of femur; superficial, includes 1385 27065 27065 autograft, when performed $ 1,318.50 Excision of bone cyst or benign tumor, wing of ilium, symphysis pubis, or greater trochanter of femur; deep (subfascial), includes 1386 27066 27066 autograft, when performed $ 1,965.60 Excision of bone cyst or benign tumor, wing of ilium, symphysis pubis, or greater trochanter of femur; with autograft requiring 1387 27067 27067 separate incision $ 2,286.90 Partial excision, wing of ilium, symphysis pubis, or greater trochanter of femur, (craterization, saucerization) (eg, osteomyelitis 1388 27070 27070 or bone abscess); superficial $ 1,739.70 Partial excision, wing of ilium, symphysis pubis, or greater trochanter of femur, (craterization, saucerization) (eg, osteomyelitis 1389 27071 27071 or bone abscess); deep (subfascial or intramuscular) $ 1,902.60 Radical resection of tumor; wing of ilium, 1 pubic or ischial ramus or 1390 27075 27075 symphysis pubis $ 3,087.90 Radical resection of tumor; ilium, including acetabulum, both pubic 1391 27076 27076 rami, or ischium and acetabulum $ 4,360.50 1392 27077 27077 Radical resection of tumor; innominate bone, total $ 5,816.70 Radical resection of tumor; ischial tuberosity and greater trochanter 1393 27078 27078 of femur $ 1,979.10 1394 27080 27080 Coccygectomy, primary $ 1,275.30 1395 27086 27086 Removal of foreign body, pelvis or hip; subcutaneous tissue $ 332.10 Removal of foreign body, pelvis or hip; deep (subfascial or 1396 27087 27087 intramuscular) $ 1,123.53 1397 27090 27090 Removal of hip prosthesis; (separate procedure) $ 2,482.20 Removal of hip prosthesis; complicated, including total hip 1398 27091 27091 prosthesis, methylmethacrylate with or without insertion of spacer $ 5,319.90 1399 27093 27093 Injection procedure for hip arthrography; without anesthesia $ 275.40 1400 27095 27095 Injection procedure for hip arthrography; with anesthesia $ 504.00 Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or ct) including arthrography when 1401 27096 27096 performed $ 769.50 1402 27097 27097 Release or recession, hamstring, proximal $ 1,754.10 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price 1403 27098 27098 Transfer, adductor to ischium $ 2,065.50 Transfer external oblique muscle to greater trochanter including 1404 27100 27100 fascial or tendon extension (graft) $ 2,358.90 Transfer paraspinal muscle to hip (includes fascial or tendon 1405 27105 27105 extension graft) $ 2,504.70 1406 27110 27110 Transfer iliopsoas; to greater trochanter of femur $ 2,935.80 1407 27111 27111 Transfer iliopsoas; to femoral neck $ 2,898.90 1408 27120 27120 Acetabuloplasty; (eg, Whitman, Colonna, Haygroves, or cup type) $ 3,783.60 Acetabuloplasty; resection, femoral head (eg, Girdlestone 1409 27122 27122 procedure) $ 3,681.00 Hemiarthroplasty, hip, partial (eg, femoral stem prosthesis, bipolar 1410 27125 27125 arthroplasty) $ 4,079.70 Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or 1411 27130 27130 allograft $ 5,616.90 Conversion of previous hip surgery to total hip arthroplasty, with or 1412 27132 27132 without autograft or allograft $ 6,371.10 Revision of total hip arthroplasty; both components, with or 1413 27134 27134 without autograft or allograft $ 8,532.18 Revision of total hip arthroplasty; acetabular component only, with 1414 27137 27137 or without autograft or allograft $ 5,851.80 Revision of total hip arthroplasty; femoral component only, with or 1415 27138 27138 without allograft $ 5,899.50 Osteotomy and transfer of greater trochanter of femur (separate 1416 27140 27140 procedure) $ 2,176.20 1417 27146 27146 Osteotomy, iliac, acetabular or innominate bone; $ 3,255.30 Osteotomy, iliac, acetabular or innominate bone; with open 1418 27147 27147 reduction of hip $ 3,914.10 Osteotomy, iliac, acetabular or innominate bone; with femoral 1419 27151 27151 osteotomy $ 3,619.80 Osteotomy, iliac, acetabular or innominate bone; with femoral 1420 27156 27156 osteotomy and with open reduction of hip $ 4,401.00 1421 27158 27158 Osteotomy, pelvis, bilateral (eg, congenital malformation) $ 3,836.70 1422 27161 27161 Osteotomy, femoral neck (separate procedure) $ 3,132.00 Osteotomy, intertrochanteric or subtrochanteric including internal 1423 27165 27165 or external fixation and/or cast $ 3,549.60 Bone graft, femoral head, neck, intertrochanteric or subtrochanteric 1424 27170 27170 area (includes obtaining bone graft) $ 3,708.00 Treatment of slipped femoral epiphysis; by traction, without 1425 27175 27175 reduction $ 1,855.80 Treatment of slipped femoral epiphysis; by single or multiple 1426 27176 27176 pinning, in situ $ 2,770.20 Open treatment of slipped femoral epiphysis; single or multiple 1427 27177 27177 pinning or bone graft (includes obtaining graft) $ 3,270.60 Open treatment of slipped femoral epiphysis; closed manipulation 1428 27178 27178 with single or multiple pinning $ 3,458.70 Open treatment of slipped femoral epiphysis; osteoplasty of 1429 27179 27179 femoral neck (Heyman type procedure) $ 2,672.10 Open treatment of slipped femoral epiphysis; osteotomy and 1430 27181 27181 internal fixation $ 3,789.90 Epiphyseal arrest by epiphysiodesis or stapling, greater trochanter 1431 27185 27185 of femur $ 1,233.00 Prophylactic treatment (nailing, pinning, plating or wiring) with or 1432 27187 27187 without methylmethacrylate, femoral neck and proximal femur $ 4,241.70 Closed treatment of pelvic ring fracture, dislocation, diastasis or 1433 27193 27193 subluxation; without manipulation $ 1,030.50 Closed treatment of pelvic ring fracture, dislocation, diastasis or subluxation; with manipulation, requiring more than local 1434 27194 27194 anesthesia $ 1,568.70 1435 27200 27200 Closed treatment of coccygeal fracture $ 441.90 1436 27202 27202 Open treatment of coccygeal fracture $ 897.30 Open treatment of iliac spine(s), tuberosity avulsion, or iliac wing fracture(s), unilateral, for pelvic bone fracture patterns that do not 1437 27215 27215 disrupt the pelvic ring, includes internal fixation, when performed $ 2,472.30 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Percutaneous skeletal fixation of posterior pelvic bone fracture and/or dislocation, for fracture patterns that disrupt the pelvic ring, 1438 27216 27216 unilateral (includes ipsilateral ilium, sacroiliac joint and/or sacrum) $ 2,767.50 Open treatment of anterior pelvic bone fracture and/or dislocation for fracture patterns that disrupt the pelvic ring, unilateral, includes internal fixation, when performed (includes pubic symphysis and/or 1439 27217 27217 ipsilateral superior/inferior rami) $ 3,654.90 Open treatment of posterior pelvic bone fracture and/or dislocation, for fracture patterns that disrupt the pelvic ring, unilateral, includes internal fixation, when performed (includes 1440 27218 27218 ipsilateral ilium, sacroiliac joint and/or sacrum) $ 4,345.20 Closed treatment of acetabulum (hip socket) fracture(s); without 1441 27220 27220 manipulation $ 896.40 Closed treatment of acetabulum (hip socket) fracture(s); with 1442 27222 27222 manipulation, with or without skeletal traction $ 1,599.30 Open treatment of posterior or anterior acetabular wall fracture, 1443 27226 27226 with internal fixation $ 3,602.70 Open treatment of acetabular fracture(s) involving anterior or posterior (one) column, or a fracture running transversely across 1444 27227 27227 the acetabulum, with internal fixation $ 6,057.90 Open treatment of acetabular fracture(s) involving anterior and posterior (two) columns, includes T-fracture and both column fracture with complete articular detachment, or single column or 1445 27228 27228 transverse fracture with associated acetabular wall fracture, wit $ 6,196.50 Closed treatment of femoral fracture, proximal end, neck; without 1446 27230 27230 manipulation $ 1,077.30 Closed treatment of femoral fracture, proximal end, neck; with 1447 27232 27232 manipulation, with or without skeletal traction $ 1,769.40 Percutaneous skeletal fixation of femoral fracture, proximal end, 1448 27235 27235 neck $ 3,135.60 Open treatment of femoral fracture, proximal end, neck, internal 1449 27236 27236 fixation or prosthetic replacement $ 3,712.50 Closed treatment of intertrochanteric, peritrochanteric, or 1450 27238 27238 subtrochanteric femoral fracture; without manipulation $ 1,142.10 Closed treatment of intertrochanteric, peritrochanteric, or subtrochanteric femoral fracture; with manipulation, with or 1451 27240 27240 without skin or skeletal traction $ 2,139.30 Treatment of intertrochanteric, peritrochanteric, or subtrochanteric femoral fracture; with plate/screw type implant, with or without 1452 27244 27244 cerclage $ 3,339.00 Treatment of intertrochanteric, peritrochanteric, or subtrochanteric femoral fracture; with intramedullary implant, with or without 1453 27245 27245 interlocking screws and/or cerclage $ 3,947.40 Closed treatment of greater trochanteric fracture, without 1454 27246 27246 manipulation $ 903.60 Open treatment of greater trochanteric fracture, includes internal 1455 27248 27248 fixation, when performed $ 2,221.20 1456 27250 27250 Closed treatment of hip dislocation, traumatic; without anesthesia $ 764.10 1457 27252 27252 Closed treatment of hip dislocation, traumatic; requiring anesthesia $ 1,134.90 Open treatment of hip dislocation, traumatic, without internal 1458 27253 27253 fixation $ 2,451.60 Open treatment of hip dislocation, traumatic, with acetabular wall and femoral head fracture, with or without internal or external 1459 27254 27254 fixation $ 3,348.00 Treatment of spontaneous hip dislocation (developmental, including congenital or pathological), by abduction, splint or 1460 27256 27256 traction; without anesthesia, without manipulation $ 1,652.40 Treatment of spontaneous hip dislocation (developmental, including congenital or pathological), by abduction, splint or 1461 27257 27257 traction; with manipulation, requiring anesthesia $ 1,835.10 Open treatment of spontaneous hip dislocation (developmental, including congenital or pathological), replacement of femoral head 1462 27258 27258 in acetabulum (including tenotomy, etc); $ 2,468.70 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Open treatment of spontaneous hip dislocation (developmental, including congenital or pathological), replacement of femoral head in acetabulum (including tenotomy, etc); with femoral shaft 1463 27259 27259 shortening $ 2,904.30 Closed treatment of post hip arthroplasty dislocation; without 1464 27265 27265 anesthesia $ 772.20 Closed treatment of post hip arthroplasty dislocation; requiring 1465 27266 27266 regional or general anesthesia $ 1,535.40 Closed treatment of femoral fracture, proximal end, head; without 1466 27267 27267 manipulation $ 864.17 Closed treatment of femoral fracture, proximal end, head; with 1467 27268 27268 manipulation $ 1,109.74 Open treatment of femoral fracture, proximal end, head, includes 1468 27269 27269 internal fixation, when performed $ 2,878.69 1469 27275 27275 Manipulation, hip joint, requiring general anesthesia $ 505.80 1470 27280 27280 Arthrodesis, sacroiliac joint (including obtaining graft) $ 2,464.20 1471 27282 27282 Arthrodesis, symphysis pubis (including obtaining graft) $ 2,461.50 1472 27284 27284 Arthrodesis, hip joint (including obtaining graft); $ 4,975.20 Arthrodesis, hip joint (including obtaining graft); with 1473 27286 27286 subtrochanteric osteotomy $ 4,097.70 1474 27290 27290 Interpelviabdominal amputation (hindquarter amputation) $ 5,978.70 1475 27295 27295 Disarticulation of hip $ 4,355.10 1476 27299 27299 Unlisted procedure, pelvis or hip joint Cost Incision and drainage, deep abscess, bursa, or hematoma, thigh or 1477 27301 27301 knee region $ 832.94 Incision, deep, with opening of bone cortex, femur or knee (eg, 1478 27303 27303 osteomyelitis or bone abscess) $ 1,818.00 1479 27305 27305 Fasciotomy, iliotibial (tenotomy), open $ 1,055.70 Tenotomy, percutaneous, adductor or hamstring; single tendon 1480 27306 27306 (separate procedure) $ 681.30 1481 27307 27307 Tenotomy, percutaneous, adductor or hamstring; multiple tendons $ 1,024.20 Arthrotomy, knee, with exploration, drainage, or removal of foreign 1482 27310 27310 body (eg, infection) $ 1,787.40 1483 27323 27323 Biopsy, soft tissue of thigh or knee area; superficial $ 360.90 Biopsy, soft tissue of thigh or knee area; deep (subfascial or 1484 27324 27324 intramuscular) $ 807.30 1485 27325 27325 Neurectomy, hamstring muscle $ 1,757.66 1486 27326 27326 Neurectomy, popliteal (gastrocnemius) $ 1,605.75 Excision, tumor, soft tissue of thigh or knee area, subcutaneous; less 1487 27327 27327 than 3 cm $ 720.00 Excision, tumor, soft tissue of thigh or knee area, subfascial (eg, 1488 27328 27328 intramuscular); less than 5 cm $ 1,256.40 Radical resection of tumor (eg, sarcoma), soft tissue of thigh or 1489 27329 27329 knee area; less than 5 cm $ 2,625.30 1490 27330 27330 Arthrotomy, knee; with synovial biopsy only $ 2,022.30 Arthrotomy, knee; including joint exploration, biopsy, or removal of 1491 27331 27331 loose or foreign bodies $ 1,806.30 Arthrotomy, with excision of semilunar cartilage (meniscectomy) 1492 27332 27332 knee; medial OR lateral $ 2,399.40 Arthrotomy, with excision of semilunar cartilage (meniscectomy) 1493 27333 27333 knee; medial AND lateral $ 3,174.14 1494 27334 27334 Arthrotomy, with synovectomy, knee; anterior OR posterior $ 2,421.00 Arthrotomy, with synovectomy, knee; anterior AND posterior 1495 27335 27335 including popliteal area $ 2,895.30 Excision, tumor, soft tissue of thigh or knee area, subcutaneous; 3 1496 27337 27337 cm or greater $ 1,376.91 Excision, tumor, soft tissue of thigh or knee area, subfascial (eg, 1497 27339 27339 intramuscular); 5 cm or greater $ 2,414.25 1498 27340 27340 Excision, prepatellar bursa $ 1,103.40 1499 27345 27345 Excision of synovial cyst of popliteal space (eg, Baker's cyst) $ 1,524.60 1500 27347 27347 Excision of lesion of meniscus or capsule (eg, cyst, ganglion), knee $ 784.80 1501 27350 27350 Patellectomy or hemipatellectomy $ 2,124.00 1502 27355 27355 Excision or curettage of bone cyst or benign tumor of femur; $ 1,802.70 Excision or curettage of bone cyst or benign tumor of femur; with 1503 27356 27356 allograft $ 2,199.60 Excision or curettage of bone cyst or benign tumor of femur; with 1504 27357 27357 autograft (includes obtaining graft) $ 2,436.30 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Excision or curettage of bone cyst or benign tumor of femur; with 1505 27358 27358 internal fixation (List in addition to code for primary procedure) $ 2,508.30 Partial excision (craterization, saucerization, or diaphysectomy) bone, femur, proximal tibia and/or fibula (eg, osteomyelitis or bone 1506 27360 27360 abscess) $ 1,926.90 Radical resection of tumor (eg, sarcoma), soft tissue of thigh or 1507 27364 27364 knee area; 5 cm or greater $ 4,912.84 1508 27365 27365 Radical resection of tumor, femur or knee $ 3,127.50 1509 27370 27370 Injection procedure for knee arthrography $ 197.10 1510 27372 27372 Removal of foreign body, deep, thigh region or knee area $ 955.80 1511 27380 27380 Suture of infrapatellar tendon; primary $ 1,602.00 Suture of infrapatellar tendon; secondary reconstruction, including 1512 27381 27381 fascial or tendon graft $ 2,480.40 1513 27385 27385 Suture of quadriceps or hamstring muscle rupture; primary $ 1,827.90 Suture of quadriceps or hamstring muscle rupture; secondary 1514 27386 27386 reconstruction, including fascial or tendon graft $ 2,734.20 1515 27390 27390 Tenotomy, open, hamstring, knee to hip; single tendon $ 1,061.10 1516 27391 27391 Tenotomy, open, hamstring, knee to hip; multiple tendons, 1 leg $ 1,390.50 1517 27392 27392 Tenotomy, open, hamstring, knee to hip; multiple tendons, bilateral $ 2,008.80 1518 27393 27393 Lengthening of hamstring tendon; single tendon $ 1,071.00 1519 27394 27394 Lengthening of hamstring tendon; multiple tendons, 1 leg $ 1,632.60 1520 27395 27395 Lengthening of hamstring tendon; multiple tendons, bilateral $ 2,038.50 Transplant or transfer (with muscle redirection or rerouting), thigh 1521 27396 27396 (eg, extensor to flexor); single tendon $ 2,131.20 Transplant or transfer (with muscle redirection or rerouting), thigh 1522 27397 27397 (eg, extensor to flexor); multiple tendons $ 2,707.20 Transfer, tendon or muscle, hamstrings to femur (eg, Egger's type 1523 27400 27400 procedure) $ 1,980.00 1524 27403 27403 Arthrotomy with meniscus repair, knee $ 2,745.00 1525 27405 27405 Repair, primary, torn ligament and/or capsule, knee; collateral $ 2,272.50 1526 27407 27407 Repair, primary, torn ligament and/or capsule, knee; cruciate $ 3,190.50 Repair, primary, torn ligament and/or capsule, knee; collateral and 1527 27409 27409 cruciate ligaments $ 3,634.20 1528 27412 27412 Autologous chondrocyte implantation, knee $ 5,606.85 1529 27415 27415 Osteochondral allograft, knee, open $ 4,366.31 Osteochondral autograft(s), knee, open (eg, mosaicplasty) (includes 1530 27416 27416 harvesting of autograft[s]) $ 2,968.11 1531 27418 27418 Anterior tibial tubercleplasty (eg, Maquet type procedure) $ 3,002.40 1532 27420 27420 Reconstruction of dislocating patella; (eg, Hauser type procedure) $ 2,293.20 Reconstruction of dislocating patella;

with extensor realignment and/or muscle advancement or release (eg, Campbell, Goldwaite 1533 27422 27422 type procedure) $ 2,475.00 1534 27424 27424 Reconstruction of dislocating patella; with patellectomy $ 2,765.70 1535 27425 27425 Lateral retinacular release, open $ 2,367.00 1536 27427 27427 Ligamentous reconstruction (augmentation), knee; extra-articular $ 3,698.10 Ligamentous reconstruction (augmentation), knee; intra-articular 1537 27428 27428 (open) $ 3,715.20 Ligamentous reconstruction (augmentation), knee; intra-articular 1538 27429 27429 (open) and extra-articular $ 4,960.80 1539 27430 27430 Quadricepsplasty (eg, Bennett or Thompson type) $ 2,210.40 1540 27435 27435 Capsulotomy, posterior capsular release, knee $ 2,236.50 1541 27437 27437 Arthroplasty, patella; without prosthesis $ 2,274.30 1542 27438 27438 Arthroplasty, patella; with prosthesis $ 2,720.70 1543 27440 27440 Arthroplasty, knee, tibial plateau; $ 3,292.20 Arthroplasty, knee, tibial plateau; with debridement and partial 1544 27441 27441 synovectomy $ 3,002.40 1545 27442 27442 Arthroplasty, femoral condyles or tibial plateau(s), knee; $ 3,510.00 Arthroplasty, femoral condyles or tibial plateau(s), knee; with 1546 27443 27443 debridement and partial synovectomy $ 3,554.10 1547 27445 27445 Arthroplasty, knee, hinge prosthesis (eg, Walldius type) $ 4,499.10 Arthroplasty, knee, condyle and plateau; medial OR lateral 1548 27446 27446 compartment $ 4,126.63 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing (total knee 1549 27447 27447 arthroplasty) $ 5,226.12 1550 27448 27448 Osteotomy, femur, shaft or supracondylar; without fixation $ 2,877.30 1551 27450 27450 Osteotomy, femur, shaft or supracondylar; with fixation $ 2,826.90 Osteotomy, multiple, with realignment on intramedullary rod, 1552 27454 27454 femoral shaft (eg, Sofield type procedure) $ 3,295.80 Osteotomy, proximal tibia, including fibular excision or osteotomy (includes correction of genu varus [bowleg] or genu valgus [knock- 1553 27455 27455 knee]); before epiphyseal closure $ 2,394.90 Osteotomy, proximal tibia, including fibular excision or osteotomy (includes correction of genu varus [bowleg] or genu valgus [knock- 1554 27457 27457 knee]); after epiphyseal closure $ 2,886.30 1555 27465 27465 Osteoplasty, femur; shortening (excluding 64876) $ 3,267.90 1556 27466 27466 Osteoplasty, femur; lengthening $ 3,707.10 Osteoplasty, femur; combined, lengthening and shortening with 1557 27468 27468 femoral segment transfer $ 4,853.70 Repair, nonunion or malunion, femur, distal to head and neck; 1558 27470 27470 without graft (eg, compression technique) $ 3,579.30 Repair, nonunion or malunion, femur, distal to head and neck; with 1559 27472 27472 iliac or other autogenous bone graft (includes obtaining graft) $ 4,050.00 1560 27475 27475 Arrest, epiphyseal, any method (eg, epiphysiodesis); distal femur $ 2,453.40 Arrest, epiphyseal, any method (eg, epiphysiodesis); tibia and fibula, 1561 27477 27477 proximal $ 2,636.10 Arrest, epiphyseal, any method (eg, epiphysiodesis); combined 1562 27479 27479 distal femur, proximal tibia and fibula $ 3,160.80 Arrest, hemiepiphyseal, distal femur or proximal tibia or fibula (eg, 1563 27485 27485 genu varus or valgus) $ 1,805.40 Revision of total knee arthroplasty, with or without allograft; 1 1564 27486 27486 component $ 5,175.90 Revision of total knee arthroplasty, with or without allograft; 1565 27487 27487 femoral and entire tibial component $ 6,452.10 Removal of prosthesis, including total knee prosthesis, 1566 27488 27488 methylmethacrylate with or without insertion of spacer, knee $ 3,144.60 Prophylactic treatment (nailing, pinning, plating, or wiring) with or 1567 27495 27495 without methylmethacrylate, femur $ 3,450.60 Decompression fasciotomy, thigh and/or knee, 1 compartment 1568 27496 27496 (flexor or extensor or adductor); $ 1,184.40 Decompression fasciotomy, thigh and/or knee, 1 compartment (flexor or extensor or adductor); with debridement of nonviable 1569 27497 27497 muscle and/or nerve $ 1,555.20 Decompression fasciotomy, thigh and/or knee, multiple 1570 27498 27498 compartments; $ 2,394.90 Decompression fasciotomy, thigh and/or knee, multiple 1571 27499 27499 compartments; with debridement of nonviable muscle and/or nerve $ 2,421.00 1572 27500 27500 Closed treatment of femoral shaft fracture, without manipulation $ 1,207.80 Closed treatment of supracondylar or transcondylar femoral fracture with or without intercondylar extension, without 1573 27501 27501 manipulation $ 1,495.80 Closed treatment of femoral shaft fracture, with manipulation, with 1574 27502 27502 or without skin or skeletal traction $ 1,648.80 Closed treatment of supracondylar or transcondylar femoral fracture with or without intercondylar extension, with 1575 27503 27503 manipulation, with or without skin or skeletal traction $ 2,035.80 Open treatment of femoral shaft fracture, with or without external fixation, with insertion of intramedullary implant, with or without 1576 27506 27506 cerclage and/or locking screws $ 3,828.60 Open treatment of femoral shaft fracture with plate/screws, with or 1577 27507 27507 without cerclage $ 3,386.70 Closed treatment of femoral fracture, distal end, medial or lateral 1578 27508 27508 condyle, without manipulation $ 1,017.00 Percutaneous skeletal fixation of femoral fracture, distal end, medial or lateral condyle, or supracondylar or transcondylar, with or without intercondylar extension, or distal femoral epiphyseal 1579 27509 27509 separation $ 1,913.40 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Closed treatment of femoral fracture, distal end, medial or lateral 1580 27510 27510 condyle, with manipulation $ 1,447.20 Open treatment of femoral supracondylar or transcondylar fracture without intercondylar extension, includes internal fixation, when 1581 27511 27511 performed $ 3,213.90 Open treatment of femoral supracondylar or transcondylar fracture with intercondylar extension, includes internal fixation, when 1582 27513 27513 performed $ 3,411.90 Open treatment of femoral fracture, distal end, medial or lateral 1583 27514 27514 condyle, includes internal fixation, when performed $ 3,283.20 Closed treatment of distal femoral epiphyseal separation; without 1584 27516 27516 manipulation $ 1,274.40 Closed treatment of distal femoral epiphyseal separation; with 1585 27517 27517 manipulation, with or without skin or skeletal traction $ 1,467.90 Open treatment of distal femoral epiphyseal separation, includes 1586 27519 27519 internal fixation, when performed $ 3,119.40 1587 27520 27520 Closed treatment of patellar fracture, without manipulation $ 578.70 Open treatment of patellar fracture, with internal fixation and/or 1588 27524 27524 partial or complete patellectomy and soft tissue repair $ 2,121.30 Closed treatment of tibial fracture, proximal (plateau); without 1589 27530 27530 manipulation $ 852.30 Closed treatment of tibial fracture, proximal (plateau); with or 1590 27532 27532 without manipulation, with skeletal traction $ 1,169.10 Open treatment of tibial fracture, proximal (plateau); unicondylar, 1591 27535 27535 includes internal fixation, when performed $ 2,665.80 Open treatment of tibial fracture, proximal (plateau); bicondylar, 1592 27536 27536 with or without internal fixation $ 2,615.40 Closed treatment of intercondylar spine(s) and/or tuberosity 1593 27538 27538 fracture(s) of knee, with or without manipulation $ 950.40 Open treatment of intercondylar spine(s) and/or tuberosity 1594 27540 27540 fracture(s) of the knee, includes internal fixation, when performed $ 2,468.70 1595 27550 27550 Closed treatment of knee dislocation; without anesthesia $ 669.60 1596 27552 27552 Closed treatment of knee dislocation; requiring anesthesia $ 1,050.30 Open treatment of knee dislocation, includes internal fixation, when performed; without primary ligamentous repair or 1597 27556 27556 augmentation/reconstruction $ 2,856.60 Open treatment of knee dislocation, includes internal fixation, when 1598 27557 27557 performed; with primary ligamentous repair $ 3,537.90 Open treatment of knee dislocation, includes internal fixation, when performed; with primary ligamentous repair, with 1599 27558 27558 augmentation/reconstruction $ 3,331.80 1600 27560 27560 Closed treatment of patellar dislocation; without anesthesia $ 461.70 1601 27562 27562 Closed treatment of patellar dislocation; requiring anesthesia $ 789.30 Open treatment of patellar dislocation, with or without partial or 1602 27566 27566 total patellectomy $ 2,060.10 Manipulation of knee joint under general anesthesia (includes 1603 27570 27570 application of traction or other fixation devices) $ 529.96 1604 27580 27580 Arthrodesis, knee, any technique $ 3,822.30 1605 27590 27590 Amputation, thigh, through femur, any level; $ 2,446.20 Amputation, thigh, through femur, any level; immediate fitting 1606 27591 27591 technique including first cast $ 2,583.00 Amputation, thigh, through femur, any level; open, circular 1607 27592 27592 (guillotine) $ 2,543.40 Amputation, thigh, through femur, any level; secondary closure or 1608 27594 27594 scar revision $ 1,235.70 1609 27596 27596 Amputation, thigh, through femur, any level; re-amputation $ 2,379.60 1610 27598 27598 Disarticulation at knee $ 2,443.50 1611 27599 27599 Unlisted procedure, femur or knee Cost Decompression fasciotomy, leg; anterior and/or lateral 1612 27600 27600 compartments only $ 991.80 1613 27601 27601 Decompression fasciotomy, leg; posterior compartment(s) only $ 1,097.10 Decompression fasciotomy, leg; anterior and/or lateral, and 1614 27602 27602 posterior compartment(s) $ 1,403.10 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price 1615 27603 27603 Incision and drainage, leg or ankle; deep abscess or hematoma $ 799.29 1616 27604 27604 Incision and drainage, leg or ankle; infected bursa $ 529.20 Tenotomy, percutaneous, Achilles tendon (separate procedure); 1617 27605 27605 local anesthesia $ 489.60 Tenotomy, percutaneous, Achilles tendon (separate procedure); 1618 27606 27606 general anesthesia $ 918.90 1619 27607 27607 Incision (eg, osteomyelitis or bone abscess), leg or ankle $ 1,390.50 Arthrotomy, ankle, including exploration, drainage, or removal of 1620 27610 27610 foreign body $ 1,504.80 Arthrotomy, posterior capsular release, ankle, with or without 1621 27612 27612 Achilles tendon lengthening $ 1,591.20 1622 27613 27613 Biopsy, soft tissue of leg or ankle area; superficial $ 421.20 Biopsy, soft tissue of leg or ankle area; deep (subfascial or 1623 27614 27614 intramuscular) $ 842.40 Radical resection of tumor (eg, sarcoma), soft tissue of leg or ankle 1624 27615 27615 area; less than 5 cm $ 2,870.10 Radical resection of tumor (eg, sarcoma), soft tissue of leg or ankle 1625 27616 27616 area; 5 cm or greater $ 3,296.27 Excision, tumor, soft tissue of leg or ankle area, subcutaneous; less 1626 27618 27618 than 3 cm $ 846.00 Excision, tumor, soft tissue of leg or ankle area, subfascial (eg, 1627 27619 27619 intramuscular); less than 5 cm $ 1,333.80 Arthrotomy, ankle, with joint exploration, with or without biopsy, 1628 27620 27620 with or without removal of loose or foreign body $ 1,577.70 1629 27625 27625 Arthrotomy, with synovectomy, ankle; $ 2,103.30 1630 27626 27626 Arthrotomy, with synovectomy, ankle; including tenosynovectomy $ 2,202.30 Excision of lesion of tendon sheath or capsule (eg, cyst or ganglion), 1631 27630 27630 leg and/or ankle $ 867.60 Excision, tumor, soft tissue of leg or ankle area, subcutaneous; 3 cm 1632 27632 27632 or greater $ 802.95 Excision, tumor, soft tissue of leg or ankle area, subfascial (eg, 1633 27634 27634 intramuscular); 5 cm or greater $ 1,801.95 1634 27635 27635 Excision or curettage of bone cyst or benign tumor, tibia or fibula; $ 1,979.10 Excision or curettage of bone cyst or benign tumor, tibia or fibula; 1635 27637 27637 with autograft (includes obtaining graft) $ 2,095.20 Excision or curettage of bone cyst or benign tumor, tibia or fibula; 1636 27638 27638 with allograft $ 2,301.30 Partial excision (craterization, saucerization, or diaphysectomy), 1637 27640 27640 bone (eg, osteomyelitis); tibia $ 2,338.20 Partial excision (craterization, saucerization, or diaphysectomy), 1638 27641 27641 bone (eg, osteomyelitis); fibula $ 1,883.70 1639 27645 27645 Radical resection of tumor; tibia $ 2,884.50 1640 27646 27646 Radical resection of tumor; fibula $ 2,287.80 1641 27647 27647 Radical resection of tumor; talus or calcaneus $ 2,766.60 1642 27648 27648 Injection procedure for ankle arthrography $ 187.20 1643 27650 27650 Repair, primary, open or percutaneous, ruptured Achilles tendon; $ 1,908.66 Repair, primary, open or percutaneous, ruptured Achilles tendon; 1644 27652 27652 with graft (includes obtaining graft) $ 2,335.50 1645 27654 27654 Repair, secondary, Achilles tendon, with or without graft $ 2,672.10 1646 27656 27656 Repair, fascial defect of leg $ 1,035.90 1647 27658 27658 Repair, flexor tendon, leg; primary, without graft, each tendon $ 1,115.10 Repair, flexor tendon, leg; secondary, with or without graft, each 1648 27659 27659 tendon $ 1,606.50 1649 27664 27664 Repair, extensor tendon, leg; primary, without graft, each tendon $ 1,085.40 Repair, extensor tendon, leg; secondary, with or without graft, each 1650 27665 27665 tendon $ 1,157.40 1651 27675 27675 Repair, dislocating peroneal tendons; without fibular osteotomy $ 1,295.10 1652 27676 27676 Repair, dislocating peroneal tendons; with fibular osteotomy $ 1,339.20 Tenolysis, flexor or extensor tendon, leg and/or ankle; single, each 1653 27680 27680 tendon $ 1,331.10 Tenolysis, flexor or extensor tendon, leg and/or ankle; multiple 1654 27681 27681 tendons (through separate incision(s)) $ 1,042.20 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Lengthening or shortening of tendon, leg or ankle; single tendon 1655 27685 27685 (separate procedure) $ 1,200.60 Lengthening or shortening of tendon, leg or ankle; multiple tendons 1656 27686 27686 (through same incision), each $ 1,363.50 1657 27687 27687 Gastrocnemius recession (eg, Strayer procedure) $ 1,171.80 Transfer or transplant of single tendon (with muscle redirection or 1658 27690 27690 rerouting); superficial (eg, anterior tibial extensors into midfoot) $ 1,647.90 Transfer or transplant of single tendon (with muscle redirection or rerouting); deep (eg, anterior tibial or posterior tibial through interosseous space, flexor digitorum longus, flexor hallucis longus, 1659 27691 27691 or peroneal tendon to midfoot or hindfoot) $ 1,859.40 Transfer or transplant of single tendon (with muscle redirection or rerouting); each additional tendon (List separately in addition to 1660 27692 27692 code for primary procedure) $ 544.50 1661 27695 27695 Repair, primary, disrupted ligament, ankle; collateral $ 1,703.70 1662 27696 27696 Repair, primary, disrupted ligament, ankle; both collateral ligaments $ 2,338.20 Repair, secondary, disrupted ligament, ankle, collateral (eg, Watson- 1663 27698 27698 Jones procedure) $ 2,367.00 1664 27700 27700 Arthroplasty, ankle; $ 2,807.10 1665 27702 27702 Arthroplasty, ankle; with implant (total ankle) $ 4,042.80 1666 27703 27703 Arthroplasty, ankle; revision, total ankle $ 3,919.50 1667 27704 27704 Removal of ankle implant $ 2,137.50 1668 27705 27705 Osteotomy; tibia $ 2,241.00 1669 27707 27707 Osteotomy; fibula $ 1,283.40 1670 27709 27709 Osteotomy; tibia and fibula $ 2,755.80 Osteotomy; multiple, with realignment on intramedullary rod (eg, 1671 27712 27712 Sofield type procedure) $ 2,601.00 1672 27715 27715 Osteoplasty, tibia and fibula, lengthening or shortening $ 3,445.20 Repair of nonunion or malunion, tibia; without graft, (eg, 1673 27720 27720 compression technique) $ 2,987.10 1674 27722 27722 Repair of nonunion or malunion, tibia; with sliding graft $ 3,027.60 Repair of nonunion or malunion, tibia; with iliac or other autograft 1675 27724 27724 (includes obtaining graft) $ 3,375.90 Repair of nonunion or malunion, tibia; by synostosis, with fibula, 1676 27725 27725 any method $ 3,711.60 1677 27726 27726 Repair of fibula nonunion and/or malunion with internal fixation $ 2,950.61 1678 27727 27727 Repair of congenital pseudarthrosis, tibia $ 2,699.10 1679 27730 27730 Arrest, epiphyseal (epiphysiodesis), open; distal tibia $ 1,624.50 1680 27732 27732 Arrest, epiphyseal (epiphysiodesis), open; distal fibula $ 1,235.70 1681 27734 27734 Arrest, epiphyseal (epiphysiodesis), open; distal tibia and fibula $ 1,830.60 Arrest, epiphyseal (epiphysiodesis), any method, combined, 1682 27740 27740 proximal and distal tibia and fibula; $ 2,415.60 Arrest, epiphyseal (epiphysiodesis), any method, combined, 1683 27742 27742 proximal and distal tibia and fibula; and distal femur $ 3,129.30 Prophylactic treatment (nailing, pinning, plating or wiring) with or 1684 27745 27745 without methylmethacrylate, tibia $ 2,493.00 Closed treatment of tibial shaft fracture (with or without fibular 1685 27750 27750 fracture); without manipulation $ 702.97 Closed treatment of tibial shaft fracture (with or without fibular 1686 27752 27752 fracture); with manipulation, with or without skeletal traction $ 1,081.80 Percutaneous skeletal fixation of tibial shaft fracture (with or 1687 27756 27756 without fibular fracture) (eg, pins or screws) $ 2,086.20 Open treatment of tibial shaft fracture (with or without fibular 1688 27758 27758 fracture), with plate/screws, with or without cerclage $ 2,968.20 Treatment of tibial shaft fracture (with or without fibular fracture) by intramedullary implant, with or without interlocking screws 1689 27759 27759 and/or cerclage $ 3,328.20 Closed treatment of medial malleolus fracture; without 1690 27760 27760 manipulation $ 503.10 Closed treatment of medial malleolus fracture; with manipulation, 1691 27762 27762 with or without skin or skeletal traction $ 824.40 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Open treatment of medial malleolus fracture, includes internal 1692 27766 27766 fixation, when performed $ 1,553.40 Closed treatment of posterior malleolus fracture; without 1693 27767 27767 manipulation $ 548.09 1694 27768 27768 Closed treatment of posterior malleolus fracture; with manipulation $ 868.53 Open treatment of posterior malleolus fracture, includes internal 1695 27769 27769 fixation, when performed $ 1,707.43 Closed treatment of proximal fibula or shaft fracture; without 1696 27780 27780 manipulation $ 562.50 Closed treatment of proximal fibula or shaft fracture; with 1697 27781 27781 manipulation $ 893.70 Open treatment of proximal fibula or shaft fracture, includes 1698 27784 27784 internal fixation, when performed $ 1,605.60 Closed treatment of distal fibular fracture (lateral malleolus); 1699 27786 27786 without manipulation $ 463.50 Closed treatment of distal fibular fracture (lateral malleolus); with 1700 27788 27788 manipulation $ 818.10 Open treatment of distal fibular fracture (lateral malleolus), 1701 27792 27792 includes internal fixation, when performed $ 1,539.90 Closed treatment of bimalleolar ankle fracture (eg, lateral and medial malleoli, or lateral and posterior malleoli, or medial and 1702 27808 27808 posterior malleoli); without manipulation $ 643.50 Closed treatment of bimalleolar ankle fracture (eg, lateral and medial malleoli, or lateral and posterior malleoli, or medial and 1703 27810 27810 posterior malleoli); with manipulation $ 1,189.80 Open treatment of bimalleolar ankle fracture (eg, lateral and medial malleoli, or lateral and posterior malleoli, or medial and posterior 1704 27814 27814 malleoli), includes internal fixation, when performed $ 2,196.90 Closed treatment of trimalleolar ankle fracture; without 1705 27816 27816 manipulation $ 842.40 1706 27818 27818 Closed treatment of trimalleolar ankle fracture; with manipulation $ 1,312.20 Open treatment of trimalleolar ankle fracture, includes internal fixation, when performed, medial and/or lateral malleolus; without 1707 27822 27822 fixation of posterior lip $ 2,358.90 Open treatment of trimalleolar ankle fracture, includes internal fixation, when performed, medial and/or lateral malleolus; with 1708 27823 27823 fixation of posterior lip $ 2,880.90 Closed treatment of fracture of weight bearing articular portion of distal tibia (eg, pilon or tibial plafond), with or without anesthesia; 1709 27824 27824 without manipulation $ 813.60 Closed treatment of fracture of weight bearing articular portion of distal tibia (eg, pilon or tibial plafond), with or without anesthesia; 1710 27825 27825 with skeletal traction and/or requiring manipulation $ 1,673.10 Open treatment of fracture of weight bearing articular surface/portion of distal tibia (eg, pilon or tibial plafond), with 1711 27826 27826 internal fixation, when performed; of fibula only $ 2,421.00 Open treatment of fracture of weight bearing articular surface/portion of distal tibia (eg, pilon or tibial plafond), with 1712 27827 27827 internal fixation, when performed; of tibia only $ 2,786.40 Open treatment of fracture of weight bearing articular surface/portion of distal tibia (eg, pilon or tibial plafond), with 1713 27828 27828 internal fixation, when performed; of both tibia and fibula $ 3,352.50 Open treatment of distal tibiofibular joint (syndesmosis) disruption, 1714 27829 27829 includes internal fixation, when performed $ 1,629.90 Closed treatment of proximal tibiofibular joint dislocation; without 1715 27830 27830 anesthesia $ 607.50 Closed treatment of proximal tibiofibular joint dislocation; requiring 1716 27831 27831 anesthesia $ 695.70 Open treatment of proximal tibiofibular joint dislocation, includes internal fixation, when performed, or with excision of proximal 1717 27832 27832 fibula $ 1,254.60 1718 27840 27840 Closed treatment of ankle dislocation; without anesthesia $ 537.30 Closed treatment of ankle dislocation; requiring anesthesia, with or 1719 27842 27842 without percutaneous skeletal fixation $ 761.40 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Open treatment of ankle dislocation, with or without percutaneous 1720 27846 27846 skeletal fixation; without repair or internal fixation $ 1,946.70 Open treatment of ankle dislocation, with or without percutaneous 1721 27848 27848 skeletal fixation; with repair or internal or external fixation $ 2,139.30 Manipulation of ankle under general anesthesia (includes 1722 27860 27860 application of traction or other fixation apparatus) $ 425.70 1723 27870 27870 Arthrodesis, ankle, open $ 2,708.10 1724 27871 27871 Arthrodesis, tibiofibular joint, proximal or distal $ 2,174.40 1725 27880 27880 Amputation, leg, through tibia and fibula; $ 2,462.40 Amputation, leg, through tibia and fibula; with immediate fitting 1726 27881 27881 technique including application of first cast $ 2,837.70 1727 27882 27882 Amputation, leg, through tibia and fibula; open, circular (guillotine) $ 2,366.10 Amputation, leg, through tibia and fibula; secondary closure or scar 1728 27884 27884 revision $ 1,488.60 1729 27886 27886 Amputation, leg, through tibia and fibula; re-amputation $ 2,375.10 Amputation, ankle, through malleoli of tibia and fibula (eg, Syme, Pirogoff type procedures), with plastic closure and resection of 1730 27888 27888 nerves $ 2,007.90 1731 27889 27889 Ankle disarticulation $ 1,886.40 Decompression fasciotomy, leg; anterior and/or lateral compartments only, with debridement of nonviable muscle and/or 1732 27892 27892 nerve $ 1,674.00 Decompression fasciotomy, leg; posterior compartment(s) only, 1733 27893 27893 with debridement of nonviable muscle and/or nerve $ 1,622.70 Decompression fasciotomy, leg; anterior and/or lateral, and posterior compartment(s), with debridement of nonviable muscle 1734 27894 27894 and/or nerve $ 1,946.70 1735 27899 27899 Unlisted procedure, leg or ankle Cost 1736 28001 28001 Incision and drainage, bursa, foot $ 412.20 Incision and drainage below fascia, with or without tendon sheath 1737 28002 28002 involvement, foot; single bursal space $ 779.40 Incision and drainage below fascia, with or without tendon sheath 1738 28003 28003 involvement, foot; multiple areas $ 973.80 1739 28005 28005 Incision, bone cortex (eg, osteomyelitis or bone abscess), foot $ 991.80 1740 28008 28008 Fasciotomy, foot and/or toe $ 700.20 1741 28010 28010 Tenotomy, percutaneous, toe; single tendon $ 425.70 1742 28011 28011 Tenotomy, percutaneous, toe; multiple tendons $ 526.50 Arthrotomy, including exploration, drainage, or removal of loose or 1743 28020 28020 foreign body; intertarsal or tarsometatarsal joint $ 1,106.10 Arthrotomy, including exploration, drainage, or removal of loose or 1744 28022 28022 foreign body; metatarsophalangeal joint $ 725.40 Arthrotomy, including exploration, drainage, or removal of loose or 1745 28024 28024 foreign body; interphalangeal joint $ 669.60 1746 28035 28035 Release, tarsal tunnel (posterior tibial nerve decompression) $ 1,653.30 Excision, tumor, soft tissue of foot or toe, subcutaneous; 1.5 cm or 1747 28039 28039 greater $ 805.26 Excision, tumor, soft tissue of foot or toe, subfascial (eg, 1748 28041 28041 intramuscular); 1.5 cm or greater $ 941.09 Excision, tumor, soft tissue of foot or toe, subcutaneous; less than 1749 28043 28043 1.5 cm $ 525.60 Excision, tumor, soft tissue of foot or toe, subfascial (eg, 1750 28045 28045 intramuscular); less than 1.5 cm $ 1,077.30 Radical resection of tumor (eg, sarcoma), soft tissue of foot or toe; 1751 28046 28046 less than 3 cm $ 1,923.30 Radical resection of tumor (eg, sarcoma), soft tissue of foot or toe; 3 1752 28047 28047 cm or greater $ 1,845.03 1753 28050 28050 Arthrotomy with biopsy; intertarsal or tarsometatarsal joint $ 1,000.80 1754 28052 28052 Arthrotomy with biopsy; metatarsophalangeal joint $ 690.30 1755 28054 28054 Arthrotomy with biopsy; interphalangeal joint $ 588.60 1756 28055 28055 Neurectomy, intrinsic musculature of foot $ 757.64 1757 28060 28060 Fasciectomy, plantar fascia; partial (separate procedure) $ 1,038.60 1758 28062 28062 Fasciectomy, plantar fascia; radical (separate procedure) $ 1,872.90 1759 28070 28070 Synovectomy; intertarsal or tarsometatarsal joint, each $ 1,097.10 1760 28072 28072 Synovectomy; metatarsophalangeal joint, each $ 727.20 1761 28080 28080 Excision, interdigital (Morton) neuroma, single, each $ 817.76 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price 1762 28086 28086 Synovectomy, tendon sheath, foot; flexor $ 1,244.70 1763 28088 28088 Synovectomy, tendon sheath, foot; extensor $ 873.90 Excision of lesion, tendon, tendon sheath, or capsule (including 1764 28090 28090 synovectomy) (eg, cyst or ganglion); foot $ 762.08 Excision of lesion, tendon, tendon sheath, or capsule (including 1765 28092 28092 synovectomy) (eg, cyst or ganglion); toe(s), each $ 675.00 Excision or curettage of bone cyst or benign tumor, talus or 1766 28100 28100 calcaneus; $ 1,274.40 Excision or curettage of bone cyst or benign tumor, talus or 1767 28102 28102 calcaneus; with iliac or other autograft (includes obtaining graft) $ 1,674.00 Excision or curettage of bone cyst or benign tumor, talus or 1768 28103 28103 calcaneus; with allograft $ 1,577.70 Excision or curettage of bone cyst or benign tumor, tarsal or 1769 28104 28104 metatarsal, except talus or calcaneus; $ 1,057.50 Excision or curettage of bone cyst or benign tumor, tarsal or metatarsal, except talus or calcaneus; with iliac or other autograft 1770 28106 28106 (includes obtaining graft) $ 1,435.50 Excision or curettage of bone cyst or benign tumor, tarsal or 1771 28107 28107 metatarsal, except talus or calcaneus; with allograft $ 1,215.90 Excision or curettage of bone cyst or benign tumor, phalanges of 1772 28108 28108 foot $ 862.20 Ostectomy, partial excision, fifth metatarsal head (bunionette) 1773 28110 28110 (separate procedure) $ 828.90 1774 28111 28111 Ostectomy, complete excision; first metatarsal head $ 1,013.40 Ostectomy, complete excision; other metatarsal head (second, third 1775 28112 28112 or fourth) $ 956.70 1776 28113 28113 Ostectomy, complete excision; fifth metatarsal head $ 973.80 Ostectomy, complete excision; all metatarsal heads, with partial proximal phalangectomy, excluding first metatarsal (eg, Clayton 1777 28114 28114 type procedure) $ 2,032.20 1778 28116 28116 Ostectomy, excision of tarsal coalition $ 1,553.40 1779 28118 28118 Ostectomy, calcaneus; $ 1,267.20 Ostectomy, calcaneus; for spur, with or without plantar fascial 1780 28119 28119 release $ 1,184.40 Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (eg, osteomyelitis or bossing); talus or 1781 28120 28120 calcaneus $ 1,287.90 Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (eg, osteomyelitis or bossing); tarsal or 1782 28122 28122 metatarsal bone, except talus or calcaneus $ 1,105.20 Partial excision (craterization, saucerization, sequestrectomy, or 1783 28124 28124 diaphysectomy) bone (eg, osteomyelitis or bossing); phalanx of toe $ 754.20 1784 28126 28126 Resection, partial or complete, phalangeal base, each toe $ 708.30 1785 28130 28130 Talectomy (astragalectomy) $ 1,640.70 1786 28140 28140 Metatarsectomy $ 1,133.10 1787 28150 28150 Phalangectomy, toe, each toe $ 699.30 1788 28153 28153 Resection, condyle(s), distal end of phalanx, each toe $ 751.50 Hemiphalangectomy or interphalangeal joint excision, toe, proximal 1789 28160 28160 end of phalanx, each $ 651.60 1790 28171 28171 Radical resection of tumor; tarsal (except talus or calcaneus) $ 1,622.70 1791 28173 28173 Radical resection of tumor; metatarsal $ 1,408.50 1792 28175 28175 Radical resection of tumor; phalanx of toe $ 999.00 1793 28190 28190 Removal of foreign body, foot; subcutaneous $ 346.50 1794 28192 28192 Removal of foreign body, foot; deep $ 671.40 1795 28193 28193 Removal of foreign body, foot; complicated $ 1,028.70 Repair, tendon, flexor, foot; primary or secondary, without free 1796 28200 28200 graft, each tendon $ 1,134.00 Repair, tendon, flexor, foot; secondary with free graft, each tendon 1797 28202 28202 (includes obtaining graft) $ 1,766.70 1798 28208 28208 Repair, tendon, extensor, foot; primary or secondary, each tendon $ 967.50 Repair, tendon, extensor, foot; secondary with free graft, each 1799 28210 28210 tendon (includes obtaining graft) $ 1,038.60 1800 28222 28222 Tenolysis, flexor, foot; multiple tendons $ 1,048.50 1801 28225 28225 Tenolysis, extensor, foot; single tendon $ 580.50 1802 28226 28226 Tenolysis, extensor, foot; multiple tendons $ 747.00 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Tenotomy, open, tendon flexor; foot, single or multiple tendon(s) 1803 28230 28230 (separate procedure) $ 724.50 Tenotomy, open, tendon flexor; toe, single tendon (separate 1804 28232 28232 procedure) $ 399.60 1805 28234 28234 Tenotomy, open, extensor, foot or toe, each tendon $ 517.50 Reconstruction (advancement), posterior tibial tendon with excision 1806 28238 28238 of accessory tarsal navicular bone (eg, Kidner type procedure) $ 1,545.30 1807 28240 28240 Tenotomy, lengthening, or release, abductor hallucis muscle $ 711.90 Division of plantar fascia and muscle (eg, Steindler stripping) 1808 28250 28250 (separate procedure) $ 1,148.40 1809 28260 28260 Capsulotomy, midfoot; medial release only (separate procedure) $ 1,608.30 1810 28261 28261 Capsulotomy, midfoot; with tendon lengthening $ 1,545.30 Capsulotomy, midfoot; extensive, including posterior talotibial capsulotomy and tendon(s) lengthening (eg, resistant clubfoot 1811 28262 28262 deformity) $ 2,923.20 1812 28264 28264 Capsulotomy, midtarsal (eg, Heyman type procedure) $ 2,145.60 Capsulotomy; metatarsophalangeal joint, with or without 1813 28270 28270 tenorrhaphy, each joint (separate procedure) $ 712.80 1814 28272 28272 Capsulotomy; interphalangeal joint, each joint (separate procedure) $ 654.30 1815 28280 28280 Syndactylization, toes (eg, webbing or Kelikian type procedure) $ 747.00 Correction, hammertoe (eg, interphalangeal fusion, partial or total 1816 28285 28285 phalangectomy) $ 813.60 Correction, cock-up fifth toe, with plastic skin closure (eg, Ruiz- 1817 28286 28286 Mora type procedure) $ 875.70 Ostectomy, partial, exostectomy or condylectomy, metatarsal head, 1818 28288 28288 each metatarsal head $ 1,009.80 Hallux rigidus correction with cheilectomy, debridement and 1819 28289 28289 capsular release of the first metatarsophalangeal joint $ 896.40 Correction, hallux valgus (bunion), with or without 1820 28290 28290 sesamoidectomy; simple exostectomy (eg, Silver type procedure) $ 1,244.70 Correction, hallux valgus (bunion), with or without 1821 28292 28292 sesamoidectomy; Keller, McBride, or Mayo type procedure $ 1,545.30 Correction, hallux valgus (bunion), with or without 1822 28293 28293 sesamoidectomy; resection of joint with implant $ 1,776.60 Correction, hallux valgus (bunion), with or without sesamoidectomy; with tendon transplants (eg, Joplin type 1823 28294 28294 procedure) $ 1,939.50 Correction, hallux valgus (bunion), with or without sesamoidectomy; with metatarsal osteotomy (eg, Mitchell, 1824 28296 28296 Chevron, or concentric type procedures) $ 1,827.42 Correction, hallux valgus (bunion), with or without 1825 28297 28297 sesamoidectomy; Lapidus-type procedure $ 1,831.50 Correction, hallux valgus (bunion), with or without 1826 28298 28298 sesamoidectomy; by phalanx osteotomy $ 1,392.30 Correction, hallux valgus (bunion), with or without 1827 28299 28299 sesamoidectomy; by double osteotomy $ 1,931.40 Osteotomy; calcaneus (eg, Dwyer or Chambers type procedure), 1828 28300 28300 with or without internal fixation $ 1,506.60 1829 28302 28302 Osteotomy; talus $ 1,606.50 1830 28304 28304 Osteotomy, tarsal bones, other than calcaneus or talus; $ 1,385.10 Osteotomy, tarsal bones, other than calcaneus or talus; with 1831 28305 28305 autograft (includes obtaining graft) (eg, Fowler type) $ 1,545.30 Osteotomy, with or without lengthening, shortening or angular 1832 28306 28306 correction, metatarsal; first metatarsal $ 1,287.90 Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; first metatarsal with autograft (other than 1833 28307 28307 first toe) $ 1,416.60 Osteotomy, with or without lengthening, shortening or angular 1834 28308 28308 correction, metatarsal; other than first metatarsal, each $ 1,104.30 Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; multiple (eg, Swanson type cavus foot 1835 28309 28309 procedure) $ 1,880.10 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Osteotomy, shortening, angular or rotational correction; proximal 1836 28310 28310 phalanx, first toe (separate procedure) $ 986.40 Osteotomy, shortening, angular or rotational correction; other 1837 28312 28312 phalanges, any toe $ 724.50 Reconstruction, angular deformity of toe, soft tissue procedures 1838 28313 28313 only (eg, overlapping second toe, fifth toe, curly toes) $ 919.80 1839 28315 28315 Sesamoidectomy, first toe (separate procedure) $ 1,097.10 1840 28320 28320 Repair, nonunion or malunion; tarsal bones $ 1,640.70 Repair, nonunion or malunion; metatarsal, with or without bone 1841 28322 28322 graft (includes obtaining graft) $ 1,387.80 1842 28340 28340 Reconstruction, toe, macrodactyly; soft tissue resection $ 1,427.40 1843 28341 28341 Reconstruction, toe, macrodactyly; requiring bone resection $ 1,542.60 1844 28344 28344 Reconstruction, toe(s); polydactyly $ 1,073.70 Reconstruction, toe(s); syndactyly, with or without skin graft(s), 1845 28345 28345 each web $ 1,471.50 1846 28360 28360 Reconstruction, cleft foot $ 2,493.00 1847 28400 28400 Closed treatment of calcaneal fracture; without manipulation $ 621.90 1848 28405 28405 Closed treatment of calcaneal fracture; with manipulation $ 1,003.50 Percutaneous skeletal fixation of calcaneal fracture, with 1849 28406 28406 manipulation $ 1,278.00 Open treatment of calcaneal fracture, includes internal fixation, 1850 28415 28415 when performed; $ 2,162.70 Open treatment of calcaneal fracture, includes internal fixation, when performed; with primary iliac or other autogenous bone graft 1851 28420 28420 (includes obtaining graft) $ 2,753.10 1852 28430 28430 Closed treatment of talus fracture; without manipulation $ 514.80 1853 28435 28435 Closed treatment of talus fracture; with manipulation $ 768.60 1854 28436 28436 Percutaneous skeletal fixation of talus fracture, with manipulation $ 918.00 Open treatment of talus fracture, includes internal fixation, when 1855 28445 28445 performed $ 1,998.00 1856 28446 28446 Open osteochondral autograft, talus (includes obtaining graft[s]) $ 2,581.39 Treatment of tarsal bone fracture (except talus and calcaneus); 1857 28450 28450 without manipulation, each $ 496.80 Treatment of tarsal bone fracture (except talus and calcaneus); with 1858 28455 28455 manipulation, each $ 643.50 Percutaneous skeletal fixation of tarsal bone fracture (except talus 1859 28456 28456 and calcaneus), with manipulation, each $ 710.10 Open treatment of tarsal bone fracture (except talus and 1860 28465 28465 calcaneus), includes internal fixation, when performed, each $ 1,416.60 Closed treatment of metatarsal fracture; without manipulation, 1861 28470 28470 each $ 459.00 1862 28475 28475 Closed treatment of metatarsal fracture; with manipulation, each $ 514.80 Percutaneous skeletal fixation of metatarsal fracture, with 1863 28476 28476 manipulation, each $ 925.20 Open treatment of metatarsal fracture, includes internal fixation, 1864 28485 28485 when performed, each $ 1,177.20 Closed treatment of fracture great toe, phalanx or phalanges; 1865 28490 28490 without manipulation $ 266.40 Closed treatment of fracture great toe, phalanx or phalanges; with 1866 28495 28495 manipulation $ 378.90 Percutaneous skeletal fixation of fracture great toe, phalanx or 1867 28496 28496 phalanges, with manipulation $ 576.90 Open treatment of fracture, great toe, phalanx or phalanges, 1868 28505 28505 includes internal fixation, when performed $ 783.90 Closed treatment of fracture, phalanx or phalanges, other than 1869 28510 28510 great toe; without manipulation, each $ 208.80 Closed treatment of fracture, phalanx or phalanges, other than 1870 28515 28515 great toe; with manipulation, each $ 297.00 Open treatment of fracture, phalanx or phalanges, other than great 1871 28525 28525 toe, includes internal fixation, when performed, each $ 744.30 1872 28530 28530 Closed treatment of sesamoid fracture $ 348.30 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Open treatment of sesamoid fracture, with or without internal 1873 28531 28531 fixation $ 880.47 Closed treatment of tarsal bone dislocation, other than talotarsal; 1874 28540 28540 without anesthesia $ 410.40 Closed treatment of tarsal bone dislocation, other than talotarsal; 1875 28545 28545 requiring anesthesia $ 564.30 Percutaneous skeletal fixation of tarsal bone dislocation, other than 1876 28546 28546 talotarsal, with manipulation $ 690.30 Open treatment of tarsal bone dislocation, includes internal 1877 28555 28555 fixation, when performed $ 1,030.50 1878 28570 28570 Closed treatment of talotarsal joint dislocation; without anesthesia $ 425.70 1879 28575 28575 Closed treatment of talotarsal joint dislocation; requiring anesthesia $ 577.80 Percutaneous skeletal fixation of talotarsal joint dislocation, with 1880 28576 28576 manipulation $ 801.00 Open treatment of talotarsal joint dislocation, includes internal 1881 28585 28585 fixation, when performed $ 1,476.00 Closed treatment of tarsometatarsal joint dislocation; without 1882 28600 28600 anesthesia $ 530.10 Closed treatment of tarsometatarsal joint dislocation; requiring 1883 28605 28605 anesthesia $ 592.20 Percutaneous skeletal fixation of tarsometatarsal joint dislocation, 1884 28606 28606 with manipulation $ 1,009.80 Open treatment of tarsometatarsal joint dislocation, includes 1885 28615 28615 internal fixation, when performed $ 1,235.70 Closed treatment of metatarsophalangeal joint dislocation; without 1886 28630 28630 anesthesia $ 335.70 Closed treatment of metatarsophalangeal joint dislocation; 1887 28635 28635 requiring anesthesia $ 369.90 Percutaneous skeletal fixation of metatarsophalangeal joint 1888 28636 28636 dislocation, with manipulation $ 566.10 Open treatment of metatarsophalangeal joint dislocation, includes 1889 28645 28645 internal fixation, when performed $ 782.10 Closed treatment of interphalangeal joint dislocation; without 1890 28660 28660 anesthesia $ 239.40 Closed treatment of interphalangeal joint dislocation; requiring 1891 28665 28665 anesthesia $ 320.40 Percutaneous skeletal fixation of interphalangeal joint dislocation, 1892 28666 28666 with manipulation $ 564.30 Open treatment of interphalangeal joint dislocation, includes 1893 28675 28675 internal fixation, when performed $ 684.90 1894 28705 28705 Arthrodesis; pantalar $ 2,897.10 1895 28715 28715 Arthrodesis; triple $ 3,185.10 1896 28725 28725 Arthrodesis; subtalar $ 2,137.50 1897 28730 28730 Arthrodesis, midtarsal or tarsometatarsal, multiple or transverse; $ 2,230.20 Arthrodesis, midtarsal or tarsometatarsal, multiple or transverse; 1898 28735 28735 with osteotomy (eg, flatfoot correction) $ 2,173.50 Arthrodesis, with tendon lengthening and advancement, midtarsal, 1899 28737 28737 tarsal navicular-cuneiform (eg, Miller type procedure) $ 1,982.70 1900 28740 28740 Arthrodesis, midtarsal or tarsometatarsal, single joint $ 1,674.00 1901 28750 28750 Arthrodesis, great toe; metatarsophalangeal joint $ 1,392.70 1902 28755 28755 Arthrodesis, great toe; interphalangeal joint $ 1,186.20 Arthrodesis, with extensor hallucis longus transfer to first metatarsal neck, great toe, interphalangeal joint (eg, Jones type 1903 28760 28760 procedure) $ 1,071.90 1904 28800 28800 Amputation, foot; midtarsal (eg, Chopart type procedure) $ 1,847.70 1905 28805 28805 Amputation, foot; transmetatarsal $ 2,238.30 1906 28810 28810 Amputation, metatarsal, with toe, single $ 1,152.90 1907 28820 28820 Amputation, toe; metatarsophalangeal joint $ 875.70 1908 28825 28825 Amputation, toe; interphalangeal joint $ 782.10 Extracorporeal shock wave, high energy, performed by a physician or other qualified health care professional, requiring anesthesia other than local, including ultrasound guidance, involving the 1909 28890 28890 plantar fascia $ 905.09 1910 28899 28899 Unlisted procedure, foot or toes Cost 1911 29000 29000 Application of halo type body cast (see 20661-20663 for insertion) $ 608.40 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price 1912 29010 29010 Application of Risser jacket, localizer, body; only $ 492.30 1913 29015 29015 Application of Risser jacket, localizer, body; including head $ 670.50 1914 29020 29020 Application of turnbuckle jacket, body; only $ 534.60 1915 29025 29025 Application of turnbuckle jacket, body; including head $ 578.70 1916 29035 29035 Application of body cast, shoulder to hips; $ 475.20 Application of body cast, shoulder to hips; including head, Minerva 1917 29040 29040 type $ 495.90 1918 29044 29044 Application of body cast, shoulder to hips; including 1 thigh $ 380.70 1919 29046 29046 Application of body cast, shoulder to hips; including both thighs $ 469.80 1920 29049 29049 Application, cast; figure-of-eight $ 194.40 1921 29055 29055 Application, cast; shoulder spica $ 389.70 1922 29058 29058 Application, cast; plaster Velpeau $ 198.90 1923 29065 29065 Application, cast; shoulder to hand (long arm) $ 206.10 1924 29075 29075 Application, cast; elbow to finger (short arm) $ 157.50 1925 29085 29085 Application, cast; hand and lower forearm (gauntlet) $ 156.05 1926 29086 29086 Application, cast; finger (eg, contracture) $ 110.50 1927 29105 29105 Application of long arm splint (shoulder to hand) $ 128.70 1928 29125 29125 Application of short arm splint (forearm to hand); static $ 99.00 1929 29126 29126 Application of short arm splint (forearm to hand); dynamic $ 134.10 1930 29130 29130 Application of finger splint; static $ 82.80 1931 29131 29131 Application of finger splint; dynamic $ 134.10 1932 29200 29200 Strapping; thorax $ 81.00 1933 29240 29240 Strapping; shoulder (eg, Velpeau) $ 90.00 1934 29260 29260 Strapping; elbow or wrist $ 65.68 1935 29280 29280 Strapping; hand or finger $ 86.40 1936 29305 29305 Application of hip spica cast; 1 leg $ 540.90 1937 29325 29325 Application of hip spica cast; 1 and one-half spica or both legs $ 494.10 1938 29345 29345 Application of long leg cast (thigh to toes); $ 297.00 Application of long leg cast (thigh to toes); walker or ambulatory 1939 29355 29355 type $ 270.90 1940 29358 29358 Application of long leg cast brace $ 451.80 1941 29365 29365 Application of cylinder cast (thigh to ankle) $ 236.70 1942 29405 29405 Application of short leg cast (below knee to toes); $ 215.17 Application of short leg cast (below knee to toes); walking or 1943 29425 29425 ambulatory type $ 237.60 1944 29435 29435 Application of patellar tendon bearing (PTB) cast $ 282.60 1945 29440 29440 Adding walker to previously applied cast $ 83.70 1946 29445 29445 Application of rigid total contact leg cast $ 339.30 Application of clubfoot cast with molding or manipulation, long or 1947 29450 29450 short leg $ 173.70 1948 29505 29505 Application of long leg splint (thigh to ankle or toes) $ 153.90 1949 29515 29515 Application of short leg splint (calf to foot) $ 120.60 1950 29520 29520 Strapping; hip $ 98.10 1951 29530 29530 Strapping; knee $ 95.40 1952 29540 29540 Strapping; ankle and/or foot $ 73.52 1953 29550 29550 Strapping; toes $ 66.60 1954 29580 29580 Strapping; Unna boot $ 96.09 Application of multi-layer compression system; leg (below knee), 1955 29581 29581 including ankle and foot $ 132.61 1956 29700 29700 Removal or bivalving; gauntlet, boot or body cast $ 92.42 1957 29705 29705 Removal or bivalving; full arm or full leg cast $ 90.31 Removal or bivalving; shoulder or hip spica, Minerva, or Risser 1958 29710 29710 jacket, etc. $ 186.30 1959 29715 29715 Removal or bivalving; turnbuckle jacket $ 124.20 1960 29720 29720 Repair of spica, body cast or jacket $ 87.30 1961 29730 29730 Windowing of cast $ 85.50 1962 29740 29740 Wedging of cast (except clubfoot casts) $ 136.80 1963 29750 29750 Wedging of clubfoot cast $ 97.20 1964 29799 29799 Unlisted procedure, casting or strapping $ 100.21 Arthroscopy, temporomandibular joint, diagnostic, with or without 1965 29800 29800 synovial biopsy (separate procedure) $ 1,545.30 1966 29804 29804 Arthroscopy, temporomandibular joint, surgical $ 2,266.20 Arthroscopy, shoulder, diagnostic, with or without synovial biopsy 1967 29805 29805 (separate procedure) $ 1,129.02 1968 29806 29806 Arthroscopy, shoulder, surgical; capsulorrhaphy $ 2,796.86 1969 29807 29807 Arthroscopy, shoulder, surgical; repair of SLAP lesion $ 2,663.48 Arthroscopy, shoulder, surgical; with removal of loose body or 1970 29819 29819 foreign body $ 2,304.90 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price 1971 29820 29820 Arthroscopy, shoulder, surgical;

synovectomy, partial $ 2,215.80 1972 29821 29821 Arthroscopy, shoulder, surgical; synovectomy, complete $ 2,396.70 1973 29822 29822 Arthroscopy, shoulder, surgical; debridement, limited $ 2,419.20 1974 29823 29823 Arthroscopy, shoulder, surgical; debridement, extensive $ 2,801.70 Arthroscopy, shoulder, surgical; distal claviculectomy including 1975 29824 29824 distal articular surface (Mumford procedure) $ 1,813.74 Arthroscopy, shoulder, surgical; with lysis and resection of 1976 29825 29825 adhesions, with or without manipulation $ 2,412.00 Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch)release, when performed (List separately in addition to code 1977 29826 29826 for primary procedure) $ 2,722.75 1978 29827 29827 Arthroscopy, shoulder, surgical; with rotator cuff repair $ 2,928.75 1979 29828 29828 Arthroscopy, shoulder, surgical; biceps tenodesis $ 2,558.94 Arthroscopy, elbow, diagnostic, with or without synovial biopsy 1980 29830 29830 (separate procedure) $ 1,206.00 Arthroscopy, elbow, surgical; with removal of loose body or foreign 1981 29834 29834 body $ 2,052.00 1982 29835 29835 Arthroscopy, elbow, surgical; synovectomy, partial $ 2,308.50 1983 29836 29836 Arthroscopy, elbow, surgical; synovectomy, complete $ 2,322.90 1984 29837 29837 Arthroscopy, elbow, surgical; debridement, limited $ 1,981.80 1985 29838 29838 Arthroscopy, elbow, surgical; debridement, extensive $ 2,250.90 Arthroscopy, wrist, diagnostic, with or without synovial biopsy 1986 29840 29840 (separate procedure) $ 1,214.10 1987 29843 29843 Arthroscopy, wrist, surgical; for infection, lavage and drainage $ 1,751.40 1988 29844 29844 Arthroscopy, wrist, surgical; synovectomy, partial $ 1,881.00 1989 29845 29845 Arthroscopy, wrist, surgical; synovectomy, complete $ 1,916.10 Arthroscopy, wrist, surgical; excision and/or repair of triangular 1990 29846 29846 fibrocartilage and/or joint debridement $ 2,266.20 Arthroscopy, wrist, surgical; internal fixation for fracture or 1991 29847 29847 instability $ 2,093.40 Endoscopy, wrist, surgical, with release of transverse carpal 1992 29848 29848 ligament $ 1,758.60 Arthroscopically aided treatment of intercondylar spine(s) and/or tuberosity fracture(s) of the knee, with or without manipulation; 1993 29850 29850 without internal or external fixation (includes arthroscopy) $ 2,285.10 Arthroscopically aided treatment of intercondylar spine(s) and/or tuberosity fracture(s) of the knee, with or without manipulation; 1994 29851 29851 with internal or external fixation (includes arthroscopy) $ 2,887.20 Arthroscopically aided treatment of tibial fracture, proximal (plateau); unicondylar, includes internal fixation, when performed 1995 29855 29855 (includes arthroscopy) $ 2,574.90 Arthroscopically aided treatment of tibial fracture, proximal (plateau); bicondylar, includes internal fixation, when performed 1996 29856 29856 (includes arthroscopy) $ 2,907.90 Arthroscopy, hip, diagnostic with or without synovial biopsy 1997 29860 29860 (separate procedure) $ 1,547.10 Arthroscopy, hip, surgical; with removal of loose body or foreign 1998 29861 29861 body $ 2,295.90 Arthroscopy, hip, surgical; with debridement/shaving of articular cartilage (chondroplasty), abrasion arthroplasty, and/or resection of 1999 29862 29862 labrum $ 2,525.40 2000 29863 29863 Arthroscopy, hip, surgical; with synovectomy $ 2,306.70 Arthroscopy, knee, surgical; osteochondral autograft(s) (eg, 2001 29866 29866 mosaicplasty) (includes harvesting of the autograft[s]) $ 2,666.26 Arthroscopy, knee, surgical; osteochondral allograft (eg, 2002 29867 29867 mosaicplasty) $ 4,120.16 Arthroscopy, knee, surgical; meniscal transplantation (includes 2003 29868 29868 arthrotomy for meniscal insertion), medial or lateral $ 5,488.61 Arthroscopy, knee, diagnostic, with or without synovial biopsy 2004 29870 29870 (separate procedure) $ 1,352.70 2005 29871 29871 Arthroscopy, knee, surgical; for infection, lavage and drainage $ 1,984.50 2006 29873 29873 Arthroscopy, knee, surgical; with lateral release $ 1,675.37 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Arthroscopy, knee, surgical; for removal of loose body or foreign body (eg, osteochondritis dissecans fragmentation, chondral 2007 29874 29874 fragmentation) $ 2,348.10 Arthroscopy, knee, surgical; synovectomy, limited (eg, plica or shelf 2008 29875 29875 resection) (separate procedure) $ 2,459.70 Arthroscopy, knee, surgical; synovectomy, major, 2 or more 2009 29876 29876 compartments (eg, medial or lateral) $ 2,733.79 Arthroscopy, knee, surgical; debridement/shaving of articular 2010 29877 29877 cartilage (chondroplasty) $ 2,552.87 Arthroscopy, knee, surgical; abrasion arthroplasty (includes chondroplasty where necessary) or multiple drilling or 2011 29879 29879 microfracture $ 2,652.30 Arthroscopy, knee, surgical; with meniscectomy (medial AND lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or 2012 29880 29880 separate compartment(s), when performed $ 3,254.71 Arthroscopy, knee, surgical; with meniscus repair (medial OR 2013 29882 29882 lateral) $ 2,919.72 Arthroscopy, knee, surgical; with meniscus repair (medial AND 2014 29883 29883 lateral) $ 3,747.60 Arthroscopy, knee, surgical; with lysis of adhesions, with or without 2015 29884 29884 manipulation (separate procedure) $ 2,337.30 Arthroscopy, knee, surgical; drilling for osteochondritis dissecans with bone grafting, with or without internal fixation (including 2016 29885 29885 debridement of base of lesion) $ 2,697.30 Arthroscopy, knee, surgical; drilling for intact osteochondritis 2017 29886 29886 dissecans lesion $ 2,547.90 Arthroscopy, knee, surgical; drilling for intact osteochondritis 2018 29887 29887 dissecans lesion with internal fixation $ 3,380.40 Arthroscopically aided anterior cruciate ligament 2019 29888 29888 repair/augmentation or reconstruction $ 4,793.75 Arthroscopically aided posterior cruciate ligament 2020 29889 29889 repair/augmentation or reconstruction $ 4,867.20 Arthroscopy, ankle, surgical, excision of osteochondral defect of 2021 29891 29891 talus and/or tibia, including drilling of the defect $ 2,214.90 Arthroscopically aided repair of large osteochondritis dissecans lesion, talar dome fracture, or tibial plafond fracture, with or 2022 29892 29892 without internal fixation (includes arthroscopy) $ 2,223.90 2023 29893 29893 Endoscopic plantar fasciotomy $ 1,233.00 Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; with 2024 29894 29894 removal of loose body or foreign body $ 2,206.80 Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; 2025 29895 29895 synovectomy, partial $ 2,299.50 Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; 2026 29897 29897 debridement, limited $ 2,115.00 Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; 2027 29898 29898 debridement, extensive $ 2,721.60 Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; with 2028 29899 29899 ankle arthrodesis $ 2,665.75 Arthroscopy, metacarpophalangeal joint, diagnostic, includes 2029 29900 29900 synovial biopsy $ 1,121.89 Arthroscopy, metacarpophalangeal joint, surgical; with 2030 29901 29901 debridement $ 1,598.44 Arthroscopy, metacarpophalangeal joint, surgical; with reduction of 2031 29902 29902 displaced ulnar collateral ligament (eg, Stenar lesion) $ 1,839.03 Arthroscopy, subtalar joint, surgical; with removal of loose body or 2032 29904 29904 foreign body $ 2,032.59 2033 29905 29905 Arthroscopy, subtalar joint, surgical; with synovectomy $ 2,146.58 2034 29906 29906 Arthroscopy, subtalar joint, surgical; with debridement $ 2,078.55 2035 29907 29907 Arthroscopy, subtalar joint, surgical; with subtalar arthrodesis $ 2,547.20 2036 29999 29999 Unlisted procedure, arthroscopy Cost 2037 30000 30000 Drainage abscess or hematoma, nasal, internal approach $ 329.40 2038 30020 30020 Drainage abscess or hematoma, nasal septum $ 311.40 2039 30100 30100 Biopsy, intranasal $ 187.20 2040 30110 30110 Excision, nasal polyp(s), simple $ 385.20 2041 30115 30115 Excision, nasal polyp(s), extensive $ 992.70 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Excision or destruction (eg, laser), intranasal lesion; internal 2042 30117 30117 approach $ 871.20 Excision or destruction (eg, laser), intranasal lesion; external 2043 30118 30118 approach (lateral rhinotomy) $ 2,187.00 2044 30120 30120 Excision or surgical planing of skin of nose for rhinophyma $ 2,003.40 2045 30124 30124 Excision dermoid cyst, nose; simple, skin, subcutaneous $ 774.00 2046 30125 30125 Excision dermoid cyst, nose; complex, under bone or cartilage $ 1,936.80 2047 30130 30130 Excision inferior turbinate, partial or complete, any method $ 785.70 Submucous resection inferior turbinate, partial or complete, any 2048 30140 30140 method $ 1,149.30 2049 30150 30150 Rhinectomy; partial $ 2,242.80 2050 30160 30160 Rhinectomy; total $ 2,889.00 2051 30200 30200 Injection into turbinate(s), therapeutic $ 129.60 2052 30210 30210 Displacement therapy (Proetz type) $ 211.50 2053 30220 30220 Insertion, nasal septal prosthesis (button) $ 401.40 2054 30300 30300 Removal foreign body, intranasal; office type procedure $ 134.21 2055 30310 30310 Removal foreign body, intranasal; requiring general anesthesia $ 567.90 2056 30320 30320 Removal foreign body, intranasal; by lateral rhinotomy $ 1,482.30 Rhinoplasty, primary; lateral and alar cartilages and/or elevation of 2057 30400 30400 nasal tip $ 3,656.70 Rhinoplasty, primary; complete, external parts including bony 2058 30410 30410 pyramid, lateral and alar cartilages, and/or elevation of nasal tip $ 3,969.90 2059 30420 30420 Rhinoplasty, primary; including major septal repair $ 4,673.70 Rhinoplasty, secondary; minor revision (small amount of nasal tip 2060 30430 30430 work) $ 1,877.40 Rhinoplasty, secondary; intermediate revision (bony work with 2061 30435 30435 osteotomies) $ 2,531.70 Rhinoplasty, secondary; major revision (nasal tip work and 2062 30450 30450 osteotomies) $ 4,104.90 Rhinoplasty for nasal deformity secondary to congenital cleft lip 2063 30460 30460 and/or palate, including columellar lengthening; tip only $ 2,551.50 Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columellar lengthening; tip, septum, 2064 30462 30462 osteotomies $ 4,778.10 Repair of nasal vestibular stenosis (eg, spreader grafting, lateral 2065 30465 30465 nasal wall reconstruction) $ 2,367.57 Septoplasty or submucous resection, with or without cartilage 2066 30520 30520 scoring, contouring or replacement with graft $ 2,891.27 2067 30540 30540 Repair choanal atresia; intranasal $ 2,054.70 2068 30545 30545 Repair choanal atresia; transpalatine $ 3,063.60 2069 30560 30560 Lysis intranasal synechia $ 240.30 Repair fistula; oromaxillary (combine with 31030 if antrotomy is 2070 30580 30580 included) $ 1,683.00 2071 30600 30600 Repair fistula; oronasal $ 1,819.80 Septal or other intranasal dermatoplasty (does not include 2072 30620 30620 obtaining graft) $ 2,832.30 2073 30630 30630 Repair nasal septal perforations $ 2,162.70 Ablation, soft tissue of inferior turbinates, unilateral or bilateral, any method (eg, electrocautery, radiofrequency ablation, or tissue 2074 30801 30801 volume reduction); superficial $ 264.60 Ablation, soft tissue of inferior turbinates, unilateral or bilateral, any method (eg, electrocautery, radiofrequency ablation, or tissue 2075 30802 30802 volume reduction); intramural (ie, submucosal) $ 407.70 Control nasal hemorrhage, anterior, simple (limited cautery and/or 2076 30901 30901 packing) any method $ 189.81 Control nasal hemorrhage, anterior, complex (extensive cautery 2077 30903 30903 and/or packing) any method $ 280.57 Control nasal hemorrhage, posterior, with posterior nasal packs 2078 30905 30905 and/or cautery, any method; initial $ 495.90 Control nasal hemorrhage, posterior, with posterior nasal packs 2079 30906 30906 and/or cautery, any method; subsequent $ 449.10 2080 30915 30915 Ligation arteries; ethmoidal $ 1,781.10 2081 30920 30920 Ligation arteries; internal maxillary artery, transantral $ 2,600.10 2082 30930 30930 Fracture nasal inferior turbinate(s), therapeutic $ 437.40 2083 30999 30999 Unlisted procedure, nose Cost Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Lavage by cannulation; maxillary sinus (antrum puncture or natural 2084 31000 31000 ostium) $ 134.23 2085 31002 31002 Lavage by cannulation; sphenoid sinus $ 291.60 2086 31020 31020 Sinusotomy, maxillary (antrotomy); intranasal $ 822.60 Sinusotomy, maxillary (antrotomy); radical (Caldwell-Luc) without 2087 31030 31030 removal of antrochoanal polyps $ 1,966.50 Sinusotomy, maxillary (antrotomy); radical (Caldwell-Luc) with 2088 31032 31032 removal of antrochoanal polyps $ 2,162.70 2089 31040 31040 Pterygomaxillary fossa surgery, any approach $ 3,172.50 2090 31050 31050 Sinusotomy, sphenoid, with or without biopsy; $ 1,484.10 Sinusotomy, sphenoid, with or without biopsy; with mucosal 2091 31051 31051 stripping or removal of polyp(s) $ 2,057.40 2092 31070 31070 Sinusotomy frontal; external, simple (trephine operation) $ 1,499.40 Sinusotomy frontal; transorbital, unilateral (for mucocele or 2093 31075 31075 osteoma, Lynch type) $ 2,574.00 Sinusotomy frontal; obliterative without osteoplastic flap, brow 2094 31080 31080 incision (includes ablation) $ 3,005.10 Sinusotomy frontal; obliterative, without osteoplastic flap, coronal 2095 31081 31081 incision (includes ablation) $ 2,971.80 Sinusotomy frontal; obliterative, with osteoplastic flap, brow 2096 31084 31084 incision $ 3,605.40 Sinusotomy frontal; obliterative, with osteoplastic flap, coronal 2097 31085 31085 incision $ 3,885.30 Sinusotomy frontal; nonobliterative, with osteoplastic flap, brow 2098 31086 31086 incision $ 3,278.70 Sinusotomy frontal; nonobliterative, with osteoplastic flap, coronal 2099 31087 31087 incision $ 3,210.30 Sinusotomy, unilateral, 3 or more paranasal sinuses (frontal, 2100 31090 31090 maxillary, ethmoid, sphenoid) $ 4,236.30 2101 31200 31200 Ethmoidectomy; intranasal, anterior $ 1,301.40 2102 31201 31201 Ethmoidectomy; intranasal, total $ 2,008.80 2103 31205 31205 Ethmoidectomy; extranasal, total $ 2,160.00 2104 31225 31225 Maxillectomy; without orbital exenteration $ 4,426.20 2105 31230 31230 Maxillectomy; with orbital exenteration (en bloc) $ 5,388.30 Nasal endoscopy, diagnostic, unilateral or bilateral (separate 2106 31231 31231 procedure) $ 244.28 Nasal/sinus endoscopy, diagnostic with maxillary sinusoscopy (via 2107 31233 31233 inferior meatus or canine fossa puncture) $ 683.10 Nasal/sinus endoscopy, diagnostic with sphenoid sinusoscopy (via 2108 31235 31235 puncture of sphenoidal face or cannulation of ostium) $ 760.50 Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or 2109 31237 31237 debridement (separate procedure) $ 871.20 2110 31238 31238 Nasal/sinus endoscopy, surgical; with control of nasal hemorrhage $ 909.90 2111 31239 31239 Nasal/sinus endoscopy, surgical; with dacryocystorhinostomy $ 2,768.40 2112 31240 31240 Nasal/sinus endoscopy, surgical; with concha bullosa resection $ 842.40 Nasal/sinus endoscopy, surgical; with ethmoidectomy, partial 2113 31254 31254 (anterior) $ 1,690.20 Nasal/sinus endoscopy, surgical; with ethmoidectomy, total 2114 31255 31255 (anterior and posterior) $ 1,789.35 2115 31256 31256 Nasal/sinus endoscopy, surgical, with maxillary antrostomy; $ 1,530.00 Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with 2116 31267 31267 removal of tissue from maxillary sinus $ 1,867.50 Nasal/sinus endoscopy, surgical with frontal sinus exploration, with 2117 31276 31276 or without removal of tissue from frontal sinus $ 1,931.40 2118 31287 31287 Nasal/sinus endoscopy, surgical, with sphenoidotomy; $ 1,337.40 Nasal/sinus endoscopy, surgical, with sphenoidotomy; with removal 2119 31288 31288 of tissue from the sphenoid sinus $ 1,647.90 Nasal/sinus endoscopy, surgical, with repair of cerebrospinal fluid 2120 31290 31290 leak; ethmoid region $ 3,514.50 Nasal/sinus endoscopy, surgical, with repair of cerebrospinal fluid 2121 31291 31291 leak; sphenoid region $ 3,903.30 Nasal/sinus endoscopy, surgical; with medial or inferior orbital wall 2122 31292 31292 decompression $ 3,122.10 Nasal/sinus endoscopy, surgical; with medial orbital wall and 2123 31293 31293 inferior orbital wall decompression $ 3,414.60 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price 2124 31294 31294 Nasal/sinus endoscopy, surgical; with optic nerve decompression $ 3,854.70 2125 31299 31299 Unlisted procedure, accessory sinuses Cost Laryngotomy (thyrotomy, laryngofissure); with removal of tumor or 2126 31300 31300 laryngocele, cordectomy $ 2,842.20 2127 31320 31320 Laryngotomy (thyrotomy, laryngofissure); diagnostic $ 1,349.10 2128 31360 31360 Laryngectomy; total, without radical neck dissection $ 3,825.90 2129 31365 31365 Laryngectomy; total, with radical neck dissection $ 5,740.20 2130 31367 31367 Laryngectomy; subtotal supraglottic, without radical neck dissection $ 4,111.20 2131 31368 31368 Laryngectomy; subtotal supraglottic, with radical neck dissection $ 6,336.00 2132 31370 31370 Partial laryngectomy (hemilaryngectomy); horizontal $ 4,670.10 2133 31375 31375 Partial laryngectomy (hemilaryngectomy); laterovertical $ 3,898.80 2134 31380 31380 Partial laryngectomy (hemilaryngectomy); anterovertical $ 3,970.80 2135 31382 31382 Partial laryngectomy (hemilaryngectomy); antero-latero-vertical $ 4,020.30 Pharyngolaryngectomy, with radical neck dissection; without 2136 31390 31390 reconstruction $ 5,854.50 Pharyngolaryngectomy, with radical neck dissection; with 2137 31395 31395 reconstruction $ 6,849.90 2138 31400 31400 Arytenoidectomy or arytenoidopexy, external approach $ 2,953.80 2139 31420 31420 Epiglottidectomy $ 2,694.60 2140 31500 31500 Intubation, endotracheal, emergency procedure $ 307.80 2141 31502 31502 Tracheotomy tube change prior to establishment of fistula tract $ 195.30 2142 31505 31505 Laryngoscopy, indirect; diagnostic (separate procedure) $ 217.68 2143 31510 31510 Laryngoscopy, indirect; with biopsy $ 306.90 2144 31511 31511 Laryngoscopy, indirect; with removal of foreign body $ 391.50 2145 31512 31512 Laryngoscopy, indirect; with removal of lesion $ 429.30 2146 31513 31513 Laryngoscopy, indirect; with vocal cord injection $ 585.90 2147 31515 31515 Laryngoscopy direct, with or without tracheoscopy; for aspiration $ 377.10 Laryngoscopy direct, with or without tracheoscopy; diagnostic, 2148 31520 31520 newborn $ 460.04 Laryngoscopy direct, with or without tracheoscopy; diagnostic, 2149 31525 31525 except newborn $ 647.10 Laryngoscopy direct, with or without tracheoscopy; diagnostic, with 2150 31526 31526 operating microscope or telescope $ 978.30 Laryngoscopy direct, with or without tracheoscopy; with insertion of 2151 31527 31527 obturator $ 1,164.60 Laryngoscopy direct, with or without tracheoscopy; with dilation, 2152 31528 31528 initial $ 824.40 Laryngoscopy direct, with or without tracheoscopy; with dilation, 2153 31529 31529 subsequent $ 772.20 2154 31530 31530 Laryngoscopy, direct, operative, with foreign body removal; $ 896.40 Laryngoscopy, direct, operative, with foreign body removal; with 2155 31531 31531 operating microscope or telescope $ 1,302.30 2156 31535 31535 Laryngoscopy, direct, operative, with biopsy; $ 903.60 Laryngoscopy, direct, operative, with biopsy; with operating 2157 31536 31536 microscope or telescope $ 1,141.20 Laryngoscopy, direct, operative, with excision of tumor and/or 2158 31540 31540 stripping of vocal cords or epiglottis; $ 1,155.60 Laryngoscopy, direct, operative, with excision of tumor and/or stripping of vocal cords or epiglottis; with operating microscope or 2159 31541 31541 telescope $ 1,328.82 Laryngoscopy, direct, operative, with operating microscope or telescope, with submucosal removal of non-neoplastic lesion(s) of 2160 31545 31545 vocal cord; reconstruction with local tissue flap(s) $ 1,137.51 Laryngoscopy, direct, operative, with operating microscope or telescope, with submucosal removal of non-neoplastic lesion(s) of vocal cord; reconstruction with graft(s) (includes obtaining 2161 31546 31546 autograft) $ 1,746.43 2162 31560 31560 Laryngoscopy, direct, operative, with arytenoidectomy; $ 2,224.80 Laryngoscopy, direct, operative, with arytenoidectomy; with 2163 31561 31561 operating microscope or telescope $ 2,378.70 2164 31570 31570 Laryngoscopy, direct, with injection into vocal cord(s), therapeutic; $ 1,323.90 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Laryngoscopy, direct, with injection into vocal cord(s), therapeutic; 2165 31571 31571 with operating microscope or telescope $ 1,458.90 2166 31575 31575 Laryngoscopy, flexible fiberoptic; diagnostic $ 323.11 2167 31576 31576 Laryngoscopy, flexible fiberoptic; with biopsy $ 568.80 2168 31577 31577 Laryngoscopy, flexible fiberoptic; with removal of foreign body $ 982.80 2169 31578 31578 Laryngoscopy, flexible fiberoptic; with removal of lesion $ 1,133.10 2170 31579 31579 Laryngoscopy, flexible or rigid fiberoptic, with stroboscopy $ 626.40 Laryngoplasty; for laryngeal web, 2- stage, with keel insertion and 2171 31580 31580 removal $ 3,399.30 Laryngoplasty; for laryngeal stenosis, with graft or core mold, 2172 31582 31582 including tracheotomy $ 4,155.30 2173 31584 31584 Laryngoplasty; with open reduction of fracture $ 3,971.70 2174 31587 31587 Laryngoplasty, cricoid split $ 2,544.30 Laryngoplasty, not otherwise specified (eg, for burns, reconstruction 2175 31588 31588 after partial laryngectomy) $ 3,209.40 2176 31590 31590 Laryngeal reinnervation by neuromuscular pedicle $ 2,811.60 Section recurrent laryngeal nerve, therapeutic (separate 2177 31595 31595 procedure), unilateral $ 2,338.20 2178 31599 31599 Unlisted procedure, larynx Cost 2179 31600 31600 Tracheostomy, planned (separate procedure); $ 1,148.40 2180 31601 31601 Tracheostomy, planned (separate procedure); younger than 2 years $ 1,423.80 2181 31605 31605 Tracheostomy, emergency procedure; cricothyroid membrane $ 957.60 2182 31610 31610 Tracheostomy, fenestration procedure with skin flaps $ 1,731.60 Construction of tracheoesophageal fistula and subsequent insertion of an alaryngeal speech prosthesis (eg, voice button, Blom-Singer 2183 31611 31611 prosthesis) $ 1,748.70 Tracheal puncture, percutaneous with transtracheal aspiration 2184 31612 31612 and/or injection $ 232.20 2185 31613 31613 Tracheostoma revision; simple, without flap rotation $ 767.70 2186 31614 31614 Tracheostoma revision; complex, with flap rotation $ 1,881.90 2187 31615 31615 Tracheobronchoscopy through established tracheostomy incision $ 555.30 Endobronchial ultrasound (EBUS) during bronchoscopic diagnostic or therapeutic intervention(s) (List separately in addition to code for 2188 31620 31620 primary procedure[s]) $ 798.23 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; diagnostic, with cell washing, when performed 2189 31622 31622 (separate procedure) $ 715.50 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, 2190 31623 31623 when performed; with brushing or protected brushings $ 686.70 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, 2191 31624 31624 when performed; with bronchial alveolar lavage $ 693.00 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial or endobronchial biopsy(s), single 2192 31625 31625 or multiple sites $ 822.60 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with placement of fiducial markers, single or 2193 31626 31626 multiple $ 823.11 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with computer-assisted, image-guided navigation 2194 31627 31627 (List separately in addition to code for primary procedure[s]) $ 948.86 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, 2195 31628 31628 when performed; with transbronchial lung biopsy(s), single lobe $ 915.30 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transbronchial needle aspiration biopsy(s), 2196 31629 31629 trachea, main stem and/or lobar bronchus(i) $ 922.50 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with tracheal/bronchial dilation or closed 2197 31630 31630 reduction of fracture $ 874.80 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transbronchial lung biopsy(s), each additional lobe (List separately in addition to code for primary 2198 31632 31632 procedure) $ 221.90 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transbronchial needle aspiration biopsy(s), each additional lobe (List separately in addition to code for primary 2199 31633 31633 procedure) $ 302.61 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, 2200 31635 31635 when performed; with removal of foreign body $ 992.70 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with placement of bronchial stent(s) (includes 2201 31636 31636 tracheal/bronchial dilation as required), initial bronchus $ 822.83 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; each additional major bronchus stented (List 2202 31637 31637 separately in addition to code for primary procedure) $ 274.30 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with revision of tracheal or bronchial stent inserted at previous session (includes tracheal/bronchial dilation as 2203 31638 31638 required) $ 907.48 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, 2204 31640 31640 when performed; with excision of tumor $ 1,161.00 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with destruction of tumor or relief of stenosis by 2205 31641 31641 any method other than excision (eg, laser therapy, cryotherapy) $ 1,545.30 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with placement of catheter(s) for intracavitary 2206 31643 31643 radioelement application $ 606.60 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with therapeutic aspiration of tracheobronchial 2207 31645 31645 tree, initial (eg, drainage of lung abscess) $ 801.00 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with therapeutic aspiration of tracheobronchial 2208 31646 31646 tree, subsequent $ 706.50 2209 31717 31717 Catheterization with bronchial brush biopsy $ 230.40 2210 31720 31720 Catheter aspiration (separate procedure); nasotracheal $ 169.20 Catheter aspiration (separate procedure); tracheobronchial with 2211 31725 31725 fiberscope, bedside $ 406.80 Transtracheal (percutaneous) introduction of needle wire 2212 31730 31730 dilator/stent or indwelling tube for oxygen therapy $ 668.70 2213 31750 31750 Tracheoplasty; cervical $ 3,236.40 2214 31755 31755 Tracheoplasty; tracheopharyngeal fistulization, each stage $ 3,572.10 2215 31760 31760 Tracheoplasty; intrathoracic $ 3,681.00 2216 31766 31766 Carinal reconstruction $ 4,428.90 2217 31770 31770 Bronchoplasty; graft repair $ 3,687.30 2218 31775 31775 Bronchoplasty; excision stenosis and anastomosis $ 4,083.30 2219 31780 31780 Excision tracheal stenosis and anastomosis; cervical $ 3,804.30 2220 31781 31781 Excision tracheal stenosis and anastomosis; cervicothoracic $ 4,003.20 2221 31785 31785 Excision of tracheal tumor or carcinoma; cervical $ 3,078.00 2222 31786 31786 Excision of tracheal tumor or carcinoma; thoracic $ 4,113.90 2223 31800 31800 Suture of tracheal wound or injury; cervical $ 2,929.50 2224 31805 31805 Suture of tracheal wound or injury; intrathoracic $ 2,932.20 2225 31820 31820 Surgical closure tracheostomy or fistula; without plastic repair $ 899.10 2226 31825 31825 Surgical closure tracheostomy or fistula; with plastic repair $ 1,259.10 2227 31830 31830 Revision of tracheostomy scar $ 927.00 2228 31899 31899 Unlisted procedure, trachea, bronchi $ 951.62 2229 32035 32035 Thoracostomy; with rib resection for empyema $ 1,596.60 2230 32036 32036 Thoracostomy; with open flap drainage for empyema $ 1,944.00 Thoracotomy, with diagnostic biopsy(ies) of lung infiltrate(s) (eg, 2231 32096 32096 wedge, incisional), unilateral $ 2,016.26 Thoracotomy, with diagnostic biopsy(ies) of lung nodule(s) or 2232 32097 32097 mass(es) (eg, wedge, incisional), unilateral $ 2,016.26 2233 32098 32098 Thoracotomy, with biopsy(ies) of pleura $ 1,955.37 2234 32100 32100 Thoracotomy; with exploration $ 2,701.80 Thoracotomy; with control of traumatic hemorrhage and/or repair 2235 32110 32110 of lung tear $ 3,024.90 2236 32120 32120 Thoracotomy; for postoperative complications $ 2,522.70 2237 32124 32124 Thoracotomy; with open intrapleural pneumonolysis $ 2,365.20 Thoracotomy; with cyst(s) removal, includes pleural procedure 2238 32140 32140 when performed $ 2,574.90 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Thoracotomy; with resection-plication of bullae, includes any 2239 32141 32141 pleural procedure when performed $ 2,962.80 Thoracotomy; with removal of intrapleural foreign body or fibrin 2240 32150 32150 deposit $ 2,801.70 2241 32151 32151 Thoracotomy; with removal of intrapulmonary foreign body $ 2,255.40 2242 32160 32160 Thoracotomy; with cardiac massage $ 2,646.00 2243 32200 32200 Pneumonostomy, with open drainage of abscess or cyst $ 2,478.60 2244 32215 32215 Pleural scarification for repeat pneumothorax $ 2,565.90 2245 32220 32220 Decortication, pulmonary (separate procedure); total $ 3,480.30 2246 32225 32225 Decortication, pulmonary (separate procedure); partial $ 2,477.70 2247 32310 32310 Pleurectomy, parietal (separate procedure) $ 3,073.50 2248 32320 32320 Decortication and parietal pleurectomy $ 4,303.80 2249 32400 32400 Biopsy, pleura; percutaneous needle $ 387.90 2250 32405 32405 Biopsy, lung or mediastinum, percutaneous needle; $ 518.40 2251 32440 32440 Removal of lung, pneumonectomy; $ 4,605.30 Removal of lung, pneumonectomy; with resection of segment of trachea followed by broncho-tracheal anastomosis (sleeve 2252 32442 32442 pneumonectomy) $ 4,649.40 2253 32445 32445 Removal of lung, pneumonectomy; extrapleural $ 4,839.30 Removal of lung, other than pneumonectomy; single lobe 2254 32480 32480 (lobectomy) $ 4,327.20 Removal of lung, other than pneumonectomy; 2 lobes 2255 32482 32482 (bilobectomy) $ 4,661.10 Removal of lung, other than pneumonectomy; single segment 2256 32484 32484 (segmentectomy) $ 4,255.20 Removal of lung, other than pneumonectomy; with circumferential resection of segment of bronchus followed by broncho-bronchial 2257 32486 32486 anastomosis (sleeve lobectomy) $ 4,365.00 Removal of lung, other than pneumonectomy; with all remaining lung following previous removal of a portion of lung (completion 2258 32488 32488 pneumonectomy) $ 5,346.00 Removal of lung, other than pneumonectomy; with resection- plication of emphysematous lung(s) (bullous or non-bullous) for lung volume reduction, sternal split or transthoracic approach, 2259 32491 32491 includes any pleural procedure, when performed $ 3,131.92 Resection and repair of portion of bronchus (bronchoplasty) when performed at time of lobectomy or segmentectomy (List separately 2260 32501 32501 in addition to code for primary procedure) $ 529.40 Resection of apical lung tumor (eg, Pancoast tumor), including chest wall resection, rib(s) resection(s), neurovascular dissection, when 2261 32503 32503 performed; without chest wall reconstruction(s) $ 4,016.73 Resection of apical lung tumor (eg, Pancoast tumor), including chest wall resection, rib(s) resection(s), neurovascular dissection, when 2262 32504 32504 performed; with chest wall reconstruction $ 4,300.61 Thoracotomy; with therapeutic wedge resection (eg, mass, nodule), 2263 32505 32505 initial $ 2,383.63 Thoracotomy; with therapeutic wedge resection (eg, mass or nodule), each additional resection, ipsilateral (List separately in 2264 32506 32506 addition to code for primary procedure) $ 409.31 Thoracotomy; with diagnostic wedge resection followed by anatomic lung resection (List separately in addition to code for 2265 32507 32507 primary procedure) $ 409.31 2266 32540 32540 Extrapleural enucleation of empyema (empyemectomy) $ 3,656.70 2267 32550 32550 Insertion of indwelling tunneled pleural catheter with cuff $ 739.02 Tube thoracostomy, includes connection to drainage system (eg, 2268 32551 32551 water seal), when performed, open (separate procedure) $ 397.73 2269 32552 32552 Removal of indwelling tunneled pleural catheter with cuff $ 393.46 Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), percutaneous, intra-thoracic, 2270 32553 32553 single or multiple $ 603.94 Thoracentesis, needle or catheter, aspiration of the pleural space; 2271 32554 32554 without imaging guidance $ 1,393.37 Thoracentesis, needle or catheter, aspiration of the pleural space; 2272 32555 32555 with imaging guidance $ 1,606.11 Instillation, via chest tube/catheter, agent for pleurodesis (eg, talc 2273 32560 32560 for recurrent or persistent pneumothorax) $ 300.45 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Instillation(s), via chest tube/catheter, agent for fibrinolysis (eg, 2274 32561 32561 fibrinolytic agent for break up of multiloculated effusion); initial day $ 184.63 Instillation(s), via chest tube/catheter, agent for fibrinolysis (eg, fibrinolytic agent for break up of multiloculated effusion); 2275 32562 32562 subsequent day $ 170.85 Thoracoscopy, diagnostic (separate procedure); lungs, pericardial 2276 32601 32601 sac, mediastinal or pleural space, without biopsy $ 1,074.60 Thoracoscopy, diagnostic (separate procedure); pericardial sac, with 2277 32604 32604 biopsy $ 1,803.60 Thoracoscopy, diagnostic (separate procedure); mediastinal space, 2278 32606 32606 with biopsy $ 1,832.40 Thoracoscopy; with diagnostic biopsy(ies) of lung infiltrate(s) (eg, 2279 32607 32607 wedge, incisional), unilateral $ 795.40 Thoracoscopy; with diagnostic biopsy(ies) of lung nodule(s) or 2280 32608 32608 mass(es) (eg, wedge, incisional), unilateral $ 979.00 2281 32609 32609 Thoracoscopy; with biopsy(ies) of pleura $ 675.96 Thoracoscopy, surgical; with pleurodesis (eg, mechanical or 2282 32650 32650 chemical) $ 2,230.20 2283 32651 32651 Thoracoscopy, surgical; with partial pulmonary decortication $ 2,722.50 Thoracoscopy, surgical; with total pulmonary decortication, 2284 32652 32652 including intrapleural pneumonolysis $ 3,548.70 Thoracoscopy, surgical; with removal of intrapleural foreign body or 2285 32653 32653 fibrin deposit $ 2,567.70 2286 32654 32654 Thoracoscopy, surgical; with control of traumatic hemorrhage $ 2,729.70 Thoracoscopy, surgical; with resection-plication of bullae, includes 2287 32655 32655 any pleural procedure when performed $ 2,972.70 2288 32656 32656 Thoracoscopy, surgical; with parietal pleurectomy $ 2,995.20 Thoracoscopy, surgical; with removal of clot or foreign body from 2289 32658 32658 pericardial sac $ 2,766.60 Thoracoscopy, surgical; with creation of pericardial window or 2290 32659 32659 partial resection of pericardial sac for drainage $ 2,986.20 Thoracoscopy, surgical; with excision of pericardial cyst, tumor, or 2291 32661 32661 mass $ 3,141.90 Thoracoscopy, surgical; with excision of mediastinal cyst, tumor, or 2292 32662 32662 mass $ 3,102.30 2293 32663 32663 Thoracoscopy, surgical; with lobectomy (single lobe) $ 3,747.60 2294 32664 32664 Thoracoscopy, surgical; with thoracic sympathectomy $ 2,699.10 2295 32665 32665 Thoracoscopy, surgical; with esophagomyotomy (Heller type) $ 3,350.70 Thoracoscopy, surgical; with therapeutic wedge resection (eg, mass, 2296 32666 32666 nodule), initial unilateral $ 2,222.05 Thoracoscopy, surgical; with therapeutic wedge resection (eg, mass or nodule), each additional resection, ipsilateral (List separately in 2297 32667 32667 addition to code for primary procedure) $ 409.31 Thoracoscopy, surgical; with diagnostic wedge resection followed by anatomic lung resection (List separately in addition to code for 2298 32668 32668 primary procedure) $ 411.71 Thoracoscopy, surgical; with removal of a single lung segment 2299 32669 32669 (segmentectomy) $ 3,335.83 2300 32670 32670 Thoracoscopy, surgical; with removal of two lobes (bilobectomy) $ 3,974.02 2301 32671 32671 Thoracoscopy, surgical; with removal of lung (pneumonectomy) $ 4,409.85 Thoracoscopy, surgical; with resection-plication for emphysematous lung (bullous or non-bullous) for lung volume reduction (LVRS), 2302 32672 32672 unilateral includes any pleural procedure, when performed $ 3,774.81 Thoracoscopy, surgical; with resection of thymus, unilateral or 2303 32673 32673 bilateral $ 2,957.25 Thoracoscopy, surgical; with mediastinal and regional lymphadenectomy (List separately in addition to code for primary 2304 32674 32674 procedure) $ 531.96 2305 32800 32800 Repair lung hernia through chest wall $ 2,565.00 Closure of chest wall following open flap drainage for empyema 2306 32810 32810 (Clagett type procedure) $ 2,710.80 2307 32815 32815 Open closure of major bronchial fistula $ 4,140.90 2308 32820 32820 Major reconstruction, chest wall (posttraumatic) $ 3,856.50 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Donor pneumonectomy(s) (including cold preservation), from 2309 32850 32850 cadaver donor $ - 2310 32851 32851 Lung transplant, single; without cardiopulmonary bypass $ 8,134.00 2311 32852 32852 Lung transplant, single; with cardiopulmonary bypass $ 8,881.42 Lung transplant, double (bilateral sequential or en bloc); without 2312 32853 32853 cardiopulmonary bypass $ 11,365.84 Lung transplant, double (bilateral sequential or en bloc); with 2313 32854 32854 cardiopulmonary bypass $ 12,075.71 Backbench standard preparation of cadaver donor lung allograft prior to transplantation, including dissection of allograft from surrounding soft tissues to prepare pulmonary venous/atrial cuff, 2314 32855 32855 pulmonary artery, and bronchus; unilateral $ - Backbench standard preparation of cadaver donor lung allograft prior to transplantation, including dissection of allograft from surrounding soft tissues to prepare pulmonary venous/atrial cuff, 2315 32856 32856 pulmonary artery, and bronchus; bilateral $ - 2316 32900 32900 Resection of ribs, extrapleural, all stages $ 2,188.80 2317 32905 32905 Thoracoplasty, Schede type or extrapleural (all stages); $ 2,652.30 Thoracoplasty, Schede type or extrapleural (all stages); with closure 2318 32906 32906 of bronchopleural fistula $ 3,554.10 Pneumonolysis, extraperiosteal, including filling or packing 2319 32940 32940 procedures $ 2,266.20 2320 32960 32960 Pneumothorax, therapeutic, intrapleural injection of air $ 261.00 2321 32997 32997 Total lung lavage (unilateral) $ 993.60 Ablation therapy for reduction or eradication of 1 or more pulmonary tumor(s) including pleura or chest wall when involved by 2322 32998 32998 tumor extension, percutaneous, radiofrequency, unilateral $ 2,369.98 2323 32999 32999 Unlisted procedure, lungs and pleura Cost 2324 33010 33010 Pericardiocentesis; initial $ 483.30 2325 33011 33011 Pericardiocentesis; subsequent $ 407.70 2326 33015 33015 Tube pericardiostomy $ 1,074.60 Pericardiotomy for removal of clot or foreign body (primary 2327 33020 33020 procedure) $ 2,667.60 2328 33025 33025 Creation of pericardial window or partial resection for drainage $ 3,193.20 Pericardiectomy, subtotal or complete; without cardiopulmonary 2329 33030 33030 bypass $ 4,041.00 Pericardiectomy, subtotal or complete; with cardiopulmonary 2330 33031 33031 bypass $ 5,037.30 2331 33050 33050 Resection of pericardial cyst or tumor $ 3,219.30 Excision of intracardiac tumor, resection with cardiopulmonary 2332 33120 33120 bypass $ 6,552.90 2333 33130 33130 Resection of external cardiac tumor $ 4,139.10 Transmyocardial laser revascularization, by thoracotomy; (separate 2334 33140 33140 procedure) $ 3,384.56 Transmyocardial laser revascularization, by thoracotomy; performed at the time of other open cardiac procedure(s) (List 2335 33141 33141 separately in addition to code for primary procedure) $ 1,649.90 Insertion of epicardial electrode(s); open incision (eg, thoracotomy, 2336 33202 33202 median sternotomy, subxiphoid approach) $ 2,051.82 Insertion of epicardial electrode(s); endoscopic approach (eg, 2337 33203 33203 thoracoscopy, pericardioscopy) $ 2,105.33 Insertion of new or replacement of permanent pacemaker with 2338 33206 33206 transvenous electrode(s); atrial $ 2,232.90 Insertion of new or replacement of permanent pacemaker with 2339 33207 33207 transvenous electrode(s); ventricular $ 2,424.60 Insertion of new or replacement of permanent pacemaker with 2340 33208 33208 transvenous electrode(s); atrial and ventricular $ 3,028.50 Insertion or replacement of temporary transvenous single chamber 2341 33210 33210 cardiac electrode or pacemaker catheter (separate procedure) $ 874.80 Insertion or replacement of temporary transvenous dual chamber 2342 33211 33211 pacing electrodes (separate procedure) $ 1,017.90 Insertion of pacemaker pulse generator only; with existing single 2343 33212 33212 lead $ 1,445.40 Insertion of pacemaker pulse generator only; with existing dual 2344 33213 33213 leads $ 1,467.90 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Upgrade of implanted pacemaker system, conversion of single chamber system to dual chamber system (includes removal of previously placed pulse generator, testing of existing lead, insertion 2345 33214 33214 of new lead, insertion of new pulse generator) $ 1,986.30 Repositioning of previously implanted transvenous pacemaker or pacing cardioverter-defibrillator (right atrial or right ventricular) 2346 33215 33215 electrode $ 829.37 Insertion of a single transvenous electrode, permanent pacemaker 2347 33216 33216 or cardioverter-defibrillator $ 1,427.40 Insertion of 2 transvenous electrodes, permanent pacemaker or 2348 33217 33217 cardioverter-defibrillator $ 1,512.90 Repair of single transvenous electrode, permanent pacemaker or 2349 33218 33218 pacing cardioverter-defibrillator $ 1,392.30 Repair of 2 transvenous electrodes for permanent pacemaker or 2350 33220 33220 pacing cardioverter-defibrillator $ 1,192.50 2351 33222 33222 Relocation of skin pocket for pacemaker $ 1,442.70 2352 33223 33223 Relocation of skin pocket for cardioverter-defibrillator $ 1,238.40 Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, with attachment to previously placed pacemaker or pacing cardioverter-defibrillator pulse generator (including 2353 33224 33224 revision of pocket, removal, insertion, and/or replacement of $ 1,345.09 Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of pacing cardioverter- defibrillator or pacemaker pulse generator (eg, for upgrade to dual 2354 33225 33225 chamber system) (List separately in addition to code for pri $ 1,199.61 Repositioning of previously implanted cardiac venous system (left ventricular) electrode (including removal, insertion and/or 2355 33226 33226 replacement of existing generator) $ 1,296.07 2356 33233 33233 Removal of permanent pacemaker pulse generator only $ 995.40 Removal of transvenous pacemaker electrode(s); single lead system, 2357 33234 33234 atrial or ventricular $ 1,511.10 2358 33235 33235 Removal of transvenous pacemaker electrode(s); dual lead system $ 1,649.70 Removal of permanent epicardial pacemaker and electrodes by 2359 33236 33236 thoracotomy; single lead system, atrial or ventricular $ 1,722.60 Removal of permanent epicardial pacemaker and electrodes by 2360 33237 33237 thoracotomy; dual lead system $ 2,735.10 2361 33238 33238 Removal of permanent transvenous electrode(s) by thoracotomy $ 2,816.10 Insertion of pacing cardioverter-defibrillator pulse generator only; 2362 33240 33240 with existing single lead $ 1,513.80 2363 33241 33241 Removal of pacing cardioverter-defibrillator pulse generator only $ 1,061.10 Removal of single or dual chamber pacing cardioverter-defibrillator 2364 33243 33243 electrode(s); by thoracotomy $ 3,192.30 Removal of single or dual chamber pacing cardioverter-defibrillator 2365 33244 33244 electrode(s); by transvenous extraction $ 2,707.20 Insertion or replacement of permanent pacing cardioverter- defibrillator system with transvenous lead(s), single or dual 2366 33249 33249 chamber $ 3,577.50 Operative ablation of supraventricular arrhythmogenic focus or pathway (eg, Wolff-Parkinson-White, atrioventricular node re- 2367 33250 33250 entry), tract(s) and/or focus (foci); without cardiopulmonary bypass $ 3,759.30 Operative ablation of supraventricular arrhythmogenic focus or pathway (eg, Wolff-Parkinson-White, atrioventricular node re- 2368 33251 33251 entry), tract(s) and/or focus (foci); with cardiopulmonary bypass $ 5,150.70 Operative tissue ablation and reconstruction of atria, limited (eg, 2369 33254 33254 modified maze procedure) $ 2,975.87 Operative tissue ablation and reconstruction of atria, extensive (eg, 2370 33255 33255 maze procedure); without cardiopulmonary bypass $ 3,580.01 Operative tissue ablation and reconstruction of atria, extensive (eg, 2371 33256 33256 maze procedure); with cardiopulmonary bypass $ 4,278.05 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Operative tissue ablation and reconstruction of atria, performed at the time of other cardiac procedure(s), limited (eg, modified maze procedure) (List separately in addition to code for primary 2372 33257 33257 procedure) $ 1,362.89 Operative tissue ablation and reconstruction of atria, performed at the time of other cardiac procedure(s), extensive (eg, maze procedure), without cardiopulmonary bypass (List separately in 2373 33258 33258 addition to code for primary procedure) $ 1,535.93 Operative tissue ablation and reconstruction of atria, performed at the time of other cardiac procedure(s), extensive (eg, maze procedure), with cardiopulmonary bypass (List separately in 2374 33259 33259 addition to code for primary procedure) $ 2,004.34 Operative ablation of ventricular arrhythmogenic focus with 2375 33261 33261 cardiopulmonary bypass $ 5,135.40 Endoscopy, surgical; operative tissue ablation and reconstruction of atria, limited (eg, modified maze procedure), without 2376 33265 33265 cardiopulmonary bypass $ 2,970.81 Endoscopy, surgical; operative tissue ablation and reconstruction of atria, extensive (eg, maze procedure), without cardiopulmonary 2377 33266 33266 bypass $ 4,068.64 2378 33282 33282 Implantation of patient-activated cardiac event recorder $ 786.37 2379 33284 33284 Removal of an implantable, patient-activated cardiac event recorder $ 567.29 2380 33300 33300 Repair of cardiac wound; without bypass $ 3,836.70 2381 33305 33305 Repair of cardiac wound;

with cardiopulmonary bypass $ 5,122.80 Cardiotomy, exploratory (includes removal of foreign body, atrial or 2382 33310 33310 ventricular thrombus); without bypass $ 3,654.90 Cardiotomy, exploratory (includes removal of foreign body, atrial or 2383 33315 33315 ventricular thrombus); with cardiopulmonary bypass $ 5,318.10 Suture repair of aorta or great vessels; without shunt or 2384 33320 33320 cardiopulmonary bypass $ 4,713.30 2385 33321 33321 Suture repair of aorta or great vessels; with shunt bypass $ 3,833.13 Suture repair of aorta or great vessels; with cardiopulmonary 2386 33322 33322 bypass $ 5,744.70 Insertion of graft, aorta or great vessels; without shunt, or 2387 33330 33330 cardiopulmonary bypass $ 6,261.30 2388 33332 33332 Insertion of graft, aorta or great vessels; with shunt bypass $ 5,066.72 Insertion of graft, aorta or great vessels; with cardiopulmonary 2389 33335 33335 bypass $ 6,984.00 2390 33400 33400 Valvuloplasty, aortic valve; open, with cardiopulmonary bypass $ 5,665.50 2391 33401 33401 Valvuloplasty, aortic valve; open, with inflow occlusion $ 5,706.90 Valvuloplasty, aortic valve; using transventricular dilation, with 2392 33403 33403 cardiopulmonary bypass $ 6,159.60 2393 33404 33404 Construction of apical-aortic conduit $ 6,695.10 Replacement, aortic valve, with cardiopulmonary bypass; with 2394 33405 33405 prosthetic valve other than homograft or stentless valve $ 7,717.50 Replacement, aortic valve, with cardiopulmonary bypass; with 2395 33406 33406 allograft valve (freehand) $ 7,029.90 Replacement, aortic valve, with cardiopulmonary bypass; with 2396 33410 33410 stentless tissue valve $ 6,661.86 Replacement, aortic valve; with aortic annulus enlargement, 2397 33411 33411 noncoronary sinus $ 7,921.80 Replacement, aortic valve; with transventricular aortic annulus 2398 33412 33412 enlargement (Konno procedure) $ 8,019.00 Replacement, aortic valve; by translocation of autologous pulmonary valve with allograft replacement of pulmonary valve 2399 33413 33413 (Ross procedure) $ 7,622.10 Repair of left ventricular outflow tract obstruction by patch 2400 33414 33414 enlargement of the outflow tract $ 6,825.57 Resection or incision of subvalvular tissue for discrete subvalvular 2401 33415 33415 aortic stenosis $ 6,087.60 Ventriculomyotomy (-myectomy) for idiopathic hypertrophic 2402 33416 33416 subaortic stenosis (eg, asymmetric septal hypertrophy) $ 6,592.50 2403 33417 33417 Aortoplasty (gusset) for supravalvular stenosis $ 6,952.50 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price 2404 33420 33420 Valvotomy, mitral valve; closed heart $ 5,495.40 2405 33422 33422 Valvotomy, mitral valve; open heart, with cardiopulmonary bypass $ 6,451.20 2406 33425 33425 Valvuloplasty, mitral valve, with cardiopulmonary bypass; $ 6,628.50 Valvuloplasty, mitral valve, with cardiopulmonary bypass; with 2407 33426 33426 prosthetic ring $ 7,905.60 Valvuloplasty, mitral valve, with cardiopulmonary bypass; radical 2408 33427 33427 reconstruction, with or without ring $ 6,978.60 2409 33430 33430 Replacement, mitral valve, with cardiopulmonary bypass $ 7,627.50 2410 33460 33460 Valvectomy, tricuspid valve, with cardiopulmonary bypass $ 6,223.50 2411 33463 33463 Valvuloplasty, tricuspid valve; without ring insertion $ 7,105.50 2412 33464 33464 Valvuloplasty, tricuspid valve; with ring insertion $ 6,801.30 2413 33465 33465 Replacement, tricuspid valve, with cardiopulmonary bypass $ 6,721.20 2414 33468 33468 Tricuspid valve repositioning and plication for Ebstein anomaly $ 6,988.50 2415 33470 33470 Valvotomy, pulmonary valve, closed heart; transventricular $ 5,030.10 2416 33471 33471 Valvotomy, pulmonary valve, closed heart; via pulmonary artery $ 4,708.80 2417 33472 33472 Valvotomy, pulmonary valve, open heart; with inflow occlusion $ 4,979.70 Valvotomy, pulmonary valve, open heart; with cardiopulmonary 2418 33474 33474 bypass $ 5,535.90 2419 33475 33475 Replacement, pulmonary valve $ 7,105.50 Right ventricular resection for infundibular stenosis, with or without 2420 33476 33476 commissurotomy $ 5,840.10 Outflow tract augmentation (gusset), with or without 2421 33478 33478 commissurotomy or infundibular resection $ 5,840.10 Repair of non-structural prosthetic valve dysfunction with 2422 33496 33496 cardiopulmonary bypass (separate procedure) $ 5,799.60 Repair of coronary arteriovenous or arteriocardiac chamber fistula; 2423 33500 33500 with cardiopulmonary bypass $ 5,355.90 Repair of coronary arteriovenous or arteriocardiac chamber fistula; 2424 33501 33501 without cardiopulmonary bypass $ 4,027.50 Repair of anomalous coronary artery from pulmonary artery origin; 2425 33502 33502 by ligation $ 3,878.10 Repair of anomalous coronary artery from pulmonary artery origin; 2426 33503 33503 by graft, without cardiopulmonary bypass $ 4,377.60 Repair of anomalous coronary artery from pulmonary artery origin; 2427 33504 33504 by graft, with cardiopulmonary bypass $ 6,170.40 Repair of anomalous coronary artery from pulmonary artery origin; with construction of intrapulmonary artery tunnel (Takeuchi 2428 33505 33505 procedure) $ 5,183.04 Repair of anomalous coronary artery from pulmonary artery origin; 2429 33506 33506 by translocation from pulmonary artery to aorta $ 5,719.19 Repair of anomalous (eg, intramural) aortic origin of coronary artery 2430 33507 33507 by unroofing or translocation $ 5,300.00 Endoscopy, surgical, including video-assisted harvest of vein(s) for coronary artery bypass procedure (List separately in addition to 2431 33508 33508 code for primary procedure) $ 260.39 2432 33510 33510 Coronary artery bypass, vein only; single coronary venous graft $ 7,254.00 2433 33511 33511 Coronary artery bypass, vein only; 2 coronary venous grafts $ 7,448.40 2434 33512 33512 Coronary artery bypass, vein only; 3 coronary venous grafts $ 8,284.50 2435 33513 33513 Coronary artery bypass, vein only; 4 coronary venous grafts $ 9,268.20 2436 33514 33514 Coronary artery bypass, vein only; 5 coronary venous grafts $ 10,083.60 2437 33516 33516 Coronary artery bypass, vein only; 6 or more coronary venous grafts $ 10,809.00 Coronary artery bypass, using venous graft(s) and arterial graft(s); single vein graft (List separately in addition to code for primary 2438 33517 33517 procedure) $ 1,161.90 Coronary artery bypass, using venous graft(s) and arterial graft(s); 2 venous grafts (List separately in addition to code for primary 2439 33518 33518 procedure) $ 1,747.80 Coronary artery bypass, using venous graft(s) and arterial graft(s); 3 venous grafts (List separately in addition to code for primary 2440 33519 33519 procedure) $ 2,054.70 Coronary artery bypass, using venous graft(s) and arterial graft(s); 4 venous grafts (List separately in addition to code for primary 2441 33521 33521 procedure) $ 2,816.10 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Coronary artery bypass, using venous graft(s) and arterial graft(s); 5 venous grafts (List separately in addition to code for primary 2442 33522 33522 procedure) $ 3,634.20 Coronary artery bypass, using venous graft(s) and arterial graft(s); 6 or more venous grafts (List separately in addition to code for 2443 33523 33523 primary procedure) $ 4,606.20 Reoperation, coronary artery bypass procedure or valve procedure, more than 1 month after original operation (List separately in 2444 33530 33530 addition to code for primary procedure) $ 2,003.40 2445 33533 33533 Coronary artery bypass, using arterial graft(s); single arterial graft $ 6,878.70 Coronary artery bypass, using arterial graft(s); 2 coronary arterial 2446 33534 33534 grafts $ 7,822.80 Coronary artery bypass, using arterial graft(s); 3 coronary arterial 2447 33535 33535 grafts $ 8,479.80 Coronary artery bypass, using arterial graft(s); 4 or more coronary 2448 33536 33536 arterial grafts $ 8,454.60 2449 33542 33542 Myocardial resection (eg, ventricular aneurysmectomy) $ 6,769.80 Repair of postinfarction ventricular septal defect, with or without 2450 33545 33545 myocardial resection $ 7,679.70 Surgical ventricular restoration procedure, includes prosthetic patch, when performed (eg, ventricular remodeling, SVR, SAVER, 2451 33548 33548 Dor procedures) $ 7,924.63 Coronary endarterectomy, open, any method, of left anterior descending, circumflex, or right coronary artery performed in conjunction with coronary artery bypass graft procedure, each 2452 33572 33572 vessel (List separately in addition to primary procedure) $ 1,008.00 Closure of atrioventricular valve (mitral or tricuspid) by suture or 2453 33600 33600 patch $ 6,489.00 2454 33602 33602 Closure of semilunar valve (aortic or pulmonary) by suture or patch $ 6,479.10 Anastomosis of pulmonary artery to aorta (Damus-Kaye-Stansel 2455 33606 33606 procedure) $ 6,581.70 Repair of complex cardiac anomaly other than pulmonary atresia with ventricular septal defect by construction or replacement of 2456 33608 33608 conduit from right or left ventricle to pulmonary artery $ 6,643.80 Repair of complex cardiac anomalies (eg, single ventricle with subaortic obstruction) by surgical enlargement of ventricular septal 2457 33610 33610 defect $ 6,591.66 Repair of double outlet right ventricle with intraventricular tunnel 2458 33611 33611 repair; $ 6,644.56 Repair of double outlet right ventricle with intraventricular tunnel 2459 33612 33612 repair; with repair of right ventricular outflow tract obstruction $ 7,416.00 Repair of complex cardiac anomalies (eg, tricuspid atresia) by closure of atrial septal defect and anastomosis of atria or vena cava 2460 33615 33615 to pulmonary artery (simple Fontan procedure) $ 7,004.70 Repair of complex cardiac anomalies (eg, single ventricle) by 2461 33617 33617 modified Fontan procedure $ 7,584.08 Repair of single ventricle with aortic outflow obstruction and aortic arch hypoplasia (hypoplastic left heart syndrome) (eg, Norwood 2462 33619 33619 procedure) $ 8,214.30 Repair atrial septal defect, secundum, with cardiopulmonary 2463 33641 33641 bypass, with or without patch $ 5,459.40 Direct or patch closure, sinus venosus, with or without anomalous 2464 33645 33645 pulmonary venous drainage $ 6,368.40 Repair of atrial septal defect and ventricular septal defect, with 2465 33647 33647 direct or patch closure $ 7,210.80 Repair of incomplete or partial atrioventricular canal (ostium primum atrial septal defect), with or without atrioventricular valve 2466 33660 33660 repair $ 6,916.50 Repair of intermediate or transitional atrioventricular canal, with or 2467 33665 33665 without atrioventricular valve repair $ 7,938.00 Repair of complete atrioventricular canal, with or without 2468 33670 33670 prosthetic valve $ 7,625.70 2469 33675 33675 Closure of multiple ventricular septal defects; $ 6,647.90 Closure of multiple ventricular septal defects; with pulmonary 2470 33676 33676 valvotomy or infundibular resection (acyanotic) $ 6,341.84 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Closure of multiple ventricular septal defects; with removal of 2471 33677 33677 pulmonary artery band, with or without gusset $ 6,334.62 2472 33681 33681 Closure of single ventricular septal defect, with or without patch; $ 6,144.30 Closure of single ventricular septal defect, with or without patch; 2473 33684 33684 with pulmonary valvotomy or infundibular resection (acyanotic) $ 6,494.40 Closure of single ventricular septal defect, with or without patch; 2474 33688 33688 with removal of pulmonary artery band, with or without gusset $ 6,613.20 2475 33690 33690 Banding of pulmonary artery $ 3,090.60 2476 33692 33692 Complete repair tetralogy of Fallot without pulmonary atresia; $ 6,437.70 Complete repair tetralogy of Fallot without pulmonary atresia; with 2477 33694 33694 transannular patch $ 7,090.20 Complete repair tetralogy of Fallot with pulmonary atresia including construction of conduit from right ventricle to pulmonary artery 2478 33697 33697 and closure of ventricular septal defect $ 7,173.90 2479 33702 33702 Repair sinus of Valsalva fistula, with cardiopulmonary bypass; $ 5,951.70 Repair sinus of Valsalva fistula, with cardiopulmonary bypass; with 2480 33710 33710 repair of ventricular septal defect $ 7,786.80 2481 33720 33720 Repair sinus of Valsalva aneurysm, with cardiopulmonary bypass $ 6,746.40 2482 33722 33722 Closure of aortico-left ventricular tunnel $ 6,437.70 Repair of isolated partial anomalous pulmonary venous return (eg, 2483 33724 33724 Scimitar Syndrome) $ 5,384.20 2484 33726 33726 Repair of pulmonary venous stenosis $ 6,373.14 Complete repair of anomalous pulmonary venous return 2485 33730 33730 (supracardiac, intracardiac, or infracardiac types) $ 6,602.40 Repair of cor triatriatum or supravalvular mitral ring by resection of 2486 33732 33732 left atrial membrane $ 5,942.70 Atrial septectomy or septostomy; closed heart (Blalock-Hanlon type 2487 33735 33735 operation) $ 4,538.70 Atrial septectomy or septostomy; open heart with cardiopulmonary 2488 33736 33736 bypass $ 5,480.10 2489 33737 33737 Atrial septectomy or septostomy; open heart, with inflow occlusion $ 4,892.40 Shunt; subclavian to pulmonary artery (Blalock-Taussig type 2490 33750 33750 operation) $ 4,233.60 Shunt; ascending aorta to pulmonary artery (Waterston type 2491 33755 33755 operation) $ 4,748.40 Shunt; descending aorta to pulmonary artery (Potts-Smith type 2492 33762 33762 operation) $ 4,645.80 2493 33764 33764 Shunt; central, with prosthetic graft $ 4,686.30 Shunt; superior vena cava to pulmonary artery for flow to 1 lung 2494 33766 33766 (classical Glenn procedure) $ 4,068.90 Shunt; superior vena cava to pulmonary artery for flow to both 2495 33767 33767 lungs (bidirectional Glenn procedure) $ 4,686.30 Anastomosis, cavopulmonary, second superior vena cava (List 2496 33768 33768 separately in addition to primary procedure) $ 1,373.84 Repair of transposition of the great arteries with ventricular septal defect and subpulmonary stenosis; without surgical enlargement of 2497 33770 33770 ventricular septal defect $ 7,014.60 Repair of transposition of the great arteries with ventricular septal defect and subpulmonary stenosis; with surgical enlargement of 2498 33771 33771 ventricular septal defect $ 7,655.60 Repair of transposition of the great arteries, atrial baffle procedure 2499 33774 33774 (eg, Mustard or Senning type) with cardiopulmonary bypass; $ 6,746.40 Repair of transposition of the great arteries, atrial baffle procedure (eg, Mustard or Senning type) with cardiopulmonary bypass; with 2500 33775 33775 removal of pulmonary band $ 6,685.20 Repair of transposition of the great arteries, atrial baffle procedure (eg, Mustard or Senning type) with cardiopulmonary bypass; with 2501 33776 33776 closure of ventricular septal defect $ 8,601.30 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Repair of transposition of the great arteries, atrial baffle procedure (eg, Mustard or Senning type) with cardiopulmonary bypass; with 2502 33777 33777 repair of subpulmonic obstruction $ 8,343.00 Repair of transposition of the great arteries, aortic pulmonary 2503 33778 33778 artery reconstruction (eg, Jatene type); $ 9,038.70 Repair of transposition of the great arteries, aortic pulmonary artery reconstruction (eg, Jatene type); with removal of pulmonary 2504 33779 33779 band $ 8,766.00 Repair of transposition of the great arteries, aortic pulmonary artery reconstruction (eg, Jatene type); with closure of ventricular 2505 33780 33780 septal defect $ 8,766.00 Repair of transposition of the great arteries, aortic pulmonary artery reconstruction (eg, Jatene type); with repair of subpulmonic 2506 33781 33781 obstruction $ 8,766.00 Aortic root translocation with ventricular septal defect and pulmonary stenosis repair (ie, Nikaidoh procedure); without 2507 33782 33782 coronary ostium reimplantation $ 12,843.24 Aortic root translocation with ventricular septal defect and pulmonary stenosis repair (ie, Nikaidoh procedure); with 2508 33783 33783 reimplantation of 1 or both coronary ostia $ 13,932.80 2509 33786 33786 Total repair, truncus arteriosus (Rastelli type operation) $ 7,416.00 2510 33788 33788 Reimplantation of an anomalous pulmonary artery $ 5,548.50 Aortic suspension (aortopexy) for tracheal decompression (eg, for 2511 33800 33800 tracheomalacia) (separate procedure) $ 2,654.10 2512 33802 33802 Division of aberrant vessel (vascular ring); $ 3,554.10 2513 33803 33803 Division of aberrant vessel (vascular ring); with reanastomosis $ 3,893.40 Obliteration of aortopulmonary septal defect; without 2514 33813 33813 cardiopulmonary bypass $ 4,243.50 Obliteration of aortopulmonary septal defect; with 2515 33814 33814 cardiopulmonary bypass $ 5,994.90 2516 33820 33820 Repair of patent ductus arteriosus; by ligation $ 3,869.10 Repair of patent ductus arteriosus; by division, younger than 18 2517 33822 33822 years $ 3,641.40 2518 33824 33824 Repair of patent ductus arteriosus; by division, 18 years and older $ 4,058.10 Excision of coarctation of aorta, with or without associated patent 2519 33840 33840 ductus arteriosus; with direct anastomosis $ 4,342.50 Excision of coarctation of aorta, with or without associated patent 2520 33845 33845 ductus arteriosus; with graft $ 6,087.60 Excision of coarctation of aorta, with or without associated patent ductus arteriosus; repair using either left subclavian artery or 2521 33851 33851 prosthetic material as gusset for enlargement $ 5,986.48 Repair of hypoplastic or interrupted aortic arch using autogenous or 2522 33852 33852 prosthetic material; without cardiopulmonary bypass $ 5,514.30 Repair of hypoplastic or interrupted aortic arch using autogenous or 2523 33853 33853 prosthetic material; with cardiopulmonary bypass $ 6,901.20 Ascending aorta graft, with cardiopulmonary bypass, includes valve 2524 33860 33860 suspension, when performed $ 7,323.30 Ascending aorta graft, with cardiopulmonary bypass, with aortic root replacement using valved conduit and coronary reconstruction 2525 33863 33863 (eg, Bentall) $ 7,577.10 Ascending aorta graft, with cardiopulmonary bypass with valve suspension, with coronary reconstruction and valve-sparing aortic 2526 33864 33864 root remodeling (eg, David Procedure, Yacoub Procedure) $ 7,601.41 2527 33870 33870 Transverse arch graft, with cardiopulmonary bypass $ 9,652.50 2528 33875 33875 Descending thoracic aorta graft, with or without bypass $ 7,810.20 Repair of thoracoabdominal aortic aneurysm with graft, with or 2529 33877 33877 without cardiopulmonary bypass $ 9,241.20 Endovascular repair of descending thoracic aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption); involving coverage of left subclavian artery origin, initial endoprosthesis plus descending 2530 33880 33880 thora $ 5,712.22 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Endovascular repair of descending thoracic aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption); not involving coverage of left 2531 33881 33881 subclavian artery origin, initial endoprosthesis plus descending t $ 4,930.62 Placement of proximal extension prosthesis for endovascular repair of descending thoracic aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic 2532 33883 33883 disruption); initial extension $ 3,643.31 Placement of proximal extension prosthesis for endovascular repair of descending thoracic aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic 2533 33884 33884 disruption); each additional proximal extension (List separatel $ 1,385.57 Placement of distal extension prosthesis(s) delayed after 2534 33886 33886 endovascular repair of descending thoracic aorta $ 3,119.61 Open subclavian to carotid artery transposition performed in conjunction with endovascular repair of descending thoracic aorta, 2535 33889 33889 by neck incision, unilateral $ 2,690.56 Bypass graft, with other than vein, transcervical retropharyngeal carotid-carotid, performed in conjunction with endovascular repair 2536 33891 33891 of descending thoracic aorta, by neck incision $ 3,430.57 2537 33910 33910 Pulmonary artery embolectomy; with cardiopulmonary bypass $ 6,566.40 2538 33915 33915 Pulmonary artery embolectomy; without cardiopulmonary bypass $ 3,965.40 Pulmonary endarterectomy, with or without embolectomy, with 2539 33916 33916 cardiopulmonary bypass $ 4,653.00 Repair of pulmonary artery stenosis by reconstruction with patch or 2540 33917 33917 graft $ 6,633.90 Repair of pulmonary atresia with ventricular septal defect, by construction or replacement of conduit from right or left ventricle 2541 33920 33920 to pulmonary artery $ 6,891.30 2542 33922 33922 Transection of pulmonary artery with cardiopulmonary bypass $ 5,562.00 Ligation and takedown of a systemic-to-pulmonary artery shunt, performed in conjunction with a congenital heart procedure (List 2543 33924 33924 separately in addition to code for primary procedure) $ 1,096.26 Repair of pulmonary artery arborization anomalies by 2544 33925 33925 unifocalization; without cardiopulmonary bypass $ 6,455.33 Repair of pulmonary artery arborization anomalies by 2545 33926 33926 unifocalization; with cardiopulmonary bypass $ 8,708.02 2546 33930 33930 Donor cardiectomy-pneumonectomy (including cold preservation) $ - Backbench standard preparation of cadaver donor heart/lung allograft prior to transplantation, including dissection of allograft from surrounding soft tissues to prepare aorta, superior vena cava, 2547 33933 33933 inferior vena cava, and trachea for implantation $ - 2548 33935 33935 Heart-lung transplant with recipient cardiectomy-pneumonectomy $ 12,504.94 2549 33940 33940 Donor cardiectomy (including cold preservation) $ 4,149.00 Backbench standard preparation of cadaver donor heart allograft prior to transplantation, including dissection of allograft from surrounding soft tissues to prepare aorta, superior vena cava, 2550 33944 33944 inferior vena cava, pulmonary artery, and left atrium for impla $ - 2551 33945 33945 Heart transplant, with or without recipient cardiectomy $ 11,331.00 Prolonged extracorporeal circulation for cardiopulmonary 2552 33960 33960 insufficiency; initial day $ 2,981.70 Prolonged extracorporeal circulation for cardiopulmonary 2553 33961 33961 insufficiency; each subsequent day $ 1,626.30 2554 33967 33967 Insertion of intra-aortic balloon assist device, percutaneous $ 681.97 2555 33968 33968 Removal of intra-aortic balloon assist device, percutaneous $ 98.27 Insertion of intra-aortic balloon assist device through the femoral 2556 33970 33970 artery, open approach $ 2,032.20 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Removal of intra-aortic balloon assist device including repair of 2557 33971 33971 femoral artery, with or without graft $ 1,911.60 Insertion of intra-aortic balloon assist device through the ascending 2558 33973 33973 aorta $ 2,047.50 Removal of intra-aortic balloon assist device from the ascending 2559 33974 33974 aorta, including repair of the ascending aorta, with or without graft $ 2,317.50 2560 33975 33975 Insertion of ventricular assist device; extracorporeal, single ventricle $ 4,377.60 2561 33976 33976 Insertion of ventricular assist device; extracorporeal, biventricular $ 4,364.10 2562 33977 33977 Removal of ventricular assist device; extracorporeal, single ventricle $ 3,388.50 2563 33978 33978 Removal of ventricular assist device; extracorporeal, biventricular $ 3,780.00 Insertion of ventricular assist device, implantable intracorporeal, 2564 33979 33979 single ventricle $ 6,113.20 Removal of ventricular assist device, implantable intracorporeal, 2565 33980 33980 single ventricle $ 9,056.83 Replacement of extracorporeal ventricular assist device, single or 2566 33981 33981 biventricular, pump(s), single or each pump $ 2,099.36 Replacement of ventricular assist device pump(s); implantable 2567 33982 33982 intracorporeal, single ventricle, without cardiopulmonary bypass $ 5,143.44 Replacement of ventricular assist device pump(s); implantable 2568 33983 33983 intracorporeal, single ventricle, with cardiopulmonary bypass $ 5,744.73 2569 33999 33999 Unlisted procedure, cardiac surgery $ - Embolectomy or thrombectomy, with or without catheter; carotid, 2570 34001 34001 subclavian or innominate artery, by neck incision $ 2,654.10 Embolectomy or thrombectomy, with or without catheter; 2571 34051 34051 innominate, subclavian artery, by thoracic incision $ 2,909.70 Embolectomy or thrombectomy, with or without catheter; axillary, 2572 34101 34101 brachial, innominate, subclavian artery, by arm incision $ 2,623.50 Embolectomy or thrombectomy, with or without catheter; radial or 2573 34111 34111 ulnar artery, by arm incision $ 2,964.60 Embolectomy or thrombectomy, with or without catheter; renal, 2574 34151 34151 celiac, mesentery, aortoiliac artery, by abdominal incision $ 3,651.30 Embolectomy or thrombectomy, with or without catheter; 2575 34201 34201 femoropopliteal, aortoiliac artery, by leg incision $ 2,886.30 Embolectomy or thrombectomy, with or without catheter; popliteal- 2576 34203 34203 tibio-peroneal artery, by leg incision $ 2,952.90 Thrombectomy, direct or with catheter; vena cava, iliac vein, by 2577 34401 34401 abdominal incision $ 2,884.50 Thrombectomy, direct or with catheter; vena cava, iliac, 2578 34421 34421 femoropopliteal vein, by leg incision $ 2,549.70 Thrombectomy, direct or with catheter; vena cava, iliac, 2579 34451 34451 femoropopliteal vein, by abdominal and leg incision $ 2,923.20 Thrombectomy, direct or with catheter; subclavian vein, by neck 2580 34471 34471 incision $ 2,317.50 Thrombectomy, direct or with catheter; axillary and subclavian vein, 2581 34490 34490 by arm incision $ 2,148.30 2582 34501 34501 Valvuloplasty, femoral vein $ 2,421.00 2583 34502 34502 Reconstruction of vena cava, any method $ 5,296.50 2584 34510 34510 Venous valve transposition, any vein donor $ 2,574.90 2585 34520 34520 Cross-over vein graft to venous system $ 3,444.30 2586 34530 34530 Saphenopopliteal vein anastomosis $ 2,738.70 Endovascular repair of infrarenal abdominal aortic aneurysm or 2587 34800 34800 dissection; using aorto-aortic tube prosthesis $ 3,621.60 Endovascular repair of infrarenal abdominal aortic aneurysm or 2588 34802 34802 dissection; using modular bifurcated prosthesis (1 docking limb) $ 3,996.90 Endovascular repair of infrarenal abdominal aortic aneurysm or 2589 34803 34803 dissection; using modular bifurcated prosthesis (2 docking limbs) $ 4,301.78 Endovascular repair of infrarenal abdominal aortic aneurysm or 2590 34804 34804 dissection; using unibody bifurcated prosthesis $ 3,996.90 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Endovascular repair of infrarenal abdominal aortic aneurysm or 2591 34805 34805 dissection; using aorto-uniiliac or aorto-unifemoral prosthesis $ 3,987.05 Transcatheter placement of wireless physiologic sensor in aneurysmal sac during endovascular repair, including radiological supervision and interpretation, instrument calibration, and 2592 34806 34806 collection of pressure data (List separately in addition to code for pr $ 420.95 Endovascular placement of iliac artery occlusion device (List 2593 34808 34808 separately in addition to code for primary procedure) $ 688.50 Open femoral artery exposure for delivery of endovascular 2594 34812 34812 prosthesis, by groin incision, unilateral $ 1,125.90 Placement of femoral-femoral prosthetic graft during endovascular aortic aneurysm repair (List separately in addition to code for 2595 34813 34813 primary procedure) $ 800.10 Open iliac artery exposure for delivery of endovascular prosthesis or iliac occlusion during endovascular therapy, by abdominal or 2596 34820 34820 retroperitoneal incision, unilateral $ 1,626.30 Placement of proximal or distal extension prosthesis for endovascular repair of infrarenal abdominal aortic or iliac 2597 34825 34825 aneurysm, false aneurysm, or dissection; initial vessel $ 2,162.70 Placement of proximal or distal extension prosthesis for endovascular repair of infrarenal abdominal aortic or iliac aneurysm, false aneurysm, or dissection; each additional vessel (List 2598 34826 34826 separately in addition to code for primary procedure) $ 688.50 Open repair of infrarenal aortic aneurysm or dissection, plus repair of associated arterial trauma, following unsuccessful endovascular 2599 34830 34830 repair; tube prosthesis $ 5,635.80 Open repair of infrarenal aortic aneurysm or dissection, plus repair of associated arterial trauma, following unsuccessful endovascular 2600 34831 34831 repair; aorto-bi-iliac prosthesis $ 6,093.00 Open repair of infrarenal aortic aneurysm or dissection, plus repair of associated arterial trauma, following unsuccessful endovascular 2601 34832 34832 repair; aorto-bifemoral prosthesis $ 6,093.00 Open iliac artery exposure with creation of conduit for delivery of aortic or iliac endovascular prosthesis, by abdominal or 2602 34833 34833 retroperitoneal incision, unilateral $ 1,682.17 Open brachial artery exposure to assist in the deployment of aortic 2603 34834 34834 or iliac endovascular prosthesis by arm incision, unilateral $ 965.20 Endovascular repair of iliac artery (eg, aneurysm, pseudoaneurysm, arteriovenous malformation, trauma) using ilio-iliac tube 2604 34900 34900 endoprosthesis $ 2,239.64 Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm and associated occlusive disease, carotid, subclavian artery, by neck 2605 35001 35001 incision $ 3,978.00 Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for ruptured 2606 35002 35002 aneurysm, carotid, subclavian artery, by neck incision $ 4,092.30 Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm, 2607 35005 35005 pseudoaneurysm, and associated occlusive disease, vertebral artery $ 3,744.00 Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm and associated occlusive disease, axillary-brachial artery, by arm 2608 35011 35011 incision $ 3,550.50 Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for ruptured 2609 35013 35013 aneurysm, axillary-brachial artery, by arm incision $ 3,780.90 Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm, pseudoaneurysm, and associated occlusive disease, innominate, 2610 35021 35021 subclavian artery, by thoracic incision $ 4,011.30 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for ruptured 2611 35022 35022 aneurysm, innominate, subclavian artery, by thoracic incision $ 4,035.60 Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm, pseudoaneurysm, and associated occlusive disease, radial or ulnar 2612 35045 35045 artery $ 3,766.50 Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm, pseudoaneurysm, and associated occlusive disease, abdominal 2613 35081 35081 aorta $ 5,967.00 Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for ruptured 2614 35082 35082 aneurysm, abdominal aorta $ 7,056.00 Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm, pseudoaneurysm, and associated occlusive disease, abdominal 2615 35091 35091 aorta involving visceral vessels (mesenteric, celiac, ren $ 6,876.00 Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for ruptured aneurysm, abdominal aorta involving visceral vessels (mesenteric, 2616 35092 35092 celiac, renal) $ 7,870.50 Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm, pseudoaneurysm, and associated occlusive disease, abdominal 2617 35102 35102 aorta involving iliac vessels (common, hypogastric, exter $ 6,484.50 Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for ruptured aneurysm, abdominal aorta involving iliac vessels (common, 2618 35103 35103 hypogastric, external) $ 6,972.30 Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm, 2619 35111 35111 pseudoaneurysm, and associated occlusive disease, splenic artery $ 4,826.70 Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for ruptured 2620 35112 35112 aneurysm, splenic artery $ 3,327.30 Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm, pseudoaneurysm, and associated occlusive disease, hepatic, celiac, 2621 35121 35121 renal, or mesenteric artery $ 4,541.40 Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for ruptured 2622 35122 35122 aneurysm, hepatic, celiac, renal, or mesenteric artery $ 4,851.90 Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm, pseudoaneurysm, and associated occlusive disease, iliac artery 2623 35131 35131 (common, hypogastric, external) $ 4,762.80 Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for ruptured 2624 35132 35132 aneurysm, iliac artery (common, hypogastric, external) $ 4,635.00 Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm, pseudoaneurysm, and associated occlusive disease, common 2625 35141 35141 femoral artery (profunda femoris, superficial femoral) $ 4,068.90 Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for ruptured aneurysm, common femoral artery (profunda femoris, superficial 2626 35142 35142 femoral) $ 4,619.70 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for aneurysm, 2627 35151 35151 pseudoaneurysm, and associated occlusive disease, popliteal artery $ 4,226.40 Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for ruptured 2628 35152 35152 aneurysm, popliteal artery $ 3,790.80 2629 35180 35180 Repair, congenital arteriovenous fistula; head and neck $ 3,141.90 2630 35182 35182 Repair, congenital arteriovenous fistula; thorax and abdomen $ 4,532.40 2631 35184 35184 Repair, congenital arteriovenous fistula; extremities $ 3,888.00 2632 35188 35188 Repair, acquired or traumatic arteriovenous fistula; head and neck $ 3,234.60 Repair, acquired or traumatic arteriovenous fistula; thorax and 2633 35189 35189 abdomen $ 4,228.20 2634 35190 35190 Repair, acquired or traumatic arteriovenous fistula; extremities $ 3,682.80 2635 35201 35201 Repair blood vessel, direct; neck $ 3,811.50 2636 35206 35206 Repair blood vessel, direct; upper extremity $ 3,393.00 2637 35207 35207 Repair blood vessel, direct; hand, finger $ 3,836.70 2638 35211 35211 Repair blood vessel, direct; intrathoracic, with bypass $ 4,775.40 2639 35216 35216 Repair blood vessel, direct; intrathoracic, without bypass $ 4,719.60 2640 35221 35221 Repair blood vessel, direct; intra-abdominal $ 4,332.60 2641 35226 35226 Repair blood vessel, direct; lower extremity $ 4,322.70 2642 35231 35231 Repair blood vessel with vein graft; neck $ 3,770.10 2643 35236 35236 Repair blood vessel with vein graft; upper extremity $ 5,035.50 2644 35241 35241 Repair blood vessel with vein graft; intrathoracic, with bypass $ 4,771.80 2645 35246 35246 Repair blood vessel with vein graft; intrathoracic, without bypass $ 4,289.40 2646 35251 35251 Repair blood vessel with vein graft; intra-abdominal $ 5,365.80 2647 35256 35256 Repair blood vessel with vein graft; lower extremity $ 4,428.90 2648 35261 35261 Repair blood vessel with graft other than vein; neck $ 3,811.50 2649 35266 35266 Repair blood vessel with graft other than vein; upper extremity $ 3,907.80 Repair blood vessel with graft other than vein; intrathoracic, with 2650 35271 35271 bypass $ 5,134.50 Repair blood vessel with graft other than vein; intrathoracic, 2651 35276 35276 without bypass $ 3,682.80 2652 35281 35281 Repair blood vessel with graft other than vein; intra-abdominal $ 4,377.60 2653 35286 35286 Repair blood vessel with graft other than vein; lower extremity $ 4,189.50 Thromboendarterectomy, including patch graft, if performed; 2654 35301 35301 carotid, vertebral, subclavian, by neck incision $ 4,066.20 Thromboendarterectomy, including patch graft, if performed; 2655 35302 35302 superficial femoral artery $ 3,050.03 Thromboendarterectomy, including patch graft, if performed; 2656 35303 35303 popliteal artery $ 3,211.06 Thromboendarterectomy, including patch graft, if performed; 2657 35304 35304 tibioperoneal trunk artery $ 3,248.55 Thromboendarterectomy, including patch graft, if performed; tibial 2658 35305 35305 or peroneal artery, initial vessel $ 3,210.32 Thromboendarterectomy, including patch graft, if performed; each additional tibial or peroneal artery (List separately in addition to 2659 35306 35306 code for primary procedure) $ 1,331.62 Thromboendarterectomy, including patch graft, if performed; 2660 35311 35311 subclavian, innominate, by thoracic incision $ 3,872.70 Thromboendarterectomy, including patch graft, if performed; 2661 35321 35321 axillary-brachial $ 3,862.80 Thromboendarterectomy, including patch graft, if performed; 2662 35331 35331 abdominal aorta $ 5,119.20 Thromboendarterectomy, including patch graft, if performed; 2663 35341 35341 mesenteric, celiac, or renal $ 4,953.60 2664 35351 35351 Thromboendarterectomy, including patch graft, if performed; iliac $ 4,340.70 Thromboendarterectomy, including patch graft, if performed; 2665 35355 35355 iliofemoral $ 4,176.00 Thromboendarterectomy, including patch graft, if performed; 2666 35361 35361 combined aortoiliac $ 5,794.20 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Thromboendarterectomy, including patch graft, if performed; 2667 35363 35363 combined aortoiliofemoral $ 4,686.30 Thromboendarterectomy, including patch graft, if performed; 2668 35371 35371 common femoral $ 3,605.40 Thromboendarterectomy, including patch graft, if performed; deep 2669 35372 35372 (profunda) femoral $ 4,039.20 Reoperation, carotid, thromboendarterectomy, more than 1 month after original operation (List separately in addition to code for 2670 35390 35390 primary procedure) $ 855.00 Angioscopy (non-coronary vessels or grafts) during therapeutic intervention (List separately in addition to code for primary 2671 35400 35400 procedure) $ 570.60 Transluminal balloon angioplasty, open; renal or other visceral 2672 35450 35450 artery $ 2,514.60 2673 35452 35452 Transluminal balloon angioplasty, open; aortic $ 1,345.50 Transluminal balloon angioplasty, open; brachiocephalic trunk or 2674 35458 35458 branches, each vessel $ 2,317.50 2675 35460 35460 Transluminal balloon angioplasty, open; venous $ 1,596.60 Transluminal balloon angioplasty, percutaneous; renal or visceral 2676 35471 35471 artery $ 2,348.10 2677 35472 35472 Transluminal balloon angioplasty, percutaneous; aortic $ 2,743.20 Transluminal balloon angioplasty, percutaneous; brachiocephalic 2678 35475 35475 trunk or branches, each vessel $ 2,426.40 2679 35476 35476 Transluminal balloon angioplasty, percutaneous; venous $ 1,415.70 Harvest of upper extremity vein, 1 segment, for lower extremity or coronary artery bypass procedure (List separately in addition to 2680 35500 35500 code for primary procedure) $ 871.62 2681 35501 35501 Bypass graft, with vein; common carotid-ipsilateral internal carotid $ 3,636.00 2682 35506 35506 Bypass graft, with vein; carotid-subclavian or subclavian-carotid $ 4,938.30 2683 35508 35508 Bypass graft, with vein; carotid-vertebral $ 3,759.30 2684 35509 35509 Bypass graft, with vein; carotid-contralateral carotid $ 3,682.80 2685 35510 35510 Bypass graft, with vein; carotid-brachial $ 3,271.58 2686 35511 35511 Bypass graft, with vein; subclavian-subclavian $ 3,365.10 2687 35512 35512 Bypass graft, with vein; subclavian-brachial $ 3,264.42 2688 35515 35515 Bypass graft, with vein; subclavian-vertebral $ 3,420.00 2689 35516 35516 Bypass graft, with vein; subclavian-axillary $ 3,505.50 2690 35518 35518 Bypass graft, with vein; axillary-axillary $ 4,264.20 2691 35521 35521 Bypass graft, with vein; axillary-femoral $ 4,596.30 2692 35522 35522 Bypass graft, with vein; axillary-brachial $ 3,209.65 2693 35523 35523 Bypass graft, with vein; brachial-ulnar or -radial $ 3,277.08 2694 35525 35525 Bypass graft, with vein; brachial-brachial $ 3,187.18 Bypass graft, with vein; aortosubclavian, aortoinnominate, or 2695 35526 35526 aortocarotid $ 4,275.00 2696 35531 35531 Bypass graft, with vein; aortoceliac or aortomesenteric $ 4,910.40 2697 35533 35533 Bypass graft, with vein; axillary-femoral-femoral $ 4,089.60 2698 35535 35535 Bypass graft, with vein; hepatorenal $ 4,060.85 2699 35536 35536 Bypass graft, with vein; splenorenal $ 4,485.60 2700 35537 35537 Bypass graft, with vein; aortoiliac $ 4,523.50 2701 35538 35538 Bypass graft, with vein; aortobi-iliac $ 5,514.25 2702 35539 35539 Bypass graft, with vein; aortofemoral $ 5,177.02 2703 35540 35540 Bypass graft, with vein; aortobifemoral $ 5,915.40 2704 35556 35556 Bypass graft, with vein; femoral-popliteal $ 4,336.20 2705 35558 35558 Bypass graft, with vein; femoral-femoral $ 4,312.80 2706 35560 35560 Bypass graft, with vein; aortorenal $ 4,439.70 2707 35563 35563 Bypass graft, with vein; ilioiliac $ 3,582.90 2708 35565 35565 Bypass graft, with vein; iliofemoral $ 4,176.90 Bypass graft, with vein; femoral-anterior tibial, posterior tibial, 2709 35566 35566 peroneal artery or other distal vessels $ 5,097.60 Bypass graft, with vein; tibial-tibial, peroneal-tibial, or 2710 35570 35570 tibial/peroneal trunk-tibial $ 3,570.22 Bypass graft, with vein; popliteal-tibial, -peroneal artery or other 2711 35571 35571 distal vessels $ 4,784.40 Harvest of femoropopliteal vein, 1 segment, for vascular reconstruction procedure (eg, aortic, vena caval, coronary, peripheral artery) (List separately in addition to code for primary 2712 35572 35572 procedure) $ 878.05 2713 35583 35583 In-situ vein bypass; femoral-popliteal $ 4,646.70 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price In-situ vein bypass; femoral-anterior tibial, posterior tibial, or 2714 35585 35585 peroneal artery $ 5,580.90 2715 35587 35587 In-situ vein bypass; popliteal-tibial, peroneal $ 5,259.60 Harvest of upper extremity artery, 1 segment, for coronary artery bypass procedure (List separately in addition to code for primary 2716 35600 35600 procedure) $ 922.50 Bypass graft, with other than vein; common carotid-ipsilateral 2717 35601 35601 internal carotid $ 3,828.60 2718 35606 35606 Bypass graft, with other than vein; carotid-subclavian $ 4,417.20 2719 35612 35612 Bypass graft, with other than vein; subclavian-subclavian $ 4,006.80 2720 35616 35616 Bypass graft, with other than vein; subclavian-axillary $ 3,502.80 2721 35621 35621 Bypass graft, with other than vein; axillary-femoral $ 4,295.70 2722 35623 35623 Bypass graft, with other than vein; axillary-popliteal or -tibial $ 4,099.50 Bypass graft, with other than vein; aortosubclavian, 2723 35626 35626 aortoinnominate, or aortocarotid $ 5,134.50 Bypass graft, with other than vein; aortoceliac, aortomesenteric, 2724 35631 35631 aortorenal $ 4,752.00 2725 35632 35632 Bypass graft, with other than vein; ilio-celiac $ 3,986.67 2726 35633 35633 Bypass graft, with other than vein; ilio-mesenteric $ 4,261.60 2727 35634 35634 Bypass graft, with other than vein; iliorenal $ 3,929.70 Bypass graft, with other than vein; splenorenal (splenic to renal 2728 35636 35636 arterial anastomosis) $ 4,275.00 2729 35637 35637 Bypass graft, with other than vein; aortoiliac $ 3,861.68 2730 35638 35638 Bypass graft, with other than vein; aortobi-iliac $ 3,898.02 2731 35642 35642 Bypass graft, with other than vein; carotid-vertebral $ 3,672.00 2732 35645 35645 Bypass graft, with other than vein; subclavian-vertebral $ 3,720.60 2733 35646 35646 Bypass graft, with other than vein; aortobifemoral $ 5,142.60 2734 35647 35647 Bypass graft, with other than vein; aortofemoral $ 3,664.37 2735 35650 35650 Bypass graft, with other than vein; axillary-axillary $ 4,328.10 2736 35654 35654 Bypass graft, with other than vein; axillary-femoral-femoral $ 5,381.10 2737 35656 35656 Bypass graft, with other than vein; femoral-popliteal $ 4,311.00 2738 35661 35661 Bypass graft, with other than vein; femoral-femoral $ 4,134.60 2739 35663 35663 Bypass graft, with other than vein; ilioiliac $ 3,662.10 2740 35665 35665 Bypass graft, with other than vein; iliofemoral $ 4,484.70 Bypass graft, with other than vein; femoral-anterior tibial, posterior 2741 35666 35666 tibial, or peroneal artery $ 4,851.90 Bypass graft, with other than vein; popliteal-tibial or -peroneal 2742 35671 35671 artery $ 4,197.60 Bypass graft; composite, prosthetic and vein (List separately in 2743 35681 35681 addition to code for primary procedure) $ 3,032.10 Bypass graft; autogenous composite, 2 segments of veins from 2 2744 35682 35682 locations (List separately in addition to code for primary procedure) $ 1,248.30 Bypass graft; autogenous composite, 3 or more segments of vein from 2 or more locations (List separately in addition to code for 2745 35683 35683 primary procedure) $ 1,425.60 Placement of vein patch or cuff at distal anastomosis of bypass graft, synthetic conduit (List separately in addition to code for 2746 35685 35685 primary procedure) $ 840.77 Creation of distal arteriovenous fistula during lower extremity bypass surgery (non-hemodialysis) (List separately in addition to 2747 35686 35686 code for primary procedure) $ 858.30 2748 35691 35691 Transposition and/or reimplantation; vertebral to carotid artery $ 3,834.00 2749 35693 35693 Transposition and/or reimplantation; vertebral to subclavian artery $ 3,316.50 2750 35694 35694 Transposition and/or reimplantation; subclavian to carotid artery $ 3,399.30 2751 35695 35695 Transposition and/or reimplantation;

carotid to subclavian artery $ 3,321.00 Reimplantation, visceral artery to infrarenal aortic prosthesis, each 2752 35697 35697 artery (List separately in addition to code for primary procedure) $ 1,617.23 Reoperation, femoral-popliteal or femoral (popliteal)-anterior tibial, posterior tibial, peroneal artery, or other distal vessels, more than 1 month after original operation (List separately in addition to code 2753 35700 35700 for primary procedure) $ 978.30 Exploration (not followed by surgical repair), with or without lysis of 2754 35701 35701 artery; carotid artery $ 1,827.90 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Exploration (not followed by surgical repair), with or without lysis of 2755 35721 35721 artery; femoral artery $ 1,711.80 Exploration (not followed by surgical repair), with or without lysis of 2756 35741 35741 artery; popliteal artery $ 1,733.40 Exploration (not followed by surgical repair), with or without lysis of 2757 35761 35761 artery; other vessels $ 1,645.20 Exploration for postoperative hemorrhage, thrombosis or infection; 2758 35800 35800 neck $ 1,757.70 Exploration for postoperative hemorrhage, thrombosis or infection; 2759 35820 35820 chest $ 2,691.90 Exploration for postoperative hemorrhage, thrombosis or infection; 2760 35840 35840 abdomen $ 2,632.50 Exploration for postoperative hemorrhage, thrombosis or infection; 2761 35860 35860 extremity $ 1,816.20 2762 35870 35870 Repair of graft-enteric fistula $ 5,026.50 Thrombectomy of arterial or venous graft (other than hemodialysis 2763 35875 35875 graft or fistula); $ 2,820.60 Thrombectomy of arterial or venous graft (other than hemodialysis 2764 35876 35876 graft or fistula); with revision of arterial or venous graft $ 3,186.90 Revision, lower extremity arterial bypass, without thrombectomy, 2765 35879 35879 open; with vein patch angioplasty $ 3,326.40 Revision, lower extremity arterial bypass, without thrombectomy, 2766 35881 35881 open; with segmental vein interposition $ 3,647.70 Revision, femoral anastomosis of synthetic arterial bypass graft in groin, open; with nonautogenous patch graft (eg, Dacron, ePTFE, 2767 35883 35883 bovine pericardium) $ 3,256.61 Revision, femoral anastomosis of synthetic arterial bypass graft in 2768 35884 35884 groin, open; with autogenous vein patch graft $ 3,453.76 2769 35901 35901 Excision of infected graft; neck $ 2,307.60 2770 35903 35903 Excision of infected graft; extremity $ 2,663.10 2771 35905 35905 Excision of infected graft; thorax $ 2,797.20 2772 35907 35907 Excision of infected graft; abdomen $ 3,213.90 2773 36000 36000 Introduction of needle or intracatheter, vein $ 128.91 Injection procedures (eg, thrombin) for percutaneous treatment of 2774 36002 36002 extremity pseudoaneurysm $ 282.31 Injection procedure for extremity venography (including 2775 36005 36005 introduction of needle or intracatheter) $ 186.30 2776 36010 36010 Introduction of catheter, superior or inferior vena cava $ 647.10 Selective catheter placement, venous system; first order branch (eg, 2777 36011 36011 renal vein, jugular vein) $ 510.30 Selective catheter placement, venous system; second order, or 2778 36012 36012 more selective, branch (eg, left adrenal vein, petrosal sinus) $ 679.50 2779 36013 36013 Introduction of catheter, right heart or main pulmonary artery $ 789.30 2780 36014 36014 Selective catheter placement, left or right pulmonary artery $ 591.30 Selective catheter placement, segmental or subsegmental 2781 36015 36015 pulmonary artery $ 628.20 2782 36100 36100 Introduction of needle or intracatheter, carotid or vertebral artery $ 628.20 2783 36120 36120 Introduction of needle or intracatheter; retrograde brachial artery $ 741.60 2784 36140 36140 Introduction of needle or intracatheter; extremity artery $ 503.10 Introduction of needle and/or catheter, arteriovenous shunt created for dialysis (graft/fistula); initial access with complete radiological evaluation of dialysis access, including fluoroscopy, 2785 36147 36147 image documentation and report (includes access of shunt, inj $ 1,052.96 Introduction of needle and/or catheter, arteriovenous shunt created for dialysis (graft/fistula); additional access for therapeutic intervention (List separately in addition to code for primary 2786 36148 36148 procedure) $ 325.12 2787 36160 36160 Introduction of needle or intracatheter, aortic, translumbar $ 650.70 2788 36200 36200 Introduction of catheter, aorta $ 624.60 Selective catheter placement, arterial system; each first order 2789 36215 36215 thoracic or brachiocephalic branch, within a vascular family $ 710.10 Selective catheter placement, arterial system; initial second order 2790 36216 36216 thoracic or brachiocephalic branch, within a vascular family $ 729.00 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Selective catheter placement, arterial system; initial third order or more selective thoracic or brachiocephalic branch, within a vascular 2791 36217 36217 family $ 978.30 Selective catheter placement, arterial system; additional second order, third order, and beyond, thoracic or brachiocephalic branch, within a vascular family (List in addition to code for initial second or 2792 36218 36218 third order vessel as appropriate) $ 232.20 Non-selective catheter placement, thoracic aorta, with angiography of the extracranial carotid, vertebral, and/or intracranial vessels, unilateral or bilateral, and all associated radiological supervision 2793 36221 36221 and interpretation, includes angiography of the ce $ 2,880.37 Selective catheter placement, common carotid or innominate artery, unilateral, any approach, with angiography of the ipsilateral extracranial carotid circulation and all associated radiological 2794 36222 36222 supervision and interpretation, includes angiography of the c $ 3,561.38 Selective catheter placement, common carotid or innominate artery, unilateral, any approach, with angiography of the ipsilateral intracranial carotid circulation and all associated radiological 2795 36223 36223 supervision and interpretation, includes angiography of the e $ 3,896.31 Selective catheter placement, internal carotid artery, unilateral, with angiography of the ipsilateral intracranial carotid circulation and all associated radiological supervision and interpretation, 2796 36224 36224 includes angiography of the extracranial carotid and ce $ 4,230.34 Selective catheter placement, subclavian or innominate artery, unilateral, with angiography of the ipsilateral vertebral circulation and all associated radiological supervision and interpretation, 2797 36225 36225 includes angiography of the cervicocerebral arch, when per $ 3,867.22 Selective catheter placement, vertebral artery, unilateral, with angiography of the ipsilateral vertebral circulation and all associated radiological supervision and interpretation, includes angiography of 2798 36226 36226 the cervicocerebral arch, when performed $ 4,313.16 Selective catheter placement, external carotid artery, unilateral, with angiography of the ipsilateral external carotid circulation and all associated radiological supervision and interpretation (List 2799 36227 36227 separately in addition to code for primary procedure) $ 614.41 Selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity artery branch, within a 2800 36245 36245 vascular family $ 768.60 Selective catheter placement, arterial system; initial second order abdominal, pelvic, or lower extremity artery branch, within a 2801 36246 36246 vascular family $ 875.70 Selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, or lower extremity artery branch, 2802 36247 36247 within a vascular family $ 1,114.20 Selective catheter placement, arterial system; additional second order, third order, and beyond, abdominal, pelvic, or lower extremity artery branch, within a vascular family (List in addition to 2803 36248 36248 code for initial second or third order vessel as appropriat $ 236.70 Selective catheter placement (first-order), main renal artery and any accessory renal artery(s) for renal angiography, including arterial puncture and catheter placement(s), fluoroscopy, contrast 2804 36252 36252 injection(s), image postprocessing, permanent recording of $ 4,101.15 Superselective catheter placement (one or more second order or higher renal artery branches) renal artery and any accessory renal artery(s) for renal angiography, including arterial puncture, 2805 36254 36254 catheterization, fluoroscopy, contrast injection(s), image post $ 5,947.12 Insertion of implantable intra-arterial infusion pump (eg, for 2806 36260 36260 chemotherapy of liver) $ 2,344.50 2807 36261 36261 Revision of implanted intra-arterial infusion pump $ 919.80 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price 2808 36262 36262 Removal of implanted intra-arterial infusion pump $ 849.60 2809 36299 36299 Unlisted procedure, vascular injection Cost Venipuncture, younger than age 3 years, necessitating the skill of a physician or other qualified health care professional, not to be used 2810 36400 36400 for routine venipuncture; femoral or jugular vein $ 57.60 Venipuncture, younger than age 3 years, necessitating the skill of a physician or other qualified health care professional, not to be used 2811 36405 36405 for routine venipuncture; scalp vein $ 87.30 Venipuncture, younger than age 3 years, necessitating the skill of a physician or other qualified health care professional, not to be used 2812 36406 36406 for routine venipuncture; other vein $ 93.20 Venipuncture, age 3 years or older, necessitating the skill of a physician or other qualified health care professional (separate procedure), for diagnostic or therapeutic purposes (not to be used 2813 36410 36410 for routine venipuncture) $ 75.26 2814 36415 36415 Collection of venous blood by venipuncture $ 17.04 2815 36416 36416 Collection of capillary blood specimen (eg, finger, heel, ear stick) $ - 2816 36420 36420 Venipuncture, cutdown; younger than age 1 year $ 212.40 2817 36425 36425 Venipuncture, cutdown; age 1 or over $ 236.70 2818 36430 36430 Transfusion, blood or blood components $ 122.40 2819 36440 36440 Push transfusion, blood, 2 years or younger $ 212.40 2820 36450 36450 Exchange transfusion, blood; newborn $ 824.40 2821 36455 36455 Exchange transfusion, blood; other than newborn $ 875.70 2822 36460 36460 Transfusion, intrauterine, fetal $ 1,153.80 Single or multiple injections of sclerosing solutions, spider veins 2823 36468 36468 (telangiectasia); limb or trunk $ 327.60 Single or multiple injections of sclerosing solutions, spider veins 2824 36469 36469 (telangiectasia); face $ 202.50 2825 36470 36470 Injection of sclerosing solution; single vein $ 152.52 2826 36471 36471 Injection of sclerosing solution; multiple veins, same leg $ 246.87 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, 2827 36475 36475 radiofrequency; first vein treated $ 3,072.75 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; second and subsequent veins treated in a single 2828 36476 36476 extremity, each through separate access sites (List separately in a $ 1,042.37 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, 2829 36478 36478 laser; first vein treated $ 2,978.33 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; second and subsequent veins treated in a single extremity, 2830 36479 36479 each through separate access sites (List separately in addition t $ 1,045.01 2831 36481 36481 Percutaneous portal vein catheterization by any method $ 1,143.00 2832 36500 36500 Venous catheterization for selective organ blood sampling $ 475.20 2833 36510 36510 Catheterization of umbilical vein for diagnosis or therapy, newborn $ 265.50 2834 36511 36511 Therapeutic apheresis; for white blood cells $ 274.52 2835 36512 36512 Therapeutic apheresis; for red blood cells $ 273.39 2836 36513 36513 Therapeutic apheresis; for platelets $ 276.08 Therapeutic apheresis; with extracorporeal immunoadsorption and 2837 36515 36515 plasma reinfusion $ 2,040.30 Therapeutic apheresis; with extracorporeal selective adsorption or 2838 36516 36516 selective filtration and plasma reinfusion $ 2,129.80 2839 36522 36522 Photopheresis, extracorporeal $ 550.80 Insertion of non-tunneled centrally inserted central venous 2840 36555 36555 catheter; younger than 5 years of age $ 500.71 Insertion of non-tunneled centrally inserted central venous 2841 36556 36556 catheter; age 5 years or older $ 373.52 Insertion of tunneled centrally inserted central venous catheter, 2842 36557 36557 without subcutaneous port or pump; younger than 5 years of age $ 1,519.07 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Insertion of tunneled centrally inserted central venous catheter, 2843 36558 36558 without subcutaneous port or pump; age 5 years or older $ 1,287.53 Insertion of tunneled centrally inserted central venous access 2844 36560 36560 device, with subcutaneous port; younger than 5 years of age $ 1,595.76 Insertion of tunneled centrally inserted central venous access 2845 36561 36561 device, with subcutaneous port; age 5 years or older $ 1,280.08 Insertion of tunneled centrally inserted central venous access device 2846 36563 36563 with subcutaneous pump $ 1,557.18 Insertion of tunneled centrally inserted central venous access device, requiring 2 catheters via 2 separate venous access sites; 2847 36565 36565 without subcutaneous port or pump (eg, Tesio type catheter) $ 1,535.22 Insertion of tunneled centrally inserted central venous access device, requiring 2 catheters via 2 separate venous access sites; 2848 36566 36566 with subcutaneous port(s) $ 2,580.53 Insertion of peripherally inserted central venous catheter (PICC), 2849 36568 36568 without subcutaneous port or pump; younger than 5 years of age $ 548.20 Insertion of peripherally inserted central venous catheter (PICC), 2850 36569 36569 without subcutaneous port or pump; age 5 years or older $ 459.11 Insertion of peripherally inserted central venous access device, with 2851 36570 36570 subcutaneous port; younger than 5 years of age $ 1,264.84 Insertion of peripherally inserted central venous access device, with 2852 36571 36571 subcutaneous port; age 5 years or older $ 1,302.40 Repair of tunneled or non-tunneled central venous access catheter, without subcutaneous port or pump, central or peripheral insertion 2853 36575 36575 site $ 294.90 Repair of central venous access device, with subcutaneous port or 2854 36576 36576 pump, central or peripheral insertion site $ 671.12 Replacement, catheter only, of central venous access device, with 2855 36578 36578 subcutaneous port or pump, central or peripheral insertion site $ 1,052.89 Replacement, complete, of a non-tunneled centrally inserted central venous catheter, without subcutaneous port or pump, 2856 36580 36580 through same venous access $ 402.39 Replacement, complete, of a tunneled centrally inserted central venous catheter, without subcutaneous port or pump, through 2857 36581 36581 same venous access $ 1,347.18 Replacement, complete, of a tunneled centrally inserted central venous access device, with subcutaneous port, through same 2858 36582 36582 venous access $ 1,777.44 Replacement, complete, of a tunneled centrally inserted central venous access device, with subcutaneous pump, through same 2859 36583 36583 venous access $ 1,809.20 Replacement, complete, of a peripherally inserted central venous catheter (PICC), without subcutaneous port or pump, through same 2860 36584 36584 venous access $ 423.34 Replacement, complete, of a peripherally inserted central venous 2861 36585 36585 access device, with subcutaneous port, through same venous access $ 1,778.45 Removal of tunneled central venous catheter, without 2862 36589 36589 subcutaneous port or pump $ 388.65 Removal of tunneled central venous access device, with 2863 36590 36590 subcutaneous port or pump, central or peripheral insertion $ 579.93 Collection of blood specimen from a completely implantable venous 2864 36591 36591 access device $ 40.50 Collection of blood specimen using established central or peripheral 2865 36592 36592 catheter, venous, not otherwise specified $ 52.78 Declotting by thrombolytic agent of implanted vascular access 2866 36593 36593 device or catheter $ 146.47 Mechanical removal of pericatheter obstructive material (eg, fibrin 2867 36595 36595 sheath) from central venous device via separate venous access $ 1,257.21 Mechanical removal of intraluminal (intracatheter) obstructive 2868 36596 36596 material from central venous device through device lumen $ 265.15 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Repositioning of previously placed central venous catheter under 2869 36597 36597 fluoroscopic guidance $ 238.99 Contrast injection(s) for radiologic evaluation of existing central venous access device, including fluoroscopy, image documentation 2870 36598 36598 and report $ 282.77 2871 36600 36600 Arterial puncture, withdrawal of blood for diagnosis $ 91.80 Arterial catheterization or cannulation for sampling, monitoring or 2872 36620 36620 transfusion (separate procedure); percutaneous $ 256.50 Arterial catheterization or cannulation for sampling, monitoring or 2873 36625 36625 transfusion (separate procedure); cutdown $ 391.50 Arterial catheterization for prolonged infusion therapy 2874 36640 36640 (chemotherapy), cutdown $ 550.80 2875 36660 36660 Catheterization, umbilical artery, newborn, for diagnosis or therapy $ 322.20 2876 36680 36680 Placement of needle for intraosseous infusion $ 256.50 Insertion of cannula for hemodialysis, other purpose (separate 2877 36800 36800 procedure); vein to vein $ 885.60 Insertion of cannula for hemodialysis, other purpose (separate 2878 36810 36810 procedure); arteriovenous, external (Scribner type) $ 1,357.20 Insertion of cannula for hemodialysis, other purpose (separate 2879 36815 36815 procedure); arteriovenous, external revision, or closure $ 1,125.90 Arteriovenous anastomosis, open; by upper arm cephalic vein 2880 36818 36818 transposition $ 1,990.48 Arteriovenous anastomosis, open; by upper arm basilic vein 2881 36819 36819 transposition $ 4,174.20 2882 36820 36820 Arteriovenous anastomosis, open; by forearm vein transposition $ 2,132.80 Arteriovenous anastomosis, open; direct, any site (eg, Cimino type) 2883 36821 36821 (separate procedure) $ 2,295.00 Insertion of arterial and venous cannula(s) for isolated extracorporeal circulation including regional chemotherapy perfusion to an extremity, with or without hyperthermia, with 2884 36823 36823 removal of cannula(s) and repair of arteriotomy and venotomy sites $ 3,310.72 Creation of arteriovenous fistula by other than direct arteriovenous 2885 36825 36825 anastomosis (separate procedure); autogenous graft $ 3,141.90 Thrombectomy, open, arteriovenous fistula without revision, 2886 36831 36831 autogenous or nonautogenous dialysis graft (separate procedure) $ 1,346.40 Revision, open, arteriovenous fistula; without thrombectomy, 2887 36832 36832 autogenous or nonautogenous dialysis graft (separate procedure) $ 2,439.90 Revision, open, arteriovenous fistula; with thrombectomy, 2888 36833 36833 autogenous or nonautogenous dialysis graft (separate procedure) $ 1,944.90 2889 36835 36835 Insertion of Thomas shunt (separate procedure) $ 1,480.23 Distal revascularization and interval ligation (DRIL), upper extremity 2890 36838 36838 hemodialysis access (steal syndrome) $ 3,556.18 External cannula declotting (separate procedure); without balloon 2891 36860 36860 catheter $ 412.20 External cannula declotting (separate procedure); with balloon 2892 36861 36861 catheter $ 891.00 Thrombectomy, percutaneous, arteriovenous fistula, autogenous or nonautogenous graft (includes mechanical thrombus extraction and 2893 36870 36870 intra-graft thrombolysis) $ 3,973.50 2894 37140 37140 Venous anastomosis, open; portocaval $ 5,608.80 2895 37145 37145 Venous anastomosis, open; renoportal $ 3,990.60 2896 37160 37160 Venous anastomosis, open; caval-mesenteric $ 5,255.10 2897 37180 37180 Venous anastomosis, open; splenorenal, proximal $ 4,969.80 Venous anastomosis, open; splenorenal, distal (selective 2898 37181 37181 decompression of esophagogastric varices, any technique) $ 5,961.60 Insertion of transvenous intrahepatic portosystemic shunt(s) (TIPS) (includes venous access, hepatic and portal vein catheterization, portography with hemodynamic evaluation, intrahepatic tract 2899 37182 37182 formation/dilatation, stent placement and all associated imag $ 1,959.09 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Revision of transvenous intrahepatic portosystemic shunt(s) (TIPS) (includes venous access, hepatic and portal vein catheterization, portography with hemodynamic evaluation, intrahepatic tract 2900 37183 37183 recanulization/dilatation, stent placement and all associated $ 15,255.65 Primary percutaneous transluminal mechanical thrombectomy, noncoronary, arterial or arterial bypass graft, including fluoroscopic guidance and intraprocedural pharmacological thrombolytic 2901 37184 37184 injection(s); initial vessel $ 2,214.84 Primary percutaneous transluminal mechanical thrombectomy, noncoronary, arterial or arterial bypass graft, including fluoroscopic guidance and intraprocedural pharmacological thrombolytic 2902 37185 37185 injection(s); second and all subsequent vessel(s) within the same v $ 872.39 Secondary percutaneous transluminal thrombectomy (eg, nonprimary mechanical, snare basket, suction technique), noncoronary, arterial or arterial bypass graft, including fluoroscopic guidance and intraprocedural pharmacological thrombolytic 2903 37186 37186 injections, pro $ 1,250.30 Percutaneous transluminal mechanical thrombectomy, vein(s), including intraprocedural pharmacological thrombolytic injections 2904 37187 37187 and fluoroscopic guidance $ 1,941.11 Percutaneous transluminal mechanical thrombectomy, vein(s), including intraprocedural pharmacological thrombolytic injections and fluoroscopic guidance, repeat treatment on subsequent day 2905 37188 37188 during course of thrombolytic therapy $ 1,473.77 Insertion of intravascular vena cava filter, endovascular approach including vascular access, vessel selection, and radiological supervision and interpretation, intraprocedural roadmapping, and 2906 37191 37191 imaging guidance (ultrasound and fluoroscopy), when performed $ 6,918.36 37192 37192 Repositioning of intravascular vena cava filter, endovascular approach including vascular access, vessel selection, and radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance (ultrasound and fluoroscopy), 2907 when performed $ 4,487.46 37193 37193 Retrieval (removal) of intravascular vena cava filter, endovascular approach including vascular access, vessel selection, and radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance (ultrasound and fluoroscopy), 2908 when performed $ 4,282.95 2909 37195 37195 Thrombolysis, cerebral, by intravenous infusion $ 846.90 Transcatheter retrieval, percutaneous, of intravascular foreign body (eg, fractured venous or arterial catheter), includes radiological supervision and interpretation, and imaging guidance (ultrasound or 2910 37197 37197 fluoroscopy), when performed $ 3,887.58 2911 37200 37200 Transcatheter biopsy $ 814.79 Transcatheter therapy, infusion other than for thrombolysis, any 2912 37202 37202 type (eg, spasmolytic, vasoconstrictive) $ 973.80 Transcatheter therapy, arterial infusion for thrombolysis other than coronary, any method, including radiological supervision and 2913 37211 37211 interpretation, initial treatment day $ 972.47 Transcatheter therapy, venous infusion for thrombolysis, any method, including radiological supervision and interpretation, initial 2914 37212 37212 treatment day $ 858.67 Transcatheter therapy, arterial or venous infusion for thrombolysis other than coronary, any method, including radiological supervision and interpretation, continued treatment on subsequent day during 2915 37213 37213 course of thrombolytic therapy, including follow-up ca $ 599.49 Transcatheter therapy, arterial or venous infusion for thrombolysis other than coronary, any method, including radiological supervision and interpretation, continued treatment on subsequent day during 2916 37214 37214 course of thrombolytic therapy, including follow-up ca $ 353.25 Transcatheter placement of intravascular stent(s), cervical carotid 2917 37215 37215 artery, percutaneous; with distal embolic protection $ 3,812.78 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Transcatheter placement of intravascular stent(s), cervical carotid 2918 37216 37216 artery, percutaneous; without distal embolic protection $ 3,498.17 Revascularization, endovascular, open or percutaneous, iliac artery, 2919 37220 37220 unilateral, initial vessel; with transluminal angioplasty $ 2,257.95 Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal stent placement(s), 2920 37221 37221 includes angioplasty within the same vessel, when performed $ 3,035.71 Revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel; with transluminal angioplasty 2921 37222 37222 (List separately in addition to code for primary procedure) $ 861.42 Revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when 2922 37223 37223 performed (List separately in addition to code for prima $ 1,606.46 Revascularization, endovascular, open or percutaneous, femoral, 2923 37224 37224 popliteal artery(s), unilateral; with transluminal angioplasty $ 2,605.53 Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with atherectomy, includes 2924 37225 37225 angioplasty within the same vessel, when performed $ 5,405.06 Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s), 2925 37226 37226 includes angioplasty within the same vessel, when performed $ 4,490.45 Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, 2926 37227 37227 when performed $ 7,098.85 Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal 2927 37228 37228 angioplasty $ 3,436.34 Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with atherectomy, includes 2928 37229 37229 angioplasty within the same vessel, when performed $ 5,676.63 Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when 2929 37230 37230 performed $ 4,780.81 Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal stent placement(s) and atherectomy, includes angioplasty within the 2930 37231 37231 same vessel, when performed $ 6,604.22 Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with transluminal angioplasty (List separately in addition to code for 2931 37232 37232 primary procedure) $ 1,046.39 Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with atherectomy, includes angioplasty within the same vessel, when performed (List separately in addition to code for primary 2932 37233 37233 procedure) $ 1,367.77 Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed (List separately in addition to code 2933 37234 37234 for p $ 2,092.73 Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed (List separately 2934 37235 37235 in additi $ 2,470.73 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Transcatheter placement of an intravascular stent(s) (except lower extremity, cervical carotid, extracranial vertebral or intrathoracic carotid, intracranial, or coronary), open or percutaneous, including 2935 37236 37236 radiological supervision and interpretation and in $ 9,119.70 Transcatheter placement of an intravascular stent(s) (except lower extremity, cervical carotid, extracranial vertebral or intrathoracic carotid, intracranial, or coronary), open or percutaneous, including 2936 37237 37237 radiological supervision and interpretation and in $ 4,410.41 Transcatheter placement of an intravascular stent(s), open or percutaneous, including radiological supervision and interpretation and including angioplasty within the same vessel, when performed; 2937 37238 37238 initial vein $ 9,119.70 Transcatheter placement of an intravascular stent(s), open or percutaneous, including radiological supervision and interpretation and including angioplasty within the same vessel, when performed; 2938 37239 37239 each additional vein (List separately in addition to code f $ 4,410.41 Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; venous, 2939 37241 37241 other than hemorrhage (eg, congenital or acquired venous ma $ 8,842.66 Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; arterial, 2940 37242 37242 other than hemorrhage or tumor (eg, congenital or acquire $ 8,842.66 Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; for 2941 37243 37243 tumors, organ ischemia, or infarction $ 8,842.66 Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; for 2942 37244 37244 arterial or venous hemorrhage or lymphatic extravasation $ 8,842.66 Intravascular ultrasound (non-coronary vessel) during diagnostic evaluation and/or therapeutic intervention; initial vessel (List 2943 37250 37250 separately in addition to code for primary procedure) $ 408.08 Intravascular ultrasound (non-coronary vessel) during diagnostic evaluation and/or therapeutic intervention; each additional vessel 2944 37251 37251 (List separately in addition to code for primary procedure) $ 319.58 Vascular endoscopy, surgical, with ligation of perforator veins, 2945 37500 37500 subfascial (SEPS) $ 2,240.80 2946 37501 37501 Unlisted vascular endoscopy procedure Cost 2947 37565 37565 Ligation, internal jugular vein $ 1,462.50 2948 37600 37600 Ligation; external carotid artery $ 1,596.60 2949 37605 37605 Ligation; internal or common carotid artery $ 1,402.20 Ligation; internal or common carotid artery, with gradual occlusion, 2950 37606 37606 as with Selverstone or Crutchfield clamp $ 1,670.40 2951 37607 37607 Ligation or banding of angioaccess arteriovenous fistula $ 1,293.30 2952 37609 37609 Ligation or biopsy, temporal artery $ 689.40 2953 37615 37615 Ligation, major artery (eg, post-traumatic, rupture); neck $ 1,608.30 2954 37616 37616 Ligation, major artery (eg, post-traumatic, rupture); chest $ 2,796.30 2955 37617 37617 Ligation, major artery (eg, post-traumatic, rupture); abdomen $ 2,619.00 2956 37618 37618 Ligation, major artery (eg, post-traumatic, rupture); extremity $ 1,545.30 2957 37619 37619 Ligation of inferior vena cava $ 4,215.75 2958 37650 37650 Ligation of femoral vein $ 1,337.40 2959 37660 37660 Ligation of common iliac vein $ 1,606.50 Ligation and division of long saphenous vein at saphenofemoral 2960 37700 37700 junction, or distal interruptions $ 998.10 2961 37718 37718 Ligation, division, and stripping, short saphenous vein $ 1,006.21 Ligation, division, and stripping, long (greater) saphenous veins 2962 37722 37722 from saphenofemoral junction to knee or below $ 1,208.89 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Ligation and division and complete stripping of long or short saphenous veins with radical excision of ulcer and skin graft and/or interruption of communicating veins of lower leg, with excision of 2963 37735 37735 deep fascia $ 2,844.00 Ligation of perforator veins, subfascial, radical (Linton type), 2964 37760 37760 including skin graft, when performed, open, 1 leg $ 2,987.10 Ligation of perforator vein(s), subfascial, open, including ultrasound 2965 37761 37761 guidance, when performed, 1 leg $ 1,390.71 Stab phlebectomy of varicose veins, 1 extremity; 10-20 stab 2966 37765 37765 incisions $ 1,167.91 Stab phlebectomy of varicose veins, 1 extremity; more than 20 2967 37766 37766 incisions $ 1,416.38 Ligation and division of short saphenous vein at saphenopopliteal 2968 37780 37780 junction (separate procedure) $ 641.70 2969 37785 37785 Ligation, division, and/or excision of varicose vein cluster(s), 1 leg $ 739.80 2970 37788 37788 Penile revascularization, artery, with or without vein graft $ 4,092.33 2971 37790 37790 Penile venous occlusive procedure $ 1,527.94 2972 37799 37799 Unlisted procedure, vascular surgery Cost 2973 38100 38100 Splenectomy; total (separate procedure) $ 2,660.40 2974 38101 38101 Splenectomy; partial (separate procedure) $ 2,975.40 Splenectomy; total, en bloc for extensive disease, in conjunction with other procedure (List in addition to code for primary 2975 38102 38102 procedure) $ 1,835.10 Repair of ruptured spleen (splenorrhaphy) with or without partial 2976 38115 38115 splenectomy $ 2,743.20 2977 38120 38120 Laparoscopy, surgical, splenectomy $ 3,954.23 2978 38129 38129 Unlisted laparoscopy procedure, spleen Cost 2979 38200 38200 Injection procedure for splenoportography $ 351.00 Management of recipient hematopoietic progenitor cell donor 2980 38204 38204 search and cell acquisition $ 232.57 Blood-derived hematopoietic progenitor cell harvesting for 2981 38205 38205 transplantation, per collection; allogeneic $ 718.59 Blood-derived hematopoietic progenitor cell harvesting for 2982 38206 38206 transplantation, per collection; autologous $ 718.94 Transplant preparation of hematopoietic progenitor cells; 2983 38207 38207 cryopreservation and storage $ 78.09 Transplant preparation of hematopoietic progenitor cells; thawing 2984 38208 38208 of previously frozen harvest, without washing, per donor $ 50.46 Transplant preparation of hematopoietic progenitor cells; thawing 2985 38209 38209 of previously frozen harvest, with washing, per donor $ 20.85 Transplant preparation of hematopoietic progenitor cells; specific 2986 38210 38210 cell depletion within harvest, T-cell depletion $ 140.03 Transplant preparation of hematopoietic progenitor cells; tumor 2987 38211 38211 cell depletion $ 128.01 Transplant preparation of hematopoietic progenitor cells; red blood 2988 38212 38212 cell removal $ 82.28 Transplant preparation of hematopoietic progenitor cells; platelet 2989 38213 38213 depletion $ 20.85 Transplant preparation of hematopoietic progenitor cells; plasma 2990 38214 38214 (volume) depletion $ 71.84 Transplant preparation of hematopoietic progenitor cells; cell 2991 38215 38215 concentration in plasma, mononuclear, or buffy coat layer $ 82.28 2992 38220 38220 Bone marrow; aspiration only $ 293.47 2993 38221 38221 Bone marrow; biopsy, needle or trocar $ 316.63 2994 38230 38230 Bone marrow harvesting for transplantation; allogeneic $ 1,390.50 Hematopoietic progenitor cell (HPC); allogeneic transplantation per 2995 38240 38240 donor $ 1,089.69 2996 38241 38241 Hematopoietic progenitor cell (HPC); autologous transplantation $ 986.52 2997 38242 38242 Allogeneic lymphocyte infusions $ 1,082.79 2998 38300 38300 Drainage of lymph node abscess or lymphadenitis; simple $ 293.40 2999 38305 38305 Drainage of lymph node abscess or lymphadenitis; extensive $ 729.00 3000 38308 38308 Lymphangiotomy or other operations on lymphatic channels $ 884.70 3001 38380 38380 Suture and/or ligation of thoracic duct; cervical approach $ 1,355.40 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price 3002 38381 38381 Suture and/or ligation of thoracic duct; thoracic approach $ 2,421.00 3003 38382 38382 Suture and/or ligation of thoracic duct; abdominal approach $ 2,037.60 3004 38500 38500 Biopsy or excision of lymph node(s); open, superficial $ 587.77 Biopsy or excision of lymph node(s); by needle, superficial (eg, 3005 38505 38505 cervical, inguinal, axillary) $ 399.60 3006 38510 38510 Biopsy or excision of lymph node(s); open, deep cervical node(s) $ 850.50 Biopsy or excision of lymph node(s); open, deep cervical node(s) 3007 38520 38520 with excision scalene fat pad $ 918.90 3008 38525 38525 Biopsy or excision of lymph node(s); open, deep axillary node(s) $ 1,233.90 3009 38542 38542 Dissection, deep jugular node(s) $ 1,244.70 Excision of cystic hygroma, axillary or cervical; without deep 3010 38550 38550 neurovascular dissection $ 1,267.20 Excision of cystic hygroma, axillary or cervical; with deep 3011 38555 38555 neurovascular dissection $ 2,374.20 Limited lymphadenectomy for staging (separate procedure); pelvic 3012 38562 38562 and para-aortic $ 2,771.10 Limited lymphadenectomy for staging (separate procedure); 3013 38564 38564 retroperitoneal (aortic and/or splenic) $ 2,665.80 Laparoscopy, surgical; with retroperitoneal lymph node sampling 3014 38570 38570 (biopsy), single or multiple $ 2,667.60 3015 38571 38571 Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy $ 3,213.90 Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy 3016 38572 38572 and peri-aortic lymph node sampling (biopsy), single or multiple $ 3,295.80 3017 38589 38589 Unlisted laparoscopy procedure, lymphatic system Cost 3018 38700 38700 Suprahyoid lymphadenectomy $ 2,449.80 3019 38720 38720 Cervical lymphadenectomy (complete) $ 3,872.70 3020 38724 38724 Cervical lymphadenectomy (modified radical neck dissection) $ 3,672.00 3021 38740 38740 Axillary lymphadenectomy; superficial $ 1,797.30 3022 38745 38745 Axillary lymphadenectomy; complete $ 2,779.20 Thoracic lymphadenectomy by thoracotomy, mediastinal and regional lymphadenectomy (List separately in addition to code for 3023 38746 38746 primary procedure) $ 846.00 Abdominal lymphadenectomy, regional, including celiac, gastric, portal, peripancreatic, with or without para-aortic and vena caval 3024 38747 38747 nodes (List separately in addition to code for primary procedure) $ 1,178.10 Inguinofemoral lymphadenectomy, superficial, including Cloquets 3025 38760 38760 node (separate procedure) $ 2,240.10 Inguinofemoral lymphadenectomy, superficial, in continuity with pelvic lymphadenectomy, including external iliac, hypogastric, and 3026 38765 38765 obturator nodes (separate procedure) $ 3,024.90 Pelvic lymphadenectomy, including external iliac, hypogastric, and 3027 38770 38770 obturator nodes (separate procedure) $ 3,276.00 Retroperitoneal transabdominal lymphadenectomy, extensive, 3028 38780 38780 including pelvic, aortic, and renal nodes (separate procedure) $ 4,169.70 3029 38790 38790 Injection procedure; lymphangiography $ 396.90 Injection procedure; radioactive tracer for identification of sentinel 3030 38792 38792 node $ 174.37 3031 38794 38794 Cannulation, thoracic duct $ 1,099.47 3032 38999 38999 Unlisted procedure, hemic or lymphatic system Cost Mediastinotomy with exploration, drainage, removal of foreign 3033 39000 39000 body, or biopsy; cervical approach $ 1,619.10 3034 39200 39200 Resection of mediastinal cyst $ 2,801.70 3035 39220 39220 Resection of mediastinal tumor $ 3,410.10 3036 39400 39400 Mediastinoscopy, includes biopsy(ies), when performed $ 1,290.60 3037 39499 39499 Unlisted procedure, mediastinum Cost 3038 39501 39501 Repair, laceration of diaphragm, any approach $ 2,970.00 Repair, neonatal diaphragmatic hernia, with or without chest tube 3039 39503 39503 insertion and with or without creation of ventral hernia $ 3,626.10 Repair, diaphragmatic hernia (other than neonatal), traumatic; 3040 39540 39540 acute $ 3,577.50 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Repair, diaphragmatic hernia (other than neonatal), traumatic; 3041 39541 39541 chronic $ 3,515.40 Imbrication of diaphragm for eventration, transthoracic or 3042 39545 39545 transabdominal, paralytic or nonparalytic $ 3,464.10 3043 39560 39560 Resection, diaphragm; with simple repair (eg, primary suture) $ 3,485.19 Resection, diaphragm; with complex repair (eg, prosthetic material, 3044 39561 39561 local muscle flap) $ 5,241.89 3045 39599 39599 Unlisted procedure, diaphragm Cost 3046 40490 40490 Biopsy of lip $ 206.10 3047 40500 40500 Vermilionectomy (lip shave), with mucosal advancement $ 1,545.30 3048 40510 40510 Excision of lip; transverse wedge excision with primary closure $ 1,710.90 3049 40520 40520 Excision of lip; V-excision with primary direct linear closure $ 1,390.50 Excision of lip; full thickness, reconstruction with local flap (eg, 3050 40525 40525 Estlander or fan) $ 3,300.30 Excision of lip; full thickness, reconstruction with cross lip flap (Abbe- 3051 40527 40527 Estlander) $ 3,558.60 3052 40530 40530 Resection of lip, more than one-fourth, without reconstruction $ 1,647.90 3053 40650 40650 Repair lip, full thickness; vermilion only $ 1,409.40 3054 40652 40652 Repair lip, full thickness; up to half vertical height $ 1,440.00 3055 40654 40654 Repair lip, full thickness; over one-half vertical height, or complex $ 1,681.20 Plastic repair of cleft lip/nasal deformity; primary, partial or 3056 40700 40700 complete, unilateral $ 2,646.90 Plastic repair of cleft lip/nasal deformity; primary bilateral, 1-stage 3057 40701 40701 procedure $ 4,107.60 Plastic repair of cleft lip/nasal deformity; primary bilateral, 1 of 2 3058 40702 40702 stages $ 2,590.20 Plastic repair of cleft lip/nasal deformity; secondary, by recreation 3059 40720 40720 of defect and reclosure $ 2,788.20 Plastic repair of cleft lip/nasal deformity; with cross lip pedicle flap 3060 40761 40761 (Abbe-Estlander type), including sectioning and inserting of pedicle $ 3,038.40 3061 40799 40799 Unlisted procedure, lips Cost 3062 40800 40800 Drainage of abscess, cyst, hematoma, vestibule of mouth; simple $ 201.60 Drainage of abscess, cyst, hematoma, vestibule of mouth; 3063 40801 40801 complicated $ 579.60 3064 40804 40804 Removal of embedded foreign body, vestibule of mouth; simple $ 236.70 Removal of embedded foreign body, vestibule of mouth; 3065 40805 40805 complicated $ 657.90 3066 40806 40806 Incision of labial frenum (frenotomy) $ 315.90 3067 40808 40808 Biopsy, vestibule of mouth $ 202.50 Excision of lesion of mucosa and submucosa, vestibule of mouth; 3068 40810 40810 without repair $ 262.80 Excision of lesion of mucosa and submucosa, vestibule of mouth; 3069 40812 40812 with simple repair $ 398.70 Excision of lesion of mucosa and submucosa, vestibule of mouth; 3070 40814 40814 with complex repair $ 870.30 Excision of lesion of mucosa and submucosa, vestibule of mouth; 3071 40816 40816 complex, with excision of underlying muscle $ 1,030.50 3072 40818 40818 Excision of mucosa of vestibule of mouth as donor graft $ 627.30 Excision of frenum, labial or buccal (frenumectomy, frenulectomy, 3073 40819 40819 frenectomy) $ 414.00 Destruction of lesion or scar of vestibule of mouth by physical 3074 40820 40820 methods (eg, laser, thermal, cryo, chemical) $ 349.20 3075 40830 40830 Closure of laceration, vestibule of mouth; 2.5 cm or less $ 232.24 3076 40831 40831 Closure of laceration, vestibule of mouth; over 2.5 cm or complex $ 528.30 3077 40840 40840 Vestibuloplasty; anterior $ 1,712.70 3078 40842 40842 Vestibuloplasty; posterior, unilateral $ 1,566.90 3079 40843 40843 Vestibuloplasty; posterior, bilateral $ 2,436.30 3080 40844 40844 Vestibuloplasty; entire arch $ 3,133.80 Vestibuloplasty; complex (including ridge extension, muscle 3081 40845 40845 repositioning) $ 3,672.90 3082 40899 40899 Unlisted procedure, vestibule of mouth Cost Intraoral incision and drainage of abscess, cyst, or hematoma of 3083 41000 41000 tongue or floor of mouth; lingual $ 256.50 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Intraoral incision and drainage of abscess, cyst, or hematoma of 3084 41005 41005 tongue or floor of mouth; sublingual, superficial $ 286.20 Intraoral incision and drainage of abscess, cyst, or hematoma of 3085 41006 41006 tongue or floor of mouth; sublingual, deep, supramylohyoid $ 610.20 Intraoral incision and drainage of abscess, cyst, or hematoma of 3086 41007 41007 tongue or floor of mouth; submental space $ 703.80 Intraoral incision and drainage of abscess, cyst, or hematoma of 3087 41008 41008 tongue or floor of mouth; submandibular space $ 718.20 Intraoral incision and drainage of abscess, cyst, or hematoma of 3088 41009 41009 tongue or floor of mouth; masticator space $ 810.00 3089 41010 41010 Incision of lingual frenum (frenotomy) $ 247.50 Extraoral incision and drainage of abscess, cyst, or hematoma of 3090 41015 41015 floor of mouth; sublingual $ 772.20 Extraoral incision and drainage of abscess, cyst, or hematoma of 3091 41016 41016 floor of mouth; submental $ 839.70 Extraoral incision and drainage of abscess, cyst, or hematoma of 3092 41017 41017 floor of mouth; submandibular $ 829.80 Extraoral incision and drainage of abscess, cyst, or hematoma of 3093 41018 41018 floor of mouth; masticator space $ 956.70 Placement of needles, catheters, or other device(s) into the head and/or neck region (percutaneous, transoral, or transnasal) for 3094 41019 41019 subsequent interstitial radioelement application $ 1,028.05 3095 41100 41100 Biopsy of tongue; anterior two-thirds $ 261.00 3096 41105 41105 Biopsy of tongue; posterior one-third $ 309.60 3097 41108 41108 Biopsy of floor of mouth $ 239.40 3098 41110 41110 Excision of lesion of tongue without closure $ 393.30 3099 41112 41112 Excision of lesion of tongue with closure; anterior two-thirds $ 642.60 3100 41113 41113 Excision of lesion of tongue with closure; posterior one-third $ 954.00 3101 41114 41114 Excision of lesion of tongue with closure;

with local tongue flap $ 2,168.10 3102 41115 41115 Excision of lingual frenum (frenectomy) $ 426.60 3103 41116 41116 Excision, lesion of floor of mouth $ 715.50 3104 41120 41120 Glossectomy; less than one-half tongue $ 1,905.30 3105 41130 41130 Glossectomy; hemiglossectomy $ 2,204.10 3106 41135 41135 Glossectomy; partial, with unilateral radical neck dissection $ 4,789.80 Glossectomy; complete or total, with or without tracheostomy, 3107 41140 41140 without radical neck dissection $ 4,610.70 Glossectomy; complete or total, with or without tracheostomy, with 3108 41145 41145 unilateral radical neck dissection $ 5,366.70 Glossectomy; composite procedure with resection floor of mouth 3109 41150 41150 and mandibular resection, without radical neck dissection $ 4,663.80 Glossectomy; composite procedure with resection floor of mouth, 3110 41153 41153 with suprahyoid neck dissection $ 4,880.70 Glossectomy; composite procedure with resection floor of mouth, 3111 41155 41155 mandibular resection, and radical neck dissection (Commando type) $ 6,470.10 Repair of laceration 2.5 cm or less; floor of mouth and/or anterior 3112 41250 41250 two-thirds of tongue $ 361.80 3113 41251 41251 Repair of laceration 2.5 cm or less; posterior one-third of tongue $ 513.00 Repair of laceration of tongue, floor of mouth, over 2.6 cm or 3114 41252 41252 complex $ 838.80 3115 41500 41500 Fixation of tongue, mechanical, other than suture (eg, K-wire) $ 766.80 3116 41510 41510 Suture of tongue to lip for micrognathia (Douglas type procedure) $ 1,354.50 3117 41512 41512 Tongue base suspension, permanent suture technique $ 1,094.85 3118 41520 41520 Frenoplasty (surgical revision of frenum, eg, with Z-plasty) $ 647.10 Submucosal ablation of the tongue base, radiofrequency, 1 or more 3119 41530 41530 sites, per session $ 6,950.37 3120 41599 41599 Unlisted procedure, tongue, floor of mouth Cost 3121 41800 41800 Drainage of abscess, cyst, hematoma from dentoalveolar structures $ 229.50 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Removal of embedded foreign body from dentoalveolar structures; 3122 41805 41805 soft tissues $ 298.80 Removal of embedded foreign body from dentoalveolar structures; 3123 41806 41806 bone $ 493.20 3124 41821 41821 Operculectomy, excision pericoronal tissues $ - 3125 41822 41822 Excision of fibrous tuberosities, dentoalveolar structures $ 429.30 3126 41823 41823 Excision of osseous tuberosities, dentoalveolar structures $ 705.60 Excision of lesion or tumor (except listed above), dentoalveolar 3127 41825 41825 structures; without repair $ 369.00 Excision of lesion or tumor (except listed above), dentoalveolar 3128 41826 41826 structures; with simple repair $ 546.30 Excision of lesion or tumor (except listed above), dentoalveolar 3129 41827 41827 structures; with complex repair $ 849.60 3130 41828 41828 Excision of hyperplastic alveolar mucosa, each quadrant (specify) $ 726.30 3131 41830 41830 Alveolectomy, including curettage of osteitis or sequestrectomy $ 849.60 3132 41850 41850 Destruction of lesion (except excision), dentoalveolar structures $ 180.00 3133 41870 41870 Periodontal mucosal grafting $ 726.30 3134 41872 41872 Gingivoplasty, each quadrant (specify) $ 669.60 3135 41874 41874 Alveoloplasty, each quadrant (specify) $ 756.90 3136 41899 41899 Unlisted procedure, dentoalveolar structures Cost 3137 42000 42000 Drainage of abscess of palate, uvula $ 236.70 3138 42100 42100 Biopsy of palate, uvula $ 273.60 3139 42104 42104 Excision, lesion of palate, uvula; without closure $ 478.80 3140 42106 42106 Excision, lesion of palate, uvula; with simple primary closure $ 618.30 3141 42107 42107 Excision, lesion of palate, uvula; with local flap closure $ 1,787.40 3142 42120 42120 Resection of palate or extensive resection of lesion $ 2,958.30 3143 42140 42140 Uvulectomy, excision of uvula $ 470.70 Palatopharyngoplasty (eg, uvulopalatopharyngoplasty, 3144 42145 42145 uvulopharyngoplasty) $ 2,509.20 3145 42160 42160 Destruction of lesion, palate or uvula (thermal, cryo or chemical) $ 448.20 3146 42180 42180 Repair, laceration of palate; up to 2 cm $ 416.96 3147 42182 42182 Repair, laceration of palate; over 2 cm or complex $ 825.30 3148 42200 42200 Palatoplasty for cleft palate, soft and/or hard palate only $ 2,801.70 Palatoplasty for cleft palate, with closure of alveolar ridge; soft 3149 42205 42205 tissue only $ 3,186.00 Palatoplasty for cleft palate, with closure of alveolar ridge; with 3150 42210 42210 bone graft to alveolar ridge (includes obtaining graft) $ 4,377.60 3151 42215 42215 Palatoplasty for cleft palate; major revision $ 2,664.90 3152 42220 42220 Palatoplasty for cleft palate; secondary lengthening procedure $ 2,497.50 3153 42225 42225 Palatoplasty for cleft palate; attachment pharyngeal flap $ 2,811.60 3154 42226 42226 Lengthening of palate, and pharyngeal flap $ 3,475.80 3155 42227 42227 Lengthening of palate, with island flap $ 2,935.80 3156 42235 42235 Repair of anterior palate, including vomer flap $ 2,310.30 3157 42260 42260 Repair of nasolabial fistula $ 1,653.30 3158 42280 42280 Maxillary impression for palatal prosthesis $ 309.60 3159 42281 42281 Insertion of pin-retained palatal prosthesis $ 355.50 3160 42299 42299 Unlisted procedure, palate, uvula Cost 3161 42300 42300 Drainage of abscess; parotid, simple $ 324.90 3162 42305 42305 Drainage of abscess; parotid, complicated $ 806.40 3163 42310 42310 Drainage of abscess; submaxillary or sublingual, intraoral $ 360.90 3164 42320 42320 Drainage of abscess; submaxillary, external $ 597.60 Sialolithotomy; submandibular (submaxillary), sublingual or parotid, 3165 42330 42330 uncomplicated, intraoral $ 415.95 Sialolithotomy; submandibular (submaxillary), complicated, 3166 42335 42335 intraoral $ 789.30 3167 42340 42340 Sialolithotomy; parotid, extraoral or complicated intraoral $ 1,092.60 3168 42400 42400 Biopsy of salivary gland; needle $ 250.20 3169 42405 42405 Biopsy of salivary gland; incisional $ 578.70 3170 42408 42408 Excision of sublingual salivary cyst (ranula) $ 1,061.10 3171 42409 42409 Marsupialization of sublingual salivary cyst (ranula) $ 772.20 Excision of parotid tumor or parotid gland; lateral lobe, without 3172 42410 42410 nerve dissection $ 2,012.40 Excision of parotid tumor or parotid gland; lateral lobe, with 3173 42415 42415 dissection and preservation of facial nerve $ 3,630.60 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Excision of parotid tumor or parotid gland; total, with dissection 3174 42420 42420 and preservation of facial nerve $ 4,627.80 Excision of parotid tumor or parotid gland; total, en bloc removal 3175 42425 42425 with sacrifice of facial nerve $ 3,363.30 Excision of parotid tumor or parotid gland; total, with unilateral 3176 42426 42426 radical neck dissection $ 6,180.30 3177 42440 42440 Excision of submandibular (submaxillary) gland $ 2,312.10 3178 42450 42450 Excision of sublingual gland $ 1,911.60 3179 42500 42500 Plastic repair of salivary duct, sialodochoplasty; primary or simple $ 1,374.30 Plastic repair of salivary duct, sialodochoplasty; secondary or 3180 42505 42505 complicated $ 1,757.70 3181 42507 42507 Parotid duct diversion, bilateral (Wilke type procedure); $ 2,302.20 Parotid duct diversion, bilateral (Wilke type procedure); with 3182 42508 42508 excision of 1 submandibular gland $ 2,601.00 Parotid duct diversion, bilateral (Wilke type procedure); with 3183 42509 42509 excision of both submandibular glands $ 3,194.10 Parotid duct diversion, bilateral (Wilke type procedure); with 3184 42510 42510 ligation of both submandibular (Wharton's) ducts $ 2,726.10 3185 42550 42550 Injection procedure for sialography $ 193.50 3186 42600 42600 Closure salivary fistula $ 1,476.00 3187 42650 42650 Dilation salivary duct $ 143.10 Dilation and catheterization of salivary duct, with or without 3188 42660 42660 injection $ 215.10 3189 42665 42665 Ligation salivary duct, intraoral $ 456.30 3190 42699 42699 Unlisted procedure, salivary glands or ducts Cost 3191 42700 42700 Incision and drainage abscess; peritonsillar $ 318.60 Incision and drainage abscess; retropharyngeal or parapharyngeal, 3192 42720 42720 intraoral approach $ 688.50 Incision and drainage abscess; retropharyngeal or parapharyngeal, 3193 42725 42725 external approach $ 1,467.00 3194 42800 42800 Biopsy; oropharynx $ 250.20 3195 42804 42804 Biopsy; nasopharynx, visible lesion, simple $ 308.70 3196 42806 42806 Biopsy; nasopharynx, survey for unknown primary lesion $ 373.50 3197 42808 42808 Excision or destruction of lesion of pharynx, any method $ 592.20 3198 42809 42809 Removal of foreign body from pharynx $ 312.30 Excision branchial cleft cyst or vestige, confined to skin and 3199 42810 42810 subcutaneous tissues $ 878.40 Excision branchial cleft cyst, vestige, or fistula, extending beneath 3200 42815 42815 subcutaneous tissues and/or into pharynx $ 1,880.10 3201 42820 42820 Tonsillectomy and adenoidectomy; younger than age 12 $ 816.61 3202 42821 42821 Tonsillectomy and adenoidectomy; age 12 or over $ 1,031.40 3203 42825 42825 Tonsillectomy, primary or secondary; younger than age 12 $ 820.80 3204 42826 42826 Tonsillectomy, primary or secondary; age 12 or over $ 841.50 3205 42830 42830 Adenoidectomy, primary; younger than age 12 $ 581.64 3206 42831 42831 Adenoidectomy, primary; age 12 or over $ 675.00 3207 42835 42835 Adenoidectomy, secondary; younger than age 12 $ 536.40 3208 42836 42836 Adenoidectomy, secondary; age 12 or over $ 669.60 Radical resection of tonsil, tonsillar pillars, and/or retromolar 3209 42842 42842 trigone; without closure $ 2,421.00 Radical resection of tonsil, tonsillar pillars, and/or retromolar 3210 42844 42844 trigone; closure with local flap (eg, tongue, buccal) $ 3,346.20 Radical resection of tonsil, tonsillar pillars, and/or retromolar 3211 42845 42845 trigone; closure with other flap $ 4,507.20 3212 42860 42860 Excision of tonsil tags $ 570.60 Excision or destruction lingual tonsil, any method (separate 3213 42870 42870 procedure) $ 844.20 3214 42890 42890 Limited pharyngectomy $ 2,689.20 Resection of lateral pharyngeal wall or pyriform sinus, direct closure 3215 42892 42892 by advancement of lateral and posterior pharyngeal walls $ 3,450.60 Resection of pharyngeal wall requiring closure with myocutaneous or fasciocutaneous flap or free muscle, skin, or fascial flap with 3216 42894 42894 microvascular anastomosis $ 4,776.30 3217 42900 42900 Suture pharynx for wound or injury $ 977.40 3218 42950 42950 Pharyngoplasty (plastic or reconstructive operation on pharynx) $ 1,989.90 3219 42953 42953 Pharyngoesophageal repair $ 2,523.60 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price 3220 42955 42955 Pharyngostomy (fistulization of pharynx, external for feeding) $ 1,579.50 Control oropharyngeal hemorrhage, primary or secondary (eg, post- 3221 42960 42960 tonsillectomy); simple $ 366.30 Control oropharyngeal hemorrhage, primary or secondary (eg, post- 3222 42961 42961 tonsillectomy); complicated, requiring hospitalization $ 600.30 Control oropharyngeal hemorrhage, primary or secondary (eg, post- 3223 42962 42962 tonsillectomy); with secondary surgical intervention $ 947.70 Control of nasopharyngeal hemorrhage, primary or secondary (eg, postadenoidectomy); simple, with posterior nasal packs, with or 3224 42970 42970 without anterior packs and/or cautery $ 629.10 Control of nasopharyngeal hemorrhage, primary or secondary (eg, 3225 42971 42971 postadenoidectomy); complicated, requiring hospitalization $ 945.00 Control of nasopharyngeal hemorrhage, primary or secondary (eg, 3226 42972 42972 postadenoidectomy); with secondary surgical intervention $ 1,179.00 3227 42999 42999 Unlisted procedure, pharynx, adenoids, or tonsils Cost 3228 43020 43020 Esophagotomy, cervical approach, with removal of foreign body $ 1,996.20 3229 43030 43030 Cricopharyngeal myotomy $ 2,510.10 3230 43045 43045 Esophagotomy, thoracic approach, with removal of foreign body $ 3,352.50 3231 43100 43100 Excision of lesion, esophagus, with primary repair; cervical approach $ 2,568.60 Excision of lesion, esophagus, with primary repair; thoracic or 3232 43101 43101 abdominal approach $ 3,299.40 Total or near total esophagectomy, without thoracotomy; with pharyngogastrostomy or cervical esophagogastrostomy, with or 3233 43107 43107 without pyloroplasty (transhiatal) $ 5,637.60 Total or near total esophagectomy, without thoracotomy; with colon interposition or small intestine reconstruction, including 3234 43108 43108 intestine mobilization, preparation and anastomosis(es) $ 6,282.90 Total or near total esophagectomy, with thoracotomy; with pharyngogastrostomy or cervical esophagogastrostomy, with or 3235 43112 43112 without pyloroplasty $ 6,437.70 Total or near total esophagectomy, with thoracotomy; with colon interposition or small intestine reconstruction, including intestine 3236 43113 43113 mobilization, preparation, and anastomosis(es) $ 5,426.85 Partial esophagectomy, cervical, with free intestinal graft, including microvascular anastomosis, obtaining the graft and intestinal 3237 43116 43116 reconstruction $ 6,171.24 Partial esophagectomy, distal two-thirds, with thoracotomy and separate abdominal incision, with or without proximal gastrectomy; with thoracic esophagogastrostomy, with or without pyloroplasty 3238 43117 43117 (Ivor Lewis) $ 6,574.50 Partial esophagectomy, distal two-thirds, with thoracotomy and separate abdominal incision, with or without proximal gastrectomy; with colon interposition or small intestine reconstruction, including 3239 43118 43118 intestine mobilization, preparation, and anastomosis(es $ 5,531.39 Partial esophagectomy, distal two-thirds, with thoracotomy only, with or without proximal gastrectomy, with thoracic 3240 43121 43121 esophagogastrostomy, with or without pyloroplasty $ 6,251.40 Partial esophagectomy, thoracoabdominal or abdominal approach, with or without proximal gastrectomy; with esophagogastrostomy, 3241 43122 43122 with or without pyloroplasty $ 5,902.20 Partial esophagectomy, thoracoabdominal or abdominal approach, with or without proximal gastrectomy; with colon interposition or small intestine reconstruction, including intestine mobilization, 3242 43123 43123 preparation, and anastomosis(es) $ 6,437.70 Total or partial esophagectomy, without reconstruction (any 3243 43124 43124 approach), with cervical esophagostomy $ 4,452.63 Diverticulectomy of hypopharynx or esophagus, with or without 3244 43130 43130 myotomy; cervical approach $ 2,642.40 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Diverticulectomy of hypopharynx or esophagus, with or without 3245 43135 43135 myotomy; thoracic approach $ 3,141.90 Esophagoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate 3246 43200 43200 procedure) $ 567.90 Esophagoscopy, flexible, transoral; with directed submucosal 3247 43201 43201 injection(s), any substance $ 754.53 3248 43202 43202 Esophagoscopy, flexible, transoral; with biopsy, single or multiple $ 654.30 Esophagoscopy, flexible, transoral; with injection sclerosis of 3249 43204 43204 esophageal varices $ 973.80 Esophagoscopy, flexible, transoral; with band ligation of esophageal 3250 43205 43205 varices $ 978.30 Esophagoscopy, flexible, transoral; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when 3251 43212 43212 performed) $2,371.40 3252 43215 43215 Esophagoscopy, flexible, transoral; with removal of foreign body $ 832.50 Esophagoscopy, flexible, transoral; with removal of tumor(s), 3253 43216 43216 polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery $ 839.70 Esophagoscopy, flexible, transoral; with removal of tumor(s), 3254 43217 43217 polyp(s), or other lesion(s) by snare technique $ 929.70 Esophagoscopy, flexible, transoral; with transendoscopic balloon 3255 43220 43220 dilation (less than 30 mm diameter) $ 760.50 Esophagoscopy, flexible, transoral; with insertion of guide wire 3256 43226 43226 followed by passage of dilator(s) over guide wire $ 681.30 Esophagoscopy, flexible, transoral; with control of bleeding, any 3257 43227 43227 method $ 1,059.30 Esophagoscopy, flexible, transoral; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and 3258 43229 43229 guide wire passage, when performed) $1,968.75 Esophagoscopy, flexible, transoral; with endoscopic ultrasound 3259 43231 43231 examination $ 762.30 Esophagoscopy, flexible, transoral; with transendoscopic ultrasound- 3260 43232 43232 guided intramural or transmural fine needle aspiration/biopsy(s) $ 782.57 Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when 3261 43235 43235 performed (separate procedure) $ 575.48 Esophagogastroduodenoscopy, flexible, transoral; with directed 3262 43236 43236 submucosal injection(s), any substance $ 833.87 Esophagogastroduodenoscopy, flexible, transoral; with endoscopic ultrasound examination limited to the esophagus, stomach or 3263 43237 43237 duodenum, and adjacent structures $ 605.29 Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s), (includes endoscopic ultrasound examination limited to the esophagus, stomach or duodenum, and 3264 43238 43238 adjacent stru $ 712.37 Esophagogastroduodenoscopy, flexible, transoral; with biopsy, 3265 43239 43239 single or multiple $ 645.72 Esophagogastroduodenoscopy, flexible, transoral; with transmural drainage of pseudocyst (includes placement of transmural drainage catheter[s]/stent[s], when performed, and endoscopic ultrasound, 3266 43240 43240 when performed) $ 1,233.90 Esophagogastroduodenoscopy, flexible, transoral; with insertion of 3267 43241 43241 intraluminal tube or catheter $ 972.00 Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s) (includes endoscopic ultrasound examination of the esophagus, stomach, and either the duodenum 3268 43242 43242 or a surgicall $ 968.40 Esophagogastroduodenoscopy, flexible, transoral; with injection 3269 43243 43243 sclerosis of esophageal/gastric varices $ 953.10 Esophagogastroduodenoscopy, flexible, transoral; with band 3270 43244 43244 ligation of esophageal/gastric varices $ 978.30 Esophagogastroduodenoscopy, flexible, transoral; with dilation of 3271 43245 43245 gastric/duodenal stricture(s) (eg, balloon, bougie) $ 822.60 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Esophagogastroduodenoscopy, flexible, transoral; with directed 3272 43246 43246 placement of percutaneous gastrostomy tube $ 1,133.10 Esophagogastroduodenoscopy, flexible, transoral; with removal of 3273 43247 43247 foreign body $ 828.90 Esophagogastroduodenoscopy, flexible, transoral; with insertion of guide wire followed by passage of dilator(s) through esophagus over 3274 43248 43248 guide wire $ 733.50 Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic balloon dilation of esophagus (less than 30 mm 3275 43249 43249 diameter) $ 747.00 Esophagogastroduodenoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or 3276 43250 43250 bipolar cautery $ 972.00 Esophagogastroduodenoscopy, flexible, transoral; with removal of 3277 43251 43251 tumor(s), polyp(s), or other lesion(s) by snare technique $ 953.10 Esophagogastroduodenoscopy, flexible, transoral; with control of 3278 43255 43255 bleeding, any method $ 992.70 Esophagogastroduodenoscopy, flexible, transoral; with delivery of thermal energy to the muscle of lower esophageal sphincter and/or 3279 43257 43257 gastric cardia, for treatment of gastroesophageal reflux disease $ 1,070.28 Esophagogastroduodenoscopy, flexible, transoral; with endoscopic ultrasound examination, including the esophagus, stomach, and either the duodenum or a surgically altered stomach where the 3280 43259 43259 jejunum is examined distal to the anastomosis $ 844.20 Endoscopic retrograde cholangiopancreatography (ERCP); diagnostic, including collection of specimen(s) by brushing or 3281 43260 43260 washing, when performed (separate procedure) $ 1,159.20 Endoscopic retrograde cholangiopancreatography (ERCP); with 3282 43261 43261 biopsy, single or multiple $ 1,349.10 Endoscopic retrograde cholangiopancreatography (ERCP); with 3283 43262 43262 sphincterotomy/papillotomy $ 1,642.50 Endoscopic retrograde cholangiopancreatography (ERCP); with 3284 43263 43263 pressure measurement of sphincter of Oddi $ 1,542.60 Endoscopic retrograde cholangiopancreatography (ERCP); with 3285 43264 43264 removal of calculi/debris from biliary/pancreatic duct(s) $ 1,781.10 Endoscopic retrograde cholangiopancreatography (ERCP); with destruction of calculi, any method (eg, mechanical, electrohydraulic, 3286 43265 43265 lithotripsy) $ 1,833.30 Esophagogastroduodenoscopy, flexible, transoral; with placement of endoscopic stent (includes pre- and post-dilation and guide wire 3287 43266 43266 passage, when performed) $2,371.40 Esophagogastroduodenoscopy, flexible, transoral; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation 3288 43270 43270 and guide wire passage, when performed) $1,013.05 Endoscopic cannulation of papilla with direct visualization of pancreatic/common bile duct(s) (List separately in addition to 3289 43273 43273 code(s) for primary procedure) $ 320.58 Endoscopic retrograde cholangiopancreatography (ERCP); with placement of endoscopic stent into biliary or pancreatic duct, including pre- and post-dilation and guide wire passage, when 3290 43274 43274 performed, including sphincterotomy, when performed, each stent $ 1,933.69 Endoscopic retrograde cholangiopancreatography (ERCP); with removal of foreign body(s) or stent(s) from biliary/pancreatic 3291 43275 43275 duct(s) $ 1,933.69 Endoscopic retrograde cholangiopancreatography (ERCP); with removal and exchange of stent(s), biliary or pancreatic duct, including pre- and post-dilation and guide wire passage, when performed, including sphincterotomy, when performed, each stent 3292 43276 43276 exchang $ 1,933.69 Endoscopic retrograde cholangiopancreatography (ERCP); with trans-endoscopic balloon dilation of biliary/pancreatic duct(s) or of ampulla (sphincteroplasty), including sphincterotomy, when 3293 43277 43277 performed, each duct $ 1,933.69 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Endoscopic retrograde cholangiopancreatography (ERCP); with ablation of tumor(s), polyp(s), or other lesion(s), including pre- and 3294 43278 43278 post-dilation and guide wire passage, when performed $ 1,933.69 Laparoscopy, surgical, esophagomyotomy (Heller type), with 3295 43279 43279 fundoplasty, when performed $ 2,872.69 Laparoscopy, surgical, esophagogastric fundoplasty (eg, Nissen, 3296 43280 43280 Toupet procedures) $ 3,501.90 Laparoscopy, surgical, repair of paraesophageal hernia, includes 3297 43281 43281 fundoplasty, when performed; without implantation of mesh $ 3,859.31 Laparoscopy, surgical, repair of paraesophageal hernia, includes 3298 43282 43282 fundoplasty, when performed; with implantation of mesh $ 4,088.80 3299 43289 43289 Unlisted laparoscopy procedure, esophagus Cost Esophagoplasty (plastic repair or reconstruction), cervical approach; 3300 43300 43300 without repair of tracheoesophageal fistula $ 3,110.40 Esophagoplasty (plastic repair or reconstruction), cervical approach; 3301 43305 43305 with repair of tracheoesophageal fistula $ 3,627.90 Esophagoplasty (plastic repair or reconstruction), thoracic 3302 43310 43310 approach; without repair of tracheoesophageal fistula $ 4,030.20 Esophagoplasty (plastic repair or reconstruction), thoracic 3303 43312 43312 approach; with repair of tracheoesophageal fistula $ 4,640.40 Esophagoplasty for congenital defect (plastic repair or reconstruction), thoracic approach; without repair of congenital 3304 43313 43313 tracheoesophageal fistula $ 5,873.36 Esophagoplasty for congenital defect (plastic repair or reconstruction), thoracic approach; with repair of congenital 3305 43314 43314 tracheoesophageal fistula $ 6,478.08 Esophagogastrostomy (cardioplasty), with or without vagotomy and 3306 43320 43320 pyloroplasty, transabdominal or transthoracic approach $ 3,590.10 Esophagogastric fundoplasty; with fundic patch (Thal-Nissen 3307 43325 43325 procedure) $ 3,429.90 3308 43330 43330 Esophagomyotomy (Heller type); abdominal approach $ 2,917.80 3309 43331 43331 Esophagomyotomy (Heller type); thoracic approach $ 3,198.60 Repair, paraesophageal hiatal hernia (including fundoplication), via laparotomy, except neonatal; without implantation of mesh or 3310 43332 43332 other prosthesis $ 2,635.13 Repair, paraesophageal hiatal hernia (including fundoplication), via laparotomy, except neonatal; with implantation of mesh or other 3311 43333 43333 prosthesis $ 2,873.14 Repair, paraesophageal hiatal hernia (including fundoplication), via thoracotomy, except neonatal; without implantation of mesh or 3312 43334 43334 other prosthesis $ 2,906.96 Repair, paraesophageal hiatal hernia (including fundoplication), via thoracotomy, except neonatal; with implantation of mesh or other 3313 43335 43335 prosthesis $ 3,144.71 Repair, paraesophageal hiatal hernia (including fundoplication), via thoracoabdominal incision, except neonatal; without implantation 3314 43336 43336 of mesh or other prosthesis $ 3,422.52 Repair, paraesophageal hiatal hernia (including fundoplication), via thoracoabdominal incision, except neonatal; with implantation of 3315 43337 43337 mesh or other prosthesis $ 3,761.84 Esophagojejunostomy (without total gastrectomy); abdominal 3316 43340 43340 approach $ 3,551.40 Esophagostomy, fistulization of esophagus, external; abdominal 3317 43350 43350 approach $ 2,381.40 Esophagostomy, fistulization of esophagus, external; thoracic 3318 43351 43351 approach $ 2,477.70 Esophagostomy, fistulization of esophagus, external; cervical 3319 43352 43352 approach $ 2,368.80 Gastrointestinal reconstruction for previous esophagectomy, for obstructing esophageal lesion or fistula, or for previous esophageal 3320 43360 43360 exclusion; with stomach, with or without pyloroplasty $ 5,664.60 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Gastrointestinal reconstruction for previous esophagectomy, for obstructing esophageal lesion or fistula, or for previous esophageal exclusion; with colon interposition or small intestine reconstruction, 3321 43361 43361 including intestine mobilization, preparation, and $ 6,695.10 3322 43400 43400 Ligation, direct, esophageal varices $ 3,172.50 3323 43401 43401 Transection of esophagus with repair, for esophageal varices $ 3,348.00 Ligation or stapling at gastroesophageal junction for pre-existing 3324 43405 43405 esophageal perforation $ 3,349.80 3325 43410 43410 Suture of esophageal wound or injury; cervical approach $ 2,574.90 Suture of esophageal wound or injury; transthoracic or 3326 43415 43415 transabdominal approach $ 3,114.00 3327 43420 43420 Closure of esophagostomy or fistula; cervical approach $ 1,954.80 Closure of esophagostomy or fistula; transthoracic or 3328 43425 43425 transabdominal approach $ 3,115.80 Dilation of esophagus, by unguided sound or bougie, single or 3329 43450 43450 multiple passes $ 285.30 3330 43453 43453 Dilation of esophagus, over guide wire $ 414.90 3331 43460 43460 Esophagogastric tamponade, with balloon (Sengstaken type) $ 697.50 3332 43496 43496 Free jejunum transfer with microvascular anastomosis $ - 3333 43499 43499 Unlisted procedure, esophagus Cost 3334 43500 43500 Gastrotomy; with exploration or foreign body removal $ 1,981.80 3335 43501 43501 Gastrotomy; with suture repair of bleeding ulcer $ 2,765.70 Gastrotomy; with suture repair of pre-existing esophagogastric 3336 43502 43502 laceration (eg, Mallory-Weiss) $ 2,601.00 Gastrotomy; with esophageal dilation and insertion of permanent 3337 43510 43510 intraluminal tube (eg, Celestin or Mousseaux-Barbin) $ 2,067.30 Pyloromyotomy, cutting of pyloric muscle (Fredet-Ramstedt type 3338 43520 43520 operation) $ 1,850.40 3339 43605 43605 Biopsy of stomach, by laparotomy $ 1,977.30 3340 43610 43610 Excision, local; ulcer or benign tumor of stomach $ 2,572.20 3341 43611 43611 Excision, local; malignant tumor of stomach $ 2,837.70 3342 43620 43620 Gastrectomy, total; with esophagoenterostomy $ 4,644.90 3343 43621 43621 Gastrectomy, total; with Roux-en-Y reconstruction $ 4,995.90 3344 43622 43622 Gastrectomy, total; with formation of intestinal pouch, any type $ 5,047.20 3345 43631 43631 Gastrectomy, partial, distal; with gastroduodenostomy $ 3,541.50 3346 43632 43632 Gastrectomy, partial, distal; with gastrojejunostomy $ 3,864.60 3347 43633 43633 Gastrectomy, partial, distal; with Roux-en-Y reconstruction $ 3,953.70 3348 43634 43634 Gastrectomy, partial, distal; with formation of intestinal pouch $ 4,851.90 Vagotomy when performed with partial distal gastrectomy (List 3349 43635 43635 separately in addition to code[s] for primary procedure) $ 1,287.90 Vagotomy including pyloroplasty, with or without gastrostomy; 3350 43640 43640 truncal or selective $ 3,064.50 Vagotomy including pyloroplasty, with or without gastrostomy; 3351 43641 43641 parietal cell (highly selective) $ 2,904.30 Laparoscopy, surgical, gastric restrictive procedure; with gastric 3352 43644 43644 bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less) $ 5,644.84 Laparoscopy, surgical, gastric restrictive procedure; with gastric 3353 43645 43645 bypass and small intestine reconstruction to limit absorption $ 6,078.45 Laparoscopy, surgical; implantation or replacement of gastric 3354 43647 43647 neurostimulator electrodes, antrum $ - Laparoscopy, surgical; revision or removal of gastric 3355 43648 43648 neurostimulator electrodes, antrum $ - 3356 43651 43651 Laparoscopy, surgical; transection of vagus nerves, truncal $ 2,584.61 Laparoscopy, surgical; transection of vagus nerves, selective or 3357 43652 43652 highly selective $ 2,984.62 Laparoscopy, surgical; gastrostomy, without construction of gastric 3358 43653 43653 tube (eg, Stamm procedure) (separate procedure) $ 1,909.82 3359 43659 43659 Unlisted laparoscopy procedure, stomach Cost Naso- or oro-gastric tube placement, requiring physician's skill and fluoroscopic guidance (includes fluoroscopy, image documentation 3360 43752 43752 and report) $ 87.45 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Gastric intubation and aspiration(s) therapeutic, necessitating physician's skill (eg, for gastrointestinal hemorrhage), including 3361 43753 43753 lavage if performed $ 51.44 Gastric intubation and aspiration, diagnostic; single specimen (eg, 3362 43754 43754 acid analysis) $ 92.15 Gastric intubation and aspiration, diagnostic; collection of multiple fractional specimens with gastric stimulation, single or double lumen tube (gastric secretory study) (eg, histamine, insulin, 3363 43755 43755 pentagastrin, calcium, secretin), includes drug administrat $ 216.19 Change of gastrostomy tube, percutaneous, without imaging or 3364 43760 43760 endoscopic guidance $ 192.60 Repositioning of a naso- or oro-gastric feeding tube, through the 3365 43761 43761 duodenum for enteric nutrition $ 320.40 Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (eg, gastric band and 3366 43770 43770 subcutaneous port components) $ 3,192.15 Laparoscopy, surgical, gastric restrictive procedure; revision of 3367 43771 43771 adjustable gastric restrictive device component only $ 2,947.87 Laparoscopy, surgical, gastric restrictive procedure; removal of 3368 43772 43772 adjustable gastric restrictive device component only $ 2,562.77 Laparoscopy, surgical, gastric restrictive procedure; removal and 3369 43773 43773 replacement of adjustable gastric restrictive device component only $ 3,259.75 Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device and subcutaneous port 3370 43774 43774 components $ 2,594.55 Laparoscopy, surgical, gastric restrictive procedure; longitudinal 3371 43775 43775 gastrectomy (ie, sleeve gastrectomy) $ 3,427.22 3372 43800 43800 Pyloroplasty $ 2,172.60 3373 43810 43810 Gastroduodenostomy $ 2,296.80 3374 43820 43820 Gastrojejunostomy; without vagotomy $ 2,688.30 3375 43825 43825 Gastrojejunostomy; with vagotomy, any type $ 3,096.00 Gastrostomy, open; without construction of gastric tube (eg, Stamm 3376 43830 43830 procedure) (separate procedure) $ 1,784.70 3377 43831 43831 Gastrostomy, open; neonatal, for feeding $ 1,642.50 Gastrostomy, open; with construction of gastric tube (eg, Janeway 3378 43832 43832 procedure) $ 2,553.30 Gastrorrhaphy, suture of perforated duodenal or gastric ulcer, 3379 43840 43840 wound, or injury $ 2,344.50 Gastric restrictive procedure, without gastric bypass, for morbid 3380 43842 43842 obesity; vertical-banded gastroplasty $ 3,656.70 Gastric restrictive procedure, without gastric bypass, for morbid 3381 43843 43843 obesity; other than vertical-banded gastroplasty $ 3,605.40 Gastric restrictive procedure with partial gastrectomy, pylorus- preserving duodenoileostomy and ileoileostomy (50 to 100 cm common channel) to limit absorption (biliopancreatic diversion with 3382 43845 43845 duodenal switch) $ 5,446.89 Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150 cm or less) Roux-en-Y 3383 43846 43846 gastroenterostomy $ 4,532.40 Gastric restrictive procedure, with gastric bypass for morbid 3384 43847 43847 obesity; with small intestine reconstruction to limit absorption $ 5,096.43 Revision, open, of gastric restrictive procedure for morbid obesity, 3385 43848 43848 other than adjustable gastric restrictive device (separate procedure) $ 5,284.93 Revision of gastroduodenal anastomosis (gastroduodenostomy) 3386 43850 43850 with reconstruction; without vagotomy $ 4,078.80 Revision of gastroduodenal anastomosis (gastroduodenostomy) 3387 43855 43855 with reconstruction; with vagotomy $ 4,171.50 Revision of gastrojejunal anastomosis (gastrojejunostomy) with reconstruction, with or without partial gastrectomy or intestine 3388 43860 43860 resection; without vagotomy $ 4,131.90 Revision of gastrojejunal anastomosis (gastrojejunostomy) with reconstruction, with or without partial gastrectomy or intestine 3389 43865 43865 resection; with vagotomy $ 3,879.90 3390 43870 43870 Closure of gastrostomy, surgical $ 1,687.50 3391 43880 43880 Closure of gastrocolic fistula $ 3,295.80 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Implantation or replacement of gastric neurostimulator electrodes, 3392 43881 43881 antrum, open $ - Revision or removal of gastric neurostimulator electrodes, antrum, 3393 43882 43882 open $ - Gastric restrictive procedure, open; revision of subcutaneous port 3394 43886 43886 component only $ 925.03 Gastric restrictive procedure, open; removal of subcutaneous port 3395 43887 43887 component only $ 886.07 Gastric restrictive procedure, open; removal and replacement of 3396 43888 43888 subcutaneous port component only $ 1,353.63 3397 43999 43999 Unlisted procedure, stomach Cost 3398 44005 44005 Enterolysis (freeing of intestinal adhesion) (separate procedure) $ 2,305.69 3399 44010 44010 Duodenotomy, for exploration, biopsy(s), or foreign body removal $ 2,306.70 Tube or needle catheter jejunostomy for enteral alimentation, intraoperative, any method (List separately in addition to primary 3400 44015 44015 procedure) $ 1,448.10 Enterotomy, small intestine, other than duodenum; for exploration, 3401 44020 44020 biopsy(s), or foreign body removal $ 2,232.00 Enterotomy, small intestine, other than duodenum; for 3402 44021 44021 decompression (eg, Baker tube) $ 2,319.30 3403 44025 44025 Colotomy, for exploration, biopsy(s), or foreign body removal $ 2,389.50 Reduction of volvulus, intussusception, internal hernia, by 3404 44050 44050 laparotomy $ 2,321.10 Correction of malrotation by lysis of duodenal bands and/or 3405 44055 44055 reduction of midgut volvulus (eg, Ladd procedure) $ 2,601.00 3406 44100 44100 Biopsy of intestine by capsule, tube, peroral (1 or more specimens) $ 485.10 Excision of 1 or more lesions of small or large intestine not requiring 3407 44110 44110 anastomosis, exteriorization, or fistulization; single enterotomy $ 2,351.70 Excision of 1 or more lesions of small or large intestine not requiring 3408 44111 44111 anastomosis, exteriorization, or fistulization; multiple enterotomies $ 3,157.20 Enterectomy, resection of small intestine; single resection and 3409 44120 44120 anastomosis $ 2,880.00 Enterectomy, resection of small intestine; each additional resection and anastomosis (List separately in addition to code for primary 3410 44121 44121 procedure) $ 918.90 3411 44125 44125 Enterectomy, resection of small intestine; with enterostomy $ 3,114.00 Enterectomy, resection of small intestine for congenital atresia, single resection and anastomosis of proximal segment of intestine; 3412 44126 44126 without tapering $ 5,370.66 Enterectomy, resection of small intestine for congenital atresia, single resection and anastomosis of proximal segment of intestine; 3413 44127 44127 with tapering $ 5,598.46 Enterectomy, resection of small intestine for congenital atresia, single resection and anastomosis of proximal segment of intestine; each additional resection and anastomosis (List separately in 3414 44128 44128 addition to code for primary procedure) $ 1,016.67 Enteroenterostomy, anastomosis of intestine, with or without 3415 44130 44130 cutaneous enterostomy (separate procedure) $ 2,694.60 Donor enterectomy (including cold preservation), open; from 3416 44132 44132 cadaver donor $ - Donor enterectomy (including cold preservation), open; partial, 3417 44133 44133 from living donor $ - 3418 44136 44136 Intestinal allotransplantation; from living donor $ - 3419 44137 44137 Removal of transplanted intestinal allograft, complete $ - Mobilization (take-down) of splenic flexure performed in conjunction with partial colectomy (List separately in addition to 3420 44139 44139 primary procedure) $ 514.80 3421 44140 44140 Colectomy, partial; with anastomosis $ 3,340.80 3422 44141 44141 Colectomy, partial; with skin level cecostomy or colostomy $ 3,333.65 Colectomy, partial; with end colostomy and closure of distal 3423 44143 44143 segment (Hartmann type procedure) $ 3,331.80 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Colectomy, partial; with resection, with colostomy or ileostomy and 3424 44144 44144 creation of mucofistula $ 3,348.00 3425 44145 44145 Colectomy, partial; with coloproctostomy (low pelvic anastomosis) $ 3,887.10 Colectomy, partial; with coloproctostomy (low pelvic anastomosis), 3426 44146 44146 with colostomy $ 4,293.90 3427 44147 44147 Colectomy, partial; abdominal and transanal approach $ 4,626.90 Colectomy, total, abdominal, without proctectomy; with ileostomy 3428 44150 44150 or ileoproctostomy $ 4,718.70 Colectomy, total, abdominal, without proctectomy; with continent 3429 44151 44151 ileostomy $ 5,408.10 3430 44155 44155 Colectomy, total, abdominal, with proctectomy; with ileostomy $ 5,751.90 Colectomy, total, abdominal, with proctectomy; with continent 3431 44156 44156 ileostomy $ 5,768.10 Colectomy, total, abdominal, with proctectomy; with ileoanal anastomosis, includes loop ileostomy, and rectal mucosectomy, 3432 44157 44157 when performed $ 4,865.79 Colectomy, total, abdominal, with proctectomy; with ileoanal anastomosis, creation of ileal reservoir (S or J), includes loop 3433 44158 44158 ileostomy, and rectal mucosectomy, when performed $ 5,014.80 Colectomy, partial, with removal of terminal ileum with 3434 44160 44160 ileocolostomy $ 4,014.90 Laparoscopy, surgical, enterolysis (freeing of intestinal adhesion) 3435 44180 44180 (separate procedure) $ 1,859.50 Laparoscopy, surgical; jejunostomy (eg, for decompression or 3436 44186 44186 feeding) $ 1,441.07 3437 44187 44187 Laparoscopy, surgical; ileostomy or jejunostomy, non-tube $ 2,229.44 3438 44188 44188 Laparoscopy, surgical, colostomy or skin level cecostomy $ 2,477.27 Laparoscopy, surgical; enterectomy, resection of small intestine, 3439 44202 44202 single resection and anastomosis $ 4,013.10 Laparoscopy, surgical; each additional small intestine resection and anastomosis (List separately in addition to code for primary 3440 44203 44203 procedure) $ 742.32 3441 44204 44204 Laparoscopy, surgical; colectomy, partial, with anastomosis $ 3,237.04 Laparoscopy, surgical; colectomy, partial, with removal of terminal 3442 44205 44205 ileum with ileocolostomy $ 3,053.39 Laparoscopy, surgical; colectomy, partial, with end colostomy and 3443 44206 44206 closure of distal segment (Hartmann type procedure) $ 3,562.31 Laparoscopy, surgical; colectomy, partial, with anastomosis, with 3444 44207 44207 coloproctostomy (low pelvic anastomosis) $ 3,989.43 Laparoscopy, surgical; colectomy, partial, with anastomosis, with 3445 44208 44208 coloproctostomy (low pelvic anastomosis) with colostomy $ 4,162.98 Laparoscopy, surgical; colectomy, total, abdominal, without 3446 44210 44210 proctectomy, with ileostomy or ileoproctostomy $ 3,925.87 Laparoscopy, surgical; colectomy, total, abdominal, with proctectomy, with ileoanal anastomosis, creation of ileal reservoir (S or J), with loop ileostomy, includes rectal mucosectomy, when 3447 44211 44211 performed $ 5,320.26 Laparoscopy, surgical; colectomy, total, abdominal, with 3448 44212 44212 proctectomy, with ileostomy $ 4,588.99 Laparoscopy, surgical, mobilization (take-down) of splenic flexure performed in conjunction with partial colectomy (List separately in 3449 44213 44213 addition to primary procedure) $ 455.45 Laparoscopy, surgical, closure of enterostomy, large or small 3450 44227 44227 intestine, with resection and anastomosis $ 3,432.69 3451 44238 44238 Unlisted laparoscopy procedure, intestine (except rectum) $ - Placement, enterostomy or cecostomy, tube open (eg, for feeding 3452 44300 44300 or decompression) (separate procedure) $ 2,121.30 3453 44310 44310 Ileostomy or jejunostomy, non-tube $ 2,271.60 Revision of ileostomy; simple (release of superficial scar) (separate 3454 44312 44312 procedure) $ 1,269.00 Revision of ileostomy; complicated (reconstruction in-depth) 3455 44314 44314 (separate procedure) $ 2,343.60 3456 44316 44316 Continent ileostomy (Kock procedure) (separate procedure) $ 3,295.80 3457 44320 44320 Colostomy or skin level cecostomy; $ 2,201.40 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Colostomy or skin level cecostomy; with multiple biopsies (eg, for 3458 44322 44322 congenital megacolon) (separate procedure) $ 2,568.60 Revision of colostomy; simple (release of superficial scar) (separate 3459 44340 44340 procedure) $ 918.00 Revision of colostomy; complicated (reconstruction in-depth) 3460 44345 44345 (separate procedure) $ 2,093.40 Revision of colostomy; with repair of paracolostomy hernia 3461 44346 44346 (separate procedure) $ 2,365.20 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; diagnostic, with or without collection of specimen(s) by brushing or washing (separate 3462 44360 44360 procedure) $ 864.90 Small intestinal endoscopy, enteroscopy beyond second portion of 3463 44361 44361 duodenum, not including ileum; with biopsy, single or multiple $ 863.10 Small intestinal endoscopy, enteroscopy beyond second portion of 3464 44363 44363 duodenum, not including ileum; with removal of foreign body $ 804.60 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with removal of tumor(s), polyp(s), 3465 44364 44364 or other lesion(s) by snare technique $ 978.30 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with removal of tumor(s), polyp(s), 3466 44365 44365 or other lesion(s) by hot biopsy forceps or bipolar cautery $ 978.30 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, 3467 44366 44366 stapler, plasma coagulator) $ 1,076.40 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, 3468 44369 44369 bipolar cautery or snare technique $ 1,133.10 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with transendoscopic stent 3469 44370 44370 placement (includes predilation) $ 760.50 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with placement of percutaneous 3470 44372 44372 jejunostomy tube $ 1,199.70 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with conversion of percutaneous 3471 44373 44373 gastrostomy tube to percutaneous jejunostomy tube $ 904.50 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; diagnostic, with or without collection of 3472 44376 44376 specimen(s) by brushing or washing (separate procedure) $ 1,007.10 Small intestinal endoscopy, enteroscopy beyond second portion of 3473 44377 44377 duodenum, including ileum; with biopsy, single or multiple $ 1,061.10 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, 3474 44378 44378 plasma coagulator) $ 1,359.90 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; with transendoscopic stent placement 3475 44379 44379 (includes predilation) $ 1,137.60 Ileoscopy, through stoma; diagnostic, with or without collection of 3476 44380 44380 specimen(s) by brushing or washing (separate procedure) $ 546.30 3477 44382 44382 Ileoscopy, through stoma; with biopsy, single or multiple $ 681.30 Ileoscopy, through stoma; with transendoscopic stent placement 3478 44383 44383 (includes predilation) $ 917.99 Endoscopic evaluation of small intestinal (abdominal or pelvic) pouch; diagnostic, with or without collection of specimen(s) by 3479 44385 44385 brushing or washing (separate procedure) $ 715.50 Endoscopic evaluation of small intestinal (abdominal or pelvic) 3480 44386 44386 pouch; with biopsy, single or multiple $ 741.60 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Colonoscopy through stoma; diagnostic, with or without collection 3481 44388 44388 of specimen(s) by brushing or washing (separate procedure) $ 739.80 3482 44389 44389 Colonoscopy through stoma; with biopsy, single or multiple $ 796.50 3483 44390 44390 Colonoscopy through stoma; with removal of foreign body $ 841.50 Colonoscopy through stoma;

with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, 3484 44391 44391 plasma coagulator) $ 1,166.40 Colonoscopy through stoma; with removal of tumor(s), polyp(s), or 3485 44392 44392 other lesion(s) by hot biopsy forceps or bipolar cautery $ 1,255.50 Colonoscopy through stoma; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, 3486 44393 44393 bipolar cautery or snare technique $ 1,321.20 Colonoscopy through stoma; with removal of tumor(s), polyp(s), or 3487 44394 44394 other lesion(s) by snare technique $ 1,102.50 Colonoscopy through stoma; with transendoscopic stent placement 3488 44397 44397 (includes predilation) $ 596.70 Introduction of long gastrointestinal tube (eg, Miller-Abbott) 3489 44500 44500 (separate procedure) $ 123.30 Suture of small intestine (enterorrhaphy) for perforated ulcer, 3490 44602 44602 diverticulum, wound, injury or rupture; single perforation $ 2,248.20 Suture of small intestine (enterorrhaphy) for perforated ulcer, 3491 44603 44603 diverticulum, wound, injury or rupture; multiple perforations $ 2,656.80 Suture of large intestine (colorrhaphy) for perforated ulcer, diverticulum, wound, injury or rupture (single or multiple 3492 44604 44604 perforations); without colostomy $ 2,258.45 Suture of large intestine (colorrhaphy) for perforated ulcer, diverticulum, wound, injury or rupture (single or multiple 3493 44605 44605 perforations); with colostomy $ 2,991.60 Intestinal stricturoplasty (enterotomy and enterorrhaphy) with or 3494 44615 44615 without dilation, for intestinal obstruction $ 2,626.20 3495 44620 44620 Closure of enterostomy, large or small intestine; $ 1,713.65 Closure of enterostomy, large or small intestine; with resection and 3496 44625 44625 anastomosis other than colorectal $ 3,033.90 Closure of enterostomy, large or small intestine; with resection and 3497 44626 44626 colorectal anastomosis (eg, closure of Hartmann type procedure) $ 3,744.90 3498 44640 44640 Closure of intestinal cutaneous fistula $ 2,372.40 3499 44650 44650 Closure of enteroenteric or enterocolic fistula $ 3,090.60 Closure of enterovesical fistula; without intestinal or bladder 3500 44660 44660 resection $ 2,729.70 Closure of enterovesical fistula; with intestine and/or bladder 3501 44661 44661 resection $ 3,927.60 3502 44680 44680 Intestinal plication (separate procedure) $ 2,871.90 Exclusion of small intestine from pelvis by mesh or other prosthesis, 3503 44700 44700 or native tissue (eg, bladder or omentum) $ 2,709.90 Intraoperative colonic lavage (List separately in addition to code for 3504 44701 44701 primary procedure) $ 305.32 Backbench standard preparation of cadaver or living donor intestine allograft prior to transplantation, including mobilization and 3505 44715 44715 fashioning of the superior mesenteric artery and vein $ - Backbench reconstruction of cadaver or living donor intestine 3506 44720 44720 allograft prior to transplantation; venous anastomosis, each $ 581.85 Backbench reconstruction of cadaver or living donor intestine 3507 44721 44721 allograft prior to transplantation; arterial anastomosis, each $ 929.76 3508 44799 44799 Unlisted procedure, intestine Cost Excision of Meckel's diverticulum (diverticulectomy) or 3509 44800 44800 omphalomesenteric duct $ 1,913.40 3510 44820 44820 Excision of lesion of mesentery (separate procedure) $ 2,034.00 3511 44850 44850 Suture of mesentery (separate procedure) $ 1,802.70 3512 44899 44899 Unlisted procedure, Meckel's diverticulum and the mesentery Cost 3513 44900 44900 Incision and drainage of appendiceal abscess, open $ 1,545.30 3514 44950 44950 Appendectomy; $ 1,537.19 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Appendectomy; when done for indicated purpose at time of other major procedure (not as separate procedure) (List separately in 3515 44955 44955 addition to code for primary procedure) $ 1,133.10 Appendectomy; for ruptured appendix with abscess or generalized 3516 44960 44960 peritonitis $ 2,357.10 3517 44970 44970 Laparoscopy, surgical, appendectomy $ 2,130.30 3518 44979 44979 Unlisted laparoscopy procedure, appendix Cost 3519 45000 45000 Transrectal drainage of pelvic abscess $ 953.10 3520 45005 45005 Incision and drainage of submucosal abscess, rectum $ 522.90 Incision and drainage of deep supralevator, pelvirectal, or 3521 45020 45020 retrorectal abscess $ 893.70 3522 45100 45100 Biopsy of anorectal wall, anal approach (eg, congenital megacolon) $ 767.70 3523 45108 45108 Anorectal myomectomy $ 1,184.40 Proctectomy; complete, combined abdominoperineal, with 3524 45110 45110 colostomy $ 4,392.90 3525 45111 45111 Proctectomy; partial resection of rectum, transabdominal approach $ 3,498.30 Proctectomy, combined abdominoperineal, pull-through procedure 3526 45112 45112 (eg, colo-anal anastomosis) $ 4,645.80 Proctectomy, partial, with rectal mucosectomy, ileoanal anastomosis, creation of ileal reservoir (S or J), with or without loop 3527 45113 45113 ileostomy $ 4,837.19 Proctectomy, partial, with anastomosis; abdominal and transsacral 3528 45114 45114 approach $ 4,489.20 Proctectomy, partial, with anastomosis; transsacral approach only 3529 45116 45116 (Kraske type) $ 3,295.80 Proctectomy, combined abdominoperineal pull-through procedure (eg, colo-anal anastomosis), with creation of colonic reservoir (eg, J- 3530 45119 45119 pouch), with diverting enterostomy when performed $ 4,377.60 Proctectomy, complete (for congenital megacolon), abdominal and perineal approach; with pull-through procedure and anastomosis 3531 45120 45120 (eg, Swenson, Duhamel, or Soave type operation) $ 4,650.30 Proctectomy, complete (for congenital megacolon), abdominal and perineal approach; with subtotal or total colectomy, with multiple 3532 45121 45121 biopsies $ 4,738.50 3533 45123 45123 Proctectomy, partial, without anastomosis, perineal approach $ 3,149.10 Pelvic exenteration for colorectal malignancy, with proctectomy (with or without colostomy), with removal of bladder and ureteral transplantations, and/or hysterectomy, or cervicectomy, with or 3534 45126 45126 without removal of tube(s), with or without removal of ovary( $ 6,470.10 3535 45130 45130 Excision of rectal procidentia, with anastomosis; perineal approach $ 2,864.70 Excision of rectal procidentia, with anastomosis; abdominal and 3536 45135 45135 perineal approach $ 4,033.80 3537 45136 45136 Excision of ileoanal reservoir with ileostomy $ 4,548.02 3538 45150 45150 Division of stricture of rectum $ 1,278.00 Excision of rectal tumor by proctotomy, transsacral or 3539 45160 45160 transcoccygeal approach $ 2,827.80 Excision of rectal tumor, transanal approach; not including 3540 45171 45171 muscularis propria (ie, partial thickness) $ 1,349.29 Excision of rectal tumor, transanal approach; including muscularis 3541 45172 45172 propria (ie, full thickness) $ 1,853.35 Destruction of rectal tumor (eg, electrodesiccation, electrosurgery, 3542 45190 45190 laser ablation, laser resection, cryosurgery) transanal approach $ 1,441.80 Proctosigmoidoscopy, rigid; diagnostic, with or without collection of 3543 45300 45300 specimen(s) by brushing or washing (separate procedure) $ 142.39 Proctosigmoidoscopy, rigid; with dilation (eg, balloon, guide wire, 3544 45303 45303 bougie) $ 220.50 3545 45305 45305 Proctosigmoidoscopy, rigid; with biopsy, single or multiple $ 257.40 3546 45307 45307 Proctosigmoidoscopy, rigid; with removal of foreign body $ 386.10 Proctosigmoidoscopy, rigid; with removal of single tumor, polyp, or 3547 45308 45308 other lesion by hot biopsy forceps or bipolar cautery $ 417.60 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Proctosigmoidoscopy, rigid; with removal of single tumor, polyp, or 3548 45309 45309 other lesion by snare technique $ 430.20 Proctosigmoidoscopy, rigid; with removal of multiple tumors, polyps, or other lesions by hot biopsy forceps, bipolar cautery or 3549 45315 45315 snare technique $ 582.30 Proctosigmoidoscopy, rigid; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, 3550 45317 45317 plasma coagulator) $ 585.00 Proctosigmoidoscopy, rigid; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, 3551 45320 45320 bipolar cautery or snare technique (eg, laser) $ 639.00 3552 45321 45321 Proctosigmoidoscopy, rigid; with decompression of volvulus $ 534.60 Proctosigmoidoscopy, rigid; with transendoscopic stent placement 3553 45327 45327 (includes predilation) $ 219.12 Sigmoidoscopy, flexible; diagnostic, with or without collection of 3554 45330 45330 specimen(s) by brushing or washing (separate procedure) $ 253.73 3555 45331 45331 Sigmoidoscopy, flexible; with biopsy, single or multiple $ 339.86 3556 45332 45332 Sigmoidoscopy, flexible; with removal of foreign body $ 449.10 Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other 3557 45333 45333 lesion(s) by hot biopsy forceps or bipolar cautery $ 558.90 Sigmoidoscopy, flexible; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, 3558 45334 45334 plasma coagulator) $ 570.60 Sigmoidoscopy, flexible; with directed submucosal injection(s), any 3559 45335 45335 substance $ 714.94 Sigmoidoscopy, flexible; with decompression of volvulus, any 3560 45337 45337 method $ 772.20 Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other 3561 45338 45338 lesion(s) by snare technique $ 605.70 Sigmoidoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar 3562 45339 45339 cautery or snare technique $ 604.80 Sigmoidoscopy, flexible; with dilation by balloon, 1 or more 3563 45340 45340 strictures $ 400.18 3564 45341 45341 Sigmoidoscopy, flexible; with endoscopic ultrasound examination $ 607.50 Sigmoidoscopy, flexible; with transendoscopic ultrasound guided 3565 45342 45342 intramural or transmural fine needle aspiration/biopsy(s) $ 700.20 Sigmoidoscopy, flexible; with transendoscopic stent placement 3566 45345 45345 (includes predilation) $ 468.90 Colonoscopy, rigid or flexible, transabdominal via colotomy, single 3567 45355 45355 or multiple $ 785.70 Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or 3568 45378 45378 without colon decompression (separate procedure) $ 858.15 Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or 3569 45378-53 53 45378 without colon decompression (separate procedure) $ 304.71 Colonoscopy, flexible, proximal to splenic flexure; with removal of 3570 45379 45379 foreign body $ 1,099.80 Colonoscopy, flexible, proximal to splenic flexure; with biopsy, 3571 45380 45380 single or multiple $ 961.77 Colonoscopy, flexible, proximal to splenic flexure; with directed 3572 45381 45381 submucosal injection(s), any substance $ 975.00 Colonoscopy, flexible, proximal to splenic flexure; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, 3573 45382 45382 heater probe, stapler, plasma coagulator) $ 1,107.00 Colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by 3574 45383 45383 hot biopsy forceps, bipolar cautery or snare technique $ 1,203.49 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or 3575 45384 45384 bipolar cautery $ 1,162.09 Colonoscopy, flexible, proximal to splenic flexure; with removal of 3576 45385 45385 tumor(s), polyp(s), or other lesion(s) by snare technique $ 1,287.91 Colonoscopy, flexible, proximal to splenic flexure; with dilation by 3577 45386 45386 balloon, 1 or more strictures $ 958.72 Colonoscopy, flexible, proximal to splenic flexure; with 3578 45387 45387 transendoscopic stent placement (includes predilation) $ 950.40 Colonoscopy, flexible, proximal to splenic flexure; with endoscopic 3579 45391 45391 ultrasound examination $ 568.04 Colonoscopy, flexible, proximal to splenic flexure; with transendoscopic ultrasound guided intramural or transmural fine 3580 45392 45392 needle aspiration/biopsy(s) $ 718.20 Laparoscopy, surgical; proctectomy, complete, combined 3581 45395 45395 abdominoperineal, with colostomy $ 3,966.46 Laparoscopy, surgical; proctectomy, combined abdominoperineal pull-through procedure (eg, colo-anal anastomosis), with creation of colonic reservoir (eg, J-pouch), with diverting enterostomy, when 3582 45397 45397 performed $ 4,303.15 3583 45400 45400 Laparoscopy, surgical; proctopexy (for prolapse) $ 2,322.57 Laparoscopy, surgical; proctopexy (for prolapse), with sigmoid 3584 45402 45402 resection $ 3,124.42 3585 45499 45499 Unlisted laparoscopy procedure, rectum Cost 3586 45500 45500 Proctoplasty; for stenosis $ 1,570.50 3587 45505 45505 Proctoplasty; for prolapse of mucous membrane $ 1,647.90 3588 45520 45520 Perirectal injection of sclerosing solution for prolapse $ 144.00 3589 45540 45540 Proctopexy (eg, for prolapse); abdominal approach $ 3,206.70 3590 45541 45541 Proctopexy (eg, for prolapse); perineal approach $ 2,523.60 Proctopexy (eg, for prolapse); with sigmoid resection, abdominal 3591 45550 45550 approach $ 3,591.00 3592 45560 45560 Repair of rectocele (separate procedure) $ 1,494.00 3593 45562 45562 Exploration, repair, and presacral drainage for rectal injury; $ 2,657.70 Exploration, repair, and presacral drainage for rectal injury; with 3594 45563 45563 colostomy $ 3,095.10 3595 45800 45800 Closure of rectovesical fistula; $ 3,066.30 3596 45805 45805 Closure of rectovesical fistula; with colostomy $ 3,103.20 3597 45820 45820 Closure of rectourethral fistula; $ 2,729.70 3598 45825 45825 Closure of rectourethral fistula; with colostomy $ 3,057.30 3599 45900 45900 Reduction of procidentia (separate procedure) under anesthesia $ 497.70 Dilation of anal sphincter (separate procedure) under anesthesia 3600 45905 45905 other than local $ 360.90 Dilation of rectal stricture (separate procedure) under anesthesia 3601 45910 45910 other than local $ 384.30 Removal of fecal impaction or foreign body (separate procedure) 3602 45915 45915 under anesthesia $ 425.70 Anorectal exam, surgical, requiring anesthesia (general, spinal, or 3603 45990 45990 epidural), diagnostic $ 219.72 3604 45999 45999 Unlisted procedure, rectum Cost 3605 46020 46020 Placement of seton $ 230.01 3606 46030 46030 Removal of anal seton, other marker $ 293.40 Incision and drainage of ischiorectal and/or perirectal abscess 3607 46040 46040 (separate procedure) $ 703.80 Incision and drainage of intramural, intramuscular, or submucosal 3608 46045 46045 abscess, transanal, under anesthesia $ 775.80 3609 46050 46050 Incision and drainage, perianal abscess, superficial $ 282.60 Incision and drainage of ischiorectal or intramural abscess, with fistulectomy or fistulotomy, submuscular, with or without 3610 46060 46060 placement of seton $ 1,665.00 3611 46070 46070 Incision, anal septum (infant) $ 432.90 3612 46080 46080 Sphincterotomy, anal, division of sphincter (separate procedure) $ 820.80 3613 46083 46083 Incision of thrombosed hemorrhoid, external $ 214.20 3614 46200 46200 Fissurectomy, including sphincterotomy, when performed $ 867.60 3615 46220 46220 Excision of single external papilla or tag, anus $ 343.80 3616 46221 46221 Hemorrhoidectomy, internal, by rubber band ligation(s) $ 391.50 3617 46230 46230 Excision of multiple external papillae or tags, anus $ 380.70 3618 46250 46250 Hemorrhoidectomy, external, 2 or more columns/groups $ 952.20 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price 3619 46255 46255 Hemorrhoidectomy, internal and external, single column/group; $ 1,133.02 Hemorrhoidectomy, internal and external, single column/group; 3620 46257 46257 with fissurectomy $ 1,395.90 Hemorrhoidectomy, internal and external, single column/group; 3621 46258 46258 with fistulectomy, including fissurectomy, when performed $ 1,494.90 Hemorrhoidectomy, internal and external, 2 or more 3622 46260 46260 columns/groups; $ 1,744.20 Hemorrhoidectomy, internal and external, 2 or more 3623 46261 46261 columns/groups; with fissurectomy $ 1,469.73 Hemorrhoidectomy, internal and external, 2 or more columns/groups; with fistulectomy, including fissurectomy, when 3624 46262 46262 performed $ 1,658.70 Surgical treatment of anal fistula (fistulectomy/fistulotomy); 3625 46270 46270 subcutaneous $ 813.60 Surgical treatment of anal fistula (fistulectomy/fistulotomy); 3626 46275 46275 intersphincteric $ 1,426.50 Surgical treatment of anal fistula (fistulectomy/fistulotomy); transsphincteric, suprasphincteric, extrasphincteric or multiple, 3627 46280 46280 including placement of seton, when performed $ 1,668.60 Surgical treatment of anal fistula (fistulectomy/fistulotomy); second 3628 46285 46285 stage $ 578.70 3629 46288 46288 Closure of anal fistula with rectal advancement flap $ 1,596.60 3630 46320 46320 Excision of thrombosed hemorrhoid, external $ 252.07 3631 46500 46500 Injection of sclerosing solution, hemorrhoids $ 104.40 3632 46505 46505 Chemodenervation of internal anal sphincter $ 620.82 Anoscopy; diagnostic, with or without collection of specimen(s) by 3633 46600 46600 brushing or washing (separate procedure) $ 70.85 3634 46604 46604 Anoscopy; with dilation (eg, balloon, guide wire, bougie) $ 197.10 3635 46606 46606 Anoscopy; with biopsy, single or multiple $ 156.60 3636 46608 46608 Anoscopy; with removal of foreign body $ 236.70 Anoscopy; with removal of single tumor, polyp, or other lesion by 3637 46610 46610 hot biopsy forceps or bipolar cautery $ 277.20 Anoscopy; with removal of single tumor, polyp, or other lesion by 3638 46611 46611 snare technique $ 283.50 Anoscopy; with removal of multiple tumors, polyps, or other lesions 3639 46612 46612 by hot biopsy forceps, bipolar cautery or snare technique $ 343.80 Anoscopy; with control of bleeding (eg, injection, bipolar cautery, 3640 46614 46614 unipolar cautery, laser, heater probe, stapler, plasma coagulator) $ 407.70 Anoscopy; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or 3641 46615 46615 snare technique $ 414.00 3642 46700 46700 Anoplasty, plastic operation for stricture; adult $ 1,498.68 3643 46705 46705 Anoplasty, plastic operation for stricture; infant $ 1,416.60 3644 46706 46706 Repair of anal fistula with fibrin glue $ 389.22 Repair of anorectal fistula with plug (eg, porcine small intestine 3645 46707 46707 submucosa [SIS]) $ 1,162.37 Repair of ileoanal pouch fistula/sinus (eg, perineal or vaginal), 3646 46710 46710 pouch advancement; transperineal approach $ 2,534.97 Repair of ileoanal pouch fistula/sinus (eg, perineal or vaginal), pouch advancement; combined transperineal and transabdominal 3647 46712 46712 approach $ 4,490.29 Repair of low imperforate anus; with anoperineal fistula (cut-back 3648 46715 46715 procedure) $ 1,563.30 Repair of low imperforate anus; with transposition of anoperineal 3649 46716 46716 or anovestibular fistula $ 1,954.80 Repair of high imperforate anus without fistula; perineal or 3650 46730 46730 sacroperineal approach $ 3,294.00 Repair of high imperforate anus without fistula; combined 3651 46735 46735 transabdominal and sacroperineal approaches $ 3,994.20 Repair of high imperforate anus with rectourethral or rectovaginal 3652 46740 46740 fistula; perineal or sacroperineal approach $ 4,257.00 Repair of high imperforate anus with rectourethral or rectovaginal 3653 46742 46742 fistula; combined transabdominal and sacroperineal approaches $ 5,047.20 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Repair of cloacal anomaly by anorectovaginoplasty and 3654 46744 46744 urethroplasty, sacroperineal approach $ 5,304.60 Repair of cloacal anomaly by anorectovaginoplasty and 3655 46746 46746 urethroplasty, combined abdominal and sacroperineal approach; $ 6,437.70 Repair of cloacal anomaly by anorectovaginoplasty and urethroplasty, combined abdominal and sacroperineal approach; 3656 46748 46748 with vaginal lengthening by intestinal graft or pedicle flaps $ 7,020.00 3657 46750 46750 Sphincteroplasty, anal, for incontinence or prolapse; adult $ 1,944.72 3658 46751 46751 Sphincteroplasty, anal, for incontinence or prolapse; child $ 1,653.30 3659 46753 46753 Graft (Thiersch operation) for rectal incontinence and/or prolapse $ 1,352.70 3660 46754 46754 Removal of Thiersch wire or suture, anal canal $ 287.10 3661 46760 46760 Sphincteroplasty, anal, for incontinence, adult; muscle transplant $ 1,932.30 Sphincteroplasty, anal, for incontinence, adult; levator muscle 3662 46761 46761 imbrication (Park posterior anal repair) $ 2,142.41 Sphincteroplasty, anal, for incontinence, adult; implantation 3663 46762 46762 artificial sphincter $ 2,033.00 Destruction of lesion(s), anus (eg, condyloma, papilloma, molluscum 3664 46900 46900 contagiosum, herpetic vesicle), simple; chemical $ 190.80 Destruction of lesion(s), anus (eg, condyloma, papilloma, molluscum 3665 46910 46910 contagiosum, herpetic vesicle), simple; electrodesiccation $ 325.80 Destruction of lesion(s), anus (eg, condyloma, papilloma, molluscum 3666 46916 46916 contagiosum, herpetic vesicle), simple; cryosurgery $ 330.30 Destruction of lesion(s), anus (eg, condyloma, papilloma, molluscum 3667 46917 46917 contagiosum, herpetic vesicle), simple; laser surgery $ 570.60 Destruction of lesion(s), anus (eg, condyloma, papilloma, molluscum 3668 46922 46922 contagiosum, herpetic vesicle), simple; surgical excision $ 441.90 Destruction of lesion(s), anus (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), extensive (eg, laser surgery, 3669 46924 46924 electrosurgery, cryosurgery, chemosurgery) $ 861.30 Destruction of internal hemorrhoid(s) by thermal energy (eg, 3670 46930 46930 infrared coagulation, cautery, radiofrequency) $ 309.16 Curettage or cautery of anal fissure, including dilation of anal 3671 46940 46940 sphincter (separate procedure); initial $ 342.90 Curettage or cautery of anal fissure, including dilation of anal 3672 46942 46942 sphincter (separate procedure); subsequent $ 241.20 Hemorrhoidectomy, internal, by ligation other than rubber band; 3673 46945 46945 single hemorrhoid column/group $ 319.50 Hemorrhoidectomy, internal, by ligation other than rubber band; 2 3674 46946 46946 or more hemorrhoid columns/groups $ 372.60 Hemorrhoidopexy (eg, for prolapsing internal hemorrhoids) by 3675 46947 46947 stapling $ 578.58 3676 46999 46999 Unlisted procedure, anus $ 472.86 3677 47000 47000 Biopsy of liver, needle; percutaneous $ 378.90 Biopsy of liver, needle; when done for indicated purpose at time of other major procedure (List separately in addition to code for 3678 47001 47001 primary procedure) $ 362.70 3679 47010 47010 Hepatotomy, for open drainage of abscess or cyst, 1 or 2 stages $ 2,399.40 Laparotomy, with aspiration and/or injection of hepatic parasitic 3680 47015 47015 (eg, amoebic or echinococcal) cyst(s) or abscess(es) $ 1,859.40 3681 47120 47120 Hepatectomy, resection of liver; partial lobectomy $ 4,094.10 3682 47122 47122 Hepatectomy, resection of liver; trisegmentectomy $ 5,055.30 3683 47125 47125 Hepatectomy, resection of liver; total left lobectomy $ 5,123.70 3684 47130 47130 Hepatectomy, resection of liver; total right lobectomy $ 5,660.10 Donor hepatectomy (including cold preservation), from cadaver 3685 47133 47133 donor $ - Liver allotransplantation; orthotopic, partial or whole, from cadaver 3686 47135 47135 or living donor, any age $ 11,907.94 Liver allotransplantation; heterotopic, partial or whole, from 3687 47136 47136 cadaver or living donor, any age $ 10,222.38 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Donor hepatectomy (including cold preservation), from living donor; 3688 47140 47140 left lateral segment only (segments II and III) $ 8,705.32 Donor hepatectomy (including cold preservation), from living donor; 3689 47141 47141 total left lobectomy (segments II, III and IV) $ 9,173.83 Donor hepatectomy (including cold preservation), from living donor; 3690 47142 47142 total right lobectomy (segments V, VI, VII and VIII) $ 11,446.63 Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation, including cholecystectomy, if necessary, and dissection and removal of surrounding soft tissues to prepare 3691 47143 47143 the vena cava, portal vein, hepatic artery, and comm $ - Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation, including cholecystectomy, if necessary, and dissection and removal of surrounding soft tissues to prepare 3692 47144 47144 the vena cava, portal vein, hepatic artery, and comm $ - Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation, including cholecystectomy, if necessary, and dissection and removal of surrounding soft tissues to prepare 3693 47145 47145 the vena cava, portal vein, hepatic artery, and comm $ - Backbench reconstruction of cadaver or living donor liver graft prior 3694 47146 47146 to allotransplantation; venous anastomosis, each $ 795.89 Backbench reconstruction of cadaver or living donor liver graft prior 3695 47147 47147 to allotransplantation; arterial anastomosis, each $ 928.21 3696 47300 47300 Marsupialization of cyst or abscess of liver $ 2,345.40 Management of liver hemorrhage; simple suture of liver wound or 3697 47350 47350 injury $ 2,863.80 Management of liver hemorrhage; complex suture of liver wound or 3698 47360 47360 injury, with or without hepatic artery ligation $ 3,404.70 Management of liver hemorrhage; exploration of hepatic wound, extensive debridement, coagulation and/or suture, with or without 3699 47361 47361 packing of liver $ 5,294.70 Management of liver hemorrhage; re-exploration of hepatic wound 3700 47362 47362 for removal of packing $ 2,229.30 Laparoscopy, surgical, ablation of 1 or more liver tumor(s); 3701 47370 47370 radiofrequency $ 3,013.06 Laparoscopy, surgical, ablation of 1 or more liver tumor(s); 3702 47371 47371 cryosurgical $ 3,066.51 3703 47379 47379 Unlisted laparoscopic procedure, liver Cost 3704 47380 47380 Ablation, open, of 1 or more liver tumor(s); radiofrequency $ 3,485.82 3705 47381 47381 Ablation, open, of 1 or more liver tumor(s); cryosurgical $ 3,608.38 3706 47382 47382 Ablation, 1 or more liver tumor(s), percutaneous, radiofrequency $ 12,779.28 3707 47399 47399 Unlisted procedure, liver Cost Hepaticotomy or hepaticostomy with exploration, drainage, or 3708 47400 47400 removal of calculus $ 2,941.20 Choledochotomy or choledochostomy with exploration, drainage, or removal of calculus, with or without cholecystotomy; without 3709 47420 47420 transduodenal sphincterotomy or sphincteroplasty $ 2,731.50 Choledochotomy or choledochostomy with exploration, drainage, or removal of calculus, with or without cholecystotomy; with 3710 47425 47425 transduodenal sphincterotomy or sphincteroplasty $ 3,064.50 Transduodenal sphincterotomy or sphincteroplasty, with or without 3711 47460 47460 transduodenal extraction of calculus (separate procedure) $ 3,170.70 Cholecystotomy or cholecystostomy, open, with exploration, 3712 47480 47480 drainage, or removal of calculus (separate procedure) $ 1,964.70 Cholecystostomy, percutaneous, complete procedure, including imaging guidance, catheter placement, cholecystogram when 3713 47490 47490 performed, and radiological supervision and interpretation $ 947.70 3714 47500 47500 Injection procedure for percutaneous transhepatic cholangiography $ 501.30 Injection procedure for cholangiography through an existing 3715 47505 47505 catheter (eg, percutaneous transhepatic or T-tube) $ 239.40 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Introduction of percutaneous transhepatic catheter for biliary 3716 47510 47510 drainage $ 825.30 Introduction of percutaneous transhepatic stent for internal and 3717 47511 47511 external biliary drainage $ 932.40 3718 47525 47525 Change of percutaneous biliary drainage catheter $ 473.40 3719 47530 47530 Revision and/or reinsertion of transhepatic tube $ 613.80 Biliary endoscopy, intraoperative (choledochoscopy) (List separately 3720 47550 47550 in addition to code for primary procedure) $ 785.70 Biliary endoscopy, percutaneous via T-tube or other tract; diagnostic, with collection of specimen(s) by brushing and/or 3721 47552 47552 washing, when performed (separate procedure) $ 1,030.50 Biliary endoscopy, percutaneous via T-tube or other tract; with 3722 47553 47553 biopsy, single or multiple $ 978.30 Biliary endoscopy, percutaneous via T-tube or other tract; with 3723 47554 47554 removal of calculus/calculi $ 1,421.10 Biliary endoscopy, percutaneous via T-tube or other tract; with 3724 47555 47555 dilation of biliary duct stricture(s) without stent $ 1,138.50 Biliary endoscopy, percutaneous via T-tube or other tract; with 3725 47556 47556 dilation of biliary duct stricture(s) with stent $ 1,133.10 Laparoscopy, surgical; with guided transhepatic cholangiography, 3726 47560 47560 without biopsy $ 1,510.58 Laparoscopy, surgical; with guided transhepatic cholangiography 3727 47561 47561 with biopsy $ 1,159.20 3728 47562 47562 Laparoscopy, surgical; cholecystectomy $ 2,884.50 3729 47563 47563 Laparoscopy, surgical; cholecystectomy with cholangiography $ 2,978.08 Laparoscopy, surgical; cholecystectomy with exploration of common 3730 47564 47564 duct $ 3,501.90 3731 47570 47570 Laparoscopy, surgical; cholecystoenterostomy $ 2,934.90 3732 47579 47579 Unlisted laparoscopy procedure, biliary tract Cost 3733 47600 47600 Cholecystectomy; $ 2,425.73 3734 47605 47605 Cholecystectomy; with cholangiography $ 2,408.40 3735 47610 47610 Cholecystectomy with exploration of common duct; $ 3,090.60 Cholecystectomy with exploration of common duct; with 3736 47612 47612 choledochoenterostomy $ 3,743.10 Cholecystectomy with exploration of common duct; with transduodenal sphincterotomy or sphincteroplasty, with or without 3737 47620 47620 cholangiography $ 3,605.40 Biliary duct stone extraction, percutaneous via T-tube tract, basket, 3738 47630 47630 or snare (eg, Burhenne technique) $ 1,591.20 Exploration for congenital atresia of bile ducts, without repair, with 3739 47700 47700 or without liver biopsy, with or without cholangiography $ 2,565.00 3740 47701 47701 Portoenterostomy (eg, Kasai procedure) $ 3,919.50 Excision of bile duct tumor, with or without primary repair of bile 3741 47711 47711 duct; extrahepatic $ 3,893.40 Excision of bile duct tumor, with or without primary repair of bile 3742 47712 47712 duct; intrahepatic $ 4,233.60 3743 47715 47715 Excision of choledochal cyst $ 2,894.40 3744 47720 47720 Cholecystoenterostomy; direct $ 2,518.20 3745 47721 47721 Cholecystoenterostomy; with gastroenterostomy $ 3,141.90 3746 47740 47740 Cholecystoenterostomy; Roux-en-Y $ 3,231.00 3747 47741 47741 Cholecystoenterostomy; Roux-en-Y with gastroenterostomy $ 3,558.60 3748 47760 47760 Anastomosis, of extrahepatic biliary ducts and gastrointestinal tract $ 3,577.50 3749 47765 47765 Anastomosis, of intrahepatic ducts and gastrointestinal tract $ 3,862.80 Anastomosis, Roux-en-Y, of extrahepatic biliary ducts and 3750 47780 47780 gastrointestinal tract $ 4,051.80 Anastomosis, Roux-en-Y, of intrahepatic biliary ducts and 3751 47785 47785 gastrointestinal tract $ 4,861.80 Reconstruction, plastic, of extrahepatic biliary ducts with end-to- 3752 47800 47800 end anastomosis $ 3,579.30 3753 47801 47801 Placement of choledochal stent $ 2,097.00 3754 47802 47802 U-tube hepaticoenterostomy $ 3,399.30 Suture of extrahepatic biliary duct for pre-existing injury (separate 3755 47900 47900 procedure) $ 3,095.10 3756 47999 47999 Unlisted procedure, biliary tract Cost 3757 48000 48000 Placement of drains, peripancreatic, for acute pancreatitis; $ 2,626.20 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Placement of drains, peripancreatic, for acute pancreatitis; with 3758 48001 48001 cholecystostomy, gastrostomy, and jejunostomy $ 2,832.30 3759 48020 48020 Removal of pancreatic calculus $ 2,904.30 Biopsy of pancreas, open (eg, fine needle aspiration, needle core 3760 48100 48100 biopsy, wedge biopsy) $ 2,138.40 3761 48102 48102 Biopsy of pancreas, percutaneous needle $ 634.50 Resection or debridement of pancreas and peripancreatic tissue for 3762 48105 48105 acute necrotizing pancreatitis $ 5,451.85 3763 48120 48120 Excision of lesion of pancreas (eg, cyst, adenoma) $ 2,574.90 Pancreatectomy, distal subtotal, with or without splenectomy; 3764 48140 48140 without pancreaticojejunostomy $ 3,533.40 Pancreatectomy, distal subtotal, with or without splenectomy; with 3765 48145 48145 pancreaticojejunostomy $ 3,700.80 Pancreatectomy, distal, near-total with preservation of duodenum 3766 48146 48146 (Child-type procedure) $ 3,965.40 3767 48148 48148 Excision of ampulla of Vater $ 3,132.00 Pancreatectomy, proximal subtotal with total duodenectomy, partial gastrectomy, choledochoenterostomy and gastrojejunostomy (Whipple-type procedure); with 3768 48150 48150 pancreatojejunostomy $ 6,010.20 Pancreatectomy, proximal subtotal with total duodenectomy, partial gastrectomy, choledochoenterostomy and gastrojejunostomy (Whipple-type procedure); without 3769 48152 48152 pancreatojejunostomy $ 5,525.10 Pancreatectomy, proximal subtotal with near-total duodenectomy, choledochoenterostomy and duodenojejunostomy (pylorus-sparing, 3770 48153 48153 Whipple-type procedure); with pancreatojejunostomy $ 6,282.90 Pancreatectomy, proximal subtotal with near-total duodenectomy, choledochoenterostomy and duodenojejunostomy (pylorus-sparing, 3771 48154 48154 Whipple-type procedure); without pancreatojejunostomy $ 5,545.84 3772 48155 48155 Pancreatectomy, total $ 5,987.70 Pancreatectomy, total or subtotal, with autologous transplantation 3773 48160 48160 of pancreas or pancreatic islet cells $ - Injection procedure for intraoperative pancreatography (List 3774 48400 48400 separately in addition to code for primary procedure) $ 278.10 3775 48500 48500 Marsupialization of pancreatic cyst $ 2,574.90 3776 48510 48510 External drainage, pseudocyst of pancreas, open $ 3,393.00 Internal anastomosis of pancreatic cyst to gastrointestinal tract; 3777 48520 48520 direct $ 3,391.20 Internal anastomosis of pancreatic cyst to gastrointestinal tract; 3778 48540 48540 Roux-en-Y $ 3,727.80 3779 48545 48545 Pancreatorrhaphy for injury $ 2,807.10 3780 48547 48547 Duodenal exclusion with gastrojejunostomy for pancreatic injury $ 4,583.70 Pancreaticojejunostomy, side-to-side anastomosis (Puestow-type 3781 48548 48548 operation) $ 3,894.97 Donor pancreatectomy (including cold preservation), with or 3782 48550 48550 without duodenal segment for transplantation $ - Backbench standard preparation of cadaver donor pancreas allograft prior to transplantation, including dissection of allograft from surrounding soft tissues, splenectomy, duodenotomy, ligation 3783 48551 48551 of bile duct, ligation of mesenteric vessels, and Y-graft arte $ - Backbench reconstruction of cadaver donor pancreas allograft prior 3784 48552 48552 to transplantation, venous anastomosis, each $ 568.43 3785 48554 48554 Transplantation of pancreatic allograft $ 5,886.90 3786 48556 48556 Removal of transplanted pancreatic allograft $ 2,919.60 3787 48999 48999 Unlisted procedure, pancreas Cost Exploratory laparotomy, exploratory celiotomy with or without 3788 49000 49000 biopsy(s) (separate procedure) $ 2,088.85 3789 49002 49002 Reopening of recent laparotomy $ 1,898.10 Exploration, retroperitoneal area with or without biopsy(s) 3790 49010 49010 (separate procedure) $ 2,083.50 Drainage of peritoneal abscess or localized peritonitis, exclusive of 3791 49020 49020 appendiceal abscess, open $ 1,682.10 3792 49040 49040 Drainage of subdiaphragmatic or subphrenic abscess, open $ 1,975.50 3793 49060 49060 Drainage of retroperitoneal abscess, open $ 1,845.90 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price 3794 49062 49062 Drainage of extraperitoneal lymphocele to peritoneal cavity, open $ 1,874.70 Abdominal paracentesis (diagnostic or therapeutic); without 3795 49082 49082 imaging guidance $ 439.20 Abdominal paracentesis (diagnostic or therapeutic); with imaging 3796 49083 49083 guidance $ 793.44 3797 49084 49084 Peritoneal lavage, including imaging guidance, when performed $ 237.37 3798 49180 49180 Biopsy, abdominal or retroperitoneal mass, percutaneous needle $ 811.80 Excision or destruction, open, intra-abdominal tumors, cysts or endometriomas, 1 or more peritoneal, mesenteric, or retroperitoneal primary or secondary tumors; largest tumor 5 cm 3799 49203 49203 diameter or less $ 2,801.62 Excision or destruction, open, intra-abdominal tumors, cysts or endometriomas, 1 or more peritoneal, mesenteric, or retroperitoneal primary or secondary tumors; largest tumor 5.1- 3800 49204 49204 10.0 cm diameter $ 3,508.35 Excision or destruction, open, intra-abdominal tumors, cysts or endometriomas, 1 or more peritoneal, mesenteric, or retroperitoneal primary or secondary tumors; largest tumor greater 3801 49205 49205 than 10.0 cm diameter $ 4,192.01 3802 49215 49215 Excision of presacral or sacrococcygeal tumor $ 3,955.50 Staging laparotomy for Hodgkins disease or lymphoma (includes splenectomy, needle or open biopsies of both liver lobes, possibly also removal of abdominal nodes, abdominal node and/or bone 3803 49220 49220 marrow biopsies, ovarian repositioning) $ 3,829.50 Umbilectomy, omphalectomy, excision of umbilicus (separate 3804 49250 49250 procedure) $ 1,416.60 Omentectomy, epiploectomy, resection of omentum (separate 3805 49255 49255 procedure) $ 1,802.70 Laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or without collection of specimen(s) by brushing or washing 3806 49320 49320 (separate procedure) $ 1,557.11 3807 49321 49321 Laparoscopy, surgical; with biopsy (single or multiple) $ 1,716.30 Laparoscopy, surgical; with aspiration of cavity or cyst (eg, ovarian 3808 49322 49322 cyst) (single or multiple) $ 1,802.70 Laparoscopy, surgical; with drainage of lymphocele to peritoneal 3809 49323 49323 cavity $ 1,908.90 Laparoscopy, surgical; with insertion of tunneled intraperitoneal 3810 49324 49324 catheter $ 943.82 Laparoscopy, surgical; with revision of previously placed intraperitoneal cannula or catheter, with removal of intraluminal 3811 49325 49325 obstructive material if performed $ 950.46 Laparoscopy, surgical; with omentopexy (omental tacking procedure) (List separately in addition to code for primary 3812 49326 49326 procedure) $ 706.80 Unlisted laparoscopy procedure, abdomen, peritoneum and 3813 49329 49329 omentum Cost Injection of air or contrast into peritoneal cavity (separate 3814 49400 49400 procedure) $ 233.10 3815 49402 49402 Removal of peritoneal foreign body from peritoneal cavity $ 1,902.20 Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst); visceral (eg, kidney, liver, 3816 49405 49405 spleen, lung/mediastinum), percutaneous $ 1,223.25 Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst); peritoneal or 3817 49406 49406 retroperitoneal, percutaneous $ 1,223.25 Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst); peritoneal or 3818 49407 49407 retroperitoneal, transvaginal or transrectal $ 757.76 Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), percutaneous, intra-abdominal, intra-pelvic (except prostate), and/or retroperitoneum, single or 3819 49411 49411 multiple $ 880.63 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Insertion of tunneled intraperitoneal catheter (eg, dialysis, intraperitoneal chemotherapy instillation, management of ascites), complete procedure, including imaging guidance, catheter placement, contrast injection when performed, and radiological 3820 49418 49418 superv $ 1,335.02 Insertion of tunneled intraperitoneal catheter, with subcutaneous 3821 49419 49419 port (ie, totally implantable) $ 985.96 3822 49421 49421 Insertion of tunneled intraperitoneal catheter for dialysis, open $ 1,449.00 3823 49422 49422 Removal of tunneled intraperitoneal catheter $ 1,191.60 Exchange of previously placed abscess or cyst drainage catheter 3824 49423 49423 under radiological guidance (separate procedure) $ 277.20 Contrast injection for assessment of abscess or cyst via previously 3825 49424 49424 placed drainage catheter or tube (separate procedure) $ 144.00 3826 49425 49425 Insertion of peritoneal-venous shunt $ 2,162.70 3827 49426 49426 Revision of peritoneal-venous shunt $ 1,984.50 Injection procedure (eg, contrast media) for evaluation of previously 3828 49427 49427 placed peritoneal-venous shunt $ 216.00 3829 49428 49428 Ligation of peritoneal-venous shunt $ 953.79 3830 49429 49429 Removal of peritoneal-venous shunt $ 1,148.24 Insertion of subcutaneous extension to intraperitoneal cannula or catheter with remote chest exit site (List separately in addition to 3831 49435 49435 code for primary procedure) $ 343.46 Delayed creation of exit site from embedded subcutaneous 3832 49436 49436 segment of intraperitoneal cannula or catheter $ 485.16 Insertion of gastrostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and 3833 49440 49440 report $ 2,849.89 Insertion of duodenostomy or jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image 3834 49441 49441 documentation and report $ 3,205.41 Insertion of cecostomy or other colonic tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image 3835 49442 49442 documentation and report $ 2,719.49 Conversion of gastrostomy tube to gastro-jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast 3836 49446 49446 injection(s), image documentation and report $ 2,770.54 Replacement of gastrostomy or cecostomy (or other colonic) tube, percutaneous, under fluoroscopic guidance including contrast 3837 49450 49450 injection(s), image documentation and report $ 2,007.64 Replacement of duodenostomy or jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image 3838 49451 49451 documentation and report $ 2,121.12 Replacement of gastro-jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image 3839 49452 49452 documentation and report $ 2,487.98 Mechanical removal of obstructive material from gastrostomy, duodenostomy, jejunostomy, gastro-jejunostomy, or cecostomy (or other colonic) tube, any method, under fluoroscopic guidance including contrast injection(s), if performed, image documentation 3840 49460 49460 an $ 2,124.43 Contrast injection(s) for radiological evaluation of existing gastrostomy, duodenostomy, jejunostomy, gastro-jejunostomy, or cecostomy (or other colonic) tube, from a percutaneous approach 3841 49465 49465 including image documentation and report $ 492.81 Repair, initial inguinal hernia, preterm infant (younger than 37 weeks gestation at birth), performed from birth up to 50 weeks 3842 49491 49491 postconception age, with or without hydrocelectomy; reducible $ 1,510.04 Repair, initial inguinal hernia, preterm infant (younger than 37 weeks gestation at birth), performed from birth up to 50 weeks postconception age, with or without hydrocelectomy; incarcerated 3843 49492 49492 or strangulated $ 1,735.71 Repair, initial inguinal hernia, full term infant younger than age 6 months, or preterm infant older than 50 weeks postconception age and younger than age 6 months at the time of surgery, with or 3844 49495 49495 without hydrocelectomy; reducible $ 1,575.90 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Repair, initial inguinal hernia, full term infant younger than age 6 months, or preterm infant older than 50 weeks postconception age and younger than age 6 months at the time of surgery, with or 3845 49496 49496 without hydrocelectomy; incarcerated or strangulated $ 1,755.00 Repair initial inguinal hernia, age 6 months to younger than 5 years, 3846 49500 49500 with or without hydrocelectomy; reducible $ 1,390.50 Repair initial inguinal hernia, age 6 months to younger than 5 years, 3847 49501 49501 with or without hydrocelectomy; incarcerated or strangulated $ 1,555.20 3848 49505 49505 Repair initial inguinal hernia, age 5 years or older; reducible $ 1,547.55 Repair initial inguinal hernia, age 5 years or older; incarcerated or 3849 49507 49507 strangulated $ 1,889.72 3850 49520 49520 Repair recurrent inguinal hernia, any age; reducible $ 2,031.30 Repair recurrent inguinal hernia, any age; incarcerated or 3851 49521 49521 strangulated $ 2,214.90 3852 49525 49525 Repair inguinal hernia, sliding, any age $ 1,647.90 3853 49540 49540 Repair lumbar hernia $ 1,574.10 3854 49550 49550 Repair initial femoral hernia, any age; reducible $ 1,616.40 3855 49553 49553 Repair initial femoral hernia, any age; incarcerated or strangulated $ 1,931.40 3856 49555 49555 Repair recurrent femoral hernia; reducible $ 1,916.10 3857 49557 49557 Repair recurrent femoral hernia; incarcerated or strangulated $ 2,497.50 3858 49560 49560 Repair initial incisional or ventral hernia; reducible $ 1,978.57 Repair initial incisional or ventral hernia; incarcerated or 3859 49561 49561 strangulated $ 2,116.80 3860 49565 49565 Repair recurrent incisional or ventral hernia; reducible $ 2,480.40 Repair recurrent incisional or ventral hernia; incarcerated or 3861 49566 49566 strangulated $ 2,693.70 Implantation of mesh or other prosthesis for open incisional or ventral hernia repair or mesh for closure of debridement for necrotizing soft tissue infection (List separately in addition to code 3862 49568 49568 for the incisional or ventral hernia repair) $ 736.24 Repair epigastric hernia (eg, preperitoneal fat); reducible (separate 3863 49570 49570 procedure) $ 1,421.10 Repair epigastric hernia (eg, preperitoneal fat); incarcerated or 3864 49572 49572 strangulated $ 1,670.40 3865 49580 49580 Repair umbilical hernia, younger than age 5 years; reducible $ 1,189.80 Repair umbilical hernia, younger than age 5 years; incarcerated or 3866 49582 49582 strangulated $ 1,545.30 3867 49585 49585 Repair umbilical hernia, age 5 years or older; reducible $ 1,441.80 Repair umbilical hernia, age 5 years or older; incarcerated or 3868 49587 49587 strangulated $ 1,646.00 3869 49590 49590 Repair spigelian hernia $ 1,654.20 3870 49600 49600 Repair of small omphalocele, with primary closure $ 1,622.70 Repair of large omphalocele or gastroschisis; with or without 3871 49605 49605 prosthesis $ 3,263.40 Repair of large omphalocele or gastroschisis;

with removal of 3872 49606 49606 prosthesis, final reduction and closure, in operating room $ 2,832.30 3873 49610 49610 Repair of omphalocele (Gross type operation); first stage $ 2,008.80 3874 49611 49611 Repair of omphalocele (Gross type operation); second stage $ 1,946.70 3875 49650 49650 Laparoscopy, surgical; repair initial inguinal hernia $ 1,924.20 3876 49651 49651 Laparoscopy, surgical; repair recurrent inguinal hernia $ 2,074.50 Laparoscopy, surgical, repair, ventral, umbilical, spigelian or epigastric hernia (includes mesh insertion, when performed); 3877 49652 49652 reducible $ 2,109.14 Laparoscopy, surgical, repair, ventral, umbilical, spigelian or epigastric hernia (includes mesh insertion, when performed); 3878 49653 49653 incarcerated or strangulated $ 2,603.68 Laparoscopy, surgical, repair, incisional hernia (includes mesh 3879 49654 49654 insertion, when performed); reducible $ 2,373.28 Laparoscopy, surgical, repair, incisional hernia (includes mesh 3880 49655 49655 insertion, when performed); incarcerated or strangulated $ 2,891.21 Laparoscopy, surgical, repair, recurrent incisional hernia (includes 3881 49656 49656 mesh insertion, when performed); reducible $ 2,400.68 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Laparoscopy, surgical, repair, recurrent incisional hernia (includes 3882 49657 49657 mesh insertion, when performed); incarcerated or strangulated $ 3,469.04 Unlisted laparoscopy procedure, hernioplasty, herniorrhaphy, 3883 49659 49659 herniotomy Cost 3884 49900 49900 Suture, secondary, of abdominal wall for evisceration or dehiscence $ 1,555.20 Omental flap, extra-abdominal (eg, for reconstruction of sternal and 3885 49904 49904 chest wall defects) $ 3,010.88 Omental flap, intra-abdominal (List separately in addition to code 3886 49905 49905 for primary procedure) $ 1,532.70 3887 49906 49906 Free omental flap with microvascular anastomosis $ - 3888 49999 49999 Unlisted procedure, abdomen, peritoneum and omentum Cost 3889 50010 50010 Renal exploration, not necessitating other specific procedures $ 2,369.70 3890 50020 50020 Drainage of perirenal or renal abscess, open $ 2,348.10 3891 50040 50040 Nephrostomy, nephrotomy with drainage $ 2,388.60 3892 50045 50045 Nephrotomy, with exploration $ 2,695.50 3893 50060 50060 Nephrolithotomy; removal of calculus $ 3,464.10 3894 50065 50065 Nephrolithotomy; secondary surgical operation for calculus $ 3,301.20 3895 50070 50070 Nephrolithotomy; complicated by congenital kidney abnormality $ 3,739.50 Nephrolithotomy; removal of large staghorn calculus filling renal 3896 50075 50075 pelvis and calyces (including anatrophic pyelolithotomy) $ 3,556.80 Percutaneous nephrostolithotomy or pyelostolithotomy, with or without dilation, endoscopy, lithotripsy, stenting, or basket 3897 50080 50080 extraction; up to 2 cm $ 3,374.10 Percutaneous nephrostolithotomy or pyelostolithotomy, with or without dilation, endoscopy, lithotripsy, stenting, or basket 3898 50081 50081 extraction; over 2 cm $ 3,953.70 Transection or repositioning of aberrant renal vessels (separate 3899 50100 50100 procedure) $ 2,421.00 3900 50120 50120 Pyelotomy; with exploration $ 2,788.20 3901 50125 50125 Pyelotomy; with drainage, pyelostomy $ 2,860.20 Pyelotomy; with removal of calculus (pyelolithotomy, 3902 50130 50130 pelviolithotomy, including coagulum pyelolithotomy) $ 3,258.00 Pyelotomy; complicated (eg, secondary operation, congenital 3903 50135 50135 kidney abnormality) $ 3,535.20 3904 50200 50200 Renal biopsy; percutaneous, by trocar or needle $ 563.40 3905 50205 50205 Renal biopsy; by surgical exposure of kidney $ 1,523.70 Nephrectomy, including partial ureterectomy, any open approach 3906 50220 50220 including rib resection; $ 3,236.40 Nephrectomy, including partial ureterectomy, any open approach including rib resection; complicated because of previous surgery on 3907 50225 50225 same kidney $ 3,862.80 Nephrectomy, including partial ureterectomy, any open approach including rib resection; radical, with regional lymphadenectomy 3908 50230 50230 and/or vena caval thrombectomy $ 4,735.80 Nephrectomy with total ureterectomy and bladder cuff; through 3909 50234 50234 same incision $ 4,532.40 Nephrectomy with total ureterectomy and bladder cuff; through 3910 50236 50236 separate incision $ 4,327.20 3911 50240 50240 Nephrectomy, partial $ 3,764.70 Ablation, open, 1 or more renal mass lesion(s), cryosurgical, including intraoperative ultrasound guidance and monitoring, if 3912 50250 50250 performed $ 3,098.95 3913 50280 50280 Excision or unroofing of cyst(s) of kidney $ 2,828.70 3914 50290 50290 Excision of perinephric cyst $ 2,653.20 Donor nephrectomy (including cold preservation); from cadaver 3915 50300 50300 donor, unilateral or bilateral $ 2,830.50 Donor nephrectomy (including cold preservation); open, from living 3916 50320 50320 donor $ 4,686.30 Backbench standard preparation of cadaver donor renal allograft prior to transplantation, including dissection and removal of perinephric fat, diaphragmatic and retroperitoneal attachments, 3917 50323 50323 excision of adrenal gland, and preparation of ureter(s), renal ve $ - Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Backbench standard preparation of living donor renal allograft (open or laparoscopic) prior to transplantation, including dissection and removal of perinephric fat and preparation of ureter(s), renal 3918 50325 50325 vein(s), and renal artery(s), ligating branches, as nec $ - Backbench reconstruction of cadaver or living donor renal allograft 3919 50327 50327 prior to transplantation; venous anastomosis, each $ 518.41 Backbench reconstruction of cadaver or living donor renal allograft 3920 50328 50328 prior to transplantation; arterial anastomosis, each $ 452.32 Backbench reconstruction of cadaver or living donor renal allograft 3921 50329 50329 prior to transplantation; ureteral anastomosis, each $ 410.96 3922 50340 50340 Recipient nephrectomy (separate procedure) $ 2,797.20 Renal allotransplantation, implantation of graft; without recipient 3923 50360 50360 nephrectomy $ 6,304.50 Renal allotransplantation, implantation of graft; with recipient 3924 50365 50365 nephrectomy $ 7,696.80 3925 50370 50370 Removal of transplanted renal allograft $ 2,430.90 3926 50380 50380 Renal autotransplantation, reimplantation of kidney $ 4,360.50 Removal (via snare/capture) and replacement of internally dwelling ureteral stent via percutaneous approach, including radiological 3927 50382 50382 supervision and interpretation $ 1,292.64 Removal (via snare/capture) of internally dwelling ureteral stent via percutaneous approach, including radiological supervision and 3928 50384 50384 interpretation $ 1,139.86 Removal (via snare/capture) and replacement of internally dwelling ureteral stent via transurethral approach, without use of 3929 50385 50385 cystoscopy, including radiological supervision and interpretation $ 1,174.03 Removal (via snare/capture) of internally dwelling ureteral stent via transurethral approach, without use of cystoscopy, including 3930 50386 50386 radiological supervision and interpretation $ 916.76 Removal and replacement of externally accessible transnephric ureteral stent (eg, external/internal stent) requiring fluoroscopic 3931 50387 50387 guidance, including radiological supervision and interpretation $ 540.10 Removal of nephrostomy tube, requiring fluoroscopic guidance (eg, 3932 50389 50389 with concurrent indwelling ureteral stent) $ 344.26 Aspiration and/or injection of renal cyst or pelvis by needle, 3933 50390 50390 percutaneous $ 465.30 Instillation(s) of therapeutic agent into renal pelvis and/or ureter through established nephrostomy, pyelostomy or ureterostomy 3934 50391 50391 tube (eg, anticarcinogenic or antifungal agent) $ 374.44 Introduction of intracatheter or catheter into renal pelvis for 3935 50392 50392 drainage and/or injection, percutaneous $ 666.00 Introduction of ureteral catheter or stent into ureter through renal 3936 50393 50393 pelvis for drainage and/or injection, percutaneous $ 703.80 Injection procedure for pyelography (as nephrostogram, pyelostogram, antegrade pyeloureterograms) through nephrostomy 3937 50394 50394 or pyelostomy tube, or indwelling ureteral catheter $ 221.40 Introduction of guide into renal pelvis and/or ureter with dilation to 3938 50395 50395 establish nephrostomy tract, percutaneous $ 870.30 Manometric studies through nephrostomy or pyelostomy tube, or 3939 50396 50396 indwelling ureteral catheter $ 164.70 3940 50398 50398 Change of nephrostomy or pyelostomy tube $ 257.40 Pyeloplasty (Foley Y-pyeloplasty), plastic operation on renal pelvis, with or without plastic operation on ureter, nephropexy, 3941 50400 50400 nephrostomy, pyelostomy, or ureteral splinting; simple $ 3,541.50 Pyeloplasty (Foley Y-pyeloplasty), plastic operation on renal pelvis, with or without plastic operation on ureter, nephropexy, nephrostomy, pyelostomy, or ureteral splinting; complicated 3942 50405 50405 (congenital kidney abnormality, secondary pyeloplasty, solitary kidn $ 3,802.50 3943 50500 50500 Nephrorrhaphy, suture of kidney wound or injury $ 3,298.50 3944 50520 50520 Closure of nephrocutaneous or pyelocutaneous fistula $ 2,853.00 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Closure of nephrovisceral fistula (eg, renocolic), including visceral 3945 50525 50525 repair; abdominal approach $ 3,438.00 Closure of nephrovisceral fistula (eg, renocolic), including visceral 3946 50526 50526 repair; thoracic approach $ 3,501.90 Symphysiotomy for horseshoe kidney with or without pyeloplasty 3947 50540 50540 and/or other plastic procedure, unilateral or bilateral (1 operation) $ 4,071.60 3948 50541 50541 Laparoscopy, surgical; ablation of renal cysts $ 2,673.90 Laparoscopy, surgical; ablation of renal mass lesion(s), including intraoperative ultrasound guidance and monitoring, when 3949 50542 50542 performed $ 2,662.34 3950 50543 50543 Laparoscopy, surgical; partial nephrectomy $ 3,268.75 3951 50544 50544 Laparoscopy, surgical; pyeloplasty $ 3,692.70 Laparoscopy, surgical; radical nephrectomy (includes removal of Gerota's fascia and surrounding fatty tissue, removal of regional 3952 50545 50545 lymph nodes, and adrenalectomy) $ 3,990.60 3953 50546 50546 Laparoscopy, surgical; nephrectomy, including partial ureterectomy $ 3,727.80 Laparoscopy, surgical; donor nephrectomy (including cold 3954 50547 50547 preservation), from living donor $ 4,762.80 3955 50548 50548 Laparoscopy, surgical; nephrectomy with total ureterectomy $ 5,098.50 3956 50549 50549 Unlisted laparoscopy procedure, renal Cost Renal endoscopy through established nephrostomy or pyelostomy, with or without irrigation, instillation, or ureteropyelography, 3957 50551 50551 exclusive of radiologic service; $ 777.60 Renal endoscopy through established nephrostomy or pyelostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with ureteral catheterization, with or 3958 50553 50553 without dilation of ureter $ 774.00 Renal endoscopy through established nephrostomy or pyelostomy, with or without irrigation, instillation, or ureteropyelography, 3959 50555 50555 exclusive of radiologic service; with biopsy $ 995.40 Renal endoscopy through established nephrostomy or pyelostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with fulguration and/or incision, with 3960 50557 50557 or without biopsy $ 1,017.90 Renal endoscopy through established nephrostomy or pyelostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with removal of foreign body or 3961 50561 50561 calculus $ 1,484.10 Renal endoscopy through established nephrostomy or pyelostomy, with or without irrigation, instillation, or ureteropyelography, 3962 50562 50562 exclusive of radiologic service; with resection of tumor $ 1,158.89 Renal endoscopy through nephrotomy or pyelotomy, with or without irrigation, instillation, or ureteropyelography, exclusive of 3963 50570 50570 radiologic service; $ 1,117.80 Renal endoscopy through nephrotomy or pyelotomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with ureteral catheterization, with or without 3964 50572 50572 dilation of ureter $ 2,024.10 Renal endoscopy through nephrotomy or pyelotomy, with or without irrigation, instillation, or ureteropyelography, exclusive of 3965 50574 50574 radiologic service; with biopsy $ 2,061.00 Renal endoscopy through nephrotomy or pyelotomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with endopyelotomy (includes cystoscopy, 3966 50575 50575 ureteroscopy, dilation of ureter and ureteral pelvic junction, inci $ 2,292.30 Renal endoscopy through nephrotomy or pyelotomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with fulguration and/or incision, with or without 3967 50576 50576 biopsy $ 1,647.90 Renal endoscopy through nephrotomy or pyelotomy, with or without irrigation, instillation, or ureteropyelography, exclusive of 3968 50580 50580 radiologic service; with removal of foreign body or calculus $ 2,277.00 3969 50590 50590 Lithotripsy, extracorporeal shock wave $ 3,424.50 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Ablation, 1 or more renal tumor(s), percutaneous, unilateral, 3970 50592 50592 radiofrequency $ 2,900.54 3971 50593 50593 Ablation, renal tumor(s), unilateral, percutaneous, cryotherapy $ 3,501.52 3972 50600 50600 Ureterotomy with exploration or drainage (separate procedure) $ 2,530.80 3973 50605 50605 Ureterotomy for insertion of indwelling stent, all types $ 2,730.60 3974 50610 50610 Ureterolithotomy; upper one-third of ureter $ 3,156.30 3975 50620 50620 Ureterolithotomy; middle one-third of ureter $ 3,373.20 3976 50630 50630 Ureterolithotomy; lower one-third of ureter $ 3,577.50 3977 50650 50650 Ureterectomy, with bladder cuff (separate procedure) $ 3,143.70 Ureterectomy, total, ectopic ureter, combination abdominal, 3978 50660 50660 vaginal and/or perineal approach $ 3,429.00 Injection procedure for ureterography or ureteropyelography 3979 50684 50684 through ureterostomy or indwelling ureteral catheter $ 153.90 Manometric studies through ureterostomy or indwelling ureteral 3980 50686 50686 catheter $ 120.60 Change of ureterostomy tube or externally accessible ureteral stent 3981 50688 50688 via ileal conduit $ 162.00 Injection procedure for visualization of ileal conduit and/or 3982 50690 50690 ureteropyelography, exclusive of radiologic service $ 143.10 3983 50700 50700 Ureteroplasty, plastic operation on ureter (eg, stricture) $ 2,943.00 Ureterolysis, with or without repositioning of ureter for 3984 50715 50715 retroperitoneal fibrosis $ 2,781.00 3985 50722 50722 Ureterolysis for ovarian vein syndrome $ 2,421.00 Ureterolysis for retrocaval ureter, with reanastomosis of upper 3986 50725 50725 urinary tract or vena cava $ 3,769.20 3987 50727 50727 Revision of urinary-cutaneous anastomosis (any type urostomy); $ 1,869.30 Revision of urinary-cutaneous anastomosis (any type urostomy); 3988 50728 50728 with repair of fascial defect and hernia $ 2,663.10 3989 50740 50740 Ureteropyelostomy, anastomosis of ureter and renal pelvis $ 3,374.10 3990 50750 50750 Ureterocalycostomy, anastomosis of ureter to renal calyx $ 3,605.40 3991 50760 50760 Ureteroureterostomy $ 3,244.50 Transureteroureterostomy, anastomosis of ureter to contralateral 3992 50770 50770 ureter $ 3,445.20 3993 50780 50780 Ureteroneocystostomy; anastomosis of single ureter to bladder $ 3,356.10 3994 50782 50782 Ureteroneocystostomy; anastomosis of duplicated ureter to bladder $ 3,492.90 3995 50783 50783 Ureteroneocystostomy; with extensive ureteral tailoring $ 3,594.60 3996 50785 50785 Ureteroneocystostomy; with vesico-psoas hitch or bladder flap $ 3,877.20 3997 50800 50800 Ureteroenterostomy, direct anastomosis of ureter to intestine $ 3,301.20 Ureterosigmoidostomy, with creation of sigmoid bladder and establishment of abdominal or perineal colostomy, including 3998 50810 50810 intestine anastomosis $ 4,635.00 3999 50815 50815 Ureterocolon conduit, including intestine anastomosis $ 4,789.80 Ureteroileal conduit (ileal bladder), including intestine anastomosis 4000 50820 50820 (Bricker operation) $ 5,985.00 Continent diversion, including intestine anastomosis using any segment of small and/or large intestine (Kock pouch or Camey 4001 50825 50825 enterocystoplasty) $ 5,768.10 Urinary undiversion (eg, taking down of ureteroileal conduit, ureterosigmoidostomy or ureteroenterostomy with 4002 50830 50830 ureteroureterostomy or ureteroneocystostomy) $ 5,469.30 Replacement of all or part of ureter by intestine segment, including 4003 50840 50840 intestine anastomosis $ 3,718.80 4004 50845 50845 Cutaneous appendico-vesicostomy $ 4,222.80 4005 50860 50860 Ureterostomy, transplantation of ureter to skin $ 2,807.10 4006 50900 50900 Ureterorrhaphy, suture of ureter (separate procedure) $ 2,652.30 4007 50920 50920 Closure of ureterocutaneous fistula $ 2,907.90 4008 50930 50930 Closure of ureterovisceral fistula (including visceral repair) $ 3,404.70 4009 50940 50940 Deligation of ureter $ 2,729.70 4010 50945 50945 Laparoscopy, surgical; ureterolithotomy $ 2,889.90 Laparoscopy, surgical; ureteroneocystostomy with cystoscopy and 4011 50947 50947 ureteral stent placement $ 4,301.10 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Laparoscopy, surgical; ureteroneocystostomy without cystoscopy 4012 50948 50948 and ureteral stent placement $ 3,933.00 4013 50949 50949 Unlisted laparoscopy procedure, ureter Cost Ureteral endoscopy through established ureterostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of 4014 50951 50951 radiologic service; $ 607.50 Ureteral endoscopy through established ureterostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with ureteral catheterization, with or without 4015 50953 50953 dilation of ureter $ 669.60 Ureteral endoscopy through established ureterostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of 4016 50955 50955 radiologic service; with biopsy $ 731.70 Ureteral endoscopy through established ureterostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with fulguration and/or incision, with or without 4017 50957 50957 biopsy $ 751.50 Ureteral endoscopy through established ureterostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of 4018 50961 50961 radiologic service; with removal of foreign body or calculus $ 978.30 Ureteral endoscopy through ureterotomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic 4019 50970 50970 service; $ 824.40 Ureteral endoscopy through ureterotomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with ureteral catheterization, with or without dilation of 4020 50972 50972 ureter $ 791.10 Ureteral endoscopy through ureterotomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic 4021 50974 50974 service; with biopsy $ 1,133.10 Ureteral endoscopy through ureterotomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic 4022 50976 50976 service; with fulguration and/or incision, with or without biopsy $ 1,040.40 Ureteral endoscopy through ureterotomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic 4023 50980 50980 service; with removal of foreign body or calculus $ 936.90 Cystotomy or cystostomy; with fulguration and/or insertion of 4024 51020 51020 radioactive material $ 1,968.30 Cystotomy or cystostomy; with cryosurgical destruction of 4025 51030 51030 intravesical lesion $ 1,923.30 4026 51040 51040 Cystostomy, cystotomy with drainage $ 1,717.20 Cystotomy, with insertion of ureteral catheter or stent (separate 4027 51045 51045 procedure) $ 1,909.80 Cystolithotomy, cystotomy with removal of calculus, without vesical 4028 51050 51050 neck resection $ 2,162.70 4029 51060 51060 Transvesical ureterolithotomy $ 2,581.20 Cystotomy, with calculus basket extraction and/or ultrasonic or 4030 51065 51065 electrohydraulic fragmentation of ureteral calculus $ 2,421.00 4031 51080 51080 Drainage of perivesical or prevesical space abscess $ 1,701.90 4032 51100 51100 Aspiration of bladder; by needle $ 178.51 4033 51101 51101 Aspiration of bladder; by trocar or intracatheter $ 271.08 4034 51102 51102 Aspiration of bladder; with insertion of suprapubic catheter $ 591.70 Excision of urachal cyst or sinus, with or without umbilical hernia 4035 51500 51500 repair $ 2,151.00 4036 51520 51520 Cystotomy; for simple excision of vesical neck (separate procedure) $ 2,277.00 Cystotomy; for excision of bladder diverticulum, single or multiple 4037 51525 51525 (separate procedure) $ 2,837.70 4038 51530 51530 Cystotomy; for excision of bladder tumor $ 2,457.00 4039 51535 51535 Cystotomy for excision, incision, or repair of ureterocele $ 2,631.60 4040 51550 51550 Cystectomy, partial; simple $ 2,953.80 Cystectomy, partial; complicated (eg, postradiation, previous 4041 51555 51555 surgery, difficult location) $ 3,749.40 Cystectomy, partial, with reimplantation of ureter(s) into bladder 4042 51565 51565 (ureteroneocystostomy) $ 4,053.60 4043 51570 51570 Cystectomy, complete; (separate procedure) $ 5,027.40 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Cystectomy, complete; with bilateral pelvic lymphadenectomy, 4044 51575 51575 including external iliac, hypogastric, and obturator nodes $ 6,365.70 Cystectomy, complete, with ureterosigmoidostomy or 4045 51580 51580 ureterocutaneous transplantations; $ 5,994.00 Cystectomy, complete, with ureterosigmoidostomy or ureterocutaneous transplantations; with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and 4046 51585 51585 obturator nodes $ 6,684.30 Cystectomy, complete, with ureteroileal conduit or sigmoid bladder, 4047 51590 51590 including intestine anastomosis; $ 7,559.10 Cystectomy, complete, with ureteroileal conduit or sigmoid bladder, including intestine anastomosis; with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and 4048 51595 51595 obturator nodes $ 8,475.30 Cystectomy, complete, with continent diversion, any open technique, using any segment of small and/or large intestine to 4049 51596 51596 construct neobladder $ 8,883.90 Pelvic exenteration, complete, for vesical, prostatic or urethral malignancy, with removal of bladder and ureteral transplantations, with or without hysterectomy and/or abdominoperineal resection 4050 51597 51597 of rectum and colon and colostomy, or any combination there $ 10,661.40 4051 51600 51600 Injection procedure for cystography or voiding urethrocystography $ 147.60 Injection procedure and placement of chain for contrast and/or 4052 51605 51605 chain urethrocystography $ 128.70 4053 51610 51610 Injection procedure for retrograde urethrocystography $ 185.40 4054 51700 51700 Bladder irrigation, simple, lavage and/or instillation $ 116.10 Insertion of non-indwelling bladder catheter (eg, straight 4055 51701 51701 catheterization for residual urine) $ 119.17 Insertion of temporary indwelling bladder catheter; simple (eg, 4056 51702 51702 Foley) $ 222.55 4057 51705 51705 Change of cystostomy tube; simple $ 105.30 4058 51710 51710 Change of cystostomy tube; complicated $ 319.50 Endoscopic injection of implant material into the submucosal 4059 51715 51715 tissues of the urethra and/or bladder neck $ 925.20 Bladder instillation of anticarcinogenic agent (including retention 4060 51720 51720 time) $ 173.70 4061 51725 51725 Simple cystometrogram (CMG) (eg, spinal manometer) $ 301.50 4062 51725-26 26 51725 Simple cystometrogram (CMG) (eg, spinal manometer) $ 253.80 4063 51725-TC TC 51725 Simple cystometrogram (CMG) (eg, spinal manometer) $ 187.19 4064 51726 51726 Complex cystometrogram (ie, calibrated electronic equipment); $ 369.00 4065 51726-26 26 51726 Complex cystometrogram (ie, calibrated electronic equipment); $ 369.00 4066 51726-TC TC 51726 Complex cystometrogram (ie, calibrated electronic equipment); $ 369.00 Complex cystometrogram (ie, calibrated electronic equipment); with urethral pressure profile studies (ie, urethral closure pressure 4067 51727 51727 profile), any technique $ 686.90 Complex cystometrogram (ie, calibrated electronic equipment); with voiding pressure studies (ie, bladder voiding pressure), any 4068 51728 51728 technique $ 686.02 Complex cystometrogram (ie, calibrated electronic equipment); with voiding pressure studies (ie, bladder voiding pressure) and urethral pressure profile studies (ie, urethral closure pressure 4069 51729 51729 profile), any technique $ 704.40 Simple uroflowmetry (UFR) (eg, stop-watch flow rate, mechanical 4070 51736 51736 uroflowmeter) $ 157.50 Simple uroflowmetry (UFR) (eg, stop-watch flow rate, mechanical 4071 51736-26 26 51736 uroflowmeter) $ 131.40 Simple uroflowmetry (UFR) (eg, stop-watch flow rate, mechanical 4072 51736-TC TC 51736 uroflowmeter) $ 77.28 4073 51741 51741 Complex uroflowmetry (eg, calibrated electronic equipment) $ 159.30 4074 51741-26 26 51741 Complex uroflowmetry (eg, calibrated electronic equipment) $ 134.10 4075 51741-TC TC 51741 Complex uroflowmetry (eg, calibrated electronic equipment) $ 79.98 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Electromyography studies (EMG) of anal or urethral sphincter, other 4076 51784 51784 than needle, any technique $ 236.70 Electromyography studies (EMG) of anal or urethral sphincter, other 4077 51784-26 26 51784 than needle, any technique $ 201.60 Electromyography studies (EMG) of anal or urethral sphincter, other 4078 51784-TC TC 51784 than needle, any technique $ 148.69 Needle electromyography studies (EMG) of anal or urethral 4079 51785 51785 sphincter, any technique $ 247.50 Needle electromyography studies (EMG) of anal or urethral 4080 51785-26 26 51785 sphincter, any technique $ 207.00 Needle electromyography studies (EMG) of anal or urethral 4081 51785-TC TC 51785 sphincter, any technique $ 175.98 Stimulus evoked response (eg, measurement of bulbocavernosus 4082 51792 51792 reflex latency time) $ 239.40 Stimulus evoked response (eg, measurement of bulbocavernosus 4083 51792-26 26 51792 reflex latency time) $ 202.50 Stimulus evoked response (eg, measurement of bulbocavernosus 4084 51792-TC TC 51792 reflex latency time) $ 181.58 Voiding pressure studies, intra-abdominal (ie, rectal, gastric, intraperitoneal) (List separately in addition to code for primary 4085 51797 51797 procedure) $ 247.50 Voiding pressure studies, intra-abdominal (ie, rectal, gastric, intraperitoneal) (List separately in addition to code for primary 4086 51797-26 26 51797 procedure) $ 207.00 Voiding pressure studies, intra-abdominal (ie, rectal, gastric, intraperitoneal) (List separately in addition to code for primary 4087 51797-TC TC 51797 procedure) $ 166.46 Measurement of post-voiding residual urine and/or bladder 4088 51798 51798 capacity by ultrasound, non-imaging $ 51.15 Cystoplasty or cystourethroplasty, plastic operation on bladder and/or vesical neck (anterior Y-plasty, vesical fundus resection), any procedure, with or without wedge resection of posterior vesical 4089 51800 51800 neck $ 2,849.40 Cystourethroplasty with unilateral or bilateral 4090 51820 51820 ureteroneocystostomy $ 3,780.00 Anterior vesicourethropexy, or urethropexy (eg, Marshall-Marchetti- 4091 51840 51840 Krantz, Burch); simple $ 2,495.70 Anterior vesicourethropexy, or urethropexy (eg, Marshall-Marchetti- 4092 51841 51841 Krantz, Burch); complicated (eg, secondary repair) $ 2,781.00 Abdomino-vaginal vesical neck suspension, with or without 4093 51845 51845 endoscopic control (eg, Stamey, Raz, modified Pereyra) $ 2,781.00 4094 51860 51860 Cystorrhaphy, suture of bladder wound, injury or rupture; simple $ 2,200.50 Cystorrhaphy, suture of bladder wound, injury or rupture; 4095 51865 51865 complicated $ 2,982.60 4096 51880 51880 Closure of cystostomy (separate procedure) $ 1,339.20 4097 51900 51900 Closure of vesicovaginal fistula, abdominal approach $ 3,454.20 4098 51920 51920 Closure of vesicouterine fistula; $ 2,559.60 4099 51925 51925 Closure of vesicouterine fistula; with hysterectomy $ 3,301.20 4100 51940 51940 Closure, exstrophy of bladder $ 4,738.50 4101 51960 51960 Enterocystoplasty, including intestinal anastomosis $ 4,652.10 4102 51980 51980 Cutaneous vesicostomy $ 2,439.00 4103 51990 51990 Laparoscopy, surgical; urethral suspension for stress incontinence $ 2,447.10 Laparoscopy, surgical; sling operation for stress incontinence (eg, 4104 51992 51992 fascia or synthetic) $ 2,637.00 4105 51999 51999 Unlisted laparoscopy procedure, bladder Cost 4106 52000 52000 Cystourethroscopy (separate procedure) $ 405.34 Cystourethroscopy with irrigation and evacuation of multiple 4107 52001 52001 obstructing clots $ 676.66 Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic 4108 52005 52005 service; $ 579.60 Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic 4109 52007 52007 service; with brush biopsy of ureter and/or renal pelvis $ 640.80 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Cystourethroscopy, with ejaculatory duct catheterization, with or without irrigation, instillation, or duct radiography, exclusive of 4110 52010 52010 radiologic service $ 576.00 4111 52204 52204 Cystourethroscopy, with biopsy(s) $ 595.75 Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) of trigone, bladder neck, prostatic fossa, urethra, or 4112 52214 52214 periurethral glands $ 769.50 Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) or treatment of MINOR (less than 0.5 cm) lesion(s) with or 4113 52224 52224 without biopsy $ 747.00 Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; SMALL bladder tumor(s) (0.5 up to 2.0 4114 52234 52234 cm) $ 1,017.90 Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; MEDIUM bladder tumor(s) (2.0 to 5.0 4115 52235 52235 cm) $ 1,761.30 Cystourethroscopy, with fulguration (including cryosurgery or laser 4116 52240 52240 surgery) and/or resection of; LARGE bladder tumor(s) $ 2,543.40 Cystourethroscopy with insertion of radioactive substance, with or 4117 52250 52250 without biopsy or fulguration $ 849.60 Cystourethroscopy, with dilation of bladder for interstitial cystitis; 4118 52260 52260 general or conduction (spinal) anesthesia $ 592.18 Cystourethroscopy, with dilation of bladder for interstitial cystitis; 4119 52265 52265 local anesthesia $ 540.90 4120 52270 52270 Cystourethroscopy, with internal urethrotomy; female $ 819.00 4121 52275 52275 Cystourethroscopy, with internal urethrotomy; male $ 882.00 4122 52276 52276 Cystourethroscopy with direct vision internal urethrotomy $ 1,261.80 Cystourethroscopy, with resection of external sphincter 4123 52277 52277 (sphincterotomy) $ 1,206.90 Cystourethroscopy, with calibration and/or dilation of urethral stricture or stenosis, with or without meatotomy, with or without 4124 52281 52281 injection procedure for cystography, male or female $ 580.93 4125 52282 52282 Cystourethroscopy, with insertion of permanent urethral stent $ 1,030.50 4126 52283 52283 Cystourethroscopy, with steroid injection into stricture $ 563.40 Cystourethroscopy for treatment of the female urethral syndrome with any or all of the following: urethral meatotomy, urethral dilation, internal urethrotomy, lysis of urethrovaginal septal fibrosis, 4127 52285 52285 lateral incisions of the bladder neck, and fulguration $ 686.56 4128 52290 52290 Cystourethroscopy; with ureteral meatotomy, unilateral or bilateral $ 737.10 Cystourethroscopy; with resection or fulguration of orthotopic 4129 52300 52300 ureterocele(s), unilateral or bilateral $ 975.60 Cystourethroscopy; with resection or fulguration of ectopic 4130 52301 52301 ureterocele(s), unilateral or bilateral $ 1,035.00 Cystourethroscopy; with incision or resection of orifice of bladder 4131 52305 52305 diverticulum, single or multiple $ 1,019.70 Cystourethroscopy, with removal of foreign body, calculus, or 4132 52310 52310 ureteral stent from urethra or bladder (separate procedure); simple $ 751.50 Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder (separate procedure); 4133 52315 52315 complicated $ 1,328.40 Litholapaxy: crushing or fragmentation of calculus by any means in bladder and removal of fragments; simple or small (less than 2.5 4134 52317 52317 cm) $ 1,377.90 Litholapaxy: crushing or fragmentation of calculus by any means in bladder and removal of fragments; complicated or large (over 2.5 4135 52318 52318 cm) $ 1,948.50 Cystourethroscopy (including ureteral catheterization); with 4136 52320 52320 removal of ureteral calculus $ 1,344.60 Cystourethroscopy (including ureteral catheterization); with fragmentation of ureteral calculus (eg, ultrasonic or electro- 4137 52325 52325 hydraulic technique) $ 1,559.70 Cystourethroscopy (including ureteral catheterization); with 4138 52327 52327 subureteric injection of implant material $ 1,081.80 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Cystourethroscopy (including ureteral catheterization); with 4139 52330 52330 manipulation, without removal of ureteral calculus $ 953.10 Cystourethroscopy, with insertion of indwelling ureteral stent (eg, 4140 52332 52332 Gibbons or double-J type) $ 924.30 Cystourethroscopy with insertion of ureteral guide wire through 4141 52334 52334 kidney to establish a percutaneous nephrostomy, retrograde $ 875.70 Cystourethroscopy; with treatment of ureteral stricture (eg, balloon 4142 52341 52341 dilation, laser, electrocautery, and incision) $ 1,350.00 Cystourethroscopy; with treatment of ureteropelvic junction 4143 52342 52342 stricture (eg, balloon dilation, laser, electrocautery, and incision) $ 1,461.60 Cystourethroscopy; with treatment of intra-renal stricture (eg, 4144 52343 52343 balloon dilation, laser, electrocautery, and incision) $ 1,619.10 Cystourethroscopy with ureteroscopy; with treatment of ureteral 4145 52344 52344 stricture (eg, balloon dilation, laser, electrocautery, and incision) $ 1,776.60 Cystourethroscopy with ureteroscopy; with treatment of ureteropelvic junction stricture (eg, balloon dilation, laser, 4146 52345 52345 electrocautery, and incision) $ 1,845.00 Cystourethroscopy with ureteroscopy; with treatment of intra-renal 4147 52346 52346 stricture (eg, balloon dilation, laser, electrocautery, and incision) $ 2,074.50 Cystourethroscopy, with ureteroscopy and/or pyeloscopy; 4148 52351 52351 diagnostic $ 1,377.90 Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with removal or manipulation of calculus (ureteral catheterization is 4149 52352 52352 included) $ 1,629.42 Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with 4150 52353 52353 lithotripsy (ureteral catheterization is included) $ 2,027.72 Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with 4151 52354 52354 biopsy and/or fulguration of ureteral or renal pelvic lesion $ 1,728.00 Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with 4152 52355 52355 resection of ureteral or renal pelvic tumor $ 2,030.40 Cystourethroscopy with incision, fulguration, or resection of congenital posterior urethral valves, or congenital obstructive 4153 52400 52400 hypertrophic mucosal folds $ 2,414.70 Cystourethroscopy with transurethral resection or incision of 4154 52402 52402 ejaculatory ducts $ 641.48 4155 52450 52450 Transurethral incision of prostate $ 1,562.40 4156 52500 52500 Transurethral resection of bladder neck (separate procedure) $ 1,719.90 Transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal 4157 52601 52601 urethrotomy are included) $ 2,701.80 Transurethral resection; residual or regrowth of obstructive prostate tissue including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral 4158 52630 52630 calibration and/or dilation, and internal urethrotomy are included) $ 2,482.20 4159 52640 52640 Transurethral resection; of postoperative bladder neck contracture $ 2,140.20 Laser coagulation of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are 4160 52647 52647 included if performed) $ 2,169.90 Laser vaporization of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, internal urethrotomy and 4161 52648 52648 transurethral resection of prostate are included if performed) $ 2,472.30 Laser enucleation of the prostate with morcellation, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, 4162 52649 52649 internal urethrotomy and transurethral resection of prostate are inc $ 2,156.95 4163 52700 52700 Transurethral drainage of prostatic abscess $ 1,305.00 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Urethrotomy or urethrostomy, external (separate procedure); 4164 53000 53000 pendulous urethra $ 414.90 Urethrotomy or urethrostomy, external (separate procedure); 4165 53010 53010 perineal urethra, external $ 914.40 4166 53020 53020 Meatotomy, cutting of meatus (separate procedure); except infant $ 583.86 4167 53025 53025 Meatotomy, cutting of meatus (separate procedure); infant $ 236.70 4168 53040 53040 Drainage of deep periurethral abscess $ 692.10 4169 53060 53060 Drainage of Skene's gland abscess or cyst $ 322.20 Drainage of perineal urinary extravasation; uncomplicated (separate 4170 53080 53080 procedure) $ 761.40 4171 53085 53085 Drainage of perineal urinary extravasation; complicated $ 1,825.20 4172 53200 53200 Biopsy of urethra $ 473.40 4173 53210 53210 Urethrectomy, total, including cystostomy; female $ 2,104.20 4174 53215 53215 Urethrectomy, total, including cystostomy; male $ 2,781.00 4175 53220 53220 Excision or fulguration of carcinoma of urethra $ 1,617.30 4176 53230 53230 Excision of urethral diverticulum (separate procedure); female $ 2,214.90 4177 53235 53235 Excision of urethral diverticulum (separate procedure); male $ 2,060.10 4178 53240 53240 Marsupialization of urethral diverticulum, male or female $ 852.30 4179 53250 53250 Excision of bulbourethral gland (Cowper's gland) $ 1,313.10 4180 53260 53260 Excision or fulguration; urethral polyp(s), distal urethra $ 520.20 4181 53265 53265 Excision or fulguration; urethral caruncle $ 530.10 4182 53270 53270 Excision or fulguration; Skene's glands $ 564.30 4183 53275 53275 Excision or fulguration; urethral prolapse $ 622.80 Urethroplasty; first stage, for fistula, diverticulum, or stricture (eg, 4184 53400 53400 Johannsen type) $ 1,926.90 Urethroplasty; second stage (formation of urethra), including 4185 53405 53405 urinary diversion $ 2,250.90 4186 53410 53410 Urethroplasty, 1-stage reconstruction of male anterior urethra $ 2,686.50 Urethroplasty, transpubic or perineal, 1-stage, for reconstruction or 4187 53415 53415 repair of prostatic or membranous urethra $ 3,239.10 Urethroplasty, 2-stage reconstruction or repair of prostatic or 4188 53420 53420 membranous urethra; first stage $ 2,888.10 Urethroplasty, 2-stage reconstruction or repair of prostatic or 4189 53425 53425 membranous urethra; second stage $ 2,995.20 4190 53430 53430 Urethroplasty, reconstruction of female urethra $ 2,496.60 Urethroplasty with tubularization of posterior urethra and/or lower 4191 53431 53431 bladder for incontinence (eg, Tenago, Leadbetter procedure) $ 2,797.78 Sling operation for correction of male urinary incontinence (eg, 4192 53440 53440 fascia or synthetic) $ 2,991.60 Removal or revision of sling for male urinary incontinence (eg, fascia 4193 53442 53442 or synthetic) $ 1,171.80 4194 53444 53444 Insertion of tandem cuff (dual cuff) $ 2,081.89 Insertion of inflatable urethral/bladder neck sphincter, including 4195 53445 53445 placement of pump, reservoir, and cuff $ 5,150.70 Removal of inflatable urethral/bladder neck sphincter, including 4196 53446 53446 pump, reservoir, and cuff $ 1,825.77 Removal and replacement of inflatable urethral/bladder neck sphincter including pump, reservoir, and cuff at the same operative 4197 53447 53447 session $ 2,507.40 Removal and replacement of inflatable urethral/bladder neck sphincter including pump, reservoir, and cuff through an infected field at the same operative session including irrigation and 4198 53448 53448 debridement of infected tissue $ 3,364.59 Repair of inflatable urethral/bladder neck sphincter, including 4199 53449 53449 pump, reservoir, and cuff $ 1,864.80 4200 53450 53450 Urethromeatoplasty, with mucosal advancement $ 720.90 Urethromeatoplasty, with partial excision of distal urethral segment 4201 53460 53460 (Richardson type procedure) $ 726.30 Urethrolysis, transvaginal, secondary, open, including 4202 53500 53500 cystourethroscopy (eg, postsurgical obstruction, scarring) $ 1,914.08 4203 53502 53502 Urethrorrhaphy, suture of urethral wound or injury, female $ 1,486.80 4204 53505 53505 Urethrorrhaphy, suture of urethral wound or injury; penile $ 1,532.70 4205 53510 53510 Urethrorrhaphy, suture of urethral wound or injury; perineal $ 1,917.90 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Urethrorrhaphy, suture of urethral wound or injury; 4206 53515 53515 prostatomembranous $ 2,654.10 Closure of urethrostomy or urethrocutaneous fistula, male 4207 53520 53520 (separate procedure) $ 1,213.20 Dilation of urethral stricture by passage of sound or urethral dilator, 4208 53600 53600 male; initial $ 154.80 Dilation of urethral stricture by passage of sound or urethral dilator, 4209 53601 53601 male; subsequent $ 149.40 Dilation of urethral stricture or vesical neck by passage of sound or 4210 53605 53605 urethral dilator, male, general or conduction (spinal) anesthesia $ 230.40 Dilation of urethral stricture by passage of filiform and follower, 4211 53620 53620 male; initial $ 218.70 Dilation of urethral stricture by passage of filiform and follower, 4212 53621 53621 male; subsequent $ 137.70 Dilation of female urethra including suppository and/or instillation; 4213 53660 53660 initial $ 114.30 Dilation of female urethra including suppository and/or instillation; 4214 53661 53661 subsequent $ 120.60 4215 53665 53665 Dilation of female urethra, general or conduction (spinal) anesthesia $ 215.10 Transurethral destruction of prostate tissue; by microwave 4216 53850 53850 thermotherapy $ 1,637.10 Transurethral destruction of prostate tissue; by radiofrequency 4217 53852 53852 thermotherapy $ 1,448.10 Insertion of a temporary prostatic urethral stent, including urethral 4218 53855 53855 measurement $ 1,749.79 4219 53899 53899 Unlisted procedure, urinary system Cost 4220 54000 54000 Slitting of prepuce, dorsal or lateral (separate procedure); newborn $ 164.70 Slitting of prepuce, dorsal or lateral (separate procedure); except 4221 54001 54001 newborn $ 314.10 4222 54015 54015 Incision and drainage of penis, deep $ 437.40 Destruction of lesion(s), penis (eg, condyloma, papilloma, 4223 54050 54050 molluscum contagiosum, herpetic vesicle), simple; chemical $ 134.50 Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; 4224 54055 54055 electrodesiccation $ 271.58 Destruction of lesion(s), penis (eg, condyloma, papilloma, 4225 54056 54056 molluscum contagiosum, herpetic vesicle), simple; cryosurgery $ 239.88 Destruction of lesion(s), penis (eg, condyloma, papilloma, 4226 54057 54057 molluscum contagiosum, herpetic vesicle), simple; laser surgery $ 601.20 Destruction of lesion(s), penis (eg, condyloma, papilloma, 4227 54060 54060 molluscum contagiosum, herpetic vesicle), simple; surgical excision $ 481.62 Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), extensive (eg, laser 4228 54065 54065 surgery, electrosurgery, cryosurgery, chemosurgery) $ 906.65 4229 54100 54100 Biopsy of penis; (separate procedure) $ 266.40 4230 54105 54105 Biopsy of penis; deep structures $ 447.30 4231 54110 54110 Excision of penile plaque (Peyronie disease); $ 1,395.90 Excision of penile plaque (Peyronie disease); with graft to 5 cm in 4232 54111 54111 length $ 2,362.50 Excision of penile plaque (Peyronie disease); with graft greater than 4233 54112 54112 5 cm in length $ 2,682.90 4234 54115 54115 Removal foreign body from deep penile tissue (eg, plastic implant) $ 1,062.00 4235 54120 54120 Amputation of penis; partial $ 2,043.00 4236 54125 54125 Amputation of penis; complete $ 2,709.00 Amputation of penis, radical; with bilateral inguinofemoral 4237 54130 54130 lymphadenectomy $ 3,754.80 Amputation of penis, radical; in continuity with bilateral pelvic lymphadenectomy, including external iliac, hypogastric and 4238 54135 54135 obturator nodes $ 4,963.50 Circumcision, using clamp or other device with regional dorsal 4239 54150 54150 penile or ring block $ 272.00 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Circumcision, surgical excision other than clamp, device, or dorsal 4240 54160 54160 slit; neonate (28 days of age or less) $ 403.94 Circumcision, surgical excision other than clamp, device, or dorsal 4241 54161 54161 slit; older than 28 days of age $ 860.79 4242 54162 54162 Lysis or excision of penile post-circumcision adhesions $ 426.82 4243 54163 54163 Repair incomplete circumcision $ 415.19 4244 54164 54164 Frenulotomy of penis $ 409.15 4245 54200 54200 Injection procedure for Peyronie disease; $ 129.60 Injection procedure for Peyronie disease;

with surgical exposure of 4246 54205 54205 plaque $ 1,035.00 4247 54220 54220 Irrigation of corpora cavernosa for priapism $ 500.40 4248 54230 54230 Injection procedure for corpora cavernosography $ 298.80 Dynamic cavernosometry, including intracavernosal injection of 4249 54231 54231 vasoactive drugs (eg, papaverine, phentolamine) $ 468.90 Injection of corpora cavernosa with pharmacologic agent(s) (eg, 4250 54235 54235 papaverine, phentolamine) $ 206.10 4251 54240 54240 Penile plethysmography $ 298.80 4252 54240-26 26 54240 Penile plethysmography $ 250.20 4253 54240-TC TC 54240 Penile plethysmography $ 114.40 4254 54250 54250 Nocturnal penile tumescence and/or rigidity test $ 354.60 4255 54250-26 26 54250 Nocturnal penile tumescence and/or rigidity test $ 300.60 4256 54250-TC TC 54250 Nocturnal penile tumescence and/or rigidity test $ 36.49 Plastic operation of penis for straightening of chordee (eg, 4257 54300 54300 hypospadias), with or without mobilization of urethra $ 1,865.70 Plastic operation on penis for correction of chordee or for first stage hypospadias repair with or without transplantation of prepuce 4258 54304 54304 and/or skin flaps $ 2,242.80 Urethroplasty for second stage hypospadias repair (including 4259 54308 54308 urinary diversion); less than 3 cm $ 2,268.00 Urethroplasty for second stage hypospadias repair (including 4260 54312 54312 urinary diversion); greater than 3 cm $ 2,523.60 Urethroplasty for second stage hypospadias repair (including urinary diversion) with free skin graft obtained from site other than 4261 54316 54316 genitalia $ 3,016.80 Urethroplasty for third stage hypospadias repair to release penis 4262 54318 54318 from scrotum (eg, third stage Cecil repair) $ 1,798.20 1-stage distal hypospadias repair (with or without chordee or 4263 54322 54322 circumcision); with simple meatal advancement (eg, Magpi, V-flap) $ 2,155.50 1-stage distal hypospadias repair (with or without chordee or circumcision); with urethroplasty by local skin flaps (eg, flip-flap, 4264 54324 54324 prepucial flap) $ 2,382.30 1-stage distal hypospadias repair (with or without chordee or circumcision); with urethroplasty by local skin flaps and mobilization 4265 54326 54326 of urethra $ 2,894.40 1-stage distal hypospadias repair (with or without chordee or circumcision); with extensive dissection to correct chordee and urethroplasty with local skin flaps, skin graft patch, and/or island 4266 54328 54328 flap $ 3,250.80 1-stage proximal penile or penoscrotal hypospadias repair requiring extensive dissection to correct chordee and urethroplasty by use of 4267 54332 54332 skin graft tube and/or island flap $ 3,355.20 1-stage perineal hypospadias repair requiring extensive dissection to correct chordee and urethroplasty by use of skin graft tube 4268 54336 54336 and/or island flap $ 3,821.40 Repair of hypospadias complications (ie, fistula, stricture, 4269 54340 54340 diverticula); by closure, incision, or excision, simple $ 1,658.70 Repair of hypospadias complications (ie, fistula, stricture, diverticula); requiring mobilization of skin flaps and urethroplasty 4270 54344 54344 with flap or patch graft $ 2,642.40 Repair of hypospadias complications (ie, fistula, stricture, diverticula); requiring extensive dissection and urethroplasty with 4271 54348 54348 flap, patch or tubed graft (includes urinary diversion) $ 2,793.60 Repair of hypospadias cripple requiring extensive dissection and excision of previously constructed structures including re-release of chordee and reconstruction of urethra and penis by use of local skin 4272 54352 54352 as grafts and island flaps and skin brought in as f $ 4,481.10 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price 4273 54360 54360 Plastic operation on penis to correct angulation $ 2,171.70 4274 54380 54380 Plastic operation on penis for epispadias distal to external sphincter; $ 1,931.40 Plastic operation on penis for epispadias distal to external sphincter; 4275 54385 54385 with incontinence $ 2,791.80 Plastic operation on penis for epispadias distal to external sphincter; 4276 54390 54390 with exstrophy of bladder $ 3,728.70 4277 54400 54400 Insertion of penile prosthesis; non-inflatable (semi-rigid) $ 2,731.50 4278 54401 54401 Insertion of penile prosthesis; inflatable (self-contained) $ 3,038.40 Insertion of multi-component, inflatable penile prosthesis, including 4279 54405 54405 placement of pump, cylinders, and reservoir $ 4,616.10 Removal of all components of a multi-component, inflatable penile 4280 54406 54406 prosthesis without replacement of prosthesis $ 1,880.16 Repair of component(s) of a multi-component, inflatable penile 4281 54408 54408 prosthesis $ 1,921.58 Removal and replacement of all component(s) of a multi- component, inflatable penile prosthesis at the same operative 4282 54410 54410 session $ 2,100.99 Removal and replacement of all components of a multi-component inflatable penile prosthesis through an infected field at the same operative session, including irrigation and debridement of infected 4283 54411 54411 tissue $ 2,627.25 Removal of non-inflatable (semi-rigid) or inflatable (self-contained) 4284 54415 54415 penile prosthesis, without replacement of prosthesis $ 1,371.75 Removal and replacement of non-inflatable (semi-rigid) or inflatable 4285 54416 54416 (self-contained) penile prosthesis at the same operative session $ 1,604.70 Removal and replacement of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis through an infected field at the same operative session, including irrigation and debridement of 4286 54417 54417 infected tissue $ 2,244.96 Corpora cavernosa-saphenous vein shunt (priapism operation), 4287 54420 54420 unilateral or bilateral $ 2,497.50 Corpora cavernosa-corpus spongiosum shunt (priapism operation), 4288 54430 54430 unilateral or bilateral $ 2,107.80 Corpora cavernosa-glans penis fistulization (eg, biopsy needle, 4289 54435 54435 Winter procedure, rongeur, or punch) for priapism $ 1,043.10 4290 54440 54440 Plastic operation of penis for injury $ 2,582.10 Foreskin manipulation including lysis of preputial adhesions and 4291 54450 54450 stretching $ 306.90 4292 54500 54500 Biopsy of testis, needle (separate procedure) $ 216.90 4293 54505 54505 Biopsy of testis, incisional (separate procedure) $ 644.40 4294 54512 54512 Excision of extraparenchymal lesion of testis $ 1,581.30 Orchiectomy, simple (including subcapsular), with or without 4295 54520 54520 testicular prosthesis, scrotal or inguinal approach $ 1,175.40 4296 54522 54522 Orchiectomy, partial $ 1,944.00 4297 54530 54530 Orchiectomy, radical, for tumor; inguinal approach $ 1,833.30 4298 54535 54535 Orchiectomy, radical, for tumor; with abdominal exploration $ 2,160.00 4299 54550 54550 Exploration for undescended testis (inguinal or scrotal area) $ 1,594.80 4300 54560 54560 Exploration for undescended testis with abdominal exploration $ 1,918.80 Reduction of torsion of testis, surgical, with or without fixation of 4301 54600 54600 contralateral testis $ 1,393.65 4302 54620 54620 Fixation of contralateral testis (separate procedure) $ 835.20 4303 54640 54640 Orchiopexy, inguinal approach, with or without hernia repair $ 1,790.10 Orchiopexy, abdominal approach, for intra-abdominal testis (eg, 4304 54650 54650 Fowler-Stephens) $ 2,026.80 4305 54660 54660 Insertion of testicular prosthesis (separate procedure) $ 810.90 4306 54670 54670 Suture or repair of testicular injury $ 1,364.40 Transplantation of testis(es) to thigh (because of scrotal 4307 54680 54680 destruction) $ 1,658.70 4308 54690 54690 Laparoscopy, surgical; orchiectomy $ 1,737.90 4309 54692 54692 Laparoscopy, surgical; orchiopexy for intra-abdominal testis $ 1,801.80 4310 54699 54699 Unlisted laparoscopy procedure, testis Cost Incision and drainage of epididymis, testis and/or scrotal space (eg, 4311 54700 54700 abscess or hematoma) $ 458.10 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price 4312 54800 54800 Biopsy of epididymis, needle $ 265.50 4313 54830 54830 Excision of local lesion of epididymis $ 927.90 4314 54840 54840 Excision of spermatocele, with or without epididymectomy $ 1,296.00 4315 54860 54860 Epididymectomy; unilateral $ 1,228.50 4316 54861 54861 Epididymectomy; bilateral $ 1,728.00 4317 54865 54865 Exploration of epididymis, with or without biopsy $ 355.87 Epididymovasostomy, anastomosis of epididymis to vas deferens; 4318 54900 54900 unilateral $ 2,325.60 Epididymovasostomy, anastomosis of epididymis to vas deferens; 4319 54901 54901 bilateral $ 3,038.40 Puncture aspiration of hydrocele, tunica vaginalis, with or without 4320 55000 55000 injection of medication $ 195.30 4321 55040 55040 Excision of hydrocele; unilateral $ 1,405.80 4322 55041 55041 Excision of hydrocele; bilateral $ 2,132.10 4323 55060 55060 Repair of tunica vaginalis hydrocele (Bottle type) $ 1,287.90 4324 55100 55100 Drainage of scrotal wall abscess $ 311.40 4325 55110 55110 Scrotal exploration $ 1,147.50 4326 55120 55120 Removal of foreign body in scrotum $ 633.60 4327 55150 55150 Resection of scrotum $ 1,387.80 4328 55175 55175 Scrotoplasty; simple $ 1,220.40 4329 55180 55180 Scrotoplasty; complicated $ 2,162.70 Vasotomy, cannulization with or without incision of vas, unilateral 4330 55200 55200 or bilateral (separate procedure) $ 648.90 Vasectomy, unilateral or bilateral (separate procedure), including 4331 55250 55250 postoperative semen examination(s) $ 699.30 Vasotomy for vasograms, seminal vesiculograms, or 4332 55300 55300 epididymograms, unilateral or bilateral $ 647.10 4333 55400 55400 Vasovasostomy, vasovasorrhaphy $ 2,832.30 Ligation (percutaneous) of vas deferens, unilateral or bilateral 4334 55450 55450 (separate procedure) $ 628.20 Excision of hydrocele of spermatic cord, unilateral (separate 4335 55500 55500 procedure) $ 1,228.50 4336 55520 55520 Excision of lesion of spermatic cord (separate procedure) $ 1,085.40 Excision of varicocele or ligation of spermatic veins for varicocele; 4337 55530 55530 (separate procedure) $ 1,527.30 Excision of varicocele or ligation of spermatic veins for varicocele; 4338 55535 55535 abdominal approach $ 1,635.30 Excision of varicocele or ligation of spermatic veins for varicocele; 4339 55540 55540 with hernia repair $ 1,801.80 4340 55550 55550 Laparoscopy, surgical, with ligation of spermatic veins for varicocele $ 1,717.20 4341 55559 55559 Unlisted laparoscopy procedure, spermatic cord Cost 4342 55600 55600 Vesiculotomy; $ 1,231.20 4343 55605 55605 Vesiculotomy; complicated $ 1,653.30 4344 55650 55650 Vesiculectomy, any approach $ 2,868.30 4345 55680 55680 Excision of Mullerian duct cyst $ 2,533.50 4346 55700 55700 Biopsy, prostate; needle or punch, single or multiple, any approach $ 395.58 4347 55705 55705 Biopsy, prostate; incisional, any approach $ 1,171.80 Biopsies, prostate, needle, transperineal, stereotactic template 4348 55706 55706 guided saturation sampling, including imaging guidance $ 1,380.90 Prostatotomy, external drainage of prostatic abscess, any approach; 4349 55720 55720 simple $ 1,424.70 Prostatotomy, external drainage of prostatic abscess, any approach; 4350 55725 55725 complicated $ 1,768.50 Prostatectomy, perineal, subtotal (including control of postoperative bleeding, vasectomy, meatotomy, urethral calibration 4351 55801 55801 and/or dilation, and internal urethrotomy) $ 2,970.00 4352 55810 55810 Prostatectomy, perineal radical; $ 3,842.10 Prostatectomy, perineal radical; with lymph node biopsy(s) (limited 4353 55812 55812 pelvic lymphadenectomy) $ 4,482.00 Prostatectomy, perineal radical; with bilateral pelvic lymphadenectomy, including external iliac, hypogastric and 4354 55815 55815 obturator nodes $ 6,071.40 Prostatectomy (including control of postoperative bleeding, vasectomy, meatotomy, urethral calibration and/or dilation, and 4355 55821 55821 internal urethrotomy); suprapubic, subtotal, 1 or 2 stages $ 3,183.30 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Prostatectomy (including control of postoperative bleeding, vasectomy, meatotomy, urethral calibration and/or dilation, and 4356 55831 55831 internal urethrotomy); retropubic, subtotal $ 3,345.30 4357 55840 55840 Prostatectomy, retropubic radical, with or without nerve sparing; $ 3,969.90 Prostatectomy, retropubic radical, with or without nerve sparing; 4358 55842 55842 with lymph node biopsy(s) (limited pelvic lymphadenectomy) $ 4,228.20 Prostatectomy, retropubic radical, with or without nerve sparing; with bilateral pelvic lymphadenectomy, including external iliac, 4359 55845 55845 hypogastric, and obturator nodes $ 5,271.39 Exposure of prostate, any approach, for insertion of radioactive 4360 55860 55860 substance; $ 2,182.50 Exposure of prostate, any approach, for insertion of radioactive substance; with lymph node biopsy(s) (limited pelvic 4361 55862 55862 lymphadenectomy) $ 3,091.50 Exposure of prostate, any approach, for insertion of radioactive substance; with bilateral pelvic lymphadenectomy, including 4362 55865 55865 external iliac, hypogastric and obturator nodes $ 3,793.50 Laparoscopy, surgical prostatectomy, retropubic radical, including 4363 55866 55866 nerve sparing, includes robotic assistance, when performed $ 4,611.87 4364 55870 55870 Electroejaculation $ 236.70 Cryosurgical ablation of the prostate (includes ultrasonic guidance 4365 55873 55873 and monitoring) $ 2,685.60 Transperineal placement of needles or catheters into prostate for 4366 55875 55875 interstitial radioelement application, with or without cystoscopy $ 1,796.65 Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), prostate (via needle, any 4367 55876 55876 approach), single or multiple $ 323.66 4368 55899 55899 Unlisted procedure, male genital system Cost Placement of needles or catheters into pelvic organs and/or genitalia (except prostate) for subsequent interstitial radioelement 4369 55920 55920 application $ 1,072.06 4370 55970 55970 Intersex surgery; male to female $ - 4371 55980 55980 Intersex surgery; female to male $ - 4372 56405 56405 Incision and drainage of vulva or perineal abscess $ 259.20 4373 56420 56420 Incision and drainage of Bartholin's gland abscess $ 243.90 4374 56440 56440 Marsupialization of Bartholin's gland cyst $ 718.20 4375 56441 56441 Lysis of labial adhesions $ 456.30 4376 56442 56442 Hymenotomy, simple incision $ 126.23 Destruction of lesion(s), vulva; simple (eg, laser surgery, 4377 56501 56501 electrosurgery, cryosurgery, chemosurgery) $ 259.47 Destruction of lesion(s), vulva; extensive (eg, laser surgery, 4378 56515 56515 electrosurgery, cryosurgery, chemosurgery) $ 850.10 4379 56605 56605 Biopsy of vulva or perineum (separate procedure); 1 lesion $ 199.48 Biopsy of vulva or perineum (separate procedure); each separate additional lesion (List separately in addition to code for primary 4380 56606 56606 procedure) $ 102.60 4381 56620 56620 Vulvectomy simple; partial $ 2,186.10 4382 56625 56625 Vulvectomy simple; complete $ 2,652.30 4383 56630 56630 Vulvectomy, radical, partial; $ 3,249.90 Vulvectomy, radical, partial; with unilateral inguinofemoral 4384 56631 56631 lymphadenectomy $ 4,042.80 Vulvectomy, radical, partial; with bilateral inguinofemoral 4385 56632 56632 lymphadenectomy $ 4,846.50 4386 56633 56633 Vulvectomy, radical, complete; $ 4,097.70 Vulvectomy, radical, complete; with unilateral inguinofemoral 4387 56634 56634 lymphadenectomy $ 4,748.40 Vulvectomy, radical, complete; with bilateral inguinofemoral 4388 56637 56637 lymphadenectomy $ 5,682.60 Vulvectomy, radical, complete, with inguinofemoral, iliac, and pelvic 4389 56640 56640 lymphadenectomy $ 5,745.60 4390 56700 56700 Partial hymenectomy or revision of hymenal ring $ 637.20 4391 56740 56740 Excision of Bartholin's gland or cyst $ 920.70 4392 56800 56800 Plastic repair of introitus $ 898.20 4393 56805 56805 Clitoroplasty for intersex state $ 2,296.80 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Perineoplasty, repair of perineum, nonobstetrical (separate 4394 56810 56810 procedure) $ 1,035.90 4395 56820 56820 Colposcopy of the vulva; $ 198.44 4396 56821 56821 Colposcopy of the vulva; with biopsy(s) $ 293.12 4397 57000 57000 Colpotomy; with exploration $ 914.40 4398 57010 57010 Colpotomy; with drainage of pelvic abscess $ 1,030.50 4399 57020 57020 Colpocentesis (separate procedure) $ 249.30 4400 57022 57022 Incision and drainage of vaginal hematoma; obstetrical/postpartum $ 398.70 Incision and drainage of vaginal hematoma; non-obstetrical (eg, 4401 57023 57023 post-trauma, spontaneous bleeding) $ 398.70 Destruction of vaginal lesion(s); simple (eg, laser surgery, 4402 57061 57061 electrosurgery, cryosurgery, chemosurgery) $ 442.80 Destruction of vaginal lesion(s); extensive (eg, laser surgery, 4403 57065 57065 electrosurgery, cryosurgery, chemosurgery) $ 1,008.47 4404 57100 57100 Biopsy of vaginal mucosa; simple (separate procedure) $ 232.20 Biopsy of vaginal mucosa; extensive, requiring suture (including 4405 57105 57105 cysts) $ 724.50 4406 57106 57106 Vaginectomy, partial removal of vaginal wall; $ 1,195.20 Vaginectomy, partial removal of vaginal wall; with removal of 4407 57107 57107 paravaginal tissue (radical vaginectomy) $ 3,107.70 Vaginectomy, partial removal of vaginal wall; with removal of paravaginal tissue (radical vaginectomy) with bilateral total pelvic 4408 57109 57109 lymphadenectomy and para-aortic lymph node sampling (biopsy) $ 3,578.40 4409 57110 57110 Vaginectomy, complete removal of vaginal wall; $ 2,316.60 Vaginectomy, complete removal of vaginal wall; with removal of 4410 57111 57111 paravaginal tissue (radical vaginectomy) $ 3,666.60 Vaginectomy, complete removal of vaginal wall; with removal of paravaginal tissue (radical vaginectomy) with bilateral total pelvic 4411 57112 57112 lymphadenectomy and para-aortic lymph node sampling (biopsy) $ 3,849.30 4412 57120 57120 Colpocleisis (Le Fort type) $ 2,274.30 4413 57130 57130 Excision of vaginal septum $ 940.50 4414 57135 57135 Excision of vaginal cyst or tumor $ 710.87 Irrigation of vagina and/or application of medicament for treatment 4415 57150 57150 of bacterial, parasitic, or fungoid disease $ 100.80 Insertion of uterine tandem and/or vaginal ovoids for clinical 4416 57155 57155 brachytherapy $ 1,064.04 4417 57160 57160 Fitting and insertion of pessary or other intravaginal support device $ 113.40 4418 57170 57170 Diaphragm or cervical cap fitting with instructions $ 99.00 Introduction of any hemostatic agent or pack for spontaneous or 4419 57180 57180 traumatic nonobstetrical vaginal hemorrhage (separate procedure) $ 322.20 4420 57200 57200 Colporrhaphy, suture of injury of vagina (nonobstetrical) $ 978.30 Colpoperineorrhaphy, suture of injury of vagina and/or perineum 4421 57210 57210 (nonobstetrical) $ 1,352.70 Plastic operation on urethral sphincter, vaginal approach (eg, Kelly 4422 57220 57220 urethral plication) $ 1,349.10 4423 57230 57230 Plastic repair of urethrocele $ 1,215.90 Anterior colporrhaphy, repair of cystocele with or without repair of 4424 57240 57240 urethrocele $ 1,586.70 Posterior colporrhaphy, repair of rectocele with or without 4425 57250 57250 perineorrhaphy $ 1,559.70 4426 57260 57260 Combined anteroposterior colporrhaphy; $ 2,090.70 4427 57265 57265 Combined anteroposterior colporrhaphy; with enterocele repair $ 2,418.62 Insertion of mesh or other prosthesis for repair of pelvic floor defect, each site (anterior, posterior compartment), vaginal 4428 57267 57267 approach (List separately in addition to code for primary procedure) $ 693.09 4429 57268 57268 Repair of enterocele, vaginal approach (separate procedure) $ 1,725.30 4430 57270 57270 Repair of enterocele, abdominal approach (separate procedure) $ 2,124.90 4431 57280 57280 Colpopexy, abdominal approach $ 2,472.30 Colpopexy, vaginal; extra-peritoneal approach (sacrospinous, 4432 57282 57282 iliococcygeus) $ 2,729.70 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Colpopexy, vaginal; intra-peritoneal approach (uterosacral, levator 4433 57283 57283 myorrhaphy) $ 1,612.15 Paravaginal defect repair (including repair of cystocele, if 4434 57284 57284 performed); open abdominal approach $ 2,523.60 Removal or revision of sling for stress incontinence (eg, fascia or 4435 57287 57287 synthetic) $ 2,081.70 4436 57288 57288 Sling operation for stress incontinence (eg, fascia or synthetic) $ 2,816.10 4437 57289 57289 Pereyra procedure, including anterior colporrhaphy $ 2,429.10 4438 57291 57291 Construction of artificial vagina; without graft $ 3,295.80 4439 57292 57292 Construction of artificial vagina; with graft $ 3,924.90 Revision (including removal) of prosthetic vaginal graft; vaginal 4440 57295 57295 approach $ 1,167.58 Revision (including removal) of prosthetic vaginal graft; open 4441 57296 57296 abdominal approach $ 2,490.17 4442 57300 57300 Closure of rectovaginal fistula; vaginal or transanal approach $ 1,933.20 4443 57305 57305 Closure of rectovaginal fistula; abdominal approach $ 2,477.70 Closure of rectovaginal fistula; abdominal approach, with 4444 57307 57307 concomitant colostomy $ 2,581.20 Closure of rectovaginal fistula; transperineal approach, with 4445 57308 57308 perineal body reconstruction, with or without levator plication $ 2,317.50 4446 57310 57310 Closure of urethrovaginal fistula; $ 2,374.20 4447 57311 57311 Closure of urethrovaginal fistula; with bulbocavernosus transplant $ 2,729.70 4448 57320 57320 Closure of vesicovaginal fistula; vaginal approach $ 2,652.30 4449 57330 57330 Closure of vesicovaginal fistula; transvesical and vaginal approach $ 2,680.20 4450 57335 57335 Vaginoplasty for intersex state $ 3,069.90 4451 57400 57400 Dilation of vagina under anesthesia (other than local) $ 370.80 4452 57410 57410 Pelvic examination under anesthesia (other than local) $ 318.60 Removal of impacted vaginal foreign body (separate procedure) 4453 57415 57415 under anesthesia (other than local) $ 415.80 4454 57420 57420 Colposcopy of the entire vagina, with cervix if present; $ 238.08 Colposcopy of the entire vagina, with cervix if present; with 4455 57421 57421 biopsy(s) of vagina/cervix $ 339.81 Paravaginal defect repair (including repair of cystocele, if 4456 57423 57423 performed), laparoscopic approach $ 2,061.99 4457 57425 57425 Laparoscopy, surgical, colpopexy (suspension of vaginal apex) $ 2,099.02 Revision (including removal) of prosthetic vaginal graft, laparoscopic 4458 57426 57426 approach $ 1,885.00 4459 57452 57452 Colposcopy of the cervix including upper/adjacent vagina; $ 242.93 Colposcopy of the cervix including upper/adjacent vagina; with 4460 57454 57454 biopsy(s) of the cervix and endocervical curettage $ 343.46 Colposcopy of the cervix including upper/adjacent vagina; with 4461 57455 57455 biopsy(s) of the cervix $ 169.72 Colposcopy of the cervix including upper/adjacent vagina; with 4462 57456 57456 endocervical curettage $ 187.31 Colposcopy of the cervix including upper/adjacent vagina; with loop 4463 57460 57460 electrode biopsy(s) of the cervix $ 953.23 Colposcopy of the cervix including upper/adjacent vagina; with loop 4464 57461 57461 electrode conization of the cervix $ 893.18 Biopsy of cervix, single or multiple, or local excision of lesion, with 4465 57500 57500 or without fulguration (separate procedure) $ 251.05 Endocervical curettage (not done as part of a dilation and 4466 57505 57505 curettage) $ 221.40 4467 57510 57510 Cautery of cervix; electro or thermal $ 308.03 4468 57511 57511 Cautery of cervix; cryocautery, initial or repeat $ 287.10 4469 57513 57513 Cautery of cervix; laser ablation $ 1,030.50 Conization of cervix, with or without fulguration, with or without 4470 57520 57520 dilation and curettage, with or without repair; cold knife or laser $ 1,079.10 Conization of cervix, with or without fulguration, with or without dilation and curettage, with or without repair; loop electrode 4471 57522 57522 excision $ 1,080.48 Trachelectomy (cervicectomy), amputation of cervix (separate 4472 57530 57530 procedure) $ 979.20 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Radical trachelectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling biopsy, with or without 4473 57531 57531 removal of tube(s), with or without removal of ovary(s) $ 4,499.10 4474 57540 57540 Excision of cervical stump, abdominal approach; $ 2,022.30 Excision of cervical stump, abdominal approach; with pelvic floor 4475 57545 57545 repair $ 2,276.10 4476 57550 57550 Excision of cervical stump, vaginal approach; $ 1,606.50 Excision of cervical stump, vaginal approach; with anterior and/or 4477 57555 57555 posterior repair $ 2,096.10 Excision of cervical stump, vaginal approach; with repair of 4478 57556 57556 enterocele $ 2,295.90 4479 57558 57558 Dilation and curettage of cervical stump $ 286.85 4480 57700 57700 Cerclage of uterine cervix, nonobstetrical $ 1,133.10 4481 57720 57720 Trachelorrhaphy, plastic repair of uterine cervix, vaginal approach $ 1,098.90 4482 57800 57800 Dilation of cervical canal, instrumental (separate procedure) $ 262.80 Endometrial sampling (biopsy) with or without endocervical sampling (biopsy), without cervical dilation, any method (separate 4483 58100 58100 procedure) $ 266.06 Endometrial sampling (biopsy) performed in conjunction with colposcopy (List separately in addition to code for primary 4484 58110 58110 procedure) $ 146.06 Dilation and curettage, diagnostic and/or therapeutic 4485 58120 58120 (nonobstetrical) $ 903.20 Myomectomy, excision of fibroid tumor(s) of uterus, 1 to 4 intramural myoma(s) with total weight of 250 g or less and/or 4486 58140 58140 removal of surface myomas; abdominal approach $ 2,851.59 Myomectomy, excision of fibroid tumor(s) of uterus, 1 to 4 intramural myoma(s) with total weight of 250 g or less and/or 4487 58145 58145 removal of surface myomas; vaginal approach $ 2,299.50 Myomectomy, excision of fibroid tumor(s) of uterus, 5 or more intramural myomas and/or intramural myomas with total weight 4488 58146 58146 greater than 250 g, abdominal approach $ 2,845.00 Total abdominal hysterectomy (corpus and cervix), with or without 4489 58150 58150 removal of tube(s), with or without removal of ovary(s); $ 3,175.21 Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s); with colpo- 4490 58152 58152 urethrocystopexy (eg, Marshall-Marchetti-Krantz, Burch) $ 3,904.20 Supracervical abdominal hysterectomy (subtotal hysterectomy), with or without removal of tube(s), with or without removal of 4491 58180 58180 ovary(s) $ 3,280.50 Total abdominal hysterectomy, including partial vaginectomy, with para-aortic and pelvic lymph node sampling, with or without 4492 58200 58200 removal of tube(s), with or without removal of ovary(s) $ 3,940.20 Radical abdominal hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy), with or without removal of tube(s), with or without removal of 4493 58210 58210 ovary(s) $ 6,048.90 Pelvic exenteration for gynecologic malignancy, with total abdominal hysterectomy or cervicectomy, with or without removal of tube(s), with or without removal of ovary(s), with removal of bladder and ureteral transplantations, and/or abdominoperineal 4494 58240 58240 rese $ 8,435.70 4495 58260 58260 Vaginal hysterectomy, for uterus 250 g or less; $ 3,085.20 Vaginal hysterectomy, for uterus 250 g or less; with removal of 4496 58262 58262 tube(s), and/or ovary(s) $ 3,554.10 Vaginal hysterectomy, for uterus 250 g or less; with removal of 4497 58263 58263 tube(s), and/or ovary(s), with repair of enterocele $ 3,879.90 Vaginal hysterectomy, for uterus 250 g or less; with colpo- urethrocystopexy (Marshall-Marchetti-Krantz type, Pereyra type) 4498 58267 58267 with or without endoscopic control $ 3,544.20 Vaginal hysterectomy, for uterus 250 g or less; with repair of 4499 58270 58270 enterocele $ 3,762.90 4500 58275 58275 Vaginal hysterectomy, with total or partial vaginectomy; $ 3,759.30 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Vaginal hysterectomy, with total or partial vaginectomy; with repair 4501 58280 58280 of enterocele $ 3,493.80 4502 58285 58285 Vaginal hysterectomy, radical (Schauta type operation) $ 3,948.30 4503 58290 58290 Vaginal hysterectomy, for uterus greater than 250 g; $ 3,249.20 Vaginal hysterectomy, for uterus greater than 250 g; with removal 4504 58291 58291 of tube(s) and/or ovary(s) $ 3,588.32 Vaginal hysterectomy, for uterus greater than 250 g; with removal 4505 58292 58292 of tube(s) and/or ovary(s), with repair of enterocele $ 3,867.52 Vaginal hysterectomy, for uterus greater than 250 g; with colpo- urethrocystopexy (Marshall-Marchetti-Krantz type, Pereyra type) 4506 58293 58293 with or without endoscopic control $ 4,011.49 Vaginal hysterectomy, for uterus greater than 250 g; with repair of 4507 58294 58294 enterocele $ 3,502.18 4508 58300 58300 Insertion of intrauterine device (IUD) $ 308.70 4509 58301 58301 Removal of intrauterine device (IUD) $ 124.20 4510 58321 58321 Artificial insemination; intra-cervical $ 183.60 4511 58322 58322 Artificial insemination; intra-uterine $ 226.80 4512 58323 58323 Sperm washing for artificial insemination $ 200.70 Catheterization and introduction of saline or contrast material for 4513 58340 58340 saline infusion sonohysterography (SIS) or hysterosalpingography $ 279.39 Transcervical introduction of fallopian tube catheter for diagnosis and/or re-establishing patency (any method), with or without 4514 58345 58345 hysterosalpingography $ 1,163.70 4515 58346 58346 Insertion of Heyman capsules for clinical brachytherapy $ 1,416.42 4516 58350 58350 Chromotubation of oviduct, including materials $ 360.90 4517 58353 58353 Endometrial ablation, thermal, without hysteroscopic guidance $ 681.30 Endometrial cryoablation with ultrasonic guidance, including 4518 58356 58356 endometrial curettage, when performed $ 2,930.73 Uterine suspension, with or without shortening of round ligaments, with or without shortening of sacrouterine ligaments; (separate 4519 58400 58400 procedure) $ 1,903.50 Uterine suspension, with or without shortening of round ligaments, with or without shortening of sacrouterine ligaments; with 4520 58410 58410 presacral sympathectomy $ 2,566.80 4521 58520 58520 Hysterorrhaphy, repair of ruptured uterus (nonobstetrical) $ 1,658.70 4522 58540 58540 Hysteroplasty, repair of uterine anomaly (Strassman type) $ 2,497.50 Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g 4523 58541 58541 or less; $ 2,275.20 Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g 4524 58542 58542 or less; with removal of tube(s) and/or ovary(s) $ 2,512.31 Laparoscopy, surgical, supracervical hysterectomy, for uterus 4525 58543 58543 greater than 250 g; $ 2,546.70 Laparoscopy, surgical, supracervical hysterectomy, for uterus 4526 58544 58544 greater than 250 g; with removal of tube(s) and/or ovary(s) $ 2,839.57 Laparoscopy, surgical, myomectomy, excision; 1 to 4 intramural myomas with total weight of 250 g or less and/or removal of 4527 58545 58545 surface myomas $ 2,496.86 Laparoscopy, surgical, myomectomy, excision; 5 or more intramural myomas and/or intramural myomas with total weight greater than 4528 58546 58546 250 g $ 3,009.13 Laparoscopy, surgical, with radical hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling 4529 58548 58548 (biopsy), with removal of tube(s) and ovary(s), if performed $ 4,382.63 Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g 4530 58550 58550 or less; $ 3,277.49 Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g 4531 58552 58552 or less; with removal of tube(s) and/or ovary(s) $ 2,608.28 Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater 4532 58553 58553 than 250 g; $ 3,010.69 Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater 4533 58554 58554 than 250 g; with removal of tube(s) and/or ovary(s) $ 3,357.56 4534 58555 58555 Hysteroscopy, diagnostic (separate procedure) $ 857.70 Hysteroscopy, surgical; with sampling (biopsy) of endometrium 4535 58558 58558 and/or polypectomy, with or without D & C $ 1,402.27 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Hysteroscopy, surgical; with lysis of intrauterine adhesions (any 4536 58559 58559 method) $ 1,555.20 Hysteroscopy, surgical; with division or resection of intrauterine 4537 58560 58560 septum (any method) $ 1,865.70 4538 58561 58561 Hysteroscopy, surgical; with removal of leiomyomata $ 2,065.50 4539 58562 58562 Hysteroscopy, surgical; with removal of impacted foreign body $ 1,035.00 Hysteroscopy, surgical; with endometrial ablation (eg, endometrial 4540 58563 58563 resection, electrosurgical ablation, thermoablation) $ 2,528.26 Hysteroscopy, surgical; with bilateral fallopian tube cannulation to 4541 58565 58565 induce occlusion by placement of permanent implants $ 4,424.15 Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or 4542 58570 58570 less; $ 2,503.83 Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or 4543 58571 58571 less; with removal of tube(s) and/or ovary(s) $ 2,801.61 Laparoscopy, surgical, with total hysterectomy, for uterus greater 4544 58572 58572 than 250 g; $ 3,013.79 Laparoscopy, surgical, with total hysterectomy, for uterus greater 4545 58573 58573 than 250 g; with removal of tube(s) and/or ovary(s) $ 3,509.08 4546 58578 58578 Unlisted laparoscopy procedure, uterus Cost 4547 58579 58579 Unlisted hysteroscopy procedure, uterus Cost Ligation or transection of fallopian tube(s), abdominal or vaginal 4548 58600 58600 approach, unilateral or bilateral $ 1,508.40 Ligation or transection of fallopian tube(s), abdominal or vaginal approach, postpartum, unilateral or bilateral, during same 4549 58605 58605 hospitalization (separate procedure) $ 1,312.20 Ligation or transection of fallopian tube(s) when done at the time of cesarean delivery or intra-abdominal surgery (not a separate procedure) (List separately in addition to code for primary 4550 58611 58611 procedure) $ 861.75 Occlusion of fallopian tube(s) by device (eg, band, clip, Falope ring) 4551 58615 58615 vaginal or suprapubic approach $ 1,441.80 Laparoscopy, surgical; with lysis of adhesions (salpingolysis, 4552 58660 58660 ovariolysis) (separate procedure) $ 2,250.71 Laparoscopy, surgical; with removal of adnexal structures (partial or 4553 58661 58661 total oophorectomy and/or salpingectomy) $ 2,277.00 Laparoscopy, surgical; with fulguration or excision of lesions of the 4554 58662 58662 ovary, pelvic viscera, or peritoneal surface by any method $ 2,523.37 Laparoscopy, surgical; with fulguration of oviducts (with or without 4555 58670 58670 transection) $ 1,802.70 Laparoscopy, surgical; with occlusion of oviducts by device (eg, 4556 58671 58671 band, clip, or Falope ring) $ 1,802.70 4557 58672 58672 Laparoscopy, surgical; with fimbrioplasty $ 2,601.00 4558 58673 58673 Laparoscopy, surgical; with salpingostomy (salpingoneostomy) $ 1,854.00 4559 58679 58679 Unlisted laparoscopy procedure, oviduct, ovary Cost Salpingectomy, complete or partial, unilateral or bilateral (separate 4560 58700 58700 procedure) $ 2,060.10 Salpingo-oophorectomy, complete or partial, unilateral or bilateral 4561 58720 58720 (separate procedure) $ 2,178.51 4562 58740 58740 Lysis of adhesions (salpingolysis, ovariolysis) $ 2,415.84 4563 58750 58750 Tubotubal anastomosis $ 3,936.60 4564 58752 58752 Tubouterine implantation $ 3,450.60 4565 58760 58760 Fimbrioplasty $ 3,038.40 4566 58770 58770 Salpingostomy (salpingoneostomy) $ 3,193.20 Drainage of ovarian cyst(s), unilateral or bilateral (separate 4567 58800 58800 procedure); vaginal approach $ 1,184.40 Drainage of ovarian cyst(s), unilateral or bilateral (separate 4568 58805 58805 procedure); abdominal approach $ 1,800.90 4569 58820 58820 Drainage of ovarian abscess; vaginal approach, open $ 1,287.90 4570 58822 58822 Drainage of ovarian abscess; abdominal approach $ 1,772.10 4571 58825 58825 Transposition, ovary(s) $ 1,837.80 4572 58900 58900 Biopsy of ovary, unilateral or bilateral (separate procedure) $ 1,833.30 4573 58920 58920 Wedge resection or bisection of ovary, unilateral or bilateral $ 2,329.20 4574 58925 58925 Ovarian cystectomy, unilateral or bilateral $ 2,331.00 4575 58940 58940 Oophorectomy, partial or total, unilateral or bilateral; $ 2,069.10 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Oophorectomy, partial or total, unilateral or bilateral; for ovarian, tubal or primary peritoneal malignancy, with para-aortic and pelvic lymph node biopsies, peritoneal washings, peritoneal biopsies, 4576 58943 58943 diaphragmatic assessments, with or without salpingecto $ 3,457.80 Resection (initial) of ovarian, tubal or primary peritoneal malignancy 4577 58950 58950 with bilateral salpingo-oophorectomy and omentectomy; $ 3,549.60 Resection (initial) of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy; with total abdominal hysterectomy, pelvic and limited para-aortic 4578 58951 58951 lymphadenectomy $ 4,583.70 Resection (initial) of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and omentectomy; with radical dissection for debulking (ie, radical excision or destruction, 4579 58952 58952 intra-abdominal or retroperitoneal tumors) $ 5,935.50 Bilateral salpingo-oophorectomy with omentectomy, total 4580 58953 58953 abdominal hysterectomy and radical dissection for debulking; $ 7,745.77 Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy and radical dissection for debulking; with 4581 58954 58954 pelvic lymphadenectomy and limited para-aortic lymphadenectomy $ 8,407.75 Bilateral salpingo-oophorectomy with total omentectomy, total 4582 58956 58956 abdominal hysterectomy for malignancy $ 5,467.49 Resection (tumor debulking) of recurrent ovarian, tubal, primary peritoneal, uterine malignancy (intra-abdominal, retroperitoneal 4583 58957 58957 tumors), with omentectomy, if performed; $ 5,807.52 Resection (tumor debulking) of recurrent ovarian, tubal, primary peritoneal, uterine malignancy (intra-abdominal, retroperitoneal tumors), with omentectomy, if performed; with pelvic 4584 58958 58958 lymphadenectomy and limited para-aortic lymphadenectomy $ 6,432.44 Laparotomy, for staging or restaging of ovarian, tubal, or primary peritoneal malignancy (second look), with or without omentectomy, peritoneal washing, biopsy of abdominal and pelvic peritoneum, 4585 58960 58960 diaphragmatic assessment with pelvic and limited para-aorti $ 3,839.96 4586 58970 58970 Follicle puncture for oocyte retrieval, any method $ 1,406.70 4587 58974 58974 Embryo transfer, intrauterine $ 537.30 4588 58976 58976 Gamete, zygote, or embryo intrafallopian transfer, any method $ 1,545.30 4589 58999 58999 Unlisted procedure, female genital system (nonobstetrical) Cost 4590 59000 59000 Amniocentesis; diagnostic $ 332.21 Amniocentesis; therapeutic amniotic fluid reduction (includes 4591 59001 59001 ultrasound guidance) $ 440.43 4592 59012 59012 Cordocentesis (intrauterine), any method $ 669.60 4593 59015 59015 Chorionic villus sampling, any method $ 360.90 4594 59020 59020 Fetal contraction stress test $ 178.81 4595 59020-26 26 59020 Fetal contraction stress test $ 90.59 4596 59020-TC TC 59020 Fetal contraction stress test $ 88.22 4597 59025 59025 Fetal non-stress test $ 115.69 4598 59025-26 26 59025 Fetal non-stress test $ 69.45 4599 59025-TC TC 59025 Fetal non-stress test $ 46.24 4600 59030 59030 Fetal scalp blood sampling $ 194.40 Fetal monitoring during labor by consulting physician (ie, non- attending physician) with written report; supervision and 4601 59050 59050 interpretation $ 285.30 Fetal monitoring during labor by consulting physician (ie, non- 4602 59051 59051 attending physician) with written report; interpretation only $ 109.29 4603 59070 59070 Transabdominal amnioinfusion, including ultrasound guidance $ 959.77 4604 59072 59072 Fetal umbilical cord occlusion, including ultrasound guidance $ 1,227.78 Fetal fluid drainage (eg, vesicocentesis, thoracocentesis, 4605 59074 59074 paracentesis), including ultrasound guidance $ 935.82 4606 59076 59076 Fetal shunt placement, including ultrasound guidance $ 1,204.41 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price 4607 59100 59100 Hysterotomy, abdominal (eg, for hydatidiform mole, abortion) $ 1,908.00 Surgical treatment of ectopic pregnancy; tubal or ovarian, requiring salpingectomy and/or oophorectomy, abdominal or vaginal 4608 59120 59120 approach $ 2,453.40 Surgical treatment of ectopic pregnancy; tubal or ovarian, without 4609 59121 59121 salpingectomy and/or oophorectomy $ 2,041.20 4610 59130 59130 Surgical treatment of ectopic pregnancy; abdominal pregnancy $ 2,061.90 Surgical treatment of ectopic pregnancy; interstitial, uterine 4611 59135 59135 pregnancy requiring total hysterectomy $ 2,800.80 Surgical treatment of ectopic pregnancy; interstitial, uterine 4612 59136 59136 pregnancy with partial resection of uterus $ 2,285.10 4613 59140 59140 Surgical treatment of ectopic pregnancy; cervical, with evacuation $ 1,562.40 Laparoscopic treatment of ectopic pregnancy; without 4614 59150 59150 salpingectomy and/or oophorectomy $ 2,317.50 Laparoscopic treatment of ectopic pregnancy; with salpingectomy 4615 59151 59151 and/or oophorectomy $ 2,414.78 4616 59160 59160 Curettage, postpartum $ 765.00 Insertion of cervical dilator (eg, laminaria, prostaglandin) (separate 4617 59200 59200 procedure) $ 276.79 4618 59300 59300 Episiotomy or vaginal repair, by other than attending $ 566.10 4619 59320 59320 Cerclage of cervix, during pregnancy; vaginal $ 1,122.47 4620 59325 59325 Cerclage of cervix, during pregnancy; abdominal $ 1,416.60 4621 59350 59350 Hysterorrhaphy of ruptured uterus $ 2,176.20 Routine obstetric care including antepartum care, vaginal delivery 4622 59400 59400 (with or without episiotomy, and/or forceps) and postpartum care $ 2,781.00 4623 59409 59409 Vaginal delivery only (with or without episiotomy and/or forceps); $ 1,588.98 Vaginal delivery only (with or without episiotomy and/or forceps); 4624 59410 59410 including postpartum care $ 1,924.97 4625 59412 59412 External cephalic version, with or without tocolysis $ 540.90 4626 59414 59414 Delivery of placenta (separate procedure) $ 484.20 4627 59425 59425 Antepartum care only; 4-6 visits $ 747.00 4628 59426 59426 Antepartum care only; 7 or more visits $ 1,168.00 4629 59430 59430 Postpartum care only (separate procedure) $ 240.30 4630 59514 59514 Cesarean delivery only; $ 2,233.35 4631 59515 59515 Cesarean delivery only; including postpartum care $ 2,676.17 Subtotal or total hysterectomy after cesarean delivery (List 4632 59525 59525 separately in addition to code for primary procedure) $ 1,751.40 Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care, 4633 59610 59610 after previous cesarean delivery $ 3,295.80 Vaginal delivery only, after previous cesarean delivery (with or 4634 59612 59612 without episiotomy and/or forceps); $ 2,271.60 Vaginal delivery only, after previous cesarean delivery (with or 4635 59614 59614 without episiotomy and/or forceps); including postpartum care $ 2,339.10 Routine obstetric care including antepartum care, cesarean delivery, and postpartum care, following attempted vaginal delivery after 4636 59618 59618 previous cesarean delivery $ 3,965.40 Cesarean delivery only, following attempted vaginal delivery after 4637 59620 59620 previous cesarean delivery; $ 2,781.00 Cesarean delivery only, following attempted vaginal delivery after 4638 59622 59622 previous cesarean delivery; including postpartum care $ 2,632.19 Treatment of incomplete abortion, any trimester, completed 4639 59812 59812 surgically $ 800.34 4640 59820 59820 Treatment of missed abortion, completed surgically; first trimester $ 815.24 Treatment of missed abortion, completed surgically; second 4641 59821 59821 trimester $ 1,081.80 4642 59830 59830 Treatment of septic abortion, completed surgically $ 1,153.80 4643 59840 59840 Induced abortion, by dilation and curettage $ 947.70 4644 59841 59841 Induced abortion, by dilation and evacuation $ 1,118.90 Induced abortion, by 1 or more intra-amniotic injections (amniocentesis-injections), including hospital admission and visits, 4645 59850 59850 delivery of fetus and secundines; $ 1,398.60 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Induced abortion, by 1 or more intra-amniotic injections (amniocentesis-injections), including hospital admission and visits, delivery of fetus and secundines; with dilation and curettage and/or 4646 59851 59851 evacuation $ 1,555.20 Induced abortion, by 1 or more intra-amniotic injections (amniocentesis-injections), including hospital admission and visits, delivery of fetus and secundines; with hysterotomy (failed intra- 4647 59852 59852 amniotic injection) $ 1,869.30 Induced abortion, by 1 or more vaginal suppositories (eg, prostaglandin) with or without cervical dilation (eg, laminaria), including hospital admission and visits, delivery of fetus and 4648 59855 59855 secundines; $ 1,235.70 Induced abortion, by 1 or more vaginal suppositories (eg, prostaglandin) with or without cervical dilation (eg, laminaria), including hospital admission and visits, delivery of fetus and 4649 59856 59856 secundines; with dilation and curettage and/or evacuation $ 1,441.80 Induced abortion, by 1 or more vaginal suppositories (eg, prostaglandin) with or without cervical dilation (eg, laminaria), including hospital admission and visits, delivery of fetus and 4650 59857 59857 secundines; with hysterotomy (failed medical evacuation) $ 1,810.80 4651 59866 59866 Multifetal pregnancy reduction(s) (MPR) $ 796.50 4652 59870 59870 Uterine evacuation and curettage for hydatidiform mole $ 1,081.80 4653 59871 59871 Removal of cerclage suture under anesthesia (other than local) $ 444.60 Unlisted fetal invasive procedure, including ultrasound guidance, 4654 59897 59897 when performed Cost 4655 59898 59898 Unlisted laparoscopy procedure, maternity care and delivery Cost 4656 59899 59899 Unlisted procedure, maternity care and delivery Cost 4657 60000 60000 Incision and drainage of thyroglossal duct cyst, infected $ 305.10 4658 60100 60100 Biopsy thyroid, percutaneous core needle $ 279.00 4659 60200 60200 Excision of cyst or adenoma of thyroid, or transection of isthmus $ 1,590.30 Partial thyroid lobectomy, unilateral; with or without 4660 60210 60210 isthmusectomy $ 2,587.50 Partial thyroid lobectomy, unilateral; with contralateral subtotal 4661 60212 60212 lobectomy, including isthmusectomy $ 3,165.30 4662 60220 60220 Total thyroid lobectomy, unilateral; with or without isthmusectomy $ 2,613.60 Total thyroid lobectomy, unilateral; with contralateral subtotal 4663 60225 60225 lobectomy, including isthmusectomy $ 3,329.10 4664 60240 60240 Thyroidectomy, total or complete $ 3,250.80 Thyroidectomy, total or subtotal for malignancy;

with limited neck 4665 60252 60252 dissection $ 3,743.10 Thyroidectomy, total or subtotal for malignancy; with radical neck 4666 60254 60254 dissection $ 5,427.00 Thyroidectomy, removal of all remaining thyroid tissue following 4667 60260 60260 previous removal of a portion of thyroid $ 2,396.70 Thyroidectomy, including substernal thyroid; sternal split or 4668 60270 60270 transthoracic approach $ 4,066.20 4669 60271 60271 Thyroidectomy, including substernal thyroid; cervical approach $ 3,284.10 4670 60280 60280 Excision of thyroglossal duct cyst or sinus; $ 2,004.30 4671 60281 60281 Excision of thyroglossal duct cyst or sinus; recurrent $ 2,155.50 4672 60300 60001 Aspiration and/or injection, thyroid cyst $ 304.43 4673 60500 60500 Parathyroidectomy or exploration of parathyroid(s); $ 3,088.80 4674 60502 60502 Parathyroidectomy or exploration of parathyroid(s); re-exploration $ 3,404.70 Parathyroidectomy or exploration of parathyroid(s); with 4675 60505 60505 mediastinal exploration, sternal split or transthoracic approach $ 3,624.30 Parathyroid autotransplantation (List separately in addition to code 4676 60512 60512 for primary procedure) $ 802.80 Thymectomy, partial or total; transcervical approach (separate 4677 60520 60520 procedure) $ 3,260.70 Thymectomy, partial or total; sternal split or transthoracic approach, without radical mediastinal dissection (separate 4678 60521 60521 procedure) $ 3,193.20 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Thymectomy, partial or total; sternal split or transthoracic 4679 60522 60522 approach, with radical mediastinal dissection (separate procedure) $ 4,230.00 Adrenalectomy, partial or complete, or exploration of adrenal gland with or without biopsy, transabdominal, lumbar or dorsal (separate 4680 60540 60540 procedure); $ 3,249.90 Adrenalectomy, partial or complete, or exploration of adrenal gland with or without biopsy, transabdominal, lumbar or dorsal (separate 4681 60545 60545 procedure); with excision of adjacent retroperitoneal tumor $ 3,646.80 4682 60600 60600 Excision of carotid body tumor; without excision of carotid artery $ 3,170.70 4683 60605 60605 Excision of carotid body tumor; with excision of carotid artery $ 3,828.60 Laparoscopy, surgical, with adrenalectomy, partial or complete, or exploration of adrenal gland with or without biopsy, 4684 60650 60650 transabdominal, lumbar or dorsal $ 2,901.27 4685 60659 60659 Unlisted laparoscopy procedure, endocrine system Cost 4686 60699 60699 Unlisted procedure, endocrine system Cost Subdural tap through fontanelle, or suture, infant, unilateral or 4687 61000 61000 bilateral; initial $ 347.40 Subdural tap through fontanelle, or suture, infant, unilateral or 4688 61001 61001 bilateral; subsequent taps $ 268.20 Ventricular puncture through previous burr hole, fontanelle, suture, 4689 61020 61020 or implanted ventricular catheter/reservoir; without injection $ 477.00 Ventricular puncture through previous burr hole, fontanelle, suture, or implanted ventricular catheter/reservoir; with injection of 4690 61026 61026 medication or other substance for diagnosis or treatment $ 539.10 Cisternal or lateral cervical (C1-C2) puncture; without injection 4691 61050 61050 (separate procedure) $ 422.10 Cisternal or lateral cervical (C1-C2) puncture; with injection of medication or other substance for diagnosis or treatment (eg, C1- 4692 61055 61055 C2) $ 605.70 Puncture of shunt tubing or reservoir for aspiration or injection 4693 61070 61070 procedure $ 314.10 4694 61105 61105 Twist drill hole for subdural or ventricular puncture $ 1,647.90 Twist drill hole(s) for subdural, intracerebral, or ventricular puncture; for implanting ventricular catheter, pressure recording 4695 61107 61107 device, or other intracerebral monitoring device $ 2,286.90 Twist drill hole(s) for subdural, intracerebral, or ventricular 4696 61108 61108 puncture; for evacuation and/or drainage of subdural hematoma $ 3,141.90 Burr hole(s) for ventricular puncture (including injection of gas, 4697 61120 contrast media, dye, or radioactive material) $ 1,748.70 4698 61140 Burr hole(s) or trephine; with biopsy of brain or intracranial lesion $ 3,785.40 4699 61150 Burr hole(s) or trephine; with drainage of brain abscess or cyst $ 3,656.70 Burr hole(s) or trephine; with subsequent tapping (aspiration) of 4700 61151 intracranial abscess or cyst $ 1,149.30 Burr hole(s) with evacuation and/or drainage of hematoma, 4701 61154 61154 extradural or subdural $ 4,333.50 4702 61156 61156 Burr hole(s); with aspiration of hematoma or cyst, intracerebral $ 3,850.20 Burr hole(s); for implanting ventricular catheter, reservoir, EEG electrode(s), pressure recording device, or other cerebral 4703 61210 monitoring device (separate procedure) $ 2,266.20 Insertion of subcutaneous reservoir, pump or continuous infusion 4704 61215 system for connection to ventricular catheter $ 2,421.00 Burr hole(s) or trephine, supratentorial, exploratory, not followed 4705 61250 by other surgery $ 2,483.10 4706 61253 61253 Burr hole(s) or trephine, infratentorial, unilateral or bilateral $ 3,609.90 4707 61304 Craniectomy or craniotomy, exploratory; supratentorial $ 5,562.00 Craniectomy or craniotomy, exploratory; infratentorial (posterior 4708 61305 fossa) $ 5,964.30 Craniectomy or craniotomy for evacuation of hematoma, 4709 61312 61312 supratentorial; extradural or subdural $ 6,644.70 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Craniectomy or craniotomy for evacuation of hematoma, 4710 61313 supratentorial; intracerebral $ 6,731.10 Craniectomy or craniotomy for evacuation of hematoma, 4711 61314 infratentorial; extradural or subdural $ 6,798.60 Craniectomy or craniotomy for evacuation of hematoma, 4712 61315 infratentorial; intracerebellar $ 7,305.30 Incision and subcutaneous placement of cranial bone graft (List 4713 61316 61316 separately in addition to code for primary procedure) $ 1,146.13 Craniectomy or craniotomy, drainage of intracranial abscess; 4714 61320 supratentorial $ 6,000.30 Craniectomy or craniotomy, drainage of intracranial abscess; 4715 61321 infratentorial $ 5,699.70 Craniectomy or craniotomy, decompressive, with or without duraplasty, for treatment of intracranial hypertension, without evacuation of associated intraparenchymal hematoma; without 4716 61322 lobectomy $ 5,756.79 Craniectomy or craniotomy, decompressive, with or without duraplasty, for treatment of intracranial hypertension, without evacuation of associated intraparenchymal hematoma; with 4717 61323 lobectomy $ 6,798.55 4718 61330 Decompression of orbit only, transcranial approach $ 4,500.90 4719 61332 Exploration of orbit (transcranial approach); with biopsy $ 5,355.00 4720 61333 Exploration of orbit (transcranial approach); with removal of lesion $ 5,422.50 Exploration of orbit (transcranial approach); with removal of foreign 4721 61334 body $ 5,355.00 Subtemporal cranial decompression (pseudotumor cerebri, slit 4722 61340 ventricle syndrome) $ 4,254.30 Craniectomy, suboccipital with cervical laminectomy for decompression of medulla and spinal cord, with or without dural 4723 61343 graft (eg, Arnold-Chiari malformation) $ 7,812.00 4724 61345 61345 Other cranial decompression, posterior fossa $ 3,861.00 4725 61440 61440 Craniotomy for section of tentorium cerebelli (separate procedure) $ 3,904.20 Craniectomy, subtemporal, for section, compression, or 4726 61450 61450 decompression of sensory root of gasserian ganglion $ 5,769.00 Craniectomy, suboccipital; for exploration or decompression of 4727 61458 61458 cranial nerves $ 6,541.20 4728 61460 61460 Craniectomy, suboccipital; for section of 1 or more cranial nerves $ 6,573.60 4729 61470 61470 Craniectomy, suboccipital; for medullary tractotomy $ 5,194.80 Craniectomy, suboccipital; for mesencephalic tractotomy or 4730 61480 61480 pedunculotomy $ 4,833.00 4731 61490 61490 Craniotomy for lobotomy, including cingulotomy $ 3,848.40 4732 61500 61500 Craniectomy; with excision of tumor or other bone lesion of skull $ 5,799.60 4733 61501 61501 Craniectomy; for osteomyelitis $ 5,518.80 Craniectomy, trephination, bone flap craniotomy; for excision of 4734 61510 61510 brain tumor, supratentorial, except meningioma $ 7,210.80 Craniectomy, trephination, bone flap craniotomy; for excision of 4735 61512 61512 meningioma, supratentorial $ 7,498.80 Craniectomy, trephination, bone flap craniotomy; for excision of 4736 61514 61514 brain abscess, supratentorial $ 6,441.30 Craniectomy, trephination, bone flap craniotomy; for excision or 4737 61516 61516 fenestration of cyst, supratentorial $ 6,448.50 Implantation of brain intracavitary chemotherapy agent (List 4738 61517 61517 separately in addition to code for primary procedure) $ 317.57 Craniectomy for excision of brain tumor, infratentorial or posterior fossa; except meningioma, cerebellopontine angle tumor, or 4739 61518 61518 midline tumor at base of skull $ 7,177.50 Craniectomy for excision of brain tumor, infratentorial or posterior 4740 61519 61519 fossa; meningioma $ 7,713.00 Craniectomy for excision of brain tumor, infratentorial or posterior 4741 61520 61520 fossa; cerebellopontine angle tumor $ 8,054.10 Craniectomy for excision of brain tumor, infratentorial or posterior 4742 61521 61521 fossa; midline tumor at base of skull $ 8,868.60 Craniectomy, infratentorial or posterior fossa; for excision of brain 4743 61522 61522 abscess $ 6,534.00 Craniectomy, infratentorial or posterior fossa; for excision or 4744 61524 61524 fenestration of cyst $ 6,491.70 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Craniectomy, bone flap craniotomy, transtemporal (mastoid) for 4745 61526 61526 excision of cerebellopontine angle tumor; $ 7,533.00 Craniectomy, bone flap craniotomy, transtemporal (mastoid) for excision of cerebellopontine angle tumor; combined with 4746 61530 61530 middle/posterior fossa craniotomy/craniectomy $ 7,915.50 Subdural implantation of strip electrodes through 1 or more burr or 4747 61531 61531 trephine hole(s) for long-term seizure monitoring $ 4,017.60 Craniotomy with elevation of bone flap; for subdural implantation 4748 61533 61533 of an electrode array, for long-term seizure monitoring $ 5,459.40 Craniotomy with elevation of bone flap; for excision of 4749 61534 61534 epileptogenic focus without electrocorticography during surgery $ 5,832.00 Craniotomy with elevation of bone flap; for removal of epidural or subdural electrode array, without excision of cerebral tissue 4750 61535 61535 (separate procedure) $ 3,613.50 Craniotomy with elevation of bone flap; for excision of cerebral epileptogenic focus, with electrocorticography during surgery 4751 61536 61536 (includes removal of electrode array) $ 6,593.40 Craniotomy with elevation of bone flap; for lobectomy, temporal 4752 61537 61537 lobe, without electrocorticography during surgery $ 5,691.54 Craniotomy with elevation of bone flap; for lobectomy, temporal 4753 61538 61538 lobe, with electrocorticography during surgery $ 7,169.40 Craniotomy with elevation of bone flap; for lobectomy, other than temporal lobe, partial or total, with electrocorticography during 4754 61539 61539 surgery $ 6,920.10 Craniotomy with elevation of bone flap; for lobectomy, other than temporal lobe, partial or total, without electrocorticography during 4755 61540 61540 surgery $ 6,750.11 Craniotomy with elevation of bone flap; for transection of corpus 4756 61541 61541 callosum $ 7,540.20 4757 61542 61542 Craniotomy with elevation of bone flap; for total hemispherectomy $ 7,416.00 Craniotomy with elevation of bone flap; for partial or subtotal 4758 61543 61543 (functional) hemispherectomy $ 6,798.60 Craniotomy with elevation of bone flap; for excision or coagulation 4759 61544 61544 of choroid plexus $ 5,931.00 Craniotomy with elevation of bone flap; for excision of 4760 61545 61545 craniopharyngioma $ 9,750.60 Craniotomy for hypophysectomy or excision of pituitary tumor, 4761 61546 61546 intracranial approach $ 7,222.50 Hypophysectomy or excision of pituitary tumor, transnasal or 4762 61548 61548 transseptal approach, nonstereotactic $ 6,168.60 4763 61550 61550 Craniectomy for craniosynostosis; single cranial suture $ 3,863.70 4764 61552 61552 Craniectomy for craniosynostosis; multiple cranial sutures $ 4,626.90 4765 61556 61556 Craniotomy for craniosynostosis; frontal or parietal bone flap $ 4,708.80 4766 61557 61557 Craniotomy for craniosynostosis; bifrontal bone flap $ 5,355.90 Extensive craniectomy for multiple cranial suture craniosynostosis 4767 61558 61558 (eg, cloverleaf skull); not requiring bone grafts $ 6,180.30 Extensive craniectomy for multiple cranial suture craniosynostosis (eg, cloverleaf skull); recontouring with multiple osteotomies and bone autografts (eg, barrel-stave procedure) (includes obtaining 4768 61559 61559 grafts) $ 7,004.70 Excision, intra and extracranial, benign tumor of cranial bone (eg, 4769 61563 61563 fibrous dysplasia); without optic nerve decompression $ 5,598.00 Excision, intra and extracranial, benign tumor of cranial bone (eg, 4770 61564 61564 fibrous dysplasia); with optic nerve decompression $ 7,004.70 Craniotomy with elevation of bone flap; for selective 4771 61566 61566 amygdalohippocampectomy $ 6,648.74 Craniotomy with elevation of bone flap; for multiple subpial 4772 61567 61567 transections, with electrocorticography during surgery $ 7,585.18 Craniectomy or craniotomy; with excision of foreign body from 4773 61570 61570 brain $ 6,655.50 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Craniectomy or craniotomy; with treatment of penetrating wound 4774 61571 61571 of brain $ 7,112.70 Transoral approach to skull base, brain stem or upper spinal cord 4775 61575 61575 for biopsy, decompression or excision of lesion; $ 5,925.60 Transoral approach to skull base, brain stem or upper spinal cord for biopsy, decompression or excision of lesion; requiring splitting of 4776 61576 61576 tongue and/or mandible (including tracheostomy) $ 6,066.00 Craniofacial approach to anterior cranial fossa; extradural, including lateral rhinotomy, ethmoidectomy, sphenoidectomy, without 4777 61580 61580 maxillectomy or orbital exenteration $ 5,279.40 Craniofacial approach to anterior cranial fossa; extradural, including lateral rhinotomy, orbital exenteration, ethmoidectomy, 4778 61581 61581 sphenoidectomy and/or maxillectomy $ 6,869.70 Craniofacial approach to anterior cranial fossa; extradural, including unilateral or bifrontal craniotomy, elevation of frontal lobe(s), 4779 61582 61582 osteotomy of base of anterior cranial fossa $ 6,235.20 Craniofacial approach to anterior cranial fossa; intradural, including unilateral or bifrontal craniotomy, elevation or resection of frontal 4780 61583 61583 lobe, osteotomy of base of anterior cranial fossa $ 6,881.40 Orbitocranial approach to anterior cranial fossa, extradural, including supraorbital ridge osteotomy and elevation of frontal 4781 61584 61584 and/or temporal lobe(s); without orbital exenteration $ 6,746.40 Orbitocranial approach to anterior cranial fossa, extradural, including supraorbital ridge osteotomy and elevation of frontal 4782 61585 61585 and/or temporal lobe(s); with orbital exenteration $ 7,112.70 Bicoronal, transzygomatic and/or LeFort I osteotomy approach to anterior cranial fossa with or without internal fixation, without 4783 61586 61586 bone graft $ 4,247.10 Infratemporal pre-auricular approach to middle cranial fossa (parapharyngeal space, infratemporal and midline skull base, nasopharynx), with or without disarticulation of the mandible, including parotidectomy, craniotomy, decompression and/or 4784 61590 61590 mobilization $ 8,847.90 Infratemporal post-auricular approach to middle cranial fossa (internal auditory meatus, petrous apex, tentorium, cavernous sinus, parasellar area, infratemporal fossa) including mastoidectomy, resection of sigmoid sinus, with or without 4785 61591 61591 decompression and $ 9,154.80 Orbitocranial zygomatic approach to middle cranial fossa (cavernous sinus and carotid artery, clivus, basilar artery or petrous apex) including osteotomy of zygoma, craniotomy, extra- or 4786 61592 61592 intradural elevation of temporal lobe $ 7,725.60 Transtemporal approach to posterior cranial fossa, jugular foramen or midline skull base, including mastoidectomy, decompression of 4787 61595 61595 sigmoid sinus and/or facial nerve, with or without mobilization $ 6,030.00 Transcochlear approach to posterior cranial fossa, jugular foramen or midline skull base, including labyrinthectomy, decompression, with or without mobilization of facial nerve and/or petrous carotid 4788 61596 61596 artery $ 6,489.00 Transcondylar (far lateral) approach to posterior cranial fossa, jugular foramen or midline skull base, including occipital condylectomy, mastoidectomy, resection of C1-C3 vertebral body(s), decompression of vertebral artery, with or without 4789 61597 61597 mobilization $ 7,729.20 Transpetrosal approach to posterior cranial fossa, clivus or foramen magnum, including ligation of superior petrosal sinus and/or 4790 61598 61598 sigmoid sinus $ 6,545.70 Resection or excision of neoplastic, vascular or infectious lesion of 4791 61600 61600 base of anterior cranial fossa; extradural $ 5,345.10 Resection or excision of neoplastic, vascular or infectious lesion of base of anterior cranial fossa; intradural, including dural repair, with 4792 61601 61601 or without graft $ 6,008.40 Resection or excision of neoplastic, vascular or infectious lesion of infratemporal fossa, parapharyngeal space, petrous apex; 4793 61605 61605 extradural $ 5,562.90 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Resection or excision of neoplastic, vascular or infectious lesion of infratemporal fossa, parapharyngeal space, petrous apex; 4794 61606 61606 intradural, including dural repair, with or without graft $ 7,875.00 Resection or excision of neoplastic, vascular or infectious lesion of parasellar area, cavernous sinus, clivus or midline skull base; 4795 61607 61607 extradural $ 7,877.70 Resection or excision of neoplastic, vascular or infectious lesion of parasellar area, cavernous sinus, clivus or midline skull base; 4796 61608 61608 intradural, including dural repair, with or without graft $ 8,641.80 Transection or ligation, carotid artery in cavernous sinus; without 4797 61609 61609 repair (List separately in addition to code for primary procedure) $ 2,159.10 Transection or ligation, carotid artery in cavernous sinus; with repair by anastomosis or graft (List separately in addition to code 4798 61610 61610 for primary procedure) $ 5,758.20 Transection or ligation, carotid artery in petrous canal; without 4799 61611 61611 repair (List separately in addition to code for primary procedure) $ 1,481.40 Transection or ligation, carotid artery in petrous canal; with repair by anastomosis or graft (List separately in addition to code for 4800 61612 61612 primary procedure) $ 5,562.00 Obliteration of carotid aneurysm, arteriovenous malformation, or 4801 61613 61613 carotid-cavernous fistula by dissection within cavernous sinus $ 8,973.90 Resection or excision of neoplastic, vascular or infectious lesion of base of posterior cranial fossa, jugular foramen, foramen magnum, 4802 61615 61615 or C1-C3 vertebral bodies; extradural $ 6,874.20 Resection or excision of neoplastic, vascular or infectious lesion of base of posterior cranial fossa, jugular foramen, foramen magnum, or C1-C3 vertebral bodies; intradural, including dural repair, with or 4803 61616 without graft $ 8,987.40 Secondary repair of dura for cerebrospinal fluid leak, anterior, middle or posterior cranial fossa following surgery of the skull base; by free tissue graft (eg, pericranium, fascia, tensor fascia lata, 4804 61618 61618 adipose tissue, homologous or synthetic grafts) $ 3,795.30 Secondary repair of dura for cerebrospinal fluid leak, anterior, middle or posterior cranial fossa following surgery of the skull base; by local or regionalized vascularized pedicle flap or myocutaneous 4805 61619 61619 flap (including galea, temporalis, frontalis or occi $ 6,327.00 Endovascular temporary balloon arterial occlusion, head or neck (extracranial/intracranial) including selective catheterization of vessel to be occluded, positioning and inflation of occlusion balloon, 4806 61623 61623 concomitant neurological monitoring, and radiologic s $ 2,587.65 Transcatheter permanent occlusion or embolization (eg, for tumor destruction, to achieve hemostasis, to occlude a vascular malformation), percutaneous, any method; central nervous system 4807 61624 61624 (intracranial, spinal cord) $ 4,705.20 Transcatheter permanent occlusion or embolization (eg, for tumor destruction, to achieve hemostasis, to occlude a vascular malformation), percutaneous, any method; non-central nervous 4808 61626 61626 system, head or neck (extracranial, brachiocephalic branch) $ 3,346.20 Balloon angioplasty, intracranial (eg, atherosclerotic stenosis), 4809 61630 61630 percutaneous $ 4,445.59 Transcatheter placement of intravascular stent(s), intracranial (eg, atherosclerotic stenosis), including balloon angioplasty, if 4810 61635 61635 performed $ 5,059.80 Balloon dilatation of intracranial vasospasm, percutaneous; initial 4811 61640 61640 vessel $ 3,692.54 Balloon dilatation of intracranial vasospasm, percutaneous; each additional vessel in same vascular family (List separately in addition 4812 61641 61641 to code for primary procedure) $ 1,825.26 Balloon dilatation of intracranial vasospasm, percutaneous; each additional vessel in different vascular family (List separately in 4813 61642 61642 addition to code for primary procedure) $ 1,874.98 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Surgery of intracranial arteriovenous malformation; supratentorial, 4814 61680 61680 simple $ 7,841.70 Surgery of intracranial arteriovenous malformation; supratentorial, 4815 61682 61682 complex $ 9,553.50 Surgery of intracranial arteriovenous malformation; infratentorial, 4816 61684 61684 simple $ 8,433.00 Surgery of intracranial arteriovenous malformation; infratentorial, 4817 61686 61686 complex $ 10,935.90 4818 61690 61690 Surgery of intracranial arteriovenous malformation; dural, simple $ 7,769.70 4819 61692 61692 Surgery of intracranial arteriovenous malformation; dural, complex $ 8,279.10 Surgery of complex intracranial aneurysm, intracranial approach; 4820 61697 61697 carotid circulation $ 8,145.00 Surgery of complex intracranial aneurysm, intracranial approach; 4821 61698 61698 vertebrobasilar circulation $ 7,839.00 Surgery of simple intracranial aneurysm, intracranial approach; 4822 61700 61700 carotid circulation $ 8,034.30 Surgery of simple intracranial aneurysm, intracranial approach; 4823 61702 61702 vertebrobasilar circulation $ 7,725.60 Surgery of intracranial aneurysm, cervical approach by application of occluding clamp to cervical carotid artery (Selverstone- 4824 61703 61703 Crutchfield type) $ 3,445.20 Surgery of aneurysm, vascular malformation or carotid-cavernous 4825 61705 61705 fistula; by intracranial and cervical occlusion of carotid artery $ 8,181.00 Surgery of aneurysm, vascular malformation or carotid-cavernous 4826 61708 61708 fistula; by intracranial electrothrombosis $ 6,218.10 Surgery of aneurysm, vascular malformation or carotid-cavernous fistula; by intra-arterial embolization, injection procedure, or 4827 61710 61710 balloon catheter $ 5,119.20 Anastomosis, arterial, extracranial-intracranial (eg, middle 4828 61711 61711 cerebral/cortical) arteries $ 6,508.80 Creation of lesion by stereotactic method, including burr hole(s) and localizing and recording techniques, single or multiple stages; 4829 61720 61720 globus pallidus or thalamus $ 4,897.80 Creation of lesion by stereotactic method, including burr hole(s) and localizing and recording techniques, single or multiple stages; 4830 61735 61735 subcortical structure(s) other than globus pallidus or thalamus $ 5,054.40 Stereotactic biopsy, aspiration, or excision, including burr hole(s), 4831 61750 61750 for intracranial lesion; $ 5,047.20 Stereotactic biopsy, aspiration, or excision, including burr hole(s), for intracranial lesion; with computed tomography and/or magnetic 4832 61751 61751 resonance guidance $ 5,544.00 Stereotactic implantation of depth electrodes into the cerebrum for 4833 61760 61760 long-term seizure monitoring $ 5,960.70 Stereotactic localization, including burr hole(s), with insertion of 4834 61770 61770 catheter(s) or probe(s) for placement of radiation source $ 5,312.70 Creation of lesion by stereotactic method, percutaneous, by neurolytic agent (eg, alcohol, thermal, electrical, radiofrequency); 4835 61790 61790 gasserian ganglion $ 4,118.40 Creation of lesion by stereotactic method, percutaneous, by neurolytic agent (eg, alcohol, thermal, electrical, radiofrequency); 4836 61791 61791 trigeminal medullary tract $ 3,960.90 Stereotactic radiosurgery (particle beam, gamma ray, or linear 4837 61796 61796 accelerator); 1 simple cranial lesion $ 4,260.08 Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional cranial lesion, simple (List separately in 4838 61797 61797 addition to code for primary procedure) $ 1,148.15 Stereotactic radiosurgery (particle beam, gamma ray, or linear 4839 61798 61798 accelerator); 1 complex cranial lesion $ 4,339.38 Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional cranial lesion, complex (List separately 4840 61799 61799 in addition to code for primary procedure) $ 1,612.19 Application of stereotactic headframe for stereotactic radiosurgery 4841 61800 61800 (List separately in addition to code for primary procedure) $ 806.16 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Twist drill or burr hole(s) for implantation of neurostimulator 4842 61850 61850 electrodes, cortical $ 3,304.80 Craniectomy or craniotomy for implantation of neurostimulator 4843 61860 61860 electrodes, cerebral, cortical $ 4,075.20 Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (eg, thalamus, globus pallidus, subthalamic nucleus, periventricular, 4844 61863 61863 periaqueductal gray), without use of intraoperat $ 3,473.61 Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (eg, thalamus, globus pallidus, subthalamic nucleus, periventricular, 4845 61864 61864 periaqueductal gray), without use of intraoperat $ 1,609.63 Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (eg, thalamus, globus pallidus, subthalamic nucleus, periventricular, 4846 61867 61867 periaqueductal gray), with use of intraoperative $ 5,176.91 Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (eg, thalamus, globus pallidus, subthalamic nucleus, periventricular, 4847 61868 61868 periaqueductal gray), with use of intraoperative $ 2,433.01 Craniectomy for implantation of neurostimulator electrodes, 4848 61870 61870 cerebellar; cortical $ 3,723.30 Craniectomy for implantation of neurostimulator electrodes, 4849 61875 61875 cerebellar; subcortical $ 3,501.90 4850 61880 61880 Revision or removal of intracranial neurostimulator electrodes $ 2,471.40 Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single 4851 61885 61885 electrode array $ 943.20 Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to 2 or 4852 61886 61886 more electrode arrays $ 1,390.50 Revision or removal of cranial neurostimulator pulse generator or 4853 61888 61888 receiver $ 1,009.80 4854 62000 62000 Elevation of depressed skull fracture; simple, extradural $ 3,420.00 Elevation of depressed skull fracture; compound or comminuted, 4855 62005 extradural $ 4,185.00 Elevation of depressed skull fracture; with repair of dura and/or 4856 62010 62010 debridement of brain $ 5,310.00 Craniotomy for repair of dural/cerebrospinal fluid leak, including 4857 62100 62100 surgery for rhinorrhea/otorrhea $ 5,804.10 Reduction of craniomegalic skull (eg, treated hydrocephalus); not 4858 62115 62115 requiring bone grafts or cranioplasty $ 2,946.76 Reduction of craniomegalic skull (eg, treated hydrocephalus); with 4859 62116 62116 simple cranioplasty $ 4,497.88 Reduction of craniomegalic skull (eg, treated hydrocephalus); requiring craniotomy and reconstruction with or without bone graft 4860 62117 62117 (includes obtaining grafts) $ 4,892.40 4861 62120 62120 Repair of encephalocele, skull vault, including cranioplasty $ 4,874.40 4862 62121 62121 Craniotomy for repair of encephalocele, skull base $ 4,878.00 4863 62140 62140 Cranioplasty for skull defect; up to 5 cm diameter $ 4,598.10 4864 62141 62141 Cranioplasty for skull defect; larger than 5 cm diameter $ 4,816.80 4865 62142 62142 Removal of bone flap or prosthetic plate of skull $ 3,197.70 4866 62143 62143 Replacement of bone flap or prosthetic plate of skull $ 3,862.80 4867 62145 62145 Cranioplasty for skull defect with reparative brain surgery $ 4,948.20 Cranioplasty with autograft (includes obtaining bone grafts); up to 5 4868 62146 62146 cm diameter $ 4,377.60 Cranioplasty with autograft (includes obtaining bone grafts); larger 4869 62147 62147 than 5 cm diameter $ 4,841.10 Incision and retrieval of subcutaneous cranial bone graft for cranioplasty (List separately in addition to code for primary 4870 62148 62148 procedure) $ 445.59 Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external 4871 62160 drainage (List separately in addition to code for primary procedure) $ 479.08 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Neuroendoscopy, intracranial; with dissection of adhesions, fenestration of septum pellucidum or intraventricular cysts (including placement, replacement, or removal of ventricular 4872 62161 catheter) $ 5,992.94 Neuroendoscopy, intracranial; with fenestration or excision of colloid cyst, including placement of external ventricular catheter for 4873 62162 drainage $ 6,085.95 4874 62163 Neuroendoscopy, intracranial; with retrieval of foreign body $ 6,926.90 Neuroendoscopy, intracranial; with excision of brain tumor, 4875 62164 including placement of external ventricular catheter for drainage $ 7,165.41 Neuroendoscopy, intracranial; with excision of pituitary tumor, 4876 62165 transnasal or trans-sphenoidal approach $ 6,442.36 4877 62180 Ventriculocisternostomy (Torkildsen type operation) $ 4,006.80 4878 62190 Creation of shunt; subarachnoid/subdural-atrial, -jugular, -auricular $ 3,469.50 Creation of shunt; subarachnoid/subdural-peritoneal, -pleural, 4879 62192 other terminus $ 3,523.50 4880 62194 Replacement or irrigation, subarachnoid/subdural catheter $ 1,296.90 4881 62200 Ventriculocisternostomy, third ventricle; $ 4,726.80 Ventriculocisternostomy, third ventricle; stereotactic, 4882 62201 neuroendoscopic method $ 4,996.62 4883 62220 Creation of shunt; ventriculo-atrial, -jugular, -auricular $ 4,307.40 4884 62223 Creation of shunt; ventriculo-peritoneal, -pleural, other terminus $ 4,331.70 4885 62225 Replacement or irrigation, ventricular catheter $ 1,852.20 Replacement or revision of cerebrospinal fluid shunt, obstructed 4886 62230 valve, or distal catheter in shunt system $ 3,162.60 4887 62252 62252 Reprogramming of programmable cerebrospinal shunt $ 236.70 4888 62252-26 26 62252 Reprogramming of programmable cerebrospinal shunt $ 122.96 4889 62252-TC TC 62252 Reprogramming of programmable cerebrospinal shunt $ 113.74 Removal of complete cerebrospinal fluid shunt system; without 4890 62256 replacement $ 1,863.00 Removal of complete cerebrospinal fluid shunt system; with 4891 62258 replacement by similar or other shunt at same operation $ 4,531.50 Percutaneous lysis of epidural adhesions using solution injection (eg, hypertonic saline, enzyme) or mechanical means (eg, catheter) including radiologic localization (includes contrast when 4892 62263 62263 administered), multiple adhesiolysis sessions; 2 or more days $ 1,090.80 Percutaneous lysis of epidural adhesions using solution injection (eg, hypertonic saline, enzyme) or mechanical means (eg, catheter) including radiologic localization (includes contrast when 4893 62264 62264 administered), multiple adhesiolysis sessions; 1 day $ 1,042.86 Percutaneous aspiration within the nucleus pulposus, intervertebral 4894 62267 disc, or paravertebral tissue for diagnostic purposes $ 816.24 4895 62268 Percutaneous aspiration, spinal cord cyst or syrinx $ 1,906.20 4896 62269 Biopsy of spinal cord, percutaneous needle $ 1,579.50 4897 62270 62270 Spinal puncture, lumbar, diagnostic $ 215.10 Spinal puncture, therapeutic, for drainage of cerebrospinal fluid (by 4898 62272 62272 needle or catheter) $ 283.50 4899 62273 62273 Injection, epidural, of blood or clot patch $ 512.10 Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced saline solutions), with or without other therapeutic substance; 4900 62280 subarachnoid $ 483.30 Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced saline solutions), with or without other therapeutic substance; 4901 62281 epidural, cervical or thoracic $ 566.10 Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced saline solutions), with or without other therapeutic substance; 4902 62282 epidural, lumbar, sacral (caudal) $ 636.30 Injection procedure for myelography and/or computed 4903 62284 62284 tomography, spinal (other than C1-C2 and posterior fossa) $ 522.90 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, any method utilizing needle based technique to remove disc material under fluoroscopic imaging or other form of 4904 62287 indirect visualization, with the use of an endoscope, with d $ 3,543.30 4905 62290 62290 Injection procedure for discography, each level; lumbar $ 551.70 4906 62291 62291 Injection procedure for discography, each level; cervical or thoracic $ 524.70 Injection procedure for chemonucleolysis, including discography, 4907 62292 62292 intervertebral disc, single or multiple levels, lumbar $ 2,452.50 Injection procedure, arterial, for occlusion of arteriovenous 4908 62294 62294 malformation, spinal $ 1,232.10 Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter 4909 62310 62310 placement, includes contrast for localization when performed, $ 875.70 Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter 4910 62311 placement, includes contrast for localization when performed, $ 933.30 Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, 4911 62318 62318 other solution), not including neurolytic substances, includ $ 968.40 Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, 4912 62319 62319 other solution), not including neurolytic substances, includ $ 942.30 Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; without 4913 62350 62350 laminectomy $ 1,545.30 Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; with 4914 62351 62351 laminectomy $ 2,763.90 4915 62355 62355 Removal of previously implanted intrathecal or epidural catheter $ 1,368.00 Implantation or replacement of device for intrathecal or epidural 4916 62360 62360 drug infusion; subcutaneous reservoir $ 566.10 Implantation or replacement of device for intrathecal or epidural 4917 62361 drug infusion; nonprogrammable pump $ 1,849.28 Implantation or replacement of device for intrathecal or epidural drug infusion; programmable pump, including preparation of pump, 4918 62362 62362 with or without programming $ 1,653.30 Removal of subcutaneous reservoir or pump, previously implanted 4919 62365 62365 for intrathecal or epidural infusion $ 1,313.10 Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); without 4920 62367 62367 reprogramming or refill $ 103.05 Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); with 4921 62368 62368 reprogramming $ 136.97 Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or 4922 63001 63001 discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; cervical $ 4,944.60 Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or 4923 63003 63003 discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; thoracic $ 5,364.90 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; lumbar, 4924 63005 63005 except for spondylolisthesis $ 4,862.70 Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or 4925 63011 63011 discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; sacral $ 4,583.70 Laminectomy with removal of abnormal facets and/or pars inter- articularis with decompression of cauda equina and nerve roots for 4926 63012 63012 spondylolisthesis, lumbar (Gill type procedure) $ 4,892.40 Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebral segments; 4927 63015 63015 cervical $ 6,095.70 Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebral segments; 4928 63016 63016 thoracic $ 5,768.10 Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebral segments; 4929 63017 63017 lumbar $ 5,402.70 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or 4930 63020 63020 excision of herniated intervertebral disc; 1 interspace, cervical $ 4,932.00 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or 4931 63030 63030 excision of herniated intervertebral disc; 1 interspace, lumbar $ 5,275.80 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; each additional interspace, 4932 63035 63035 cervical or lumbar (List separately in addition to code for primar $ 1,433.70 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single 4933 63040 63040 interspace; cervical $ 5,602.50 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single 4934 63042 63042 interspace; lumbar $ 6,077.70 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; each additional cervical interspace (List separately in 4935 63043 addi $ 304.43 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; each additional lumbar interspace (List separately in 4936 63044 63044 additi $ - Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral 4937 63045 63045 segment; cervical $ 5,896.80 Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral 4938 63046 63046 segment; thoracic $ 5,850.90 Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral 4939 63047 63047 segment; lumbar $ 6,197.40 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral 4940 63048 63048 segment; each additional segment, cervical, thoracic, or lu $ 2,574.90 Laminoplasty, cervical, with decompression of the spinal cord, 2 or 4941 63050 more vertebral segments; $ 5,247.21 Laminoplasty, cervical, with decompression of the spinal cord, 2 or more vertebral segments; with reconstruction of the posterior bony elements (including the application of bridging bone graft and non- 4942 63051 segmental fixation devices [eg, wire, suture, mini-pl $ 5,950.77 Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single 4943 63055 63055 segment; thoracic $ 6,694.20 Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; lumbar (including transfacet, or lateral extraforaminal 4944 63056 63056 approach) (eg, far lateral herniated intervertebral disc) $ 5,550.30 Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; each additional segment, thoracic or lumbar (List 4945 63057 63057 separately in addition to code for primary procedure) $ 1,699.20 Costovertebral approach with decompression of spinal cord or nerve root(s) (eg, herniated intervertebral disc), thoracic; single 4946 63064 63064 segment $ 5,833.80 Costovertebral approach with decompression of spinal cord or nerve root(s) (eg, herniated intervertebral disc), thoracic; each additional segment (List separately in addition to code for primary 4947 63066 63066 procedure) $ 1,287.90 Discectomy, anterior, with decompression of spinal cord and/or 4948 63075 63075 nerve root(s), including osteophytectomy; cervical, single interspace $ 5,081.40 Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, each additional interspace (List separately in addition to code for primary 4949 63076 63076 procedure) $ 1,952.10 Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; thoracic, single 4950 63077 63077 interspace $ 4,871.70 Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; thoracic, each additional interspace (List separately in addition to code for primary 4951 63078 63078 procedure) $ 1,342.80 Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord 4952 63081 63081 and/or nerve root(s); cervical, single segment $ 6,626.70 Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, each additional segment (List 4953 63082 63082 separately in addition to code for primary procedure) $ 1,591.20 Vertebral corpectomy (vertebral body resection), partial or complete, transthoracic approach with decompression of spinal 4954 63085 63085 cord and/or nerve root(s); thoracic, single segment $ 7,022.70 Vertebral corpectomy (vertebral body resection), partial or complete, transthoracic approach with decompression of spinal cord and/or nerve root(s); thoracic, each additional segment (List 4955 63086 63086 separately in addition to code for primary procedure) $ 1,986.30 Vertebral corpectomy (vertebral body resection), partial or complete, combined thoracolumbar approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic or 4956 63087 63087 lumbar; single segment $ 6,282.90 Vertebral corpectomy (vertebral body resection), partial or complete, combined thoracolumbar approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic or 4957 63088 63088 lumbar; each additional segment (List separately in addition to code $ 1,699.20 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Vertebral corpectomy (vertebral body resection), partial or complete, transperitoneal or retroperitoneal approach with decompression of spinal cord, cauda equina or nerve root(s), lower 4958 63090 63090 thoracic, lumbar, or sacral; single segment $ 6,551.10 Vertebral corpectomy (vertebral body resection), partial or complete, transperitoneal or retroperitoneal approach with decompression of spinal cord, cauda equina or nerve root(s), lower 4959 63091 63091 thoracic, lumbar, or sacral; each additional segment (List separately $ 1,787.40 Vertebral corpectomy (vertebral body resection), partial or complete, lateral extracavitary approach with decompression of spinal cord and/or nerve root(s) (eg, for tumor or retropulsed bone 4960 63101 fragments); thoracic, single segment $ 6,101.26 Vertebral corpectomy (vertebral body resection), partial or complete, lateral extracavitary approach with decompression of spinal cord and/or nerve root(s) (eg, for tumor or retropulsed bone 4961 63102 fragments); lumbar, single segment $ 6,074.85 Vertebral corpectomy (vertebral body resection), partial or complete, lateral extracavitary approach with decompression of spinal cord and/or nerve root(s) (eg, for tumor or retropulsed bone 4962 63103 fragments);

thoracic or lumbar, each additional segment (List se $ 1,901.26 Laminectomy with myelotomy (eg, Bischof or DREZ type), cervical, 4963 63170 63170 thoracic, or thoracolumbar $ 5,840.10 Laminectomy with drainage of intramedullary cyst/syrinx; to 4964 63172 63172 subarachnoid space $ 5,694.30 Laminectomy with drainage of intramedullary cyst/syrinx; to 4965 63173 63173 peritoneal or pleural space $ 5,922.90 Laminectomy and section of dentate ligaments, with or without 4966 63180 63180 dural graft, cervical; 1 or 2 segments $ 5,348.70 Laminectomy and section of dentate ligaments, with or without 4967 63182 63182 dural graft, cervical; more than 2 segments $ 5,603.40 4968 63185 63185 Laminectomy with rhizotomy; 1 or 2 segments $ 4,599.00 4969 63190 63190 Laminectomy with rhizotomy; more than 2 segments $ 5,452.20 4970 63191 63191 Laminectomy with section of spinal accessory nerve $ 3,994.20 Laminectomy with cordotomy, with section of 1 spinothalamic tract, 4971 63194 63194 1 stage; cervical $ 4,356.90 Laminectomy with cordotomy, with section of 1 spinothalamic tract, 4972 63195 63195 1 stage; thoracic $ 4,849.20 Laminectomy with cordotomy, with section of both spinothalamic 4973 63196 63196 tracts, 1 stage; cervical $ 4,980.60 Laminectomy with cordotomy, with section of both spinothalamic 4974 63197 63197 tracts, 1 stage; thoracic $ 5,346.00 Laminectomy with cordotomy with section of both spinothalamic 4975 63198 63198 tracts, 2 stages within 14 days; cervical $ 5,892.30 Laminectomy with cordotomy with section of both spinothalamic 4976 63199 63199 tracts, 2 stages within 14 days; thoracic $ 5,892.30 4977 63200 63200 Laminectomy, with release of tethered spinal cord, lumbar $ 4,874.40 Laminectomy for excision or occlusion of arteriovenous 4978 63250 63250 malformation of spinal cord; cervical $ 6,437.70 Laminectomy for excision or occlusion of arteriovenous 4979 63251 63251 malformation of spinal cord; thoracic $ 6,669.90 Laminectomy for excision or occlusion of arteriovenous 4980 63252 63252 malformation of spinal cord; thoracolumbar $ 7,471.80 Laminectomy for excision or evacuation of intraspinal lesion other 4981 63265 63265 than neoplasm, extradural; cervical $ 5,824.80 Laminectomy for excision or evacuation of intraspinal lesion other 4982 63266 63266 than neoplasm, extradural; thoracic $ 6,412.50 Laminectomy for excision or evacuation of intraspinal lesion other 4983 63267 63267 than neoplasm, extradural; lumbar $ 5,632.20 Laminectomy for excision or evacuation of intraspinal lesion other 4984 63268 63268 than neoplasm, extradural; sacral $ 4,805.10 Laminectomy for excision of intraspinal lesion other than neoplasm, 4985 63270 63270 intradural; cervical $ 5,739.30 Laminectomy for excision of intraspinal lesion other than neoplasm, 4986 63271 63271 intradural; thoracic $ 5,804.10 Laminectomy for excision of intraspinal lesion other than neoplasm, 4987 63272 63272 intradural; lumbar $ 5,796.00 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Laminectomy for excision of intraspinal lesion other than neoplasm, 4988 63273 63273 intradural; sacral $ 5,023.80 Laminectomy for biopsy/excision of intraspinal neoplasm; 4989 63275 63275 extradural, cervical $ 6,346.80 Laminectomy for biopsy/excision of intraspinal neoplasm; 4990 63276 63276 extradural, thoracic $ 6,246.90 Laminectomy for biopsy/excision of intraspinal neoplasm; 4991 63277 63277 extradural, lumbar $ 5,616.90 Laminectomy for biopsy/excision of intraspinal neoplasm; 4992 63278 63278 extradural, sacral $ 5,306.40 Laminectomy for biopsy/excision of intraspinal neoplasm; 4993 63280 63280 intradural, extramedullary, cervical $ 6,412.50 Laminectomy for biopsy/excision of intraspinal neoplasm; 4994 63281 63281 intradural, extramedullary, thoracic $ 6,556.50 Laminectomy for biopsy/excision of intraspinal neoplasm; 4995 63282 63282 intradural, extramedullary, lumbar $ 6,702.30 Laminectomy for biopsy/excision of intraspinal neoplasm; 4996 63283 63283 intradural, sacral $ 5,282.10 Laminectomy for biopsy/excision of intraspinal neoplasm; 4997 63285 63285 intradural, intramedullary, cervical $ 6,808.50 Laminectomy for biopsy/excision of intraspinal neoplasm; 4998 63286 63286 intradural, intramedullary, thoracic $ 7,128.00 Laminectomy for biopsy/excision of intraspinal neoplasm; 4999 63287 63287 intradural, intramedullary, thoracolumbar $ 7,533.00 Laminectomy for biopsy/excision of intraspinal neoplasm; combined 5000 63290 63290 extradural-intradural lesion, any level $ 7,120.80 Osteoplastic reconstruction of dorsal spinal elements, following primary intraspinal procedure (List separately in addition to code 5001 63295 for primary procedure) $ 876.68 Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; 5002 63300 63300 extradural, cervical $ 6,033.60 Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; 5003 63301 63301 extradural, thoracic by transthoracic approach $ 6,150.60 Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; 5004 63302 63302 extradural, thoracic by thoracolumbar approach $ 6,551.10 Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; extradural, lumbar or sacral by transperitoneal or retroperitoneal 5005 63303 63303 approach $ 6,489.00 Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; 5006 63304 63304 intradural, cervical $ 6,502.50 Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; 5007 63305 63305 intradural, thoracic by transthoracic approach $ 6,653.70 Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; 5008 63306 63306 intradural, thoracic by thoracolumbar approach $ 6,643.80 Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; intradural, lumbar or sacral by transperitoneal or retroperitoneal 5009 63307 63307 approach $ 7,065.90 Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; each additional segment (List separately in addition to codes for single 5010 63308 63308 segment) $ 1,661.40 Creation of lesion of spinal cord by stereotactic method, percutaneous, any modality (including stimulation and/or 5011 63600 63600 recording) $ 3,244.50 Stereotactic stimulation of spinal cord, percutaneous, separate 5012 63610 63610 procedure not followed by other surgery $ 2,502.90 5013 63615 63615 Stereotactic biopsy, aspiration, or excision of lesion, spinal cord $ 3,785.40 Stereotactic radiosurgery (particle beam, gamma ray, or linear 5014 63620 63620 accelerator); 1 spinal lesion $ 1,894.72 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional spinal lesion (List separately in 5015 63621 63621 addition to code for primary procedure) $ 590.80 Percutaneous implantation of neurostimulator electrode array, 5016 63650 63650 epidural $ 3,397.50 Laminectomy for implantation of neurostimulator electrodes, 5017 63655 63655 plate/paddle, epidural $ 4,462.20 Removal of spinal neurostimulator electrode percutaneous array(s), 5018 63661 including fluoroscopy, when performed $ 1,863.09 Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when 5019 63662 performed $ 3,176.79 Revision including replacement, when performed, of spinal neurostimulator electrode percutaneous array(s), including 5020 63663 fluoroscopy, when performed $ 2,705.03 Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or 5021 63664 laminectomy, including fluoroscopy, when performed $ 3,472.26 Insertion or replacement of spinal neurostimulator pulse generator 5022 63685 63685 or receiver, direct or inductive coupling $ 2,304.90 Revision or removal of implanted spinal neurostimulator pulse 5023 63688 generator or receiver $ 1,452.60 5024 63700 63700 Repair of meningocele; less than 5 cm diameter $ 3,715.20 5025 63702 63702 Repair of meningocele; larger than 5 cm diameter $ 3,716.10 5026 63704 63704 Repair of myelomeningocele; less than 5 cm diameter $ 4,053.60 5027 63706 63706 Repair of myelomeningocele; larger than 5 cm diameter $ 4,401.00 5028 63707 63707 Repair of dural/cerebrospinal fluid leak, not requiring laminectomy $ 4,411.80 Repair of dural/cerebrospinal fluid leak or pseudomeningocele, with 5029 63709 63709 laminectomy $ 5,055.30 5030 63710 63710 Dural graft, spinal $ 4,424.40 Creation of shunt, lumbar, subarachnoid-peritoneal, -pleural, or 5031 63740 63740 other; including laminectomy $ 4,424.40 Creation of shunt, lumbar, subarachnoid-peritoneal, -pleural, or 5032 63741 63741 other; percutaneous, not requiring laminectomy $ 2,841.30 5033 63744 63744 Replacement, irrigation or revision of lumbosubarachnoid shunt $ 2,214.90 Removal of entire lumbosubarachnoid shunt system without 5034 63746 63746 replacement $ 1,661.40 5035 64400 Injection, anesthetic agent; trigeminal nerve, any division or branch $ 369.00 5036 64402 64402 Injection, anesthetic agent; facial nerve $ 243.90 5037 64405 64405 Injection, anesthetic agent; greater occipital nerve $ 242.10 5038 64408 64408 Injection, anesthetic agent; vagus nerve $ 284.40 5039 64410 64410 Injection, anesthetic agent; phrenic nerve $ 250.20 5040 64412 64412 Injection, anesthetic agent; spinal accessory nerve $ 242.10 5041 64413 64413 Injection, anesthetic agent; cervical plexus $ 299.70 5042 64415 64415 Injection, anesthetic agent; brachial plexus, single $ 268.20 Injection, anesthetic agent; brachial plexus, continuous infusion by 5043 64416 64416 catheter (including catheter placement) $ 305.64 5044 64417 64417 Injection, anesthetic agent; axillary nerve $ 250.20 5045 64418 64418 Injection, anesthetic agent; suprascapular nerve $ 274.07 5046 64420 64420 Injection, anesthetic agent; intercostal nerve, single $ 261.90 Injection, anesthetic agent; intercostal nerves, multiple, regional 5047 64421 64421 block $ 486.90 5048 64425 64425 Injection, anesthetic agent; ilioinguinal, iliohypogastric nerves $ 257.40 5049 64430 64430 Injection, anesthetic agent; pudendal nerve $ 261.00 5050 64435 64435 Injection, anesthetic agent; paracervical (uterine) nerve $ 234.90 5051 64445 64445 Injection, anesthetic agent; sciatic nerve, single $ 326.70 Injection, anesthetic agent; sciatic nerve, continuous infusion by 5052 64446 64446 catheter (including catheter placement) $ 305.97 5053 64447 64447 Injection, anesthetic agent; femoral nerve, single $ 228.81 Injection, anesthetic agent; femoral nerve, continuous infusion by 5054 64448 64448 catheter (including catheter placement) $ 275.13 Injection, anesthetic agent; lumbar plexus, posterior approach, 5055 64449 64449 continuous infusion by catheter (including catheter placement) $ 306.30 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price 5056 64450 64450 Injection, anesthetic agent; other peripheral nerve or branch $ 185.40 Injection(s), anesthetic agent and/or steroid, plantar common 5057 64455 64455 digital nerve(s) (eg, Morton's neuroma) $ 157.67 Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or 5058 64479 64479 thoracic, single level $ 485.10 Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional level (List separately in addition to code for 5059 64480 64480 primary procedure) $ 436.50 Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or 5060 64483 64483 sacral, single level $ 398.11 Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional level (List separately in addition to code for 5061 64484 64484 primary procedure) $ 447.30 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image 5062 64490 64490 guidance (fluoroscopy or CT), cervical or thoracic; single level $ 404.72 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; second level (List 5063 64491 64491 separately in addition to code for primary proced $ 287.25 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; third and any 5064 64492 64492 additional level(s) (List separately in addition to co $ 287.36 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image 5065 64493 64493 guidance (fluoroscopy or CT), lumbar or sacral; single level $ 398.98 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (List 5066 64494 64494 separately in addition to code for primary procedure) $ 227.39 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any 5067 64495 64495 additional level(s) (List separately in addition to code f $ 227.49 5068 64505 64505 Injection, anesthetic agent; sphenopalatine ganglion $ 244.80 5069 64508 64508 Injection, anesthetic agent; carotid sinus (separate procedure) $ 262.80 5070 64510 64510 Injection, anesthetic agent; stellate ganglion (cervical sympathetic) $ 295.20 5071 64517 64517 Injection, anesthetic agent; superior hypogastric plexus $ 385.18 Injection, anesthetic agent; lumbar or thoracic (paravertebral 5072 64520 64520 sympathetic) $ 490.41 Injection, anesthetic agent; celiac plexus, with or without radiologic 5073 64530 64530 monitoring $ 540.90 5074 64550 64550 Application of surface (transcutaneous) neurostimulator $ 123.54 Percutaneous implantation of neurostimulator electrode array; 5075 64553 64553 cranial nerve $ 360.90 Percutaneous implantation of neurostimulator electrode array; 5076 64555 64555 peripheral nerve (excludes sacral nerve) $ 309.60 Percutaneous implantation of neurostimulator electrode array; sacral nerve (transforaminal placement) including image guidance, 5077 64561 64561 if performed $ 1,611.28 Percutaneous implantation of neurostimulator electrode array; 5078 64565 64565 neuromuscular $ 293.40 Posterior tibial neurostimulation, percutaneous needle electrode, 5079 64566 64566 single treatment, includes programming $ 266.83 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Incision for implantation of cranial nerve (eg, vagus nerve) 5080 64568 64568 neurostimulator electrode array and pulse generator $ 1,127.59 Revision or replacement of cranial nerve (eg, vagus nerve) neurostimulator electrode array, including connection to existing 5081 64569 64569 pulse generator $ 1,130.12 Removal of cranial nerve (eg, vagus nerve) neurostimulator 5082 64570 64570 electrode array and pulse generator $ 999.18 Incision for implantation of neurostimulator electrode array; 5083 64575 64575 peripheral nerve (excludes sacral nerve) $ 963.90 Incision for implantation of neurostimulator electrode array; 5084 64580 64580 neuromuscular $ 793.80 Incision for implantation of neurostimulator electrode array; sacral 5085 64581 64581 nerve (transforaminal placement) $ 1,141.09 5086 64585 64585 Revision or removal of peripheral neurostimulator electrode array $ 678.60 Insertion or replacement of peripheral or gastric neurostimulator 5087 64590 64590 pulse generator or receiver, direct or inductive coupling $ 738.90 Revision or removal of peripheral or gastric neurostimulator pulse 5088 64595 64595 generator or receiver $ 530.10 Destruction by neurolytic agent, trigeminal nerve; supraorbital, 5089 64600 64600 infraorbital, mental, or inferior alveolar branch $ 540.90 Destruction by neurolytic agent, trigeminal nerve; second and third 5090 64605 64605 division branches at foramen ovale $ 669.60 Destruction by neurolytic agent, trigeminal nerve; second and third 5091 64610 64610 division branches at foramen ovale under radiologic monitoring $ 1,837.80 Chemodenervation of muscle(s); muscle(s) innervated by facial 5092 64612 64612 nerve, unilateral (eg, for blepharospasm, hemifacial spasm) $ 377.10 Chemodenervation of muscle(s); neck muscle(s), excluding muscles of the larynx, unilateral (eg, for cervical dystonia, spasmodic 5093 64616 64616 torticollis) $ 202.21 Chemodenervation of muscle(s); larynx, unilateral, percutaneous (eg, for spasmodic dysphonia), includes guidance by needle 5094 64617 64617 electromyography, when performed $ 353.99 5095 64620 64620 Destruction by neurolytic agent, intercostal nerve $ 417.60 5096 64630 64630 Destruction by neurolytic agent; pudendal nerve $ 391.50 5097 64632 64632 Destruction by neurolytic agent; plantar common digital nerve $ 278.02 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, 5098 64633 64633 single facet joint $ 1,004.45 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint (List separately in addition to code for primary 5099 64634 64634 procedure) $ 457.76 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single 5100 64635 64635 facet joint $ 986.15 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary 5101 64636 64636 procedure) $ 412.31 5102 64640 64640 Destruction by neurolytic agent; other peripheral nerve or branch $ 394.20 5103 64642 64642 Chemodenervation of one extremity; 1-4 muscle(s) $ 353.99 Chemodenervation of one extremity; each additional extremity, 1-4 5104 64643 64643 muscle(s) (List separately in addition to code for primary procedure) $ 73.55 5105 64644 64644 Chemodenervation of one extremity; 5 or more muscle(s) $ 353.99 Chemodenervation of one extremity; each additional extremity, 5 or more muscle(s) (List separately in addition to code for primary 5106 64645 64645 procedure) $ 84.31 5107 64646 64646 Chemodenervation of trunk muscle(s); 1-5 muscle(s) $ 353.99 5108 64647 64647 Chemodenervation of trunk muscle(s); 6 or more muscle(s) $ 353.99 5109 64650 64650 Chemodenervation of eccrine glands; both axillae $ 106.28 Chemodenervation of eccrine glands; other area(s) (eg, scalp, face, 5110 64653 64653 neck), per day $ 139.04 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Destruction by neurolytic agent, with or without radiologic 5111 64680 64680 monitoring; celiac plexus $ 685.80 Destruction by neurolytic agent, with or without radiologic 5112 64681 64681 monitoring; superior hypogastric plexus $ 734.56 5113 64702 64702 Neuroplasty; digital, 1 or both, same digit $ 1,325.70 5114 64704 64704 Neuroplasty; nerve of hand or foot $ 1,467.90 Neuroplasty, major peripheral nerve, arm or leg, open; other than 5115 64708 64708 specified $ 1,944.90 5116 64712 64712 Neuroplasty, major peripheral nerve, arm or leg, open; sciatic nerve $ 2,121.30 Neuroplasty, major peripheral nerve, arm or leg, open; brachial 5117 64713 64713 plexus $ 2,725.20 Neuroplasty, major peripheral nerve, arm or leg, open; lumbar 5118 64714 64714 plexus $ 2,422.80 5119 64716 64716 Neuroplasty and/or transposition; cranial nerve (specify) $ 2,464.20 5120 64718 64718 Neuroplasty and/or transposition; ulnar nerve at elbow $ 2,523.60 5121 64719 64719 Neuroplasty and/or transposition; ulnar nerve at wrist $ 1,989.90 5122 64721 64721 Neuroplasty and/or transposition; median nerve at carpal tunnel $ 1,854.00 5123 64722 64722 Decompression; unspecified nerve(s) (specify) $ 2,050.20 5124 64726 64726 Decompression; plantar digital nerve $ 751.50 Internal neurolysis, requiring use of operating microscope (List separately in addition to code for neuroplasty) (Neuroplasty 5125 64727 64727 includes external neurolysis) $ 2,111.40 5126 64732 64732 Transection or avulsion of; supraorbital nerve $ 1,287.90 5127 64734 64734 Transection or avulsion of; infraorbital nerve $ 1,476.00 5128 64736 64736 Transection or avulsion of; mental nerve $ 1,255.50 5129 64738 64738 Transection or avulsion of; inferior alveolar nerve by osteotomy $ 1,447.20 5130 64740 64740 Transection or avulsion of; lingual nerve $ 1,586.70 5131 64742 64742 Transection or avulsion of; facial nerve, differential or complete $ 1,668.60 5132 64744 64744 Transection or avulsion of; greater occipital nerve $ 1,597.50 5133 64746 64746 Transection or avulsion of; phrenic nerve $ 803.70 5134 64752 64752 Transection or avulsion of; vagus nerve (vagotomy), transthoracic $ 2,326.50 Transection or avulsion of; vagus nerves limited to proximal stomach (selective proximal vagotomy, proximal gastric vagotomy, 5135 64755 64755 parietal cell vagotomy, supra- or highly selective vagotomy) $ 3,316.50 5136 64760 64760 Transection or avulsion of; vagus nerve (vagotomy), abdominal $ 1,964.70 5137 64761 64761 Transection or avulsion of; pudendal nerve $ 855.00 Transection or avulsion of obturator nerve, extrapelvic, with or 5138 64763 64763 without adductor tenotomy $ 1,021.50 Transection or avulsion of obturator nerve, intrapelvic, with or 5139 64766 64766 without adductor tenotomy $ 1,606.50 5140 64771 64771 Transection or avulsion of other cranial nerve, extradural $ 1,647.90 5141 64772 64772 Transection or avulsion of other spinal nerve, extradural $ 2,052.90 5142 64774 64774 Excision of neuroma; cutaneous nerve, surgically identifiable $ 922.50 5143 64776 64776 Excision of neuroma; digital nerve, 1 or both, same digit $ 1,074.60 Excision of neuroma; digital nerve, each additional digit (List 5144 64778 64778 separately in addition to code for primary procedure) $ 461.70 5145 64782 64782 Excision of neuroma; hand or foot, except digital nerve $ 1,261.80 Excision of neuroma; hand or foot, each additional nerve, except same digit (List separately in addition to code for primary 5146 64783 64783 procedure) $ 669.60 5147 64784 64784 Excision of neuroma; major peripheral nerve, except sciatic $ 1,841.40 5148 64786 64786 Excision of neuroma; sciatic nerve $ 2,403.00 Implantation of nerve end into bone or muscle (List separately in 5149 64787 64787 addition to neuroma excision) $ 1,390.50 5150 64788 64788 Excision of neurofibroma or neurolemmoma; cutaneous nerve $ 1,159.20 Excision of neurofibroma or neurolemmoma; major peripheral 5151 64790 64790 nerve $ 2,151.90 Excision of neurofibroma or neurolemmoma; extensive (including 5152 64792 64792 malignant type) $ 2,224.80 5153 64795 64795 Biopsy of nerve $ 914.40 5154 64802 64802 Sympathectomy, cervical $ 2,657.70 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price 5155 64804 64804 Sympathectomy, cervicothoracic $ 3,587.40 5156 64809 64809 Sympathectomy, thoracolumbar $ 2,945.70 5157 64818 64818 Sympathectomy, lumbar $ 2,699.10 5158 64820 64820 Sympathectomy; digital arteries, each digit $ 1,219.55 5159 64821 64821 Sympathectomy; radial artery $ 1,203.16 5160 64822 64822 Sympathectomy; ulnar artery $ 1,201.92 5161 64823 64823 Sympathectomy; superficial palmar arch $ 1,223.47 5162 64831 64831 Suture of digital nerve, hand or foot; 1 nerve $ 1,704.60 Suture of digital nerve, hand or foot; each additional digital nerve 5163 64832 64832 (List separately in addition to code for primary procedure) $ 927.90 5164 64834 64834 Suture of 1 nerve; hand or foot, common sensory nerve $ 1,899.00 5165 64835 64835 Suture of 1 nerve; median motor thenar $ 1,967.40 5166 64836 64836 Suture of 1 nerve; ulnar motor $ 2,360.70 Suture of each additional nerve, hand or foot (List separately in 5167 64837 64837 addition to code for primary procedure) $ 1,134.90 5168 64840 64840 Suture of posterior tibial nerve $ 2,778.30 Suture of major peripheral nerve, arm or leg, except sciatic; 5169 64856 64856 including transposition $ 2,831.40 Suture of major peripheral nerve, arm or leg, except sciatic; without 5170 64857 64857 transposition $ 2,518.20 5171 64858 64858 Suture of sciatic nerve $ 2,503.80 Suture of each additional major peripheral nerve (List separately in 5172 64859 64859 addition to code for primary procedure) $ 1,147.50 5173 64861 64861 Suture of; brachial plexus $ 2,703.60 5174 64862 64862 Suture of; lumbar plexus $ 3,292.20 5175 64864 64864 Suture of facial nerve; extracranial $ 2,355.30 5176 64865 64865 Suture of facial nerve; infratemporal, with or without grafting $ 3,441.60 5177 64866 64866 Anastomosis; facial-spinal accessory $ 3,690.90 5178 64868 64868 Anastomosis; facial-hypoglossal $ 4,108.50 5179 64870 64870 Anastomosis; facial-phrenic $ 3,644.10 Suture of nerve; requiring secondary or delayed suture (List 5180 64872 64872 separately in addition to code for primary neurorrhaphy) $ 1,768.50 Suture of nerve; requiring extensive mobilization, or transposition 5181 64874 64874 of nerve (List separately in addition to code for nerve suture) $ 2,524.50 Suture of nerve; requiring shortening of bone of extremity (List 5182 64876 64876 separately in addition to code for nerve suture) $ 441.19 Nerve graft (includes obtaining graft), head or neck; up to 4 cm in 5183 64885 length $ 3,759.30 Nerve graft (includes obtaining graft), head or neck; more than 4 cm 5184 64886 length $ 3,234.60 Nerve graft (includes obtaining graft), single strand, hand or foot; 5185 64890 up to 4 cm length $ 3,495.60 Nerve graft (includes obtaining graft), single strand, hand or foot; 5186 64891 more than 4 cm length $ 2,845.80 Nerve graft (includes obtaining graft), single strand, arm or leg; up 5187 64892 to 4 cm length $ 2,796.30 Nerve graft (includes obtaining graft), single strand, arm or leg; 5188 64893 more than 4 cm length $ 3,074.40 Nerve graft (includes obtaining graft), multiple strands (cable), hand 5189 64895 or foot; up to 4 cm length $ 3,388.50 Nerve graft (includes obtaining graft), multiple strands (cable), hand 5190 64896 or foot; more than 4 cm length $ 3,841.20 Nerve graft (includes obtaining graft), multiple strands (cable), arm 5191 64897 or leg; up to 4 cm length $ 3,540.60 Nerve graft (includes obtaining graft), multiple strands (cable), arm 5192 64898 or leg; more than 4 cm length $ 3,940.20 Nerve graft, each additional nerve; single strand (List separately in 5193 64901 addition to code for primary procedure) $ 2,362.50 Nerve graft, each additional nerve; multiple strands (cable) (List 5194 64902 64902 separately in addition to code for primary procedure) $ 2,455.20 5195 64905 Nerve pedicle transfer; first stage $ 2,021.40 5196 64907 Nerve pedicle transfer; second stage $ 2,226.60 Nerve repair; with synthetic conduit or vein allograft (eg, nerve 5197 64910 tube), each nerve $ 1,599.15 Nerve repair; with autogenous vein graft (includes harvest of vein 5198 64911 graft), each nerve $ 1,901.18 5199 64999 64999 Unlisted procedure, nervous system $ 468.58 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price 5200 65091 65091 Evisceration of ocular contents; without implant $ 1,363.50 5201 65093 65093 Evisceration of ocular contents; with implant $ 1,705.50 5202 65101 65101 Enucleation of eye; without implant $ 2,083.44 5203 65103 65103 Enucleation of eye; with implant, muscles not attached to implant $ 1,895.40 5204 65105 65105 Enucleation of eye; with implant, muscles attached to implant $ 2,379.60 Exenteration of orbit (does not include skin graft), removal of 5205 65110 65110 orbital contents; only $ 3,046.50 Exenteration of orbit (does not include skin graft), removal of 5206 65112 65112 orbital contents; with therapeutic removal of bone $ 3,127.50 Exenteration of orbit (does not include skin graft), removal of 5207 65114 65114 orbital contents; with muscle or myocutaneous flap $ 3,379.50 Modification of ocular implant with placement or replacement of pegs (eg, drilling receptacle for prosthesis appendage) (separate 5208 65125 65125 procedure) $ 772.20 Insertion of ocular implant secondary; after evisceration, in scleral 5209 65130 65130 shell $ 1,467.90 Insertion of ocular implant secondary; after enucleation, muscles 5210 65135 65135 not attached to implant $ 1,566.00 Insertion of ocular implant secondary; after enucleation, muscles 5211 65140 65140 attached to implant $ 2,068.20 5212 65150 65150 Reinsertion of ocular implant; with or without conjunctival graft $ 1,441.80 Reinsertion of ocular implant; with use of foreign material for 5213 65155 65155 reinforcement and/or attachment of muscles to implant $ 1,653.30 5214 65175 65175 Removal of ocular implant $ 1,166.40 5215 65205 65205 Removal of foreign body, external eye; conjunctival superficial $ 116.74 Removal of foreign body, external eye; conjunctival embedded 5216 65210 65210 (includes concretions), subconjunctival, or scleral nonperforating $ 131.60 5217 65220 65220 Removal of foreign body, external eye; corneal, without slit lamp $ 112.50 5218 65222 65222 Removal of foreign body, external eye; corneal, with slit lamp $ 163.91 Removal of foreign body, intraocular; from anterior chamber of eye 5219 65235 65235 or lens $ 1,715.40 Removal of foreign body, intraocular; from posterior segment, 5220 65260 65260 magnetic extraction, anterior or posterior route $ 1,864.80 Removal of foreign body, intraocular; from posterior segment, 5221 65265 65265 nonmagnetic extraction $ 2,199.60 Repair of laceration; conjunctiva, with or without nonperforating 5222 65270 65270 laceration sclera, direct closure $ 275.02 Repair of laceration; conjunctiva, by mobilization and 5223 65272 65272 rearrangement, without hospitalization $ 494.10 Repair of laceration; conjunctiva, by mobilization and 5224 65273 65273 rearrangement, with hospitalization $ 726.30 Repair of laceration; cornea, nonperforating, with or without 5225 65275 65275 removal foreign body $ 821.70 Repair of laceration; cornea and/or sclera, perforating, not involving 5226 65280 65280 uveal tissue $ 2,082.60 Repair of laceration; cornea and/or sclera, perforating, with 5227 65285 65285 reposition or resection of uveal tissue $ 3,026.69 Repair of laceration; application of tissue glue, wounds of cornea 5228 65286 65286 and/or sclera $ 927.00 Repair of wound, extraocular muscle, tendon and/or Tenon's 5229 65290 65290 capsule $ 1,153.80 Excision of lesion, cornea (keratectomy, lamellar, partial), except 5230 65400 65400 pterygium $ 1,133.10 5231 65410 65410 Biopsy of cornea $ 466.20 5232 65420 65420 Excision or transposition of pterygium; without graft $ 944.78 5233 65426 65426 Excision or transposition of pterygium; with graft $ 1,369.33 5234 65430 65430 Scraping of cornea, diagnostic, for smear and/or culture $ 122.40 Removal of corneal epithelium; with or without chemocauterization 5235 65435 65435 (abrasion, curettage) $ 157.50 Removal of corneal epithelium; with application of chelating agent 5236 65436 65436 (eg, EDTA) $ 463.50 Destruction of lesion of cornea by cryotherapy, photocoagulation or 5237 65450 65450 thermocauterization $ 483.30 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Multiple punctures of anterior cornea (eg, for corneal erosion, 5238 65600 65600 tattoo) $ 817.20 5239 65710 65710 Keratoplasty (corneal transplant); anterior lamellar $ 3,068.10 Keratoplasty (corneal transplant); penetrating (except in aphakia or 5240 65730 65730 pseudophakia) $ 3,759.30 5241 65750 65750 Keratoplasty (corneal transplant); penetrating (in aphakia) $ 3,811.50 5242 65755 65755 Keratoplasty (corneal transplant); penetrating (in pseudophakia) $ 3,698.10 5243 65756 65756 Keratoplasty (corneal transplant); endothelial $ 2,478.45 Backbench preparation of corneal endothelial allograft prior to transplantation (List separately in addition to code for primary 5244 65757 65757 procedure) $ - 5245 65760 65760 Keratomileusis $ 3,709.80 5246 65765 65765 Keratophakia $ 3,844.80 5247 65767 65767 Epikeratoplasty $ 3,079.80 5248 65770 65770 Keratoprosthesis $ 3,605.40 5249 65771 65771 Radial keratotomy $ 1,617.30 Corneal relaxing incision for correction of surgically induced 5250 65772 65772 astigmatism $ 1,199.70 Corneal wedge resection for correction of surgically induced 5251 65775 65775 astigmatism $ 1,380.60 Ocular surface reconstruction; amniotic membrane transplantation, 5252 65780 65780 multiple layers $ 1,555.66 Ocular surface reconstruction; limbal stem cell allograft (eg, 5253 65781 65781 cadaveric or living donor) $ 2,458.31 Ocular surface reconstruction; limbal conjunctival autograft 5254 65782 65782 (includes obtaining graft) $ 1,989.88 Paracentesis of anterior chamber of eye (separate procedure); with 5255 65800 65800 removal of aqueous $ 360.90 Paracentesis of anterior chamber of eye (separate procedure); with removal of vitreous and/or discission of anterior hyaloid membrane, 5256 65810 65810 with or without air injection $ 1,247.40 Paracentesis of anterior chamber of eye (separate procedure); with 5257 65815 65815 removal of blood, with or without irrigation and/or air injection $ 1,110.60 5258 65820 65820 Goniotomy $ 1,758.60 5259 65850 65850 Trabeculotomy ab externo $ 2,154.60 Trabeculoplasty by laser surgery, 1 or more sessions (defined 5260 65855 65855 treatment series) $ 1,647.90 Severing adhesions of anterior segment, laser technique (separate 5261 65860 65860 procedure) $ 1,277.10 Severing adhesions of anterior segment of eye, incisional technique (with or without injection of air or liquid) (separate procedure); 5262 65865 65865 goniosynechiae $ 1,256.40 Severing adhesions of anterior segment of eye, incisional technique (with or without injection of air or liquid) (separate procedure); 5263 65870 65870 anterior synechiae, except goniosynechiae $ 1,376.10 Severing adhesions of anterior segment of eye, incisional technique (with or without injection of air or liquid) (separate procedure); 5264 65875 65875 posterior synechiae $ 1,417.50 Severing adhesions of anterior segment of eye, incisional technique (with or without injection of air or liquid) (separate procedure); 5265 65880 65880 corneovitreal adhesions $ 1,403.10 5266 65900 65900 Removal of epithelial downgrowth, anterior chamber of eye $ 1,668.60 5267 65920 65920 Removal of implanted material, anterior segment of eye $ 1,873.17 5268 65930 65930 Removal of blood clot, anterior segment of eye $ 1,298.70 Injection, anterior chamber of eye (separate procedure); air or 5269 66020 66020 liquid $ 360.90 5270 66030 66030 Injection, anterior chamber of eye (separate procedure); medication $ 232.20 5271 66130 66130 Excision of lesion, sclera $ 1,153.80 5272 66150 66150 Fistulization of sclera for glaucoma; trephination with iridectomy $ 1,913.40 Fistulization of sclera for glaucoma; thermocauterization with 5273 66155 66155 iridectomy $ 1,854.00 Fistulization of sclera for glaucoma; sclerectomy with punch or 5274 66160 66160 scissors, with iridectomy $ 1,874.70 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price 5275 66165 66165 Fistulization of sclera for glaucoma; iridencleisis or iridotasis $ 1,788.30 Fistulization of sclera for glaucoma; trabeculectomy ab externo in 5276 66170 66170 absence of previous surgery $ 2,064.60 Fistulization of sclera for glaucoma; trabeculectomy ab externo with scarring from previous ocular surgery or trauma (includes injection 5277 66172 66172 of antifibrotic agents) $ 2,304.00 Aqueous shunt to extraocular reservoir (eg, Molteno, Schocket, 5278 66180 66180 Denver-Krupin) $ 2,621.70 5279 66185 66185 Revision of aqueous shunt to extraocular reservoir $ 1,754.10 5280 66220 66220 Repair of scleral staphyloma; without graft $ 2,317.50 5281 66225 66225 Repair of scleral staphyloma; with graft $ 3,115.80 Revision or repair of operative wound of anterior segment, any 5282 66250 66250 type, early or late, major or minor procedure $ 1,555.20 5283 66500 66500 Iridotomy by stab incision (separate procedure); except transfixion $ 891.00 Iridotomy by stab incision (separate procedure); with transfixion as 5284 66505 66505 for iris bombe $ 844.20 Iridectomy, with corneoscleral or corneal section; for removal of 5285 66600 66600 lesion $ 1,434.60 5286 66605 66605 Iridectomy, with corneoscleral or corneal section; with cyclectomy $ 2,086.20 Iridectomy, with corneoscleral or corneal section; peripheral for 5287 66625 66625 glaucoma (separate procedure) $ 1,401.30 Iridectomy, with corneoscleral or corneal section; sector for 5288 66630 66630 glaucoma (separate procedure) $ 1,356.30 Iridectomy, with corneoscleral or corneal section; optical (separate 5289 66635 66635 procedure) $ 1,356.30 5290 66680 66680 Repair of iris, ciliary body (as for iridodialysis) $ 1,522.80 Suture of iris, ciliary body (separate procedure) with retrieval of 5291 66682 66682 suture through small incision (eg, McCannel suture) $ 1,645.20 5292 66700 66700 Ciliary body destruction; diathermy $ 1,231.20 5293 66710 66710 Ciliary body destruction; cyclophotocoagulation, transscleral $ 1,313.10 5294 66711 66711 Ciliary body destruction; cyclophotocoagulation, endoscopic $ 1,283.69 5295 66720 66720 Ciliary body destruction; cryotherapy $ 1,313.10 5296 66740 66740 Ciliary body destruction; cyclodialysis $ 1,275.30 Iridotomy/iridectomy by laser surgery (eg, for glaucoma) (per 5297 66761 66761 session) $ 1,380.60 Iridoplasty by photocoagulation (1 or more sessions) (eg, for 5298 66762 66762 improvement of vision, for widening of anterior chamber angle) $ 1,241.10 Destruction of cyst or lesion iris or ciliary body (nonexcisional 5299 66770 66770 procedure) $ 1,347.30 Discission of secondary membranous cataract (opacified posterior lens capsule and/or anterior hyaloid); stab incision technique 5300 66820 66820 (Ziegler or Wheeler knife) $ 1,007.10 Discission of secondary membranous cataract (opacified posterior lens capsule and/or anterior hyaloid); laser surgery (eg, YAG laser) 5301 66821 66821 (1 or more stages) $ 1,117.54 Repositioning of intraocular lens prosthesis, requiring an incision 5302 66825 66825 (separate procedure) $ 1,701.90 Removal of secondary membranous cataract (opacified posterior lens capsule and/or anterior hyaloid) with corneo-scleral section, 5303 66830 66830 with or without iridectomy (iridocapsulotomy, iridocapsulectomy) $ 1,787.40 5304 66840 66840 Removal of lens material; aspiration technique, 1 or more stages $ 2,086.20 Removal of lens material; phacofragmentation technique 5305 66850 66850 (mechanical or ultrasonic) (eg, phacoemulsification), with aspiration $ 2,266.20 Removal of lens material; pars plana approach, with or without 5306 66852 66852 vitrectomy $ 2,191.50 5307 66920 66920 Removal of lens material; intracapsular $ 2,442.60 5308 66930 66930 Removal of lens material; intracapsular, for dislocated lens $ 2,337.30 Removal of lens material; extracapsular (other than 66840, 66850, 5309 66940 66940 66852) $ 2,358.90 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification), complex, 5310 66982 66982 requiring devices or techniques not generally used in routine $ 2,692.80 Intracapsular cataract extraction with insertion of intraocular lens 5311 66983 66983 prosthesis (1 stage procedure) $ 2,913.30 Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique 5312 66984 66984 (eg, irrigation and aspiration or phacoemulsification) $ 2,961.00 Insertion of intraocular lens prosthesis (secondary implant), not 5313 66985 66985 associated with concurrent cataract removal $ 2,276.10 5314 66986 66986 Exchange of intraocular lens $ 2,513.70 Use of ophthalmic endoscope (List separately in addition to code for 5315 66990 66990 primary procedure) $ 208.58 5316 66999 66999 Unlisted procedure, anterior segment of eye Cost Removal of vitreous, anterior approach (open sky technique or 5317 67005 67005 limbal incision); partial removal $ 2,368.80 Removal of vitreous, anterior approach (open sky technique or 5318 67010 67010 limbal incision); subtotal removal with mechanical vitrectomy $ 3,078.00 Aspiration or release of vitreous, subretinal or choroidal fluid, pars 5319 67015 67015 plana approach (posterior sclerotomy) $ 1,328.40 Injection of vitreous substitute, pars plana or limbal approach (fluid- 5320 67025 67025 gas exchange), with or without aspiration (separate procedure) $ 1,447.20 Implantation of intravitreal drug delivery system (eg, ganciclovir 5321 67027 67027 implant), includes concomitant removal of vitreous $ 2,884.50 5322 67028 67028 Intravitreal injection of a pharmacologic agent (separate procedure) $ 677.70 Discission of vitreous strands (without removal), pars plana 5323 67030 67030 approach $ 1,555.20 Severing of vitreous strands, vitreous face adhesions, sheets, 5324 67031 67031 membranes or opacities, laser surgery (1 or more stages) $ 1,725.30 5325 67036 67036 Vitrectomy, mechanical, pars plana approach; $ 3,816.00 Vitrectomy, mechanical, pars plana approach; with focal endolaser 5326 67039 67039 photocoagulation $ 4,336.20 Vitrectomy, mechanical, pars plana approach; with endolaser 5327 67040 67040 panretinal photocoagulation $ 4,686.30 Vitrectomy, mechanical, pars plana approach; with removal of 5328 67041 67041 preretinal cellular membrane (eg, macular pucker) $ 3,643.85 Vitrectomy, mechanical, pars plana approach; with removal of internal limiting membrane of retina (eg, for repair of macular hole, diabetic macular edema), includes, if performed, intraocular 5329 67042 67042 tamponade (ie, air, gas or silicone oil) $ 4,430.03 Vitrectomy, mechanical, pars plana approach; with removal of subretinal membrane (eg, choroidal neovascularization), includes, if performed, intraocular tamponade (ie, air, gas or silicone oil) and 5330 67043 67043 laser photocoagulation $ 4,581.88 Repair of retinal detachment, 1 or more sessions; cryotherapy or 5331 67101 67101 diathermy, with or without drainage of subretinal fluid $ 2,293.20 Repair of retinal detachment, 1 or more sessions; photocoagulation, 5332 67105 67105 with or without drainage of subretinal fluid $ 2,421.00 Repair of retinal detachment; scleral buckling (such as lamellar scleral dissection, imbrication or encircling procedure), with or without implant, with or without cryotherapy, photocoagulation, 5333 67107 67107 and drainage of subretinal fluid $ 3,351.60 Repair of retinal detachment; with vitrectomy, any method, with or without air or gas tamponade, focal endolaser photocoagulation, cryotherapy, drainage of subretinal fluid, scleral buckling, and/or 5334 67108 67108 removal of lens by same technique $ 4,954.50 Repair of retinal detachment; by injection of air or other gas (eg, 5335 67110 67110 pneumatic retinopexy) $ 2,899.80 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Repair of retinal detachment; by scleral buckling or vitrectomy, on patient having previous ipsilateral retinal detachment repair(s) 5336 67112 67112 using scleral buckling or vitrectomy techniques $ 3,100.50 Repair of complex retinal detachment (eg, proliferative vitreoretinopathy, stage C-1 or greater, diabetic traction retinal detachment, retinopathy of prematurity, retinal tear of greater than 5337 67113 67113 90 degrees), with vitrectomy and membrane peeling, may include $ 4,729.72 5338 67115 67115 Release of encircling material (posterior segment) $ 1,184.40 5339 67120 67120 Removal of implanted material, posterior segment; extraocular $ 1,269.90 5340 67121 67121 Removal of implanted material, posterior segment; intraocular $ 1,663.20 Prophylaxis of retinal detachment (eg, retinal break, lattice degeneration) without drainage, 1 or more sessions; cryotherapy, 5341 67141 67141 diathermy $ 1,359.90 Prophylaxis of retinal detachment (eg, retinal break, lattice degeneration) without drainage, 1 or more sessions; 5342 67145 67145 photocoagulation (laser or xenon arc) $ 1,518.03 Destruction of localized lesion of retina (eg, macular edema, 5343 67208 67208 tumors), 1 or more sessions; cryotherapy, diathermy $ 1,661.40 Destruction of localized lesion of retina (eg, macular edema, 5344 67210 67210 tumors), 1 or more sessions; photocoagulation $ 1,524.43 Destruction of localized lesion of retina (eg, macular edema, tumors), 1 or more sessions; radiation by implantation of source 5345 67218 67218 (includes removal of source) $ 2,276.10 Destruction of localized lesion of choroid (eg, choroidal neovascularization); photocoagulation (eg, laser), 1 or more 5346 67220 67220 sessions $ 1,760.40 Destruction of localized lesion of choroid (eg, choroidal neovascularization); photodynamic therapy (includes intravenous 5347 67221 67221 infusion) $ 1,009.80 Destruction of localized lesion of choroid (eg, choroidal neovascularization); photodynamic therapy, second eye, at single session (List separately in addition to code for primary eye 5348 67225 67225 treatment) $ 424.48 Destruction of extensive or progressive retinopathy (eg, diabetic 5349 67227 67227 retinopathy), 1 or more sessions, cryotherapy, diathermy $ 1,713.60 Treatment of extensive or progressive retinopathy, 1 or more 5350 67228 67228 sessions; (eg, diabetic retinopathy), photocoagulation $ 1,702.39 Treatment of extensive or progressive retinopathy, 1 or more sessions; preterm infant (less than 37 weeks gestation at birth), performed from birth up to 1 year of age (eg, retinopathy of 5351 67229 67229 prematurity), photocoagulation or cryotherapy $ 1,631.69 5352 67250 67250 Scleral reinforcement (separate procedure); without graft $ 1,955.70 5353 67255 67255 Scleral reinforcement (separate procedure); with graft $ 2,400.30 5354 67299 67299 Unlisted procedure, posterior segment Cost Strabismus surgery, recession or resection procedure; 1 horizontal 5355 67311 67311 muscle $ 1,532.70 Strabismus surgery, recession or resection procedure; 2 horizontal 5356 67312 67312 muscles $ 2,008.80 Strabismus surgery, recession or resection procedure; 1 vertical 5357 67314 67314 muscle (excluding superior oblique) $ 1,854.00 Strabismus surgery, recession or resection procedure;

2 or more 5358 67316 67316 vertical muscles (excluding superior oblique) $ 2,276.10 5359 67318 67318 Strabismus surgery, any procedure, superior oblique muscle $ 2,106.90 Transposition procedure (eg, for paretic extraocular muscle), any extraocular muscle (specify) (List separately in addition to code for 5360 67320 67320 primary procedure) $ 2,286.90 Strabismus surgery on patient with previous eye surgery or injury that did not involve the extraocular muscles (List separately in 5361 67331 67331 addition to code for primary procedure) $ 1,467.90 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Strabismus surgery on patient with scarring of extraocular muscles (eg, prior ocular injury, strabismus or retinal detachment surgery) or restrictive myopathy (eg, dysthyroid ophthalmopathy) (List 5362 67332 67332 separately in addition to code for primary procedure) $ 2,152.80 Strabismus surgery by posterior fixation suture technique, with or without muscle recession (List separately in addition to code for 5363 67334 67334 primary procedure) $ 1,441.80 Placement of adjustable suture(s) during strabismus surgery, including postoperative adjustment(s) of suture(s) (List separately in 5364 67335 67335 addition to code for specific strabismus surgery) $ 720.90 Strabismus surgery involving exploration and/or repair of detached extraocular muscle(s) (List separately in addition to code for 5365 67340 67340 primary procedure) $ 1,802.70 Release of extensive scar tissue without detaching extraocular 5366 67343 67343 muscle (separate procedure) $ 1,390.50 5367 67345 67345 Chemodenervation of extraocular muscle $ 539.10 5368 67346 67346 Biopsy of extraocular muscle $ 544.18 5369 67399 67399 Unlisted procedure, ocular muscle Cost Orbitotomy without bone flap (frontal or transconjunctival 5370 67400 67400 approach); for exploration, with or without biopsy $ 2,160.00 Orbitotomy without bone flap (frontal or transconjunctival 5371 67405 67405 approach); with drainage only $ 1,980.90 Orbitotomy without bone flap (frontal or transconjunctival 5372 67412 67412 approach); with removal of lesion $ 2,352.60 Orbitotomy without bone flap (frontal or transconjunctival 5373 67413 67413 approach); with removal of foreign body $ 2,716.20 Orbitotomy without bone flap (frontal or transconjunctival 5374 67414 67414 approach); with removal of bone for decompression $ 2,228.40 5375 67415 67415 Fine needle aspiration of orbital contents $ 437.40 Orbitotomy with bone flap or window, lateral approach (eg, 5376 67420 67420 Kroenlein); with removal of lesion $ 3,352.50 Orbitotomy with bone flap or window, lateral approach (eg, 5377 67430 67430 Kroenlein); with removal of foreign body $ 2,887.20 Orbitotomy with bone flap or window, lateral approach (eg, 5378 67440 67440 Kroenlein); with drainage $ 3,031.20 Orbitotomy with bone flap or window, lateral approach (eg, 5379 67445 67445 Kroenlein); with removal of bone for decompression $ 2,722.50 Orbitotomy with bone flap or window, lateral approach (eg, 5380 67450 67450 Kroenlein); for exploration, with or without biopsy $ 2,966.40 Retrobulbar injection; medication (separate procedure, does not 5381 67500 67500 include supply of medication) $ 175.50 5382 67505 67505 Retrobulbar injection; alcohol $ 280.80 5383 67515 67515 Injection of medication or other substance into Tenon's capsule $ 139.50 5384 67550 67550 Orbital implant (implant outside muscle cone); insertion $ 1,802.70 5385 67560 67560 Orbital implant (implant outside muscle cone); removal or revision $ 1,784.70 Optic nerve decompression (eg, incision or fenestration of optic 5386 67570 67570 nerve sheath) $ 2,440.80 5387 67599 67599 Unlisted procedure, orbit Cost 5388 67700 67700 Blepharotomy, drainage of abscess, eyelid $ 184.47 5389 67710 67710 Severing of tarsorrhaphy $ 311.40 5390 67715 67715 Canthotomy (separate procedure) $ 366.30 5391 67800 67800 Excision of chalazion; single $ 218.88 5392 67801 67801 Excision of chalazion; multiple, same lid $ 304.59 5393 67805 67805 Excision of chalazion; multiple, different lids $ 356.44 Excision of chalazion; under general anesthesia and/or requiring 5394 67808 67808 hospitalization, single or multiple $ 565.20 5395 67810 67810 Incisional biopsy of eyelid skin including lid margin $ 250.20 5396 67820 67820 Correction of trichiasis; epilation, by forceps only $ 94.99 Correction of trichiasis; epilation by other than forceps (eg, by 5397 67825 67825 electrosurgery, cryotherapy, laser surgery) $ 178.20 5398 67830 67830 Correction of trichiasis; incision of lid margin $ 503.10 Correction of trichiasis; incision of lid margin, with free mucous 5399 67835 67835 membrane graft $ 1,691.10 Excision of lesion of eyelid (except chalazion) without closure or 5400 67840 67840 with simple direct closure $ 353.47 5401 67850 67850 Destruction of lesion of lid margin (up to 1 cm) $ 252.00 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price 5402 67875 67875 Temporary closure of eyelids by suture (eg, Frost suture) $ 442.80 Construction of intermarginal adhesions, median tarsorrhaphy, or 5403 67880 67880 canthorrhaphy; $ 864.00 Construction of intermarginal adhesions, median tarsorrhaphy, or 5404 67882 67882 canthorrhaphy; with transposition of tarsal plate $ 1,364.40 Repair of brow ptosis (supraciliary, mid-forehead or coronal 5405 67900 67900 approach) $ 1,399.50 Repair of blepharoptosis; frontalis muscle technique with suture or 5406 67901 67901 other material (eg, banked fascia) $ 2,169.00 Repair of blepharoptosis; frontalis muscle technique with 5407 67902 67902 autologous fascial sling (includes obtaining fascia) $ 2,372.40 Repair of blepharoptosis; (tarso) levator resection or advancement, 5408 67903 67903 internal approach $ 2,374.20 Repair of blepharoptosis; (tarso) levator resection or advancement, 5409 67904 67904 external approach $ 2,879.10 Repair of blepharoptosis; superior rectus technique with fascial sling 5410 67906 67906 (includes obtaining fascia) $ 2,122.20 Repair of blepharoptosis; conjunctivo-tarso-Muller's muscle-levator 5411 67908 67908 resection (eg, Fasanella-Servat type) $ 1,909.80 5412 67909 67909 Reduction of overcorrection of ptosis $ 1,689.30 5413 67911 67911 Correction of lid retraction $ 2,162.70 Correction of lagophthalmos, with implantation of upper eyelid lid 5414 67912 67912 load (eg, gold weight) $ 2,145.90 5415 67914 67914 Repair of ectropion; suture $ 977.40 5416 67915 67915 Repair of ectropion; thermocauterization $ 483.30 5417 67916 67916 Repair of ectropion; excision tarsal wedge $ 1,341.90 5418 67917 67917 Repair of ectropion; extensive (eg, tarsal strip operations) $ 1,854.00 5419 67921 67921 Repair of entropion; suture $ 769.50 5420 67922 67922 Repair of entropion; thermocauterization $ 378.90 5421 67923 67923 Repair of entropion; excision tarsal wedge $ 1,467.90 Repair of entropion; extensive (eg, tarsal strip or capsulopalpebral 5422 67924 67924 fascia repairs operation) $ 1,857.60 Suture of recent wound, eyelid, involving lid margin, tarsus, and/or 5423 67930 67930 palpebral conjunctiva direct closure; partial thickness $ 949.50 Suture of recent wound, eyelid, involving lid margin, tarsus, and/or 5424 67935 67935 palpebral conjunctiva direct closure; full thickness $ 1,545.30 5425 67938 67938 Removal of embedded foreign body, eyelid $ 222.30 5426 67950 67950 Canthoplasty (reconstruction of canthus) $ 1,822.50 Excision and repair of eyelid, involving lid margin, tarsus, conjunctiva, canthus, or full thickness, may include preparation for skin graft or pedicle flap with adjacent tissue transfer or 5427 67961 67961 rearrangement; up to one-fourth of lid margin $ 2,062.80 Excision and repair of eyelid, involving lid margin, tarsus, conjunctiva, canthus, or full thickness, may include preparation for skin graft or pedicle flap with adjacent tissue transfer or 5428 67966 67966 rearrangement; over one-fourth of lid margin $ 2,368.80 Reconstruction of eyelid, full thickness by transfer of tarsoconjunctival flap from opposing eyelid; up to two-thirds of 5429 67971 67971 eyelid, 1 stage or first stage $ 2,272.50 Reconstruction of eyelid, full thickness by transfer of tarsoconjunctival flap from opposing eyelid; total eyelid, lower, 1 5430 67973 67973 stage or first stage $ 3,181.50 Reconstruction of eyelid, full thickness by transfer of tarsoconjunctival flap from opposing eyelid; total eyelid, upper, 1 5431 67974 67974 stage or first stage $ 3,420.90 Reconstruction of eyelid, full thickness by transfer of 5432 67975 67975 tarsoconjunctival flap from opposing eyelid; second stage $ 1,535.40 5433 67999 67999 Unlisted procedure, eyelids Cost 5434 68020 68020 Incision of conjunctiva, drainage of cyst $ 166.30 5435 68040 68040 Expression of conjunctival follicles (eg, for trachoma) $ 128.70 5436 68100 68100 Biopsy of conjunctiva $ 187.20 5437 68110 68110 Excision of lesion, conjunctiva; up to 1 cm $ 365.72 5438 68115 68115 Excision of lesion, conjunctiva; over 1 cm $ 454.50 5439 68130 68130 Excision of lesion, conjunctiva; with adjacent sclera $ 813.60 5440 68135 68135 Destruction of lesion, conjunctiva $ 247.50 5441 68200 68200 Subconjunctival injection $ 178.20 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Conjunctivoplasty; with conjunctival graft or extensive 5442 68320 68320 rearrangement $ 1,654.20 Conjunctivoplasty; with buccal mucous membrane graft (includes 5443 68325 68325 obtaining graft) $ 2,090.70 Conjunctivoplasty, reconstruction cul-de-sac; with conjunctival graft 5444 68326 68326 or extensive rearrangement $ 2,130.30 Conjunctivoplasty, reconstruction cul-de-sac; with buccal mucous 5445 68328 68328 membrane graft (includes obtaining graft) $ 2,104.20 5446 68330 68330 Repair of symblepharon; conjunctivoplasty, without graft $ 1,292.40 Repair of symblepharon; with free graft conjunctiva or buccal 5447 68335 68335 mucous membrane (includes obtaining graft) $ 1,466.10 Repair of symblepharon; division of symblepharon, with or without 5448 68340 68340 insertion of conformer or contact lens $ 1,123.20 5449 68360 68360 Conjunctival flap; bridge or partial (separate procedure) $ 978.30 Conjunctival flap; total (such as Gunderson thin flap or purse string 5450 68362 68362 flap) $ 1,544.40 5451 68371 68371 Harvesting conjunctival allograft, living donor $ 817.41 5452 68399 68399 Unlisted procedure, conjunctiva Cost 5453 68400 68400 Incision, drainage of lacrimal gland $ 301.50 Incision, drainage of lacrimal sac (dacryocystotomy or 5454 68420 68420 dacryocystostomy) $ 362.70 5455 68440 68440 Snip incision of lacrimal punctum $ 276.30 Excision of lacrimal gland (dacryoadenectomy), except for tumor; 5456 68500 68500 total $ 1,859.40 Excision of lacrimal gland (dacryoadenectomy), except for tumor; 5457 68505 68505 partial $ 1,574.10 5458 68510 68510 Biopsy of lacrimal gland $ 674.10 5459 68520 68520 Excision of lacrimal sac (dacryocystectomy) $ 1,632.60 5460 68525 68525 Biopsy of lacrimal sac $ 518.40 5461 68530 68530 Removal of foreign body or dacryolith, lacrimal passages $ 947.70 5462 68540 68540 Excision of lacrimal gland tumor; frontal approach $ 2,062.80 5463 68550 68550 Excision of lacrimal gland tumor; involving osteotomy $ 2,482.20 5464 68700 68700 Plastic repair of canaliculi $ 1,694.70 5465 68705 68705 Correction of everted punctum, cautery $ 265.50 5466 68720 68720 Dacryocystorhinostomy (fistulization of lacrimal sac to nasal cavity) $ 2,123.10 Conjunctivorhinostomy (fistulization of conjunctiva to nasal cavity); 5467 68745 68745 without tube $ 2,060.10 Conjunctivorhinostomy (fistulization of conjunctiva to nasal cavity); 5468 68750 68750 with insertion of tube or stent $ 2,332.80 Closure of the lacrimal punctum; by thermocauterization, ligation, 5469 68760 68760 or laser surgery $ 283.50 5470 68761 68761 Closure of the lacrimal punctum; by plug, each $ 256.50 5471 68770 68770 Closure of lacrimal fistula (separate procedure) $ 925.20 5472 68801 68801 Dilation of lacrimal punctum, with or without irrigation $ 136.80 5473 68810 68810 Probing of nasolacrimal duct, with or without irrigation; $ 195.30 Probing of nasolacrimal duct, with or without irrigation; requiring 5474 68811 68811 general anesthesia $ 422.10 Probing of nasolacrimal duct, with or without irrigation; with 5475 68815 68815 insertion of tube or stent $ 532.80 Probing of nasolacrimal duct, with or without irrigation; with 5476 68816 68816 transluminal balloon catheter dilation $ 1,322.33 5477 68840 68840 Probing of lacrimal canaliculi, with or without irrigation $ 178.20 5478 68850 68850 Injection of contrast medium for dacryocystography $ 170.10 5479 68899 68899 Unlisted procedure, lacrimal system Cost 5480 69000 69000 Drainage external ear, abscess or hematoma; simple $ 190.80 5481 69005 69005 Drainage external ear, abscess or hematoma; complicated $ 526.50 5482 69020 69020 Drainage external auditory canal, abscess $ 200.70 5483 69090 69090 Ear piercing $ 105.30 5484 69100 69100 Biopsy external ear $ 164.70 5485 69105 69105 Biopsy external auditory canal $ 234.90 5486 69110 69110 Excision external ear; partial, simple repair $ 848.70 5487 69120 69120 Excision external ear; complete amputation $ 1,729.80 5488 69140 69140 Excision exostosis(es), external auditory canal $ 1,996.20 5489 69145 69145 Excision soft tissue lesion, external auditory canal $ 643.50 Radical excision external auditory canal lesion; without neck 5490 69150 69150 dissection $ 2,611.80 5491 69155 69155 Radical excision external auditory canal lesion; with neck dissection $ 4,492.80 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Removal foreign body from external auditory canal; without general 5492 69200 69200 anesthesia $ 128.70 Removal foreign body from external auditory canal; with general 5493 69205 69205 anesthesia $ 525.89 5494 69210 69210 Removal impacted cerumen requiring instrumentation, unilateral $ 64.34 5495 69220 69220 Debridement, mastoidectomy cavity, simple (eg, routine cleaning) $ 104.73 Debridement, mastoidectomy cavity, complex (eg, with anesthesia 5496 69222 69222 or more than routine cleaning) $ 315.90 5497 69300 69300 Otoplasty, protruding ear, with or without size reduction $ 2,126.70 Reconstruction of external auditory canal (meatoplasty) (eg, for 5498 69310 69310 stenosis due to injury, infection) (separate procedure) $ 3,252.60 Reconstruction external auditory canal for congenital atresia, single 5499 69320 69320 stage $ 3,473.10 5500 69399 69399 Unlisted procedure, external ear Cost 5501 69400 69400 Eustachian tube inflation, transnasal; with catheterization $ 144.90 5502 69401 69401 Eustachian tube inflation, transnasal; without catheterization $ 108.90 5503 69405 69405 Eustachian tube catheterization, transtympanic $ 154.80 5504 69420 69420 Myringotomy including aspiration and/or eustachian tube inflation $ 268.20 Myringotomy including aspiration and/or eustachian tube inflation 5505 69421 69421 requiring general anesthesia $ 380.70 5506 69424 69424 Ventilating tube removal requiring general anesthesia $ 226.80 Tympanostomy (requiring insertion of ventilating tube), local or 5507 69433 69433 topical anesthesia $ 426.42 Tympanostomy (requiring insertion of ventilating tube), general 5508 69436 69436 anesthesia $ 621.90 5509 69440 69440 Middle ear exploration through postauricular or ear canal incision $ 2,028.60 5510 69450 69450 Tympanolysis, transcanal $ 2,083.50 5511 69501 69501 Transmastoid antrotomy (simple mastoidectomy) $ 2,442.60 5512 69502 69502 Mastoidectomy; complete $ 3,323.70 5513 69505 69505 Mastoidectomy; modified radical $ 3,462.30 5514 69511 69511 Mastoidectomy; radical $ 3,429.00 5515 69530 69530 Petrous apicectomy including radical mastoidectomy $ 4,139.10 5516 69535 69535 Resection temporal bone, external approach $ 6,341.40 5517 69540 69540 Excision aural polyp $ 322.20 5518 69550 69550 Excision aural glomus tumor; transcanal $ 3,636.90 5519 69552 69552 Excision aural glomus tumor; transmastoid $ 4,195.80 5520 69554 69554 Excision aural glomus tumor; extended (extratemporal) $ 5,842.80 5521 69601 69601 Revision mastoidectomy; resulting in complete mastoidectomy $ 3,073.50 Revision mastoidectomy; resulting in modified radical 5522 69602 69602 mastoidectomy $ 3,607.20 5523 69603 69603 Revision mastoidectomy; resulting in radical mastoidectomy $ 3,481.20 5524 69604 69604 Revision mastoidectomy; resulting in tympanoplasty $ 3,876.30 5525 69605 69605 Revision mastoidectomy; with apicectomy $ 3,746.70 Tympanic membrane repair, with or without site preparation of 5526 69610 69610 perforation for closure, with or without patch $ 432.90 5527 69620 69620 Myringoplasty (surgery confined to drumhead and donor area) $ 2,461.50 Tympanoplasty without mastoidectomy (including canalplasty, atticotomy and/or middle ear surgery), initial or revision; without 5528 69631 69631 ossicular chain reconstruction $ 3,134.70 Tympanoplasty without mastoidectomy (including canalplasty, atticotomy and/or middle ear surgery), initial or revision; with 5529 69632 69632 ossicular chain reconstruction (eg, postfenestration) $ 3,681.00 Tympanoplasty without mastoidectomy (including canalplasty, atticotomy and/or middle ear surgery), initial or revision; with ossicular chain reconstruction and synthetic prosthesis (eg, partial 5530 69633 69633 ossicular replacement prosthesis [PORP], total ossicular repl $ 3,594.60 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Tympanoplasty with antrotomy or mastoidotomy (including canalplasty, atticotomy, middle ear surgery, and/or tympanic 5531 69635 69635 membrane repair); without ossicular chain reconstruction $ 3,904.20 Tympanoplasty with antrotomy or mastoidotomy (including canalplasty, atticotomy, middle ear surgery, and/or tympanic 5532 69636 69636 membrane repair); with ossicular chain reconstruction $ 4,133.70 Tympanoplasty with antrotomy or mastoidotomy (including canalplasty, atticotomy, middle ear surgery, and/or tympanic membrane repair); with ossicular chain reconstruction and synthetic 5533 69637 69637 prosthesis (eg, partial ossicular replacement prosthesis [PORP], total $ 4,131.90 Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repair); without ossicular chain 5534 69641 69641 reconstruction $ 3,818.70 Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repair); with ossicular chain 5535 69642 69642 reconstruction $ 4,161.60 Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repair); with intact or 5536 69643 69643 reconstructed wall, without ossicular chain reconstruction $ 4,333.50 Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repair); with intact or 5537 69644 69644 reconstructed canal wall, with ossicular chain reconstruction $ 4,814.10 Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repair); radical or complete, 5538 69645 69645 without ossicular chain reconstruction $ 4,619.70 Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repair); radical or complete, with 5539 69646 69646 ossicular chain reconstruction $ 5,045.40 5540 69650 69650 Stapes mobilization $ 2,429.10 Stapedectomy or stapedotomy with reestablishment of ossicular 5541 69660 69660 continuity, with or without use of foreign material; $ 3,344.40 Stapedectomy or stapedotomy with reestablishment of ossicular continuity, with or without use of foreign material; with footplate 5542 69661 69661 drill out $ 3,737.70 5543 69662 69662 Revision of stapedectomy or stapedotomy $ 4,239.90 5544 69666 69666 Repair oval window fistula $ 3,217.50 5545 69667 69667 Repair round window fistula $ 3,156.30 5546 69670 69670 Mastoid obliteration (separate procedure) $ 3,295.80 5547 69676 69676 Tympanic neurectomy $ 2,268.90 5548 69700 69700 Closure postauricular fistula, mastoid (separate procedure) $ 1,625.40 Implantation or replacement of electromagnetic bone conduction 5549 69710 69710 hearing device in temporal bone $ 1,761.30 Removal or repair of electromagnetic bone conduction hearing 5550 69711 69711 device in temporal bone $ 1,287.90 Implantation, osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear 5551 69714 69714 stimulator; without mastoidectomy $ 2,985.05 Implantation, osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear 5552 69715 69715 stimulator; with mastoidectomy $ 3,580.56 Replacement (including removal of existing device), osseointegrated implant, temporal bone, with percutaneous attachment to external 5553 69717 69717 speech processor/cochlear stimulator; without mastoidectomy $ 3,079.84 Replacement (including removal of existing device), osseointegrated implant, temporal bone, with percutaneous attachment to external 5554 69718 69718 speech processor/cochlear stimulator; with mastoidectomy $ 3,691.07 Decompression facial nerve, intratemporal; lateral to geniculate 5555 69720 69720 ganglion $ 3,883.50 Decompression facial nerve, intratemporal; including medial to 5556 69725 69725 geniculate ganglion $ 5,624.10 Suture facial nerve, intratemporal, with or without graft or 5557 69740 69740 decompression; lateral to geniculate ganglion $ 4,449.60 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Suture facial nerve, intratemporal, with or without graft or 5558 69745 69745 decompression; including medial to geniculate ganglion $ 5,244.30 5559 69799 69799 Unlisted procedure, middle ear Cost Labyrinthotomy, with perfusion of vestibuloactive drug(s); 5560 69801 69801 transcanal $ 3,175.20 5561 69805 69805 Endolymphatic sac operation; without shunt $ 3,862.80 5562 69806 69806 Endolymphatic sac operation; with shunt $ 4,377.60 5563 69820 69820 Fenestration semicircular canal $ 3,438.00 5564 69840 69840 Revision fenestration operation $ 2,353.50 5565 69905 69905 Labyrinthectomy; transcanal $ 3,857.40 5566 69910 69910 Labyrinthectomy; with mastoidectomy $ 4,439.70 5567 69915 69915 Vestibular nerve section, translabyrinthine approach $ 5,052.60 5568 69930 69930 Cochlear device implantation, with or without mastoidectomy $ 5,318.10 5569 69949 69949 Unlisted procedure, inner ear Cost 5570 69950 69950 Vestibular nerve section, transcranial approach $ 5,448.60 5571 69955 69955 Total facial nerve decompression and/or repair (may include graft) $ 5,846.40 5572 69960 69960 Decompression internal auditory canal $ 5,529.60 5573 69970 69970 Removal of tumor, temporal bone $ 6,309.00 5574 69979 69979 Unlisted procedure, temporal bone, middle fossa approach Cost Microsurgical techniques, requiring use of operating microscope 5575 69990 69990 (List separately in addition to code for primary procedure) $ 834.30 Cytomegalovirus immune globulin (CMV-IgIV), human, for 5576 90291 90291 intravenous use $ 72.90 5577 90296 90296 Diphtheria antitoxin, equine, any route $ 77.40 Immunization administration by intranasal or oral route; each additional vaccine (single or combination vaccine/toxoid) (List 5578 90474 90474 separately in addition to code for primary procedure) $ 17.03 5579 90703 90703 Tetanus toxoid adsorbed, for intramuscular use $ 19.30 Interactive complexity (List separately in addition to the code for 5580 90785 90785 primary procedure) $ 8.74 5581 90791 90791 Psychiatric diagnostic evaluation $ 276.51 5582 90792 90792 Psychiatric diagnostic evaluation with medical services $ 222.74 5583 90832 90832 Psychotherapy, 30 minutes with patient and/or family member $ 114.22 Psychotherapy, 30 minutes with patient and/or family member when performed with an evaluation and management service (List 5584 90833 90833 separately in addition to the code for primary procedure) $ 74.62 5585 90834 90834 Psychotherapy, 45 minutes with patient and/or family member $ 144.87 Psychotherapy, 45 minutes with patient and/or family member when performed with an evaluation and management service (List 5586 90836 90836 separately in addition to the code for primary procedure) $ 120.89 5587 90837 90837 Psychotherapy, 60 minutes with patient and/or family member $ 211.77 Psychotherapy, 60 minutes with patient and/or family member when performed with an evaluation and management service (List 5588 90838 90838 separately in addition to the code for primary procedure) $ 195.68 5589 90845 90845 Psychoanalysis $ 166.50 5590 90846 90846 Family psychotherapy (without the patient present) $ 159.30 Family psychotherapy (conjoint psychotherapy) (with patient 5591 90847 90847 present) $ 151.62 5592 90849 90849 Multiple-family group psychotherapy $ 129.60 5593 90853 90853 Group psychotherapy (other than of a multiple-family group) $ 87.30 Pharmacologic management, including prescription and review of medication, when performed with psychotherapy services (List 5594 90863 90863 separately in addition to the code for primary procedure) $ 93.77 Narcosynthesis for psychiatric diagnostic and therapeutic purposes 5595 90865 90865 (eg, sodium amobarbital (Amytal) interview) $ 271.80 5596 90870 90870 Electroconvulsive therapy (includes necessary monitoring) $ 209.70 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy (eg, insight oriented, behavior modifying or 5597 90875 90875 supportive psychotherapy); 30 minutes $ 117.06 Individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with the patient), with psychotherapy (eg, insight oriented, behavior modifying or 5598 90876 90876 supportive psychotherapy); 45 minutes $ 226.80 5599 90880 90880 Hypnotherapy $ 183.60 Environmental intervention for medical management purposes on a 5600 90882 90882 psychiatric patient's behalf with agencies, employers, or institutions $ 118.80 Psychiatric evaluation of hospital records, other psychiatric reports, psychometric and/or projective tests, and other accumulated data 5601 90885 90885 for medical diagnostic purposes $ 120.97 Interpretation or explanation of results of psychiatric, other medical examinations and procedures, or other accumulated data to family 5602 90887 90887 or other responsible persons, or advising them how to assist patient $ 159.30 Preparation of report of patient's psychiatric status, history, treatment, or progress (other than for legal or consultative 5603 90889 90889 purposes) for other individuals, agencies, or insurance carriers $ 171.00 5604 90899 90899 Unlisted psychiatric service or procedure Cost 5605 90901 90901 Biofeedback training by any modality $ 123.30 Biofeedback training, perineal muscles, anorectal or urethral 5606 90911 90911 sphincter, including EMG and/or manometry $ 180.00 Hemodialysis procedure with single evaluation by a physician or 5607 90935 90935 other qualified health care professional $ 249.80 Hemodialysis procedure requiring repeated evaluation(s) with or 5608 90937 90937 without substantial revision of dialysis prescription $ 566.10 Hemodialysis access flow study to determine blood flow in grafts 5609 90940 90940 and arteriovenous fistulae by an indicator method $ - Dialysis procedure other than hemodialysis (eg, peritoneal dialysis, hemofiltration, or other continuous renal replacement therapies), with single evaluation by a physician or other qualified health care 5610 90945 90945 professional $ 300.60 Dialysis procedure other than hemodialysis (eg, peritoneal dialysis, hemofiltration, or other continuous renal replacement therapies) requiring repeated evaluations by a physician or other qualified 5611 90947 90947 health care professional, with or without substantial re $ 482.40 End-stage renal disease (ESRD) related services monthly, for patients younger than 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and 5612 90951 90951 counseling of parents; with 4 or more face-to-face visits by a $ 1,568.42 End-stage renal disease (ESRD) related services monthly, for patients younger than 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and 5613 90952 90952 counseling of parents; with 2-3 face-to-face visits by a physi $ - End-stage renal disease (ESRD) related services monthly, for patients younger than 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and 5614 90953 90953 counseling of parents; with 1 face-to-face visit by a physicia $ - End-stage renal disease (ESRD) related services monthly, for patients 2-11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling 5615 90954 90954 of parents; with 4 or more face-to-face visits by a physician $ 1,325.75 End-stage renal disease (ESRD) related services monthly, for patients 2-11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling 5616 90955 90955 of parents; with 2-3 face-to-face visits by a physician or ot $ 742.53 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price End-stage renal disease (ESRD) related services monthly, for patients 2-11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling 5617 90956 90956 of parents; with 1 face-to-face visit by a physician or other $ 521.08 End-stage renal disease (ESRD) related services monthly, for patients 12-19 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 4 or more face-to-face visits by a 5618 90957 90957 physicia $ 1,046.60 End-stage renal disease (ESRD) related services monthly, for patients 12-19 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and 5619 90958 90958 counseling of parents; with 2-3 face-to-face visits by a physician or o $ 702.47 End-stage renal disease (ESRD) related services monthly, for patients 12-19 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 1 face-to-face visit by a physician or 5620 90959 90959 othe $ 462.30 End-stage renal disease (ESRD) related services monthly, for patients 20 years of age and older; with 4 or more face-to-face visits 5621 90960 90960 by a physician or other qualified health care professional per month $ 515.18 End-stage renal disease (ESRD) related services monthly, for patients 20 years of age and older; with 2-3 face-to-face visits by a 5622 90961 90961 physician or other qualified health care professional per month $ 413.70 End-stage renal disease (ESRD) related services monthly, for patients 20 years of age and older; with 1 face-to-face visit by a 5623 90962 90962 physician or other qualified health care professional per month $ 301.29 End-stage renal disease (ESRD) related services for home dialysis per full month, for patients younger than 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and 5624 90963 90963 development, and counseling of parents $ 898.85 End-stage renal disease (ESRD) related services for home dialysis per full month, for patients 2-11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and 5625 90964 90964 development, and counseling of parents $ 750.40 End-stage renal disease (ESRD) related services for home dialysis per full month, for patients 12-19 years of age to include monitoring for the adequacy of nutrition, assessment of growth and 5626 90965 90965 development, and counseling of parents $ 704.13 End-stage renal disease (ESRD) related services for home dialysis 5627 90966 90966 per full month, for patients 20 years of age and older $ 368.71 End-stage renal disease (ESRD) related services for dialysis less than a full month of service, per day; for patients younger than 2 years of 5628 90967 90967 age $ 33.03 End-stage renal disease (ESRD) related services for dialysis less than 5629 90968 90968 a full month of service, per day; for patients 2-11 years of age $ 26.85 End-stage renal disease (ESRD) related services for dialysis less than 5630 90969 90969 a full month of service, per day; for patients 12-19 years of age $ 19.63 End-stage renal disease (ESRD) related services for dialysis less than a full month of service, per day; for patients 20 years of age and 5631 90970 90970 older $ 13.50 Dialysis training, patient, including helper where applicable, any 5632 90989 90989 mode, completed course $ 653.40 Dialysis training, patient, including helper where applicable, any 5633 90993 90993 mode, course not completed, per training session $ 135.90 5634 90997 90997 Hemoperfusion (eg, with activated charcoal or resin) $ 597.60 5635 90999 90999 Unlisted dialysis procedure, inpatient or outpatient Cost Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Esophageal motility (manometric study of the esophagus and/or 5636 91010 91010 gastroesophageal junction) study with interpretation and report; $ 101.54 Esophageal motility (manometric study of the esophagus and/or gastroesophageal junction) study with interpretation and report; with stimulation or perfusion (eg, stimulant, acid or alkali perfusion) 5637 91013 (List separately in addition to code for primary procedu $ 68.42 Esophageal motility (manometric study of the esophagus and/or gastroesophageal junction) study with interpretation and report; with stimulation or perfusion (eg, stimulant, acid or alkali perfusion) 5638 91013-26 26 (List separately in addition to code for primary procedu $ 29.29 5639 91013-TC TC $ 39.13 5640 91020 91020 Gastric motility (manometric) studies $ 255.60 5641 91020-26 26 91020 Gastric motility (manometric) studies $ 74.00 5642 91020-TC TC 91020 Gastric motility (manometric) studies $ 181.60 5643 91022 91022 Duodenal motility (manometric) study $ 213.12 5644 91030 91030 Esophagus, acid perfusion (Bernstein) test for esophagitis $ 158.40 5645 91030-26 26 91030 Esophagus, acid perfusion (Bernstein) test for esophagitis $ 49.29 5646 91030-TC TC 91030 Esophagus, acid perfusion (Bernstein) test for esophagitis $ 109.11 Esophagus, gastroesophageal reflux test; with nasal catheter pH 5647 91034 91034 electrode(s) placement, recording, analysis and interpretation $ 170.59 Esophagus, gastroesophageal reflux test; with mucosal attached telemetry pH electrode placement, recording, analysis and 5648 91035 91035 interpretation $ 236.07 Esophageal function test, gastroesophageal reflux test with nasal catheter intraluminal impedance electrode(s) placement, recording, 5649 91037 91037 analysis and interpretation; $ 148.35 Esophageal function test, gastroesophageal reflux test with nasal catheter intraluminal impedance electrode(s) placement, recording, analysis and interpretation; prolonged (greater than 1 hour, up to 5650 91038 91038 24 hours) $ 163.99 5651 91040 91040 Esophageal balloon distension provocation study $ 142.29 Breath hydrogen or methane test (eg, for detection of lactase deficiency, fructose intolerance, bacterial overgrowth, or oro-cecal 5652 91065 91065 gastrointestinal transit) $ 16.38 Gastrointestinal tract imaging, intraluminal (eg, capsule endoscopy), 5653 91110 91110 esophagus through ileum, with interpretation and report $ 522.07 Gastrointestinal tract imaging, intraluminal (eg, capsule endoscopy), 5654 91111 91111 esophagus with interpretation and report $ 122.66 Rectal sensation, tone, and compliance test (ie, response to graded 5655 91120 91120 balloon distention) $ 129.65 5656 91122 91122 Anorectal manometry $ 357.30 5657 91122-26 26 91122 Anorectal manometry $ 131.95 5658 91122-TC TC 91122 Anorectal manometry $ 225.35 5659 91132 91132 Electrogastrography, diagnostic, transcutaneous; $ 74.61 Electrogastrography, diagnostic, transcutaneous; with provocative 5660 91133 91133 testing $ 110.50 5661 91299 91299 Unlisted diagnostic gastroenterology procedure Cost Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; intermediate, 5662 92002 92002 new patient $ 87.67 Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; 5663 92004 92004 comprehensive, new patient, 1 or more visits $ 103.19 Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment 5664 92012 92012 program; intermediate, established patient $ 62.82 Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment 5665 92014 92014 program; comprehensive, established patient, 1 or more visits $ 87.18 5666 92015 92015 Determination of refractive state $ 28.58 Ophthalmological examination and evaluation, under general anesthesia, with or without manipulation of globe for passive range of motion or other manipulation to facilitate diagnostic 5667 92018 92018 examination; complete $ 246.60 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Ophthalmological examination and evaluation, under general anesthesia, with or without manipulation of globe for passive range of motion or other manipulation to facilitate diagnostic 5668 92019 92019 examination; limited $ 153.90 5669 92020 92020 Gonioscopy (separate procedure) $ 53.27 Computerized corneal topography, unilateral or bilateral, with 5670 92025 92025 interpretation and report $ 28.67 Sensorimotor examination with multiple measurements of ocular deviation (eg, restrictive or paretic muscle with diplopia) with 5671 92060 92060 interpretation and report (separate procedure) $ 66.59 Sensorimotor examination with multiple measurements of ocular deviation (eg, restrictive or paretic muscle with diplopia) with 5672 92060-26 26 92060 interpretation and report (separate procedure) $ 37.17 Sensorimotor examination with multiple measurements of ocular deviation (eg, restrictive or paretic muscle with diplopia) with 5673 92060-TC TC 92060 interpretation and report (separate procedure) $ 29.42 Orthoptic and/or pleoptic training, with continuing medical 5674 92065 92065 direction and evaluation $ 56.70 Orthoptic and/or pleoptic training, with continuing medical 5675 92065-26 26 92065 direction and evaluation $ 16.99 Orthoptic and/or pleoptic training, with continuing medical 5676 92065-TC TC 92065 direction and evaluation $ 39.71 5677 92071 92071 Fitting of contact lens for treatment of ocular surface disease $ 62.75 5678 92072 92072 Fitting of contact lens for management of keratoconus, initial fitting $ 238.67 Visual field examination, unilateral or bilateral, with interpretation and report; limited examination (eg, tangent screen, Autoplot, arc perimeter, or single stimulus level automated test, such as Octopus 5679 92081 92081 3 or 7 equivalent) $ 46.80 Visual field examination, unilateral or bilateral, with interpretation and report; limited examination (eg, tangent screen, Autoplot, arc perimeter, or single stimulus level automated test, such as Octopus 5680 92081-26 26 92081 3 or 7 equivalent) $ 21.54 Visual field examination, unilateral or bilateral, with interpretation and report; limited examination (eg, tangent screen, Autoplot, arc perimeter, or single stimulus level automated test, such as Octopus 5681 92081-TC TC 92081 3 or 7 equivalent) $ 25.26 Visual field examination, unilateral or bilateral, with interpretation and report; intermediate examination (eg, at least 2 isopters on Goldmann perimeter, or semiquantitative, automated suprathreshold screening program, Humphrey suprathreshold 5682 92082 92082 automatic $ 81.78 Visual field examination, unilateral or bilateral, with interpretation and report; intermediate examination (eg, at least 2 isopters on Goldmann perimeter, or semiquantitative, automated suprathreshold screening program, Humphrey suprathreshold 5683 92082-26 26 92082 automatic $ 35.28 Visual field examination, unilateral or bilateral, with interpretation and report; intermediate examination (eg, at least 2 isopters on Goldmann perimeter, or semiquantitative, automated suprathreshold screening program, Humphrey suprathreshold 5684 92082-TC TC 92082 automatic $ 46.50 Visual field examination, unilateral or bilateral, with interpretation and report; extended examination (eg, Goldmann visual fields with at least 3 isopters plotted and static determination within the 5685 92083 92083 central 30 , or quantitative, automated threshold peri $ 125.94 Visual field examination, unilateral or bilateral, with interpretation and report; extended examination (eg, Goldmann visual fields with at least 3 isopters plotted and static determination within the 5686 92083-26 26 92083 central 30 , or quantitative, automated threshold peri $ 51.26 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Visual field examination, unilateral or bilateral, with interpretation and report; extended examination (eg, Goldmann visual fields with at least 3 isopters plotted and static determination within the 5687 92083-TC TC 92083 central 30 , or quantitative, automated threshold peri $ 74.68 Serial tonometry (separate procedure) with multiple measurements of intraocular pressure over an extended time period with interpretation and report, same day (eg, diurnal curve or medical 5688 92100 92100 treatment of acute elevation of intraocular pressure) $ 52.70 Ophthalmic biometry by partial coherence interferometry with 5689 92136 92136 intraocular lens power calculation $ 123.93 Ophthalmic biometry by partial coherence interferometry with 5690 92136-26 26 92136 intraocular lens power calculation $ 44.16 Ophthalmic biometry by partial coherence interferometry with 5691 92136-TC TC 92136 intraocular lens power calculation $ 79.77 Provocative tests for glaucoma, with interpretation and report, 5692 92140 92140 without tonography $ 57.90 Ophthalmoscopy, extended, with retinal drawing (eg, for retinal 5693 92225 92225 detachment, melanoma), with interpretation and report; initial $ 79.44 Ophthalmoscopy, extended, with retinal drawing (eg, for retinal detachment, melanoma), with interpretation and report; 5694 92226 92226 subsequent $ 70.28 5695 92230 92230 Fluorescein angioscopy with interpretation and report $ 126.90 Fluorescein angiography (includes multiframe imaging) with 5696 92235 92235 interpretation and report $ 247.50 Fluorescein angiography (includes multiframe imaging) with 5697 92235-26 26 92235 interpretation and report $ 98.35 Fluorescein angiography (includes multiframe imaging) with 5698 92235-TC TC 92235 interpretation and report $ 149.15 Indocyanine-green angiography (includes multiframe imaging) with 5699 92240 92240 interpretation and report $ 225.00 Indocyanine-green angiography (includes multiframe imaging) with 5700 92240-26 26 92240 interpretation and report $ 50.91 Indocyanine-green angiography (includes multiframe imaging) with 5701 92240-TC TC 92240 interpretation and report $ 174.09 5702 92250 92250 Fundus photography with interpretation and report $ 79.20 5703 92250-26 26 92250 Fundus photography with interpretation and report $ 21.57 5704 92250-TC TC 92250 Fundus photography with interpretation and report $ 57.63 5705 92260 92260 Ophthalmodynamometry $ 66.60 Needle oculoelectromyography, 1 or more extraocular muscles, 1 or 5706 92265 92265 both eyes, with interpretation and report $ 128.70 Needle oculoelectromyography, 1 or more extraocular muscles, 1 or 5707 92265-26 26 92265 both eyes, with interpretation and report $ 64.52 Needle oculoelectromyography, 1 or more extraocular muscles, 1 or 5708 92265-TC TC 92265 both eyes, with interpretation and report $ 64.18 5709 92270 92270 Electro-oculography with interpretation and report $ 128.70 5710 92270-26 26 92270 Electro-oculography with interpretation and report $ 53.38 5711 92270-TC TC 92270 Electro-oculography with interpretation and report $ 75.32 5712 92275 92275 Electroretinography with interpretation and report $ 162.90 5713 92275-26 26 92275 Electroretinography with interpretation and report $ 55.10 5714 92275-TC TC 92275 Electroretinography with interpretation and report $ 107.80 Color vision examination, extended, eg, anomaloscope or 5715 92283 92283 equivalent $ 56.70 Color vision examination, extended, eg, anomaloscope or 5716 92283-26 26 92283 equivalent $ 8.54 Color vision examination, extended, eg, anomaloscope or 5717 92283-TC TC 92283 equivalent $ 48.16 5718 92284 92284 Dark adaptation examination with interpretation and report $ 113.40 5719 92284-26 26 92284 Dark adaptation examination with interpretation and report $ 20.35 5720 92284-TC TC 92284 Dark adaptation examination with interpretation and report $ 93.05 External ocular photography with interpretation and report for documentation of medical progress (eg, close-up photography, slit 5721 92285 92285 lamp photography, goniophotography, stereo-photography) $ 59.40 External ocular photography with interpretation and report for documentation of medical progress (eg, close-up photography, slit 5722 92285-26 26 92285 lamp photography, goniophotography, stereo-photography) $ 8.25 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price External ocular photography with interpretation and report for documentation of medical progress (eg, close-up photography, slit 5723 92285-TC TC 92285 lamp photography, goniophotography, stereo-photography) $ 51.15 Anterior segment imaging with interpretation and report; with 5724 92286 92286 specular microscopy and endothelial cell analysis $ 235.92 Anterior segment imaging with interpretation and report; with 5725 92286-26 26 92286 specular microscopy and endothelial cell analysis $ 127.49 Anterior segment imaging with interpretation and report; with 5726 92286-TC TC 92286 specular microscopy and endothelial cell analysis $ 108.43 Anterior segment imaging with interpretation and report; with 5727 92287 92287 fluorescein angiography $ 180.00 Anterior segment imaging with interpretation and report; with 5728 92287-26 26 92287 fluorescein angiography $ 56.26 Anterior segment imaging with interpretation and report; with 5729 92287-TC TC 92287 fluorescein angiography $ 123.74 Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens, 5730 92310 92310 both eyes, except for aphakia $ 268.20 Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens 5731 92311 92311 for aphakia, 1 eye $ 180.90 Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation; corneal lens 5732 92312 92312 for aphakia, both eyes $ 247.50 Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of adaptation;

corneoscleral 5733 92313 92313 lens $ 91.51 Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and direction of fitting by 5734 92314 92314 independent technician; corneal lens, both eyes except for aphakia $ 67.48 Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and direction of fitting by 5735 92315 92315 independent technician; corneal lens for aphakia, 1 eye $ 63.02 Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and direction of fitting by 5736 92316 92316 independent technician; corneal lens for aphakia, both eyes $ 98.58 Prescription of optical and physical characteristics of contact lens, with medical supervision of adaptation and direction of fitting by 5737 92317 92317 independent technician; corneoscleral lens $ 66.07 Modification of contact lens (separate procedure), with medical 5738 92325 92325 supervision of adaptation $ 43.20 5739 92326 92326 Replacement of contact lens $ 118.80 5740 92340 92340 Fitting of spectacles, except for aphakia; monofocal $ 56.70 5741 92341 92341 Fitting of spectacles, except for aphakia; bifocal $ 40.23 Fitting of spectacles, except for aphakia; multifocal, other than 5742 92342 92342 bifocal $ 52.41 5743 92352 92352 Fitting of spectacle prosthesis for aphakia; monofocal $ 22.45 5744 92353 92353 Fitting of spectacle prosthesis for aphakia; multifocal $ 51.30 5745 92354 92354 Fitting of spectacle mounted low vision aid; single element system $ 28.49 Fitting of spectacle mounted low vision aid; telescopic or other 5746 92355 92355 compound lens system $ 43.94 Prosthesis service for aphakia, temporary (disposable or loan, 5747 92358 92358 including materials) $ 23.79 5748 92370 92370 Repair and refitting spectacles; except for aphakia $ 48.20 5749 92371 92371 Repair and refitting spectacles; spectacle prosthesis for aphakia $ 70.29 5750 92499 92499 Unlisted ophthalmological service or procedure $ - 5751 92502 92502 Otolaryngologic examination under general anesthesia $ 297.00 5752 92504 92504 Binocular microscopy (separate diagnostic procedure) $ 61.25 5753 92511 92511 Nasopharyngoscopy with endoscope (separate procedure) $ 229.50 5754 92512 92512 Nasal function studies (eg, rhinomanometry) $ 144.00 5755 92516 92516 Facial nerve function studies (eg, electroneuronography) $ 123.30 Laryngeal function studies (ie, aerodynamic testing and acoustic 5756 92520 92520 testing) $ 257.40 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price 5757 92521 92521 Evaluation of speech fluency (eg, stuttering, cluttering) $ 114.48 5758 92521 92521 Speech therapy, in the home, per diem $ 114.48 Evaluation of speech sound production (eg, articulation, 5759 92522 92522 phonological process, apraxia, dysarthria); $ 92.94 Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (eg, receptive and 5760 92523 92523 expressive language) $ 193.07 5761 92524 92524 Behavioral and qualitative analysis of voice and resonance $ 96.89 Treatment of swallowing dysfunction and/or oral function for 5762 92526 92526 feeding $ 123.30 5763 92531 92531 Spontaneous nystagmus, including gaze $ 54.00 5764 92532 92532 Positional nystagmus test $ 62.10 Caloric vestibular test, each irrigation (binaural, bithermal 5765 92533 92533 stimulation constitutes 4 tests) $ 76.50 5766 92534 92534 Optokinetic nystagmus test $ 63.00 Basic vestibular evaluation, includes spontaneous nystagmus test with eccentric gaze fixation nystagmus, with recording, positional nystagmus test, minimum of 4 positions, with recording, optokinetic 5767 92540 92540 nystagmus test, bidirectional foveal and peripheral sti $ 124.58 Spontaneous nystagmus test, including gaze and fixation 5768 92541 92541 nystagmus, with recording $ 121.50 Spontaneous nystagmus test, including gaze and fixation 5769 92541-26 26 92541 nystagmus, with recording $ 79.30 Spontaneous nystagmus test, including gaze and fixation 5770 92541-TC TC 92541 nystagmus, with recording $ 42.20 5771 92542 92542 Positional nystagmus test, minimum of 4 positions, with recording $ 114.30 5772 92542-26 26 92542 Positional nystagmus test, minimum of 4 positions, with recording $ 69.82 5773 92542-TC TC 92542 Positional nystagmus test, minimum of 4 positions, with recording $ 44.48 Caloric vestibular test, each irrigation (binaural, bithermal 5774 92543 92543 stimulation constitutes 4 tests), with recording $ 128.70 Caloric vestibular test, each irrigation (binaural, bithermal 5775 92543-26 26 92543 stimulation constitutes 4 tests), with recording $ 40.96 Caloric vestibular test, each irrigation (binaural, bithermal 5776 92543-TC TC 92543 stimulation constitutes 4 tests), with recording $ 87.74 Optokinetic nystagmus test, bidirectional, foveal or peripheral 5777 92544 92544 stimulation, with recording $ 77.40 Optokinetic nystagmus test, bidirectional, foveal or peripheral 5778 92544-26 26 92544 stimulation, with recording $ 43.16 Optokinetic nystagmus test, bidirectional, foveal or peripheral 5779 92544-TC TC 92544 stimulation, with recording $ 34.24 5780 92545 92545 Oscillating tracking test, with recording $ 77.40 5781 92545-26 26 92545 Oscillating tracking test, with recording $ 41.96 5782 92545-TC TC 92545 Oscillating tracking test, with recording $ 35.44 5783 92546 92546 Sinusoidal vertical axis rotational testing $ 101.70 5784 92546-26 26 92546 Sinusoidal vertical axis rotational testing $ 12.98 5785 92546-TC TC 92546 Sinusoidal vertical axis rotational testing $ 88.72 Use of vertical electrodes (List separately in addition to code for 5786 92547 92547 primary procedure) $ 72.00 5787 92548 92548 Computerized dynamic posturography $ 216.00 5788 92548-26 26 92548 Computerized dynamic posturography $ 47.62 5789 92548-TC TC 92548 Computerized dynamic posturography $ 168.38 5790 92550 92550 Tympanometry and reflex threshold measurements $ 38.60 5791 92551 92551 Screening test, pure tone, air only $ 34.20 5792 92552 92552 Pure tone audiometry (threshold); air only $ 40.77 5793 92553 92553 Pure tone audiometry (threshold); air and bone $ 61.69 5794 92555 92555 Speech audiometry threshold; $ 36.90 5795 92556 92556 Speech audiometry threshold; with speech recognition $ 54.76 Comprehensive audiometry threshold evaluation and speech 5796 92557 92557 recognition (92553 and 92556 combined) $ 92.70 5797 92559 92559 Audiometric testing of groups $ 41.40 5798 92560 92560 Bekesy audiometry; screening $ 66.60 5799 92561 92561 Bekesy audiometry; diagnostic $ 83.70 5800 92562 92562 Loudness balance test, alternate binaural or monaural $ 40.50 5801 92563 92563 Tone decay test $ 45.00 5802 92564 92564 Short increment sensitivity index (SISI) $ 41.40 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price 5803 92565 92565 Stenger test, pure tone $ 50.40 5804 92567 92567 Tympanometry (impedance testing) $ 43.18 5805 92568 92568 Acoustic reflex testing, threshold $ 41.40 Acoustic immittance testing, includes tympanometry (impedance testing), acoustic reflex threshold testing, and acoustic reflex decay 5806 92570 92570 testing $ 58.15 5807 92571 92571 Filtered speech test $ 38.70 5808 92572 92572 Staggered spondaic word test $ 42.30 5809 92575 92575 Sensorineural acuity level test $ 36.00 5810 92576 92576 Synthetic sentence identification test $ 38.70 5811 92577 92577 Stenger test, speech $ 51.30 5812 92579 92579 Visual reinforcement audiometry (VRA) $ 102.60 5813 92582 92582 Conditioning play audiometry $ 65.70 5814 92583 92583 Select picture audiometry $ 72.00 5815 92584 92584 Electrocochleography $ 252.00 Auditory evoked potentials for evoked response audiometry and/or 5816 92585 92585 testing of the central nervous system; comprehensive $ 353.70 Auditory evoked potentials for evoked response audiometry and/or 5817 92585-26 26 92585 testing of the central nervous system; comprehensive $ 65.25 Auditory evoked potentials for evoked response audiometry and/or 5818 92585-TC TC 92585 testing of the central nervous system; comprehensive $ 288.45 Auditory evoked potentials for evoked response audiometry and/or 5819 92586 92586 testing of the central nervous system; limited $ 151.11 Distortion product evoked otoacoustic emissions; limited evaluation (to confirm the presence or absence of hearing disorder, 3-6 frequencies) or transient otoacoustic emissions, with interpretation 5820 92587 92587 and report $ 124.20 Distortion product evoked otoacoustic emissions; limited evaluation (to confirm the presence or absence of hearing disorder, 3-6 frequencies) or transient otoacoustic emissions, with interpretation 5821 92587-26 26 92587 and report $ 105.08 Distortion product evoked otoacoustic emissions; limited evaluation (to confirm the presence or absence of hearing disorder, 3-6 frequencies) or transient otoacoustic emissions, with interpretation 5822 92587-TC TC 92587 and report $ 19.12 Distortion product evoked otoacoustic emissions; comprehensive diagnostic evaluation (quantitative analysis of outer hair cell function by cochlear mapping, minimum of 12 frequencies), with 5823 92588 92588 interpretation and report $ 141.30 Distortion product evoked otoacoustic emissions; comprehensive diagnostic evaluation (quantitative analysis of outer hair cell function by cochlear mapping, minimum of 12 frequencies), with 5824 92588-26 26 92588 interpretation and report $ 122.06 Distortion product evoked otoacoustic emissions; comprehensive diagnostic evaluation (quantitative analysis of outer hair cell function by cochlear mapping, minimum of 12 frequencies), with 5825 92588-TC TC 92588 interpretation and report $ 19.24 5826 92590 92590 Hearing aid examination and selection; monaural $ 113.40 5827 92591 92591 Hearing aid examination and selection; binaural $ 146.70 5828 92592 92592 Hearing aid check; monaural $ 40.50 5829 92593 92593 Hearing aid check; binaural $ 57.60 5830 92594 92594 Electroacoustic evaluation for hearing aid; monaural $ 36.00 5831 92595 92595 Electroacoustic evaluation for hearing aid; binaural $ 38.70 5832 92596 92596 Ear protector attenuation measurements $ 51.30 Evaluation for use and/or fitting of voice prosthetic device to 5833 92597 92597 supplement oral speech $ 188.10 Diagnostic analysis of cochlear implant, patient younger than 7 5834 92601 92601 years of age; with programming $ 279.88 Diagnostic analysis of cochlear implant, patient younger than 7 5835 92602 92602 years of age; subsequent reprogramming $ 200.79 Diagnostic analysis of cochlear implant, age 7 years or older; with 5836 92603 92603 programming $ 187.38 Diagnostic analysis of cochlear implant, age 7 years or older; 5837 92604 92604 subsequent reprogramming $ 124.41 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Evaluation for prescription of non-speech-generating augmentative and alternative communication device, face-to-face with the 5838 92605 92605 patient; first hour $ 166.79 Therapeutic service(s) for the use of non-speech-generating device, 5839 92606 92606 including programming and modification $ 151.11 Evaluation for prescription for speech-generating augmentative and alternative communication device, face-to-face with the patient; 5840 92607 92607 first hour $ 259.20 Evaluation for prescription for speech-generating augmentative and alternative communication device, face-to-face with the patient; each additional 30 minutes (List separately in addition to code for 5841 92608 92608 primary procedure) $ 57.16 Therapeutic services for the use of speech-generating device, 5842 92609 92609 including programming and modification $ 139.99 5843 92610 92610 Evaluation of oral and pharyngeal swallowing function $ 270.34 Motion fluoroscopic evaluation of swallowing function by cine or 5844 92611 92611 video recording $ 264.89 Flexible fiberoptic endoscopic evaluation of swallowing by cine or 5845 92612 92612 video recording; $ 336.75 Flexible fiberoptic endoscopic evaluation of swallowing by cine or 5846 92613 92613 video recording; interpretation and report only $ 86.41 Flexible fiberoptic endoscopic evaluation, laryngeal sensory testing 5847 92614 92614 by cine or video recording; $ 296.87 Flexible fiberoptic endoscopic evaluation, laryngeal sensory testing 5848 92615 92615 by cine or video recording; interpretation and report only $ 78.45 Flexible fiberoptic endoscopic evaluation of swallowing and 5849 92616 92616 laryngeal sensory testing by cine or video recording; $ 438.23 Flexible fiberoptic endoscopic evaluation of swallowing and laryngeal sensory testing by cine or video recording; interpretation 5850 92617 92617 and report only $ 103.33 Evaluation of central auditory function, with report; initial 60 5851 92620 92620 minutes $ 99.31 Evaluation of central auditory function, with report; each additional 15 minutes (List separately in addition to code for primary 5852 92621 92621 procedure) $ 25.94 Assessment of tinnitus (includes pitch, loudness matching, and 5853 92625 92625 masking) $ 93.11 5854 92626 92626 Evaluation of auditory rehabilitation status; first hour $ 174.65 Evaluation of auditory rehabilitation status; each additional 15 5855 92627 92627 minutes (List separately in addition to code for primary procedure) $ 43.12 5856 92630 92630 Auditory rehabilitation; prelingual hearing loss $ - 5857 92633 92633 Auditory rehabilitation; postlingual hearing loss $ - Diagnostic analysis with programming of auditory brainstem 5858 92640 92640 implant, per hour $ 122.67 5859 92700 92700 Unlisted otorhinolaryngological service or procedure $ 32.92 Percutaneous transluminal coronary angioplasty; single major 5860 92920 92920 coronary artery or branch $ 1,048.78 Percutaneous transluminal coronary angioplasty; each additional branch of a major coronary artery (List separately in addition to 5861 92921 92921 code for primary procedure) $ 4,410.41 Percutaneous transluminal coronary atherectomy, with coronary angioplasty when performed; single major coronary artery or 5862 92924 92924 branch $ 1,247.20 Percutaneous transluminal coronary atherectomy, with coronary angioplasty when performed; each additional branch of a major coronary artery (List separately in addition to code for primary 5863 92925 92925 procedure) $ 8,842.66 Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; single major coronary 5864 92928 92928 artery or branch $ 1,165.44 Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; each additional branch of a major coronary artery (List separately in addition to code for 5865 92929 92929 primary procedure) $ 6,363.75 Percutaneous transluminal coronary atherectomy, with intracoronary stent, with coronary angioplasty when performed; 5866 92933 92933 single major coronary artery or branch $ 1,303.22 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Percutaneous transluminal coronary atherectomy, with intracoronary stent, with coronary angioplasty when performed; each additional branch of a major coronary artery (List separately in 5867 92934 92934 addition to code for primary procedure) $ 6,363.75 Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of intracoronary stent, atherectomy and angioplasty, 5868 92937 92937 including distal protection when performed; single vesse $ 1,164.19 Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of intracoronary stent, atherectomy and angioplasty, 5869 92938 92938 including distal protection when performed; each additio $ 6,363.75 Percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary artery bypass graft, any combination of intracoronary 5870 92941 92941 stent, atherectomy and angioplasty, including aspiration th $ 1,306.01 Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of intracoronary stent, 5871 92943 92943 atherectomy and angioplasty; single vessel $ 1,306.01 Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of intracoronary stent, atherectomy and angioplasty; each additional coronary artery, 5872 92944 92944 coronar $ 6,363.75 5873 92950 92950 Cardiopulmonary resuscitation (eg, in cardiac arrest) $ 482.59 5874 92953 92953 Temporary transcutaneous pacing $ 329.40 5875 92960 92960 Cardioversion, elective, electrical conversion of arrhythmia; external $ 425.70 Cardioversion, elective, electrical conversion of arrhythmia; internal 5876 92961 92961 (separate procedure) $ 945.23 5877 92970 92970 Cardioassist-method of circulatory assist; internal $ 684.90 5878 92971 92971 Cardioassist-method of circulatory assist; external $ 275.40 Percutaneous transluminal coronary thrombectomy mechanical 5879 92973 92973 (List separately in addition to code for primary procedure) $ 1,041.07 Transcatheter placement of radiation delivery device for subsequent coronary intravascular brachytherapy (List separately in 5880 92974 92974 addition to code for primary procedure) $ 801.14 Thrombolysis, coronary; by intracoronary infusion, including 5881 92975 92975 selective coronary angiography $ 1,488.60 5882 92977 92977 Thrombolysis, coronary; by intravenous infusion $ 753.30 Intravascular ultrasound (coronary vessel or graft) during diagnostic evaluation and/or therapeutic intervention including imaging supervision, interpretation and report; initial vessel (List separately 5883 92978 92978 in addition to code for primary procedure) $ 333.84 Intravascular ultrasound (coronary vessel or graft) during diagnostic evaluation and/or therapeutic intervention including imaging supervision, interpretation and report; each additional vessel (List 5884 92979 92979 separately in addition to code for primary procedure) $ 236.88 5885 92986 92986 Percutaneous balloon valvuloplasty; aortic valve $ 3,656.70 5886 92987 92987 Percutaneous balloon valvuloplasty; mitral valve $ 3,403.45 5887 92990 92990 Percutaneous balloon valvuloplasty; pulmonary valve $ 2,477.70 Atrial septectomy or septostomy; transvenous method, balloon (eg, 5888 92992 92992 Rashkind type) (includes cardiac catheterization) $ - Atrial septectomy or septostomy; blade method (Park septostomy) 5889 92993 92993 (includes cardiac catheterization) $ 4,408.20 Percutaneous transluminal pulmonary artery balloon angioplasty; 5890 92997 92997 single vessel $ 2,449.80 Percutaneous transluminal pulmonary artery balloon angioplasty; each additional vessel (List separately in addition to code for 5891 92998 92998 primary procedure) $ 949.50 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Electrocardiogram, routine ECG with at least 12 leads; with 5892 93000 93000 interpretation and report $ 71.00 Electrocardiogram, routine ECG with at least 12 leads; tracing only, 5893 93005 93005 without interpretation and report $ 56.70 Electrocardiogram, routine ECG with at least 12 leads; 5894 93010 93010 interpretation and report only $ 51.30 Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; with supervision, interpretation and 5895 93015 93015 report $ 338.10 Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; supervision only, without 5896 93016 93016 interpretation and report $ 100.80 Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; tracing only, without interpretation 5897 93017 93017 and report $ 164.70 Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, 5898 93018 93018 and/or pharmacological stress; interpretation and report only $ 170.10 5899 93024 93024 Ergonovine provocation test $ 380.70 5900 93024-26 26 93024 Ergonovine provocation test $ 180.32 5901 93024-TC TC 93024 Ergonovine provocation test $ 200.38 Microvolt T-wave alternans for assessment of ventricular 5902 93025 93025 arrhythmias $ 119.07 5903 93040 93040 Rhythm ECG, 1-3 leads; with interpretation and report $ 49.49 Rhythm ECG, 1-3 leads; tracing only without interpretation and 5904 93041 93041 report $ 44.10 5905 93042 93042 Rhythm ECG, 1-3 leads; interpretation and report only $ 36.00 External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; includes recording, scanning analysis with report, review and interpretation by a 5906 93224 93224 physician or other qualified health care professional $ 481.75 External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; recording (includes 5907 93225 93225 connection, recording, and disconnection) $ 162.00 External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; scanning analysis with 5908 93226 93226 report $ 175.50 External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; review and interpretation by a physician or other qualified health care 5909 93227 93227 professional $ 173.70 External mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data storage (retrievable 5910 93228 93228 with query) with ECG triggered and patient selected events $ 71.24 External mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data storage (retrievable 5911 93229 93229 with query) with ECG triggered and patient selected events $ 1,453.15 External patient and, when performed, auto activated electrocardiographic rhythm derived event recording with symptom- related memory loop with remote download capability up to 30 days, 24-hour attended monitoring; includes transmission, review 5912 93268 93268 and interpr $ 382.17 External patient and, when performed, auto activated electrocardiographic rhythm derived event recording with symptom- related memory loop with remote download capability up to 30 days, 24-hour attended monitoring; recording (includes connection, 5913 93270 93270 recording $ 136.80 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price External patient and, when performed, auto activated electrocardiographic rhythm derived event recording with symptom- related memory loop with remote download capability up to 30 5914 93271 93271 days, 24-hour attended monitoring; transmission and analysis $ 215.10 External patient and, when performed, auto activated electrocardiographic rhythm derived event recording with symptom- related memory loop with remote download capability up to 30 days, 24-hour attended monitoring; review and interpretation by a 5915 93272 93272 physician $ 91.80 5916 93278 93278 Signal-averaged electrocardiography (SAECG), with or without ECG $ 211.50 5917 93278-26 26 93278 Signal-averaged electrocardiography (SAECG), with or without ECG $ 79.25 5918 93278-TC TC 93278 Signal-averaged electrocardiography (SAECG), with or without ECG $ 132.25 Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report by a physician or other qualified health 5919 93279 93279 care $ 82.45 Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report by a physician or other qualified health 5920 93280 93280 care $ 98.60 Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report by a physician or other qualified health 5921 93281 93281 care $ 114.49 Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report by a physician or other qualified health 5922 93282 93282 care $ 107.41 Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report by a physician or other qualified health 5923 93283 93283 care $ 135.22 Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report by a physician or other qualified health 5924 93284 93284 care $ 171.39 Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report by a physician or other qualified health 5925 93285 93285 care $ 67.31 Peri-procedural device evaluation (in person) and programming of device system parameters before or after a surgery, procedure, or test with analysis, review and report by a physician or other 5926 93286 93286 qualified health care professional; single, dual, or multiple $ 31.89 Peri-procedural device evaluation (in person) and programming of device system parameters before or after a surgery, procedure, or test with analysis, review and report by a physician or other 5927 93287 93287 qualified health care professional; single, dual, or multiple $ 56.46 Interrogation device evaluation (in person) with analysis, review and report by a physician or other qualified health care professional, includes connection, recording and disconnection per patient 5928 93288 93288 encounter; single, dual, or multiple lead pacemaker syste $ 55.14 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Interrogation device evaluation (in person) with analysis, review and report by a physician or other qualified health care professional, includes connection, recording and disconnection per patient 5929 93289 93289 encounter; single, dual, or multiple lead implantable car $ 100.80 Interrogation device evaluation (in person) with analysis, review and report by a physician or other qualified health care professional, includes connection, recording and disconnection per patient 5930 93290 93290 encounter; implantable cardiovascular monitor system, inc $ 52.49 Interrogation device evaluation (in person) with analysis, review and report by a physician or other qualified health care professional, includes connection, recording and disconnection per patient 5931 93291 93291 encounter; implantable loop recorder system, including he $ 55.68 Transtelephonic rhythm strip pacemaker evaluation(s) single, dual, or multiple lead pacemaker system, includes recording with and without magnet application with analysis, review and report(s) by a 5932 93293 93293 physician or other qualified health care professional, up $ 38.13 Interrogation device evaluation(s) (remote), up to 90 days; single, dual, or multiple lead pacemaker system with interim analysis, review(s) and report(s) by a physician or other qualified health care 5933 93294 93294 professional $ 94.89 Interrogation device evaluation(s) (remote), up to 90 days; single, dual, or multiple lead implantable cardioverter-defibrillator system with interim analysis, review(s) and report(s) by a physician or other 5934 93295 93295 qualified health care professional $ 152.27 Interrogation device evaluation(s) (remote), up to 90 days; single, dual, or multiple lead pacemaker system or implantable cardioverter-defibrillator system, remote data acquisition(s), receipt 5935 93296 93296 of transmissions and technician review, technical support and $ 93.78 Interrogation device evaluation(s), (remote) up to 30 days; implantable cardiovascular monitor system, including analysis of 1 or more recorded physiologic cardiovascular data elements from all 5936 93297 93297 internal and external sensors, analysis, review(s) and report $ 56.66 Interrogation device evaluation(s), (remote) up to 30 days; implantable loop recorder system, including analysis of recorded heart rhythm data, analysis, review(s) and report(s) by a physician 5937 93298 93298 or other qualified health care professional $ 75.22 Interrogation device evaluation(s), (remote) up to 30 days; implantable cardiovascular monitor system or implantable loop recorder system, remote data acquisition(s), receipt of transmissions and technician review, technical support and 5938 93299 93299 distribution of re $ - Transthoracic echocardiography for congenital cardiac anomalies; 5939 93303 93303 complete $ 513.90 Transthoracic echocardiography for congenital cardiac anomalies; 5940 93303-26 26 93303 complete $ 152.41 Transthoracic echocardiography for congenital cardiac anomalies; 5941 93303-TC TC 93303 complete $ 361.49 Transthoracic echocardiography for congenital cardiac anomalies; 5942 93304 93304 follow-up or limited study $ 280.80 Transthoracic echocardiography for congenital cardiac anomalies; 5943 93304-26 26 93304 follow-up or limited study $ 72.52 Transthoracic echocardiography for congenital cardiac anomalies; 5944 93304-TC TC 93304 follow-up or limited study $ 208.28 Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler echocardiography, and with color 5945 93306 93306 flow Doppler echocardiography $ 230.29 Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, 5946 93307 93307 complete, without spectral or color Doppler echocardiography $ 499.03 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, 5947 93307-26 26 93307 complete, without spectral or color Doppler echocardiography $ 182.92 Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, 5948 93307-TC TC 93307 complete, without spectral or color Doppler echocardiography $ 316.11 Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, 5949 93308 93308 follow-up or limited study $ 58.08 Echocardiography, transesophageal, real-time with image documentation (2D) (with or without M-mode recording); including 5950 93312 93312 probe placement, image acquisition, interpretation and report $ 665.35 Echocardiography, transesophageal, real-time with image documentation (2D) (with or without M-mode recording); including 5951 93312-26 26 93312 probe placement, image acquisition, interpretation and report $ 208.89 Echocardiography, transesophageal, real-time with image documentation (2D) (with or without M-mode recording); including 5952 93312-TC TC 93312 probe placement, image acquisition, interpretation and report $ 456.47 Echocardiography, transesophageal, real-time with image documentation (2D) (with or without M-mode recording); 5953 93313 93313 placement of transesophageal probe only $ 257.40 Echocardiography, transesophageal, real-time with image documentation (2D) (with or without M-mode recording); image 5954 93314 93314 acquisition, interpretation and report only $ 424.80 Echocardiography, transesophageal, real-time with image documentation (2D) (with or without M-mode recording); image 5955 93314-26 26 93314 acquisition, interpretation and report only $ 81.18 Echocardiography, transesophageal, real-time with image documentation (2D) (with or without M-mode recording); image 5956 93314-TC TC 93314 acquisition, interpretation and report only $ 343.62 Transesophageal echocardiography for congenital cardiac anomalies; including probe placement, image acquisition, 5957 93315 93315 interpretation and report $ 663.30 Transesophageal echocardiography for congenital cardiac anomalies; including probe placement, image acquisition, 5958 93315-26 26 93315 interpretation and report $ 463.40 Transesophageal echocardiography for congenital cardiac 5959 93316 93316 anomalies; placement of transesophageal probe only $ 135.90 Transesophageal echocardiography for congenital cardiac 5960 93317 93317 anomalies; image acquisition, interpretation and report only $ 526.50 Transesophageal echocardiography for congenital cardiac 5961 93317-26 26 93317 anomalies; image acquisition, interpretation and report only $ 300.16 Echocardiography, transesophageal (TEE) for monitoring purposes, including probe placement, real time 2-dimensional image acquisition and interpretation leading to ongoing (continuous) assessment of (dynamically changing) cardiac pumping function and 5962 93318 93318 to t $ 847.00 Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (List separately in addition to codes for 5963 93320 93320 echocardiographic imaging); complete $ 307.08 Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (List separately in addition to codes for 5964 93320-26 26 93320 echocardiographic imaging); complete $ 116.49 Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (List separately in addition to codes for 5965 93320-TC TC 93320 echocardiographic imaging); complete $ 190.59 Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (List separately in addition to codes for echocardiographic imaging); follow-up or limited study (List 5966 93321 93321 separately in addition to codes for echocardiographic imaging) $ 187.20 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (List separately in addition to codes for echocardiographic imaging); follow-up or limited study (List 5967 93321-26 26 93321 separately in addition to codes for echocardiographic imaging) $ 52.95 Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (List separately in addition to codes for echocardiographic imaging); follow-up or limited study (List 5968 93321-TC TC 93321 separately in addition to codes for echocardiographic imaging) $ 134.25 Doppler echocardiography color flow velocity mapping (List 5969 93325 93325 separately in addition to codes for echocardiography) $ 247.27 Doppler echocardiography color flow velocity mapping (List 5970 93325-26 26 93325 separately in addition to codes for echocardiography) $ 44.14 Doppler echocardiography color flow velocity mapping (List 5971 93325-TC TC 93325 separately in addition to codes for echocardiography) $ 203.13 Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with 5972 93350 93350 interpretation $ 853.56 Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with 5973 93350-26 26 93350 interpretation $ 280.69 Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with 5974 93350-TC TC 93350 interpretation $ 572.87 Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with 5975 93351 93351 interpretation $ 274.13 Use of echocardiographic contrast agent during stress echocardiography (List separately in addition to code for primary 5976 93352 93352 procedure) $ 113.06 Left heart catheterization by transseptal puncture through intact septum or by transapical puncture (List separately in addition to 5977 93462 93462 code for primary procedure) $ 756.48 Insertion and placement of flow directed catheter (eg, Swan-Ganz) 5978 93503 93503 for monitoring purposes $ 725.40 5979 93505 93505 Endomyocardial biopsy $ 1,007.10 5980 93505-26 26 93505 Endomyocardial biopsy $ 290.16 5981 93505-TC TC 93505 Endomyocardial biopsy $ 716.94 5982 93530 93530 Right heart catheterization, for congenital cardiac anomalies $ - Combined right heart catheterization and retrograde left heart 5983 93531 93531 catheterization, for congenital cardiac anomalies $ - Combined right heart catheterization and transseptal left heart catheterization through intact septum with or without retrograde 5984 93532 93532 left heart catheterization, for congenital cardiac anomalies $ - Combined right heart catheterization and transseptal left heart catheterization through existing septal opening, with or without retrograde left heart catheterization, for congenital cardiac 5985 93533 93533 anomalies $ - Indicator dilution studies such as dye or thermodilution, including arterial and/or venous catheterization; with cardiac output 5986 93561 93561 measurement (separate procedure) $ - Indicator dilution studies such as dye or thermodilution, including arterial and/or venous catheterization; subsequent measurement of 5987 93562 93562 cardiac output $ - Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for selective coronary angiography during congenital heart catheterization (List separately 5988 93563 93563 in addition to code for primary procedure) $ 206.77 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for selective opacification of aortocoronary venous or arterial bypass graft(s) (eg, aortocoronary 5989 93564 93564 saphenous vein, free radial artery, or free ma $ 207.05 Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for selective left ventricular or left atrial angiography (List separately in addition to code for 5990 93565 93565 primary procedure) $ 160.18 Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for selective right ventricular or right atrial angiography (List separately in addition to 5991 93566 93566 code for primary procedure) $ 642.05 Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for supravalvular aortography (List separately in addition to code for primary 5992 93567 93567 procedure) $ 525.96 Injection procedure during cardiac catheterization including imaging supervision, interpretation, and report; for pulmonary angiography 5993 93568 93568 (List separately in addition to code for primary procedure) $ 578.40 Intravascular Doppler velocity and/or pressure derived coronary flow reserve measurement (coronary vessel or graft) during coronary angiography including pharmacologically induced stress; 5994 93571 93571 initial vessel (List separately in addition to code for primary pro $ 693.90 Intravascular Doppler velocity and/or pressure derived coronary flow reserve measurement (coronary vessel or graft) during coronary angiography including pharmacologically induced stress; 5995 93571-26 26 93571 initial vessel (List separately in addition to code for primary pro $ 352.53 Intravascular Doppler velocity and/or pressure derived coronary flow reserve measurement (coronary vessel or graft) during coronary angiography including pharmacologically induced stress; 5996 93572 93572 each additional vessel (List separately in addition to code for pri $ 637.20 Intravascular Doppler velocity and/or pressure derived coronary flow reserve measurement (coronary vessel or graft) during coronary angiography including pharmacologically induced stress; 5997 93572-26 26 93572 each additional vessel (List separately in addition to code for pri $ 290.14 Percutaneous transcatheter closure of congenital interatrial communication (ie, Fontan fenestration, atrial septal defect) with 5998 93580 93580 implant $ 10,167.89 5999 93600 93600 Bundle of His recording $ 772.20 6000 93600-26 26 93600 Bundle of His recording $ 310.59 6001 93602 93602 Intra-atrial recording $ 510.30 6002 93602-26 26 93602 Intra-atrial recording $ 254.62 6003 93603 93603 Right ventricular recording $ 605.70 6004 93603-26 26 93603 Right ventricular recording $ 221.61 Intraventricular and/or intra-atrial mapping of tachycardia site(s) with catheter manipulation to record from multiple sites to identify origin of tachycardia (List separately in addition to code for primary 6005 93609 93609 procedure) $ 1,494.00 Intraventricular and/or intra-atrial mapping of tachycardia site(s) with catheter manipulation to record from multiple sites to identify origin of tachycardia (List separately in addition to code for primary 6006 93609-26 26 93609 procedure) $ 825.96 6007 93610 93610 Intra-atrial pacing $ 592.20 6008 93610-26 26 93610 Intra-atrial pacing $ 416.14 6009 93612 93612 Intraventricular pacing $ 568.80 6010 93612-26 26 93612 Intraventricular pacing $ 327.81 Intracardiac electrophysiologic 3-dimensional mapping (List 6011 93613 93613 separately in addition to code for primary procedure) $ 1,153.65 Esophageal recording of atrial electrogram with or without 6012 93615 93615 ventricular electrogram(s); $ 134.10 Esophageal recording of atrial electrogram with or without 6013 93615-26 26 93615 ventricular electrogram(s); $ 103.31 Esophageal recording of atrial electrogram with or without 6014 93616 93616 ventricular electrogram(s); with pacing $ 358.20 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Esophageal recording of atrial electrogram with or without 6015 93616-26 26 93616 ventricular electrogram(s); with pacing $ 165.00 6016 93618 93618 Induction of arrhythmia by electrical pacing $ 1,287.90 6017 93618-26 26 93618 Induction of arrhythmia by electrical pacing $ 730.18 Comprehensive electrophysiologic evaluation with right atrial pacing and recording, right ventricular pacing and recording, His bundle recording, including insertion and repositioning of multiple 6018 93619 93619 electrode catheters, without induction or attempted inducti $ 2,567.70 Comprehensive electrophysiologic evaluation with right atrial pacing and recording, right ventricular pacing and recording, His bundle recording, including insertion and repositioning of multiple 6019 93619-26 26 93619 electrode catheters, without induction or attempted inducti $ 1,141.78 Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with right atrial pacing and 6020 93620 93620 recording, right ventricular pacing and recording, His bund $ 3,511.80 Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with right atrial pacing and 6021 93620-26 26 93620 recording, right ventricular pacing and recording, His bund $ 1,780.00 Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with left atrial pacing and 6022 93621 93621 recording from coronary sinus or left atrium (List separatel $ 3,800.70 Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with left atrial pacing and 6023 93621-26 26 93621 recording from coronary sinus or left atrium (List separatel $ 425.44 Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia;

with left ventricular pacing and 6024 93622 93622 recording (List separately in addition to code for prim $ - Programmed stimulation and pacing after intravenous drug infusion 6025 93623 93623 (List separately in addition to code for primary procedure) $ 625.50 Programmed stimulation and pacing after intravenous drug infusion 6026 93623-26 26 93623 (List separately in addition to code for primary procedure) $ 377.16 Electrophysiologic follow-up study with pacing and recording to test effectiveness of therapy, including induction or attempted induction 6027 93624 93624 of arrhythmia $ 1,545.30 Electrophysiologic follow-up study with pacing and recording to test effectiveness of therapy, including induction or attempted induction 6028 93624-26 26 93624 of arrhythmia $ 841.51 Intraoperative epicardial and endocardial pacing and mapping to localize the site of tachycardia or zone of slow conduction for 6029 93631 93631 surgical correction $ 1,283.52 Electrophysiologic evaluation of single or dual chamber pacing cardioverter-defibrillator leads including defibrillation threshold evaluation (induction of arrhythmia, evaluation of sensing and 6030 93640 93640 pacing for arrhythmia termination) at time of initial implant $ 578.16 Electrophysiologic evaluation of single or dual chamber pacing cardioverter-defibrillator leads including defibrillation threshold evaluation (induction of arrhythmia, evaluation of sensing and 6031 93641 93641 pacing for arrhythmia termination) at time of initial implant $ 1,702.80 Electrophysiologic evaluation of single or dual chamber pacing cardioverter-defibrillator leads including defibrillation threshold evaluation (induction of arrhythmia, evaluation of sensing and 6032 93641-26 26 93641 pacing for arrhythmia termination) at time of initial implant $ 890.84 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Electrophysiologic evaluation of single or dual chamber pacing cardioverter-defibrillator (includes defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing and pacing for arrhythmia termination, and programming or 6033 93642 93642 reprogramming $ 841.38 Intracardiac catheter ablation of atrioventricular node function, atrioventricular conduction for creation of complete heart block, 6034 93650 93650 with or without temporary pacemaker placement $ 3,193.20 Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of an arrhythmia with right atrial pacing and 6035 93653 93653 recording, right ventricular pacing and recording (when n $ 1,587.14 Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of an arrhythmia with right atrial pacing and 6036 93654 93654 recording, right ventricular pacing and recording (when n $ 2,118.20 Intracardiac catheter ablation of a discrete mechanism of arrhythmia which is distinct from the primary ablated mechanism, including repeat diagnostic maneuvers, to treat a spontaneous or 6037 93655 93655 induced arrhythmia (List separately in addition to code for primary $ 793.43 Comprehensive electrophysiologic evaluation including transseptal catheterizations, insertion and repositioning of multiple electrode catheters with induction or attempted induction of an arrhythmia 6038 93656 93656 including left or right atrial pacing/recording when nec $ 2,118.70 Additional linear or focal intracardiac catheter ablation of the left or right atrium for treatment of atrial fibrillation remaining after completion of pulmonary vein isolation (List separately in addition 6039 93657 93657 to code for primary procedure) $ 794.38 Evaluation of cardiovascular function with tilt table evaluation, with continuous ECG monitoring and intermittent blood pressure 6040 93660 93660 monitoring, with or without pharmacological intervention $ 639.00 Evaluation of cardiovascular function with tilt table evaluation, with continuous ECG monitoring and intermittent blood pressure 6041 93660-26 26 93660 monitoring, with or without pharmacological intervention $ 361.25 Evaluation of cardiovascular function with tilt table evaluation, with continuous ECG monitoring and intermittent blood pressure 6042 93660-TC TC 93660 monitoring, with or without pharmacological intervention $ 277.75 Intracardiac echocardiography during therapeutic/diagnostic intervention, including imaging supervision and interpretation (List 6043 93662 93662 separately in addition to code for primary procedure) $ - 6044 93668 93668 Peripheral arterial disease (PAD) rehabilitation, per session $ 142.65 6045 93701 93701 Bioimpedance-derived physiologic cardiovascular analysis $ 86.57 Plethysmography for determination of lung volumes and, when 6046 93721-26 26 93721 performed, airway resistance $ 23.56 Plethysmography for determination of lung volumes and, when 6047 93721-TC TC 93721 performed, airway resistance $ 95.27 Plethysmography for determination of lung volumes and, when 6048 93722-26 26 93722 performed, airway resistance $ 23.56 Plethysmography for determination of lung volumes and, when 6049 93722-TC TC 93722 performed, airway resistance $ 95.27 Electronic analysis of antitachycardia pacemaker system (includes electrocardiographic recording, programming of device, induction and termination of tachycardia via implanted pacemaker, and 6050 93724 93724 interpretation of recordings) $ 575.15 Transtelephonic rhythm strip pacemaker evaluation(s) single, dual, or multiple lead pacemaker system, includes recording with and without magnet application with analysis, review and report(s) by a 6051 93733-26 26 93733 physician or other qualified health care professional, up $ 38.13 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Transtelephonic rhythm strip pacemaker evaluation(s) single, dual, or multiple lead pacemaker system, includes recording with and without magnet application with analysis, review and report(s) by a 6052 93733-TC TC 93733 physician or other qualified health care professional, up $ 98.63 Transtelephonic rhythm strip pacemaker evaluation(s) single, dual, or multiple lead pacemaker system, includes recording with and without magnet application with analysis, review and report(s) by a 6053 93736-26 26 93736 physician or other qualified health care professional, up $ 38.13 Transtelephonic rhythm strip pacemaker evaluation(s) single, dual, or multiple lead pacemaker system, includes recording with and without magnet application with analysis, review and report(s) by a 6054 93736-TC TC 93736 physician or other qualified health care professional, up $ 98.63 6055 93740 93740 Temperature gradient studies $ 108.00 Initial set-up and programming by a physician or other qualified health care professional of wearable cardioverter-defibrillator includes initial programming of system, establishing baseline 6056 93745 93745 electronic ECG, transmission of data to data repository, patient $ - Interrogation of ventricular assist device (VAD), in person, with physician or other qualified health care professional analysis of device parameters (eg, drivelines, alarms, power surges), review of 6057 93750 93750 device function (eg, flow and volume status, septum sta $ 107.14 6058 93770 93770 Determination of venous pressure $ 30.60 Ambulatory blood pressure monitoring, utilizing a system such as magnetic tape and/or computer disk, for 24 hours or longer; 6059 93784 93784 including recording, scanning analysis, interpretation and report $ 369.90 Ambulatory blood pressure monitoring, utilizing a system such as magnetic tape and/or computer disk, for 24 hours or longer; 6060 93786 93786 recording only $ 65.66 Ambulatory blood pressure monitoring, utilizing a system such as magnetic tape and/or computer disk, for 24 hours or longer; 6061 93788 93788 scanning analysis with report $ 137.83 Ambulatory blood pressure monitoring, utilizing a system such as magnetic tape and/or computer disk, for 24 hours or longer; review 6062 93790 93790 with interpretation and report $ 65.76 Physician or other qualified health care professional services for outpatient cardiac rehabilitation; without continuous ECG 6063 93797 93797 monitoring (per session) $ 46.80 Physician or other qualified health care professional services for outpatient cardiac rehabilitation; with continuous ECG monitoring 6064 93798 93798 (per session) $ 68.76 6065 93799 93799 Unlisted cardiovascular service or procedure Cost 6066 93875-26 26 93875 Duplex scan of extracranial arteries; complete bilateral study $ 47.85 6067 93875-TC TC 93875 Duplex scan of extracranial arteries; complete bilateral study $ 383.73 6068 93880 93880 Duplex scan of extracranial arteries; complete bilateral study $ 431.58 6069 93880-26 26 93880 Duplex scan of extracranial arteries; complete bilateral study $ 47.85 6070 93880-TC TC 93880 Duplex scan of extracranial arteries; complete bilateral study $ 383.73 6071 93882 93882 Duplex scan of extracranial arteries; unilateral or limited study $ 43.57 Transcranial Doppler study of the intracranial arteries; complete 6072 93886 93886 study $ 53.54 6073 93888 93888 Transcranial Doppler study of the intracranial arteries; limited study $ 44.63 Transcranial Doppler study of the intracranial arteries; 6074 93890 93890 vasoreactivity study $ 121.20 Transcranial Doppler study of the intracranial arteries; emboli 6075 93892 93892 detection without intravenous microbubble injection $ 138.59 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Limited bilateral noninvasive physiologic studies of upper or lower extremity arteries, (eg, for lower extremity: ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries 6076 93922 93922 plus bidirectional, Doppler waveform recording $ 26.81 Complete bilateral noninvasive physiologic studies of upper or lower extremity arteries, 3 or more levels (eg, for lower extremity: ankle/brachial indices at distal posterior tibial and anterior 6077 93923 93923 tibial/dorsalis pedis arteries plus segmental blood pressure $ 364.50 Complete bilateral noninvasive physiologic studies of upper or lower extremity arteries, 3 or more levels (eg, for lower extremity: ankle/brachial indices at distal posterior tibial and anterior 6078 93923-26 26 93923 tibial/dorsalis pedis arteries plus segmental blood pressure $ 51.22 Complete bilateral noninvasive physiologic studies of upper or lower extremity arteries, 3 or more levels (eg, for lower extremity: ankle/brachial indices at distal posterior tibial and anterior 6079 93923-TC TC 93923 tibial/dorsalis pedis arteries plus segmental blood pressure $ 313.28 Noninvasive physiologic studies of lower extremity arteries, at rest and following treadmill stress testing, (ie, bidirectional Doppler waveform or volume plethysmography recording and analysis at 6080 93924 93924 rest with ankle/brachial indices immediately after and at $ 369.00 Noninvasive physiologic studies of lower extremity arteries, at rest and following treadmill stress testing, (ie, bidirectional Doppler waveform or volume plethysmography recording and analysis at 6081 93924-26 26 93924 rest with ankle/brachial indices immediately after and at $ 45.73 Noninvasive physiologic studies of lower extremity arteries, at rest and following treadmill stress testing, (ie, bidirectional Doppler waveform or volume plethysmography recording and analysis at 6082 93924-TC TC 93924 rest with ankle/brachial indices immediately after and at $ 323.27 Duplex scan of lower extremity arteries or arterial bypass grafts; 6083 93925 93925 complete bilateral study $ 398.17 Duplex scan of lower extremity arteries or arterial bypass grafts; 6084 93925-26 26 93925 complete bilateral study $ 56.52 Duplex scan of lower extremity arteries or arterial bypass grafts; 6085 93925-TC TC 93925 complete bilateral study $ 341.65 Duplex scan of lower extremity arteries or arterial bypass grafts; 6086 93926 93926 unilateral or limited study $ 245.96 Duplex scan of lower extremity arteries or arterial bypass grafts; 6087 93926-26 26 93926 unilateral or limited study $ 38.91 Duplex scan of lower extremity arteries or arterial bypass grafts; 6088 93926-TC TC 93926 unilateral or limited study $ 207.05 Duplex scan of upper extremity arteries or arterial bypass grafts; 6089 93930 93930 complete bilateral study $ 432.90 Duplex scan of upper extremity arteries or arterial bypass grafts; 6090 93930-26 26 93930 complete bilateral study $ 37.29 Duplex scan of upper extremity arteries or arterial bypass grafts; 6091 93930-TC TC 93930 complete bilateral study $ 395.61 Duplex scan of upper extremity arteries or arterial bypass grafts; 6092 93931 93931 unilateral or limited study $ 270.90 Duplex scan of upper extremity arteries or arterial bypass grafts; 6093 93931-26 26 93931 unilateral or limited study $ 23.26 Duplex scan of upper extremity arteries or arterial bypass grafts; 6094 93931-TC TC 93931 unilateral or limited study $ 247.64 Noninvasive physiologic studies of extremity veins, complete bilateral study (eg, Doppler waveform analysis with responses to compression and other maneuvers, phleborheography, impedance 6095 93965 93965 plethysmography) $ 243.31 Noninvasive physiologic studies of extremity veins, complete bilateral study (eg, Doppler waveform analysis with responses to compression and other maneuvers, phleborheography, impedance 6096 93965-26 26 93965 plethysmography) $ 30.99 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Noninvasive physiologic studies of extremity veins, complete bilateral study (eg, Doppler waveform analysis with responses to compression and other maneuvers, phleborheography, impedance 6097 93965-TC TC 93965 plethysmography) $ 212.32 Duplex scan of extremity veins including responses to compression 6098 93970 93970 and other maneuvers; complete bilateral study $ 382.93 Duplex scan of extremity veins including responses to compression 6099 93970-26 26 93970 and other maneuvers; complete bilateral study $ 64.54 Duplex scan of extremity veins including responses to compression 6100 93970-TC TC 93970 and other maneuvers; complete bilateral study $ 318.39 Duplex scan of extremity veins including responses to compression 6101 93971 93971 and other maneuvers; unilateral or limited study $ 237.86 Duplex scan of extremity veins including responses to compression 6102 93971-26 26 93971 and other maneuvers; unilateral or limited study $ 41.87 Duplex scan of extremity veins including responses to compression 6103 93971-TC TC 93971 and other maneuvers; unilateral or limited study $ 195.99 Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; complete 6104 93975 93975 study $ 387.90 Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; complete 6105 93975-26 26 93975 study $ 86.92 Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; complete 6106 93975-TC TC 93975 study $ 300.98 Duplex scan of arterial inflow and venous outflow of abdominal, 6107 93976 93976 pelvic, scrotal contents and/or retroperitoneal organs; limited study $ 109.12 Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass 6108 93978 93978 grafts; complete study $ 46.67 Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass 6109 93979 93979 grafts; unilateral or limited study $ 32.53 Duplex scan of arterial inflow and venous outflow of penile vessels; 6110 93980 93980 complete study $ 179.39 Duplex scan of arterial inflow and venous outflow of penile vessels; 6111 93981 93981 follow-up or limited study $ 63.58 Noninvasive physiologic study of implanted wireless pressure sensor in aneurysmal sac following endovascular repair, complete study including recording, analysis of pressure and waveform tracings, 6112 93982 93982 interpretation and report $ 101.76 Duplex scan of hemodialysis access (including arterial inflow, body 6113 93990 93990 of access and venous outflow) $ 16.62 Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; hospital 6114 94002 94002 inpatient/observation, initial day $ 218.34 Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; hospital 6115 94003 94003 inpatient/observation, each subsequent day $ 157.25 Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; nursing 6116 94004 94004 facility, per day $ 114.51 Home ventilator management care plan oversight of a patient (patient not present) in home, domiciliary or rest home (eg, assisted living) requiring review of status, review of laboratories and other 6117 94005 94005 studies and revision of orders and respiratory care plan $ 203.72 Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement(s), with or without maximal 6118 94010 94010 voluntary ventilation $ 92.70 Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement(s), with or without maximal 6119 94010-26 26 94010 voluntary ventilation $ 18.97 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement(s), with or without maximal 6120 94010-TC TC 94010 voluntary ventilation $ 73.73 Measurement of spirometric forced expiratory flows in an infant or 6121 94011 94011 child through 2 years of age $ 216.23 Measurement of spirometric forced expiratory flows, before and 6122 94012 94012 after bronchodilator, in an infant or child through 2 years of age $ 352.90 Measurement of lung volumes (ie, functional residual capacity [FRC], forced vital capacity [FVC], and expiratory reserve volume 6123 94013 94013 [ERV]) in an infant or child through 2 years of age $ 76.21 Patient-initiated spirometric recording per 30-day period of time; includes reinforced education, transmission of spirometric tracing, data capture, analysis of transmitted data, periodic recalibration 6124 94014 94014 and review and interpretation by a physician or other $ 91.80 Patient-initiated spirometric recording per 30-day period of time; recording (includes hook-up, reinforced education, data transmission, data capture, trend analysis, and periodic 6125 94015 94015 recalibration) $ 54.46 Patient-initiated spirometric recording per 30-day period of time; review and interpretation only by a physician or other qualified 6126 94016 94016 health care professional $ 58.50 Bronchodilation responsiveness, spirometry as in 94010, pre- and 6127 94060 94060 post-bronchodilator administration $ 128.70 Bronchodilation responsiveness, spirometry as in 94010, pre- and 6128 94060-26 26 94060 post-bronchodilator administration $ 24.14 Bronchodilation responsiveness, spirometry as in 94010, pre- and 6129 94060-TC TC 94060 post-bronchodilator administration $ 104.56 6130 94150 94150 Vital capacity, total (separate procedure) $ 5.54 6131 94200 94200 Maximum breathing capacity, maximal voluntary ventilation $ 11.13 Expired gas collection, quantitative, single procedure (separate 6132 94250 94250 procedure) $ 33.30 Expired gas collection, quantitative, single procedure (separate 6133 94250-26 26 94250 procedure) $ 6.45 Expired gas collection, quantitative, single procedure (separate 6134 94250-TC TC 94250 procedure) $ 26.85 6135 94375 94375 Respiratory flow volume loop $ 99.00 6136 94375-26 26 94375 Respiratory flow volume loop $ 33.70 6137 94375-TC TC 94375 Respiratory flow volume loop $ 65.30 6138 94450 94450 Breathing response to hypoxia (hypoxia response curve) $ 24.61 High altitude simulation test (HAST), with interpretation and report 6139 94452 94452 by a physician or other qualified health care professional; $ 37.46 High altitude simulation test (HAST), with interpretation and report by a physician or other qualified health care professional; with 6140 94453 94453 supplemental oxygen titration $ 48.67 Intrapulmonary surfactant administration by a physician or other 6141 94610 94610 qualified health care professional through endotracheal tube $ 157.18 Pulmonary stress testing; simple (eg, 6-minute walk test, prolonged exercise test for bronchospasm with pre- and post-spirometry and 6142 94620 94620 oximetry) $ 254.70 Pulmonary stress testing; simple (eg, 6-minute walk test, prolonged exercise test for bronchospasm with pre- and post-spirometry and 6143 94620-26 26 94620 oximetry) $ 129.42 Pulmonary stress testing; simple (eg, 6-minute walk test, prolonged exercise test for bronchospasm with pre- and post-spirometry and 6144 94620-TC TC 94620 oximetry) $ 125.28 Pulmonary stress testing; complex (including measurements of CO2 6145 94621 94621 production, O2 uptake, and electrocardiographic recordings) $ 81.55 Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes (eg, with an aerosol generator, nebulizer, metered dose inhaler or 6146 94640 94640 intermittent positive pressure breathing [IPPB] device) $ 41.40 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Continuous inhalation treatment with aerosol medication for acute airway obstruction; each additional hour (List separately in addition 6147 94645 94645 to code for primary procedure) $ 32.68 Continuous positive airway pressure ventilation (CPAP), initiation 6148 94660 94660 and management $ 180.90 Demonstration and/or evaluation of patient utilization of an aerosol 6149 94664 94664 generator, nebulizer, metered dose inhaler or IPPB device $ 49.61 Manipulation chest wall, such as cupping, percussing, and vibration 6150 94667 94667 to facilitate lung function; initial demonstration and/or evaluation $ 63.00 Manipulation chest wall, such as cupping, percussing, and vibration 6151 94668 94668 to facilitate lung function; subsequent $ 54.90 Oxygen uptake, expired gas analysis; rest and exercise, direct, 6152 94680 94680 simple $ 26.96 Oxygen uptake, expired gas analysis; including CO2 output, 6153 94681 94681 percentage oxygen extracted $ 169.20 Oxygen uptake, expired gas analysis; including CO2 output, 6154 94681-26 26 94681 percentage oxygen extracted $ 28.35 Oxygen uptake, expired gas analysis; including CO2 output, 6155 94681-TC TC 94681 percentage oxygen extracted $ 140.85 Pulmonary compliance study (eg, plethysmography, volume and 6156 94750 94750 pressure measurements) $ 98.10 Pulmonary compliance study (eg, plethysmography, volume and 6157 94750-26 26 94750 pressure measurements) $ 11.39 Pulmonary compliance study (eg, plethysmography, volume and 6158 94750-TC TC 94750 pressure measurements) $ 86.71 Noninvasive ear or pulse oximetry for oxygen saturation; single 6159 94760 94760 determination $ 34.98 Noninvasive ear or pulse oximetry for oxygen saturation; multiple 6160 94761 94761 determinations (eg, during exercise) $ 72.00 Pediatric home apnea monitoring event recording including respiratory rate, pattern and heart rate per 30-day period of time; includes monitor attachment, download of data, review, interpretation, and preparation of a report by a physician or other 6161 94774 94774 qualif $ - Pediatric home apnea monitoring event recording including respiratory rate, pattern and heart rate per 30-day period of time; monitor attachment only (includes hook-up, initiation of recording 6162 94775 94775 and disconnection) $ - Pediatric home apnea monitoring event recording including respiratory rate, pattern and heart rate per 30-day period of time; monitoring, download of information, receipt of transmission(s) and 6163 94776 94776 analyses by computer only $ - Pediatric home apnea monitoring event recording including respiratory rate, pattern and heart rate per 30-day period of time; review, interpretation and preparation of report only by a physician 6164 94777 94777 or other qualified health care professional $ - 6165 94799 94799 Unlisted pulmonary service or procedure $ 27.50 Percutaneous tests (scratch, puncture, prick) with allergenic extracts, immediate type reaction, including test interpretation and 6166 95004 95004 report, specify number of tests $ 7.55 6167 95012 95012 Nitric oxide expired gas determination $ 56.16 Allergy testing, any combination of percutaneous (scratch, puncture, prick) and intracutaneous (intradermal), sequential and incremental, with venoms, immediate type reaction, including test 6168 95017 95017 interpretation and report, specify number of tests $ 17.14 Allergy testing, any combination of percutaneous (scratch, puncture, prick) and intracutaneous (intradermal), sequential and incremental, with drugs or biologicals, immediate type reaction, 6169 95018 95018 including test interpretation and report, specify number of tests $ 42.06 Intracutaneous (intradermal) tests with allergenic extracts, immediate type reaction, including test interpretation and report, 6170 95024 95024 specify number of tests $ 14.40 Intracutaneous (intradermal) tests, sequential and incremental, with allergenic extracts for airborne allergens, immediate type reaction, including test interpretation and report, specify number of 6171 95027 95027 tests $ 12.83 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Intracutaneous (intradermal) tests with allergenic extracts, delayed 6172 95028 95028 type reaction, including reading, specify number of tests $ 20.70 6173 95044 95044 Patch or application test(s) (specify number of tests) $ 19.08 6174 95052 95052 Photo patch test(s) (specify number of tests) $ 13.50 6175 95056 95056 Photo tests $ 12.60 6176 95060 95060 Ophthalmic mucous membrane tests $ 23.40 6177 95065 95065 Direct nasal mucous membrane test $ 20.70 Inhalation bronchial challenge testing (not including necessary pulmonary function tests); with histamine, methacholine, or similar 6178 95070 95070 compounds $ 175.50 Inhalation bronchial challenge testing (not including necessary 6179 95071 95071 pulmonary function tests); with antigens or gases, specify $ 204.30 Ingestion challenge test (sequential and incremental ingestion of test items, eg, food, drug or other substance); initial 120 minutes of 6180 95076 95076 testing $ 219.54 Ingestion challenge test (sequential and incremental ingestion of test items, eg, food, drug or other substance); each additional 60 minutes of testing (List separately in addition to code for primary 6181 95079 95079 procedure) $ 152.06 Professional services for allergen immunotherapy not including 6182 95115 95115 provision of allergenic extracts; single injection $ 17.96 Professional services for allergen immunotherapy not including 6183 95117 95117 provision of allergenic extracts; 2 or more injections $ 23.11 Professional services for allergen immunotherapy in the office or institution of the prescribing physician or other qualified health care professional, including provision of allergenic extract; single 6184 95120 95120 injection $ 26.10 Professional services for allergen immunotherapy in the office or institution of the prescribing physician or other qualified health care professional, including provision of allergenic extract; 2 or more 6185 95125 95125 injections $ 28.80 Professional services for allergen immunotherapy in the office or institution of the prescribing physician or other qualified health care professional, including provision of allergenic extract; single stinging 6186 95130 95130 insect venom $ 34.20 Professional services for allergen immunotherapy in the office or institution of the prescribing physician or other qualified health care professional, including provision of allergenic extract; 2 stinging 6187 95131 95131 insect venoms $ 47.70 Professional services for allergen immunotherapy in the office or institution of the prescribing physician or other qualified health care professional, including provision of allergenic extract; 3 stinging 6188 95132 95132 insect venoms $ 62.10 Professional services for allergen immunotherapy in the office or institution of the prescribing physician or other qualified health care professional, including provision of allergenic extract; 4 stinging 6189 95133 95133 insect venoms $ 63.90 Professional services for allergen immunotherapy in the office or institution of the prescribing physician or other qualified health care professional, including provision of allergenic extract; 5 stinging 6190 95134 95134 insect venoms $ 65.70 Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy, single dose 6191 95144 95144 vial(s) (specify number of vials) $ 33.49 Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy (specify number 6192 95145 95145 of doses); single stinging insect venom $ 36.00 Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy (specify number 6193 95146 95146 of doses); 2 single stinging insect venoms $ 46.80 Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy (specify number 6194 95147 95147 of doses); 3 single stinging insect venoms $ 64.80 Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy (specify number 6195 95148 95148 of doses); 4 single stinging insect venoms $ 65.70 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy (specify number 6196 95149 95149 of doses); 5 single stinging insect venoms $ 81.00 Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; single or multiple 6197 95165 95165 antigens (specify number of doses) $ 15.30 Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; whole body extract of 6198 95170 95170 biting insect or other arthropod (specify number of doses) $ 33.30 Rapid desensitization procedure, each hour (eg, insulin, penicillin, 6199 95180 95180 equine serum) $ 207.00 6200 95199 95199 Unlisted allergy/clinical immunologic service or procedure Cost Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours; sensor placement, hook-up, calibration of monitor, patient training, 6201 95250 95250 removal of sensor, and printout of recording $ 265.16 Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours; 6202 95251 95251 interpretation and report $ 62.92 Actigraphy testing, recording, analysis, interpretation, and report 6203 95803 95803 (minimum of 72 hours to 14 consecutive days of recording) $ 80.02 Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of physiological 6204 95805 95805 measurements of sleep during multiple trials to assess sleepiness $ 566.10 Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of physiological 6205 95805-26 26 95805 measurements of sleep during multiple trials to assess sleepiness $ 70.32 Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of physiological 6206 95805-TC TC 95805 measurements of sleep during multiple trials to assess sleepiness $ 495.78 Sleep study, unattended, simultaneous recording of, heart rate, oxygen saturation, respiratory airflow, and respiratory effort (eg, 6207 95806 95806 thoracoabdominal movement) $ 66.94 Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a 6208 95807 95807 technologist $ 713.70 Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a 6209 95807-26 26 95807 technologist $ 80.56 Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a 6210 95807-TC TC 95807 technologist $ 633.14 Polysomnography; any age, sleep staging with 1-3 additional 6211 95808 95808 parameters of sleep, attended by a technologist $ 756.90 Polysomnography; any age, sleep staging with 1-3 additional 6212 95808-26 26 95808 parameters of sleep, attended by a technologist $ 91.44 Polysomnography; any age, sleep staging with 1-3 additional 6213 95808-TC TC 95808 parameters of sleep, attended by a technologist $ 665.46 Polysomnography; age 6 years or older, sleep staging with 4 or 6214 95810 95810 more additional parameters of sleep, attended by a technologist $ 747.00 Polysomnography; age 6 years or older, sleep staging with 4 or 6215 95810-26 26 95810 more additional parameters of sleep, attended by a technologist $ 129.14 Polysomnography; age 6 years or older, sleep staging with 4 or 6216 95810-TC TC 95810 more additional parameters of sleep, attended by a technologist $ 617.86 Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by 6217 95811 95811 a technologist $ 455.02 6218 95812 95812 Electroencephalogram (EEG) extended monitoring; 41-60 minutes $ 174.48 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Electroencephalogram (EEG) extended monitoring; greater than 1 6219 95813 95813 hour $ 221.97 6220 95816 95816 Electroencephalogram (EEG); including recording awake and drowsy $ 266.90 6221 95816-26 26 95816 Electroencephalogram (EEG); including recording awake and drowsy $ 33.98 6222 95816-TC TC 95816 Electroencephalogram (EEG); including recording awake and drowsy $ 232.92 6223 95819 95819 Electroencephalogram (EEG); including recording awake and asleep $ 215.10 6224 95819-26 26 95819 Electroencephalogram (EEG); including recording awake and asleep $ 23.60 6225 95819-TC TC 95819 Electroencephalogram (EEG); including recording awake and asleep $ 191.50 6226 95822 95822 Electroencephalogram (EEG); recording in coma or sleep only $ 270.90 6227 95822-26 26 95822 Electroencephalogram (EEG); recording in coma or sleep only $ 33.28 6228 95822-TC TC 95822 Electroencephalogram (EEG); recording in coma or sleep only $ 237.62 6229 95824 95824 Electroencephalogram (EEG); cerebral death evaluation only $ 177.30 6230 95827 95827 Electroencephalogram (EEG); all night recording $ 343.80 6231 95827-26 26 95827 Electroencephalogram (EEG); all night recording $ 22.14 6232 95827-TC TC 95827 Electroencephalogram (EEG); all night recording $ 321.66 6233 95829 95829 Electrocorticogram at surgery (separate procedure) $ 533.70 6234 95829-26 26 95829 Electrocorticogram at surgery (separate procedure) $ 80.52 6235 95829-TC TC 95829 Electrocorticogram at surgery (separate procedure) $ 453.18 Insertion by physician or other qualified health care professional of 6236 95830 95830 sphenoidal electrodes for electroencephalographic (EEG) recording $ 241.20 Muscle testing, manual (separate procedure) with report; extremity 6237 95831 95831 (excluding hand) or trunk $ 105.30 Muscle testing, manual (separate procedure) with report; hand, 6238 95832 95832 with or without comparison with normal side $ 72.90 Muscle testing, manual (separate procedure) with report; total 6239 95833 95833 evaluation of body, excluding hands $ 113.40 Muscle testing, manual (separate procedure) with report; total 6240 95834 95834 evaluation of body, including hands $ 139.50 Range of motion measurements and report (separate procedure); 6241 95851 95851 each extremity (excluding hand) or each trunk section (spine) $ 87.30 Range of motion measurements and report (separate procedure); 6242 95852 95852 hand, with or without comparison with normal side $ 72.00 6243 95857 95857 Cholinesterase inhibitor challenge test for myasthenia gravis $ 122.40 Needle electromyography; 1 extremity with or without related 6244 95860 95860 paraspinal areas $ 216.72 Needle electromyography; 1 extremity with or without related 6245 95860-26 26 95860 paraspinal areas $ 82.27 Needle electromyography; 1 extremity with or without related 6246 95860-TC TC 95860 paraspinal areas $ 134.45 Needle electromyography; 2 extremities with or without related 6247 95861 95861 paraspinal areas $ 282.23 Needle electromyography; 2 extremities with or without related 6248 95861-26 26 95861 paraspinal areas $ 125.43 Needle electromyography; 2 extremities with or without related 6249 95861-TC TC 95861 paraspinal areas $ 156.80 Needle electromyography; 3 extremities with or without related 6250 95863 95863 paraspinal areas $ 473.40 Needle electromyography; 3 extremities with or without related 6251 95863-26 26 95863 paraspinal areas $ 207.62 Needle electromyography; 3 extremities with or without related 6252 95863-TC TC 95863 paraspinal areas $ 265.78 Needle electromyography; 4 extremities with or without related 6253 95864 95864 paraspinal areas $ 618.30 Needle electromyography; 4 extremities with or without related 6254 95864-26 26 95864 paraspinal areas $ 251.46 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Needle electromyography; 4 extremities with or without related 6255 95864-TC TC 95864 paraspinal areas $ 366.84 6256 95865 95865 Needle electromyography; larynx $ 201.02 6257 95866 95866 Needle electromyography; hemidiaphragm $ 154.18 Needle electromyography; cranial nerve supplied muscle(s), 6258 95867 95867 unilateral $ 211.50 Needle electromyography; cranial nerve supplied muscle(s), 6259 95867-26 26 95867 unilateral $ 71.74 Needle electromyography; cranial nerve supplied muscle(s), 6260 95867-TC TC 95867 unilateral $ 139.76 6261 95868 95868 Needle electromyography; cranial nerve supplied muscles, bilateral $ 257.40 6262 95868-26 26 95868 Needle electromyography; cranial nerve supplied muscles, bilateral $ 104.05 6263 95868-TC TC 95868 Needle electromyography; cranial nerve supplied muscles, bilateral $ 153.35 Needle electromyography; thoracic paraspinal muscles (excluding 6264 95869 95869 T1 or T12) $ 162.34 Needle electromyography; thoracic paraspinal muscles (excluding 6265 95869-26 26 95869 T1 or T12) $ 33.27 Needle electromyography; thoracic paraspinal muscles (excluding 6266 95869-TC TC 95869 T1 or T12) $ 129.07 Needle electromyography; limited study of muscles in 1 extremity or non-limb (axial) muscles (unilateral or bilateral), other than 6267 95870 95870 thoracic paraspinal, cranial nerve supplied muscles, or sphincters $ 99.09 Needle electromyography; limited study of muscles in 1 extremity or non-limb (axial) muscles (unilateral or bilateral), other than 6268 95870-26 26 95870 thoracic paraspinal, cranial nerve supplied muscles, or sphincters $ 64.59 Needle electromyography; limited study of muscles in 1 extremity or non-limb (axial) muscles (unilateral or bilateral), other than 6269 95870-TC TC 95870 thoracic paraspinal, cranial nerve supplied muscles, or sphincters $ 34.50 Needle electromyography using single fiber electrode, with quantitative measurement of jitter, blocking and/or fiber density, 6270 95872 95872 any/all sites of each muscle studied $ 257.40 Needle electromyography using single fiber electrode, with quantitative measurement of jitter, blocking and/or fiber density, 6271 95872-26 26 95872 any/all sites of each muscle studied $ 186.60 Needle electromyography using single fiber electrode, with quantitative measurement of jitter, blocking and/or fiber density, 6272 95872-TC TC 95872 any/all sites of each muscle studied $ 70.80 Electrical stimulation for guidance in conjunction with chemodenervation (List separately in addition to code for primary 6273 95873 95873 procedure) $ 55.40 Needle electromyography for guidance in conjunction with chemodenervation (List separately in addition to code for primary 6274 95874 95874 procedure) $ 56.80 Ischemic limb exercise test with serial specimen(s) acquisition for 6275 95875 95875 muscle(s) metabolite(s) $ 144.00 Ischemic limb exercise test with serial specimen(s) acquisition for 6276 95875-26 26 95875 muscle(s) metabolite(s) $ 61.86 Ischemic limb exercise test with serial specimen(s) acquisition for 6277 95875-TC TC 95875 muscle(s) metabolite(s) $ 82.14 Motor and/or sensory nerve conduction, using preconfigured electrode array(s), amplitude and latency/velocity study, each limb, includes F-wave study when performed, with interpretation and 6278 95905 95905 report $ 7.78 Testing of autonomic nervous system function; cardiovagal innervation (parasympathetic function), including 2 or more of the following: heart rate response to deep breathing with recorded R-R 6279 95921 95921 interval, Valsalva ratio, and 30:15 ratio $ 104.40 Testing of autonomic nervous system function; cardiovagal innervation (parasympathetic function), including 2 or more of the following: heart rate response to deep breathing with recorded R-R 6280 95921-26 26 95921 interval, Valsalva ratio, and 30:15 ratio $ 49.70 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Testing of autonomic nervous system function; cardiovagal innervation (parasympathetic function), including 2 or more of the following: heart rate response to deep breathing with recorded R-R 6281 95921-TC TC 95921 interval, Valsalva ratio, and 30:15 ratio $ 54.70 Testing of autonomic nervous system function; vasomotor adrenergic innervation (sympathetic adrenergic function), including beat-to-beat blood pressure and R-R interval changes during 6282 95922 95922 Valsalva maneuver and at least 5 minutes of passive tilt $ 108.90 Testing of autonomic nervous system function; vasomotor adrenergic innervation (sympathetic adrenergic function), including beat-to-beat blood pressure and R-R interval changes during 6283 95922-26 26 95922 Valsalva maneuver and at least 5 minutes of passive tilt $ 46.18 Testing of autonomic nervous system function; vasomotor adrenergic innervation (sympathetic adrenergic function), including beat-to-beat blood pressure and R-R interval changes during 6284 95922-TC TC 95922 Valsalva maneuver and at least 5 minutes of passive tilt $ 62.72 Testing of autonomic nervous system function; sudomotor, including 1 or more of the following: quantitative sudomotor axon reflex test (QSART), silastic sweat imprint, thermoregulatory sweat 6285 95923 95923 test, and changes in sympathetic skin potential $ 100.80 Testing of autonomic nervous system function; sudomotor, including 1 or more of the following: quantitative sudomotor axon reflex test (QSART), silastic sweat imprint, thermoregulatory sweat 6286 95923-26 26 95923 test, and changes in sympathetic skin potential $ 16.78 Testing of autonomic nervous system function; sudomotor, including 1 or more of the following: quantitative sudomotor axon reflex test (QSART), silastic sweat imprint, thermoregulatory sweat 6287 95923-TC TC 95923 test, and changes in sympathetic skin potential $ 84.02 Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central 6288 95925 95925 nervous system; in upper limbs $ 369.00 Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central 6289 95925-26 26 95925 nervous system; in upper limbs $ 47.98 Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central 6290 95925-TC TC 95925 nervous system; in upper limbs $ 321.02 Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central 6291 95926 95926 nervous system; in lower limbs $ 298.80 Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central 6292 95926-26 26 95926 nervous system; in lower limbs $ 41.65 Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central 6293 95926-TC TC 95926 nervous system; in lower limbs $ 257.15 Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central 6294 95927 95927 nervous system; in the trunk or head $ 298.80 Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central 6295 95927-26 26 95927 nervous system; in the trunk or head $ 43.75 Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central 6296 95927-TC TC 95927 nervous system; in the trunk or head $ 255.05 Central motor evoked potential study (transcranial motor 6297 95929 95929 stimulation);

lower limbs $ 280.97 Visual evoked potential (VEP) testing central nervous system, 6298 95930 95930 checkerboard or flash $ 339.30 Visual evoked potential (VEP) testing central nervous system, 6299 95930-26 26 95930 checkerboard or flash $ 34.63 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Visual evoked potential (VEP) testing central nervous system, 6300 95930-TC TC 95930 checkerboard or flash $ 304.67 6301 95933 95933 Orbicularis oculi (blink) reflex, by electrodiagnostic testing $ 175.50 6302 95933-26 26 95933 Orbicularis oculi (blink) reflex, by electrodiagnostic testing $ 56.06 6303 95933-TC TC 95933 Orbicularis oculi (blink) reflex, by electrodiagnostic testing $ 119.44 Neuromuscular junction testing (repetitive stimulation, paired 6304 95937 95937 stimuli), each nerve, any 1 method $ 180.00 Neuromuscular junction testing (repetitive stimulation, paired 6305 95937-26 26 95937 stimuli), each nerve, any 1 method $ 73.30 Neuromuscular junction testing (repetitive stimulation, paired 6306 95937-TC TC 95937 stimuli), each nerve, any 1 method $ 106.70 Continuous intraoperative neurophysiology monitoring in the operating room, one on one monitoring requiring personal attendance, each 15 minutes (List separately in addition to code for 6307 95940 95940 primary procedure) $ 58.81 Continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby) or for monitoring of more than one case while in the operating room, per hour (List 6308 95941 95941 separately in addition to code for primary procedure) $ 414.90 Monitoring for identification and lateralization of cerebral seizure focus, electroencephalographic (eg, 8 channel EEG) recording and 6309 95950 95950 interpretation, each 24 hours $ 655.20 Monitoring for identification and lateralization of cerebral seizure focus, electroencephalographic (eg, 8 channel EEG) recording and 6310 95950-26 26 95950 interpretation, each 24 hours $ 138.80 Monitoring for identification and lateralization of cerebral seizure focus, electroencephalographic (eg, 8 channel EEG) recording and 6311 95950-TC TC 95950 interpretation, each 24 hours $ 516.40 Monitoring for localization of cerebral seizure focus by cable or radio, 16 or more channel telemetry, combined electroencephalographic (EEG) and video recording and 6312 95951 95951 interpretation (eg, for presurgical localization), each 24 hours $ 906.30 Monitoring for localization of cerebral seizure focus by cable or radio, 16 or more channel telemetry, combined electroencephalographic (EEG) and video recording and 6313 95951-26 26 95951 interpretation (eg, for presurgical localization), each 24 hours $ 514.81 Monitoring for localization of cerebral seizure focus by computerized portable 16 or more channel EEG, electroencephalographic (EEG) recording and interpretation, each 6314 95953 95953 24 hours, unattended $ 763.20 Monitoring for localization of cerebral seizure focus by computerized portable 16 or more channel EEG, electroencephalographic (EEG) recording and interpretation, each 6315 95953-26 26 95953 24 hours, unattended $ 262.86 Monitoring for localization of cerebral seizure focus by computerized portable 16 or more channel EEG, electroencephalographic (EEG) recording and interpretation, each 6316 95953-TC TC 95953 24 hours, unattended $ 500.34 Pharmacological or physical activation requiring physician or other qualified health care professional attendance during EEG recording 6317 95954 95954 of activation phase (eg, thiopental activation test) $ 355.50 Pharmacological or physical activation requiring physician or other qualified health care professional attendance during EEG recording 6318 95954-26 26 95954 of activation phase (eg, thiopental activation test) $ 84.88 Pharmacological or physical activation requiring physician or other qualified health care professional attendance during EEG recording 6319 95954-TC TC 95954 of activation phase (eg, thiopental activation test) $ 270.62 Electroencephalogram (EEG) during nonintracranial surgery (eg, 6320 95955 95955 carotid surgery) $ 340.20 Electroencephalogram (EEG) during nonintracranial surgery (eg, 6321 95955-26 26 95955 carotid surgery) $ 70.64 Electroencephalogram (EEG) during nonintracranial surgery (eg, 6322 95955-TC TC 95955 carotid surgery) $ 269.56 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Monitoring for localization of cerebral seizure focus by cable or radio, 16 or more channel telemetry, electroencephalographic (EEG) recording and interpretation, each 24 hours, attended by a 6323 95956 95956 technologist or nurse $ 779.40 Monitoring for localization of cerebral seizure focus by cable or radio, 16 or more channel telemetry, electroencephalographic (EEG) recording and interpretation, each 24 hours, attended by a 6324 95956-26 26 95956 technologist or nurse $ 78.24 Monitoring for localization of cerebral seizure focus by cable or radio, 16 or more channel telemetry, electroencephalographic (EEG) recording and interpretation, each 24 hours, attended by a 6325 95956-TC TC 95956 technologist or nurse $ 701.16 Digital analysis of electroencephalogram (EEG) (eg, for epileptic 6326 95957 95957 spike analysis) $ 166.54 Wada activation test for hemispheric function, including 6327 95958 95958 electroencephalographic (EEG) monitoring $ 654.30 Wada activation test for hemispheric function, including 6328 95958-26 26 95958 electroencephalographic (EEG) monitoring $ 232.62 Wada activation test for hemispheric function, including 6329 95958-TC TC 95958 electroencephalographic (EEG) monitoring $ 421.68 Functional cortical and subcortical mapping by stimulation and/or recording of electrodes on brain surface, or of depth electrodes, to provoke seizures or identify vital brain structures; initial hour of 6330 95961 95961 attendance by a physician or other qualified health $ 429.30 Functional cortical and subcortical mapping by stimulation and/or recording of electrodes on brain surface, or of depth electrodes, to provoke seizures or identify vital brain structures; initial hour of 6331 95961-26 26 95961 attendance by a physician or other qualified health $ 222.66 Functional cortical and subcortical mapping by stimulation and/or recording of electrodes on brain surface, or of depth electrodes, to provoke seizures or identify vital brain structures; initial hour of 6332 95961-TC TC 95961 attendance by a physician or other qualified health $ 206.64 Functional cortical and subcortical mapping by stimulation and/or recording of electrodes on brain surface, or of depth electrodes, to provoke seizures or identify vital brain structures; each additional 6333 95962 95962 hour of attendance by a physician or other qualifie $ 448.20 Functional cortical and subcortical mapping by stimulation and/or recording of electrodes on brain surface, or of depth electrodes, to provoke seizures or identify vital brain structures; each additional 6334 95962-26 26 95962 hour of attendance by a physician or other qualifie $ 291.69 Functional cortical and subcortical mapping by stimulation and/or recording of electrodes on brain surface, or of depth electrodes, to provoke seizures or identify vital brain structures; each additional 6335 95962-TC TC 95962 hour of attendance by a physician or other qualifie $ 156.51 Magnetoencephalography (MEG), recording and analysis; for spontaneous brain magnetic activity (eg, epileptic cerebral cortex 6336 95965 95965 localization) $ - Magnetoencephalography (MEG), recording and analysis; for evoked magnetic fields, single modality (eg, sensory, motor, 6337 95966 95966 language, or visual cortex localization) $ - Magnetoencephalography (MEG), recording and analysis; for evoked magnetic fields, each additional modality (eg, sensory, motor, language, or visual cortex localization) (List separately in 6338 95967 95967 addition to code for primary procedure) $ - Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude, pulse duration, configuration of wave form, battery status, electrode selectability, output 6339 95970 95970 modulation, cycling, impedance and patient compliance measureme $ 47.70 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude, pulse duration, configuration of wave form, battery status, electrode selectability, output 6340 95971 95971 modulation, cycling, impedance and patient compliance measureme $ 78.30 Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude, pulse duration, configuration of wave form, battery status, electrode selectability, output 6341 95972 95972 modulation, cycling, impedance and patient compliance measureme $ 143.10 Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude, pulse duration, configuration of wave form, battery status, electrode selectability, output 6342 95973 95973 modulation, cycling, impedance and patient compliance measureme $ 90.90 Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude, pulse duration, configuration of wave form, battery status, electrode selectability, output 6343 95974 95974 modulation, cycling, impedance and patient compliance measureme $ 292.50 Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude, pulse duration, configuration of wave form, battery status, electrode selectability, output 6344 95975 95975 modulation, cycling, impedance and patient compliance measureme $ 173.70 Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator 6345 95978 95978 pulse $ 527.16 Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and duration, battery status, electrode selectability and polarity, impedance and patient compliance measurements), complex deep brain neurostimulator 6346 95979 95979 pulse $ 253.83 Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient measurements) gastric 6347 95980 95980 n $ 114.21 Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient measurements) gastric 6348 95981 95981 n $ 82.55 Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and duration, configuration of wave form, battery status, electrode selectability, output modulation, cycling, impedance and patient measurements) gastric 6349 95982 95982 n $ 118.30 Refilling and maintenance of implantable pump or reservoir for drug delivery, spinal (intrathecal, epidural) or brain (intraventricular), includes electronic analysis of pump, when 6350 95990 95990 performed; $ 122.42 Canalith repositioning procedure(s) (eg, Epley maneuver, Semont 6351 95992 95992 maneuver), per day $ 115.18 6352 95999 95999 Unlisted neurological or neuromuscular diagnostic procedure Cost Comprehensive computer-based motion analysis by video-taping 6353 96000 96000 and 3D kinematics; $ 180.36 Comprehensive computer-based motion analysis by video-taping and 3D kinematics; with dynamic plantar pressure measurements 6354 96001 96001 during walking $ 174.93 Dynamic surface electromyography, during walking or other 6355 96002 96002 functional activities, 1-12 muscles $ 39.63 Dynamic fine wire electromyography, during walking or other 6356 96003 96003 functional activities, 1 muscle $ 30.57 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Review and interpretation by physician or other qualified health care professional of comprehensive computer-based motion analysis, dynamic plantar pressure measurements, dynamic surface 6357 96004 96004 electromyography during walking or other functional activities, and $ 206.48 Neurofunctional testing selection and administration during noninvasive imaging functional brain mapping, with test administered entirely by a physician or other qualified health care 6358 96020 96020 professional (ie, psychologist), with review of test results and report $ - Medical genetics and genetic counseling services, each 30 minutes 6359 96040 96040 face-to-face with patient/family $ 98.24 Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, eg, MMPI, Rorschach, WAIS), per hour of the psychologist's or 6360 96101 96101 physician's time, both face-to-face time administering test $ 191.25 Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, eg, MMPI and WAIS), with qualified health care professional 6361 96102 96102 interpretation and report, administered by technician, per ho $ 93.33 Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, eg, MMPI), administered by a computer, with qualified health care 6362 96103 96103 professional interpretation and report $ 87.96 Assessment of aphasia (includes assessment of expressive and receptive speech and language function, language comprehension, speech production ability, reading, spelling, writing, eg, by Boston 6363 96105 96105 Diagnostic Aphasia Examination) with interpretation and repor $ 170.98 Developmental screening, with interpretation and report, per 6364 96110 96110 standardized instrument form $ 41.77 Developmental testing, (includes assessment of motor, language, social, adaptive, and/or cognitive functioning by standardized 6365 96111 96111 developmental instruments) with interpretation and report $ 175.28 Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, eg, acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial 6366 96116 96116 abilities), per hour of the psychologist's or physician's time, bot $ 226.49 Neuropsychological testing (eg, Halstead-Reitan Neuropsychological Battery, Wechsler Memory Scales and Wisconsin Card Sorting Test), per hour of the psychologist's or physician's time, both face-to-face 6367 96118 96118 time administering tests to the patient and time int $ 234.56 Neuropsychological testing (eg, Halstead-Reitan Neuropsychological Battery, Wechsler Memory Scales and Wisconsin Card Sorting Test), with qualified health care professional interpretation and report, 6368 96119 96119 administered by technician, per hour of technician time $ 156.24 Neuropsychological testing (eg, Wisconsin Card Sorting Test), administered by a computer, with qualified health care professional 6369 96120 96120 interpretation and report $ 115.84 Standardized cognitive performance testing (eg, Ross Information Processing Assessment) per hour of a qualified health care professional's time, both face-to-face time administering tests to 6370 96125 96125 the patient and time interpreting these test results and prepari $ 208.77 Health and behavior assessment (eg, health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with 6371 96150 96150 the patient; initial assessment $ 51.14 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Health and behavior assessment (eg, health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires), each 15 minutes face-to-face with 6372 96151 96151 the patient; re-assessment $ 27.87 Health and behavior intervention, each 15 minutes, face-to-face; 6373 96152 96152 individual $ 27.63 Health and behavior intervention, each 15 minutes, face-to-face; 6374 96153 96153 group (2 or more patients) $ 34.17 Health and behavior intervention, each 15 minutes, face-to-face; 6375 96154 96154 family (with the patient present) $ 37.46 Health and behavior intervention, each 15 minutes, face-to-face; 6376 96155 96155 family (without the patient present) $ 38.51 6377 96360 96360 Intravenous infusion, hydration; initial, 31 minutes to 1 hour $ 115.16 Intravenous infusion, hydration; each additional hour (List 6378 96361 96361 separately in addition to code for primary procedure) $ 46.20 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify 6379 96365 96365 substance or drug); initial, up to 1 hour $ 132.82 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List separately in addition 6380 96366 96366 to code for primary procedure) $ 58.35 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); additional sequential infusion of a new drug/substance, up to 1 hour (List separately in addition to code for 6381 96367 96367 primary procedure) $ 84.16 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); concurrent infusion (List separately in addition 6382 96368 96368 to code for primary procedure) $ 48.93 Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); initial, up to 1 hour, including pump set-up and 6383 96369 96369 establishment of subcutaneous infusion site(s) $ 299.67 Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); each additional hour (List separately in addition to code 6384 96370 96370 for primary procedure) $ 33.76 Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); additional pump set-up with establishment of new subcutaneous infusion site(s) (List separately in addition to code for 6385 96371 96371 primary procedure) $ 126.53 Therapeutic, prophylactic, or diagnostic injection (specify substance 6386 96372 90772 or drug); subcutaneous or intramuscular $ 34.73 Therapeutic, prophylactic, or diagnostic injection (specify substance 6387 96373 96373 or drug); intra-arterial $ 31.87 Therapeutic, prophylactic, or diagnostic injection (specify substance 6388 96374 90774 or drug); intravenous push, single or initial substance/drug $ 97.45 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug (List separately in addition to code for primary 6389 96375 96375 procedure) $ 56.42 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of the same substance/drug provided in a facility (List separately in addition to 6390 96376 96376 code for primary procedure) $ - Unlisted therapeutic, prophylactic, or diagnostic intravenous or 6391 96379 96379 intra-arterial injection or infusion Cost Chemotherapy administration, subcutaneous or intramuscular; non- 6392 96401 96401 hormonal anti-neoplastic $ 153.81 Chemotherapy administration, subcutaneous or intramuscular; 6393 96402 96402 hormonal anti-neoplastic $ 82.57 Chemotherapy administration; intralesional, up to and including 7 6394 96405 96405 lesions $ 93.60 6395 96406 96406 Chemotherapy administration; intralesional, more than 7 lesions $ 126.00 Chemotherapy administration; intravenous, push technique, single 6396 96409 96409 or initial substance/drug $ 278.82 Chemotherapy administration; intravenous, push technique, each additional substance/drug (List separately in addition to code for 6397 96411 96411 primary procedure) $ 159.52 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Chemotherapy administration, intravenous infusion technique; up 6398 96413 96413 to 1 hour, single or initial substance/drug $ 398.03 Chemotherapy administration, intravenous infusion technique; each additional hour (List separately in addition to code for primary 6399 96415 96415 procedure) $ 89.79 Chemotherapy administration, intravenous infusion technique; initiation of prolonged chemotherapy infusion (more than 8 hours), 6400 96416 96416 requiring use of a portable or implantable pump $ 426.61 Chemotherapy administration, intravenous infusion technique; each additional sequential infusion (different substance/drug), up to 1 6401 96417 96417 hour (List separately in addition to code for primary procedure) $ 190.54 6402 96420 96420 Chemotherapy administration, intra-arterial; push technique $ 146.70 Chemotherapy administration, intra-arterial; infusion technique, up 6403 96422 96422 to 1 hour $ 159.30 Chemotherapy administration, intra-arterial; infusion technique, each additional hour (List separately in addition to code for primary 6404 96423 96423 procedure) $ 63.90 Chemotherapy administration, intra-arterial; infusion technique, initiation of prolonged infusion (more than 8 hours), requiring the 6405 96425 96425 use of a portable or implantable pump $ 108.00 Chemotherapy administration into pleural cavity, requiring and 6406 96440 96440 including thoracentesis $ 268.20 Chemotherapy administration, into CNS (eg, intrathecal), requiring 6407 96450 96450 and including spinal puncture $ 228.60 6408 96521 96521 Refilling and maintenance of portable pump $ 338.81 Refilling and maintenance of implantable pump or reservoir for 6409 96522 96522 drug delivery, systemic (eg, intravenous, intra-arterial) $ 255.97 Irrigation of implanted venous access device for drug delivery 6410 96523 96523 systems $ 79.65 Chemotherapy injection, subarachnoid or intraventricular via 6411 96542 96542 subcutaneous reservoir, single or multiple agents $ 195.30 6412 96549 96549 Unlisted chemotherapy procedure Cost Photodynamic therapy by external application of light to destroy premalignant and/or malignant lesions of the skin and adjacent mucosa (eg, lip) by activation of photosensitive drug(s), each 6413 96567 96567 phototherapy exposure session $ 663.01 Photodynamic therapy by endoscopic application of light to ablate abnormal tissue via activation of photosensitive drug(s); first 30 minutes (List separately in addition to code for endoscopy or 6414 96570 96570 bronchoscopy procedures of lung and gastrointestinal tract) $ 329.38 Photodynamic therapy by endoscopic application of light to ablate abnormal tissue via activation of photosensitive drug(s); each additional 15 minutes (List separately in addition to code for 6415 96571 96571 endoscopy or bronchoscopy procedures of lung and gastrointestin $ 163.85 6416 96900 96900 Actinotherapy (ultraviolet light) $ 34.20 Microscopic examination of hairs plucked or clipped by the examiner (excluding hair collected by the patient) to determine 6417 96902 96902 telogen and anagen counts, or structural hair shaft abnormality $ 55.80 Whole body integumentary photography, for monitoring of high risk patients with dysplastic nevus syndrome or a history of dysplastic nevi, or patients with a personal or familial history of 6418 96904 96904 melanoma $ 200.24 Photochemotherapy; tar and ultraviolet B (Goeckerman treatment) 6419 96910 96910 or petrolatum and ultraviolet B $ 45.00 6420 96912 96912 Photochemotherapy; psoralens and ultraviolet A (PUVA) $ 51.30 Photochemotherapy (Goeckerman and/or PUVA) for severe photoresponsive dermatoses requiring at least 4-8 hours of care under direct supervision of the physician (includes application of 6421 96913 96913 medication and dressings) $ 195.30 Laser treatment for inflammatory skin disease (psoriasis); total area 6422 96920 96920 less than 250 sq cm $ 398.75 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Laser treatment for inflammatory skin disease (psoriasis); 250 sq cm 6423 96921 96921 to 500 sq cm $ 408.97 Laser treatment for inflammatory skin disease (psoriasis); over 500 6424 96922 96922 sq cm $ 620.53 6425 96999 96999 Unlisted special dermatological service or procedure Cost 6426 97001 97001 Physical therapy evaluation $ 88.97 6427 97002 97002 Physical therapy re-evaluation $ 43.47 6428 97003 97003 Occupational therapy evaluation $ 73.80 6429 97004 97004 Occupational therapy re-evaluation $ 36.00 6430 97005 97005 Athletic training evaluation $ 63.80 6431 97006 97006 Athletic training re-evaluation $ 36.00 6432 97010 97010 Application of a modality to 1 or more areas; hot or cold packs $ 32.94 6433 97012 97012 Application of a modality to 1 or more areas; traction, mechanical $ 39.16 Application of a modality to 1 or more areas; electrical stimulation 6434 97014 97014 (unattended) $ 35.31 Application of a modality to 1 or more areas; vasopneumatic 6435 97016 97016 devices $ 58.50 6436 97018 97018 Application of a modality to 1 or more areas; paraffin bath $ 43.20 6437 97022 97022 Application of a modality to 1 or more areas; whirlpool $ 41.40 Application of a modality to 1 or more areas; diathermy (eg, 6438 97024 97024 microwave) $ 37.81 Application of a modality to 1 or more areas; electrical stimulation 6439 97032 97032 (manual), each 15 minutes $ 44.42 Application of a modality to 1 or more areas; iontophoresis, each 15 6440 97033 97033 minutes $ 54.90 Application of a modality to 1 or more areas; ultrasound, each 15 6441 97035 97035 minutes $ 37.77 6442 97039 97039 Unlisted modality (specify type and time if constant attendance) $ 10.00 Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of 6443 97110 97110 motion and flexibility $ 46.60 Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or 6444 97112 97112 standing activities $ 43.21 Therapeutic procedure, 1 or more areas, each 15 minutes; aquatic 6445 97113 97113 therapy with therapeutic exercises $ 52.59 Therapeutic procedure, 1 or more areas, each 15 minutes; gait 6446 97116 97116 training (includes stair climbing) $ 43.91 Therapeutic procedure, 1 or more areas, each 15 minutes; massage, including effleurage, petrissage and/or tapotement (stroking, 6447 97124 97124 compression, percussion) $ 41.79 Manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 6448 97140 97140 minutes $ 48.65 6449 97150 97150 Therapeutic procedure(s), group (2 or more individuals) $ 27.21 Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 6450 97530 97530 minutes $ 56.70 Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on- 6451 97532 97532 one) patient contact, each 15 minutes $ 36.03 Self-care/home management training (eg, activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact, each 15 6452 97535 97535 minutes $ 56.70 Community/work reintegration training (eg, shopping, transportation, money management, avocational activities and/or work environment/modification analysis, work task analysis, use of assistive technology device/adaptive equipment), direct one-on-one 6453 97537 97537 cont $ 39.24 Wheelchair management (eg, assessment, fitting, training), each 15 6454 97542 97542 minutes $ 29.60 6455 97545 97545 Work hardening/conditioning; initial 2 hours $ 190.80 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Work hardening/conditioning; each additional hour (List separately 6456 97546 97546 in addition to code for primary procedure) $ 99.90 Debridement (eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (eg, fibrin, devitalized epidermis and/or dermis, 6457 97597 97597 exudate, debris, biofilm), including topical application(s), wound $ 104.34 Debridement (eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (eg, fibrin, devitalized epidermis and/or dermis, 6458 97598 97598 exudate, debris, biofilm), including topical application(s), wound $ 114.89 Removal of devitalized tissue from wound(s), non-selective debridement, without anesthesia (eg, wet-to-moist dressings, enzymatic, abrasion), including topical application(s), wound 6459 97602 97602 assessment, and instruction(s) for ongoing care, per session $ 126.66 Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(s), lower 6460 97760 97760 extremity(s) and/or trunk, each 15 minutes $ 63.04 Prosthetic training, upper and/or lower extremity(s), each 15 6461 97761 97761 minutes $ 57.46 Checkout for orthotic/prosthetic use, established patient, each 15 6462 97762 97762 minutes $ 57.79 Medical nutrition therapy; initial assessment and intervention, 6463 97802 97802 individual, face-to-face with the patient, each 15 minutes $ 32.69 Medical nutrition therapy; re-assessment and intervention, 6464 97803 97803 individual, face-to-face with the patient, each 15 minutes $ 31.73 Medical nutrition therapy; group (2 or more individuals), each 30 6465 97804 97804 minutes $ 12.42 Acupuncture, 1 or more needles; without electrical stimulation, 6466 97810 97810 initial 15 minutes of personal one-on-one contact with the patient $ 60.96 Acupuncture, 1 or more needles; without electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s) (List separately in addition to 6467 97811 97811 code for primary procedure) $ 51.38 Acupuncture, 1 or more needles; with electrical stimulation, initial 6468 97813 97813 15 minutes of personal one-on-one contact with the patient $ 66.59 Acupuncture, 1 or more needles; with electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s) (List separately in addition to 6469 97814 97814 code for primary procedure) $ 57.30 Osteopathic manipulative treatment (OMT); 1-2 body regions 6470 98925 98925 involved $ 53.46 Osteopathic manipulative treatment (OMT); 3-4 body regions 6471 98926 98926 involved $ 83.70 Osteopathic manipulative treatment (OMT); 5-6 body regions 6472 98927 98927 involved $ 100.80 Osteopathic manipulative treatment (OMT); 7-8 body regions 6473 98928 98928 involved $ 115.20 Osteopathic manipulative treatment (OMT); 9-10 body regions 6474 98929 98929 involved $ 135.00 6475 98940 98940 Chiropractic manipulative treatment (CMT); spinal, 1-2 regions $ 48.32 6476 98941 98941 Chiropractic manipulative treatment (CMT); spinal, 3-4 regions $ 63.55 6477 98942 98942 Chiropractic manipulative treatment (CMT); spinal, 5 regions $ 91.80 Chiropractic manipulative treatment (CMT); extraspinal, 1 or more 6478 98943 98943 regions $ 49.50 Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include 6479 98960 98960 caregiver/family) each 30 minutes; individual patient $ 63.65 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include 6480 98961 98961 caregiver/family) each 30 minutes; 2-4 patients $ 49.81 Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include 6481 98962 98962 caregiver/family) each 30 minutes; 5-8 patients $ 36.96 Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 6482 98966 98966 7 days n $ 40.02 Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 6483 98967 98967 7 days n $ 78.06 Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 6484 98968 98968 7 days n $ 111.03 Online assessment and management service provided by a qualified nonphysician health care professional to an established patient or guardian, not originating from a related assessment and management service provided within the previous 7 days, using the 6485 98969 98969 I $ - Handling and/or conveyance of specimen for transfer from the 6486 99000 99000 office to a laboratory $ 23.40 Handling and/or conveyance of specimen for transfer from the patient in other than an office to a laboratory (distance may be 6487 99001 99001 indicated) $ 26.10 Handling, conveyance, and/or any other service in connection with the implementation of an order involving devices (eg, designing, fitting, packaging, handling, delivery or mailing) when devices such 6488 99002 99002 as orthotics, protectives, prosthetics are fabricated b $ 27.00 Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) 6489 99024 99024 related to the original procedure $ - Services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed 6490 99050 99050 (eg, holidays, Saturday or Sunday), in addition to basic service $ 81.00 Service(s) provided in the office during regularly scheduled evening, 6491 99051 99051 weekend, or holiday office hours, in addition to basic service $ - Service(s) provided between 10:00 PM and 8:00 AM at 24-hour 6492 99053 99053 facility, in addition to basic service $ - Service(s) typically provided in the office, provided out of the office 6493 99056 99056 at request of patient, in addition to basic service $ 101.70 Service(s) provided on an emergency basis in the office, which 6494 99058 99058 disrupts other scheduled office services, in addition to basic service $ 96.58 6495 99075 99075 Medical testimony $ 627.30 Physician or other qualified health care professional qualified by education, training, licensure/regulation (when applicable) educational services rendered to patients in a group setting (eg, 6496 99078 99078 prenatal, obesity, or diabetic instructions) $ 72.00 Special reports such as insurance forms, more than the information conveyed in the usual medical communications or standard 6497 99080 99080 reporting form $ 102.60 6498 99082 99082 Unusual travel (eg, transportation and escort of patient) $ 369.00 Analysis of clinical data stored in computers (eg, ECGs, blood 6499 99090 99090 pressures, hematologic data) $ 232.20 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Collection and interpretation of physiologic data (eg, ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified 6500 99091 99091 health care professional, qualified by education, train $ 101.30 Anesthesia for patient of extreme age, younger than 1 year or older than 70 (List separately in addition to code for primary anesthesia 6501 99100 99100 procedure) $ 88.00 Anesthesia complicated by utilization of total body hypothermia (List separately in addition to code for primary anesthesia 6502 99116 99116 procedure) $ - Anesthesia complicated by utilization of controlled hypotension (List 6503 99135 99135 separately in addition to code for primary anesthesia procedure) $ - Anesthesia complicated by emergency conditions (specify) (List 6504 99140 99140 separately in addition to code for primary anesthesia procedure) $ 192.50 Moderate sedation services (other than those services described by codes 00100-01999) provided by the same physician or other qualified health care professional performing the diagnostic or 6505 99143 99143 therapeutic service that the sedation supports, requiring the pre $ 192.50 Moderate sedation services (other than those services described by codes 00100-01999) provided by the same physician or other qualified health care professional performing the diagnostic or 6506 99144 99144 therapeutic service that the sedation supports, requiring the pre $ 192.50 Moderate sedation services (other than those services described by codes 00100-01999) provided by the same physician or other qualified health care professional performing the diagnostic or 6507 99145 99145 therapeutic service that the sedation supports, requiring the pre $ - Moderate sedation services (other than those services described by codes 00100-01999), provided by a physician or other qualified health care professional other than the health care professional 6508 99148 99148 performing the diagnostic or therapeutic service that the se $ 143.00 Moderate sedation services (other than those services described by codes 00100-01999), provided by a physician or other qualified health care professional other than the health care professional 6509 99149 99149 performing the diagnostic or therapeutic service that the se $ - Moderate sedation services (other than those services described by codes 00100-01999), provided by a physician or other qualified health care professional other than the health care professional 6510 99150 99150 performing the diagnostic or therapeutic service that the se $ - Anogenital examination, magnified, in childhood for suspected 6511 99170 99170 trauma, including image recording when performed $ 363.95 6512 99173 99173 Screening test of visual acuity, quantitative, bilateral $ 29.89 Instrument-based ocular screening (eg, photoscreening, automated- 6513 99174 99174 refraction), bilateral $ 39.61 Ipecac or similar administration for individual emesis and continued 6514 99175 99175 observation until stomach adequately emptied of poison $ 106.20 Physician or other qualified health care professional attendance and 6515 99183 99183 supervision of hyperbaric oxygen therapy, per session $ 271.80 Assembly and operation of pump with oxygenator or heat exchanger (with or without ECG and/or pressure monitoring); each 6516 99190 99190 hour $ - Assembly and operation of pump with oxygenator or heat exchanger (with or without ECG and/or pressure monitoring); 45 6517 99191 99191 minutes $ - Assembly and operation of pump with oxygenator or heat exchanger (with or without ECG and/or pressure monitoring); 30 6518 99192 99192 minutes $ - 6519 99195 99195 Phlebotomy, therapeutic (separate procedure) $ 69.30 6520 99199 99199 Unlisted special service, procedure or report Cost Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or 6521 99201 99201 coordination o $ 75.03 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; Straightforward medical decision making. Counseling 6522 99202 99202 a $ 86.93 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making 6523 99203 99203 of low complexity. Counseling and/or coordination of care with $ 119.33 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity. Counseling and/or 6524 99204 99204 coordinatio $ 157.94 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination 6525 99205 99205 of $ 207.38 Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the 6526 99211 99211 presenting problem(s) are minimal. Typically, 5 minute $ 36.97 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused 6527 99212 99212 examination; Straightforward medical decision making. Counselin $ 56.87 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded 6528 99213 99213 problem focused examination; Medical decision making of low $ 74.01 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical 6529 99214 99214 decision making of moderate complexity. Counseling and/o $ 101.53 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. 6530 99215 99215 Counseling $ 156.37 Initial observation care, per day, for the evaluation and management of a patient which requires these 3 key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward 6531 99218 99218 or o $ 134.10 Initial observation care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling 6532 99219 99219 and/or coordinat $ 185.40 Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A detailed or comprehensive history; A detailed or comprehensive examination; 6533 99221 99221 and Medical decision making that is straightforward or of $ 146.86 Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision 6534 99222 99222 making of moderate complexity. Counseling and/or coordination $ 215.43 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision 6535 99223 99223 making of high complexity. Counseling and/or coordination of $ 242.77 Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A problem focused interval history; A problem focused 6536 99231 99231 examination; Medical decision making that is straightforward or o $ 76.73 Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making 6537 99232 99232 of moder $ 99.73 Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; 6538 99233 99233 Medical decision making of high complexity. Counseling and/or coor $ 152.75 Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date, which requires these 3 key components: A detailed or 6539 99234 99234 comprehensive history; A detailed or comprehensive examination; $ 174.35 Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical 6540 99235 99235 decision ma $ 238.54 Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical 6541 99236 99236 decision ma $ 384.38 6542 99238 99238 Hospital discharge day management; 30 minutes or less $ 133.05 6543 99239 99239 Hospital discharge day management; more than 30 minutes $ 172.27 Office consultation for a new or established patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. 6544 99241 99241 Counseling and/or coordination of care with other physician $ 105.67 Office consultation for a new or established patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Straightforward 6545 99242 99242 medical decision making. Counseling and/or coordination of care $ 143.19 Office consultation for a new or established patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of low complexity. Counseling and/or 6546 99243 99243 coordination of care with other physicians, other qua $ 182.41 Office consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with 6547 99244 99244 other physic $ 234.86 Office consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other 6548 99245 99245 physicians $ 298.54 Inpatient consultation for a new or established patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making.

Counseling and/or coordination of care with other 6549 99251 99251 physic $ 122.67 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Inpatient consultation for a new or established patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Straightforward medical decision making. Counseling and/or 6550 99252 99252 coordination of ca $ 160.52 Inpatient consultation for a new or established patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of low complexity. 6551 99253 99253 Counseling and/or coordination of care with other physicians, other $ 198.36 Inpatient consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with 6552 99254 99254 other phy $ 242.77 Inpatient consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other 6553 99255 99255 physici $ 314.79 Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or 6554 99281 99281 coordination of care $ 91.71 Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of low complexity. 6555 99282 99282 Counseling and/o $ 120.82 Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of moderate complexity. 6556 99283 99283 Counseling $ 183.70 Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with 6557 99284 99284 o $ 260.67 Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A 6558 99285 99285 comprehensi $ 355.91 Physician or other qualified health care professional direction of emergency medical systems (EMS) emergency care, advanced life 6559 99288 99288 support $ 125.00 Critical care, evaluation and management of the critically ill or 6560 99291 99291 critically injured patient; first 30-74 minutes $ 370.17 Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately 6561 99292 99292 in addition to code for primary service) $ 187.78 Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components: A detailed or comprehensive history; A detailed or comprehensive 6562 99304 99304 examination; and Medical decision making that is straightforwar $ 91.71 Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling 6563 99305 99305 and/or coor $ 128.46 Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or 6564 99306 99306 coordina $ 157.46 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Home visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical 6565 99341 99341 decision making. Counseling and/or coordination of care with other $ 88.12 Home visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of low complexity. Counseling and/or 6566 99342 99342 coordinati $ 99.69 Home visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other 6567 99343 99343 physici $ 135.42 Home visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with 6568 99344 99344 oth $ 189.85 Home visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high 6569 99345 99345 complexity. Counseling and/or coordination of care with other p $ 250.72 Home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused interval history; A problem focused examination; 6570 99347 99347 Straightforward medical decision making. Counseling and/or coor $ 63.21 Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour (List separately in addition to code for office or other outpatient 6571 99354 99354 Evaluation and Management service) $ 186.25 Prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service; first hour (List separately in addition to code for inpatient Evaluation and Management 6572 99356 99356 service) $ 224.06 Prolonged evaluation and management service before and/or after 6573 99358 99358 direct patient care; first hour $ 202.71 Standby service, requiring prolonged attendance, each 30 minutes (eg, operative standby, standby for frozen section, for 6574 99360 99360 cesarean/high risk delivery, for monitoring EEG) $ 186.05 Medical team conference with interdisciplinary team of health care professionals, patient and/or family not present, 30 minutes or 6575 99367 99367 more; participation by physician $ 64.15 Medical team conference with interdisciplinary team of health care professionals, patient and/or family not present, 30 minutes or more; participation by nonphysician qualified health care 6576 99368 99368 professional $ 41.06 Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of 6577 99385 99385 laboratory/diagnos $ 142.18 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of 6578 99391 99391 laboratory/diag $ 82.75 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of 6579 99392 99392 laboratory/diag $ 86.88 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of 6580 99393 99393 laboratory/diag $ 89.13 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of 6581 99394 99394 laboratory/diag $ 105.22 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of 6582 99395 99395 laboratory/diag $ 115.76 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of 6583 99396 99396 laboratory/diag $ 135.29 Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); 6584 99401 99401 approximately 15 minutes $ 48.03 Initial hospital or birthing center care, per day, for evaluation and 6585 99460 99460 management of normal newborn infant $ 144.33 Initial care, per day, for evaluation and management of normal 6586 99461 99461 newborn infant seen in other than hospital or birthing center $ 98.43 Subsequent hospital care, per day, for evaluation and management 6587 99462 99462 of normal newborn $ 68.89 Initial hospital or birthing center care, per day, for evaluation and management of normal newborn infant admitted and discharged on 6588 99463 99463 the same date $ 157.01 Attendance at delivery (when requested by the delivering physician or other qualified health care professional) and initial stabilization 6589 99464 99464 of newborn $ 155.16 Delivery/birthing room resuscitation, provision of positive pressure ventilation and/or chest compressions in the presence of acute 6590 99465 99465 inadequate ventilation and/or cardiac output $ 278.60 Critical care face-to-face services, during an interfacility transport of critically ill or critically injured pediatric patient, 24 months of age 6591 99466 99466 or younger; first 30-74 minutes of hands-on care during transport $ 410.44 Critical care face-to-face services, during an interfacility transport of critically ill or critically injured pediatric patient, 24 months of age or younger; each additional 30 minutes (List separately in addition 6592 99467 99467 to code for primary service) $ 231.30 Initial inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or 6593 99468 99468 younger $ 1,541.18 Subsequent inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of 6594 99469 99469 age or younger $ 961.49 Initial inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 29 days 6595 99471 99471 through 24 months of age $ 1,358.69 Subsequent inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 6596 99472 99472 29 days through 24 months of age $ 920.42 Initial inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 2 through 5 6597 99475 99475 years of age $ 1,108.22 Subsequent inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 2 6598 99476 99476 through 5 years of age $ 815.58 Subsequent intensive care, per day, for the evaluation and management of the recovering very low birth weight infant (present 6599 99478 99478 body weight less than 1500 grams) $ 398.22 Subsequent intensive care, per day, for the evaluation and management of the recovering low birth weight infant (present 6600 99479 99479 body weight of 1500-2500 grams) $ 373.08 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Subsequent intensive care, per day, for the evaluation and management of the recovering infant (present body weight of 2501- 6601 99480 99480 5000 grams) $ 350.97 6602 99499 99499 Unlisted evaluation and management service $ 38.50 Home visit for prenatal monitoring and assessment to include fetal heart rate, non-stress test, uterine monitoring, and gestational 6603 99500 99500 diabetes monitoring $ - 6604 99502 99502 Home visit for newborn care and assessment $ 38.50 Home visit for respiratory therapy care (eg, bronchodilator, oxygen 6605 99503 99503 therapy, respiratory assessment, apnea evaluation) $ - 6606 99504 99504 Home visit for mechanical ventilation care $ - Home visit for stoma care and maintenance including colostomy 6607 99505 99505 and cystostomy $ - 6608 99506 99506 Home visit for intramuscular injections $ - Home visit for care and maintenance of catheter(s) (eg, urinary, 6609 99507 99507 drainage, and enteral) $ 27.50 Home visit for assistance with activities of daily living and personal 6610 99509 99509 care $ 33.00 6611 99510 99510 Home visit for individual, family, or marriage counseling $ - Home visit for fecal impaction management and enema 6612 99511 99511 administration $ - 6613 99512 99512 Home visit for hemodialysis $ - 6614 99600 99600 Unlisted home visit service or procedure Cost Home infusion/specialty drug administration, per visit (up to 2 6615 99601 99601 hours); $ - Home infusion/specialty drug administration, per visit (up to 2 hours); each additional hour (List separately in addition to code for 6616 99602 99602 primary procedure) $ - Medication therapy management service(s) provided by a pharmacist, individual, face-to-face with patient, with assessment 6617 99605 99605 and intervention if provided; initial 15 minutes, new patient $ - Medication therapy management service(s) provided by a pharmacist, individual, face-to-face with patient, with assessment 6618 99606 99606 and intervention if provided; initial 15 minutes, established patient $ - Medication therapy management service(s) provided by a pharmacist, individual, face-to-face with patient, with assessment and intervention if provided; each additional 15 minutes (List 6619 99607 99607 separately in addition to code for primary service) $ - 6620 A0380 A0380 BLS mileage (per mile) $ 8.25 Ambulance service, advanced life support, emergency transport, 6621 A0427 A0427 level 1 (ALS1- emergency) $ 187.00 Ambulance service, basic life support, non-emergency transport, 6622 A0428 A0428 (BLS) $ 137.50 Ambulance service, conventional air services, transport, one way 6623 A0430 A0430 (fixed wing) $ 220.00 6624 A0998 A0998 Ambulance response and treatment, no transport $ 137.50 6625 D0120 D0120 Periodic oral evaluation - established patient $ 30.00 6626 D0140 D0140 Limited oral evaluation - problem focused $ 30.00 6627 D0150 D0150 Comprehensive oral evaluation - new or established patient $ 60.00 6628 D0160 D0160 Detailed and extensive oral evaluation - problem focused, by report $ 71.50 Re-evaluation - limited, problem focused (established patient; not 6629 D0170 D0170 post-operative visit) $ 39.00 6630 D0210 D0210 Intraoral - complete series of radiographic images $ 85.00 6631 D0220 D0220 Intraoral - periapical first radiographic image $ 18.00 6632 D0230 D0230 Intraoral - periapical each additional radiographic image $ 8.00 6633 D0240 D0240 Intraoral - occlusal radiographic image $ 27.50 6634 D0250 D0250 Extraoral - first radiographic image $ 38.00 6635 D0260 D0260 Extraoral - each additional radiographic image $ 32.00 6636 D0270 D0270 Bitewing - single radiographic image $ 18.00 6637 D0272 D0272 Bitewings - two radiographic images $ 35.50 6638 D0274 D0274 Bitewings - four radiographic images $ 41.00 6639 D0277 D0277 Vertical bitewings - 7 to 8 radiographic images $ 57.00 Posterior-anterior or lateral skull and facial bone survey 6640 D0290 D0290 radiographic image $ 81.00 6641 D0310 D0310 Sialography $ 155.00 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price 6642 D0320 D0320 Temporomandibular joint arthrogram, including injection $ 369.00 6643 D0321 D0321 Other temporomandibular joint radiographic images, by report $ 148.00 6644 D0322 D0322 Tomographic survey $ 265.00 6645 D0330 D0330 Panoramic radiographic image $ 60.00 6646 D0340 D0340 Cephalometric radiographic image $ 55.00 6647 D0350 D0350 Oral/facial photographic images $ 43.00 6648 D0415 D0415 Collection of microorganisms for culture and sensitivity $ 95.00 6649 D0425 D0425 Caries susceptibility tests $ 61.00 6650 D0460 D0460 Pulp vitality tests $ 36.00 6651 D0470 D0470 Diagnostic casts $ 69.00 Accession of tissue, gross examination, preparation and 6652 D0472 D0472 transmission of written report $ 55.00 HISTOPATHOLOGIC EXAMINATIONS Refers to gross and microscopic evaluations of presumptively abnormal tissue(s) that have been previously excised. Includes preparation and transmission of written 6653 D0501 D0501 report. $ 127.00 6654 D0502 D0502 Other oral pathology procedures, by report $ 114.00 6655 D0999 D0999 Unspecified diagnostic procedure, by report Individual Report 6656 D1110 D1110 Prophylaxis - adult $ 88.00 6657 D1120 D1120 Prophylaxis - child $ 44.00 6658 D1206 D1206 Topical application of fluoride varnish $ 60.00 6659 D1208 D1208 Topical application of fluoride $ 60.00 6660 D1310 D1310 Nutritional counseling for control of dental disease $ 47.00 6661 D1320 D1320 Tobacco counseling for the control and prevention of oral disease $ 51.00 6662 D1330 D1330 Oral hygiene instructions $ 70.00 6663 D1351 D1351 Sealant - per tooth $ 55.00 6664 D1510 D1510 Space maintainer - fixed - unilateral $ 221.00 6665 D1515 D1515 Space maintainer - fixed - bilateral $ 311.00 6666 D1520 D1520 Space maintainer - removable - unilateral $ 266.00 6667 D1525 D1525 Space maintainer - removable - bilateral $ 346.00 6668 D1550 D1550 Re-cementation of space maintainer $ 53.00 6669 D2140 D2140 Amalgam - one surface, primary or permanent $ 75.00 6670 D2150 D2150 Amalgam - two surfaces, primary or permanent $ 108.00 6671 D2160 D2160 Amalgam - three surfaces, primary or permanent $ 119.00 6672 D2161 D2161 Amalgam - four or more surfaces, primary or permanent $ 130.00 6673 D2330 D2330 Resin-based composite - one surface, anterior $ 132.00 6674 D2331 D2331 Resin-based composite - two surfaces, anterior $ 198.00 6675 D2332 D2332 Resin-based composite - three surfaces, anterior $ 220.00 Resin-based composite - four or more surfaces or involving incisal 6676 D2335 D2335 angle (anterior) $ 242.00 6677 D2390 D2390 Resin-based composite crown, anterior $ 250.00 6678 D2391 D2391 Resin-based composite - one surface, posterior $ 66.00 6679 D2392 D2392 Resin-based composite - two surfaces, posterior $ 99.00 6680 D2393 D2393 Resin-based composite - three surfaces, posterior $ 110.00 6681 D2394 D2394 Resin-based composite - four or more surfaces, posterior $ 121.00 6682 D2410 D2410 Gold foil - one surface $ 360.00 6683 D2420 D2420 Gold foil - two surfaces $ 443.00 6684 D2430 D2430 Gold foil - three surfaces $ 525.00 6685 D2510 D2510 Inlay - metallic - one surface $ 522.00 6686 D2520 D2520 Inlay - metallic - two surfaces $ 580.00 6687 D2530 D2530 Inlay - metallic - three or more surfaces $ 625.00 6688 D2542 D2542 Onlay - metallic-two surfaces $ 650.00 6689 D2543 D2543 Onlay - metallic-three surfaces $ 691.00 6690 D2544 D2544 Onlay - metallic-four or more surfaces $ 720.00 6691 D2610 D2610 Inlay - porcelain/ceramic - one surface $ 583.00 6692 D2620 D2620 Inlay - porcelain/ceramic - two surfaces $ 630.00 6693 D2630 D2630 Inlay - porcelain/ceramic - three or more surfaces $ 671.00 6694 D2642 D2642 Onlay - porcelain/ceramic - two surfaces $ 688.00 6695 D2643 D2643 Onlay - porcelain/ceramic - three surfaces $ 717.00 6696 D2644 D2644 Onlay - porcelain/ceramic - four or more surfaces $ 744.00 6697 D2650 D2650 Inlay - resin-based composite - one surface $ 526.00 6698 D2651 D2651 Inlay - resin-based composite - two surfaces $ 569.00 6699 D2652 D2652 Inlay - resin-based composite - three or more surfaces $ 613.00 6700 D2662 D2662 Onlay - resin-based composite - two surfaces $ 650.00 6701 D2663 D2663 Onlay - resin-based composite - three surfaces $ 669.00 6702 D2664 D2664 Onlay - resin-based composite - four or more surfaces $ 695.00 6703 D2710 D2710 Crown - resin-based composite (indirect) $ 385.00 6704 D2720 D2720 Crown - resin with high noble metal $ 733.00 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price 6705 D2721 D2721 Crown - resin with predominantly base metal $ 661.00 6706 D2722 D2722 Crown - resin with noble metal $ 703.00 6707 D2740 D2740 Crown - porcelain/ceramic substrate $ 751.00 6708 D2750 D2750 Crown - porcelain fused to high noble metal $ 744.00 6709 D2751 D2751 Crown - porcelain fused to predominantly base metal $ 540.00 6710 D2752 D2752 Crown - porcelain fused to noble metal $ 795.00 6711 D2780 D2780 Crown - 3/4 cast high noble metal $ 738.00 6712 D2781 D2781 Crown - 3/4 cast predominantly base metal $ 697.00 6713 D2782 D2782 Crown - 3/4 cast noble metal $ 715.00 6714 D2783 D2783 Crown - 3/4 porcelain/ceramic $ 750.00 6715 D2790 D2790 Crown - full cast high noble metal $ 728.00 6716 D2791 D2791 Crown - full cast predominantly base metal $ 675.00 6717 D2792 D2792 Crown - full cast noble metal $ 700.00 Provisional crown - further treatment or completion of diagnosis 6718 D2799 D2799 necessary prior to final impression $ 215.00 6719 D2910 D2910 Recement inlay, onlay, or partial coverage restoration $ 77.00 6720 D2915 D2915 Recement cast or prefabricated post and core $ 218.00 6721 D2920 D2920 Recement crown $ 99.00 6722 D2930 D2930 Prefabricated stainless steel crown - primary tooth $ 150.00 6723 D2931 D2931 Prefabricated stainless steel crown - permanent tooth $ 150.00 6724 D2932 D2932 Prefabricated resin crown $ 200.00 6725 D2933 D2933 Prefabricated stainless steel crown with resin window $ 239.00 6726 D2940 D2940 Protective restoration $ 71.50 6727 D2950 D2950 Core buildup, including any pins $ 150.00 6728 D2951 D2951 Pin retention - per tooth, in addition to restoration $ 77.00 6729 D2952 D2952 Post and core in addition to crown, indirectly fabricated $ 303.50 6730 D2953 D2953 Each additional indirectly fabricated post - same tooth $ 188.00 6731 D2954 D2954 Prefabricated post and core in addition to crown $ 765.00 6732 D2955 D2955 Post removal $ 187.00 6733 D2957 D2957 Each additional prefabricated post - same tooth $ 66.00 6734 D2960 D2960 Labial veneer (resin laminate) - chairside $ 375.00 6735 D2961 D2961 Labial veneer (resin laminate) - laboratory $ 450.00 6736 D2962 D2962 Labial veneer (porcelain laminate) - laboratory $ 495.00 6737 D2970 D2970 Temporary crown (fractured tooth) $ 137.50 6738 D2980 D2980 Crown repair necessitated by restorative material failure $ 180.00 6739 D2999 D2999 Unspecified restorative procedure, by report Individual Report 6740 D3110 D3110 Pulp cap - direct (excluding final restoration) $ 55.00 6741 D3120 D3120 Pulp cap - indirect (excluding final restoration) $ 33.00 Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of 6742 D3220 D3220 medicament $ 77.00 6743 D3221 D3221 Pulpal debridement, primary and permanent teeth $ 88.00 Pulpal therapy (resorbable filling) - anterior, primary tooth 6744 D3230 D3230 (excluding final restoration) $ 175.00 Pulpal therapy (resorbable filling) - posterior, primary tooth 6745 D3240 D3240 (excluding final restoration) $ 196.00 6746 D3310 D3310 Endodontic therapy, anterior tooth (excluding final restoration) $ 247.50 6747 D3320 D3320 Endodontic therapy, bicuspid tooth (excluding final restoration) $ 605.00 6748 D3330 D3330 Endodontic therapy, molar (excluding final restoration) $ 852.50 6749 D3331 D3331 Treatment of root canal obstruction; non-surgical access $ 210.00 Incomplete endodontic therapy; inoperable, unrestorable or 6750 D3332 D3332 fractured tooth $ 233.00 6751 D3333 D3333 Internal root repair of perforation defects $ 133.00 6752 D3346 D3346 Retreatment of previous root canal therapy - anterior $ 360.00 6753 D3347 D3347 Retreatment of previous root canal therapy - bicuspid $ 360.00 6754 D3348 D3348 Retreatment of previous root canal therapy - molar $ 360.00 Apexification/recalcification/pulpal regeneration - initial visit (apical closure/calcific repair of perforations, root resorption, pulp space 6755 D3351 D3351 disinfection, etc.) $ 110.00 Apexification/recalcification/pulpal regeneration - interim medication replacement (apical closure/calcific repair of 6756 D3352 D3352 perforations, root resorption, pulp space disinfection, etc.) $ 110.00 Apexification/recalcification - final visit (includes completed root canal therapy - apical closure/calcific repair of perforations, root 6757 D3353 D3353 resorption, etc.) $ 110.00 6758 D3410 D3410 Apicoectomy/periradicular surgery - anterior $ 330.00 6759 D3421 D3421 Apicoectomy/periradicular surgery - bicuspid (first root) $ 330.00 6760 D3425 D3425 Apicoectomy/periradicular surgery - molar (first root) $ 330.00 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price 6761 D3426 D3426 Apicoectomy/periradicular surgery (each additional root) $ 210.00 6762 D3430 D3430 Retrograde filling - per root $ 170.00 6763 D3450 D3450 Root amputation - per root $ 300.00 6764 D3460 D3460 Endodontic endosseous implant $ 759.00 6765 D3470 D3470 Intentional reimplantation (including necessary splinting) $ 539.00 6766 D3910 D3910 Surgical procedure for isolation of tooth with rubber dam $ 125.00 Hemisection (including any root removal), not including root canal 6767 D3920 D3920 therapy $ 299.00 6768 D3950 D3950 Canal preparation and fitting of preformed dowel or post $ 160.00 6769 D3999 D3999 Unspecified endodontic procedure, by report Individual Report Gingivectomy or gingivoplasty - four or more contiguous teeth or 6770 D4210 D4210 tooth bounded spaces per quadrant $ 420.00 Gingivectomy or gingivoplasty - one to three contiguous teeth or 6771 D4211 D4211 tooth bounded spaces per quadrant $ 148.00 Gingival flap procedure, including root planing - four or more 6772 D4240 D4240 contiguous teeth or tooth bounded spaces per quadrant $ 493.00 Gingival flap procedure, including root planing - one to three 6773 D4241 D4241 contiguous teeth or tooth bounded spaces per quadrant $ 207.00 6774 D4245 D4245 Apically positioned flap $ 554.00 6775 D4249 D4249 Clinical crown lengthening - hard tissue $ 478.00 Osseous surgery (including flap entry and closure) - four or more 6776 D4260 D4260 contiguous teeth or tooth bounded spaces per quadrant $ 724.00 6777 D4263 D4263 Bone replacement graft - first site in quadrant $ 456.00 6778 D4264 D4264 Bone replacement graft - each additional site in quadrant $ 335.00 6779 D4266 D4266 Guided tissue regeneration - resorbable barrier, per site $ 603.00 Guided tissue regeneration - nonresorbable barrier, per site 6780 D4267 D4267 (includes membrane removal) $ 688.00 6781 D4268 D4268 Surgical revision procedure, per tooth $ 534.00 6782 D4270 D4270 Pedicle soft tissue graft procedure $ 536.00 6783 D4273 D4273 Subepithelial connective tissue graft procedures, per tooth $ 735.00 Free soft tissue graft procedure (including donor site surgery), first 6784 D4277 D4277 tooth or edentulous tooth position in graft $ 595.00 Free soft tissue graft procedure (including donor site surgery), each additional contiguous tooth or edentulous tooth position in same 6785 D4278 D4278 graft site $ 595.00 6786 D4320 D4320 Provisional splinting - intracoronal $ 332.00 6787 D4321 D4321 Provisional splinting - extracoronal $ 300.00 Periodontal scaling and root planing - four or more teeth per 6788 D4341 D4341 quadrant $ 132.00 Full mouth debridement to enable comprehensive evaluation and 6789 D4355 D4355 diagnosis $ 264.00 6790 D4360 D4360 Trismus appliance (not for TMD treatment) $ 220.00 6791 D4910 D4910 Periodontal maintenance $ 88.00 Unscheduled dressing change (by someone other than treating 6792 D4920 D4920 dentist) $ 71.00 6793 D4921 D4921 Gingival irrigation per quad $ 207.00 6794 D4999 D4999 Unspecified periodontal procedure, by report Individual Report 6795 D5110 D5110 Complete denture - maxillary $ 600.00 6796 D5120 D5120 Complete denture - mandibular $ 600.00 6797 D5130 D5130 Immediate denture - maxillary $ 700.00 6798 D5140 D5140 Immediate denture - mandibular $ 700.00 Maxillary partial denture - resin base (including any conventional 6799 D5211 D5211 clasps, rests and teeth) $ 250.00 Mandibular partial denture - resin base (including any conventional 6800 D5212 D5212 clasps, rests and teeth) $ 250.00 Maxillary partial denture - cast metal framework with resin denture 6801 D5213 D5213 bases (including any conventional clasps, rests and teeth) $ 650.00 Mandibular partial denture - cast metal framework with resin 6802 D5214 D5214 denture bases (including any conventional clasps, rests and teeth) $ 650.00 Mandibular partial denture - flexible base (including any clasps, 6803 D5226 D5226 rests and teeth) $ 605.00 Mandibular partial denture - cast metal framework with resin 6804 D5231 D5231 denture bases (including any conventional clasps, rests and teeth) $ 605.00 6805 D5251 D5251 Complete denture - maxillary $ 605.00 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Removable unilateral partial denture - one piece cast metal 6806 D5281 D5281 (including clasps and teeth $ 625.00 6807 D5310 D5310 Repair or replace broken clasp $ 27.50 6808 D5320 D5320 Add tooth to existing partial denture $ 27.50 6809 D5410 D5410 Adjust complete denture - maxillary $ 30.00 6810 D5411 D5411 Adjust complete denture - mandibular $ 30.00 6811 D5421 D5421 Adjust partial denture - maxillary $ 25.00 6812 D5422 D5422 Adjust partial denture - mandibular $ 25.00 6813 D5510 D5510 Repair broken complete denture base $ 55.00 6814 D5520 D5520 Replace missing or broken teeth - complete denture (each tooth) $ 55.00 6815 D5610 D5610 Repair resin denture base $ 50.00 6816 D5620 D5620 Repair cast framework $ 55.00 6817 D5630 D5630 Repair or replace broken clasp $ 55.00 6818 D5640 D5640 Replace broken teeth - per tooth $ 55.00 6819 D5650 D5650 Add tooth to existing partial denture $ 55.00 6820 D5660 D5660 Add clasp to existing partial denture $ 50.00 6821 D5710 D5710 Rebase complete maxillary denture $ 379.00 6822 D5711 D5711 Rebase complete mandibular denture $ 380.00 6823 D5720 D5720 Rebase maxillary partial denture $ 367.00 6824 D5721 D5721 Rebase mandibular partial denture $ 366.00 6825 D5730 D5730 Reline complete maxillary denture (chairside) $ 248.00 6826 D5731 D5731 Reline complete mandibular denture (chairside) $ 249.00 6827 D5740 D5740 Reline maxillary partial denture (chairside) $ 245.00 6828 D5741 D5741 Reline mandibular partial denture (chairside) $ 244.00 6829 D5750 D5750 Reline complete maxillary denture (laboratory) $ 110.00 6830 D5751 D5751 Reline complete mandibular denture (laboratory) $ 110.00 6831 D5760 D5760 Reline maxillary partial denture (laboratory) $ 110.00 6832 D5761 D5761 Reline mandibular partial denture (laboratory) $ 110.00 6833 D5810 D5810 Interim complete denture (maxillary) $ 517.00 6834 D5811 D5811 Interim complete denture (mandibular) $ 524.00 6835 D5820 D5820 Interim partial denture (maxillary) $ 442.00 6836 D5821 D5821 Interim partial denture (mandibular) $ 442.00 6837 D5850 D5850 Tissue conditioning, maxillary $ 125.00 6838 D5851 D5851 Tissue conditioning, mandibular $ 125.00 6839 D5860 D5860 Overdenture - complete, by report $ 660.00 6840 D5861 D5861 Overdenture - partial, by report $ 660.00 6841 D5862 D5862 Precision attachment, by report $ 435.00 6842 D5875 D5875 Modification of removable prosthesis following implant surgery $ 236.00 6843 D5899 D5899 Unspecified removable prosthodontic procedure, by report Individual Report 6844 D5911 D5911 Facial moulage (sectional) Individual Report 6845 D5912 D5912 Facial moulage (complete) Individual Report 6846 D5913 D5913 Nasal prosthesis Individual Report 6847 D5914 D5914 Auricular prosthesis Individual Report 6848 D5915 D5915 Orbital prosthesis Individual Report 6849 D5916 D5916 Ocular prosthesis Individual Report 6850 D5919 D5919 Facial prosthesis Individual Report 6851 D5922 D5922 Nasal septal prosthesis Individual Report 6852 D5923 D5923 Ocular prosthesis, interim Individual Report 6853 D5924 D5924 Cranial prosthesis Individual Report 6854 D5925 D5925 Facial augmentation implant prosthesis Individual Report 6855 D5926 D5926 Nasal prosthesis, replacement Individual Report 6856 D5927 D5927 Auricular prosthesis, replacement Individual Report 6857 D5928 D5928 Orbital prosthesis, replacement Individual Report 6858 D5929 D5929 Facial prosthesis, replacement Individual Report 6859 D5931 D5931 Obturator prosthesis, surgical Individual Report 6860 D5932 D5932 Obturator prosthesis, definitive Individual Report 6861 D5933 D5933 Obturator prosthesis, modification Individual Report 6862 D5934 D5934 Mandibular resection prosthesis with guide flange Individual Report 6863 D5935 D5935 Mandibular resection prosthesis without guide flange Individual Report 6864 D5936 D5936 Obturator prosthesis, interim Individual Report 6865 D5937 D5937 Trismus appliance (not for TMD treatment) Individual Report 6866 D5951 D5951 Feeding aid Individual Report 6867 D5952 D5952 Speech aid prosthesis, pediatric Individual Report 6868 D5953 D5953 Speech aid prosthesis, adult Individual Report 6869 D5954 D5954 Palatal augmentation prosthesis Individual Report 6870 D5955 D5955 Palatal lift prosthesis, definitive Individual Report 6871 D5958 D5958 Palatal lift prosthesis, interim Individual Report 6872 D5959 D5959 Palatal lift prosthesis, modification Individual Report Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price 6873 D5960 D5960 Speech aid prosthesis, modification Individual Report 6874 D5982 D5982 Surgical stent $ 273.00 6875 D5983 D5983 Radiation carrier Individual Report 6876 D5984 D5984 Radiation shield Individual Report 6877 D5985 D5985 Radiation cone locator Individual Report 6878 D5986 D5986 Fluoride gel carrier $ 115.00 6879 D5987 D5987 Commissure splint Individual Report 6880 D5988 D5988 Surgical splint $ 549.00 6881 D5992 D5992 Adjust maxillofacial prosthetic appliance, by report $ 220.00 6882 D5999 D5999 Unspecified maxillofacial prosthesis, by report Individual Report 6883 D6010 D6010 Surgical placement of implant body: endosteal implant $ 1,425.00 Surgical placement of interim implant body for transitional 6884 D6012 D6012 prosthesis: endosteal implant $ 650.00 6885 D6040 D6040 Surgical placement: eposteal implant $ 6,023.00 6886 D6050 D6050 Surgical placement: transosteal implant $ 4,153.00 6887 D6055 D6055 Connecting bar - implant supported or abutment supported $ 1,667.00 6888 D6056 D6056 Prefabricated abutment - includes modification and placement $ 429.00 6889 D6057 D6057 Custom fabricated abutment - includes placement $ 600.00 6890 D6058 D6058 Abutment supported porcelain/ceramic crown $ 850.00 Abutment supported porcelain fused to metal crown (high noble 6891 D6059 D6059 metal) $ 861.00 Abutment supported porcelain fused to metal crown 6892 D6060 D6060 (predominantly base metal) $ 730.00 6893 D6061 D6061 Abutment supported porcelain fused to metal crown (noble metal) $ 800.00 6894 D6062 D6062 Abutment supported cast metal crown (high noble metal) $ 844.00 6895 D6063 D6063 Abutment supported cast metal crown (predominantly base metal) $ 755.00 6896 D6064 D6064 Abutment supported cast metal crown (noble metal) $ 800.00 6897 D6065 D6065 Implant supported porcelain/ceramic crown $ 960.00 Implant supported porcelain fused to metal crown (titanium, 6898 D6066 D6066 titanium alloy, high noble metal) $ 981.00 Implant supported metal crown (titanium, titanium alloy, high noble 6899 D6067 D6067 metal) $ 950.00 6900 D6068 D6068 ABUTMENT SUPPORTED RETAINER FOR PORCELAIN/CERAMIC FPD $ 844.00 Abutment supported retainer for porcelain fused to metal FPD (high 6901 D6069 D6069 noble metal) $ 836.00 Abutment supported retainer for porcelain fused to metal FPD 6902 D6070 D6070 (predominantly base metal) $ 703.00 Abutment supported retainer for porcelain fused to metal FPD 6903 D6071 D6071 (noble metal) $ 792.00 6904 D6072 D6072 Abutment supported retainer for cast metal FPD (high noble metal) $ 810.00 Abutment supported retainer for cast metal FPD (predominantly 6905 D6073 D6073 base metal) $ 760.00 6906 D6074 D6074 Abutment supported retainer for cast metal FPD (noble metal) $ 775.00 6907 D6075 D6075 Implant supported retainer for ceramic FPD $ 906.00 Implant supported retainer for cast metal FPD (titanium, titanium 6908 D6077 D6077 alloy, or high noble metal) $ 935.00 Implant/abutment supported fixed denture for completely 6909 D6078 D6078 edentulous arch $ 2,500.00 Implant/abutment supported fixed denture for partially edentulous 6910 D6079 D6079 arch $ 1,650.00 6911 D6090 D6090 Repair implant supported prosthesis, by report $ 493.00 6912 D6095 D6095 REPAIR IMPLANT ABUTMENT, BY REPORT $ 500.00 6913 D6100 D6100 Implant removal, by report $ 526.00 6914 D6199 D6199 Unspecified implant procedure, by report Individual Report 6915 D6210 D6210 Pontic - cast high noble metal $ 725.00 6916 D6211 D6211 Pontic - cast predominantly base metal $ 675.00 6917 D6212 D6212 Pontic - cast noble metal $ 778.00 6918 D6240 D6240 Pontic - porcelain fused to high noble metal $ 735.00 6919 D6241 D6241 Pontic - porcelain fused to predominantly base metal $ 680.00 6920 D6242 D6242 Pontic - porcelain fused to noble metal $ 745.00 6921 D6245 D6245 Pontic - porcelain/ceramic $ 749.00 6922 D6250 D6250 Pontic - resin with high noble metal $ 727.00 6923 D6251 D6251 Pontic - resin with predominantly base metal $ 680.00 6924 D6252 D6252 Pontic - resin with noble metal $ 722.00 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price 6925 D6545 D6545 Retainer - cast metal for resin bonded fixed prosthesis $ 452.00 6926 D6548 D6548 Retainer - porcelain/ceramic for resin bonded fixed prosthesis $ 603.00 6927 D6600 D6600 Inlay - porcelain/ceramic, two surfaces $ 750.00 6928 D6601 D6601 Inlay - porcelain/ceramic, three or more surfaces $ 750.00 6929 D6608 D6608 Onlay -porcelain/ceramic, two surfaces $ 750.00 6930 D6609 D6609 Onlay - porcelain/ceramic, three or more surfaces $ 750.00 6931 D6710 D6710 Crown - indirect resin based composite $ 250.00 6932 D6720 D6720 Crown - resin with high noble metal $ 750.00 6933 D6721 D6721 Crown - resin with predominantly base metal $ 700.00 6934 D6722 D6722 Crown - resin with noble metal $ 727.00 6935 D6740 D6740 Crown - porcelain/ceramic $ 768.00 6936 D6750 D6750 Crown - porcelain fused to high noble metal $ 745.00 6937 D6751 D6751 Crown - porcelain fused to predominantly base metal $ 685.00 6938 D6752 D6752 Crown - porcelain fused to noble metal $ 745.00 6939 D6780 D6780 Crown - 3/4 cast high noble metal $ 727.00 6940 D6781 D6781 Crown - 3/4 cast predominantly base metal $ 718.00 6941 D6782 D6782 Crown - 3/4 cast noble metal $ 748.00 6942 D6783 D6783 Crown - 3/4 porcelain/ceramic $ 773.00 6943 D6790 D6790 Crown - full cast high noble metal $ 778.00 6944 D6791 D6791 Crown - full cast predominantly base metal $ 675.00 6945 D6792 D6792 Crown - full cast noble metal $ 709.00 6946 D6920 D6920 Connector bar $ 647.00 6947 D6930 D6930 Recement fixed partial denture $ 95.00 6948 D6940 D6940 Stress breaker $ 272.00 6949 D6950 D6950 Precision attachment $ 427.00 6950 D6975 D6975 Coping $ 471.00 Fixed partial denture repair necessitated by restorative material 6951 D6980 D6980 failure $ 250.00 6952 D6999 D6999 Unspecified fixed prosthodontic procedure, by report Individual Report 6953 D7111 D7111 Extraction, coronal remnants - deciduous tooth $ 77.00 Extraction, erupted tooth or exposed root (elevation and/or forceps 6954 D7140 D7140 removal) $ 77.00 Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if 6955 D7210 D7210 indicated $ 300.00 6956 D7220 D7220 Removal of impacted tooth - soft tissue $ 330.00 6957 D7230 D7230 Removal of impacted tooth - partially bony $ 270.00 6958 D7240 D7240 Removal of impacted tooth - completely bony $ 300.00 Removal of impacted tooth - completely bony, with unusual surgical 6959 D7241 D7241 complications $ 395.00 6960 D7250 D7250 Surgical removal of residual tooth roots (cutting procedure) $ 193.00 6961 D7260 D7260 Oroantral fistula closure $ 445.00 Tooth reimplantation and/or stabilization of accidentally evulsed or 6962 D7270 D7270 displaced tooth $ 334.00 Tooth transplantation (includes reimplantation from one site to 6963 D7272 D7272 another and splinting and/or stabilization) $ 444.00 6964 D7280 D7280 Surgical access of an unerupted tooth $ 310.00 6965 D7282 D7282 Mobilization of erupted or malpositioned tooth to aid eruption $ 250.00 6966 D7283 D7283 Placement of device to facilitate eruption of impacted tooth $ 250.00 6967 D7285 D7285 Biopsy of oral tissue - hard (bone, tooth) $ 165.00 6968 D7286 D7286 Biopsy of oral tissue - soft $ 165.00 6969 D7290 D7290 Surgical repositioning of teeth $ 280.00 6970 D7291 D7291 Transseptal fiberotomy/supra crestal fiberotomy, by report $ 190.00 Alveoloplasty in conjunction with extractions - four or more teeth or 6971 D7310 D7310 tooth spaces, per quadrant $ 165.00 Alveoloplasty not in conjunction with extractions -four or more 6972 D7320 D7320 teeth or tooth spaces, per quadrant $ 277.00 6973 D7340 D7340 Vestibuloplasty - ridge extension (secondary epithelialization) $ 602.00 6974 D7410 D7410 Excision of benign lesion up to 1.25 cm $ 262.00 6975 D7440 D7440 Excision of malignant tumor - lesion diameter up to 1.25 cm $ 364.00 6976 D7441 D7441 Excision of malignant tumor - lesion diameter greater than 1.25 cm $ 707.00 Removal of benign odontogenic cyst or tumor - lesion diameter up 6977 D7450 D7450 to 1.25 cm $ 323.00 Removal of benign odontogenic cyst or tumor - lesion diameter 6978 D7451 D7451 greater than 1.25 cm $ 448.00 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Removal of benign nonodontogenic cyst or tumor - lesion diameter 6979 D7460 D7460 up to 1.25 cm $ 315.00 Removal of benign nonodontogenic cyst or tumor - lesion diameter 6980 D7461 D7461 greater than 1.25 cm $ 453.00 6981 D7465 D7465 Destruction of lesion(s) by physical or chemical method, by report $ 229.00 6982 D7471 D7471 Removal of lateral exostosis (maxilla or mandible) $ 373.00 6983 D7490 D7490 Radical resection of maxilla or mandible $ 6,125.00 6984 D7510 D7510 Incision and drainage of abscess - intraoral soft tissue $ 145.00 6985 D7520 D7520 Incision and drainage of abscess - extraoral soft tissue $ 232.00 Removal of foreign body from mucosa, skin, or subcutaneous 6986 D7530 D7530 alveolar tissue $ 223.00 Removal of reaction producing foreign bodies, musculoskeletal 6987 D7540 D7540 system $ 359.00 6988 D7550 D7550 Partial ostectomy/sequestrectomy for removal of non-vital bone $ 313.00 6989 D7560 D7560 Maxillary sinusotomy for removal of tooth fragment or foreign body $ 679.00 6990 D7610 D7610 Maxilla - open reduction (teeth immobilized, if present) $ 2,989.00 6991 D7620 D7620 Maxilla - closed reduction (teeth immobilized, if present) $ 2,295.00 6992 D7630 D7630 Mandible - open reduction (teeth immobilized, if present) $ 2,959.00 6993 D7640 D7640 Mandible - closed reduction (teeth immobilized, if present) $ 2,174.00 6994 D7650 D7650 Malar and/or zygomatic arch - open reduction $ 2,720.00 6995 D7660 D7660 Malar and/or zygomatic arch - closed reduction $ 2,227.00 6996 D7670 D7670 Alveolus closed reduction may include stabilization of teeth $ 862.00 Facial bones - complicated reduction with fixation and multiple 6997 D7680 D7680 surgical approaches $ 4,768.00 6998 D7710 D7710 Maxilla open reduction $ 3,259.00 6999 D7720 D7720 Maxilla - closed reduction $ 2,161.00 7000 D7730 D7730 Mandible - open reduction $ 3,294.00 7001 D7740 D7740 Mandible - closed reduction $ 2,435.00 7002 D7750 D7750 Malar and/or zygomatic arch - open reduction $ 2,875.00 7003 D7760 D7760 Malar and/or zygomatic arch - closed reduction $ 2,669.00 7004 D7770 D7770 Alveolus - open reduction stabilization of teeth $ 1,675.00 Facial bones - complicated reduction with fixation and multiple 7005 D7780 D7780 surgical approaches $ 5,886.00 7006 D7810 D7810 Open reduction of dislocation $ 2,980.00 7007 D7820 D7820 Closed reduction of dislocation $ 305.00 7008 D7830 D7830 Manipulation under anesthesia $ 397.00 7009 D7840 D7840 Condylectomy $ 3,974.00 7010 D7850 D7850 Surgical discectomy, with/without implant $ 3,935.00 7011 D7852 D7852 Disc repair $ 4,188.00 7012 D7854 D7854 Synovectomy $ 4,157.00 7013 D7856 D7856 Myotomy Individual Report 7014 D7858 D7858 Joint reconstruction Individual Report 7015 D7860 D7860 Arthrotomy Individual Report 7016 D7865 D7865 Arthroplasty Individual Report 7017 D7870 D7870 Arthrocentesis Individual Report 7018 D7871 D7871 Non-arthroscopic lysis and lavage Individual Report 7019 D7872 D7872 Arthroscopy - diagnosis, with or without biopsy Individual Report 7020 D7873 D7873 Arthroscopy - surgical: lavage and lysis of adhesions Individual Report 7021 D7874 D7874 Arthroscopy - surgical: disc repositioning and stabilization Individual Report 7022 D7875 D7875 Arthroscopy - surgical: synovectomy Individual Report 7023 D7876 D7876 Arthroscopy - surgical: discectomy Individual Report 7024 D7877 D7877 Arthroscopy - surgical: debridement Individual Report 7025 D7880 D7880 Occlusal orthotic device, by report $ 598.00 7026 D7899 D7899 Unspecified TMD therapy, by report Individual Report 7027 D7910 D7910 Suture of recent small wounds up to 5 cm $ 190.00 7028 D7911 D7911 Complicated suture - up to 5 cm $ 294.00 7029 D7912 D7912 Complicated suture - greater than 5 cm $ 415.00 7030 D7920 D7920 Skin graft (identify defect covered, location and type of graft) $ 1,611.00 7031 D7940 D7940 Osteoplasty - for orthognathic deformities $ 2,476.00 7032 D7941 D7941 Osteotomy - mandibular rami $ 6,322.00 Osteotomy - mandibular rami with bone graft;

includes obtaining 7033 D7943 D7943 the graft $ 5,948.00 7034 D7944 D7944 Osteotomy - segmented or subapical $ 4,735.00 7035 D7945 D7945 Osteotomy - body of mandible $ 4,895.00 7036 D7946 D7946 LeFort I (maxilla - total) $ 5,962.00 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price 7037 D7947 D7947 LeFort I (maxilla - segmented) $ 6,104.00 7038 D7949 D7949 LeFort II or LeFort III - with bone graft $ 8,333.00 7039 D7955 D7955 Repair of maxillofacial soft and/or hard tissue defect $ 1,898.00 Frenulectomy - also known as frenectomy or frenotomy - separate 7040 D7960 D7960 procedure not incidental to another procedure $ 275.00 7041 D7970 D7970 Excision of hyperplastic tissue - per arch $ 320.00 7042 D7971 D7971 Excision of pericoronal gingiva $ 150.00 7043 D7980 D7980 Sialolithotomy $ 399.00 7044 D7981 D7981 Excision of salivary gland, by report $ 2,389.00 7045 D7982 D7982 Sialodochoplasty $ 1,150.00 7046 D7983 D7983 Closure of salivary fistula $ 610.00 7047 D7990 D7990 Emergency tracheotomy $ 870.00 7048 D7991 D7991 Coronoidectomy $ 2,775.00 7049 D7995 D7995 Synthetic graft - mandible or facial bones, by report Individual Report Implant-mandible for augmentation purposes (excluding alveolar 7050 D7996 D7996 ridge), by report Individual Report Appliance removal (not by dentist who placed appliance), includes 7051 D7997 D7997 removal of archbar Individual Report 7052 D7999 D7999 Unspecified oral surgery procedure, by report Individual Report 7053 D8010 D8010 Limited orthodontic treatment of the primary dentition $ 1,200.00 7054 D8020 D8020 Limited orthodontic treatment of the transitional dentition $ 1,485.00 7055 D8030 D8030 Limited orthodontic treatment of the adolescent dentition $ 1,616.00 7056 D8040 D8040 Limited orthodontic treatment of the adult dentition $ 1,562.00 7057 D8050 D8050 Interceptive orthodontic treatment of the primary dentition $ 1,545.00 7058 D8060 D8060 Interceptive orthodontic treatment of the transitional dentition $ 1,775.00 7059 D8070 D8070 Comprehensive orthodontic treatment of the transitional dentition $ 3,968.00 7060 D8080 D8080 Comprehensive orthodontic treatment of the adolescent dentition $ 3,998.00 7061 D8090 D8090 Comprehensive orthodontic treatment of the adult dentition $ 4,125.00 7062 D8210 D8210 Removable appliance therapy $ 231.00 7063 D8220 D8220 Fixed appliance therapy $ 231.00 7064 D8660 D8660 Pre-orthodontic treatment visit $ 170.00 7065 D8670 D8670 Periodic orthodontic treatment visit (as part of contract) $ 129.00 Orthodontic retention (removal of appliances, construction and 7066 D8680 D8680 placement of retainer(s)) $ 275.00 7067 D8690 D8690 Orthodontic treatment (alternative billing to a contract fee) $ 160.00 7068 D8691 D8691 Repair of orthodontic appliance $ 134.00 7069 D8692 D8692 Replacement of lost or broken retainer $ 232.00 7070 D8999 D8999 Unspecified orthodontic procedure, by report Individual Report 7071 D9110 D9110 Palliative (emergency) treatment of dental pain - minor procedure $ 79.00 Local anesthesia not in conjunction with operative or surgical 7072 D9210 D9210 procedures $ 45.00 7073 D9211 D9211 Regional block anesthesia $ 64.00 7074 D9212 D9212 Trigeminal division block anesthesia $ 168.00 Local anesthesia in conjunction with operative or surgical 7075 D9215 D9215 procedures $ 39.00 7076 D9220 D9220 Deep sedation/general anesthesia - first 30 minutes $ 250.00 7077 D9221 D9221 Deep sedation/general anesthesia - each additional 15 minutes $ 105.00 7078 D9230 D9230 Inhalation of nitrous oxide / anxiolysis, analgesia $ 45.00 7079 D9241 D9241 Intravenous conscious sedation/analgesia - first 30 minutes $ 250.00 Intravenous conscious sedation/analgesia - each additional 15 7080 D9242 D9242 minutes $ 95.00 7081 D9248 D9248 Non-intravenous conscious sedation $ 194.00 7082 D9410 D9410 House/extended care facility call $ 129.00 7083 D9420 D9420 Hospital or ambulatory surgical center call $ 150.00 Office visit for observation (during regularly scheduled hours) - no 7084 D9430 D9430 other services performed $ 47.00 7085 D9440 D9440 Office visit - after regularly scheduled hours $ 95.00 7086 D9610 D9610 Therapeutic parenteral drug, single administration $ 60.00 7087 D9630 D9630 Other drugs and/or medicaments, by report $ 30.00 7088 D9910 D9910 Application of desensitizing medicament $ 40.00 Application of desensitizing resin for cervical and/or root surface, 7089 D9911 D9911 per tooth $ 46.00 7090 D9920 D9920 Behavior management, by report $ 85.00 Cayman Islands Health Services Authority Charge Master Row # Bill Code Modifer CPT-4 HCPCS CPT/HCPCS Long Description Price Treatment of complications (post-surgical) - unusual circumstances, 7091 D9930 D9930 by report $ 91.00 7092 D9940 D9940 Occlusal guard, by report $ 250.00 7093 D9941 D9941 Fabrication of athletic mouthguard $ 80.00 7094 D9950 D9950 Occlusion analysis - mounted case $ 210.00 7095 D9951 D9951 Occlusal adjustment - limited $ 110.00 7096 D9952 D9952 Occlusal adjustment - complete $ 220.00 7097 D9970 D9970 Enamel microabrasion $ 142.00 7098 D9971 D9971 Odontoplasty 1 - 2 teeth; includes removal of enamel projections $ 85.00 7099 D9972 D9972 External bleaching - per arch - performed in office $ 211.00 7100 D9973 D9973 External bleaching - per tooth $ 160.00 7101 D9974 D9974 Internal bleaching - per tooth $ 189.00 7102 D9999 D9999 Unspecified adjunctive procedure, by report Individual Report 7103 HS0002 ROOM/BED: Critical Care $ 1,507.00 7104 HS0003 ROOM/BED: High Dependancy $ 440.00 7105 HS0009 ROOM/BED: Neonatal $ - 7106 HS0040 ROOM/BED: Isolation $ 330.00 7107 HS0042 ROOM/BED: Semi Private $ 330.00 7108 HS0043 ROOM/BED: Maternal Care $ 495.00 7109 HS0045 ROOM/BED: Neonatal - High Dependency $ 440.00 7110 HS0046 ROOM/BED: Neonatal - Special Care $ 330.00 7111 HS0048 ROOM/BED: Neonatal - Intensive $ 1,507.00 7112 HS0050 ROOM/BED: Psychiatry $ 330.00 7113 HS0060 ROOM/BED: Private $ 467.50 7114 HS0070 Day Treatment $ 220.00 7115 HS0070 ROOM/BED: Day Treatment $ 220.00 7116 HS0080 ROOM/BED: Sub Acute $ 220.00 7117 HS0106 Operating Room Facility Fee 1st Hour $ 660.00 7118 HS0108 Operating Room Facility Fee Add. Hours $ 192.50 7119 HS1013 Labour & Delivery Room $ 825.00 7120 HS1015 OR Facility Fee Dental <1 Hr $ 286.00 7121 HS1017 OR Facility Fee Dental >1 Hr $ 517.00 7122 S9460 S9460 Diabetic management program, nurse visit $ 36.97 7123 S9981 S9981 Medical records copying fee, administrative $ 5.50 7124 S9982 S9982 Medical records copying fee, per page $ 0.55 7125 V5014 V5014 Repair/modification of a hearing aid ( In- House) $ 25.00 7126 V5030 V5030 Hearing aid, monaural, body worn, air conduction Cost