Treatment of missed abortion, completed surgically
        
    
    
        
            
                up to $2334*
            
        
    
                     
                
                    
                        
    
    
    
        
            Posterior colporrhaphy, repair of rectocele with or without perineorrhaphy
        
    
    
        
            
                up to $3414*
            
        
    
                     
                
                    
                        
    
    
    
        
            Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without D&C
        
    
    
        
            
                up to $3388*
            
        
    
                     
                
                    
                        
    
    
    
        
            Marsupialization of Bartholin's gland cyst
        
    
    
        
            
                up to $788*
            
        
    
                     
                
                    
                        
    
    
    
        
            Endometrial biopsy
        
    
    
        
            
                up to $536*
            
        
    
                     
                
                    
                        
    
    
    
        
            Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method
        
    
    
        
            
                up to $4079*
            
        
    
                     
                
                    
                        
    
    
    
        
            Abdominal myomectomy, removal of fibroids through abdominal incision
        
    
    
        
            
                up to $5275*
            
        
    
                     
                
                    
                        
    
    
    
        
            Colpopexy, vaginal
        
    
    
        
            
                up to $2933*
            
        
    
                     
                
                    
                        
    
    
    
        
            Cryosurgery of the penis
        
    
    
        
            
                up to $827*
            
        
    
                     
                
                    
                        
    
    
    
        
            Treatment of ectopic pregnancy with salpingostomy
        
    
    
        
            
                up to $4630*
            
        
    
                     
                
                    
                        
    
    
    
        
            Colpopexy, abdominal approach
        
    
    
        
            
                up to $3555*
            
        
    
                     
                
                    
                        
    
    
    
        
            Laparoscopy, surgical; with lysis of adhesions (salpingolysis, ovariolysis) (separate procedure)
        
    
    
        
            
                up to $3877*
            
        
    
                     
                
                    
                        
    
    
    
        
            Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less
        
    
    
        
            
                up to $4521*
            
        
    
                     
                
                    
                        
    
    
    
        
            Laparoscopic treatment of ectopic pregnancy
        
    
    
        
            
                up to $2956*
            
        
    
                     
                
                    
                        
    
    
    
        
            Endometrial ablation, thermal
        
    
    
        
            
                up to $5813*
            
        
    
                     
                
                    
                        
    
    
    
        
            Loop electrosurgical excision procedure (LEEP)
        
    
    
        
            
                up to $1580*
            
        
    
                     
                
                    
                        
    
    
    
        
            Colpopexy, vaginal approach
        
    
    
        
            
                up to $3940*
            
        
    
                     
                
                    
                        
    
    
    
        
            Hysteroscopy, surgical; with endometrial ablation (eg, endometrial resection, electrosurgical ablation, thermoablation)
        
    
    
        
            
                up to $6952*
            
        
    
                     
                
                    
                        
    
    
    
        
            Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g
        
    
    
        
            
                up to $4676*
            
        
    
                     
                
                    
                        
    
    
    
        
            Induced abortion by dilation and curettage
        
    
    
        
            
                up to $1349*
            
        
    
                     
                
                    
                        
    
    
    
        
            Destruction of anal warts by electrocautery
        
    
    
        
            
                up to $3124*
            
        
    
                     
                
                    
                        
    
    
    
        
            Ovarian cystectomy, unilateral or bilateral
        
    
    
        
            
                up to $4350*
            
        
    
                     
                
                    
                        
    
    
    
        
            Incision and drainage of Bartholin's gland abscess
        
    
    
        
            
                up to $660*
            
        
    
                     
                
                    
                        
    
    
    
        
            New patient preventive medicine evaluation for individuals aged 18-39 years
        
    
    
        
            
                up to $235*
            
        
    
                     
                
                    
                        
    
    
    
        
            Cervical biopsy
        
    
    
        
            
                up to $779*
            
        
    
                     
                
                    
                        
    
    
    
        
            Laparoscopy, surgical; with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy)
        
    
    
        
            
                up to $3744*
            
        
    
                     
                
                    
                        
    
    
    
        
            Treatment of incomplete abortion, any trimester, completed surgically
        
    
    
        
            
                up to $1783*
            
        
    
                     
                
                    
                        
    
    
    
        
            Hysteroscopy, surgical; with lysis of intrauterine adhesions (any method)
        
    
    
        
            
                up to $1097*
            
        
    
                     
                
                    
                        
    
    
    
        
            Hysteroscopy, diagnostic (separate procedure)
        
    
    
        
            
                up to $1721*
            
        
    
                     
                
                    
                        
    
    
    
        
            Tubal ligation reversal, microsurgical technique
        
    
    
        
            
                up to $5113*
            
        
    
                     
                
                    
                        
    
    
    
        
            Anterior and/or posterior colporrhaphy
        
    
    
        
            
                up to $2937*
            
        
    
                     
                
                    
                        
    
    
    
        
            Laparoscopic vaginal hysterectomy, with removal of tubes and/or ovaries
        
    
    
        
            
                up to $5656*
            
        
    
                     
                
                    
                        
    
    
    
        
            Chromotubation of oviduct, including materials
        
    
    
        
            
                up to $627*
            
        
    
                     
                
                    
                        
    
    
    
        
            Laparoscopic colpopexy
        
    
    
        
            
                up to $5554*
            
        
    
                     
                
                    
                        
    
    
    
        
            Unlisted procedure, female genital system (nonobstetrical)
        
    
    
        
            
                up to $98*
            
        
    
                     
                
                    
                        
    
    
    
        
            Mastectomy for gynecomastia
        
    
    
        
            
                up to $3178*
            
        
    
                     
                
                    
                        
    
    
    
        
            Vulvar biopsy, single lesion
        
    
    
        
            
                up to $380*
            
        
    
                     
                
                    
                        
    
    
    
        
            Human chorionic gonadotropin (hCG) quantitative test
        
    
    
        
            
                up to $26*
            
        
    
                     
                
                    
                        
    
    
    
        
            Dilation and curettage, diagnostic and/or therapeutic
        
    
    
        
            
                up to $1557*
            
        
    
                     
                
                    
                        
    
    
    
        
            Hysteroscopy, surgical; with removal of leiomyomata and/or polyps
        
    
    
        
            
                up to $2116*
            
        
    
                     
                
                    
                        
    
    
    
        
            Laparoscopy, abdomen, peritoneum, and omentum, diagnostic
        
    
    
        
            
                up to $1936*
            
        
    
                     
                
                    
                        
    
    
    
        
            Salpingo-oophorectomy, complete or partial, unilateral or bilateral (separate procedure)
        
    
    
        
            
                up to $4339*
            
        
    
                     
                
                    
                        
    
    
    
        
            Clitoroplasty for intersex state
        
    
    
        
            
                up to $6518*
            
        
    
                     
                
                    
                        
    
    
    
        
            Cytopathology, cervical or vaginal
        
    
    
        
            
                up to $111*
            
        
    
                     
                
                    
                        
    
    
    
        
            Laparoscopic myomectomy, removal of very large or multiple fibroids
        
    
    
        
            
                up to $6340*
            
        
    
                     
                
                    
                        
    
    
    
        
            Oophorectomy, partial or total, unilateral or bilateral
        
    
    
        
            
                up to $3124*
            
        
    
                     
                
                    
                        
    
    
    
        
            Vaginal hysterectomy, for uterus 250 g or less
        
    
    
        
            
                up to $4715*
            
        
    
                     
                
                    
                        
    
    
    
        
            Laparoscopic supracervical hysterectomy, with removal of tubes and/or ovaries
        
    
    
        
            
                up to $5254*
            
        
    
                     
                
                    
                        
    
    
    
        
            Endocervical curettage
        
    
    
        
            
                up to $535*
            
        
    
                     
                
                    
                        
    
    
    
        
            Hysterosalpingography, radiological supervision and interpretation
        
    
    
        
            
                up to $319*
            
        
    
                     
                
                    
                        
    
    
    
        
            Embryo transfer, intrauterine
        
    
    
        
            
                up to $1165*
            
        
    
                     
                
                    
                        
    
    
    
        
            Excision of breast lesion identified by preoperative placement of radiological marker, open
        
    
    
        
            
                up to $3281*
            
        
    
                     
                
                    
                        
    
    
    
        
            Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus
        
    
    
        
            
                up to $814*
            
        
    
                     
                
                    
                        
    
    
    
        
            Salpingectomy, complete or partial, unilateral or bilateral (separate procedure)
        
    
    
        
            
                up to $4537*
            
        
    
                     
                
                    
                        
    
    
    
        
            Neisseria gonorrhoeae, direct probe technique
        
    
    
        
            
                up to $26*
            
        
    
                     
                
                    
                        
    
    
    
        
            Vaginal dilation under anesthesia
        
    
    
        
            
                up to $282*
            
        
    
                     
                
                    
                        
    
    
    
        
            Hysterosalpingography
        
    
    
        
            
                up to $445*
            
        
    
                     
                
                    
                        
    
    
    
        
            Total abdominal hysterectomy with removal of tubes and/or ovaries
        
    
    
        
            
                up to $5900*
            
        
    
                     
                
                    
                        
    
    
    
        
            Hysteroscopy, surgical, with bilateral fallopian tube cannulation
        
    
    
        
            
                up to $10723*
            
        
    
                     
                
                    
                        
    
    
    
        
            Labiaplasty, wedge excision
        
    
    
        
            
                up to $2417*
            
        
    
                     
                
                    
                        
    
    
    
        
            Routine obstetric (pregnancy) care for vaginal delivery, incl pre- and post- delivery care
        
    
    
        
            
                up to $15522*
            
        
    
                     
                
                    
                        
    
    
    
        
            Vaginoplasty for congenital anomaly
        
    
    
        
            
                up to $5094*
            
        
    
                     
                
                    
                        
    
    
    
        
            Laparoscopy, surgical, supracervical hysterectomy
        
    
    
        
            
                up to $4080*
            
        
    
                     
                
                    
                        
    
    
    
        
            Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; SMALL bladder tumor(s) (0.5 up to 2.0 cm)
        
    
    
        
            
                up to $2753*
            
        
    
                     
                
                    
                        
    
    
    
        
            In vitro fertilization
        
    
    
        
            
                up to $863*
            
        
    
                     
                
                    
                        
    
    
    
        
            Laparoscopic myomectomy, removal of fibroids
        
    
    
        
            
                up to $5166*
            
        
    
                     
                
                    
                        
    
    
    
        
            Vulvar biopsy, each additional lesion
        
    
    
        
            
                up to $222*
            
        
    
                     
                
                    
                        
    
    
    
        
            Hysteroscopy, surgical; with division or resection of intrauterine septum
        
    
    
        
            
                up to $1435*
            
        
    
                     
                
                    
                        
    
    
    
        
            Insertion, non-biodegradable drug delivery implant
        
    
    
        
            
                up to $584*
            
        
    
                     
                
                    
                        
    
    
    
        
            Mammography, screening, bilateral
        
    
    
        
            
                up to $789*
            
        
    
                     
                
                    
                        
    
    
    
        
            Complex cystometrogram with voiding pressure studies
        
    
    
        
            
                up to $2094*
            
        
    
                     
                
                    
                        
    
    
    
        
            Insertion of mesh or other prosthesis for repair of pelvic floor
        
    
    
        
            
                up to $965*
            
        
    
                     
                
                    
                        
    
    
    
        
            Ultrasound, retroperitoneal, limited
        
    
    
        
            
                up to $224*
            
        
    
                     
                
                    
                        
    
    
    
        
            HPV vaccine, types 6, 11, 16, 18
        
    
    
        
            
                up to $229*
            
        
    
                     
                
                    
                        
    
    
    
        
            Ultrasound guidance for aspiration of ova
        
    
    
        
            
                up to $1140*
            
        
    
                     
                
                    
                        
    
    
    
        
            Stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s)
        
    
    
        
            
                up to $5935*
            
        
    
                     
                
                    
                        
    
    
    
        
            Enterocele repair
        
    
    
        
            
                up to $3397*
            
        
    
                     
                
                    
                        
    
    
    
        
            Mammogram, both breasts (not for routine screening)
        
    
    
        
            
                up to $980*
            
        
    
                     
                
                    
                        
    
    
    
        
            Automated urinalysis test
        
    
    
        
            
                up to $7*
            
        
    
                     
                
                    
                        
    
    
    
        
            Biopsy of breast; percutaneous, needle core, not using imaging guidance
        
    
    
        
            
                up to $3802*