Treatment of missed abortion, completed surgically
        
    
    
        
            
                up to $1396*
            
        
    
                     
                
                    
                        
    
    
    
        
            Posterior colporrhaphy, repair of rectocele with or without perineorrhaphy
        
    
    
        
            
                up to $1669*
            
        
    
                     
                
                    
                        
    
    
    
        
            Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without D&C
        
    
    
        
            
                up to $2363*
            
        
    
                     
                
                    
                        
    
    
    
        
            Marsupialization of Bartholin's gland cyst
        
    
    
        
            
                up to $411*
            
        
    
                     
                
                    
                        
    
    
    
        
            Endometrial biopsy
        
    
    
        
            
                up to $1152*
            
        
    
                     
                
                    
                        
    
    
    
        
            Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method
        
    
    
        
            
                up to $5433*
            
        
    
                     
                
                    
                        
    
    
    
        
            Abdominal myomectomy, removal of fibroids through abdominal incision
        
    
    
        
            
                up to $7087*
            
        
    
                     
                
                    
                        
    
    
    
        
            Colpopexy, vaginal
        
    
    
        
            
                up to $1310*
            
        
    
                     
                
                    
                        
    
    
    
        
            Cryosurgery of the penis
        
    
    
        
            
                up to $460*
            
        
    
                     
                
                    
                        
    
    
    
        
            Treatment of ectopic pregnancy with salpingostomy
        
    
    
        
            
                up to $1960*
            
        
    
                     
                
                    
                        
    
    
    
        
            Colpopexy, abdominal approach
        
    
    
        
            
                up to $2454*
            
        
    
                     
                
                    
                        
    
    
    
        
            Laparoscopy, surgical; with lysis of adhesions (salpingolysis, ovariolysis) (separate procedure)
        
    
    
        
            
                up to $1702*
            
        
    
                     
                
                    
                        
    
    
    
        
            Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less
        
    
    
        
            
                up to $2328*
            
        
    
                     
                
                    
                        
    
    
    
        
            Laparoscopic treatment of ectopic pregnancy
        
    
    
        
            
                up to $1913*
            
        
    
                     
                
                    
                        
    
    
    
        
            Endometrial ablation, thermal
        
    
    
        
            
                up to $3208*
            
        
    
                     
                
                    
                        
    
    
    
        
            Loop electrosurgical excision procedure (LEEP)
        
    
    
        
            
                up to $970*
            
        
    
                     
                
                    
                        
    
    
    
        
            Colpopexy, vaginal approach
        
    
    
        
            
                up to $1743*
            
        
    
                     
                
                    
                        
    
    
    
        
            Hysteroscopy, surgical; with endometrial ablation (eg, endometrial resection, electrosurgical ablation, thermoablation)
        
    
    
        
            
                up to $11811*
            
        
    
                     
                
                    
                        
    
    
    
        
            Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g
        
    
    
        
            
                up to $11811*
            
        
    
                     
                
                    
                        
    
    
    
        
            Induced abortion by dilation and curettage
        
    
    
        
            
                up to $824*
            
        
    
                     
                
                    
                        
    
    
    
        
            Destruction of anal warts by electrocautery
        
    
    
        
            
                up to $1302*
            
        
    
                     
                
                    
                        
    
    
    
        
            Ovarian cystectomy, unilateral or bilateral
        
    
    
        
            
                up to $1851*
            
        
    
                     
                
                    
                        
    
    
    
        
            Incision and drainage of Bartholin's gland abscess
        
    
    
        
            
                up to $282*
            
        
    
                     
                
                    
                        
    
    
    
        
            New patient preventive medicine evaluation for individuals aged 18-39 years
        
    
    
        
            
                up to $240*
            
        
    
                     
                
                    
                        
    
    
    
        
            Cervical biopsy
        
    
    
        
            
                up to $388*
            
        
    
                     
                
                    
                        
    
    
    
        
            Laparoscopy, surgical; with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy)
        
    
    
        
            
                up to $5512*
            
        
    
                     
                
                    
                        
    
    
    
        
            Treatment of incomplete abortion, any trimester, completed surgically
        
    
    
        
            
                up to $1161*
            
        
    
                     
                
                    
                        
    
    
    
        
            Hysteroscopy, surgical; with lysis of intrauterine adhesions (any method)
        
    
    
        
            
                up to $878*
            
        
    
                     
                
                    
                        
    
    
    
        
            Hysteroscopy, diagnostic (separate procedure)
        
    
    
        
            
                up to $671*
            
        
    
                     
                
                    
                        
    
    
    
        
            Tubal ligation reversal, microsurgical technique
        
    
    
        
            
                up to $2299*
            
        
    
                     
                
                    
                        
    
    
    
        
            Anterior and/or posterior colporrhaphy
        
    
    
        
            
                up to $1305*
            
        
    
                     
                
                    
                        
    
    
    
        
            Laparoscopic vaginal hysterectomy, with removal of tubes and/or ovaries
        
    
    
        
            
                up to $10630*
            
        
    
                     
                
                    
                        
    
    
    
        
            Chromotubation of oviduct, including materials
        
    
    
        
            
                up to $336*
            
        
    
                     
                
                    
                        
    
    
    
        
            Laparoscopic colpopexy
        
    
    
        
            
                up to $2473*
            
        
    
                     
                
                    
                        
    
    
    
        
            Unlisted procedure, female genital system (nonobstetrical)
        
    
    
        
            
                up to $98*
            
        
    
                     
                
                    
                        
    
    
    
        
            Mastectomy for gynecomastia
        
    
    
        
            
                up to $1599*
            
        
    
                     
                
                    
                        
    
    
    
        
            Vulvar biopsy, single lesion
        
    
    
        
            
                up to $269*
            
        
    
                     
                
                    
                        
    
    
    
        
            Human chorionic gonadotropin (hCG) quantitative test
        
    
    
        
            
                up to $18*
            
        
    
                     
                
                    
                        
    
    
    
        
            Dilation and curettage, diagnostic and/or therapeutic
        
    
    
        
            
                up to $2552*
            
        
    
                     
                
                    
                        
    
    
    
        
            Hysteroscopy, surgical; with removal of leiomyomata and/or polyps
        
    
    
        
            
                up to $888*
            
        
    
                     
                
                    
                        
    
    
    
        
            Laparoscopy, abdomen, peritoneum, and omentum, diagnostic
        
    
    
        
            
                up to $1999*
            
        
    
                     
                
                    
                        
    
    
    
        
            Salpingo-oophorectomy, complete or partial, unilateral or bilateral (separate procedure)
        
    
    
        
            
                up to $5433*
            
        
    
                     
                
                    
                        
    
    
    
        
            Clitoroplasty for intersex state
        
    
    
        
            
                up to $2903*
            
        
    
                     
                
                    
                        
    
    
    
        
            Cytopathology, cervical or vaginal
        
    
    
        
            
                up to $50*
            
        
    
                     
                
                    
                        
    
    
    
        
            Laparoscopic myomectomy, removal of very large or multiple fibroids
        
    
    
        
            
                up to $2860*
            
        
    
                     
                
                    
                        
    
    
    
        
            Oophorectomy, partial or total, unilateral or bilateral
        
    
    
        
            
                up to $1274*
            
        
    
                     
                
                    
                        
    
    
    
        
            Vaginal hysterectomy, for uterus 250 g or less
        
    
    
        
            
                up to $2092*
            
        
    
                     
                
                    
                        
    
    
    
        
            Laparoscopic supracervical hysterectomy, with removal of tubes and/or ovaries
        
    
    
        
            
                up to $2550*
            
        
    
                     
                
                    
                        
    
    
    
        
            Endocervical curettage
        
    
    
        
            
                up to $375*
            
        
    
                     
                
                    
                        
    
    
    
        
            Hysterosalpingography, radiological supervision and interpretation
        
    
    
        
            
                up to $227*
            
        
    
                     
                
                    
                        
    
    
    
        
            Embryo transfer, intrauterine
        
    
    
        
            
                up to $290*
            
        
    
                     
                
                    
                        
    
    
    
        
            Excision of breast lesion identified by preoperative placement of radiological marker, open
        
    
    
        
            
                up to $4257*
            
        
    
                     
                
                    
                        
    
    
    
        
            Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus
        
    
    
        
            
                up to $422*
            
        
    
                     
                
                    
                        
    
    
    
        
            Salpingectomy, complete or partial, unilateral or bilateral (separate procedure)
        
    
    
        
            
                up to $1931*
            
        
    
                     
                
                    
                        
    
    
    
        
            Neisseria gonorrhoeae, direct probe technique
        
    
    
        
            
                up to $21*
            
        
    
                     
                
                    
                        
    
    
    
        
            Vaginal dilation under anesthesia
        
    
    
        
            
                up to $154*
            
        
    
                     
                
                    
                        
    
    
    
        
            Hysterosalpingography
        
    
    
        
            
                up to $352*
            
        
    
                     
                
                    
                        
    
    
    
        
            Total abdominal hysterectomy with removal of tubes and/or ovaries
        
    
    
        
            
                up to $9449*
            
        
    
                     
                
                    
                        
    
    
    
        
            Hysteroscopy, surgical, with bilateral fallopian tube cannulation
        
    
    
        
            
                up to $5541*
            
        
    
                     
                
                    
                        
    
    
    
        
            Labiaplasty, wedge excision
        
    
    
        
            
                up to $1510*
            
        
    
                     
                
                    
                        
    
    
    
        
            Routine obstetric (pregnancy) care for vaginal delivery, incl pre- and post- delivery care
        
    
    
        
            
                up to $14173*
            
        
    
                     
                
                    
                        
    
    
    
        
            Vaginoplasty for congenital anomaly
        
    
    
        
            
                up to $2282*
            
        
    
                     
                
                    
                        
    
    
    
        
            Laparoscopy, surgical, supracervical hysterectomy
        
    
    
        
            
                up to $2170*
            
        
    
                     
                
                    
                        
    
    
    
        
            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 $1749*
            
        
    
                     
                
                    
                        
    
    
    
        
            In vitro fertilization
        
    
    
        
            
                up to $555*
            
        
    
                     
                
                    
                        
    
    
    
        
            Laparoscopic myomectomy, removal of fibroids
        
    
    
        
            
                up to $8268*
            
        
    
                     
                
                    
                        
    
    
    
        
            Vulvar biopsy, each additional lesion
        
    
    
        
            
                up to $129*
            
        
    
                     
                
                    
                        
    
    
    
        
            Hysteroscopy, surgical; with division or resection of intrauterine septum
        
    
    
        
            
                up to $992*
            
        
    
                     
                
                    
                        
    
    
    
        
            Insertion, non-biodegradable drug delivery implant
        
    
    
        
            
                up to $350*
            
        
    
                     
                
                    
                        
    
    
    
        
            Mammography, screening, bilateral
        
    
    
        
            
                up to $378*
            
        
    
                     
                
                    
                        
    
    
    
        
            Complex cystometrogram with voiding pressure studies
        
    
    
        
            
                up to $937*
            
        
    
                     
                
                    
                        
    
    
    
        
            Insertion of mesh or other prosthesis for repair of pelvic floor
        
    
    
        
            
                up to $687*
            
        
    
                     
                
                    
                        
    
    
    
        
            Ultrasound, retroperitoneal, limited
        
    
    
        
            
                up to $164*
            
        
    
                     
                
                    
                        
    
    
    
        
            HPV vaccine, types 6, 11, 16, 18
        
    
    
        
            
                up to $229*
            
        
    
                     
                
                    
                        
    
    
    
        
            Ultrasound guidance for aspiration of ova
        
    
    
        
            
                up to $128*
            
        
    
                     
                
                    
                        
    
    
    
        
            Stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s)
        
    
    
        
            
                up to $2352*
            
        
    
                     
                
                    
                        
    
    
    
        
            Enterocele repair
        
    
    
        
            
                up to $2273*
            
        
    
                     
                
                    
                        
    
    
    
        
            Mammogram, both breasts (not for routine screening)
        
    
    
        
            
                up to $468*
            
        
    
                     
                
                    
                        
    
    
    
        
            Automated urinalysis test
        
    
    
        
            
                up to $2*
            
        
    
                     
                
                    
                        
    
    
    
        
            Biopsy of breast; percutaneous, needle core, not using imaging guidance
        
    
    
        
            
                up to $1869*