Ministry of Health Price List For Ambulatory and Hospitalization Services

Ministry of Health Price List for Ambulatory and Hospitalization Services
Onset date: 01/07/18

Sorted by service code
Service Service name Price A Price B Price C Price for

code )ILS( )ILS( )ILS( Patient
from
Abroad
)ILS(
01996 Day care management of epidural/subarachnoid continuous drug administration 550.00 538.00 550.00 807.00
01999 General anesthesia for ambulatory treatment, under anesthesiologist supervision 1,410.00 1,380.00 1,410.00 2,070.00
10060 Incision and drainage of abscess/cyst 448.00 438.00 448.00 657.00
11100 Biopsy, excluding procedures with specific code 213.00 208.00 213.00 312.00
11750 Excision of ingrown nail 344.00 337.00 344.00 506.00
11770 Excision of cyst, eg, pilonidal 686.00 671.00 686.00 1,007.00
11975 Insertion, implantable contraceptive capsules (eg, Norplant), including the cost of 2,063.00 2,019.00 2,063.00 3,029.00
contraceptive
11976 Removal, implantable contraceptive capsules 193.00 189.00 193.00 284.00
12001 Simple repair of superficial wounds 164.00 160.00 164.00 240.00
16030 Dressings and/or debridement, without anesthesia, large lesion 417.00 408.00 417.00 612.00
17000 Removal of skin lesions, any method 213.00 208.00 213.00 312.00
17311 Mohs micrographic technique 9,816.00 9,605.00 9,816.00 14,408.00
17999 Soft laser treatment, 1/2 level, per treatment 213.00 208.00 213.00 312.00
19085 Biopsy of breast, MRI guidance, per one breast 7,039.00 6,887.00 7,039.00 10,331.00
19100 Biopsy of breast; needle core, not using imaging guidance 213.00 208.00 213.00 312.00
19101 Biopsy of breast; open, incisional 514.00 503.00 514.00 755.00
19102 Biopsy of breast, imaging guidance, excluding CT/MRI 2,465.00 2,412.00 2,465.00 3,618.00
19499 Breast examination 0.00 0.00 0.00 0.00
20205 Biopsy, muscle, including histological examinations 1,222.00 1,196.00 1,222.00 1,794.00
20206 Biopsy, muscle, including all tests, stains, EM 3,438.00 3,364.00 3,438.00 5,046.00
20220 Biopsy, bone, trocar/needle, superficial 280.00 274.00 280.00 411.00
20520 Foreign body removal, muscle/tendon, local anaesthesia 150.00 147.00 150.00 221.00
20600 Arthrocentesis, aspiration and/or injection; small joint or bursa (eg, fingers, toes) 280.00 274.00 280.00 411.00
20605 Arthrocentesis, aspiration and/or injection; intermediate joint or bursa (eg, 280.00 274.00 280.00 411.00
temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa)
20610 Arthrocentesis, aspiration and/or injection; major joint or bursa (eg, shoulder, hip, 280.00 274.00 280.00 411.00
knee joint, subacromial bursa)
20902 Harvesting of cortical bone, cartilage 4,534.00 4,436.00 4,534.00 6,654.00
21310 Closed treatment of nasal bone fracture 280.00 274.00 280.00 411.00
28899 Intra compartment pressure 630.00 616.00 630.00 924.00
29035 Application, body cast, shoulder to hips 358.00 350.00 358.00 525.00
29065 Application, cast; shoulder to hand (long arm) 213.00 208.00 213.00 312.00
29075 Application, cast, elbow to finger (short arm) 150.00 147.00 150.00 221.00
29085 Application, cast, hand and lower forearm (gauntlet) 150.00 147.00 150.00 221.00
29345 Application, cast, long leg (thigh to toes) 213.00 208.00 213.00 312.00
29405 Application, cast, short leg (below knee to toes) 150.00 147.00 150.00 221.00
29700 Cast removal 128.00 125.00 128.00 188.00
29720 Repair of spica, body cast or jacket 0.00 0.00 0.00 0.00
30110 Excision, nasal polyp(s), simple 280.00 274.00 280.00 411.00
30200 Injection into turbinate(s) 155.00 152.00 155.00 228.00
30300 Foreign body removal, intranasal, superficial 0.00 0.00 0.00 0.00
30801 Cautery and/or ablation, mucosa of turbinates, unilateral/bilateral, any method 280.00 274.00 280.00 411.00
31002 Sinuses lavage 155.00 152.00 155.00 228.00
31575 Laryngoscopy, flexible fiberoptic, diagnostic 103.00 101.00 103.00 152.00
31579 Laryngoscopy, fiberoptic, with stroboscopy 176.00 172.00 176.00 258.00
31622 Bronchoscopy, diagnostic, with/without brushing/washing 1,604.00 1,569.00 1,604.00 2,354.00
31636 Bronchoscopy with bronchial stent(s) placement, ambulatory care 14,495.00 14,183.00 14,495.00 21,275.00
32000 Thoracentesis, puncture of pleural cavity for aspiration 280.00 274.00 280.00 411.00
36005 Injection of contrast material, including radiology/fluoroscopy 591.00 578.00 591.00 867.00
36468 Injections of sclerosing solutions, spider veins (telangiectasia) 128.00 125.00 128.00 188.00
36511 Therapeutic apheresis, for white blood cells 4,039.00 3,952.00 4,039.00 5,928.00
from
Abroad
)ILS(
36513 Therapeutic apheresis, for platelets 3,256.00 3,186.00 3,256.00 4,779.00

36515 Therapeutic apheresis; with extracorporeal immunoadsorption and plasma reinfusion 10,641.00 10,412.00 10,641.00 15,618.00
36522 Photopheresis, extracorporeal 8,556.00 8,372.00 8,556.00 12,558.00

36590 Removal of tunneled central venous access device, with subcutaneous port or pump, 399.00 390.00 399.00 585.00
central or peripheral insertion
36600 Arterial blood sampling and diagnosis 213.00 208.00 213.00 312.00
38220 Bone marrow aspiration and smear 447.00 437.00 447.00 656.00
38221 Bone marrow biopsy and smear 447.00 437.00 447.00 656.00
38505 Biopsy or excision of lymph node(s); by needle, superficial 213.00 208.00 213.00 312.00
40808 Biopsy, vestibule of mouth 198.00 194.00 198.00 291.00
40840 Vestibuloplasty, anterior 913.00 893.00 913.00 1,340.00
41010 Incision of lingual frenum (frenotomy) 667.00 653.00 667.00 980.00
42699 Salivary glands endoscopy 8,662.00 8,476.00 8,662.00 12,714.00
42700 Incision and drainage of peritonsillar abscess 280.00 274.00 280.00 411.00
42809 Foreign body removal, pharynx, superficial 0.00 0.00 0.00 0.00
43200 Esophagoscopy, diagnostic 325.00 318.00 325.00 477.00
43204 Esophagoscopy, with injection sclerosis of esophageal varices 4,005.00 3,919.00 4,005.00 5,879.00
43219 Esophageal dilation and stent placement, ambulatory care 19,382.00 18,965.00 19,382.00 28,448.00
43235 UGI endoscopy, with/without sampling 1,347.00 1,318.00 1,347.00 1,977.00
43240 Endoscopic drainage of pseudocyst of pancreas, EUS guidance 11,060.00 10,822.00 11,060.00 16,233.00
43259 Upper gastrointestinal endoscopy; with endoscopic ultrasound examination 1,628.00 1,593.00 1,628.00 2,390.00
43260 ERCP (Endoscopic retrograde cholangiopancreatography), diagnostic 4,344.00 4,250.00 4,344.00 6,375.00
43264 ERCP (Endoscopic retrograde cholangiopancreatography), therapeutic 7,373.00 7,214.00 7,373.00 10,821.00
43450 Esophageal dilation, without using imaging guidance 325.00 318.00 325.00 477.00
43750 PEG (Percutaneous Endoscopic Gastrostomy) 2,654.00 2,597.00 2,654.00 3,896.00
43760 Replacement of PEG (Percutaneous Endoscopic Gastrostomy) 1,457.00 1,426.00 1,457.00 2,139.00
44360 Small intestinal endoscopy, enteroscopy, diagnostic, with/without collection of 3,012.00 2,947.00 3,012.00 4,421.00
specimen(s)
45300 Proctosigmoidoscopy, diagnostic 236.00 231.00 236.00 347.00
45331 Sigmoidoscopy, flexible, with/without biopsy 778.00 761.00 778.00 1,142.00
45378 Colonoscopy, flexible; diagnostic, with/without collection of specimen(s), population 1,215.00 1,189.00 1,215.00 1,784.00
at risk
45383 Colonoscopy, with excision of lesion 2,489.00 2,435.00 2,489.00 3,653.00
45387 Colonoscopy with dilation and stent placement, ambulatory care 19,382.00 18,965.00 19,382.00 28,448.00
45905 Dilation of anal sphincter 369.00 361.00 369.00 542.00
46080 Sphincterotomy, anal, division of sphincter under general/regional anesthesia 2,342.00 2,292.00 2,342.00 3,438.00
46500 Injection of sclerosing solution, hemorrhoids 128.00 125.00 128.00 188.00
46600 Anoscopy, diagnostic 95.00 93.00 95.00 140.00
47999 Extracorporeal shockwave lithotripsy, biliary tract, simple 7,158.00 7,004.00 7,158.00 10,506.00
49321 Laparoscopy, surgical, with biopsy (single or multiple) 6,576.00 6,434.00 6,576.00 9,651.00
50040 Nephrostomy, nephrotomy with drainage 3,100.00 3,033.00 3,100.00 4,550.00
50398 Repositioning/change of nephrostomy or pyelostomy tube 1,848.00 1,808.00 1,848.00 2,712.00
50590 Extracorporeal shockwave lithotripsy, kidney, simple, ambulatory care 7,429.00 7,269.00 7,429.00 10,904.00
51045 Insertion of urethral or ureteral stent 3,100.00 3,033.00 3,100.00 4,550.00
51700 Bladder irrigation, simple, lavage and/or instillation 150.00 147.00 150.00 221.00
51703 Insertion of urethral catheter 155.00 152.00 155.00 228.00
51720 Bladder instillation of anticarcinogenic agent 398.00 389.00 398.00 584.00
51726 Cystometrogram 591.00 578.00 591.00 867.00
51736 Simple uroflowmetry (UFR) 280.00 274.00 280.00 411.00
51741 Complex uroflowmetry 1,934.00 1,892.00 1,934.00 2,838.00
51772 Urethral pressure profile studies (UPP) (urethral closure pressure profile) 591.00 578.00 591.00 867.00
51784 EMG of anal/urethral sphincter, any technique 591.00 578.00 591.00 867.00
52000 Cystourethroscopy 577.00 565.00 577.00 848.00
52204 Cystourethroscopy, with biopsy/other surgical procedure 1,502.00 1,470.00 1,502.00 2,205.00
53000 Urethrotomy or urethrostomy 577.00 565.00 577.00 848.00
53850 Destruction of prostate tissue by thermotherapy 5,238.00 5,125.00 5,238.00 7,688.00
from
Abroad
)ILS(
53899 Cystoscopic injection of botulinum toxin, including cost of material 3,615.00 3,537.00 3,615.00 5,306.00
54235 Injection of corpora cavernosa 106.00 104.00 106.00 156.00
54250 Nocturnal penile tumescence and/or rigidity test 760.00 744.00 760.00 1,116.00
55000 Puncture aspiration of hydrocele, with/without injection of medication 325.00 318.00 325.00 477.00
55700 Biopsy, prostate; needle or punch, single or multiple, any approach 2,069.00 2,024.00 2,069.00 3,036.00
55870 Electroejaculation 7,260.00 7,104.00 7,260.00 10,656.00
57452 Colposcopy, vaginoscopy 149.00 146.00 149.00 219.00
57510 Cautery of cervix, any method 150.00 147.00 150.00 221.00
58120 Dilation and curettage, diagnostic and/or therapeutic, excluding induced abortion 3,087.00 3,021.00 3,087.00 4,532.00
58300 Insertion of intrauterine device (IUD) 325.00 318.00 325.00 477.00
58301 Removal of intrauterine device (IUD) 150.00 147.00 150.00 221.00
58321 Artificial insemination, intra-cervical 150.00 147.00 150.00 221.00
58322 Artificial insemination, intra-uterine 206.00 202.00 206.00 303.00
58323 Sperm washing for artificial insemination 631.00 617.00 631.00 926.00
58345 Fallopian tube dilation, catheterization, diagnostic/therapeutic, ambulatory care 4,572.00 4,474.00 4,572.00 6,711.00
58555 Hysteroscopy 577.00 565.00 577.00 848.00
58558 Hysteroscopy, surgical, with biopsy/other surgical procedure 1,052.00 1,029.00 1,052.00 1,544.00
58563 Uterine thermal therapy 6,753.00 6,608.00 6,753.00 9,912.00
58974 Cryopreserved embryos transfer, intrauterine 4,613.00 4,514.00 4,613.00 6,771.00
59000 Amniocentesis 285.00 279.00 285.00 419.00
59012 Cordocentesis (intrauterine), any method 3,246.00 3,176.00 3,246.00 4,764.00
59020 Fetal contraction stress test 832.00 814.00 832.00 1,221.00
59025 Fetal NST (Nonstress Test) 391.00 383.00 391.00 575.00
59866 Multifetal pregnancy reduction(s) (MPR), including US guidance 3,087.00 3,021.00 3,087.00 4,532.00
59871 Removal of cerclage suture 213.00 208.00 213.00 312.00
62270 Spinal puncture, lumbar, diagnostic 786.00 769.00 786.00 1,154.00
62272 Spinal puncture, therapeutic 786.00 769.00 786.00 1,154.00
62310 Injection, epidural/subarachnoid; cervical/thoracic 550.00 538.00 550.00 807.00
62311 Injection, epidural/subarachnoid; lumbar/sacral (caudal) 550.00 538.00 550.00 807.00
64400 Injection, anesthetic agent (eg, Lignocaine) 269.00 263.00 269.00 395.00
64470 Paravertebral injection 155.00 152.00 155.00 228.00
64550 Application of surface (transcutaneous) neurostimulator 280.00 274.00 280.00 411.00
64612 Injection of Botulinum toxin, 10 units Botox 297.00 291.00 297.00 437.00
65205 Foreign body removal, external eye, superficial 0.00 0.00 0.00 0.00
66984 Cataract surgery with insertion of intraocular lens, including cost of lens, ambulatory 6,181.00 6,048.00 6,181.00 9,072.00
care
66999 Intracorneal rings for keratoconus treatment, Intacs 8,094.00 7,920.00 8,094.00 11,880.00
67210 Retinal photocoagulation, PDT, without material 2,093.00 2,048.00 2,093.00 3,072.00
67912 Implantation of upper eyelid gold weight 5,348.00 5,233.00 5,348.00 7,850.00
68810 Probing of nasolacrimal duct, with/without irrigation 1,467.00 1,435.00 1,467.00 2,153.00
68811 Probing of nasolacrimal duct, with/without irrigation; requiring general anesthesia 3,959.00 3,874.00 3,959.00 5,811.00
69000 Puncture/drainage external ear abscess/hematoma 280.00 274.00 280.00 411.00

69200 Foreign body removal, ear, superficial 0.00 0.00 0.00 0.00
69210 Removal impacted cerumen 155.00 152.00 155.00 228.00
69420 Myringotomy including puncture/aspiration 280.00 274.00 280.00 411.00
69436 Tympanostomy (requiring insertion of ventilating tube), general anesthesia 1,690.00 1,654.00 1,690.00 2,481.00
70030 Eye radiology, foreign body detection 337.00 330.00 337.00 495.00
70100 Mandible radiology, up to two views 283.00 277.00 283.00 416.00
70120 Mastoids radiology, up to two views 150.00 147.00 150.00 221.00
70170 Dacryocystography, radiological supervision and interpretation 206.00 202.00 206.00 303.00
70200 Orbits radiology, up to two views 201.00 197.00 201.00 296.00
70210 Paranasal sinuses radiology, up to two views 199.00 195.00 199.00 293.00
70240 Sella turcica radiology 280.00 274.00 280.00 411.00
70250 Skull radiology, up to two views 140.00 137.00 140.00 206.00
70332 TMJ arthrography, including injection and interpretation 358.00 350.00 358.00 525.00
70336 TMJ (temporomandibular joint(s)) MRI 2,034.00 1,990.00 2,034.00 2,985.00
from
Abroad
)ILS(
70360 Neck, soft tissue radiology, trachea 448.00 438.00 448.00 657.00
70390 Salivary glands radiology, sialography 424.00 415.00 424.00 623.00
70540 Orbit, face and neck MRI 2,034.00 1,990.00 2,034.00 2,985.00
70544 Brain MRA 2,221.00 2,173.00 2,221.00 3,260.00
70547 Head and/or neck MRA 2,221.00 2,173.00 2,221.00 3,260.00
70551 Brain/brain stem MRI, without contrast material 2,034.00 1,990.00 2,034.00 2,985.00
71020 Chest radiology, up to two views 130.00 127.00 130.00 191.00
71023 Chest radiology, up to two views, with fluoroscopy 398.00 389.00 398.00 584.00
71100 Ribs radiology, up to two views 195.00 191.00 195.00 287.00
71120 Sternum radiology, up to two views 206.00 202.00 206.00 303.00
71550 Thoracic MRI, without contrast material 2,034.00 1,990.00 2,034.00 2,985.00
71555 Thoracic MRA, excluding myocardium 2,221.00 2,173.00 2,221.00 3,260.00
72010 Spine radiology, entire, up to two views 201.00 197.00 201.00 296.00
72040 Cervical spine radiology, up to two views 140.00 137.00 140.00 206.00
72070 Thoracic spine radiology, up to two views 140.00 137.00 140.00 206.00
72080 Thoracolumbar spine radiology, up to two views 140.00 137.00 140.00 206.00
72100 Lumbosacral spine radiology, up to two views 140.00 137.00 140.00 206.00
72141 Cervical spine MRI, per patient 2,034.00 1,990.00 2,034.00 2,985.00
72146 Thoracic spine MRI, per patient 2,034.00 1,990.00 2,034.00 2,985.00
72148 Lumbar spine MRI, per patient 2,034.00 1,990.00 2,034.00 2,985.00
72159 Spinal canal and contents MRA 2,221.00 2,173.00 2,221.00 3,260.00
72170 Pelvis radiology, up to two views 154.00 151.00 154.00 227.00
72198 Pelvic MRA 2,221.00 2,173.00 2,221.00 3,260.00
72200 SIJ radiology, up to two views 206.00 202.00 206.00 303.00
72270 Myelography 1,606.00 1,571.00 1,606.00 2,357.00
73000 Clavicle radiology 167.00 163.00 167.00 245.00
73010 Scapula radiology 167.00 163.00 167.00 245.00
73030 Shoulder radiology, complete, one side, up to two views 150.00 147.00 150.00 221.00
73040 Shoulder arthrography, including injection and interpretation 358.00 350.00 358.00 525.00
73060 Humerus radiology, up to two views 140.00 137.00 140.00 206.00
73070 Elbow radiology, up to two views 140.00 137.00 140.00 206.00
73085 Elbow arthrography, including injection and interpretation 358.00 350.00 358.00 525.00
73090 Forearm radiology, up to two views 140.00 137.00 140.00 206.00
73092 Upper extremity radiology, infant, up to two views 140.00 137.00 140.00 206.00
73100 Wrist radiology, up to two views 140.00 137.00 140.00 206.00
73115 Wrist, arthrography, including injection and interpretation 358.00 350.00 358.00 525.00
73120 Hand radiology, up to two views 140.00 137.00 140.00 206.00
73140 Finger(s) radiology, up to two views 140.00 137.00 140.00 206.00
73221 Upper extremity joints MRI, without contrast material, per patient 2,034.00 1,990.00 2,034.00 2,985.00
73225 Upper extremity MRA 2,221.00 2,173.00 2,221.00 3,260.00
73500 Hip radiology, unilateral, one view 140.00 137.00 140.00 206.00
73520 Hip radiology, bilateral, including pelvis 140.00 137.00 140.00 206.00
73525 Hip arthrography, including injection and interpretation 358.00 350.00 358.00 525.00
73542 SIJ arthrography, including injection and interpretation 358.00 350.00 358.00 525.00
73550 Femur radiology, up to two views 140.00 137.00 140.00 206.00
73560 Knee radiology, up to two views, per side 140.00 137.00 140.00 206.00
73562 Knee radiology, third or more additional views 150.00 147.00 150.00 221.00
73580 Knee arthrography, including injection and interpretation 358.00 350.00 358.00 525.00
73590 Tibia and fibula radiology, up to two views 140.00 137.00 140.00 206.00
73592 Lower extremity radiology, infant, up to two views 140.00 137.00 140.00 206.00
73610 Ankle radiology, complete, one side 140.00 137.00 140.00 206.00
73615 Ankle arthrography, including injection and interpretation 358.00 350.00 358.00 525.00
73620 Foot radiology, up to two views 140.00 137.00 140.00 206.00
73721 Lower extremity joints MRI, without contrast material, per patient 2,034.00 1,990.00 2,034.00 2,985.00
73725 Lower extremity MRA 2,221.00 2,173.00 2,221.00 3,260.00
74000 Abdomen radiology, without contrast material 199.00 195.00 199.00 293.00
from
Abroad
)ILS(
74181 Abdominal MRI, per patient 2,034.00 1,990.00 2,034.00 2,985.00

74185 Abdominal MRA 2,221.00 2,173.00 2,221.00 3,260.00
74220 Esophagus radiology 496.00 485.00 496.00 728.00
74230 Swallowing function, with cineradiography/videoradiography 791.00 774.00 791.00 1,161.00
74241 UGI fluoroscopy and/or radiology, with/without delayed films 832.00 814.00 832.00 1,221.00
74245 UGI fluoroscopy, including serial films 1,025.00 1,003.00 1,025.00 1,505.00
74249 Abdomen radiology, small intestine follow-through 496.00 485.00 496.00 728.00
74270 Barium enema 591.00 578.00 591.00 867.00
74280 Air barium enema, with/without glucagon 949.00 929.00 949.00 1,394.00
74290 Cholecystography, oral contrast 494.00 483.00 494.00 725.00
74360 Esophageal dilation, imaging guidance 6,597.00 6,455.00 6,597.00 9,683.00
74400 IVP, with or without tomography 733.00 717.00 733.00 1,076.00
74420 Urography, retrograde 602.00 589.00 602.00 884.00
74450 Urethrocystography, retrograde, radiological supervision and interpretation 465.00 455.00 465.00 683.00
74455 Urethrocystography, radiological supervision and interpretation 583.00 570.00 583.00 855.00
74740 Hysterosalpingography, radiology 606.00 593.00 606.00 890.00
75552 Cardiac MRI for morphology, per patient 4,567.00 4,469.00 4,567.00 6,704.00
75554 Cardiac FMRI, with/without morphology, complete study, per patient 4,567.00 4,469.00 4,567.00 6,704.00
75803 Lymphangiography, extremities 2,335.00 2,285.00 2,335.00 3,428.00
75822 Phlebography, venography, including injection and imaging 786.00 769.00 786.00 1,154.00
76000 Fluoroscopy 128.00 125.00 128.00 188.00
76120 Cineradiography/videoradiography, video capsule 5,935.00 5,807.00 5,935.00 8,711.00
76140 Interpretation/consultation on imaging made elsewhere 150.00 147.00 150.00 221.00
76390 MRS (Magnetic resonance spectroscopy), per patient 2,947.00 2,884.00 2,947.00 4,326.00
76512 Ophthalmic US (ultrasound) 195.00 191.00 195.00 287.00
76514 Ophthalmic US, corneal pachymetry, determination of corneal thickness, per patient 108.00 106.00 108.00 159.00
76536 Head and neck soft tissues US, with image documentation 391.00 383.00 391.00 575.00
76604 Chest US, including mediastinum, with image documentation 671.00 657.00 671.00 986.00
76645 Breasts and chest wall US, with image documentation 271.00 265.00 271.00 398.00
76700 Abdominal US, excluding screening for aortic aneurysm diagnosis, with image 391.00 383.00 391.00 575.00
documentation
76805 Fetal anatomic US, with image documentation 1,005.00 983.00 1,005.00 1,475.00
76813 Fetal nuchal translucency US, per one fetus, with image documentation 412.00 403.00 412.00 605.00
76814 Fetal nuchal translucency US, per each additional fetus, with image documentation 271.00 265.00 271.00 398.00
76815 Obstetric US, with image documentation 550.00 538.00 550.00 807.00
76825 Echocardiography, fetal, with image documentation 1,152.00 1,127.00 1,152.00 1,691.00
76827 Doppler echocardiography, fetal 1,421.00 1,390.00 1,421.00 2,085.00
76830 TVUS (Transvaginal Ultrasound) 321.00 314.00 321.00 471.00
76831 Uterus and fallopian tube sonography, with contrast material 1,116.00 1,092.00 1,116.00 1,638.00
76857 Gynecological US, follicles 204.00 200.00 204.00 300.00
76870 Scrotum US, with image documentation 671.00 657.00 671.00 986.00
76872 TRUS (transrectal ultrasound), with image documentation 978.00 957.00 978.00 1,436.00
76942 Biopsy/surgical procedure, US guidance 3,099.00 3,032.00 3,099.00 4,548.00
77002 Biopsy/surgical procedure, fluoroscopic guidance 3,099.00 3,032.00 3,099.00 4,548.00
77012 Biopsy/surgical procedure, CT guidance, ambulatory care 5,609.00 5,488.00 5,609.00 8,232.00
77021 Biopsy/surgical procedure, MRI guidance, excluding breast, ambulatory care 8,414.00 8,233.00 8,414.00 12,350.00
77031 Stereotactic localization guidance for breast biopsy/needle placement, including 5,607.00 5,486.00 5,607.00 8,229.00
biopsy, using imaging guidance (eg, mammography)
77032 Mammographic guidance for needle placement, breast (eg, for wire localization or for 852.00 834.00 852.00 1,251.00
injection), each lesion, radiological supervision and interpretation
77054 Mammary ductogram/galactogram, including interpretation 1,101.00 1,077.00 1,101.00 1,616.00
77056 Mammography; bilateral 273.00 267.00 273.00 401.00
77059 Breast MRI, bilateral 2,034.00 1,990.00 2,034.00 2,985.00
77073 Bone length studies (orthoroentgenogram, scanogram) 396.00 387.00 396.00 581.00
77080 DXA, bone density study 244.00 239.00 244.00 359.00
from
Abroad
)ILS(
77261 Therapeutic radiology treatment planning, radiotherapy 642.00 628.00 642.00 942.00
77280 Radiotherapy simulation 2,552.00 2,497.00 2,552.00 3,746.00
77295 Radiology simulation-aided field setting, three-dimensional 3,190.00 3,121.00 3,190.00 4,682.00
77401 Radiation treatment delivery, per field 561.00 491.00 503.00 824.00
78000 Thyroid uptake, single determination 321.00 314.00 321.00 471.00
78001 Thyroid uptake, multiple determinations 548.00 536.00 548.00 804.00
78007 Thyroid imaging, with uptake, multiple determinations 1,094.00 1,070.00 1,094.00 1,605.00
78010 Thyroid imaging 713.00 698.00 713.00 1,047.00
78018 Thyroid imaging; I-131, whole body 3,301.00 3,230.00 3,301.00 4,845.00
78070 Parathyroid imaging 1,646.00 1,611.00 1,646.00 2,417.00
78104 Bone marrow imaging, whole body 3,077.00 3,011.00 3,077.00 4,517.00
78122 Whole blood volume determination, radiopharmaceutical technique 2,044.00 2,000.00 2,044.00 3,000.00
78130 Red cell survival study 3,486.00 3,411.00 3,486.00 5,117.00
78191 Platelet survival study 1,104.00 1,080.00 1,104.00 1,620.00
78195 Lymphatics and lymph nodes imaging 3,049.00 2,983.00 3,049.00 4,475.00
78205 Liver and spleen imaging, SPECT 963.00 942.00 963.00 1,413.00
78215 Liver and spleen imaging, static 852.00 834.00 852.00 1,251.00
78216 Liver and spleen imaging, dynamic and static 904.00 885.00 904.00 1,328.00
78223 Hepatobiliary imaging, with/without pharmacologic intervention, with/without 2,510.00 2,456.00 2,510.00 3,684.00
quantitative measurement of gallbladder function
78231 Salivary gland imaging, with serial images 1,047.00 1,024.00 1,047.00 1,536.00
78258 Esophageal motility, dynamic 1,083.00 1,060.00 1,083.00 1,590.00
78262 Gastroesophageal reflux study 817.00 799.00 817.00 1,199.00
78264 Gastric emptying study 3,250.00 3,180.00 3,250.00 4,770.00
78270 Vitamin B-12 absorption, without intrinsic factor 783.00 766.00 783.00 1,149.00
78271 Vitamin B-12 absorption, with intrinsic factor 1,072.00 1,049.00 1,072.00 1,574.00
78278 Acute GI bleeding imaging, dynamic and static 3,167.00 3,099.00 3,167.00 4,649.00
78290 Intestine imaging (eg, Meckel's, ectopic gastric mucosa) 1,568.00 1,534.00 1,568.00 2,301.00
78291 Peritoneal-venous shunt patency test (eg, for LeVeen, Denver shunt) 2,219.00 2,171.00 2,219.00 3,257.00
78300 Bone and/or joint imaging, limited area 1,325.00 1,296.00 1,325.00 1,944.00
78306 Bone and/or joint imaging, whole body 829.00 811.00 829.00 1,217.00
78315 Bone and/or joint imaging, three phase 2,668.00 2,611.00 2,668.00 3,917.00
78320 Bone and/or joint imaging, SPECT 932.00 912.00 932.00 1,368.00
78399 Bone and/or joint imaging, whole body, 24 hours later 381.00 373.00 381.00 560.00
78428 Cardiac shunt detection, dynamic 871.00 852.00 871.00 1,278.00
78445 Vascular flow imaging, perfusion 1,140.00 1,115.00 1,140.00 1,673.00
78458 Venous thrombosis imaging, bilateral 1,502.00 1,470.00 1,502.00 2,205.00
78461 Myocardial perfusion imaging, at rest and/or stress, planar 3,651.00 3,572.00 3,651.00 5,358.00
78465 Myocardial perfusion imaging, rest and/or stress, SPECT 4,140.00 1,926.00 1,973.00 6,074.00
78466 Myocardial imaging, infarct, planar 2,714.00 2,656.00 2,714.00 3,984.00
78468 Myocardial imaging, infarct, planar first pass, EF 3,225.00 3,156.00 3,225.00 4,734.00
78469 Myocardial imaging, infarct, SPECT 3,739.00 3,659.00 3,739.00 5,489.00
78472 Cardiac BP imaging, gated planar, rest/stress, EF 1,712.00 1,675.00 1,712.00 2,513.00
78473 Cardiac BP imaging, gated, rest and stress, EF 4,058.00 3,971.00 4,058.00 5,957.00
78478 Myocardial perfusion imaging, with wall motion 5,059.00 4,950.00 5,059.00 7,425.00
78480 Myocardial perfusion study with EF 5,291.00 5,177.00 5,291.00 7,766.00
78481 Cardiac BP imaging, gated planar, rest/stress, first pass, EF 1,689.00 1,653.00 1,689.00 2,480.00
78499 Cardiac BP (pool imaging)imaging, static 819.00 801.00 819.00 1,202.00
78580 Pulmonary imaging, perfusion 979.00 958.00 979.00 1,437.00
78585 Pulmonary imaging, ventilation and perfusion, Xenon 2,286.00 2,237.00 2,286.00 3,356.00
78587 Pulmonary imaging, ventilation, aerosol 1,882.00 1,841.00 1,882.00 2,762.00
78594 Pulmonary imaging, ventilation, xenon 1,960.00 1,918.00 1,960.00 2,877.00
78596 Pulmonary imaging, ventilation and perfusion, quantitative differential function 2,890.00 2,828.00 2,890.00 4,242.00
78605 Brain imaging, static 1,363.00 1,334.00 1,363.00 2,001.00
78606 Brain imaging, dynamic and static 1,832.00 1,793.00 1,832.00 2,690.00
78607 Brain imaging, SPECT 3,505.00 3,430.00 3,505.00 5,145.00
78610 Brain imaging, dynamic 1,271.00 1,244.00 1,271.00 1,866.00
from
Abroad
)ILS(
78630 CSF (Cerebrospinal fluid) imaging, cisternography 5,262.00 5,149.00 5,262.00 7,724.00
78645 CSF flow imaging, shunt evaluation 1,080.00 1,057.00 1,080.00 1,586.00
78650 CSF leakage detection and localization 3,123.00 3,056.00 3,123.00 4,584.00
78660 Radiopharmaceutical dacryocystography 1,314.00 1,286.00 1,314.00 1,929.00
78699 Brain tumor imaging, SPECT 3,164.00 3,096.00 3,164.00 4,644.00
78700 Kidney imaging, static 1,617.00 1,582.00 1,617.00 2,373.00
78701 Kidney imaging, dynamic, GFR 1,832.00 1,793.00 1,832.00 2,690.00
78707 Kidney imaging, dynamic, without pharmacological intervention 1,248.00 1,221.00 1,248.00 1,832.00
78708 Kidney imaging, dynamic, with pharmacological intervention 1,486.00 1,454.00 1,486.00 2,181.00
78710 Kidney imaging, SPECT 1,597.00 1,563.00 1,597.00 2,345.00
78740 Ureteral reflux imaging (cystogram) 1,397.00 1,367.00 1,397.00 2,051.00
78761 Testicular imaging, dynamic and static 811.00 794.00 811.00 1,191.00
78802 Tumor imaging, planar 4,959.00 4,852.00 4,959.00 7,278.00
78803 Tumor imaging, SPECT 4,321.00 4,228.00 4,321.00 6,342.00
78805 Inflammatory process imaging, limited area 4,843.00 4,739.00 4,843.00 7,109.00
78806 Inflammatory process imaging, whole body 5,954.00 5,826.00 5,954.00 8,739.00
78807 Inflammatory process imaging, SPECT 4,321.00 4,228.00 4,321.00 6,342.00
78813 FDG PET imaging 4,937.00 4,831.00 4,937.00 7,247.00
78999 Tumor imaging, monoclonal Ab, SPECT 9,137.00 8,940.00 9,137.00 13,410.00
79101 Radiopharmaceutical therapy, polycythemia vera 2,305.00 2,255.00 2,305.00 3,383.00
79403 Radiopharmaceutical therapy, intravenous administration, Zevalin, 90Y-Ibritumomab 1,960.00 1,918.00 1,960.00 2,877.00
tiuxetan
79440 Radiopharmaceutical therapy, by intra-articular administration 6,331.00 6,195.00 6,331.00 9,293.00
80053 Chemistry panel 65.00 64.00 65.00 96.00
80061 Lipids panel - blood: Cholesterol, TG, HDL, LDL 53.00 52.00 53.00 78.00
80076 Hepatic function panel 75.00 73.00 75.00 110.00
80100 Drug, qualitative - urine 148.00 145.00 148.00 218.00
80101 Drug, qualitative 213.00 208.00 213.00 312.00
80162 Digoxin 103.00 101.00 103.00 152.00
80178 Lithium 155.00 152.00 155.00 228.00
80195 Sirolimus 356.00 348.00 356.00 522.00
80299 Drug, quantitative 213.00 208.00 213.00 312.00
80400 ACTH stimulation, including blood hormones levels 552.00 540.00 552.00 810.00
80420 Dexamethasone suppression test, 48 hour, include: free cortisol, urine cortisol, volume 165.00 161.00 165.00 242.00
measurement
81000 Urinalysis, with microscopy 48.00 47.00 48.00 71.00
81002 Urinalysis stick, manual - urine, panel billing code 21.00 21.00 21.00 32.00
81235 EGFR (Epidermal Growth Factor Receptor) mutation - blood, per patient 4,525.00 4,428.00 4,525.00 6,642.00
82010 Acetone, quantitative 95.00 93.00 95.00 140.00
82013 Acetylcholinesterase - amniotic fluid 606.00 593.00 606.00 890.00
82017 Acylcarnitine, quantitative - blood/urine 734.00 718.00 734.00 1,077.00
82030 Cyclic AMP - blood and urine 868.00 849.00 868.00 1,274.00
82040 Albumin - serum 19.00 19.00 19.00 29.00
82042 Albumin, quantitative - urine/other source, excluding serum 19.00 19.00 19.00 29.00
82043 Microalbumin - urine / 24 hours 103.00 101.00 103.00 152.00
82085 Aldolase 213.00 208.00 213.00 312.00
82088 Aldosterone 283.00 277.00 283.00 416.00
82103 Alpha 1 antitrypsin, total 325.00 318.00 325.00 477.00
82105 Alpha-fetoprotein - serum 38.00 37.00 38.00 56.00
82128 Amino acids, qualitative 136.00 133.00 136.00 200.00
82131 Amino acids, quantitative 385.00 377.00 385.00 566.00
82135 Aminolevulinic acid (ALA), quantitative - urine 373.00 365.00 373.00 548.00
82140 Ammonia 207.00 203.00 207.00 305.00
82150 Amylase 37.00 36.00 37.00 54.00
82154 Androstenedione/androstenediol glucoronide 231.00 226.00 231.00 339.00
82160 Androsterone 465.00 455.00 465.00 683.00
82172 Apolipoprotein B1/A1 155.00 152.00 155.00 228.00
from
Abroad
)ILS(
82180 Vitamin C, ascorbic acid - blood 150.00 147.00 150.00 221.00

82205 Barbiturates, qualitative - urine 213.00 208.00 213.00 312.00
82232 Beta 2 microglobulin 324.00 317.00 324.00 476.00
82239 Bile acids degradation test 326.00 319.00 326.00 479.00
82247 Bilirubin, total 19.00 19.00 19.00 29.00
82248 Bilirubin, direct 19.00 19.00 19.00 29.00
82261 Biotinidase 309.00 302.00 309.00 453.00
82270 Occult blood - feces 95.00 93.00 95.00 140.00
82306 Calcifediol (25-OH Vitamin D-3) 137.00 134.00 137.00 201.00
82307 Calciferol (Vitamin D) 137.00 134.00 137.00 201.00
82308 Calcitonin 283.00 277.00 283.00 416.00
82310 Calcium, total, excluding urine 19.00 19.00 19.00 29.00
82340 Calcium - urine 36.00 35.00 36.00 53.00
82360 Calculus, quantitative and qualitative analysis 1,151.00 1,126.00 1,151.00 1,689.00
82374 Carbon dioxide (bicarbonate) 128.00 125.00 128.00 188.00
82378 CEA (Carcinoembryonic Ag), including dilution 38.00 37.00 38.00 56.00
82380 Carotene 150.00 147.00 150.00 221.00
82382 Catecholamines, total 671.00 657.00 671.00 986.00
82390 Ceruloplasmin 213.00 208.00 213.00 312.00
82435 Chloride - blood 36.00 35.00 36.00 53.00
82436 Chloride - urine 36.00 35.00 36.00 53.00
82438 Chloride - other source, excluding blood/urine 36.00 35.00 36.00 53.00
82465 Cholesterol, total - blood 19.00 19.00 19.00 29.00
82480 Cholinesterase - serum 95.00 93.00 95.00 140.00
82486 Chromatography, qualitative 155.00 152.00 155.00 228.00
82492 Chromatography, quantitative, any method 155.00 152.00 155.00 228.00
82525 Copper 87.00 85.00 87.00 128.00
82533 Cortisol, total 48.00 47.00 48.00 71.00
82540 Creatine 95.00 93.00 95.00 140.00
82550 CK (Creatine Kinase, CPK), total 19.00 19.00 19.00 29.00
82552 CK (Creatine Kinase, CPK) isoenzymes 311.00 304.00 311.00 456.00
82565 Creatinine - blood 22.00 22.00 22.00 33.00
82570 Creatinine - other fluids, excluding blood 48.00 47.00 48.00 71.00
82575 Creatinine clearance test 64.00 63.00 64.00 95.00
82585 Cryofibrinogen 317.00 310.00 317.00 465.00
82595 Cryoglobulin, qualitative or semi-quantitative (eg, cryocrit) 155.00 152.00 155.00 228.00
82607 Vitamin B-12, cyanocobalamin 176.00 172.00 176.00 258.00
82608 Vitamin B-12, cyanocobalamin, binding capacity 61.00 60.00 61.00 90.00
82626 Dehydroepiandrosterone (DHEA) 75.00 73.00 75.00 110.00
82627 Dehydroepiandrosterone-sulfate (DHEA-S) 75.00 73.00 75.00 110.00
82652 Vitamin D (Calciferol) 1,25-Dihydroxy 552.00 540.00 552.00 810.00
82657 Enzyme activity in blood cells, cultured cells, or tissue, each 213.00 208.00 213.00 312.00
82670 Estradiol 75.00 73.00 75.00 110.00
82672 Estrogens, total, all derivatives 465.00 455.00 465.00 683.00
82677 Estriol 325.00 318.00 325.00 477.00
82679 Estrone 317.00 310.00 317.00 465.00
82705 Fat, qualitative - feces 150.00 147.00 150.00 221.00
82710 Fat, quantitative - feces 494.00 483.00 494.00 725.00
82726 Very long chain fatty acids 1,048.00 1,025.00 1,048.00 1,538.00
82728 Ferritin 35.00 34.00 35.00 51.00
82731 Fetal fibronectin 510.00 499.00 510.00 749.00
82746 Folic acid - serum 154.00 151.00 154.00 227.00
82757 Fructose - seminal fluid 325.00 318.00 325.00 477.00
82759 Galactokinase 920.00 900.00 920.00 1,350.00
82760 Galactose 317.00 310.00 317.00 465.00
82775 Galactose 1 phosphate uridyl transferase, quantitative 494.00 483.00 494.00 725.00
from
Abroad
)ILS(
82787 Gammaglobulin, immunoglobulin subclasses 779.00 762.00 779.00 1,143.00

82800 Gases, pH only - blood 155.00 152.00 155.00 228.00
82803 Gases - blood 198.00 194.00 198.00 291.00
82941 Gastrin 283.00 277.00 283.00 416.00
82945 Glucose - other fluids, excluding blood 95.00 93.00 95.00 140.00
82947 Glucose, quantitative - blood 19.00 19.00 19.00 29.00
82951 Glucose tolerance test (GTT) 213.00 208.00 213.00 312.00
82955 Glucose-6-phosphate dehydrogenase (G6PD), quantitative 465.00 455.00 465.00 683.00
82960 Glucose-6-phosphate dehydrogenase (G6PD), screen 317.00 310.00 317.00 465.00
82977 Gamma glutamyltransferase (GGT) 35.00 34.00 35.00 51.00
82985 Fructosamine/glycated protein 465.00 455.00 465.00 683.00
83001 Gonadotropin, FSH (Follicle stimulating hormone) 35.00 34.00 35.00 51.00
83002 Gonadotropin, LH (Luteinizing hormone) 71.00 69.00 71.00 104.00
83003 GH (Growth hormone), somatotropin 75.00 73.00 75.00 110.00
83010 Haptoglobin, quantitative 358.00 350.00 358.00 525.00
83013 Rapid urease test, helicobacter pylori - exhaled air 53.00 52.00 53.00 78.00
83015 Heavy metal (arsenic, barium, beryllium, bismuth, antimony, mercury, thallium), 213.00 208.00 213.00 312.00
screen
83020 Hemoglobin, electrophoresis 133.00 130.00 133.00 195.00
83036 Hemoglobin; glycosylated (A1C) 48.00 47.00 48.00 71.00
83045 Hemoglobin, methemoglobin, qualitative 465.00 455.00 465.00 683.00
83069 Hemoglobin - urine 269.00 263.00 269.00 395.00
83070 Hemosiderin, qualitative - urine 280.00 274.00 280.00 411.00
83071 Hemosiderin, quantitative - urine 280.00 274.00 280.00 411.00
83090 Homocysteine 290.00 284.00 290.00 426.00
83491 Hydroxycorticosteroids, 17- (17-OHCS) 357.00 349.00 357.00 524.00
83497 Hydroxyindolacetic acid, 5-(HIAA) 172.00 168.00 172.00 252.00
83525 Insulin, total 75.00 73.00 75.00 110.00
83540 Iron 48.00 47.00 48.00 71.00
83550 Iron binding capacity 213.00 208.00 213.00 312.00
83586 Ketosteroids , total 317.00 310.00 317.00 465.00
83593 Ketosteroids, 17- (17-KS), fractionation 1,753.00 1,715.00 1,753.00 2,573.00
83605 Lactate (lactic acid) 112.00 110.00 112.00 165.00
83615 Lactate dehydrogenase (LD), (LDH) 19.00 19.00 19.00 29.00
83625 Lactate dehydrogenase (LD), (LDH), isoenzymes, total 465.00 455.00 465.00 683.00
83655 Lead 103.00 101.00 103.00 152.00
83661 Fetal lung maturity assessment, Lecithin/Sphingomyelin ratio - amniotic fluid 591.00 578.00 591.00 867.00
83690 Lipase 37.00 36.00 37.00 54.00
83700 Lipoprotein, electrophoresis - blood 30.00 29.00 30.00 44.00
83718 Lipoprotein, HDL cholesterol 36.00 35.00 36.00 53.00
83719 Lipoprotein, VLDL cholesterol 36.00 35.00 36.00 53.00
83735 Magnesium 19.00 19.00 19.00 29.00
83825 Mercury, quantitative 213.00 208.00 213.00 312.00
83866 Mucopolysaccharides, screen - urine, per patient 337.00 330.00 337.00 495.00
83872 Mucin/other material - synovial fluid, including biochemistry, cytology and culture 337.00 330.00 337.00 495.00
83874 Myoglobin 291.00 285.00 291.00 428.00

83896 Molecular diagnosis of hematologic malignancies 1,494.00 1,462.00 1,494.00 2,193.00
83898 RT-PCR, molecular diagnostics 3,626.00 3,548.00 3,626.00 5,322.00
83918 Organic acids, quantitative - urine 685.00 670.00 685.00 1,005.00
83930 Osmolality - blood 95.00 93.00 95.00 140.00
83935 Osmolality - urine 95.00 93.00 95.00 140.00
83945 Oxalate, qualitative/quantitative - urine 391.00 383.00 391.00 575.00
83970 Parathormone (parathyroid hormone) 267.00 261.00 267.00 392.00
84060 Acid phosphatase, total 95.00 93.00 95.00 140.00
84061 Acid phosphatase stain 213.00 208.00 213.00 312.00
84066 Acid phosphatase, prostatic 150.00 147.00 150.00 221.00
from
Abroad
)ILS(
84075 Alkaline phosphatase 19.00 19.00 19.00 29.00

84080 Alkaline phosphatase isoenzymes 465.00 455.00 465.00 683.00
84100 Phosphorus - blood 19.00 19.00 19.00 29.00
84105 Phosphorus - urine 19.00 19.00 19.00 29.00
84110 Porphobilinogen, quantitative, collection - urine 272.00 266.00 272.00 399.00
84119 Porphobilinogen, quantitative - urine 150.00 147.00 150.00 221.00
84127 Porphyrins, qualitative - feces 243.00 238.00 243.00 357.00
84132 Potassium - blood 19.00 19.00 19.00 29.00
84135 Pregnanediol 317.00 310.00 317.00 465.00
84138 Pregnanetriol 465.00 455.00 465.00 683.00
84144 Progesterone 75.00 73.00 75.00 110.00
84146 Prolactin 109.00 107.00 109.00 161.00
84153 PSA (Prostate specific Ag), total 48.00 47.00 48.00 71.00
84154 PSA (Prostate specific Ag), free 95.00 93.00 95.00 140.00
84155 Protein, total - serum 19.00 19.00 19.00 29.00
84156 Protein, total - urine 19.00 19.00 19.00 29.00
84165 Protein electrophoretic 103.00 101.00 103.00 152.00
84207 Vitamin B-6 (pyridoxal phosphate) 328.00 321.00 328.00 482.00
84210 Phenylpyruvic acid - urine 48.00 47.00 48.00 71.00
84233 Receptor assay, estrogene 730.00 714.00 730.00 1,071.00
84244 Renin 283.00 277.00 283.00 416.00
84260 Serotonin 172.00 168.00 172.00 252.00
84295 Sodium - blood 19.00 19.00 19.00 29.00
84375 Sugars chromatography 155.00 152.00 155.00 228.00
84376 Sugars (mono-, di-, and oligosaccharides), qualitative - body fluids 337.00 330.00 337.00 495.00
84402 Testosterone, free 150.00 147.00 150.00 221.00
84403 Testosterone, total 75.00 73.00 75.00 110.00
84432 Thyroglobulin 403.00 394.00 403.00 591.00
84436 Thyroxine, total 40.00 39.00 40.00 59.00
84443 Thyroid stimulating hormone (TSH) 40.00 39.00 40.00 59.00
84446 Tocopherol alpha (Vitamin E) 213.00 208.00 213.00 312.00
84450 AST (GOT) Aspartate aminotransferase 35.00 34.00 35.00 51.00
84460 ALT (GPT) Alanine amino transferase 35.00 34.00 35.00 51.00
84466 Transferrin 139.00 136.00 139.00 204.00
84478 Triglycerides 19.00 19.00 19.00 29.00
84479 Thyroid hormone (T3/T4) uptake or binding ratio (THBR) 88.00 86.00 88.00 129.00
84480 Triiodothyronine T3, total (TT-3) 88.00 86.00 88.00 129.00
84484 Troponin, quantitative 180.00 176.00 180.00 264.00
84490 Chymotrypsin, quantitative - feces 269.00 263.00 269.00 395.00
84520 Urea, quantitative - blood 19.00 19.00 19.00 29.00
84540 Urea, quantitative - urine/other fluids, excluding blood 48.00 47.00 48.00 71.00
84550 Uric acid - blood 19.00 19.00 19.00 29.00
84560 Uric acid - body fluids, excluding blood 48.00 47.00 48.00 71.00
84585 Vanillylmandelic acid (VMA) - urine 213.00 208.00 213.00 312.00
84588 Vasopressin (antidiuretic hormone, ADH) 552.00 540.00 552.00 810.00
84590 Vitamin A 150.00 147.00 150.00 221.00
84620 Xylose absorption test - blood/urine 155.00 152.00 155.00 228.00
84681 C-peptide 150.00 147.00 150.00 221.00
84702 hCG (Human chorionic gonadotropin), qualitative/quantitative 103.00 101.00 103.00 152.00
85002 Bleeding time 90.00 88.00 90.00 132.00
85007 Manual differential 44.00 43.00 44.00 65.00
85009 Blood count, manual differential, buffy coat 213.00 208.00 213.00 312.00
85025 CBC (complete blood count) with differential 30.00 29.00 30.00 44.00
85032 Blood smear, manual test 128.00 125.00 128.00 188.00
85044 Reticulocytes manual count 75.00 73.00 75.00 110.00
85049 Platelet, thrombocyte 82.00 80.00 82.00 120.00
from
Abroad
)ILS(
85170 Clot retraction 128.00 125.00 128.00 188.00

85210 Clotting, factor II, prothrombin 242.00 237.00 242.00 356.00
85220 Clotting, factor V (AcG or proaccelerin) 317.00 310.00 317.00 465.00
85230 Clotting, factor VII, proconvertin 242.00 237.00 242.00 356.00
85244 Clotting, factor VIII related Ag 314.00 307.00 314.00 461.00
85245 Clotting, factor VIII, ristocetin cofactor 733.00 717.00 733.00 1,076.00
85250 Clotting, factor IX 350.00 342.00 350.00 513.00
85260 Clotting, factor X (Stuart-Prower) 242.00 237.00 242.00 356.00
85270 Clotting, factor XI (PTA) 242.00 237.00 242.00 356.00
85280 Clotting, factor XII (Hageman) 591.00 578.00 591.00 867.00
85290 Clotting, factor XIII (fibrin stabilizing) 317.00 310.00 317.00 465.00
85301 Clotting anticoagulant, antithrombin III antigen 345.00 338.00 345.00 507.00
85302 Protein C, anticoagulant 431.00 422.00 431.00 633.00
85305 Protein S, anticoagulant 358.00 350.00 358.00 525.00
85362 Fibrinogen degradation (split) products (FDP) (FSP 591.00 578.00 591.00 867.00
85384 Fibrinogen activity 103.00 101.00 103.00 152.00
85390 Fibrinolysins or coagulopathy, screen 465.00 455.00 465.00 683.00
85460 HbF (Hemoglobin fetal) stain 213.00 208.00 213.00 312.00
85475 Hemolysin, acid, Ham test 280.00 274.00 280.00 411.00
85540 LAP (Leukocyte Alkaline Phosphatase) with count 317.00 310.00 317.00 465.00
85549 Muramidase 552.00 540.00 552.00 810.00
85557 Osmotic fragility 317.00 310.00 317.00 465.00
85576 Platelet aggregation 494.00 483.00 494.00 725.00
85597 Platelet neutralization 606.00 593.00 606.00 890.00
85610 PT (Prothrombin time) 43.00 42.00 43.00 63.00
85635 Reptilase test 213.00 208.00 213.00 312.00
85651 Sedimentation rate - blood 21.00 21.00 21.00 32.00
85670 TT (Thrombin time) - plasma 95.00 93.00 95.00 140.00
85730 PTT (Thromboplastin time) - plasma/blood 48.00 47.00 48.00 71.00
85810 Viscosity - blood 317.00 310.00 317.00 465.00
86000 Agglutinins, febrile, per test 128.00 125.00 128.00 188.00
86021 Leucocyte Ab 269.00 263.00 269.00 395.00
86022 Platelet Ab 557.00 545.00 557.00 818.00
86038 ANA (Antinuclear antibodies) 285.00 279.00 285.00 419.00
86060 ASL0 (Antistreptolysin 0), titer 155.00 152.00 155.00 228.00
86140 C-reactive protein 57.00 56.00 57.00 84.00
86147 Cardiolipin Ab 75.00 73.00 75.00 110.00
86155 Chemotaxis assay 1,490.00 1,458.00 1,490.00 2,187.00
86156 Cold agglutinin, screen 128.00 125.00 128.00 188.00
86157 Cold agglutinin, quantitative 128.00 125.00 128.00 188.00
86162 Complement total hemolytic activity 858.00 840.00 858.00 1,260.00
86171 Complement fixation 195.00 191.00 195.00 287.00
86225 DNA, native or double stranded, Ab 955.00 934.00 955.00 1,401.00
86235 ENA (Extractable nuclear Ag) Ab, any method (eg, nRNP, SS-A, SS-B, Sm, RNP, 133.00 130.00 133.00 195.00
Sc170, J01), each Ab
86255 Fluorescent noninfectious agent Ab, not otherwise specified 109.00 107.00 109.00 161.00
86300 CA 15.3 tumor antigen 53.00 52.00 53.00 78.00
86301 CA 19.9, tumor antigen 110.00 108.00 110.00 162.00
86304 CA 125 tumor antigen 48.00 47.00 48.00 71.00
86320 Immunoelectrophoresis - serum 335.00 328.00 335.00 492.00
86325 Immunoelectrophoresis - body fluids, excluding serum, eg, urine, CSF 95.00 93.00 95.00 140.00
86336 Inhibin - serum 260.00 254.00 260.00 381.00
86337 Insulin Ab 309.00 302.00 309.00 453.00
86341 Islet cell Ab 133.00 130.00 133.00 195.00
86344 Leukocyte phagocytosis 2,526.00 2,472.00 2,526.00 3,708.00
86353 Lymphocyte transformation 1,819.00 1,780.00 1,819.00 2,670.00
86359 T and B cell count 717.00 702.00 717.00 1,053.00
from
Abroad
)ILS(
86360 T cells absolute CD4 and CD8 count, including ratio 2,236.00 2,188.00 2,236.00 3,282.00
86376 Microsomal Ab, eg, thyroid or liver-kidney 306.00 299.00 306.00 449.00
86382 Virus neutralization test 366.00 358.00 366.00 537.00
86403 Agglutination, screen (latex, Rose Waller) 150.00 147.00 150.00 221.00
86406 Agglutination, particle, titer, each Ab 325.00 318.00 325.00 477.00
86431 Rheumatoid factor, qualitative/quantitative 128.00 125.00 128.00 188.00
86580 Skin test; tuberculosis, intradermal 68.00 67.00 68.00 101.00
86592 Syphilis test, VDRL, RPR, TPHA, FTA, ELISA 128.00 125.00 128.00 188.00
86619 Borrelia (relapsing fever) Ab 430.00 421.00 430.00 632.00
86644 CMV (cytomegalovirus) Ab 263.00 257.00 263.00 386.00
86648 Diphtheria Ab 213.00 208.00 213.00 312.00
86677 Helicobacter pylori Ab - Blood 53.00 52.00 53.00 78.00
86692 Hepatitis delta Ab 110.00 108.00 110.00 162.00
86703 HIV screening, central blood bank 0.00 0.00 0.00 0.00
86704 HBcAb (Hepatitis B core Antibody), total, IgG and IgM 64.00 63.00 64.00 95.00
86705 HBcAb (Hepatitis B core Ab) IgM 71.00 69.00 71.00 104.00
86706 HBsAb (Hepatitis B surface Ab) 35.00 34.00 35.00 51.00
86707 HBeAb (Hepatitis Be Ab) 89.00 87.00 89.00 131.00
86708 HAAb (Hepatitis A antibody), total, IgG and IgM 93.00 91.00 93.00 137.00
86709 HAAb (Hepatitis A Ab) IgM/IgG 115.00 113.00 115.00 170.00
86720 Leptospira Ab 195.00 191.00 195.00 287.00
86738 Mycoplasma Ab 269.00 263.00 269.00 395.00
86762 Rubella virus IgG and IgM 133.00 130.00 133.00 195.00
86778 Toxoplasma IgM 82.00 80.00 82.00 120.00
86789 West Nile virus IgG and IgM 421.00 412.00 421.00 618.00
86790 Virus/bacteria Ab, not otherwise specified 213.00 208.00 213.00 312.00
86800 Thyroglobulin Ab 325.00 318.00 325.00 477.00
86803 Hepatitis C Ab 38.00 37.00 38.00 56.00
86805 Lymphocytotoxicity assay, visual crossmatch; with titration 344.00 337.00 344.00 506.00
86813 HLA typing, A, B, C 1,773.00 1,735.00 1,773.00 2,603.00
86817 HLA typing, DR/DQ 2,293.00 2,244.00 2,293.00 3,366.00
86821 HLA typing, MLC (mixed lymphocyte culture) 2,293.00 2,244.00 2,293.00 3,366.00
86880 DAT (Direct Antiglobulin Test) / Coombs 155.00 152.00 155.00 228.00
86900 Blood typing, including RH 102.00 100.00 102.00 150.00
86901 Rh test 128.00 125.00 128.00 188.00
86903 Blood typing and Rh, Ab, screen 448.00 438.00 448.00 657.00
86904 Blood typing and Rh, Ab 891.00 872.00 891.00 1,308.00
86905 Blood typing; RBC antigens, other than ABO or Rh (D) 1,357.00 1,328.00 1,357.00 1,992.00
86940 Hemolysins and agglutinins, screen 465.00 455.00 465.00 683.00
87001 Animal inoculation, eg, tuberculosis 465.00 455.00 465.00 683.00
87040 Blood culture and susceptibility 95.00 93.00 95.00 140.00
87045 Feces culture 128.00 125.00 128.00 188.00
87070 Culture, other source, excluding blood/urine/feces 95.00 93.00 95.00 140.00
87081 Urine culture, nonquantitative 128.00 125.00 128.00 188.00
87086 Urine culture, quantitative 262.00 256.00 262.00 384.00
87088 Urine culture and susceptibility 147.00 144.00 147.00 216.00
87106 Fungi culture 128.00 125.00 128.00 188.00
87109 Mycoplasma culture 195.00 191.00 195.00 287.00
87110 Chlamydia culture 398.00 389.00 398.00 584.00
87116 Mycobacteria culture and identification 424.00 415.00 424.00 623.00
87118 Mycobacterial definitive identification, MTb 211.00 206.00 211.00 309.00
87140 Fluorescence or darkfield microscopy 128.00 125.00 128.00 188.00
87177 Ova and parasites, direct smear, identification - feces 95.00 93.00 95.00 140.00
87181 Susceptibility studies, antimicrobial agent, per agent 128.00 125.00 128.00 188.00
87190 Susceptibility studies, antimycobacterial agent, mycobacteria 288.00 282.00 288.00 423.00
87205 Smear interpretation, stain for bacteria, fungi, parasites or cell types 95.00 93.00 95.00 140.00
from
Abroad
)ILS(
87207 Smear, special stain for parasites 128.00 125.00 128.00 188.00
87250 Virus isolation, including nucleic acid identification, polymerase chain reaction, PCR 496.00 485.00 496.00 728.00
87252 Virus isolation, tissue culture 155.00 152.00 155.00 228.00

87253 Virus isolation and identification, tissue culture, any method 786.00 769.00 786.00 1,154.00
87278 Legionella Ag - urine 193.00 189.00 193.00 284.00
87299 Immunofluorescent study; not otherwise specified 269.00 263.00 269.00 395.00
87340 HBsAg (Hepatitis B surface Antigen), any method, including immunofluorescent 109.00 107.00 109.00 161.00
study
87350 HBeAg (Hepatitis Be Antigen), any method, including immunofluorescent study 89.00 87.00 89.00 131.00
87389 HIV Ab and P24 Ag, ELISA/EIA, at MOH recognized HIV laboratory 27.00 26.00 27.00 39.00
87449 Infectious agent Ag detection, not otherwise specified 447.00 437.00 447.00 656.00
87472 Bartonella henselae and Bartonella quintana, quantification 340.00 333.00 340.00 500.00
87517 Hepatitis B DNA/RNA, quantitative 606.00 593.00 606.00 890.00
87522 Hepatitis C DNA/RNA, quantitative 1,124.00 1,100.00 1,124.00 1,650.00
87536 HIV-1 DNA/RNA, quantitative 1,573.00 1,539.00 1,573.00 2,309.00
87539 HIV-2 DNA/RNA, quantitative 1,573.00 1,539.00 1,573.00 2,309.00
87556 Mycobacteria tuberculosis, AMTD 542.00 530.00 542.00 795.00
87590 Gonorrhoeae smear 0.00 0.00 0.00 0.00
87620 Papillomavirus (HPV) - tissue, including biopsy 2,235.00 2,187.00 2,235.00 3,281.00
87622 HPV (Human Papillomavirus) smear 466.00 456.00 466.00 684.00
88036 Necropsy (autopsy), limited, gross and/or microscopic; regional 786.00 769.00 786.00 1,154.00
88130 Sex chromatin identification, Barr bodies 155.00 152.00 155.00 228.00
88141 Pap smear, cervical/vaginal, cytopathology, including sampling 134.00 131.00 134.00 197.00
88160 Cytopathology examination and interpretation 213.00 208.00 213.00 312.00
88230 Karyotype, leukocyte culture 1,360.00 1,331.00 1,360.00 1,997.00
88233 Karyotype, tissue culture 1,753.00 1,715.00 1,753.00 2,573.00
88240 Cryopreservation of cells (eg, bone marrow), per year 1,705.00 1,668.00 1,705.00 2,502.00
88299 B &T cell receptor gene rearrangment analysis 1,272.00 1,245.00 1,272.00 1,868.00
88305 Histologic examination, microscopy and interpretation 213.00 208.00 213.00 312.00
88313 Bone marrow sampling and iron stain 494.00 483.00 494.00 725.00
88319 Histochemistry/cytochemistry stain for enzyme identification 213.00 208.00 213.00 312.00
88346 Immunofluorescent study, each Ab; direct method 1,151.00 1,126.00 1,151.00 1,689.00
88347 Immunofluorescent study, each Ab; indirect method 1,151.00 1,126.00 1,151.00 1,689.00
88348 EM (Electron microscopy), diagnostic 3,848.00 3,765.00 3,848.00 5,648.00
89051 Cell count - body fluids, eg, CSF, joint fluid, excluding blood 150.00 147.00 150.00 221.00
89258 Cryopreserved embryos storage for 5 years 786.00 769.00 786.00 1,154.00
89259 Cryopreservation, sperm, one year, up to 5 test tubes/straws 867.00 848.00 867.00 1,272.00
89280 Assisted oocyte fertilization, microtechnique 5,207.00 3,806.00 3,905.00 7,643.00
89290 Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre- 11,223.00 10,981.00 11,223.00 16,472.00
implantation genetic diagnosis)
89300 Semen analysis; presence and/or motility of sperm including Huhner test (post coital) 295.00 289.00 295.00 434.00
89320 Semen analysis, complete (volume, count, motility, and differential) 182.00 178.00 182.00 267.00
89325 Sperm Ab 288.00 282.00 288.00 423.00
90371 HBIg (Hepatitis B immune globulin), IM 4,964.00 4,857.00 4,964.00 7,286.00
90375 Rlg (Rabies immune globulin), IM and/or subcutaneous 3,392.00 3,319.00 3,392.00 4,979.00
90384 Rho(D) immune globulin (Rhlg), Anti-D 606.00 593.00 606.00 890.00
90585 BCG (Bacillus Calmette-Guerin) vaccine for tuberculosis 0.00 0.00 0.00 0.00
90586 BCG vaccine for bladder, live, for intravesical use, per treatment, including material 1,094.00 1,070.00 1,094.00 1,605.00
90749 Immunization for contagious diseases, not otherwise specified 128.00 125.00 128.00 188.00
90772 Subcutaneous/IM injection, therapeutic/prophylactic/diagnostic 44.00 43.00 44.00 65.00
90862 Psychiatric pharmacological management/review 130.00 127.00 130.00 191.00
90870 Electroconvulsive therapy 1,325.00 1,296.00 1,325.00 1,944.00
90880 Hypnotherapy 157.00 154.00 157.00 231.00
90889 Psychiatric medical opinion 726.00 710.00 726.00 1,065.00
from
Abroad
)ILS(
90901 Biofeedback training 478.00 468.00 478.00 702.00

90935 Hemodialysis procedure, per treatment 1,479.00 1,447.00 1,479.00 2,171.00
90945 Dialysis procedure other than hemodialysis (eg, peritoneal dialysis) 669.00 655.00 669.00 983.00
91010 Esophageal motility (manometric study) 1,330.00 1,301.00 1,330.00 1,952.00
91034 Esophagus, acid reflux test, with intraluminal pH electrode for dection of 1,330.00 1,301.00 1,330.00 1,952.00
gastroesophageal reflux; prolonged recording
91065 Breath hydrogen test (eg, for detection of lactase deficiency) 244.00 239.00 244.00 359.00
91122 Anorectal manometry 1,330.00 1,301.00 1,330.00 1,952.00
92004 Ophthalmological examination, initial 591.00 578.00 591.00 867.00
92065 Orthoptic evaluation and therapy 128.00 125.00 128.00 188.00
92081 Computerised visual field examination 198.00 194.00 198.00 291.00
92083 Visual field examination (eg, Goldmann visual fields) 155.00 152.00 155.00 228.00
92230 Fluorescein angioscopy, unilateral 838.00 820.00 838.00 1,230.00
92235 Fluorescein angioscopy, bilateral 1,155.00 1,130.00 1,155.00 1,695.00
92240 ICGI eye imaging, with interpretation and report 2,119.00 2,073.00 2,119.00 3,110.00
92250 Fundus photography, one eye 253.00 248.00 253.00 372.00
92270 Electro-oculography with interpretation and report 398.00 389.00 398.00 584.00
92275 Electroretinography with interpretation 919.00 899.00 919.00 1,349.00
92283 Color vision examination 155.00 152.00 155.00 228.00
92284 Dark adaptation examination with interpretation 465.00 455.00 465.00 683.00
92285 External eye photography, with interpretation and report 496.00 485.00 496.00 728.00
92286 Anterior segment photography, one eye 398.00 389.00 398.00 584.00
92287 Anterior segment photography, both eyes 595.00 582.00 595.00 873.00
92310 Contact lens fitting, including adjustment 128.00 125.00 128.00 188.00
92355 Fitting of telescopic lens system, age-related macular degeneration 179.00 175.00 179.00 263.00
92506 Evaluation of speech, language, voice 155.00 152.00 155.00 228.00
92507 Speech therapy, individual 151.00 148.00 151.00 222.00
92508 Speech therapy, group, per hour 128.00 125.00 128.00 188.00
92512 Rhinomanometry 244.00 239.00 244.00 359.00
92526 Feeding and swallowing therapy, per treatment 147.00 144.00 147.00 216.00
92541 Spontaneous nystagmus test, ENG (electronystagmography) 591.00 578.00 591.00 867.00
92551 Auditory test, screening 35.00 34.00 35.00 51.00
92557 Auditory test, comprehensive 213.00 208.00 213.00 312.00
92567 Tympanometry (impedance testing) 93.00 91.00 93.00 137.00
92568 Acoustic reflex testing 206.00 202.00 206.00 303.00
92585 Brain auditory evoked potentials, adult 752.00 736.00 752.00 1,104.00
92588 Brain evoked potentials, child 1,022.00 1,000.00 1,022.00 1,500.00
92590 Hearing aid fitting 285.00 279.00 285.00 419.00
92593 Hearing aid check/counseling, binaural 213.00 208.00 213.00 312.00
92601 Diagnostic analysis and programing of cochlear implant, binaural, under age 7 1,997.00 1,954.00 1,997.00 2,931.00
92602 Diagnostic analysis and subsequent programing of cochlear implant, monaural, under 649.00 635.00 649.00 953.00
age 7
92603 Diagnostic analysis and programing of cochlear implant, binaural, age 7 or over 1,997.00 1,954.00 1,997.00 2,931.00
92604 Diagnostic analysis and subsequent programing of cochlear implant, monaural, age 7 649.00 635.00 649.00 953.00
or over
92620 Central auditory function test(s) 425.00 416.00 425.00 624.00
92633 Auditory rehabilitation following cochlear implant 150.00 147.00 150.00 221.00
93000 ECG (Electrocardiogram), with interpretation and report 43.00 42.00 43.00 63.00
93012 CardioBeeper device loan 224.00 219.00 224.00 329.00
93015 Cardiovascular stress test 335.00 328.00 335.00 492.00
93224 ECG monitoring for 24 hours (Holter) 600.00 587.00 600.00 881.00
93295 Follow up of patient with defibrillator pacemaker, per year 450.00 440.00 450.00 660.00
93307 TTE (transthoracic echocardiography), adult 507.00 496.00 507.00 744.00
93312 TEE (transesophageal echocardiography) 1,917.00 1,876.00 1,917.00 2,814.00
93350 Effort or Dobutamine stress echocardiography (DSE) 1,196.00 1,170.00 1,196.00 1,755.00
93720 Pulmonary function tests, infant, plethysmography, with interpretation 3,677.00 3,598.00 3,677.00 5,397.00
93784 Blood pressure monitoring, for 24 hours 529.00 518.00 529.00 777.00
from
Abroad
)ILS(
93797 Cardiac rehabilitation, per month 986.00 965.00 986.00 1,448.00

93880 Cervical arteries duplex, bilateral 468.00 458.00 468.00 687.00
93923 Extremities arteries duplex, stress and rest 443.00 433.00 443.00 650.00
93925 Extremity arteries/bypass grafts duplex 468.00 458.00 468.00 687.00
93965 Peripheral vessels flow study (eg, Doppler) 195.00 191.00 195.00 287.00
93975 Abdomen, pelvis and retroperitoneal vessels duplex 443.00 433.00 443.00 650.00
93980 Penile vessels duplex, per patient 604.00 591.00 604.00 887.00
94010 Spirometry, simple 138.00 135.00 138.00 203.00
94060 Spirometry with bronchodilator 167.00 163.00 167.00 245.00
94070 Prolonged bronchi evaluation, methacholine or other chemical agent 979.00 958.00 979.00 1,437.00
94200 Maximal voluntary ventilation 65.00 64.00 65.00 96.00
94240 Functional residual volume, noble gas 700.00 685.00 700.00 1,028.00
94250 Expired gas collection, quantitative 349.00 341.00 349.00 512.00
94360 Resistance to airflow, plethysmographic method 600.00 587.00 600.00 881.00
94400 Breathing response to CO2 (CO2 response curve) 1,169.00 1,144.00 1,169.00 1,716.00
94620 Pulmonary stress test, simple, including pre- and post-spirometry 193.00 189.00 193.00 284.00
94621 Pulmonary stress testing, complex 1,479.00 1,447.00 1,479.00 2,171.00
94640 Inhalation treatment 44.00 43.00 44.00 65.00
94664 Demonstration of an aerosol/inhaler use 80.00 78.00 80.00 117.00
94667 Physiotherapy, lung patient, per treatment 151.00 148.00 151.00 222.00
94720 Carbon monoxide diffusing capacity 349.00 341.00 349.00 512.00
94760 Noninvasive ear or pulse oximetry for oxygen saturation 95.00 93.00 95.00 140.00
94762 Oxygen saturation, overnight oximetry 198.00 194.00 198.00 291.00
94772 Pulmonary function tests, passive, child 3,672.00 3,593.00 3,672.00 5,390.00
95004 Aeroallergens/food, up to 10 allergens, screen 150.00 147.00 150.00 221.00
95012 Nitric oxide determination - exhaled air, per patient 369.00 361.00 369.00 542.00
95028 Aeroallergens/food, 11 or over allergens, extended test 358.00 350.00 358.00 525.00
95044 Patch or application skin alergy test 194.00 190.00 194.00 285.00
95120 Allergen immunotherapy, normal allergen 211.00 206.00 211.00 309.00
95130 Allergen immunotherapy, pure allergen 435.00 426.00 435.00 639.00
95199 Susceptibility studies, antimicrobial agent; lymphocyte and serum 1,151.00 1,126.00 1,151.00 1,689.00
95810 Polysomnography, including EEG, adult 1,294.00 1,266.00 1,294.00 1,899.00
95812 EEG (Electroencephalogram) 465.00 455.00 465.00 683.00
95813 EEG (Electroencephalogram) extended monitoring 1,005.00 983.00 1,005.00 1,475.00
95822 EEG (Electroencephalogram), sleep 760.00 744.00 760.00 1,116.00
95830 EEG (Electroencephalogram), sphenoidal recording 832.00 814.00 832.00 1,221.00
95857 Tensilon test for myasthenia gravis 206.00 202.00 206.00 303.00
95861 EMG (electromyography) 280.00 274.00 280.00 411.00
95872 EMG (Electromyography) 804.00 787.00 804.00 1,181.00
95900 NCT (Nerve conduction test) 642.00 628.00 642.00 942.00
95922 Testing of autonomic nervous system function; vasomotor adrenergic innervation 558.00 546.00 558.00 819.00
(sympathetic adrenergic function), including beat-to-beat blood pressure and R-R
interval changes during Valsalva maneuver and at least five minutes of passive tilt
95923 Electrolyte concentration determination, sweat imprint 155.00 152.00 155.00 228.00
95930 VEP (visual evoked potential), adult 752.00 736.00 752.00 1,104.00
95950 EEG (electroencephalogram), 24 hours 2,264.00 2,215.00 2,264.00 3,323.00
95990 Refilling and maintenance of implantable pump or reservoir for drug delivery, spinal 1,024.00 1,002.00 1,024.00 1,503.00
(intrathecal, epidural) or brain (intraventricular)
96001 Computerized three dimensional motion and walking analysis, per patient 4,323.00 4,230.00 4,323.00 6,345.00
96567 PDT (Photodynamic therapy), dermal lesions, nonsolar keratosis 1,051.00 1,028.00 1,051.00 1,542.00
96910 Phototherapy by UVB and tar/petrolatum 154.00 151.00 154.00 227.00
96912 Photochemotherapy by PUVA, including psoralens 182.00 178.00 182.00 267.00
97001 Physiotherapy, evaluation and treatment planning, adult 243.00 238.00 243.00 357.00
97003 Occupational therapy, evaluation and treatment planning, adult 243.00 238.00 243.00 357.00
97113 Aquatic physiotherapy/rehabilitation, individual, hydrotherapy 235.00 230.00 235.00 345.00
97140 Physiotherapy, individual 151.00 148.00 151.00 222.00
from
Abroad
)ILS(
97150 Physiotherapy/rehabilitation, group, 4 or more individuals, including child, per 44.00 43.00 44.00 65.00
individual
97530 Occupational therapy, individual 151.00 148.00 151.00 222.00
97750 Physical performance test or measurement (eg, musculoskeletal, functional capacity), 717.00 702.00 717.00 1,053.00
with written report, eg, evaluation of pressure on sole
97802 Medical nutrition counseling and therapy 150.00 147.00 150.00 221.00
97810 Acupuncture 213.00 208.00 213.00 312.00
99001 Histopathology slides preparation for shipment 340.00 333.00 340.00 500.00
99002 Histopathology slides preparation in Israel 494.00 483.00 494.00 725.00
99075 Forensic medical opinion 1,997.00 1,954.00 1,997.00 2,931.00
99080 Medical opinion 733.00 717.00 733.00 1,076.00
99183 Elective hyperbaric oxygen therapy, per treatment, up to 2 hours 1,025.00 1,003.00 1,025.00 1,505.00
99195 Phlebotomy 150.00 147.00 150.00 221.00
99212 Follow up allergy testing after 95028 128.00 125.00 128.00 188.00
99214 Post hospitalization examination 0.00 0.00 0.00 0.00
99223 Pre-operation evaluation, serial tests 970.00 949.00 970.00 1,424.00
99242 Physician examination, excluding tests with specific code 279.00 147.00 150.00 410.00
99283 ER visit, global payment 910.00 890.00 910.00 1,335.00
99315 Clinic nurse service, up to 30 minutes 88.00 86.00 88.00 129.00
99316 Clinic nurse service, over 30 minutes (eg, guidance for patient with stoma) 185.00 181.00 185.00 272.00
99362 Multidisciplinary team examination 591.00 578.00 591.00 867.00
99371 Telephonic consultation for poisoning/medication information/teratology 232.00 227.00 232.00 341.00
99600 Home visit, care worker 202.00 198.00 202.00 297.00
C0443 Release of carpal tunnel, in surgical day care 2,222.00 2,174.00 2,222.00 3,261.00
C0449 Peripheral nerve decompression/lysis of adhesions, excluding endoneurolysis, in 4,328.00 4,235.00 4,328.00 6,353.00
surgical day care
C0460 Peripheral nerve transposition, eg, ulnar nerve, in surgical day care 4,328.00 4,235.00 4,328.00 6,353.00
C0476 Peripheral nerve repair, old traumatic injury, eg, ulnar nerve, in surgical day care 4,328.00 4,235.00 4,328.00 6,353.00
C0492 Implantation of sacral nerve stimulation electrode/lead, excluding for chronic pain 7,090.00 6,937.00 7,090.00 10,406.00
management, in surgical day care, excluding device cost
C0494 Implantation of temporary spinal cord/root/peripheral nerve stimulation lead(s) for 4,912.00 4,806.00 4,912.00 7,209.00
chronic pain management, in surgical day care, excluding device cost
C0495 Implantation of permanent spinal cord/root/peripheral nerve stimulation lead(s) and 9,187.00 8,989.00 9,187.00 13,484.00
generator for chronic pain management, in surgical day care, excluding device cost
C0496 Replacement of permanent spinal cord/root/peripheral nerve stimulation generator for 4,912.00 4,806.00 4,912.00 7,209.00
chronic pain management, in surgical day care, excluding device cost
C0670 Excision of thyroglossal/branchial cleft cyst/sinus, in surgical day care 4,328.00 4,235.00 4,328.00 6,353.00
C0823 Excision of lesion(s) and/or tissue of eyelid, excluding chalazion, in surgical day care 4,328.00 4,235.00 4,328.00 6,353.00
C0849 Repair of eyelid position, excluding complex repair, in surgical day care 4,328.00 4,235.00 4,328.00 6,353.00
C0870 Reconstruction of eyelid, in surgical day care 4,328.00 4,235.00 4,328.00 6,353.00
C0889 Repair of eyelid position, complex, in surgical day care 4,328.00 4,235.00 4,328.00 6,353.00
C0920 Lacrimal system operation, excluding fistulization, in surgical day care 4,328.00 4,235.00 4,328.00 6,353.00
C1000 Conjunctiva operation, excluding removal of superficial foreign body, in surgical day 4,328.00 4,235.00 4,328.00 6,353.00
care
C1139 Excision of pterygium, without graft, in surgical day care 4,328.00 4,235.00 4,328.00 6,353.00
C1511 Extraocular muscle(s) operation for strabismus repair, in surgical day care 4,328.00 4,235.00 4,328.00 6,353.00
C1985 Focused US treatment of bone metastasis, MRI guidance, in surgical day care 33,722.00 32,996.00 33,722.00 49,494.00
C2169 Turbinectomy, in surgical day care 4,328.00 4,235.00 4,328.00 6,353.00
C2189 Nose operation/rhinoplasty, in surgical day care 4,328.00 4,235.00 4,328.00 6,353.00
C2220 Intranasal antrotomy, excluding FESS, in surgical day care 4,328.00 4,235.00 4,328.00 6,353.00
C2840 Excision of tonsil tag/lingual tonsil or adenoidectomy without tonsillectomy, in 5,875.00 5,749.00 5,875.00 8,624.00
surgical day care
C3143 Laryngoscopy with biopsy, in surgical day care 4,328.00 4,235.00 4,328.00 6,353.00
C3321 Bronchoscopy through artificial stoma, in surgical day care 4,328.00 4,235.00 4,328.00 6,353.00
C3324 Bronchoscopy with biopsy, in surgical day care 4,328.00 4,235.00 4,328.00 6,353.00
from
Abroad
)ILS(
C4011 Biopsy of lymphatic structure, in surgical day care 4,328.00 4,235.00 4,328.00 6,353.00
C4021 Excision of lymph node(s), excluding internal mammary, in surgical day care 4,328.00 4,235.00 4,328.00 6,353.00
C4911 Anal fistulotomy/fistulectomy under general anesthesia, in surgical day care 4,328.00 4,235.00 4,328.00 6,353.00
C4943 Destruction of hemorrhoids by cauterization/cryotherapy, in surgical day care 4,328.00 4,235.00 4,328.00 6,353.00
C4945 Ligation of hemorrhoids, in surgical day care 7,717.00 7,551.00 7,717.00 11,327.00
C5011 Biopsy of liver, needle; percutaneous, not using CT/MRI guidance, in surgical day 4,328.00 4,235.00 4,328.00 6,353.00
care
C5349 Umbilical hernia repair, up to 5 years of age, in surgical day care 4,328.00 4,235.00 4,328.00 6,353.00
C5810 Urethral meatotomy, in surgical day care 4,328.00 4,235.00 4,328.00 6,353.00
C5860 Dilation of urethra, in surgical day care 4,328.00 4,235.00 4,328.00 6,353.00
C6120 Excision of lesion(s) and/or hydrocele and/or varicocele of tunica vaginalis/spermatic 4,328.00 4,235.00 4,328.00 6,353.00
cord, in surgical day care
C6212 Micro TESE (Microsurgical Testicular Sperm Extraction), in surgical day care 12,200.00 11,937.00 12,200.00 17,906.00
C6250 Orchiopexy, in surgical day care 4,328.00 4,235.00 4,328.00 6,353.00
C6420 Excision/destruction of lesion(s) and/or tissue of penis under general anesthesia, in 4,328.00 4,235.00 4,328.00 6,353.00
surgical day care
C6720 Biopsy/conization of cervix, excluding by cauterization/cryosurgery, in surgical day 4,328.00 4,235.00 4,328.00 6,353.00
care
C6739 Excision of lesion(s) of cervix, including by cauterization/cryosurgery, in surgical day 4,328.00 4,235.00 4,328.00 6,353.00
care
C6759 Cerclage/repair of uterine cervix, in surgical day care 4,328.00 4,235.00 4,328.00 6,353.00
C7011 Hymenotomy/hymenectomy, in surgical day care 4,328.00 4,235.00 4,328.00 6,353.00
C7024 Biopsy/excision/destruction of lesion(s) of vagina, in surgical day care 4,328.00 4,235.00 4,328.00 6,353.00
C7129 Bartholin's gland/cyst operation under general anesthesia, in surgical day care 4,328.00 4,235.00 4,328.00 6,353.00
C7609 SARPE (Surgically Assisted Rapid Palatal Expansion), in surgical day care 8,912.00 8,720.00 8,912.00 13,080.00
C7744 Biopsy of bone/arthrotomy of hand/foot and finger(s)/toe(s), in surgical day care 4,328.00 4,235.00 4,328.00 6,353.00
C7752 Bunion (eg, hallux valgus) surgery, excluding hammer toe, in surgical day care 9,651.00 9,443.00 9,651.00 14,165.00
C7753 Bunion (eg, hallux valgus) surgery with hammer toe surgery, in surgical day care 16,578.00 16,221.00 16,578.00 24,332.00
C7756 Hammer toe surgery, in surgical day care 9,349.00 9,148.00 9,349.00 13,722.00
C7860 Removal of implanted device from bone, excluding face/hand/foot, in surgical day 4,328.00 4,235.00 4,328.00 6,353.00
care
C8044 Capsulotomy of hand/foot and finger(s)/toe(s), in surgical day care 4,328.00 4,235.00 4,328.00 6,353.00
C8149 Ankle ligament reconstruction, in surgical day care 11,941.00 11,684.00 11,941.00 17,526.00
C8201 Tendon sheath incision, in surgical day care 4,328.00 4,235.00 4,328.00 6,353.00
C8313 Tenotomy, excluding of hand, in surgical day care 4,328.00 4,235.00 4,328.00 6,353.00
C8331 Excision of lesion(s) of tendon sheath, in surgical day care 4,328.00 4,235.00 4,328.00 6,353.00
C8350 Excision of bursa, in surgical day care 4,328.00 4,235.00 4,328.00 6,353.00
C8611 Biopsy of subcutaneous tissue under general anesthesia, in surgical day care 4,328.00 4,235.00 4,328.00 6,353.00
C8630 Excision/destruction of lesions of skin and subcutaneous tissue, 4 or more, in surgical 4,328.00 4,235.00 4,328.00 6,353.00
day care
C8660 Free skin grafting, including excision of skin for autogenous graft, in surgical day care 4,328.00 4,235.00 4,328.00 6,353.00
C8689 Repair and reconstruction of skin and subcutaneous tissue, in surgical day care 4,328.00 4,235.00 4,328.00 6,353.00
C8694 Implantation of sacral nerve stimulation generator, excluding for chronic pain 2,687.00 2,629.00 2,687.00 3,944.00
management, in surgical day care, excluding device cost
C9802 Esophagoscopy for removal of foreign body, in surgical day care 4,328.00 4,235.00 4,328.00 6,353.00
C999C Surgical hospital day care, excluding procedures with specific code 4,328.00 4,235.00 4,328.00 6,353.00
D0210 Intra oral radiograph - complete series 405.00 396.00 405.00 594.00
D0220 Intraoral - periapical first radiographic image 44.00 43.00 44.00 65.00
D0230 Intraoral - periapical each additional radiographic image 44.00 43.00 44.00 65.00
D0240 Intraoral - occlusal radiographic image 95.00 93.00 95.00 140.00
D0330 Panoramic radiographic image 358.00 350.00 358.00 525.00
D1201 Application of fluoride, complete 112.00 110.00 112.00 165.00
D1351 Sealant, per tooth 167.00 163.00 167.00 245.00
D1510 Space maintainer, fixed 839.00 821.00 839.00 1,232.00
D2140 Restoration - one surface, local anesthesia 283.00 277.00 283.00 416.00
D2150 Restoration -2/more surfaces, any material 358.00 350.00 358.00 525.00
D2330 Resin-based composite restoration - one surface, anterior 481.00 471.00 481.00 707.00
from
Abroad
)ILS(
D2335 Resin-based composite restoration, anterior 598.00 585.00 598.00 878.00

D2390 Resin-based composite restoration - crown 518.00 507.00 518.00 761.00
D2752 Crown - porcelain fused to noble metal 3,053.00 2,987.00 3,053.00 4,481.00
D2950 Core build-up, including any pins 984.00 963.00 984.00 1,445.00
D2952 Post and core in addition to crown 1,437.00 1,406.00 1,437.00 2,109.00
D2980 Crown repair 280.00 274.00 280.00 411.00
D3220 Pulpotomy, primary/permanent tooth 263.00 257.00 263.00 386.00
D3230 Pulpal therapy, resorbable filling - primary tooth, excluding final restoration 518.00 507.00 518.00 761.00
D3310 Root canal therapy - anterior, excluding final restoration 1,065.00 1,042.00 1,065.00 1,563.00
D3320 Root canal therapy - bicuspid, excluding final restoration 1,065.00 1,042.00 1,065.00 1,563.00
D3330 Root canal therapy - molar, excluding final restoration 1,065.00 1,042.00 1,065.00 1,563.00
D3351 Apexification 429.00 420.00 429.00 630.00
D3410 Apicoectomy, anterior, including placement of retrograde filling material 1,067.00 1,044.00 1,067.00 1,566.00
D3421 Apicoectomy - bicuspid, including placement of retrograde filling material 1,334.00 1,305.00 1,334.00 1,958.00
D3425 Apicoectomy - molar, including placement of retrograde filling material 2,264.00 2,215.00 2,264.00 3,323.00
D3450 Root amputation 1,334.00 1,305.00 1,334.00 1,958.00
D3920 Hemisection 932.00 912.00 932.00 1,368.00
D4240 Gingival flap, with root planing, per quadrant 917.00 897.00 917.00 1,346.00
D4249 Clinical crown lengthening 853.00 835.00 853.00 1,253.00
D4260 Osseous surgery, including flap entry and closure, per quadrant 1,176.00 1,151.00 1,176.00 1,727.00
D4341 Periodontal scaling and root planing, per meeting, 30 minutes 155.00 152.00 155.00 228.00
D5110 Complete acrylic denture - pair 8,928.00 8,736.00 8,928.00 13,104.00
D5213 Partial denture 8,226.00 8,049.00 8,226.00 12,074.00
D5730 Reline denture (chairside) 953.00 932.00 953.00 1,398.00
D5750 Reline denture - laboratory 2,351.00 2,300.00 2,351.00 3,450.00
D5951 Feeding aid; feeding prosthesis 739.00 723.00 739.00 1,085.00
D5952 Speech aid prosthesis, pediatric 739.00 723.00 739.00 1,085.00
D6010 Surgical placement of dental implant body: endosteal implant, includes placement of 4,105.00 4,017.00 4,105.00 6,026.00
healing cap
D6056 Prefabricated abutment for dental implant 2,564.00 2,509.00 2,564.00 3,764.00
D7111 Extraction, coronal remnants - deciduous tooth 282.00 276.00 282.00 414.00
D7140 Extraction, erupted tooth or exposed root, single 282.00 276.00 282.00 414.00
D7141 Extraction, erupted tooth or exposed root, second in the same session 206.00 202.00 206.00 303.00
D7142 Extraction, erupted tooth or exposed root, each additional tooth in the same session 140.00 137.00 140.00 206.00
D7210 Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and 291.00 285.00 291.00 428.00
removal of bone and/or section of tooth
D7220 Removal of impacted tooth - soft tissue 667.00 653.00 667.00 980.00
D7230 Removal of impacted tooth - partially bony 932.00 912.00 932.00 1,368.00
D7240 Removal of impacted tooth - completely bony 932.00 912.00 932.00 1,368.00
D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth 679.00 664.00 679.00 996.00
and/or alveolus
D7280 Exposure of impacted/unerupted tooth for orthodontic reasons, including orthodontic 932.00 912.00 932.00 1,368.00
attachments
D7320 Alveoloplasty not in conjunction with extractions - per quadrant 686.00 671.00 686.00 1,007.00
D7340 Vestibuloplasty - ridge extension (secondary epithelialization) 913.00 893.00 913.00 1,340.00
D7450 Removal of odontogenic cyst 686.00 671.00 686.00 1,007.00
D7950 Bone graft to maxilla/mandible, unilateral 11,715.00 11,463.00 11,715.00 17,195.00
D7952 Open sinus augmentation, including bone graft, unilateral 5,542.00 5,423.00 5,542.00 8,135.00
D7960 Frenulectomy (frenectomy or frenotomy) 667.00 653.00 667.00 980.00
D7993 Bone graft to maxilla/mandible, bilateral 17,855.00 17,471.00 17,855.00 26,207.00
D7994 Open sinus augmentation, including bone graft, bilateral 10,605.00 10,377.00 10,605.00 15,566.00
D8050 Interceptive orthodontic therapy, including chin cup 1,794.00 1,755.00 1,794.00 2,633.00
D8080 Comprehensive orthodontic treatment of the adolescent dentition, for one year, up to 3 4,751.00 4,649.00 4,751.00 6,974.00
years
D8089 Follow up code of D8080, established adolescent patient for comprehensive 0.00 0.00 0.00 0.00
orthodontic treatment
from
Abroad
)ILS(
D8210 Removable dental appliance therapy 953.00 932.00 953.00 1,398.00

D8998 Orthodontic treatment preparatory to, and accompanying, orthognathic surgery, per 22,905.00 22,412.00 22,905.00 33,618.00
patient
D8999 Orthodontic preparation for orthognathic face mask 1,794.00 1,755.00 1,794.00 2,633.00
D9110 Emergency treatment of dental pain 198.00 194.00 198.00 291.00
D9220 Deep sedation/general anesthesia, for dental procedure - first hour 1,410.00 1,380.00 1,410.00 2,070.00
D9221 Deep sedation/general anesthesia, for complex dental procedure - more than one hour 1,597.00 1,563.00 1,597.00 2,345.00
D9230 Analgesia, including nitrous, excluding dental treatment 262.00 256.00 262.00 384.00
J0011 Costeff syndrome, Methylglutaconic aciduria, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J0021 Adrenoleukodystrophy X-linked, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J0031 Canavan disease, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J0041 Carnitine Palmitoyl Tranferase, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J0051 Cystinuria, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J0061 Glycogen storage disease type 1, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J0071 Hyperglycinemia, nonketotic, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J0081 Hyperoxaluria, primary, type 1, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J0091 Isovalericacidemia, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J0101 Lipoamide Dehydrogenase Deficiency, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J0111 Maple syrup urine disease, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J0121 Methylmalonicaciduria, mutase deficiency, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J0131 Molybdenum cofactor deficiency, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J0141 Peroxysomal disorders, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J0151 Phenylketonuria, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J0161 Thiamine-responsive megaloblastic anemia, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J0171 Tyrosinemia, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J0181 VLCAD (Very Long Chain Acyl CoA Dehydrogenase) deficiency, molecular 515.00 504.00 515.00 756.00
diagnostics, special case
J0191 Wilson disease, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J0201 Xanthinuria, type I, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J0211 CTX (Cerebrotendinous xanthomatosis), molecular diagnostics, special case 515.00 504.00 515.00 756.00
J0221 Hypercholesterolemia, familial, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J0232 Lysosomal acid phosphatase deficiency, biochemical diagnostics 1,462.00 1,431.00 1,462.00 2,147.00
J0241 Aspartylglucosaminuria, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J0242 Aspartylglucosaminuria, biochemical diagnostics 1,462.00 1,431.00 1,462.00 2,147.00
J0251 Ceroid lipofuscinosis, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J0252 Ceroid lipofuscinosis, biochemical diagnostics 1,462.00 1,431.00 1,462.00 2,147.00
J0262 Cholesteryl ester storage disease, biochemical diagnostics 1,462.00 1,431.00 1,462.00 2,147.00
J0272 Cystinosis, nephropathic, biochemical diagnostics 1,462.00 1,431.00 1,462.00 2,147.00
J0281 Fabry disease, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J0282 Fabry disease, biochemical diagnostics 1,462.00 1,431.00 1,462.00 2,147.00
J0292 Free sialic acid storage disease, biochemical diagnostics 1,462.00 1,431.00 1,462.00 2,147.00
J0302 Fucosidosis, biochemical diagnostics 1,462.00 1,431.00 1,462.00 2,147.00
J0312 GM1 gangliosidosis, biochemical diagnostics 1,462.00 1,431.00 1,462.00 2,147.00
J0322 Galactosialidosis, biochemical diagnostics 1,462.00 1,431.00 1,462.00 2,147.00
J0331 Gaucher disease, molecular diagnostics, special case 665.00 651.00 665.00 977.00
J0332 Gaucher disease, biochemical diagnostics 1,462.00 1,431.00 1,462.00 2,147.00
J0341 Glycogen storage disease type 2, Pompe, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J0342 Glycogen storage disease type 2, Pompe, biochemical diagnostics 1,462.00 1,431.00 1,462.00 2,147.00
J0351 Ichthyosis, X-linked, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J0352 Ichthyosis, X-linked, biochemical diagnostics 1,462.00 1,431.00 1,462.00 2,147.00
J0361 Krabbe disease, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J0362 Krabbe disease, biochemical diagnostics 1,462.00 1,431.00 1,462.00 2,147.00
J0372 Mannosidosis, alpha, biochemical diagnostics 1,462.00 1,431.00 1,462.00 2,147.00
J0382 Mannosidosis, beta, biochemical diagnostics 1,462.00 1,431.00 1,462.00 2,147.00
J0392 Maroteaux-Lamy syndrome, biochemical diagnostics 1,462.00 1,431.00 1,462.00 2,147.00
J0400 MLD (Metachromatic Leukodystrophy), pseudo deficiency, molecular diagnostics 665.00 651.00 665.00 977.00
from
Abroad
)ILS(
J0401 MLD (Metachromatic Leukodystrophy), molecular diagnostics, special case 515.00 504.00 515.00 756.00
J0402 MLD (Metachromatic Leukodystrophy), biochemical diagnostics 1,462.00 1,431.00 1,462.00 2,147.00
J0412 Mucolipidosis II, biochemical diagnostics 3,333.00 3,261.00 3,333.00 4,892.00
J0421 Mucolipidosis III, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J0422 Mucolipidosis III, biochemical diagnostics 3,333.00 3,261.00 3,333.00 4,892.00
J0431 Mucolipidosis IV, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J0442 Mucopolysaccharidosis II, biochemical diagnostics 1,462.00 1,431.00 1,462.00 2,147.00
J0452 Mucopolysaccharidosis IV, biochemical diagnostics 1,462.00 1,431.00 1,462.00 2,147.00
J0462 Mucopolysaccharidosis I, biochemical diagnostics 1,462.00 1,431.00 1,462.00 2,147.00
J0472 Mucopolysaccharidosis VII, biochemical diagnostics 1,462.00 1,431.00 1,462.00 2,147.00
J0482 Multiple sulfatase deficiency, biochemical diagnostics 3,333.00 3,261.00 3,333.00 4,892.00
J0491 Niemann-Pick disease, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J0492 Niemann-Pick disease, biochemical diagnostics 1,462.00 1,431.00 1,462.00 2,147.00
J0501 Niemann-Pick disease type C, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J0502 Niemann-Pick disease type C, biochemical diagnostics 4,978.00 4,871.00 4,978.00 7,307.00
J0511 Pycnodysostosis, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J0512 Pycnodysostosis, biochemical diagnostics 1,462.00 1,431.00 1,462.00 2,147.00
J0522 Salla disease, biochemical diagnostics 1,462.00 1,431.00 1,462.00 2,147.00
J0532 Sanfilippo syndrome, biochemical diagnostics 3,333.00 3,261.00 3,333.00 4,892.00
J0542 Schindler disease, biochemical diagnostics 1,462.00 1,431.00 1,462.00 2,147.00
J0552 Sialidosis, biochemical diagnostics 1,462.00 1,431.00 1,462.00 2,147.00
J0561 Tay Sachs, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J0562 Tay Sachs, biochemical diagnostics 1,462.00 1,431.00 1,462.00 2,147.00
J0572 Wolman disease, biochemical diagnostics 1,462.00 1,431.00 1,462.00 2,147.00
J0581 Mitochondrial disorder, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J0582 Mitochondrial disorder, biochemical diagnostics
J0591 Deafness, mitochondrial, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J0600 Kearns Sayre Syndrome, KSS, molecular diagnostics 1,216.00 1,190.00 1,216.00 1,785.00
J0610 Leber Optic Atrophy, LHON, molecular diagnostics 665.00 651.00 665.00 977.00
J0621 Leigh syndrome, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J0622 Leigh syndrome, biochemical diagnostics
J0631 Mitochondrial myopathy, Encephalopathy, Lactic Acidosis and Stroke-like episodes, 665.00 651.00 665.00 977.00
MELAS, molecular diagnostics, special case
J0641 Myoclonic Epilepsy with Ragged Red Fibers, MERFF, molecular diagnostics, special 1,216.00 1,190.00 1,216.00 1,785.00
case
J0651 Mitochondrial depletion syndrome, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J0652 Mitochondrial depletion syndrome, biochemical diagnostics
J0661 Alzheimer, early onset/familial, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J0671 Ataxia Telangiectasia, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J0673 Ataxia Telangiectasia, cytogenetic diagnostics 3,756.00 3,675.00 3,756.00 5,513.00
J0681 Charcot-Marie-Tooth neuropathy, molecular diagnostics, special case 1,051.00 1,028.00 1,051.00 1,542.00
J0691 Creutzfeldt-Jakob disease, familial, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J0701 Duchenne, Becker muscular dystrophy, molecular diagnostics, special case 7,338.00 7,180.00 7,338.00 10,770.00
J0710 Familial dysautonomia, molecular diagnostics 332.00 325.00 332.00 488.00
J0720 Dystonia, torsion, molecular diagnostics 665.00 651.00 665.00 977.00
J0730 Facioscapulohumeral muscular dystrophy-1A, molecular diagnostics 1,051.00 1,028.00 1,051.00 1,542.00
J0740 Hereditary Nerve Pressure Palsy, HNPP, molecular diagnostics 1,216.00 1,190.00 1,216.00 1,785.00
J0750 Huntington disease, molecular diagnostics 1,216.00 1,190.00 1,216.00 1,785.00
J0761 Inclusion body myopathy, autosomal recessive, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J0771 Insensitivity to pain, congenital, with anhidrosis, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J0781 LGMD (Limb girdle muscular dystrophy), dysferlin deficiency, molecular diagnostics, 515.00 504.00 515.00 756.00
special case
J0790 Myotonic dystrophy, molecular diagnostics 1,216.00 1,190.00 1,216.00 1,785.00
J0801 Neurofibromatosis, type 1, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J0810 Oculopharyngeal muscular dystrophy, molecular diagnostics 1,216.00 1,190.00 1,216.00 1,785.00
from
Abroad
)ILS(
J0820 SMA (Spinal Muscular Atrophy), molecular diagnostics 1,216.00 1,190.00 1,216.00 1,785.00
J0830 Spinocerebellar ataxia due to an expansion including Friedrich ataxia, molecular 1,216.00 1,190.00 1,216.00 1,785.00
diagnostics
J0840 Adenomatous polyposis coli, molecular diagnostics 5,902.00 5,775.00 5,902.00 8,663.00
J0841 Adenomatous polyposis coli, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J0850 Multiple endocrine neoplasia 2A, molecular diagnostics 1,330.00 1,301.00 1,330.00 1,952.00
J0851 Multiple endocrine neoplasia 2A, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J0860 Retinoblastoma, molecular diagnostics 5,902.00 5,775.00 5,902.00 8,663.00
J0861 Retinoblastoma, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J0870 Von Hippel-Lindau, molecular diagnostics 1,082.00 1,059.00 1,082.00 1,589.00
J0871 Von Hippel-Lindau, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J0881 Adrenal hyperplasia, congenital, 11-beta-hydroxylase deficiency, molecular 515.00 504.00 515.00 756.00
J0891 Adrenal hyperplasia, congenital, 17-alpha-hydroxylase deficiency, molecular 515.00 504.00 515.00 756.00
J0901 Adrenal hyperplasia, congenital, 21-hydroxylase deficiency, molecular diagnostics, 515.00 504.00 515.00 756.00
special case
J0911 Adrenal hypoplasia, congenital, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J0921 Pendred syndrome, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J0931 Persistent hyperinsulinemic hypoglycemia of infancy, molecular diagnostics, special 515.00 504.00 515.00 756.00
case
J0941 Combined factor V and VII deficiency, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J0951 Factor V deficiency, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J0961 Factor VII deficiency, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J0971 Factor XI deficiency, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J0981 Factor XIIIA deficiency, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J0991 Fanconi anemia, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J0993 Fanconi anemia, cytogenetic diagnostics 3,756.00 3,675.00 3,756.00 5,513.00
J1001 Hemoglobinopathies alpha, alpha thalassemias, molecular diagnostics, special case 1,561.00 1,527.00 1,561.00 2,291.00
J1011 Hemoglobinopathies beta, beta thalassemias, molecular diagnostics, special case 1,561.00 1,527.00 1,561.00 2,291.00
J1021 Hemophilia A, factor VIII deficiency, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J1031 Hemophilia B, factor IX deficiency, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J1040 Achondroplasia/thanatophoric dwarfism, molecular diagnostics 515.00 504.00 515.00 756.00
J1051 Achromatopsia, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J1061 Albinism, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J1070 Angelman syndrome/Prader Willi, molecular diagnostics 1,051.00 1,028.00 1,051.00 1,542.00
J1081 Autoimmune polyglandular disease, type I, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J1091 Bardet-Biedl syndrome, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J1100 Beckwith-Wiedemann syndrome, molecular diagnostics 1,051.00 1,028.00 1,051.00 1,542.00
J1111 Bloom syndrome, molecular diagnostics, special case 332.00 325.00 332.00 488.00
J1113 Bloom syndrome, cytogenetic diagnostics 3,756.00 3,675.00 3,756.00 5,513.00
J1121 Cockayne syndrome, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J1122 Cockayne syndrome, biochemical diagnostics 4,978.00 4,871.00 4,978.00 7,307.00
J1131 Craniosynostosis, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J1140 Cystic fibrosis, molecular diagnostics 665.00 651.00 665.00 977.00
J1151 Deafness, congenital, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J1161 Epidermolysis Bullosa, congenital, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J1171 Osteopetrosis, recessive, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J1181 Polycystic kidneys, dominant, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J1191 Polycystic kidneys, recessive, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J1203 Roberts syndrome, cytogenetic diagnostics 3,756.00 3,675.00 3,756.00 5,513.00
J1211 Tuberous sclerosis, molecular diagnostics, special case 515.00 504.00 515.00 756.00
J1222 Xeroderma pigmentosum, biochemical diagnostics 4,978.00 4,871.00 4,978.00 7,307.00
J1233 DiGeorge/velocardiofacial syndrome, FISH, cytogenetic diagnostics 1,573.00 1,539.00 1,573.00 2,309.00
J1243 Rubinstein-Taybi syndrome, FISH, cytogenetic diagnostics 1,573.00 1,539.00 1,573.00 2,309.00
J1253 Smith-Magenis syndrome, FISH, cytogenetic diagnostics 1,573.00 1,539.00 1,573.00 2,309.00
from
Abroad
)ILS(
J1263 Williams syndrome, FISH, cytogenetic diagnostics 1,573.00 1,539.00 1,573.00 2,309.00
J1270 Amplicon sequencing, price per each additional amplicon 187.00 183.00 187.00 275.00
J1271 FMF, molecular diagnostics, special case 665.00 651.00 665.00 977.00
J1280 Amplicon sequencing, price for single/first amplicon 367.00 359.00 367.00 539.00
J1311 BRCA1/BRCA2 founder mutation, breast/ovarian cancer, per patient 621.00 608.00 621.00 912.00
J1312 BRCA1/BRCA2 somatic mutations, breast/ovarian cancer 4,028.00 3,941.00 4,028.00 5,912.00
J3001 Familial known mutation, molecular diagnostics 515.00 504.00 515.00 756.00
J8003 Karyotype, cytogenetic diagnostics - chorionic villus 2,353.00 2,302.00 2,353.00 3,453.00
J8830 Rapid aneuploidy detection, quantitative fluorescent PCR - amniotic fluid/chorionic 1,155.00 1,130.00 1,155.00 1,695.00
villus
J8831 Newborn screening for immunodeficiency, including SCID (Severe Combined 41.00 40.00 41.00 60.00
Immunodeficiency)
J8891 Prenatal molecular diagnostics, basic 1,698.00 1,661.00 1,698.00 2,492.00
J9001 Prenatal molecular diagnostics, complex 2,484.00 2,431.00 2,484.00 3,647.00
J9900 Fragile X, molecular diagnostics 613.00 600.00 613.00 900.00
J9903 Mental retardation, cytogenetic diagnostics 932.00 912.00 932.00 1,368.00
J9913 Male infertility, cytogenetic diagnostics 932.00 912.00 932.00 1,368.00
J9941 Y chromosome deletion, molecular diagnostics, special case 1,006.00 984.00 1,006.00 1,476.00
J9991 Monogenic disease in family, molecular diagnostics, special case 3,761.00 3,680.00 3,761.00 5,520.00
L0005 Long cast, local anesthesia 317.00 310.00 317.00 465.00
L0019 Elastic bandage, elstoplast 13.00 13.00 13.00 20.00
L0020 Needle aspiration, US guidance, including cytology 582.00 569.00 582.00 854.00
L0021 Breast needle aspiration, US guidance, including cytology 582.00 569.00 582.00 854.00
L0022 Thyroid needle aspiration, US guidance, including cytology, per patient 1,709.00 1,672.00 1,709.00 2,508.00
L0023 Bandage placement or replacement 90.00 88.00 90.00 132.00
L0025 Stitches 0.00 0.00 0.00 0.00
L0026 Stitches removal 49.00 48.00 49.00 72.00
L0030 Parotid needle aspiration, US guidance, including cytology, per patient 1,557.00 1,523.00 1,557.00 2,285.00
L0040 Focused US ablation of uterine leiomyomata, MRI guidance 18,122.00 17,732.00 18,122.00 26,598.00
L0042 Nephrostomy tube removal 357.00 349.00 357.00 524.00
L0062 Vaginal smear, sampling, processing and interpretation 213.00 208.00 213.00 312.00
L0080 Rehabilitation day care 874.00 855.00 874.00 1,283.00
L0100 TMJ radiology, up to two views 283.00 277.00 283.00 416.00
L0106 Radiology additional view, not elsewhere specified 68.00 67.00 68.00 101.00
L0107 Jaw radiology, third or more additional views 68.00 67.00 68.00 101.00
L0108 Mastoids radiology, third or more additional views 68.00 67.00 68.00 101.00
L0109 Nasal bones radiology, third or more additional views 68.00 67.00 68.00 101.00
L0110 Paranasal sinuses radiology, third or more additional views 68.00 67.00 68.00 101.00
L0111 Skull radiology, third or more additional views 68.00 67.00 68.00 101.00
L0112 Pelvis radiology, third or more additional views 68.00 67.00 68.00 101.00
L0113 Shoulder radiology, complete, one side, third or more additional views 68.00 67.00 68.00 101.00
L0114 Elbow radiology, third or more additional views 68.00 67.00 68.00 101.00
L0115 Wrist radiology, third or more additional views 68.00 67.00 68.00 101.00
L0116 Hand radiology, third or more additional views 68.00 67.00 68.00 101.00
L0117 Hip radiology, unilateral, second or more additional views 68.00 67.00 68.00 101.00
L0118 Ankle radiology, third or more additional views 68.00 67.00 68.00 101.00
L0119 Abdomen radiology, second or more additional views 68.00 67.00 68.00 101.00
L0120 TMJ radiology, third or more additional views 68.00 67.00 68.00 101.00
L0121 Calcaneus radiology, third or more additional views 68.00 67.00 68.00 101.00
L0122 Toe(s) radiology, third or more additional views 68.00 67.00 68.00 101.00
L0123 Cervicothoracic spine radiology, Pawlow/Twining, up to two views 68.00 67.00 68.00 101.00
L0124 Cervicothoracic spine radiology, Pawlow/Twining, third or more additional views 68.00 67.00 68.00 101.00
L0125 Pelvis radiology, outlet 68.00 67.00 68.00 101.00
L0126 Pelvis radiology, inlet 68.00 67.00 68.00 101.00
L0138 Spine radiology, two parts, up to three views 317.00 310.00 317.00 465.00
L0151 Arthrography, including injection and interpretation 358.00 350.00 358.00 525.00
L0160 Chest radiology, third or more additional views 128.00 125.00 128.00 188.00
from
Abroad
)ILS(
L0167 Additional charge for device for insertion of left atrial appendage device 36,267.00 36,267.00 36,267.00 36,267.00
L0168 Additional charge for device for implantation of diaphragmatic pacemaker for spinal 163,350.00 163,350.00 163,350.00 163,350.00
cord injured patients
L0169 Additional charge for device for implantation of diaphragmatic pacemaker for ALS 142,079.00 142,079.00 142,079.00 142,079.00
patients
L0170 Additional charge for programmable pump for chronic pain management/spasticity 47,989.00 47,989.00 47,989.00 47,989.00
treatment
L0171 Additional charge for mechanical pump for pain management 32,691.00 32,691.00 32,691.00 32,691.00
L0177 Additional charge for vertical expandable prosthetic titanium rib system 87,500.00 87,500.00 87,500.00 87,500.00
L0178 Additional charge for BAHA (Bone Anchored Hearing Aid), adult 31,854.00 31,854.00 31,854.00 31,854.00
L0179 Additional charge for BAHA (Bone Anchored Hearing Aid), child 33,806.00 33,806.00 33,806.00 33,806.00
L0180 Additional charge for VNS (Vagus Nerve Stimulator) kit for epilepsy treatment 80,040.00 80,040.00 80,040.00 80,040.00
L0182 Additional charge for intracranial single array neurostimulator pulse generator kit, 95,651.00 95,651.00 95,651.00 95,651.00
including leads
L0183 Additional charge for intracranial dual array neurostimulator pulse generators kit, 110,501.00 110,501.00 110,501.00 110,501.00
including leads
L0184 Additional charge for rechargeable intracranial neurostimulator pulse generator kit 162,912.00 162,912.00 162,912.00 162,912.00
L0185 Additional charge for leads of intracranial neurostimulator pulse generator 29,803.00 29,803.00 29,803.00 29,803.00
L0187 Additional charge for single/dual array neurostimulator pulse generator for 80,801.00 80,801.00 80,801.00 80,801.00
intracranial stimulation, without leads
L0188 Additional charge for rechargeable neurostimulator pulse generator for intracranial 133,212.00 133,212.00 133,212.00 133,212.00
stimulation, without leads
L0194 Large bandage, bandages & cotton 280.00 274.00 280.00 411.00
L0209 Pregnancy termination approval committee 440.00 431.00 440.00 647.00
L0210 Nasal bones radiology, up to two views 199.00 195.00 199.00 293.00
L0248 Storage of corpse, 2 to 24 hours 385.00 377.00 385.00 566.00
L0268 Spotting and copying patient records, first 10 pages 106.00 104.00 106.00 156.00
L0269 Copying patient records, each 2 additional pages 1.00 1.00 1.00 2.00
L0280 Additional charge for 90Y for SIRT (Selective Internal Radiation Therapy) for liver 60,000.00 60,000.00 60,000.00 60,000.00
tumor, 90Y
L0300 Additional charge for device for percutaneous mitral valve repair 138,842.00 138,842.00 138,842.00 138,842.00
L0303 Additional charge for total internal biventricular artificial heart system 602,091.00 602,091.00 602,091.00 602,091.00
L0372 HBIg (Hepatitis B immune globulin), IV 7,140.00 6,986.00 7,140.00 10,479.00
L0396 Varicella Zoster passive immunization, under 12 years of age, eg, varitect 3,101.00 3,034.00 3,101.00 4,551.00
L0397 Varicella Zoster passive immunization, age 12 years or older, eg, varitect 10,863.00 10,629.00 10,863.00 15,944.00
L0409 Small splints, occupational therapy, including cost of material and number of sessions 226.00 221.00 226.00 332.00
L0410 Medium splints, static mouth splint, occupational therapy, including cost of material 438.00 429.00 438.00 644.00
and number of sessions
L0411 Medium splints, occupational therapy, including cost of material and number of 438.00 429.00 438.00 644.00
sessions
L0412 Complex medium splints, occupational therapy, including cost of material and number 641.00 627.00 641.00 941.00
of sessions
L0413 Big splints, occupational therapy, including cost of material and number of sessions 865.00 846.00 865.00 1,269.00
L0415 Compression suit fitting (eg, JOBST) 280.00 274.00 280.00 411.00
L0416 Complex medium splints, dynamic mouth splint, occupational therapy, including cost 641.00 627.00 641.00 941.00
of material and number of sessions
L0438 TRH (Thyrotropin releasing hormone) stimulation panel 786.00 769.00 786.00 1,154.00
L0444 MRI (Magnetic resonance imaging), excluding tests with specific code 2,034.00 1,990.00 2,034.00 2,985.00
L0446 MRI under general anesthesia, per test 10,287.00 10,066.00 10,287.00 15,099.00
L0486 Geriatric hospital day care 663.00 649.00 663.00 974.00
L0487 Cognitive geriatric hospital day care 343.00 336.00 343.00 504.00
L0491 Cytotoxic capacity testing 1,022.00 1,000.00 1,022.00 1,500.00
L0534 Orthoptic treatment, per treatment 95.00 93.00 95.00 140.00
L0546 Auditory test for cochlear implant surgery candidate 770.00 753.00 770.00 1,130.00
L0550 MR arthrography 4,614.00 4,515.00 4,614.00 6,773.00
L0554 FMRI (functional magnetic resonance imaging) 6,867.00 6,719.00 6,867.00 10,079.00
from
Abroad
)ILS(
L0560 Internal hospital day care 1,397.00 1,367.00 1,397.00 2,051.00

L0561 Rehabilitative hospital day care 1,397.00 1,367.00 1,397.00 2,051.00
L0564 Histochemical staining including immunohistochemistry 2,036.00 1,992.00 2,036.00 2,988.00
L0566 PD-L1 immunohistochemistry - tissue 939.00 919.00 939.00 1,379.00
L0574 Breathing capability test 95.00 93.00 95.00 140.00
L0591 Extracorporeal shockwave lithotripsy, kidney, complex, ambulatory care 23,316.00 22,814.00 23,316.00 34,221.00
L0621 Kit test 1,104.00 1,080.00 1,104.00 1,620.00
L0690 Hotel care, per day, including medical supervision 494.00 483.00 494.00 725.00
L0692 Home care, per day, including medical supervision 742.00 726.00 742.00 1,089.00
L0717 Harvesting of cornea 7,013.00 6,862.00 7,013.00 10,293.00
L0745 Additional charge for MRI for patient with cardiac pacemaker 595.00 582.00 595.00 873.00
L0748 Additional charge for MRI contrast material(s) 287.00 281.00 287.00 422.00
L0770 Evaluation subscription, children and adolescents, mental health 1,052.00 1,029.00 1,052.00 1,544.00
L0771 Evaluation subscription, adult, mental health 748.00 732.00 748.00 1,098.00
L0772 Psychotherapy short term subscription, children and adolescents, mental health 1,756.00 1,718.00 1,756.00 2,577.00
L0773 Psychotherapy short term subscription, adult, mental health 1,087.00 1,064.00 1,087.00 1,596.00
L0774 Psychotherapy long term subscription, children and adolescents, mental health 3,799.00 3,717.00 3,799.00 5,576.00
L0775 Psychotherapy long term subscription, adult, mental health 3,761.00 3,680.00 3,761.00 5,520.00
L0784 IV (Intravenous) infusion of fluids 280.00 274.00 280.00 411.00
L0785 IV (Intravenous) infusion of drugs 280.00 274.00 280.00 411.00
L0787 Deflux injection, vesicoureteral reflux therapy, unilateral, ambulatory care 8,162.00 7,986.00 8,162.00 11,979.00
L0788 Deflux injection, vesicoureteral reflux therapy, bilateral, ambulatory care 14,418.00 14,108.00 14,418.00 21,162.00
L0790 Preparation of blood unit/blood product, price per preparation of one unit 282.00 276.00 282.00 414.00
L0791 Blood unit/blood product, price per one unit 405.00 405.00 405.00 405.00
L0797 Additional charge for pump for subcutaneous apomorphine injection 10,000.00 10,000.00 10,000.00 10,000.00
L0799 IV (Intravenous) iloprost 1,315.00 1,287.00 1,315.00 1,931.00
L0804 Home visit, psychiatric team 434.00 425.00 434.00 638.00
L0805 Comprehensive cognitive and functional evaluation 1,268.00 1,241.00 1,268.00 1,862.00
L0806 Multiprofessional evaluation for rehabilitation planning 1,747.00 1,709.00 1,747.00 2,564.00
L0807 Psychological assessment for rehabilitation framework 1,144.00 1,119.00 1,144.00 1,679.00
L0808 Psychodiagnostic assessment, complete battery 1,144.00 1,119.00 1,144.00 1,679.00
L0809 Psychodiagnostic assessment, partial battery 587.00 574.00 587.00 861.00
L0820 Psychiatric hospital day care, adult 469.00 459.00 469.00 689.00
L0821 Psychiatric hospital day care, children and adolescents 502.00 491.00 502.00 737.00
L0822 Psychiatric community day care, adult 473.00 463.00 473.00 695.00
L0823 Psychiatric community day care, children and adolescents 511.00 500.00 511.00 750.00
L0830 Intake/periodic evaluation and treatment planning, team, mental health
L0841 Psychotherapy, individual 278.00 272.00 278.00 408.00
L0846 Family/conjoint therapy/counseling, mental health 461.00 451.00 461.00 677.00
L0849 Psychotherapy, group 130.00 127.00 130.00 191.00
L0882 Family consultation, mental health 325.00 318.00 325.00 477.00
L0886 Guidance for other agencies, individual, within service site 325.00 318.00 325.00 477.00
L0887 Guidance for other agencies, group, within service site 217.00 212.00 217.00 318.00
L0888 Guidance for other agencies, outside service site 461.00 451.00 461.00 677.00
L0889 Consultation/coordination with other agencies, within service site, mental health 325.00 318.00 325.00 477.00
L0890 Consultation/coordination with other agencies, outside service site, mental health 461.00 451.00 461.00 677.00
L0892 Psychiatric medical opinion for rehabilitation committee 726.00 710.00 726.00 1,065.00
L0898 Documented telephone consultation to welfare, education and rehabilitation
institutions, per three months, mental health
L0911 Auditory test, complete with anamnesis, child 280.00 274.00 280.00 411.00
L0914 Biofeedback training, gastroenterology, single session 385.00 377.00 385.00 566.00
L0915 Biofeedback training, gastroenterology, 6 sessions 2,312.00 2,262.00 2,312.00 3,393.00
L0934 Circulating anticoagulants, eg, LAC 398.00 389.00 398.00 584.00
L0959 Sexual counseling and therapy 465.00 455.00 465.00 683.00
L0962 ER (Emergency room) medical examination 324.00 317.00 324.00 476.00
L0964 ER (Emergency room) fee 217.00 212.00 217.00 318.00
L0969 Collar or sling, including materials 150.00 147.00 150.00 221.00
from
Abroad
)ILS(
L1015 Enzymes activity with cells separation, six or more enzymes 1,490.00 1,458.00 1,490.00 2,187.00
L1028 US (ultrasound), with image documentation 391.00 383.00 391.00 575.00
L1030 FibroScan for assessment of liver fibrosis 518.00 507.00 518.00 761.00
L1031 FibroTest - blood 804.00 787.00 804.00 1,181.00
L1039 CT (Computed Tomography), excluding tests with specific code 700.00 685.00 700.00 1,028.00
L1040 CTA / CT arthrography / CT urography, per patient, excluding coronary arteries CTA 1,265.00 1,238.00 1,265.00 1,857.00
L1077 Surgical obturator, assessment and preparation 12,581.00 12,310.00 12,581.00 18,465.00
L1079 Interim obturator 6,604.00 6,462.00 6,604.00 9,693.00
L1080 Definitive obturator 18,090.00 17,701.00 18,090.00 26,552.00
L1133 Establishing paternity, per patient, including medical forensic opinion 2,039.00 1,995.00 2,039.00 2,993.00
L1139 Pilot medical examination 1,674.00 1,638.00 1,674.00 2,457.00
L1275 Thoracic CTA, coronary arteries 3,112.00 3,045.00 3,112.00 4,568.00
L1611 Initial insertion/replacement of speech prosthesis post laryngectomy 3,189.00 3,120.00 3,189.00 4,680.00
L1714 Intravesical instillation of Hyaluronic acid, per treatment, including material 684.00 669.00 684.00 1,004.00
L1720 Bladder instillation of Mitomycin, per treatment, including material 1,198.00 1,172.00 1,198.00 1,758.00
L1721 Bladder hyperthermia and Mitomycin instillation, per treatment 5,057.00 4,948.00 5,057.00 7,422.00
L1922 CT under general anesthesia 2,044.00 2,000.00 2,044.00 3,000.00
L1996 Chronic pain control, infiltration 337.00 330.00 337.00 495.00
L1997 Chronic pain control, nerves block, fluoroscopic guidance, with contrast material 1,693.00 1,657.00 1,693.00 2,486.00
L1998 Chronic pain control, nerves block, fluoroscopic guidance, with neurolytic substance 1,693.00 1,657.00 1,693.00 2,486.00
L2001 Radiofrequency treatment for pain control, per treatment 5,391.00 5,275.00 5,391.00 7,913.00
L2002 Loading of pump for spasticity treatment, Baclofen 3,906.00 3,822.00 3,906.00 5,733.00
L2003 Ozone treatment for skin ulcers, per day 268.00 262.00 268.00 393.00
L2004 Negative pressure treatment for skin ulcers, per session 693.00 678.00 693.00 1,017.00
L2005 Maggot debridement therapy, per session 553.00 541.00 553.00 812.00
L2013 Acetylcholinesterase Ab - serum 443.00 433.00 443.00 650.00
L2136 OCT3 (Optical Coherence Tomography), per patient 396.00 387.00 396.00 581.00
L2190 Obstetric MRI, fetus, per one fetus 4,614.00 4,515.00 4,614.00 6,773.00
L2195 MR enterography 2,941.00 2,878.00 2,941.00 4,317.00
L2196 Pelvic/genitalia MRI, excluding prostate 2,034.00 1,990.00 2,034.00 2,985.00
L2197 Prostate MRI 4,460.00 4,364.00 4,460.00 6,546.00
L2250 Fundus photography, both eyes 391.00 383.00 391.00 575.00
L2340 Optometry by an optometrist, per patient 155.00 152.00 155.00 228.00
L2498 Corneal imaging 205.00 201.00 205.00 302.00
L2528 Nasal potential difference measurements for cystic fibrosis diagnonsis 1,743.00 1,705.00 1,743.00 2,558.00
L2529 Rectal biopsy sampling and testing for Cystic Fibrosis diagnosis, per patient 1,743.00 1,705.00 1,743.00 2,558.00
L2585 Auditory screening test, OAE, infant 0.00 0.00 0.00 0.00
L2586 Auditory screening test, AABR, infant 0.00 0.00 0.00 0.00
L2588 OAE (Otoacoustic Emissions), diagnostic 95.00 93.00 95.00 140.00
L2589 Auditory screening test, AABR, subsequent test, baby 196.00 192.00 196.00 288.00
L2699 Extracorporeal shock wave lithotripsy, salivary glands, ambulatory care 5,696.00 5,573.00 5,696.00 8,360.00
L2731 Fibronectin 510.00 499.00 510.00 749.00
L2985 Shoulder arthroscopy, simple, ambulatory care 10,928.00 10,693.00 10,928.00 16,040.00
L2986 Shoulder arthroscopy, complex, ambulatory care 24,035.00 23,518.00 24,035.00 35,277.00
L2987 Elbow/wrist/hand and finger arthroscopy, simple, ambulatory care 13,110.00 12,828.00 13,110.00 19,242.00
L2988 Elbow arthroscopy, complex, ambulatory care 19,182.00 18,769.00 19,182.00 28,154.00
L2989 Hip arthroscopy, simple, ambulatory care 21,850.00 21,380.00 21,850.00 32,070.00
L2990 Hip arthroscopy, complex, ambulatory care 32,780.00 32,074.00 32,780.00 48,111.00
L2991 Knee arthroscopy, simple, ambulatory care 8,414.00 8,233.00 8,414.00 12,350.00
L2992 Knee arthroscopy, complex, ambulatory care 20,528.00 20,086.00 20,528.00 30,129.00
L2993 Ankle/foot and toe arthroscopy, simple, ambulatory care 11,862.00 11,607.00 11,862.00 17,411.00
L2994 Ankle arthroscopy, complex, ambulatory care 16,827.00 16,465.00 16,827.00 24,698.00
L2995 Arthroscopy, simple/complex, excluding procedures with specific code, ambulatory 8,414.00 8,233.00 8,414.00 12,350.00
care
L3003 ECG monitoring, Flecainide infusion, IV 761.00 745.00 761.00 1,118.00
from
Abroad
)ILS(
L3013 Rapid urease test, helicobacter pylori, child - exhaled air 53.00 52.00 53.00 78.00
L3239 Biopsy, additional payment to EUS, excluding EUS (Endoscopic ultrasound) 2,654.00 2,597.00 2,654.00 3,896.00
L3250 Endoscopic polyp marking, in addition to endoscopy, per patient 946.00 926.00 946.00 1,389.00
L3253 RFA (Radiofrequency Ablation) of Barrett's esophagus, per treatment 16,518.00 16,162.00 16,518.00 24,243.00
L3255 Balloon enteroscopy 12,339.00 12,073.00 12,339.00 18,110.00
L3307 TTE (transthoracic echocardiography), child 507.00 496.00 507.00 744.00
L3560 Patella radiology, up to two views, per side 140.00 137.00 140.00 206.00
L3562 Patella radiology, third or more additional views 150.00 147.00 150.00 221.00
L3620 Toe(s) radiology, up to two views 140.00 137.00 140.00 206.00
L3621 Calcaneus radiology, up to two views 140.00 137.00 140.00 206.00
L3711 Apolipoprotein E, genotype 481.00 471.00 481.00 707.00
L3727 Implantation of loop recorder system, including retrieval of recorded and stored ECG 13,955.00 13,655.00 13,955.00 20,483.00
data, physician review and interpretation of retrieved ECG data, per ILR
L3795 External Counter Pulsation Therapy (ECPT) / Enhanced External Counter Pulsation 779.00 762.00 779.00 1,143.00
(EECP) therapy
L3799 Rehabilitation workshop, lung diseases patients, per session 113.00 111.00 113.00 167.00
L3890 Apolipoprotein E4, genotype 1,151.00 1,126.00 1,151.00 1,689.00
L3900 Prenatal diagnosis, age 35-37, including US, amniocentesis and laboratory tests 2,918.00 2,855.00 2,918.00 4,283.00
L3902 Prenatal diagnosis, over age 37, including US, amniocentesis and laboratory tests 1,915.00 1,874.00 1,915.00 2,811.00
L3903 Prenatal diagnosis, younger than age 35, including US, amniocentesis and karyotype 2,674.00 2,490.00 2,545.00 3,926.00
L4110 Porphobilinogen deaminase, quantitative - RBC 504.00 493.00 504.00 740.00

L4152 Hospital circumcision, excluding newborn, ambulatory care 2,836.00 2,775.00 2,836.00 4,163.00
L4233 Her-2/neu, immunohistochemistry 398.00 389.00 398.00 584.00
L4234 Her-2/neu, FISH method 3,463.00 3,388.00 3,463.00 5,082.00
L4283 Enema 29.00 28.00 29.00 42.00
L4298 Electrolytes, sodium and potassium 29.00 28.00 29.00 42.00
L4450 Urethrocystography, retrograde, under sedation 1,308.00 1,280.00 1,308.00 1,920.00
L4581 Additional charge for device for implantation of spinal cord/root/peripheral nerve 13,243.00 13,243.00 13,243.00 13,243.00
stimulation electrode/lead
L4583 Additional charge for device for implantation of spinal cord/root/peripheral nerve 60,110.00 60,110.00 60,110.00 60,110.00
stimulation generator
L4612 Injection of Botulinum toxin, 30 units Dysport 297.00 291.00 297.00 437.00
L4705 hCG and PAPP-A, quantitative - serum 205.00 201.00 205.00 302.00
L4793 Ambulatory evaluaiton of TB suspected patient 1,749.00 1,711.00 1,749.00 2,567.00
L4794 Basic evaluation of Mantoux positive patient 210.00 205.00 210.00 308.00
L4795 Treatment of active TB patient, first 5 months 8,360.00 8,180.00 8,360.00 12,270.00
L4796 Treatment of active TB patient, last month 10,897.00 10,662.00 10,897.00 15,993.00
L4797 Evaluation of close contact of Tb patient 693.00 678.00 693.00 1,017.00
L4798 Ambulatory treatment of close contact patient, prevention 244.00 239.00 244.00 359.00
L4799 Ambulatory pharmacological treatment of close contact patient, last month 325.00 318.00 325.00 477.00
L4990 Genotype characterization by caryotype analysis 3,377.00 3,304.00 3,377.00 4,956.00
L4991 Malignancies genotype, FISH (Fluorescent in Situ Hybridization) 1,511.00 1,478.00 1,511.00 2,217.00
L4992 Malignancies genotype, DNA index 1,125.00 1,101.00 1,125.00 1,652.00
L4999 Orotic acid - urine 94.00 92.00 94.00 138.00
L5339 Laser, additional payment to endoscopy, excluding endoscopy 1,205.00 1,179.00 1,205.00 1,769.00
L5378 Colonoscopy, flexible; diagnostic, with/without collection of specimen(s) 1,215.00 1,189.00 1,215.00 1,784.00
L5400 Endoscopic Argon laser treatment 417.00 408.00 417.00 612.00
L5441 Femur head from bone bank 1,801.00 1,762.00 1,801.00 2,643.00
L5461 Kappa or Lambda light chain, Ig, free - blood 396.00 387.00 396.00 581.00
L5799 Angiography 3,598.00 3,521.00 3,598.00 5,282.00
L5810 Polysomnography, including EEG, child 1,294.00 1,266.00 1,294.00 1,899.00
L5858 Tensilon test for myasthenia gravis; with electromyographic recording 591.00 578.00 591.00 867.00
L5872 Single fiber electromyography, per patient 832.00 814.00 832.00 1,221.00
L5925 Sensory evoked potentials (SEP) study, per patient 515.00 504.00 515.00 756.00
L5990 Minor ambulatory surgery, including foreign body removal, local anesthesia 358.00 350.00 358.00 525.00
L6002 Cytokins 324.00 317.00 324.00 476.00
from
Abroad
)ILS(
L6015 Gliadin Ab 253.00 248.00 253.00 372.00

L6030 Intraocular injection, excluding material cost 344.00 337.00 344.00 506.00
L6031 Intraocular injection of Bevacizumab (Avastin) 756.00 740.00 756.00 1,110.00
L6161 KRAS and NRAS mutations, per patient 3,174.00 3,106.00 3,174.00 4,659.00
L6171 Additional charge for intraocular shunt, eg, Ex-PRESS, for trabeculectomy 3,748.00 3,748.00 3,748.00 3,748.00
L6312 CA 72.4 tumor antigen 149.00 146.00 149.00 219.00
L6313 NSE (Neuron specific enolase), tumor antigen 149.00 146.00 149.00 219.00
L6316 Immunoassay for tumor antigen, quantitative; CA 21-1 135.00 132.00 135.00 198.00
L6358 Lymphocyte CD antigen determination, over 6 CD 3,146.00 3,078.00 3,146.00 4,617.00
L6375 CT (Computed tomographic) virtual colonoscopy 1,274.00 1,247.00 1,274.00 1,871.00
L6414 Hickman placement, angiography guidance 3,491.00 3,416.00 3,491.00 5,124.00
L6415 Hickman placement under general anasthesia 5,237.00 5,124.00 5,237.00 7,686.00
L6416 Portacath placement, angiography guidance 5,062.00 4,953.00 5,062.00 7,430.00
L6417 Portacath placement under general anasthesia 6,968.00 6,818.00 6,968.00 10,227.00
L6418 Declotting by thrombolytic agent of Hickman/portacath catheter 193.00 189.00 193.00 284.00
L6497 Copying video, echo, catheterization, CD 112.00 110.00 112.00 165.00
L6498 Copying of films from folder 44.00 43.00 44.00 65.00
L6499 Copying of films from folder, each additional film 21.00 21.00 21.00 32.00
L6520 Low density lipoprotein (LDL) apheresis 11,223.00 10,981.00 11,223.00 16,472.00
L6538 HLA B57 568.00 556.00 568.00 834.00
L6539 HLA B5701 373.00 365.00 373.00 548.00
L6550 Oncological treatment, adult, with chemotherapeutic/biological medications, per 1,593.00 1,559.00 1,593.00 2,339.00
patient per day
L6551 Oncological treatment, child, with chemotherapeutic/biological medications, per 2,069.00 2,024.00 2,069.00 3,036.00
patient per day
L6552 Oncological/hematological treatment, adult, without chemotherapeutic/ biological 956.00 935.00 956.00 1,403.00
medications, per patient per day
L6553 Oncological/hematological treatment, child, without chemotherapeutic/ biological 1,241.00 1,214.00 1,241.00 1,821.00
medications, per patient per day
L6567 PDT (Photodynamic therapy), dermal lesions, solar keratosis 2,103.00 2,058.00 2,103.00 3,087.00
L6611 Bartonella henselae (Cat scratch) IgG - blood 284.00 278.00 284.00 417.00
L6612 Bartonella henselae (Cat scratch) IgM - blood 284.00 278.00 284.00 417.00
L6689 HIV or HTLV resistance to medication 2,904.00 2,841.00 2,904.00 4,262.00
L6705 HBV, HCV and HIV-1 detection, NAT, at blood bank 149.00 146.00 149.00 219.00
L6707 Hepatitis E Ab 283.00 277.00 283.00 416.00
L6762 Rubella virus IgG or IgM 140.00 137.00 140.00 206.00
L6776 Toxoplasma, Sabin Feldman dye test 250.00 245.00 250.00 368.00
L6777 Toxoplasmosis confirmation test 646.00 632.00 646.00 948.00
L6778 Toxoplasma avidity testing 344.00 337.00 344.00 506.00
L6815 Ultrasound, pregnant uterus, without image documentation 357.00 349.00 357.00 524.00
L6821 Ophthalmic YAG laser treatment, per patient 468.00 458.00 468.00 687.00
L6822 Ophthalmic Argon laser treatment, per patient 364.00 356.00 364.00 534.00
L6830 Creation of arteriovenous fistula for renal dialysis, native or using graft, ambulatory 14,727.00 14,410.00 14,727.00 21,615.00
care
L6831 Therapeutic catheterization of AV shunt for renal dialysis, native/with graft, 24,761.00 24,228.00 24,761.00 36,342.00
ambulatory care
L6849 Interferon Ab 375.00 367.00 375.00 551.00
L6855 Abdominal US for aortic aneurysm diagnosis, screening 112.00 110.00 112.00 165.00
L6856 Pelvis US, nonobstetric, with image documentation, complete 391.00 383.00 391.00 575.00
L6857 Hips US 391.00 383.00 391.00 575.00
L6999 Collagen corneal cross linking for keratoconus and keratectasia treatment 3,533.00 3,457.00 3,533.00 5,186.00
L7001 Physiotherapy, evaluation and treatment planning, child 435.00 426.00 435.00 639.00
L7002 Isokinetic assessment and treatment planning 288.00 282.00 288.00 423.00
L7003 Occupational therapy, evaluation and treatment planning, child 435.00 426.00 435.00 639.00
L7004 Isokinetic physiotherapeutic treatment 240.00 235.00 240.00 353.00
L7118 NTM (Nontuberculous Mycobacteria) identification 461.00 451.00 461.00 677.00
from
Abroad
)ILS(
L7140 Physiotherapy/rehabilitation, group, up to 4 individuals, including child, per 93.00 91.00 93.00 137.00
individual
L7154 Toxoplasma, molecular diagnostics - body fluids 1,271.00 1,244.00 1,271.00 1,866.00
L7204 Spermatic veins embolization, ambulatory care 8,514.00 8,331.00 8,514.00 12,497.00
L7210 Photocoagulation, PDT, retina, including material 12,425.00 12,158.00 12,425.00 18,237.00
L7525 Replacement/repositioning of biliary drain, percutaneous 3,166.00 3,098.00 3,166.00 4,647.00
L7619 Malignant hyperthermia diagnosis test (muscle biopsy) 9,707.00 9,498.00 9,707.00 14,247.00
L7751 Brachytherapy, female genitalia 11,920.00 11,663.00 11,920.00 17,495.00
L7752 Brachytherapy, lung 7,438.00 7,278.00 7,438.00 10,917.00
L7753 Brachytherapy, prostate, ambulatory care 47,679.00 46,653.00 47,679.00 69,980.00
L7771 Occupational therapy, group 93.00 91.00 93.00 137.00
L7900 Radiotherapy, brain, total, adult, 3D
L7901 Radiotherapy, brain, total, adult, IMRT
L7902 Radiotherapy, brain, total, adult, VMAT
L7903 Radiotherapy, brain, partial, adult, 3D
L7904 Radiotherapy, brain, partial, adult, IMRT
L7905 Radiotherapy, brain, partial, adult, VMAT
L7906 Radiotherapy, brain, partial, adult, stereotactic
L7907 Radiotherapy, brain, child, 3D
L7908 Radiotherapy, brain, child, IMRT
L7909 Radiotherapy, brain, child, VMAT
L7910 Radiotherapy, brain, child, stereotactic
L7911 Radiotherapy, brain and spinal canal and contents, 3D
L7912 Radiotherapy, brain and spinal canal and contents, IMRT
L7913 Radiotherapy, brain and spinal canal and contents, VMAT
L7914 Radiotherapy, head and neck, 3D
L7915 Radiotherapy, head and neck, IMRT
L7916 Radiotherapy, head and neck, VMAT
L7917 Radiotherapy, head and neck, stereotactic
L7918 Radiotherapy, lung and mediastinum, 3D
L7919 Radiotherapy, lung and mediastinum, IMRT
L7920 Radiotherapy, lung and mediastinum, VMAT
L7921 Radiotherapy, lung and mediastinum, stereotactic
L7922 Radiotherapy, breast, without lymph nodes, 3D
L7923 Radiotherapy, breast, without lymph nodes, IMRT
L7924 Radiotherapy, breast, without lymph nodes, VMAT
L7925 Radiotherapy, breast, with lymph nodes, 3D
L7926 Radiotherapy, breast, with lymph nodes, IMRT
L7927 Radiotherapy, breast, with lymph nodes, VMAT
L7928 Radiotherapy, liver, pancreas, gallbladder, stomach, esophagus, 3D
L7929 Radiotherapy, liver, pancreas, gallbladder, stomach, esophagus, IMRT
L7930 Radiotherapy, liver, pancreas, gallbladder, stomach, esophagus, VMAT
L7931 Radiotherapy, liver, pancreas, gallbladder, stomach, esophagus, stereotactic
L7932 Radiotherapy, rectum, 3D
L7933 Radiotherapy, rectum, IMRT
L7934 Radiotherapy, rectum, VMAT
L7935 Radiotherapy, anus, 3D
L7936 Radiotherapy, anus, IMRT
L7937 Radiotherapy, anus, VMAT
L7938 Radiotherapy, urinary system, excluding prostate, 3D
L7939 Radiotherapy, urinary system, excluding prostate, IMRT
L7940 Radiotherapy, urinary system, excluding prostate, VMAT
L7941 Radiotherapy, prostate, without lymph nodes, 3D
L7942 Radiotherapy, prostate, without lymph nodes, IMRT
L7943 Radiotherapy, prostate, without lymph nodes, VMAT
L7944 Radiotherapy, prostate, without lymph nodes, stereotactic
L7945 Radiotherapy, prostate, with lymph nodes, 3D
from
Abroad
)ILS(
L7946 Radiotherapy, prostate, with lymph nodes, IMRT

L7947 Radiotherapy, prostate, with lymph nodes, VMAT
L7948 Radiotherapy, female genitalia, 3D
L7949 Radiotherapy, female genitalia, IMRT
L7950 Radiotherapy, female genitalia, VMAT
L7951 Radiotherapy, skin, total, 3D
L7952 Radiotherapy, skin, total, IMRT
L7953 Radiotherapy, skin, total, VMAT
L7954 Radiotherapy, skin, partial, 3D
L7955 Radiotherapy, skin, partial, IMRT
L7956 Radiotherapy, skin, partial, VMAT
L7957 Radiotherapy, sarcoma, extremities, adult, 3D
L7958 Radiotherapy, sarcoma, extremities, adult, IMRT
L7959 Radiotherapy, sarcoma, extremities, adult, VMAT
L7960 Radiotherapy, benign tumor, excluding head/neck/nervous system, 3D
L7961 Radiotherapy, benign tumor, excluding head/neck/nervous system, IMRT
L7962 Radiotherapy, benign tumor, excluding head/neck/nervous system, VMAT
L7963 Palliative radiotherapy, soft tissue metastases, 3D
L7964 Palliative radiotherapy, soft tissue metastases, IMRT
L7965 Palliative radiotherapy, soft tissue metastases, VMAT
L7966 Palliative radiotherapy, soft tissue metastases, stereotactic
L7967 Palliative radiotherapy, bone metastases, 3D
L7968 Palliative radiotherapy, bone metastases, IMRT
L7969 Palliative radiotherapy, bone metastases, VMAT
L7970 Palliative radiotherapy, bone metastases, stereotactic
L7971 Radiotherapy, whole body for bone marrow transplantation candidate, 3D 0.00 0.00 0.00 0.00
L7972 Radiotherapy, whole body for bone marrow transplantation candidate, IMRT 0.00 0.00 0.00 0.00
L7973 Radiotherapy, whole body for bone marrow transplantation candidate, VMAT 0.00 0.00 0.00 0.00
L8074 Adrenal imaging, medulla, I-123 MIBG, up to 7 years of age 11,506.00 11,258.00 11,506.00 16,887.00
L8075 Adrenal imaging, medulla, I-123 MIBG, over 7 years of age 19,970.00 19,540.00 19,970.00 29,310.00
L8076 Adrenal imaging, cortex 11,731.00 11,478.00 11,731.00 17,217.00
L8170 Surgical testicular sperm production, excluding Micro TESE 6,915.00 6,766.00 6,915.00 10,149.00
L8180 Chemotherapy resistance, Facs 916.00 896.00 916.00 1,344.00
L8181 CD membrane antigen, up to 4 antigens 1,314.00 1,286.00 1,314.00 1,929.00
L8182 Testes removal, for sperm isolation; cadaver, at the forensic medicine institute 1,327.00 1,298.00 1,327.00 1,947.00
L8183 Pathological specimen, preparation of slides, at the forensic medicine institute 108.00 106.00 108.00 159.00
L8184 DNA analysis in liquid blood, soft tissue, semen, at the forensic institute 2,882.00 2,820.00 2,882.00 4,230.00
L8186 DNA analysis in dry blood, at the forensic institute 3,033.00 2,968.00 3,033.00 4,452.00
L8188 DNA analysis in bone tissue, at the forensic institute 10,585.00 10,357.00 10,585.00 15,536.00
L8190 Harvesting of cardiac valve (homograft bank) 1,814.00 1,775.00 1,814.00 2,663.00
L8213 Aminolevulinic acid dehydratase (ALA-D), quantitative - RBC 755.00 739.00 755.00 1,109.00
L8240 Collection and cryopreservation of umbilical cord blood for families at risk for 4 years 9,715.00 9,506.00 9,715.00 14,259.00
L8242 Allogeneic donor lymphocyte infusions, DLI 4,037.00 3,950.00 4,037.00 5,925.00
L8244 Allogeneic lymphocyte proliferation 6,075.00 5,944.00 6,075.00 8,916.00
L8245 Allogeneic lymphocyte activation 38,433.00 37,606.00 38,433.00 56,409.00
L8250 Chromosome 1 and 19 analysis, per patient 2,155.00 2,109.00 2,155.00 3,164.00
L8252 FLT3 and NPM1 internal random duplications, PCR 891.00 872.00 891.00 1,308.00
L8268 Cholyl-14-C-Glycine breath test for bile salts deconjugation
L8269 C-13 urea test, helicobacter pylori - exhaled air 180.00 176.00 180.00 264.00
L8299 Spleen imaging, with heated RBC (red blood cells) 1,263.00 1,236.00 1,263.00 1,854.00
L8307 Examination of abortus for diagnosis of malformations 6,685.00 6,541.00 6,685.00 9,812.00
L8379 EGFR (Epidermal Growth Factor Receptor) mutation - tissue, per patient 1,198.00 1,172.00 1,198.00 1,758.00
L8381 BRAF mutation, per patient 794.00 777.00 794.00 1,166.00
L8382 ALK and ROS1 mutations, per patient 3,206.00 3,137.00 3,206.00 4,706.00
L8383 MSI (Microsatellite Instability), dMMR (Deficient Mismatch Repair) tumor 1,293.00 1,265.00 1,293.00 1,898.00
L8400 DNA extraction - whole blood 95.00 93.00 95.00 140.00
from
Abroad
)ILS(
L8410 Porphyrins, qualitative - plasma 172.00 168.00 172.00 252.00

L8411 Porphyrins, chromatography - plasma 642.00 628.00 642.00 942.00
L8412 Porphyrins, chromatography - urine 593.00 580.00 593.00 870.00
L8413 Porphyrins, chromatography - feces 679.00 664.00 679.00 996.00
L8414 Porphyrins, chromatography - RBC 738.00 722.00 738.00 1,083.00
L8599 Pulmonary imaging, dynamic, mucociliary clearence 4,103.00 4,015.00 4,103.00 6,023.00
L8606 DatScan brain imaging 14,096.00 13,793.00 14,096.00 20,690.00
L8738 HIV Ab and P24 Ag, ELISA/EIA, at MOH recognized HIV clinic 51.00 50.00 51.00 75.00
L8739 Delivering a nonnegative HIV test result by a physician at MOH recognized HIV 136.00 133.00 136.00 200.00
clinic
L8802 Somatostatin receptor scintegraphy 22,692.00 22,204.00 22,692.00 33,306.00
L8812 PET imaging, eg, F-18 Choline / Ga-68 PSMA 6,642.00 6,499.00 6,642.00 9,749.00
L8970 First stage IVF, including hormonal tests 5,938.00 4,343.00 4,456.00 8,712.00
L8971 First stage IVF, excluding hormonal tests 4,626.00 3,388.00 3,473.00 6,792.00
L8972 Second stage IVF, excluding hospitalization days 7,159.00 5,234.00 5,366.00 10,507.00
L8975 Ovarian tissue cryopreservation 5,898.00 5,771.00 5,898.00 8,657.00
L8976 Cryopreserved ovarian tissue storage for 5 years 786.00 769.00 786.00 1,154.00
L8977 Oocyte retrieval and cryopreservation, eg, vitrification 7,159.00 5,234.00 5,366.00 10,507.00
L8978 Cryopreserved oocytes storage for 5 years 786.00 769.00 786.00 1,154.00
L8979 Cryopreserved oocytes transfer, intrauterine, including thawing and fertilization 4,613.00 4,514.00 4,613.00 6,771.00
L8990 Detection of tumor cells in cryopreserved ovarian tissue 15,050.00 14,726.00 15,050.00 22,089.00
L9000 Radiopharmaceutical therapy, hyper-thyroidism 1,820.00 1,781.00 1,820.00 2,672.00
L9015 Chorionic villus sampling, excluding laboratory processing and interpretation 519.00 508.00 519.00 762.00
L9030 Radiopharmaceutical ablation of gland for thyroid carcinoma 7,505.00 7,343.00 7,505.00 11,015.00
L9035 Radiopharmaceutical therapy for metastases of thyroid carcinoma 11,907.00 11,651.00 11,907.00 17,477.00
L9079 Injection (eg, neurolytic substance) 106.00 104.00 106.00 156.00
L9080 Medical opinion for appointment of legal guardian, including completion of form and 734.00 718.00 734.00 1,077.00
reports
L9183 Emergency hyperbaric oxygen therapy, excluding diving accidents 12,576.00 12,305.00 12,576.00 18,458.00
L9184 Hyperbaric pretreatment assessment 1,775.00 1,737.00 1,775.00 2,606.00
L9201 Physician consulation for a patient insured by another sick fund 179.00 175.00 179.00 263.00
L9211 Fire arm license physician examination 134.00 131.00 134.00 197.00
L9212 Driving license physician examination 134.00 131.00 134.00 197.00
L9215 Fire arm license specialist examination 391.00 383.00 391.00 575.00
L9232 Routine examinations for candidates for renal transplantation 5,637.00 5,516.00 5,637.00 8,274.00
L9241 Perenatal genetic consultation 621.00 608.00 621.00 912.00
L9242 Examination by medical specialist for appointment of legal guardian, for established 280.00 274.00 280.00 411.00
patient
L9243 Genetic consultation 621.00 608.00 621.00 912.00
L9244 Physician examination, oncologist 279.00 147.00 150.00 410.00
L9245 Physician examination, hematologist 279.00 147.00 150.00 410.00
L9246 Physician examination, hemato-oncologist 279.00 147.00 150.00 410.00
L9247 Physician examination, internal physician 279.00 147.00 150.00 410.00
L9248 Physician examination, urologist 279.00 147.00 150.00 410.00
L9249 Physician examination, orthopedic physician 279.00 147.00 150.00 410.00
L9250 Stammering treatment, individual/group, per course 9,754.00 9,544.00 9,754.00 14,316.00
L9251 Stammering treatment, individual/group, per patient/session 186.00 182.00 186.00 273.00
L9252 Physician examination, alergologist 279.00 147.00 150.00 410.00
L9253 Physician examination, endocrinologist 279.00 147.00 150.00 410.00
L9254 Physician examination, otorhinolaryngologist 279.00 147.00 150.00 410.00
L9255 Physician examination, obstetrician/gynecologist 279.00 147.00 150.00 410.00
L9256 Physician examination, medical geneticist 279.00 147.00 150.00 410.00
L9257 Physician examination, gastroenterologist 279.00 147.00 150.00 410.00
L9258 Physician examination, pediatrician 279.00 147.00 150.00 410.00
L9259 Cryopreservation, sperm, any additional year, up to 5 test tubes/straws 347.00 340.00 347.00 510.00
L9260 Physician examination, surgeon 279.00 147.00 150.00 410.00
L9261 Physician examination, thoracic surgeon 279.00 147.00 150.00 410.00
from
Abroad
)ILS(
L9262 Physician examination, vascular surgeon 279.00 147.00 150.00 410.00

L9263 Physician examination, hand surgeon 279.00 147.00 150.00 410.00
L9264 Physician examination, maxillofacial surgeon 279.00 147.00 150.00 410.00
L9265 Physician examination, proctologist surgeon 279.00 147.00 150.00 410.00
L9266 Physician examination, breast surgeon 279.00 147.00 150.00 410.00
L9267 Physician examination, plastic surgeon 279.00 147.00 150.00 410.00
L9268 Physician examination, anesthesiologist 279.00 147.00 150.00 410.00
L9269 Physician examination, neurosurgeon 279.00 147.00 150.00 410.00
L9270 Physician examination, neurologist 279.00 147.00 150.00 410.00
L9271 Consultation with a specialist 465.00 455.00 465.00 683.00
L9273 Physician examination, nephrologist 279.00 147.00 150.00 410.00
L9274 Physician examination, dermatologist 279.00 147.00 150.00 410.00
L9275 Physician examination, ophthalmologist 279.00 147.00 150.00 410.00
L9276 Physician examination, cardiologist 279.00 147.00 150.00 410.00
L9277 Physician examination, rheumatologist 279.00 147.00 150.00 410.00
L9278 Physician examination, pulmonologist 279.00 147.00 150.00 410.00
L9279 Physician examination, rehabilitation physician 279.00 147.00 150.00 410.00
L9281 Emergency physician consulation at sick fund clinic 291.00 285.00 291.00 428.00
L9301 Clinic nurse evaluation for a patient insured by another sick fund 127.00 124.00 127.00 186.00
L9311 Home visit, nurse 155.00 152.00 155.00 228.00
L9321 Outpatient social treatment 155.00 152.00 155.00 228.00
L9331 Rehabilitative day care center - long term 306.00 299.00 306.00 449.00
L9342 Prosthesis extension 283.00 277.00 283.00 416.00
L9343 Sheltered housing, per day 37.00 36.00 37.00 54.00
L9345 Care hostel, per day 141.00 138.00 141.00 207.00
L9346 Care hostel, extended, per day 176.00 172.00 176.00 258.00
L9347 Short term treatment center, per day 134.00 131.00 134.00 197.00
L9348 Club activity, per month, 8 visits at least, child 380.00 372.00 380.00 558.00
L9349 Treatment boarding school services, per month 7,734.00 7,568.00 7,734.00 11,352.00
L9350 Club activity, per month, 8 visits at least 306.00 299.00 306.00 449.00
L9351 Occupational club activity, per day 48.00 47.00 48.00 71.00
L9352 Sheltered factory, per day 71.00 69.00 71.00 104.00
L9353 Occupational rehabilitation, extended, per day 88.00 86.00 88.00 129.00
L9354 Sheltered housing, extended, per day 94.00 92.00 94.00 138.00
L9355 School, per month, child/adolescent 1,192.00 1,166.00 1,192.00 1,749.00
L9359 Medical evaluation based on documents 133.00 130.00 133.00 195.00
L9360 Risk assessment of sex offenders 3,809.00 3,727.00 3,809.00 5,591.00
L9377 Physician services in parent home 283.00 277.00 283.00 416.00
L9379 Physician services in hostel 150.00 147.00 150.00 221.00
L9394 Physician services in boarding school 93.00 91.00 93.00 137.00
L9413 Medical records printout 48.00 47.00 48.00 71.00
L9420 Calibration of instruments for measuring radiation 769.00 752.00 769.00 1,128.00
L9480 Results reporting, free of charge 0.00 0.00 0.00 0.00
L9490 Follow up service, free of charge 0.00 0.00 0.00 0.00
L9499 Social services - coordination, connection and mediation 172.00 168.00 172.00 252.00
L9500 Medical examination, first visit - child development 718.00 703.00 718.00 1,055.00
L9501 Medical examination, follow up - child development 429.00 420.00 429.00 630.00
L9502 Psychological cognitive assessment - child development 883.00 864.00 883.00 1,296.00
L9503 Family workup and diagnosis - child development 429.00 420.00 429.00 630.00
L9504 Neuropsychological assessment - child development 1,211.00 1,185.00 1,211.00 1,778.00
L9505 Cognitive evaluation for rehabilitation - child development 1,098.00 1,074.00 1,098.00 1,611.00
L9506 Learning disabilities evaluation - child development 1,490.00 1,458.00 1,490.00 2,187.00
L9507 Multidisciplinary team for rehabilitation - child development 1,502.00 1,470.00 1,502.00 2,205.00
L9509 Patient presentation to rehabilitation/district psychiatric committee
L9510 Speech therapy, evaluation and treatment planning - child development 435.00 426.00 435.00 639.00
L9511 Aquatic physiotherapy/rehabilitation, group, up to 4 individuals, inculding child, 171.00 167.00 171.00 251.00
hydrotherapy
from
Abroad
)ILS(
L9512 Speech therapy, individual - child development 221.00 216.00 221.00 324.00
L9513 Occupational therapy, individual - child development 221.00 216.00 221.00 324.00
L9514 Physiotherapy, individual - child development 243.00 238.00 243.00 357.00
L9516 Psycho/behavioral therapy - child development 269.00 263.00 269.00 395.00
L9517 Developmental examination - nurse - child development 194.00 190.00 194.00 285.00
L9518 Family/conjoint therapy/counseling - child development 595.00 582.00 595.00 873.00
L9519 Biofeedback training - child development 478.00 468.00 478.00 702.00
L9520 Evaluation of supportive communication - child development 1,585.00 1,551.00 1,585.00 2,327.00
L9521 Staff meeting with parents - child development 532.00 521.00 532.00 782.00
L9523 Multiprofessional consulation for parents - child development 167.00 163.00 167.00 245.00
L9525 Additional consulation - child development 205.00 201.00 205.00 302.00
L9528 Physiotherapy, group - child development 176.00 172.00 176.00 258.00
L9529 Speech therapy, group - child development 176.00 172.00 176.00 258.00
L9530 Occupational therapy, group - child development 176.00 172.00 176.00 258.00
L9600 Home visit, health care professional - child development 314.00 307.00 314.00 461.00
L9611 Psychological evaluation due to physical disease 198.00 194.00 198.00 291.00
L9612 Therapeutic support, individual, due to physical disease 153.00 150.00 153.00 225.00
L9616 Neuropsychological assessment, complete battery
L9617 Neuropsychological assessment, partial battery 1,416.00 1,386.00 1,416.00 2,079.00
L9636 Additional charge for Plerixafor (Mozobil), per ampoule 32,985.00 32,985.00 32,985.00 32,985.00
L9638 Additional charge for Defibrotide (Defitelio), adult, per treatment cycle 361,890.00 361,890.00 361,890.00 361,890.00
L9639 Additional charge for Defibrotide (Defitelio), child, per treatment cycle 96,504.00 96,504.00 96,504.00 96,504.00
L9855 Induced abortion, surgical, including curettage 3,087.00 3,021.00 3,087.00 4,532.00
L9856 Induced abortion, pharmaceutical 2,224.00 2,176.00 2,224.00 3,264.00
L9857 Induced abortion, surgical, following pharmaceutical abortion 0.00 0.00 0.00 0.00
L9899 Prenatal course 671.00 657.00 671.00 986.00
L9900 Provision of therapeutic radiopharmaceutical(s) 925.00 905.00 925.00 1,358.00
L9999 Radiopharmaceutical therapy, pheochromocytoma/neuroblastoma; I-131-MIBG 30,633.00 29,974.00 30,633.00 44,961.00
G0018 Transjugular intrahepatic portosystemic stent/shunt, TIPS 37,097.00 36,298.00 37,097.00 36,298.00
G0024 Obstetric and neonatal hospitalization 3,310.00 13,705.00 6,300.00
G0026 Preterm infant hospitalization 3,310.00 217,437.00 6,300.00
G0028 Cryotherapy of prostatic cancer 39,224.00 38,380.00 39,224.00 38,380.00
G0031 Insertion of stent to abdominal aortic aneurysm, stent graft 126,210.00 123,493.00 126,210.00 123,493.00
G0032 Bone marrow transplantation, haploid, including stem cells separation 596,641.00 583,797.00 596,641.00 583,797.00
G0033 Isolated limb perfusion in patient with sarcoma 119,733.00 117,156.00 119,733.00 117,156.00
G0035 Interventional neuroradiology for intracranial aneurysm embolization/occlusion by 105,176.00 102,912.00 105,176.00 102,912.00
catheterization, including use of stent, eg, SILK, and coils
G0036 Insertion of intraocular lens, including cost of lens, inpatient care 6,181.00 6,048.00 6,181.00 9,072.00
G0037 Tension free vaging tape for incontinence (TVT) 9,494.00 9,290.00 9,494.00 9,290.00
G0045 Mastectomy, bilateral 29,041.00 28,416.00 29,041.00 28,416.00
G0047 Breast reconstruction, bilateral 47,842.00 46,812.00 47,842.00 46,812.00
G0048 Breast reconstruction following mastectomy, bilateral 72,486.00 70,926.00 72,486.00 70,926.00
G0049 Breast reconstruction following mastectomy, unilateral 43,283.00 42,351.00 43,283.00 42,351.00
G0050 Breast reconstruction, unilateral, including nipple reconstruction 28,376.00 27,765.00 28,376.00 27,765.00
G0051 Mastectomy, unilateral 19,359.00 18,942.00 19,359.00 18,942.00
G0054 Lower extremities veins surgery, including varicose veins 11,967.00 11,709.00 11,967.00 11,709.00
G0055 Blood vessels surgery, including nonautogenous graft 68,459.00 66,985.00 68,459.00 66,985.00
G0057 Lung transplantation 417,283.00 408,300.00 417,283.00 408,300.00
G0058 Heart-lung transplant 584,200.00 571,624.00 584,200.00 571,624.00
G0059 Bone marrow transplantation; allogenic 387,434.00 379,094.00 387,434.00 379,094.00
G0060 Bone marrow transplantation; autologous 254,543.00 249,064.00 254,543.00 249,064.00
G0061 Renal and/or pancreas transplantation 278,189.00 272,201.00 278,189.00 272,201.00
G0062 Heart transplantation 417,283.00 408,300.00 417,283.00 408,300.00
G0063 Liver transplantation 1,202,447.00 1,176,563.00 1,202,447.00 1,176,563.00
G0064 Corneal surgery, including cost of cornea 23,839.00 23,326.00 23,839.00 23,326.00
G0066 Inguinal/femoral hernia repair, hospital day care 4,231.00 4,140.00 4,231.00 6,210.00
G0067 Craniotomy 77,638.00 75,967.00 77,638.00 75,967.00
from
Abroad
)ILS(
G0070 Prostatectomy, open 18,445.00 18,048.00 18,445.00 18,048.00

G0074 Therapeutic catheterization, excluding cardiac catheterization 41,051.00 40,167.00 41,051.00 40,167.00
G0075 Hysterectomy 18,122.00 17,732.00 18,122.00 17,732.00
G0077 Transurethral prostatectomy 18,445.00 18,048.00 18,445.00 18,048.00
G0078 Hospital circumcision, excluding newborn, inpatient care 2,836.00 2,775.00 2,836.00 4,163.00
G0083 Osteotomy of spine, including implants, discectomy 33,781.00 33,054.00 33,781.00 33,054.00
G0084 Osteotomy of spine, including implants, excluding discectomy 62,034.00 60,699.00 62,034.00 60,699.00
G0089 Treatment of heavy burns 236,537.00 231,445.00 236,537.00 231,445.00
G0090 Treatment of medium burns 135,156.00 132,247.00 135,156.00 132,247.00
G0096 Gastric banding, laparoscopic, excluding band cost 14,821.00 14,502.00 14,821.00 14,502.00
G00A1 Transcatheter placement of an intravascular stent graft, thoracic aorta 203,228.00 198,853.00 203,228.00 198,853.00
G00A2 Hyperbaric chamber treatment of patients injured in diving accidents, up to 8 hours 40,350.00 39,481.00 40,350.00 39,481.00
G00A3 Hyperbaric chamber treatment of patients injured in diving accidents, over 8 hours, 54,730.00 53,552.00 54,730.00 53,552.00
and/or using a mixture of gases eg, Heliox
G00A4 Spermatic veins embolization, inpatient care 8,514.00 8,331.00 8,514.00 12,497.00
G00A5 Chemotherapy administration, inpatients, in addition to inpatient day charge 3,367.00 3,295.00 3,367.00 4,943.00
G00A6 Open/closed reduction with internal fixation of fracture of neck of femur or internal 31,147.00 30,477.00 31,147.00 30,477.00
fixation only of fracture of neck of femur
G00A8 Insertion of biventricular cardiac pacemaker 62,811.00 61,459.00 62,811.00 61,459.00
G00A9 Insertion of cardiac pacemaker/defibrillator, excluding machine cost
G00B1 Repair of cleft lip 22,319.00 21,839.00 22,319.00 21,839.00
G00B2 Correction of cleft palate (including Push-Back palatoplasty) 22,319.00 21,839.00 22,319.00 21,839.00
G00B3 Revision of cleft palate repair, velopharyngoplasty 22,319.00 21,839.00 22,319.00 21,839.00
G00B4 Repair of cleft lip & limited rhinoplasty, for cleft palate 22,319.00 21,839.00 22,319.00 21,839.00
G00B5 Closure of fistulae of mouth, for cleft palate 15,128.00 14,802.00 15,128.00 14,802.00
G00B6 Bone graft to facial bone, for cleft palate 26,513.00 25,942.00 26,513.00 25,942.00
G00B7 Jaw distraction osteogenesis, excluding device cost 22,319.00 21,839.00 22,319.00 21,839.00
G00C1 Fallopian tube catheterization, diagnostic or therapeutic, inpatient care 4,572.00 4,474.00 4,572.00 6,711.00
G00C2 RFA (Radiofrequency Ablation) of liver lesion(s) 17,060.00 16,693.00 17,060.00 16,693.00
G00C3 Esophageal dilation and stent placement, inpatient care 19,382.00 18,965.00 19,382.00 28,448.00
G00C5 Local excision of lesion or tissue of bone (i.e. osteoid osteoma), CT guidance 10,602.00 10,374.00 10,602.00 10,374.00
G00C6 Intra-amniotic injection for late abortion 3,836.00 3,753.00 3,836.00 3,753.00
G00C7 Arthroplasty with prosthetic replacement or implant of total or partial wrist (distal 14,282.00 13,975.00 14,282.00 13,975.00
radius, carpocarpal or carpometacarpal joints)
G00C8 Arthroplasty with prosthetic replacement or implant of foot or toe joint 24,750.00 24,217.00 24,750.00 24,217.00
G00D1 Implantation or replacement of artificial urinary sphincter 56,093.00 54,886.00 56,093.00 54,886.00
G00D2 Insertion of skin tissue expander(s), excluding breast 23,820.00 23,307.00 23,820.00 23,307.00
G00D3 Closed (percutaneous) biopsy of brain, stereotactic method including burr holes 17,933.00 17,547.00 17,933.00 17,547.00
G00D4 Orthopedic oncologic surgery, excision of soft tissues 74,758.00 73,149.00 74,758.00 73,149.00
G00D5 Orthopedic oncologic surgery, revision of an artificial joint or implant 237,929.00 232,807.00 237,929.00 232,807.00
G00D6 Orthopedic oncologic surgery, complex amputation or disarticulation 86,067.00 84,214.00 86,067.00 84,214.00
G00D7 Orthopedic oncologic surgery, destructive and reconstructive surgery 213,011.00 208,426.00 213,011.00 208,426.00
G00D8 Thoracic surgery 46,166.00 45,172.00 46,166.00 45,172.00
G00E1 Intra-arterial administration of chemotherapy or chemoembolization, under 14,710.00 14,393.00 14,710.00 14,393.00
angiography
G00E5 Insertion (initial or replacement) of single/dual chamber cardiac pacemaker 31,595.00 30,915.00 31,595.00 30,915.00
G00E6 Radical trachelectomy and lymphadenectomy 19,613.00 19,191.00 19,613.00 19,191.00
G00E7 Brachytherapy, eye 35,061.00 34,306.00 35,061.00 34,306.00
G00E9 Video and EEG monitoring, inpatient care 54,087.00 52,923.00 54,087.00 52,923.00
G00F1 Creation of arteriovenous fistula for renal dialysis, native or using graft, inpatient care 14,727.00 14,410.00 14,727.00 21,615.00
G00F2 Gastric bypass, laparoscopic 63,146.00 61,787.00 63,146.00 61,787.00

G00F3 Thoracic sympathectomy 10,458.00 10,233.00 10,458.00 10,233.00
G00F4 Thyroidectomy, complete/partial 18,934.00 18,526.00 18,934.00 18,526.00
G00F5 Gastrectomy, total/partial 64,476.00 63,088.00 64,476.00 63,088.00
G00F6 Appendectomy, laparoscopic 20,632.00 20,188.00 20,632.00 20,188.00
from
Abroad
)ILS(
G00F7 Whipple operation (radical pancreatic duodenectomy or radical subtotal 112,184.00 109,769.00 112,184.00 109,769.00
pancreatectomy)
G00F8 Vertebroplasty 11,225.00 10,983.00 11,225.00 10,983.00
G00F9 Wada test 12,250.00 11,986.00 12,250.00 11,986.00
G00G1 Catheterization, insertion of umbrella like device for repair of cardial septal defects or 82,768.00 80,986.00 82,768.00 80,986.00
patent ductus arteriosus (PDA)
G00G2 Kyphoplasty 53,190.00 52,045.00 53,190.00 52,045.00
G00G3 Mastectomy, partial (eg, lumpectomy), excludes biopsy of breast 9,816.00 9,605.00 9,816.00 9,605.00
G00G4 Brachytherapy, prostate, inpatient care 47,679.00 46,653.00 47,679.00 69,980.00
G00G5 Therapeutic catheterization of AV shunt for renal dialysis, native/with graft, inpatient 24,761.00 24,228.00 24,761.00 36,342.00
care
G00G6 Extracorporeal shockwave lithotripsy, salivary stones, inpatient care 5,696.00 5,573.00 5,696.00 8,360.00
G00G7 Deflux injection, vesicoureteral reflux therapy, unilateral, inpatient care 8,162.00 7,986.00 8,162.00 11,979.00
G00G8 Deflux injection, vesicoureteral reflux therapy, bilateral, inpatient care 14,418.00 14,108.00 14,418.00 21,162.00
G00G9 Extracorporeal shockwave lithotripsy, kidney, simple, inpatient care 7,429.00 7,269.00 7,429.00 10,904.00
G00H2 Inpatient, per day, up to 3 days in acute care hospital, excluding departments with 3,310.00 3,150.00 3,219.00 6,300.00
specific code
G00H4 Inpatient, per day, for fourth day or longer in acute care hospital, excluding 2,877.00 2,738.00 2,798.00 5,476.00
departments with specific code
G00H5 Inpatient, per day, Dermatology and Venereology Department in acute care hospital 2,877.00 2,738.00 2,798.00 5,476.00
G00H6 Inpatient, per day, Ophthalmology and Pediatric Ophthalmology Departments in acute 2,877.00 2,738.00 2,798.00 5,476.00
care hospital
G00H7 Inpatient, per day, Rehabilitation Department in acute care hospital 2,877.00 2,738.00 2,798.00 5,476.00
G00J3 Inpatient day, Acute Geriatric, Pulmonary and Tuberculosis Departments, geriatric 2,189.00 2,083.00 2,129.00 4,166.00
hospitals and centers
G00J4 Inpatient day, Geriatric Rehabilitation Department, geriatric hospitals and centers 1,368.00 1,302.00 1,331.00 2,604.00
G00J5 Inpatient day, Complex Care Nursing Department, geriatric hospitals and centers 826.00 786.00 803.00 1,572.00
G00J7 Inpatient day, Departments for the Independent, geriatric hospitals and centers 301.00 286.00 292.00 572.00
G00J8 Inpatient day, Departments for the Frail, geriatric hospitals and centers 480.00 457.00 467.00 914.00
G00M1 Inpatient day, Department of Internal Medicine in acute care hospital 2,344.00 2,230.00 2,279.00 4,460.00
G00M2 Inpatient day, Rheumatology Department in acute care hospital 2,344.00 2,230.00 2,279.00 4,460.00
G00M3 Inpatient day, Department of Pulmonary Medicine in acute care hospital 2,344.00 2,230.00 2,279.00 4,460.00
G00M4 Inpatient day, Department of Geriatric Internal Medicine in acute care hospital 2,344.00 2,230.00 2,279.00 4,460.00
G00M5 Inpatient day, Gastroenterology Department in acute care hospital 2,344.00 2,230.00 2,279.00 4,460.00
G00M6 Inpatient day, Observation Department in acute care hospital 2,344.00 2,230.00 2,279.00 4,460.00
G00N1 Inpatient day, General Intensive Care Department in acute care hospital 2,877.00 2,738.00 2,798.00 5,476.00
G00N3 Inpatient day, Respiratory Intensive Care Department in acute care hospital 2,877.00 2,738.00 2,798.00 5,476.00
G00N5 Inpatient day, Pediatric Intensive Care Department in acute care hospital 2,877.00 2,738.00 2,798.00 5,476.00
G00N7 Inpatient day, Neurosurgical Intensive Care Department in acute care hospital 2,877.00 2,738.00 2,798.00 5,476.00
G00N9 Additional inpatient day charge, Intensive Care Departments: General, Respirtory, 5,764.00 5,485.00 5,606.00 10,970.00
Pediatric and Neurosurgery, up to 4 during the same hospitalization
G00P1 Inpatient day, Acute geriatric Department in acute care hospital 1,742.00 1,658.00 1,694.00 3,316.00
G00P2 Inpatient day, Geriatric Rehabilitation Department in acute care hospital 1,742.00 1,658.00 1,694.00 3,316.00
G00P3 Inpatient day, Department of high Dependency Nursing in acute care hospital 1,742.00 1,658.00 1,694.00 3,316.00
G00Q1 Acute inpatient day, psychiatric department 1,259.00 1,198.00 1,224.00 2,396.00
G00Q2 Long term inpatient day, psychiatric department 968.00 921.00 941.00 1,842.00
G00Q3 Inpatient day, children and adolescents, psychiatric department 1,510.00 1,437.00 1,469.00 2,874.00
G00Q4 Inpatient day, secure acute psychiatric department 1,259.00 1,198.00 1,224.00 2,396.00
G00Q5 Hospitalization leave for acclimatization, per day, adult, psychiatric department 482.00 459.00 469.00 918.00
G00Q6 Hospitalization leave for acclimatization, per day, children and adolescents, 516.00 491.00 502.00 982.00
psychiatric department
G00Q7 Artificial liver therapy, eg, MARS, additional inpatient day charge 29,629.00 28,991.00 29,629.00 43,487.00
G00Q8 Chronic artificial ventilation care, per day, all hospitals 1,859.00 1,769.00 1,808.00 3,538.00
G00R1 Extracorporeal shockwave lithotripsy, kidney, complex, inpatient care 23,316.00 22,814.00 23,316.00 34,221.00
G00R2 Biopsy, CT guidance, inpatient care 5,609.00 5,488.00 5,609.00 8,232.00
G00R3 Biopsy, MRI guidance, excluding breast, inpatient care 8,414.00 8,233.00 8,414.00 12,350.00
G00R4 Continuous intra-arterial administration of chemotherapeutic substance 22,421.00 21,938.00 22,421.00 21,938.00
from
Abroad
)ILS(
G00R5 Vertebral excision and fusion 194,660.00 190,470.00 194,660.00 190,470.00

G00R6 Vertebral refusion 237,929.00 232,807.00 237,929.00 232,807.00
G00R7 Secondary insertion of intraocular lens prosthesis 3,933.00 3,848.00 3,933.00 3,848.00
G00R8 Single suture loop pupilloplasty 6,294.00 6,159.00 6,294.00 6,159.00
G00R9 Vitrectomy 17,047.00 16,680.00 17,047.00 16,680.00
G00S1 Bronchoscopy with bronchial stent(s) placement, inpatient care 14,495.00 14,183.00 14,495.00 21,275.00
G00S4 Radical neck lymph nodes dissection, unilateral/bilateral 31,033.00 30,365.00 31,033.00 30,365.00
G00S5 Lobectomy of liver 91,873.00 89,895.00 91,873.00 89,895.00
G00S6 Partial hepatectomy 51,424.00 50,317.00 51,424.00 50,317.00
G00S7 Maxillectomy/mandibulectomy, partial/total, including immediate insertion of 44,192.00 43,241.00 44,192.00 43,241.00
surgical obturator
G00S8 Stereotactic radiosurgery, brain 55,055.00 53,870.00 55,055.00 53,870.00
G00S9 Implantation of heart assist system 633,236.00 619,605.00 633,236.00 619,605.00
G00T3 Isolated limb perfusion in patient with melanoma 119,733.00 117,156.00 119,733.00 117,156.00
G00T4 Colonoscopy with dilation and stent placement, inpatient care 19,382.00 18,965.00 19,382.00 28,448.00
G00T5 Removal of heart pacemaker lead(s) (electrodes) without replacement 39,139.00 38,296.00 39,139.00 38,296.00
G00T6 Removal of heart pacemaker lead(s) (electrodes) with replacement of electrodes and 54,939.00 53,756.00 54,939.00 53,756.00
pacemaker device
G00T7 Scoliosis/kyphosis repair operation 137,308.00 134,352.00 137,308.00 134,352.00
G00T8 Emergency coronary artery catheterization for removal of obstruction, including 60,722.00 59,415.00 60,722.00 59,415.00
insertion of drug eluting stent(s)
G00T9 Radical hysterectomy, abdominal/vaginal 28,049.00 27,445.00 28,049.00 27,445.00
G00U1 Colorectal surgery 56,202.00 54,992.00 56,202.00 54,992.00
G00U2 Surgical fistulization of lacrimal tract to nasal cavity using balloon dilatation, 8,170.00 7,994.00 8,170.00 7,994.00
including dacryocystorhinostomy
G00U3 Intravenous injection of rtPA, acute cerebrovascular stroke within 4.5 hours of stroke 49,082.00 48,025.00 49,082.00 48,025.00
symptoms onset
G00U4 Therapeutic catheterization, acute cerebrovascular stroke within 8 hours of stroke 126,210.00 123,493.00 126,210.00 123,493.00
symptoms onset
G00U5 Functional endoscopic nasal/sinus surgery (FESS), simple 16,826.00 16,464.00 16,826.00 16,464.00
G00U6 Functional endoscopic nasal/sinus surgery (FESS), complex 40,376.00 39,507.00 40,376.00 39,507.00
G00U7 Tonsillectomy without/with adenoidectomy 5,875.00 5,749.00 5,875.00 5,749.00
G00U9 Enucleation of eyeball 16,872.00 16,509.00 16,872.00 16,509.00
G00V2 Lengthening and adjustment of vertical expandable prosthetic titanium rib system 27,314.00 26,726.00 27,314.00 26,726.00
G00V3 Replacement of vertical expandable prosthetic titanium rib system implants 61,136.00 59,820.00 61,136.00 59,820.00
G00V4 Percutaneous pulmonary valve replacement, excluding valve cost 46,128.00 45,135.00 46,128.00 45,135.00
G00V5 Percutaneous aortic valve replacement, excluding valve cost 52,505.00 51,375.00 52,505.00 51,375.00
G00V6 Repair of inguinal/femoral hernia, unilateral, inpatient care 12,098.00 11,838.00 12,098.00 11,838.00
G00V7 Repair of inguinal/femoral hernia, bilateral, inpatient care 16,128.00 15,781.00 16,128.00 15,781.00
G00V8 Plastic surgery following significant weight loss 38,434.00 37,607.00 38,434.00 37,607.00
G00V9 Bone graft to maxilla/mandible, autogenic graft from pelvis/scalp 35,606.00 34,840.00 35,606.00 34,840.00
G00W1 Scleral buckling, with/without implant 12,063.00 11,803.00 12,063.00 11,803.00
G00W2 Trabeculectomy 5,837.00 5,711.00 5,837.00 5,711.00
G00W3 Intraocular valve implantation, eg, Ahmed, for glaucoma therapy 15,967.00 15,623.00 15,967.00 15,623.00
G00W4 Repair of blepharoptosis, under 18 years, unilateral/bilateral 9,315.00 9,114.00 9,315.00 9,114.00
G00W5 Repair of blepharoptosis, 18 years and older, unilateral/bilateral 5,769.00 5,645.00 5,769.00 5,645.00
G0100 Additional charge for DRG in multiple trauma, admission from ER 14,022.00 13,720.00 14,022.00 13,720.00
G0101 ORIF/CRIF of pelvis, closed/open fracture 69,331.00 67,839.00 69,331.00 67,839.00
G0102 Arthroplasty with prosthetic replacement/implant of radial head, excluding open 40,568.00 39,695.00 40,568.00 39,695.00
fracture
G0103 Arthroplasty with prosthetic replacement/implant of radial head, open fracture 63,402.00 62,037.00 63,402.00 62,037.00
G0104 ORIF of foot, closed fracture, excluding calcaneus 43,370.00 42,436.00 43,370.00 42,436.00
G0105 ORIF of foot, open fracture, excluding calcaneus 63,402.00 62,037.00 63,402.00 62,037.00
G0106 ORIF of calcaneus/operation on femur, excluding neck of femur, closed fracture 34,821.00 34,071.00 34,821.00 34,071.00
G0107 ORIF of calcaneus/operation on femur, excluding neck of femur, open fracture 53,398.00 52,249.00 53,398.00 52,249.00
G0108 Operation on clavicle/humerus/forearm, closed fracture, including closed dislocation 29,850.00 29,207.00 29,850.00 29,207.00
of acromioclavicular joint, excluding distal humerus and shaft of radius/ulna,
including bone graft
from
Abroad
)ILS(
G0109 Operation on clavicle/humerus/forearm, open fracture, including open dislocation of 43,077.00 42,150.00 43,077.00 42,150.00
acromioclavicular joint, excluding distal humerus and shaft of radius/ulna
G0110 ORIF/CRIF/EF of tibia and/or fibula, closed fracture 40,094.00 39,231.00 40,094.00 39,231.00
G0111 ORIF/CRIF/EF of tibia and/or fibula, open fracture, including use of bone marrow 67,719.00 66,261.00 67,719.00 66,261.00
aspiration concentrate
G0112 ORIF of patella/ankle / CRIF of calcaneus, closed fracture 23,917.00 23,402.00 23,917.00 23,402.00
G0113 ORIF of patella/ankle / CRIF of calcaneus, open fracture 38,755.00 37,921.00 38,755.00 37,921.00
G0114 CRIF of ankle/foot, closed fracture, excluding calcaneus 15,609.00 15,273.00 15,609.00 15,273.00
G0115 CRIF of ankle/foot, open fracture, excluding calcaneus 26,867.00 26,289.00 26,867.00 26,289.00
G0116 Exploration of tendon/nerve of upper limb, including ganglion decompression/lysis of 8,975.00 8,782.00 8,975.00 8,782.00
adhesions
G0117 Suture of extensor tendons of hand, including delayed suture 14,827.00 14,508.00 14,827.00 14,508.00
G0118 Suture of tendons/nerves of upper limb, including delayed suture, excluding extensor 25,557.00 25,007.00 25,557.00 25,007.00
tendons of hand
G0120 ORIF/EF of phalange of hand, closed fracture, including bone graft 17,674.00 17,294.00 17,674.00 17,294.00
G0121 ORIF/EF of phalange of hand, open/complex fracture 24,090.00 23,571.00 24,090.00 23,571.00
G0122 ORIF/EF of phalange of hand, with suture of tendons/nerves, closed/open fracture 33,917.00 33,187.00 33,917.00 33,187.00
G0123 ORIF/EF of phalanges of hand, closed fractures, including bone graft 24,586.00 24,057.00 24,586.00 24,057.00
G0124 ORIF/EF of phalanges of hand, open/complex fractures 31,522.00 30,843.00 31,522.00 30,843.00
G0125 ORIF/EF of phalanges of hand, with suture of tendons/nerves, closed/open fractures 41,528.00 40,634.00 41,528.00 40,634.00
G0126 ORIF/EF of metacarpal, closed fracture, including bone graft 19,115.00 18,704.00 19,115.00 18,704.00
G0127 ORIF/EF of metacarpal, open/complex fracture 24,724.00 24,192.00 24,724.00 24,192.00
G0128 ORIF/EF of metacarpal, with suture of tendons/nerves, closed/open fracture 35,430.00 34,667.00 35,430.00 34,667.00
G0129 ORIF/EF of metacarpals, closed fractures, including bone graft 28,381.00 27,770.00 28,381.00 27,770.00
G0130 ORIF/EF of metacarpals, open/complex fractures 35,563.00 34,797.00 35,563.00 34,797.00
G0131 ORIF/EF of metacarpals, with suture of tendons/nerves, closed/open fractures 43,548.00 42,611.00 43,548.00 42,611.00
G0132 ORIF of carpal(s), closed fracture, including bone graft 24,245.00 23,723.00 24,245.00 23,723.00
G0133 ORIF of carpal(s), open/complex fracture, including bone graft 30,655.00 29,995.00 30,655.00 29,995.00
G0134 ORIF of carpal(s), with suture of tendons/nerves, closed/open fracture, including bone 40,906.00 40,025.00 40,906.00 40,025.00
graft
G0135 CRIF of hand, with suture of tendons/nerves, closed/open fracture(s) 36,274.00 35,493.00 36,274.00 35,493.00
G0136 Open reduction of closed dislocation of wrist 28,381.00 27,770.00 28,381.00 27,770.00
G0137 Open reduction of open/complex dislocation of wrist 35,563.00 34,797.00 35,563.00 34,797.00
G0138 Open reduction of dislocation of wrist, with suture of tendons/nerves 43,548.00 42,611.00 43,548.00 42,611.00
G0139 Reattachment of any part of upper extremity 76,963.00 75,306.00 76,963.00 75,306.00
G0140 Open/close reduction of fracture(s) of zygoma/maxilla/mandible, including internal 25,961.00 25,402.00 25,961.00 25,402.00
fixation
G0141 Open reduction of fractures of orbit/ Le Fort type 2 or 3 / TMJ fracture with 40,040.00 39,178.00 40,040.00 39,178.00
dislocation, with insertion of synthetic implant/bone graft to facial bone
G0142 Open reduction of comminuted fractures of facial bones, with insertion of synthetic 115,121.00 112,643.00 115,121.00 112,643.00
implant/bone graft
G0144 ORIF of distal humerus, closed fracture, including bone graft 40,568.00 39,695.00 40,568.00 39,695.00
G0145 ORIF of distal humerus, open fracture 63,402.00 62,037.00 63,402.00 62,037.00
G0146 ORIF/EF of shaft of radius/ulna, closed fracture, including bone graft 22,119.00 21,643.00 22,119.00 21,643.00
G0147 ORIF/EF of shaft of radius/ulna, open fracture 38,755.00 37,921.00 38,755.00 37,921.00
G0148 CRIF of distal humerus/forearm/hand, closed fracture, including bone graft 14,490.00 14,178.00 14,490.00 14,178.00
G0149 CRIF of distal humerus/forearm/hand, open fracture, including complex fracture(s) of 26,867.00 26,289.00 26,867.00 26,289.00
hand
G0150 Removal of gastric band 14,821.00 14,502.00 14,821.00 14,502.00
G0151 Sleeve gastrectomy 51,182.00 50,080.00 51,182.00 50,080.00
G0152 Sleeve gastrectomy with removal of gastric band 52,514.00 51,384.00 52,514.00 51,384.00
G0153 Sleeve gastrectomy with repair of diaphragmatic hernia 52,514.00 51,384.00 52,514.00 51,384.00
G0154 Sleeve gastrectomy with total cholecystectomy 54,145.00 52,979.00 54,145.00 52,979.00
G0155 Gastric bypass surgery with removal of gastric band 64,484.00 63,096.00 64,484.00 63,096.00
G0156 Gastric bypass surgery with repair of diaphragmatic hernia 64,484.00 63,096.00 64,484.00 63,096.00
G0157 Gastric bypass surgery with total cholecystectomy 66,001.00 64,580.00 66,001.00 64,580.00
from
Abroad
)ILS(
G0158 Ovarian tissue retrieval, laparoscopic 7,980.00 7,808.00 7,980.00 7,808.00

G0159 Transplantation of cryopreserved ovarian tissue 16,243.00 15,893.00 16,243.00 15,893.00
G0160 Implantation/replacement/removal of cochlear prosthetic device, excluding device 17,905.00 17,520.00 17,905.00 17,520.00
cost
G0161 Repair of cystocele with graft/prosthesis 13,013.00 12,733.00 13,013.00 12,733.00
G0162 Repair of rectocele with graft/prosthesis 13,013.00 12,733.00 13,013.00 12,733.00
G0163 Repair of cystocele and rectocele with graft/prosthesis 21,184.00 20,728.00 21,184.00 20,728.00
G0164 Repair of cystocele with graft/prosthesis and tension free vaging tape for incontinence 19,294.00 18,879.00 19,294.00 18,879.00
G0165 Repair of rectocele with graft/prosthesis and tension free vaging tape for incontinence 19,294.00 18,879.00 19,294.00 18,879.00
G0166 Repair of cystocele and rectocele with graft/prosthesis and tension free vaging tape for 27,465.00 26,874.00 27,465.00 26,874.00
incontinence
G0167 Percutaneous insertion of left atrial appendage device, excluding device cost 14,802.00 14,483.00 14,802.00 14,483.00
G0168 Implantation of diaphragmatic pacemaker, excluding device cost 19,122.00 18,710.00 19,122.00 18,710.00
G0169 Pump for spasticity treatment preimplantation assessment, Baclofen 15,918.00 15,575.00 15,918.00 15,575.00
G0170 Implantation of pump for chronic pain management/spasticity treatment, with drug 16,446.00 16,092.00 16,446.00 16,092.00
loading, eg, Baclofen/Morphine, excluding pump cost
G0171 Heart surgery, valves 82,768.00 80,986.00 82,768.00 80,986.00
G0172 Heart surgery, bypass 82,768.00 80,986.00 82,768.00 80,986.00
G0173 Heart surgery, valves and bypass 82,768.00 80,986.00 82,768.00 80,986.00
G0174 Heart surgery, excluding valves and bypass surgery 82,768.00 80,986.00 82,768.00 80,986.00
G0175 Cholecystectomy, open, partial/complete 19,416.00 18,998.00 19,416.00 18,998.00
G0176 Cholecystectomy, laparoscopic, partial/complete 19,416.00 18,998.00 19,416.00 18,998.00
G0177 Implantation of vertical expandable prosthetic titanium rib system, excluding system 29,489.00 28,854.00 29,489.00 28,854.00
cost
G0178 Implantation of BAHA (Bone Anchored Hearing Aid), excluding device cost 11,543.00 11,295.00 11,543.00 11,295.00
G0179 Diagnostic catheterization, excluding cardiac catheterization 16,010.00 15,665.00 16,010.00 15,665.00
G0180 Implantation of VNS (Vagus Nerve Stimulator) kit for epilepsy treatment, excluding 18,562.00 18,162.00 18,562.00 18,162.00
device cost
G0181 Diagnostic cardiac catheterization 16,010.00 15,665.00 16,010.00 15,665.00
G0182 Implantation of intracranial neurostimulator pulse generator kit, including leads, or 37,128.00 36,329.00 37,128.00 36,329.00
replacement of leads, excluding devices cost
G0184 Therapeutic cardiac catheterization, excision/destruction of lesion/tissue of heart 44,990.00 44,022.00 44,990.00 44,022.00
G0185 Therapeutic cardiac catheterization, coronary arteries 44,990.00 44,022.00 44,990.00 44,022.00
G0186 Percutaneous balloon valvuloplasty 44,990.00 44,022.00 44,990.00 44,022.00
G0187 Replacement of neurostimulator pulse generator for intracranial stimulation, without 18,562.00 18,162.00 18,562.00 18,162.00
leads, excluding device cost
G0188 Parathyroidectomy, partial 21,590.00 21,125.00 21,590.00 21,125.00
G0189 Parathyroidectomy, complete 21,590.00 21,125.00 21,590.00 21,125.00
G0190 Type 2/3 tympanoplasty, including replacement of auditory ossicles 14,253.00 13,946.00 14,253.00 13,946.00
G0191 Simple mastoidectomy 25,552.00 25,002.00 25,552.00 25,002.00
G0192 Radical mastoidectomy, including modified radical mastoidectomy 32,078.00 31,387.00 32,078.00 31,387.00
G0193 Myringoplasty, including perforation closure 15,833.00 15,492.00 15,833.00 15,492.00
G0194 Excision of salivary glands, excluding parotid, partial/complete 17,407.00 17,032.00 17,407.00 17,032.00
G0195 Excision/destruction of vocal cord(s) lesion/tissue 14,107.00 13,803.00 14,107.00 13,803.00
G0196 Excision of vocal cord(s) 24,321.00 23,797.00 24,321.00 23,797.00
G0197 Maxillectomy/mandibulectomy with microsurgical reconstruction 78,814.00 77,117.00 78,814.00 77,117.00
G01H4 Inpatient, per day, for fourth day or longer in acute care hospital, excluding 2,877.00 2,738.00 2,798.00 5,476.00
departments with specific code - out of cap
G01H5 Inpatient, per day, Dermatology and Venereology Department in acute care hospital - 2,877.00 2,738.00 2,798.00 5,476.00
out of cap
G01H6 Inpatient, per day, Ophthalmology and Pediatric Ophthalmology Departments in acute 2,877.00 2,738.00 2,798.00 5,476.00
care hospital - out of cap
G01H7 Inpatient, per day, Rehabilitation Department in acute care hospital - out of cap 2,877.00 2,738.00 2,798.00 5,476.00
G01M1 Inpatient day, Department of Internal Medicine in acute care hospital - out of cap 2,344.00 2,230.00 2,279.00 4,460.00
G01M2 Inpatient day, Rheumatology Department in acute care hospital - out of cap 2,344.00 2,230.00 2,279.00 4,460.00
from
Abroad
)ILS(
G01M3 Inpatient day, Department of Pulmonary Medicine in acute care hospital - out of cap 2,344.00 2,230.00 2,279.00 4,460.00
G01M4 Inpatient day, Department of Geriatric Internal Medicine in acute care hospital - out of 2,344.00 2,230.00 2,279.00 4,460.00
cap
G01M5 Inpatient day, Gastroenterology Department in acute care hospital - out of cap 2,344.00 2,230.00 2,279.00 4,460.00
G01M6 Inpatient day, Observation Department in acute care hospital - out of cap 2,344.00 2,230.00 2,279.00 4,460.00
G01N1 Inpatient day, General Intensive Care Department in acute care hospital - out of cap 2,877.00 2,738.00 2,798.00 5,476.00
G01N3 Inpatient day, Respiratory Intensive Care Department in acute care hospital - out of 2,877.00 2,738.00 2,798.00 5,476.00
cap
G01N5 Inpatient day, Pediatric Intensive Care Department in acute care hospital - out of cap 2,877.00 2,738.00 2,798.00 5,476.00
G01N7 Inpatient day, Neurosurgical Intensive Care Department in acute care hospital - out of 2,877.00 2,738.00 2,798.00 5,476.00
cap
G01P1 Inpatient day, Acute geriatric Department in acute care hospital - out of cap 1,742.00 1,658.00 1,694.00 3,316.00
G01P2 Inpatient day, Geriatric Rehabilitation Department in acute care hospital - out of cap 1,742.00 1,658.00 1,694.00 3,316.00
G01P3 Inpatient day, Department of high Dependency Nursing in acute care hospital - out of 1,742.00 1,658.00 1,694.00 3,316.00
cap
G01Q8 Chronic artificial ventilation care, per day, all hospitals - out of cap 1,859.00 1,769.00 1,808.00 3,538.00
G0200 POVH (Postoperative Ventral Hernia) repair, open 31,868.00 31,182.00 31,868.00 31,182.00
G0201 POVH (Postoperative Ventral Hernia) repair, laparoscopic 31,868.00 31,182.00 31,868.00 31,182.00
G0202 Anterior abdominal wall hernia repair, excluding POVH, open 22,689.00 22,201.00 22,689.00 22,201.00
G0203 Anterior abdominal wall hernia repair, excluding POVH, laparoscopic 22,689.00 22,201.00 22,689.00 22,201.00
G0204 Diaphragmatic hernia repair, laparoscopic 29,599.00 28,962.00 29,599.00 28,962.00
G0206 Umbilical hernia repair, age 5 years or older, open 14,529.00 14,216.00 14,529.00 14,216.00
G0207 Umbilical hernia repair, age 5 years or older, laparoscopic 14,529.00 14,216.00 14,529.00 14,216.00
G0208 Esophagogastric sphincteric competence creation 32,726.00 32,022.00 32,726.00 32,022.00
G0209 Cytoreductive surgery and HIPEC (Hyperthermic Intraperitoneal Chemotherapy) 106,669.00 104,373.00 106,669.00 104,373.00
G0210 Percutaneous nephrostomy, including fragmentation 41,915.00 41,013.00 41,915.00 41,013.00
G0211 RFA (Radiofrequency Ablation) of renal lesion(s) 17,060.00 16,693.00 17,060.00 16,693.00
G0214 Partial nephrectomy, open 39,337.00 38,490.00 39,337.00 38,490.00
G0215 Partial nephrectomy, laparoscopic 39,337.00 38,490.00 39,337.00 38,490.00
G0216 Complete nephrectomy, including ureterectomy, open 41,650.00 40,753.00 41,650.00 40,753.00
G0217 Complete nephrectomy, including ureterectomy, laparoscopic 41,650.00 40,753.00 41,650.00 40,753.00
G0220 Ureteroscopy, diagnostic, with/without biopsy 13,342.00 13,055.00 13,342.00 13,055.00
G0221 Ureteroscopy, therapeutic, including RIRS 20,487.00 20,046.00 20,487.00 20,046.00
G0225 Endoscopic excision of rectal tumor, transanal approach 8,859.00 8,668.00 8,859.00 8,668.00
G0229 Excision of hemorrhoids 5,759.00 5,635.00 5,759.00 5,635.00
G0230 Salpingectomy, laparoscopic, unilateral/bilateral 15,779.00 15,439.00 15,779.00 15,439.00
G0231 Salpingo-oophorectomy, laparoscopic, unilateral/bilateral 15,779.00 15,439.00 15,779.00 15,439.00
G0240 Reduction mammoplasty, female, excluding surgery following significant weight loss 18,880.00 18,474.00 18,880.00 18,474.00
G0241 Reduction mammoplasty, male, excluding surgery following significant weight loss 14,773.00 14,455.00 14,773.00 14,455.00
G0250 Corneal surgery with insertion of intraocular lens, including cost of cornea and lens 27,237.00 26,651.00 27,237.00 26,651.00
G0251 Insertion of intraocular lens with trabeculectomy, including cost of lens 7,985.00 7,813.00 7,985.00 7,813.00
G0252 Vitrectomy with insertion of intraocular lens, including cost of lens 20,699.00 20,253.00 20,699.00 20,253.00
G0253 Vitrectomy with scleral buckling, with/without implant 21,128.00 20,673.00 21,128.00 20,673.00
G0254 Single suture loop pupilloplasty with insertion of intraocular lens, including cost of 10,343.00 10,120.00 10,343.00 10,120.00
lens
G0255 Single suture loop pupilloplasty with secondary insertion of intraocular lens, including 9,322.00 9,121.00 9,322.00 9,121.00
cost of lens
G0256 Repair of corneal injury 12,353.00 12,087.00 12,353.00 12,087.00
G0257 Repair of retinal detachment by injection of gas 8,844.00 8,654.00 8,844.00 8,654.00
G0258 Foreign body removal from posterior segment of eye, with/ without use of magnet 20,225.00 19,790.00 20,225.00 19,790.00
G0259 Diagnostic aspiration of vitreous 14,955.00 14,633.00 14,955.00 14,633.00
from
Abroad
)ILS(
G0260 Excision of lesion of orbit 18,944.00 18,536.00 18,944.00 18,536.00

G0265 Focused US treatment for essential tremor and Parkinson, MRI guidance 80,008.00 78,286.00 80,008.00 78,286.00
G0269 RFA (Radiofrequency Ablation) of pulmonary lesion(s) 17,060.00 16,693.00 17,060.00 16,693.00
G0270 Radical prostatectomy, open 33,229.00 32,514.00 33,229.00 32,514.00
G0277 Radical prostatectomy, laparoscopic 33,229.00 32,514.00 33,229.00 32,514.00
G0280 SIRT (Selective Internal Radiation Therapy) for liver tumor, 90Y, excluding material 51,513.00 50,404.00 51,513.00 50,404.00
cost
G0287 Orthognathic surgery of jaw, excluding distraction osteogenesis 27,195.00 26,610.00 27,195.00 26,610.00
G0288 Orthognathic surgery of jaws for severe congenital functional disorder, excluding 36,366.00 35,583.00 36,366.00 35,583.00
distraction osteogenesis
G0289 Orthognathic surgery of jaws for severe developmental functional disorder, excluding 36,366.00 35,583.00 36,366.00 35,583.00
distraction osteogenesis
G0290 Splenectomy, open, partial/complete 31,088.00 30,419.00 31,088.00 30,419.00
G0291 Splenectomy, laparoscopic, partial/complete 31,088.00 30,419.00 31,088.00 30,419.00
G0292 Partial pancreatectomy, open 37,795.00 36,981.00 37,795.00 36,981.00
G0293 Partial pancreatectomy, laparoscopic 37,795.00 36,981.00 37,795.00 36,981.00
G0300 Percutaneous mitral valve repair with implanted device, excluding device cost 23,210.00 22,710.00 23,210.00 22,710.00
G0303 Implantation of total internal biventricular artificial heart system, excluding system 135,449.00 132,533.00 135,449.00 132,533.00
cost
G0310 Partial hip replacement for fracture of neck of femur, within 48 hours of 58,899.00 57,631.00 58,899.00 57,631.00
hospitalization
G0311 Total hip replacement for fracture of neck of femur, within 48 hours of hospitalization 65,554.00 64,143.00 65,554.00 64,143.00
G0312 Hip replacement, primary, excluding for fracture 43,280.00 42,348.00 43,280.00 42,348.00
G0313 Total knee replacement, primary 43,280.00 42,348.00 43,280.00 42,348.00
G0314 Total ankle replacement, primary 43,280.00 42,348.00 43,280.00 42,348.00
G0315 Total shoulder replacement, primary 43,280.00 42,348.00 43,280.00 42,348.00
G0316 Partial shoulder replacement, primary 39,266.00 38,421.00 39,266.00 38,421.00
G0317 Metacarpophalangeal and interphalangeal joint replacement, including arthroplasty 18,879.00 18,473.00 18,879.00 18,473.00
without implant
G0318 Hip/knee liner replacement, revision 43,280.00 42,348.00 43,280.00 42,348.00
G0319 Joint replacement, revision, excluding liner replacement and first stage for infection 74,653.00 73,046.00 74,653.00 73,046.00
G0320 Joint replacement, revision, first stage for infection, including spacer implantation 36,538.00 35,751.00 36,538.00 35,751.00
G0321 Joint replacement, revision, two stage for infection, during the same hospitalization 94,671.00 92,633.00 94,671.00 92,633.00
G0322 Pelvic osteotomy for CDH/DDH (Congenital/Developmental Dislocation of Hip) 22,463.00 21,979.00 22,463.00 21,979.00
treatment, child
G0323 Femoral osteotomy for CDH/DDH (Congenital/Developmental Dislocation of Hip) 24,160.00 23,640.00 24,160.00 23,640.00
treatment, child
G0324 Hip arthrotomy for CDH/DDH (Congenital/Developmental Dislocation of Hip) 27,802.00 27,204.00 27,802.00 27,204.00
treatment, child
G0325 Shoulder arthroscopy, simple, inpatient care 10,928.00 10,693.00 10,928.00 16,040.00
G0326 Shoulder arthroscopy, complex, inpatient care 24,035.00 23,518.00 24,035.00 35,277.00
G0327 Elbow/wrist/hand and finger arthroscopy, simple, inpatient care 13,110.00 12,828.00 13,110.00 19,242.00
G0328 Elbow arthroscopy, complex, inpatient care 19,182.00 18,769.00 19,182.00 28,154.00
G0329 Hip arthroscopy, simple, inpatient care 21,850.00 21,380.00 21,850.00 32,070.00
G0330 Hip arthroscopy, complex, inpatient care 32,780.00 32,074.00 32,780.00 48,111.00
G0331 Knee arthroscopy, simple, inpatient care 8,414.00 8,233.00 8,414.00 12,350.00
G0332 Knee arthroscopy, complex, inpatient care 20,528.00 20,086.00 20,528.00 30,129.00
G0333 Ankle/foot and toe arthroscopy, simple, inpatient care 11,862.00 11,607.00 11,862.00 17,411.00
G0334 Ankle arthroscopy, complex, inpatient care 16,827.00 16,465.00 16,827.00 24,698.00
G0335 Arthroscopy, simple/complex, excluding procedures with specific code, inpatient care 8,414.00 8,233.00 8,414.00 12,350.00
G0336 Subtalar arthrodesis 14,377.00 14,068.00 14,377.00 14,068.00

G0337 Triple arthrodesis 19,260.00 18,845.00 19,260.00 18,845.00
G0338 Ankle arthrodesis, tibiotalar/fibulotalar 20,702.00 20,256.00 20,702.00 20,256.00
from
Abroad
)ILS(
G0339 Ankle arthrodesis, tibiotalar/talofibular, with subtalar/triple arthrodesis 18,893.00 18,486.00 18,893.00 18,486.00
G0340 Midtarsal/tarsometatarsal arthrodesis 11,740.00 11,487.00 11,740.00 11,487.00
G0341 Wrist arthrodesis, radiocarpal 26,497.00 25,927.00 26,497.00 25,927.00
G0342 Wrist arthrodesis, carpometacarpal 9,047.00 8,852.00 9,047.00 8,852.00
G0343 Wrist arthrodesis, total 21,339.00 20,880.00 21,339.00 20,880.00
G0344 Tendon/ligament release, child, excluding for clubfoot 15,930.00 15,587.00 15,930.00 15,587.00
G0345 Tendons/ligaments release, child, excluding for clubfoot 16,389.00 16,036.00 16,389.00 16,036.00
G0346 Tendon/ligament release for clubfoot, child 17,294.00 16,922.00 17,294.00 16,922.00
G0347 Tendon of hand transfer/transplantation 11,895.00 11,639.00 11,895.00 11,639.00
G0348 Tendon of foot transfer/transplantation 14,630.00 14,315.00 14,630.00 14,315.00
G0349 Lower limb epiphyseal stapling, including external/internal fixation 28,093.00 27,488.00 28,093.00 27,488.00
G0350 Lower limb lengthening for deformity correction, including external/internal fixation 97,977.00 95,868.00 97,977.00 95,868.00
G0369 Pump for chronic pain management preimplantation assessment 9,103.00 8,907.00 9,103.00 8,907.00
G0371 Auricular and middle ear reconstruction, first stage 57,562.00 56,323.00 57,562.00 56,323.00
G0372 Auricular and middle ear reconstruction, second stage 53,187.00 52,042.00 53,187.00 52,042.00
G0373 Auricular and middle ear reconstruction, third stage 19,033.00 18,623.00 19,033.00 18,623.00
G0374 Auricular reconstruction without middle ear, first stage 53,799.00 52,641.00 53,799.00 52,641.00
G0375 Auricular reconstruction without middle ear, second stage 33,809.00 33,081.00 33,809.00 33,081.00
G0376 Auricular reconstruction without middle ear, third stage 8,119.00 7,944.00 8,119.00 7,944.00

Ministry of Health Price List For Ambulatory and Hospitalization Services

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Ministry of Health Price List For Ambulatory and Hospitalization Services

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Ministry of Health Price List for Ambulatory and Hospitalization Services

Onset date: 01/07/18

Service Service name Price A Price B Price C Price for

36513 Therapeutic apheresis, for platelets 3,256.00 3,186.00 3,256.00 4,779.00

36522 Photopheresis, extracorporeal 8,556.00 8,372.00 8,556.00 12,558.00

69000 Puncture/drainage external ear abscess/hematoma 280.00 274.00 280.00 411.00

74181 Abdominal MRI, per patient 2,034.00 1,990.00 2,034.00 2,985.00

82180 Vitamin C, ascorbic acid - blood 150.00 147.00 150.00 221.00

82787 Gammaglobulin, immunoglobulin subclasses 779.00 762.00 779.00 1,143.00

83874 Myoglobin 291.00 285.00 291.00 428.00

84075 Alkaline phosphatase 19.00 19.00 19.00 29.00

85170 Clot retraction 128.00 125.00 128.00 188.00

87252 Virus isolation, tissue culture 155.00 152.00 155.00 228.00

90901 Biofeedback training 478.00 468.00 478.00 702.00

93797 Cardiac rehabilitation, per month 986.00 965.00 986.00 1,448.00

D2335 Resin-based composite restoration, anterior 598.00 585.00 598.00 878.00

D8210 Removable dental appliance therapy 953.00 932.00 953.00 1,398.00

L0560 Internal hospital day care 1,397.00 1,367.00 1,397.00 2,051.00

L4110 Porphobilinogen deaminase, quantitative - RBC 504.00 493.00 504.00 740.00

L6015 Gliadin Ab 253.00 248.00 253.00 372.00

L7946 Radiotherapy, prostate, with lymph nodes, IMRT

L8410 Porphyrins, qualitative - plasma 172.00 168.00 172.00 252.00

L9262 Physician examination, vascular surgeon 279.00 147.00 150.00 410.00

G0070 Prostatectomy, open 18,445.00 18,048.00 18,445.00 18,048.00

G00F2 Gastric bypass, laparoscopic 63,146.00 61,787.00 63,146.00 61,787.00

G00R5 Vertebral excision and fusion 194,660.00 190,470.00 194,660.00 190,470.00

G0158 Ovarian tissue retrieval, laparoscopic 7,980.00 7,808.00 7,980.00 7,808.00

G0260 Excision of lesion of orbit 18,944.00 18,536.00 18,944.00 18,536.00

G0336 Subtalar arthrodesis 14,377.00 14,068.00 14,377.00 14,068.00

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