SURGERY CENTER SUMMARY OF SERVICES AND AVERAGE PRICING Prices Include the Following: Facility, Surgeon, Anesthesia, immediate pre- and post-op care & surgical supplies. Implants, when applicable, are excluded, but will be added on to the final price at a maximum of 5% mark-up over actual invoice cost (invoice must be submitted for reimbursement). This facility requires a referral and may not provide all of the listed services. Please contact Medical Care Analyst at (888) 711-9060 for assistance with a referral to this facility. The listed services are for information purposes only and do not guarantee benefits are available. Please refer to the Plan Document or call 800-749-1422 to verify if a service is covered by your plan. ARTHROSCOPY Procedure Code Average Price SLAP Lesion Repair 29807 $ 6,000 Shoulder w/debridement (limited) 29822 $ 6,000 Debridement (extensive) 29823 $ 7,100 Distal Claviculectomy (Mumford) 29824 $ 6,000 Tibial Plateau Fracture Repair (Scope) 29855 $ 5,600 Knee 29871 $ 3,840 Knee with Lateral Release 29873 $ 4,460 Knee with Microfracture 29879 $ 4,460 Knee Foreign Body Removal 29874 $ 3,590 Knee Synovectomy, Major 29876 $ 3,590 Knee Debridement Chondroplasty 29877 $ 3,590 Knee with Meniscectomy 29880/29881 $ 3,590 Knee with Meniscal Repair 29882 $ 3,590 Shoulder 29806/29827 $ 6,000 Elbow 29830 $ 3,740 Wrist 29840 $ 4,150 Hip 29862 $ 5,300 Ankle 29891 $ 3,590 OPEN PROCEDURES KNEE Anterior Cruciate Ligament Repair 29888 $ 6,820 Posterior Cruciate Ligament Repair, Arthro-Aided 29889 $ 6,600 Collateral & Cruciate Ligament Repair 27409 $ 6,400 Medial Collateral Ligament 27405 $ 6,100 Osteochondral Autografts 27416 $ 6,000 Arthroplasty (uni) 27446 $ 20,000
Tibial Tubercle Osteotomy 27455 $ 6,165 Manipulation 27570 $ 1,900 SHOULDER Open Rotator Cuff Repair 23410 $ 6,160 Open Rotator Cuff Repair - Chronic 23412 $ 5,590 Repair/Reconstruction with Labral 23455 $ 6,000 Bankhart Stabilization 23466 $ 5,860 Distal Clavicle Excision 23120/23170 $ 4,600 Manipulation 23700 $ 1,900 Osteology Hardware Removal-Deep 20680 $ 2,700 HIP Total Hip Arthroplasty 27130 (Phy) $ 2,788 ELBOW Ulnar Nerve Transposition/Epicondylectomy 64718/24358 $ 4,460 Tenodesis 24340 $ 5,590 Humerus/Elbow with Tendon 24359 $ 4,590 WRIST/HAND Carpal Tunnel Release 64721 $ 2,620 Dupuytrens Contracture 25000 $ 2,810 Arthroplasty 25447 $ 4,480 Trigger Finger 26055 $ 2,630 Ganglion Excision 25111 $ 2,630 Fasciectomy 26123 $ 5,900 Excision of Lesion-Finger or Hand 26160 $ 2,630 ANKLE Achilles Repair 27650 $ 5,590 Secondary Repair (Watson-Jones or Brostrom) 27698 $ 4,690 FOOT Bunionectomy 28292 $ 4,050 Hammertoe (1) 28285 $ 2,350 Hammertoe (2) 28285 $ 2,910 Hammertoe (3) 28285 $ 3,355
Gastrocnemius Recession 27687 $ 4,050 Arthrodesis, great toe 28750 $ 4,000 Plantar Fasciotomy 28060 $ 3,030 Neuroma Excision 28080 $ 2,640 FRACTURES Closed Reduction and Casting-Radius 25605 $ 1,925 Open Treatment, fracture/separation 25608/25609 $ 6,250 Percutaneous Pinning - finger 1-2 pins 26756 $ 2,745 Ankle Fracture or Dislocation 27792 $ 6,000 Open Treatment of Metatarsal Fracture 28485 $ 6,000 Open Treatment of Phalangeal Shaft Fracture 26735 $ 3,700 OPEN REDUCTION INTERNAL FIXATION Closed Proximal Humeral Fracture 23600 $ 4,300 Open Treatment of Proximal Humeral Fracture 23615 $ 6,075 HARDWARE REMOVAL Simple 20680 $ 2,530 Complex 20680 $ 4,310 GENERAL SURGERY HERNIA - INCLUDES MESH Inguinal 49505 $ 3,200 Bilateral 49505 $ 4,150 Umbilical 49585 $ 3,100 Incisional 49560 $ 4,300 Cholecystectomy 47563/47562 $ 5,715 BREAST Mass - Excision/Biopsy 19120 $ 2,500 Mastectomy with or without Node Dissection 19302 $ 5,050 1st stage: Reconstruction w/expanders, single 19342 $ 5,080 1st stage: Reconstruction w/explanders, bilateral 19342 $ 7,000 2nd stage: w/implant placement, single 19357 $ 4,000 2nd stage: w/implant placement bilateral 19357 $ 5,250 MISCELLANEOUS Hermorrhoidectomy 46250 $ 3,250
Vein Stripping - Single 37718 $ 3,420 Vein Stripping - right and left 37718 $ 4,745 Central Venous Catheter 36561 $ 3,090 Neuroplasty - Ulnar Nerve Elbow 64718 $ 2,640 SPINE Microdiscectomy 63030 $ 8,650 Lumbar Laminectomy 63047 $ 9,200 Anterior Cervical Disc Fusion, One Level 63081 $ 15,100 Anterior Cervical Disc Fusion, Two Levels 63082 (add-on) $ 20,000 PAIN Lumbar Epidural Steroid 62311 $ 1,250 Cervical Epidural 62310 $ 1,400 Lumbar Sympathetic 64520 $ 1,600 Stellate Ganglion Block 64510 $ 1,100 Reblock for Acute Post-Op Pain 64415 $ 1,200 Epidural Blood Patch 62273 $ 1,100 Large Join Injection/Aspiration 20610 $ 350 Trigger Point Injection (1-2 Muscles) 20552 $ 150 Injection/Steroid, Lumbar, Epidural, Sacral (Single Level) 64483 $ 1,100 Injection/Steroid, Lumbar, Epidural, Sacral (Add. Level) 64484 $ 550 EYE Nasolacrimal Duct Probe, Single 68815 $ 1,820 Nasolacrimal Duct Probe, Right and Left 68815 $ 2,320 Strabismus, 1 or 2 Muscles 67311 $ 3,500 Strabismus, More than 2 Muscles 67312 $ 4,600 Chalazion 67808 $ 1,820 NECK Thyroidectomy 60210/60220/60225 $ 6,000 Lymph Node Excision/Biopsy 38500 $ 2,200 EAR Myringoplasty 69620 $ 2,450 Bilateral Myringotomy with Tubes 69436 $ 1,550
Tympanoplasty 69645 $ 4,910 Tympanoplasty - Mastoidectomy 69641 $ 6,650 Mastoidectomy 69715 $ 6,300 Inner Ear - Stapedectomy 69660 $ 5,240 Ossiculoplasty 69661 $ 4,900 Cochlear Implant 69930 $ 8,190 Foreign Body Removal-Peritoneal 49402 $ 1,550 NOSE Bilateral SMR Turbinate 30140 $ 3,080 Septoplasty 30520 $ 3,850 Septoplasty and Sinus/Turbinates 30520/30140 $ 5,360 Nasal Fracture Simple Closed 21310 $ 2,250 Nasal Fracture Complex Open 21325 $ 4,300 THROAT Tonsillectomy 42825/42826 $ 3,150 Adenoidectomy 42830 $ 2,450 Tonsillectomy and Adenoidectomy 42820 $ 3,495 Adenoidectomy and BMT 42830/69436 $ 3,100 Tonsillectomy and Adenoidectomy and BMT 42820/69436 $ 4,200 Frenulectomy 40819 $ 1,600 Uvulopalatopharyngoplasty (UPP) 42145 $ 5,195 Diagnostic Laryngoscopy with Biopsy 31510 $ 2,870 ORAL SURGERY Madibular Osteotomy 21193 $ 11,000 UROLOGY Mini-Arc Mid-Urethral Suspension 57288 $ 4,280 Anterior Repair 57240 $ 6,185 Posterior Repair 57250 $ 5,800 Hydrocelectomy (Unilateral) 55040 $ 3,450 Epididymectomy - Partial 54860 $ 3,450 Epididymectomy - Total 54860 $ 3,950 Testicular Biopsy 54500 $ 1,850 Vasovasostomy 55400 $ 4,950
Penile Prosthesis 54400 $ 14,125 Ultrasound and Biopsy of Prostate 55700/76942 $ 1,850 Lithotripsy of Kidney Stone 50590 $ 5,700 Scope Bladder/Ureter-Simple Removal Stone/Stent 52310 $ 1,100 Scope Bladder/Ureter-Break Up Kidney Stone 52353 $ 2,500 CYSTOSCOPY Cystoscopy 52000 $ 1,250 With Bilateral Retrograde Pyelogram 52351 $ 2,150 Stone Extraction/Stint 52332 $ 3,450 Transurethral Resection of Prostate (TURP) 52601 $ 3,450 GYNECOLOGY Hysterectomy (Includes Overnight Stay) 58552 $ 7,500 Tubal Reversal (Includes Overnight Stay) 58750 $ 8,500 GASTROINTESTINAL EGD 43235/43239 $ 2,100 EGD with Balloon 43238 $ 2,300 Screening Colonoscopy 45378/45379/45380 $ 2,400 Colonoscopies with Biopsies, Snares, etc. 45381 thru 45385 $ 2,700 EGD (when combined with a Colonoscopy: add-on) 43235/43239/43248 $ 1,100