| Item Number | Description | Schedule Fee |
|---|---|---|
| 45542 | Breast reconstruction (unilateral), following mastectomy, using tissue expansion—removal of tissue expansion unit and insertion of permanent prosthesis, other than a service associated with a service to which item 45006 or 45012 applies (H) (Anaes.) (Assist.) |
$715.55 |
| Total: | $715.55 | |