Outpatient Surgery Facility Codes and Fees

[Pages:29]Exhibit 4

Codes

Outpatient Surgery Facility Codes and Fees

CPT Code Description

Dollar Value

10140 INCISION AND DRAINAGE OF HEMATOMA, SEROMA OR FLUID COLLECTION

10180 INCISION AND DRAINAGE, COMPLEX, POSTOPERATIVE WOUND INFECTION

11043 DEBRIDEMENT, SKIN, SUBCUTANEOUS TISSUE, AND MUSCLE. 11044 DEBRIDEMENT; SUBCUTANEOUS TISSUE, MUSCLE AND BONE.

14001 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, TRUNK; DEFECT 10.1 SQ CM TO 30 SQ CM

14020 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, SCALP, ARMS, AND/OR LEGS; DEFECT 10 SQ CM OR LESS

14021 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, SCALP, ARMS, AND/OR LEGS; DEFECT 10 SQ CM TO 30 SQ CM

14040 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; DEFECT 10 SQ CM OR LESS

14041 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; DEFECT 10 SQ CM TO 30 SQ CM

14060 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS, NOSE, EARS AND/OR LIPS; DEFECT 10 SQ CM OR LESS

14061 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS, NOSE, EARS AND/OR LIPS; DEFECT 10 SQ CM TO 30 SQ CM

14300 ADJACENT TISSUE TRANSFER OR REARRANGEMENT; DEFECT MORE THAN 30 SQ CM, UNUSUAL OR COMPLICATED, ANY AREA

14350 FILLETED FINGER OR TOE FLAP, INCLUDING PREPARATION OF RECIPIENT SITE

15000 SURG PREP RECIP SITE; 1ST 100 CM/1%

15001 SURG PREP RECIP SITE; EA ADD 100 CM 15050 PINCH GFT 1/MX-SM AREA UP TO 2 CM 15100 SPLIT GFT TRUNK; 1ST 100 SQ CM/ ................
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