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Ambulatory Surgery Unit

As of August 31, 2022

ServiceRateProfessional Fee
MinimumMaximum
ALVEOLOPLASTY 18,000.00 8,400.00 8,400.00
APPLICATION OF BODY CAST, SHOULDER TO HIPS; ELBOW TO FINGER (SHORT ARM) 5,560.00 1,260.00 1,260.00
Application of body cast, shoulder to hips; hand and lower forearm (gauntlet) 5,560.00 1,260.00 1,260.00
APPLICATION OF BODY CAST, SHOULDER TO HIPS; SHOULDER TO HAND (LONG ARM) 5,680.00 1,680.00 1,680.00
APPLICATION OF LONG LEG CAST (THIGH TO TOES) 8,020.00 2,520.00 2,520.00
APPLICATION OF LONG LEG CAST (THIGH TO TOES); 8,020.00 2,520.00 2,520.00
Application of short leg cast (below knee to toes); walking or ambulatory type 8,020.00 2,520.00 2,520.00
Bilateral Tubal Ligation 4,000.00 1,000.00 1,000.00
BIOPSY, SINGLE OR MULTIPLE, OR LOCAL EXCISION OF LESION, W/ OR W/O FULGURATION 5,680.00 1,680.00 1,680.00
CAUTERIZATION OF CERVIX; ANY METHOD 4,000.00 1,680.00 1,680.00
Cauterization of Genital Warts, Vulva (Local Anesthesia) 9,300.00 2,100.00 2,100.00
CHANGE OF TRACHEOSTOMY 12,120.00 6,720.00 6,720.00
CIRCUMCISION, USING CLAMP OR OTHER DEVICE; EXCEPT NEWBORN 3,000.00 840.00 840.00
CLOSED TREATMENT OF MANDIBULAR FRACTURE; W/ INTERDENTAL FIXATION 14,960.00 7,560.00 7,560.00
CLOSED TREATMENT OF MANDIBULAR OR MAXILLARY ALVEOLAR RIDGE FRACTURE 12,120.00 6,720.00 6,720.00
Creation of arteriovenous fistula by other than direct arteriovenous anastomosis ; autogenous graft 12,900.00 6,300.00 6,300.00
Cystourethroscopy, w/ removal of foreign body, calculus, or ureteral stent from urethra or bladder 10,540.00 5,040.00 5,040.00
Debridement including removal of foreign material associated w/ open fracture(s) and/or dislocation(s); skin and subcutaneous tissues 10,540.00 5,040.00 5,040.00
Debridement; skin, and subcutaneous tissue 5,680.00 1,680.00 1,680.00
DESTRUCTION OF LESION (EXCEPT EXCISION), DENTOALVEOLAR STRUCTURES 8,260.00 3,360.00 3,360.00
Dilation and Curettage 7,000.00 4,400.00 4,400.00
DRAINAGE OF ABSCESS, CYST, HEMATOMA FROM DENTOALVEOLAR STRUCTURES 5,680.00 1,680.00 1,680.00
ENUCLEATION 12,120.00 6,720.00 6,720.00
Evisceration of ocular contents; with implant 12,120.00 6,720.00 6,720.00
Evisceration of ocular contents; without implant 12,120.00 6,720.00 6,720.00
Excision Of Baker'S Cyst 20,980.00 10,080.00 10,080.00
EXCISION OF HYDROCELE; UNILATERAL 9,700.00 4,200.00 4,200.00
Excision of Sublingual Cyst 9,300.00 2,100.00 2,100.00
Excision, benign lesion, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; lesion diameter 0.5 cm or less 3,640.00 840.00 840.00
EXCISION, NASAL POLYP(S), SIMPLE 8,020.00 2,520.00 2,520.00
Excision, other benign lesion (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.5 cm or less 4,108.00 1,008.00 1,008.00
EXCISION, OTHER BENIGN LESION (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 0.6 TO 1.0 CM 4,108.00 1,008.00 1,008.00
EXCISION, OTHER BENIGN LESION (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 1.1 TO 2.0 CM 4,108.00 1,008.00 1,008.00
EXCISION, OTHER BENIGN LESION (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 2.1 TO 3.0 CM 4,108.00 1,008.00 1,008.00
EXCISION, OTHER BENIGN LESION (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 3.1 TO 4.0 CM 4,108.00 1,008.00 1,008.00
EXCISION, OTHER BENIGN LESION (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER OVER 4.0 CM 4,108.00 1,008.00 1,008.00
Excision, other benign lesions diameter 0.5 cm or less 4,108.00 1,008.00 1,008.00
Extracapsular cataract removal with insertion of intraocular lens prosthesis 16,000.00 6,400.00 6,400.00
Extracapsular cataract removal with insertion of intraocular lens prosthesis (one stage procedure) 16,000.00 6,400.00 6,400.00
Fractional Curettage 11,000.00 4,400.00 4,400.00
Hemorrhoidectomy, internal and external, simple 12,120.00 6,720.00 6,720.00
HERNIORRHAPHY ADULT / PEDIA 21,000.00 8,400.00 8,400.00
INTERDENTAL WIRING, FOR CONDITION OTHER THAN FRACTURE 12,120.00 6,720.00 6,720.00
INTRAVITREAL INJECTION 12,120.00 6,720.00 6,720.00
Iridectomy, With corneoscleral or corneal suction; sector for glaucoma 12,120.00 6,720.00 6,720.00
Ligation or transection of fallopian tube(s), abdominal or vaginal approach, unilateral or bilateral 7,000.00 1,000.00 1,000.00
MARSUPIALIZATION OF BARTHOLINS GLAND CYST 7,000.00 4,200.00 4,200.00
NASAL ENDOSCOPY, DIAGNOSTIC, UNILATERAL OR BILATERAL 10,540.00 5,040.00 5,040.00
NASAL/SINUS ENDOSCOPY, SURGICAL; W/ BIOPSY, POLYPECTOMY OR DEBRIDEMENT 12,120.00 6,720.00 6,720.00
OPERCULECTOMY, EXCISION PERICORONAL TISSUES 8,020.00 2,520.00 2,520.00
PLACEMENT OF CENTRAL VENOUS CATHETER (SUBCLAVIAN, JUGULAR, OR OTHER VEIN) (E.G., FOR CENTRAL VENOUS PRESSURE, HYPERALIMENTATION, HEMODIALYSIS, OR CHEMOTHERAPY); PERCUTANEOUS OR CUTDOWN 9,700.00 4,200.00 4,200.00
POLYPECTOMY (NASAL) 8,020.00 2,520.00 2,520.00
PTERYGIUM EXCISION 9,700.00 4,200.00 4,200.00
RECTAL DILATATION 8,260.00 3,360.00 3,360.00
Removal of implant; deep (e.g., buried wire, pin, screw, metal band, nail, rod or plate) 11,980.00 5,880.00 5,880.00
REMOVAL OF IMPLANT; SUPERFICIAL (E.G., BURIED WIRE, PIN OR ROD) 10,540.00 5,040.00 5,040.00
REMOVAL OF INTERDENTAL WIRING 10,540.00 5,040.00 5,040.00
REMOVAL OF LENS MATERIAL; EXTRACAPSULAR 16,000.00 6,400.00 6,400.00
REPAIR INITIAL INGUINAL HERNIA, AGE 5 YEARS OR OVER; REDUCIBLE 21,000.00 8,400.00 8,400.00
Repair initial inguinal hernia, age 6 months to under 5 years, w/ or w/o hydrocelectomy; reducible 21,000.00 8,400.00 8,400.00
Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less 5,680.00 1,680.00 1,680.00
Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less 3,640.00 840.00 840.00
Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.6 cm to 7.5 cm 5,560.00 1,260.00 1,260.00
Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 7.6 cm to 12.5 cm 5,680.00 1,680.00 1,680.00
Strabismus Surgery, any procedure; superior oblique muscle 18,000.00 8,400.00 8,400.00
SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); SUBCUTANEOUS 12,120.00 6,720.00 6,720.00
THYROIDECTOMY, TOTAL OR COMPLETE 31,000.00 12,400.00 12,400.00
TRABECULECTOMY 23,300.00 12,600.00 12,600.00
Vitrectomy, Mechanical, Pars Plana Approach with Internal Tamponade with Air, Gas, Silicone Oil, Perfluorocarbon Liquid 46,500.00 25,200.00 25,200.00