Treatment of missed abortion, completed surgically
        
    
    
        
            
                up to $1500*
            
        
    
                     
                
                    
                        
    
    
    
        
            Posterior colporrhaphy, repair of rectocele with or without perineorrhaphy
        
    
    
        
            
                up to $3932*
            
        
    
                     
                
                    
                        
    
    
    
        
            Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without D&C
        
    
    
        
            
                up to $9337*
            
        
    
                     
                
                    
                        
    
    
    
        
            Marsupialization of Bartholin's gland cyst
        
    
    
        
            
                up to $825*
            
        
    
                     
                
                    
                        
    
    
    
        
            Endometrial biopsy
        
    
    
        
            
                up to $729*
            
        
    
                     
                
                    
                        
    
    
    
        
            Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method
        
    
    
        
            
                up to $4748*
            
        
    
                     
                
                    
                        
    
    
    
        
            Abdominal myomectomy, removal of fibroids through abdominal incision
        
    
    
        
            
                up to $6109*
            
        
    
                     
                
                    
                        
    
    
    
        
            Colpopexy, vaginal
        
    
    
        
            
                up to $3336*
            
        
    
                     
                
                    
                        
    
    
    
        
            Cryosurgery of the penis
        
    
    
        
            
                up to $964*
            
        
    
                     
                
                    
                        
    
    
    
        
            Treatment of ectopic pregnancy with salpingostomy
        
    
    
        
            
                up to $2119*
            
        
    
                     
                
                    
                        
    
    
    
        
            Colpopexy, abdominal approach
        
    
    
        
            
                up to $6343*
            
        
    
                     
                
                    
                        
    
    
    
        
            Laparoscopy, surgical; with lysis of adhesions (salpingolysis, ovariolysis) (separate procedure)
        
    
    
        
            
                up to $4496*
            
        
    
                     
                
                    
                        
    
    
    
        
            Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less
        
    
    
        
            
                up to $5205*
            
        
    
                     
                
                    
                        
    
    
    
        
            Laparoscopic treatment of ectopic pregnancy
        
    
    
        
            
                up to $2052*
            
        
    
                     
                
                    
                        
    
    
    
        
            Endometrial ablation, thermal
        
    
    
        
            
                up to $6878*
            
        
    
                     
                
                    
                        
    
    
    
        
            Loop electrosurgical excision procedure (LEEP)
        
    
    
        
            
                up to $1769*
            
        
    
                     
                
                    
                        
    
    
    
        
            Colpopexy, vaginal approach
        
    
    
        
            
                up to $4566*
            
        
    
                     
                
                    
                        
    
    
    
        
            Hysteroscopy, surgical; with endometrial ablation (eg, endometrial resection, electrosurgical ablation, thermoablation)
        
    
    
        
            
                up to $10900*
            
        
    
                     
                
                    
                        
    
    
    
        
            Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g
        
    
    
        
            
                up to $5413*
            
        
    
                     
                
                    
                        
    
    
    
        
            Induced abortion by dilation and curettage
        
    
    
        
            
                up to $655*
            
        
    
                     
                
                    
                        
    
    
    
        
            Destruction of anal warts by electrocautery
        
    
    
        
            
                up to $2240*
            
        
    
                     
                
                    
                        
    
    
    
        
            Ovarian cystectomy, unilateral or bilateral
        
    
    
        
            
                up to $3348*
            
        
    
                     
                
                    
                        
    
    
    
        
            Incision and drainage of Bartholin's gland abscess
        
    
    
        
            
                up to $735*
            
        
    
                     
                
                    
                        
    
    
    
        
            New patient preventive medicine evaluation for individuals aged 18-39 years
        
    
    
        
            
                up to $309*
            
        
    
                     
                
                    
                        
    
    
    
        
            Cervical biopsy
        
    
    
        
            
                up to $863*
            
        
    
                     
                
                    
                        
    
    
    
        
            Laparoscopy, surgical; with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy)
        
    
    
        
            
                up to $2899*
            
        
    
                     
                
                    
                        
    
    
    
        
            Treatment of incomplete abortion, any trimester, completed surgically
        
    
    
        
            
                up to $936*
            
        
    
                     
                
                    
                        
    
    
    
        
            Hysteroscopy, surgical; with lysis of intrauterine adhesions (any method)
        
    
    
        
            
                up to $1938*
            
        
    
                     
                
                    
                        
    
    
    
        
            Hysteroscopy, diagnostic (separate procedure)
        
    
    
        
            
                up to $1814*
            
        
    
                     
                
                    
                        
    
    
    
        
            Tubal ligation reversal, microsurgical technique
        
    
    
        
            
                up to $5931*
            
        
    
                     
                
                    
                        
    
    
    
        
            Anterior and/or posterior colporrhaphy
        
    
    
        
            
                up to $3378*
            
        
    
                     
                
                    
                        
    
    
    
        
            Laparoscopic vaginal hysterectomy, with removal of tubes and/or ovaries
        
    
    
        
            
                up to $6595*
            
        
    
                     
                
                    
                        
    
    
    
        
            Chromotubation of oviduct, including materials
        
    
    
        
            
                up to $653*
            
        
    
                     
                
                    
                        
    
    
    
        
            Laparoscopic colpopexy
        
    
    
        
            
                up to $6443*
            
        
    
                     
                
                    
                        
    
    
    
        
            Unlisted procedure, female genital system (nonobstetrical)
        
    
    
        
            
                up to $98*
            
        
    
                     
                
                    
                        
    
    
    
        
            Mastectomy for gynecomastia
        
    
    
        
            
                up to $4455*
            
        
    
                     
                
                    
                        
    
    
    
        
            Vulvar biopsy, single lesion
        
    
    
        
            
                up to $553*
            
        
    
                     
                
                    
                        
    
    
    
        
            Human chorionic gonadotropin (hCG) quantitative test
        
    
    
        
            
                up to $15*
            
        
    
                     
                
                    
                        
    
    
    
        
            Dilation and curettage, diagnostic and/or therapeutic
        
    
    
        
            
                up to $1741*
            
        
    
                     
                
                    
                        
    
    
    
        
            Hysteroscopy, surgical; with removal of leiomyomata and/or polyps
        
    
    
        
            
                up to $2286*
            
        
    
                     
                
                    
                        
    
    
    
        
            Laparoscopy, abdomen, peritoneum, and omentum, diagnostic
        
    
    
        
            
                up to $2095*
            
        
    
                     
                
                    
                        
    
    
    
        
            Salpingo-oophorectomy, complete or partial, unilateral or bilateral (separate procedure)
        
    
    
        
            
                up to $4988*
            
        
    
                     
                
                    
                        
    
    
    
        
            Clitoroplasty for intersex state
        
    
    
        
            
                up to $7543*
            
        
    
                     
                
                    
                        
    
    
    
        
            Cytopathology, cervical or vaginal
        
    
    
        
            
                up to $57*
            
        
    
                     
                
                    
                        
    
    
    
        
            Laparoscopic myomectomy, removal of very large or multiple fibroids
        
    
    
        
            
                up to $7400*
            
        
    
                     
                
                    
                        
    
    
    
        
            Oophorectomy, partial or total, unilateral or bilateral
        
    
    
        
            
                up to $2388*
            
        
    
                     
                
                    
                        
    
    
    
        
            Vaginal hysterectomy, for uterus 250 g or less
        
    
    
        
            
                up to $5466*
            
        
    
                     
                
                    
                        
    
    
    
        
            Laparoscopic supracervical hysterectomy, with removal of tubes and/or ovaries
        
    
    
        
            
                up to $6069*
            
        
    
                     
                
                    
                        
    
    
    
        
            Endocervical curettage
        
    
    
        
            
                up to $694*
            
        
    
                     
                
                    
                        
    
    
    
        
            Hysterosalpingography, radiological supervision and interpretation
        
    
    
        
            
                up to $316*
            
        
    
                     
                
                    
                        
    
    
    
        
            Embryo transfer, intrauterine
        
    
    
        
            
                up to $299*
            
        
    
                     
                
                    
                        
    
    
    
        
            Excision of breast lesion identified by preoperative placement of radiological marker, open
        
    
    
        
            
                up to $4642*
            
        
    
                     
                
                    
                        
    
    
    
        
            Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus
        
    
    
        
            
                up to $404*
            
        
    
                     
                
                    
                        
    
    
    
        
            Salpingectomy, complete or partial, unilateral or bilateral (separate procedure)
        
    
    
        
            
                up to $5241*
            
        
    
                     
                
                    
                        
    
    
    
        
            Neisseria gonorrhoeae, direct probe technique
        
    
    
        
            
                up to $38*
            
        
    
                     
                
                    
                        
    
    
    
        
            Vaginal dilation under anesthesia
        
    
    
        
            
                up to $304*
            
        
    
                     
                
                    
                        
    
    
    
        
            Hysterosalpingography
        
    
    
        
            
                up to $816*
            
        
    
                     
                
                    
                        
    
    
    
        
            Total abdominal hysterectomy with removal of tubes and/or ovaries
        
    
    
        
            
                up to $6849*
            
        
    
                     
                
                    
                        
    
    
    
        
            Hysteroscopy, surgical, with bilateral fallopian tube cannulation
        
    
    
        
            
                up to $8496*
            
        
    
                     
                
                    
                        
    
    
    
        
            Labiaplasty, wedge excision
        
    
    
        
            
                up to $4338*
            
        
    
                     
                
                    
                        
    
    
    
        
            Routine obstetric (pregnancy) care for vaginal delivery, incl pre- and post- delivery care
        
    
    
        
            
                up to $15170*
            
        
    
                     
                
                    
                        
    
    
    
        
            Vaginoplasty for congenital anomaly
        
    
    
        
            
                up to $5912*
            
        
    
                     
                
                    
                        
    
    
    
        
            Laparoscopy, surgical, supracervical hysterectomy
        
    
    
        
            
                up to $3163*
            
        
    
                     
                
                    
                        
    
    
    
        
            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 $5172*
            
        
    
                     
                
                    
                        
    
    
    
        
            In vitro fertilization
        
    
    
        
            
                up to $528*
            
        
    
                     
                
                    
                        
    
    
    
        
            Laparoscopic myomectomy, removal of fibroids
        
    
    
        
            
                up to $6026*
            
        
    
                     
                
                    
                        
    
    
    
        
            Vulvar biopsy, each additional lesion
        
    
    
        
            
                up to $257*
            
        
    
                     
                
                    
                        
    
    
    
        
            Hysteroscopy, surgical; with division or resection of intrauterine septum
        
    
    
        
            
                up to $2105*
            
        
    
                     
                
                    
                        
    
    
    
        
            Insertion, non-biodegradable drug delivery implant
        
    
    
        
            
                up to $794*
            
        
    
                     
                
                    
                        
    
    
    
        
            Mammography, screening, bilateral
        
    
    
        
            
                up to $583*
            
        
    
                     
                
                    
                        
    
    
    
        
            Complex cystometrogram with voiding pressure studies
        
    
    
        
            
                up to $2625*
            
        
    
                     
                
                    
                        
    
    
    
        
            Insertion of mesh or other prosthesis for repair of pelvic floor
        
    
    
        
            
                up to $1702*
            
        
    
                     
                
                    
                        
    
    
    
        
            Ultrasound, retroperitoneal, limited
        
    
    
        
            
                up to $244*
            
        
    
                     
                
                    
                        
    
    
    
        
            HPV vaccine, types 6, 11, 16, 18
        
    
    
        
            
                up to $229*
            
        
    
                     
                
                    
                        
    
    
    
        
            Ultrasound guidance for aspiration of ova
        
    
    
        
            
                up to $302*
            
        
    
                     
                
                    
                        
    
    
    
        
            Stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s)
        
    
    
        
            
                up to $2592*
            
        
    
                     
                
                    
                        
    
    
    
        
            Enterocele repair
        
    
    
        
            
                up to $2436*
            
        
    
                     
                
                    
                        
    
    
    
        
            Mammogram, both breasts (not for routine screening)
        
    
    
        
            
                up to $615*
            
        
    
                     
                
                    
                        
    
    
    
        
            Automated urinalysis test
        
    
    
        
            
                up to $5*
            
        
    
                     
                
                    
                        
    
    
    
        
            Biopsy of breast; percutaneous, needle core, not using imaging guidance
        
    
    
        
            
                up to $5797*