Gazette No. 15 dated 7 March, 2014. THE STANDARD HEALTH INSURANCE

CAYMAN ISLANDS Supplement No. 1 published with Extraordinary Gazette No. 15 dated 7 March, 2014. THE STANDARD HEALTH INSURANCE FEES FOR THE CAYMAN ISLANDS - JUNE 2005 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 10021 Fine needle aspiration w/o imaging guidance 1 96.46 10022 Fine needle aspiration with imaging guidance 2 15.09 10040 Acne surgery (eg, marsupialization, opening or removal of multiple milia, comedones, cysts, pustules) 1 2 2 . 4 0 10060 Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous 1 34.44 10061 Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous 3 58.05 10080 Incision and drainage of pilonidal cyst; simple 1 9 0 . 8 0 10081 Incision and drainage of pilonidal cyst; complicated 4 5 0 . 9 0 10120 Incision and removal of foreign body, subcutaneous tissues; simple 1 4 9 . 6 7 10121 Incision and removal of foreign body, subcutaneous tissues; complicated 4 1 3 . 4 5 10140 Incision and drainage of hematoma, seroma or fluid collection 1 8 3 . 3 2 10160 Puncture aspiration of abscess, hematoma, bulla, or cyst 1 2 5 . 3 4 10180 Incision and drainage, complex, postoperative wound infection 5 6 0 . 3 2 11000 Debridement of extensive eczematous or infected skin; up to 10% of body surface 1 0 5 . 8 6 11001 Debridement of extensive eczematous or infected skin; each additional 10% of the body surface (List 1 12.50 11004 Dbrdmt skn subq t/m/f necro infctj gent&pr 7 56.94 11005 Dbrdmt skn subq t/m/f necro infctj abdl wall 1 ,068.79 11006 Dbrdmt skn subq t/m/f necro infctj gent/abdl 9 73.26 11008 Removal prosthetic matrl abdl wall for infection 4 37.12 11010 Debridement including removal of foreign material associated with open fracture(s) and/or dislocation(s); 1 ,060.20 11011 Debridement including removal of foreign material associated with open fracture(s) and/or dislocation(s); 1 ,257.30 11012 Debridement including removal of foreign material associated with open fracture(s) and/or dislocation(s); 1 ,781.10 11042 Debridement; skin, and subcutaneous tissue 3 2 9 . 2 6 11043 Debridement; skin, subcutaneous tissue, and muscle 6 5 7 . 9 0 11044 Debridement; skin, subcutaneous tissue, muscle, and bone 8 4 6 . 9 0 11045 Deb subq tissue add-on 4 3.79 11046 Deb musc/fascia add-on 9 9.37 11047 Deb bone add-on 1 91.93 11055 Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); single lesion 5 3 . 9 0 11056 Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); two to four lesions 7 1 . 2 1 11057 Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); more than four lesions 9 4 . 7 6 11100 Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise 1 34.31 11101 Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise 7 7.57 11200 Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions 1 3 0 . 5 5 11201 Removal of skin tags, multiple fibrocutaneous tags, any area; each additional ten lesions (List separately in 9 4.70 11300 Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.5 cm or less 1 1 3 . 8 0 11301 Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.6 to 1.0 cm 1 4 2 . 4 5 11302 Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 1.1 to 2.0 cm 1 7 8 . 7 4 11303 Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter over 2.0 cm 2 8 9 . 8 0 11305 Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 0.5 1 25.15 11306 Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 0.6 1 66.40 11307 Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 1.1 2 32.20 11308 Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 2 61.50 11310 Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; 1 41.10 11311 Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; 2 16.00 11312 Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; 2 52.00 11313 Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; 2 83.29 11400 Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms or legs; lesion diameter 0.5 1 51.78 11401 Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms or legs; lesion diameter 0.6 to 1 95.44 11402 Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms or legs; lesion diameter 1.1 to 3 04.20 11403 Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms or legs; lesion diameter 2.1 to 3 23.56 11404 Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms or legs; lesion diameter 3.1 to 4 35.46 11406 Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms or legs; lesion diameter over 5 97.16 11420 Excision, benign lesion, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; lesion 1 69.16 11421 Excision, benign lesion, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; lesion 2 16.78 11422 Excision, benign lesion, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; lesion 2 86.82 11423 Excision, benign lesion, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; lesion 3 92.07 11424 Excision, benign lesion, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; lesion 4 92.99 11426 Excision, benign lesion, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; lesion 6 63.24 11440 Excision, other benign lesion (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; 1 95.81 11441 Excision, other benign lesion (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; 2 62.16 11442 Excision, other benign lesion (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; 3 45.79 11443 Excision, other benign lesion (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; 4 90.50 11444 Excision, other benign lesion (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; 6 32.70 11446 Excision, other benign lesion (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; 7 91.10 11450 Excision of skin and subcutaneous tissue for hidradenitis, axillary; with simple or intermediate repair 1 , 2 8 3 . 4 0 11451 Excision of skin and subcutaneous tissue for hidradenitis, axillary; with complex repair 1 , 6 1 2 . 8 0 11462 Excision of skin and subcutaneous tissue for hidradenitis, inguinal; with simple or intermediate repair 1 , 2 1 8 . 6 0 11463 Excision of skin and subcutaneous tissue for hidradenitis, inguinal; with complex repair 1 , 3 9 0 . 5 0 11470 Excision of skin and subcutaneous tissue for hidradenitis, perianal, perineal, or umbilical; with simple or 1 ,282.38 11471 Excision of skin and subcutaneous tissue for hidradenitis, perianal, perineal, or umbilical; with complex 1 ,171.35 1 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 11600 Excision, malignant lesion, trunk, arms, or legs; lesion diameter 0.5 cm or less 2 3 4 . 5 7 11601 Excision, malignant lesion, trunk, arms, or legs; lesion diameter 0.6 to 1.0 cm 2 7 5 . 7 1 11602 Excision, malignant lesion, trunk, arms, or legs; lesion diameter 1.1 to 2.0 cm 3 4 4 . 9 9 11603 Excision, malignant lesion, trunk, arms, or legs; lesion diameter 2.1 to 3.0 cm 4 3 8 . 1 3 11604 Excision, malignant lesion, trunk, arms, or legs; lesion diameter 3.1 to 4.0 cm 5 8 2 . 4 3 11606 Excision, malignant lesion, trunk, arms, or legs; lesion diameter over 4.0 cm 7 8 0 . 7 4 11620 Excision, malignant lesion, scalp, neck, hands, feet, genitalia; lesion diameter 0.5 cm or less 3 0 5 . 9 3 11621 Excision, malignant lesion, scalp, neck, hands, feet, genitalia; lesion diameter 0.6 to 1.0 cm 3 8 9 . 8 6 11622 Excision, malignant lesion, scalp, neck, hands, feet, genitalia; lesion diameter 1.1 to 2.0 cm 4 6 8 . 6 8 11623 Excision, malignant lesion, scalp, neck, hands, feet, genitalia; lesion diameter 2.1 to 3.0 cm 5 6 8 . 3 1 11624 Excision, malignant lesion, scalp, neck, hands, feet, genitalia; lesion diameter 3.1 to 4.0 cm 8 2 0 . 8 0 11626 Excision, malignant lesion, scalp, neck, hands, feet, genitalia; lesion diameter over 4.0 cm 9 9 0 . 0 0 11640 Excision, malignant lesion, face, ears, eyelids, nose, lips; lesion diameter 0.5 cm or less 3 5 6 . 8 9 11641 Excision, malignant lesion, face, ears, eyelids, nose, lips; lesion diameter 0.6 to 1.0 cm 4 5 7 . 4 3 11642 Excision, malignant lesion, face, ears, eyelids, nose, lips; lesion diameter 1.1 to 2.0 cm 5 8 4 . 3 4 11643 Excision, malignant lesion, face, ears, eyelids, nose, lips; lesion diameter 2.1 to 3.0 cm 8 5 0 . 5 0 11644 Excision, malignant lesion, face, ears, eyelids, nose, lips; lesion diameter 3.1 to 4.0 cm 1 , 0 3 0 . 5 0 11646 Excision, malignant lesion, face, ears, eyelids, nose, lips; lesion diameter over 4.0 cm 1 , 1 7 4 . 5 0 11719 Trimming of nondystrophic nails, any number 3 9 . 4 6 11720 Debridement of nail(s) by any method(s); one to five 8 7 . 3 0 11721 Debridement of nail(s) by any method(s); six or more 1 2 2 . 4 0 11730 Avulsion of nail plate, partial or complete, simple; single 1 0 9 . 0 4 11732 Avulsion of nail plate, partial or complete, simple; each additional nail plate (List separately in addition to 1 01.70 11740 Evacuation of subungual hematoma 1 1 7 . 0 0 11750 Excision of nail and nail matrix, partial or complete, (eg, ingrown or deformed nail) for permanent removal; 3 4 1 . 3 8 11752 Excision of nail and nail matrix, partial or complete, (eg, ingrown or deformed nail) for permanent removal; 7 48.80 11755 Biopsy of nail unit, any method (eg, plate, bed, matrix, hyponychium, proximal and lateral nail folds) 4 26.60 11760 Repair of nail bed 4 9 4 . 1 0 11762 Reconstruction of nail bed with graft 7 2 0 . 9 0 11765 Wedge excision of skin of nail fold (eg, for ingrown toenail) 2 2 6 . 3 9 11770 Excision of pilonidal cyst or sinus; simple 6 6 9 . 1 8 11771 Excision of pilonidal cyst or sinus; extensive 1 , 3 1 5 . 8 0 11772 Excision of pilonidal cyst or sinus; complicated 1 , 6 7 3 . 1 0 11900 Injection, intralesional; up to and including seven lesions 6 8 . 3 8 11901 Injection, intralesional; more than seven lesions 1 0 3 . 0 2 11920 Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including 7 41.60 11921 Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including 1 ,409.40 11922 Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including 9 27.00 11950 Subcutaneous injection of filling material (eg, collagen); 1 cc or less 3 4 8 . 3 0 11951 Subcutaneous injection of filling material (eg, collagen); 1.1 to 5.0 cc 5 4 9 . 9 0 11952 Subcutaneous injection of filling material (eg, collagen); 5.1 to 10.0 cc 8 9 9 . 1 0 11954 Subcutaneous injection of filling material (eg, collagen); over 10.0 cc 1 , 2 1 5 . 9 0 11960 Insertion of tissue expander(s) for other than breast, including subsequent expansion 3 , 0 0 0 . 6 0 11970 Replacement of tissue expander with permanent prosthesis 3 , 0 6 0 . 9 0 11971 Removal of tissue expander(s) without insertion of prosthesis 1 , 1 0 2 . 5 0 11976 Removal, implantable contraceptive capsules 3 1 8 . 6 0 11980 Subcutaneous hormone pellet implantation (implantation of estradiol and/or testosterone pellets beneath the 4 30.20 11981 Insj non-biodegradable drug delivery implant 1 62.00 11982 Removal non-biodegradable drug delivery implant 1 65.40 11983 Rmvl w/rinsj non-biodegradable drug dlvr implt 1 93.58 12001 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities 1 79.15 12002 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities 2 30.42 12004 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities 3 27.60 12005 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities 4 21.20 12006 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities 4 87.80 12007 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities 6 75.90 12011 Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or 2 22.77 12013 Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 2 88.43 12014 Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 5.1 cm to 3 63.06 12015 Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 7.6 cm to 4 77.90 12016 Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 12.6 cm to 6 29.10 12017 Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 20.1 cm to 7 79.40 12018 Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; over 30.0 1 ,124.10 12020 Treatment of superficial wound dehiscence; simple closure 3 8 8 . 7 9 12021 Treatment of superficial wound dehiscence; with packing 3 6 9 . 0 0 12031 Layer closure of wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.5 cm or less 2 5 5 . 6 0 12032 Layer closure of wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.6 cm to 7.5 3 43.80 12034 Layer closure of wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 7.6 cm to 4 23.00 12035 Layer closure of wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 12.6 cm to 5 55.30 12036 Layer closure of wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 20.1 cm to 7 19.10 2 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 12037 Layer closure of wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); over 30.0 cm 9 2 2 . 5 0 12041 Layer closure of wounds of neck, hands, feet and/or external genitalia; 2.5 cm or less 2 9 1 . 6 0 12042 Layer closure of wounds of neck, hands, feet and/or external genitalia; 2.6 cm to 7.5 cm 3 5 2 . 0 9 12044 Layer closure of wounds of neck, hands, feet and/or external genitalia; 7.6 cm to 12.5 cm 4 6 8 . 9 0 12045 Layer closure of wounds of neck, hands, feet and/or external genitalia; 12.6 cm to 20.0 cm 5 7 9 . 6 0 12046 Layer closure of wounds of neck, hands, feet and/or external genitalia; 20.1 cm to 30.0 cm 8 1 2 . 7 0 12047 Layer closure of wounds of neck, hands, feet and/or external genitalia; over 30.0 cm 9 6 3 . 0 0 12051 Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less 3 5 0 . 1 0 12052 Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm 4 7 0 . 7 0 12053 Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 5.1 cm to 7.5 cm 5 4 9 . 0 0 12054 Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 7.6 cm to 12.5 cm 7 0 4 . 7 0 12055 Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 12.6 cm to 20.0 cm 9 4 2 . 3 0 12056 Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 20.1 cm to 30.0 cm 1 , 1 4 1 . 2 0 12057 Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membranes; over 30.0 cm 1 , 3 3 8 . 3 0 13100 Repair, complex, trunk; 1.1 cm to 2.5 cm 3 9 6 . 9 0 13101 Repair, complex, trunk; 2.6 cm to 7.5 cm 5 9 9 . 4 0 13102 Repair, complex, trunk; each additional 5 cm or less (List separately in addition to code for primary 2 64.60 13120 Repair, complex, scalp, arms, and/or legs; 1.1 cm to 2.5 cm 5 0 6 . 7 0 13121 Repair, complex, scalp, arms, and/or legs; 2.6 cm to 7.5 cm 7 8 6 . 6 0 13122 Repair, complex, scalp, arms, and/or legs; each additional 5 cm or less (List separately in addition to code 3 04.20 13131 Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 1.1 cm to 2.5 5 38.80 13132 Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 2.6 cm to 7.5 9 91.80 13133 Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; each additional 2 77.20 13150 Repair, complex, eyelids, nose, ears and/or lips; 1.0 cm or less 5 9 0 . 4 0 13151 Repair, complex, eyelids, nose, ears and/or lips; 1.1 cm to 2.5 cm 7 2 0 . 9 0 13152 Repair, complex, eyelids, nose, ears and/or lips; 2.6 cm to 7.5 cm 1 , 2 6 9 . 0 0 13153 Repair, complex, eyelids, nose, ears and/or lips; each additional 5 cm or less (List separately in addition to 4 26.60 13160 Secondary closure of surgical wound or dehiscence, extensive or complicated 1 , 0 5 9 . 6 9 14000 Adjacent tissue transfer or rearrangement, trunk; defect 10 sq cm or less 1 , 0 8 8 . 1 0 14001 Adjacent tissue transfer or rearrangement, trunk; defect 10.1 sq cm to 30.0 sq cm 1 , 6 1 2 . 8 0 14020 Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10 sq cm or less 1 , 4 3 4 . 6 0 14021 Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10.1 sq cm to 30.0 sq cm 1 , 8 2 9 . 7 0 14040 Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands 1 ,531.29 14041 Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands 2 ,181.60 14060 Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10 sq cm or less 1 , 9 9 5 . 3 0 14061 Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10.1 sq cm to 30.0 sq cm 3 , 1 6 9 . 8 0 14301 Att/r any area defect 30.1-60sqcm 2 ,113.30 14302 Att/r any area defect ea addl 30sqcm or part 4 80.88 14350 Filleted finger or toe flap, including preparation of recipient site 1 , 5 8 3 . 1 0 15002 Prep site trunk/arm/leg 1st 100 sq cm/1pct 7 00.87 15003 Prep site t/a/l addl 100 sq cm/1pct 1 65.33 15004 Prep site f/s/n/h/f/g/m/d gt 1st 100 sq cm/1pct 8 32.59 15005 Prep site f/s/n/h/f/g/m/d gt addl 100 sq cm/1pct 2 65.38 15040 Harvest skin tissue cltr skin agrft 100 cm/< 5 63.25 15050 Pinch graft, single or multiple, to cover small ulcer, tip of digit, or other minimal open area (except on face), 8 55.00 15100 Split graft, trunk, arms, legs; first 100 sq cm or less, or one percent of body area of infants and children 1 ,463.40 15101 Split graft, trunk, arms, legs; each additional 100 sq cm, or each additional one percent of body area of 8 89.20 15110 Epidrm agrft t/a/l 1st 100 cm/</1% bdy inft/chld 1 ,887.78 15111 Epidrm agrft t/a/l ea 100 cm/ea 1% bdy inft/chld 2 94.39 15115 Epidermal agrft f/s/n/h/f/g/m/d gt 1st 100 cm 1 ,815.60 15116 Epidermal agrft f/s/n/h/f/g/m/d gt ea 100 cm/ea 4 02.77 15120 Split graft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 1 ,939.50 15121 Split graft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; each 1 ,542.60 15130 Dermal autograft trunk/arm/leg 1st 100 cm 1 ,469.33 15131 Dermal autograft trunk/arm/leg ea 100 cm/ea 2 46.06 15135 Dermal autograft f/s/n/h/f/g/m/d gt 1st 100 1 ,861.86 15136 Dermal agrft f/s/n/h/f/g/m/d gt ea 100 cm/ea 2 27.31 15150 Cltr epidermal autograft t/a/l 1st 25 cm/< 1 ,481.15 15151 Cltr epidermal agrft t/a/l addl 1 cm-75 cm 2 97.75 15152 Cltr epidrm agrft t/a/l ea 100 cm/ea 1 % bdy 3 91.91 15155 Cltr epidrm agrft f/s/n/h/f/g/m/d gt 1st 25cm/< 1 ,472.04 15156 Cltr epidrm agrft f/s/n/h/f/g/m/d gt addl 1-75cm 4 24.98 15157 Cltr epidrm agrft f/s/n/h/f/g/m/d gt ea 100 ea 4 81.51 15200 Full thickness graft, free, including direct closure of donor site, trunk; 20 sq cm or less 1 , 2 9 9 . 6 0 15201 Full thickness graft, free, including direct closure of donor site, trunk; each additional 20 sq cm (List 7 62.30 15220 Full thickness graft, free, including direct closure of donor site, scalp, arms, and/or legs; 20 sq cm or less 1 , 4 3 9 . 1 0 15221 Full thickness graft, free, including direct closure of donor site, scalp, arms, and/or legs; each additional 20 1 ,093.50 15240 Full thickness graft, free, including direct closure of donor site, forehead, cheeks, chin, mouth, neck, axillae, 1 ,896.30 15241 Full thickness graft, free, including direct closure of donor site, forehead, cheeks, chin, mouth, neck, axillae, 9 77.40 15260 Full thickness graft, free, including direct closure of donor site, nose, ears, eyelids, and/or lips; 20 sq cm or 2 ,362.50 3 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 15261 Full thickness graft, free, including direct closure of donor site, nose, ears, eyelids, and/or lips; each 1 ,210.50 15271 Skin sub graft trnk/arm/leg 3 33.18 15272 Skin sub graft t/a/l add-on 6 1.22 15273 Skin sub grft t/arm/lg child 6 66.04 15274 Skn sub grft t/a/l child add 1 48.68 15275 Skin sub graft face/nk/hf/g 3 75.67 15276 Skin sub graft f/n/hf/g addl 8 2.06 15277 Skn sub grft f/n/hf/g child 7 22.08 15278 Skn sub grft f/n/hf/g ch add 1 78.84 15570 Formation of direct or tubed pedicle, with or without transfer; trunk 2 , 6 0 1 . 0 0 15572 Formation of direct or tubed pedicle, with or without transfer; scalp, arms, or legs 2 , 7 0 4 . 5 0 15574 Formation of direct or tubed pedicle, with or without transfer; forehead, cheeks, chin, mouth, neck, axillae, 3 ,028.50 15576 Formation of direct or tubed pedicle, with or without transfer; eyelids, nose, ears, lips, or intraoral 2 , 9 8 7 . 1 0 15600 Delay of flap or sectioning of flap (division and inset); at trunk 1 , 0 5 5 . 7 0 15610 Delay of flap or sectioning of flap (division and inset); at scalp, arms, or legs 1 , 3 1 8 . 5 0 15620 Delay of flap or sectioning of flap (division and inset); at forehead, cheeks, chin, neck, axillae, genitalia, 1 ,596.60 15630 Delay of flap or sectioning of flap (division and inset); at eyelids, nose, ears, or lips 1 , 6 3 7 . 1 0 15650 Transfer, intermediate, of any pedicle flap (eg, abdomen to wrist, Walking tube), any location 1 , 5 3 4 . 5 0 15731 Forehead flap w/ preservation vascular pedicle 2 ,785.60 15732 Muscle, myocutaneous, or fasciocutaneous flap; head and neck (eg, temporalis, masseter, 4 ,818.60 15734 Muscle, myocutaneous, or fasciocutaneous flap; trunk 4 , 8 7 8 . 9 0 15736 Muscle, myocutaneous, or fasciocutaneous flap; upper extremity 5 , 1 5 0 . 7 0 15738 Muscle, myocutaneous, or fasciocutaneous flap; lower extremity 5 , 2 7 9 . 4 0 15740 Flap; island pedicle 2 , 6 8 2 . 0 0 15750 Flap; neurovascular pedicle 2 , 9 7 3 . 6 0 15756 Free muscle flap with or without skin with microvascular anastomosis 8 , 0 0 5 .5 0 15757 Free skin flap with microvascular anastomosis 8 , 0 0 5 . 5 0 15758 Free fascial flap with microvascular anastomosis 7 , 9 9 0 . 2 0 15760 Graft; composite (eg, full thickness of external ear or nasal ala), including primary closure, donor area 2 , 4 8 5 . 8 0 15770 Graft; derma-fat-fascia 1 , 9 6 2 .0 0 15775 Punch graft for hair transplant; 1 to 15 punch grafts 2 8 0 . 8 0 15776 Punch graft for hair transplant; more than 15 punch grafts 4 7 7 . 0 0 15777 Acellular derm matrix implt 4 86.36 15780 Dermabrasion; total face (eg, for acne scarring, fine wrinkling, rhytids, general keratosis) 2 , 7 6 3 . 9 0 15781 Dermabrasion; segmental, face 1 , 1 4 8 . 4 0 15782 Dermabrasion; regional, other than face 7 7 2 . 2 0 15783 Dermabrasion; superficial, any site, (eg, tattoo removal) 7 7 2 . 2 0 15786 Abrasion; single lesion (eg, keratosis, scar) 4 1 2 . 2 0 15787 Abrasion; each additional four lesions or less (List separately in addition to code for primary procedure) 2 0 7 . 9 0 15788 Chemical peel, facial; epidermal 1 , 5 4 5 . 3 0 15789 Chemical peel, facial; dermal 1 , 9 0 1 . 7 0 15792 Chemical peel, nonfacial; epidermal 5 4 4 . 5 0 15793 Chemical peel, nonfacial; dermal 8 4 9 . 6 0 15819 Cervicoplasty 2 , 2 4 6 . 4 0 15820 Blepharoplasty, lower eyelid; 2 , 2 5 3 . 6 0 15821 Blepharoplasty, lower eyelid; with extensive herniated fat pad 2 , 1 1 1 . 4 0 15822 Blepharoplasty, upper eyelid; 2 , 5 4 2 . 5 0 15823 Blepharoplasty, upper eyelid; with excessive skin weighting down lid 1 , 8 1 5 . 3 0 15824 Rhytidectomy; forehead 2 , 4 7 1 . 4 0 15825 Rhytidectomy; neck with platysmal tightening (platysmal flap, P-flap) 3 , 5 1 1 . 8 0 15826 Rhytidectomy; glabellar frown lines 2 , 0 1 0 . 6 0 15828 Rhytidectomy; cheek, chin, and neck 6 , 5 9 9 . 7 0 15829 Rhytidectomy; superficial musculoaponeurotic system (SMAS) flap 4 , 6 3 0 . 5 0 15830 Excision skin abd infraumbilical panniculectomy 1 ,777.49 15832 Excision, excessive skin and subcutaneous tissue (including lipectomy); thigh 4 , 5 8 9 . 1 0 15833 Excision, excessive skin and subcutaneous tissue (including lipectomy); leg 4 , 3 4 9 . 7 0 15834 Excision, excessive skin and subcutaneous tissue (including lipectomy); hip 4 , 2 9 2 . 1 0 15835 Excision, excessive skin and subcutaneous tissue (including lipectomy); buttock 4 , 6 7 4 . 6 0 15836 Excision, excessive skin and subcutaneous tissue (including lipectomy); arm 2 , 9 2 0 . 5 0 15837 Excision, excessive skin and subcutaneous tissue (including lipectomy); forearm or hand 2 , 1 5 5 . 5 0 15838 Excision, excessive skin and subcutaneous tissue (including lipectomy); submental fat pad 2 , 3 7 9 . 6 0 15839 Excision, excessive skin and subcutaneous tissue (including lipectomy); other area 2 , 4 6 2 . 4 0 15840 Graft for facial nerve paralysis; free fascia graft (including obtaining fascia) 3 , 7 4 4 . 0 0 15841 Graft for facial nerve paralysis; free muscle graft (including obtaining graft) 4 , 2 7 5 . 0 0 15842 Graft for facial nerve paralysis; free muscle flap by microsurgical technique 6 , 1 9 0 . 2 0 15845 Graft for facial nerve paralysis; regional muscle transfer 3 , 7 2 1 . 5 0 15850 Removal of sutures under anesthesia (other than local), same surgeon 2 1 5 . 0 3 15851 Removal of sutures under anesthesia (other than local), other surgeon 2 5 9 . 4 9 15852 Dressing change (for other than burns) under anesthesia (other than local) 3 7 3 . 5 0 15860 Intravenous injection of agent (eg, fluorescein) to test blood flow in flap or graft 3 7 0 . 8 0 4 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 15920 Excision, coccygeal pressure ulcer, with coccygectomy; with primary suture 1 , 4 1 9 . 3 0 15922 Excision, coccygeal pressure ulcer, with coccygectomy; with flap closure 1 , 9 4 6 . 7 0 15931 Excision, sacral pressure ulcer, with primary suture; 1 , 5 4 0 . 8 0 15933 Excision, sacral pressure ulcer, with primary suture; with ostectomy 2 , 3 8 8 . 6 0 15934 Excision, sacral pressure ulcer, with skin flap closure; 2 , 9 3 7 . 6 0 15935 Excision, sacral pressure ulcer, with skin flap closure; with ostectomy 3 , 4 4 5 . 2 0 15936 Excision, sacral pressure ulcer, in preparation for muscle or myocutaneous flap or skin graft closure; 3 , 2 3 6 . 4 0 15937 Excision, sacral pressure ulcer, in preparation for muscle or myocutaneous flap or skin graft closure; with 4 ,108.50 15940 Excision, ischial pressure ulcer, with primary suture; 1 , 6 4 7 . 9 0 15941 Excision, ischial pressure ulcer, with primary suture; with ostectomy (ischiectomy) 2 , 3 1 7 . 5 0 15944 Excision, ischial pressure ulcer, with skin flap closure; 2 , 5 7 4 . 9 0 15945 Excision, ischial pressure ulcer, with skin flap closure; with ostectomy 3 , 0 3 8 . 4 0 15946 Excision, ischial pressure ulcer, with ostectomy, in preparation for muscle or myocutaneous flap or skin graft 3 ,663.00 15950 Excision, trochanteric pressure ulcer, with primary suture; 1 , 4 9 4 . 0 0 15951 Excision, trochanteric pressure ulcer, with primary suture; with ostectomy 2 , 2 1 4 . 9 0 15952 Excision, trochanteric pressure ulcer, with skin flap closure; 2 , 2 7 6 . 1 0 15953 Excision, trochanteric pressure ulcer, with skin flap closure; with ostectomy 2 , 5 2 3 . 6 0 15956 Excision, trochanteric pressure ulcer, in preparation for muscle or myocutaneous flap or skin graft closure; 3 , 9 2 4 . 9 0 15958 Excision, trochanteric pressure ulcer, in preparation for muscle or myocutaneous flap or skin graft closure; 4 ,222.80 16000 Initial treatment, first degree burn, when no more than local treatment is required 1 0 4 . 4 0 16020 Dressings and/or debridement, initial or subsequent; without anesthesia, office or hospital, small 1 1 5 . 8 9 16025 Dressings and/or debridement, initial or subsequent; without anesthesia, medium (eg, whole face or whole 2 17.86 16030 Dressings and/or debridement, initial or subsequent; without anesthesia, large (eg, more than one 3 63.34 16035 Escharotomy; initial incision 8 7 4 . 8 0 16036 Escharotomy; each additional incision (List separately in addition to code for primary procedure) 2 9 1 . 6 0 17000 Destruction by any method, including laser, with or without surgical curettement, all benign or premalignant 9 7.34 17003 Destruction by any method, including laser, with or without surgical curettement, all benign or premalignant 3 7.26 17004 Destruction by any method, including laser, with or without surgical curettement, all benign or premalignant 5 40.00 17106 Destruction of cutaneous vascular proliferative lesions (eg, laser technique); less than 10 sq cm 6 2 1 . 0 0 17107 Destruction of cutaneous vascular proliferative lesions (eg, laser technique); 10.0 - 50.0 sq cm 1 , 3 2 6 . 6 0 17108 Destruction of cutaneous vascular proliferative lesions (eg, laser technique); over 50.0 sq cm 2 , 0 0 8 . 8 0 17110 Destruction by any method of flat warts, molluscum contagiosum, or milia; up to 14 lesions 1 1 0 . 0 3 17111 Destruction by any method of flat warts, molluscum contagiosum, or milia; 15 or more lesions 1 7 8 . 2 0 17250 Chemical cauterization of granulation tissue (proud flesh, sinus or fistula) 1 5 2 . 1 0 17260 Destruction, malignant lesion, any method, trunk, arms or legs; lesion diameter 0.5 cm or less 2 2 0 . 5 0 17261 Destruction, malignant lesion, any method, trunk, arms or legs; lesion diameter 0.6 to 1.0 cm 2 1 1 . 9 8 17262 Destruction, malignant lesion, any method, trunk, arms or legs; lesion diameter 1.1 to 2.0 cm 2 9 8 . 8 0 17263 Destruction, malignant lesion, any method, trunk, arms or legs; lesion diameter 2.1 to 3.0 cm 3 3 3 . 9 0 17264 Destruction, malignant lesion, any method, trunk, arms or legs; lesion diameter 3.1 to 4.0 cm 3 8 5 . 2 0 17266 Destruction, malignant lesion, any method, trunk, arms or legs; lesion diameter over 4.0 cm 5 6 5 . 2 0 17270 Destruction, malignant lesion, any method, scalp, neck, hands, feet, genitalia; lesion diameter 0.5 cm or 2 34.00 17271 Destruction, malignant lesion, any method, scalp, neck, hands, feet, genitalia; lesion diameter 0.6 to 1.0 cm 2 9 8 . 8 0 17272 Destruction, malignant lesion, any method, scalp, neck, hands, feet, genitalia; lesion diameter 1.1 to 2.0 cm 3 7 1 . 7 0 17273 Destruction, malignant lesion, any method, scalp, neck, hands, feet, genitalia; lesion diameter 2.1 to 3.0 cm 3 4 4 . 9 7 17274 Destruction, malignant lesion, any method, scalp, neck, hands, feet, genitalia; lesion diameter 3.1 to 4.0 cm 5 6 8 . 8 0 17276 Destruction, malignant lesion, any method, scalp, neck, hands, feet, genitalia; lesion diameter over 4.0 cm 7 0 4 . 7 0 17280 Destruction, malignant lesion, any method, face, ears, eyelids, nose, lips, mucous membrane; lesion 2 43.00 17281 Destruction, malignant lesion, any method, face, ears, eyelids, nose, lips, mucous membrane; lesion 2 79.83 17282 Destruction, malignant lesion, any method, face, ears, eyelids, nose, lips, mucous membrane; lesion 4 42.80 17283 Destruction, malignant lesion, any method, face, ears, eyelids, nose, lips, mucous membrane; lesion 5 21.10 17284 Destruction, malignant lesion, any method, face, ears, eyelids, nose, lips, mucous membrane; lesion 6 77.70 17286 Destruction, malignant lesion, any method, face, ears, eyelids, nose, lips, mucous membrane; lesion 9 32.40 17311 Mohs micrographic h/n/h/f/g 1st stage 5 blocks 1 ,151.03 17312 Mohs micrographic h/n/h/f/g each addl stage 6 98.32 17313 Mohs trunk/arm/leg 1st stage 5 blocks 1 ,056.66 17314 Mohs trunk/arm/leg ea stage after 1st stage 6 51.22 17315 Mohs trunk/arm/leg ea addl block any stage 1 39.63 17340 Cryotherapy (CO2 slush, liquid N2) for acne 7 4 . 8 3 17360 Chemical exfoliation for acne (eg, acne paste, acid) 1 4 2 . 2 0 17380 Electrolysis epilation, each 1/2 hour 1 3 4 . 1 0 19000 Puncture aspiration of cyst of breast; 1 5 8 . 2 1 19001 Puncture aspiration of cyst of breast; each additional cyst (List separately in addition to code for primary 8 3.70 19020 Mastotomy with exploration or drainage of abscess, deep 5 9 2 . 2 0 19030 Injection procedure only for mammary ductogram or galactogram 1 5 4 . 8 0 19100 Biopsy of breast; percutaneous, needle core, not using imaging guidance (separate procedure) 2 5 7 . 4 0 19101 Biopsy of breast; open, incisional 7 8 1 . 2 0 19102 Biopsy of breast; percutaneous, needle core, using imaging guidance 3 8 6 . 3 4 19103 Biopsy of breast; percutaneous, automated vacuum assisted or rotating biopsy device, using imaging 9 10.80 19105 Abltj cryosurgical w/ us gid ea fibroadenoma 3 ,171.04 19110 Nipple exploration, with or without excision of a solitary lactiferous duct or a papilloma lactiferous duct 1 , 2 3 5 . 7 0 5 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 19112 Excision of lactiferous duct fistula 1 , 0 0 4 . 4 0 19120 Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, 1 ,105.37 19125 Excision of breast lesion identified by preoperative placement of radiological marker, open; single lesion 1 , 2 8 9 . 7 0 19126 Excision of breast lesion identified by preoperative placement of radiological marker, open; each additional 8 32.50 19260 Excision of chest wall tumor including ribs 3 , 1 4 6 . 4 0 19271 Excision of chest wall tumor involving ribs, with plastic reconstruction; without mediastinal 4 ,221.90 19272 Excision of chest wall tumor involving ribs, with plastic reconstruction; with mediastinal lymphadenectomy 5 , 6 2 2 . 3 0 19290 Preoperative placement of needle localization wire, breast; 2 7 0 . 0 0 19291 Preoperative placement of needle localization wire, breast; each additional lesion (List separately in addition 1 43.10 19295 Image guided placement, metallic localization clip, percutaneous, during breast biopsy (List separately in 1 40.40 19296 Plmt expandable cath brst following prtl mast 9 ,940.72 19297 Plmt expandable cath brst concurrent prtl mast 2 18.27 19298 Plmt radthx brachytx brst following prtl mast 3 ,605.44 19300 Mastectomy gynecomastia 1 ,131.18 19301 Mastectomy partial 9 33.84 19302 Mastectomy partial w/axillary lymphadenectomy 1 ,977.47 19303 Mastectomy simple complete 1 ,597.79 19304 Mastectomy subcutaneous 1 ,169.33 19305 Mast rad w/pectoral muscles axillary lymph nodes 2 ,032.87 19306 Mast rad w/pectoral musc ax int mam lymph nodes 2 ,299.98 19307 Mast modf rad w/ax lymph nod w/wo pect/alis min 2 ,325.26 19316 Mastopexy 2 , 8 9 1 . 7 0 19318 Reduction mammaplasty 4 , 1 3 7 . 8 0 19324 Mammaplasty, augmentation; without prosthetic implant 1 , 7 6 1 . 3 0 19325 Mammaplasty, augmentation; with prosthetic implant 2 , 7 1 1 . 7 0 19328 Removal of intact mammary implant 1 , 8 4 8 . 6 0 19330 Removal of mammary implant material 3 , 0 3 0 . 3 0 19340 Immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction 3 , 0 3 1 . 2 0 19342 Delayed insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction 2 , 7 8 6 . 4 0 19350 Nipple/areola reconstruction 2 , 3 1 7 . 5 0 19355 Correction of inverted nipples 1 , 6 2 2 . 7 0 19357 Breast reconstruction, immediate or delayed, with tissue expander, including subsequent expansion 4 , 0 6 8 . 9 0 19361 Breast reconstruction with latissimus dorsi flap, with or without prosthetic implant 5 , 4 0 8 . 1 0 19364 Breast reconstruction with free flap 5 , 6 7 5 . 4 0 19366 Breast reconstruction with other technique 5 , 7 7 8 . 9 0 19367 Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), single pedicle, 8 ,446.50 19368 Breast reconstruction tram 1 pedcl mvasc anast 6 ,352.72 19369 Breast reconstruction tram flap double pedicle 5 ,552.58 19370 Open periprosthetic capsulotomy, breast 2 , 2 6 6 . 2 0 19371 Periprosthetic capsulectomy, breast 2 , 5 2 3 . 6 0 19380 Revision of reconstructed breast 2 , 8 8 4 . 5 0 19396 Preparation of moulage for custom breast implant 2 1 1 . 5 0 20005 Incision of soft tissue abscess (eg, secondary to osteomyelitis); deep or complicated 6 6 4 . 6 3 20100 Exploration of penetrating wound (separate procedure); neck 1 , 6 1 0 . 1 0 20101 Exploration of penetrating wound (separate procedure); chest 6 7 5 . 0 0 20102 Exploration of penetrating wound (separate procedure); abdomen/flank/back 7 9 8 . 3 0 20103 Exploration of penetrating wound (separate procedure); extremity 1 , 1 3 4 . 0 0 20150 Excision of epiphyseal bar, with or without autogenous soft tissue graft obtained through same fascial 2 ,912.40 20200 Biopsy, muscle; superficial 4 1 2 . 2 0 20205 Biopsy, muscle; deep 6 1 7 . 4 0 20206 Biopsy, muscle, percutaneous needle 2 7 2 . 7 0 20220 Biopsy, bone, trocar, or needle; superficial (eg, ilium, sternum, spinous process, ribs) 3 6 0 . 9 0 20225 Biopsy, bone, trocar, or needle; deep (vertebral body, femur) 8 1 4 . 5 0 20240 Biopsy, bone, excisional; superficial (eg, ilium, sternum, spinous process, ribs, trochanter of femur) 6 5 4 . 3 0 20245 Biopsy, bone, excisional; deep (eg, humerus, ischium, femur) 1 , 0 2 8 . 7 0 20250 Biopsy, vertebral body, open; thoracic 3 , 1 4 1 . 0 0 20251 Biopsy, vertebral body, open; lumbar or cervical 2 , 5 8 9 . 3 0 20500 Injection of sinus tract; therapeutic (separate procedure) 1 1 4 . 3 0 20501 Injection of sinus tract; diagnostic (sinogram) 1 4 7 . 6 0 20520 Removal of foreign body in muscle or tendon sheath; simple 3 0 7 . 4 6 20525 Removal of foreign body in muscle or tendon sheath; deep or complicated 7 2 0 . 9 0 20526 Injection therapeutic carpal tunnel 1 35.84 20527 Inj dupuytren cord w/enzyme 1 84.62 20550 Injection, tendon sheath, ligament, trigger points or ganglion cyst 1 0 8 . 1 8 20551 Injection single tendon origin/insertion 1 04.87 20552 Injection single/mlt trigger point 1/2 muscles 1 03.78 20553 Injection single/mlt trigger point 3/> muscles 1 21.48 20555 Placement needles muscle subsequent radioelement 5 82.66 20600 Arthrocentesis, aspiration and/or injection; small joint, bursa or ganglion cyst (eg, fingers, toes) 9 4 . 9 6 20605 Arthrocentesis, aspiration and/or injection; intermediate joint, bursa or ganglion cyst (eg, 1 07.28 6 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 20610 Arthrocentesis, aspiration and/or injection; major joint or bursa (eg, shoulder, hip, knee joint, subacromial 1 35.03 20612 Aspiration&/injection ganglion cyst any location 1 05.01 20615 Aspiration and injection for treatment of bone cyst 5 2 7 . 4 0 20650 Insertion of wire or pin with application of skeletal traction, including removal (separate procedure) 4 6 8 . 9 0 20660 Application of cranial tongs, caliper, or stereotactic frame, including removal (separate procedure) 8 5 3 . 2 0 20661 Application of halo, including removal; cranial 1 , 3 2 6 . 6 0 20662 Application of halo, including removal; pelvic 9 0 2 . 7 0 20663 Application of halo, including removal; femoral 7 6 5 . 0 0 20664 Application of halo, including removal, cranial, 6 or more pins placed, for thin skull osteology (eg, pediatric 1 ,032.30 20665 Removal of tongs or halo applied by another physician 2 3 4 . 9 0 20670 Removal of implant; superficial, (eg, buried wire, pin or rod) (separate procedure) 4 6 3 . 5 0 20680 Removal of implant; deep (eg, buried wire, pin, screw, metal band, nail, rod or plate) 8 5 7 . 9 0 20690 Application of a uniplane (pins or wires in one plane), unilateral, external fixation system 1 , 1 3 8 . 5 0 20692 Application of a multiplane (pins or wires in more than one plane), unilateral, external fixation system (eg, 1 ,752.30 20693 Adjustment or revision of external fixation system requiring anesthesia (eg, new pin(s) or wire(s) and/or new 9 08.10 20694 Removal, under anesthesia, of external fixation system 8 2 4 . 4 0 20696 Xtrnl fixj w/stereotactic adjustment 1st&subq 1 ,752.70 20697 Xtrnl fixj w/strtctc adjustment exchange strut 2 ,193.99 20802 Replantation, arm (includes surgical neck of humerus through elbow joint), complete amputation 9 , 7 2 0 . 9 0 20805 Replantation, forearm (includes radius and ulna to radial carpal joint), complete amputation 1 0 , 0 8 5 . 4 0 20808 Replantation, hand (includes hand through metacarpophalangeal joints), complete amputation 1 1 , 0 4 0 . 3 0 20816 Replantation, digit, excluding thumb (includes metacarpophalangeal joint to insertion of flexor sublimis 5 ,793.30 20822 Replantation, digit, excluding thumb (includes distal tip to sublimis tendon insertion), complete amputation 5 , 7 9 4 . 2 0 20824 Replantation, thumb (includes carpometacarpal joint to MP joint), complete amputation 6 , 5 7 1 . 8 0 20827 Replantation, thumb (includes distal tip to MP joint), complete amputation 5 , 0 4 7 . 2 0 20838 Replantation, foot, complete amputation 9 , 8 8 8 . 3 0 20900 Bone graft, any donor area; minor or small (eg, dowel or button) 9 4 7 . 7 0 20902 Bone graft, any donor area; major or large 1 , 5 8 7 . 6 0 20910 Cartilage graft; costochondral 1 , 4 9 1 . 3 0 20912 Cartilage graft; nasal septum 1 , 4 6 7 . 9 0 20920 Fascia lata graft; by stripper 8 8 5 . 6 0 20922 Fascia lata graft; by incision and area exposure, complex or sheet 1 , 2 4 1 . 1 0 20924 Tendon graft, from a distance (eg, palmaris, toe extensor, plantaris) 1 , 3 6 0 . 8 0 20926 Tissue grafts, other (eg, paratenon, fat, dermis) 1 , 0 1 4 . 3 0 20930 Allograft for spine surgery only; morselized 9 7 8 . 3 0 20931 Allograft for spine surgery only; structural 6 1 8 . 3 0 20936 Autograft for spine surgery only (includes harvesting the graft); local (eg, ribs, spinous process, or laminar 1 ,545.30 20937 Autograft for spine surgery only (includes harvesting the graft); morselized (through separate skin or fascial 1 ,235.70 20938 Autograft for spine surgery only (includes harvesting the graft); structural, bicortical or tricortical (through 1 ,506.60 20950 Monitoring of interstitial fluid pressure (includes insertion of device, eg, wick catheter technique, needle 2 93.40 20955 Bone graft with microvascular anastomosis; fibula 1 0 , 7 9 1 . 9 0 20956 Bone graft with microvascular anastomosis; iliac crest 8 , 6 5 5 . 3 0 20957 Bone graft with microvascular anastomosis; metatarsal 8 , 9 6 7 . 6 0 20962 Bone graft with microvascular anastomosis; other than fibula, iliac crest, or metatarsal 8 , 1 6 8 . 4 0 20969 Free osteocutaneous flap with microvascular anastomosis; other than iliac crest, metatarsal, or great toe 7 , 7 5 0 . 8 0 20970 Free osteocutaneous flap with microvascular anastomosis; iliac crest 9 , 9 0 7 . 2 0 20972 Free osteocutaneous flap with microvascular anastomosis; metatarsal 8 , 7 4 5 . 3 0 20973 Free osteocutaneous flap with microvascular anastomosis; great toe with web space 8 , 7 4 5 . 3 0 20974 Electrical stimulation to aid bone healing; noninvasive (nonoperative) 9 1 5 . 3 0 20975 Electrical stimulation to aid bone healing; invasive (operative) 1 , 3 4 4 . 6 0 20979 Low intensity ultrasound stimulation to aid bone healing, noninvasive (nonoperative) 1 2 4 . 2 0 20982 Ablate bone tumor(s) perq 8 ,951.44 20985 Cptr-asst surgical navigation image-less 2 07.47 21010 Arthrotomy, temporomandibular joint 2 , 8 3 6 . 8 0 21011 Excision tumor soft tiss face/scalp subq < 2cm 4 41.95 21012 Excision tumor soft tiss face/scalp subq 2+cm 4 65.84 21013 Exc tumor soft tiss face&scalp subfascial < 2cm 7 67.09 21014 Exc tumor soft tiss face&scalp subfascial 2+cm 8 13.32 21015 Radical resection of tumor (eg, malignant neoplasm), soft tissue of face or scalp 1 , 7 7 3 . 9 0 21016 Rad resection tumor soft tiss face/scalp 2+cm 1 ,706.33 21025 Excision of bone (eg, for osteomyelitis or bone abscess); mandible 1 , 6 0 2 . 0 0 21026 Excision of bone (eg, for osteomyelitis or bone abscess); facial bone(s) 1 , 4 9 8 . 5 0 21029 Removal by contouring of benign tumor of facial bone (eg, fibrous dysplasia) 1 , 5 3 2 . 7 0 21030 Excision of benign tumor or cyst of facial bone other than mandible 2 , 1 9 3 . 3 0 21031 Excision of torus mandibularis 6 9 6 . 6 0 21032 Excision of maxillary torus palatinus 1 , 0 5 6 . 6 0 21034 Excision of malignant tumor of facial bone other than mandible 3 , 1 6 9 . 8 0 21040 Excision of benign cyst or tumor of mandible; simple 1 , 2 4 6 . 5 0 21044 Excision of malignant tumor of mandible; 2 , 8 5 1 . 2 0 21045 Excision of malignant tumor of mandible; radical resection 5 , 9 1 8 . 4 0 7 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 21046 Exc benign tumor/cyst mndbl intra-oral osteot 1 ,872.04 21047 Exc b9 tum/cst mndbl xtr-oral osteot&prtl mndblc 2 ,304.17 21048 Exc benign tumor/cyst maxl intra-oral osteot 1 ,918.12 21049 Exc b9 tum/cst maxl xtr-oral osteot&prtl maxlct 2 ,210.72 21050 Condylectomy, temporomandibular joint (separate procedure) 3 , 3 5 5 . 2 0 21060 Meniscectomy, partial or complete, temporomandibular joint (separate procedure) 3 , 3 3 0 . 0 0 21070 Coronoidectomy (separate procedure) 2 , 7 2 4 . 3 0 21073 Mnpj of tmj w/anesth 5 24.35 21076 Impression&preparation surg obturator prosthesis 1 ,781.92 21077 Impression & preparation orbital prosthesis 4 ,473.18 21079 Impression&preparation interim obturator prosth 2 ,974.29 21080 Impression&prepj definitive obturator prosthesis 3 ,342.10 21081 Impression&prepj mandibular resection prosthesis 3 ,048.99 21082 Impression&prepj palatal augmentation prosthesis 2 ,792.30 21083 Impression&preparation palatal lift prosthesis 2 ,579.92 21084 Impression&preparation speech aid prosthesis 3 ,019.99 21085 Impression and custom preparation; oral surgical splint 3 9 8 . 7 0 21086 Impression&preparation auricular prosthesis 3 ,303.10 21087 Impression&preparation nasal prosthesis 3 ,302.27 21100 Application of halo type appliance for maxillofacial fixation, includes removal (separate procedure) 5 6 6 . 1 0 21110 Application of interdental fixation device for conditions other than fracture or dislocation, includes removal 1 , 3 6 4 . 4 0 21116 Injection procedure for temporomandibular joint arthrography 1 7 8 . 2 0 21120 Genioplasty; augmentation (autograft, allograft, prosthetic material) 2 , 8 8 0 . 9 0 21121 Genioplasty; sliding osteotomy, single piece 2 , 5 7 4 . 9 0 21122 Genioplasty;

sliding osteotomies, two or more osteotomies (eg, wedge excision or bone wedge reversal for 2 ,385.00 21123 Genioplasty; sliding, augmentation with interpositional bone grafts (includes obtaining autografts) 2 , 4 9 0 . 3 0 21125 Augmentation, mandibular body or angle; prosthetic material 2 , 3 9 4 . 9 0 21127 Augmentation, mandibular body or angle; with bone graft, onlay or interpositional (includes obtaining 2 ,266.20 21137 Reduction forehead; contouring only 2 , 2 6 6 . 2 0 21138 Reduction forehead; contouring and application of prosthetic material or bone graft (includes obtaining 2 ,652.30 21139 Rdctj fhd cntrg&setback ant frontal sinus wall 3 ,278.60 21141 Reconstruction midface, LeFort I; single piece, segment movement in any direction (eg, for Long Face 4 ,120.20 21142 Reconstruction midface, LeFort I; two pieces, segment movement in any direction, without bone graft 4 , 3 2 6 . 3 0 21143 Reconstruction midface, LeFort I; three or more pieces, segment movement in any direction, without bone 4 ,428.90 21145 Rcnstj midface lefort i 1 piece w/bone grafts 4 ,496.20 21146 Reconstruction midface, LeFort I; two pieces, segment movement in any direction, requiring bone grafts 5 ,983.20 21147 Reconstruction midface, LeFort I; three or more pieces, segment movement in any direction, requiring bone 6 ,391.80 21150 Reconstruction midface, LeFort II; anterior intrusion (eg, Treacher-Collins Syndrome) 5 , 5 6 8 . 3 0 21151 Reconstruction midface, LeFort II; any direction, requiring bone grafts (includes obtaining autografts) 6 , 6 9 5 . 1 0 21154 Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining 6 ,677.10 21155 Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes obtaining 6 ,431.40 21159 Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (eg, mono bloc), 9 ,682.20 21160 Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (eg, mono bloc), 1 0,815.30 21172 Reconstruction superior-lateral orbital rim and lower forehead, advancement or alteration, with or without 8 ,767.80 21175 Reconstruction, bifrontal, superior-lateral orbital rims and lower forehead, advancement or alteration (eg, 9 ,409.50 21179 Reconstruction, entire or majority of forehead and/or supraorbital rims; with grafts (allograft or prosthetic 7 ,056.00 21180 Reconstruction, entire or majority of forehead and/or supraorbital rims; with autograft (includes obtaining 6 ,390.00 21181 Reconstruction by contouring of benign tumor of cranial bones (eg, fibrous dysplasia), extracranial 1 , 5 3 9 . 9 0 21182 Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following intra- and extracranial 6 ,723.90 21183 Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following intra- and extracranial 7 ,144.20 21184 Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following intra- and extracranial 7 ,754.40 21188 Reconstruction midface, osteotomies (other than LeFort type) and bone grafts (includes obtaining 4 ,563.00 21193 Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; without bone graft 4 , 5 8 6 . 4 0 21194 Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; with bone graft (includes 5 ,648.40 21195 Reconstruction of mandibular rami and/or body, sagittal split; without internal rigid fixation 4 , 8 9 1 . 5 0 21196 Reconstruction of mandibular rami and/or body, sagittal split; with internal rigid fixation 5 , 5 4 7 . 6 0 21198 Osteotomy, mandible, segmental; 3 , 8 0 4 . 3 0 21199 Osteotomy, mandible, segmental; with genioglossus advancement 3 , 8 7 9 . 0 0 21206 Osteotomy, maxilla, segmental (eg, Wassmund or Schuchard) 4 , 4 2 5 . 3 0 21208 Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant) 2 , 6 0 8 . 2 0 21209 Osteoplasty, facial bones; reduction 2 , 7 1 3 . 5 0 21210 Graft, bone; nasal, maxillary or malar areas (includes obtaining graft) 3 , 5 1 0 . 0 0 21215 Graft, bone; mandible (includes obtaining graft) 3 , 8 7 8 . 1 0 21230 Graft; rib cartilage, autogenous, to face, chin, nose or ear (includes obtaining graft) 4 , 3 0 5 . 6 0 21235 Graft; ear cartilage, autogenous, to nose or ear (includes obtaining graft) 2 , 5 4 7 . 9 0 21240 Arthroplasty, temporomandibular joint, with or without autograft (includes obtaining graft) 4 , 1 2 0 . 2 0 21242 Arthroplasty, temporomandibular joint, with allograft 3 , 9 3 3 . 0 0 21243 Arthroplasty, temporomandibular joint, with prosthetic joint replacement 5 , 0 4 9 . 9 0 21244 Reconstruction of mandible, extraoral, with transosteal bone plate (eg, mandibular staple bone plate) 4 , 2 0 4 . 8 0 21245 Reconstruction of mandible or maxilla, subperiosteal implant; partial 3 , 7 5 9 . 3 0 8 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 21246 Reconstruction of mandible or maxilla, subperiosteal implant; complete 5 , 7 8 1 . 6 0 21247 Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for 5 ,665.50 21248 Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); partial 3 , 9 8 5 . 2 0 21249 Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); complete 7 , 4 1 6 . 0 0 21255 Reconstruction of zygomatic arch and glenoid fossa with bone and cartilage (includes obtaining autografts) 5 , 6 6 5 . 5 0 21256 Reconstruction of orbit with osteotomies (extracranial) and with bone grafts (includes obtaining autografts) 5 ,800.50 21260 Periorbital osteotomies for orbital hypertelorism, with bone grafts; extracranial approach 6 , 6 8 7 . 0 0 21261 Periorbital osteotomies for orbital hypertelorism, with bone grafts; combined intra- and extracranial approach 8 , 1 9 1 . 8 0 21263 Periorbital osteotomies for orbital hypertelorism, with bone grafts; with forehead advancement 9 , 2 7 5 . 4 0 21267 Orbital repositioning, periorbital osteotomies, unilateral, with bone grafts; extracranial approach 6 , 2 4 6 . 9 0 21268 Orbital repositioning, periorbital osteotomies, unilateral, with bone grafts; combined intra- and extracranial 9 ,558.90 21270 Malar augmentation, prosthetic material 4 , 6 4 8 . 5 0 21275 Secondary revision of orbitocraniofacial reconstruction 6 , 3 8 6 . 4 0 21280 Medial canthopexy (separate procedure) 2 , 3 6 8 . 8 0 21282 Lateral canthopexy 1 , 9 5 7 . 5 0 21295 Reduction masseter muscle&bone extraoral 2 ,487.73 21296 Reduction masseter muscle&bone intraoral 2 ,095.08 21310 Closed treatment of nasal bone fracture without manipulation 3 9 6 . 9 0 21315 Closed treatment of nasal bone fracture; without stabilization 4 8 9 . 6 0 21320 Closed treatment of nasal bone fracture; with stabilization 8 2 8 . 9 0 21325 Open treatment of nasal fracture; uncomplicated 1 , 7 0 8 . 2 0 21330 Open treatment of nasal fracture; complicated, with internal and/or external skeletal fixation 2 , 5 6 3 . 2 0 21335 Open treatment of nasal fracture; with concomitant open treatment of fractured septum 2 , 9 5 9 . 2 0 21336 Open treatment of nasal septal fracture, with or without stabilization 1 , 7 3 8 . 8 0 21337 Closed treatment of nasal septal fracture, with or without stabilization 1 , 3 2 5 . 7 0 21338 Open treatment of nasoethmoid fracture; without external fixation 2 , 7 5 0 . 4 0 21339 Open treatment of nasoethmoid fracture; with external fixation 3 , 0 1 9 . 5 0 21340 Percutaneous treatment of nasoethmoid complex fracture, with splint, wire or headcap fixation, including 3 ,490.20 21343 Open treatment of depressed frontal sinus fracture 3 , 5 5 0 . 5 0 21344 Open treatment of complicated (eg, comminuted or involving posterior wall) frontal sinus fracture, via 3 ,872.70 21345 Closed treatment of nasomaxillary complex fracture (LeFort II type), with interdental wire fixation or fixation 3 ,108.60 21346 Open treatment of nasomaxillary complex fracture (LeFort II type); with wiring and/or local fixation 3 , 8 3 7 . 6 0 21347 Open treatment of nasomaxillary complex fracture (LeFort II type); requiring multiple open approaches 4 , 2 7 5 . 0 0 21348 Open treatment of nasomaxillary complex fracture (LeFort II type); with bone grafting (includes obtaining 3 ,829.50 21355 Percutaneous treatment of fracture of malar area, including zygomatic arch and malar tripod, with 2 ,138.40 21356 Open treatment of depressed zygomatic arch fracture (eg, Gillies approach) 1 , 7 9 6 . 4 0 21360 Open treatment of depressed malar fracture, including zygomatic arch and malar tripod 2 , 4 0 7 . 5 0 21365 Open treatment of complicated (eg, comminuted or involving cranial nerve foramina) fracture(s) of malar 3 ,566.70 21366 Open treatment of complicated (eg, comminuted or involving cranial nerve foramina) fracture(s) of malar 3 ,804.30 21385 Open treatment of orbital floor blowout fracture; transantral approach (Caldwell-Luc type operation) 2 , 7 4 3 . 2 0 21386 Open treatment of orbital floor blowout fracture; periorbital approach 2 , 9 8 4 . 4 0 21387 Open treatment of orbital floor blowout fracture; combined approach 3 , 2 6 7 . 0 0 21390 Open treatment of orbital floor blowout fracture; periorbital approach, with alloplastic or other implant 3 , 5 0 2 . 8 0 21395 Open treatment of orbital floor blowout fracture; periorbital approach with bone graft (includes obtaining 3 ,692.70 21400 Closed treatment of fracture of orbit, except blowout; without manipulation 8 7 9 . 3 0 21401 Closed treatment of fracture of orbit, except blowout; with manipulation 2 , 4 7 5 . 9 0 21406 Open treatment of fracture of orbit, except blowout; without implant 2 , 8 7 7 . 3 0 21407 Open treatment of fracture of orbit, except blowout; with implant 3 , 4 0 0 . 2 0 21408 Open treatment of fracture of orbit, except blowout; with bone grafting (includes obtaining graft) 3 , 3 4 6 . 2 0 21421 Closed treatment of palatal or maxillary fracture (LeFort I type), with interdental wire fixation or fixation of 2 ,632.50 21422 Open treatment of palatal or maxillary fracture (LeFort I type); 3 , 3 4 8 . 9 0 21423 Open treatment of palatal or maxillary fracture (LeFort I type); complicated (comminuted or involving cranial 2 ,865.60 21431 Closed treatment of craniofacial separation (LeFort III type) using interdental wire fixation of denture or 2 ,807.10 21432 Open treatment of craniofacial separation (LeFort III type); with wiring and/or internal fixation 3 , 5 9 4 . 6 0 21433 Open treatment of craniofacial separation (LeFort III type); complicated (eg, comminuted or involving cranial 5 ,049.90 21435 Open treatment of craniofacial separation (LeFort III type); complicated, utilizing internal and/or external 4 ,278.60 21436 Open treatment of craniofacial separation (LeFort III type); complicated, multiple surgical approaches, 5 ,112.00 21440 Closed treatment of mandibular or maxillary alveolar ridge fracture (separate procedure) 1 , 8 0 8 . 1 0 21445 Open treatment of mandibular or maxillary alveolar ridge fracture (separate procedure) 2 , 0 8 8 . 0 0 21450 Closed treatment of mandibular fracture; without manipulation 8 1 2 . 7 0 21451 Closed treatment of mandibular fracture; with manipulation 2 , 1 9 3 . 3 0 21452 Percutaneous treatment of mandibular fracture, with external fixation 1 , 5 4 0 . 8 0 21453 Closed treatment of mandibular fracture with interdental fixation 2 , 7 3 5 . 1 0 21454 Open treatment of mandibular fracture with external fixation 2 , 8 2 0 . 6 0 21461 Open treatment of mandibular fracture; without interdental fixation 2 , 7 7 4 . 7 0 21462 Open treatment of mandibular fracture; with interdental fixation 3 , 2 8 8 . 6 0 21465 Open treatment of mandibular condylar fracture 2 , 8 7 1 . 0 0 21470 Open treatment of complicated mandibular fracture by multiple surgical approaches including internal 4 ,006.80 21480 Closed treatment of temporomandibular dislocation; initial or subsequent 3 8 5 . 2 0 21485 Closed treatment of temporomandibular dislocation; complicated (eg, recurrent requiring intermaxillary 9 03.60 9 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 21490 Open treatment of temporomandibular dislocation 2 , 5 7 8 . 5 0 21495 Open treatment of hyoid fracture 2 , 7 2 6 . 1 0 21497 Interdental wiring, for condition other than fracture 2 , 0 4 6 . 6 0 21501 Incision and drainage, deep abscess or hematoma, soft tissues of neck or thorax; 7 7 9 . 4 0 21502 Incision and drainage, deep abscess or hematoma, soft tissues of neck or thorax; with partial rib ostectomy 9 4 6 . 8 0 21510 Incision, deep, with opening of bone cortex (eg, for osteomyelitis or bone abscess), thorax 1 , 1 6 1 . 9 0 21550 Biopsy, soft tissue of neck or thorax 4 0 5 . 0 0 21552 Exc tumor soft tissue neck/ant thorax subq 3+cm 7 91.93 21554 Exc tumor soft tissue neck/thorax subfasc 5+cm 1 ,366.14 21555 Excision tumor, soft tissue of neck or thorax; subcutaneous 6 3 2 . 1 4 21556 Excision tumor, soft tissue of neck or thorax; deep, subfascial, intramuscular 1 , 1 2 7 . 3 0 21557 Radical resection of tumor (eg, malignant neoplasm), soft tissue of neck or thorax 3 , 0 9 0 . 6 0 21558 Rad resect tumor soft tiss neck/ant thorax 5+cm 2 ,439.66 21600 Excision of rib, partial 1 , 2 5 6 . 4 0 21610 Costotransversectomy (separate procedure) 3 , 4 7 6 . 7 0 21615 Excision first and/or cervical rib; 3 , 0 3 2 . 1 0 21616 Excision first and/or cervical rib; with sympathectomy 2 , 8 9 6 . 2 0 21620 Ostectomy of sternum, partial 3 , 2 6 9 . 7 0 21627 Sternal debridement 1 , 9 6 0 . 2 0 21630 Radical resection of sternum; 3 , 8 2 6 . 8 0 21632 Radical resection of sternum; with mediastinal lymphadenectomy 4 , 8 9 2 . 4 0 21685 Hyoid myotomy & suspension 2 ,168.29 21700 Division of scalenus anticus; without resection of cervical rib 1 , 6 4 7 . 9 0 21705 Division of scalenus anticus; with resection of cervical rib 2 , 2 8 6 . 9 0 21720 Division of sternocleidomastoid for torticollis, open operation; without cast application 1 , 3 3 3 . 8 0 21725 Division of sternocleidomastoid for torticollis, open operation; with cast application 1 , 4 8 6 . 8 0 21740 Reconstructive repair of pectus excavatum or carinatum 3 , 5 7 7 . 5 0 21750 Closure of sternotomy separation with or without debridement (separate procedure) 2 , 7 2 9 . 7 0 21800 Closed treatment of rib fracture, uncomplicated, each 2 1 9 . 6 0 21805 Open treatment of rib fracture without fixation, each 1 , 4 2 6 . 5 0 21810 Treatment of rib fracture requiring external fixation (flail chest) 3 , 4 0 9 . 2 0 21820 Closed treatment of sternum fracture 4 5 6 . 3 0 21825 Open treatment of sternum fracture with or without skeletal fixation 1 , 7 9 1 . 9 0 21920 Biopsy, soft tissue of back or flank; superficial 4 6 6 . 2 0 21925 Biopsy, soft tissue of back or flank; deep 7 9 6 . 5 0 21930 Excision, tumor, soft tissue of back or flank 1 , 8 4 6 . 8 0 21931 Excision tumor soft tissue back/flank subq 3+cm 1 ,124.11 21932 Exc tumor soft tiss back/flank subfascial <5cm 1 ,469.92 21933 Exc tumor soft tiss back/flank subfascial 5+cm 1 ,605.17 21935 Radical resection of tumor (eg, malignant neoplasm), soft tissue of back or flank 3 , 5 4 7 . 8 0 21936 Rad resection tumor soft tissue back/flank 5+cm 3 ,109.09 22010 I&d deep abscess pst spine crv thrc/cervicothrc 1 ,829.44 22015 I&d deep abscess pst spine lumbar sac/lumbosac 1 ,795.54 22100 Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony 1 ,579.50 22101 Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony 1 ,560.60 22102 Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for intrinsic bony 1 ,827.00 22103 Prtl exc pst vrt intrnsc b1y les 1 vrt sgm ea 4 21.75 22110 Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal cord or nerve 2 ,437.20 22112 Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal cord or nerve 2 ,290.50 22114 Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal cord or nerve 1 ,809.90 22116 Prtl exc vrt bdy b1y les w/o spi cord 1 sgm ea 5 10.03 22206 Osteotomy spine posterior 3 column thoracic 8 ,139.79 22207 Osteotomy spine posterior 3 column lumbar 7 ,918.14 22208 Osteotomy spine posterior 3 column ea addl sgm 2 ,343.90 22210 Osteotomy of spine, posterior or posterolateral approach, one vertebral segment; cervical 5 , 4 7 4 . 7 0 22212 Osteotomy of spine, posterior or posterolateral approach, one vertebral segment; thoracic 5 , 8 2 6 . 6 0 22214 Osteotomy of spine, posterior or posterolateral approach, one vertebral segment; lumbar 5 , 0 7 6 . 0 0 22216 Osteot spi pst/pstlat appr 1 vrt sgm ea vrt sgm 1 ,650.31 22220 Osteotomy of spine, including diskectomy, anterior approach, single vertebral segment; cervical 5 , 0 6 2 . 5 0 22222 Osteotomy of spine, including diskectomy, anterior approach, single vertebral segment; thoracic 4 , 8 9 2 . 4 0 22224 Osteotomy of spine, including diskectomy, anterior approach, single vertebral segment; lumbar 4 , 7 3 8 . 5 0 22226 Osteot spi w/dskc ant appr 1 vrt sgm ea vrt sgm 1 ,576.45 22305 Closed treatment of vertebral process fracture(s) 6 4 6 . 2 0 22310 Closed treatment of vertebral body fracture(s), without manipulation, requiring and including casting or 1 ,089.00 22315 Closed treatment of vertebral fracture(s) and/or dislocation(s) requiring casting or bracing, with and 1 ,676.70 22318 Open treatment and/or reduction of odontoid fracture(s) and or dislocation(s) (including os odontoideum), 4 ,835.70 22319 Open treatment and/or reduction of odontoid fracture(s) and or dislocation(s) (including os odontoideum), 5 ,462.10 22325 Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, one 3 ,702.60 22326 Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, one 4 ,303.80 22327 Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, one 3 ,861.00 10 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 22328 Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior approach, one 1 ,339.20 22505 Manipulation of spine requiring anesthesia, any region 5 9 4 . 0 0 22520 Percut vertebroplasty thor 1 0,247.30 22521 Percutaneous vertebroplasty lumbar 4 ,183.34 22522 Percutaneous vertebroplasty ea addl thrc/lmbr 4 99.51 22523 Percutaneous vertebral augmentation thoracic 1 ,477.34 22524 Percutaneous vertebral augmentation lumbar 1 ,382.74 22525 Perq vertebral augmentation ea addl thrc/lmbr 7 16.85 22526 Perq intrdscl electrothrm annuloplasty 1 lvl 3 ,625.48 22527 Perq intrdscl electrothrm annuloplasty addl lvl 2 ,933.60 22532 Arthrodesis lateral extracavitary thoracic 7 ,248.19 22533 Arthrodesis lateral extracavitary lumbar 6 ,841.56 22534 Arthrodesis lat extracavitary ea addl thrc/lmbr 1 ,793.42 22548 Arthrodesis, anterior transoral or extraoral technique, clivus-C1-C2 (atlas-axis), with or without excision of 4 ,671.90 22551 Arthrd ant interbody decompress cervical belw c2 7 ,163.83 22552 Arthrd ant interdy cervcl belw c2 ea addl ntrspc 2 ,029.38 22554 Arthrodesis, anterior interbody technique, including minimal diskectomy to prepare interspace (other than for 5 ,047.20 22556 Arthrodesis, anterior interbody technique, including minimal diskectomy to prepare interspace (other than for 5 ,232.60 22558 Arthrodesis, anterior interbody technique, including minimal diskectomy to prepare interspace (other than for 4 ,895.10 22585 Arthrodesis, anterior interbody technique, including minimal diskectomy to prepare interspace (other than for 2 ,109.60 22586 Prescrl fuse w/ instr l5/s1 3 ,759.12 22590 Arthrodesis, posterior technique, craniocervical (occiput-C2) 6 , 6 9 5 . 1 0 22595 Arthrodesis, posterior technique, atlas-axis (C1-C2) 5 , 8 3 9 . 2 0 22600 Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment 4 , 4 2 8 . 9 0 22610 Arthrodesis, posterior or posterolateral technique, single level; thoracic (with or without lateral transverse 4 ,143.60 22612 Arthrodesis, posterior or posterolateral technique, single level; lumbar (with or without lateral transverse 4 ,961.70 22614 Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment (List 1 ,858.50 22630 Arthrodesis, posterior interbody technique, including laminectomy and/or diskectomy to prepare interspace 4 ,412.70 22632 Arthrodesis, posterior interbody technique, including laminectomy and/or diskectomy to prepare interspace 1 ,555.20 22633 Lumbar spine fusion combined 4 ,570.04 22634 Spine fusion extra segment 1 ,228.63 22800 Arthrodesis, posterior, for spinal deformity, with or without cast; up to 6 vertebral segments 4 , 9 5 3 . 6 0 22802 Arthrodesis, posterior, for spinal deformity, with or without cast; 7 to 12 vertebral segments 6 , 0 3 0 . 0 0 22804 Arthrodesis, posterior, for spinal deformity, with or without cast; 13 or more vertebral segments 6 , 6 4 6 . 5 0 22808 Arthrodesis, anterior, for spinal deformity, with or without cast; 2 to 3 vertebral segments 4 , 5 5 5 . 8 0 22810 Arthrodesis, anterior, for spinal deformity, with or without cast; 4 to 7 vertebral segments 4 , 8 9 2 . 4 0 22812 Arthrodesis, anterior, for spinal deformity, with or without cast; 8 or more vertebral segments 5 , 9 8 5 . 9 0 22818 Kyphectomy, circumferential exposure of spine and resection of vertebral segment(s) (including body and 6 ,687.90 22819 Kyphectomy, circumferential exposure of spine and resection of vertebral segment(s) (including body and 7 ,163.10 22830 Exploration of spinal fusion 4 , 4 1 1 . 8 0 22840 Posterior non-segmental instrumentation (eg, Harrington rod technique), pedicle fixation across one 5 ,926.50 22841 Internal spinal fixation by wiring of spinous processes 3 , 8 6 2 . 8 0 22842 Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar 6 ,488.10 22843 Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar 2 ,050.20 22844 Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar 2 ,503.80 22845 Anterior instrumentation; 2 to 3 vertebral segments 6 , 0 8 8 . 5 0 22846 Anterior instrumentation; 4 to 7 vertebral segments 6 , 1 2 9 . 0 0 22847 Anterior instrumentation 8/> vertebral segments 4 ,006.54 22848 Pelvic fixation other than sacrum 1 ,716.14 22849 Reinsertion of spinal fixation device 3 , 6 3 7 . 8 0 22850 Removal of posterior nonsegmental instrumentation (eg, Harrington rod) 2 , 1 9 6 . 9 0 22851 Application of intervertebral biomechanical device(s) (eg, synthetic cage(s), threaded bone dowel(s), 2 ,188.80 22852 Removal of posterior segmental instrumentation 2 , 5 7 8 . 5 0 22855 Removal of anterior instrumentation 3 , 1 7 4 . 3 0 22856 Tot disc arthrp art disc ant appro 1 ntrspc crv 7 ,409.11 22857 Tot disc arthrp art disc ant appro 1 ntrspc lmbr 7 ,481.77 22861 Revj rplcmt disc arthroplasty ant 1 ntrspc crv 9 ,122.80 22862 Revj rplcmt disc arthroplasty ant 1 ntrspc lmbr 8 ,973.95 22864 Rmvl disc arthroplasty ant 1 interspace cervical 8 ,487.18 22865 Rmvl disc arthroplasty ant 1 interspace lumbar 9 ,570.92 22900 Excision, abdominal wall tumor, subfascial (eg, desmoid) 1 , 5 9 2 . 1 0 22901 Exc tumor soft tissue abdl wall subfascial 5+cm 1 ,370.05 22902 Exc tumor soft tissue abdominal wall subq <3cm 8 61.30 22903 Exc tumor soft tissue abdominal wall subq 3+cm 9 01.22 22904 Rad resection tumor soft tissue abdl wall <5cm 2 ,178.75 22905 Rad resection tumor soft tissue abdl wall 5+cm 2 ,821.24 23000 Removal of subdeltoid (or intratendinous) calcareous deposits, any method 1 , 0 4 8 . 5 0 23020 Capsular contracture release (eg, Sever type procedure) 1 , 6 7 6 . 7 0 23030 Incision and drainage, shoulder area; deep abscess or hematoma 6 4 3 . 5 0 23031 Incision and drainage, shoulder area; infected bursa 5 1 3 . 0 0 11 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 23035 Incision, bone cortex (eg, osteomyelitis or bone abscess), shoulder area 1 , 6 2 0 . 0 0 23040 Arthrotomy, glenohumeral joint, including exploration, drainage, or removal of foreign body 1 , 9 7 6 . 4 0 23044 Arthrotomy, acromioclavicular, sternoclavicular joint, including exploration, drainage, or removal of foreign 1 ,288.80 23065 Biopsy, soft tissue of shoulder area; superficial 4 2 9 . 3 0 23066 Biopsy, soft tissue of shoulder area; deep 7 7 2 . 2 0 23071 Excision tumor soft tissue shoulder subq 3+cm 6 56.15 23073 Exc tumor soft tissue shoulder subfascial 5+cm 1 ,601.52 23075 Excision, soft tissue tumor, shoulder area; subcutaneous 6 9 0 . 3 0 23076 Excision, soft tissue tumor, shoulder area; deep, subfascial, or intramuscular 9 7 2 . 0 0 23077 Radical resection of tumor (eg, malignant neoplasm), soft tissue of shoulder area 3 , 4 5 7 . 8 0 23078 Rad resection tumor soft tissue shoulder 5+cm 3 ,049.94 23100 Arthrotomy, glenohumeral joint, including biopsy 1 , 9 0 0 . 8 0 23101 Arthrotomy, acromioclavicular joint or sternoclavicular joint, including biopsy and/or excision of torn cartilage 1 , 5 1 0 . 2 0 23105 Arthrotomy; glenohumeral joint, with synovectomy, with or without biopsy 2 , 5 4 7 . 9 0 23106 Arthrotomy; sternoclavicular joint, with synovectomy, with or without biopsy 1 , 8 4 1 . 4 0 23107 Arthrotomy, glenohumeral joint, with joint exploration, with or without removal of loose or foreign body 2 , 5 2 1 . 8 0 23120 Claviculectomy; partial 1 , 3 5 9 . 9 0 23125 Claviculectomy; total 2 , 2 1 2 . 2 0 23130 Acromioplasty or acromionectomy, partial, with or without coracoacromial ligament release 1 , 8 7 6 . 5 0 23140 Excision or curettage of bone cyst or benign tumor of clavicle or scapula; 1 , 1 5 2 . 9 0 23145 Excision or curettage of bone cyst or benign tumor of clavicle or scapula; with autograft (includes obtaining 1 ,894.50 23146 Excision or curettage of bone cyst or benign tumor of clavicle or scapula; with allograft 1 , 2 7 6 . 2 0 23150 Excision or curettage of bone cyst or benign tumor of proximal humerus; 1 , 9 0 2 . 6 0 23155 Excision or curettage of bone cyst or benign tumor of proximal humerus; with autograft (includes obtaining 2 ,513.70 23156 Excision or curettage of bone cyst or benign tumor of proximal humerus; with allograft 2 , 1 3 6 . 6 0 23170 Sequestrectomy (eg, for osteomyelitis or bone abscess), clavicle 1 , 1 3 3 . 1 0 23172 Sequestrectomy (eg, for osteomyelitis or bone abscess), scapula 1 , 0 3 5 . 0 0 23174 Sequestrectomy (eg, for osteomyelitis or bone abscess), humeral head to surgical neck 2 , 0 2 9 . 5 0 23180 Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis), clavicle 1 , 1 4 2 . 1 0 23182 Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis), scapula 1 , 1 4 6 . 6 0 23184 Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis), proximal humerus 1 , 8 0 5 . 4 0 23190 Ostectomy of scapula, partial (eg, superior medial angle) 1 , 4 1 5 . 7 0 23195 Resection, humeral head 2 , 0 2 3 . 2 0 23200 Radical resection for tumor; clavicle 1 , 9 8 7 . 2 0 23210 Radical resection for tumor; scapula 2 , 7 0 9 . 0 0 23220 Radical resection of bone tumor, proximal humerus; 2 , 7 1 8 . 9 0 23330 Removal of foreign body, shoulder; subcutaneous 7 4 7 . 0 0 23331 Removal of foreign body, shoulder; deep (eg, Neer hemiarthroplasty removal) 1 , 8 5 1 . 3 0 23332 Removal of foreign body, shoulder; complicated (eg, total shoulder) 3 , 0 4 4 . 7 0 23350 Injection procedure for shoulder arthrography 1 7 7 . 3 0 23395 Muscle transfer, any type, shoulder or upper arm; single 2 , 4 7 2 . 3 0 23397 Muscle transfer, any type, shoulder or upper arm; multiple 2 , 6 5 7 . 7 0 23400 Scapulopexy (eg, Sprengels deformity or for paralysis) 2 , 5 4 9 . 7 0 23405 Tenotomy, shoulder area; single tendon 1 , 4 9 7 . 6 0 23406 Tenotomy, shoulder area; multiple tendons through same incision 2 , 1 5 4 . 6 0 23410 Repair of ruptured musculotendinous cuff (eg, rotator cuff); acute 2 , 4 9 2 . 1 0 23412 Repair of ruptured musculotendinous cuff (eg, rotator cuff); chronic 3 , 0 2 7 . 6 0 23415 Coracoacromial ligament release, with or without acromioplasty 1 , 8 8 2 . 8 0 23420 Reconstruction of complete shoulder (rotator) cuff avulsion, chronic (includes acromioplasty) 3 , 3 4 5 . 3 0 23430 Tenodesis of long tendon of biceps 1 , 8 6 5 . 7 0 23440 Resection or transplantation of long tendon of biceps 1 , 8 2 3 . 4 0 23450 Capsulorrhaphy, anterior; Putti-Platt procedure or Magnuson type operation 3 , 3 3 1 . 8 0 23455 Capsulorrhaphy, anterior; with labral repair (eg, Bankart procedure) 3 , 3 9 2 . 1 0 23460 Capsulorrhaphy, anterior, any type; with bone block 3 , 1 1 6 . 7 0 23462 Capsulorrhaphy, anterior, any type; with coracoid process transfer 3 , 3 3 7 . 2 0 23465 Capsulorrhaphy, glenohumeral joint, posterior, with or without bone block 2 , 9 4 5 . 7 0 23466 Capsulorrhaphy, glenohumeral joint, any type multi-directional instability 3 , 5 0 8 . 2 0 23470 Arthroplasty, glenohumeral joint; hemiarthroplasty 3 , 5 9 8 . 2 0 23472 Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (eg, total 5 ,374.80 23473 Revis reconst shoulder joint 3 ,981.38 23474 Revis reconst shoulder joint 4 ,302.35 23480 Osteotomy, clavicle, with or without internal fixation; 1 , 8 6 3 . 0 0 23485 Osteotomy, clavicle, with or without internal fixation; with bone graft for nonunion or malunion (includes 2 ,413.80 23490 Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate; clavicle 2 , 1 2 3 . 1 0 23491 Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate; proximal 2 ,097.00 23500 Closed treatment of clavicular fracture; without manipulation 3 4 2 . 9 0 23505 Closed treatment of clavicular fracture; with manipulation 5 8 6 . 8 0 23515 Open treatment of clavicular fracture, with or without internal or external fixation 1 , 5 9 5 . 7 0 23520 Closed treatment of sternoclavicular dislocation; without manipulation 3 8 7 . 9 0 23525 Closed treatment of sternoclavicular dislocation; with manipulation 5 5 6 . 2 0 12 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 23530 Open treatment of sternoclavicular dislocation, acute or chronic; 1 , 4 5 5 . 3 0 23532 Open treatment of sternoclavicular dislocation, acute or chronic; with fascial graft (includes obtaining graft) 1 , 7 0 1 . 9 0 23540 Closed treatment of acromioclavicular dislocation; without manipulation 4 1 8 . 5 0 23545 Closed treatment of acromioclavicular dislocation; with manipulation 5 6 5 . 2 0 23550 Open treatment of acromioclavicular dislocation, acute or chronic; 1 , 8 9 0 . 0 0 23552 Open treatment of acromioclavicular dislocation, acute or chronic; with fascial graft (includes obtaining graft) 2 , 2 8 3 . 3 0 23570 Closed treatment of scapular fracture; without manipulation 3 7 2 . 6 0 23575 Closed treatment of scapular fracture; with manipulation, with or without skeletal traction (with or without 5 33.70 23585 Open treatment of scapular fracture (body, glenoid or acromion) with or without internal fixation 2 , 1 5 2 . 8 0 23600 Closed treatment of proximal humeral (surgical or anatomical neck) fracture; without manipulation 5 3 7 . 3 0 23605 Closed treatment of proximal humeral (surgical or anatomical neck) fracture; with manipulation, with or 8 71.20 23615 Open treatment of proximal humeral (surgical or anatomical neck) fracture, with or without internal or 2 ,034.00 23616 Open treatment of proximal humeral (surgical or anatomical neck) fracture, with or without internal or 3 ,965.40 23620 Closed treatment of greater humeral tuberosity fracture; without manipulation 4 7 1 . 6 0 23625 Closed treatment of greater humeral tuberosity fracture; with manipulation 7 4 4 . 3 0 23630 Open treatment of greater humeral tuberosity fracture, with or without internal or external fixation 1 , 6 1 6 . 4 0 23650 Closed treatment of shoulder dislocation, with manipulation; without anesthesia 4 5 7 . 2 0 23655 Closed treatment of shoulder dislocation, with manipulation; requiring anesthesia 6 6 9 . 6 0 23660 Open treatment of acute shoulder dislocation 1 , 9 9 6 . 2 0 23665 Closed treatment of shoulder dislocation, with fracture of greater humeral tuberosity, with manipulation 7 4 9 . 7 0 23670 Open treatment of shoulder dislocation, with fracture of greater humeral tuberosity, with or without internal 1 ,975.50 23675 Closed treatment of shoulder dislocation, with surgical or anatomical neck fracture, with manipulation 8 8 8 . 3 0 23680 Open treatment of shoulder dislocation, with surgical or anatomical neck fracture, with or without internal or 2 ,415.60 23700 Manipulation under anesthesia, shoulder joint, including application of fixation apparatus (dislocation 6 25.50 23800 Arthrodesis, glenohumeral joint; 3 , 6 0 4 . 5 0 23802 Arthrodesis, glenohumeral joint; with autogenous graft (includes obtaining graft) 3 , 4 4 5 . 2 0 23900 Interthoracoscapular amputation (forequarter) 4 , 0 6 3 . 5 0 23920 Disarticulation of shoulder; 3 , 1 6 2 . 6 0 23921 Disarticulation of shoulder; secondary closure or scar revision 9 0 9 . 9 0 23930 Incision and drainage, upper arm or elbow area; deep abscess or hematoma 8 1 9 . 9 0 23931 Incision and drainage, upper arm or elbow area; bursa 6 7 5 . 9 0 23935 Incision, deep, with opening of bone cortex (eg, for osteomyelitis or bone abscess), humerus or elbow 1 , 3 7 4 . 3 0 24000 Arthrotomy, elbow, including exploration, drainage, or removal of foreign body 1 , 8 0 5 . 4 0 24006 Arthrotomy of the elbow, with capsular excision for capsular release (separate procedure) 1 , 7 8 4 . 7 0 24065 Biopsy, soft tissue of upper arm or elbow area; superficial 3 8 5 . 2 0 24066 Biopsy, soft tissue of upper arm or elbow area; deep (subfascial or intramuscular) 7 0 7 . 8 9 24071 Exc tumor soft tissue upper arm/elbow subq 3+cm 9 72.78 24073 Exc tumor soft tiss upper arm/elbw subfasc 5+cm 1 ,396.93 24075 Excision, tumor, upper arm or elbow area; subcutaneous 6 8 6 . 7 0 24076 Excision, tumor, upper arm or elbow area; deep, subfascial or intramuscular 1 , 1 7 9 . 0 0 24077 Radical resection of tumor (eg, malignant neoplasm), soft tissue of upper arm or elbow area 2 , 4 3 0 . 9 0 24079 Rad resect tumor soft tiss upper arm/elbow 5+cm 2 ,604.12 24100 Arthrotomy, elbow; with synovial biopsy only 1 , 0 8 2 . 7 0 24101 Arthrotomy, elbow; with joint exploration, with or without biopsy, with or without removal of loose or foreign 1 ,861.20 24102 Arthrotomy, elbow; with synovectomy 2 , 2 2 4 . 8 0 24105 Excision, olecranon bursa 8 9 8 . 2 0 24110 Excision or curettage of bone cyst or benign tumor, humerus; 1 , 5 8 1 . 3 0 24115 Excision or curettage of bone cyst or benign tumor, humerus; with autograft (includes obtaining graft) 1 , 8 8 7 . 3 0 24116 Excision or curettage of bone cyst or benign tumor, humerus; with allograft 1 , 8 4 1 . 4 0 24120 Excision or curettage of bone cyst or benign tumor of head or neck of radius or olecranon process; 1 , 4 8 5 . 0 0 24125 Excision or curettage of bone cyst or benign tumor of head or neck of radius or olecranon process; with 1 ,740.60 24126 Excision or curettage of bone cyst or benign tumor of head or neck of radius or olecranon process; with 1 ,524.60 24130 Excision, radial head 1 , 4 5 9 . 8 0 24134 Sequestrectomy (eg, for osteomyelitis or bone abscess), shaft or distal humerus 1 , 8 5 4 . 0 0 24136 Sequestrectomy (eg, for osteomyelitis or bone abscess), radial head or neck 1 , 6 5 4 . 2 0 24138 Sequestrectomy (eg, for osteomyelitis or bone abscess), olecranon process 1 , 6 2 2 . 7 0 24140 Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis), humerus 2 , 1 6 8 . 1 0 24145 Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis), radial head or 1 ,442.70 24147 Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis), olecranon process 1 , 2 9 6 . 0 0 24149 Radical resection of capsule, soft tissue, and heterotopic bone, elbow, with contracture release (separate 2 ,652.30 24150 Radical resection for tumor, shaft or distal humerus; 2 , 4 4 3 . 5 0 24152 Radical resection for tumor, radial head or neck; 2 , 1 5 8 . 2 0 24155 Resection of elbow joint (arthrectomy) 2 , 1 9 9 . 6 0 24160 Implant removal; elbow joint 1 , 4 8 9 . 5 0 24164 Implant removal; radial head 1 , 3 5 9 . 9 0 24200 Removal of foreign body, upper arm or elbow area; subcutaneous 3 6 8 . 1 0 24201 Removal of foreign body, upper arm or elbow area; deep (subfascial or intramuscular) 9 6 2 . 1 0 24220 Injection procedure for elbow arthrography 1 7 7 . 3 0 24300 Manipulation elbow under anesthesia 7 77.16 24301 Muscle or tendon transfer, any type, upper arm or elbow, single (excluding 24320-24331) 1 , 9 9 8 . 0 0 13 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 24305 Tendon lengthening, upper arm or elbow, each tendon 9 0 0 . 9 0 24310 Tenotomy, open, elbow to shoulder, each tendon 9 5 5 . 8 0 24320 Tenoplasty, with muscle transfer, with or without free graft, elbow to shoulder, single (Seddon-Brookes type 2 ,311.20 24330 Flexor-plasty, elbow (eg, Steindler type advancement); 2 , 2 6 9 . 8 0 24331 Flexor-plasty, elbow (eg, Steindler type advancement); with extensor advancement 2 , 0 8 6 . 2 0 24332 Tenolysis triceps 1 ,181.38 24340 Tenodesis of biceps tendon at elbow (separate procedure) 1 , 9 2 2 . 4 0 24341 Repair, tendon or muscle, upper arm or elbow, each tendon or muscle, primary or secondary (excludes 1 ,816.20 24342 Reinsertion of ruptured biceps or triceps tendon, distal, with or without tendon graft 2 , 4 1 6 . 5 0 24343 Repair lateral collateral ligament elbow 1 ,858.95 24344 Rcnstj lat coltrl ligm elbow w/tendon graft 2 ,485.31 24345 Repair medial collateral ligament elbow 1 ,857.96 24346 Rcnstj medial coltrl ligm elbw w/tdn grf 2 ,718.04 24357 Tenotomy elbow lateral/medial percutaneous 1 ,115.21 24358 Tnot elbow lateral/medial debride open 1 ,270.13 24359 Tnot elbow lateral/medial debride open tdn rpr 1 ,520.03 24360 Arthroplasty, elbow; with membrane (eg, fascial) 3 , 2 6 7 . 0 0 24361 Arthroplasty, elbow; with distal humeral prosthetic replacement 2 , 9 7 0 . 0 0 24362 Arthroplasty, elbow; with implant and fascia lata ligament reconstruction 3 , 4 4 6 . 1 0 24363 Arthroplasty, elbow; with distal humerus and proximal ulnar prosthetic replacement (eg, total elbow) 4 , 6 1 4 . 3 0 24365 Arthroplasty, radial head; 1 , 6 0 1 . 1 0 24366 Arthroplasty, radial head; with implant 2 , 0 5 4 . 7 0 24370 Revise reconst elbow joint 3 ,755.40 24371 Revise reconst elbow joint 4 ,324.97 24400 Osteotomy, humerus, with or without internal fixation 2 , 4 5 1 . 6 0 24410 Multiple osteotomies with realignment on intramedullary rod, humeral shaft (Sofield type procedure) 2 , 6 4 6 . 9 0 24420 Osteoplasty, humerus (eg, shortening or lengthening) (excluding 64876) 2 , 3 9 7 . 6 0 24430 Repair of nonunion or malunion, humerus; without graft (eg, compression technique) 2 , 6 2 9 . 8 0 24435 Repair of nonunion or malunion, humerus; with iliac or other autograft (includes obtaining graft) 3 , 2 9 8 . 5 0 24470 Hemiepiphyseal arrest (eg, cubitus varus or valgus, distal humerus) 1 , 4 7 6 . 0 0 24495 Decompression fasciotomy, forearm, with brachial artery exploration 2 , 0 7 0 . 0 0 24498 Prophylactic treatment (nailing, pinning, plating or wiring), with or without methylmethacrylate, humeral shaft 1 , 9 8 4 . 5 0 24500 Closed treatment of humeral shaft fracture; without manipulation 5 0 3 . 1 0 24505 Closed treatment of humeral shaft fracture; with manipulation, with or without skeletal traction 1 , 0 4 6 . 7 0 24515 Open treatment of humeral shaft fracture with plate/screws, with or without cerclage 2 , 3 1 4 . 8 0 24516 Open treatment of humeral shaft fracture, with insertion of intramedullary implant, with or without cerclage 2 ,646.90 24530 Closed treatment of supracondylar or transcondylar humeral fracture, with or without intercondylar 6 12.20 24535 Closed treatment of supracondylar or transcondylar humeral fracture, with or without intercondylar 1 ,064.70 24538 Percutaneous skeletal fixation of supracondylar or transcondylar humeral fracture, with or without 1 ,833.30 24545 Open treatment of humeral supracondylar or transcondylar fracture, with or without internal or external 2 ,343.60 24546 Open treatment of humeral supracondylar or transcondylar fracture, with or without internal or external 2 ,875.50 24560 Closed treatment of humeral epicondylar fracture, medial or lateral; without manipulation 5 3 5 . 5 0 24565 Closed treatment of humeral epicondylar fracture, medial or lateral; with manipulation 7 8 8 . 4 0 24566 Percutaneous skeletal fixation of humeral epicondylar fracture, medial or lateral, with manipulation 1 , 2 7 7 . 1 0 24575 Open treatment of humeral epicondylar fracture, medial or lateral, with or without internal or external fixation 1 , 7 5 9 . 5 0 24576 Closed treatment of humeral condylar fracture, medial or lateral; without manipulation 5 4 9 . 9 0 24577 Closed treatment of humeral condylar fracture, medial or lateral; with manipulation 9 9 1 . 8 0 24579 Open treatment of humeral condylar fracture, medial or lateral, with or without internal or external fixation 1 , 8 5 9 . 4 0 24582 Percutaneous skeletal fixation of humeral condylar fracture, medial or lateral, with manipulation 1 , 4 9 4 . 0 0 24586 Open treatment of periarticular fracture and/or dislocation of the elbow (fracture distal humerus and proximal 2 ,680.20 24587 Open treatment of periarticular fracture and/or dislocation of the elbow (fracture distal humerus and proximal 3 ,429.00 24600 Treatment of closed elbow dislocation; without anesthesia 4 6 2 . 6 0 24605 Treatment of closed elbow dislocation; requiring anesthesia 7 5 3 . 3 0 24615 Open treatment of acute or chronic elbow dislocation 1 , 8 3 1 . 5 0 24620 Closed treatment of Monteggia type of fracture dislocation at elbow (fracture proximal end of ulna with 9 52.20 24635 Open treatment of Monteggia type of fracture dislocation at elbow (fracture proximal end of ulna with 2 ,043.00 24640 Closed treatment of radial head subluxation in child, nursemaid elbow, with manipulation 2 8 0 . 8 0 24650 Closed treatment of radial head or neck fracture; without manipulation 4 1 3 . 1 0 24655 Closed treatment of radial head or neck fracture; with manipulation 7 7 8 . 5 0 24665 Open treatment of radial head or neck fracture, with or without internal fixation or radial head excision; 1 , 5 4 4 . 4 0 24666 Open treatment of radial head or neck fracture, with or without internal fixation or radial head excision; with 1 ,931.40 24670 Closed treatment of ulnar fracture, proximal end (olecranon process); without manipulation 4 7 8 . 8 0 24675 Closed treatment of ulnar fracture, proximal end (olecranon process); with manipulation 8 0 1 . 0 0 24685 Open treatment of ulnar fracture proximal end (olecranon process), with or without internal or external 1 ,825.20 24800 Arthrodesis, elbow joint; local 2 , 2 7 1 . 6 0 24802 Arthrodesis, elbow joint; with autogenous graft (includes obtaining graft) 2 , 7 8 8 . 2 0 24900 Amputation, arm through humerus; with primary closure 1 , 8 3 4 . 2 0 24920 Amputation, arm through humerus; open, circular (guillotine) 1 , 5 9 9 . 3 0 24925 Amputation, arm through humerus; secondary closure or scar revision 7 7 4 . 9 0 24930 Amputation, arm through humerus; re-amputation 1 , 4 7 0 . 6 0 14 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 24931 Amputation, arm through humerus; with implant 1 , 9 0 0 . 8 0 24935 Stump elongation, upper extremity 2 , 4 9 9 . 3 0 24940 Cineplasty, upper extremity, complete procedure 2 , 6 3 2 . 5 0 25000 Incision, extensor tendon sheath, wrist (eg, deQuervains disease) 1 , 0 8 0 . 9 0 25001 Incision flexor tendon sheath wrist 9 63.51 25020 Decompression fasciotomy, forearm and/or wrist; flexor or extensor compartment 1 , 3 9 0 . 5 0 25023 Decompression fasciotomy, forearm and/or wrist; with debridement of nonviable muscle and/or nerve 1 , 7 5 1 . 4 0 25024 Dcmprn fasct f/arm&/wrst flxr&xtnsr w/o dbrdmt 1 ,555.24 25025 Dcmprn fasct f/arm&/wrst flxr&xtnsr dbrdmt nv 2 ,070.11 25028 Incision and drainage, forearm and/or wrist; deep abscess or hematoma 9 8 1 . 0 0 25031 Incision and drainage, forearm and/or wrist; bursa 5 8 6 . 8 0 25035 Incision, deep, bone cortex, forearm and/or wrist (eg, osteomyelitis or bone abscess) 1 , 4 1 6 . 6 0 25040 Arthrotomy, radiocarpal or midcarpal joint, with exploration, drainage, or removal of foreign body 1 , 4 7 9 .6 0 25065 Biopsy, soft tissue of forearm and/or wrist; superficial 4 3 4 . 7 0 25066 Biopsy, soft tissue of forearm and/or wrist; deep (subfascial or intramuscular) 7 1 0 . 1 0 25071 Exc tumor soft tiss forearm and/wrist subq 3+cm 1 ,308.04 25073 Exc tumor sft tiss forearm&//wrist subfasc 3+cm 1 ,806.54 25075 Excision, tumor, forearm and/or wrist area; subcutaneous 6 5 0 . 7 0 25076 Excision, tumor, forearm and/or wrist area; deep, subfascial or intramuscular 1 , 1 4 8 . 4 0 25077 Radical resection of tumor (eg, malignant neoplasm), soft tissue of forearm and/or wrist area 2 , 5 9 0 . 2 0 25078 Rad rescj tum soft tissue forearm&/wrist 3+cm 3 ,198.24 25085 Capsulotomy, wrist (eg, contracture) 1 ,6 0 1 . 1 0 25100 Arthrotomy, wrist joint; with biopsy 1 , 3 3 0 . 2 0 25101 Arthrotomy, wrist joint; with joint exploration, with or without biopsy, with or without removal of loose or 1 ,323.00 25105 Arthrotomy, wrist joint; with synovectomy 1 , 7 2 2 . 6 0 25107 Arthrotomy, distal radioulnar joint including repair of triangular cartilage, complex 1 , 4 5 3 . 5 0 25109 Exc tendon forearm&/wrist flexor/extensor ea 1 ,481.65 25110 Excision, lesion of tendon sheath, forearm and/or wrist 8 0 1 . 0 0 25111 Excision of ganglion, wrist (dorsal or volar); primary 9 4 3 . 1 0 25112 Excision of ganglion, wrist (dorsal or volar); recurrent 1 , 3 5 7 . 2 0 25115 Radical excision of bursa, synovia of wrist, or forearm tendon sheaths (eg, tenosynovitis, fungus, Tbc, or 2 ,098.80 25116 Radical excision of bursa, synovia of wrist, or forearm tendon sheaths (eg, tenosynovitis, fungus, Tbc, or 2 ,058.30 25118 Synovectomy, extensor tendon sheath, wrist, single compartment; 1 , 9 2 6 . 0 0 25119 Synovectomy, extensor tendon sheath, wrist, single compartment; with resection of distal ulna 1 , 5 5 6 . 1 0 25120 Excision or curettage of bone cyst or benign tumor of radius or ulna (excluding head or neck of radius and 1 ,530.90 25125 Excision or curettage of bone cyst or benign tumor of radius or ulna (excluding head or neck of radius and 1 ,812.60 25126 Excision or curettage of bone cyst or benign tumor of radius or ulna (excluding head or neck of radius and 1 ,601.10 25130 Excision or curettage of bone cyst or benign tumor of carpal bones; 1 , 5 5 2 . 5 0 25135 Excision or curettage of bone cyst or benign tumor of carpal bones; with autograft (includes obtaining graft) 1 , 7 8 1 . 1 0 25136 Excision or curettage of bone cyst or benign tumor of carpal bones; with allograft 1 , 6 6 9 .5 0 25145 Sequestrectomy (eg, for osteomyelitis or bone abscess), forearm and/or wrist 1 , 8 3 7 . 8 0 25150 Partial excision (craterization, saucerization, or diaphysectomy) of bone (eg, for osteomyelitis); ulna 1 , 5 9 9 .

3 0 25151 Partial excision (craterization, saucerization, or diaphysectomy) of bone (eg, for osteomyelitis); radius 1 , 5 2 2 . 8 0 25170 Radical resection for tumor, radius or ulna 2 , 4 4 6 . 2 0 25210 Carpectomy; one bone 1 , 4 8 3 . 2 0 25215 Carpectomy; all bones of proximal row 2 , 2 7 8 . 8 0 25230 Radial styloidectomy (separate procedure) 1 , 1 6 3 . 7 0 25240 Excision distal ulna partial or complete (eg, Darrach type or matched resection) 1 , 5 1 6 . 5 0 25246 Injection procedure for wrist arthrography 2 2 3 . 2 0 25248 Exploration with removal of deep foreign body, forearm or wrist 1 , 0 0 3 . 5 0 25250 Removal of wrist prosthesis; (separate procedure) 1 , 6 4 7 . 9 0 25251 Removal of wrist prosthesis; complicated, including total wrist 2 , 1 9 4 . 2 0 25259 Manipulate wrist w/anesthes 1 ,033.88 25260 Repair, tendon or muscle, flexor, forearm and/or wrist; primary, single, each tendon or muscle 1 , 4 7 5 . 1 0 25263 Repair, tendon or muscle, flexor, forearm and/or wrist; secondary, single, each tendon or muscle 1 , 4 7 6 . 0 0 25265 Repair, tendon or muscle, flexor, forearm and/or wrist; secondary, with free graft (includes obtaining graft), 1 ,890.00 25270 Repair, tendon or muscle, extensor, forearm and/or wrist; primary, single, each tendon or muscle 1 , 2 0 6 . 9 0 25272 Repair, tendon or muscle, extensor, forearm and/or wrist; secondary, single, each tendon or muscle 1 , 3 2 5 . 7 0 25274 Repair, tendon or muscle, extensor, secondary, with tendon graft (includes obtaining graft), forearm and/or 2 ,003.40 25275 Rpr tendon sheath extensor f/arm&/wrst w/graft 1 ,683.67 25280 Lengthening or shortening of flexor or extensor tendon, forearm and/or wrist, single, each tendon 1 , 4 1 5 . 7 0 25290 Tenotomy, open, flexor or extensor tendon, forearm and/or wrist, single, each tendon 9 4 3 . 2 0 25295 Tenolysis, flexor or extensor tendon, forearm and/or wrist, single, each tendon 1 , 3 8 7 . 8 0 25300 Tenodesis at wrist; flexors of fingers 1 , 8 9 3 . 6 0 25301 Tenodesis at wrist; extensors of fingers 1 , 5 8 1 . 3 0 25310 Tendon transplantation or transfer, flexor or extensor, forearm and/or wrist, single; each tendon 1 , 8 7 0 . 2 0 25312 Tendon transplantation or transfer, flexor or extensor, forearm and/or wrist, single; with tendon graft(s) 2 ,202.30 25315 Flexor origin slide (eg, for cerebral palsy, Volkmann contracture), forearm and/or wrist; 2 , 0 3 5 . 8 0 25316 Flexor origin slide (eg, for cerebral palsy, Volkmann contracture), forearm and/or wrist; with tendon(s) 2 ,677.50 25320 Capsulorrhaphy or reconstruction, wrist, any method (eg, capsulodesis, ligament repair, tendon transfer or 3 ,002.40 15 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 25332 Arthroplasty, wrist, with or without interposition, with or without external or internal fixation 2 , 5 3 7 . 1 0 25335 Centralization of wrist on ulna (eg, radial club hand) 3 , 4 9 3 . 8 0 25337 Reconstruction for stabilization of unstable distal ulna or distal radioulnar joint, secondary by soft tissue 1 ,961.10 25350 Osteotomy, radius; distal third 1 , 8 8 1 . 9 0 25355 Osteotomy, radius; middle or proximal third 1 , 9 6 2 . 9 0 25360 Osteotomy; ulna 1 , 7 7 3 . 0 0 25365 Osteotomy; radius AND ulna 2 , 2 0 9 . 5 0 25370 Multiple osteotomies, with realignment on intramedullary rod (Sofield type procedure); radius OR ulna 2 , 2 5 9 . 0 0 25375 Multiple osteotomies, with realignment on intramedullary rod (Sofield type procedure); radius AND ulna 3 , 0 6 0 . 9 0 25390 Osteoplasty, radius OR ulna; shortening 2 , 2 0 4 . 1 0 25391 Osteoplasty, radius OR ulna; lengthening with autograft 2 , 9 3 8 . 5 0 25392 Osteoplasty, radius AND ulna; shortening (excluding 64876) 2 , 7 1 0 . 8 0 25393 Osteoplasty, radius AND ulna; lengthening with autograft 3 , 0 2 9 . 4 0 25394 Osteoplasty carpal bone shortening 1 ,709.09 25400 Repair of nonunion or malunion, radius OR ulna; without graft (eg, compression technique) 1 , 7 7 3 . 9 0 25405 Repair of nonunion or malunion, radius OR ulna; with iliac or other autograft (includes obtaining graft) 2 , 5 0 0 . 2 0 25415 Repair of nonunion or malunion, radius AND ulna; without graft (eg, compression technique) 2 , 6 1 5 . 4 0 25420 Repair of nonunion or malunion, radius AND ulna; with iliac or other autograft (includes obtaining graft) 2 , 6 8 8 . 3 0 25425 Repair of defect with autograft; radius OR ulna 2 , 2 0 7 . 7 0 25426 Repair of defect with autograft; radius AND ulna 3 , 1 4 1 . 0 0 25430 Vasc graft into carpal bone 1 ,713.16 25431 Repair nonunion carpal bone each bone 2 ,472.29 25440 Repair of nonunion, scaphoid (navicular) bone, with or without radial styloidectomy (includes obtaining graft 2 ,318.40 25441 Arthroplasty with prosthetic replacement; distal radius 2 , 3 3 8 . 2 0 25442 Arthroplasty with prosthetic replacement; distal ulna 1 , 8 4 0 . 5 0 25443 Arthroplasty with prosthetic replacement; scaphoid (navicular) 2 , 0 1 0 . 6 0 25444 Arthroplasty with prosthetic replacement; lunate 2 , 4 0 4 . 8 0 25445 Arthroplasty with prosthetic replacement; trapezium 2 , 3 2 1 . 1 0 25446 Arthroplasty with prosthetic replacement; distal radius and partial or entire carpus (total wrist) 3 , 8 2 3 . 2 0 25447 Arthroplasty, interposition, intercarpal or carpometacarpal joints 2 , 8 0 6 . 2 0 25449 Revision of arthroplasty, including removal of implant, wrist joint 1 , 7 6 3 . 1 0 25450 Epiphyseal arrest by epiphysiodesis or stapling; distal radius OR ulna 1 , 0 5 3 . 0 0 25455 Epiphyseal arrest by epiphysiodesis or stapling; distal radius AND ulna 1 , 5 4 8 . 0 0 25490 Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate; radius 1 , 5 8 6 . 7 0 25491 Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate; ulna 1 , 6 8 1 . 2 0 25492 Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate; radius AND 1 ,881.90 25500 Closed treatment of radial shaft fracture; without manipulation 5 1 3 . 0 0 25505 Closed treatment of radial shaft fracture; with manipulation 7 7 5 . 8 0 25515 Open treatment of radial shaft fracture, with or without internal or external fixation 1 , 5 8 7 . 6 0 25520 Closed treatment of radial shaft fracture, with dislocation of distal radio-ulnar joint (Galeazzi 1 ,447.20 25525 Open treatment of radial shaft fracture, with internal and/ or external fixation and closed treatment of 2 ,566.80 25526 Open treatment of radial shaft fracture, with internal and/or external fixation and open treatment, with or 2 ,663.10 25530 Closed treatment of ulnar shaft fracture; without manipulation 4 7 5 . 2 0 25535 Closed treatment of ulnar shaft fracture; with manipulation 8 1 1 . 8 0 25545 Open treatment of ulnar shaft fracture, with or without internal or external fixation 1 , 7 0 4 . 6 0 25560 Closed treatment of radial and ulnar shaft fractures; without manipulation 6 1 2 . 9 0 25565 Closed treatment of radial and ulnar shaft fractures; with manipulation 1 , 0 0 8 . 0 0 25574 Open treatment of radial AND ulnar shaft fractures, with internal or external fixation; of radius OR ulna 2 , 3 5 3 .5 0 25575 Open treatment of radial AND ulnar shaft fractures, with internal or external fixation; of radius AND ulna 2 , 4 2 5 . 5 0 25600 Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, with or without 5 50.80 25605 Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, with or without 7 96.50 25606 Perq skel fixj distal radial fx/epiphysl sep 1 ,524.64 25607 Optx dstl radl x-artic fx/epiphysl sep 1 ,539.22 25608 Optx dstl radl i-artic fx/epiphysl sep 2 frag 1 ,895.26 25609 Optx dstl radl i-artic fx/epiphysl sep 3 frag 2 ,255.07 25622 Closed treatment of carpal scaphoid (navicular) fracture; without manipulation 6 1 2 . 9 0 25624 Closed treatment of carpal scaphoid (navicular) fracture; with manipulation 8 0 8 . 2 0 25628 Open treatment of carpal scaphoid (navicular) fracture, with or without internal or external fixation 1 , 7 5 1 . 4 0 25630 Closed treatment of carpal bone fracture (excluding carpal scaphoid (navicular)); without manipulation, each 5 06.70 25635 Closed treatment of carpal bone fracture (excluding carpal scaphoid (navicular)); with manipulation, each 6 99.30 25645 Open treatment of carpal bone fracture (excluding carpal scaphoid (navicular)), each bone 1 , 3 7 6 . 1 0 25650 Closed treatment of ulnar styloid fracture 7 5 8 . 7 0 25651 Prq skeletal fixation ulnar styloid fracture 1 ,006.20 25652 Open treatment ulnar styloid fracture 1 ,318.22 25660 Closed treatment of radiocarpal or intercarpal dislocation, one or more bones, with manipulation 7 8 1 . 2 0 25670 Open treatment of radiocarpal or intercarpal dislocation, one or more bones 1 , 6 2 4 . 5 0 25671 Prq skeletal fixj distal radioulnar dislocation 1 ,128.99 25675 Closed treatment of distal radioulnar dislocation with manipulation 7 7 6 . 7 0 25676 Open treatment of distal radioulnar dislocation, acute or chronic 1 , 6 9 9 . 2 0 25680 Closed treatment of trans-scaphoperilunar type of fracture dislocation, with manipulation 1 , 1 0 7 . 9 0 16 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 25685 Open treatment of trans-scaphoperilunar type of fracture dislocation 2 , 0 0 5 . 2 0 25690 Closed treatment of lunate dislocation, with manipulation 1 , 1 4 1 . 2 0 25695 Open treatment of lunate dislocation 1 , 8 6 4 . 8 0 25800 Arthrodesis, wrist; complete, without bone graft (includes radiocarpal and/or intercarpal and/or 2 ,785.50 25805 Arthrodesis, wrist; with sliding graft 2 , 8 8 8 . 1 0 25810 Arthrodesis, wrist; with iliac or other autograft (includes obtaining graft) 3 , 3 6 6 . 0 0 25820 Arthrodesis, wrist; limited, without bone graft (eg, intercarpal or radiocarpal) 2 , 2 2 3 . 0 0 25825 Arthrodesis, wrist; with autograft (includes obtaining graft) 2 , 6 8 0 . 2 0 25830 Arthrodesis, distal radioulnar joint with segmental resection of ulna, with or without bone graft (eg, Sauve- 2 ,169.90 25900 Amputation, forearm, through radius and ulna; 1 , 9 2 6 . 0 0 25905 Amputation, forearm, through radius and ulna; open, circular (guillotine) 1 , 7 4 6 . 0 0 25907 Amputation, forearm, through radius and ulna; secondary closure or scar revision 8 3 7 . 0 0 25909 Amputation, forearm, through radius and ulna; re-amputation 1 , 6 2 5 . 4 0 25915 Krukenberg procedure 2 , 5 7 0 . 4 0 25920 Disarticulation through wrist; 1 , 6 1 1 . 9 0 25922 Disarticulation through wrist; secondary closure or scar revision 9 4 5 . 9 0 25924 Disarticulation through wrist; re-amputation 1 , 6 4 6 . 1 0 25927 Transmetacarpal amputation; 1 , 9 5 2 . 1 0 25929 Transmetacarpal amputation; secondary closure or scar revision 8 7 0 .3 0 25931 Transmetacarpal amputation; re-amputation 1 , 7 9 4 . 6 0 26010 Drainage of finger abscess; simple 2 9 3 . 4 0 26011 Drainage of finger abscess; complicated (eg, felon) 5 6 8 . 8 0 26020 Drainage of tendon sheath, digit and/or palm, each 1 , 3 1 3 . 1 0 26025 Drainage of palmar bursa; single, bursa 1 , 3 2 3 . 9 0 26030 Drainage of palmar bursa; multiple bursa 1 , 9 1 3 . 4 0 26034 Incision, bone cortex, hand or finger (eg, osteomyelitis or bone abscess) 1 , 7 8 2 . 0 0 26035 Decompression fingers and/or hand, injection injury (eg, grease gun) 2 , 3 9 5 . 8 0 26037 Decompressive fasciotomy, hand (excludes 26035) 2 , 1 7 5 . 3 0 26040 Fasciotomy, palmar (eg, Dupuytren's contracture); percutaneous 1 , 0 0 8 . 0 0 26045 Fasciotomy, palmar (eg, Dupuytren's contracture); open, partial 1 , 4 5 7 . 1 0 26055 Tendon sheath incision (eg, for trigger finger) 9 3 1 . 8 8 26060 Tenotomy, percutaneous, single, each digit 4 9 9 . 5 0 26070 Arthrotomy, with exploration, drainage, or removal of loose or foreign body; carpometacarpal joint 8 4 1 . 5 0 26075 Arthrotomy, with exploration, drainage, or removal of loose or foreign body; metacarpophalangeal joint, 1 ,145.70 26080 Arthrotomy, with exploration, drainage, or removal of loose or foreign body; interphalangeal joint, each 8 9 5 . 5 0 26100 Arthrotomy with biopsy; carpometacarpal joint, each 9 2 0 . 7 0 26105 Arthrotomy with biopsy; metacarpophalangeal joint, each 1 , 0 5 0 . 3 0 26110 Arthrotomy with biopsy; interphalangeal joint, each 8 4 2 . 4 0 26111 Ex tum/vasc malf sft tiss hand/fngr subq 1.5+cm 1 ,075.54 26113 Ex tum/vasc mal sft tis hand/fngr subfsc 1.5+cm 1 ,621.65 26115 Excision, tumor or vascular malformation, hand or finger; subcutaneous 9 2 7 . 0 0 26116 Excision, tumor or vascular malformation, hand or finger; deep, subfascial, intramuscular 1 , 2 8 4 . 3 0 26117 Radical resection of tumor (eg, malignant neoplasm), soft tissue of hand or finger 2 , 4 4 5 . 3 0 26118 Rad rescj tum soft tissue hand/finger 3+cm 3 ,201.59 26121 Fasciectomy, palm only, with or without Z-plasty, other local tissue rearrangement, or skin grafting (includes 2 ,585.70 26123 Fasciectomy, partial palmar with release of single digit including proximal interphalangeal joint, with or 2 ,606.40 26125 Fasciectomy, partial palmar with release of single digit including proximal interphalangeal joint, with or 2 ,230.20 26130 Synovectomy, carpometacarpal joint 1 , 5 6 6 . 0 0 26135 Synovectomy, metacarpophalangeal joint including intrinsic release and extensor hood reconstruction, each 1 ,762.20 26140 Synovectomy, proximal interphalangeal joint, including extensor reconstruction, each interphalangeal joint 1 , 7 0 8 . 2 0 26145 Synovectomy, tendon sheath, radical (tenosynovectomy), flexor tendon, palm and/or finger, each tendon 1 , 7 4 4 . 2 0 26160 Excision of lesion of tendon sheath or capsule (eg, cyst, mucous cyst, or ganglion), hand or finger 9 1 3 . 5 0 26170 Excision of tendon, palm, flexor, single (separate procedure), each 9 4 5 . 9 0 26180 Excision of tendon, finger, flexor (separate procedure), each tendon 8 3 4 . 3 0 26185 Sesamoidectomy, thumb or finger (separate procedure) 9 2 9 . 7 0 26200 Excision or curettage of bone cyst or benign tumor of metacarpal; 1 , 1 3 7 . 6 0 26205 Excision or curettage of bone cyst or benign tumor of metacarpal; with autograft (includes obtaining graft) 1 , 6 9 5 . 6 0 26210 Excision or curettage of bone cyst or benign tumor of proximal, middle, or distal phalanx of finger; 1 ,2 3 4 . 8 0 26215 Excision or curettage of bone cyst or benign tumor of proximal, middle, or distal phalanx of finger; with 1 ,538.10 26230 Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis); metacarpal 1 , 1 2 1 . 4 0 26235 Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis); proximal or middle 1 ,081.80 26236 Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis); distal phalanx of 9 31.50 26250 Radical resection, metacarpal; (eg, tumor) 1 , 5 6 1 . 5 0 26260 Radical resection, proximal or middle phalanx of finger (eg, tumor); 1 , 6 9 2 . 0 0 26262 Radical resection, distal phalanx of finger (eg, tumor) 1 , 5 6 8 . 7 0 26320 Removal of implant from finger or hand 9 5 6 . 7 0 26340 Manipulation finger joint under anes each joint 8 41.74 26341 Manipulat palm cord post inj 2 43.56 26350 Repair or advancement, flexor tendon, not in digital flexor tendon sheath (eg, no man's land); primary or 2 ,094.30 26352 Repair or advancement, flexor tendon, not in digital flexor tendon sheath (eg, no man's land); secondary 2 ,346.30 17 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 26356 Repair or advancement, flexor tendon, in digital flexor tendon sheath (eg, no man's land); primary, each 2 ,266.20 26357 Repair or advancement, flexor tendon, in digital flexor tendon sheath (eg, no man's land); secondary, each 2 ,317.50 26358 Repair or advancement, flexor tendon, in digital flexor tendon sheath (eg, no man's land); secondary with 2 ,396.70 26370 Repair or advancement of profundus tendon, with intact superficialis tendon; primary, each tendon 1 , 9 0 0 . 8 0 26372 Repair or advancement of profundus tendon, with intact superficialis tendon; secondary with free graft 1 ,975.50 26373 Repair or advancement of profundus tendon, with intact superficialis tendon; secondary without free graft, 1 ,825.20 26390 Excision flexor tendon, implantation of prosthetic rod for delayed tendon graft, hand or finger, each tendon 1 , 7 5 3 . 2 0 26392 Removal of prosthetic rod and insertion of flexor tendon graft, hand or finger (includes obtaining graft), each 2 ,260.80 26410 Repair, extensor tendon, hand, primary or secondary; without free graft, each tendon 1 , 0 6 4 . 7 0 26412 Repair, extensor tendon, hand, primary or secondary; with free graft (includes obtaining graft), each tendon 1 , 5 1 5 . 6 0 26415 Excision of extensor tendon, implantation of prosthetic rod for delayed tendon graft, hand or finger 1 , 4 4 4 . 5 0 26416 Removal of prosthetic rod and insertion of extensor tendon graft (includes obtaining graft), hand or finger, 1 ,515.60 26418 Repair, extensor tendon, finger, primary or secondary; without free graft, each tendon 1 , 2 5 1 . 9 0 26420 Repair, extensor tendon, finger, primary or secondary; with free graft (includes obtaining graft) each tendon 1 , 4 1 6 . 6 0 26426 Repair of extensor tendon, central slip, secondary (eg, boutonniere deformity); using local tissue(s), 1 ,654.20 26428 Repair of extensor tendon, central slip, secondary (eg, boutonniere deformity); with free graft (includes 1 ,773.00 26432 Closed treatment of distal extensor tendon insertion, with or without percutaneous pinning (eg, mallet finger) 1 , 1 3 9 . 4 0 26433 Repair of extensor tendon, distal insertion, primary or secondary; without graft (eg, mallet finger) 1 , 4 8 5 . 0 0 26434 Repair of extensor tendon, distal insertion, primary or secondary; with free graft (includes obtaining graft) 1 , 3 6 8 . 0 0 26437 Realignment of extensor tendon, hand, each tendon 1 , 4 8 4 . 1 0 26440 Tenolysis, flexor tendon; palm OR finger; each tendon 1 , 2 4 7 . 4 0 26442 Tenolysis, flexor tendon; palm AND finger, each tendon 1 , 4 4 0 . 9 0 26445 Tenolysis, extensor tendon, hand or finger; each tendon 1 , 2 1 2 . 3 0 26449 Tenolysis, complex, extensor tendon, finger, including forearm, each tendon 1 , 6 9 9 . 2 0 26450 Tenotomy, flexor, palm, open, each tendon 7 3 3 . 5 0 26455 Tenotomy, flexor, finger, open, each tendon 8 4 7 . 8 0 26460 Tenotomy, extensor, hand or finger, open, each tendon 8 4 9 . 6 0 26471 Tenodesis; of proximal interphalangeal joint, each joint 1 , 3 8 4 . 2 0 26474 Tenodesis; of distal joint, each joint 9 8 1 . 0 0 26476 Lengthening of tendon, extensor, hand or finger, each tendon 1 , 0 1 2 . 5 0 26477 Shortening of tendon, extensor, hand or finger, each tendon 1 , 0 7 8 . 2 0 26478 Lengthening of tendon, flexor, hand or finger, each tendon 1 , 3 4 5 . 5 0 26479 Shortening of tendon, flexor, hand or finger, each tendon 1 , 3 4 8 .2 0 26480 Transfer or transplant of tendon, carpometacarpal area or dorsum of hand; without free graft, each tendon 1 , 8 3 8 . 7 0 26483 Transfer or transplant of tendon, carpometacarpal area or dorsum of hand; with free tendon graft (includes 2 ,086.20 26485 Transfer or transplant of tendon, palmar; without free tendon graft, each tendon 1 , 9 2 6 . 9 0 26489 Transfer or transplant of tendon, palmar; with free tendon graft (includes obtaining graft), each tendon 2 , 2 3 2 . 9 0 26490 Opponensplasty; superficialis tendon transfer type, each tendon 2 , 0 4 5 . 7 0 26492 Opponensplasty; tendon transfer with graft (includes obtaining graft), each tendon 2 , 2 3 7 . 4 0 26494 Opponensplasty; hypothenar muscle transfer 2 , 0 3 2 . 2 0 26496 Opponensplasty; other methods 2 , 3 1 7 . 5 0 26497 Transfer of tendon to restore intrinsic function; ring and small finger 2 , 2 0 1 . 4 0 26498 Transfer of tendon to restore intrinsic function; all four fingers 2 , 5 4 4 . 3 0 26499 Correction claw finger, other methods 2 , 4 0 3 . 9 0 26500 Reconstruction of tendon pulley, each tendon; with local tissues (separate procedure) 1 , 2 5 7 . 3 0 26502 Reconstruction of tendon pulley, each tendon; with tendon or fascial graft (includes obtaining graft) 1 ,802.70 26508 Release of thenar muscle(s) (eg, thumb contracture) 1 , 4 6 0 . 7 0 26510 Cross intrinsic transfer 1 , 8 7 0 . 2 0 26516 Capsulodesis, metacarpophalangeal joint; single digit 1 , 5 9 3 . 9 0 26517 Capsulodesis, metacarpophalangeal joint; two digits 1 , 6 2 9 . 9 0 26518 Capsulodesis, metacarpophalangeal joint; three or four digits 2 , 0 3 1 . 3 0 26520 Capsulectomy or capsulotomy; metacarpophalangeal joint, each joint 1 , 5 4 8 . 0 0 26525 Capsulectomy or capsulotomy; interphalangeal joint, each joint 1 , 6 4 9 . 7 0 26530 Arthroplasty, metacarpophalangeal joint; each joint 1 , 6 1 1 . 9 0 26531 Arthroplasty, metacarpophalangeal joint; with prosthetic implant, each joint 1 , 8 4 7 . 7 0 26535 Arthroplasty, interphalangeal joint; each joint 1 , 6 5 7 . 8 0 26536 Arthroplasty, interphalangeal joint; with prosthetic implant, each joint 1 , 9 1 1 . 6 0 26540 Repair of collateral ligament, metacarpophalangeal or interphalangeal joint 1 , 7 9 1 . 0 0 26541 Reconstruction, collateral ligament, metacarpophalangeal joint, single; with tendon or fascial graft (includes 2 ,261.70 26542 Reconstruction, collateral ligament, metacarpophalangeal joint, single; with local tissue (eg, adductor 2 ,025.00 26545 Reconstruction, collateral ligament, interphalangeal joint, single, including graft, each joint 1 , 5 8 9 . 4 0 26546 Repair non-union, metacarpal or phalanx, (includes obtaining bone graft with or without external or internal 1 ,758.60 26548 Repair and reconstruction, finger, volar plate, interphalangeal joint 1 , 9 4 6 . 7 0 26550 Pollicization of a digit 3 , 4 0 5 . 6 0 26551 Transfer, toe-to-hand with microvascular anastomosis; great toe wrap-around with bone graft 9 , 1 6 0 . 2 0 26553 Transfer, toe-to-hand with microvascular anastomosis; other than great toe, single 9 , 0 9 6 . 3 0 26554 Transfer, toe-to-hand with microvascular anastomosis; other than great toe, double 1 0 , 8 4 7 . 7 0 26555 Transfer, finger to another position without microvascular anastomosis 2 , 5 8 7 . 5 0 26556 Transfer, free toe joint, with microvascular anastomosis 9 , 2 5 1 . 1 0 26560 Repair of syndactyly (web finger) each web space; with skin flaps 1 , 6 5 8 . 7 0 18 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 26561 Repair of syndactyly (web finger) each web space; with skin flaps and grafts 2 , 2 1 4 . 9 0 26562 Repair of syndactyly (web finger) each web space; complex (eg, involving bone, nails) 2 , 7 2 1 . 6 0 26565 Osteotomy; metacarpal, each 1 , 8 4 4 . 1 0 26567 Osteotomy; phalanx of finger, each 1 , 4 8 3 . 2 0 26568 Osteoplasty, lengthening, metacarpal or phalanx 2 , 2 4 0 . 1 0 26580 Repair cleft hand 3 , 3 5 0 . 7 0 26587 Reconstruction of supernumerary digit, soft tissue and bone 1 , 9 7 5 . 5 0 26590 Repair macrodactylia 2 , 2 4 1 . 0 0 26591 Repair, intrinsic muscles of hand, each muscle 1 , 8 6 1 . 2 0 26593 Release, intrinsic muscles of hand, each muscle 1 , 6 8 4 .8 0 26596 Excision of constricting ring of finger, with multiple Z-plasties 1 , 8 8 4 . 6 0 26600 Closed treatment of metacarpal fracture, single; without manipulation, each bone 3 4 1 . 1 0 26605 Closed treatment of metacarpal fracture, single; with manipulation, each bone 5 0 4 . 0 0 26607 Closed treatment of metacarpal fracture, with manipulation, with internal or external fixation, each bone 9 8 3 . 7 0 26608 Percutaneous skeletal fixation of metacarpal fracture, each bone 1 , 0 7 9 . 1 0 26615 Open treatment of metacarpal fracture, single, with or without internal or external fixation, each bone 1 , 5 1 1 . 1 0 26641 Closed treatment of carpometacarpal dislocation, thumb, with manipulation 5 2 6 . 5 0 26645 Closed treatment of carpometacarpal fracture dislocation, thumb (Bennett fracture), with manipulation 7 0 3 . 8 0 26650 Percutaneous skeletal fixation of carpometacarpal fracture dislocation, thumb (Bennett fracture), with 1 ,207.80 26665 Open treatment of carpometacarpal fracture dislocation, thumb (Bennett fracture), with or without internal or 1 ,818.90 26670 Closed treatment of carpometacarpal dislocation, other than thumb (Bennett fracture), single, with 3 73.50 26675 Closed treatment of carpometacarpal dislocation, other than thumb (Bennett fracture), single, with 6 17.66 26676 Percutaneous skeletal fixation of carpometacarpal dislocation, other than thumb (Bennett fracture), single, 8 85.60 26685 Open treatment of carpometacarpal dislocation, other than thumb (Bennett fracture); single, with or without 1 ,269.00 26686 Open treatment of carpometacarpal dislocation, other than thumb (Bennett fracture); complex, multiple or 1 ,341.00 26700 Closed treatment of metacarpophalangeal dislocation, single, with manipulation; without anesthesia 3 4 0 . 2 0 26705 Closed treatment of metacarpophalangeal dislocation, single, with manipulation; requiring anesthesia 5 2 5 . 6 0 26706 Percutaneous skeletal fixation of metacarpophalangeal dislocation, single, with manipulation 8 4 7 . 8 0 26715 Open treatment of metacarpophalangeal dislocation, single, with or without internal or external fixation 1 , 2 2 5 . 8 0 26720 Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; without 2 78.10 26725 Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; with 4 62.60 26727 Percutaneous skeletal fixation of unstable phalangeal shaft fracture, proximal or middle phalanx, finger or 9 67.50 26735 Open treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb, with or without 1 ,345.50 26740 Closed treatment of articular fracture, involving metacarpophalangeal or interphalangeal joint; without 4 92.30 26742 Closed treatment of articular fracture, involving metacarpophalangeal or interphalangeal joint; with 6 47.10 26746 Open treatment of articular fracture, involving metacarpophalangeal or interphalangeal joint, with or without 1 ,380.60 26750 Closed treatment of distal phalangeal fracture, finger or thumb; without manipulation, each 2 2 7 . 7 0 26755 Closed treatment of distal phalangeal fracture, finger or thumb; with manipulation, each 3 6 8 . 4 0 26756 Percutaneous skeletal fixation of distal phalangeal fracture, finger or thumb, each 7 5 1 . 5 0 26765 Open treatment of distal phalangeal fracture, finger or thumb, with or without internal or external fixation, 8 89.20 26770 Closed treatment of interphalangeal joint dislocation, single, with manipulation; without anesthesia 2 4 4 . 5 6 26775 Closed treatment of interphalangeal joint dislocation, single, with manipulation; requiring anesthesia 4 4 8 . 2 0 26776 Percutaneous skeletal fixation of interphalangeal joint dislocation, single, with manipulation 7 1 2 . 8 0 26785 Open treatment of interphalangeal joint dislocation, with or without internal or external fixation, single 9 9 0 . 9 0 26820 Fusion in opposition, thumb, with autogenous graft (includes obtaining graft) 1 , 8 0 8 . 1 0 26841 Arthrodesis, carpometacarpal joint, thumb, with or without internal fixation; 1 , 6 9 9 . 2 0 26842 Arthrodesis, carpometacarpal joint, thumb, with or without internal fixation; with autograft (includes obtaining 1 ,946.70 26843 Arthrodesis, carpometacarpal joint, digits, other than thumb; 1 , 4 1 5 . 7 0 26844 Arthrodesis, carpometacarpal joint, digits, other than thumb; with autograft (includes obtaining graft) 1 , 5 4 5 . 3 0 26850 Arthrodesis, metacarpophalangeal joint, with or without internal fixation; 1 , 9 1 9 . 7 0 26852 Arthrodesis, metacarpophalangeal joint, with or without internal fixation; with autograft (includes obtaining 1 ,494.00 26860 Arthrodesis, interphalangeal joint, with or without internal fixation; 1 , 2 5 0 . 1 0 26861 Arthrodesis, interphalangeal joint, with or without internal fixation; each additional interphalangeal joint (List 5 40.90 26862 Arthrodesis, interphalangeal joint, with or without internal fixation; with autograft (includes obtaining graft) 1 , 6 2 9 . 9 0 26863 Arthrodesis, interphalangeal joint, with or without internal fixation; with autograft (includes obtaining graft), 6 46.20 26910 Amputation, metacarpal, with finger or thumb (ray amputation), single, with or without interosseous transfer 1 , 8 7 0 . 2 0 26951 Amputation, finger or thumb, primary or secondary, any joint or phalanx, single, including neurectomies; with 9 10.80 26952 Amputation, finger or thumb, primary or secondary, any joint or phalanx, single, including neurectomies; with 1 ,376.10 26990 Incision and drainage, pelvis or hip joint area; deep abscess or hematoma 9 0 0 . 9 0 26991 Incision and drainage, pelvis or hip joint area; infected bursa 7 7 2 . 2 0 26992 Incision, bone cortex, pelvis and/or hip joint (eg, osteomyelitis or bone abscess) 1 , 7 9 3 . 7 0 27000 Tenotomy, adductor of hip, percutaneous (separate procedure) 4 9 8 . 6 0 27001 Tenotomy, adductor of hip, open 9 1 2 . 6 0 27003 Tenotomy, adductor, subcutaneous, open, with obturator neurectomy 1 , 0 6 4 . 7 0 27005 Tenotomy, hip flexor(s), open (separate procedure) 1 , 4 5 2 . 6 0 27006 Tenotomy, abductors and/or extensor(s) of hip, open (separate procedure) 1 , 0 1 2 . 5 0 27025 Fasciotomy, hip or thigh, any type 1 , 6 9 8 . 3 0 27027 Decompression fasciotomy pelvic compartment uni 1 ,637.28 27030 Arthrotomy, hip, with drainage (eg, infection) 2 , 1 7 3 . 5 0 27033 Arthrotomy, hip, including exploration or removal of loose or foreign body 2 , 3 3 2 . 8 0 19 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 27035 Denervation, hip joint, intrapelvic or extrapelvic intra-articular branches of sciatic, femoral, or obturator 2 ,578.50 27036 Capsulectomy or capsulotomy, hip, with or without excision of heterotopic bone, with release of hip flexor 2 ,480.40 27040 Biopsy, soft tissue of pelvis and hip area; superficial 4 6 2 . 6 0 27041 Biopsy, soft tissue of pelvis and hip area; deep, subfascial or intramuscular 7 6 7 . 7 0 27043 Excision tumor soft tissue pelvis&hip subq 3+cm 8 77.66 27045 Exc tumor soft tissue pelvis & hip subfasc 5+cm 1 ,380.69 27047 Excision, tumor, pelvis and hip area; subcutaneous tissue 6 9 7 . 5 0 27048 Excision, tumor, pelvis and hip area; deep, subfascial, intramuscular 1 , 3 2 3 . 0 0 27049 Radical resection of tumor, soft tissue of pelvis and hip area (eg, malignant neoplasm) 3 , 1 2 6 . 6 0 27050 Arthrotomy, with biopsy; sacroiliac joint 1 , 0 0 7 . 1 0 27052 Arthrotomy, with biopsy; hip joint 2 , 2 1 8 . 5 0 27054 Arthrotomy with synovectomy, hip joint 2 , 6 3 8 . 8 0 27057 Dcmprn fasciotomy pelvic cmprt dbrdmt muscle uni 1 ,660.89 27059 Rad resection tumor soft tiss pelvis&hip 5+cm 3 ,359.14 27060 Excision; ischial bursa 9 9 9 . 9 0 27062 Excision; trochanteric bursa or calcification 9 0 4 . 5 0 27065 Excision of bone cyst or benign tumor; superficial (wing of ilium, symphysis pubis, or greater trochanter of 1 ,318.50 27066 Excision of bone cyst or benign tumor; deep, with or without autograft 1 , 9 6 5 . 6 0 27067 Excision of bone cyst or benign tumor; with autograft requiring separate incision 2 , 2 8 6 . 9 0 27070 Partial excision (craterization, saucerization) (eg, osteomyelitis or bone abscess); superficial (eg, wing of 1 ,739.70 27071 Partial excision (craterization, saucerization) (eg, osteomyelitis or bone abscess); deep (subfascial or 1 ,902.60 27075 Radical resection of tumor or infection; wing of ilium, one pubic or ischial ramus or symphysis pubis 3 , 0 8 7 . 9 0 27076 Radical resection of tumor or infection; ilium, including acetabulum, both pubic rami, or ischium and 4 ,360.50 27077 Radical resection of tumor or infection; innominate bone, total 5 , 8 1 6 . 7 0 27078 Radical resection of tumor or infection; ischial tuberosity and greater trochanter of femur 1 , 9 7 9 . 1 0 27080 Coccygectomy, primary 1 , 2 7 5 . 3 0 27086 Removal of foreign body, pelvis or hip; subcutaneous tissue 3 3 2 . 1 0 27087 Removal of foreign body, pelvis or hip; deep (subfascial or intramuscular) 1 , 1 2 3 . 5 3 27090 Removal of hip prosthesis; (separate procedure) 2 , 4 8 2 . 2 0 27091 Removal of hip prosthesis; complicated, including total hip prosthesis, methylmethacrylate with or without 5 ,319.90 27093 Injection procedure for hip arthrography; without anesthesia 2 7 5 . 4 0 27095 Injection procedure for hip arthrography; with anesthesia 5 0 4 . 0 0 27096 Injection procedure for sacroiliac joint, arthrography and/or anesthetic/steroid 7 6 9 . 5 0 27097 Release or recession, hamstring, proximal 1 , 7 5 4 . 1 0 27098 Transfer, adductor to ischium 2 , 0 6 5 . 5 0 27100 Transfer external oblique muscle to greater trochanter including fascial or tendon extension (graft) 2 , 3 5 8 . 9 0 27105 Transfer paraspinal muscle to hip (includes fascial or tendon extension graft) 2 , 5 0 4 . 7 0 27110 Transfer iliopsoas; to greater trochanter 2 , 9 3 5 . 8 0 27111 Transfer iliopsoas; to femoral neck 2 , 8 9 8 . 9 0 27120 Acetabuloplasty; (eg, Whitman, Colonna, Haygroves, or cup type) 3 , 7 8 3 . 6 0 27122 Acetabuloplasty; resection, femoral head (eg, Girdlestone procedure) 3 , 6 8 1 . 0 0 27125 Hemiarthroplasty, hip, partial (eg, femoral stem prosthesis, bipolar arthroplasty) 4 , 0 7 9 . 7 0 27130 Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip replacement), with or without 5 ,616.90 27132 Conversion of previous hip surgery to total hip replacement, with or without autograft or allograft 6 , 3 7 1 . 1 0 27134 Revision of total hip arthroplasty; both components, with or without autograft or allograft 8 , 5 3 2 . 1 8 27137 Revision of total hip arthroplasty; acetabular component only, with or without autograft or allograft 5 , 8 5 1 . 8 0 27138 Revision of total hip arthroplasty; femoral component only, with or without allograft 5 , 8 9 9 . 5 0 27140 Osteotomy and transfer of greater trochanter (separate procedure) 2 , 1 7 6 . 2 0 27146 Osteotomy, iliac, acetabular or innominate bone; 3 , 2 5 5 . 3 0 27147 Osteotomy, iliac, acetabular or innominate bone; with open reduction of hip 3 , 9 1 4 . 1 0 27151 Osteotomy, iliac, acetabular or innominate bone; with femoral osteotomy 3 , 6 1 9 . 8 0 27156 Osteotomy, iliac, acetabular or innominate bone; with femoral osteotomy and with open reduction of hip 4 , 4 0 1 . 0 0 27158 Osteotomy, pelvis, bilateral (eg, congenital malformation) 3 , 8 3 6 . 7 0 27161 Osteotomy, femoral neck (separate procedure) 3 , 1 3 2 . 0 0 27165 Osteotomy, intertrochanteric or subtrochanteric including internal or external fixation and/or cast 3 , 5 4 9 . 6 0 27170 Bone graft, femoral head, neck, intertrochanteric or subtrochanteric area (includes obtaining bone graft) 3 , 7 0 8 . 0 0 27175 Treatment of slipped femoral epiphysis; by traction, without reduction 1 , 8 5 5 . 8 0 27176 Treatment of slipped femoral epiphysis; by single or multiple pinning, in situ 2 , 7 7 0 . 2 0 27177 Open treatment of slipped femoral epiphysis; single or multiple pinning or bone graft (includes obtaining 3 ,270.60 27178 Open treatment of slipped femoral epiphysis; closed manipulation with single or multiple pinning 3 , 4 5 8 . 7 0 27179 Open treatment of slipped femoral epiphysis; osteoplasty of femoral neck (Heyman type procedure) 2 , 6 7 2 . 1 0 27181 Open treatment of slipped femoral epiphysis; osteotomy and internal fixation 3 , 7 8 9 . 9 0 27185 Epiphyseal arrest by epiphysiodesis or stapling, greater trochanter 1 , 2 3 3 . 0 0 27187 Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate, femoral neck 4 ,241.70 27193 Closed treatment of pelvic ring fracture, dislocation, diastasis or subluxation; without manipulation 1 , 0 3 0 . 5 0 27194 Closed treatment of pelvic ring fracture, dislocation, diastasis or subluxation; with manipulation, requiring 1 ,568.70 27200 Closed treatment of coccygeal fracture 4 4 1 . 9 0 27202 Open treatment of coccygeal fracture 8 9 7 . 3 0 27220 Closed treatment of acetabulum (hip socket) fracture(s); without manipulation 8 9 6 . 4 0 27222 Closed treatment of acetabulum (hip socket) fracture(s); with manipulation, with or without skeletal traction 1 , 5 9 9 . 3 0 20 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 27226 Open treatment of posterior or anterior acetabular wall fracture, with internal fixation 3 , 6 0 2 . 7 0 27227 Open treatment of acetabular fracture(s) involving anterior or posterior (one) column, or a fracture running 6 ,057.90 27228 Open treatment of acetabular fracture(s) involving anterior and posterior (two) columns, includes T-fracture 6 ,196.50 27230 Closed treatment of femoral fracture, proximal end, neck; without manipulation 1 , 0 7 7 . 3 0 27232 Closed treatment of femoral fracture, proximal end, neck; with manipulation, with or without skeletal traction 1 , 7 6 9 . 4 0 27235 Percutaneous skeletal fixation of femoral fracture, proximal end, neck, undisplaced, mildly displaced, or 3 ,135.60 27236 Open treatment of femoral fracture, proximal end, neck, internal fixation or prosthetic replacement 3 , 7 1 2 . 5 0 27238 Closed treatment of intertrochanteric, pertrochanteric, or subtrochanteric femoral fracture; without 1 ,142.10 27240 Closed treatment of intertrochanteric, pertrochanteric, or subtrochanteric femoral fracture; with 2 ,139.30 27244 Open treatment of intertrochanteric, pertrochanteric, or subtrochanteric femoral fracture; with plate/screw 3 ,339.00 27245 Open treatment of intertrochanteric, pertrochanteric, or subtrochanteric femoral fracture; with intramedullary 3 ,947.40 27246 Closed treatment of greater trochanteric fracture, without manipulation 9 0 3 . 6 0 27248 Open treatment of greater trochanteric fracture, with or without internal or external fixation 2 , 2 2 1 . 2 0 27250 Closed treatment of hip dislocation, traumatic; without anesthesia 7 6 4 . 1 0 27252 Closed treatment of hip dislocation, traumatic; requiring anesthesia 1 , 1 3 4 . 9 0 27253 Open treatment of hip dislocation, traumatic, without internal fixation 2 , 4 5 1 . 6 0 27254 Open treatment of hip dislocation, traumatic, with acetabular wall and femoral head fracture, with or without 3 ,348.00 27256 Treatment of spontaneous hip dislocation (developmental, including congenital or pathological), by 1 ,652.40 27257 Treatment of spontaneous hip dislocation (developmental, including congenital or pathological), by 1 ,835.10 27258 Open treatment of spontaneous hip dislocation (developmental, including congenital or pathological), 2 ,468.70 27259 Open treatment of spontaneous hip dislocation (developmental, including congenital or pathological), 2 ,904.30 27265 Closed treatment of post hip arthroplasty dislocation; without anesthesia 7 7 2 . 2 0 27266 Closed treatment of post hip arthroplasty dislocation; requiring regional or general anesthesia 1 , 5 3 5 . 4 0 27267 Closed tx femoral fracture prox head w/o mnpj 8 64.17 27268 Closed tx femoral fracture prox head w mnpj 1 ,109.74 27269 Open tx femoral fracture proximal end head 2 ,878.69 27275 Manipulation, hip joint, requiring general anesthesia 5 0 5 . 8 0 27280 Arthrodesis, sacroiliac joint (including obtaining graft) 2 , 4 6 4 . 2 0 27282 Arthrodesis, symphysis pubis (including obtaining graft) 2 , 4 6 1 . 5 0 27284 Arthrodesis, hip joint (including obtaining graft); 4 , 9 7 5 . 2 0 27286 Arthrodesis, hip joint (including obtaining graft); with subtrochanteric osteotomy 4 , 0 9 7 . 7 0 27290 Interpelviabdominal amputation (hindquarter amputation) 5 , 9 7 8 . 7 0 27295 Disarticulation of hip 4 , 3 5 5 . 1 0 27301 Incision and drainage, deep abscess, bursa, or hematoma, thigh or knee region 8 3 2 . 9 4 27303 Incision, deep, with opening of bone cortex, femur or knee (eg, osteomyelitis or bone abscess) 1 , 8 1 8 . 0 0 27305 Fasciotomy, iliotibial (tenotomy), open 1 , 0 5 5 . 7 0 27306 Tenotomy, percutaneous, adductor or hamstring; single tendon (separate procedure) 6 8 1 . 3 0 27307 Tenotomy, percutaneous, adductor or hamstring; multiple tendons 1 , 0 2 4 . 2 0 27310 Arthrotomy, knee, with exploration, drainage, or removal of foreign body (eg, infection) 1 , 7 8 7 . 4 0 27323 Biopsy, soft tissue of thigh or knee area; superficial 3 6 0 . 9 0 27324 Biopsy, soft tissue of thigh or knee area; deep (subfascial or intramuscular) 8 0 7 . 3 0 27325 Neurectomy hamstring muscle 1 ,757.66 27326 Neurectomy popliteal 1 ,605.75 27327 Excision, tumor, thigh or knee area; subcutaneous 7 2 0 . 0 0 27328 Excision, tumor, thigh or knee area; deep, subfascial, or intramuscular 1 , 2 5 6 . 4 0 27329 Radical resection of tumor (eg, malignant neoplasm), soft tissue of thigh or knee area 2 , 6 2 5 . 3 0 27330 Arthrotomy, knee; with synovial biopsy only 2 , 0 2 2 . 3 0 27331 Arthrotomy, knee; including joint exploration, biopsy, or removal of loose or foreign bodies 1 , 8 0 6 . 3 0 27332 Arthrotomy, with excision of semilunar cartilage (meniscectomy) knee; medial OR lateral 2 , 3 9 9 . 4 0 27333 Arthrotomy, with excision of semilunar cartilage (meniscectomy) knee; medial AND lateral 3 , 1 7 4 . 1 4 27334 Arthrotomy, with synovectomy, knee; anterior OR posterior 2 , 4 2 1 . 0 0 27335 Arthrotomy, with synovectomy, knee; anterior AND posterior including popliteal area 2 , 8 9 5 . 3 0 27337 Excison tumor soft tissue thigh/knee subq 3+cm 1 ,376.91 27339 Exc tumor soft tissue thigh/knee subfasc 5+cm 2 ,414.25 27340 Excision, prepatellar bursa 1 , 1 0 3 . 4 0 27345 Excision of synovial cyst of popliteal space (eg, Baker's cyst) 1 , 5 2 4 . 6 0 27347 Excision of lesion of meniscus or capsule (eg, cyst, ganglion), knee 7 8 4 . 8 0 27350 Patellectomy or hemipatellectomy 2 , 1 2 4 . 0 0 27355 Excision or curettage of bone cyst or benign tumor of femur; 1 , 8 0 2 . 7 0 27356 Excision or curettage of bone cyst or benign tumor of femur; with allograft 2 , 1 9 9 . 6 0 27357 Excision or curettage of bone cyst or benign tumor of femur; with autograft (includes obtaining graft) 2 , 4 3 6 . 3 0 27358 Excision or curettage of bone cyst or benign tumor of femur; with internal fixation (List in addition to code for 2 ,508.30 27360 Partial excision (craterization, saucerization, or diaphysectomy) bone, femur, proximal tibia and/or fibula (eg, 1 ,926.90 27364 Rad resection tumor soft tissue thigh/knee 5+cm 4 ,912.84 27365 Radical resection of tumor, bone, femur or knee 3 , 1 2 7 . 5 0 27370 Injection procedure for knee arthrography 1 9 7 . 1 0 27372 Removal of foreign body, deep, thigh region or knee area 9 5 5 . 8 0 27380 Suture of infrapatellar tendon; primary 1 , 6 0 2 . 0 0 27381 Suture of infrapatellar tendon; secondary reconstruction, including fascial or tendon graft 2 , 4 8 0 . 4 0 27385 Suture of quadriceps or hamstring muscle rupture; primary 1 , 8 2 7 . 9 0 21 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 27386 Suture of quadriceps or hamstring muscle rupture; secondary reconstruction, including fascial or tendon 2 ,734.20 27390 Tenotomy, open, hamstring, knee to hip; single tendon 1 , 0 6 1 . 1 0 27391 Tenotomy, open, hamstring, knee to hip; multiple tendons, one leg 1 , 3 9 0 . 5 0 27392 Tenotomy, open, hamstring, knee to hip; multiple tendons, bilateral 2 , 0 0 8 . 8 0 27393 Lengthening of hamstring tendon; single tendon 1 , 0 7 1 . 0 0 27394 Lengthening of hamstring tendon; multiple tendons, one leg 1 , 6 3 2 . 6 0 27395 Lengthening of hamstring tendon; multiple tendons, bilateral 2 , 0 3 8 . 5 0 27396 Transplant, hamstring tendon to patella; single tendon 2 , 1 3 1 . 2 0 27397 Transplant, hamstring tendon to patella; multiple tendons 2 , 7 0 7 . 2 0 27400 Transfer, tendon or muscle, hamstrings to femur (eg, Egger's type procedure) 1 , 9 8 0 . 0 0 27403 Arthrotomy with meniscus repair, knee 2 , 7 4 5 . 0 0 27405 Repair, primary, torn ligament and/or capsule, knee; collateral 2 , 2 7 2 . 5 0 27407 Repair, primary, torn ligament and/or capsule, knee; cruciate 3 , 1 9 0 . 5 0 27409 Repair, primary, torn ligament and/or capsule, knee; collateral and cruciate ligaments 3 , 6 3 4 . 2 0 27412 Autologous chondrocyte implantation knee 5 ,606.85 27415 Osteochondral allograft knee open 4 ,366.31 27416 Osteochondral autograft knee open mosaicplasty 2 ,968.11 27418 Anterior tibial tubercleplasty (eg, Maquet type procedure) 3 , 0 0 2 . 4 0 27420 Reconstruction of dislocating patella; (eg, Hauser type procedure) 2 , 2 9 3 . 2 0 27422 Reconstruction of dislocating patella; with extensor realignment and/or muscle advancement or release (eg, 2 ,475.00 27424 Reconstruction of dislocating patella; with patellectomy 2 , 7 6 5 . 7 0 27425 Lateral retinacular release (any method) 2 , 3 6 7 . 0 0 27427 Ligamentous reconstruction (augmentation), knee; extra-articular 3 , 6 9 8 . 1 0 27428 Ligamentous reconstruction (augmentation), knee; intra-articular (open) 3 , 7 1 5 . 2 0 27429 Ligamentous reconstruction (augmentation), knee; intra-articular (open) and extra-articular 4 , 9 6 0 . 8 0 27430 Quadricepsplasty (eg, Bennett or Thompson type) 2 , 2 1 0 . 4 0 27435 Capsulotomy, posterior capsular release, knee 2 , 2 3 6 . 5 0 27437 Arthroplasty, patella; without prosthesis 2 , 2 7 4 . 3 0 27438 Arthroplasty, patella; with prosthesis 2 , 7 2 0 . 7 0 27440 Arthroplasty, knee, tibial plateau; 3 , 2 9 2 . 2 0 27441 Arthroplasty, knee, tibial plateau; with debridement and partial synovectomy 3 , 0 0 2 . 4 0 27442 Arthroplasty, femoral condyles or tibial plateau(s), knee; 3 , 5 1 0 . 0 0 27443 Arthroplasty, femoral condyles or tibial plateau(s), knee; with debridement and partial synovectomy 3 , 5 5 4 . 1 0 27445 Arthroplasty, knee, hinge prosthesis (eg, Walldius type) 4 , 4 9 9 . 1 0 27446 Arthroplasty, knee, condyle and plateau; medial OR lateral compartment 4 , 1 2 6 . 6 3 27447 Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella 5 ,226.12 27448 Osteotomy, femur, shaft or supracondylar; without fixation 2 , 8 7 7 . 3 0 27450 Osteotomy, femur, shaft or supracondylar; with fixation 2 , 8 2 6 . 9 0 27454 Osteotomy, multiple, with realignment on intramedullary rod, femoral shaft (eg, Sofield type procedure) 3 , 2 9 5 . 8 0 27455 Osteotomy, proximal tibia, including fibular excision or osteotomy (includes correction of genu varus 2 ,394.90 27457 Osteotomy, proximal tibia, including fibular excision or osteotomy (includes correction of genu varus 2 ,886.30 27465 Osteoplasty, femur; shortening (excluding 64876) 3 , 2 6 7 . 9 0 27466 Osteoplasty, femur; lengthening 3 , 7 0 7 . 1 0 27468 Osteoplasty, femur; combined, lengthening and shortening with femoral segment transfer 4 , 8 5 3 . 7 0 27470 Repair, nonunion or malunion, femur, distal to head and neck; without graft (eg, compression technique) 3 , 5 7 9 . 3 0 27472 Repair, nonunion or malunion, femur, distal to head and neck; with iliac or other autogenous bone graft 4 ,050.00 27475 Arrest, epiphyseal, any method (eg, epiphydiodesis); distal femur 2 , 4 5 3 . 4 0 27477 Arrest, epiphyseal, any method (eg, epiphydiodesis); tibia and fibula, proximal 2 , 6 3 6 . 1 0 27479 Arrest, epiphyseal, any method (eg, epiphydiodesis); combined distal femur, proximal tibia and fibula 3 , 1 6 0 . 8 0 27485 Arrest, hemiepiphyseal, distal femur or proximal tibia or fibula (eg, genu varus or valgus) 1 , 8 0 5 . 4 0 27486 Revision of total knee arthroplasty, with or without allograft; one component 5 , 1 7 5 . 9 0 27487 Revision of total knee arthroplasty, with or without allograft; femoral and entire tibial component 6 , 4 5 2 .

1 0 27488 Removal of prosthesis, including total knee prosthesis, methylmethacrylate with or without insertion of 3 ,144.60 27495 Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate, femur 3 , 4 5 0 . 6 0 27496 Decompression fasciotomy, thigh and/or knee, one compartment (flexor or extensor or adductor); 1 , 1 8 4 . 4 0 27497 Decompression fasciotomy, thigh and/or knee, one compartment (flexor or extensor or adductor); with 1 ,555.20 27498 Decompression fasciotomy, thigh and/or knee, multiple compartments; 2 , 3 9 4 . 9 0 27499 Decompression fasciotomy, thigh and/or knee, multiple compartments; with debridement of nonviable 2 ,421.00 27500 Closed treatment of femoral shaft fracture, without manipulation 1 , 2 0 7 . 8 0 27501 Closed treatment of supracondylar or transcondylar femoral fracture with or without intercondylar extension, 1 ,495.80 27502 Closed treatment of femoral shaft fracture, with manipulation, with or without skin or skeletal traction 1 , 6 4 8 . 8 0 27503 Closed treatment of supracondylar or transcondylar femoral fracture with or without intercondylar extension, 2 ,035.80 27506 Open treatment of femoral shaft fracture, with or without external fixation, with insertion of intramedullary 3 ,828.60 27507 Open treatment of femoral shaft fracture with plate/screws, with or without cerclage 3 , 3 8 6 . 7 0 27508 Closed treatment of femoral fracture, distal end, medial or lateral condyle, without manipulation 1 , 0 1 7 . 0 0 27509 Percutaneous skeletal fixation of femoral fracture, distal end, medial or lateral condyle, or supracondylar or 1 ,913.40 27510 Closed treatment of femoral fracture, distal end, medial or lateral condyle, with manipulation 1 , 4 4 7 . 2 0 27511 Open treatment of femoral supracondylar or transcondylar fracture without intercondylar extension, with or 3 ,213.90 27513 Open treatment of femoral supracondylar or transcondylar fracture with intercondylar extension, with or 3 ,411.90 27514 Open treatment of femoral fracture, distal end, medial or lateral condyle, with or without internal or external 3 ,283.20 22 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 27516 Closed treatment of distal femoral epiphyseal separation; without manipulation 1 , 2 7 4 . 4 0 27517 Closed treatment of distal femoral epiphyseal separation; with manipulation, with or without skin or skeletal 1 ,467.90 27519 Open treatment of distal femoral epiphyseal separation, with or without internal or external fixation 3 , 1 1 9 . 4 0 27520 Closed treatment of patellar fracture, without manipulation 5 7 8 . 7 0 27524 Open treatment of patellar fracture, with internal fixation and/or partial or complete patellectomy and soft 2 ,121.30 27530 Closed treatment of tibial fracture, proximal (plateau); without manipulation 8 5 2 . 3 0 27532 Closed treatment of tibial fracture, proximal (plateau); with or without manipulation, with skeletal traction 1 , 1 6 9 . 1 0 27535 Open treatment of tibial fracture, proximal (plateau); unicondylar, with or without internal or external fixation 2 , 6 6 5 . 8 0 27536 Open treatment of tibial fracture, proximal (plateau); bicondylar, with or without internal fixation 2 , 6 1 5 . 4 0 27538 Closed treatment of intercondylar spine(s) and/or tuberosity fracture(s) of knee, with or without manipulation 9 5 0 . 4 0 27540 Open treatment of intercondylar spine(s) and/or tuberosity fracture(s) of the knee, with or without internal or 2 ,468.70 27550 Closed treatment of knee dislocation; without anesthesia 6 6 9 . 6 0 27552 Closed treatment of knee dislocation; requiring anesthesia 1 , 0 5 0 . 3 0 27556 Open treatment of knee dislocation, with or without internal or external fixation; without primary ligamentous 2 ,856.60 27557 Open treatment of knee dislocation, with or without internal or external fixation; with primary ligamentous 3 ,537.90 27558 Open treatment of knee dislocation, with or without internal or external fixation; with primary ligamentous 3 ,331.80 27560 Closed treatment of patellar dislocation; without anesthesia 4 6 1 . 7 0 27562 Closed treatment of patellar dislocation; requiring anesthesia 7 8 9 . 3 0 27566 Open treatment of patellar dislocation, with or without partial or total patellectomy 2 , 0 6 0 . 1 0 27570 Manipulation of knee joint under general anesthesia (includes application of traction or other fixation 5 29.96 27580 Arthrodesis, knee, any technique 3 , 8 2 2 . 3 0 27590 Amputation, thigh, through femur, any level; 2 , 4 4 6 . 2 0 27591 Amputation, thigh, through femur, any level; immediate fitting technique including first cast 2 , 5 8 3 . 0 0 27592 Amputation, thigh, through femur, any level; open, circular (guillotine) 2 , 5 4 3 . 4 0 27594 Amputation, thigh, through femur, any level; secondary closure or scar revision 1 , 2 3 5 . 7 0 27596 Amputation, thigh, through femur, any level; re-amputation 2 , 3 7 9 . 6 0 27598 Disarticulation at knee 2 , 4 4 3 . 5 0 27600 Decompression fasciotomy, leg; anterior and/or lateral compartments only 9 9 1 . 8 0 27601 Decompression fasciotomy, leg; posterior compartment(s) only 1 , 0 9 7 . 1 0 27602 Decompression fasciotomy, leg; anterior and/or lateral, and posterior compartment(s) 1 , 4 0 3 . 1 0 27603 Incision and drainage, leg or ankle; deep abscess or hematoma 7 9 9 . 2 9 27604 Incision and drainage, leg or ankle; infected bursa 5 2 9 . 2 0 27605 Tenotomy, percutaneous, Achilles tendon (separate procedure); local anesthesia 4 8 9 . 6 0 27606 Tenotomy, percutaneous, Achilles tendon (separate procedure); general anesthesia 9 1 8 . 9 0 27607 Incision (eg, osteomyelitis or bone abscess), leg or ankle 1 , 3 9 0 . 5 0 27610 Arthrotomy, ankle, including exploration, drainage, or removal of foreign body 1 , 5 0 4 . 8 0 27612 Arthrotomy, posterior capsular release, ankle, with or without Achilles tendon lengthening 1 , 5 9 1 . 2 0 27613 Biopsy, soft tissue of leg or ankle area; superficial 4 2 1 . 2 0 27614 Biopsy, soft tissue of leg or ankle area; deep (subfascial or intramuscular) 8 4 2 . 4 0 27615 Radical resection of tumor (eg, malignant neoplasm), soft tissue of leg or ankle area 2 , 8 7 0 . 1 0 27616 Rad rescj tum soft tissue leg/ankle 5+cm 3 ,296.27 27618 Excision, tumor, leg or ankle area; subcutaneous tissue 8 4 6 . 0 0 27619 Excision, tumor, leg or ankle area; deep (subfascial or intramuscular) 1 , 3 3 3 . 8 0 27620 Arthrotomy, ankle, with joint exploration, with or without biopsy, with or without removal of loose or foreign 1 ,577.70 27625 Arthrotomy, with synovectomy, ankle; 2 , 1 0 3 . 3 0 27626 Arthrotomy, with synovectomy, ankle; including tenosynovectomy 2 , 2 0 2 . 3 0 27630 Excision of lesion of tendon sheath or capsule (eg, cyst or ganglion), leg and/or ankle 8 6 7 . 6 0 27632 Excision tumor soft tissue leg/ankle subq 3+ cm 8 02.95 27634 Exc tumor soft tissue leg/ankle subfasc 5+cm 1 ,801.95 27635 Excision or curettage of bone cyst or benign tumor, tibia or fibula; 1 , 9 7 9 . 1 0 27637 Excision or curettage of bone cyst or benign tumor, tibia or fibula; with autograft (includes obtaining graft) 2 , 0 9 5 . 2 0 27638 Excision or curettage of bone cyst or benign tumor, tibia or fibula; with allograft 2 , 3 0 1 . 3 0 27640 Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis or exostosis); tibia 2 , 3 3 8 . 2 0 27641 Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis or exostosis); fibula 1 , 8 8 3 . 7 0 27645 Radical resection of tumor, bone; tibia 2 , 8 8 4 . 5 0 27646 Radical resection of tumor, bone; fibula 2 , 2 8 7 . 8 0 27647 Radical resection of tumor, bone; talus or calcaneus 2 , 7 6 6 . 6 0 27648 Injection procedure for ankle arthrography 1 8 7 . 2 0 27650 Repair, primary, open or percutaneous, ruptured Achilles tendon; 1 , 9 0 8 . 6 6 27652 Repair, primary, open or percutaneous, ruptured Achilles tendon; with graft (includes obtaining graft) 2 , 3 3 5 . 5 0 27654 Repair, secondary, Achilles tendon, with or without graft 2 , 6 7 2 . 1 0 27656 Repair, fascial defect of leg 1 , 0 3 5 . 9 0 27658 Repair, flexor tendon, leg; primary, without graft, each tendon 1 , 1 1 5 . 1 0 27659 Repair, flexor tendon, leg; secondary, with or without graft, each tendon 1 , 6 0 6 . 5 0 27664 Repair, extensor tendon, leg; primary, without graft, each tendon 1 , 0 8 5 . 4 0 27665 Repair, extensor tendon, leg; secondary, with or without graft, each tendon 1 , 1 5 7 . 4 0 27675 Repair, dislocating peroneal tendons; without fibular osteotomy 1 , 2 9 5 . 1 0 27676 Repair, dislocating peroneal tendons; with fibular osteotomy 1 , 3 3 9 . 2 0 27680 Tenolysis, flexor or extensor tendon, leg and/or ankle; single, each tendon 1 , 3 3 1 . 1 0 27681 Tenolysis, flexor or extensor tendon, leg and/or ankle; multiple tendons (through separate incision(s)) 1 , 0 4 2 . 2 0 23 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 27685 Lengthening or shortening of tendon, leg or ankle; single tendon (separate procedure) 1 , 2 0 0 . 6 0 27686 Lengthening or shortening of tendon, leg or ankle; multiple tendons (through same incision), each 1 , 3 6 3 . 5 0 27687 Gastrocnemius recession (eg, Strayer procedure) 1 , 1 7 1 . 8 0 27690 Transfer or transplant of single tendon (with muscle redirection or rerouting); superficial (eg, anterior tibial 1 ,647.90 27691 Transfer or transplant of single tendon (with muscle redirection or rerouting); deep (eg, anterior tibial or 1 ,859.40 27692 Transfer or transplant of single tendon (with muscle redirection or rerouting); each additional tendon (List 5 44.50 27695 Repair, primary, disrupted ligament, ankle; collateral 1 , 7 0 3 . 7 0 27696 Repair, primary, disrupted ligament, ankle; both collateral ligaments 2 , 3 3 8 . 2 0 27698 Repair, secondary, disrupted ligament, ankle, collateral (eg, Watson-Jones procedure) 2 , 3 6 7 . 0 0 27700 Arthroplasty, ankle; 2 , 8 0 7 . 1 0 27702 Arthroplasty, ankle; with implant (total ankle) 4 , 0 4 2 . 8 0 27703 Arthroplasty, ankle; revision, total ankle 3 , 9 1 9 . 5 0 27704 Removal of ankle implant 2 , 1 3 7 . 5 0 27705 Osteotomy; tibia 2 , 2 4 1 . 0 0 27707 Osteotomy; fibula 1 , 2 8 3 . 4 0 27709 Osteotomy; tibia and fibula 2 , 7 5 5 . 8 0 27712 Osteotomy; multiple, with realignment on intramedullary rod (eg, Sofield type procedure) 2 , 6 0 1 . 0 0 27715 Osteoplasty, tibia and fibula, lengthening or shortening 3 , 4 4 5 . 2 0 27720 Repair of nonunion or malunion, tibia; without graft, (eg, compression technique) 2 , 9 8 7 . 1 0 27722 Repair of nonunion or malunion, tibia; with sliding graft 3 , 0 2 7 . 6 0 27724 Repair of nonunion or malunion, tibia; with iliac or other autograft (includes obtaining graft) 3 , 3 7 5 . 9 0 27725 Repair of nonunion or malunion, tibia; by synostosis, with fibula, any method 3 , 7 1 1 . 6 0 27726 Repair fibula nonunion/malunion w int fixation 2 ,950.61 27727 Repair of congenital pseudarthrosis, tibia 2 , 6 9 9 . 1 0 27730 Arrest, epiphyseal (epiphysiodesis), any method; distal tibia 1 , 6 2 4 . 5 0 27732 Arrest, epiphyseal (epiphysiodesis), any method; distal fibula 1 , 2 3 5 . 7 0 27734 Arrest, epiphyseal (epiphysiodesis), any method; distal tibia and fibula 1 , 8 3 0 . 6 0 27740 Arrest, epiphyseal (epiphysiodesis), any method, combined, proximal and distal tibia and fibula; 2 , 4 1 5 . 6 0 27742 Arrest, epiphyseal (epiphysiodesis), any method, combined, proximal and distal tibia and fibula; and distal 3 ,129.30 27745 Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate, tibia 2 , 4 9 3 . 0 0 27750 Closed treatment of tibial shaft fracture (with or without fibular fracture); without manipulation 7 0 2 . 9 7 27752 Closed treatment of tibial shaft fracture (with or without fibular fracture); with manipulation, with or without 1 ,081.80 27756 Percutaneous skeletal fixation of tibial shaft fracture (with or without fibular fracture) (eg, pins or screws) 2 , 0 8 6 . 2 0 27758 Open treatment of tibial shaft fracture, (with or without fibular fracture) with plate/screws, with or without 2 ,968.20 27759 Open treatment of tibial shaft fracture (with or without fibular fracture) by intramedullary implant, with or 3 ,328.20 27760 Closed treatment of medial malleolus fracture; without manipulation 5 0 3 . 1 0 27762 Closed treatment of medial malleolus fracture; with manipulation, with or without skin or skeletal traction 8 2 4 . 4 0 27766 Open treatment of medial malleolus fracture, with or without internal or external fixation 1 , 5 5 3 . 4 0 27767 Cltx post ankle fx 5 48.09 27768 Closed treatment pst malleolus fracture w mnpj 8 68.53 27769 Open treatment posterior malleolus fracture 1 ,707.43 27780 Closed treatment of proximal fibula or shaft fracture; without manipulation 5 6 2 . 5 0 27781 Closed treatment of proximal fibula or shaft fracture; with manipulation 8 9 3 . 7 0 27784 Open treatment of proximal fibula or shaft fracture, with or without internal or external fixation 1 , 6 0 5 . 6 0 27786 Closed treatment of distal fibular fracture (lateral malleolus); without manipulation 4 6 3 . 5 0 27788 Closed treatment of distal fibular fracture (lateral malleolus); with manipulation 8 1 8 . 1 0 27792 Open treatment of distal fibular fracture (lateral malleolus), with or without internal or external fixation 1 , 5 3 9 . 9 0 27808 Closed treatment of bimalleolar ankle fracture, (including Potts); without manipulation 6 4 3 .5 0 27810 Closed treatment of bimalleolar ankle fracture, (including Potts); with manipulation 1 , 1 8 9 . 8 0 27814 Open treatment of bimalleolar ankle fracture, with or without internal or external fixation 2 , 1 9 6 . 9 0 27816 Closed treatment of trimalleolar ankle fracture; without manipulation 8 4 2 . 4 0 27818 Closed treatment of trimalleolar ankle fracture; with manipulation 1 , 3 1 2 . 2 0 27822 Open treatment of trimalleolar ankle fracture, with or without internal or external fixation, medial and/or 2 ,358.90 27823 Open treatment of trimalleolar ankle fracture, with or without internal or external fixation, medial and/or 2 ,880.90 27824 Closed treatment of fracture of weight bearing articular portion of distal tibia (eg, pilon or tibial plafond), with 8 13.60 27825 Closed treatment of fracture of weight bearing articular portion of distal tibia (eg, pilon or tibial plafond), with 1 ,673.10 27826 Open treatment of fracture of weight bearing articular surface/portion of distal tibia (eg, pilon or tibial 2 ,421.00 27827 Open treatment of fracture of weight bearing articular surface/portion of distal tibia (eg, pilon or tibial 2 ,786.40 27828 Open treatment of fracture of weight bearing articular surface/portion of distal tibia (eg, pilon or tibial 3 ,352.50 27829 Open treatment of distal tibiofibular joint (syndesmosis) disruption, with or without internal or external 1 ,629.90 27830 Closed treatment of proximal tibiofibular joint dislocation; without anesthesia 6 0 7 . 5 0 27831 Closed treatment of proximal tibiofibular joint dislocation; requiring anesthesia 6 9 5 . 7 0 27832 Open treatment of proximal tibiofibular joint dislocation, with or without internal or external fixation, or with 1 ,254.60 27840 Closed treatment of ankle dislocation; without anesthesia 5 3 7 . 3 0 27842 Closed treatment of ankle dislocation; requiring anesthesia, with or without percutaneous skeletal fixation 7 6 1 . 4 0 27846 Open treatment of ankle dislocation, with or without percutaneous skeletal fixation; without repair or internal 1 ,946.70 27848 Open treatment of ankle dislocation, with or without percutaneous skeletal fixation; with repair or internal or 2 ,139.30 27860 Manipulation of ankle under general anesthesia (includes application of traction or other fixation apparatus) 4 2 5 . 7 0 27870 Arthrodesis, ankle, any method 2 , 7 0 8 . 1 0 27871 Arthrodesis, tibiofibular joint, proximal or distal 2 , 1 7 4 . 4 0 24 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 27880 Amputation, leg, through tibia and fibula; 2 , 4 6 2 . 4 0 27881 Amputation, leg, through tibia and fibula; with immediate fitting technique including application of first cast 2 , 8 3 7 . 7 0 27882 Amputation, leg, through tibia and fibula; open, circular (guillotine) 2 , 3 6 6 . 1 0 27884 Amputation, leg, through tibia and fibula; secondary closure or scar revision 1 , 4 8 8 . 6 0 27886 Amputation, leg, through tibia and fibula; re-amputation 2 , 3 7 5 . 1 0 27888 Amputation, ankle, through malleoli of tibia and fibula (eg, Syme, Pirogoff type procedures), with plastic 2 ,007.90 27889 Ankle disarticulation 1 , 8 8 6 .4 0 27892 Decompression fasciotomy, leg; anterior and/or lateral compartments only, with debridement of nonviable 1 ,674.00 27893 Decompression fasciotomy, leg; posterior compartment(s) only, with debridement of nonviable muscle 1 ,622.70 27894 Decompression fasciotomy, leg; anterior and/or lateral, and posterior compartment(s), with debridement of 1 ,946.70 28001 Incision and drainage, bursa, foot 4 1 2 . 2 0 28002 Incision and drainage below fascia, with or without tendon sheath involvement, foot; single bursal space 7 7 9 . 4 0 28003 Incision and drainage below fascia, with or without tendon sheath involvement, foot; multiple areas 9 7 3 . 8 0 28005 Incision, bone cortex (eg, osteomyelitis or bone abscess), foot 9 9 1 . 8 0 28008 Fasciotomy, foot and/or toe 7 0 0 . 2 0 28010 Tenotomy, percutaneous, toe; single tendon 4 2 5 . 7 0 28011 Tenotomy, percutaneous, toe; multiple tendons 5 2 6 . 5 0 28020 Arthrotomy, including exploration, drainage, or removal of loose or foreign body; intertarsal or 1 ,106.10 28022 Arthrotomy, including exploration, drainage, or removal of loose or foreign body; metatarsophalangeal joint 7 2 5 . 4 0 28024 Arthrotomy, including exploration, drainage, or removal of loose or foreign body; interphalangeal joint 6 6 9 . 6 0 28035 Release, tarsal tunnel (posterior tibial nerve decompression) 1 , 6 5 3 . 3 0 28039 Excision tumor soft tissue foot/toe subq 1.5+cm 8 05.26 28041 Exc tumor soft tissue foot/toe subfasc 1.5+cm 9 41.09 28043 Excision, tumor, foot; subcutaneous tissue 5 2 5 . 6 0 28045 Excision, tumor, foot; deep, subfascial, intramuscular 1 , 0 7 7 . 3 0 28046 Radical resection of tumor (eg, malignant neoplasm), soft tissue of foot 1 , 9 2 3 . 3 0 28047 Rad resection tumor soft tissue foot/toe 3+cm 1 ,845.03 28050 Arthrotomy with biopsy; intertarsal or tarsometatarsal joint 1 , 0 0 0 . 8 0 28052 Arthrotomy with biopsy; metatarsophalangeal joint 6 9 0 . 3 0 28054 Arthrotomy with biopsy; interphalangeal joint 5 8 8 . 6 0 28055 Neurectomy intrinsic musculature of foot 7 57.64 28060 Fasciectomy, plantar fascia; partial (separate procedure) 1 , 0 3 8 . 6 0 28062 Fasciectomy, plantar fascia; radical (separate procedure) 1 , 8 7 2 . 9 0 28070 Synovectomy; intertarsal or tarsometatarsal joint, each 1 , 0 9 7 . 1 0 28072 Synovectomy; metatarsophalangeal joint, each 7 2 7 . 2 0 28080 Excision, interdigital (Morton) neuroma, single, each 8 1 7 . 7 6 28086 Synovectomy, tendon sheath, foot; flexor 1 , 2 4 4 . 7 0 28088 Synovectomy, tendon sheath, foot; extensor 8 7 3 . 9 0 28090 Excision of lesion, tendon, tendon sheath, or capsule (including synovectomy) (eg, cyst or ganglion); foot 7 6 2 . 0 8 28092 Excision of lesion, tendon, tendon sheath, or capsule (including synovectomy) (eg, cyst or ganglion); toe(s), 6 75.00 28100 Excision or curettage of bone cyst or benign tumor, talus or calcaneus; 1 , 2 7 4 . 4 0 28102 Excision or curettage of bone cyst or benign tumor, talus or calcaneus; with iliac or other autograft (includes 1 ,674.00 28103 Excision or curettage of bone cyst or benign tumor, talus or calcaneus; with allograft 1 , 5 7 7 . 7 0 28104 Excision or curettage of bone cyst or benign tumor, tarsal or metatarsal bones, except talus or calcaneus; 1 , 0 5 7 . 5 0 28106 Excision or curettage of bone cyst or benign tumor, tarsal or metatarsal bones, except talus or calcaneus; 1 ,435.50 28107 Excision or curettage of bone cyst or benign tumor, tarsal or metatarsal bones, except talus or calcaneus; 1 ,215.90 28108 Excision or curettage of bone cyst or benign tumor, phalanges of foot 8 6 2 . 2 0 28110 Ostectomy, partial excision, fifth metatarsal head (bunionette) (separate procedure) 8 2 8 . 9 0 28111 Ostectomy, complete excision; first metatarsal head 1 , 0 1 3 . 4 0 28112 Ostectomy, complete excision; other metatarsal head (second, third or fourth) 9 5 6 . 7 0 28113 Ostectomy, complete excision; fifth metatarsal head 9 7 3 . 8 0 28114 Ostectomy, complete excision; all metatarsal heads, with partial proximal phalangectomy, excluding first 2 ,032.20 28116 Ostectomy, excision of tarsal coalition 1 , 5 5 3 . 4 0 28118 Ostectomy, calcaneus; 1 , 2 6 7 . 2 0 28119 Ostectomy, calcaneus; for spur, with or without plantar fascial release 1 , 1 8 4 . 4 0 28120 Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (eg, osteomyelitis or 1 ,287.90 28122 Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (eg, osteomyelitis or 1 ,105.20 28124 Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (eg, osteomyelitis or 7 54.20 28126 Resection, partial or complete, phalangeal base, each toe 7 0 8 . 3 0 28130 Talectomy (astragalectomy) 1 , 6 4 0 . 7 0 28140 Metatarsectomy 1 , 1 3 3 . 1 0 28150 Phalangectomy, toe, each toe 6 9 9 . 3 0 28153 Resection, condyle(s), distal end of phalanx, each toe 7 5 1 . 5 0 28160 Hemiphalangectomy or interphalangeal joint excision, toe, proximal end of phalanx, each 6 5 1 . 6 0 28171 Radical resection of tumor, bone; tarsal (except talus or calcaneus) 1 , 6 2 2 . 7 0 28173 Radical resection of tumor, bone; metatarsal 1 , 4 0 8 . 5 0 28175 Radical resection of tumor, bone; phalanx of toe 9 9 9 . 0 0 28190 Removal of foreign body, foot; subcutaneous 3 4 6 . 5 0 28192 Removal of foreign body, foot; deep 6 7 1 . 4 0 28193 Removal of foreign body, foot; complicated 1 , 0 2 8 . 7 0 25 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 28200 Repair, tendon, flexor, foot; primary or secondary, without free graft, each tendon 1 , 1 3 4 . 0 0 28202 Repair, tendon, flexor, foot; secondary with free graft, each tendon (includes obtaining graft) 1 , 7 6 6 . 7 0 28208 Repair, tendon, extensor, foot; primary or secondary, each tendon 9 6 7 . 5 0 28210 Repair, tendon, extensor, foot; secondary with free graft, each tendon (includes obtaining graft) 1 , 0 3 8 . 6 0 28220 Tenolysis, flexor, foot; single tendon 8 0 3 . 7 0 28222 Tenolysis, flexor, foot; multiple tendons 1 , 0 4 8 . 5 0 28225 Tenolysis, extensor, foot; single tendon 5 8 0 . 5 0 28226 Tenolysis, extensor, foot; multiple tendons 7 4 7 . 0 0 28230 Tenotomy, open, tendon flexor; foot, single or multiple tendon(s) (separate procedure) 7 2 4 . 5 0 28232 Tenotomy, open, tendon flexor; toe, single tendon (separate procedure) 3 9 9 . 6 0 28234 Tenotomy, open, extensor, foot or toe, each tendon 5 1 7 . 5 0 28238 Reconstruction (advancement), posterior tibial tendon with excision of accessory navicular bone (eg, Kidner 1 ,545.30 28240 Tenotomy, lengthening, or release, abductor hallucis muscle 7 1 1 . 9 0 28250 Division of plantar fascia and muscle (eg, Steindler stripping) (separate procedure) 1 , 1 4 8 . 4 0 28260 Capsulotomy, midfoot; medial release only (separate procedure) 1 , 6 0 8 . 3 0 28261 Capsulotomy, midfoot; with tendon lengthening 1 , 5 4 5 . 3 0 28262 Capsulotomy, midfoot; extensive, including posterior talotibial capsulotomy and tendon(s) lengthening (eg, 2 ,923.20 28264 Capsulotomy, midtarsal (eg, Heyman type procedure) 2 ,1 4 5 . 6 0 28270 Capsulotomy; metatarsophalangeal joint, with or without tenorrhaphy, each joint (separate procedure) 7 1 2 . 8 0 28272 Capsulotomy; interphalangeal joint, each joint (separate procedure) 6 5 4 . 3 0 28280 Syndactylization, toes (eg, webbing or Kelikian type procedure) 7 4 7 . 0 0 28285 Correction, hammertoe (eg, interphalangeal fusion, partial or total phalangectomy) 8 1 3 . 6 0 28286 Correction, cock-up fifth toe, with plastic skin closure (eg, Ruiz-Mora type procedure) 8 7 5 . 7 0 28288 Ostectomy, partial, exostectomy or condylectomy, metatarsal head, each metatarsal head 1 , 0 0 9 . 8 0 28289 Hallux rigidus correction with cheilectomy, debridement and capsular release of the first 8 96.40 28290 Correction, hallux valgus (bunion), with or without sesamoidectomy; simple exostectomy (eg, Silver type 1 ,244.70 28292 Correction, hallux valgus (bunion), with or without sesamoidectomy; Keller, McBride, or Mayo type 1 ,545.30 28293 Correction, hallux valgus (bunion), with or without sesamoidectomy; resection of joint with implant 1 , 7 7 6 . 6 0 28294 Correction, hallux valgus (bunion), with or without sesamoidectomy; with tendon transplants (eg, Joplin type 1 ,939.50 28296 Correction, hallux valgus (bunion), with or without sesamoidectomy; with metatarsal osteotomy (eg, Mitchell, 1 ,827.42 28297 Correction, hallux valgus (bunion), with or without sesamoidectomy; Lapidus type procedure 1 , 8 3 1 . 5 0 28298 Correction, hallux valgus (bunion), with or without sesamoidectomy; by phalanx osteotomy 1 , 3 9 2 . 3 0 28299 Correction, hallux valgus (bunion), with or without sesamoidectomy; by other methods (eg, double 1 ,931.40 28300 Osteotomy; calcaneus (eg, Dwyer or Chambers type procedure), with or without internal fixation 1 , 5 0 6 . 6 0 28302 Osteotomy; talus 1 , 6 0 6 . 5 0 28304 Osteotomy, tarsal bones, other than calcaneus or talus; 1 , 3 8 5 . 1 0 28305 Osteotomy, tarsal bones, other than calcaneus or talus; with autograft (includes obtaining graft) (eg, Fowler 1 ,545.30 28306 Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; first metatarsal 1 , 2 8 7 . 9 0 28307 Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; first metatarsal with 1 ,416.60 28308 Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; other than first 1 ,104.30 28309 Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; multiple (eg, Swanson 1 ,880.10 28310 Osteotomy, shortening, angular or rotational correction; proximal phalanx, first toe (separate procedure) 9 8 6 . 4 0 28312 Osteotomy, shortening, angular or rotational correction; other phalanges, any toe 7 2 4 . 5 0 28313 Reconstruction, angular deformity of toe, soft tissue procedures only (eg, overlapping second toe, fifth toe, 9 19.80 28315 Sesamoidectomy, first toe (separate procedure) 1 , 0 9 7 . 1 0 28320 Repair, nonunion or malunion; tarsal bones 1 , 6 4 0 . 7 0 28322 Repair, nonunion or malunion; metatarsal, with or without bone graft (includes obtaining graft) 1 , 3 8 7 . 8 0 28340 Reconstruction, toe, macrodactyly; soft tissue resection 1 , 4 2 7 . 4 0 28341 Reconstruction, toe, macrodactyly; requiring bone resection 1 , 5 4 2 . 6 0 28344 Reconstruction, toe(s); polydactyly 1 , 0 7 3 . 7 0 28345 Reconstruction, toe(s); syndactyly, with or without skin graft(s), each web 1 , 4 7 1 . 5 0 28360 Reconstruction, cleft foot 2 , 4 9 3 . 0 0 28400 Closed treatment of calcaneal fracture; without manipulation 6 2 1 . 9 0 28405 Closed treatment of calcaneal fracture; with manipulation 1 , 0 0 3 . 5 0 28406 Percutaneous skeletal fixation of calcaneal fracture, with manipulation 1 , 2 7 8 . 0 0 28415 Open treatment of calcaneal fracture, with or without internal or external fixation; 2 , 1 6 2 . 7 0 28420 Open treatment of calcaneal fracture, with or without internal or external fixation; with primary iliac or other 2 ,753.10 28430 Closed treatment of talus fracture; without manipulation 5 1 4 . 8 0 28435 Closed treatment of talus fracture; with manipulation 7 6 8 . 6 0 28436 Percutaneous skeletal fixation of talus fracture, with manipulation 9 1 8 . 0 0 28445 Open treatment of talus fracture, with or without internal or external fixation 1 , 9 9 8 . 0 0 28446 Open osteochondral autograft talus 2 ,581.39 28450 Treatment of tarsal bone fracture (except talus and calcaneus); without manipulation, each 4 9 6 . 8 0 28455 Treatment of tarsal bone fracture (except talus and calcaneus); with manipulation, each 6 4 3 . 5 0 28456 Percutaneous skeletal fixation of tarsal bone fracture (except talus and calcaneus), with manipulation, each 7 1 0 . 1 0 28465 Open treatment of tarsal bone fracture (except talus and calcaneus), with or without internal or external 1 ,416.60 28470 Closed treatment of metatarsal fracture; without manipulation, each 4 5 9 . 0 0 28475 Closed treatment of metatarsal fracture; with manipulation, each 5 1 4 . 8 0 28476 Percutaneous skeletal fixation of metatarsal fracture, with manipulation, each 9 2 5 . 2 0 28485 Open treatment of metatarsal fracture, with or without internal or external fixation, each 1 , 1 7 7 . 2 0 26 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 28490 Closed treatment of fracture great toe, phalanx or phalanges; without manipulation 2 6 6 . 4 0 28495 Closed treatment of fracture great toe, phalanx or phalanges; with manipulation 3 7 8 . 9 0 28496 Percutaneous skeletal fixation of fracture great toe, phalanx or phalanges, with manipulation 5 7 6 . 9 0 28505 Open treatment of fracture great toe, phalanx or phalanges, with or without internal or external fixation 7 8 3 . 9 0 28510 Closed treatment of fracture, phalanx or phalanges, other than great toe; without manipulation, each 2 0 8 . 8 0 28515 Closed treatment of fracture, phalanx or phalanges, other than great toe; with manipulation, each 2 9 7 . 0 0 28525 Open treatment of fracture, phalanx or phalanges, other than great toe, with or without internal or external 7 44.30 28530 Closed treatment of sesamoid fracture 3 4 8 . 3 0 28531 Open tx sesamoid fracture +-internal fixation 8 80.47 28540 Closed treatment of tarsal bone dislocation, other than talotarsal; without anesthesia 4 1 0 . 4 0 28545 Closed treatment of tarsal bone dislocation, other than talotarsal; requiring anesthesia 5 6 4 . 3 0 28546 Percutaneous skeletal fixation of tarsal bone dislocation, other than talotarsal, with manipulation 6 9 0 . 3 0 28555 Open treatment of tarsal bone dislocation, with or without internal or external fixation 1 , 0 3 0 . 5 0 28570 Closed treatment of talotarsal joint dislocation; without anesthesia 4 2 5 . 7 0 28575 Closed treatment of talotarsal joint dislocation; requiring anesthesia 5 7 7 . 8 0 28576 Percutaneous skeletal fixation of talotarsal joint dislocation, with manipulation 8 0 1 . 0 0 28585 Open treatment of talotarsal joint dislocation, with or without internal or external fixation 1 , 4 7 6 . 0 0 28600 Closed treatment of tarsometatarsal joint dislocation; without anesthesia 5 3 0 . 1 0 28605 Closed treatment of tarsometatarsal joint dislocation; requiring anesthesia 5 9 2 . 2 0 28606 Percutaneous skeletal fixation of tarsometatarsal joint dislocation, with manipulation 1 , 0 0 9 . 8 0 28615 Open treatment of tarsometatarsal joint dislocation, with or without internal or external fixation 1 , 2 3 5 . 7 0 28630 Closed treatment of metatarsophalangeal joint dislocation; without anesthesia 3 3 5 . 7 0 28635 Closed treatment of metatarsophalangeal joint dislocation; requiring anesthesia 3 6 9 . 9 0 28636 Percutaneous skeletal fixation of metatarsophalangeal joint dislocation, with manipulation 5 6 6 . 1 0 28645 Open treatment of metatarsophalangeal joint dislocation, with or without internal or external fixation 7 8 2 . 1 0 28660 Closed treatment of interphalangeal joint dislocation; without anesthesia 2 3 9 . 4 0 28665 Closed treatment of interphalangeal joint dislocation; requiring anesthesia 3 2 0 . 4 0 28666 Percutaneous skeletal fixation of interphalangeal joint dislocation, with manipulation 5 6 4 . 3 0 28675 Open treatment of interphalangeal joint dislocation, with or without internal or external fixation 6 8 4 . 9 0 28705 Arthrodesis; pantalar 2 , 8 9 7 . 1 0 28715 Arthrodesis; triple 3 , 1 8 5 . 1 0 28725 Arthrodesis; subtalar 2 , 1 3 7 .5 0 28730 Arthrodesis, midtarsal or tarsometatarsal, multiple or transverse; 2 , 2 3 0 . 2 0 28735 Arthrodesis, midtarsal or tarsometatarsal, multiple or transverse; with osteotomy (eg, flatfoot correction) 2 , 1 7 3 . 5 0 28737 Arthrodesis, with tendon lengthening and advancement, midtarsal navicular-cuneiform (eg, Miller type 1 ,982.70 28740 Arthrodesis, midtarsal or tarsometatarsal, single joint 1 , 6 7 4 . 0 0 28750 Arthrodesis, great toe; metatarsophalangeal joint 1 , 3 9 2 . 7 0 28755 Arthrodesis, great toe; interphalangeal joint 1 , 1 8 6 . 2 0 28760 Arthrodesis, with extensor hallucis longus transfer to first metatarsal neck, great toe, interphalangeal joint 1 ,071.90 28800 Amputation, foot; midtarsal (eg, Chopart type procedure) 1 , 8 4 7 . 7 0 28805 Amputation, foot; transmetatarsal 2 , 2 3 8 . 3 0 28810 Amputation, metatarsal, with toe, single 1 ,1 5 2 . 9 0 28820 Amputation, toe; metatarsophalangeal joint 8 7 5 . 7 0 28825 Amputation, toe; interphalangeal joint 7 8 2 . 1 0 28890 Eswt hi nrg pfrmd phys w/us gdn invg plntar fsca 9 05.09 29000 Application of halo type body cast (see 20661-20663 for insertion) 6 0 8 . 4 0 29010 Application of Risser jacket, localizer, body; only 4 9 2 . 3 0 29015 Application of Risser jacket, localizer, body; including head 6 7 0 . 5 0 29020 Application of turnbuckle jacket, body; only 5 3 4 . 6 0 29025 Application of turnbuckle jacket, body; including head 5 7 8 . 7 0 29035 Application of body cast, shoulder to hips; 4 7 5 . 2 0 29040 Application of body cast, shoulder to hips; including head, Minerva type 4 9 5 . 9 0 29044 Application of body cast, shoulder to hips; including one thigh 3 8 0 . 7 0 29046 Application of body cast, shoulder to hips; including both thighs 4 6 9 . 8 0 29049 Application; plaster figure-of-eight 1 9 4 . 4 0 29055 Application; shoulder spica 3 8 9 . 7 0 29058 Application; plaster Velpeau 1 9 8 . 9 0 29065 Application; shoulder to hand (long arm) 2 0 6 . 1 0 29075 Application; elbow to finger (short arm) 1 5 7 . 5 0 29085 Application; hand and lower forearm (gauntlet) 1 5 6 . 0 5 29086 Application cast finger 1 10.50 29105 Application of long arm splint (shoulder to hand) 1 2 8 . 7 0 29125 Application of short arm splint (forearm to hand); static 9 9 . 0 0 29126 Application of short arm splint (forearm to hand); dynamic 1 3 4 . 1 0 29130 Application of finger splint; static 8 2 . 8 0 29131 Application of finger splint; dynamic 1 3 4 . 1 0 29200 Strapping; thorax 8 1 . 0 0 29240 Strapping; shoulder (eg, Velpeau) 9 0 . 0 0 29260 Strapping; elbow or wrist 6 5 . 6 8 29280 Strapping; hand or finger 8 6 . 4 0 27 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 29305 Application of hip spica cast; one leg 5 4 0 . 9 0 29325 Application of hip spica cast; one and one-half spica or both legs 4 9 4 . 1 0 29345 Application of long leg cast (thigh to toes); 2 9 7 . 0 0 29355 Application of long leg cast (thigh to toes); walker or ambulatory type 2 7 0 . 9 0 29358 Application of long leg cast brace 4 5 1 . 8 0 29365 Application of cylinder cast (thigh to ankle) 2 3 6 . 7 0 29405 Application of short leg cast (below knee to toes); 2 1 5 . 1 7 29425 Application of short leg cast (below knee to toes); walking or ambulatory type 2 3 7 . 6 0 29435 Application of patellar tendon bearing (PTB) cast 2 8 2 . 6 0 29440 Adding walker to previously applied cast 8 3 . 7 0 29445 Application of rigid total contact leg cast 3 3 9 . 3 0 29450 Application of clubfoot cast with molding or manipulation, long or short leg 1 7 3 . 7 0 29505 Application of long leg splint (thigh to ankle or toes) 1 5 3 . 9 0 29515 Application of short leg splint (calf to foot) 1 2 0 . 6 0 29520 Strapping; hip 9 8 . 1 0 29530 Strapping; knee 9 5 . 4 0 29540 Strapping; ankle 7 3 . 5 2 29550 Strapping; toes 6 6 . 6 0 29580 Strapping; Unna boot 9 6 . 0 9 29581 Appl mlt-layer venous wound compress below knee 1 32.61 29582 Apply multlay comprs upr leg 1 77.41 29583 Apply multlay comprs upr arm 1 10.04 29584 Appl multlay comprs arm/hand 1 77.41 29700 Removal or bivalving; gauntlet, boot or body cast 9 2 . 4 2 29705 Removal or bivalving; full arm or full leg cast 9 0 . 3 1 29710 Removal or bivalving; shoulder or hip spica, Minerva, or Risser jacket, etc. 1 8 6 . 3 0 29715 Removal or bivalving; turnbuckle jacket 1 2 4 . 2 0 29720 Repair of spica, body cast or jacket 8 7 . 3 0 29730 Windowing of cast 8 5 . 5 0 29740 Wedging of cast (except clubfoot casts) 1 3 6 . 8 0 29750 Wedging of clubfoot cast 9 7 . 2 0 29800 Arthroscopy, temporomandibular joint, diagnostic, with or without synovial biopsy (separate procedure) 1 , 5 4 5 . 3 0 29804 Arthroscopy, temporomandibular joint, surgical 2 , 2 6 6 . 2 0 29805 Arthroscopy shoulder dx +-synovial biopsy spx 1 ,129.02 29806 Arthroscopy shoulder surgical capsulorrhaphy 2 ,796.86 29807 Arthroscopy shoulder surgical repair slap lesion 2 ,663.48 29819 Arthroscopy, shoulder, surgical; with removal of loose body or foreign body 2 , 3 0 4 . 9 0 29820 Arthroscopy, shoulder, surgical; synovectomy, partial 2 , 2 1 5 . 8 0 29821 Arthroscopy, shoulder, surgical; synovectomy, complete 2 , 3 9 6 . 7 0 29822 Arthroscopy, shoulder, surgical; debridement, limited 2 , 4 1 9 . 2 0 29823 Arthroscopy, shoulder, surgical; debridement, extensive 2 , 8 0 1 . 7 0 29824 Arthroscopy shoulder distal claviculectomy 1 ,813.74 29825 Arthroscopy, shoulder, surgical; with lysis and resection of adhesions, with or without manipulation 2 , 4 1 2 . 0 0 29826 Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with or 2 ,722.75 29827 Arthroscopy shoulder rotator cuff repair 2 ,928.75 29828 Arthroscopy shoulder biceps tenodesis 2 ,558.94 29830 Arthroscopy, elbow, diagnostic, with or without synovial biopsy (separate procedure) 1 , 2 0 6 . 0 0 29834 Arthroscopy, elbow, surgical; with removal of loose body or foreign body 2 , 0 5 2 . 0 0 29835 Arthroscopy, elbow, surgical; synovectomy, partial 2 , 3 0 8 . 5 0 29836 Arthroscopy, elbow, surgical; synovectomy, complete 2 , 3 2 2 . 9 0 29837 Arthroscopy, elbow, surgical; debridement, limited 1 , 9 8 1 . 8 0 29838 Arthroscopy, elbow, surgical; debridement, extensive 2 , 2 5 0 . 9 0 29840 Arthroscopy, wrist, diagnostic, with or without synovial biopsy (separate procedure) 1 , 2 1 4 . 1 0 29843 Arthroscopy, wrist, surgical; for infection, lavage and drainage 1 , 7 5 1 . 4 0 29844 Arthroscopy, wrist, surgical; synovectomy, partial 1 , 8 8 1 . 0 0 29845 Arthroscopy, wrist, surgical; synovectomy, complete 1 , 9 1 6 . 1 0 29846 Arthroscopy, wrist, surgical; excision and/or repair of triangular fibrocartilage and/or joint debridement 2 , 2 6 6 . 2 0 29847 Arthroscopy, wrist, surgical; internal fixation for fracture or instability 2 , 0 9 3 . 4 0 29848 Endoscopy, wrist, surgical, with release of transverse carpal ligament 1 , 7 5 8 . 6 0 29850 Arthroscopically aided treatment of intercondylar spine(s) and/or tuberosity fracture(s) of the knee, with or 2 ,285.10 29851 Arthroscopically aided treatment of intercondylar spine(s) and/or tuberosity fracture(s) of the knee, with or 2 ,887.20 29855 Arthroscopically aided treatment of tibial fracture, proximal (plateau); unicondylar, with or without internal or 2 ,574.90 29856 Arthroscopically aided treatment of tibial fracture, proximal (plateau); bicondylar, with or without internal or 2 ,907.90 29860 Arthroscopy, hip, diagnostic with or without synovial biopsy (separate procedure) 1 , 5 4 7 . 1 0 29861 Arthroscopy, hip, surgical; with removal of loose body or foreign body 2 , 2 9 5 . 9 0 29862 Arthroscopy, hip, surgical; with debridement/shaving of articular cartilage (chondroplasty), abrasion 2 ,525.40 29863 Arthroscopy, hip, surgical; with synovectomy 2 , 3 0 6 . 7 0 29866 Arthroscopy knee osteochondral agrft mosaicplast 2 ,666.26 29867 Arthroscopy knee osteochondral allograft 4 ,120.16 29868 Arthroscopy knee meniscal trnsplj med/lat 5 ,488.61 28 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 29870 Arthroscopy, knee, diagnostic, with or without synovial biopsy (separate procedure) 1 , 3 5 2 . 7 0 29871 Arthroscopy, knee, surgical; for infection, lavage and drainage 1 , 9 8 4 . 5 0 29873 Arthroscopy knee lateral release 1 ,675.37 29874 Arthroscopy, knee, surgical; for removal of loose body or foreign body (eg, osteochondritis dissecans 2 ,348.10 29875 Arthroscopy, knee, surgical; synovectomy, limited (eg, plica or shelf resection) (separate procedure) 2 , 4 5 9 . 7 0 29876 Arthroscopy, knee, surgical; synovectomy, major, two or more compartments (eg, medial or lateral) 2 , 7 3 3 . 7 9 29877 Arthroscopy, knee, surgical; debridement/shaving of articular cartilage (chondroplasty) 2 , 5 5 2 . 8 7 29879 Arthroscopy, knee, surgical; abrasion arthroplasty (includes chondroplasty where necessary) or multiple 2 ,652.30 29880 Arthroscopy, knee, surgical; with meniscectomy (medial AND lateral, including any meniscal shaving) 3 , 2 5 4 . 7 1 29881 Arthroscopy, knee, surgical; with meniscectomy (medial OR lateral, including any meniscal shaving) 2 , 7 8 7 . 1 3 29882 Arthroscopy, knee, surgical; with meniscus repair (medial OR lateral) 2 , 9 1 9 . 7 2 29883 Arthroscopy, knee, surgical; with meniscus repair (medial AND lateral) 3 , 7 4 7 . 6 0 29884 Arthroscopy, knee, surgical; with lysis of adhesions, with or without manipulation (separate procedure) 2 , 3 3 7 . 3 0 29885 Arthroscopy, knee, surgical; drilling for osteochondritis dissecans with bone grafting, with or without internal 2 ,697.30 29886 Arthroscopy, knee, surgical; drilling for intact osteochondritis dissecans lesion 2 , 5 4 7 . 9 0 29887 Arthroscopy, knee, surgical; drilling for intact osteochondritis dissecans lesion with internal fixation 3 , 3 8 0 . 4 0 29888 Arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction 4 , 7 9 3 . 7 5 29889 Arthroscopically aided posterior cruciate ligament repair/augmentation or reconstruction 4 , 8 6 7 . 2 0 29891 Arthroscopy, ankle, surgical; excision of osteochondral defect of talus and/or tibia, including drilling of the 2 ,214.90 29892 Arthroscopically aided repair of large osteochondritis dissecans lesion, talar dome fracture, or tibial plafond 2 ,223.90 29893 Endoscopic plantar fasciotomy 1 , 2 3 3 . 0 0 29894 Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; with removal of loose body or foreign body 2 , 2 0 6 . 8 0 29895 Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; synovectomy, partial 2 ,2 9 9 . 5 0 29897 Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; debridement, limited 2 , 1 1 5 . 0 0 29898 Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; debridement, extensive 2 , 7 2 1 . 6 0 29899 Arthroscopy ankle surgical w/ankle arthrodesis 2 ,665.75 29900 Arthroscopy metacarpophalangeal synovial biopsy 1 ,121.89 29901 Arthrs metacarpophalangeal joint debridement 1 ,598.44 29902 Arthrs mtcarphlngl jt w/rdctj ur coltrl ligm 1 ,839.03 29904 Arthrs subtalar joint remove loose/foreign body 2 ,032.59 29905 Arthroscopy subtalar joint with synovectomy 2 ,146.58 29906 Arthroscopy subtalar joint with debridement 2 ,078.55 29907 Arthroscopy subtalar joint subtalar arthrodesis 2 ,547.20 29914 Arthroscopy hip w/femoroplasty 2 ,638.07 29915 Arthroscopy hip w/acetabuloplasty 2 ,795.34 29916 Arthroscopy hip w/labral repair 2 ,795.34 30000 Drainage abscess or hematoma, nasal, internal approach 3 2 9 . 4 0 30020 Drainage abscess or hematoma, nasal septum 3 1 1 . 4 0 30100 Biopsy, intranasal 1 8 7 . 2 0 30110 Excision, nasal polyp(s), simple 3 8 5 . 2 0 30115 Excision, nasal polyp(s), extensive 9 9 2 . 7 0 30117 Excision or destruction, any method (including laser), intranasal lesion; internal approach 8 7 1 . 2 0 30118 Excision or destruction, any method (including laser), intranasal lesion; external approach (lateral 2 ,187.00 30120 Excision or surgical planing of skin of nose for rhinophyma 2 , 0 0 3 . 4 0 30124 Excision dermoid cyst, nose; simple, skin, subcutaneous 7 7 4 . 0 0 30125 Excision dermoid cyst, nose; complex, under bone or cartilage 1 , 9 3 6 . 8 0 30130 Excision turbinate, partial or complete, any method 7 8 5 . 7 0 30140 Submucous resection turbinate, partial or complete, any method 1 , 1 4 9 . 3 0 30150 Rhinectomy; partial 2 , 2 4 2 . 8 0 30160 Rhinectomy; total 2 , 8 8 9 . 0 0 30200 Injection into turbinate(s), therapeutic 1 2 9 . 6 0 30210 Displacement therapy (Proetz type) 2 1 1 . 5 0 30220 Insertion, nasal septal prosthesis (button) 4 0 1 . 4 0 30300 Removal foreign body, intranasal; office type procedure 1 3 4 . 2 1 30310 Removal foreign body, intranasal; requiring general anesthesia 5 6 7 . 9 0 30320 Removal foreign body, intranasal; by lateral rhinotomy 1 , 4 8 2 . 3 0 30400 Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip 3 , 6 5 6 . 7 0 30410 Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages, and/or 3 ,969.90 30420 Rhinoplasty, primary; including major septal repair 4 , 6 7 3 . 7 0 30430 Rhinoplasty, secondary; minor revision (small amount of nasal tip work) 1 , 8 7 7 . 4 0 30435 Rhinoplasty, secondary; intermediate revision (bony work with osteotomies) 2 , 5 3 1 . 7 0 30450 Rhinoplasty, secondary; major revision (nasal tip work and osteotomies) 4 , 1 0 4 . 9 0 30460 Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columellar 2 ,551.50 30462 Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columellar 4 ,778.10 30465 Repair nasal vestibular stenosis 2 ,367.57 30520 Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft 2 , 8 9 1 . 2 7 30540 Repair choanal atresia; intranasal 2 , 0 5 4 . 7 0 30545 Repair choanal atresia; transpalatine 3 , 0 6 3 .6 0 30560 Lysis intranasal synechia 2 4 0 . 3 0 30580 Repair fistula; oromaxillary (combine with 31030 if antrotomy is included) 1 , 6 8 3 . 0 0 29 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 30600 Repair fistula; oronasal 1 , 8 1 9 . 8 0 30620 Septal or other intranasal dermatoplasty (does not include obtaining graft) 2 , 8 3 2 . 3 0 30630 Repair nasal septal perforations 2 , 1 6 2 . 7 0 30801 Cauterization and/or ablation, mucosa of turbinates, unilateral or bilateral, any method, (separate 2 64.60 30802 Cauterization and/or ablation, mucosa of turbinates, unilateral or bilateral, any method, (separate 4 07.70 30901 Control nasal hemorrhage, anterior, simple (limited cautery and/or packing) any method 1 8 9 . 8 1 30903 Control nasal hemorrhage, anterior, complex (extensive cautery and/or packing) any method 2 8 0 . 5 7 30905 Control nasal hemorrhage, posterior, with posterior nasal packs and/or cauterization, any method; initial 4 9 5 . 9 0 30906 Control nasal hemorrhage, posterior, with posterior nasal packs and/or cauterization, any method; 4 49.10 30915 Ligation arteries; ethmoidal 1 , 7 8 1 . 1 0 30920 Ligation arteries; internal maxillary artery, transantral 2 , 6 0 0 . 1 0 30930 Fracture nasal turbinate(s), therapeutic 4 3 7 . 4 0 31000 Lavage by cannulation; maxillary sinus (antrum puncture or natural ostium) 1 3 4 . 2 3 31002 Lavage by cannulation; sphenoid sinus 2 9 1 . 6 0 31020 Sinusotomy, maxillary (antrotomy); intranasal 8 2 2 . 6 0 31030 Sinusotomy, maxillary (antrotomy); radical (Caldwell-Luc) without removal of antrochoanal polyps 1 , 9 6 6 . 5 0 31032 Sinusotomy, maxillary (antrotomy);

radical (Caldwell-Luc) with removal of antrochoanal polyps 2 , 1 6 2 . 7 0 31040 Pterygomaxillary fossa surgery, any approach 3 , 1 7 2 . 5 0 31050 Sinusotomy, sphenoid, with or without biopsy; 1 , 4 8 4 . 1 0 31051 Sinusotomy, sphenoid, with or without biopsy; with mucosal stripping or removal of polyp(s) 2 , 0 5 7 . 4 0 31070 Sinusotomy frontal; external, simple (trephine operation) 1 , 4 9 9 . 4 0 31075 Sinusotomy frontal; transorbital, unilateral (for mucocele or osteoma, Lynch type) 2 , 5 7 4 . 0 0 31080 Sinusotomy frontal; obliterative without osteoplastic flap, brow incision (includes ablation) 3 , 0 0 5 . 1 0 31081 Sinusotomy frontal; obliterative, without osteoplastic flap, coronal incision (includes ablation) 2 , 9 7 1 . 8 0 31084 Sinusotomy frontal; obliterative, with osteoplastic flap, brow incision 3 , 6 0 5 . 4 0 31085 Sinusotomy frontal; obliterative, with osteoplastic flap, coronal incision 3 , 8 8 5 . 3 0 31086 Sinusotomy frontal; nonobliterative, with osteoplastic flap, brow incision 3 , 2 7 8 . 7 0 31087 Sinusotomy frontal; nonobliterative, with osteoplastic flap, coronal incision 3 , 2 1 0 . 3 0 31090 Sinusotomy, unilateral, three or more paranasal sinuses (frontal, maxillary, ethmoid, sphenoid) 4 , 2 3 6 . 3 0 31200 Ethmoidectomy; intranasal, anterior 1 , 3 0 1 . 4 0 31201 Ethmoidectomy; intranasal, total 2 , 0 0 8 . 8 0 31205 Ethmoidectomy; extranasal, total 2 , 1 6 0 . 0 0 31225 Maxillectomy; without orbital exenteration 4 , 4 2 6 . 2 0 31230 Maxillectomy; with orbital exenteration (en bloc) 5 , 3 8 8 . 3 0 31231 Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure) 2 4 4 . 2 8 31233 Nasal/sinus endoscopy, diagnostic with maxillary sinusoscopy (via inferior meatus or canine fossa puncture) 6 8 3 . 1 0 31235 Nasal/sinus endoscopy, diagnostic with sphenoid sinusoscopy (via puncture of sphenoidal face or 7 60.50 31237 Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement (separate procedure) 8 7 1 . 2 0 31238 Nasal/sinus endoscopy, surgical; with control of epistaxis 9 0 9 . 9 0 31239 Nasal/sinus endoscopy, surgical; with dacryocystorhinostomy 2 , 7 6 8 . 4 0 31240 Nasal/sinus endoscopy, surgical; with concha bullosa resection 8 4 2 . 4 0 31254 Nasal/sinus endoscopy, surgical; with ethmoidectomy, partial (anterior) 1 , 6 9 0 . 2 0 31255 Nasal/sinus endoscopy, surgical; with ethmoidectomy, total (anterior and posterior) 1 , 7 8 9 . 3 5 31256 Nasal/sinus endoscopy, surgical, with maxillary antrostomy; 1 , 5 3 0 . 0 0 31267 Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus 1 , 8 6 7 . 5 0 31276 Nasal/sinus endoscopy, surgical with frontal sinus exploration, with or without removal of tissue from frontal 1 ,931.40 31287 Nasal/sinus endoscopy, surgical, with sphenoidotomy; 1 , 3 3 7 . 4 0 31288 Nasal/sinus endoscopy, surgical, with sphenoidotomy; with removal of tissue from the sphenoid sinus 1 , 6 4 7 . 9 0 31290 Nasal/sinus endoscopy, surgical, with repair of cerebrospinal fluid leak; ethmoid region 3 , 5 1 4 . 5 0 31291 Nasal/sinus endoscopy, surgical, with repair of cerebrospinal fluid leak; sphenoid region 3 , 9 0 3 . 3 0 31292 Nasal/sinus endoscopy, surgical; with medial or inferior orbital wall decompression 3 , 1 2 2 . 1 0 31293 Nasal/sinus endoscopy, surgical; with medial orbital wall and inferior orbital wall decompression 3 , 4 1 4 . 6 0 31294 Nasal/sinus endoscopy, surgical; with optic nerve decompression 3 , 8 5 4 . 7 0 31295 Sinus endo w/balloon dil 2 ,597.07 31296 Sinus endo w/balloon dil 2 ,881.60 31297 Sinus endo w/balloon dil 2 ,872.95 31300 Laryngotomy (thyrotomy, laryngofissure); with removal of tumor or laryngocele, cordectomy 2 , 8 4 2 . 2 0 31320 Laryngotomy (thyrotomy, laryngofissure); diagnostic 1 , 3 4 9 . 1 0 31360 Laryngectomy; total, without radical neck dissection 3 , 8 2 5 . 9 0 31365 Laryngectomy; total, with radical neck dissection 5 , 7 4 0 . 2 0 31367 Laryngectomy; subtotal supraglottic, without radical neck dissection 4 , 1 1 1 . 2 0 31368 Laryngectomy; subtotal supraglottic, with radical neck dissection 6 , 3 3 6 . 0 0 31370 Partial laryngectomy (hemilaryngectomy); horizontal 4 , 6 7 0 . 1 0 31375 Partial laryngectomy (hemilaryngectomy); laterovertical 3 , 8 9 8 . 8 0 31380 Partial laryngectomy (hemilaryngectomy); anterovertical 3 , 9 7 0 . 8 0 31382 Partial laryngectomy (hemilaryngectomy); antero-latero-vertical 4 , 0 2 0 . 3 0 31390 Pharyngolaryngectomy, with radical neck dissection; without reconstruction 5 , 8 5 4 . 5 0 31395 Pharyngolaryngectomy, with radical neck dissection; with reconstruction 6 , 8 4 9 . 9 0 31400 Arytenoidectomy or arytenoidopexy, external approach 2 , 9 5 3 . 8 0 31420 Epiglottidectomy 2 , 6 9 4 . 6 0 30 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 31500 Intubation, endotracheal, emergency procedure 3 0 7 . 8 0 31502 Tracheotomy tube change prior to establishment of fistula tract 1 9 5 . 3 0 31505 Laryngoscopy, indirect; diagnostic (separate procedure) 2 1 7 . 6 8 31510 Laryngoscopy, indirect; with biopsy 3 0 6 . 9 0 31511 Laryngoscopy, indirect; with removal of foreign body 3 9 1 . 5 0 31512 Laryngoscopy, indirect; with removal of lesion 4 2 9 . 3 0 31513 Laryngoscopy, indirect; with vocal cord injection 5 8 5 . 9 0 31515 Laryngoscopy direct, with or without tracheoscopy; for aspiration 3 7 7 . 1 0 31520 Laryngoscopy direct, with or without tracheoscopy; diagnostic, newborn 4 6 0 . 0 4 31525 Laryngoscopy direct, with or without tracheoscopy; diagnostic, except newborn 6 4 7 . 1 0 31526 Laryngoscopy direct, with or without tracheoscopy; diagnostic, with operating microscope 9 7 8 . 3 0 31527 Laryngoscopy direct, with or without tracheoscopy; with insertion of obturator 1 , 1 6 4 . 6 0 31528 Laryngoscopy direct, with or without tracheoscopy; with dilatation, initial 8 2 4 . 4 0 31529 Laryngoscopy direct, with or without tracheoscopy; with dilatation, subsequent 7 7 2 . 2 0 31530 Laryngoscopy, direct, operative, with foreign body removal; 8 9 6 . 4 0 31531 Laryngoscopy, direct, operative, with foreign body removal; with operating microscope 1 , 3 0 2 . 3 0 31535 Laryngoscopy, direct, operative, with biopsy; 9 0 3 . 6 0 31536 Laryngoscopy, direct, operative, with biopsy; with operating microscope 1 , 1 4 1 . 2 0 31540 Laryngoscopy, direct, operative, with excision of tumor and/or stripping of vocal cords or epiglottis; 1 , 1 5 5 . 6 0 31541 Laryngoscopy, direct, operative, with excision of tumor and/or stripping of vocal cords or epiglottis; with 1 ,328.82 31545 Largsc mcrscp/tlscp rmvl les vocal c/d flap 1 ,137.51 31546 Largsc mcrscp/tlscp rmvl les vocal c/d grf 1 ,746.43 31560 Laryngoscopy, direct, operative, with arytenoidectomy; 2 , 2 2 4 . 8 0 31561 Laryngoscopy, direct, operative, with arytenoidectomy; with operating microscope 2 , 3 7 8 . 7 0 31570 Laryngoscopy, direct, with injection into vocal cord(s), therapeutic; 1 , 3 2 3 . 9 0 31571 Laryngoscopy, direct, with injection into vocal cord(s), therapeutic; with operating microscope 1 , 4 5 8 . 9 0 31575 Laryngoscopy, flexible fiberoptic; diagnostic 3 2 3 . 1 1 31576 Laryngoscopy, flexible fiberoptic; with biopsy 5 6 8 . 8 0 31577 Laryngoscopy, flexible fiberoptic; with removal of foreign body 9 8 2 . 8 0 31578 Laryngoscopy, flexible fiberoptic; with removal of lesion 1 , 1 3 3 . 1 0 31579 Laryngoscopy, flexible or rigid fiberoptic, with stroboscopy 6 2 6 . 4 0 31580 Laryngoplasty; for laryngeal web, two stage, with keel insertion and removal 3 , 3 9 9 . 3 0 31582 Laryngoplasty; for laryngeal stenosis, with graft or core mold, including tracheotomy 4 , 1 5 5 . 3 0 31584 Laryngoplasty; with open reduction of fracture 3 , 9 7 1 . 7 0 31587 Laryngoplasty, cricoid split 2 , 5 4 4 . 3 0 31588 Laryngoplasty, not otherwise specified (eg, for burns, reconstruction after partial laryngectomy) 3 , 2 0 9 . 4 0 31590 Laryngeal reinnervation by neuromuscular pedicle 2 , 8 1 1 . 6 0 31595 Section recurrent laryngeal nerve, therapeutic (separate procedure), unilateral 2 , 3 3 8 . 2 0 31600 Tracheostomy, planned (separate procedure); 1 , 1 4 8 . 4 0 31601 Tracheostomy, planned (separate procedure); under two years 1 , 4 2 3 . 8 0 31603 Tracheostomy, emergency procedure; transtracheal 1 , 2 3 0 . 3 0 31605 Tracheostomy, emergency procedure; cricothyroid membrane 9 5 7 . 6 0 31610 Tracheostomy, fenestration procedure with skin flaps 1 , 7 3 1 . 6 0 31611 Construction of tracheoesophageal fistula and subsequent insertion of an alaryngeal speech prosthesis (eg, 1 ,748.70 31612 Tracheal puncture, percutaneous with transtracheal aspiration and/or injection 2 3 2 . 2 0 31613 Tracheostoma revision; simple, without flap rotation 7 6 7 . 7 0 31614 Tracheostoma revision; complex, with flap rotation 1 , 8 8 1 . 9 0 31615 Tracheobronchoscopy through established tracheostomy incision 5 5 5 . 3 0 31620 Endobrncl us bronchoscopic dx/ther ivntj 7 98.23 31622 Bronchoscopy (rigid or flexible); diagnostic, with or without cell washing (separate procedure) 7 1 5 . 5 0 31623 Bronchoscopy (rigid or flexible); with brushing or protected brushings 6 8 6 . 7 0 31624 Bronchoscopy (rigid or flexible); with bronchial alveolar lavage 6 9 3 . 0 0 31625 Bronchoscopy (rigid or flexible); with biopsy 8 2 2 . 6 0 31626 Brnchsc w/plmt fiducial markers 1/mlt 8 23.11 31627 Brnchsc w/cptr-asst image-guided navigation 9 48.86 31628 Bronchoscopy (rigid or flexible); with transbronchial lung biopsy, with or without fluoroscopic guidance 9 1 5 . 3 0 31629 Bronchoscopy (rigid or flexible); with transbronchial needle aspiration biopsy 9 2 2 . 5 0 31630 Bronchoscopy (rigid or flexible); with tracheal or bronchial dilation or closed reduction of fracture 8 7 4 . 8 0 31631 Bronchoscopy (rigid or flexible); with tracheal dilation and placement of tracheal stent 1 , 0 1 8 . 8 0 31632 Brnchsc w/transbrncl lung bx ea lobe 2 21.90 31633 Brnchsc w/transbrncl ndl aspir bx ea lobe 3 02.61 31634 Bronch w/balloon occlusion 4 ,626.58 31635 Bronchoscopy (rigid or flexible); with removal of foreign body 9 9 2 . 7 0 31636 Brnchsc w/placement brncl stent 1st bronchus 8 22.83 31637 Brnchsc ea major bronchus stented 2 74.30 31638 Brnchsc revj tracheal/brncl stent ins prev sess 9 07.48 31640 Bronchoscopy (rigid or flexible); with excision of tumor 1 , 1 6 1 . 0 0 31641 Bronchoscopy (rigid or flexible); with destruction of tumor or relief of stenosis by any method other than 1 ,545.30 31643 Bronchoscopy (rigid or flexible); with placement of catheter(s) for intracavitary radioelement application 6 0 6 . 6 0 31645 Bronchoscopy (rigid or flexible); with therapeutic aspiration of tracheobronchial tree, initial (eg, drainage of 8 01.00 31 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 31646 Bronchoscopy (rigid or flexible); with therapeutic aspiration of tracheobronchial tree, subsequent 7 0 6 . 5 0 31647 Bronchial valve init insert 5 33.65 31648 Bronchial valve addl insert 5 60.82 31649 Bronchial valve remov init 1 72.16 31651 Bronchial valve remov addl 1 81.98 31660 Bronch thermoplsty 1 lobe 5 36.25 31661 Bronch thermoplsty 2/> lobes 5 66.59 31717 Catheterization with bronchial brush biopsy 2 3 0 . 4 0 31720 Catheter aspiration (separate procedure); nasotracheal 1 6 9 . 2 0 31725 Catheter aspiration (separate procedure); tracheobronchial with fiberscope, bedside 4 0 6 . 8 0 31730 Transtracheal (percutaneous) introduction of needle wire dilator/stent or indwelling tube for oxygen therapy 6 6 8 . 7 0 31750 Tracheoplasty; cervical 3 , 2 3 6 . 4 0 31755 Tracheoplasty; tracheopharyngeal fistulization, each stage 3 , 5 7 2 . 1 0 31760 Tracheoplasty; intrathoracic 3 , 6 8 1 . 0 0 31766 Carinal reconstruction 4 , 4 2 8 . 9 0 31770 Bronchoplasty; graft repair 3 , 6 8 7 . 3 0 31775 Bronchoplasty; excision stenosis and anastomosis 4 , 0 8 3 . 3 0 31780 Excision tracheal stenosis and anastomosis; cervical 3 , 8 0 4 . 3 0 31781 Excision tracheal stenosis and anastomosis; cervicothoracic 4 , 0 0 3 . 2 0 31785 Excision of tracheal tumor or carcinoma; cervical 3 , 0 7 8 . 0 0 31786 Excision of tracheal tumor or carcinoma; thoracic 4 , 1 1 3 . 9 0 31800 Suture of tracheal wound or injury; cervical 2 , 9 2 9 . 5 0 31805 Suture of tracheal wound or injury; intrathoracic 2 , 9 3 2 . 2 0 31820 Surgical closure tracheostomy or fistula; without plastic repair 8 9 9 . 1 0 31825 Surgical closure tracheostomy or fistula; with plastic repair 1 , 2 5 9 . 1 0 31830 Revision of tracheostomy scar 9 2 7 . 0 0 32035 Thoracostomy; with rib resection for empyema 1 , 5 9 6 . 6 0 32036 Thoracostomy; with open flap drainage for empyema 1 , 9 4 4 . 0 0 32096 Open wedge/bx lung infiltr 2 ,016.26 32097 Open wedge/bx lung nodule 2 ,016.26 32098 Open biopsy of lung pleura 1 ,955.37 32100 Thoracotomy, major; with exploration and biopsy 2 , 7 0 1 . 8 0 32110 Thoracotomy, major; with control of traumatic hemorrhage and/or repair of lung tear 3 , 0 2 4 . 9 0 32120 Thoracotomy, major; for postoperative complications 2 , 5 2 2 . 7 0 32124 Thoracotomy, major; with open intrapleural pneumonolysis 2 , 3 6 5 . 2 0 32140 Thoracotomy, major; with cyst(s) removal, with or without a pleural procedure 2 , 5 7 4 . 9 0 32141 Thoracotomy, major; with excision-plication of bullae, with or without any pleural procedure 2 , 9 6 2 . 8 0 32150 Thoracotomy, major; with removal of intrapleural foreign body or fibrin deposit 2 , 8 0 1 . 7 0 32151 Thoracotomy, major; with removal of intrapulmonary foreign body 2 , 2 5 5 . 4 0 32160 Thoracotomy, major; with cardiac massage 2 , 6 4 6 . 0 0 32200 Pneumonostomy; with open drainage of abscess or cyst 2 , 4 7 8 . 6 0 32201 Pneumonostomy; with percutaneous drainage of abscess or cyst 7 6 0 . 5 0 32215 Pleural scarification for repeat pneumothorax 2 , 5 6 5 . 9 0 32220 Decortication, pulmonary (separate procedure); total 3 , 4 8 0 . 3 0 32225 Decortication, pulmonary (separate procedure); partial 2 , 4 7 7 . 7 0 32310 Pleurectomy, parietal (separate procedure) 3 , 0 7 3 . 5 0 32320 Decortication and parietal pleurectomy 4 , 3 0 3 . 8 0 32400 Biopsy, pleura; percutaneous needle 3 8 7 . 9 0 32405 Biopsy, lung or mediastinum, percutaneous needle 5 1 8 . 4 0 32440 Removal of lung, total pneumonectomy; 4 , 6 0 5 . 3 0 32442 Removal of lung, total pneumonectomy; with resection of segment of trachea followed by broncho-tracheal 4 ,649.40 32445 Removal of lung, total pneumonectomy; extrapleural 4 , 8 3 9 . 3 0 32480 Removal of lung, other than total pneumonectomy; single lobe (lobectomy) 4 , 3 2 7 . 2 0 32482 Removal of lung, other than total pneumonectomy; two lobes (bilobectomy) 4 , 6 6 1 . 1 0 32484 Removal of lung, other than total pneumonectomy; single segment (segmentectomy) 4 , 2 5 5 . 2 0 32486 Removal of lung, other than total pneumonectomy; with circumferential resection of segment of bronchus 4 ,365.00 32488 Removal of lung, other than total pneumonectomy; all remaining lung following previous removal of a 5 ,346.00 32491 Rmvl lng oth/thn pnumec exc-plctj emphy lng 3 ,131.92 32501 Rescj&bronchoplasty pfrmd tm lobec/sgmectomy 5 29.40 32503 Rescj apical lng tum w/o ch wall rcnstj 4 ,016.73 32504 Rescj apical lng tum w/ch wall rcnstj 4 ,300.61 32505 Wedge resect of lung initial 2 ,383.63 32506 Wedge resect of lung add-on 4 09.31 32507 Wedge resect of lung diag 4 09.31 32540 Extrapleural enucleation of empyema (empyemectomy) 3 , 6 5 6 . 7 0 32550 Insert pleural cath 7 39.02 32551 Tube thoracostomy includes water seal 3 97.73 32552 Remove lung catheter 3 93.46 32553 Ins mark thor for rt perq 6 03.94 32554 Aspirate pleura w/o imaging 1 ,393.37 32 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 32555 Aspirate pleura w/ imaging 1 ,606.11 32556 Insert cath pleura w/o image 1 ,464.89 32557 Insert cath pleura w/ image 2 ,398.33 32560 Treat pleurodesis w/agent 3 00.45 32561 Lyse chest fibrin init day 1 84.63 32562 Lyse chest fibrin subq day 1 70.85 32601 Thoracoscopy, diagnostic (separate procedure); lungs and pleural space, without biopsy 1 , 0 7 4 . 6 0 32604 Thoracoscopy, diagnostic (separate procedure); pericardial sac, with biopsy 1 , 8 0 3 . 6 0 32606 Thoracoscopy, diagnostic (separate procedure); mediastinal space, with biopsy 1 , 8 3 2 . 4 0 32607 Thoracoscopy w/bx infiltrate 7 95.40 32608 Thoracoscopy w/bx nodule 9 79.00 32609 Thoracoscopy w/bx pleura 6 75.96 32650 Thoracoscopy, surgical; with pleurodesis, any method 2 , 2 3 0 . 2 0 32651 Thoracoscopy, surgical; with partial pulmonary decortication 2 , 7 2 2 . 5 0 32652 Thoracoscopy, surgical; with total pulmonary decortication, including intrapleural pneumonolysis 3 , 5 4 8 . 7 0 32653 Thoracoscopy, surgical; with removal of intrapleural foreign body or fibrin deposit 2 , 5 6 7 . 7 0 32654 Thoracoscopy, surgical; with control of traumatic hemorrhage 2 , 7 2 9 . 7 0 32655 Thoracoscopy, surgical; with excision-plication of bullae, including any pleural procedure 2 , 9 7 2 . 7 0 32656 Thoracoscopy, surgical; with parietal pleurectomy 2 , 9 9 5 . 2 0 32658 Thoracoscopy, surgical; with removal of clot or foreign body from pericardial sac 2 , 7 6 6 . 6 0 32659 Thoracoscopy, surgical; with creation of pericardial window or partial resection of pericardial sac for 2 ,986.20 32661 Thoracoscopy, surgical; with excision of pericardial cyst, tumor, or mass 3 , 1 4 1 . 9 0 32662 Thoracoscopy, surgical; with excision of mediastinal cyst, tumor, or mass 3 , 1 0 2 . 3 0 32663 Thoracoscopy, surgical; with lobectomy, total or segmental 3 , 7 4 7 . 6 0 32664 Thoracoscopy, surgical; with thoracic sympathectomy 2 , 6 9 9 . 1 0 32665 Thoracoscopy, surgical; with esophagomyotomy (Heller type) 3 , 3 5 0 . 7 0 32666 Thoracoscopy w/wedge resect 2 ,222.05 32667 Thoracoscopy w/w resect addl 4 09.31 32668 Thoracoscopy w/w resect diag 4 11.71 32669 Thoracoscopy remove segment 3 ,335.83 32670 Thoracoscopy bilobectomy 3 ,974.02 32671 Thoracoscopy pneumonectomy 4 ,409.85 32672 Thoracoscopy for lvrs 3 ,774.81 32673 Thoracoscopy w/thymus resect 2 ,957.25 32674 Thoracoscopy lymph node exc 5 31.96 32701 Thorax stereo rad targetw/tx 5 45.49 32800 Repair lung hernia through chest wall 2 , 5 6 5 . 0 0 32810 Closure of chest wall following open flap drainage for empyema (Clagett type procedure) 2 , 7 1 0 . 8 0 32815 Open closure of major bronchial fistula 4 , 1 4 0 . 9 0 32820 Major reconstruction, chest wall (posttraumatic) 3 , 8 5 6 . 5 0 32851 Lung transplant single 8 ,134.00 32852 Lung transplant with bypass 8 ,881.42 32853 Lung transplant double 1 1,365.84 32854 Lung transplant with bypass 1 2,075.71 32900 Resection of ribs, extrapleural, all stages 2 , 1 8 8 . 8 0 32905 Thoracoplasty, Schede type or extrapleural (all stages); 2 , 6 5 2 . 3 0 32906 Thoracoplasty, Schede type or extrapleural (all stages); with closure of bronchopleural fistula 3 , 5 5 4 . 1 0 32940 Pneumonolysis, extraperiosteal, including filling or packing procedures 2 , 2 6 6 . 2 0 32960 Pneumothorax, therapeutic, intrapleural injection of air 2 6 1 . 0 0 32997 Total lung lavage (unilateral) 9 9 3 . 6 0 32998 Ablation pulmonary tumor perq rf uni 2 ,369.98 33010 Pericardiocentesis; initial 4 8 3 . 3 0 33011 Pericardiocentesis; subsequent 4 0 7 . 7 0 33015 Tube pericardiostomy 1 , 0 7 4 . 6 0 33020 Pericardiotomy for removal of clot or foreign body (primary procedure) 2 , 6 6 7 . 6 0 33025 Creation of pericardial window or partial resection for drainage 3 , 1 9 3 . 2 0 33030 Pericardiectomy, subtotal or complete; without cardiopulmonary bypass 4 , 0 4 1 . 0 0 33031 Pericardiectomy, subtotal or complete; with cardiopulmonary bypass 5 , 0 3 7 . 3 0 33050 Excision of pericardial cyst or tumor 3 , 2 1 9 . 3 0 33120 Excision of intracardiac tumor, resection with cardiopulmonary bypass 6 , 5 5 2 . 9 0 33130 Resection of external cardiac tumor 4 , 1 3 9 . 1 0 33140 Transmyocrd laser revsc thorcom spx 3 ,384.56 33141 Transmyocrd laser revsc pfrmd tm oth opn car px 1 ,649.90 33202 Insertion epicardial electrode open 2 ,051.82 33203 Insertion epicardial electrode endoscopic 2 ,105.33 33206 Insertion or replacement of permanent pacemaker with transvenous electrode(s); atrial 2 , 2 3 2 . 9 0 33207 Insertion or replacement of permanent pacemaker with transvenous electrode(s); ventricular 2 , 4 2 4 . 6 0 33208 Insertion or replacement of permanent pacemaker with transvenous electrode(s); atrial and ventricular 3 , 0 2 8 . 5 0 33210 Insertion or replacement of temporary transvenous single chamber cardiac electrode or pacemaker catheter 8 74.80 33211 Insertion or replacement of temporary transvenous dual chamber pacing electrodes (separate procedure) 1 , 0 1 7 . 9 0 33 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 33212 Insertion or replacement of pacemaker pulse generator only; single chamber, atrial or ventricular 1 , 4 4 5 . 4 0 33213 Insertion or replacement of pacemaker pulse generator only; dual chamber 1 , 4 6 7 . 9 0 33214 Upgrade of implanted pacemaker system, conversion of single chamber system to dual chamber system 1 ,986.30 33215 Rpsg prev implted pm/cvdfb r atr/r ventr eltrd 8 29.37 33216 Insertion or repositioning of a transvenous electrode (15 days or more after initial insertion); single chamber 1 ,427.40 33217 Insertion or repositioning of a transvenous electrode (15 days or more after initial insertion); dual chamber 1 ,512.90 33218 Repair of single transvenous electrode for a single chamber, permanent pacemaker or single chamber 1 ,392.30 33220 Repair of two transvenous electrodes for a dual chamber permanent pacemaker or dual chamber pacing 1 ,192.50 33221 Insert pulse gen mult leads 8 87.15 33222 Revision or relocation of skin pocket for pacemaker 1 , 4 4 2 . 7 0 33223 Revision of skin pocket for single or dual chamber pacing cardioverter-defibrillator 1 , 2 3 8 . 4 0 33224 Insj eltrd car ven sys attch pm/cvdfb pls gen 1 ,345.09 33225 Insj eltrd car ven sys tm insj cvdfb/pm pls gen 1 ,199.61 33226 Rpsg prev implted car ven sys l ventr eltrd 1 ,296.07 33227 Remove&replace pm gen singl 8 48.55 33228 Remv&replc pm gen dual lead 8 84.94 33229 Remv&replc pm gen mult leads 9 20.48 33230 Insrt pulse gen w/dual leads 9 60.14 33231 Insrt pulse gen w/mult leads 9 95.68 33233 Removal of permanent pacemaker pulse generator 9 9 5 . 4 0 33234 Removal of transvenous pacemaker electrode(s); single lead system, atrial or ventricular 1 , 5 1 1 . 1 0 33235 Removal of transvenous pacemaker electrode(s); dual lead system 1 , 6 4 9 . 7 0 33236 Removal of permanent epicardial pacemaker and electrodes by thoracotomy; single lead system, atrial or 1 ,722.60 33237 Removal of permanent epicardial pacemaker and electrodes by thoracotomy; dual lead system 2 , 7 3 5 . 1 0 33238 Removal of permanent transvenous electrode(s) by thoracotomy 2 , 8 1 6 . 1 0 33240 Insertion of single or dual chamber pacing cardioverter-defibrillator pulse generator 1 , 5 1 3 . 8 0 33241 Subcutaneous removal of single or dual chamber pacing cardioverter-defibrillator pulse generator 1 , 0 6 1 . 1 0 33243 Removal of single or dual chamber pacing cardioverter-defibrillator electrode(s); by thoracotomy 3 , 1 9 2 . 3 0 33244 Removal of single or dual chamber pacing cardioverter-defibrillator electrode(s); by transvenous extraction 2 , 7 0 7 . 2 0 33249 Insertion or repositioning of electrode lead(s) for single or dual chamber pacing cardioverter-defibrillator and 3 ,577.50 33250 Operative ablation of supraventricular arrhythmogenic focus or pathway (eg, Wolff-Parkinson-White, A-V 3 ,759.30 33251 Operative ablation of supraventricular arrhythmogenic focus or pathway (eg, Wolff-Parkinson-White, A-V 5 ,150.70 33254 Ablation & rcnstj atria lmtd 2 ,975.87 33255 Ablation & rcnstj atria x10sv w/o bypass 3 ,580.01 33256 Ablation & rcnstj atria x10sv w/bypass 4 ,278.05 33257 Atria ablate & rcnstj w other procedure limited 1 ,362.89 33258 Atria abltj &rcnstj w other px extensive w/o byp 1 ,535.93 33259 Atria ablate &rcnstj w other px extensive w byp 2 ,004.34 33261 Operative ablation of ventricular arrhythmogenic focus with cardiopulmonary bypass 5 , 1 3 5 . 4 0 33262 Remv&replc cvd gen sing lead 9 25.34 33263 Remv&replc cvd gen dual lead 9 61.72 33264 Remv&replc cvd gen mult lead 9 97.26 33265 Ndsc ablation & rcnstj atria lmtd w/o bypass 2 ,970.81 33266 Ndsc ablation & rcnstj atria x10sv w/o bypass 4 ,068.64 33282 Implant pat-active ht record 7 86.37 33284 Remove pat-active ht record 5 67.29 33300 Repair of cardiac wound; without bypass 3 , 8 3 6 . 7 0 33305 Repair of cardiac wound; with cardiopulmonary bypass 5 , 1 2 2 . 8 0 33310 Cardiotomy, exploratory (includes removal of foreign body); without bypass 3 , 6 5 4 . 9 0 33315 Cardiotomy, exploratory (includes removal of foreign body); with cardiopulmonary bypass 5 , 3 1 8 . 1 0 33320 Suture repair of aorta or great vessels; without shunt or cardiopulmonary bypass 4 , 7 1 3 . 3 0 33321 Sutr rpr aorta/grt vsl w/shunt byp 3 ,833.13 33322 Suture repair of aorta or great vessels; with cardiopulmonary bypass 5 , 7 4 4 . 7 0 33330 Insertion of graft, aorta or great vessels; without shunt, or cardiopulmonary bypass 6 , 2 6 1 . 3 0 33332 Insj grf aorta/grt vsl w/shunt byp 5 ,066.72 33335 Insertion of graft, aorta or great vessels; with cardiopulmonary bypass 6 , 9 8 4 . 0 0 33361 Replace aortic valve perq 3 ,285.90 33362 Replace aortic valve open 3 ,594.86 33363 Replace aortic valve open 3 ,722.19 33364 Replace aortic valve open 3 ,961.38 33365 Replace aortic valve open 4 ,362.52 33367 Replace aortic valve w/byp 1 ,531.20 33368 Replace aortic valve w/byp 1 ,856.07 33369 Replace aortic valve w/byp 2 ,450.22 33400 Valvuloplasty, aortic valve; open, with cardiopulmonary bypass 5 , 6 6 5 . 5 0 33401 Valvuloplasty, aortic valve; open, with inflow occlusion 5 , 7 0 6 . 9 0 33403 Valvuloplasty, aortic valve; using transventricular dilation, with cardiopulmonary bypass 6 , 1 5 9 . 6 0 33404 Construction of apical-aortic conduit 6 , 6 9 5 . 1 0 33405 Replacement, aortic valve, with cardiopulmonary bypass; with prosthetic valve other than homograft or 7 ,717.50 33406 Replacement, aortic valve, with cardiopulmonary bypass; with homograft valve (freehand) 7 , 0 2 9 . 9 0 34 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 33410 Rplcmt a-valve stent< tiss valve 6 ,661.86 33411 Replacement, aortic valve; with aortic annulus enlargement, noncoronary cusp 7 , 9 2 1 . 8 0 33412 Replacement, aortic valve; with transventricular aortic annulus enlargement (Konno procedure) 8 , 0 1 9 . 0 0 33413 Replacement, aortic valve; by translocation of autologous pulmonary valve with homograft replacement of 7 ,622.10 33414 Rpr ventr o/f trc obstrcj patch enlgment o/f trc 6 ,825.57 33415 Resection or incision of subvalvular tissue for discrete subvalvular aortic stenosis 6 , 0 8 7 . 6 0 33416 Ventriculomyotomy (-myectomy) for idiopathic hypertrophic subaortic stenosis (eg, asymmetric septal 6 ,592.50 33417 Aortoplasty (gusset) for supravalvular stenosis 6 , 9 5 2 . 5 0 33420 Valvotomy, mitral valve; closed heart 5 , 4 9 5 . 4 0 33422 Valvotomy, mitral valve; open heart, with cardiopulmonary bypass 6 , 4 5 1 . 2 0 33425 Valvuloplasty, mitral valve, with cardiopulmonary bypass; 6 , 6 2 8 . 5 0 33426 Valvuloplasty, mitral valve, with cardiopulmonary bypass; with prosthetic ring 7 , 9 0 5 . 6 0 33427 Valvuloplasty, mitral valve, with cardiopulmonary bypass; radical reconstruction, with or without ring 6 , 9 7 8 . 6 0 33430 Replacement, mitral valve, with cardiopulmonary bypass 7 , 6 2 7 . 5 0 33460 Valvectomy, tricuspid valve, with cardiopulmonary bypass 6 , 2 2 3 . 5 0 33463 Valvuloplasty, tricuspid valve; without ring insertion 7 , 1 0 5 . 5 0 33464 Valvuloplasty, tricuspid valve; with ring insertion 6 , 8 0 1 . 3 0 33465 Replacement, tricuspid valve, with cardiopulmonary bypass 6 , 7 2 1 . 2 0 33468 Tricuspid valve repositioning and plication for Ebstein anomaly 6 , 9 8 8 . 5 0 33470 Valvotomy, pulmonary valve, closed heart; transventricular 5 , 0 3 0 . 1 0 33471 Valvotomy, pulmonary valve, closed heart; via pulmonary artery 4 , 7 0 8 . 8 0 33472 Valvotomy, pulmonary valve, open heart; with inflow occlusion 4 , 9 7 9 . 7 0 33474 Valvotomy, pulmonary valve, open heart; with cardiopulmonary bypass 5 , 5 3 5 . 9 0 33475 Replacement, pulmonary valve 7 , 1 0 5 . 5 0 33476 Right ventricular resection for infundibular stenosis, with or without commissurotomy 5 , 8 4 0 . 1 0 33478 Outflow tract augmentation (gusset), with or without commissurotomy or infundibular resection 5 , 8 4 0 . 1 0 33496 Repair of non-structural prosthetic valve dysfunction with cardiopulmonary bypass (separate procedure) 5 , 7 9 9 . 6 0 33500 Repair of coronary arteriovenous or arteriocardiac chamber fistula; with cardiopulmonary bypass 5 , 3 5 5 . 9 0 33501 Repair of coronary arteriovenous or arteriocardiac chamber fistula; without cardiopulmonary bypass 4 , 0 2 7 . 5 0 33502 Repair of anomalous coronary artery; by ligation 3 , 8 7 8 . 1 0 33503 Repair of anomalous coronary artery; by graft, without cardiopulmonary bypass 4 , 3 7 7 . 6 0 33504 Repair of anomalous coronary artery; by graft, with cardiopulmonary bypass 6 , 1 7 0 . 4 0 33505 Rpr anom c art w/constj intrap-art tunnel 5 ,183.04 33506 Rpr anom c art from p-art to aorta 5 ,719.19 33507 Rpr anom aortic origin c art unroofing/tlcj 5 ,300.00 33508 Ndsc surg w/vid-asstd harvest vein cab 2 60.39 33510 Coronary artery bypass, vein only; single coronary venous graft 7 , 2 5 4 . 0 0 33511 Coronary artery bypass, vein only; two coronary venous grafts 7 , 4 4 8 . 4 0 33512 Coronary artery bypass, vein only; three coronary venous grafts 8 , 2 8 4 . 5 0 33513 Coronary artery bypass, vein only; four coronary venous grafts 9 , 2 6 8 . 2 0 33514 Coronary artery bypass, vein only; five coronary venous grafts 1 0 , 0 8 3 . 6 0 33516 Coronary artery bypass, vein only; six or more coronary venous grafts 1 0 , 8 0 9 . 0 0 33517 Coronary artery bypass, using venous graft(s) and arterial graft(s); single vein graft (List separately in 1 ,161.90 33518 Coronary artery bypass, using venous graft(s) and arterial graft(s); two venous grafts (List separately in 1 ,747.80 33519 Coronary artery bypass, using venous graft(s) and arterial graft(s); three venous grafts (List separately in 2 ,054.70 33521 Coronary artery bypass, using venous graft(s) and arterial graft(s); four venous grafts (List separately in 2 ,816.10 33522 Coronary artery bypass, using venous graft(s) and arterial graft(s); five venous grafts (List separately in 3 ,634.20 33523 Coronary artery bypass, using venous graft(s) and arterial graft(s); six or more venous grafts (List 4 ,606.20 33530 Reoperation, coronary artery bypass procedure or valve procedure, more than one month after original 2 ,003.40 33533 Coronary artery bypass, using arterial graft(s); single arterial graft 6 , 8 7 8 . 7 0 33534 Coronary artery bypass, using arterial graft(s); two coronary arterial grafts 7 , 8 2 2 . 8 0 33535 Coronary artery bypass, using arterial graft(s); three coronary arterial grafts 8 , 4 7 9 . 8 0 33536 Coronary artery bypass, using arterial graft(s); four or more coronary arterial grafts 8 , 4 5 4 . 6 0 33542 Myocardial resection (eg, ventricular aneurysmectomy) 6 , 7 6 9 . 8 0 33545 Repair of postinfarction ventricular septal defect, with or without myocardial resection 7 , 6 7 9 . 7 0 33548 Surg ventr rstrj px w/prostc patch pfrmd 7 ,924.63 33572 Coronary endarterectomy, open, any method, of left anterior descending, circumflex, or right coronary artery 1 ,008.00 33600 Closure of atrioventricular valve (mitral or tricuspid) by suture or patch 6 , 4 8 9 . 0 0 33602 Closure of semilunar valve (aortic or pulmonary) by suture or patch 6 , 4 7 9 . 1 0 33606 Anastomosis of pulmonary artery to aorta (Damus-Kaye-Stansel procedure) 6 , 5 8 1 . 7 0 33608 Repair of complex cardiac anomaly other than pulmonary atresia with ventricular septal defect by 6 ,643.80 33610 Rpr car anomal surg enlgment ventr septl dfct 6 ,591.66 33611 Rpr 2 outlet r vntrc w/intraventr tunnel rpr 6 ,644.56 33612 Repair of double outlet right ventricle with intraventricular tunnel repair; with repair of right ventricular outflow 7 ,416.00 33615 Repair of complex cardiac anomalies (eg, tricuspid atresia) by closure of atrial septal defect and 7 ,004.70 33617 Rpr cplx car anomal modf fontan px 7 ,584.08 33619 Repair of single ventricle with aortic outflow obstruction and aortic arch hypoplasia (hypoplastic left heart 8 ,214.30 33620 Application right & left pulmonary artery bands 5 ,156.44 33621 Tthrc catheter insert for stent placement 2 ,733.50 33622 Reconstruction complex cardiac anomaly 1 0,660.54 35 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 33641 Repair atrial septal defect, secundum, with cardiopulmonary bypass, with or without patch 5 , 4 5 9 . 4 0 33645 Direct or patch closure, sinus venosus, with or without anomalous pulmonary venous drainage 6 , 3 6 8 . 4 0 33647 Repair of atrial septal defect and ventricular septal defect, with direct or patch closure 7 , 2 1 0 . 8 0 33660 Repair of incomplete or partial atrioventricular canal (ostium primum atrial septal defect), with or without 6 ,916.50 33665 Repair of intermediate or transitional atrioventricular canal, with or without atrioventricular valve repair 7 , 9 3 8 . 0 0 33670 Repair of complete atrioventricular canal, with or without prosthetic valve 7 , 6 2 5 . 7 0 33675 Closure multiple ventricular septal defects 6 ,647.90 33676 Closure multiple vsd w/resection 6 ,341.84 33677 Closure multiple vsd w/removal artery band 6 ,334.62 33681 Closure of ventricular septal defect, with or without patch; 6 , 1 4 4 . 3 0 33684 Closure of ventricular septal defect, with or without patch; with pulmonary valvotomy or infundibular 6 ,494.40 33688 Closure of ventricular septal defect, with or without patch; with removal of pulmonary artery band, with or 6 ,613.20 33690 Banding of pulmonary artery 3 , 0 9 0 . 6 0 33692 Complete repair tetralogy of Fallot without pulmonary atresia; 6 , 4 3 7 . 7 0 33694 Complete repair tetralogy of Fallot without pulmonary atresia; with transannular patch 7 , 0 9 0 . 2 0 33697 Complete repair tetralogy of Fallot with pulmonary atresia including construction of conduit from right 7 ,173.90 33702 Repair sinus of Valsalva fistula, with cardiopulmonary bypass; 5 , 9 5 1 . 7 0 33710 Repair sinus of Valsalva fistula, with cardiopulmonary bypass; with repair of ventricular septal defect 7 , 7 8 6 . 8 0 33720 Repair sinus of Valsalva aneurysm, with cardiopulmonary bypass 6 , 7 4 6 . 4 0 33722 Closure of aortico-left ventricular tunnel 6 , 4 3 7 . 7 0 33724 Repair isolated partial pulm venous return 5 ,384.20 33726 Repair pulmonary venous stenosis 6 ,373.14 33730 Complete repair of anomalous venous return (supracardiac, intracardiac, or infracardiac types) 6 , 6 0 2 . 4 0 33732 Repair of cor triatriatum or supravalvular mitral ring by resection of left atrial membrane 5 , 9 4 2 . 7 0 33735 Atrial septectomy or septostomy; closed heart (Blalock-Hanlon type operation) 4 , 5 3 8 . 7 0 33736 Atrial septectomy or septostomy; open heart with cardiopulmonary bypass 5 , 4 8 0 . 1 0 33737 Atrial septectomy or septostomy; open heart, with inflow occlusion 4 , 8 9 2 . 4 0 33750 Shunt; subclavian to pulmonary artery (Blalock-Taussig type operation) 4 , 2 3 3 . 6 0 33755 Shunt; ascending aorta to pulmonary artery (Waterston type operation) 4 , 7 4 8 . 4 0 33762 Shunt; descending aorta to pulmonary artery (Potts-Smith type operation) 4 , 6 4 5 . 8 0 33764 Shunt; central, with prosthetic graft 4 , 6 8 6 . 3 0 33766 Shunt; superior vena cava to pulmonary artery for flow to one lung (classical Glenn procedure) 4 , 0 6 8 . 9 0 33767 Shunt; superior vena cava to pulmonary artery for flow to both lungs (bidirectional Glenn procedure) 4 , 6 8 6 . 3 0 33768 Anast cavopulm 2nd suprior v/c 1 ,373.84 33770 Repair of transposition of the great arteries with ventricular septal defect and subpulmonary stenosis; 7 ,014.60 33771 Rpr tga enlgmnt v-septl dfct 7 ,655.60 33774 Repair of transposition of the great arteries, atrial baffle procedure (eg, Mustard or Senning type) with 6 ,746.40 33775 Repair of transposition of the great arteries, atrial baffle procedure (eg, Mustard or Senning type) with 6 ,685.20 33776 Repair of transposition of the great arteries, atrial baffle procedure (eg, Mustard or Senning type) with 8 ,601.30 33777 Repair of transposition of the great arteries, atrial baffle procedure (eg, Mustard or Senning type) with 8 ,343.00 33778 Repair of transposition of the great arteries, aortic pulmonary artery reconstruction (eg, Jatene type); 9 , 0 3 8 . 7 0 33779 Repair of transposition of the great arteries, aortic pulmonary artery reconstruction (eg, Jatene type); with 8 ,766.00 33780 Repair of transposition of the great arteries, aortic pulmonary artery reconstruction (eg, Jatene type); with 8 ,766.00 33781 Repair of transposition of the great arteries, aortic pulmonary artery reconstruction (eg, Jatene type); with 8 ,766.00 33782 A-root tlcj vsd pulm stns rpr w/o c ost rimpltj 1 2,843.24 33783 A-root tlcj vsd pulm stns rpr w/ rimpltj c ostia 1 3,932.80 33786 Total repair, truncus arteriosus (Rastelli type operation) 7 , 4 1 6 . 0 0 33788 Reimplantation of an anomalous pulmonary artery 5 , 5 4 8 . 5 0 33800 Aortic suspension (aortopexy) for tracheal decompression (eg, for tracheomalacia) (separate procedure) 2 , 6 5 4 . 1 0 33802 Division of aberrant vessel (vascular ring); 3 , 5 5 4 . 1 0 33803 Division of aberrant vessel (vascular ring); with reanastomosis 3 , 8 9 3 . 4 0 33813 Obliteration of aortopulmonary septal defect; without cardiopulmonary bypass 4 , 2 4 3 . 5 0 33814 Obliteration of aortopulmonary septal defect; with cardiopulmonary bypass 5 , 9 9 4 . 9 0 33820 Repair of patent ductus arteriosus; by ligation 3 , 8 6 9 . 1 0 33822 Repair of patent ductus arteriosus; by division, under 18 years 3 , 6 4 1 . 4 0 33824 Repair of patent ductus arteriosus; by division, 18 years and older 4 , 0 5 8 . 1 0 33840 Excision of coarctation of aorta, with or without associated patent ductus arteriosus; with direct anastomosis 4 , 3 4 2 . 5 0 33845 Excision of coarctation of aorta, with or without associated patent ductus arteriosus; with graft 6 , 0 8 7 . 6 0 33851 Exc coarcj aorta w/l subcla art/prostc as gusset 5 ,986.48 33852 Repair of hypoplastic or interrupted aortic arch using autogenous or prosthetic material; without 5 ,514.30 33853 Repair of hypoplastic or interrupted aortic arch using autogenous or prosthetic material; with 6 ,901.20 33860 Ascending aorta graft, with cardiopulmonary bypass, with or without valve suspension; 7 , 3 2 3 . 3 0 33863 Ascending aorta graft, with cardiopulmonary bypass, with or without valve suspension; with aortic root 7 ,577.10 33864 Ascending aorta grf valve spare root remodel 7 ,601.41 33870 Transverse arch graft, with cardiopulmonary bypass 9 , 6 5 2 . 5 0 33875 Descending thoracic aorta graft, with or without bypass 7 , 8 1 0 . 2 0 33877 Repair of thoracoabdominal aortic aneurysm with graft, with or without cardiopulmonary bypass 9 , 2 4 1 . 2 0 33880 Evasc rpr dta coverage art origin 1st endoprosth 5 ,712.22 33881 Evasc rpr dta exp coverage w/o art origin 4 ,930.62 33883 Plmt prox xtn prosth evasc rpr dta 1st xtn 3 ,643.31 36 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 33884 Plmt prox xtn prosth evasc rpr dta ea prox xtn 1 ,385.57 33886 Plmt dstl xtn prosth dlyd after evasc rpr dta 3 ,119.61 33889 Opn subcla crtd art trpos nck inc ulat 2 ,690.56 33891 Byp grf w/dta rpr nck inc 3 ,430.57 33910 Pulmonary artery embolectomy; with cardiopulmonary bypass 6 , 5 6 6 . 4 0 33915 Pulmonary artery embolectomy; without cardiopulmonary bypass 3 , 9 6 5 . 4 0 33916 Pulmonary endarterectomy, with or without embolectomy, with cardiopulmonary bypass 4 , 6 5 3 . 0 0 33917 Repair of pulmonary artery stenosis by reconstruction with patch or graft 6 , 6 3 3 . 9 0 33920 Repair of pulmonary atresia with ventricular septal defect, by construction or replacement of conduit from 6 ,891.30 33922 Transection of pulmonary artery with cardiopulmonary bypass 5 , 5 6 2 . 0 0 33924 Lig&tkdn sysic-to-p-art shunt w/cgen hrt px 1 ,096.26 33925 Rpr p-art arborizj anomal unifclizj w/o card byp 6 ,455.33 33926 Rpr p-art arborizj anomal unifclizj w/card byp 8 ,708.02 33935 Transplantation heart/lung 1 2,504.94 33945 Heart transplant, with or without recipient cardiectomy 1 1 , 3 3 1 . 0 0 33960 Prolonged extracorporeal circulation for cardiopulmonary insufficiency; initial 24 hours 2 , 9 8 1 . 7 0 33961 Prolonged extracorporeal circulation for cardiopulmonary insufficiency; each additional 24 hours (List 1 ,626.30 33967 Insertion intra-aortic balloon assist dev prq 6 81.97 33968 Removal intra-aortic balloon assist device prq 9 8.27 33970 Insertion of intra-aortic balloon assist device through the femoral artery, open approach 2 , 0 3 2 . 2 0 33971 Removal of intra-aortic balloon assist device including repair of femoral artery, with or without graft 1 , 9 1 1 . 6 0 33973 Insertion of intra-aortic balloon assist device through the ascending aorta 2 , 0 4 7 . 5 0 33974 Removal of intra-aortic balloon assist device from the ascending aorta, including repair of the ascending 2 ,317.50 33975 Implantation of ventricular assist device; single ventricle support 4 , 3 7 7 . 6 0 33976 Implantation of ventricular assist device; biventricular support 4 , 3 6 4 . 1 0 33977 Removal of ventricular assist device; single ventricle support 3 , 3 8 8 . 5 0 33978 Removal of ventricular assist device; biventricular support 3 , 7 8 0 . 0 0 33979 Insj ventr assist dev impltable icorp 1 vntrc 6 ,113.20 33980 Rmvl ventr assist dev impltable icorp 1 vntrc 9 ,056.83 33981 Replace vad pump ext 2 ,099.36 33982 Replace vad intra w/o bp 5 ,143.44 33983 Replace vad intra w/bp 5 ,744.73 33990 Insert vad artery access 1 ,068.94 33991 Insert vad art&vein access 1 ,557.41 33992 Remove vad different session 5 07.95 33993 Reposition vad diff session 4 45.98 34001 Embolectomy or thrombectomy, with or without catheter; carotid, subclavian or innominate artery, by neck 2 ,654.10 34051 Embolectomy or thrombectomy, with or without catheter; innominate, subclavian artery, by thoracic incision 2 , 9 0 9 . 7 0 34101 Embolectomy or thrombectomy, with or without catheter; axillary, brachial, innominate, subclavian artery, by 2 ,623.50 34111 Embolectomy or thrombectomy, with or without catheter; radial or ulnar artery, by arm incision 2 , 9 6 4 . 6 0 34151 Embolectomy or thrombectomy, with or without catheter; renal, celiac, mesentery, aortoiliac artery, by 3 ,651.30 34201 Embolectomy or thrombectomy, with or without catheter; femoropopliteal, aortoiliac artery, by leg incision 2 , 8 8 6 . 3 0 34203 Embolectomy or thrombectomy, with or without catheter; popliteal-tibio-peroneal artery, by leg incision 2 , 9 5 2 . 9 0 34401 Thrombectomy, direct or with catheter; vena cava, iliac vein, by abdominal incision 2 , 8 8 4 . 5 0 34421 Thrombectomy, direct or with catheter; vena cava, iliac, femoropopliteal vein, by leg incision 2 , 5 4 9 . 7 0 34451 Thrombectomy, direct or with catheter; vena cava, iliac, femoropopliteal vein, by abdominal and leg incision 2 , 9 2 3 . 2 0 34471 Thrombectomy, direct or with catheter; subclavian vein, by neck incision 2 , 3 1 7 . 5 0 34490 Thrombectomy, direct or with catheter; axillary and subclavian vein, by arm incision 2 , 1 4 8 . 3 0 34501 Valvuloplasty, femoral vein 2 , 4 2 1 . 0 0 34502 Reconstruction of vena cava, any method 5 , 2 9 6 . 5 0 34510 Venous valve transposition, any vein donor 2 , 5 7 4 . 9 0 34520 Cross-over vein graft to venous system 3 , 4 4 4 . 3 0 34530 Saphenopopliteal vein anastomosis 2 , 7 3 8 . 7 0 34800 Endovascular repair of infrarenal abdominal aortic aneurysm or dissection; using aorto-aortic tube 3 ,621.60 34802 Endovascular repair of infrarenal abdominal aortic aneurysm or dissection; using modular bifurcated 3 ,996.90 34803 Evasc rpr aaa w/mdlr bfrc prosth 2 limbs 4 ,301.78 34804 Endovascular repair of infrarenal abdominal aortic aneurysm or dissection; using unibody bifurcated 3 ,996.90 34805 Evasc rpr aaa aorto-uniiliac/aorto-unifem prosth 3 ,987.05 34806 Tcat placement physiologic sensor aneurysmal sac 4 20.95 34808 Endovascular placement of iliac artery occlusion device (List separately in addition to code for primary 6 88.50 34812 Open femoral artery exposure for delivery of aortic endovascular prosthesis, by groin incision, unilateral 1 , 1 2 5 .

9 0 34813 Placement of femoral-femoral prosthetic graft during endovascular aortic aneurysm repair (List separately in 8 00.10 34820 Open iliac artery exposure for delivery of endovascular prosthesis or iliac occlusion during endovascular 1 ,626.30 34825 Placement of proximal or distal extension prosthesis for endovascular repair of infrarenal abdominal aortic 2 ,162.70 34826 Placement of proximal or distal extension prosthesis for endovascular repair of infrarenal abdominal aortic 6 88.50 34830 Open repair of infrarenal aortic aneurysm or dissection, plus repair of associated arterial trauma, following 5 ,635.80 34831 Open repair of infrarenal aortic aneurysm or dissection, plus repair of associated arterial trauma, following 6 ,093.00 34832 Open repair of infrarenal aortic aneurysm or dissection, plus repair of associated arterial trauma, following 6 ,093.00 34833 Iliac art expos w/crtj conduit uni 1 ,682.17 34834 Brach art expos dplmnt aortic/iliac prosth uni 9 65.20 37 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 34900 Endovasc iliac repr w/graft 2 ,239.64 35001 Direct repair of aneurysm, false aneurysm, or excision (partial or total) and graft insertion, with or without 3 ,978.00 35002 Direct repair of aneurysm, false aneurysm, or excision (partial or total) and graft insertion, with or without 4 ,092.30 35005 Direct repair of aneurysm, false aneurysm, or excision (partial or total) and graft insertion, with or without 3 ,744.00 35011 Direct repair of aneurysm, false aneurysm, or excision (partial or total) and graft insertion, with or without 3 ,550.50 35013 Direct repair of aneurysm, false aneurysm, or excision (partial or total) and graft insertion, with or without 3 ,780.90 35021 Direct repair of aneurysm, false aneurysm, or excision (partial or total) and graft insertion, with or without 4 ,011.30 35022 Direct repair of aneurysm, false aneurysm, or excision (partial or total) and graft insertion, with or without 4 ,035.60 35045 Direct repair of aneurysm, false aneurysm, or excision (partial or total) and graft insertion, with or without 3 ,766.50 35081 Direct repair of aneurysm, false aneurysm, or excision (partial or total) and graft insertion, with or without 5 ,967.00 35082 Direct repair of aneurysm, false aneurysm, or excision (partial or total) and graft insertion, with or without 7 ,056.00 35091 Direct repair of aneurysm, false aneurysm, or excision (partial or total) and graft insertion, with or without 6 ,876.00 35092 Direct repair of aneurysm, false aneurysm, or excision (partial or total) and graft insertion, with or without 7 ,870.50 35102 Direct repair of aneurysm, false aneurysm, or excision (partial or total) and graft insertion, with or without 6 ,484.50 35103 Direct repair of aneurysm, false aneurysm, or excision (partial or total) and graft insertion, with or without 6 ,972.30 35111 Direct repair of aneurysm, false aneurysm, or excision (partial or total) and graft insertion, with or without 4 ,826.70 35112 Direct repair of aneurysm, false aneurysm, or excision (partial or total) and graft insertion, with or without 3 ,327.30 35121 Direct repair of aneurysm, false aneurysm, or excision (partial or total) and graft insertion, with or without 4 ,541.40 35122 Direct repair of aneurysm, false aneurysm, or excision (partial or total) and graft insertion, with or without 4 ,851.90 35131 Direct repair of aneurysm, false aneurysm, or excision (partial or total) and graft insertion, with or without 4 ,762.80 35132 Direct repair of aneurysm, false aneurysm, or excision (partial or total) and graft insertion, with or without 4 ,635.00 35141 Direct repair of aneurysm, false aneurysm, or excision (partial or total) and graft insertion, with or without 4 ,068.90 35142 Direct repair of aneurysm, false aneurysm, or excision (partial or total) and graft insertion, with or without 4 ,619.70 35151 Direct repair of aneurysm, false aneurysm, or excision (partial or total) and graft insertion, with or without 4 ,226.40 35152 Direct repair of aneurysm, false aneurysm, or excision (partial or total) and graft insertion, with or without 3 ,790.80 35180 Repair, congenital arteriovenous fistula; head and neck 3 , 1 4 1 . 9 0 35182 Repair, congenital arteriovenous fistula; thorax and abdomen 4 , 5 3 2 . 4 0 35184 Repair, congenital arteriovenous fistula; extremities 3 , 8 8 8 . 0 0 35188 Repair, acquired or traumatic arteriovenous fistula; head and neck 3 , 2 3 4 . 6 0 35189 Repair, acquired or traumatic arteriovenous fistula; thorax and abdomen 4 , 2 2 8 . 2 0 35190 Repair, acquired or traumatic arteriovenous fistula; extremities 3 , 6 8 2 . 8 0 35201 Repair blood vessel, direct; neck 3 , 8 1 1 . 5 0 35206 Repair blood vessel, direct; upper extremity 3 , 3 9 3 . 0 0 35207 Repair blood vessel, direct; hand, finger 3 , 8 3 6 . 7 0 35211 Repair blood vessel, direct; intrathoracic, with bypass 4 , 7 7 5 . 4 0 35216 Repair blood vessel, direct; intrathoracic, without bypass 4 , 7 1 9 . 6 0 35221 Repair blood vessel, direct; intra-abdominal 4 , 3 3 2 . 6 0 35226 Repair blood vessel, direct; lower extremity 4 , 3 2 2 . 7 0 35231 Repair blood vessel with vein graft; neck 3 , 7 7 0 . 1 0 35236 Repair blood vessel with vein graft; upper extremity 5 , 0 3 5 . 5 0 35241 Repair blood vessel with vein graft; intrathoracic, with bypass 4 , 7 7 1 . 8 0 35246 Repair blood vessel with vein graft; intrathoracic, without bypass 4 , 2 8 9 . 4 0 35251 Repair blood vessel with vein graft; intra-abdominal 5 , 3 6 5 . 8 0 35256 Repair blood vessel with vein graft; lower extremity 4 , 4 2 8 . 9 0 35261 Repair blood vessel with graft other than vein; neck 3 , 8 1 1 . 5 0 35266 Repair blood vessel with graft other than vein; upper extremity 3 , 9 0 7 . 8 0 35271 Repair blood vessel with graft other than vein; intrathoracic, with bypass 5 , 1 3 4 . 5 0 35276 Repair blood vessel with graft other than vein; intrathoracic, without bypass 3 , 6 8 2 . 8 0 35281 Repair blood vessel with graft other than vein; intra-abdominal 4 , 3 7 7 . 6 0 35286 Repair blood vessel with graft other than vein; lower extremity 4 , 1 8 9 . 5 0 35301 Thromboendarterectomy, with or without patch graft; carotid, vertebral, subclavian, by neck incision 4 , 0 6 6 . 2 0 35302 Teaec w/graft superficial femoral art 3 ,050.03 35303 Teaec w/graft popliteal art 3 ,211.06 35304 Teaec w/graft tibioperoneal trunk art 3 ,248.55 35305 Teaec w/graft tibial/peroneal art 1st vessel 3 ,210.32 35306 Teaec w/graft ea addl tibial/peroneal art 1 ,331.62 35311 Thromboendarterectomy, with or without patch graft; subclavian, innominate, by thoracic incision 3 , 8 7 2 . 7 0 35321 Thromboendarterectomy, with or without patch graft; axillary-brachial 3 , 8 6 2 . 8 0 35331 Thromboendarterectomy, with or without patch graft; abdominal aorta 5 , 1 1 9 . 2 0 35341 Thromboendarterectomy, with or without patch graft; mesenteric, celiac, or renal 4 , 9 5 3 . 6 0 35351 Thromboendarterectomy, with or without patch graft; iliac 4 , 3 4 0 . 7 0 35355 Thromboendarterectomy, with or without patch graft; iliofemoral 4 , 1 7 6 . 0 0 35361 Thromboendarterectomy, with or without patch graft; combined aortoiliac 5 , 7 9 4 . 2 0 35363 Thromboendarterectomy, with or without patch graft; combined aortoiliofemoral 4 , 6 8 6 . 3 0 35371 Thromboendarterectomy, with or without patch graft; common femoral 3 , 6 0 5 . 4 0 35372 Thromboendarterectomy, with or without patch graft; deep (profunda) femoral 4 , 0 3 9 . 2 0 35390 Reoperation, carotid, thromboendarterectomy, more than one month after original operation (List separately 8 55.00 35400 Angioscopy (non-coronary vessels or grafts) during therapeutic intervention (List separately in addition to 5 70.60 35450 Transluminal balloon angioplasty, open; renal or other visceral artery 2 , 5 1 4 . 6 0 35452 Transluminal balloon angioplasty, open; aortic 1 , 3 4 5 . 5 0 38 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 35458 Transluminal balloon angioplasty, open; brachiocephalic trunk or branches, each vessel 2 , 3 1 7 . 5 0 35460 Transluminal balloon angioplasty, open; venous 1 , 5 9 6 . 6 0 35471 Transluminal balloon angioplasty, percutaneous; renal or visceral artery 2 , 3 4 8 . 1 0 35472 Transluminal balloon angioplasty, percutaneous; aortic 2 , 7 4 3 . 2 0 35475 Transluminal balloon angioplasty, percutaneous; brachiocephalic trunk or branches, each vessel 2 , 4 2 6 . 4 0 35476 Transluminal balloon angioplasty, percutaneous; venous 1 , 4 1 5 . 7 0 35500 Harvest uxtr vein 1 sgm lxtr/cab px 8 71.62 35501 Bypass graft, with vein; carotid 3 , 6 3 6 . 0 0 35506 Bypass graft, with vein; carotid-subclavian 4 , 9 3 8 . 3 0 35508 Bypass graft, with vein; carotid-vertebral 3 , 7 5 9 . 3 0 35509 Bypass graft, with vein; carotid-carotid 3 , 6 8 2 . 8 0 35510 Byp w/vein crtd-brach 3 ,271.58 35511 Bypass graft, with vein; subclavian-subclavian 3 , 3 6 5 . 1 0 35512 Byp w/vein subcla-brach 3 ,264.42 35515 Bypass graft, with vein; subclavian-vertebral 3 , 4 2 0 . 0 0 35516 Bypass graft, with vein; subclavian-axillary 3 , 5 0 5 . 5 0 35518 Bypass graft, with vein; axillary-axillary 4 , 2 6 4 . 2 0 35521 Bypass graft, with vein; axillary-femoral 4 , 5 9 6 . 3 0 35522 Byp w/vein ax-brach 3 ,209.65 35523 Bypass graft with vein brachial-ulnar/-radial 3 ,277.08 35525 Byp w/vein brach-brach 3 ,187.18 35526 Bypass graft, with vein; aortosubclavian or carotid 4 , 2 7 5 . 0 0 35531 Bypass graft, with vein; aortoceliac or aortomesenteric 4 , 9 1 0 . 4 0 35533 Bypass graft, with vein; axillary-femoral-femoral 4 , 0 8 9 . 6 0 35535 Bypass graft with vein hepatorenal 4 ,060.85 35536 Bypass graft, with vein; splenorenal 4 , 4 8 5 . 6 0 35537 Byp w/vein aortoiliac 4 ,523.50 35538 Byp w/vein aortobi-iliac 5 ,514.25 35539 Byp w/vein aortofemoral 5 ,177.02 35540 Byp w/vein aortobifemoral 5 ,915.40 35556 Bypass graft, with vein; femoral-popliteal 4 , 3 3 6 . 2 0 35558 Bypass graft, with vein; femoral-femoral 4 , 3 1 2 . 8 0 35560 Bypass graft, with vein; aortorenal 4 , 4 3 9 . 7 0 35563 Bypass graft, with vein; ilioiliac 3 , 5 8 2 . 9 0 35565 Bypass graft, with vein; iliofemoral 4 , 1 7 6 . 9 0 35566 Bypass graft, with vein; femoral-anterior tibial, posterior tibial, peroneal artery or other distal vessels 5 , 0 9 7 . 6 0 35570 Byp tibl-tibl/proneal-tibl/tibl/proneal trk-tibl 3 ,570.22 35571 Bypass graft, with vein; popliteal-tibial, -peroneal artery or other distal vessels 4 , 7 8 4 . 4 0 35572 Harvest fempop vein 1 sgm vasc rcnstj px 8 78.05 35583 In-situ vein bypass; femoral-popliteal 4 , 6 4 6 . 7 0 35585 In-situ vein bypass; femoral-anterior tibial, posterior tibial, or peroneal artery 5 , 5 8 0 . 9 0 35587 In-situ vein bypass; popliteal-tibial, peroneal 5 , 2 5 9 . 6 0 35600 Harvest of upper extremity artery, one segment, for coronary artery bypass procedure 9 2 2 . 5 0 35601 Bypass graft, with other than vein; carotid 3 , 8 2 8 . 6 0 35606 Bypass graft, with other than vein; carotid-subclavian 4 , 4 1 7 . 2 0 35612 Bypass graft, with other than vein; subclavian-subclavian 4 , 0 0 6 . 8 0 35616 Bypass graft, with other than vein; subclavian-axillary 3 , 5 0 2 . 8 0 35621 Bypass graft, with other than vein; axillary-femoral 4 , 2 9 5 . 7 0 35623 Bypass graft, with other than vein; axillary-popliteal or -tibial 4 , 0 9 9 . 5 0 35626 Bypass graft, with other than vein; aortosubclavian or carotid 5 , 1 3 4 . 5 0 35631 Bypass graft, with other than vein; aortoceliac, aortomesenteric, aortorenal 4 , 7 5 2 . 0 0 35632 Bypass graft w/other than vein ilio-celiac 3 ,986.67 35633 Bypass graft w/other than vein ilio-mesenteric 4 ,261.60 35634 Bypass graft w/other than vein iliorenal 3 ,929.70 35636 Bypass graft, with other than vein; splenorenal (splenic to renal arterial anastomosis) 4 , 2 7 5 . 0 0 35637 Byp oth/thn vein aortoiliac 3 ,861.68 35638 Byp oth/thn vein aortobi-iliac 3 ,898.02 35642 Bypass graft, with other than vein; carotid-vertebral 3 , 6 7 2 . 0 0 35645 Bypass graft, with other than vein; subclavian-vertebral 3 , 7 2 0 . 6 0 35646 Bypass graft, with other than vein; aortofemoral or bifemoral 5 , 1 4 2 . 6 0 35647 Byp oth/thn vein aortofem 3 ,664.37 35650 Bypass graft, with other than vein; axillary-axillary 4 , 3 2 8 . 1 0 35654 Bypass graft, with other than vein; axillary-femoral-femoral 5 , 3 8 1 . 1 0 35656 Bypass graft, with other than vein; femoral-popliteal 4 , 3 1 1 . 0 0 35661 Bypass graft, with other than vein; femoral-femoral 4 , 1 3 4 . 6 0 35663 Bypass graft, with other than vein; ilioiliac 3 , 6 6 2 . 1 0 35665 Bypass graft, with other than vein; iliofemoral 4 , 4 8 4 . 7 0 35666 Bypass graft, with other than vein; femoral-anterior tibial, posterior tibial, or peroneal artery 4 , 8 5 1 . 9 0 35671 Bypass graft, with other than vein; popliteal-tibial or -peroneal artery 4 , 1 9 7 . 6 0 35681 Bypass graft; composite, prosthetic and vein (List separately in addition to code for primary procedure) 3 , 0 3 2 . 1 0 39 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 35682 Bypass graft; autogenous composite, two segments of veins from two locations (List separately in addition 1 ,248.30 35683 Bypass graft; autogenous composite, three or more segments of vein from two or more locations (List 1 ,425.60 35685 Plmt vein patch/cuff dstl anast byp conduit 8 40.77 35686 Crtj dstl arven fstl lxtr byp surg non-hemo 8 58.30 35691 Transposition and/or reimplantation; vertebral to carotid artery 3 , 8 3 4 . 0 0 35693 Transposition and/or reimplantation; vertebral to subclavian artery 3 , 3 1 6 . 5 0 35694 Transposition and/or reimplantation; subclavian to carotid artery 3 , 3 9 9 . 3 0 35695 Transposition and/or reimplantation; carotid to subclavian artery 3 , 3 2 1 . 0 0 35697 Rimpltj visc art infrarnl aortic prosth ea art 1 ,617.23 35700 Reoperation, femoral-popliteal or femoral (popliteal)-anterior tibial, posterior tibial, peroneal artery or other 9 78.30 35701 Exploration (not followed by surgical repair), with or without lysis of artery; carotid artery 1 , 8 2 7 . 9 0 35721 Exploration (not followed by surgical repair), with or without lysis of artery; femoral artery 1 , 7 1 1 . 8 0 35741 Exploration (not followed by surgical repair), with or without lysis of artery; popliteal artery 1 , 7 3 3 . 4 0 35761 Exploration (not followed by surgical repair), with or without lysis of artery; other vessels 1 , 6 4 5 . 2 0 35800 Exploration for postoperative hemorrhage, thrombosis or infection; neck 1 , 7 5 7 . 7 0 35820 Exploration for postoperative hemorrhage, thrombosis or infection; chest 2 , 6 9 1 . 9 0 35840 Exploration for postoperative hemorrhage, thrombosis or infection; abdomen 2 , 6 3 2 . 5 0 35860 Exploration for postoperative hemorrhage, thrombosis or infection; extremity 1 , 8 1 6 . 2 0 35870 Repair of graft-enteric fistula 5 , 0 2 6 . 5 0 35875 Thrombectomy of arterial or venous graft (other than hemodialysis graft or fistula); 2 , 8 2 0 . 6 0 35876 Thrombectomy of arterial or venous graft (other than hemodialysis graft or fistula); with revision of arterial or 3 ,186.90 35879 Revision, lower extremity arterial bypass, without thrombectomy, open; with vein patch angioplasty 3 , 3 2 6 . 4 0 35881 Revision, lower extremity arterial bypass, without thrombectomy, open; with segmental vein interposition 3 , 6 4 7 . 7 0 35883 Revision femoral anast open nonautog graft 3 ,256.61 35884 Revision femoral anast open w/autog graft 3 ,453.76 35901 Excision of infected graft; neck 2 , 3 0 7 . 6 0 35903 Excision of infected graft; extremity 2 , 6 6 3 . 1 0 35905 Excision of infected graft; thorax 2 , 7 9 7 . 2 0 35907 Excision of infected graft; abdomen 3 , 2 1 3 . 9 0 36000 Introduction of needle or intracatheter, vein 1 2 8 . 9 1 36002 Njx px prq tx xtr pseudoarysm 2 82.31 36005 Injection procedure for contrast venography (including introduction of needle or intracatheter) 1 8 6 . 3 0 36010 Introduction of catheter, superior or inferior vena cava 6 4 7 . 1 0 36011 Selective catheter placement, venous system; first order branch (eg, renal vein, jugular vein) 5 1 0 . 3 0 36012 Selective catheter placement, venous system; second order, or more selective, branch (eg, left adrenal 6 79.50 36013 Introduction of catheter, right heart or main pulmonary artery 7 8 9 . 3 0 36014 Selective catheter placement, left or right pulmonary artery 5 9 1 . 3 0 36015 Selective catheter placement, segmental or subsegmental pulmonary artery 6 2 8 . 2 0 36100 Introduction of needle or intracatheter, carotid or vertebral artery 6 2 8 . 2 0 36120 Introduction of needle or intracatheter; retrograde brachial artery 7 4 1 . 6 0 36140 Introduction of needle or intracatheter; extremity artery 5 0 3 . 1 0 36147 Access av dial grft for eval 1 ,052.96 36148 Access av dial grft for proc 3 25.12 36160 Introduction of needle or intracatheter, aortic, translumbar 6 5 0 . 7 0 36200 Introduction of catheter, aorta 6 2 4 . 6 0 36215 Selective catheter placement, arterial system; each first order thoracic or brachiocephalic branch, within a 7 10.10 36216 Selective catheter placement, arterial system; initial second order thoracic or brachiocephalic branch, within 7 29.00 36217 Selective catheter placement, arterial system; initial third order or more selective thoracic or brachiocephalic 9 78.30 36218 Selective catheter placement, arterial system; additional second order, third order, and beyond, thoracic or 2 32.20 36221 Place cath thoracic aorta 2 ,880.37 36222 Place cath carotid/inom art 3 ,561.38 36223 Place cath carotid/inom art 3 ,896.31 36224 Place cath carotd art 4 ,230.34 36225 Place cath subclavian art 3 ,867.22 36226 Place cath vertebral art 4 ,313.16 36227 Place cath xtrnl carotid 6 14.41 36228 Place cath intracranial art 2 ,960.01 36245 Selective catheter placement, arterial system; each first order abdominal, pelvic, or lower extremity artery 7 68.60 36246 Selective catheter placement, arterial system; initial second order abdominal, pelvic, or lower extremity 8 75.70 36247 Selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, or lower 1 ,114.20 36248 Selective catheter placement, arterial system; additional second order, third order, and beyond, abdominal, 2 36.70 36251 Ins cath ren art 1st unilat 3 ,755.03 36252 Ins cath ren art 1st bilat 4 ,101.15 36253 Ins cath ren art 2nd+ unilat 5 ,728.31 36254 Ins cath ren art 2nd+ bilat 5 ,947.12 36260 Insertion of implantable intra-arterial infusion pump (eg, for chemotherapy of liver) 2 , 3 4 4 . 5 0 36261 Revision of implanted intra-arterial infusion pump 9 1 9 . 8 0 36262 Removal of implanted intra-arterial infusion pump 8 4 9 . 6 0 36400 Venipuncture, under age 3 years; femoral, jugular or sagittal sinus 5 7 . 6 0 36405 Venipuncture, under age 3 years; scalp vein 8 7 . 3 0 40 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 36406 Venipuncture, under age 3 years; other vein 9 3 . 2 0 36410 Venipuncture, child over age 3 years or adult, necessitating physician's skill (separate procedure), for 7 5.26 36415 Routine venipuncture or finger/heel/ear stick for collection of specimen(s) 1 7 . 0 4 36420 Venipuncture, cutdown; under age 1 year 2 1 2 . 4 0 36425 Venipuncture, cutdown; age 1 or over 2 3 6 . 7 0 36430 Transfusion, blood or blood components 1 2 2 . 4 0 36440 Push transfusion, blood, 2 years or under 2 1 2 . 4 0 36450 Exchange transfusion, blood; newborn 8 2 4 . 4 0 36455 Exchange transfusion, blood; other than newborn 8 7 5 . 7 0 36460 Transfusion, intrauterine, fetal 1 , 1 5 3 . 8 0 36470 Injection of sclerosing solution; single vein 1 5 2 . 5 2 36471 Injection of sclerosing solution; multiple veins, same leg 2 4 6 . 8 7 36475 Endoven abltj incmptnt vein xtr rf 1st vein 3 ,072.75 36476 Endoven abltj incmptnt vein xtr rf 2nd+ veins 1 ,042.37 36478 Endoven abltj incmptnt vein xtr laser 1st vein 2 ,978.33 36479 Endoven abltj incmptnt vein xtr laser 2nd+ veins 1 ,045.01 36481 Percutaneous portal vein catheterization by any method 1 , 1 4 3 . 0 0 36500 Venous catheterization for selective organ blood sampling 4 7 5 . 2 0 36510 Catheterization of umbilical vein for diagnosis or therapy, newborn 2 6 5 . 5 0 36511 Ther apheresis white bld cells 2 74.52 36512 Ther apheresis red bld cells 2 73.39 36513 Ther apheresis pltlts 2 76.08 36514 Ther apheresis plsm pheresis 4 82.70 36515 Apheresis adsorp/reinfuse 2 ,040.30 36516 Apheresis selective 2 ,129.80 36522 Photopheresis, extracorporeal 5 5 0 . 8 0 36555 Insj non-tun ctr cvc under 5 yr 5 00.71 36556 Insj non-tun ctr cvc age 5 yr/> 3 73.52 36557 Insj tun ctr cvc w/o subq port/pmp under 5 yr 1 ,519.07 36558 Insj tun ctr cvc w/o subq port/pmp age 5 yr/> 1 ,287.53 36560 Insj tun ctr ctr vad w/subq port under 5 yr 1 ,595.76 36561 Insj tun ctr ctr vad w/subq port age 5 yr/> 1 ,280.08 36563 Insj tun ctr ctr vad w/subq pmp 1 ,557.18 36565 Insj tun vad req 2 cath 2 sits w/o subq port/pmp 1 ,535.22 36566 Insj tun vad req 2 cath 2 sits w/subq port 2 ,580.53 36568 Insj prph cvc w/o subq port/pmp under 5 yr 5 48.20 36569 Insj prph cvc w/o subq port/pmp age 5 yr/> 4 59.11 36570 Insj prph ctr vad w/subq port under 5 yr 1 ,264.84 36571 Insj prph ctr vad w/subq port age 5 yr/> 1 ,302.40 36575 Rpr tun/non-tun ctr vad cath w/o subq port/pmp 2 94.90 36576 Rpr ctr vad w/subq port/pmp ctr/prph insj sit 6 71.12 36578 Rplcmt cath ctr vad subq port/pmp 1 ,052.89 36580 Rplcmt compl non-tun cvc w/o subq port/pmp 4 02.39 36581 Rplcmt compl tun cvc w/o subq port/pmp 1 ,347.18 36582 Rplcmt compl tun ctr vad w/subq port 1 ,777.44 36583 Rplcmt compl tun ctr vad w/subq pmp 1 ,809.20 36584 Rplcmt compl prph cvc w/o subq port/pmp 4 23.34 36585 Rplcmt compl prph ctr vad w/subq port 1 ,778.45 36589 Rmvl tun cvc w/o subq port/pmp 3 88.65 36590 Rmvl tun ctr vad w/subq port/pmp ctr/prph insj 5 79.93 36591 Collect blood from implant venous access device 4 0.50 36592 Collect blood from catheter venous nos 5 2.78 36593 Declot by thrombolytic agent implant device/cath 1 46.47 36595 Mchnl rmvl pricath obstr cv dev via ven access 1 ,257.21 36596 Mchnl rmvl intral obstr cv dev thru dev lumen 2 65.15 36597 Rpsg previously placed cvc under fluor gdn 2 38.99 36598 Cntrst njx rad eval ctr vad fluor img&reprt 2 82.77 36600 Arterial puncture, withdrawal of blood for diagnosis 9 1 . 8 0 36620 Arterial catheterization or cannulation for sampling, monitoring or transfusion (separate procedure); 2 56.50 36625 Arterial catheterization or cannulation for sampling, monitoring or transfusion (separate procedure); cutdown 3 9 1 . 5 0 36640 Arterial catheterization for prolonged infusion therapy (chemotherapy), cutdown 5 5 0 . 8 0 36660 Catheterization, umbilical artery, newborn, for diagnosis or therapy 3 2 2 . 2 0 36680 Placement of needle for intraosseous infusion 2 5 6 . 5 0 36800 Insertion of cannula for hemodialysis, other purpose (separate procedure); vein to vein 8 8 5 . 6 0 36810 Insertion of cannula for hemodialysis, other purpose (separate procedure); arteriovenous, external (Scribner 1 ,357.20 36815 Insertion of cannula for hemodialysis, other purpose (separate procedure); arteriovenous, external revision, 1 ,125.90 36818 Arven anast opn upr arm cephalic vein trpos 1 ,990.48 36819 Arteriovenous anastomosis, open; by basilic vein transposition 4 , 1 7 4 . 2 0 36820 Arven anast opn f/arm vein trpos 2 ,132.80 36821 Arteriovenous anastomosis, open; direct, any site (eg, Cimino type) (separate procedure) 2 , 2 9 5 . 0 0 41 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 36822 Insertion of cannula(s) for prolonged extracorporeal circulation for cardiopulmonary insufficiency (ECMO) 1 ,916.10 36823 Insertion of cannula(s) 3 ,310.72 36825 Creation of arteriovenous fistula by other than direct arteriovenous anastomosis (separate procedure); 3 ,141.90 36830 Creation of arteriovenous fistula by other than direct arteriovenous anastomosis (separate procedure); 3 ,022.20 36831 Thrombectomy, open, arteriovenous fistula without revision, autogenous or nonautogenous dialysis graft 1 ,346.40 36832 Revision, open, arteriovenous fistula; without thrombectomy, autogenous or nonautogenous dialysis graft 2 ,439.90 36833 Revision, open, arteriovenous fistula; with thrombectomy, autogenous or nonautogenous dialysis graft 1 ,944.90 36835 Insj thomas shunt spx 1 ,480.23 36838 Dstl revsc&interval lig uxtr hemo access 3 ,556.18 36860 External cannula declotting (separate procedure); without balloon catheter 4 1 2 . 2 0 36861 External cannula declotting (separate procedure); with balloon catheter 8 9 1 . 0 0 36870 Thrombectomy, percutaneous, arteriovenous fistula, autogenous or nonautogenous graft (includes 3 ,973.50 37140 Venous anastomosis; portocaval 5 , 6 0 8 . 8 0 37145 Venous anastomosis; renoportal 3 , 9 9 0 . 6 0 37160 Venous anastomosis; caval-mesenteric 5 , 2 5 5 . 1 0 37180 Venous anastomosis; splenorenal, proximal 4 , 9 6 9 . 8 0 37181 Venous anastomosis; splenorenal, distal (selective decompression of esophagogastric varices, any 5 ,961.60 37182 Insert hepatic shunt (tips) 1 ,959.09 37183 Remove hepatic shunt (tips) 1 5,255.65 37184 Prim prq trluml mchnl thrmbc 1st vsl 2 ,214.84 37185 Prim prq trluml mchnl thrmbc sbsq vsl 8 72.39 37186 Sec prq trluml thrmbc 1 ,250.30 37187 Prq trluml mchnl thrmbc vein 1 ,941.11 37188 Prq trluml mchnl thrmbc vein repeat tx 1 ,473.77 37191 Ins endovas vena cava filtr 6 ,918.36 37192 Redo endovas vena cava filtr 4 ,487.46 37193 Rem endovas vena cava filter 4 ,282.95 37195 Thrombolysis, cerebral, by intravenous infusion 8 4 6 . 9 0 37197 Remove intrvas foreign body 3 ,887.58 37200 Tcat bx 8 14.79 37202 Transcatheter therapy, infusion other than for thrombolysis, any type (eg, spasmolytic, vasoconstrictive) 9 7 3 . 8 0 37204 Transcatheter occlusion or embolization (eg, for tumor destruction, to achieve hemostasis, to occlude a 2 ,935.80 37205 Transcatheter placement of an intravascular stent(s), (non-coronary vessel), percutaneous; initial vessel 1 , 9 0 5 . 3 0 37206 Transcatheter placement of an intravascular stent(s), (non-coronary vessel), percutaneous; each additional 8 67.60 37207 Transcatheter placement of an intravascular stent(s), (non-coronary vessel), open; initial vessel 2 , 0 7 0 . 0 0 37208 Transcatheter placement of an intravascular stent(s), (non-coronary vessel), open; each additional vessel 1 ,061.10 37210 Uterine fibroid embolization perq w/rad gid 2 ,665.16 37211 Thrombolytic art therapy 9 72.47 37212 Thrombolytic venous therapy 8 58.67 37213 Thromblytic art/ven therapy 5 99.49 37214 Cessj therapy cath removal 3 53.25 37215 Tcat iv stent crv crtd art embolic protecj 3 ,812.78 37216 Tcat iv stent crv crtd art w/o embolic protecj 3 ,498.17 37220 Iliac revasc 2 ,257.95 37221 Iliac revasc w/stent 3 ,035.71 37222 Iliac revasc add-on 8 61.42 37223 Iliac revasc w/stent add-on 1 ,606.46 37224 Fem/popl revas w/tla 2 ,605.53 37225 Fem/popl revas w/ather 5 ,405.06 37226 Fem/popl revasc w/stent 4 ,490.45 37227 Fem/popl revasc stnt & ather 7 ,098.85 37228 Tib/per revasc w/tla 3 ,436.34 37229 Tib/per revasc w/ather 5 ,676.63 37230 Tib/per revasc w/stent 4 ,780.81 37231 Tib/per revasc stent & ather 6 ,604.22 37232 Tib/per revasc add-on 1 ,046.39 37233 Tibper revasc w/ather add-on 1 ,367.77 37234 Revsc opn/prq tib/pero stent 2 ,092.73 37235 Tib/per revasc stnt & ather 2 ,470.73 37250 Iv us non-c vsl dx eval&/ther ivntj 1st vsl 4 08.08 37251 Iv us non-c vsl dx eval&/ther ivntj ea vsl 3 19.58 37500 Vasc ndsc seps 2 ,240.80 37565 Ligation, internal jugular vein 1 , 4 6 2 . 5 0 37600 Ligation; external carotid artery 1 , 5 9 6 . 6 0 37605 Ligation; internal or common carotid artery 1 , 4 0 2 . 2 0 37606 Ligation; internal or common carotid artery, with gradual occlusion, as with Selverstone or Crutchfield clamp 1 , 6 7 0 . 4 0 37607 Ligation or banding of angioaccess arteriovenous fistula 1 , 2 9 3 . 3 0 37609 Ligation or biopsy, temporal artery 6 8 9 . 4 0 37615 Ligation, major artery (eg, post-traumatic, rupture); neck 1 , 6 0 8 . 3 0 37616 Ligation, major artery (eg, post-traumatic, rupture); chest 2 , 7 9 6 . 3 0 42 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 37617 Ligation, major artery (eg, post-traumatic, rupture); abdomen 2 , 6 1 9 . 0 0 37618 Ligation, major artery (eg, post-traumatic, rupture); extremity 1 , 5 4 5 . 3 0 37619 Ligation of inf vena cava 4 ,215.75 37650 Ligation of femoral vein 1 , 3 3 7 . 4 0 37660 Ligation of common iliac vein 1 , 6 0 6 . 5 0 37700 Ligation and division of long saphenous vein at saphenofemoral junction, or distal interruptions 9 9 8 . 1 0 37718 Lig div&stripping short saphenous vein 1 ,006.21 37722 Lig div&strip long saph saphfem junct kne/belw 1 ,208.89 37735 Ligation and division and complete stripping of long or short saphenous veins with radical excision of ulcer 2 ,844.00 37760 Ligation of perforators, subfascial, radical (Linton type), with or without skin graft 2 , 9 8 7 . 1 0 37761 Lig prfratr vein subfscal open incl us gid 1 leg 1 ,390.71 37765 Stab phlebt varicose veins 1 xtr 10-20 stab incs 1 ,167.91 37766 Stab phlebt varicose veins 1 xtr > 20 incs 1 ,416.38 37780 Ligation and division of short saphenous vein at saphenopopliteal junction (separate procedure) 6 4 1 . 7 0 37785 Ligation, division, and/or excision of recurrent or secondary varicose veins (clusters), one leg 7 3 9 . 8 0 37788 Pen revsc art +-vein grf 4 ,092.33 37790 Pen ven occlusive px 1 ,527.94 38100 Splenectomy; total (separate procedure) 2 , 6 6 0 . 4 0 38101 Splenectomy; partial (separate procedure) 2 , 9 7 5 . 4 0 38102 Splenectomy; total, en bloc for extensive disease, in conjunction with other procedure (List in addition to 1 ,835.10 38115 Repair of ruptured spleen (splenorrhaphy) with or without partial splenectomy 2 , 7 4 3 . 2 0 38120 Laps surg splenc 3 ,954.23 38200 Injection procedure for splenoportography 3 5 1 . 0 0 38204 Bl donor search management 2 32.57 38205 Bld-drv hematop progen cell hrvg trnsplj algnc 7 18.59 38206 Bld-drv hematop progen cell hrvg trnsplj autol 7 18.94 38220 Marrow aspiration only 2 93.47 38221 Marrow bx ndl/trocar 3 16.63 38230 Bone marrow harvesting for transplantation 1 , 3 9 0 . 5 0 38232 Bone marrow harvest autolog 5 07.29 38240 Marrow/bld-drv prph stem cell trnsplj allogeneic 1 ,089.69 38241 Marrow/bld-drv prph stem cell trnsplj autol 9 86.52 38242 Marrow/bld-drv prph stem cell trnsplj algc don 1 ,082.79 38243 Transplj hematopoietic boost 2 70.17 38300 Drainage of lymph node abscess or lymphadenitis; simple 2 9 3 . 4 0 38305 Drainage of lymph node abscess or lymphadenitis; extensive 7 2 9 . 0 0 38308 Lymphangiotomy or other operations on lymphatic channels 8 8 4 . 7 0 38380 Suture and/or ligation of thoracic duct; cervical approach 1 , 3 5 5 . 4 0 38381 Suture and/or ligation of thoracic duct; thoracic approach 2 , 4 2 1 . 0 0 38382 Suture and/or ligation of thoracic duct; abdominal approach 2 , 0 3 7 . 6 0 38500 Biopsy or excision of lymph node(s); open, superficial 5 8 7 . 7 7 38505 Biopsy or excision of lymph node(s); by needle, superficial (eg, cervical, inguinal, axillary) 3 9 9 . 6 0 38510 Biopsy or excision of lymph node(s); open, deep cervical node(s) 8 5 0 . 5 0 38520 Biopsy or excision of lymph node(s); open, deep cervical node(s) with excision scalene fat pad 9 1 8 . 9 0 38525 Biopsy or excision of lymph node(s); open, deep axillary node(s) 1 , 2 3 3 . 9 0 38530 Biopsy or excision of lymph node(s); open, internal mammary node(s) 1 , 2 1 0 . 5 0 38542 Dissection, deep jugular node(s) 1 , 2 4 4 . 7 0 38550 Excision of cystic hygroma, axillary or cervical; without deep neurovascular dissection 1 , 2 6 7 . 2 0 38555 Excision of cystic hygroma, axillary or cervical; with deep neurovascular dissection 2 , 3 7 4 . 2 0 38562 Limited lymphadenectomy for staging (separate procedure); pelvic and para-aortic 2 , 7 7 1 . 1 0 38564 Limited lymphadenectomy for staging (separate procedure); retroperitoneal (aortic and/or splenic) 2 , 6 6 5 . 8 0 38570 Laparoscopy, surgical; with retroperitoneal lymph node sampling (biopsy), single or multiple 2 , 6 6 7 . 6 0 38571 Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy 3 , 2 1 3 . 9 0 38572 Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy and peri-aortic lymph node sampling 3 ,295.80 38700 Suprahyoid lymphadenectomy 2 , 4 4 9 . 8 0 38720 Cervical lymphadenectomy (complete) 3 , 8 7 2 . 7 0 38724 Cervical lymphadenectomy (modified radical neck dissection) 3 , 6 7 2 . 0 0 38740 Axillary lymphadenectomy; superficial 1 , 7 9 7 . 3 0 38745 Axillary lymphadenectomy; complete 2 , 7 7 9 . 2 0 38746 Thoracic lymphadenectomy, regional, including mediastinal and peritracheal nodes (List separately in 8 46.00 38747 Abdominal lymphadenectomy, regional, including celiac, gastric, portal, peripancreatic, with or without para- 1 ,178.10 38760 Inguinofemoral lymphadenectomy, superficial, including Cloquets node (separate procedure) 2 , 2 4 0 . 1 0 38765 Inguinofemoral lymphadenectomy, superficial, in continuity with pelvic lymphadenectomy, including external 3 ,024.90 38770 Pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes (separate procedure) 3 , 2 7 6 . 0 0 38780 Retroperitoneal transabdominal lymphadenectomy, extensive, including pelvic, aortic, and renal nodes 4 ,169.70 38790 Injection procedure; lymphangiography 3 9 6 . 9 0 38792 Injection for identification of sentinel node 1 74.37 38794 Cannulation thrc dux 1 ,099.47 38900 Intraop sentinel lymph id w/dye njx 5 26.99 39000 Mediastinotomy with exploration, drainage, removal of foreign body, or biopsy; cervical approach 1 , 6 1 9 .1 0 43 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 39010 Mediastinotomy with exploration, drainage, removal of foreign body, or biopsy; transthoracic approach, 2 ,430.90 39200 Excision of mediastinal cyst 2 , 8 0 1 . 7 0 39220 Excision of mediastinal tumor 3 , 4 1 0 . 1 0 39400 Mediastinoscopy, with or without biopsy 1 , 2 9 0 . 6 0 39501 Repair, laceration of diaphragm, any approach 2 , 9 7 0 . 0 0 39503 Repair, neonatal diaphragmatic hernia, with or without chest tube insertion and with or without creation of 3 ,626.10 39540 Repair, diaphragmatic hernia (other than neonatal), traumatic; acute 3 , 5 7 7 . 5 0 39541 Repair, diaphragmatic hernia (other than neonatal), traumatic; chronic 3 , 5 1 5 . 4 0 39545 Imbrication of diaphragm for eventration, transthoracic or transabdominal, paralytic or nonparalytic 3 , 4 6 4 . 1 0 39560 Rescj dphrm smpl rpr 3 ,485.19 39561 Rescj dphrm cplx rpr 5 ,241.89 40490 Biopsy of lip 2 0 6 . 1 0 40500 Vermilionectomy (lip shave), with mucosal advancement 1 , 5 4 5 . 3 0 40510 Excision of lip; transverse wedge excision with primary closure 1 , 7 1 0 . 9 0 40520 Excision of lip; V-excision with primary direct linear closure 1 , 3 9 0 . 5 0 40525 Excision of lip; full thickness, reconstruction with local flap (eg, Estlander or fan) 3 , 3 0 0 . 3 0 40527 Excision of lip; full thickness, reconstruction with cross lip flap (Abbe-Estlander) 3 , 5 5 8 . 6 0 40530 Resection of lip, more than one-fourth, without reconstruction 1 , 6 4 7 . 9 0 40650 Repair lip, full thickness; vermilion only 1 , 4 0 9 . 4 0 40652 Repair lip, full thickness; up to half vertical height 1 , 4 4 0 . 0 0 40654 Repair lip, full thickness; over one-half vertical height, or complex 1 , 6 8 1 . 2 0 40700 Plastic repair of cleft lip/nasal deformity; primary, partial or complete, unilateral 2 , 6 4 6 . 9 0 40701 Plastic repair of cleft lip/nasal deformity; primary bilateral, one stage procedure 4 , 1 0 7 . 6 0 40702 Plastic repair of cleft lip/nasal deformity; primary bilateral, one of two stages 2 , 5 9 0 . 2 0 40720 Plastic repair of cleft lip/nasal deformity; secondary, by recreation of defect and reclosure 2 , 7 8 8 . 2 0 40761 Plastic repair of cleft lip/nasal deformity; with cross lip pedicle flap (Abbe-Estlander type), including 3 ,038.40 40800 Drainage of abscess, cyst, hematoma, vestibule of mouth; simple 2 0 1 . 6 0 40801 Drainage of abscess, cyst, hematoma, vestibule of mouth; complicated 5 7 9 . 6 0 40804 Removal of embedded foreign body, vestibule of mouth; simple 2 3 6 . 7 0 40805 Removal of embedded foreign body, vestibule of mouth; complicated 6 5 7 . 9 0 40806 Incision of labial frenum (frenotomy) 3 1 5 . 9 0 40808 Biopsy, vestibule of mouth 2 0 2 . 5 0 40810 Excision of lesion of mucosa and submucosa, vestibule of mouth; without repair 2 6 2 . 8 0 40812 Excision of lesion of mucosa and submucosa, vestibule of mouth; with simple repair 3 9 8 . 7 0 40814 Excision of lesion of mucosa and submucosa, vestibule of mouth; with complex repair 8 7 0 . 3 0 40816 Excision of lesion of mucosa and submucosa, vestibule of mouth; complex, with excision of underlying 1 ,030.50 40818 Excision of mucosa of vestibule of mouth as donor graft 6 2 7 . 3 0 40819 Excision of frenum, labial or buccal (frenumectomy, frenulectomy, frenectomy) 4 1 4 . 0 0 40820 Destruction of lesion or scar of vestibule of mouth by physical methods (eg, laser, thermal, cryo, chemical) 3 4 9 . 2 0 40830 Closure of laceration, vestibule of mouth; 2.5 cm or less 2 3 2 . 2 4 40831 Closure of laceration, vestibule of mouth; over 2.5 cm or complex 5 2 8 . 3 0 40840 Vestibuloplasty; anterior 1 , 7 1 2 . 7 0 40842 Vestibuloplasty; posterior, unilateral 1 , 5 6 6 . 9 0 40843 Vestibuloplasty; posterior, bilateral 2 , 4 3 6 . 3 0 40844 Vestibuloplasty; entire arch 3 , 1 3 3 . 8 0 40845 Vestibuloplasty; complex (including ridge extension, muscle repositioning) 3 , 6 7 2 . 9 0 41000 Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; lingual 2 5 6 . 5 0 41005 Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; sublingual, 2 86.20 41006 Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; sublingual, deep, 6 10.20 41007 Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; submental space 7 0 3 . 8 0 41008 Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; submandibular 7 18.20 41009 Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; masticator space 8 1 0 . 0 0 41010 Incision of lingual frenum (frenotomy) 2 4 7 . 5 0 41015 Extraoral incision and drainage of abscess, cyst, or hematoma of floor of mouth; sublingual 7 7 2 . 2 0 41016 Extraoral incision and drainage of abscess, cyst, or hematoma of floor of mouth; submental 8 3 9 . 7 0 41017 Extraoral incision and drainage of abscess, cyst, or hematoma of floor of mouth; submandibular 8 2 9 . 8 0 41018 Extraoral incision and drainage of abscess, cyst, or hematoma of floor of mouth; masticator space 9 5 6 . 7 0 41019 Placement needle head/neck radioelement applicat 1 ,028.05 41100 Biopsy of tongue; anterior two-thirds 2 6 1 . 0 0 41105 Biopsy of tongue; posterior one-third 3 0 9 . 6 0 41108 Biopsy of floor of mouth 2 3 9 . 4 0 41110 Excision of lesion of tongue without closure 3 9 3 . 3 0 41112 Excision of lesion of tongue with closure; anterior two-thirds 6 4 2 . 6 0 41113 Excision of lesion of tongue with closure; posterior one-third 9 5 4 . 0 0 41114 Excision of lesion of tongue with closure; with local tongue flap 2 , 1 6 8 . 1 0 41115 Excision of lingual frenum (frenectomy) 4 2 6 . 6 0 41116 Excision, lesion of floor of mouth 7 1 5 . 5 0 41120 Glossectomy; less than one-half tongue 1 , 9 0 5 . 3 0 41130 Glossectomy; hemiglossectomy 2 , 2 0 4 . 1 0 41135 Glossectomy; partial, with unilateral radical neck dissection 4 , 7 8 9 . 8 0 44 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 41140 Glossectomy; complete or total, with or without tracheostomy, without radical neck dissection 4 , 6 1 0 . 7 0 41145 Glossectomy; complete or total, with or without tracheostomy, with unilateral radical neck dissection 5 , 3 6 6 . 7 0 41150 Glossectomy; composite procedure with resection floor of mouth and mandibular resection, without radical 4 ,663.80 41153 Glossectomy; composite procedure with resection floor of mouth, with suprahyoid neck dissection 4 , 8 8 0 . 7 0 41155 Glossectomy; composite procedure with resection floor of mouth, mandibular resection, and radical neck 6 ,470.10 41250 Repair of laceration 2.5 cm or less; floor of mouth and/or anterior two-thirds of tongue 3 6 1 . 8 0 41251 Repair of laceration 2.5 cm or less; posterior one-third of tongue 5 1 3 . 0 0 41252 Repair of laceration of tongue, floor of mouth, over 2.6 cm or complex 8 3 8 . 8 0 41500 Fixation of tongue, mechanical, other than suture (eg, K-wire) 7 6 6 . 8 0 41510 Suture of tongue to lip for micrognathia (Douglas type procedure) 1 , 3 5 4 . 5 0 41512 Tongue base suspension permanent suture tq 1 ,094.85 41520 Frenoplasty (surgical revision of frenum, eg, with Z-plasty) 6 4 7 . 1 0 41530 Tongue base vol reduction 6 ,950.37 41800 Drainage of abscess, cyst, hematoma from dentoalveolar structures 2 2 9 . 5 0 41805 Removal of embedded foreign body from dentoalveolar structures; soft tissues 2 9 8 . 8 0 41806 Removal of embedded foreign body from dentoalveolar structures; bone 4 9 3 . 2 0 41820 Gingivectomy, excision gingiva, each quadrant 6 2 2 . 8 0 41822 Excision of fibrous tuberosities, dentoalveolar structures 4 2 9 . 3 0 41823 Excision of osseous tuberosities, dentoalveolar structures 7 0 5 . 6 0 41825 Excision of lesion or tumor (except listed above), dentoalveolar structures; without repair 3 6 9 . 0 0 41826 Excision of lesion or tumor (except listed above), dentoalveolar structures; with simple repair 5 4 6 . 3 0 41827 Excision of lesion or tumor (except listed above), dentoalveolar structures; with complex repair 8 4 9 . 6 0 41828 Excision of hyperplastic alveolar mucosa, each quadrant (specify) 7 2 6 . 3 0 41830 Alveolectomy, including curettage of osteitis or sequestrectomy 8 4 9 . 6 0 41850 Destruction of lesion (except excision), dentoalveolar structures 1 8 0 . 0 0 41870 Periodontal mucosal grafting 7 2 6 . 3 0 41872 Gingivoplasty, each quadrant (specify) 6 6 9 . 6 0 41874 Alveoloplasty, each quadrant (specify) 7 5 6 . 9 0 42000 Drainage of abscess of palate, uvula 2 3 6 . 7 0 42100 Biopsy of palate, uvula 2 7 3 . 6 0 42104 Excision, lesion of palate, uvula; without closure 4 7 8 . 8 0 42106 Excision, lesion of palate, uvula; with simple primary closure 6 1 8 . 3 0 42107 Excision, lesion of palate, uvula; with local flap closure 1 , 7 8 7 . 4 0 42120 Resection of palate or extensive resection of lesion 2 , 9 5 8 . 3 0 42140 Uvulectomy, excision of uvula 4 7 0 . 7 0 42145 Palatopharyngoplasty (eg, uvulopalatopharyngoplasty, uvulopharyngoplasty) 2 , 5 0 9 . 2 0 42160 Destruction of lesion, palate or uvula (thermal, cryo or chemical) 4 4 8 . 2 0 42180 Repair, laceration of palate; up to 2 cm 4 1 6 . 9 6 42182 Repair, laceration of palate; over 2 cm or complex 8 2 5 . 3 0 42200 Palatoplasty for cleft palate, soft and/or hard palate only 2 , 8 0 1 . 7 0 42205 Palatoplasty for cleft palate, with closure of alveolar ridge; soft tissue only 3 , 1 8 6 . 0 0 42210 Palatoplasty for cleft palate, with closure of alveolar ridge; with bone graft to alveolar ridge (includes 4 ,377.60 42215 Palatoplasty for cleft palate; major revision 2 , 6 6 4 . 9 0 42220 Palatoplasty for cleft palate; secondary lengthening procedure 2 , 4 9 7 . 5 0 42225 Palatoplasty for cleft palate; attachment pharyngeal flap 2 , 8 1 1 . 6 0 42226 Lengthening of palate, and pharyngeal flap 3 , 4 7 5 . 8 0 42227 Lengthening of palate, with island flap 2 , 9 3 5 . 8 0 42235 Repair of anterior palate, including vomer flap 2 , 3 1 0 . 3 0 42260 Repair of nasolabial fistula 1 , 6 5 3 . 3 0 42280 Maxillary impression for palatal prosthesis 3 0 9 . 6 0 42281 Insertion of pin-retained palatal prosthesis 3 5 5 . 5 0 42300 Drainage of abscess; parotid, simple 3 2 4 . 9 0 42305 Drainage of abscess; parotid, complicated 8 0 6 . 4 0 42310 Drainage of abscess; submaxillary or sublingual, intraoral 3 6 0 . 9 0 42320 Drainage of abscess; submaxillary, external 5 9 7 . 6 0 42330 Sialolithotomy; submandibular (submaxillary), sublingual or parotid, uncomplicated, intraoral 4 1 5 . 9 5 42335 Sialolithotomy; submandibular (submaxillary), complicated, intraoral 7 8 9 . 3 0 42340 Sialolithotomy; parotid, extraoral or complicated intraoral 1 , 0 9 2 . 6 0 42400 Biopsy of salivary gland; needle 2 5 0 . 2 0 42405 Biopsy of salivary gland; incisional 5 7 8 . 7 0 42408 Excision of sublingual salivary cyst (ranula) 1 , 0 6 1 . 1 0 42409 Marsupialization of sublingual salivary cyst (ranula) 7 7 2 . 2 0 42410 Excision of parotid tumor or parotid gland; lateral lobe, without nerve dissection 2 , 0 1 2 . 4 0 42415 Excision of parotid tumor or parotid gland; lateral lobe, with dissection and preservation of facial nerve 3 , 6 3 0 . 6 0 42420 Excision of parotid tumor or parotid gland; total, with dissection and preservation of facial nerve 4 , 6 2 7 . 8 0 42425 Excision of parotid tumor or parotid gland; total, en bloc removal with sacrifice of facial nerve 3 , 3 6 3 . 3 0 42426 Excision of parotid tumor or parotid gland; total, with unilateral radical neck dissection 6 , 1 8 0 . 3 0 42440 Excision of submandibular (submaxillary) gland 2 , 3 1 2 . 1 0 42450 Excision of sublingual gland 1 , 9 1 1 . 6 0 42500 Plastic repair of salivary duct, sialodochoplasty; primary or simple 1 , 3 7 4 . 3 0 45 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 42505 Plastic repair of salivary duct, sialodochoplasty; secondary or complicated 1 , 7 5 7 . 7 0 42507 Parotid duct diversion, bilateral (Wilke type procedure); 2 , 3 0 2 . 2 0 42508 Parotid duct diversion, bilateral (Wilke type procedure); with excision of one submandibular gland 2 , 6 0 1 . 0 0 42509 Parotid duct diversion, bilateral (Wilke type procedure); with excision of both submandibular glands 3 , 1 9 4 . 1 0 42510 Parotid duct diversion, bilateral (Wilke type procedure); with ligation of both submandibular (Wharton's) 2 ,726.10 42550 Injection procedure for sialography 1 9 3 . 5 0 42600 Closure salivary fistula 1 , 4 7 6 . 0 0 42650 Dilation salivary duct 1 4 3 .1 0 42660 Dilation and catheterization of salivary duct, with or without injection 2 1 5 . 1 0 42665 Ligation salivary duct, intraoral 4 5 6 . 3 0 42700 Incision and drainage abscess; peritonsillar 3 1 8 . 6 0 42720 Incision and drainage abscess; retropharyngeal or parapharyngeal, intraoral approach 6 8 8 . 5 0 42725 Incision and drainage abscess; retropharyngeal or parapharyngeal, external approach 1 , 4 6 7 . 0 0 42800 Biopsy; oropharynx 2 5 0 . 2 0 42802 Biopsy; hypopharynx 3 4 2 . 9 0 42804 Biopsy; nasopharynx, visible lesion, simple 3 0 8 . 7 0 42806 Biopsy; nasopharynx, survey for unknown primary lesion 3 7 3 . 5 0 42808 Excision or destruction of lesion of pharynx, any method 5 9 2 . 2 0 42809 Removal of foreign body from pharynx 3 1 2 . 3 0 42810 Excision branchial cleft cyst or vestige, confined to skin and subcutaneous tissues 8 7 8 . 4 0 42815 Excision branchial cleft cyst, vestige, or fistula, extending beneath subcutaneous tissues and/or into 1 ,880.10 42820 Tonsillectomy and adenoidectomy; under age 12 8 1 6 . 6 1 42821 Tonsillectomy and adenoidectomy; age 12 or over 1 , 0 3 1 . 4 0 42825 Tonsillectomy, primary or secondary; under age 12 8 2 0 . 8 0 42826 Tonsillectomy, primary or secondary; age 12 or over 8 4 1 . 5 0 42830 Adenoidectomy, primary; under age 12 5 8 1 . 6 4 42831 Adenoidectomy, primary; age 12 or over 6 7 5 . 0 0 42835 Adenoidectomy, secondary; under age 12 5 3 6 .

4 0 42836 Adenoidectomy, secondary; age 12 or over 6 6 9 . 6 0 42842 Radical resection of tonsil, tonsillar pillars, and/or retromolar trigone; without closure 2 , 4 2 1 . 0 0 42844 Radical resection of tonsil, tonsillar pillars, and/or retromolar trigone; closure with local flap (eg, tongue, 3 ,346.20 42845 Radical resection of tonsil, tonsillar pillars, and/or retromolar trigone; closure with other flap 4 , 5 0 7 . 2 0 42860 Excision of tonsil tags 5 7 0 . 6 0 42870 Excision or destruction lingual tonsil, any method (separate procedure) 8 4 4 . 2 0 42890 Limited pharyngectomy 2 , 6 8 9 . 2 0 42892 Resection of lateral pharyngeal wall or pyriform sinus, direct closure by advancement of lateral and posterior 3 ,450.60 42894 Resection of pharyngeal wall requiring closure with myocutaneous flap 4 , 7 7 6 . 3 0 42900 Suture pharynx for wound or injury 9 7 7 . 4 0 42950 Pharyngoplasty (plastic or reconstructive operation on pharynx) 1 , 9 8 9 . 9 0 42953 Pharyngoesophageal repair 2 , 5 2 3 . 6 0 42955 Pharyngostomy (fistulization of pharynx, external for feeding) 1 , 5 7 9 . 5 0 42960 Control oropharyngeal hemorrhage, primary or secondary (eg, post-tonsillectomy); simple 3 6 6 . 3 0 42961 Control oropharyngeal hemorrhage, primary or secondary (eg, post-tonsillectomy); complicated, requiring 6 00.30 42962 Control oropharyngeal hemorrhage, primary or secondary (eg, post-tonsillectomy); with secondary surgical 9 47.70 42970 Control of nasopharyngeal hemorrhage, primary or secondary (eg, postadenoidectomy); simple, with 6 29.10 42971 Control of nasopharyngeal hemorrhage, primary or secondary (eg, postadenoidectomy); complicated, 9 45.00 42972 Control of nasopharyngeal hemorrhage, primary or secondary (eg, postadenoidectomy); with secondary 1 ,179.00 43020 Esophagotomy, cervical approach, with removal of foreign body 1 , 9 9 6 . 2 0 43030 Cricopharyngeal myotomy 2 , 5 1 0 . 1 0 43045 Esophagotomy, thoracic approach, with removal of foreign body 3 , 3 5 2 . 5 0 43100 Excision of lesion, esophagus, with primary repair; cervical approach 2 , 5 6 8 . 6 0 43101 Excision of lesion, esophagus, with primary repair; thoracic or abdominal approach 3 , 2 9 9 . 4 0 43107 Total or near total esophagectomy, without thoracotomy; with pharyngogastrostomy or cervical 5 ,637.60 43108 Total or near total esophagectomy, without thoracotomy; with colon interposition or small bowel 6 ,282.90 43112 Total or near total esophagectomy, with thoracotomy; with pharyngogastrostomy or cervical 6 ,437.70 43113 Tot esphg w/thorcom w/colon ntrpstj/int rcnstj 5 ,426.85 43116 Prtl esphg crv w/fr intstinal grf 6 ,171.24 43117 Partial esophagectomy, distal two-thirds, with thoracotomy and separate abdominal incision, with or without 6 ,574.50 43118 Prtl esphg dstl thorcom abdl inc ntrpstj/rcnstj 5 ,531.39 43121 Partial esophagectomy, distal two-thirds, with thoracotomy only, with or without proximal gastrectomy, with 6 ,251.40 43122 Partial esophagectomy, thoracoabdominal or abdominal approach, with or without proximal gastrectomy; 5 ,902.20 43123 Partial esophagectomy, thoracoabdominal or abdominal approach, with or without proximal gastrectomy; 6 ,437.70 43124 Tot/prtl esphg w/o rcnstj w/crv esophagostomy 4 ,452.63 43130 Diverticulectomy of hypopharynx or esophagus, with or without myotomy; cervical approach 2 , 6 4 2 . 4 0 43135 Diverticulectomy of hypopharynx or esophagus, with or without myotomy; thoracic approach 3 , 1 4 1 . 9 0 43200 Esophagoscopy, rigid or flexible; diagnostic, with or without collection of specimen(s) by brushing or 5 67.90 43201 Esphgsc rgd/flx dired sbmcsl njx any sbst 7 54.53 43202 Esophagoscopy, rigid or flexible; with biopsy, single or multiple 6 5 4 . 3 0 43204 Esophagoscopy, rigid or flexible; with injection sclerosis of esophageal varices 9 7 3 . 8 0 43205 Esophagoscopy, rigid or flexible; with band ligation of esophageal varices 9 7 8 . 3 0 46 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 43215 Esophagoscopy, rigid or flexible; with removal of foreign body 8 3 2 . 5 0 43216 Esophagoscopy, rigid or flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps 8 39.70 43217 Esophagoscopy, rigid or flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique 9 2 9 . 7 0 43219 Esophagoscopy, rigid or flexible; with insertion of plastic tube or stent 1 , 0 2 2 . 4 0 43220 Esophagoscopy, rigid or flexible; with balloon dilation (less than 30 mm diameter) 7 6 0 . 5 0 43226 Esophagoscopy, rigid or flexible; with insertion of guide wire followed by dilation over guide wire 6 8 1 . 3 0 43227 Esophagoscopy, rigid or flexible; with control of bleeding, any method 1 , 0 5 9 . 3 0 43228 Esophagoscopy, rigid or flexible; with ablation of tumor(s), polyp(s), or other lesion(s), not amenable to 1 ,025.10 43231 Esophagoscopy, rigid or flexible; with endoscopic ultrasound examination 7 6 2 . 3 0 43232 Esophagoscopy, rigid or flexible; with transendoscopic ultrasound-guided intramural or transmural fine 7 82.57 43235 Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum 5 75.48 43236 Stomach-intestine scope inject intestine wall 8 33.87 43237 Upr gi ndsc ndsc us xm lmtd esoph 6 05.29 43238 Upr gi ndsc tndsc us fine ndl aspir/bx esoph 7 12.37 43239 Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum 6 45.72 43240 Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum 1 ,233.90 43241 Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum 9 72.00 43242 Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum 9 68.40 43243 Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum 9 53.10 43244 Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum 9 78.30 43245 Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum 8 22.60 43246 Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum 1 ,133.10 43247 Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum 8 28.90 43248 Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum 7 33.50 43249 Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum 7 47.00 43250 Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum 9 72.00 43251 Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum 9 53.10 43255 Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum 9 92.70 43256 Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum 7 62.30 43257 Upr gi ndsc dlvr thermal nrg sphnctr/cardia 1 ,070.28 43258 Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum 9 29.70 43259 Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum 8 44.20 43260 Endoscopic retrograde cholangio-pancreatography (ERCP); diagnostic, with or without collection of 1 ,159.20 43261 Endoscopic retrograde cholangio-pancreatography (ERCP); with biopsy, single or multiple 1 , 3 4 9 . 1 0 43262 Endoscopic retrograde cholangio-pancreatography (ERCP); with sphincterotomy/papillotomy 1 , 6 4 2 . 5 0 43263 Endoscopic retrograde cholangio-pancreatography (ERCP); with pressure measurement of sphincter of 1 ,542.60 43264 Endoscopic retrograde cholangio-pancreatography (ERCP); with endoscopic retrograde removal of stone(s) 1 ,781.10 43265 Endoscopic retrograde cholangio-pancreatography (ERCP); with endoscopic retrograde destruction, 1 ,833.30 43267 Endoscopic retrograde cholangio-pancreatography (ERCP); with endoscopic retrograde insertion of 1 ,494.00 43268 Endoscopic retrograde cholangio-pancreatography (ERCP); with endoscopic retrograde insertion of tube or 1 ,681.20 43269 Endoscopic retrograde cholangio-pancreatography (ERCP); with endoscopic retrograde removal of foreign 1 ,462.50 43271 Endoscopic retrograde cholangio-pancreatography (ERCP); with endoscopic retrograde balloon dilation of 1 ,741.50 43272 Endoscopic retrograde cholangio-pancreatography (ERCP); with ablation of tumor(s), polyp(s), or other 1 ,364.40 43273 Endoscopic papilla cannulation bile pancreatic 3 20.58 43279 Laps esophagomyotomy w/fundoplasty if performed 2 ,872.69 43280 Laparoscopy, surgical, esophagogastric fundoplasty (eg, Nissen, Toupet procedures) 3 , 5 0 1 . 9 0 43281 Laps rpr paraesphgl hrna incl fundplsty w/o mesh 3 ,859.31 43282 Laps rpr paraesphgl hrna incl fundplsty w/mesh 4 ,088.80 43283 Laps esophageal lengthening addl 4 05.69 43300 Esophagoplasty, (plastic repair or reconstruction), cervical approach; without repair of tracheoesophageal 3 ,110.40 43305 Esophagoplasty, (plastic repair or reconstruction), cervical approach; with repair of tracheoesophageal 3 ,627.90 43310 Esophagoplasty, (plastic repair or reconstruction), thoracic approach; without repair of tracheoesophageal 4 ,030.20 43312 Esophagoplasty, (plastic repair or reconstruction), thoracic approach; with repair of tracheoesophageal 4 ,640.40 43313 Esphgp cgen dfct thrc appr w/o rpr fstl 5 ,873.36 43314 Esphgp cgen dfct thrc appr w/rpr fstl 6 ,478.08 43320 Esophagogastrostomy (cardioplasty), with or without vagotomy and pyloroplasty, transabdominal or 3 ,590.10 43325 Esophagogastric fundoplasty; with fundic patch (Thal-Nissen procedure) 3 , 4 2 9 . 9 0 43327 Esopg/gstr fundoplasty w/lapt 1 ,847.23 43328 Esopg/gstr fundoplasty w/thorcom 2 ,706.08 43330 Esophagomyotomy (Heller type); abdominal approach 2 , 9 1 7 . 8 0 43331 Esophagomyotomy (Heller type); thoracic approach 3 , 1 9 8 . 6 0 43332 Rpr paraesoph hiatal hernia w/lapt w/o mesh 2 ,635.13 43333 Lapt rpr paraesoph hiatal hernia w/ mesh 2 ,873.14 43334 Rpr paraesoph hiatal hernia w/thorcom w/o mesh 2 ,906.96 43335 Rpr paraesoph hiatal hernia w/thorcom w/mesh 3 ,144.71 43336 Rpr paraesoph hiatal hernia thorcoabdom w/o mesh 3 ,422.52 43337 Rpr paraesoph hiatal hernia thorcoabdom w/mesh 3 ,761.84 43338 Esophagus lengthening 3 07.64 43340 Esophagojejunostomy (without total gastrectomy); abdominal approach 3 , 5 5 1 . 4 0 43341 Esophagojejunostomy (without total gastrectomy); thoracic approach 4 , 2 2 8 . 2 0 47 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 43350 Esophagostomy, fistulization of esophagus, external; abdominal approach 2 , 3 8 1 . 4 0 43351 Esophagostomy, fistulization of esophagus, external; thoracic approach 2 , 4 7 7 . 7 0 43352 Esophagostomy, fistulization of esophagus, external; cervical approach 2 , 3 6 8 . 8 0 43360 Gastrointestinal reconstruction for previous esophagectomy, for obstructing esophageal lesion or fistula, or 5 ,664.60 43361 Gastrointestinal reconstruction for previous esophagectomy, for obstructing esophageal lesion or fistula, or 6 ,695.10 43400 Ligation, direct, esophageal varices 3 , 1 7 2 . 5 0 43401 Transection of esophagus with repair, for esophageal varices 3 , 3 4 8 . 0 0 43405 Ligation or stapling at gastroesophageal junction for pre-existing esophageal perforation 3 , 3 4 9 . 8 0 43410 Suture of esophageal wound or injury; cervical approach 2 , 5 7 4 . 9 0 43415 Suture of esophageal wound or injury; transthoracic or transabdominal approach 3 , 1 1 4 . 0 0 43420 Closure of esophagostomy or fistula; cervical approach 1 , 9 5 4 . 8 0 43425 Closure of esophagostomy or fistula; transthoracic or transabdominal approach 3 , 1 1 5 . 8 0 43450 Dilation of esophagus, by unguided sound or bougie, single or multiple passes 2 8 5 . 3 0 43453 Dilation of esophagus, over guide wire 4 1 4 . 9 0 43456 Dilation of esophagus, by balloon or dilator, retrograde 7 3 9 . 8 0 43458 Dilation of esophagus with balloon (30 mm diameter or larger) for achalasia 5 2 0 . 2 0 43460 Esophagogastric tamponade, with balloon (Sengstaaken type) 6 9 7 . 5 0 43500 Gastrotomy; with exploration or foreign body removal 1 , 9 8 1 . 8 0 43501 Gastrotomy; with suture repair of bleeding ulcer 2 , 7 6 5 . 7 0 43502 Gastrotomy; with suture repair of pre-existing esophagogastric laceration (eg, Mallory-Weiss) 2 , 6 0 1 . 0 0 43510 Gastrotomy; with esophageal dilation and insertion of permanent intraluminal tube (eg, Celestin or 2 ,067.30 43520 Pyloromyotomy, cutting of pyloric muscle (Fredet-Ramstedt type operation) 1 , 8 5 0 . 4 0 43605 Biopsy of stomach; by laparotomy 1 , 9 7 7 . 3 0 43610 Excision, local; ulcer or benign tumor of stomach 2 , 5 7 2 . 2 0 43611 Excision, local; malignant tumor of stomach 2 , 8 3 7 . 7 0 43620 Gastrectomy, total; with esophagoenterostomy 4 , 6 4 4 . 9 0 43621 Gastrectomy, total; with Roux-en-Y reconstruction 4 , 9 9 5 . 9 0 43622 Gastrectomy, total; with formation of intestinal pouch, any type 5 , 0 4 7 . 2 0 43631 Gastrectomy, partial, distal; with gastroduodenostomy 3 , 5 4 1 . 5 0 43632 Gastrectomy, partial, distal; with gastrojejunostomy 3 , 8 6 4 . 6 0 43633 Gastrectomy, partial, distal; with Roux-en-Y reconstruction 3 , 9 5 3 . 7 0 43634 Gastrectomy, partial, distal; with formation of intestinal pouch 4 , 8 5 1 . 9 0 43635 Vagotomy when performed with partial distal gastrectomy (List separately in addition to code(s) for primary 1 ,287.90 43640 Vagotomy including pyloroplasty, with or without gastrostomy; truncal or selective 3 , 0 6 4 .5 0 43641 Vagotomy including pyloroplasty, with or without gastrostomy; parietal cell (highly selective) 2 , 9 0 4 . 3 0 43644 Laps gstr rstcv px w/byp roux-en-y <150 cm 5 ,644.84 43645 Laps gstr rstcv px w/byp&sm int rcnstj 6 ,078.45 43651 Laps surg trnsxj vagus nrv truncal 2 ,584.61 43652 Laps surg trnsxj vagus nrv slctv/hily slctv 2 ,984.62 43653 Laps surg gastrostomy w/o constj gstr tube spx 1 ,909.82 43752 Naso/oro-gastric tube plmt req phys&fluor gdn 8 7.45 43753 Gastric tube plmt w/aspir & lavage 5 1.44 43754 Dx gastr intub w/asp spec 9 2.15 43755 Dx gastr intub w/asp specs 2 16.19 43756 Dx duod intub w/asp spec 2 25.22 43757 Dx duod intub w/asp specs 3 30.91 43760 Change of gastrostomy tube 1 9 2 . 6 0 43761 Repositioning of the gastric feeding tube, any method, through the duodenum for enteric nutrition 3 2 0 . 4 0 43770 Laps gastric restrictive procedure place device 3 ,192.15 43771 Laps gastric restrictive px revision device 2 ,947.87 43772 Laps gastric restrictive px remove device 2 ,562.77 43773 Laps gastric restrictive px remove&rplcmt device 3 ,259.75 43774 Laps gastric restrictive px remove device &port 2 ,594.55 43775 Laps gstrc rstrictiv px longitudinal gastrectomy 3 ,427.22 43800 Pyloroplasty 2 , 1 7 2 . 6 0 43810 Gastroduodenostomy 2 , 2 9 6 . 8 0 43820 Gastrojejunostomy; without vagotomy 2 , 6 8 8 . 3 0 43825 Gastrojejunostomy; with vagotomy, any type 3 , 0 9 6 . 0 0 43830 Gastrostomy, open; without construction of gastric tube (eg, Stamm procedure) (separate procedure) 1 , 7 8 4 . 7 0 43831 Gastrostomy, open; neonatal, for feeding 1 , 6 4 2 . 5 0 43832 Gastrostomy, open; with construction of gastric tube (eg, Janeway procedure) 2 , 5 5 3 . 3 0 43840 Gastrorrhaphy, suture of perforated duodenal or gastric ulcer, wound, or injury 2 , 3 4 4 . 5 0 43842 Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical-banded gastroplasty 3 , 6 5 6 . 7 0 43843 Gastric restrictive procedure, without gastric bypass, for morbid obesity; other than vertical-banded 3 ,605.40 43845 Gstr rstcv w/prtl gstrct 50-100 cm 5 ,446.89 43846 Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (less than 100 cm) Roux- 4 ,532.40 43847 Gstr rstcv w/byp w/sm int rcnstj limit absrpj 5 ,096.43 43848 Revision open gastric restrictive px not device 5 ,284.93 43850 Revision of gastroduodenal anastomosis (gastroduodenostomy) with reconstruction; without vagotomy 4 , 0 7 8 . 8 0 43855 Revision of gastroduodenal anastomosis (gastroduodenostomy) with reconstruction; with vagotomy 4 , 1 7 1 . 5 0 48 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 43860 Revision of gastrojejunal anastomosis (gastrojejunostomy) with reconstruction, with or without partial 4 ,131.90 43865 Revision of gastrojejunal anastomosis (gastrojejunostomy) with reconstruction, with or without partial 3 ,879.90 43870 Closure of gastrostomy, surgical 1 , 6 8 7 . 5 0 43880 Closure of gastrocolic fistula 3 , 2 9 5 . 8 0 43886 Gstr rstcv px opn revj subq port component only 9 25.03 43887 Gstr rstcv px opn rmvl subq port component only 8 86.07 43888 Gstr rstcv opn rmvl&rplcmt subq port 1 ,353.63 44005 Enterolysis (freeing of intestinal adhesion) (separate procedure) 2 , 3 0 5 . 6 9 44010 Duodenotomy, for exploration, biopsy(s), or foreign body removal 2 , 3 0 6 . 7 0 44015 Tube or needle catheter jejunostomy for enteral alimentation, intraoperative, any method (List separately in 1 ,448.10 44020 Enterotomy, small bowel, other than duodenum; for exploration, biopsy(s), or foreign body removal 2 , 2 3 2 . 0 0 44021 Enterotomy, small bowel, other than duodenum; for decompression (eg, Baker tube) 2 , 3 1 9 . 3 0 44025 Colotomy, for exploration, biopsy(s), or foreign body removal 2 , 3 8 9 . 5 0 44050 Reduction of volvulus, intussusception, internal hernia, by laparotomy 2 , 3 2 1 . 1 0 44055 Correction of malrotation by lysis of duodenal bands and/or reduction of midgut volvulus (eg, Ladd 2 ,601.00 44100 Biopsy of intestine by capsule, tube, peroral (one or more specimens) 4 8 5 . 1 0 44110 Excision of one or more lesions of small or large bowel not requiring anastomosis, exteriorization, or 2 ,351.70 44111 Excision of one or more lesions of small or large bowel not requiring anastomosis, exteriorization, or 3 ,157.20 44120 Enterectomy, resection of small intestine; single resection and anastomosis 2 , 8 8 0 . 0 0 44121 Enterectomy, resection of small intestine; each additional resection and anastomosis (List separately in 9 18.90 44125 Enterectomy, resection of small intestine; with enterostomy 3 , 1 1 4 . 0 0 44126 Entrc rescj atresia rescj&anast w/o tapring 5 ,370.66 44127 Entrc rescj atresia rescj&anast sgm w/tapring 5 ,598.46 44128 Entrc rescj atresia ea rescj&anast 1 ,016.67 44130 Enteroenterostomy, anastomosis of intestine, with or without cutaneous enterostomy (separate procedure) 2 , 6 9 4 . 6 0 44139 Mobilization (take-down) of splenic flexure performed in conjunction with partial colectomy (List separately in 5 14.80 44140 Colectomy, partial; with anastomosis 3 , 3 4 0 . 8 0 44141 Colectomy, partial; with skin level cecostomy or colostomy 3 , 3 3 3 . 6 5 44143 Colectomy, partial; with end colostomy and closure of distal segment (Hartmann type procedure) 3 , 3 3 1 . 8 0 44144 Colectomy, partial; with resection, with colostomy or ileostomy and creation of mucofistula 3 , 3 4 8 . 0 0 44145 Colectomy, partial; with coloproctostomy (low pelvic anastomosis) 3 , 8 8 7 . 1 0 44146 Colectomy, partial; with coloproctostomy (low pelvic anastomosis), with colostomy 4 , 2 9 3 . 9 0 44147 Colectomy, partial; abdominal and transanal approach 4 , 6 2 6 . 9 0 44150 Colectomy, total, abdominal, without proctectomy; with ileostomy or ileoproctostomy 4 , 7 1 8 . 7 0 44151 Colectomy, total, abdominal, without proctectomy; with continent ileostomy 5 , 4 0 8 . 1 0 44155 Colectomy, total, abdominal, with proctectomy; with ileostomy 5 , 7 5 1 . 9 0 44156 Colectomy, total, abdominal, with proctectomy; with continent ileostomy 5 , 7 6 8 . 1 0 44157 Colct ttl abd w/prctect ileoanal anast 4 ,865.79 44158 Colct ttl abd w/prctect ileoanal anast & rsvr 5 ,014.80 44160 Colectomy with removal of terminal ileum and ileocolostomy 4 , 0 1 4 . 9 0 44180 Laps enterolss fring intstinal adhesion spx 1 ,859.50 44186 Laps jejunostomy 1 ,441.07 44187 Laps ileost/jejunostomy non-tube 2 ,229.44 44188 Laps clst/skn lvl cecostomy 2 ,477.27 44202 Laparoscopy, surgical; intestinal resection, with anastomosis (intra or extracorporeal) 4 , 0 1 3 . 1 0 44203 Laps ea sm int rescj&anast 7 42.32 44204 Laps colct prtl w/anast 3 ,237.04 44205 Laps colct prtl w/rmvl terminal ile 3 ,053.39 44206 Laps colct prtl w/end clst&clsr dstl sgm 3 ,562.31 44207 Laps colct prtl w/colopxtstmy lw anast 3 ,989.43 44208 Laps colct prtl w/colopxtstmy lw anast w/clst 4 ,162.98 44210 Laps colct tot w/o prctect w/ileost/ileopxts 3 ,925.87 44211 Laps colct ttl abd w/prctect ileoanal anast&rsvr 5 ,320.26 44212 Laps colct abdl w/prctect w/ileost 4 ,588.99 44213 Laps moblj splenic flxr pfrmd w/prtl colct 4 55.45 44227 Laps clsr ntrstm lg/sm int w/rescj&anast 3 ,432.69 44300 Enterostomy or cecostomy, tube (eg, for decompression or feeding) (separate procedure) 2 , 1 2 1 . 3 0 44310 Ileostomy or jejunostomy, non-tube (separate procedure) 2 , 2 7 1 . 6 0 44312 Revision of ileostomy; simple (release of superficial scar) (separate procedure) 1 , 2 6 9 . 0 0 44314 Revision of ileostomy; complicated (reconstruction in-depth) (separate procedure) 2 , 3 4 3 . 6 0 44316 Continent ileostomy (Kock procedure) (separate procedure) 3 , 2 9 5 . 8 0 44320 Colostomy or skin level cecostomy; (separate procedure) 2 , 2 0 1 . 4 0 44322 Colostomy or skin level cecostomy; with multiple biopsies (eg, for Hirschsprung disease) (separate 2 ,568.60 44340 Revision of colostomy; simple (release of superficial scar) (separate procedure) 9 1 8 . 0 0 44345 Revision of colostomy; complicated (reconstruction in-depth) (separate procedure) 2 , 0 9 3 . 4 0 44346 Revision of colostomy; with repair of paracolostomy hernia (separate procedure) 2 , 3 6 5 . 2 0 44360 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; 8 64.90 44361 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with 8 63.10 44363 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with 8 04.60 44364 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with 9 78.30 49 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 44365 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with 9 78.30 44366 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with 1 ,076.40 44369 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with 1 ,133.10 44370 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with 7 60.50 44372 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with 1 ,199.70 44373 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with 9 04.50 44376 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; diagnostic, 1 ,007.10 44377 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; with biopsy, 1 ,061.10 44378 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; with control 1 ,359.90 44379 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; with 1 ,137.60 44380 Ileoscopy, through stoma; diagnostic, with or without collection of specimen(s) by brushing or washing 5 46.30 44382 Ileoscopy, through stoma; with biopsy, single or multiple 6 8 1 . 3 0 44383 Ilesc thru stoma w/tndsc stent plmt 9 17.99 44385 Endoscopic evaluation of small intestinal (abdominal or pelvic) pouch; diagnostic, with or without collection 7 15.50 44386 Endoscopic evaluation of small intestinal (abdominal or pelvic) pouch; with biopsy, single or multiple 7 4 1 . 6 0 44388 Colonoscopy through stoma; diagnostic, with or without collection of specimen(s) by brushing or washing 7 39.80 44389 Colonoscopy through stoma; with biopsy, single or multiple 7 9 6 . 5 0 44390 Colonoscopy through stoma; with removal of foreign body 8 4 1 . 5 0 44391 Colonoscopy through stoma; with control of bleeding, any method 1 , 1 6 6 . 4 0 44392 Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or 1 ,255.50 44393 Colonoscopy through stoma; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal 1 ,321.20 44394 Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique 1 , 1 0 2 . 5 0 44397 Colonoscopy through stoma; with transendoscopic stent placement (includes predilation) 5 9 6 . 7 0 44500 Introduction of long gastrointestinal tube (eg, Miller-Abbott) (separate procedure) 1 2 3 . 3 0 44602 Suture of small intestine (enterorrhaphy) for perforated ulcer, diverticulum, wound, injury or rupture; single 2 ,248.20 44603 Suture of small intestine (enterorrhaphy) for perforated ulcer, diverticulum, wound, injury or rupture; multiple 2 ,656.80 44604 Suture of large intestine (colorrhaphy) for perforated ulcer, diverticulum, wound, injury or rupture (single or 2 ,258.45 44605 Suture of large intestine (colorrhaphy) for perforated ulcer, diverticulum, wound, injury or rupture (single or 2 ,991.60 44615 Intestinal stricturoplasty (enterotomy and enterorrhaphy) with or without dilation, for intestinal obstruction 2 , 6 2 6 . 2 0 44620 Closure of enterostomy, large or small intestine; 1 , 7 1 3 . 6 5 44625 Closure of enterostomy, large or small intestine; with resection and anastomosis other than colorectal 3 , 0 3 3 . 9 0 44626 Closure of enterostomy, large or small intestine; with resection and colorectal anastomosis (eg, closure of 3 ,744.90 44640 Closure of intestinal cutaneous fistula 2 , 3 7 2 . 4 0 44650 Closure of enteroenteric or enterocolic fistula 3 , 0 9 0 . 6 0 44660 Closure of enterovesical fistula; without intestinal or bladder resection 2 , 7 2 9 . 7 0 44661 Closure of enterovesical fistula; with bowel and/or bladder resection 3 , 9 2 7 . 6 0 44680 Intestinal plication (separate procedure) 2 , 8 7 1 . 9 0 44700 Exclusion of small bowel from pelvis by mesh or other prosthesis, or native tissue (eg, bladder or omentum) 2 , 7 0 9 . 9 0 44701 Intraop colonic lvg 3 05.32 44720 Prep donor intestine/venous 5 81.85 44721 Prep donor intestine/artery 9 29.76 44800 Excision of Meckel's diverticulum (diverticulectomy) or omphalomesenteric duct 1 , 9 1 3 . 4 0 44820 Excision of lesion of mesentery (separate procedure) 2 , 0 3 4 . 0 0 44850 Suture of mesentery (separate procedure) 1 , 8 0 2 . 7 0 44900 Incision and drainage of appendiceal abscess; open 1 , 5 4 5 . 3 0 44901 Incision and drainage of appendiceal abscess; percutaneous 6 2 8 . 2 0 44950 Appendectomy; 1 , 5 3 7 . 1 9 44955 Appendectomy; when done for indicated purpose at time of other major procedure (not as separate 1 ,133.10 44960 Appendectomy; for ruptured appendix with abscess or generalized peritonitis 2 , 3 5 7 . 1 0 44970 Laparoscopy, surgical, appendectomy 2 , 1 3 0 . 3 0 45000 Transrectal drainage of pelvic abscess 9 5 3 . 1 0 45005 Incision and drainage of submucosal abscess, rectum 5 2 2 . 9 0 45020 Incision and drainage of deep supralevator, pelvirectal, or retrorectal abscess 8 9 3 . 7 0 45100 Biopsy of anorectal wall, anal approach (eg, congenital megacolon) 7 6 7 . 7 0 45108 Anorectal myomectomy 1 , 1 8 4 . 4 0 45110 Proctectomy; complete, combined abdominoperineal, with colostomy 4 , 3 9 2 . 9 0 45111 Proctectomy; partial resection of rectum, transabdominal approach 3 , 4 9 8 . 3 0 45112 Proctectomy, combined abdominoperineal, pull-through procedure (eg, colo-anal anastomosis) 4 , 6 4 5 . 8 0 45113 Prctect prtl w/mucosec ileoanal anast rsvr 4 ,837.19 45114 Proctectomy, partial, with anastomosis; abdominal and transsacral approach 4 , 4 8 9 . 2 0 45116 Proctectomy, partial, with anastomosis; transsacral approach only (Kraske type) 3 , 2 9 5 . 8 0 45119 Proctectomy, combined abdominoperineal pull-through procedure (eg, colo-anal anastomosis), with creation 4 ,377.60 45120 Proctectomy, complete (for congenital megacolon), abdominal and perineal approach; with pull-through 4 ,650.30 45121 Proctectomy, complete (for congenital megacolon), abdominal and perineal approach; with subtotal or total 4 ,738.50 45123 Proctectomy, partial, without anastomosis, perineal approach 3 , 1 4 9 . 1 0 45126 Pelvic exenteration for colorectal malignancy, with proctectomy (with or without colostomy), with removal of 6 ,470.10 45130 Excision of rectal procidentia, with anastomosis; perineal approach 2 , 8 6 4 . 7 0 45135 Excision of rectal procidentia, with anastomosis; abdominal and perineal approach 4 , 0 3 3 . 8 0 45136 Exc ileoanal rsvr w/ileost 4 ,548.02 45150 Division of stricture of rectum 1 , 2 7 8 . 0 0 50 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 45160 Excision of rectal tumor by proctotomy, transsacral or transcoccygeal approach 2 , 8 2 7 . 8 0 45171 Exc rct tum not incl muscularis propria 1 ,349.29 45172 Exc rct tum incl muscularis propria 1 ,853.35 45190 Destruction of rectal tumor, any method (eg, electrodesiccation) transanal approach 1 , 4 4 1 . 8 0 45300 Proctosigmoidoscopy, rigid; diagnostic, with or without collection of specimen(s) by brushing or washing 1 42.39 45303 Proctosigmoidoscopy, rigid; with dilation, any method 2 2 0 . 5 0 45305 Proctosigmoidoscopy, rigid; with biopsy, single or multiple 2 5 7 . 4 0 45307 Proctosigmoidoscopy, rigid; with removal of foreign body 3 8 6 . 1 0 45308 Proctosigmoidoscopy, rigid; with removal of single tumor, polyp, or other lesion by hot biopsy forceps or 4 17.60 45309 Proctosigmoidoscopy, rigid; with removal of single tumor, polyp, or other lesion by snare technique 4 3 0 . 2 0 45315 Proctosigmoidoscopy, rigid; with removal of multiple tumors, polyps, or other lesions by hot biopsy forceps, 5 82.30 45317 Proctosigmoidoscopy, rigid; with control of bleeding, any method 5 8 5 .0 0 45320 Proctosigmoidoscopy, rigid; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal 6 39.00 45321 Proctosigmoidoscopy, rigid; with decompression of volvulus 5 3 4 . 6 0 45327 Proctosgmdsc rgd tndsc stent plmt 2 19.12 45330 Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen(s) by brushing or washing 2 53.73 45331 Sigmoidoscopy, flexible; with biopsy, single or multiple 3 3 9 . 8 6 45332 Sigmoidoscopy, flexible; with removal of foreign body 4 4 9 . 1 0 45333 Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or 5 58.90 45334 Sigmoidoscopy, flexible; with control of bleeding, any method 5 7 0 . 6 0 45335 Sgmdsc flx dired sbmcsl njx any sbst 7 14.94 45337 Sigmoidoscopy, flexible; with decompression of volvulus, any method 7 7 2 . 2 0 45338 Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique 6 0 5 . 7 0 45339 Sigmoidoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by 6 04.80 45340 Sgmdsc flx dilat balo 1/more strixs 4 00.18 45341 Sigmoidoscopy, flexible; with endoscopic ultrasound examination 6 0 7 . 5 0 45342 Sigmoidoscopy, flexible; with transendoscopic ultrasound guided intramural or transmural fine needle 7 00.20 45345 Sigmoidoscopy, flexible; with transendoscopic stent placement (includes predilation) 4 6 8 . 9 0 45355 Colonoscopy, rigid or flexible, transabdominal via colotomy, single or multiple 7 8 5 . 7 0 45378 53 Diagnostic colonoscopy 3 04.71 45378 Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by 8 58.15 45379 Colonoscopy, flexible, proximal to splenic flexure; with removal of foreign body 1 , 0 9 9 . 8 0 45380 Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple 9 6 1 . 7 7 45381 Colsc flx prox splenic flxr sbmcsl njx 9 75.00 45382 Colonoscopy, flexible, proximal to splenic flexure; with control of bleeding, any method 1 , 1 0 7 . 0 0 45383 Colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor(s), polyp(s), or other lesion(s) not 1 ,203.49 45384 Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by 1 ,162.09 45385 Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by 1 ,287.91 45386 Colsc flx prox splenic flxr dilat balo 1+ strixs 9 58.72 45387 Colonoscopy, flexible, proximal to splenic flexure; with transendoscopic stent placement (includes 9 50.40 45391 Colsc flx prox splenic flxr ndsc us xm 5 68.04 45392 Colsc flx prox splenic flxr us gid ndl aspir/bx 7 18.20 45395 Laps prctect compl cmbn abdominoprnl w/clst 3 ,966.46 45397 Laps prctect cmbn pull-thru crtj rsvr 4 ,303.15 45400 Laps proctopexy for prolapse 2 ,322.57 45402 Laps proctopexy for prolapse sigmoid rescj 3 ,124.42 45500 Proctoplasty; for stenosis 1 , 5 7 0 . 5 0 45505 Proctoplasty; for prolapse of mucous membrane 1 , 6 4 7 . 9 0 45520 Perirectal injection of sclerosing solution for prolapse 1 4 4 . 0 0 45540 Proctopexy for prolapse; abdominal approach 3 , 2 0 6 . 7 0 45541 Proctopexy for prolapse; perineal approach 2 , 5 2 3 . 6 0 45550 Proctopexy combined with sigmoid resection, abdominal approach 3 , 5 9 1 . 0 0 45560 Repair of rectocele (separate procedure) 1 , 4 9 4 . 0 0 45562 Exploration, repair, and presacral drainage for rectal injury; 2 , 6 5 7 . 7 0 45563 Exploration, repair, and presacral drainage for rectal injury; with colostomy 3 , 0 9 5 . 1 0 45800 Closure of rectovesical fistula; 3 , 0 6 6 . 3 0 45805 Closure of rectovesical fistula; with colostomy 3 , 1 0 3 . 2 0 45820 Closure of rectourethral fistula; 2 , 7 2 9 . 7 0 45825 Closure of rectourethral fistula; with colostomy 3 , 0 5 7 . 3 0 45900 Reduction of procidentia (separate procedure) under anesthesia 4 9 7 . 7 0 45905 Dilation of anal sphincter (separate procedure) under anesthesia other than local 3 6 0 . 9 0 45910 Dilation of rectal stricture (separate procedure) under anesthesia other than local 3 8 4 . 3 0 45915 Removal of fecal impaction or foreign body (separate procedure) under anesthesia 4 2 5 . 7 0 45990 Anrct xm surg req anes general spi/edrl dx 2 19.72 46020 Plmt seton 2 30.01 46030 Removal of anal seton, other marker 2 9 3 . 4 0 46040 Incision and drainage of ischiorectal and/or perirectal abscess (separate procedure) 7 0 3 . 8 0 46045 Incision and drainage of intramural, intramuscular, or submucosal abscess, transanal, under anesthesia 7 7 5 . 8 0 46050 Incision and drainage, perianal abscess, superficial 2 8 2 . 6 0 46060 Incision and drainage of ischiorectal or intramural abscess, with fistulectomy or fistulotomy, submuscular, 1 ,665.00 51 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 46070 Incision, anal septum (infant) 4 3 2 . 9 0 46080 Sphincterotomy, anal, division of sphincter (separate procedure) 8 2 0 . 8 0 46083 Incision of thrombosed hemorrhoid, external 2 1 4 . 2 0 46200 Fissurectomy, with or without sphincterotomy 8 6 7 . 6 0 46220 Papillectomy or excision of single tag, anus (separate procedure) 3 4 3 . 8 0 46221 Hemorrhoidectomy, by simple ligature (eg, rubber band) 3 9 1 . 5 0 46230 Excision of external hemorrhoid tags and/or multiple papillae 3 8 0 . 7 0 46250 Hemorrhoidectomy, external, complete 9 5 2 . 2 0 46255 Hemorrhoidectomy, internal and external, simple; 1 , 1 3 3 . 0 2 46257 Hemorrhoidectomy, internal and external, simple; with fissurectomy 1 , 3 9 5 . 9 0 46258 Hemorrhoidectomy, internal and external, simple; with fistulectomy, with or without fissurectomy 1 , 4 9 4 . 9 0 46260 Hemorrhoidectomy, internal and external, complex or extensive; 1 , 7 4 4 . 2 0 46261 Hemorrhoidectomy, internal and external, complex or extensive; with fissurectomy 1 , 4 6 9 . 7 3 46262 Hemorrhoidectomy, internal and external, complex or extensive; with fistulectomy, with or without 1 ,658.70 46270 Surgical treatment of anal fistula (fistulectomy/fistulotomy); subcutaneous 8 1 3 . 6 0 46275 Surgical treatment of anal fistula (fistulectomy/fistulotomy); submuscular 1 , 4 2 6 . 5 0 46280 Surgical treatment of anal fistula (fistulectomy/fistulotomy); complex or multiple, with or without placement of 1 ,668.60 46285 Surgical treatment of anal fistula (fistulectomy/fistulotomy); second stage 5 7 8 . 7 0 46288 Closure of anal fistula with rectal advancement flap 1 , 5 9 6 . 6 0 46320 Enucleation or excision of external thrombotic hemorrhoid 2 5 2 . 0 7 46500 Injection of sclerosing solution, hemorrhoids 1 0 4 . 4 0 46505 Chemodnrvtj int anal sphnctr 6 20.82 46600 Anoscopy; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) 7 0 . 8 5 46604 Anoscopy; with dilation, any method 1 9 7 . 1 0 46606 Anoscopy; with biopsy, single or multiple 1 5 6 . 6 0 46608 Anoscopy; with removal of foreign body 2 3 6 . 7 0 46610 Anoscopy; with removal of single tumor, polyp, or other lesion by hot biopsy forceps or bipolar cautery 2 7 7 . 2 0 46611 Anoscopy; with removal of single tumor, polyp, or other lesion by snare technique 2 8 3 . 5 0 46612 Anoscopy; with removal of multiple tumors, polyps, or other lesions by hot biopsy forceps, bipolar cautery or 3 43.80 46614 Anoscopy; with control of bleeding, any method 4 0 7 . 7 0 46615 Anoscopy; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy 4 14.00 46700 Anoplasty, plastic operation for stricture; adult 1 , 4 9 8 . 6 8 46705 Anoplasty, plastic operation for stricture; infant 1 , 4 1 6 . 6 0 46706 Rpr anal fstl w/fibrin glue 3 89.22 46707 Repair anorectal fistula plug 1 ,162.37 46710 Rpr ileoanal pouch fstl/pouch advmnt tprnl appr 2 ,534.97 46712 Rpr ileoanal pouch fstl/pouch advmnt cmbn appr 4 ,490.29 46715 Repair of low imperforate anus; with anoperineal fistula (cut-back procedure) 1 , 5 6 3 . 3 0 46716 Repair of low imperforate anus; with transposition of anoperineal or anovestibular fistula 1 , 9 5 4 . 8 0 46730 Repair of high imperforate anus without fistula; perineal or sacroperineal approach 3 , 2 9 4 . 0 0 46735 Repair of high imperforate anus without fistula; combined transabdominal and sacroperineal approaches 3 , 9 9 4 . 2 0 46740 Repair of high imperforate anus with rectourethral or rectovaginal fistula; perineal or sacroperineal approach 4 , 2 5 7 . 0 0 46742 Repair of high imperforate anus with rectourethral or rectovaginal fistula; combined transabdominal and 5 ,047.20 46744 Repair of cloacal anomaly by anorectovaginoplasty and urethroplasty, sacroperineal approach 5 , 3 0 4 .6 0 46746 Repair of cloacal anomaly by anorectovaginoplasty and urethroplasty, combined abdominal and 6 ,437.70 46748 Repair of cloacal anomaly by anorectovaginoplasty and urethroplasty, combined abdominal and 7 ,020.00 46750 Sphincteroplasty, anal, for incontinence or prolapse; adult 1 , 9 4 4 . 7 2 46751 Sphincteroplasty, anal, for incontinence or prolapse; child 1 , 6 5 3 .3 0 46753 Graft (Thiersch operation) for rectal incontinence and/or prolapse 1 , 3 5 2 . 7 0 46754 Removal of Thiersch wire or suture, anal canal 2 8 7 . 1 0 46760 Sphincteroplasty, anal, for incontinence, adult; muscle transplant 1 , 9 3 2 . 3 0 46761 Sphnctrop anal levator musc imbrcj 2 ,142.41 46762 Sphnctrop anal impltj artif sphnctr 2 ,033.00 46900 Destruction of lesion(s), anus (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; 1 90.80 46910 Destruction of lesion(s), anus (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; 3 25.80 46916 Destruction of lesion(s), anus (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; 3 30.30 46917 Destruction of lesion(s), anus (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; 5 70.60 46922 Destruction of lesion(s), anus (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; 4 41.90 46924 Destruction of lesion(s), anus (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), 8 61.30 46930 Destroy internal hemorrhoids 3 09.16 46940 Curettage or cauterization of anal fissure, including dilation of anal sphincter (separate procedure); initial 3 4 2 . 9 0 46942 Curettage or cauterization of anal fissure, including dilation of anal sphincter (separate procedure); 2 41.20 46945 Ligation of internal hemorrhoids; single procedure 3 1 9 . 5 0 46946 Ligation of internal hemorrhoids; multiple procedures 3 7 2 . 6 0 46947 Hemorrhoidopexy stapling 5 78.58 47000 Biopsy of liver, needle; percutaneous 3 7 8 . 9 0 47001 Biopsy of liver, needle; when done for indicated purpose at time of other major procedure (List separately in 3 62.70 47010 Hepatotomy; for open drainage of abscess or cyst, one or two stages 2 , 3 9 9 . 4 0 47011 Hepatotomy; for percutaneous drainage of abscess or cyst, one or two stages 5 6 2 . 5 0 47015 Laparotomy, with aspiration and/or injection of hepatic parasitic (eg, amoebic or echinococcal) cyst(s) or 1 ,859.40 52 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 47100 Biopsy of liver, wedge 1 , 6 5 9 . 6 0 47120 Hepatectomy, resection of liver; partial lobectomy 4 , 0 9 4 . 1 0 47122 Hepatectomy, resection of liver; trisegmentectomy 5 , 0 5 5 . 3 0 47125 Hepatectomy, resection of liver; total left lobectomy 5 , 1 2 3 . 7 0 47130 Hepatectomy, resection of liver; total right lobectomy 5 , 6 6 0 . 1 0 47135 Transplantation of liver 1 1,907.94 47136 Transplantation of liver 1 0,222.38 47140 Partial removal donor liver 8 ,705.32 47141 Partial removal donor liver 9 ,173.83 47142 Partial removal donor liver 1 1,446.63 47146 Prep donor liver/venous 7 95.89 47147 Prep donor liver/arterial 9 28.21 47300 Marsupialization of cyst or abscess of liver 2 , 3 4 5 . 4 0 47350 Management of liver hemorrhage; simple suture of liver wound or injury 2 , 8 6 3 . 8 0 47360 Management of liver hemorrhage; complex suture of liver wound or injury, with or without hepatic artery 3 ,404.70 47361 Management of liver hemorrhage; exploration of hepatic wound, extensive debridement, coagulation and/or 5 ,294.70 47362 Management of liver hemorrhage; re-exploration of hepatic wound for removal of packing 2 , 2 2 9 . 3 0 47370 Laparo ablate liver tumor rf 3 ,013.06 47371 Laparo ablate liver cryosurg 3 ,066.51 47380 Open ablate liver tumor rf 3 ,485.82 47381 Open ablate liver tumor cryo 3 ,608.38 47382 Percut ablate liver rf 1 2,779.28 47400 Hepaticotomy or hepaticostomy with exploration, drainage, or removal of calculus 2 , 9 4 1 . 2 0 47420 Choledochotomy or choledochostomy with exploration, drainage, or removal of calculus, with or without 2 ,731.50 47425 Choledochotomy or choledochostomy with exploration, drainage, or removal of calculus, with or without 3 ,064.50 47460 Transduodenal sphincterotomy or sphincteroplasty, with or without transduodenal extraction of calculus 3 ,170.70 47480 Cholecystotomy or cholecystostomy with exploration, drainage, or removal of calculus (separate procedure) 1 , 9 6 4 . 7 0 47490 Percutaneous cholecystostomy 9 4 7 . 7 0 47500 Injection procedure for percutaneous transhepatic cholangiography 5 0 1 . 3 0 47505 Injection procedure for cholangiography through an existing catheter (eg, percutaneous transhepatic or T- 2 39.40 47510 Introduction of percutaneous transhepatic catheter for biliary drainage 8 2 5 . 3 0 47511 Introduction of percutaneous transhepatic stent for internal and external biliary drainage 9 3 2 . 4 0 47525 Change of percutaneous biliary drainage catheter 4 7 3 . 4 0 47530 Revision and/or reinsertion of transhepatic tube 6 1 3 . 8 0 47550 Biliary endoscopy, intraoperative (choledochoscopy) (List separately in addition to code for primary 7 85.70 47552 Biliary endoscopy, percutaneous via T-tube or other tract; diagnostic, with or without collection of 1 ,030.50 47553 Biliary endoscopy, percutaneous via T-tube or other tract; with biopsy, single or multiple 9 7 8 . 3 0 47554 Biliary endoscopy, percutaneous via T-tube or other tract; with removal of stone(s) 1 , 4 2 1 . 1 0 47555 Biliary endoscopy, percutaneous via T-tube or other tract; with dilation of biliary duct stricture(s) without 1 ,138.50 47556 Biliary endoscopy, percutaneous via T-tube or other tract; with dilation of biliary duct stricture(s) with stent 1 , 1 3 3 . 1 0 47560 Laps surg w/gid transhepatc cholangrph w/o bx 1 ,510.58 47561 Laparoscopy, surgical; with guided transhepatic cholangiography with biopsy 1 , 1 5 9 . 2 0 47562 Laparoscopy, surgical; cholecystectomy 2 , 8 8 4 . 5 0 47563 Laparoscopy, surgical; cholecystectomy with cholangiography 2 , 9 7 8 . 0 8 47564 Laparoscopy, surgical; cholecystectomy with exploration of common duct 3 , 5 0 1 . 9 0 47570 Laparoscopy, surgical; cholecystoenterostomy 2 , 9 3 4 . 9 0 47600 Cholecystectomy; 2 , 4 2 5 . 7 3 47605 Cholecystectomy; with cholangiography 2 , 4 0 8 . 4 0 47610 Cholecystectomy with exploration of common duct; 3 , 0 9 0 . 6 0 47612 Cholecystectomy with exploration of common duct; with choledochoenterostomy 3 , 7 4 3 . 1 0 47620 Cholecystectomy with exploration of common duct; with transduodenal sphincterotomy or sphincteroplasty, 3 ,605.40 47630 Biliary duct stone extraction, percutaneous via T-tube tract, basket, or snare (eg, Burhenne technique) 1 , 5 9 1 . 2 0 47700 Exploration for congenital atresia of bile ducts, without repair, with or without liver biopsy, with or without 2 ,565.00 47701 Portoenterostomy (eg, Kasai procedure) 3 , 9 1 9 . 5 0 47711 Excision of bile duct tumor, with or without primary repair of bile duct; extrahepatic 3 , 8 9 3 .4 0 47712 Excision of bile duct tumor, with or without primary repair of bile duct; intrahepatic 4 , 2 3 3 . 6 0 47715 Excision of choledochal cyst 2 , 8 9 4 . 4 0 47720 Cholecystoenterostomy; direct 2 , 5 1 8 . 2 0 47721 Cholecystoenterostomy; with gastroenterostomy 3 , 1 4 1 . 9 0 47740 Cholecystoenterostomy; Roux-en-Y 3 , 2 3 1 . 0 0 47741 Cholecystoenterostomy; Roux-en-Y with gastroenterostomy 3 , 5 5 8 . 6 0 47760 Anastomosis, of extrahepatic biliary ducts and gastrointestinal tract 3 , 5 7 7 . 5 0 47765 Anastomosis, of intrahepatic ducts and gastrointestinal tract 3 , 8 6 2 . 8 0 47780 Anastomosis, Roux-en-Y, of extrahepatic biliary ducts and gastrointestinal tract 4 , 0 5 1 . 8 0 47785 Anastomosis, Roux-en-Y, of intrahepatic biliary ducts and gastrointestinal tract 4 , 8 6 1 . 8 0 47800 Reconstruction, plastic, of extrahepatic biliary ducts with end-to-end anastomosis 3 , 5 7 9 . 3 0 47801 Placement of choledochal stent 2 , 0 9 7 . 0 0 47802 U-tube hepaticoenterostomy 3 , 3 9 9 . 3 0 47900 Suture of extrahepatic biliary duct for pre-existing injury (separate procedure) 3 , 0 9 5 . 1 0 48000 Placement of drains, peripancreatic, for acute pancreatitis; 2 , 6 2 6 . 2 0 53 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 48001 Placement of drains, peripancreatic, for acute pancreatitis; with cholecystostomy, gastrostomy, and 2 ,832.30 48020 Removal of pancreatic calculus 2 , 9 0 4 . 3 0 48100 Biopsy of pancreas, open, any method (eg, fine needle aspiration, needle core biopsy, wedge biopsy) 2 , 1 3 8 . 4 0 48102 Biopsy of pancreas, percutaneous needle 6 3 4 . 5 0 48105 Resecj/dbrdmt pancreas necrotizing pancreatitis 5 ,451.85 48120 Excision of lesion of pancreas (eg, cyst, adenoma) 2 , 5 7 4 .

9 0 48140 Pancreatectomy, distal subtotal, with or without splenectomy; without pancreaticojejunostomy 3 , 5 3 3 . 4 0 48145 Pancreatectomy, distal subtotal, with or without splenectomy; with pancreaticojejunostomy 3 , 7 0 0 . 8 0 48146 Pancreatectomy, distal, near-total with preservation of duodenum (Child-type procedure) 3 , 9 6 5 . 4 0 48148 Excision of ampulla of Vater 3 , 1 3 2 . 0 0 48150 Pancreatectomy, proximal subtotal with total duodenectomy, partial gastrectomy, choledochoenterostomy 6 ,010.20 48152 Pancreatectomy, proximal subtotal with total duodenectomy, partial gastrectomy, choledochoenterostomy 5 ,525.10 48153 Pancreatectomy, proximal subtotal with near-total duodenectomy, choledochoenterostomy and 6 ,282.90 48154 Pncrtect prox stot w/o pancreatojejunostomy 5 ,545.84 48155 Pancreatectomy, total 5 , 9 8 7 . 7 0 48400 Injection procedure for intraoperative pancreatography (List separately in addition to code for primary 2 78.10 48500 Marsupialization of cyst of pancreas 2 , 5 7 4 . 9 0 48510 External drainage, pseudocyst of pancreas; open 3 , 3 9 3 . 0 0 48511 External drainage, pseudocyst of pancreas; percutaneous 9 4 7 . 7 0 48520 Internal anastomosis of pancreatic cyst to gastrointestinal tract; direct 3 , 3 9 1 . 2 0 48540 Internal anastomosis of pancreatic cyst to gastrointestinal tract; Roux-en-Y 3 , 7 2 7 . 8 0 48545 Pancreatorrhaphy for trauma 2 , 8 0 7 . 1 0 48547 Duodenal exclusion with gastrojejunostomy for pancreatic trauma 4 , 5 8 3 . 7 0 48548 Pancreaticojejunostomy side-to-side anast 3 ,894.97 48552 Prep donor pancreas/venous 5 68.43 48554 Transplantation of pancreatic allograft 5 , 8 8 6 . 9 0 48556 Removal of transplanted pancreatic allograft 2 , 9 1 9 . 6 0 49000 Exploratory laparotomy, exploratory celiotomy with or without biopsy(s) (separate procedure) 2 , 0 8 8 . 8 5 49002 Reopening of recent laparotomy 1 , 8 9 8 . 1 0 49010 Exploration, retroperitoneal area with or without biopsy(s) (separate procedure) 2 , 0 8 3 . 5 0 49020 Drainage of peritoneal abscess or localized peritonitis, exclusive of appendiceal abscess; open 1 , 6 8 2 . 1 0 49021 Drainage of peritoneal abscess or localized peritonitis, exclusive of appendiceal abscess; percutaneous 1 , 3 8 7 . 8 0 49040 Drainage of subdiaphragmatic or subphrenic abscess; open 1 , 9 7 5 . 5 0 49041 Drainage of subdiaphragmatic or subphrenic abscess; percutaneous 7 6 0 . 5 0 49060 Drainage of retroperitoneal abscess; open 1 , 8 4 5 . 9 0 49061 Drainage of retroperitoneal abscess; percutaneous 6 3 3 . 6 0 49062 Drainage of extraperitoneal lymphocele to peritoneal cavity, open 1 , 8 7 4 . 7 0 49082 Abd paracentesis 4 39.20 49083 Abd paracentesis w/imaging 7 93.44 49084 Peritoneal lavage 2 37.37 49180 Biopsy, abdominal or retroperitoneal mass, percutaneous needle 8 1 1 . 8 0 49203 Excision/destruction open abdominal tumors 5 cm 2 ,801.62 49204 Exc/destruction open abdmnl tumors 5.1-10.0 cm 3 ,508.35 49205 Exc/destruction open abdominal tumors >10.0 cm 4 ,192.01 49215 Excision of presacral or sacrococcygeal tumor 3 , 9 5 5 . 5 0 49220 Staging celiotomy (laparotomy) for Hodgkins disease or lymphoma (includes splenectomy, needle or open 3 ,829.50 49250 Umbilectomy, omphalectomy, excision of umbilicus (separate procedure) 1 , 4 1 6 . 6 0 49255 Omentectomy, epiploectomy, resection of omentum (separate procedure) 1 , 8 0 2 . 7 0 49320 Laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or without collection of specimen(s) by 1 ,557.11 49321 Laparoscopy, surgical; with biopsy (single or multiple) 1 , 7 1 6 . 3 0 49322 Laparoscopy, surgical; with aspiration of cavity or cyst (eg, ovarian cyst) (single or multiple) 1 , 8 0 2 . 7 0 49323 Laparoscopy, surgical; with drainage of lymphocele to peritoneal cavity 1 , 9 0 8 . 9 0 49324 Laps insertion tunneled intraperitoneal catheter 9 43.82 49325 Laps w/revision intraperitoneal catheter 9 50.46 49326 Laps w/omentopexy 7 06.80 49327 Laps w/insertion ntrstl dev w/img gid 1+ 3 78.09 49400 Injection of air or contrast into peritoneal cavity (separate procedure) 2 3 3 . 1 0 49402 Removal peritoneal foreign body from cavity 1 ,902.20 49411 Interstitial dev plmt radiation therapy 1/mlt 8 80.63 49412 Plmt intrstl dev opn w/img gid 1+ 3 03.29 49418 Insert tun ip cath perc 1 ,335.02 49419 Insertion tunnel intraperitoneal cath subq port 9 85.96 49421 Insertion of intraperitoneal cannula or catheter for drainage or dialysis; permanent 1 , 4 4 9 . 0 0 49422 Removal of permanent intraperitoneal cannula or catheter 1 , 1 9 1 . 6 0 49423 Exchange of previously placed abscess or cyst drainage catheter under radiological guidance (separate 2 77.20 49424 Contrast injection for assessment of abscess or cyst via previously placed catheter (separate procedure) 1 4 4 . 0 0 49425 Insertion of peritoneal-venous shunt 2 , 1 6 2 . 7 0 49426 Revision of peritoneal-venous shunt 1 , 9 8 4 . 5 0 49427 Injection procedure (eg, contrast media) for evaluation of previously placed peritoneal-venous shunt 2 1 6 . 0 0 49428 Lig prtl-ven shunt 9 53.79 54 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 49429 Rmvl prtl-ven shunt 1 ,148.24 49435 Insj subq extension intraperitoneal catheter 3 43.46 49436 Delayed creation exit site embedded catheter 4 85.16 49440 Place gastrostomy tube perc 2 ,849.89 49441 Place duod/jej tube perc 3 ,205.41 49442 Place cecostomy tube perc 2 ,719.49 49446 Change g-tube to g-j perc 2 ,770.54 49450 Replace g/c tube perc 2 ,007.64 49451 Replace duod/jej tube perc 2 ,121.12 49452 Replace g-j tube perc 2 ,487.98 49460 Fix g/colon tube w/device 2 ,124.43 49465 Fluoro exam of g/colon tube 4 92.81 49491 Rpr 1st ingun hrna preterm inft rdc 1 ,510.04 49492 Rpr 1st ingun hrna preterm inft ncrc8 1 ,735.71 49495 Repair initial inguinal hernia, under age 6 months, with or without hydrocelectomy; reducible 1 , 5 7 5 . 9 0 49496 Repair initial inguinal hernia, under age 6 months, with or without hydrocelectomy; incarcerated or 1 ,755.00 49500 Repair initial inguinal hernia, age 6 months to under 5 years, with or without hydrocelectomy; reducible 1 , 3 9 0 . 5 0 49501 Repair initial inguinal hernia, age 6 months to under 5 years, with or without hydrocelectomy; incarcerated or 1 ,555.20 49505 Repair initial inguinal hernia, age 5 years or over; reducible 1 , 5 4 7 . 5 5 49507 Repair initial inguinal hernia, age 5 years or over; incarcerated or strangulated 1 , 8 8 9 . 7 2 49520 Repair recurrent inguinal hernia, any age; reducible 2 , 0 3 1 . 3 0 49521 Repair recurrent inguinal hernia, any age; incarcerated or strangulated 2 , 2 1 4 . 9 0 49525 Repair inguinal hernia, sliding, any age 1 , 6 4 7 . 9 0 49540 Repair lumbar hernia 1 , 5 7 4 . 1 0 49550 Repair initial femoral hernia, any age; reducible 1 , 6 1 6 . 4 0 49553 Repair initial femoral hernia, any age; incarcerated or strangulated 1 , 9 3 1 . 4 0 49555 Repair recurrent femoral hernia; reducible 1 , 9 1 6 . 1 0 49557 Repair recurrent femoral hernia; incarcerated or strangulated 2 , 4 9 7 . 5 0 49560 Repair initial incisional or ventral hernia; reducible 1 , 9 7 8 . 5 7 49561 Repair initial incisional or ventral hernia; incarcerated or strangulated 2 , 1 1 6 . 8 0 49565 Repair recurrent incisional or ventral hernia; reducible 2 , 4 8 0 . 4 0 49566 Repair recurrent incisional or ventral hernia; incarcerated or strangulated 2 , 6 9 3 . 7 0 49568 Implantation of mesh or other prosthesis for incisional or ventral hernia repair (List separately in addition to 7 36.24 49570 Repair epigastric hernia (eg, preperitoneal fat); reducible (separate procedure) 1 , 4 2 1 . 1 0 49572 Repair epigastric hernia (eg, preperitoneal fat); incarcerated or strangulated 1 , 6 7 0 . 4 0 49580 Repair umbilical hernia, under age 5 years; reducible 1 , 1 8 9 . 8 0 49582 Repair umbilical hernia, under age 5 years; incarcerated or strangulated 1 , 5 4 5 . 3 0 49585 Repair umbilical hernia, age 5 years or over; reducible 1 , 4 4 1 . 8 0 49587 Repair umbilical hernia, age 5 years or over; incarcerated or strangulated 1 , 6 4 6 . 0 0 49590 Repair spigelian hernia 1 , 6 5 4 . 2 0 49600 Repair of small omphalocele, with primary closure 1 , 6 2 2 . 7 0 49605 Repair of large omphalocele or gastroschisis; with or without prosthesis 3 , 2 6 3 . 4 0 49606 Repair of large omphalocele or gastroschisis; with removal of prosthesis, final reduction and closure, in 2 ,832.30 49610 Repair of omphalocele (Gross type operation); first stage 2 , 0 0 8 . 8 0 49611 Repair of omphalocele (Gross type operation); second stage 1 , 9 4 6 . 7 0 49650 Laparoscopy, surgical; repair initial inguinal hernia 1 , 9 2 4 . 2 0 49651 Laparoscopy, surgical; repair recurrent inguinal hernia 2 , 0 7 4 . 5 0 49652 Laps repair hernia except incal/ingun reducible 2 ,109.14 49653 Lap rpr hrna xcpt incal/ingun ncrc8/strangulated 2 ,603.68 49654 Laparoscopy repair incisional hernia reducible 2 ,373.28 49655 Laps rpr incisional hernia ncrc8/strangulated 2 ,891.21 49656 Laps rpr recurrent incisional hernia reducible 2 ,400.68 49657 Laps rpr recurrent incal hrna ncrc8/strangulated 3 ,469.04 49900 Suture, secondary, of abdominal wall for evisceration or dehiscence 1 , 5 5 5 . 2 0 49904 Omental flap xtr-abdl 3 ,010.88 49905 Omental flap (eg, for reconstruction of sternal and chest wall defects) (List separately in addition to code for 1 ,532.70 50010 Renal exploration, not necessitating other specific procedures 2 , 3 6 9 . 7 0 50020 Drainage of perirenal or renal abscess; open 2 , 3 4 8 . 1 0 50021 Drainage of perirenal or renal abscess; percutaneous 5 7 8 . 7 0 50040 Nephrostomy, nephrotomy with drainage 2 , 3 8 8 . 6 0 50045 Nephrotomy, with exploration 2 , 6 9 5 . 5 0 50060 Nephrolithotomy; removal of calculus 3 , 4 6 4 . 1 0 50065 Nephrolithotomy; secondary surgical operation for calculus 3 , 3 0 1 . 2 0 50070 Nephrolithotomy; complicated by congenital kidney abnormality 3 , 7 3 9 . 5 0 50075 Nephrolithotomy; removal of large staghorn calculus filling renal pelvis and calyces (including anatrophic 3 ,556.80 50080 Percutaneous nephrostolithotomy or pyelostolithotomy, with or without dilation, endoscopy, lithotripsy, 3 ,374.10 50081 Percutaneous nephrostolithotomy or pyelostolithotomy, with or without dilation, endoscopy, lithotripsy, 3 ,953.70 50100 Transection or repositioning of aberrant renal vessels (separate procedure) 2 , 4 2 1 . 0 0 50120 Pyelotomy; with exploration 2 , 7 8 8 . 2 0 50125 Pyelotomy; with drainage, pyelostomy 2 , 8 6 0 . 2 0 55 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 50130 Pyelotomy; with removal of calculus (pyelolithotomy, pelviolithotomy, including coagulum pyelolithotomy) 3 , 2 5 8 . 0 0 50135 Pyelotomy; complicated (eg, secondary operation, congenital kidney abnormality) 3 , 5 3 5 . 2 0 50200 Renal biopsy; percutaneous, by trocar or needle 5 6 3 . 4 0 50205 Renal biopsy; by surgical exposure of kidney 1 , 5 2 3 . 7 0 50220 Nephrectomy, including partial ureterectomy, any approach including rib resection; 3 , 2 3 6 . 4 0 50225 Nephrectomy, including partial ureterectomy, any approach including rib resection; complicated because of 3 ,862.80 50230 Nephrectomy, including partial ureterectomy, any approach including rib resection; radical, with regional 4 ,735.80 50234 Nephrectomy with total ureterectomy and bladder cuff; through same incision 4 , 5 3 2 . 4 0 50236 Nephrectomy with total ureterectomy and bladder cuff; through separate incision 4 , 3 2 7 . 2 0 50240 Nephrectomy, partial 3 , 7 6 4 . 7 0 50250 Open ablation renal mass cryosurg ultrasound 3 ,098.95 50280 Excision or unroofing of cyst(s) of kidney 2 , 8 2 8 . 7 0 50290 Excision of perinephric cyst 2 , 6 5 3 . 2 0 50320 Donor nephrectomy, open from living donor (excluding preparation and maintenance of allograft) 4 , 6 8 6 . 3 0 50327 Prep renal graft/venous 5 18.41 50328 Prep renal graft/arterial 4 52.32 50329 Prep renal graft/ureteral 4 10.96 50340 Recipient nephrectomy (separate procedure) 2 , 7 9 7 . 2 0 50360 Renal allotransplantation, implantation of graft; excluding donor and recipient nephrectomy 6 , 3 0 4 . 5 0 50365 Renal allotransplantation, implantation of graft; with recipient nephrectomy 7 , 6 9 6 . 8 0 50370 Removal of transplanted renal allograft 2 , 4 3 0 . 9 0 50380 Renal autotransplantation, reimplantation of kidney 4 , 3 6 0 . 5 0 50382 Change ureter stent percut 1 ,292.64 50384 Remove ureter stent percut 1 ,139.86 50385 Change stent via transureth 1 ,174.03 50386 Remove stent via transureth 9 16.76 50387 Rmvl&rplcmt xtrnlly accessible urtrl stent 5 40.10 50389 Rmvl nfros tube req fluor gid 3 44.26 50390 Aspiration and/or injection of renal cyst or pelvis by needle, percutaneous 4 6 5 . 3 0 50391 Instlj agt rnl pelvis&/urtr thru tube 3 74.44 50392 Introduction of intracatheter or catheter into renal pelvis for drainage and/or injection, percutaneous 6 6 6 . 0 0 50393 Introduction of ureteral catheter or stent into ureter through renal pelvis for drainage and/or injection, 7 03.80 50394 Injection procedure for pyelography (as nephrostogram, pyelostogram, antegrade pyeloureterograms) 2 21.40 50395 Introduction of guide into renal pelvis and/or ureter with dilation to establish nephrostomy tract, 8 70.30 50396 Manometric studies through nephrostomy or pyelostomy tube, or indwelling ureteral catheter 1 6 4 . 7 0 50398 Change of nephrostomy or pyelostomy tube 2 5 7 . 4 0 50400 Pyeloplasty (Foley Y-pyeloplasty), plastic operation on renal pelvis, with or without plastic operation on 3 ,541.50 50405 Pyeloplasty (Foley Y-pyeloplasty), plastic operation on renal pelvis, with or without plastic operation on 3 ,802.50 50500 Nephrorrhaphy, suture of kidney wound or injury 3 , 2 9 8 . 5 0 50520 Closure of nephrocutaneous or pyelocutaneous fistula 2 , 8 5 3 . 0 0 50525 Closure of nephrovisceral fistula (eg, renocolic), including visceral repair; abdominal approach 3 , 4 3 8 . 0 0 50526 Closure of nephrovisceral fistula (eg, renocolic), including visceral repair; thoracic approach 3 , 5 0 1 . 9 0 50540 Symphysiotomy for horseshoe kidney with or without pyeloplasty and/or other plastic procedure, unilateral or 4 ,071.60 50541 Laparoscopy, surgical; ablation of renal cysts 2 , 6 7 3 . 9 0 50542 Laps abltj rnl mass les w/intraop us 2 ,662.34 50543 Laps prtl nfrct 3 ,268.75 50544 Laparoscopy, surgical; pyeloplasty 3 , 6 9 2 . 7 0 50545 Laparoscopy, surgical; radical nephrectomy (includes removal of Gerota's fascia and surrounding fatty 3 ,990.60 50546 Laparoscopy, surgical; nephrectomy, including partial ureterectomy 3 , 7 2 7 . 8 0 50547 Laparoscopy, surgical; donor nephrectomy from living donor (excluding preparation and maintenance of 4 ,762.80 50548 Laparoscopy, surgical; nephrectomy with total ureterectomy 5 , 0 9 8 . 5 0 50551 Renal endoscopy through established nephrostomy or pyelostomy, with or without irrigation, instillation, or 7 77.60 50553 Renal endoscopy through established nephrostomy or pyelostomy, with or without irrigation, instillation, or 7 74.00 50555 Renal endoscopy through established nephrostomy or pyelostomy, with or without irrigation, instillation, or 9 95.40 50557 Renal endoscopy through established nephrostomy or pyelostomy, with or without irrigation, instillation, or 1 ,017.90 50561 Renal endoscopy through established nephrostomy or pyelostomy, with or without irrigation, instillation, or 1 ,484.10 50562 Rnl ndsc nfros/pyelostomy rescj tum 1 ,158.89 50570 Renal endoscopy through nephrotomy or pyelotomy, with or without irrigation, instillation, or 1 ,117.80 50572 Renal endoscopy through nephrotomy or pyelotomy, with or without irrigation, instillation, or 2 ,024.10 50574 Renal endoscopy through nephrotomy or pyelotomy, with or without irrigation, instillation, or 2 ,061.00 50575 Renal endoscopy through nephrotomy or pyelotomy, with or without irrigation, instillation, or 2 ,292.30 50576 Renal endoscopy through nephrotomy or pyelotomy, with or without irrigation, instillation, or 1 ,647.90 50580 Renal endoscopy through nephrotomy or pyelotomy, with or without irrigation, instillation, or 2 ,277.00 50590 Lithotripsy, extracorporeal shock wave 3 , 4 2 4 . 5 0 50592 Abltj 1+ rnl tum prq uni rf 2 ,900.54 50593 Perc cryo ablate renal tum 3 ,501.52 50600 Ureterotomy with exploration or drainage (separate procedure) 2 , 5 3 0 . 8 0 50605 Ureterotomy for insertion of indwelling stent, all types 2 , 7 3 0 . 6 0 50610 Ureterolithotomy; upper one-third of ureter 3 , 1 5 6 . 3 0 50620 Ureterolithotomy; middle one-third of ureter 3 , 3 7 3 . 2 0 56 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 50630 Ureterolithotomy; lower one-third of ureter 3 , 5 7 7 . 5 0 50650 Ureterectomy, with bladder cuff (separate procedure) 3 , 1 4 3 . 7 0 50660 Ureterectomy, total, ectopic ureter, combination abdominal, vaginal and/or perineal approach 3 , 4 2 9 . 0 0 50684 Injection procedure for ureterography or ureteropyelography through ureterostomy or indwelling ureteral 1 53.90 50686 Manometric studies through ureterostomy or indwelling ureteral catheter 1 2 0 . 6 0 50688 Change of ureterostomy tube 1 6 2 . 0 0 50690 Injection procedure for visualization of ileal conduit and/or ureteropyelography, exclusive of radiologic 1 43.10 50700 Ureteroplasty, plastic operation on ureter (eg, stricture) 2 , 9 4 3 . 0 0 50715 Ureterolysis, with or without repositioning of ureter for retroperitoneal fibrosis 2 , 7 8 1 . 0 0 50722 Ureterolysis for ovarian vein syndrome 2 , 4 2 1 . 0 0 50725 Ureterolysis for retrocaval ureter, with reanastomosis of upper urinary tract or vena cava 3 , 7 6 9 . 2 0 50727 Revision of urinary-cutaneous anastomosis (any type urostomy); 1 , 8 6 9 . 3 0 50728 Revision of urinary-cutaneous anastomosis (any type urostomy); with repair of fascial defect and hernia 2 , 6 6 3 . 1 0 50740 Ureteropyelostomy, anastomosis of ureter and renal pelvis 3 , 3 7 4 . 1 0 50750 Ureterocalycostomy, anastomosis of ureter to renal calyx 3 , 6 0 5 . 4 0 50760 Ureteroureterostomy 3 , 2 4 4 . 5 0 50770 Transureteroureterostomy, anastomosis of ureter to contralateral ureter 3 , 4 4 5 . 2 0 50780 Ureteroneocystostomy; anastomosis of single ureter to bladder 3 , 3 5 6 . 1 0 50782 Ureteroneocystostomy; anastomosis of duplicated ureter to bladder 3 , 4 9 2 . 9 0 50783 Ureteroneocystostomy; with extensive ureteral tailoring 3 , 5 9 4 . 6 0 50785 Ureteroneocystostomy; with vesico-psoas hitch or bladder flap 3 , 8 7 7 . 2 0 50800 Ureteroenterostomy, direct anastomosis of ureter to intestine 3 , 3 0 1 . 2 0 50810 Ureterosigmoidostomy, with creation of sigmoid bladder and establishment of abdominal or perineal 4 ,635.00 50815 Ureterocolon conduit, including bowel anastomosis 4 , 7 8 9 . 8 0 50820 Ureteroileal conduit (ileal bladder), including bowel anastomosis (Bricker operation) 5 , 9 8 5 . 0 0 50825 Continent diversion, including bowel anastomosis using any segment of small and/or large bowel (Kock 5 ,768.10 50830 Urinary undiversion (eg, taking down of ureteroileal conduit, ureterosigmoidostomy or ureteroenterostomy 5 ,469.30 50840 Replacement of all or part of ureter by bowel segment, including bowel anastomosis 3 , 7 1 8 . 8 0 50845 Cutaneous appendico-vesicostomy 4 , 2 2 2 . 8 0 50860 Ureterostomy, transplantation of ureter to skin 2 , 8 0 7 . 1 0 50900 Ureterorrhaphy, suture of ureter (separate procedure) 2 , 6 5 2 . 3 0 50920 Closure of ureterocutaneous fistula 2 , 9 0 7 . 9 0 50930 Closure of ureterovisceral fistula (including visceral repair) 3 , 4 0 4 . 7 0 50940 Deligation of ureter 2 , 7 2 9 . 7 0 50945 Laparoscopy, surgical; ureterolithotomy 2 , 8 8 9 . 9 0 50947 Laparoscopy, surgical; ureteroneocystostomy with cystoscopy and ureteral stent placement 4 , 3 0 1 . 1 0 50948 Laparoscopy, surgical; ureteroneocystostomy without cystoscopy and ureteral stent placement 3 , 9 3 3 . 0 0 50951 Ureteral endoscopy through established ureterostomy, with or without irrigation, instillation, or 6 07.50 50953 Ureteral endoscopy through established ureterostomy, with or without irrigation, instillation, or 6 69.60 50955 Ureteral endoscopy through established ureterostomy, with or without irrigation, instillation, or 7 31.70 50957 Ureteral endoscopy through established ureterostomy, with or without irrigation, instillation, or 7 51.50 50961 Ureteral endoscopy through established ureterostomy, with or without irrigation, instillation, or 9 78.30 50970 Ureteral endoscopy through ureterotomy, with or without irrigation, instillation, or ureteropyelography, 8 24.40 50972 Ureteral endoscopy through ureterotomy, with or without irrigation, instillation, or ureteropyelography, 7 91.10 50974 Ureteral endoscopy through ureterotomy, with or without irrigation, instillation, or ureteropyelography, 1 ,133.10 50976 Ureteral endoscopy through ureterotomy, with or without irrigation, instillation, or ureteropyelography, 1 ,040.40 50980 Ureteral endoscopy through ureterotomy, with or without irrigation, instillation, or ureteropyelography, 9 36.90 51020 Cystotomy or cystostomy; with fulguration and/or insertion of radioactive material 1 , 9 6 8 . 3 0 51030 Cystotomy or cystostomy; with cryosurgical destruction of intravesical lesion 1 , 9 2 3 . 3 0 51040 Cystostomy, cystotomy with drainage 1 , 7 1 7 . 2 0 51045 Cystotomy, with insertion of ureteral catheter or stent (separate procedure) 1 , 9 0 9 . 8 0 51050 Cystolithotomy, cystotomy with removal of calculus, without vesical neck resection 2 , 1 6 2 . 7 0 51060 Transvesical ureterolithotomy 2 , 5 8 1 . 2 0 51065 Cystotomy, with stone basket extraction and/or ultrasonic or electrohydraulic fragmentation of ureteral 2 ,421.00 51080 Drainage of perivesical or prevesical space abscess 1 , 7 0 1 . 9 0 51100 Drain bladder by needle 1 78.51 51101 Drain bladder by trocar/cath 2 71.08 51102 Drain bl w/cath insertion 5 91.70 51500 Excision of urachal cyst or sinus, with or without umbilical hernia repair 2 , 1 5 1 . 0 0 51520 Cystotomy; for simple excision of vesical neck (separate procedure) 2 , 2 7 7 . 0 0 51525 Cystotomy; for excision of bladder diverticulum, single or multiple (separate procedure) 2 , 8 3 7 . 7 0 51530 Cystotomy; for excision of bladder tumor 2 , 4 5 7 . 0 0 51535 Cystotomy for excision, incision, or repair of ureterocele 2 , 6 3 1 . 6 0 51550 Cystectomy, partial; simple 2 , 9 5 3 . 8 0 51555 Cystectomy, partial; complicated (eg, postradiation, previous surgery, difficult location) 3 , 7 4 9 . 4 0 51565 Cystectomy, partial, with reimplantation of ureter(s) into bladder (ureteroneocystostomy) 4 , 0 5 3 . 6 0 51570 Cystectomy, complete; (separate procedure) 5 , 0 2 7 . 4 0 51575 Cystectomy, complete; with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and 6 ,365.70 51580 Cystectomy, complete, with ureterosigmoidostomy or ureterocutaneous transplantations; 5 , 9 9 4 . 0 0 51585 Cystectomy, complete, with ureterosigmoidostomy or ureterocutaneous transplantations; with bilateral pelvic 6 ,684.30 57 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 51590 Cystectomy, complete, with ureteroileal conduit or sigmoid bladder, including bowel anastomosis; 7 , 5 5 9 . 1 0 51595 Cystectomy, complete, with ureteroileal conduit or sigmoid bladder, including bowel anastomosis; with 8 ,475.30 51596 Cystectomy, complete, with continent diversion, any technique, using any segment of small and/or large 8 ,883.90 51597 Pelvic exenteration, complete, for vesical, prostatic or urethral malignancy, with removal of bladder and 1 0,661.40 51600 Injection procedure for cystography or voiding urethrocystography 1 4 7 . 6 0 51605 Injection procedure and placement of chain for contrast and/or chain urethrocystography 1 2 8 . 7 0 51610 Injection procedure for retrograde urethrocystography 1 8 5 . 4 0 51700 Bladder irrigation, simple, lavage and/or instillation 1 1 6 . 1 0 51701 Insj non-ndwellg bldr cath 1 19.17 51702 Insj temp ndwellg bldr cath smpl 2 22.55 51703 Insj temp ndwellg bldr cath comp 2 22.42 51705 Change of cystostomy tube; simple 1 0 5 . 3 0 51710 Change of cystostomy tube; complicated 3 1 9 . 5 0 51715 Endoscopic injection of implant material into the submucosal tissues of the urethra and/or bladder neck 9 2 5 . 2 0 51720 Bladder instillation of anticarcinogenic agent (including detention time) 1 7 3 . 7 0 51725 26 Simple cystometrogram (CMG) (eg, spinal manometer) 2 5 3 . 8 0 51725 Simple cystometrogram (CMG) (eg, spinal manometer) 3 0 1 . 5 0 51725 TC Simple cystometrogram 1 87.19 51726 26 Complex cystometrogram (eg, calibrated electronic equipment) 3 0 9 . 6 0 51726 Complex cystometrogram (eg, calibrated electronic equipment) 3 6 9 . 0 0 51726 TC Complex cystometrogram 2 58.79 51727 26 Complex cystometrogram urethral press profile 2 52.33 51727 Complex cystometrogram urethral press profile 6 86.90 51727 TC Complex cystometrogram urethral press profile 4 34.58 51728 26 Complex cystometrogram voiding pressure studies 2 51.61 51728 Complex cystometrogram voiding pressure studies 6 86.02 51728 TC Complex cystometrogram voiding pressure studies 4 34.41 51729 26 Complx cystometro w/void press&urethral profile 2 61.04 51729 Complx cystometro w/void press&urethral profile 7 04.40 51729 TC Complx cystometro w/void press&urethral profile 4 43.36 51736 26 Simple uroflowmetry (UFR) (eg, stop-watch flow rate, mechanical uroflowmeter) 1 3 1 . 4 0 51736 Simple uroflowmetry (UFR) (eg, stop-watch flow rate, mechanical uroflowmeter) 1 5 7 . 5 0 51736 TC Urine flow measurement 7 7.28 51741 26 Complex uroflowmetry (eg, calibrated electronic equipment) 1 3 4 . 1 0 51741 Complex uroflowmetry (eg, calibrated electronic equipment) 1 5 9 . 3 0 51741 TC Electro-uroflowmetry first 7 9.98 51784 26 Electromyography studies (EMG) of anal or urethral sphincter, other than needle, any technique 2 0 1 . 6 0 51784 Electromyography studies (EMG) of anal or urethral sphincter, other than needle, any technique 2 3 6 . 7 0 51784 TC Anal/urinary muscle study 1 48.69 51785 26 Needle electromyography studies (EMG) of anal or urethral sphincter, any technique 2 0 7 . 0 0 51785 Needle electromyography studies (EMG) of anal or urethral sphincter, any technique 2 4 7 . 5 0 51785 TC Anal/urinary muscle study 1 75.98 51792 26 Stimulus evoked response (eg, measurement of bulbocavernosus reflex latency time) 2 0 2 . 5 0 51792 Stimulus evoked response (eg, measurement of bulbocavernosus reflex latency time) 2 3 9 . 4 0 51792 TC Urinary reflex study 1 81.58 51797 26 Voiding pressure studies (VP); intra-abdominal voiding pressure (AP) (rectal, gastric, intraperitoneal) 2 0 7 . 0 0 51797 Voiding pressure studies (VP); intra-abdominal voiding pressure (AP) (rectal, gastric, intraperitoneal) 2 4 7 . 5 0 51797 TC Intraabdominal pressure test 1 66.46 51798 Meas post-voiding residual urine&/bldr cap 5 1.15 51800 Cystoplasty or cystourethroplasty, plastic operation on bladder and/or vesical neck (anterior Y-plasty, 2 ,849.40 51820 Cystourethroplasty with unilateral or bilateral ureteroneocystostomy 3 , 7 8 0 . 0 0 51840 Anterior vesicourethropexy, or urethropexy (eg, Marshall-Marchetti-Krantz, Burch); simple 2 , 4 9 5 . 7 0 51841 Anterior vesicourethropexy, or urethropexy (eg, Marshall-Marchetti-Krantz, Burch); complicated (eg, 2 ,781.00 51845 Abdomino-vaginal vesical neck suspension, with or without endoscopic control (eg, Stamey, Raz, modified 2 ,781.00 51860 Cystorrhaphy, suture of bladder wound, injury or rupture; simple 2 , 2 0 0 . 5 0 51865 Cystorrhaphy, suture of bladder wound, injury or rupture; complicated 2 , 9 8 2 . 6 0 51880 Closure of cystostomy (separate procedure) 1 , 3 3 9 . 2 0 51900 Closure of vesicovaginal fistula, abdominal approach 3 , 4 5 4 . 2 0 51920 Closure of vesicouterine fistula; 2 , 5 5 9 . 6 0 51925 Closure of vesicouterine fistula; with hysterectomy 3 , 3 0 1 . 2 0 51940 Closure of bladder exstrophy 4 , 7 3 8 . 5 0 51960 Enterocystoplasty, including bowel anastomosis 4 , 6 5 2 . 1 0 51980 Cutaneous vesicostomy 2 , 4 3 9 . 0 0 51990 Laparoscopy, surgical; urethral suspension for stress incontinence 2 , 4 4 7 . 1 0 51992 Laparoscopy, surgical; sling operation for stress incontinence (eg, fascia or synthetic) 2 , 6 3 7 . 0 0 52000 Cystourethroscopy (separate procedure) 4 0 5 . 3 4 52001 Csto w/irrg&evac mlt obstructing clots 6 76.66 52005 Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, 5 79.60 52007 Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, 6 40.80 52010 Cystourethroscopy, with ejaculatory duct catheterization, with or without irrigation, instillation, or duct 5 76.00 58 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 52204 Cystourethroscopy, with biopsy 5 9 5 . 7 5 52214 Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) of trigone, bladder neck, 7 69.50 52224 Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) or treatment of MINOR (less 7 47.00 52234 Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; SMALL 1 ,017.90 52235 Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; MEDIUM 1 ,761.30 52240 Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; LARGE 2 ,543.40 52250 Cystourethroscopy with insertion of radioactive substance, with or without biopsy or fulguration 8 4 9 . 6 0 52260 Cystourethroscopy, with dilation of bladder for interstitial cystitis; general or conduction (spinal) anesthesia 5 9 2 . 1 8 52265 Cystourethroscopy, with dilation of bladder for interstitial cystitis; local anesthesia 5 4 0 . 9 0 52270 Cystourethroscopy, with internal urethrotomy; female 8 1 9 . 0 0 52275 Cystourethroscopy, with internal urethrotomy; male 8 8 2 . 0 0 52276 Cystourethroscopy with direct vision internal urethrotomy 1 , 2 6 1 . 8 0 52277 Cystourethroscopy, with resection of external sphincter (sphincterotomy) 1 , 2 0 6 . 9 0 52281 Cystourethroscopy, with calibration and/or dilation of urethral stricture or stenosis, with or without 5 80.93 52282 Cystourethroscopy, with insertion of urethral stent 1 , 0 3 0 . 5 0 52283 Cystourethroscopy, with steroid injection into stricture 5 6 3 . 4 0 52285 Cystourethroscopy for treatment of the female urethral syndrome with any or all of the following: urethral 6 86.56 52287 Cystoscopy chemodenervation 7 45.19 52290 Cystourethroscopy; with ureteral meatotomy, unilateral or bilateral 7 3 7 . 1 0 52300 Cystourethroscopy; with resection or fulguration of orthotopic ureterocele(s), unilateral or bilateral 9 7 5 . 6 0 52301 Cystourethroscopy; with resection or fulguration of ectopic ureterocele(s), unilateral or bilateral 1 , 0 3 5 . 0 0 52305 Cystourethroscopy; with incision or resection of orifice of bladder diverticulum, single or multiple 1 , 0 1 9 . 7 0 52310 Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder 7 51.50 52315 Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder 1 ,328.40 52317 Litholapaxy: crushing or fragmentation of calculus by any means in bladder and removal of fragments; 1 ,377.90 52318 Litholapaxy: crushing or fragmentation of calculus by any means in bladder and removal of fragments; 1 ,948.50 52320 Cystourethroscopy (including ureteral catheterization); with removal of ureteral calculus 1 , 3 4 4 . 6 0 52325 Cystourethroscopy (including ureteral catheterization); with fragmentation of ureteral calculus (eg, ultrasonic 1 ,559.70 52327 Cystourethroscopy (including ureteral catheterization); with subureteric injection of implant material 1 , 0 8 1 . 8 0 52330 Cystourethroscopy (including ureteral catheterization); with manipulation, without removal of ureteral 9 53.10 52332 Cystourethroscopy, with insertion of indwelling ureteral stent (eg, Gibbons or double-J type) 9 2 4 . 3 0 52334 Cystourethroscopy with insertion of ureteral guide wire through kidney to establish a percutaneous 8 75.70 52341 Cystourethroscopy; with treatment of ureteral stricture (eg, balloon dilation, laser, electrocautery, and 1 ,350.00 52342 Cystourethroscopy; with treatment of ureteropelvic junction stricture (eg, balloon dilation, laser, 1 ,461.60 52343 Cystourethroscopy; with treatment of intra-renal stricture (eg, balloon dilation, laser, electrocautery, and 1 ,619.10 52344 Cystourethroscopy with ureteroscopy; with treatment of ureteral stricture (eg, balloon dilation, laser, 1 ,776.60 52345 Cystourethroscopy with ureteroscopy; with treatment of ureteropelvic junction stricture (eg, balloon dilation, 1 ,845.00 52346 Cystourethroscopy with ureteroscopy; with treatment of intra-renal stricture (eg, balloon dilation, laser, 2 ,074.50 52351 Cystourethroscopy, with ureteroscopy and/or pyeloscopy; diagnostic 1 , 3 7 7 . 9 0 52352 Scope bladder & ureter remove or move stones 1 ,629.42 52353 Scope bladder & ureter break up kidney stone 2 ,027.72 52354 Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with biopsy and/or fulguration of lesion 1 , 7 2 8 . 0 0 52355 Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with resection of tumor 2 , 0 3 0 . 4 0 52400 Cystourethroscopy with incision, fulguration, or resection of congenital posterior urethral valves, or 2 ,414.70 52402 Csto w/trurl rescj/inc ejaculatory duxs 6 41.48 52450 Transurethral incision of prostate 1 , 5 6 2 . 4 0 52500 Transurethral resection of bladder neck (separate procedure) 1 , 7 1 9 . 9 0 52601 Transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete 2 ,701.80 52630 Transurethral resection; of regrowth of obstructive tissue longer than one year postoperative 2 , 4 8 2 . 2 0 52640 Transurethral resection; of postoperative bladder neck contracture 2 , 1 4 0 . 2 0 52647 Non-contact laser coagulation of prostate, including control of postoperative bleeding, complete 2 ,169.90 52648 Contact laser vaporization with or without transurethral resection of prostate, including control of 2 ,472.30 52649 Laser enucleation prostate w morcellation 2 ,156.95 52700 Transurethral drainage of prostatic abscess 1 , 3 0 5 . 0 0 53000 Urethrotomy or urethrostomy, external (separate procedure); pendulous urethra 4 1 4 . 9 0 53010 Urethrotomy or urethrostomy, external (separate procedure); perineal urethra, external 9 1 4 . 4 0 53020 Meatotomy, cutting of meatus (separate procedure); except infant 5 8 3 . 8 6 53025 Meatotomy, cutting of meatus (separate procedure); infant 2 3 6 . 7 0 53040 Drainage of deep periurethral abscess 6 9 2 . 1 0 53060 Drainage of Skene's gland abscess or cyst 3 2 2 . 2 0 53080 Drainage of perineal urinary extravasation; uncomplicated (separate procedure) 7 6 1 . 4 0 53085 Drainage of perineal urinary extravasation; complicated 1 , 8 2 5 . 2 0 53200 Biopsy of urethra 4 7 3 . 4 0 53210 Urethrectomy, total, including cystostomy; female 2 , 1 0 4 . 2 0 53215 Urethrectomy, total, including cystostomy; male 2 , 7 8 1 . 0 0 53220 Excision or fulguration of carcinoma of urethra 1 , 6 1 7 . 3 0 53230 Excision of urethral diverticulum (separate procedure); female 2 , 2 1 4 . 9 0 53235 Excision of urethral diverticulum (separate procedure); male 2 , 0 6 0 . 1 0 53240 Marsupialization of urethral diverticulum, male or female 8 5 2 . 3 0 53250 Excision of bulbourethral gland (Cowper's gland) 1 , 3 1 3 . 1 0 59 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 53260 Excision or fulguration; urethral polyp(s), distal urethra 5 2 0 . 2 0 53265 Excision or fulguration; urethral caruncle 5 3 0 . 1 0 53270 Excision or fulguration; Skene's glands 5 6 4 . 3 0 53275 Excision or fulguration; urethral prolapse 6 2 2 . 8 0 53400 Urethroplasty; first stage, for fistula, diverticulum, or stricture (eg, Johannsen type) 1 , 9 2 6 . 9 0 53405 Urethroplasty; second stage (formation of urethra), including urinary diversion 2 , 2 5 0 . 9 0 53410 Urethroplasty, one-stage reconstruction of male anterior urethra 2 , 6 8 6 . 5 0 53415 Urethroplasty, transpubic or perineal, one stage, for reconstruction or repair of prostatic or membranous 3 ,239.10 53420 Urethroplasty, two-stage reconstruction or repair of prostatic or membranous urethra; first stage 2 , 8 8 8 . 1 0 53425 Urethroplasty, two-stage reconstruction or repair of prostatic or membranous urethra; second stage 2 , 9 9 5 . 2 0 53430 Urethroplasty, reconstruction of female urethra 2 , 4 9 6 . 6 0 53431 Urtp w/tubularization post urt&/lwr bldr 2 ,797.78 53440 Operation for correction of male urinary incontinence, with or without introduction of prosthesis 2 , 9 9 1 . 6 0 53442 Removal of perineal prosthesis introduced for continence 1 , 1 7 1 . 8 0 53444 Insj tandem cuff 2 ,081.89 53445 Operation for correction of urinary incontinence with placement of inflatable urethral or bladder neck 5 ,150.70 53446 Rmvl nfltbl urtl/bldr nck sphnctr 1 ,825.77 53447 Removal, repair, or replacement of inflatable sphincter including pump and/or reservoir and/or cuff 2 , 5 0 7 . 4 0 53448 Rmvl&rplcmt nfltbl nck sphnctr thru infct fld 3 ,364.59 53449 Surgical correction of hydraulic abnormality of inflatable sphincter device 1 , 8 6 4 . 8 0 53450 Urethromeatoplasty, with mucosal advancement 7 2 0 . 9 0 53460 Urethromeatoplasty, with partial excision of distal urethral segment (Richardson type procedure) 7 2 6 . 3 0 53500 Urethrolss trvg sec opn w/csto 1 ,914.08 53502 Urethrorrhaphy, suture of urethral wound or injury, female 1 , 4 8 6 . 8 0 53505 Urethrorrhaphy, suture of urethral wound or injury; penile 1 , 5 3 2 . 7 0 53510 Urethrorrhaphy, suture of urethral wound or injury; perineal 1 , 9 1 7 . 9 0 53515 Urethrorrhaphy, suture of urethral wound or injury; prostatomembranous 2 , 6 5 4 . 1 0 53520 Closure of urethrostomy or urethrocutaneous fistula, male (separate procedure) 1 , 2 1 3 . 2 0 53600 Dilation of urethral stricture by passage of sound or urethral dilator, male; initial 1 5 4 . 8 0 53601 Dilation of urethral stricture by passage of sound or urethral dilator, male; subsequent 1 4 9 . 4 0 53605 Dilation of urethral stricture or vesical neck by passage of sound or urethral dilator, male, general or 2 30.40 53620 Dilation of urethral stricture by passage of filiform and follower, male; initial 2 1 8 . 7 0 53621 Dilation of urethral stricture by passage of filiform and follower, male; subsequent 1 3 7 . 7 0 53660 Dilation of female urethra including suppository and/or instillation; initial 1 1 4 . 3 0 53661 Dilation of female urethra including suppository and/or instillation; subsequent 1 2 0 . 6 0 53665 Dilation of female urethra, general or conduction (spinal) anesthesia 2 1 5 . 1 0 53850 Transurethral destruction of prostate tissue; by microwave thermotherapy 1 , 6 3 7 . 1 0 53852 Transurethral destruction of prostate tissue; by radiofrequency thermotherapy 1 , 4 4 8 . 1 0 53855 Insert temp prostatic ureth stent w/measurement 1 ,749.79 53860 Transurethral rf treatment 4 ,303.14 54000 Slitting of prepuce, dorsal or lateral (separate procedure); newborn 1 6 4 . 7 0 54001 Slitting of prepuce, dorsal or lateral (separate procedure); except newborn 3 1 4 . 1 0 54015 Incision and drainage of penis, deep 4 3 7 . 4 0 54050 Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), 1 34.50 54055 Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), 2 71.58 54056 Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), 2 39.88 54057 Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), 6 01.20 54060 Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), 4 81.62 54065 Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic vesicle), 9 06.65 54100 Biopsy of penis; (separate procedure) 2 6 6 . 4 0 54105 Biopsy of penis; deep structures 4 4 7 . 3 0 54110 Excision of penile plaque (Peyronie disease); 1 , 3 9 5 . 9 0 54111 Excision of penile plaque (Peyronie disease); with graft to 5 cm in length 2 , 3 6 2 . 5 0 54112 Excision of penile plaque (Peyronie disease); with graft greater than 5 cm in length 2 , 6 8 2 . 9 0 54115 Removal foreign body from deep penile tissue (eg, plastic implant) 1 , 0 6 2 . 0 0 54120 Amputation of penis; partial 2 , 0 4 3 . 0 0 54125 Amputation of penis; complete 2 , 7 0 9 . 0 0 54130 Amputation of penis, radical; with bilateral inguinofemoral lymphadenectomy 3 , 7 5 4 . 8 0 54135 Amputation of penis, radical; in continuity with bilateral pelvic lymphadenectomy, including external iliac, 4 ,963.50 54150 Circumcision, using clamp or other device; newborn 2 7 2 . 0 0 54160 Circumcision, surgical excision other than clamp, device or dorsal slit; newborn 4 0 3 . 9 4 54161 Circumcision, surgical excision other than clamp, device or dorsal slit; except newborn 8 6 0 . 7 9 54162 Lss/exc pen post-circumcision ads 4 26.82 54163 Rpr incompl circumcision 4 15.19 54164 Frenulotomy pns 4 09.15 54200 Injection procedure for Peyronie disease; 1 2 9 . 6 0 54205 Injection procedure for Peyronie disease; with surgical exposure of plaque 1 , 0 3 5 . 0 0 54220 Irrigation of corpora cavernosa for priapism 5 0 0 . 4 0 54230 Injection procedure for corpora cavernosography 2 9 8 . 8 0 54231 Dynamic cavernosometry, including intracavernosal injection of vasoactive drugs (eg, papaverine, 4 68.90 60 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 54235 Injection of corpora cavernosa with pharmacologic agent(s) (eg, papaverine, phentolamine) 2 0 6 . 1 0 54240 26 Penile plethysmography 2 5 0 . 2 0 54240 Penile plethysmography 2 9 8 . 8 0 54240 TC Penis study 1 14.40 54250 26 Nocturnal penile tumescence and/or rigidity test 3 0 0 . 6 0 54250 Nocturnal penile tumescence and/or rigidity test 3 5 4 . 6 0 54250 TC Penis study 3 6.49 54300 Plastic operation of penis for straightening of chordee (eg, hypospadias), with or without mobilization of 1 ,865.70 54304 Plastic operation on penis for correction of chordee or for first stage hypospadias repair with or without 2 ,242.80 54308 Urethroplasty for second stage hypospadias repair (including urinary diversion); less than 3 cm 2 , 2 6 8 . 0 0 54312 Urethroplasty for second stage hypospadias repair (including urinary diversion); greater than 3 cm 2 , 5 2 3 . 6 0 54316 Urethroplasty for second stage hypospadias repair (including urinary diversion) with free skin graft obtained 3 ,016.80 54318 Urethroplasty for third stage hypospadias repair to release penis from scrotum (eg, third stage Cecil repair) 1 , 7 9 8 . 2 0 54322 One stage distal hypospadias repair (with or without chordee or circumcision); with simple meatal 2 ,155.50 54324 One stage distal hypospadias repair (with or without chordee or circumcision); with urethroplasty by local 2 ,382.30 54326 One stage distal hypospadias repair (with or without chordee or circumcision); with urethroplasty by local 2 ,894.40 54328 One stage distal hypospadias repair (with or without chordee or circumcision); with extensive dissection to 3 ,250.80 54332 One stage proximal penile or penoscrotal hypospadias repair requiring extensive dissection to correct 3 ,355.20 54336 One stage perineal hypospadias repair requiring extensive dissection to correct chordee and urethroplasty 3 ,821.40 54340 Repair of hypospadias complications (ie, fistula, stricture, diverticula); by closure, incision, or excision, 1 ,658.70 54344 Repair of hypospadias complications (ie, fistula, stricture, diverticula); requiring mobilization of skin flaps 2 ,642.40 54348 Repair of hypospadias complications (ie, fistula, stricture, diverticula); requiring extensive dissection and 2 ,793.60 54352 Repair of hypospadias cripple requiring extensive dissection and excision of previously constructed 4 ,481.10 54360 Plastic operation on penis to correct angulation 2 , 1 7 1 . 7 0 54380 Plastic operation on penis for epispadias distal to external sphincter; 1 , 9 3 1 . 4 0 54385 Plastic operation on penis for epispadias distal to external sphincter; with incontinence 2 , 7 9 1 . 8 0 54390 Plastic operation on penis for epispadias distal to external sphincter; with exstrophy of bladder 3 , 7 2 8 . 7 0 54400 Insertion of penile prosthesis; non-inflatable (semi-rigid) 2 , 7 3 1 . 5 0 54401 Insertion of penile prosthesis; inflatable (self-contained) 3 , 0 3 8 . 4 0 54405 Insertion of inflatable (multi-component) penile prosthesis, including placement of pump, cylinders, and/or 4 ,616.10 54406 Rmvl nfltbl pen prosth w/o rplcmt prosth 1 ,880.16 54408 Rpr component multi-component nfltbl pen prosth 1 ,921.58 54410 Rmvl&rplcmt nfltbl pen prosth sm sess 2 ,100.99 54411 Rmvl&rplcmt nfltbl pen prosth thru infct fld 2 ,627.25 54415 Rmvl non-nfltbl/nfltbl pen prosth w/o rplcmt 1 ,371.75 54416 Rmvl&rplcmt non-nfltbl/nfltbl prosth sm sess 1 ,604.70 54417 Rmvl&rplcmt non-nfltbl/nfltbl pen infct sm sess 2 ,244.96 54420 Corpora cavernosa-saphenous vein shunt (priapism operation), unilateral or bilateral 2 , 4 9 7 . 5 0 54430 Corpora cavernosa-corpus spongiosum shunt (priapism operation), unilateral or bilateral 2 , 1 0 7 . 8 0 54435 Corpora cavernosa-glans penis fistulization (eg, biopsy needle, Winter procedure, rongeur, or punch) for 1 ,043.10 54440 Plastic operation of penis for injury 2 , 5 8 2 . 1 0 54450 Foreskin manipulation including lysis of preputial adhesions and stretching 3 0 6 . 9 0 54500 Biopsy of testis, needle (separate procedure) 2 1 6 . 9 0 54505 Biopsy of testis, incisional (separate procedure) 6 4 4 . 4 0 54512 Excision of extraparenchymal lesion of testis 1 , 5 8 1 . 3 0 54520 Orchiectomy, simple (including subcapsular), with or without testicular prosthesis, scrotal or inguinal 1 ,175.40 54522 Orchiectomy, partial 1 , 9 4 4 .0 0 54530 Orchiectomy, radical, for tumor; inguinal approach 1 , 8 3 3 . 3 0 54535 Orchiectomy, radical, for tumor; with abdominal exploration 2 , 1 6 0 . 0 0 54550 Exploration for undescended testis (inguinal or scrotal area) 1 , 5 9 4 . 8 0 54560 Exploration for undescended testis with abdominal exploration 1 , 9 1 8 . 8 0 54600 Reduction of torsion of testis, surgical, with or without fixation of contralateral testis 1 , 3 9 3 . 6 5 54620 Fixation of contralateral testis (separate procedure) 8 3 5 . 2 0 54640 Orchiopexy, inguinal approach, with or without hernia repair 1 , 7 9 0 . 1 0 54650 Orchiopexy, abdominal approach, for intra-abdominal testis (eg, Fowler-Stephens) 2 , 0 2 6 . 8 0 54660 Insertion of testicular prosthesis (separate procedure) 8 1 0 . 9 0 54670 Suture or repair of testicular injury 1 , 3 6 4 . 4 0 54680 Transplantation of testis(es) to thigh (because of scrotal destruction) 1 , 6 5 8 .7 0 54690 Laparoscopy, surgical; orchiectomy 1 , 7 3 7 . 9 0 54692 Laparoscopy, surgical; orchiopexy for intra-abdominal testis 1 , 8 0 1 . 8 0 54700 Incision and drainage of epididymis, testis and/or scrotal space (eg, abscess or hematoma) 4 5 8 . 1 0 54800 Biopsy of epididymis, needle 2 6 5 . 5 0 54830 Excision of local lesion of epididymis 9 2 7 . 9 0 54840 Excision of spermatocele, with or without epididymectomy 1 , 2 9 6 . 0 0 54860 Epididymectomy; unilateral 1 , 2 2 8 . 5 0 54861 Epididymectomy; bilateral 1 , 7 2 8 . 0 0 54865 Exploration epididymis w/wo biopsy 3 55.87 54900 Epididymovasostomy, anastomosis of epididymis to vas deferens; unilateral 2 , 3 2 5 . 6 0 54901 Epididymovasostomy, anastomosis of epididymis to vas deferens; bilateral 3 , 0 3 8 .

4 0 55000 Puncture aspiration of hydrocele, tunica vaginalis, with or without injection of medication 1 9 5 . 3 0 61 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 55040 Excision of hydrocele; unilateral 1 , 4 0 5 . 8 0 55041 Excision of hydrocele; bilateral 2 , 1 3 2 . 1 0 55060 Repair of tunica vaginalis hydrocele (Bottle type) 1 , 2 8 7 . 9 0 55100 Drainage of scrotal wall abscess 3 1 1 . 4 0 55110 Scrotal exploration 1 , 1 4 7 . 5 0 55120 Removal of foreign body in scrotum 6 3 3 . 6 0 55150 Resection of scrotum 1 , 3 8 7 . 8 0 55175 Scrotoplasty; simple 1 , 2 2 0 . 4 0 55180 Scrotoplasty; complicated 2 , 1 6 2 . 7 0 55200 Vasotomy, cannulization with or without incision of vas, unilateral or bilateral (separate procedure) 6 4 8 . 9 0 55250 Vasectomy, unilateral or bilateral (separate procedure), including postoperative semen examination(s) 6 9 9 . 3 0 55300 Vasotomy for vasograms, seminal vesiculograms, or epididymograms, unilateral or bilateral 6 4 7 . 1 0 55400 Vasovasostomy, vasovasorrhaphy 2 , 8 3 2 . 3 0 55450 Ligation (percutaneous) of vas deferens, unilateral or bilateral (separate procedure) 6 2 8 . 2 0 55500 Excision of hydrocele of spermatic cord, unilateral (separate procedure) 1 , 2 2 8 . 5 0 55520 Excision of lesion of spermatic cord (separate procedure) 1 , 0 8 5 . 4 0 55530 Excision of varicocele or ligation of spermatic veins for varicocele; (separate procedure) 1 , 5 2 7 . 3 0 55535 Excision of varicocele or ligation of spermatic veins for varicocele; abdominal approach 1 , 6 3 5 . 3 0 55540 Excision of varicocele or ligation of spermatic veins for varicocele; with hernia repair 1 , 8 0 1 . 8 0 55550 Laparoscopy, surgical, with ligation of spermatic veins for varicocele 1 , 7 1 7 . 2 0 55600 Vesiculotomy; 1 , 2 3 1 . 2 0 55605 Vesiculotomy; complicated 1 , 6 5 3 . 3 0 55650 Vesiculectomy, any approach 2 , 8 6 8 . 3 0 55680 Excision of Mullerian duct cyst 2 , 5 3 3 . 5 0 55700 Biopsy, prostate; needle or punch, single or multiple, any approach 3 9 5 . 5 8 55705 Biopsy, prostate; incisional, any approach 1 , 1 7 1 . 8 0 55706 Bx prostate strtctc saturation sampling img gid 1 ,380.90 55720 Prostatotomy, external drainage of prostatic abscess, any approach; simple 1 , 4 2 4 . 7 0 55725 Prostatotomy, external drainage of prostatic abscess, any approach; complicated 1 , 7 6 8 . 5 0 55801 Prostatectomy, perineal, subtotal (including control of postoperative bleeding, vasectomy, meatotomy, 2 ,970.00 55810 Prostatectomy, perineal radical; 3 , 8 4 2 . 1 0 55812 Prostatectomy, perineal radical; with lymph node biopsy(s) (limited pelvic lymphadenectomy) 4 , 4 8 2 . 0 0 55815 Prostatectomy, perineal radical; with bilateral pelvic lymphadenectomy, including external iliac, hypogastric 6 ,071.40 55821 Prostatectomy (including control of postoperative bleeding, vasectomy, meatotomy, urethral calibration 3 ,183.30 55831 Prostatectomy (including control of postoperative bleeding, vasectomy, meatotomy, urethral calibration 3 ,345.30 55840 Prostatectomy, retropubic radical, with or without nerve sparing; 3 , 9 6 9 . 9 0 55842 Prostatectomy, retropubic radical, with or without nerve sparing; with lymph node biopsy(s) (limited pelvic 4 ,228.20 55845 Prostatectomy, retropubic radical, with or without nerve sparing; with bilateral pelvic lymphadenectomy, 5 ,271.39 55860 Exposure of prostate, any approach, for insertion of radioactive substance; 2 , 1 8 2 . 5 0 55862 Exposure of prostate, any approach, for insertion of radioactive substance; with lymph node biopsy(s) 3 ,091.50 55865 Exposure of prostate, any approach, for insertion of radioactive substance; with bilateral pelvic 3 ,793.50 55866 Laps prstect retropubic rad w/nrv sparing robot 4 ,611.87 55870 Electroejaculation 2 3 6 . 7 0 55873 Cryosurgical ablation of the prostate (includes ultrasonic guidance for interstitial cryosurgical probe 2 ,685.60 55875 Tprnl plmt ndl/caths into prst8 radj insj 1 ,796.65 55876 Place interstitial dev radiation tx prostate 1+ 3 23.66 55920 Placement needle pelvic organ radioelement appl 1 ,072.06 56405 Incision and drainage of vulva or perineal abscess 2 5 9 . 2 0 56420 Incision and drainage of Bartholin's gland abscess 2 4 3 . 9 0 56440 Marsupialization of Bartholin's gland cyst 7 1 8 . 2 0 56441 Lysis of labial adhesions 4 5 6 . 3 0 56442 Hymenotomy simple incision 1 26.23 56501 Destruction of lesion(s), vulva; simple, any method 2 5 9 . 4 7 56515 Destruction of lesion(s), vulva; extensive, any method 8 5 0 . 1 0 56605 Biopsy of vulva or perineum (separate procedure); one lesion 1 9 9 . 4 8 56606 Biopsy of vulva or perineum (separate procedure); each separate additional lesion (List separately in 1 02.60 56620 Vulvectomy simple; partial 2 , 1 8 6 . 1 0 56625 Vulvectomy simple; complete 2 , 6 5 2 . 3 0 56630 Vulvectomy, radical, partial; 3 , 2 4 9 . 9 0 56631 Vulvectomy, radical, partial; with unilateral inguinofemoral lymphadenectomy 4 , 0 4 2 . 8 0 56632 Vulvectomy, radical, partial; with bilateral inguinofemoral lymphadenectomy 4 , 8 4 6 . 5 0 56633 Vulvectomy, radical, complete; 4 , 0 9 7 . 7 0 56634 Vulvectomy, radical, complete; with unilateral inguinofemoral lymphadenectomy 4 , 7 4 8 . 4 0 56637 Vulvectomy, radical, complete; with bilateral inguinofemoral lymphadenectomy 5 , 6 8 2 . 6 0 56640 Vulvectomy, radical, complete, with inguinofemoral, iliac, and pelvic lymphadenectomy 5 , 7 4 5 . 6 0 56700 Partial hymenectomy or revision of hymenal ring 6 3 7 . 2 0 56740 Excision of Bartholin's gland or cyst 9 2 0 . 7 0 56800 Plastic repair of introitus 8 9 8 . 2 0 56805 Clitoroplasty for intersex state 2 , 2 9 6 . 8 0 56810 Perineoplasty, repair of perineum, nonobstetrical (separate procedure) 1 , 0 3 5 . 9 0 62 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 56820 Colposcopy vulva 1 98.44 56821 Colposcopy vulva w/bx 2 93.12 57000 Colpotomy; with exploration 9 1 4 . 4 0 57010 Colpotomy; with drainage of pelvic abscess 1 , 0 3 0 . 5 0 57020 Colpocentesis (separate procedure) 2 4 9 . 3 0 57022 Incision and drainage of vaginal hematoma; post-obstetrical 3 9 8 . 7 0 57023 Incision and drainage of vaginal hematoma; non-obstetrical (eg, post-trauma, spontaneous bleeding) 3 9 8 . 7 0 57061 Destruction of vaginal lesion(s); simple, any method 4 4 2 . 8 0 57065 Destruction of vaginal lesion(s); extensive, any method 1 , 0 0 8 . 4 7 57100 Biopsy of vaginal mucosa; simple (separate procedure) 2 3 2 . 2 0 57105 Biopsy of vaginal mucosa; extensive, requiring suture (including cysts) 7 2 4 . 5 0 57106 Vaginectomy, partial removal of vaginal wall; 1 , 1 9 5 . 2 0 57107 Vaginectomy, partial removal of vaginal wall; with removal of paravaginal tissue (radical vaginectomy) 3 , 1 0 7 . 7 0 57109 Vaginectomy, partial removal of vaginal wall; with removal of paravaginal tissue (radical vaginectomy) with 3 ,578.40 57110 Vaginectomy, complete removal of vaginal wall; 2 , 3 1 6 . 6 0 57111 Vaginectomy, complete removal of vaginal wall; with removal of paravaginal tissue (radical vaginectomy) 3 , 6 6 6 . 6 0 57112 Vaginectomy, complete removal of vaginal wall; with removal of paravaginal tissue (radical vaginectomy) 3 ,849.30 57120 Colpocleisis (Le Fort type) 2 , 2 7 4 . 3 0 57130 Excision of vaginal septum 9 4 0 . 5 0 57135 Excision of vaginal cyst or tumor 7 1 0 . 8 7 57150 Irrigation of vagina and/or application of medicament for treatment of bacterial, parasitic, or fungoid disease 1 0 0 . 8 0 57155 Insj uterine tandem&/vag ovoids 1 ,064.04 57156 Ins vag brachytx device 5 49.64 57160 Fitting and insertion of pessary or other intravaginal support device 1 1 3 . 4 0 57170 Diaphragm or cervical cap fitting with instructions 9 9 . 0 0 57180 Introduction of any hemostatic agent or pack for spontaneous or traumatic nonobstetrical vaginal 3 22.20 57200 Colporrhaphy, suture of injury of vagina (nonobstetrical) 9 7 8 . 3 0 57210 Colpoperineorrhaphy, suture of injury of vagina and/or perineum (nonobstetrical) 1 , 3 5 2 . 7 0 57220 Plastic operation on urethral sphincter, vaginal approach (eg, Kelly urethral plication) 1 , 3 4 9 . 1 0 57230 Plastic repair of urethrocele 1 , 2 1 5 . 9 0 57240 Anterior colporrhaphy, repair of cystocele with or without repair of urethrocele 1 , 5 8 6 . 7 0 57250 Posterior colporrhaphy, repair of rectocele with or without perineorrhaphy 1 , 5 5 9 . 7 0 57260 Combined anteroposterior colporrhaphy; 2 , 0 9 0 . 7 0 57265 Combined anteroposterior colporrhaphy; with enterocele repair 2 , 4 1 8 . 6 2 57267 Insj mesh/prosth pel floor dfct ea sit 6 93.09 57268 Repair of enterocele, vaginal approach (separate procedure) 1 , 7 2 5 . 3 0 57270 Repair of enterocele, abdominal approach (separate procedure) 2 , 1 2 4 . 9 0 57280 Colpopexy, abdominal approach 2 , 4 7 2 . 3 0 57282 Sacrospinous ligament fixation for prolapse of vagina 2 , 7 2 9 . 7 0 57283 Colpopexy vag intra-prtl appr 1 ,612.15 57284 Paravaginal defect repair (including repair of cystocele, stress urinary incontinence, and/or incomplete 2 ,523.60 57285 Paravaginal defect repair vaginal approach 1 ,555.83 57287 Removal or revision of sling for stress incontinence (eg, fascia or synthetic) 2 , 0 8 1 . 7 0 57288 Sling operation for stress incontinence (eg, fascia or synthetic) 2 , 8 1 6 . 1 0 57289 Pereyra procedure, including anterior colporrhaphy 2 , 4 2 9 . 1 0 57291 Construction of artificial vagina; without graft 3 , 2 9 5 . 8 0 57292 Construction of artificial vagina; with graft 3 , 9 2 4 . 9 0 57295 Revj rmvl prostc vag grf vag appr 1 ,167.58 57296 Revj w/rmvl prosthetic vag grf abd appro 2 ,490.17 57300 Closure of rectovaginal fistula; vaginal or transanal approach 1 , 9 3 3 . 2 0 57305 Closure of rectovaginal fistula; abdominal approach 2 , 4 7 7 . 7 0 57307 Closure of rectovaginal fistula; abdominal approach, with concomitant colostomy 2 , 5 8 1 . 2 0 57308 Closure of rectovaginal fistula; transperineal approach, with perineal body reconstruction, with or without 2 ,317.50 57310 Closure of urethrovaginal fistula; 2 , 3 7 4 . 2 0 57311 Closure of urethrovaginal fistula; with bulbocavernosus transplant 2 , 7 2 9 . 7 0 57320 Closure of vesicovaginal fistula; vaginal approach 2 , 6 5 2 . 3 0 57330 Closure of vesicovaginal fistula; transvesical and vaginal approach 2 , 6 8 0 . 2 0 57335 Vaginoplasty for intersex state 3 , 0 6 9 . 9 0 57400 Dilation of vagina under anesthesia 3 7 0 . 8 0 57410 Pelvic examination under anesthesia 3 1 8 . 6 0 57415 Removal of impacted vaginal foreign body (separate procedure) under anesthesia 4 1 5 . 8 0 57420 Colposcopy entire vag w/cervix if present 2 38.08 57421 Colposcopy entire vag w/cervix bx 3 39.81 57423 Paravaginal defect repair laparoscopic approach 2 ,061.99 57425 Laps surg colpopexy ssp vag apex 2 ,099.02 57426 Revision prosthetic vaginal graft laparoscopic 1 ,885.00 57452 Colposcopy (vaginoscopy); (separate procedure) 2 4 2 . 9 3 57454 Colposcopy (vaginoscopy); with biopsy(s) of the cervix and/or endocervical curettage 3 4 3 . 4 6 57455 Colposcopy cervix vag bx cervix 1 69.72 57456 Colposcopy cervix vag endocrv curtg 1 87.31 63 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 57460 Colposcopy (vaginoscopy); with loop electrode excision procedure of the cervix 9 5 3 . 2 3 57461 Colposcopy cervix vag eltrd conization cervix 8 93.18 57500 Biopsy, single or multiple, or local excision of lesion, with or without fulguration (separate procedure) 2 5 1 . 0 5 57505 Endocervical curettage (not done as part of a dilation and curettage) 2 2 1 . 4 0 57510 Cauterization of cervix; electro or thermal 3 0 8 . 0 3 57511 Cauterization of cervix; cryocautery, initial or repeat 2 8 7 . 1 0 57513 Cauterization of cervix; laser ablation 1 , 0 3 0 . 5 0 57520 Conization of cervix, with or without fulguration, with or without dilation and curettage, with or without repair; 1 ,079.10 57522 Conization of cervix, with or without fulguration, with or without dilation and curettage, with or without repair; 1 ,080.48 57530 Trachelectomy (cervicectomy), amputation of cervix (separate procedure) 9 7 9 . 2 0 57531 Radical trachelectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling 4 ,499.10 57540 Excision of cervical stump, abdominal approach; 2 , 0 2 2 . 3 0 57545 Excision of cervical stump, abdominal approach; with pelvic floor repair 2 , 2 7 6 . 1 0 57550 Excision of cervical stump, vaginal approach; 1 , 6 0 6 . 5 0 57555 Excision of cervical stump, vaginal approach; with anterior and/or posterior repair 2 , 0 9 6 . 1 0 57556 Excision of cervical stump, vaginal approach; with repair of enterocele 2 , 2 9 5 . 9 0 57558 Dilation & curettage cervical stump 2 86.85 57700 Cerclage of uterine cervix, nonobstetrical 1 , 1 3 3 . 1 0 57720 Trachelorrhaphy, plastic repair of uterine cervix, vaginal approach 1 , 0 9 8 . 9 0 57800 Dilation of cervical canal, instrumental (separate procedure) 2 6 2 . 8 0 58100 Endometrial sampling (biopsy) with or without endocervical sampling (biopsy), without cervical dilation, any 2 66.06 58110 Endometrial bx conjunct w/colposcopy 1 46.06 58120 Dilation and curettage, diagnostic and/or therapeutic (nonobstetrical) 9 0 3 . 2 0 58140 Myomectomy, excision of fibroid tumor of uterus, single or multiple (separate procedure); abdominal 2 ,851.59 58145 Myomectomy, excision of fibroid tumor of uterus, single or multiple (separate procedure); vaginal approach 2 , 2 9 9 . 5 0 58146 Myomectomy 5+ > 250 gm abdl 2 ,845.00 58150 Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without 3 ,175.21 58152 Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without 3 ,904.20 58180 Supracervical abdominal hysterectomy (subtotal hysterectomy), with or without removal of tube(s), with or 3 ,280.50 58200 Total abdominal hysterectomy, including partial vaginectomy, with para-aortic and pelvic lymph node 3 ,940.20 58210 Radical abdominal hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node 6 ,048.90 58240 Pelvic exenteration for gynecologic malignancy, with total abdominal hysterectomy or cervicectomy, with or 8 ,435.70 58260 Vaginal hysterectomy; 3 , 0 8 5 . 2 0 58262 Vaginal hysterectomy; with removal of tube(s), and/or ovary(s) 3 , 5 5 4 . 1 0 58263 Vaginal hysterectomy; with removal of tube(s), and/or ovary(s), with repair of enterocele 3 , 8 7 9 . 9 0 58267 Vaginal hysterectomy; with colpo-urethrocystopexy (Marshall-Marchetti-Krantz type, Pereyra type, with or 3 ,544.20 58270 Vaginal hysterectomy; with repair of enterocele 3 , 7 6 2 . 9 0 58275 Vaginal hysterectomy, with total or partial colpectomy; 3 , 7 5 9 . 3 0 58280 Vaginal hysterectomy, with total or partial colpectomy; with repair of enterocele 3 , 4 9 3 . 8 0 58285 Vaginal hysterectomy, radical (Schauta type operation) 3 , 9 4 8 . 3 0 58290 Vaginal hysterectomy uterus > 250 gm 3 ,249.20 58291 Vag hyst > 250 gm rmvl tube&/ovary 3 ,588.32 58292 Vag hyst > 250 gm rmvl tube&/ovary w/rpr ntrcl 3 ,867.52 58293 Vag hyst > 250 gm colpo-urtcstopexy +-ndsc ctrl 4 ,011.49 58294 Vag hyst > 250 gm rpr ntrcl 3 ,502.18 58300 Insertion of intrauterine device (IUD) 3 0 8 . 7 0 58301 Removal of intrauterine device (IUD) 1 2 4 . 2 0 58321 Artificial insemination; intra-cervical 1 8 3 . 6 0 58322 Artificial insemination; intra-uterine 2 2 6 . 8 0 58323 Sperm washing for artificial insemination 2 0 0 . 7 0 58340 Catheterization and introduction of saline or contrast material for hysterosonography or 2 79.39 58345 Transcervical introduction of fallopian tube catheter for diagnosis and/or re-establishing patency (any 1 ,163.70 58346 Insj heyman capsls clinical brachytx 1 ,416.42 58350 Chromotubation of oviduct, including materials 3 6 0 . 9 0 58353 Endometrial ablation, thermal, without hysteroscopic guidance 6 8 1 . 3 0 58356 Endometrial cryoablation 2 ,930.73 58400 Uterine suspension, with or without shortening of round ligaments, with or without shortening of sacrouterine 1 ,903.50 58410 Uterine suspension, with or without shortening of round ligaments, with or without shortening of sacrouterine 2 ,566.80 58520 Hysterorrhaphy, repair of ruptured uterus (nonobstetrical) 1 , 6 5 8 . 7 0 58540 Hysteroplasty, repair of uterine anomaly (Strassman type) 2 , 4 9 7 . 5 0 58541 Laps supracrv hyst 250 g/< 2 ,275.20 58542 Laps supracrv hyst 250 g/< rmvl tube/ovary 2 ,512.31 58543 Laps supracrv hyst >250 g 2 ,546.70 58544 Laps supracrv hyst >250 g rmvl tube/ovary 2 ,839.57 58545 Laps myomectomy exc 1-4 250 gm/< 2 ,496.86 58546 Laps myomectomy exc 5+ > 250 grams 3 ,009.13 58548 Laps w/rad hyst w/bilat lmphadec rmvl tube/ovary 4 ,382.63 58550 Laparoscopy, surgical; with vaginal hysterectomy with or without removal of tube(s), with or without removal 3 ,277.49 58552 Laps w/vag hyst 250 gm/< rmvl tube&/ovary 2 ,608.28 58553 Laps w/vag hyst > 250 grams 3 ,010.69 64 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 58554 Laps vag hyst > 250 gm rmvl tube&/ovary 3 ,357.56 58555 Hysteroscopy, diagnostic (separate procedure) 8 5 7 . 7 0 58558 Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without D & C 1 , 4 0 2 . 2 7 58559 Hysteroscopy, surgical; with lysis of intrauterine adhesions (any method) 1 , 5 5 5 . 2 0 58560 Hysteroscopy, surgical; with division or resection of intrauterine septum (any method) 1 , 8 6 5 . 7 0 58561 Hysteroscopy, surgical; with removal of leiomyomata 2 , 0 6 5 . 5 0 58562 Hysteroscopy, surgical; with removal of impacted foreign body 1 , 0 3 5 . 0 0 58563 Hysteroscopy, surgical; with endometrial ablation (any method) 2 , 5 2 8 . 2 6 58565 Hystsc occlusion plmt prm 4 ,424.15 58570 Laparoscopy w total hysterectomy uterus 250 g/< 2 ,503.83 58571 Laps total hysterectomy 250 g/<w tube/ovary 2 ,801.61 58572 Laparoscopy total hysterectomy uterus>250 g 3 ,013.79 58573 Laparoscopy tot hysterectomy >250 g w tube/ovary 3 ,509.08 58600 Ligation or transection of fallopian tube(s), abdominal or vaginal approach, unilateral or bilateral 1 , 5 0 8 . 4 0 58605 Ligation or transection of fallopian tube(s), abdominal or vaginal approach, postpartum, unilateral or 1 ,312.20 58611 Ligation or transection of fallopian tube(s) when done at the time of cesarean section or intra-abdominal 8 61.75 58615 Occlusion of fallopian tube(s) by device (eg, band, clip, Falope ring) vaginal or suprapubic approach 1 , 4 4 1 . 8 0 58660 Laparoscopy, surgical; with lysis of adhesions (salpingolysis, ovariolysis) (separate procedure) 2 , 2 5 0 . 7 1 58661 Laparoscopy, surgical; with removal of adnexal structures (partial or total oophorectomy and/or 2 ,277.00 58662 Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal 2 ,523.37 58670 Laparoscopy, surgical; with fulguration of oviducts (with or without transection) 1 , 8 0 2 . 7 0 58671 Laparoscopy, surgical; with occlusion of oviducts by device (eg, band, clip, or Falope ring) 1 , 8 0 2 . 7 0 58672 Laparoscopy, surgical; with fimbrioplasty 2 , 6 0 1 . 0 0 58673 Laparoscopy, surgical; with salpingostomy (salpingoneostomy) 1 , 8 5 4 . 0 0 58700 Salpingectomy, complete or partial, unilateral or bilateral (separate procedure) 2 , 0 6 0 . 1 0 58720 Salpingo-oophorectomy, complete or partial, unilateral or bilateral (separate procedure) 2 , 1 7 8 . 5 1 58740 Lysis of adhesions (salpingolysis, ovariolysis) 2 , 4 1 5 . 8 4 58750 Tubotubal anastomosis 3 , 9 3 6 . 6 0 58752 Tubouterine implantation 3 , 4 5 0 . 6 0 58760 Fimbrioplasty 3 , 0 3 8 . 4 0 58770 Salpingostomy (salpingoneostomy) 3 , 1 9 3 . 2 0 58800 Drainage of ovarian cyst(s), unilateral or bilateral, (separate procedure); vaginal approach 1 , 1 8 4 . 4 0 58805 Drainage of ovarian cyst(s), unilateral or bilateral, (separate procedure); abdominal approach 1 ,8 0 0 . 9 0 58820 Drainage of ovarian abscess; vaginal approach, open 1 , 2 8 7 . 9 0 58822 Drainage of ovarian abscess; abdominal approach 1 , 7 7 2 . 1 0 58823 Drainage of pelvic abscess, transvaginal or transrectal approach, percutaneous (eg, ovarian, pericolic) 7 0 6 . 5 0 58825 Transposition, ovary(s) 1 , 8 3 7 . 8 0 58900 Biopsy of ovary, unilateral or bilateral (separate procedure) 1 , 8 3 3 . 3 0 58920 Wedge resection or bisection of ovary, unilateral or bilateral 2 , 3 2 9 . 2 0 58925 Ovarian cystectomy, unilateral or bilateral 2 , 3 3 1 . 0 0 58940 Oophorectomy, partial or total, unilateral or bilateral; 2 , 0 6 9 . 1 0 58943 Oophorectomy, partial or total, unilateral or bilateral; for ovarian, tubal or primary peritoneal malignancy, 3 ,457.80 58950 Resection of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and 3 ,549.60 58951 Resection of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and 4 ,583.70 58952 Resection of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo-oophorectomy and 5 ,935.50 58953 Bso w/omntc tah&rad dsj debulking 7 ,745.77 58954 Bso w/omntc tah debulking w/lmphadec 8 ,407.75 58956 Bso tot omntc tah mal 5 ,467.49 58957 Resection recrt mal w/omentectomy 5 ,807.52 58958 Resection recrt mal w/omentectomy pel lmphadec 6 ,432.44 58960 Laparotomy, for staging or restaging of ovarian, tubal or primary peritoneal malignancy (second look), with 3 ,839.96 58970 Follicle puncture for oocyte retrieval, any method 1 , 4 0 6 . 7 0 58974 Embryo transfer, intrauterine 5 3 7 . 3 0 58976 Gamete, zygote, or embryo intrafallopian transfer, any method 1 , 5 4 5 . 3 0 59000 Amniocentesis, any method 3 3 2 . 2 1 59001 Amniocnts ther amniotic flu rdctj us gid 4 40.43 59012 Cordocentesis (intrauterine), any method 6 6 9 . 6 0 59015 Chorionic villus sampling, any method 3 6 0 . 9 0 59020 26 Fetal contract stress test 9 0.59 59020 Fetal contraction stress test 1 7 8 . 8 1 59020 TC Fetal contract stress test 8 8.22 59025 26 Fetal non-stress test 6 9.45 59025 Fetal non-stress test 1 1 5 . 6 9 59025 TC Fetal non-stress test 4 6.24 59030 Fetal scalp blood sampling 1 9 4 . 4 0 59050 Fetal monitoring during labor by consulting physician (ie, non-attending physician) with written report; 2 85.30 59051 Ftl mntr labor phys wrttn reprt interpj only 1 09.29 59070 Tabdl amnionfs us gid 9 59.77 59072 Ftl umbilical cord occlusion w/us gid 1 ,227.78 59074 Ftl flu drg us gid 9 35.82 65 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 59076 Ftl shunt plmt us gid 1 ,204.41 59100 Hysterotomy, abdominal (eg, for hydatidiform mole, abortion) 1 , 9 0 8 . 0 0 59120 Surgical treatment of ectopic pregnancy; tubal or ovarian, requiring salpingectomy and/or oophorectomy, 2 ,453.40 59121 Surgical treatment of ectopic pregnancy; tubal or ovarian, without salpingectomy and/or oophorectomy 2 , 0 4 1 . 2 0 59130 Surgical treatment of ectopic pregnancy; abdominal pregnancy 2 , 0 6 1 . 9 0 59135 Surgical treatment of ectopic pregnancy; interstitial, uterine pregnancy requiring total hysterectomy 2 , 8 0 0 . 8 0 59136 Surgical treatment of ectopic pregnancy; interstitial, uterine pregnancy with partial resection of uterus 2 , 2 8 5 . 1 0 59140 Surgical treatment of ectopic pregnancy; cervical, with evacuation 1 , 5 6 2 .4 0 59150 Laparoscopic treatment of ectopic pregnancy; without salpingectomy and/or oophorectomy 2 , 3 1 7 . 5 0 59151 Laparoscopic treatment of ectopic pregnancy; with salpingectomy and/or oophorectomy 2 , 4 1 4 . 7 8 59160 Curettage, postpartum 7 6 5 . 0 0 59200 Insertion of cervical dilator (eg, laminaria, prostaglandin) (separate procedure) 2 7 6 . 7 9 59300 Episiotomy or vaginal repair, by other than attending physician 5 6 6 . 1 0 59320 Cerclage of cervix, during pregnancy; vaginal 1 , 1 2 2 . 4 7 59325 Cerclage of cervix, during pregnancy; abdominal 1 , 4 1 6 . 6 0 59350 Hysterorrhaphy of ruptured uterus 2 , 1 7 6 . 2 0 59400 Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or 2 ,781.00 59409 Vaginal delivery only (with or without episiotomy and/or forceps); 1 , 5 8 8 . 9 8 59410 Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum care 1 , 9 2 4 . 9 7 59412 External cephalic version, with or without tocolysis (List in addition to code(s) for delivery) 5 4 0 . 9 0 59414 Delivery of placenta (separate procedure) 4 8 4 . 2 0 59425 Antepartum care only; 4-6 visits 7 4 7 . 0 0 59426 Antepartum care only; 7 or more visits 1 ,1 6 8 . 0 0 59430 Postpartum care only (separate procedure) 2 4 0 . 3 0 59510 Routine obstetric care including antepartum care, cesarean delivery, and postpartum care 3 , 4 5 0 . 6 0 59514 Cesarean delivery only; 2 , 2 3 3 . 3 5 59515 Cesarean delivery only; including postpartum care 2 , 6 7 6 . 1 7 59525 Subtotal or total hysterectomy after cesarean delivery (List separately in addition to code for primary 1 ,751.40 59610 Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or 3 ,295.80 59612 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps); 2 , 2 7 1 . 6 0 59614 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps); including 2 ,339.10 59618 Routine obstetric care including antepartum care, cesarean delivery, and postpartum care, following 3 ,965.40 59620 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery; 2 , 7 8 1 . 0 0 59622 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery; including 2 ,632.19 59812 Treatment of incomplete abortion, any trimester, completed surgically 8 0 0 . 3 4 59820 Treatment of missed abortion, completed surgically; first trimester 8 1 5 . 2 4 59821 Treatment of missed abortion, completed surgically; second trimester 1 , 0 8 1 . 8 0 59830 Treatment of septic abortion, completed surgically 1 , 1 5 3 . 8 0 59840 Induced abortion, by dilation and curettage 9 4 7 . 7 0 59841 Induced abortion, by dilation and evacuation 1 , 1 1 8 . 9 0 59850 Induced abortion, by one or more intra-amniotic injections (amniocentesis-injections), including hospital 1 ,398.60 59851 Induced abortion, by one or more intra-amniotic injections (amniocentesis-injections), including hospital 1 ,555.20 59852 Induced abortion, by one or more intra-amniotic injections (amniocentesis-injections), including hospital 1 ,869.30 59855 Induced abortion, by one or more vaginal suppositories (eg, prostaglandin) with or without cervical dilation 1 ,235.70 59856 Induced abortion, by one or more vaginal suppositories (eg, prostaglandin) with or without cervical dilation 1 ,441.80 59857 Induced abortion, by one or more vaginal suppositories (eg, prostaglandin) with or without cervical dilation 1 ,810.80 59866 Multifetal pregnancy reduction(s) (MPR) 7 9 6 . 5 0 59870 Uterine evacuation and curettage for hydatidiform mole 1 , 0 8 1 . 8 0 59871 Removal of cerclage suture under anesthesia (other than local) 4 4 4 . 6 0 60000 Incision and drainage of thyroglossal cyst, infected 3 0 5 . 1 0 60100 Biopsy thyroid, percutaneous core needle 2 7 9 . 0 0 60200 Excision of cyst or adenoma of thyroid, or transection of isthmus 1 , 5 9 0 . 3 0 60210 Partial thyroid lobectomy, unilateral; with or without isthmusectomy 2 , 5 8 7 . 5 0 60212 Partial thyroid lobectomy, unilateral; with contralateral subtotal lobectomy, including isthmusectomy 3 , 1 6 5 . 3 0 60220 Total thyroid lobectomy, unilateral; with or without isthmusectomy 2 , 6 1 3 . 6 0 60225 Total thyroid lobectomy, unilateral; with contralateral subtotal lobectomy, including isthmusectomy 3 , 3 2 9 . 1 0 60240 Thyroidectomy, total or complete 3 , 2 5 0 . 8 0 60252 Thyroidectomy, total or subtotal for malignancy; with limited neck dissection 3 , 7 4 3 . 1 0 60254 Thyroidectomy, total or subtotal for malignancy; with radical neck dissection 5 , 4 2 7 . 0 0 60260 Thyroidectomy, removal of all remaining thyroid tissue following previous removal of a portion of thyroid 2 , 3 9 6 . 7 0 60270 Thyroidectomy, including substernal thyroid gland; sternal split or transthoracic approach 4 , 0 6 6 . 2 0 60271 Thyroidectomy, including substernal thyroid gland; cervical approach 3 , 2 8 4 . 1 0 60280 Excision of thyroglossal duct cyst or sinus; 2 , 0 0 4 . 3 0 60281 Excision of thyroglossal duct cyst or sinus; recurrent 2 , 1 5 5 . 5 0 60300 Aspir/inj thyroid cyst 3 04.43 60500 Parathyroidectomy or exploration of parathyroid(s); 3 , 0 8 8 . 8 0 60502 Parathyroidectomy or exploration of parathyroid(s); re-exploration 3 , 4 0 4 . 7 0 60505 Parathyroidectomy or exploration of parathyroid(s); with mediastinal exploration, sternal split or transthoracic 3 ,624.30 60512 Parathyroid autotransplantation (List separately in addition to code for primary procedure) 8 0 2 . 8 0 60520 Thymectomy, partial or total; transcervical approach (separate procedure) 3 , 2 6 0 . 7 0 66 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 60521 Thymectomy, partial or total; sternal split or transthoracic approach, without radical mediastinal dissection 3 ,193.20 60522 Thymectomy, partial or total; sternal split or transthoracic approach, with radical mediastinal dissection 4 ,230.00 60540 Adrenalectomy, partial or complete, or exploration of adrenal gland with or without biopsy, transabdominal, 3 ,249.90 60545 Adrenalectomy, partial or complete, or exploration of adrenal gland with or without biopsy, transabdominal, 3 ,646.80 60600 Excision of carotid body tumor; without excision of carotid artery 3 , 1 7 0 . 7 0 60605 Excision of carotid body tumor; with excision of carotid artery 3 , 8 2 8 . 6 0 60650 Laps adrnlectomy prtl/compl tabdl 2 ,901.27 61000 Subdural tap through fontanelle, or suture, infant, unilateral or bilateral; initial 3 4 7 . 4 0 61001 Subdural tap through fontanelle, or suture, infant, unilateral or bilateral; subsequent taps 2 6 8 . 2 0 61020 Ventricular puncture through previous burr hole, fontanelle, suture, or implanted ventricular 4 77.00 61026 Ventricular puncture through previous burr hole, fontanelle, suture, or implanted ventricular 5 39.10 61050 Cisternal or lateral cervical (C1-C2) puncture; without injection (separate procedure) 4 2 2 . 1 0 61055 Cisternal or lateral cervical (C1-C2) puncture; with injection of drug or other substance for diagnosis or 6 05.70 61070 Puncture of shunt tubing or reservoir for aspiration or injection procedure 3 1 4 . 1 0 61105 Twist drill hole for subdural or ventricular puncture; 1 , 6 4 7 . 9 0 61107 Twist drill hole for subdural or ventricular puncture; for implanting ventricular catheter or pressure recording 2 ,286.90 61108 Twist drill hole for subdural or ventricular puncture; for evacuation and/or drainage of subdural hematoma 3 , 1 4 1 . 9 0 61120 Burr hole(s) for ventricular puncture (including injection of gas, contrast media, dye, or radioactive material) 1 , 7 4 8 . 7 0 61140 Burr hole(s) or trephine; with biopsy of brain or intracranial lesion 3 , 7 8 5 . 4 0 61150 Burr hole(s) or trephine; with drainage of brain abscess or cyst 3 , 6 5 6 . 7 0 61151 Burr hole(s) or trephine; with subsequent tapping (aspiration) of intracranial abscess or cyst 1 , 1 4 9 . 3 0 61154 Burr hole(s) with evacuation and/or drainage of hematoma, extradural or subdural 4 , 3 3 3 . 5 0 61156 Burr hole(s); with aspiration of hematoma or cyst, intracerebral 3 , 8 5 0 . 2 0 61210 Burr hole(s); for implanting ventricular catheter, reservoir, EEG electrode(s) or pressure recording device 2 ,266.20 61215 Insertion of subcutaneous reservoir, pump or continuous infusion system for connection to ventricular 2 ,421.00 61250 Burr hole(s) or trephine, supratentorial, exploratory, not followed by other surgery 2 , 4 8 3 . 1 0 61253 Burr hole(s) or trephine, infratentorial, unilateral or bilateral 3 , 6 0 9 . 9 0 61304 Craniectomy or craniotomy, exploratory; supratentorial 5 , 5 6 2 . 0 0 61305 Craniectomy or craniotomy, exploratory; infratentorial (posterior fossa) 5 , 9 6 4 . 3 0 61312 Craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural 6 , 6 4 4 . 7 0 61313 Craniectomy or craniotomy for evacuation of hematoma, supratentorial; intracerebral 6 , 7 3 1 . 1 0 61314 Craniectomy or craniotomy for evacuation of hematoma, infratentorial; extradural or subdural 6 , 7 9 8 . 6 0 61315 Craniectomy or craniotomy for evacuation of hematoma, infratentorial; intracerebellar 7 , 3 0 5 . 3 0 61316 Inc&subq plmt crnl b1 grf 1 ,146.13 61320 Craniectomy or craniotomy, drainage of intracranial abscess; supratentorial 6 , 0 0 0 . 3 0 61321 Craniectomy or craniotomy, drainage of intracranial abscess; infratentorial 5 , 6 9 9 . 7 0 61322 Crnec/crx dcmprive w/o lobec 5 ,756.79 61323 Crnec/crx dcmprive w/lobec 6 ,798.55 61330 Decompression of orbit only, transcranial approach 4 , 5 0 0 . 9 0 61332 Exploration of orbit (transcranial approach); with biopsy 5 , 3 5 5 . 0 0 61333 Exploration of orbit (transcranial approach); with removal of lesion 5 , 4 2 2 . 5 0 61334 Exploration of orbit (transcranial approach); with removal of foreign body 5 , 3 5 5 . 0 0 61340 Other cranial decompression (eg, subtemporal), supratentorial 4 , 2 5 4 . 3 0 61343 Craniectomy, suboccipital with cervical laminectomy for decompression of medulla and spinal cord, with or 7 ,812.00 61345 Other cranial decompression, posterior fossa 3 , 8 6 1 . 0 0 61440 Craniotomy for section of tentorium cerebelli (separate procedure) 3 , 9 0 4 . 2 0 61450 Craniectomy, subtemporal, for section, compression, or decompression of sensory root of gasserian 5 ,769.00 61458 Craniectomy, suboccipital; for exploration or decompression of cranial nerves 6 , 5 4 1 . 2 0 61460 Craniectomy, suboccipital; for section of one or more cranial nerves 6 , 5 7 3 . 6 0 61470 Craniectomy, suboccipital; for medullary tractotomy 5 , 1 9 4 . 8 0 61480 Craniectomy, suboccipital; for mesencephalic tractotomy or pedunculotomy 4 , 8 3 3 . 0 0 61490 Craniotomy for lobotomy, including cingulotomy 3 , 8 4 8 . 4 0 61500 Craniectomy; with excision of tumor or other bone lesion of skull 5 , 7 9 9 . 6 0 61501 Craniectomy; for osteomyelitis 5 , 5 1 8 . 8 0 61510 Craniectomy, trephination, bone flap craniotomy; for excision of brain tumor, supratentorial, except 7 ,210.80 61512 Craniectomy, trephination, bone flap craniotomy; for excision of meningioma, supratentorial 7 , 4 9 8 . 8 0 61514 Craniectomy, trephination, bone flap craniotomy; for excision of brain abscess, supratentorial 6 , 4 4 1 . 3 0 61516 Craniectomy, trephination, bone flap craniotomy; for excision or fenestration of cyst, supratentorial 6 , 4 4 8 . 5 0 61517 Impltj brn intrcv chemotx agt 3 17.57 61518 Craniectomy for excision of brain tumor, infratentorial or posterior fossa; except meningioma, 7 ,177.50 61519 Craniectomy for excision of brain tumor, infratentorial or posterior fossa; meningioma 7 , 7 1 3 . 0 0 61520 Craniectomy for excision of brain tumor, infratentorial or posterior fossa; cerebellopontine angle tumor 8 , 0 5 4 . 1 0 61521 Craniectomy for excision of brain tumor, infratentorial or posterior fossa; midline tumor at base of skull 8 , 8 6 8 . 6 0 61522 Craniectomy, infratentorial or posterior fossa; for excision of brain abscess 6 , 5 3 4 . 0 0 61524 Craniectomy, infratentorial or posterior fossa; for excision or fenestration of cyst 6 , 4 9 1 . 7 0 61526 Craniectomy, bone flap craniotomy, transtemporal (mastoid) for excision of cerebellopontine angle tumor; 7 , 5 3 3 . 0 0 61530 Craniectomy, bone flap craniotomy, transtemporal (mastoid) for excision of cerebellopontine angle tumor; 7 ,915.50 61531 Subdural implantation of strip electrodes through one or more burr or trephine hole(s) for long term seizure 4 ,017.60 61533 Craniotomy with elevation of bone flap; for subdural implantation of an electrode array, for long term seizure 5 ,459.40 61534 Craniotomy with elevation of bone flap; for excision of epileptogenic focus without electrocorticography 5 ,832.00 67 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 61535 Craniotomy with elevation of bone flap; for removal of epidural or subdural electrode array, without excision 3 ,613.50 61536 Craniotomy with elevation of bone flap; for excision of cerebral epileptogenic focus, with 6 ,593.40 61537 Crx b1 flap temporal lobe w/o ecog 5 ,691.54 61538 Craniotomy with elevation of bone flap; for lobectomy with electrocorticography during surgery, temporal 7 ,169.40 61539 Craniotomy with elevation of bone flap; for lobectomy with electrocorticography during surgery, other than 6 ,920.10 61540 Crx b1 flap lobec oth/thn temporal lobe w/o ecog 6 ,750.11 61541 Craniotomy with elevation of bone flap; for transection of corpus callosum 7 , 5 4 0 . 2 0 61542 Craniotomy with elevation of bone flap; for total hemispherectomy 7 , 4 1 6 . 0 0 61543 Craniotomy with elevation of bone flap; for partial or subtotal hemispherectomy 6 , 7 9 8 . 6 0 61544 Craniotomy with elevation of bone flap; for excision or coagulation of choroid plexus 5 , 9 3 1 . 0 0 61545 Craniotomy with elevation of bone flap; for excision of craniopharyngioma 9 , 7 5 0 . 6 0 61546 Craniotomy for hypophysectomy or excision of pituitary tumor, intracranial approach 7 , 2 2 2 . 5 0 61548 Hypophysectomy or excision of pituitary tumor, transnasal or transseptal approach, nonstereotactic 6 , 1 6 8 . 6 0 61550 Craniectomy for craniosynostosis; single cranial suture 3 , 8 6 3 . 7 0 61552 Craniectomy for craniosynostosis; multiple cranial sutures 4 , 6 2 6 . 9 0 61556 Craniotomy for craniosynostosis; frontal or parietal bone flap 4 , 7 0 8 . 8 0 61557 Craniotomy for craniosynostosis; bifrontal bone flap 5 , 3 5 5 . 9 0 61558 Extensive craniectomy for multiple cranial suture craniosynostosis (eg, cloverleaf skull); not requiring bone 6 ,180.30 61559 Extensive craniectomy for multiple cranial suture craniosynostosis (eg, cloverleaf skull); recontouring with 7 ,004.70 61563 Excision, intra and extracranial, benign tumor of cranial bone (eg, fibrous dysplasia); without optic nerve 5 ,598.00 61564 Excision, intra and extracranial, benign tumor of cranial bone (eg, fibrous dysplasia); with optic nerve 7 ,004.70 61566 Crx b1 flap slctv amygdalohippocampectomy 6 ,648.74 61567 Crx b1 flap mlt subpial trnsxjs w/ecog 7 ,585.18 61570 Craniectomy or craniotomy; with excision of foreign body from brain 6 , 6 5 5 . 5 0 61571 Craniectomy or craniotomy; with treatment of penetrating wound of brain 7 , 1 1 2 . 7 0 61575 Transoral approach to skull base, brain stem or upper spinal cord for biopsy, decompression or excision of 5 ,925.60 61576 Transoral approach to skull base, brain stem or upper spinal cord for biopsy, decompression or excision of 6 ,066.00 61580 Craniofacial approach to anterior cranial fossa; extradural, including lateral rhinotomy, ethmoidectomy, 5 ,279.40 61581 Craniofacial approach to anterior cranial fossa; extradural, including lateral rhinotomy, orbital exenteration, 6 ,869.70 61582 Craniofacial approach to anterior cranial fossa; extradural, including unilateral or bifrontal craniotomy, 6 ,235.20 61583 Craniofacial approach to anterior cranial fossa; intradural, including unilateral or bifrontal craniotomy, 6 ,881.40 61584 Orbitocranial approach to anterior cranial fossa, extradural, including supraorbital ridge osteotomy and 6 ,746.40 61585 Orbitocranial approach to anterior cranial fossa, extradural, including supraorbital ridge osteotomy and 7 ,112.70 61586 Bicoronal, transzygomatic and/or LeFort I osteotomy approach to anterior cranial fossa with or without 4 ,247.10 61590 Infratemporal pre-auricular approach to middle cranial fossa (parapharyngeal space, infratemporal and 8 ,847.90 61591 Infratemporal post-auricular approach to middle cranial fossa (internal auditory meatus, petrous apex, 9 ,154.80 61592 Orbitocranial zygomatic approach to middle cranial fossa (cavernous sinus and carotid artery, clivus, basilar 7 ,725.60 61595 Transtemporal approach to posterior cranial fossa, jugular foramen or midline skull base, including 6 ,030.00 61596 Transcochlear approach to posterior cranial fossa, jugular foramen or midline skull base, including 6 ,489.00 61597 Transcondylar (far lateral) approach to posterior cranial fossa, jugular foramen or midline skull base, 7 ,729.20 61598 Transpetrosal approach to posterior cranial fossa, clivus or foramen magnum, including ligation of superior 6 ,545.70 61600 Resection or excision of neoplastic, vascular or infectious lesion of base of anterior cranial fossa; extradural 5 , 3 4 5 . 1 0 61601 Resection or excision of neoplastic, vascular or infectious lesion of base of anterior cranial fossa; intradural, 6 ,008.40 61605 Resection or excision of neoplastic, vascular or infectious lesion of infratemporal fossa, parapharyngeal 5 ,562.90 61606 Resection or excision of neoplastic, vascular or infectious lesion of infratemporal fossa, parapharyngeal 7 ,875.00 61607 Resection or excision of neoplastic, vascular or infectious lesion of parasellar area, cavernous sinus, clivus 7 ,877.70 61608 Resection or excision of neoplastic, vascular or infectious lesion of parasellar area, cavernous sinus, clivus 8 ,641.80 61609 Transection or ligation, carotid artery in cavernous sinus; without repair (List separately in addition to code 2 ,159.10 61610 Transection or ligation, carotid artery in cavernous sinus; with repair by anastomosis or graft (List separately 5 ,758.20 61611 Transection or ligation, carotid artery in petrous canal; without repair (List separately in addition to code for 1 ,481.40 61612 Transection or ligation, carotid artery in petrous canal; with repair by anastomosis or graft (List separately in 5 ,562.00 61613 Obliteration of carotid aneurysm, arteriovenous malformation, or carotid-cavernous fistula by dissection 8 ,973.90 61615 Resection or excision of neoplastic, vascular or infectious lesion of base of posterior cranial fossa, jugular 6 ,874.20 61616 Resection or excision of neoplastic, vascular or infectious lesion of base of posterior cranial fossa, jugular 8 ,987.40 61618 Secondary repair of dura for CSF leak, anterior, middle or posterior cranial fossa following surgery of the 3 ,795.30 61619 Secondary repair of dura for CSF leak, anterior, middle or posterior cranial fossa following surgery of the 6 ,327.00 61623 Evasc temp balo artl occlusion 2 ,587.65 61624 Transcatheter occlusion or embolization (eg, for tumor destruction, to achieve hemostasis, to occlude a 4 ,705.20 61626 Transcatheter occlusion or embolization (eg, for tumor destruction, to achieve hemostasis, to occlude a 3 ,346.20 61630 Balo angiop icra prq 4 ,445.59 61635 Tcat plmt iv stent icra w/balo angiop if pfrmd 5 ,059.80 61640 Balo dilat icra prq 1st vsl 3 ,692.54 61641 Balo dilat icra prq ea vsl sm vasc fam 1 ,825.26 61642 Balo dilat icra prq ea vsl diff vasc fam 1 ,874.98 61680 Surgery of intracranial arteriovenous malformation; supratentorial, simple 7 , 8 4 1 . 7 0 61682 Surgery of intracranial arteriovenous malformation; supratentorial, complex 9 , 5 5 3 . 5 0 61684 Surgery of intracranial arteriovenous malformation; infratentorial, simple 8 , 4 3 3 . 0 0 61686 Surgery of intracranial arteriovenous malformation; infratentorial, complex 1 0 , 9 3 5 . 9 0 61690 Surgery of intracranial arteriovenous malformation; dural, simple 7 , 7 6 9 . 7 0 61692 Surgery of intracranial arteriovenous malformation; dural, complex 8 , 2 7 9 . 1 0 68 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 61697 Surgery of complex intracranial aneurysm, intracranial approach; carotid circulation 8 , 1 4 5 . 0 0 61698 Surgery of complex intracranial aneurysm, intracranial approach; vertebrobasilar circulation 7 , 8 3 9 . 0 0 61700 Surgery of simple intracranial aneurysm, intracranial approach; carotid circulation 8 , 0 3 4 . 3 0 61702 Surgery of simple intracranial aneurysm, intracranial approach; vertebrobasilar circulation 7 , 7 2 5 . 6 0 61703 Surgery of intracranial aneurysm, cervical approach by application of occluding clamp to cervical carotid 3 ,445.20 61705 Surgery of aneurysm, vascular malformation or carotid-cavernous fistula; by intracranial and cervical 8 ,181.00 61708 Surgery of aneurysm, vascular malformation or carotid-cavernous fistula; by intracranial electrothrombosis 6 , 2 1 8 . 1 0 61710 Surgery of aneurysm, vascular malformation or carotid-cavernous fistula; by intra-arterial embolization, 5 ,119.20 61711 Anastomosis, arterial, extracranial-intracranial (eg, middle cerebral/cortical) arteries 6 , 5 0 8 . 8 0 61720 Creation of lesion by stereotactic method, including burr hole(s) and localizing and recording techniques, 4 ,897.80 61735 Creation of lesion by stereotactic method, including burr hole(s) and localizing and recording techniques, 5 ,054.40 61750 Stereotactic biopsy, aspiration, or excision, including burr hole(s), for intracranial lesion; 5 , 0 4 7 . 2 0 61751 Stereotactic biopsy, aspiration, or excision, including burr hole(s), for intracranial lesion; with computerized 5 ,544.00 61760 Stereotactic implantation of depth electrodes into the cerebrum for long term seizure monitoring 5 , 9 6 0 . 7 0 61770 Stereotactic localization, including burr hole(s), with insertion of catheter(s) or probe(s) for placement of 5 ,312.70 61781 Strtctc cptr asstd px idrl crnl 9 46.82 61782 Strtctc cptr asstd px xdrl crnl 7 58.02 61783 Strtctc cptr asstd px spinal 7 98.88 61790 Creation of lesion by stereotactic method, percutaneous, by neurolytic agent (eg, alcohol, thermal, 4 ,118.40 61791 Creation of lesion by stereotactic method, percutaneous, by neurolytic agent (eg, alcohol, thermal, 3 ,960.90 61796 Stereotactic radiosurgery 1 simple cranial les 4 ,260.08 61797 Strtctc radiosurgery ea addl cranial les simple 1 ,148.15 61798 Stereotactic radiosurgery 1 complex cranial les 4 ,339.38 61799 Strtctc radiosurgery ea addl cranial les complex 1 ,612.19 61800 Appl strtctc headframe stereotactic radiosurgery 8 06.16 61850 Twist drill or burr hole(s) for implantation of neurostimulator electrodes, cortical 3 , 3 0 4 . 8 0 61860 Craniectomy or craniotomy for implantation of neurostimulator electrodes, cerebral, cortical 4 , 0 7 5 . 2 0 61863 Strtctc impltj nstim eltrd w/o mer 1st ra 3 ,473.61 61864 Strtctc impltj nstim eltrd w/o mer ea ra 1 ,609.63 61867 Strtctc impltj nstim eltrd w/mer 1st ra 5 ,176.91 61868 Strtctc impltj nstim eltrdw/mer ea ra 2 ,433.01 61870 Craniectomy for implantation of neurostimulator electrodes, cerebellar; cortical 3 , 7 2 3 . 3 0 61875 Craniectomy for implantation of neurostimulator electrodes, cerebellar; subcortical 3 , 5 0 1 . 9 0 61880 Revision or removal of intracranial neurostimulator electrodes 2 , 4 7 1 . 4 0 61885 Incision and subcutaneous placement of cranial neurostimulator pulse generator or receiver, direct or 9 43.20 61886 Incision and subcutaneous placement of cranial neurostimulator pulse generator or receiver, direct or 1 ,390.50 61888 Revision or removal of cranial neurostimulator pulse generator or receiver 1 , 0 0 9 . 8 0 62000 Elevation of depressed skull fracture; simple, extradural 3 , 4 2 0 . 0 0 62005 Elevation of depressed skull fracture; compound or comminuted, extradural 4 , 1 8 5 . 0 0 62010 Elevation of depressed skull fracture; with repair of dura and/or debridement of brain 5 , 3 1 0 . 0 0 62100 Craniotomy for repair of dural/CSF leak, including surgery for rhinorrhea/otorrhea 5 , 8 0 4 . 1 0 62115 Reduction of skull defect 2 ,946.76 62116 Reduction of skull defect 4 ,497.88 62117 Reduction of craniomegalic skull (eg, treated hydrocephalus);

requiring craniotomy and reconstruction with 4 ,892.40 62120 Repair of encephalocele, skull vault, including cranioplasty 4 , 8 7 4 . 4 0 62121 Craniotomy for repair of encephalocele, skull base 4 , 8 7 8 . 0 0 62140 Cranioplasty for skull defect; up to 5 cm diameter 4 , 5 9 8 . 1 0 62141 Cranioplasty for skull defect; larger than 5 cm diameter 4 , 8 1 6 . 8 0 62142 Removal of bone flap or prosthetic plate of skull 3 , 1 9 7 . 7 0 62143 Replacement of bone flap or prosthetic plate of skull 3 , 8 6 2 . 8 0 62145 Cranioplasty for skull defect with reparative brain surgery 4 , 9 4 8 . 2 0 62146 Cranioplasty with autograft (includes obtaining bone grafts); up to 5 cm diameter 4 , 3 7 7 . 6 0 62147 Cranioplasty with autograft (includes obtaining bone grafts); larger than 5 cm diameter 4 , 8 4 1 . 1 0 62148 Incise&retrieval subq cranioplasty bone graft 4 45.59 62160 Neuroendoscopy add-on 4 79.08 62161 Nundsc icra dsj ads fenestration septum csts 5 ,992.94 62162 Nundsc icra fenestration/exc cst plmt cath drg 6 ,085.95 62163 Nundsc icra w/retrieval fb 6 ,926.90 62164 Nundsc icra exc tum plmt cath drg 7 ,165.41 62165 Nundsc icra exc pituitary tum 6 ,442.36 62180 Ventriculocisternostomy (Torkildsen type operation) 4 , 0 0 6 . 8 0 62190 Creation of shunt; subarachnoid/subdural-atrial, -jugular, -auricular 3 , 4 6 9 . 5 0 62192 Creation of shunt; subarachnoid/subdural-peritoneal, -pleural, other terminus 3 , 5 2 3 . 5 0 62194 Replacement or irrigation, subarachnoid/subdural catheter 1 , 2 9 6 . 9 0 62200 Ventriculocisternostomy, third ventricle; 4 , 7 2 6 . 8 0 62201 Ventriculocisternostomy 3rd vntrc neurondsc 4 ,996.62 62220 Creation of shunt; ventriculo-atrial, -jugular, -auricular 4 , 3 0 7 . 4 0 62223 Creation of shunt; ventriculo-peritoneal, -pleural, other terminus 4 , 3 3 1 . 7 0 62225 Replacement or irrigation, ventricular catheter 1 , 8 5 2 . 2 0 62230 Replacement or revision of CSF shunt, obstructed valve, or distal catheter in shunt system 3 , 1 6 2 . 6 0 69 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 62252 26 Csf shunt reprogram 1 22.96 62252 Reprogramming of programmable CSF shunt 2 3 6 . 7 0 62252 TC Csf shunt reprogram 1 13.74 62256 Removal of complete CSF shunt system; without replacement 1 , 8 6 3 . 0 0 62258 Removal of complete CSF shunt system; with replacement by similar or other shunt at same operation 4 , 5 3 1 . 5 0 62263 Percutaneous lysis of epidural adhesions using solution injection (eg, hypertonic saline, enzyme) or 1 ,090.80 62264 Prq lss edrl ads sln njx/mchnl loclzj 1 d 1 ,042.86 62267 Interdiscal perq aspir dx 8 16.24 62268 Percutaneous aspiration, spinal cord cyst or syrinx 1 , 9 0 6 . 2 0 62269 Biopsy of spinal cord, percutaneous needle 1 , 5 7 9 . 5 0 62270 Spinal puncture, lumbar, diagnostic 2 1 5 . 1 0 62272 Spinal puncture, therapeutic, for drainage of spinal fluid (by needle or catheter) 2 8 3 . 5 0 62273 Injection, epidural, of blood or clot patch 5 1 2 . 1 0 62280 Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced saline solutions), with or without other 4 83.30 62281 Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced saline solutions), with or without other 5 66.10 62282 Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced saline solutions), with or without other 6 36.30 62284 Injection procedure for myelography and/or computerized axial tomography, spinal (other than C1-C2 and 5 22.90 62287 Aspiration or decompression procedure, percutaneous, of nucleus pulposus of intervertebral disk, any 3 ,543.30 62290 Injection procedure for diskography, each level; lumbar 5 5 1 . 7 0 62291 Injection procedure for diskography, each level; cervical or thoracic 5 2 4 . 7 0 62292 Injection procedure for chemonucleolysis, including diskography, intervertebral disk, single or multiple 2 ,452.50 62294 Injection procedure, arterial, for occlusion of arteriovenous malformation, spinal 1 , 2 3 2 . 1 0 62310 Injection, single (not via indwelling catheter), not including neurolytic substances, with or without contrast 8 75.70 62311 Injection, single (not via indwelling catheter), not including neurolytic substances, with or without contrast 9 33.30 62318 Injection, including catheter placement, continuous infusion or intermittent bolus, not including neurolytic 9 68.40 62319 Injection, including catheter placement, continuous infusion or intermittent bolus, not including neurolytic 9 42.30 62350 Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication 1 ,545.30 62351 Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication 2 ,763.90 62355 Removal of previously implanted intrathecal or epidural catheter 1 , 3 6 8 . 0 0 62360 Implantation or replacement of device for intrathecal or epidural drug infusion; subcutaneous reservoir 5 6 6 . 1 0 62361 Impltj/rplcmt ithcl/edrl nfs non-prgrbl pmp 1 ,849.28 62362 Implantation or replacement of device for intrathecal or epidural drug infusion; programmable pump, 1 ,653.30 62365 Removal of subcutaneous reservoir or pump, previously implanted for intrathecal or epidural infusion 1 , 3 1 3 . 1 0 62367 Analyze spine infus pump 1 03.05 62368 Analyze sp inf pump w/reprog 1 36.97 62369 Anal sp inf pmp w/reprg&fill 3 14.44 62370 Anl sp inf pmp w/mdreprg&fil 3 26.18 63001 Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without 4 ,944.60 63003 Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without 5 ,364.90 63005 Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without 4 ,862.70 63011 Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without 4 ,583.70 63012 Laminectomy with removal of abnormal facets and/or pars inter-articularis with decompression of cauda 4 ,892.40 63015 Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without 6 ,095.70 63016 Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without 5 ,768.10 63017 Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without 5 ,402.70 63020 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, 4 ,932.00 63030 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, 5 ,275.80 63035 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, 1 ,433.70 63040 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, 5 ,602.50 63042 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, 6 ,077.70 63045 Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, 5 ,896.80 63046 Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, 5 ,850.90 63047 Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, 6 ,197.40 63048 Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, 2 ,574.90 63050 Lamop crv w/dcmprn spi cord 2/more vrt seg 5 ,247.21 63051 Lamop crv dcmprn spi cord 2+ seg rcnstj b1 5 ,950.77 63055 Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated 6 ,694.20 63056 Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated 5 ,550.30 63057 Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated 1 ,699.20 63064 Costovertebral approach with decompression of spinal cord or nerve root(s), (eg, herniated intervertebral 5 ,833.80 63066 Costovertebral approach with decompression of spinal cord or nerve root(s), (eg, herniated intervertebral 1 ,287.90 63075 Diskectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; 5 ,081.40 63076 Diskectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; 1 ,952.10 63077 Diskectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; 4 ,871.70 63078 Diskectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; 1 ,342.80 63081 Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression 6 ,626.70 63082 Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression 1 ,591.20 63085 Vertebral corpectomy (vertebral body resection), partial or complete, transthoracic approach with 7 ,022.70 63086 Vertebral corpectomy (vertebral body resection), partial or complete, transthoracic approach with 1 ,986.30 63087 Vertebral corpectomy (vertebral body resection), partial or complete, combined thoracolumbar approach 6 ,282.90 70 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 63088 Vertebral corpectomy (vertebral body resection), partial or complete, combined thoracolumbar approach 1 ,699.20 63090 Vertebral corpectomy (vertebral body resection), partial or complete, transperitoneal or retroperitoneal 6 ,551.10 63091 Vertebral corpectomy (vertebral body resection), partial or complete, transperitoneal or retroperitoneal 1 ,787.40 63101 Vcrpec lat xtrcavitary dcmprn thrc 1 sgm 6 ,101.26 63102 Vcrpec lat xtrcavitary dcmprn lmbr 1 sgm 6 ,074.85 63103 Vcrpec lat xtrcavitary dcmprn thrc/lmbr ea sgm 1 ,901.26 63170 Laminectomy with myelotomy (eg, Bischof or DREZ type), cervical, thoracic, or thoracolumbar 5 , 8 4 0 . 1 0 63172 Laminectomy with drainage of intramedullary cyst/syrinx; to subarachnoid space 5 , 6 9 4 . 3 0 63173 Laminectomy with drainage of intramedullary cyst/syrinx; to peritoneal space 5 , 9 2 2 . 9 0 63180 Laminectomy and section of dentate ligaments, with or without dural graft, cervical; one or two segments 5 , 3 4 8 . 7 0 63182 Laminectomy and section of dentate ligaments, with or without dural graft, cervical; more than two segments 5 , 6 0 3 . 4 0 63185 Laminectomy with rhizotomy; one or two segments 4 , 5 9 9 . 0 0 63190 Laminectomy with rhizotomy; more than two segments 5 , 4 5 2 . 2 0 63191 Laminectomy with section of spinal accessory nerve 3 , 9 9 4 . 2 0 63194 Laminectomy with cordotomy, with section of one spinothalamic tract, one stage; cervical 4 , 3 5 6 . 9 0 63195 Laminectomy with cordotomy, with section of one spinothalamic tract, one stage; thoracic 4 , 8 4 9 . 2 0 63196 Laminectomy with cordotomy, with section of both spinothalamic tracts, one stage; cervical 4 , 9 8 0 . 6 0 63197 Laminectomy with cordotomy, with section of both spinothalamic tracts, one stage; thoracic 5 , 3 4 6 . 0 0 63198 Laminectomy with cordotomy with section of both spinothalamic tracts, two stages within 14 days; cervical 5 , 8 9 2 . 3 0 63199 Laminectomy with cordotomy with section of both spinothalamic tracts, two stages within 14 days; thoracic 5 , 8 9 2 . 3 0 63200 Laminectomy, with release of tethered spinal cord, lumbar 4 , 8 7 4 . 4 0 63250 Laminectomy for excision or occlusion of arteriovenous malformation of spinal cord; cervical 6 , 4 3 7 . 7 0 63251 Laminectomy for excision or occlusion of arteriovenous malformation of spinal cord; thoracic 6 , 6 6 9 . 9 0 63252 Laminectomy for excision or occlusion of arteriovenous malformation of spinal cord; thoracolumbar 7 , 4 7 1 . 8 0 63265 Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; cervical 5 , 8 2 4 . 8 0 63266 Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; thoracic 6 , 4 1 2 . 5 0 63267 Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; lumbar 5 , 6 3 2 . 2 0 63268 Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; sacral 4 , 8 0 5 . 1 0 63270 Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; cervical 5 , 7 3 9 . 3 0 63271 Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; thoracic 5 , 8 0 4 . 1 0 63272 Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; lumbar 5 , 7 9 6 . 0 0 63273 Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; sacral 5 , 0 2 3 . 8 0 63275 Laminectomy for biopsy/excision of intraspinal neoplasm; extradural, cervical 6 , 3 4 6 . 8 0 63276 Laminectomy for biopsy/excision of intraspinal neoplasm; extradural, thoracic 6 , 2 4 6 . 9 0 63277 Laminectomy for biopsy/excision of intraspinal neoplasm; extradural, lumbar 5 , 6 1 6 . 9 0 63278 Laminectomy for biopsy/excision of intraspinal neoplasm; extradural, sacral 5 , 3 0 6 . 4 0 63280 Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, extramedullary, cervical 6 , 4 1 2 . 5 0 63281 Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, extramedullary, thoracic 6 , 5 5 6 . 5 0 63282 Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, extramedullary, lumbar 6 ,7 0 2 . 3 0 63283 Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, sacral 5 , 2 8 2 . 1 0 63285 Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, intramedullary, cervical 6 , 8 0 8 . 5 0 63286 Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, intramedullary, thoracic 7 , 1 2 8 . 0 0 63287 Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, intramedullary, thoracolumbar 7 , 5 3 3 . 0 0 63290 Laminectomy for biopsy/excision of intraspinal neoplasm; combined extradural-intradural lesion, any level 7 , 1 2 0 . 8 0 63295 Ostpl rcnstj dorsal spi elmnts flwg ispi px 8 76.68 63300 Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single 6 ,033.60 63301 Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single 6 ,150.60 63302 Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single 6 ,551.10 63303 Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single 6 ,489.00 63304 Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single 6 ,502.50 63305 Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single 6 ,653.70 63306 Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single 6 ,643.80 63307 Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single 7 ,065.90 63308 Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single 1 ,661.40 63600 Creation of lesion of spinal cord by stereotactic method, percutaneous, any modality (including stimulation 3 ,244.50 63610 Stereotactic stimulation of spinal cord, percutaneous, separate procedure not followed by other surgery 2 , 5 0 2 .9 0 63615 Stereotactic biopsy, aspiration, or excision of lesion, spinal cord 3 , 7 8 5 . 4 0 63620 Stereotactic radiosurgery 1 spinal lesion 1 ,894.72 63621 Stereotactic radiosurgery ea addl spinal lesion 5 90.80 63650 Percutaneous implantation of neurostimulator electrode array, epidural 3 , 3 9 7 . 5 0 63655 Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural 4 , 4 6 2 . 2 0 63661 Remove spine eltrd perq aray 1 ,863.09 63662 Rmvl spinal nstim eltrd plate/paddle incl fluor 3 ,176.79 63663 Revise spine eltrd perq aray 2 ,705.03 63664 Revj incl rplcmt nstim eltrd plt/pdle incl fluor 3 ,472.26 63685 Incision and subcutaneous placement of spinal neurostimulator pulse generator or receiver, direct or 2 ,304.90 63688 Revision or removal of implanted spinal neurostimulator pulse generator or receiver 1 , 4 5 2 . 6 0 63700 Repair of meningocele; less than 5 cm diameter 3 , 7 1 5 . 2 0 63702 Repair of meningocele; larger than 5 cm diameter 3 , 7 1 6 . 1 0 63704 Repair of myelomeningocele; less than 5 cm diameter 4 , 0 5 3 . 6 0 71 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 63706 Repair of myelomeningocele; larger than 5 cm diameter 4 , 4 0 1 . 0 0 63707 Repair of dural/CSF leak, not requiring laminectomy 4 , 4 1 1 . 8 0 63709 Repair of dural/CSF leak or pseudomeningocele, with laminectomy 5 , 0 5 5 . 3 0 63710 Dural graft, spinal 4 , 4 2 4 . 4 0 63740 Creation of shunt, lumbar, subarachnoid-peritoneal, -pleural, or other; including laminectomy 4 , 4 2 4 . 4 0 63741 Creation of shunt, lumbar, subarachnoid-peritoneal, -pleural, or other; percutaneous, not requiring 2 ,841.30 63744 Replacement, irrigation or revision of lumbosubarachnoid shunt 2 , 2 1 4 . 9 0 63746 Removal of entire lumbosubarachnoid shunt system without replacement 1 , 6 6 1 . 4 0 64400 Injection, anesthetic agent; trigeminal nerve, any division or branch 3 6 9 . 0 0 64402 Injection, anesthetic agent; facial nerve 2 4 3 . 9 0 64405 Injection, anesthetic agent; greater occipital nerve 2 4 2 . 1 0 64408 Injection, anesthetic agent; vagus nerve 2 8 4 . 4 0 64410 Injection, anesthetic agent; phrenic nerve 2 5 0 . 2 0 64412 Injection, anesthetic agent; spinal accessory nerve 2 4 2 . 1 0 64413 Injection, anesthetic agent; cervical plexus 2 9 9 . 7 0 64415 Injection, anesthetic agent; brachial plexus 2 6 8 . 2 0 64416 Injection anes brachial plexus cont nfs cath 3 05.64 64417 Injection, anesthetic agent; axillary nerve 2 5 0 . 2 0 64418 Injection, anesthetic agent; suprascapular nerve 2 7 4 . 0 7 64420 Injection, anesthetic agent; intercostal nerve, single 2 6 1 . 9 0 64421 Injection, anesthetic agent; intercostal nerves, multiple, regional block 4 8 6 . 9 0 64425 Injection, anesthetic agent; ilioinguinal, iliohypogastric nerves 2 5 7 . 4 0 64430 Injection, anesthetic agent; pudendal nerve 2 6 1 .0 0 64435 Injection, anesthetic agent; paracervical (uterine) nerve 2 3 4 . 9 0 64445 Injection, anesthetic agent; sciatic nerve 3 2 6 . 7 0 64446 Injection anes sciatic nerve cont infusion cath 3 05.97 64447 Njx anes fem nrv 1 2 28.81 64448 Injection anes femoral nerve cont infusion cath 2 75.13 64449 Injection anes lumbar plexus post cont nfs cath 3 06.30 64450 Injection, anesthetic agent; other peripheral nerve or branch 1 8 5 . 4 0 64455 N block inj plantar digit 1 57.67 64479 Injection, anesthetic agent and/or steroid, transforaminal epidural; cervical or thoracic, single level 4 8 5 . 1 0 64480 Injection, anesthetic agent and/or steroid, transforaminal epidural; cervical or thoracic, each additional level 4 36.50 64483 Injection, anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, single level 3 9 8 . 1 1 64484 Injection, anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, each additional level 4 47.30 64490 Inj paravert f jnt c/t 1 lev 4 04.72 64491 Inj paravert f jnt c/t 2 lev 2 87.25 64492 Inj paravert f jnt c/t 3 lev 2 87.36 64493 Inj paravert f jnt l/s 1 lev 3 98.98 64494 Inj paravert f jnt l/s 2 lev 2 27.39 64495 Inj paravert f jnt l/s 3 lev 2 27.49 64505 Injection, anesthetic agent; sphenopalatine ganglion 2 4 4 . 8 0 64508 Injection, anesthetic agent; carotid sinus (separate procedure) 2 6 2 . 8 0 64510 Injection, anesthetic agent; stellate ganglion (cervical sympathetic) 2 9 5 . 2 0 64517 Njx anes suprior hypogstr plexus 3 85.18 64520 Injection, anesthetic agent; lumbar or thoracic (paravertebral sympathetic) 4 9 0 . 4 1 64530 Injection, anesthetic agent; celiac plexus, with or without radiologic monitoring 5 4 0 . 9 0 64550 Application of surface (transcutaneous) neurostimulator 1 2 3 . 5 4 64553 Percutaneous implantation of neurostimulator electrodes; cranial nerve 3 6 0 . 9 0 64555 Percutaneous implantation of neurostimulator electrodes; peripheral nerve 3 0 9 . 6 0 64561 Prq impltj nstim eltrds sac nrv 1 ,611.28 64565 Percutaneous implantation of neurostimulator electrodes; neuromuscular 2 9 3 . 4 0 64566 Neuroeltrd stim post tibial 2 66.83 64568 Inc impltj crnl nrv nstim eltrds & pulse gener 1 ,127.59 64569 Revision/replmt nstim crnl eltrds 1 ,130.12 64570 Removal crnl nrv nstim eltrds & pulse generator 9 99.18 64575 Incision for implantation of neurostimulator electrodes; peripheral nerve 9 6 3 . 9 0 64580 Incision for implantation of neurostimulator electrodes; neuromuscular 7 9 3 . 8 0 64581 Inc impltj nstim eltrds sac nrv 1 ,141.09 64585 Revision or removal of peripheral neurostimulator electrodes 6 7 8 . 6 0 64590 Incision and subcutaneous placement of peripheral neurostimulator pulse generator or receiver, direct or 7 38.90 64595 Revision or removal of peripheral neurostimulator pulse generator or receiver 5 3 0 . 1 0 64600 Destruction by neurolytic agent, trigeminal nerve; supraorbital, infraorbital, mental, or inferior alveolar 5 40.90 64605 Destruction by neurolytic agent, trigeminal nerve; second and third division branches at foramen ovale 6 6 9 . 6 0 64610 Destruction by neurolytic agent, trigeminal nerve; second and third division branches at foramen ovale 1 ,837.80 64611 Chemodenerv saliv glands 1 40.10 64612 Chemodenervation of muscle(s); muscle(s) innervated by facial nerve (eg, for blepharospasm, hemifacial 3 77.10 64613 Chemodenervation of muscle(s); cervical spinal muscle(s) (eg, for spasmodic torticollis) 4 0 6 . 8 0 64614 Chemodenervation of muscle(s); extremity(s) and/or trunk muscle(s) (eg, for dystonia, cerebral palsy, 4 59.00 64615 Chemodenerv musc migraine 3 58.72 72 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 64620 Destruction by neurolytic agent, intercostal nerve 4 1 7 . 6 0 64630 Destruction by neurolytic agent; pudendal nerve 3 9 1 . 5 0 64632 N block inj common digit 2 78.02 64633 Destroy cerv/thor facet jnt 1 ,004.45 64634 Destroy c/th facet jnt addl 4 57.76 64635 Destroy lumb/sac facet jnt 9 86.15 64636 Destroy l/s facet jnt addl 4 12.31 64640 Destruction by neurolytic agent; other peripheral nerve or branch 3 9 4 . 2 0 64650 Chemodnrvtj eccrine glnds bth ax 1 06.28 64653 Chemodnrvtj eccrine glnds oth area pr d 1 39.04 64680 Destruction by neurolytic agent, celiac plexus, with or without radiologic monitoring 6 8 5 . 8 0 64681 Dstrj nulyt +-rad mntr suprior hypogstr plexus 7 34.56 64702 Neuroplasty; digital, one or both, same digit 1 , 3 2 5 . 7 0 64704 Neuroplasty; nerve of hand or foot 1 , 4 6 7 . 9 0 64708 Neuroplasty, major peripheral nerve, arm or leg; other than specified 1 , 9 4 4 . 9 0 64712 Neuroplasty, major peripheral nerve, arm or leg; sciatic nerve 2 , 1 2 1 . 3 0 64713 Neuroplasty, major peripheral nerve, arm or leg; brachial plexus 2 , 7 2 5 . 2 0 64714 Neuroplasty, major peripheral nerve, arm or leg; lumbar plexus 2 , 4 2 2 . 8 0 64716 Neuroplasty and/or transposition; cranial nerve (specify) 2 , 4 6 4 . 2 0 64718 Neuroplasty and/or transposition; ulnar nerve at elbow 2 , 5 2 3 . 6 0 64719 Neuroplasty and/or transposition; ulnar nerve at wrist 1 , 9 8 9 . 9 0 64721 Neuroplasty and/or transposition; median nerve at carpal tunnel 1 , 8 5 4 . 0 0 64722 Decompression; unspecified nerve(s) (specify) 2 , 0 5 0 . 2 0 64726 Decompression; plantar digital nerve 7 5 1 . 5 0 64727 Internal neurolysis, requiring use of operating microscope (List separately in addition to code for 2 ,111.40 64732 Transection or avulsion of; supraorbital nerve 1 , 2 8 7 . 9 0 64734 Transection or avulsion of; infraorbital nerve 1 , 4 7 6 . 0 0 64736 Transection or avulsion of; mental nerve 1 , 2 5 5 . 5 0 64738 Transection or avulsion of; inferior alveolar nerve by osteotomy 1 , 4 4 7 . 2 0 64740 Transection or avulsion of; lingual nerve 1 , 5 8 6 . 7 0 64742 Transection or avulsion of; facial nerve, differential or complete 1 , 6 6 8 . 6 0 64744 Transection or avulsion of; greater occipital nerve 1 , 5 9 7 . 5 0 64746 Transection or avulsion of; phrenic nerve 8 0 3 . 7 0 64752 Transection or avulsion of; vagus nerve (vagotomy), transthoracic 2 , 3 2 6 . 5 0 64755 Transection or avulsion of; vagi limited to proximal stomach (selective proximal vagotomy, proximal gastric 3 ,316.50 64760 Transection or avulsion of; vagus nerve (vagotomy), abdominal 1 , 9 6 4 . 7 0 64761 Transection or avulsion of; pudendal nerve 8 5 5 . 0 0 64763 Transection or avulsion of obturator nerve, extrapelvic, with or without adductor tenotomy 1 , 0 2 1 . 5 0 64766 Transection or avulsion of obturator nerve, intrapelvic, with or without adductor tenotomy 1 , 6 0 6 . 5 0 64771 Transection or avulsion of other cranial nerve, extradural 1 , 6 4 7 . 9 0 64772 Transection or avulsion of other spinal nerve, extradural 2 , 0 5 2 . 9 0 64774 Excision of neuroma; cutaneous nerve, surgically identifiable 9 2 2 . 5 0 64776 Excision of neuroma; digital nerve, one or both, same digit 1 , 0 7 4 . 6 0 64778 Excision of neuroma; digital nerve, each additional digit (List separately in addition to code for primary 4 61.70 64782 Excision of neuroma; hand or foot, except digital nerve 1 , 2 6 1 . 8 0 64783 Excision of neuroma; hand or foot, each additional nerve, except same digit (List separately in addition to 6 69.60 64784 Excision of neuroma; major peripheral nerve, except sciatic 1 , 8 4 1 . 4 0 64786 Excision of neuroma; sciatic nerve 2 , 4 0 3 . 0 0 64787 Implantation of nerve end into bone or muscle (List separately in addition to neuroma excision) 1 , 3 9 0 . 5 0 64788 Excision of neurofibroma or neurolemmoma; cutaneous nerve 1 , 1 5 9 . 2 0 64790 Excision of neurofibroma or neurolemmoma; major peripheral nerve 2 , 1 5 1 . 9 0 64792 Excision of neurofibroma or neurolemmoma; extensive (including malignant type) 2 , 2 2 4 . 8 0 64795 Biopsy of nerve 9 1 4 . 4 0 64802 Sympathectomy, cervical 2 , 6 5 7 . 7 0 64804 Sympathectomy, cervicothoracic 3 , 5 8 7 . 4 0 64809 Sympathectomy, thoracolumbar 2 , 9 4 5 . 7 0 64818 Sympathectomy, lumbar 2 , 6 9 9 . 1 0 64820 Sympth dgtal arts ea dgt 1 ,219.55 64821 Sympth rdl art 1 ,203.16 64822 Sympth ur art 1 ,201.92 64823 Sympth supfc plmr arch 1 ,223.47 64831 Suture of digital nerve, hand or foot; one nerve 1 , 7 0 4 . 6 0 64832 Suture of digital nerve, hand or foot; each additional digital nerve (List separately in addition to code for 9 27.90 64834 Suture of one nerve, hand or foot; common sensory nerve 1 ,8 9 9 . 0 0 64835 Suture of one nerve, hand or foot; median motor thenar 1 , 9 6 7 . 4 0 64836 Suture of one nerve, hand or foot; ulnar motor 2 , 3 6 0 . 7 0 64837 Suture of each additional nerve, hand or foot (List separately in addition to code for primary procedure) 1 , 1 3 4 . 9 0 64840 Suture of posterior tibial nerve 2 , 7 7 8 . 3 0 64856 Suture of major peripheral nerve, arm or leg, except sciatic; including transposition 2 , 8 3 1 . 4 0 64857 Suture of major peripheral nerve, arm or leg, except sciatic; without transposition 2 , 5 1 8 . 2 0 73 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 64858 Suture of sciatic nerve 2 , 5 0 3 . 8 0 64859 Suture of each additional major peripheral nerve (List separately in addition to code for primary procedure) 1 , 1 4 7 . 5 0 64861 Suture of; brachial plexus 2 , 7 0 3 . 6 0 64862 Suture of; lumbar plexus 3 , 2 9 2 . 2 0 64864 Suture of facial nerve; extracranial 2 , 3 5 5 . 3 0 64865 Suture of facial nerve; infratemporal, with or without grafting 3 , 4 4 1 . 6 0 64866 Anastomosis; facial-spinal accessory 3 , 6 9 0 . 9 0 64868 Anastomosis; facial-hypoglossal 4 , 1 0 8 . 5 0 64870 Anastomosis; facial-phrenic 3 , 6 4 4 . 1 0 64872 Suture of nerve; requiring secondary or delayed suture (List separately in addition to code for primary 1 ,768.50 64874 Suture of nerve; requiring extensive mobilization, or transposition of nerve (List separately in addition to 2 ,524.50 64876 Repair nerve/shorten bone 4 41.19 64885 Nerve graft (includes obtaining graft), head or neck; up to 4 cm in length 3 , 7 5 9 . 3 0 64886 Nerve graft (includes obtaining graft), head or neck; more than 4 cm length 3 , 2 3 4 . 6 0 64890 Nerve graft (includes obtaining graft), single strand, hand or foot; up to 4 cm length 3 , 4 9 5 . 6 0 64891 Nerve graft (includes obtaining graft), single strand, hand or foot; more than 4 cm length 2 , 8 4 5 . 8 0 64892 Nerve graft (includes obtaining graft), single strand, arm or leg; up to 4 cm length 2 , 7 9 6 . 3 0 64893 Nerve graft (includes obtaining graft), single strand, arm or leg; more than 4 cm length 3 , 0 7 4 . 4 0 64895 Nerve graft (includes obtaining graft), multiple strands (cable), hand or foot; up to 4 cm length 3 , 3 8 8 . 5 0 64896 Nerve graft (includes obtaining graft), multiple strands (cable), hand or foot; more than 4 cm length 3 , 8 4 1 . 2 0 64897 Nerve graft (includes obtaining graft), multiple strands (cable), arm or leg; up to 4 cm length 3 , 5 4 0 . 6 0 64898 Nerve graft (includes obtaining graft), multiple strands (cable), arm or leg; more than 4 cm length 3 , 9 4 0 . 2 0 64901 Nerve graft, each additional nerve; single strand (List separately in addition to code for primary procedure) 2 , 3 6 2 . 5 0 64902 Nerve graft, each additional nerve; multiple strands (cable) (List separately in addition to code for primary 2 ,455.20 64905 Nerve pedicle transfer; first stage 2 , 0 2 1 . 4 0 64907 Nerve pedicle transfer; second stage 2 , 2 2 6 . 6 0 64910 Nerve repair w/conduit ea nerve 1 ,599.15 64911 Nerve repair w/autogenous vein graft ea nerve 1 ,901.18 65091 Evisceration of ocular contents; without implant 1 , 3 6 3 . 5 0 65093 Evisceration of ocular contents; with implant 1 , 7 0 5 . 5 0 65101 Enucleation of eye; without implant 2 , 0 8 3 . 4 4 65103 Enucleation of eye; with implant, muscles not attached to implant 1 , 8 9 5 . 4 0 65105 Enucleation of eye; with implant, muscles attached to implant 2 , 3 7 9 . 6 0 65110 Exenteration of orbit (does not include skin graft), removal of orbital contents; only 3 , 0 4 6 . 5 0 65112 Exenteration of orbit (does not include skin graft), removal of orbital contents; with therapeutic removal of 3 ,127.50 65114 Exenteration of orbit (does not include skin graft), removal of orbital contents; with muscle or myocutaneous 3 ,379.50 65125 Modification of ocular implant with placement or replacement of pegs (eg, drilling receptacle for prosthesis 7 72.20 65130 Insertion of ocular implant secondary; after evisceration, in scleral shell 1 , 4 6 7 . 9 0 65135 Insertion of ocular implant secondary; after enucleation, muscles not attached to implant 1 , 5 6 6 . 0 0 65140 Insertion of ocular implant secondary; after enucleation, muscles attached to implant 2 , 0 6 8 . 2 0 65150 Reinsertion of ocular implant; with or without conjunctival graft 1 , 4 4 1 . 8 0 65155 Reinsertion of ocular implant; with use of foreign material for reinforcement and/or attachment of muscles to 1 ,653.30 65175 Removal of ocular implant 1 , 1 6 6 . 4 0 65205 Removal of foreign body, external eye; conjunctival superficial 1 1 6 . 7 4 65210 Removal of foreign body, external eye; conjunctival embedded (includes concretions), subconjunctival, or 1 31.60 65220 Removal of foreign body, external eye; corneal, without slit lamp 1 1 2 . 5 0 65222 Removal of foreign body, external eye; corneal, with slit lamp 1 6 3 . 9 1 65235 Removal of foreign body, intraocular; from anterior chamber or lens 1 , 7 1 5 . 4 0 65260 Removal of foreign body, intraocular; from posterior segment, magnetic extraction, anterior or posterior 1 ,864.80 65265 Removal of foreign body, intraocular; from posterior segment, nonmagnetic extraction 2 , 1 9 9 . 6 0 65270 Repair of laceration; conjunctiva, with or without nonperforating laceration sclera, direct closure 2 7 5 . 0 2 65272 Repair of laceration; conjunctiva, by mobilization and rearrangement, without hospitalization 4 9 4 . 1 0 65273 Repair of laceration; conjunctiva, by mobilization and rearrangement, with hospitalization 7 2 6 . 3 0 65275 Repair of laceration; cornea, nonperforating, with or without removal foreign body 8 2 1 . 7 0 65280 Repair of laceration; cornea and/or sclera, perforating, not involving uveal tissue 2 , 0 8 2 . 6 0 65285 Repair of laceration; cornea and/or sclera, perforating, with reposition or resection of uveal tissue 3 , 0 2 6 . 6 9 65286 Repair of laceration; application of tissue glue, wounds of cornea and/or sclera 9 2 7 . 0 0 65290 Repair of wound, extraocular muscle, tendon and/or Tenon's capsule 1 , 1 5 3 . 8 0 65400 Excision of lesion, cornea (keratectomy, lamellar, partial), except pterygium 1 , 1 3 3 . 1 0 65410 Biopsy of cornea 4 6 6 . 2 0 65420 Excision or transposition of pterygium; without graft 9 4 4 . 7 8 65426 Excision or transposition of pterygium; with graft 1 , 3 6 9 . 3 3 65430 Scraping of cornea, diagnostic, for smear and/or culture 1 2 2 . 4 0 65435 Removal of corneal epithelium; with or without chemocauterization (abrasion, curettage) 1 5 7 . 5 0 65436 Removal of corneal epithelium; with application of chelating agent (eg, EDTA) 4 6 3 . 5 0 65450 Destruction of lesion of cornea by cryotherapy, photocoagulation or thermocauterization 4 8 3 . 3 0 65600 Multiple punctures of anterior cornea (eg, for corneal erosion, tattoo) 8 1 7 . 2 0 65710 Keratoplasty (corneal transplant); lamellar 3 , 0 6 8 . 1 0 65730 Keratoplasty (corneal transplant); penetrating (except in aphakia) 3 , 7 5 9 . 3 0 65750 Keratoplasty (corneal transplant); penetrating (in aphakia) 3 , 8 1 1 . 5 0 74 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 65755 Keratoplasty (corneal transplant); penetrating (in pseudophakia) 3 , 6 9 8 . 1 0 65756 Keratoplasty endothelial 2 ,478.45 65760 Keratomileusis 3 , 7 0 9 . 8 0 65765 Keratophakia 3 , 8 4 4 . 8 0 65767 Epikeratoplasty 3 , 0 7 9 . 8 0 65770 Keratoprosthesis 3 , 6 0 5 . 4 0 65771 Radial keratotomy 1 , 6 1 7 .3 0 65772 Corneal relaxing incision for correction of surgically induced astigmatism 1 , 1 9 9 . 7 0 65775 Corneal wedge resection for correction of surgically induced astigmatism 1 , 3 8 0 . 6 0 65778 Cover eye w/membrane 2 ,613.91 65779 Cover eye w/membrane suture 2 ,106.15 65780 Ocular surface reconstruction amniotic membrane 1 ,555.66 65781 Ocular surface reconstruction limbal allograft 2 ,458.31 65782 Occular surface reconstruction limbal autograft 1 ,989.88 65800 Paracentesis of anterior chamber of eye (separate procedure); with diagnostic aspiration of aqueous 3 6 0 . 9 0 65810 Paracentesis of anterior chamber of eye (separate procedure); with removal of vitreous and/or discission of 1 ,247.40 65815 Paracentesis of anterior chamber of eye (separate procedure); with removal of blood, with or without 1 ,110.60 65820 Goniotomy 1 , 7 5 8 . 6 0 65850 Trabeculotomy ab externo 2 , 1 5 4 . 6 0 65855 Trabeculoplasty by laser surgery, one or more sessions (defined treatment series) 1 , 6 4 7 . 9 0 65860 Severing adhesions of anterior segment, laser technique (separate procedure) 1 , 2 7 7 . 1 0 65865 Severing adhesions of anterior segment of eye, incisional technique (with or without injection of air or liquid) 1 ,256.40 65870 Severing adhesions of anterior segment of eye, incisional technique (with or without injection of air or liquid) 1 ,376.10 65875 Severing adhesions of anterior segment of eye, incisional technique (with or without injection of air or liquid) 1 ,417.50 65880 Severing adhesions of anterior segment of eye, incisional technique (with or without injection of air or liquid) 1 ,403.10 65900 Removal of epithelial downgrowth, anterior chamber eye 1 , 6 6 8 . 6 0 65920 Removal of implanted material, anterior segment eye 1 , 8 7 3 . 1 7 65930 Removal of blood clot, anterior segment eye 1 , 2 9 8 . 7 0 66020 Injection, anterior chamber (separate procedure); air or liquid 3 6 0 . 9 0 66030 Injection, anterior chamber (separate procedure); medication 2 3 2 . 2 0 66130 Excision of lesion, sclera 1 , 1 5 3 . 8 0 66150 Fistulization of sclera for glaucoma; trephination with iridectomy 1 , 9 1 3 . 4 0 66155 Fistulization of sclera for glaucoma; thermocauterization with iridectomy 1 , 8 5 4 . 0 0 66160 Fistulization of sclera for glaucoma; sclerectomy with punch or scissors, with iridectomy 1 , 8 7 4 . 7 0 66165 Fistulization of sclera for glaucoma; iridencleisis or iridotasis 1 , 7 8 8 . 3 0 66170 Fistulization of sclera for glaucoma; trabeculectomy ab externo in absence of previous surgery 2 , 0 6 4 . 6 0 66172 Fistulization of sclera for glaucoma; trabeculectomy ab externo with scarring from previous ocular surgery or 2 ,304.00 66174 Trluml dilat aqueous canal w/o dev/stnt 1 ,664.54 66175 Trluml dilat aqueous canal w/dev/stnt 1 ,755.21 66180 Aqueous shunt to extraocular reservoir (eg, Molteno, Schocket, Denver-Krupin) 2 , 6 2 1 . 7 0 66185 Revision of aqueous shunt to extraocular reservoir 1 , 7 5 4 . 1 0 66220 Repair of scleral staphyloma; without graft 2 , 3 1 7 . 5 0 66225 Repair of scleral staphyloma; with graft 3 , 1 1 5 . 8 0 66250 Revision or repair of operative wound of anterior segment, any type, early or late, major or minor procedure 1 , 5 5 5 . 2 0 66500 Iridotomy by stab incision (separate procedure); except transfixion 8 9 1 . 0 0 66505 Iridotomy by stab incision (separate procedure); with transfixion as for iris bombe 8 4 4 . 2 0 66600 Iridectomy, with corneoscleral or corneal section; for removal of lesion 1 , 4 3 4 . 6 0 66605 Iridectomy, with corneoscleral or corneal section; with cyclectomy 2 , 0 8 6 . 2 0 66625 Iridectomy, with corneoscleral or corneal section; peripheral for glaucoma (separate procedure) 1 , 4 0 1 . 3 0 66630 Iridectomy, with corneoscleral or corneal section; sector for glaucoma (separate procedure) 1 , 3 5 6 . 3 0 66635 Iridectomy, with corneoscleral or corneal section; optical (separate procedure) 1 , 3 5 6 . 3 0 66680 Repair of iris, ciliary body (as for iridodialysis) 1 , 5 2 2 . 8 0 66682 Suture of iris, ciliary body (separate procedure) with retrieval of suture through small incision (eg, McCannel 1 ,645.20 66700 Ciliary body destruction; diathermy 1 , 2 3 1 . 2 0 66710 Ciliary body destruction; cyclophotocoagulation 1 , 3 1 3 . 1 0 66711 Ciliary bdy dstrj cyclopc ndsc 1 ,283.69 66720 Ciliary body destruction; cryotherapy 1 , 3 1 3 . 1 0 66740 Ciliary body destruction; cyclodialysis 1 , 2 7 5 . 3 0 66761 Iridotomy/iridectomy by laser surgery (eg, for glaucoma) (one or more sessions) 1 , 3 8 0 . 6 0 66762 Iridoplasty by photocoagulation (one or more sessions) (eg, for improvement of vision, for widening of 1 ,241.10 66770 Destruction of cyst or lesion iris or ciliary body (nonexcisional procedure) 1 , 3 4 7 . 3 0 66820 Discission of secondary membranous cataract (opacified posterior lens capsule and/or anterior hyaloid); 1 ,007.10 66821 Discission of secondary membranous cataract (opacified posterior lens capsule and/or anterior hyaloid); 1 ,117.54 66825 Repositioning of intraocular lens prosthesis, requiring an incision (separate procedure) 1 , 7 0 1 . 9 0 66830 Removal of secondary membranous cataract (opacified posterior lens capsule and/or anterior hyaloid) with 1 ,787.40 66840 Removal of lens material; aspiration technique, one or more stages 2 , 0 8 6 . 2 0 66850 Removal of lens material; phacofragmentation technique (mechanical or ultrasonic) (eg, 2 ,266.20 66852 Removal of lens material; pars plana approach, with or without vitrectomy 2 , 1 9 1 . 5 0 66920 Removal of lens material; intracapsular 2 , 4 4 2 . 6 0 66930 Removal of lens material; intracapsular, for dislocated lens 2 , 3 3 7 . 3 0 75 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 66940 Removal of lens material; extracapsular (other than 66840, 66850, 66852) 2 , 3 5 8 . 9 0 66982 Extracapsular cataract removal with insertion of intraocular lens prosthesis (one stage procedure), manual 2 ,692.80 66983 Intracapsular cataract extraction with insertion of intraocular lens prosthesis (one stage procedure) 2 , 9 1 3 . 3 0 66984 Extracapsular cataract removal with insertion of intraocular lens prosthesis (one stage procedure), manual 2 ,961.00 66985 Insertion of intraocular lens prosthesis (secondary implant), not associated with concurrent cataract removal 2 , 2 7 6 . 1 0 66986 Exchange of intraocular lens 2 , 5 1 3 . 7 0 66990 Ophthalmic endoscope add-on 2 08.58 67005 Removal of vitreous, anterior approach (open sky technique or limbal incision); partial removal 2 , 3 6 8 . 8 0 67010 Removal of vitreous, anterior approach (open sky technique or limbal incision); subtotal removal with 3 ,078.00 67015 Aspiration or release of vitreous, subretinal or choroidal fluid, pars plana approach (posterior sclerotomy) 1 , 3 2 8 . 4 0 67025 Injection of vitreous substitute, pars plana or limbal approach, (fluid-gas exchange), with or without 1 ,447.20 67027 Implantation of intravitreal drug delivery system (eg, ganciclovir implant), includes concomitant removal of 2 ,884.50 67028 Intravitreal injection of a pharmacologic agent (separate procedure) 6 7 7 . 7 0 67030 Discission of vitreous strands (without removal), pars plana approach 1 , 5 5 5 . 2 0 67031 Severing of vitreous strands, vitreous face adhesions, sheets, membranes or opacities, laser surgery (one 1 ,725.30 67036 Vitrectomy, mechanical, pars plana approach; 3 , 8 1 6 . 0 0 67039 Vitrectomy, mechanical, pars plana approach; with focal endolaser photocoagulation 4 , 3 3 6 . 2 0 67040 Vitrectomy, mechanical, pars plana approach; with endolaser panretinal photocoagulation 4 , 6 8 6 . 3 0 67041 Vitrectomy pars plana remove preretinal membrane 3 ,643.85 67042 Vitrectomy pars plana remove int memb retina 4 ,430.03 67043 Vitrectomy pars plana remove subretinal membrane 4 ,581.88 67101 Repair of retinal detachment, one or more sessions; cryotherapy or diathermy, with or without drainage of 2 ,293.20 67105 Repair of retinal detachment, one or more sessions; photocoagulation, with or without drainage of subretinal 2 ,421.00 67107 Repair of retinal detachment; scleral buckling (such as lamellar scleral dissection, imbrication or encircling 3 ,351.60 67108 Repair of retinal detachment; with vitrectomy, any method, with or without air or gas tamponade, focal 4 ,954.50 67110 Repair of retinal detachment; by injection of air or other gas (eg, pneumatic retinopexy) 2 , 8 9 9 . 8 0 67112 Repair of retinal detachment; by scleral buckling or vitrectomy, on patient having previous ipsilateral retinal 3 ,100.50 67113 Rpr complex retina detach vitrectomy & memb peel 4 ,729.72 67115 Release of encircling material (posterior segment) 1 , 1 8 4 . 4 0 67120 Removal of implanted material, posterior segment; extraocular 1 , 2 6 9 . 9 0 67121 Removal of implanted material, posterior segment; intraocular 1 , 6 6 3 . 2 0 67141 Prophylaxis of retinal detachment (eg, retinal break, lattice degeneration) without drainage, one or more 1 ,359.90 67145 Prophylaxis of retinal detachment (eg, retinal break, lattice degeneration) without drainage, one or more 1 ,518.03 67208 Destruction of localized lesion of retina (eg, macular edema, tumors), one or more sessions; cryotherapy, 1 ,661.40 67210 Destruction of localized lesion of retina (eg, macular edema, tumors), one or more sessions; 1 ,524.43 67218 Destruction of localized lesion of retina (eg, macular edema, tumors), one or more sessions; radiation by 2 ,276.10 67220 Destruction of localized lesion of choroid (eg, choroidal neovascularization); photocoagulation (eg, laser), 1 ,760.40 67221 Destruction of localized lesion of choroid (eg, choroidal neovascularization); photodynamic therapy (includes 1 ,009.80 67225 Dstrj les choroid pdt 2nd eye 1 sess 4 24.48 67227 Destruction of extensive or progressive retinopathy (eg, diabetic retinopathy), one or more sessions; 1 ,713.60 67228 Destruction of extensive or progressive retinopathy (eg, diabetic retinopathy), one or more sessions; 1 ,702.39 67229 Extensive retinopathy 1+ sess preterm infant 1 ,631.69 67250 Scleral reinforcement (separate procedure); without graft 1 , 9 5 5 . 7 0 67255 Scleral reinforcement (separate procedure); with graft 2 , 4 0 0 . 3 0 67311 Strabismus surgery, recession or resection procedure; one horizontal muscle 1 , 5 3 2 . 7 0 67312 Strabismus surgery, recession or resection procedure; two horizontal muscles 2 , 0 0 8 . 8 0 67314 Strabismus surgery, recession or resection procedure; one vertical muscle (excluding superior oblique) 1 , 8 5 4 . 0 0 67316 Strabismus surgery, recession or resection procedure; two or more vertical muscles (excluding superior 2 ,276.10 67318 Strabismus surgery, any procedure, superior oblique muscle 2 , 1 0 6 . 9 0 67320 Transposition procedure (eg, for paretic extraocular muscle), any extraocular muscle (specify) (List 2 ,286.90 67331 Strabismus surgery on patient with previous eye surgery or injury that did not involve the extraocular 1 ,467.90 67332 Strabismus surgery on patient with scarring of extraocular muscles (eg, prior ocular injury, strabismus or 2 ,152.80 67334 Strabismus surgery by posterior fixation suture technique, with or without muscle recession (List separately 1 ,441.80 67335 Placement of adjustable suture(s) during strabismus surgery, including postoperative adjustment(s) of 7 20.90 67340 Strabismus surgery involving exploration and/or repair of detached extraocular muscle(s) (List separately in 1 ,802.70 67343 Release of extensive scar tissue without detaching extraocular muscle (separate procedure) 1 , 3 9 0 . 5 0 67345 Chemodenervation of extraocular muscle 5 3 9 . 1 0 67346 Biopsy extraocular muscle 5 44.18 67400 Orbitotomy without bone flap (frontal or transconjunctival approach); for exploration, with or without biopsy 2 , 1 6 0 . 0 0 67405 Orbitotomy without bone flap (frontal or transconjunctival approach); with drainage only 1 , 9 8 0 . 9 0 67412 Orbitotomy without bone flap (frontal or transconjunctival approach); with removal of lesion 2 , 3 5 2 . 6 0 67413 Orbitotomy without bone flap (frontal or transconjunctival approach); with removal of foreign body 2 , 7 1 6 . 2 0 67414 Orbitotomy without bone flap (frontal or transconjunctival approach); with removal of bone for 2 ,228.40 67415 Fine needle aspiration of orbital contents 4 3 7 . 4 0 67420 Orbitotomy with bone flap or window, lateral approach (eg, Kroenlein); with removal of lesion 3 , 3 5 2 . 5 0 67430 Orbitotomy with bone flap or window, lateral approach (eg, Kroenlein); with removal of foreign body 2 , 8 8 7 . 2 0 67440 Orbitotomy with bone flap or window, lateral approach (eg, Kroenlein); with drainage 3 , 0 3 1 . 2 0 67445 Orbitotomy with bone flap or window, lateral approach (eg, Kroenlein); with removal of bone for 2 ,722.50 67450 Orbitotomy with bone flap or window, lateral approach (eg, Kroenlein); for exploration, with or without biopsy 2 , 9 6 6 . 4 0 67500 Retrobulbar injection; medication (separate procedure, does not include supply of medication) 1 7 5 . 5 0 76 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 67505 Retrobulbar injection; alcohol 2 8 0 . 8 0 67515 Injection of therapeutic agent into Tenon's capsule 1 3 9 . 5 0 67550 Orbital implant (implant outside muscle cone); insertion 1 , 8 0 2 . 7 0 67560 Orbital implant (implant outside muscle cone); removal or revision 1 , 7 8 4 . 7 0 67570 Optic nerve decompression (eg, incision or fenestration of optic nerve sheath) 2 , 4 4 0 . 8 0 67700 Blepharotomy, drainage of abscess, eyelid 1 8 4 . 4 7 67710 Severing of tarsorrhaphy 3 1 1 .

4 0 67715 Canthotomy (separate procedure) 3 6 6 . 3 0 67800 Excision of chalazion; single 2 1 8 . 8 8 67801 Excision of chalazion; multiple, same lid 3 0 4 . 5 9 67805 Excision of chalazion; multiple, different lids 3 5 6 . 4 4 67808 Excision of chalazion; under general anesthesia and/or requiring hospitalization, single or multiple 5 6 5 . 2 0 67810 Biopsy of eyelid 2 5 0 . 2 0 67820 Correction of trichiasis; epilation, by forceps only 9 4 . 9 9 67825 Correction of trichiasis; epilation by other than forceps (eg, by electrosurgery, cryotherapy, laser surgery) 1 7 8 . 2 0 67830 Correction of trichiasis; incision of lid margin 5 0 3 . 1 0 67835 Correction of trichiasis; incision of lid margin, with free mucous membrane graft 1 , 6 9 1 . 1 0 67840 Excision of lesion of eyelid (except chalazion) without closure or with simple direct closure 3 5 3 . 4 7 67850 Destruction of lesion of lid margin (up to 1 cm) 2 5 2 . 0 0 67875 Temporary closure of eyelids by suture (eg, Frost suture) 4 4 2 . 8 0 67880 Construction of intermarginal adhesions, median tarsorrhaphy, or canthorrhaphy; 8 6 4 . 0 0 67882 Construction of intermarginal adhesions, median tarsorrhaphy, or canthorrhaphy; with transposition of tarsal 1 ,364.40 67900 Repair of brow ptosis (supraciliary, mid-forehead or coronal approach) 1 , 3 9 9 . 5 0 67901 Repair of blepharoptosis; frontalis muscle technique with suture or other material 2 ,1 6 9 . 0 0 67902 Repair of blepharoptosis; frontalis muscle technique with fascial sling (includes obtaining fascia) 2 , 3 7 2 . 4 0 67903 Repair of blepharoptosis; (tarso) levator resection or advancement, internal approach 2 , 3 7 4 . 2 0 67904 Repair of blepharoptosis; (tarso) levator resection or advancement, external approach 2 , 8 7 9 . 1 0 67906 Repair of blepharoptosis; superior rectus technique with fascial sling (includes obtaining fascia) 2 , 1 2 2 . 2 0 67908 Repair of blepharoptosis; conjunctivo-tarso-Muller's muscle-levator resection (eg, Fasanella-Servat type) 1 , 9 0 9 . 8 0 67909 Reduction of overcorrection of ptosis 1 , 6 8 9 . 3 0 67911 Correction of lid retraction 2 , 1 6 2 . 7 0 67912 Corrj lagophthalmos impltj upr eyelid lid load 2 ,145.90 67914 Repair of ectropion; suture 9 7 7 . 4 0 67915 Repair of ectropion; thermocauterization 4 8 3 . 3 0 67916 Repair of ectropion; blepharoplasty, excision tarsal wedge 1 , 3 4 1 . 9 0 67917 Repair of ectropion; blepharoplasty, extensive (eg, Kuhnt-Szymanowski or tarsal strip operations) 1 , 8 5 4 . 0 0 67921 Repair of entropion; suture 7 6 9 . 5 0 67922 Repair of entropion; thermocauterization 3 7 8 . 9 0 67923 Repair of entropion; blepharoplasty, excision tarsal wedge 1 , 4 6 7 . 9 0 67924 Repair of entropion; blepharoplasty, extensive (eg, Wheeler operation) 1 , 8 5 7 . 6 0 67930 Suture of recent wound, eyelid, involving lid margin, tarsus, and/or palpebral conjunctiva direct closure; 9 49.50 67935 Suture of recent wound, eyelid, involving lid margin, tarsus, and/or palpebral conjunctiva direct closure; full 1 ,545.30 67938 Removal of embedded foreign body, eyelid 2 2 2 . 3 0 67950 Canthoplasty (reconstruction of canthus) 1 , 8 2 2 . 5 0 67961 Excision and repair of eyelid, involving lid margin, tarsus, conjunctiva, canthus, or full thickness, may 2 ,062.80 67966 Excision and repair of eyelid, involving lid margin, tarsus, conjunctiva, canthus, or full thickness, may 2 ,368.80 67971 Reconstruction of eyelid, full thickness by transfer of tarsoconjunctival flap from opposing eyelid; up to two- 2 ,272.50 67973 Reconstruction of eyelid, full thickness by transfer of tarsoconjunctival flap from opposing eyelid; total 3 ,181.50 67974 Reconstruction of eyelid, full thickness by transfer of tarsoconjunctival flap from opposing eyelid; total 3 ,420.90 67975 Reconstruction of eyelid, full thickness by transfer of tarsoconjunctival flap from opposing eyelid; second 1 ,535.40 68020 Incision of conjunctiva, drainage of cyst 1 6 6 . 3 0 68040 Expression of conjunctival follicles (eg, for trachoma) 1 2 8 . 7 0 68100 Biopsy of conjunctiva 1 8 7 . 2 0 68110 Excision of lesion, conjunctiva; up to 1 cm 3 6 5 . 7 2 68115 Excision of lesion, conjunctiva; over 1 cm 4 5 4 . 5 0 68130 Excision of lesion, conjunctiva; with adjacent sclera 8 1 3 . 6 0 68135 Destruction of lesion, conjunctiva 2 4 7 . 5 0 68200 Subconjunctival injection 1 7 8 . 2 0 68320 Conjunctivoplasty; with conjunctival graft or extensive rearrangement 1 , 6 5 4 . 2 0 68325 Conjunctivoplasty; with buccal mucous membrane graft (includes obtaining graft) 2 , 0 9 0 . 7 0 68326 Conjunctivoplasty, reconstruction cul-de-sac; with conjunctival graft or extensive rearrangement 2 , 1 3 0 . 3 0 68328 Conjunctivoplasty, reconstruction cul-de-sac; with buccal mucous membrane graft (includes obtaining graft) 2 , 1 0 4 . 2 0 68330 Repair of symblepharon; conjunctivoplasty, without graft 1 , 2 9 2 . 4 0 68335 Repair of symblepharon; with free graft conjunctiva or buccal mucous membrane (includes obtaining graft) 1 , 4 6 6 .1 0 68340 Repair of symblepharon; division of symblepharon, with or without insertion of conformer or contact lens 1 , 1 2 3 . 2 0 68360 Conjunctival flap; bridge or partial (separate procedure) 9 7 8 . 3 0 68362 Conjunctival flap; total (such as Gunderson thin flap or purse string flap) 1 , 5 4 4 . 4 0 68371 Hrvg cjncl algrft liv don 8 17.41 68400 Incision, drainage of lacrimal gland 3 0 1 . 5 0 68420 Incision, drainage of lacrimal sac (dacryocystotomy or dacryocystostomy) 3 6 2 . 7 0 77 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 68440 Snip incision of lacrimal punctum 2 7 6 . 3 0 68500 Excision of lacrimal gland (dacryoadenectomy), except for tumor; total 1 , 8 5 9 . 4 0 68505 Excision of lacrimal gland (dacryoadenectomy), except for tumor; partial 1 , 5 7 4 . 1 0 68510 Biopsy of lacrimal gland 6 7 4 . 1 0 68520 Excision of lacrimal sac (dacryocystectomy) 1 , 6 3 2 . 6 0 68525 Biopsy of lacrimal sac 5 1 8 . 4 0 68530 Removal of foreign body or dacryolith, lacrimal passages 9 4 7 . 7 0 68540 Excision of lacrimal gland tumor; frontal approach 2 , 0 6 2 . 8 0 68550 Excision of lacrimal gland tumor; involving osteotomy 2 , 4 8 2 . 2 0 68700 Plastic repair of canaliculi 1 , 6 9 4 . 7 0 68705 Correction of everted punctum, cautery 2 6 5 . 5 0 68720 Dacryocystorhinostomy (fistulization of lacrimal sac to nasal cavity) 2 , 1 2 3 . 1 0 68745 Conjunctivorhinostomy (fistulization of conjunctiva to nasal cavity); without tube 2 , 0 6 0 . 1 0 68750 Conjunctivorhinostomy (fistulization of conjunctiva to nasal cavity); with insertion of tube or stent 2 , 3 3 2 . 8 0 68760 Closure of the lacrimal punctum; by thermocauterization, ligation, or laser surgery 2 8 3 . 5 0 68761 Closure of the lacrimal punctum; by plug, each 2 5 6 . 5 0 68770 Closure of lacrimal fistula (separate procedure) 9 2 5 . 2 0 68801 Dilation of lacrimal punctum, with or without irrigation 1 3 6 . 8 0 68810 Probing of nasolacrimal duct, with or without irrigation; 1 9 5 . 3 0 68811 Probing of nasolacrimal duct, with or without irrigation; requiring general anesthesia 4 2 2 . 1 0 68815 Probing of nasolacrimal duct, with or without irrigation; with insertion of tube or stent 5 3 2 . 8 0 68816 Probe nl duct w/balloon 1 ,322.33 68840 Probing of lacrimal canaliculi, with or without irrigation 1 7 8 . 2 0 68850 Injection of contrast medium for dacryocystography 1 7 0 . 1 0 69000 Drainage external ear, abscess or hematoma; simple 1 9 0 . 8 0 69005 Drainage external ear, abscess or hematoma; complicated 5 2 6 . 5 0 69020 Drainage external auditory canal, abscess 2 0 0 . 7 0 69090 Ear piercing 1 0 5 . 3 0 69100 Biopsy external ear 1 6 4 . 7 0 69105 Biopsy external auditory canal 2 3 4 . 9 0 69110 Excision external ear; partial, simple repair 8 4 8 . 7 0 69120 Excision external ear; complete amputation 1 , 7 2 9 . 8 0 69140 Excision exostosis(es), external auditory canal 1 , 9 9 6 . 2 0 69145 Excision soft tissue lesion, external auditory canal 6 4 3 . 5 0 69150 Radical excision external auditory canal lesion; without neck dissection 2 , 6 1 1 . 8 0 69155 Radical excision external auditory canal lesion; with neck dissection 4 , 4 9 2 . 8 0 69200 Removal foreign body from external auditory canal; without general anesthesia 1 2 8 . 7 0 69205 Removal foreign body from external auditory canal; with general anesthesia 5 2 5 . 8 9 69210 Removal impacted cerumen (separate procedure), one or both ears 6 4 . 3 4 69220 Debridement, mastoidectomy cavity, simple (eg, routine cleaning) 1 0 4 . 7 3 69222 Debridement, mastoidectomy cavity, complex (eg, with anesthesia or more than routine cleaning) 3 1 5 . 9 0 69300 Otoplasty, protruding ear, with or without size reduction 2 , 1 2 6 . 7 0 69310 Reconstruction of external auditory canal (meatoplasty) (eg, for stenosis due to trauma, infection) (separate 3 ,252.60 69320 Reconstruction external auditory canal for congenital atresia, single stage 3 , 4 7 3 . 1 0 69400 Eustachian tube inflation, transnasal; with catheterization 1 4 4 . 9 0 69401 Eustachian tube inflation, transnasal; without catheterization 1 0 8 . 9 0 69405 Eustachian tube catheterization, transtympanic 1 5 4 . 8 0 69420 Myringotomy including aspiration and/or eustachian tube inflation 2 6 8 . 2 0 69421 Myringotomy including aspiration and/or eustachian tube inflation requiring general anesthesia 3 8 0 . 7 0 69424 Ventilating tube removal when originally inserted by another physician 2 2 6 . 8 0 69433 Tympanostomy (requiring insertion of ventilating tube), local or topical anesthesia 4 2 6 . 4 2 69436 Tympanostomy (requiring insertion of ventilating tube), general anesthesia 6 2 1 . 9 0 69440 Middle ear exploration through postauricular or ear canal incision 2 , 0 2 8 . 6 0 69450 Tympanolysis, transcanal 2 , 0 8 3 . 5 0 69501 Transmastoid antrotomy (simple mastoidectomy) 2 , 4 4 2 . 6 0 69502 Mastoidectomy; complete 3 , 3 2 3 . 7 0 69505 Mastoidectomy; modified radical 3 , 4 6 2 . 3 0 69511 Mastoidectomy; radical 3 , 4 2 9 . 0 0 69530 Petrous apicectomy including radical mastoidectomy 4 , 1 3 9 . 1 0 69535 Resection temporal bone, external approach 6 , 3 4 1 . 4 0 69540 Excision aural polyp 3 2 2 . 2 0 69550 Excision aural glomus tumor; transcanal 3 , 6 3 6 . 9 0 69552 Excision aural glomus tumor; transmastoid 4 , 1 9 5 . 8 0 69554 Excision aural glomus tumor; extended (extratemporal) 5 , 8 4 2 . 8 0 69601 Revision mastoidectomy; resulting in complete mastoidectomy 3 , 0 7 3 . 5 0 69602 Revision mastoidectomy; resulting in modified radical mastoidectomy 3 , 6 0 7 . 2 0 69603 Revision mastoidectomy; resulting in radical mastoidectomy 3 , 4 8 1 . 2 0 69604 Revision mastoidectomy; resulting in tympanoplasty 3 , 8 7 6 . 3 0 69605 Revision mastoidectomy; with apicectomy 3 , 7 4 6 . 7 0 69610 Tympanic membrane repair, with or without site preparation or perforation for closure, with or without patch 4 3 2 . 9 0 78 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 69620 Myringoplasty (surgery confined to drumhead and donor area) 2 , 4 6 1 . 5 0 69631 Tympanoplasty without mastoidectomy (including canalplasty, atticotomy and/or middle ear surgery), initial 3 ,134.70 69632 Tympanoplasty without mastoidectomy (including canalplasty, atticotomy and/or middle ear surgery), initial 3 ,681.00 69633 Tympanoplasty without mastoidectomy (including canalplasty, atticotomy and/or middle ear surgery), initial 3 ,594.60 69635 Tympanoplasty with antrotomy or mastoidotomy (including canalplasty, atticotomy, middle ear surgery, 3 ,904.20 69636 Tympanoplasty with antrotomy or mastoidotomy (including canalplasty, atticotomy, middle ear surgery, 4 ,133.70 69637 Tympanoplasty with antrotomy or mastoidotomy (including canalplasty, atticotomy, middle ear surgery, 4 ,131.90 69641 Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repair); 3 ,818.70 69642 Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repair); 4 ,161.60 69643 Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repair); 4 ,333.50 69644 Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repair); 4 ,814.10 69645 Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repair); 4 ,619.70 69646 Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repair); 5 ,045.40 69650 Stapes mobilization 2 , 4 2 9 . 1 0 69660 Stapedectomy or stapedotomy with reestablishment of ossicular continuity, with or without use of foreign 3 ,344.40 69661 Stapedectomy or stapedotomy with reestablishment of ossicular continuity, with or without use of foreign 3 ,737.70 69662 Revision of stapedectomy or stapedotomy 4 , 2 3 9 . 9 0 69666 Repair oval window fistula 3 , 2 1 7 . 5 0 69667 Repair round window fistula 3 , 1 5 6 . 3 0 69670 Mastoid obliteration (separate procedure) 3 , 2 9 5 . 8 0 69676 Tympanic neurectomy 2 , 2 6 8 . 9 0 69700 Closure postauricular fistula, mastoid (separate procedure) 1 , 6 2 5 . 4 0 69711 Removal or repair of electromagnetic bone conduction hearing device in temporal bone 1 , 2 8 7 . 9 0 69714 Impltj oi implt b1 w/o mstdc 2 ,985.05 69715 Impltj oi implt b1 mstdc 3 ,580.56 69717 Rplcmt oi implt b1 w/o mstdc 3 ,079.84 69718 Rplcmt oi implt b1 mstdc 3 ,691.07 69720 Decompression facial nerve, intratemporal; lateral to geniculate ganglion 3 , 8 8 3 . 5 0 69725 Decompression facial nerve, intratemporal; including medial to geniculate ganglion 5 , 6 2 4 . 1 0 69740 Suture facial nerve, intratemporal, with or without graft or decompression; lateral to geniculate ganglion 4 , 4 4 9 . 6 0 69745 Suture facial nerve, intratemporal, with or without graft or decompression; including medial to geniculate 5 ,244.30 69801 Labyrinthotomy, with or without cryosurgery including other nonexcisional destructive procedures or 3 ,175.20 69805 Endolymphatic sac operation; without shunt 3 , 8 6 2 . 8 0 69806 Endolymphatic sac operation; with shunt 4 , 3 7 7 . 6 0 69820 Fenestration semicircular canal 3 , 4 3 8 . 0 0 69840 Revision fenestration operation 2 , 3 5 3 . 5 0 69905 Labyrinthectomy; transcanal 3 , 8 5 7 . 4 0 69910 Labyrinthectomy; with mastoidectomy 4 , 4 3 9 . 7 0 69915 Vestibular nerve section, translabyrinthine approach 5 , 0 5 2 . 6 0 69930 Cochlear device implantation, with or without mastoidectomy 5 , 3 1 8 . 1 0 69950 Vestibular nerve section, transcranial approach 5 , 4 4 8 . 6 0 69955 Total facial nerve decompression and/or repair (may include graft) 5 , 8 4 6 . 4 0 69960 Decompression internal auditory canal 5 , 5 2 9 . 6 0 69970 Removal of tumor, temporal bone 6 , 3 0 9 . 0 0 69990 Use of operating microscope (List separately in addition to code for primary procedure) 8 3 4 . 3 0 70010 Myelography, posterior fossa, radiological supervision and interpretation 4 3 2 . 9 0 70015 26 Cisternography, positive contrast, radiological supervision and interpretation 2 0 4 . 3 0 70015 Cisternography, positive contrast, radiological supervision and interpretation 3 4 0 . 2 0 70015 TC Contrast x-ray of brain 2 20.54 70030 26 Radiologic examination, eye, for detection of foreign body 3 7 . 8 0 70030 Radiologic examination, eye, for detection of foreign body 9 4 . 5 0 70030 TC X-ray eye for foreign body 7 0.25 70100 26 Radiologic examination, mandible; partial, less than four views 3 4 . 2 0 70100 Radiologic examination, mandible; partial, less than four views 8 5 . 5 0 70100 TC X-ray exam of jaw <4views 6 5.59 70110 26 Radiologic examination, mandible; complete, minimum of four views 4 8 . 6 0 70110 Radiologic examination, mandible; complete, minimum of four views 1 2 1 . 5 0 70110 TC X-ray exam of jaw 4/> views 8 7.20 70120 26 Radiologic examination, mastoids; less than three views per side 3 0 . 6 0 70120 Radiologic examination, mastoids; less than three views per side 7 7 . 4 0 70120 TC X-ray exam of mastoids 6 0.05 70130 26 Radiologic examination, mastoids; complete, minimum of three views per side 5 4 . 0 0 70130 Radiologic examination, mastoids; complete, minimum of three views per side 1 3 4 . 1 0 70130 TC X-ray exam of mastoids 9 9.47 70134 26 Radiologic examination, internal auditory meati, complete 5 4 . 0 0 70134 Radiologic examination, internal auditory meati, complete 1 3 3 . 2 0 70134 TC X-ray exam of middle ear 9 0.87 70140 26 X-ray exam of facial bones 3 3.04 70140 Radiologic examination, facial bones; less than three views 1 0 9 . 4 9 70140 TC X-ray exam of facial bones 7 6.44 79 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 70150 26 Radiologic examination, facial bones; complete, minimum of three views 1 3 6 . 3 1 70150 Radiologic examination, facial bones; complete, minimum of three views 1 1 6 . 1 0 70150 TC X-ray exam of facial bones 8 4.82 70160 26 X-ray exam of nasal bones 2 0.43 70160 Radiologic examination, nasal bones, complete, minimum of three views 8 8 . 5 1 70160 TC X-ray exam of nasal bones 6 8.08 70170 26 Dacryocystography, nasolacrimal duct, radiological supervision and interpretation 4 5 . 0 0 70170 Dacryocystography, nasolacrimal duct, radiological supervision and interpretation 1 2 8 . 7 0 70190 26 Radiologic examination; optic foramina 4 0 . 5 0 70190 Radiologic examination; optic foramina 1 1 2 . 5 5 70190 TC X-ray exam of eye sockets 8 2.66 70200 26 Radiologic examination; orbits, complete, minimum of four views 5 1 . 3 0 70200 Radiologic examination; orbits, complete, minimum of four views 1 4 4 . 0 4 70200 TC X-ray exam of eye sockets 1 03.00 70210 26 Radiologic examination, sinuses, paranasal, less than three views 3 5 . 1 0 70210 Radiologic examination, sinuses, paranasal, less than three views 9 7 . 9 0 70210 TC X-ray exam of sinuses 7 3.35 70220 26 Radiologic examination, sinuses, paranasal, complete, minimum of three views 4 9 . 5 0 70220 Radiologic examination, sinuses, paranasal, complete, minimum of three views 1 4 9 . 6 9 70220 TC X-ray exam of sinuses 1 06.70 70240 26 Radiologic examination, sella turcica 3 4 . 2 0 70240 Radiologic examination, sella turcica 8 5 . 5 0 70240 TC X-ray exam pituitary saddle 6 0.65 70250 26 Radiologic examination, skull; less than four views, with or without stereo 3 8 . 7 0 70250 Radiologic examination, skull; less than four views, with or without stereo 1 1 2 . 1 9 70250 TC X-ray exam of skull 7 8.42 70260 26 Radiologic examination, skull; complete, minimum of four views, with or without stereo 5 5 . 8 0 70260 Radiologic examination, skull; complete, minimum of four views, with or without stereo 1 5 6 . 8 9 70260 TC X-ray exam of skull 1 05.84 70300 26 Radiologic examination, teeth; single view 1 2 . 6 0 70300 Radiologic examination, teeth; single view 3 0 . 6 0 70300 TC X-ray exam of teeth 1 9.52 70310 26 Radiologic examination, teeth; partial examination, less than full mouth 1 9 . 8 0 70310 Radiologic examination, teeth; partial examination, less than full mouth 4 8 . 6 0 70310 TC X-ray exam of teeth 3 9.63 70320 26 Radiologic examination, teeth; complete, full mouth 3 6 . 9 0 70320 Radiologic examination, teeth; complete, full mouth 9 2 . 7 0 70320 TC Full mouth x-ray of teeth 7 4.62 70328 26 Radiologic examination, temporomandibular joint, open and closed mouth; unilateral 4 7 . 7 0 70328 Radiologic examination, temporomandibular joint, open and closed mouth; unilateral 1 1 8 . 8 0 70328 TC X-ray exam of jaw joint 8 7.57 70330 26 Radiologic examination, temporomandibular joint, open and closed mouth; bilateral 5 5 . 8 0 70330 Radiologic examination, temporomandibular joint, open and closed mouth; bilateral 1 3 9 . 5 0 70330 TC X-ray exam of jaw joints 1 07.37 70332 26 Temporomandibular joint arthrography, radiological supervision and interpretation 7 9 . 2 0 70332 Temporomandibular joint arthrography, radiological supervision and interpretation 2 2 6 . 8 0 70332 TC X-ray exam of jaw joint 1 49.30 70336 26 Magnetic resonance (eg, proton) imaging, temporomandibular joint(s) 2 4 4 . 8 0 70336 Magnetic resonance (eg, proton) imaging, temporomandibular joint(s) 1 , 2 2 7 . 6 0 70336 TC Magnetic image jaw joint 1 ,005.20 70350 26 Cephalogram, orthodontic 3 0 . 6 0 70350 Cephalogram, orthodontic 7 7 . 4 0 70350 TC X-ray head for orthodontia 4 4.28 70355 26 Orthopantogram 3 6 . 9 0 70355 Orthopantogram 9 2 . 7 0 70355 TC Panoramic x-ray of jaws 4 7.54 70360 26 Radiologic examination; neck, soft tissue 3 0 . 6 0 70360 Radiologic examination; neck, soft tissue 9 9 . 3 5 70360 TC X-ray exam of neck 7 2.62 70370 26 Radiologic examination; pharynx or larynx, including fluoroscopy and/or magnification technique 6 2 . 1 0 70370 Radiologic examination; pharynx or larynx, including fluoroscopy and/or magnification technique 2 0 6 . 1 0 70370 TC Throat x-ray & fluoroscopy 1 71.02 70371 26 Cplx dynamic pharyngeal&sp eval c/v rec 1 16.96 70371 Cplx dynamic pharyngeal&sp eval c/v rec 3 39.02 70371 TC Cplx dynamic pharyngeal&sp eval c/v rec 2 22.06 70373 26 Laryngography, contrast, radiological supervision and interpretation 7 2 . 0 0 70373 Laryngography, contrast, radiological supervision and interpretation 2 4 2 . 1 0 70373 TC Contrast x-ray of larynx 1 83.66 70380 26 Radiologic examination, salivary gland for calculus 2 8 . 8 0 70380 Radiologic examination, salivary gland for calculus 9 8 . 1 0 80 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 70380 TC X-ray exam of salivary gland 7 7.06 70390 26 Sialography, radiological supervision and interpretation 8 3 . 7 0 70390 Sialography, radiological supervision and interpretation 2 3 7 . 6 0 70390 TC X-ray exam of salivary duct 1 97.41 70450 26 Computerized axial tomography, head or brain; without contrast material 2 1 2 . 4 0 70450 Computerized axial tomography, head or brain; without contrast material 7 5 8 . 1 6 70450 TC Ct head/brain w/o dye 5 84.36 70460 26 Computerized axial tomography, head or brain; with contrast material(s) 2 2 8 . 6 0 70460 Computerized axial tomography, head or brain; with contrast material(s) 8 4 8 . 8 6 70460 TC Ct head/brain w/dye 6 52.28 70470 26 Computerized axial tomography, head or brain; without contrast material, followed by contrast material(s) 2 84.40 70470 Computerized axial tomography, head or brain; without contrast material, followed by contrast material(s) 1 ,034.56 70470 TC Ct head/brain w/o & w/dye 7 64.80 70480 26 Computerized axial tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without 2 00.70 70480 Computerized axial tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without 7 73.58 70480 TC Ct orbit/ear/fossa w/o dye 6 13.43 70481 26 Computerized axial tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; with contrast 2 54.70 70481 Computerized axial tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; with contrast 8 44.20 70481 TC Ct orbit/ear/fossa w/dye 6 81.77 70482 26 Computerized axial tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without 2 78.10 70482 Computerized axial tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without 1 ,072.55 70482 TC Ct orbit/ear/fossa w/o&w/dye 8 78.02 70486 26 Computerized axial tomography, maxillofacial area; without contrast material 2 2 0 . 5 0 70486 Computerized axial tomography, maxillofacial area; without contrast material 7 3 1 . 7 0 70486 TC Ct maxillofacial w/o dye 5 67.96 70487 26 Computerized axial tomography, maxillofacial area; with contrast material(s) 2 3 2 . 2 0 70487 Computerized axial tomography, maxillofacial area; with contrast material(s) 7 7 2 . 2 0 70487 TC Ct maxillofacial w/dye 6 09.02 70488 26 Computerized axial tomography, maxillofacial area; without contrast material, followed by contrast 2 93.40 70488 Computerized axial tomography, maxillofacial area; without contrast material, followed by contrast 9 78.30 70488 TC Ct maxillofacial w/o & w/dye 7 90.88 70490 26 Computerized axial tomography, soft tissue neck; without contrast material 2 3 2 . 2 0 70490 Computerized axial tomography, soft tissue neck; without contrast material 7 7 2 . 2 0 70490 TC Ct soft tissue neck w/o dye 5 71.99 70491 26 Computerized axial tomography, soft tissue neck; with contrast material(s) 2 2 8 . 6 0 70491 Computerized axial tomography, soft tissue neck; with contrast material(s) 7 6 2 . 3 0 70491 TC Ct soft tissue neck w/dye 5 86.24 70492 26 Computerized axial tomography, soft tissue neck; without contrast material followed by contrast material(s) 3 15.90 70492 Computerized axial tomography, soft tissue neck; without contrast material followed by contrast material(s) 1 ,050.30 70492 TC Ct sft tsue nck w/o & w/dye 8 38.10 70496 26 Ct angiography head 1 76.34 70496 Computed tomographic angiography, head, without contrast material(s), followed by contrast material(s) and 1 ,133.10 70496 TC Ct angiography head 9 56.76 70498 26 Ct angiography neck 1 70.45 70498 Computed tomographic angiography, neck, without contrast material(s), followed by contrast material(s) and 1 ,133.10 70498 TC Ct angiography neck 9 62.65 70540 26 Magnetic resonance (eg, proton) imaging, orbit, face, and neck; without contrast material(s) 2 7 5 . 4 0 70540 Magnetic resonance (eg, proton) imaging, orbit, face, and neck; without contrast material(s) 1 , 3 7 7 . 9 0 70540 TC Mri orbit/face/neck w/o dye 1 ,175.21 70542 26 Mri orbit face&nck c+ matrl 3 08.94 70542 Mri orbit face&nck c+ matrl 2 ,211.94 70542 TC Mri orbit face&nck c+ matrl 1 ,903.00 70543 26 Mri orbit face&nck c-/c+ 2 73.12 70543 Mri orbit face&nck c-/c+ 2 ,662.89 70543 TC Mri orbit face&nck c-/c+ 2 ,389.78 70544 26 Mra head c-matrl 2 02.12 70544 Mra head c-matrl 1 ,705.17 70544 TC Mra head c-matrl 1 ,503.06 70545 26 Mra head c+ matrl 2 22.98 70545 Mra head c+ matrl 1 ,878.16 70545 TC Mra head c+ matrl 1 ,655.18 70546 26 Mra head c-/c+ 2 42.33 70546 Mra head c-/c+ 2 ,427.25 70546 TC Mra head c-/c+ 2 ,184.92 70547 26 Mra nck c-matrl 1 99.21 70547 Mra nck c-matrl 1 ,680.70 70547 TC Mra nck c-matrl 1 ,481.49 70548 26 Mra nck c+ matrl 2 25.62 70548 Mra nck c+ matrl 1 ,907.79 70548 TC Mra nck c+ matrl 1 ,682.17 81 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 70549 26 Mra nck c-/c+ 2 42.21 70549 Mra nck c-/c+ 2 ,427.31 70549 TC Mra nck c-/c+ 2 ,185.10 70551 26 Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material 2 7 6 . 3 0 70551 Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material 1 , 3 8 0 . 6 0 70551 TC Mri brain stem w/o dye 1 ,169.28 70552 26 Magnetic resonance (eg, proton) imaging, brain (including brain stem); with contrast material(s) 3 1 5 . 0 0 70552 Magnetic resonance (eg, proton) imaging, brain (including brain stem); with contrast material(s) 1 , 5 7 5 . 9 0 70552 TC Mri brain stem w/dye 1 ,313.73 70553 26 Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material, followed by 3 79.80 70553 Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material, followed by 1 ,899.00 70553 TC Mri brain stem w/o & w/dye 1 ,543.06 70554 26 Mri brain functional w/o physician admnistration 3 53.42 70554 Mri brain functional w/o physician admnistration 2 ,075.79 70554 TC Mri brain functional w/o physician admnistration 1 ,722.37 71010 26 Radiologic examination, chest; single view, frontal 2 8 . 8 0 71010 Radiologic examination, chest; single view, frontal 7 7 . 8 4 71010 TC Chest x-ray 1 view frontal 5 0.46 71015 26 Radiologic examination, chest; stereo, frontal 3 4 . 2 0 71015 Radiologic examination, chest; stereo, frontal 8 5 . 5 0 71015 TC Chest x-ray stereo frontal 5 9.20 71020 26 Radiologic examination, chest, two views, frontal and lateral; 3 6 . 9 0 71020 Radiologic examination, chest, two views, frontal and lateral; 9 7 . 8 7 71020 TC Chest x-ray 2vw frontal&latl 6 6.43 71021 26 Radiologic examination, chest, two views, frontal and lateral; with apical lordotic procedure 4 7 . 7 0 71021 Radiologic examination, chest, two views, frontal and lateral; with apical lordotic procedure 1 1 8 . 8 0 71021 TC Chest x-ray frnt lat lordotc 8 0.10 71022 26 Radiologic examination, chest, two views, frontal and lateral; with oblique projections 5 0 . 4 0 71022 Radiologic examination, chest, two views, frontal and lateral; with oblique projections 1 2 6 . 0 0 71022 TC Chest x-ray frnt lat oblique 8 8.93 71023 26 Radiologic examination, chest, two views, frontal and lateral; with fluoroscopy 5 7 . 6 0 71023 Radiologic examination, chest, two views, frontal and lateral; with fluoroscopy 1 4 4 . 9 0 71023 TC Chest x-ray and fluoroscopy 1 08.64 71030 26 Radiologic examination, chest, complete, minimum of four views; 5 0 . 4 0 71030 Radiologic examination, chest, complete, minimum of four views; 1 4 3 . 5 2 71030 TC Chest x-ray 4/> views 1 01.54 71034 26 Radiologic examination, chest, complete, minimum of four views; with fluoroscopy 8 0 . 1 0 71034 Radiologic examination, chest, complete, minimum of four views; with fluoroscopy 1 9 9 . 8 0 71034 TC Chest x-ray&fluoro 4/> views 1 53.58 71035 26 Radiologic examination, chest, special views (eg, lateral decubitus, Bucky studies) 3 5 . 1 0 71035 Radiologic examination, chest, special views (eg, lateral decubitus, Bucky studies) 8 7 . 3 0 71035 TC Chest x-ray special views 6 8.36 71100 26 Radiologic examination, ribs, unilateral; two views 4 1 . 4 0 71100 Radiologic examination, ribs, unilateral; two views 1 0 6 . 9 2 71100 TC X-ray exam ribs uni 2 views 7 3.97 71101 26 Radiologic examination, ribs, unilateral; including posteroanterior chest, minimum of three views 4 7 . 7 0 71101 Radiologic examination, ribs, unilateral; including posteroanterior chest, minimum of three views 1 1 9 . 7 0 71101 TC X-ray exam unilat ribs/chest 8 3.75 71110 26 Radiologic examination, ribs, bilateral; three views 5 2 . 2 0 71110 Radiologic examination, ribs, bilateral; three views 1 3 2 . 6 7 71110 TC X-ray exam ribs bil 3 views 9 3.05 71111 26 Radiologic examination, ribs, bilateral; including posteroanterior chest, minimum of four views 6 4 . 8 0 71111 Radiologic examination, ribs, bilateral; including posteroanterior chest, minimum of four views 1 6 2 . 9 0 71111 TC X-ray exam ribs/chest4/> vws 1 19.20 71120 26 Radiologic examination; sternum, minimum of two views 3 8 . 7 0 71120 Radiologic examination; sternum, minimum of two views 9 8 . 1 0 71120 TC X-ray exam breastbone 2/>vws 7 0.91 71130 26 Radiologic examination; sternoclavicular joint or joints, minimum of three views 4 4 . 1 0 71130 Radiologic examination; sternoclavicular joint or joints, minimum of three views 1 0 9 . 8 0 71130 TC X-ray strenoclavic jt 3/>vws 8 0.53 71250 26 Computerized axial tomography, thorax; without contrast material 1 9 0 . 8 0 71250 Computerized axial tomography, thorax; without contrast material 7 6 2 . 3 0 71250 TC Ct thorax w/o dye 5 97.55 71260 26 Computerized axial tomography, thorax; with contrast material(s) 1 7 5 . 5 0 71260 Computerized axial tomography, thorax; with contrast material(s) 8 7 9 . 3 0 71260 TC Ct thorax w/dye 6 92.10 71270 26 Computerized axial tomography, thorax; without contrast material, followed by contrast material(s) and 2 15.10 71270 Computerized axial tomography, thorax; without contrast material, followed by contrast material(s) and 1 ,165.08 71270 TC Ct thorax w/o & w/dye 9 40.42 71275 26 Ct angiography chest w/contrast/noncontrast 2 62.35 82 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 71275 Ct angiography chest w/contrast/noncontrast 1 ,529.25 71275 TC Ct angiography chest w/contrast/noncontrast 1 ,266.90 71550 26 Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal 3 28.50 71550 Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal 1 ,642.50 71550 TC Mri chest w/o dye 1 ,417.10 71551 26 Mri ch c+ matrl 2 97.91 71551 Mri ch c+ matrl 2 ,011.20 71551 TC Mri ch c+ matrl 1 ,713.29 71552 26 Mri ch c-/c+ 2 97.95 71552 Mri ch c-/c+ 2 ,678.97 71552 TC Mri ch c-/c+ 2 ,381.02 71555 26 Magnetic resonance angiography, chest (excluding myocardium), with or without contrast material(s) 2 7 3 . 6 0 71555 Magnetic resonance angiography, chest (excluding myocardium), with or without contrast material(s) 1 , 3 6 9 . 8 0 71555 TC Mri angio chest w or w/o dye 1 ,132.07 72010 26 Radiologic examination, spine, entire, survey study, anteroposterior and lateral 9 4 . 5 0 72010 Radiologic examination, spine, entire, survey study, anteroposterior and lateral 2 3 4 . 1 5 72010 TC X-ray exam spine ap&lat 1 72.13 72020 26 Radiologic examination, spine, single view, specify level 3 0 . 6 0 72020 Radiologic examination, spine, single view, specify level 8 1 . 1 2 72020 TC X-ray exam of spine 1 view 5 7.34 72040 26 Radiologic examination, spine, cervical; two or three views 4 0 . 5 0 72040 Radiologic examination, spine, cervical; two or three views 1 1 1 . 0 6 72040 TC X-ray exam neck spine 3/<vws 7 7.35 72050 26 Radiologic examination, spine, cervical; minimum of four views 5 9 . 4 0 72050 Radiologic examination, spine, cervical; minimum of four views 1 5 1 . 9 0 72050 TC X-ray exam neck spine 4/5vws 1 06.15 72052 26 Radiologic examination, spine, cervical; complete, including oblique and flexion and/or extension studies 8 0 . 1 0 72052 Radiologic examination, spine, cervical; complete, including oblique and flexion and/or extension studies 1 9 2 . 8 7 72052 TC X-ray exam neck spine 6/>vws 1 41.14 72069 26 Radiologic examination, spine, thoracolumbar, standing (scoliosis) 4 2 . 3 0 72069 Radiologic examination, spine, thoracolumbar, standing (scoliosis) 1 0 5 . 3 0 72069 TC X-ray exam trunk spine stand 7 5.82 72070 26 Radiologic examination, spine; thoracic, two views 4 3 . 2 0 72070 Radiologic examination, spine; thoracic, two views 1 1 2 . 5 3 72070 TC X-ray exam thorac spine 2vws 7 9.23 72072 26 Radiologic examination, spine; thoracic, three views 4 6 . 8 0 72072 Radiologic examination, spine; thoracic, three views 1 2 9 . 3 8 72072 TC X-ray exam thorac spine 3vws 9 5.75 72074 26 Radiologic examination, spine; thoracic, minimum of four views 5 8 . 5 0 72074 Radiologic examination, spine; thoracic, minimum of four views 1 6 8 . 3 0 72074 TC X-ray exam thorac spine4/>vw 1 31.85 72080 26 Radiologic examination, spine; thoracolumbar, two views 4 5 . 0 0 72080 Radiologic examination, spine; thoracolumbar, two views 1 1 2 . 5 0 72080 TC X-ray exam trunk spine 2 vws 7 9.28 72090 26 Radiologic examination, spine; scoliosis study, including supine and erect studies 5 2 . 2 0 72090 Radiologic examination, spine; scoliosis study, including supine and erect studies 1 3 0 . 5 0 72090 TC X-ray exam scloiosis erect 9 5.41 72100 26 Radiologic examination, spine, lumbosacral; two or three views 4 2 . 3 0 72100 Radiologic examination, spine, lumbosacral; two or three views 1 1 0 . 0 2 72100 TC X-ray exam l-s spine 2/3 vws 7 6.93 72110 26 Radiologic examination, spine, lumbosacral; minimum of four views 6 3 . 0 0 72110 Radiologic examination, spine, lumbosacral; minimum of four views 1 5 9 . 3 4 72110 TC X-ray exam l-2 spine 4/>vws 1 12.01 72114 26 Radiologic examination, spine, lumbosacral; complete, including bending views 9 0 . 9 0 72114 Radiologic examination, spine, lumbosacral; complete, including bending views 2 1 4 . 7 5 72114 TC X-ray exam l-s spine bending 1 62.66 72120 26 Radiologic examination, spine, lumbosacral, bending views only, minimum of four views 5 0 . 4 0 72120 Radiologic examination, spine, lumbosacral, bending views only, minimum of four views 1 6 8 . 3 0 72120 TC X-ray bend only l-s spine 1 24.29 72125 26 Computerized axial tomography, cervical spine; without contrast material 1 9 2 . 6 0 72125 Computerized axial tomography, cervical spine; without contrast material 7 6 9 . 5 0 72125 TC Ct neck spine w/o dye 5 98.95 72126 26 Computerized axial tomography, cervical spine; with contrast material 1 7 5 . 5 0 72126 Computerized axial tomography, cervical spine; with contrast material 8 7 6 . 6 0 72126 TC Ct neck spine w/dye 6 94.06 72127 26 Computerized axial tomography, cervical spine; without contrast material, followed by contrast material(s) 2 12.40 72127 Computerized axial tomography, cervical spine; without contrast material, followed by contrast material(s) 1 ,062.00 72127 TC Ct neck spine w/o & w/dye 8 70.28 72128 26 Computerized axial tomography, thoracic spine; without contrast material 1 8 7 . 2 0 72128 Computerized axial tomography, thoracic spine; without contrast material 7 5 1 . 5 0 83 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 72128 TC Ct chest spine w/o dye 5 92.76 72129 26 Computerized axial tomography, thoracic spine; with contrast material 1 7 5 . 5 0 72129 Computerized axial tomography, thoracic spine; with contrast material 8 7 6 . 6 0 72129 TC Ct chest spine w/dye 6 94.77 72130 26 Computerized axial tomography, thoracic spine; without contrast material, followed by contrast material(s) 2 12.40 72130 Computerized axial tomography, thoracic spine; without contrast material, followed by contrast material(s) 1 ,062.00 72130 TC Ct chest spine w/o & w/dye 8 71.32 72131 26 Computerized axial tomography, lumbar spine; without contrast material 1 9 1 . 7 0 72131 Computerized axial tomography, lumbar spine; without contrast material 8 6 5 . 7 8 72131 TC Ct lumbar spine w/o dye 6 82.30 72132 26 Computerized axial tomography, lumbar spine; with contrast material 1 7 5 . 5 0 72132 Computerized axial tomography, lumbar spine; with contrast material 9 9 2 . 0 7 72132 TC Ct lumbar spine w/dye 7 85.75 72133 26 Computerized axial tomography, lumbar spine; without contrast material, followed by contrast material(s) 2 12.40 72133 Computerized axial tomography, lumbar spine; without contrast material, followed by contrast material(s) 1 ,062.00 72133 TC Ct lumbar spine w/o & w/dye 8 71.43 72141 26 Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; without contrast material 2 6 9 . 1 0 72141 Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; without contrast material 1 , 3 4 4 . 6 0 72141 TC Mri neck spine w/o dye 1 ,090.97 72142 26 Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; with contrast material(s) 3 2 2 . 2 0 72142 Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; with contrast material(s) 1 , 6 1 1 . 9 0 72142 TC Mri neck spine w/dye 1 ,328.48 72146 26 Magnetic resonance (eg, proton) imaging, spinal canal and contents, thoracic; without contrast material 2 9 3 . 4 0 72146 Magnetic resonance (eg, proton) imaging, spinal canal and contents, thoracic; without contrast material 1 , 4 6 8 . 8 0 72146 TC Mri chest spine w/o dye 1 ,192.23 72147 26 Magnetic resonance (eg, proton) imaging, spinal canal and contents, thoracic; with contrast material(s) 3 2 2 . 2 0 72147 Magnetic resonance (eg, proton) imaging, spinal canal and contents, thoracic; with contrast material(s) 1 , 6 1 1 . 9 0 72147 TC Mri chest spine w/dye 1 ,291.68 72148 26 Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; without contrast material 2 9 0 . 7 0 72148 Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; without contrast material 1 , 4 5 1 . 7 0 72148 TC Mri lumbar spine w/o dye 1 ,193.47 72149 26 Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; with contrast material(s) 3 1 8 . 6 0 72149 Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; with contrast material(s) 1 , 5 9 3 . 9 0 72149 TC Mri lumbar spine w/dye 1 ,324.94 72156 26 Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by 4 49.10 72156 Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by 2 ,248.20 72156 TC Mri neck spine w/o & w/dye 1 ,787.03 72157 26 Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by 4 50.90 72157 Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by 2 ,253.60 72157 TC Mri chest spine w/o & w/dye 1 ,755.53 72158 26 Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by 4 39.20 72158 Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by 2 ,196.00 72158 TC Mri lumbar spine w/o & w/dye 1 ,770.53 72159 26 Magnetic resonance angiography, spinal canal and contents, with or without contrast material(s) 2 9 7 . 9 0 72159 Magnetic resonance angiography, spinal canal and contents, with or without contrast material(s) 1 , 4 8 8 . 6 0 72159 TC Mr angio spine w/o&w/dye 1 ,241.44 72170 26 Radiologic examination, pelvis; one or two views 3 5 . 1 0 72170 Radiologic examination, pelvis; one or two views 1 0 0 . 0 7 72170 TC X-ray exam of pelvis 7 0.25 72190 26 Radiologic examination, pelvis; complete, minimum of three views 5 4 . 0 0 72190 Radiologic examination, pelvis; complete, minimum of three views 1 3 8 . 8 9 72190 TC X-ray exam of pelvis 1 05.42 72191 26 Ct angiography pelvis w/contrast/noncontrast 2 43.76 72191 Ct angiography pelvis w/contrast/noncontrast 1 ,421.72 72191 TC Ct angiography pelvis w/contrast/noncontrast 1 ,177.96 72192 26 Computerized axial tomography, pelvis; without contrast material 1 6 4 . 7 0 72192 Computerized axial tomography, pelvis; without contrast material 6 5 8 . 8 0 72192 TC Ct pelvis w/o dye 4 75.28 72193 26 Computerized axial tomography, pelvis; with contrast material(s) 1 5 3 . 9 0 72193 Computerized axial tomography, pelvis; with contrast material(s) 7 6 7 . 7 0 72193 TC Ct pelvis w/dye 6 21.83 72194 26 Computerized axial tomography, pelvis; without contrast material, followed by contrast material(s) and 1 80.90 72194 Computerized axial tomography, pelvis; without contrast material, followed by contrast material(s) and 1 ,009.01 72194 TC Ct pelvis w/o & w/dye 8 30.05 72195 26 Mri pelvis c-matrl 2 43.96 72195 Mri pelvis c-matrl 1 ,640.10 72195 TC Mri pelvis c-matrl 1 ,396.14 72196 26 Magnetic resonance (eg, proton) imaging, pelvis; with contrast material(s) 2 6 9 . 1 0 72196 Magnetic resonance (eg, proton) imaging, pelvis; with contrast material(s) 1 , 3 4 4 . 6 0 72196 TC Mri pelvis w/dye 1 ,124.60 84 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 72197 26 Mri pelvis c-/c+ 2 60.00 72197 Mri pelvis c-/c+ 2 ,310.35 72197 TC Mri pelvis c-/c+ 2 ,050.35 72198 26 Magnetic resonance angiography, pelvis, with or without contrast material(s) 2 7 3 . 6 0 72198 Magnetic resonance angiography, pelvis, with or without contrast material(s) 1 , 3 6 8 . 9 0 72198 TC Mr angio pelvis w/o & w/dye 1 ,135.28 72200 26 Radiologic examination, sacroiliac joints; less than three views 4 1 . 4 0 72200 Radiologic examination, sacroiliac joints; less than three views 1 1 2 . 0 7 72200 TC X-ray exam si joints 8 2.69 72202 26 Radiologic examination, sacroiliac joints; three or more views 4 1 . 4 0 72202 Radiologic examination, sacroiliac joints; three or more views 1 2 3 . 0 4 72202 TC X-ray exam si joints 3/> vws 9 3.32 72220 26 Radiologic examination, sacrum and coccyx, minimum of two views 3 8 . 7 0 72220 Radiologic examination, sacrum and coccyx, minimum of two views 1 0 9 . 9 1 72220 TC X-ray exam sacrum tailbone 8 0.44 72240 26 Myelography, cervical, radiological supervision and interpretation 1 8 7 . 2 0 72240 Myelography, cervical, radiological supervision and interpretation 6 2 7 . 3 0 72240 TC Myelography neck spine 4 28.51 72255 26 Myelography, thoracic, radiological supervision and interpretation 1 5 8 . 4 0 72255 Myelography, thoracic, radiological supervision and interpretation 5 2 8 . 3 0 72255 TC Myelography thoracic spine 3 51.43 72265 26 Myelography, lumbosacral, radiological supervision and interpretation 1 6 2 . 9 0 72265 Myelography, lumbosacral, radiological supervision and interpretation 5 4 0 . 9 0 72265 TC Myelography l-s spine 3 81.71 72270 26 Myelography, entire spinal canal, radiological supervision and interpretation 2 3 9 . 4 0 72270 Myelography, entire spinal canal, radiological supervision and interpretation 7 9 5 . 6 0 72270 TC Myelogphy 2/> spine regions 5 54.19 72275 26 Epidurograpy rs&i 1 98.36 72275 Epidurograpy rs&i 6 59.11 72275 TC Epidurograpy rs&i 4 60.76 72285 26 Diskography, cervical or thoracic, radiological supervision and interpretation 2 2 5 . 9 0 72285 Diskography, cervical or thoracic, radiological supervision and interpretation 9 0 2 . 7 0 72285 TC Discography cerv/thor spine 4 69.02 72295 26 Diskography, lumbar, radiological supervision and interpretation 2 1 4 . 2 0 72295 Diskography, lumbar, radiological supervision and interpretation 8 5 4 . 1 0 72295 TC X-ray of lower spine disk 5 19.20 73000 26 Radiologic examination; clavicle, complete 2 9 . 7 0 73000 Radiologic examination; clavicle, complete 9 1 . 4 6 73000 TC X-ray exam of collar bone 6 7.89 73010 26 Radiologic examination; scapula, complete 3 6 . 9 0 73010 Radiologic examination; scapula, complete 9 8 . 8 3 73010 TC X-ray exam of shoulder blade 7 1.38 73020 26 Radiologic examination, shoulder; one view 2 8 . 8 0 73020 Radiologic examination, shoulder; one view 8 0 . 8 6 73020 TC X-ray exam of shoulder 5 7.49 73030 26 Radiologic examination, shoulder; complete, minimum of two views 3 8 . 7 0 73030 Radiologic examination, shoulder; complete, minimum of two views 9 5 . 6 2 73030 TC X-ray exam of shoulder 6 7.00 73040 26 Radiologic examination, shoulder, arthrography, radiological supervision and interpretation 9 0 . 0 0 73040 Radiologic examination, shoulder, arthrography, radiological supervision and interpretation 2 5 3 . 8 0 73040 TC Contrast x-ray of shoulder 1 94.60 73050 26 Radiologic examination; acromioclavicular joints, bilateral, with or without weighted distraction 3 5 . 1 0 73050 Radiologic examination; acromioclavicular joints, bilateral, with or without weighted distraction 9 9 . 9 0 73050 TC X-ray exam of shoulders 7 4.79 73060 26 Radiologic examination; humerus, minimum of two views 3 3 . 3 0 73060 Radiologic examination; humerus, minimum of two views 9 3 . 1 8 73060 TC X-ray exam of humerus 6 8.19 73070 26 Radiologic examination, elbow; two views 2 7 . 9 0 73070 Radiologic examination, elbow; two views 8 1 . 1 3 73070 TC X-ray exam of elbow 6 0.84 73080 26 Radiologic examination, elbow; complete, minimum of three views 3 5 . 1 0 73080 Radiologic examination, elbow; complete, minimum of three views 9 7 . 2 3 73080 TC X-ray exam of elbow 7 4.78 73085 26 Radiologic examination, elbow, arthrography, radiological supervision and interpretation 9 9 . 9 0 73085 Radiologic examination, elbow, arthrography, radiological supervision and interpretation 2 8 5 . 3 0 73085 TC Contrast x-ray of elbow 2 12.67 73090 26 Radiologic examination; forearm, two views 3 3 . 3 0 73090 Radiologic examination; forearm, two views 8 0 . 8 7 73090 TC X-ray exam of forearm 5 9.28 73092 26 Radiologic examination; upper extremity, infant, minimum of two views 3 6 . 0 0 85 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 73092 Radiologic examination; upper extremity, infant, minimum of two views 9 0 . 9 0 73092 TC X-ray exam of arm infant 7 0.11 73100 26 Radiologic examination, wrist; two views 3 0 . 6 0 73100 Radiologic examination, wrist;

two views 7 6 . 2 9 73100 TC X-ray exam of wrist 5 5.81 73110 26 Radiologic examination, wrist; complete, minimum of three views 3 6 . 9 0 73110 Radiologic examination, wrist; complete, minimum of three views 8 8 . 3 3 73110 TC X-ray exam of wrist 7 0.27 73115 26 Radiologic examination, wrist, arthrography, radiological supervision and interpretation 9 1 . 8 0 73115 Radiologic examination, wrist, arthrography, radiological supervision and interpretation 2 2 9 . 5 0 73115 TC Contrast x-ray of wrist 1 77.32 73120 26 Radiologic examination, hand; two views 2 8 . 8 0 73120 Radiologic examination, hand; two views 7 3 . 9 5 73120 TC X-ray exam of hand 5 3.97 73130 26 Radiologic examination, hand; minimum of three views 3 6 . 9 0 73130 Radiologic examination, hand; minimum of three views 8 7 . 8 8 73130 TC X-ray exam of hand 6 6.97 73140 26 Radiologic examination, finger(s), minimum of two views 2 8 . 8 0 73140 Radiologic examination, finger(s), minimum of two views 6 7 . 8 9 73140 TC X-ray exam of finger(s) 5 5.43 73200 26 Computerized axial tomography, upper extremity; without contrast material 2 1 6 . 0 0 73200 Computerized axial tomography, upper extremity; without contrast material 7 2 1 . 8 0 73200 TC Ct upper extremity w/o dye 5 65.21 73201 26 Computerized axial tomography, upper extremity; with contrast material(s) 2 2 5 . 9 0 73201 Computerized axial tomography, upper extremity; with contrast material(s) 7 5 1 . 5 0 73201 TC Ct upper extremity w/dye 5 98.85 73202 26 Computerized axial tomography, upper extremity; without contrast material, followed by contrast material(s) 1 83.60 73202 Computerized axial tomography, upper extremity; without contrast material, followed by contrast material(s) 9 17.10 73202 TC Ct uppr extremity w/o&w/dye 7 64.26 73206 26 Ct angiography upper extremity 2 00.46 73206 Ct angiography upper extremity 1 ,105.19 73206 TC Ct angiography upper extremity 9 04.73 73218 26 Mri uxtr oth/thn jt c-matrl 1 54.29 73218 Mri uxtr oth/thn jt c-matrl 1 ,120.22 73218 TC Mri uxtr oth/thn jt c-matrl 9 65.93 73219 26 Mri uxtr oth/thn jt c+ matrl 1 84.15 73219 Mri uxtr oth/thn jt c+ matrl 1 ,320.16 73219 TC Mri uxtr oth/thn jt c+ matrl 1 ,136.01 73220 26 without contrast material(s), followed by contrast material(s) and further sequences 3 5 1 . 0 0 73220 without contrast material(s), followed by contrast material(s) and further sequences 1 , 7 5 7 . 7 0 73220 TC Mri uppr extremity w/o&w/dye 1 ,463.40 73221 26 Magnetic resonance (eg, proton) imaging, any joint of upper extremity; without contrast material(s) 2 7 0 . 0 0 73221 Magnetic resonance (eg, proton) imaging, any joint of upper extremity; without contrast material(s) 1 , 3 4 9 . 1 0 73221 TC Mri joint upr extrem w/o dye 1 ,046.87 73222 26 Mri any jt uxtr c+ matrl 2 00.81 73222 Mri any jt uxtr c+ matrl 1 ,431.78 73222 TC Mri any jt uxtr c+ matrl 1 ,230.96 73223 26 Mri any jt uxtr c-/c+ 1 85.05 73223 Mri any jt uxtr c-/c+ 1 ,773.84 73223 TC Mri any jt uxtr c-/c+ 1 ,588.79 73225 26 Mra uxtr c+-matrl 2 31.15 73225 Mra uxtr c+-matrl 1 ,324.05 73225 TC Mra uxtr c+-matrl 1 ,092.90 73500 26 Radiologic examination, hip, unilateral; one view 3 1 . 5 0 73500 Radiologic examination, hip, unilateral; one view 7 3 . 9 2 73500 TC X-ray exam of hip 4 9.95 73510 26 Radiologic examination, hip, unilateral; complete, minimum of two views 4 1 . 4 0 73510 Radiologic examination, hip, unilateral; complete, minimum of two views 9 2 . 4 0 73510 TC X-ray exam of hip 6 7.89 73520 26 Radiologic examination, hips, bilateral, minimum of two views of each hip, including anteroposterior view of 5 1.30 73520 Radiologic examination, hips, bilateral, minimum of two views of each hip, including anteroposterior view of 1 19.00 73520 TC X-ray exam of hips 8 2.41 73525 26 Radiologic examination, hip, arthrography, radiological supervision and interpretation 9 0 . 9 0 73525 Radiologic examination, hip, arthrography, radiological supervision and interpretation 2 5 7 . 4 0 73525 TC Contrast x-ray of hip 1 93.09 73530 26 Radiologic examination, hip, during operative procedure 5 7 . 6 0 73530 Radiologic examination, hip, during operative procedure 1 4 4 . 0 0 73540 26 Radiologic examination, pelvis and hips, infant or child, minimum of two views 4 0 . 5 0 73540 Radiologic examination, pelvis and hips, infant or child, minimum of two views 1 0 1 . 7 0 73540 TC X-ray exam of pelvis & hips 7 8.77 86 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 73550 26 Radiologic examination, femur, two views 3 6 . 9 0 73550 Radiologic examination, femur, two views 8 7 . 0 0 73550 TC X-ray exam of thigh 6 0.77 73560 26 Radiologic examination, knee; one or two views 3 6 . 0 0 73560 Radiologic examination, knee; one or two views 8 3 . 4 0 73560 TC X-ray exam of knee 1 or 2 5 9.50 73562 26 Radiologic examination, knee; three views 4 1 . 4 0 73562 Radiologic examination, knee; three views 9 5 . 3 4 73562 TC X-ray exam of knee 3 7 2.04 73564 26 Radiologic examination, knee; complete, four or more views 5 2 . 2 0 73564 Radiologic examination, knee; complete, four or more views 1 1 5 . 1 6 73564 TC X-ray exam knee 4 or more 8 6.18 73565 26 Radiologic examination, knee; both knees, standing, anteroposterior 4 6 . 8 0 73565 Radiologic examination, knee; both knees, standing, anteroposterior 9 5 . 3 1 73565 TC X-ray exam of knees 7 0.87 73580 26 Radiologic examination, knee, arthrography, radiological supervision and interpretation 1 1 5 . 2 0 73580 Radiologic examination, knee, arthrography, radiological supervision and interpretation 3 2 7 . 6 0 73580 TC Contrast x-ray of knee joint 2 61.54 73590 26 Radiologic examination; tibia and fibula, two views 3 6 . 0 0 73590 Radiologic examination; tibia and fibula, two views 8 4 . 7 5 73590 TC X-ray exam of lower leg 6 0.92 73592 26 Radiologic examination; lower extremity, infant, minimum of two views 3 1 . 5 0 73592 Radiologic examination; lower extremity, infant, minimum of two views 8 0 . 7 0 73592 TC X-ray exam of leg infant 6 0.12 73600 26 Radiologic examination, ankle; two views 3 1 . 5 0 73600 Radiologic examination, ankle; two views 7 7 . 0 8 73600 TC X-ray exam of ankle 5 7.22 73610 26 Radiologic examination, ankle; complete, minimum of three views 3 8 . 7 0 73610 Radiologic examination, ankle; complete, minimum of three views 9 4 . 7 2 73610 TC X-ray exam of ankle 7 2.85 73615 26 Radiologic examination, ankle, arthrography, radiological supervision and interpretation 7 9 . 2 0 73615 Radiologic examination, ankle, arthrography, radiological supervision and interpretation 2 6 1 . 9 0 73615 TC Contrast x-ray of ankle 1 97.29 73620 26 Radiologic examination, foot; two views 3 1 . 5 0 73620 Radiologic examination, foot; two views 7 9 . 3 4 73620 TC X-ray exam of foot 5 9.82 73630 26 Radiologic examination, foot; complete, minimum of three views 3 8 . 7 0 73630 Radiologic examination, foot; complete, minimum of three views 8 8 . 0 2 73630 TC X-ray exam of foot 6 7.34 73650 26 Radiologic examination; calcaneus, minimum of two views 3 1 . 5 0 73650 Radiologic examination; calcaneus, minimum of two views 7 3 . 4 7 73650 TC X-ray exam of heel 5 5.17 73660 26 Radiologic examination; toe(s), minimum of two views 2 7 . 9 0 73660 Radiologic examination; toe(s), minimum of two views 6 4 . 9 1 73660 TC X-ray exam of toe(s) 5 2.41 73700 26 Computerized axial tomography, lower extremity; without contrast material 2 3 7 . 6 0 73700 Computerized axial tomography, lower extremity; without contrast material 7 1 2 . 0 3 73700 TC Ct lower extremity w/o dye 5 58.06 73701 26 Computerized axial tomography, lower extremity; with contrast material(s) 2 5 4 . 7 0 73701 Computerized axial tomography, lower extremity; with contrast material(s) 7 8 6 . 8 9 73701 TC Ct lower extremity w/dye 6 29.35 73702 26 Computerized axial tomography, lower extremity; without contrast material, followed by contrast material(s) 1 85.40 73702 Computerized axial tomography, lower extremity; without contrast material, followed by contrast material(s) 9 27.00 73702 TC Ct lwr extremity w/o&w/dye 7 72.18 73706 26 Ct angiography lower extremity 2 50.57 73706 Ct angiography lower extremity 1 ,319.96 73706 TC Ct angiography lower extremity 1 ,069.39 73718 26 Mri lxtr oth/thn jt c-matrl 1 76.75 73718 Mri lxtr oth/thn jt c-matrl 1 ,277.59 73718 TC Mri lxtr oth/thn jt c-matrl 1 ,100.84 73719 26 Mri img lxtr oth/thn jt c+ matrl 2 02.15 73719 Mri img lxtr oth/thn jt c+ matrl 1 ,448.72 73719 TC Mri img lxtr oth/thn jt c+ matrl 1 ,246.57 73720 26 without contrast material(s), followed by contrast material(s) and further sequences 3 5 0 . 1 0 73720 without contrast material(s), followed by contrast material(s) and further sequences 1 , 7 5 5 . 9 0 73720 TC Mri lwr extremity w/o&w/dye 1 ,464.84 73721 26 Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material 2 9 3 . 4 0 73721 Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material 1 , 3 8 1 . 2 7 73721 TC Mri jnt of lwr extre w/o dye 1 ,071.83 73722 26 Mri any jt lxtr c+ matrl 2 00.52 87 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 73722 Mri any jt lxtr c+ matrl 1 ,430.28 73722 TC Mri any jt lxtr c+ matrl 1 ,229.76 73723 26 Mri any jt lxtr c-/c+ 1 80.97 73723 Mri any jt lxtr c-/c+ 1 ,732.45 73723 TC Mri any jt lxtr c-/c+ 1 ,551.48 73725 26 Magnetic resonance angiography, lower extremity, with or without contrast material(s) 3 0 7 . 8 0 73725 Magnetic resonance angiography, lower extremity, with or without contrast material(s) 1 , 5 3 4 . 5 0 73725 TC Mr ang lwr ext w or w/o dye 1 ,272.15 74000 26 Radiologic examination, abdomen; single anteroposterior view 3 3 . 3 0 74000 Radiologic examination, abdomen; single anteroposterior view 8 3 . 1 7 74000 TC X-ray exam of abdomen 5 5.14 74010 26 Radiologic examination, abdomen; anteroposterior and additional oblique and cone views 4 1 . 4 0 74010 Radiologic examination, abdomen; anteroposterior and additional oblique and cone views 1 0 1 . 7 0 74010 TC X-ray exam of abdomen 7 4.73 74020 26 Radiologic examination, abdomen; complete, including decubitus and/or erect views 4 4 . 1 0 74020 Radiologic examination, abdomen; complete, including decubitus and/or erect views 1 2 1 . 3 7 74020 TC X-ray exam of abdomen 8 5.83 74022 26 Radiologic examination, abdomen; complete acute abdomen series, including supine, erect, and/or 5 4.90 74022 Radiologic examination, abdomen; complete acute abdomen series, including supine, erect, and/or 1 59.47 74022 TC X-ray exam series abdomen 1 13.63 74150 26 Computerized axial tomography, abdomen; without contrast material 1 8 3 . 6 0 74150 Computerized axial tomography, abdomen; without contrast material 8 2 9 . 5 6 74150 TC Ct abdomen w/o dye 5 78.22 74160 26 Computerized axial tomography, abdomen; with contrast material(s) 2 1 5 . 1 0 74160 Computerized axial tomography, abdomen; with contrast material(s) 1 , 0 2 8 . 9 2 74160 TC Ct abdomen w/dye 8 18.08 74170 26 Computerized axial tomography, abdomen; without contrast material, followed by contrast material(s) and 2 61.00 74170 Computerized axial tomography, abdomen; without contrast material, followed by contrast material(s) and 1 ,162.71 74170 TC Ct abdomen w/o & w/dye 9 35.32 74174 26 Ct angio abd&pelv w/o&w/dye 2 79.53 74174 TC Ct angio abd&pelv w/o&w/dye 1 ,137.30 74174 Ct angio abd&pelv w/o&w/dye 1 ,416.83 74175 26 Ct angiography abdomen w/contrast/noncontrast 2 81.04 74175 Ct angiography abdomen w/contrast/noncontrast 1 ,414.10 74175 TC Ct angiography abdomen w/contrast/noncontrast 1 ,133.06 74176 26 Ct abd & pelvis w/o contrast 2 51.39 74176 Ct abd & pelvis w/o contrast 6 46.96 74176 TC Ct abd & pelvis w/o contrast 3 95.57 74177 26 Ct abd & pelvis w/contrast 2 57.26 74177 Ct abd & pelvis w/contrast 9 94.23 74177 TC Ct abd & pelvis w/contrast 7 36.97 74178 26 Ct abd & pelvis w/o contrst 1+ body regns 2 96.15 74178 Ct abd & pelvis w/o contrst 1+ body regns 1 ,294.62 74178 TC Ct abd & pelvis w/o contrst 1+ body regns 9 98.47 74181 26 Magnetic resonance (eg, proton) imaging, abdomen; without contrast material(s) 2 6 9 . 1 0 74181 Magnetic resonance (eg, proton) imaging, abdomen; without contrast material(s) 1 , 3 4 4 . 6 0 74181 TC Mri abdomen w/o dye 1 ,113.50 74182 26 Mri abd c+ matrl 2 68.02 74182 Mri abd c+ matrl 1 ,925.46 74182 TC Mri abd c+ matrl 1 ,657.45 74183 26 Mri abd c-/c+ 3 43.24 74183 Mri abd c-/c+ 2 ,299.20 74183 TC Mri abd c-/c+ 1 ,955.96 74185 26 Magnetic resonance angiography, abdomen, with or without contrast material(s) 3 3 3 . 9 0 74185 Magnetic resonance angiography, abdomen, with or without contrast material(s) 1 , 6 7 4 . 0 0 74185 TC Mri angio abdom w orw/o dye 1 ,388.10 74190 26 Peritoneogram (eg, after injection of air or contrast), radiological supervision and interpretation 7 0 . 2 0 74190 Peritoneogram (eg, after injection of air or contrast), radiological supervision and interpretation 1 7 5 . 5 0 74210 26 Radiologic examination; pharynx and/or cervical esophagus 6 6 . 6 0 74210 Radiologic examination; pharynx and/or cervical esophagus 1 8 0 . 2 3 74210 TC Contrst x-ray exam of throat 1 44.68 74220 26 Radiologic examination; esophagus 7 3 . 8 0 74220 Radiologic examination; esophagus 1 8 5 . 4 0 74220 TC Contrast x-ray esophagus 1 43.55 74230 26 Swallowing function, pharynx and/or esophagus, with cineradiography and/or video 9 3 . 6 0 74230 Swallowing function, pharynx and/or esophagus, with cineradiography and/or video 2 3 3 . 1 0 74230 TC Cine/vid x-ray throat/esoph 1 72.89 74235 26 Removal of foreign body(s), esophageal, with use of balloon catheter, radiological supervision and 1 85.40 74235 Removal of foreign body(s), esophageal, with use of balloon catheter, radiological supervision and 4 63.50 74240 26 Radiologic examination, gastrointestinal tract, upper; with or without delayed films, without KUB 1 0 5 . 3 0 88 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 74240 Radiologic examination, gastrointestinal tract, upper; with or without delayed films, without KUB 2 6 4 . 8 7 74240 TC X-ray upper gi delay w/o kub 1 92.76 74241 26 Radiologic examination, gastrointestinal tract, upper; with or without delayed films, with KUB 1 0 8 . 9 0 74241 Radiologic examination, gastrointestinal tract, upper; with or without delayed films, with KUB 2 7 1 . 2 5 74241 TC X-rayupper gi delay w/kub 2 02.52 74245 26 Radiologic examination, gastrointestinal tract, upper; with small bowel, includes multiple serial films 1 4 6 . 7 0 74245 Radiologic examination, gastrointestinal tract, upper; with small bowel, includes multiple serial films 3 6 5 . 4 0 74245 TC X-ray upper gi&small intest 2 82.73 74246 26 Radiological examination, gastrointestinal tract, upper, air contrast, with specific high density barium, 1 04.40 74246 Radiological examination, gastrointestinal tract, upper, air contrast, with specific high density barium, 2 61.90 74246 TC Contrst x-ray uppr gi tract 1 99.51 74247 26 Radiological examination, gastrointestinal tract, upper, air contrast, with specific high density barium, 1 08.90 74247 Radiological examination, gastrointestinal tract, upper, air contrast, with specific high density barium, 2 72.70 74247 TC Contrst x-ray uppr gi tract 2 14.46 74249 26 Radiological examination, gastrointestinal tract, upper, air contrast, with specific high density barium, 1 53.90 74249 Radiological examination, gastrointestinal tract, upper, air contrast, with specific high density barium, 3 84.30 74249 TC Contrst x-ray uppr gi tract 3 03.91 74250 26 Radiologic examination, small bowel, includes multiple serial films; 8 3 . 7 0 74250 Radiologic examination, small bowel, includes multiple serial films; 2 1 5 . 5 5 74250 TC X-ray exam of small bowel 1 74.11 74251 26 Radiologic examination, small bowel, includes multiple serial films; via enteroclysis tube 1 0 7 . 1 0 74251 Radiologic examination, small bowel, includes multiple serial films; via enteroclysis tube 2 6 4 . 6 0 74251 TC X-ray exam of small bowel 2 45.53 74260 26 Duodenography, hypotonic 8 7 . 3 0 74260 Duodenography, hypotonic 2 1 8 . 7 0 74260 TC X-ray exam of small bowel 2 04.84 74261 26 Ct colonogrphy dx image postprocess no contrast 2 53.22 74261 Ct colonogrphy dx image postprocess no contrast 1 ,384.23 74261 TC Ct colonogrphy dx image postprocess no contrast 1 ,131.01 74262 26 Ct colonogrphy dx image postprocess w/contrast 2 82.77 74262 Ct colonogrphy dx image postprocess w/contrast 1 ,555.63 74262 TC Ct colonogrphy dx image postprocess w/contrast 1 ,272.86 74263 26 Ct colonography screening image postprocessing 2 61.58 74263 Ct colonography screening image postprocessing 1 ,656.89 74263 TC Ct colonography screening image postprocessing 1 ,395.31 74270 26 Radiologic examination, colon; barium enema, with or without KUB 1 0 7 . 1 0 74270 Radiologic examination, colon; barium enema, with or without KUB 2 9 1 . 3 2 74270 TC Contrast x-ray exam of colon 2 34.93 74280 26 Radiologic examination, colon; air contrast with specific high density barium, with or without glucagon 1 4 4 . 9 0 74280 Radiologic examination, colon; air contrast with specific high density barium, with or without glucagon 3 8 6 . 6 4 74280 TC Contrast x-ray exam of colon 3 10.24 74283 26 Therapeutic enema, contrast or air, for reduction of intussusception or other intraluminal obstruction (eg, 1 98.90 74283 Therapeutic enema, contrast or air, for reduction of intussusception or other intraluminal obstruction (eg, 4 95.90 74283 TC Contrast x-ray exam of colon 2 75.11 74290 26 Cholecystography, oral contrast; 5 5 . 8 0 74290 Cholecystography, oral contrast; 1 3 7 . 7 0 74290 TC Contrast x-ray gallbladder 1 10.32 74291 26 Cholecystography, oral contrast; additional or repeat examination or multiple day examination 3 7 . 8 0 74291 Cholecystography, oral contrast; additional or repeat examination or multiple day examination 9 4 . 5 0 74291 TC Contrast x-rays gallbladder 8 2.14 74300 26 X-ray bile ducts/pancreas 6 7.14 74300 Cholangiography and/or pancreatography; intraoperative, radiological supervision and interpretation 2 0 6 . 1 0 74301 26 X-rays at surgery add-on 4 6.90 74301 Cholangiography and/or pancreatography; additional set intraoperative, radiological supervision and 1 28.70 74305 26 Cholangiography and/or pancreatography; postoperative, radiological supervision and interpretation 7 0 . 2 0 74305 Cholangiography and/or pancreatography; postoperative, radiological supervision and interpretation 1 3 9 . 5 0 74320 26 Cholangiography, percutaneous, transhepatic, radiological supervision and interpretation 9 1 . 8 0 74320 Cholangiography, percutaneous, transhepatic, radiological supervision and interpretation 3 6 9 . 9 0 74320 TC Contrast x-ray of bile ducts 2 80.43 74327 26 Postoperative biliary duct stone removal, percutaneous via T-tube tract, basket, or snare (eg, Burhenne 1 66.50 74327 Postoperative biliary duct stone removal, percutaneous via T-tube tract, basket, or snare (eg, Burhenne 4 17.60 74327 TC X-ray bile stone removal 3 15.00 74328 26 Endoscopic catheterization of the biliary ductal system, radiological supervision and interpretation 1 2 4 . 2 0 74328 Endoscopic catheterization of the biliary ductal system, radiological supervision and interpretation 4 1 3 . 1 0 74329 26 Endoscopic catheterization of the pancreatic ductal system, radiological supervision and interpretation 1 2 4 . 2 0 74329 Endoscopic catheterization of the pancreatic ductal system, radiological supervision and interpretation 4 1 3 . 1 0 74330 26 Combined endoscopic catheterization of the biliary and pancreatic ductal systems, radiological supervision 1 29.60 74330 Combined endoscopic catheterization of the biliary and pancreatic ductal systems, radiological supervision 4 32.90 74340 26 Introduction of long gastrointestinal tube (eg, Miller-Abbott), including multiple fluoroscopies and films, 1 00.80 74340 Introduction of long gastrointestinal tube (eg, Miller-Abbott), including multiple fluoroscopies and films, 3 34.80 89 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 74355 26 Percutaneous placement of enteroclysis tube, radiological supervision and interpretation 1 0 5 . 3 0 74355 Percutaneous placement of enteroclysis tube, radiological supervision and interpretation 3 4 9 . 2 0 74400 26 Urography (pyelography), intravenous, with or without KUB, with or without tomography 7 6 . 5 0 74400 Urography (pyelography), intravenous, with or without KUB, with or without tomography 2 4 2 . 9 5 74400 TC Contrst x-ray urinary tract 1 96.03 74410 26 Urography, infusion, drip technique and/or bolus technique; 7 8 . 3 0 74410 Urography, infusion, drip technique and/or bolus technique; 2 6 2 . 8 0 74410 TC Contrst x-ray urinary tract 2 12.22 74415 26 Urography, infusion, drip technique and/or bolus technique; with nephrotomography 8 4 . 6 0 74415 Urography, infusion, drip technique and/or bolus technique; with nephrotomography 2 8 4 . 4 0 74415 TC Contrst x-ray urinary tract 2 39.70 74420 26 Urography, retrograde, with or without KUB 6 3 . 0 0 74420 Urography, retrograde, with or without KUB 3 1 4 . 1 0 74425 26 Urography, antegrade, (pyelostogram, nephrostogram, loopogram), radiological supervision and 8 3.70 74425 Urography, antegrade, (pyelostogram, nephrostogram, loopogram), radiological supervision and 2 07.12 74430 26 Cystography, minimum of three views, radiological supervision and interpretation 6 3 . 0 0 74430 Cystography, minimum of three views, radiological supervision and interpretation 1 7 7 . 3 0 74430 TC Contrast x-ray bladder 1 17.10 74440 26 Vasograpy vesiculograpy/epididymograpy rs&i 6 9.94 74440 Vasograpy vesiculograpy/epididymograpy rs&i 2 39.72 74440 TC Vasograpy vesiculograpy/epididymograpy rs&i 1 69.77 74445 26 Corpora cavernosography, radiological supervision and interpretation 1 4 7 . 6 0 74445 Corpora cavernosography, radiological supervision and interpretation 2 4 6 . 6 0 74450 26 Urethrocystography, retrograde, radiological supervision and interpretation 6 3 . 0 0 74450 Urethrocystography, retrograde, radiological supervision and interpretation 1 8 0 . 9 0 74455 26 Urethrocystography, voiding, radiological supervision and interpretation 7 8 . 3 0 74455 Urethrocystography, voiding, radiological supervision and interpretation 2 2 3 . 2 0 74455 TC X-ray urethra/bladder 1 85.78 74470 26 Radiologic examination, renal cyst study, translumbar, contrast visualization, radiological supervision and 8 3.70 74470 Radiologic examination, renal cyst study, translumbar, contrast visualization, radiological supervision and 2 35.80 74475 26 Intro cath in rnl pelvis drg&/njx prq rs&i 1 13.11 74475 Intro cath in rnl pelvis drg&/njx prq rs&i 7 38.97 74475 TC Intro cath in rnl pelvis drg&/njx prq rs&i 6 25.86 74480 26 Intro urtrl cath/stent prq rs&i 1 11.45 74480 Intro urtrl cath/stent prq rs&i 7 27.96 74480 TC Intro urtrl cath/stent prq rs&i 6 16.52 74485 26 Dilat nfros urtrs/urt rs&i 9 4.43 74485 Dilat nfros urtrs/urt rs&i 5 16.61 74485 TC Dilat nfros urtrs/urt rs&i 4 22.18 74710 26 Pelvimetry, with or without placental localization 6 2 . 1 0 74710 Pelvimetry, with or without placental localization 1 5 3 . 9 0 74710 TC X-ray measurement of pelvis 8 9.33 74740 26 Hysterosalpingography, radiological supervision and interpretation 7 0 . 2 0 74740 Hysterosalpingography, radiological supervision and interpretation 2 1 1 . 0 1 74740 TC X-ray female genital tract 1 66.28 74775 26 Perineogram (eg, vaginogram, for sex determination or extent of anomalies) 9 9 . 0 0 74775 Perineogram (eg, vaginogram, for sex determination or extent of anomalies) 2 4 7 . 5 0 75557 26 Cardiac mri morphology & function w/o contrast 4 45.94 75557 Cardiac mri morphology & function w/o contrast 1 ,929.44 75557 TC Cardiac mri morphology & function w/o contrast 1 ,483.50 75559 26 Cardiac mri w/o contrast w stress imaging 5 94.96 75559 Cardiac mri w/o contrast w stress imaging 2 ,492.69 75559 TC Cardiac mri w/o contrast w stress imaging 1 ,897.73 75561 26 Cardiac mri w/w/o contrast & further seq 5 23.12 75561 Cardiac mri w/w/o contrast & further seq 2 ,389.24 75561 TC Cardiac mri w/w/o contrast & further seq 1 ,866.12 75563 26 Cardiac mri w/w/o contrast w stress 6 61.87 75563 Cardiac mri w/w/o contrast w stress 3 ,028.15 75563 TC Cardiac mri w/w/o contrast w stress 2 ,366.29 75565 26 Cardiac mri for velocity flow mapping 4 3.41 75565 Cardiac mri for velocity flow mapping 3 07.65 75565 TC Cardiac mri for velocity flow mapping 2 64.25 75571 26 Ct heart no contrast quant eval coronry calcium 9 2.13 75571 Ct heart no contrast quant eval coronry calcium 3 99.50 75571 TC Ct heart no contrast quant eval coronry calcium 3 07.37 75572 26 Ct heart contrast eval cardiac structure&morph 2 85.42 75572 Ct heart contrast eval cardiac structure&morph 5 02.21 75572 TC Ct heart contrast eval cardiac structure&morph 2 16.79 75573 26 Ct hrt contrst cardiac struct&morph cong hrt dx 4 10.16 75573 Ct hrt contrst cardiac struct&morph cong hrt dx 6 77.66 90 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 75573 TC Ct hrt contrst cardiac struct&morph cong hrt dx 2 67.50 75574 26 Cta hrt cornry art/bypass grfts contrst 3d post 3 91.64 75574 Cta hrt cornry art/bypass grfts contrst 3d post 1 ,934.02 75574 TC Cta hrt cornry art/bypass grfts contrst 3d post 1 ,542.37 75600 26 Contrast exam thoracic aorta 1 8.09 75600 Aortography, thoracic, without serialography, radiological supervision and interpretation 1 7 9 . 1 0 75600 TC Contrast exam thoracic aorta 1 61.01 75605 26 Aortograpy thrc srlograpy rs&i 2 22.53 75605 Aortograpy thrc srlograpy rs&i 1 ,358.34 75605 TC Aortograpy thrc srlograpy rs&i 1 ,135.81 75625 26 Contrast exam abdominl aorta 7 8.33 75625 Aortography, abdominal, by serialography, radiological supervision and interpretation 2 3 6 . 7 0 75625 TC Contrast exam abdominl aorta 1 58.37 75630 26 X-ray aorta leg arteries 1 24.01 75630 Aortography, abdominal plus bilateral iliofemoral lower extremity, catheter, by serialography, radiological 2 85.30 75630 TC X-ray aorta leg arteries 1 61.29 75635 26 Cta aa&bi iliofem lxtr rs&i c-/c+ post-pxessing 4 17.99 75635 Cta aa&bi iliofem lxtr rs&i c-/c+ post-pxessing 2 ,186.77 75635 TC Cta aa&bi iliofem lxtr rs&i c-/c+ post-pxessing 1 ,768.78 75658 26 Artery x-rays arm 8 0.43 75658 Angiography, brachial, retrograde, radiological supervision and interpretation 2 5 7 . 4 0 75658 TC Artery x-rays arm 1 76.97 75705 26 Artery x-rays spine 1 13.08 75705 Angiography, spinal, selective, radiological supervision and interpretation 2 8 3 . 5 0 75705 TC Artery x-rays spine 1 70.42 75710 26 Artery x-rays arm/leg 6 8.99 75710 Angiography, extremity, unilateral, radiological supervision and interpretation 2 5 0 . 2 0 75710 TC Artery x-rays arm/leg 1 81.21 75716 26 Artery x-rays arms/legs 8 3.89 75716 Angiography, extremity, bilateral, radiological supervision and interpretation 3 0 8 . 7 0 75716 TC Artery x-rays arms/legs 2 24.81 75726 26 Artery x-rays abdomen 8 1.80 75726 Angiography, visceral, selective or supraselective, (with or without flush aortogram), radiological supervision 2 88.00 75726 TC Artery x-rays abdomen 2 06.20 75731 26 Artery x-rays adrenal gland 7 7.96 75731 Angiography, adrenal, unilateral, selective, radiological supervision and interpretation 2 5 7 . 4 0 75731 TC Artery x-rays adrenal gland 1 79.44 75733 26 Artery x-rays adrenals 7 4.40 75733 Angiography, adrenal, bilateral, selective, radiological supervision and interpretation 2 6 8 . 2 0 75733 TC Artery x-rays adrenals 1 93.80 75736 26 Artery x-rays pelvis 6 9.91 75736 Angiography, pelvic, selective or supraselective, radiological supervision and interpretation 2 4 7 . 5 0 75736 TC Artery x-rays pelvis 1 77.59 75741 26 Artery x-rays lung 9 6.14 75741 Angiography, pulmonary, unilateral, selective, radiological supervision and interpretation 2 6 5 . 5 0 75741 TC Artery x-rays lung 1 69.36 75743 26 Artery x-rays lungs 1 25.32 75743 Angiography, pulmonary, bilateral, selective, radiological supervision and interpretation 3 1 8 . 6 0 75743 TC Artery x-rays lungs 1 93.28 75746 26 Artery x-rays lung 6 5.62 75746 Angiography, pulmonary, by nonselective catheter or venous injection, radiological supervision and 2 16.00 75746 TC Artery x-rays lung 1 50.38 75756 26 Artery x-rays chest 7 0.34 75756 Angiography, internal mammary, radiological supervision and interpretation 2 3 6 . 7 0 75756 TC Artery x-rays chest 1 66.36 75774 26 Artery x-ray each vessel 2 5.09 75774 Angiography, selective, each additional vessel studied after basic examination, radiological supervision and 1 57.50 75774 TC Artery x-ray each vessel 1 32.41 75791 26 Angiogrphy av shunt complete eval fluor s&i 3 96.90 75791 Angiogrphy av shunt complete eval fluor s&i 1 ,479.93 75791 TC Angiogrphy av shunt complete eval fluor s&i 1 ,083.03 75801 26 Lymph vessel x-ray arm/leg 1 14.60 75801 Lymphangiography, extremity only, unilateral, radiological supervision and interpretation 1 3 6 . 8 0 75803 26 Lymph vessel x-ray arms/legs 1 57.54 75803 Lymphangiography, extremity only, bilateral, radiological supervision and interpretation 1 9 4 . 4 0 75805 26 Lymph vessel x-ray trunk 1 24.70 75805 Lymphangiography, pelvic/abdominal, unilateral, radiological supervision and interpretation 1 4 9 . 4 0 75807 26 Lymph vessel x-ray trunk 1 82.44 75807 Lymphangiography, pelvic/abdominal, bilateral, radiological supervision and interpretation 2 1 2 . 4 0 75809 26 Nonvascular shunt x-ray 1 7.39 91 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 75809 Shuntogram for investigation of previously placed indwelling nonvascular shunt (eg, LeVeen shunt, 8 4.60 75809 TC Nonvascular shunt x-ray 6 7.21 75810 26 Vein x-ray spleen/liver 1 35.11 75810 Splenoportography, radiological supervision and interpretation 2 1 4 . 2 0 75820 26 Vein x-ray arm/leg 3 8.02 75820 Venography, extremity, unilateral, radiological supervision and interpretation 1 5 3 . 9 0 75820 TC Vein x-ray arm/leg 1 15.88 75822 26 Vein x-ray arms/legs 6 4.72 75822 Venography, extremity, bilateral, radiological supervision and interpretation 2 1 5 . 1 0 75822 TC Vein x-ray arms/legs 1 50.38 75825 26 Vein x-ray trunk 7 5.33 75825 Venography, caval, inferior, with serialography, radiological supervision and interpretation 2 2 1 . 4 0 75825 TC Vein x-ray trunk 1 46.07 75827 26 Vein x-ray chest 7 6.56 75827 Venography, caval, superior, with serialography, radiological supervision and interpretation 2 3 2 . 2 0 75827 TC Vein x-ray chest 1 55.64 75831 26 Vein x-ray kidney 8 5.46 75831 Venography, renal, unilateral, selective, radiological supervision and interpretation 2 3 6 . 7 0 75831 TC Vein x-ray kidney 1 51.24 75833 26 Vein x-ray kidneys 1 08.15 75833 Venography, renal, bilateral, selective, radiological supervision and interpretation 3 1 2 . 3 0 75833 TC Vein x-ray kidneys 2 04.15 75840 26 Vein x-ray adrenal gland 9 4.90 75840 Venography, adrenal, unilateral, selective, radiological supervision and interpretation 2 5 7 . 4 0 75840 TC Vein x-ray adrenal gland 1 62.50 75842 26 Vein x-ray adrenal glands 1 10.73 75842 Venography, adrenal, bilateral, selective, radiological supervision and interpretation 3 1 4 . 1 0 75842 TC Vein x-ray adrenal glands 2 03.37 75860 26 Vein x-ray neck 7 0.19 75860 Venography, sinus or jugular, catheter, radiological supervision and interpretation 2 1 1 . 5 0 75860 TC Vein x-ray neck 1 41.31 75870 26 Vein x-ray skull 7 0.69 75870 Venography, superior sagittal sinus, radiological supervision and interpretation 2 1 1 . 5 0 75870 TC Vein x-ray skull 1 40.81 75872 26 Vein x-ray skull epidural 7 0.69 75872 Venography, epidural, radiological supervision and interpretation 2 1 1 . 5 0 75872 TC Vein x-ray skull epidural 1 40.81 75880 26 Vein x-ray eye socket 1 9.98 75880 Venography, orbital, radiological supervision and interpretation 1 3 9 . 5 0 75880 TC Vein x-ray eye socket 1 19.52 75885 26 Vein x-ray liver w/hemodynam 1 04.28 75885 Percutaneous transhepatic portography with hemodynamic evaluation, radiological supervision and 2 73.60 75885 TC Vein x-ray liver w/hemodynam 1 69.32 75887 26 Vein x-ray liver w/o hemodyn 9 3.37 75887 Percutaneous transhepatic portography without hemodynamic evaluation, radiological supervision and 2 47.50 75887 TC Vein x-ray liver w/o hemodyn 1 54.13 75889 26 Vein x-ray liver w/hemodynam 7 4.13 75889 Hepatic venography, wedged or free, with hemodynamic evaluation, radiological supervision and 2 26.80 75889 TC Vein x-ray liver w/hemodynam 1 52.67 75891 26 Vein x-ray liver 7 1.08 75891 Hepatic venography, wedged or free, without hemodynamic evaluation, radiological supervision and 2 16.00 75891 TC Vein x-ray liver 1 44.92 75893 26 Venous sampling by catheter 3 5.44 75893 Venous sampling through catheter, with or without angiography (eg, for parathyroid hormone, renin), 1 95.30 75893 TC Venous sampling by catheter 1 59.86 75894 26 X-rays transcath therapy 1 79.45 75894 Transcatheter therapy, embolization, any method, radiological supervision and interpretation 2 9 8 . 8 0 75896 26 X-rays transcath therapy 1 97.36 75896 Transcatheter therapy, infusion, any method (eg, thrombolysis other than coronary), radiological supervision 2 83.50 75898 26 Follow-up angiography 3 01.96 75898 Angiogram through existing catheter for follow-up study for transcatheter therapy, embolization or infusion 3 1 9 . 5 0 75901 26 Mchnl rmvl pricath obstr matrl rs&i 9 0.97 75901 Mchnl rmvl pricath obstr matrl rs&i 3 97.59 75901 TC Mchnl rmvl pricath obstr matrl rs&i 3 06.62 75902 26 Mchnl rmvl intral obstr matrl rs&i 6 5.17 75902 Mchnl rmvl intral obstr matrl rs&i 3 21.61 75902 TC Mchnl rmvl intral obstr matrl rs&i 2 56.44 75960 26 Transcath iv stent rs&i 6 2.48 75960 Transcatheter introduction of intravascular stent(s), (non-coronary vessel), percutaneous and/or open, 2 16.00 75960 TC Transcath iv stent rs&i 1 53.52 92 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 75962 26 Repair arterial blockage 3 6.90 75962 Transluminal balloon angioplasty, peripheral artery, radiological supervision and interpretation 2 3 6 . 7 0 75962 TC Repair arterial blockage 1 99.80 75964 26 Repair artery blockage each 2 2.81 75964 Transluminal balloon angioplasty, each additional peripheral artery, radiological supervision and 1 34.10 75964 TC Repair artery blockage each 1 11.29 75966 26 Repair arterial blockage 9 2.08 75966 Transluminal balloon angioplasty, renal or other visceral artery, radiological supervision and interpretation 2 8 3 . 5 0 75966 TC Repair arterial blockage 1 91.42 75968 26 Repair artery blockage each 2 4.33 75968 Transluminal balloon angioplasty, each additional visceral artery, radiological supervision and interpretation 1 41.30 75968 TC Repair artery blockage each 1 16.97 75970 26 Vascular biopsy 1 21.35 75970 Transcatheter biopsy, radiological supervision and interpretation 1 3 4 . 1 0 75978 26 Repair venous blockage 3 3.27 75978 Transluminal balloon angioplasty, venous (eg, subclavian stenosis), radiological supervision and 2 11.50 75978 TC Repair venous blockage 1 78.23 75980 26 Contrast xray exam bile duct 2 23.85 75980 Percutaneous transhepatic biliary drainage with contrast monitoring, radiological supervision and 2 61.90 75982 26 Contrast xray exam bile duct 2 10.75 75982 Percutaneous placement of drainage catheter for combined internal and external biliary drainage or of a 2 82.60 75984 26 Xray control catheter change 4 1.16 75984 Change of percutaneous tube or drainage catheter with contrast monitoring (eg, gastrointestinal system, 1 44.00 75984 TC Xray control catheter change 1 02.84 75989 26 Abscess drainage under x-ray 1 00.69 75989 Radiological guidance (ie, fluoroscopy, ultrasound, or computed tomography) for percutaneous drainage 2 36.70 75989 TC Abscess drainage under x-ray 1 36.01 76000 26 Fluoroscopy (separate procedure), up to one hour physician time, other than 71023 or 71034 (eg, cardiac 3 8.70 76000 Fluoroscopy (separate procedure), up to one hour physician time, other than 71023 or 71034 (eg, cardiac 2 01.24 76000 TC Fluoroscope examination 1 71.01 76010 26 Radiologic examination from nose to rectum for foreign body, single view, child 2 8 . 8 0 76010 Radiologic examination from nose to rectum for foreign body, single view, child 7 2 . 0 0 76010 TC X-ray nose to rectum 5 0.17 76080 26 Radiologic examination, abscess, fistula or sinus tract study, radiological supervision and interpretation 8 7 . 3 0 76080 Radiologic examination, abscess, fistula or sinus tract study, radiological supervision and interpretation 1 7 3 . 7 0 76080 TC X-ray exam of fistula 1 04.19 76098 26 Radiological examination, surgical specimen 3 1 . 5 0 76098 Radiological examination, surgical specimen 7 9 . 2 0 76098 TC X-ray exam breast specimen 4 8.31 76100 26 Radiologic examination, single plane body section (eg, tomography), other than with urography 9 8 . 1 0 76100 Radiologic examination, single plane body section (eg, tomography), other than with urography 2 1 6 .0 0 76100 TC X-ray exam of body section 1 54.34 76101 26 Radiologic examination, complex motion (ie, hypercycloidal) body section (eg, mastoid polytomography), 1 02.60 76101 Radiologic examination, complex motion (ie, hypercycloidal) body section (eg, mastoid polytomography), 2 57.40 76101 TC Complex body section x-ray 2 01.61 76102 26 Radiologic examination, complex motion (ie, hypercycloidal) body section (eg, mastoid polytomography), 1 26.00 76102 Radiologic examination, complex motion (ie, hypercycloidal) body section (eg, mastoid polytomography), 3 14.10 76102 TC Complex body section x-rays 2 61.89 76120 26 Cine/video x-rays 4 2.57 76120 Cineradiography, except where specifically included 1 8 5 . 4 0 76120 TC Cine/video x-rays 1 42.83 76125 26 Cine/video x-rays add-on 4 0.64 76125 Cineradiography to complement routine examination (List separately in addition to code for primary 1 47.60 76376 26 3d rndr i&r ct mri us/oth x req postpcx 2 9.96 76376 3d rndr i&r ct mri us/oth x req postpcx 3 61.98 76376 TC 3d rndr i&r ct mri us/oth x req postpcx 3 32.02 76377 26 3d rndr i&r ct mri us/oth req postpcx 1 07.30 76377 3d rndr i&r ct mri us/oth req postpcx 4 48.98 76377 TC 3d rndr i&r ct mri us/oth req postpcx 3 41.68 76380 26 CAT scan follow-up study 1 16.87 76380 Computerized tomography, limited or localized follow-up study 4 4 3 . 7 0 76380 TC CAT scan follow-up study 3 26.83 76390 26 Magnetic resonance spectroscopy 1 9 1 . 7 0 76390 Magnetic resonance spectroscopy 1 , 2 7 5 . 3 0 76390 TC Mr spectroscopy 1 ,099.81 76506 26 Echoencephalography, B-scan and/or real time with image documentation (gray scale) (for determination of 1 19.70 76506 Echoencephalography, B-scan and/or real time with image documentation (gray scale) (for determination of 2 98.80 76506 TC Echo exam of head 2 30.67 76510 26 Oph us dx b-scan&quan a-scan sm pt enctr 2 02.99 76510 Oph us dx b-scan&quan a-scan sm pt enctr 4 01.87 93 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 76510 TC Oph us dx b-scan&quan a-scan sm pt enctr 1 98.88 76511 26 Ophthalmic ultrasound, echography, diagnostic; A-scan only, with amplitude quantification 1 4 2 . 2 0 76511 Ophthalmic ultrasound, echography, diagnostic; A-scan only, with amplitude quantification 2 8 3 . 5 0 76511 TC Ophth us quant a only 1 45.66 76512 26 Ophthalmic ultrasound, echography, diagnostic; contact B-scan (with or without simultaneous A-scan) 1 2 0 . 6 0 76512 Ophthalmic ultrasound, echography, diagnostic; contact B-scan (with or without simultaneous A-scan) 3 0 2 . 4 0 76512 TC Ophth us b w/non-quant a 1 38.31 76513 26 Ophthalmic ultrasound, echography, diagnostic; anterior segment ultrasound, immersion (water bath) B- 1 20.60 76513 Ophthalmic ultrasound, echography, diagnostic; anterior segment ultrasound, immersion (water bath) B- 3 02.40 76513 TC Echo exam of eye water bath 1 99.67 76514 26 Oph us dx crnl pachymetry uni/bi 3 1.94 76514 Oph us dx crnl pachymetry uni/bi 4 0.07 76514 TC Oph us dx crnl pachymetry uni/bi 8 .13 76516 26 Ophthalmic biometry by ultrasound echography, A-scan; 9 1 . 8 0 76516 Ophthalmic biometry by ultrasound echography, A-scan; 2 2 7 . 7 0 76516 TC Echo exam of eye 1 45.73 76519 26 Ophthalmic biometry by ultrasound echography, A-scan; with intraocular lens power calculation 9 9 . 0 0 76519 Ophthalmic biometry by ultrasound echography, A-scan; with intraocular lens power calculation 2 4 8 . 4 0 76519 TC Echo exam of eye 1 62.58 76529 26 Ophthalmic ultrasonic foreign body localization 1 0 6 . 2 0 76529 Ophthalmic ultrasonic foreign body localization 2 6 4 . 6 0 76529 TC Echo exam of eye 1 62.79 76536 26 Echography, soft tissues of head and neck (eg, thyroid, parathyroid, parotid), B-scan and/or real time with 1 08.00 76536 Echography, soft tissues of head and neck (eg, thyroid, parathyroid, parotid), B-scan and/or real time with 2 57.72 76536 TC Us exam of head and neck 2 04.91 76604 26 Echography, chest, B-scan (includes mediastinum) and/or real time with image documentation 1 0 2 . 6 0 76604 Echography, chest, B-scan (includes mediastinum) and/or real time with image documentation 2 5 7 . 4 0 76604 TC Us exam chest 1 85.54 76645 26 Echography, breast(s) (unilateral or bilateral), B-scan and/or real time with image documentation 1 1 3 . 4 0 76645 Echography, breast(s) (unilateral or bilateral), B-scan and/or real time with image documentation 2 5 1 . 9 3 76645 TC Us exam breast(s) 1 88.77 76700 26 Echography, abdominal, B-scan and/or real time with image documentation; complete 1 2 6 . 9 0 76700 Echography, abdominal, B-scan and/or real time with image documentation; complete 3 2 0 . 0 1 76700 TC Us exam abdom complete 2 37.60 76705 26 Echography, abdominal, B-scan and/or real time with image documentation; limited (eg, single organ, 9 9.90 76705 Echography, abdominal, B-scan and/or real time with image documentation; limited (eg, single organ, 2 46.20 76705 TC Echo exam of abdomen 1 86.85 76770 26 Echography, retroperitoneal (eg, renal, aorta, nodes), B-scan and/or real time with image documentation; 1 30.50 76770 Echography, retroperitoneal (eg, renal, aorta, nodes), B-scan and/or real time with image documentation; 3 18.12 76770 TC Us exam abdo back wall comp 2 38.77 76775 26 Echography, retroperitoneal (eg, renal, aorta, nodes), B-scan and/or real time with image documentation; 9 2.70 76775 Echography, retroperitoneal (eg, renal, aorta, nodes), B-scan and/or real time with image documentation; 2 14.87 76775 TC Us exam abdo back wall lim 1 64.00 76776 26 Us trnspl kdn r-t img +- duplex dop std 9 4.76 76776 Us trnspl kdn r-t img +- duplex dop std 3 24.32 76776 TC Us trnspl kdn r-t img +- duplex dop std 2 29.57 76800 26 Echography, spinal canal and contents 1 6 3 . 8 0 76800 Echography, spinal canal and contents 3 2 7 . 6 0 76800 TC Us exam spinal canal 2 00.59 76801 26 Us pg uter img f&mat 14 wk tabdl 1/1st gestation 1 20.01 76801 Us pg uter img f&mat 14 wk tabdl 1/1st gestation 3 18.00 76801 TC Us pg uter img f&mat 14 wk tabdl 1/1st gestation 1 97.99 76802 26 Us pg uter f&mat 14 wk tabdl ea gestation 9 0.37 76802 Us pg uter f&mat 14 wk tabdl ea gestation 1 78.50 76802 TC Us pg uter f&mat 14 wk tabdl ea gestation 8 8.13 76805 26 Echography, pregnant uterus, B-scan and/or real time with image documentation; complete (complete fetal 1 26.90 76805 Echography, pregnant uterus, B-scan and/or real time with image documentation; complete (complete fetal 2 75.25 76805 TC Ob us >/= 14 wks sngl fetus 1 92.07 76810 26 Echography, pregnant uterus, B-scan and/or real time with image documentation; complete (complete fetal 2 07.90 76810 Echography, pregnant uterus, B-scan and/or real time with image documentation; complete (complete fetal 5 20.20 76810 TC Ob us >/= 14 wks addl fetus 2 79.50 76811 26 Us pg uter f&mat detailed ftl xm 1st gestation 2 15.59 76811 Us pg uter f&mat detailed ftl xm 1st gestation 5 31.56 76811 TC Us pg uter f&mat detailed ftl xm 1st gestation 3 15.97 76812 26 Us pg uter f&mat detailed ftl antmc xm ea 2 13.69 76812 Us pg uter f&mat detailed ftl antmc xm ea 3 57.40 76812 TC Us pg uter f&mat detailed ftl antmc xm ea 1 43.71 76813 26 Us fetal nuchal translucency 1st gestation 1 33.46 76813 Us fetal nuchal translucency 1st gestation 2 97.61 76813 TC Us fetal nuchal translucency 1st gestation 1 64.15 94 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 76814 26 Us fetal nuchal translucency ea addl gestation 1 12.56 76814 Us fetal nuchal translucency ea addl gestation 1 97.24 76814 TC Us fetal nuchal translucency ea addl gestation 8 4.68 76815 26 Echography, pregnant uterus, B-scan and/or real time with image documentation; limited (fetal size, heart 8 5.50 76815 Echography, pregnant uterus, B-scan and/or real time with image documentation; limited (fetal size, heart 1 99.06 76815 TC Ob us limited fetus(s) 1 36.06 76816 26 Echography, pregnant uterus, B-scan and/or real time with image documentation; follow-up or repeat 8 6 . 4 0 76816 Echography, pregnant uterus, B-scan and/or real time with image documentation; follow-up or repeat 1 9 2 . 6 0 76816 TC Ob us follow-up per fetus 1 29.46 76817 26 Us pg uter r-t img trvg 1 05.50 76817 Us pg uter r-t img trvg 2 67.84 76817 TC Us pg uter r-t img trvg 1 62.34 76818 26 Fetal biophysical profile; with non-stress testing 1 3 6 . 8 0 76818 Fetal biophysical profile; with non-stress testing 2 8 4 . 1 2 76818 TC Fetal biophys profile w/nst 1 73.25 76819 26 Ftl biophysical profile w/o non-strs tstg 1 15.96 76819 Ftl biophysical profile w/o non-strs tstg 2 97.07 76819 TC Ftl biophysical profile w/o non-strs tstg 1 81.10 76820 26 Dop velocimetry ftl umbilical art 6 6.54 76820 Dop velocimetry ftl umbilical art 2 21.10 76820 TC Dop velocimetry ftl umbilical art 1 54.56 76821 26 Dop velocimetry ftl middle cere art 1 03.74 76821 Dop velocimetry ftl middle cere art 2 82.43 76821 TC Dop velocimetry ftl middle cere art 1 78.69 76825 26 Echocardiography, fetal, cardiovascular system, real time with image documentation (2D), with or without M- 1 80.00 76825 Echocardiography, fetal, cardiovascular system, real time with image documentation (2D), with or without M- 3 45.33 76825 TC Echo exam of fetal heart 2 26.21 76826 26 Echocardiography, fetal, cardiovascular system, real time with image documentation (2D), with or without M- 1 66.50 76826 Echocardiography, fetal, cardiovascular system, real time with image documentation (2D), with or without M- 2 36.70 76826 TC Echo exam of fetal heart 1 69.14 76827 26 Doppler echocardiography, fetal, cardiovascular system, pulsed wave and/or continuous wave with spectral 1 07.10 76827 Doppler echocardiography, fetal, cardiovascular system, pulsed wave and/or continuous wave with spectral 2 68.20 76827 TC Echo exam of fetal heart 1 50.88 76828 26 Doppler echocardiography, fetal, cardiovascular system, pulsed wave and/or continuous wave with spectral 8 6.40 76828 Doppler echocardiography, fetal, cardiovascular system, pulsed wave and/or continuous wave with spectral 1 71.00 76828 TC Echo exam of fetal heart 7 1.34 76830 26 Echography, transvaginal 1 1 9 . 7 0 76830 Echography, transvaginal 2 7 1 . 1 7 76830 TC Transvaginal us non-ob 1 56.86 76831 26 Echo exam uterus 7 4.65 76831 Hysterosonography, with or without color flow Doppler 2 8 5 . 8 0 76831 TC Echo exam uterus 2 11.16 76856 26 Echography, pelvic (nonobstetric), B-scan and/or real time with image documentation; complete 1 0 6 .

2 0 76856 Echography, pelvic (nonobstetric), B-scan and/or real time with image documentation; complete 2 6 2 . 1 6 76856 TC Us exam pelvic complete 1 98.09 76857 26 Echography, pelvic (nonobstetric), B-scan and/or real time with image documentation; limited or follow-up 7 8.30 76857 Echography, pelvic (nonobstetric), B-scan and/or real time with image documentation; limited or follow-up 2 10.38 76857 TC Us exam pelvic limited 1 72.16 76870 26 Echography, scrotum and contents 1 0 9 . 8 0 76870 Echography, scrotum and contents 2 4 4 . 2 6 76870 TC Us exam scrotum 1 88.02 76872 26 Echography, transrectal; 1 5 3 . 9 0 76872 Echography, transrectal; 3 4 3 . 5 3 76872 TC Us transrectal 1 96.06 76873 26 Echography, transrectal; prostate volume study for brachytherapy treatment planning (separate procedure) 2 6 2 . 8 0 76873 Echography, transrectal; prostate volume study for brachytherapy treatment planning (separate procedure) 5 2 5 . 6 0 76873 TC Echograp trans r pros study 3 05.43 76881 26 Us extremity non-vasc real-time img compl 8 7.64 76881 Us extremity non-vasc real-time img compl 3 52.03 76881 TC Us extremity non-vasc real-time img compl 2 64.39 76882 26 Us extremity non-vasc real-time img lmtd 6 5.70 76882 Us extremity non-vasc real-time img lmtd 9 9.72 76882 TC Us extremity non-vasc real-time img lmtd 3 4.02 76885 26 Us exam infant hips dynamic 6 8.44 76885 Echography of infant hips, real time with imaging documentation; dynamic (eg, requiring manipulation) 3 0 9 . 6 0 76885 TC Us exam infant hips dynamic 2 41.16 76886 26 Us exam infant hips static 7 0.64 76886 Echography of infant hips, real time with imaging documentation; limited, static (eg, not requiring 2 78.10 76886 TC Us exam infant hips static 2 07.46 76930 26 Ultrasonic guidance for pericardiocentesis, imaging supervision and interpretation 1 0 5 . 3 0 95 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 76930 Ultrasonic guidance for pericardiocentesis, imaging supervision and interpretation 2 6 2 . 8 0 76930 TC Echo guide cardiocentesis 1 72.61 76932 26 Ultrasonic guidance for endomyocardial biopsy, imaging supervision and interpretation 1 2 7 . 8 0 76932 Ultrasonic guidance for endomyocardial biopsy, imaging supervision and interpretation 3 1 9 . 5 0 76936 26 Ultrasound guided compression repair of arterial pseudo-aneurysm or arteriovenous fistulae (includes 3 72.60 76936 Ultrasound guided compression repair of arterial pseudo-aneurysm or arteriovenous fistulae (includes 9 32.40 76936 TC Echo guide for artery repair 6 30.31 76937 26 Us vasc access sits vsl patency ndl entry 4 4.58 76937 Us vasc access sits vsl patency ndl entry 9 5.77 76937 TC Us vasc access sits vsl patency ndl entry 5 1.19 76941 26 Ultrasonic guidance for intrauterine fetal transfusion or cordocentesis, imaging supervision and 1 42.20 76941 Ultrasonic guidance for intrauterine fetal transfusion or cordocentesis, imaging supervision and 2 83.50 76942 26 Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging 1 23.30 76942 Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging 3 08.70 76942 TC Echo guide for biopsy 2 63.36 76945 26 Ultrasonic guidance for chorionic villus sampling, imaging supervision and interpretation 1 2 9 . 6 0 76945 Ultrasonic guidance for chorionic villus sampling, imaging supervision and interpretation 2 5 7 . 4 0 76946 26 Ultrasonic guidance for amniocentesis, imaging supervision and interpretation 6 3 . 9 0 76946 Ultrasonic guidance for amniocentesis, imaging supervision and interpretation 2 9 6 . 4 4 76946 TC Echo guide for amniocentesis 1 33.52 76948 26 Ultrasonic guidance for aspiration of ova, imaging supervision and interpretation 8 5 . 5 0 76948 Ultrasonic guidance for aspiration of ova, imaging supervision and interpretation 2 8 5 . 3 0 76948 TC Echo guide ova aspiration 1 26.33 76950 26 Ultrasonic guidance for placement of radiation therapy fields 9 9 . 0 0 76950 Ultrasonic guidance for placement of radiation therapy fields 2 4 6 . 6 0 76950 TC Echo guidance radiotherapy 1 11.85 76965 26 Ultrasonic guidance for interstitial radioelement application 2 7 9 . 0 0 76965 Ultrasonic guidance for interstitial radioelement application 6 9 7 . 5 0 76965 TC Echo guidance radiotherapy 2 01.59 76970 26 Ultrasound study follow-up (specify) 7 2 . 9 0 76970 Ultrasound study follow-up (specify) 1 8 3 . 6 0 76970 TC Ultrasound exam follow-up 1 49.49 76975 26 Gastrointestinal endoscopic ultrasound, supervision and interpretation 1 1 8 . 8 0 76975 Gastrointestinal endoscopic ultrasound, supervision and interpretation 2 6 3 . 7 0 76977 26 Us bone density measure 6 5.88 76977 Ultrasound bone density measurement and interpretation, peripheral site(s), any method 1 7 9 . 5 3 76977 TC Us bone density measure 1 13.66 77001 26 Fluor gid ctr vad plmt rplcmt/rmvl 5 5.57 77001 Fluor gid ctr vad plmt rplcmt/rmvl 2 60.72 77001 TC Fluor gid ctr vad plmt rplcmt/rmvl 2 05.15 77002 26 Fluoroscopic guidance needle placement 7 7.53 77002 Fluoroscopic guidance needle placement 2 27.71 77002 TC Fluoroscopic guidance needle placement 1 50.18 77003 26 Fluor gid & loclzj ndl/cath spi dx/ther njx 8 4.18 77003 Fluor gid & loclzj ndl/cath spi dx/ther njx 2 18.53 77003 TC Fluor gid & loclzj ndl/cath spi dx/ther njx 1 34.36 77011 26 Ct guidance stereotactic localization 1 72.26 77011 Ct guidance stereotactic localization 1 ,109.83 77011 TC Ct guidance stereotactic localization 9 37.57 77012 26 Ct guidance needle placement 1 60.08 77012 Ct guidance needle placement 1 ,017.89 77012 TC Ct guidance needle placement 8 57.81 77014 26 Ct guidance radiation therapy flds placement 1 38.15 77014 Ct guidance radiation therapy flds placement 5 22.89 77014 TC Ct guidance radiation therapy flds placement 3 84.74 77021 26 Mr guidance needle placement 2 58.11 77021 Mr guidance needle placement 1 ,609.20 77021 TC Mr guidance needle placement 1 ,351.09 77031 26 Strtctc loclzj gid breast bx/needle placement 2 16.08 77031 Strtctc loclzj gid breast bx/needle placement 8 96.06 77031 TC Strtctc loclzj gid breast bx/needle placement 6 79.99 77032 26 Mammographic gid needle placementt breast 8 3.67 77032 Mammographic gid needle placementt breast 2 27.89 77032 TC Mammographic gid needle placementt breast 1 44.22 77051 26 Computer-aided detection dx mammography 9 .78 77051 Computer-aided detection dx mammography 5 6.04 77051 TC Computer-aided detection dx mammography 4 6.26 77052 26 Computer-aided detection screening mammography 9 .49 77052 Computer-aided detection screening mammography 5 4.33 77052 TC Computer-aided detection screening mammography 4 4.84 96 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 77053 26 Mammary ductogram or galactogram single 4 7.05 77053 Mammary ductogram or galactogram single 3 02.99 77053 TC Mammary ductogram or galactogram single 2 55.93 77054 26 Mammary ductogram or galactogram multiple 5 0.96 77054 Mammary ductogram or galactogram multiple 3 48.54 77054 TC Mammary ductogram or galactogram multiple 2 97.57 77055 26 Mammography unilateral 7 4.51 77055 Mammography unilateral 1 65.49 77055 TC Mammography unilateral 9 0.98 77056 26 Mammography bilateral 9 7.02 77056 Mammography bilateral 2 16.05 77056 TC Mammography bilateral 1 19.03 77057 26 Screening mammography bilateral 6 9.47 77057 Screening mammography bilateral 1 65.80 77057 TC Screening mammography bilateral 9 6.33 77058 26 Mri breast unilateral 2 48.53 77058 Mri breast unilateral 2 ,273.48 77058 TC Mri breast unilateral 2 ,024.95 77059 26 Mri breast bilateral 2 38.70 77059 Mri breast bilateral 2 ,939.71 77059 TC Mri breast bilateral 2 ,701.01 77071 Manual appl stress pfrmd phys joint radiography 6 8.11 77072 26 Bone age studies 2 5.66 77072 Bone age studies 7 9.09 77072 TC Bone age studies 5 3.43 77073 26 Bone length studies 3 5.07 77073 Bone length studies 1 11.25 77073 TC Bone length studies 7 6.19 77074 26 Radiologic examination osseous survey limited 4 6.67 77074 Radiologic examination osseous survey limited 1 29.11 77074 TC Radiologic examination osseous survey limited 8 2.44 77075 26 Radiologic examination osseous survey compl 6 5.81 77075 Radiologic examination osseous survey compl 2 06.10 77075 TC Radiologic examination osseous survey compl 1 40.29 77076 26 Radiologic examination osseous survey infant 7 0.08 77076 Radiologic examination osseous survey infant 1 37.87 77076 TC Radiologic examination osseous survey infant 6 7.80 77077 26 Joint survey single view 2 or more joints 3 2.33 77077 Joint survey single view 2 or more joints 1 15.37 77077 TC Joint survey single view 2 or more joints 8 3.04 77078 26 Ct bone mineral density study 1+ sits axial skel 2 9.88 77078 Ct bone mineral density study 1+ sits axial skel 3 10.42 77078 TC Ct bone mineral density study 1+ sits axial skel 2 80.54 77080 26 Dxa bone density study 1+ sits axial skel 3 4.02 77080 Dxa bone density study 1+ sits axial skel 3 11.04 77080 TC Dxa bone density study 1+ sits axial skel 2 77.02 77081 26 Dxa bone density study 1+ sits appendicular skel 2 7.53 77081 Dxa bone density study 1+ sits appendicular skel 9 7.24 77081 TC Dxa bone density study 1+ sits appendicular skel 6 9.71 77082 26 Dxa bone density study vertebral fracture 1 9.41 77082 Dxa bone density study vertebral fracture 8 4.82 77082 TC Dxa bone density study vertebral fracture 6 5.41 77084 26 Bone marrow blood supply 6 6.56 77084 Bone marrow blood supply 2 53.26 77084 TC Bone marrow blood supply 1 86.69 77261 Therapeutic radiology treatment planning; simple 3 4 0 . 2 0 77262 Therapeutic radiology treatment planning; intermediate 4 9 6 . 8 0 77263 Therapeutic radiology treatment planning; complex 6 2 2 . 8 0 77280 26 Therapeutic radiology simulation-aided field setting; simple 1 3 6 . 8 0 77280 Therapeutic radiology simulation-aided field setting; simple 4 5 3 . 6 0 77280 TC Set radiation therapy field 3 72.97 77285 26 Therapeutic radiology simulation-aided field setting; intermediate 1 9 2 . 6 0 77285 Therapeutic radiology simulation-aided field setting; intermediate 6 4 0 . 8 0 77285 TC Set radiation therapy field 5 43.91 77290 26 Therapeutic radiology simulation-aided field setting; complex 2 6 1 . 0 0 77290 Therapeutic radiology simulation-aided field setting; complex 8 6 9 . 4 0 77290 TC Set radiation therapy field 7 51.87 77295 26 Therapeutic radiology simulation-aided field setting; three-dimensional 8 5 7 . 7 0 77295 Therapeutic radiology simulation-aided field setting; three-dimensional 3 , 4 2 9 . 0 0 77295 TC Set radiation therapy field 1 ,754.09 97 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 77300 26 Basic radiation dosimetry calculation, central axis depth dose, TDF, NSD, gap calculation, off axis factor, 1 21.50 77300 Basic radiation dosimetry calculation, central axis depth dose, TDF, NSD, gap calculation, off axis factor, 2 69.10 77300 TC Radiation therapy dose plan 1 50.95 77301 26 Ntsty modul radthx pln dose-vol histos 1 ,060.49 77301 Ntsty modul radthx pln dose-vol histos 4 ,104.56 77301 TC Ntsty modul radthx pln dose-vol histos 3 ,044.07 77305 26 Teletherapy, isodose plan (whether hand or computer calculated); simple (one or two parallel opposed 1 56.60 77305 Teletherapy, isodose plan (whether hand or computer calculated); simple (one or two parallel opposed 3 47.40 77305 TC Teletx isodose plan simple 1 50.65 77310 26 Teletherapy, isodose plan (whether hand or computer calculated); intermediate (three or more treatment 2 07.90 77310 Teletherapy, isodose plan (whether hand or computer calculated); intermediate (three or more treatment 4 62.60 77310 TC Teletx isodose plan intermed 1 88.17 77315 26 Teletherapy, isodose plan (whether hand or computer calculated); complex (mantle or inverted Y, tangential 2 95.20 77315 Teletherapy, isodose plan (whether hand or computer calculated); complex (mantle or inverted Y, tangential 5 90.40 77315 TC Teletx isodose plan complex 2 62.65 77321 26 Special teletherapy port plan, particles, hemibody, total body 1 6 2 . 0 0 77321 Special teletherapy port plan, particles, hemibody, total body 5 3 6 . 4 0 77321 TC Special teletx port plan 2 70.22 77326 26 Brachytherapy isodose calculation; simple (calculation made from single plane, one to four sources/ribbon 1 46.70 77326 Brachytherapy isodose calculation; simple (calculation made from single plane, one to four sources/ribbon 3 66.30 77326 TC Brachytx isodose calc simp 2 57.77 77327 26 Brachytherapy isodose calculation; intermediate (multiplane dosage calculations, application involving 5 to 2 15.10 77327 Brachytherapy isodose calculation; intermediate (multiplane dosage calculations, application involving 5 to 5 40.00 77327 TC Brachytx isodose calc interm 3 67.40 77328 26 Brachytherapy isodose calculation; complex (multiplane isodose plan, volume implant calculations, over 10 3 14.10 77328 Brachytherapy isodose calculation; complex (multiplane isodose plan, volume implant calculations, over 10 7 84.80 77328 TC Brachytx isodose plan compl 5 01.72 77331 26 Special dosimetry (eg, TLD, microdosimetry) (specify), only when prescribed by the treating physician 1 6 6 . 5 0 77331 Special dosimetry (eg, TLD, microdosimetry) (specify), only when prescribed by the treating physician 2 0 7 . 9 0 77331 TC Special radiation dosimetry 6 7.83 77332 26 Treatment devices, design and construction; simple (simple block, simple bolus) 1 1 2 . 5 0 77332 Treatment devices, design and construction; simple (simple block, simple bolus) 2 7 9 . 0 0 77332 TC Radiation treatment aid(s) 1 90.34 77333 26 Treatment devices, design and construction; intermediate (multiple blocks, stents, bite blocks, special 1 49.40 77333 Treatment devices, design and construction; intermediate (multiple blocks, stents, bite blocks, special 3 75.30 77333 TC Radiation treatment aid(s) 7 5.48 77334 26 Treatment devices, design and construction; complex (irregular blocks, special shields, compensators, 2 43.00 77334 Treatment devices, design and construction; complex (irregular blocks, special shields, compensators, 6 06.60 77334 TC Radiation treatment aid(s) 3 72.27 77336 Continuing medical physics consultation, including assessment of treatment parameters, quality assurance 2 49.30 77338 26 Mlc imrt design & construction per imrt plan 5 76.91 77338 Mlc imrt design & construction per imrt plan 1 ,236.29 77338 TC Mlc imrt design & construction per imrt plan 6 59.38 77370 Special medical radiation physics consultation 3 0 1 . 5 0 77372 Radiation delivery stereotactic cranial linear 3 ,063.96 77373 Stereotactic body radiation delivery 5 ,714.33 77401 Radiation treatment delivery, superficial and/or ortho voltage 1 6 3 . 8 0 77402 Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or 1 63.80 77403 Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or 1 63.80 77404 Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or 1 63.80 77406 Radj dlvr 1 area 1/prll opsd ports smpl 20mev/< 2 37.77 77407 Radiation treatment delivery, two separate treatment areas, three or more ports on a single treatment area, 1 92.60 77408 Radiation treatment delivery, two separate treatment areas, three or more ports on a single treatment area, 1 92.60 77409 Radiation treatment delivery, two separate treatment areas, three or more ports on a single treatment area, 1 92.60 77411 Radiation treatment delivery, two separate treatment areas, three or more ports on a single treatment area, 1 92.60 77412 Radiation treatment delivery, three or more separate treatment areas, custom blocking, tangential ports, 2 14.20 77413 Radiation treatment delivery, three or more separate treatment areas, custom blocking, tangential ports, 2 14.20 77414 Radiation treatment delivery, three or more separate treatment areas, custom blocking, tangential ports, 2 14.20 77416 Radiation treatment delivery, three or more separate treatment areas, custom blocking, tangential ports, 2 14.20 77417 Therapeutic radiology port film(s) 7 7 . 4 0 77418 Ntsty modul dlvr 1/mlt flds/arcs pr tx session 2 ,378.84 77421 26 Strsc x-ray gdn loclzj target vol dlvr radj ther 7 1.58 77421 Strsc x-ray gdn loclzj target vol dlvr radj ther 4 74.62 77421 TC Strsc x-ray gdn loclzj target vol dlvr radj ther 4 03.04 77422 Hi nrg neutron radj tx dlvr 1 tx area 2 48.82 77423 Hi nrg neutron radj tx dlvr 1/> isocenter 3 61.47 77427 Radiation treatment management, five treatments 4 2 8 . 4 0 77431 Radiation therapy management with complete course of therapy consisting of one or two fractions only 2 6 8 . 2 0 77432 Stereotactic radiation treatment management of cerebral lesion(s) (complete course of treatment consisting 1 ,313.10 77435 Stereotactic body radiation management 2 ,444.40 98 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 77469 Io radiation tx management 8 01.93 77470 26 Special treatment procedure (eg, total body irradiation, hemibody radiation, per oral, endocavitary or 4 28.40 77470 Special treatment procedure (eg, total body irradiation, hemibody radiation, per oral, endocavitary or 1 ,327.50 77470 TC Special radiation treatment 4 44.04 77600 26 Hyperthermia, externally generated; superficial (ie, heating to a depth of 4 cm or less) 3 3 4 . 8 0 77600 Hyperthermia, externally generated; superficial (ie, heating to a depth of 4 cm or less) 6 6 9 . 6 0 77600 TC Hyperthermia treatment 5 57.89 77605 26 Hyperthermia, externally generated; deep (ie, heating to depths greater than 4 cm) 4 2 5 . 7 0 77605 Hyperthermia, externally generated; deep (ie, heating to depths greater than 4 cm) 8 4 9 . 6 0 77605 TC Hyperthermia treatment 7 69.93 77610 26 Hyperthermia generated by interstitial probe(s); 5 or fewer interstitial applicators 3 1 9 . 5 0 77610 Hyperthermia generated by interstitial probe(s); 5 or fewer interstitial applicators 6 3 7 . 2 0 77610 TC Hyperthermia treatment 5 95.82 77615 26 Hyperthermia generated by interstitial probe(s); more than 5 interstitial applicators 4 2 5 . 7 0 77615 Hyperthermia generated by interstitial probe(s); more than 5 interstitial applicators 8 4 9 . 6 0 77615 TC Hyperthermia treatment 7 69.26 77620 26 Hyperthermia generated by intracavitary probe(s) 3 2 0 . 4 0 77620 Hyperthermia generated by intracavitary probe(s) 6 3 9 . 0 0 77620 TC Hyperthermia treatment 5 62.91 77750 26 Infusion or instillation of radioelement solution 8 7 6 . 6 0 77750 Infusion or instillation of radioelement solution 9 7 3 . 8 0 77750 TC Infuse radioactive materials 3 21.96 77761 26 Intracavitary radiation source application; simple 5 7 3 . 3 0 77761 Intracavitary radiation source application; simple 7 6 5 . 0 0 77761 TC Apply intrcav radiat simple 4 01.39 77762 26 Intracavitary radiation source application; intermediate 8 4 9 . 6 0 77762 Intracavitary radiation source application; intermediate 1 , 1 3 3 . 1 0 77762 TC Apply intrcav radiat interm 5 19.25 77763 26 Intracavitary radiation source application; complex 1 , 1 7 8 . 1 0 77763 Intracavitary radiation source application; complex 1 , 4 7 3 . 3 0 77763 TC Apply intrcav radiat compl 6 19.07 77776 26 Interstitial radiation source application; simple 7 8 3 . 0 0 77776 Interstitial radiation source application; simple 9 7 8 . 3 0 77776 TC Apply interstit radiat simpl 4 60.40 77777 26 Interstitial radiation source application; intermediate 1 , 1 7 8 . 1 0 77777 Interstitial radiation source application; intermediate 1 , 4 7 1 . 5 0 77777 TC Apply interstit radiat inter 5 51.41 77778 26 Interstitial radiation source application; complex 1 , 8 1 7 . 1 0 77778 Interstitial radiation source application; complex 2 , 2 7 1 . 6 0 77778 TC Apply interstit radiat compl 8 21.73 77785 26 Remote aftld radionuclide brachytx 1 channel 1 75.33 77785 Remote aftld radionuclide brachytx 1 channel 4 71.94 77785 TC Remote aftld radionuclide brachytx 1 channel 2 96.61 77786 26 Remote aftld radionuclide brachytx 2-12 channel 4 01.03 77786 Remote aftld radionuclide brachytx 2-12 channel 1 ,393.84 77786 TC Remote aftld radionuclide brachytx 2-12 channel 9 92.82 77787 26 Remote aftld radionuclide brachytx > 12 channel 6 16.72 77787 Remote aftld radionuclide brachytx > 12 channel 2 ,088.30 77787 TC Remote aftld radionuclide brachytx > 12 channel 1 ,471.58 77789 26 Surface application of radiation source 1 4 8 . 5 0 77789 Surface application of radiation source 1 8 5 . 4 0 77789 TC Apply surface radiation 9 9.89 77790 26 Supervision, handling, loading of radiation source 1 8 0 . 9 0 77790 Supervision, handling, loading of radiation source 2 2 6 . 8 0 77790 TC Radiation handling 1 08.39 78012 26 Thyroid uptake measurement 2 4.11 78012 TC Thyroid uptake measurement 2 09.83 78012 Thyroid uptake measurement 2 33.94 78013 26 Thyroid imaging w/blood flow 4 6.01 78013 TC Thyroid imaging w/blood flow 5 46.50 78013 Thyroid imaging w/blood flow 5 92.51 78014 26 Thyroid imaging w/blood flow 6 2.58 78014 TC Thyroid imaging w/blood flow 6 21.78 78014 Thyroid imaging w/blood flow 6 84.36 78015 26 Thyroid carcinoma metastases imaging; limited area (eg, neck and chest only) 1 3 3 . 2 0 78015 Thyroid carcinoma metastases imaging; limited area (eg, neck and chest only) 4 4 2 . 8 0 78015 TC Thyroid met imaging 3 84.78 78016 26 Thyroid carcinoma metastases imaging; with additional studies (eg, urinary recovery) 1 4 8 . 5 0 78016 Thyroid carcinoma metastases imaging; with additional studies (eg, urinary recovery) 4 9 3 . 2 0 78016 TC Thyroid met imaging/studies 4 40.64 99 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 78018 26 Thyroid carcinoma metastases imaging; whole body 1 6 6 . 5 0 78018 Thyroid carcinoma metastases imaging; whole body 6 6 8 . 7 0 78018 TC Thyroid met imaging body 5 92.04 78020 26 Thyroid met uptake 3 3.33 78020 Thyroid carcinoma metastases uptake (List separately in addition to code for primary procedure) 1 1 1 . 6 0 78020 TC Thyroid met uptake 7 8.27 78070 26 Parathyroid imaging 8 6 . 4 0 78070 Parathyroid imaging 2 1 6 . 0 0 78070 TC Parathyroid planar imaging 1 91.52 78071 26 Parathyrd planar w/wo subtrj 1 47.77 78071 TC Parathyrd planar w/wo subtrj 8 66.92 78071 Parathyrd planar w/wo subtrj 1 ,014.69 78075 26 Adrenal imaging, cortex and/or medulla 9 8 . 1 0 78075 Adrenal imaging, cortex and/or medulla 4 8 6 . 9 0 78075 TC Adrenal cortex & medulla img 4 52.51 78102 26 Bone marrow imaging; limited area 8 2 . 8 0 78102 Bone marrow imaging; limited area 2 7 3 . 6 0 78102 TC Bone marrow imaging ltd 2 36.36 78103 26 Bone marrow imaging; multiple areas 1 2 1 . 5 0 78103 Bone marrow imaging; multiple areas 4 0 7 . 7 0 78103 TC Bone marrow imaging mult 3 49.18 78104 26 Bone marrow imaging; whole body 1 5 0 . 3 0 78104 Bone marrow imaging; whole body 5 0 1 . 3 0 78104 TC Bone marrow imaging body 4 32.94 78110 26 Plasma volume, radiopharmaceutical volume-dilution technique (separate procedure); single sampling 4 3 . 2 0 78110 Plasma volume, radiopharmaceutical volume-dilution technique (separate procedure); single sampling 1 4 4 . 0 0 78110 TC Plasma volume single 1 31.07 78111 26 Plasma volume, radiopharmaceutical volume-dilution technique (separate procedure); multiple samplings 6 1 . 2 0 78111 Plasma volume, radiopharmaceutical volume-dilution technique (separate procedure); multiple samplings 3 0 4 . 2 0 78111 TC Plasma volume multiple 2 73.53 78120 26 Red cell volume determination (separate procedure); single sampling 3 7 . 8 0 78120 Red cell volume determination (separate procedure); single sampling 1 8 9 . 9 0 78120 TC Red cell mass single 1 69.46 78121 26 Red cell volume determination (separate procedure); multiple samplings 6 2 . 1 0 78121 Red cell volume determination (separate procedure); multiple samplings 3 0 6 . 9 0 78121 TC Red cell mass multiple 2 61.23 78122 26 Whole blood volume determination, including separate measurement of plasma volume and red cell volume 9 5.40 78122 Whole blood volume determination, including separate measurement of plasma volume and red cell volume 4 78.80 78122 TC Blood volume 3 89.48 78130 26 Red cell survival study; 1 0 1 . 7 0 78130 Red cell survival study; 3 3 9 . 3 0 78130 TC Red cell survival study 2 81.51 78135 26 Red cell survival study; differential organ/tissue kinetics, (eg, splenic and/or hepatic sequestration) 1 0 5 . 3 0 78135 Red cell survival study; differential organ/tissue kinetics, (eg, splenic and/or hepatic sequestration) 5 2 7 . 4 0 78135 TC Red cell survival kinetics 4 85.50 78140 26 Labeled red cell sequestration, differential organ/tissue, (eg, splenic and/or hepatic) 1 0 8 . 9 0 78140 Labeled red cell sequestration, differential organ/tissue, (eg, splenic and/or hepatic) 4 3 7 . 4 0 78140 TC Red cell sequestration 3 49.46 78185 26 Spleen imaging only, with or without vascular flow 8 6 . 4 0 78185 Spleen imaging only, with or without vascular flow 3 4 7 . 4 0 78185 TC Spleen imaging 3 19.50 78190 26 Kinetics, study of platelet survival, with or without differential organ/tissue localization 1 6 5 . 6 0 78190 Kinetics, study of platelet survival, with or without differential organ/tissue localization 6 6 1 . 5 0 78190 TC Platelet survival kinetics 5 83.62 78191 26 Platelet survival study 1 4 1 . 3 0 78191 Platelet survival study 7 0 4 . 7 0 78191 TC Platelet survival 5 84.92 78195 26 Lymphatics and lymph glands imaging 1 5 5 . 7 0 78195 Lymphatics and lymph glands imaging 5 1 9 . 3 0 78195 TC Lymph system imaging 4 44.29 78201 26 Liver imaging; static only 1 0 8 . 9 0 78201 Liver imaging; static only 3 6 3 . 6 0 78201 TC Liver imaging 3 26.66 78202 26 Liver imaging; with vascular flow 1 3 1 . 4 0 78202 Liver imaging; with vascular flow 4 4 0 . 1 0 78202 TC Liver imaging with flow 3 96.48 78205 26 Liver imaging (SPECT); 2 0 4 . 3 0 78205 Liver imaging (SPECT); 8 1 0 . 9 0 78205 TC Liver imaging (3D) 6 96.85 78206 26 Liver image (3d) with flow 7 1.32 100 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 78206 Liver imaging (SPECT); with vascular flow 6 0 3 . 0 0 78206 TC Liver image (3d) with flow 5 31.68 78215 26 Liver and spleen imaging; static only 1 1 5 . 2 0 78215 Liver and spleen imaging; static only 4 5 9 . 0 0 78215 TC Liver and spleen imaging 4 09.00 78216 26 Liver and spleen imaging; with vascular flow 1 2 4 . 2 0 78216 Liver and spleen imaging; with vascular flow 4 9 4 . 1 0 78216 TC Liver & spleen image/flow 3 98.64 78226 26 Hepatobiliary system imaging 9 6.68 78226 TC Hepatobiliary system imaging 1 ,002.03 78226 Hepatobiliary system imaging 1 ,098.72 78227 26 Hepatobil syst image w/drug 1 15.93 78227 TC Hepatobil syst image w/drug 1 ,372.08 78227 Hepatobil syst image w/drug 1 ,488.01 78230 26 Salivary gland imaging; 1 0 2 . 6 0 78230 Salivary gland imaging; 3 4 2 . 9 0 78230 TC Salivary gland imaging 3 03.73 78231 26 Salivary gland imaging; with serial images 9 2 . 7 0 78231 Salivary gland imaging; with serial images 3 6 9 . 0 0 78231 TC Serial salivary imaging 3 05.83 78232 26 Salivary gland function study 9 4 . 5 0 78232 Salivary gland function study 3 7 6 . 2 0 78232 TC Salivary gland function exam 3 08.33 78258 26 Esophageal motility 1 1 7 . 0 0 78258 Esophageal motility 3 9 2 . 4 0 78258 TC Esophageal motility study 3 37.65 78261 26 Gastric mucosa imaging 1 2 0 . 6 0 78261 Gastric mucosa imaging 4 8 0 . 6 0 78261 TC Gastric mucosa imaging 4 23.10 78262 26 Gastroesophageal reflux study 1 2 3 . 3 0 78262 Gastroesophageal reflux study 4 9 3 . 2 0 78262 TC Gastroesophageal reflux exam 4 37.00 78264 26 Gastric emptying study 1 5 1 . 2 0 78264 Gastric emptying study 5 0 4 . 9 0 78264 TC Gastric emptying study 4 45.17 78270 26 Vitamin B-12 absorption study (eg, Schilling test); without intrinsic factor 3 4 . 2 0 78270 Vitamin B-12 absorption study (eg, Schilling test); without intrinsic factor 1 7 0 . 1 0 78270 TC Vit B-12 absorption exam 1 52.94 78271 26 Vitamin B-12 absorption study (eg, Schilling test); with intrinsic factor 4 1 . 4 0 78271 Vitamin B-12 absorption study (eg, Schilling test); with intrinsic factor 2 0 4 . 3 0 78271 TC Vit b-12 absrp exam int fac 1 84.73 78272 26 Vitamin B-12 absorption studies combined, with and without intrinsic factor 5 4 . 9 0 78272 Vitamin B-12 absorption studies combined, with and without intrinsic factor 2 7 1 . 8 0 78272 TC Vit b-12 absorp combined 2 38.14 78278 26 Acute gastrointestinal blood loss imaging 1 8 8 . 1 0 78278 Acute gastrointestinal blood loss imaging 6 2 6 . 4 0 78278 TC Acute GI blood loss imaging 5 50.16 78290 26 Bowel imaging (eg, ectopic gastric mucosa, Meckels localization, volvulus) 1 0 9 . 8 0 78290 Bowel imaging (eg, ectopic gastric mucosa, Meckels localization, volvulus) 3 6 9 . 0 0 78290 TC Meckels divert exam 3 36.84 78291 26 Peritoneal-venous shunt patency test (eg, for LeVeen, Denver shunt) 1 1 7 . 0 0 78291 Peritoneal-venous shunt patency test (eg, for LeVeen, Denver shunt) 3 9 2 . 4 0 78291 TC Leveen/shunt patency exam 3 34.62 78300 26 Bone and/or joint imaging; limited area 1 2 2 . 4 0 78300 Bone and/or joint imaging; limited area 4 0 6 . 8 0 78300 TC Bone imaging limited area 3 46.26 78305 26 Bone and/or joint imaging; multiple areas 1 4 4 . 0 0 78305 Bone and/or joint imaging; multiple areas 4 8 3 . 3 0 78305 TC Bone imaging multiple areas 4 10.38 78306 26 Bone and/or joint imaging; whole body 1 6 4 . 7 0 78306 Bone and/or joint imaging; whole body 5 4 8 . 1 0 78306 TC Bone imaging whole body 4 68.07 78315 26 Bone and/or joint imaging; three phase study 1 8 5 . 4 0 78315 Bone and/or joint imaging; three phase study 6 1 9 . 2 0 78315 TC Bone imaging 3 phase 5 41.52 78320 26 Bone and/or joint imaging; tomographic (SPECT) 1 9 8 . 9 0 78320 Bone and/or joint imaging; tomographic (SPECT) 7 9 2 . 9 0 78320 TC Bone imaging (3D) 6 39.32 78350 26 Bone density (bone mineral content) study, one or more sites; single photon absorptiometry 6 4 . 8 0 78350 Bone density (bone mineral content) study, one or more sites; single photon absorptiometry 2 1 6 . 0 0 101 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 78350 TC Bone mineral single photon 1 50.11 78351 B1 dns std 1+ sits dual phtn absrptm 1+ sits 2 33.90 78428 26 Cardiac shunt detection 1 3 4 . 1 0 78428 Cardiac shunt detection 3 3 5 . 7 0 78428 TC Cardiac shunt imaging 2 75.68 78445 26 Non-cardiac vascular flow imaging (ie, angiography, venography) 1 1 2 . 5 0 78445 Non-cardiac vascular flow imaging (ie, angiography, venography) 3 7 0 . 8 0 78445 TC Vascular flow imaging 3 28.42 78451 26 Myocardial spect single study at rest or stress 1 69.90 78451 Myocardial spect single study at rest or stress 6 00.93 78451 TC Myocardial spect single study at rest or stress 4 31.03 78452 26 Myocardial spect multiple studies 1 96.26 78452 Myocardial spect multiple studies 9 68.65 78452 TC Myocardial spect multiple studies 7 72.38 78453 26 Myocardial perfusion planar 1 study rest/stress 1 21.18 78453 Myocardial perfusion planar 1 study rest/stress 5 13.38 78453 TC Myocardial perfusion planar 1 study rest/stress 3 92.20 78454 26 Myocardial perfusion planar multiple studies 1 61.76 78454 Myocardial perfusion planar multiple studies 5 39.02 78454 TC Myocardial perfusion planar multiple studies 3 77.27 78456 26 Aqt ven thrombosis img peptide 1 29.45 78456 Aqt ven thrombosis img peptide 8 23.92 78456 TC Aqt ven thrombosis img peptide 6 94.47 78457 26 Venous thrombosis imaging, venogram; unilateral 1 0 1 . 7 0 78457 Venous thrombosis imaging, venogram; unilateral 3 4 2 . 0 0 78457 TC Venous thrombosis imaging 2 86.06 78458 26 Venous thrombosis imaging, venogram; bilateral 1 5 8 . 4 0 78458 Venous thrombosis imaging, venogram; bilateral 5 2 7 . 4 0 78458 TC Ven thrombosis images bilat 4 24.77 78466 26 Myocardial imaging, infarct avid, planar; qualitative or quantitative 1 3 1 . 4 0 78466 Myocardial imaging, infarct avid, planar; qualitative or quantitative 4 4 1 . 0 0 78466 TC Heart infarct image 3 71.78 78468 26 Myocardial imaging, infarct avid, planar; with ejection fraction by first pass technique 1 4 4 . 0 0 78468 Myocardial imaging, infarct avid, planar; with ejection fraction by first pass technique 4 7 7 . 9 0 78468 TC Heart infarct image (ef) 3 95.49 78469 26 Myocardial imaging, infarct avid, planar; tomographic SPECT with or without quantification 1 7 1 . 9 0 78469 Myocardial imaging, infarct avid, planar; tomographic SPECT with or without quantification 6 8 9 . 4 0 78469 TC Heart infarct image (3D) 5 67.89 78472 26 Cardiac blood pool imaging, gated equilibrium; planar, single study at rest or stress (exercise and/or 1 95.30 78472 Cardiac blood pool imaging, gated equilibrium; planar, single study at rest or stress (exercise and/or 6 51.60 78472 TC Gated heart planar single 5 33.70 78473 26 Cardiac blood pool imaging, gated equilibrium; multiple studies, wall motion study plus ejection fraction, at 2 99.70 78473 Cardiac blood pool imaging, gated equilibrium; multiple studies, wall motion study plus ejection fraction, at 9 97.20 78473 TC Gated heart multiple 7 83.46 78481 26 Cardiac blood pool imaging, (planar), first pass technique; single study, at rest or with stress (exercise 2 01.60 78481 Cardiac blood pool imaging, (planar), first pass technique; single study, at rest or with stress (exercise 6 69.60 78481 TC Heart first pass single 5 15.31 78483 26 Cardiac blood pool imaging, (planar), first pass technique; multiple studies, at rest and with stress (exercise 1 87.20 78483 Cardiac blood pool imaging, (planar), first pass technique; multiple studies, at rest and with stress (exercise 9 40.50 78483 TC Heart first pass multiple 6 95.14 78494 26 Heart image spect 1 63.27 78494 Cardiac blood pool imaging, gated equilibrium, SPECT, at rest, wall motion study plus ejection fraction, with 7 36.20 78494 TC Heart image spect 5 72.93 78496 26 Heart first pass add-on 1 13.47 78496 Cardiac blood pool imaging, gated equilibrium, single study, at rest, with right ventricular ejection fraction by 2 29.50 78496 TC Heart first pass add-on 1 16.03 78579 26 Lung ventilation imaging 6 4.63 78579 TC Lung ventilation imaging 5 63.47 78579 Lung ventilation imaging 6 28.10 78580 26 Pulmonary perfusion imaging, particulate 1 2 2 . 4 0 78580 Pulmonary perfusion imaging, particulate 4 0 8 . 6 0 78580 TC Lung perfusion imaging 3 54.80 78582 26 Lung ventilat&perfus imaging 1 38.36 78582 TC Lung ventilat&perfus imaging 9 63.43 78582 Lung ventilat&perfus imaging 1 ,101.79 78597 26 Lung perfusion differential 9 4.78 78597 TC Lung perfusion differential 5 89.53 78597 Lung perfusion differential 6 84.31 78598 26 Lung perf&ventilat diferentl 1 08.43 78598 TC Lung perf&ventilat diferentl 9 16.14 102 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 78598 Lung perf&ventilat diferentl 1 ,024.57 78600 26 Brain imaging, limited procedure; static 1 0 4 . 4 0 78600 Brain imaging, limited procedure; static 4 1 4 . 0 0 78600 TC Brain image < 4 views 3 72.10 78601 26 Brain imaging, limited procedure; with vascular flow 1 2 2 . 4 0 78601 Brain imaging, limited procedure; with vascular flow 4 8 7 . 8 0 78601 TC Brain image w/flow < 4 views 4 38.56 78605 26 Brain imaging, complete study; static 1 2 3 . 3 0 78605 Brain imaging, complete study; static 4 9 1 . 4 0 78605 TC Brain image 4+ views 4 33.91 78606 26 Brain imaging, complete study; with vascular flow 1 2 9 . 6 0 78606 Brain imaging, complete study; with vascular flow 5 1 3 . 9 0 78606 TC Brain image w/flow 4 + views 4 73.22 78607 26 Brain imaging, complete study; tomographic (SPECT) 2 0 7 . 0 0 78607 Brain imaging, complete study; tomographic (SPECT) 8 2 7 . 1 0 78607 TC Brain imaging (3D) 7 08.09 78609 26 Brn img p+ emij tomog prfuj eval 1 74.63 78609 Brn img p+ emij tomog prfuj eval 1 ,322.05 78610 26 Brain imaging, vascular flow only 7 3 . 8 0 78610 Brain imaging, vascular flow only 2 4 6 . 6 0 78610 TC Brain flow imaging only 2 28.75 78630 26 Cerebrospinal fluid flow, imaging (not including introduction of material); cisternography 1 4 4 . 0 0 78630 Cerebrospinal fluid flow, imaging (not including introduction of material); cisternography 6 3 6 . 6 8 78630 TC Cerebrospinal fluid scan 5 83.08 78635 26 Cerebrospinal fluid flow, imaging (not including introduction of material); ventriculography 1 0 5 . 3 0 78635 Cerebrospinal fluid flow, imaging (not including introduction of material); ventriculography 3 5 0 . 1 0 78635 TC CSF ventriculography 3 23.78 78645 26 Cerebrospinal fluid flow, imaging (not including introduction of material); shunt evaluation 1 2 3 . 3 0 78645 Cerebrospinal fluid flow, imaging (not including introduction of material); shunt evaluation 4 9 3 . 2 0 78645 TC CSF shunt evaluation 4 56.59 78647 26 Cerebrospinal fluid flow, imaging (not including introduction of material); tomographic (SPECT) 1 7 6 . 4 0 78647 Cerebrospinal fluid flow, imaging (not including introduction of material); tomographic (SPECT) 8 7 8 . 4 0 78647 TC Cerebrospinal fluid scan 7 86.20 78650 26 CSF leakage detection and localization 1 6 8 . 3 0 78650 CSF leakage detection and localization 6 7 1 . 4 0 78650 TC CSF leakage imaging 6 18.78 78660 26 Radiopharmaceutical dacryocystography 1 0 5 . 3 0 78660 Radiopharmaceutical dacryocystography 3 5 0 . 1 0 78660 TC Nuclear exam of tear flow 3 05.42 78700 26 Kidney imaging; static only 1 1 2 . 5 0 78700 Kidney imaging; static only 4 4 9 . 1 0 78700 TC Kidney imaging morphol 3 98.96 78701 26 Kidney imaging; with vascular flow 1 0 2 . 6 0 78701 Kidney imaging; with vascular flow 4 1 2 . 2 0 78701 TC Kidney imaging with flow 3 71.14 78707 26 Kidney imaging with vascular flow and function; single study without pharmacological intervention 1 6 9 . 2 0 78707 Kidney imaging with vascular flow and function; single study without pharmacological intervention 5 6 1 . 6 0 78707 TC K flow/funct image w/o drug 4 63.30 78708 26 Kidney imaging with vascular flow and function; single study, with pharmacological intervention (eg, 1 78.20 78708 Kidney imaging with vascular flow and function; single study, with pharmacological intervention (eg, 5 92.20 78708 TC K flow/funct image w/drug 4 12.52 78709 26 Kidney imaging with vascular flow and function; multiple studies, with and without pharmacological 1 85.40 78709 Kidney imaging with vascular flow and function; multiple studies, with and without pharmacological 6 17.40 78709 TC K flow/funct image multiple 5 16.85 78710 26 Kidney imaging, tomographic (SPECT) 1 7 1 . 0 0 78710 Kidney imaging, tomographic (SPECT) 6 8 5 . 8 0 78710 TC Kidney imaging (3D) 5 99.46 78725 26 Kidney function study, non-imaging radioisotopic study 8 2 . 8 0 78725 Kidney function study, non-imaging radioisotopic study 2 7 0 . 0 0 78725 TC Kidney function study 2 31.31 78730 26 Urinary bladder residual study 5 8 . 5 0 78730 Urinary bladder residual study 1 9 7 . 1 0 78730 TC Urinary bladder retention 1 77.78 78740 26 Ureteral reflux study (radiopharmaceutical voiding cystogram) 1 0 5 . 3 0 78740 Ureteral reflux study (radiopharmaceutical voiding cystogram) 3 5 0 . 1 0 78740 TC Ureteral reflux study 3 12.41 78761 26 Testicular imaging; with vascular flow 1 3 9 . 5 0 78761 Testicular imaging; with vascular flow 4 6 3 . 5 0 78761 TC Testicular imaging w/flow 3 97.17 78800 26 Radiopharmaceutical localization of tumor; limited area 1 2 2 . 4 0 103 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 78800 Radiopharmaceutical localization of tumor; limited area 4 0 8 . 6 0 78800 TC Tumor imaging limited area 3 45.92 78801 26 Radiopharmaceutical localization of tumor; multiple areas 1 5 1 . 2 0 78801 Radiopharmaceutical localization of tumor; multiple areas 5 0 4 . 0 0 78801 TC Tumor imaging mult areas 4 33.88 78802 26 Radiopharmaceutical localization of tumor; whole body 1 6 1 . 1 0 78802 Radiopharmaceutical localization of tumor; whole body 6 3 9 . 0 0 78802 TC Tumor imaging whole body 5 67.43 78803 26 Radiopharmaceutical localization of tumor; tomographic (SPECT) 1 8 5 . 4 0 78803 Radiopharmaceutical localization of tumor; tomographic (SPECT) 7 3 8 . 9 0 78803 TC Tumor imaging (3D) 6 40.97 78804 26 Rp loclzj tum/dstrbj agt whbdy req 2/> d img 1 85.68 78804 Rp loclzj tum/dstrbj agt whbdy req 2/> d img 1 ,723.26 78804 TC Rp loclzj tum/dstrbj agt whbdy req 2/> d img 1 ,537.58 78805 26 Radiopharmaceutical localization of inflammatory process; limited area 1 2 8 . 7 0 78805 Radiopharmaceutical localization of inflammatory process; limited area 4 2 8 . 4 0 78805 TC Abscess imaging ltd area 3 54.35 78806 26 Radiopharmaceutical localization of inflammatory process; whole body 1 8 5 . 4 0 78806 Radiopharmaceutical localization of inflammatory process; whole body 7 3 8 . 9 0 78806 TC Abscess imaging whole body 6 58.22 78807 26 Radiopharmaceutical localization of inflammatory process; tomographic (SPECT) 1 8 4 . 5 0 78807 Radiopharmaceutical localization of inflammatory process; tomographic (SPECT) 7 3 8 . 9 0 78807 TC Nuclear localization/abscess 6 41.83 78808 Njx rp loclzj non-img probe study intravenous 1 85.07 79005 26 Rp ther oral admn 3 96.85 79005 Rp ther oral admn 7 57.99 79005 TC Rp ther oral admn 3 61.14 79101 26 Rp ther iv admn 4 24.82 79101 Rp ther iv admn 7 81.38 79101 TC Rp ther iv admn 3 56.56 79200 26 Intracavitary radioactive colloid therapy 3 1 3 . 2 0 79200 Intracavitary radioactive colloid therapy 5 2 1 . 1 0 79200 TC Nuclear rx intracav admin 1 99.42 79403 26 Rp ther radiolbld monoclonal antb iv nfs 5 08.30 79403 Rp ther radiolbld monoclonal antb iv nfs 1 ,097.46 79403 TC Rp ther radiolbld monoclonal antb iv nfs 5 89.16 79440 26 Intra-articular radiopharmaceutical therapy 3 9 5 . 1 0 79440 Intra-articular radiopharmaceutical therapy 6 5 8 . 8 0 79440 TC Nuclear rx intra-articular 2 36.36 80047 Metabolic panel ionized ca 4 0.47 80048 Basic metabolic panel This panel must include the following: Calcium (82310) Carbon dioxide (82374) 3 5.13 80050 General health panel This panel must include the following: Comprehensive metabolic panel (80053) 9 2.38 80051 Electrolyte panel This panel must include the following: Carbon dioxide (82374) Chloride (82435) Potassium 3 2.38 80053 Comprehensive metabolic panel This panel must include the following: Albumin (82040) Bilirubin, total 4 4.50 80061 Lipid panel This panel must include the following: Cholesterol, serum, total (82465) Lipoprotein, direct 5 9.76 80069 Renal function panel This panel must include the following: Albumin (82040) Calcium (82310) Carbon 3 5.68 80074 Acute hepatitis panel This panel must include the following: Hepatitis A antibody (HAAb), IgM antibody 1 37.37 80076 Hepatic function panel This panel must include the following: Albumin (82040) Bilirubin, total (82247) 4 5.97 80102 Drug confirmation, each procedure 9 8 . 1 0 80150 Amikacin 8 0 . 1 0 80152 Amitriptyline 8 7 . 3 0 80154 Benzodiazepines 8 7 . 3 0 80156 Carbamazepine; total 6 4 . 8 0 80157 Assay carbamazepine free 4 8.78 80158 Cyclosporine 8 5 . 0 6 80160 Desipramine 9 3 . 6 0 80162 Digoxin 4 5 . 4 9 80164 Dipropylacetic acid (valproic acid) 4 6 . 9 6 80166 Doxepin 8 1 . 0 0 80168 Ethosuximide 7 3 . 8 0 80170 Gentamicin 7 6 . 5 0 80172 Gold 8 6 . 4 0 80173 Haloperidol 7 8 . 3 0 80174 Imipramine 8 7 . 3 0 80176 Lidocaine 7 8 . 3 0 80178 Lithium 2 9 . 9 6 80182 Nortriptyline 8 6 . 4 0 80184 Phenobarbital 6 9 . 3 0 80185 Phenytoin; total 6 2 . 1 0 80186 Phenytoin; free 8 3 . 7 0 104 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 80188 Primidone 7 2 . 9 0 80190 Procainamide; 7 2 . 9 0 80192 Procainamide; with metabolites (eg, n-acetyl procainamide) 7 9 . 2 0 80194 Quinidine 7 3 . 8 0 80195 Assay of sirolimus 6 6.33 80196 Salicylate 5 0 . 4 0 80197 Tacrolimus 1 0 4 . 4 0 80198 Theophylline 6 1 . 2 0 80200 Tobramycin 9 9 . 0 0 80201 Topiramate 6 9 . 3 0 80202 Vancomycin 7 2 . 0 0 80299 Quantitative assay drug 5 4.77 80400 ACTH stimulation panel; for adrenal insufficiency This panel must include the following: Cortisol (82533 x 2) 1 2 3 . 3 0 80402 ACTH stimulation panel; for 21 hydroxylase deficiency This panel must include the following: Cortisol (82533 2 57.40 80406 ACTH stimulation panel; for 3 beta-hydroxydehydrogenase deficiency This panel must include the following: 2 52.00 80500 Clinical pathology consultation; limited, without review of patient's history and medical records 5 9 . 4 0 80502 Clinical pathology consultation; comprehensive, for a complex diagnostic problem, with review of patient's 1 40.40 81000 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, 1 7.96 81001 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, 1 6.53 81002 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, 1 5.26 81003 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, 1 5.04 81005 Urinalysis; qualitative or semiquantitative, except immunoassays 1 6 . 5 4 81007 Urinalysis; bacteriuria screen, except by culture or dipstick 2 3 . 4 0 81015 Urinalysis; microscopic only 1 4 . 0 5 81020 Urinalysis; two or three glass test 1 5 . 8 2 81025 Urine pregnancy test, by visual color comparison methods 2 5 . 6 4 81050 Volume measurement for timed collection, each 2 2 . 5 0 82000 Acetaldehyde, blood 5 6 . 1 3 82003 Acetaminophen 7 7 . 4 0 82009 Acetone or other ketone bodies, serum; qualitative 2 7 . 0 0 82010 Acetone or other ketone bodies, serum; quantitative 6 4 . 8 0 82013 Acetylcholinesterase 6 3 . 0 0 82016 Acylcarnitines; qualitative, each specimen 8 4 . 6 0 82017 Acylcarnitines; quantitative, each specimen 9 0 . 9 0 82024 Adrenocorticotropic hormone (ACTH) 1 6 2 . 9 0 82030 Adenosine, 5-monophosphate, cyclic (cyclic AMP) 1 1 3 . 4 0 82040 Albumin; serum 1 9 . 5 0 82042 Albumin; urine or other source, quantitative, each specimen 3 6 . 0 0 82043 Albumin; urine, microalbumin, quantitative 6 4 . 8 0 82044 Albumin; urine, microalbumin, semiquantitative (eg, reagent strip assay) 2 3 . 3 3 82055 Alcohol (ethanol); any specimen except breath 6 1 . 2 0 82075 Alcohol (ethanol); breath 4 0 . 5 0 82085 Aldolase 5 0 . 4 0 82088 Aldosterone 1 5 8 . 4 0 82101 Alkaloids, urine, quantitative 1 1 5 . 2 0 82103 Alpha-1-antitrypsin; total 6 5 . 7 5 82104 Alpha-1-antitrypsin; phenotype 7 6 . 3 5 82105 Alpha-fetoprotein; serum 6 0 . 2 3 82106 Alpha-fetoprotein; amniotic fluid 6 3 . 8 3 82107 Alpha-fetoprotein l3 8 4.35 82108 Aluminum 1 0 8 . 0 0 82127 Amino acids; single, qualitative, each specimen 6 3 . 9 0 82128 Amino acids; multiple, qualitative, each specimen 4 8 . 6 0 82131 Amino acids; single, quantitative, each specimen 1 6 5 . 6 0 82135 Aminolevulinic acid, delta (ALA) 7 2 . 0 0 82136 Amino acids, 2 to 5 amino acids, quantitative, each specimen 1 0 2 . 6 0 82139 Amino acids, 6 or more amino acids, quantitative, each specimen 1 0 2 . 6 0 82140 Ammonia 8 1 . 0 0 82143 Amniotic fluid scan (spectrophotometric) 6 9 . 3 0 82145 Amphetamine or methamphetamine 8 2 . 8 0 82150 Amylase 2 4 . 5 9 82154 Androstanediol glucuronide 1 1 6 . 1 0 82157 Androstenedione 1 2 9 . 6 0 82160 Androsterone 9 9 . 3 1 82163 Angiotensin II 1 1 1 . 6 0 82164 Angiotensin I - converting enzyme (ACE) 7 6 . 5 0 82172 Apolipoprotein, each 7 7 . 4 0 82175 Arsenic 8 7 . 3 0 82180 Ascorbic acid (Vitamin C), blood 5 4 . 0 0 82190 Atomic absorption spectroscopy, each analyte 8 0 .

1 0 105 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 82205 Barbiturates, not elsewhere specified 6 2 . 1 0 82232 Beta-2 microglobulin 7 4 . 5 5 82239 Bile acids; total 7 8 . 3 0 82240 Bile acids; cholylglycine 1 2 3 . 3 0 82247 Bilirubin; total 1 9 . 5 0 82248 Bilirubin; direct 2 0 . 8 5 82252 Bilirubin; feces, qualitative 1 6 . 2 0 82261 Biotinidase, each specimen 6 5 . 7 0 82270 Blood, occult, by peroxidase activity (eg, guaiac); feces, 1-3 simultaneous determinations 1 5 . 1 4 82271 Occult blood other sources 1 2.71 82272 Occult bld feces 1-3 tests 1 1.59 82274 Assay test for blood fecal 4 6.67 82286 Bradykinin 1 2 8 . 7 0 82300 Cadmium 8 0 . 1 0 82306 Calcifediol (25-OH Vitamin D-3) 1 4 4 . 0 0 82308 Calcitonin 1 4 4 . 9 0 82310 Calcium; total 1 8 . 8 3 82330 Calcium; ionized 6 4 . 8 0 82331 Calcium; after calcium infusion test 3 5 . 1 0 82340 Calcium; urine quantitative, timed specimen 4 1 . 4 0 82355 Calculus (stone); qualitative analysis 6 5 . 7 0 82360 Calculus (stone); quantitative analysis, chemical 6 6 . 6 0 82365 Calculus (stone); infrared spectroscopy 6 6 . 6 0 82370 Calculus (stone); x-ray diffraction 6 3 . 9 0 82373 Carbohydrate deficient transferrin 3 8 . 7 0 82374 Carbon dioxide (bicarbonate) 2 6 . 1 0 82375 Carbon monoxide, (carboxyhemoglobin); quantitative 6 4 . 8 0 82376 Carbon monoxide, (carboxyhemoglobin); qualitative 2 1 . 6 0 82378 Carcinoembryonic antigen (CEA) 6 9 . 4 8 82379 Carnitine (total and free), quantitative, each specimen 9 0 . 9 0 82380 Carotene 5 6 . 7 0 82382 Catecholamines; total urine 1 1 1 . 6 0 82383 Catecholamines; blood 1 5 2 . 1 0 82384 Catecholamines; fractionated 1 3 3 . 2 0 82387 Cathepsin-D 1 1 1 . 6 0 82390 Ceruloplasmin 4 7 . 5 0 82397 Chemiluminescent assay 6 5 . 7 0 82415 Chloramphenicol 7 7 . 4 0 82435 Chloride; blood 2 1 . 6 0 82436 Chloride; urine 3 5 . 1 0 82438 Chloride; other source 2 6 . 1 0 82441 Chlorinated hydrocarbons, screen 3 0 . 6 0 82465 Cholesterol, serum or whole blood, total 1 9 . 7 3 82480 Cholinesterase; serum 5 0 . 4 0 82482 Cholinesterase; RBC 6 3 . 9 0 82485 Chondroitin B sulfate, quantitative 1 1 3 . 4 0 82486 Chromatography, qualitative; column (eg, gas liquid or HPLC), analyte not elsewhere specified 1 0 8 . 9 0 82487 Chromatography, qualitative; paper, 1-dimensional, analyte not elsewhere specified 8 6 . 4 0 82488 Chromatography, qualitative; paper, 2-dimensional, analyte not elsewhere specified 1 1 5 . 2 0 82489 Chromatography, qualitative; thin layer, analyte not elsewhere specified 7 7 . 4 0 82491 Chromatography, quantitative, column (eg, gas liquid or HPLC); single analyte not elsewhere specified, 8 7.30 82492 Chromatography, quantitative, column (eg, gas liquid or HPLC); multiple analytes, single stationary and 6 7.10 82495 Chromium 1 0 8 . 9 0 82507 Citrate 1 5 0 . 3 0 82520 Cocaine or metabolite 8 2 . 8 0 82523 Collagen cross links, any method 1 0 0 . 8 0 82525 Copper 4 9 . 3 6 82528 Corticosterone 1 0 2 . 6 0 82530 Cortisol; free 1 1 2 . 5 0 82533 Cortisol; total 6 0 . 1 6 82540 Creatine 2 5 . 4 5 82541 Column chromatography/mass spectrometry (eg, GC/MS, or HPLC/MS), analyte not elsewhere specified; 8 2.80 82542 Column chromatography/mass spectrometry (eg, GC/MS, or HPLC/MS), analyte not elsewhere specified; 8 2.80 82543 Column chromatography/mass spectrometry (eg, GC/MS, or HPLC/MS), analyte not elsewhere specified; 8 2.80 82544 Column chromatography/mass spectrometry (eg, GC/MS, or HPLC/MS), analyte not elsewhere specified; 8 2.80 82550 Creatine kinase (CK), (CPK); total 2 6 . 9 3 82552 Creatine kinase (CK), (CPK); isoenzymes 5 1 . 6 1 82553 Creatine kinase (CK), (CPK); MB fraction only 3 7 . 8 6 82554 Creatine kinase (CK), (CPK); isoforms 5 5 . 8 0 82565 Creatinine; blood 2 0 . 6 3 106 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 82570 Creatinine; other source 3 0 . 6 0 82575 Creatinine; clearance 3 9 . 2 1 82585 Cryofibrinogen 3 6 . 0 0 82595 Cryoglobulin, qualitative or semi-quantitative (eg, cryocrit) 3 6 . 9 0 82600 Cyanide 7 7 . 4 0 82607 Cyanocobalamin (Vitamin B-12); 5 8 . 3 6 82608 Cyanocobalamin (Vitamin B-12); unsaturated binding capacity 7 6 . 5 0 82615 Cystine and homocystine, urine, qualitative 5 2 . 2 0 82626 Dehydroepiandrosterone (DHEA) 1 2 2 . 4 0 82627 Dehydroepiandrosterone-sulfate (DHEA-S) 1 2 2 . 4 0 82633 Desoxycorticosterone, 11- 1 5 4 . 8 0 82634 Deoxycortisol, 11- 1 4 7 . 6 0 82638 Dibucaine number 4 8 . 6 0 82646 Dihydrocodeinone 9 4 . 5 0 82649 Dihydromorphinone 9 9 . 0 0 82651 Dihydrotestosterone (DHT) 1 0 8 . 0 0 82652 Dihydroxyvitamin D, 1,25- 1 6 2 . 0 0 82654 Dimethadione 9 1 . 8 0 82658 Enzyme activity in blood cells, cultured cells, or tissue, not elsewhere specified; radioactive substrate, each 8 2.80 82664 Electrophoretic technique, not elsewhere specified 1 0 2 . 6 0 82666 Epiandrosterone 9 9 . 0 0 82668 Erythropoietin 8 7 . 8 6 82670 Estradiol 7 5 . 6 9 82671 Estrogens; fractionated 1 1 8 . 1 7 82672 Estrogens; total 9 4 . 8 8 82677 Estriol 7 5 . 1 9 82679 Estrone 1 6 6 . 5 0 82690 Ethchlorvynol 9 2 . 7 0 82693 Ethylene glycol 8 0 . 1 0 82696 Etiocholanolone 1 2 7 . 8 0 82705 Fat or lipids, feces; qualitative 3 4 . 2 0 82710 Fat or lipids, feces; quantitative 1 0 7 . 1 0 82715 Fat differential, feces, quantitative 6 4 . 8 0 82725 Fatty acids, nonesterified 6 1 . 2 0 82728 Ferritin 5 3 . 2 7 82731 Assay of fetal fibronectin 1 06.77 82735 Fluoride 8 6 . 4 0 82742 Flurazepam 9 0 . 9 0 82746 Folic acid; serum 6 0 . 5 3 82747 Folic acid; RBC 8 8 . 2 0 82757 Fructose, semen 4 7 . 7 0 82759 Galactokinase, RBC 5 4 . 0 0 82760 Galactose 5 4 . 0 0 82775 Galactose-1-phosphate uridyl transferase; quantitative 7 1 . 1 0 82776 Galactose-1-phosphate uridyl transferase; screen 2 7 . 0 0 82784 Gammaglobulin; IgA, IgD, IgG, IgM, each 6 1 . 2 0 82785 Gammaglobulin; IgE 6 7 . 0 9 82787 Gammaglobulin; immunoglobulin subclasses, (IgG1, 2, 3, or 4), each 1 8 0 . 0 0 82800 Gases, blood, pH only 3 8 . 7 0 82803 Gases, blood, any combination of pH, pCO2, pO2, CO2, HCO3 (including calculated O2 saturation); 8 0 . 1 0 82805 Gases, blood, any combination of pH, pCO2, pO2, CO2, HCO3 (including calculated O2 saturation); with O2 9 0.90 82810 Gases, blood, O2 saturation only, by direct measurement, except pulse oximetry 4 7 . 7 0 82820 Hemoglobin-oxygen affinity (pO2 for 50% hemoglobin saturation with oxygen) 6 2 . 1 0 82930 Gastric analy w/ph ea spec 2 1.15 82938 Gastrin after secretin stimulation 8 6 . 4 0 82941 Gastrin 8 0 . 1 0 82943 Glucagon 9 4 . 5 0 82945 Glucose, body fluid, other than blood 3 5 . 1 4 82946 Glucagon tolerance test 5 9 . 4 0 82947 Glucose; quantitative, blood (except reagent strip) 1 6 . 9 4 82948 Glucose; blood, reagent strip 1 3 . 8 6 82950 Glucose; post glucose dose (includes glucose) 2 6 . 4 5 82951 Glucose; tolerance test (GTT), three specimens (includes glucose) 5 4 . 6 2 82952 Glucose; tolerance test, each additional beyond three specimens 2 7 . 3 6 82953 Glucose; tolbutamide tolerance test 7 2 . 9 0 82955 Glucose-6-phosphate dehydrogenase (G6PD); quantitative 7 1 . 1 0 82960 Glucose-6-phosphate dehydrogenase (G6PD); screen 2 8 . 6 3 82962 Glucose, blood by glucose monitoring device(s) cleared by the FDA specifically for home use 1 7 . 0 1 82963 Glucosidase, beta 8 2 . 8 0 82965 Glutamate dehydrogenase 2 8 . 8 0 107 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 82975 Glutamine (glutamic acid amide) 5 9 . 4 0 82977 Glutamyltransferase, gamma (GGT) 2 2 . 7 9 82978 Glutathione 5 9 . 4 0 82979 Glutathione reductase, RBC 4 6 . 8 0 82980 Glutethimide 8 4 . 6 0 82985 Glycated protein 4 0 . 9 0 83001 Gonadotropin; follicle stimulating hormone (FSH) 6 7 . 5 2 83002 Gonadotropin; luteinizing hormone (LH) 6 9 . 3 2 83003 Growth hormone, human (HGH) (somatotropin) 9 0 . 0 0 83008 Guanosine monophosphate (GMP), cyclic 9 0 . 9 0 83010 Haptoglobin; quantitative 7 1 . 1 0 83012 Haptoglobin; phenotypes 8 2 . 8 0 83015 Heavy metal (arsenic, barium, beryllium, bismuth, antimony, mercury); screen 1 2 9 . 6 0 83018 Heavy metal (arsenic, barium, beryllium, bismuth, antimony, mercury); quantitative, each 1 1 7 . 0 0 83020 26 Hemoglobin electrophoresis 4 8.11 83020 Hemoglobin fractionation and quantitation; electrophoresis (eg, A2, S, C, and/or F) 5 6 . 4 8 83021 Hemoglobin fractionation and quantitation; chromatography (eg, A2, S, C, and/or F) 6 9 . 9 1 83026 Hemoglobin; by copper sulfate method, non-automated 1 4 . 4 0 83030 Hemoglobin; F (fetal), chemical 4 5 . 0 0 83033 Hemoglobin; F (fetal), qualitative 2 7 . 0 0 83036 Hemoglobin; glycated 3 8 . 5 7 83037 Glycosylated hb home device 3 6.80 83045 Hemoglobin; methemoglobin, qualitative 2 2 . 5 0 83050 Hemoglobin; methemoglobin, quantitative 2 7 . 9 0 83051 Hemoglobin; plasma 3 3 . 3 0 83055 Hemoglobin; sulfhemoglobin, qualitative 2 7 . 0 0 83060 Hemoglobin; sulfhemoglobin, quantitative 4 3 . 2 0 83065 Hemoglobin; thermolabile 3 7 . 8 0 83068 Hemoglobin; unstable, screen 3 8 . 7 0 83069 Hemoglobin; urine 2 2 . 5 0 83070 Hemosiderin; qualitative 2 6 . 1 0 83071 Hemosiderin; quantitative 3 0 . 6 0 83080 b-Hexosaminidase, each assay 6 5 . 7 0 83088 Histamine 1 2 7 . 8 0 83090 Homocystine 7 8 . 3 0 83150 Homovanillic acid (HVA) 9 0 . 9 0 83491 Hydroxycorticosteroids, 17- (17-OHCS) 9 0 . 0 0 83497 Hydroxyindolacetic acid, 5-(HIAA) 7 2 . 9 0 83498 Hydroxyprogesterone, 17-d 1 2 0 . 6 0 83499 Hydroxyprogesterone, 20- 1 0 5 . 3 0 83500 Hydroxyproline; free 9 8 .1 0 83505 Hydroxyproline; total 1 2 1 . 5 0 83516 Immunoassay for analyte other than infectious agent antibody or infectious agent antigen, qualitative or 5 4.24 83518 Immunoassay for analyte other than infectious agent antibody or infectious agent antigen, qualitative or 7 7.40 83519 Immunoassay, analyte, quantitative; by radiopharmaceutical technique (eg, RIA) 8 5 . 5 0 83520 Immunoassay, analyte, quantitative; not otherwise specified 7 2 . 7 2 83525 Insulin; total 6 6 . 6 0 83527 Insulin; free 7 0 . 2 0 83528 Intrinsic factor 8 6 . 4 0 83540 Iron 2 3 . 1 6 83550 Iron binding capacity 3 3 . 3 8 83570 Isocitric dehydrogenase (IDH) 4 7 . 7 0 83582 Ketogenic steroids, fractionation 7 6 . 5 0 83586 Ketosteroids, 17- (17-KS); total 7 9 . 2 0 83593 Ketosteroids, 17- (17-KS); fractionation 1 4 2 . 2 0 83605 Lactate (lactic acid) 4 9 . 5 0 83615 Lactate dehydrogenase (LD), (LDH); 2 0 . 4 6 83625 Lactate dehydrogenase (LD), (LDH); isoenzymes, separation and quantitation 7 1 . 1 0 83630 Lactoferrin fecal (qual) 5 7.08 83631 Lactoferrin fecal (quant) 5 7.08 83632 Lactogen, human placental (HPL) human chorionic somatomammotropin 1 0 8 . 9 0 83633 Lactose, urine; qualitative 3 3 . 3 0 83634 Lactose, urine; quantitative 5 0 . 4 0 83655 Lead 5 1 . 3 0 83661 Fetal lung maturity assessment; lecithin sphingomyelin (L/S) ratio 1 2 3 . 3 0 83662 Fetal lung maturity assessment; foam stability test 7 2 . 0 0 83663 Fetal lung maturity assessment; fluorescence polarization 4 3 . 2 0 83664 Fetal lung maturity assessment; lamellar body density 2 4 . 3 0 83670 Leucine aminopeptidase (LAP) 4 3 . 2 0 83690 Lipase 3 8 . 7 0 108 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 83695 Assay of lipoprotein(a) 4 2.74 83698 Assay lipoprotein pla2 7 1.98 83700 Lipopro bld electrophoretic 5 4.59 83701 Lipoprotein bld hr fraction 7 8.62 83704 Lipoprotein bld by nmr 8 9.82 83718 Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol) 2 9 . 2 8 83719 Lipoprotein, direct measurement; direct measurement, VLDL cholesterol 4 7 . 7 0 83721 Lipoprotein, direct measurement; direct measurement, LDL cholesterol 3 6 . 9 0 83727 Luteinizing releasing factor (LRH) 9 2 . 7 0 83735 Magnesium 2 5 . 0 4 83775 Malate dehydrogenase 3 8 . 7 0 83785 Manganese 1 1 3 . 4 0 83788 Mass spectrometry and tandem mass spectrometry (MS, MS/MS), analyte not elsewhere specified; 8 2.80 83789 Mass spectrometry and tandem mass spectrometry (MS, MS/MS), analyte not elsewhere specified; 8 2.80 83805 Meprobamate 8 2 . 8 0 83825 Mercury, quantitative 9 0 . 0 0 83835 Metanephrines 1 0 2 . 6 0 83840 Methadone 8 7 . 3 0 83857 Methemalbumin 5 7 . 6 0 83858 Methsuximide 9 1 . 8 0 83864 Mucopolysaccharides, acid; quantitative 4 0 . 6 1 83866 Mucopolysaccharides, acid; screen 3 8 . 7 0 83872 Mucin, synovial fluid (Ropes test) 2 7 . 0 0 83873 Myelin basic protein, CSF 9 4 . 5 0 83874 Myoglobin 5 8 . 4 5 83876 Assay myeloperoxidase 7 0.01 83880 Assay of natriuretic peptide 7 4.87 83883 Nephelometry, each analyte not elsewhere specified 6 2 . 1 0 83885 Nickel 9 8 . 1 0 83887 Nicotine 9 0 . 9 0 83915 Nucleotidase 5- 4 5 . 0 0 83916 Oligoclonal immunoglobulin (oligoclonal bands) 9 3 . 6 0 83918 Organic acids; total, quantitative, each specimen 9 2 . 7 0 83919 Organic acids qual each 5 6.54 83921 Organic acid single quant 5 1.15 83925 Opiates, (eg, morphine, meperidine) 6 6 . 6 0 83930 Osmolality; blood 4 2 . 3 0 83935 Osmolality; urine 5 8 . 5 0 83937 Osteocalcin (bone g1a protein) 1 1 5 . 2 0 83945 Oxalate 7 2 . 9 0 83950 Oncoprotein her-2/neu 2 03.90 83951 Oncoprotein dcp 2 03.90 83970 Parathormone (parathyroid hormone) 1 2 4 . 2 0 83986 pH, body fluid, except blood 2 0 . 7 0 83987 Exhaled breath condensate 1 8.52 83992 Phencyclidine (PCP) 7 2 . 0 0 83993 Assay for calprotectin fecal 6 7.79 84022 Phenothiazine 6 8 . 4 0 84030 Phenylalanine (PKU), blood 1 9 . 1 9 84035 Phenylketones, qualitative 2 0 . 7 0 84060 Phosphatase, acid; total 4 1 . 5 7 84061 Phosphatase, acid; forensic examination 4 3 . 2 0 84066 Phosphatase, acid; prostatic 5 7 . 6 0 84075 Phosphatase, alkaline; 1 9 . 2 0 84078 Phosphatase, alkaline; heat stable (total not included) 4 6 . 8 0 84080 Phosphatase, alkaline; isoenzymes 7 7 . 4 0 84081 Phosphatidylglycerol 9 5 . 4 0 84085 Phosphogluconate, 6-, dehydrogenase, RBC 3 8 . 7 0 84087 Phosphohexose isomerase 4 7 . 7 0 84100 Phosphorus inorganic (phosphate); 1 7 . 4 0 84105 Phosphorus inorganic (phosphate); urine 3 1 . 5 0 84106 Porphobilinogen, urine; qualitative 3 3 . 3 0 84110 Porphobilinogen, urine; quantitative 4 8 . 6 0 84112 Placenta alpha micro ig c/v 6 2.66 84119 Porphyrins, urine; qualitative 4 4 . 1 0 84120 Porphyrins, urine; quantitation and fractionation 7 8 . 3 0 84126 Porphyrins, feces; quantitative 7 8 . 3 0 84127 Porphyrins, feces; qualitative 4 5 . 0 0 84132 Potassium; serum 1 8 . 7 5 84133 Potassium; urine 3 6 . 0 0 109 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 84134 Prealbumin 5 5 . 8 0 84135 Pregnanediol 8 8 . 2 0 84138 Pregnanetriol 8 6 . 4 0 84140 Pregnenolone 9 4 . 5 0 84143 17-hydroxypregnenolone 7 8 . 9 7 84144 Progesterone 6 6 . 0 4 84146 Prolactin 6 5 . 1 4 84150 Prostaglandin, each 9 7 . 2 0 84152 Prostate specific antigen (PSA); complexed (direct measurement) 6 4 . 2 4 84153 Prostate specific antigen (PSA); total 5 8 . 7 2 84154 Prostate specific antigen (PSA); free 8 4 . 6 0 84155 Protein; total, except refractometry 2 1 . 0 0 84156 Assay of protein urine 1 6.88 84157 Assay of protein other 1 5.80 84160 Protein; refractometric 1 7 . 1 0 84165 Protein; electrophoretic fractionation and quantitation 4 7 . 2 9 84166 26 Protein e-phoresis/urine/csf 4 8.11 84166 Protein e-phoresis/urine/csf 4 9.66 84181 26 Western blot test 4 8.11 84181 Protein; Western Blot, with interpretation and report, blood or other body fluid 9 1 . 8 0 84182 26 Protein western blot test 4 3.78 84182 Protein; Western Blot, with interpretation and report, blood or other body fluid, immunological probe for band 1 34.10 84202 Protoporphyrin, RBC; quantitative 7 1 . 1 0 84203 Protoporphyrin, RBC; screen 2 7 . 9 0 84206 Proinsulin 9 7 . 2 0 84207 Pyridoxal phosphate (Vitamin B-6) 1 2 9 . 6 0 84210 Pyruvate 6 6 . 6 0 84220 Pyruvate kinase 5 7 . 6 0 84228 Quinine 6 3 . 9 0 84233 Receptor assay; estrogen 1 9 2 . 6 0 84234 Receptor assay; progesterone 1 9 2 . 6 0 84235 Receptor assay; endocrine, other than estrogen or progesterone (specify hormone) 2 3 6 . 7 0 84238 Receptor assay; non-endocrine (eg, acetylcholine) (specify receptor) 1 9 1 . 7 0 84244 Renin 1 0 5 . 3 0 84252 Riboflavin (Vitamin B-2) 8 2 . 8 0 84255 Selenium 8 7 . 3 0 84260 Serotonin 1 5 6 . 6 0 84270 Sex hormone binding globulin (SHBG) 1 0 0 . 8 0 84275 Sialic acid 7 8 . 3 0 84285 Silica 1 2 7 . 8 0 84295 Sodium; serum 2 4 . 3 0 84300 Sodium; urine 2 4 . 3 0 84302 Assay of sweat sodium 1 7.46 84305 Somatomedin 1 2 3 . 3 0 84307 Somatostatin 9 9 . 0 0 84311 Spectrophotometry, analyte not elsewhere specified 3 6 . 9 0 84315 Specific gravity (except urine) 1 4 . 4 0 84375 Sugars, chromatographic, TLC or paper chromatography 4 9 . 5 0 84402 Testosterone; free 1 0 1 . 5 2 84403 Testosterone; total 7 9 . 8 2 84425 Thiamine (Vitamin B-1) 1 1 1 . 6 0 84430 Thiocyanate 6 6 . 6 0 84432 Thyroglobulin 1 0 0 . 8 0 84436 Thyroxine; total 2 6 . 3 7 84437 Thyroxine; requiring elution (eg, neonatal) 3 5 . 1 0 84439 Thyroxine; free 4 5 . 9 1 84442 Thyroxine binding globulin (TBG) 6 5 . 7 0 84443 Thyroid stimulating hormone (TSH) 6 1 . 9 2 84445 Thyroid stimulating immunoglobulins (TSI) 2 3 0 . 4 0 84446 Tocopherol alpha (Vitamin E) 6 6 . 6 0 84449 Transcortin (cortisol binding globulin) 8 2 . 8 0 84450 Transferase; aspartate amino (AST) (SGOT) 2 1 . 0 4 84460 Transferase; alanine amino (ALT) (SGPT) 2 2 . 4 2 84466 Transferrin 4 3 . 9 8 84478 Triglycerides 2 0 . 1 9 84479 Thyroid hormone (T3 or T4) uptake or thyroid hormone binding ratio (THBR) 3 1 . 9 4 84480 Triiodothyronine T3; total (TT-3) 5 7 . 9 8 84481 Triiodothyronine T3; free 7 5 . 4 7 84482 Triiodothyronine T3; reverse 7 8 . 7 3 84485 Trypsin; duodenal fluid 3 6 . 0 0 110 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 84488 Trypsin; feces, qualitative 2 8 . 8 0 84490 Trypsin; feces, quantitative, 24-hour collection 2 4 . 3 0 84510 Tyrosine 4 4 . 1 0 84520 Urea nitrogen; quantitative 2 0 .1 9 84525 Urea nitrogen; semiquantitative (eg, reagent strip test) 1 3 . 5 9 84540 Urea nitrogen, urine 2 5 . 8 9 84545 Urea nitrogen, clearance 3 6 . 0 0 84550 Uric acid; blood 2 0 . 1 9 84560 Uric acid; other source 3 3 . 3 0 84577 Urobilinogen, feces, quantitative 5 7 . 6 0 84578 Urobilinogen, urine; qualitative 1 5 . 3 0 84580 Urobilinogen, urine; quantitative, timed specimen 3 6 . 0 0 84583 Urobilinogen, urine; semiquantitative 1 7 . 1 0 84585 Vanillylmandelic acid (VMA), urine 6 9 . 3 0 84586 Assay of vip 1 12.57 84588 Vasopressin (antidiuretic hormone, ADH) 1 4 0 . 4 0 84590 Vitamin A 8 3 . 7 0 84591 Vitamin, not otherwise specified 6 2 . 1 0 84597 Vitamin K 8 7 . 3 0 84600 Volatiles (eg, acetic anhydride, carbon tetrachloride, dichloroethane, dichloromethane, diethylether, 5 7.60 84620 Xylose absorption test, blood and/or urine 6 8 . 4 0 84630 Zinc 5 9 . 4 0 84681 C-peptide 9 9 . 0 0 84702 Gonadotropin, chorionic (hCG); quantitative 6 0 . 6 8 84703 Gonadotropin, chorionic (hCG); qualitative 3 1 . 9 9 84704 Hcg free betachain test 5 4.40 84830 Ovulation tests, by visual color comparison methods for human luteinizing hormone 5 4 . 0 0 85002 Bleeding time 2 5 . 6 1 85004 Automated diff wbc count 1 8.87 85007 Blood count; manual differential WBC count (includes RBC morphology and platelet estimation) 1 7 . 8 5 85008 Blood count; manual blood smear examination without differential parameters 1 5 . 3 0 85009 Blood count; differential WBC count, buffy coat 2 0 . 7 0 85013 Blood count; spun microhematocrit 1 5 . 3 0 85014 Blood count; other than spun hematocrit 1 5 . 3 0 85018 Blood count; hemoglobin 1 4 . 2 4 85025 Blood count; hemogram and platelet count, automated, and automated complete differential WBC count 2 6.32 85027 Blood count; hemogram and platelet count, automated 2 4 . 2 7 85032 Manual cell count each 1 9.02 85041 Blood count; red blood cell (RBC) only 1 4 . 8 3 85044 Blood count; reticulocyte count, manual 2 0 . 7 4 85045 Blood count; reticulocyte count, flow cytometry 2 0 . 6 8 85048 Blood count; white blood cell (WBC) 1 8 . 9 0 85049 Automated platelet count 1 6.68 85060 Blood smear, peripheral, interpretation by physician with written report 5 6 . 7 0 85097 Bone marrow; smear interpretation only, with or without differential cell count 1 3 9 . 5 0 85130 Chromogenic substrate assay 5 5 . 8 0 85170 Clot retraction 2 2 . 5 0 85175 Clot lysis time, whole blood dilution 3 6 . 0 0 85210 Clotting; factor II, prothrombin, specific 5 4 . 0 0 85220 Clotting; factor V (AcG or proaccelerin), labile factor 1 0 0 . 8 0 85230 Clotting; factor VII (proconvertin, stable factor) 1 1 6 . 1 0 85240 Clotting; factor VIII (AHG), one stage 1 0 2 . 6 0 85244 Clotting; factor VIII related antigen 1 2 6 . 0 0 85245 Clotting; factor VIII, VW factor, ristocetin cofactor 1 0 5 . 3 0 85246 Clotting; factor VIII, VW factor antigen 1 0 5 . 3 0 85247 Clotting; factor VIII, von Willebrand factor, multimetric analysis 1 0 5 . 3 0 85250 Clotting; factor IX (PTC or Christmas) 1 1 7 . 0 0 85260 Clotting; factor X (Stuart-Prower) 9 7 . 2 0 85270 Clotting; factor XI (PTA) 9 7 . 2 0 85280 Clotting; factor XII (Hageman) 9 7 . 2 0 85290 Clotting; factor XIII (fibrin stabilizing) 1 0 0 . 8 0 85291 Clotting; factor XIII (fibrin stabilizing), screen solubility 5 6 . 7 0 85292 Clotting; prekallikrein assay (Fletcher factor assay) 1 0 2 . 6 0 85293 Clotting; high molecular weight kininogen assay (Fitzgerald factor assay) 1 0 2 . 6 0 85300 Clotting inhibitors or anticoagulants; antithrombin III, activity 6 2 . 8 0 85301 Clotting inhibitors or anticoagulants; antithrombin III, antigen assay 5 5 . 2 4 85302 Clotting inhibitors or anticoagulants; protein C, antigen 1 3 3 . 2 0 85303 Clotting inhibitors or anticoagulants; protein C, activity 7 2 . 7 7 85305 Clotting inhibitors or anticoagulants; protein S, total 1 2 8 . 7 0 85306 Clotting inhibitors or anticoagulants; protein S, free 7 6 . 8 1 111 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 85307 Activated Protein C (APC) resistance assay 1 0 7 . 1 0 85335 Factor inhibitor test 5 9 . 4 0 85337 Thrombomodulin 5 5 . 8 0 85345 Coagulation time; Lee and White 1 3 . 9 3 85347 Coagulation time; activated 2 1 . 6 0 85348 Coagulation time; other methods 2 8 . 8 0 85360 Euglobulin lysis 4 6 . 8 0 85362 Fibrin(ogen) degradation (split) products (FDP)(FSP); agglutination slide, semiquantitative 4 2 . 3 0 85366 Fibrin(ogen) degradation (split) products (FDP)(FSP); paracoagulation 4 7 . 7 0 85370 Fibrin(ogen) degradation (split) products (FDP)(FSP); quantitative 6 2 . 1 0 85378 Fibrin degradation products, D-dimer; semiquantitative 2 7 . 6 7 85379 Fibrin degradation products, D-dimer; quantitative 5 6 . 7 0 85380 Fibrin degradj d-dimer 5 2.91 85384 Fibrinogen; activity 4 4 . 1 0 85385 Fibrinogen; antigen 4 5 . 0 0 85390 Fibrinolysins or coagulopathy screen, interpretation and report 4 6 . 8 0 85396 Coagj/fbrnlys assay whl bld use additive pr d 4 1.59 85397 Clotting funct activity 6 5.98 85400 Fibrinolytic factors and inhibitors; plasmin 4 7 . 7 0 85410 Fibrinolytic factors and inhibitors; alpha-2 antiplasmin 4 7 . 7 0 85415 Fibrinolytic factors and inhibitors; plasminogen activator 6 5 . 7 0 85420 Fibrinolytic factors and inhibitors; plasminogen, except antigenic assay 5 1 . 3 0 85421 Fibrinolytic factors and inhibitors; plasminogen, antigenic assay 9 8 . 1 0 85441 Heinz bodies; direct 1 5 . 3 0 85445 Heinz bodies; induced, acetyl phenylhydrazine 2 8 . 8 0 85460 Hemoglobin or RBCs, fetal, for fetomaternal hemorrhage; differential lysis (Kleihauer-Betke) 4 1 . 4 0 85461 Hemoglobin or RBCs, fetal, for fetomaternal hemorrhage; rosette 4 4 . 1 0 85475 Hemolysin, acid 5 5 . 8 0 85520 Heparin assay 7 0 . 2 0 85525 Heparin neutralization 6 3 . 9 0 85530 Heparin-protamine tolerance test 7 6 . 5 0 85536 Iron stain, peripheral blood 3 8 . 7 0 85540 Leukocyte alkaline phosphatase with count 5 0 . 4 0 85547 Mechanical fragility, RBC 4 8 . 6 0 85549 Muramidase 9 2 . 7 0 85555 Osmotic fragility, RBC; unincubated 4 4 . 1 0 85557 Osmotic fragility, RBC; incubated 8 3 . 7 0 85576 26 Blood platelet aggregation 3 3.67 85576 Platelet; aggregation (in vitro), each agent 8 2 . 8 0 85597 Platelet neutralization 7 2 . 0 0 85598 Hexagnal phosph pltlt neutrl 6 6.30 85610 Prothrombin time; 1 6 . 0 9 85611 Prothrombin time; substitution, plasma fractions, each 2 6 . 1 0 85612 Russell viper venom time (includes venom); undiluted 4 7 . 7 0 85613 Russell viper venom time (includes venom); diluted 5 6 . 7 0 85635 Reptilase test 4 5 . 0 0 85651 Sedimentation rate, erythrocyte; non-automated 1 4 . 6 0 85652 Sedimentation rate, erythrocyte; automated 1 3 . 2 5 85660 Sickling of RBC, reduction 1 6 . 8 0 85670 Thrombin time; plasma 3 6 . 0 0 85675 Thrombin time; titer 3 6 . 0 0 85705 Thromboplastin inhibition; tissue 6 4 . 8 0 85730 Thromboplastin time, partial (PTT); plasma or whole blood 2 0 . 3 0 85732 Thromboplastin time, partial (PTT); substitution, plasma fractions, each 3 4 . 2 0 85810 Viscosity 4 6 . 8 0 86000 Agglutinins, febrile (eg, Brucella, Francisella, Murine typhus, Q fever, Rocky Mountain spotted fever, scrub 5 9.40 86001 Allergen specific IgG quantitative or semiquantitative, each allergen 1 8 . 9 0 86003 Allergen specific IgE; quantitative or semiquantitative, each allergen 1 8 . 3 9 86005 Allergen specific IgE; qualitative, multiallergen screen (dipstick, paddle or disk) 4 6 .8 0 86021 Antibody identification; leukocyte antibodies 1 1 3 . 4 0 86022 Antibody identification; platelet antibodies 1 6 4 . 7 0 86023 Antibody identification; platelet associated immunoglobulin assay 8 4 . 6 0 86038 Antinuclear antibodies (ANA); 4 6 . 5 4 86039 Antinuclear antibodies (ANA); titer 6 5 . 7 0 86060 Antistreptolysin 0; titer 3 0 . 2 8 86063 Antistreptolysin 0; screen 2 6 . 2 0 86077 Blood bank physician services; difficult cross match and/or evaluation of irregular antibody(s), interpretation 1 23.30 86078 Blood bank physician services; investigation of transfusion reaction including suspicion of transmissible 1 24.20 86079 Blood bank physician services; authorization for deviation from standard blood banking procedures (eg, use 1 13.40 86140 C-reactive protein 2 6 . 2 0 112 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 86141 C-reactive protein hs 3 9.84 86146 Beta 2 Glycoprotein I antibody, each 1 3 7 . 7 0 86147 Cardiolipin (phospholipid) antibody, each Ig class 9 3 . 9 7 86155 Chemotaxis assay, specify method 5 1 . 3 0 86156 Cold agglutinin; screen 3 1 . 5 0 86157 Cold agglutinin; titer 3 6 . 9 0 86160 Complement; antigen, each component 5 9 . 6 4 86161 Complement; functional activity, each component 5 9 . 6 4 86162 Complement; total hemolytic (CH50) 1 1 8 . 8 0 86171 Complement fixation tests, each antigen 7 9 . 2 0 86185 Counterimmunoelectrophoresis, each antigen 4 9 . 5 0 86200 Ccp antibody 6 0.48 86215 Deoxyribonuclease, antibody 6 6 . 6 0 86225 Deoxyribonucleic acid (DNA) antibody; native or double stranded 5 9 . 1 8 86226 Deoxyribonucleic acid (DNA) antibody; single stranded 6 6 . 6 0 86235 Extractable nuclear antigen, antibody to, any method (eg, nRNP, SS-A, SS-B, Sm, RNP, Sc170, J01), each 6 5.00 86243 Fc receptor 9 0 . 0 0 86255 26 Fluorescent antibody screen 3 0.55 86255 Fluorescent noninfectious agent antibody; screen, each antibody 5 0 . 5 9 86256 26 Fluorescent antibody titer 2 8.02 86256 Fluorescent noninfectious agent antibody; titer, each antibody 7 9 . 2 0 86277 Growth hormone, human (HGH), antibody 7 2 . 0 0 86280 Hemagglutination inhibition test (HAI) 4 9 . 5 0 86294 Immunoassay tumor qual 1 25.22 86300 Immunoassay for tumor antigen, quantitative; CA 15-3 (27.29) 7 3 . 3 2 86301 Immunoassay for tumor antigen, quantitative; CA 19-9 9 7 . 2 0 86304 Immunoassay for tumor antigen, quantitative; CA 125 7 3 . 3 2 86308 Heterophile antibodies; screening 2 1 . 5 8 86309 Heterophile antibodies; titer 4 2 . 3 0 86310 Heterophile antibodies; titers after absorption with beef cells and guinea pig kidney 4 2 . 3 0 86316 Immunoassay for tumor antigen; other antigen, quantitative (eg, CA 50, 72-4, 549), each 7 1 . 9 7 86317 Immunoassay for infectious agent antibody, quantitative, not otherwise specified 7 8 . 3 0 86318 Immunoassay for infectious agent antibody, qualitative or semiquantitative, single step method (eg, reagent 5 3.71 86320 26 Serum immunoelectrophoresis 4 3.05 86320 Immunoelectrophoresis; serum 8 9 . 3 4 86325 26 Other immunoelectrophoresis 3 5.94 86325 Immunoelectrophoresis; other fluids (eg, urine, CSF) with concentration 1 2 9 . 6 0 86327 26 Immunoelectrophoresis assay 3 0.11 86327 Immunoelectrophoresis; crossed (2-dimensional assay) 8 6 . 4 0 86329 Immunodiffusion; not elsewhere specified 7 2 . 0 0 86331 Immunodiffusion; gel diffusion, qualitative (Ouchterlony), each antigen or antibody 6 0 . 0 9 86332 Immune complex assay 1 1 3 . 4 0 86334 26 Immunofix e-phoresis serum 3 1.14 86334 Immunofixation electrophoresis 8 0 . 5 6 86335 26 Immunfix e-phorsis/urine/csf 3 1.24 86335 Immunfix e-phorsis/urine/csf 1 41.90 86336 Inhibin A 1 23.77 86337 Insulin antibodies 8 6 . 6 4 86340 Intrinsic factor antibodies 8 0 . 1 0 86341 Islet cell antibody 6 6 . 6 0 86343 Leukocyte histamine release test (LHR) 6 8 . 4 0 86344 Leukocyte phagocytosis 4 3 . 2 0 86353 Lymphocyte transformation, mitogen (phytomitogen) or antigen induced blastogenesis 2 0 0 . 7 0 86355 B cells total count 1 45.98 86356 Mononuclear cell antigen 1 31.19 86357 Nk cells total count 1 60.16 86359 T cells; total count 1 4 4 . 0 0 86360 T cell absolute count/ratio 1 64.67 86361 T cells; absolute CD4 count 1 2 3 . 3 0 86367 Stem cells total count 1 67.25 86376 Microsomal antibodies (eg, thyroid or liver-kidney), each 8 8 . 2 0 86378 Migration inhibitory factor test (MIF) 9 0 . 9 0 86382 Neutralization test, viral 9 0 . 9 0 86384 Nitroblue tetrazolium dye test (NTD) 5 4 . 0 0 86403 Particle agglutination; screen, each antibody 3 2 . 0 4 86406 Particle agglutination; titer, each antibody 3 8 . 7 0 86430 Rheumatoid factor; qualitative 3 3 . 7 7 86431 Rheumatoid factor; quantitative 3 7 . 8 0 86480 Tb test cell immun measure 7 8.05 86481 Tb ag response t-cell susp 7 8.05 113 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 86485 Skin test; candida 2 6 . 1 0 86486 Skin test unlisted antigen each 1 5.85 86490 Skin test; coccidioidomycosis 2 9 . 7 0 86510 Skin test; histoplasmosis 2 7 . 9 0 86580 Skin test; tuberculosis, intradermal 2 0 . 7 0 86590 Streptokinase, antibody 3 4 . 2 0 86592 Syphilis test; qualitative (eg, VDRL, RPR, ART) 2 5 . 8 1 86593 Syphilis test; quantitative 2 7 . 5 8 86602 Antibody; actinomyces 5 9 . 4 0 86603 Antibody; adenovirus 5 7 . 8 7 86606 Antibody; Aspergillus 7 9 . 2 0 86609 Antibody; bacterium, not elsewhere specified 1 0 8 . 0 0 86611 Antibody; Bartonella 5 5 . 8 0 86612 Antibody; Blastomyces 7 0 . 2 0 86615 Antibody; Bordetella 6 7 . 9 5 86617 Antibody; Borrelia burgdorferi (Lyme disease) confirmatory test (eg, Western blot or immunoblot) 1 0 0 . 8 0 86618 Antibody; Borrelia burgdorferi (Lyme disease) 9 8 . 1 0 86619 Antibody; Borrelia (relapsing fever) 7 2 . 9 0 86622 Antibody; Brucella 4 4 . 1 0 86625 Antibody; Campylobacter 9 2 . 7 0 86628 Antibody; Candida 8 2 . 8 0 86631 Antibody; Chlamydia 5 5 . 5 3 86632 Antibody; Chlamydia, IgM 6 6 . 6 0 86635 Antibody; Coccidioides 8 0 . 1 0 86638 Antibody; Coxiella Brunetii (Q fever) 7 3 . 8 0 86641 Antibody; Cryptococcus 5 6 . 7 0 86644 Antibody; cytomegalovirus (CMV) 7 1 . 1 1 86645 Antibody; cytomegalovirus (CMV), IgM 7 3 . 9 0 86648 Antibody; Diphtheria 8 2 . 8 0 86651 Antibody; encephalitis, California (La Crosse) 7 0 . 2 0 86652 Antibody; encephalitis, Eastern equine 7 0 . 2 0 86653 Antibody; encephalitis, St. Louis 7 0 . 2 0 86654 Antibody; encephalitis, Western equine 7 0 . 2 0 86658 Antibody; enterovirus (eg, coxsackie, echo, polio) 9 0 . 9 0 86663 Antibody; Epstein-Barr (EB) virus, early antigen (EA) 7 7 . 1 8 86664 Antibody; Epstein-Barr (EB) virus, nuclear antigen (EBNA) 8 2 . 8 0 86665 Antibody; Epstein-Barr (EB) virus, viral capsid (VCA) 8 7 . 3 0 86666 Antibody; Ehrlichia 5 5 . 8 0 86668 Antibody; Francisella Tularensis 5 2 . 2 0 86671 Antibody; fungus, not elsewhere specified 9 4 . 5 0 86674 Antibody; Giardia Lamblia 7 5 . 6 0 86677 Antibody; Helicobacter pylori 8 0 . 0 8 86682 Antibody; helminth, not elsewhere specified 9 4 . 5 0 86684 Antibody; Hemophilus influenza 8 4 . 6 0 86687 Antibody; HTLV-I 5 8 . 7 7 86688 Antibody; HTLV-II 5 4 . 5 0 86689 Antibody; HTLV or HIV antibody, confirmatory test (eg, Western Blot) 9 3 . 9 2 86692 Antibody; hepatitis, delta agent 9 1 . 8 0 86694 Antibody; herpes simplex, non-specific type test 7 0 . 0 0 86695 Antibody; herpes simplex, type I 6 9 . 5 5 86696 Antibody; herpes simplex, type 2 6 8 . 6 5 86698 Antibody; histoplasma 7 1 . 1 0 86701 Antibody; HIV-1 5 8 . 1 2 86702 Antibody; HIV-2 6 7 . 5 0 86703 Antibody; HIV-1 and HIV-2, single assay 5 4 . 5 2 86704 Hepatitis B core antibody (HBcAb); total 5 1 . 9 3 86705 Hepatitis B core antibody (HBcAb); IgM antibody 7 6 . 5 0 86706 Hepatitis B surface antibody (HBsAb) 4 4 . 3 0 86707 Hepatitis Be antibody (HBeAb) 5 3 . 6 2 86708 Hepatitis A antibody (HAAb); total 5 3 . 9 4 86709 Hepatitis A antibody (HAAb); IgM antibody 6 6 . 6 0 86710 Antibody; influenza virus 6 6 . 6 0 86713 Antibody; Legionella 8 4 . 6 0 86717 Antibody; Leishmania 6 5 . 7 0 86720 Antibody; Leptospira 7 0 . 2 0 86723 Antibody; Listeria monocytogenes 7 0 . 2 0 86727 Antibody; lymphocytic choriomeningitis 7 0 . 2 0 86729 Antibody; Lymphogranuloma Venereum 7 2 . 0 0 86732 Antibody; mucormycosis 7 0 . 2 0 86735 Antibody; mumps 8 0 . 1 0 114 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 86738 Antibody; Mycoplasma 8 4 . 6 0 86741 Antibody; Neisseria meningitidis 7 0 . 2 0 86744 Antibody; Nocardia 7 0 . 2 0 86747 Antibody; parvovirus 8 3 . 7 0 86750 Antibody; Plasmodium (malaria) 7 0 . 2 0 86753 Antibody; protozoa, not elsewhere specified 6 5 . 7 0 86756 Antibody; respiratory syncytial virus 7 0 . 2 0 86757 Antibody; Rickettsia 1 0 5 . 3 0 86759 Antibody; rotavirus 7 5 . 6 0 86762 Antibody; rubella 3 4 . 8 8 86765 Antibody; rubeola 9 0 . 9 0 86768 Antibody; Salmonella 7 2 . 0 0 86771 Antibody; Shigella 7 0 . 2 0 86774 Antibody; tetanus 8 7 . 3 0 86777 Antibody; Toxoplasma 6 9 . 3 0 86778 Antibody; Toxoplasma, IgM 9 0 . 0 0 86780 Treponema pallidum 4 9.96 86784 Antibody; trichinella 7 8 . 3 0 86787 Antibody; varicella-zoster 7 7 . 4 0 86788 West nile virus ab igm 6 3.23 86789 West nile virus antibody 6 2.04 86790 Antibody; virus, not elsewhere specified 8 7 . 3 9 86793 Antibody; Yersinia 7 2 . 0 0 86800 Thyroglobulin antibody 8 4 . 6 0 86803 Hepatitis C antibody; 7 1 . 4 4 86804 Hepatitis C antibody; confirmatory test (eg, immunoblot) 1 1 3 . 4 0 86805 Lymphocytotoxicity assay, visual crossmatch; with titration 2 4 1 . 2 0 86806 Lymphocytotoxicity assay, visual crossmatch; without titration 1 8 3 . 6 0 86807 Serum screening for cytotoxic percent reactive antibody (PRA); standard method 1 4 4 . 0 0 86808 Serum screening for cytotoxic percent reactive antibody (PRA); quick method 1 1 2 . 5 0 86812 HLA typing; A, B, or C (eg, A10, B7, B27), single antigen 1 1 1 . 0 5 86813 HLA typing; A, B, or C, multiple antigens 1 6 4 . 7 0 86816 HLA typing; DR/DQ, single antigen 1 7 5 . 5 0 86817 HLA typing; DR/DQ, multiple antigens 4 0 6 . 8 0 86821 HLA typing; lymphocyte culture, mixed (MLC) 3 9 1 . 5 0 86822 HLA typing; lymphocyte culture, primed (PLC) 1 4 0 . 4 0 86850 Antibody screen, RBC, each serum technique 2 4 . 2 6 86870 Antibody identification, RBC antibodies, each panel for each serum technique 6 1 . 2 0 86880 Antihuman globulin test (Coombs test); direct, each antiserum 1 9 . 9 3 86885 Antihuman globulin test (Coombs test); indirect, qualitative, each antiserum 2 0 . 6 2 86886 Antihuman globulin test (Coombs test); indirect, titer, each antiserum 2 8 . 9 0 86890 Autologous blood or component, collection processing and storage; predeposited 1 1 7 .0 0 86900 Blood typing; ABO 1 7 . 2 3 86901 Blood typing; Rh (D) 1 8 . 2 0 86902 Blood type antigen donor ea 1 7.46 86904 Blood typing; antigen screening for compatible unit using patient serum, per unit screened 2 0 . 5 6 86905 Blood typing; RBC antigens, other than ABO or Rh (D), each 2 0 . 7 0 86906 Blood typing; Rh phenotyping, complete 2 9 . 7 0 86940 Hemolysins and agglutinins; auto, screen, each 3 7 . 8 0 86941 Hemolysins and agglutinins; incubated 4 7 . 7 0 87001 Animal inoculation, small animal; with observation 6 2 . 1 0 87003 Animal inoculation, small animal; with observation and dissection 7 8 . 3 0 87015 Concentration (any type), for infectious agents 3 8 . 7 0 87040 Culture, bacterial; blood, with isolation and presumptive identification of isolates (includes anaerobic culture, 3 4.47 87045 Culture, bacterial; stool, with isolation and preliminary examination (eg, KIA, LIA), Salmonella and Shigella 3 6.27 87046 Stool cultr aerobic bact ea 3 5.98 87070 Culture, bacterial; any other source except urine, blood or stool, with isolation and presumptive identification 3 2.27 87071 Culture aerobic quant other 3 5.98 87073 Culture bacteria anaerobic 3 8.23 87075 Culture, bacterial; any source, anaerobic with isolation and presumptive identification of isolates 3 4 . 9 2 87076 Culture, bacterial; anaerobic isolate, additional methods required for definitive identification, each isolate 5 6 . 7 0 87077 Culture aerobic identify 3 7.57 87081 Culture, presumptive, pathogenic organisms, screening only; 2 4 . 6 6 87084 Culture, presumptive, pathogenic organisms, screening only; with colony estimation from density chart 3 4 . 2 0 87086 Culture, bacterial; quantitative colony count, urine 2 7 . 7 4 87088 Culture, bacterial; with isolation and presumptive identification of isolates, urine 2 6 . 5 2 87101 Culture, fungi (mold or yeast) isolation, with presumptive identification of isolates; skin, hair, or nail 2 6 . 9 8 87102 Culture, fungi (mold or yeast) isolation, with presumptive identification of isolates; other source (except 3 2.07 87103 Culture, fungi (mold or yeast) isolation, with presumptive identification of isolates; blood 5 6 . 7 0 87106 Culture, fungi, definitive identification, each organism; yeast 2 7 . 4 2 115 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 87107 Culture, fungi, definitive identification, each organism; mold 4 7 . 7 0 87109 Culture, mycoplasma, any source 6 0 . 8 4 87110 Culture, chlamydia, any source 5 2 . 4 6 87116 Culture, tubercle or other acid-fast bacilli (eg, TB, AFB, mycobacteria) any source, with isolation and 6 2.10 87118 Culture, mycobacterial, definitive identification, each isolate 5 8 . 5 0 87140 Culture, typing; immunofluorescent method, each antiserum 3 6 . 0 0 87143 Culture, typing; gas liquid chromatography (GLC) or high pressure liquid chromatography (HPLC) method 6 8 . 4 0 87147 Culture, typing; immunologic method, other than immunofluoresence (eg, agglutination grouping), per 2 4.30 87149 Culture, typing; identification by nucleic acid probe 7 6 . 5 0 87150 Dna/rna amplified probe 6 1.94 87152 Culture, typing; identification by pulse field gel typing 2 4 . 3 0 87153 Dna/rna sequencing 1 03.30 87158 Culture, typing; other methods 2 4 . 3 0 87164 26 Dark field examination 3 2.96 87164 Dark field examination, any source (eg, penile, vaginal, oral, skin); includes specimen collection 6 2 . 1 0 87166 Dark field examination 3 7.65 87168 Macroscopic exam arthropod 1 9.30 87169 Macroscopic exam parasite 1 9.30 87172 Pinworm exam 1 9.30 87176 Homogenization, tissue, for culture 3 3 . 3 0 87177 Ova and parasites, direct smears, concentration and identification 4 1 . 0 2 87181 Susceptibility studies, antimicrobial agent; agar dilution method, per agent (eg, antibiotic gradient strip) 2 8 . 8 0 87184 Susceptibility studies, antimicrobial agent; disk method, per plate (12 or fewer agents) 2 8 . 4 0 87185 Microbe susceptible enzyme 2 1.83 87186 Susceptibility studies, antimicrobial agent; microdilution or agar dilution (minimum inhibitory concentration 3 4.20 87187 Susceptibility studies, antimicrobial agent; microdilution or agar dilution, minimum lethal concentration 3 6.90 87188 Susceptibility studies, antimicrobial agent; macrobroth dilution method, each agent 3 0 . 6 0 87190 Susceptibility studies, antimicrobial agent; mycobacteria, proportion method, each agent 2 6 . 1 0 87197 Serum bactericidal titer (Schlicter test) 5 6 . 7 0 87205 Smear, primary source with interpretation; Gram or Giemsa stain for bacteria, fungi, or cell types 2 1 . 2 7 87206 Smear, primary source with interpretation; fluorescent and/or acid fast stain for bacteria, fungi, parasites, 4 8.60 87207 Smear, primary source with interpretation; special stain for inclusion bodies or intracellular parasites (eg, 3 7.58 87209 Smear complex stain 2 9.42 87210 Smear, primary source with interpretation; wet mount for infectious agents (eg, saline, India ink, KOH preps) 2 0 . 6 4 87220 Tissue examination by KOH slide of samples from skin, hair, or nails for fungi or ectoparasite ova or mites 2 6.10 87230 Toxin or antitoxin assay, tissue culture (eg, Clostridium difficile toxin) 8 5 . 5 0 87250 Virus isolation; inoculation of embryonated eggs, or small animal, includes observation and dissection 9 5 . 4 0 87252 Virus isolation; tissue culture inoculation, observation, and presumptive identification by cytopathic effect 9 2 . 7 0 87253 Virus isolation; tissue culture, additional studies or definitive identification (eg, hemabsorption, 7 5.60 87254 Virus inoculation shell via 6 6.93 87255 Genet virus isolate hsv 7 3.90 87260 Infectious agent antigen detection by immunofluorescent technique; adenovirus 6 3 . 9 0 87265 Infectious agent antigen detection by immunofluorescent technique; Bordetella pertussis/parapertussis 6 3 . 9 0 87267 Enterovirus antibody dfa 3 8.38 87269 Giardia ag if 3 8.38 87270 Infectious agent antigen detection by immunofluorescent technique; Chlamydia trachomatis 5 2 . 6 9 87271 Cytomegalovirus dfa 4 4.89 87272 Infectious agent antigen detection by immunofluorescent technique; cryptosporidium/giardia 5 2 . 6 9 87273 Infectious agent antigen detection by immunofluorescent technique; Herpes simplex virus type 2 6 3 . 9 0 87274 Infectious agent antigen detection by immunofluorescent technique; Herpes simplex virus type 1 5 1 . 7 9 87275 Infectious agent antigen detection by immunofluorescent technique; Influenza B virus 6 2 . 1 0 87276 Infectious agent antigen detection by immunofluorescent technique; influenza A virus 6 2 . 1 0 87277 Infectious agent antigen detection by immunofluorescent technique; Legionella micdadei 6 2 . 1 0 87278 Infectious agent antigen detection by immunofluorescent technique; Legionella pneumophila 6 2 . 1 0 87279 Infectious agent antigen detection by immunofluorescent technique; Parainfluenza virus, each type 6 2 . 1 0 87280 Infectious agent antigen detection by immunofluorescent technique; respiratory syncytial virus 6 2 . 1 0 87281 Infectious agent antigen detection by immunofluorescent technique; Pneumocystis carinii 6 2 . 1 0 87283 Infectious agent antigen detection by immunofluorescent technique; Rubeola 6 2 . 1 0 87285 Infectious agent antigen detection by immunofluorescent technique; Treponema pallidum 6 2 . 1 0 87290 Infectious agent antigen detection by immunofluorescent technique; Varicella zoster virus 6 2 . 1 0 87299 Infectious agent antigen detection by immunofluorescent technique; not otherwise specified, each organism 5 1 . 7 9 87300 Infectious agent antigen detection by immunofluorescent technique, polyvalent for multiple organisms, each 2 7.00 87301 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, 6 2.10 87305 Aspergillus ag eia 3 1.87 87320 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, 4 2.46 87324 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, 6 2.10 87327 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, 6 2.10 87328 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, 6 2.10 87329 Giardia ag eia 3 1.87 87332 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, 6 2.10 116 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 87335 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, 6 2.10 87336 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, 6 2.10 87337 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, 6 2.10 87338 Hpylori stool eia 3 1.22 87339 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, 5 5.80 87340 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, 4 2.94 87341 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, 5 5.80 87350 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, 5 6.70 87380 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, 6 6.60 87385 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, 5 5.80 87390 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, 6 5.77 87391 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, 6 5.77 87400 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, 2 7.00 87420 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, 5 5.80 87425 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, 5 5.80 87427 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, 5 5.80 87430 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, 3 9.31 87449 Infectious agent antigen detection by enzyme immunoassay technique qualitative or semiquantitative; 6 2.10 87450 Infectious agent antigen detection by enzyme immunoassay technique qualitative or semiquantitative; single 4 3.20 87451 Infectious agent antigen detection by enzyme immunoassay technique qualitative or semiquantitative; 4 3.20 87470 Infectious agent detection by nucleic acid (DNA or RNA); Bartonella henselae and Bartonella quintana, 7 6.50 87471 Infectious agent detection by nucleic acid (DNA or RNA); Bartonella henselae and Bartonella quintana, 1 35.90 87472 Infectious agent detection by nucleic acid (DNA or RNA); Bartonella henselae and Bartonella quintana, 1 64.70 87475 Infectious agent detection by nucleic acid (DNA or RNA); Borrelia burgdorferi, direct probe technique 7 6 . 5 0 87476 Infectious agent detection by nucleic acid (DNA or RNA); Borrelia burgdorferi, amplified probe technique 1 3 5 . 9 0 87477 Infectious agent detection by nucleic acid (DNA or RNA); Borrelia burgdorferi, quantification 1 6 4 . 7 0 87480 Infectious agent detection by nucleic acid (DNA or RNA); Candida species, direct probe technique 7 6 . 5 0 87481 Infectious agent detection by nucleic acid (DNA or RNA);

Candida species, amplified probe technique 1 3 5 . 9 0 87482 Infectious agent detection by nucleic acid (DNA or RNA); Candida species, quantification 1 6 1 . 1 0 87485 Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia pneumoniae, direct probe technique 7 6 . 5 0 87486 Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia pneumoniae, amplified probe 1 35.90 87487 Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia pneumoniae, quantification 1 6 4 . 7 0 87490 Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, direct probe technique 7 1 . 1 0 87491 Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique 1 3 5 . 9 0 87492 Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, quantification 1 3 4 . 1 0 87493 C diff amplified probe 8 1.36 87495 Infectious agent detection by nucleic acid (DNA or RNA); cytomegalovirus, direct probe technique 7 6 . 5 0 87496 Infectious agent detection by nucleic acid (DNA or RNA); cytomegalovirus, amplified probe technique 1 3 5 . 9 0 87497 Infectious agent detection by nucleic acid (DNA or RNA); cytomegalovirus, quantification 1 6 4 . 7 0 87498 Enterovirus probe&revrs trns 1 06.58 87500 Vanomycin dna amp probe 1 06.58 87501 Influenza dna amp prob 1+ 1 14.48 87502 Influenza dna amp probe 1 30.94 87503 Influenza dna amp prob addl 9 9.59 87510 Infectious agent detection by nucleic acid (DNA or RNA); Gardnerella vaginalis, direct probe technique 7 6 . 5 0 87511 Infectious agent detection by nucleic acid (DNA or RNA); Gardnerella vaginalis, amplified probe technique 1 3 5 . 9 0 87512 Infectious agent detection by nucleic acid (DNA or RNA); Gardnerella vaginalis, quantification 1 6 1 . 1 0 87515 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis B virus, direct probe technique 5 8 . 9 9 87516 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis B virus, amplified probe technique 1 3 5 . 9 0 87517 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis B virus, quantification 1 6 4 . 7 0 87520 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, direct probe technique 5 8 . 9 9 87521 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, amplified probe technique 1 1 8 . 8 0 87522 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, quantification 1 9 8 . 0 0 87525 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis G, direct probe technique 7 6 . 5 0 87526 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis G, amplified probe technique 1 3 5 . 9 0 87527 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis G, quantification 1 6 1 . 1 0 87528 Infectious agent detection by nucleic acid (DNA or RNA); Herpes simplex virus, direct probe technique 8 0 . 1 0 87529 Infectious agent detection by nucleic acid (DNA or RNA); Herpes simplex virus, amplified probe technique 1 3 5 . 9 0 87530 Infectious agent detection by nucleic acid (DNA or RNA); Herpes simplex virus, quantification 1 2 4 . 0 8 87531 Infectious agent detection by nucleic acid (DNA or RNA); Herpes virus-6, direct probe technique 7 6 . 5 0 87532 Infectious agent detection by nucleic acid (DNA or RNA); Herpes virus-6, amplified probe technique 1 3 5 . 9 0 87533 Infectious agent detection by nucleic acid (DNA or RNA); Herpes virus-6, quantification 1 6 1 . 1 0 87534 Infectious agent detection by nucleic acid (DNA or RNA); HIV-1, direct probe technique 7 6 . 5 0 87535 Infectious agent detection by nucleic acid (DNA or RNA); HIV-1, amplified probe technique 1 3 5 . 9 0 87536 Infectious agent detection by nucleic acid (DNA or RNA); HIV-1, quantification 2 5 7 . 4 0 87537 Infectious agent detection by nucleic acid (DNA or RNA); HIV-2, direct probe technique 8 0 . 1 0 87538 Infectious agent detection by nucleic acid (DNA or RNA); HIV-2, amplified probe technique 1 3 5 . 9 0 87539 Infectious agent detection by nucleic acid (DNA or RNA); HIV-2, quantification 1 6 4 . 7 0 87540 Infectious agent detection by nucleic acid (DNA or RNA); Legionella pneumophila, direct probe technique 7 6 . 5 0 87541 Infectious agent detection by nucleic acid (DNA or RNA); Legionella pneumophila, amplified probe 1 35.90 117 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 87542 Infectious agent detection by nucleic acid (DNA or RNA); Legionella pneumophila, quantification 1 6 1 . 1 0 87550 Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria species, direct probe technique 7 6 . 5 0 87551 Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria species, amplified probe technique 1 3 5 . 9 0 87552 Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria species, quantification 1 6 4 . 7 0 87555 Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria tuberculosis, direct probe technique 7 6 . 5 0 87556 Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria tuberculosis, amplified probe 1 35.90 87557 Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria tuberculosis, quantification 1 2 4 . 0 8 87560 Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria avium-intracellulare, direct probe 7 6.50 87561 Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria avium-intracellulare, amplified probe 1 35.90 87562 Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria avium-intracellulare, quantification 1 6 4 . 7 0 87580 Infectious agent detection by nucleic acid (DNA or RNA); Mycoplasma pneumoniae, direct probe technique 7 6 . 5 0 87581 Infectious agent detection by nucleic acid (DNA or RNA); Mycoplasma pneumoniae, amplified probe 1 35.90 87582 Infectious agent detection by nucleic acid (DNA or RNA); Mycoplasma pneumoniae, quantification 1 6 1 . 1 0 87590 Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, direct probe technique 8 0 . 1 0 87591 Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, amplified probe technique 1 3 5 . 9 0 87592 Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, quantification 1 6 4 . 7 0 87620 Infectious agent detection by nucleic acid (DNA or RNA); papillomavirus, human, direct probe technique 5 8 . 9 9 87621 Infectious agent detection by nucleic acid (DNA or RNA); papillomavirus, human, amplified probe technique 1 0 9 . 4 3 87622 Infectious agent detection by nucleic acid (DNA or RNA); papillomavirus, human, quantification 1 6 1 . 1 0 87640 Staph a dna amp probe 8 2.17 87641 Mr-staph dna amp probe 8 2.17 87650 Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, direct probe technique 7 6 . 5 0 87651 Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, amplified probe technique 1 3 5 . 9 0 87652 Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, quantification 1 6 1 . 1 0 87653 Strep b dna amp probe 8 2.17 87660 Trichomonas vagin dir probe 4 2.31 87797 Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; direct probe technique, 7 6.50 87798 Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe 1 35.90 87799 Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; quantification, each 1 64.70 87802 Strep b assay w/optic 3 8.38 87803 Clostridium toxin a w/optic 3 8.38 87804 Influenza assay w/optic 3 4.32 87807 Rsv assay w/optic 3 8.38 87808 Trichomonas assay w/optic 3 8.38 87809 Adenovirus assay w/optic 3 8.38 87810 Infectious agent detection by immunoassay with direct optical observation; Chlamydia trachomatis 5 5 . 8 0 87850 Infectious agent detection by immunoassay with direct optical observation; Neisseria gonorrhoeae 5 5 . 8 0 87880 Infectious agent detection by immunoassay with direct optical observation; Streptococcus, group A 5 5 . 8 0 87899 Infectious agent detection by immunoassay with direct optical observation; not otherwise specified 4 6 . 0 5 87901 Genotype dna hiv reverse t 4 86.60 87902 Genotype dna/rna hep c 4 86.60 87903 Phenotype dna hiv w/culture 8 88.83 87904 Phenotype dna hiv w/clt add 8 5.91 87905 Sialidase enzyme assay 4 6.63 87906 Genotype dna/rna hiv 1 03.39 88000 Necropsy (autopsy), gross examination only; without CNS 8 9 1 . 0 0 88005 Necropsy (autopsy), gross examination only; with brain 1 , 1 1 3 . 3 0 88007 Necropsy (autopsy), gross examination only; with brain and spinal cord 1 , 1 7 6 . 3 0 88012 Necropsy (autopsy), gross examination only; infant with brain 1 , 0 0 8 . 0 0 88014 Necropsy (autopsy), gross examination only; stillborn or newborn with brain 9 9 8 . 1 0 88016 Necropsy (autopsy), gross examination only; macerated stillborn 8 9 1 . 0 0 88020 Necropsy (autopsy), gross and microscopic; without CNS 1 , 1 7 6 . 3 0 88025 Necropsy (autopsy), gross and microscopic; with brain 1 , 3 1 3 . 1 0 88027 Necropsy (autopsy), gross and microscopic; with brain and spinal cord 1 , 3 9 1 . 4 0 88028 Necropsy (autopsy), gross and microscopic; infant with brain 1 , 1 6 1 . 0 0 88029 Necropsy (autopsy), gross and microscopic; stillborn or newborn with brain 1 , 1 6 1 . 0 0 88036 Necropsy (autopsy), limited, gross and/or microscopic; regional 9 3 9 . 6 0 88037 Necropsy (autopsy), limited, gross and/or microscopic; single organ 7 5 6 . 0 0 88040 Necropsy (autopsy); forensic examination 2 , 8 8 9 . 0 0 88104 26 Cytopath fl nongyn smears 3 3.51 88104 Cytopathology, fluids, washings or brushings, except cervical or vaginal; smears with interpretation 9 4 . 4 4 88104 TC Cytopath fl nongyn smears 6 0.93 88106 26 Cytopath fl nongyn filter 1 7.04 88106 Cytopathology, fluids, washings or brushings, except cervical or vaginal; filter method only with 8 1.51 88106 TC Cytopath fl nongyn filter 6 4.46 88108 26 Cytopath concentrate tech 2 7.70 88108 Cytopathology, concentration technique, smears and interpretation (eg, Saccomanno technique) 1 0 5 . 3 0 88108 TC Cytopath concentrate tech 7 7.60 88112 26 Cytp slctv cell enhancement interpj xcpt c/v 1 68.70 88112 Cytp slctv cell enhancement interpj xcpt c/v 3 07.74 118 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 88112 TC Cytp slctv cell enhancement interpj xcpt c/v 1 39.04 88120 26 Cytp insitu hybrid urine spec 3-5 probes ea mnl 1 46.37 88120 Cytp insitu hybrid urine spec 3-5 probes ea mnl 1 ,335.40 88120 TC Cytp insitu hybrid urine spec 3-5 probes ea mnl 1 ,189.03 88121 26 Cytp insitu hybrid urne spec 3-5 probes cptr ea 1 35.86 88121 Cytp insitu hybrid urne spec 3-5 probes cptr ea 1 ,138.87 88121 TC Cytp insitu hybrid urne spec 3-5 probes cptr ea 1 ,003.01 88125 26 Cytp forensic 3 8.83 88125 Cytp forensic 6 4.93 88125 TC Cytp forensic 2 6.10 88130 Sex chromatin identification; Barr bodies 5 6 . 7 0 88140 Sex chromatin identification; peripheral blood smear, polymorphonuclear drumsticks 3 6 . 0 7 88141 Cytopathology, cervical or vaginal (any reporting system); requiring interpretation by physician (List 4 1.51 88142 Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin 5 4.42 88143 Cytopath c/v thin layer redo 6 2.30 88147 Cytopath c/v automated 5 6.87 88148 Cytopath c/v auto rescreen 6 1.22 88150 Cytopathology, slides, cervical or vaginal; manual screening under physician supervision 3 1 . 6 2 88152 Cytopathology, slides, cervical or vaginal; with manual screening and computer-assisted rescreening under 3 4.20 88153 Cytopathology, slides, cervical or vaginal; with manual screening and rescreening under physician 3 0.60 88154 Cytopathology, slides, cervical or vaginal; with manual screening and computer-assisted rescreening using 3 0.60 88155 Cytopathology, slides, cervical or vaginal, definitive hormonal evaluation (eg, maturation index, 3 6.90 88160 26 Cytopath smear other source 2 5.25 88160 Cytopathology, smears, any other source; screening and interpretation 6 6 . 3 8 88160 TC Cytopath smear other source 4 1.13 88161 26 Cytopath smear other source 2 6.87 88161 Cytopathology, smears, any other source; preparation, screening and interpretation 7 0 . 2 0 88161 TC Cytopath smear other source 4 3.33 88162 26 Cytopath smear other source 5 1.60 88162 Cytopathology, smears, any other source; extended study involving over 5 slides and/or multiple stains 1 3 3 . 2 0 88162 TC Cytopath smear other source 8 1.60 88164 Cytopathology, slides, cervical or vaginal (the Bethesda System); manual screening under physician 3 3.30 88165 Cytopathology, slides, cervical or vaginal (the Bethesda System); with manual screening and rescreening 3 0.60 88166 Cytopathology, slides, cervical or vaginal (the Bethesda System); with manual screening and computer- 3 0.60 88167 Cytopathology, slides, cervical or vaginal (the Bethesda System); with manual screening and computer- 3 0.60 88172 26 Cytp dx eval fna 1st ea site 8 9.95 88172 Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy of 1 44.00 88172 TC Cytp dx eval fna 1st ea site 5 4.05 88173 26 Cytopath eval fna report 7 8.34 88173 Cytopathology, evaluation of fine needle aspirate; interpretation and report 1 7 5 . 5 0 88173 TC Cytopath eval fna report 9 7.16 88174 Cytopath c/v auto in fluid 6 4.19 88175 Cytopath c/v auto fluid redo 6 7.52 88177 26 Cytp c/v auto thin lyr prepj adequacy ea eval 3 7.13 88177 Cytp c/v auto thin lyr prepj adequacy ea eval 4 8.41 88177 TC Cytp c/v auto thin lyr prepj adequacy ea eval 1 1.27 88182 26 Flo cytometry cell cycle/dna alys 1 44.95 88182 Flo cytometry cell cycle/dna alys 3 68.04 88182 TC Flo cytometry cell cycle/dna alys 2 23.10 88184 Flo cytometry cell surf marker techl only 1st 1 82.21 88185 Flo cytometry cell surf marker techl only ea 1 34.89 88187 Flo cytometry interpj 2-8 markers 2 54.03 88188 Flo cytometry interpj 9-15 markers 3 17.39 88189 Flo cytometry interpj 16/> markers 4 16.98 88230 Tissue culture for non-neoplastic disorders; lymphocyte 2 3 7 . 3 6 88233 Tissue culture for non-neoplastic disorders; skin or other solid tissue biopsy 4 6 3 . 5 0 88235 Tissue culture for non-neoplastic disorders; amniotic fluid or chorionic villus cells 3 5 7 . 8 9 88237 Tissue culture for neoplastic disorders; bone marrow, blood cells 3 8 6 . 1 0 88239 Tissue culture for neoplastic disorders; solid tumor 4 7 3 . 4 0 88240 Cell cryopreserve/storage 3 02.21 88241 Frozen cell preparation 2 27.89 88245 Chromosome analysis for breakage syndromes; baseline Sister Chromatid Exchange (SCE), 20-25 cells 4 3 7 . 4 0 88248 Chromosome analysis for breakage syndromes; baseline breakage, score 50-100 cells, count 20 cells, 2 4 32.90 88249 Chromosome analysis 100 8 87.07 88261 Chromosome analysis; count 5 cells, 1 karyotype, with banding 5 4 6 . 3 0 88262 Chromosome analysis; count 15-20 cells, 2 karyotypes, with banding 4 6 4 . 7 8 88263 Chromosome analysis; count 45 cells for mosaicism, 2 karyotypes, with banding 6 0 7 . 5 0 88264 Chromosome analysis 20-25 9 52.60 88267 Chromosome analysis, amniotic fluid or chorionic villus, count 15 cells, 1 karyotype, with banding 6 6 9 . 6 0 88269 Chromosome analysis, in situ for amniotic fluid cells, count cells from 6-12 colonies, 1 karyotype, with 4 68.15 119 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 88280 Chromosome analysis; additional karyotypes, each study 1 2 2 . 2 2 88283 Chromosome analysis; additional specialized banding technique (eg, NOR, C-banding) 1 8 5 . 4 0 88285 Chromosome analysis; additional cells counted, each study 5 8 . 5 0 88289 Chromosome analysis; additional high resolution study 1 3 0 . 5 0 88291 Cytogenetics&molec cytogenetics i&r 1 55.70 88300 26 Surgical path gross 1 6.41 88300 Level I - Surgical pathology, gross examination only 5 6 . 7 0 88300 TC Surgical path gross 4 0.29 88302 26 Tissue exam by pathologist 1 7.92 88302 Level II - Surgical pathology, gross and microscopic examination 8 6 . 1 7 88302 TC Tissue exam by pathologist 6 8.25 88304 26 Tissue exam by pathologist 2 5.81 88304 Level III - Surgical pathology, gross and microscopic examination 1 0 8 . 8 2 88304 TC Tissue exam by pathologist 8 3.02 88305 26 Tissue exam by pathologist 7 2.55 88305 Level IV - Surgical pathology, gross and microscopic examination 1 4 4 . 8 4 88305 TC Tissue exam by pathologist 7 2.28 88307 26 Tissue exam by pathologist 5 9.81 88307 Level V - Surgical pathology, gross and microscopic examination 2 3 0 . 2 5 88307 TC Tissue exam by pathologist 1 70.44 88309 26 Tissue exam by pathologist 1 10.95 88309 Level VI - Surgical pathology, gross and microscopic examination 3 6 3 . 7 1 88309 TC Tissue exam by pathologist 2 52.76 88311 26 Decalcify tissue 2 9.61 88311 Decalcification procedure (List separately in addition to code for surgical pathology examination) 5 1 . 3 0 88311 TC Decalcify tissue 2 1.69 88312 26 Special stains group 1 1 5.12 88312 Special stains (List separately in addition to code for surgical pathology examination); Group I for 5 9.40 88312 TC Special stains group 1 4 4.28 88313 26 Special stains group 2 7 .69 88313 Special stains (List separately in addition to code for surgical pathology examination); Group II, all other, 4 6.80 88313 TC Special stains group 2 3 9.11 88314 26 Histochemical stains add-on 1 8.73 88314 Special stains (List separately in addition to code for surgical pathology examination); histochemical staining 7 2.00 88314 TC Histochemical stains add-on 5 3.27 88319 26 Enzyme histochemistry 2 3.68 88319 Determinative histochemistry or cytochemistry to identify enzyme constituents, each 8 0 . 1 0 88319 TC Enzyme histochemistry 5 6.42 88321 Consultation and report on referred slides prepared elsewhere 1 4 0 . 4 0 88323 26 Microslide consultation 8 4.12 88323 Consultation and report on referred material requiring preparation of slides 1 4 9 . 4 0 88323 TC Microslide consultation 6 5.28 88325 Consultation, comprehensive, with review of records and specimens, with report on referred material 1 9 3 . 5 0 88329 Pathology consultation during surgery; 1 1 6 . 1 0 88331 26 Path consult intraop 1 bloc 1 08.84 88331 Pathology consultation during surgery; first tissue block, with frozen section(s), single specimen 1 8 3 . 6 0 88331 TC Path consult intraop 1 bloc 7 4.76 88332 26 Path consult intraop addl 6 6.21 88332 Pathology consultation during surgery; each additional tissue block with frozen section(s) 9 8 . 1 0 88332 TC Path consult intraop addl 3 1.89 88333 26 Path consltj surg cytologic xm 1st sit 1 33.51 88333 Path consltj surg cytologic xm 1st sit 1 82.31 88333 TC Path consltj surg cytologic xm 1st sit 4 8.80 88334 26 Path consltj surg cytol xm ea addl 7 9.28 88334 Path consltj surg cytol xm ea addl 1 13.82 88334 TC Path consltj surg cytol xm ea addl 3 4.54 88342 26 Immunohistochemistry 5 3.68 88342 Immunocytochemistry (including tissue immunoperoxidase), each antibody 1 5 4 . 8 0 88342 TC Immunohistochemistry 1 01.12 88346 26 Immunofluorescent study 4 6.53 88346 Immunofluorescent study, each antibody; direct method 1 2 8 . 7 0 88346 TC Immunofluorescent study 8 2.17 88347 26 Immunofluorescent study 5 4.06 88347 Immunofluorescent study, each antibody; indirect method 1 1 8 . 8 0 88347 TC Immunofluorescent study 6 4.74 88348 26 Electron microscopy 4 6.39 88348 Electron microscopy; diagnostic 4 9 0 . 5 0 88348 TC Electron microscopy 4 44.11 88349 26 Electron mic scanning 1 10.11 88349 Electron mic scanning 4 95.33 120 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 88349 TC Electron mic scanning 3 85.22 88355 26 Analysis skeletal muscle 1 54.88 88355 Morphometric analysis; skeletal muscle 3 6 0 . 9 0 88355 TC Analysis skeletal muscle 2 06.02 88356 26 Analysis nerve 1 78.64 88356 Morphometric analysis; nerve 4 0 8 . 6 0 88356 TC Analysis nerve 2 29.96 88358 26 Analysis tumor 1 65.47 88358 Morphometric analysis; tumor 3 2 5 . 8 0 88358 TC Analysis tumor 1 60.33 88360 26 M/phmtrc alys tum imhchem ea antb mnl 1 24.91 88360 M/phmtrc alys tum imhchem ea antb mnl 2 65.15 88360 TC M/phmtrc alys tum imhchem ea antb mnl 1 40.25 88361 26 M/phmtrc alys tum imhchem ea antb cptr 1 30.81 88361 M/phmtrc alys tum imhchem ea antb cptr 3 55.82 88361 TC M/phmtrc alys tum imhchem ea antb cptr 2 25.02 88362 26 Nerve teasing preparations 1 09.43 88362 Nerve teasing preparations 3 2 9 . 4 0 88362 TC Nerve teasing preparations 2 19.97 88363 Xm archive tissue molec anal 8 0.43 88365 26 Insitu hybridization (fish) 4 7.49 88365 Tissue in situ hybridization, interpretation and report 1 5 4 . 8 0 88365 TC Insitu hybridization (fish) 1 07.31 88367 26 M/phmtrc alys ish ea prb cptr-asst technology 1 53.51 88367 M/phmtrc alys ish ea prb cptr-asst technology 4 62.18 88367 TC M/phmtrc alys ish ea prb cptr-asst technology 3 08.67 88368 26 M/phmtrc alys ish ea prb mnl 1 66.25 88368 M/phmtrc alys ish ea prb mnl 3 71.20 88368 TC M/phmtrc alys ish ea prb mnl 2 04.94 88371 26 Protein western blot tissue 4 0.10 88371 Protein analysis of tissue by Western Blot, with interpretation and report; 6 6 . 6 0 88372 26 Protein analysis w/probe 3 8.28 88372 Protein analysis of tissue by Western Blot, with interpretation and report; immunological probe for band 8 6.40 88380 26 Microdissection prep identified target laser 1 28.33 88380 Microdissection prep identified target laser 3 21.70 88380 TC Microdissection prep identified target laser 1 93.37 88381 26 Microdissection prep identified target manual 1 16.25 88381 Microdissection prep identified target manual 4 03.93 88381 TC Microdissection prep identified target manual 2 87.68 88387 26 Macro exam dissect&prep tiss nonmicro std ea 5 8.34 88387 Macro exam dissect&prep tiss nonmicro std ea 7 3.38 88387 TC Macro exam dissect&prep tiss nonmicro std ea 1 5.04 88388 26 Macr exm diss&prp nonmicr imprnt/conslt/frz sec 3 7.42 88388 Macr exm diss&prp nonmicr imprnt/conslt/frz sec 4 5.35 88388 TC Macr exm diss&prp nonmicr imprnt/conslt/frz sec 7 .93 88720 Bilirubin total transcut 2 0.76 88738 Hgb quant transcutaneous 2 0.76 88740 Transcutaneous carboxyhb 2 0.76 88741 Transcutaneous methb 2 0.76 89049 Caffeine halothane contrcure 2 50.65 89050 Cell count, miscellaneous body fluids (eg, CSF, joint fluid), except blood; 2 3 . 4 6 89051 Cell count, miscellaneous body fluids (eg, CSF, joint fluid), except blood; with differential count 3 8 . 7 0 89055 Leukocyte assessment fecal 2 6.49 89060 26 Exam synovial fluid crystals 2 5.45 89060 Crystal identification by light microscopy with or without polarizing lens analysis, any body fluid (except 4 8.60 89125 Fat stain, feces, urine, or respiratory secretions 2 2 . 0 3 89160 Meat fibers, feces 1 8 . 9 0 89190 Nasal smear for eosinophils 2 4 . 3 0 89220 Sptm obtg spec aersl induced spx 3 6.20 89230 Sweat collj iontophoresis 6 9.49 89300 Semen analysis; presence and/or motility of sperm including Huhner test (post coital) 6 6 . 6 0 89310 Semen analysis; motility and count 5 6 . 7 0 89320 Semen analysis; complete (volume, count, motility, and differential) 7 0 . 5 7 89321 Semen anal sperm detection 5 9.28 89322 Semen anal strict criteria 1 14.37 89325 Sperm antibodies 1 5 2 . 1 0 89329 Sperm evaluation; hamster penetration test 3 6 5 . 4 0 89330 Sperm evaluation; cervical mucus penetration test, with or without spinnbarkeit test 8 7 . 3 0 90460 Imadm through 18yr any route 1st vac/toxoid 2 9.43 90461 Imadm through 18yr any route ea addl vac/toxoid 1 7.03 121 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 90471 Immunization administration (includes percutaneous, intradermal, subcutaneous, intramuscular and jet 2 1.07 90472 Immunization administration (includes percutaneous, intradermal, subcutaneous, intramuscular and jet 2 4.81 90473 Imadm intransl/oral 1 vacc 2 1.56 90474 Imadm intransl/oral ea vacc 1 7.03 90632 Hepatitis A vaccine, adult dosage, for intramuscular use 9 0 . 9 6 90645 Hemophilus influenza b vaccine (Hib), HbOC conjugate (4 dose schedule), for intramuscular use 3 8 . 5 4 90646 Hemophilus influenza b vaccine (Hib), PRP-D conjugate, for booster use only, intramuscular use 4 1 . 4 0 90648 Hemophilus influenza b vaccine (Hib), PRP-T conjugate (4 dose schedule), for intramuscular use 3 8 . 7 0 90657 Influenza virus vaccine, split virus, 6-35 months dosage, for intramuscular or jet injection use 1 5 . 9 3 90669 Pneumococcal conjugate vaccine, polyvalent, for children under five years, for intramuscular use 8 4 . 3 1 90680 Rotavirus vaccine, tetravalent, live, for oral use 7 6 . 5 0 90700 Diphtheria, tetanus toxoids, and acellular pertussis vaccine (DTaP), for intramuscular use 4 3 . 3 6 90702 Diphtheria and tetanus toxoids (DT) adsorbed for use in individuals younger than seven years, for 1 8.62 90703 Tetanus toxoid adsorbed, for intramuscular or jet injection use 1 9 . 3 0 90704 Mumps virus vaccine, live, for subcutaneous or jet injection use 4 5 . 0 0 90705 Measles virus vaccine, live, for subcutaneous or jet injection use 4 1 . 4 0 90706 Rubella virus vaccine, live, for subcutaneous or jet injection use 4 7 . 7 0 90707 Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous or jet injection use 5 8 . 1 5 90710 Measles, mumps, rubella, and varicella vaccine (MMRV), live, for subcutaneous use 5 8 . 5 0 90713 Poliovirus vaccine, inactivated, (IPV), for subcutaneous use 4 1 . 2 3 90716 Varicella virus vaccine, live, for subcutaneous use 8 6 . 6 8 90717 Yellow fever vaccine, live, for subcutaneous use 8 3 . 3 0 90732 Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, for 3 1.50 90733 Meningococcal polysaccharide vaccine (any group(s)), for subcutaneous or jet injection use 9 0 . 2 4 90735 Japanese encephalitis virus vaccine, for subcutaneous use 1 0 0 . 8 0 90744 Hepatitis B vaccine, pediatric/adolescent dosage (3 dose schedule), for intramuscular use 6 1 . 3 7 90746 Hepatitis B vaccine, adult dosage, for intramuscular use 9 0 . 5 1 90785 Psytx complex interactive 8 .74 90791 Psych diagnostic evaluation 2 76.51 90792 Psych diag eval w/med srvcs 2 22.74 90832 Psytx pt&/family 30 minutes 1 14.22 90833 Psytx pt&/fam w/e&m 30 min 7 4.62 90834 Psytx pt&/family 45 minutes 1 44.87 90836 Psytx pt&/fam w/e&m 45 min 1 20.89 90837 Psytx pt&/family 60 minutes 2 11.77 90838 Psytx pt&/fam w/e&m 60 min 1 95.68 90845 Psychoanalysis 1 6 6 . 5 0 90846 Family psychotherapy (without the patient present) 1 5 9 . 3 0 90847 Family psychotherapy (conjoint psychotherapy) (with patient present) 1 5 1 . 6 2 90849 Multiple-family group psychotherapy 1 2 9 . 6 0 90853 Group psychotherapy (other than of a multiple-family group) 8 7 . 3 0 90865 Narcosynthesis for psychiatric diagnostic and therapeutic purposes (eg, sodium amobarbital (Amytal) 2 71.80 90870 Electroconvulsive therapy (includes necessary monitoring); single seizure 2 0 9 . 7 0 90875 Individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with 1 17.06 90876 Individual psychophysiological therapy incorporating biofeedback training by any modality (face-to-face with 2 26.80 90880 Hypnotherapy 1 8 3 . 6 0 90882 Environmental intervention for medical management purposes on a psychiatric patient's behalf with 1 18.80 90885 Psyc eval hosp records dx purposes 1 20.97 90887 Interpretation or explanation of results of psychiatric, other medical examinations and procedures, or other 1 59.30 90889 Preparation of report of patient's psychiatric status, history, treatment, or progress (other than for legal or 1 71.00 90901 Biofeedback training by any modality 1 2 3 . 3 0 90911 Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry 1 8 0 . 0 0 90935 Hemodialysis procedure with single physician evaluation 2 4 9 . 8 0 90937 Hemodialysis procedure requiring repeated evaluation(s) with or without substantial revision of dialysis 5 66.10 90945 Dialysis procedure other than hemodialysis (eg, peritoneal dialysis, hemofiltration, or other continuous renal 3 00.60 90947 Dialysis procedure other than hemodialysis (eg, peritoneal dialysis, hemofiltration, or other continuous renal 4 82.40 90951 Esrd related svc monthly <2 yr old 4/>visits 1 ,568.42 90954 Esrd related svc monthly 2-11 yr old 4/>visits 1 ,325.75 90955 Esrd related svc monthly 2-11 yr old 2/3 visits 7 42.53 90956 Esrd related svc monthly 2-11 yr old 1 visit 5 21.08 90957 Esrd related svc monthly 12-19 yr old 4/>visits 1 ,046.60 90958 Esrd related svc monthly 12-19 yr old 2/3 visits 7 02.47 90959 Esrd related svc monthly 12-19 yr old 1 visit 4 62.30 90960 Esrd related svc monthly 20&> yr old 4/> visits 5 15.18 90961 Esrd related svc monthly 20&> yr old 2/3 visits 4 13.70 90962 Esrd related svc monthly 20&> yr old 1 visit 3 01.29 90963 Esrd svc home dialysis full month <2yr old 8 98.85 90964 Esrd svc home dialysis full month 2-11 yr old 7 50.40 90965 Esrd svc home dialysis full month 12-19 yr old 7 04.13 90966 Esrd svc home dialysis full month 20 yr old 3 68.71 122 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 90967 Esrd related svc <full month < 2 yr old 3 3.03 90968 Esrd related svc <full month 2-11 yr old 2 6.85 90969 Esrd related svc <full month 12-19 yr old 1 9.63 90970 Esrd related svc <full month 20&> yr old 1 3.50 90989 Dialysis training, patient, including helper where applicable, any mode, completed course 6 5 3 . 4 0 90993 Dialysis training, patient, including helper where applicable, any mode, course not completed, per training 1 35.90 90997 Hemoperfusion (eg, with activated charcoal or resin) 5 9 7 . 6 0 91010 26 Esophagus motility study 1 01.54 91010 Esophageal motility (manometric study of the esophagus and/or gastroesophageal junction) study; 2 9 3 . 4 0 91010 TC Esophagus motility study 1 91.86 91013 26 Esophgl motility std w/i&r stim/perfusion 2 9.29 91013 Esophgl motility std w/i&r stim/perfusion 6 8.42 91013 TC Esophgl motility std w/i&r stim/perfusion 3 9.13 91020 26 Gastric motility studies 7 4.00 91020 Gastric motility (manometric) studies 2 5 5 . 6 0 91020 TC Gastric motility studies 1 81.60 91022 26 Duol motility std 2 13.12 91022 Duol motility std 4 97.91 91022 TC Duol motility std 2 84.78 91030 26 Acid perfusion of esophagus 4 9.29 91030 Esophagus, acid perfusion (Bernstein) test for esophagitis 1 5 8 . 4 0 91030 TC Acid perfusion of esophagus 1 09.11 91034 26 Esoph g-esop rflx ncath eltrd plmt 1 70.59 91034 Esoph g-esop rflx ncath eltrd plmt 6 58.66 91034 TC Esoph g-esop rflx ncath eltrd plmt 4 88.07 91035 26 Esoph g-esop rflx tlmtr eltrd plmt 2 36.07 91035 Esoph g-esop rflx tlmtr eltrd plmt 1 ,202.01 91035 TC Esoph g-esop rflx tlmtr eltrd plmt 9 65.94 91037 26 Esophgl funcj g-esop rflx impd eltrd plmt 1 48.35 91037 Esophgl funcj g-esop rflx impd eltrd plmt 4 51.78 91037 TC Esophgl funcj g-esop rflx impd eltrd plmt 3 03.43 91038 26 Esophgl funcj g-esop rflx impd eltrd prolng 1 63.99 91038 Esophgl funcj g-esop rflx impd eltrd prolng 4 41.22 91038 TC Esophgl funcj g-esop rflx impd eltrd prolng 2 77.23 91040 26 Esophgl balo distension provocation std 1 42.29 91040 Esophgl balo distension provocation std 9 56.84 91040 TC Esophgl balo distension provocation std 8 14.55 91065 26 Breath hydrogen test 1 6.38 91065 Breath hydrogen test (eg, for detection of lactase deficiency) 1 6 6 . 5 0 91065 TC Breath hydrogen test 1 50.12 91110 26 Gi trc img intral esoph thru ile phys i&r 5 22.07 91110 Gi trc img intral esoph thru ile phys i&r 2 ,494.19 91110 TC Gi trc img intral esoph thru ile phys i&r 1 ,972.12 91111 26 Gastrointestinal tract imaging esophagus 1 22.66 91111 Gastrointestinal tract imaging esophagus 1 ,753.90 91111 TC Gastrointestinal tract imaging esophagus 1 ,631.24 91112 26 Gi wireless capsule measure 2 05.41 91112 TC Gi wireless capsule measure 2 ,122.83 91112 Gi wireless capsule measure 2 ,328.25 91117 Colon motility 6 hr study 4 53.93 91120 26 Rct sensation tone&compliance 1 29.65 91120 Rct sensation tone&compliance 1 ,002.67 91120 TC Rct sensation tone&compliance 8 73.02 91122 26 Anal pressure record 1 31.95 91122 Anorectal manometry 3 5 7 . 3 0 91122 TC Anal pressure record 2 25.35 91132 26 Egg dx tc 7 4.61 91132 Egg dx tc 1 40.33 91132 TC Egg dx tc 6 5.72 91133 26 Egg dx tc provocative tstg 1 10.50 91133 Egg dx tc provocative tstg 2 00.44 91133 TC Egg dx tc provocative tstg 8 9.94 92002 Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment 8 7.67 92004 Ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment 1 03.19 92012 Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic 6 2.82 92014 Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic 8 7.18 92015 Determination of refractive state 2 8 . 5 8 92018 Ophthalmological examination and evaluation, under general anesthesia, with or without manipulation of 2 46.60 92019 Ophthalmological examination and evaluation, under general anesthesia, with or without manipulation of 1 53.90 92020 Gonioscopy (separate procedure) 5 3 . 2 7 123 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 92025 26 Computerized corneal topography uni/bi 2 8.67 92025 Computerized corneal topography uni/bi 5 3.37 92025 TC Computerized corneal topography uni/bi 2 4.70 92060 26 Special eye evaluation 3 7.17 92060 Sensorimotor examination with multiple measurements of ocular deviation (eg, restrictive or paretic muscle 6 6.59 92060 TC Special eye evaluation 2 9.42 92065 26 Orthoptic/pleoptic training 1 6.99 92065 Orthoptic and/or pleoptic training, with continuing medical direction and evaluation 5 6 . 7 0 92065 TC Orthoptic/pleoptic training 3 9.71 92071 Contact lens fitting for tx 6 2.75 92072 Fit contac lens for managmnt 2 38.67 92081 26 Visual field examination(s) 2 1.54 92081 Visual field examination, unilateral or bilateral, with interpretation and report; limited examination (eg, 4 6.80 92081 TC Visual field examination(s) 2 5.26 92082 26 Visual field examination(s) 3 5.28 92082 Visual field examination, unilateral or bilateral, with interpretation and report; intermediate examination (eg, 8 1.78 92082 TC Visual field examination(s) 4 6.50 92083 26 Visual field examination(s) 5 1.26 92083 Visual field examination, unilateral or bilateral, with interpretation and report; extended examination (eg, 1 25.94 92083 TC Visual field examination(s) 7 4.68 92100 Serial tonometry (separate procedure) with multiple measurements of intraocular pressure over an extended 5 2.70 92132 26 Cmptr ophthalmic dx img ant segmt w/i&r uni/bi 3 3.05 92132 Cmptr ophthalmic dx img ant segmt w/i&r uni/bi 5 7.24 92132 TC Cmptr ophthalmic dx img ant segmt w/i&r uni/bi 2 4.18 92133 26 Computerized ophthalmic imaging optic nerve 4 5.63 92133 Computerized ophthalmic imaging optic nerve 6 9.48 92133 TC Computerized ophthalmic imaging optic nerve 2 3.84 92134 26 Computerized ophthalmic imaging retina 4 5.63 92134 Computerized ophthalmic imaging retina 6 9.48 92134 TC Computerized ophthalmic imaging retina 2 3.84 92136 26 Oph bmtry prtl coher intrfrmtry io lens pwr cal 4 4.16 92136 Oph bmtry prtl coher intrfrmtry io lens pwr cal 1 23.93 92136 TC Oph bmtry prtl coher intrfrmtry io lens pwr cal 7 9.77 92140 Provocative tests for glaucoma, with interpretation and report, without tonography 5 7 . 9 0 92225 Ophthalmoscopy, extended, with retinal drawing (eg, for retinal detachment, melanoma), with interpretation 7 9.44 92226 Ophthalmoscopy, extended, with retinal drawing (eg, for retinal detachment, melanoma), with interpretation 7 0.28 92227 Remote img dx retinl dis w/alys & report uni/bi 2 8.24 92228 26 Remote retinal imaging mgmt 3 5.20 92228 Remote img mgt retinl dis w/i&r uni/bi 6 1.25 92228 TC Remote retinal imaging mgmt 2 6.05 92230 Fluorescein angioscopy with interpretation and report 1 2 6 . 9 0 92235 26 Eye exam with photos 9 8.35 92235 Fluorescein angiography (includes multiframe imaging) with interpretation and report 2 4 7 . 5 0 92235 TC Eye exam with photos 1 49.15 92240 26 Icg angiography 5 0.91 92240 Indocyanine-green angiography (includes multiframe imaging) with interpretation and report 2 2 5 . 0 0 92240 TC Icg angiography 1 74.09 92250 26 Eye exam with photos 2 1.57 92250 Fundus photography with interpretation and report 7 9 . 2 0 92250 TC Eye exam with photos 5 7.63 92260 Ophthalmodynamometry 6 6 . 6 0 92265 26 Eye muscle evaluation 6 4.52 92265 Needle oculoelectromyography, one or more extraocular muscles, one or both eyes, with interpretation and 1 28.70 92265 TC Eye muscle evaluation 6 4.18 92270 26 Electro-oculography 5 3.38 92270 Electro-oculography with interpretation and report 1 2 8 . 7 0 92270 TC Electro-oculography 7 5.32 92275 26 Electroretinography 5 5.10 92275 Electroretinography with interpretation and report 1 6 2 . 9 0 92275 TC Electroretinography 1 07.80 92283 26 Color vision examination 8 .54 92283 Color vision examination, extended, eg, anomaloscope or equivalent 5 6 . 7 0 92283 TC Color vision examination 4 8.16 92284 26 Dark adaptation eye exam 2 0.35 92284 Dark adaptation examination with interpretation and report 1 1 3 . 4 0 92284 TC Dark adaptation eye exam 9 3.05 92285 26 Eye photography 8 .25 92285 External ocular photography with interpretation and report for documentation of medical progress (eg, close- 5 9.40 92285 TC Eye photography 5 1.15 92286 26 Internal eye photography 1 27.49 124 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 92286 Special anterior segment photography with interpretation and report; with specular endothelial microscopy 2 35.92 92286 TC Internal eye photography 1 08.43 92287 26 Internal eye photography 5 6.26 92287 Special anterior segment photography with interpretation and report; with fluorescein angiography 1 8 0 . 0 0 92287 TC Internal eye photography 1 23.74 92310 Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of 2 68.20 92311 Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of 1 80.90 92312 Prescription of optical and physical characteristics of and fitting of contact lens, with medical supervision of 2 47.50 92313 Rx&fitg c-lens supvj crnlsclrl lens 9 1.51 92314 Rx c-lens supvj&dirion fitg tech ou xcpt aphk 6 7.48 92315 Rx c-lens supvj fitg tech crnl aphk 1o 6 3.02 92316 Rx c-lens supvj fitg tech crnl aphk ou 9 8.58 92317 Rx c-lens supvj fitg tech crnlsclrl 6 6.07 92325 Modification of contact lens (separate procedure), with medical supervision of adaptation 4 3 . 2 0 92326 Replacement of contact lens 1 1 8 . 8 0 92340 Fitting of spectacles, except for aphakia; monofocal 5 6 . 7 0 92341 Fitg spectls xcpt aphk bifocal 4 0.23 92342 Fitg spectls xcpt aphk mltfcl 5 2.41 92352 Fitg spectl prosth aphk monofocal 2 2.45 92353 Fitting of spectacle prosthesis for aphakia; multifocal 5 1 . 3 0 92354 Fit spectacles single system 2 8.49 92355 Fit spectacles compound lens 4 3.94 92358 Aphakia prosth service temp 2 3.79 92370 Rpr&refitg spectls xcpt aphk 4 8.20 92371 Rpr&refitg spectls spectl prosth aphk 7 0.29 92502 Otolaryngologic examination under general anesthesia 2 9 7 . 0 0 92504 Binocular microscopy (separate diagnostic procedure) 6 1 . 2 5 92506 Evaluation of speech, language, voice, communication, auditory processing, and/or aural rehabilitation 1 40.40 92507 Treatment of speech, language, voice, communication, and/or auditory processing disorder (includes aural 6 0.61 92508 Treatment of speech, language, voice, communication, and/or auditory processing disorder (includes aural 4 7.70 92511 Nasopharyngoscopy with endoscope (separate procedure) 2 2 9 . 5 0 92512 Nasal function studies (eg, rhinomanometry) 1 4 4 . 0 0 92516 Facial nerve function studies (eg, electroneuronography) 1 2 3 . 3 0 92520 Laryngeal function studies 2 5 7 . 4 0 92526 Treatment of swallowing dysfunction and/or oral function for feeding 1 2 3 . 3 0 92531 Spontaneous nystagmus, including gaze 5 4 . 0 0 92532 Positional nystagmus 6 2 . 1 0 92533 Caloric vestibular test, each irrigation (binaural, bithermal stimulation constitutes four tests) 7 6 . 5 0 92534 Optokinetic nystagmus 6 3 . 0 0 92540 26 Vstblr funcj nystag fovl&perph stimj oscil trkg 1 24.58 92540 Vstblr funcj nystag fovl&perph stimj oscil trkg 1 51.13 92540 TC Vstblr funcj nystag fovl&perph stimj oscil trkg 2 6.55 92541 26 Spontaneous nystagmus test 7 9.30 92541 Spontaneous nystagmus test, including gaze and fixation nystagmus, with recording 1 2 1 . 5 0 92541 TC Spontaneous nystagmus test 4 2.20 92542 26 Positional nystagmus test 6 9.82 92542 Positional nystagmus test, minimum of 4 positions, with recording 1 1 4 . 3 0 92542 TC Positional nystagmus test 4 4.48 92543 26 Caloric vestibular test 4 0.96 92543 Caloric vestibular test, each irrigation (binaural, bithermal stimulation constitutes four tests), with recording 1 2 8 . 7 0 92543 TC Caloric vestibular test 8 7.74 92544 26 Optokinetic nystagmus test 4 3.16 92544 Optokinetic nystagmus test, bidirectional, foveal or peripheral stimulation, with recording 7 7 . 4 0 92544 TC Optokinetic nystagmus test 3 4.24 92545 26 Oscillating tracking test 4 1.96 92545 Oscillating tracking test, with recording 7 7 . 4 0 92545 TC Oscillating tracking test 3 5.44 92546 26 Sinusoidal rotational test 1 2.98 92546 Sinusoidal vertical axis rotational testing 1 0 1 . 7 0 92546 TC Sinusoidal rotational test 8 8.72 92547 Use of vertical electrodes (List separately in addition to code for primary procedure) 7 2 . 0 0 92548 26 Posturography 4 7.62 92548 Computerized dynamic posturography 2 1 6 . 0 0 92548 TC Posturography 1 68.38 92550 Tympanometry and reflex threshold measurements 3 8.60 92551 Screening test, pure tone, air only 3 4 . 2 0 92552 Pure tone audiometry (threshold); air only 4 0 . 7 7 92553 Pure tone audiometry (threshold); air and bone 6 1 . 6 9 92555 Speech audiometry threshold; 3 6 . 9 0 92556 Speech audiometry threshold; with speech recognition 5 4 . 7 6 125 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 92557 Comprehensive audiometry threshold evaluation and speech recognition (92553 and 92556 combined) 9 2 . 7 0 92559 Audiometric testing of groups 4 1 . 4 0 92560 Bekesy audiometry; screening 6 6 . 6 0 92561 Bekesy audiometry; diagnostic 8 3 . 7 0 92562 Loudness balance test, alternate binaural or monaural 4 0 . 5 0 92563 Tone decay test 4 5 . 0 0 92564 Short increment sensitivity index (SISI) 4 1 . 4 0 92565 Stenger test, pure tone 5 0 . 4 0 92567 Tympanometry (impedance testing) 4 3 . 1 8 92568 Acoustic reflex testing 4 1 . 4 0 92570 Acoustic immit test tympanom/acoust reflx/decay 5 8.15 92571 Filtered speech test 3 8 . 7 0 92572 Staggered spondaic word test 4 2 . 3 0 92575 Sensorineural acuity level test 3 6 . 0 0 92576 Synthetic sentence identification test 3 8 . 7 0 92577 Stenger test, speech 5 1 . 3 0 92579 Visual reinforcement audiometry (VRA) 1 0 2 . 6 0 92582 Conditioning play audiometry 6 5 . 7 0 92583 Select picture audiometry 7 2 . 0 0 92584 Electrocochleography 2 5 2 . 0 0 92585 26 Auditor evoke potent compre 6 5.25 92585 Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; 3 53.70 92585 TC Auditor evoke potent compre 2 88.45 92586 Aep era&/tstg cns lmtd 1 51.11 92587 26 Evoked auditory test limited 1 05.08 92587 Evoked otoacoustic emissions; limited (single stimulus level, either transient or distortion products) 1 2 4 . 2 0 92587 TC Evoked auditory test limited 1 9.12 92588 26 Evoked auditory tst complete 1 22.06 92588 Evoked otoacoustic emissions; comprehensive or diagnostic evaluation (comparison of transient and/or 1 41.30 92588 TC Evoked auditory tst complete 1 9.24 92590 Hearing aid examination and selection; monaural 1 1 3 . 4 0 92591 Hearing aid examination and selection; binaural 1 4 6 . 7 0 92592 Hearing aid check; monaural 4 0 . 5 0 92593 Hearing aid check; binaural 5 7 . 6 0 92594 Electroacoustic evaluation for hearing aid; monaural 3 6 . 0 0 92595 Electroacoustic evaluation for hearing aid; binaural 3 8 . 7 0 92596 Ear protector attenuation measurements 5 1 . 3 0 92597 Evaluation for use and/or fitting of voice prosthetic or augmentative/alternative communication device to 1 88.10 92601 Alys cochlear implt pt <7 yr prgrmg 2 79.88 92602 Alys cochlear implt pt <7 yr sbsq reprgrmg 2 00.79 92603 Alys cochlear implt 7 yr/> prgrmg 1 87.38 92604 Alys cochlear implt 7 yr/> sbsq reprgrmg 1 24.41 92605 Ex for nonspeech device rx 1 66.79 92606 Non-speech device service 1 51.11 92607 Rx sp-genratj augmnt&comunicaj dev 1st hr 2 59.20 92608 Rx sp-genratj augmnt&comunicaj dev ea 30 min 5 7.16 92609 Ther sp-genratj dev prgrmg&modificaj 1 39.99 92610 Eval oral&pharyngeal swlng funcj 2 70.34 92611 Motion fluor eval swlng funcj c/v rec 2 64.89 92612 Flx fibopt ndsc eval swlng c/v rec 3 36.75 92613 Flx fibopt ndsc eval swlng c/v rec phys i&r 8 6.41 92614 Flx fibopt ndsc eval laryn sens c/v rec 2 96.87 92615 Flx fibopt ndsc eval laryn sens phys i&r 7 8.45 92616 Flx fibopt ndsc eval swlng&laryn sens c/v rec 4 38.23 92617 Flx fibopt ndsc eval swlng&laryn sens phys i&r 1 03.33 92618 Ex for nonspeech dev rx add 5 9.72 92620 Eval ctr aud funcj w/reprt 1st 60 min 9 9.31 92621 Eval ctr aud funcj w/reprt ea 15 min 2 5.94 92625 Assmt tinnitus 9 3.11 92626 Eval aud rhab status 1st hr 1 74.65 92627 Eval aud rhab status ea 15 min 4 3.12 92640 Analysis w/prgrmg aud brainstem implant pr hr 1 22.67 92920 Prq cardiac angioplast 1 art 1 ,048.78 92924 Prq card angio/athrect 1 art 1 ,247.20 92928 Prq card stent w/angio 1 vsl 1 ,165.44 92933 Prq card stent/ath/angio 1 ,303.22 92937 Prq revasc byp graft 1 vsl 1 ,164.19 92941 Prq card revasc mi 1 vsl 1 ,306.01 92943 Prq card revasc chronic 1vsl 1 ,306.01 92950 Cardiopulmonary resuscitation (eg, in cardiac arrest) 4 8 2 . 5 9 126 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 92953 Temporary transcutaneous pacing 3 2 9 . 4 0 92960 Cardioversion, elective, electrical conversion of arrhythmia; external 4 2 5 . 7 0 92961 Cardioversion elective arrhyt int spx 9 45.23 92970 Cardioassist-method of circulatory assist; internal 6 8 4 . 9 0 92971 Cardioassist-method of circulatory assist; external 2 7 5 . 4 0 92973 Prq trluml c thrmbc 1 ,041.07 92974 Tcat plmt radj dlvr dev sbsq c iv brachytx 8 01.14 92975 Thrombolysis, coronary; by intracoronary infusion, including selective coronary angiography 1 , 4 8 8 . 6 0 92977 Thrombolysis, coronary; by intravenous infusion 7 5 3 . 3 0 92978 26 Intravasc us heart add-on 3 33.84 92978 Intravascular ultrasound (coronary vessel or graft) during diagnostic evaluation and/or therapeutic 6 13.80 92979 26 Intravasc us heart add-on 2 36.88 92979 Intravascular ultrasound (coronary vessel or graft) during diagnostic evaluation and/or therapeutic 3 78.90 92986 Percutaneous balloon valvuloplasty; aortic valve 3 , 6 5 6 . 7 0 92987 Prq balo vlvp mitral valve 3 ,403.45 92990 Percutaneous balloon valvuloplasty; pulmonary valve 2 , 4 7 7 . 7 0 92993 Atrial septectomy or septostomy; blade method (Park septostomy) (includes cardiac catheterization) 4 , 4 0 8 . 2 0 92997 Percutaneous transluminal pulmonary artery balloon angioplasty; single vessel 2 , 4 4 9 . 8 0 92998 Percutaneous transluminal pulmonary artery balloon angioplasty;

each additional vessel (List separately in 9 49.50 93000 Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report 7 1 . 0 0 93005 Electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report 5 6 . 7 0 93010 Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only 5 1 . 3 0 93015 Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous 3 38.10 93016 Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous 1 00.80 93017 Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous 1 64.70 93018 Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous 1 70.10 93024 26 Cardiac drug stress test 1 80.32 93024 Ergonovine provocation test 3 8 0 . 7 0 93024 TC Cardiac drug stress test 2 00.38 93025 26 Microvolt t-wave assess ventricular arrhythmias 1 19.07 93025 Microvolt t-wave assess ventricular arrhythmias 6 26.33 93025 TC Microvolt t-wave assess ventricular arrhythmias 5 07.27 93040 Rhythm ECG, one to three leads; with interpretation and report 4 9 . 4 9 93041 Rhythm ECG, one to three leads; tracing only without interpretation and report 4 4 . 1 0 93042 Rhythm ECG, one to three leads; interpretation and report only 3 6 . 0 0 93224 Electrocardiographic monitoring for 24 hours by continuous original ECG waveform recording and storage, 4 81.75 93225 Electrocardiographic monitoring for 24 hours by continuous original ECG waveform recording and storage, 1 62.00 93226 Electrocardiographic monitoring for 24 hours by continuous original ECG waveform recording and storage, 1 75.50 93227 Electrocardiographic monitoring for 24 hours by continuous original ECG waveform recording and storage, 1 73.70 93228 Xtrnl mobile cv telemetry w/phys r&i w/report 7 1.24 93229 Remote 30 day ecg tech supp 1 ,453.15 93268 Patient demand single or multiple event recording with presymptom memory loop, per 30 day period of time; 3 82.17 93270 Patient demand single or multiple event recording with presymptom memory loop, per 30 day period of time; 1 36.80 93271 Patient demand single or multiple event recording with presymptom memory loop, per 30 day period of time; 2 15.10 93272 Patient demand single or multiple event recording with presymptom memory loop, per 30 day period of time; 9 1.80 93278 26 ECG/signal-averaged 7 9.25 93278 Signal-averaged electrocardiography (SAECG), with or without ECG 2 1 1 . 5 0 93278 TC ECG/signal-averaged 1 32.25 93279 26 Program eval implantable in prsn 1 ld pacemaker 8 2.45 93279 Program eval implantable in prsn 1 ld pacemaker 1 27.18 93279 TC Program eval implantable in prsn 1 ld pacemaker 4 4.73 93280 26 Program eval implantable in persn dual ld pacer 9 8.60 93280 Program eval implantable in persn dual ld pacer 1 49.93 93280 TC Program eval implantable in persn dual ld pacer 5 1.32 93281 26 Program eval implantable in prsn multi ld pacer 1 14.49 93281 Program eval implantable in prsn multi ld pacer 1 76.45 93281 TC Program eval implantable in prsn multi ld pacer 6 1.96 93282 26 Program eval implantable in persn 1 ld card/dfb 1 07.41 93282 Program eval implantable in persn 1 ld card/dfb 1 63.00 93282 TC Program eval implantable in persn 1 ld card/dfb 5 5.59 93283 26 Progrm eval implantable in prsn dual l card/dfb 1 35.22 93283 Progrm eval implantable in prsn dual l card/dfb 1 98.77 93283 TC Progrm eval implantable in prsn dual l card/dfb 6 3.55 93284 26 Progrm eval implantable in prsn mlt ld card/dfb 1 71.39 93284 Progrm eval implantable in prsn mlt ld card/dfb 2 45.58 93284 TC Progrm eval implantable in prsn mlt ld card/dfb 7 4.19 93285 26 Program eval implantable dev in prsn ilr system 6 7.31 93285 Program eval implantable dev in prsn ilr system 1 10.64 93285 TC Program eval implantable dev in prsn ilr system 4 3.33 93286 26 Peri-px eval&program in prsn pacemaker system 3 1.89 127 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 93286 Peri-px eval&program in prsn pacemaker system 5 8.25 93286 TC Peri-px eval&program in prsn pacemaker system 2 6.36 93287 26 Peri-px eval&program cardioverter/defibrillator 5 6.46 93287 Peri-px eval&program cardioverter/defibrillator 9 2.64 93287 TC Peri-px eval&program cardioverter/defibrillator 3 6.18 93288 26 Interrogation eval in person 1/dual/mlt lead pm 5 5.14 93288 Interrogation eval in person 1/dual/mlt lead pm 9 8.78 93288 TC Interrogation eval in person 1/dual/mlt lead pm 4 3.64 93289 26 Interrogation eval f2f 1/dual/mlt leads cvdfb 1 00.80 93289 Interrogation eval f2f 1/dual/mlt leads cvdfb 1 52.54 93289 TC Interrogation eval f2f 1/dual/mlt leads cvdfb 5 1.74 93290 26 Interrogation eval f2f implantable cv mntr sys 5 2.49 93290 Interrogation eval f2f implantable cv mntr sys 7 9.59 93290 TC Interrogation eval f2f implantable cv mntr sys 2 7.10 93291 26 Interrogation evaluation in person ilr system 5 5.68 93291 Interrogation evaluation in person ilr system 9 4.74 93291 TC Interrogation evaluation in person ilr system 3 9.06 93292 26 Interrogation eval in person wr defibrillator 6 1.49 93292 Interrogation eval in person wr defibrillator 9 6.18 93292 TC Interrogation eval in person wr defibrillator 3 4.69 93293 26 Transtelephonic rhythm strip pacemaker eval 3 8.13 93293 Transtelephonic rhythm strip pacemaker eval 1 36.76 93293 TC Transtelephonic rhythm strip pacemaker eval 9 8.63 93294 Interrogation eval remote </90 d 1/2/mlt lead pm 9 4.89 93295 Interrogation eval remote </90 d 1/2/> ld cvdfb 1 52.27 93296 Interrogation remote </90 d technician review 9 3.78 93297 Interrogation eval remote </30 d cv mntr sys 5 6.66 93298 Interrogation evaluation remote </30 d ilr sys 7 5.22 93303 26 Echo transthoracic 1 52.41 93303 Transthoracic echocardiography for congenital cardiac anomalies; complete 5 1 3 . 9 0 93303 TC Echo transthoracic 3 61.49 93304 26 Echo transthoracic 7 2.52 93304 Transthoracic echocardiography for congenital cardiac anomalies; follow-up or limited study 2 8 0 . 8 0 93304 TC Echo transthoracic 2 08.28 93306 26 Echo tthrc r-t 2d -+m-mode compl spec&color dop 2 30.29 93306 Echo tthrc r-t 2d -+m-mode compl spec&color dop 8 51.82 93306 TC Echo tthrc r-t 2d -+m-mode compl spec&color dop 6 21.52 93307 26 Tte w/o doppler complete 1 82.92 93307 Echocardiography, transthoracic, real-time with image documentation (2D) with or without M-mode 4 99.03 93307 TC Tte w/o doppler complete 3 16.11 93308 26 Tte f-up or lmtd 5 8.08 93308 Echocardiography, transthoracic, real-time with image documentation (2D) with or without M-mode 2 52.00 93308 TC Tte f-up or lmtd 1 93.92 93312 26 Echo transesophageal 2 08.89 93312 Echocardiography, transesophageal, real time with image documentation (2D) (with or without M-mode 6 65.35 93312 TC Echo transesophageal 4 56.47 93313 Echocardiography, transesophageal, real time with image documentation (2D) (with or without M-mode 2 57.40 93314 26 Echo transesophageal 8 1.18 93314 Echocardiography, transesophageal, real time with image documentation (2D) (with or without M-mode 4 24.80 93314 TC Echo transesophageal 3 43.62 93315 26 Echo transesophageal 4 63.40 93315 Transesophageal echocardiography for congenital cardiac anomalies; including probe placement, image 6 63.30 93316 Transesophageal echocardiography for congenital cardiac anomalies; placement of transesophageal probe 1 35.90 93317 26 Echo transesophageal 3 00.16 93317 Transesophageal echocardiography for congenital cardiac anomalies; image acquisition, interpretation and 5 26.50 93320 26 Doppler echo exam heart 1 16.49 93320 Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (List separately in 3 07.08 93320 TC Doppler echo exam heart 1 90.59 93321 26 Doppler echo exam heart 5 2.95 93321 Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (List separately in 1 87.20 93321 TC Doppler echo exam heart 1 34.25 93325 26 Doppler color flow add-on 4 4.14 93325 Doppler echocardiography color flow velocity mapping (List separately in addition to codes for 2 47.27 93325 TC Doppler color flow add-on 2 03.13 93350 26 Stress tte only 2 80.69 93350 Echocardiography, transthoracic, real-time with image documentation (2D), with or without M-mode 8 53.56 93350 TC Stress tte only 5 72.87 93351 26 Stress tte complete 2 74.13 93351 Echo tthrc r-t 2d -+m-mode rest&strs cont ecg 8 17.51 93351 TC Stress tte complete 5 43.38 128 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 93352 Use of echo contrast agent during stress echo 1 13.06 93451 26 Right heart cath o2 saturation & cardiac output 5 42.12 93451 Right heart cath o2 saturation & cardiac output 2 ,852.54 93451 TC Right heart cath o2 saturation & cardiac output 2 ,310.41 93452 26 L hrt cath w/njx l ventriculography img s&i 9 80.59 93452 L hrt cath w/njx l ventriculography img s&i 3 ,168.34 93452 TC L hrt cath w/njx l ventriculography img s&i 2 ,187.75 93453 26 R & l hrt cath w/njx l ventriculog img s&i 1 ,283.91 93453 R & l hrt cath w/njx l ventriculog img s&i 4 ,148.15 93453 TC R & l hrt cath w/njx l ventriculog img s&i 2 ,864.24 93454 26 Cath plmt & njx coronary art angio img s&i 9 51.44 93454 Cath plmt & njx coronary art angio img s&i 3 ,175.12 93454 TC Cath plmt & njx coronary art angio img s&i 2 ,223.68 93455 26 Cath plmt & njx coronary art/grft angio img s&i 1 ,138.35 93455 Cath plmt & njx coronary art/grft angio img s&i 3 ,801.70 93455 TC Cath plmt & njx coronary art/grft angio img s&i 2 ,663.36 93456 26 Cath plmt r hrt & arts w/njx & angio img s&i 1 ,267.49 93456 Cath plmt r hrt & arts w/njx & angio img s&i 4 ,095.86 93456 TC Cath plmt r hrt & arts w/njx & angio img s&i 2 ,828.37 93457 26 Cath plmt r hrt/arts/grfts w/njx&angio img s&i 1 ,369.90 93457 Cath plmt r hrt/arts/grfts w/njx&angio img s&i 4 ,567.94 93457 TC Cath plmt r hrt/arts/grfts w/njx&angio img s&i 3 ,198.04 93458 26 Cath plmt l hrt & arts w/njx & angio img s&i 1 ,177.53 93458 Cath plmt l hrt & arts w/njx & angio img s&i 3 ,926.59 93458 TC Cath plmt l hrt & arts w/njx & angio img s&i 2 ,749.06 93459 26 Cath plmt l hrt/arts/grfts wnjx & angio img s&i 1 ,348.53 93459 Cath plmt l hrt/arts/grfts wnjx & angio img s&i 4 ,355.53 93459 TC Cath plmt l hrt/arts/grfts wnjx & angio img s&i 3 ,007.00 93460 26 R & l hrt cath winjx hrt art& l ventr img s&i 1 ,492.01 93460 R & l hrt cath winjx hrt art& l ventr img s&i 4 ,666.19 93460 TC R & l hrt cath winjx hrt art& l ventr img s&i 3 ,174.18 93461 26 R&l hrt cath w/injec hrt art/grft&l vent img s&i 1 ,652.40 93461 R&l hrt cath w/injec hrt art/grft&l vent img s&i 5 ,335.97 93461 TC R&l hrt cath w/injec hrt art/grft&l vent img s&i 3 ,683.58 93462 Left heart cath by transeptal puncture 7 56.48 93463 Medication admin & hemodynamic measurment 3 98.95 93464 26 Physiologic exercise study & hemodynamic measure 3 56.00 93464 Physiologic exercise study & hemodynamic measure 9 38.52 93464 TC Physiologic exercise study & hemodynamic measure 5 82.53 93503 Insertion and placement of flow directed catheter (eg, Swan-Ganz) for monitoring purposes 7 2 5 . 4 0 93505 26 Biopsy of heart lining 2 90.16 93505 Endomyocardial biopsy 1 , 0 0 7 . 1 0 93505 TC Biopsy of heart lining 7 16.94 93563 Njx sel hrt art congenital hrt cath w/s&i 2 06.77 93564 Njx sel hrt art/grft congenital hrt cath w/s&i 2 07.05 93565 Njx sel l vent/atrial angio hrt cath w/s&i 1 60.18 93566 Inject r ventr/atrial angio 6 42.05 93567 Inject suprvlv aortography 5 25.96 93568 Inject pulm art hrt cath 5 78.40 93571 26 Heart flow reserve measure 3 52.53 93571 Intravascular doppler velocity and/or pressure derived coronary flow reserve measurement (coronary vessel 6 93.90 93572 26 Heart flow reserve measure 2 90.14 93572 Intravascular doppler velocity and/or pressure derived coronary flow reserve measurement (coronary vessel 6 37.20 93580 Prq tcat clsr cgen intratrl comunicaj w/implt 1 0,167.89 93581 Prq tcat clsr cgen ventr septal dfct w/implt 1 3,877.29 93600 26 Bundle of His recording 3 10.59 93600 Bundle of His recording 7 7 2 . 2 0 93602 26 Intra-atrial recording 2 54.62 93602 Intra-atrial recording 5 1 0 . 3 0 93603 26 Right ventricular recording 2 21.61 93603 Right ventricular recording 6 0 5 . 7 0 93609 26 Map tachycardia add-on 8 25.96 93609 Intraventricular and/or intra-atrial mapping of tachycardia site(s) with catheter manipulation to record from 1 ,494.00 93610 26 Intra-atrial pacing 4 16.14 93610 Intra-atrial pacing 5 9 2 . 2 0 93612 26 Intraventricular pacing 3 27.81 93612 Intraventricular pacing 5 6 8 . 8 0 93613 Icar ephys 3-dimensional mapg 1 ,153.65 93615 26 Esophageal recording 1 03.31 93615 Esophageal recording of atrial electrogram with or without ventricular electrogram(s); 1 3 4 . 1 0 129 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 93616 26 Esophageal recording 1 65.00 93616 Esophageal recording of atrial electrogram with or without ventricular electrogram(s); with pacing 3 5 8 . 2 0 93618 26 Heart rhythm pacing 7 30.18 93618 Induction of arrhythmia by electrical pacing 1 , 2 8 7 . 9 0 93619 26 Electrophysiology evaluation 1 ,141.78 93619 Comprehensive electrophysiologic evaluation with right atrial pacing and recording, right ventricular pacing 2 ,567.70 93620 26 Electrophysiology evaluation 1 ,780.00 93620 Comprehensive electrophysiologic evaluation with right atrial pacing and recording, right ventricular pacing 3 ,511.80 93621 26 Electrophysiology evaluation 4 25.44 93621 Comprehensive electrophysiologic evaluation with right atrial pacing and recording, right ventricular pacing 3 ,800.70 93623 26 Stimulation pacing heart 3 77.16 93623 Programmed stimulation and pacing after intravenous drug infusion (List separately in addition to code for 6 25.50 93624 26 Electrophysiologic study 8 41.51 93624 Electrophysiologic follow-up study with pacing and recording to test effectiveness of therapy, including 1 ,545.30 93631 26 Heart pacing mapping 1 ,283.52 93631 Intra-operative epicardial and endocardial pacing and mapping to localize the site of tachycardia or zone of 2 ,189.70 93640 26 Evaluation heart device 5 78.16 93640 Electrophysiologic evaluation of single or dual chamber pacing cardioverter-defibrillator leads including 1 ,735.20 93641 26 Electrophysiology evaluation 8 90.84 93641 Electrophysiologic evaluation of single or dual chamber pacing cardioverter-defibrillator leads including 1 ,702.80 93642 26 Ephys eval pacg cvdfb prgrmg/reprgrmg parameters 8 41.38 93642 Ephys eval pacg cvdfb prgrmg/reprgrmg parameters 1 ,697.82 93642 TC Ephys eval pacg cvdfb prgrmg/reprgrmg parameters 8 56.44 93650 Intracardiac catheter ablation of atrioventricular node function, atrioventricular conduction for creation of 3 ,193.20 93653 Ep & ablate supravent arrhyt 1 ,587.14 93654 Ep & ablate ventric tachy 2 ,118.20 93655 Ablate arrhythmia add on 7 93.43 93656 Tx atrial fib pulm vein isol 2 ,118.70 93657 Tx l/r atrial fib addl 7 94.38 93660 26 Tilt table evaluation 3 61.25 93660 Evaluation of cardiovascular function with tilt table evaluation, with continuous ECG monitoring and 6 39.00 93660 TC Tilt table evaluation 2 77.75 93668 Prph artl disease rhab pr sess 1 42.65 93701 Biompedance-derived physiologic cv analysis 8 6.57 93724 26 Elec alys antitachycardia pm system 5 75.15 93724 Elec alys antitachycardia pm system 7 15.67 93724 TC Elec alys antitachycardia pm system 1 40.53 93740 Temperature gradient studies 1 0 8 . 0 0 93750 Interrogation vad in person 1 07.14 93770 Determination of venous pressure 3 0 . 6 0 93784 Ambulatory blood pressure monitoring, utilizing a system such as magnetic tape and/or computer disk, for 3 69.90 93786 Ambl bld press w/tape&/disk 24+ hr + rec only 6 5.66 93788 Ambl bld press w/tape/disk 24+ hr alys w/reprt 1 37.83 93790 Ambl bld press tape&/disk 24+ hr phys rev w/i&r 6 5.76 93797 Physician services for outpatient cardiac rehabilitation; without continuous ECG monitoring (per session) 4 6 . 8 0 93798 Outpatient cardiac rehab w/cont ecg monitoring 6 8.76 93880 26 Extracranial bilat study 4 7.85 93880 Duplex scan of extracranial arteries; complete bilateral study 4 3 1 . 5 8 93880 TC Extracranial bilat study 3 83.73 93882 26 Extracranial uni/ltd study 4 3.57 93882 Duplex scan of extracranial arteries; unilateral or limited study 4 0 7 . 7 0 93882 TC Extracranial uni/ltd study 3 64.13 93886 26 Intracranial complete study 5 3.54 93886 Transcranial Doppler study of the intracranial arteries; complete study 4 6 1 . 7 0 93886 TC Intracranial complete study 4 08.16 93888 26 Intracranial limited study 4 4.63 93888 Transcranial Doppler study of the intracranial arteries; limited study 3 3 9 . 3 0 93888 TC Intracranial limited study 2 94.67 93890 26 Tcd std icra art vasoreactv std 1 21.20 93890 Tcd std icra art vasoreactv std 5 45.02 93890 TC Tcd std icra art vasoreactv std 4 23.82 93892 26 Tcd std icra art emboli detcj w/o iv mbubb njx 1 38.59 93892 Tcd std icra art emboli detcj w/o iv mbubb njx 5 81.23 93892 TC Tcd std icra art emboli detcj w/o iv mbubb njx 4 42.64 93893 26 Tcd std icra art emboli detcj w/iv mbubb njx 1 36.38 93893 Tcd std icra art emboli detcj w/iv mbubb njx 5 75.75 93893 TC Tcd std icra art emboli detcj w/iv mbubb njx 4 39.36 93922 26 Upr/l xtremity art 2 levels 2 6.81 93922 Non-invasive physiologic studies of upper or lower extremity arteries, single level, bilateral (eg, 2 28.60 93922 TC Upr/l xtremity art 2 levels 2 01.79 130 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 93923 26 Upr/lxtr art stdy 3+ lvls 5 1.22 93923 Non-invasive physiologic studies of upper or lower extremity arteries, multiple levels or with provocative 3 64.50 93923 TC Upr/lxtr art stdy 3+ lvls 3 13.28 93924 26 Lwr xtr vasc stdy bilat 4 5.73 93924 Non-invasive physiologic studies of lower extremity arteries, at rest and following treadmill stress testing, 3 69.00 93924 TC Lwr xtr vasc stdy bilat 3 23.27 93925 26 Lower extremity study 5 6.52 93925 Duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral study 3 9 8 . 1 7 93925 TC Lower extremity study 3 41.65 93926 26 Lower extremity study 3 8.91 93926 Duplex scan of lower extremity arteries or arterial bypass grafts; unilateral or limited study 2 4 5 . 9 6 93926 TC Lower extremity study 2 07.05 93930 26 Upper extremity study 3 7.29 93930 Duplex scan of upper extremity arteries or arterial bypass grafts; complete bilateral study 4 3 2 . 9 0 93930 TC Upper extremity study 3 95.61 93931 26 Upper extremity study 2 3.26 93931 Duplex scan of upper extremity arteries or arterial bypass grafts; unilateral or limited study 2 7 0 . 9 0 93931 TC Upper extremity study 2 47.64 93965 26 Extremity study 3 0.99 93965 Non-invasive physiologic studies of extremity veins, complete bilateral study (eg, Doppler waveform 2 43.31 93965 TC Extremity study 2 12.32 93970 26 Extremity study 6 4.54 93970 Duplex scan of extremity veins including responses to compression and other maneuvers; complete 3 82.93 93970 TC Extremity study 3 18.39 93971 26 Extremity study 4 1.87 93971 Duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or 2 37.86 93971 TC Extremity study 1 95.99 93975 26 Vascular study 8 6.92 93975 Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or 3 87.90 93975 TC Vascular study 3 00.98 93976 26 Vascular study 1 09.12 93976 Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or 4 22.10 93976 TC Vascular study 3 12.98 93978 26 Vascular study 4 6.67 93978 Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; complete study 3 6 4 . 5 0 93978 TC Vascular study 3 17.83 93979 26 Vascular study 3 2.53 93979 Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; unilateral or limited study 2 6 8 . 2 0 93979 TC Vascular study 2 35.67 93980 26 Penile vascular study 1 79.39 93980 Duplex scan of arterial inflow and venous outflow of penile vessels; complete study 5 1 4 . 8 0 93980 TC Penile vascular study 3 35.41 93981 26 Penile vascular study 6 3.58 93981 Duplex scan of arterial inflow and venous outflow of penile vessels; follow-up or limited study 3 6 0 . 9 0 93981 TC Penile vascular study 2 97.32 93982 Implant wireless press sensor study aneurysm sac 1 01.76 93990 26 Doppler flow testing 1 6.62 93990 Duplex scan of hemodialysis access (including arterial inflow, body of access and venous outflow) 2 9 7 . 0 0 93990 TC Doppler flow testing 2 80.38 94002 Ventilation assist & mgmt inpatient 1st day 2 18.34 94003 Ventilation assist & mgmt inpatient ea sbsq day 1 57.25 94004 Ventilation assist & mgmt nursing fac pr day 1 14.51 94005 Home ventilator mgmt care oversight 30 min/> 2 03.72 94010 26 Breathing capacity test 1 8.97 94010 Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement(s), 9 2.70 94010 TC Breathing capacity test 7 3.73 94011 Meas spiromtrc forcd expiratory flo infant-2 yr 2 16.23 94012 Meas spiro forcd exp flo pre&post bronch inf-2y 3 52.90 94013 Meas lung volumes infant or child thru 2 yrs 7 6.21 94014 Patient-initiated spirometric recording per 30-day period of time; includes reinforced education, transmission 9 1.80 94015 Patient-initiated spirometric recording 5 4.46 94016 Patient-initiated spirometric recording per 30-day period of time; physician review and interpretation only 5 8 . 5 0 94060 26 Evaluation of wheezing 2 4.14 94060 Bronchospasm evaluation: spirometry as in 94010, before and after bronchodilator (aerosol or parenteral) 1 2 8 . 7 0 94060 TC Evaluation of wheezing 1 04.56 94070 26 Evaluation of wheezing 9 4.68 94070 Prolonged postexposure evaluation of bronchospasm with multiple spirometric determinations after antigen, 2 12.40 94070 TC Evaluation of wheezing 1 17.72 94150 26 Vital capacity test 5 .54 94150 Vital capacity, total (separate procedure) 4 0 . 5 0 131 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 94150 TC Vital capacity test 3 4.96 94200 26 Lung function test (MBC/MVV) 1 1.13 94200 Maximum breathing capacity, maximal voluntary ventilation 5 6 . 7 0 94200 TC Lung function test (MBC/MVV) 4 5.57 94250 26 Expired gas collection 6 .45 94250 Expired gas collection, quantitative, single procedure (separate procedure) 3 3 . 3 0 94250 TC Expired gas collection 2 6.85 94375 26 Respiratory flow volume loop 3 3.70 94375 Respiratory flow volume loop 9 9 . 0 0 94375 TC Respiratory flow volume loop 6 5.30 94400 26 CO2 breathing response curve 3 9.27 94400 Breathing response to CO2 (CO2 response curve) 1 3 4 . 1 0 94400 TC CO2 breathing response curve 9 4.83 94450 26 Hypoxia response curve 2 4.61 94450 Breathing response to hypoxia (hypoxia response curve) 9 5 . 4 0 94450 TC Hypoxia response curve 7 0.79 94452 26 Hast w/phys i&r 3 7.46 94452 Hast w/phys i&r 1 24.52 94452 TC Hast w/phys i&r 8 7.06 94453 26 Hast w/phys i&r w/suppl o2 titrj 4 8.67 94453 Hast w/phys i&r w/suppl o2 titrj 1 77.79 94453 TC Hast w/phys i&r w/suppl o2 titrj 1 29.13 94610 Intrapulmonary surfactant administration 1 57.18 94620 26 Pulmonary stress test/simple 1 29.42 94620 Pulmonary stress testing; simple (eg, prolonged exercise test for bronchospasm with pre- and post- 2 54.70 94620 TC Pulmonary stress test/simple 1 25.28 94621 26 Pulm stress test/complex 8 1.55 94621 Pulmonary stress testing; complex (including measurements of CO2 production, O2 uptake, and 2 12.40 94621 TC Pulm stress test/complex 1 30.85 94640 Nonpressurized inhalation treatment for acute airway obstruction 4 1 . 4 0 94642 Aerosol inhalation of pentamidine for pneumocystis carinii pneumonia treatment or prophylaxis 4 7 . 7 0 94644 Continuous inhalation treatment 1st hr 8 5.99 94645 Continuous inhalation treatment ea addl hr 3 2.68 94660 Continuous positive airway pressure ventilation (CPAP), initiation and management 1 8 0 . 9 0 94662 Continuous negative pressure ventilation (CNP), initiation and management 1 1 8 . 8 0 94664 Aerosol or vapor inhalations for sputum mobilization, bronchodilation, or sputum induction for diagnostic 4 9.61 94667 Manipulation chest wall, such as cupping, percussing, and vibration to facilitate lung function; initial 6 3.00 94668 Manipulation chest wall, such as cupping, percussing, and vibration to facilitate lung function; subsequent 5 4 . 9 0 94680 26 Exhaled air analysis o2 2 6.96 94680 Oxygen uptake, expired gas analysis; rest and exercise, direct, simple 1 4 0 . 4 0 94680 TC Exhaled air analysis o2 1 13.44 94681 26 Exhaled air analysis o2/co2 2 8.35 94681 Oxygen uptake, expired gas analysis; including CO2 output, percentage oxygen extracted 1 6 9 . 2 0 94681 TC Exhaled air analysis o2/co2 1 40.85 94690 26 Exhaled air analysis 3 .93 94690 Oxygen uptake, expired gas analysis; rest, indirect (separate procedure) 5 6 . 7 0 94690 TC Exhaled air analysis 5 2.77 94726 26 Pulm funct tst plethysmograp 2 3.56 94726 TC Pulm funct tst plethysmograp 9 5.27 94726 Pulm funct tst plethysmograp 1 18.84 94727 26 Pulm function test by gas 2 3.56 94727 TC Pulm function test by gas 6 8.80 94727 Pulm function test by gas 9 2.36 94728 26 Pulm funct test oscillometry 2 3.56 94728 TC Pulm funct test oscillometry 6 5.44 94728 Pulm funct test oscillometry 8 9.00 94729 26 Co/membane diffuse capacity 1 7.45 94729 TC Co/membane diffuse capacity 1 05.07 94729 Co/membane diffuse capacity 1 22.52 94750 26 Pulmonary compliance study 1 1.39 94750 Pulmonary compliance study, any method 9 8 . 1 0 94750 TC Pulmonary compliance study 8 6.71 94760 Noninvasive ear or pulse oximetry for oxygen saturation; single determination 3 4 . 9 8 94761 Noninvasive ear or pulse oximetry for oxygen saturation; multiple determinations (eg, during exercise) 7 2 . 0 0 94762 Noninvasive ear or pulse oximetry for oxygen saturation; by continuous overnight monitoring (separate 1 06.20 94770 Carbon dioxide, expired gas determination by infrared analyzer 6 2 . 1 0 94780 Car seat/bed test 60 min 1 00.15 94781 Car seat/bed test + 30 min 3 9.79 95004 Percutaneous tests (scratch, puncture, prick) with allergenic extracts, immediate type reaction, specify 7 .55 95012 Nitric oxide expired gas determination 5 6.16 132 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 95017 Perq & icut allg test venoms 1 7.14 95018 Perq&ic allg test drugs/biol 4 2.06 95024 Intracutaneous (intradermal) tests with allergenic extracts, immediate type reaction, specify number of tests 1 4 . 4 0 95027 Skin end point titration 1 2 . 8 3 95028 Intracutaneous (intradermal) tests with allergenic extracts, delayed type reaction, including reading, specify 2 0.70 95044 Patch or application test(s) (specify number of tests) 1 9 . 0 8 95052 Photo patch test(s) (specify number of tests) 1 3 . 5 0 95056 Photo tests 1 2 . 6 0 95060 Ophthalmic mucous membrane tests 2 3 . 4 0 95065 Direct nasal mucous membrane test 2 0 . 7 0 95070 Inhalation bronchial challenge testing (not including necessary pulmonary function tests); with histamine, 1 75.50 95071 Inhalation bronchial challenge testing (not including necessary pulmonary function tests); with antigens or 2 04.30 95076 Ingest challenge ini 120 min 2 19.54 95079 Ingest challenge addl 60 min 1 52.06 95115 Professional services for allergen immunotherapy not including provision of allergenic extracts; single 1 7.96 95117 Professional services for allergen immunotherapy not including provision of allergenic extracts; two or more 2 3.11 95144 Professional services for the supervision and provision of antigens for allergen immunotherapy, single or 3 3.49 95145 Professional services for the supervision and provision of antigens for allergen immunotherapy (specify 3 6.00 95146 Professional services for the supervision and provision of antigens for allergen immunotherapy (specify 4 6.80 95147 Professional services for the supervision and provision of antigens for allergen immunotherapy (specify 6 4.80 95148 Professional services for the supervision and provision of antigens for allergen immunotherapy (specify 6 5.70 95149 Professional services for the supervision and provision of antigens for allergen immunotherapy (specify 8 1.00 95165 Professional services for the supervision and provision of antigens for allergen immunotherapy; single or 1 5.30 95170 Professional services for the supervision and provision of antigens for allergen immunotherapy; whole body 3 3.30 95180 Rapid desensitization procedure, each hour (eg, insulin, penicillin, horse serum) 2 0 7 . 0 0 95250 Gluc mntr cont rec from interstitial tiss fluid 2 65.16 95251 Gluc mntr cont rec from ntrstl tiss flu i&r 6 2.92 95782 26 Polysom <6 yrs 4/> paramtrs 2 32.28 95782 TC Polysom <6 yrs 4/> paramtrs 1 ,816.92 95782 Polysom <6 yrs 4/> paramtrs 2 ,049.21 95783 26 Polysom <6 yrs cpap/bilvl 2 54.37 95783 TC Polysom <6 yrs cpap/bilvl 1 ,933.02 95783 Polysom <6 yrs cpap/bilvl 2 ,187.39 95800 26 Slp stdy unatnd w/hrt rate/o2 sat/resp/slp time 1 42.31 95800 Slp stdy unatnd w/hrt rate/o2 sat/resp/slp time 3 ,262.03 95800 TC Slp stdy unatnd w/hrt rate/o2 sat/resp/slp time 3 ,119.72 95801 26 Slp stdy unatnd w/min hrt rate/o2 sat/resp anal 1 20.72 95801 Slp stdy unatnd w/min hrt rate/o2 sat/resp anal 5 ,454.71 95801 TC Slp stdy unatnd w/min hrt rate/o2 sat/resp anal 5 ,333.99 95803 26 Actigraphy testing 8 0.02 95803 TC Actigraphy testing 2 14.55 95803 Actigraphy testing 2 94.57 95805 26 Multiple sleep latency test 7 0.32 95805 Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of 5 66.10 95805 TC Multiple sleep latency test 4 95.78 95806 26 Sleep study unatt&resp efft 6 6.94 95806 Sleep std airflow hrt rate&o2 sat effort unattn 2 13.46 95806 TC Sleep study unatt&resp efft 1 46.52 95807 26 Sleep study attended 8 0.56 95807 Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen 7 13.70 95807 TC Sleep study attended 6 33.14 95808 26 Polysom any age 1-3> param 9 1.44 95808 Polysomnography; sleep staging with 1-3 additional parameters of sleep, attended by a technologist 7 5 6 . 9 0 95808 TC Polysom any age 1-3> param 6 65.46 95810 26 Polysom 6/> yrs 4/> param 1 29.14 95810 Polysomnography; sleep staging with 4 or more additional parameters of sleep, attended by a technologist 7 4 7 . 0 0 95810 TC Polysom 6/> yrs 4/> param 6 17.86 95811 26 Polysm sleep staging 4/> addl param w/cpap tx 4 55.02 95811 Polysm sleep staging 4/> addl param w/cpap tx 2 ,117.10 95811 TC Polysm sleep staging 4/> addl param w/cpap tx 1 ,662.09 95812 26 Eeg extnd mntr 41-60 min 1 74.48 95812 Eeg extnd mntr 41-60 min 6 19.00 95812 TC Eeg extnd mntr 41-60 min 4 44.52 95813 26 Eeg extnd mntr > 1 hr 2 21.97 95813 Eeg extnd mntr > 1 hr 6 49.47 95813 TC Eeg extnd mntr > 1 hr 4 27.50 95816 26 Eeg awake and drowsy 3 3.98 95816 Electroencephalogram (EEG) including recording awake and drowsy (including hyperventilation and/or 2 66.90 95816 TC Eeg awake and drowsy 2 32.92 95819 26 Eeg awake and asleep 2 3.60 133 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 95819 Electroencephalogram (EEG) including recording awake and asleep (including hyperventilation and/or 2 15.10 95819 TC Eeg awake and asleep 1 91.50 95822 26 Eeg coma or sleep only 3 3.28 95822 Electroencephalogram (EEG); sleep only 2 7 0 . 9 0 95822 TC Eeg coma or sleep only 2 37.62 95824 Electroencephalogram (EEG); cerebral death evaluation only 1 7 7 . 3 0 95827 26 Eeg all night recording 2 2.14 95827 Electroencephalogram (EEG); all night sleep only 3 4 3 . 8 0 95827 TC Eeg all night recording 3 21.66 95829 26 Surgery electrocorticogram 8 0.52 95829 Electrocorticogram at surgery (separate procedure) 5 3 3 . 7 0 95829 TC Surgery electrocorticogram 4 53.18 95830 Insertion by physician of sphenoidal electrodes for electroencephalographic (EEG) recording 2 4 1 . 2 0 95831 Muscle testing, manual (separate procedure) with report; extremity (excluding hand) or trunk 1 0 5 . 3 0 95832 Muscle testing, manual (separate procedure) with report; hand, with or without comparison with normal side 7 2 . 9 0 95833 Muscle testing, manual (separate procedure) with report; total evaluation of body, excluding hands 1 1 3 . 4 0 95834 Muscle testing, manual (separate procedure) with report; total evaluation of body, including hands 1 3 9 . 5 0 95851 Range of motion measurements and report (separate procedure); each extremity (excluding hand) or each 8 7.30 95852 Range of motion measurements and report (separate procedure); hand, with or without comparison with 7 2.00 95857 Tensilon test for myasthenia gravis; 1 2 2 . 4 0 95860 26 Muscle test one limb 8 2.27 95860 Needle electromyography, one extremity with or without related paraspinal areas 2 1 6 . 7 2 95860 TC Muscle test one limb 1 34.45 95861 26 Muscle test 2 limbs 1 25.43 95861 Needle electromyography, two extremities with or without related paraspinal areas 2 8 2 . 2 3 95861 TC Muscle test 2 limbs 1 56.80 95863 26 Muscle test 3 limbs 2 07.62 95863 Needle electromyography, three extremities with or without related paraspinal areas 4 7 3 . 4 0 95863 TC Muscle test 3 limbs 2 65.78 95864 26 Muscle test 4 limbs 2 51.46 95864 Needle electromyography, four extremities with or without related paraspinal areas 6 1 8 . 3 0 95864 TC Muscle test 4 limbs 3 66.84 95865 26 Ndl emg larx 2 01.02 95865 Ndl emg larx 2 65.24 95865 TC Ndl emg larx 6 4.22 95866 26 Ndl emg hemidphrm 1 54.18 95866 Ndl emg hemidphrm 1 81.64 95866 TC Ndl emg hemidphrm 2 7.47 95867 26 Muscle test cran nerv unilat 7 1.74 95867 Needle electromyography, cranial nerve supplied muscles, unilateral 2 1 1 . 5 0 95867 TC Muscle test cran nerv unilat 1 39.76 95868 26 Muscle test cran nerve bilat 1 04.05 95868 Needle electromyography, cranial nerve supplied muscles, bilateral 2 5 7 . 4 0 95868 TC Muscle test cran nerve bilat 1 53.35 95869 26 Muscle test thor paraspinal 3 3.27 95869 Needle electromyography; thoracic paraspinal muscles 1 6 2 . 3 4 95869 TC Muscle test thor paraspinal 1 29.07 95870 26 Ndl emg lmtd std musc 1 xtr/non-limb uni/bi 6 4.59 95870 Ndl emg lmtd std musc 1 xtr/non-limb uni/bi 9 9.09 95870 TC Ndl emg lmtd std musc 1 xtr/non-limb uni/bi 3 4.50 95872 26 Muscle test one fiber 1 86.60 95872 Needle electromyography using single fiber electrode, with quantitative measurement of jitter, blocking 2 57.40 95872 TC Muscle test one fiber 7 0.80 95873 26 Estim gdn conjunct chemodnrvtj 5 5.40 95873 Estim gdn conjunct chemodnrvtj 8 6.04 95873 TC Estim gdn conjunct chemodnrvtj 3 0.64 95874 26 Ndl emg gdn conjunct chemodnrvtj 5 6.80 95874 Ndl emg gdn conjunct chemodnrvtj 8 6.55 95874 TC Ndl emg gdn conjunct chemodnrvtj 2 9.75 95875 26 Limb exercise test 6 1.86 95875 Ischemic limb exercise with needle electromyography, with lactic acid determination 1 4 4 . 0 0 95875 TC Limb exercise test 8 2.14 95885 26 Musc tst done w/nerv tst lim 3 3.53 95885 TC Musc tst done w/nerv tst lim 8 4.92 95885 Musc tst done w/nerv tst lim 1 18.45 95886 26 Musc test done w/n test comp 6 7.07 95886 TC Musc test done w/n test comp 9 4.99 95886 Musc test done w/n test comp 1 62.06 95887 26 Musc tst done w/n tst nonext 4 4.59 95887 TC Musc tst done w/n tst nonext 9 2.98 134 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 95887 Musc tst done w/n tst nonext 1 37.57 95905 26 Motor &/sens nrv cndj preconf eltrd array limb 7 .78 95905 Motor &/sens nrv cndj preconf eltrd array limb 1 97.22 95905 TC Motor &/sens nrv cndj preconf eltrd array limb 1 89.44 95907 26 Motor&/sens 1-2 nrv cndj tst 9 4.32 95907 TC Motor&/sens 1-2 nrv cndj tst 8 5.48 95907 Motor&/sens 1-2 nrv cndj tst 1 79.80 95908 26 Motor&/sens 3-4 nrv cndj tst 1 18.64 95908 TC Motor&/sens 3-4 nrv cndj tst 1 02.94 95908 Motor&/sens 3-4 nrv cndj tst 2 21.59 95909 26 Motor&/sens 5-6 nrv cndj tst 1 41.34 95909 TC Motor&/sens 5-6 nrv cndj tst 1 24.33 95909 Motor&/sens 5-6 nrv cndj tst 2 65.67 95910 26 Motor&sens 7-8 nrv cndj test 1 89.31 95910 TC Motor&sens 7-8 nrv cndj test 1 60.21 95910 Motor&sens 7-8 nrv cndj test 3 49.52 95911 26 Motor&sen 9-10 nrv cndj test 2 36.33 95911 TC Motor&sen 9-10 nrv cndj test 1 86.30 95911 Motor&sen 9-10 nrv cndj test 4 22.63 95912 26 Motor&sen 11-12 nrv cnd test 2 83.63 95912 TC Motor&sen 11-12 nrv cnd test 2 10.77 95912 Motor&sen 11-12 nrv cnd test 4 94.40 95913 26 Motor&sens 13/> nrv cnd test 3 36.17 95913 TC Motor&sens 13/> nrv cnd test 2 36.18 95913 Motor&sens 13/> nrv cnd test 5 72.36 95921 26 Autonomic nrv parasym inervj 4 9.70 95921 Testing of autonomic nervous system function; cardiovagal innervation (parasympathetic function), 1 04.40 95921 TC Autonomic nrv parasym inervj 5 4.70 95922 26 Autonomic nrv adrenrg inervj 4 6.18 95922 Testing of autonomic nervous system function; vasomotor adrenergic innervation (sympathetic adrenergic 1 08.90 95922 TC Autonomic nrv adrenrg inervj 6 2.72 95923 26 Autonomic nrv syst funj test 1 6.78 95923 Testing of autonomic nervous system function; sudomotor, including one or more of the following: 1 00.80 95923 TC Autonomic nrv syst funj test 8 4.02 95924 26 Ans parasymp & symp w/tilt 1 58.62 95924 TC Ans parasymp & symp w/tilt 1 20.52 95924 Ans parasymp & symp w/tilt 2 79.13 95925 26 Somatosensory testing 4 7.98 95925 Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, 3 69.00 95925 TC Somatosensory testing 3 21.02 95926 26 Somatosensory testing 4 1.65 95926 Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, 2 98.80 95926 TC Somatosensory testing 2 57.15 95927 26 Somatosensory testing 4 3.75 95927 Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, 2 98.80 95927 TC Somatosensory testing 2 55.05 95928 26 Ctr motor ep std transcrnl motor stimj upr limbs 2 85.32 95928 Ctr motor ep std transcrnl motor stimj upr limbs 6 15.63 95928 TC Ctr motor ep std transcrnl motor stimj upr limbs 3 30.30 95929 26 Ctr motor ep std transcrnl motor stimj lwr limbs 2 80.97 95929 Ctr motor ep std transcrnl motor stimj lwr limbs 6 33.74 95929 TC Ctr motor ep std transcrnl motor stimj lwr limbs 3 52.77 95930 26 Visual evoked potential test 3 4.63 95930 Visual evoked potential (VEP) testing central nervous system, checkerboard or flash 3 3 9 . 3 0 95930 TC Visual evoked potential test 3 04.67 95933 26 Blink reflex test 5 6.06 95933 Orbicularis oculi (blink) reflex, by electrodiagnostic testing 1 7 5 . 5 0 95933 TC Blink reflex test 1 19.44 95937 26 Neuromuscular junction test 7 3.30 95937 Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any one method 1 8 0 . 0 0 95937 TC Neuromuscular junction test 1 06.70 95938 26 Somatosensory testing 8 2.38 95938 TC Somatosensory testing 5 71.11 95938 Somatosensory testing 6 53.49 95939 26 C motor evoked upr&lwr limbs 2 16.10 95939 TC C motor evoked upr&lwr limbs 7 75.59 95939 C motor evoked upr&lwr limbs 9 91.70 95940 Ionm in operatng room 15 min 5 8.81 95950 26 Ambulatory eeg monitoring 1 38.80 95950 Monitoring for identification and lateralization of cerebral seizure focus, electroencephalographic (eg, 8 6 55.20 135 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 95950 TC Ambulatory eeg monitoring 5 16.40 95951 26 EEG monitoring/videorecord 5 14.81 95951 Monitoring for localization of cerebral seizure focus by cable or radio, 16 or more channel telemetry, 9 06.30 95953 26 EEG monitoring/computer 2 62.86 95953 Monitoring for localization of cerebral seizure focus by computerized portable 16 or more channel EEG, 7 63.20 95953 TC EEG monitoring/computer 5 00.34 95954 26 EEG monitoring/giving drugs 8 4.88 95954 Pharmacological or physical activation requiring physician attendance during EEG recording of activation 3 55.50 95954 TC EEG monitoring/giving drugs 2 70.62 95955 26 EEG during surgery 7 0.64 95955 Electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery) 3 4 0 . 2 0 95955 TC EEG during surgery 2 69.56 95956 26 Eeg monitor technol attended 7 8.24 95956 Monitoring for localization of cerebral seizure focus by cable or radio, 16 or more channel telemetry, 7 79.40 95956 TC Eeg monitor technol attended 7 01.16 95957 26 Dgtal alys eeg 1 66.54 95957 Dgtal alys eeg 3 15.45 95957 TC Dgtal alys eeg 1 48.91 95958 26 EEG monitoring/function test 2 32.62 95958 Wada activation test for hemispheric function, including electroencephalographic (EEG) monitoring 6 5 4 . 3 0 95958 TC EEG monitoring/function test 4 21.68 95961 26 Electrode stimulation brain 2 22.66 95961 Functional cortical and subcortical mapping by stimulation and/or recording of electrodes on brain surface, 4 29.30 95961 TC Electrode stimulation brain 2 06.64 95962 26 Electrode stim brain add-on 2 91.69 95962 Functional cortical and subcortical mapping by stimulation and/or recording of electrodes on brain surface, 4 48.20 95962 TC Electrode stim brain add-on 1 56.51 95970 Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and 4 7.70 95971 Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and 7 8.30 95972 Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and 1 43.10 95973 Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and 9 0.90 95974 Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and 2 92.50 95975 Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude and 1 73.70 95978 Elec alys nstim pls gen cplx dp brn 1st hr 5 27.16 95979 Elec alys nstim pls gen cplx dp brn ea 30 min 2 53.83 95980 Elec alys nstim pls gen gastric intraop w/prgrmg 1 14.21 95981 Io anal gast n-stim subsq 8 2.55 95982 Io ga n-stim subsq w/reprog 1 18.30 95990 Refill&maintenance pump drug dlvr spinal/brain 1 22.42 95991 Rfl&main implt pmp/rsvr rx dlvr spi/brn by phys 1 35.39 95992 Canalith repositioning proc 1 15.18 96000 Motion analysis video/3d 1 80.36 96001 Motion test w/ft press meas 1 74.93 96002 Dynamic surface emg 3 9.63 96003 Dynamic fine wire emg 3 0.57 96004 Phys review of motion tests 2 06.48 96040 Genetic counseling 30 min 9 8.24 96101 Psychological testing pr hr f2f time w/pt 1 91.25 96102 Psycl tstg pr hr admn by tech pr hr 9 3.33 96103 Psycl tstg pr hr admn by cptr w/prof i&r 8 7.96 96105 Assmt aphasia w/i&r pr hr 1 70.98 96110 Developmental tstg lmtd w/i&r 4 1.77 96111 Developmental tstg extnd w/i&r 1 75.28 96116 Nubhvl status xm pr hr f2f w/pt interpj&prepj 2 26.49 96118 Nuropsyc testing pr hr f2f w/pt + interpj time 2 34.56 96119 Nuropsyc tstg wprof i&r admn by tech pr hr 1 56.24 96120 Nuropsyc tstg admn by cptr w/prof i&r 1 15.84 96125 Standardized cognitive performance testing 2 08.77 96150 Hlth&behavior assmt ea 15 min f2f w/pt 1st assmt 5 1.14 96151 Hlth&behavior assmt ea 15 min f2f w/pt re-assmt 2 7.87 96152 Hlth&behavior ivntj ea 15 min f2f indiv 2 7.63 96153 Hlth&behavior ivntj ea 15 min f2f grp 2/> pts 3 4.17 96154 Hlth&behavior ivntj ea 15 min f2f fam w/pt 3 7.46 96155 Hlth&behavior ivntj ea 15 min f2f fam w/o pt 3 8.51 96360 Iv infusion hydration initial 31 min-1 hour 1 15.16 96361 Iv infusion hydration each additional hour 4 6.20 96365 Iv infusion therapy/prophylaxis /dx 1st to 1 hr 1 32.82 96366 Iv infusion therapy prophylaxis/dx ea hour 5 8.35 96367 Iv infusion ther proph addl sequential to 1 hr 8 4.16 96368 Iv nfs therapy prophylaxis/dx concurrent nfs 4 8.93 136 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 96369 Subcutaneous infusion initial 1 hr w/pump set-up 2 99.67 96370 Subcutaneous infusion each additional hour 3 3.76 96371 Subq infusion additional pump infusion site 1 26.53 96372 Therapeutic prophylactic/dx injection subq/im 3 4.73 96373 Therapeutic prophylactic/dx njx intra-arterial 3 1.87 96374 Ther proph/dx njx iv push single/1st sbst/drug 9 7.45 96375 Therapeutic injection iv push each new drug 5 6.42 96401 Chemotx admn subq/im non-hormonal anti-neo 1 53.81 96402 Chemotx admn subq/im hormonal anti-neo 8 2.57 96405 Chemotherapy administration, intralesional; up to and including 7 lesions 9 3 . 6 0 96406 Chemotherapy administration, intralesional; more than 7 lesions 1 2 6 . 0 0 96409 Chemotx admn iv push tq 1/1st sbst/drug 2 78.82 96411 Chemotx admn iv push tq ea sbst/drug 1 59.52 96413 Chemotx admn iv nfs tq up 1 hr 1/1st sbst/drug 3 98.03 96415 Chemotherapy admn iv infusion tq ea hr 8 9.79 96416 Chemotx admn tq init prolng chemotx nfus pmp 4 26.61 96417 Chemotx admn iv nfs tq ea seql nfs to 1 hr 1 90.54 96420 Chemotherapy administration, intra-arterial; push technique 1 4 6 . 7 0 96422 Chemotherapy administration, intra-arterial; infusion technique, up to one hour 1 5 9 . 3 0 96423 Chemotherapy administration, intra-arterial; infusion technique, one to 8 hours, each additional hour (List 6 3.90 96425 Chemotherapy administration, intra-arterial; infusion technique, initiation of prolonged infusion (more than 8 1 08.00 96440 Chemotherapy administration into pleural cavity, requiring and including thoracentesis 2 6 8 . 2 0 96446 Chemotx admn prtl cavity 5 88.26 96450 Chemotherapy administration, into CNS (eg, intrathecal), requiring and including lumbar puncture 2 2 8 . 6 0 96521 Rfl/main portable pmp 3 38.81 96522 Refill&maintenance pump drug dlvr systemic 2 55.97 96523 Irrigation implanted vad for drug dlvr 7 9.65 96542 Chemotherapy injection, subarachnoid or intraventricular via subcutaneous reservoir, single or multiple 1 95.30 96567 Pdt xtrnl appl light dstr les skn by activj rx 6 63.01 96570 Pdt ndsc abl abnor tiss via activj rx 30 min 3 29.38 96571 Pdt ndsc abl abnor tiss via activj rx a 15 min 1 63.85 96900 Actinotherapy (ultraviolet light) 3 4 . 2 0 96902 Microscopic examination of hairs plucked or clipped by the examiner (excluding hair collected by the 5 5.80 96904 Whole body integumentary photography 2 00.24 96910 Photochemotherapy; tar and ultraviolet B (Goeckerman treatment) or petrolatum and ultraviolet B 4 5 . 0 0 96912 Photochemotherapy; psoralens and ultraviolet A (PUVA) 5 1 . 3 0 96913 Photochemotherapy (Goeckerman and/or PUVA) for severe photoresponsive dermatoses requiring at least 1 95.30 96920 Laser skin disease psoriasis tot area <250 sq cm 3 98.75 96921 Laser skin disease psoriasis 250-500 sq cm 4 08.97 96922 Laser skin disease psoriasis >500 sq cm 6 20.53 97001 Physical therapy evaluation 8 8 . 9 7 97002 Physical therapy re-evaluation 4 3 . 4 7 97003 Occupational therapy evaluation 7 3 . 8 0 97004 Occupational therapy re-evaluation 3 6 . 0 0 97010 Application of a modality to one or more areas; hot or cold packs 3 2 . 9 4 97012 Application of a modality to one or more areas; traction, mechanical 3 9 . 1 6 97016 Application of a modality to one or more areas; vasopneumatic devices 5 8 . 5 0 97018 Application of a modality to one or more areas; paraffin bath 4 3 . 2 0 97022 Application of a modality to one or more areas; whirlpool 4 1 . 4 0 97024 Application of a modality to one or more areas; diathermy 3 7 . 8 1 97026 Application of a modality to one or more areas; infrared 2 2 . 5 0 97028 Application of a modality to one or more areas; ultraviolet 3 3 . 3 0 97032 Application of a modality to one or more areas; electrical stimulation (manual), each 15 minutes 4 4 .

4 2 97033 Application of a modality to one or more areas; iontophoresis, each 15 minutes 5 4 . 9 0 97034 Application of a modality to one or more areas; contrast baths, each 15 minutes 3 3 . 3 0 97035 Application of a modality to one or more areas; ultrasound, each 15 minutes 3 7 . 7 7 97036 Application of a modality to one or more areas; Hubbard tank, each 15 minutes 4 7 . 7 0 97110 Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and 4 6.60 97112 Therapeutic procedure, one or more areas, each 15 minutes; neuromuscular reeducation of movement, 4 3.21 97113 Therapeutic procedure, one or more areas, each 15 minutes; aquatic therapy with therapeutic exercises 5 2 . 5 9 97116 Therapeutic procedure, one or more areas, each 15 minutes; gait training (includes stair climbing) 4 3 . 9 1 97124 Therapeutic procedure, one or more areas, each 15 minutes; massage, including effleurage, petrissage 4 1.79 97140 Manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 4 8.65 97150 Ther px grp 2/> indivs 2 7.21 97530 Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to 5 6.70 97532 Development of cognitive skills ea 15 min 3 6.03 97533 Sensory integrative tqs ea 15 min 3 8.27 97535 Self care/home management training (eg, activities of daily living (ADL) and compensatory training, meal 5 6.70 97537 Community/work reintegration trainj ea 15 min 3 9.24 97542 Wheelchair mgmt ea 15 min 2 9.60 137 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 97545 Work hardening/conditioning; initial 2 hours 1 9 0 . 8 0 97546 Work hardening/conditioning; each additional hour (List separately in addition to code for primary 9 9.90 97597 Debridement open wound 20 sq cm< 1 04.34 97598 Debridement open wound addl 20 sq cm 1 14.89 97605 Neg press wnd ther </equal 50 sq cm 6 8.79 97606 Neg press wnd ther > 50 sq cm 1 12.59 97750 Physical performance test or measurement (eg, musculoskeletal, functional capacity), with written report, 7 9.20 97755 Asstv techn assmt dir cntct w/reprt 15 min 6 9.48 97760 Orthotic mgmt&trainj uxtr lxtr&/trnk ea 15 min 6 3.04 97761 Prostc trainj upr&/lxtr ea 15 min 5 7.46 97762 Checkout orthotic/prosthetic use 5 7.79 97802 Med nutr ther 1st assmt&ivntj indiv ea 15 min 3 2.69 97803 Med nutr ther re-assmt&ivntj indiv ea 15 min 3 1.73 97804 Med nutr ther grp2/> indiv ea 30 min 1 2.42 97810 Acup 1/> ndls w/o elec stimj 1st 15 min 6 0.96 97811 Acup 1/> ndls w/o elec stimj ea 15 min 5 1.38 97813 Acup 1/> ndls w/elec stimj 1st 15 min 6 6.59 97814 Acup 1/> ndls w/elec stimj ea 15 min w/re-insj 5 7.30 98925 Osteopathic manipulative treatment (OMT); one to two body regions involved 5 3 . 4 6 98926 Osteopathic manipulative treatment (OMT); three to four body regions involved 8 3 . 7 0 98927 Osteopathic manipulative treatment (OMT); five to six body regions involved 1 0 0 . 8 0 98928 Osteopathic manipulative treatment (OMT); seven to eight body regions involved 1 1 5 . 2 0 98929 Osteopathic manipulative treatment (OMT); nine to ten body regions involved 1 3 5 . 0 0 98940 Chiropractic manipulative treatment (CMT); spinal, one to two regions 4 8 . 3 2 98941 Chiropractic manipulative treatment (CMT); spinal, three to four regions 6 3 . 5 5 98942 Chiropractic manipulative treatment (CMT); spinal, five regions 9 1 . 8 0 98943 Chiropractic manipulative treatment (CMT); extraspinal, one or more regions 4 9 . 5 0 98960 Education&training self-mgmt nonphys 1 pt 6 3.65 98961 Education&training self-mgmt nonphys 2-4 pts 4 9.81 98962 Education&training self-mgmt nonphys 5-8 pts 3 6.96 98966 Hc pro phone call 5-10 min 4 0.02 98967 Hc pro phone call 11-20 min 7 8.06 98968 Hc pro phone call 21-30 min 1 11.03 99000 Handling and/or conveyance of specimen for transfer from the physician's office to a laboratory 2 3 . 4 0 99001 Handling and/or conveyance of specimen for transfer from the patient in other than a physician's office to a 2 6.10 99002 Handling, conveyance, and/or any other service in connection with the implementation of an order involving 2 7.00 99050 Services requested after office hours in addition to basic service 8 1 . 0 0 99056 Services provided at request of patient in a location other than physician's office which are normally 1 01.70 99058 Office services provided on an emergency basis 9 6 . 5 8 99091 Collect/review data from pt 1 01.30 99170 Collj/int physio data dig strd/trans minim 30min 3 63.95 99173 Screening 2 9.89 99174 Ocular photoscreening interpretation bilateral 3 9.61 99175 Ipecac or similar administration for individual emesis and continued observation until stomach adequately 1 06.20 99183 Physician attendance and supervision of hyperbaric oxygen therapy, per session 2 7 1 . 8 0 99195 Phlebotomy, therapeutic (separate procedure) 6 9 . 3 0 99201 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 7 5.03 99202 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 8 6.93 99203 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 1 19.33 99204 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 1 57.94 99205 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 2 07.38 99211 Office or other outpatient visit for the evaluation and management of an established patient, that may not 3 6.97 99212 Office or other outpatient visit for the evaluation and management of an established patient, which requires 5 6.87 99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires 7 4.01 99214 Office or other outpatient visit for the evaluation and management of an established patient, which requires 1 01.53 99215 Office or other outpatient visit for the evaluation and management of an established patient, which requires 1 56.37 99217 Obs care dschrg d mgmt 1 23.12 99218 Initial observation care, per day, for the evaluation and management of a patient which requires these three 1 34.10 99219 Initial observation care, per day, for the evaluation and management of a patient, which requires these three 1 85.40 99220 1st obs care pr d high severity 2 63.08 99221 Initial hospital care, per day, for the evaluation and management of a patient which requires these three key 1 46.86 99222 Initial hospital care, per day, for the evaluation and management of a patient, which requires these three 2 15.43 99223 Initial hospital care, per day, for the evaluation and management of a patient, which requires these three 2 42.77 99224 Sbsq obs care pr d low severity 4 6.14 99225 Sbsq obs care pr d moderate severity 9 0.63 99226 Sbsq obs care pr d high severity 1 27.71 99231 Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 7 6.73 99232 Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 9 9.73 99233 Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 1 52.75 99234 Observation or inpatient hospital care, for the evaluation and management of a patient including admission 1 74.35 138 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 99235 Observation or inpatient hospital care, for the evaluation and management of a patient including admission 2 38.54 99236 Obs/i/p hosp care high severity 3 84.38 99238 Hospital discharge day management; 30 minutes or less 1 3 3 . 0 5 99239 Hospital discharge day management; more than 30 minutes 1 7 2 . 2 7 99281 Emergency department visit for the evaluation and management of a patient, which requires these three key 9 1.71 99282 Emergency department visit for the evaluation and management of a patient, which requires these three key 1 20.82 99283 Emergency department visit for the evaluation and management of a patient, which requires these three key 1 83.70 99284 Emergency department visit for the evaluation and management of a patient, which requires these three key 2 60.67 99285 Emergency department visit for the evaluation and management of a patient, which requires these three key 3 55.91 99291 Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes 3 7 0 . 1 7 99292 Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 1 87.78 99304 1st nf care pr d e/m lw severity 9 1.71 99305 1st nf care pr d e/m mod severity 1 28.46 99306 1st nf care pr d e/m hi severity 1 57.46 99307 Sbsq nf care pr d e/m stable 4 9.66 99308 Sbsq nf care pr d e/m minor complctj 6 9.18 99309 Sbsq nf care pr d e/m new problem 9 8.10 99310 Sbsq nf care pr d e/m unstable/new problem 1 36.08 99315 Nf dschrg d mgmt 30 min/< 8 8.44 99316 Nf dschrg d mgmt > 30 min 1 11.15 99318 E/m pt invg annual nf assmt 9 9.15 99324 Dom/r-home lw severity 8 2.70 99325 Dom/r-home e/m new pt mod severity 1 11.12 99326 Dom/r-home e/m new pt mod hi severity 1 47.93 99327 Dom/r-home e/m new pt hi severity 2 04.83 99328 Dom/r-home e/m new pt significant new problem 2 61.61 99334 Dom/r-home e/m est pt self-lmtd/minor 6 3.42 99335 Dom/r-home e/m est pt lw mod severity 9 2.06 99336 Dom/r-home e/m est pt mod hi severity 1 36.21 99337 Dom/r-home e/m est pt significant new problem 1 91.90 99339 Indiv phys supvj home/dom/r-home mo 15-29 min 7 4.71 99340 Domicil/r-home care supervis 1 56.46 99341 Home visit for the evaluation and management of a new patient, which requires these three key 8 8.12 99342 Home vst new pt mod severity 9 9.69 99343 Home vst new pt mod to hi severity 1 35.42 99344 Home vst new pt hi severity 1 89.85 99345 Home vst new pt unstable/significant new problem 2 50.72 99347 Home vst est pt self limited/minor 6 3.21 99348 Home vst est pt low to mod severity 8 3.81 99349 Home vst est pt mod to hi severity 1 22.05 99350 Home vst est pt unstable/significant new problem 1 89.52 99354 Prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) patient 1 86.25 99355 Prolng phys svc office o/p dir contact ea 30 min 9 0.80 99356 Prolonged physician service in the inpatient setting, requiring direct (face-to-face) patient contact beyond 2 24.06 99357 Prolonged physician service in the inpatient setting, requiring direct (face-to-face) patient contact beyond 1 42.40 99358 Prolonged evaluation and management service before and/or after direct (face-to-face) patient care (eg, 2 02.71 99359 Prolng e/m before&/after dir care ea 30 min 9 6.23 99360 Physician standby service, requiring prolonged physician attendance, each 30 minutes (eg, operative 1 86.05 99363 Anticoagulant mgmt outpatient 1st 90 days 1 28.97 99364 Anticoagulant mgmt outpatient ea sbsq 90 days 5 6.96 99366 Team conference face-to-face nonphysician 4 8.20 99367 Team conference non-face-to-face physician 6 4.15 99368 Team conference non-face-to-face nonphysician 4 1.06 99374 Phys supvj pt home hlth agency mo 15-29 minutes 7 0.15 99377 Phys supvj hospice pt mo 15-29 min 8 0.18 99379 Phys supvj nf pt mo 15-29 min 7 3.02 99380 Phys supvj nf pt mo 30 min/> 1 13.75 99381 1st preventive medicine new patient < 1yr 1 12.83 99382 1st preventive medicine new patient age 1-4 yrs 1 21.55 99383 1st preventive medicine new patient age 5-11 yrs 1 28.47 99384 1st preventive medicine new patient age 12-17 yr 1 37.51 99385 Initial preventive medicine evaluation and management of an individual including a comprehensive history, 1 42.18 99386 1st preventive medicine new patient age 40-64yrs 1 95.28 99387 1st preventive medicine new patient age 65yrs&> 2 19.39 99391 Periodic preventive medicine reevaluation and management of an individual including a comprehensive 8 2.75 99392 Periodic preventive medicine reevaluation and management of an individual including a comprehensive 8 6.88 99393 Periodic preventive medicine reevaluation and management of an individual including a comprehensive 8 9.13 99394 Periodic preventive medicine reevaluation and management of an individual including a comprehensive 1 05.22 99395 Periodic preventive medicine reevaluation and management of an individual including a comprehensive 1 15.76 99396 Periodic preventive medicine reevaluation and management of an individual including a comprehensive 1 35.29 139 The Standard Health Insurance Fees for the Cayman Islands - June 2005 A p p e n d i x O n e CPT Mod DESCRIPTION FEE 99397 Periodic preventive med est patient age 65yrs&> 1 83.69 99401 Prev med cnsl indiv spx 15 min 4 8.03 99402 Prev med cnsl indiv spx 30 min 9 1.34 99403 Prev med cnsl indiv spx 45 min 1 36.56 99404 Prev med cnsl indiv spx 60 min 1 77.16 99406 Tobacco use cessation intermediate 3-10 minutes 2 6.43 99407 Tobacco use cessation intensive >10 minutes 5 2.70 99408 Alcohol/substance screen & interven 15-30 min 6 3.89 99409 Alcohol/substance screen & interven >30 min 1 24.96 99411 Prev med cnsl grp spx 30 min 4 5.69 99412 Prev med cnsl grp spx 60 min 7 4.76 99420 Health risk assessment test 1 7.61 99441 Phone e/m phys/qhp 5-10 min 4 0.16 99442 Phone e/m phys/qhp 11-20 min 7 2.79 99443 Phone e/m phys/qhp 21-30 min 9 8.26 99460 1st hosp/birthing center care per day nml nb 1 44.33 99461 Init nb em per day non-fac 9 8.43 99462 Subq hospital care per day e/m normal newborn 6 8.89 99463 1st hosp/birthing center nb admit&dschg sm date 1 57.01 99464 Attn at delivery& 1st stabilization of newborn 1 55.16 99465 Delivery/birthing room resuscitation 2 78.60 99466 Ped crit care transport 4 10.44 99467 Ped crit care transport addl 2 31.30 99468 Neonate crit care initial 1 ,541.18 99469 Neonate crit care subsq 9 61.49 99471 Ped critical care initial 1 ,358.69 99472 Ped critical care subsq 9 20.42 99475 Ped crit care age 2-5 init 1 ,108.22 99476 Ped crit care age 2-5 subsq 8 15.58 99477 Init day hosp neonate care 8 59.88 99478 Ic lbw inf < 1500 gm subsq 3 98.22 99479 Ic lbw inf 1500-2500 g subsq 3 73.08 99480 Ic inf pbw 2501-5000 g subsq 3 50.97 99485 Suprv interfacilty transport 2 12.34 99486 Suprv interfac trnsport addl 1 85.75 99487 Cmplx chron care w/o pt vsit 2 41.17 99488 Cmplx chron care w/ pt vsit 5 38.47 99489 Complx chron care addl30 min 1 21.11 99495 Trans care mgmt 14 day disch 4 81.75 99496 Trans care mgmt 7 day disch 6 78.77 140