Procedure Code Description Pricing Action Code Maximum

Transcription

Procedure Code
0001F
0001M
0002M
0002T
0003M
0004M
0005F
0006M
0007M
0008M
0009M
00100
00102
00103
00104
0010M
00120
00124
00126
0012F
00140
00142
00144
00145
00147
00148
0014F
0015F
00160
00162
00164
00170
00172
00174
00176
00190
00192
0019T
00210
00211
00212
00214
00215
00216
00218
00220
00222
Description
HEART FAILURE COMPOSITE
INFECTIOUS DIS HCV 6 ASSAYS
LIVER DIS 10 ASSAYS W/ASH
ENDOVAS REPR ABDO AO ANEURYS
LIVER DIS 10 ASSAYS W/NASH
SCOLIOSIS DNA ALYS
OSTEOARTHRITIS COMPOSITE
ONC HEP GENE RISK CLASSIFIER
ONC GASTRO 51 GENE NOMOGRAM
ONC BREAST RISK SCORE
FETAL ANEUPLOIDY TRISOM RISK
ANESTH SALIVARY GLAND
ANESTH REPAIR OF CLEFT LIP
ANESTH BLEPHAROPLASTY
ANESTH ELECTROSHOCK
ONC PROSTATE PROB SCORE
ANESTH EAR SURGERY
ANESTH EAR EXAM
ANESTH TYMPANOTOMY
CAP BACTERIAL ASSESS
ANESTH PROCEDURES ON EYE
ANESTH LENS SURGERY
ANESTH CORNEAL TRANSPLANT
ANESTH VITREORETINAL SURG
ANESTH IRIDECTOMY
ANESTH EYE EXAM
COMP PREOP ASSESS CAT SURG
MELAN FOLLOW-UP COMPLETE
ANESTH NOSE/SINUS SURGERY
ANESTH BIOPSY OF NOSE
ANESTH PROCEDURE ON MOUTH
ANESTH CLEFT PALATE REPAIR
ANESTH PHARYNGEAL SURGERY
ANESTH FACE/SKULL BONE SURG
ANESTH FACIAL BONE SURGERY
EXTRACORP SHOCK WV TX MS NOS
ANESTH CRANIAL SURG NOS
ANESTH CRAN SURG HEMOTOMA
ANESTH SKULL DRAINAGE
ANESTH SKULL REPAIR/FRACT
ANESTH HEAD VESSEL SURGERY
ANESTH SPECIAL HEAD SURGERY
ANESTH INTRCRN NERVE
ANESTH HEAD NERVE SURGERY
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
9
A
A
A
A
9
A
A
A
9
A
A
A
A
A
A
9
9
A
A
A
A
A
A
A
A
A
9
A
A
A
A
A
A
A
A
A
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
00300
00320
00322
00326
00350
00352
00400
00402
00404
00406
00410
00420
0042T
00450
00454
00470
00472
00474
00500
0051T
00520
00522
00524
00528
00529
0052T
00530
00532
00534
00537
00539
0053T
00540
00541
00542
00546
00548
00550
00560
00561
00562
00563
00566
00567
00580
0058T
00600
Description
ANESTH HEAD/NECK/PTRUNK
ANESTH NECK ORGAN 1YR/>
ANESTH BIOPSY OF THYROID
ANESTH LARYNX/TRACH < 1 YR
ANESTH NECK VESSEL SURGERY
ANESTH SKIN EXT/PER/ATRUNK
ANESTH SURGERY OF BREAST
ANESTH CORRECT HEART RHYTHM
ANESTH, SKIN SURGERY, BACK
CT PERFUSION W/CONTRAST CBF
ANESTH SURGERY OF SHOULDER
ANESTH COLLAR BONE BIOPSY
ANESTH REMOVAL OF RIB
ANESTH CHEST WALL REPAIR
ANESTH SURGERY OF RIB
ANESTH ESOPHAGEAL SURGERY
IMPLANT TOTAL HEART SYSTEM
ANESTH CHEST PROCEDURE
ANESTH CHEST LINING BIOPSY
ANESTH CHEST DRAINAGE
ANES MEDIASCPY & DX THORSCPY
ANES MEDSCPY&THORSCPY 1 LUNG
REPLACE THRC UNIT HRT SYST
ANESTH PACEMAKER INSERTION
ANESTH VASCULAR ACCESS
ANESTH CARDIOVERTER/DEFIB
ANESTH CARDIAC ELECTROPHYS
ANESTH TRACH-BRONCH RECONST
REPLACE IMPLANTABLE HRT SYST
ANESTH CHEST SURGERY
ANESTH ONE LUNG VENTILATION
ANESTHESIA REMOVAL PLEURA
ANESTH LUNG CHEST WALL SURG
ANESTH TRACHEA BRONCHI SURG
ANESTH STERNAL DEBRIDEMENT
ANESTH HEART SURG W/O PUMP
ANESTH HEART SURG <1 YR
ANESTH HRT SURG W/PMP AGE 1+
ANESTH HEART SURG W/ARREST
ANESTH CABG W/O PUMP
ANESTH CABG W/PUMP
ANESTH HEART/LUNG TRANSPLNT
CRYOPRESERVATION OVARY TISS
ANESTH SPINE CORD SURGERY
Pricing Action Code
A
A
A
A
A
A
A
A
A
A
A
9
9
A
A
A
A
A
A
9
A
A
A
A
9
9
A
A
A
A
A
9
A
A
A
A
A
A
A
A
A
A
A
A
A
9
A
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
00604
00620
00625
00626
00630
00632
00635
00640
00670
00700
00702
0071T
0072T
00730
00740
00750
00752
00754
00756
0075T
0076T
00770
00790
00792
00794
00796
00797
00800
00802
00810
00820
00830
00832
00834
00836
00840
00842
00844
00846
00848
00850
00851
00855
00857
0085T
00860
00862
Description
ANESTH SITTING PROCEDURE
ANES SPINE TRANTHOR W/O VENT
ANES SPINE TRANSTHOR W/VENT
ANESTH REMOVAL OF NERVES
ANESTH LUMBAR PUNCTURE
ANESTH SPINE MANIPULATION
ANESTH ABDOMINAL WALL SURG
ANESTH FOR LIVER BIOPSY
US LEIOMYOMATA ABLATE <200
US LEIOMYOMATA ABLATE >200
ANESTH UPPER GI VISUALIZE
ANESTH REPAIR OF HERNIA
PERQ STENT/CHEST VERT ART
S&I STENT/CHEST VERT ART
ANESTH BLOOD VESSEL REPAIR
ANESTH SURG UPPER ABDOMEN
ANESTH HEMORR/EXCISE LIVER
ANESTH PANCREAS REMOVAL
ANESTH FOR LIVER TRANSPLANT
ANESTH SURGERY FOR OBESITY
ANESTH FAT LAYER REMOVAL
ANESTH LOW INTESTINE SCOPE
ANESTH HERNIA REPAIR < 1 YR
ANESTH HERNIA REPAIR PREEMIE
ANESTH SURG LOWER ABDOMEN
ANESTH AMNIOCENTESIS
ANESTH PELVIS SURGERY
ANESTH HYSTERECTOMY
ANESTH PELVIC ORGAN SURG
ANESTH, CESAREAN SECTION
ANESTH TUBAL LIGATION
ANESTH, HYSTERECTOMY
ANALGESIA, LABOR & C-SECTION
BREATH TEST HEART REJECT
ANESTH SURGERY OF ABDOMEN
ANESTH KIDNEY/URETER SURG
Pricing Action Code
A
A
A
A
A
A
A
A
A
A
A
9
9
A
A
A
A
A
A
9
9
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
9
A
9
9
9
A
A
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
00864
00865
00866
00868
00870
00872
00873
00880
00882
00884
00900
00902
00904
00906
00908
00910
00912
00914
00916
00918
00920
00921
00922
00924
00926
00928
00930
00932
00934
00936
00938
00940
00942
00944
00946
00948
00950
00952
00955
0095T
0098T
01000
0100T
0101T
0102T
0106T
0107T
Description
ANESTH REMOVAL OF BLADDER
ANESTH REMOVAL OF PROSTATE
ANESTH REMOVAL OF ADRENAL
ANESTH KIDNEY TRANSPLANT
ANESTH BLADDER STONE SURG
ANESTH KIDNEY STONE DESTRUCT
ANESTH ABDOMEN VESSEL SURG
ANESTH MAJOR VEIN LIGATION
ANESTH, MAJOR VEIN REVISION
ANESTH, PERINEAL PROCEDURE
ANESTH ANORECTAL SURGERY
ANESTH PERINEAL SURGERY
ANESTH REMOVAL OF VULVA
ANESTH BLADDER SURGERY
ANESTH BLADDER TUMOR SURG
ANESTH BLEEDING CONTROL
ANESTH STONE REMOVAL
ANESTH GENITALIA SURGERY
ANESTH VASECTOMY
ANESTH SPERM DUCT SURGERY
ANESTH TESTIS EXPLORATION
ANESTH REMOVAL OF TESTIS
ANESTH TESTIS SUSPENSION
ANESTH AMPUTATION OF PENIS
ANESTH PENIS NODES REMOVAL
ANESTH INSERT PENIS DEVICE
ANESTH VAGINAL PROCEDURES
ANESTH SURG ON VAG/URETHRAL
ANESTH VAGINAL HYSTERECTOMY
ANESTH, VAGINAL DELIVERY
ANESTH REPAIR OF CERVIX
ANESTH VAGINAL ENDOSCOPY
ANESTH HYSTEROSCOPE/GRAPH
ANALGESIA, VAGINAL DELIVERY
RMVL ARTIFIC DISC ADDL CRVCL
REV ARTIFIC DISC ADDL
ANESTH, SKIN SURGERY, PELVIS
PROSTH RETINA RECEIVE&GEN
EXTRACORP SHOCKWV TX HI ENRG
EXTRACORP SHOCKWV TX ANESTH
TOUCH QUANT SENSORY TEST
VIBRATE QUANT SENSORY TEST
Pricing Action Code
A
A
A
A
A
A
A
A
A
9
9
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
9
A
A
A
9
A
A
A
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
0108T
0109T
0110T
01110
01112
0111T
01120
01130
01140
01150
01160
01170
01173
01180
01190
01200
01202
01210
01212
01214
01215
01220
01230
01232
01234
01240
01250
01260
0126T
01270
01272
01274
01300
01320
01340
01360
01380
01382
01390
01392
01400
01402
01404
01420
01430
01432
01440
Description
COOL QUANT SENSORY TEST
HEAT QUANT SENSORY TEST
NOS QUANT SENSORY TEST
ANESTH, SKIN SURGERY, PELVIS
ANESTH BONE ASPIRATE/BX
RBC MEMBRANES FATTY ACIDS
ANESTH BODY CAST PROCEDURE
ANESTH AMPUTATION AT PELVIS
ANESTH PELVIC TUMOR SURGERY
ANESTH PELVIS PROCEDURE
ANESTH FX REPAIR PELVIS
ANESTH PELVIS NERVE REMOVAL
ANESTH HIP JOINT PROCEDURE
ANESTH ARTHROSCOPY OF HIP
ANESTH HIP JOINT SURGERY
ANESTH HIP DISARTICULATION
ANESTH HIP ARTHROPLASTY
ANESTH REVISE HIP REPAIR
ANESTH PROCEDURE ON FEMUR
ANESTH SURGERY OF FEMUR
ANESTH AMPUTATION OF FEMUR
ANESTH RADICAL FEMUR SURG
ANESTH, UPPER LEG SKIN SURG
ANESTH UPPER LEG SURGERY
ANESTH UPPER LEG VEINS SURG
CHD RISK IMT STUDY
ANESTH THIGH ARTERIES SURG
ANESTH FEMORAL ARTERY SURG
ANESTH FEMORAL EMBOLECTOMY
ANESTH, SKIN SURGERY, KNEE
ANESTH KNEE AREA SURGERY
ANESTH KNEE AREA PROCEDURE
ANESTH KNEE JOINT PROCEDURE
ANESTH DX KNEE ARTHROSCOPY
ANESTH KNEE JOINT SURGERY
ANESTH KNEE ARTHROPLASTY
ANESTH AMPUTATION AT KNEE
ANESTH KNEE JOINT CASTING
ANESTH KNEE VEINS SURGERY
ANESTH KNEE VESSEL SURG
ANESTH KNEE ARTERIES SURG
Pricing Action Code
9
9
9
9
A
9
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
A
9
A
A
9
A
A
A
9
A
A
A
A
A
A
A
A
A
A
A
A
A
A
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
01442
01444
01460
01462
01464
01470
01472
01474
01480
01482
01484
01486
01490
01500
01502
01520
01522
0152T
0159T
01600
01610
01620
01622
01630
01634
01636
01638
0163T
0164T
01650
01652
01654
01656
0165T
01670
01680
01682
0169T
01700
01710
01712
01714
01716
0171T
0172T
01730
01732
Description
ANESTH KNEE ARTERY SURG
ANESTH KNEE ARTERY REPAIR
ANESTH, LOWER LEG SKIN SURG
ANESTH LOWER LEG PROCEDURE
ANESTH ANKLE/FT ARTHROSCOPY
ANESTH LOWER LEG SURGERY
ANESTH ACHILLES TENDON SURG
ANESTH LOWER LEG BONE SURG
ANESTH RADICAL LEG SURGERY
ANESTH LOWER LEG REVISION
ANESTH ANKLE REPLACEMENT
ANESTH LOWER LEG CASTING
ANESTH LEG ARTERIES SURG
ANESTH LWR LEG EMBOLECTOMY
ANESTH LOWER LEG VEIN SURG
COMPUTER CHEST ADD-ON
CAD BREAST MRI
ANESTH, SHOULDER SKIN SURG
ANESTH SHOULDER PROCEDURE
ANES DX SHOULDER ARTHROSCOPY
ANESTH SHOULDER JOINT AMPUT
ANESTH FOREQUARTER AMPUT
ANESTH SHOULDER REPLACEMENT
LUMB ARTIF DISKECTOMY ADDL
REMOVE LUMB ARTIF DISC ADDL
ANESTH SHOULDER ARTERY SURG
ANESTH SHOULDER VESSEL SURG
ANESTH ARM-LEG VESSEL SURG
REVISE LUMB ARTIF DISC ADDL
ANESTH SHOULDER VEIN SURG
ANESTH SHOULDER CASTING
ANESTH AIRPLANE CAST
PLACE STEREO CATH BRAIN
ANESTH, ELBOW AREA SKIN SURG
ANESTH ELBOW AREA SURGERY
ANESTH UPPR ARM TENDON SURG
ANESTH BICEPS TENDON REPAIR
LUMBAR SPINE PROCES DISTRACT
LUMBAR SPINE PROCESS ADDL
ANESTH UPPR ARM PROCEDURE
ANESTH DX ELBOW ARTHROSCOPY
Pricing Action Code
A
A
9
A
A
A
A
A
A
A
A
A
A
A
A
A
A
9
9
9
A
A
A
A
A
A
A
9
9
A
A
A
A
9
A
A
A
9
9
A
A
A
A
9
9
A
A
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
01740
01742
01744
0174T
01756
01758
0175T
01760
01770
01772
01780
01782
01800
01810
01820
01829
01830
01832
01840
01842
01844
0184T
01850
01852
01860
0188T
0189T
01900
01902
01904
01906
01908
0190T
01910
01912
01914
01916
01918
0191T
01920
01921
01922
01924
01925
01926
01930
01931
Description
ANESTH UPPER ARM SURGERY
ANESTH HUMERUS SURGERY
ANESTH HUMERUS REPAIR
CAD CXR WITH INTERP
ANESTH RADICAL HUMERUS SURG
ANESTH HUMERAL LESION SURG
CAD CXR REMOTE
ANESTH ELBOW REPLACEMENT
ANESTH UPPR ARM ARTERY SURG
ANESTH UPPR ARM EMBOLECTOMY
ANESTH UPPER ARM VEIN SURG
ANESTH UPPR ARM VEIN REPAIR
ANESTH, LOWER ARM SKIN SURG
ANESTH LOWER ARM SURGERY
ANESTH LOWER ARM PROCEDURE
ANESTH DX WRIST ARTHROSCOPY
ANESTH WRIST REPLACEMENT
ANESTH LWR ARM ARTERY SURG
ANESTH LWR ARM EMBOLECTOMY
ANESTH VASCULAR SHUNT SURG
EXC RECTAL TUMOR ENDOSCOPIC
ANESTH LOWER ARM VEIN SURG
ANESTH LWR ARM VEIN REPAIR
ANESTH LOWER ARM CASTING
VIDEOCONF CRIT CARE 74 MIN
VIDEOCONF CRIT CARE ADDL 30
ANESTH, UTERUS/TUBE INJECT
ANESTH, BURR HOLES, SKULL
ANESTH, SKULL X-RAY INJECT
ANESTH, LUMBAR MYELOGRAPHY
ANESTH, CERVICAL MYELOGRAPHY
PLACE INTRAOC RADIATION SRC
ANESTH, SKULL MYELOGRAPHY
ANESTH, LUMBAR DISKOGRAPHY
ANESTH, CERVICAL DISKOGRAPHY
ANESTH DX ARTERIOGRAPHY
ANESTH, LIMB ARTERIOGRAM
INSERT ANT SEGMENT DRAIN INT
ANESTH CATHETERIZE HEART
ANESTH, VESSEL SURGERY
ANESTH CAT OR MRI SCAN
ANES THER INTERVEN RAD ARTRL
ANES THER INTERVEN RAD CARD
ANES TX INTERV RAD HRT/CRAN
ANES THER INTERVEN RAD VEIN
ANES THER INTERVEN RAD TIPS
Pricing Action Code
A
A
A
9
A
A
9
A
A
A
A
A
9
A
A
A
A
A
A
A
A
9
A
A
A
9
9
9
9
9
9
9
9
9
9
9
A
9
9
A
9
A
A
A
A
A
A
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
01932
01933
01935
01936
01951
01952
01953
01958
0195T
01960
01961
01962
01963
01965
01966
01967
01968
01969
0196T
0198T
01990
01991
01992
01996
01999
0200T
0201T
0202T
0205T
0206T
0207T
0208T
0209T
0210T
0211T
0212T
0213T
0214T
0215T
0216T
0217T
0218T
0219T
0220T
0221T
0222T
0228T
Description
ANES TX INTERV RAD TH VEIN
ANES TX INTERV RAD CRAN VEIN
ANESTH PERC IMG DX SP PROC
ANESTH PERC IMG TX SP PROC
ANESTH BURN LESS 4 PERCENT
ANESTH BURN 4-9 PERCENT
ANESTH BURN EACH 9 PERCENT
ANESTH ANTEPARTUM MANIPUL
PRESCRL FUSE W/O INSTR L5/S1
ANESTH VAGINAL DELIVERY
ANESTH CS DELIVERY
ANESTH EMER HYSTERECTOMY
ANESTH CS HYSTERECTOMY
ANESTH INC/MISSED AB PROC
ANESTH INDUCED AB PROCEDURE
ANESTH/ANALG VAG DELIVERY
ANES/ANALG CS DELIVER ADD-ON
ANESTH/ANALG CS HYST ADD-ON
PRESCRL FUSE W/O INSTR L4/L5
OCULAR BLOOD FLOW MEASURE
SUPPORT FOR ORGAN DONOR
ANESTH NERVE BLOCK/INJ
ANESTH N BLOCK/INJ PRONE
HOSP MANAGE CONT DRUG ADMIN
UNLISTED ANESTH PROCEDURE
PERQ SACRAL AUGMT UNILAT INJ
PERQ SACRAL AUGMT BILAT INJ
POST VERT ARTHRPLST 1 LUMBAR
INIRS EACH VESSEL ADD-ON
CPTR DBS ALYS CAR ELEC DTA
CLEAR EYELID GLAND W/HEAT
AUDIOMETRY AIR ONLY
AUDIOMETRY AIR & BONE
SPEECH AUDIOMETRY THRESHOLD
SPEECH AUDIOM THRESH & RECOG
COMPRE AUDIOMETRY EVALUATION
NJX PARAVERT W/US CER/THOR
NJX PARAVERT W/US LUMB/SAC
PLMT POST FACET IMPLT CERV
PLMT POST FACET IMPLT THOR
PLMT POST FACET IMPLT LUMB
PLMT POST FACET IMPLT ADDL
NJX TFRML EPRL W/US CER/THOR
Pricing Action Code
A
A
A
A
A
A
5
A
9
A
A
A
A
A
A
A
A
A
9
9
A
A
A
3
5
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$48.15
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
0229T
0230T
0231T
0232T
0234T
0235T
0236T
0237T
0238T
0249T
0253T
0254T
0255T
0263T
0264T
0265T
0266T
0267T
0268T
0269T
0270T
0271T
0272T
0273T
0274T
0275T
0278T
0281T
0282T
0283T
0284T
0285T
0286T
0287T
0288T
0289T
0290T
0291T
0292T
0293T
0294T
0295T
0296T
0297T
0298T
0299T
0300T
Description
NJX TFRML EPRL W/US CER/THOR
NJX TFRML EPRL W/US LUMB/SAC
NJX TFRML EPRL W/US LUMB/SAC
NJX PLATELET PLASMA
TRLUML PERIP ATHRC RENAL ART
TRLUML PERIP ATHRC VISCERAL
TRLUML PERIP ATHRC ABD AORTA
TRLUML PERIP ATHRC BRCHIOCPH
TRLUML PERIP ATHRC ILIAC ART
LIGATION HEMORRHOID W/US
INSERT AQUEOUS DRAIN DEVICE
EVASC RPR ILIAC ART BIFUR
EVASC RPR ILIAC ART BIFR S&I
IM B1 MRW CEL THER CMPL
IM B1 MRW CEL THER XCL HRVST
IM B1 MRW CEL THER HRVST ONL
IMPLT/RPL CRTD SNS DEV TOTAL
IMPLT/RPL CRTD SNS DEV LEAD
IMPLT/RPL CRTD SNS DEV GEN
REV/REMVL CRTD SNS DEV TOTAL
REV/REMVL CRTD SNS DEV LEAD
REV/REMVL CRTD SNS DEV GEN
INTERROGATE CRTD SNS DEV
INTERROGATE CRTD SNS W/PGRMG
PERQ LAMOT/LAM CRV/THRC
PERQ LAMOT/LAM LUMBAR
TEMPR
LAA CLOSURE W/IMPLANT
PERIPH FIELD STIMUL TRIAL
PERIPH FIELD STIMUL PERM
PERIPH FIELD STIMUL REVISE
PERIPH FIELD STIMUL ANALYS
NEAR IFR SPECTRSC OF WOUNDS
NEAR IFR GUIDE OF VASC SITE
ANOSCOPY W/RF DELIVERY
LASER INC FOR PKP/LKP DONOR
LASER INC FOR PKP/LKP RECIP
IV OCT FOR PROC INIT VESSEL
IV OCT FOR PROC ADDL VESSEL
INS LT ATRL PRESS MONITOR
INS LT ATRL MONT PRES LEAD
EXT ECG COMPLETE
EXT ECG RECORDING
EXT ECG SCAN W/REPORT
EXT ECG REVIEW AND INTERP
ESW WOUND HEALING INIT WOUND
ESW WOUND HEALING ADDL WOUND
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
0301T
0302T
0303T
0304T
0305T
0306T
0307T
0308T
0309T
0310T
0312T
0313T
0314T
0315T
0316T
0317T
0329T
0330T
0331T
0332T
0333T
0335T
0336T
0337T
0338T
0339T
0340T
0341T
0342T
0345T
0346T
0347T
0348T
0349T
0350T
0351T
0352T
0353T
0354T
0355T
0356T
0357T
0358T
0359T
0360T
0361T
0362T
Description
MW THERAPY FOR BREAST TUMOR
ICAR ISCHM MNTRNG SYS COMPL
ICAR ISCHM MNTRNG SYS ELTRD
ICAR ISCHM MNTRNG SYS DEVICE
ICAR ISCHM MNTRNG PRGRM EVAL
ICAR ISCHM MNTR INTERR EVAL
RMVL ICAR ISCHM MNTRNG DVCE
INSJ OCULAR TELESCOPE PROSTH
PRESCRL FUSE W/ INSTR L4/L5
MOTOR FUNCTION MAPPING NTMS
LAPS IMPLTJ NSTIM VAGUS
LAPS RMVL NSTIM ARRAY VAGUS
LAPS RMVL VGL ARRY&PLS GEN
RMVL VAGUS NERVE PLS GEN
REPLC VAGUS NERVE PLS GEN
ELEC ALYS VAGUS NRV PLS GEN
MNTR IO PRESS 24HRS/> UNI/BI
TEAR FILM IMG UNI/BI W/I&R
HEART SYMP IMAGE PLNR
HEART SYMP IMAGE PLNR SPECT
VISUAL EP ACUITY SCREEN AUTO
EXTRAOSSEOUS JOINT STBLZTION
LAP ABLAT UTERINE FIBROIDS
ENDOTHEL FXNASSMNT NON-INVAS
TRNSCTH RENAL SYMP DENRV UNL
TRNSCTH RENAL SYMP DENRV BIL
ABLATE PULM TUMORS + EXTNSN
QUANT PUPILLOMETRY W/ RPRT
THXP APHERESIS W/HDL DELIP
TRANSCATH MTRAL VLVE REPAIR
ULTRASOUND ELASTOGRAPHY
INS BONE DEVICE FOR RSA
RSA SPINE EXAM
RSA UPPER EXTR EXAM
RSA LOWER EXTR EXAM
INTRAOP OCT BRST/NODE SPEC
OCT BRST/NODE I&R PER SPEC
INTRAOP OCT BREAST CAVITY
OCT BREAST SURG CAVITY I&R
GI TRACT CAPSULE ENDOSCOPY
INSRT DRUG DEVICE FOR IOP
CRYOPRESERVATION OOCYTE(S)
BIA WHOLE BODY
BEHAVIORAL ID ASSESSMENT
OBSERV BEHAV ASSESSMENT
OBSERV BEHAV ASSESS ADDL
EXPOSE BEHAV ASSESSMENT
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
0363T
0364T
0365T
0366T
0367T
0368T
0369T
0370T
0371T
0372T
0373T
0374T
0375T
0376T
0377T
0378T
0379T
0380T
0381T
0382T
0383T
0384T
0385T
0386T
0387T
0388T
0389T
0390T
0391T
0392T
0393T
0394T
0395T
0396T
0397T
0398T
0399T
0400T
0401T
0402T
0403T
0404T
0405T
0406T
0407T
0408T
0409T
Description
EXPOSE BEHAV ASSESS ADDL
ADAPTIVE BEHAVIOR TREATMENT
ADAPTIVE BEHAVIOR TX ADDL
GROUP BEHAVIOR TREATMENT
GROUP BEHAV TREATMENT ADDL
BEHAVIOR TREATMENT MODIFIED
BEHAV TREATMENT MODIFY ADDL
FAM BEHAV TREATMENT GUIDANCE
MULT FAM BEHAV TREAT GUIDE
SOCIAL SKILLS TRAINING GROUP
EXPOSURE BEHAVIOR TREATMENT
EXPOSE BEHAV TREATMENT ADDL
TOTAL DISC ARTHRP ANT APPR
INSERT ANT SEGMENT DRAIN INT
ANOSCPY INJ AGENT FOR INCONT
VISUAL FIELD ASSMNT REV/RPRT
VIS FIELD ASSMNT TECH SUPPT
COMP ANIMAT RET IMAG SERIES
EXT H RATE EPI SZ 14 DAYS
EXT H RATE SZ 14 DAY RI ONLY
EXT H RATE SZ UP TO 30 DAYS
EX H RATE SZ 30 DAY RI ONLY
EX H RATE FOR SZ OVR 30 DAY
EX H RATE SZ 30+ DAY RI ONLY
LEADLESS C PM INS/RPL VENTR
LEADLESS C PM REMOVE VENTR
PROG EVAL INPER LEADLS PM
PERIPROC EVAL INPER LEDLS PM
INTERGT EVAL INPER LEADLS PM
LAP ES SPH AUGMENT DEV PLACE
ES SPH AUGMNT DEVICE REMOVAL
HDR ELCTRNC SKN SURF BRCHYTX
HDR ELCTR NTRST/NTRCV BRCHTX
INTRAOP KINETIC BALNCE SENSR
ERCP W/OPTICAL ENDOMICROSCPY
MRGFUS STRTCTC LES ABLTJ
MYOCARDIAL STRAIN IMAGING
MLTISPECTRL DIGITAL LES ALYS
MLTISPECTRL DIGITAL LES ALYS
COLLAGEN CROSSLINKING CORNEA
DIABETES PREV STANDARD CURR
TRNSCRV UTERIN FIBROID ABLTJ
OVRSGHT XTRCORP LIV ASST PAT
SIN NDSC PLMT DRG ELUT MPLNT
SIN NDSC PLMT DRG ELUT MPLNT
INSJ/RPLC CARDIAC MODULJ SYS
INSJ/RPLC CARDIAC MODULJ PLS
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
0410T
0411T
0412T
0413T
0414T
0415T
0416T
0417T
0418T
0419T
0420T
0421T
0422T
0423T
0424T
0425T
0426T
0427T
0428T
0429T
0430T
0431T
0432T
0433T
0434T
0435T
0436T
0500F
0501F
0502F
0503F
0505F
0507F
0509F
0513F
0514F
0516F
0517F
0518F
0519F
0520F
0521F
0525F
0526F
0528F
0529F
0535F
Description
INSJ/RPLC CAR MODULJ ATR ELT
INSJ/RPLC CAR MODULJ VNT ELT
RMVL CARDIAC MODULJ PLS GEN
RMVL CAR MODULJ TRANVNS ELT
RMVL & RPL CAR MODULJ PLS GN
REPOS CAR MODULJ TRANVNS ELT
RELOC SKIN POCKET PLS GEN
PRGRMG EVAL CARDIAC MODULJ
INTERRO EVAL CARDIAC MODULJ
DSTRJ NEUROFIBROMATA XTNSV
DSTRJ NEUROFIBROMATA XTNSV
WATERJET PROSTATE ABLTJ CMPL
TACTILE BREAST IMG UNI/BI
ASSAY SECRETORY TYPE II PLA2
INSJ/RPLC NSTIM APNEA COMPL
INSJ/RPLC NSTIM APNEA SEN LD
INSJ/RPLC NSTIM APNEA STM LD
INSJ/RPLC NSTIM APNEA PLS GN
RMVL NSTIM APNEA PLS GEN
RMVL NSTIM APNEA SEN LD
RMVL NSTIM APNEA STIMJ LD
RMVL/RPLC NSTIM APNEA PLS GN
REPOS NSTIM APNEA STIMJ LD
REPOS NSTIM APNEA SENSING LD
INTERRO EVAL NPGS SLEEP APNE
PRGRMG EVAL NPGS APNEA 1 SES
PRGRMG EVAL NPGS APNEA STUDY
INITIAL PRENATAL CARE VISIT
PRENATAL FLOW SHEET
SUBSEQUENT PRENATAL CARE
POSTPARTUM CARE VISIT
HEMODIALYSIS PLAN DOCD
PERITON DIALYSIS PLAN DOCD
URINE INCON PLAN DOCD
ELEV BP PLAN OF CARE DOCD
CARE PLAN HGB DOCD ESA PT
ANEMIA PLAN OF CARE DOCD
GLAUCOMA PLAN OF CARE DOCD
FALL PLAN OF CARE DOCD
PLAND CHEMO DOCD B/4 TXMNT
RAD DOS LIMTS B/4 3D RAD
PLAN OF CARE 4 PAIN DOCD
INITIAL VISIT FOR EPISODE
SUBS VISIT FOR EPISODE
RCMND FLW-UP 10 YRS DOCD
INTRVL 3/>YR PTS CLNSCP DOCD
DYSPNEA MNGMNT PLAN DOCD
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
0540F
0545F
0550F
0551F
0555F
0556F
0557F
0575F
0580F
0581F
0582F
0583F
0584F
1000F
10021
10022
1002F
10030
10035
10036
1003F
10040
1004F
1005F
10060
10061
1006F
1007F
10080
10081
1008F
1010F
1011F
10120
10121
1012F
10140
1015F
10160
10180
1018F
1019F
1022F
1026F
1030F
1031F
1032F
Description
GLUCO MNGMNT PLAN DOCD
FOLLOW UP CARE PLAN MDD DOCD
CYTOPATH REPORT NONGYN SPCMN
CYTOPATH REPORT NON ROUTINE
SYMPTOM MGMNT PLAN CARE DOCD
PLAN CARE LIPID CONTROL DOCD
PLAN CAREMNG ANGNL SYMPTDOCD
HIV RNA PLAN CARE DOCD
MULTIDISCIPLINARY CARE PLAN
PT TRNSFRD FROM ANESTH TO CC
NO TRNSFR FROM ANESTH TO CC
TRANSFER CARE CHECKLIST USED
NO TRANSFERCARE CHKLIST USED
TOBACCO USE ASSESSED
FNA W/O IMAGE
FNA W/IMAGE
ASSESS ANGINAL SYMPTOM/LEVEL
GUIDE CATHET FLUID DRAINAGE
PERQ DEV SOFT TISS 1ST IMAG
PERQ DEV SOFT TISS ADD IMAG
LEVEL OF ACTIVITY ASSESS
ACNE SURGERY
CLIN SYMP VOL OVRLD ASSESS
ASTHMA SYMPTOMS EVALUATE
DRAINAGE OF SKIN ABSCESS
DRAINAGE OF SKIN ABSCESS
OSTEOARTHRITIS ASSESS
ANTI-INFLM/ANLGSC OTC ASSESS
DRAINAGE OF PILONIDAL CYST
DRAINAGE OF PILONIDAL CYST
GI/RENAL RISK ASSESS
SEVERITY ANGINA BY ACTVTY
ANGINA PRESENT
REMOVE FOREIGN BODY
REMOVE FOREIGN BODY
ANGINA ABSENT
DRAINAGE OF HEMATOMA/FLUID
COPD SYMPTOMS ASSESS
PUNCTURE DRAINAGE OF LESION
COMPLEX DRAINAGE WOUND
ASSESS DYSPNEA NOT PRESENT
ASSESS DYSPNEA PRESENT
PNEUMO IMM STATUS ASSESS
CO-MORBID CONDITION ASSESS
INFLUENZA IMM STATUS ASSESS
SMOKING & 2ND HAND ASSESSED
SMOKER/EXPOSED 2ND HND SMOKE
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
9
9
9
9
3
3
9
3
3
3
9
3
9
9
3
3
9
9
3
3
9
9
9
3
3
9
3
9
3
3
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$126.17
$143.82
$0.00
$175.95
$548.69
$477.07
$0.00
$104.13
$0.00
$0.00
$119.61
$210.68
$0.00
$0.00
$183.04
$274.09
$0.00
$0.00
$0.00
$155.10
$281.64
$0.00
$166.18
$0.00
$99.01
$253.50
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
1033F
1034F
1035F
1036F
1038F
1039F
1040F
1050F
1052F
1055F
1060F
1061F
1065F
1066F
1070F
1071F
1090F
1091F
11000
11001
11004
11005
11006
11008
1100F
11010
11011
11012
1101F
11042
11043
11044
11045
11046
11047
11055
11056
11057
11100
11101
1110F
1111F
1116F
1118F
1119F
11200
11201
Description
TOBACCO NONSMOKER NOR 2NDHND
CURRENT TOBACCO SMOKER
SMOKELESS TOBACCO USER
TOBACCO NON-USER
PERSISTENT ASTHMA
INTERMITTENT ASTHMA
DSM-5 INFO MDD DOCD
HISTORY OF MOLE CHANGES
TYPE LOCATION ACTIVITYASSESS
VISUAL FUNCT STATUS ASSESS
DOC PERM/CONT/PAROX ATR FIB
DOC LACK PERM+CONT+PAROX FIB
ISCHM STROKE SYMP LT3 HRSB/4
ISCHM STROKE SYMP GE3 HRSB/4
ALARM SYMP ASSESSED-ABSENT
ALARM SYMP ASSESSED-1+ PRSNT
PRES/ABSN URINE INCON ASSESS
URINE INCON CHARACTERIZED
DEBRIDE INFECTED SKIN
DEBRIDE INFECTED SKIN ADD-ON
DEBRIDE GENITALIA & PERINEUM
DEBRIDE ABDOM WALL
DEBRIDE GENIT/PER/ABDOM WALL
REMOVE MESH FROM ABD WALL
PTFALLS ASSESS-DOCD GE2>/YR
DEBRIDE SKIN AT FX SITE
DEBRIDE SKIN MUSC AT FX SITE
DEB SKIN BONE AT FX SITE
PT FALLS ASSESS-DOCD LE1/YR
DEB SUBQ TISSUE 20 SQ CM/<
DEB MUSC/FASCIA 20 SQ CM/<
DEB BONE 20 SQ CM/<
DEB SUBQ TISSUE ADD-ON
DEB MUSC/FASCIA ADD-ON
DEB BONE ADD-ON
TRIM SKIN LESION
TRIM SKIN LESIONS 2 TO 4
TRIM SKIN LESIONS OVER 4
BIOPSY SKIN LESION
BIOPSY SKIN ADD-ON
PT LFT INPT FAC W/IN 60 DAYS
DSCHRG MED/CURRENT MED MERGE
AURIC/PERI PAIN ASSESSED
GERD SYMPS ASSESSED 12 MONTH
INIT EVAL FOR CONDITION
REMOVAL OF SKIN TAGS <W/15
REMOVE SKIN TAGS ADD-ON
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
3
3
3
3
3
3
9
3
3
3
9
3
3
3
3
3
3
3
3
3
3
3
9
9
9
9
9
3
3
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$55.80
$21.93
$604.35
$819.63
$733.30
$288.39
$0.00
$506.13
$550.21
$738.68
$0.00
$119.36
$233.87
$323.55
$41.79
$75.30
$127.93
$48.68
$59.45
$66.97
$105.72
$33.51
$0.00
$0.00
$0.00
$0.00
$0.00
$89.79
$19.42
Procedure Code
1121F
1123F
1124F
1125F
1126F
1127F
1128F
11300
11301
11302
11303
11305
11306
11307
11308
1130F
11310
11311
11312
11313
1134F
1135F
1136F
1137F
11400
11401
11402
11403
11404
11406
11420
11421
11422
11423
11424
11426
11440
11441
11442
11443
11444
11446
11450
11451
11462
11463
11470
Description
SUBS EVAL FOR CONDITION
ACP DISCUSS/DSCN MKR DOCD
ACP DISCUSS-NO DSCNMKR DOCD
AMNT PAIN NOTED PAIN PRSNT
AMNT PAIN NOTED NONE PRSNT
NEW EPISODE FOR CONDITION
SUBS EPISODE FOR CONDITION
SHAVE SKIN LESION 0.5 CM/<
SHAVE SKIN LESION 0.6-1.0 CM
SHAVE SKIN LESION >2.0 CM
BK PAIN & FXN ASSESSED
EPSD BK PAIN FOR 6 WKS/<
EPSD BK PAIN FOR >6 WKS
EPSD BK PAIN FOR 12 WKS/<
EPSD BK PAIN FOR >12 WKS
EXC TR-EXT B9+MARG 0.5 CM<
EXC TR-EXT B9+MARG 0.6-1 CM
EXC TR-EXT B9+MARG 2.1-3CM/<
EXC TR-EXT B9+MARG >4.0 CM
EXC H-F-NK-SP B9+MARG 0.5/<
EXC H-F-NK-SP B9+MARG 0.6-1
EXC H-F-NK-SP B9+MARG >4 CM
EXC FACE-MM B9+MARG 0.5 CM/<
EXC FACE-MM B9+MARG 0.6-1 CM
EXC FACE-MM B9+MARG >4 CM
REMOVAL SWEAT GLAND LESION
Pricing Action Code
9
9
9
9
9
9
9
3
3
3
3
3
3
3
3
9
3
3
3
3
9
9
9
9
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$99.29
$121.97
$144.01
$159.13
$101.31
$124.45
$146.44
$153.85
$0.00
$116.23
$114.31
$163.83
$190.11
$0.00
$0.00
$0.00
$0.00
$126.33
$151.89
$169.23
$195.56
$222.66
$321.87
$124.76
$159.75
$178.89
$206.29
$238.76
$342.94
$137.45
$171.33
$192.64
$229.72
$288.42
$401.51
$391.55
$500.89
$382.50
$506.97
$425.34
Procedure Code
11471
1150F
1151F
1152F
1153F
1157F
1158F
1159F
11600
11601
11602
11603
11604
11606
1160F
11620
11621
11622
11623
11624
11626
11640
11641
11642
11643
11644
11646
1170F
11719
11720
11721
11730
11732
11740
11750
11752
11755
1175F
11760
11762
11765
11770
11771
11772
1180F
1181F
1182F
Description
DOC PT RSK DEATH W/IN 1YR
DOC NO PT RSK DEATH W/IN 1YR
DOC ADVNCD DIS COMFORT 1ST
DOC ADVNCD DIS CMFRT NOT 1ST
ADVNC CARE PLAN IN RCRD
ADVNC CARE PLAN TLK DOCD
MED LIST DOCD IN RCRD
EXC TR-EXT MAL+MARG 0.5 CM/<
EXC TR-EXT MAL+MARG 0.6-1 CM
EXC TR-EXT MAL+MARG >4 CM
RVW MEDS BY RX/DR IN RCRD
EXC H-F-NK-SP MAL+MARG 0.5/<
EXC S/N/H/F/G MAL+MRG 0.6-1
EXC S/N/H/F/G MAL+MRG >4 CM
EXC F/E/E/N/L MAL+MRG 0.5CM<
EXC F/E/E/N/L MAL+MRG 0.6-1
EXC F/E/E/N/L MAL+MRG >4 CM
FXNL STATUS ASSESSED
TRIM NAIL(S) ANY NUMBER
DEBRIDE NAIL 1-5
DEBRIDE NAIL 6 OR MORE
REMOVAL OF NAIL PLATE
REMOVE NAIL PLATE ADD-ON
DRAIN BLOOD FROM UNDER NAIL
REMOVAL OF NAIL BED
REMOVE NAIL BED/TIP
BIOPSY NAIL UNIT
FUNCTION STAT ASSESSED RVWD
REPAIR OF NAIL BED
RECONSTRUCTION OF NAIL BED
EXCISION OF NAIL FOLD TOE
REMOVE PILONIDAL CYST SIMPLE
REMOVE PILONIDAL CYST EXTEN
REMOVE PILONIDAL CYST COMPL
THROMBOEMB RISK ASSESSED
NEUROPSYCHIA SYMPTS ASSESSED
NEUROPSYCHI SYMPT 1+PRESENT
Pricing Action Code
3
9
9
9
9
9
9
9
3
3
3
3
3
3
9
3
3
3
3
3
3
3
3
3
3
3
3
9
3
3
3
3
3
3
3
3
3
9
3
3
3
3
3
3
9
9
9
Maximum Allowable
$526.55
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$195.90
$233.03
$253.23
$289.98
$322.82
$463.50
$0.00
$198.10
$234.86
$262.24
$308.35
$347.65
$420.53
$204.59
$243.14
$278.10
$328.12
$405.65
$531.35
$0.00
$14.39
$32.76
$45.69
$101.14
$36.32
$50.85
$183.78
$331.37
$136.14
$0.00
$199.82
$287.77
$170.94
$284.89
$589.98
$715.24
$0.00
$0.00
$0.00
Procedure Code
1183F
11900
11901
11920
11921
11922
11950
11951
11952
11954
11960
11970
11971
11976
11980
11981
11982
11983
12001
12002
12004
12005
12006
12007
1200F
12011
12013
12014
12015
12016
12017
12018
12020
12021
12031
12032
12034
12035
12036
12037
12041
12042
12044
12045
12046
12047
12051
Description
NEUROPSYCHIATRIC SYMP ABSENT
INJECT SKIN LESIONS </W 7
INJECT SKIN LESIONS >7
CORRECT SKIN COLOR 6.0 CM/<
CORRECT SKN COLOR 6.1-20.0CM
CORRECT SKIN COLOR EA 20.0CM
TX CONTOUR DEFECTS 1 CC/<
TX CONTOUR DEFECTS 1.1-5.0CC
TX CONTOUR DEFECTS 5.1-10CC
TX CONTOUR DEFECTS >10.0 CC
INSERT TISSUE EXPANDER(S)
REPLACE TISSUE EXPANDER
REMOVE TISSUE EXPANDER(S)
REMOVE CONTRACEPTIVE CAPSULE
IMPLANT HORMONE PELLET(S)
INSERT DRUG IMPLANT DEVICE
REMOVE DRUG IMPLANT DEVICE
REMOVE/INSERT DRUG IMPLANT
RPR S/N/AX/GEN/TRNK 2.5CM/<
RPR S/N/AX/GEN/TRNK2.6-7.5CM
RPR S/N/AX/GEN/TRK7.6-12.5CM
RPR S/N/A/GEN/TRK12.6-20.0CM
RPR S/N/A/GEN/TRK20.1-30.0CM
RPR S/N/AX/GEN/TRNK >30.0 CM
SEIZURE TYPE& FREQU DOCD
RPR F/E/E/N/L/M 2.5 CM/<
RPR F/E/E/N/L/M 2.6-5.0 CM
RPR FE/E/EN/L/M 12.6-20.0 CM
RPR FE/E/EN/L/M 20.1-30.0 CM
RPR F/E/E/N/L/M >30.0 CM
CLOSURE OF SPLIT WOUND
CLOSURE OF SPLIT WOUND
INTMD RPR S/A/T/EXT 2.5 CM/<
INTMD RPR S/A/T/EXT 2.6-7.5
INTMD RPR S/TR/EXT 7.6-12.5
INTMD RPR S/A/T/EXT 12.6-20
INTMD RPR S/A/T/EXT 20.1-30
INTMD RPR S/TR/EXT >30.0 CM
INTMD RPR N-HF/GENIT 2.5CM/<
INTMD RPR N-HF/GENIT2.6-7.5
INTMD RPR N-HF/GENIT7.6-12.5
INTMD RPR N-HF/GENIT12.6-20
INTMD RPR N-HF/GENIT20.1-30
INTMD RPR N-HF/GENIT >30.0CM
INTMD RPR FACE/MM 2.5 CM/<
Pricing Action Code
9
3
3
3
3
3
3
3
3
3
3
3
3
3
5
5
3
5
3
3
3
3
3
3
9
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$0.00
$56.61
$71.34
$175.69
$204.91
$63.53
$75.22
$99.86
$134.00
$162.95
$983.08
$636.50
$487.10
$145.80
$0.00
$0.00
$163.73
$0.00
$90.87
$110.64
$130.45
$164.63
$195.25
$228.43
$0.00
$111.42
$116.42
$136.19
$164.98
$209.25
$158.45
$179.63
$297.87
$171.31
$242.49
$310.33
$319.26
$392.62
$433.76
$492.17
$242.43
$295.74
$367.99
$413.08
$491.33
$534.03
$264.81
Procedure Code
12052
12053
12054
12055
12056
12057
1205F
1220F
13100
13101
13102
13120
13121
13122
13131
13132
13133
13151
13152
13153
13160
14000
14001
1400F
14020
14021
14040
14041
14060
14061
14301
14302
14350
1450F
1451F
1460F
1461F
1490F
1491F
1493F
1494F
15002
15003
15004
15005
1500F
1501F
Description
INTMD RPR FACE/MM 2.6-5.0 CM
INTMD RPR FACE/MM 5.1-7.5 CM
INTMD RPR FACE/MM 7.6-12.5CM
INTMD RPR FACE/MM 12.6-20 CM
INTMD RPR FACE/MM 20.1-30.0
INTMD RPR FACE/MM >30.0 CM
EPI ETIOL SYND RVWD AND DOCD
PT SCREENED FOR DEPRESSION
CMPLX RPR TRUNK 1.1-2.5 CM
CMPLX RPR TRUNK 2.6-7.5 CM
CMPLX RPR TRUNK ADDL 5CM/<
CMPLX RPR S/A/L 1.1-2.5 CM
CMPLX RPR S/A/L 2.6-7.5 CM
CMPLX RPR S/A/L ADDL 5 CM/>
CMPLX RPR F/C/C/M/N/AX/G/H/F
CMPLX RPR E/N/E/L 1.1-2.5 CM
CMPLX RPR E/N/E/L 2.6-7.5 CM
CMPLX RPR E/N/E/L ADDL 5CM/<
LATE CLOSURE OF WOUND
TIS TRNFR TRUNK 10 SQ CM/<
TIS TRNFR TRUNK 10.1-30SQCM
PRKNS DIAG RVIEWED
TIS TRNFR S/A/L 10 SQ CM/<
TIS TRNFR S/A/L 10.1-30 SQCM
TIS TRNFR F/C/C/M/N/A/G/H/F
TIS TRNFR F/C/C/M/N/A/G/H/F
TIS TRNFR E/N/E/L 10 SQ CM/<
TIS TRNFR E/N/E/L10.1-30SQCM
TIS TRNFR ANY 30.1-60 SQ CM
TIS TRNFR ADDL 30 SQ CM/<
FILLETED FINGER/TOE FLAP
SYMPTOMS IMPROVED/CONSIST
SYMPT SHOW CLIN IMPORT DROP
QUAL CARD DIAG PRIOR 12 MONS
NO QUAL CARD DIAG PRIOR12MON
DEM SEVERITY CLASSIFIED MILD
DEM SEVERITY CLASSIFIED MOD
DEM SEVERITY CLASS SEVERE
COGNIT ASSESSED AND REVIEWED
WOUND PREP TRK/ARM/LEG
WOUND PREP ADDL 100 CM
WOUND PREP F/N/HF/G
WND PREP F/N/HF/G ADDL CM
SYMPTOM+SIGN SYMM POLYNEURO
NOT INITIAL EVAL FOR COND
Pricing Action Code
3
3
3
3
3
3
9
9
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
9
3
3
3
3
3
3
3
3
3
9
9
9
9
9
9
9
9
3
3
3
3
9
9
Maximum Allowable
$301.50
$353.88
$369.69
$480.47
$566.07
$580.59
$0.00
$0.00
$343.10
$405.90
$125.55
$359.31
$437.91
$137.03
$395.28
$488.65
$183.42
$433.43
$520.67
$199.66
$838.43
$642.15
$825.32
$0.00
$718.10
$897.76
$785.11
$971.41
$800.40
$1,045.00
$1,113.26
$231.08
$719.25
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$359.29
$78.29
$413.67
$129.06
$0.00
$0.00
Procedure Code
1502F
1503F
15040
1504F
15050
1505F
15100
15101
15110
15111
15115
15116
15120
15121
15130
15131
15135
15136
15150
15151
15152
15155
15156
15157
15200
15201
15220
15221
15240
15241
15260
15261
15271
15272
15273
15274
15275
15276
15277
15278
15570
15572
15574
15576
15600
15610
15620
Description
PT QUERIED PAIN FXN W/ INSTR
PT QUERIED SYMP RESP INSUFF
HARVEST CULTURED SKIN GRAFT
PT HAS RESP INSUFFICIENCY
SKIN PINCH GRAFT
PT HAS NO RESP INSUFFICIENCY
SKIN SPLT GRFT TRNK/ARM/LEG
SKIN SPLT GRFT T/A/L ADD-ON
EPIDRM AUTOGRFT TRNK/ARM/LEG
EPIDRM AUTOGRFT T/A/L ADD-ON
EPIDRM A-GRFT FACE/NCK/HF/G
EPIDRM A-GRFT F/N/HF/G ADDL
SKN SPLT A-GRFT FAC/NCK/HF/G
SKN SPLT A-GRFT F/N/HF/G ADD
DERM AUTOGRAFT TRNK/ARM/LEG
DERM AUTOGRAFT T/A/L ADD-ON
DERM AUTOGRAFT FACE/NCK/HF/G
DERM AUTOGRAFT F/N/HF/G ADD
CULT SKIN GRFT T/ARM/LEG
CULT SKIN GRFT T/A/L ADDL
CULT SKIN GRAFT T/A/L +%
CULT SKIN GRAFT F/N/HF/G
CULT SKIN GRFT F/N/HFG ADD
CULT EPIDERM GRFT F/N/HFG +%
SKIN FULL GRAFT TRUNK
SKIN FULL GRAFT TRUNK ADD-ON
SKIN FULL GRAFT SCLP/ARM/LEG
SKIN FULL GRAFT ADD-ON
SKIN FULL GRFT FACE/GENIT/HF
SKIN FULL GRAFT EEN & LIPS
SKIN SUB GRAFT TRNK/ARM/LEG
SKIN SUB GRAFT T/A/L ADD-ON
SKIN SUB GRFT T/ARM/LG CHILD
SKN SUB GRFT T/A/L CHILD ADD
SKIN SUB GRAFT FACE/NK/HF/G
SKIN SUB GRAFT F/N/HF/G ADDL
SKN SUB GRFT F/N/HF/G CHILD
SKN SUB GRFT F/N/HF/G CH ADD
SKIN PEDICLE FLAP TRUNK
SKIN PEDICLE FLAP ARMS/LEGS
PEDCLE FH/CH/CH/M/N/AX/G/H/F
PEDICLE E/N/E/L/NTRORAL
DELAY FLAP TRUNK
DELAY FLAP ARMS/LEGS
DELAY FLAP F/C/C/N/AX/G/H/F
Pricing Action Code
9
9
3
9
3
9
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$0.00
$0.00
$264.00
$0.00
$578.53
$0.00
$888.90
$192.45
$825.59
$120.06
$849.11
$158.69
$881.13
$215.49
$694.47
$103.73
$869.81
$98.63
$721.88
$126.93
$155.41
$743.39
$163.91
$179.76
$858.79
$153.05
$795.63
$141.13
$964.49
$191.19
$1,042.65
$222.50
$144.18
$27.74
$304.70
$73.63
$152.23
$35.61
$331.55
$88.02
$948.30
$919.53
$944.86
$832.56
$334.49
$367.98
$455.07
Procedure Code
15630
15650
15731
15732
15734
15736
15738
15740
15750
15756
15757
15758
15760
15770
15775
15776
15777
15780
15781
15782
15783
15786
15787
15788
15789
15792
15793
15819
15820
15821
15822
15823
15824
15825
15826
15828
15829
15830
15832
15833
15834
15835
15836
15837
15838
15839
15840
Description
DELAY FLAP EYE/NOS/EAR/LIP
TRANSFER SKIN PEDICLE FLAP
FOREHEAD FLAP W/VASC PEDICLE
MUSCLE-SKIN GRAFT HEAD/NECK
MUSCLE-SKIN GRAFT TRUNK
MUSCLE-SKIN GRAFT ARM
MUSCLE-SKIN GRAFT LEG
ISLAND PEDICLE FLAP GRAFT
NEUROVASCULAR PEDICLE FLAP
FREE MYO/SKIN FLAP MICROVASC
FREE SKIN FLAP MICROVASC
FREE FASCIAL FLAP MICROVASC
COMPOSITE SKIN GRAFT
DERMA-FAT-FASCIA GRAFT
HAIR TRNSPL 1-15 PUNCH GRFTS
HAIR TRNSPL >15 PUNCH GRAFTS
ACELLULAR DERM MATRIX IMPLT
DERMABRASION TOTAL FACE
DERMABRASION SEGMENTAL FACE
DERMABRASION OTHER THAN FACE
DERMABRASION SUPRFL ANY SITE
ABRASION LESION SINGLE
ABRASION LESIONS ADD-ON
CHEMICAL PEEL FACE EPIDERM
CHEMICAL PEEL FACE DERMAL
CHEMICAL PEEL NONFACIAL
CHEMICAL PEEL NONFACIAL
PLASTIC SURGERY NECK
REVISION OF LOWER EYELID
REVISION OF LOWER EYELID
REVISION OF UPPER EYELID
REVISION OF UPPER EYELID
REMOVAL OF FOREHEAD WRINKLES
REMOVAL OF NECK WRINKLES
REMOVAL OF BROW WRINKLES
REMOVAL OF FACE WRINKLES
REMOVAL OF SKIN WRINKLES
EXC SKIN ABD
EXCISE EXCESSIVE SKIN THIGH
EXCISE EXCESSIVE SKIN LEG
EXCISE EXCESSIVE SKIN HIP
EXCISE EXCESSIVE SKIN BUTTCK
EXCISE EXCESSIVE SKIN ARM
EXCISE EXCESS SKIN ARM/HAND
EXCISE EXCESS SKIN FAT PAD
EXCISE EXCESS SKIN & TISSUE
NERVE PALSY FASCIAL GRAFT
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
9
9
3
3
3
3
3
3
3
9
9
9
9
3
3
3
3
3
9
5
5
5
5
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$473.39
$519.12
$1,167.83
$1,330.44
$1,378.28
$1,374.69
$1,456.94
$1,052.92
$959.48
$2,430.04
$2,393.92
$2,397.93
$882.68
$700.81
$0.00
$0.00
$224.01
$861.53
$574.51
$661.48
$473.95
$250.27
$50.16
$0.00
$0.00
$0.00
$0.00
$765.52
$576.33
$622.13
$456.44
$620.93
$0.00
$0.00
$0.00
$0.00
$0.00
$1,224.84
$959.59
$900.53
$928.96
$970.48
$795.19
$834.44
$594.48
$914.02
$1,050.02
Procedure Code
15841
15842
15845
15847
15850
15851
15852
15860
15876
15877
15878
15879
15920
15922
15931
15933
15934
15935
15936
15937
15940
15941
15944
15945
15946
15950
15951
15952
15953
15956
15958
15999
16000
16020
16025
16030
16035
16036
17000
17003
17004
17106
17107
17108
17110
17111
17250
Description
NERVE PALSY MUSCLE GRAFT
NERVE PALSY MICROSURG GRAFT
SKIN AND MUSCLE REPAIR FACE
EXC SKIN ABD ADD-ON
REMOVE SUTURES SAME SURGEON
REMOVE SUTURES DIFF SURGEON
DRESSING CHANGE NOT FOR BURN
TEST FOR BLOOD FLOW IN GRAFT
SUCTION LIPECTOMY HEAD&NECK
SUCTION LIPECTOMY TRUNK
SUCTION LIPECTOMY UPR EXTREM
SUCTION LIPECTOMY LWR EXTREM
REMOVAL OF TAIL BONE ULCER
REMOVAL OF TAIL BONE ULCER
REMOVE SACRUM PRESSURE SORE
REMOVE HIP PRESSURE SORE
REMOVE THIGH PRESSURE SORE
REMOVAL OF PRESSURE SORE
INITIAL TREATMENT OF BURN(S)
DRESS/DEBRID P-THICK BURN S
DRESS/DEBRID P-THICK BURN M
DRESS/DEBRID P-THICK BURN L
INCISION OF BURN SCAB INITI
ESCHAROTOMY ADDL INCISION
DESTRUCT PREMALG LESION
DESTRUCT PREMALG LES 2-14
DESTROY PREMAL LESIONS 15/>
DESTRUCTION OF SKIN LESIONS
DESTRUCT B9 LESION 1-14
DESTRUCT LESION 15 OR MORE
CHEMICAL CAUTERY TISSUE
Pricing Action Code
3
3
3
6
9
3
3
3
5
9
9
9
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
5
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$1,685.05
$2,756.34
$1,037.71
$0.00
$0.00
$100.95
$48.55
$115.54
$0.00
$0.00
$0.00
$0.00
$630.53
$816.27
$713.86
$883.86
$965.98
$1,138.20
$927.52
$1,078.08
$730.19
$936.26
$922.07
$1,015.76
$1,709.86
$614.26
$917.94
$936.49
$1,039.24
$1,199.52
$1,222.91
$0.00
$70.20
$83.31
$151.33
$190.73
$201.52
$84.18
$68.18
$5.78
$153.66
$349.99
$445.14
$656.34
$113.37
$134.25
$81.24
Procedure Code
17260
17261
17262
17263
17264
17266
17270
17271
17272
17273
17274
17276
17280
17281
17282
17283
17284
17286
17311
17312
17313
17314
17315
17340
17360
17380
17999
19000
19001
19020
19030
19081
19082
19083
19084
19085
19086
19100
19101
19105
19110
19112
19120
19125
19126
19260
19271
Description
MOHS 1 STAGE H/N/HF/G
MOHS ADDL STAGE
MOHS 1 STAGE T/A/L
MOHS ADDL STAGE T/A/L
MOHS SURG ADDL BLOCK
CRYOTHERAPY OF SKIN
SKIN PEEL THERAPY
HAIR REMOVAL BY ELECTROLYSIS
SKIN TISSUE PROCEDURE
DRAINAGE OF BREAST LESION
DRAIN BREAST LESION ADD-ON
INCISION OF BREAST LESION
INJECTION FOR BREAST X-RAY
BX BREAST 1ST LESION STRTCTC
BX BREAST ADD LESION STRTCTC
BX BREAST 1ST LESION US IMAG
BX BREAST ADD LESION US IMAG
BX BREAST 1ST LESION MR IMAG
BX BREAST ADD LESION MR IMAG
BX BREAST PERCUT W/O IMAGE
BIOPSY OF BREAST OPEN
CRYOSURG ABLATE FA EACH
NIPPLE EXPLORATION
EXCISE BREAST DUCT FISTULA
REMOVAL OF BREAST LESION
EXCISION BREAST LESION
EXCISION ADDL BREAST LESION
REMOVAL OF CHEST WALL LESION
REVISION OF CHEST WALL
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
9
5
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$96.99
$146.84
$178.90
$195.47
$209.89
$237.58
$153.66
$166.62
$190.41
$212.37
$250.88
$290.81
$143.95
$181.74
$209.13
$250.15
$286.13
$367.11
$678.17
$397.64
$633.87
$381.79
$81.83
$52.50
$132.26
$0.00
$0.00
$115.85
$27.69
$485.92
$168.29
$175.54
$87.94
$165.09
$82.17
$193.42
$95.75
$154.61
$351.44
$2,191.57
$500.36
$469.03
$510.51
$477.80
$169.48
$1,256.92
$1,702.96
Procedure Code
19272
19281
19282
19283
19284
19285
19286
19287
19288
19296
19297
19298
19300
19301
19302
19303
19304
19305
19306
19307
19316
19318
19324
19325
19328
19330
19340
19342
19350
19355
19357
19361
19364
19366
19367
19368
19369
19370
19371
19380
19396
19499
20005
2000F
2001F
2002F
2004F
Description
EXTENSIVE CHEST WALL SURGERY
PERQ DEVICE BREAST 1ST IMAG
PERQ DEVICE BREAST EA IMAG
PERQ DEV BREAST 1ST STRTCTC
PERQ DEV BREAST ADD STRTCTC
PERQ DEV BREAST 1ST US IMAG
PERQ DEV BREAST ADD US IMAG
PERQ DEV BREAST 1ST MR GUIDE
PERQ DEV BREAST ADD MR GUIDE
PLACE PO BREAST CATH FOR RAD
PLACE BREAST CATH FOR RAD
PLACE BREAST RAD TUBE/CATHS
REMOVAL OF BREAST TISSUE
PARTIAL MASTECTOMY
P-MASTECTOMY W/LN REMOVAL
MAST SIMPLE COMPLETE
MAST SUBQ
MAST RADICAL
MAST RAD URBAN TYPE
MAST MOD RAD
SUSPENSION OF BREAST
REDUCTION OF LARGE BREAST
ENLARGE BREAST
ENLARGE BREAST WITH IMPLANT
REMOVAL OF BREAST IMPLANT
REMOVAL OF IMPLANT MATERIAL
IMMEDIATE BREAST PROSTHESIS
DELAYED BREAST PROSTHESIS
BREAST RECONSTRUCTION
CORRECT INVERTED NIPPLE(S)
BREAST RECONSTR W/LAT FLAP
SURGERY OF BREAST CAPSULE
REMOVAL OF BREAST CAPSULE
REVISE BREAST RECONSTRUCTION
DESIGN CUSTOM BREAST IMPLANT
BREAST SURGERY PROCEDURE
I&D ABSCESS SUBFASCIAL
BLOOD PRESSURE MEASURE
WEIGHT RECORD
CLIN SIGN VOL OVRLD ASSESS
INITIAL EXAM INVOLVED JOINTS
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
9
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
9
3
3
3
3
3
3
3
3
3
3
3
5
3
9
9
9
9
Maximum Allowable
$1,858.65
$244.43
$171.46
$275.62
$208.06
$527.33
$463.31
$881.69
$711.04
$4,064.73
$99.15
$1,064.99
$0.00
$680.42
$935.80
$1,052.29
$596.50
$1,174.54
$1,249.25
$1,245.82
$801.74
$1,151.62
$508.87
$668.73
$518.37
$663.18
$1,049.98
$964.95
$857.68
$0.00
$1,574.72
$1,645.70
$2,885.71
$1,467.30
$1,871.08
$2,307.06
$2,135.59
$717.94
$820.24
$808.71
$287.71
$0.00
$318.66
$0.00
$0.00
$0.00
$0.00
Procedure Code
20100
20101
20102
20103
2010F
2014F
20150
2015F
2016F
2018F
2019F
20200
20205
20206
2020F
2021F
20220
20225
2022F
20240
20245
2024F
20250
20251
2026F
2027F
2028F
2029F
2030F
2031F
2035F
2040F
2044F
20500
20501
2050F
20520
20525
20526
20527
20550
20551
20552
20553
20555
20600
20604
Description
EXPLORE WOUND NECK
EXPLORE WOUND CHEST
EXPLORE WOUND ABDOMEN
EXPLORE WOUND EXTREMITY
VITAL SIGNS RECORDED
MENTAL STATUS ASSESS
EXCISE EPIPHYSEAL BAR
ASTHMA IMPAIRMENT ASSESSED
ASTHMA RISK ASSESSED
HYDRATION STATUS ASSESS
DILATED MACUL EXAM DONE
MUSCLE BIOPSY
DEEP MUSCLE BIOPSY
NEEDLE BIOPSY MUSCLE
DILATED FUNDUS EVAL DONE
DILAT MACULAR EXAM DONE
BONE BIOPSY TROCAR/NEEDLE
BONE BIOPSY TROCAR/NEEDLE
DIL RETINA EXAM INTERP REV
BONE BIOPSY EXCISIONAL
BONE BIOPSY EXCISIONAL
7 FIELD PHOTO INTERP DOC REV
OPEN BONE BIOPSY
OPEN BONE BIOPSY
EYE IMAGE VALID TO DX REV
OPTIC NERVE HEAD EVAL DONE
FOOT EXAM PERFORMED
COMPLETE PHYS SKIN EXAM DONE
H2O STAT DOCD NORMAL
H2O STAT DOCD DEHYDRATED
TYMP MEMB MOTION EXAMD
BK PN XM ON INIT VISIT DATE
DOC MNTL TST B/4 BK TRXMNT
INJECTION OF SINUS TRACT
INJECT SINUS TRACT FOR X-RAY
WOUND CHAR SIZE ETC DOCD
REMOVAL OF FOREIGN BODY
THER INJECTION CARP TUNNEL
INJ DUPUYTREN CORD W/ENZYME
INJ TENDON SHEATH/LIGAMENT
INJ TENDON ORIGIN/INSERTION
INJ TRIGGER POINT 1/2 MUSCL
INJECT TRIGGER POINTS 3/>
PLACE NDL MUSC/TIS FOR RT
DRAIN/INJ JOINT/BURSA W/O US
DRAIN/INJ JOINT/BURSA W/US
Pricing Action Code
3
3
3
3
9
9
3
9
9
9
9
3
3
3
9
9
3
3
9
3
3
9
3
3
9
9
9
9
9
9
9
9
9
3
3
9
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$633.80
$462.27
$507.27
$603.82
$0.00
$0.00
$940.64
$0.00
$0.00
$0.00
$0.00
$213.64
$298.62
$242.06
$0.00
$0.00
$172.41
$112.77
$0.00
$161.14
$535.44
$0.00
$409.31
$441.65
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$106.52
$39.45
$0.00
$209.18
$497.28
$79.66
$87.27
$60.48
$62.29
$56.52
$65.17
$338.87
$48.92
$74.16
Procedure Code
20605
20606
2060F
20610
20611
20612
20615
20650
20660
20661
20662
20663
20664
20665
20670
20680
20690
20692
20693
20694
20696
20697
20802
20805
20808
20816
20822
20824
20827
20838
20900
20902
20910
20912
20920
20922
20924
20926
20930
20931
20936
20937
20938
20950
20955
20956
20957
Description
PT TALK EVAL HLTHWKR RE MDD
ASPIRATE/INJ GANGLION CYST
TREATMENT OF BONE CYST
INSERT AND REMOVE BONE PIN
APPLY REM FIXATION DEVICE
APPLICATION OF HEAD BRACE
APPLICATION OF PELVIS BRACE
APPLICATION OF THIGH BRACE
APPLICATION OF HALO
REMOVAL OF FIXATION DEVICE
REMOVAL OF SUPPORT IMPLANT
REMOVAL OF SUPPORT IMPLANT
APPLY BONE FIXATION DEVICE
APPLY BONE FIXATION DEVICE
ADJUST BONE FIXATION DEVICE
REMOVE BONE FIXATION DEVICE
COMP MULTIPLANE EXT FIXATION
COMP EXT FIXATE STRUT CHANGE
REPLANTATION ARM COMPLETE
REPLANT FOREARM COMPLETE
REPLANTATION HAND COMPLETE
REPLANTATION DIGIT COMPLETE
REPLANTATION DIGIT COMPLETE
REPLANTATION THUMB COMPLETE
REPLANTATION THUMB COMPLETE
REPLANTATION FOOT COMPLETE
REMOVAL OF BONE FOR GRAFT
REMOVAL OF BONE FOR GRAFT
REMOVE CARTILAGE FOR GRAFT
REMOVE CARTILAGE FOR GRAFT
REMOVAL OF FASCIA FOR GRAFT
REMOVAL OF FASCIA FOR GRAFT
REMOVAL OF TENDON FOR GRAFT
REMOVAL OF TISSUE FOR GRAFT
SP BONE ALGRFT MORSEL ADD-ON
SP BONE ALGRFT STRUCT ADD-ON
SP BONE AGRFT LOCAL ADD-ON
SP BONE AGRFT MORSEL ADD-ON
SP BONE AGRFT STRUCT ADD-ON
FLUID PRESSURE MUSCLE
FIBULA BONE GRAFT MICROVASC
ILIAC BONE GRAFT MICROVASC
MT BONE GRAFT MICROVASC
Pricing Action Code
3
3
9
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
5
3
5
3
3
3
3
3
3
Maximum Allowable
$51.46
$82.08
$0.00
$61.96
$94.04
$62.32
$251.66
$214.80
$258.10
$534.33
$445.01
$488.51
$926.30
$107.88
$153.16
$440.63
$619.94
$1,163.60
$461.16
$438.03
$1,251.57
$2,051.48
$2,493.16
$3,454.57
$4,206.96
$2,164.17
$1,879.88
$2,141.44
$1,910.48
$2,518.76
$431.17
$297.15
$425.69
$500.32
$407.20
$649.47
$522.98
$441.07
$0.00
$119.36
$0.00
$172.67
$191.35
$260.94
$2,620.23
$2,776.94
$2,554.60
Procedure Code
20962
20969
20970
20972
20973
20974
20975
20979
20982
20983
20985
20999
21010
21011
21012
21013
21014
21015
21016
21025
21026
21029
21030
21031
21032
21034
21040
21044
21045
21046
21047
21048
21049
21050
21060
21070
21073
21076
21077
21079
21080
21081
21082
21083
21084
21085
21086
Description
OTHER BONE GRAFT MICROVASC
BONE/SKIN GRAFT MICROVASC
BONE/SKIN GRAFT ILIAC CREST
BONE/SKIN GRAFT METATARSAL
BONE/SKIN GRAFT GREAT TOE
ELECTRICAL BONE STIMULATION
ELECTRICAL BONE STIMULATION
US BONE STIMULATION
ABLATE BONE TUMOR(S) PERQ
ABLATE BONE TUMOR(S) PERQ
CPTR-ASST DIR MS PX
MUSCULOSKELETAL SURGERY
INCISION OF JAW JOINT
EXC FACE LES SC <2 CM
EXC FACE LES SBQ 2 CM/>
EXC FACE TUM DEEP < 2 CM
EXC FACE TUM DEEP 2 CM/>
RESECT FACE/SCALP TUM < 2 CM
RESECT FACE/SCALP TUM 2 CM/>
EXCISION OF BONE LOWER JAW
EXCISION OF FACIAL BONE(S)
CONTOUR OF FACE BONE LESION
EXCISE MAX/ZYGOMA B9 TUMOR
REMOVE EXOSTOSIS MANDIBLE
REMOVE EXOSTOSIS MAXILLA
EXCISE MAX/ZYGOMA MAL TUMOR
EXCISE MANDIBLE LESION
REMOVAL OF JAW BONE LESION
EXTENSIVE JAW SURGERY
REMOVE MANDIBLE CYST COMPLEX
EXCISE LWR JAW CYST W/REPAIR
REMOVE MAXILLA CYST COMPLEX
EXCIS UPPR JAW CYST W/REPAIR
REMOVAL OF JAW JOINT
REMOVE JAW JOINT CARTILAGE
REMOVE CORONOID PROCESS
MNPJ OF TMJ W/ANESTH
PREPARE FACE/ORAL PROSTHESIS
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
5
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$2,197.22
$2,890.66
$3,064.39
$2,439.54
$2,741.02
$79.12
$183.58
$53.67
$3,103.69
$7,509.80
$153.82
$0.00
$772.46
$361.00
$352.74
$539.00
$543.62
$741.77
$1,070.08
$936.52
$648.82
$802.34
$544.87
$414.39
$421.26
$1,373.67
$549.22
$917.06
$1,287.18
$1,178.70
$1,388.91
$1,208.18
$1,265.15
$880.96
$834.16
$636.56
$405.28
$1,053.76
$2,641.91
$1,778.96
$1,996.13
$1,843.55
$1,742.57
$1,659.48
$1,908.88
$799.00
$1,965.22
Procedure Code
21087
21088
21089
21100
21110
21116
21120
21121
21122
21123
21125
21127
21137
21138
21139
21141
21142
21143
21145
21146
21147
21150
21151
21154
21155
21159
21160
21172
21175
21179
21180
21181
21182
21183
21184
21188
21193
21194
21195
21196
21198
21199
21206
21208
21209
21210
21215
Description
MAXILLOFACIAL FIXATION
INTERDENTAL FIXATION
INJECTION JAW JOINT X-RAY
RECONSTRUCTION OF CHIN
AUGMENTATION LOWER JAW BONE
AUGMENTATION LOWER JAW BONE
REDUCTION OF FOREHEAD
LEFORT I-1 PIECE W/O GRAFT
LEFORT I-2 PIECE W/O GRAFT
LEFORT I-3/> PIECE W/O GRAFT
LEFORT I-1 PIECE W/ GRAFT
LEFORT I-2 PIECE W/ GRAFT
LEFORT I-3/> PIECE W/ GRAFT
LEFORT II ANTERIOR INTRUSION
LEFORT II W/BONE GRAFTS
LEFORT III W/O LEFORT I
LEFORT III W/ LEFORT I
LEFORT III W/FHDW/O LEFORT I
LEFORT III W/FHD W/ LEFORT I
RECONSTRUCT ORBIT/FOREHEAD
RECONSTRUCT ORBIT/FOREHEAD
RECONSTRUCT ENTIRE FOREHEAD
RECONSTRUCT ENTIRE FOREHEAD
CONTOUR CRANIAL BONE LESION
RECONSTRUCT CRANIAL BONE
RECONSTRUCTION OF MIDFACE
RECONST LWR JAW W/O GRAFT
RECONST LWR JAW W/GRAFT
RECONST LWR JAW W/O FIXATION
RECONST LWR JAW W/FIXATION
RECONSTR LWR JAW SEGMENT
RECONSTR LWR JAW W/ADVANCE
RECONSTRUCT UPPER JAW BONE
AUGMENTATION OF FACIAL BONES
REDUCTION OF FACIAL BONES
FACE BONE GRAFT
LOWER JAW BONE GRAFT
Pricing Action Code
3
5
5
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$1,961.95
$0.00
$0.00
$1,077.60
$845.70
$150.23
$688.54
$852.68
$685.65
$988.98
$3,176.89
$4,629.94
$795.16
$926.57
$988.93
$1,409.79
$1,480.35
$1,486.91
$1,656.53
$1,613.98
$1,836.24
$1,752.92
$2,128.24
$2,187.95
$2,250.79
$2,604.79
$3,347.85
$1,881.51
$2,257.07
$1,507.43
$1,605.36
$776.14
$2,020.74
$2,431.67
$2,220.06
$1,687.33
$1,275.23
$1,502.53
$1,401.16
$1,561.50
$1,232.60
$1,125.37
$1,238.47
$1,981.12
$845.43
$2,399.88
$949.92
Procedure Code
21230
21235
21240
21242
21243
21244
21245
21246
21247
21248
21249
21255
21256
21260
21261
21263
21267
21268
21270
21275
21280
21282
21295
21296
21299
21310
21315
21320
21325
21330
21335
21336
21337
21338
21339
21340
21343
21344
21345
21346
21347
21348
21355
21356
21360
21365
21366
Description
RIB CARTILAGE GRAFT
EAR CARTILAGE GRAFT
RECONSTRUCTION OF JAW JOINT
RECONSTRUCTION OF LOWER JAW
RECONSTRUCTION OF JAW
RECONSTRUCT LOWER JAW BONE
RECONSTRUCT LOWER JAW BONE
RECONSTRUCTION OF ORBIT
REVISE EYE SOCKETS
REVISE EYE SOCKETS
REVISE EYE SOCKETS
REVISE EYE SOCKETS
REVISE EYE SOCKETS
AUGMENTATION CHEEK BONE
REVISION ORBITOFACIAL BONES
REVISION OF EYELID
REVISION OF EYELID
REVISION OF JAW MUSCLE/BONE
REVISION OF JAW MUSCLE/BONE
CRANIO/MAXILLOFACIAL SURGERY
CLOSED TX NOSE FX W/O MANJ
CLOSED TX NOSE FX W/O STABLJ
CLOSED TX NOSE FX W/ STABLJ
OPEN TX NOSE FX UNCOMPLICATD
OPEN TX NOSE FX W/SKELE FIXJ
OPEN TX NOSE & SEPTAL FX
OPEN TX SEPTAL FX W/WO STABJ
CLOSED TX SEPTAL&NOSE FX
OPEN NASOETHMOID FX W/O FIXJ
OPEN NASOETHMOID FX W/ FIXJ
PERQ TX NASOETHMOID FX
OPEN TX DPRSD FRONT SINUS FX
OPEN TX COMPL FRONT SINUS FX
CLOSED TX NOSE/JAW FX
OPN TX NASOMAX FX W/FIXJ
OPN TX NASOMAX FX MULTPLE
OPN TX NASOMAX FX W/GRAFT
PERQ TX MALAR FRACTURE
OPN TX DPRSD ZYGOMATIC ARCH
OPN TX DPRSD MALAR FRACTURE
OPN TX COMPLX MALAR FX
OPN TX COMPLX MALAR W/GRFT
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
5
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$741.61
$756.57
$1,180.61
$1,082.31
$1,790.15
$1,123.62
$1,154.98
$910.74
$1,623.08
$1,166.91
$1,597.41
$1,458.32
$1,250.30
$1,461.41
$2,190.44
$2,023.75
$1,626.16
$1,808.55
$997.39
$877.69
$585.87
$394.11
$186.38
$450.28
$0.00
$135.50
$287.06
$266.41
$495.08
$591.84
$758.09
$672.13
$420.43
$756.41
$801.96
$785.35
$1,265.88
$1,452.42
$845.70
$946.33
$1,196.35
$1,268.45
$444.90
$523.84
$563.11
$1,164.81
$1,202.05
Procedure Code
21385
21386
21387
21390
21395
21400
21401
21406
21407
21408
21421
21422
21423
21431
21432
21433
21435
21436
21440
21445
21450
21451
21452
21453
21454
21461
21462
21465
21470
21480
21485
21490
21495
21497
21499
21501
21502
21510
21550
21552
21554
21555
21556
21557
21558
21600
21610
Description
OPN TX ORBIT FX TRANSANTRAL
OPN TX ORBIT FX PERIORBITAL
OPN TX ORBIT FX COMBINED
OPN TX ORBIT PERIORBTL IMPLT
OPN TX ORBIT PERIORBT W/GRFT
CLOSED TX ORBIT W/O MANIPULJ
CLOSED TX ORBIT W/MANIPULJ
OPN TX ORBIT FX W/O IMPLANT
OPN TX ORBIT FX W/IMPLANT
OPN TX ORBIT FX W/BONE GRFT
TREAT MOUTH ROOF FRACTURE
TREAT CRANIOFACIAL FRACTURE
TREAT DENTAL RIDGE FRACTURE
TREAT DENTAL RIDGE FRACTURE
TREAT LOWER JAW FRACTURE
RESET DISLOCATED JAW
RESET DISLOCATED JAW
REPAIR DISLOCATED JAW
TREAT HYOID BONE FRACTURE
INTERDENTAL WIRING
HEAD SURGERY PROCEDURE
DRAIN NECK/CHEST LESION
DRAIN CHEST LESION
DRAINAGE OF BONE LESION
BIOPSY OF NECK/CHEST
EXC NECK LES SC 3 CM/>
EXC NECK TUM DEEP 5 CM/>
EXC NECK LES SC < 3 CM
EXC NECK TUM DEEP < 5 CM
RESECT NECK THORAX TUMOR<5CM
RESECT NECK TUMOR 5 CM/>
PARTIAL REMOVAL OF RIB
PARTIAL REMOVAL OF RIB
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
5
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$709.56
$728.89
$741.33
$827.50
$1,051.67
$199.63
$459.05
$540.43
$673.65
$919.20
$791.76
$706.67
$861.28
$776.48
$683.67
$1,821.13
$1,313.93
$2,191.19
$606.92
$810.88
$644.10
$802.00
$624.62
$962.70
$626.20
$991.35
$2,389.16
$1,010.76
$1,266.43
$102.57
$737.88
$962.35
$736.50
$776.30
$0.00
$470.11
$555.04
$469.62
$271.40
$465.70
$763.64
$430.01
$552.92
$1,001.59
$1,409.53
$580.81
$1,263.76
Procedure Code
21615
21616
21620
21627
21630
21632
21685
21700
21705
21720
21725
21740
21742
21743
21750
21811
21812
21813
21820
21825
21899
21920
21925
21930
21931
21932
21933
21935
21936
22010
22015
22100
22101
22102
22103
22110
22112
22114
22116
22206
22207
22208
22210
22212
22214
22216
22220
Description
REMOVAL OF RIB
REMOVAL OF RIB AND NERVES
PARTIAL REMOVAL OF STERNUM
STERNAL DEBRIDEMENT
EXTENSIVE STERNUM SURGERY
EXTENSIVE STERNUM SURGERY
HYOID MYOTOMY & SUSPENSION
REVISION OF NECK MUSCLE
REVISION OF NECK MUSCLE/RIB
RECONSTRUCTION OF STERNUM
REPAIR STERN/NUSS W/O SCOPE
REPAIR STERNUM/NUSS W/SCOPE
REPAIR OF STERNUM SEPARATION
OPTX OF RIB FX W/FIXJ SCOPE
TREATMENT OF RIB FRACTURE
TREATMENT OF RIB FRACTURE
TREAT STERNUM FRACTURE
TREAT STERNUM FRACTURE
NECK/CHEST SURGERY PROCEDURE
BIOPSY SOFT TISSUE OF BACK
BIOPSY SOFT TISSUE OF BACK
EXC BACK LES SC < 3 CM
EXC BACK LES SC 3 CM/>
EXC BACK TUM DEEP < 5 CM
EXC BACK TUM DEEP 5 CM/>
RESECT BACK TUM < 5 CM
RESECT BACK TUM 5 CM/>
I&D P-SPINE C/T/CERV-THOR
I&D ABSCESS P-SPINE L/S/LS
REMOVE PART OF NECK VERTEBRA
REMOVE PART THORAX VERTEBRA
REMOVE PART LUMBAR VERTEBRA
REMOVE EXTRA SPINE SEGMENT
REMOVE PART OF NECK VERTEBRA
REMOVE PART THORAX VERTEBRA
REMOVE PART LUMBAR VERTEBRA
REMOVE EXTRA SPINE SEGMENT
INCIS SPINE 3 COLUMN THORAC
INCIS SPINE 3 COLUMN LUMBAR
INCIS SPINE 3 COLUMN ADL SEG
INCIS 1 VERTEBRAL SEG CERV
INCIS 1 VERTEBRAL SEG THORAC
INCIS 1 VERTEBRAL SEG LUMBAR
INCIS ADDL SPINE SEGMENT
INCIS W/DISCECTOMY CERVICAL
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
5
5
3
3
3
3
3
3
5
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$642.85
$785.21
$525.82
$561.39
$1,260.85
$1,268.16
$1,045.53
$389.29
$577.16
$473.35
$554.07
$1,071.43
$0.00
$0.00
$714.17
$639.95
$767.60
$1,003.28
$144.69
$565.20
$0.00
$265.63
$457.36
$489.91
$490.28
$690.80
$769.39
$1,072.86
$1,476.45
$1,002.03
$980.44
$920.43
$896.37
$820.97
$145.71
$1,097.21
$1,035.69
$1,039.99
$145.78
$2,559.99
$2,507.75
$595.79
$1,873.61
$1,547.58
$1,548.93
$374.61
$1,674.55
Procedure Code
22222
22224
22226
22305
22310
22315
22318
22319
22325
22326
22327
22328
22505
22510
22511
22512
22513
22514
22515
22526
22527
22532
22533
22534
22548
22551
22552
22554
22556
22558
22585
22586
22590
22595
22600
22610
22612
22614
22630
22632
22633
22634
22800
22802
22804
22808
22810
Description
INCIS W/DISCECTOMY THORACIC
INCIS W/DISCECTOMY LUMBAR
REVISE EXTRA SPINE SEGMENT
CLOSED TX SPINE PROCESS FX
CLOSED TX VERT FX W/O MANJ
CLOSED TX VERT FX W/MANJ
TREAT ODONTOID FX W/O GRAFT
TREAT ODONTOID FX W/GRAFT
TREAT SPINE FRACTURE
TREAT NECK SPINE FRACTURE
TREAT THORAX SPINE FRACTURE
TREAT EACH ADD SPINE FX
MANIPULATION OF SPINE
PERQ CERVICOTHORACIC INJECT
PERQ LUMBOSACRAL INJECTION
VERTEBROPLASTY ADDL INJECT
PERQ VERTEBRAL AUGMENTATION
IDET SINGLE LEVEL
IDET 1 OR MORE LEVELS
LAT THORAX SPINE FUSION
LAT LUMBAR SPINE FUSION
LAT THOR/LUMB ADDL SEG
NECK SPINE FUSION
NECK SPINE FUSE&REMOV BEL C2
ADDL NECK SPINE FUSION
NECK SPINE FUSION
THORAX SPINE FUSION
LUMBAR SPINE FUSION
ADDITIONAL SPINAL FUSION
PRESCRL FUSE W/ INSTR L5-S1
SPINE & SKULL SPINAL FUSION
NECK SPINAL FUSION
NECK SPINE FUSION
THORAX SPINE FUSION
LUMBAR SPINE FUSION
SPINE FUSION EXTRA SEGMENT
LUMBAR SPINE FUSION
LUMBAR SPINE FUSION COMBINED
POST FUSION </6 VERT SEG
POST FUSION 7-12 VERT SEG
POST FUSION 13/> VERT SEG
ANT FUSION 2-3 VERT SEG
ANT FUSION 4-7 VERT SEG
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
9
9
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$1,630.84
$1,649.18
$372.46
$198.05
$320.01
$920.66
$1,734.72
$1,940.08
$1,498.21
$1,567.37
$1,580.96
$289.42
$133.37
$1,819.07
$1,801.26
$1,009.83
$563.76
$7,571.15
$238.16
$0.00
$0.00
$1,860.93
$1,725.14
$370.26
$2,106.35
$1,803.08
$409.69
$1,310.17
$1,753.19
$1,616.08
$340.47
$1,894.79
$1,669.76
$1,592.19
$1,354.66
$1,323.82
$1,665.28
$404.14
$1,645.54
$329.96
$1,939.17
$508.21
$1,410.06
$2,195.83
$2,543.31
$1,929.26
$2,125.43
Procedure Code
22812
22818
22819
22830
22840
22841
22842
22843
22844
22845
22846
22847
22848
22849
22850
22851
22852
22855
22856
22857
22858
22861
22862
22864
22865
22899
22900
22901
22902
22903
22904
22905
22999
23000
23020
23030
23031
23035
23040
23044
23065
23066
23071
23073
23075
23076
23077
Description
ANT FUSION 8/> VERT SEG
KYPHECTOMY 1-2 SEGMENTS
KYPHECTOMY 3 OR MORE
EXPLORATION OF SPINAL FUSION
INSERT SPINE FIXATION DEVICE
INSERT PELV FIXATION DEVICE
REINSERT SPINAL FIXATION
REMOVE SPINE FIXATION DEVICE
APPLY SPINE PROSTH DEVICE
CERV ARTIFIC DISKECTOMY
LUMBAR ARTIF DISKECTOMY
SECOND LEVEL CER DISKECTOMY
REVISE CERV ARTIFIC DISC
REVISE LUMBAR ARTIF DISC
REMOVE CERV ARTIF DISC
REMOVE LUMB ARTIF DISC
SPINE SURGERY PROCEDURE
EXC ABDL TUM DEEP < 5 CM
EXC ABDL TUM DEEP 5 CM/>
EXC ABD LES SC < 3 CM
EXC ABD LES SC 3 CM/>
RADICAL RESECT ABD TUMOR<5CM
RAD RESECT ABD TUMOR 5 CM/>
ABDOMEN SURGERY PROCEDURE
REMOVAL OF CALCIUM DEPOSITS
RELEASE SHOULDER JOINT
DRAIN SHOULDER LESION
DRAIN SHOULDER BURSA
DRAIN SHOULDER BONE LESION
EXPLORATORY SHOULDER SURGERY
EXPLORATORY SHOULDER SURGERY
BIOPSY SHOULDER TISSUES
BIOPSY SHOULDER TISSUES
EXC SHOULDER LES SC 3 CM/>
EXC SHOULDER TUM DEEP 5 CM/>
EXC SHOULDER LES SC < 3 CM
EXC SHOULDER TUM DEEP < 5 CM
RESECT SHOULDER TUMOR < 5 CM
Pricing Action Code
3
3
3
3
3
9
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
5
3
3
3
3
3
3
5
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$2,559.82
$2,278.47
$2,952.16
$848.22
$781.29
$0.00
$784.95
$847.31
$1,024.85
$749.98
$777.66
$853.72
$372.83
$1,360.71
$756.73
$417.35
$725.60
$1,156.82
$1,702.76
$2,076.91
$533.56
$2,103.07
$2,099.58
$2,191.14
$2,149.89
$0.00
$588.72
$693.29
$454.69
$457.87
$1,096.22
$1,389.64
$0.00
$605.29
$711.50
$458.01
$441.13
$703.45
$748.56
$590.09
$223.21
$574.37
$437.30
$722.40
$483.60
$562.78
$1,197.86
Procedure Code
23078
23100
23101
23105
23106
23107
23120
23125
23130
23140
23145
23146
23150
23155
23156
23170
23172
23174
23180
23182
23184
23190
23195
23200
23210
23220
23330
23333
23334
23335
23350
23395
23397
23400
23405
23406
23410
23412
23415
23420
23430
23440
23450
23455
23460
23462
23465
Description
RESECT SHOULDER TUMOR 5 CM/>
BIOPSY OF SHOULDER JOINT
SHOULDER JOINT SURGERY
REMOVE SHOULDER JOINT LINING
INCISION OF COLLARBONE JOINT
EXPLORE TREAT SHOULDER JOINT
PARTIAL REMOVAL COLLAR BONE
REMOVAL OF COLLAR BONE
REMOVE SHOULDER BONE PART
REMOVAL OF BONE LESION
REMOVAL OF HUMERUS LESION
REMOVE COLLAR BONE LESION
REMOVE SHOULDER BLADE LESION
REMOVE HUMERUS LESION
REMOVE COLLAR BONE LESION
REMOVE SHOULDER BLADE LESION
PARTIAL REMOVAL OF SCAPULA
REMOVAL OF HEAD OF HUMERUS
RESECT CLAVICLE TUMOR
RESECT SCAPULA TUMOR
RESECT PROX HUMERUS TUMOR
REMOVE SHOULDER FOREIGN BODY
REMOVE SHOULDER FB DEEP
SHOULDER PROSTHESIS REMOVAL
SHOULDER PROSTHESIS REMOVAL
INJECTION FOR SHOULDER X-RAY
MUSCLE TRANSFER SHOULDER/ARM
MUSCLE TRANSFERS
FIXATION OF SHOULDER BLADE
INCISION OF TENDON & MUSCLE
INCISE TENDON(S) & MUSCLE(S)
REPAIR ROTATOR CUFF ACUTE
REPAIR ROTATOR CUFF CHRONIC
RELEASE OF SHOULDER LIGAMENT
REPAIR OF SHOULDER
REPAIR BICEPS TENDON
REMOVE/TRANSPLANT TENDON
REPAIR SHOULDER CAPSULE
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$1,501.20
$518.41
$472.25
$660.88
$511.92
$684.24
$604.73
$738.97
$634.87
$553.64
$724.20
$645.20
$680.16
$826.96
$703.50
$580.06
$590.04
$781.03
$690.71
$671.65
$764.05
$589.21
$784.69
$1,554.90
$1,853.83
$2,023.67
$245.10
$471.88
$1,124.54
$1,337.78
$133.44
$1,334.85
$1,190.05
$1,013.61
$647.03
$795.85
$853.67
$884.19
$725.67
$1,006.47
$772.83
$783.20
$982.94
$1,039.35
$1,137.94
$1,103.18
$1,152.87
Procedure Code
23466
23470
23472
23473
23474
23480
23485
23490
23491
23500
23505
23515
23520
23525
23530
23532
23540
23545
23550
23552
23570
23575
23585
23600
23605
23615
23616
23620
23625
23630
23650
23655
23660
23665
23670
23675
23680
23700
23800
23802
23900
23920
23921
23929
23930
23931
23935
Description
RECONSTRUCT SHOULDER JOINT
RECONSTRUCT SHOULDER JOINT
REVIS RECONST SHOULDER JOINT
REVIS RECONST SHOULDER JOINT
REVISION OF COLLAR BONE
REVISION OF COLLAR BONE
REINFORCE CLAVICLE
REINFORCE SHOULDER BONES
TREAT CLAVICLE FRACTURE
TREAT CLAVICLE DISLOCATION
TREAT SHOULDER BLADE FX
TREAT SHOULDER BLADE FX
TREAT SCAPULA FRACTURE
TREAT HUMERUS FRACTURE
TREAT SHOULDER DISLOCATION
TREAT DISLOCATION/FRACTURE
FIXATION OF SHOULDER
FUSION OF SHOULDER JOINT
FUSION OF SHOULDER JOINT
AMPUTATION OF ARM & GIRDLE
AMPUTATION AT SHOULDER JOINT
AMPUTATION FOLLOW-UP SURGERY
SHOULDER SURGERY PROCEDURE
DRAINAGE OF ARM LESION
DRAINAGE OF ARM BURSA
DRAIN ARM/ELBOW BONE LESION
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
5
3
3
3
Maximum Allowable
$1,159.62
$1,251.95
$1,514.28
$1,681.27
$1,817.00
$856.07
$992.59
$876.43
$1,056.47
$226.95
$366.23
$748.11
$231.32
$389.43
$571.44
$646.78
$234.13
$349.48
$582.42
$679.57
$239.97
$413.26
$1,020.33
$338.23
$481.72
$920.38
$1,292.77
$278.27
$393.67
$813.04
$321.18
$417.39
$602.84
$441.27
$910.23
$571.83
$965.67
$204.12
$1,070.57
$1,321.74
$1,451.74
$1,173.34
$487.43
$0.00
$364.78
$296.60
$526.54
Procedure Code
24000
24006
24065
24066
24071
24073
24075
24076
24077
24079
24100
24101
24102
24105
24110
24115
24116
24120
24125
24126
24130
24134
24136
24138
24140
24145
24147
24149
24150
24152
24155
24160
24164
24200
24201
24220
24300
24301
24305
24310
24320
24330
24331
24332
24340
24341
24342
Description
EXPLORATORY ELBOW SURGERY
RELEASE ELBOW JOINT
BIOPSY ARM/ELBOW SOFT TISSUE
BIOPSY ARM/ELBOW SOFT TISSUE
EXC ARM/ELBOW LES SC 3 CM/>
EX ARM/ELBOW TUM DEEP 5 CM/>
EXC ARM/ELBOW LES SC < 3 CM
EX ARM/ELBOW TUM DEEP < 5 CM
RESECT ARM/ELBOW TUM < 5 CM
RESECT ARM/ELBOW TUM 5 CM/>
BIOPSY ELBOW JOINT LINING
EXPLORE/TREAT ELBOW JOINT
REMOVE ELBOW JOINT LINING
REMOVAL OF ELBOW BURSA
REMOVE/GRAFT BONE LESION
REMOVE ELBOW LESION
REMOVAL OF HEAD OF RADIUS
REMOVAL OF ARM BONE LESION
REMOVE RADIUS BONE LESION
REMOVE ELBOW BONE LESION
PARTIAL REMOVAL OF ARM BONE
PARTIAL REMOVAL OF RADIUS
PARTIAL REMOVAL OF ELBOW
RADICAL RESECTION OF ELBOW
RESECT DISTAL HUMERUS TUMOR
RESECT RADIUS TUMOR
REMOVAL OF ELBOW JOINT
REMOVE ELBOW JOINT IMPLANT
REMOVE RADIUS HEAD IMPLANT
REMOVAL OF ARM FOREIGN BODY
REMOVAL OF ARM FOREIGN BODY
INJECTION FOR ELBOW X-RAY
MANIPULATE ELBOW W/ANESTH
MUSCLE/TENDON TRANSFER
ARM TENDON LENGTHENING
REVISION OF ARM TENDON
REPAIR OF ARM TENDON
REVISION OF ARM MUSCLES
REVISION OF ARM MUSCLES
TENOLYSIS TRICEPS
REPAIR OF BICEPS TENDON
REPAIR ARM TENDON/MUSCLE
REPAIR OF RUPTURED TENDON
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$495.86
$735.32
$264.18
$645.50
$422.79
$721.96
$507.81
$566.29
$1,082.95
$1,382.16
$435.14
$520.41
$641.37
$364.88
$603.65
$769.26
$899.32
$550.27
$637.63
$675.92
$530.19
$777.85
$658.61
$699.46
$728.94
$616.42
$647.46
$1,225.92
$1,628.46
$1,393.19
$879.72
$1,322.88
$762.05
$212.91
$563.78
$164.43
$433.84
$779.54
$601.25
$489.50
$814.65
$748.36
$820.06
$636.31
$634.20
$776.05
$805.92
Procedure Code
24343
24344
24345
24346
24357
24358
24359
24360
24361
24362
24363
24365
24366
24370
24371
24400
24410
24420
24430
24435
24470
24495
24498
24500
24505
24515
24516
24530
24535
24538
24545
24546
24560
24565
24566
24575
24576
24577
24579
24582
24586
24587
24600
24605
24615
24620
24635
Description
REPR ELBOW LAT LIGMNT W/TISS
RECONSTRUCT ELBOW LAT LIGMNT
REPR ELBW MED LIGMNT W/TISSU
RECONSTRUCT ELBOW MED LIGMNT
REPAIR ELBOW PERC
REPAIR ELBOW W/DEB OPEN
REPAIR ELBOW DEB/ATTCH OPEN
RECONSTRUCT ELBOW JOINT
REPLACE ELBOW JOINT
RECONSTRUCT HEAD OF RADIUS
RECONSTRUCT HEAD OF RADIUS
REVISE RECONST ELBOW JOINT
REVISE RECONST ELBOW JOINT
REVISION OF HUMERUS
REVISION OF HUMERUS
REVISION OF HUMERUS
REPAIR OF HUMERUS
REPAIR HUMERUS WITH GRAFT
REVISION OF ELBOW JOINT
DECOMPRESSION OF FOREARM
REINFORCE HUMERUS
TREAT ELBOW FRACTURE
TREAT ELBOW DISLOCATION
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$733.70
$1,142.80
$731.22
$1,140.75
$444.00
$543.43
$686.74
$922.87
$1,040.92
$1,106.23
$1,519.07
$661.35
$707.23
$1,623.31
$1,858.15
$848.58
$1,103.40
$1,018.14
$1,099.67
$1,120.77
$585.64
$680.13
$901.20
$370.67
$518.18
$910.99
$895.13
$394.52
$638.24
$774.38
$966.40
$1,081.70
$331.64
$547.87
$747.10
$760.80
$351.95
$564.00
$869.94
$838.18
$1,128.44
$1,126.06
$375.22
$488.82
$741.94
$572.50
$700.29
Procedure Code
24640
24650
24655
24665
24666
24670
24675
24685
24800
24802
24900
24920
24925
24930
24931
24935
24940
24999
25000
25001
25020
25023
25024
25025
25028
25031
25035
25040
25065
25066
25071
25073
25075
25076
25077
25078
25085
25100
25101
25105
25107
25109
25110
25111
25112
25115
25116
Description
TREAT RADIUS FRACTURE
TREAT ULNAR FRACTURE
FUSION OF ELBOW JOINT
FUSION/GRAFT OF ELBOW JOINT
AMPUTATION OF UPPER ARM
AMPUTATION OF UPPER ARM
AMPUTATE UPPER ARM & IMPLANT
REVISION OF AMPUTATION
REVISION OF UPPER ARM
UPPER ARM/ELBOW SURGERY
INCISION OF TENDON SHEATH
INCISE FLEXOR CARPI RADIALIS
DECOMPRESS FOREARM 1 SPACE
DECOMPRESS FOREARM 1 SPACE
DECOMPRESS FOREARM 2 SPACES
DECOMPRESS FOREARM 2 SPACES
DRAINAGE OF FOREARM LESION
DRAINAGE OF FOREARM BURSA
TREAT FOREARM BONE LESION
EXPLORE/TREAT WRIST JOINT
BIOPSY FOREARM SOFT TISSUES
BIOPSY FOREARM SOFT TISSUES
EXC FOREARM LES SC 3 CM/>
EXC FOREARM TUM DEEP 3 CM/>
EXC FOREARM LES SC < 3 CM
EXC FOREARM TUM DEEP < 3 CM
RESECT FOREARM/WRIST TUM<3CM
RESECT FORARM/WRIST TUM 3CM>
INCISION OF WRIST CAPSULE
BIOPSY OF WRIST JOINT
EXPLORE/TREAT WRIST JOINT
REMOVE WRIST JOINT LINING
REMOVE WRIST JOINT CARTILAGE
EXCISE TENDON FOREARM/WRIST
REMOVE WRIST TENDON LESION
REMOVE WRIST TENDON LESION
REREMOVE WRIST TENDON LESION
REMOVE WRIST/FOREARM LESION
REMOVE WRIST/FOREARM LESION
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
5
5
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$139.26
$270.36
$449.86
$677.18
$762.52
$301.39
$469.74
$680.14
$864.80
$1,020.59
$762.29
$761.90
$569.56
$801.32
$829.20
$1,156.80
$0.00
$0.00
$350.75
$355.32
$600.41
$1,147.24
$807.35
$1,260.22
$544.66
$371.93
$602.46
$585.80
$261.65
$371.21
$443.66
$554.26
$494.81
$539.10
$924.59
$1,216.39
$467.32
$357.53
$418.69
$502.99
$641.05
$562.01
$355.69
$333.04
$402.55
$792.00
$624.78
Procedure Code
25118
25119
25120
25125
25126
25130
25135
25136
25145
25150
25151
25170
25210
25215
25230
25240
25246
25248
25250
25251
25259
25260
25263
25265
25270
25272
25274
25275
25280
25290
25295
25300
25301
25310
25312
25315
25316
25320
25332
25335
25337
25350
25355
25360
25365
25370
25375
Description
EXCISE WRIST TENDON SHEATH
PARTIAL REMOVAL OF ULNA
REMOVAL OF FOREARM LESION
REMOVE/GRAFT FOREARM LESION
REMOVE/GRAFT FOREARM LESION
REMOVAL OF WRIST LESION
REMOVE & GRAFT WRIST LESION
REMOVE & GRAFT WRIST LESION
REMOVE FOREARM BONE LESION
RESECT RADIUS/ULNAR TUMOR
REMOVAL OF WRIST BONE
REMOVAL OF WRIST BONES
INJECTION FOR WRIST X-RAY
REMOVE FOREARM FOREIGN BODY
REMOVAL OF WRIST PROSTHESIS
REMOVAL OF WRIST PROSTHESIS
MANIPULATE WRIST W/ANESTHES
REPAIR FOREARM TENDON/MUSCLE
REPAIR FOREARM TENDON SHEATH
REVISE WRIST/FOREARM TENDON
INCISE WRIST/FOREARM TENDON
RELEASE WRIST/FOREARM TENDON
FUSION OF TENDONS AT WRIST
FUSION OF TENDONS AT WRIST
TRANSPLANT FOREARM TENDON
TRANSPLANT FOREARM TENDON
REVISE PALSY HAND TENDON(S)
REVISE PALSY HAND TENDON(S)
REPAIR/REVISE WRIST JOINT
REVISE WRIST JOINT
REALIGNMENT OF HAND
RECONSTRUCT ULNA/RADIOULNAR
REVISION OF RADIUS
REVISION OF RADIUS
REVISION OF ULNA
REVISE RADIUS & ULNA
REVISE RADIUS OR ULNA
REVISE RADIUS & ULNA
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$397.83
$515.22
$517.78
$601.16
$617.14
$465.15
$575.33
$511.55
$538.23
$590.75
$605.50
$1,546.61
$507.94
$643.08
$450.78
$445.20
$165.81
$431.78
$549.19
$746.56
$432.39
$656.95
$647.78
$778.59
$509.41
$575.07
$692.11
$700.80
$586.37
$455.45
$545.50
$710.11
$668.28
$644.48
$743.36
$803.40
$953.07
$1,029.28
$877.54
$834.28
$929.38
$702.50
$781.94
$679.47
$949.22
$1,051.69
$993.42
Procedure Code
25390
25391
25392
25393
25394
25400
25405
25415
25420
25425
25426
25430
25431
25440
25441
25442
25443
25444
25445
25446
25447
25449
25450
25455
25490
25491
25492
25500
25505
25515
25520
25525
25526
25530
25535
25545
25560
25565
25574
25575
25600
25605
25606
25607
25608
25609
25622
Description
SHORTEN RADIUS OR ULNA
LENGTHEN RADIUS OR ULNA
SHORTEN RADIUS & ULNA
LENGTHEN RADIUS & ULNA
REPAIR CARPAL BONE SHORTEN
REPAIR RADIUS OR ULNA
REPAIR/GRAFT RADIUS OR ULNA
REPAIR RADIUS & ULNA
REPAIR/GRAFT RADIUS & ULNA
REPAIR/GRAFT RADIUS OR ULNA
REPAIR/GRAFT RADIUS & ULNA
VASC GRAFT INTO CARPAL BONE
REPAIR NONUNION CARPAL BONE
REPAIR/GRAFT WRIST BONE
RECONSTRUCT WRIST JOINT
WRIST REPLACEMENT
REPAIR WRIST JOINTS
REMOVE WRIST JOINT IMPLANT
REVISION OF WRIST JOINT
REVISION OF WRIST JOINT
REINFORCE RADIUS
REINFORCE ULNA
REINFORCE RADIUS AND ULNA
TREAT FRACTURE OF RADIUS
TREAT FRACTURE OF ULNA
TREAT FRACTURE RADIUS & ULNA
TREAT FRACTURE RADIUS/ULNA
TREAT FX DISTAL RADIAL
TREAT FX RAD EXTRA-ARTICUL
TREAT FX RAD INTRA-ARTICUL
TREAT FX RADIAL 3+ FRAG
TREAT WRIST BONE FRACTURE
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$801.47
$1,039.21
$899.66
$1,192.02
$811.62
$836.90
$1,079.97
$1,003.00
$1,217.07
$1,004.26
$1,173.25
$761.75
$818.44
$799.33
$982.61
$841.07
$813.99
$861.19
$752.75
$1,221.62
$862.86
$1,077.67
$535.33
$633.82
$747.28
$770.69
$942.63
$281.81
$520.58
$695.95
$578.32
$817.01
$991.07
$271.12
$506.21
$648.04
$286.50
$539.68
$699.22
$937.79
$339.72
$569.98
$690.08
$764.81
$857.70
$1,088.94
$314.70
Procedure Code
25624
25628
25630
25635
25645
25650
25651
25652
25660
25670
25671
25675
25676
25680
25685
25690
25695
25800
25805
25810
25820
25825
25830
25900
25905
25907
25909
25915
25920
25922
25924
25927
25929
25931
25999
26010
26011
26020
26025
26030
26034
26035
26037
26040
26045
26055
26060
Description
PIN ULNAR STYLOID FRACTURE
TREAT FRACTURE ULNAR STYLOID
TREAT WRIST DISLOCATION
PIN RADIOULNAR DISLOCATION
TREAT WRIST FRACTURE
TREAT WRIST FRACTURE
FUSION OF WRIST JOINT
FUSION/GRAFT OF WRIST JOINT
FUSION/GRAFT OF WRIST JOINT
FUSION OF HAND BONES
FUSE HAND BONES WITH GRAFT
FUSION RADIOULNAR JNT/ULNA
AMPUTATION OF FOREARM
AMPUTATE HAND AT WRIST
AMPUTATE HAND AT WRIST
AMPUTATION OF HAND
FOREARM OR WRIST SURGERY
DRAINAGE OF FINGER ABSCESS
DRAINAGE OF FINGER ABSCESS
DRAIN HAND TENDON SHEATH
DRAINAGE OF PALM BURSA
DRAINAGE OF PALM BURSAS
TREAT HAND BONE LESION
DECOMPRESS FINGERS/HAND
DECOMPRESS FINGERS/HAND
RELEASE PALM CONTRACTURE
INCISE FINGER TENDON SHEATH
INCISION OF FINGER TENDON
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
5
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$491.60
$750.86
$316.43
$435.95
$589.68
$331.18
$500.72
$649.83
$422.51
$626.35
$551.96
$448.53
$648.88
$488.94
$764.11
$493.10
$659.27
$762.25
$880.61
$904.17
$640.35
$789.81
$985.33
$738.41
$673.02
$604.29
$713.36
$1,232.80
$722.14
$586.44
$629.94
$844.15
$613.95
$687.12
$0.00
$271.22
$403.95
$452.71
$440.40
$511.98
$560.12
$893.37
$591.21
$324.99
$488.06
$579.65
$275.60
Procedure Code
26070
26075
26080
26100
26105
26110
26111
26113
26115
26116
26117
26118
26121
26123
26125
26130
26135
26140
26145
26160
26170
26180
26185
26200
26205
26210
26215
26230
26235
26236
26250
26260
26262
26320
26340
26341
26350
26352
26356
26357
26358
26370
26372
26373
26390
26392
26410
Description
EXPLORE/TREAT HAND JOINT
EXPLORE/TREAT FINGER JOINT
EXPLORE/TREAT FINGER JOINT
BIOPSY HAND JOINT LINING
BIOPSY FINGER JOINT LINING
BIOPSY FINGER JOINT LINING
EXC HAND LES SC 1.5 CM/>
EXC HAND TUM DEEP 1.5 CM/>
EXC HAND LES SC < 1.5 CM
EXC HAND TUM DEEP < 1.5 CM
RAD RESECT HAND TUMOR < 3 CM
RAD RESECT HAND TUMOR 3 CM/>
REMOVE WRIST JOINT LINING
REVISE FINGER JOINT EACH
REVISE FINGER JOINT EACH
TENDON EXCISION PALM/FINGER
REMOVE TENDON SHEATH LESION
REMOVAL OF PALM TENDON EACH
REMOVAL OF FINGER TENDON
REMOVE FINGER BONE
REMOVE HAND BONE LESION
REMOVAL OF FINGER LESION
REMOVE/GRAFT FINGER LESION
PARTIAL REMOVAL OF HAND BONE
PARTIAL REMOVAL FINGER BONE
PARTIAL REMOVAL FINGER BONE
EXTENSIVE HAND SURGERY
RESECT PROX FINGER TUMOR
RESECT DISTAL FINGER TUMOR
REMOVAL OF IMPLANT FROM HAND
MANIPULATE FINGER W/ANESTH
MANIPULAT PALM CORD POST INJ
REPAIR FINGER/HAND TENDON
REPAIR/GRAFT HAND TENDON
REVISE HAND/FINGER TENDON
REPAIR HAND TENDON
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$321.87
$344.39
$406.52
$345.68
$346.27
$333.99
$435.94
$572.14
$523.99
$550.23
$783.01
$1,097.53
$622.70
$871.07
$287.38
$480.57
$572.08
$526.06
$533.33
$595.77
$421.83
$461.84
$570.61
$469.11
$626.53
$461.28
$585.81
$520.20
$515.19
$460.87
$1,128.07
$837.36
$656.77
$361.72
$348.05
$102.87
$732.85
$839.05
$901.48
$892.87
$991.24
$779.14
$900.77
$865.93
$859.57
$992.72
$581.66
Procedure Code
26412
26415
26416
26418
26420
26426
26428
26432
26433
26434
26437
26440
26442
26445
26449
26450
26455
26460
26471
26474
26476
26477
26478
26479
26480
26483
26485
26489
26490
26492
26494
26496
26497
26498
26499
26500
26502
26508
26510
26516
26517
26518
26520
26525
26530
26531
26535
Description
EXCISION HAND/FINGER TENDON
GRAFT HAND OR FINGER TENDON
REPAIR FINGER TENDON
REPAIR/GRAFT FINGER TENDON
REALIGNMENT OF TENDONS
RELEASE PALM/FINGER TENDON
RELEASE PALM & FINGER TENDON
RELEASE HAND/FINGER TENDON
RELEASE FOREARM/HAND TENDON
INCISION OF PALM TENDON
INCISION OF FINGER TENDON
INCISE HAND/FINGER TENDON
FUSION OF FINGER TENDONS
FUSION OF FINGER TENDONS
TENDON LENGTHENING
TENDON SHORTENING
LENGTHENING OF HAND TENDON
SHORTENING OF HAND TENDON
TRANSPLANT HAND TENDON
TRANSPLANT/GRAFT HAND TENDON
TRANSPLANT PALM TENDON
TRANSPLANT/GRAFT PALM TENDON
REVISE THUMB TENDON
TENDON TRANSFER WITH GRAFT
HAND TENDON/MUSCLE TRANSFER
REVISE THUMB TENDON
FINGER TENDON TRANSFER
FINGER TENDON TRANSFER
REVISION OF FINGER
HAND TENDON RECONSTRUCTION
HAND TENDON RECONSTRUCTION
RELEASE THUMB CONTRACTURE
THUMB TENDON TRANSFER
FUSION OF KNUCKLE JOINT
FUSION OF KNUCKLE JOINTS
FUSION OF KNUCKLE JOINTS
RELEASE KNUCKLE CONTRACTURE
RELEASE FINGER CONTRACTURE
REVISE KNUCKLE JOINT
REVISE KNUCKLE WITH IMPLANT
REVISE FINGER JOINT
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$701.29
$783.45
$736.47
$594.04
$727.82
$522.49
$773.84
$512.69
$546.54
$662.01
$641.34
$637.94
$993.37
$593.67
$724.36
$418.65
$411.68
$405.36
$631.10
$615.97
$600.02
$598.80
$637.64
$634.92
$771.83
$867.06
$829.92
$943.99
$810.09
$904.30
$809.81
$884.23
$889.88
$1,178.21
$852.74
$640.52
$721.61
$657.72
$608.98
$717.72
$844.68
$855.22
$669.72
$670.44
$557.72
$649.93
$438.93
Procedure Code
26536
26540
26541
26542
26545
26546
26548
26550
26551
26553
26554
26555
26556
26560
26561
26562
26565
26567
26568
26580
26587
26590
26591
26593
26596
26600
26605
26607
26608
26615
26641
26645
26650
26665
26670
26675
26676
26685
26686
26700
26705
26706
26715
26720
26725
26727
26735
Description
REVISE/IMPLANT FINGER JOINT
REPAIR HAND JOINT
REPAIR HAND JOINT WITH GRAFT
REPAIR HAND JOINT WITH GRAFT
RECONSTRUCT FINGER JOINT
REPAIR NONUNION HAND
RECONSTRUCT FINGER JOINT
CONSTRUCT THUMB REPLACEMENT
GREAT TOE-HAND TRANSFER
SINGLE TRANSFER TOE-HAND
DOUBLE TRANSFER TOE-HAND
POSITIONAL CHANGE OF FINGER
TOE JOINT TRANSFER
REPAIR OF WEB FINGER
CORRECT METACARPAL FLAW
CORRECT FINGER DEFORMITY
LENGTHEN METACARPAL/FINGER
REPAIR HAND DEFORMITY
RECONSTRUCT EXTRA FINGER
REPAIR FINGER DEFORMITY
REPAIR MUSCLES OF HAND
RELEASE MUSCLES OF HAND
EXCISION CONSTRICTING TISSUE
TREAT METACARPAL FRACTURE
TREAT THUMB DISLOCATION
TREAT THUMB FRACTURE
TREAT HAND DISLOCATION
PIN HAND DISLOCATION
TREAT KNUCKLE DISLOCATION
PIN KNUCKLE DISLOCATION
TREAT FINGER FRACTURE EACH
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$733.30
$675.81
$823.48
$696.64
$709.95
$1,021.53
$781.65
$1,596.36
$2,935.28
$3,406.39
$3,413.57
$1,391.99
$2,903.14
$576.52
$960.46
$1,385.68
$696.31
$700.64
$923.60
$1,517.72
$940.26
$1,392.12
$447.70
$618.61
$781.73
$304.63
$333.12
$472.82
$495.62
$600.86
$377.82
$435.86
$497.16
$657.30
$349.35
$466.30
$520.90
$601.54
$648.91
$331.18
$431.48
$458.39
$596.07
$204.60
$349.22
$488.43
$622.08
Procedure Code
26740
26742
26746
26750
26755
26756
26765
26770
26775
26776
26785
26820
26841
26842
26843
26844
26850
26852
26860
26861
26862
26863
26910
26951
26952
26989
26990
26991
26992
27000
27001
27003
27005
27006
27025
27027
27030
27033
27035
27036
27040
27041
27043
27045
27047
27048
27049
Description
PIN FINGER FRACTURE EACH
TREAT FINGER DISLOCATION
PIN FINGER DISLOCATION
THUMB FUSION WITH GRAFT
FUSION OF THUMB
THUMB FUSION WITH GRAFT
FUSION OF HAND JOINT
FUSION/GRAFT OF HAND JOINT
FUSION OF KNUCKLE
FUSION OF KNUCKLE WITH GRAFT
FUSION OF FINGER JOINT
FUSION OF FINGER JNT ADD-ON
FUSION/GRAFT OF FINGER JOINT
FUSE/GRAFT ADDED JOINT
AMPUTATE METACARPAL BONE
AMPUTATION OF FINGER/THUMB
AMPUTATION OF FINGER/THUMB
HAND/FINGER SURGERY
DRAINAGE OF PELVIS LESION
DRAINAGE OF PELVIS BURSA
INCISION OF HIP TENDON
INCISION OF HIP TENDONS
INCISION OF HIP/THIGH FASCIA
BUTTOCK FASCIOTOMY
DRAINAGE OF HIP JOINT
EXPLORATION OF HIP JOINT
DENERVATION OF HIP JOINT
EXCISION OF HIP JOINT/MUSCLE
BIOPSY OF SOFT TISSUES
BIOPSY OF SOFT TISSUES
EXC HIP PELVIS LES SC 3 CM/>
EXC HIP/PELV TUM DEEP 5 CM/>
EXC HIP/PELVIS LES SC < 3 CM
EXC HIP/PELV TUM DEEP < 5 CM
RESECT HIP/PELV TUM < 5 CM
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
5
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$238.21
$381.65
$774.40
$190.46
$325.35
$434.71
$521.93
$280.72
$395.41
$461.06
$570.94
$806.53
$745.14
$806.29
$758.32
$840.98
$711.43
$817.29
$580.86
$108.39
$747.14
$240.70
$741.13
$673.25
$664.67
$0.00
$649.72
$727.96
$998.47
$417.68
$555.58
$619.24
$748.97
$763.51
$950.19
$938.78
$975.42
$1,011.47
$1,196.22
$1,047.39
$353.31
$710.18
$490.32
$779.62
$482.71
$634.43
$1,406.85
Procedure Code
27050
27052
27054
27057
27059
27060
27062
27065
27066
27067
27070
27071
27075
27076
27077
27078
27080
27086
27087
27090
27091
27093
27095
27096
27097
27098
27100
27105
27110
27111
27120
27122
27125
27130
27132
27134
27137
27138
27140
27146
27147
27151
27156
27158
27161
27165
27170
Description
BIOPSY OF SACROILIAC JOINT
BIOPSY OF HIP JOINT
REMOVAL OF HIP JOINT LINING
BUTTOCK FASCIOTOMY W/DBRDMT
RESECT HIP/PELV TUM 5 CM/>
REMOVAL OF ISCHIAL BURSA
REMOVE FEMUR LESION/BURSA
REMOVE HIP BONE LES SUPER
REMOVE HIP BONE LES DEEP
REMOVE/GRAFT HIP BONE LESION
PART REMOVE HIP BONE SUPER
PART REMOVAL HIP BONE DEEP
RESECT HIP TUMOR
RESECT HIP TUM INCL ACETABUL
RESECT HIP TUM W/INNOM BONE
RSECT HIP TUM INCL FEMUR
REMOVAL OF TAIL BONE
REMOVE HIP FOREIGN BODY
REMOVE HIP FOREIGN BODY
REMOVAL OF HIP PROSTHESIS
REMOVAL OF HIP PROSTHESIS
INJECTION FOR HIP X-RAY
INJECTION FOR HIP X-RAY
INJECT SACROILIAC JOINT
REVISION OF HIP TENDON
TRANSFER TENDON TO PELVIS
TRANSFER OF ABDOMINAL MUSCLE
TRANSFER OF SPINAL MUSCLE
TRANSFER OF ILIOPSOAS MUSCLE
TRANSFER OF ILIOPSOAS MUSCLE
RECONSTRUCTION OF HIP SOCKET
RECONSTRUCTION OF HIP SOCKET
PARTIAL HIP REPLACEMENT
TOTAL HIP ARTHROPLASTY
TOTAL HIP ARTHROPLASTY
REVISE HIP JOINT REPLACEMENT
TRANSPLANT FEMUR RIDGE
INCISION OF HIP BONE
REVISION OF HIP BONE
INCISION OF HIP BONES
REVISION OF HIP BONES
REVISION OF PELVIS
INCISION OF NECK OF FEMUR
INCISION/FIXATION OF FEMUR
REPAIR/GRAFT FEMUR HEAD/NECK
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$394.00
$598.72
$709.08
$1,059.32
$1,899.78
$481.20
$475.47
$529.71
$839.49
$1,056.74
$881.56
$953.38
$2,189.99
$2,640.95
$2,974.66
$2,158.19
$535.81
$300.25
$651.44
$863.39
$1,663.74
$192.70
$249.13
$166.49
$697.58
$695.18
$848.04
$903.72
$1,008.81
$938.67
$1,359.21
$1,145.90
$1,182.73
$1,411.38
$1,742.83
$1,990.56
$1,530.46
$1,590.95
$928.06
$1,344.53
$1,538.32
$1,660.60
$1,795.98
$1,491.65
$1,261.34
$1,430.73
$1,223.93
Procedure Code
27175
27176
27177
27178
27179
27181
27185
27187
27193
27194
27200
27202
27215
27216
27217
27218
27220
27222
27226
27227
27228
27230
27232
27235
27236
27238
27240
27244
27245
27246
27248
27250
27252
27253
27254
27256
27257
27258
27259
27265
27266
27267
27268
27269
27275
27279
27280
Description
TREAT SLIPPED EPIPHYSIS
REVISE HEAD/NECK OF FEMUR
REVISION OF FEMUR EPIPHYSIS
REINFORCE HIP BONES
TREAT PELVIC RING FRACTURE
TREAT TAIL BONE FRACTURE
TREAT TAIL BONE FRACTURE
TREAT PELVIC FRACTURE(S)
TREAT HIP SOCKET FRACTURE
TREAT HIP SOCKET FRACTURE
TREAT HIP WALL FRACTURE
TREAT HIP FRACTURE(S)
TREAT HIP FRACTURE(S)
TREAT THIGH FRACTURE
TREAT HIP DISLOCATION
CLTX THIGH FX
CLTX THIGH FX W/MNPJ
OPTX THIGH FX
MANIPULATION OF HIP JOINT
ARTHRODESIS SACROILIAC JOINT
FUSION OF SACROILIAC JOINT
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$695.59
$937.62
$1,163.93
$958.12
$1,019.38
$999.29
$630.17
$1,031.29
$489.39
$729.73
$187.24
$551.57
$646.18
$957.85
$898.55
$1,242.40
$551.82
$1,020.98
$1,100.39
$1,730.62
$1,970.02
$494.17
$788.70
$949.74
$1,248.28
$478.63
$1,000.81
$1,286.22
$1,285.84
$400.75
$773.93
$187.15
$793.07
$979.44
$1,320.52
$308.60
$379.30
$1,159.89
$1,624.90
$414.03
$605.52
$454.09
$553.09
$1,292.70
$189.31
$727.98
$1,426.45
Procedure Code
27282
27284
27286
27290
27295
27299
27301
27303
27305
27306
27307
27310
27323
27324
27325
27326
27327
27328
27329
27330
27331
27332
27333
27334
27335
27337
27339
27340
27345
27347
27350
27355
27356
27357
27358
27360
27364
27365
27370
27372
27380
27381
27385
27386
27390
27391
27392
Description
FUSION OF PUBIC BONES
FUSION OF HIP JOINT
FUSION OF HIP JOINT
AMPUTATION OF LEG AT HIP
AMPUTATION OF LEG AT HIP
PELVIS/HIP JOINT SURGERY
DRAIN THIGH/KNEE LESION
INCISE THIGH TENDON & FASCIA
INCISION OF THIGH TENDON
INCISION OF THIGH TENDONS
EXPLORATION OF KNEE JOINT
BIOPSY THIGH SOFT TISSUES
BIOPSY THIGH SOFT TISSUES
NEURECTOMY HAMSTRING
NEURECTOMY POPLITEAL
EXC THIGH/KNEE LES SC < 3 CM
EXC THIGH/KNEE TUM DEEP <5CM
RESECT THIGH/KNEE TUM < 5 CM
BIOPSY KNEE JOINT LINING
EXPLORE/TREAT KNEE JOINT
REMOVAL OF KNEE CARTILAGE
REMOVAL OF KNEE CARTILAGE
REMOVE KNEE JOINT LINING
REMOVE KNEE JOINT LINING
EXC THIGH/KNEE LES SC 3 CM/>
EXC THIGH/KNEE TUM DEP 5CM/>
REMOVAL OF KNEECAP BURSA
REMOVAL OF KNEE CYST
REMOVE KNEE CYST
REMOVAL OF KNEECAP
REMOVE FEMUR LESION
REMOVE FEMUR LESION/GRAFT
REMOVE FEMUR LESION/GRAFT
REMOVE FEMUR LESION/FIXATION
PARTIAL REMOVAL LEG BONE(S)
RESECT THIGH/KNEE TUM 5 CM/>
RESECT FEMUR/KNEE TUMOR
INJECTION FOR KNEE X-RAY
REPAIR OF KNEECAP TENDON
REPAIR/GRAFT KNEECAP TENDON
REPAIR OF THIGH MUSCLE
REPAIR/GRAFT OF THIGH MUSCLE
INCISION OF THIGH TENDON
Pricing Action Code
3
3
3
3
3
5
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$858.73
$1,621.45
$1,707.21
$1,682.82
$1,313.44
$0.00
$697.16
$661.26
$498.62
$364.68
$478.06
$761.18
$279.74
$413.25
$570.44
$540.66
$476.06
$646.68
$1,081.68
$435.11
$493.39
$664.61
$609.99
$708.42
$791.20
$436.20
$785.84
$386.83
$497.66
$550.03
$675.31
$623.43
$764.66
$846.63
$291.43
$884.84
$1,632.66
$2,158.93
$158.84
$628.32
$615.99
$826.29
$596.60
$860.95
$465.70
$600.22
$738.66
Procedure Code
27393
27394
27395
27396
27397
27400
27403
27405
27407
27409
27412
27415
27416
27418
27420
27422
27424
27425
27427
27428
27429
27430
27435
27437
27438
27440
27441
27442
27443
27445
27446
27447
27448
27450
27454
27455
27457
27465
27466
27468
27470
27472
27475
27477
27479
27485
27486
Description
LENGTHENING OF THIGH TENDON
LENGTHENING OF THIGH TENDONS
LENGTHENING OF THIGH TENDONS
TRANSPLANT OF THIGH TENDON
TRANSPLANTS OF THIGH TENDONS
REVISE THIGH MUSCLES/TENDONS
REPAIR OF KNEE CARTILAGE
REPAIR OF KNEE LIGAMENT
REPAIR OF KNEE LIGAMENT
REPAIR OF KNEE LIGAMENTS
AUTOCHONDROCYTE IMPLANT KNEE
OSTEOCHONDRAL KNEE ALLOGRAFT
OSTEOCHONDRAL KNEE AUTOGRAFT
REPAIR DEGENERATED KNEECAP
REVISION OF UNSTABLE KNEECAP
REVISION OF UNSTABLE KNEECAP
REVISION/REMOVAL OF KNEECAP
LAT RETINACULAR RELEASE OPEN
RECONSTRUCTION KNEE
RECONSTRUCTION KNEE
RECONSTRUCTION KNEE
REVISION OF THIGH MUSCLES
INCISION OF KNEE JOINT
REVISE KNEECAP
REVISE KNEECAP WITH IMPLANT
REVISION OF KNEE JOINT
TOTAL KNEE ARTHROPLASTY
INCISION OF THIGH
INCISION OF THIGH
REALIGNMENT OF THIGH BONE
REALIGNMENT OF KNEE
REALIGNMENT OF KNEE
SHORTENING OF THIGH BONE
LENGTHENING OF THIGH BONE
SHORTEN/LENGTHEN THIGHS
REPAIR OF THIGH
REPAIR/GRAFT OF THIGH
SURGERY TO STOP LEG GROWTH
REVISE/REPLACE KNEE JOINT
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$521.97
$656.23
$916.33
$641.30
$941.90
$723.49
$662.99
$699.40
$814.55
$992.73
$1,728.94
$1,432.02
$1,020.97
$861.18
$772.95
$769.63
$780.08
$466.53
$738.60
$1,158.29
$1,288.63
$765.98
$832.55
$686.28
$874.11
$832.69
$858.17
$902.55
$840.35
$1,299.94
$1,204.92
$1,411.41
$795.33
$1,049.48
$1,358.89
$981.77
$980.68
$1,281.58
$1,219.62
$1,282.09
$1,223.67
$1,314.78
$689.21
$762.26
$816.64
$698.56
$1,462.60
Procedure Code
27487
27488
27495
27496
27497
27498
27499
27500
27501
27502
27503
27506
27507
27508
27509
27510
27511
27513
27514
27516
27517
27519
27520
27524
27530
27532
27535
27536
27538
27540
27550
27552
27556
27557
27558
27560
27562
27566
27570
27580
27590
27591
27592
27594
27596
27598
27599
Description
REVISE/REPLACE KNEE JOINT
REMOVAL OF KNEE PROSTHESIS
REINFORCE THIGH
DECOMPRESSION OF THIGH/KNEE
TREATMENT OF THIGH FRACTURE
TREAT THIGH FX GROWTH PLATE
TREAT KNEECAP FRACTURE
TREAT KNEECAP FRACTURE
TREAT KNEE FRACTURE
TREAT KNEE FRACTURE
TREAT KNEE FRACTURE
TREAT KNEE FRACTURE
TREAT KNEE FRACTURE(S)
TREAT KNEE FRACTURE
TREAT KNEE DISLOCATION
TREAT KNEECAP DISLOCATION
FIXATION OF KNEE JOINT
FUSION OF KNEE
AMPUTATE LEG AT THIGH
AMPUTATE LOWER LEG AT KNEE
LEG SURGERY PROCEDURE
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
5
Maximum Allowable
$1,825.81
$1,250.31
$1,174.36
$563.49
$602.43
$671.55
$726.92
$540.01
$524.09
$805.86
$837.59
$1,395.36
$1,011.98
$546.88
$667.52
$718.77
$1,039.40
$1,293.71
$1,008.44
$528.01
$701.26
$931.60
$334.22
$783.10
$312.65
$638.51
$935.69
$1,239.95
$489.68
$842.12
$527.28
$650.97
$911.14
$1,095.64
$1,243.33
$375.82
$487.55
$928.65
$157.31
$1,495.75
$845.56
$1,006.66
$717.92
$532.44
$760.24
$759.07
$0.00
Procedure Code
27600
27601
27602
27603
27604
27605
27606
27607
27610
27612
27613
27614
27615
27616
27618
27619
27620
27625
27626
27630
27632
27634
27635
27637
27638
27640
27641
27645
27646
27647
27648
27650
27652
27654
27656
27658
27659
27664
27665
27675
27676
27680
27681
27685
27686
27687
27690
Description
DECOMPRESSION OF LOWER LEG
DRAIN LOWER LEG LESION
DRAIN LOWER LEG BURSA
INCISION OF ACHILLES TENDON
INCISION OF ACHILLES TENDON
TREAT LOWER LEG BONE LESION
EXPLORE/TREAT ANKLE JOINT
EXPLORATION OF ANKLE JOINT
BIOPSY LOWER LEG SOFT TISSUE
BIOPSY LOWER LEG SOFT TISSUE
RESECT LEG/ANKLE TUM < 5 CM
RESECT LEG/ANKLE TUM 5 CM/>
EXC LEG/ANKLE TUM < 3 CM
EXC LEG/ANKLE TUM DEEP <5 CM
EXPLORE/TREAT ANKLE JOINT
REMOVE ANKLE JOINT LINING
REMOVE ANKLE JOINT LINING
REMOVAL OF TENDON LESION
EXC LEG/ANKLE LES SC 3 CM/>
EXC LEG/ANKLE TUM DEP 5 CM/>
REMOVE LOWER LEG BONE LESION
REMOVE/GRAFT LEG BONE LESION
REMOVE/GRAFT LEG BONE LESION
PARTIAL REMOVAL OF TIBIA
PARTIAL REMOVAL OF FIBULA
RESECT TIBIA TUMOR
RESECT FIBULA TUMOR
RESECT TALUS/CALCANEUS TUM
INJECTION FOR ANKLE X-RAY
REPAIR ACHILLES TENDON
REPAIR/GRAFT ACHILLES TENDON
REPAIR OF ACHILLES TENDON
REPAIR LEG FASCIA DEFECT
REPAIR OF LEG TENDON EACH
REPAIR LOWER LEG TENDONS
REPAIR LOWER LEG TENDONS
RELEASE OF LOWER LEG TENDON
RELEASE OF LOWER LEG TENDONS
REVISION OF LOWER LEG TENDON
REVISE LOWER LEG TENDONS
REVISION OF CALF TENDON
REVISE LOWER LEG TENDON
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$434.52
$458.40
$521.79
$550.13
$511.68
$353.34
$293.14
$631.77
$677.49
$576.54
$259.71
$596.21
$1,069.45
$1,330.58
$464.71
$488.32
$473.05
$607.06
$640.12
$581.65
$432.40
$716.29
$610.21
$775.46
$791.92
$868.36
$694.74
$1,855.26
$1,608.79
$1,057.31
$169.01
$684.63
$709.29
$731.92
$660.76
$385.96
$497.30
$374.27
$424.54
$503.27
$625.12
$442.34
$567.74
$685.65
$579.04
$470.17
$650.26
Procedure Code
27691
27692
27695
27696
27698
27700
27702
27703
27704
27705
27707
27709
27712
27715
27720
27722
27724
27725
27726
27727
27730
27732
27734
27740
27742
27745
27750
27752
27756
27758
27759
27760
27762
27766
27767
27768
27769
27780
27781
27784
27786
27788
27792
27808
27810
27814
27816
Description
REVISE LOWER LEG TENDON
REVISE ADDITIONAL LEG TENDON
REPAIR OF ANKLE LIGAMENT
REPAIR OF ANKLE LIGAMENTS
REPAIR OF ANKLE LIGAMENT
REVISION OF ANKLE JOINT
RECONSTRUCT ANKLE JOINT
RECONSTRUCTION ANKLE JOINT
REMOVAL OF ANKLE IMPLANT
INCISION OF TIBIA
INCISION OF FIBULA
INCISION OF TIBIA & FIBULA
REALIGNMENT OF LOWER LEG
REVISION OF LOWER LEG
REPAIR OF TIBIA
REPAIR/GRAFT OF TIBIA
REPAIR/GRAFT OF TIBIA
REPAIR OF LOWER LEG
REPAIR FIBULA NONUNION
REPAIR OF LOWER LEG
REPAIR OF TIBIA EPIPHYSIS
REPAIR OF FIBULA EPIPHYSIS
REPAIR LOWER LEG EPIPHYSES
REPAIR OF LEG EPIPHYSES
REPAIR OF LEG EPIPHYSES
REINFORCE TIBIA
TREATMENT OF TIBIA FRACTURE
CLTX MEDIAL ANKLE FX
CLTX MED ANKLE FX W/MNPJ
OPTX MEDIAL ANKLE FX
CLTX POST ANKLE FX
CLTX POST ANKLE FX W/MNPJ
OPTX POST ANKLE FX
TREATMENT OF FIBULA FRACTURE
TREATMENT OF ANKLE FRACTURE
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$778.49
$108.62
$486.29
$575.49
$662.25
$616.09
$1,004.67
$1,154.30
$601.25
$786.58
$420.20
$1,215.78
$1,149.61
$1,118.80
$910.15
$917.20
$1,316.69
$1,255.87
$1,010.71
$1,082.84
$593.53
$421.65
$683.45
$738.25
$815.25
$785.14
$358.75
$559.58
$594.56
$926.84
$1,041.06
$345.29
$492.61
$635.42
$290.14
$457.52
$764.47
$316.87
$434.70
$745.68
$327.64
$436.82
$679.63
$346.14
$485.47
$804.32
$331.59
Procedure Code
27818
27822
27823
27824
27825
27826
27827
27828
27829
27830
27831
27832
27840
27842
27846
27848
27860
27870
27871
27880
27881
27882
27884
27886
27888
27889
27892
27893
27894
27899
28001
28002
28003
28005
28008
28010
28011
28020
28022
28024
28035
28039
28041
28043
28045
28046
28047
Description
TREAT LOWER LEG FRACTURE
TREAT LOWER LEG JOINT
TREAT LOWER LEG DISLOCATION
TREAT ANKLE DISLOCATION
FIXATION OF ANKLE JOINT
FUSION OF ANKLE JOINT OPEN
FUSION OF TIBIOFIBULAR JOINT
AMPUTATION OF LOWER LEG
AMPUTATION OF FOOT AT ANKLE
AMPUTATION OF FOOT AT ANKLE
DECOMPRESSION OF LEG
LEG/ANKLE SURGERY PROCEDURE
DRAINAGE OF BURSA OF FOOT
TREATMENT OF FOOT INFECTION
TREATMENT OF FOOT INFECTION
TREAT FOOT BONE LESION
INCISION OF FOOT FASCIA
INCISION OF TOE TENDON
INCISION OF TOE TENDONS
EXPLORATION OF FOOT JOINT
EXPLORATION OF FOOT JOINT
EXPLORATION OF TOE JOINT
DECOMPRESSION OF TIBIA NERVE
EXC FOOT/TOE TUM SC 1.5 CM/>
EXC FOOT/TOE TUM DEP 1.5CM/>
EXC FOOT/TOE TUM SC < 1.5 CM
EXC FOOT/TOE TUM DEEP <1.5CM
RESECT FOOT/TOE TUMOR < 3 CM
RESECT FOOT/TOE TUMOR 3 CM/>
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
5
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$502.29
$875.41
$994.25
$325.07
$562.52
$867.10
$1,125.59
$1,348.12
$711.04
$394.52
$408.07
$789.52
$379.39
$515.99
$754.58
$843.21
$180.84
$1,071.95
$708.80
$966.59
$915.42
$633.57
$607.37
$693.93
$715.41
$685.40
$576.02
$630.53
$896.24
$0.00
$287.42
$459.26
$738.93
$600.30
$447.23
$238.44
$331.99
$562.13
$512.86
$481.78
$548.18
$532.60
$479.70
$415.75
$515.97
$755.92
$1,115.68
Procedure Code
28050
28052
28054
28055
28060
28062
28070
28072
28080
28086
28088
28090
28092
28100
28102
28103
28104
28106
28107
28108
28110
28111
28112
28113
28114
28116
28118
28119
28120
28122
28124
28126
28130
28140
28150
28153
28160
28171
28173
28175
28190
28192
28193
28200
28202
28208
28210
Description
BIOPSY OF FOOT JOINT LINING
BIOPSY OF FOOT JOINT LINING
BIOPSY OF TOE JOINT LINING
NEURECTOMY FOOT
PARTIAL REMOVAL FOOT FASCIA
REMOVAL OF FOOT FASCIA
REMOVAL OF FOOT JOINT LINING
REMOVAL OF FOOT JOINT LINING
REMOVAL OF FOOT LESION
EXCISE FOOT TENDON SHEATH
EXCISE FOOT TENDON SHEATH
REMOVAL OF TOE LESIONS
REMOVAL OF ANKLE/HEEL LESION
REMOVE/GRAFT FOOT LESION
REMOVAL OF TOE LESIONS
PART REMOVAL OF METATARSAL
REMOVAL OF METATARSAL HEADS
REVISION OF FOOT
REMOVAL OF HEEL BONE
REMOVAL OF HEEL SPUR
PART REMOVAL OF ANKLE/HEEL
PARTIAL REMOVAL OF FOOT BONE
PARTIAL REMOVAL OF TOE
REMOVAL OF ANKLE BONE
REMOVAL OF METATARSAL
REMOVAL OF TOE
RESECT TARSAL TUMOR
RESECT METATARSAL TUMOR
RESECT PHALANX OF TOE TUMOR
REMOVAL OF FOOT FOREIGN BODY
REPAIR OF FOOT TENDON
REPAIR/GRAFT OF FOOT TENDON
REPAIR OF FOOT TENDON
REPAIR/GRAFT OF FOOT TENDON
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$442.16
$474.57
$411.21
$388.76
$538.91
$610.89
$551.42
$529.31
$547.48
$570.67
$465.49
$491.55
$441.23
$630.63
$629.71
$405.10
$551.77
$483.01
$587.64
$458.99
$482.27
$513.81
$506.03
$614.18
$1,121.45
$783.04
$617.36
$547.09
$700.54
$622.97
$496.21
$411.20
$663.92
$623.53
$445.34
$424.85
$437.52
$876.60
$790.99
$506.87
$267.59
$492.14
$552.30
$511.03
$622.29
$497.43
$595.53
Procedure Code
28220
28222
28225
28226
28230
28232
28234
28238
28240
28250
28260
28261
28262
28264
28270
28272
28280
28285
28286
28288
28289
28290
28292
28293
28294
28296
28297
28298
28299
28300
28302
28304
28305
28306
28307
28308
28309
28310
28312
28313
28315
28320
28322
28340
28341
28344
28345
Description
RELEASE OF FOOT TENDON
RELEASE OF FOOT TENDONS
RELEASE OF FOOT TENDON
RELEASE OF FOOT TENDONS
INCISION OF FOOT TENDON(S)
INCISION OF TOE TENDON
INCISION OF FOOT TENDON
REVISION OF FOOT TENDON
RELEASE OF BIG TOE
REVISION OF FOOT FASCIA
RELEASE OF MIDFOOT JOINT
REVISION OF FOOT TENDON
REVISION OF FOOT AND ANKLE
RELEASE OF MIDFOOT JOINT
RELEASE OF FOOT CONTRACTURE
RELEASE OF TOE JOINT EACH
FUSION OF TOES
REPAIR OF HAMMERTOE
REPAIR OF HAMMERTOE
PARTIAL REMOVAL OF FOOT BONE
REPAIR HALLUX RIGIDUS
CORRECTION OF BUNION
INCISION OF HEEL BONE
INCISION OF ANKLE BONE
INCISION OF MIDFOOT BONES
INCISE/GRAFT MIDFOOT BONES
INCISION OF METATARSAL
INCISION OF METATARSALS
REVISION OF BIG TOE
REVISION OF TOE
REPAIR DEFORMITY OF TOE
REMOVAL OF SESAMOID BONE
REPAIR OF FOOT BONES
REPAIR OF METATARSALS
RESECT ENLARGED TOE TISSUE
RESECT ENLARGED TOE
REPAIR EXTRA TOE(S)
REPAIR WEBBED TOE(S)
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$465.26
$525.09
$420.53
$636.50
$447.33
$398.90
$417.38
$698.45
$455.61
$601.48
$712.61
$1,016.44
$1,538.61
$1,046.63
$507.23
$409.85
$539.71
$552.47
$471.38
$628.06
$763.65
$607.27
$820.07
$1,092.25
$799.60
$742.57
$845.65
$751.98
$933.71
$672.03
$746.18
$843.31
$682.87
$634.80
$711.19
$586.33
$943.29
$571.04
$529.14
$538.82
$500.68
$631.76
$825.58
$602.47
$698.64
$483.45
$544.41
Procedure Code
28360
28400
28405
28406
28415
28420
28430
28435
28436
28445
28446
28450
28455
28456
28465
28470
28475
28476
28485
28490
28495
28496
28505
28510
28515
28525
28530
28531
28540
28545
28546
28555
28570
28575
28576
28585
28600
28605
28606
28615
28630
28635
28636
28645
28660
28665
28666
Description
RECONSTRUCT CLEFT FOOT
TREATMENT OF HEEL FRACTURE
TREAT HEEL FRACTURE
TREAT/GRAFT HEEL FRACTURE
TREAT ANKLE FRACTURE
OSTEOCHONDRAL TALUS AUTOGRFT
TREAT MIDFOOT FRACTURE EACH
TREAT MIDFOOT FRACTURE
TREAT METATARSAL FRACTURE
TREAT BIG TOE FRACTURE
TREATMENT OF TOE FRACTURE
TREATMENT OF TOE FRACTURE
TREAT TOE FRACTURE
TREAT SESAMOID BONE FRACTURE
TREAT SESAMOID BONE FRACTURE
TREAT FOOT DISLOCATION
REPAIR FOOT DISLOCATION
TREAT TOE DISLOCATION
REPAIR TOE DISLOCATION
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$955.29
$257.95
$405.67
$544.40
$1,150.80
$1,310.53
$245.68
$328.67
$468.09
$1,104.70
$1,264.61
$223.23
$298.61
$332.57
$643.41
$227.25
$265.83
$365.75
$543.31
$149.72
$183.47
$458.38
$696.82
$127.61
$166.13
$584.52
$120.00
$360.63
$213.59
$302.52
$579.89
$913.59
$231.49
$380.55
$402.56
$880.29
$225.39
$339.42
$407.92
$818.15
$161.77
$180.42
$294.28
$683.59
$120.36
$159.05
$194.76
Procedure Code
28675
28705
28715
28725
28730
28735
28737
28740
28750
28755
28760
28800
28805
28810
28820
28825
28890
28899
29000
29010
29015
29035
29040
29044
29046
29049
29055
29058
29065
29075
29085
29086
29105
29125
29126
29130
29131
29200
29240
29260
29280
29305
29325
29345
29355
29358
29365
Description
REPAIR OF TOE DISLOCATION
FUSION OF FOOT BONES
REVISION OF FOOT BONES
FUSION OF BIG TOE JOINT
AMPUTATION OF MIDFOOT
AMPUTATION THRU METATARSAL
AMPUTATION TOE & METATARSAL
AMPUTATION OF TOE
PARTIAL AMPUTATION OF TOE
HI ENRGY ESWT PLANTAR FASCIA
FOOT/TOES SURGERY PROCEDURE
APPLICATION OF BODY CAST
APPLICATION OF FIGURE EIGHT
APPLICATION OF SHOULDER CAST
APPLICATION OF SHOULDER CAST
APPLICATION OF LONG ARM CAST
APPLICATION OF FOREARM CAST
APPLY HAND/WRIST CAST
APPLY FINGER CAST
APPLY LONG ARM SPLINT
APPLY FOREARM SPLINT
APPLY FOREARM SPLINT
APPLICATION OF FINGER SPLINT
APPLICATION OF FINGER SPLINT
STRAPPING OF CHEST
STRAPPING OF SHOULDER
STRAPPING OF ELBOW OR WRIST
STRAPPING OF HAND OR FINGER
APPLICATION OF HIP CAST
APPLICATION OF HIP CASTS
APPLICATION OF LONG LEG CAST
APPLY LONG LEG CAST BRACE
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
5
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$611.53
$1,301.80
$975.08
$807.75
$762.16
$811.20
$710.67
$643.66
$850.42
$530.17
$598.78
$565.37
$764.56
$452.32
$593.05
$564.95
$335.27
$0.00
$306.50
$246.15
$295.58
$200.89
$232.92
$291.91
$250.59
$86.93
$231.53
$127.35
$100.35
$90.60
$99.61
$81.18
$90.89
$66.77
$79.35
$42.51
$52.62
$30.18
$29.46
$29.86
$30.22
$256.78
$282.06
$141.81
$146.10
$166.82
$127.40
Procedure Code
29405
29425
29435
29440
29445
29450
29505
29515
29520
29530
29540
29550
29580
29581
29582
29583
29584
29700
29705
29710
29720
29730
29740
29750
29799
29800
29804
29805
29806
29807
29819
29820
29821
29822
29823
29824
29825
29826
29827
29828
29830
29834
29835
29836
29837
29838
29840
Description
APPLY SHORT LEG CAST
ADDITION OF WALKER TO CAST
APPLY RIGID LEG CAST
APPLICATION OF LEG CAST
APPLICATION LONG LEG SPLINT
APPLICATION LOWER LEG SPLINT
STRAPPING OF HIP
STRAPPING OF KNEE
STRAPPING OF ANKLE AND/OR FT
STRAPPING OF TOES
APPLICATION OF PASTE BOOT
APPLY MULTLAY COMPRS LWR LEG
APPLY MULTLAY COMPRS UPR LEG
APPLY MULTLAY COMPRS UPR ARM
APPL MULTLAY COMPRS ARM/HAND
REMOVAL/REVISION OF CAST
REPAIR OF BODY CAST
WINDOWING OF CAST
WEDGING OF CAST
WEDGING OF CLUBFOOT CAST
CASTING/STRAPPING PROCEDURE
JAW ARTHROSCOPY/SURGERY
JAW ARTHROSCOPY/SURGERY
SHOULDER ARTHROSCOPY DX
SHOULDER ARTHROSCOPY/SURGERY
ARTHROSCOP ROTATOR CUFF REPR
ARTHROSCOPY BICEPS TENODESIS
ELBOW ARTHROSCOPY
ELBOW ARTHROSCOPY/SURGERY
WRIST ARTHROSCOPY
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
5
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$84.75
$81.10
$120.84
$44.94
$138.91
$147.74
$85.88
$73.88
$32.00
$29.48
$26.58
$19.41
$54.06
$63.20
$71.82
$44.74
$71.82
$64.58
$69.24
$126.65
$88.49
$67.05
$103.20
$92.10
$0.00
$531.21
$674.23
$492.74
$1,108.74
$1,082.48
$611.31
$556.84
$607.60
$589.89
$643.91
$695.48
$601.81
$181.02
$1,101.03
$952.64
$475.20
$506.71
$527.33
$592.33
$545.31
$611.37
$471.88
Procedure Code
29843
29844
29845
29846
29847
29848
29850
29851
29855
29856
29860
29861
29862
29863
29866
29867
29868
29870
29871
29873
29874
29875
29876
29877
29879
29880
29881
29882
29883
29884
29885
29886
29887
29888
29889
29891
29892
29893
29894
29895
29897
29898
29899
29900
29901
29902
29904
Description
WRIST ARTHROSCOPY/SURGERY
WRIST ENDOSCOPY/SURGERY
KNEE ARTHROSCOPY/SURGERY
TIBIAL ARTHROSCOPY/SURGERY
TIBIAL ARTHROSCOPY/SURGERY
HIP ARTHROSCOPY DX
HIP ARTHRO W/FB REMOVAL
HIP ARTHR0 W/DEBRIDEMENT
HIP ARTHR0 W/SYNOVECTOMY
AUTGRFT IMPLNT KNEE W/SCOPE
ALLGRFT IMPLNT KNEE W/SCOPE
MENISCAL TRNSPL KNEE W/SCPE
KNEE ARTHROSCOPY DX
KNEE ARTHROSCOPY/DRAINAGE
ANKLE ARTHROSCOPY/SURGERY
SCOPE PLANTAR FASCIOTOMY
MCP JOINT ARTHROSCOPY DX
MCP JOINT ARTHROSCOPY SURG
MCP JOINT ARTHROSCOPY SURG
SUBTALAR ARTHRO W/FB RMVL
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$505.40
$517.17
$600.71
$543.90
$556.23
$534.46
$642.86
$922.91
$812.91
$1,042.47
$687.94
$749.57
$840.63
$841.05
$1,088.51
$1,319.89
$1,676.72
$608.10
$537.45
$548.08
$560.36
$517.20
$686.69
$649.09
$691.24
$586.36
$565.14
$731.73
$878.68
$640.85
$785.06
$665.10
$779.70
$1,025.73
$1,275.67
$703.37
$603.76
$635.91
$518.06
$494.83
$527.96
$586.28
$1,078.24
$473.06
$555.94
$591.38
$666.13
Procedure Code
29905
29906
29907
29914
29915
29916
29999
30000
30020
3006F
3008F
30100
30110
30115
30117
30118
3011F
30120
30124
30125
30130
30140
3014F
30150
3015F
30160
3016F
3017F
3018F
3019F
30200
3020F
30210
3021F
30220
3022F
3023F
3025F
3027F
3028F
30300
30310
30320
3035F
3037F
3038F
30400
Description
SUBTALAR ARTHRO W/EXC
SUBTALAR ARTHRO W/DEB
SUBTALAR ARTHRO W/FUSION
HIP ARTHRO W/FEMOROPLASTY
HIP ARTHRO ACETABULOPLASTY
HIP ARTHRO W/LABRAL REPAIR
ARTHROSCOPY OF JOINT
DRAINAGE OF NOSE LESION
DRAINAGE OF NOSE LESION
CXR DOC REV
BODY MASS INDEX DOCD
INTRANASAL BIOPSY
REMOVAL OF NOSE POLYP(S)
REMOVAL OF NOSE POLYP(S)
REMOVAL OF INTRANASAL LESION
REMOVAL OF INTRANASAL LESION
LIPID PANEL DOC REV
REVISION OF NOSE
REMOVAL OF NOSE LESION
REMOVAL OF NOSE LESION
EXCISE INFERIOR TURBINATE
RESECT INFERIOR TURBINATE
SCREEN MAMMO DOC REV
PARTIAL REMOVAL OF NOSE
CERV CANCER SCREEN DOCD
REMOVAL OF NOSE
PT SCRND UNHLTHY OH USE
COLORECTAL CA SCREEN DOC REV
PRE-PRXD RSK ET AL DOCD
LVEF ASSESS PLANPOST DSCHRGE
INJECTION TREATMENT OF NOSE
LVF ASSESS
NASAL SINUS THERAPY
LVEF MOD/SEVER DEPRS SYST
INSERT NASAL SEPTAL BUTTON
LVEF >/=40% SYSTOLIC
SPIROM DOC REV
SPIROM FEV/FVC <70% W/COPD
SPIROM FEV/FVC>/=70%/W/OCOPD
O2 SATURATION DOC REV
REMOVE NASAL FOREIGN BODY
O2 SATURATION</=88%/PAO</=55
O2 SATURATION >88%/PAO>55 HG
PULM FX W/IN 12 MON B/4 SURG
RECONSTRUCTION OF NOSE
Pricing Action Code
3
3
3
3
3
3
5
3
3
9
9
3
3
3
3
3
9
3
3
3
3
3
9
3
9
3
9
9
9
9
3
9
3
9
9
9
9
9
9
9
3
3
3
9
9
9
3
Maximum Allowable
$715.87
$751.56
$915.99
$1,038.24
$1,055.71
$1,056.78
$0.00
$237.59
$241.23
$0.00
$0.00
$145.85
$238.24
$447.11
$908.74
$796.10
$0.00
$539.51
$295.54
$629.19
$392.79
$456.13
$0.00
$797.12
$0.00
$798.28
$0.00
$0.00
$0.00
$0.00
$117.33
$0.00
$154.84
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$191.75
$213.11
$457.87
$0.00
$0.00
$0.00
$1,045.87
Procedure Code
3040F
30410
30420
3042F
30430
30435
3044F
30450
3045F
30460
30462
30465
3046F
3048F
3049F
3050F
30520
30540
30545
3055F
30560
3056F
30580
30600
3060F
3061F
30620
3062F
30630
3066F
3072F
3073F
3074F
3075F
3077F
3078F
3079F
30801
30802
3080F
3082F
3083F
3084F
3085F
3088F
3089F
30901
Description
FEV <40% PREDICTED VALUE
FEV >/=40% PREDICTED VALUE
REVISION OF NOSE
REVISION OF NOSE
HG A1C LEVEL LT 7.0%
REVISION OF NOSE
HG A1C LEVEL 7.0-9.0%
REVISION OF NOSE
REVISION OF NOSE
REPAIR NASAL STENOSIS
HEMOGLOBIN A1C LEVEL >9.0%
LDL-C <100 MG/DL
LDL-C 100-129 MG/DL
LDL-C >/= 130 MG/DL
REPAIR OF NASAL SEPTUM
REPAIR NASAL DEFECT
REPAIR NASAL DEFECT
LVEF LESS THAN/EQUAL TO 35%
RELEASE OF NASAL ADHESIONS
LVEF GREATER THAN 35%
REPAIR UPPER JAW FISTULA
REPAIR MOUTH/NOSE FISTULA
POS MICROALBUMINURIA REV
NEG MICROALBUMINURIA REV
INTRANASAL RECONSTRUCTION
POS MACROALBUMINURIA REV
REPAIR NASAL SEPTUM DEFECT
NEPHROPATHY DOC TX
LOW RISK FOR RETINOPATHY
PRE-SURG EYE MEASURES DOCD
SYST BP LT 130 MM HG
SYST BP GE 130 - 139MM HG
SYST BP >/= 140 MM HG
DIAST BP <80 MM HG
DIAST BP 80-89 MM HG
ABLATE INF TURBINATE SUPERF
ABLATE INF TURBINATE SUBMUC
DIAST BP >/= 90 MM HG
KT/V <1.2
KT/V =/> 1.2 & <1.7
KT/V >/= 1.7
SUICIDE RISK ASSESSED
MDD MILD
MDD MODERATE
CONTROL OF NOSEBLEED
Pricing Action Code
9
3
3
9
3
9
9
3
9
3
3
3
9
9
9
9
3
3
3
9
3
9
3
3
9
9
3
9
3
9
9
9
9
9
9
9
9
3
3
9
9
9
9
9
9
9
3
Maximum Allowable
$0.00
$1,222.31
$1,419.67
$0.00
$1,006.31
$0.00
$0.00
$1,544.72
$0.00
$736.69
$1,629.13
$1,015.26
$0.00
$0.00
$0.00
$0.00
$644.82
$717.61
$908.15
$0.00
$277.85
$0.00
$680.98
$612.75
$0.00
$0.00
$646.69
$0.00
$644.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$236.98
$300.70
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$98.02
Procedure Code
30903
30905
30906
3090F
30915
3091F
30920
3092F
30930
3093F
3095F
3096F
30999
31000
31002
3100F
31020
31030
31032
31040
31050
31051
31070
31075
31080
31081
31084
31085
31086
31087
31090
3110F
3111F
3112F
3115F
3117F
3118F
3119F
31200
31201
31205
3120F
31225
31230
31231
31233
31235
Description
REPEAT CONTROL OF NOSEBLEED
MDD SEVERE W/O PSYCH
LIGATION NASAL SINUS ARTERY
MDD SEVERE W/PSYCH
LIGATION UPPER JAW ARTERY
MDD IN REMISSION
THER FX NASAL INF TURBINATE
DOC NEW DIAG 1ST/ADDL MDD
CENTRAL DEXA RESULTS DOCD
CENTRAL DEXA ORDERED
NASAL SURGERY PROCEDURE
IRRIGATION MAXILLARY SINUS
IRRIGATION SPHENOID SINUS
IMAGE TEST REF CAROT DIAM
EXPLORATION MAXILLARY SINUS
EXPLORE SINUS REMOVE POLYPS
EXPLORATION BEHIND UPPER JAW
EXPLORATION SPHENOID SINUS
SPHENOID SINUS SURGERY
EXPLORATION OF FRONTAL SINUS
EXPLORATION OF FRONTAL SINUS
REMOVAL OF FRONTAL SINUS
EXPLORATION OF SINUSES
PRES/ABSN HMRHG/LESION DOCD
CT/MRI BRAIN DONE W/IN 24HRS
CT/MRI BRAIN DONE 24 HRS
QUANT RESULTS ACTIVITY &SYMP
HF ASSESSMENT TOOL COMPLETED
NY HEART ASSOC CLASS DOCD
NO EVAL ACTIVITY CLIN SYMP
REMOVAL OF ETHMOID SINUS
12-LEAD ECG PERFORMED
REMOVAL OF UPPER JAW
REMOVAL OF UPPER JAW
NASAL ENDOSCOPY DX
NASAL/SINUS ENDOSCOPY DX
NASAL/SINUS ENDOSCOPY DX
Pricing Action Code
3
3
3
9
3
9
3
9
3
9
9
9
5
3
3
9
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
9
9
9
9
9
9
9
3
3
3
9
3
3
3
3
3
Maximum Allowable
$227.79
$279.40
$359.55
$0.00
$595.43
$0.00
$863.65
$0.00
$127.62
$0.00
$0.00
$0.00
$0.00
$189.92
$199.69
$0.00
$501.57
$717.70
$595.04
$787.85
$503.98
$667.54
$454.00
$812.70
$1,071.40
$1,540.76
$1,197.54
$1,644.99
$1,166.20
$1,121.07
$1,057.59
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$584.57
$764.00
$922.86
$0.00
$1,942.11
$2,155.35
$216.74
$271.70
$309.51
Procedure Code
31237
31238
31239
31240
31254
31255
31256
31267
3126F
31276
31287
31288
31290
31291
31292
31293
31294
31295
31296
31297
31299
31300
3130F
31320
3132F
31360
31365
31367
31368
31370
31375
31380
31382
31390
31395
31400
3140F
3141F
31420
3142F
31500
31502
31505
3150F
31510
31511
31512
Description
NASAL/SINUS ENDOSCOPY SURG
REVISION OF ETHMOID SINUS
ENDOSCOPY MAXILLARY SINUS
ESOPH BX RPRT W/DYSPL INFO
SINUS ENDOSCOPY SURGICAL
SINUS ENDO W/BALLOON DIL
SINUS SURGERY PROCEDURE
REMOVAL OF LARYNX LESION
UPPER GI ENDOSCOPY PERFORMED
DIAGNOSTIC INCISION LARYNX
DOC REF UPPER GI ENDOSCOPY
REMOVAL OF LARYNX
REMOVAL OF LARYNX
PARTIAL REMOVAL OF LARYNX
REMOVAL OF LARYNX & PHARYNX
RECONSTRUCT LARYNX & PHARYNX
REVISION OF LARYNX
UPPER GI ENDO SHOWS BARRTTS
UPPER GI ENDO NOT BARRTTS
REMOVAL OF EPIGLOTTIS
BARIUM SWALLOW TEST ORDERED
INSERT EMERGENCY AIRWAY
CHANGE OF WINDPIPE AIRWAY
DIAGNOSTIC LARYNGOSCOPY
FORCEPS ESOPH BIOPSY DONE
LARYNGOSCOPY WITH BIOPSY
REMOVE FOREIGN BODY LARYNX
Pricing Action Code
3
3
3
3
3
3
3
3
9
3
3
3
3
3
3
3
3
3
3
3
5
3
9
3
9
3
3
3
3
3
3
3
3
3
3
3
9
9
3
9
3
3
3
9
3
3
3
Maximum Allowable
$267.18
$266.77
$635.05
$167.29
$283.39
$416.42
$205.72
$330.14
$0.00
$525.00
$241.32
$279.06
$1,200.96
$1,283.57
$1,039.17
$1,127.48
$1,287.83
$2,114.43
$2,155.09
$2,117.71
$0.00
$1,358.21
$0.00
$726.42
$0.00
$2,200.63
$2,714.41
$2,331.62
$2,602.93
$2,197.19
$2,075.27
$2,053.52
$2,262.32
$3,028.52
$3,200.29
$1,014.73
$0.00
$0.00
$865.30
$0.00
$113.71
$36.27
$85.90
$0.00
$218.24
$218.87
$211.28
Procedure Code
31513
31515
31520
31525
31526
31527
31528
31529
31530
31531
31535
31536
31540
31541
31545
31546
3155F
31560
31561
31570
31571
31575
31576
31577
31578
31579
31580
31582
31584
31587
31588
31590
31595
31599
31600
31601
31603
31605
3160F
31610
31611
31612
31613
31614
31615
31622
31623
Description
INJECTION INTO VOCAL CORD
LARYNGOSCOPY FOR ASPIRATION
DX LARYNGOSCOPY NEWBORN
DX LARYNGOSCOPY EXCL NB
DX LARYNGOSCOPY W/OPER SCOPE
LARYNGOSCOPY FOR TREATMENT
LARYNGOSCOPY AND DILATION
LARYNGOSCOPY AND DILATION
LARYNGOSCOPY W/FB REMOVAL
LARYNGOSCOPY W/FB & OP SCOPE
LARYNGOSCOPY W/BIOPSY
LARYNGOSCOPY W/BX & OP SCOPE
LARYNGOSCOPY W/EXC OF TUMOR
LARYNSCOP W/TUMR EXC + SCOPE
REMOVE VC LESION W/SCOPE
REMOVE VC LESION SCOPE/GRAFT
CYTOGEN TEST MARROW B/4 TX
LARYNGOSCOP W/ARYTENOIDECTOM
LARYNSCOP REMVE CART + SCOP
LARYNGOSCOPE W/VC INJ
LARYNGOSCOP W/VC INJ + SCOPE
LARYNGOSCOPY WITH BIOPSY
REMOVE FOREIGN BODY LARYNX
REVISION OF LARYNX
REVISION OF LARYNX
TREAT LARYNX FRACTURE
REVISION OF LARYNX
REVISION OF LARYNX
REINNERVATE LARYNX
LARYNX NERVE SURGERY
LARYNX SURGERY PROCEDURE
INCISION OF WINDPIPE
DOC FE+ STORES B/4 EPO THX
SURGERY/SPEECH PROSTHESIS
PUNCTURE/CLEAR WINDPIPE
REPAIR WINDPIPE OPENING
REPAIR WINDPIPE OPENING
VISUALIZATION OF WINDPIPE
DX BRONCHOSCOPE/WASH
DX BRONCHOSCOPE/BRUSH
Pricing Action Code
9
3
3
3
3
9
3
9
3
3
3
3
3
3
3
3
9
3
3
3
3
3
3
9
3
3
3
3
3
3
3
9
9
5
3
3
3
3
9
3
3
3
3
9
3
3
3
Maximum Allowable
$0.00
$190.28
$162.92
$262.11
$164.40
$0.00
$151.08
$0.00
$206.79
$222.64
$198.56
$220.83
$253.19
$275.82
$379.75
$577.95
$0.00
$327.95
$359.25
$351.83
$261.46
$117.91
$231.95
$0.00
$288.82
$217.36
$1,268.01
$1,967.97
$1,570.75
$1,039.41
$1,182.80
$0.00
$0.00
$0.00
$415.14
$262.17
$233.87
$190.67
$0.00
$743.24
$560.87
$86.18
$472.52
$0.00
$187.72
$148.92
$339.54
Procedure Code
31624
31625
31626
31627
31628
31629
31630
31631
31632
31633
31634
31635
31636
31637
31638
31640
31641
31643
31645
31646
31647
31648
31649
31651
31652
31653
31654
31660
31661
3170F
31717
31720
31725
31730
31750
31755
31760
31766
31770
31775
31780
31781
31785
31786
31800
31805
31820
Description
DX BRONCHOSCOPE/LAVAGE
BRONCHOSCOPY W/BIOPSY(S)
BRONCHOSCOPY W/MARKERS
NAVIGATIONAL BRONCHOSCOPY
BRONCHOSCOPY/LUNG BX EACH
BRONCHOSCOPY/NEEDLE BX EACH
BRONCHOSCOPY DILATE/FX REPR
BRONCHOSCOPY DILATE W/STENT
BRONCHOSCOPY/LUNG BX ADDL
BRONCHOSCOPY/NEEDLE BX ADDL
BRONCH W/BALLOON OCCLUSION
BRONCHOSCOPY W/FB REMOVAL
BRONCHOSCOPY BRONCH STENTS
BRONCHOSCOPY STENT ADD-ON
BRONCHOSCOPY REVISE STENT
BRONCHOSCOPY W/TUMOR EXCISE
BRONCHOSCOPY TREAT BLOCKAGE
DIAG BRONCHOSCOPE/CATHETER
BRONCHOSCOPY CLEAR AIRWAYS
BRONCHOSCOPY RECLEAR AIRWAY
BRONCHIAL VALVE INIT INSERT
BRONCHIAL VALVE REMOV INIT
BRONCHIAL VALVE REMOV ADDL
BRONCHIAL VALVE ADDL INSERT
BRONCH EBUS SAMPLNG 1/2 NODE
BRONCH EBUS SAMPLNG 3/> NODE
BRONCH EBUS IVNTJ PERPH LES
BRONCH THERMOPLSTY 1 LOBE
BRONCH THERMOPLSTY 2/> LOBES
FLOW CYTO DONE B/4 TX
BRONCHIAL BRUSH BIOPSY
CLEARANCE OF AIRWAYS
CLEARANCE OF AIRWAYS
INTRO WINDPIPE WIRE/TUBE
REPAIR OF WINDPIPE
REPAIR OF WINDPIPE
REPAIR OF WINDPIPE
RECONSTRUCTION OF WINDPIPE
REPAIR/GRAFT OF BRONCHUS
RECONSTRUCT BRONCHUS
RECONSTRUCT WINDPIPE
RECONSTRUCT WINDPIPE
REMOVE WINDPIPE LESION
REMOVE WINDPIPE LESION
REPAIR OF WINDPIPE INJURY
REPAIR OF WINDPIPE INJURY
CLOSURE OF WINDPIPE LESION
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
9
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$152.74
$405.94
$935.66
$1,453.92
$194.58
$206.13
$207.55
$238.91
$76.57
$94.52
$1,914.67
$358.47
$230.14
$76.64
$262.49
$263.87
$267.36
$182.86
$166.73
$144.15
$229.13
$211.80
$72.08
$82.24
$927.98
$986.02
$111.16
$216.78
$227.12
$0.00
$267.12
$53.04
$93.14
$1,277.99
$1,470.64
$1,839.32
$1,465.20
$1,879.57
$1,410.82
$1,341.74
$1,233.65
$1,509.03
$1,133.55
$1,514.46
$765.74
$868.18
$450.36
Procedure Code
31825
31830
31899
3200F
32035
32036
32096
32097
32098
32100
3210F
32110
32120
32124
32140
32141
32150
32151
3215F
32160
3216F
3218F
32200
3220F
32215
32220
32225
3230F
32310
32320
32400
32405
32440
32442
32445
32480
32482
32484
32486
32488
32491
32501
32503
32504
32505
32506
32507
Description
REPAIR OF WINDPIPE DEFECT
REVISE WINDPIPE SCAR
AIRWAYS SURGICAL PROCEDURE
BARIUM SWALLOW TEST NOT REQ
THORACOSTOMY W/RIB RESECTION
THORACOSTOMY W/FLAP DRAINAGE
OPEN WEDGE/BX LUNG INFILTR
OPEN WEDGE/BX LUNG NODULE
OPEN BIOPSY OF LUNG PLEURA
EXPLORATION OF CHEST
GRP A STREP TEST PERFORMED
EXPLORE/REPAIR CHEST
RE-EXPLORATION OF CHEST
EXPLORE CHEST FREE ADHESIONS
REMOVAL OF LUNG LESION(S)
REMOVE/TREAT LUNG LESIONS
REMOVAL OF LUNG LESION(S)
REMOVE LUNG FOREIGN BODY
PT IMMUNITY TO HEP A DOCD
OPEN CHEST HEART MASSAGE
PT IMMUNITY TO HEP B DOCD
RNA TSTNG HEP C DOCD DONE
DRAIN OPEN LUNG LESION
HEP C QUANT RNA TSTNG DOCD
TREAT CHEST LINING
RELEASE OF LUNG
PARTIAL RELEASE OF LUNG
NOTE HRING TST W/IN 6 MON
REMOVAL OF CHEST LINING
FREE/REMOVE CHEST LINING
NEEDLE BIOPSY CHEST LINING
PERCUT BX LUNG/MEDIASTINUM
REMOVE LUNG PNEUMONECTOMY
SLEEVE PNEUMONECTOMY
REMOVAL OF LUNG EXTRAPLEURAL
PARTIAL REMOVAL OF LUNG
BILOBECTOMY
SEGMENTECTOMY
SLEEVE LOBECTOMY
COMPLETION PNEUMONECTOMY
LUNG VOLUME REDUCTION
REPAIR BRONCHUS ADD-ON
RESECT APICAL LUNG TUMOR
RESECT APICAL LUNG TUM/CHEST
WEDGE RESECT OF LUNG INITIAL
WEDGE RESECT OF LUNG ADD-ON
WEDGE RESECT OF LUNG DIAG
Pricing Action Code
3
3
5
9
3
3
3
3
3
3
9
3
3
3
3
3
3
3
9
3
9
9
3
9
3
3
3
9
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$622.77
$460.61
$0.00
$0.00
$754.14
$813.60
$846.64
$845.08
$802.28
$849.14
$0.00
$1,533.25
$914.12
$970.26
$1,049.66
$1,603.52
$1,055.88
$1,055.61
$0.00
$828.74
$0.00
$0.00
$1,191.57
$0.00
$833.45
$1,660.69
$1,042.72
$0.00
$951.56
$1,677.25
$154.78
$461.30
$1,644.36
$3,365.46
$3,732.27
$1,550.50
$1,658.91
$1,509.87
$2,472.24
$2,514.24
$1,552.13
$256.14
$1,895.14
$2,168.01
$978.96
$163.15
$161.63
Procedure Code
3250F
32540
32550
32551
32552
32553
32554
32555
32556
32557
32560
32561
32562
32601
32604
32606
32607
32608
32609
3260F
32650
32651
32652
32653
32654
32655
32656
32658
32659
3265F
32661
32662
32663
32664
32665
32666
32667
32668
32669
3266F
32670
32671
32672
32673
32674
3267F
3268F
Description
NONPRIM LOC ANAT BX SITE TUM
REMOVAL OF LUNG LESION
INSERT PLEURAL CATH
INSERTION OF CHEST TUBE
REMOVE LUNG CATHETER
INS MARK THOR FOR RT PERQ
ASPIRATE PLEURA W/O IMAGING
ASPIRATE PLEURA W/ IMAGING
INSERT CATH PLEURA W/O IMAGE
INSERT CATH PLEURA W/ IMAGE
TREAT PLEURODESIS W/AGENT
LYSE CHEST FIBRIN INIT DAY
LYSE CHEST FIBRIN SUBQ DAY
THORACOSCOPY DIAGNOSTIC
THORACOSCOPY WBX SAC
THORACOSCOPY W/BX MED SPACE
THORACOSCOPY W/BX INFILTRATE
THORACOSCOPY W/BX NODULE
THORACOSCOPY W/BX PLEURA
PT CAT/PN CAT/HIST GRD DOCD
THORACOSCOPY W/PLEURODESIS
THORACOSCOPY REMOVE CORTEX
THORACOSCOPY REM TOTL CORTEX
THORACOSCOPY REMOV FB/FIBRIN
THORACOSCOPY CONTRL BLEEDING
THORACOSCOPY RESECT BULLAE
THORACOSCOPY W/PLEURECTOMY
THORACOSCOPY W/SAC FB REMOVE
THORACOSCOPY W/SAC DRAINAGE
RNA TSTNG HEPC VIR ORD/DOCD
THORACOSCOPY W/PERICARD EXC
THORACOSCOPY W/MEDIAST EXC
THORACOSCOPY W/LOBECTOMY
THORACOSCOPY W/ TH NRV EXC
THORACOSCOP W/ESOPH MUSC EXC
THORACOSCOPY W/WEDGE RESECT
THORACOSCOPY W/W RESECT ADDL
THORACOSCOPY W/W RESECT DIAG
THORACOSCOPY REMOVE SEGMENT
HEPC GN TSTNG DOCD B/4TXMNT
THORACOSCOPY BILOBECTOMY
THORACOSCOPY PNEUMONECTOMY
THORACOSCOPY FOR LVRS
THORACOSCOPY W/THYMUS RESECT
THORACOSCOPY LYMPH NODE EXC
PATH RPRT W/ PT PN CAT ET AL
PSA/T/GLSC DOCD B/4 TXMNT
Pricing Action Code
9
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
9
3
3
3
3
3
3
3
3
3
9
3
3
3
3
3
3
3
3
3
9
3
3
3
3
3
9
9
Maximum Allowable
$0.00
$1,826.69
$804.54
$176.50
$191.25
$606.24
$205.09
$116.50
$554.07
$159.17
$251.00
$95.30
$86.00
$324.75
$507.98
$486.66
$325.54
$398.67
$272.84
$0.00
$698.05
$1,153.22
$1,746.45
$1,113.02
$1,238.47
$1,005.00
$842.37
$752.05
$767.37
$0.00
$843.70
$936.77
$1,470.09
$894.65
$1,289.16
$914.87
$163.13
$163.15
$1,415.53
$0.00
$1,678.96
$1,865.24
$1,601.05
$1,280.58
$224.38
$0.00
$0.00
Procedure Code
3269F
32701
3270F
3271F
3272F
3273F
3274F
3278F
3279F
32800
3280F
32810
32815
3281F
32820
3284F
32850
32851
32852
32853
32854
32855
32856
3285F
3288F
32900
32905
32906
3290F
3291F
3292F
3293F
32940
3294F
32960
32997
32998
32999
3300F
33010
33011
33015
3301F
33020
33025
33030
33031
Description
BONE SCN B/4 TXMNT/AFTR DX
THORAX STEREO RAD TARGETW/TX
NO BONE SCN B/4 TXMNT/AFTRDX
LOW RISK PROSTATE CANCER
MED RISK PROSTATE CANCER
HIGH RISK PROSTATE CANCER
PROST CNCR RSK NOT LW/MD/HGH
SERUM LVLS CA/IPTH/LPD ORD
HGB LVL >/= 13 G/DL
REPAIR LUNG HERNIA
HGB LVL 11-12.9 G/DL
CLOSE CHEST AFTER DRAINAGE
CLOSE BRONCHIAL FISTULA
HGB LVL <11 G/DL
RECONSTRUCT INJURED CHEST
IOP DOWN >15% OF PRE-SVC LVL
DONOR PNEUMONECTOMY
LUNG TRANSPLANT SINGLE
LUNG TRANSPLANT WITH BYPASS
LUNG TRANSPLANT DOUBLE
LUNG TRANSPLANT WITH BYPASS
PREPARE DONOR LUNG SINGLE
PREPARE DONOR LUNG DOUBLE
IOP DOWN <15% OF PRE-SVC LVL
FALL RISK ASSESSMENT DOCD
REMOVAL OF RIB(S)
REVISE & REPAIR CHEST WALL
REVISE & REPAIR CHEST WALL
PT=D(RH)- AND UNSENSITIZED
PT=D(RH)+ OR SENSITIZED
HIV TSTNG ASKED/DOCD/REVWD
ABO RH BLOOD TYPING DOCD
REVISION OF LUNG
GRP B STREP SCREENING DOCD
THERAPEUTIC PNEUMOTHORAX
TOTAL LUNG LAVAGE
PERQ RF ABLATE TX PUL TUMOR
CHEST SURGERY PROCEDURE
AJCC STAGE DOCD B/4 THXPY
DRAINAGE OF HEART SAC
REPEAT DRAINAGE OF HEART SAC
INCISION OF HEART SAC
CANCER STAGE DOCD METAST
PARTIAL REMOVAL OF HEART SAC
PARTIAL REMOVAL OF HEART SAC
Pricing Action Code
9
3
9
9
9
9
9
9
9
3
9
3
3
9
3
9
9
3
3
3
3
9
9
9
9
3
3
3
9
9
9
9
3
9
3
3
3
5
9
3
3
3
9
3
3
3
3
Maximum Allowable
$0.00
$229.17
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$995.57
$0.00
$949.41
$2,946.45
$0.00
$1,406.47
$0.00
$0.00
$3,471.51
$3,801.37
$4,836.00
$5,141.52
$0.00
$0.00
$0.00
$0.00
$1,466.53
$1,413.29
$1,745.64
$0.00
$0.00
$0.00
$0.00
$1,299.82
$0.00
$146.36
$354.93
$2,456.19
$0.00
$0.00
$125.73
$126.12
$531.42
$0.00
$924.50
$840.12
$2,105.62
$2,596.38
Procedure Code
33050
33120
33130
33140
33141
3315F
3316F
3317F
3318F
3319F
33202
33203
33206
33207
33208
3320F
33210
33211
33212
33213
33214
33215
33216
33217
33218
3321F
33220
33221
33222
33223
33224
33225
33226
33227
33228
33229
3322F
33230
33231
33233
33234
33235
33236
33237
33238
3323F
33240
Description
RESECT HEART SAC LESION
REMOVAL OF HEART LESION
HEART REVASCULARIZE (TMR)
HEART TMR W/OTHER PROCEDURE
ER+ OR PR+ BREAST CANCER
ER- OR PR- BREAST CANCER
PATH RPT MALIG CANCER DOCD
PATH RPT MALIG CANCER DOCD
X-RAY/CT/ULTRSND ET AL ORD
INSERT EPICARD ELTRD OPEN
INSERT EPICARD ELTRD ENDO
INSERT HEART PM ATRIAL
INSERT HEART PM VENTRICULAR
INSRT HEART PM ATRIAL & VENT
NO XRAY/CT/ ET AL ORDD
INSERT ELECTRD/PM CATH SNGL
INSERT CARD ELECTRODES DUAL
INSERT PULSE GEN SNGL LEAD
INSERT PULSE GEN DUAL LEADS
UPGRADE OF PACEMAKER SYSTEM
REPOSITION PACING-DEFIB LEAD
INSERT 1 ELECTRODE PM-DEFIB
INSERT 2 ELECTRODE PM-DEFIB
REPAIR LEAD PACE-DEFIB ONE
AJCC CNCR 0/IA MELAN DOCD
REPAIR LEAD PACE-DEFIB DUAL
INSERT PULSE GEN MULT LEADS
RELOCATION POCKET PACEMAKER
RELOCATE POCKET FOR DEFIB
INSERT PACING LEAD & CONNECT
L VENTRIC PACING LEAD ADD-ON
REPOSITION L VENTRIC LEAD
REMOVE&REPLACE PM GEN SINGL
REMV&REPLC PM GEN DUAL LEAD
REMV&REPLC PM GEN MULT LEADS
MELANOMAAJCC STAGE 0 OR IA
INSRT PULSE GEN W/DUAL LEADS
INSRT PULSE GEN W/MULT LEADS
REMOVAL OF PM GENERATOR
REMOVAL OF PACEMAKER SYSTEM
REMOVAL PACEMAKER ELECTRODE
REMOVE ELECTRODE/THORACOTOMY
CLIN NODE STGNG DOCDB/4 SURG
INSRT PULSE GEN W/SINGL LEAD
Pricing Action Code
3
3
3
3
3
9
9
9
9
9
3
3
3
3
3
9
3
3
3
3
3
3
3
3
3
9
3
3
3
3
3
3
3
3
3
3
9
3
3
3
3
3
3
3
3
9
3
Maximum Allowable
$1,047.62
$2,199.65
$1,453.62
$1,659.06
$136.44
$0.00
$0.00
$0.00
$0.00
$0.00
$816.91
$847.47
$482.54
$514.65
$557.58
$0.00
$187.77
$191.73
$348.81
$363.94
$511.73
$323.93
$400.06
$392.46
$418.86
$0.00
$419.55
$389.95
$364.77
$439.35
$539.42
$489.98
$517.00
$366.85
$382.35
$402.94
$0.00
$415.20
$432.12
$253.32
$519.40
$677.43
$825.71
$886.15
$980.42
$0.00
$395.30
Procedure Code
33241
33243
33244
33249
3324F
33250
33251
33254
33255
33256
33257
33258
33259
3325F
33261
33262
33263
33264
33265
33266
33270
33271
33272
33273
33282
33284
3328F
33300
33305
3330F
33310
33315
3331F
33320
33321
33322
33330
33335
33361
33362
33363
33364
33365
33366
33367
33368
33369
Description
REMOVE PULSE GENERATOR
REMOVE ELTRD/THORACOTOMY
REMOVE ELCTRD TRANSVENOUSLY
INSJ/RPLCMT DEFIB W/LEAD(S)
MRI CT SCAN ORD RVWD RQSTD
ABLATE HEART DYSRHYTHM FOCUS
ABLATE ATRIA LMTD
ABLATE ATRIA W/O BYPASS EXT
ABLATE ATRIA W/BYPASS EXTEN
ABLATE ATRIA LMTD ADD-ON
ABLATE ATRIA X10SV ADD-ON
ABLATE ATRIA W/BYPASS ADD-ON
PREOP ASSES 4 CATARACT SURG
RMVL& REPLC PULSE GEN 1 LEAD
RMVL & RPLCMT DFB GEN 2 LEAD
RMVL & RPLCMT DFB GEN MLT LD
ABLATE ATRIA LMTD ENDO
ABLATE ATRIA X10SV ENDO
INS/REP SUBQ DEFIBRILLATOR
INSJ SUBQ IMPLTBL DFB ELCTRD
RMVL OF SUBQ DEFIBRILLATOR
REPOS PREV IMPLTBL SUBQ DFB
IMPLANT PAT-ACTIVE HT RECORD
REMOVE PAT-ACTIVE HT RECORD
PRFRMNC DOCD 2 WKS B/4 SURG
REPAIR OF HEART WOUND
REPAIR OF HEART WOUND
IMAGING STUDY ORDERED (BKP)
EXPLORATORY HEART SURGERY
EXPLORATORY HEART SURGERY
BK IMAGING TST NOT ORDERED
REPAIR MAJOR BLOOD VESSEL(S)
REPAIR MAJOR VESSEL
REPAIR MAJOR BLOOD VESSEL(S)
INSERT MAJOR VESSEL GRAFT
INSERT MAJOR VESSEL GRAFT
REPLACE AORTIC VALVE PERQ
REPLACE AORTIC VALVE OPEN
TRCATH REPLACE AORTIC VALVE
REPLACE AORTIC VALVE W/BYP
Pricing Action Code
3
3
3
3
9
3
3
3
3
3
3
3
3
9
3
3
3
3
3
3
3
3
3
3
3
3
9
3
3
9
3
3
9
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$238.15
$1,435.18
$910.03
$969.83
$0.00
$1,546.30
$1,702.67
$1,446.11
$1,698.17
$2,059.57
$613.01
$685.98
$886.92
$0.00
$1,718.37
$402.55
$418.41
$436.10
$1,424.64
$1,938.48
$618.75
$521.01
$367.66
$420.30
$248.94
$220.48
$0.00
$2,580.66
$4,316.93
$0.00
$1,241.36
$2,003.07
$0.00
$1,115.45
$1,296.45
$1,458.87
$1,500.55
$1,957.94
$1,429.29
$1,563.13
$1,623.62
$1,702.27
$1,873.79
$2,027.44
$658.39
$789.85
$1,043.61
Procedure Code
33400
33401
33403
33404
33405
33406
3340F
33410
33411
33412
33413
33414
33415
33416
33417
33418
33419
3341F
33420
33422
33425
33426
33427
3342F
33430
3343F
3344F
3345F
33460
33463
33464
33465
33468
33470
33471
33474
33475
33476
33477
33478
33496
33500
33501
33502
33503
33504
33505
Description
REPAIR OF AORTIC VALVE
VALVULOPLASTY OPEN
VALVULOPLASTY W/CP BYPASS
PREPARE HEART-AORTA CONDUIT
REPLACEMENT OF AORTIC VALVE
MAMMO ASSESS INC XRAY DOCD
REVISION SUBVALVULAR TISSUE
REVISE VENTRICLE MUSCLE
REPAIR TCAT MITRAL VALVE
REPAIR TCAT MITRAL VALVE
MAMMO ASSESS NEGATIVE DOCD
REVISION OF MITRAL VALVE
REPAIR OF MITRAL VALVE
MAMMO ASSESS BENGN DOCD
REPLACEMENT OF MITRAL VALVE
MAMMO PROBABLY BENGN DOCD
MAMMO ASSESS SUSP DOCD
MAMMO ASSESS HGHLYMALIG DOC
REVISION OF TRICUSPID VALVE
VALVULOPLASTY TRICUSPID
VALVULOPLASTY TRICUSPID
REPLACE TRICUSPID VALVE
REVISION OF TRICUSPID VALVE
REVISION OF PULMONARY VALVE
VALVOTOMY PULMONARY VALVE
REPLACEMENT PULMONARY VALVE
REVISION OF HEART CHAMBER
IMPLANT TCAT PULM VLV PERQ
REPAIR PROSTH VALVE CLOT
REPAIR HEART VESSEL FISTULA
REPAIR HEART VESSEL FISTULA
CORONARY ARTERY CORRECTION
CORONARY ARTERY GRAFT
CORONARY ARTERY GRAFT
REPAIR ARTERY W/TUNNEL
Pricing Action Code
3
3
3
3
3
3
9
3
3
3
3
3
3
3
3
3
3
9
3
3
3
3
3
9
3
9
9
9
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$2,387.26
$1,543.42
$1,565.56
$1,858.56
$2,382.10
$3,015.43
$0.00
$2,656.09
$3,523.13
$3,345.80
$3,432.52
$2,268.43
$2,120.07
$2,128.03
$1,761.37
$1,884.53
$443.30
$0.00
$1,638.30
$1,759.22
$2,871.25
$2,498.80
$2,563.11
$0.00
$2,939.38
$0.00
$0.00
$0.00
$2,576.01
$3,251.02
$2,563.09
$2,900.07
$2,586.79
$1,364.22
$1,458.01
$2,306.80
$2,449.27
$1,615.38
$1,351.05
$1,653.91
$1,763.84
$1,648.59
$1,195.97
$1,343.50
$1,407.43
$1,566.04
$2,189.74
Procedure Code
33506
33507
33508
3350F
33510
33511
33512
33513
33514
33516
33517
33518
33519
3351F
33521
33522
33523
3352F
33530
33533
33534
33535
33536
3353F
33542
33545
33548
3354F
33572
33600
33602
33606
33608
33610
33611
33612
33615
33617
33619
33620
33621
33622
33641
33645
33647
33660
33665
Description
REPAIR ARTERY TRANSLOCATION
REPAIR ART INTRAMURAL
ENDOSCOPIC VEIN HARVEST
MAMMO BX PROVEN MALIG DOCD
CABG VEIN SINGLE
CABG VEIN TWO
CABG VEIN THREE
CABG VEIN FOUR
CABG VEIN FIVE
CABG VEIN SIX OR MORE
CABG ARTERY-VEIN SINGLE
CABG ARTERY-VEIN TWO
CABG ARTERY-VEIN THREE
NEG SCRN DEP SYMP BY DEPTOOL
CABG ARTERY-VEIN FOUR
CABG ARTERY-VEIN FIVE
CABG ART-VEIN SIX OR MORE
NO SIG DEP SYMP BY DEP TOOL
CORONARY ARTERY BYPASS/REOP
CABG ARTERIAL SINGLE
CABG ARTERIAL TWO
CABG ARTERIAL THREE
CABG ARTERIAL FOUR OR MORE
MILD-MOD DEP SYMP BY DEPTOOL
REPAIR OF HEART DAMAGE
RESTORE/REMODEL VENTRICLE
CLIN SIG DEP SYM BY DEP TOOL
OPEN CORONARY ENDARTERECTOMY
CLOSURE OF VALVE
CLOSURE OF VALVE
ANASTOMOSIS/ARTERY-AORTA
REPAIR ANOMALY W/CONDUIT
REPAIR BY ENLARGEMENT
REPAIR DOUBLE VENTRICLE
REPAIR DOUBLE VENTRICLE
REPAIR MODIFIED FONTAN
REPAIR SINGLE VENTRICLE
REPAIR SINGLE VENTRICLE
APPLY R&L PULM ART BANDS
TRANSTHOR CATH FOR STENT
REDO COMPL CARDIAC ANOMALY
REPAIR HEART SEPTUM DEFECT
REVISION OF HEART VEINS
REPAIR HEART SEPTUM DEFECTS
REPAIR OF HEART DEFECTS
Pricing Action Code
3
3
3
9
3
3
3
3
3
3
3
3
3
9
3
3
3
9
3
3
3
3
3
9
3
3
3
9
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$2,213.76
$1,814.12
$16.55
$0.00
$2,020.60
$2,225.53
$2,533.42
$2,607.30
$2,745.39
$2,880.24
$195.94
$430.04
$567.20
$0.00
$678.75
$762.67
$871.59
$0.00
$548.12
$1,963.11
$2,306.00
$2,567.28
$2,764.06
$0.00
$2,761.00
$3,262.63
$3,115.26
$0.00
$237.92
$1,808.20
$1,784.54
$1,967.21
$1,897.62
$2,008.16
$2,172.29
$2,126.79
$2,153.37
$2,281.52
$2,893.29
$1,626.92
$987.86
$3,837.92
$1,736.71
$1,827.54
$1,937.19
$1,832.85
$2,019.65
Procedure Code
33670
33675
33676
33677
33681
33684
33688
33690
33692
33694
33697
33702
3370F
33710
33720
33722
33724
33726
3372F
33730
33732
33735
33736
33737
3374F
33750
33755
33762
33764
33766
33767
33768
3376F
33770
33771
33774
33775
33776
33777
33778
33779
33780
33781
33782
33783
33786
33788
Description
REPAIR OF HEART CHAMBERS
CLOSE MULT VSD
CLOSE MULT VSD W/RESECTION
CL MULT VSD W/REM PUL BAND
REINFORCE PULMONARY ARTERY
AJCC BRST CNCR STAGE 0 DOCD
REPAIR OF HEART DEFECT
REPAIR OF HEART DEFECT
REPAIR VENOUS ANOMALY
REPAIR PUL VENOUS STENOSIS
REPAIR HEART-VEIN DEFECT(S)
REPAIR HEART-VEIN DEFECT
MAJOR VESSEL SHUNT
MAJOR VESSEL SHUNT
MAJOR VESSEL SHUNT
MAJOR VESSEL SHUNT & GRAFT
MAJOR VESSEL SHUNT
MAJOR VESSEL SHUNT
CAVOPULMONARY SHUNTING
AJCC BRSTCNCR STAGE 2 DOCD
REPAIR GREAT VESSELS DEFECT
NIKAIDOH PROC
NIKAIDOH PROC W/OSTIA IMPLT
REPAIR ARTERIAL TRUNK
REVISION OF PULMONARY ARTERY
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
9
3
3
3
3
3
9
3
3
3
3
3
9
3
3
3
3
3
3
3
9
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$2,093.14
$2,083.51
$2,253.77
$2,341.76
$1,944.21
$2,101.59
$1,991.81
$1,171.19
$2,184.09
$2,172.29
$2,206.22
$1,630.44
$0.00
$2,285.16
$1,641.65
$1,791.45
$1,630.36
$2,113.28
$0.00
$2,168.16
$1,748.79
$1,358.28
$1,481.95
$1,429.53
$0.00
$1,331.84
$1,387.49
$1,416.82
$1,396.91
$1,400.30
$1,509.98
$440.19
$0.00
$2,361.90
$2,435.38
$1,909.62
$2,052.32
$2,167.74
$2,100.54
$2,613.01
$2,598.79
$2,516.11
$2,587.23
$3,429.76
$3,901.02
$2,416.28
$1,698.82
Procedure Code
3378F
33800
33802
33803
3380F
33813
33814
33820
33822
33824
3382F
33840
33845
3384F
33851
33852
33853
33860
33863
33864
3386F
33870
33875
33877
33880
33881
33883
33884
33886
33889
3388F
33891
3390F
33910
33915
33916
33917
33920
33922
33924
33925
33926
33930
33933
33935
33940
33944
Description
AORTIC SUSPENSION
REPAIR VESSEL DEFECT
REPAIR VESSEL DEFECT
REPAIR SEPTAL DEFECT
REVISE MAJOR VESSEL
REVISE MAJOR VESSEL
REVISE MAJOR VESSEL
AJCC CLN CNCR STAGE 0 DOCD
REMOVE AORTA CONSTRICTION
ASCENDING AORTIC GRAFT
TRANSVERSE AORTIC ARCH GRAFT
THORACIC AORTIC GRAFT
THORACOABDOMINAL GRAFT
ENDOVASC TAA REPR INCL SUBCL
ENDOVASC TAA REPR W/O SUBCL
INSERT ENDOVASC PROSTH TAA
ENDOVASC PROSTH TAA ADD-ON
ENDOVASC PROSTH DELAYED
ARTERY TRANSPOSE/ENDOVAS TAA
CAR-CAR BP GRFT/ENDOVAS TAA
REMOVE LUNG ARTERY EMBOLI
REMOVE LUNG ARTERY EMBOLI
SURGERY OF GREAT VESSEL
REPAIR PULMONARY ARTERY
REPAIR PULMONARY ATRESIA
TRANSECT PULMONARY ARTERY
REMOVE PULMONARY SHUNT
RPR PUL ART UNIFOCAL W/O CPB
REPR PUL ART UNIFOCAL W/CPB
REMOVAL OF DONOR HEART/LUNG
PREPARE DONOR HEART/LUNG
TRANSPLANTATION HEART/LUNG
REMOVAL OF DONOR HEART
PREPARE DONOR HEART
Pricing Action Code
9
3
3
3
9
3
3
3
3
3
9
3
3
9
3
3
3
3
3
3
9
3
3
3
3
3
3
3
3
3
9
3
9
3
3
3
3
3
3
3
3
3
9
9
3
9
9
Maximum Allowable
$0.00
$1,001.72
$1,137.94
$1,213.53
$0.00
$1,364.63
$1,691.40
$1,027.20
$1,125.78
$1,284.16
$0.00
$1,359.92
$1,405.53
$0.00
$1,220.39
$1,484.09
$1,945.28
$3,370.29
$3,306.07
$3,380.87
$0.00
$2,642.14
$2,896.54
$3,840.82
$1,908.72
$1,638.86
$1,185.26
$432.93
$1,024.56
$837.40
$0.00
$1,029.47
$0.00
$2,769.86
$1,331.38
$4,447.97
$1,529.16
$2,010.38
$1,471.83
$302.49
$1,824.65
$2,698.36
$0.00
$0.00
$5,274.22
$0.00
$0.00
Procedure Code
33945
33946
33947
33948
33949
3394F
33951
33952
33953
33954
33955
33956
33957
33958
33959
3395F
33962
33963
33964
33965
33966
33967
33968
33969
33970
33971
33973
33974
33975
33976
33977
33978
33979
33980
33981
33982
33983
33984
33985
33986
33987
33988
33989
33990
33991
33992
33993
Description
TRANSPLANTATION OF HEART
ECMO/ECLS INITIATION VENOUS
ECMO/ECLS INITIATION ARTERY
ECMO/ECLS DAILY MGMT-VENOUS
ECMO/ECLS DAILY MGMT ARTERY
QUANT HER2 IHC EVAL BRST CX
ECMO/ECLS INSJ PRPH CANNULA
ECMO/ECLS INSJ CTR CANNULA
ECMO/ECLS INSJ CTR CANNULA
ECMO/ECLS REPOS PERPH CNULA
QUANT NONHER2 IHC BRST CX
ECMO/ECLS RMVL PERPH CANNULA
ECMO/ECLS RMVL PRPH CANNULA
INSERT I-AORT PERCUT DEVICE
REMOVE AORTIC ASSIST DEVICE
ECMO/ECLS RMVL PERPH CANNULA
AORTIC CIRCULATION ASSIST
AORTIC CIRCULATION ASSIST
INSERT BALLOON DEVICE
REMOVE INTRA-AORTIC BALLOON
IMPLANT VENTRICULAR DEVICE
IMPLANT VENTRICULAR DEVICE
REMOVE VENTRICULAR DEVICE
REMOVE VENTRICULAR DEVICE
INSERT INTRACORPOREAL DEVICE
REMOVE INTRACORPOREAL DEVICE
REPLACE VAD PUMP EXT
REPLACE VAD INTRA W/O BP
REPLACE VAD INTRA W/BP
ECMO/ECLS RMVL PRPH CANNULA
ECMO/ECLS RMVL CTR CANNULA
ECMO/ECLS RMVL CTR CANNULA
ARTERY EXPOS/GRAFT ARTERY
INSERTION OF LEFT HEART VENT
REMOVAL OF LEFT HEART VENT
INSERT VAD ARTERY ACCESS
INSERT VAD ART&VEIN ACCESS
REMOVE VAD DIFFERENT SESSION
REPOSITION VAD DIFF SESSION
Pricing Action Code
3
3
3
3
3
9
3
3
3
3
3
3
3
3
3
9
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$5,125.83
$322.43
$356.62
$253.95
$247.12
$0.00
$437.03
$453.47
$488.05
$506.84
$877.74
$885.19
$194.74
$192.28
$247.19
$0.00
$252.22
$495.12
$515.36
$194.74
$249.00
$272.85
$35.29
$288.51
$374.05
$747.77
$541.21
$932.64
$1,385.32
$1,686.43
$1,188.36
$1,413.78
$2,053.49
$1,880.94
$885.01
$2,092.06
$2,439.40
$301.63
$543.61
$559.55
$220.15
$821.21
$530.76
$461.83
$672.71
$219.11
$192.06
Procedure Code
33999
34001
34051
34101
34111
34151
34201
34203
34401
34421
34451
34471
34490
34501
34502
3450F
34510
3451F
34520
3452F
34530
3455F
3470F
3471F
3472F
3475F
3476F
34800
34802
34803
34804
34805
34806
34808
34812
34813
34820
34825
34826
34830
34831
34832
34833
34834
34839
34841
34842
Description
CARDIAC SURGERY PROCEDURE
REMOVAL OF ARTERY CLOT
REMOVAL OF ARM ARTERY CLOT
REMOVAL OF LEG ARTERY CLOT
REMOVAL OF VEIN CLOT
REPAIR VALVE FEMORAL VEIN
RECONSTRUCT VENA CAVA
DYSPNEA SCRND NO-MILD DYSP
TRANSPOSITION OF VEIN VALVE
DYSPNEA SCRND MOD-HIGH DYSP
CROSS-OVER VEIN GRAFT
DYSPNEA NOT SCREENED
LEG VEIN FUSION
TB SCRNG DONE-INTERPD 6MON
RA DISEASE ACTIVITY LOW
RA DISEASE ACTIVITY MOD
RA DISEASE ACTIVITY HIGH
DISEASE PROGN RA POOR DOCD
DISEASE PROGN RA GOOD DOCD
ENDOVAS AAA REPR W/SM TUBE
ENDOVAS AAA REPR W/2-P PART
ENDOVAS AAA REPR W/LONG TUBE
ANEURYSM PRESS SENSOR ADD-ON
ENDOVAS ILIAC A DEVICE ADDON
XPOSE FOR ENDOPROSTH FEMORL
FEMORAL ENDOVAS GRAFT ADD-ON
XPOSE FOR ENDOPROSTH ILIAC
ENDOVASC EXTEND PROSTH INIT
ENDOVASC EXTEN PROSTH ADDL
OPEN AORTIC TUBE PROSTH REPR
OPEN AORTOILIAC PROSTH REPR
OPEN AORTOFEMOR PROSTH REPR
XPOSE FOR ENDOPROSTH ILIAC
XPOSE ENDOPROSTH BRACHIAL
PLNNING PT SPEC FENEST GRAFT
ENDOVASC VISC AORTA 1 GRAFT
Pricing Action Code
5
3
3
3
3
3
3
3
3
3
3
3
3
3
3
9
3
9
3
9
3
9
9
9
9
9
9
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
6
6
6
Maximum Allowable
$0.00
$1,039.98
$1,047.70
$641.02
$639.46
$1,490.39
$1,098.27
$1,017.56
$1,535.64
$777.83
$1,536.62
$1,150.13
$654.42
$1,041.56
$1,624.46
$0.00
$1,262.69
$0.00
$1,068.27
$0.00
$1,158.97
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$1,202.91
$1,325.66
$1,368.77
$1,324.64
$1,269.15
$106.27
$220.23
$359.28
$251.47
$524.00
$737.83
$217.18
$1,879.59
$2,026.16
$2,009.26
$648.32
$290.82
$0.00
$0.00
$0.00
Procedure Code
34843
34844
34845
34846
34847
34848
34900
3490F
3491F
3492F
3493F
3494F
3495F
3496F
3497F
3498F
35001
35002
35005
3500F
35011
35013
35021
35022
3502F
3503F
35045
35081
35082
35091
35092
35102
35103
3510F
35111
35112
3511F
35121
35122
3512F
35131
35132
3513F
35141
35142
3514F
35151
Description
VISC & INFRAREN ABD 1 PROSTH
VISC & INFRAREN ABD 4+ PROST
ENDOVASC ILIAC REPR W/GRAFT
HISTORY AIDS-DEFINING COND
HIV UNSURE BABY OF HIV+MOMS
HISTORY CD4+ CELL COUNT <350
NO HIST CD4+ CELL COUNT <350
CD4+CELL COUNT <200CELLS/MM3
CD4+CELL CNT 200-499 CELLS
CD4+ CELL COUNT + 500 CELLS
CD4+ CELL PERCENTAGE <15%
CD4+ CELL =15% (HIV)
REPAIR DEFECT OF ARTERY
REPAIR ARTERY RUPTURE NECK
CD4+CELL CNT/% DOCD AS DONE
REPAIR ARTERY RUPTURE ARM
REPAIR ARTERY RUPTURE CHEST
HIV RNA VRL LD <LMTS QUANTIF
HIV RNA VRL LDNOT<LMTS QUNTF
REPAIR DEFECT OF ARM ARTERY
REPAIR ARTERY RUPTURE AORTA
DOC TB SCRNG-RSLTS INTERPD
REPAIR ARTERY RUPTURE SPLEEN
CHLMYD/GONRH TSTS DOCD DONE
REPAIR ARTERY RUPTURE BELLY
SYPH SCRNG DOCD AS DONE
REPAIR ARTERY RUPTURE GROIN
HEP B SCRNG DOCD AS DONE
REPAIR ARTERY RUPTURE THIGH
HEP C SCRNG DOCD AS DONE
Pricing Action Code
6
6
6
6
6
6
3
9
9
9
9
9
9
9
9
9
3
3
3
9
3
3
3
3
9
9
3
3
3
3
3
3
3
9
3
3
9
3
3
9
3
3
9
3
3
9
3
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$953.20
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$1,191.23
$1,210.31
$1,150.79
$0.00
$1,067.77
$1,337.45
$1,334.32
$1,475.42
$0.00
$0.00
$1,057.21
$1,862.57
$2,342.88
$1,912.91
$2,773.48
$2,014.97
$2,397.50
$0.00
$1,622.38
$1,960.08
$0.00
$1,753.20
$2,286.55
$0.00
$1,479.87
$1,737.68
$0.00
$1,180.02
$1,410.68
$0.00
$1,324.47
Procedure Code
35152
3515F
3517F
35180
35182
35184
35188
35189
35190
35201
35206
35207
3520F
35211
35216
35221
35226
35231
35236
35241
35246
35251
35256
35261
35266
35271
35276
35281
35286
35301
35302
35303
35304
35305
35306
35311
35321
35331
35341
35351
35355
35361
35363
35371
35372
35390
35400
Description
REPAIR RUPTD POPLITEAL ART
PT HAS DOCD IMMUN TO HEP C
HBV ASSESS&RESULTS INTRP 1YR
REPAIR BLOOD VESSEL LESION
CDIFFICILE TESTING PERFORMED
RECHANNELING OF ARTERY
REOPERATION CAROTID ADD-ON
ANGIOSCOPY
Pricing Action Code
3
9
9
3
3
3
3
3
3
3
3
3
9
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$1,493.44
$0.00
$0.00
$990.28
$1,850.24
$1,110.61
$1,229.65
$1,630.24
$809.84
$1,009.29
$822.97
$797.05
$0.00
$1,448.31
$2,166.32
$1,537.19
$886.03
$1,276.06
$1,040.11
$1,438.86
$1,669.84
$1,803.85
$1,085.63
$1,117.74
$928.74
$1,442.50
$1,544.89
$1,717.07
$997.81
$1,205.33
$1,199.02
$1,327.33
$1,365.73
$1,308.76
$483.27
$1,553.87
$949.50
$1,543.45
$1,456.36
$1,364.47
$1,104.64
$1,639.82
$1,870.94
$872.97
$1,045.89
$167.79
$158.94
Procedure Code
35450
35452
35458
35460
35471
35472
35475
35476
35500
35501
35506
35508
35509
3550F
35510
35511
35512
35515
35516
35518
3551F
35521
35522
35523
35525
35526
3552F
35531
35533
35535
35536
35537
35538
35539
35540
35556
35558
3555F
35560
35563
35565
35566
35570
35571
35572
35583
35585
Description
REPAIR ARTERIAL BLOCKAGE
REPAIR VENOUS BLOCKAGE
HARVEST VEIN FOR BYPASS
ART BYP GRFT IPSILAT CAROTID
ART BYP GRFT SUBCLAV-CAROTID
ART BYP GRFT CAROTID-VERTBRL
ART BYP GRFT CONTRAL CAROTID
LOW RSK THROMBOEMBOLISM
ART BYP GRFT CAROTID-BRCHIAL
ART BYP GRFT SUBCLAV-SUBCLAV
ART BYP GRFT SUBCLAV-BRCHIAL
ART BYP GRFT SUBCLAV-VERTBRL
ART BYP GRFT SUBCLAV-AXILARY
ART BYP GRFT AXILLARY-AXILRY
INTRMED RSK THROMBOEMBOLISM
ART BYP GRFT AXILL-FEMORAL
ART BYP GRFT AXILL-BRACHIAL
ART BYP GRFT BRCHL-ULNR-RDL
ART BYP GRFT BRACHIAL-BRCHL
ART BYP GRFT AOR/CAROT/INNOM
HGH RISK FOR THROMBOEMBOLISM
ART BYP GRFT AORCEL/AORMESEN
ART BYP GRFT AXILL/FEM/FEM
ART BYP GRFT HEPATORENAL
ART BYP GRFT SPLENORENAL
ART BYP GRFT AORTOILIAC
ART BYP GRFT AORTOBI-ILIAC
ART BYP GRFT AORTOFEMORAL
ART BYP GRFT AORTBIFEMORAL
ART BYP GRFT FEM-POPLITEAL
ART BYP GRFT FEM-FEMORAL
PT INR MEASUREMENT PERFORMED
ART BYP GRFT AORTORENAL
ART BYP GRFT ILIOILIAC
ART BYP GRFT ILIOFEMORAL
ART BYP FEM-ANT-POST TIB/PRL
ART BYP TIBIAL-TIB/PERONEAL
ART BYP POP-TIBL-PRL-OTHER
HARVEST FEMOROPOPLITEAL VEIN
VEIN BYP GRFT FEM-POPLITEAL
VEIN BYP FEM-TIBIAL PERONEAL
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
9
3
3
3
3
3
3
9
3
3
3
3
3
9
3
3
3
3
3
3
3
3
3
3
9
3
3
3
3
3
3
3
3
3
Maximum Allowable
$538.81
$363.18
$525.57
$334.87
$551.99
$376.39
$349.88
$282.81
$337.47
$1,594.94
$1,359.78
$1,445.17
$1,504.72
$0.00
$1,313.33
$1,196.21
$1,301.54
$1,526.60
$1,302.14
$1,238.53
$0.00
$1,318.12
$1,287.99
$1,367.56
$1,220.66
$1,813.78
$0.00
$2,160.26
$1,597.17
$2,044.25
$1,803.07
$2,332.81
$2,502.46
$2,341.73
$2,617.72
$1,492.54
$1,316.89
$0.00
$1,830.54
$1,412.74
$1,413.96
$1,781.91
$1,622.63
$1,418.50
$367.13
$1,543.43
$1,790.33
Procedure Code
35587
35600
35601
35606
35612
35616
35621
35623
35626
35631
35632
35633
35634
35636
35637
35638
35642
35645
35646
35647
35650
35654
35656
35661
35663
35665
35666
35671
35681
35682
35683
35685
35686
35691
35693
35694
35695
35697
35700
35701
3570F
35721
3572F
3573F
35741
35761
35800
Description
VEIN BYP POP-TIBL PERONEAL
HARVEST ART FOR CABG ADD-ON
ART BYP COMMON IPSI CAROTID
ART BYP CAROTID-SUBCLAVIAN
ART BYP SUBCLAV-SUBCLAVIAN
ART BYP SUBCLAV-AXILLARY
ART BYP AXILLARY-FEMORAL
ART BYP AXILLARY-POP-TIBIAL
ART BYP AORSUBCL/CAROT/INNOM
ART BYP AOR-CELIAC-MSN-RENAL
ART BYP ILIO-CELIAC
ART BYP ILIO-MESENTERIC
ART BYP ILIORENAL
ART BYP SPENORENAL
ART BYP AORTOILIAC
ART BYP AORTOBI-ILIAC
ART BYP CAROTID-VERTEBRAL
ART BYP SUBCLAV-VERTEBRL
ART BYP AORTOBIFEMORAL
ART BYP AORTOFEMORAL
ART BYP AXILLARY-AXILLARY
ART BYP AXILL-FEM-FEMORAL
ART BYP FEMORAL-POPLITEAL
ART BYP FEMORAL-FEMORAL
ART BYP ILIOILIAC
ART BYP ILIOFEMORAL
ART BYP FEM-ANT-POST TIB/PRL
ART BYP POP-TIBL-PRL-OTHER
COMPOSITE BYP GRFT PROS&VEIN
COMPOSITE BYP GRFT 2 VEINS
COMPOSITE BYP GRFT 3/> SEGMT
BYPASS GRAFT PATENCY/PATCH
BYPASS GRAFT/AV FIST PATENCY
ART TRNSPOSJ VERTBRL CAROTID
ART TRNSPOSJ SUBCLAVIAN
ART TRNSPOSJ SUBCLAV CAROTID
ART TRNSPOSJ CAROTID SUBCLAV
REIMPLANT ARTERY EACH
REOPERATION BYPASS GRAFT
EXPLORATION CAROTID ARTERY
RPRT BONE SCINT XREF W XRAY
EXPLORATION FEMORAL ARTERY
PT CONSID POSS RISK FX
PT NOT CONSID POSS RISK FX
EXPLORATION POPLITEAL ARTERY
EXPLORATION OF ARTERY/VEIN
EXPLORE NECK VESSELS
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
9
3
9
9
3
3
3
Maximum Allowable
$1,456.98
$264.90
$1,496.65
$1,251.98
$1,147.48
$1,177.48
$1,173.87
$1,402.72
$1,675.76
$1,974.94
$1,921.48
$2,139.87
$1,883.11
$1,718.21
$1,843.26
$1,883.55
$1,051.79
$1,092.23
$1,833.25
$1,665.61
$1,149.38
$1,462.85
$1,157.61
$1,159.15
$1,343.08
$1,252.70
$1,354.19
$1,193.40
$83.86
$377.24
$439.59
$211.08
$172.24
$1,025.96
$867.24
$1,056.75
$1,121.25
$156.31
$161.71
$595.94
$0.00
$482.47
$0.00
$0.00
$544.76
$411.13
$756.33
Procedure Code
35820
35840
35860
35870
35875
35876
35879
35881
35883
35884
35901
35903
35905
35907
36000
36002
36005
36010
36011
36012
36013
36014
36015
36100
36120
36140
36147
36148
36160
36200
36215
36216
36217
36218
36221
36222
36223
36224
36225
36226
36227
36228
36245
36246
36247
36248
36251
Description
EXPLORE CHEST VESSELS
EXPLORE ABDOMINAL VESSELS
EXPLORE LIMB VESSELS
REPAIR VESSEL GRAFT DEFECT
REMOVAL OF CLOT IN GRAFT
REMOVAL OF CLOT IN GRAFT
REVISE GRAFT W/VEIN
REVISE GRAFT W/VEIN
REVISE GRAFT W/NONAUTO GRAFT
REVISE GRAFT W/VEIN
EXCISION GRAFT NECK
EXCISION GRAFT EXTREMITY
EXCISION GRAFT THORAX
EXCISION GRAFT ABDOMEN
PLACE NEEDLE IN VEIN
PSEUDOANEURYSM INJECTION TRT
INJECTION EXT VENOGRAPHY
PLACE CATHETER IN VEIN
PLACE CATHETER IN ARTERY
ESTABLISH ACCESS TO ARTERY
ACCESS AV DIAL GRFT FOR EVAL
ACCESS AV DIAL GRFT FOR PROC
ESTABLISH ACCESS TO AORTA
PLACE CATHETER IN AORTA
PLACE CATH THORACIC AORTA
PLACE CATH CAROTID/INOM ART
PLACE CATH CAROTID/INOM ART
PLACE CATH CAROTD ART
PLACE CATH SUBCLAVIAN ART
PLACE CATH VERTEBRAL ART
PLACE CATH XTRNL CAROTID
PLACE CATH INTRACRANIAL ART
INS CATH ABD/L-EXT ART 1ST
INS CATH ABD/L-EXT ART 2ND
INS CATH ABD/L-EXT ART 3RD
INS CATH ABD/L-EXT ART ADDL
INS CATH REN ART 1ST UNILAT
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$2,120.74
$1,256.09
$896.25
$1,326.85
$636.05
$1,007.31
$984.27
$1,087.67
$1,288.72
$1,321.08
$503.64
$602.23
$1,796.39
$2,042.13
$26.34
$166.81
$50.30
$128.00
$164.20
$884.40
$814.90
$834.16
$892.08
$501.24
$432.66
$108.01
$860.02
$268.89
$506.00
$161.33
$246.15
$291.68
$347.43
$55.78
$226.51
$310.91
$339.74
$378.12
$334.56
$379.60
$259.36
$245.46
$264.70
$282.92
$334.91
$157.02
$1,466.31
Procedure Code
36252
36253
36254
36260
36261
36262
36299
36400
36405
36406
36410
36415
36416
36420
36425
36430
36440
36450
36455
36460
36468
36470
36471
36475
36476
36478
36479
36481
36500
3650F
36510
36511
36512
36513
36514
36515
36516
36522
36555
36556
36557
36558
36560
36561
36563
36565
36566
Description
INS CATH REN ART 1ST BILAT
INS CATH REN ART 2ND+ UNILAT
INS CATH REN ART 2ND+ BILAT
INSERTION OF INFUSION PUMP
REVISION OF INFUSION PUMP
REMOVAL OF INFUSION PUMP
VESSEL INJECTION PROCEDURE
BL DRAW < 3 YRS FEM/JUGULAR
BL DRAW <3 YRS SCALP VEIN
BL DRAW <3 YRS OTHER VEIN
NON-ROUTINE BL DRAW 3/> YRS
ROUTINE VENIPUNCTURE
CAPILLARY BLOOD DRAW
VEIN ACCESS CUTDOWN < 1 YR
VEIN ACCESS CUTDOWN > 1 YR
BLOOD TRANSFUSION SERVICE
BL PUSH TRANSFUSE 2 YR/<
BL EXCHANGE/TRANSFUSE NB
BL EXCHANGE/TRANSFUSE NON-NB
TRANSFUSION SERVICE FETAL
INJECTION(S) SPIDER VEINS
INJECTION THERAPY OF VEIN
INJECTION THERAPY OF VEINS
ENDOVENOUS RF 1ST VEIN
ENDOVENOUS RF VEIN ADD-ON
ENDOVENOUS LASER 1ST VEIN
ENDOVENOUS LASER VEIN ADDON
INSERTION OF CATHETER VEIN
EEG ORDERED RVWD REQSTD
APHERESIS WBC
APHERESIS RBC
APHERESIS PLATELETS
APHERESIS PLASMA
APHERESIS ADSORP/REINFUSE
APHERESIS SELECTIVE
PHOTOPHERESIS
INSERT NON-TUNNEL CV CATH
INSERT NON-TUNNEL CV CATH
INSERT TUNNELED CV CATH
Pricing Action Code
3
3
3
3
3
3
5
3
3
3
3
3
9
3
3
3
3
3
3
3
5
3
3
3
3
3
3
3
3
9
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$1,590.27
$2,325.82
$2,265.79
$662.04
$384.67
$320.54
$0.00
$30.61
$26.64
$17.30
$17.30
$2.94
$0.00
$54.24
$41.31
$35.52
$59.22
$121.04
$131.75
$358.89
$0.00
$153.48
$179.72
$296.07
$142.97
$294.53
$143.62
$2,092.54
$190.95
$0.00
$92.86
$96.43
$97.16
$100.25
$551.55
$2,111.86
$2,135.16
$105.17
$274.46
$125.92
$344.89
$287.91
$408.61
$370.80
$401.43
$1,004.79
$5,622.43
Procedure Code
36568
36569
36570
36571
36575
36576
36578
36580
36581
36582
36583
36584
36585
36589
36590
36591
36592
36593
36595
36596
36597
36598
36600
36620
36625
36640
36660
36680
36800
36810
36815
36818
36819
36820
36821
36823
36825
36830
36831
36832
36833
36835
36838
36860
36861
36870
3700F
Description
INSERT PICC CATH
INSERT PICC CATH
INSERT PICVAD CATH
INSERT PICVAD CATH
REPAIR TUNNELED CV CATH
REPAIR TUNNELED CV CATH
REPLACE TUNNELED CV CATH
REPLACE CVAD CATH
REPLACE PICC CATH
REPLACE PICVAD CATH
REMOVAL TUNNELED CV CATH
REMOVAL TUNNELED CV CATH
DRAW BLOOD OFF VENOUS DEVICE
COLLECT BLOOD FROM PICC
DECLOT VASCULAR DEVICE
MECH REMOV TUNNELED CV CATH
MECH REMOV TUNNELED CV CATH
REPOSITION VENOUS CATHETER
INJ W/FLUOR EVAL CV DEVICE
WITHDRAWAL OF ARTERIAL BLOOD
INSERTION CATHETER ARTERY
INSERT NEEDLE BONE CAVITY
INSERTION OF CANNULA
AV FUSE UPPR ARM CEPHALIC
AV FUSE UPPR ARM BASILIC
AV FUSION/FOREARM VEIN
AV FUSION DIRECT ANY SITE
INSERTION OF CANNULA(S)
ARTERY-VEIN AUTOGRAFT
ARTERY-VEIN NONAUTOGRAFT
OPEN THROMBECT AV FISTULA
AV FISTULA REVISION OPEN
AV FISTULA REVISION
ARTERY TO VEIN SHUNT
DIST REVAS LIGATION HEMO
EXTERNAL CANNULA DECLOTTING
CANNULA DECLOTTING
PERCUT THROMBECT AV FISTULA
PSYCH DISORDERS ASSESSED
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
9
Maximum Allowable
$100.75
$95.01
$1,191.39
$339.01
$170.94
$401.15
$535.84
$69.63
$204.42
$1,134.86
$1,410.65
$210.08
$1,185.18
$170.30
$302.98
$23.91
$26.80
$31.89
$600.68
$137.24
$130.82
$113.30
$32.42
$53.35
$108.92
$122.70
$66.60
$60.70
$128.63
$228.21
$153.94
$737.99
$779.74
$778.37
$706.96
$1,419.63
$853.40
$709.39
$657.64
$806.12
$863.77
$523.97
$1,217.50
$213.27
$138.67
$313.05
$0.00
Procedure Code
37140
37145
37160
37180
37181
37182
37183
37184
37185
37186
37187
37188
37191
37192
37193
37195
37197
37200
3720F
37211
37212
37213
37214
37215
37216
37217
37218
37220
37221
37222
37223
37224
37225
37226
37227
37228
37229
37230
37231
37232
37233
37234
37235
37236
37237
37238
37239
Description
REVISION OF CIRCULATION
SPLICE SPLEEN/KIDNEY VEINS
INSERT HEPATIC SHUNT (TIPS)
REMOVE HEPATIC SHUNT (TIPS)
PRIM ART M-THRMBC 1ST VSL
PRIM ART M-THRMBC SBSQ VSL
SEC ART THROMBECTOMY ADD-ON
VENOUS MECH THROMBECTOMY
VENOUS M-THROMBECTOMY ADD-ON
INS ENDOVAS VENA CAVA FILTR
REDO ENDOVAS VENA CAVA FILTR
REM ENDOVAS VENA CAVA FILTER
THROMBOLYTIC THERAPY STROKE
REMOVE INTRVAS FOREIGN BODY
TRANSCATHETER BIOPSY
COGNIT IMPAIRMENT ASSESSED
THROMBOLYTIC ART THERAPY
THROMBOLYTIC VENOUS THERAPY
THROMBLYTIC ART/VEN THERAPY
CESSJ THERAPY CATH REMOVAL
TRANSCATH STENT CCA W/EPS
TRANSCATH STENT CCA W/O EPS
STENT PLACEMT RETRO CAROTID
STENT PLACEMT ANTE CAROTID
ILIAC REVASC
ILIAC REVASC W/STENT
ILIAC REVASC ADD-ON
ILIAC REVASC W/STENT ADD-ON
FEM/POPL REVAS W/TLA
FEM/POPL REVAS W/ATHER
FEM/POPL REVASC W/STENT
FEM/POPL REVASC STNT & ATHER
TIB/PER REVASC W/TLA
TIB/PER REVASC W/ATHER
TIB/PER REVASC W/STENT
TIB/PER REVASC STENT & ATHER
TIB/PER REVASC ADD-ON
TIBPER REVASC W/ATHER ADD-ON
REVSC OPN/PRQ TIB/PERO STENT
TIB/PER REVASC STNT & ATHER
OPEN/PERQ PLACE STENT 1ST
OPEN/PERQ PLACE STENT EA ADD
OPEN/PERQ PLACE STENT SAME
OPEN/PERQ PLACE STENT EA ADD
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
9
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$2,406.96
$2,259.56
$2,320.52
$2,133.50
$2,441.40
$868.55
$6,076.80
$484.74
$743.38
$1,418.68
$428.23
$1,827.96
$250.43
$386.24
$384.00
$326.02
$1,564.03
$229.02
$0.00
$420.38
$369.58
$259.36
$141.89
$1,060.29
$1,043.27
$1,156.42
$866.95
$440.14
$540.60
$912.69
$227.62
$483.91
$656.76
$569.13
$15,304.36
$591.69
$765.86
$8,540.22
$13,741.04
$214.99
$1,507.41
$3,989.96
$4,200.22
$4,230.81
$2,529.82
$4,312.65
$2,087.80
Procedure Code
37241
37242
37243
37244
37252
37253
3725F
37500
37501
3750F
3751F
3752F
3753F
3754F
3755F
37565
3756F
3757F
3758F
3759F
37600
37605
37606
37607
37609
3760F
37615
37616
37617
37618
37619
3761F
3762F
3763F
37650
37660
37700
37718
37722
37735
3775F
37760
37761
37765
37766
3776F
37780
Description
VASC EMBOLIZE/OCCLUDE VENOUS
VASC EMBOLIZE/OCCLUDE ARTERY
VASC EMBOLIZE/OCCLUDE ORGAN
VASC EMBOLIZE/OCCLUDE BLEED
INTRVASC US NONCORONARY 1ST
INTRVASC US NONCORONARY ADDL
SCREEN DEPRESSION PERFORMED
ENDOSCOPY LIGATE PERF VEINS
VASCULAR ENDOSCOPY PROCEDURE
PTNOTRCVNGSTEROID>/=10MG/DAY
ELECTRODIAG POLYNEURO 6 MN
NO ELECTRODIAG POLYNEURO 6MN
PT HAS SYMP&SIGNS NEUROPATHY
SCREENING TESTS DM DONE
COG&BEHAV IMPRMNT SCRNG DONE
LIGATION OF NECK VEIN
PT W/PSEUDOBULB AFFECT/ALS
PT W/O PSEUDOBULBAFFECT/ALS
PT REF PULM FX TEST/PEAKFLOW
PT SCRN DYSPHAG/WT LOSS/NUTR
LIGATION OF NECK ARTERY
LIGATION OF A-V FISTULA
TEMPORAL ARTERY PROCEDURE
PT W/ DYSPHAG/WT LOSS/NUTR
LIGATION OF CHEST ARTERY
LIGATION OF ABDOMEN ARTERY
LIGATION OF EXTREMITY ARTERY
LIGATION OF INF VENA CAVA
PT W/O DYSPHAG/WT LOSS/NUTR
PATIENT IS DYSARTHRIC
PATIENT IS NOT DYSARTHRIC
REVISION OF MAJOR VEIN
REVISION OF MAJOR VEIN
REVISE LEG VEIN
LIGATE/STRIP SHORT LEG VEIN
LIGATE/STRIP LONG LEG VEIN
REMOVAL OF LEG VEINS/LESION
ADENOMA DETECTED SCREENING
LIGATE LEG VEINS RADICAL
LIGATE LEG VEINS OPEN
STAB PHLEB VEINS XTR 10-20
PHLEB VEINS - EXTREM 20+
ADENOMA NOT DETECT SCREENING
REVISION OF LEG VEIN
Pricing Action Code
3
3
3
3
3
3
9
3
5
9
9
9
9
9
9
3
9
9
9
9
3
3
3
3
3
9
3
3
3
3
3
9
9
9
3
3
3
3
3
3
9
3
3
3
3
9
3
Maximum Allowable
$474.43
$517.60
$609.99
$714.82
$1,436.66
$223.00
$0.00
$803.95
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$761.57
$0.00
$0.00
$0.00
$0.00
$747.90
$851.27
$613.23
$399.23
$321.66
$0.00
$536.08
$1,160.98
$1,410.09
$406.09
$1,728.39
$0.00
$0.00
$0.00
$539.88
$1,229.59
$264.42
$464.94
$509.24
$728.46
$0.00
$655.88
$584.96
$681.65
$809.91
$0.00
$269.47
Procedure Code
37785
37788
37790
37799
38100
38101
38102
38115
38120
38129
38200
38204
38205
38206
38207
38208
38209
38210
38211
38212
38213
38214
38215
38220
38221
38230
38232
38240
38241
38242
38243
38300
38305
38308
38380
38381
38382
38500
38505
38510
38520
38525
38530
38542
38550
38555
38562
Description
LIGATE/DIVIDE/EXCISE VEIN
REVASCULARIZATION PENIS
PENILE VENOUS OCCLUSION
VASCULAR SURGERY PROCEDURE
REMOVAL OF SPLEEN TOTAL
REMOVAL OF SPLEEN PARTIAL
REMOVAL OF SPLEEN TOTAL
REPAIR OF RUPTURED SPLEEN
LAPAROSCOPY SPLENECTOMY
LAPAROSCOPE PROC SPLEEN
INJECTION FOR SPLEEN X-RAY
BL DONOR SEARCH MANAGEMENT
HARVEST ALLOGENEIC STEM CELL
HARVEST AUTO STEM CELLS
CRYOPRESERVE STEM CELLS
THAW PRESERVED STEM CELLS
WASH HARVEST STEM CELLS
T-CELL DEPLETION OF HARVEST
TUMOR CELL DEPLETE OF HARVST
RBC DEPLETION OF HARVEST
PLATELET DEPLETE OF HARVEST
VOLUME DEPLETE OF HARVEST
HARVEST STEM CELL CONCENTRTE
BONE MARROW ASPIRATION
BONE MARROW BIOPSY
BONE MARROW HARVEST ALLOGEN
BONE MARROW HARVEST AUTOLOG
TRANSPLT ALLO HCT/DONOR
TRANSPLT AUTOL HCT/DONOR
TRANSPLT ALLO LYMPHOCYTES
TRANSPLJ HEMATOPOIETIC BOOST
DRAINAGE LYMPH NODE LESION
DRAINAGE LYMPH NODE LESION
INCISION OF LYMPH CHANNELS
THORACIC DUCT PROCEDURE
BIOPSY/REMOVAL LYMPH NODES
NEEDLE BIOPSY LYMPH NODES
EXPLORE DEEP NODE(S) NECK
REMOVAL NECK/ARMPIT LESION
REMOVAL NECK/ARMPIT LESION
REMOVAL PELVIC LYMPH NODES
Pricing Action Code
3
3
3
5
3
3
3
3
3
5
3
9
9
3
9
9
9
9
9
9
9
9
9
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
9
3
3
3
Maximum Allowable
$372.61
$1,338.59
$523.35
$0.00
$1,209.86
$1,212.51
$274.62
$1,326.39
$1,102.64
$0.00
$120.29
$0.00
$0.00
$85.70
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$168.95
$171.20
$205.90
$205.17
$230.21
$172.47
$121.19
$120.81
$284.16
$497.22
$460.92
$592.89
$841.26
$644.35
$344.80
$130.12
$540.57
$484.97
$457.23
$575.07
$0.00
$528.72
$1,050.98
$731.83
Procedure Code
38564
38570
38571
38572
38589
38700
38720
38724
38740
38745
38746
38747
38760
38765
38770
38780
38790
38792
38794
38900
38999
39000
39010
39200
39220
39401
39402
39499
39501
39503
39540
39541
39545
39560
39561
39599
4000F
4001F
4003F
4004F
4005F
4008F
4010F
4011F
4012F
4013F
4014F
Description
REMOVAL ABDOMEN LYMPH NODES
LAPAROSCOPY LYMPH NODE BIOP
LAPAROSCOPY LYMPHADENECTOMY
LAPAROSCOPY LYMPHADENECTOMY
LAPAROSCOPE PROC LYMPHATIC
REMOVAL OF LYMPH NODES NECK
REMOVE ARMPIT LYMPH NODES
REMOVE ARMPIT LYMPH NODES
REMOVE THORACIC LYMPH NODES
REMOVE ABDOMINAL LYMPH NODES
REMOVE GROIN LYMPH NODES
REMOVE GROIN LYMPH NODES
REMOVE PELVIS LYMPH NODES
REMOVE ABDOMEN LYMPH NODES
INJECT FOR LYMPHATIC X-RAY
RA TRACER ID OF SENTINL NODE
ACCESS THORACIC LYMPH DUCT
IO MAP OF SENT LYMPH NODE
BLOOD/LYMPH SYSTEM PROCEDURE
RESECT MEDIASTINAL CYST
RESECT MEDIASTINAL TUMOR
MEDIASTINOSCPY W/MEDSTNL BX
MEDIASTINOSCPY W/LMPH NOD BX
CHEST PROCEDURE
REPAIR DIAPHRAGM LACERATION
REPAIR OF DIAPHRAGM HERNIA
REVISION OF DIAPHRAGM
RESECT DIAPHRAGM SIMPLE
RESECT DIAPHRAGM COMPLEX
DIAPHRAGM SURGERY PROCEDURE
TOBACCO USE TXMNT COUNSELING
TOBACCO USE TXMNT PHARMACOL
PT ED WRITE/ORAL PTS W/ HF
PT TOBACCO SCREEN RCVD TLK
PHARM THX FOR OP RXD
BETA-BLOCKER THERAPY RXD/TKN
ACE/ARB THERAPY RXD/TAKEN
ORAL ANTIPLATELET THERAPY RX
WARFARIN THERAPY RX
STATIN THERAPY/CURRENTLY TKN
WRITTEN DISCHARGE INSTR PRVD
Pricing Action Code
3
3
3
3
5
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
5
3
3
3
3
3
3
5
3
3
3
3
3
3
3
5
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$736.99
$524.07
$689.86
$965.22
$0.00
$841.44
$1,406.53
$1,519.19
$726.26
$916.23
$223.26
$278.96
$879.36
$1,351.01
$838.74
$1,064.82
$86.78
$40.67
$308.66
$144.57
$0.00
$521.52
$826.76
$928.54
$1,194.16
$328.18
$428.03
$0.00
$886.25
$6,454.81
$905.68
$988.14
$939.09
$832.55
$1,300.80
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
4015F
4016F
4017F
4018F
4019F
4025F
4030F
4033F
4035F
4037F
4040F
4041F
4042F
4043F
4044F
4045F
4046F
4047F
4048F
40490
4049F
40500
4050F
40510
4051F
40520
40525
40527
4052F
40530
4053F
4054F
4055F
4056F
4058F
4060F
4062F
4063F
4064F
40650
40652
40654
4065F
4066F
4067F
4069F
40700
Description
PERSIST ASTHMA MEDICINE CTRL
ANTI-INFLM/ANLGSC AGENT RX
GI PROPHYLAXIS FOR NSAID RX
THERAPY EXERCISE JOINT RX
DOC RECPT COUNSL VIT D/CALC+
INHALED BRONCHODILATOR RX
OXYGEN THERAPY RX
PULMONARY REHAB REC
INFLUENZA IMM REC
INFLUENZA IMM ORDER/ADMIN
PNEUMOC VAC/ADMIN/RCVD
DOC ORDER CEFAZOLIN/CEFUROX
DOC ANTIBIO NOT GIVEN
DOC ORDER GIVEN STOP ANTIBIO
DOC ORDER GIVEN VTE PROPHYLX
EMPIRIC ANTIBIOTIC RX
DOC ANTIBIO GIVEN B/4 SURG
BIOPSY OF LIP
DOC ORDER GIVEN STOP ANTIBIO
PARTIAL EXCISION OF LIP
HT CARE PLAN DOC
REFERRED FOR AN AV FISTULA
RECONSTRUCT LIP WITH FLAP
RECONSTRUCT LIP WITH FLAP
HEMODIALYSIS VIA AV FISTULA
PARTIAL REMOVAL OF LIP
HEMODIALYSIS VIA AV GRAFT
HEMODIALYSIS VIA CATHETER
PT RCVNG PERITON DIALYSIS
APPROP ORAL REHYD RECOMMD
PED GASTRO ED GIVEN CAREGVR
PSYCH SVCS PROVIDED
PT REFERRAL PSYCH DOCD
ANTIDEPRES RXTHXPY NOT RXD
ANTIDEPRESSANT RX
REPAIR LIP
REPAIR LIP
REPAIR LIP
ANTIPSYCHOTIC RX
ECT PROVIDED
PT REFERRAL FOR ECT DOCD
VTE PROPHYLAXIS RCVD
REPAIR CLEFT LIP/NASAL
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
3
9
3
9
3
9
3
3
3
9
3
9
9
9
9
9
9
9
9
9
3
3
3
9
9
9
9
3
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$133.07
$0.00
$529.00
$0.00
$507.18
$0.00
$512.99
$580.69
$646.79
$0.00
$565.58
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$461.15
$510.57
$598.56
$0.00
$0.00
$0.00
$0.00
$945.67
Procedure Code
40701
40702
4070F
40720
4073F
4075F
40761
4077F
40799
4079F
40800
40801
40804
40805
40806
40808
40810
40812
40814
40816
40818
40819
40820
40830
40831
40840
40842
40843
40844
40845
4084F
4086F
40899
4090F
4095F
41000
41005
41006
41007
41008
41009
4100F
41010
41015
41016
41017
41018
Description
DVT PROPHYLX RECVD DAY 2
ORAL ANTIPLAT THX RX DISCHRG
ANTICOAG THX RX AT DISCHRG
DOC T-PA ADMIN CONSIDERED
LIP SURGERY PROCEDURE
DOC REHAB SVCS CONSIDERED
DRAINAGE OF MOUTH LESION
REMOVAL FOREIGN BODY MOUTH
REMOVAL FOREIGN BODY MOUTH
INCISION OF LIP FOLD
BIOPSY OF MOUTH LESION
EXCISION OF MOUTH LESION
EXCISE/REPAIR MOUTH LESION
EXCISE/REPAIR MOUTH LESION
EXCISE ORAL MUCOSA FOR GRAFT
EXCISE LIP OR CHEEK FOLD
TREATMENT OF MOUTH LESION
REPAIR MOUTH LACERATION
REPAIR MOUTH LACERATION
RECONSTRUCTION OF MOUTH
ASPIRIN RECVD W/IN 24 HRS
ASPIRIN/CLOPIDOGREL RXD
MOUTH SURGERY PROCEDURE
PT RCVNG EPO THXPY
PT NOT RCVNG EPO THXPY
BIPHOS THXPY VEIN ORD/RECVD
INCISION OF TONGUE FOLD
Pricing Action Code
3
3
9
3
9
9
3
9
5
9
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
9
9
5
9
9
3
3
3
3
3
3
9
3
3
3
3
3
Maximum Allowable
$1,059.31
$886.31
$0.00
$1,077.21
$0.00
$0.00
$1,139.80
$0.00
$0.00
$0.00
$225.07
$334.62
$201.12
$384.25
$118.22
$197.63
$218.12
$306.10
$408.49
$426.47
$378.16
$336.49
$281.10
$280.17
$357.40
$856.34
$819.56
$1,140.81
$1,364.79
$1,537.17
$0.00
$0.00
$0.00
$0.00
$0.00
$171.43
$239.84
$377.32
$368.65
$401.63
$426.52
$0.00
$213.49
$481.46
$467.64
$472.36
$537.86
Procedure Code
41019
41100
41105
41108
4110F
41110
41112
41113
41114
41115
41116
41120
41130
41135
41140
41145
41150
41153
41155
4115F
4120F
4124F
41250
41251
41252
4130F
4131F
4132F
4133F
4134F
4135F
4136F
4140F
4142F
4144F
4145F
4148F
4149F
41500
4150F
41510
41512
4151F
41520
41530
4153F
4155F
Description
PLACE NEEDLES H&N FOR RT
BIOPSY OF TONGUE
BIOPSY OF TONGUE
BIOPSY OF FLOOR OF MOUTH
INT MAM ART USED FOR CABG
EXCISION OF TONGUE LESION
EXCISION OF TONGUE FOLD
PARTIAL REMOVAL OF TONGUE
PARTIAL REMOVAL OF TONGUE
TONGUE AND NECK SURGERY
REMOVAL OF TONGUE
TONGUE REMOVAL NECK SURGERY
TONGUE MOUTH JAW SURGERY
TONGUE MOUTH NECK SURGERY
TONGUE JAW & NECK SURGERY
BETA BLCKR ADMIN W/IN 24 HRS
ANTIBIOT RXD/GIVEN
ANTIBIOT NOT RXD/GIVEN
REPAIR TONGUE LACERATION
TOPICAL PREP RX AOE
SYST ANTIMICROBIAL THX RX
NO SYST ANTIMICROBIAL THX RX
ANTIHIST/DECONG RX/RECOM
NO ANTIHIST/DECONG RX/RECOM
SYSTEMIC CORTICOSTEROIDS RX
SYST CORTICOSTEROIDS NOT RX
INHALED CORTICOSTEROIDS RXD
CORTICOSTER SPARNG THRPY RXD
ALT LONG-TERM CNTRL MED RXD
2+ ANTI-HYPRTNSV AGENTS TKN
HEP A VAC INJXN ADMIN/RECVD
HEP B VAC INJXN ADMIN/RECVD
FIXATION OF TONGUE
PT RECVNG ANTIVIR TXMNT HEPC
TONGUE TO LIP SURGERY
TONGUE SUSPENSION
PT NOT RECVNG ANTIV HEP C
RECONSTRUCTION TONGUE FOLD
TONGUE BASE VOL REDUCTION
COMBO PEGINTF/RIB RX
HEP A VAC SERIES PREV RECVD
Pricing Action Code
3
3
3
3
9
3
3
3
3
3
3
3
3
3
3
3
3
3
3
9
9
9
3
3
3
9
9
9
9
9
9
9
9
9
9
9
9
9
3
9
3
3
9
3
3
9
9
Maximum Allowable
$484.81
$177.19
$180.44
$155.96
$0.00
$223.82
$354.78
$388.29
$672.53
$262.16
$351.25
$1,147.51
$1,411.01
$2,310.40
$2,330.46
$2,961.73
$2,345.16
$2,555.10
$3,202.11
$0.00
$0.00
$0.00
$280.82
$306.10
$331.87
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$435.96
$0.00
$446.68
$703.16
$0.00
$375.10
$1,035.72
$0.00
$0.00
Procedure Code
4157F
4158F
41599
4159F
4163F
4164F
4165F
4167F
4168F
4169F
4171F
4172F
4174F
4175F
4176F
4177F
4178F
4179F
41800
41805
41806
4180F
4181F
41820
41821
41822
41823
41825
41826
41827
41828
4182F
41830
41850
4185F
4186F
41870
41872
41874
4187F
4188F
41899
4189F
4190F
4191F
4192F
4193F
Description
HEP B VAC SERIES PREV RECVD
PT EDU RE ALCOH DRNKNG DONE
TONGUE AND MOUTH SURGERY
CONTRCP TALK B/4 ANTIV TXMNT
PT COUNS 4 TXMNT OPT PROST
ADJV HRMNL THXPY RXD
3D-CRT/IMRT RECEIVED
HD BED TILTED 1ST DAY VENT
PT CARE ICU&VENT W/IN 24HRS
NO PT CARE ICU/VENT IN 24HRS
PT RCVNG ESA THXPY
PT NOT RCVNG ESA THXPY
COUNS POTENT GLAUC IMPCT
VIS 20/40/> W/IN 90 DAYS
TALK RE UV LIGHT PT/CRGVR
TALK PT/CRGVR RE AREDS PREV
ANTID GLBLN RCVD W/IN 26WKS
TAMOXIFEN/AI PRESCRIBED
DRAINAGE OF GUM LESION
REMOVAL FOREIGN BODY GUM
REMOVAL FOREIGN BODY JAWBONE
ADJV THXPYRXD/RCVD COLON CA
CONFORMAL RADN THXPY RCVD
EXCISION GUM EACH QUADRANT
EXCISION OF GUM FLAP
EXCISION OF GUM LESION
NO CONFORMAL RADN THXPY
REMOVAL OF GUM TISSUE
TREATMENT OF GUM LESION
CONTINUOUS PPI OR H2RA RCVD
NO CONT PPI OR H2RA RCVD
GUM GRAFT
REPAIR GUM
REPAIR TOOTH SOCKET
ANTI RHEUM DRUGTHXPYRXD/GVN
APPROP ACE/ARB TSTNG DONE
DENTAL SURGERY PROCEDURE
APPROP DIGOXIN TSTNG DONE
APPROP DIURETIC TSTNG DONE
APPROP ANTICONVULS TSTNG
PT NOT RCVNG GLUCOCO THXPY
PT RCVNG<10MG DAILY PREDNISO
Pricing Action Code
9
9
5
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
3
3
3
9
9
5
5
3
3
3
3
3
3
9
3
5
9
9
5
3
3
9
9
5
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$286.54
$273.90
$376.21
$0.00
$0.00
$0.00
$0.00
$311.18
$454.41
$225.01
$335.41
$468.47
$327.95
$0.00
$418.70
$0.00
$0.00
$0.00
$0.00
$388.71
$400.67
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
4194F
4195F
4196F
42000
4200F
4201F
42100
42104
42106
42107
4210F
42120
42140
42145
42160
42180
42182
42200
42205
4220F
42210
42215
4221F
42220
42225
42226
42227
42235
42260
42280
42281
42299
42300
42305
4230F
42310
42320
42330
42335
42340
42400
42405
42408
42409
4240F
42410
42415
Description
PT RCVNG10MG DAILY PREDNISO
PT RCVNG ANTI-RHEUM THXPY RA
PTNOT RCVNG ANTI-RHM THXPYRA
DRAINAGE MOUTH ROOF LESION
EXTERNAL BEAM TO PROST ONLY
EXTRNL BEAM OTHER THAN PROST
BIOPSY ROOF OF MOUTH
EXCISION LESION MOUTH ROOF
ACE/ARB THXPY FOR MOS/>
REMOVE PALATE/LESION
EXCISION OF UVULA
REPAIR PALATE PHARYNX/UVULA
TREATMENT MOUTH ROOF LESION
REPAIR PALATE
REPAIR PALATE
RECONSTRUCT CLEFT PALATE
DIGOXIN THXPY FOR 6 MOS/>
DIURETIC THXPY FOR 6 MOS/>
LENGTHENING OF PALATE
LENGTHENING OF PALATE
REPAIR PALATE
REPAIR NOSE TO LIP FISTULA
PREPARATION PALATE MOLD
INSERTION PALATE PROSTHESIS
PALATE/UVULA SURGERY
DRAINAGE OF SALIVARY GLAND
ANTICONV THXPY FOR 6 MOS/>
REMOVAL OF SALIVARY STONE
BIOPSY OF SALIVARY GLAND
BIOPSY OF SALIVARY GLAND
EXCISION OF SALIVARY CYST
DRAINAGE OF SALIVARY CYST
INSTR XRCZ BACK PAIN 12 WKS
EXCISE PAROTID GLAND/LESION
Pricing Action Code
9
9
9
3
9
9
3
3
3
3
9
3
3
3
3
3
3
3
3
9
3
3
9
3
3
3
3
3
3
9
3
5
3
3
9
3
3
3
3
3
3
3
3
3
9
3
3
Maximum Allowable
$0.00
$0.00
$0.00
$167.46
$0.00
$0.00
$158.40
$227.77
$290.61
$488.78
$0.00
$1,080.97
$266.48
$739.99
$244.72
$256.36
$336.20
$894.91
$929.92
$0.00
$1,041.74
$692.61
$0.00
$522.31
$924.26
$945.77
$896.04
$772.86
$856.08
$0.00
$215.33
$0.00
$220.03
$453.71
$0.00
$168.77
$262.21
$244.17
$394.69
$487.17
$110.78
$312.88
$473.78
$349.22
$0.00
$652.41
$1,106.03
Procedure Code
42420
42425
42426
4242F
42440
42450
4245F
4248F
42500
42505
42507
42509
4250F
42510
42550
4255F
4256F
42600
4260F
4261F
42650
4265F
42660
42665
4266F
4267F
4268F
42699
4269F
42700
4270F
4271F
42720
42725
4274F
4276F
4279F
42800
42804
42806
42808
42809
4280F
42810
42815
42820
42821
Description
SPRVSD XRCZ BACK PN >12 WKS
EXCISE SUBMAXILLARY GLAND
EXCISE SUBLINGUAL GLAND
PT INSTR NRML LIFEST
PT INSTR NO BD REST 4 DAYS/>
REPAIR SALIVARY DUCT
REPAIR SALIVARY DUCT
PAROTID DUCT DIVERSION
WRMNG 4 SURG NORMOTHERMIA
INJECTION FOR SALIVARY X-RAY
ANESTH 60 MIN/> AS DOCD
ANESTHE <60 MIN AS DOCD
CLOSURE OF SALIVARY FISTULA
WOUND SRFC CULTURETECH USED
TECH OTHER THAN SURFC CULTR
DILATION OF SALIVARY DUCT
WET-DRY DRESSINGS RX RECMD
DILATION OF SALIVARY DUCT
LIGATION OF SALIVARY DUCT
NO WET-DRY DRSSINGS RX RECMD
COMPRSSION THXPY PRESCRIBED
PT ED RE COMP THXPY RCVD
SALIVARY SURGERY PROCEDURE
APPROPOS MTHD OFFLOADING RXD
DRAINAGE OF TONSIL ABSCESS
PT RCVNG ANTI R-VIRAL THXPY
PT RCVNG ANTI R-VIRAL THXPY
DRAINAGE OF THROAT ABSCESS
DRAINAGE OF THROAT ABSCESS
FLU IMMUNO ADMIND RCVD
POTENT ANTIVIR THXPY RXD
PCP PROPHYLAXIS RXD
BIOPSY OF THROAT
BIOPSY OF UPPER NOSE/THROAT
BIOPSY OF UPPER NOSE/THROAT
EXCISE PHARYNX LESION
REMOVE PHARYNX FOREIGN BODY
PCP PROPHYLAX RXD 3MON LOW %
EXCISION OF NECK CYST
EXCISION OF NECK CYST
REMOVE TONSILS AND ADENOIDS
REMOVE TONSILS AND ADENOIDS
Pricing Action Code
3
3
3
9
3
3
9
9
3
3
3
3
9
3
3
9
9
3
9
9
3
9
3
3
9
9
9
5
9
3
9
9
3
3
9
9
9
3
3
3
3
3
9
3
3
3
3
Maximum Allowable
$1,242.32
$875.47
$1,412.33
$0.00
$432.37
$474.55
$0.00
$0.00
$455.82
$584.32
$542.50
$887.26
$0.00
$676.99
$138.74
$0.00
$0.00
$502.28
$0.00
$0.00
$88.01
$0.00
$134.53
$323.32
$0.00
$0.00
$0.00
$0.00
$0.00
$198.78
$0.00
$0.00
$476.45
$858.24
$0.00
$0.00
$0.00
$165.94
$205.10
$230.31
$237.97
$211.75
$0.00
$406.25
$587.21
$304.18
$315.72
Procedure Code
42825
42826
42830
42831
42835
42836
42842
42844
42845
42860
42870
42890
42892
42894
42900
4290F
4293F
42950
42953
42955
42960
42961
42962
42970
42971
42972
42999
4300F
4301F
43020
43030
43045
4305F
4306F
43100
43101
43107
43108
43112
43113
43116
43117
43118
43121
43122
43123
43124
Description
REMOVAL OF TONSILS
REMOVAL OF TONSILS
REMOVAL OF ADENOIDS
REMOVAL OF ADENOIDS
REMOVAL OF ADENOIDS
REMOVAL OF ADENOIDS
EXTENSIVE SURGERY OF THROAT
EXCISION OF TONSIL TAGS
EXCISION OF LINGUAL TONSIL
PARTIAL REMOVAL OF PHARYNX
REVISION OF PHARYNGEAL WALLS
REVISION OF PHARYNGEAL WALLS
REPAIR THROAT WOUND
PT SCRNED FOR INJ DRUG USE
PT SCRND HGH-RISK SEX BEHAV
RECONSTRUCTION OF THROAT
REPAIR THROAT ESOPHAGUS
SURGICAL OPENING OF THROAT
CONTROL THROAT BLEEDING
CONTROL NOSE/THROAT BLEEDING
THROAT SURGERY PROCEDURE
PT RCVNG WARF THXPY
PT NOT RCVNG WARF THXPY
INCISION OF ESOPHAGUS
THROAT MUSCLE SURGERY
INCISION OF ESOPHAGUS
PT ED RE FT CARE INSPCT RCVD
PT TLK PSYCH & RX OPD ADDIC
EXCISION OF ESOPHAGUS LESION
EXCISION OF ESOPHAGUS LESION
REMOVAL OF ESOPHAGUS
PARTIAL REMOVAL OF ESOPHAGUS
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
9
9
3
3
3
3
3
3
3
3
3
5
9
9
3
3
3
9
9
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$274.79
$263.59
$217.21
$234.90
$201.75
$252.45
$1,078.23
$1,476.32
$2,376.12
$197.44
$636.34
$1,522.84
$2,009.69
$2,526.17
$353.70
$0.00
$0.00
$870.96
$1,049.37
$821.00
$178.61
$445.17
$545.13
$421.84
$479.62
$536.74
$0.00
$0.00
$0.00
$555.96
$544.01
$1,376.82
$0.00
$0.00
$653.61
$1,073.75
$2,689.93
$4,818.56
$2,840.20
$4,767.67
$5,307.97
$2,598.65
$3,889.93
$3,032.42
$2,701.35
$4,977.23
$4,039.98
Procedure Code
43130
43135
43180
43191
43192
43193
43194
43195
43196
43197
43198
43200
43201
43202
43204
43205
43206
4320F
43210
43211
43212
43213
43214
43215
43216
43217
43220
43226
43227
43229
4322F
43231
43232
43233
43235
43236
43237
43238
43239
43240
43241
43242
43243
43244
43245
43246
43247
Description
REMOVAL OF ESOPHAGUS POUCH
REMOVAL OF ESOPHAGUS POUCH
ESOPHAGOSCOPY RIGID TRNSO
ESOPHAGOSCOPY RIGID TRNSO DX
ESOPHAGOSCP RIG TRNSO INJECT
ESOPHAGOSCP RIG TRNSO BIOPSY
ESOPHAGOSCP RIG TRNSO REM FB
ESOPHAGOSCOPY RIGID BALLOON
ESOPHAGOSCP GUIDE WIRE DILAT
ESOPHAGOSCOPY FLEX DX BRUSH
ESOPHAGOSC FLEX TRNSN BIOPSY
ESOPHAGOSCOPY FLEXIBLE BRUSH
ESOPH SCOPE W/SUBMUCOUS INJ
ESOPHAGOSCOPY FLEX BIOPSY
ESOPH SCOPE W/SCLEROSIS INJ
ESOPHAGUS ENDOSCOPY/LIGATION
ESOPH OPTICAL ENDOMICROSCOPY
PT TALK PSYCHSOC&RX OH DPND
EGD ESOPHAGOGASTRC FNDOPLSTY
ESOPHAGOSCOP MUCOSAL RESECT
ESOPHAGOSCOP STENT PLACEMENT
ESOPHAGOSCOPY RETRO BALLOON
ESOPHAGOSC DILATE BALLOON 30
ESOPHAGOSCOPY FLEX REMOVE FB
ESOPHAGOSCOPY LESION REMOVAL
ESOPHAGOSCOPY SNARE LES REMV
ESOPHAGOSCOPY BALLOON <30MM
ESOPH ENDOSCOPY DILATION
ESOPHAGOSCOPY CONTROL BLEED
ESOPHAGOSCOPY LESION ABLATE
CRGVR PROV W/ ED ADDL RSRCS
ESOPHAGOSCOP ULTRASOUND EXAM
ESOPHAGOSCOPY W/US NEEDLE BX
EGD BALLOON DIL ESOPH30 MM/>
EGD DIAGNOSTIC BRUSH WASH
UPPR GI SCOPE W/SUBMUC INJ
ENDOSCOPIC US EXAM ESOPH
EGD US FINE NEEDLE BX/ASPIR
EGD BIOPSY SINGLE/MULTIPLE
EGD W/TRANSMURAL DRAIN CYST
EGD TUBE/CATH INSERTION
EGD US FINE NEEDLE BX/ASPIR
EGD INJECTION VARICES
EGD VARICES LIGATION
EGD DILATE STRICTURE
EGD PLACE GASTROSTOMY TUBE
EGD REMOVE FOREIGN BODY
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
9
3
3
3
3
3
3
3
3
3
3
3
3
9
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$825.32
$1,563.01
$575.95
$161.55
$178.06
$177.73
$202.17
$193.17
$206.87
$195.25
$216.85
$279.96
$284.51
$372.86
$148.09
$154.57
$339.31
$0.00
$446.64
$254.45
$206.54
$1,258.12
$208.12
$430.92
$425.40
$459.33
$1,165.87
$391.50
$714.42
$742.05
$0.00
$411.41
$491.02
$246.24
$319.45
$397.50
$212.40
$251.56
$407.64
$420.81
$156.04
$283.50
$256.25
$265.20
$630.44
$217.23
$426.93
Procedure Code
43248
43249
4324F
43250
43251
43252
43253
43254
43255
43257
43259
4325F
43260
43261
43262
43263
43264
43265
43266
4326F
43270
43273
43274
43275
43276
43277
43278
43279
43280
43281
43282
43283
43289
4328F
43300
43305
4330F
43310
43312
43313
43314
43320
43325
43327
43328
43330
43331
Description
EGD GUIDE WIRE INSERTION
ESOPH EGD DILATION <30 MM
PT QUERIED PRKNS COMPLIC
EGD CAUTERY TUMOR POLYP
EGD REMOVE LESION SNARE
EGD OPTICAL ENDOMICROSCOPY
EGD US TRANSMURAL INJXN/MARK
EGD ENDO MUCOSAL RESECTION
EGD CONTROL BLEEDING ANY
EGD W/THRML TXMNT GERD
EGD US EXAM DUODENUM/JEJUNUM
MED TXMNT OPTIONS RVWD W/PT
ERCP W/SPECIMEN COLLECTION
ENDO CHOLANGIOPANCREATOGRAPH
ENDO CHOLANGIOPANCREATOGRAPH
ERCP SPHINCTER PRESSURE MEAS
ERCP REMOVE DUCT CALCULI
ERCP LITHOTRIPSY CALCULI
EGD ENDOSCOPIC STENT PLACE
PT ASKED RE SYMP AUTO DYSFXN
EGD LESION ABLATION
ENDOSCOPIC PANCREATOSCOPY
ERCP DUCT STENT PLACEMENT
ERCP REMOVE FORGN BODY DUCT
ERCP STENT EXCHANGE W/DILATE
ERCP EA DUCT/AMPULLA DILATE
ERCP LESION ABLATE W/DILATE
LAP MYOTOMY HELLER
LAPAROSCOPY FUNDOPLASTY
LAP PARAESOPHAG HERN REPAIR
LAP PARAESOPH HER RPR W/MESH
LAP ESOPH LENGTHENING
LAPAROSCOPE PROC ESOPH
PT ASKED RE SLEEP DISTURB
REPAIR OF ESOPHAGUS
REPAIR ESOPHAGUS AND FISTULA
CNSLNG EPI SPEC SFTY ISSUES
REPAIR OF ESOPHAGUS
REPAIR ESOPHAGUS AND FISTULA
ESOPHAGOPLASTY CONGENITAL
TRACHEO-ESOPHAGOPLASTY CONG
FUSE ESOPHAGUS & STOMACH
REVISE ESOPHAGUS & STOMACH
ESOPH FUNDOPLASTY LAP
ESOPH FUNDOPLASTY THOR
ESOPHAGOMYOTOMY ABDOMINAL
ESOPHAGOMYOTOMY THORACIC
Pricing Action Code
3
3
9
3
3
3
3
3
3
3
3
9
3
3
3
3
3
3
3
9
3
3
3
3
3
3
3
3
3
3
3
3
5
9
3
3
9
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$418.98
$167.88
$0.00
$467.96
$512.17
$377.04
$282.77
$291.45
$749.20
$251.97
$244.71
$0.00
$346.38
$364.01
$383.41
$384.14
$390.57
$464.25
$244.81
$0.00
$771.39
$126.46
$495.50
$403.89
$515.62
$406.03
$463.88
$1,356.33
$1,132.02
$1,616.09
$1,816.09
$165.78
$0.00
$0.00
$645.70
$1,150.36
$0.00
$1,570.20
$1,702.46
$2,829.23
$3,240.80
$1,461.28
$1,404.61
$859.92
$1,193.00
$1,394.76
$1,418.65
Procedure Code
43332
43333
43334
43335
43336
43337
43338
43340
43341
43351
43352
43360
43361
43400
43401
43405
4340F
43410
43415
43420
43425
43450
43453
43460
43496
43499
43500
43501
43502
4350F
43510
43520
43605
43610
43611
43620
43621
43622
43631
43632
43633
43634
43635
43640
43641
43644
43645
Description
TRANSAB ESOPH HIAT HERN RPR
TRANSAB ESOPH HIAT HERN RPR
TRANSTHOR DIAPHRAG HERN RPR
TRANSTHOR DIAPHRAG HERN RPR
THORABD DIAPHR HERN REPAIR
THORABD DIAPHR HERN REPAIR
ESOPH LENGTHENING
FUSE ESOPHAGUS & INTESTINE
FUSE ESOPHAGUS & INTESTINE
SURGICAL OPENING ESOPHAGUS
SURGICAL OPENING ESOPHAGUS
GASTROINTESTINAL REPAIR
GASTROINTESTINAL REPAIR
LIGATE ESOPHAGUS VEINS
ESOPHAGUS SURGERY FOR VEINS
LIGATE/STAPLE ESOPHAGUS
CNSLNG CHLDBRNG WOMEN EPI
REPAIR ESOPHAGUS WOUND
REPAIR ESOPHAGUS WOUND
REPAIR ESOPHAGUS OPENING
REPAIR ESOPHAGUS OPENING
DILATE ESOPHAGUS 1/MULT PASS
DILATE ESOPHAGUS
PRESSURE TREATMENT ESOPHAGUS
FREE JEJUNUM FLAP MICROVASC
ESOPHAGUS SURGERY PROCEDURE
SURGICAL OPENING OF STOMACH
SURGICAL REPAIR OF STOMACH
SURGICAL REPAIR OF STOMACH
CNSLNG PROVIDED SYMP MNGMNT
SURGICAL OPENING OF STOMACH
INCISION OF PYLORIC MUSCLE
BIOPSY OF STOMACH
EXCISION OF STOMACH LESION
EXCISION OF STOMACH LESION
REMOVAL OF STOMACH
REMOVAL OF STOMACH
REMOVAL OF STOMACH
REMOVAL OF STOMACH PARTIAL
VAGOTOMY & PYLORUS REPAIR
VAGOTOMY & PYLORUS REPAIR
LAP GASTRIC BYPASS/ROUX-EN-Y
LAP GASTR BYPASS INCL SMLL I
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
9
3
3
3
3
3
3
3
5
5
3
3
3
9
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$1,217.14
$1,327.55
$1,320.03
$1,417.11
$1,588.43
$1,713.68
$122.18
$1,429.68
$1,553.28
$1,354.20
$1,128.53
$2,486.33
$2,695.83
$1,552.55
$1,645.34
$1,540.85
$0.00
$1,103.62
$2,710.12
$1,063.65
$1,516.33
$217.33
$993.02
$224.98
$0.00
$0.00
$820.35
$1,409.05
$1,596.42
$0.00
$990.42
$721.70
$877.11
$1,026.41
$1,283.66
$2,053.02
$2,384.54
$2,431.20
$1,519.01
$2,130.54
$2,012.95
$2,220.26
$117.51
$1,234.55
$1,242.91
$1,810.48
$1,933.81
Procedure Code
43647
43648
43651
43652
43653
43659
43752
43753
43754
43755
43756
43757
43760
43761
43770
43771
43772
43773
43774
43775
43800
43810
43820
43825
43830
43831
43832
43840
43842
43843
43845
43846
43847
43848
43850
43855
43860
43865
43870
43880
43881
43882
43886
43887
43888
43999
44005
Description
LAP IMPL ELECTRODE ANTRUM
LAP REVISE/REMV ELTRD ANTRUM
LAPAROSCOPY VAGUS NERVE
LAPAROSCOPY VAGUS NERVE
LAPAROSCOPY GASTROSTOMY
LAPAROSCOPE PROC STOM
NASAL/OROGASTRIC W/TUBE PLMT
TX GASTRO INTUB W/ASP
DX GASTR INTUB W/ASP SPEC
DX GASTR INTUB W/ASP SPECS
DX DUOD INTUB W/ASP SPEC
DX DUOD INTUB W/ASP SPECS
CHANGE GASTROSTOMY TUBE
REPOSITION GASTROSTOMY TUBE
LAP PLACE GASTR ADJ DEVICE
LAP REVISE GASTR ADJ DEVICE
LAP RMVL GASTR ADJ DEVICE
LAP REPLACE GASTR ADJ DEVICE
LAP RMVL GASTR ADJ ALL PARTS
LAP SLEEVE GASTRECTOMY
RECONSTRUCTION OF PYLORUS
FUSION OF STOMACH AND BOWEL
PLACE GASTROSTOMY TUBE
REPAIR OF STOMACH LESION
V-BAND GASTROPLASTY
GASTROPLASTY W/O V-BAND
GASTROPLASTY DUODENAL SWITCH
GASTRIC BYPASS FOR OBESITY
GASTRIC BYPASS INCL SMALL I
REVISION GASTROPLASTY
REVISE STOMACH-BOWEL FUSION
REPAIR STOMACH OPENING
REPAIR STOMACH-BOWEL FISTULA
IMPL/REDO ELECTRD ANTRUM
REVISE/REMOVE ELECTRD ANTRUM
REVISE GASTRIC PORT OPEN
REMOVE GASTRIC PORT OPEN
CHANGE GASTRIC PORT OPEN
STOMACH SURGERY PROCEDURE
FREEING OF BOWEL ADHESION
Pricing Action Code
6
6
3
3
3
5
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
6
6
3
3
3
5
3
Maximum Allowable
$0.00
$0.00
$683.48
$802.11
$598.97
$0.00
$42.33
$22.62
$109.07
$145.27
$211.44
$298.46
$48.87
$119.95
$1,171.22
$1,333.13
$992.04
$1,328.16
$1,002.94
$1,281.79
$973.04
$1,065.44
$1,406.20
$1,368.94
$732.26
$610.30
$1,088.30
$1,424.62
$1,240.92
$1,340.00
$2,055.28
$1,688.04
$1,859.69
$2,016.60
$1,699.51
$1,718.54
$1,713.23
$1,785.60
$744.75
$1,675.08
$0.00
$0.00
$377.96
$338.25
$478.87
$0.00
$1,145.98
Procedure Code
4400F
44010
44015
44020
44021
44025
44050
44055
44100
44110
44111
44120
44121
44125
44126
44127
44128
44130
44132
44133
44135
44136
44137
44139
44140
44141
44143
44144
44145
44146
44147
44150
44151
44155
44156
44157
44158
44160
44180
44186
44187
44188
44202
44203
44204
44205
44206
Description
REHAB THXPY OPTIONS W/PT
INCISION OF SMALL BOWEL
INSERT NEEDLE CATH BOWEL
EXPLORE SMALL INTESTINE
DECOMPRESS SMALL BOWEL
INCISION OF LARGE BOWEL
REDUCE BOWEL OBSTRUCTION
CORRECT MALROTATION OF BOWEL
BIOPSY OF BOWEL
EXCISE INTESTINE LESION(S)
EXCISION OF BOWEL LESION(S)
REMOVAL OF SMALL INTESTINE
ENTERECTOMY W/O TAPER CONG
ENTERECTOMY W/TAPER CONG
ENTERECTOMY CONG ADD-ON
BOWEL TO BOWEL FUSION
ENTERECTOMY CADAVER DONOR
ENTERECTOMY LIVE DONOR
INTESTINE TRANSPLNT CADAVER
INTESTINE TRANSPLANT LIVE
REMOVE INTESTINAL ALLOGRAFT
MOBILIZATION OF COLON
PARTIAL REMOVAL OF COLON
REMOVAL OF COLON
REMOVAL OF COLON/ILEOSTOMY
COLECTOMY W/ILEOANAL ANAST
COLECTOMY W/NEO-RECTUM POUCH
REMOVAL OF COLON
LAP ENTEROLYSIS
LAP JEJUNOSTOMY
LAP ILEO/JEJUNO-STOMY
LAP COLOSTOMY
LAP ENTERECTOMY
LAP RESECT S/INTESTINE ADDL
LAPARO PARTIAL COLECTOMY
LAP COLECTOMY PART W/ILEUM
LAP PART COLECTOMY W/STOMA
Pricing Action Code
9
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
9
5
5
5
6
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$0.00
$902.30
$149.23
$1,020.98
$1,020.37
$1,033.07
$980.62
$1,563.37
$113.54
$892.11
$1,031.24
$1,282.64
$253.73
$1,237.30
$2,587.60
$2,968.96
$257.88
$1,375.91
$0.00
$0.00
$0.00
$0.00
$0.00
$126.45
$1,405.13
$1,913.40
$1,744.51
$1,856.21
$1,736.05
$2,217.27
$2,036.34
$1,958.90
$2,242.36
$2,180.05
$2,409.02
$2,257.22
$2,226.34
$1,301.22
$960.93
$683.97
$1,159.18
$1,283.16
$1,451.59
$253.33
$1,609.05
$1,399.96
$1,836.46
Procedure Code
44207
44208
44210
44211
44212
44213
44227
44238
44300
44310
44312
44314
44316
44320
44322
44340
44345
44346
44360
44361
44363
44364
44365
44366
44369
44370
44372
44373
44376
44377
44378
44379
44380
44381
44382
44384
44385
44386
44388
44389
44390
44391
44392
44394
44401
44402
44403
Description
L COLECTOMY/COLOPROCTOSTOMY
L COLECTOMY/COLOPROCTOSTOMY
LAPARO TOTAL PROCTOCOLECTOMY
LAP COLECTOMY W/PROCTECTOMY
LAPARO TOTAL PROCTOCOLECTOMY
LAP MOBIL SPLENIC FL ADD-ON
LAP CLOSE ENTEROSTOMY
LAPAROSCOPE PROC INTESTINE
OPEN BOWEL TO SKIN
ILEOSTOMY/JEJUNOSTOMY
REVISION OF ILEOSTOMY
REVISION OF ILEOSTOMY
DEVISE BOWEL POUCH
COLOSTOMY
COLOSTOMY WITH BIOPSIES
REVISION OF COLOSTOMY
SMALL BOWEL ENDOSCOPY
SMALL BOWEL ENDOSCOPY/BIOPSY
SMALL BOWEL ENDOSCOPY/STENT
SMALL BOWEL ENDOSCOPY/BIOPSY
S BOWEL ENDOSCOPE W/STENT
SMALL BOWEL ENDOSCOPY BR/WA
SMALL BOWEL ENDOSCOPY BR/WA
ENDOSCOPY OF BOWEL POUCH
ENDOSCOPY BOWEL POUCH/BIOP
COLONOSCOPY THRU STOMA SPX
COLONOSCOPY WITH BIOPSY
COLONOSCOPY FOR FOREIGN BODY
COLONOSCOPY FOR BLEEDING
COLONOSCOPY & POLYPECTOMY
COLONOSCOPY W/SNARE
COLONOSCOPY WITH ABLATION
COLONOSCOPY W/STENT PLCMT
COLONOSCOPY W/RESECTION
Pricing Action Code
3
3
3
3
3
3
3
5
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
9
3
9
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$1,904.86
$2,079.76
$1,863.66
$2,283.40
$2,142.04
$196.60
$1,747.21
$0.00
$881.84
$1,093.93
$614.62
$1,048.40
$1,485.59
$1,258.27
$1,045.72
$654.69
$1,101.28
$1,238.14
$157.43
$173.61
$208.12
$221.36
$194.62
$259.45
$265.55
$287.61
$259.56
$208.54
$305.86
$322.76
$412.48
$439.55
$226.20
$0.00
$328.52
$0.00
$249.61
$351.58
$362.38
$457.03
$455.92
$787.38
$429.00
$483.41
$3,348.19
$283.75
$325.35
Procedure Code
44404
44405
44406
44407
44408
44500
4450F
44602
44603
44604
44605
44615
44620
44625
44626
44640
44650
44660
44661
44680
44700
44701
44705
4470F
44715
44720
44721
44799
44800
4480F
4481F
44820
44850
44899
44900
44950
44955
44960
44970
44979
45000
45005
4500F
45020
45100
45108
4510F
Description
COLONOSCOPY W/INJECTION
COLONOSCOPY W/DILATION
COLONOSCOPY W/ULTRASOUND
COLONOSCOPY W/NDL ASPIR/BX
COLONOSCOPY W/DECOMPRESSION
INTRO GASTROINTESTINAL TUBE
SELF-CARE ED PROVIDED TO PT
SUTURE SMALL INTESTINE
SUTURE SMALL INTESTINE
SUTURE LARGE INTESTINE
REPAIR OF BOWEL LESION
INTESTINAL STRICTUROPLASTY
REPAIR BOWEL OPENING
REPAIR BOWEL-SKIN FISTULA
REPAIR BOWEL FISTULA
REPAIR BOWEL-BLADDER FISTULA
REPAIR BOWEL-BLADDER FISTULA
SURGICAL REVISION INTESTINE
SUSPEND BOWEL W/PROSTHESIS
INTRAOP COLON LAVAGE ADD-ON
PREPARE FECAL MICROBIOTA
ICD COUNSELING PROVIDED
PREPARE DONOR INTESTINE
PREP DONOR INTESTINE/VENOUS
PREP DONOR INTESTINE/ARTERY
UNLISTED PX SMALL INTESTINE
EXCISION OF BOWEL POUCH
PT RCVNG ACE/ARB B-BLOCKERTX
PT RCVNG ACE/ARB BLKER >3MOS
EXCISION OF MESENTERY LESION
REPAIR OF MESENTERY
BOWEL SURGERY PROCEDURE
DRAIN APPENDIX ABSCESS OPEN
APPENDECTOMY
APPENDECTOMY ADD-ON
APPENDECTOMY
LAPAROSCOPY APPENDECTOMY
LAPAROSCOPE PROC APP
DRAINAGE OF PELVIC ABSCESS
DRAINAGE OF RECTAL ABSCESS
REF TO OUTPT CARD REHAB PROG
DRAINAGE OF RECTAL ABSCESS
BIOPSY OF RECTUM
REMOVAL OF ANORECTAL LESION
PREV CARDREHAB QUALCARDEVENT
Pricing Action Code
3
3
3
3
3
9
9
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
6
9
9
9
9
5
3
9
9
3
3
5
3
3
3
3
3
5
3
3
9
3
3
3
9
Maximum Allowable
$437.90
$628.22
$248.51
$297.44
$251.04
$0.00
$0.00
$1,481.52
$1,697.63
$1,107.52
$1,368.67
$1,127.43
$908.30
$1,064.73
$1,680.11
$1,469.92
$1,520.26
$1,382.24
$1,623.16
$1,115.93
$1,066.71
$175.79
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$797.67
$0.00
$0.00
$878.71
$786.21
$0.00
$807.44
$672.65
$87.54
$916.52
$629.15
$0.00
$440.73
$283.62
$0.00
$596.36
$312.24
$382.53
$0.00
Procedure Code
45110
45111
45112
45113
45114
45116
45119
45120
45121
45123
45126
45130
45135
45136
45150
45160
45171
45172
45190
4525F
4526F
45300
45303
45305
45307
45308
45309
45315
45317
45320
45321
45327
45330
45331
45332
45333
45334
45335
45337
45338
45340
45341
45342
45346
45347
45349
45350
Description
REMOVAL OF RECTUM
PARTIAL REMOVAL OF RECTUM
REMOVAL OF RECTUM
PARTIAL PROCTECTOMY
REMOVE RECTUM W/RESERVOIR
REMOVAL OF RECTUM
REMOVAL OF RECTUM AND COLON
PARTIAL PROCTECTOMY
PELVIC EXENTERATION
EXCISION OF RECTAL PROLAPSE
EXCISION OF RECTAL PROLAPSE
EXCISE ILEOANAL RESERVIOR
EXCISION OF RECTAL STRICTURE
EXCISION OF RECTAL LESION
EXC RECT TUM TRANSANAL PART
EXC RECT TUM TRANSANAL FULL
DESTRUCTION RECTAL TUMOR
NEUROPSYCHIA INTERVEN ORDER
NEUROPSYCHIA INTERVEN RCVD
PROCTOSIGMOIDOSCOPY DX
PROCTOSIGMOIDOSCOPY DILATE
PROCTOSIGMOIDOSCOPY W/BX
PROCTOSIGMOIDOSCOPY FB
PROCTOSIGMOIDOSCOPY REMOVAL
PROCTOSIGMOIDOSCOPY BLEED
PROCTOSIGMOIDOSCOPY ABLATE
PROCTOSIGMOIDOSCOPY VOLVUL
PROCTOSIGMOIDOSCOPY W/STENT
DIAGNOSTIC SIGMOIDOSCOPY
SIGMOIDOSCOPY AND BIOPSY
SIGMOIDOSCOPY W/FB REMOVAL
SIGMOIDOSCOPY & POLYPECTOMY
SIGMOIDOSCOPY FOR BLEEDING
SIGMOIDOSCOPY W/SUBMUC INJ
SIGMOIDOSCOPY & DECOMPRESS
SIGMOIDOSCOPY W/TUMR REMOVE
SIG W/TNDSC BALLOON DILATION
SIGMOIDOSCOPY W/ULTRASOUND
SIGMOIDOSCOPY W/US GUIDE BX
SIGMOIDOSCOPY W/ABLATION
SIGMOIDOSCOPY W/PLCMT STENT
SIGMOIDOSCOPY W/RESECTION
SGMDSC W/BAND LIGATION
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
9
9
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$1,932.92
$1,137.01
$1,964.39
$1,977.63
$1,906.35
$1,724.43
$2,035.67
$1,569.22
$1,820.98
$1,170.52
$2,925.46
$1,136.06
$1,434.47
$1,889.07
$406.73
$1,070.37
$627.08
$844.57
$723.00
$0.00
$0.00
$126.40
$988.85
$200.48
$240.71
$221.92
$232.77
$231.84
$250.50
$250.80
$112.05
$127.65
$171.25
$263.05
$318.91
$358.09
$626.09
$296.73
$127.26
$332.88
$503.37
$136.61
$185.08
$3,207.54
$168.59
$215.03
$599.48
Procedure Code
45378
45379
45380
45381
45382
45384
45385
45386
45388
45389
45390
45391
45392
45393
45395
45397
45398
45399
45400
45402
4540F
4541F
45499
45500
45505
4550F
4551F
45520
4552F
4553F
45540
45541
4554F
45550
4555F
45560
45562
45563
4556F
4557F
4558F
4559F
4560F
4561F
4562F
4563F
45800
Description
DIAGNOSTIC COLONOSCOPY
COLONOSCOPY W/FB REMOVAL
COLONOSCOPY AND BIOPSY
COLONOSCOPY SUBMUCOUS NJX
COLONOSCOPY W/CONTROL BLEED
COLONOSCOPY W/LESION REMOVAL
COLONOSCOPY W/LESION REMOVAL
COLONOSCOPY W/BALLOON DILAT
COLONOSCOPY W/ABLATION
COLONOSCOPY W/STENT PLCMT
COLONOSCOPY W/RESECTION
COLONOSCOPY W/ENDOSCOPE US
COLONOSCOPY W/ENDOSCOPIC FNB
COLONOSCOPY W/DECOMPRESSION
LAP REMOVAL OF RECTUM
LAP REMOVE RECTUM W/POUCH
COLONOSCOPY W/BAND LIGATION
UNLISTED PROCEDURE COLON
LAPAROSCOPIC PROC
LAP PROCTOPEXY W/SIG RESECT
DISEASE MODIF PHARMACOTHXPY
PT OFFERED TX FOR PSEUDOBULB
LAPAROSCOPE PROC RECTUM
REPAIR OF RECTUM
REPAIR OF RECTUM
NONINVAS RESP SUPPORT TALK
NUTRITIONAL SUPPORT OFFERED
TREATMENT OF RECTAL PROLAPSE
PT REF FOR SPEECH LANG PATH
PT ASST RE END LIFE ISSUES
CORRECT RECTAL PROLAPSE
CORRECT RECTAL PROLAPSE
PT RECVD INHAL ANESTHETIC
REPAIR RECTUM/REMOVE SIGMOID
PT RECVD NO INHAL ANESTHIC
REPAIR OF RECTOCELE
EXPLORATION/REPAIR OF RECTUM
EXPLORATION/REPAIR OF RECTUM
PT W/ 3+ POST-OP NAUSEA&VOM
PT W/O 3+ POST-OPNAUSEA&VOM
PT RECVD 2 RX ANTI-EMET AGT
1 BODYTEMP >=35.5CW/IN 30MIN
ANESTH W/O GEN/NEURAX ANESTH
PT W/ CORONARY ARTERY STENT
PT W/O CORONARY ARTERY STENT
PT RECVD ASPIRIN W/IN 24 HRS
REPAIR RECT/BLADDER FISTULA
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
6
3
3
9
9
6
3
3
9
9
3
9
9
3
3
9
3
9
3
3
3
9
9
9
9
9
9
9
9
3
Maximum Allowable
$388.86
$490.51
$480.99
$462.52
$814.26
$527.98
$504.11
$672.83
$3,368.19
$312.38
$356.67
$277.77
$327.42
$272.83
$2,068.28
$2,251.40
$752.01
$0.00
$1,190.84
$1,587.58
$0.00
$0.00
$0.00
$542.82
$618.24
$0.00
$0.00
$161.57
$0.00
$0.00
$1,105.69
$986.19
$0.00
$1,523.72
$0.00
$714.03
$1,173.67
$1,728.13
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$1,245.18
Procedure Code
45805
45820
45825
45900
45905
45910
45915
45990
45999
46020
46030
46040
46045
46050
46060
46070
46080
46083
46200
46220
46221
46230
46250
46255
46257
46258
46260
46261
46262
46270
46275
46280
46285
46288
46320
46500
46505
46600
46601
46604
46606
46607
46608
46610
46611
46612
46614
Description
REPAIR FISTULA W/COLOSTOMY
REPAIR RECTOURETHRAL FISTULA
REPAIR FISTULA W/COLOSTOMY
REDUCTION OF RECTAL PROLAPSE
DILATION OF ANAL SPHINCTER
DILATION OF RECTAL NARROWING
REMOVE RECTAL OBSTRUCTION
SURG DX EXAM ANORECTAL
RECTUM SURGERY PROCEDURE
PLACEMENT OF SETON
REMOVAL OF RECTAL MARKER
INCISION OF RECTAL ABSCESS
INCISION OF ANAL ABSCESS
INCISION OF ANAL SEPTUM
INCISION OF ANAL SPHINCTER
INCISE EXTERNAL HEMORRHOID
REMOVAL OF ANAL FISSURE
EXCISE ANAL EXT TAG/PAPILLA
LIGATION OF HEMORRHOID(S)
REMOVAL OF ANAL TAGS
REMOVE EXT HEM GROUPS 2+
REMOVE INT/EXT HEM 1 GROUP
REMOVE IN/EX HEM GRP & FISS
REMOVE IN/EX HEM GRP W/FISTU
REMOVE IN/EX HEM GROUPS 2+
REMOVE IN/EX HEM GRPS & FISS
REMOVE IN/EX HEM GRPS W/FIST
REMOVE ANAL FIST SUBQ
REMOVE ANAL FIST INTER
REMOVE ANAL FIST COMPLEX
REMOVE ANAL FIST 2 STAGE
REPAIR ANAL FISTULA
REMOVAL OF HEMORRHOID CLOT
INJECTION INTO HEMORRHOID(S)
CHEMODENERVATION ANAL MUSC
DIAGNOSTIC ANOSCOPY SPX
DIAGNOSTIC ANOSCOPY
ANOSCOPY AND DILATION
ANOSCOPY AND BIOPSY
DIAGNOSTIC ANOSCOPY & BIOPSY
ANOSCOPY REMOVE FOR BODY
ANOSCOPY REMOVE LESION
ANOSCOPY
ANOSCOPY REMOVE LESIONS
ANOSCOPY CONTROL BLEEDING
Pricing Action Code
3
3
3
3
3
3
3
3
5
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$1,534.17
$1,242.19
$1,440.85
$211.93
$177.00
$202.46
$341.58
$112.74
$0.00
$286.12
$143.66
$554.54
$451.97
$207.38
$496.54
$235.22
$255.93
$180.83
$458.90
$212.71
$276.39
$281.49
$479.89
$524.55
$439.17
$486.94
$495.79
$543.74
$574.05
$526.79
$556.81
$488.40
$551.70
$572.65
$188.78
$200.02
$294.69
$91.02
$140.33
$637.46
$232.33
$195.84
$238.87
$232.39
$180.54
$264.92
$131.75
Procedure Code
46615
46700
46705
46706
46707
46710
46712
46715
46716
46730
46735
46740
46742
46744
46746
46748
46750
46751
46753
46754
46760
46761
46762
46900
46910
46916
46917
46922
46924
46930
46940
46942
46945
46946
46947
46999
47000
47001
47010
47015
47100
47120
47122
47125
47130
47133
47135
Description
ANOSCOPY
REPAIR OF ANAL STRICTURE
REPAIR OF ANAL STRICTURE
REPR OF ANAL FISTULA W/GLUE
REPAIR ANORECTAL FIST W/PLUG
REPR PER/VAG POUCH SNGL PROC
REPR PER/VAG POUCH DBL PROC
REP PERF ANOPER FISTU
REP PERF ANOPER/VESTIB FISTU
CONSTRUCTION OF ABSENT ANUS
REPAIR OF IMPERFORATED ANUS
REPAIR OF CLOACAL ANOMALY
REPAIR OF ANAL SPHINCTER
RECONSTRUCTION OF ANUS
REMOVAL OF SUTURE FROM ANUS
IMPLANT ARTIFICIAL SPHINCTER
DESTRUCTION ANAL LESION(S)
CRYOSURGERY ANAL LESION(S)
LASER SURGERY ANAL LESIONS
EXCISION OF ANAL LESION(S)
DESTROY INTERNAL HEMORRHOIDS
TREATMENT OF ANAL FISSURE
TREATMENT OF ANAL FISSURE
REMOVE BY LIGAT INT HEM GRP
REMOVE BY LIGAT INT HEM GRPS
HEMORRHOIDOPEXY BY STAPLING
ANUS SURGERY PROCEDURE
NEEDLE BIOPSY OF LIVER
NEEDLE BIOPSY LIVER ADD-ON
OPEN DRAINAGE LIVER LESION
INJECT/ASPIRATE LIVER CYST
WEDGE BIOPSY OF LIVER
PARTIAL REMOVAL OF LIVER
EXTENSIVE REMOVAL OF LIVER
REMOVAL OF DONOR LIVER
TRANSPLANTATION OF LIVER
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
5
3
3
3
3
3
3
3
3
3
9
3
Maximum Allowable
$148.29
$680.05
$520.75
$172.41
$496.67
$1,096.52
$2,229.87
$565.96
$1,152.22
$1,894.66
$2,195.78
$2,248.28
$2,539.14
$3,696.66
$3,801.03
$4,127.96
$784.41
$619.87
$638.46
$301.01
$1,135.73
$954.60
$964.08
$249.74
$264.33
$236.67
$464.36
$275.24
$190.83
$211.45
$235.51
$222.56
$318.94
$323.45
$398.88
$0.00
$371.90
$108.88
$1,260.04
$1,196.22
$883.51
$2,444.02
$3,607.57
$3,223.85
$3,464.38
$0.00
$5,628.48
Procedure Code
47140
47141
47142
47143
47144
47145
47146
47147
47300
47350
47360
47361
47362
47370
47371
47379
47380
47381
47382
47383
47399
47400
47420
47425
47460
47480
47490
47531
47532
47533
47534
47535
47536
47537
47538
47539
47540
47541
47542
47543
47544
47550
47552
47553
47554
47555
47556
Description
PARTIAL REMOVAL DONOR LIVER
PREP DONOR LIVER WHOLE
PREP DONOR LIVER 3-SEGMENT
PREP DONOR LIVER LOBE SPLIT
PREP DONOR LIVER/VENOUS
PREP DONOR LIVER/ARTERIAL
SURGERY FOR LIVER LESION
REPAIR LIVER WOUND
REPAIR LIVER WOUND
REPAIR LIVER WOUND
REPAIR LIVER WOUND
LAPARO ABLATE LIVER TUMOR RF
LAPARO ABLATE LIVER CRYOSURG
LAPAROSCOPE PROCEDURE LIVER
OPEN ABLATE LIVER TUMOR RF
OPEN ABLATE LIVER TUMOR CRYO
PERCUT ABLATE LIVER RF
PERQ ABLTJ LVR CRYOABLATION
LIVER SURGERY PROCEDURE
INCISION OF LIVER DUCT
INCISION OF BILE DUCT
INCISION OF BILE DUCT
INCISE BILE DUCT SPHINCTER
INCISION OF GALLBLADDER
INCISION OF GALLBLADDER
INJECTION FOR CHOLANGIOGRAM
INJECTION FOR CHOLANGIOGRAM
PLMT BILIARY DRAINAGE CATH
PLMT BILIARY DRAINAGE CATH
CONVERSION EXT BIL DRG CATH
EXCHANGE BILIARY DRG CATH
REMOVAL BILIARY DRG CATH
PERQ PLMT BILE DUCT STENT
PLMT ACCESS BIL TREE SM BWL
DILATE BILIARY DUCT/AMPULLA
ENDOLUMINAL BX BILIARY TREE
REMOVAL DUCT GLBLDR CALCULI
BILE DUCT ENDOSCOPY ADD-ON
BILIARY ENDO PERQ DX W/SPECI
BILIARY ENDOSCOPY THRU SKIN
Pricing Action Code
9
9
9
9
9
9
9
9
3
3
3
3
3
3
3
5
3
3
3
3
5
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$1,186.38
$1,435.39
$1,948.37
$3,166.37
$1,519.21
$1,307.08
$1,172.11
$0.00
$1,511.74
$1,386.16
$5,139.96
$7,744.88
$0.00
$2,253.97
$1,406.00
$1,418.64
$1,312.51
$915.24
$344.38
$381.38
$838.89
$1,370.01
$1,688.01
$1,132.56
$835.49
$413.34
$4,614.30
$5,042.80
$5,243.19
$1,209.28
$529.74
$1,363.67
$831.25
$173.78
$323.16
$318.97
$498.81
$381.70
$434.79
Procedure Code
47562
47563
47564
47570
47579
47600
47605
47610
47612
47620
47700
47701
47711
47712
47715
47720
47721
47740
47741
47760
47765
47780
47785
47800
47801
47802
47900
47999
48000
48001
48020
48100
48102
48105
48120
48140
48145
48146
48148
48150
48152
48153
48154
48155
48160
48400
48500
Description
LAPAROSCOPIC CHOLECYSTECTOMY
LAPARO CHOLECYSTECTOMY/GRAPH
LAPARO CHOLECYSTECTOMY/EXPLR
LAPARO CHOLECYSTOENTEROSTOMY
LAPAROSCOPE PROC BILIARY
REMOVAL OF GALLBLADDER
EXPLORATION OF BILE DUCTS
BILE DUCT REVISION
EXCISION OF BILE DUCT TUMOR
EXCISION OF BILE DUCT TUMOR
EXCISION OF BILE DUCT CYST
FUSE GALLBLADDER & BOWEL
FUSE UPPER GI STRUCTURES
FUSE BILE DUCTS AND BOWEL
FUSE LIVER DUCTS & BOWEL
RECONSTRUCTION OF BILE DUCTS
PLACEMENT BILE DUCT SUPPORT
FUSE LIVER DUCT & INTESTINE
SUTURE BILE DUCT INJURY
BILE TRACT SURGERY PROCEDURE
DRAINAGE OF ABDOMEN
PLACEMENT OF DRAIN PANCREAS
REMOVAL OF PANCREATIC STONE
BIOPSY OF PANCREAS OPEN
NEEDLE BIOPSY PANCREAS
RESECT/DEBRIDE PANCREAS
REMOVAL OF PANCREAS LESION
PARTIAL REMOVAL OF PANCREAS
PANCREATECTOMY
REMOVAL OF PANCREATIC DUCT
PANCREATECTOMY
PANCREATECTOMY
PANCREATECTOMY
REMOVAL OF PANCREAS
PANCREAS REMOVAL/TRANSPLANT
INJECTION INTRAOP ADD-ON
SURGERY OF PANCREATIC CYST
Pricing Action Code
3
3
3
3
5
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
5
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
5
9
3
Maximum Allowable
$687.51
$746.65
$1,165.11
$802.16
$0.00
$1,117.39
$1,176.94
$1,314.69
$1,330.92
$1,442.84
$1,084.01
$1,774.02
$1,630.25
$2,081.71
$1,396.26
$1,204.20
$1,421.88
$1,362.48
$1,537.54
$2,368.28
$3,180.57
$2,591.92
$3,404.53
$1,649.43
$1,028.44
$1,571.17
$1,435.26
$0.00
$1,962.39
$2,398.49
$1,225.55
$924.90
$547.14
$2,989.46
$1,161.29
$1,640.00
$1,705.72
$1,967.45
$1,305.02
$3,267.15
$3,009.45
$3,246.28
$3,046.50
$1,908.58
$0.00
$0.00
$1,174.76
Procedure Code
48510
48520
48540
48545
48547
48548
48550
48551
48552
48554
48556
48999
49000
49002
49010
49020
49040
49060
49062
49082
49083
49084
49180
49185
49203
49204
49205
49215
49220
49250
49255
49320
49321
49322
49323
49324
49325
49326
49327
49329
49400
49402
49405
49406
49407
49411
49412
Description
DRAIN PANCREATIC PSEUDOCYST
FUSE PANCREAS CYST AND BOWEL
FUSE PANCREAS CYST AND BOWEL
PANCREATORRHAPHY
DUODENAL EXCLUSION
FUSE PANCREAS AND BOWEL
DONOR PANCREATECTOMY
PREP DONOR PANCREAS
PREP DONOR PANCREAS/VENOUS
TRANSPL ALLOGRAFT PANCREAS
REMOVAL ALLOGRAFT PANCREAS
PANCREAS SURGERY PROCEDURE
EXPLORATION OF ABDOMEN
REOPENING OF ABDOMEN
EXPLORATION BEHIND ABDOMEN
DRAINAGE ABDOM ABSCESS OPEN
DRAIN OPEN ABDOM ABSCESS
DRAIN OPEN RETROPERI ABSCESS
DRAIN TO PERITONEAL CAVITY
ABD PARACENTESIS
ABD PARACENTESIS W/IMAGING
PERITONEAL LAVAGE
BIOPSY ABDOMINAL MASS
SCLEROTX FLUID COLLECTION
EXC ABD TUM 5 CM OR LESS
EXC ABD TUM OVER 5 CM
EXC ABD TUM OVER 10 CM
EXCISE SACRAL SPINE TUMOR
MULTIPLE SURGERY ABDOMEN
EXCISION OF UMBILICUS
REMOVAL OF OMENTUM
DIAG LAPARO SEPARATE PROC
LAPAROSCOPY BIOPSY
LAPAROSCOPY ASPIRATION
LAPARO DRAIN LYMPHOCELE
LAP INSERT TUNNEL IP CATH
LAP REVISION PERM IP CATH
LAP W/OMENTOPEXY ADD-ON
LAP INS DEVICE FOR RT
LAPARO PROC ABDM/PER/OMENT
AIR INJECTION INTO ABDOMEN
REMOVE FOREIGN BODY ADBOMEN
IMAGE CATH FLUID COLXN VISC
IMAGE CATH FLUID PERI/RETRO
IMAGE CATH FLUID TRNS/VGNL
INS MARK ABD/PEL FOR RT PERQ
INS DEVICE FOR RT GUIDE OPEN
Pricing Action Code
3
3
3
3
3
3
9
9
9
3
3
5
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
5
3
3
3
3
3
3
3
Maximum Allowable
$1,140.22
$1,145.85
$1,361.18
$1,396.86
$1,875.40
$1,744.89
$0.00
$0.00
$0.00
$2,676.56
$1,328.40
$0.00
$806.30
$1,095.80
$977.11
$1,666.57
$1,046.02
$1,149.59
$766.69
$197.12
$300.54
$113.10
$167.45
$1,020.79
$1,251.75
$1,602.06
$1,840.61
$2,321.70
$925.32
$615.75
$826.76
$339.51
$360.52
$383.65
$663.37
$407.87
$435.27
$197.88
$137.40
$0.00
$139.60
$896.21
$219.75
$897.41
$749.37
$561.71
$86.92
Procedure Code
49418
49419
49421
49422
49423
49424
49425
49426
49427
49428
49429
49435
49436
49440
49441
49442
49446
49450
49451
49452
49460
49465
49491
49492
49495
49496
49500
49501
49505
49507
49520
49521
49525
49540
49550
49553
49555
49557
49560
49561
49565
49566
49568
49570
49572
49580
49582
Description
INSERT TUN IP CATH PERC
INSERT TUN IP CATH W/PORT
INS TUN IP CATH FOR DIAL OPN
REMOVE TUNNELED IP CATH
EXCHANGE DRAINAGE CATHETER
ASSESS CYST CONTRAST INJECT
INSERT ABDOMEN-VENOUS DRAIN
REVISE ABDOMEN-VENOUS SHUNT
INJECTION ABDOMINAL SHUNT
LIGATION OF SHUNT
REMOVAL OF SHUNT
INSERT SUBQ EXTEN TO IP CATH
EMBEDDED IP CATH EXIT-SITE
PLACE GASTROSTOMY TUBE PERC
PLACE DUOD/JEJ TUBE PERC
PLACE CECOSTOMY TUBE PERC
CHANGE G-TUBE TO G-J PERC
REPLACE G/C TUBE PERC
REPLACE DUOD/JEJ TUBE PERC
REPLACE G-J TUBE PERC
FIX G/COLON TUBE W/DEVICE
FLUORO EXAM OF G/COLON TUBE
RPR HERN PREEMIE REDUC
RPR ING HERN PREMIE BLOCKED
RPR ING HERNIA BABY REDUC
RPR ING HERNIA BABY BLOCKED
RPR ING HERNIA INIT REDUCE
RPR ING HERNIA INIT BLOCKED
PRP I/HERN INIT REDUC >5 YR
PRP I/HERN INIT BLOCK >5 YR
REREPAIR ING HERNIA REDUCE
REREPAIR ING HERNIA BLOCKED
REPAIR ING HERNIA SLIDING
REPAIR LUMBAR HERNIA
RPR REM HERNIA INIT REDUCE
RPR FEM HERNIA INIT BLOCKED
REREPAIR FEM HERNIA REDUCE
REREPAIR FEM HERNIA BLOCKED
RPR VENTRAL HERN INIT REDUC
RPR VENTRAL HERN INIT BLOCK
REREPAIR VENTRL HERN REDUCE
REREPAIR VENTRL HERN BLOCK
HERNIA REPAIR W/MESH
RPR EPIGASTRIC HERN REDUCE
RPR EPIGASTRIC HERN BLOCKED
RPR UMBIL HERN REDUC < 5 YR
RPR UMBIL HERN BLOCK < 5 YR
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$1,472.03
$461.21
$241.86
$398.44
$74.92
$39.80
$763.07
$639.00
$48.14
$451.34
$479.84
$125.42
$195.20
$1,066.20
$1,200.81
$992.76
$1,026.78
$69.56
$94.67
$145.52
$753.94
$167.29
$766.55
$1,003.02
$397.50
$643.41
$373.92
$608.11
$543.29
$611.84
$660.50
$748.09
$598.83
$701.48
$601.36
$659.80
$624.81
$756.81
$769.97
$972.34
$802.45
$980.94
$279.70
$434.79
$539.37
$347.28
$505.26
Procedure Code
49585
49587
49590
49600
49605
49606
49610
49611
49650
49651
49652
49653
49654
49655
49656
49657
49659
49900
49904
49905
49906
49999
50010
50020
50040
50045
5005F
50060
50065
50070
50075
50080
50081
50100
5010F
50120
50125
50130
50135
5015F
50200
50205
5020F
50220
50225
50230
50234
Description
RPR UMBIL HERN REDUC > 5 YR
RPR UMBIL HERN BLOCK > 5 YR
REPAIR SPIGELIAN HERNIA
REPAIR UMBILICAL LESION
LAP ING HERNIA REPAIR INIT
LAP ING HERNIA REPAIR RECUR
LAP VENT/ABD HERNIA REPAIR
LAP VENT/ABD HERN PROC COMP
LAP INC HERNIA REPAIR
LAP INC HERN REPAIR COMP
LAP INC HERNIA REPAIR RECUR
LAP INC HERN RECUR COMP
LAPARO PROC HERNIA REPAIR
REPAIR OF ABDOMINAL WALL
OMENTAL FLAP EXTRA-ABDOM
OMENTAL FLAP INTRA-ABDOM
FREE OMENTAL FLAP MICROVASC
ABDOMEN SURGERY PROCEDURE
EXPLORATION OF KIDNEY
RENAL ABSCESS OPEN DRAIN
DRAINAGE OF KIDNEY
PT COUNSLD ON EXAM FOR MOLES
REMOVAL OF KIDNEY STONE
INCISION OF KIDNEY
INCISION OF KIDNEY
REVISE KIDNEY BLOOD VESSELS
MACUL RESULT PHY/QHP MNG DM
EXPLORE AND DRAIN KIDNEY
DOC FX & TEST/TXMNT FOR OP
RENAL BIOPSY PERQ
RENAL BIOPSY OPEN
TXMNTS 2 PHYS/QHP BY 1 MON
REMOVE KIDNEY OPEN
REMOVAL KIDNEY OPEN COMPLEX
REMOVAL KIDNEY OPEN RADICAL
REMOVAL OF KIDNEY & URETER
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
5
3
3
3
5
5
3
3
3
3
9
3
3
3
3
3
3
3
9
3
3
3
3
9
3
3
9
3
3
3
3
Maximum Allowable
$464.71
$496.46
$597.73
$732.75
$5,190.33
$1,169.10
$720.55
$634.38
$446.64
$580.08
$777.27
$969.51
$882.53
$1,077.61
$960.46
$1,380.11
$0.00
$851.60
$1,505.06
$369.21
$0.00
$0.00
$766.73
$1,052.50
$955.21
$998.88
$0.00
$1,180.35
$1,248.00
$1,223.61
$1,505.01
$897.39
$1,317.70
$1,095.68
$0.00
$979.59
$1,068.48
$1,066.10
$1,177.08
$0.00
$629.68
$782.61
$0.00
$1,082.24
$1,244.91
$1,325.15
$1,342.97
Procedure Code
50236
50240
50250
50280
50290
50300
50320
50323
50325
50327
50328
50329
50340
50360
50365
50370
50380
50382
50384
50385
50386
50387
50389
50390
50391
50395
50396
50400
50405
50430
50431
50432
50433
50434
50435
50500
5050F
50520
50525
50526
50540
50541
50542
50543
50544
50545
50546
Description
REMOVAL OF KIDNEY & URETER
PARTIAL REMOVAL OF KIDNEY
CRYOABLATE RENAL MASS OPEN
REMOVAL OF KIDNEY LESION
REMOVAL OF KIDNEY LESION
REMOVE CADAVER DONOR KIDNEY
REMOVE KIDNEY LIVING DONOR
PREP CADAVER RENAL ALLOGRAFT
PREP DONOR RENAL GRAFT
PREP RENAL GRAFT/VENOUS
PREP RENAL GRAFT/ARTERIAL
PREP RENAL GRAFT/URETERAL
REMOVAL OF KIDNEY
TRANSPLANTATION OF KIDNEY
TRANSPLANTATION OF KIDNEY
REMOVE TRANSPLANTED KIDNEY
REIMPLANTATION OF KIDNEY
CHANGE URETER STENT PERCUT
REMOVE URETER STENT PERCUT
CHANGE STENT VIA TRANSURETH
REMOVE STENT VIA TRANSURETH
CHANGE NEPHROURETERAL CATH
REMOVE RENAL TUBE W/FLUORO
DRAINAGE OF KIDNEY LESION
INSTLL RX AGNT INTO RNAL TUB
CREATE PASSAGE TO KIDNEY
MEASURE KIDNEY PRESSURE
REVISION OF KIDNEY/URETER
REVISION OF KIDNEY/URETER
NJX PX NFROSGRM &/URTRGRM
NJX PX NFROSGRM &/URTRGRM
PLMT NEPHROSTOMY CATHETER
PLMT NEPHROURETERAL CATHETER
CONVERT NEPHROSTOMY CATHETER
EXCHANGE NEPHROSTOMY CATH
REPAIR OF KIDNEY WOUND
PLAN 2 MAIN DR BY 1 MONTH
CLOSE KIDNEY-SKIN FISTULA
CLOSE NEPHROVISCERAL FISTULA
CLOSE NEPHROVISCERAL FISTULA
REVISION OF HORSESHOE KIDNEY
LAPARO ABLATE RENAL CYST
LAPARO ABLATE RENAL MASS
LAPARO PARTIAL NEPHRECTOMY
LAPAROSCOPY PYELOPLASTY
LAPARO RADICAL NEPHRECTOMY
LAPAROSCOPIC NEPHRECTOMY
Pricing Action Code
3
3
3
3
3
9
3
9
9
9
9
9
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
9
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$1,516.87
$1,367.09
$1,255.99
$986.12
$926.86
$0.00
$1,514.10
$0.00
$0.00
$0.00
$0.00
$0.00
$978.69
$2,531.98
$2,958.10
$1,253.89
$2,080.00
$1,217.54
$970.55
$1,172.18
$764.08
$558.63
$304.25
$100.00
$125.03
$185.13
$122.01
$1,196.17
$1,443.02
$533.44
$165.61
$864.82
$1,164.41
$921.81
$483.80
$1,332.13
$0.00
$1,174.75
$1,486.49
$1,538.83
$1,188.91
$949.41
$1,204.69
$1,535.26
$1,284.75
$1,384.04
$1,243.18
Procedure Code
50547
50548
50549
50551
50553
50555
50557
50561
50562
50570
50572
50574
50575
50576
50580
50590
50592
50593
50600
50605
50606
5060F
50610
50620
5062F
50630
50650
50660
50684
50686
50688
50690
50693
50694
50695
50700
50705
50706
50715
50722
50725
50727
50728
50740
50750
50760
50770
Description
LAPARO REMOVAL DONOR KIDNEY
LAPARO REMOVE W/URETER
LAPAROSCOPE PROC RENAL
KIDNEY ENDOSCOPY
KIDNEY ENDOSCOPY
KIDNEY ENDOSCOPY & BIOPSY
KIDNEY ENDOSCOPY & TREATMENT
RENAL SCOPE W/TUMOR RESECT
KIDNEY ENDOSCOPY
KIDNEY ENDOSCOPY
KIDNEY ENDOSCOPY & BIOPSY
KIDNEY ENDOSCOPY
FRAGMENTING OF KIDNEY STONE
PERC RF ABLATE RENAL TUMOR
PERC CRYO ABLATE RENAL TUM
EXPLORATION OF URETER
INSERT URETERAL SUPPORT
ENDOLUMINAL BX URTR RNL PLVS
FNDNGS MAMMO 2PT W/IN 3 DAYS
REMOVAL OF URETER STONE
MAMMO RESULT COM TO PT 5 DAY
REMOVAL OF URETER
REMOVAL OF URETER
INJECTION FOR URETER X-RAY
MEASURE URETER PRESSURE
CHANGE OF URETER TUBE/STENT
INJECTION FOR URETER X-RAY
PLMT URETERAL STENT PRQ
REVISION OF URETER
URETERAL EMBOLIZATION/OCCL
BALLOON DILATE URTRL STRIX
RELEASE OF URETER
RELEASE OF URETER
RELEASE/REVISE URETER
REVISE URETER
REVISE URETER
FUSION OF URETER & KIDNEY
FUSION OF URETER & KIDNEY
FUSION OF URETERS
SPLICING OF URETERS
Pricing Action Code
3
3
5
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
9
3
3
9
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$1,680.27
$1,391.86
$0.00
$369.90
$392.84
$422.33
$431.72
$489.56
$600.59
$508.56
$550.19
$584.98
$738.91
$584.70
$629.90
$738.69
$2,611.65
$4,753.89
$975.35
$1,013.00
$541.17
$0.00
$1,015.75
$936.31
$0.00
$919.68
$1,070.24
$1,187.38
$52.13
$148.09
$82.30
$101.15
$1,084.22
$1,193.63
$1,455.28
$961.24
$1,748.79
$783.29
$1,267.89
$1,057.33
$1,168.88
$524.15
$723.88
$1,281.49
$1,190.59
$1,168.90
$1,189.02
Procedure Code
50780
50782
50783
50785
50800
50810
50815
50820
50825
50830
50840
50845
50860
50900
50920
50930
50940
50945
50947
50948
50949
50951
50953
50955
50957
50961
50970
50972
50974
50976
50980
5100F
51020
51030
51040
51045
51050
51060
51065
51080
51100
51101
51102
51500
51520
51525
51530
Description
REIMPLANT URETER IN BLADDER
IMPLANT URETER IN BOWEL
FUSION OF URETER & BOWEL
URINE SHUNT TO INTESTINE
CONSTRUCT BOWEL BLADDER
CONSTRUCT BOWEL BLADDER
REVISE URINE FLOW
REPLACE URETER BY BOWEL
APPENDICO-VESICOSTOMY
TRANSPLANT URETER TO SKIN
REPAIR OF URETER
CLOSURE URETER/SKIN FISTULA
CLOSURE URETER/BOWEL FISTULA
RELEASE OF URETER
LAPAROSCOPY URETEROLITHOTOMY
LAPARO NEW URETER/BLADDER
LAPARO NEW URETER/BLADDER
LAPAROSCOPE PROC URETER
ENDOSCOPY OF URETER
ENDOSCOPY OF URETER
URETER ENDOSCOPY & BIOPSY
URETER ENDOSCOPY & TREATMENT
URETER ENDOSCOPY
URETER ENDOSCOPY & CATHETER
URETER ENDOSCOPY & BIOPSY
RSK FX REF W/N 24 HRS XRAY
INCISE & TREAT BLADDER
INCISE & TREAT BLADDER
INCISE & DRAIN BLADDER
INCISE BLADDER/DRAIN URETER
REMOVAL OF BLADDER STONE
REMOVE URETER CALCULUS
DRAINAGE OF BLADDER ABSCESS
DRAIN BLADDER BY NEEDLE
DRAIN BLADDER BY TROCAR/CATH
DRAIN BL W/CATH INSERTION
REMOVAL OF BLADDER CYST
REMOVAL OF BLADDER LESION
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
5
3
3
3
3
3
3
3
3
3
3
9
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$1,145.96
$1,093.20
$1,169.79
$1,253.42
$954.48
$1,305.76
$1,264.44
$1,358.73
$1,711.87
$1,871.14
$1,271.99
$1,290.71
$974.93
$886.79
$910.55
$1,225.55
$913.78
$1,003.81
$1,434.84
$1,318.71
$0.00
$386.08
$407.61
$437.08
$441.40
$397.57
$384.77
$374.57
$489.55
$481.60
$366.06
$0.00
$484.09
$491.88
$298.03
$501.03
$486.83
$602.82
$596.70
$423.42
$62.63
$127.32
$232.22
$659.29
$618.16
$886.01
$816.40
Procedure Code
51535
51550
51555
51565
51570
51575
51580
51585
51590
51595
51596
51597
51600
51605
51610
51700
51701
51702
51703
51705
51710
51715
51720
51725
51726
51727
51728
51729
51736
51741
51784
51785
51792
51797
51798
51800
51820
51840
51841
51845
51860
51865
51880
51900
51920
51925
51940
Description
REPAIR OF URETER LESION
PARTIAL REMOVAL OF BLADDER
PARTIAL REMOVAL OF BLADDER
REVISE BLADDER & URETER(S)
REMOVAL OF BLADDER
REMOVAL OF BLADDER & NODES
REMOVE BLADDER/REVISE TRACT
REMOVAL OF BLADDER & NODES
REMOVE BLADDER/CREATE POUCH
REMOVAL OF PELVIC STRUCTURES
INJECTION FOR BLADDER X-RAY
PREPARATION FOR BLADDER XRAY
INJECTION FOR BLADDER X-RAY
IRRIGATION OF BLADDER
INSERT BLADDER CATHETER
INSERT TEMP BLADDER CATH
INSERT BLADDER CATH COMPLEX
CHANGE OF BLADDER TUBE
CHANGE OF BLADDER TUBE
ENDOSCOPIC INJECTION/IMPLANT
TREATMENT OF BLADDER LESION
SIMPLE CYSTOMETROGRAM
COMPLEX CYSTOMETROGRAM
CYSTOMETROGRAM W/UP
CYSTOMETROGRAM W/VP
CYSTOMETROGRAM W/VP&UP
URINE FLOW MEASUREMENT
ELECTRO-UROFLOWMETRY FIRST
ANAL/URINARY MUSCLE STUDY
ANAL/URINARY MUSCLE STUDY
URINARY REFLEX STUDY
INTRAABDOMINAL PRESSURE TEST
US URINE CAPACITY MEASURE
REVISION OF BLADDER/URETHRA
REVISION OF URINARY TRACT
ATTACH BLADDER/URETHRA
ATTACH BLADDER/URETHRA
REPAIR BLADDER NECK
REPAIR OF BLADDER WOUND
REPAIR OF BLADDER WOUND
REPAIR OF BLADDER OPENING
REPAIR BLADDER/VAGINA LESION
CLOSE BLADDER-UTERUS FISTULA
HYSTERECTOMY/BLADDER REPAIR
CORRECTION OF BLADDER DEFECT
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$804.47
$992.00
$1,309.64
$1,343.81
$1,526.83
$1,883.05
$1,956.94
$2,178.39
$1,998.41
$2,259.79
$2,428.58
$2,373.30
$45.53
$39.52
$109.17
$85.02
$55.89
$72.18
$132.53
$92.98
$131.51
$297.29
$111.15
$190.75
$268.12
$318.24
$320.39
$346.63
$15.85
$16.21
$195.81
$262.10
$215.60
$113.98
$19.58
$1,075.94
$1,152.50
$678.36
$803.71
$604.28
$765.56
$923.19
$482.40
$861.19
$901.36
$1,142.28
$1,708.25
Procedure Code
51960
51980
51990
51992
51999
52000
52001
52005
52007
5200F
52010
52204
52214
52224
52234
52235
52240
52250
52260
52265
52270
52275
52276
52277
52281
52282
52283
52285
52287
52290
52300
52301
52305
52310
52315
52317
52318
52320
52325
52327
52330
52332
52334
52341
52342
52343
52344
Description
REVISION OF BLADDER & BOWEL
CONSTRUCT BLADDER OPENING
LAPARO URETHRAL SUSPENSION
LAPARO SLING OPERATION
LAPAROSCOPE PROC BLA
CYSTOSCOPY
CYSTOSCOPY REMOVAL OF CLOTS
CYSTOSCOPY & URETER CATHETER
CYSTOSCOPY AND BIOPSY
EVAL APPROS SURG THXPY EPI
CYSTOSCOPY & DUCT CATHETER
CYSTOSCOPY W/BIOPSY(S)
CYSTOSCOPY AND TREATMENT
CYSTOSCOPY AND RADIOTRACER
CYSTOSCOPY & REVISE URETHRA
CYSTOSCOPY & REVISE URETHRA
CYSTOSCOPY IMPLANT STENT
CYSTOSCOPY CHEMODENERVATION
REMOVE BLADDER STONE
REMOVE BLADDER STONE
CYSTOSCOPY STONE REMOVAL
CYSTOSCOPY INJECT MATERIAL
CREATE PASSAGE TO KIDNEY
CYSTO W/URETER STRICTURE TX
CYSTO W/UP STRICTURE TX
CYSTO W/RENAL STRICTURE TX
CYSTO/URETERO STRICTURE TX
Pricing Action Code
3
3
3
3
6
3
3
3
3
9
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$1,438.42
$735.56
$773.98
$867.92
$0.00
$130.02
$380.48
$271.14
$452.19
$0.00
$379.85
$146.50
$672.42
$703.65
$254.53
$298.30
$405.60
$248.08
$217.57
$373.33
$362.60
$489.05
$273.54
$334.55
$277.83
$347.86
$282.81
$285.42
$317.80
$252.36
$290.03
$300.08
$288.61
$248.49
$421.85
$359.27
$490.28
$254.84
$332.41
$270.91
$272.78
$160.88
$264.92
$293.64
$319.10
$356.08
$382.31
Procedure Code
52345
52346
52351
52352
52353
52354
52355
52356
52400
52402
52441
52442
52450
52500
5250F
52601
52630
52640
52647
52648
52649
52700
53000
53010
53020
53025
53040
53060
53080
53085
53200
53210
53215
53220
53230
53235
53240
53250
53260
53265
53270
53275
53400
53405
53410
53415
53420
Description
CYSTO/URETERO W/UP STRICTURE
CYSTOURETERO W/RENAL STRICT
CYSTOURETERO & OR PYELOSCOPE
CYSTOURETERO W/STONE REMOVE
CYSTOURETERO W/LITHOTRIPSY
CYSTOURETERO W/BIOPSY
CYSTOURETERO W/EXCISE TUMOR
CYSTO/URETERO W/LITHOTRIPSY
CYSTOURETERO W/CONGEN REPR
CYSTOURETHRO CUT EJACUL DUCT
CYSTOURETHRO W/IMPLANT
CYSTOURETHRO W/ADDL IMPLANT
INCISION OF PROSTATE
REVISION OF BLADDER NECK
ASTHMA DISCHARGE PLAN PRESNT
PROSTATECTOMY (TURP)
REMOVE PROSTATE REGROWTH
RELIEVE BLADDER CONTRACTURE
LASER SURGERY OF PROSTATE
LASER SURGERY OF PROSTATE
PROSTATE LASER ENUCLEATION
DRAINAGE OF PROSTATE ABSCESS
INCISION OF URETHRA
INCISION OF URETHRA
INCISION OF URETHRA
INCISION OF URETHRA
DRAINAGE OF URETHRA ABSCESS
DRAINAGE OF URETHRA ABSCESS
DRAINAGE OF URINARY LEAKAGE
DRAINAGE OF URINARY LEAKAGE
BIOPSY OF URETHRA
REMOVAL OF URETHRA
REMOVAL OF URETHRA
TREATMENT OF URETHRA LESION
REMOVAL OF URETHRA LESION
REMOVAL OF URETHRA LESION
SURGERY FOR URETHRA POUCH
REMOVAL OF URETHRA GLAND
REMOVAL OF URETHRA GLAND
REPAIR OF URETHRA DEFECT
REVISE URETHRA STAGE 1
REVISE URETHRA STAGE 2
RECONSTRUCTION OF URETHRA
RECONSTRUCT URETHRA STAGE 1
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
9
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$408.48
$461.95
$312.99
$366.12
$405.60
$431.43
$483.84
$429.98
$494.12
$275.94
$1,268.97
$971.06
$484.75
$503.41
$0.00
$872.63
$412.55
$324.65
$668.12
$1,868.48
$848.68
$454.83
$152.41
$304.55
$100.19
$74.45
$404.57
$188.46
$433.38
$686.68
$160.65
$794.42
$959.19
$468.21
$625.08
$652.68
$441.04
$427.22
$206.78
$223.34
$213.64
$270.47
$826.87
$900.66
$1,009.06
$1,166.97
$881.06
Procedure Code
53425
53430
53431
53440
53442
53444
53445
53446
53447
53448
53449
53450
53460
53500
53502
53505
53510
53515
53520
53600
53601
53605
53620
53621
53660
53661
53665
53850
53852
53855
53860
53899
54000
54001
54015
54050
54055
54056
54057
54060
54065
54100
54105
54110
54111
54112
54115
Description
RECONSTRUCT URETHRA STAGE 2
RECONSTRUCT URETHRA/BLADDER
MALE SLING PROCEDURE
REMOVE/REVISE MALE SLING
INSERT TANDEM CUFF
INSERT URO/VES NCK SPHINCTER
REMOVE URO SPHINCTER
REMOVE/REPLACE UR SPHINCTER
REMOV/REPLC UR SPHINCTR COMP
REPAIR URO SPHINCTER
REVISION OF URETHRA
REVISION OF URETHRA
URETHRLYS TRANSVAG W/ SCOPE
REPAIR OF URETHRA INJURY
REPAIR OF URETHRA DEFECT
DILATE URETHRA STRICTURE
DILATION OF URETHRA
DILATION OF URETHRA
DILATION OF URETHRA
PROSTATIC MICROWAVE THERMOTX
PROSTATIC RF THERMOTX
INSERT PROST URETHRAL STENT
TRANSURETHRAL RF TREATMENT
UROLOGY SURGERY PROCEDURE
SLITTING OF PREPUCE
SLITTING OF PREPUCE
DRAIN PENIS LESION
DESTRUCTION PENIS LESION(S)
CRYOSURGERY PENIS LESION(S)
LASER SURG PENIS LESION(S)
EXCISION OF PENIS LESION(S)
BIOPSY OF PENIS
BIOPSY OF PENIS
TREATMENT OF PENIS LESION
TREAT PENIS LESION GRAFT
TREAT PENIS LESION GRAFT
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
5
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$966.25
$994.80
$1,195.87
$776.46
$807.19
$817.69
$776.29
$662.45
$833.61
$1,328.11
$630.43
$421.52
$472.09
$772.40
$501.90
$503.78
$651.63
$820.60
$574.49
$84.86
$82.81
$66.75
$118.71
$111.96
$72.07
$70.62
$39.84
$2,113.07
$1,947.28
$790.93
$1,577.93
$0.00
$151.30
$188.29
$319.77
$135.20
$121.81
$145.72
$138.78
$183.36
$224.84
$204.46
$270.59
$653.26
$826.32
$969.27
$465.61
Procedure Code
54120
54125
54130
54135
54150
54160
54161
54162
54163
54164
54200
54205
54220
54230
54300
54304
54308
54312
54316
54318
54322
54324
54326
54328
54332
54336
54340
54344
54348
54352
54360
54380
54385
54390
54406
54408
54410
54411
54415
54416
54417
54420
54430
54435
54437
54438
54440
Description
PARTIAL REMOVAL OF PENIS
REMOVAL OF PENIS
REMOVE PENIS & NODES
REMOVE PENIS & NODES
CIRCUMCISION W/REGIONL BLOCK
CIRCUMCISION NEONATE
CIRCUM 28 DAYS OR OLDER
LYSIS PENIL CIRCUMIC LESION
REPAIR OF CIRCUMCISION
FRENULOTOMY OF PENIS
PREPARE PENIS STUDY
REVISION OF PENIS
REVISION OF PENIS
REVISE PENIS/URETHRA
SECONDARY URETHRAL SURGERY
RECONSTRUCT URETHRA/PENIS
PENIS PLASTIC SURGERY
REPAIR PENIS
REPAIR PENIS
REPAIR PENIS AND BLADDER
REMOVE MUTI-COMP PENIS PROS
REPAIR MULTI-COMP PENIS PROS
REMOVE/REPLACE PENIS PROSTH
REMOV/REPLC PENIS PROS COMP
REMOVE SELF-CONTD PENIS PROS
REMV/REPL PENIS CONTAIN PROS
REMV/REPLC PENIS PROS COMPL
REVISION OF PENIS
REVISION OF PENIS
REVISION OF PENIS
REPAIR CORPOREAL TEAR
REPLANTATION OF PENIS
REPAIR OF PENIS
Pricing Action Code
3
3
3
3
3
3
3
3
3
9
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
9
9
9
9
9
9
9
3
3
3
3
3
5
Maximum Allowable
$651.96
$838.29
$1,228.91
$1,547.29
$100.87
$150.54
$203.01
$263.10
$225.09
$0.00
$109.52
$549.37
$208.90
$98.93
$661.26
$773.98
$738.08
$890.30
$1,085.40
$773.50
$795.52
$1,029.69
$975.68
$969.23
$1,108.35
$1,293.88
$588.12
$1,079.54
$1,046.78
$1,462.74
$743.44
$824.25
$1,009.65
$1,349.16
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$727.34
$660.62
$428.71
$704.13
$1,420.46
$0.00
Procedure Code
54450
54500
54505
54512
54520
54522
54530
54535
54550
54560
54600
54620
54640
54650
54660
54670
54680
54690
54692
54699
54700
54800
54830
54840
54860
54861
54865
54900
54901
55000
55040
55041
55060
55100
55110
55120
55150
55175
55180
55200
55250
55300
55400
55450
55500
55520
55530
Description
PREPUTIAL STRETCHING
BIOPSY OF TESTIS
BIOPSY OF TESTIS
EXCISE LESION TESTIS
REMOVAL OF TESTIS
ORCHIECTOMY PARTIAL
REMOVAL OF TESTIS
EXTENSIVE TESTIS SURGERY
EXPLORATION FOR TESTIS
EXPLORATION FOR TESTIS
REDUCE TESTIS TORSION
SUSPENSION OF TESTIS
SUSPENSION OF TESTIS
ORCHIOPEXY (FOWLER-STEPHENS)
REVISION OF TESTIS
REPAIR TESTIS INJURY
RELOCATION OF TESTIS(ES)
LAPAROSCOPY ORCHIECTOMY
LAPAROSCOPY ORCHIOPEXY
LAPAROSCOPE PROC TESTIS
DRAINAGE OF SCROTUM
BIOPSY OF EPIDIDYMIS
REMOVE EPIDIDYMIS LESION
REMOVE EPIDIDYMIS LESION
REMOVAL OF EPIDIDYMIS
REMOVAL OF EPIDIDYMIS
EXPLORE EPIDIDYMIS
FUSION OF SPERMATIC DUCTS
FUSION OF SPERMATIC DUCTS
DRAINAGE OF HYDROCELE
REMOVAL OF HYDROCELE
REMOVAL OF HYDROCELES
REPAIR OF HYDROCELE
DRAINAGE OF SCROTUM ABSCESS
EXPLORE SCROTUM
REMOVAL OF SCROTUM LESION
REMOVAL OF SCROTUM
REVISION OF SCROTUM
REVISION OF SCROTUM
INCISION OF SPERM DUCT
REMOVAL OF SPERM DUCT(S)
PREPARE SPERM DUCT X-RAY
REPAIR OF SPERM DUCT
LIGATION OF SPERM DUCT
REMOVAL OF HYDROCELE
REMOVAL OF SPERM CORD LESION
REVISE SPERMATIC CORD VEINS
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
9
3
3
3
3
5
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
9
3
9
9
3
3
3
3
Maximum Allowable
$71.89
$76.85
$217.02
$557.64
$335.01
$640.95
$521.42
$767.11
$509.87
$709.01
$469.99
$310.75
$495.13
$732.31
$0.00
$417.18
$817.11
$770.11
$890.80
$0.00
$221.14
$131.79
$384.62
$330.60
$432.29
$584.87
$369.81
$870.50
$1,148.66
$120.27
$348.33
$526.48
$392.91
$221.58
$400.45
$368.49
$507.91
$373.76
$716.21
$0.00
$234.10
$0.00
$0.00
$367.18
$408.40
$469.58
$362.28
Procedure Code
55535
55540
55550
55559
55600
55605
55650
55680
55700
55705
55706
55720
55725
55801
55810
55812
55815
55821
55831
55840
55842
55845
55860
55862
55865
55866
55873
55875
55876
55899
55920
55970
55980
56405
56420
56440
56441
56442
56501
56515
56605
56606
56620
56625
56630
56631
56632
Description
REVISE SPERMATIC CORD VEINS
REVISE HERNIA & SPERM VEINS
LAPARO LIGATE SPERMATIC VEIN
LAPARO PROC SPERMATIC CORD
INCISE SPERM DUCT POUCH
INCISE SPERM DUCT POUCH
REMOVE SPERM DUCT POUCH
REMOVE SPERM POUCH LESION
BIOPSY OF PROSTATE
BIOPSY OF PROSTATE
PROSTATE SATURATION SAMPLING
REMOVAL OF PROSTATE
EXTENSIVE PROSTATE SURGERY
REMOVAL OF PROSTATE
REMOVAL OF PROSTATE
SURGICAL EXPOSURE PROSTATE
LAPARO RADICAL PROSTATECTOMY
CRYOABLATE PROSTATE
TRANSPERI NEEDLE PLACE PROS
PLACE RT DEVICE/MARKER PROS
GENITAL SURGERY PROCEDURE
PLACE NEEDLES PELVIC FOR RT
SEX TRANSFORMATION M TO F
SEX TRANSFORMATION F TO M
I & D OF VULVA/PERINEUM
DRAINAGE OF GLAND ABSCESS
SURGERY FOR VULVA LESION
LYSIS OF LABIAL LESION(S)
HYMENOTOMY
DESTROY VULVA LESIONS SIM
DESTROY VULVA LESION/S COMPL
BIOPSY OF VULVA/PERINEUM
BIOPSY OF VULVA/PERINEUM
PARTIAL REMOVAL OF VULVA
COMPLETE REMOVAL OF VULVA
EXTENSIVE VULVA SURGERY
Pricing Action Code
3
3
3
5
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
5
3
9
9
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$444.12
$564.38
$443.40
$0.00
$434.79
$567.98
$741.73
$367.12
$222.52
$274.08
$385.19
$467.39
$612.23
$1,137.71
$1,362.56
$1,661.18
$1,829.12
$901.73
$975.62
$1,210.88
$1,209.74
$1,410.02
$903.13
$1,192.43
$1,377.29
$1,448.22
$7,244.69
$787.17
$138.91
$0.00
$462.55
$0.00
$0.00
$111.57
$124.25
$186.25
$147.15
$48.92
$133.61
$231.52
$83.87
$38.88
$537.28
$650.05
$963.05
$1,229.17
$1,426.51
Procedure Code
56633
56634
56637
56640
56700
56740
56800
56805
56810
56820
56821
57000
57010
57020
57022
57023
57061
57065
57100
57105
57106
57107
57109
57110
57111
57112
57120
57126
57130
57135
57150
57155
57156
57160
57170
57180
57200
57210
57220
57230
57240
57250
57260
57265
57267
57268
57270
Description
PARTIAL REMOVAL OF HYMEN
REMOVE VAGINA GLAND LESION
REPAIR OF VAGINA
REPAIR CLITORIS
REPAIR OF PERINEUM
EXAM OF VULVA W/SCOPE
EXAM/BIOPSY OF VULVA W/SCOPE
EXPLORATION OF VAGINA
DRAINAGE OF PELVIC ABSCESS
DRAINAGE OF PELVIC FLUID
I & D VAGINAL HEMATOMA PP
I & D VAG HEMATOMA NON-OB
DESTROY VAG LESIONS SIMPLE
DESTROY VAG LESIONS COMPLEX
BIOPSY OF VAGINA
BIOPSY OF VAGINA
REMOVE VAGINA WALL PARTIAL
REMOVE VAGINA TISSUE PART
VAGINECTOMY PARTIAL W/NODES
REMOVE VAGINA WALL COMPLETE
REMOVE VAGINA TISSUE COMPL
VAGINECTOMY W/NODES COMPL
CLOSURE OF VAGINA
COMPLEX CYSTOMETROGRAM (EG, CALI
REMOVE VAGINA LESION
REMOVE VAGINA LESION
TREAT VAGINA INFECTION
INSERT UTERI TANDEM/OVOIDS
INS VAG BRACHYTX DEVICE
INSERT PESSARY/OTHER DEVICE
FITTING OF DIAPHRAGM/CAP
TREAT VAGINAL BLEEDING
REPAIR OF VAGINA
REPAIR VAGINA/PERINEUM
REVISION OF URETHRA
REPAIR OF URETHRAL LESION
REPAIR BLADDER & VAGINA
REPAIR RECTUM & VAGINA
REPAIR OF VAGINA
EXTENSIVE REPAIR OF VAGINA
INSERT MESH/PELVIC FLR ADDON
REPAIR OF BOWEL BULGE
REPAIR OF BOWEL POUCH
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
9
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$1,258.62
$1,363.90
$1,565.31
$1,580.97
$190.21
$308.29
$245.90
$1,192.94
$265.64
$115.28
$151.58
$192.30
$442.95
$94.89
$173.28
$315.85
$116.00
$199.52
$91.11
$139.77
$511.79
$1,502.19
$1,804.33
$911.10
$1,647.93
$1,925.82
$520.14
$0.00
$180.25
$195.78
$46.08
$440.36
$201.65
$77.78
$61.86
$143.35
$307.69
$375.85
$325.45
$403.39
$685.52
$689.90
$848.93
$930.07
$262.04
$494.47
$814.78
Procedure Code
57280
57282
57283
57284
57285
57287
57288
57289
57291
57292
57295
57296
57300
57305
57307
57308
57310
57311
57320
57330
57335
57400
57410
57415
57420
57421
57423
57425
57426
57452
57454
57455
57456
57460
57461
57500
57505
57510
57511
57513
57520
57522
57530
57531
57540
57545
57550
Description
SUSPENSION OF VAGINA
COLPOPEXY EXTRAPERITONEAL
COLPOPEXY INTRAPERITONEAL
REPAIR PARAVAG DEFECT OPEN
REPAIR PARAVAG DEFECT VAG
REVISE/REMOVE SLING REPAIR
REPAIR BLADDER DEFECT
REPAIR BLADDER & VAGINA
CONSTRUCTION OF VAGINA
CONSTRUCT VAGINA WITH GRAFT
REVISE VAG GRAFT VIA VAGINA
REVISE VAG GRAFT OPEN ABD
REPAIR RECTUM-VAGINA FISTULA
REPAIR RECTUM-VAGINA FISTULA
FISTULA REPAIR & COLOSTOMY
FISTULA REPAIR TRANSPERINE
REPAIR URETHROVAGINAL LESION
REPAIR URETHROVAGINAL LESION
REPAIR BLADDER-VAGINA LESION
REPAIR BLADDER-VAGINA LESION
REPAIR VAGINA
DILATION OF VAGINA
PELVIC EXAMINATION
REMOVE VAGINAL FOREIGN BODY
EXAM OF VAGINA W/SCOPE
EXAM/BIOPSY OF VAG W/SCOPE
REPAIR PARAVAG DEFECT LAP
LAPAROSCOPY SURG COLPOPEXY
REVISE PROSTH VAG GRAFT LAP
EXAM OF CERVIX W/SCOPE
BX/CURETT OF CERVIX W/SCOPE
BIOPSY OF CERVIX W/SCOPE
ENDOCERV CURETTAGE W/SCOPE
BX OF CERVIX W/SCOPE LEEP
CONZ OF CERVIX W/SCOPE LEEP
BIOPSY OF CERVIX
ENDOCERVICAL CURETTAGE
CAUTERIZATION OF CERVIX
CRYOCAUTERY OF CERVIX
LASER SURGERY OF CERVIX
CONIZATION OF CERVIX
CONIZATION OF CERVIX
REMOVAL OF CERVIX
REMOVAL OF CERVIX RADICAL
REMOVAL OF RESIDUAL CERVIX
REMOVE CERVIX/REPAIR PELVIS
REMOVAL OF RESIDUAL CERVIX
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$972.88
$511.56
$702.89
$831.95
$685.81
$695.76
$730.42
$750.97
$631.31
$842.05
$487.72
$966.76
$577.83
$961.52
$1,119.80
$677.04
$474.66
$543.33
$549.59
$761.29
$1,158.32
$138.86
$110.77
$163.59
$120.66
$161.69
$930.06
$988.60
$861.33
$111.58
$156.07
$145.74
$137.46
$288.35
$326.10
$130.52
$104.48
$133.82
$147.54
$147.97
$314.00
$268.08
$355.87
$1,901.70
$800.95
$866.08
$415.23
Procedure Code
57555
57556
57558
57700
57720
57800
58100
58110
58120
58140
58145
58146
58150
58152
58180
58200
58210
58240
58260
58262
58263
58267
58270
58275
58280
58285
58290
58291
58292
58293
58294
58300
58301
58310
58311
58321
58322
58323
58340
58345
58346
58350
58353
58356
58400
58410
58520
Description
REMOVE CERVIX/REPAIR VAGINA
REMOVE CERVIX REPAIR BOWEL
D&C OF CERVICAL STUMP
REVISION OF CERVIX
REVISION OF CERVIX
DILATION OF CERVICAL CANAL
BIOPSY OF UTERUS LINING
BX DONE W/COLPOSCOPY ADD-ON
DILATION AND CURETTAGE
MYOMECTOMY ABDOM METHOD
MYOMECTOMY VAG METHOD
MYOMECTOMY ABDOM COMPLEX
TOTAL HYSTERECTOMY
TOTAL HYSTERECTOMY
PARTIAL HYSTERECTOMY
EXTENSIVE HYSTERECTOMY
REMOVAL OF PELVIS CONTENTS
VAGINAL HYSTERECTOMY
VAG HYST INCLUDING T/O
VAG HYST W/T/O & VAG REPAIR
VAG HYST W/URINARY REPAIR
VAG HYST W/ENTEROCELE REPAIR
HYSTERECTOMY/REVISE VAGINA
HYSTERECTOMY/REVISE VAGINA
VAG HYST COMPLEX
VAG HYST INCL T/O COMPLEX
VAG HYST T/O & REPAIR COMPL
VAG HYST W/URO REPAIR COMPL
VAG HYST W/ENTEROCELE COMPL
INSERT INTRAUTERINE DEVICE
REMOVE INTRAUTERINE DEVICE
ARTIFICIAL INSEMINATION
ARTIFICIAL INSEMINATION WITH SPERM
SPERM WASHING
CATHETER FOR HYSTEROGRAPHY
REOPEN FALLOPIAN TUBE
INSERT HEYMAN UTERI CAPSULE
REOPEN FALLOPIAN TUBE
ENDOMETR ABLATE THERMAL
ENDOMETRIAL CRYOABLATION
SUSPENSION OF UTERUS
SUSPENSION OF UTERUS
REPAIR OF RUPTURED UTERUS
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
5
3
9
9
9
9
9
3
9
3
9
3
3
3
3
3
Maximum Allowable
$611.66
$580.12
$127.00
$325.18
$312.85
$61.57
$111.18
$48.88
$263.46
$942.70
$561.38
$1,172.41
$1,039.47
$1,276.47
$985.32
$1,414.62
$1,909.18
$3,013.68
$841.86
$939.95
$1,008.09
$1,075.03
$898.22
$1,003.61
$1,069.06
$1,378.73
$1,173.00
$1,265.39
$1,336.51
$1,389.27
$1,242.95
$0.00
$96.44
$0.00
$0.00
$0.00
$0.00
$0.00
$121.23
$0.00
$455.68
$0.00
$223.19
$1,920.46
$450.83
$838.43
$875.78
Procedure Code
58540
58541
58542
58543
58544
58545
58546
58548
58550
58552
58553
58554
58555
58558
58559
58560
58561
58562
58563
58565
58570
58571
58572
58573
58578
58579
58600
58605
58611
58615
58660
58661
58662
58670
58671
58672
58673
58679
58700
58720
58740
58750
58752
58760
58770
58800
58805
Description
REVISION OF UTERUS
LSH UTERUS 250 G OR LESS
LSH W/T/O UT 250 G OR LESS
LSH UTERUS ABOVE 250 G
LSH W/T/O UTERUS ABOVE 250 G
LAPAROSCOPIC MYOMECTOMY
LAPARO-MYOMECTOMY COMPLEX
LAP RADICAL HYST
LAPARO-ASST VAG HYSTERECTOMY
LAPARO-VAG HYST INCL T/O
LAPARO-VAG HYST COMPLEX
LAPARO-VAG HYST W/T/O COMPL
HYSTEROSCOPY DX SEP PROC
HYSTEROSCOPY BIOPSY
HYSTEROSCOPY LYSIS
HYSTEROSCOPY RESECT SEPTUM
HYSTEROSCOPY REMOVE MYOMA
HYSTEROSCOPY REMOVE FB
HYSTEROSCOPY ABLATION
HYSTEROSCOPY STERILIZATION
TLH UTERUS 250 G OR LESS
TLH W/T/O 250 G OR LESS
TLH UTERUS OVER 250 G
TLH W/T/O UTERUS OVER 250 G
LAPARO PROC UTERUS
HYSTEROSCOPE PROCEDURE
DIVISION OF FALLOPIAN TUBE
DIVISION OF FALLOPIAN TUBE
LIGATE OVIDUCT(S) ADD-ON
OCCLUDE FALLOPIAN TUBE(S)
LAPAROSCOPY LYSIS
LAPAROSCOPY REMOVE ADNEXA
LAPAROSCOPY EXCISE LESIONS
LAPAROSCOPY TUBAL CAUTERY
LAPAROSCOPY TUBAL BLOCK
LAPAROSCOPY FIMBRIOPLASTY
LAPAROSCOPY SALPINGOSTOMY
LAPARO PROC OVIDUCT-OVARY
REMOVAL OF FALLOPIAN TUBE
REMOVAL OF OVARY/TUBE(S)
ADHESIOLYSIS TUBE OVARY
REPAIR OVIDUCT
REVISE OVARIAN TUBE(S)
FIMBRIOPLASTY
CREATE NEW TUBAL OPENING
DRAINAGE OF OVARIAN CYST(S)
DRAINAGE OF OVARIAN CYST(S)
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
5
5
3
3
3
3
3
3
3
3
3
3
3
5
3
3
3
9
9
9
3
3
3
Maximum Allowable
$923.25
$730.79
$835.77
$844.61
$922.66
$922.90
$1,143.63
$1,965.50
$898.66
$1,010.24
$1,159.48
$1,358.59
$317.43
$412.77
$348.42
$392.52
$557.38
$426.65
$348.02
$440.97
$794.55
$920.66
$1,042.42
$1,245.67
$0.00
$0.00
$370.54
$334.59
$78.63
$247.26
$689.16
$665.12
$725.09
$372.06
$371.67
$747.51
$812.19
$0.00
$796.11
$755.76
$904.25
$0.00
$0.00
$0.00
$952.12
$322.98
$411.23
Procedure Code
58820
58822
58825
58900
58920
58925
58940
58943
58950
58951
58952
58953
58954
58956
58957
58958
58960
58970
58974
58976
58999
59000
59001
59012
59015
59020
59025
59030
59050
59051
59070
59072
59074
59076
59100
59120
59121
59130
59135
59136
59140
59150
59151
59160
59200
59300
59320
Description
DRAIN OVARY ABSCESS OPEN
DRAIN OVARY ABSCESS PERCUT
TRANSPOSITION OVARY(S)
BIOPSY OF OVARY(S)
PARTIAL REMOVAL OF OVARY(S)
REMOVAL OF OVARIAN CYST(S)
REMOVAL OF OVARY(S)
REMOVAL OF OVARY(S)
RESECT OVARIAN MALIGNANCY
TAH RAD DISSECT FOR DEBULK
TAH RAD DEBULK/LYMPH REMOVE
BSO OMENTECTOMY W/TAH
RESECT RECURRENT GYN MAL
RESECT RECUR GYN MAL W/LYM
EXPLORATION OF ABDOMEN
RETRIEVAL OF OOCYTE
TRANSFER OF EMBRYO
TRANSFER OF EMBRYO
GENITAL SURGERY PROCEDURE
AMNIOCENTESIS DIAGNOSTIC
AMNIOCENTESIS THERAPEUTIC
FETAL CORD PUNCTURE PRENATAL
CHORION BIOPSY
FETAL CONTRACT STRESS TEST
FETAL NON-STRESS TEST
FETAL SCALP BLOOD SAMPLE
FETAL MONITOR W/REPORT
FETAL MONITOR/INTERPRET ONLY
TRANSABDOM AMNIOINFUS W/US
UMBILICAL CORD OCCLUD W/US
FETAL FLUID DRAINAGE W/US
FETAL SHUNT PLACEMENT W/US
REMOVE UTERUS LESION
TREAT ECTOPIC PREGNANCY
D & C AFTER DELIVERY
INSERT CERVICAL DILATOR
EPISIOTOMY OR VAGINAL REPAIR
REVISION OF CERVIX
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
9
9
9
5
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$317.51
$770.88
$712.71
$468.49
$785.24
$764.04
$537.52
$1,216.66
$1,170.13
$1,503.87
$1,700.02
$2,103.41
$2,282.81
$1,429.21
$1,645.56
$1,806.03
$1,008.42
$0.00
$0.00
$0.00
$0.00
$130.06
$188.77
$212.92
$162.09
$73.33
$49.84
$103.55
$53.04
$44.02
$413.32
$483.88
$395.40
$483.88
$821.36
$828.67
$831.63
$971.29
$857.61
$882.97
$414.20
$804.93
$780.96
$211.96
$74.39
$200.43
$159.50
Procedure Code
59325
59350
59400
59409
59410
59412
59414
59425
59426
59430
59510
59514
59515
59525
59610
59612
59614
59618
59620
59622
59812
59820
59821
59830
59840
59841
59850
59851
59852
59855
59856
59857
59866
59870
59871
59897
59898
59899
60000
6005F
60100
6010F
6015F
60200
6020F
60210
60212
Description
REVISION OF CERVIX
REPAIR OF UTERUS
OBSTETRICAL CARE
OBSTETRICAL CARE
OBSTETRICAL CARE
ANTEPARTUM MANIPULATION
DELIVER PLACENTA
ANTEPARTUM CARE ONLY
ANTEPARTUM CARE ONLY
CARE AFTER DELIVERY
CESAREAN DELIVERY
CESAREAN DELIVERY ONLY
CESAREAN DELIVERY
REMOVE UTERUS AFTER CESAREAN
VBAC DELIVERY
VBAC DELIVERY ONLY
VBAC CARE AFTER DELIVERY
ATTEMPTED VBAC DELIVERY
ATTEMPTED VBAC DELIVERY ONLY
ATTEMPTED VBAC AFTER CARE
TREATMENT OF MISCARRIAGE
CARE OF MISCARRIAGE
TREATMENT OF MISCARRIAGE
TREAT UTERUS INFECTION
ABORTION
ABORTION
ABORTION
ABORTION
ABORTION
ABORTION
ABORTION
ABORTION
ABORTION (MPR)
EVACUATE MOLE OF UTERUS
REMOVE CERCLAGE SUTURE
FETAL INVAS PX W/US
LAPARO PROC OB CARE/DELIVER
MATERNITY CARE PROCEDURE
DRAIN THYROID/TONGUE CYST
CARE LEVEL RATIONALE DOC
BIOPSY OF THYROID
DYSPHAG TEST DONE B/4 EATING
DYSPHAG TEST DONE B/4 EATING
REMOVE THYROID LESION
NPO (NOTHING-MOUTH) ORDERED
PARTIAL THYROID EXCISION
PARTIAL THYROID EXCISION
Pricing Action Code
3
3
7
3
3
9
3
9
9
3
7
3
3
3
9
3
3
9
3
3
3
3
3
3
3
3
3
3
3
3
3
3
9
3
3
6
5
5
3
9
3
9
9
3
9
3
3
Maximum Allowable
$254.82
$270.55
$0.00
$851.83
$1,085.25
$0.00
$96.34
$0.00
$0.00
$191.25
$0.00
$851.83
$1,085.25
$506.48
$0.00
$851.83
$1,085.25
$0.00
$851.83
$1,085.25
$331.46
$394.37
$397.94
$455.58
$226.05
$398.58
$359.21
$381.28
$519.78
$433.53
$509.65
$534.05
$0.00
$492.16
$139.28
$0.00
$0.00
$0.00
$176.66
$0.00
$115.80
$0.00
$0.00
$687.76
$0.00
$737.59
$1,049.09
Procedure Code
60220
60225
60240
60252
60254
60260
60270
60271
60280
60281
60300
6030F
6040F
6045F
60500
60502
60505
60512
60520
60521
60522
60540
60545
60600
60605
60650
60659
60699
6070F
6080F
6090F
61000
61001
6100F
6101F
61020
61026
6102F
61050
61055
61070
61105
61107
61108
6110F
61120
61140
Description
PARTIAL REMOVAL OF THYROID
PARTIAL REMOVAL OF THYROID
REMOVAL OF THYROID
REMOVAL OF THYROID
EXTENSIVE THYROID SURGERY
REPEAT THYROID SURGERY
REMOVAL OF THYROID
REMOVAL OF THYROID
REMOVE THYROID DUCT LESION
REMOVE THYROID DUCT LESION
ASPIR/INJ THYROID CYST
MAX STERILE BARRIERS FOLLWD
APPRO RAD DS DVCS TECHS DOCD
RADXPS IN END RPRT4FLURO PXD
EXPLORE PARATHYROID GLANDS
RE-EXPLORE PARATHYROIDS
EXPLORE PARATHYROID GLANDS
AUTOTRANSPLANT PARATHYROID
REMOVAL OF THYMUS GLAND
EXPLORE ADRENAL GLAND
EXPLORE ADRENAL GLAND
REMOVE CAROTID BODY LESION
REMOVE CAROTID BODY LESION
LAPAROSCOPY ADRENALECTOMY
LAPARO PROC ENDOCRINE
ENDOCRINE SURGERY PROCEDURE
PT ASKED/CNSLD AED EFFECTS
PT/CAREGIVER QUERIED FALLS
PT/CAREGIVER COUNSEL SAFETY
REMOVE CRANIAL CAVITY FLUID
REMOVE CRANIAL CAVITY FLUID
VERIFY PT SITE PXD DOCD
SAFETY COUNSELING DEMENTIA
REMOVE BRAIN CAVITY FLUID
INJECTION INTO BRAIN CANAL
SAFETY COUNSELING DEM ORDER
REMOVE BRAIN CANAL FLUID
INJECTION INTO BRAIN CANAL
BRAIN CANAL SHUNT PROCEDURE
TWIST DRILL HOLE
DRILL SKULL FOR IMPLANTATION
DRILL SKULL FOR DRAINAGE
COUNSEL PROV DRIVING RISKS
BURR HOLE FOR PUNCTURE
PIERCE SKULL FOR BIOPSY
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
9
9
9
3
3
3
3
3
3
3
3
3
3
3
3
5
5
9
9
9
3
3
9
9
3
3
9
3
3
3
3
3
3
9
3
3
Maximum Allowable
$737.38
$972.49
$959.03
$1,378.97
$1,748.85
$1,141.27
$1,429.42
$1,103.90
$462.48
$612.26
$121.55
$0.00
$0.00
$0.00
$1,006.95
$1,343.26
$1,447.03
$253.89
$1,091.15
$1,174.37
$1,423.11
$1,104.94
$1,268.02
$1,457.38
$1,799.67
$1,243.75
$0.00
$0.00
$0.00
$0.00
$0.00
$110.20
$88.06
$0.00
$0.00
$106.20
$107.22
$0.00
$88.70
$125.58
$60.15
$484.32
$339.19
$967.99
$0.00
$793.58
$1,349.98
Procedure Code
61150
61151
61154
61156
61210
61215
61250
61253
61304
61305
61312
61313
61314
61315
61316
61320
61321
61322
61323
61330
61332
61333
61340
61343
61345
61450
61458
61460
61480
61500
61501
6150F
61510
61512
61514
61516
61517
61518
61519
61520
61521
61522
61524
61526
61530
61531
61533
Description
PIERCE SKULL FOR DRAINAGE
PIERCE SKULL & REMOVE CLOT
PIERCE SKULL IMPLANT DEVICE
INSERT BRAIN-FLUID DEVICE
PIERCE SKULL & EXPLORE
PIERCE SKULL & EXPLORE
OPEN SKULL FOR EXPLORATION
OPEN SKULL FOR EXPLORATION
OPEN SKULL FOR DRAINAGE
IMPLT CRAN BONE FLAP TO ABDO
DECOMPRESSIVE CRANIOTOMY
DECOMPRESSIVE LOBECTOMY
DECOMPRESS EYE SOCKET
EXPLORE/BIOPSY EYE SOCKET
EXPLORE ORBIT/REMOVE LESION
SUBTEMPORAL DECOMPRESSION
INCISE SKULL (PRESS RELIEF)
RELIEVE CRANIAL PRESSURE
INCISE SKULL FOR SURGERY
INCISE SKULL FOR BRAIN WOUND
REMOVAL OF SKULL LESION
REMOVE INFECTED SKULL BONE
PT NOTRCVNG1ST ANTITNF TXMNT
REMOVAL OF BRAIN LESION
REMOVE BRAIN LINING LESION
REMOVAL OF BRAIN ABSCESS
IMPLT BRAIN CHEMOTX ADD-ON
REMOVE BRAIN LINING LESION
REMOVAL OF BRAIN ABSCESS
IMPLANT BRAIN ELECTRODES
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
9
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$1,434.01
$1,068.93
$1,358.43
$1,331.32
$397.63
$539.91
$860.65
$852.53
$1,753.68
$2,146.49
$2,222.86
$2,119.16
$1,939.63
$2,203.43
$94.60
$2,024.87
$2,249.10
$2,546.46
$2,580.89
$1,688.69
$1,850.52
$1,915.31
$1,515.07
$2,335.16
$2,177.43
$2,061.03
$2,135.12
$2,267.06
$1,680.37
$1,397.70
$1,223.78
$0.00
$2,324.20
$2,706.82
$2,020.72
$1,972.50
$94.24
$2,933.08
$3,114.65
$4,013.18
$3,378.05
$2,322.86
$2,217.48
$3,936.89
$3,318.43
$1,304.95
$1,622.92
Procedure Code
61534
61535
61536
61537
61538
61539
61540
61541
61543
61544
61545
61546
61548
61550
61552
61556
61557
61558
61559
61563
61564
61566
61567
61570
61571
61575
61576
61580
61581
61582
61583
61584
61585
61586
61590
61591
61592
61595
61596
61597
61598
61600
61601
61605
61606
61607
61608
Description
REMOVE BRAIN ELECTRODES
REMOVAL OF BRAIN TISSUE
INCISION OF BRAIN TISSUE
REMOVE & TREAT BRAIN LESION
EXCISION OF BRAIN TUMOR
REMOVAL OF PITUITARY GLAND
REMOVAL OF PITUITARY GLAND
RELEASE OF SKULL SEAMS
RELEASE OF SKULL SEAMS
INCISE SKULL/SUTURES
INCISE SKULL/SUTURES
EXCISION OF SKULL/SUTURES
EXCISION OF SKULL/SUTURES
EXCISION OF SKULL TUMOR
EXCISION OF SKULL TUMOR
INCISION OF BRAIN TISSUE
REMOVE FOREIGN BODY BRAIN
INCISE SKULL FOR BRAIN WOUND
SKULL BASE/BRAINSTEM SURGERY
SKULL BASE/BRAINSTEM SURGERY
CRANIOFACIAL APPROACH SKULL
ORBITOCRANIAL APPROACH/SKULL
RESECT NASOPHARYNX SKULL
INFRATEMPORAL APPROACH/SKULL
INFRATEMPORAL APPROACH/SKULL
TRANSTEMPORAL APPROACH/SKULL
TRANSCOCHLEAR APPROACH/SKULL
TRANSCONDYLAR APPROACH/SKULL
TRANSPETROSAL APPROACH/SKULL
RESECT/EXCISE CRANIAL LESION
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$1,735.76
$1,064.18
$2,780.04
$2,629.36
$2,872.01
$2,513.99
$2,351.88
$2,315.29
$2,257.00
$2,048.83
$3,432.53
$2,486.38
$1,678.71
$1,005.91
$1,207.85
$1,619.28
$1,704.83
$1,866.30
$2,188.53
$2,039.01
$2,445.65
$2,408.55
$2,760.78
$1,998.56
$2,130.28
$2,248.75
$3,809.26
$2,628.78
$2,778.82
$3,072.80
$3,083.23
$3,041.16
$3,453.51
$2,555.47
$3,179.46
$3,256.74
$3,363.36
$2,453.91
$2,544.44
$2,948.07
$3,030.88
$2,219.11
$2,552.94
$2,273.32
$3,152.66
$2,849.17
$3,474.58
Procedure Code
61610
61611
61612
61613
61615
61616
61618
61619
61623
61624
61626
61630
61635
61640
61641
61642
61645
61650
61651
61680
61682
61684
61686
61690
61692
61697
61698
61700
61702
61703
61705
61708
61710
61711
61720
61735
61750
61751
61760
61770
61781
61782
61783
61790
61791
61796
61797
Description
TRANSECT ARTERY SINUS
REMOVE ANEURYSM SINUS
RESECT/EXCISE LESION SKULL
RESECT/EXCISE LESION SKULL
REPAIR DURA
REPAIR DURA
ENDOVASC TEMPORY VESSEL OCCL
TRANSCATH OCCLUSION CNS
TRANSCATH OCCLUSION NON-CNS
INTRACRANIAL ANGIOPLASTY
INTRACRAN ANGIOPLSTY W/STENT
DILATE IC VASOSPASM INIT
DILATE IC VASOSPASM ADD-ON
DILATE IC VASOSPASM ADD-ON
PERQ ART M-THROMBECT &/NFS
EVASC PRLNG ADMN RX AGNT 1ST
EVASC PRLNG ADMN RX AGNT ADD
INTRACRANIAL VESSEL SURGERY
BRAIN ANEURYSM REPR COMPLX
BRAIN ANEURYSM REPR COMPLX
BRAIN ANEURYSM REPR SIMPLE
INNER SKULL VESSEL SURGERY
CLAMP NECK ARTERY
REVISE CIRCULATION TO HEAD
FUSION OF SKULL ARTERIES
INCISE SKULL/BRAIN SURGERY
INCISE SKULL/BRAIN SURGERY
INCISE SKULL/BRAIN BIOPSY
BRAIN BIOPSY W/CT/MR GUIDE
INCISE SKULL FOR TREATMENT
SCAN PROC CRANIAL INTRA
SCAN PROC CRANIAL EXTRA
SCAN PROC SPINAL
TREAT TRIGEMINAL NERVE
TREAT TRIGEMINAL TRACT
SRS CRANIAL LESION SIMPLE
SRS CRAN LES SIMPLE ADDL
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$1,618.88
$404.91
$1,521.54
$3,441.88
$2,385.02
$3,550.58
$1,355.53
$1,501.37
$598.17
$1,203.03
$898.22
$1,400.11
$1,499.56
$673.29
$236.39
$473.16
$813.37
$557.41
$237.47
$2,385.79
$4,441.38
$3,066.80
$4,814.69
$2,323.88
$3,909.16
$4,525.28
$4,975.26
$3,637.50
$4,307.37
$1,461.51
$2,745.22
$2,205.90
$2,318.56
$2,776.33
$1,366.18
$1,688.79
$1,507.35
$1,481.00
$1,701.90
$1,735.70
$253.61
$183.75
$249.38
$944.14
$1,140.31
$1,087.56
$237.78
Procedure Code
61798
61799
61800
61850
61860
61863
61864
61867
61868
61870
61880
61885
61886
61888
62000
62005
62010
62100
62115
62117
62120
62121
62140
62141
62142
62143
62145
62146
62147
62148
62160
62161
62162
62163
62164
62165
62180
62190
62192
62194
62200
62201
62220
62223
62225
62230
62252
Description
SRS CRANIAL LESION COMPLEX
SRS CRAN LES COMPLEX ADDL
APPLY SRS HEADFRAME ADD-ON
IMPLANT NEUROELECTRODES
IMPLANT NEUROELECTRODE
IMPLANT NEUROELECTRDE ADDL
IMPLANT NEUROELECTRODE
IMPLANT NEUROELECTRDE ADDL
REVISE/REMOVE NEUROELECTRODE
INSRT/REDO NEUROSTIM 1 ARRAY
IMPLANT NEUROSTIM ARRAYS
REVISE/REMOVE NEURORECEIVER
TREAT SKULL FRACTURE
TREAT SKULL FRACTURE
TREATMENT OF HEAD INJURY
REPAIR BRAIN FLUID LEAKAGE
REDUCTION OF SKULL DEFECT
REDUCTION OF SKULL DEFECT
REPAIR SKULL CAVITY LESION
INCISE SKULL REPAIR
REPAIR OF SKULL DEFECT
REPAIR OF SKULL DEFECT
REMOVE SKULL PLATE/FLAP
REPLACE SKULL PLATE/FLAP
REPAIR OF SKULL & BRAIN
REPAIR OF SKULL WITH GRAFT
REPAIR OF SKULL WITH GRAFT
RETR BONE FLAP TO FIX SKULL
NEUROENDOSCOPY ADD-ON
DISSECT BRAIN W/SCOPE
REMOVE COLLOID CYST W/SCOPE
ZNEUROENDOSCOPY W/FB REMOVAL
REMOVE BRAIN TUMOR W/SCOPE
REMOVE PITUIT TUMOR W/SCOPE
ESTABLISH BRAIN CAVITY SHUNT
REPLACE/IRRIGATE CATHETER
BRAIN CAVITY SHUNT W/SCOPE
REPLACE/IRRIGATE CATHETER
REPLACE/REVISE BRAIN SHUNT
CSF SHUNT REPROGRAM
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$1,481.25
$326.11
$165.99
$1,055.52
$1,684.87
$1,603.69
$304.73
$2,423.78
$530.20
$1,222.84
$606.73
$547.87
$900.23
$421.67
$1,107.33
$1,325.48
$1,636.42
$1,694.48
$1,362.11
$1,699.07
$1,743.31
$1,682.28
$1,094.33
$1,206.20
$943.75
$1,102.07
$1,482.42
$1,326.89
$1,510.01
$137.03
$205.56
$1,626.29
$2,024.65
$1,172.39
$2,225.24
$1,644.60
$1,708.08
$935.26
$1,037.64
$491.48
$1,475.09
$1,292.86
$1,097.58
$1,119.81
$559.47
$898.26
$89.44
Procedure Code
62256
62258
62263
62264
62267
62268
62269
62270
62272
62273
62280
62281
62282
62284
62287
62290
62291
62292
62294
62302
62303
62304
62305
62310
62311
62318
62319
62350
62351
62355
62360
62361
62362
62365
62367
62368
62369
62370
63001
63003
63005
63011
63012
63015
63016
63017
63020
Description
REMOVE BRAIN CAVITY SHUNT
REPLACE BRAIN CAVITY SHUNT
EPIDURAL LYSIS MULT SESSIONS
EPIDURAL LYSIS ON SINGLE DAY
INTERDISCAL PERQ ASPIR DX
DRAIN SPINAL CORD CYST
NEEDLE BIOPSY SPINAL CORD
SPINAL FLUID TAP DIAGNOSTIC
DRAIN CEREBRO SPINAL FLUID
INJECT EPIDURAL PATCH
TREAT SPINAL CORD LESION
TREAT SPINAL CORD LESION
TREAT SPINAL CANAL LESION
INJECTION FOR MYELOGRAM
PERCUTANEOUS DISKECTOMY
INJECT FOR SPINE DISK X-RAY
INJECT FOR SPINE DISK X-RAY
INJECTION INTO DISK LESION
INJECTION INTO SPINAL ARTERY
MYELOGRAPHY LUMBAR INJECTION
INJECT SPINE CERV/THORACIC
INJECT SPINE LUMBAR/SACRAL
INJECT SPINE W/CATH CRV/THRC
INJECT SPINE W/CATH LMB/SCRL
IMPLANT SPINAL CANAL CATH
IMPLANT SPINAL CANAL CATH
REMOVE SPINAL CANAL CATHETER
INSERT SPINE INFUSION DEVICE
IMPLANT SPINE INFUSION PUMP
IMPLANT SPINE INFUSION PUMP
REMOVE SPINE INFUSION DEVICE
ANALYZE SPINE INFUS PUMP
ANALYZE SP INF PUMP W/REPROG
ANAL SP INF PMP W/REPRG&FILL
ANL SP INF PMP W/MDREPRG&FIL
REMOVE SPINE LAMINA 1/2 CRVL
REMOVE SPINE LAMINA 1/2 THRC
REMOVE SPINE LAMINA 1/2 LMBR
REMOVE SPINE LAMINA 1/2 SCRL
REMOVE LAMINA/FACETS LUMBAR
REMOVE SPINE LAMINA >2 CRVCL
REMOVE SPINE LAMINA >2 THRC
REMOVE SPINE LAMINA >2 LMBR
NECK SPINE DISK SURGERY
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$636.91
$1,199.13
$674.33
$439.38
$255.15
$269.55
$280.80
$163.42
$209.24
$179.91
$317.42
$250.08
$302.69
$187.14
$590.94
$345.32
$341.69
$603.00
$814.30
$247.55
$257.32
$245.04
$266.70
$249.52
$230.55
$245.45
$176.78
$421.62
$920.96
$277.27
$329.41
$380.33
$407.98
$312.60
$42.85
$58.68
$124.57
$131.33
$1,315.58
$1,306.60
$1,243.07
$1,140.22
$1,244.43
$1,571.68
$1,611.72
$1,320.65
$1,225.08
Procedure Code
63030
63035
63040
63042
63043
63044
63045
63046
63047
63048
63050
63051
63055
63056
63057
63064
63066
63075
63076
63077
63078
63081
63082
63085
63086
63087
63088
63090
63091
63101
63102
63103
63170
63172
63173
63180
63182
63185
63190
63191
63194
63195
63196
63197
63198
63199
63200
Description
LOW BACK DISK SURGERY
SPINAL DISK SURGERY ADD-ON
LAMINOTOMY SINGLE CERVICAL
LAMINOTOMY SINGLE LUMBAR
LAMINOTOMY ADDL CERVICAL
LAMINOTOMY ADDL LUMBAR
REMOVE SPINE LAMINA 1 CRVL
REMOVE SPINE LAMINA 1 THRC
REMOVE SPINE LAMINA 1 LMBR
REMOVE SPINAL LAMINA ADD-ON
CERVICAL LAMINOPLSTY 2/> SEG
C-LAMINOPLASTY W/GRAFT/PLATE
DECOMPRESS SPINAL CORD THRC
DECOMPRESS SPINAL CORD LMBR
DECOMPRESS SPINE CORD ADD-ON
DECOMPRESS SPINAL CORD THRC
DECOMPRESS SPINE CORD ADD-ON
SPINE DISK SURGERY THORAX
SPINE DISK SURGERY THORAX
REMOVE VERT BODY DCMPRN CRVL
REMOVE VERTEBRAL BODY ADD-ON
REMOVE VERT BODY DCMPRN THRC
REMOV VERTBR DCMPRN THRCLMBR
REMOVE VERT BODY DCMPRN LMBR
REMOVE VERT BODY DCMPRN THRC
REMOVE VERT BODY DCMPRN LMBR
INCISE SPINAL CORD TRACT(S)
DRAINAGE OF SPINAL CYST
DRAINAGE OF SPINAL CYST
REVISE SPINAL CORD LIGAMENTS
REVISE SPINAL CORD LIGAMENTS
INCISE SPINE NRV HALF SEGMNT
INCISE SPINE NRV >2 SEGMNTS
INCISE SPINE ACCESSORY NERVE
INCISE SPINE & CORD CERVICAL
INCISE SPINE & CORD THORACIC
INCISE SPINE&CORD 2 TRX CRVL
INCISE SPINE&CORD 2 TRX THRC
INCISE SPIN&CORD 2 STGS CRVL
INCISE SPIN&CORD 2 STGS THRC
RELEASE SPINAL CORD LUMBAR
Pricing Action Code
3
3
3
3
5
5
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$1,019.71
$197.73
$1,464.87
$1,361.47
$0.00
$0.00
$1,357.63
$1,283.88
$1,160.59
$217.56
$1,571.04
$1,797.00
$1,717.90
$1,552.92
$327.55
$1,864.20
$224.06
$1,429.09
$255.62
$1,567.55
$198.19
$1,850.11
$273.51
$2,024.32
$198.94
$2,541.32
$270.67
$2,049.07
$180.82
$2,449.78
$2,388.29
$303.10
$1,714.18
$1,471.28
$1,833.85
$1,598.53
$1,444.82
$1,191.88
$1,314.83
$1,446.41
$1,719.24
$1,654.75
$1,470.84
$1,841.78
$1,731.72
$1,817.95
$1,632.12
Procedure Code
63250
63251
63252
63265
63266
63267
63268
63270
63271
63272
63273
63275
63276
63277
63278
63280
63281
63282
63283
63285
63286
63287
63290
63295
63300
63301
63302
63303
63304
63305
63306
63307
63308
63600
63610
63615
63620
63621
63650
63655
63661
63662
63663
63664
63685
63688
63700
Description
REVISE SPINAL CORD VSLS CRVL
REVISE SPINAL CORD VSLS THRC
REVISE SPINE CORD VSL THRLMB
EXCISE INTRASPINL LESION CRV
EXCISE INTRSPINL LESION THRC
EXCISE INTRSPINL LESION LMBR
EXCISE INTRSPINL LESION SCRL
EXCISE INTRSPINL LESION CRVL
EXCISE INTRSPINL LESION THRC
EXCISE INTRSPINL LESION LMBR
EXCISE INTRSPINL LESION SCRL
BX/EXC XDRL SPINE LESN CRVL
BX/EXC XDRL SPINE LESN THRC
BX/EXC XDRL SPINE LESN LMBR
BX/EXC XDRL SPINE LESN SCRL
BX/EXC IDRL SPINE LESN CRVL
BX/EXC IDRL SPINE LESN THRC
BX/EXC IDRL SPINE LESN LMBR
BX/EXC IDRL SPINE LESN SCRL
BX/EXC IDRL IMED LESN CERVL
BX/EXC IDRL IMED LESN THRC
BX/EXC IDRL IMED LESN THRLMB
BX/EXC XDRL/IDRL LSN ANY LVL
REPAIR LAMINECTOMY DEFECT
REMOVE VERT XDRL BODY CRVCL
REMOVE VERT XDRL BODY THRC
REMOVE VERT XDRL BODY THRLMB
REMOV VERT XDRL BDY LMBR/SAC
REMOVE VERT IDRL BODY CRVCL
REMOVE VERT IDRL BODY THRC
REMOV VERT IDRL BDY THRCLMBR
REMOV VERT IDRL BDY LMBR/SAC
REMOVE SPINAL CORD LESION
STIMULATION OF SPINAL CORD
REMOVE LESION OF SPINAL CORD
SRS SPINAL LESION
SRS SPINAL LESION ADDL
REMOVE SPINE ELTRD PERQ ARAY
REMOVE SPINE ELTRD PLATE
REVISE SPINE ELTRD PERQ ARAY
REVISE SPINE ELTRD PLATE
INSRT/REDO SPINE N GENERATOR
REVISE/REMOVE NEURORECEIVER
REPAIR OF SPINAL HERNIATION
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$2,995.30
$3,261.70
$3,257.61
$1,769.12
$1,821.94
$1,438.89
$1,529.52
$2,231.27
$2,194.24
$1,998.41
$1,995.29
$1,908.36
$1,889.94
$1,631.33
$1,709.46
$2,240.01
$2,212.16
$2,076.18
$2,022.43
$2,812.28
$2,741.50
$2,959.48
$2,939.72
$358.49
$1,947.31
$2,363.90
$2,323.25
$2,475.78
$2,497.46
$2,595.62
$2,446.25
$2,454.91
$347.08
$942.50
$450.11
$1,015.83
$1,197.67
$273.29
$1,381.09
$867.88
$600.27
$880.39
$823.41
$904.76
$383.73
$385.83
$1,224.48
Procedure Code
63702
63704
63706
63707
63709
63710
63740
63741
63744
63746
64400
64402
64405
64408
64410
64413
64415
64416
64417
64418
64420
64421
64425
64430
64435
64445
64446
64447
64448
64449
64450
64455
64461
64462
64463
64479
64480
64483
64484
64486
64487
64488
64489
64490
64491
64492
64493
Description
REPAIR SPINAL FLUID LEAKAGE
REPAIR SPINAL FLUID LEAKAGE
GRAFT REPAIR OF SPINE DEFECT
INSTALL SPINAL SHUNT
INSTALL SPINAL SHUNT
REVISION OF SPINAL SHUNT
REMOVAL OF SPINAL SHUNT
N BLOCK INJ TRIGEMINAL
N BLOCK INJ FACIAL
N BLOCK INJ OCCIPITAL
N BLOCK INJ VAGUS
N BLOCK INJ PHRENIC
N BLOCK INJ CERVICAL PLEXUS
N BLOCK INJ BRACHIAL PLEXUS
N BLOCK CONT INFUSE B PLEX
N BLOCK INJ AXILLARY
N BLOCK INJ SUPRASCAPULAR
N BLOCK INJ INTERCOST SNG
N BLOCK INJ INTERCOST MLT
N BLOCK INJ ILIO-ING/HYPOGI
N BLOCK INJ PUDENDAL
N BLOCK INJ PARACERVICAL
N BLOCK INJ SCIATIC SNG
N BLK INJ SCIATIC CONT INF
N BLOCK INJ FEM SINGLE
N BLOCK INJ FEM CONT INF
N BLOCK INJ LUMBAR PLEXUS
N BLOCK OTHER PERIPHERAL
N BLOCK INJ PLANTAR DIGIT
PVB THORACIC SINGLE INJ SITE
PVB THORACIC 2ND+ INJ SITE
PVB THORACIC CONT INFUSION
INJ FORAMEN EPIDURAL C/T
INJ FORAMEN EPIDURAL ADD-ON
INJ FORAMEN EPIDURAL L/S
INJ FORAMEN EPIDURAL ADD-ON
TAP BLOCK UNIL BY INJECTION
TAP BLOCK UNI BY INFUSION
TAP BLOCK BI INJECTION
TAP BLOCK BI BY INFUSION
INJ PARAVERT F JNT C/T 1 LEV
INJ PARAVERT F JNT L/S 1 LEV
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$1,334.81
$1,772.48
$1,792.55
$970.32
$1,160.13
$1,136.62
$1,000.65
$715.97
$712.74
$642.58
$131.79
$134.66
$104.34
$107.88
$129.57
$131.18
$125.20
$82.67
$137.20
$149.97
$116.34
$155.88
$137.08
$142.65
$139.80
$141.57
$82.67
$127.01
$74.44
$87.79
$82.16
$48.84
$152.98
$86.33
$168.82
$243.55
$116.69
$226.72
$90.70
$128.24
$158.93
$158.14
$222.48
$110.94
$62.76
$63.48
$95.17
Procedure Code
64494
64495
64505
64508
64510
64517
64520
64530
64550
64553
64555
64561
64565
64566
64568
64569
64570
64575
64580
64581
64585
64590
64595
64600
64605
64610
64611
64612
64615
64616
64617
64620
64630
64632
64633
64634
64635
64636
64640
64642
64643
64644
64645
64646
64647
64650
64653
Description
N BLOCK SPENOPALATINE GANGL
N BLOCK CAROTID SINUS S/P
N BLOCK STELLATE GANGLION
N BLOCK INJ HYPOGAS PLXS
N BLOCK LUMBAR/THORACIC
N BLOCK INJ CELIAC PELUS
APPLY NEUROSTIMULATOR
NEUROELTRD STIM POST TIBIAL
INC FOR VAGUS N ELECT IMPL
REVISE/REPL VAGUS N ELTRD
REMOVE VAGUS N ELTRD
REVISE/REMOVE NEUROELECTRODE
INSRT/REDO PN/GASTR STIMUL
REVISE/RMV PN/GASTR STIMUL
INJECTION TREATMENT OF NERVE
CHEMODENERV SALIV GLANDS
DESTROY NERVE FACE MUSCLE
CHEMODENERV MUSC MIGRAINE
CHEMODENERV MUSC NECK DYSTON
CHEMODENER MUSCLE LARYNX EMG
N BLOCK INJ COMMON DIGIT
DESTROY CERV/THOR FACET JNT
DESTROY C/TH FACET JNT ADDL
DESTROY LUMB/SAC FACET JNT
DESTROY L/S FACET JNT ADDL
CHEMODENERV 1 EXTREMITY 1-4
CHEMODENERV 1 EXTREM 1-4 EA
CHEMODENERV 1 EXTREM 5/> MUS
CHEMODENERV 1 EXTREM 5/> EA
CHEMODENERV TRUNK MUSC 1-5
CHEMODENERV TRUNK MUSC 6/>
CHEMODENERV ECCRINE GLANDS
CHEMODENERV ECCRINE GLANDS
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$54.15
$54.88
$107.60
$63.95
$132.22
$188.90
$193.35
$197.92
$16.19
$215.65
$216.80
$311.72
$193.61
$129.68
$692.88
$828.97
$686.82
$334.97
$315.07
$684.48
$251.02
$271.52
$251.91
$406.80
$781.44
$777.62
$120.93
$136.10
$149.76
$130.96
$202.16
$211.73
$240.26
$87.65
$437.47
$196.97
$432.43
$178.94
$136.93
$146.58
$95.95
$168.27
$118.41
$155.60
$183.44
$79.77
$99.78
Procedure Code
64680
64681
64702
64704
64708
64712
64713
64714
64716
64718
64719
64721
64722
64726
64727
64732
64734
64736
64738
64740
64742
64744
64746
64755
64760
64763
64766
64771
64772
64774
64776
64778
64782
64783
64784
64786
64787
64788
64790
64792
64795
64802
64804
64809
64818
64820
64821
Description
REVISE FINGER/TOE NERVE
REVISE HAND/FOOT NERVE
REVISE ARM/LEG NERVE
REVISION OF SCIATIC NERVE
REVISION OF ARM NERVE(S)
REVISE LOW BACK NERVE(S)
REVISION OF CRANIAL NERVE
REVISE ULNAR NERVE AT ELBOW
REVISE ULNAR NERVE AT WRIST
CARPAL TUNNEL SURGERY
RELIEVE PRESSURE ON NERVE(S)
RELEASE FOOT/TOE NERVE
INTERNAL NERVE REVISION
INCISION OF BROW NERVE
INCISION OF CHEEK NERVE
INCISION OF CHIN NERVE
INCISION OF JAW NERVE
INCISION OF TONGUE NERVE
INCISION OF FACIAL NERVE
INCISE NERVE BACK OF HEAD
INCISE DIAPHRAGM NERVE
INCISION OF STOMACH NERVES
INCISION OF VAGUS NERVE
INCISE HIP/THIGH NERVE
INCISE HIP/THIGH NERVE
SEVER CRANIAL NERVE
INCISION OF SPINAL NERVE
REMOVE SKIN NERVE LESION
REMOVE DIGIT NERVE LESION
DIGIT NERVE SURGERY ADD-ON
REMOVE LIMB NERVE LESION
LIMB NERVE SURGERY ADD-ON
REMOVE NERVE LESION
REMOVE SCIATIC NERVE LESION
IMPLANT NERVE END
REMOVE SKIN NERVE LESION
REMOVAL OF NERVE LESION
REMOVAL OF NERVE LESION
BIOPSY OF NERVE
SYMPATHECTOMY CERVICAL
REMOVE SYMPATHETIC NERVES
SYMPATHECTOMY DIGITAL ARTERY
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
9
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$319.78
$365.45
$518.71
$328.27
$517.81
$595.36
$757.15
$668.91
$560.43
$618.34
$418.79
$448.55
$383.33
$281.27
$193.51
$391.17
$427.54
$413.68
$438.70
$474.99
$501.56
$519.94
$479.90
$0.00
$522.77
$525.72
$628.65
$627.45
$584.49
$434.69
$406.47
$147.87
$467.32
$233.18
$764.25
$1,121.09
$254.65
$417.81
$880.92
$1,274.36
$202.91
$691.90
$1,054.28
$1,071.68
$642.61
$754.31
$725.27
Procedure Code
64822
64823
64831
64832
64834
64835
64836
64837
64840
64856
64857
64858
64859
64861
64862
64864
64865
64866
64868
64872
64874
64876
64885
64886
64890
64891
64892
64893
64895
64896
64897
64898
64901
64902
64905
64907
64910
64911
64999
65091
65093
65101
65103
65105
65110
65112
65114
Description
SYMPATHECTOMY SUPFC PALMAR
REPAIR OF DIGIT NERVE
REPAIR NERVE ADD-ON
REPAIR OF HAND OR FOOT NERVE
REPAIR NERVE ADD-ON
REPAIR OF LEG NERVE
REPAIR/TRANSPOSE NERVE
REPAIR ARM/LEG NERVE
REPAIR SCIATIC NERVE
NERVE SURGERY
REPAIR OF ARM NERVES
REPAIR OF LOW BACK NERVES
REPAIR OF FACIAL NERVE
REPAIR OF FACIAL NERVE
FUSION OF FACIAL/OTHER NERVE
FUSION OF FACIAL/OTHER NERVE
SUBSEQUENT REPAIR OF NERVE
REPAIR & REVISE NERVE ADD-ON
REPAIR NERVE/SHORTEN BONE
NERVE GRAFT HEAD/NECK </4 CM
NERVE GRAFT HEAD/NECK >4 CM
NERVE GRAFT HAND/FOOT </4 CM
NERVE GRAFT HAND/FOOT >4 CM
NERVE GRAFT ARM/LEG <4 CM
NERVE GRAFT ARM/LEG >4 CM
NERVE GRAFT HAND/FOOT </4 CM
NERVE GRAFT HAND/FOOT >4 CM
NERVE GRAFT ARM/LEG </4 CM
NERVE GRAFT ARM/LEG >4 CM
NERVE GRAFT ADD-ON
NERVE GRAFT ADD-ON
NERVE PEDICLE TRANSFER
NERVE PEDICLE TRANSFER
NERVE REPAIR W/ALLOGRAFT
NEURORRAPHY W/VEIN AUTOGRAFT
NERVOUS SYSTEM SURGERY
REVISE EYE
REVISE EYE WITH IMPLANT
REMOVAL OF EYE
REMOVE EYE/INSERT IMPLANT
REMOVE EYE/ATTACH IMPLANT
REMOVAL OF EYE
REMOVE EYE/REVISE SOCKET
REMOVE EYE/REVISE SOCKET
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
5
3
3
3
3
3
3
3
3
Maximum Allowable
$725.27
$824.58
$718.08
$355.41
$775.69
$842.84
$845.41
$393.35
$1,065.00
$1,064.52
$1,105.44
$1,181.60
$267.03
$1,382.40
$1,636.62
$922.71
$1,175.99
$1,199.44
$1,058.20
$127.44
$179.27
$183.94
$1,204.87
$1,361.72
$1,145.65
$1,225.08
$1,092.19
$1,191.15
$1,410.37
$1,516.59
$1,303.47
$1,429.37
$583.04
$687.19
$1,081.29
$1,448.34
$864.21
$1,061.97
$0.00
$647.72
$640.61
$752.15
$785.15
$866.42
$1,247.98
$1,451.60
$1,523.76
Procedure Code
65125
65130
65135
65140
65150
65155
65175
65205
65210
65220
65222
65235
65260
65265
65270
65272
65273
65275
65280
65285
65286
65290
65400
65410
65420
65426
65430
65435
65436
65450
65600
65710
65730
65750
65755
65756
65757
65760
65765
65767
65770
65771
65772
65775
65778
65779
65780
Description
REVISE OCULAR IMPLANT
INSERT OCULAR IMPLANT
INSERT OCULAR IMPLANT
ATTACH OCULAR IMPLANT
REVISE OCULAR IMPLANT
REINSERT OCULAR IMPLANT
REMOVAL OF OCULAR IMPLANT
REMOVE FOREIGN BODY FROM EYE
REPAIR OF EYE WOUND
REPAIR OF EYE WOUND
REPAIR OF EYE WOUND
REPAIR OF EYE WOUND
REPAIR OF EYE WOUND
REPAIR OF EYE WOUND
REPAIR OF EYE WOUND
REPAIR OF EYE SOCKET WOUND
REMOVAL OF EYE LESION
BIOPSY OF CORNEA
CORNEAL SMEAR
CURETTE/TREAT CORNEA
CURETTE/TREAT CORNEA
TREATMENT OF CORNEAL LESION
REVISION OF CORNEA
CORNEAL TRANSPLANT
CORNEAL TRANSPLANT
CORNEAL TRANSPLANT
CORNEAL TRANSPLANT
CORNEAL TRNSPL ENDOTHELIAL
PREP CORNEAL ENDO ALLOGRAFT
REVISION OF CORNEA
REVISION OF CORNEA
CORNEAL TISSUE TRANSPLANT
REVISE CORNEA WITH IMPLANT
RADIAL KERATOTOMY
CORRECTION OF ASTIGMATISM
CORRECTION OF ASTIGMATISM
COVER EYE W/MEMBRANE
COVER EYE W/MEMBRANE SUTURE
OCULAR RECONST TRANSPLANT
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
6
5
5
5
3
5
3
3
3
3
3
Maximum Allowable
$467.46
$746.28
$757.06
$823.58
$580.80
$862.70
$670.83
$56.81
$69.39
$58.68
$67.59
$725.71
$980.48
$1,105.17
$271.92
$358.45
$388.93
$589.96
$685.46
$1,132.13
$718.28
$498.63
$693.58
$145.47
$526.92
$665.02
$116.49
$80.95
$395.26
$331.56
$402.09
$1,130.44
$1,252.86
$1,259.45
$1,252.63
$1,209.90
$0.00
$0.00
$0.00
$0.00
$1,433.12
$0.00
$459.91
$562.83
$1,468.81
$1,232.71
$732.14
Procedure Code
65781
65782
65785
65800
65810
65815
65820
65850
65855
65860
65865
65870
65875
65880
65900
65920
65930
66020
66030
66130
66150
66155
66160
66170
66172
66174
66175
66179
66180
66183
66184
66185
66220
66225
66250
66500
66505
66600
66605
66625
66630
66635
66680
66682
66700
66710
66711
Description
IMPLTJ NTRSTRML CRNL RNG SEG
DRAINAGE OF EYE
DRAINAGE OF EYE
DRAINAGE OF EYE
RELIEVE INNER EYE PRESSURE
INCISION OF EYE
TRABECULOPLASTY LASER SURG
INCISE INNER EYE ADHESIONS
REMOVE EYE LESION
REMOVE IMPLANT OF EYE
REMOVE BLOOD CLOT FROM EYE
INJECTION TREATMENT OF EYE
INJECTION TREATMENT OF EYE
REMOVE EYE LESION
GLAUCOMA SURGERY
GLAUCOMA SURGERY
GLAUCOMA SURGERY
GLAUCOMA SURGERY
INCISION OF EYE
TRANSLUM DIL EYE CANAL
TRNSLUM DIL EYE CANAL W/STNT
AQUEOUS SHUNT EYE W/O GRAFT
AQUEOUS SHUNT EYE W/GRAFT
INSERT ANT DRAINAGE DEVICE
REVISION OF AQUEOUS SHUNT
REVISE AQUEOUS SHUNT EYE
REPAIR EYE LESION
REPAIR/GRAFT EYE LESION
FOLLOW-UP SURGERY OF EYE
INCISION OF IRIS
INCISION OF IRIS
REMOVE IRIS AND LESION
REMOVAL OF IRIS
REMOVAL OF IRIS
REMOVAL OF IRIS
REMOVAL OF IRIS
REPAIR IRIS & CILIARY BODY
REPAIR IRIS & CILIARY BODY
DESTRUCTION CILIARY BODY
CILIARY TRANSSLERAL THERAPY
CILIARY ENDOSCOPIC ABLATION
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
9
3
3
3
Maximum Allowable
$1,361.59
$1,174.81
$2,167.59
$121.54
$475.47
$651.29
$764.49
$856.94
$278.40
$314.83
$482.72
$603.48
$643.45
$676.11
$979.40
$805.56
$650.73
$190.26
$169.09
$709.70
$895.05
$894.69
$1,008.80
$988.05
$1,246.55
$967.32
$1,013.60
$1,100.64
$1,161.63
$1,052.19
$801.80
$863.16
$762.16
$950.45
$764.37
$361.04
$396.31
$848.95
$1,078.80
$438.45
$581.10
$586.85
$528.00
$0.00
$458.80
$448.65
$654.23
Procedure Code
66720
66740
66761
66762
66770
66820
66821
66825
66830
66840
66850
66852
66920
66930
66940
66982
66983
66984
66985
66986
66990
66999
67005
67010
67015
67025
67027
67028
67030
67031
67036
67039
67040
67041
67042
67043
67101
67105
67107
67108
67110
67113
67115
67120
67121
67141
67145
Description
REVISION OF IRIS
REVISION OF IRIS
REMOVAL OF INNER EYE LESION
INCISION SECONDARY CATARACT
AFTER CATARACT LASER SURGERY
REPOSITION INTRAOCULAR LENS
REMOVAL OF LENS LESION
REMOVAL OF LENS MATERIAL
EXTRACTION OF LENS
EXTRACTION OF LENS
EXTRACTION OF LENS
CATARACT SURGERY COMPLEX
CATARACT SURG W/IOL 1 STAGE
CATARACT SURG W/IOL 1 STAGE
INSERT LENS PROSTHESIS
EXCHANGE LENS PROSTHESIS
OPHTHALMIC ENDOSCOPE ADD-ON
EYE SURGERY PROCEDURE
PARTIAL REMOVAL OF EYE FLUID
PARTIAL REMOVAL OF EYE FLUID
RELEASE OF EYE FLUID
REPLACE EYE FLUID
IMPLANT EYE DRUG SYSTEM
INJECTION EYE DRUG
INCISE INNER EYE STRANDS
LASER SURGERY EYE STRANDS
REMOVAL OF INNER EYE FLUID
LASER TREATMENT OF RETINA
LASER TREATMENT OF RETINA
VIT FOR MACULAR PUCKER
VIT FOR MACULAR HOLE
VIT FOR MEMBRANE DISSECT
REPAIR DETACHED RETINA
REPAIR RETINAL DETACH CPLX
RELEASE ENCIRCLING MATERIAL
REMOVE EYE IMPLANT MATERIAL
REMOVE EYE IMPLANT MATERIAL
TREATMENT OF RETINA
TREATMENT OF RETINA
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
5
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$483.52
$446.13
$302.11
$484.37
$538.28
$398.20
$335.56
$775.30
$721.80
$711.13
$808.88
$862.35
$770.02
$874.92
$799.21
$807.84
$714.38
$643.73
$782.00
$927.06
$92.23
$0.00
$481.93
$553.72
$592.04
$741.02
$870.57
$103.86
$543.72
$396.54
$920.63
$986.32
$1,065.62
$1,177.23
$1,177.23
$1,242.89
$799.66
$733.92
$1,038.71
$1,107.97
$776.04
$1,368.75
$510.06
$670.61
$927.79
$534.29
$537.45
Procedure Code
67208
67210
67218
67220
67221
67225
67227
67228
67229
67250
67255
67299
67311
67312
67314
67316
67318
67320
67331
67332
67334
67335
67340
67343
67345
67346
67399
67400
67405
67412
67413
67414
67415
67420
67430
67440
67445
67450
67500
67505
67515
67550
67560
67570
67599
67700
67710
Description
TREATMENT OF RETINAL LESION
TREATMENT OF CHOROID LESION
OCULAR PHOTODYNAMIC THER
EYE PHOTODYNAMIC THER ADD-ON
DSTRJ EXTENSIVE RETINOPATHY
TREATMENT X10SV RETINOPATHY
TR RETINAL LES PRETERM INF
REINFORCE EYE WALL
REINFORCE/GRAFT EYE WALL
EYE SURGERY PROCEDURE
REVISE EYE MUSCLE
REVISE TWO EYE MUSCLES
REVISE EYE MUSCLE
REVISE TWO EYE MUSCLES
REVISE EYE MUSCLE(S)
REVISE EYE MUSCLE(S) ADD-ON
EYE SURGERY FOLLOW-UP ADD-ON
REREVISE EYE MUSCLES ADD-ON
REVISE EYE MUSCLE W/SUTURE
EYE SUTURE DURING SURGERY
REVISE EYE MUSCLE ADD-ON
RELEASE EYE TISSUE
DESTROY NERVE OF EYE MUSCLE
BIOPSY EYE MUSCLE
UNLISTED PX EXTRAOCULAR MUSC
EXPLORE/DRAIN EYE SOCKET
EXPLORE/TREAT EYE SOCKET
EXPLR/DECOMPRESS EYE SOCKET
ASPIRATION ORBITAL CONTENTS
EXPLORE/DRAIN EYE SOCKET
EXPLR/DECOMPRESS EYE SOCKET
INJECT/TREAT EYE SOCKET
INSERT EYE SOCKET IMPLANT
REVISE EYE SOCKET IMPLANT
DECOMPRESS OPTIC NERVE
ORBIT SURGERY PROCEDURE
DRAINAGE OF EYELID ABSCESS
INCISION OF EYELID
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
5
3
3
3
3
3
3
3
3
3
3
3
3
3
3
5
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
5
3
3
Maximum Allowable
$611.68
$528.38
$1,412.55
$545.03
$292.46
$30.14
$295.32
$347.70
$1,140.67
$797.07
$697.80
$0.00
$610.89
$727.55
$687.44
$818.46
$718.75
$329.45
$312.57
$339.49
$308.26
$152.15
$366.40
$668.12
$248.54
$197.63
$0.00
$949.78
$811.97
$869.17
$874.74
$1,352.84
$106.96
$1,652.56
$1,265.57
$1,229.42
$1,430.86
$1,282.35
$80.69
$90.90
$98.79
$984.98
$1,009.79
$1,186.39
$0.00
$273.67
$228.21
Procedure Code
67715
67800
67801
67805
67808
67810
67820
67825
67830
67835
67840
67850
67875
67880
67882
67900
67901
67902
67903
67904
67906
67908
67909
67911
67912
67914
67915
67916
67917
67921
67922
67923
67924
67930
67935
67938
67950
67961
67966
67971
67973
67974
67975
67999
68020
68040
68100
Description
INCISION OF EYELID FOLD
REMOVE EYELID LESION
REMOVE EYELID LESIONS
REMOVE EYELID LESIONS
REMOVE EYELID LESION(S)
BIOPSY EYELID & LID MARGIN
REVISE EYELASHES
REVISE EYELASHES
REVISE EYELASHES
REVISE EYELASHES
REMOVE EYELID LESION
TREAT EYELID LESION
CLOSURE OF EYELID BY SUTURE
REVISION OF EYELID
REVISION OF EYELID
REPAIR BROW DEFECT
REPAIR EYELID DEFECT
REVISE EYELID DEFECT
REVISE EYELID DEFECT
CORRECTION EYELID W/IMPLANT
REPAIR EYELID WOUND
REPAIR EYELID WOUND
REMOVE EYELID FOREIGN BODY
REVISION OF EYELID
REVISION OF EYELID
REVISION OF EYELID
RECONSTRUCTION OF EYELID
REVISION OF EYELID
INCISE/DRAIN EYELID LINING
TREATMENT OF EYELID LESIONS
BIOPSY OF EYELID LINING
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
5
3
3
3
Maximum Allowable
$244.44
$129.57
$164.78
$205.50
$377.32
$175.78
$50.64
$131.00
$272.04
$447.29
$280.53
$218.92
$174.87
$467.44
$574.92
$653.93
$771.79
$739.94
$605.12
$746.98
$517.63
$502.89
$546.98
$574.53
$902.61
$479.12
$298.66
$603.84
$614.81
$469.48
$295.75
$603.08
$643.04
$370.57
$606.38
$245.04
$584.06
$586.25
$784.49
$739.73
$951.32
$949.16
$699.93
$0.00
$121.59
$63.60
$173.04
Procedure Code
68110
68115
68130
68135
68200
68320
68325
68326
68328
68330
68335
68340
68360
68362
68371
68399
68400
68420
68440
68500
68505
68510
68520
68525
68530
68540
68550
68700
68705
68720
68745
68750
68760
68761
68770
68801
68810
68811
68815
68816
68840
68850
68899
69000
69005
69020
69090
Description
REMOVE EYELID LINING LESION
TREAT EYELID BY INJECTION
REVISE/GRAFT EYELID LINING
REVISE EYELID LINING
SEPARATE EYELID ADHESIONS
HARVEST EYE TISSUE ALOGRAFT
EYELID LINING SURGERY
INCISE/DRAIN TEAR GLAND
INCISE/DRAIN TEAR SAC
INCISE TEAR DUCT OPENING
REMOVAL OF TEAR GLAND
PARTIAL REMOVAL TEAR GLAND
BIOPSY OF TEAR GLAND
REMOVAL OF TEAR SAC
BIOPSY OF TEAR SAC
CLEARANCE OF TEAR DUCT
REMOVE TEAR GLAND LESION
REMOVE TEAR GLAND LESION
REPAIR TEAR DUCTS
REVISE TEAR DUCT OPENING
CREATE TEAR SAC DRAIN
CREATE TEAR DUCT DRAIN
CREATE TEAR DUCT DRAIN
CLOSE TEAR DUCT OPENING
CLOSE TEAR DUCT OPENING
CLOSE TEAR SYSTEM FISTULA
DILATE TEAR DUCT OPENING
PROBE NASOLACRIMAL DUCT
PROBE NL DUCT W/BALLOON
EXPLORE/IRRIGATE TEAR DUCTS
INJECTION FOR TEAR SAC X-RAY
TEAR DUCT SYSTEM SURGERY
DRAIN EXTERNAL EAR LESION
DRAIN EXTERNAL EAR LESION
DRAIN OUTER EAR CANAL LESION
PIERCE EARLOBES
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
5
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
5
3
3
3
9
Maximum Allowable
$229.61
$317.64
$549.32
$159.36
$42.10
$738.94
$673.89
$659.79
$724.11
$616.31
$661.57
$555.92
$543.58
$670.54
$421.90
$0.00
$289.40
$328.20
$104.45
$996.31
$990.61
$453.69
$703.90
$269.57
$435.70
$951.09
$1,131.57
$616.66
$241.06
$773.05
$776.28
$803.77
$205.03
$149.45
$641.73
$102.35
$198.64
$169.94
$405.08
$659.90
$130.34
$62.22
$0.00
$192.65
$222.12
$240.84
$0.00
Procedure Code
69100
69105
69110
69120
69140
69145
69150
69155
69200
69205
69209
69220
69222
69300
69310
69320
69399
69420
69421
69424
69433
69436
69440
69450
69501
69502
69505
69511
69530
69535
69540
69550
69552
69554
69601
69602
69603
69604
69605
69610
69620
69631
69632
69633
69635
69636
69637
Description
BIOPSY OF EXTERNAL EAR
BIOPSY OF EXTERNAL EAR CANAL
REMOVE EXTERNAL EAR PARTIAL
REMOVAL OF EXTERNAL EAR
REMOVE EAR CANAL LESION(S)
REMOVE EAR CANAL LESION(S)
EXTENSIVE EAR CANAL SURGERY
EXTENSIVE EAR/NECK SURGERY
CLEAR OUTER EAR CANAL
CLEAR OUTER EAR CANAL
REMOVE IMPACTED EAR WAX UNI
CLEAN OUT MASTOID CAVITY
CLEAN OUT MASTOID CAVITY
REVISE EXTERNAL EAR
REBUILD OUTER EAR CANAL
REBUILD OUTER EAR CANAL
OUTER EAR SURGERY PROCEDURE
INCISION OF EARDRUM
INCISION OF EARDRUM
REMOVE VENTILATING TUBE
CREATE EARDRUM OPENING
CREATE EARDRUM OPENING
EXPLORATION OF MIDDLE EAR
EARDRUM REVISION
MASTOIDECTOMY
MASTOIDECTOMY
REMOVE MASTOID STRUCTURES
EXTENSIVE MASTOID SURGERY
EXTENSIVE MASTOID SURGERY
REMOVE PART OF TEMPORAL BONE
REMOVE EAR LESION
REMOVE EAR LESION
REMOVE EAR LESION
REMOVE EAR LESION
MASTOID SURGERY REVISION
REPAIR OF EARDRUM
REPAIR OF EARDRUM
REPAIR EARDRUM STRUCTURES
REBUILD EARDRUM STRUCTURES
REPAIR EARDRUM STRUCTURES
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
5
3
3
3
3
3
3
9
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$103.19
$145.18
$475.42
$421.81
$914.41
$411.95
$1,093.07
$1,737.40
$102.12
$105.57
$13.05
$114.05
$227.84
$762.86
$1,137.82
$1,611.60
$0.00
$198.55
$155.31
$131.78
$210.05
$167.16
$719.49
$0.00
$765.61
$1,013.34
$1,254.13
$1,281.38
$1,727.68
$2,799.80
$216.70
$1,086.22
$1,630.12
$2,536.11
$1,090.74
$1,134.78
$1,328.55
$1,160.32
$1,627.66
$398.56
$721.59
$922.35
$1,122.43
$1,089.83
$1,290.42
$1,441.81
$1,433.90
Procedure Code
69641
69642
69643
69644
69645
69646
69650
69660
69661
69662
69666
69667
69670
69676
69700
69710
69711
69714
69715
69717
69718
69720
69725
69740
69745
69799
69801
69805
69806
69820
69840
69905
69910
69915
69930
69949
69950
69955
69960
69970
69979
69990
70010
70015
70030
70100
7010F
Description
REVISE MIDDLE EAR & MASTOID
RELEASE MIDDLE EAR BONE
REVISE MIDDLE EAR BONE
REPAIR MIDDLE EAR STRUCTURES
REPAIR MIDDLE EAR STRUCTURES
REMOVE MASTOID AIR CELLS
REMOVE MIDDLE EAR NERVE
CLOSE MASTOID FISTULA
IMPLANT/REPLACE HEARING AID
REMOVE/REPAIR HEARING AID
IMPLANT TEMPLE BONE W/STIMUL
TEMPLE BNE IMPLNT W/STIMULAT
TEMPLE BONE IMPLANT REVISION
REVISE TEMPLE BONE IMPLANT
RELEASE FACIAL NERVE
REPAIR FACIAL NERVE
REPAIR FACIAL NERVE
MIDDLE EAR SURGERY PROCEDURE
INCISE INNER EAR
EXPLORE INNER EAR
EXPLORE INNER EAR
ESTABLISH INNER EAR WINDOW
REVISE INNER EAR WINDOW
REMOVE INNER EAR
REMOVE INNER EAR & MASTOID
INCISE INNER EAR NERVE
IMPLANT COCHLEAR DEVICE
INNER EAR SURGERY PROCEDURE
INCISE INNER EAR NERVE
RELEASE INNER EAR CANAL
REMOVE INNER EAR LESION
TEMPORAL BONE SURGERY
MICROSURGERY ADD-ON
CONTRAST X-RAY OF BRAIN
CONTRAST X-RAY OF BRAIN
X-RAY EYE FOR FOREIGN BODY
X-RAY EXAM OF JAW <4VIEWS
PT INFO INTO RECALL SYSTEM
Pricing Action Code
3
3
3
3
3
3
3
3
9
3
3
3
3
3
3
5
3
3
3
3
3
3
3
3
3
5
3
3
3
3
3
3
3
3
3
5
3
3
3
3
5
3
3
3
3
3
9
Maximum Allowable
$1,086.26
$1,393.03
$1,276.73
$1,541.35
$1,516.31
$1,610.79
$840.94
$967.17
$0.00
$1,209.09
$843.12
$843.84
$988.71
$866.73
$714.86
$0.00
$901.06
$1,123.72
$1,385.74
$1,180.84
$1,400.13
$1,271.76
$1,961.10
$1,217.41
$1,478.29
$0.00
$202.98
$1,100.03
$985.72
$893.54
$949.64
$956.97
$1,060.51
$1,604.67
$1,277.28
$0.00
$1,859.38
$2,081.42
$2,000.21
$2,238.23
$0.00
$230.62
$62.74
$155.49
$28.16
$33.22
$0.00
Procedure Code
70110
70120
70130
70134
70140
70150
70160
70170
70190
70200
7020F
70210
70220
70240
70250
7025F
70260
70300
70310
70320
70328
70330
70332
70336
70350
70355
70360
70370
70371
70380
70390
70450
70460
70470
70480
70481
70482
70486
70487
70488
70490
70491
70492
70496
70498
70540
70542
Description
X-RAY EXAM OF JAW 4/> VIEWS
X-RAY EXAM OF MASTOIDS
X-RAY EXAM OF MASTOIDS
X-RAY EXAM OF MIDDLE EAR
X-RAY EXAM OF FACIAL BONES
X-RAY EXAM OF FACIAL BONES
X-RAY EXAM OF NASAL BONES
X-RAY EXAM OF TEAR DUCT
X-RAY EXAM OF EYE SOCKETS
X-RAY EXAM OF EYE SOCKETS
MAMMO ASSESS CAT IN DBASE
X-RAY EXAM OF SINUSES
X-RAY EXAM OF SINUSES
X-RAY EXAM PITUITARY SADDLE
X-RAY EXAM OF SKULL
PT INFOSYS ALARM 4 NXT MAMMO
X-RAY EXAM OF SKULL
X-RAY EXAM OF TEETH
X-RAY EXAM OF TEETH
FULL MOUTH X-RAY OF TEETH
X-RAY EXAM OF JAW JOINT
X-RAY EXAM OF JAW JOINTS
X-RAY EXAM OF JAW JOINT
MAGNETIC IMAGE JAW JOINT
X-RAY HEAD FOR ORTHODONTIA
PANORAMIC X-RAY OF JAWS
X-RAY EXAM OF NECK
THROAT X-RAY & FLUOROSCOPY
SPEECH EVALUATION COMPLEX
X-RAY EXAM OF SALIVARY GLAND
X-RAY EXAM OF SALIVARY DUCT
CT HEAD/BRAIN W/O DYE
CT HEAD/BRAIN W/DYE
CT HEAD/BRAIN W/O & W/DYE
CT ORBIT/EAR/FOSSA W/O DYE
CT ORBIT/EAR/FOSSA W/DYE
CT ORBIT/EAR/FOSSA W/O&W/DYE
CT MAXILLOFACIAL W/O DYE
CT MAXILLOFACIAL W/DYE
CT MAXILLOFACIAL W/O & W/DYE
CT SOFT TISSUE NECK W/O DYE
CT SOFT TISSUE NECK W/DYE
CT SFT TSUE NCK W/O & W/DYE
CT ANGIOGRAPHY HEAD
CT ANGIOGRAPHY NECK
MRI ORBIT/FACE/NECK W/O DYE
MRI ORBIT/FACE/NECK W/DYE
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
9
3
3
3
3
9
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$38.24
$34.31
$55.21
$51.94
$29.96
$41.86
$32.87
$0.00
$36.09
$42.56
$0.00
$29.97
$37.88
$30.32
$36.44
$0.00
$46.17
$15.17
$37.22
$53.11
$31.05
$47.66
$82.62
$324.63
$20.22
$20.91
$28.52
$77.67
$92.58
$36.49
$95.37
$117.19
$163.72
$193.69
$179.20
$279.79
$305.47
$141.81
$170.24
$207.81
$178.84
$238.88
$281.19
$298.42
$296.98
$344.63
$407.45
Procedure Code
70543
70544
70545
70546
70547
70548
70549
70551
70552
70553
70554
70555
70557
70558
70559
71010
71015
71020
71021
71022
71023
71030
71034
71035
71100
71101
71110
71111
71120
71130
71250
71260
71270
71275
71550
71551
71552
71555
72020
72040
72050
72052
72070
72072
72074
72080
72081
Description
MRI ORBT/FAC/NCK W/O &W/DYE
MR ANGIOGRAPHY HEAD W/O DYE
MR ANGIOGRAPHY HEAD W/DYE
MR ANGIOGRAPH HEAD W/O&W/DYE
MR ANGIOGRAPHY NECK W/O DYE
MR ANGIOGRAPHY NECK W/DYE
MR ANGIOGRAPH NECK W/O&W/DYE
MRI BRAIN STEM W/O DYE
MRI BRAIN STEM W/DYE
MRI BRAIN STEM W/O & W/DYE
FMRI BRAIN BY TECH
FMRI BRAIN BY PHYS/PSYCH
MRI BRAIN W/O DYE
MRI BRAIN W/DYE
MRI BRAIN W/O & W/DYE
CHEST X-RAY 1 VIEW FRONTAL
CHEST X-RAY STEREO FRONTAL
CHEST X-RAY 2VW FRONTAL&LATL
CHEST X-RAY FRNT LAT LORDOTC
CHEST X-RAY FRNT LAT OBLIQUE
CHEST X-RAY AND FLUOROSCOPY
CHEST X-RAY 4/> VIEWS
CHEST X-RAY&FLUORO 4/> VIEWS
CHEST X-RAY SPECIAL VIEWS
X-RAY EXAM RIBS UNI 2 VIEWS
X-RAY EXAM UNILAT RIBS/CHEST
X-RAY EXAM RIBS BIL 3 VIEWS
X-RAY EXAM RIBS/CHEST4/> VWS
X-RAY EXAM BREASTBONE 2/>VWS
X-RAY STRENOCLAVIC JT 3/>VWS
CT THORAX W/O DYE
CT THORAX W/DYE
CT THORAX W/O & W/DYE
CT ANGIOGRAPHY CHEST
MRI CHEST W/O DYE
MRI CHEST W/DYE
MRI CHEST W/O & W/DYE
MRI ANGIO CHEST W OR W/O DYE
X-RAY EXAM OF SPINE 1 VIEW
X-RAY EXAM NECK SPINE 2-3 VW
X-RAY EXAM NECK SPINE 4/5VWS
X-RAY EXAM NECK SPINE 6/>VWS
X-RAY EXAM THORAC SPINE 2VWS
X-RAY EXAM THORAC SPINE 3VWS
X-RAY EXAM THORAC SPINE4/>VW
X-RAY EXAM THORACOLMB 2/> VW
X-RAY EXAM ENTIRE SPI 1 VW
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$498.38
$337.11
$392.49
$549.61
$337.47
$418.56
$549.61
$233.39
$323.74
$382.46
$457.17
$0.00
$0.00
$0.00
$0.00
$22.73
$28.14
$28.13
$34.25
$42.18
$64.24
$42.20
$84.13
$33.22
$33.19
$36.80
$37.87
$48.35
$29.95
$36.46
$165.60
$232.45
$278.70
$303.45
$350.35
$464.60
$573.27
$402.62
$22.38
$33.56
$45.46
$57.01
$34.28
$35.01
$39.71
$31.02
$39.34
Procedure Code
72082
72083
72084
72100
72110
72114
72120
72125
72126
72127
72128
72129
72130
72131
72132
72133
72141
72142
72146
72147
72148
72149
72156
72157
72158
72159
72170
72190
72191
72192
72193
72194
72195
72196
72197
72198
72200
72202
72220
72240
72255
72265
72270
72275
72285
72295
73000
Description
X-RAY EXAM ENTIRE SPI 2/3 VW
X-RAY EXAM ENTIRE SPI 4/5 VW
X-RAY EXAM ENTIRE SPI 6/> VW
X-RAY EXAM L-S SPINE 2/3 VWS
X-RAY EXAM L-2 SPINE 4/>VWS
X-RAY EXAM L-S SPINE BENDING
X-RAY BEND ONLY L-S SPINE
CT NECK SPINE W/O DYE
CT NECK SPINE W/DYE
CT NECK SPINE W/O & W/DYE
CT CHEST SPINE W/O DYE
CT CHEST SPINE W/DYE
CT CHEST SPINE W/O & W/DYE
CT LUMBAR SPINE W/O DYE
CT LUMBAR SPINE W/DYE
CT LUMBAR SPINE W/O & W/DYE
MRI NECK SPINE W/O DYE
MRI NECK SPINE W/DYE
MRI CHEST SPINE W/O DYE
MRI CHEST SPINE W/DYE
MRI LUMBAR SPINE W/O DYE
MRI LUMBAR SPINE W/DYE
MRI NECK SPINE W/O & W/DYE
MRI CHEST SPINE W/O & W/DYE
MRI LUMBAR SPINE W/O & W/DYE
MR ANGIO SPINE W/O&W/DYE
X-RAY EXAM OF PELVIS
X-RAY EXAM OF PELVIS
CT ANGIOGRAPH PELV W/O&W/DYE
CT PELVIS W/O DYE
CT PELVIS W/DYE
CT PELVIS W/O & W/DYE
MRI PELVIS W/O DYE
MRI PELVIS W/DYE
MRI PELVIS W/O & W/DYE
MR ANGIO PELVIS W/O & W/DYE
X-RAY EXAM SI JOINTS
X-RAY EXAM SI JOINTS 3/> VWS
X-RAY EXAM SACRUM TAILBONE
MYELOGRAPHY NECK SPINE
MYELOGRAPHY THORACIC SPINE
MYELOGRAPHY L-S SPINE
MYELOGPHY 2/> SPINE REGIONS
EPIDUROGRAPHY
DISCOGRAPHY CERV/THOR SPINE
X-RAY OF LOWER SPINE DISK
X-RAY EXAM OF COLLAR BONE
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$63.20
$68.60
$81.59
$35.37
$49.44
$63.19
$40.80
$168.11
$232.09
$274.42
$164.53
$232.46
$276.22
$164.53
$231.37
$274.08
$226.53
$329.19
$226.89
$325.56
$225.44
$324.85
$384.28
$384.64
$383.19
$422.19
$32.14
$38.63
$309.26
$147.46
$228.88
$263.59
$350.35
$416.81
$512.08
$405.54
$28.88
$33.21
$28.52
$99.05
$98.71
$93.32
$128.87
$117.60
$116.30
$100.57
$27.80
Procedure Code
73010
73020
73030
73040
73050
73060
73070
73080
73085
73090
73092
73100
73110
73115
73120
73130
73140
73200
73201
73202
73206
73218
73219
73220
73221
73222
73223
73225
73501
73502
73503
73521
73522
73523
73525
73551
73552
73560
73562
73564
73565
73580
73590
73592
73600
73610
73615
Description
X-RAY EXAM OF SHOULDER BLADE
X-RAY EXAM OF SHOULDER
X-RAY EXAM OF SHOULDER
CONTRAST X-RAY OF SHOULDER
X-RAY EXAM OF SHOULDERS
X-RAY EXAM OF HUMERUS
X-RAY EXAM OF ELBOW
X-RAY EXAM OF ELBOW
CONTRAST X-RAY OF ELBOW
X-RAY EXAM OF FOREARM
X-RAY EXAM OF ARM INFANT
X-RAY EXAM OF WRIST
X-RAY EXAM OF WRIST
CONTRAST X-RAY OF WRIST
X-RAY EXAM OF HAND
X-RAY EXAM OF HAND
X-RAY EXAM OF FINGER(S)
CT UPPER EXTREMITY W/O DYE
CT UPPER EXTREMITY W/DYE
CT UPPR EXTREMITY W/O&W/DYE
CT ANGIO UPR EXTRM W/O&W/DYE
MRI UPPER EXTREMITY W/O DYE
MRI UPPER EXTREMITY W/DYE
MRI UPPR EXTREMITY W/O&W/DYE
MRI JOINT UPR EXTREM W/O DYE
MRI JOINT UPR EXTREM W/DYE
MRI JOINT UPR EXTR W/O&W/DYE
MR ANGIO UPR EXTR W/O&W/DYE
X-RAY EXAM HIP UNI 1 VIEW
X-RAY EXAM HIP UNI 2-3 VIEWS
X-RAY EXAM HIP UNI 4/> VIEWS
X-RAY EXAM HIPS BI 2 VIEWS
X-RAY EXAM HIPS BI 3-4 VIEWS
X-RAY EXAM HIPS BI 5/> VIEWS
CONTRAST X-RAY OF HIP
X-RAY EXAM OF FEMUR 1
X-RAY EXAM OF FEMUR 2/>
X-RAY EXAM OF KNEE 1 OR 2
X-RAY EXAM OF KNEE 3
X-RAY EXAM KNEE 4 OR MORE
X-RAY EXAM OF KNEES
CONTRAST X-RAY OF KNEE JOINT
X-RAY EXAM OF LOWER LEG
X-RAY EXAM OF LEG INFANT
X-RAY EXAM OF ANKLE
X-RAY EXAM OF ANKLE
CONTRAST X-RAY OF ANKLE
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$30.33
$23.11
$29.23
$101.43
$36.10
$29.25
$27.81
$31.42
$98.92
$25.99
$27.44
$29.62
$35.76
$108.33
$26.35
$31.06
$31.80
$164.53
$225.63
$281.33
$330.24
$344.99
$409.63
$506.71
$239.29
$383.20
$475.57
$410.66
$30.32
$41.89
$52.36
$40.43
$49.45
$57.41
$103.26
$28.17
$32.86
$31.42
$36.11
$40.07
$36.50
$117.02
$28.89
$28.17
$30.34
$31.78
$106.87
Procedure Code
73620
73630
73650
73660
73700
73701
73702
73706
73718
73719
73720
73721
73722
73723
73725
74000
74010
74020
74022
74150
74160
74170
74174
74175
74176
74177
74178
74181
74182
74183
74185
74190
74210
74220
74230
74235
74240
74241
74245
74246
74247
74249
74250
74251
74260
74261
74262
Description
X-RAY EXAM OF FOOT
X-RAY EXAM OF FOOT
X-RAY EXAM OF HEEL
X-RAY EXAM OF TOE(S)
CT LOWER EXTREMITY W/O DYE
CT LOWER EXTREMITY W/DYE
CT LWR EXTREMITY W/O&W/DYE
CT ANGIO LWR EXTR W/O&W/DYE
MRI LOWER EXTREMITY W/O DYE
MRI LOWER EXTREMITY W/DYE
MRI LWR EXTREMITY W/O&W/DYE
MRI JNT OF LWR EXTRE W/O DYE
MRI JOINT OF LWR EXTR W/DYE
MRI JOINT LWR EXTR W/O&W/DYE
MR ANG LWR EXT W OR W/O DYE
X-RAY EXAM OF ABDOMEN
X-RAY EXAM SERIES ABDOMEN
CT ABDOMEN W/O DYE
CT ABDOMEN W/DYE
CT ABDOMEN W/O & W/DYE
CT ANGIO ABD&PELV W/O&W/DYE
CT ANGIO ABDOM W/O & W/DYE
CT ABD & PELVIS W/O CONTRAST
CT ABD & PELV W/CONTRAST
CT ABD & PELV 1/> REGNS
MRI ABDOMEN W/O DYE
MRI ABDOMEN W/DYE
MRI ABDOMEN W/O & W/DYE
MRI ANGIO ABDOM W ORW/O DYE
X-RAY EXAM OF PERITONEUM
CONTRST X-RAY EXAM OF THROAT
CONTRAST X-RAY ESOPHAGUS
CINE/VID X-RAY THROAT/ESOPH
REMOVE ESOPHAGUS OBSTRUCTION
X-RAY UPPER GI DELAY W/O KUB
X-RAY UPPER GI DELAY W/KUB
X-RAY UPPER GI&SMALL INTEST
CONTRST X-RAY UPPR GI TRACT
X-RAY EXAM OF SMALL BOWEL
CT COLONOGRAPHY DX
CT COLONOGRAPHY DX W/DYE
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$26.35
$29.61
$27.44
$28.55
$164.53
$229.24
$278.43
$335.29
$344.99
$409.63
$509.24
$239.65
$387.18
$476.66
$406.61
$23.80
$35.72
$37.89
$45.09
$151.39
$233.51
$265.66
$393.38
$310.69
$202.13
$315.37
$357.28
$337.32
$460.25
$513.17
$408.43
$0.00
$78.73
$89.91
$128.60
$0.00
$114.75
$119.45
$173.63
$128.50
$136.83
$186.30
$105.11
$229.13
$219.11
$236.50
$366.39
Procedure Code
74263
74270
74280
74283
74290
74301
74328
74329
74330
74340
74355
74360
74363
74400
74410
74415
74420
74425
74430
74440
74445
74450
74455
74470
74485
74710
74712
74713
74740
74742
74775
75557
75559
75561
75563
75565
75571
75572
75573
75574
75600
75605
75625
75630
75635
75658
75705
Description
CT COLONOGRAPHY SCREENING
CONTRAST X-RAY EXAM OF COLON
CONTRAST X-RAY GALLBLADDER
X-RAYS AT SURGERY ADD-ON
X-RAY BILE DUCT ENDOSCOPY
X-RAY FOR PANCREAS ENDOSCOPY
X-RAY BILE/PANC ENDOSCOPY
X-RAY GUIDE FOR GI TUBE
X-RAY GUIDE INTESTINAL TUBE
X-RAY GUIDE GI DILATION
X-RAY BILE DUCT DILATION
CONTRST X-RAY URINARY TRACT
CONTRAST X-RAY BLADDER
X-RAY MALE GENITAL TRACT
X-RAY EXAM OF PENIS
X-RAY URETHRA/BLADDER
X-RAY URETHRA/BLADDER
X-RAY EXAM OF KIDNEY LESION
X-RAY GUIDE GU DILATION
X-RAY MEASUREMENT OF PELVIS
MRI FETAL SNGL/1ST GESTATION
MRI FETAL EA ADDL GESTATION
X-RAY FEMALE GENITAL TRACT
X-RAY FALLOPIAN TUBE
X-RAY EXAM OF PERINEUM
CARDIAC MRI FOR MORPH
CARDIAC MRI W/STRESS IMG
CARDIAC MRI FOR MORPH W/DYE
CARD MRI W/STRESS IMG & DYE
CARD MRI VELOC FLOW MAPPING
CT HRT W/O DYE W/CA TEST
CT HRT W/3D IMAGE
CT HRT W/3D IMAGE CONGEN
CT ANGIO HRT W/3D IMAGE
CONTRAST EXAM THORACIC AORTA
CONTRAST EXAM THORACIC AORTA
CONTRAST EXAM ABDOMINL AORTA
X-RAY AORTA LEG ARTERIES
CT ANGIO ABDOMINAL ARTERIES
ARTERY X-RAYS ARM
ARTERY X-RAYS SPINE
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
9
3
3
3
3
3
3
9
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$766.80
$136.83
$215.58
$207.76
$71.16
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$110.88
$109.43
$138.40
$0.00
$0.00
$37.85
$82.32
$0.00
$0.00
$82.73
$0.00
$93.45
$37.11
$429.49
$234.31
$75.82
$0.00
$0.00
$321.92
$440.61
$427.85
$507.94
$55.60
$0.00
$287.18
$366.73
$358.85
$201.06
$141.35
$140.68
$173.64
$360.35
$168.85
$248.17
Procedure Code
75710
75716
75726
75731
75733
75736
75741
75743
75746
75756
75774
75791
75801
75803
75805
75807
75809
75810
75820
75822
75825
75827
75831
75833
75840
75842
75860
75870
75872
75880
75885
75887
75889
75891
75893
75894
75898
75901
75902
75952
75953
75954
75956
75957
75958
75959
75962
Description
ARTERY X-RAYS ARM/LEG
ARTERY X-RAYS ARMS/LEGS
ARTERY X-RAYS ABDOMEN
ARTERY X-RAYS ADRENAL GLAND
ARTERY X-RAYS ADRENALS
ARTERY X-RAYS PELVIS
ARTERY X-RAYS LUNG
ARTERY X-RAYS LUNGS
ARTERY X-RAYS LUNG
ARTERY X-RAYS CHEST
ARTERY X-RAY EACH VESSEL
AV DIALYSIS SHUNT IMAGING
LYMPH VESSEL X-RAY ARM/LEG
LYMPH VESSEL X-RAY ARMS/LEGS
LYMPH VESSEL X-RAY TRUNK
LYMPH VESSEL X-RAY TRUNK
NONVASCULAR SHUNT X-RAY
VEIN X-RAY SPLEEN/LIVER
VEIN X-RAY ARM/LEG
VEIN X-RAY ARMS/LEGS
VEIN X-RAY TRUNK
VEIN X-RAY CHEST
VEIN X-RAY KIDNEY
VEIN X-RAY KIDNEYS
VEIN X-RAY ADRENAL GLAND
VEIN X-RAY ADRENAL GLANDS
VEIN X-RAY NECK
VEIN X-RAY SKULL
VEIN X-RAY SKULL EPIDURAL
VEIN X-RAY EYE SOCKET
VEIN X-RAY LIVER W/HEMODYNAM
VEIN X-RAY LIVER W/O HEMODYN
VEIN X-RAY LIVER W/HEMODYNAM
VEIN X-RAY LIVER
VENOUS SAMPLING BY CATHETER
X-RAYS TRANSCATH THERAPY
FOLLOW-UP ANGIOGRAPHY
REMOVE CVA DEVICE OBSTRUCT
REMOVE CVA LUMEN OBSTRUCT
ENDOVASC REPAIR ABDOM AORTA
ABDOM ANEURYSM ENDOVAS RPR
ILIAC ANEURYSM ENDOVAS RPR
XRAY ENDOVASC THOR AO REPR
XRAY ENDOVASC THOR AO REPR
XRAY PLACE PROX EXT THOR AO
XRAY PLACE DIST EXT THOR AO
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$166.39
$190.57
$151.80
$175.31
$186.79
$162.72
$153.50
$171.78
$154.70
$169.30
$89.25
$330.18
$0.00
$0.00
$0.00
$0.00
$101.12
$0.00
$117.67
$139.93
$139.23
$141.05
$142.80
$167.34
$151.05
$183.45
$145.67
$150.32
$142.76
$145.51
$160.67
$161.38
$146.35
$147.80
$120.26
$0.00
$0.00
$180.03
$72.93
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$142.78
Procedure Code
75964
75966
75968
75970
75978
75984
75989
76000
76001
76010
76080
76098
76100
76101
76102
76120
76125
76140
76376
76377
76380
76390
76496
76497
76498
76499
76506
76510
76511
76512
76513
76514
76516
76519
76529
76536
76604
76641
76642
76700
76705
76770
76775
76776
76800
76801
76802
Description
REPAIR ARTERY BLOCKAGE EACH
REPAIR ARTERY BLOCKAGE EACH
VASCULAR BIOPSY
XRAY CONTROL CATHETER CHANGE
ABSCESS DRAINAGE UNDER X-RAY
FLUOROSCOPE EXAMINATION
FLUOROSCOPE EXAM EXTENSIVE
X-RAY NOSE TO RECTUM
X-RAY EXAM OF FISTULA
X-RAY EXAM BREAST SPECIMEN
X-RAY EXAM OF BODY SECTION
COMPLEX BODY SECTION X-RAY
COMPLEX BODY SECTION X-RAYS
CINE/VIDEO X-RAYS
CINE/VIDEO X-RAYS ADD-ON
X-RAY CONSULTATION
3D RENDER W/INTRP POSTPROCES
3D RENDER W/INTRP POSTPROCES
CAT SCAN FOLLOW-UP STUDY
MR SPECTROSCOPY
FLUOROSCOPIC PROCEDURE
CT PROCEDURE
MRI PROCEDURE
RADIOGRAPHIC PROCEDURE
ECHO EXAM OF HEAD
OPHTH US B & QUANT A
OPHTH US QUANT A ONLY
OPHTH US B W/NON-QUANT A
ECHO EXAM OF EYE WATER BATH
ECHO EXAM OF EYE THICKNESS
ECHO EXAM OF EYE
ECHO EXAM OF EYE
ECHO EXAM OF EYE
US EXAM OF HEAD AND NECK
US EXAM CHEST
ULTRASOUND BREAST COMPLETE
ULTRASOUND BREAST LIMITED
US EXAM ABDOM COMPLETE
ECHO EXAM OF ABDOMEN
US EXAM ABDO BACK WALL COMP
US EXAM ABDO BACK WALL LIM
US EXAM K TRANSPL W/DOPPLER
US EXAM SPINAL CANAL
OB US < 14 WKS SINGLE FETUS
OB US < 14 WKS ADDL FETUS
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
5
5
5
5
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$90.00
$174.24
$89.25
$0.00
$140.96
$108.21
$122.43
$48.09
$0.00
$26.34
$55.82
$16.94
$94.21
$133.99
$178.18
$84.87
$0.00
$38.59
$23.43
$65.46
$111.69
$452.02
$0.00
$0.00
$0.00
$0.00
$120.60
$173.50
$102.94
$94.26
$96.61
$15.49
$80.40
$86.19
$80.74
$118.43
$89.85
$109.65
$90.14
$125.17
$93.07
$115.43
$59.05
$159.95
$144.72
$126.17
$66.16
Procedure Code
76805
76810
76811
76812
76813
76814
76815
76816
76817
76818
76819
76820
76821
76825
76826
76827
76828
76830
76831
76856
76857
76870
76872
76873
76881
76882
76885
76886
76930
76932
76936
76937
76940
76941
76942
76945
76946
76948
76965
76970
76975
76977
76998
76999
77001
77002
77003
Description
OB US >/= 14 WKS SNGL FETUS
OB US >/= 14 WKS ADDL FETUS
OB US DETAILED SNGL FETUS
OB US DETAILED ADDL FETUS
OB US NUCHAL MEAS 1 GEST
OB US NUCHAL MEAS ADD-ON
OB US LIMITED FETUS(S)
OB US FOLLOW-UP PER FETUS
TRANSVAGINAL US OBSTETRIC
FETAL BIOPHYS PROFILE W/NST
FETAL BIOPHYS PROFIL W/O NST
UMBILICAL ARTERY ECHO
MIDDLE CEREBRAL ARTERY ECHO
ECHO EXAM OF FETAL HEART
TRANSVAGINAL US NON-OB
ECHO EXAM UTERUS
US EXAM PELVIC COMPLETE
US EXAM PELVIC LIMITED
US EXAM SCROTUM
US TRANSRECTAL
ECHOGRAP TRANS R PROS STUDY
US XTR NON-VASC COMPLETE
US XTR NON-VASC LMTD
US EXAM INFANT HIPS DYNAMIC
US EXAM INFANT HIPS STATIC
ECHO GUIDE CARDIOCENTESIS
ECHO GUIDE FOR HEART BIOPSY
ECHO GUIDE FOR ARTERY REPAIR
US GUIDE VASCULAR ACCESS
US GUIDE TISSUE ABLATION
ECHO GUIDE FOR TRANSFUSION
ECHO GUIDE FOR BIOPSY
ECHO GUIDE VILLUS SAMPLING
ECHO GUIDE FOR AMNIOCENTESIS
ECHO GUIDE OVA ASPIRATION
ECHO GUIDANCE RADIOTHERAPY
ULTRASOUND EXAM FOLLOW-UP
GI ENDOSCOPIC ULTRASOUND
US BONE DENSITY MEASURE
US GUIDE INTRAOP
ECHO EXAMINATION PROCEDURE
FLUOROGUIDE FOR VEIN DEVICE
NEEDLE LOCALIZATION BY XRAY
FLUOROGUIDE FOR SPINE INJECT
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
9
3
3
3
3
3
5
3
3
3
Maximum Allowable
$145.01
$95.77
$186.57
$211.60
$124.30
$83.51
$86.17
$117.95
$99.52
$124.75
$91.20
$48.99
$95.23
$282.92
$167.14
$77.52
$54.74
$124.52
$121.62
$112.21
$48.25
$68.81
$95.88
$170.68
$117.67
$36.67
$130.64
$108.26
$0.00
$0.00
$277.20
$32.06
$0.00
$0.00
$62.27
$0.00
$33.49
$0.00
$91.50
$95.35
$0.00
$7.24
$0.00
$0.00
$71.48
$94.57
$87.64
Procedure Code
77011
77012
77013
77014
77021
77022
77051
77052
77053
77054
77055
77056
77057
77058
77059
77061
77062
77063
77071
77072
77073
77074
77075
77076
77077
77078
77080
77081
77084
77085
77086
77261
77262
77263
77280
77285
77290
77293
77295
77299
77300
77301
77306
77307
77316
77317
77318
Description
CT SCAN FOR LOCALIZATION
CT SCAN FOR NEEDLE BIOPSY
CT GUIDE FOR TISSUE ABLATION
CT SCAN FOR THERAPY GUIDE
MR GUIDANCE FOR NEEDLE PLACE
MRI FOR TISSUE ABLATION
COMPUTER DX MAMMOGRAM ADD-ON
COMP SCREEN MAMMOGRAM ADD-ON
X-RAY OF MAMMARY DUCT
X-RAY OF MAMMARY DUCTS
MAMMOGRAM ONE BREAST
MAMMOGRAM BOTH BREASTS
MAMMOGRAM SCREENING
MRI ONE BREAST
MRI BOTH BREASTS
BREAST TOMOSYNTHESIS UNI
BREAST TOMOSYNTHESIS BI
BREAST TOMOSYNTHESIS BI
X-RAY STRESS VIEW
X-RAYS FOR BONE AGE
X-RAYS BONE LENGTH STUDIES
X-RAYS BONE SURVEY LIMITED
X-RAYS BONE SURVEY COMPLETE
X-RAYS BONE SURVEY INFANT
JOINT SURVEY SINGLE VIEW
CT BONE DENSITY AXIAL
DXA BONE DENSITY AXIAL
DXA BONE DENSITY/PERIPHERAL
MAGNETIC IMAGE BONE MARROW
DXA BONE DENSITY STUDY
FRACTURE ASSESSMENT VIA DXA
RADIATION THERAPY PLANNING
SET RADIATION THERAPY FIELD
RESPIRATOR MOTION MGMT SIMUL
3-D RADIOTHERAPY PLAN
RADIATION THERAPY DOSE PLAN
RADIOTHERAPY DOSE PLAN IMRT
TELETHX ISODOSE PLAN SIMPLE
TELETHX ISODOSE PLAN CPLX
BRACHYTX ISODOSE PLAN SIMPLE
BRACHYTX ISODOSE INTERMED
BRACHYTX ISODOSE COMPLEX
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
9
9
9
3
3
3
3
3
3
3
3
3
3
3
9
9
3
3
3
3
3
3
3
3
5
3
3
3
3
3
3
3
Maximum Allowable
$226.31
$126.07
$0.00
$119.71
$408.96
$0.00
$8.29
$8.29
$59.18
$77.97
$91.21
$117.18
$83.60
$541.04
$541.04
$0.00
$0.00
$0.00
$49.45
$23.44
$36.80
$65.30
$88.77
$97.36
$37.86
$74.08
$41.90
$28.49
$357.88
$0.00
$0.00
$76.70
$114.71
$167.74
$278.70
$439.60
$524.73
$474.54
$498.20
$0.00
$67.72
$1,990.00
$151.62
$293.01
$191.82
$249.50
$360.40
Procedure Code
77321
77331
77332
77333
77334
77336
77338
77370
77371
77372
77373
77385
77386
77387
77399
77401
77402
77407
77412
77417
77422
77423
77424
77425
77427
77431
77432
77435
77469
77470
77499
77520
77522
77523
77525
77600
77605
77610
77615
77620
77750
77761
77762
77763
77767
77768
77770
Description
SPECIAL TELETX PORT PLAN
SPECIAL RADIATION DOSIMETRY
RADIATION TREATMENT AID(S)
RADIATION PHYSICS CONSULT
DESIGN MLC DEVICE FOR IMRT
RADIATION PHYSICS CONSULT
SRS MULTISOURCE
SRS LINEAR BASED
SBRT DELIVERY
NTSTY MODUL RAD TX DLVR SMPL
NTSTY MODUL RAD TX DLVR CPLX
GUIDANCE FOR RADIAJ TX DLVR
EXTERNAL RADIATION DOSIMETRY
RADIATION TREATMENT DELIVERY
RADIOLOGY PORT IMAGES(S)
NEUTRON BEAM TX SIMPLE
NEUTRON BEAM TX COMPLEX
IO RAD TX DELIVERY BY X-RAY
IO RAD TX DELIVER BY ELCTRNS
RADIATION TX MANAGEMENT X5
RADIATION THERAPY MANAGEMENT
STEREOTACTIC RADIATION TRMT
SBRT MANAGEMENT
IO RADIATION TX MANAGEMENT
SPECIAL RADIATION TREATMENT
RADIATION THERAPY MANAGEMENT
PROTON TRMT SIMPLE W/O COMP
PROTON TRMT SIMPLE W/COMP
PROTON TRMT INTERMEDIATE
PROTON TREATMENT COMPLEX
HYPERTHERMIA TREATMENT
INFUSE RADIOACTIVE MATERIALS
APPLY INTRCAV RADIAT SIMPLE
APPLY INTRCAV RADIAT INTERM
APPLY INTRCAV RADIAT COMPL
HDR RDNCL SKN SURF BRACHYTX
HDR RDNCL SKN SURF BRACHYTX
HDR RDNCL NTRSTL/ICAV BRCHTX
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
9
9
9
5
3
9
9
9
3
3
3
6
6
3
3
3
3
3
3
5
5
5
5
5
9
9
9
9
3
3
3
3
3
9
9
9
Maximum Allowable
$94.31
$64.67
$84.76
$53.83
$154.94
$81.21
$515.96
$124.38
$1,188.49
$1,095.34
$1,391.88
$0.00
$0.00
$0.00
$0.00
$25.00
$0.00
$0.00
$0.00
$11.24
$33.98
$66.15
$0.00
$0.00
$187.88
$103.28
$422.57
$637.67
$325.92
$158.45
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$390.84
$376.13
$395.34
$525.60
$744.04
$0.00
$0.00
$0.00
Procedure Code
77771
77772
77778
77789
77790
77799
78012
78013
78014
78015
78016
78018
78020
78070
78071
78072
78075
78099
78102
78103
78104
78110
78111
78120
78121
78122
78130
78135
78140
78185
78190
78191
78195
78199
78201
78202
78205
78206
78215
78216
78226
78227
78230
78231
78232
78258
78261
Description
APPLY INTERSTIT RADIAT COMPL
APPLY SURF LDR RADIONUCLIDE
RADIATION HANDLING
RADIUM/RADIOISOTOPE THERAPY
THYROID UPTAKE MEASUREMENT
THYROID IMAGING W/BLOOD FLOW
THYROID IMAGING W/BLOOD FLOW
THYROID MET IMAGING
THYROID MET IMAGING/STUDIES
THYROID MET IMAGING BODY
THYROID MET UPTAKE
PARATHYROID PLANAR IMAGING
PARATHYRD PLANAR W/WO SUBTRJ
PARATHYRD PLANAR W/SPECT&CT
ADRENAL CORTEX & MEDULLA IMG
ENDOCRINE NUCLEAR PROCEDURE
BONE MARROW IMAGING LTD
BONE MARROW IMAGING MULT
BONE MARROW IMAGING BODY
PLASMA VOLUME SINGLE
PLASMA VOLUME MULTIPLE
RED CELL MASS SINGLE
RED CELL MASS MULTIPLE
BLOOD VOLUME
RED CELL SURVIVAL STUDY
RED CELL SURVIVAL KINETICS
RED CELL SEQUESTRATION
SPLEEN IMAGING
PLATELET SURVIVAL KINETICS
PLATELET SURVIVAL
LYMPH SYSTEM IMAGING
BLOOD/LYMPH NUCLEAR EXAM
LIVER IMAGING
LIVER IMAGING WITH FLOW
LIVER IMAGING (3D)
LIVER IMAGE (3D) WITH FLOW
LIVER AND SPLEEN IMAGING
LIVER & SPLEEN IMAGE/FLOW
HEPATOBILIARY SYSTEM IMAGING
HEPATOBIL SYST IMAGE W/DRUG
SALIVARY GLAND IMAGING
SERIAL SALIVARY IMAGING
SALIVARY GLAND FUNCTION EXAM
ESOPHAGEAL MOTILITY STUDY
GASTRIC MUCOSA IMAGING
Pricing Action Code
9
9
3
3
3
5
3
3
3
3
3
3
3
3
3
3
3
5
3
3
3
3
3
3
3
9
3
3
3
3
3
3
3
5
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$0.00
$0.00
$792.26
$122.07
$15.22
$0.00
$83.19
$200.39
$253.90
$231.34
$292.77
$327.91
$87.28
$314.53
$375.86
$433.90
$449.61
$0.00
$177.85
$233.48
$257.34
$98.41
$100.92
$98.38
$107.03
$0.00
$176.72
$367.85
$142.69
$222.45
$413.88
$176.72
$373.70
$0.00
$197.09
$211.89
$222.26
$360.07
$204.67
$131.50
$348.62
$380.75
$147.83
$136.24
$103.29
$232.76
$261.03
Procedure Code
78262
78264
78265
78266
78267
78268
78270
78271
78272
78278
78282
78290
78291
78299
78300
78305
78306
78315
78320
78350
78351
78399
78414
78428
78445
78451
78452
78453
78454
78456
78457
78458
78459
78466
78468
78469
78472
78473
78481
78483
78491
78492
78494
78496
78499
78579
78580
Description
GASTROESOPHAGEAL REFLUX EXAM
GASTRIC EMPTYING IMAG STUDY
BREATH TST ATTAIN/ANAL C-14
BREATH TEST ANALYSIS C-14
VIT B-12 ABSORPTION EXAM
VIT B-12 ABSRP EXAM INT FAC
VIT B-12 ABSORP COMBINED
ACUTE GI BLOOD LOSS IMAGING
GI PROTEIN LOSS EXAM
MECKELS DIVERT EXAM
LEVEEN/SHUNT PATENCY EXAM
GI NUCLEAR PROCEDURE
BONE IMAGING LIMITED AREA
BONE IMAGING MULTIPLE AREAS
BONE IMAGING WHOLE BODY
BONE IMAGING 3 PHASE
BONE IMAGING (3D)
BONE MINERAL SINGLE PHOTON
BONE MINERAL DUAL PHOTON
MUSCULOSKELETAL NUCLEAR EXAM
NON-IMAGING HEART FUNCTION
CARDIAC SHUNT IMAGING
VASCULAR FLOW IMAGING
HT MUSCLE IMAGE SPECT SING
HT MUSCLE IMAGE SPECT MULT
HT MUSCLE IMAGE PLANAR SING
HT MUSC IMAGE PLANAR MULT
ACUTE VENOUS THROMBUS IMAGE
VENOUS THROMBOSIS IMAGING
VEN THROMBOSIS IMAGES BILAT
HEART MUSCLE IMAGING (PET)
HEART INFARCT IMAGE
HEART INFARCT IMAGE (EF)
HEART INFARCT IMAGE (3D)
GATED HEART PLANAR SINGLE
GATED HEART MULTIPLE
HEART FIRST PASS SINGLE
HEART FIRST PASS MULTIPLE
HEART IMAGE (PET) SINGLE
HEART IMAGE (PET) MULTIPLE
HEART IMAGE SPECT
HEART FIRST PASS ADD-ON
CARDIOVASCULAR NUCLEAR EXAM
LUNG VENTILATION IMAGING
LUNG PERFUSION IMAGING
Pricing Action Code
3
3
3
3
5
5
3
3
3
3
3
3
3
5
3
3
3
3
3
3
3
5
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
5
3
3
Maximum Allowable
$256.67
$351.88
$384.34
$497.59
$0.00
$0.00
$106.01
$95.15
$101.62
$366.57
$0.00
$350.83
$264.52
$0.00
$190.13
$242.85
$265.28
$364.37
$238.73
$33.56
$15.41
$0.00
$0.00
$188.91
$183.66
$357.64
$496.55
$319.14
$459.06
$331.79
$197.32
$175.06
$0.00
$202.73
$207.36
$238.43
$240.94
$302.92
$182.26
$252.59
$0.00
$0.00
$235.01
$45.70
$0.00
$195.97
$251.59
Procedure Code
78582
78597
78598
78599
78600
78601
78605
78606
78607
78608
78609
78610
78630
78635
78645
78647
78650
78660
78699
78700
78701
78707
78708
78709
78710
78725
78730
78740
78761
78799
78800
78801
78802
78803
78804
78805
78806
78807
78808
78811
78812
78813
78814
78815
78816
78999
79005
Description
LUNG VENTILAT&PERFUS IMAGING
LUNG PERFUSION DIFFERENTIAL
LUNG PERF&VENTILAT DIFERENTL
RESPIRATORY NUCLEAR EXAM
BRAIN IMAGE < 4 VIEWS
BRAIN IMAGE W/FLOW < 4 VIEWS
BRAIN IMAGE 4+ VIEWS
BRAIN IMAGE W/FLOW 4 + VIEWS
BRAIN IMAGING (3D)
BRAIN IMAGING (PET)
BRAIN IMAGING (PET)
BRAIN FLOW IMAGING ONLY
CEREBROSPINAL FLUID SCAN
CSF VENTRICULOGRAPHY
CSF SHUNT EVALUATION
CEREBROSPINAL FLUID SCAN
CSF LEAKAGE IMAGING
NUCLEAR EXAM OF TEAR FLOW
NERVOUS SYSTEM NUCLEAR EXAM
KIDNEY IMAGING MORPHOL
KIDNEY IMAGING WITH FLOW
K FLOW/FUNCT IMAGE W/O DRUG
K FLOW/FUNCT IMAGE W/DRUG
K FLOW/FUNCT IMAGE MULTIPLE
KIDNEY IMAGING (3D)
KIDNEY FUNCTION STUDY
URINARY BLADDER RETENTION
URETERAL REFLUX STUDY
TESTICULAR IMAGING W/FLOW
GENITOURINARY NUCLEAR EXAM
TUMOR IMAGING LIMITED AREA
TUMOR IMAGING MULT AREAS
TUMOR IMAGING WHOLE BODY
TUMOR IMAGING (3D)
TUMOR IMAGING WHOLE BODY
ABSCESS IMAGING LTD AREA
ABSCESS IMAGING WHOLE BODY
NUCLEAR LOCALIZATION/ABSCESS
IV INJ RA DRUG DX STUDY
PET IMAGE LTD AREA
PET IMAGE SKULL-THIGH
PET IMAGE FULL BODY
PET IMAGE W/CT LMTD
PET IMAGE W/CT SKULL-THIGH
PET IMAGE W/CT FULL BODY
NUCLEAR DIAGNOSTIC EXAM
NUCLEAR RX ORAL ADMIN
Pricing Action Code
3
3
3
5
3
3
3
3
3
3
3
3
3
3
3
3
3
3
5
3
3
3
3
3
3
3
3
3
3
5
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
5
3
Maximum Allowable
$352.06
$212.10
$322.48
$0.00
$194.21
$224.93
$209.36
$347.94
$368.60
$0.00
$75.45
$183.79
$356.26
$356.65
$339.67
$368.08
$346.52
$189.44
$0.00
$180.79
$221.67
$243.85
$181.82
$381.53
$209.99
$113.14
$80.30
$228.86
$219.02
$0.00
$201.00
$274.41
$341.66
$357.46
$596.08
$191.14
$349.62
$357.09
$47.35
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$139.43
Procedure Code
79101
79200
79300
79403
79440
79445
79999
80047
80048
80049
80050
80051
80052
80053
80054
80055
80056
80057
80061
80069
80074
80076
80081
80150
80155
80156
80157
80158
80159
80162
80163
80164
80165
80168
80169
80170
80171
80173
80175
80176
80177
80178
80180
80183
80184
80185
80186
Description
Pricing Action Code
NUCLEAR RX IV ADMIN
NUCLEAR RX INTRACAV ADMIN
NUCLR RX INTERSTIT COLLOID
HEMATOPOIETIC NUCLEAR TX
NUCLEAR RX INTRA-ARTICULAR
NUCLEAR RX INTRA-ARTERIAL
NUCLEAR MEDICINE THERAPY
METABOLIC PANEL IONIZED CA
METABOLIC PANEL TOTAL CA
METABOLIC PANEL, BASIC
GENERAL HEALTH PANEL
ELECTROLYTE PANEL
PRE-MARITAL PROFILE
COMPREHEN METABOLIC PANEL
COMPREHEN METABOLIC PANEL
OBSTETRIC PANEL
AMENORRHEA PROFILE
MALE INFERTILITY AND/OR GYNECOMAS
LIPID PANEL
RENAL FUNCTION PANEL
ACUTE HEPATITIS PANEL
HEPATIC FUNCTION PANEL
OBSTETRIC PANEL
ASSAY OF AMIKACIN
DRUG ASSAY CAFFEINE
ASSAY CARBAMAZEPINE TOTAL
ASSAY CARBAMAZEPINE FREE
DRUG ASSAY CYCLOSPORINE
DRUG ASSAY CLOZAPINE
ASSAY OF DIGOXIN TOTAL
ASSAY OF DIGOXIN FREE
ASSAY DIPROPYLACETIC ACD TOT
DIPROPYLACETIC ACID FREE
ASSAY OF ETHOSUXIMIDE
DRUG ASSAY EVEROLIMUS
ASSAY OF GENTAMICIN
DRUG SCREEN QUANT GABAPENTIN
ASSAY OF HALOPERIDOL
DRUG SCREEN QUAN LAMOTRIGINE
ASSAY OF LIDOCAINE
DRUG SCRN QUAN LEVETIRACETAM
ASSAY OF LITHIUM
DRUG SCRN QUAN MYCOPHENOLATE
DRUG SCRN QUANT OXCARBAZEPIN
ASSAY OF PHENOBARBITAL
ASSAY OF PHENYTOIN TOTAL
ASSAY OF PHENYTOIN FREE
3
3
3
3
3
3
5
3
3
9
3
3
9
3
9
3
9
9
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$145.46
$163.20
$0.00
$196.74
$147.60
$0.00
$0.00
$11.29
$11.29
$0.00
$16.32
$9.36
$0.00
$14.10
$0.00
$63.82
$0.00
$0.00
$17.88
$11.59
$63.35
$10.91
$99.93
$20.13
$18.88
$19.44
$17.70
$24.10
$21.43
$17.73
$17.73
$18.09
$18.09
$20.11
$18.34
$21.87
$17.70
$19.44
$17.70
$19.61
$17.70
$8.83
$24.10
$17.70
$15.29
$17.70
$18.37
Procedure Code
80188
80190
80192
80194
80195
80197
80198
80199
80200
80201
80202
80203
80299
80300
80301
80302
80303
80304
80320
80321
80322
80323
80324
80325
80326
80327
80328
80329
80330
80331
80332
80333
80334
80335
80336
80337
80338
80339
80340
80341
80342
80343
80344
80345
80346
80347
80348
Description
ASSAY OF PRIMIDONE
ASSAY OF PROCAINAMIDE
ASSAY OF PROCAINAMIDE
ASSAY OF QUINIDINE
ASSAY OF SIROLIMUS
ASSAY OF TACROLIMUS
ASSAY OF THEOPHYLLINE
DRUG SCREEN QUANT TIAGABINE
ASSAY OF TOBRAMYCIN
ASSAY OF TOPIRAMATE
ASSAY OF VANCOMYCIN
DRUG SCREEN QUANT ZONISAMIDE
QUANTITATIVE ASSAY DRUG
DRUG SCREEN NON TLC DEVICES
DRUG SCREEN CLASS LIST A
DRUG SCREEN PRSMPTV 1 CLASS
DRUG SCREEN ONE/MULT CLASS
DRUG SCREEN ONE/MULT CLASS
DRUG SCREEN QUANTALCOHOLS
ALCOHOLS BIOMARKERS 1OR 2
ALCOHOLS BIOMARKERS 3/MORE
ALKALOIDS NOS
DRUG SCREEN AMPHETAMINES 1/2
AMPHETAMINES 3OR 4
AMPHETAMINES 5 OR MORE
ANABOLIC STEROID 1 OR 2
ANABOLIC STEROID 3 OR MORE
ANALGESICS NON-OPIOID 1 OR 2
ANALGESICS NON-OPIOID 3-5
ANALGESICS NON-OPIOID 6/MORE
ANTIDEPRESSANTS CLASS 1 OR 2
ANTIDEPRESSANTS CLASS 3-5
ANTIDEPRESSANTS CLASS 6/MORE
ANTIDEPRESSANT TRICYCLIC 1/2
ANTIDEPRESSANT TRICYCLIC 3-5
TRICYCLIC & CYCLICALS 6/MORE
ANTIDEPRESSANT NOT SPECIFIED
ANTIEPILEPTICS NOS 1-3
ANTIEPILEPTICS NOS 4-6
ANTIEPILEPTICS NOS 7/MORE
ANTIPSYCHOTICS NOS 1-3
ANTIPSYCHOTICS NOS 4-6
ANTIPSYCHOTICS NOS 7/MORE
DRUG SCREENING BARBITURATES
BENZODIAZEPINES1-12
BENZODIAZEPINES 13 OR MORE
DRUG SCREENING BUPRENORPHINE
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$22.16
$22.36
$22.36
$19.49
$18.34
$18.34
$18.88
$24.11
$21.52
$15.92
$18.09
$17.70
$18.29
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
80349
80350
80351
80352
80353
80354
80355
80356
80357
80358
80359
80360
80361
80362
80363
80364
80365
80366
80367
80368
80369
80370
80371
80372
80373
80374
80375
80376
80377
80400
80402
80406
80408
80410
80412
80414
80415
80416
80417
80418
80420
80422
80424
80426
80428
80430
80432
Description
CANNABINOIDS NATURAL
CANNABINOIDS SYNTHETIC 1-3
CANNABINOIDS SYNTHETIC 4-6
CANNABINOID SYNTHETIC 7/MORE
DRUG SCREENING COCAINE
DRUG SCREENING FENTANYL
GABAPENTIN NON-BLOOD
HEROIN METABOLITE
KETAMINE AND NORKETAMINE
DRUG SCREENING METHADONE
METHYLENEDIOXYAMPHETAMINES
METHYLPHENIDATE
OPIATES 1 OR MORE
OPIOIDS & OPIATE ANALOGS 1/2
OPIOIDS & OPIATE ANALOGS 3/4
OPIOID &OPIATE ANALOG 5/MORE
DRUG SCREENING OXYCODONE
DRUG SCREENING PREGABALIN
DRUG SCREENING PROPOXYPHENE
SEDATIVE HYPNOTICS
SKELETAL MUSCLE RELAXANT 1/2
SKEL MUSC RELAXANT 3 OR MORE
STIMULANTS SYNTHETIC
DRUG SCREENING TAPENTADOL
DRUG SCREENING TRAMADOL
STEREOISOMER ANALYSIS
DRUG/SUBSTANCE NOS 1-3
DRUG/SUBSTANCE NOS 4-6
DRUG/SUBSTANCE NOS 7/MORE
ACTH STIMULATION PANEL
ALDOSTERONE SUPPRESSION EVAL
CALCITONIN STIMUL PANEL
CRH STIMULATION PANEL
TESTOSTERONE RESPONSE
ESTRADIOL RESPONSE PANEL
RENIN STIMULATION PANEL
RENIN STIMULATION PANEL
PITUITARY EVALUATION PANEL
DEXAMETHASONE PANEL
GLUCAGON TOLERANCE PANEL
GLUCAGON TOLERANCE PANEL
GONADOTROPIN HORMONE PANEL
GROWTH HORMONE PANEL
GROWTH HORMONE PANEL
INSULIN SUPPRESSION PANEL
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$43.54
$116.08
$104.47
$167.53
$59.98
$440.04
$68.93
$74.61
$176.16
$58.72
$773.74
$95.86
$61.50
$67.41
$198.12
$89.04
$104.77
$180.35
Procedure Code
80434
80435
80436
80438
80439
80500
80502
81000
81001
81002
81003
81005
81007
81015
81020
81025
81050
81099
81161
81162
81170
81200
81201
81202
81203
81205
81206
81207
81208
81209
81210
81211
81212
81213
81214
81215
81216
81217
81218
81219
81220
81221
81222
81223
81224
81225
81226
Description
INSULIN TOLERANCE PANEL
INSULIN TOLERANCE PANEL
METYRAPONE PANEL
TRH STIMULATION PANEL
TRH STIMULATION PANEL
LAB PATHOLOGY CONSULTATION
LAB PATHOLOGY CONSULTATION
URINALYSIS NONAUTO W/SCOPE
URINALYSIS AUTO W/SCOPE
URINALYSIS NONAUTO W/O SCOPE
URINALYSIS AUTO W/O SCOPE
URINALYSIS
URINE SCREEN FOR BACTERIA
MICROSCOPIC EXAM OF URINE
URINALYSIS GLASS TEST
URINE PREGNANCY TEST
URINALYSIS VOLUME MEASURE
URINALYSIS TEST PROCEDURE
DMD DUP/DELET ANALYSIS
BRCA1&2 SEQ & FULL DUP/DEL
ABL1 GENE
ASPA GENE
APC GENE FULL SEQUENCE
APC GENE KNOWN FAM VARIANTS
APC GENE DUP/DELET VARIANTS
BCKDHB GENE
BCR/ABL1 GENE MAJOR BP
BCR/ABL1 GENE MINOR BP
BCR/ABL1 GENE OTHER BP
BLM GENE
BRAF GENE
BRCA1&2 SEQ & COM DUP/DEL
BRCA1&2 185&5385&6174 VAR
BRCA1&2 UNCOM DUP/DEL VAR
BRCA1 FULL SEQ & COM DUP/DEL
BRCA1 GENE KNOWN FAM VARIANT
BRCA2 GENE FULL SEQUENCE
BRCA2 GENE KNOWN FAM VARIANT
CEBPA GENE FULL SEQUENCE
CALR GENE COM VARIANTS
CFTR GENE COM VARIANTS
CFTR GENE KNOWN FAM VARIANTS
CFTR GENE DUP/DELET VARIANTS
CFTR GENE FULL SEQUENCE
CFTR GENE INTRON POLY T
CYP2C19 GENE COM VARIANTS
CYP2D6 GENE COM VARIANTS
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
5
3
3
3
6
5
5
5
9
9
9
9
6
9
3
3
3
3
3
5
3
3
3
5
9
9
9
9
9
9
Maximum Allowable
$135.06
$137.52
$121.70
$67.30
$89.73
$22.88
$76.36
$4.21
$4.21
$3.41
$3.00
$2.89
$3.42
$4.07
$4.10
$8.44
$3.84
$0.00
$137.34
$2,436.14
$322.92
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$2,136.62
$172.91
$570.20
$1,407.25
$91.24
$0.00
$91.24
$322.92
$162.37
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
81227
81228
81229
81235
81240
81241
81242
81243
81244
81245
81246
81250
81251
81252
81253
81254
81255
81256
81257
81260
81261
81262
81263
81264
81265
81266
81267
81268
81270
81272
81273
81275
81276
81280
81281
81282
81287
81288
81290
81291
81292
81293
81294
81295
81296
81297
81298
Description
CYP2C9 GENE COM VARIANTS
CYTOGEN MICRARRAY COPY NMBR
CYTOGEN M ARRAY COPY NO&SNP
EGFR GENE COM VARIANTS
F2 GENE
F5 GENE
FANCC GENE
FMR1 GENE DETECTION
FMR1 GENE CHARACTERIZATION
FLT3 GENE
FLT3 GENE ANALYSIS
G6PC GENE
GBA GENE
GJB2 GENE FULL SEQUENCE
GJB2 GENE KNOWN FAM VARIANTS
GJB6 GENE COM VARIANTS
HEXA GENE
HFE GENE
HBA1/HBA2 GENE
IKBKAP GENE
IGH GENE REARRANGE AMP METH
IGH GENE REARRANG DIR PROBE
IGH VARI REGIONAL MUTATION
IGK REARRANGEABN CLONAL POP
STR MARKERS SPECIMEN ANAL
STR MARKERS SPEC ANAL ADDL
CHIMERISM ANAL NO CELL SELEC
CHIMERISM ANAL W/CELL SELECT
JAK2 GENE
KIT GENE TARGETED SEQ ANALYS
KIT GENE ANALYS D816 VARIANT
KRAS GENE VARIANTS EXON 2
KRAS GENE ADDL VARIANTS
LONG QT SYND GENE FULL SEQ
LONG QT SYND KNOWN FAM VAR
LONG QT SYN GENE DUP/DLT VAR
MGMT GENE METHYLATION ANAL
MLH1 GENE
MCOLN1 GENE
MTHFR GENE
MLH1 GENE FULL SEQ
MLH1 GENE KNOWN VARIANTS
MLH1 GENE DUP/DELETE VARIANT
MSH2 GENE FULL SEQ
MSH2 GENE KNOWN VARIANTS
MSH2 GENE DUP/DELETE VARIANT
MSH6 GENE FULL SEQ
Pricing Action Code
9
9
9
9
3
3
6
6
9
9
9
9
6
9
9
9
6
9
9
9
9
9
9
9
9
9
9
9
9
3
3
9
3
9
9
9
9
9
6
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$65.69
$81.58
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$322.92
$122.37
$0.00
$193.25
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
81299
81300
81301
81302
81303
81304
81310
81311
81313
81314
81315
81316
81317
81318
81319
81321
81322
81323
81324
81325
81326
81330
81331
81332
81340
81341
81342
81350
81355
81370
81371
81372
81373
81374
81375
81376
81377
81378
81379
81380
81381
81382
81383
81400
81401
81402
81403
Description
MSH6 GENE KNOWN VARIANTS
MSH6 GENE DUP/DELETE VARIANT
MICROSATELLITE INSTABILITY
MECP2 GENE FULL SEQ
MECP2 GENE KNOWN VARIANT
MECP2 GENE DUP/DELET VARIANT
NPM1 GENE
NRAS GENE VARIANTS EXON 2&3
PCA3/KLK3 ANTIGEN
PDGFRA GENE
PML/RARALPHA COM BREAKPOINTS
PML/RARALPHA 1 BREAKPOINT
PMS2 GENE FULL SEQ ANALYSIS
PMS2 KNOWN FAMILIAL VARIANTS
PMS2 GENE DUP/DELET VARIANTS
PTEN GENE FULL SEQUENCE
PTEN GENE KNOWN FAM VARIANT
PTEN GENE DUP/DELET VARIANT
PMP22 GENE DUP/DELET
PMP22 GENE FULL SEQUENCE
PMP22 GENE KNOWN FAM VARIANT
SMPD1 GENE COMMON VARIANTS
SNRPN/UBE3A GENE
SERPINA1 GENE
TRB@ GENE REARRANGE AMPLIFY
TRB@ GENE REARRANGE DIRPROBE
TRG GENE REARRANGEMENT ANAL
UGT1A1 GENE
VKORC1 GENE
HLA I & II TYPING LR
HLA I & II TYPE VERIFY LR
HLA I TYPING COMPLETE LR
HLA I TYPING 1 LOCUS LR
HLA I TYPING 1 ANTIGEN LR
HLA II TYPING AG EQUIV LR
HLA II TYPING 1 LOCUS LR
HLA II TYPE 1 AG EQUIV LR
HLA I & II TYPING HR
HLA I TYPING COMPLETE HR
HLA I TYPING 1 LOCUS HR
HLA I TYPING 1 ALLELE HR
HLA II TYPING 1 LOC HR
HLA II TYPING 1 ALLELE HR
MOPATH PROCEDURE LEVEL 1
Pricing Action Code
9
9
9
9
9
9
9
3
9
3
9
9
9
9
9
3
9
9
9
9
9
6
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
6
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$289.87
$0.00
$322.92
$0.00
$0.00
$0.00
$0.00
$0.00
$587.80
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
81404
81405
81406
81407
81408
81410
81411
81412
81415
81416
81417
81420
81425
81426
81427
81430
81431
81432
81433
81434
81435
81436
81437
81438
81440
81442
81445
81450
81455
81460
81465
81470
81471
81479
81490
81493
81500
81503
81504
81506
81507
81508
81509
81510
81511
81512
81519
Description
AORTIC DYSFUNCTION/DILATION
AORTIC DYSFUNCTION/DILATION
ASHKENAZI JEWISH ASSOC DIS
EXOME SEQUENCE ANALYSIS
EXOME SEQUENCE ANALYSIS
EXOME RE-EVALUATION
FETAL CHRMOML ANEUPLOIDY
GENOME SEQUENCE ANALYSIS
GENOME SEQUENCE ANALYSIS
GENOME RE-EVALUATION
HEARING LOSS SEQUENCE ANALYS
HEARING LOSS DUP/DEL ANALYS
HRDTRY BRST CA-RLATD DSORDRS
HRDTRY BRST CA-RLATD DSORDRS
HEREDITARY RETINAL DISORDERS
HEREDITARY COLON CA DSORDRS
HEREDITARY COLON CA DSORDRS
HEREDTRY NURONDCRN TUM DSRDR
HEREDTRY NURONDCRN TUM DSRDR
MITOCHONDRIAL GENE
NOONAN SPECTRUM DISORDERS
TARGETED GENOMIC SEQ ANALYS
WHOLE MITOCHONDRIAL GENOME
WHOLE MITOCHONDRIAL GENOME
X-LINKED INTELLECTUAL DBLT
X-LINKED INTELLECTUAL DBLT
UNLISTED MOLECULAR PATHOLOGY
AUTOIMMUNE RHEUMATOID ARTHR
COR ARTERY DISEASE MRNA
ONCO (OVAR) TWO PROTEINS
ONCO (OVAR) FIVE PROTEINS
ONCOLOGY TISSUE OF ORIGIN
ENDO ASSAY SEVEN ANAL
FETAL ANEUPLOIDY TRISOM RISK
FTL CGEN ABNOR TWO PROTEINS
FTL CGEN ABNOR 3 PROTEINS
FTL CGEN ABNOR THREE ANAL
FTL CGEN ABNOR FOUR ANAL
FTL CGEN ABNOR FIVE ANAL
ONCOLOGY BREAST MRNA
Pricing Action Code
9
9
9
9
9
9
9
6
9
9
9
9
9
9
9
9
9
6
6
6
9
9
6
6
9
6
9
9
9
9
9
9
9
6
9
6
9
9
6
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
81525
81528
81535
81536
81538
81540
81545
81595
81599
82009
82010
82013
82016
82017
82024
82030
82040
82042
82043
82044
82045
82075
82085
82088
82103
82104
82105
82106
82107
82108
82120
82127
82128
82131
82135
82136
82139
82140
82143
82150
82154
82157
82160
82163
82164
82172
82175
Description
ONCOLOGY COLON MRNA
ONCOLOGY COLORECTAL SCR
ONCOLOGY GYNECOLOGIC
ONCOLOGY GYNECOLOGIC
ONCOLOGY LUNG
ONCOLOGY TUM UNKNOWN ORIGIN
ONCOLOGY THYROID
CARDIOLOGY HRT TRNSPL MRNA
UNLISTED MAAA
TEST FOR ACETONE/KETONES
ACETONE ASSAY
ACETYLCHOLINESTERASE ASSAY
ACYLCARNITINES QUAL
ACYLCARNITINES QUANT
ASSAY OF ACTH
ASSAY OF ADP & AMP
ASSAY OF SERUM ALBUMIN
ASSAY OF URINE ALBUMIN
MICROALBUMIN QUANTITATIVE
MICROALBUMIN SEMIQUANT
ALBUMIN ISCHEMIA MODIFIED
ASSAY OF BREATH ETHANOL
ASSAY OF ALDOLASE
ASSAY OF ALDOSTERONE
ALPHA-1-ANTITRYPSIN TOTAL
ALPHA-1-ANTITRYPSIN PHENO
ALPHA-FETOPROTEIN SERUM
ALPHA-FETOPROTEIN AMNIOTIC
ALPHA-FETOPROTEIN L3
ASSAY OF ALUMINUM
AMINES VAGINAL FLUID QUAL
AMINO ACID SINGLE QUAL
AMINO ACIDS MULT QUAL
AMINO ACIDS SINGLE QUANT
ASSAY AMINOLEVULINIC ACID
AMINO ACIDS QUANT 2-5
AMINO ACIDS QUAN 6 OR MORE
ASSAY OF AMMONIA
AMNIOTIC FLUID SCAN
ASSAY OF AMYLASE
ANDROSTANEDIOL GLUCURONIDE
ASSAY OF ANDROSTENEDIONE
ASSAY OF ANDROSTERONE
ASSAY OF ANGIOTENSIN II
ANGIOTENSIN I ENZYME TEST
ASSAY OF APOLIPOPROTEIN
ASSAY OF ARSENIC
Pricing Action Code
6
3
3
3
6
6
6
6
9
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$0.00
$498.69
$567.87
$174.01
$0.00
$0.00
$0.00
$0.00
$0.00
$6.04
$10.91
$11.53
$18.51
$22.51
$51.56
$34.44
$6.61
$2.35
$7.71
$3.38
$45.32
$16.08
$12.96
$54.40
$17.93
$19.31
$22.39
$22.39
$84.57
$34.02
$5.03
$18.51
$18.51
$22.52
$21.96
$22.51
$22.51
$19.45
$9.16
$8.65
$38.49
$39.08
$33.38
$27.40
$19.49
$20.69
$25.32
Procedure Code
82180
82190
82232
82239
82240
82247
82248
82252
82261
82270
82271
82272
82274
82286
82300
82306
82308
82310
82330
82331
82340
82355
82360
82365
82370
82373
82374
82375
82376
82378
82379
82380
82382
82383
82384
82387
82390
82397
82415
82435
82436
82438
82441
82465
82480
82482
82485
Description
ASSAY OF ASCORBIC ACID
ATOMIC ABSORPTION
ASSAY OF BETA-2 PROTEIN
BILE ACIDS TOTAL
BILE ACIDS CHOLYLGLYCINE
BILIRUBIN TOTAL
BILIRUBIN DIRECT
FECAL BILIRUBIN TEST
ASSAY OF BIOTINIDASE
OCCULT BLOOD FECES
OCCULT BLOOD OTHER SOURCES
OCCULT BLD FECES 1-3 TESTS
ASSAY TEST FOR BLOOD FECAL
ASSAY OF BRADYKININ
ASSAY OF CADMIUM
VITAMIN D 25 HYDROXY
ASSAY OF CALCITONIN
ASSAY OF CALCIUM
ASSAY OF CALCIUM
CALCIUM INFUSION TEST
ASSAY OF CALCIUM IN URINE
CALCULUS ANALYSIS QUAL
CALCULUS ASSAY QUANT
CALCULUS SPECTROSCOPY
X-RAY ASSAY CALCULUS
ASSAY C-D TRANSFER MEASURE
ASSAY BLOOD CARBON DIOXIDE
ASSAY CARBOXYHB QUANT
ASSAY CARBOXYHB QUAL
CARCINOEMBRYONIC ANTIGEN
ASSAY OF CARNITINE
ASSAY OF CAROTENE
ASSAY URINE CATECHOLAMINES
ASSAY BLOOD CATECHOLAMINES
ASSAY THREE CATECHOLAMINES
ASSAY OF CATHEPSIN-D
ASSAY OF CERULOPLASMIN
CHEMILUMINESCENT ASSAY
ASSAY OF CHLORAMPHENICOL
ASSAY OF BLOOD CHLORIDE
ASSAY OF URINE CHLORIDE
ASSAY OTHER FLUID CHLORIDES
TEST FOR CHLOROHYDROCARBONS
ASSAY BLD/SERUM CHOLESTEROL
ASSAY SERUM CHOLINESTERASE
ASSAY RBC CHOLINESTERASE
ASSAY CHONDROITIN SULFATE
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$13.19
$19.90
$21.60
$22.86
$35.49
$6.69
$6.69
$6.08
$22.51
$4.34
$4.34
$4.34
$21.24
$9.19
$30.89
$39.52
$19.99
$6.89
$8.46
$6.91
$8.05
$15.45
$17.18
$17.21
$16.72
$24.11
$6.53
$16.44
$7.33
$25.32
$22.51
$12.32
$22.95
$33.46
$33.71
$27.78
$14.34
$18.86
$16.91
$6.13
$6.71
$6.53
$8.02
$5.80
$10.52
$10.25
$27.57
Procedure Code
82495
82507
82523
82525
82528
82530
82533
82540
82542
82550
82552
82553
82554
82565
82570
82575
82585
82595
82600
82607
82608
82610
82615
82626
82627
82633
82634
82638
82652
82656
82657
82658
82664
82668
82670
82671
82672
82677
82679
82693
82696
82705
82710
82715
82725
82726
82728
Description
ASSAY OF CHROMIUM
ASSAY OF CITRATE
COLLAGEN CROSSLINKS
ASSAY OF COPPER
ASSAY OF CORTICOSTERONE
CORTISOL FREE
TOTAL CORTISOL
ASSAY OF CREATINE
COL CHROMOTOGRAPHY QUAL/QUAN
ASSAY OF CK (CPK)
ASSAY OF CPK IN BLOOD
CREATINE MB FRACTION
CREATINE ISOFORMS
ASSAY OF CREATININE
ASSAY OF URINE CREATININE
CREATININE CLEARANCE TEST
ASSAY OF CRYOFIBRINOGEN
ASSAY OF CRYOGLOBULIN
ASSAY OF CYANIDE
VITAMIN B-12
B-12 BINDING CAPACITY
CYSTATIN C
TEST FOR URINE CYSTINES
DEHYDROEPIANDROSTERONE
DEHYDROEPIANDROSTERONE
DESOXYCORTICOSTERONE
DEOXYCORTISOL
ASSAY OF DIBUCAINE NUMBER
VIT D 1 25-DIHYDROXY
PANCREATIC ELASTASE FECAL
ENZYME CELL ACTIVITY
ENZYME CELL ACTIVITY RA
ELECTROPHORETIC TEST
ASSAY OF ERYTHROPOIETIN
ASSAY OF ESTRADIOL
ASSAY OF ESTROGENS
ASSAY OF ESTROGEN
ASSAY OF ESTRIOL
ASSAY OF ESTRONE
ASSAY OF ETHYLENE GLYCOL
ASSAY OF ETIOCHOLANOLONE
FATS/LIPIDS FECES QUAL
FATS/LIPIDS FECES QUANT
ASSAY OF FECAL FAT
ASSAY OF BLOOD FATTY ACIDS
LONG CHAIN FATTY ACIDS
ASSAY OF FERRITIN
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$27.08
$37.11
$14.49
$16.56
$30.06
$22.30
$21.77
$6.19
$24.11
$8.69
$17.88
$10.12
$15.85
$6.12
$6.91
$12.62
$11.46
$8.63
$25.90
$20.13
$19.12
$18.15
$10.90
$33.73
$29.68
$41.36
$39.08
$15.54
$51.39
$14.69
$24.11
$24.11
$45.86
$23.22
$37.30
$43.12
$13.30
$32.28
$31.33
$17.22
$31.48
$6.79
$3.84
$11.67
$17.77
$24.11
$18.20
Procedure Code
82731
82735
82746
82747
82757
82759
82760
82775
82776
82777
82784
82785
82787
82800
82803
82805
82810
82820
82930
82938
82941
82943
82945
82946
82947
82948
82950
82951
82952
82955
82960
82962
82963
82965
82977
82978
82979
82985
83001
83002
83003
83006
83009
83010
83012
83013
83014
Description
ASSAY OF FETAL FIBRONECTIN
ASSAY OF FLUORIDE
ASSAY OF FOLIC ACID SERUM
ASSAY OF FOLIC ACID RBC
ASSAY OF SEMEN FRUCTOSE
ASSAY OF RBC GALACTOKINASE
ASSAY OF GALACTOSE
ASSAY GALACTOSE TRANSFERASE
GALACTOSE TRANSFERASE TEST
GALECTIN-3
ASSAY IGA/IGD/IGG/IGM EACH
ASSAY OF IGE
IGG 1 2 3 OR 4 EACH
BLOOD PH
BLOOD GASES ANY COMBINATION
BLOOD GASES W/O2 SATURATION
BLOOD GASES O2 SAT ONLY
HEMOGLOBIN-OXYGEN AFFINITY
GASTRIC ANALY W/PH EA SPEC
GASTRIN TEST
ASSAY OF GASTRIN
ASSAY OF GLUCAGON
GLUCOSE OTHER FLUID
GLUCAGON TOLERANCE TEST
ASSAY GLUCOSE BLOOD QUANT
REAGENT STRIP/BLOOD GLUCOSE
GLUCOSE TEST
GLUCOSE TOLERANCE TEST (GTT)
GTT-ADDED SAMPLES
ASSAY OF G6PD ENZYME
TEST FOR G6PD ENZYME
GLUCOSE BLOOD TEST
ASSAY OF GLUCOSIDASE
ASSAY OF GDH ENZYME
ASSAY OF GGT
ASSAY OF GLUTATHIONE
ASSAY RBC GLUTATHIONE
ASSAY OF GLYCATED PROTEIN
ASSAY OF GONADOTROPIN (FSH)
ASSAY OF GONADOTROPIN (LH)
ASSAY GROWTH HORMONE (HGH)
GROWTH STIMULATION GENE 2
H PYLORI (C-13) BLOOD
ASSAY OF HAPTOGLOBIN QUANT
ASSAY OF HAPTOGLOBINS
H PYLORI (C-13) BREATH
H PYLORI DRUG ADMIN
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
9
3
3
3
3
3
Maximum Allowable
$84.57
$24.75
$19.63
$22.99
$23.15
$28.68
$14.94
$28.13
$11.20
$29.36
$12.42
$21.98
$10.70
$11.30
$25.83
$37.88
$11.65
$13.34
$7.27
$23.62
$23.54
$19.07
$5.24
$20.13
$5.24
$4.23
$6.34
$17.18
$3.84
$12.95
$8.08
$3.13
$28.68
$10.31
$8.94
$7.95
$9.19
$20.13
$24.80
$24.72
$22.27
$0.00
$89.91
$16.79
$22.95
$89.91
$10.50
Procedure Code
83015
83018
83020
83021
83026
83030
83033
83036
83037
83045
83050
83051
83060
83065
83068
83069
83070
83080
83088
83090
83150
83491
83497
83498
83499
83500
83505
83516
83518
83519
83520
83525
83527
83528
83540
83550
83570
83582
83586
83593
83605
83615
83625
83630
83631
83632
83633
Description
HEAVY METAL SCREEN
QUANTITATIVE SCREEN METALS
HEMOGLOBIN ELECTROPHORESIS
HEMOGLOBIN CHROMOTOGRAPHY
HEMOGLOBIN COPPER SULFATE
FETAL HEMOGLOBIN CHEMICAL
FETAL HEMOGLOBIN ASSAY QUAL
GLYCOSYLATED HEMOGLOBIN TEST
GLYCOSYLATED HB HOME DEVICE
BLOOD METHEMOGLOBIN TEST
BLOOD METHEMOGLOBIN ASSAY
ASSAY OF PLASMA HEMOGLOBIN
BLOOD SULFHEMOGLOBIN ASSAY
ASSAY OF HEMOGLOBIN HEAT
HEMOGLOBIN STABILITY SCREEN
ASSAY OF URINE HEMOGLOBIN
ASSAY OF HEMOSIDERIN QUAL
ASSAY OF B HEXOSAMINIDASE
ASSAY OF HISTAMINE
ASSAY OF HOMOCYSTINE
ASSAY OF HOMOVANILLIC ACID
ASSAY OF CORTICOSTEROIDS 17
ASSAY OF 5-HIAA
ASSAY OF PROGESTERONE 17-D
ASSAY OF PROGESTERONE 20ASSAY FREE HYDROXYPROLINE
ASSAY TOTAL HYDROXYPROLINE
IMMUNOASSAY NONANTIBODY
IMMUNOASSAY DIPSTICK
RIA NONANTIBODY
IMMUNOASSAY QUANT NOS NONAB
ASSAY OF INSULIN
ASSAY OF INSULIN
ASSAY OF INTRINSIC FACTOR
ASSAY OF IRON
IRON BINDING TEST
ASSAY OF IDH ENZYME
ASSAY OF KETOGENIC STEROIDS
ASSAY 17- KETOSTEROIDS
FRACTIONATION KETOSTEROIDS
ASSAY OF LACTIC ACID
LACTATE (LD) (LDH) ENZYME
ASSAY OF LDH ENZYMES
LACTOFERRIN FECAL (QUAL)
LACTOFERRIN FECAL (QUANT)
PLACENTAL LACTOGEN
TEST URINE FOR LACTOSE
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$25.14
$29.32
$17.18
$24.11
$3.16
$11.03
$7.70
$12.96
$12.96
$6.62
$9.78
$3.84
$11.03
$9.19
$3.13
$5.27
$6.34
$22.51
$39.43
$22.52
$25.83
$23.39
$17.21
$36.27
$19.37
$30.23
$32.46
$14.69
$11.31
$18.03
$17.28
$15.26
$17.29
$21.24
$8.64
$11.67
$10.04
$18.92
$17.09
$35.10
$14.26
$7.48
$17.08
$26.21
$26.21
$26.99
$7.34
Procedure Code
83655
83661
83662
83663
83664
83670
83690
83695
83698
83700
83701
83704
83718
83719
83721
83727
83735
83775
83785
83789
83825
83835
83857
83861
83864
83872
83873
83874
83876
83880
83883
83885
83915
83916
83918
83919
83921
83930
83935
83937
83945
83950
83951
83970
83986
83987
83992
Description
ASSAY OF LEAD
L/S RATIO FETAL LUNG
FOAM STABILITY FETAL LUNG
FLUORO POLARIZE FETAL LUNG
LAMELLAR BDY FETAL LUNG
ASSAY OF LAP ENZYME
ASSAY OF LIPASE
ASSAY OF LIPOPROTEIN(A)
ASSAY LIPOPROTEIN PLA2
LIPOPRO BLD ELECTROPHORETIC
LIPOPROTEIN BLD HR FRACTION
LIPOPROTEIN BLD BY NMR
ASSAY OF LIPOPROTEIN
ASSAY OF BLOOD LIPOPROTEIN
ASSAY OF BLOOD LIPOPROTEIN
ASSAY OF LRH HORMONE
ASSAY OF MAGNESIUM
ASSAY MALATE DEHYDROGENASE
ASSAY OF MANGANESE
MASS SPECTROMETRY QUAL/QUAN
ASSAY OF MERCURY
ASSAY OF METANEPHRINES
ASSAY OF METHEMALBUMIN
MICROFLUID ANALY TEARS
MUCOPOLYSACCHARIDES
ASSAY SYNOVIAL FLUID MUCIN
ASSAY OF CSF PROTEIN
ASSAY OF MYOGLOBIN
ASSAY MYELOPEROXIDASE
ASSAY OF NATRIURETIC PEPTIDE
ASSAY NEPHELOMETRY NOT SPEC
ASSAY OF NICKEL
ASSAY OF NUCLEOTIDASE
OLIGOCLONAL BANDS
ORGANIC ACIDS TOTAL QUANT
ORGANIC ACIDS QUAL EACH
ORGANIC ACID SINGLE QUANT
ASSAY OF BLOOD OSMOLALITY
ASSAY OF URINE OSMOLALITY
ASSAY OF OSTEOCALCIN
ASSAY OF OXALATE
ONCOPROTEIN HER-2/NEU
ONCOPROTEIN DCP
ASSAY OF PARATHORMONE
ASSAY PH BODY FLUID NOS
EXHALED BREATH CONDENSATE
ASSAY FOR PHENCYCLIDINE
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$16.16
$29.35
$25.24
$25.24
$25.24
$12.23
$9.19
$17.28
$45.32
$15.02
$33.14
$42.12
$10.94
$15.53
$12.74
$22.95
$8.94
$9.84
$14.53
$24.11
$21.70
$22.61
$14.34
$22.05
$26.59
$7.82
$22.97
$17.24
$45.32
$45.32
$18.15
$32.71
$14.89
$26.84
$21.96
$21.96
$21.96
$8.83
$9.10
$39.85
$17.18
$84.57
$84.57
$55.11
$3.13
$21.20
$19.62
Procedure Code
83993
84030
84035
84060
84061
84066
84075
84078
84080
84081
84085
84087
84100
84105
84106
84110
84112
84119
84120
84126
84132
84133
84134
84135
84138
84140
84143
84144
84145
84146
84150
84152
84153
84154
84155
84156
84157
84160
84163
84165
84166
84181
84182
84202
84203
84206
84207
Description
ASSAY FOR CALPROTECTIN FECAL
ASSAY OF BLOOD PKU
ASSAY OF PHENYLKETONES
ASSAY ACID PHOSPHATASE
PHOSPHATASE FORENSIC EXAM
ASSAY PROSTATE PHOSPHATASE
ASSAY ALKALINE PHOSPHATASE
ASSAY ALKALINE PHOSPHATASE
ASSAY ALKALINE PHOSPHATASES
ASSAY PHOSPHATIDYLGLYCEROL
ASSAY OF RBC PG6D ENZYME
ASSAY PHOSPHOHEXOSE ENZYMES
ASSAY OF PHOSPHORUS
ASSAY OF URINE PHOSPHORUS
TEST FOR PORPHOBILINOGEN
ASSAY OF PORPHOBILINOGEN
EVAL AMNIOTIC FLUID PROTEIN
TEST URINE FOR PORPHYRINS
ASSAY OF URINE PORPHYRINS
ASSAY OF FECES PORPHYRINS
ASSAY OF SERUM POTASSIUM
ASSAY OF URINE POTASSIUM
ASSAY OF PREALBUMIN
ASSAY OF PREGNANEDIOL
ASSAY OF PREGNANETRIOL
ASSAY OF PREGNENOLONE
ASSAY OF 17-HYDROXYPREGNENO
ASSAY OF PROGESTERONE
PROCALCITONIN (PCT)
ASSAY OF PROLACTIN
ASSAY OF PROSTAGLANDIN
ASSAY OF PSA COMPLEXED
ASSAY OF PSA TOTAL
ASSAY OF PSA FREE
ASSAY OF PROTEIN SERUM
ASSAY OF PROTEIN URINE
ASSAY OF PROTEIN OTHER
ASSAY OF PROTEIN ANY SOURCE
PAPPA SERUM
PROTEIN E-PHORESIS SERUM
PROTEIN E-PHORESIS/URINE/CSF
WESTERN BLOT TEST
PROTEIN WESTERN BLOT TEST
ASSAY RBC PROTOPORPHYRIN
TEST RBC PROTOPORPHYRIN
ASSAY OF PROINSULIN
ASSAY OF VITAMIN B-6
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$26.21
$7.34
$4.89
$7.70
$7.70
$12.51
$6.09
$9.75
$19.74
$22.05
$9.00
$13.79
$6.33
$6.91
$5.71
$10.32
$84.57
$11.51
$19.48
$34.01
$6.13
$5.74
$19.47
$25.54
$25.27
$27.60
$30.46
$27.85
$19.99
$25.87
$33.32
$24.56
$24.56
$24.56
$4.47
$4.47
$4.47
$6.91
$19.36
$14.34
$23.80
$22.74
$24.03
$19.15
$11.50
$10.41
$37.50
Procedure Code
84210
84220
84228
84233
84234
84235
84238
84244
84252
84255
84260
84270
84275
84285
84295
84300
84302
84305
84307
84311
84315
84375
84376
84377
84378
84379
84392
84402
84403
84425
84430
84431
84432
84436
84437
84439
84442
84443
84445
84446
84449
84450
84460
84466
84478
84479
84480
Description
ASSAY OF PYRUVATE
ASSAY OF PYRUVATE KINASE
ASSAY OF QUININE
ASSAY OF ESTROGEN
ASSAY OF PROGESTERONE
ASSAY OF ENDOCRINE HORMONE
ASSAY NONENDOCRINE RECEPTOR
ASSAY OF RENIN
ASSAY OF SELENIUM
ASSAY OF SEROTONIN
ASSAY OF SEX HORMONE GLOBUL
ASSAY OF SIALIC ACID
ASSAY OF SILICA
ASSAY OF SERUM SODIUM
ASSAY OF URINE SODIUM
ASSAY OF SWEAT SODIUM
ASSAY OF SOMATOMEDIN
ASSAY OF SOMATOSTATIN
SPECTROPHOTOMETRY
BODY FLUID SPECIFIC GRAVITY
CHROMATOGRAM ASSAY SUGARS
SUGARS SINGLE QUAL
SUGARS MULTIPLE QUAL
SUGARS SINGLE QUANT
SUGARS MULTIPLE QUANT
ASSAY OF URINE SULFATE
ASSAY OF FREE TESTOSTERONE
ASSAY OF TOTAL TESTOSTERONE
ASSAY OF THIOCYANATE
THROMBOXANE URINE
ASSAY OF THYROGLOBULIN
ASSAY OF TOTAL THYROXINE
ASSAY OF NEONATAL THYROXINE
ASSAY OF FREE THYROXINE
ASSAY OF THYROID ACTIVITY
ASSAY THYROID STIM HORMONE
ASSAY OF TSI GLOBULIN
ASSAY OF VITAMIN E
ASSAY OF TRANSCORTIN
TRANSFERASE (AST) (SGOT)
ALANINE AMINO (ALT) (SGPT)
ASSAY OF TRANSFERRIN
ASSAY OF TRIGLYCERIDES
ASSAY OF THYROID (T3 OR T4)
ASSAY TRIIODOTHYRONINE (T3)
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$14.49
$12.60
$15.53
$84.57
$86.61
$69.87
$48.82
$29.36
$26.34
$34.08
$41.36
$26.34
$17.93
$31.43
$6.20
$6.50
$6.50
$26.22
$24.40
$9.33
$3.35
$26.18
$7.34
$7.34
$15.39
$15.39
$6.34
$34.00
$34.47
$28.34
$6.09
$22.43
$21.44
$9.16
$8.63
$12.03
$19.74
$22.43
$67.88
$18.92
$24.03
$6.91
$7.08
$17.04
$7.67
$8.63
$18.92
Procedure Code
84481
84482
84484
84485
84488
84490
84510
84512
84520
84525
84540
84545
84550
84560
84577
84578
84580
84583
84585
84586
84588
84590
84591
84597
84600
84620
84630
84681
84702
84703
84704
84830
84999
85002
85004
85007
85008
85009
85013
85014
85018
85025
85027
85032
85041
85044
85045
Description
FREE ASSAY (FT-3)
T3 REVERSE
ASSAY OF TROPONIN QUANT
ASSAY DUODENAL FLUID TRYPSIN
TEST FECES FOR TRYPSIN
ASSAY OF FECES FOR TRYPSIN
ASSAY OF TYROSINE
ASSAY OF TROPONIN QUAL
ASSAY OF UREA NITROGEN
UREA NITROGEN SEMI-QUANT
ASSAY OF URINE/UREA-N
UREA-N CLEARANCE TEST
ASSAY OF BLOOD/URIC ACID
ASSAY OF URINE/URIC ACID
ASSAY OF FECES/UROBILINOGEN
TEST URINE UROBILINOGEN
ASSAY OF URINE UROBILINOGEN
ASSAY OF URINE UROBILINOGEN
ASSAY OF URINE VMA
ASSAY OF VIP
ASSAY OF VASOPRESSIN
ASSAY OF VITAMIN A
ASSAY OF NOS VITAMIN
ASSAY OF VITAMIN K
ASSAY OF VOLATILES
XYLOSE TOLERANCE TEST
ASSAY OF ZINC
ASSAY OF C-PEPTIDE
CHORIONIC GONADOTROPIN TEST
CHORIONIC GONADOTROPIN ASSAY
HCG FREE BETACHAIN TEST
OVULATION TESTS
CLINICAL CHEMISTRY TEST
BLEEDING TIME TEST
AUTOMATED DIFF WBC COUNT
BL SMEAR W/DIFF WBC COUNT
BL SMEAR W/O DIFF WBC COUNT
MANUAL DIFF WBC COUNT B-COAT
SPUN MICROHEMATOCRIT
HEMATOCRIT
HEMOGLOBIN
COMPLETE CBC W/AUTO DIFF WBC
COMPLETE CBC AUTOMATED
MANUAL CELL COUNT EACH
AUTOMATED RBC COUNT
MANUAL RETICULOCYTE COUNT
AUTOMATED RETICULOCYTE COUNT
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
9
5
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$22.61
$21.04
$11.63
$10.03
$9.75
$10.14
$13.89
$9.85
$5.27
$5.03
$6.34
$8.82
$6.04
$4.61
$16.66
$3.84
$9.47
$6.71
$20.69
$47.17
$45.32
$15.49
$15.49
$18.32
$21.46
$6.20
$15.20
$27.78
$19.36
$10.04
$19.36
$0.00
$0.00
$6.02
$8.63
$4.59
$4.59
$4.97
$3.17
$3.17
$3.17
$10.38
$8.63
$5.74
$3.84
$5.74
$5.34
Procedure Code
85046
85048
85049
85055
85060
85097
85130
85170
85175
85210
85220
85230
85240
85244
85245
85246
85247
85250
85260
85270
85280
85290
85291
85292
85293
85300
85301
85302
85303
85305
85306
85307
85335
85337
85345
85347
85348
85360
85362
85366
85370
85378
85379
85380
85384
85385
85390
Description
RETICYTE/HGB CONCENTRATE
AUTOMATED LEUKOCYTE COUNT
AUTOMATED PLATELET COUNT
RETICULATED PLATELET ASSAY
BLOOD SMEAR INTERPRETATION
BONE MARROW INTERPRETATION
CHROMOGENIC SUBSTRATE ASSAY
BLOOD CLOT RETRACTION
BLOOD CLOT LYSIS TIME
CLOT FACTOR II PROTHROM SPEC
BLOOC CLOT FACTOR V TEST
CLOT FACTOR VII PROCONVERTIN
CLOT FACTOR VIII AHG 1 STAGE
CLOT FACTOR VIII RELTD ANTGN
CLOT FACTOR VIII VW RISTOCTN
CLOT FACTOR VIII VW ANTIGEN
CLOT FACTOR VIII MULTIMETRIC
CLOT FACTOR IX PTC/CHRSTMAS
CLOT FACTOR X STUART-POWER
CLOT FACTOR XI PTA
CLOT FACTOR XII HAGEMAN
CLOT FACTOR XIII FIBRIN STAB
CLOT FACTOR XIII FIBRIN SCRN
CLOT FACTOR FLETCHER FACT
CLOT FACTOR WGHT KININOGEN
ANTITHROMBIN III ACTIVITY
ANTITHROMBIN III ANTIGEN
CLOT INHIBIT PROT C ANTIGEN
CLOT INHIBIT PROT C ACTIVITY
CLOT INHIBIT PROT S TOTAL
CLOT INHIBIT PROT S FREE
ASSAY ACTIVATED PROTEIN C
FACTOR INHIBITOR TEST
THROMBOMODULIN
COAGULATION TIME LEE & WHITE
COAGULATION TIME ACTIVATED
COAGULATION TIME OTR METHOD
EUGLOBULIN LYSIS
FIBRIN DEGRADATION PRODUCTS
FIBRINOGEN TEST
FIBRINOGEN TEST
FIBRIN DEGRADE SEMIQUANT
FIBRIN DEGRADATION QUANT
FIBRIN DEGRADJ D-DIMER
FIBRINOGEN ACTIVITY
FIBRINOGEN ANTIGEN
FIBRINOLYSINS SCREEN I&R
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$7.44
$3.39
$5.98
$35.74
$25.45
$104.59
$15.88
$4.83
$6.08
$7.70
$23.56
$23.90
$23.90
$27.26
$30.62
$30.62
$30.62
$25.42
$23.90
$23.90
$25.83
$10.81
$10.81
$25.28
$25.28
$12.93
$14.44
$16.04
$18.46
$15.49
$20.46
$20.46
$17.18
$13.92
$4.47
$5.68
$4.98
$11.19
$9.19
$11.51
$10.81
$9.53
$10.81
$10.81
$11.34
$11.34
$6.90
Procedure Code
85396
85397
85400
85410
85415
85420
85421
85441
85445
85460
85461
85475
85520
85525
85530
85536
85540
85547
85549
85555
85557
85576
85597
85598
85610
85611
85612
85613
85635
85651
85652
85660
85670
85675
85705
85730
85732
85810
85999
86000
86001
86003
86005
86021
86022
86023
86038
Description
CLOTTING ASSAY WHOLE BLOOD
CLOTTING FUNCT ACTIVITY
FIBRINOLYTIC PLASMIN
FIBRINOLYTIC ANTIPLASMIN
FIBRINOLYTIC PLASMINOGEN
HEINZ BODIES DIRECT
HEINZ BODIES INDUCED
HEMOGLOBIN FETAL
HEMOGLOBIN FETAL
HEMOLYSIN ACID
HEPARIN ASSAY
HEPARIN NEUTRALIZATION
HEPARIN-PROTAMINE TOLERANCE
IRON STAIN PERIPHERAL BLOOD
WBC ALKALINE PHOSPHATASE
RBC MECHANICAL FRAGILITY
MURAMIDASE
RBC OSMOTIC FRAGILITY
RBC OSMOTIC FRAGILITY
BLOOD PLATELET AGGREGATION
PHOSPHOLIPID PLTLT NEUTRALIZ
HEXAGNAL PHOSPH PLTLT NEUTRL
PROTHROMBIN TIME
PROTHROMBIN TEST
VIPER VENOM PROTHROMBIN TIME
RUSSELL VIPER VENOM DILUTED
REPTILASE TEST
RBC SED RATE NONAUTOMATED
RBC SED RATE AUTOMATED
RBC SICKLE CELL TEST
THROMBIN TIME PLASMA
THROMBIN TIME TITER
THROMBOPLASTIN INHIBITION
THROMBOPLASTIN TIME PARTIAL
THROMBOPLASTIN TIME PARTIAL
BLOOD VISCOSITY EXAMINATION
HEMATOLOGY PROCEDURE
AGGLUTININS FEBRILE ANTIGEN
ALLERGEN SPECIFIC IGG
ALLERGEN SPECIFIC IGE
ALLERGEN SPECIFIC IGE
WBC ANTIBODY IDENTIFICATION
PLATELET ANTIBODIES
IMMUNOGLOBULIN ASSAY
ANTINUCLEAR ANTIBODIES
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
5
3
3
3
3
3
3
3
3
Maximum Allowable
$21.84
$30.62
$11.81
$10.29
$19.39
$8.72
$13.60
$5.62
$7.70
$10.33
$8.86
$10.41
$17.47
$15.81
$18.92
$8.63
$11.49
$11.49
$19.37
$8.92
$17.84
$28.68
$24.00
$24.00
$5.25
$5.26
$12.79
$12.79
$9.34
$4.73
$3.61
$6.02
$7.70
$9.13
$11.36
$8.02
$8.63
$15.58
$0.00
$9.32
$6.97
$6.97
$3.87
$17.75
$17.75
$16.63
$16.14
Procedure Code
86039
86060
86063
86077
86078
86079
86140
86141
86146
86147
86148
86152
86153
86155
86156
86157
86160
86161
86162
86171
86185
86200
86215
86225
86226
86235
86243
86255
86256
86277
86280
86294
86300
86301
86304
86305
86308
86309
86310
86316
86317
86318
86320
86325
86327
86329
86331
Description
ANTINUCLEAR ANTIBODIES (ANA)
ANTISTREPTOLYSIN O TITER
ANTISTREPTOLYSIN O SCREEN
PHYS BLOOD BANK SERV XMATCH
PHYS BLOOD BANK SERV REACTJ
PHYS BLOOD BANK SERV AUTHRJ
C-REACTIVE PROTEIN
C-REACTIVE PROTEIN HS
BETA-2 GLYCOPROTEIN ANTIBODY
CARDIOLIPIN ANTIBODY EA IG
ANTI-PHOSPHOLIPID ANTIBODY
CELL ENUMERATION & ID
CELL ENUMERATION PHYS INTERP
CHEMOTAXIS ASSAY
COLD AGGLUTININ SCREEN
COLD AGGLUTININ TITER
COMPLEMENT ANTIGEN
COMPLEMENT/FUNCTION ACTIVITY
COMPLEMENT TOTAL (CH50)
COMPLEMENT FIXATION EACH
COUNTERIMMUNOELECTROPHORESIS
CCP ANTIBODY
DEOXYRIBONUCLEASE ANTIBODY
DNA ANTIBODY NATIVE
DNA ANTIBODY SINGLE STRAND
NUCLEAR ANTIGEN ANTIBODY
FC RECEPTOR
FLUORESCENT ANTIBODY SCREEN
FLUORESCENT ANTIBODY TITER
GROWTH HORMONE ANTIBODY
HEMAGGLUTINATION INHIBITION
IMMUNOASSAY TUMOR QUAL
IMMUNOASSAY TUMOR CA 15-3
IMMUNOASSAY TUMOR CA 19-9
IMMUNOASSAY TUMOR CA 125
HUMAN EPIDIDYMIS PROTEIN 4
HETEROPHILE ANTIBODY SCREEN
HETEROPHILE ANTIBODY TITER
HETEROPHILE ANTIBODY ABSRBJ
IMMUNOASSAY TUMOR OTHER
IMMUNOASSAY INFECTIOUS AGENT
IMMUNOASSAY INFECTIOUS AGENT
SERUM IMMUNOELECTROPHORESIS
OTHER IMMUNOELECTROPHORESIS
IMMUNOELECTROPHORESIS ASSAY
IMMUNODIFFUSION NES
IMMUNODIFFUSION OUCHTERLONY
Pricing Action Code
3
3
3
9
9
9
3
3
3
3
3
3
6
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$14.90
$9.75
$7.70
$0.00
$0.00
$0.00
$6.91
$17.28
$33.97
$33.97
$13.25
$328.01
$0.00
$21.34
$8.52
$10.76
$16.02
$16.02
$27.13
$9.44
$11.95
$17.28
$17.69
$18.34
$16.16
$23.94
$27.39
$16.08
$11.67
$21.01
$10.94
$23.35
$27.78
$27.78
$27.78
$27.78
$6.91
$8.21
$9.84
$27.78
$20.01
$17.28
$29.92
$28.47
$30.29
$18.75
$15.99
Procedure Code
86332
86334
86335
86336
86337
86340
86341
86343
86344
86352
86353
86355
86356
86357
86359
86360
86361
86367
86376
86378
86382
86384
86386
86403
86406
86422
86430
86431
86480
86481
86485
86486
86490
86510
86580
86590
86592
86593
86602
86603
86606
86609
86611
86612
86615
86617
86618
Description
Pricing Action Code
IMMUNE COMPLEX ASSAY
IMMUNOFIX E-PHORESIS SERUM
IMMUNFIX E-PHORSIS/URINE/CSF
INHIBIN A
INSULIN ANTIBODIES
INTRINSIC FACTOR ANTIBODY
ISLET CELL ANTIBODY
LEUKOCYTE HISTAMINE RELEASE
LEUKOCYTE PHAGOCYTOSIS
CELL FUNCTION ASSAY W/STIM
LYMPHOCYTE TRANSFORMATION
B CELLS TOTAL COUNT
MONONUCLEAR CELL ANTIGEN
NK CELLS TOTAL COUNT
T CELLS TOTAL COUNT
T CELL ABSOLUTE COUNT/RATIO
T CELL ABSOLUTE COUNT
STEM CELLS TOTAL COUNT
MICROSOMAL ANTIBODY EACH
MIGRATION INHIBITORY FACTOR
NEUTRALIZATION TEST VIRAL
NITROBLUE TETRAZOLIUM DYE
NUCLEAR MATRIX PROTEIN 22
PARTICLE AGGLUT ANTBDY SCRN
PARTICLE AGGLUT ANTBDY TITR
RADIOALLERGOSORBENT TEST, IN VITRO
RHEUMATOID FACTOR TEST QUAL
RHEUMATOID FACTOR QUANT
TB TEST CELL IMMUN MEASURE
TB AG RESPONSE T-CELL SUSP
SKIN TEST CANDIDA
SKIN TEST NOS ANTIGEN
COCCIDIOIDOMYCOSIS SKIN TEST
HISTOPLASMOSIS SKIN TEST
TB INTRADERMAL TEST
STREPTOKINASE ANTIBODY
SYPHILIS TEST NON-TREP QUAL
SYPHILIS TEST NON-TREP QUANT
ANTINOMYCES ANTIBODY
ADENOVIRUS ANTIBODY
ASPERGILLUS ANTIBODY
BACTERIUM ANTIBODY
BARTONELLA ANTIBODY
BLASTOMYCES ANTIBODY
BORDETELLA ANTIBODY
LYME DISEASE ANTIBODY
LYME DISEASE ANTIBODY
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
9
3
3
3
3
3
6
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$32.54
$29.83
$39.17
$20.81
$19.50
$20.13
$26.41
$16.64
$10.66
$181.37
$65.45
$50.36
$35.74
$50.36
$50.36
$62.73
$35.74
$50.36
$19.42
$26.29
$22.58
$15.20
$21.32
$13.60
$14.20
$0.00
$7.58
$7.58
$82.74
$100.03
$15.56
$0.00
$11.81
$12.97
$5.00
$14.74
$5.50
$5.84
$13.59
$17.17
$20.10
$17.20
$13.59
$17.23
$17.61
$20.68
$22.74
Procedure Code
86619
86622
86625
86628
86631
86632
86635
86638
86641
86644
86645
86648
86651
86652
86653
86654
86658
86663
86664
86665
86666
86668
86671
86674
86677
86682
86684
86687
86688
86689
86692
86694
86695
86696
86698
86701
86702
86703
86704
86705
86706
86707
86708
86709
86710
86711
86713
Description
BORRELIA ANTIBODY
BRUCELLA ANTIBODY
CAMPYLOBACTER ANTIBODY
CANDIDA ANTIBODY
CHLAMYDIA ANTIBODY
CHLAMYDIA IGM ANTIBODY
COCCIDIOIDES ANTIBODY
Q FEVER ANTIBODY
CRYPTOCOCCUS ANTIBODY
CMV ANTIBODY
CMV ANTIBODY IGM
DIPHTHERIA ANTIBODY
ENCEPHALITIS CALIFORN ANTBDY
ENCEPHALTIS EAST EQNE ANBDY
ENCEPHALTIS ST LOUIS ANTBODY
ENCEPHALTIS WEST EQNE ANTBDY
ENTEROVIRUS ANTIBODY
EPSTEIN-BARR ANTIBODY
EPSTEIN-BARR NUCLEAR ANTIGEN
EPSTEIN-BARR CAPSID VCA
EHRLICHIA ANTIBODY
FRANCISELLA TULARENSIS
FUNGUS NES ANTIBODY
GIARDIA LAMBLIA ANTIBODY
HELICOBACTER PYLORI ANTIBODY
HELMINTH ANTIBODY
HEMOPHILUS INFLUENZA ANTIBDY
HTLV-I ANTIBODY
HTLV-II ANTIBODY
HTLV/HIV CONFIRMJ ANTIBODY
HEPATITIS DELTA AGENT ANTBDY
HERPES SIMPLEX NES ANTBDY
HERPES SIMPLEX TYPE 1 TEST
HERPES SIMPLEX TYPE 2 TEST
HISTOPLASMA ANTIBODY
HIV-1ANTIBODY
HIV-2 ANTIBODY
HIV-1/HIV-2 1 RESULT ANTBDY
HEP B CORE ANTIBODY TOTAL
HEP B CORE ANTIBODY IGM
HEP B SURFACE ANTIBODY
HEPATITIS BE ANTIBODY
HEPATITIS A ANTIBODY
HEPATITIS A IGM ANTIBODY
INFLUENZA VIRUS ANTIBODY
JOHN CUNNINGHAM ANTIBODY
LEGIONELLA ANTIBODY
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$17.86
$10.92
$17.51
$16.02
$9.44
$16.93
$15.32
$16.18
$19.24
$19.22
$22.49
$20.31
$17.61
$17.61
$17.61
$17.61
$17.39
$17.51
$20.42
$24.23
$13.59
$13.89
$16.36
$19.65
$19.37
$17.37
$21.15
$11.20
$14.10
$25.84
$22.91
$19.22
$17.61
$25.84
$16.68
$11.87
$14.10
$18.30
$16.08
$15.72
$14.34
$15.44
$16.53
$15.02
$18.09
$19.22
$20.43
Procedure Code
86717
86720
86723
86727
86729
86732
86735
86738
86741
86744
86747
86750
86753
86756
86757
86759
86762
86765
86768
86771
86774
86777
86778
86780
86784
86787
86788
86789
86790
86793
86800
86803
86804
86805
86806
86807
86808
86812
86813
86816
86817
86821
86822
86825
86826
86828
86829
Description
LEISHMANIA ANTIBODY
LEPTOSPIRA ANTIBODY
LISTERIA MONOCYTOGENES
LYMPH CHORIOMENINGITIS AB
LYMPHO VENEREUM ANTIBODY
MUCORMYCOSIS ANTIBODY
MUMPS ANTIBODY
MYCOPLASMA ANTIBODY
NEISSERIA MENINGITIDIS
NOCARDIA ANTIBODY
PARVOVIRUS ANTIBODY
MALARIA ANTIBODY
PROTOZOA ANTIBODY NOS
RESPIRATORY VIRUS ANTIBODY
RICKETTSIA ANTIBODY
ROTAVIRUS ANTIBODY
RUBELLA ANTIBODY
RUBEOLA ANTIBODY
SALMONELLA ANTIBODY
SHIGELLA ANTIBODY
TETANUS ANTIBODY
TOXOPLASMA ANTIBODY
TOXOPLASMA ANTIBODY IGM
TREPONEMA PALLIDUM
TRICHINELLA ANTIBODY
VARICELLA-ZOSTER ANTIBODY
WEST NILE VIRUS AB IGM
WEST NILE VIRUS ANTIBODY
VIRUS ANTIBODY NOS
YERSINIA ANTIBODY
THYROGLOBULIN ANTIBODY
HEPATITIS C AB TEST
HEP C AB TEST CONFIRM
LYMPHOCYTOTOXICITY ASSAY
LYMPHOCYTOTOXICITY ASSAY
CYTOTOXIC ANTIBODY SCREENING
CYTOTOXIC ANTIBODY SCREENING
HLA TYPING A B OR C
HLA TYPING A B OR C
HLA TYPING DR/DQ
HLA TYPING DR/DQ
LYMPHOCYTE CULTURE MIXED
LYMPHOCYTE CULTURE PRIMED
HLA X-MATH NON-CYTOTOXIC
HLA X-MATCH NONCYTOTOXC ADDL
HLA CLASS I&II ANTIBODY QUAL
HLA CLASS I/II ANTIBODY QUAL
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$16.35
$17.61
$17.61
$17.17
$9.44
$17.61
$17.41
$17.68
$17.61
$17.61
$20.07
$17.61
$16.53
$17.20
$25.84
$17.61
$19.22
$13.07
$17.61
$17.61
$19.76
$19.22
$19.23
$17.67
$16.77
$17.20
$22.49
$19.22
$17.20
$11.58
$21.24
$19.05
$20.68
$44.95
$44.95
$52.83
$39.62
$34.46
$77.42
$37.19
$85.95
$75.37
$48.80
$107.22
$35.74
$52.83
$39.62
Procedure Code
86830
86831
86832
86833
86834
86835
86849
86850
86860
86870
86880
86885
86886
86890
86891
86900
86901
86902
86904
86905
86906
86910
86911
86920
86921
86922
86923
86927
86930
86931
86932
86940
86941
86945
86950
86960
86965
86970
86971
86972
86975
86976
86977
86978
86985
86999
87003
Description
HLA CLASS I PHENOTYPE QUAL
HLA CLASS II PHENOTYPE QUAL
HLA CLASS I HIGH DEFIN QUAL
HLA CLASS II HIGH DEFIN QUAL
HLA CLASS I SEMIQUANT PANEL
HLA CLASS II SEMIQUANT PANEL
IMMUNOLOGY PROCEDURE
RBC ANTIBODY SCREEN
RBC ANTIBODY ELUTION
RBC ANTIBODY IDENTIFICATION
COOMBS TEST DIRECT
COOMBS TEST INDIRECT QUAL
COOMBS TEST INDIRECT TITER
AUTOLOGOUS BLOOD PROCESS
AUTOLOGOUS BLOOD OP SALVAGE
BLOOD TYPING SEROLOGIC ABO
BLOOD TYPING SEROLOGIC RH(D)
BLOOD TYPE ANTIGEN DONOR EA
BLOOD TYPING PATIENT SERUM
BLOOD TYPING RBC ANTIGENS
BLD TYPING SEROLOGIC RH PHNT
BLOOD TYPING PATERNITY TEST
BLOOD TYPING ANTIGEN SYSTEM
COMPATIBILITY TEST SPIN
COMPATIBILITY TEST INCUBATE
COMPATIBILITY TEST ANTIGLOB
COMPATIBILITY TEST ELECTRIC
PLASMA FRESH FROZEN
FROZEN BLOOD PREP
FROZEN BLOOD THAW
FROZEN BLOOD FREEZE/THAW
HEMOLYSINS/AGGLUTININS AUTO
HEMOLYSINS/AGGLUTININS
BLOOD PRODUCT/IRRADIATION
LEUKACYTE TRANSFUSION
VOL REDUCTION OF BLOOD/PROD
POOLING BLOOD PLATELETS
RBC PRETX INCUBATJ W/CHEMICL
RBC PRETX INCUBATJ W/ENZYMES
RBC PRETX INCUBATJ W/DENSITY
RBC SERUM PRETX INCUBJ DRUGS
RBC SERUM PRETX ID DILUTION
RBC SERUM PRETX INCUBJ/INHIB
RBC PRETREATMENT SERUM
SPLIT BLOOD OR PRODUCTS
TRANSFUSION PROCEDURE
SMALL ANIMAL INOCULATION
Pricing Action Code
3
3
3
3
3
3
5
3
3
3
3
3
3
5
5
3
3
3
3
3
3
9
9
3
3
3
6
5
5
5
5
3
3
3
5
6
5
5
5
5
5
5
5
5
5
5
3
Maximum Allowable
$102.86
$88.16
$161.63
$146.94
$455.51
$411.43
$0.00
$5.11
$24.37
$15.00
$7.18
$7.64
$6.91
$0.00
$0.00
$3.99
$3.99
$5.11
$12.70
$5.11
$10.34
$0.00
$0.00
$36.00
$36.00
$36.00
$0.00
$0.00
$0.00
$0.00
$0.00
$8.15
$15.89
$42.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$22.47
Procedure Code
87015
87040
87045
87046
87070
87071
87073
87075
87076
87077
87081
87084
87086
87088
87101
87102
87103
87106
87107
87109
87110
87116
87118
87140
87143
87147
87149
87150
87152
87153
87158
87164
87166
87168
87169
87172
87176
87177
87181
87184
87185
87186
87187
87188
87190
87197
87205
Description
SPECIMEN INFECT AGNT CONCNTJ
BLOOD CULTURE FOR BACTERIA
FECES CULTURE AEROBIC BACT
STOOL CULTR AEROBIC BACT EA
CULTURE OTHR SPECIMN AEROBIC
CULTURE AEROBIC QUANT OTHER
CULTURE BACTERIA ANAEROBIC
CULTR BACTERIA EXCEPT BLOOD
CULTURE ANAEROBE IDENT EACH
CULTURE AEROBIC IDENTIFY
CULTURE SCREEN ONLY
CULTURE OF SPECIMEN BY KIT
URINE CULTURE/COLONY COUNT
URINE BACTERIA CULTURE
SKIN FUNGI CULTURE
FUNGUS ISOLATION CULTURE
BLOOD FUNGUS CULTURE
FUNGI IDENTIFICATION YEAST
FUNGI IDENTIFICATION MOLD
MYCOPLASMA
CHLAMYDIA CULTURE
MYCOBACTERIA CULTURE
MYCOBACTERIC IDENTIFICATION
CULTURE TYPE IMMUNOFLUORESC
CULTURE TYPING GLC/HPLC
CULTURE TYPE IMMUNOLOGIC
DNA/RNA DIRECT PROBE
DNA/RNA AMPLIFIED PROBE
CULTURE TYPE PULSE FIELD GEL
DNA/RNA SEQUENCING
CULTURE TYPING ADDED METHOD
DARK FIELD EXAMINATION
DARK FIELD EXAMINATION
MACROSCOPIC EXAM ARTHROPOD
MACROSCOPIC EXAM PARASITE
PINWORM EXAM
TISSUE HOMOGENIZATION CULTR
OVA AND PARASITES SMEARS
MICROBE SUSCEPTIBLE DIFFUSE
MICROBE SUSCEPTIBLE DISK
MICROBE SUSCEPTIBLE ENZYME
MICROBE SUSCEPTIBLE MIC
MICROBE SUSCEPTIBLE MLC
MICROBE SUSCEPT MACROBROTH
MICROBE SUSCEPT MYCOBACTERI
BACTERICIDAL LEVEL SERUM
SMEAR GRAM STAIN
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$8.91
$13.79
$12.60
$12.60
$11.51
$12.60
$12.60
$12.64
$10.78
$10.78
$8.85
$11.51
$10.78
$10.81
$10.29
$11.22
$12.03
$13.79
$13.79
$20.54
$26.16
$14.42
$14.61
$6.46
$16.72
$6.91
$26.77
$46.84
$6.99
$154.00
$6.99
$14.34
$15.07
$5.70
$5.70
$5.70
$7.85
$11.88
$6.34
$9.20
$6.34
$11.54
$13.84
$8.57
$7.55
$15.52
$5.70
Procedure Code
87206
87207
87209
87210
87220
87230
87250
87252
87253
87254
87255
87260
87265
87267
87269
87270
87271
87272
87273
87274
87275
87276
87277
87278
87279
87280
87281
87283
87285
87290
87299
87300
87301
87305
87320
87324
87327
87328
87329
87332
87335
87336
87337
87338
87339
87340
87341
Description
SMEAR FLUORESCENT/ACID STAI
SMEAR SPECIAL STAIN
SMEAR COMPLEX STAIN
SMEAR WET MOUNT SALINE/INK
TISSUE EXAM FOR FUNGI
ASSAY TOXIN OR ANTITOXIN
VIRUS INOCULATE EGGS/ANIMAL
VIRUS INOCULATION TISSUE
VIRUS INOCULATE TISSUE ADDL
VIRUS INOCULATION SHELL VIA
GENET VIRUS ISOLATE HSV
ADENOVIRUS AG IF
PERTUSSIS AG IF
ENTEROVIRUS ANTIBODY DFA
GIARDIA AG IF
CHLAMYDIA TRACHOMATIS AG IF
CYTOMEGALOVIRUS DFA
CRYPTOSPORIDIUM AG IF
HERPES SIMPLEX 2 AG IF
HERPES SIMPLEX 1 AG IF
INFLUENZA B AG IF
INFLUENZA A AG IF
LEGIONELLA MICDADEI AG IF
LEGION PNEUMOPHILIA AG IF
PARAINFLUENZA AG IF
RESPIRATORY SYNCYTIAL AG IF
PNEUMOCYSTIS CARINII AG IF
RUBEOLA AG IF
TREPONEMA PALLIDUM AG IF
VARICELLA ZOSTER AG IF
ANTIBODY DETECTION NOS IF
AG DETECTION POLYVAL IF
ADENOVIRUS AG IA
ASPERGILLUS AG IA
CHYLMD TRACH AG IA
CLOSTRIDIUM AG IA
CRYPTOCOCCUS NEOFORM AG IA
CRYPTOSPORIDIUM AG IA
GIARDIA AG IA
CYTOMEGALOVIRUS AG IA
E COLI 0157 AG IA
ENTAMOEB HIST DISPR AG IA
ENTAMOEB HIST GROUP AG IA
HPYLORI STOOL IA
H PYLORI AG IA
HEPATITIS B SURFACE AG IA
HEPATITIS B SURFACE AG IA
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$6.46
$7.70
$23.11
$5.70
$4.61
$23.28
$26.12
$34.80
$26.97
$26.12
$45.21
$14.69
$14.69
$14.69
$14.69
$14.69
$14.69
$14.69
$14.69
$14.69
$14.69
$14.69
$14.69
$14.69
$14.69
$14.69
$14.69
$14.69
$14.69
$14.69
$14.69
$14.69
$14.69
$14.69
$14.69
$14.69
$14.69
$14.69
$14.69
$14.69
$14.69
$14.69
$14.69
$14.69
$14.69
$13.55
$13.55
Procedure Code
87350
87380
87385
87389
87390
87391
87400
87420
87425
87427
87430
87449
87450
87451
87470
87471
87472
87475
87476
87477
87480
87481
87482
87485
87486
87487
87490
87491
87492
87493
87495
87496
87497
87498
87500
87501
87502
87503
87505
87506
87507
87510
87511
87512
87515
87516
87517
Description
HEPATITIS BE AG IA
HEPATITIS DELTA AG IA
HISTOPLASMA CAPSUL AG IA
HIV-1 AG W/HIV-1 & HIV-2 AB
HIV-1 AG IA
HIV-2 AG IA
INFLUENZA A/B AG IA
RESP SYNCYTIAL AG IA
ROTAVIRUS AG IA
SHIGA-LIKE TOXIN AG IA
STREP A AG IA
AG DETECT NOS IA MULT
AG DETECT NOS IA SINGLE
AG DETECT POLYVAL IA MULT
BARTONELLA DNA DIR PROBE
BARTONELLA DNA AMP PROBE
BARTONELLA DNA QUANT
LYME DIS DNA DIR PROBE
LYME DIS DNA AMP PROBE
LYME DIS DNA QUANT
CANDIDA DNA DIR PROBE
CANDIDA DNA AMP PROBE
CANDIDA DNA QUANT
CHYLMD PNEUM DNA DIR PROBE
CHYLMD PNEUM DNA AMP PROBE
CHYLMD PNEUM DNA QUANT
CHYLMD TRACH DNA DIR PROBE
CHYLMD TRACH DNA AMP PROBE
CHYLMD TRACH DNA QUANT
C DIFF AMPLIFIED PROBE
CYTOMEG DNA DIR PROBE
CYTOMEG DNA AMP PROBE
CYTOMEG DNA QUANT
ENTEROVIRUS PROBE&REVRS TRNS
VANOMYCIN DNA AMP PROBE
INFLUENZA DNA AMP PROB 1+
INFLUENZA DNA AMP PROBE
INFLUENZA DNA AMP PROB ADDL
NFCT AGENT DETECTION GI
IADNA-DNA/RNA PROBE TQ 6-11
IADNA-DNA/RNA PROBE TQ 12-25
GARDNER VAG DNA DIR PROBE
GARDNER VAG DNA AMP PROBE
GARDNER VAG DNA QUANT
HEPATITIS B DNA DIR PROBE
HEPATITIS B DNA AMP PROBE
HEPATITIS B DNA QUANT
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$15.39
$21.91
$14.69
$32.14
$23.55
$23.55
$14.69
$14.69
$14.69
$14.69
$14.69
$14.69
$12.81
$12.81
$26.77
$46.84
$37.88
$26.77
$46.84
$37.88
$26.77
$46.84
$37.88
$26.77
$46.84
$37.88
$26.77
$46.84
$37.88
$46.84
$26.77
$46.84
$37.88
$46.84
$46.84
$68.50
$113.60
$27.72
$171.26
$284.93
$556.39
$26.77
$46.84
$37.88
$26.77
$46.84
$37.88
Procedure Code
87520
87521
87522
87525
87526
87527
87528
87529
87530
87531
87532
87533
87534
87535
87536
87537
87538
87539
87540
87541
87542
87550
87551
87552
87555
87556
87557
87560
87561
87562
87580
87581
87582
87590
87591
87592
87623
87624
87625
87631
87632
87633
87640
87641
87650
87651
87652
Description
HEPATITIS C RNA DIR PROBE
HEPATITIS C PROBE&RVRS TRNSC
HEPATITIS C REVRS TRNSCRPJ
HEPATITIS G DNA DIR PROBE
HEPATITIS G DNA AMP PROBE
HEPATITIS G DNA QUANT
HSV DNA DIR PROBE
HSV DNA AMP PROBE
HSV DNA QUANT
HHV-6 DNA DIR PROBE
HHV-6 DNA AMP PROBE
HHV-6 DNA QUANT
HIV-1 DNA DIR PROBE
HIV-1 PROBE&REVERSE TRNSCRPJ
HIV-1 QUANT&REVRSE TRNSCRPJ
HIV-2 DNA DIR PROBE
HIV-2 PROBE&REVRSE TRNSCRIPJ
HIV-2 QUANT&REVRSE TRNSCRIPJ
LEGION PNEUMO DNA DIR PROB
LEGION PNEUMO DNA AMP PROB
LEGION PNEUMO DNA QUANT
MYCOBACTERIA DNA DIR PROBE
MYCOBACTERIA DNA AMP PROBE
MYCOBACTERIA DNA QUANT
M.TUBERCULO DNA DIR PROBE
M.TUBERCULO DNA AMP PROBE
M.TUBERCULO DNA QUANT
M.AVIUM-INTRA DNA DIR PROB
M.AVIUM-INTRA DNA AMP PROB
M.AVIUM-INTRA DNA QUANT
M.PNEUMON DNA DIR PROBE
M.PNEUMON DNA AMP PROBE
M.PNEUMON DNA QUANT
N.GONORRHOEAE DNA DIR PROB
N.GONORRHOEAE DNA AMP PROB
N.GONORRHOEAE DNA QUANT
HPV LOW-RISK TYPES
HPV HIGH-RISK TYPES
HPV TYPES 16 & 18 ONLY
RESP VIRUS 3-5 TARGETS
STAPH A DNA AMP PROBE
MR-STAPH DNA AMP PROBE
STREP A DNA DIR PROBE
STREP A DNA AMP PROBE
STREP A DNA QUANT
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
9
9
9
3
3
3
3
3
Maximum Allowable
$26.77
$46.84
$37.88
$26.77
$46.84
$37.88
$26.77
$46.84
$37.88
$26.77
$46.84
$37.88
$26.77
$46.84
$113.60
$26.77
$46.84
$37.88
$26.77
$46.84
$37.88
$26.77
$46.84
$37.88
$26.77
$46.84
$37.88
$26.77
$46.84
$37.88
$26.77
$46.84
$37.88
$26.77
$46.84
$37.88
$46.84
$46.84
$46.84
$0.00
$0.00
$0.00
$46.84
$46.84
$26.77
$46.84
$37.88
Procedure Code
87653
87660
87661
87797
87798
87799
87800
87801
87802
87803
87804
87806
87807
87808
87809
87810
87850
87880
87899
87900
87901
87902
87903
87904
87905
87906
87910
87912
87999
88000
88005
88007
88012
88014
88016
88020
88025
88027
88028
88029
88036
88037
88040
88045
88099
88104
88106
Description
STREP B DNA AMP PROBE
TRICHOMONAS VAGIN DIR PROBE
TRICHOMONAS VAGINALIS AMPLIF
DETECT AGENT NOS DNA DIR
DETECT AGENT NOS DNA AMP
DETECT AGENT NOS DNA QUANT
DETECT AGNT MULT DNA DIREC
DETECT AGNT MULT DNA AMPLI
STREP B ASSAY W/OPTIC
CLOSTRIDIUM TOXIN A W/OPTIC
INFLUENZA ASSAY W/OPTIC
HIV ANTIGEN W/HIV ANTIBODIES
RSV ASSAY W/OPTIC
TRICHOMONAS ASSAY W/OPTIC
ADENOVIRUS ASSAY W/OPTIC
CHYLMD TRACH ASSAY W/OPTIC
N. GONORRHOEAE ASSAY W/OPTIC
STREP A ASSAY W/OPTIC
AGENT NOS ASSAY W/OPTIC
PHENOTYPE INFECT AGENT DRUG
GENOTYPE DNA HIV REVERSE T
GENOTYPE DNA/RNA HEP C
PHENOTYPE DNA HIV W/CULTURE
PHENOTYPE DNA HIV W/CLT ADD
SIALIDASE ENZYME ASSAY
GENOTYPE DNA/RNA HIV
GENOTYPE CYTOMEGALOVIRUS
GENOTYPE DNA HEPATITIS B
MICROBIOLOGY PROCEDURE
AUTOPSY (NECROPSY) GROSS
AUTOPSY (NECROPSY) COMPLETE
LIMITED AUTOPSY
LIMITED AUTOPSY
FORENSIC AUTOPSY (NECROPSY)
CORONERS AUTOPSY (NECROPSY)
NECROPSY (AUTOPSY) PROCEDURE
CYTOPATH FL NONGYN SMEARS
CYTOPATH FL NONGYN FILTER
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
9
9
5
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
3
3
Maximum Allowable
$46.84
$26.77
$46.84
$26.77
$46.84
$57.18
$53.55
$93.71
$14.69
$14.69
$14.69
$32.14
$14.69
$14.69
$14.69
$14.69
$14.69
$14.69
$14.69
$174.01
$343.68
$343.68
$652.33
$34.80
$8.40
$171.84
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$51.49
$46.46
Procedure Code
88108
88112
88120
88121
88125
88130
88140
88141
88142
88143
88147
88148
88150
88152
88153
88154
88155
88160
88161
88162
88164
88165
88166
88167
88172
88173
88174
88175
88177
88182
88184
88185
88187
88188
88189
88199
88230
88233
88235
88237
88239
88240
88241
88245
88248
88249
88261
Description
CYTOPATH CONCENTRATE TECH
CYTOPATH CELL ENHANCE TECH
CYTP URNE 3-5 PROBES EA SPEC
CYTP URINE 3-5 PROBES CMPTR
FORENSIC CYTOPATHOLOGY
SEX CHROMATIN IDENTIFICATION
SEX CHROMATIN IDENTIFICATION
CYTOPATH C/V INTERPRET
CYTOPATH C/V THIN LAYER
CYTOPATH C/V THIN LAYER REDO
CYTOPATH C/V AUTOMATED
CYTOPATH C/V AUTO RESCREEN
CYTOPATH C/V MANUAL
CYTOPATH C/V AUTO REDO
CYTOPATH C/V REDO
CYTOPATH C/V SELECT
CYTOPATH C/V INDEX ADD-ON
CYTOPATH SMEAR OTHER SOURCE
CYTOPATH TBS C/V MANUAL
CYTOPATH TBS C/V REDO
CYTOPATH TBS C/V AUTO REDO
CYTOPATH TBS C/V SELECT
CYTP DX EVAL FNA 1ST EA SITE
CYTOPATH EVAL FNA REPORT
CYTOPATH C/V AUTO IN FLUID
CYTOPATH C/V AUTO FLUID REDO
CYTP FNA EVAL EA ADDL
CELL MARKER STUDY
FLOWCYTOMETRY/ TC 1 MARKER
FLOWCYTOMETRY/TC ADD-ON
FLOWCYTOMETRY/READ 2-8
FLOWCYTOMETRY/READ 9-15
FLOWCYTOMETRY/READ 16 & >
CYTOPATHOLOGY PROCEDURE
TISSUE CULTURE LYMPHOCYTE
TISSUE CULTURE SKIN/BIOPSY
TISSUE CULTURE PLACENTA
TISSUE CULTURE BONE MARROW
TISSUE CULTURE TUMOR
CELL CRYOPRESERVE/STORAGE
FROZEN CELL PREPARATION
CHROMOSOME ANALYSIS 20-25
CHROMOSOME ANALYSIS 100
Pricing Action Code
3
3
6
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
5
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$53.81
$123.81
$0.00
$543.28
$20.54
$20.10
$10.67
$23.24
$27.05
$27.05
$15.19
$20.29
$14.10
$14.10
$14.10
$14.10
$8.00
$55.77
$54.23
$56.99
$14.10
$14.10
$14.10
$14.10
$49.53
$122.91
$28.53
$35.37
$27.77
$93.14
$49.26
$24.22
$63.03
$83.19
$109.59
$0.00
$155.52
$187.87
$196.59
$168.62
$196.93
$13.48
$13.48
$198.72
$231.18
$231.18
$235.94
Procedure Code
88262
88263
88264
88267
88269
88271
88272
88273
88274
88275
88280
88283
88285
88289
88291
88299
88300
88302
88304
88305
88307
88309
88311
88312
88313
88314
88319
88321
88323
88325
88329
88331
88332
88333
88334
88341
88342
88344
88346
88348
88350
88355
88356
88358
88360
88361
88362
Description
CHROMOSOME ANALYS PLACENTA
CHROMOSOME ANALYS AMNIOTIC
CYTOGENETICS DNA PROBE
CYTOGENETICS 3-5
CYTOGENETICS 10-30
CYTOGENETICS 25-99
CYTOGENETICS 100-300
CHROMOSOME KARYOTYPE STUDY
CHROMOSOME BANDING STUDY
CHROMOSOME COUNT ADDITIONAL
CHROMOSOME STUDY ADDITIONAL
CYTO/MOLECULAR REPORT
CYTOGENETIC STUDY
SURGICAL PATH GROSS
TISSUE EXAM BY PATHOLOGIST
DECALCIFY TISSUE
SPECIAL STAINS GROUP 1
SPECIAL STAINS GROUP 2
HISTOCHEMICAL STAINS ADD-ON
ENZYME HISTOCHEMISTRY
MICROSLIDE CONSULTATION
MICROSLIDE CONSULTATION
COMPREHENSIVE REVIEW OF DATA
PATH CONSULT INTROP
PATH CONSULT INTRAOP 1 BLOC
PATH CONSULT INTRAOP ADDL
INTRAOP CYTO PATH CONSULT 1
INTRAOP CYTO PATH CONSULT 2
IMMUNOHISTO ANTB ADDL SLIDE
IMMUNOHISTO ANTB 1ST STAIN
IMMUNOHISTO ANTIBODY SLIDE
IMMUNOFLUOR ANTB 1ST STAIN
ELECTRON MICROSCOPY
IMMUNOFLUOR ANTB ADDL STAIN
ANALYSIS SKELETAL MUSCLE
ANALYSIS NERVE
ANALYSIS TUMOR
TUMOR IMMUNOHISTOCHEM/MANUAL
TUMOR IMMUNOHISTOCHEM/COMPUT
NERVE TEASING PREPARATIONS
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
5
3
3
3
3
3
3
3
3
3
3
3
3
9
3
3
3
3
3
3
3
3
3
3
3
6
3
3
3
3
3
3
Maximum Allowable
$166.39
$200.64
$166.39
$239.99
$222.04
$28.59
$35.74
$42.89
$46.47
$53.61
$33.51
$91.58
$25.36
$45.97
$31.20
$0.00
$14.46
$32.51
$42.89
$97.57
$166.79
$217.13
$17.46
$73.61
$51.85
$52.71
$94.40
$82.65
$0.00
$199.53
$50.44
$85.84
$42.97
$90.40
$52.97
$68.03
$86.31
$117.66
$90.16
$388.66
$0.00
$175.05
$231.50
$63.47
$106.57
$141.54
$256.79
Procedure Code
88363
88364
88365
88366
88367
88368
88369
88371
88372
88373
88374
88375
88377
88380
88381
88387
88388
88399
88720
88738
88740
88741
88749
89049
89050
89051
89055
89060
89125
89160
89190
89220
89230
89240
89250
89251
89253
89254
89255
89257
89258
89259
89260
89261
89264
89268
89272
Description
XM ARCHIVE TISSUE MOLEC ANAL
INSITU HYBRIDIZATION (FISH)
INSITU HYBRIDIZATION AUTO
INSITU HYBRIDIZATION MANUAL
M/PHMTRC ALYSISHQUANT/SEMIQ
PROTEIN WESTERN BLOT TISSUE
PROTEIN ANALYSIS W/PROBE
M/PHMTRC ALYS ISHQUANT/SEMIQ
OPTICAL ENDOMICROSCPY INTERP
MICRODISSECTION LASER
MICRODISSECTION MANUAL
TISS EXAM MOLECULAR STUDY
TISS EX MOLECUL STUDY ADD-ON
SURGICAL PATHOLOGY PROCEDURE
BILIRUBIN TOTAL TRANSCUT
HGB QUANT TRANSCUTANEOUS
TRANSCUTANEOUS CARBOXYHB
TRANSCUTANEOUS METHB
IN VIVO LAB SERVICE
CHCT FOR MAL HYPERTHERMIA
BODY FLUID CELL COUNT
BODY FLUID CELL COUNT
LEUKOCYTE ASSESSMENT FECAL
EXAM SYNOVIAL FLUID CRYSTALS
SPECIMEN FAT STAIN
EXAM FECES FOR MEAT FIBERS
NASAL SMEAR FOR EOSINOPHILS
SPUTUM SPECIMEN COLLECTION
COLLECT SWEAT FOR TEST
PATHOLOGY LAB PROCEDURE
CULTR OOCYTE/EMBRYO <4 DAYS
CULTR OOCYTE/EMBRYO <4 DAYS
EMBRYO HATCHING
OOCYTE IDENTIFICATION
PREPARE EMBRYO FOR TRANSFER
SPERM IDENTIFICATION
CRYOPRESERVATION EMBRYO(S)
CRYOPRESERVATION SPERM
SPERM ISOLATION SIMPLE
SPERM ISOLATION COMPLEX
IDENTIFY SPERM TISSUE
INSEMINATION OF OOCYTES
EXTENDED CULTURE OF OOCYTES
Pricing Action Code
6
3
3
3
3
3
3
3
3
3
3
9
3
5
3
3
6
5
3
3
3
3
6
6
3
3
3
3
3
3
3
3
3
6
9
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$97.94
$122.58
$150.21
$200.25
$143.52
$74.11
$29.66
$30.36
$60.80
$206.05
$0.00
$215.14
$0.00
$162.32
$40.15
$0.00
$0.00
$6.69
$6.69
$6.69
$6.69
$0.00
$0.00
$6.31
$7.35
$5.70
$9.55
$5.76
$4.92
$6.34
$16.06
$17.60
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
89280
89281
89290
89291
89300
89310
89320
89321
89322
89325
89329
89330
89331
89335
89337
89342
89343
89344
89346
89352
89353
89354
89356
89398
9001F
9002F
9003F
9004F
9005F
9006F
9007F
90281
90283
90284
90287
90288
90291
90296
90371
90375
90376
90378
90384
90385
90386
90389
90393
Description
ASSIST OOCYTE FERTILIZATION
ASSIST OOCYTE FERTILIZATION
BIOPSY OOCYTE POLAR BODY
BIOPSY OOCYTE POLAR BODY
SEMEN ANALYSIS W/HUHNER
SEMEN ANALYSIS W/COUNT
SEMEN ANAL VOL/COUNT/MOT
SEMEN ANAL SPERM DETECTION
SEMEN ANAL STRICT CRITERIA
SPERM ANTIBODY TEST
SPERM EVALUATION TEST
EVALUATION CERVICAL MUCUS
RETROGRADE EJACULATION ANAL
CRYOPRESERVE TESTICULAR TISS
CRYOPRESERVATION OOCYTE(S)
STORAGE/YEAR EMBRYO(S)
STORAGE/YEAR SPERM/SEMEN
STORAGE/YEAR REPROD TISSUE
STORAGE/YEAR OOCYTE(S)
THAWING CRYOPRESRVED EMBRYO
THAWING CRYOPRESRVED SPERM
THAW CRYOPRSVRD REPROD TISS
THAWING CRYOPRESRVED OOCYTE
UNLISTED REPROD MED LAB PROC
AORTIC ANEURYSM<5CM DIAM CT
AORTIC ANEURYSM 5-5.4CM DIAM
AORTIC ANRYSM5.5-5.9CM DIAM
AORTIC ANRYSM 6/> CM DIAM
ASYMPT CAROT/VRTBRBAS STEN
SYMPT STEN-TIA/STRK<120DAYS
OTHER CAROT STEN 120 DAYS/>
HUMAN IG IM
HUMAN IG IV
HUMAN IG SC
BOTULINUM ANTITOXIN
BOTULISM IG IV
CMV IG IV
DIPHTHERIA ANTITOXIN
HEP B IG IM
RABIES IG IM/SC
RABIES IG HEAT TREATED
RSV MAB IM 50MG
RH IG FULL-DOSE IM
RH IG MINIDOSE IM
RH IG IV
TETANUS IG IM
VACCINA IG IM
Pricing Action Code
9
9
9
9
9
3
3
3
3
3
9
9
3
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
5
5
6
5
5
5
5
3
3
3
5
5
6
5
5
5
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$11.50
$16.08
$16.08
$20.69
$14.25
$0.00
$0.00
$26.16
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$113.22
$285.18
$262.81
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
90396
90399
90460
90461
90471
90472
90473
90474
90476
90477
90581
90585
90586
90590
90592
90621
90625
90630
90632
90633
90634
90636
90640
90641
90642
90643
90644
90647
90648
90649
90650
90651
90652
90653
90654
90655
90656
90657
90658
90660
90661
90662
90664
90666
90667
90668
90670
Description
Pricing Action Code
VARICELLA-ZOSTER IG IM
IMMUNE GLOBULIN
IM ADMIN 1ST/ONLY COMPONENT
IM ADMIN EACH ADDL COMPONENT
IMMUNIZATION ADMIN
IMMUNIZATION ADMIN EACH ADD
IMMUNE ADMIN ORAL/NASAL
IMMUNE ADMIN ORAL/NASAL ADDL
ADENOVIRUS VACCINE TYPE 4
ADENOVIRUS VACCINE TYPE 7
ANTHRAX VACCINE SC OR IM
BCG VACCINE PERCUT
BCG VACCINE INTRAVESICAL
PHYSICIAN DIRECTION OF EMERGENCY M
CHOLERA VACCINE, ORAL
MENB RLP VACCINE IM
CHOLERA VACCINE LIVE ORAL
FLU VACC IIV4 NO PRESERV ID
HEPA VACCINE ADULT IM
HEPA VACC PED/ADOL 2 DOSE IM
HEPA VACC PED/ADOL 3 DOSE
HEP A/HEP B VACC ADULT IM
FOLLOW-UP CONSULTATION BRIEF
FOLLOW-UP CONSULTATION LIMITED
FOLLOW-UP CONSULTATION INTERMEDI
FOLLOW-UP CONSULTATION COMPLEX
HIB-MENCY VACCINE 4 DOSE IM
HIB PRP-OMP VACC 3 DOSE IM
HIB PRP-T VACCINE 4 DOSE IM
4VHPV VACCINE 3 DOSE IM
CONFIRMATORY CONSULTATION EXTEND
IIV ADJUVANT VACCINE IM
FLU VACC IIV3 NO PRESERV ID
IIV3 VACC NO PRSV 6-35 MO IM
IIV3 VACC NO PRSV 3 YRS+ IM
IIV3 VACCINE 6-35 MONTHS IM
IIV3 VACCINE 3 YRS+ IM
LAIV3 VACCINE INTRANASAL
CCIIV3 VAC IM CULT PRSV FREE
IIV NO PRSV INCREASED AG IM
LAIV VACC PANDEMIC INTRANASL
FLU VAC PANDEM PRSRV FREE IM
IIV VACC PANDEMIC ADJUVT IM
IIV VACCINE PANDEMIC IM
PCV13 VACCINE IM
5
5
9
9
9
9
9
9
5
5
5
3
3
9
9
6
9
6
3
5
5
6
9
9
9
9
9
5
5
6
6
3
9
9
6
5
3
3
3
5
3
3
9
9
9
9
3
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$123.76
$123.76
$0.00
$0.00
$0.00
$0.00
$0.00
$51.23
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$158.41
$0.00
$0.00
$0.00
$0.00
$13.88
$6.02
$12.38
$0.00
$22.29
$36.31
$0.00
$0.00
$0.00
$0.00
$173.15
Procedure Code
90672
90673
90675
90676
90680
90681
90685
90686
90687
90688
90690
90691
90696
90697
90698
90700
90702
90707
90710
90713
90714
90715
90716
90717
90723
90732
90733
90734
90736
90738
90739
90740
90743
90744
90746
90747
90748
90749
90750
90751
90755
90785
90791
90792
90820
90825
90832
Description
Pricing Action Code
LAIV4 VACCINE INTRANASAL
RIV3 VACCINE NO PRESERV IM
RABIES VACCINE IM
RABIES VACCINE ID
RV5 VACC 3 DOSE LIVE ORAL
RV1 VACC 2 DOSE LIVE ORAL
IIV4 VACC NO PRSV 6-35 M IM
IIV4 VACC NO PRSV 3 YRS+ IM
IIV4 VACCINE 6-35 MONTHS IM
IIV4 VACCINE 3 YRS PLUS IM
TYPHOID VACCINE ORAL
TYPHOID VACCINE IM
DTAP-IPV VACCINE 4-6 YRS IM
DTAP-IPV-HIB-HEPB VACCINE IM
DTAP-IPV/HIB VACCINE IM
DTAP VACCINE < 7 YRS IM
DT VACCINE UNDER 7 YRS IM
MMR VACCINE SC
MMRV VACCINE SC
POLIOVIRUS IPV SC/IM
TD VACC NO PRESV 7 YRS+ IM
TDAP VACCINE 7 YRS/> IM
VAR VACCINE LIVE SUBQ
YELLOW FEVER VACCINE SUBQ
DTAP-HEP B-IPV VACCINE IM
PPSV23 VACC 2 YRS+ SUBQ/IM
MPSV4 VACCINE SUBQ
MENACWY VACCINE IM
HZV VACCINE LIVE SUBQ
INACTIVATED JE VACC IM
HEPB VACC 2 DOSE ADULT IM
HEPB VACC 3 DOSE IMMUNSUP IM
HEPB VACC 2 DOSE ADOLESC IM
HEPB VACC 3 DOSE PED/ADOL IM
HEPB VACCINE 3 DOSE ADULT IM
HEPB VACC 4 DOSE IMMUNSUP IM
HIB-HEPB VACCINE IM
VACCINE TOXOID
INITIAL HISTORY AND EXAMINATION REL
INITIAL HISTORY AND EXAMINATION REL
INFANT CARE TO ONE YEAR OF AGE, WIT
PSYTX COMPLEX INTERACTIVE
PSYCH DIAGNOSTIC EVALUATION
PSYCH DIAG EVAL W/MED SRVCS
INTERACTIVE MEDICAL PSYCHIATRIC DIA
PSYCHIATRIC EVALUATION OF HOSPITAL
PSYTX PT&/FAMILY 30 MINUTES
3
3
3
5
5
6
3
3
3
3
9
3
6
6
6
5
5
6
5
6
3
3
6
9
5
3
6
3
6
9
9
3
3
3
3
3
6
5
9
9
9
3
3
3
9
9
3
Maximum Allowable
$26.88
$37.19
$280.21
$0.00
$0.00
$0.00
$24.60
$18.15
$9.13
$9.13
$0.00
$75.12
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$22.75
$31.21
$0.00
$0.00
$0.00
$82.52
$0.00
$109.65
$0.00
$0.00
$0.00
$119.42
$24.22
$24.22
$59.71
$119.42
$0.00
$0.00
$0.00
$0.00
$0.00
$13.92
$131.78
$146.15
$0.00
$0.00
$63.89
Procedure Code
90833
90834
90835
90836
90837
90838
90839
90840
90841
90842
90843
90844
90845
90846
90847
90849
90853
90855
90863
90865
90867
90868
90869
90870
90875
90876
90880
90882
90885
90887
90889
90901
90906
90911
90935
90937
90940
90945
90947
90951
90952
90953
90954
90955
90956
90957
90958
Description
Pricing Action Code
PSYTX PT&/FAM W/E&M 30 MIN
NARCOSYNTHESIS FOR PSYCHIATRIC DIAG
PSYTX CRISIS INITIAL 60 MIN
PSYTX CRISIS EA ADDL 30 MIN
INDIVIDUAL MEDICAL PSYCHOTHERAPY B
PSYCHOANALYSIS
FAMILY PSYTX W/O PATIENT
FAMILY PSYTX W/PATIENT
MULTIPLE FAMILY GROUP PSYTX
GROUP PSYCHOTHERAPY
INTERACTIVE INDIVIDUAL MEDICAL PSYC
PHARMACOLOGIC MGMT W/PSYTX
NARCOSYNTHESIS
TCRANIAL MAGN STIM TX PLAN
TCRANIAL MAGN STIM TX DELI
TCRAN MAGN STIM REDETEMINE
ELECTROCONVULSIVE THERAPY
PSYCHOPHYSIOLOGICAL THERAPY
PSYCHOPHYSIOLOGICAL THERAPY
HYPNOTHERAPY
ENVIRONMENTAL MANIPULATION
PSY EVALUATION OF RECORDS
CONSULTATION WITH FAMILY
PREPARATION OF REPORT
BIOFEEDBACK TRAIN ANY METH
BIOFEEDBACK TRAINING REGULATION O
BIOFEEDBACK PERI/URO/RECTAL
HEMODIALYSIS ONE EVALUATION
HEMODIALYSIS REPEATED EVAL
HEMODIALYSIS ACCESS STUDY
DIALYSIS ONE EVALUATION
DIALYSIS REPEATED EVAL
ESRD SERV 4 VISITS P MO <2YR
ESRD SERV 2-3 VSTS P MO <2YR
ESRD SERV 1 VISIT P MO <2YRS
ESRD SERV 4 VSTS P MO 2-11
ESRD SRV 2-3 VSTS P MO 2-11
ESRD SRV 1 VISIT P MO 2-11
ESRD SRV 4 VSTS P MO 12-19
ESRD SRV 2-3 VSTS P MO 12-19
3
3
9
3
3
3
3
3
9
9
9
9
3
3
3
3
3
9
6
9
3
3
3
3
9
9
9
9
3
9
9
9
9
3
3
3
5
3
3
3
6
6
3
3
3
3
3
Maximum Allowable
$66.08
$84.95
$0.00
$83.95
$127.43
$110.75
$133.14
$63.52
$0.00
$0.00
$0.00
$0.00
$91.78
$103.18
$106.73
$34.42
$25.71
$0.00
$0.00
$0.00
$134.62
$23.74
$113.18
$179.15
$0.00
$0.00
$0.00
$0.00
$50.15
$0.00
$0.00
$0.00
$0.00
$85.31
$73.01
$104.88
$0.00
$86.73
$125.29
$953.77
$0.00
$0.00
$824.16
$461.34
$321.74
$651.52
$439.86
Procedure Code
90959
90960
90961
90962
90963
90964
90965
90966
90967
90968
90969
90970
90989
90992
90993
90997
90999
91010
91013
91020
91022
91030
91034
91035
91037
91038
91040
91065
91110
91111
91112
91117
91120
91122
91132
91133
91200
91299
92002
92004
92012
92014
92015
92018
92019
92020
92025
Description
Pricing Action Code
ESRD SERV 1 VST P MO 12-19
ESRD SRV 4 VISITS P MO 20+
ESRD SRV 2-3 VSTS P MO 20+
ESRD SERV 1 VISIT P MO 20+
ESRD HOME PT SERV P MO <2YRS
ESRD HOME PT SERV P MO 2-11
ESRD HOME PT SERV P MO 12-19
ESRD HOME PT SERV P MO 20+
ESRD HOME PT SERV P DAY <2
ESRD HOME PT SRV P DAY 2-11
ESRD HOME PT SRV P DAY 12-19
ESRD HOME PT SERV P DAY 20+
DIALYSIS TRAINING COMPLETE
PERITONEAL DIALYSIS TRAINING AND/OR
DIALYSIS TRAINING INCOMPL
HEMOPERFUSION
DIALYSIS PROCEDURE
ESOPHAGUS MOTILITY STUDY
ESOPHGL MOTIL W/STIM/PERFUS
GASTRIC MOTILITY STUDIES
DUODENAL MOTILITY STUDY
ACID PERFUSION OF ESOPHAGUS
GASTROESOPHAGEAL REFLUX TEST
G-ESOPH REFLX TST W/ELECTROD
ESOPH IMPED FUNCTION TEST
ESOPH IMPED FUNCT TEST > 1HR
ESOPH BALLOON DISTENSION TST
BREATH HYDROGEN/METHANE TEST
GI TRACT CAPSULE ENDOSCOPY
ESOPHAGEAL CAPSULE ENDOSCOPY
GI WIRELESS CAPSULE MEASURE
COLON MOTILITY 6 HR STUDY
RECTAL SENSATION TEST
ANAL PRESSURE RECORD
ELECTROGASTROGRAPHY
ELECTROGASTROGRAPHY W/TEST
LIVER ELASTOGRAPHY
GASTROENTEROLOGY PROCEDURE
EYE EXAM NEW PATIENT
EYE EXAM NEW PATIENT
EYE EXAM ESTABLISH PATIENT
EYE EXAM&TX ESTAB PT 1/>VST
DETERMINE REFRACTIVE STATE
NEW EYE EXAM & TREATMENT
EYE EXAM & TREATMENT
SPECIAL EYE EVALUATION
CORNEAL TOPOGRAPHY
3
3
3
3
3
3
3
3
3
3
3
3
9
9
9
3
5
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
5
3
3
3
3
3
3
3
3
3
Maximum Allowable
$298.82
$286.33
$240.87
$185.74
$549.41
$480.37
$457.06
$240.14
$18.27
$15.77
$15.41
$7.89
$0.00
$0.00
$0.00
$94.54
$0.00
$179.22
$23.79
$238.48
$170.39
$138.49
$193.17
$490.41
$163.08
$459.13
$442.87
$79.91
$899.98
$739.72
$1,103.27
$141.29
$434.26
$231.13
$157.63
$175.20
$28.81
$0.00
$81.64
$149.51
$86.34
$125.14
$20.05
$147.66
$72.71
$26.92
$38.53
Procedure Code
92060
92065
92071
92072
92081
92082
92083
92100
92132
92133
92134
92136
92140
92145
92225
92226
92227
92228
92230
92235
92240
92250
92260
92265
92270
92275
92283
92284
92285
92286
92287
92310
92313
92314
92317
92325
92326
92340
92341
92342
92352
92353
92354
92355
92358
92370
92371
Description
SPECIAL EYE EVALUATION
ORTHOPTIC/PLEOPTIC TRAINING
CONTACT LENS FITTING FOR TX
FIT CONTAC LENS FOR MANAGMNT
VISUAL FIELD EXAMINATION(S)
SERIAL TONOMETRY EXAM(S)
CMPTR OPHTH DX IMG ANT SEGMT
CMPTR OPHTH IMG OPTIC NERVE
CPTR OPHTH DX IMG POST SEGMT
OPHTHALMIC BIOMETRY
GLAUCOMA PROVOCATIVE TESTS
CORNEAL HYSTERESIS DETER
SPECIAL EYE EXAM INITIAL
SPECIAL EYE EXAM SUBSEQUENT
REMOTE DX RETINAL IMAGING
REMOTE RETINAL IMAGING MGMT
EYE EXAM WITH PHOTOS
ICG ANGIOGRAPHY
OPHTHALMOSCOPY/DYNAMOMETRY
EYE MUSCLE EVALUATION
ELECTRO-OCULOGRAPHY
ELECTRORETINOGRAPHY
COLOR VISION EXAMINATION
DARK ADAPTATION EYE EXAM
EYE PHOTOGRAPHY
INTERNAL EYE PHOTOGRAPHY
INTERNAL EYE PHOTOGRAPHY
CONTACT LENS FITTING
CONTACT LENS FITTING
PRESCRIPTION OF CONTACT LENS
RX CORNEOSCLERAL CNTACT LENS
MODIFICATION OF CONTACT LENS
REPLACEMENT OF CONTACT LENS
FIT SPECTACLES MONOFOCAL
FIT SPECTACLES BIFOCAL
FIT SPECTACLES MULTIFOCAL
FIT APHAKIA SPECTCL MONOFOCL
FIT APHAKIA SPECTCL MULTIFOC
FIT SPECTACLES SINGLE SYSTEM
FIT SPECTACLES COMPOUND LENS
APHAKIA PROSTH SERVICE TEMP
REPAIR & ADJUST SPECTACLES
REPAIR & ADJUST SPECTACLES
Pricing Action Code
3
3
9
9
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$65.83
$52.65
$0.00
$0.00
$34.22
$48.27
$65.23
$81.08
$35.28
$44.59
$45.68
$91.98
$64.16
$15.85
$27.27
$25.14
$14.86
$34.91
$59.03
$111.72
$260.32
$79.38
$18.71
$79.54
$92.92
$149.24
$56.04
$61.42
$21.00
$38.50
$139.61
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
92499
92502
92504
92507
92508
92511
92512
92516
92520
92521
92522
92523
92524
92526
92531
92532
92533
92534
92537
92538
92540
92541
92542
92544
92545
92546
92547
92548
92550
92551
92552
92553
92555
92556
92557
92558
92559
92560
92561
92562
92563
92564
92565
92567
92568
92570
92571
Description
EYE SERVICE OR PROCEDURE
EAR AND THROAT EXAMINATION
EAR MICROSCOPY EXAMINATION
SPEECH/HEARING THERAPY
SPEECH/HEARING THERAPY
NASOPHARYNGOSCOPY
NASAL FUNCTION STUDIES
FACIAL NERVE FUNCTION TEST
LARYNGEAL FUNCTION STUDIES
EVALUATION OF SPEECH FLUENCY
EVALUATE SPEECH PRODUCTION
SPEECH SOUND LANG COMPREHEN
BEHAVRAL QUALIT ANALYS VOICE
ORAL FUNCTION THERAPY
SPONTANEOUS NYSTAGMUS STUDY
POSITIONAL NYSTAGMUS TEST
CALORIC VESTIBULAR TEST
OPTOKINETIC NYSTAGMUS TEST
CALORIC VSTBLR TEST W/REC
CALORIC VSTBLR TEST W/REC
BASIC VESTIBULAR EVALUATION
SPONTANEOUS NYSTAGMUS TEST
POSITIONAL NYSTAGMUS TEST
OPTOKINETIC NYSTAGMUS TEST
OSCILLATING TRACKING TEST
SINUSOIDAL ROTATIONAL TEST
SUPPLEMENTAL ELECTRICAL TEST
POSTUROGRAPHY
TYMPANOMETRY & REFLEX THRESH
PURE TONE HEARING TEST AIR
PURE TONE AUDIOMETRY AIR
AUDIOMETRY AIR & BONE
SPEECH THRESHOLD AUDIOMETRY
SPEECH AUDIOMETRY COMPLETE
COMPREHENSIVE HEARING TEST
EVOKED AUDITORY TEST QUAL
GROUP AUDIOMETRIC TESTING
BEKESY AUDIOMETRY SCREEN
BEKESY AUDIOMETRY DIAGNOSIS
LOUDNESS BALANCE TEST
TONE DECAY HEARING TEST
SISI HEARING TEST
STENGER TEST PURE TONE
TYMPANOMETRY
ACOUSTIC REFL THRESHOLD TST
ACOUSTIC IMMITANCE TESTING
FILTERED SPEECH HEARING TEST
Pricing Action Code
5
3
3
3
3
3
3
3
3
3
3
3
3
3
5
5
5
5
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
6
9
5
3
3
3
3
3
3
3
3
3
Maximum Allowable
$0.00
$99.47
$30.66
$79.95
$23.32
$114.78
$62.33
$72.17
$77.08
$112.29
$93.61
$196.25
$90.35
$86.80
$0.00
$0.00
$0.00
$0.00
$40.92
$20.83
$103.00
$24.38
$28.33
$16.87
$15.44
$104.84
$6.15
$103.98
$21.52
$12.33
$31.87
$38.02
$23.55
$38.02
$38.02
$0.00
$0.00
$0.00
$38.77
$47.44
$31.52
$28.62
$16.31
$14.73
$16.13
$32.63
$27.53
Procedure Code
92572
92575
92576
92577
92579
92582
92583
92584
92585
92586
92587
92588
92590
92591
92592
92593
92594
92595
92596
92597
92601
92602
92603
92604
92605
92606
92607
92608
92609
92610
92611
92612
92613
92614
92615
92616
92617
92618
92620
92621
92625
92626
92627
92630
92633
92640
92700
Description
STAGGERED SPONDAIC WORD TEST
SENSORINEURAL ACUITY TEST
SYNTHETIC SENTENCE TEST
STENGER TEST SPEECH
VISUAL AUDIOMETRY (VRA)
CONDITIONING PLAY AUDIOMETRY
SELECT PICTURE AUDIOMETRY
ELECTROCOCHLEOGRAPHY
AUDITOR EVOKE POTENT COMPRE
AUDITOR EVOKE POTENT LIMIT
EVOKED AUDITORY TEST LIMITED
EVOKED AUDITORY TST COMPLETE
HEARING AID EXAM ONE EAR
HEARING AID EXAM BOTH EARS
HEARING AID CHECK ONE EAR
HEARING AID CHECK BOTH EARS
ELECTRO HEARNG AID TEST ONE
ELECTRO HEARNG AID TST BOTH
EAR PROTECTOR EVALUATION
ORAL SPEECH DEVICE EVAL
COCHLEAR IMPLT F/UP EXAM <7
REPROGRAM COCHLEAR IMPLT 7/>
COCHLEAR IMPLT F/UP EXAM 7/>
REPROGRAM COCHLEAR IMPLT 7/>
EX FOR NONSPEECH DEVICE RX
NON-SPEECH DEVICE SERVICE
EX FOR SPEECH DEVICE RX 1HR
EX FOR SPEECH DEVICE RX ADDL
USE OF SPEECH DEVICE SERVICE
EVALUATE SWALLOWING FUNCTION
MOTION FLUOROSCOPY/SWALLOW
ENDOSCOPY SWALLOW TST (FEES)
ENDOSCOPY SWALLOW TST (FEES)
LARYNGOSCOPIC SENSORY TEST
EVAL LARYNGOSCOPY SENSE TST
FEES W/LARYNGEAL SENSE TEST
INTERPRT FEES/LARYNGEAL TEST
EX FOR NONSPEECH DEV RX ADD
AUDITORY FUNCTION 60 MIN
AUDITORY FUNCTION + 15 MIN
TINNITUS ASSESSMENT
EVAL AUD REHAB STATUS
EVAL AUD STATUS REHAB ADD-ON
AUD REHAB PRE-LING HEAR LOSS
AUD REHAB POSTLING HEAR LOSS
AUD BRAINSTEM IMPLT PROGRAMG
ENT PROCEDURE/SERVICE
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
9
9
9
9
9
9
9
9
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
9
9
9
9
9
9
9
3
5
Maximum Allowable
$36.58
$73.88
$36.58
$17.03
$42.70
$69.18
$53.23
$74.97
$138.02
$86.92
$21.88
$33.34
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$143.52
$90.85
$153.62
$90.48
$94.58
$84.28
$127.78
$53.53
$112.03
$86.49
$88.32
$190.07
$39.09
$148.80
$34.41
$212.54
$42.64
$34.39
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$114.80
$0.00
Procedure Code
92920
92921
92924
92925
92928
92929
92933
92934
92937
92938
92941
92943
92944
92950
92953
92960
92961
92970
92971
92973
92974
92975
92977
92978
92979
92986
92987
92990
92992
92993
92997
92998
93000
93005
93010
93015
93016
93017
93018
93024
93025
93040
93041
93042
93050
93224
93225
Description
PRQ CARDIAC ANGIOPLAST 1 ART
PRQ CARDIAC ANGIO ADDL ART
PRQ CARD ANGIO/ATHRECT 1 ART
PRQ CARD ANGIO/ATHRECT ADDL
PRQ CARD STENT W/ANGIO 1 VSL
PRQ CARD STENT W/ANGIO ADDL
PRQ CARD STENT/ATH/ANGIO
PRQ CARD STENT/ATH/ANGIO
PRQ REVASC BYP GRAFT 1 VSL
PRQ REVASC BYP GRAFT ADDL
PRQ CARD REVASC MI 1 VSL
PRQ CARD REVASC CHRONIC 1VSL
PRQ CARD REVASC CHRONIC ADDL
HEART/LUNG RESUSCITATION CPR
TEMPORARY EXTERNAL PACING
CARDIOVERSION ELECTRIC EXT
CARDIOVERSION ELECTRIC INT
CARDIOASSIST INTERNAL
CARDIOASSIST EXTERNAL
PRQ CORONARY MECH THROMBECT
CATH PLACE CARDIO BRACHYTX
DISSOLVE CLOT HEART VESSEL
DISSOLVE CLOT HEART VESSEL
INTRAVASC US HEART ADD-ON
INTRAVASC US HEART ADD-ON
REVISION OF AORTIC VALVE
PUL ART BALLOON REPR PERCUT
PUL ART BALLOON REPR PERCUT
ELECTROCARDIOGRAM COMPLETE
ELECTROCARDIOGRAM TRACING
ELECTROCARDIOGRAM REPORT
CARDIOVASCULAR STRESS TEST
CARDIAC DRUG STRESS TEST
MICROVOLT T-WAVE ASSESS
RHYTHM ECG WITH REPORT
RHYTHM ECG TRACING
RHYTHM ECG REPORT
ART PRESSURE WAVEFORM ANALYS
ECG MONIT/REPRT UP TO 48 HRS
Pricing Action Code
3
6
3
6
3
6
3
6
3
6
3
3
6
3
9
3
9
3
3
3
3
3
3
3
3
3
3
3
5
5
3
3
3
3
3
3
9
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$572.05
$0.00
$679.10
$0.00
$635.15
$0.00
$710.50
$0.00
$634.43
$0.00
$711.95
$711.57
$0.00
$309.31
$0.00
$209.09
$0.00
$194.20
$105.27
$185.63
$169.76
$409.09
$63.58
$0.00
$0.00
$1,396.15
$1,439.21
$1,136.32
$0.00
$0.00
$687.20
$338.42
$17.30
$8.70
$8.59
$76.68
$0.00
$39.84
$14.66
$113.36
$162.11
$12.97
$5.81
$7.15
$18.02
$92.76
$27.17
Procedure Code
93226
93227
93228
93229
93260
93261
93268
93270
93271
93272
93278
93279
93280
93281
93282
93283
93284
93285
93286
93287
93288
93289
93290
93291
93292
93293
93294
93295
93296
93297
93298
93299
93303
93304
93306
93307
93308
93312
93313
93314
93315
93316
93317
93318
93320
93321
93325
Description
REMOTE 30 DAY ECG REV/REPORT
REMOTE 30 DAY ECG TECH SUPP
PRGRMG DEV EVAL IMPLTBL SYS
INTERROGATE SUBQ DEFIB
ECG RECORD/REVIEW
REMOTE 30 DAY ECG REV/REPORT
ECG/MONITORING AND ANALYSIS
ECG/REVIEW INTERPRET ONLY
ECG/SIGNAL-AVERAGED
PM DEVICE PROGR EVAL SNGL
PM DEVICE PROGR EVAL DUAL
PM DEVICE PROGR EVAL MULTI
PRGRMG EVAL IMPLANTABLE DFB
ILR DEVICE EVAL PROGR
PERI-PX PACEMAKER DEVICE EVL
PERI-PX DEVICE EVAL & PRGR
PM DEVICE EVAL IN PERSON
INTERROG DEVICE EVAL HEART
ICM DEVICE EVAL
ILR DEVICE INTERROGATE
WCD DEVICE INTERROGATE
PM PHONE R-STRIP DEVICE EVAL
PM DEVICE INTERROGATE REMOTE
DEV INTERROG REMOTE 1/2/MLT
PM/ICD REMOTE TECH SERV
ICM DEVICE INTERROGAT REMOTE
ILR DEVICE INTERROGAT REMOTE
ICM/ILR REMOTE TECH SERV
ECHO TRANSTHORACIC
ECHO TRANSTHORACIC
TTE W/DOPPLER COMPLETE
TTE W/O DOPPLER COMPLETE
TTE F-UP OR LMTD
ECHO TRANSESOPHAGEAL
ECHO TRANSESOPHAGEAL INTRAOP
DOPPLER ECHO EXAM HEART
DOPPLER ECHO EXAM HEART
DOPPLER COLOR FLOW ADD-ON
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$38.75
$26.84
$26.50
$740.40
$67.92
$61.47
$208.60
$9.43
$173.41
$25.75
$30.63
$50.30
$58.56
$68.97
$63.58
$82.58
$91.22
$42.79
$27.71
$36.68
$37.42
$66.07
$31.62
$36.69
$32.71
$54.13
$34.39
$68.08
$26.44
$26.86
$26.86
$44.25
$242.52
$158.49
$231.66
$132.31
$126.76
$312.38
$23.27
$305.59
$0.00
$39.38
$0.00
$0.00
$55.15
$27.79
$26.02
Procedure Code
93350
93351
93352
93355
93451
93452
93453
93454
93455
93456
93457
93458
93459
93460
93461
93462
93463
93464
93503
93505
93530
93531
93532
93533
93561
93562
93563
93564
93565
93566
93567
93568
93571
93572
93580
93581
93582
93583
93600
93602
93603
93609
93610
93612
93613
93615
93616
Description
STRESS TTE ONLY
STRESS TTE COMPLETE
ADMIN ECG CONTRAST AGENT
ECHO TRANSESOPHAGEAL (TEE)
RIGHT HEART CATH
LEFT HRT CATH W/VENTRCLGRPHY
R&L HRT CATH W/VENTRICLGRPHY
CORONARY ARTERY ANGIO S&I
CORONARY ART/GRFT ANGIO S&I
R HRT CORONARY ARTERY ANGIO
R HRT ART/GRFT ANGIO
L HRT ARTERY/VENTRICLE ANGIO
L HRT ART/GRFT ANGIO
R&L HRT ART/VENTRICLE ANGIO
R&L HRT ART/VENTRICLE ANGIO
L HRT CATH TRNSPTL PUNCTURE
DRUG ADMIN & HEMODYNMIC MEAS
EXERCISE W/HEMODYNAMIC MEAS
INSERT/PLACE HEART CATHETER
BIOPSY OF HEART LINING
RT HEART CATH CONGENITAL
R & L HEART CATH CONGENITAL
CARDIAC OUTPUT MEASUREMENT
CARD OUTPUT MEASURE SUBSQ
INJECT CONGENITAL CARD CATH
INJECT HRT CONGNTL ART/GRFT
INJECT L VENTR/ATRIAL ANGIO
INJECT R VENTR/ATRIAL ANGIO
INJECT SUPRVLV AORTOGRAPHY
INJECT PULM ART HRT CATH
HEART FLOW RESERVE MEASURE
HEART FLOW RESERVE MEASURE
TRANSCATH CLOSURE OF ASD
TRANSCATH CLOSURE OF VSD
PERQ TRANSCATH CLOSURE PDA
PERQ TRANSCATH SEPTAL REDUXN
BUNDLE OF HIS RECORDING
INTRA-ATRIAL RECORDING
RIGHT VENTRICULAR RECORDING
MAP TACHYCARDIA ADD-ON
INTRA-ATRIAL PACING
INTRAVENTRICULAR PACING
ELECTROPHYS MAP 3D ADD-ON
ESOPHAGEAL RECORDING
ESOPHAGEAL RECORDING
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$244.59
$275.20
$34.66
$230.60
$801.01
$904.29
$1,164.60
$916.69
$1,067.80
$1,148.70
$1,299.09
$1,100.30
$1,215.55
$1,303.65
$1,490.98
$218.83
$100.63
$279.15
$134.62
$781.38
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$60.82
$64.16
$47.88
$174.98
$144.55
$157.23
$0.00
$0.00
$1,023.75
$1,397.16
$699.32
$790.58
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$416.46
$0.00
$0.00
Procedure Code
93618
93619
93620
93621
93622
93623
93624
93631
93640
93641
93642
93644
93650
93653
93654
93655
93656
93657
93660
93662
93668
93701
93702
93724
93745
93750
93770
93784
93786
93788
93790
93797
93798
93799
93880
93882
93886
93888
93890
93892
93893
93895
93922
93923
93924
93925
93926
Description
HEART RHYTHM PACING
ELECTROPHYSIOLOGY EVALUATION
STIMULATION PACING HEART
ELECTROPHYSIOLOGIC STUDY
HEART PACING MAPPING
EVALUATION HEART DEVICE
EP & ABLATE SUPRAVENT ARRHYT
EP & ABLATE VENTRIC TACHY
ABLATE ARRHYTHMIA ADD ON
TX ATRIAL FIB PULM VEIN ISOL
TX L/R ATRIAL FIB ADDL
TILT TABLE EVALUATION
INTRACARDIAC ECG (ICE)
PERIPHERAL VASCULAR REHAB
BIOIMPEDANCE CV ANALYSIS
BIS XTRACELL FLUID ANALYSIS
ANALYZE PACEMAKER SYSTEM
SET-UP CARDIOVERT-DEFIBRILL
INTERROGATION VAD IN PERSON
MEASURE VENOUS PRESSURE
AMBULATORY BP MONITORING
AMBULATORY BP RECORDING
AMBULATORY BP ANALYSIS
REVIEW/REPORT BP RECORDING
CARDIAC REHAB
CARDIAC REHAB/MONITOR
CARDIOVASCULAR PROCEDURE
EXTRACRANIAL BILAT STUDY
EXTRACRANIAL UNI/LTD STUDY
INTRACRANIAL COMPLETE STUDY
INTRACRANIAL LIMITED STUDY
TCD VASOREACTIVITY STUDY
TCD EMBOLI DETECT W/O INJ
TCD EMBOLI DETECT W/INJ
CAROTID INTIMA ATHEROMA EVAL
UPR/L XTREMITY ART 2 LEVELS
UPR/LXTR ART STDY 3+ LVLS
LWR XTR VASC STDY BILAT
LOWER EXTREMITY STUDY
LOWER EXTREMITY STUDY
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
9
3
3
3
3
3
3
3
3
3
3
3
3
5
3
3
3
3
3
3
3
9
3
3
3
3
3
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$438.15
$283.28
$631.36
$888.40
$1,182.97
$444.21
$1,183.66
$443.85
$160.36
$0.00
$0.00
$24.64
$110.43
$274.02
$215.95
$56.76
$8.24
$54.82
$30.43
$5.45
$18.95
$16.55
$25.55
$0.00
$195.83
$132.66
$202.98
$150.71
$207.25
$155.48
$153.97
$0.00
$91.13
$141.73
$177.90
$194.71
$156.90
Procedure Code
93930
93931
93965
93970
93971
93975
93976
93978
93979
93980
93981
93982
93990
93998
94002
94003
94004
94005
94010
94011
94012
94013
94014
94015
94016
94060
94070
94150
94200
94250
94375
94400
94450
94452
94453
94610
94620
94621
94640
94642
94644
94645
94660
94662
94664
94667
94668
Description
UPPER EXTREMITY STUDY
UPPER EXTREMITY STUDY
EXTREMITY STUDY
EXTREMITY STUDY
EXTREMITY STUDY
VASCULAR STUDY
VASCULAR STUDY
VASCULAR STUDY
VASCULAR STUDY
PENILE VASCULAR STUDY
PENILE VASCULAR STUDY
ANEURYSM PRESSURE SENS STUDY
DOPPLER FLOW TESTING
NONINVAS VASC DX STUDY PROC
VENT MGMT INPAT INIT DAY
VENT MGMT INPAT SUBQ DAY
VENT MGMT NF PER DAY
HOME VENT MGMT SUPERVISION
BREATHING CAPACITY TEST
SPIROMETRY UP TO 2 YRS OLD
SPIRMTRY W/BRNCHDIL INF-2 YR
MEAS LUNG VOL THRU 2 YRS
PATIENT RECORDED SPIROMETRY
PATIENT RECORDED SPIROMETRY
REVIEW PATIENT SPIROMETRY
EVALUATION OF WHEEZING
EVALUATION OF WHEEZING
VITAL CAPACITY TEST
LUNG FUNCTION TEST (MBC/MVV)
EXPIRED GAS COLLECTION
RESPIRATORY FLOW VOLUME LOOP
CO2 BREATHING RESPONSE CURVE
HYPOXIA RESPONSE CURVE
HAST W/REPORT
HAST W/OXYGEN TITRATE
SURFACTANT ADMIN THRU TUBE
PULMONARY STRESS TEST/SIMPLE
PULM STRESS TEST/COMPLEX
AIRWAY INHALATION TREATMENT
AEROSOL INHALATION TREATMENT
CBT 1ST HOUR
CBT EACH ADDL HOUR
POS AIRWAY PRESSURE CPAP
NEG PRESS VENTILATION CNP
EVALUATE PT USE OF INHALER
CHEST WALL MANIPULATION
CHEST WALL MANIPULATION
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
6
9
9
9
9
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
9
9
3
9
9
Maximum Allowable
$195.85
$131.55
$122.20
$190.45
$123.24
$213.73
$166.82
$195.51
$122.87
$123.08
$75.11
$44.04
$118.21
$0.00
$0.00
$0.00
$0.00
$0.00
$36.49
$104.24
$159.31
$35.24
$57.26
$31.52
$25.75
$62.12
$60.85
$26.06
$25.67
$26.75
$40.01
$56.99
$69.66
$58.84
$81.59
$60.53
$56.84
$165.72
$18.85
$34.88
$44.90
$14.49
$0.00
$0.00
$17.76
$0.00
$0.00
Procedure Code
94669
94680
94681
94690
94726
94727
94728
94729
94750
94760
94761
94762
94770
94772
94774
94775
94776
94777
94780
94781
95004
95012
95017
95018
95024
95027
95028
95044
95050
95051
95052
95056
95060
95065
95070
95071
95076
95079
95080
95081
95082
95115
95117
95120
95125
95130
95131
Description
Pricing Action Code
MECHANICAL CHEST WALL OSCILL
EXHALED AIR ANALYSIS O2
EXHALED AIR ANALYSIS O2/CO2
EXHALED AIR ANALYSIS
PULM FUNCT TST PLETHYSMOGRAP
PULM FUNCTION TEST BY GAS
PULM FUNCT TEST OSCILLOMETRY
CO/MEMBANE DIFFUSE CAPACITY
PULMONARY COMPLIANCE STUDY
MEASURE BLOOD OXYGEN LEVEL
EXHALED CARBON DIOXIDE TEST
BREATH RECORDING INFANT
PED HOME APNEA REC COMPL
PED HOME APNEA REC HK-UP
PED HOME APNEA REC DOWNLD
PED HOME APNEA REC REPORT
CAR SEAT/BED TEST 60 MIN
CAR SEAT/BED TEST + 30 MIN
PERCUT ALLERGY SKIN TESTS
EXHALED NITRIC OXIDE MEAS
PERQ & ICUT ALLG TEST VENOMS
PERQ&IC ALLG TEST DRUGS/BIOL
ICUT ALLERGY TEST DRUG/BUG
ICUT ALLERGY TITRATE-AIRBORN
ICUT ALLERGY TEST-DELAYED
ALLERGY PATCH TESTS
PHOTO PATCH TESTS UP TO 10 TESTS
PHOTO PATCH TESTS MORE THAN 10 TES
PHOTO PATCH TEST
PHOTOSENSITIVITY TESTS
EYE ALLERGY TESTS
NOSE ALLERGY TEST
BRONCHIAL ALLERGY TESTS
BRONCHIAL ALLERGY TESTS
INGEST CHALLENGE INI 120 MIN
INGEST CHALLENGE ADDL 60 MIN
PASSIVE TRANSFER TESTS UP TO 10 TES
PASSIVE TRANSFER TESTS 11-20 TESTS
PASSIVE TRANSFER TESTS MORE THAN 2
IMMUNOTHERAPY ONE INJECTION
IMMUNOTHERAPY INJECTIONS
IMMUNOTHERAPY ONE INJECTION
IMMUNOTHERAPY 2/> INJECTIONS
IMMNTX 1 STING INSECT
IMMNTX 2 STING INSECTS
9
3
3
3
3
3
3
3
3
3
3
3
3
3
9
9
9
9
9
9
3
3
3
3
3
3
3
3
9
9
3
3
3
3
3
3
3
3
9
9
9
3
3
9
9
9
9
Maximum Allowable
$0.00
$58.51
$53.84
$51.03
$53.80
$42.94
$41.13
$55.65
$82.06
$3.27
$5.09
$25.00
$7.52
$167.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$6.89
$19.57
$7.94
$20.92
$7.98
$4.71
$13.78
$5.81
$0.00
$0.00
$6.90
$45.65
$35.86
$26.08
$31.16
$35.88
$118.21
$83.88
$0.00
$0.00
$0.00
$9.07
$10.52
$0.00
$0.00
$0.00
$0.00
Procedure Code
95132
95133
95134
95135
95140
95144
95145
95146
95147
95148
95149
95150
95165
95170
95180
95199
95250
95251
95782
95783
95800
95801
95803
95805
95806
95807
95808
95810
95811
95812
95813
95816
95819
95822
95824
95827
95829
95830
95831
95832
95833
95834
95851
95852
95857
95860
95861
Description
Pricing Action Code
PROFESSIONAL SERVICES FOR THE SUPER
PROFESSIONAL SERVICES FOR THE SUPER
ANTIGEN THERAPY SERVICES
PROFESSIONAL SERVICE FOR THE SUPERV
RAPID DESENSITIZATION
ALLERGY IMMUNOLOGY SERVICES
GLUCOSE MONITORING CONT
GLUC MONITOR CONT PHYS I&R
POLYSOM <6 YRS 4/> PARAMTRS
POLYSOM <6 YRS CPAP/BILVL
SLP STDY UNATTENDED
SLP STDY UNATND W/ANAL
ACTIGRAPHY TESTING
MULTIPLE SLEEP LATENCY TEST
SLEEP STUDY UNATT&RESP EFFT
SLEEP STUDY ATTENDED
POLYSOM ANY AGE 1-3> PARAM
POLYSOM 6/> YRS 4/> PARAM
POLYSOM 6/>YRS CPAP 4/> PARM
EEG 41-60 MINUTES
EEG OVER 1 HOUR
EEG AWAKE AND DROWSY
EEG AWAKE AND ASLEEP
EEG COMA OR SLEEP ONLY
EEG CEREBRAL DEATH ONLY
EEG ALL NIGHT RECORDING
SURGERY ELECTROCORTICOGRAM
INSERT ELECTRODES FOR EEG
LIMB MUSCLE TESTING MANUAL
HAND MUSCLE TESTING MANUAL
BODY MUSCLE TESTING MANUAL
BODY MUSCLE TESTING MANUAL
RANGE OF MOTION MEASUREMENTS
RANGE OF MOTION MEASUREMENTS
CHOLINESTERASE CHALLENGE
MUSCLE TEST ONE LIMB
MUSCLE TEST 2 LIMBS
9
9
9
9
9
3
3
3
3
3
3
9
3
3
3
5
3
3
3
3
9
9
9
3
3
3
3
3
3
3
3
3
3
3
3
3
3
9
3
3
3
3
9
3
3
3
3
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$12.65
$22.06
$39.80
$35.82
$53.19
$71.66
$0.00
$13.01
$9.75
$135.64
$0.00
$161.16
$44.05
$1,047.87
$1,101.26
$0.00
$0.00
$0.00
$435.99
$171.23
$488.44
$643.13
$635.81
$668.00
$356.01
$429.84
$368.69
$421.91
$379.91
$0.00
$710.91
$1,918.77
$0.00
$31.00
$30.29
$37.73
$51.80
$0.00
$16.60
$55.11
$124.34
$174.36
Procedure Code
95863
95864
95865
95866
95867
95868
95869
95870
95872
95873
95874
95875
95885
95886
95887
95905
95907
95908
95909
95910
95911
95912
95913
95921
95922
95923
95924
95925
95926
95927
95928
95929
95930
95933
95937
95938
95939
95940
95941
95943
95950
95951
95952
95953
95954
95955
95956
Description
Pricing Action Code
MUSCLE TEST 3 LIMBS
MUSCLE TEST 4 LIMBS
MUSCLE TEST LARYNX
MUSCLE TEST HEMIDIAPHRAGM
MUSCLE TEST CRAN NERV UNILAT
MUSCLE TEST CRAN NERVE BILAT
MUSCLE TEST THOR PARASPINAL
MUSCLE TEST NONPARASPINAL
MUSCLE TEST ONE FIBER
GUIDE NERV DESTR ELEC STIM
GUIDE NERV DESTR NEEDLE EMG
LIMB EXERCISE TEST
MUSC TST DONE W/NERV TST LIM
MUSC TEST DONE W/N TEST COMP
MUSC TST DONE W/N TST NONEXT
MOTOR &/ SENS NRVE CNDJ TEST
NVR CNDJ TST 1-2 STUDIES
NRV CNDJ TST 3-4 STUDIES
NRV CNDJ TST 5-6 STUDIES
NRV CNDJ TEST 7-8 STUDIES
NRV CNDJ TEST 13/> STUDIES
AUTONOMIC NRV PARASYM INERVJ
AUTONOMIC NRV ADRENRG INERVJ
AUTONOMIC NRV SYST FUNJ TEST
ANS PARASYMP & SYMP W/TILT
SOMATOSENSORY TESTING
C MOTOR EVOKED UPPR LIMBS
C MOTOR EVOKED LWR LIMBS
VISUAL EVOKED POTENTIAL TEST
BLINK REFLEX TEST
NEUROMUSCULAR JUNCTION TEST
C MOTOR EVOKED UPR&LWR LIMBS
IONM IN OPERATNG ROOM 15 MIN
IONM REMOTE/>1 PT OR PER HR
PARASYMP&SYMP HRT RATE TEST
AMBULATORY EEG MONITORING
EEG MONITORING/VIDEORECORD
MONITORING FOR LOCALIZATION OF CER
EEG MONITORING/COMPUTER
EEG MONITORING/GIVING DRUGS
EEG DURING SURGERY
EEG MONITOR TECHNOL ATTENDED
3
3
3
3
3
3
3
3
9
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
6
6
3
3
9
3
9
9
3
Maximum Allowable
$216.49
$244.38
$146.86
$135.75
$96.22
$135.11
$95.01
$94.65
$0.00
$75.07
$74.36
$127.19
$59.54
$92.53
$82.50
$72.04
$97.19
$120.20
$146.84
$195.07
$235.68
$263.99
$301.69
$87.46
$102.62
$167.13
$151.47
$158.65
$140.19
$144.91
$229.04
$230.52
$130.51
$76.42
$82.92
$348.17
$509.93
$33.36
$0.00
$0.00
$336.57
$0.00
$0.00
$428.74
$0.00
$0.00
$1,672.18
Procedure Code
95957
95958
95961
95962
95965
95966
95967
95970
95971
95972
95974
95975
95978
95979
95980
95981
95982
95990
95991
95992
95999
96000
96001
96002
96003
96004
96020
96040
96101
96102
96103
96105
96110
96111
96116
96118
96119
96120
96125
96127
96150
96151
96152
96153
96154
96155
96360
Description
EEG DIGITAL ANALYSIS
EEG MONITORING/FUNCTION TEST
ELECTRODE STIMULATION BRAIN
ELECTRODE STIM BRAIN ADD-ON
MEG SPONTANEOUS
MEG EVOKED SINGLE
MEG EVOKED EACH ADDL
ANALYZE NEUROSTIM NO PROG
ANALYZE NEUROSTIM SIMPLE
ANALYZE NEUROSTIM COMPLEX
CRANIAL NEUROSTIM COMPLEX
CRANIAL NEUROSTIM COMPLEX
ANALYZE NEUROSTIM BRAIN/1H
ANALYZ NEUROSTIM BRAIN ADDON
IO ANAL GAST N-STIM INIT
IO ANAL GAST N-STIM SUBSQ
IO GA N-STIM SUBSQ W/REPROG
SPIN/BRAIN PUMP REFIL & MAIN
SPIN/BRAIN PUMP REFIL & MAIN
CANALITH REPOSITIONING PROC
NEUROLOGICAL PROCEDURE
MOTION ANALYSIS VIDEO/3D
MOTION TEST W/FT PRESS MEAS
DYNAMIC SURFACE EMG
DYNAMIC FINE WIRE EMG
PHYS REVIEW OF MOTION TESTS
FUNCTIONAL BRAIN MAPPING
GENETIC COUNSELING 30 MIN
PSYCHO TESTING BY PSYCH/PHYS
PSYCHO TESTING BY TECHNICIAN
PSYCHO TESTING ADMIN BY COMP
ASSESSMENT OF APHASIA
DEVELOPMENTAL SCREEN W/SCORE
DEVELOPMENTAL TEST EXTEND
NEUROBEHAVIORAL STATUS EXAM
NEUROPSYCH TST BY PSYCH/PHYS
NEUROPSYCH TESTING BY TEC
NEUROPSYCH TST ADMIN W/COMP
COGNITIVE TEST BY HC PRO
BRIEF EMOTIONAL/BEHAV ASSMT
ASSESS HLTH/BEHAVE INIT
ASSESS HLTH/BEHAVE SUBSEQ
INTERVENE HLTH/BEHAVE INDIV
INTERVENE HLTH/BEHAVE GROUP
INTERV HLTH/BEHAV FAM W/PT
INTERV HLTH/BEHAV FAM NO PT
HYDRATION IV INFUSION INIT
Pricing Action Code
3
9
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
5
9
9
9
9
9
3
9
3
3
3
9
3
7
9
3
3
3
3
3
3
3
3
3
3
7
3
Maximum Allowable
$320.37
$0.00
$299.75
$266.18
$0.00
$0.00
$0.00
$69.64
$51.01
$59.70
$211.02
$113.53
$253.54
$109.96
$47.56
$32.46
$53.66
$94.18
$124.85
$43.74
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$80.34
$64.52
$28.33
$0.00
$9.07
$0.00
$0.00
$98.79
$81.48
$48.96
$118.82
$5.45
$21.79
$20.71
$20.00
$4.66
$19.65
$0.00
$58.22
Procedure Code
96361
96365
96366
96367
96368
96369
96370
96371
96372
96373
96374
96375
96376
96379
96401
96402
96405
96406
96409
96411
96413
96415
96416
96417
96420
96422
96423
96425
96440
96446
96450
96521
96522
96523
96542
96549
96567
96570
96571
96900
96902
96904
96910
96912
96913
96920
96921
Description
HYDRATE IV INFUSION ADD-ON
THER/PROPH/DIAG IV INF INIT
THER/PROPH/DIAG IV INF ADDON
TX/PROPH/DG ADDL SEQ IV INF
THER/DIAG CONCURRENT INF
SC THER INFUSION UP TO 1 HR
SC THER INFUSION ADDL HR
SC THER INFUSION RESET PUMP
THER/PROPH/DIAG INJ SC/IM
THER/PROPH/DIAG INJ IA
THER/PROPH/DIAG INJ IV PUSH
TX/PRO/DX INJ NEW DRUG ADDON
TX/PRO/DX INJ SAME DRUG ADON
THER/PROP/DIAG INJ/INF PROC
CHEMO ANTI-NEOPL SQ/IM
CHEMO HORMON ANTINEOPL SQ/IM
CHEMO INTRALESIONAL UP TO 7
CHEMO INTRALESIONAL OVER 7
CHEMO IV PUSH SNGL DRUG
CHEMO IV PUSH ADDL DRUG
CHEMO IV INFUSION 1 HR
CHEMO IV INFUSION ADDL HR
CHEMO PROLONG INFUSE W/PUMP
CHEMO IV INFUS EACH ADDL SEQ
CHEMO IA PUSH TECNIQUE
CHEMO IA INFUSION UP TO 1 HR
CHEMO IA INFUSE EACH ADDL HR
CHEMOTHERAPY INFUSION METHOD
CHEMOTHERAPY INTRACAVITARY
CHEMOTX ADMN PRTL CAVITY
CHEMOTHERAPY INTO CNS
REFILL/MAINT PORTABLE PUMP
REFILL/MAINT PUMP/RESVR SYST
IRRIG DRUG DELIVERY DEVICE
CHEMOTHERAPY INJECTION
CHEMOTHERAPY UNSPECIFIED
PHOTODYNAMIC TX SKIN
PHOTODYNMC TX 30 MIN ADD-ON
PHOTODYNAMIC TX ADDL 15 MIN
ULTRAVIOLET LIGHT THERAPY
TRICHOGRAM
WHOLE BODY PHOTOGRAPHY
PHOTOCHEMOTHERAPY WITH UV-B
PHOTOCHEMOTHERAPY WITH UV-A
PHOTOCHEMOTHERAPY UV-A OR B
LASER TX SKIN < 250 SQ CM
LASER TX SKIN 250-500 SQ CM
Pricing Action Code
3
3
3
3
3
3
3
3
3
9
9
9
6
9
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
5
3
3
3
3
3
9
3
3
3
3
3
Maximum Allowable
$15.52
$70.52
$19.08
$31.05
$20.90
$195.76
$15.10
$73.84
$25.61
$0.00
$0.00
$0.00
$0.00
$0.00
$75.97
$32.85
$83.69
$118.66
$112.55
$63.29
$137.51
$28.87
$142.99
$63.64
$105.36
$172.74
$79.98
$184.72
$871.13
$205.13
$184.91
$140.08
$115.12
$25.33
$122.69
$0.00
$138.32
$59.36
$27.60
$21.01
$21.84
$0.00
$73.14
$93.41
$134.00
$158.26
$174.45
Procedure Code
96922
96931
96932
96933
96934
96935
96936
96999
97001
97002
97003
97004
97005
97006
97010
97012
97014
97016
97018
97022
97024
97026
97028
97032
97033
97034
97035
97036
97039
97110
97112
97113
97116
97124
97139
97140
97150
97530
97532
97533
97535
97537
97542
97597
97598
97602
97605
Description
LASER TX SKIN >500 SQ CM
RCM CELULR SUBCELULR IMG SKN
DERMATOLOGICAL PROCEDURE
PT EVALUATION
PT RE-EVALUATION
OT EVALUATION
OT RE-EVALUATION
ATHLETIC TRAIN EVAL
ATHLETIC TRAIN REEVAL
HOT OR COLD PACKS THERAPY
MECHANICAL TRACTION THERAPY
ELECTRIC STIMULATION THERAPY
VASOPNEUMATIC DEVICE THERAPY
PARAFFIN BATH THERAPY
WHIRLPOOL THERAPY
DIATHERMY EG MICROWAVE
INFRARED THERAPY
ULTRAVIOLET THERAPY
ELECTRICAL STIMULATION
ELECTRIC CURRENT THERAPY
CONTRAST BATH THERAPY
ULTRASOUND THERAPY
HYDROTHERAPY
PHYSICAL THERAPY TREATMENT
THERAPEUTIC EXERCISES
NEUROMUSCULAR REEDUCATION
AQUATIC THERAPY/EXERCISES
GAIT TRAINING THERAPY
MASSAGE THERAPY
PHYSICAL MEDICINE PROCEDURE
MANUAL THERAPY 1/> REGIONS
GROUP THERAPEUTIC PROCEDURES
THERAPEUTIC ACTIVITIES
COGNITIVE SKILLS DEVELOPMENT
SENSORY INTEGRATION
SELF CARE MNGMENT TRAINING
COMMUNITY/WORK REINTEGRATION
WHEELCHAIR MNGMENT TRAINING
RMVL DEVITAL TIS 20 CM/<
RMVL DEVITAL TIS ADDL 20CM/<
WOUND(S) CARE NON-SELECTIVE
NEG PRESS WOUND TX </=50 CM
Pricing Action Code
3
6
6
6
6
6
6
5
3
3
3
3
9
9
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
9
3
Maximum Allowable
$241.70
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$75.68
$42.36
$85.81
$53.21
$0.00
$0.00
$6.13
$16.14
$16.19
$19.44
$11.20
$23.79
$6.50
$6.13
$7.57
$19.40
$26.64
$18.34
$12.54
$33.50
$11.27
$32.68
$34.12
$43.52
$28.71
$26.57
$15.30
$30.14
$17.56
$35.20
$26.87
$29.41
$35.57
$30.51
$31.23
$76.44
$24.83
$0.00
$41.66
Procedure Code
97606
97607
97608
97610
97750
97755
97760
97761
97762
97799
97802
97803
97804
97810
97811
97813
97814
98925
98926
98927
98928
98929
98940
98941
98942
98943
98960
98961
98962
98966
98967
98968
98969
99000
99001
99002
99024
99026
99027
99050
99051
99053
99058
99060
99071
99075
99078
Description
NEG PRESS WOUND TX >50 CM
NEG PRESS WND TX </=50 SQ CM
NEG PRESS WOUND TX >50 CM
LOW FREQUENCY NON-THERMAL US
PHYSICAL PERFORMANCE TEST
ASSISTIVE TECHNOLOGY ASSESS
ORTHOTIC MGMT AND TRAINING
PROSTHETIC TRAINING
C/O FOR ORTHOTIC/PROSTH USE
MEDICAL NUTRITION INDIV IN
MED NUTRITION INDIV SUBSEQ
MEDICAL NUTRITION GROUP
ACUPUNCT W/O STIMUL 15 MIN
ACUPUNCT W/O STIMUL ADDL 15M
ACUPUNCT W/STIMUL 15 MIN
ACUPUNCT W/STIMUL ADDL 15M
OSTEOPATH MANJ 1-2 REGIONS
CHIROPRACT MANJ 1-2 REGIONS
CHIROPRACT MANJ 3-4 REGIONS
CHIROPRACTIC MANJ 5 REGIONS
CHIROPRACT MANJ XTRSPINL 1/>
SELF-MGMT EDUC & TRAIN 1 PT
SELF-MGMT EDUC/TRAIN 2-4 PT
SELF-MGMT EDUC/TRAIN 5-8 PT
HC PRO PHONE CALL 5-10 MIN
ONLINE SERVICE BY HC PRO
SPECIMEN HANDLING OFFICE-LAB
SPECIMEN HANDLING PT-LAB
DEVICE HANDLING PHYS/QHP
POSTOP FOLLOW-UP VISIT
IN-HOSPITAL ON CALL SERVICE
OUT-OF-HOSP ON CALL SERVICE
MEDICAL SERVICES AFTER HRS
MED SERV EVE/WKEND/HOLIDAY
MED SERV 10PM-8AM 24 HR FAC
OFFICE EMERGENCY CARE
OUT OF OFFICE EMERG MED SERV
PATIENT EDUCATION MATERIALS
MEDICAL TESTIMONY
GROUP HEALTH EDUCATION
Pricing Action Code
3
9
9
9
3
3
3
3
3
5
7
7
9
9
9
9
9
3
3
3
3
3
3
3
3
9
9
9
9
9
9
9
9
9
3
9
9
9
9
3
9
9
9
9
9
9
9
Maximum Allowable
$49.23
$0.00
$0.00
$0.00
$33.40
$36.18
$38.47
$33.40
$48.36
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$31.97
$46.30
$59.91
$73.51
$87.85
$28.68
$41.19
$53.35
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$3.10
$0.00
$0.00
$0.00
$0.00
$20.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
99080
99082
99090
99091
99100
99116
99135
99140
99143
99144
99145
99148
99149
99150
99170
99173
99174
99175
99177
99183
99184
99188
99190
99191
99192
99195
99199
99201
99202
99203
99204
99205
99211
99212
99213
99214
99215
99217
99218
99219
99220
99221
99222
99223
99224
99225
99226
Description
SPECIAL REPORTS OR FORMS
UNUSUAL PHYSICIAN TRAVEL
COMPUTER DATA ANALYSIS
COLLECT/REVIEW DATA FROM PT
SPECIAL ANESTHESIA SERVICE
ANESTHESIA WITH HYPOTHERMIA
SPECIAL ANESTHESIA PROCEDURE
EMERGENCY ANESTHESIA
MOD SEDAT PHYS/QHP <5 YRS
MOD SEDAT PHYS/QHP 5YRS/>
MOD SEDAT PHYS/QHP EA 15 MIN
MOD SED DIFF PHYS/QHP<5 YRS
MOD SED DIFF PHYS/QHP 5/>YRS
MOD SED DIFF PHYS/QHP ADD ON
ANOGENITAL EXAM CHILD W IMAG
VISUAL ACUITY SCREEN
OCULAR INSTRUMNT SCREEN BIL
INDUCTION OF VOMITING
OCULAR INSTRUMNT SCREEN BIL
HYPERBARIC OXYGEN THERAPY
HYPOTHERMIA ILL NEONATE
APP TOPICAL FLUORIDE VARNISH
SPECIAL PUMP SERVICES
PHLEBOTOMY
SPECIAL SERVICE/PROC/REPORT
OFFICE/OUTPATIENT VISIT NEW
OFFICE/OUTPATIENT VISIT EST
OBSERVATION CARE DISCHARGE
INITIAL OBSERVATION CARE
INITIAL HOSPITAL CARE
SUBSEQUENT OBSERVATION CARE
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
9
3
3
3
3
3
3
3
6
3
3
3
9
9
9
3
5
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$112.36
$112.36
$56.18
$176.41
$3.27
$7.60
$17.40
$0.00
$112.36
$232.43
$20.00
$0.00
$0.00
$0.00
$101.83
$0.00
$44.66
$75.91
$109.74
$166.75
$209.09
$20.17
$44.28
$73.69
$108.51
$146.20
$73.52
$100.71
$136.51
$187.02
$102.60
$138.38
$204.29
$40.15
$73.45
$105.69
Procedure Code
99231
99232
99233
99234
99235
99236
99238
99239
99241
99242
99243
99244
99245
99251
99252
99253
99254
99255
99281
99282
99283
99284
99285
99288
99291
99292
99304
99305
99306
99307
99308
99309
99310
99315
99316
99318
99324
99325
99326
99327
99328
99334
99335
99336
99337
99339
99340
Description
SUBSEQUENT HOSPITAL CARE
OBSERV/HOSP SAME DATE
HOSPITAL DISCHARGE DAY
HOSPITAL DISCHARGE DAY
OFFICE CONSULTATION
OFFICE CONSULTATION
OFFICE CONSULTATION
OFFICE CONSULTATION
OFFICE CONSULTATION
INPATIENT CONSULTATION
EMERGENCY DEPT VISIT
DIRECT ADVANCED LIFE SUPPORT
CRITICAL CARE FIRST HOUR
CRITICAL CARE ADDL 30 MIN
NURSING FACILITY CARE INIT
NURSING FAC CARE SUBSEQ
NURSING FAC DISCHARGE DAY
NURSING FAC DISCHARGE DAY
ANNUAL NURSING FAC ASSESSMNT
DOMICIL/R-HOME VISIT NEW PAT
DOMICIL/R-HOME VISIT EST PAT
DOMICIL/R-HOME CARE SUPERVIS
DOMICIL/R-HOME CARE SUPERVIS
Pricing Action Code
3
3
3
3
3
3
3
3
9
9
9
9
9
9
9
9
9
9
3
3
3
3
3
9
3
3
3
3
3
3
3
3
3
9
9
3
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$39.79
$72.73
$104.99
$134.77
$170.57
$219.63
$73.14
$108.27
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$21.49
$41.91
$62.67
$118.89
$175.48
$0.00
$277.90
$124.10
$92.50
$131.56
$167.72
$45.20
$69.60
$91.82
$137.00
$0.00
$0.00
$96.80
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
99341
99342
99343
99344
99345
99347
99348
99349
99350
99354
99355
99356
99357
99358
99359
99360
99363
99364
99366
99367
99368
99374
99375
99376
99377
99378
99379
99380
99381
99382
99383
99384
99385
99386
99387
99391
99392
99393
99394
99395
99396
99397
99401
99402
99403
99404
99406
Description
HOME VISIT NEW PATIENT
HOME VISIT EST PATIENT
PROLONG E&M/PSYCTX SERV O/P
PROLONG E&M/PSYCTX SERV O/P
PROLONGED SERVICE INPATIENT
PROLONGED SERVICE INPATIENT
PROLONG SERVICE W/O CONTACT
PROLONG SERV W/O CONTACT ADD
PHYSICIAN STANDBY SERVICES
ANTICOAGULANT MGMT INITIAL
ANTICOAGULANT MGMT SUBSEQ
TEAM CONF W/PAT BY HC PROF
TEAM CONF W/O PAT BY PHYS
TEAM CONF W/O PAT BY HC PRO
HOME HEALTH CARE SUPERVISION
PHYSICIAN SUPERVISION OF PATIENTS U
HOSPICE CARE SUPERVISION
NURSING FAC CARE SUPERVISION
NURSING FAC CARE SUPERVISION
INIT PM E/M NEW PAT INFANT
INIT PM E/M NEW PAT 1-4 YRS
PREV VISIT NEW AGE 5-11
INIT PM E/M NEW PAT 65+ YRS
PER PM REEVAL EST PAT INFANT
PREV VISIT EST AGE 1-4
PER PM REEVAL EST PAT 65+ YR
PREVENTIVE COUNSELING INDIV
BEHAV CHNG SMOKING 3-10 MIN
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
9
9
3
9
9
9
9
9
9
9
9
9
9
9
9
3
3
3
3
3
3
3
3
3
3
3
3
3
3
7
7
7
7
9
Maximum Allowable
$55.93
$80.25
$131.11
$183.51
$222.60
$56.29
$85.32
$129.42
$179.23
$101.14
$98.23
$92.45
$92.09
$0.00
$0.00
$61.96
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$111.75
$116.75
$121.40
$137.17
$132.86
$154.36
$167.30
$100.23
$107.04
$106.67
$117.06
$119.56
$127.44
$137.53
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
99407
99408
99409
99411
99412
99415
99416
99420
99429
99441
99442
99443
99444
99446
99447
99448
99449
99450
99455
99456
99460
99461
99462
99463
99464
99465
99466
99467
99468
99469
99471
99472
99475
99476
99477
99478
99479
99480
99485
99486
99487
99489
99490
99495
99496
99497
99498
Description
BEHAV CHNG SMOKING > 10 MIN
AUDIT/DAST 15-30 MIN
AUDIT/DAST OVER 30 MIN
PREVENTIVE COUNSELING GROUP
PREVENTIVE COUNSELING GROUP
PROLONG CLINCL STAFF SVC
PROLONG CLINCL STAFF SVC ADD
HEALTH RISK ASSESSMENT TEST
UNLISTED PREVENTIVE SERVICE
PHONE E/M PHYS/QHP 5-10 MIN
ONLINE E/M BY PHYS/QHP
INTERPROF PHONE/ONLINE 5-10
INTERPROF PHONE/ONLINE 31/>
BASIC LIFE DISABILITY EXAM
WORK RELATED DISABILITY EXAM
DISABILITY EXAMINATION
INIT NB EM PER DAY HOSP
INIT NB EM PER DAY NON-FAC
SBSQ NB EM PER DAY HOSP
SAME DAY NB DISCHARGE
ATTENDANCE AT DELIVERY
NB RESUSCITATION
PED CRIT CARE TRANSPORT
PED CRIT CARE TRANSPORT ADDL
NEONATE CRIT CARE INITIAL
NEONATE CRIT CARE SUBSQ
PED CRITICAL CARE INITIAL
PED CRITICAL CARE SUBSQ
PED CRIT CARE AGE 2-5 INIT
PED CRIT CARE AGE 2-5 SUBSQ
INIT DAY HOSP NEONATE CARE
IC LBW INF < 1500 GM SUBSQ
IC LBW INF 1500-2500 G SUBSQ
IC INF PBW 2501-5000 G SUBSQ
SUPRV INTERFACILTY TRANSPORT
SUPRV INTERFAC TRNSPORT ADDL
CMPLX CHRON CARE W/O PT VSIT
CMPLX CHRON CARE ADDL 30 MIN
CHRON CARE MGMT SRVC 20 MIN
TRANS CARE MGMT 14 DAY DISCH
TRANS CARE MGMT 7 DAY DISCH
ADVNCD CARE PLAN 30 MIN
ADVNCD CARE PLAN ADDL 30 MIN
Pricing Action Code
9
3
3
9
9
3
3
9
9
9
9
9
9
9
9
9
9
9
9
9
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$35.48
$69.15
$0.00
$0.00
$9.07
$0.74
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$97.40
$100.30
$42.25
$120.46
$72.32
$154.41
$232.36
$117.37
$953.72
$401.76
$888.73
$414.26
$583.41
$350.50
$360.97
$138.23
$125.69
$120.67
$77.35
$67.34
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
99499
99500
99501
99502
99503
99504
99505
99506
99507
99508
99509
99510
99511
99512
99539
99600
99601
99602
99605
99606
99607
A0010
A0020
A0021
A0030
A0050
A0060
A0080
A0090
A0100
A0110
A0120
A0130
A0140
A0160
A0170
A0180
A0190
A0200
A0210
A0215
A0220
A0221
A0222
A0223
A0225
A0300
Description
Pricing Action Code
UNLISTED E&M SERVICE
HOME VISIT PRENATAL
HOME VISIT POSTNATAL
HOME VISIT NB CARE
HOME VISIT RESP THERAPY
HOME VISIT MECH VENTILATOR
HOME VISIT STOMA CARE
HOME VISIT IM INJECTION
HOME VISIT CATH MAINTAIN
HOME VISIT, SLEEP STUDIES
HOME VISIT DAY LIFE ACTIVITY
HOME VISIT SING/M/FAM COUNS
HOME VISIT FECAL/ENEMA MGMT
HOME VISIT FOR HEMODIALYSIS
HOME VISIT, NOS
HOME VISIT NOS
HOME INFUSION/VISIT 2 HRS
HOME INFUSION EACH ADDTL HR
MTMS BY PHARM NP 15 MIN
MTMS BY PHARM EST 15 MIN
MTMS BY PHARM ADDL 15 MIN
AMBULANCE SERVICE, BASIC LIFE SUPPO
AMBULANCE SERVICE, (BLS) PER MILE,
OUTSIDE STATE AMBULANCE SERV
AIR AMBULANCE SERVICE
WATER AMB SERVICE EMERGENCY
AMBULANCE SERVICE, WAITING TIME, O
NONINTEREST ESCORT IN NON ER
INTEREST ESCORT IN NON ER
NONEMERGENCY TRANSPORT TAXI
NONEMERGENCY TRANSPORT BUS
NONER TRANSPORT MINI-BUS
NONER TRANSPORT WHEELCH VAN
NONEMERGENCY TRANSPORT AIR
NONER TRANSPORT CASE WORKER
TRANSPORT PARKING FEES/TOLLS
NONER TRANSPORT LODGNG RECIP
NONER TRANSPORT MEALS RECIP
NONER TRANSPORT LODGNG ESCRT
NONER TRANSPORT MEALS ESCORT
AMBULANCE SERVICE, MISCELLANEOUS
AMBULANCE SERVICE, ADVANCED LIFE S
AMBULANCE SERVICE, (ALS) PER MILE,
AMBULANCE SERVICE, RETURN TRIP, TRA
AMBULANCE SERVICE, ADVANCED LIFE S
NEONATAL EMERGENCY TRANSPORT
AMBULANCE BASIC NON-EMER ALL
5
9
9
9
9
9
9
9
9
9
9
7
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
3
7
7
7
3
5
9
5
5
5
5
5
9
9
9
9
9
3
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.20
$0.00
$0.00
$0.00
$11.01
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$95.00
$0.00
Procedure Code
A0302
A0304
A0306
A0308
A0310
A0320
A0322
A0324
A0326
A0328
A0330
A0340
A0342
A0344
A0346
A0348
A0350
A0360
A0362
A0364
A0366
A0368
A0370
A0380
A0382
A0384
A0390
A0392
A0394
A0396
A0398
A0420
A0422
A0424
A0425
A0426
A0427
A0428
A0429
A0430
A0431
A0432
A0433
A0434
A0435
A0436
A0888
Description
AMBULANCE BASIC EMERGENY ALL
AMB ADV NON-ER NO SERV ALL
AMB ADV NON-ER SPEC SERV ALL
AMB ADV ER NO SPEC SERV ALL
AMB ADV ER SPEC SERV ALL
AMB BASIC NON-ER + SUPPLIES
AMB BASIC EMERG + SUPPLIES
ADV NON-ER SERV SEP MILEAGE
ADV NON-ER NO SERV SEP MILE
ADV ER NO SERV SEP MILEAGE
ADV ER SPEC SERV SEP MILE
AMB BASIC NON-ER + MILEAGE
AMBUL BASIC EMER + MILEAGE
AMB ADV NON-ER NO SERV +MILE
AMB ADV NON-ER SERV + MILE
ADV EMER NO SPEC SERV + MILE
ADV EMER SPEC SERV + MILEAGE
BASIC NON-ER SEP MILE & SUPP
BASIC EMER SEP MILE & SUPPLY
ADV NON-ER NO SERV SEP MI&SU
ADV NON-ER SERV SEP MIL&SUPP
ADV ER NO SERV SEP MILE&SUPP
ADV ER SPEC SERV SEP MI&SUPP
BASIC LIFE SUPPORT MILEAGE
BASIC SUPPORT ROUTINE SUPPLS
BLS DEFIBRILLATION SUPPLIES
ADVANCED LIFE SUPPORT MILEAG
ALS DEFIBRILLATION SUPPLIES
ALS IV DRUG THERAPY SUPPLIES
ALS ESOPHAGEAL INTUB SUPPLS
ALS ROUTINE DISPOSBLE SUPPLS
AMBULANCE WAITING 1/2 HR
AMBULANCE 02 LIFE SUSTAINING
EXTRA AMBULANCE ATTENDANT
GROUND MILEAGE
ALS 1
ALS1-EMERGENCY
BLS
BLS-EMERGENCY
FIXED WING AIR TRANSPORT
ROTARY WING AIR TRANSPORT
PI VOLUNTEER AMBULANCE CO
ALS 2
SPECIALTY CARE TRANSPORT
FIXED WING AIR MILEAGE
ROTARY WING AIR MILEAGE
NONCOVERED AMBULANCE MILEAGE
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
3
9
9
3
9
9
9
9
9
3
5
9
3
3
3
3
9
3
9
9
9
9
3
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$2.41
$0.00
$0.00
$2.41
$0.00
$0.00
$0.00
$0.00
$0.00
$12.00
$0.00
$0.00
$35.00
$57.38
$35.00
$63.18
$0.00
$2,068.99
$0.00
$0.00
$0.00
$0.00
$12.93
$0.00
Procedure Code
A0998
A0999
A2000
A4206
A4207
A4208
A4209
A4210
A4212
A4213
A4215
A4216
A4217
A4218
A4220
A4221
A4222
A4223
A4230
A4231
A4232
A4233
A4234
A4235
A4236
A4244
A4245
A4246
A4247
A4248
A4250
A4252
A4253
A4255
A4256
A4257
A4258
A4259
A4261
A4262
A4263
A4264
A4265
A4266
A4267
A4268
A4269
Description
Pricing Action Code
AMBULANCE RESPONSE/TREATMENT
UNLISTED AMBULANCE SERVICE
MANIPULATION OF SPINE BY CHIROPRAC
1 CC STERILE SYRINGE&NEEDLE
5+ CC STERILE SYRINGE&NEEDLE
NONNEEDLE INJECTION DEVICE
NON CORING NEEDLE OR STYLET
20+ CC SYRINGE ONLY
STERILE NEEDLE
STERILE WATER/SALINE, 10 ML
STERILE WATER/SALINE, 500 ML
STERILE SALINE OR WATER
INFUSION PUMP REFILL KIT
MAINT DRUG INFUS CATH PER WK
INFUSION SUPPLIES WITH PUMP
INFUSION SUPPLIES W/O PUMP
INFUS INSULIN PUMP NON NEEDL
INFUSION INSULIN PUMP NEEDLE
SYRINGE W/NEEDLE INSULIN 3CC
ALKALIN BATT FOR GLUCOSE MON
J-CELL BATT FOR GLUCOSE MON
LITHIUM BATT FOR GLUCOSE MON
SILVR OXIDE BATT GLUCOSE MON
ALCOHOL OR PEROXIDE PER PINT
ALCOHOL WIPES PER BOX
BETADINE/PHISOHEX SOLUTION
BETADINE/IODINE SWABS/WIPES
CHLORHEXIDINE ANTISEPT
URINE REAGENT STRIPS/TABLETS
BLOOD KETONE TEST OR STRIP
BLOOD GLUCOSE/REAGENT STRIPS
GLUCOSE MONITOR PLATFORMS
CALIBRATOR SOLUTION/CHIPS
REPLACE LENSSHIELD CARTRIDGE
LANCET DEVICE EACH
LANCETS PER BOX
CERVICAL CAP CONTRACEPTIVE
TEMPORARY TEAR DUCT PLUG
PERMANENT TEAR DUCT PLUG
INTRATUBAL OCCLUSION DEVICE
PARAFFIN
DIAPHRAGM
MALE CONDOM
FEMALE CONDOM
SPERMICIDE
9
9
9
3
3
3
3
3
5
5
5
3
3
6
9
3
3
6
5
5
5
6
6
3
6
3
3
3
3
6
3
6
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.22
$0.20
$0.18
$0.36
$1.50
$0.00
$0.00
$0.00
$0.49
$3.13
$0.00
$0.00
$22.21
$44.23
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$2.34
$0.00
$1.00
$10.00
$10.00
$8.00
$0.00
$17.25
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
A4270
A4280
A4281
A4282
A4283
A4284
A4285
A4286
A4290
A4300
A4301
A4305
A4306
A4310
A4311
A4312
A4313
A4314
A4315
A4316
A4320
A4321
A4322
A4326
A4327
A4328
A4330
A4331
A4332
A4333
A4334
A4335
A4336
A4337
A4338
A4340
A4344
A4346
A4349
A4350
A4351
A4352
A4353
A4354
A4355
A4356
A4357
Description
DISPOSABLE ENDOSCOPE SHEATH
BRST PRSTHS ADHSV ATTCHMNT
REPLACEMENT BREASTPUMP TUBE
REPLACEMENT BREASTPUMP ADPT
REPLACEMENT BREASTPUMP CAP
REPLCMNT BREAST PUMP SHIELD
REPLCMNT BREAST PUMP BOTTLE
REPLCMNT BREASTPUMP LOK RING
SACRAL NERVE STIM TEST LEAD
CATH IMPL VASC ACCESS PORTAL
IMPLANTABLE ACCESS SYST PERC
DRUG DELIVERY SYSTEM >=50 ML
DRUG DELIVERY SYSTEM <=50 ML
INSERT TRAY W/O BAG/CATH
CATHETER W/O BAG 2-WAY LATEX
CATH W/O BAG 2-WAY SILICONE
CATHETER W/BAG 3-WAY
CATH W/DRAINAGE 2-WAY LATEX
CATH W/DRAINAGE 2-WAY SILCNE
CATH W/DRAINAGE 3-WAY
IRRIGATION TRAY
CATH THERAPEUTIC IRRIG AGENT
IRRIGATION SYRINGE
MALE EXTERNAL CATHETER
FEM URINARY COLLECT DEV CUP
FEM URINARY COLLECT POUCH
STOOL COLLECTION POUCH
EXTENSION DRAINAGE TUBING
LUBE STERILE PACKET
URINARY CATH ANCHOR DEVICE
URINARY CATH LEG STRAP
INCONTINENCE SUPPLY
URETHRAL INSERT
INCONTINENT RECTAL INSERT
INDWELLING CATHETER LATEX
INDWELLING CATHETER SPECIAL
CATH INDW FOLEY 2 WAY SILICN
CATH INDW FOLEY 3 WAY
DISPOSABLE MALE EXTERNAL CAT
CATHETER CARE KIT
STRAIGHT TIP URINE CATHETER
COUDE TIP URINARY CATHETER
INTERMITTENT URINARY CATH
CATH INSERTION TRAY W/BAG
BLADDER IRRIGATION TUBING
EXT URETH CLMP OR COMPR DVC
BEDSIDE DRAINAGE BAG
Pricing Action Code
9
3
5
5
5
5
5
5
5
9
9
3
3
3
3
3
3
3
3
3
3
9
3
3
3
3
3
3
3
3
3
5
9
9
3
3
3
3
3
9
3
3
3
3
3
3
3
Maximum Allowable
$0.00
$4.62
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$17.04
$29.64
$6.81
$12.04
$14.62
$17.31
$22.90
$24.61
$25.71
$4.81
$0.00
$3.26
$10.29
$40.32
$9.97
$6.82
$3.04
$0.13
$2.10
$4.71
$0.00
$0.00
$0.00
$10.08
$30.28
$12.99
$16.26
$2.02
$0.00
$1.83
$6.73
$6.66
$11.16
$8.50
$43.52
$8.77
Procedure Code
A4358
A4360
A4361
A4362
A4363
A4364
A4366
A4367
A4368
A4369
A4371
A4372
A4373
A4375
A4376
A4377
A4378
A4379
A4380
A4381
A4382
A4383
A4384
A4385
A4387
A4388
A4389
A4390
A4391
A4392
A4393
A4394
A4395
A4396
A4397
A4398
A4399
A4400
A4402
A4404
A4405
A4406
A4407
A4408
A4409
A4410
A4411
Description
URINARY LEG OR ABDOMEN BAG
DISPOSABLE EXT URETHRAL DEV
OSTOMY FACE PLATE
SOLID SKIN BARRIER
OSTOMY CLAMP, REPLACEMENT
ADHESIVE, LIQUID OR EQUAL
OSTOMY VENT
OSTOMY BELT
OSTOMY FILTER
SKIN BARRIER LIQUID PER OZ
SKIN BARRIER POWDER PER OZ
SKIN BARRIER SOLID 4X4 EQUIV
SKIN BARRIER WITH FLANGE
DRAINABLE PLASTIC PCH W FCPL
DRAINABLE RUBBER PCH W FCPLT
DRAINABLE PLSTIC PCH W/O FP
DRAINABLE RUBBER PCH W/O FP
URINARY PLASTIC POUCH W FCPL
URINARY RUBBER POUCH W FCPLT
URINARY PLASTIC POUCH W/O FP
URINARY HVY PLSTC PCH W/O FP
URINARY RUBBER POUCH W/O FP
OSTOMY FACEPLT/SILICONE RING
OST SKN BARRIER SLD EXT WEAR
OST CLSD POUCH W ATT ST BARR
DRAINABLE PCH W EX WEAR BARR
DRAINABLE PCH W ST WEAR BARR
DRAINABLE PCH EX WEAR CONVEX
URINARY POUCH W EX WEAR BARR
URINARY POUCH W ST WEAR BARR
URINE PCH W EX WEAR BAR CONV
OSTOMY POUCH LIQ DEODORANT
OSTOMY POUCH SOLID DEODORANT
PERISTOMAL HERNIA SUPPRT BLT
IRRIGATION SUPPLY SLEEVE
OSTOMY IRRIGATION BAG
OSTOMY IRRIG CONE/CATH W BRS
OSTOMY IRRIGATION SET
LUBRICANT PER OUNCE
OSTOMY RING EACH
NONPECTIN BASED OSTOMY PASTE
PECTIN BASED OSTOMY PASTE
EXT WEAR OST SKN BARR <=4SQ"
EXT WEAR OST SKN BARR >4SQ"
OST SKN BARR CONVEX <=4 SQ I
OST SKN BARR EXTND >4 SQ
OST SKN BARR EXTND =4SQ
Pricing Action Code
3
6
3
3
6
3
6
3
9
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
6
Maximum Allowable
$6.33
$0.00
$17.42
$3.30
$0.00
$2.80
$0.00
$7.01
$0.00
$2.30
$3.48
$3.98
$5.99
$16.38
$45.38
$4.09
$29.33
$14.33
$35.60
$4.40
$23.48
$26.89
$9.18
$4.86
$3.83
$4.16
$5.93
$9.17
$6.74
$6.34
$8.75
$2.46
$0.05
$38.61
$4.57
$13.17
$11.70
$46.62
$1.32
$1.52
$3.40
$6.16
$8.76
$9.87
$6.22
$9.04
$0.00
Procedure Code
A4412
A4413
A4414
A4415
A4416
A4417
A4418
A4419
A4420
A4421
A4422
A4423
A4424
A4425
A4426
A4427
A4428
A4429
A4430
A4431
A4432
A4433
A4434
A4435
A4450
A4452
A4455
A4456
A4458
A4459
A4461
A4463
A4465
A4466
A4470
A4480
A4481
A4483
A4490
A4495
A4500
A4510
A4520
A4534
A4550
A4554
A4555
Description
OST POUCH DRAIN HIGH OUTPUT
2 PC DRAINABLE OST POUCH
OST SKNBAR W/O CONV<=4 SQ IN
OST SKN BARR W/O CONV >4 SQI
OST PCH CLSD W BARRIER/FILTR
OST PCH W BAR/BLTINCONV/FLTR
OST PCH CLSD W/O BAR W FILTR
OST PCH FOR BAR W FLANGE/FLT
OST PCH CLSD FOR BAR W LK FL
OSTOMY SUPPLY MISC
OST POUCH ABSORBENT MATERIAL
OST PCH FOR BAR W LK FL/FLTR
OST PCH DRAIN W BAR & FILTER
OST PCH DRAIN FOR BARRIER FL
OST PCH DRAIN 2 PIECE SYSTEM
OST PCH DRAIN/BARR LK FLNG/F
URINE OST POUCH W FAUCET/TAP
URINE OST POUCH W BLTINCONV
OST URINE PCH W B/BLTIN CONV
OST PCH URINE W BARRIER/TAPV
OS PCH URINE W BAR/FANGE/TAP
URINE OST PCH BAR W LOCK FLN
OST PCH URINE W LOCK FLNG/FT
1PC OST PCH DRAIN HGH OUTPUT
NON-WATERPROOF TAPE
WATERPROOF TAPE
ADHESIVE REMOVER PER OUNCE
ADHESIVE REMOVER, WIPES
REUSABLE ENEMA BAG
MANUAL PUMP ENEMA, REUSABLE
SURGICL DRESS HOLD NON-REUSE
SURGICAL DRESS HOLDER REUSE
NON-ELASTIC EXTREMITY BINDER
ELASTIC GARMENT/COVERING
GRAVLEE JET WASHER
VABRA ASPIRATOR
TRACHEOSTOMA FILTER
MOISTURE EXCHANGER
ABOVE KNEE SURGICAL STOCKING
THIGH LENGTH SURG STOCKING
BELOW KNEE SURGICAL STOCKING
FULL LENGTH SURG STOCKING
INCONTINENCE GARMENT ANYTYPE
YOUTH SIZE BRIEF EACH
SURGICAL TRAYS
DISPOSABLE UNDERPADS
CA TX E-STIM ELECTR/TRANSDUC
Pricing Action Code
6
3
3
3
3
6
6
3
6
3
3
3
3
3
3
3
3
3
3
3
3
3
3
6
5
5
3
6
5
6
6
6
9
6
5
3
9
3
3
3
3
3
9
9
9
3
6
Maximum Allowable
$0.00
$5.50
$4.93
$6.00
$2.75
$0.00
$0.00
$1.74
$0.00
$200.00
$0.12
$1.86
$4.75
$3.58
$2.73
$2.78
$6.51
$8.25
$8.52
$6.22
$3.59
$3.34
$3.76
$0.00
$0.00
$0.00
$1.33
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$20.00
$0.00
$2.86
$60.00
$60.00
$30.00
$60.00
$0.00
$0.00
$0.00
$0.20
$0.00
Procedure Code
A4556
A4557
A4558
A4559
A4561
A4562
A4565
A4566
A4570
A4575
A4581
A4595
A4600
A4601
A4602
A4604
A4605
A4606
A4608
A4611
A4612
A4613
A4614
A4615
A4616
A4617
A4618
A4619
A4620
A4623
A4624
A4625
A4626
A4627
A4628
A4629
A4630
A4633
A4634
A4635
A4636
A4637
A4638
A4639
A4640
A4641
A4642
Description
ELECTRODES, PAIR
LEAD WIRES, PAIR
CONDUCTIVE GEL OR PASTE
COUPLING GEL OR PASTE
PESSARY RUBBER, ANY TYPE
PESSARY, NON RUBBER,ANY TYPE
SLINGS
SHOULD SLING/VEST/ABRESTRAIN
SPLINT
HYPERBARIC O2 CHAMBER DISPS
SUPPLIES RISSER JACKET
TENS SUPPL 2 LEAD PER MONTH
SLEEVE, INTER LIMB COMP DEV
LITH ION NON PROSTH RECHARGE
REPLACE LITHIUM BATTERY 1.5V
TUBING WITH HEATING ELEMENT
TRACH SUCTION CATH CLOSE SYS
OXYGEN PROBE USED W OXIMETER
TRANSTRACHEAL OXYGEN CATH
HEAVY DUTY BATTERY
BATTERY CABLES
BATTERY CHARGER
HAND-HELD PEFR METER
CANNULA NASAL
TUBING (OXYGEN) PER FOOT
MOUTH PIECE
BREATHING CIRCUITS
FACE TENT
VARIABLE CONCENTRATION MASK
TRACHEOSTOMY INNER CANNULA
TRACHEAL SUCTION TUBE
TRACH CARE KIT FOR NEW TRACH
TRACHEOSTOMY CLEANING BRUSH
SPACER BAG/RESERVOIR
OROPHARYNGEAL SUCTION CATH
TRACHEOSTOMY CARE KIT
REPL BAT T.E.N.S. OWN BY PT
UVL REPLACEMENT BULB
REPLACEMENT BULB TH LIGHTBOX
UNDERARM CRUTCH PAD
HANDGRIP FOR CANE ETC
REPL TIP CANE/CRUTCH/WALKER
REPL BATT PULSE GEN SYS
INFRARED HT SYS REPLCMNT PAD
ALTERNATING PRESSURE PAD
RADIOPHARM DX AGENT NOC
IN111 SATUMOMAB
Pricing Action Code
5
3
3
9
3
3
3
6
3
9
9
3
6
6
6
3
6
5
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
9
3
3
3
3
5
3
3
3
6
3
3
9
9
Maximum Allowable
$0.00
$18.82
$4.44
$0.00
$17.78
$44.25
$60.00
$0.00
$50.00
$0.00
$0.00
$24.29
$0.00
$0.00
$0.00
$52.79
$0.00
$0.00
$58.32
$187.94
$65.00
$137.96
$22.75
$20.00
$1.00
$5.00
$9.83
$1.21
$20.00
$6.87
$2.25
$6.61
$3.05
$0.00
$4.05
$4.42
$5.45
$41.04
$0.00
$4.16
$3.42
$1.90
$0.00
$287.21
$51.49
$0.00
$0.00
Procedure Code
A4648
A4649
A4650
A4651
A4652
A4653
A4655
A4657
A4660
A4663
A4670
A4671
A4672
A4673
A4674
A4680
A4690
A4700
A4705
A4706
A4707
A4708
A4709
A4714
A4719
A4720
A4721
A4722
A4723
A4724
A4725
A4726
A4728
A4730
A4735
A4736
A4737
A4740
A4750
A4755
A4760
A4765
A4766
A4770
A4771
A4772
A4773
Description
IMPLANTABLE TISSUE MARKER
SURGICAL SUPPLIES
IMPLANT RADIATION DOSIMETER
CALIBRATED MICROCAP TUBE
MICROCAPILLARY TUBE SEALANT
PD CATHETER ANCHOR BELT
ESRD SYRINGE/NEEDLE
SYRINGE W/WO NEEDLE
SPHYG/BP APP W CUFF AND STET
DIALYSIS BLOOD PRESSURE CUFF
AUTOMATIC BP MONITOR, DIAL
DISPOSABLE CYCLER SET
DRAINAGE EXT LINE, DIALYSIS
EXT LINE W EASY LOCK CONNECT
CHEM/ANTISEPT SOLUTION, 8OZ
ACTIVATED CARBON FILTER, EA
DIALYZER, EACH
STANDARD DIALYSATE SOLUTION
BICARB DIALYSATE SOLUTION
BICARBONATE CONC SOL PER GAL
BICARBONATE CONC POW PER PAC
ACETATE CONC SOL PER GALLON
ACID CONC SOL PER GALLON
TREATED WATER PER GALLON
Y SET TUBING
DIALYSAT SOL FLD VOL > 249CC
DIALYSAT SOL FLD VOL > 999CC
DIALYS SOL FLD VOL > 1999CC
DIALYSATE SOLUTION, NON-DEX
FISTULA CANNULATION SET, EA
LOCAL/TOPICAL ANESTHETICS
TOPICAL ANESTHETIC, PER GRAM
INJ ANESTHETIC PER 10 ML
SHUNT ACCESSORY
ART OR VENOUS BLOOD TUBING
COMB ART/VENOUS BLOOD TUBING
DIALYSATE SOL TEST KIT, EACH
DIALYSATE CONC POW PER PACK
DIALYSATE CONC SOL ADD 10 ML
BLOOD COLLECTION TUBE/VACUUM
SERUM CLOTTING TIME TUBE
BLOOD GLUCOSE TEST STRIPS
OCCULT BLOOD TEST STRIPS
Pricing Action Code
9
9
9
9
9
5
9
9
3
3
5
6
6
6
6
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
6
9
9
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$20.00
$6.27
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
A4774
A4780
A4790
A4800
A4801
A4802
A4820
A4850
A4860
A4870
A4880
A4890
A4900
A4901
A4905
A4910
A4911
A4912
A4913
A4914
A4918
A4919
A4920
A4921
A4927
A4928
A4929
A4930
A4931
A4932
A5051
A5052
A5053
A5054
A5055
A5056
A5057
A5061
A5062
A5063
A5071
A5072
A5073
A5081
A5082
A5083
A5093
Description
AMMONIA TEST STRIPS
ESRD STERILIZING AGENT
ESRD CLEANSING AGENTS
HEPARIN/ANTIDOTE DIALYSIS
HEPARIN PER 1000 UNITS
PROTAMINE SULFATE PER 50 MG
SUPPLIES HEMODIALYSIS KIT
RUBBER TIPPED HEMOSTATS
DISPOSABLE CATHETER TIPS
PLUMB/ELEC WK HM HEMO EQUIP
WATER STORAGE TANKS
REPAIR/MAINT CONT HEMO EQUIP
CAPD SUPPLY KIT
CCPD SUPPLY KIT
IPD SUPPLY KIT
ESRD NONMEDICAL SUPPLIES
DRAIN BAG/BOTTLE
GOMCO DRAIN BOTTLE
MISC DIALYSIS SUPPLIES NOC
PREPARATION KIT
VENOUS PRESSURE CLAMP
SUPP DIALYSIS DIALYZER HOLDE
HARVARD PRESSURE CLAMP
MEASURING CYLINDER
NON-STERILE GLOVES
SURGICAL MASK
TOURNIQUET FOR DIALYSIS, EA
STERILE, GLOVES PER PAIR
REUSABLE ORAL THERMOMETER
REUSABLE RECTAL THERMOMETER
POUCH CLSD W BARR ATTACHED
CLSD OSTOMY POUCH W/O BARR
CLSD OSTOMY POUCH FACEPLATE
CLSD OSTOMY POUCH W/FLANGE
STOMA CAP
1 PC OST POUCH W FILTER
1 PC OST POU W BUILT-IN CONV
POUCH DRAINABLE W BARRIER AT
DRNBLE OSTOMY POUCH W/O BARR
DRAIN OSTOMY POUCH W/FLANGE
URINARY POUCH W/BARRIER
URINARY POUCH W/O BARRIER
URINARY POUCH ON BARR W/FLNG
STOMA PLUG OR SEAL, ANY TYPE
CONTINENT STOMA CATHETER
STOMA ABSORPTIVE COVER
OSTOMY ACCESSORY CONVEX INSE
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
3
9
9
3
9
9
3
3
3
3
3
6
6
3
3
3
3
3
3
3
3
6
3
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$6.19
$0.00
$0.00
$0.44
$0.00
$0.00
$2.21
$1.59
$1.66
$1.37
$1.35
$0.00
$0.00
$2.58
$2.12
$2.09
$4.15
$3.36
$3.04
$3.14
$11.34
$0.00
$1.85
Procedure Code
A5102
A5105
A5112
A5113
A5114
A5120
A5121
A5122
A5126
A5131
A5200
A5500
A5501
A5502
A5503
A5504
A5505
A5506
A5507
A5508
A5510
A5512
A5513
A6000
A6010
A6011
A6021
A6022
A6023
A6024
A6025
A6154
A6196
A6197
A6198
A6199
A6203
A6204
A6205
A6206
A6207
A6208
A6209
A6210
A6211
A6212
A6213
Description
BEDSIDE DRAIN BTL W/WO TUBE
URINARY SUSPENSORY
URINARY LEG BAG
LATEX LEG STRAP
FOAM/FABRIC LEG STRAP
SKIN BARRIER, WIPE OR SWAB
SOLID SKIN BARRIER 6X6
SOLID SKIN BARRIER 8X8
DISK/FOAM PAD +OR- ADHESIVE
APPLIANCE CLEANER
PERCUTANEOUS CATHETER ANCHOR
DIAB SHOE FOR DENSITY INSERT
DIABETIC CUSTOM MOLDED SHOE
DIABETIC SHOE DENSITY INSERT
DIABETIC SHOE W/ROLLER/ROCKR
DIABETIC SHOE WITH WEDGE
DIAB SHOE W/METATARSAL BAR
DIABETIC SHOE W/OFF SET HEEL
MODIFICATION DIABETIC SHOE
DIABETIC DELUXE SHOE
COMPRESSION FORM SHOE INSERT
MULTI DEN INSERT DIRECT FORM
MULTI DEN INSERT CUSTOM MOLD
WOUND WARMING WOUND COVER
COLLAGEN BASED WOUND FILLER
COLLAGEN GEL/PASTE WOUND FIL
COLLAGEN DRESSING <=16 SQ IN
COLLAGEN DRSG>16<=48 SQ IN
COLLAGEN DRESSING >48 SQ IN
COLLAGEN DSG WOUND FILLER
SILICONE GEL SHEET, EACH
WOUND POUCH EACH
ALGINATE DRESSING <=16 SQ IN
ALGINATE DRSG >16 <=48 SQ IN
ALGINATE DRESSING > 48 SQ IN
ALGINATE DRSG WOUND FILLER
COMPOSITE DRSG <= 16 SQ IN
COMPOSITE DRSG >16<=48 SQ IN
COMPOSITE DRSG > 48 SQ IN
CONTACT LAYER <= 16 SQ IN
CONTACT LAYER >16<= 48 SQ IN
CONTACT LAYER > 48 SQ IN
FOAM DRSG <=16 SQ IN W/O BDR
FOAM DRG >16<=48 SQ IN W/O B
FOAM DRG > 48 SQ IN W/O BRDR
FOAM DRG <=16 SQ IN W/BORDER
FOAM DRG >16<=48 SQ IN W/BDR
Pricing Action Code
3
3
3
3
3
5
3
3
3
3
3
5
5
9
5
5
5
5
5
5
5
6
6
5
3
3
3
3
3
3
9
9
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$21.39
$38.88
$28.07
$4.48
$8.52
$0.00
$6.24
$10.42
$1.26
$15.13
$10.78
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$30.62
$2.28
$20.05
$20.05
$181.51
$5.90
$0.00
$0.00
$7.01
$15.68
$15.68
$5.04
$3.19
$5.94
$5.94
$2.07
$7.00
$7.00
$7.14
$19.00
$28.01
$9.25
$9.82
Procedure Code
A6214
A6215
A6216
A6217
A6218
A6219
A6220
A6221
A6222
A6223
A6224
A6228
A6229
A6230
A6231
A6232
A6233
A6234
A6235
A6236
A6237
A6238
A6239
A6240
A6241
A6242
A6243
A6244
A6245
A6246
A6247
A6248
A6250
A6251
A6252
A6253
A6254
A6255
A6256
A6257
A6258
A6259
A6260
A6261
A6262
A6266
A6402
Description
FOAM DRG > 48 SQ IN W/BORDER
FOAM DRESSING WOUND FILLER
NON-STERILE GAUZE<=16 SQ IN
NON-STERILE GAUZE>16<=48 SQ
NON-STERILE GAUZE > 48 SQ IN
GAUZE <= 16 SQ IN W/BORDER
GAUZE >16 <=48 SQ IN W/BORDR
GAUZE > 48 SQ IN W/BORDER
GAUZE <=16 IN NO W/SAL W/O B
GAUZE >16<=48 NO W/SAL W/O B
GAUZE > 48 IN NO W/SAL W/O B
GAUZE <= 16 SQ IN WATER/SAL
GAUZE >16<=48 SQ IN WATR/SAL
GAUZE > 48 SQ IN WATER/SALNE
HYDROGEL DSG<=16 SQ IN
HYDROGEL DSG>16<=48 SQ IN
HYDROGEL DRESSING >48 SQ IN
HYDROCOLLD DRG <=16 W/O BDR
HYDROCOLLD DRG >16<=48 W/O B
HYDROCOLLD DRG > 48 IN W/O B
HYDROCOLLD DRG <=16 IN W/BDR
HYDROCOLLD DRG >16<=48 W/BDR
HYDROCOLLD DRG > 48 IN W/BDR
HYDROCOLLD DRG FILLER PASTE
HYDROCOLLOID DRG FILLER DRY
HYDROGEL DRG <=16 IN W/O BDR
HYDROGEL DRG >16<=48 W/O BDR
HYDROGEL DRG >48 IN W/O BDR
HYDROGEL DRG <= 16 IN W/BDR
HYDROGEL DRG >16<=48 IN W/B
HYDROGEL DRG > 48 SQ IN W/B
HYDROGEL DRSG GEL FILLER
SKIN SEAL PROTECT MOISTURIZR
ABSORPT DRG <=16 SQ IN W/O B
ABSORPT DRG >16 <=48 W/O BDR
ABSORPT DRG > 48 SQ IN W/O B
ABSORPT DRG <=16 SQ IN W/BDR
ABSORPT DRG >16<=48 IN W/BDR
ABSORPT DRG > 48 SQ IN W/BDR
TRANSPARENT FILM <= 16 SQ IN
TRANSPARENT FILM >16<=48 IN
TRANSPARENT FILM > 48 SQ IN
WOUND CLEANSER ANY TYPE/SIZE
WOUND FILLER GEL/PASTE /OZ
WOUND FILLER DRY FORM / GRAM
IMPREG GAUZE NO H20/SAL/YARD
STERILE GAUZE <= 16 SQ IN
Pricing Action Code
3
5
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
9
3
3
3
3
3
3
3
3
3
9
5
5
3
3
Maximum Allowable
$9.82
$0.00
$0.05
$0.41
$0.41
$0.91
$2.46
$2.46
$2.03
$2.30
$3.44
$2.30
$3.44
$3.44
$4.45
$6.57
$18.30
$6.24
$16.05
$25.99
$7.54
$21.74
$21.74
$11.68
$2.45
$5.79
$11.75
$37.46
$6.93
$9.46
$22.68
$15.49
$0.00
$1.90
$3.60
$6.05
$1.16
$2.89
$2.89
$1.46
$4.10
$10.43
$0.00
$0.00
$0.00
$1.83
$0.13
Procedure Code
A6403
A6404
A6407
A6410
A6411
A6412
A6413
A6441
A6442
A6443
A6444
A6445
A6446
A6447
A6448
A6449
A6450
A6451
A6452
A6453
A6454
A6455
A6456
A6457
A6501
A6502
A6503
A6504
A6505
A6506
A6507
A6508
A6509
A6510
A6511
A6512
A6513
A6530
A6531
A6532
A6533
A6534
A6535
A6536
A6537
A6538
A6539
Description
STERILE GAUZE>16 <= 48 SQ IN
STERILE GAUZE > 48 SQ IN
PACKING STRIPS, NON-IMPREG
STERILE EYE PAD
NON-STERILE EYE PAD
OCCLUSIVE EYE PATCH
ADHESIVE BANDAGE, FIRST-AID
PAD BAND W>=3" <5"/YD
CONFORM BAND N/S W<3"/YD
CONFORM BAND N/S W>=3"<5"/YD
CONFORM BAND N/S W>=5"/YD
CONFORM BAND S W <3"/YD
CONFORM BAND S W>=3" <5"/YD
CONFORM BAND S W >=5"/YD
LT COMPRES BAND <3"/YD
LT COMPRES BAND >=3" <5"/YD
LT COMPRES BAND >=5"/YD
MOD COMPRES BAND W>=3"<5"/YD
HIGH COMPRES BAND W>=3"<5"YD
SELF-ADHER BAND W <3"/YD
SELF-ADHER BAND W>=3" <5"/YD
SELF-ADHER BAND >=5"/YD
ZINC PASTE BAND W >=3"<5"/YD
TUBULAR DRESSING
COMPRES BURNGARMENT BODYSUIT
COMPRES BURNGARMENT CHINSTRP
COMPRES BURNGARMENT FACEHOOD
CMPRSBURNGARMENT GLOVE-WRIST
CMPRSBURNGARMENT GLOVE-ELBOW
CMPRSBURNGRMNT GLOVE-AXILLA
CMPRS BURNGARMENT FOOT-KNEE
CMPRS BURNGARMENT FOOT-THIGH
COMPRES BURN GARMENT JACKET
COMPRES BURN GARMENT LEOTARD
COMPRES BURN GARMENT PANTY
COMPRES BURN GARMENT, NOC
COMPRESS BURN MASK FACE/NECK
COMPRESSION STOCKING BK18-30
GC STOCKING THIGHLNGTH 18-30
GC STOCKING FULL LNGTH 18-30
GC STOCKING WAISTLNGTH 18-30
Pricing Action Code
3
3
3
5
5
5
9
3
3
3
6
3
3
3
3
3
6
6
3
3
3
3
3
3
5
5
5
5
5
5
5
5
5
5
5
5
6
6
6
6
6
6
6
6
6
6
6
Maximum Allowable
$0.41
$0.41
$1.88
$0.00
$0.00
$0.00
$0.00
$0.67
$0.17
$0.29
$0.00
$0.32
$0.41
$0.67
$1.16
$1.75
$0.00
$0.00
$5.91
$0.61
$0.77
$1.39
$1.28
$1.14
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
A6540
A6541
A6544
A6545
A6549
A6550
A7000
A7001
A7002
A7003
A7004
A7005
A7006
A7007
A7008
A7009
A7010
A7012
A7013
A7014
A7015
A7016
A7017
A7018
A7020
A7025
A7026
A7027
A7028
A7029
A7030
A7031
A7032
A7033
A7034
A7035
A7036
A7037
A7038
A7039
A7040
A7041
A7044
A7045
A7046
A7047
A7048
Description
GC STOCKING GARTER BELT
GRAD COMP NON-ELASTIC BK
G COMPRESSION STOCKING
NEG PRES WOUND THER DRSG SET
DISPOSABLE CANISTER FOR PUMP
NONDISPOSABLE PUMP CANISTER
TUBING USED W SUCTION PUMP
NEBULIZER ADMINISTRATION SET
DISPOSABLE NEBULIZER SML VOL
NONDISPOSABLE NEBULIZER SET
FILTERED NEBULIZER ADMIN SET
LG VOL NEBULIZER DISPOSABLE
DISPOSABLE NEBULIZER PREFILL
NEBULIZER RESERVOIR BOTTLE
DISPOSABLE CORRUGATED TUBING
NEBULIZER WATER COLLEC DEVIC
DISPOSABLE COMPRESSOR FILTER
COMPRESSOR NONDISPOS FILTER
AEROSOL MASK USED W NEBULIZE
NEBULIZER DOME & MOUTHPIECE
NEBULIZER NOT USED W OXYGEN
WATER DISTILLED W/NEBULIZER
INTERFACE, COUGH STIM DEVICE
REPLACE CHEST COMPRESS VEST
REPLACE CHST CMPRSS SYS HOSE
COMBINATION ORAL/NASAL MASK
REPL ORAL CUSHION COMBO MASK
REPL NASAL PILLOW COMB MASK
CPAP FULL FACE MASK
REPLACEMENT FACEMASK INTERFA
REPLACEMENT NASAL CUSHION
REPLACEMENT NASAL PILLOWS
NASAL APPLICATION DEVICE
POS AIRWAY PRESS HEADGEAR
POS AIRWAY PRESS CHINSTRAP
POS AIRWAY PRESSURE TUBING
POS AIRWAY PRESSURE FILTER
FILTER, NON DISPOSABLE W PAP
ONE WAY CHEST DRAIN VALVE
WATER SEAL DRAIN CONTAINER
PAP ORAL INTERFACE
REPL EXHALATION PORT FOR PAP
REPL WATER CHAMBER, PAP DEV
RESP SUCTION ORAL INTERFACE
VACUUM DRAIN BOTTLE/TUBE KIT
Pricing Action Code
6
6
6
6
6
6
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
6
3
3
6
6
6
3
3
3
3
3
3
3
3
3
3
6
6
3
3
3
6
6
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$7.67
$28.55
$3.83
$2.49
$1.47
$29.15
$8.54
$4.39
$10.52
$36.26
$23.01
$3.79
$0.71
$3.87
$1.57
$6.24
$128.23
$0.37
$0.00
$434.94
$28.75
$0.00
$0.00
$0.00
$139.78
$69.77
$40.53
$28.41
$87.07
$26.71
$18.20
$26.05
$3.31
$10.81
$0.00
$0.00
$120.91
$19.47
$16.13
$0.00
$0.00
Procedure Code
A7501
A7502
A7503
A7504
A7505
A7506
A7507
A7508
A7509
A7520
A7521
A7522
A7523
A7524
A7525
A7526
A7527
A8000
A8001
A8002
A8003
A8004
A9150
A9152
A9153
A9155
A9160
A9170
A9180
A9190
A9250
A9260
A9270
A9272
A9273
A9274
A9275
A9276
A9277
A9278
A9279
A9280
A9281
A9282
A9283
A9284
A9290
Description
Pricing Action Code
TRACHEOSTOMA VALVE W DIAPHRA
REPLACEMENT DIAPHRAGM/FPLATE
HMES FILTER HOLDER OR CAP
TRACHEOSTOMA HMES FILTER
HMES OR TRACH VALVE HOUSING
HMES/TRACHVALVE ADHESIVEDISK
INTEGRATED FILTER & HOLDER
HOUSING & INTEGRATED ADHESIV
HEAT & MOISTURE EXCHANGE SYS
TRACH/LARYN TUBE NON-CUFFED
TRACH/LARYN TUBE CUFFED
TRACH/LARYN TUBE STAINLESS
TRACHEOSTOMY SHOWER PROTECT
TRACHEOSTOMA STENT/STUD/BTTN
TRACHEOSTOMY MASK
TRACHEOSTOMY TUBE COLLAR
TRACH/LARYN TUBE PLUG/STOP
SOFT PROTECT HELMET PREFAB
HARD PROTECT HELMET PREFAB
SOFT PROTECT HELMET CUSTOM
HARD PROTECT HELMET CUSTOM
REPL SOFT INTERFACE, HELMET
MISC/EXPER NON-PRESCRIPT DRU
SINGLE VITAMIN NOS
MULTI-VITAMIN NOS
ARTIFICIAL SALIVA
PODIATRIST NON-COVERED SERVI
CHIROPRACTOR NON-COVERED SER
LICE TREATMENT, TOPICAL
MISC/EXPE PERSONAL COMFORT I
NURSING HOME RENTALS
NON-CERTIFIED PHYSICAL THERAPISTS
NON-COVERED ITEM OR SERVICE
DISP WOUND SUCT, DRSG/ACCESS
HOT/COLD H2OBOT/CAP/COL/WRAP
EXT AMB INSULIN DELIVERY SYS
DISP HOME GLUCOSE MONITOR
DISPOSABLE SENSOR, CGM SYS
EXTERNAL TRANSMITTER, CGM
EXTERNAL RECEIVER, CGM SYS
MONITORING FEATURE/DEVICENOC
ALERT DEVICE, NOC
REACHING/GRABBING DEVICE
WIG ANY TYPE
FOOT PRESS OFF LOAD SUPP DEV
NON-ELECTRONIC SPIROMETER
DESCRIPTION OF SERVICE DOES NOT IND
3
3
3
3
3
3
3
3
3
6
3
6
6
6
3
3
6
6
6
6
6
6
9
9
9
6
9
9
9
9
9
9
9
6
9
6
9
6
6
6
9
6
9
9
6
9
9
Maximum Allowable
$100.18
$47.61
$10.81
$0.64
$4.46
$0.32
$2.75
$2.74
$1.56
$0.00
$49.35
$0.00
$0.00
$0.00
$2.28
$3.74
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
A9500
A9501
A9502
A9503
A9504
A9505
A9507
A9508
A9509
A9510
A9512
A9516
A9517
A9520
A9521
A9524
A9526
A9527
A9528
A9529
A9530
A9531
A9532
A9536
A9537
A9538
A9539
A9540
A9541
A9542
A9543
A9544
A9545
A9546
A9547
A9548
A9550
A9551
A9552
A9553
A9554
A9555
A9556
A9557
A9558
A9559
A9560
Description
TC99M SESTAMIBI
TECHNETIUM TC-99M TEBOROXIME
TC99M TETROFOSMIN
TC99M MEDRONATE
TC99M APCITIDE
TL201 THALLIUM
IN111 CAPROMAB
I131 IODOBENGUATE, DX
IODINE I-123 SOD IODIDE MIL
TC99M DISOFENIN
TC99M PERTECHNETATE
IODINE I-123 SOD IODIDE MIC
I131 IODIDE CAP, RX
TC99 TILMANOCEPT DIAG 0.5MCI
TC99M EXAMETAZIME
I131 SERUM ALBUMIN, DX
NITROGEN N-13 AMMONIA
IODINE I-125 SODIUM IODIDE
IODINE I-131 IODIDE CAP, DX
I131 IODIDE SOL, DX
I131 IODIDE SOL, RX
I131 MAX 100UCI
I125 SERUM ALBUMIN, DX
TC99M DEPREOTIDE
TC99M MEBROFENIN
TC99M PYROPHOSPHATE
TC99M PENTETATE
TC99M MAA
TC99M SULFUR COLLOID
IN111 IBRITUMOMAB, DX
Y90 IBRITUMOMAB, RX
I131 TOSITUMOMAB, DX
I131 TOSITUMOMAB, RX
CO57/58
IN111 OXYQUINOLINE
IN111 PENTETATE
TC99M GLUCEPTATE
TC99M SUCCIMER
F18 FDG
CR51 CHROMATE
I125 IOTHALAMATE, DX
RB82 RUBIDIUM
GA67 GALLIUM
TC99M BICISATE
XE133 XENON 10MCI
CO57 CYANO
TC99M LABELED RBC
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
A9561
A9562
A9563
A9564
A9566
A9567
A9568
A9569
A9570
A9571
A9572
A9575
A9576
A9577
A9578
A9579
A9580
A9581
A9582
A9583
A9584
A9585
A9586
A9599
A9600
A9603
A9604
A9606
A9698
A9699
A9700
A9900
A9901
A9999
B4034
B4035
B4036
B4081
B4082
B4083
B4085
B4087
B4088
B4100
B4102
B4103
B4104
Description
TC99M OXIDRONATE
TC99M MERTIATIDE
P32 NA PHOSPHATE
P32 CHROMIC PHOSPHATE
TC99M FANOLESOMAB
TECHNETIUM TC-99M AEROSOL
TECHNETIUM TC99M ARCITUMOMAB
TECHNETIUM TC-99M AUTO WBC
INDIUM IN-111 AUTO WBC
INDIUM IN-111 AUTO PLATELET
INDIUM IN-111 PENTETREOTIDE
INJ GADOTERATE MEGLUMI 0.1ML
INJ PROHANCE MULTIPACK
INJ MULTIHANCE
INJ MULTIHANCE MULTIPACK
GAD-BASE MR CONTRAST NOS,1ML
SODIUM FLUORIDE F-18
GADOXETATE DISODIUM INJ
IODINE I-123 IOBENGUANE
GADOFOSVESET TRISODIUM INJ
IODINE I-123 IOFLUPANE
GADOBUTROL INJECTION
FLORBETAPIR F18
RADIOPHA DX BETA AMYLOID PET
SR89 STRONTIUM
I-131SODIUMIODIDECAP PER MCI
SM 153 LEXIDRONAM
RADIUM RA223 DICHLORIDE THER
NON-RAD CONTRAST MATERIALNOC
RADIOPHARM RX AGENT NOC
ECHOCARDIOGRAPHY CONTRAST
SUPPLY/ACCESSORY/SERVICE
DELIVERY/SET UP/DISPENSING
DME SUPPLY OR ACCESSORY, NOS
ENTER FEED SUPKIT SYR BY DAY
ENTERAL FEED SUPP PUMP PER D
ENTERAL FEED SUP KIT GRAV BY
ENTERAL NG TUBING W/ STYLET
ENTERAL NG TUBING W/O STYLET
ENTERAL STOMACH TUBE LEVINE
GASTROSTOMY TUBE W/RING EACH
GASTRO/JEJUNO TUBE, STD
GASTRO/JEJUNO TUBE, LOW-PRO
FOOD THICKENER ORAL
EF ADULT FLUIDS AND ELECTRO
EF PED FLUID AND ELECTROLYTE
ADDITIVE FOR ENTERAL FORMULA
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
9
3
3
3
3
3
9
3
9
3
9
3
9
9
9
9
9
9
9
9
9
5
9
5
3
3
3
3
3
3
9
6
6
5
6
6
6
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.21
$1.65
$2.13
$2.01
$1.89
$0.00
$14.00
$0.00
$14.82
$0.00
$0.39
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$4.68
$8.80
$6.25
$19.78
$14.73
$2.25
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
B4149
B4150
B4152
B4153
B4154
B4155
B4157
B4158
B4159
B4160
B4161
B4162
B4164
B4168
B4172
B4176
B4178
B4180
B4185
B4189
B4193
B4197
B4199
B4216
B4220
B4224
B5000
B5100
B5200
B9000
B9002
B9004
B9006
B9998
B9999
C1000
C1001
C1003
C1004
C1006
C1007
C1008
C1009
C1012
C1013
C1014
C1019
Description
EF BLENDERIZED FOODS
EF COMPLET W/INTACT NUTRIENT
EF CALORIE DENSE>/=1.5KCAL
EF HYDROLYZED/AMINO ACIDS
EF SPEC METABOLIC NONINHERIT
EF INCOMPLETE/MODULAR
EF SPECIAL METABOLIC INHERIT
EF PED COMPLETE INTACT NUT
EF PED COMPLETE SOY BASED
EF PED CALORIC DENSE>/=0.7KC
EF PED HYDROLYZED/AMINO ACID
EF PED SPECMETABOLIC INHERIT
PARENTERAL 50% DEXTROSE SOLU
PARENTERAL SOL AMINO ACID 3.
PARENTERAL SOL AMINO ACID 5.
PARENTERAL SOL AMINO ACID 7PARENTERAL SOL AMINO ACID >
PARENTERAL SOL CARB > 50%
PARENTERAL SOL 10 GM LIPIDS
PARENTERAL SOL AMINO ACID &
PARENTERAL SOL 52-73 GM PROT
PARENTERAL SOL 74-100 GM PRO
PARENTERAL SOL > 100GM PROTE
PARENTERAL NUTRITION ADDITIV
PARENTERAL SUPPLY KIT PREMIX
PARENTERAL ADMINISTRATION KI
PARENTERAL SOL RENAL-AMIROSY
PARENTERAL SOLUTION HEPATIC
PARENTERAL SOL HEPATIC FREAM
ENTER INFUSION PUMP W/O ALRM
ENTERAL INFUSION PUMP W/ ALA
PARENTERAL INFUS PUMP PORTAB
PARENTERAL INFUS PUMP STATIO
ENTERAL SUPP NOT OTHERWISE C
PARENTERAL SUPP NOT OTHRWS C
PERCLOSCLOSR PROSTARARTVAS
ACUNAV-DIAGNSTIC ULTRSND CA
CATH, ABLATION, LIVEWIRE TC
FAST-CATH,SWARTZ,SAFL,CSTA
ARRAY POST CHAMB IOL
AMS 700/AMBICOR PROSTHESIS
UROLUME-IMPLT URETHRAL STNT
PLASMA,CRYOPRECIPITATE-REDUC
PLATELET CONC, L/R, IRRAD
PLATELET CONC, L/R, UNIT
PLATELET,APH/PHER, L/R, UNIT
PLT, APH/PHER, L/R, IRRAD
Pricing Action Code
6
3
3
3
3
3
6
5
6
6
5
6
9
9
9
9
9
9
6
9
9
9
9
9
3
3
9
9
9
3
3
3
3
5
5
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.54
$0.45
$1.57
$0.97
$0.84
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$9.19
$28.70
$0.00
$0.00
$0.00
$988.00
$939.58
$2,896.55
$1,970.80
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
C1024
C1025
C1026
C1027
C1028
C1029
C1030
C1031
C1033
C1034
C1035
C1036
C1037
C1038
C1039
C1040
C1042
C1043
C1045
C1047
C1048
C1050
C1051
C1053
C1054
C1055
C1056
C1057
C1058
C1059
C1060
C1061
C1063
C1064
C1065
C1066
C1067
C1068
C1069
C1071
C1072
C1073
C1074
C1075
C1076
C1077
C1078
Description
QUINOPRISTIN 10ML/DALFOPRIS
MARINR CS CATH
RF PERFRMR CATH 5F RF MARINR
MAGIC X/SHORT RADIUS 14MM
PRCIS TWST TRSNSVG ANCH SYS
CRE GUIDED BALLOON DIL CATH
CTHTR:MRSHAL,BLU MAX UTR DMD
MR COMP/MOD LEVEEN NED ELECT
SONICATH MDL 37-410
SURPASS, LONG30 SURPASS-CATH
CATH, ULTRA ICE
R PORT/RESERVOIR IMPL DEV
VAXCELCHRONIC DIALYSIS CATH
ULTRACROSS IMAGING CATH
WALLSTENT, RP/TRACH
WALLSTENT, TIPS
WALLSTENT, BILIARY
ATHERECTOMY SYS, CORONARY
I-131 MIBG(IOBEN-SULFATE)0.5
NOGA/NAVI-STAR CATH
NEUROCYBERNETICPROS:GEN
PROSORBA COLUMN
OASIS THROMBECTOMY CATH
ENSITE 3000 CATHETER
HYDROLYSER THROMB CATH 6/7F
TRANSESOPH 210, 210-S CATH
THERMACHOICE II CATH
MICROMARK TISSUE MARKER
TC 99M OXIDRONATE, PER VIAL
CARTICEL,AUTO CULT-CHNDR CYT
ACS MULTI-LINK TRISTAR STENT
ACS VIKING GUIDING CATH
ENDOTAK ENDURANCE EZ,RX LEAD
I-131 CAP, EACH ADD MCI
I-131 SOL, EACH ADD MCI
IN 111 SATUMOMAB PENDETIDE
MEGALINK BILIARY STENT
PULSAR DDD PMKR
DISCOVERY DR, PMKR
PULSAR MAX, PULSAR SR PMKR
GUIDANT:BLLN DIL CATH
MORCELLATOR
RX/OTW VIATRAC-PERI DIL CATH
GUIDANT:LEAD,PMKR
VENTAK MINI SC DEFIB
VENTAK VR,PRIZM VR, SC DEFIB
VENTAK:PRIZM,AV III DR DEFIB
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
C1084
C1086
C1087
C1088
C1089
C1090
C1094
C1095
C1096
C1097
C1098
C1099
C1100
C1101
C1102
C1103
C1104
C1105
C1106
C1107
C1109
C1110
C1111
C1112
C1113
C1114
C1115
C1116
C1117
C1118
C1119
C1120
C1121
C1123
C1124
C1125
C1126
C1127
C1128
C1129
C1130
C1131
C1132
C1133
C1134
C1135
C1136
Description
DENILEUKIN DIFTITOX, 300 MCG
TEMOZOLOMIDE, 5 MG
I-123 PER 100 UCI
LASER OPTIC TR SYS
CO 57, 0.5 MCI
IN 111 CHLORIDE, PER MCI
TC99MALBUMIN AGGR,PER 1.0MCI
TC 99M DEPREOTIDE, PER VIAL
TC 99M EXAMETAZIME, PER DOSE
TC 99M MEBROFENIN, PER VIAL
TC 99M PENTETATE, PER VIAL
TC 99M PYROPHOSPHATE,PER VIA
MEDTRONIC AVE GT1 GUIDEWIRE
MEDTRONIC AVE ZUMA GUIDECATH
SYNERGY NEUROSTIM GENRTR
MICRO JEWEL DEFIBRILLATOR
RF CONDUCTR ABLATION CATH
SIGMA 300VDD PMKR
SYNERGYEX PT PROGRMR
TORQR,SOLOIST CATH
IMPLANTABLE ANCHOR:ETHICON
STABLE MAPPER,CATH ELECTR
ANEURXAORT-UNI-ILIAC STNT
ANEURX STENT GRAFT/DEL CATH
TLNT ENDO SPRNG STNT GRFT SY
TALNTSPRGSTNT+GRAF ENDO PROS
5038S, 5038 5038L PACE LEAD
CAPSURESP PACING LEAD
ANCURE ENDOGRAFT DEL SYS
SIGMA300DR LEGIIDR, PMKR
SPRINT6932,6943 DEFIB LEAD
SPRINT6942,6945 DEFIB LEAD
GEM DEFIBRILLATOR
GEM II VR DEFIBRILLATOR
INTERSTIM TEST STIM KIT
KAPPA 400SR,TOPAZ II SR PMKR
KAPPA 700 DR, PMKR
KAPPA 700SR, SC PMKR
KAPPA 700D, RUBY IID PMKR
KAPPA 700VDD, PMKR
SIGMA200D, LGCY IID DC PMKR
SIGMA 200DR, PMKR
SIGMA 200 SR LEG II:SC PA
SIGMA SR, VITA SR, PMKR
SIGMA 300D PMKR
ENTITY DR 5326L/R, DC, PMKR
AFFINITY DR 5330L/R, DC, PMK
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
C1137
C1143
C1144
C1145
C1146
C1147
C1148
C1149
C1151
C1152
C1153
C1154
C1155
C1156
C1157
C1158
C1159
C1160
C1161
C1162
C1163
C1164
C1170
C1171
C1172
C1173
C1174
C1175
C1176
C1177
C1179
C1180
C1181
C1182
C1183
C1184
C1188
C1202
C1203
C1205
C1302
C1303
C1304
C1306
C1311
C1312
C1313
Description
CARDIOSEAL IMPLANT SYS
ADDVENT MOD 2060BL, VDD
AFNTY SP 5130,INTEGRITY SR
ANGIO-SEAL 6FR,8FR
VETT TUBE
AV PLUS DX 1368:LEAD
CONTOUR MD SC DEFIB
ENTITY DC 5226R,PMKR
PASSIVEPLUS DX LEAD, 10MDLS
LIFESITE ACCESS SYSTEM
REGENCY SC+2402L PMKR
SPL:SPO1,02,04-DEFIB LEAD
REPLIFORM 8 SQ CM
TR1102TRSR+2260L,2264L,5131
TRILOGY DCT 23/8L PMKR
TVL LEAD SV01,SV02,SV04
TVL RV02, RV06,RV07:LEAD
TVL-ADX 1559:LEAD
TENDRIL DX, 1388 PACING LEAD
TEMPODR TRILOGYDR+DC PMKR
TENDRIL SDX, 1488T LEAD
IODINE-125 BRACHYTX SEED
ABBI DISP BIOPSY DEVICE
AUTOSUTURE SITE MARKER STPLE
SPACEMAKER DISSECT BALLOON
COR STNTS540,S670,O-WIRE STN
BARD BRACHYTX NEEDLE
MIBB DISP BIOPSY DEVICE
MAMMOTOME HH PROBE W/VAC SYS
11-G MAMMOTOME PROBE
14-G MAMMOTOME PROBE
VIGOR SR, SC, PMKR
MERIDIAN SSI, SC, PMKR
PULSAR SSI, SC, PMKR
JADE IIS, SIGMA 300S, SC, PM
SIGMA 200S, SC, PMKR
I-131 CAP, PER 1-5 MCI
TC 99M SULFUR COLLOID, VIAL
VERTEPORFIN FOR INJ
TC 99M DISOFENIN, PER VIAL
SQ01: LEAD
CAPSURE FIX 6940/4068-110
SONCATH MDL 37-416,-418
NEUROCYBERNETICPROS:LEAD
TRILOGY DR+/DAO PMKR
MAGIC WALLSTENT--MINI
MAGIC MEDIUM,RADIUS 31MM
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
C1314
C1315
C1316
C1317
C1318
C1319
C1320
C1321
C1322
C1323
C1324
C1325
C1326
C1328
C1329
C1333
C1334
C1335
C1336
C1337
C1348
C1350
C1351
C1352
C1353
C1354
C1355
C1356
C1357
C1358
C1359
C1360
C1361
C1362
C1363
C1364
C1365
C1366
C1367
C1368
C1369
C1370
C1371
C1372
C1375
C1376
C1377
Description
MAGIC WALLSTENT--LONG
VIGOR DR, MERIDIAN DR PMKR
MERIDIAN DDD PMKR
DISCOVERY SR, PMKR
MERIDIAN SR PMKR
WALLSTENT: ENTERAL--60MM
WALLSTENT: ILIAC
PALATE/BASE OF TONGUE ELECTR
TURBINATE SOMNOPLASTY ELECTR
VAPR/T DISP ELECTRODE
LIGASURE DISPOSABLE ELECTROD
PALLADIUM-103 SEED
ANGIO-JET RHEOLYTIC THROMB
ANS RENEW NS TRNSMTR
VERSAPOINT DISP ELECTRODE
PALMAZ CORINTHIAN BIL STENT
CROWN,MINI-CROWN,CROSSLC
MESH, PROLENE
CONSTANT FLOW IMP PUMP
ISOMED 8472-20/35/60
I-131 SOL, PER 1-6 MCI
PROSTASEED I-125, PER SOURCE
CAPSURE FIX LEAD
GEM II DR
ITREL INTERSTM NEUROSTIM+EXT
KAPPA 400DR,DIAMOND II 820DR
KAPPA 600DR, VITA DR
PROFILE MD V-186HV3 SC DEFIB
ANGSTROM MD V-190HV3 SC DEF
AFFINITY DC 5230R, PMKR
PULSAR,PULSAR MAX DR, PMKR
OCULAR PHOTODYNAMIC TX
REVEAL CARDIAC RECORDER
HERCULINK,OTW,SDS BIL STNT
GEM DR, DC, DEFIB
PHOTON DR V-230HV3 DC DEFIB
GUIDEWIRE, HI-TORQUE14/18/35
GUIDEWIRE,PTCA,HI-TORQUE
GUIDE WIRE, HI-TORQUECROSSIT
ON-Q PAIN MGT SYS
ANS RENEW STIM SYS RECVR
TENSION-FREE VAGINAL TAPE
SYMP NITINOL TRANSHEP BIL SY
CORDIS NITINOL BIL STENT
STENT, CORONARY, NIR
ANS RENEW STIM SYS LEAD
SPECIFY 3988 NEURO LEAD
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
C1378
C1379
C1420
C1421
C1450
C1451
C1500
C1700
C1701
C1702
C1703
C1704
C1705
C1706
C1707
C1708
C1709
C1710
C1711
C1712
C1713
C1714
C1715
C1716
C1719
C1721
C1722
C1724
C1725
C1726
C1727
C1728
C1729
C1730
C1731
C1732
C1733
C1749
C1750
C1751
C1752
C1753
C1754
C1755
C1756
C1757
C1758
Description
INTERSTIM TX 3080/3886 LEAD
PISCES-QUAD 3887 LEAD
STAPLETAC2 BONEW/DERMIS
STAPLETAC2 BONE WO DERMIS
ORTHOSPHERE ARTHROPLASTY
ORTHOSPHERE ARTHROPLASTY KIT
ATHERECTOMY SYS, PERIPHERAL
AUTHEN MICK TP BRACHY NEEDLE
MEDTEC MT-BT-5201-25 NEEDLE
WWMT BRACHY NEEDLE
MENTOR PROSTATE BRACHY
MT-BT-5001-25/5051-25
BEST FLEXI BRACHY NEEDLE
INDIGO PROSTATE SEEDING NDL
VARISOURCE IMPLT NDL
UROMED PROSTATE SEED NDL
REMINGTON BRACHYTX NEEDLE
US BIOPSY PROSTATE NEEDLE
MD TECH BRACHYTX NEEDLE
IMAGYN BRACHYTX NEEDLE
ANCHOR/SCREW BN/BN,TIS/BN
CATH, TRANS ATHERECTOMY, DIR
BRACHYTHERAPY NEEDLE
BRACHYTX, NON-STR, GOLD-198
BRACHYTX, NS, NON-HDRIR-192
AICD, DUAL CHAMBER
AICD, SINGLE CHAMBER
CATH, TRANS ATHEREC,ROTATION
CATH, TRANSLUMIN NON-LASER
CATH, BAL DIL, NON-VASCULAR
CATH, BAL TIS DIS, NON-VAS
CATH, BRACHYTX SEED ADM
CATH, DRAINAGE
CATH, EP, 19 OR FEW ELECT
CATH, EP, 20 OR MORE ELEC
CATH, EP, DIAG/ABL, 3D/VECT
CATH, EP, OTHR THAN COOL-TIP
ENDO, COLON, RETRO IMAGING
CATH, HEMODIALYSIS,LONG-TERM
CATH, INF, PER/CENT/MIDLINE
CATH,HEMODIALYSIS,SHORT-TERM
CATH, INTRAVAS ULTRASOUND
CATHETER, INTRADISCAL
CATHETER, INTRASPINAL
CATH, PACING, TRANSESOPH
CATH, THROMBECTOMY/EMBOLECT
CATHETER, URETERAL
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
C1759
C1760
C1762
C1763
C1764
C1765
C1766
C1767
C1768
C1769
C1770
C1771
C1772
C1773
C1776
C1777
C1778
C1779
C1780
C1781
C1782
C1783
C1784
C1785
C1786
C1787
C1788
C1789
C1790
C1791
C1792
C1793
C1794
C1795
C1796
C1797
C1798
C1799
C1800
C1801
C1802
C1803
C1804
C1805
C1806
C1810
C1811
Description
CATH, INTRA ECHOCARDIOGRAPHY
CLOSURE DEV, VASC
CONN TISS, HUMAN(INC FASCIA)
CONN TISS, NON-HUMAN
EVENT RECORDER, CARDIAC
ADHESION BARRIER
INTRO/SHEATH,STRBLE,NON-PEEL
GENERATOR, NEURO NON-RECHARG
GRAFT, VASCULAR
GUIDE WIRE
IMAGING COIL, MR, INSERTABLE
REP DEV, URINARY, W/SLING
INFUSION PUMP, PROGRAMMABLE
RET DEV, INSERTABLE
JOINT DEVICE (IMPLANTABLE)
LEAD, AICD, ENDO SINGLE COIL
LEAD, NEUROSTIMULATOR
LEAD, PMKR, TRANSVENOUS VDD
LENS, INTRAOCULAR (NEW TECH)
MESH (IMPLANTABLE)
MORCELLATOR
OCULAR IMP, AQUEOUS DRAIN DE
OCULAR DEV, INTRAOP, DET RET
PMKR, DUAL, RATE-RESP
PMKR, SINGLE, RATE-RESP
PATIENT PROGR, NEUROSTIM
PORT, INDWELLING, IMP
PROSTHESIS, BREAST, IMP
IRIDIUM 192 HDR
ONCOSEED, RAPID STRAND I-125
UROMED I-125 BRACHY SEED
BARD INTERSOURCE P-103 SEED
BARD ISOSEED P-103 SEED
BARD BRACHYSOURCE I-125
SOURCETECH MED I-125
DRAXIMAGE I-125 SEED
SYNCOR I-125 PHARMASEED
I-PLANT I-125 BRACHYTX SEED
PD-103 BRACHYTX SEED
IOGOLD I-125 BRACHYTX SEED
IRIDIUM 192 BRACHYTX SEEDS
BEST IODINE 125 BRACHYTX SDS
BEST PALLADIUM 103 SEEDS
ISOSTAR IODINE-125 SEEDS
BEST GOLD 198 BRACHYTX SEED
D114S DILATATION CATH
SUGICAL DYNAMICS ANCHORS
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
C1812
C1813
C1814
C1815
C1816
C1817
C1818
C1819
C1820
C1821
C1822
C1830
C1840
C1841
C1850
C1851
C1852
C1853
C1854
C1855
C1856
C1857
C1858
C1859
C1860
C1861
C1862
C1863
C1864
C1865
C1866
C1867
C1868
C1869
C1870
C1871
C1872
C1873
C1874
C1875
C1876
C1877
C1878
C1880
C1881
C1882
C1883
Description
OBL ANCHORS
PROSTHESIS, PENILE, INFLATAB
RETINAL TAMP, SILICONE OIL
PROS, URINARY SPH, IMP
RECEIVER/TRANSMITTER, NEURO
SEPTAL DEFECT IMP SYS
INTEGRATED KERATOPROSTHESIS
TISSUE LOCALIZATION-EXCISION
GEN, NEURO, NON-HF RECHG BAT
INTERSPINOUS IMPLANT
GEN, NEURO, HF, RECHG BAT
POWER BONE MARROW BX NEEDLE
TELESCOPIC INTRAOCULAR LENS
RETINAL PROSTH INT/EXT COMP
REPLIFORM 14/21 SQ CM
REPLIFORM 24/28 SQ CM
TRANSCYTE, PER 247 SQ CM
SUSPEND, PER 8/14 SQ CM
SUSPEND, PER 24/28 SQ CM
SUSPEND, PER 36 SQ CM
DURADERM, PER 8/14 SQ CM
DURADERM, PER 21/24/28 SQ CM
DURADERM, PER 48 SQ CM
SPERMATEX, PER 13.44 SQ CM
FASLATA, PER 8/14 SQ CM
FASLATA, PER 96 SQ CM
GORE THYROPLASTY DEVICE
DERMMATRIX, PER 16 SQ CM
DERMMATRIX, 32 OR 64 SQ CM
DERMAGRAFT, PER 37.5 SQ CM
BARD 3DMAX MESH
STENT, COATED/COV W/DEL SYS
STENT, COATED/COV W/O DEL SY
STENT, NON-COA/NON-COV W/DEL
STENT, NON-COAT/COV W/O DEL
MATRL FOR VOCAL CORD
VENA CAVA FILTER
DIALYSIS ACCESS SYSTEM
AICD, OTHER THAN SING/DUAL
ADAPT/EXT, PACING/NEURO LEAD
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
C1884
C1885
C1886
C1887
C1888
C1891
C1892
C1893
C1894
C1895
C1896
C1897
C1898
C1899
C1900
C1925
C1929
C1930
C1931
C1932
C1933
C1934
C1935
C1936
C1937
C1938
C1939
C1940
C1941
C1942
C1943
C1944
C1945
C1946
C1947
C1948
C1949
C1979
C1980
C1981
C2000
C2001
C2002
C2003
C2004
C2005
C2006
Description
EMBOLIZATION PROTECT SYST
CATH, TRANSLUMIN ANGIO LASER
CATHETER, ABLATION
CATHETER, GUIDING
ENDOVAS NON-CARDIAC ABL CATH
INFUSION PUMP,NON-PROG, PERM
INTRO/SHEATH,FIXED,PEEL-AWAY
INTRO/SHEATH, FIXED,NON-PEEL
INTRO/SHEATH, NON-LASER
LEAD, AICD, ENDO DUAL COIL
LEAD, AICD, NON SING/DUAL
LEAD, NEUROSTIM TEST KIT
LEAD, PMKR, OTHER THAN TRANS
LEAD, PMKR/AICD COMBINATION
LEAD, CORONARY VENOUS
INJECTION, RISPERIDONE
MAVERICK PTCA CATH
COYOTE DIL CATH, 20/30/40MM
TALON DIL CATH
SCIMED REMEDY DIL CATH
OPTI-PLAST XL/CENTURION CATH
ULTRAVERSE 3.5F BAL DIL CATH
WORKHORSE PTA BAL CATH
UROMAX ULTRA BAL DIL CATH
SYNERGY/EXPLORER CATH
UROFORCE BAL DIL CATH
RAPTUR, NINJA PTCA DIL CATH
POWERFLEX,OPTA 5/LP BAL CATH
JUPITER PTA DIL CATH
CORDIS MAXI LD PTA BAL CATH
RXCROSSSAIL OTW OPENSAIL
RAPID EXCHANGE BIL DIL CATH
SAVVY PTA DIL CATH
R1S RAPID DIL CATH
GAZELLE BAL DIL CATH
ORACLE MEGASONICS CATH
ORACLE MEGASONICS CATH
VISIONS PV/AVANAR US CATH
ATLANTIS SR CORONARY CATH
PTCA CATHETERS
ORBITER ST STEERABLE CATH
CONSTELLATION DIAG CATH
IRVINE 5F INQUIRY EP CATH
IRVINE 6F INQUIRY EP CATH
EP CATH--OCTAPOLAR
EP TIP CATH--HEXAPOLAR
EP CATH--DECAPOLAR
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
C2007
C2008
C2009
C2010
C2011
C2012
C2013
C2014
C2015
C2016
C2017
C2018
C2019
C2020
C2021
C2022
C2023
C2100
C2101
C2102
C2103
C2104
C2151
C2152
C2153
C2200
C2300
C2597
C2598
C2599
C2600
C2601
C2602
C2603
C2604
C2605
C2606
C2607
C2608
C2609
C2610
C2611
C2612
C2613
C2614
C2615
C2616
Description
IRVINE 6F LUMA-CATH EP CATH
LUMA-CATH EP CATH 81910-15
IRVINE 7F LUMA-CATH EP CATH
FIXED CURVE EP CATH
DEFLECTABLE TIP CATH--QUAD
CELSIUS ABLN CATH
CELSIUS LARGE ABLN CATH
CELSIUS II ASYM ABLN CATH
CELSIUS II SYM ABLN CATH
NAVI-STAR DS, NAVI-STAR THER
NAVI-STAR ABLN CATH
POLARIS T ABLATION CATH
EP DEFLECTABLE CATH
BLAZER II XP ABLN CATH
SILVERFLEX EP CATH
CP CHILLI COOLED ABLN CATH
CHILLI CLD ABLNCATH-STD,LG
CP CS REFERENCE CATH
CP RV REFERENCE CATH
CP RADII 7F EP CATH
CP RADII 7F EP CATH W/TRACK
LASSO DEFLECTABLE CATH
VERIPATH GUIDING CATH
CORDIS VISTA BRITE TIP CATH
BARD VIKING CATH
ARROW-TREROTOLA PTD CATH
VARISOURCE STND CATH
CLINICATH 16/18 SGL/DBL
CLINICATH 18/20/24G--SINGLE
CLINICATH 16/18 DOUBLE
GOLD PROBE CATHETER
BARD DL URETERAL CATH
VITESSE LASER CATH 1.4/1.7MM
VITESSE LASER CATH 2.0MM
VITESSE E LASER CATH 2.0MM
EXTREME LASER CATH
SPINECATH XL CATHETER
SPINECATH INTRADISCAL CATH
SCIMED 6F WISEGUIDE CATHETER
FLEXIMA BIL DRAINAGE CATH
FLEXTIPPLUS INTRASPINAL CATH
ALGOLINE INTRASPINAL CATH
INDURA CATHETER
LUNG BX PLUG W/DEL SYS
PROBE, PERC LUMB DISC
SEALANT, PULMONARY, LIQUID
BRACHYTX, NON-STR,YTTRIUM-90
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
C2617
C2618
C2619
C2620
C2621
C2622
C2623
C2624
C2625
C2626
C2627
C2628
C2629
C2630
C2631
C2634
C2635
C2636
C2637
C2638
C2639
C2640
C2641
C2642
C2643
C2644
C2645
C2676
C2698
C2699
C2700
C2701
C2702
C2703
C2704
C2801
C2802
C2803
C2804
C2805
C2806
C2807
C2808
C3001
C3002
C3003
C3004
Description
STENT, NON-COR, TEM W/O DEL
PROBE/NEEDLE, CRYO
PMKR, DUAL, NON RATE-RESP
PMKR, SINGLE, NON RATE-RESP
PMKR, OTHER THAN SING/DUAL
PROSTHESIS, PENILE, NON-INF
CATH, TRANSLUMIN, DRUG-COAT
WIRELESS PRESSURE SENSOR
STENT, NON-COR, TEM W/DEL SY
INFUSION PUMP, NON-PROG,TEMP
CATH, SUPRAPUBIC/CYSTOSCOPIC
CATHETER, OCCLUSION
INTRO/SHEATH, LASER
CATH, EP, COOL-TIP
REP DEV, URINARY, W/O SLING
BRACHYTX, NON-STR, HA, I-125
BRACHYTX, NON-STR, HA, P-103
BRACHY LINEAR, NON-STR,P-103
BRACHY,NON-STR,YTTERBIUM-169
BRACHYTX, STRANDED, I-125
BRACHYTX, NON-STRANDED,I-125
BRACHYTX, STRANDED, P-103
BRACHYTX, NON-STRANDED,P-103
BRACHYTX, STRANDED, C-131
BRACHYTX, NON-STRANDED,C-131
BRACHYTX CESIUM-131 CHLORIDE
BRACHYTX PLANAR, P-103
RSPONSE CV CATHETER
BRACHYTX, STRANDED, NOS
BRACHYTX, NON-STRANDED, NOS
MYCROPHYLAX PLUS SC DEFIB
PHYLAX XM SC DEFIB
VENTAK PRIZM 2 VR DEFIB
VENTAK PRIZM VR HE DEFIB
VENTAK MINI IV+ DEFIB
DEFENDER IV DR 612 DC DEFIB
PHYLAX AV
VENTAK PRIZM DR HE DEFIB
VENTAK PRIZM 2 DR DEFIB
JEWEL AF 7250 DEFIB
GEM VR 7227 DEFIB
CONTAK CD 1823
CONTAK TR 1241
KAINOX SL/RV DEFIB LEAD
EASYTRAK DEFIB LEAD
ENDOTAK SQ ARAY XP LEAD
INTERVENE DEFIB LEAD
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
C3400
C3401
C3500
C3510
C3551
C3552
C3553
C3554
C3555
C3556
C3557
C3800
C3801
C3851
C4000
C4001
C4002
C4003
C4004
C4005
C4006
C4007
C4008
C4009
C4300
C4301
C4302
C4303
C4304
C4305
C4306
C4307
C4308
C4309
C4310
C4311
C4312
C4313
C4314
C4315
C4316
C4317
C4600
C4601
C4602
C4603
C4604
Description
SILTEX SPECTRUM,CONTOUR PROF
SALINE-FILLED SPECTRUM
ALPHA I INF PRO
AMS 800 URINARY PROS
CHOICE/PT GRAPHIX/LUGE/TROOP
HI-TORQUE WHISPER
CORDIS GUIDEWIRES
JINDO GUIDEWIRE
WHOLEY HI-TORQUE PLUS GW
WAVE/FLOWWIRE GUIDEWIRE
HYTEK GUIDEWIRE
SYNCHROMED EL INFUSION PUMP
ARROW/MICROJECT PCA SYS
ELASTIC UV IOLAA-4203T/TF/TL
OPUS G 4621, 4624 SC PMKR
OPUS S 4121/4124 SC PMKR
TALENT 113 SC PMKR
KAIROS SR SC PMKR
ACTROS SR, ACTROSSR-B SC PMK
PHILOS SR/SR-B SC PMKR
PULSAR MAX II SR PMKR
MARATHON SR PMKR
DISCOVERY II SSI PMKR
DISCOVERY II SR PMKR
INTEGRITY AFX DR 5342 PMKR
INTEGRITY AFX DR 5346 PMKR
AFFINITY VDR 5430 PMKR
BRIO 112 DC PMKR
BRIO212,TALENT213/223DCPMKR
BRIO 222 DC PMKR
BRIO 220 DC PMKR
KAIROS DR DC PMKR
INOS2, INOS2+ DC PMKR
ACTROS DR,D,DR-A,SLR DC PMKR
ACTROS DR-B DC PMKR
PHILOS DR/DR-B/SLR DC PMKR
PULSAR MAX II DR PMKR
MARATHON DR PMKR
MOMENTUM DR PMKR
SELECTION AFM PMKR
DISCOVERY II DR
DISCOVERY II DDD
SYNOX,POLYROX,ELOX,RETROX
AESCULA LV PMKR LEAD
TENDRIL SDX, 1488K PMKR LEAD
OSCOR PR/FLEXION PMKR LEAD
CRYSTALLINEACTFIX,CAPSUREFIX
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
C4605
C4606
C4607
C5000
C5001
C5002
C5003
C5004
C5005
C5006
C5007
C5008
C5009
C5010
C5011
C5012
C5013
C5014
C5015
C5016
C5017
C5018
C5019
C5020
C5021
C5022
C5023
C5024
C5025
C5026
C5027
C5028
C5029
C5030
C5031
C5032
C5033
C5034
C5035
C5036
C5037
C5038
C5039
C5040
C5041
C5042
C5043
Description
CAPSURE EPI PMKR LEAD
FLEXTEND PMKR LEAD
FINELINEII/EZ, THINLINEII/EZ
BX VELOCITY W/HEPACOAT
MEMOTHERM BIL STENT, SM, MED
MEMOTHERM BIL STENT, LARGE
MEMOTHERM BIL STENT, X-LARGE
PALMAZCORINTHIAN IQ BIL STNT
PALMAZCORINTHIAN IQ TRANS/BI
PALMAZTRANS BIL STENTSYS-MED
PALMAZTRANS XL BIL ST-40MM
PALMAZTRANS XL BIL ST-50MM
VISTAFLEX BILIARY STENT
RAPID EXCHANGE BIL STENT SYS
INTRASTENT, INTRASTENT LP
INTRASTENT DOUBLESTRUT LD
INTRASTENT DOUBLESTRUT, XS
AVE BRIDGE STENTSYS10/17/28
AVE/X3 BRIDGE SYS, 40-100
BILIARY STENT SINGLE USE COV
WALLSTENTRP-BIL-20/40/60/68
WALLSTENTRP BIL--80/94MM
FLEXIMA BIL STENT SYS
SMART NITINOL STENT--20MM
SMART NITINOL STENT--40/60MM
SMART NITINOL STENT--80MM
BX VELOCITY STENT--8/13MM
BX VELOCITY STENT
BX VELOCITY STENT--23MM
BX VELOCITY STENT--28/33MM
BX VELOCITY W/HEP--8/13MM
BX VELOCITY W/HEP--18MM
BX VELOCITY W/HEP--23MM
STENT, CORONARY, S660 9/12MM
STENT, CORONARY, S660 15/18
STENT,CORONARY, S660 24/30
NIROYAL STNT SYS, 9MM
NIROYAL STENT SYS, 12/15MM
NIROYAL STENT SYS, 18MM
BX VELOCITY STNT W/RAPTOR
INTRACOIL PERIP STENT--40MM
INTRACOIL PERIPH STENT--60MM
BESTENT OVER-THE-WIRE24/30MM
BESTENT OVER-THE-WIRE 18MM
BESTENT OVER-THE-WIRE 15MM
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
C5044
C5045
C5046
C5047
C5048
C5130
C5131
C5132
C5133
C5134
C5271
C5272
C5273
C5274
C5275
C5276
C5277
C5278
C5279
C5280
C5281
C5282
C5283
C5284
C5600
C5601
C6001
C6002
C6003
C6004
C6005
C6006
C6012
C6013
C6014
C6015
C6016
C6017
C6018
C6019
C6020
C6021
C6022
C6023
C6024
C6025
C6026
Description
BESTENT OVER-THE-WIRE 9/12MM
MULTILINK TETRA COR STENT SY
RADIUS 20MM COR STENT
NIROYAL ELITE COR STENT SYS
GR II CORONARY STENT
WILSON-COOK Z-STENT
BARD COLORECTAL STENT--60MM
BARD COLORECTAL STENT--80MM
BARD COLORECTAL STENT-100MM
ENTERAL WALLSTENT--90MM
LOW COST SKIN SUBSTITUTE APP
CONTOUR/PERCUFLEX STENT
INLAY DBL URETERAL STENT
WALLGRAFT TRACH SYS 70MM
WALLGRAFT TRACH SYS 20/30/50
WALLSTENT/RP TIPS--80MM
WALLSTENT TRACHULTRAFLEX
CLOSURE DEV, VASOSEAL ES
VASOSEAL 1000
COMPOSIX MESH 8/18 IN
COMPOSIX MESH 32 IN
COMPOSIX MESH 48 IN
COMPOSIX MESH 80 IN
COMPOSIX MESH 140 IN
COMPOSIX MESH 144 IN
PELVICOL COLLAGEN 8/14 SQ CM
PELVICOL COLLAGEN 21/24/28
PELVICOL COLLAGEN 40 SQ CM
GORE-TEX DUALMESH 75/96 SQCM
GORE-TEX DUALMESH 150SQCM
GORE-TEX DUALMESH 285 SQCM
GORE-TEX DUALMESH 432SQCM
GORE-TEXPLUS 1MM,75/96 SQCM
GORE-TEXPLUS 1MM, 150 SQ CM
GORE-TEXPLUS 1MM, 432 SQCM
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
C6027
C6028
C6029
C6030
C6031
C6032
C6033
C6034
C6035
C6036
C6037
C6038
C6039
C6040
C6041
C6050
C6051
C6052
C6053
C6054
C6055
C6056
C6057
C6058
C6080
C6200
C6201
C6202
C6203
C6204
C6205
C6206
C6207
C6208
C6209
C6210
C6300
C6500
C6501
C6525
C6600
C6650
C6651
C6652
C6700
C8099
C8100
Description
GORE-TEXPLUS 1MM, 600 SQCM
GORE-TEXPLUS 1MM,884 SQ CM
GORE-TEXPLUS 2MM,884 SQ CM
BARD EPTFE: 150 SQ CM-2MM
BARD EPTFE150SQCM-1MM,75-2MM
BARD EPTFE: 50/75SQCM-1,2MM
BARD EPFTE: 300SQ CM-1MM
BARD EPTFE: 600SQ CM-1MM
BARD EPTFE: 884 CM--1MM
FEMALE SLING SYS W/WO MATRL
STRATASIS SLING, 20/40CM
STRATASIS SLING, 60CM
SURGISIS SOFT GRAFT
SURGISIS ENCHANCED GRAFT
SURGISIS ENHANCED TISSUE
SURGISIS SOFT TISSUE GRAFT
SURGISIS HERNIA GRAFT
SURGIPRO HERNIA PLUG,MED/LG
MALE SLING SYS W/WO MATRL
EXXCEL SFT EPTFE VAS GRAFT
IMPRA VENAFLO-10/20CM
IMPRA VENAFLO-30/40CM
IMPRA VENAFLO-50CM/VT45
IMPRA VENAFLO-STEPPED
IMPRA CARBOFLO-10CM
IMPRA CARBOFLO-20CM
IMPRA CARBOFLO-30/34/40CM
IMPRA CARBOFLO-40/50CM
IMPRA CARBOFLO-CTRFLEX
EXXCEL EPTFE VAS GRAFT
VANGUARD III ENDOVAS GRAFT
PREFACE GUIDING SHEATH
SOFT TIP SHEATHS
SPECTRANETICS LASER SHEATH
MICRO LITHO FLEX PROBES
FAST-CATH GUIDING INTRODUCER
SEAL-AWAYGUIDING INTRODUCER
BARD EXCALIBUR INTRODUCER
FOCAL SEAL-L
SPECTRANETICS LEAD LOCK DEV
ADHESION BARRIER, ADCON-L
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
C8102
C8103
C8500
C8501
C8502
C8503
C8504
C8505
C8506
C8507
C8508
C8509
C8510
C8511
C8512
C8513
C8514
C8516
C8518
C8519
C8520
C8521
C8522
C8523
C8524
C8525
C8526
C8528
C8529
C8530
C8531
C8532
C8533
C8534
C8535
C8536
C8539
C8540
C8541
C8542
C8543
C8550
C8551
C8552
C8597
C8598
C8599
Description
SURGIVISION ESOPH COIL
CAPIO CAPTURING DEV
ATHEROCATH-GTO
VIGOR SSI, SC, PMKR
LIVEWIRE STEERABLE EP CATH
SYNCHROMED VAS CATH
VASOSEAL HEMOSTASIS DEV
SYNCHROMED INFUSION PUMP
PMKR LEADS 4057M,4058M
6721L/M/S,6939 LEAD
CAPSURE 4965 DEFIB LEAD
TRANSVENE 6933/6937 LEAD
DP-3238 DEFIB LEAD
ENDOTAK DSP DEFIB LEAD
ON-POINT,PISCES-QUAD LEAD
PISCES,RESUME II LEAD
DURA II PENILE PROSTHESIS
MENTOR ACU-FORM/MAL PROS
VIGOR DDD DC PMKR
VISTA DDD C PMKR
LEGACY II S, SC, PMKR
MEDTRONIC MATTRIX RCVR/TRMR
PALMAZ BAL STENT
WALLSTENT TRANS BIL
WALLSTENT ESOP
WALLSTENT ESOPH--DOUBLE
OPTIPLAST XT PTA CATH
MS CLASSIQUE BL DIL CATH
CRISTA CATH II DEF 20-POLE
GEL-FILLED/SMOOTH MAMMARY PR
WILSON-COOK ESOPH Z-STENT
ULTRAFLEX ESOPHAGEAL PROS
SYNCHROMED VAS CATH 8700A/V
AMS 650 PENILE PROSTHESIS
ZA/SPIRAL Z BIL STENT
ESOPH Z METAL STENT
QUANTUM DIL BALLOON
FLEX-EZ BAL DILATOR
CARSON/PASSPRT DIL CATH
URETHRAMAX DIL CATH
AMPLATZ RENAL DIL
LIVEWIRE 5F, 7F EP CATH
LIVEWIRE 7F DUO-DECAPOLAR
SANTURO FIXED CURVE CATH
WISDOM ST GUIDEWIRE
SV GUIDEWIRE-5/8/14CM
STABILIZER XS GUIDEWIRE
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
C8600
C8650
C8724
C8725
C8748
C8749
C8750
C8775
C8776
C8777
C8800
C8801
C8802
C8830
C8890
C8891
C8900
C8901
C8902
C8903
C8904
C8905
C8906
C8907
C8908
C8909
C8910
C8911
C8912
C8913
C8914
C8918
C8919
C8920
C8921
C8922
C8923
C8924
C8925
C8926
C8927
C8928
C8929
C8930
C8931
C8932
C8933
Description
SHINOBI PLUS GUIDEWIRE
XL CHECK-FLO INTRODUCER
OCTAD NEURO LEAD
SYMMIX NEURO LEAD
ENDOTAK SQ PATCH DEFIB LEAD
ENDOTAK SQ ARRAY DEFIB LEAD
UNITY VDDR DC PMKR
2188 COR PMKR LEAD
INNOMEDICA PMKR LEAD
UNIPASS PMKR LEAD
LG PALMAZ BIL STENT
GIANTURCO BIL Z STENT
OASIS STENT INTRO SYS
GIANTURCO-ROUBIN COR SNT
PERFLUORON, 2ML
PERFLUORON, 5/7ML
MRA W/CONT, ABD
MRA W/O CONT, ABD
MRA W/O FOL W/CONT, ABD
MRI W/CONT, BREAST, UNI
MRI W/O CONT, BREAST, UNI
MRI W/O FOL W/CONT, BRST, UN
MRI W/CONT, BREAST, BI
MRI W/O CONT, BREAST, BI
MRI W/O FOL W/CONT, BREAST,
MRA W/CONT, CHEST
MRA W/O CONT, CHEST
MRA W/O FOL W/CONT, CHEST
MRA W/CONT, LWR EXT
MRA W/O CONT, LWR EXT
MRA W/O FOL W/CONT, LWR EXT
MRA W/CONT, PELVIS
MRA W/O CONT, PELVIS
MRA W/O FOL W/CONT, PELVIS
TTE W OR W/O FOL W/CONT, COM
TTE W OR W/O FOL W/CONT, F/U
2D TTE W OR W/O FOL W/CON,CO
2D TTE W OR W/O FOL W/CON,FU
2D TEE W OR W/O FOL W/CON,IN
TEE W OR W/O FOL W/CONT,CONG
TEE W OR W/O FOL W/CONT, MON
TTE W OR W/O FOL W/CON,STRES
TTE W OR WO FOL WCON,DOPPLER
TTE W OR W/O CONTR, CONT ECG
MRA, W/DYE, SPINAL CANAL
MRA, W/O DYE, SPINAL CANAL
MRA, W/O&W/DYE, SPINAL CANAL
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
C8934
C8935
C8936
C8956
C8957
C9001
C9002
C9004
C9005
C9006
C9011
C9019
C9020
C9100
C9104
C9106
C9107
C9108
C9110
C9113
C9114
C9115
C9121
C9132
C9248
C9250
C9254
C9257
C9275
C9285
C9290
C9293
C9349
C9352
C9353
C9354
C9355
C9356
C9358
C9359
C9360
C9361
C9362
C9363
C9364
C9399
C9408
Description
Pricing Action Code
MRA, W/DYE, UPPER EXTREMITY
MRA, W/O DYE, UPPER EXTR
MRA, W/O&W/DYE, UPPER EXTR
REFILLING AND MAINTENANCE OF PORTA
PROLONGED IV INF, REQ PUMP
LINEZOLID INJ, 200MG
TENECTEPLASE, 50MG/VIAL
GEMTUZUMAB OZOGAMICIN INJ,5M
RETEPLASE INJ, HALF-KIT,18.8
TACROLIMUS INJ, PER 5 MG
CAFFEINE CITRATE, INJ, 1ML
CASPOFUNGIN ACETATE, 5 MG
SIROLIMUS TABLET, 1 MG
IODINATED I-131 ALBUMIN
ANTI-THYMOCYTE GLOBULIN,25MG
SIROLIMUS 1MG/ML
TINZAPARIN SODIUM, 2ML VIAL
THYROTROPIN ALFA, 1.1 MG
ALEMTUZUMAB, PER 10MG/ML
INJ PANTOPRAZOLE SODIUM, VIA
NESIRITIDE, PER 1.5 MG VIAL
INJ, ZOLEDRONIC ACID, 2 MG
INJECTION, ARGATROBAN
KCENTRA, PER I.U.
INJ, CLEVIDIPINE BUTYRATE
ARTISS FIBRIN SEALANT
INJECTION, LACOSAMIDE
BEVACIZUMAB INJECTION
HEXAMINOLEVULINATE HCL
PATCH, LIDOCAINE/TETRACAINE
INJ, BUPIVACAINE LIPOSOME
INJECTION, GLUCARPIDASE
PURAPLY, PURAPLY ANTIMIC
NEURAGEN NERVE GUIDE, PER CM
NEURAWRAP NERVE PROTECTOR,CM
VERITAS COLLAGEN MATRIX, CM2
NEUROMATRIX NERVE CUFF, CM
TENOGLIDE TENDON PROT, CM2
SURGIMEND, FETAL
IMPLNT,BON VOID FILLER-PUTTY
SURGIMEND, NEONATAL
NEUROMEND NERVE WRAP
IMPLNT,BON VOID FILLER-STRIP
INTEGRA MESHED BIL WOUND MAT
PORCINE IMPLANT, PERMACOL
UNCLASSIFIED DRUGS OR BIOLOG
FDG, BRAND, PER DOSE
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
C9416
C9434
C9447
C9458
C9459
C9460
C9497
C9500
C9501
C9502
C9504
C9505
C9600
C9601
C9602
C9603
C9604
C9605
C9606
C9607
C9608
C9700
C9702
C9708
C9725
C9726
C9727
C9728
C9733
C9734
C9739
C9740
C9741
C9742
C9743
C9800
C9898
C9899
E0100
E0105
E0110
E0111
E0112
E0113
E0114
E0116
E0117
Description
BCG LIVE INTRAVESICAL, BRAND
GALLIUM GA 67, BRAND
INJ, PHENYLEPHRINE KETOROLAC
FLORBETABEN F18
FLUTEMETAMOL F18
INJECTION, CANGRELOR
LOXAPINE, INHALATION POWDER
PLATELETS, IRRAD, EA UNIT
PLATELETS, PHERESIS, EA UNIT
PLATELETS, PHER/IRRAD, EA UN
RBC, DEGLYCEROLIZED, EA UNIT
RBC, IRRADIATED, EACH UNIT
PERC DRUG-EL COR STENT SING
PERC DRUG-EL COR STENT BRAN
PERC D-E COR STENT ATHER S
PERC D-E COR STENT ATHER BR
PERC D-E COR REVASC T CABG S
PERC D-E COR REVASC T CABG B
PERC D-E COR REVASC W AMI S
PERC D-E COR REVASC CHRO SIN
PERC D-E COR REVASC CHRO ADD
WATER INDUCED THERMO
CHKMATE/NOVOST/GALILEO BRACH
PREVIEW TX PLANNING SOFTWARE
PLACE ENDORECTAL APP
RXT BREAST APPL PLACE/REMOV
INSERT PALATE IMPLANTS
PLACE DEVICE/MARKER, NON PRO
NON-OPHTHALMIC FVA
U/S TRTMT, NOT LEIOMYOMATA
CYSTOSCOPY PROSTATIC IMP 1-3
CYSTO IMPL 4 OR MORE
IMPL PRESSURE SENSOR W/ANGIO
LARYNGOSCOPY WITH INJECTION
BULKING/SPACER MATERIAL IMPL
DERMAL FILLER INJ PX/SUPPL
INPNT STAY RADIOLABELED ITEM
INPT IMPLANT PROS DEV,NO COV
CANE ADJUST/FIXED WITH TIP
CANE ADJUST/FIXED QUAD/3 PRO
CRUTCH FOREARM PAIR
CRUTCH FOREARM EACH
CRUTCH UNDERARM PAIR WOOD
CRUTCH UNDERARM EACH WOOD
CRUTCH UNDERARM PAIR NO WOOD
CRUTCH UNDERARM EACH NO WOOD
UNDERARM SPRINGASSIST CRUTCH
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
3
3
3
3
3
3
3
3
5
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$22.10
$46.99
$69.54
$50.95
$35.40
$20.21
$49.50
$22.76
$0.00
Procedure Code
E0118
E0130
E0135
E0140
E0141
E0143
E0144
E0147
E0148
E0149
E0150
E0151
E0152
E0153
E0154
E0155
E0156
E0157
E0158
E0159
E0160
E0161
E0162
E0163
E0165
E0167
E0168
E0170
E0171
E0172
E0175
E0181
E0182
E0183
E0184
E0185
E0186
E0187
E0188
E0189
E0190
E0191
E0193
E0194
E0195
E0196
E0197
Description
Pricing Action Code
CRUTCH SUBSTITUTE
WALKER RIGID ADJUST/FIXED HT
WALKER FOLDING ADJUST/FIXED
WALKER W TRUNK SUPPORT
RIGID WHEELED WALKER ADJ/FIX
WALKER FOLDING WHEELED W/O S
ENCLOSED WALKER W REAR SEAT
WALKER VARIABLE WHEEL RESIST
HEAVYDUTY WALKER NO WHEELS
HEAVY DUTY WHEELED WALKER
UNDERARM PAD, CRUTCH, REPLACEMEN
HANDGRIP, CANE, CRUTCH, OR WALKER
TIP, CANE OR CRUTCH WALKER REPLACE
FOREARM CRUTCH PLATFORM ATTA
WALKER PLATFORM ATTACHMENT
WALKER WHEEL ATTACHMENT,PAIR
WALKER SEAT ATTACHMENT
WALKER CRUTCH ATTACHMENT
WALKER LEG EXTENDERS SET OF4
BRAKE FOR WHEELED WALKER
SITZ TYPE BATH OR EQUIPMENT
SITZ BATH/EQUIPMENT W/FAUCET
SITZ BATH CHAIR
COMMODE CHAIR WITH FIXED ARM
COMMODE CHAIR WITH DETACHARM
COMMODE CHAIR PAIL OR PAN
HEAVYDUTY/WIDE COMMODE CHAIR
COMMODE CHAIR ELECTRIC
COMMODE CHAIR NON-ELECTRIC
SEAT LIFT MECHANISM TOILET
COMMODE CHAIR FOOT REST
PRESS PAD ALTERNATING W/ PUM
REPLACE PUMP, ALT PRESS PAD
FLOTATION PAD FOR WHEELCHAIR
DRY PRESSURE MATTRESS
GEL PRESSURE MATTRESS PAD
AIR PRESSURE MATTRESS
WATER PRESSURE MATTRESS
SYNTHETIC SHEEPSKIN PAD
LAMBSWOOL SHEEPSKIN PAD
POSITIONING CUSHION
PROTECTOR HEEL OR ELBOW
POWERED AIR FLOTATION BED
AIR FLUIDIZED BED
REPLACEMENT PAD FOR USE WITH MED
GEL PRESSURE MATTRESS
AIR PRESSURE PAD FOR MATTRES
6
3
3
6
3
3
3
3
3
3
9
9
9
3
3
3
3
3
3
9
3
3
3
3
3
3
3
6
6
6
3
3
3
9
3
3
3
3
3
3
6
3
3
3
9
3
3
Maximum Allowable
$0.00
$57.13
$77.57
$0.00
$110.30
$84.03
$304.66
$549.91
$121.55
$213.53
$0.00
$0.00
$0.00
$66.38
$62.73
$30.20
$19.89
$66.61
$30.78
$0.00
$31.62
$25.09
$139.39
$91.79
$158.00
$10.11
$152.06
$0.00
$0.00
$0.00
$53.86
$244.80
$235.90
$0.00
$186.27
$280.98
$182.80
$209.20
$23.85
$36.30
$0.00
$9.56
$6,956.30
$0.00
$0.00
$287.60
$211.98
Procedure Code
E0198
E0199
E0200
E0202
E0203
E0205
E0210
E0215
E0217
E0218
E0221
E0225
E0231
E0232
E0235
E0236
E0239
E0240
E0241
E0242
E0243
E0244
E0245
E0246
E0247
E0248
E0249
E0250
E0251
E0252
E0255
E0256
E0260
E0261
E0265
E0266
E0270
E0271
E0272
E0273
E0274
E0275
E0276
E0277
E0280
E0290
E0291
Description
WATER PRESSURE PAD FOR MATTR
DRY PRESSURE PAD FOR MATTRES
HEAT LAMP WITHOUT STAND
PHOTOTHERAPY LIGHT W/ PHOTOM
THERAPEUTIC LIGHTBOX TABLETP
HEAT LAMP WITH STAND
ELECTRIC HEAT PAD STANDARD
ELECTRIC HEAT PAD MOIST
WATER CIRC HEAT PAD W PUMP
WATER CIRC COLD PAD W PUMP
INFRARED HEATING PAD SYSTEM
HYDROCOLLATOR UNIT
WOUND WARMING DEVICE
WARMING CARD FOR NWT
PARAFFIN BATH UNIT PORTABLE
PUMP FOR WATER CIRCULATING P
HYDROCOLLATOR UNIT PORTABLE
BATH/SHOWER CHAIR
BATH TUB WALL RAIL
BATH TUB RAIL FLOOR
TOILET RAIL
TOILET SEAT RAISED
TUB STOOL OR BENCH
TRANSFER TUB RAIL ATTACHMENT
TRANS BENCH W/WO COMM OPEN
HDTRANS BENCH W/WO COMM OPEN
PAD WATER CIRCULATING HEAT U
HOSP BED FIXED HT W/ MATTRES
HOSP BED FIXD HT W/O MATTRES
HOSPITAL BED, FIXED HEIGHT, WITH MA
HOSPITAL BED VAR HT W/ MATTR
HOSPITAL BED VAR HT W/O MATT
HOSP BED SEMI-ELECTR W/ MATT
HOSP BED SEMI-ELECTR W/O MAT
HOSP BED TOTAL ELECTR W/ MAT
HOSP BED TOTAL ELEC W/O MATT
HOSPITAL BED INSTITUTIONAL T
MATTRESS INNERSPRING
MATTRESS FOAM RUBBER
BED BOARD
OVER-BED TABLE
BED PAN STANDARD
BED PAN FRACTURE
POWERED PRES-REDU AIR MATTRS
BED CRADLE
HOSP BED FX HT W/O RAILS W/M
HOSP BED FX HT W/O RAIL W/O
Pricing Action Code
3
3
3
3
5
3
3
3
3
9
5
3
5
5
3
3
3
6
5
5
5
5
5
5
6
6
3
3
3
9
3
3
3
3
3
3
9
3
3
5
5
3
3
3
3
3
3
Maximum Allowable
$211.98
$30.66
$75.85
$564.10
$0.00
$157.81
$31.22
$67.77
$403.72
$0.00
$0.00
$316.04
$0.00
$0.00
$155.40
$358.90
$430.35
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$95.29
$880.70
$667.40
$0.00
$1,058.30
$0.00
$1,013.10
$1,238.10
$1,632.70
$1,359.80
$0.00
$167.27
$186.47
$0.00
$0.00
$14.64
$12.73
$0.00
$35.40
$673.30
$489.00
Procedure Code
E0292
E0293
E0294
E0295
E0296
E0297
E0300
E0301
E0302
E0303
E0304
E0305
E0310
E0315
E0316
E0325
E0326
E0328
E0329
E0350
E0352
E0370
E0371
E0372
E0373
E0424
E0425
E0430
E0431
E0433
E0434
E0435
E0439
E0440
E0441
E0442
E0443
E0444
E0445
E0446
E0453
E0457
E0458
E0459
E0462
E0465
E0466
Description
HOSP BED VAR HT W/O RAIL W/O
HOSP BED VAR HT W/O RAIL W/
HOSP BED SEMI-ELECT W/ MATTR
HOSP BED SEMI-ELECT W/O MATT
HOSP BED TOTAL ELECT W/ MATT
HOSP BED TOTAL ELECT W/O MAT
ENCLOSED PED CRIB HOSP GRADE
HD HOSP BED, 350-600 LBS
EX HD HOSP BED > 600 LBS
HOSP BED HVY DTY XTRA WIDE
HOSP BED XTRA HVY DTY X WIDE
RAILS BED SIDE HALF LENGTH
RAILS BED SIDE FULL LENGTH
BED ACCESSORY BRD/TBL/SUPPRT
BED SAFETY ENCLOSURE
URINAL MALE JUG-TYPE
URINAL FEMALE JUG-TYPE
PED HOSPITAL BED, MANUAL
PED HOSPITAL BED SEMI/ELECT
CONTROL UNIT BOWEL SYSTEM
DISPOSABLE PACK W/BOWEL SYST
AIR ELEVATOR FOR HEEL
NONPOWER MATTRESS OVERLAY
POWERED AIR MATTRESS OVERLAY
NONPOWERED PRESSURE MATTRESS
STATIONARY COMPRESSED GAS 02
GAS SYSTEM STATIONARY COMPRE
OXYGEN SYSTEM GAS PORTABLE
PORTABLE GASEOUS 02
PORTABLE LIQUID OXYGEN SYS
PORTABLE LIQUID 02
OXYGEN SYSTEM LIQUID PORTABL
STATIONARY LIQUID 02
OXYGEN SYSTEM LIQUID STATION
STATIONARY O2 CONTENTS, GAS
STATIONARY O2 CONTENTS, LIQ
PORTABLE 02 CONTENTS, GAS
PORTABLE 02 CONTENTS, LIQUID
OXIMETER NON-INVASIVE
TOPICAL OX DELIVER SYS, NOS
VENTILATOR 12 HRS/LESS PER D
CHEST SHELL
NEGATIVE PRESSURE PUMP
CHEST WRAP
ROCKING BED W/ OR W/O SIDE R
HOME VENT INVASIVE INTERFACE
HOME VENT NON-INVASIVE INTER
Pricing Action Code
3
3
3
3
3
3
6
6
6
6
6
3
3
9
5
3
3
6
6
9
9
9
5
3
5
3
5
5
3
6
3
5
3
5
3
3
3
3
5
6
9
3
9
3
3
6
6
Maximum Allowable
$701.60
$644.30
$1,177.20
$1,147.10
$1,479.10
$1,077.10
$0.00
$0.00
$0.00
$0.00
$0.00
$160.00
$185.74
$0.00
$0.00
$9.67
$9.48
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$1.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$77.45
$77.45
$77.45
$77.45
$0.00
$0.00
$0.00
$0.00
$0.00
$458.40
$2,625.00
$0.00
$0.00
Procedure Code
E0470
E0471
E0472
E0480
E0481
E0482
E0483
E0484
E0485
E0486
E0487
E0500
E0505
E0510
E0515
E0550
E0555
E0560
E0561
E0562
E0565
E0570
E0572
E0574
E0575
E0580
E0585
E0600
E0601
E0602
E0603
E0604
E0605
E0606
E0607
E0610
E0615
E0616
E0617
E0618
E0619
E0620
E0621
E0625
E0627
E0628
E0629
Description
Pricing Action Code
RAD W/O BACKUP NON-INV INTFC
RAD W/BACKUP NON INV INTRFC
RAD W BACKUP INVASIVE INTRFC
PERCUSSOR ELECT/PNEUM HOME M
INTRPULMNRY PERCUSS VENT SYS
COUGH STIMULATING DEVICE
CHEST COMPRESSION GEN SYSTEM
NON-ELEC OSCILLATORY PEP DVC
ORAL DEVICE/APPLIANCE PREFAB
ORAL DEVICE/APPLIANCE CUSFAB
ELECTRONIC SPIROMETER
IPPB ALL TYPES
IPPB MACHINES WITH MANUAL VALVES
IPPB MACHINES WITH AUTOMATIC VALV
IPPB MACHINES WITH AUTOMATIC VALV
HUMIDIF EXTENS SUPPLE W IPPB
HUMIDIFIER FOR USE W/ REGULA
HUMIDIFIER SUPPLEMENTAL W/ I
HUMIDIFIER NONHEATED W PAP
HUMIDIFIER HEATED USED W PAP
COMPRESSOR AIR POWER SOURCE
NEBULIZER WITH COMPRESSION
AEROSOL COMPRESSOR ADJUST PR
ULTRASONIC GENERATOR W SVNEB
NEBULIZER ULTRASONIC
NEBULIZER FOR USE W/ REGULAT
NEBULIZER W/ COMPRESSOR & HE
SUCTION PUMP PORTAB HOM MODL
CONT AIRWAY PRESSURE DEVICE
MANUAL BREAST PUMP
ELECTRIC BREAST PUMP
HOSP GRADE ELEC BREAST PUMP
VAPORIZER ROOM TYPE
DRAINAGE BOARD POSTURAL
BLOOD GLUCOSE MONITOR HOME
PACEMAKER MONITR AUDIBLE/VIS
PACEMAKER MONITR DIGITAL/VIS
CARDIAC EVENT RECORDER
AUTOMATIC EXT DEFIBRILLATOR
APNEA MONITOR
APNEA MONITOR W RECORDER
CAP BLD SKIN PIERCING LASER
PATIENT LIFT SLING OR SEAT
PATIENT LIFT BATHROOM OR TOI
SEAT LIFT INCORP LIFT-CHAIR
SEAT LIFT FOR PT FURN-ELECTR
SEAT LIFT FOR PT FURN-NON-EL
3
3
6
3
5
5
5
3
6
6
6
3
9
9
9
3
9
3
3
3
3
3
5
5
3
9
3
3
3
9
3
5
3
3
9
3
3
9
5
3
5
9
3
5
3
3
3
Maximum Allowable
$0.00
$0.00
$0.00
$395.80
$0.00
$0.00
$0.00
$36.92
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$451.60
$0.00
$164.09
$107.00
$216.27
$547.50
$144.90
$0.00
$0.00
$530.00
$0.00
$315.90
$0.00
$0.00
$0.00
$135.00
$0.00
$25.29
$175.60
$0.00
$227.56
$403.28
$0.00
$0.00
$3,000.00
$0.00
$0.00
$94.41
$0.00
$316.39
$316.39
$316.39
Procedure Code
E0630
E0635
E0636
E0637
E0638
E0639
E0640
E0641
E0642
E0650
E0651
E0652
E0655
E0656
E0657
E0660
E0665
E0666
E0667
E0668
E0669
E0670
E0671
E0672
E0673
E0675
E0676
E0691
E0692
E0693
E0694
E0700
E0705
E0710
E0720
E0730
E0731
E0740
E0744
E0745
E0747
E0748
E0751
E0753
E0755
E0760
E0761
Description
PATIENT LIFT HYDRAULIC
PATIENT LIFT ELECTRIC
PT SUPPORT & POSITIONING SYS
COMBINATION SIT TO STAND SYS
STANDING FRAME SYS
MOVEABLE PATIENT LIFT SYSTEM
FIXED PATIENT LIFT SYSTEM
MULTI-POSITION STND FRAM SYS
DYNAMIC STANDING FRAME
PNEUMA COMPRESOR NON-SEGMENT
PNEUM COMPRESSOR SEGMENTAL
PNEUM COMPRES W/CAL PRESSURE
PNEUMATIC APPLIANCE HALF ARM
SEGMENTAL PNEUMATIC TRUNK
SEGMENTAL PNEUMATIC CHEST
PNEUMATIC APPLIANCE FULL LEG
PNEUMATIC APPLIANCE FULL ARM
PNEUMATIC APPLIANCE HALF LEG
SEG PNEUMATIC APPL FULL LEG
SEG PNEUMATIC APPL FULL ARM
SEG PNEUMATIC APPLI HALF LEG
SEG PNEUM INT LEGS/TRUNK
PRESSURE PNEUM APPL FULL LEG
PRESSURE PNEUM APPL FULL ARM
PRESSURE PNEUM APPL HALF LEG
PNEUMATIC COMPRESSION DEVICE
INTER LIMB COMPRESS DEV NOS
UVL PNL 2 SQ FT OR LESS
UVL SYS PANEL 4 FT
UVL SYS PANEL 6 FT
UVL MD CABINET SYS 6 FT
SAFETY EQUIPMENT
TRANSFER DEVICE
RESTRAINTS ANY TYPE
TENS TWO LEAD
TENS FOUR LEAD
CONDUCTIVE GARMENT FOR TENS/
INCONTINENCE TREATMENT SYSTM
NEUROMUSCULAR STIM FOR SCOLI
NEUROMUSCULAR STIM FOR SHOCK
ELEC OSTEOGEN STIM NOT SPINE
ELEC OSTEOGEN STIM SPINAL
PULSE GENERATOR OR RECEIVER
NEUROSTIMULATOR ELECTRODES
ELECTRONIC SALIVARY REFLEX S
OSTEOGEN ULTRASOUND STIMLTOR
NONTHERM ELECTROMGNTC DEVICE
Pricing Action Code
3
3
5
6
6
6
6
6
6
3
3
3
3
6
6
3
3
3
3
3
3
6
9
9
9
6
6
5
5
5
5
5
6
5
3
3
3
9
3
3
3
3
9
9
5
9
5
Maximum Allowable
$911.20
$1,091.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$689.02
$963.38
$5,012.71
$87.76
$0.00
$0.00
$139.07
$111.40
$112.29
$309.75
$393.98
$166.53
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$314.34
$388.70
$374.15
$0.00
$824.90
$806.30
$4,173.02
$4,301.21
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
E0762
E0764
E0765
E0766
E0769
E0770
E0776
E0779
E0780
E0781
E0783
E0784
E0785
E0786
E0791
E0830
E0840
E0849
E0850
E0855
E0856
E0860
E0870
E0880
E0890
E0900
E0910
E0911
E0912
E0920
E0930
E0935
E0936
E0940
E0941
E0942
E0944
E0945
E0946
E0947
E0948
E0950
E0951
E0952
E0955
E0956
E0957
Description
TRANS ELEC JT STIM DEV SYS
FUNCTIONAL NEUROMUSCULARSTIM
NERVE STIMULATOR FOR TX N&V
ELEC STIM CANCER TREATMENT
ELECTRIC WOUND TREATMENT DEV
FUNCTIONAL ELECTRIC STIM NOS
IV POLE
AMB INFUSION PUMP MECHANICAL
MECH AMB INFUSION PUMP <8HRS
EXTERNAL AMBULATORY INFUS PU
PROGRAMMABLE INFUSION PUMP
EXT AMB INFUSN PUMP INSULIN
REPLACEMENT IMPL PUMP CATHET
IMPLANTABLE PUMP REPLACEMENT
PARENTERAL INFUSION PUMP STA
AMBULATORY TRACTION DEVICE
TRACT FRAME ATTACH HEADBOARD
CERVICAL PNEUM TRAC EQUIP
TRACTION STAND FREE STANDING
CERVICAL TRACTION EQUIPMENT
CERVIC COLLAR W AIR BLADDERS
TRACT EQUIP CERVICAL TRACT
TRACT FRAME ATTACH FOOTBOARD
TRAC STAND FREE STAND EXTREM
TRACTION FRAME ATTACH PELVIC
TRAC STAND FREE STAND PELVIC
TRAPEZE BAR ATTACHED TO BED
HD TRAPEZE BAR ATTACH TO BED
HD TRAPEZE BAR FREE STANDING
FRACTURE FRAME ATTACHED TO B
FRACTURE FRAME FREE STANDING
CONT PAS MOTION EXERCISE DEV
CPM DEVICE, OTHER THAN KNEE
TRAPEZE BAR FREE STANDING
GRAVITY ASSISTED TRACTION DE
CERVICAL HEAD HARNESS/HALTER
PELVIC BELT/HARNESS/BOOT
BELT/HARNESS EXTREMITY
FRACTURE FRAME DUAL W CROSS
FRACTURE FRAME ATTACHMNTS PE
FRACTURE FRAME ATTACHMNTS CE
TRAY
LOOP HEEL
TOE LOOP/HOLDER, EACH
CUSHIONED HEADREST
W/C LATERAL TRUNK/HIP SUPPOR
W/C MEDIAL THIGH SUPPORT
Pricing Action Code
6
6
5
6
6
6
3
3
3
3
9
5
9
9
3
5
3
6
3
3
6
3
3
3
3
3
3
6
6
3
3
5
6
3
3
3
3
3
3
3
3
3
3
3
6
6
6
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$148.01
$15.67
$9.92
$2,361.60
$0.00
$0.00
$0.00
$0.00
$2,421.20
$0.00
$59.59
$0.00
$85.43
$480.86
$0.00
$36.86
$100.51
$102.09
$97.91
$104.19
$180.80
$0.00
$0.00
$415.70
$372.00
$0.00
$0.00
$313.20
$363.00
$18.99
$43.89
$42.41
$532.90
$580.20
$561.19
$84.96
$14.95
$16.64
$0.00
$0.00
$0.00
Procedure Code
E0959
E0960
E0961
E0966
E0967
E0968
E0969
E0970
E0971
E0973
E0974
E0978
E0980
E0981
E0982
E0983
E0984
E0985
E0986
E0988
E0990
E0992
E0994
E0995
E1002
E1003
E1004
E1005
E1006
E1007
E1008
E1009
E1010
E1011
E1012
E1014
E1015
E1016
E1017
E1018
E1020
E1028
E1029
E1030
E1031
E1035
E1036
Description
AMPUTEE ADAPTER
W/C SHOULDER HARNESS/STRAPS
WHEELCHAIR BRAKE EXTENSION
WHEELCHAIR HEAD REST EXTENSI
MANUAL WC HAND RIM W PROJECT
WHEELCHAIR COMMODE SEAT
WHEELCHAIR NARROWING DEVICE
WHEELCHAIR NO. 2 FOOTPLATES
WHEELCHAIR ANTI-TIPPING DEVI
W/CH ACCESS DET ADJ ARMREST
W/CH ACCESS ANTI-ROLLBACK
W/C ACC,SAF BELT PELV STRAP
WHEELCHAIR SAFETY VEST
SEAT UPHOLSTERY, REPLACEMENT
BACK UPHOLSTERY, REPLACEMENT
ADD PWR JOYSTICK
ADD PWR TILLER
W/C SEAT LIFT MECHANISM
MAN W/C PUSH-RIM POWR SYSTEM
LEVER-ACTIVATED WHEEL DRIVE
WHEELCHAIR ELEVATING LEG RES
WHEELCHAIR SOLID SEAT INSERT
WHEELCHAIR ARM REST
WHEELCHAIR CALF REST
PWR SEAT TILT
PWR SEAT RECLINE
PWR SEAT RECLINE MECH
PWR SEAT RECLINE PWR
PWR SEAT COMBO W/O SHEAR
PWR SEAT COMBO W/SHEAR
PWR SEAT COMBO PWR SHEAR
ADD MECH LEG ELEVATION
ADD PWR LEG ELEVATION
PED WC MODIFY WIDTH ADJUSTM
CTR MOUNT PWR ELEV LEG REST
RECLINING BACK ADD PED W/C
SHOCK ABSORBER FOR MAN W/C
SHOCK ABSORBER FOR POWER W/C
HD SHCK ABSRBR FOR HD MAN WC
HD SHCK ABSRBER FOR HD POWWC
RESIDUAL LIMB SUPPORT SYSTEM
W/C MANUAL SWINGAWAY
W/C VENT TRAY FIXED
W/C VENT TRAY GIMBALED
ROLLABOUT CHAIR WITH CASTERS
PATIENT TRANSFER SYSTEM <300
PATIENT TRANSFER SYSTEM >300
Pricing Action Code
3
6
3
3
3
3
3
3
3
3
3
3
3
6
6
6
6
6
6
6
3
3
3
3
6
6
6
6
6
3
3
6
6
5
6
5
5
5
5
5
5
3
6
6
3
5
6
Maximum Allowable
$84.59
$0.00
$24.81
$69.10
$68.87
$161.60
$139.86
$46.08
$38.22
$80.62
$75.59
$32.33
$31.62
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$89.03
$85.33
$15.18
$24.94
$0.00
$0.00
$0.00
$0.00
$0.00
$7,855.70
$7,903.65
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$162.36
$0.00
$0.00
$529.90
$0.00
$0.00
Procedure Code
E1037
E1038
E1039
E1050
E1060
E1070
E1083
E1084
E1085
E1086
E1087
E1088
E1089
E1090
E1092
E1093
E1100
E1110
E1130
E1140
E1150
E1160
E1161
E1170
E1171
E1172
E1180
E1190
E1195
E1200
E1220
E1221
E1222
E1223
E1224
E1225
E1226
E1227
E1228
E1229
E1230
E1231
E1232
E1233
E1234
E1235
E1236
Description
TRANSPORT CHAIR, PED SIZE
TRANSPORT CHAIR PT WT<=300LB
TRANSPORT CHAIR PT WT >300LB
WHELCHR FXD FULL LENGTH ARMS
WHEELCHAIR DETACHABLE ARMS
WHEELCHAIR DETACHABLE FOOT R
HEMI-WHEELCHAIR FIXED ARMS
HEMI-WHEELCHAIR DETACHABLE A
HEMI-WHEELCHAIR FIXED ARMS
HEMI-WHEELCHAIR DETACHABLE A
WHEELCHAIR LIGHTWT FIXED ARM
WHEELCHAIR LIGHTWEIGHT DET A
WHEELCHAIR LIGHTWEIGHT DET A
WHEELCHAIR WIDE W/ LEG RESTS
WHEELCHAIR WIDE W/ FOOT REST
WHCHR S-RECL FXD ARM LEG RES
WHEELCHAIR SEMI-RECL DETACH
WHLCHR STAND FXD ARM FT REST
WHEELCHAIR STANDARD DETACH A
WHEELCHAIR STANDARD W/ LEG R
WHEELCHAIR FIXED ARMS
MANUAL ADULT WC W TILTINSPAC
WHLCHR AMPU FXD ARM LEG REST
WHEELCHAIR AMPUTEE W/O LEG R
WHEELCHAIR AMPUTEE DETACH AR
WHEELCHAIR AMPUTEE W/ FOOT R
WHEELCHAIR AMPUTEE W/ LEG RE
WHEELCHAIR AMPUTEE HEAVY DUT
WHEELCHAIR AMPUTEE FIXED ARM
WHLCHR SPECIAL SIZE/CONSTRC
WHEELCHAIR SPEC SIZE W FOOT
WHEELCHAIR SPEC SIZE W/ LEG
WHEELCHAIR SPEC SIZE W FOOT
WHEELCHAIR SPEC SIZE W/ LEG
MANUAL SEMI-RECLINING BACK
MANUAL FULLY RECLINING BACK
WHEELCHAIR SPEC SZ SPEC HT A
WHEELCHAIR SPEC SZ SPEC HT B
PEDIATRIC WHEELCHAIR NOS
POWER OPERATED VEHICLE
RIGID PED W/C TILT-IN-SPACE
FOLDING PED WC TILT-IN-SPACE
RIG PED WC TLTNSPC W/O SEAT
FLD PED WC TLTNSPC W/O SEAT
RIGID PED WC ADJUSTABLE
FOLDING PED WC ADJUSTABLE
Pricing Action Code
5
5
6
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
5
3
3
3
3
3
3
3
5
3
3
3
3
3
3
3
3
6
3
5
5
5
5
5
5
Maximum Allowable
$0.00
$0.00
$0.00
$917.40
$1,135.60
$838.60
$709.40
$883.70
$623.40
$757.10
$1,139.60
$1,358.29
$1,082.80
$1,042.60
$1,157.70
$995.60
$935.10
$778.30
$420.70
$647.00
$901.80
$563.00
$0.00
$804.60
$643.40
$827.40
$776.00
$1,054.70
$961.90
$689.20
$0.00
$428.10
$610.70
$666.80
$731.10
$426.30
$478.08
$265.23
$214.50
$0.00
$1,946.92
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
E1237
E1238
E1239
E1240
E1250
E1260
E1270
E1280
E1285
E1290
E1295
E1296
E1297
E1298
E1300
E1310
E1352
E1353
E1354
E1355
E1357
E1358
E1372
E1390
E1391
E1392
E1399
E1400
E1404
E1405
E1406
E1500
E1510
E1520
E1530
E1540
E1550
E1560
E1570
E1575
E1580
E1590
E1592
E1594
E1600
E1610
E1615
Description
RGD PED WC ADJSTABL W/O SEAT
FLD PED WC ADJSTABL W/O SEAT
PED POWER WHEELCHAIR NOS
WHCHR LITWT DET ARM LEG REST
WHEELCHAIR LIGHTWT FOOT REST
WHEELCHAIR LIGHTWEIGHT LEG R
WHCHR H-DUTY DET ARM LEG RES
WHEELCHAIR HEAVY DUTY FIXED
WHEELCHAIR HVY DUTY DETACH A
WHEELCHAIR HEAVY DUTY FIXED
WHEELCHAIR SPECIAL SEAT HEIG
WHEELCHAIR SPECIAL SEAT DEPT
WHEELCHAIR SPEC SEAT DEPTH/W
WHIRLPOOL PORTABLE
WHIRLPOOL NON-PORTABLE
O2 FLOW REG POS INSPIR PRESS
OXYGEN SUPPLIES REGULATOR
WHEELED CART, PORT CYL/CONC
OXYGEN SUPPLIES STAND/RACK
BATTERY CHARGER, PORT CONC
DC POWER ADAPTER, PORT CONC
OXY SUPPL HEATER FOR NEBULIZ
OXYGEN CONCENTRATOR
OXYGEN CONCENTRATOR, DUAL
PORTABLE OXYGEN CONCENTRATOR
DURABLE MEDICAL EQUIPMENT MI
OXYGEN CONCENTRATOR < 2 LITE
OXYGEN CONCENTRATOR > 5 LITE
O2/WATER VAPOR ENRICH W/HEAT
O2/WATER VAPOR ENRICH W/O HE
CENTRIFUGE
KIDNEY DIALYSATE DELIVRY SYS
HEPARIN INFUSION PUMP
REPLACEMENT AIR BUBBLE DETEC
REPLACEMENT PRESSURE ALARM
BATH CONDUCTIVITY METER
REPLACE BLOOD LEAK DETECTOR
ADJUSTABLE CHAIR FOR ESRD PT
TRANSDUCER PROTECT/FLD BAR
UNIPUNCTURE CONTROL SYSTEM
HEMODIALYSIS MACHINE
AUTO INTERM PERITONEAL DIALY
CYCLER DIALYSIS MACHINE
DELI/INSTALL CHRG HEMO EQUIP
REVERSE OSMOSIS H2O PURI SYS
DEIONIZER H2O PURI SYSTEM
Pricing Action Code
5
5
6
3
3
5
3
3
3
3
3
3
3
3
5
3
6
5
6
3
6
6
3
3
6
6
3
9
9
5
5
9
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
Maximum Allowable
$0.00
$0.00
$0.00
$1,138.90
$684.70
$0.00
$604.40
$1,005.00
$923.50
$958.20
$1,046.20
$399.82
$85.07
$365.36
$0.00
$2,054.39
$0.00
$0.00
$0.00
$46.67
$0.00
$0.00
$155.98
$0.00
$0.00
$0.00
$325.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
E1620
E1625
E1630
E1632
E1634
E1635
E1636
E1637
E1638
E1639
E1699
E1800
E1801
E1802
E1805
E1806
E1810
E1811
E1812
E1815
E1816
E1818
E1820
E1821
E1825
E1830
E1831
E1840
E1841
E1902
E2000
E2100
E2101
E2120
E2201
E2202
E2203
E2204
E2205
E2206
E2207
E2208
E2209
E2210
E2211
E2212
E2213
Description
REPLACEMENT BLOOD PUMP
WATER SOFTENING SYSTEM
RECIPROCATING PERITONEAL DIA
WEARABLE ARTIFICIAL KIDNEY
PERITONEAL DIALYSIS CLAMP
COMPACT TRAVEL HEMODIALYZER
SORBENT CARTRIDGES PER 10
HEMOSTATS FOR DIALYSIS, EACH
PERI DIALYSIS HEATING PAD
DIALYSIS SCALE
DIALYSIS EQUIPMENT NOC
ADJUST ELBOW EXT/FLEX DEVICE
SPS ELBOW DEVICE
ADJST FOREARM PRO/SUP DEVICE
ADJUST WRIST EXT/FLEX DEVICE
SPS WRIST DEVICE
ADJUST KNEE EXT/FLEX DEVICE
SPS KNEE DEVICE
KNEE EXT/FLEX W ACT RES CTRL
ADJUST ANKLE EXT/FLEX DEVICE
SPS ANKLE DEVICE
SPS FOREARM DEVICE
SOFT INTERFACE MATERIAL
REPLACEMENT INTERFACE SPSD
ADJUST FINGER EXT/FLEX DEVC
ADJUST TOE EXT/FLEX DEVICE
STATIC STR TOE DEV EXT/FLEX
ADJ SHOULDER EXT/FLEX DEVICE
STATIC STR SHLDR DEV ROM ADJ
AAC NON-ELECTRONIC BOARD
GASTRIC SUCTION PUMP HME MDL
BLD GLUCOSE MONITOR W VOICE
BLD GLUCOSE MONITOR W LANCE
PULSE GEN SYS TX ENDOLYMP FL
MAN W/CH ACC SEAT W>=20"<24"
SEAT WIDTH 24-27 IN
FRAME DEPTH LESS THAN 22 IN
FRAME DEPTH 22 TO 25 IN
MANUAL WC ACCESSORY, HANDRIM
COMPLETE WHEEL LOCK ASSEMBLY
CRUTCH AND CANE HOLDER
CYLINDER TANK CARRIER
ARM TROUGH EACH
WHEELCHAIR BEARINGS
PNEUMATIC PROPULSION TIRE
PNEUMATIC PROP TIRE TUBE
PNEUMATIC PROP TIRE INSERT
Pricing Action Code
5
5
5
5
6
5
5
9
9
9
5
9
9
5
9
9
9
9
6
9
9
9
9
9
9
9
6
9
6
5
3
5
5
6
6
6
6
6
6
3
6
6
6
6
6
6
6
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$1.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$39.59
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
E2214
E2215
E2216
E2217
E2218
E2219
E2220
E2221
E2222
E2224
E2225
E2226
E2227
E2228
E2230
E2231
E2291
E2292
E2293
E2294
E2295
E2300
E2301
E2310
E2311
E2312
E2313
E2321
E2322
E2323
E2324
E2325
E2326
E2327
E2328
E2329
E2330
E2331
E2340
E2341
E2342
E2343
E2351
E2358
E2359
E2360
E2361
Description
PNEUMATIC CASTER TIRE EACH
PNEUMATIC CASTER TIRE TUBE
FOAM FILLED PROPULSION TIRE
FOAM FILLED CASTER TIRE EACH
FOAM PROPULSION TIRE EACH
FOAM CASTER TIRE ANY SIZE EA
SOLID PROPULSION TIRE EACH
SOLID CASTER TIRE EACH
SOLID CASTER INTEGRATED WHL
PROPULSION WHL EXCLUDES TIRE
CASTER WHEEL EXCLUDES TIRE
CASTER FORK REPLACEMENT ONLY
GEAR REDUCTION DRIVE WHEEL
MWC ACC, WHEELCHAIR BRAKE
MANUAL STANDING SYSTEM
SOLID SEAT SUPPORT BASE
PLANAR BACK FOR PED SIZE WC
PLANAR SEAT FOR PED SIZE WC
CONTOUR BACK FOR PED SIZE WC
CONTOUR SEAT FOR PED SIZE WC
PED DYNAMIC SEATING FRAME
PWR SEAT ELEVATION SYS
PWR STANDING
ELECTRO CONNECT BTW CONTROL
ELECTRO CONNECT BTW 2 SYS
MINI-PROP REMOTE JOYSTICK
PWC HARNESS, EXPAND CONTROL
HAND INTERFACE JOYSTICK
MULT MECH SWITCHES
SPECIAL JOYSTICK HANDLE
CHIN CUP INTERFACE
SIP AND PUFF INTERFACE
BREATH TUBE KIT
HEAD CONTROL INTERFACE MECH
HEAD/EXTREMITY CONTROL INTER
HEAD CONTROL NONPROPORTIONAL
HEAD CONTROL PROXIMITY SWITC
ATTENDANT CONTROL
W/C WDTH 20-23 IN SEAT FRAME
W/C WDTH 24-27 IN SEAT FRAME
W/C DPTH 20-21 IN SEAT FRAME
W/C DPTH 22-25 IN SEAT FRAME
ELECTRONIC SGD INTERFACE
GR 34 NONSEALED LEADACID
GR34 SEALED LEADACID BATTERY
22NF NONSEALED LEADACID
22NF SEALED LEADACID BATTERY
Pricing Action Code
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
3
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
3
3
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$2,141.40
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$112.34
$118.49
Procedure Code
E2362
E2363
E2364
E2365
E2366
E2367
E2368
E2369
E2370
E2371
E2372
E2373
E2374
E2375
E2376
E2377
E2378
E2381
E2382
E2383
E2384
E2385
E2386
E2387
E2388
E2389
E2390
E2391
E2392
E2394
E2395
E2396
E2397
E2402
E2500
E2502
E2504
E2506
E2508
E2510
E2511
E2512
E2599
E2601
E2602
E2603
E2604
Description
GR24 NONSEALED LEADACID
U1NONSEALED LEADACID BATTERY
U1 SEALED LEADACID BATTERY
BATTERY CHARGER, SINGLE MODE
BATTERY CHARGER, DUAL MODE
PWR WC DRIVEWHEEL MOTOR REPL
PWR WC DRIVEWHEEL GEAR REPL
PWR WC DR WH MOTOR/GEAR COMB
GR27 NON-SEALED LEADACID
HAND/CHIN CTRL SPEC JOYSTICK
HAND/CHIN CTRL STD JOYSTICK
NON-EXPANDABLE CONTROLLER
EXPANDABLE CONTROLLER, REPL
EXPANDABLE CONTROLLER, INITL
PW ACTUATOR REPLACEMENT
PNEUM DRIVE WHEEL TIRE
TUBE, PNEUM WHEEL DRIVE TIRE
INSERT, PNEUM WHEEL DRIVE
PNEUMATIC CASTER TIRE
TUBE, PNEUMATIC CASTER TIRE
FOAM FILLED DRIVE WHEEL TIRE
FOAM FILLED CASTER TIRE
FOAM DRIVE WHEEL TIRE
FOAM CASTER TIRE
SOLID DRIVE WHEEL TIRE
SOLID CASTER TIRE
SOLID CASTER TIRE, INTEGRATE
DRIVE WHEEL EXCLUDES TIRE
CASTER WHEEL EXCLUDES TIRE
CASTER FORK
PWC ACC, LITH-BASED BATTERY
NEG PRESS WOUND THERAPY PUMP
SGD DIGITIZED PRE-REC <=8MIN
SGD PREREC MSG >8MIN <=20MIN
SGD PREREC MSG>20MIN <=40MIN
SGD PREREC MSG > 40 MIN
SGD SPELLING PHYS CONTACT
SGD W MULTI METHODS MSG/ACCS
SGD SFTWRE PRGRM FOR PC/PDA
SGD ACCESSORY, MOUNTING SYS
SGD ACCESSORY NOC
GEN W/C CUSHION WDTH < 22 IN
GEN W/C CUSHION WDTH >=22 IN
SKIN PROTECT WC CUS WD <22IN
SKIN PROTECT WC CUS WD>=22IN
Pricing Action Code
3
3
3
3
3
3
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
Maximum Allowable
$91.98
$153.40
$112.34
$88.42
$199.69
$419.07
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
E2605
E2606
E2607
E2608
E2609
E2610
E2611
E2612
E2613
E2614
E2615
E2616
E2617
E2619
E2620
E2621
E2622
E2623
E2624
E2625
E2626
E2627
E2628
E2629
E2630
E2631
E2632
E2633
E4610
E8000
E8001
E8002
G0002
G0004
G0005
G0006
G0007
G0008
G0009
G0010
G0015
G0016
G0027
G0050
G0051
G0052
G0053
Description
Pricing Action Code
POSITION WC CUSH WDTH <22 IN
POSITION WC CUSH WDTH>=22 IN
SKIN PRO/POS WC CUS WD <22IN
SKIN PRO/POS WC CUS WD>=22IN
CUSTOM FABRICATE W/C CUSHION
POWERED W/C CUSHION
GEN USE BACK CUSH WDTH <22IN
GEN USE BACK CUSH WDTH>=22IN
POSITION BACK CUSH WD <22IN
POSITION BACK CUSH WD>=22IN
POS BACK POST/LAT WDTH <22IN
POS BACK POST/LAT WDTH>=22IN
CUSTOM FAB W/C BACK CUSHION
REPLACE COVER W/C SEAT CUSH
WC PLANAR BACK CUSH WD <22IN
WC PLANAR BACK CUSH WD>=22IN
ADJ SKIN PRO W/C CUS WD<22IN
ADJ SKIN PRO WC CUS WD>=22IN
ADJ SKIN PRO/POS CUS<22IN
ADJ SKIN PRO/POS WC CUS>=22
SEO MOBILE ARM SUP ATT TO WC
ARM SUPP ATT TO WC RANCHO TY
MOBILE ARM SUPPORTS RECLININ
FRICTION DAMPENING ARM SUPP
MONOSUSPENSION ARM/HAND SUPP
ELEVAT PROXIMAL ARM SUPPORT
OFFSET/LAT ROCKER ARM W/ELA
MOBILE ARM SUPPORT SUPINATOR
LANCET DEVICE
POSTERIOR GAIT TRAINER
UPRIGHT GAIT TRAINER
ANTERIOR GAIT TRAINER
TEMPORARY URINARY CATHETER
ECG TRANSM PHYS REVIEW & INT
ECG 24 HOUR RECORDING
ECG TRANSMISSION & ANALYSIS
ECG PHY REVIEW & INTERPRET
ADMIN INFLUENZA VIRUS VAC
ADMIN PNEUMOCOCCAL VACCINE
ADMIN HEPATITIS B VACCINE
POST SYMPTOM ECG TRACING
POST SYMPTOM ECG MD REVIEW
SEMEN ANALYSIS
RESIDUAL URINE BY ULTRASOUND
DESTRUCTION BY ANY METHOD, INCLUD
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
9
6
6
6
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
G0062
G0063
G0064
G0065
G0066
G0071
G0072
G0073
G0074
G0075
G0076
G0077
G0078
G0079
G0080
G0081
G0082
G0083
G0084
G0085
G0086
G0087
G0088
G0089
G0090
G0091
G0092
G0093
G0094
G0101
G0102
G0103
G0104
G0105
G0106
G0108
G0109
G0117
G0118
G0120
G0121
G0122
G0123
G0124
G0126
G0127
G0128
Description
Pricing Action Code
PERIPHERAL SKELETAL BONE MINERAL D
CENTRAL SKELETAL BONE MINERAL DENS
PHYSICIAN SUPERVISION OF A PATIENT
PHYSICIAN SUPERVISION OF A HOSPICE
PHYSICIAN SUPERVISION OF A NURSING
INDIVIDUAL PSYCHOTHERAPY, INSIGHT O
INDIVIDUAL PSYCHOTHERAPY, INTERACT
CA SCREEN;PELVIC/BREAST EXAM
PROSTATE CA SCREENING; DRE
PSA SCREENING
CA SCREEN;FLEXI SIGMOIDSCOPE
COLORECTAL SCRN; HI RISK IND
COLON CA SCREEN;BARIUM ENEMA
DIAB MANAGE TRN PER INDIV
DIAB MANAGE TRN IND/GROUP
GLAUCOMA SCRN HGH RISK DIREC
GLAUCOMA SCRN HGH RISK DIREC
COLON CA SCRN; BARIUM ENEMA
COLON CA SCRN NOT HI RSK IND
COLON CA SCRN; BARIUM ENEMA
SCREEN CERV/VAG THIN LAYER
SCREEN C/V THIN LAYER BY MD
LUNG IMAGE (PET) STAGING
TRIM NAIL(S)
CORF SKILLED NURSING SERVICE
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
3
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$28.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
G0129
G0130
G0131
G0132
G0141
G0143
G0144
G0145
G0147
G0148
G0151
G0152
G0153
G0155
G0156
G0157
G0158
G0159
G0160
G0161
G0162
G0163
G0164
G0165
G0166
G0168
G0169
G0170
G0171
G0172
G0174
G0175
G0176
G0177
G0178
G0179
G0180
G0181
G0182
G0183
G0184
G0185
G0186
G0187
G0188
G0190
G0191
Description
PARTIAL HOSP PROG SERVICE
SINGLE ENERGY X-RAY STUDY
CT SCAN, BONE DENSITY STUDY
CT SCAN, BONE DENSITY STUDY
SCR C/V CYTO,AUTOSYS AND MD
SCR C/V CYTO,THINLAYER,RESCR
SCR C/V CYTO, AUTOMATED SYS
SCR C/V CYTO, AUTOSYS, RESCR
HHCP-SERV OF PT,EA 15 MIN
HHCP-SERV OF OT,EA 15 MIN
HHCP-SVS OF S/L PATH,EA 15MN
HHCP-SVS OF CSW,EA 15 MIN
HHCP-SVS OF AIDE,EA 15 MIN
HHC PT ASSISTANT EA 15
HHC OT ASSISTANT EA 15
HHC PT MAINT EA 15 MIN
HHC OCCUP THERAPY EA 15
HHC SLP EA 15 MIN
HHC RN E&M PLAN SVS, 15 MIN
HHC LPN/RN OBS/ASSES EA 15
HHC LIS NURSE TRAIN EA 15
PET,REC OF MELANOMA/MET CA
EXTRNL COUNTERPULSE, PER TX
WOUND CLOSURE BY ADHESIVE
REMOVAL TISSUE; NO ANESTHSIA
SKIN BIOGRAFT
SKIN BIOGRAFT ADD-ON
PHP;TRAIN & ED, PER DAY
INTENSITYMODULATEDRADIATION
OPPS SERVICE,SCHED TEAM CONF
OPPS/PHP;ACTIVITY THERAPY
OPPS/PHP; TRAIN & EDUC SERV
INTENSITYMODULATEDRADIATION
MD RECERTIFICATION HHA PT
MD CERTIFICATION HHA PATIENT
DESTRUCTION OF LOCALIZED LESION OF
OCULAR PHOTDYNAMICTX 2ND EYE
TRANSPUPPILLARY THERMOTX
DSTRY EYE LESN,FDR VSSL TECH
DSTRY MCLR DRUSEN,PHOTOCOAG
XRAY LWR EXTRMTY-FULL LNGTH
IMMUNIZATION ADMINISTRATION
IMMUNIZATION ADMIN,EACH ADD
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
7
7
7
9
7
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
7
3
7
9
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$10,128.26
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
G0192
G0193
G0194
G0195
G0196
G0197
G0198
G0199
G0200
G0201
G0202
G0204
G0206
G0219
G0235
G0237
G0238
G0239
G0240
G0241
G0245
G0246
G0247
G0248
G0249
G0250
G0252
G0255
G0257
G0259
G0260
G0268
G0269
G0270
G0271
G0276
G0277
G0278
G0279
G0281
G0282
G0283
G0288
G0289
G0293
G0294
G0295
Description
IMMUNIZATION ORAL/INTRANASAL
ENDOSCOPICSTUDYSWALLOWFUNCTN
SENSORYTESTINGENDOSCOPICSTUD
CLINICALEVALSWALLOWINGFUNCT
EVALOFSWALLOWINGWITHRADIOOPA
EVALOFPTFORPRESCIPSPEECHDEVI
PATIENTADAPATION&TRAINFORSPE
REEVALUATIONOFPATIENTUSESPEC
EVALOFPATIENTPRESCIPOFVOICEP
MODIFORTRAININGINUSEVOICEPRO
SCREENINGMAMMOGRAPHYDIGITAL
DIAGNOSTICMAMMOGRAPHYDIGITAL
DIAGNOSTICMAMMOGRAPHYDIGITAL
PET IMG WHOLBOD MELANO NONCO
PET NOT OTHERWISE SPECIFIED
THERAPEUTIC PROCD STRG ENDUR
OTH RESP PROC, INDIV
OTH RESP PROC, GROUP
CRITIC CARE BY MD TRANSPORT
EACH ADDITIONAL 30 MINUTES
INITIAL FOOT EXAM PT LOPS
FOLLOWUP EVAL OF FOOT PT LOP
ROUTINE FOOTCARE PT W LOPS
DEMONSTRATE USE HOME INR MON
PROVIDE INR TEST MATER/EQUIP
MD INR TEST REVIE INTER MGMT
PET IMAGING INITIAL DX
CURRENT PERCEP THRESHOLD TST
UNSCHED DIALYSIS ESRD PT HOS
INJECT FOR SACROILIAC JOINT
INJ FOR SACROILIAC JT ANESTH
REMOVAL OF IMPACTED WAX MD
OCCLUSIVE DEVICE IN VEIN ART
MNT SUBS TX FOR CHANGE DX
GROUP MNT 2 OR MORE 30 MINS
PILD/PLACEBO CONTROL CLIN TR
HBOT, FULL BODY CHAMBER, 30M
ILIAC ART ANGIO,CARDIAC CATH
TOMOSYNTHESIS, MAMMO
ELEC STIM UNATTEND FOR PRESS
ELECT STIM WOUND CARE NOT PD
ELEC STIM OTHER THAN WOUND
RECON, CTA FOR SURG PLAN
ARTHRO, LOOSE BODY + CHONDRO
NON-COV SURG PROC,CLIN TRIAL
NON-COV PROC, CLINICAL TRIAL
ELECTROMAGNETIC THERAPY ONC
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
3
3
3
9
6
9
9
9
9
9
9
9
9
9
9
9
3
5
5
5
5
9
9
5
5
9
9
3
3
5
5
9
3
3
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$140.66
$171.33
$135.08
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$521.95
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$13.85
$56.77
$0.00
$0.00
$0.00
$234.70
$84.90
$0.00
$0.00
$0.00
Procedure Code
G0296
G0297
G0299
G0300
G0302
G0303
G0304
G0305
G0306
G0307
G0328
G0329
G0333
G0337
G0339
G0340
G0341
G0342
G0343
G0364
G0365
G0372
G0378
G0379
G0380
G0381
G0382
G0383
G0384
G0389
G0390
G0396
G0397
G0398
G0399
G0400
G0402
G0403
G0404
G0405
G0406
G0407
G0408
G0409
G0410
G0411
G0412
Description
VISIT TO DETERM LDCT ELIG
LDCT FOR LUNG CA SCREEN
HHS/HOSPICE OF RN EA 15 MIN
HHS/HOSPICE OF LPN EA 15 MIN
PRE-OP SERVICE LVRS COMPLETE
PRE-OP SERVICE LVRS 10-15DOS
PRE-OP SERVICE LVRS 1-9 DOS
POST OP SERVICE LVRS MIN 6
CBC/DIFFWBC W/O PLATELET
CBC WITHOUT PLATELET
FECAL BLOOD SCRN IMMUNOASSAY
ELECTROMAGNTIC TX FOR ULCERS
DISPENSE FEE INITIAL 30 DAY
HOSPICE EVALUATION PREELECTI
ROBOT LIN-RADSURG COM, FIRST
ROBT LIN-RADSURG FRACTX 2-5
PERCUTANEOUS ISLET CELLTRANS
LAPAROSCOPY ISLET CELL TRANS
LAPAROTOMY ISLET CELL TRANSP
BONE MARROW ASPIRATE &BIOPSY
VESSEL MAPPING HEMO ACCESS
MD SERVICE REQUIRED FOR PMD
HOSPITAL OBSERVATION PER HR
DIRECT REFER HOSPITAL OBSERV
LEV 1 HOSP TYPE B ED VISIT
ULTRASOUND EXAM AAA SCREEN
TRAUMA RESPONS W/HOSP CRITI
ALCOHOL/SUBS INTERV 15-30MN
ALCOHOL/SUBS INTERV >30 MIN
HOME SLEEP TEST/TYPE 2 PORTA
INITIAL PREVENTIVE EXAM
EKG FOR INITIAL PREVENT EXAM
EKG TRACING FOR INITIAL PREV
EKG INTERPRET & REPORT PREVE
INPT/TELE FOLLOW UP 15
CORF RELATED SERV 15 MINS EA
GRP PSYCH PARTIAL HOSP 45-50
INTER ACTIVE GRP PSYCH PARTI
OPEN TX ILIAC SPINE UNI/BIL
Pricing Action Code
9
6
7
7
9
9
9
9
9
9
5
9
9
9
9
9
9
9
9
3
9
9
9
9
9
9
9
9
9
6
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$12.24
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
G0413
G0414
G0415
G0416
G0420
G0421
G0422
G0423
G0424
G0425
G0426
G0427
G0428
G0429
G0432
G0433
G0435
G0436
G0437
G0438
G0439
G0442
G0443
G0444
G0445
G0446
G0447
G0448
G0449
G0450
G0451
G0452
G0453
G0454
G0455
G0458
G0459
G0460
G0463
G0464
G0466
G0467
G0468
G0469
G0470
G0471
G0472
Description
PELVIC RING FRACTURE UNI/BIL
PELVIC RING FX TREAT INT FIX
OPEN TX POST PELVIC FXCTURE
PROSTATE BIOPSY, ANY MTHD
ED SVC CKD IND PER SESSION
ED SVC CKD GRP PER SESSION
INTENS CARDIAC REHAB W/EXERC
INTENS CARDIAC REHAB NO EXER
PULMONARY REHAB W EXER
INPT/ED TELECONSULT30
COLLAGEN MENISCUS IMPLANT
DERMAL FILLER INJECTION(S)
EIA HIV-1/HIV-2 SCREEN
ELISA HIV-1/HIV-2 SCREEN
ORAL HIV-1/HIV-2 SCREEN
TOBACCO-USE COUNSEL 3-10 MIN
TOBACCO-USE COUNSEL>10MIN
PPPS, INITIAL VISIT
PPPS, SUBSEQ VISIT
ANNUAL ALCOHOL SCREEN 15 MIN
BRIEF ALCOHOL MISUSE COUNSEL
DEPRESSION SCREEN ANNUAL
HIGH INTEN BEH COUNS STD 30M
INTENS BEHAVE THER CARDIO DX
BEHAVIOR COUNSEL OBESITY 15M
PLACE PERM PACING CARDIOVERT
ANNUAL OBESITY SCREEN 15 MIN
SCREEN STI W FOUR LAB TEST
DEVLOPMENT TEST INTERPT&REP
MOLECULAR PATHOLOGY INTERPR
CONT INTRAOP NEURO MONITOR
MD DOCUMENT VISIT BY NPP
FECAL MICROBIOTA PREP INSTIL
LDR PROSTATE BRACHY COMP RAT
TELEHEALTH INPT PHARM MGMT
AUTOLOGOUS PRP FOR ULCERS
HOSPITAL OUTPT CLINIC VISIT
COLOREC CA SCR, STO BAS DNA
FQHC VISIT NEW PATIENT
FQHC VISIT, ESTAB PT
FQHC VISIT, IPPE OR AWV
FQHC VISIT, MH NEW PT
FQHC VISIT, MH ESTAB PT
VEN BLOOD COLL SNF/HHA
HEP C SCREEN HIGH RISK/OTHER
Pricing Action Code
9
9
9
6
9
9
9
9
9
9
9
9
9
9
3
3
6
9
9
9
9
9
9
9
9
9
9
6
9
9
9
6
9
9
9
9
6
6
9
9
9
9
9
9
9
9
6
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$19.04
$18.33
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
G0473
G0475
G0476
G0477
G0478
G0479
G0480
G0481
G0482
G0483
G0913
G0914
G0915
G0916
G0917
G0918
G3001
G6001
G6002
G6003
G6004
G6005
G6006
G6007
G6008
G6009
G6010
G6011
G6012
G6013
G6014
G6015
G6016
G6017
G6030
G6031
G6032
G6034
G6035
G6036
G6037
G6038
G6039
G6040
G6041
G6042
G6043
Description
GROUP BEHAVE COUNS 2-10
HIV COMBINATION ASSAY
HPV COMBO ASSAY CA SCREEN
DRUG TEST PRESUMP OPTICAL
DRUG TEST PRESUMP OPT INST
DRUG TEST PRESUMP NOT OPT
DRUG TEST DEF 1-7 CLASSES
DRUG TEST DEF 22+ CLASSES
IMPROVE VISUAL FUNCT
SURVEY NOT COMPLETE
NO IMPROVE VISUAL FUNCT
SATISFY WITH CARE
SATISFY SURVEY NOT COMPLETE
NO SATISFY WITH CARE
ADMIN + SUPPLY, TOSITUMOMAB
ECHO GUIDANCE RADIOTHERAPY
STEREOSCOPIC X-RAY GUIDANCE
RADIATION TX DELIVERY IMRT
DELIVERY COMP IMRT
INTRAFRACTION TRACK MOTION
ASSAY OF AMITRIPTYLINE
ASSAY OF BENZODIAZEPINES
ASSAY OF DESIPRAMINE
ASSAY OF DOXEPIN
ASSAY OF GOLD
ASSAY OF IMIPRAMINE
ASSAY OF NORTIPTYLINE
ASSAY OF SALICYLATE
ASSAY OF ACETAMINOPHEN
ASSAY OF ETHANOL
ASSAY OF URINE ALKALOIDS
ASSAY OF AMPHETAMINES
ASSAY OF BARBITURATES
Pricing Action Code
6
9
9
3
3
3
3
3
3
3
9
9
9
9
9
9
6
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
9
9
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$0.00
$0.00
$0.00
$14.56
$19.41
$77.67
$78.34
$120.53
$162.71
$210.93
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$51.69
$75.66
$163.31
$126.46
$141.27
$140.55
$259.76
$147.87
$193.65
$193.65
$277.83
$230.14
$259.04
$259.04
$404.32
$0.00
$0.00
$23.87
$21.41
$22.95
$20.67
$21.72
$22.95
$18.07
$9.47
$26.99
$14.41
$40.03
$20.73
$15.27
Procedure Code
G6044
G6045
G6046
G6047
G6048
G6049
G6050
G6051
G6052
G6053
G6054
G6055
G6056
G6057
G6058
G8395
G8396
G8397
G8398
G8399
G8400
G8401
G8404
G8405
G8410
G8415
G8416
G8417
G8418
G8419
G8420
G8421
G8422
G8427
G8428
G8430
G8431
G8432
G8433
G8442
G8450
G8451
G8452
G8458
G8460
G8461
G8465
Description
ASSAY OF COCAINE
ASSAY OF DIHYDROCODEINONE
ASSAY OF DIHYDROMORPHINONE
ASSAY OF DIHYDROTESTOSTERONE
ASSAY OF DIMETHADIONE
ASSSAY OF EPIANDROSTERONE
ASSAY OF ETHCHLORVYNOL
ASSAY OF FLURAZEPAM
ASSAY OF MEPROBAMATE
ASSAY OF METHADONE
ASSAY OF METHSUXIMIDE
ASSAY OF NICOTINE
ASSAY OF OPIATES
ASSAY OF PHENOTHIAZINE
DRUG CONFIRMATION
LVEF>=40% DOC NORMAL OR MILD
LVEF NOT PERFORMED
DIL MACULA/FUNDUS EXAM/W DOC
DIL MACULAR/FUNDUS NOT PERFO
PT W/DXA RESULTS DOCUMENT
PT W/DXA NO RESULTS DOC
PT INELIG OSTEO SCREEN MEASU
LOW EXTEMITY NEUR EXAM DOCUM
LOW EXTEMITY NEUR NOT PERFOR
EVAL ON FOOT DOCUMENTED
EVAL ON FOOT NOT PERFORMED
PT INELIG FOOTWEAR EVALUATIO
CALC BMI ABV UP PARAM F/U
CALC BMI BLW LOW PARAM F/U
CALC BMI OUT NRM PARAM NOF/U
CALC BMI NORM PARAMETERS
BMI NOT CALCULATED
PT INELIG BMI CALCULATION
DOC CUR MEDS BY PROV
CUR MEDS NOT DOCUMENT
PT INELIG MED CHECK
POS CLIN DEPRES SCRN F/U DOC
CLIN DEPRESSION SCREEN NOT D
PT INELIG; SCRN CLIN DEP
PT INELIG PAIN ASSESSMENT
BETA-BLOC RX PT W/ABN LVEF
PT W/ABN LVEF INELIG B-BLOC
PT W/ABN LVEF B-BLOC NO RX
PT INELIG GENO NO ANTVIR TX
PT INELIG RNA NO ANTVIR TX
PT REC ANTIVIR TREAT HEP C
HIGH RISK RECURRENCE PRO CA
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$18.61
$27.54
$34.28
$34.43
$18.47
$28.66
$23.05
$20.97
$23.50
$21.72
$19.76
$31.59
$25.95
$20.77
$17.67
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
G8473
G8474
G8475
G8476
G8477
G8478
G8482
G8483
G8484
G8485
G8486
G8487
G8489
G8490
G8491
G8494
G8495
G8496
G8497
G8498
G8499
G8500
G8506
G8509
G8510
G8511
G8535
G8536
G8539
G8540
G8541
G8542
G8543
G8544
G8545
G8548
G8549
G8551
G8559
G8560
G8561
G8562
G8563
G8564
G8565
G8566
G8567
Description
ACE/ARB THXPY RX'D
ACE/ARB NOT RX'D; DOC REAS
ACE/ARB THXPY NOT RX'D
BP SYS <140 AND DIAS <90
BP SYS>=140 AND/OR DIAS >=90
BP NOT PERFORMED/DOC
FLU IMMUNIZE ORDER/ADMIN
FLU IMM NO ADMIN DOC REA
FLU IMMUNIZE NO ADMIN
REPORT, DIABETES MEASURES
REPORT, PREV CARE MEASURES
REPORT CKD MEASURES
CAD MEASURES GRP
RA MEASURES GRP
HIV/AIDS MEASURES GRP
DM MEAS QUAL ACT PERFORM
CKD MEAS QUAL ACT PERFORM
PREV CARE MG QUAL ACT PERFRM
CABG MEAS QUAL ACT PERFORM
CAD MEAS QUAL ACT PERFORM
RA MEAS QUAL ACT PERFORM
HIV MEAS QUAL ACT PERFORM
PT REC ACE/ARB
POS PAIN ASSESS NO F/U DOC
PT INELIG NEG SCRN DEPRES
CLIN DEPRES SCRN NO F/U DOC
PT INELIG NO ELD MAL SCRN
NO DOC ELDER MAL SCRN
DOC FUNCT AND CARE PLAN
PT INELIG FUNCT ASSESS
NO DOC CUR FUNCT ASSESS
DOC FUNCT NO DEFICIENCIES
CUR FUNCT ASSES; NO CARE PLN
CABG MEASURES GRP
HEPC MEASURES GRP
HF MEASURES GRP
HEPC MG QUAL ACT PERFORM
HF MG QUAL ACT PERFORM
PT REF DOC OTO EVAL
PT HX ACT DRAIN PREV 90 DAYS
PT INELIG FOR REF OTO EVAL
PT NO HX ACT DRAIN 90 D
PT NO REF OTO REAS NO SPEC
PT REF OTO EVAL
VER DOC HEAR LOSS
PT INELIG REF OTO EVAL
PT NO DOC HEAR LOSS
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
G8568
G8569
G8570
G8571
G8572
G8573
G8574
G8575
G8576
G8577
G8578
G8598
G8599
G8600
G8601
G8602
G8627
G8628
G8633
G8634
G8635
G8645
G8646
G8647
G8648
G8649
G8650
G8651
G8652
G8653
G8654
G8655
G8656
G8657
G8658
G8659
G8660
G8661
G8662
G8663
G8664
G8665
G8666
G8667
G8668
G8669
G8670
Description
PT NO REF OTOLO NO SPEC
PROL INTUBATION REQ
NO PROL INTUB REQ
STER WD IFX 30 D POSTOP
NO STER WD IFX
STK CABG
NO STRK CABG
POSTOP REN FAIL
NO POSTOP REN FAIL
REOP REQ BLD GRFT OTH
NO REOP REQ BLD GRFT OTH
ASP THERP USED
NO ASP THERP USED
TPA INITI W/IN 3 HRS
NO ELIG TPA INIT W/IN 3 HRS
NO TPA INIT W/IN 3 HRS
SURG PROC W/IN 30 DAYS
NO SURG PROC W/IN 30 DAYS
PHARM THER OSTEO RX
PT NO ELG PHAR THER OSTEO
NO PHARM THER OSTEO RX
ASTHMA MEASURES GRP
ASTHMA MG QUAL ACT PERFORM
FUN STAT SCORE KNEE >= 0
FUN STAT SCORE KNEE < 0
FUN STAT SCORE KNEE PT NOELG
FUN STAT SCORE KNEE NOT DONE
FUN STAT SCORE HIP >= 0
FUN STAT SCORE HIP < 0
FUN STAT SCORE HIP PT NO ELG
FUN STAT SCORE HIP NOT DONE
FUN STAT SCORE LE >= 0
FUN STAT SCORE LE < 0
FUN STAT SCORE LE PT NO ELG
FUN STAT SCORE LE NOT DONE
FUN STAT SCORE LS >= 0
FUN STAT SCORE LS < 0
FUN STAT SCORE LS PT NO ELG
FUN STAT SCORE LS NOT DONE
FUN STAT SCORE SHDL >=0
FUN STAT SCORE SHDL < 0
FUN STAT SCORE SHDL PT NO EL
FUN STAT SCORE SHDL NOT DONE
FUN STAT SCORE UE >=0
FUN STAT SCORE UE < 0
FUN STAT SCORE UE PT NO ELG
FUN STAT SCORE UE NOT DONE
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
G8671
G8672
G8673
G8674
G8694
G8696
G8697
G8698
G8708
G8709
G8710
G8711
G8712
G8721
G8722
G8723
G8724
G8725
G8726
G8728
G8730
G8731
G8732
G8733
G8734
G8735
G8749
G8752
G8753
G8754
G8755
G8756
G8757
G8758
G8759
G8761
G8762
G8765
G8783
G8784
G8785
G8797
G8798
G8806
G8807
G8808
G8809
Description
FUN STAT SCORE NECK/TS >=0
FUN STAT SCORE NECK/TS < 0
FUN STAT SCOR NEK/TS PT NO E
FUN STAT SCOR NEK/TS NOT DON
LVEF <40%
ANTITHROMB THX PRESC
ANTITHROMB NO PRESC DOC REAS
ANTITHROMB NO PRESC NO REAS
ANTIBIOTIC NOT PRES
MED REAS ANTIBIOTIC PRES
PT PRES ANTIBIOTIC
PRES ANTIBIOTIC
NOT PRES ANTIBIOTIC
PT, PN, HIST GRADE DOC
MED REAS PT, PN, NOT DOC
SPEC SIT NOT PRIM TUMOR
PT, PN, HIST GRADE NOT DOC
LIPID PROFILE PERF DOC
DOC REAS NO LIPID PROFILE
LIPID PROFILE NOT PERF
PAIN DOC POS AND PLAN
PAIN NEG NO PLAN
NO DOC OF PAIN
DOC POS ELDER MAL SCRN PLAN
DOC NEG ELDER MAL NO PLAN
ELD MAL SCRN POS NO PLAN
SIGNS OF MELANOMA ABSENT
SYS BP LESS 140
SYS BP > OR = 140
DIAS BP LESS 90
DIAS BP > OR = 90
NO BP MEASURE DOC
COPD MG QUAL ACT PERFORM
IBD MG QUAL ACT PERFORM
OSA MG QUAL ACT PERFORM
DEMENTIA MG QUAL ACT PERFORM
PD MG QUAL ACT PERFORM
CATARACT MG QUAL ACT PERFORM
BP SCRN PERF REC INTERVAL
PT NO ELIG FOR BP ASSESS
BP SCRN NO PERF AT INTERVAL
SPECIMEN SITE NOT ESOPHAGUS
SPECIMEN SITE NOT PROSTATE
TRANSAB OR TRANSVAG US
DOC REAS NO US
NO TRANSAB OR TRANSVAG US
RH-IMMUNOGLOBULIN ORDER
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
G8810
G8811
G8815
G8816
G8817
G8818
G8825
G8826
G8833
G8834
G8838
G8839
G8840
G8841
G8842
G8843
G8844
G8845
G8846
G8848
G8849
G8850
G8851
G8852
G8853
G8854
G8855
G8856
G8857
G8858
G8861
G8863
G8864
G8865
G8866
G8867
G8868
G8869
G8872
G8873
G8874
G8875
G8876
G8877
G8878
G8879
G8880
Description
DOC REAS NO RH-IMMUNO
NO RH-IMMUNOGLOBULIN ORDER
DOC REAS NO STATIN THERAPY
STATIN MED PRES AT DISCH
DOC REAS NO STATIN MED DISCH
PT DISCH TO HOME BY DAY#7
PT NOT DISCH TO HOME DAY#7
PT DISCH HOME DAY #2 EVAR
PT NOT DISCH HOME DAY#2 EVAR
PT DISCH HOME DAY #2 CEA
NOT DISCH HOME BY DAY #2
SLEEP APNEA ASSESS
DOC REAS NO SLEEP APNEA
NO SLEEP APNEA ASSESS
AHI OR RDI INITIAL DX
DOC REAS NO AHI OR RDI
NO AHI OR RDI INITIAL DX
POS AIRWAY PRESS PRESCRIBED
MOD OR SEVERE OSA
MILD OSA
DOC REAS NO POS AIR PRESS
NO PAP PRESCRIBED
ADHERE POS AIR PRESS THERAPY
POS AIR PRESS PRESCRIBE
POS AIR PRESS NOT PRESCRIBE
REAS NO ADHERE POS AIR PRES
POS AIR PRESS ADHERE NO PERF
REF FOR OTO EVAL
NO ELIG REF FOR OTO EVAL
NOT REF FOR OTO EVAL
DXA ORDERED FOR OSTEO
NO ASSESS BONE LOSS
PNEUMOCOCCAL VACCINE ADMIN
DOC MED REAS NO PNEUMOCOCCAL
DOC PT REAS NO PNEUMOCOCCAL
NO PNEUMOCOCCAL ADMIN
1ST COURSE ANTITNF
DOC IMMUN HEP B 1ST ANTITNF
INTRAOP IMAGE CONFIRM EXCISE
SPECIMEN NOT INTRAOP IMAGE
TISSUE NOT IMAGE INTRAOP
BREAST CANCER DX MIN INVSIVE
DOC REAS NO MIN INV DX
NO BRST CNCR DX MIN INVASIVE
SENT LYMPH NODE BIOPSY
NODE NEG INV BRST CNCR
DOC REAS NO LYMPH NODE BIOP
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
G8881
G8882
G8883
G8884
G8885
G8898
G8899
G8900
G8902
G8903
G8906
G8907
G8908
G8909
G8910
G8911
G8912
G8913
G8914
G8915
G8916
G8917
G8918
G8923
G8924
G8925
G8926
G8927
G8928
G8929
G8934
G8935
G8936
G8937
G8938
G8939
G8940
G8941
G8942
G8944
G8946
G8947
G8948
G8950
G8952
G8953
G8955
Description
BRST CNCR STAGE > T1N0M0
NO SENT LYMPH NODE BIOPSY
REV, COMM, TRACK, DOC BIOPSY
DOC REAS BIOPSY NOT REVIEW
NO REV, COMM, TRACK BIOPSY
COPD MEASURES GROUP
INFLAMMATORY BOWEL DIS MG
OBSTRUCTIVE SLEEP APNEA MG
DEMENTIA MEASURES GROUP
PARKINSON'S DISEASE MG
CATARACT MEASURES GROUP
PT DOC NO EVENTS ON DISCHARG
PT DOC W BURN PRIOR TO D/C
PT DOC NO BURN PRIOR TO D/C
PT DOC TO HAVE FALL IN ASC
PT DOC NO FALL IN ASC
PT DOC WITH WRONG EVENT
PT DOC NO WRONG EVENT
PT TRANS TO HOSP POST D/C
PT NOT TRANS TO HOSP AT D/C
PT W IV AB GIVEN ON TIME
PT W IV AB NOT GIVEN ON TIME
PT W/O PREOP ORDER IV AB PRO
LVEF < 40% OR LVSD
FEV<60% PRED & COPD SYM
FEV>=60% & NO COPD SYM
SPIRO NO PERF OR DOC
ADJ CHEM PRES AJCC III
ADJ CHEM NOT PRES RSN SPEC
ADJ CMO NOT PRES RSN NOT GVN
LVEF <40% OR DEP LV SYS FCN
RX ACE OR ARB THERAPY
PT NOT ELIGIBLE ACE/ARB
NO RX ACE/ARB THERAPY
BMI CALC, PT NO F/U PLAN ELG
PAIN ASSESS DOC, F/U NO DOC
SRN CLIN DEP DOC NO F/U PLN
NO DOC ELDER SCRN, PT NO EL
DOC FCN/CARE PLAN W/30 DAYS
AJCC MEL CNR STG 0 - IIC
MIBM BUT NO DX OF BREAST CA
1 OR MORE NEUROPSYCH
NO NEUROPSYCH SYMPTOMS
PRE-HTN OR HTN DOC, F/U INDC
PRE-HTN/HTN, NO F/U, NOT GVN
ONCOLOGY MG QUAL ACT PERFORM
MOST RECENT ASSESS VOL MGMT
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
G8956
G8958
G8959
G8960
G8961
G8962
G8963
G8964
G8965
G8966
G8967
G8968
G8969
G8970
G8971
G8972
G8973
G8974
G8975
G8976
G8977
G8978
G8979
G8980
G8981
G8982
G8983
G8984
G8985
G8986
G8987
G8988
G8989
G8990
G8991
G8992
G8993
G8994
G8995
G8996
G8997
G8998
G8999
G9001
G9002
G9003
G9004
Description
PT RCV HEDIA OUTPT DYLS FAC
ASSESS VOL MGMT NOT DOC
CLIN TX MDD COMM TO TX CLIN
CLIN TX MDD NOT COMM
CSIT LOWRISK SURG PTS PREOP
CSIT ON PT ANY REAS 30 DAYS
CSI PER ASX PT W/PCI 2 YRS
CSI ANY OTHER THAN PCI 2 YR
CSIT PERF ON LOW CHD RSK
CSIT PERF SX OR HIGH CHD RSK
WRFRN OR ORAL ANTIGOAG PRES
MD RSN NO PRES WRFRN OR OTHR
PT RSN NO PRES WRFRN OR OTHR
NO RSK FAC OR 1 MOD RISK TE
WARFRN OR OTHR ANTCOG NO RX
1>=RISK OR>= MOD RISK FOR TE
MST RCNT HBB < 10G/DL
HGB NOT DOC RNS NOT GVN
HGB <10G/DL, MED RSN
HGB >= 10 G/DL
ONCOLOGY MEASURES GRP
MOBILITY CURRENT STATUS
MOBILITY GOAL STATUS
MOBILITY D/C STATUS
BODY POS CURRENT STATUS
BODY POS GOAL STATUS
BODY POS D/C STATUS
CARRY CURRENT STATUS
CARRY GOAL STATUS
CARRY D/C STATUS
SELF CARE CURRENT STATUS
SELF CARE GOAL STATUS
SELF CARE D/C STATUS
OTHER PT/OT CURRENT STATUS
OTHER PT/OT GOAL STATUS
OTHER PT/OT D/C STATUS
SUB PT/OT CURRENT STATUS
SUB PT/OT GOAL STATUS
SUB PT/OT D/C STATUS
SWALLOW CURRENT STATUS
SWALLOW GOAL STATUS
SWALLOW D/C STATUS
MOTOR SPEECH CURRENT STATUS
MCCD, INITIAL RATE
MCCD,MAINTENANCE RATE
MCCD, RISK ADJ HI, INITIAL
MCCD, RISK ADJ LO, INITIAL
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
7
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
G9005
G9006
G9007
G9008
G9009
G9010
G9011
G9012
G9013
G9014
G9016
G9017
G9018
G9019
G9020
G9033
G9034
G9035
G9036
G9037
G9050
G9051
G9052
G9053
G9054
G9055
G9056
G9057
G9058
G9059
G9060
G9061
G9062
G9063
G9064
G9065
G9066
G9067
G9068
G9069
G9070
G9071
G9072
G9073
G9074
G9075
G9077
Description
MCCD, RISK ADJ, MAINTENANCE
MCCD, HOME MONITORING
MCCD, SCH TEAM CONF
MCCD,PHYS COOR-CARE OVRSGHT
MCCD, RISK ADJ, LEVEL 3
OTHER SPECIFIED CASE MGMT
ESRD DEMO BUNDLE LEVEL I
ESRD DEMO BUNDLE-LEVEL II
DEMO-SMOKING CESSATION COUN
AMANTADINE HCL 100MG ORAL
ZANAMIVIR,INHALATION PWD 10M
OSELTAMIVIR PHOSPHATE 75MG
RIMANTADINE HCL 100MG ORAL
AMANTADINE HCL ORAL BRAND
ZANAMIVIR, INH PWDR, BRAND
OSELTAMIVIR PHOSP, BRAND
RIMANTADINE HCL, BRAND
SERVICES PROVIDED BY REHABILITATIO
ONCOLOGY WORK-UP EVALUATION
ONCOLOGY TX DECISION-MGMT
ONC SURVEILLANCE FOR DISEASE
ONC EXPECTANT MANAGEMENT PT
ONC SUPERVISION PALLIATIVE
ONC VISIT UNSPECIFIED NOS
ONC PRAC MGMT ADHERES GUIDE
ONC PRACT MGMT DIFFERS TRIAL
ONC PRAC MGMT DISAGREE W/GUI
ONC PRAC MGMT PT OPT ALTERNA
ONC PRAC MGMT DIF PT COMORB
ONC PRAC COND NOADD BY GUIDE
ONC PRAC GUIDE DIFFERS NOS
ONC DX NSCLC STGI NO PROGRES
ONC DX NSCLC STG2 NO PROGRES
ONC DX NSCLC STG3A NO PROGRE
ONC DX NSCLC STG3B-4 METASTA
ONC DX NSCLC DX UNKNOWN NOS
ONC DX SCLC/NSCLC LIMITED
ONC DX SCLC/NSCLC EXT AT DX
ONC DX SCLC/NSCLC EXT UNKNWN
ONC DX BRST STG1-2B HR,NOPRO
ONC DX BRST STG1-2 NOPROGRES
ONC DX BRST STG3-HR, NO PRO
ONC DX BRST STG3-NOPROGRESS
ONC DX BRST METASTIC/ RECUR
ONC DX PROSTATE T1NO PROGRES
Pricing Action Code
7
7
7
7
7
9
7
7
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
G9078
G9079
G9080
G9083
G9084
G9085
G9086
G9087
G9088
G9089
G9090
G9091
G9092
G9093
G9094
G9095
G9096
G9097
G9098
G9099
G9100
G9101
G9102
G9103
G9104
G9105
G9106
G9107
G9108
G9109
G9110
G9111
G9112
G9113
G9114
G9115
G9116
G9117
G9123
G9124
G9125
G9126
G9128
G9129
G9130
G9131
G9132
Description
ONC DX PROSTATE T2NO PROGRES
ONC DX PROSTATE T3B-T4NOPROG
ONC DX PROSTATE W/RISE PSA
ONC DX PROSTATE UNKNWN NOS
ONC DX COLON T1-3,N1-2,NO PR
ONC DX COLON T4, N0 W/O PROG
ONC DX COLON T1-4 NO DX PROG
ONC DX COLON METAS EVID DX
ONC DX COLON METAS NOEVID DX
ONC DX COLON EXTENT UNKNOWN
ONC DX RECTAL T1-2 NO PROGR
ONC DX RECTAL T3 N0 NO PROG
ONC DX RECTAL T1-3,N1-2NOPRG
ONC DX RECTAL T4,N,M0 NO PRG
ONC DX RECTAL M1 W/METS PROG
ONC DX RECTAL EXTENT UNKNWN
ONC DX ESOPHAG T1-T3 NOPROG
ONC DX ESOPHAGEAL T4 NO PROG
ONC DX ESOPHAGEAL METS RECUR
ONC DX ESOPHAGEAL UNKNOWN
ONC DX GASTRIC NO RECURRENCE
ONC DX GASTRIC P R1-R2NOPROG
ONC DX GASTRIC UNRESECTABLE
ONC DX GASTRIC RECURRENT
ONC DX GASTRIC UNKNOWN NOS
ONC DX PANCREATC P R0 RES NO
ONC DX PANCREATC P R1/R2 NO
ONC DX PANCREATIC UNRESECTAB
ONC DX PANCREATIC UNKNWN NOS
ONC DX HEAD/NECK T1-T2NO PRG
ONC DX HEAD/NECK T3-4 NOPROG
ONC DX HEAD/NECK M1 METS REC
ONC DX HEAD/NECK EXT UNKNOWN
ONC DX OVARIAN STG1A-B NO PR
ONC DX OVARIAN STG1A-B OR 2
ONC DX OVARIAN STG3/4 NOPROG
ONC DX OVARIAN RECURRENCE
ONC DX OVARIAN UNKNOWN NOS
ONC DX CML CHRONIC PHASE
ONC DX CML ACCELER PHASE
ONC DX CML BLAST PHASE
ONC DX CML REMISSION
ONC DX MULTI MYELOMA STAGE I
ONC DX MULT MYELOMA STG2 HIG
ONC DX MULTI MYELOMA UNKNOWN
ONC DX BRST UNKNOWN NOS
ONC DX PROSTATE METS NO CAST
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
G9133
G9134
G9135
G9136
G9137
G9138
G9139
G9140
G9143
G9147
G9148
G9149
G9150
G9151
G9152
G9153
G9156
G9157
G9158
G9159
G9160
G9161
G9162
G9163
G9164
G9165
G9166
G9167
G9168
G9169
G9170
G9171
G9172
G9173
G9174
G9175
G9176
G9186
G9187
G9188
G9189
G9190
G9191
G9192
G9196
G9197
G9198
Description
ONC DX PROSTATE CLINICAL MET
ONC NHLSTG 1-2 NO RELAP NO
ONC DX NHL STG 3-4 NOT RELAP
ONC DX NHL TRANS TO LG BCELL
ONC DX NHL RELAPSE/REFRACTOR
ONC DX NHL STG UNKNOWN
ONC DX CML DX STATUS UNKNOWN
FRONTIER EXTENDED STAY DEMO
WARFARIN RESPON GENETIC TEST
OUTPT IV INSULIN TX ANY MEA
MEDICAL HOME LEVEL 1
MEDICAL HOME LEVEL II
MEDICAL HOME LEVEL III
MAPCP DEMO STATE
MAPCP DEMO COMMUNITY
MAPCP DEMO PHYSICIAN
EVALUATION FOR WHEELCHAIR
TRANSESOPH DOPPL CARDIAC MON
MOTOR SPEECH D/C STATUS
LANG COMP CURRENT STATUS
LANG COMP GOAL STATUS
LANG COMP D/C STATUS
LANG EXPRESS CURRENT STATUS
LANG EXPRESS GOAL STATUS
LANG EXPRESS D/C STATUS
ATTEN CURRENT STATUS
ATTEN GOAL STATUS
ATTEN D/C STATUS
MEMORY CURRENT STATUS
MEMORY GOAL STATUS
MEMORY D/C STATUS
VOICE CURRENT STATUS
VOICE GOAL STATUS
VOICE D/C STATUS
SPEECH LANG CURRENT STATUS
SPEECH LANG GOAL STATUS
SPEECH LANG D/C STATUS
MOTOR SPEECH GOAL STATUS
BPCI HOME VISIT
BETA NOT GIVEN NO REASON
BETA PRES OR ALREADY TAKING
MEDICAL REASON FOR NO BETA
PT REASON FOR NO BETA
SYSTEM REASON FOR NO BETA
MED REASON FOR NO CEPH
ORDER FOR CEPH
NO ORDER FOR CEPH NO REASON
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
G9203
G9204
G9205
G9206
G9207
G9208
G9209
G9210
G9211
G9212
G9213
G9217
G9219
G9222
G9223
G9225
G9226
G9227
G9228
G9229
G9230
G9231
G9232
G9233
G9234
G9235
G9236
G9237
G9238
G9239
G9240
G9241
G9242
G9243
G9244
G9245
G9246
G9247
G9250
G9251
G9254
G9255
G9256
G9257
G9258
G9259
G9260
Description
HEP C RNA DONE PRIOR TO MED
NO REASON FOR NO HEP C RNA
HEP C ANTIVIRAL STARTED
HEP C THERAPY STARTED
HEP C GENOTYPE PRIOR TO MED
NO REASON FOR NO HEP C GENO
HEP C RNA 4TO12 WK AFTER MED
NO HEPC RNA AFTER MED DOCRSN
NO HEPC RNA AFTER MED NO RSN
DOC OF DSM-IV INIT EVAL
NO DOC OF DSM-IV
NO PCP PROPH LOW CD4 NORSN
NO ODER PJP FOR MED REASON
PJP PROPH ORDERED LOW CD4
PJP PROPH ORDERED CD4 LOW
NORSN NO FOOT EXAM
3 COMP FOOT EXAM COMPLETED
DOCRSN NO CARE PLAN
GC CHL SYP DOCUMENTED
PTRSN NO GC CHL SYP TEST
NORSN FOR GC CHL SYP TEST
DOC ESRD DIA TRANS PREG
DOCRSN NO COMM COMORB
TKR COMPOSITE
TKR INTENT
GS MG COMPOSITE
OP RAD MG COMPOSITE
GS MG INTENT
OP RAD MG INTENT
DOCRSN FOR CATHETER
DOC PT W CATH MAINT DIA
DOC PT W OUT CATH MAINT DIA
DOC VIRAL LOAD >=200
DOC VIRAL LOAD <200
ANTIVIRAL NOT ORDERED
ANTIVIRAL ORDERED
NO MED VISIT IN 24MO
1 MED VISIT IN 24MO
DOC OF PAIN COMFORT 48HR
DOC NO PAIN COMFORT 48HR
DOC PT DISCHG >2D
DOC PT DISCHG <=2D
DOC DEATH AFTER CAS
DOC STROKE AFTER CAS
DOC STROKE AFTER CEA
DOC SURV NO STROKE AFTER CAS
DOC DEATH AFTER CEA
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
G9261
G9262
G9263
G9264
G9265
G9266
G9267
G9268
G9269
G9270
G9273
G9274
G9275
G9276
G9277
G9278
G9279
G9280
G9281
G9282
G9283
G9284
G9285
G9286
G9287
G9288
G9289
G9290
G9291
G9292
G9293
G9294
G9295
G9296
G9297
G9298
G9299
G9300
G9301
G9302
G9303
G9304
G9305
G9306
G9307
G9308
G9309
Description
DOC SURV NO STROKE AFTER CEA
DOC DEATH IN HOSP AAA REPAIR
DOC SURV IN HOSP AAA REPAIR
DOCRSN FOR CATH MAINT DIA
DOC CATH >90D FOR MAINT DIA
NORSN PT CATH >=90D
DOC COMP OR MORT W IN 30D
DOC COMP OR MORT W IN 90D
DOC NO COMP OR MORT W IN 30D
DOC NO COMP OR MORT W IN 90D
SYS<140 AND DIA<90
BP OUT OF NRML LIMITS
DOC OF NON TOBACCO USER
DOC OF TOBACCO USER
DOC DAILY ASPIRIN OR CONTRA
DOC NO DAILY ASPIRIN
PNE SCRN DONE DOC VAC DONE
PNE NOT GIVEN NORSN
PNE SCRN DONE DOC NOT IND
DOC MEDRSN NO HISTO TYPE
HIST TYPE DOC ON REPORT
NO HIST TYPE DOC ON REPORT
SITE NOT SMALL CELL LUNG CA
ANTIBIO RX W IN 10D OF SYMPT
NO ANTIBIO W IN 10D OF SYMPT
DOC MEDRSN NO HIST TYPE RPT
DOC TYPE NSM LUNG CA
NO DOC TYPE NSM LUNG CA
NOT NSM LUNG CA
MEDRSN NO PT CATEGORY
NO PT CATEGORY ON REPORT
PT CAT AND THCK ON REPORT
NON CUTANEOUS LOC
DOC SHARE DEC PRIOR PROC
NO DOC SHARE DEC PRIOR PROC
EVAL RISK VTE CARD 30D PRIOR
NO EVAL RISKK VTE CARD PRIOR
DOC MEDRSN NO COMPL ANTIBIO
DOC COMPL INF ANTIBIO
NORSN INCOMP INF ANTIBIO
NORSN NO PROS INFO OP RPT
PROS INFO OP RPT
NO INTERV REQ FOR LEAK
INTERV REQ FOR LEAK
NO RET FOR SURG W IN 30D
UNPLND RET TO SURG W IN 30D
NO UNPLND HOSP READM IN 30D
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
G9310
G9311
G9312
G9313
G9314
G9315
G9316
G9317
G9318
G9319
G9321
G9322
G9324
G9326
G9327
G9329
G9340
G9341
G9342
G9344
G9345
G9347
G9348
G9349
G9350
G9351
G9352
G9353
G9354
G9355
G9356
G9357
G9358
G9359
G9360
G9361
G9364
G9365
G9366
G9367
G9368
G9380
G9381
G9382
G9383
G9384
G9385
Description
UNPLND HOSP READM IN 30D
NO SURG SITE INFECTION
SURGICAL SITE INFECTION
DOCRSN NOT FIRST LINE AMOX
NORSN NOT FIRST LINE AMOX
DOC FIRST LINE AMOX
DOC COMM RISK CALC
NO DOC COMM RISK CALC
IMAGE STD NOMENCLATURE
IMAGE NOT STD NOMENCLATURE
DOC COUNT OF CT IN 12MO
NO DOC COUNT OF CT IN 12MO
NOT ALL DATA NORSN
NORSN NO CT RPT TO REG
CT RPT TO REG
NORSN NO DICOM FORMAT DOC
DICOM FORMAT DOC ON RPT
SRCH FOR CT W IN 12 MOS
NO SRCH FOR CT IN 12MO NORSN
SYSRSN NO DICOM SRCH
FOLLOW UP PULM NOD
NO FOLLOW UP PULM NOD NORSN
DOCRSN NO SINUS CT DX
DOC SINUS CT 28D
NO DOC SINUS CT 28D OR DX
DOC >1 SINUS CT W 90D DX
NOT >1 SINUS CT W 90D DX
MEDRSN >1 SINUS CT W 90D DX
1 OR NO CT SINUS W/IN 90D DX
NO EARLY IND/DELIVERY
EARLY IND/DELIVERY
PP EVAL/EDU PERF
PP EVAL/EDU NOT PERF
DOC OF NEG OR MAN POS TB SCN
NO DOC OF NEG OR MAN POS TB
MED IND FOR INDUCTION
SINUS CAUS BAC INX
1HIGH RISK MED ORD
1HIGH RISK NO ORD
2HIGH RISK MED ORD
2HIGH RISK NO ORD
OFF ASSIS EOL ISS
DOC MED REAS NO OFFER EOL
NO OFF ASSIS EOL
RECD SCRN HCV INFEC
DOC MED REAS NO ANN SRN HCV
DOC PT REAS NOT REC HCV SRN
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
6
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
G9386
G9389
G9390
G9393
G9394
G9395
G9396
G9399
G9400
G9401
G9402
G9403
G9404
G9405
G9406
G9407
G9408
G9409
G9410
G9411
G9412
G9413
G9414
G9415
G9416
G9417
G9418
G9419
G9420
G9421
G9422
G9423
G9424
G9425
G9426
G9427
G9428
G9429
G9430
G9431
G9432
G9434
G9435
G9436
G9437
G9438
G9439
Description
SCRN HCV INFEC NOT RECD
UNPLN RUP POST CAP
NO UNPLN RUP POST CAP
INI PHQ9 >9 REMISS <5
DX BIPOL, DEATH, NHRES, HOSP
INI PHQ9 >9 NO REMISS >=5
INI PHQ9 >9 NOT ASSESS
DOC DISC TX CHOICES
DOC REAS NO DISC TX OPT
NO DISC TX CHOICES
RECD F/U W/IN 30D DISCH
DOC REAS NO 30 DAY F/U
NO 30 DAY F/U
RECD F/U W/IN 7D DISCH
DOC REAS NO 7D F/U
NO 7D F/U
CARD TAMP W/IN 30D
NO CARD TAMP E/IN 30D
ADMIT W/IN 180D REQ REMOV
NO ADMIT W/IN 180D REQ REMOV
ADMIT W/IN 180D REQ SURG REV
NO ADMIT REQ SURG REV
1DOSE MENIG VAC BTWN 11 & 13
NO 1DOSE MENI VAC BTWN 11&13
TDAP OR TD OR 1TET/DIPTH
NO TDAP OR TD OR 1TET/DIPTH
LUNGCX BX RPT DOCS CLASS
MED REAS NOT INCL HISTO TYPE
SPEC SITE NO LUNG
LUNG CX BX RPT NO DOC CLASS
RPT DOC CLASS HISTO TYPE
MED REAS RPT NO HISTO TYPE
SITE NO LUNG OR LUNG CX
SPEC RPT NO DOC CLASS HISTO
IMPR MED TIME EDARR PAIN MED
NO IMPRO MED TIME PAIN MED
RPT PT CAT AND PT1
DOC MED REAS NO PT CAT
SPEC SITE NO CUTANEOUS
NO PT CAT AND PT1
ASTH CONTROLLED
ASTH NOT CONTROLLED
ASP PRESC DISCH
ASP NOT PRESC DOC REAS
ASP NOT PRESC DISCH
P2Y INHIB PRESC
P2Y INHIB NOT PRESC DOC REAS
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
G9440
G9441
G9442
G9443
G9448
G9449
G9450
G9451
G9452
G9453
G9454
G9455
G9456
G9457
G9458
G9459
G9460
G9463
G9464
G9465
G9466
G9467
G9468
G9469
G9470
G9471
G9472
G9473
G9474
G9475
G9476
G9477
G9478
G9479
G9480
G9496
G9497
G9498
G9499
G9500
G9501
G9502
G9503
G9504
G9505
G9506
G9507
Description
P2Y INHIB NOT PRESC
STATIN PRESC DISCH
STATIN NOT PRESC DOC REAS
STATIN NOT PRESC DISCH
BORN 1945-1965
HX BLD TRANSF B/F 1992
HX INJEC DRUG USE
1X SCRN HCV INFECT
DOC MED REAS NO SCRN HCV
PT REAS NO HCV INFECT
NO HCV INFECT SRN
ABD IMAG W/US, CT OR MRI
DOC MED PT REAS NO HCC SCRN
NO ABD IMAG W/O REASON
TOB USER RECD CESS INTERV
TOB NON-USER
NO TOB ASSESS OR CESS INTER
SINUSITIS INTENT
SINUSITIS COMP
AOE INTENT
AOE COMP
RECD CORTICO >=10MG/DAY >60D
NO RECD CORTICO>=10MG/D >60D
REC CORTICO>60D OR 1RX 600MG
NO REC CORTICO>60D 1RX 600MG
W/IN 2YR DXA NOT ORDER
NO DXA NO MED HX NO RV SX
CHAP SERVICES AT HOSPICE
DIET COUNSEL AT HOSPICE
OTHER COUNSELOR AT HOSPICE
VOLUN SERVICE AT HOSPICE
CARE COORD AT HOSPICE
OTHE THERAPIST AT HOSPICE
PHARMACIST AT HOSPICE
ADMISSION TO MCCM
DOC RSN NO ADENO/NEOPL DETEC
PREOP ANES OR PROXY B/4 SURG
ABX REG PRESCRIBED
NO START/REC ANTVIR TX HEP C
RAD EXP TIME W/FLUOR DOC
RAD EXP TIME W/O FLUOR DOC
MED REAS NO PERF FOOT EXAM
PT TK TAMS HCL
DOC REAS NO HBV STATUS
ABX PRES W/IN 10 DYS OF SYMP
BIO IMM RESP MOD PRESC
DOC REAS ON STATIN OR CONTRA
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
G9508
G9509
G9510
G9511
G9512
G9513
G9514
G9515
G9516
G9517
G9518
G9519
G9520
G9521
G9522
G9523
G9524
G9525
G9526
G9529
G9530
G9531
G9532
G9533
G9534
G9535
G9536
G9537
G9538
G9539
G9540
G9541
G9542
G9543
G9544
G9547
G9548
G9549
G9550
G9551
G9552
G9553
G9554
G9555
G9556
G9557
G9558
Description
DOC PT NOT ON STATIN
REMIS 12M PHQ-9 SCORE <5
REMIS 12M NOT PHQ-9 SCORE <5
PHQ-9 >9 DURING 12M TIME
INDIV PDC > 0.8
INDIV PDC NOT > 0.8
REQ RET OR W/IN 90D OF SURG
NO REAS, NO RET OR W/IN 90D
IMPR VIS ACUIT W/IN 90D
NO IMPR VIS ACUIT W/IN 90D
DOC ACTIVE INJ DRUG USE
FINAL REFRACT +/- 1.0 IN 90D
REFRACT NOT +/- 1.0 W/IN 90D
ER AND IP HOSP <2 IN 12 MOS
ER/IP HOSP =/>2 IN 12 MOS
D/C HEMO OR PERIT DIALYSIS
REFER TO HOSPICE
DOC PT REAS NO HOSPICE REFER
NO REASON, NO REFER HOSPICE
MINOR BLUNT TRAUMA W/HEAD CT
MIN HD TRAUM GCS=15 W/CT ED
INDIC FOR HEAD CT VALID
INJ >24 HR IN ED GCS <15
INDIC FOR HEAD CT NOT VALID
ADV BRAIN IMAGE NOT ORDERED
NORMAL NEURO EXAM
DOC MED REAS ADV BRAIN IMAGE
DOC SYSTEM REAS ADV IMAGING
ADV BRAIN IMAGE ORDERED
INTENT POT REMV TIME PLACEMT
PT ALIVE 3 MOS POST PROC
FILTER GONE AFT 3MOS PLACMT
DOC REASS APPR REMO FILT 3MS
DOC 2X RE-ASSESS FILT REMOV
NO FILT REMOV W/IN 3MOS PLCM
INCID CT LIVER/KID/ADRE FDG
ABD IMAG AND FOLLOWUP REC
DOC MED REAS NO FOLLOW IMAG
ABD IMAG AND FOLLOWUP NO REC
ABD IMAG W/O LIV/KID/ADR LES
INC THYR NODE <1.0 IN RPT
PRIOR THYROID DISE DX
CT/MRI CHEST/NECK FOLLUP REC
DOC MED REAS NO FOLLOW IMAG
CT/MRI CHEST FOLLUP NOT REC
CT/MRI CHEST/NECK NO THY NOD
TX BETA-LACTAM ABX THERAPY
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
G9559
G9560
G9561
G9562
G9563
G9572
G9573
G9574
G9577
G9578
G9579
G9580
G9581
G9582
G9583
G9584
G9585
G9593
G9594
G9595
G9596
G9597
G9598
G9599
G9600
G9601
G9602
G9603
G9604
G9605
G9606
G9607
G9608
G9609
G9610
G9611
G9612
G9613
G9614
G9615
G9616
G9617
G9618
G9619
G9620
G9621
G9622
Description
DOC MED REAS NO ABX THERAPY
NO BETA-LACTAM ABX THER, RNG
PRESC OPIATES >6 WKS
FOLL-UP EVAL Q3MO OPIOD TX
NO F/U EVAL Q3MO OPIOD TX
PHQ-SCR >9 DOC IN 12M TIME
REMIS 6M W/6MOS PHQ-9 <5
REMIS 6M W/O 6MOS PHQ-9 <5
DOC OPIOID TX 1X DURING THER
NO DOC OPIOID TX 1X AT THER
DOOR TO PUNC TIME <2HRS
MD DOC, DOOR TO PUNC TM >2HR
DOOR TO PUNC TIME >2HR, NRG
EVAL OPIOID USE INSTR/PT INT
NO EVAL OPI USE INSTR/INTV
LOW PECARN PED HEAD TRAUMA
GSC >15 & HD CT BY ED MD
VAL RSN HD CT ORD REG INDIC
HD INJ >24H/GCS >15/NO RES
NO LOW PECARN PED HEAD TRAUM
AOR ANE 5.5-5.9 CM MAX DIAM
AOR ANE >=6.0 CM MAX DIAM
SYMP AAA URGENT REPAIR
PT DCHG HOME POST OP DAY 7
PT NO DCHG HOME POSTOP DAY 7
PT SURV IMPROV BSLINE TX
PT SURV RESULTS NOT AVAIL
SURV SCORE NO IMPROV W/TX
INTRAOP CYST EVAL TRAC INJ
PT NOT ELIG
INTRAOP CYST EVAL NOT DONE
DOC ORDER ANTI-PLAT OR P2Y12
DOC MD RSN NO ANTIPLA/P2Y12
NO ANTIPLA/P2Y12 ORD, RS NOS
PHO DOC >1 CECAL LDMK COM EX
DOC POST SURG ANATOMY
NO PHOTODOC CECAL LDMK EXAM
PRE-OP ASST DOC
DOC RSN NO PREOP ASSMT
PRE-OP ASST NOT DOC, RNG
DOC SCR UTER MAL OR US/SAMP
DOC RSN NO SCR UTER MALIG
NO SCR UTR MALIG/US/SAMP RNG
SCR UNHEAL ETOH W/COUNSEL
NO UNHEAL ETOH USER
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
G9623
G9624
G9625
G9626
G9627
G9628
G9629
G9630
G9631
G9632
G9633
G9634
G9635
G9636
G9637
G9638
G9639
G9640
G9641
G9642
G9643
G9644
G9645
G9646
G9647
G9648
G9649
G9650
G9651
G9652
G9653
G9654
G9655
G9656
G9657
G9658
G9659
G9660
G9661
G9662
G9663
G9664
G9665
G9666
G9667
G9669
G9670
Description
DOC MED RSN NO SCR ETOH USE
NO ETOH SCR/NO COUNC/NRG
BLD INJ AT SURG/1MOS POST
PT NOT ELIG
NO BLD INJ AT SURG/1MOS POST
VIS INJ AT SURG/1MOS POST
PT NOT ELIG
NO VIS INJ AT SURG/1MOS POST
URTR INJ AT SURG/1MOS POST
PT NOT ELIG
NO URTR INJ AT SURG/1MS POST
QUAL LIFE TOOL 2X SAME/IMPR
NO DOC RSN DO QUAL LIFE ASSM
NO LIFE ASST 2X SAME/DECR
DOC >1 DOSE REDUC TECH
NO DOC >1 DOSE REDUC TECH
AMP NO REQD IN48H IELER PROC
DOC PLAN HYBRID/STAGE PROC
AMP REQD W/IN 48H IELER PROC
CURRENT CIG SMOKER
ELECTIVE SURGERY
NO SMOK B/4 ANES DAY OF SURG
HAD SMOKE B/4 ANES DAY SURG
PT W/90D MRS 0-2
NO MRS SCORE IN 90D FOLLOWUP
PT W/90D MRS >2
PSORI TOOL DOC W/BENCHMK
DOC PT NO THER CHG OR CONTRA
PSORI TOOL DOC/NO BNCHMK MET
PT TX SYS BIO MED PSORI 6MTH
PT NO TX SYS BIO RX 6 MTHS
MON ANESTH CARE
TOC TOOL INCL KEY ELEM
PT DIRECT ANESTH LOC TO PACU
TOC DUR ANETH TO ICU
TOC TOOL INCL ELEM NOT USED
>85Y NO HX COLO CA/RSN SCOPE
DOC MED RSN SCOPE PT >85Y
>85Y SCOPE OTHR RSN
PRIOR DX/ACTIVE CLIN ASCVD
FAST/DIR LDL = 190 MG/DL
TAKING STATIN OR REC'D ORDER
NO STATIN/NO ORDER STATIN
FAS/DIR LDL 70-189MG/DL MST
DOC MED RSN NO STAT TX/PRESC
INTEND RPT MULT CHR MSR GRP
QTY ACT MCC MG PERF
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
G9671
G9672
G9673
G9674
G9675
G9676
G9677
H0001
H0002
H0003
H0004
H0005
H0006
H0007
H0008
H0009
H0010
H0011
H0012
H0013
H0014
H0015
H0016
H0017
H0018
H0019
H0020
H0021
H0022
H0023
H0024
H0025
H0026
H0027
H0028
H0029
H0030
H0031
H0032
H0033
H0034
H0035
H0036
H0037
H0038
H0039
H0040
Description
INTEND RPT DIA RETIN MSR GRP
QTY ACT DIAB RETIN MG PERF
INTEND RPT CARD PREV MSR GRP
PT W/CLIN ASCVD DX
PT W/FAST/DIR LAB LDL-C >190
40-75Y W/TYPE 1/2 W/LDL-C RS
QTY ACT CARD PREV MG PERF
ALCOHOL AND/OR DRUG ASSESS
ALCOHOL AND/OR DRUG SCREENIN
ALCOHOL AND/OR DRUG SCREENIN
ALCOHOL AND/OR DRUG SERVICES
ALCOHOL AND/OR DRUG TRAINING
ALCOHOL AND/OR DRUG INTERVEN
ALCOHOL AND/OR DRUG OUTREACH
ALCOHOL AND/OR DRUG PREVENTI
ALCOHOL AND/OR DRUG HOTLINE
MH HEALTH ASSESS BY NON-MD
MH SVC PLAN DEV BY NON-MD
ORAL MED ADM DIRECT OBSERVE
MED TRNG & SUPPORT PER 15MIN
MH PARTIAL HOSP TX UNDER 24H
COMM PSY FACE-FACE PER 15MIN
COMM PSY SUP TX PGM PER DIEM
SELF-HELP/PEER SVC PER 15MIN
ASSER COM TX FACE-FACE/15MIN
ASSERT COMM TX PGM PER DIEM
Pricing Action Code
9
9
9
9
9
9
9
7
7
9
7
7
9
7
9
9
7
7
7
9
7
7
9
7
7
7
3
9
9
9
9
9
9
9
9
9
9
7
7
9
9
9
7
7
7
7
7
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$4.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
H0041
H0042
H0043
H0044
H0045
H0046
H0047
H0048
H0049
H0050
H1000
H1001
H1002
H1003
H1004
H1005
H1010
H1011
H2000
H2001
H2010
H2011
H2012
H2013
H2014
H2015
H2016
H2017
H2018
H2019
H2020
H2021
H2022
H2023
H2024
H2025
H2026
H2027
H2028
H2029
H2030
H2031
H2032
H2033
H2034
H2035
H2036
Description
FOS C CHLD NON-THER PER DIEM
FOS C CHLD NON-THER PER MON
SUPPORTED HOUSING, PER DIEM
SUPPORTED HOUSING, PER MONTH
RESPITE NOT-IN-HOME PER DIEM
MENTAL HEALTH SERVICE, NOS
ALCOHOL/DRUG ABUSE SVC NOS
SPEC COLL NON-BLOOD:A/D TEST
ALCOHOL/DRUG SCREENING
ALCOHOL/DRUG SERVICE 15 MIN
PRENATAL CARE ATRISK ASSESSM
ANTEPARTUM MANAGEMENT
CARECOORDINATION PRENATAL
PRENATAL AT RISK EDUCATION
FOLLOW UP HOME VISIT/PRENTAL
PRENATALCARE ENHANCED SRV PK
NONMED FAMILY PLANNING ED
FAMILY ASSESSMENT
COMP MULTIDISIPLN EVALUATION
REHABILITATION PROGRAM 1/2 D
COMPREHENSIVE MED SVC 15 MIN
CRISIS INTERVEN SVC, 15 MIN
BEHAV HLTH DAY TREAT, PER HR
PSYCH HLTH FAC SVC, PER DIEM
SKILLS TRAIN AND DEV, 15 MIN
COMP COMM SUPP SVC, 15 MIN
COMP COMM SUPP SVC, PER DIEM
PSYSOC REHAB SVC, PER 15 MIN
PSYSOC REHAB SVC, PER DIEM
THER BEHAV SVC, PER 15 MIN
THER BEHAV SVC, PER DIEM
COM WRAP-AROUND SV, 15 MIN
COM WRAP-AROUND SV, PER DIEM
SUPPORTED EMPLOY, PER 15 MIN
SUPPORTED EMPLOY, PER DIEM
SUPP MAINT EMPLOY, 15 MIN
SUPP MAINT EMPLOY, PER DIEM
PSYCHOED SVC, PER 15 MIN
SEX OFFEND TX SVC, 15 MIN
SEX OFFEND TX SVC, PER DIEM
MH CLUBHOUSE SVC, PER 15 MIN
MH CLUBHOUSE SVC, PER DIEM
ACTIVITY THERAPY, PER 15 MIN
MULTISYS THER/JUVENILE 15MIN
A/D HALFWAY HOUSE, PER DIEM
A/D TX PROGRAM, PER HOUR
A/D TX PROGRAM, PER DIEM
Pricing Action Code
9
9
7
9
9
7
9
7
9
9
9
9
9
9
9
9
9
9
9
9
9
7
7
9
7
9
7
7
7
7
7
7
9
7
7
9
9
7
9
9
9
9
9
9
7
7
7
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
H2037
H5010
H5020
H5025
H5030
H5040
H5050
H5060
H5090
H5100
H5110
H5120
H5130
H5160
H5170
H5180
H5190
H5200
H5220
H5230
H5240
H5299
H5300
J0120
J0129
J0130
J0131
J0132
J0133
J0135
J0153
J0171
J0178
J0180
J0190
J0200
J0202
J0205
J0207
J0210
J0215
J0220
J0221
J0256
J0257
J0270
J0275
Description
Pricing Action Code
DEV DELAY PREV DP CH, 15 MIN
THERAPY, INDIVIDUAL, BY SOCIAL WORK
PSYCHOTHERAPY, GROUP (MAXIMUM 8
PSYCHOTHERAPY, GROUP (MAXIMUM 8
OTHER SERVICES BY SOCIAL WORKER, PS
RESIDENTIAL CARE IN PUBLIC INSTITUT
RESIDENTIAL CARE IN PRIVATE INSTITU
PUBLIC SPECIAL SCHOOLS OR DAY CARE
SPECIAL CLASS PRIVATE
SPECIAL CLASS PRIVATE PROPRIETARY
SUMMER TREATMENT CAMP
SPECIALIZED CARE NURSING HOME, CON
VISITING TEACHER SERVICES
READING THERAPY
OTHER SPECIAL EDUCATION OR VOCATIO
TRANSPORTATION FOR HANDICAPPED
NURSING CARE, HOME
NURSING CARE, OTHER
REHABILITATIVE EVALUATION, 0-20 MIN
REHABILITATIVE EVALUATION, 21-40 MI
REHABILITATIVE EVALUATION, 41-60 MI
REHABILITATIVE EVALUATION, NOT OTH
OCCUPATIONAL THERAPY, EXCLUDING IN
TETRACYCLIN INJECTION
ABATACEPT INJECTION
ABCIXIMAB INJECTION
ACETAMINOPHEN INJECTION
ACETYLCYSTEINE INJECTION
ACYCLOVIR INJECTION
ADALIMUMAB INJECTION
ADENOSINE INJ 1MG
ADRENALIN EPINEPHRINE INJECT
AFLIBERCEPT INJECTION
AGALSIDASE BETA INJECTION
INJ BIPERIDEN LACTATE/5 MG
ALATROFLOXACIN MESYLATE
INJECTION, ALEMTUZUMAB
ALGLUCERASE INJECTION
AMIFOSTINE
METHYLDOPATE HCL INJECTION
ALEFACEPT
ALGLUCOSIDASE ALFA INJECTION
LUMIZYME INJECTION
ALPHA 1 PROTEINASE INHIBITOR
GLASSIA INJECTION
ALPROSTADIL FOR INJECTION
ALPROSTADIL URETHRAL SUPPOS
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
5
3
3
9
3
3
3
3
3
3
3
5
9
3
5
3
5
6
3
3
3
3
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$39.44
$1,015.54
$0.00
$1.72
$0.08
$753.26
$0.96
$0.13
$980.50
$158.48
$0.00
$0.00
$1,743.81
$0.00
$377.88
$0.00
$0.00
$206.70
$153.60
$4.59
$4.27
$0.00
$0.00
Procedure Code
J0278
J0280
J0282
J0285
J0287
J0288
J0289
J0290
J0295
J0300
J0330
J0348
J0350
J0360
J0364
J0365
J0380
J0390
J0395
J0400
J0401
J0456
J0461
J0470
J0475
J0476
J0480
J0485
J0490
J0500
J0515
J0520
J0558
J0561
J0571
J0572
J0573
J0574
J0575
J0583
J0585
J0586
J0587
J0588
J0592
J0594
J0595
Description
AMIKACIN SULFATE INJECTION
AMINOPHYLLIN 250 MG INJ
AMIODARONE HCL
AMPHOTERICIN B
AMPHOTERICIN B LIPID COMPLEX
AMPHO B CHOLESTERYL SULFATE
AMPHOTERICIN B LIPOSOME INJ
AMPICILLIN 500 MG INJ
AMPICILLIN SODIUM PER 1.5 GM
AMOBARBITAL 125 MG INJ
SUCCINYCHOLINE CHLORIDE INJ
ANIDULAFUNGIN INJECTION
INJECTION ANISTREPLASE 30 U
HYDRALAZINE HCL INJECTION
APOMORPHINE HYDROCHLORIDE
APROTONIN, 10,000 KIU
INJ METARAMINOL BITARTRATE
CHLOROQUINE INJECTION
ARBUTAMINE HCL INJECTION
ARIPIPRAZOLE INJECTION
INJ ARIPIPRAZOLE EXT REL 1MG
AZITHROMYCIN
ATROPINE SULFATE INJECTION
DIMECAPROL INJECTION
BACLOFEN 10 MG INJECTION
BACLOFEN INTRATHECAL TRIAL
BASILIXIMAB
BELATACEPT INJECTION
BELIMUMAB INJECTION
DICYCLOMINE INJECTION
INJ BENZTROPINE MESYLATE
BETHANECHOL CHLORIDE INJECT
PENG BENZATHINE/PROCAINE INJ
PENICILLIN G BENZATHINE INJ
BUPRENORPHINE ORAL 1MG
BUPREN/NAL UP TO 3MG BUPRENO
BUPREN/NAL 3.1 TO 6MG BUPREN
BUPREN/NAL 6.1 TO 10MG BUPRE
BUPREN/NAL OVER 10MG BUPRENO
BIVALIRUDIN
INJECTION,ONABOTULINUMTOXINA
ABOBOTULINUMTOXINA
INJ, RIMABOTULINUMTOXINB
INCOBOTULINUMTOXIN A
BUPRENORPHINE HYDROCHLORIDE
BUSULFAN INJECTION
BUTORPHANOL TARTRATE 1 MG
Pricing Action Code
3
3
5
3
3
5
3
3
3
5
6
3
5
3
6
6
5
5
5
3
3
3
3
3
3
3
3
3
3
3
3
5
3
3
6
6
6
6
6
3
3
3
3
3
3
3
3
Maximum Allowable
$1.16
$8.88
$0.00
$19.53
$19.53
$0.00
$18.18
$1.43
$2.27
$0.00
$0.00
$0.59
$0.00
$10.50
$0.00
$0.00
$0.00
$0.00
$0.00
$0.76
$4.25
$3.56
$0.05
$38.71
$165.96
$76.40
$2,894.72
$3.80
$41.46
$55.43
$20.33
$0.00
$6.59
$8.33
$0.00
$0.00
$0.00
$0.00
$0.00
$3.01
$5.72
$7.90
$11.61
$4.77
$2.99
$33.18
$2.39
Procedure Code
J0596
J0597
J0598
J0600
J0610
J0620
J0630
J0636
J0637
J0638
J0640
J0641
J0670
J0690
J0692
J0694
J0695
J0696
J0697
J0698
J0702
J0706
J0710
J0712
J0713
J0714
J0715
J0716
J0717
J0720
J0725
J0735
J0740
J0743
J0744
J0745
J0760
J0770
J0775
J0780
J0795
J0800
J0833
J0834
J0840
J0850
J0875
Description
INJECTION, RUCONEST
C-1 ESTERASE, BERINERT
C-1 ESTERASE, CINRYZE
EDETATE CALCIUM DISODIUM INJ
CALCIUM GLUCONATE INJECTION
CALCIUM GLYCER & LACT/10 ML
CALCITONIN SALMON INJECTION
INJ CALCITRIOL PER 0.1 MCG
CASPOFUNGIN ACETATE
CANAKINUMAB INJECTION
LEUCOVORIN CALCIUM INJECTION
LEVOLEUCOVORIN INJECTION
INJ MEPIVACAINE HCL/10 ML
CEFAZOLIN SODIUM INJECTION
CEFEPIME HCL FOR INJECTION
CEFOXITIN SODIUM INJECTION
INJ CEFTOLOZANE TAZOBACTAM
CEFTRIAXONE SODIUM INJECTION
STERILE CEFUROXIME INJECTION
CEFOTAXIME SODIUM INJECTION
BETAMETHASONE ACET&SOD PHOSP
CAFFEINE CITRATE INJECTION
CEPHAPIRIN SODIUM INJECTION
CEFTAROLINE FOSAMIL INJ
INJ CEFTAZIDIME PER 500 MG
CEFTAZIDIME AND AVIBACTAM
CEFTIZOXIME SODIUM / 500 MG
CENTRUROIDES IMMUNE F(AB)
CERTOLIZUMAB PEGOL INJ 1MG
CHLORAMPHENICOL SODIUM INJEC
CHORIONIC GONADOTROPIN/1000U
CLONIDINE HYDROCHLORIDE
CIDOFOVIR INJECTION
CILASTATIN SODIUM INJECTION
CIPROFLOXACIN IV
INJ CODEINE PHOSPHATE /30 MG
COLCHICINE INJECTION
COLISTIMETHATE SODIUM INJ
COLLAGENASE, CLOST HIST INJ
PROCHLORPERAZINE INJECTION
CORTICORELIN OVINE TRIFLUTAL
CORTICOTROPIN INJECTION
COSYNTROPIN INJECTION NOS
COSYNTROPIN CORTROSYN INJ
CROTALIDAE POLY IMMUNE FAB
CYTOMEGALOVIRUS IMM IV /VIAL
INJECTION, DALBAVANCIN
Pricing Action Code
3
3
3
3
3
5
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
6
5
3
3
3
5
6
3
3
3
3
3
3
3
5
6
3
3
3
3
3
6
3
3
3
3
Maximum Allowable
$25.28
$46.32
$54.48
$5,452.78
$3.10
$0.00
$1,931.72
$0.35
$12.94
$92.12
$3.84
$1.62
$1.97
$0.89
$2.51
$4.89
$4.23
$0.77
$2.42
$3.14
$5.83
$0.00
$0.00
$2.27
$2.40
$69.25
$0.00
$0.00
$6.47
$31.74
$20.21
$11.55
$566.86
$4.54
$1.02
$0.00
$0.00
$10.40
$38.46
$13.09
$7.72
$3,308.10
$0.00
$44.49
$2,542.98
$1,064.77
$14.58
Procedure Code
J0878
J0881
J0882
J0885
J0886
J0887
J0888
J0890
J0894
J0895
J0897
J0945
J1000
J1020
J1030
J1040
J1050
J1071
J1094
J1100
J1110
J1120
J1160
J1162
J1165
J1170
J1180
J1190
J1200
J1205
J1212
J1230
J1240
J1245
J1250
J1260
J1265
J1267
J1270
J1290
J1300
J1320
J1322
J1324
J1325
J1327
J1330
Description
DAPTOMYCIN INJECTION
DARBEPOETIN ALFA, NON-ESRD
DARBEPOETIN ALFA, ESRD USE
EPOETIN ALFA, NON-ESRD
EPOETIN ALFA 1000 UNITS ESRD
EPOETIN BETA ESRD USE
EPOETIN BETA NON ESRD
PEGINESATIDE INJECTION
DECITABINE INJECTION
DEFEROXAMINE MESYLATE INJ
DENOSUMAB INJECTION
BROMPHENIRAMINE MALEATE INJ
DEPO-ESTRADIOL CYPIONATE INJ
METHYLPREDNISOLONE 20 MG INJ
MEDROXYPROGESTERONE ACETATE
INJ TESTOSTERONE CYPIONATE
INJ DEXAMETHASONE ACETATE
DEXAMETHASONE SODIUM PHOS
INJ DIHYDROERGOTAMINE MESYLT
ACETAZOLAMID SODIUM INJECTIO
DIGOXIN INJECTION
DIGOXIN IMMUNE FAB (OVINE)
PHENYTOIN SODIUM INJECTION
HYDROMORPHONE INJECTION
DYPHYLLINE INJECTION
DEXRAZOXANE HCL INJECTION
DIPHENHYDRAMINE HCL INJECTIO
CHLOROTHIAZIDE SODIUM INJ
DIMETHYL SULFOXIDE 50% 50 ML
METHADONE INJECTION
DIMENHYDRINATE INJECTION
DIPYRIDAMOLE INJECTION
INJ DOBUTAMINE HCL/250 MG
DOLASETRON MESYLATE
DOPAMINE INJECTION
DORIPENEM INJECTION
INJECTION, DOXERCALCIFEROL
ECALLANTIDE INJECTION
ECULIZUMAB INJECTION
AMITRIPTYLINE INJECTION
ELOSULFASE ALFA, INJECTION
ENFUVIRTIDE INJECTION
EPOPROSTENOL INJECTION
EPTIFIBATIDE INJECTION
ERGONOVINE MALEATE INJECTION
Pricing Action Code
3
3
3
3
3
6
6
6
3
3
3
5
3
3
3
3
3
3
6
3
3
3
3
3
3
3
5
3
3
3
3
3
3
3
3
3
3
3
3
3
3
5
6
6
3
5
5
Maximum Allowable
$0.80
$4.15
$4.15
$12.33
$12.33
$0.00
$0.00
$0.00
$21.78
$15.01
$15.49
$0.00
$13.80
$4.50
$4.31
$8.33
$0.36
$0.03
$0.00
$0.14
$57.51
$20.76
$4.58
$2,642.71
$0.66
$2.06
$0.00
$166.78
$0.49
$115.84
$217.54
$10.26
$6.23
$0.82
$5.54
$7.77
$0.61
$0.80
$0.92
$385.88
$215.92
$0.00
$0.00
$0.00
$15.48
$0.00
$0.00
Procedure Code
J1335
J1364
J1380
J1410
J1430
J1435
J1436
J1438
J1439
J1442
J1443
J1447
J1450
J1451
J1452
J1453
J1455
J1457
J1458
J1459
J1460
J1556
J1557
J1559
J1560
J1561
J1562
J1566
J1568
J1569
J1570
J1571
J1572
J1573
J1575
J1580
J1590
J1595
J1599
J1600
J1602
J1610
J1620
J1626
J1630
J1631
J1640
Description
ERTAPENEM INJECTION
ERYTHRO LACTOBIONATE /500 MG
ESTRADIOL VALERATE 10 MG INJ
INJ ESTROGEN CONJUGATE 25 MG
ETHANOLAMINE OLEATE 100 MG
INJECTION ESTRONE PER 1 MG
ETIDRONATE DISODIUM INJ
ETANERCEPT INJECTION
INJ FERRIC CARBOXYMALTOS 1MG
INJ FILGRASTIM EXCL BIOSIMIL
INJ FERRIC PYROPHOSPHATE CIT
INJ TBO FILGRASTIM 1 MICROG
FLUCONAZOLE
FOMEPIZOLE, 15 MG
INTRAOCULAR FOMIVIRSEN NA
FOSAPREPITANT INJECTION
FOSCARNET SODIUM INJECTION
GALLIUM NITRATE INJECTION
GALSULFASE INJECTION
INJ IVIG PRIVIGEN 500 MG
GAMMA GLOBULIN 1 CC INJ
INJ, IMM GLOB BIVIGAM, 500MG
GAMMAPLEX INJECTION
HIZENTRA INJECTION
GAMMA GLOBULIN > 10 CC INJ
GAMUNEX-C/GAMMAKED
VIVAGLOBIN, INJ
IMMUNE GLOBULIN, POWDER
OCTAGAM INJECTION
GAMMAGARD LIQUID INJECTION
GANCICLOVIR SODIUM INJECTION
HEPAGAM B IM INJECTION
FLEBOGAMMA INJECTION
HEPAGAM B INTRAVENOUS, INJ
HYQVIA 100MG IMMUNEGLOBULIN
GARAMYCIN GENTAMICIN INJ
GATIFLOXACIN INJECTION
INJECTION GLATIRAMER ACETATE
IVIG NON-LYOPHILIZED, NOS
GOLD SODIUM THIOMALEATE INJ
GOLIMUMAB FOR IV USE 1MG
GLUCAGON HYDROCHLORIDE/1 MG
GONADORELIN HYDROCH/ 100 MCG
GRANISETRON HCL INJECTION
HALOPERIDOL INJECTION
HALOPERIDOL DECANOATE INJ
HEMIN, 1 MG
Pricing Action Code
3
3
3
3
3
5
5
3
3
3
3
3
3
6
5
3
6
6
3
3
3
3
3
3
3
3
6
3
3
3
3
3
3
6
3
3
5
6
6
5
3
3
5
3
3
3
3
Maximum Allowable
$41.63
$48.40
$10.27
$195.26
$404.09
$0.00
$0.00
$352.11
$1.06
$1.01
$0.02
$0.77
$4.82
$0.00
$0.00
$1.73
$0.00
$0.00
$38.26
$38.26
$33.45
$38.86
$37.31
$8.47
$334.51
$41.77
$0.00
$34.90
$42.44
$38.12
$66.18
$55.81
$39.36
$0.00
$10.83
$1.26
$0.00
$0.00
$0.00
$0.00
$24.36
$163.04
$0.00
$0.43
$1.52
$20.29
$21.77
Procedure Code
J1642
J1644
J1645
J1650
J1652
J1655
J1670
J1675
J1700
J1710
J1720
J1725
J1730
J1740
J1741
J1742
J1743
J1744
J1745
J1750
J1756
J1786
J1790
J1800
J1810
J1815
J1817
J1826
J1830
J1833
J1835
J1840
J1850
J1885
J1890
J1930
J1931
J1940
J1945
J1950
J1953
J1955
J1956
J1960
J1980
J1990
J2001
Description
INJ HEPARIN SODIUM PER 10 U
INJ HEPARIN SODIUM PER 1000U
DALTEPARIN SODIUM
INJ ENOXAPARIN SODIUM
FONDAPARINUX SODIUM
TINZAPARIN SODIUM INJECTION
TETANUS IMMUNE GLOBULIN INJ
HISTRELIN ACETATE
HYDROCORTISONE ACETATE INJ
HYDROCORTISONE SODIUM PH INJ
HYDROCORTISONE SODIUM SUCC I
HYDROXYPROGESTERONE CAPROATE
DIAZOXIDE INJECTION
IBANDRONATE SODIUM INJECTION
IBUPROFEN INJECTION
IBUTILIDE FUMARATE INJECTION
IDURSULFASE INJECTION
ICATIBANT INJECTION
INFLIXIMAB INJECTION
INJ IRON DEXTRAN
IRON SUCROSE INJECTION
IMUGLUCERASE INJECTION
DROPERIDOL INJECTION
PROPRANOLOL INJECTION
DROPERIDOL/FENTANYL INJ
INSULIN INJECTION
INSULIN FOR INSULIN PUMP USE
INTERFERON BETA-1A INJ
INTERFERON BETA-1B / .25 MG
INJECTION, ISAVUCONAZONIUM
ITRACONAZOLE INJECTION
KANAMYCIN SULFATE 500 MG INJ
KANAMYCIN SULFATE 75 MG INJ
KETOROLAC TROMETHAMINE INJ
CEPHALOTHIN SODIUM INJECTION
LANREOTIDE INJECTION
LARONIDASE INJECTION
FUROSEMIDE INJECTION
LEPIRUDIN
LEUPROLIDE ACETATE /3.75 MG
LEVETIRACETAM INJECTION
INJ LEVOCARNITINE PER 1 GM
LEVOFLOXACIN INJECTION
LEVORPHANOL TARTRATE INJ
HYOSCYAMINE SULFATE INJ
CHLORDIAZEPOXIDE INJECTION
LIDOCAINE INJECTION
Pricing Action Code
3
3
3
3
3
6
3
6
6
5
3
6
5
3
9
3
3
6
3
3
3
3
6
3
5
3
3
6
5
3
5
5
5
3
5
3
3
3
6
3
3
3
3
5
3
5
3
Maximum Allowable
$0.19
$0.21
$15.60
$1.15
$2.54
$0.00
$367.04
$0.00
$0.00
$0.00
$7.50
$0.00
$0.00
$108.35
$0.00
$94.25
$488.47
$0.00
$79.91
$12.20
$0.27
$42.00
$0.00
$2.89
$0.00
$0.79
$8.36
$0.00
$0.00
$0.62
$0.00
$0.00
$0.00
$0.70
$0.00
$48.17
$29.45
$2.89
$0.00
$928.95
$0.20
$9.08
$2.39
$0.00
$24.38
$0.00
$0.02
Procedure Code
J2010
J2020
J2060
J2150
J2170
J2175
J2180
J2185
J2210
J2212
J2248
J2250
J2260
J2265
J2270
J2274
J2278
J2280
J2300
J2310
J2315
J2320
J2323
J2325
J2353
J2354
J2355
J2357
J2358
J2360
J2370
J2400
J2405
J2407
J2410
J2425
J2426
J2430
J2440
J2460
J2469
J2501
J2502
J2503
J2504
J2505
J2507
Description
LINCOMYCIN INJECTION
LINEZOLID INJECTION
LORAZEPAM INJECTION
MANNITOL INJECTION
MECASERMIN INJECTION
MEPERIDINE HYDROCHL /100 MG
MEPERIDINE/PROMETHAZINE INJ
MEROPENEM
METHYLERGONOVIN MALEATE INJ
METHYLNALTREXONE INJECTION
MICAFUNGIN SODIUM INJECTION
INJ MIDAZOLAM HYDROCHLORIDE
INJ MILRINONE LACTATE / 5 MG
MINOCYCLINE HYDROCHLORIDE
MORPHINE SULFATE INJECTION
IN MORPHINE PRESERVATIV FREE
ZICONOTIDE INJECTION
INJ, MOXIFLOXACIN 100 MG
INJ NALBUPHINE HYDROCHLORIDE
INJ NALOXONE HYDROCHLORIDE
NALTREXONE, DEPOT FORM
NANDROLONE DECANOATE 50 MG
NATALIZUMAB INJECTION
NESIRITIDE INJECTION
OCTREOTIDE INJECTION, DEPOT
OCTREOTIDE INJ, NON-DEPOT
OPRELVEKIN INJECTION
OMALIZUMAB INJECTION
OLANZAPINE LONG-ACTING INJ
ORPHENADRINE INJECTION
PHENYLEPHRINE HCL INJECTION
CHLOROPROCAINE HCL INJECTION
ONDANSETRON HCL INJECTION
INJECTION, ORITAVANCIN
OXYMORPHONE HCL INJECTION
PALIFERMIN INJECTION
PALIPERIDONE PALMITATE INJ
PAMIDRONATE DISODIUM /30 MG
PAPAVERIN HCL INJECTION
OXYTETRACYCLINE INJECTION
PALONOSETRON HCL
PARICALCITOL
INJ, PASIREOTIDE LONG ACTING
PEGAPTANIB SODIUM INJECTION
PEGADEMASE BOVINE, 25 IU
INJECTION, PEGFILGRASTIM 6MG
PEGLOTICASE INJECTION
Pricing Action Code
3
3
3
3
6
3
6
3
3
6
3
3
5
6
3
3
3
3
3
3
3
5
3
6
3
3
3
3
3
3
5
3
3
3
3
3
3
3
5
5
3
3
6
3
3
3
3
Maximum Allowable
$11.21
$23.71
$0.76
$1.61
$0.00
$4.53
$0.00
$1.31
$4.92
$0.00
$0.97
$0.13
$0.00
$0.00
$1.22
$8.57
$7.18
$9.18
$2.37
$27.99
$3.18
$0.00
$17.02
$0.00
$150.08
$1.23
$428.43
$29.97
$2.92
$5.70
$0.00
$22.82
$0.10
$25.62
$2.84
$16.41
$8.69
$11.58
$0.00
$0.00
$21.47
$0.95
$0.00
$1,036.15
$281.40
$3,828.10
$1,701.00
Procedure Code
J2510
J2513
J2515
J2540
J2543
J2545
J2547
J2550
J2560
J2562
J2590
J2597
J2650
J2670
J2675
J2680
J2690
J2700
J2704
J2710
J2720
J2724
J2725
J2730
J2760
J2765
J2770
J2778
J2780
J2783
J2785
J2788
J2790
J2791
J2792
J2793
J2794
J2795
J2796
J2800
J2805
J2810
J2820
J2850
J2860
J2910
J2916
Description
PENICILLIN G PROCAINE INJ
PENTASTARCH 10% SOLUTION
PENTOBARBITAL SODIUM INJ
PENICILLIN G POTASSIUM INJ
PIPERACILLIN/TAZOBACTAM
PENTAMIDINE NON-COMP UNIT
INJECTION, PERAMIVIR
PROMETHAZINE HCL INJECTION
PHENOBARBITAL SODIUM INJ
PLERIXAFOR INJECTION
OXYTOCIN INJECTION
INJ DESMOPRESSIN ACETATE
PREDNISOLONE ACETATE INJ
TOTAZOLINE HCL INJECTION
INJ PROGESTERONE PER 50 MG
FLUPHENAZINE DECANOATE 25 MG
PROCAINAMIDE HCL INJECTION
OXACILLIN SODIUM INJECITON
INJ, PROPOFOL, 10 MG
NEOSTIGMINE METHYLSLFTE INJ
INJ PROTAMINE SULFATE/10 MG
PROTEIN C CONCENTRATE
INJ PROTIRELIN PER 250 MCG
PRALIDOXIME CHLORIDE INJ
PHENTOLAINE MESYLATE INJ
METOCLOPRAMIDE HCL INJECTION
QUINUPRISTIN/DALFOPRISTIN
RANIBIZUMAB INJECTION
RANITIDINE HYDROCHLORIDE INJ
RASBURICASE
REGADENOSON INJECTION
RHO D IMMUNE GLOBULIN 50 MCG
RHO D IMMUNE GLOBULIN INJ
RHOPHYLAC INJECTION
RHO(D) IMMUNE GLOBULIN H, SD
RILONACEPT INJECTION
RISPERIDONE, LONG ACTING
ROPIVACAINE HCL INJECTION
ROMIPLOSTIM INJECTION
METHOCARBAMOL INJECTION
SINCALIDE INJECTION
INJ THEOPHYLLINE PER 40 MG
SARGRAMOSTIM INJECTION
INJ SECRETIN SYNTHETIC HUMAN
INJECTION, SILTUXIMAB
AUROTHIOGLUCOSE INJECITON
NA FERRIC GLUCONATE COMPLEX
Pricing Action Code
3
6
3
3
3
3
3
3
3
3
5
3
5
5
3
3
3
3
3
6
3
3
5
5
3
3
3
3
3
3
3
3
3
3
3
6
3
3
3
3
3
3
3
3
3
5
3
Maximum Allowable
$22.52
$0.00
$41.67
$0.95
$2.59
$113.74
$1.54
$1.64
$29.20
$307.88
$0.00
$13.52
$0.00
$0.00
$0.97
$22.26
$46.14
$1.81
$0.12
$0.00
$1.17
$15.13
$0.00
$0.00
$159.00
$0.70
$313.31
$387.66
$1.06
$231.87
$54.04
$24.39
$83.74
$4.73
$20.22
$0.00
$7.28
$0.08
$59.11
$43.22
$92.09
$0.29
$34.28
$34.78
$83.40
$0.00
$2.57
Procedure Code
J2920
J2930
J2940
J2941
J2950
J2993
J2994
J2995
J2997
J3000
J3010
J3030
J3060
J3070
J3090
J3095
J3101
J3105
J3110
J3121
J3145
J3230
J3240
J3243
J3246
J3250
J3260
J3262
J3265
J3280
J3285
J3300
J3301
J3302
J3303
J3305
J3310
J3315
J3320
J3350
J3355
J3357
J3360
J3364
J3365
J3370
J3380
Description
METHYLPREDNISOLONE INJECTION
METHYLPREDNISOLONE INJECTION
SOMATREM INJECTION
SOMATROPIN INJECTION
PROMAZINE HCL INJECTION
RETEPLASE INJECTION
RETEPLASE DOUBLE BOLUS
INJ STREPTOKINASE /250000 IU
ALTEPLASE RECOMBINANT
STREPTOMYCIN INJECTION
FENTANYL CITRATE INJECITON
SUMATRIPTAN SUCCINATE / 6 MG
INJ, TALIGLUCERACE ALFA 10 U
PENTAZOCINE INJECTION
INJ TEDIZOLID PHOSPHATE
TELAVANCIN INJECTION
TENECTEPLASE INJECTION
TERBUTALINE SULFATE INJ
TERIPARATIDE INJECTION
INJ TESTOSTERO ENANTHATE 1MG
TESTOSTERONE UNDECANOATE 1MG
CHLORPROMAZINE HCL INJECTION
THYROTROPIN INJECTION
TIGECYCLINE INJECTION
TIROFIBAN HCL
TRIMETHOBENZAMIDE HCL INJ
TOBRAMYCIN SULFATE INJECTION
TOCILIZUMAB INJECTION
INJECTION TORSEMIDE 10 MG/ML
THIETHYLPERAZINE MALEATE INJ
TREPROSTINIL INJECTION
TRIAMCINOLONE A INJ PRS-FREE
TRIAMCINOLONE ACET INJ NOS
TRIAMCINOLONE DIACETATE INJ
TRIAMCINOLONE HEXACETONL INJ
INJ TRIMETREXATE GLUCORONATE
PERPHENAZINE INJECITON
TRIPTORELIN PAMOATE
SPECTINOMYCN DI-HCL INJ
UREA INJECTION
UROFOLLITROPIN, 75 IU
USTEKINUMAB INJECTION
DIAZEPAM INJECTION
UROKINASE 5000 IU INJECTION
UROKINASE 250,000 IU INJ
VANCOMYCIN HCL INJECTION
INJECTION, VEDOLIZUMAB
Pricing Action Code
3
3
5
5
5
5
9
5
3
3
3
6
3
3
3
3
3
3
6
3
6
3
3
3
6
3
3
3
5
5
3
3
3
6
3
5
5
3
5
5
9
3
3
5
5
3
3
Maximum Allowable
$2.90
$4.11
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$74.69
$11.85
$0.49
$0.00
$38.56
$120.17
$1.21
$5.30
$93.93
$0.85
$0.00
$0.04
$0.00
$19.21
$1,431.97
$2.43
$0.00
$23.73
$2.68
$4.00
$0.00
$0.00
$61.24
$3.75
$1.81
$0.00
$1.81
$0.00
$0.00
$238.97
$0.00
$0.00
$0.00
$170.98
$6.64
$0.00
$0.00
$3.87
$17.03
Procedure Code
J3385
J3396
J3400
J3410
J3411
J3415
J3420
J3430
J3465
J3470
J3471
J3472
J3473
J3475
J3480
J3485
J3486
J3489
J3490
J3520
J3530
J3535
J3570
J3590
J7030
J7040
J7042
J7050
J7060
J7070
J7100
J7110
J7120
J7121
J7131
J7140
J7150
J7178
J7180
J7181
J7182
J7183
J7185
J7186
J7187
J7188
J7189
Description
Pricing Action Code
VELAGLUCERASE ALFA
VERTEPORFIN INJECTION
TRIFLUPROMAZINE HCL INJ
HYDROXYZINE HCL INJECTION
THIAMINE HCL 100 MG
PYRIDOXINE HCL 100 MG
VITAMIN B12 INJECTION
VITAMIN K PHYTONADIONE INJ
INJECTION, VORICONAZOLE
HYALURONIDASE INJECTION
OVINE, UP TO 999 USP UNITS
OVINE, 1000 USP UNITS
HYALURONIDASE RECOMBINANT
INJ MAGNESIUM SULFATE
INJ POTASSIUM CHLORIDE
ZIDOVUDINE
ZIPRASIDONE MESYLATE
ZOLEDRONIC ACID 1MG
DRUGS UNCLASSIFIED INJECTION
EDETATE DISODIUM PER 150 MG
NASAL VACCINE INHALATION
METERED DOSE INHALER DRUG
LAETRILE AMYGDALIN VIT B17
UNCLASSIFIED BIOLOGICS
NORMAL SALINE SOLUTION INFUS
5% DEXTROSE/NORMAL SALINE
5% DEXTROSE/WATER
D5W INFUSION
DEXTRAN 40 INFUSION
DEXTRAN 75 INFUSION
RINGERS LACTATE INFUSION
5% DEXTROSE IN LAC RINGERS
HYPERTONIC SALINE SOL
PRESCRIPTION DRUG, ORAL, DISPENSED
PRESCRIPTION DRUG, ORAL CHEMOTHER
HUMAN FIBRINOGEN CONC INJ
FACTOR XIII ANTI-HEM FACTOR
FACTOR XIII RECOMB A-SUBUNIT
FACTOR VIII RECOMB NOVOEIGHT
WILATE INJECTION
XYNTHA INJ
ANTIHEMOPHILIC VIII/VWF COMP
HUMATE-P, INJ
FACTOR VIII RECOMB OBIZUR
FACTOR VIIA
3
6
5
3
3
3
3
3
3
5
6
6
3
3
3
3
3
3
5
5
9
9
9
5
3
3
6
3
3
3
5
5
3
3
6
9
9
6
3
6
6
3
3
3
3
3
3
Maximum Allowable
$342.86
$0.00
$0.00
$2.19
$3.22
$9.86
$2.64
$2.74
$3.88
$0.00
$0.00
$0.00
$0.36
$0.22
$0.14
$1.50
$15.58
$27.53
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$1.88
$0.94
$0.00
$0.46
$1.84
$3.58
$0.00
$0.00
$1.82
$1.67
$0.00
$0.00
$0.00
$0.00
$7.77
$0.00
$0.00
$1.00
$1.22
$0.97
$1.00
$1.00
$1.97
Procedure Code
J7190
J7191
J7192
J7193
J7194
J7195
J7196
J7197
J7198
J7199
J7200
J7201
J7205
J7297
J7298
J7300
J7301
J7303
J7304
J7306
J7307
J7308
J7309
J7310
J7311
J7312
J7313
J7315
J7316
J7321
J7323
J7324
J7325
J7326
J7327
J7328
J7330
J7336
J7340
J7500
J7501
J7502
J7503
J7504
J7505
J7506
J7507
Description
FACTOR VIII
FACTOR VIII (PORCINE)
FACTOR VIII RECOMBINANT NOS
FACTOR IX NON-RECOMBINANT
FACTOR IX COMPLEX
FACTOR IX RECOMBINANT NOS
ANTITHROMBIN RECOMBINANT
ANTITHROMBIN III INJECTION
ANTI-INHIBITOR
HEMOPHILIA CLOT FACTOR NOC
FACTOR IX RECOMBINAN RIXUBIS
FACTOR IX FC FUSION RECOMB
FACTOR VIII FC FUSION RECOMB
LEVONORGESTREL IU 52MG 3 YR
LEVONORGESTREL IU 52MG 5 YR
INTRAUT COPPER CONTRACEPTIVE
LEVONORGESTREL IU 13.5 MG
CONTRACEPTIVE VAGINAL RING
CONTRACEPTIVE HORMONE PATCH
LEVONORGESTREL IMPLANT SYS
ETONOGESTREL IMPLANT SYSTEM
AMINOLEVULINIC ACID HCL TOP
METHYL AMINOLEVULINATE, TOP
GANCICLOVIR LONG ACT IMPLANT
FLUOCINOLONE ACETONIDE IMPLT
DEXAMETHASONE INTRA IMPLANT
FLUOCINOL ACET INTRAVIT IMP
OPHTHALMIC MITOMYCIN
INJ, OCRIPLASMIN, 0.125 MG
HYALGAN/SUPARTZ INJ PER DOSE
EUFLEXXA INJ PER DOSE
ORTHOVISC INJ PER DOSE
SYNVISC OR SYNVISC-ONE
GEL-ONE
MONOVISC INJ PER DOSE
GEL-SYN INJECTION 0.1 MG
CULTURED CHONDROCYTES IMPLNT
CAPSAICIN 8% PATCH
CARBIDOPA LEVODOPA ENTERAL
AZATHIOPRINE ORAL 50MG
AZATHIOPRINE PARENTERAL
CYCLOSPORINE ORAL 100 MG
TACROL ENVARSUS EX REL ORAL
LYMPHOCYTE IMMUNE GLOBULIN
MONOCLONAL ANTIBODIES
PREDNISONE ORAL
TACROLIMUS IMME REL ORAL 1MG
Pricing Action Code
3
5
3
3
3
3
6
3
3
5
3
3
3
3
3
6
3
9
9
9
3
3
6
9
3
3
9
9
3
3
3
3
3
3
3
6
9
3
3
3
5
3
9
3
5
3
3
Maximum Allowable
$0.96
$0.00
$1.18
$1.10
$1.22
$1.45
$0.00
$3.62
$1.90
$0.00
$1.24
$2.81
$1.89
$607.50
$787.81
$0.00
$632.11
$0.00
$0.00
$0.00
$749.91
$292.56
$0.00
$0.00
$19,262.81
$201.12
$0.00
$0.00
$1,046.75
$88.12
$149.10
$168.54
$13.13
$563.61
$935.00
$0.00
$0.00
$2.89
$1.96
$0.36
$0.00
$3.36
$0.00
$1,071.39
$0.00
$0.06
$0.85
Procedure Code
J7508
J7509
J7510
J7511
J7512
J7513
J7515
J7516
J7517
J7518
J7520
J7525
J7527
J7599
J7604
J7605
J7606
J7607
J7608
J7609
J7610
J7611
J7612
J7613
J7614
J7615
J7620
J7622
J7624
J7626
J7627
J7628
J7629
J7631
J7632
J7633
J7634
J7635
J7636
J7637
J7638
J7639
J7640
J7641
J7642
J7643
J7644
Description
TACROL ASTAGRAF EX REL ORAL
METHYLPREDNISOLONE ORAL
PREDNISOLONE ORAL PER 5 MG
ANTITHYMOCYTE GLOBULN RABBIT
PREDNISONE IR OR DR ORAL 1MG
DACLIZUMAB, PARENTERAL
CYCLOSPORIN PARENTERAL 250MG
MYCOPHENOLATE MOFETIL ORAL
MYCOPHENOLIC ACID
SIROLIMUS, ORAL
TACROLIMUS INJECTION
ORAL EVEROLIMUS
IMMUNOSUPPRESSIVE DRUG NOC
ACETYLCYSTEINE COMP UNIT
ARFORMOTEROL NON-COMP UNIT
FORMOTEROL FUMARATE, INH
LEVALBUTEROL COMP CON
ACETYLCYSTEINE NON-COMP UNIT
ALBUTEROL COMP UNIT
ALBUTEROL COMP CON
ALBUTEROL NON-COMP CON
LEVALBUTEROL NON-COMP CON
ALBUTEROL NON-COMP UNIT
LEVALBUTEROL NON-COMP UNIT
LEVALBUTEROL COMP UNIT
ALBUTEROL IPRATROP NON-COMP
BECLOMETHASONE COMP UNIT
BETAMETHASONE COMP UNIT
BUDESONIDE NON-COMP UNIT
BUDESONIDE COMP UNIT
BITOLTEROL MESYLATE COMP CON
BITOLTEROL MESYLATE COMP UNT
CROMOLYN SODIUM NONCOMP UNIT
CROMOLYN SODIUM COMP UNIT
BUDESONIDE NON-COMP CON
BUDESONIDE COMP CON
ATROPINE COMP CON
ATROPINE COMP UNIT
DEXAMETHASONE COMP CON
DEXAMETHASONE COMP UNIT
DORNASE ALFA NON-COMP UNIT
FORMOTEROL COMP UNIT
FLUNISOLIDE COMP UNIT
GLYCOPYRROLATE COMP CON
GLYCOPYRROLATE COMP UNIT
IPRATROPIUM BROMIDE NON-COMP
Pricing Action Code
3
3
3
3
3
5
3
3
3
3
3
3
3
5
9
3
3
9
3
9
9
3
3
3
3
9
3
9
9
3
9
9
9
3
9
9
9
9
9
9
9
3
9
9
9
9
3
Maximum Allowable
$0.39
$0.33
$0.13
$643.00
$0.13
$0.00
$0.98
$42.69
$1.01
$3.06
$9.67
$160.39
$7.50
$0.00
$0.00
$8.26
$9.41
$0.00
$4.02
$0.00
$0.00
$0.12
$0.28
$0.05
$0.08
$0.00
$0.15
$0.00
$0.00
$5.32
$0.00
$0.00
$0.00
$0.80
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$38.99
$0.00
$0.00
$0.00
$0.00
$0.21
Procedure Code
J7645
J7647
J7648
J7649
J7650
J7657
J7658
J7659
J7660
J7665
J7667
J7668
J7669
J7670
J7674
J7676
J7680
J7681
J7682
J7683
J7684
J7685
J7686
J7999
J8498
J8499
J8501
J8510
J8515
J8520
J8521
J8530
J8540
J8560
J8562
J8565
J8597
J8600
J8610
J8650
J8655
J8700
J8705
J8999
J9000
J9015
J9017
Description
IPRATROPIUM BROMIDE COMP
ISOETHARINE COMP CON
ISOETHARINE NON-COMP CON
ISOETHARINE NON-COMP UNIT
ISOETHARINE COMP UNIT
ISOPROTERENOL COMP CON
ISOPROTERENOL NON-COMP CON
ISOPROTERENOL NON-COMP UNIT
ISOPROTERENOL COMP UNIT
MANNITOL FOR INHALER
METAPROTERENOL COMP CON
METAPROTERENOL NON-COMP CON
METAPROTERENOL NON-COMP UNIT
METAPROTERENOL COMP UNIT
METHACHOLINE CHLORIDE, NEB
PENTAMIDINE COMP UNIT DOSE
TERBUTALINE SULF COMP CON
TERBUTALINE SULF COMP UNIT
TOBRAMYCIN NON-COMP UNIT
TRIAMCINOLONE COMP CON
TRIAMCINOLONE COMP UNIT
TOBRAMYCIN COMP UNIT
TREPROSTINIL, NON-COMP UNIT
COMPOUNDED DRUG, NOC
ANTIEMETIC RECTAL/SUPP NOS
ORAL PRESCRIP DRUG NON CHEMO
ORAL APREPITANT
ORAL BUSULFAN
CABERGOLINE, ORAL 0.25MG
CAPECITABINE, ORAL, 150 MG
CAPECITABINE, ORAL, 500 MG
CYCLOPHOSPHAMIDE ORAL 25 MG
ORAL DEXAMETHASONE
ETOPOSIDE ORAL 50 MG
ORAL FLUDARABINE PHOSPHATE
GEFITINIB ORAL
ANTIEMETIC DRUG ORAL NOS
MELPHALAN ORAL 2 MG
METHOTREXATE ORAL 2.5 MG
NABILONE ORAL
NETUPITANT PALONOSETRON ORAL
TEMOZOLOMIDE
TOPOTECAN ORAL
ORAL PRESCRIPTION DRUG CHEMO
DOXORUBICIN HCL INJECTION
ALDESLEUKIN INJECTION
ARSENIC TRIOXIDE INJECTION
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
9
9
9
9
3
9
9
9
3
9
9
9
3
9
9
9
3
3
9
3
3
3
3
3
6
9
9
3
3
9
3
3
3
9
3
5
3
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.52
$0.00
$0.00
$0.00
$55.61
$0.00
$0.00
$0.00
$473.85
$0.00
$0.00
$0.00
$10.20
$12.34
$0.00
$5.24
$16.65
$3.68
$0.12
$68.62
$0.00
$0.00
$0.00
$11.21
$1.38
$0.00
$494.08
$3.62
$101.16
$0.00
$3.10
$0.00
$59.26
Procedure Code
J9019
J9020
J9025
J9027
J9031
J9032
J9033
J9035
J9039
J9040
J9041
J9042
J9043
J9045
J9047
J9050
J9055
J9060
J9065
J9070
J9098
J9100
J9120
J9130
J9150
J9151
J9155
J9160
J9165
J9171
J9175
J9178
J9179
J9181
J9185
J9190
J9200
J9201
J9202
J9206
J9207
J9208
J9209
J9211
J9212
J9213
J9214
Description
ERWINAZE INJECTION
ASPARAGINASE, NOS
AZACITIDINE INJECTION
CLOFARABINE INJECTION
BCG LIVE INTRAVESICAL VAC
INJECTION, BELINOSTAT, 10MG
BENDAMUSTINE INJECTION
BEVACIZUMAB INJECTION
INJECTION, BLINATUMOMAB
BLEOMYCIN SULFATE INJECTION
BORTEZOMIB INJECTION
BRENTUXIMAB VEDOTIN INJ
CABAZITAXEL INJECTION
CARBOPLATIN INJECTION
INJECTION, CARFILZOMIB, 1 MG
CARMUSTINE INJECTION
CETUXIMAB INJECTION
CISPLATIN 10 MG INJECTION
INJ CLADRIBINE PER 1 MG
CYCLOPHOSPHAMIDE 100 MG INJ
CYTARABINE LIPOSOME INJ
CYTARABINE HCL 100 MG INJ
DACTINOMYCIN INJECTION
DACARBAZINE 100 MG INJ
DAUNORUBICIN INJECTION
DAUNORUBICIN CITRATE INJ
DEGARELIX INJECTION
DENILEUKIN DIFTITOX INJ
DIETHYLSTILBESTROL INJECTION
DOCETAXEL INJECTION
ELLIOTTS B SOLUTION PER ML
INJ, EPIRUBICIN HCL, 2 MG
ERIBULIN MESYLATE INJECTION
ETOPOSIDE INJECTION
FLUDARABINE PHOSPHATE INJ
FLUOROURACIL INJECTION
FLOXURIDINE INJECTION
GEMCITABINE HCL INJECTION
GOSERELIN ACETATE IMPLANT
IRINOTECAN INJECTION
IXABEPILONE INJECTION
IFOSFAMIDE INJECTION
MESNA INJECTION
IDARUBICIN HCL INJECTION
INTERFERON ALFACON-1 INJ
INTERFERON ALFA-2A INJ
INTERFERON ALFA-2B INJ
Pricing Action Code
3
6
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
5
3
5
5
3
6
3
3
3
3
3
3
3
3
3
3
3
3
3
5
5
3
Maximum Allowable
$358.55
$0.00
$2.99
$138.32
$123.76
$32.50
$24.59
$70.84
$88.27
$21.20
$46.76
$118.39
$147.72
$3.63
$30.88
$3,217.51
$53.81
$1.55
$17.54
$48.67
$559.48
$0.88
$1,085.72
$3.78
$26.46
$0.00
$3.65
$0.00
$0.00
$2.60
$0.00
$1.61
$104.43
$0.63
$67.39
$1.81
$69.59
$8.72
$276.66
$4.18
$73.47
$30.94
$4.15
$39.05
$0.00
$0.00
$23.90
Procedure Code
J9215
J9216
J9217
J9218
J9219
J9225
J9226
J9228
J9230
J9245
J9250
J9260
J9261
J9262
J9263
J9264
J9266
J9267
J9268
J9270
J9271
J9280
J9293
J9299
J9300
J9301
J9302
J9303
J9305
J9306
J9307
J9308
J9310
J9315
J9320
J9328
J9330
J9340
J9351
J9354
J9355
J9357
J9360
J9370
J9371
J9390
J9395
Description
INTERFERON ALFA-N3 INJ
INTERFERON GAMMA 1-B INJ
LEUPROLIDE ACETATE SUSPNSION
LEUPROLIDE ACETATE INJECITON
LEUPROLIDE ACETATE IMPLANT
VANTAS IMPLANT
SUPPRELIN LA IMPLANT
IPILIMUMAB INJECTION
MECHLORETHAMINE HCL INJ
INJ MELPHALAN HYDROCHL 50 MG
METHOTREXATE SODIUM INJ
METHOTREXATE SODIUM INJ
NELARABINE INJECTION
INJ, OMACETAXINE MEP, 0.01MG
OXALIPLATIN
PACLITAXEL PROTEIN BOUND
PEGASPARGASE INJECTION
PACLITAXEL INJECTION
PENTOSTATIN INJECTION
PLICAMYCIN (MITHRAMYCIN) INJ
INJ PEMBROLIZUMAB
MITOMYCIN INJECTION
MITOXANTRONE HYDROCHL / 5 MG
INJECTION, NIVOLUMAB
GEMTUZUMAB OZOGAMICIN INJ
OBINUTUZUMAB INJ
OFATUMUMAB INJECTION
PANITUMUMAB INJECTION
PEMETREXED INJECTION
INJECTION, PERTUZUMAB, 1 MG
PRALATREXATE INJECTION
INJECTION, RAMUCIRUMAB
RITUXIMAB INJECTION
ROMIDEPSIN INJECTION
STREPTOZOCIN INJECTION
TEMOZOLOMIDE INJECTION
TEMSIROLIMUS INJECTION
THIOTEPA INJECTION
TOPOTECAN INJECTION
INJ, ADO-TRASTUZUMAB EMT 1MG
TRASTUZUMAB INJECTION
VALRUBICIN INJECTION
VINBLASTINE SULFATE INJ
VINCRISTINE SULFATE 1 MG INJ
INJ, VINCRISTINE SUL LIP 1MG
VINORELBINE TARTRATE INJ
INJECTION, FULVESTRANT
Pricing Action Code
5
5
3
3
5
3
3
3
3
3
3
3
3
3
3
3
3
3
3
5
3
3
3
3
5
3
3
3
3
3
3
3
3
3
3
3
3
5
3
3
3
3
3
3
3
3
3
Maximum Allowable
$0.00
$0.00
$252.59
$16.16
$0.00
$3,007.40
$3,207.60
$139.26
$226.17
$1,604.05
$0.23
$2.31
$148.12
$2.41
$0.39
$10.03
$8,957.17
$0.15
$1,620.74
$0.00
$45.69
$107.60
$27.37
$25.37
$0.00
$55.36
$50.53
$103.39
$61.76
$10.47
$202.74
$54.01
$726.95
$276.24
$320.01
$6.74
$63.74
$0.00
$2.00
$29.21
$89.51
$1,049.13
$2.99
$6.49
$1,767.04
$11.00
$93.58
Procedure Code
J9400
J9600
J9999
K0001
K0002
K0003
K0004
K0005
K0006
K0007
K0008
K0009
K0010
K0011
K0012
K0013
K0014
K0015
K0017
K0018
K0019
K0020
K0037
K0038
K0039
K0040
K0041
K0042
K0043
K0044
K0045
K0046
K0047
K0050
K0051
K0052
K0053
K0056
K0065
K0069
K0070
K0071
K0072
K0073
K0077
K0098
K0105
Description
INJ, ZIV-AFLIBERCEPT, 1MG
PORFIMER SODIUM INJECTION
CHEMOTHERAPY DRUG
STANDARD WHEELCHAIR
STND HEMI (LOW SEAT) WHLCHR
LIGHTWEIGHT WHEELCHAIR
HIGH STRENGTH LTWT WHLCHR
ULTRALIGHTWEIGHT WHEELCHAIR
HEAVY DUTY WHEELCHAIR
EXTRA HEAVY DUTY WHEELCHAIR
CSTM MANUAL WHEELCHAIR/BASE
OTHER MANUAL WHEELCHAIR/BASE
STND WT FRAME POWER WHLCHR
STND WT PWR WHLCHR W CONTROL
LTWT PORTBL POWER WHLCHR
CUSTOM POWER WHLCHR BASE
OTHER POWER WHLCHR BASE
DETACH NON-ADJUS HGHT ARMRST
DETACH ADJUST ARMREST BASE
DETACH ADJUST ARMRST UPPER
ARM PAD EACH
FIXED ADJUST ARMREST PAIR
HIGH MOUNT FLIP-UP FOOTREST
LEG STRAP EACH
LEG STRAP H STYLE EACH
ADJUSTABLE ANGLE FOOTPLATE
LARGE SIZE FOOTPLATE EACH
STANDARD SIZE FOOTPLATE EACH
FTRST LOWER EXTENSION TUBE
FTRST UPPER HANGER BRACKET
FOOTREST COMPLETE ASSEMBLY
ELEVAT LEGRST LOW EXTENSION
ELEVAT LEGRST UP HANGR BRACK
RATCHET ASSEMBLY
CAM RELESE ASSEM FTRST/LGRST
SWINGAWAY DETACH FOOTREST
ELEVATE FOOTREST ARTICULATE
SEAT HT <17 OR >=21 LTWT WC
SPOKE PROTECTORS
REAR WHL COMPLETE SOLID TIRE
REAR WHL COMPL PNEUM TIRE
FRONT CASTR COMPL PNEUM TIRE
FRNT CSTR CMPL SEM-PNEUM TIR
CASTER PIN LOCK EACH
FRONT CASTER ASSEM COMPLETE
DRIVE BELT POWER WHEELCHAIR
IV HANGER
Pricing Action Code
3
5
5
3
5
3
3
3
3
5
6
5
5
5
5
6
5
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$8.21
$0.00
$0.00
$418.80
$0.00
$0.00
$0.00
$2,043.83
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$146.20
$46.20
$25.93
$13.23
$46.23
$43.47
$22.47
$49.08
$60.45
$47.58
$31.73
$18.17
$15.65
$51.19
$19.44
$67.99
$32.34
$48.22
$75.67
$92.23
$95.10
$44.24
$97.75
$177.59
$112.26
$68.29
$34.63
$56.56
$27.07
$102.99
Procedure Code
K0108
K0109
K0110
K0111
K0119
K0120
K0121
K0122
K0123
K0124
K0125
K0126
K0127
K0128
K0129
K0130
K0137
K0138
K0139
K0140
K0141
K0142
K0143
K0144
K0145
K0146
K0152
K0154
K0163
K0168
K0169
K0170
K0171
K0172
K0173
K0174
K0175
K0176
K0177
K0178
K0179
K0180
K0181
K0182
K0190
K0191
K0192
Description
Pricing Action Code
W/C COMPONENT-ACCESSORY NOS
CUSTOMIZE WHLCHR BASE FRAME
SUPPLIES FOR MAINTENANCE OF DRUG I
SUPPLIES FOR EXTERNAL DRUG INFUSION
AZATHIOPRINE ORAL TAB 50 MG
AZATHIOPRINE PRENTRL 100 MG
CYCLOSPORINE PRENTRL 250 MG
IMUN/ANTITYMOCYT GLOB 250 MG
MONOCLONAL ANTIBODIES - PARENTERA
PREDNISONE - ORAL, 5 MG
REPLACE SOFT INTERFACE MATERIAL, M
REPLACE SOFT INTERFACE MATERIAL, AN
REPLACE SOFT INTERFACE MATERIAL, FO
ANKLE CONTRACTURE SPLINT
FOOT DROP SPLINT, RECUMBENT POSITI
SKIN BARRIER LIQUID PER OZ
SKIN BARRIER PASTE PER OZ
SKIN BARRIER POWDER PER OZ
ACETYLCYSTEINE, COMPOUNDED, PER M
ALBUTEROL SULFATE, COMPOUNDED, PE
CROMOLYN SODIUM, COMPOUNDED, PE
ISOETHARINE HYDROCHLORIDE, COMPO
ISOPROTHERENOL HYDROCHLORIDE, CO
METAPROTERENOL, COMPOUNDED, PER
TERBUTALINE, COMPOUNDED, PER MG,
PASTES, POWDERS, GRANULES, BEADS, C
WOUND POUCH, EACH
VACUUM ERECTION SYSTEM
DISPOSABLE NEBULIZER SET
DISPOSABLE NEBULIZER SMALL
NON DISPOSABLE NEBULIZER SET
FILTERED NEBULIZER SET
DISPOSABLE NEBULIZER UNFILL
DISPOSABLE NEBULIZER PREFILL
RESERVOIR BOTTLE W NEBULIZER
DISPOSABLE CORRUGATED TUBING
NON DISPOS CORRUGATED TUBING
WATER COLLEC DEV W NEBULIZER
DISPOSBL FILTER W COMPRESSOR
NON-DISPOS FILTER W/COMPRESS
AEROSOL MASK WITH NEBULIZER
DOME & MOUTHPIECE W/ NEBULIZ
WATER DISTILLED W/ NEBULIZER
DISPOSABLE CANISTER W/PUMP
NON-DISPOSBL CANISTER W/PUMP
TUBING USED W/ SUCTION PUMP
5
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
K0193
K0194
K0195
K0196
K0197
K0198
K0199
K0203
K0204
K0205
K0206
K0207
K0208
K0209
K0210
K0211
K0212
K0213
K0214
K0215
K0216
K0217
K0218
K0219
K0220
K0221
K0222
K0223
K0224
K0228
K0229
K0230
K0234
K0235
K0236
K0237
K0238
K0239
K0240
K0241
K0242
K0243
K0244
K0245
K0246
K0247
K0248
Description
Pricing Action Code
AIRWAY PRESSURE DEV/W HMDFER
ASSIST DEVICE W/HUMIDIFIER
ELEVATING WHLCHAIR LEG RESTS
ALGINATE DRESSING, WOUND COVER, PA
ALGINATE DRESSING, WOUND FILLER, PE
COMPOSITE DRESSING, PAD SIZE 16 SQ.
COMPOSITE DRESSING, PAD SIZE MORE T
COMPOSITE DRESSING, PAD SIZE MORE T
CONTACT LAYER, 16 SQ. IN. OR LESS,
CONTACT LAYER, MORE THAN 16 BUT LE
CONTACT LAYER, MORE THAN 48 SQ. IN.
FOAM DRESSING, WOUND COVER, PAD S
FOAM DRESSING, WOUND FILLER, PER G
GAUZE, NON-IMPREGNATED, NON-STER
GAUZE, NON-IMPREGNATED, PAD SIZE 1
GAUZE, NON-IMPREGNATED, PAD SIZE M
GAUZE, NON-IMPREGNATED, PAD SIZE M
GAUZE, IMPREGNATED, OTHER THAN WA
GAUZE, IMPREGNATED, WATER OR NOR
HYDROCOLLOID DRESSING, WOUND COV
HYDROCOLLOID DRESSING, WOUND FILL
HYDROCOLLOID DRESSING, WOUND FILL
HYDROGEL DRESSING, WOUND COVER, P
HYDROGEL DRESSING, WOUND FILLER, G
9
9
3
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
K0249
K0250
K0251
K0252
K0253
K0254
K0255
K0256
K0257
K0258
K0259
K0260
K0261
K0262
K0263
K0264
K0265
K0266
K0269
K0270
K0271
K0272
K0273
K0274
K0275
K0276
K0277
K0278
K0279
K0280
K0281
K0283
K0284
K0285
K0400
K0401
K0402
K0403
K0404
K0405
K0406
K0407
K0408
K0409
K0410
K0411
K0412
Description
Pricing Action Code
HYDROGEL DRESSING, WOUND FILLER, D
SKIN SEALANTS, PROTECTANTS, MOISTU
SPECIALTY ABSORPTIVE DRESSING, WOU
TRANSPARENT FILM, 16 SQ. IN. OR LES
TRANSPARENT FILM, MORE THAN 16 BU
TRANSPARENT FILM, MORE THAN 48 SQ
WOUND CLEANSERS, ANY TYPE, ANY SIZE
WOUND FILLER, NOT ELSEWHERE CLASS
WOUND FILLER, NOT ELSEWHERE CLASS
GAUZE, ELASTIC, NON-STERILE, ALL T
GAUZE, NON-ELASTIC, NON-STERILE, PE
TAPE, ALL TYPES, PER 18 SQUARE INCH
AEROSOL COMPRESSOR CPAP DEV
ULTRASONIC GENERATOR W NEBUL
POUCH, DRAINABLE; WITH FACEPLATE A
POUCH, DRAINABLE; WITHOUT FACEPLA
POUCH, URINARY; WITH FACEPLATE ATT
POUCH, URINARY; WITHOUT FACEPLATE
OSTOMY FACEPLATE; CONVEX; REUSABL
OSTOMY FACEPLATE; CONVEX; CUSTOM
SKIN BARRIER SOLID 4X4 EQUIV
SKIN BARRIER WITH FLANGE
SKIN BARRIER EXTENDED WEAR
EXTENSION DRAINAGE TUBING
LUBRICANT CATHETER INSERTION
SALINE SOLUTION DISPENSER
EXTERNAL INFUSION PUMP REUSE
REPAIR OF PROSTHETIC DEVICE, LABOR
SKIN SUPPORT ATTACHMENT EACH
DIABETIC DELUXE SHOE
GAUZE, NON-IMPREGNATED, STERILE, PA
GAUZE, ELASTIC, STERILE, ALL TYPES,
GAUZE, NON-ELASTIC, STERILE, PER LI
URINARY CATH SKIN ATTACHMENT
URINARY CATH LEG STRAP
STERILE H2O IRRIGATION SOLUT
MALE EXT CATH W/ADH COATING
MALE EXT CATH W/ADH STRIP
MYCOPHENOLATE MOFETIL 25O MG
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
K0417
K0418
K0419
K0420
K0421
K0422
K0423
K0424
K0425
K0426
K0427
K0428
K0429
K0430
K0431
K0432
K0433
K0434
K0435
K0436
K0437
K0438
K0439
K0440
K0441
K0442
K0443
K0444
K0445
K0446
K0447
K0448
K0449
K0450
K0451
K0453
K0455
K0462
K0501
K0503
K0504
K0505
K0506
K0507
K0508
K0509
K0511
Description
MECH INFUS PUMP SHT TRM DRUG
ORAL CYCLOSPORIN
DRAINABLE PLSTIC PCH W FCPLT
DRAINABLE RUBBER PCH W FCPLT
DRAINABLE PLSTIC PCH W/O FP
DRAINABLE RUBBER PCH W/O FP
URINARY PLSTIC POUCH W FCPLT
URINARY RUBBER POUCH W FCPLT
URINARY PLSTIC POUCH W/O FP
URINARY HVY PLSTC PCH W/O FP
URINARY RUBBER POUCH W/O FP
OSTOMY FACEPLT/SILICONE RING
SKIN BARRIER SOLID EXT WEAR
SKIN BARRIER W FLANG EX WEAR
CLOSED POUCH W ST WEAR BAR
DRAINABLE PCH W EX WEAR BAR
DRAINABLE PCH W ST WEAR BAR
DRAINABLE PCH EX WEAR CONVEX
URINARY POUCH W EX WEAR BAR
URINARY POUCH W ST WEAR BAR
URINE PCH W EX WEAR BAR CONV
OSTOMY POUCH LIQ DEODORANT
OSTOMY POUCH SOLID DEODORANT
NASAL PROSTHESIS
MIDFACIAL PROSTHESIS
ORBITAL PROSTHESIS
UPPER FACIAL PROSTHESIS
HEMI-FACIAL PROSTHESIS
AURICULAR PROSTHESIS
PARTIAL FACIAL PROSTHESIS
NASAL SEPTAL PROSTHESIS
UNSPEC MAXILLOFACIAL PROSTH
REPAIR MAXILLOFACIAL PROSTH
LIQ ADHES FOR FACIAL PROSTH
ADHESIVE REMOVER WIPES
AMPHOTERICIN B
PUMP UNINTERRUPTED INFUSION
TEMPORARY REPLACEMENT EQPMNT
AEROSOL COMPRESSOR FOR SVNEB
ACETYLCYSTEINE INH SOL U D
ALBUTEROL INH SOL CON
ALBUTEROL INH SOL U D
ATROPINE INH SOL CON
ATROPINE INH SOL U D
BITOLTEROL MES INH SOL CON
BITOLTEROL MES INH SOL U D
CROMOLYN SODIUM INH SOL U D
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
K0512
K0513
K0514
K0515
K0516
K0518
K0519
K0520
K0521
K0522
K0523
K0524
K0525
K0526
K0527
K0528
K0529
K0530
K0551
K0552
K0561
K0562
K0601
K0602
K0603
K0604
K0605
K0606
K0607
K0608
K0609
K0669
K0672
K0730
K0733
K0738
K0739
K0740
K0743
K0744
K0745
K0746
K0800
K0801
K0802
K0806
K0807
Description
DEXAMETHASONE INH SOL CON
DEXAMETHASONE INH SOL U D
DORNASE ALPHA INH SOL U D
GLYCOPYRROLATE INH SOL CON
GLYCOPYRROLATE INH SOL U D
IPRATROPIUM BROM INH SOL U D
ISOETHARINE HCL INH SOL CON
ISOETHARINE HCL INH SOL U D
ISOPROTERENOLHCL INH SOL CON
ISOPROTERENOLHCL INH SOL U D
METAPROTERENOL INH SOL CON
METAPROTERENOL INH SOL U D
TERBUTALINE SO4 INH SOL CON
TERBUTALINE SO4 INH SOL U D
TRIAMCINOLONE INH SOL CON
TRIAMCINOLONE INH SOL U D
STERILE H20 OR NSS W LV NEB
NEBULIZER NOT USED W OXYGEN
RESIDUAL LIMB SUPPORT SYSTEM
SUPPLY/EXT INF PUMP SYR TYPE
NONPECTIN BASED OSTOMY PASTE
PECTIN BASED OSTOMY PASTE
REPL BATT SILVER OXIDE 1.5 V
REPL BATT SILVER OXIDE 3 V
REPL BATT ALKALINE 1.5 V
REPL BATT LITHIUM 3.6 V
REPL BATT LITHIUM 4.5 V
AED GARMENT W ELEC ANALYSIS
REPL BATT FOR AED
REPL GARMENT FOR AED
REPL ELECTRODE FOR AED
SEAT/BACK CUS NO DMEPDAC VER
REMOVABLE SOFT INTERFACE LE
CTRL DOSE INH DRUG DELIV SYS
12-24HR SEALED LEAD ACID
PORTABLE GAS OXYGEN SYSTEM
REPAIR/SVC DME NON-OXYGEN EQ
REPAIR/SVC OXYGEN EQUIPMENT
PORTABLE HOME SUCTION PUMP
ABSORP DRG <= 16 SUC PUMP
ABSORP DRG >16<=48 SUC PUMP
ABSORP DRG >48 SUC PUMP
POV GROUP 1 STD UP TO 300LBS
POV GROUP 1 HD 301-450 LBS
POV GROUP 1 VHD 451-600 LBS
POV GROUP 2 STD UP TO 300LBS
POV GROUP 2 HD 301-450 LBS
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
6
9
9
6
6
6
6
6
6
6
6
6
6
6
6
6
6
3
9
6
6
6
6
6
6
6
6
6
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$27.38
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
K0808
K0812
K0813
K0814
K0815
K0816
K0820
K0821
K0822
K0823
K0824
K0825
K0826
K0827
K0828
K0829
K0830
K0831
K0835
K0836
K0837
K0838
K0839
K0840
K0841
K0842
K0843
K0848
K0849
K0850
K0851
K0852
K0853
K0854
K0855
K0856
K0857
K0858
K0859
K0860
K0861
K0862
K0863
K0864
K0868
K0869
K0870
Description
POV GROUP 2 VHD 451-600 LBS
POWER OPERATED VEHICLE NOC
PWC GP 1 STD PORT SEAT/BACK
PWC GP 1 STD PORT CAP CHAIR
PWC GP 1 STD SEAT/BACK
PWC GP 1 STD CAP CHAIR
PWC GP 2 STD PORT SEAT/BACK
PWC GP 2 STD PORT CAP CHAIR
PWC GP 2 HD SEAT/BACK
PWC GP 2 HD CAP CHAIR
PWC GP 2 VHD SEAT/BACK
PWC GP VHD CAP CHAIR
PWC GP 2 XTRA HD SEAT/BACK
PWC GP 2 XTRA HD CAP CHAIR
PWC GP2 STD SEAT ELEVATE S/B
PWC GP2 STD SEAT ELEVATE CAP
PWC GP2 STD SING POW OPT S/B
PWC GP2 STD SING POW OPT CAP
PWC GP 2 HD SING POW OPT S/B
PWC GP 2 HD SING POW OPT CAP
PWC GP2 VHD SING POW OPT S/B
PWC GP2 XHD SING POW OPT S/B
PWC GP2 STD MULT POW OPT S/B
PWC GP2 STD MULT POW OPT CAP
PWC GP2 HD MULT POW OPT S/B
PWC GP 3 HD CAP CHAIR
PWC GP 3 VHD CAP CHAIR
PWC GP 3 XHD SEAT/BACK
PWC GP 3 XHD CAP CHAIR
PWC GP3 HD SING POW OPT S/B
PWC GP3 HD SING POW OPT CAP
PWC GP3 HD MULT POW OPT S/B
PWC GP3 VHD MULT POW OPT S/B
PWC GP3 XHD MULT POW OPT S/B
Pricing Action Code
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
K0871
K0877
K0878
K0879
K0880
K0884
K0885
K0886
K0890
K0891
K0898
K0899
K0900
K0901
K0902
L0112
L0113
L0120
L0130
L0140
L0150
L0160
L0170
L0172
L0174
L0180
L0190
L0200
L0220
L0450
L0452
L0454
L0455
L0456
L0457
L0458
L0460
L0462
L0464
L0466
L0467
L0468
L0469
L0470
L0472
L0480
L0482
Description
PWC GP4 HD SING POW OPT S/B
PWC GP4 STD MULT POW OPT CAP
PWC GP4 HD MULT POW S/B
PWC GP5 PED SING POW OPT S/B
PWC GP5 PED MULT POW OPT S/B
POWER WHEELCHAIR NOC
POW MOBIL DEV NO DMEPDAC
CSTM DME OTHER THAN WHEELCHR
KO SINGLE UPRIGHT PRE OTS
KO DOUBLE UPRIGHT PRE OTS
CRANIAL CERVICAL ORTHOSIS
CRANIAL CERVICAL TORTICOLLIS
CERV FLEX N/ADJ FOAM PRE OTS
FLEX THERMOPLASTIC COLLAR MO
CERVICAL SEMI-RIGID ADJUSTAB
CERV SEMI-RIG ADJ MOLDED CHN
CERV SR WIRE OCC/MAN PRE OTS
CERVICAL COLLAR MOLDED TO PT
CERV COL SR FOAM 2PC PRE OTS
CERV SR 2PC THOR EXT PRE OTS
CER POST COL OCC/MAN SUP ADJ
CERV COLLAR SUPP ADJ CERV BA
CERV COL SUPP ADJ BAR & THOR
THOR RIB BELT CUSTOM FABRICA
TLSO FLEX TRUNK/THOR PRE OTS
TLSO FLEX CUSTOM FAB THORACI
TLSO TRNK SJ-T9 PRE CST
TLSO FLEX TRNK SJ-T9 PRE OTS
TLSO FLEX TRNK SJ-SS PRE CST
TLSO FLEX TRNK SJ-SS PRE OTS
TLSO 2MOD SYMPHIS-XIPHO PRE
TLSO 2 SHL SYMPHYS-STERN CST
TLSO 3MOD SACRO-SCAP PRE
TLSO 4MOD SACRO-SCAP PRE
TLSO R FRAM SOFT ANT PRE CST
TLSO R FRAM SOFT PRE OTS
TLSO RIG FRAM PELVIC PRE CST
TLSO RIG FRAM PELVIC PRE OTS
TLSO RIGID FRAME PRE SUBCLAV
TLSO RIGID FRAME HYPEREX PRE
TLSO RIGID PLASTIC CUSTOM FA
TLSO RIGID LINED CUSTOM FAB
Pricing Action Code
6
6
6
6
6
6
6
6
6
6
6
9
6
6
6
6
6
3
3
3
3
3
3
3
3
3
3
3
3
5
5
5
6
5
6
5
5
3
5
5
6
5
6
5
5
5
5
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$20.07
$141.92
$46.91
$86.11
$112.45
$463.04
$100.39
$197.24
$273.50
$355.67
$370.78
$101.25
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$1,050.90
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
L0484
L0486
L0488
L0490
L0491
L0492
L0621
L0622
L0623
L0624
L0625
L0626
L0627
L0628
L0629
L0630
L0631
L0632
L0633
L0634
L0635
L0636
L0637
L0638
L0639
L0640
L0641
L0642
L0643
L0648
L0649
L0650
L0651
L0700
L0710
L0810
L0820
L0830
L0859
L0861
L0970
L0972
L0974
L0976
L0978
L0980
L0982
Description
TLSO RIGID PLASTIC CUST FAB
TLSO RIGIDLINED CUST FAB TWO
TLSO RIGID LINED PRE ONE PIE
TLSO RIGID PLASTIC PRE ONE
TLSO 2 PIECE RIGID SHELL
TLSO 3 PIECE RIGID SHELL
SIO FLEX PELVIC/SACR PRE OTS
SIO FLEX PELVISACRAL CUSTOM
SIO RIG PNL PELV/SAC PRE OTS
SIO PANEL CUSTOM
LO FLEX L1-BELOW L5 PRE OTS
LO SAG RIG PNL STAYS PRE CST
LO SAG RI AN/POS PNL PRE CST
LSO FLEX NO RI STAYS PRE OTS
LSO FLEX W/RIGID STAYS CUST
LSO R POST PNL SJ-T9 PRE CST
LSO SAG R AN/POS PNL PRE CST
LSO SAG RIGID FRAME CUST
LSO SC R POS/LAT PNL PRE CST
LSO FLEXION CONTROL CUSTOM
LSO SAGIT RIGID PANEL PREFAB
LSO SAGITTAL RIGID PANEL CUS
LSO SC R ANT/POS PNL PRE CST
LSO SAG-CORONAL PANEL CUSTOM
LSO S/C SHELL/PANEL PREFAB
LSO S/C SHELL/PANEL CUSTOM
LO RIG POS PNL L1-L5 PRE OTS
LO SAG RI AN/POS PNL PRE OTS
LSO SAG CTR RIGI POS PRE OTS
LSO SAG R AN/POS PNL PRE OTS
LSO SC R POS/LAT PNL PRE OTS
LSO SC R ANT/POS PNL PRE OTS
LSO SAG-CO SHELL PNL PRE OTS
CTLSO A-P-L CONTROL MOLDED
CTLSO A-P-L CONTROL W/ INTER
HALO CERVICAL INTO JCKT VEST
HALO CERVICAL INTO BODY JACK
HALO CERV INTO MILWAUKEE TYP
MRI COMPATIBLE SYSTEM
HALO REPL LINER/INTERFACE
TLSO CORSET FRONT
LSO CORSET FRONT
TLSO FULL CORSET
LSO FULL CORSET
AXILLARY CRUTCH EXTENSION
PERONEAL STRAPS PAIR PRE OTS
STOCKING SUP GRIPS 4 PRE OTS
Pricing Action Code
5
5
5
5
6
6
6
6
6
6
6
6
6
6
6
3
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
3
3
3
3
3
6
6
3
3
3
3
3
3
3
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$127.26
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$1,467.79
$1,499.54
$1,875.37
$1,683.27
$2,372.22
$0.00
$0.00
$96.55
$86.71
$128.76
$114.81
$151.56
$16.53
$11.69
Procedure Code
L0984
L0999
L1000
L1001
L1005
L1010
L1020
L1025
L1030
L1040
L1050
L1060
L1070
L1080
L1085
L1090
L1100
L1110
L1120
L1200
L1210
L1220
L1230
L1240
L1250
L1260
L1270
L1280
L1290
L1300
L1310
L1499
L1600
L1610
L1620
L1630
L1640
L1650
L1652
L1660
L1680
L1685
L1686
L1690
L1700
L1710
L1720
Description
PROTECT BODY SOCK EA PRE OTS
ADD TO SPINAL ORTHOSIS NOS
CTLSO MILWAUKE INITIAL MODEL
CTLSO INFANT IMMOBILIZER
TENSION BASED SCOLIOSIS ORTH
CTLSO AXILLA SLING
KYPHOSIS PAD
KYPHOSIS PAD FLOATING
LUMBAR BOLSTER PAD
LUMBAR OR LUMBAR RIB PAD
STERNAL PAD
THORACIC PAD
TRAPEZIUS SLING
OUTRIGGER
OUTRIGGER BIL W/ VERT EXTENS
LUMBAR SLING
RING FLANGE PLASTIC/LEATHER
RING FLANGE PLAS/LEATHER MOL
COVERS FOR UPRIGHT EACH
FURNSH INITIAL ORTHOSIS ONLY
LATERAL THORACIC EXTENSION
ANTERIOR THORACIC EXTENSION
MILWAUKEE TYPE SUPERSTRUCTUR
LUMBAR DEROTATION PAD
ANTERIOR ASIS PAD
ANTERIOR THORACIC DEROTATION
ABDOMINAL PAD
RIB GUSSET (ELASTIC) EACH
LATERAL TROCHANTERIC PAD
BODY JACKET MOLD TO PATIENT
POST-OPERATIVE BODY JACKET
SPINAL ORTHOSIS NOS
HO FLEX FREJKA W/COV PRE CST
HO FREJKA COV ONLY PRE CST
HO FLEX PAVLIK HARNS PRE CST
ABDUCT CONTROL HIP SEMI-FLEX
PELV BAND/SPREAD BAR THIGH C
HO ABDUCTION HIP ADJUSTABLE
HO BI THIGHCUFFS W SPRDR BAR
HO ABDUCTION STATIC PLASTIC
PELVIC & HIP CONTROL THIGH C
POST-OP HIP ABDUCT CUSTOM FA
HO POST-OP HIP ABDUCTION
COMBINATION BILATERAL HO
LEG PERTHES ORTH TORONTO TYP
LEGG PERTHES ORTH NEWINGTON
LEGG PERTHES ORTHOSIS TRILAT
Pricing Action Code
3
5
3
6
5
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
5
3
3
3
3
3
3
5
3
3
3
3
3
3
3
3
Maximum Allowable
$48.54
$0.00
$1,472.64
$0.00
$0.00
$48.19
$62.06
$118.46
$45.67
$59.77
$72.03
$86.42
$84.40
$47.48
$128.42
$84.96
$135.65
$183.38
$31.00
$1,124.98
$187.88
$179.47
$460.04
$62.18
$62.18
$63.50
$64.52
$74.19
$58.74
$1,322.50
$1,358.90
$0.00
$92.52
$40.82
$115.65
$121.67
$370.37
$187.41
$0.00
$122.87
$874.83
$892.79
$824.39
$1,449.30
$1,096.46
$1,283.53
$946.12
Procedure Code
L1730
L1755
L1810
L1812
L1820
L1830
L1831
L1832
L1833
L1834
L1836
L1840
L1843
L1844
L1845
L1846
L1847
L1848
L1850
L1860
L1900
L1902
L1904
L1906
L1907
L1910
L1920
L1930
L1932
L1940
L1945
L1950
L1951
L1960
L1970
L1971
L1980
L1990
L2000
L2005
L2010
L2020
L2030
L2034
L2035
L2036
L2037
Description
LEGG PERTHES ORTH SCOTTISH R
LEGG PERTHES PATTEN BOTTOM T
KO ELASTIC WITH JOINTS
KO ELASTIC W/JOINTS PRE OTS
KO ELAS W/ CONDYLE PADS & JO
KO IMMOB CANVAS LONG PRE OTS
KNEE ORTH POS LOCKING JOINT
KO ADJ JNT POS R SUP PRE CST
KO ADJ JNT POS R SUP PRE OTS
KO W/0 JOINT RIGID MOLDED TO
KO RIGID W/O JOINTS PRE OTS
KO DEROT ANT CRUCIATE CUSTOM
KO SINGLE UPRIGHT PRE CST
KO W/ADJ JT ROT CNTRL MOLDED
KO DOUBLE UPRIGHT PRE CST
KO W ADJ FLEX/EXT ROTAT MOLD
KO DBL UPRIGHT W/AIR PRE CST
KO DBL UPRIGHT W/AIR PRE OTS
KO SWEDISH TYPE PRE OTS
KO SUPRACONDYLAR SOCKET MOLD
AFO SPRNG WIR DRSFLX CALF BD
AFO ANKLE GAUNTLET PRE OTS
AFO MOLDED ANKLE GAUNTLET
AFO MULTILIG ANK SUP PRE OTS
AFO SUPRAMALLEOLAR CUSTOM
AFO SING BAR CLASP ATTACH SH
AFO SING UPRIGHT W/ ADJUST S
AFO PLASTIC
AFO RIG ANT TIB PREFAB TCF/=
AFO MOLDED TO PATIENT PLASTI
AFO MOLDED PLAS RIG ANT TIB
AFO SPIRAL MOLDED TO PT PLAS
AFO SPIRAL PREFABRICATED
AFO POS SOLID ANK PLASTIC MO
AFO PLASTIC MOLDED W/ANKLE J
AFO W/ANKLE JOINT, PREFAB
AFO SING SOLID STIRRUP CALF
AFO DOUB SOLID STIRRUP CALF
KAFO SING FRE STIRR THI/CALF
KAFO SNG/DBL MECHANICAL ACT
KAFO SNG SOLID STIRRUP W/O J
KAFO DBL SOLID STIRRUP BAND/
KAFO DBL SOLID STIRRUP W/O J
KAFO PLA SIN UP W/WO K/A CUS
KAFO PLASTIC PEDIATRIC SIZE
KAFO PLAS DOUB FREE KNEE MOL
KAFO PLAS SING FREE KNEE MOL
Pricing Action Code
3
3
3
6
3
3
6
3
6
3
5
3
3
3
3
3
3
6
3
3
3
3
3
3
6
3
3
3
6
3
3
3
6
3
3
6
3
3
3
6
3
3
3
6
3
3
3
Maximum Allowable
$812.63
$1,289.59
$70.71
$0.00
$129.05
$66.62
$0.00
$630.43
$0.00
$557.35
$0.00
$742.41
$672.48
$1,165.61
$822.05
$791.83
$431.07
$0.00
$218.25
$770.45
$193.70
$66.93
$402.52
$101.71
$0.00
$196.12
$251.01
$210.87
$0.00
$418.28
$1,053.96
$698.83
$0.00
$527.07
$634.29
$0.00
$263.51
$397.34
$758.23
$0.00
$707.32
$890.63
$808.48
$0.00
$131.14
$1,713.85
$1,287.91
Procedure Code
L2038
L2040
L2050
L2060
L2070
L2080
L2090
L2106
L2108
L2112
L2114
L2116
L2126
L2128
L2132
L2134
L2136
L2180
L2182
L2184
L2186
L2188
L2190
L2192
L2200
L2210
L2220
L2230
L2232
L2240
L2250
L2260
L2265
L2270
L2275
L2280
L2300
L2310
L2320
L2330
L2335
L2340
L2350
L2360
L2370
L2375
L2380
Description
KAFO W/O JOINT MULTI-AXIS AN
HKAFO TORSION BIL ROT STRAPS
HKAFO TORSION CABLE HIP PELV
HKAFO TORSION BALL BEARING J
HKAFO TORSION UNILAT ROT STR
HKAFO UNILAT TORSION CABLE
HKAFO UNILAT TORSION BALL BR
AFO TIB FX CAST PLASTER MOLD
AFO TIB FX CAST MOLDED TO PT
AFO TIBIAL FRACTURE SOFT
AFO TIB FX SEMI-RIGID
AFO TIBIAL FRACTURE RIGID
KAFO FEM FX CAST THERMOPLAS
KAFO FEM FX CAST MOLDED TO P
KAFO FEMORAL FX CAST SOFT
KAFO FEM FX CAST SEMI-RIGID
KAFO FEMORAL FX CAST RIGID
PLAS SHOE INSERT W ANK JOINT
DROP LOCK KNEE
LIMITED MOTION KNEE JOINT
ADJ MOTION KNEE JNT LERMAN T
QUADRILATERAL BRIM
WAIST BELT
PELVIC BAND & BELT THIGH FLA
LIMITED ANKLE MOTION EA JNT
DORSIFLEXION ASSIST EACH JOI
DORSI & PLANTAR FLEX ASS/RES
SPLIT FLAT CALIPER STIRR & P
ROCKER BOTTOM, CONTACT AFO
ROUND CALIPER AND PLATE ATTA
FOOT PLATE MOLDED STIRRUP AT
REINFORCED SOLID STIRRUP
LONG TONGUE STIRRUP
VARUS/VALGUS STRAP PADDED/LI
PLASTIC MOD LOW EXT PAD/LINE
MOLDED INNER BOOT
ABDUCTION BAR JOINTED ADJUST
ABDUCTION BAR-STRAIGHT
NON-MOLDED LACER
LACER MOLDED TO PATIENT MODE
ANTERIOR SWING BAND
PRE-TIBIAL SHELL MOLDED TO P
PROSTHETIC TYPE SOCKET MOLDE
EXTENDED STEEL SHANK
PATTEN BOTTOM
TORSION ANK & HALF SOLID STI
TORSION STRAIGHT KNEE JOINT
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
6
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$1,308.30
$158.68
$342.03
$416.86
$107.04
$258.25
$314.84
$488.18
$850.00
$390.97
$490.39
$564.23
$943.82
$1,336.53
$724.60
$773.23
$922.89
$86.13
$71.37
$97.56
$135.31
$259.14
$66.96
$294.02
$42.38
$61.34
$73.00
$68.39
$0.00
$68.19
$276.47
$143.93
$104.98
$49.22
$116.04
$405.75
$204.94
$102.64
$183.41
$309.23
$190.92
$513.14
$713.86
$37.15
$240.71
$101.69
$88.39
Procedure Code
L2385
L2387
L2390
L2395
L2397
L2405
L2415
L2425
L2430
L2492
L2500
L2510
L2520
L2525
L2526
L2530
L2540
L2550
L2570
L2580
L2600
L2610
L2620
L2622
L2624
L2627
L2628
L2630
L2640
L2650
L2660
L2670
L2680
L2750
L2755
L2760
L2768
L2780
L2785
L2795
L2800
L2810
L2820
L2830
L2840
L2850
L2861
Description
STRAIGHT KNEE JOINT HEAVY DU
ADD LE POLY KNEE CUSTOM KAFO
OFFSET KNEE JOINT EACH
OFFSET KNEE JOINT HEAVY DUTY
SUSPENSION SLEEVE LOWER EXT
KNEE JOINT DROP LOCK EA JNT
KNEE JOINT CAM LOCK EACH JOI
KNEE DISC/DIAL LOCK/ADJ FLEX
KNEE JNT RATCHET LOCK EA JNT
KNEE LIFT LOOP DROP LOCK RIN
THI/GLUT/ISCHIA WGT BEARING
TH/WGHT BEAR QUAD-LAT BRIM M
TH/WGHT BEAR QUAD-LAT BRIM C
TH/WGHT BEAR NAR M-L BRIM MO
TH/WGHT BEAR NAR M-L BRIM CU
THIGH/WGHT BEAR LACER NON-MO
THIGH/WGHT BEAR LACER MOLDED
THIGH/WGHT BEAR HIGH ROLL CU
HIP CLEVIS TYPE 2 POSIT JNT
PELVIC CONTROL PELVIC SLING
HIP CLEVIS/THRUST BEARING FR
HIP CLEVIS/THRUST BEARING LO
PELVIC CONTROL HIP HEAVY DUT
HIP JOINT ADJUSTABLE FLEXION
HIP ADJ FLEX EXT ABDUCT CONT
PLASTIC MOLD RECIPRO HIP & C
METAL FRAME RECIPRO HIP & CA
PELVIC CONTROL BAND & BELT U
PELVIC CONTROL BAND & BELT B
PELV & THOR CONTROL GLUTEAL
THORACIC CONTROL THORACIC BA
THORAC CONT PARASPINAL UPRIG
THORAC CONT LAT SUPPORT UPRI
PLATING CHROME/NICKEL PR BAR
CARBON GRAPHITE LAMINATION
EXTENSION PER EXTENSION PER
ORTHO SIDEBAR DISCONNECT
NON-CORROSIVE FINISH
DROP LOCK RETAINER EACH
KNEE CONTROL FULL KNEECAP
KNEE CAP MEDIAL OR LATERAL P
KNEE CONTROL CONDYLAR PAD
SOFT INTERFACE BELOW KNEE SE
SOFT INTERFACE ABOVE KNEE SE
TIBIAL LENGTH SOCK FX OR EQU
FEMORAL LGTH SOCK FX OR EQUA
TORSION MECHANISM KNEE/ANKLE
Pricing Action Code
3
6
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
5
3
3
3
3
3
3
3
3
3
6
Maximum Allowable
$119.40
$0.00
$80.51
$112.34
$87.53
$81.11
$113.01
$133.38
$107.43
$97.54
$289.70
$649.99
$345.37
$931.80
$531.72
$168.70
$303.55
$206.21
$341.99
$333.23
$182.48
$239.95
$269.80
$246.37
$237.76
$1,297.39
$1,276.17
$177.79
$299.56
$102.75
$133.82
$129.79
$120.23
$60.02
$121.55
$51.39
$0.00
$48.59
$28.37
$76.94
$118.25
$88.08
$77.41
$83.74
$49.50
$44.46
$0.00
Procedure Code
L2999
L3000
L3001
L3002
L3003
L3010
L3020
L3030
L3031
L3040
L3050
L3060
L3070
L3080
L3090
L3100
L3140
L3150
L3160
L3170
L3201
L3202
L3203
L3204
L3206
L3207
L3208
L3209
L3211
L3212
L3213
L3214
L3215
L3216
L3217
L3219
L3221
L3222
L3224
L3225
L3230
L3250
L3251
L3252
L3253
L3254
L3255
Description
LOWER EXTREMITY ORTHOSIS NOS
FT INSERT UCB BERKELEY SHELL
FOOT INSERT REMOV MOLDED SPE
FOOT INSERT PLASTAZOTE OR EQ
FOOT INSERT SILICONE GEL EAC
FOOT LONGITUDINAL ARCH SUPPO
FOOT LONGITUD/METATARSAL SUP
FOOT ARCH SUPPORT REMOV PREM
FOOT LAMIN/PREPREG COMPOSITE
FT ARCH SUPRT PREMOLD LONGIT
FOOT ARCH SUPP PREMOLD METAT
FOOT ARCH SUPP LONGITUD/META
ARCH SUPRT ATT TO SHO LONGIT
ARCH SUPP ATT TO SHOE METATA
ARCH SUPP ATT TO SHOE LONG/M
HALLUS-VALGUS NT DYN PRE OTS
ABDUCTION ROTATION BAR SHOE
ABDUCT ROTATION BAR W/O SHOE
SHOE STYLED POSITIONING DEV
FOOT PLAS HEEL STABI PRE OTS
OXFORD W SUPINAT/PRONAT INF
OXFORD W/ SUPINAT/PRONATOR C
OXFORD W/ SUPINATOR/PRONATOR
HIGHTOP W/ SUPP/PRONATOR INF
HIGHTOP W/ SUPP/PRONATOR CHI
HIGHTOP W/ SUPP/PRONATOR JUN
SURGICAL BOOT EACH INFANT
SURGICAL BOOT EACH CHILD
SURGICAL BOOT EACH JUNIOR
BENESCH BOOT PAIR INFANT
BENESCH BOOT PAIR CHILD
BENESCH BOOT PAIR JUNIOR
ORTHOPEDIC FTWEAR LADIES OXF
ORTHOPED LADIES SHOES DPTH I
LADIES SHOES HIGHTOP DEPTH I
ORTHOPEDIC MENS SHOES OXFORD
ORTHOPEDIC MENS SHOES DPTH I
MENS SHOES HIGHTOP DEPTH INL
WOMAN'S SHOE OXFORD BRACE
MAN'S SHOE OXFORD BRACE
CUSTOM SHOES DEPTH INLAY
CUSTOM MOLD SHOE REMOV PROST
SHOE MOLDED TO PT SILICONE S
SHOE MOLDED PLASTAZOTE CUST
SHOE MOLDED PLASTAZOTE CUST
ORTH FOOT NON-STNDARD SIZE/W
ORTH FOOT NON-STANDARD SIZE/
Pricing Action Code
5
3
5
5
5
5
3
5
6
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
3
5
5
3
5
5
3
3
5
5
5
5
5
5
5
Maximum Allowable
$0.00
$277.33
$0.00
$0.00
$0.00
$0.00
$184.61
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$86.72
$0.00
$0.00
$89.02
$0.00
$0.00
$47.77
$60.89
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
L3257
L3260
L3265
L3300
L3310
L3320
L3330
L3332
L3334
L3340
L3350
L3360
L3370
L3380
L3390
L3400
L3410
L3420
L3430
L3440
L3450
L3455
L3460
L3465
L3470
L3480
L3485
L3500
L3510
L3520
L3530
L3540
L3550
L3560
L3570
L3580
L3590
L3595
L3600
L3610
L3620
L3630
L3640
L3649
L3650
L3660
L3670
Description
ORTH FOOT ADD CHARGE SPLIT S
AMBULATORY SURGICAL BOOT EAC
PLASTAZOTE SANDAL EACH
SHO LIFT TAPER TO METATARSAL
SHOE LIFT ELEV HEEL/SOLE NEO
SHOE LIFT ELEV HEEL/SOLE COR
LIFTS ELEVATION METAL EXTENS
SHOE LIFTS TAPERED TO ONE-HA
SHOE LIFTS ELEVATION HEEL /I
SHOE WEDGE SACH
SHOE HEEL WEDGE
SHOE SOLE WEDGE OUTSIDE SOLE
SHOE SOLE WEDGE BETWEEN SOLE
SHOE CLUBFOOT WEDGE
SHOE OUTFLARE WEDGE
SHOE METATARSAL BAR WEDGE RO
SHOE METATARSAL BAR BETWEEN
FULL SOLE/HEEL WEDGE BTWEEN
SHO HEEL COUNT PLAST REINFOR
HEEL LEATHER REINFORCED
SHOE HEEL SACH CUSHION TYPE
SHOE HEEL NEW LEATHER STANDA
SHOE HEEL NEW RUBBER STANDAR
SHOE HEEL THOMAS WITH WEDGE
SHOE HEEL THOMAS EXTEND TO B
SHOE HEEL PAD & DEPRESS FOR
SHOE HEEL PAD REMOVABLE FOR
ORTHO SHOE ADD LEATHER INSOL
ORTHOPEDIC SHOE ADD RUB INSL
O SHOE ADD FELT W LEATH INSL
ORTHO SHOE ADD HALF SOLE
ORTHO SHOE ADD FULL SOLE
O SHOE ADD STANDARD TOE TAP
O SHOE ADD HORSESHOE TOE TAP
O SHOE ADD INSTEP EXTENSION
O SHOE ADD INSTEP VELCRO CLO
O SHOE CONVERT TO SOF COUNTE
ORTHO SHOE ADD MARCH BAR
TRANS SHOE CALIP PLATE EXIST
TRANS SHOE CALIPER PLATE NEW
TRANS SHOE SOLID STIRRUP EXI
TRANS SHOE SOLID STIRRUP NEW
SHOE DENNIS BROWNE SPLINT BO
ORTHOPEDIC SHOE MODIFICA NOS
SO 8 ABD RESTRAINT PRE OTS
SO 8 AB RSTR CAN/WEB PRE OTS
SO ACRO/CLAV CAN WEB PRE OTS
Pricing Action Code
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
3
5
5
5
5
3
6
6
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$30.00
$0.00
$0.00
$0.00
$0.00
$47.75
$0.00
$0.00
Procedure Code
L3671
L3674
L3675
L3677
L3678
L3702
L3710
L3720
L3730
L3740
L3760
L3762
L3763
L3764
L3765
L3766
L3806
L3807
L3808
L3809
L3891
L3900
L3901
L3904
L3905
L3906
L3908
L3912
L3913
L3915
L3916
L3917
L3918
L3919
L3921
L3923
L3924
L3925
L3927
L3929
L3930
L3931
L3933
L3935
L3956
L3960
L3961
Description
SO CAP DESIGN W/O JNTS CF
SO AIRPLANE W/WO JOINT CF
SO VEST CANVAS/WEB PRE OTS
SO HARD PLAS STABILI PRE CST
SO HARD PLAS STABILI PRE OTS
EO W/O JOINTS CF
EO ELAS W/METAL JNTS PRE OTS
FOREARM/ARM CUFFS FREE MOTIO
FOREARM/ARM CUFFS EXT/FLEX A
CUFFS ADJ LOCK W/ ACTIVE CON
EO WITHJOINT, PREFABRICATED
EO RIGID W/O JOINTS PRE OTS
EWHO RIGID W/O JNTS CF
EWHO W/JOINT(S) CF
EWHFO RIGID W/O JNTS CF
EWHFO W/JOINT(S) CF
WHFO W/JOINT(S) CUSTOM FAB
WHFO W/O JOINTS PRE CST
WHFO, RIGID W/O JOINTS
WHFO W/O JOINTS PRE OTS
TORSION MECHANISM WRIST/ELBO
HINGE EXTENSION/FLEX WRIST/F
HINGE EXT/FLEX WRIST FINGER
WHFO ELECTRIC CUSTOM FITTED
WHO W/NONTORSION JNT(S) CF
WHO W/O JOINTS CF
WHO COCK-UP NONMOLDE PRE OTS
HFO FLEXION GLOVE PRE OTS
HFO W/O JOINTS CF
WHO NONTORSION JNTS PRE CST
WHO NONTORSION JNTS PRE OTS
METACARP FX ORTHOSIS PRE CST
METACARP FX ORTHOSIS PRE OTS
HO W/O JOINTS CF
HFO W/JOINT(S) CF
HFO WITHOUT JOINTS PRE CST
HFO WITHOUT JOINTS PRE OTS
FO PIP DIP JNT/SPRNG PRE OTS
FO PIP DIP NO JT SPR PRE OTS
HFO NONTORSION JNTS PRE CST
HFO NONTORSION JNTS PRE OTS
WHFO NONTORSION JOINT PREFAB
FO W/O JOINTS CF
FO NONTORSION JOINT CF
ADD JOINT UPPER EXT ORTHOSIS
SEWHO AIRPLAN DESIG ABDU POS
SEWHO CAP DESIGN W/O JNTS CF
Pricing Action Code
6
6
6
5
6
6
3
3
3
3
3
5
6
6
6
6
6
3
6
6
6
3
3
3
6
3
3
3
6
6
6
6
6
6
6
3
6
6
6
6
6
6
6
6
5
3
6
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$109.80
$489.89
$786.31
$750.90
$341.11
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$170.55
$0.00
$0.00
$0.00
$994.57
$1,129.43
$2,057.53
$0.00
$300.34
$55.68
$81.88
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$25.99
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$516.83
$0.00
Procedure Code
L3962
L3967
L3971
L3973
L3975
L3976
L3977
L3978
L3980
L3981
L3982
L3984
L3995
L3999
L4000
L4002
L4010
L4020
L4030
L4040
L4045
L4050
L4055
L4060
L4070
L4080
L4090
L4100
L4110
L4130
L4205
L4210
L4350
L4360
L4361
L4370
L4386
L4387
L4392
L4394
L4396
L4397
L4398
L4631
L5000
L5010
L5020
Description
SEWHO ERBS PALSEY DESIGN ABD
SEWHO AIRPLANE W/O JNTS CF
SEWHO CAP DESIGN W/JNT(S) CF
SEWHO AIRPLANE W/JNT(S) CF
SEWHFO CAP DESIGN W/O JNT CF
SEWHFO AIRPLANE W/O JNTS CF
SEWHFO CAP DESGN W/JNT(S) CF
SEWHFO AIRPLANE W/JNT(S) CF
UP EXT FX ORTHOS HUMERAL NOS
UE FX ORTH SHOUL CAP FOREARM
UPPER EXT FX ORTHOSIS RAD/UL
UPPER EXT FX ORTHOSIS WRIST
SOCK FRACTURE OR EQUAL EACH
UPPER LIMB ORTHOSIS NOS
REPL GIRDLE MILWAUKEE ORTH
REPLACE STRAP, ANY ORTHOSIS
REPLACE TRILATERAL SOCKET BR
REPLACE QUADLAT SOCKET BRIM
REPLACE SOCKET BRIM CUST FIT
REPLACE MOLDED THIGH LACER
REPLACE NON-MOLDED THIGH LAC
REPLACE MOLDED CALF LACER
REPLACE NON-MOLDED CALF LACE
REPLACE HIGH ROLL CUFF
REPLACE PROX & DIST UPRIGHT
REPL MET BAND KAFO-AFO PROX
REPL MET BAND KAFO-AFO CALF/
REPL LEATH CUFF KAFO PROX TH
REPL LEATH CUFF KAFO-AFO CAL
REPLACE PRETIBIAL SHELL
ORTHO DVC REPAIR PER 15 MIN
ORTH DEV REPAIR/REPL MINOR P
ANKLE CONTROL ORTHO PRE OTS
PNEUMAT WALKING BOOT PRE CST
PNEUMA/VAC WALK BOOT PRE OTS
PNEUM FULL LEG SPLNT PRE OTS
NON-PNEUM WALK BOOT PRE CST
NON-PNEUM WALK BOOT PRE OTS
REPLACE AFO SOFT INTERFACE
REPLACE FOOT DROP SPINT
STATIC OR DYNAMI AFO PRE CST
STATIC OR DYNAMI AFO PRE OTS
FOOT DROP SPLINT PRE OTS
AFO, WALK BOOT TYPE, CUS FAB
SHO INSERT W ARCH TOE FILLER
MOLD SOCKET ANK HGT W/ TOE F
TIBIAL TUBERCLE HGT W/ TOE F
Pricing Action Code
3
6
6
6
6
6
6
6
3
6
3
3
3
5
3
6
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
5
3
3
6
3
3
6
3
3
3
6
3
6
3
3
3
Maximum Allowable
$504.11
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$224.99
$0.00
$262.29
$241.83
$25.05
$0.00
$988.41
$0.00
$481.87
$673.89
$362.50
$295.81
$235.52
$296.42
$191.94
$228.18
$202.07
$82.87
$65.40
$85.87
$80.32
$362.78
$22.13
$0.00
$89.22
$220.93
$0.00
$146.11
$147.53
$0.00
$17.63
$12.87
$156.13
$0.00
$57.91
$0.00
$529.31
$931.27
$1,515.92
Procedure Code
L5050
L5060
L5100
L5105
L5150
L5160
L5200
L5210
L5220
L5230
L5250
L5270
L5280
L5301
L5312
L5321
L5331
L5341
L5400
L5410
L5420
L5430
L5450
L5460
L5500
L5505
L5510
L5520
L5530
L5535
L5540
L5560
L5570
L5580
L5585
L5590
L5595
L5600
L5610
L5611
L5613
L5614
L5616
L5617
L5618
L5620
L5622
Description
ANK SYMES MOLD SCKT SACH FT
SYMES MET FR LEATH SOCKET AR
MOLDED SOCKET SHIN SACH FOOT
PLAST SOCKET JTS/THGH LACER
MOLD SCKT EXT KNEE SHIN SACH
MOLD SOCKET BENT KNEE SHIN S
KNE SING AXIS FRIC SHIN SACH
NO KNEE/ANKLE JOINTS W/ FT B
NO KNEE JOINT WITH ARTIC ALI
FEM FOCAL DEFIC CONSTANT FRI
HIP CANAD SING AXI CONS FRIC
TILT TABLE LOCKING HIP SING
HEMIPELVECT CANAD SING AXIS
BK MOLD SOCKET SACH FT ENDO
KNEE DISART, SACH FT, ENDO
AK OPEN END SACH
HIP DISART CANADIAN SACH FT
HEMIPELVECTOMY CANADIAN SACH
POSTOP DRESS & 1 CAST CHG BK
POSTOP DSG BK EA ADD CAST CH
POSTOP DSG & 1 CAST CHG AK/D
POSTOP DSG AK EA ADD CAST CH
POSTOP APP NON-WGT BEAR DSG
POSTOP APP NON-WGT BEAR DSG
INIT BK PTB PLASTER DIRECT
INIT AK ISCHAL PLSTR DIRECT
PREP BK PTB PLASTER MOLDED
PERP BK PTB THERMOPLS DIRECT
PREP BK PTB THERMOPLS MOLDED
PREP BK PTB OPEN END SOCKET
PREP BK PTB LAMINATED SOCKET
PREP AK ISCHIAL PLAST MOLDED
PREP AK ISCHIAL DIRECT FORM
PREP AK ISCHIAL THERMO MOLD
PREP AK ISCHIAL OPEN END
PREP AK ISCHIAL LAMINATED
HIP DISARTIC SACH THERMOPLS
HIP DISART SACH LAMINAT MOLD
ABOVE KNEE HYDRACADENCE
AK 4 BAR LINK W/FRIC SWING
AK 4 BAR LING W/HYDRAUL SWIG
4-BAR LINK ABOVE KNEE W/SWNG
AK UNIV MULTIPLEX SYS FRICT
AK/BK SELF-ALIGNING UNIT EA
TEST SOCKET SYMES
TEST SOCKET BELOW KNEE
TEST SOCKET KNEE DISARTICULA
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
5
6
5
5
5
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$1,755.51
$2,112.77
$1,828.78
$2,902.64
$2,686.23
$2,921.76
$2,545.10
$2,304.46
$2,109.89
$2,909.97
$3,968.93
$3,934.16
$3,894.82
$0.00
$0.00
$0.00
$0.00
$0.00
$920.64
$403.36
$1,162.72
$513.24
$328.33
$483.92
$982.44
$1,330.47
$1,113.65
$1,100.03
$1,392.40
$1,372.22
$1,706.88
$1,486.72
$1,545.67
$1,804.46
$1,957.15
$2,282.95
$3,232.24
$3,525.47
$1,583.72
$1,530.09
$1,874.64
$1,267.18
$1,223.82
$420.17
$242.04
$264.02
$324.80
Procedure Code
L5624
L5626
L5628
L5629
L5630
L5631
L5632
L5634
L5636
L5637
L5638
L5639
L5640
L5642
L5643
L5644
L5645
L5646
L5647
L5648
L5649
L5650
L5651
L5652
L5653
L5654
L5655
L5656
L5658
L5661
L5665
L5666
L5668
L5670
L5671
L5672
L5673
L5676
L5677
L5678
L5679
L5680
L5681
L5682
L5683
L5684
L5685
Description
TEST SOCKET ABOVE KNEE
TEST SOCKET HIP DISARTICULAT
TEST SOCKET HEMIPELVECTOMY
BELOW KNEE ACRYLIC SOCKET
SYME TYP EXPANDABL WALL SCKT
AK/KNEE DISARTIC ACRYLIC SOC
SYMES TYPE PTB BRIM DESIGN S
SYMES TYPE POSTER OPENING SO
SYMES TYPE MEDIAL OPENING SO
BELOW KNEE TOTAL CONTACT
BELOW KNEE LEATHER SOCKET
BELOW KNEE WOOD SOCKET
KNEE DISARTICULAT LEATHER SO
ABOVE KNEE LEATHER SOCKET
HIP FLEX INNER SOCKET EXT FR
ABOVE KNEE WOOD SOCKET
BK FLEX INNER SOCKET EXT FRA
BELOW KNEE CUSHION SOCKET
BELOW KNEE SUCTION SOCKET
ABOVE KNEE CUSHION SOCKET
ISCH CONTAINMT/NARROW M-L SO
TOT CONTACT AK/KNEE DISART S
AK FLEX INNER SOCKET EXT FRA
SUCTION SUSP AK/KNEE DISART
KNEE DISART EXPAND WALL SOCK
SOCKET INSERT SYMES
SOCKET INSERT BELOW KNEE
SOCKET INSERT KNEE ARTICULAT
SOCKET INSERT ABOVE KNEE
MULTI-DUROMETER SYMES
MULTI-DUROMETER BELOW KNEE
BELOW KNEE CUFF SUSPENSION
BK MOLDED DISTAL CUSHION
BK MOLDED SUPRACONDYLAR SUSP
BK/AK LOCKING MECHANISM
BK REMOVABLE MEDIAL BRIM SUS
SOCKET INSERT W LOCK MECH
BK KNEE JOINTS SINGLE AXIS P
BK KNEE JOINTS POLYCENTRIC P
BK JOINT COVERS PAIR
SOCKET INSERT W/O LOCK MECH
BK THIGH LACER NON-MOLDED
INTL CUSTM CONG/LATYP INSERT
BK THIGH LACER GLUT/ISCHIA M
INITIAL CUSTOM SOCKET INSERT
BK FORK STRAP
BELOW KNEE SUS/SEAL SLEEVE
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
5
3
6
3
3
3
3
3
6
3
6
3
3
Maximum Allowable
$384.71
$435.56
$412.54
$391.12
$343.30
$509.67
$169.85
$232.68
$194.91
$323.23
$372.27
$873.31
$531.69
$476.00
$1,190.58
$451.81
$718.97
$419.12
$608.48
$503.62
$1,898.14
$463.62
$1,140.48
$329.85
$445.19
$253.68
$253.03
$302.59
$294.67
$512.05
$391.67
$58.20
$77.71
$236.56
$0.00
$289.06
$0.00
$277.19
$377.16
$30.37
$555.99
$264.93
$0.00
$478.39
$0.00
$36.81
$119.41
Procedure Code
L5686
L5688
L5690
L5692
L5694
L5695
L5696
L5697
L5698
L5699
L5700
L5701
L5702
L5703
L5704
L5705
L5706
L5707
L5710
L5711
L5712
L5714
L5716
L5718
L5722
L5724
L5726
L5728
L5780
L5781
L5782
L5785
L5790
L5795
L5810
L5811
L5812
L5814
L5816
L5818
L5822
L5824
L5826
L5828
L5830
L5840
L5845
Description
BK BACK CHECK
BK WAIST BELT WEBBING
BK WAIST BELT PADDED AND LIN
AK PELVIC CONTROL BELT LIGHT
AK PELVIC CONTROL BELT PAD/L
AK SLEEVE SUSP NEOPRENE/EQUA
AK/KNEE DISARTIC PELVIC JOIN
AK/KNEE DISARTIC PELVIC BAND
AK/KNEE DISARTIC SILESIAN BA
SHOULDER HARNESS
REPLACE SOCKET BELOW KNEE
REPLACE SOCKET ABOVE KNEE
REPLACE SOCKET HIP
SYMES ANKLE W/O (SACH) FOOT
CUSTOM SHAPE COVER BK
CUSTOM SHAPE COVER AK
CUSTOM SHAPE CVR KNEE DISART
CUSTOM SHAPE CVR HIP DISART
KNE-SHIN EXO SNG AXI MNL LOC
KNEE-SHIN EXO MNL LOCK ULTRA
KNEE-SHIN EXO FRICT SWG & ST
KNEE-SHIN EXO VARIABLE FRICT
KNEE-SHIN EXO MECH STANCE PH
KNEE-SHIN EXO FRCT SWG & STA
KNEE-SHIN PNEUM SWG FRCT EXO
KNEE-SHIN EXO FLUID SWING PH
KNEE-SHIN EXT JNTS FLD SWG E
KNEE-SHIN FLUID SWG & STANCE
KNEE-SHIN PNEUM/HYDRA PNEUM
LOWER LIMB PROS VACUUM PUMP
HD LOW LIMB PROS VACUUM PUMP
EXOSKELETAL BK ULTRALT MATER
EXOSKELETAL AK ULTRA-LIGHT M
EXOSKEL HIP ULTRA-LIGHT MATE
ENDOSKEL KNEE-SHIN MNL LOCK
ENDO KNEE-SHIN MNL LCK ULTRA
ENDO KNEE-SHIN FRCT SWG & ST
ENDO KNEE-SHIN HYDRAL SWG PH
ENDO KNEE-SHIN POLYC MCH STA
ENDO KNEE-SHIN FRCT SWG & ST
ENDO KNEE-SHIN PNEUM SWG FRC
ENDO KNEE-SHIN FLUID SWING P
MINIATURE KNEE JOINT
ENDO KNEE-SHIN FLUID SWG/STA
ENDO KNEE-SHIN PNEUM/SWG PHA
MULTI-AXIAL KNEE/SHIN SYSTEM
KNEE-SHIN SYS STANCE FLEXION
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
6
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
5
5
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$49.66
$46.72
$90.49
$105.02
$138.77
$145.59
$159.10
$64.62
$80.36
$142.63
$2,203.73
$3,394.17
$3,445.70
$0.00
$557.85
$823.79
$803.52
$1,079.50
$275.12
$417.34
$329.61
$339.91
$557.52
$696.84
$727.18
$1,154.61
$1,516.14
$1,888.89
$910.73
$0.00
$0.00
$397.43
$550.01
$821.31
$474.35
$557.88
$536.85
$3,462.39
$650.54
$734.59
$1,425.17
$1,173.08
$2,368.56
$2,236.15
$1,588.87
$2,801.79
$1,671.01
Procedure Code
L5848
L5850
L5855
L5856
L5857
L5858
L5859
L5910
L5920
L5925
L5930
L5940
L5950
L5960
L5961
L5962
L5964
L5966
L5968
L5969
L5970
L5971
L5972
L5973
L5974
L5975
L5976
L5978
L5979
L5980
L5981
L5982
L5984
L5985
L5986
L5987
L5988
L5990
L5999
L6000
L6010
L6020
L6026
L6050
L6055
L6100
L6110
Description
KNEE-SHIN SYS HYDRAUL STANCE
ENDO AK/HIP KNEE EXTENS ASSI
MECH HIP EXTENSION ASSIST
ELEC KNEE-SHIN SWING/STANCE
ELEC KNEE-SHIN SWING ONLY
STANCE PHASE ONLY
KNEE-SHIN PRO FLEX/EXT CONT
ENDO BELOW KNEE ALIGNABLE SY
ENDO AK/HIP ALIGNABLE SYSTEM
ABOVE KNEE MANUAL LOCK
HIGH ACTIVITY KNEE FRAME
ENDO BK ULTRA-LIGHT MATERIAL
ENDO AK ULTRA-LIGHT MATERIAL
ENDO HIP ULTRA-LIGHT MATERIA
ENDO POLY HIP, PNEU/HYD/ROT
BELOW KNEE FLEX COVER SYSTEM
ABOVE KNEE FLEX COVER SYSTEM
HIP FLEXIBLE COVER SYSTEM
MULTIAXIAL ANKLE W DORSIFLEX
AK/FT POWER ASST INCL MOTORS
FOOT EXTERNAL KEEL SACH FOOT
SACH FOOT, REPLACEMENT
FLEXIBLE KEEL FOOT
ANK-FOOT SYS DORS-PLANT FLEX
FOOT SINGLE AXIS ANKLE/FOOT
COMBO ANKLE/FOOT PROSTHESIS
ENERGY STORING FOOT
FT PROSTH MULTIAXIAL ANKL/FT
MULTI-AXIAL ANKLE/FT PROSTH
FLEX FOOT SYSTEM
FLEX-WALK SYS LOW EXT PROSTH
EXOSKELETAL AXIAL ROTATION U
ENDOSKELETAL AXIAL ROTATION
LWR EXT DYNAMIC PROSTH PYLON
MULTI-AXIAL ROTATION UNIT
SHANK FT W VERT LOAD PYLON
VERTICAL SHOCK REDUCING PYLO
USER ADJUSTABLE HEEL HEIGHT
LOWR EXTREMITY PROSTHES NOS
PART HAND THUMB REM
PART HAND LITTLE/RING
PART HAND NO FINGERS
PART HAND MYO EXCLU TERM DEV
WRST MLD SCK FLX HNG TRI PAD
WRST MOLD SOCK W/EXP INTERFA
ELB MOLD SOCK FLEX HINGE PAD
ELBOW MOLD SOCK SUSPENSION T
Pricing Action Code
5
3
3
6
6
6
6
3
3
3
3
3
3
3
6
3
3
3
3
6
3
6
3
6
3
3
3
3
3
3
3
3
3
3
3
3
3
5
5
3
3
3
6
3
3
3
3
Maximum Allowable
$0.00
$126.14
$236.23
$0.00
$0.00
$0.00
$0.00
$346.39
$503.89
$319.10
$2,527.60
$476.36
$804.76
$776.46
$0.00
$558.21
$805.38
$1,037.45
$2,728.85
$0.00
$167.93
$0.00
$334.69
$0.00
$227.45
$348.14
$504.63
$277.14
$1,791.29
$3,521.11
$3,043.54
$442.22
$544.14
$212.05
$604.99
$6,363.54
$1,862.45
$0.00
$0.00
$1,016.37
$1,131.05
$1,054.53
$0.00
$1,453.10
$2,309.76
$1,472.21
$1,561.53
Procedure Code
L6120
L6130
L6200
L6205
L6250
L6300
L6310
L6320
L6350
L6360
L6370
L6380
L6382
L6384
L6386
L6388
L6400
L6450
L6500
L6550
L6570
L6580
L6582
L6584
L6586
L6588
L6590
L6600
L6605
L6610
L6611
L6615
L6616
L6620
L6621
L6623
L6624
L6625
L6628
L6629
L6630
L6632
L6635
L6637
L6638
L6640
L6641
Description
ELBOW MOLD DOUB SPLT SOC STE
ELBOW STUMP ACTIVATED LOCK H
ELBOW MOLD OUTSID LOCK HINGE
ELBOW MOLDED W/ EXPAND INTER
ELBOW INTER LOC ELBOW FORARM
SHLDER DISART INT LOCK ELBOW
SHOULDER PASSIVE RESTOR COMP
SHOULDER PASSIVE RESTOR CAP
THORACIC INTERN LOCK ELBOW
THORACIC PASSIVE RESTOR COMP
THORACIC PASSIVE RESTOR CAP
POSTOP DSG CAST CHG WRST/ELB
POSTOP DSG CAST CHG ELB DIS/
POSTOP DSG CAST CHG SHLDER/T
POSTOP EA CAST CHG & REALIGN
POSTOP APPLICAT RIGID DSG ON
BELOW ELBOW PROSTH TISS SHAP
ELB DISART PROSTH TISS SHAP
ABOVE ELBOW PROSTH TISS SHAP
SHLDR DISAR PROSTH TISS SHAP
SCAP THORAC PROSTH TISS SHAP
WRIST/ELBOW BOWDEN CABLE MOL
WRIST/ELBOW BOWDEN CBL DIR F
ELBOW FAIR LEAD CABLE MOLDED
ELBOW FAIR LEAD CABLE DIR FO
SHDR FAIR LEAD CABLE MOLDED
SHDR FAIR LEAD CABLE DIRECT
POLYCENTRIC HINGE PAIR
SINGLE PIVOT HINGE PAIR
FLEXIBLE METAL HINGE PAIR
ADDITIONAL SWITCH, EXT POWER
DISCONNECT LOCKING WRIST UNI
DISCONNECT INSERT LOCKING WR
FLEXION/EXTENSION WRIST UNIT
FLEX/EXT WRIST W/WO FRICTION
SPRING-ASS ROT WRST W/ LATCH
FLEX/EXT/ROTATION WRIST UNIT
ROTATION WRST W/ CABLE LOCK
QUICK DISCONN HOOK ADAPTER O
LAMINATION COLLAR W/ COUPLIN
STAINLESS STEEL ANY WRIST
LATEX SUSPENSION SLEEVE EACH
LIFT ASSIST FOR ELBOW
NUDGE CONTROL ELBOW LOCK
ELEC LOCK ON MANUAL PW ELBOW
SHOULDER ABDUCTION JOINT PAI
EXCURSION AMPLIFIER PULLEY T
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
6
3
3
3
6
3
6
3
3
3
3
3
3
3
5
3
3
Maximum Allowable
$1,819.73
$1,980.21
$2,086.82
$3,477.47
$2,054.13
$2,849.88
$2,343.65
$1,307.24
$2,996.21
$2,459.71
$1,851.78
$1,000.12
$1,196.80
$1,460.42
$350.22
$336.28
$1,778.70
$2,358.38
$2,360.31
$2,916.91
$3,539.21
$1,235.42
$1,052.79
$1,705.33
$1,491.81
$2,462.65
$2,252.61
$151.99
$141.87
$127.35
$0.00
$157.03
$66.15
$246.46
$0.00
$564.15
$0.00
$410.51
$419.48
$111.91
$164.86
$54.98
$152.70
$316.97
$0.00
$216.31
$143.76
Procedure Code
L6642
L6645
L6646
L6647
L6648
L6650
L6655
L6660
L6665
L6670
L6672
L6675
L6676
L6677
L6680
L6682
L6684
L6686
L6687
L6688
L6689
L6690
L6691
L6692
L6693
L6694
L6695
L6696
L6697
L6698
L6703
L6704
L6706
L6707
L6708
L6709
L6711
L6712
L6713
L6714
L6715
L6721
L6722
L6805
L6810
L6880
L6881
Description
EXCURSION AMPLIFIER LEVER TY
SHOULDER FLEXION-ABDUCTION J
MULTIPO LOCKING SHOULDER JNT
SHOULDER LOCK ACTUATOR
EXT PWRD SHLDER LOCK/UNLOCK
SHOULDER UNIVERSAL JOINT
STANDARD CONTROL CABLE EXTRA
HEAVY DUTY CONTROL CABLE
TEFLON OR EQUAL CABLE LINING
HOOK TO HAND CABLE ADAPTER
HARNESS CHEST/SHLDER SADDLE
HARNESS FIGURE OF 8 SING CON
HARNESS FIGURE OF 8 DUAL CON
UE TRIPLE CONTROL HARNESS
TEST SOCK WRIST DISART/BEL E
TEST SOCK ELBW DISART/ABOVE
TEST SOCKET SHLDR DISART/THO
SUCTION SOCKET
FRAME TYP SOCKET BEL ELBOW/W
FRAME TYP SOCK ABOVE ELB/DIS
FRAME TYP SOCKET SHOULDER DI
FRAME TYP SOCK INTERSCAP-THO
REMOVABLE INSERT EACH
SILICONE GEL INSERT OR EQUAL
LOCKINGELBOW FOREARM CNTRBAL
ELBOW SOCKET INS USE W/LOCK
ELBOW SOCKET INS USE W/O LCK
CUS ELBO SKT IN FOR CON/ATYP
CUS ELBO SKT IN NOT CON/ATYP
BELOW/ABOVE ELBOW LOCK MECH
TERM DEV, PASSIVE HAND MITT
TERM DEV, SPORT/REC/WORK ATT
TERM DEV MECH HOOK VOL OPEN
TERM DEV MECH HOOK VOL CLOSE
TERM DEV MECH HAND VOL OPEN
TERM DEV MECH HAND VOL CLOSE
PED TERM DEV, HOOK, VOL OPEN
PED TERM DEV, HOOK, VOL CLOS
PED TERM DEV, HAND, VOL OPEN
PED TERM DEV, HAND, VOL CLOS
TERM DEVICE, MULTI ART DIGIT
HOOK/HAND, HVY DTY, VOL OPEN
HOOK/HAND, HVY DTY, VOL CLOS
TERM DEV MODIFIER WRIST UNIT
TERM DEV PRECISION PINCH DEV
ELEC HAND IND ART DIGITS
TERM DEV AUTO GRASP FEATURE
Pricing Action Code
3
3
5
5
5
3
3
3
3
3
3
3
3
6
3
3
3
3
3
3
3
3
3
3
3
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6
3
3
6
5
Maximum Allowable
$204.69
$248.55
$0.00
$0.00
$0.00
$258.92
$57.46
$70.21
$40.14
$38.06
$128.98
$91.86
$92.77
$0.00
$177.47
$198.90
$266.63
$495.85
$441.23
$426.80
$515.42
$558.16
$333.79
$427.78
$2,131.93
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$275.35
$150.10
$0.00
$0.00
Procedure Code
L6882
L6883
L6884
L6885
L6890
L6895
L6900
L6905
L6910
L6915
L6920
L6925
L6930
L6935
L6940
L6945
L6950
L6955
L6960
L6965
L6970
L6975
L7007
L7008
L7009
L7040
L7045
L7170
L7180
L7181
L7185
L7186
L7190
L7191
L7259
L7360
L7362
L7364
L7366
L7367
L7368
L7400
L7401
L7402
L7403
L7404
L7405
Description
MICROPROCESSOR CONTROL UPLMB
REPLC SOCKT BELOW E/W DISA
REPLC SOCKT ABOVE ELBOW DISA
REPLC SOCKT SHLDR DIS/INTERC
PREFAB GLOVE FOR TERM DEVICE
CUSTOM GLOVE FOR TERM DEVICE
HAND RESTORAT THUMB/1 FINGER
HAND RESTORATION MULTIPLE FI
HAND RESTORATION NO FINGERS
HAND RESTORATION REPLACMNT G
WRIST DISARTICUL SWITCH CTRL
WRIST DISART MYOELECTRONIC C
BELOW ELBOW SWITCH CONTROL
BELOW ELBOW MYOELECTRONIC CT
ELBOW DISARTICULATION SWITCH
ELBOW DISART MYOELECTRONIC C
ABOVE ELBOW SWITCH CONTROL
ABOVE ELBOW MYOELECTRONIC CT
SHLDR DISARTIC SWITCH CONTRO
SHLDR DISARTIC MYOELECTRONIC
INTERSCAPULAR-THOR SWITCH CT
INTERSCAP-THOR MYOELECTRONIC
ADULT ELECTRIC HAND
PEDIATRIC ELECTRIC HAND
ADULT ELECTRIC HOOK
PREHENSILE ACTUATOR
PEDIATRIC ELECTRIC HOOK
ELECTRONIC ELBOW HOSMER SWIT
ELECTRONIC ELBOW SEQUENTIAL
ELECTRONIC ELBO SIMULTANEOUS
ELECTRON ELBOW ADOLESCENT SW
ELECTRON ELBOW CHILD SWITCH
ELBOW ADOLESCENT MYOELECTRON
ELBOW CHILD MYOELECTRONIC CT
ELECTRONIC WRIST ROTATOR ANY
SIX VOLT BAT OTTO BOCK/EQ EA
BATTERY CHRGR SIX VOLT OTTO
TWELVE VOLT BATTERY UTAH/EQU
BATTERY CHRGR 12 VOLT UTAH/E
REPLACEMNT LITHIUM IONBATTER
LITHIUM ION BATTERY CHARGER
ADD UE PROST BE/WD, ULTLITE
ADD UE PROST A/E ULTLITE MAT
ADD UE PROST S/D ULTLITE MAT
ADD UE PROST B/E ACRYLIC
ADD UE PROST A/E ACRYLIC
ADD UE PROST S/D ACRYLIC
Pricing Action Code
9
6
6
6
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
6
6
6
3
3
3
3
6
3
3
3
3
6
3
3
3
3
5
5
6
6
6
6
6
6
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$130.10
$473.54
$1,228.99
$1,206.52
$1,238.56
$478.87
$5,896.34
$6,464.09
$5,578.08
$6,600.69
$7,272.04
$8,133.63
$7,706.82
$9,372.94
$9,950.82
$11,398.65
$12,251.26
$13,525.58
$0.00
$0.00
$0.00
$2,225.23
$1,236.40
$4,485.23
$26,708.37
$0.00
$4,592.13
$7,012.55
$5,978.78
$7,553.10
$0.00
$228.56
$205.92
$380.62
$512.77
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
L7499
L7510
L7520
L7600
L7900
L7902
L8000
L8001
L8002
L8010
L8015
L8020
L8030
L8031
L8032
L8035
L8039
L8040
L8041
L8042
L8043
L8044
L8045
L8046
L8047
L8048
L8049
L8300
L8310
L8320
L8330
L8400
L8410
L8415
L8417
L8420
L8430
L8435
L8440
L8460
L8465
L8470
L8480
L8485
L8499
L8500
L8501
Description
UPPER EXTREMITY PROSTHES NOS
PROSTHETIC DEVICE REPAIR REP
REPAIR PROSTHESIS PER 15 MIN
PROSTHETIC DONNING SLEEVE
MALE VACUUM ERECTION SYSTEM
TENSION RING, VAC ERECT DEV
MASTECTOMY BRA
BREAST PROSTHESIS BRA & FORM
BRST PRSTH BRA & BILAT FORM
MASTECTOMY SLEEVE
EXT BREASTPROSTHESIS GARMENT
MASTECTOMY FORM
BREAST PROSTHES W/O ADHESIVE
BREAST PROSTHESIS W ADHESIVE
REUSABLE NIPPLE PROSTHESIS
CUSTOM BREAST PROSTHESIS
BREAST PROSTHESIS NOS
NASAL PROSTHESIS
MIDFACIAL PROSTHESIS
ORBITAL PROSTHESIS
UPPER FACIAL PROSTHESIS
HEMI-FACIAL PROSTHESIS
AURICULAR PROSTHESIS
PARTIAL FACIAL PROSTHESIS
NASAL SEPTAL PROSTHESIS
UNSPEC MAXILLOFACIAL PROSTH
REPAIR MAXILLOFACIAL PROSTH
TRUSS SINGLE W/ STANDARD PAD
TRUSS DOUBLE W/ STANDARD PAD
TRUSS ADDITION TO STD PAD WA
TRUSS ADD TO STD PAD SCROTAL
SHEATH BELOW KNEE
SHEATH ABOVE KNEE
SHEATH UPPER LIMB
PROS SHEATH/SOCK W GEL CUSHN
PROSTHETIC SOCK MULTI PLY BK
PROSTHETIC SOCK MULTI PLY AK
PROS SOCK MULTI PLY UPPER LM
SHRINKER BELOW KNEE
SHRINKER ABOVE KNEE
SHRINKER UPPER LIMB
PROS SOCK SINGLE PLY BK
PROS SOCK SINGLE PLY AK
PROS SOCK SINGLE PLY UPPER L
UNLISTED MISC PROSTHETIC SER
ARTIFICIAL LARYNX
TRACHEOSTOMY SPEAKING VALVE
Pricing Action Code
5
5
3
6
9
9
3
5
5
5
3
3
3
6
6
3
5
3
3
3
3
3
3
3
3
5
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
5
3
3
Maximum Allowable
$0.00
$0.00
$30.08
$0.00
$0.00
$0.00
$34.67
$0.00
$0.00
$0.00
$45.02
$191.37
$307.51
$0.00
$0.00
$2,751.16
$0.00
$1,294.46
$1,560.25
$1,753.08
$1,963.45
$2,173.82
$1,517.49
$1,402.47
$718.77
$0.00
$15.69
$64.52
$120.01
$45.67
$37.77
$13.28
$17.75
$17.44
$56.42
$19.45
$21.02
$16.09
$39.72
$63.29
$45.15
$6.01
$8.74
$8.84
$0.00
$673.10
$114.72
Procedure Code
L8505
L8507
L8509
L8510
L8511
L8512
L8513
L8514
L8515
L8600
L8603
L8604
L8605
L8606
L8607
L8609
L8610
L8612
L8613
L8614
L8615
L8616
L8617
L8618
L8619
L8621
L8622
L8623
L8624
L8627
L8628
L8629
L8630
L8631
L8641
L8642
L8658
L8659
L8670
L8679
L8680
L8681
L8682
L8683
L8684
L8685
L8686
Description
ARTIFICIAL LARYNX, ACCESSORY
TRACH-ESOPH VOICE PROS PT IN
TRACH-ESOPH VOICE PROS MD IN
VOICE AMPLIFIER
INDWELLING TRACH INSERT
GEL CAP FOR TRACH VOICE PROS
TRACH PROS CLEANING DEVICE
REPL TRACH PUNCTURE DILATOR
GEL CAP APP DEVICE FOR TRACH
IMPLANT BREAST SILICONE/EQ
COLLAGEN IMP URINARY 2.5 ML
DEXTRANOMER/HYALURONIC ACID
INJ BULKING AGENT ANAL CANAL
SYNTHETIC IMPLNT URINARY 1ML
INJ VOCAL CORD BULKING AGENT
ARTIFICIAL CORNEA
OCULAR IMPLANT
AQUEOUS SHUNT PROSTHESIS
OSSICULAR IMPLANT
COCHLEAR DEVICE
COCH IMPLANT HEADSET REPLACE
COCH IMPLANT MICROPHONE REPL
COCH IMPLANT TRANS COIL REPL
COCH IMPLANT TRAN CABLE REPL
COCH IMP EXT PROC/CONTR RPLC
REPL ZINC AIR BATTERY
REPL ALKALINE BATTERY
LITH ION BATT CID,NON-EARLVL
LITH ION BATT CID, EAR LEVEL
CID EXT SPEECH PROCESS REPL
CID EXT CONTROLLER REPL
CID TRANSMIT COIL AND CABLE
METACARPOPHALANGEAL IMPLANT
MCP JOINT REPL 2 PC OR MORE
METATARSAL JOINT IMPLANT
HALLUX IMPLANT
INTERPHALANGEAL JOINT SPACER
INTERPHALANGEAL JOINT REPL
VASCULAR GRAFT, SYNTHETIC
IMP NEUROSTI PLS GN ANY TYPE
IMPLT NEUROSTIM ELCTR EACH
PT PRGRM FOR IMPLT NEUROSTIM
IMPLT NEUROSTIM RADIOFQ REC
RADIOFQ TRSMTR FOR IMPLT NEU
RADIOF TRSMTR IMPLT SCRL NEU
IMPLT NROSTM PLS GEN SNG REC
IMPLT NROSTM PLS GEN SNG NON
Pricing Action Code
5
5
5
5
6
6
6
6
6
9
9
9
9
3
9
6
9
9
9
9
6
6
6
6
3
6
6
6
6
6
6
6
9
9
9
9
9
9
9
9
9
6
9
6
6
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$166.75
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$6,403.44
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
L8687
L8688
L8689
L8690
L8691
L8692
L8693
L8695
L8696
L8699
L9900
M0005
M0006
M0007
M0008
M0009
M0019
M0021
M0022
M0023
M0024
M0029
M0039
M0049
M0059
M0070
M0071
M0072
M0075
M0076
M0080
M0100
M0101
M0260
M0261
M0300
M0301
M0520
M0525
M0526
M0530
M0535
M0540
M0560
M0575
M0580
M0585
Description
Pricing Action Code
IMPLT NROSTM PLS GEN DUA REC
IMPLT NROSTM PLS GEN DUA NON
EXTERNAL RECHARG SYS INTERN
AUD OSSEO DEV, INT/EXT COMP
OSSEOINTEGRATED SND PROC RPL
NON-OSSEOINTEGRATED SND PROC
AUD OSSEO DEV, ABUTMENT
EXTERNAL RECHARG SYS EXTERN
EXT ANTENNA PHREN NERVE STIM
PROSTHETIC IMPLANT NOS
O&P SUPPLY/ACCESSORY/SERVICE
OFFICE VISITS WITH TWO OR MORE MOD
OFFICE VISITS WITH ONE OF THE ABOVE
OFFICE VISITS INCLUDING COMBINATION
OFFICE VISIT INCLUDING COMBINATION
NOT OTHERWISE CLASSIFIED, OFFICE VI
NOT OTHERWISE CLASSIFIED, HOME VISI
PER DIEM INPATIENT HOSPITAL CARE WH
I.C.U. CARE FOLLOW-UP WHEN ONE OR
ROUTINE NEWBORN CARE, INHOSPITAL,
CHEMOTHERAPY(FOR MALIGNANCIES, FO
NOT OTHERWISE CLASSIFIED, HOSPITAL
NOT OTHERWISE CLASSIFIED, SNF, ECF,
NOT OTHERWISE CLASSIFIED, NH, BOARD
NOT OTHERWISE CLASSIFIED, EMERGENC
INSULIN SHOCK THERAPY, HYPOGLYCEM
ORTHOMOLECULAR THERAPY
IMMUNOTHERAPY FOR MALIGNANT DIS
CELLULAR THERAPY
PROLOTHERAPY
HYPERTHERMIA THERAPY (TO INCLUDE S
INTRAGASTRIC HYPOTHERMIA
FOOT CARE HYGIENIC/PM
TONSILLECTOMY, WITH OR WITHOUT AD
TONSILLECTOMY, WITH OR WITHOUT AD
IV CHELATIONTHERAPY
FABRIC WRAPPING OF ANEURYSM
ELECTRONIC PACEMAKER ANALYSIS, PUL
SINGLE LEAD EKG WITH ANALYSIS OF PA
COMPUTER TRACING AND INTERPRETAT
CARDIAC EVENTS RECORDER, ELECTROCA
CARDIAC EVENTS RECORDER, ELECTROCA
SIGNAL-AVERAGING EKG
PNEUMOPLETHYSMOGRAPHY VENOUS O
ELECTROENCEPHALOGRAM (EEG), INTER
TRANSTELEPHONIC ELECTROENCEPHALO
ACHILLES REFLEX RESPONSE, ELECTRICA
9
9
6
9
6
6
9
6
6
9
5
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
M0590
M0601
M0702
M0704
M0706
M0708
M0710
M0722
M0724
M0726
M0728
M0730
M0799
M0900
M0910
M0945
M0974
M0978
P2028
P2029
P2031
P2032
P2033
P2038
P3000
P3001
P7001
P7020
P9005
P9006
P9007
P9010
P9011
P9012
P9013
P9014
P9015
P9016
P9017
P9018
P9019
P9020
P9021
P9022
P9023
P9024
P9031
Description
Pricing Action Code
MONITORING ECG, EEG OR PRESSURE IN
PSYCHOLOGICAL TESTING, WITH WRITTE
BRIEF, OSTEOPATHIC MANIPULATIVE TH
LIMITED, OSTEOPATHIC MANIPULATIVE T
INTERMEDIATE OSTEOPATHIC MANIPULA
EXTENDED OSTEOPATHIC MANIPULATIV
COMPREHENSIVE OSTEOPATHIC MANIPU
BRIEF INPATIENT HOSPITAL OMT (UP TO
LIMITED INPATIENT HOSPITAL OMT (UP
INTERMEDIATE INPATIENT HOSPITAL OM
EXTENDED INPATIENT HOSPITAL OMT (U
COMPREHENSIVE INPATIENT HOSPITAL O
PHYSICAL MEDICINE, NOT OTHERWISE C
EXCISION, REVISION OR REMOVAL OF AINSERTION CATHETERS FEMORAL VEIN, U
OUTPATIENT DIALYSIS RELATED PHYSICI
SELF DIALYSIS TRAINING, ANY MODE, C
SELF DIALYSIS TRAINING, ANY MODE, C
CEPHALIN FLOCULATION TEST
CONGO RED BLOOD TEST
HAIR ANALYSIS
ICTERUS INDEX, BLOOD
BLOOD THYMOL TURBIDITY
BLOOD MUCOPROTEIN
SCREEN PAP BY TECH W MD SUPV
SCREENING PAP SMEAR BY PHYS
CULTURE BACTERIAL URINE
VACCINE, AUTOGENOUS (MEDICAL NECE
ADMINISTRATION FEE CHARGE BY A PRO
MULTIPLE PATHOLOGY SERVICES
HANDLING CHARGE FOR PURCHASED LA
WHOLE BLOOD FOR TRANSFUSION
BLOOD SPLIT UNIT
CRYOPRECIPITATE EACH UNIT
UNIT/S BLOOD FIBRINOGEN
GAMMA GLOBULIN 1 ML
RH IMMUNE GLOBULIN 1 ML
RBC LEUKOCYTES REDUCED
PLASMA 1 DONOR FRZ W/IN 8 HR
PLASMA PROTEIN FRACT, UNIT
PLATELETS, EACH UNIT
PLAELET RICH PLASMA UNIT
RED BLOOD CELLS UNIT
WASHED RED BLOOD CELLS UNIT
FROZEN PLASMA, POOLED, SD
FACTOR VIII DILUTION, EACH BOTTLE.
PLATELETS LEUKOCYTES REDUCED
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
P9032
P9033
P9034
P9035
P9036
P9037
P9038
P9039
P9040
P9041
P9042
P9043
P9044
P9045
P9046
P9047
P9048
P9050
P9051
P9052
P9053
P9054
P9055
P9056
P9057
P9058
P9059
P9060
P9070
P9071
P9072
P9603
P9604
P9610
P9612
P9615
Q0033
Q0034
Q0035
Q0039
Q0045
Q0046
Q0047
Q0066
Q0068
Q0081
Q0082
Description
Pricing Action Code
PLATELETS, IRRADIATED
PLATELETS LEUKOREDUCED IRRAD
PLATELETS, PHERESIS
PLATELET PHERES LEUKOREDUCED
PLATELET PHERESIS IRRADIATED
PLATE PHERES LEUKOREDU IRRAD
RBC IRRADIATED
RBC DEGLYCEROLIZED
RBC LEUKOREDUCED IRRADIATED
ALBUMIN (HUMAN),5%, 50ML
ALBUMIN (HUMAN), 25%
PLASMA PROTEIN FRACT,5%,50ML
CRYOPRECIPITATEREDUCEDPLASMA
ALBUMIN (HUMAN), 5%, 250 ML
ALBUMIN (HUMAN), 25%, 20 ML
ALBUMIN (HUMAN), 25%, 50ML
PLASMAPROTEIN FRACT,5%,250ML
GRANULOCYTES, PHERESIS UNIT
BLOOD, L/R, CMV-NEG
PLATELETS, HLA-M, L/R, UNIT
PLT, PHER, L/R CMV-NEG, IRR
BLOOD, L/R, FROZ/DEGLY/WASH
PLT, APH/PHER, L/R, CMV-NEG
BLOOD, L/R, IRRADIATED
RBC, FRZ/DEG/WSH, L/R, IRRAD
RBC, L/R, CMV-NEG, IRRAD
PLASMA, FRZ BETWEEN 8-24HOUR
FR FRZ PLASMA DONOR RETESTED
PATHOGEN REDUCED PLASMA POOL
PATHOGEN REDUCED PLASMA SING
PATHOGEN REDUCED PLATELETS
ONE-WAY ALLOW PRORATED MILES
ONE-WAY ALLOW PRORATED TRIP
URINE SPECIMEN COLLECT SINGL
CATHETERIZE FOR URINE SPEC
URINE SPECIMEN COLLECT MULT
LINOZ V. BOWEN AMBULANCE REIMBUR
ADMIN OF INFLUENZA VACCINE
CARDIOKYMOGRAPHY
OXYGEN CONTENTS, LIQUID, PER UNIT,
ANESTHESIA FOR IRIDECTOMY
PORTABLE LIQUID OXYGEN SYSTEM RENT
ANESTHESIA FOR BLEPHAROPLASTY
ASSESSMENT OF CARDIAC OUTPUT BY EL
EXTRACORPEAL PLASMAPHERESIS
INFUSION THER OTHER THAN CHE
ACTIVITY THERAPY W/PARTIAL H
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
Q0083
Q0084
Q0085
Q0091
Q0103
Q0104
Q0109
Q0110
Q0114
Q0115
Q0117
Q0118
Q0119
Q0120
Q0121
Q0122
Q0123
Q0132
Q0138
Q0139
Q0144
Q0156
Q0160
Q0161
Q0162
Q0163
Q0164
Q0166
Q0167
Q0169
Q0173
Q0174
Q0175
Q0177
Q0180
Q0181
Q0184
Q0185
Q0186
Q0478
Q0479
Q0480
Q0481
Q0482
Q0483
Q0484
Q0485
Description
Pricing Action Code
CHEMO BY OTHER THAN INFUSION
CHEMOTHERAPY BY INFUSION
CHEMO BY BOTH INFUSION AND O
OBTAINING SCREEN PAP SMEAR
PHYSICAL THERAPY EVALUATION, INITIA
PHYSICAL THERAPY RE-EVALUATION, PER
OCCUPATIONAL THERAPY EVALUATION,
OCCUPATIONAL THERAPY RE-EVALUATIO
FERN TEST
POST-COITAL MUCOUS EXAM
FOR DIABETICS ONLY, FITTING (INCLUD
FOR DIABETICS ONLY, FITTING (INCLUD
FOR DIABETICS ONLY, MULTIPLE DENSIT
FOR DIABETICS ONLY, MODIFICATION (I
DISPENSING FEE DME NEB DRUG
FERUMOXYTOL, NON-ESRD
FERUMOXYTOL, ESRD USE
AZITHROMYCIN DIHYDRATE, ORAL
HUMAN ALBUMIN 5%
FACTOR IX NON-RECOMBINANT
CHLORPROMAZINE HCL 5MG ORAL
ONDANSETRON ORAL
DIPHENHYDRAMINE HCL 50MG
PROCHLORPERAZINE MALEATE 5MG
GRANISETRON HCL 1 MG ORAL
DRONABINOL 2.5MG ORAL
PROMETHAZINE HCL 12.5MG ORAL
TRIMETHOBENZAMIDE HCL 250MG
THIETHYLPERAZINE MALEATE10MG
PERPHENAZINE 4MG ORAL
HYDROXYZINE PAMOATE 25MG
DOLASETRON MESYLATE ORAL
UNSPECIFIED ORAL ANTI-EMETIC
METABOLICALLY ACTIVE TISSUE
METABOLIC ACTIVE D/E TISSUE
PARAMEDIC INTERCEPT, RURAL
POWER ADAPTER, COMBO VAD
POWER MODULE COMBO VAD, REP
DRIVER PNEUMATIC VAD, REP
MICROPRCSR CU ELEC VAD, REP
MICROPRCSR CU COMBO VAD, REP
MONITOR ELEC VAD, REP
MONITOR ELEC OR COMB VAD REP
MONITOR CABLE ELEC VAD, REP
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
6
6
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
Q0486
Q0487
Q0488
Q0489
Q0490
Q0491
Q0492
Q0493
Q0494
Q0495
Q0496
Q0497
Q0498
Q0499
Q0500
Q0501
Q0502
Q0503
Q0504
Q0506
Q0507
Q0508
Q0509
Q0510
Q0511
Q0512
Q0513
Q0514
Q0515
Q1004
Q1005
Q2004
Q2009
Q2017
Q2026
Q2028
Q2034
Q2035
Q2036
Q2037
Q2038
Q2039
Q2043
Q2049
Q2050
Q2052
Q3001
Description
MON CABLE ELEC/PNEUM VAD REP
LEADS ANY TYPE VAD, REP ONLY
PWR PACK BASE ELEC VAD, REP
PWR PCK BASE COMBO VAD, REP
EMR PWR SOURCE ELEC VAD, REP
EMR PWR SOURCE COMBO VAD REP
EMR PWR CBL ELEC VAD, REP
EMR PWR CBL COMBO VAD, REP
EMR HD PMP ELEC/COMBO, REP
CHARGER ELEC/COMBO VAD, REP
BATTERY ELEC/COMBO VAD, REP
BAT CLPS ELEC/COMB VAD, REP
HOLSTER ELEC/COMBO VAD, REP
BELT/VEST ELEC/COMBO VAD REP
FILTERS ELEC/COMBO VAD, REP
SHWR COV ELEC/COMBO VAD, REP
MOBILITY CART PNEUM VAD, REP
BATTERY PNEUM VAD REPLACEMNT
PWR ADPT PNEUM VAD, REP VEH
LITH-ION BATT ELEC/PNEUM VAD
MISC SUP/ACC EXT VAD
MIS SUP/ACC IMP VAD
MIS SUP/AC IMP VAD NOPAY MED
DISPENS FEE IMMUNOSUPRESSIVE
SUP FEE ANTIEM,ANTICA,IMMUNO
PX SUP FEE ANTI-CAN SUB PRES
DISP FEE INHAL DRUGS/30 DAYS
DISP FEE INHAL DRUGS/90 DAYS
SERMORELIN ACETATE INJECTION
NTIOL CATEGORY 4
NTIOL CATEGORY 5
BLADDER CALCULI IRRIG SOL
FOSPHENYTOIN INJ PE
TENIPOSIDE, 50 MG
RADIESSE INJECTION
INJ, SCULPTRA, 0.5MG
AGRIFLU VACCINE
AFLURIA VACC, 3 YRS & >, IM
FLULAVAL VACC, 3 YRS & >, IM
FLUVIRIN VACC, 3 YRS & >, IM
FLUZONE VACC, 3 YRS & >, IM
NOS FLU VACC, 3 YRS & >, IM
SIPULEUCEL-T AUTO CD54+
IMPORTED LIPODOX INJ
DOXORUBICIN INJ 10MG
IVIG DEMO, SERVICES/SUPPLIES
BRACHYTHERAPY RADIOELEMENTS
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
6
9
9
5
5
5
9
9
9
9
9
9
9
9
9
6
6
9
5
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
Q3014
Q3017
Q3027
Q3028
Q3031
Q4001
Q4002
Q4003
Q4004
Q4005
Q4006
Q4007
Q4008
Q4009
Q4010
Q4011
Q4012
Q4013
Q4014
Q4015
Q4016
Q4017
Q4018
Q4019
Q4020
Q4021
Q4022
Q4023
Q4024
Q4025
Q4026
Q4027
Q4028
Q4029
Q4030
Q4031
Q4032
Q4033
Q4034
Q4035
Q4036
Q4037
Q4038
Q4039
Q4040
Q4041
Q4042
Description
TELEHEALTH FACILITY FEE
ALS ASSESSMENT
INJ BETA INTERFERON IM 1 MCG
INJ BETA INTERFERON SQ 1 MCG
COLLAGEN SKIN TEST
CAST SUP BODY CAST PLASTER
CAST SUP BODY CAST FIBERGLAS
CAST SUP SHOULDER CAST PLSTR
CAST SUP SHOULDER CAST FBRGL
CAST SUP LONG ARM ADULT PLST
CAST SUP LONG ARM ADULT FBRG
CAST SUP LONG ARM PED PLSTER
CAST SUP LONG ARM PED FBRGLS
CAST SUP SHT ARM ADULT PLSTR
CAST SUP SHT ARM ADULT FBRGL
CAST SUP SHT ARM PED PLASTER
CAST SUP SHT ARM PED FBRGLAS
CAST SUP GAUNTLET PLASTER
CAST SUP GAUNTLET FIBERGLASS
CAST SUP GAUNTLET PED PLSTER
CAST SUP GAUNTLET PED FBRGLS
CAST SUP LNG ARM SPLINT PLST
CAST SUP LNG ARM SPLINT FBRG
CAST SUP LNG ARM SPLNT PED P
CAST SUP LNG ARM SPLNT PED F
CAST SUP SHT ARM SPLINT PLST
CAST SUP SHT ARM SPLINT FBRG
CAST SUP SHT ARM SPLNT PED P
CAST SUP SHT ARM SPLNT PED F
CAST SUP HIP SPICA PLASTER
CAST SUP HIP SPICA FIBERGLAS
CAST SUP HIP SPICA PED PLSTR
CAST SUP HIP SPICA PED FBRGL
CAST SUP LONG LEG PLASTER
CAST SUP LONG LEG FIBERGLASS
CAST SUP LNG LEG PED PLASTER
CAST SUP LNG LEG PED FBRGLS
CAST SUP LNG LEG CYLINDER PL
CAST SUP LNG LEG CYLINDER FB
CAST SUP LNGLEG CYLNDR PED P
CAST SUP LNGLEG CYLNDR PED F
CAST SUP SHRT LEG PLASTER
CAST SUP SHRT LEG FIBERGLASS
CAST SUP SHRT LEG PED PLSTER
CAST SUP SHRT LEG PED FBRGLS
CAST SUP LNG LEG SPLNT PLSTR
CAST SUP LNG LEG SPLNT FBRGL
Pricing Action Code
3
9
6
6
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$23.76
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
Q4043
Q4044
Q4045
Q4046
Q4047
Q4048
Q4049
Q4050
Q4051
Q4074
Q4081
Q4082
Q4100
Q4101
Q4102
Q4103
Q4104
Q4105
Q4106
Q4107
Q4108
Q4110
Q4111
Q4112
Q4113
Q4114
Q4115
Q4116
Q4117
Q4118
Q4119
Q4120
Q4121
Q4122
Q4123
Q4124
Q4125
Q4126
Q4127
Q4128
Q4129
Q4130
Q4131
Q4132
Q4133
Q4134
Q4135
Description
CAST SUP LNG LEG SPLNT PED P
CAST SUP LNG LEG SPLNT PED F
CAST SUP SHT LEG SPLNT PLSTR
CAST SUP SHT LEG SPLNT FBRGL
CAST SUP SHT LEG SPLNT PED P
CAST SUP SHT LEG SPLNT PED F
FINGER SPLINT, STATIC
CAST SUPPLIES UNLISTED
SPLINT SUPPLIES MISC
ILOPROST NON-COMP UNIT DOSE
EPOETIN ALFA, 100 UNITS ESRD
DRUG/BIO NOC PART B DRUG CAP
SKIN SUBSTITUTE, NOS
APLIGRAF
OASIS WOUND MATRIX
OASIS BURN MATRIX
INTEGRA BMWD
INTEGRA DRT
DERMAGRAFT
GRAFTJACKET
INTEGRA MATRIX
PRIMATRIX
GAMMAGRAFT
CYMETRA INJECTABLE
GRAFTJACKET XPRESS
INTEGRA FLOWABLE WOUND MATRI
ALLOSKIN
ALLODERM
HYALOMATRIX
MATRISTEM MICROMATRIX
MATRISTEM WOUND MATRIX
MATRISTEM BURN MATRIX
THERASKIN
DERMACELL
ALLOSKIN
OASIS TRI-LAYER WOUND MATRIX
ARTHROFLEX
MEMODERM/DERMA/TRANZ/INTEGUP
TALYMED
FLEXHD/ALLOPATCHHD/MATRIXHD
UNITE BIOMATRIX
STRATTICE TM
EPIFIX
GRAFIX CORE
GRAFIX PRIME
HMATRIX
MEDISKIN
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
6
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
Q4136
Q4137
Q4138
Q4139
Q4140
Q4141
Q4142
Q4143
Q4145
Q4146
Q4147
Q4148
Q4149
Q4150
Q4151
Q4152
Q4153
Q4154
Q4155
Q4156
Q4157
Q4158
Q4159
Q4160
Q4161
Q4162
Q4163
Q4164
Q4165
Q5001
Q5002
Q5003
Q5004
Q5005
Q5006
Q5007
Q5008
Q5009
Q5010
Q5101
Q9950
Q9951
Q9953
Q9954
Q9955
Q9956
Q9957
Description
EZDERM
AMNIOEXCEL OR BIODEXCEL, 1CM
BIODFENCE DRYFLEX, 1CM
AMNIO OR BIODMATRIX, INJ 1CC
BIODFENCE 1CM
ALLOSKIN AC, 1 CM
XCM BIOLOGIC TISS MATRIX 1CM
REPRIZA, 1CM
EPIFIX, INJ, 1MG
TENSIX, 1CM
ARCHITECT ECM PX FX 1 SQ CM
NEOX 1K, 1CM
EXCELLAGEN, 0.1 CC
ALLOWRAP DS OR DRY 1 SQ CM
AMNIOBAND, GUARDIAN 1 SQ CM
DERMAPURE 1 SQUARE CM
DERMAVEST, PLURIVEST SQ CM
BIOVANCE 1 SQUARE CM
NEOXFLO OR CLARIXFLO 1 MG
NEOX 100 1 SQUARE CM
REVITALON 1 SQUARE CM
MARIGEN 1 SQUARE CM
AFFINITY1 SQUARE CM
NUSHIELD 1 SQUARE CM
BIO-CONNEKT PER SQUARE CM
AMNIO BIO AND WOUNDEX FLOW
AMNIO BIO AND WOUNDEX SQ CM
HELICOLL, PER SQUARE CM
KERAMATRIX, PER SQUARE CM
HOSPICE OR HOME HLTH IN HOME
HOSPICE/HOME HLTH IN ASST LV
HOSPICE IN LT/NON-SKILLED NF
HOSPICE IN SNF
HOSPICE, INPATIENT HOSPITAL
HOSPICE IN HOSPICE FACILITY
HOSPICE IN LTCH
HOSPICE IN INPATIENT PSYCH
HOSPICE/HOME HLTH, PLACE NOS
HOSPICE HOME CARE IN HOSPICE
INJ FILGRASTIM GCSF BIOSIMIL
INJ SULF HEXA LIPID MICROSPH
LOCM >= 400 MG/ML IODINE,1ML
INJ FE-BASED MR CONTRAST,1ML
ORAL MR CONTRAST, 100 ML
INJ PERFLEXANE LIP MICROS,ML
INJ OCTAFLUOROPROPANE MIC,ML
INJ PERFLUTREN LIP MICROS,ML
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
3
3
9
9
9
6
6
6
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.97
$33.06
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
Q9958
Q9959
Q9960
Q9961
Q9962
Q9963
Q9964
Q9965
Q9966
Q9967
Q9968
Q9969
Q9980
R0059
R0065
R0070
R0075
R0076
R0085
S0012
S0014
S0017
S0020
S0021
S0023
S0028
S0030
S0032
S0034
S0039
S0040
S0073
S0074
S0077
S0078
S0080
S0081
S0088
S0090
S0091
S0092
S0093
S0104
S0106
S0108
S0109
S0117
Description
HOCM <=149 MG/ML IODINE, 1ML
HOCM 150-199MG/ML IODINE,1ML
HOCM>= 400MG/ML IODINE, 1ML
LOCM 100-199MG/ML IODINE,1ML
VISUALIZATION ADJUNCT
NON-HEU TC-99M ADD-ON/DOSE
GENVISC, INJ, 1MG
NOT OTHERWISE CLASSIFIED, CHEST
CIRCULATION TIME, RADIONUCLIDE STU
TRANSPORT PORTABLE X-RAY
TRANSPORT PORT X-RAY MULTIPL
TRANSPORT PORTABLE EKG
MULTIPLE RADIOLOGY SERVICES
BUTORPHANOL TARTRATE, NASAL
TACRINE HYDROCHLORIDE, 10 MG
INJECTION, AMINOCAPROIC ACID
INJECTION, BUPIVICAINE HYDRO
INJECTION, CEFOPERAZONE SOD
INJECTION, CIMETIDINE HYDROC
INJECTION, FAMOTIDINE, 20 MG
INJECTION, METRONIDAZOLE
INJECTION, NAFCILLIN SODIUM
INJECTION, OFLOXACIN, 400 MG
INJECTION, SULFAMETHOXAZOLE
INJECTION, TICARCILLIN DISOD
INJECTION, AZTREONAM, 500 MG
INJECTION, CEFOTETAN DISODIU
INJECTION, CLINDAMYCIN PHOSP
INJECTION, FOSPHENYTOIN SODI
INJECTION, PENTAMIDINE ISETH
INJECTION, PIPERACILLIN SODI
IMATINIB 100 MG
SILDENAFIL CITRATE, 25 MG
GRANISETRON 1MG
HYDROMORPHONE 250 MG
MORPHINE 500 MG
ZIDOVUDINE, ORAL, 100 MG
BUPROPION HCL SR 60 TABLETS
MERCAPTOPURINE 50 MG
METHADONE ORAL 5MG
TRETINOIN TOPICAL 5 G
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
9
9
6
9
9
9
9
9
9
9
9
5
6
5
6
5
5
5
5
5
5
6
5
6
5
5
5
9
9
5
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
S0119
S0122
S0126
S0128
S0132
S0136
S0137
S0138
S0139
S0140
S0142
S0145
S0148
S0155
S0156
S0157
S0160
S0164
S0166
S0169
S0170
S0171
S0172
S0174
S0175
S0176
S0177
S0178
S0179
S0182
S0183
S0187
S0189
S0190
S0191
S0194
S0197
S0199
S0201
S0206
S0207
S0208
S0209
S0215
S0220
S0221
S0250
Description
ONDANSETRON 4 MG
INJ MENOTROPINS 75 IU
INJ FOLLITROPIN ALFA 75 IU
INJ FOLLITROPIN BETA 75 IU
INJ GANIRELIX ACETAT 250 MCG
CLOZAPINE, 25 MG
DIDANOSINE, 25 MG
FINASTERIDE, 5 MG
MINOXIDIL, 10 MG
SAQUINAVIR, 200 MG
COLISTIMETHATE INH SOL MG
PEG INTERFERON ALFA-2A/180
PEG INTERFERON ALFA-2B/10
EPOPROSTENOL DILUTANT
EXEMESTANE, 25 MG
BECAPLERMIN GEL 1%, 0.5 GM
DEXTROAMPHETAMINE
INJECTION PANTROPRAZOLE
INJ OLANZAPINE 2.5MG
CALCITROL
ANASTROZOLE 1 MG
BUMETANIDE 0.5 MG
CHLORAMBUCIL 2 MG
DOLASETRON 50 MG
FLUTAMIDE 125 MG
HYDROXYUREA 500 MG
LEVAMISOLE 50 MG
LOMUSTINE 10 MG
MEGESTROL 20 MG
PROCARBAZINE, ORAL
PROCHLORPERAZINE 5 MG
TAMOXIFEN 10 MG
TESTOSTERONE PELLET 75 MG
MIFEPRISTONE, ORAL, 200 MG
MISOPROSTOL, ORAL, 200 MCG
VITAMIN SUPPL 100 CAPS
PRENATAL VITAMINS 30 DAY
MED ABORTION INC ALL EX DRUG
PARTIAL HOSPITALIZATION SERV
SURGERY IN OFFICE
PARAMEDICINTERCEP NONHOSPALS
PARAMED INTRCEPT NONVOL
WC VAN MILEAGE PER MI
NONEMERG TRANSP MILEAGE
MEDICAL CONFERENCE BY PHYSIC
MEDICAL CONFERENCE, 60 MIN
COMP GERIATR ASSMT TEAM
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
9
6
6
5
5
9
9
6
9
9
9
5
9
9
9
9
9
9
9
9
9
9
9
5
5
9
9
9
9
9
9
9
3
3
6
6
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.42
$0.42
$0.00
$0.00
$0.00
Procedure Code
S0255
S0257
S0260
S0265
S0270
S0271
S0272
S0273
S0274
S0280
S0281
S0302
S0310
S0315
S0316
S0317
S0320
S0340
S0341
S0342
S0353
S0354
S0390
S0395
S0400
S0500
S0504
S0506
S0508
S0510
S0512
S0514
S0515
S0516
S0518
S0580
S0581
S0590
S0592
S0595
S0596
S0601
S0610
S0612
S0613
S0618
S0620
Description
HOSPICE REFER VISIT NONMD
END OF LIFE COUNSELING
H&P FOR SURGERY
GENETIC COUNSEL 15 MINS
HOME STD CASE RATE 30 DAYS
HOME HOSPICE CASE 30 DAYS
HOME EPISODIC CASE 30 DAYS
MD HOME VISIT OUTSIDE CAP
NURSE PRACTR VISIT OUTS CAP
MEDICAL HOME, INITIAL PLAN
MEDICAL HOME, MAINTENANCE
COMPLETED EPSDT
HOSPITALIST VISIT
DISEASE MANAGEMENT PROGRAM
FOLLOW-UP/REASSESSMENT
DISEASE MGMT PER DIEM
RN TELEPHONE CALLS TO DMP
LIFESTYLE MOD 1ST STAGE
LIFESTYLE MOD 2 OR 3 STAGE
LIFESTYLE MOD 4TH STAGE
CANCER TREATMENTPLAN INITIAL
CANCER TREATMENT PLAN CHANGE
ROUT FOOT CARE PER VISIT
IMPRESSION CASTING FT
GLOBAL ESWL KIDNEY
DISPOS CONT LENS
SINGL PRSCRP LENS
BIFOC PRSCP LENS
TRIFOC PRSCRP LENS
NON-PRSCRP LENS
DAILY CONT LENS
COLOR CONT LENS
SCLERAL LENS LIQUID BANDAGE
SAFETY FRAMES
SUNGLASS FRAMES
POLYCARB LENS
NONSTND LENS
MISC INTEGRAL LENS SERV
COMP CONT LENS EVAL
NEW LENSES IN PTS OLD FRAME
PHAKIC IOL REFRACTIVE ERROR
SCREENING PROCTOSCOPY
ANNUAL GYNECOLOGICAL EXAMINA
ANNUAL GYNECOLOGICAL EXAMINA
ANN BREAST EXAM
AUDIOMETRY FOR HEARING AID
ROUTINE OPHTHALMOLOGICAL EXA
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
5
9
9
6
9
9
9
9
6
9
9
6
9
3
6
9
6
9
9
9
3
3
9
9
6
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$18.96
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$75.91
$73.69
$0.00
$0.00
$0.00
Procedure Code
S0621
S0622
S0630
S0800
S0810
S0812
S1001
S1002
S1015
S1016
S1030
S1031
S1034
S1035
S1036
S1037
S1040
S1090
S2050
S2052
S2053
S2054
S2055
S2060
S2061
S2065
S2066
S2067
S2068
S2070
S2079
S2080
S2083
S2095
S2102
S2103
S2107
S2109
S2112
S2115
S2117
S2118
S2120
S2140
S2142
S2150
S2152
Description
ROUTINE OPHTHALMOLOGICAL EXA
PHYS EXAM FOR COLLEGE
REMOVAL OF SUTURES
LASER IN SITU KERATOMILEUSIS
PHOTOREFRACTIVE KERATECTOMY
PHOTOTHERAP KERATECT
DELUXE ITEM
CUSTOM ITEM
IV TUBING EXTENSION SET
NON-PVC INTRAVENOUS ADMINIST
GLUC MONITOR PURCHASE
GLUC MONITOR RENTAL
ART PANCREAS SYSTEM
ART PANCREAS INV DISP SENSOR
ART PANCREAS EXT TRANSMITTER
ART PANCREAS EXT RECEIVER
CRANIAL REMOLDING ORTHOSIS
MOMETASONE SINUS IMPLANT
DONOR ENTERECTOMY, WITH PREP
TRANSPLANTATION OF SMALL INT
TRANSPLANTATION OF SMALL INT
TRANSPLANTATION OF MULTIVISC
HARVESTING OF DONOR MULTIVIS
LOBAR LUNG TRANSPLANTATION
DONOR LOBECTOMY (LUNG)
SIMULT PANC KIDN TRANS
BREAST GAP FLAP RECONST
BREAST "STACKED" DIEP/GAP
BREAST DIEP OR SIEA FLAP
CYSTO LASER TX URETERAL CALC
LAP ESOPHAGOMYOTOMY
LAUP
ADJUSTMENT GASTRIC BAND
TRANSCATH EMBOLIZ MICROSPHER
ISLET CELL TISSUE TRANSPLANT
ADRENAL TISSUE TRANSPLANT
ADOPTIVE IMMUNOTHERAPY
AUTOLOGOUS CHONDROCYTE TRANS
KNEE ARTHROSCP HARV
PERIACETABULAR OSTEOTOMY
ARTHROEREISIS, SUBTALAR
TOTAL HIP RESURFACING
LOW DENSITY LIPOPROTEIN(LDL)
CORD BLOOD HARVESTING
CORD BLOOD-DERIVED STEM-CELL
BMT HARV/TRANSPL 28D PKG
SOLID ORGAN TRANSPL PKG
Pricing Action Code
6
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
6
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
5
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
S2180
S2190
S2202
S2204
S2205
S2206
S2207
S2208
S2209
S2210
S2220
S2225
S2230
S2235
S2260
S2265
S2266
S2267
S2300
S2325
S2340
S2341
S2342
S2348
S2350
S2351
S2400
S2401
S2402
S2403
S2404
S2405
S2409
S2411
S2900
S3000
S3005
S3600
S3601
S3620
S3630
S3645
S3650
S3652
S3655
S3700
S3708
Description
DONOR LEUKOCYTE INFUSION
SUBCUTANEOUS IMPLANTATION OF
ECHOSCLEROTHERAPY
TRANSMYOCARDIAL LASER REVASC
MINIMALLY INVASIVE DIRECT CO
CRYOSURGICAL ABLATION (IN SI
THROMBECTOMY, CORONARY
MYRINGOTOMY LASER-ASSIST
IMPLANT SEMI-IMP HEAR
IMPLANT AUDITORY BRAIN IMP
INDUCED ABORTION 17-24 WEEKS
INDUCED ABORTION 25-28 WKS
INDUCED ABORTION 29-31 WKS
INDUCED ABORTION 32 OR MORE
ARTHROSCOPY, SHOULDER, SURGI
HIP CORE DECOMPRESSION
CHEMODENERVATION OF ABDUCTOR
CHEMODENERV ADDUCT VOCAL
NASAL ENDOSCOP PO DEBRID
DECOMPRESS DISC RF LUMBAR
DISKECTOMY, ANTERIOR, WITH D
DISKECTOMY, ANTERIOR, WITH D
FETAL SURG CONGEN HERNIA
FETAL SURG URIN TRAC OBSTR
FETAL SURG CONG CYST MALF
FETAL SURG PULMON SEQUEST
FETAL SURG MYELOMENINGO
FETAL SURG SACROCOC TERATOMA
FETAL SURG NOC
FETOSCOP LASER THER TTTS
ROBOTIC SURGICAL SYSTEM
BILAT DIL RETINAL EXAM
EVAL SELF-ASSESS DEPRESSION
STAT LAB
STAT LAB HOME/NF
NEWBORN METABOLIC SCREENING
EOSINOPHIL BLOOD COUNT
HIV-1 ANTIBODY TESTING OF OR
SALIVA TEST, HORMONE LEVEL;
SALIVA TEST, HORMONE LEVEL;
ANTISPERM ANTIBODIES TEST
BLADDER TUMOR-ASSOCIATED
GASTROINTESTINAL FAT ABSORPT
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
6
9
9
9
9
9
9
5
9
9
9
9
5
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
S3722
S3800
S3840
S3841
S3842
S3844
S3845
S3846
S3849
S3850
S3852
S3853
S3861
S3865
S3866
S3870
S3900
S3902
S3904
S3906
S4005
S4011
S4013
S4014
S4015
S4016
S4017
S4018
S4020
S4021
S4022
S4023
S4025
S4026
S4027
S4028
S4030
S4031
S4035
S4037
S4040
S4042
S4981
S4989
S4990
S4991
S4993
Description
DOSE OPTIMIZATION AUC - 5FU
GENETIC TESTING ALS
DNA ANALYSIS RET-ONCOGENE
GENE TEST RETINOBLASTOMA
GENE TEST HIPPEL-LINDAU
DNA ANALYSIS DEAFNESS
GENE TEST ALPHA-THALASSEMIA
GENE TEST BETA-THALASSEMIA
GENE TEST NIEMANN-PICK
GENE TEST SICKLE CELL
DNA ANALYSIS APOE ALZHEIMER
GENE TEST MYO MUSCLR DYST
GENETIC TEST BRUGADA
COMP GENET TEST HYP CARDIOMY
SPEC GENE TEST HYP CARDIOMY
CGH TEST DEVELOPMENTAL DELAY
SURFACE EMG
BALLISTOCARDIOGRAM
MASTERS TWO STEP
TRANSFUSION, DIRECT, BLOOD
INTERIM LABOR FACILITY GLOBA
IVF PACKAGE
COMPL GIFT CASE RATE
COMPL ZIFT CASE RATE
COMPLETE IVF NOS CASE RATE
FROZEN IVF CASE RATE
IVF CANC A STIM CASE RATE
F EMB TRNS CANC CASE RATE
IVF CANC A ASPIR CASE RATE
IVF CANC P ASPIR CASE RATE
ASST OOCYTE FERT CASE RATE
INCOMPL DONOR EGG CASE RATE
DONOR SERV IVF CASE RATE
PROCURE DONOR SPERM
STORE PREV FROZ EMBRYOS
MICROSURG EPI SPERM ASP
SPERM PROCURE INIT VISIT
SPERM PROCURE SUBS VISIT
STIMULATED IUI CASE RATE
CRYO EMBRYO TRANSF CASE RATE
MONIT STORE CRYO EMBRYO 30 D
OVULATION MGMT PER CYCLE
INSERT LEVONORGESTREL IUS
CONTRACEPT IUD
NICOTINE PATCH LEGEND
NICOTINE PATCH NONLEGEND
CONTRACEPTIVE PILLS FOR BC
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
S4995
S5000
S5001
S5002
S5003
S5010
S5012
S5013
S5014
S5016
S5017
S5018
S5019
S5020
S5021
S5022
S5025
S5035
S5036
S5100
S5101
S5102
S5105
S5108
S5109
S5110
S5111
S5115
S5116
S5120
S5121
S5125
S5126
S5130
S5131
S5135
S5136
S5140
S5141
S5145
S5146
S5150
S5151
S5160
S5161
S5162
S5165
Description
SMOKING CESSATION GUM
PRESCRIPTION DRUG, GENERIC
PRESCRIPTION DRUG,BRAND NAME
FAT EMULSION 10% IN 250 ML
FAT EMULSION 20% IN 250 ML
5% DEXTROSE AND 0.45% SALINE
5% DEXTROSE WITH POTASSIUM
5%DEXTROSE/0.45%SALINE1000ML
D5W/0.45NS W KCL AND MGS04
ANTIBIOTIC ADMIN SUPPLIES W/
ANTIBIOTIC ADMINSUPPLIES W/O
PAIN THERAPY ADMIN SUPPLIES
CHEMOTHERAPY ADMIN SUPPLIES
CHEMOTHERAPY ADMIN SUPPLIES
HYDRATION THERAPY ADMIN SUPP
GROWTH HORMONE THERAPY
INFUSION PUMP RENTAL,PERDIEM
HIT ROUTINE DEVICE MAINT
HIT DEVICE REPAIR
ADULT DAYCARE SERVICES 15MIN
ADULT DAY CARE PER HALF DAY
ADULT DAY CARE PER DIEM
CENTERBASED DAY CARE PERDIEM
HOMECARE TRAIN PT 15 MIN
HOMECARE TRAIN PT SESSION
FAMILY HOMECARE TRAINING 15M
FAMILY HOMECARE TRAIN/SESSIO
NONFAMILY HOMECARE TRAIN/15M
NONFAMILY HC TRAIN/SESSION
CHORE SERVICES PER 15 MIN
CHORE SERVICES PER DIEM
ATTENDANT CARE SERVICE /15M
ATTENDANT CARE SERVICE /DIEM
HOMAKER SERVICE NOS PER 15M
HOMEMAKER SERVICE NOS /DIEM
ADULT COMPANIONCARE PER 15M
ADULT COMPANIONCARE PER DIEM
ADULT FOSTER CARE PER DIEM
ADULT FOSTER CARE PER MONTH
CHILD FOSTERCARE TH PER DIEM
THER FOSTERCARE CHILD /MONTH
UNSKILLED RESPITE CARE /15M
UNSKILLED RESPITECARE /DIEM
EMER RESPONSE SYS INSTAL&TST
EMER RSPNS SYS SERV PERMONTH
EMER RSPNS SYSTEM PURCHASE
HOME MODIFICATIONS PER SERV
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
7
7
7
9
9
9
9
9
9
7
9
9
9
7
9
9
9
7
9
7
9
7
9
7
7
7
5
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
S5170
S5175
S5180
S5181
S5185
S5190
S5199
S5497
S5498
S5501
S5502
S5503
S5517
S5518
S5520
S5521
S5522
S5523
S5550
S5551
S5552
S5553
S5560
S5561
S5565
S5566
S5570
S5571
S8001
S8030
S8032
S8035
S8037
S8040
S8042
S8048
S8055
S8060
S8080
S8085
S8092
S8096
S8097
S8100
S8101
S8110
S8120
Description
HOMEDELIVERED PREPARED MEAL
LAUNDRY SERV,EXT,PROF,/ORDER
HH RESPIRATORY THRPY IN EVAL
HH RESPIRATORY THRPY NOS/DAY
MED REMINDER SERV PER MONTH
WELLNESS ASSESSMENT BY NONPH
PERSONAL CARE ITEM NOS EACH
HIT CATH CARE NOC
HIT SIMPLE CATH CARE
HIT COMPLEX CATH CARE
HIT INTERIM CATH CARE
MAINTENANCE OF IMPLANTED VAS
HIT DECLOTTING KIT
HIT CATH REPAIR KIT
HIT PICC INSERT KIT
HIT MIDLINE CATH INSERT KIT
HIT PICC INSERT NO SUPP
HIP MIDLINE CATH INSERT KIT
INSULIN RAPID 5 U
INSULIN MOST RAPID 5 U
INSULIN INTERMED 5 U
INSULIN LONG ACTING 5 U
INSULIN REUSE PEN 1.5 ML
INSULIN REUSE PEN 3 ML
INSULIN CARTRIDGE 150 U
INSULIN CARTRIDGE 300 U
INSULIN DISPOS PEN 1.5 ML
INSULIN DISPOS PEN 3 ML
RADIOFREQUENCY STIMULATION
TANTALUM RING APPLICATION
LOW DOSE CT LUNG SCREENING
MAGNETIC SOURCE IMAGING
MRCP
TOPOGRAPHIC BRAIN MAPPING
MRI LOW FIELD
ISOLATED LIMB PERFUSION
US GUIDANCE FETAL REDUCT
SUPPLY OF CONTRAST MATERIAL
SCINTIMAMMOGRAPHY
FLUORINE-18 FLUORODEOXYGLUCO
ELECTRON BEAM COMPUTED TOMOG
PORTABLE PEAK FLOW METER
ASTHMA KIT
SPACER WITHOUT MASK
SPACER WITH MASK
PEAK EXPIRATORY FLOW RATE (P
O2 CONTENTS GAS CUBIC FT
Pricing Action Code
9
9
9
9
9
6
9
9
9
9
9
9
9
9
9
9
9
9
6
6
6
6
6
6
9
9
9
9
9
9
9
9
9
9
5
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
S8121
S8130
S8131
S8185
S8186
S8189
S8200
S8205
S8210
S8265
S8270
S8300
S8301
S8400
S8402
S8404
S8415
S8420
S8421
S8422
S8423
S8424
S8425
S8426
S8427
S8428
S8429
S8430
S8431
S8450
S8451
S8452
S8460
S8490
S8930
S8940
S8948
S8950
S8990
S8999
S9001
S9007
S9023
S9024
S9025
S9033
S9034
Description
O2 CONTENTS LIQUID LB
INTERFERENTIAL STIM 2 CHAN
INTERFERENTIAL STIM 4 CHAN
FLUTTER DEVICE
SWIVEL ADAPTOR
TRACH SUPPLY NOC
CHEST COMPRESSION VEST
CHEST COMPRESSION SYSTEM GEN
MUCUS TRAP
HABERMAN FEEDER
ENURESIS ALARM
SACRAL NERVE STIMULATION TES
INFECT CONTROL SUPPLIES NOS
INCONTINENCE PANTS, EACH
DIAPERS, EACH
CHILD-SIZE PULL-UP BRIEF
SUPPLIES FOR HOME DELIVERY
CUSTOM GRADIENT SLEEV/GLOV
READY GRADIENT SLEEV/GLOV
CUSTOM GRAD SLEEVE MED
CUSTOM GRAD SLEEVE HEAVY
READY GRADIENT SLEEVE
CUSTOM GRAD GLOVE MED
CUSTOM GRAD GLOVE HEAVY
READY GRADIENT GLOVE
READY GRADIENT GAUNTLET
GRADIENT PRESSURE WRAP
PADDING FOR COMPRSSN BDG
COMPRESSION BANDAGE
SPLINT DIGIT
SPLINT WRIST OR ANKLE
SPLINT ELBOW
CAMISOLE POST-MAST
100 INSULIN SYRINGES
AURICULAR ELECTROSTIMULATION
HIPPOTHERAPY PER SESSION
LOW-LEVEL LASER TRMT 15 MIN
COMPLEX LYMPHEDEMA THERAPY,
PT OR MANIP FOR MAINT
RESUSCITATION BAG
HOME UTERINE MONITOR WITH OR
ULTRAFILTRATION MONITOR
XENON REGIONAL CEREBRAL BLOO
PARANASAL SINUS ULTRASOUND
OMNICARDIOGRAM/CARDIOINTEGRA
GAIT ANALYSIS
ESWL FOR GALLSTONES
Pricing Action Code
9
6
6
9
9
9
9
9
9
5
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
6
9
9
9
9
9
9
9
9
9
5
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
S9035
S9055
S9056
S9061
S9083
S9085
S9088
S9090
S9097
S9098
S9110
S9117
S9122
S9123
S9124
S9125
S9126
S9127
S9128
S9129
S9131
S9140
S9141
S9145
S9150
S9152
S9200
S9208
S9209
S9210
S9211
S9212
S9213
S9214
S9216
S9217
S9218
S9220
S9225
S9230
S9300
S9308
S9310
S9325
S9326
S9327
S9328
Description
MEDICAL EQUIPMENT OR SUPPLIE
PROCUREN OR OTHER GROWTH FAC
COMA STIMULATION PER DIEM
MEDICAL SUPPLIES AND EQUIPME
URGENT CARE CENTER GLOBAL
MENISCAL ALLOGRAFT TRANSPLAN
SERVICES PROVIDED IN URGENT
VERTEBRAL AXIAL DECOMPRESSIO
HOME VISIT WOUND CARE
HOME PHOTOTHERAPY VISIT
TELEMONITORING/HOME PER MNTH
BACK SCHOOL VISIT
HOME HEALTH AIDE OR CERTIFIE
NURSING CARE IN HOME RN
NURSING CARE, IN THE HOME; B
RESPITE CARE, IN THE HOME, P
HOSPICE CARE, IN THE HOME, P
SOCIAL WORK VISIT, IN THE HO
SPEECH THERAPY, IN THE HOME,
OCCUPATIONAL THERAPY, IN THE
PT IN THE HOME PER DIEM
DIABETIC MANAGEMENT PROGRAM,
INSULIN PUMP INITIATION
EVALUATION BY OCULARIST
SPEECH THERAPY, RE-EVAL
NURSING SERVICES AND ALL NEC
HOME MGMT PRETERM LABOR
HOME MGMT PPROM
HOME MGMT GEST HYPERTENSION
HM POSTPAR HYPER PER DIEM
HM PREECLAMP PER DIEM
HM GEST DM PER DIEM
GEST HYPER W NURS DIEM
POSTPAR HYPER W NURS DIEM
PREECLAMP W NURS DIEM
HIT PAIN MGMT PER DIEM
HIT CONT PAIN PER DIEM
HIT INT PAIN PER DIEM
HIT PAIN IMP PUMP DIEM
Pricing Action Code
9
9
9
9
7
9
9
9
9
9
9
9
7
3
3
7
9
7
7
7
7
9
9
5
9
9
9
9
9
9
5
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$51.50
$46.14
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
S9329
S9330
S9331
S9335
S9336
S9338
S9339
S9340
S9341
S9342
S9343
S9345
S9346
S9347
S9348
S9349
S9351
S9353
S9355
S9357
S9359
S9361
S9363
S9364
S9365
S9366
S9367
S9368
S9370
S9372
S9373
S9374
S9375
S9376
S9377
S9379
S9381
S9395
S9401
S9420
S9423
S9425
S9430
S9433
S9434
S9435
S9436
Description
HIT CHEMO PER DIEM
HIT CONT CHEM DIEM
HIT INTERMIT CHEMO DIEM
HT HEMODIALYSIS DIEM
HIT CONT ANTICOAG DIEM
HIT IMMUNOTHERAPY DIEM
HIT PERITON DIALYSIS DIEM
HIT ENTERAL PER DIEM
HIT ENTERAL GRAV DIEM
HIT ENTERAL PUMP DIEM
HIT ENTERAL BOLUS NURS
HIT ANTI-HEMOPHIL DIEM
HIT ALPHA-1-PROTEINAS DIEM
HIT LONGTERM INFUSION DIEM
HIT SYMPATHOMIM DIEM
HIT TOCOLYSIS DIEM
HIT CONT ANTIEMETIC DIEM
HIT CONT INSULIN DIEM
HIT CHELATION DIEM
HIT ENZYME REPLACE DIEM
HIT ANTI-TNF PER DIEM
HIT DIURETIC INFUS DIEM
HIT ANTI-SPASMOTIC DIEM
HIT TPN TOTAL DIEM
HIT TPN 1 LITER DIEM
HIT TPN OVER 3L DIEM
HT INJ ANTIEMETIC DIEM
HT INJ ANTICOAG DIEM
HIT HYDRA TOTAL DIEM
HIT HYDRA 1 LITER DIEM
HIT HYDRA OVER 3L DIEM
HIT NOC PER DIEM
HIT HIGH RISK/ESCORT
ANTICOAG CLINIC PER SESSION
NURSING SERVICES, PATIENT AS
PHARMACY COMP/DISP SERV
MEDICAL FOOD ORAL 100% NUTR
MOD SOLID FOOD SUPPL
MEDICAL FOODS FOR INBORN ERR
LAMAZE CLASS
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
6
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
S9437
S9438
S9439
S9441
S9442
S9443
S9444
S9445
S9446
S9447
S9449
S9451
S9452
S9453
S9454
S9455
S9460
S9465
S9470
S9472
S9473
S9474
S9475
S9476
S9480
S9482
S9484
S9485
S9490
S9494
S9497
S9500
S9501
S9502
S9503
S9504
S9526
S9527
S9528
S9529
S9533
S9535
S9537
S9538
S9539
S9542
S9545
Description
CHILDBIRTH REFRESHER CLASS
CESAREAN BIRTH CLASS
VBAC CLASS
ASTHMA EDUCATION
BIRTHING CLASS
LACTATION CLASS
PARENTING CLASS
PT EDUCATION NOC INDIVID
PT EDUCATION NOC GROUP
INFANT SAFETY CLASS
WEIGHT MGMT CLASS
EXERCISE CLASS
NUTRITION CLASS
SMOKING CESSATION CLASS
STRESS MGMT CLASS
NUTRITIONAL COUNSELING, DIET
CARDIAC REHABILITATION PROGR
PULMONARY REHABILITATION PRO
ENTEROSTOMAL THERAPY BY A RE
AMBULATORY SETTING SUBSTANCE
VESTIBULAR REHAB PER DIEM
INTENSIVE OUTPATIENT PSYCHIA
FAMILY STABILIZATION 15 MIN
CRISIS INTERVENTION PER HOUR
CRISIS INTERVENTION MENTAL H
HIT CORTICOSTEROID/DIEM
HIT ANTIBIOTIC TOTAL DIEM
HIT ANTIBIOTIC Q3H DIEM
SKILLED NURSING VISITS FOR
INSERTION OF A PERIPHERALLY
INSERTION OF MIDLINE CENTRAL
VENIPUNCTURE HOME/SNF
PAIN MANAGEMENT, INTRAVENOUS
ADMINISTRATION OF HEMATOPOIE
HT HEM HORM INJ DIEM
HIT BLOOD PRODUCTS DIEM
ADMINISTRATION OF ANTIBIOTIC
HT INJ NOC PER DIEM
ADMINISTRATION OF IMMUNE GLO
Pricing Action Code
9
9
9
9
9
9
9
7
9
9
9
9
9
9
9
9
9
9
3
9
9
9
9
9
9
9
7
7
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$44.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
S9550
S9555
S9558
S9559
S9560
S9562
S9590
S9800
S9810
S9900
S9901
S9960
S9961
S9970
S9975
S9976
S9977
S9981
S9982
S9986
S9988
S9989
S9990
S9991
S9992
S9994
S9996
S9999
T1000
T1001
T1002
T1003
T1004
T1005
T1006
T1007
T1009
T1010
T1012
T1013
T1014
T1015
T1016
T1017
T1018
T1019
T1020
Description
HOME IV THERAPY, HYDRATION
ADDITIONAL HOME INFUSION
HT INJ GROWTH HORM DIEM
HIT INJ INTERFERON DIEM
HT INJ HORMONE DIEM
HT INJ PALIVIZUMAB DIEM
HT IRRIGATION DIEM
HT RN PER HOUR
HT PHARM PER HOUR
CHRISTIAN SCI PRACT VISIT
CHRISTIAN SCI NURSE VISIT
AIR AMBULANC NONEMERG FIXED
AIR AMBULAN NONEMERG ROTARY
HEALTH CLUB MEMBERSHIP YR
TRANSPLANT RELATED PER DIEM
LODGING PER DIEM
MEALS PER DIEM
MED RECORD COPY ADMIN
MED RECORD COPY PER PAGE
NOT MEDICALLY NECESSARY SVC
SERV PART OF PHASE I TRIAL
SERVICES OUTSIDE US
SERVICES PROVIDED AS PART OF
SERVICES PROVIDED AS PART OF
TRANSPORTATION COSTS TO AND
LODGING COSTS (E.G. HOTEL CH
MEALS FOR CLINICAL TRIAL PAR
SALES TAX
PRIVATE DUTY/INDEPENDENT NSG
NURSING ASSESSMENT/EVALUATN
RN SERVICES UP TO 15 MINUTES
LPN/LVN SERVICES UP TO 15MIN
NSG AIDE SERVICE UP TO 15MIN
RESPITE CARE SERVICE 15 MIN
FAMILY/COUPLE COUNSELING
TREATMENT PLAN DEVELOPMENT
CHILD SITTING SERVICES
MEALS WHEN RECEIVE SERVICES
ALCOHOL/SUBSTANCE ABUSE SKIL
SIGN LANG/ORAL INTERPRETER
TELEHEALTH TRANSMIT, PER MIN
CLINIC SERVICE
CASE MANAGEMENT
TARGETED CASE MANAGEMENT
SCHOOL-BASED IEP SER BUNDLED
PERSONAL CARE SER PER 15 MIN
PERSONAL CARE SER PER DIEM
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
7
7
3
9
9
7
9
9
9
9
9
9
9
7
9
9
9
7
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$19.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
T1021
T1022
T1023
T1024
T1025
T1026
T1027
T1028
T1029
T1030
T1031
T1035
T1502
T1503
T1505
T1999
T2001
T2002
T2003
T2004
T2005
T2007
T2010
T2011
T2012
T2013
T2014
T2015
T2016
T2017
T2018
T2019
T2020
T2021
T2022
T2023
T2024
T2025
T2026
T2027
T2028
T2029
T2030
T2031
T2032
T2033
T2034
Description
HH AIDE OR CN AIDE PER VISIT
CONTRACTED SERVICES PER DAY
PROGRAM INTAKE ASSESSMENT
TEAM EVALUATION & MANAGEMENT
PED COMPR CARE PKG, PER DIEM
PED COMPR CARE PKG, PER HOUR
FAMILY TRAINING & COUNSELING
HOME ENVIRONMENT ASSESSMENT
DWELLING LEAD INVESTIGATION
RN HOME CARE PER DIEM
LPN HOME CARE PER DIEM
UTILITY SERVICES WAIVER
MEDICATION ADMIN VISIT
MED ADMIN, NOT ORAL/INJECT
ELEC MED COMP DEV, NOC
NOC RETAIL ITEMS ANDSUPPLIES
N-ET; PATIENT ATTEND/ESCORT
N-ET; PER DIEM
N-ET; ENCOUNTER/TRIP
N-ET; COMMERC CARRIER PASS
N-ET; STRETCHER VAN
NON-EMER TRANSPORT WAIT TIME
PASRR LEVEL I
PASRR LEVEL II
HABIL ED WAIVER, PER DIEM
HABIL ED WAIVER PER HOUR
HABIL PREVOC WAIVER, PER D
HABIL PREVOC WAIVER PER HR
HABIL RES WAIVER PER DIEM
HABIL RES WAIVER 15 MIN
HABIL SUP EMPL WAIVER/DIEM
HABIL SUP EMPL WAIVER 15MIN
DAY HABIL WAIVER PER DIEM
DAY HABIL WAIVER PER 15 MIN
CASE MANAGEMENT, PER MONTH
TARGETED CASE MGMT PER MONTH
SERV ASMNT/CARE PLAN WAIVER
WAIVER SERVICE, NOS
SPECIAL CHILDCARE WAIVER/D
SPEC CHILDCARE WAIVER 15 MIN
SPECIAL SUPPLY, NOS WAIVER
SPECIAL MED EQUIP, NOSWAIVER
ASSIST LIVING WAIVER/MONTH
ASSIST LIVING WAIVER/DIEM
RES CARE, NOS WAIVER/MONTH
RES, NOS WAIVER PER DIEM
CRISIS INTERVEN WAIVER/DIEM
Pricing Action Code
9
9
7
3
7
7
9
9
5
9
9
9
3
9
9
9
3
7
3
9
9
9
9
9
9
7
7
7
7
9
7
7
7
7
7
9
9
7
9
9
9
9
9
9
9
7
9
Maximum Allowable
$0.00
$0.00
$0.00
$1,429.81
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$4.00
$0.00
$0.00
$0.00
$10.10
$0.00
$10.10
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
T2035
T2036
T2037
T2038
T2039
T2040
T2041
T2042
T2043
T2044
T2045
T2046
T2048
T2049
T2101
T4521
T4522
T4523
T4524
T4525
T4526
T4527
T4528
T4529
T4530
T4531
T4532
T4533
T4534
T4535
T4536
T4537
T4538
T4539
T4540
T4541
T4542
T4543
T4544
T5001
T5999
V2020
V2025
V2100
V2101
V2102
V2103
Description
UTILITY SERVICES WAIVER
CAMP OVERNITE WAIVER/SESSION
CAMP DAY WAIVER/SESSION
COMM TRANS WAIVER/SERVICE
VEHICLE MOD WAIVER/SERVICE
FINANCIAL MGT WAIVER/15MIN
SUPPORT BROKER WAIVER/15 MIN
HOSPICE ROUTINE HOME CARE
HOSPICE CONTINUOUS HOME CARE
HOSPICE RESPITE CARE
HOSPICE GENERAL CARE
HOSPICE LONG TERM CARE, R&B
BH LTC RES R&B, PER DIEM
N-ET; STRETCHER VAN, MILEAGE
BREAST MILK PROC/STORE/DIST
ADULT SIZE BRIEF/DIAPER SM
ADULT SIZE BRIEF/DIAPER MED
ADULT SIZE BRIEF/DIAPER LG
ADULT SIZE BRIEF/DIAPER XL
ADULT SIZE PULL-ON SM
ADULT SIZE PULL-ON MED
ADULT SIZE PULL-ON LG
ADULT SIZE PULL-ON XL
PED SIZE BRIEF/DIAPER SM/MED
PED SIZE BRIEF/DIAPER LG
PED SIZE PULL-ON SM/MED
PED SIZE PULL-ON LG
YOUTH SIZE BRIEF/DIAPER
YOUTH SIZE PULL-ON
DISPOSABLE LINER/SHIELD/PAD
REUSABLE PULL-ON ANY SIZE
REUSABLE UNDERPAD BED SIZE
DIAPER SERV REUSABLE DIAPER
REUSE DIAPER/BRIEF ANY SIZE
REUSABLE UNDERPAD CHAIR SIZE
LARGE DISPOSABLE UNDERPAD
SMALL DISPOSABLE UNDERPAD
ADULT DISP BRIEF/DIAP ABV XL
ADLT DISP UND/PULL ON ABV XL
POSITION SEAT SPEC ORTH NEED
SUPPLY, NOS
VISION SVCS FRAMES PURCHASES
EYEGLASSES DELUX FRAMES
LENS SPHER SINGLE PLANO 4.00
SINGLE VISN SPHERE 4.12-7.00
SINGL VISN SPHERE 7.12-20.00
SPHEROCYLINDR 4.00D/12-2.00D
Pricing Action Code
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
9
9
9
9
9
3
3
3
3
6
9
3
6
3
3
3
3
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.50
$0.50
$0.74
$0.88
$0.50
$0.50
$0.74
$0.88
$0.25
$0.37
$0.25
$0.37
$0.47
$0.47
$0.33
$0.00
$0.00
$0.00
$0.00
$0.00
$0.54
$0.20
$1.02
$1.02
$0.00
$0.00
$49.74
$0.00
$38.15
$40.00
$58.93
$35.97
Procedure Code
V2104
V2105
V2106
V2107
V2108
V2109
V2110
V2111
V2112
V2113
V2114
V2115
V2118
V2121
V2199
V2200
V2201
V2202
V2203
V2204
V2205
V2206
V2207
V2208
V2209
V2210
V2211
V2212
V2213
V2214
V2215
V2218
V2219
V2220
V2221
V2299
V2300
V2301
V2302
V2303
V2304
V2305
V2306
V2307
V2308
V2309
V2310
Description
SPHEROCYLINDR 4.00D/2.12-4D
SPHEROCYLINDER 4.00D/4.25-6D
SPHEROCYLINDER 4.00D/>6.00D
SPHEROCYLINDER 4.25D/12-2D
SPHEROCYLINDER 4.25D/OVER 6D
SPHEROCYLINDR 7.25D/.25-2.25
SPHEROCYLINDER OVER 12.00D
LENS LENTICULAR BIFOCAL
LENS ANISEIKONIC SINGLE
LENTICULAR LENS, SINGLE
LENS SINGLE VISION NOT OTH C
LENS SPHER BIFOC PLANO 4.00D
LENS SPHERE BIFOCAL 4.12-7.0
LENS SPHERE BIFOCAL 7.12-20.
LENS SPHCYL BIFOCAL 4.00D/.1
LENS SPHCY BIFOCAL 4.00D/2.1
LENS SPHCY BIFOCAL 4.00D/4.2
LENS SPHCY BIFOCAL 4.00D/OVE
LENS SPHCY BIFOCAL 4.25-7D/.
LENS SPHCY BIFOCAL 4.25-7/2.
LENS SPHCY BIFOCAL 4.25-7/4.
LENS SPHCY BIFOCAL 4.25-7/OV
LENS SPHCY BIFO 7.25-12/.25LENS SPHCYL BIFO 7.25-12/2.2
LENS SPHCYL BIFO 7.25-12/4.2
LENS SPHCYL BIFOCAL OVER 12.
LENS LENTICULAR BIFOCAL
LENS ANISEIKONIC BIFOCAL
LENS BIFOCAL SEG WIDTH OVER
LENS BIFOCAL ADD OVER 3.25D
LENTICULAR LENS, BIFOCAL
LENS BIFOCAL SPECIALITY
LENS SPHERE TRIFOCAL 4.00D
LENS SPHERE TRIFOCAL 4.12-7.
LENS SPHERE TRIFOCAL 7.12-20
LENS SPHCY TRIFOCAL 4.0/.12LENS SPHCY TRIFOCAL 4.0/2.25
LENS SPHCY TRIFOCAL 4.0/4.25
LENS SPHCYL TRIFOCAL 4.00/>6
LENS SPHCY TRIFOCAL 4.25-7/.
LENS SPHC TRIFOCAL 4.25-7/2.
LENS SPHC TRIFOCAL 4.25-7/4.
LENS SPHC TRIFOCAL 4.25-7/>6
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
6
6
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
6
6
3
3
3
3
3
3
3
3
3
3
3
Maximum Allowable
$38.98
$43.37
$48.13
$44.62
$47.40
$52.44
$51.74
$53.06
$58.86
$1.79
$71.89
$63.63
$77.56
$0.00
$0.00
$52.57
$57.57
$69.55
$54.25
$57.19
$61.83
$66.43
$58.71
$62.97
$67.36
$75.32
$72.60
$72.60
$68.64
$88.57
$75.38
$106.98
$47.09
$38.19
$0.00
$0.00
$62.84
$73.64
$86.73
$57.57
$67.29
$77.94
$82.73
$76.36
$79.36
$82.96
$88.00
Procedure Code
V2311
V2312
V2313
V2314
V2315
V2318
V2319
V2320
V2321
V2399
V2410
V2430
V2499
V2500
V2501
V2502
V2503
V2510
V2511
V2512
V2513
V2520
V2521
V2522
V2523
V2530
V2531
V2599
V2600
V2610
V2615
V2620
V2621
V2622
V2623
V2624
V2625
V2626
V2627
V2628
V2629
V2630
V2631
V2632
V2700
V2702
V2710
Description
LENS SPHC TRIFO 7.25-12/.25LENS SPHC TRIFO 7.25-12/2.25
LENS SPHC TRIFO 7.25-12/4.25
LENS SPHCYL TRIFOCAL OVER 12
LENS LENTICULAR TRIFOCAL
LENS ANISEIKONIC TRIFOCAL
LENS TRIFOCAL SEG WIDTH > 28
LENS TRIFOCAL ADD OVER 3.25D
LENTICULAR LENS, TRIFOCAL
LENS TRIFOCAL SPECIALITY
LENS VARIAB ASPHERICITY SING
LENS VARIABLE ASPHERICITY BI
VARIABLE ASPHERICITY LENS
CONTACT LENS PMMA SPHERICAL
CNTCT LENS PMMA-TORIC/PRISM
CONTACT LENS PMMA BIFOCAL
CNTCT LENS PMMA COLOR VISION
CNTCT GAS PERMEABLE SPHERICL
CNTCT TORIC PRISM BALLAST
CNTCT LENS GAS PERMBL BIFOCL
CONTACT LENS EXTENDED WEAR
CONTACT LENS HYDROPHILIC
CNTCT LENS HYDROPHILIC TORIC
CNTCT LENS HYDROPHIL BIFOCL
CNTCT LENS HYDROPHIL EXTEND
CONTACT LENS GAS IMPERMEABLE
CONTACT LENS GAS PERMEABLE
CONTACT LENS/ES OTHER TYPE
HAND HELD LOW VISION AIDS
SINGLE LENS SPECTACLE MOUNT
TELESCOP/OTHR COMPOUND LENS
PROSTHETIC, EYE, GLASS, STOCK
PROSTHETIC, EYE PLASTIC, STOCK
PROSTHETIC, EYE, GLASS, CUSTOM
PLASTIC EYE PROSTH CUSTOM
POLISHING ARTIFICAL EYE
ENLARGEMNT OF EYE PROSTHESIS
REDUCTION OF EYE PROSTHESIS
SCLERAL COVER SHELL
FABRICATION & FITTING
PROSTHETIC EYE OTHER TYPE
ANTER CHAMBER INTRAOCUL LENS
IRIS SUPPORT INTRAOCLR LENS
POST CHMBR INTRAOCULAR LENS
BALANCE LENS
DELUXE LENS FEATURE
GLASS/PLASTIC SLAB OFF PRISM
Pricing Action Code
3
3
3
3
3
3
3
3
6
6
3
3
6
3
3
3
3
3
3
3
3
3
3
3
3
3
3
6
6
6
6
9
9
9
3
3
3
3
3
3
6
6
6
6
3
9
3
Maximum Allowable
$79.49
$79.95
$82.94
$106.56
$94.65
$148.07
$52.52
$55.41
$0.00
$0.00
$82.58
$92.26
$0.00
$85.97
$116.84
$153.78
$148.27
$116.23
$150.69
$185.42
$151.11
$107.68
$169.90
$151.60
$149.83
$202.40
$421.66
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$712.05
$64.39
$293.59
$158.26
$1,022.12
$241.34
$0.00
$0.00
$0.00
$0.00
$42.70
$0.00
$59.65
Procedure Code
V2715
V2718
V2730
V2744
V2745
V2750
V2755
V2756
V2760
V2761
V2762
V2770
V2780
V2781
V2782
V2783
V2784
V2785
V2786
V2787
V2788
V2790
V2797
V2799
V5000
V5001
V5002
V5003
V5008
V5010
V5011
V5012
V5014
V5016
V5020
V5030
V5040
V5050
V5060
V5070
V5080
V5090
V5095
V5100
V5110
V5120
V5130
Description
Pricing Action Code
PRISM LENS/ES
FRESNELL PRISM PRESS-ON LENS
SPECIAL BASE CURVE
TINT PHOTOCHROMATIC LENS/ES
TINT, ANY COLOR/SOLID/GRAD
ANTI-REFLECTIVE COATING
UV LENS/ES
EYE GLASS CASE
SCRATCH RESISTANT COATING
MIRROR COATING
POLARIZATION, ANY LENS
OCCLUDER LENS/ES
OVERSIZE LENS/ES
PROGRESSIVE LENS PER LENS
LENS, 1.54-1.65 P/1.60-1.79G
LENS, >= 1.66 P/>=1.80 G
LENS POLYCARB OR EQUAL
CORNEAL TISSUE PROCESSING
OCCUPATIONAL MULTIFOCAL LENS
ASTIGMATISM-CORRECT FUNCTION
PRESBYOPIA-CORRECT FUNCTION
AMNIOTIC MEMBRANE
VIS ITEM/SVC IN OTHER CODE
MISC VISION ITEM OR SERVICE
BASIC AUDIOLOGIC ASSESSMENT - HEAR
COMPREHENSIVE AUDIOLOGIC ASSESSM
ASSESSMENT OF VESTIBULAR AND/OR A
ASSESSMENT OF VESTIBULAR AND/OR A
HEARING SCREENING
ASSESSMENT FOR HEARING AID
HEARING AID FITTING/CHECKING
COMPLETE COCHLEAR IMPLANT REHABIL
HEARING AID REPAIR/MODIFYING
UNLISTED AUDIOLOGIC PROCEDURE (SPE
CONFORMITY EVALUATION
BODY-WORN HEARING AID AIR
BODY-WORN HEARING AID BONE
HEARING AID MONAURAL IN EAR
BEHIND EAR HEARING AID
GLASSES AIR CONDUCTION
GLASSES BONE CONDUCTION
HEARING AID DISPENSING FEE
IMPLANT MID EAR HEARING PROS
BODY-WORN BILAT HEARING AID
HEARING AID DISPENSING FEE
BODY-WORN BINAUR HEARING AID
IN EAR BINAURAL HEARING AID
3
3
3
3
9
5
9
9
3
9
9
9
9
9
3
3
3
6
9
9
9
6
9
6
9
9
9
9
3
9
9
9
5
9
9
5
5
5
5
5
5
3
5
5
9
5
5
Maximum Allowable
$9.76
$23.48
$16.73
$15.14
$0.00
$0.00
$0.00
$0.00
$16.31
$0.00
$0.00
$0.00
$0.00
$0.00
$56.94
$64.21
$37.16
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$16.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$400.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
V5140
V5150
V5160
V5170
V5180
V5190
V5200
V5210
V5220
V5230
V5240
V5241
V5242
V5243
V5244
V5245
V5246
V5247
V5248
V5249
V5250
V5251
V5252
V5253
V5254
V5255
V5256
V5257
V5258
V5259
V5260
V5261
V5262
V5263
V5264
V5265
V5266
V5267
V5268
V5269
V5270
V5271
V5272
V5273
V5274
V5275
V5281
Description
BEHIND EAR BINAUR HEARING AI
GLASSES BINAURAL HEARING AID
DISPENSING FEE BINAURAL
WITHIN EAR CROS HEARING AID
BEHIND EAR CROS HEARING AID
GLASSES CROS HEARING AID
CROS HEARING AID DISPENS FEE
IN EAR BICROS HEARING AID
BEHIND EAR BICROS HEARING AI
GLASSES BICROS HEARING AID
DISPENSING FEE BICROS
DISPENSING FEE, MONAURAL
HEARING AID, MONAURAL, CIC
HEARING AID, MONAURAL, ITC
HEARING AID, PROG, MON, CIC
HEARING AID, PROG, MON, ITC
HEARING AID, PROG, MON, ITE
HEARING AID, PROG, MON, BTE
HEARING AID, BINAURAL, CIC
HEARING AID, BINAURAL, ITC
HEARING AID, PROG, BIN, CIC
HEARING AID, PROG, BIN, ITC
HEARING AID, PROG, BIN, ITE
HEARING AID, PROG, BIN, BTE
HEARING ID, DIGIT, MON, CIC
HEARING AID, DIGIT, MON, ITC
HEARING AID, DIGIT, MON, ITE
HEARING AID, DIGIT, MON, BTE
HEARING AID, DIGIT, BIN, CIC
HEARING AID, DIGIT, BIN, ITC
HEARING AID, DIGIT, BIN, ITE
HEARING AID, DIGIT, BIN, BTE
HEARING AID, DISP, MONAURAL
HEARING AID, DISP, BINAURAL
EAR MOLD/INSERT
EAR MOLD/INSERT, DISP
BATTERY FOR HEARING DEVICE
HEARING AID SUP/ACCESS/DEV
ALD TELEPHONE AMPLIFIER
ALERTING DEVICE, ANY TYPE
ALD, TV AMPLIFIER, ANY TYPE
ALD, TV CAPTION DECODER
TDD
ALD FOR COCHLEAR IMPLANT
ALD UNSPECIFIED
EAR IMPRESSION
ALD FM/DM SYSTEM, MONAURAL
Pricing Action Code
5
5
9
5
5
5
9
5
5
5
9
9
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
9
9
5
5
9
9
9
9
9
9
9
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
Procedure Code
V5282
V5283
V5284
V5285
V5286
V5287
V5288
V5289
V5290
V5298
V5299
V5301
V5310
V5321
V5322
V5330
V5335
V5336
V5360
V5362
V5363
V5364
WW840
WW843
Description
Pricing Action Code
ALD FM/DM SYSTEM BINAURAL
ALD NECK, LOOP IND RECEIVER
ALD FM/DM EAR LEVEL RECEIVER
ALD FM/DM AUD INPUT RECEIVER
ALD BLU TOOTH FM/DM RECEIVER
ALD FM/DM RECEIVER, NOS
ALD FM/DM TRANSMITTER ALD
ALD FM/DM ADAPT/BOOT COUPLIN
ALD TRANSMITTER MICROPHONE
HEARING AID NOC
HEARING SERVICE
BASIC ASSESSMENT OF SPECIFIC SINGLE
COMPREHENSIVE ASSESSMENT OF SPEEC
ASSESSMENT FOR ORAL OR LARYNGEAL
ASSESSMENT FOR AUGMENTATIVE COM
TREATMENT FOR SPEECH, LANGUAGE, O
REPAIR/MODIFICATION OF ORAL OR LAR
REPAIR COMMUNICATION DEVICE
UNLISTED SPEECH-LANGUAGE SERVICE (S
SPEECH SCREENING
LANGUAGE SCREENING
DYSPHAGIA SCREENING
CARBON ELECTRODES FOR APNEA MONI
LEAD WIRES FOR APNEA MONITOR-1 SET
9
9
9
9
9
9
9
9
9
5
7
9
9
9
9
9
9
5
9
3
3
3
9
9
Maximum Allowable
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$16.00
$16.00
$16.00
$0.00
$0.00
Price Action Code
3
5
6
7
9
A
O
Description
LOWER OF BILLED OR ALLOWED AMOUNT.
MANUAL PRICE - INDIVIDUAL CONSIDERATION. SET EDIT TO SUSPEND.
MANUAL PRICE - NO REASONABLE CHARGE ESTABLISHED. SET EDIT TO SUSPEND.
ONLY LEVEL I PRICING SHOULD BE USED. SET EDIT TO SUSPEND.
NON-COVERED. SET EDIT TO AUTODENY.
LOWER OF BILLED AMOUNT OR ((RVU + BILLED UNITS) X CONVERSION FACTOR DOLLAR AMOUNT) .
OBSOLETE. SET EDIT TO AUTODENY.
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Service Type
Procedure
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
00100
00102
00103
00104
00120
00124
00126
00140
00142
00144
00145
00147
00148
00160
00162
00164
00170
00172
00174
00176
00190
00192
00210
00211
00212
00214
00215
00216
00218
00220
00222
00300
00320
00322
00326
00350
00352
00400
00402
00404
00406
00410
00450
00454
00470
00472
00474
Description
ANESTH SALIVARY GLAND
ANESTH REPAIR OF CLEFT LIP
ANESTH BLEPHAROPLASTY
ANESTH ELECTROSHOCK
ANESTH EAR SURGERY
ANESTH EAR EXAM
ANESTH TYMPANOTOMY
ANESTH PROCEDURES ON EYE
ANESTH LENS SURGERY
ANESTH CORNEAL TRANSPLANT
ANESTH VITREORETINAL SURG
ANESTH IRIDECTOMY
ANESTH EYE EXAM
ANESTH BIOPSY OF NOSE
ANESTH PROCEDURE ON MOUTH
ANESTH CLEFT PALATE REPAIR
ANESTH FACE/SKULL BONE SURG
ANESTH FACIAL BONE SURGERY
ANESTH CRANIAL SURG NOS
ANESTH CRAN SURG HEMOTOMA
ANESTH SKULL REPAIR/FRACT
ANESTH HEAD VESSEL SURGERY
ANESTH SPECIAL HEAD SURGERY
ANESTH INTRCRN NERVE
ANESTH HEAD NERVE SURGERY
ANESTH HEAD/NECK/PTRUNK
ANESTH NECK ORGAN 1YR/>
ANESTH BIOPSY OF THYROID
ANESTH LARYNX/TRACH < 1 YR
ANESTH SKIN EXT/PER/ATRUNK
ANESTH CORRECT HEART RHYTHM
ANESTH COLLAR BONE BIOPSY
ANESTH REMOVAL OF RIB
ANESTH CHEST WALL REPAIR
ANESTH SURGERY OF RIB
RVU
5
6
5
4
4
4
4
5
6
6
6
4
4
5
7
4
5
6
6
7
5
7
11
10
5
9
9
15
13
10
6
5
6
3
7
10
5
3
5
5
13
4
5
3
6
10
13
RVU Factor Amount
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Service Type
Procedure
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
00500
00520
00522
00524
00528
00529
00530
00532
00534
00537
00539
00540
00541
00542
00546
00548
00550
00560
00561
00562
00563
00566
00567
00580
00600
00604
00620
00625
00626
00630
00632
00635
00640
00670
00700
00702
00730
00740
00750
00752
00754
00756
00770
00790
00792
00794
00796
Description
ANESTH ESOPHAGEAL SURGERY
ANESTH CHEST PROCEDURE
ANESTH CHEST LINING BIOPSY
ANESTH CHEST DRAINAGE
ANES MEDIASCPY & DX THORSCPY
ANES MEDSCPY&THORSCPY 1 LUNG
ANESTH PACEMAKER INSERTION
ANESTH VASCULAR ACCESS
ANESTH CARDIOVERTER/DEFIB
ANESTH CARDIAC ELECTROPHYS
ANESTH TRACH-BRONCH RECONST
ANESTH CHEST SURGERY
ANESTH ONE LUNG VENTILATION
ANESTHESIA REMOVAL PLEURA
ANESTH LUNG CHEST WALL SURG
ANESTH TRACHEA BRONCHI SURG
ANESTH STERNAL DEBRIDEMENT
ANESTH HEART SURG W/O PUMP
ANESTH HEART SURG <1 YR
ANESTH HRT SURG W/PMP AGE 1+
ANESTH HEART SURG W/ARREST
ANESTH CABG W/O PUMP
ANESTH CABG W/PUMP
ANESTH HEART/LUNG TRANSPLNT
ANESTH SITTING PROCEDURE
ANES SPINE TRANTHOR W/O VENT
ANES SPINE TRANSTHOR W/VENT
ANESTH REMOVAL OF NERVES
ANESTH LUMBAR PUNCTURE
ANESTH SPINE MANIPULATION
ANESTH FOR LIVER BIOPSY
ANESTH UPPER GI VISUALIZE
ANESTH BLOOD VESSEL REPAIR
ANESTH SURG UPPER ABDOMEN
ANESTH HEMORR/EXCISE LIVER
ANESTH PANCREAS REMOVAL
ANESTH FOR LIVER TRANSPLANT
RVU
15
6
4
4
8
11
4
4
7
10
18
13
15
15
15
17
10
15
25
20
25
25
18
20
10
13
10
13
15
8
7
4
3
13
4
4
5
5
4
6
7
7
15
7
7
13
30
RVU Factor Amount
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Service Type
Procedure
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
00797
00800
00802
00810
00820
00830
00832
00834
00836
00840
00842
00844
00846
00848
00851
00860
00862
00864
00865
00866
00868
00870
00872
00873
00880
00882
00902
00904
00906
00908
00910
00912
00914
00916
00918
00920
00921
00922
00924
00926
00928
00930
00932
00934
00936
00940
00942
Description
ANESTH SURGERY FOR OBESITY
ANESTH FAT LAYER REMOVAL
ANESTH LOW INTESTINE SCOPE
ANESTH HERNIA REPAIR < 1 YR
ANESTH HERNIA REPAIR PREEMIE
ANESTH SURG LOWER ABDOMEN
ANESTH AMNIOCENTESIS
ANESTH HYSTERECTOMY
ANESTH PELVIC ORGAN SURG
ANESTH TUBAL LIGATION
ANESTH SURGERY OF ABDOMEN
ANESTH KIDNEY/URETER SURG
ANESTH REMOVAL OF BLADDER
ANESTH REMOVAL OF ADRENAL
ANESTH KIDNEY TRANSPLANT
ANESTH BLADDER STONE SURG
ANESTH ABDOMEN VESSEL SURG
ANESTH MAJOR VEIN LIGATION
ANESTH ANORECTAL SURGERY
ANESTH PERINEAL SURGERY
ANESTH REMOVAL OF VULVA
ANESTH BLADDER SURGERY
ANESTH BLADDER TUMOR SURG
ANESTH BLEEDING CONTROL
ANESTH STONE REMOVAL
ANESTH GENITALIA SURGERY
ANESTH VASECTOMY
ANESTH SPERM DUCT SURGERY
ANESTH TESTIS EXPLORATION
ANESTH TESTIS SUSPENSION
ANESTH AMPUTATION OF PENIS
ANESTH VAGINAL PROCEDURES
ANESTH SURG ON VAG/URETHRAL
RVU
10
4
5
5
5
4
6
5
6
6
4
7
8
8
6
6
7
8
7
10
10
5
7
5
15
10
5
7
4
6
3
5
5
5
5
3
3
6
4
4
6
4
4
6
8
3
4
RVU Factor Amount
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Service Type
Procedure
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
00944
00948
00950
00952
01112
01120
01130
01140
01150
01160
01170
01173
01180
01190
01200
01202
01210
01212
01214
01215
01220
01230
01232
01234
01250
01260
01270
01272
01274
01320
01340
01360
01380
01382
01390
01392
01400
01402
01404
01420
01430
01432
01440
01442
01444
01462
01464
Description
ANESTH VAGINAL HYSTERECTOMY
ANESTH REPAIR OF CERVIX
ANESTH VAGINAL ENDOSCOPY
ANESTH HYSTEROSCOPE/GRAPH
ANESTH BONE ASPIRATE/BX
ANESTH BODY CAST PROCEDURE
ANESTH AMPUTATION AT PELVIS
ANESTH PELVIC TUMOR SURGERY
ANESTH PELVIS PROCEDURE
ANESTH FX REPAIR PELVIS
ANESTH HIP JOINT PROCEDURE
ANESTH ARTHROSCOPY OF HIP
ANESTH HIP JOINT SURGERY
ANESTH HIP DISARTICULATION
ANESTH HIP ARTHROPLASTY
ANESTH REVISE HIP REPAIR
ANESTH PROCEDURE ON FEMUR
ANESTH SURGERY OF FEMUR
ANESTH AMPUTATION OF FEMUR
ANESTH RADICAL FEMUR SURG
ANESTH UPPER LEG SURGERY
ANESTH UPPER LEG VEINS SURG
ANESTH THIGH ARTERIES SURG
ANESTH FEMORAL ARTERY SURG
ANESTH FEMORAL EMBOLECTOMY
ANESTH KNEE JOINT PROCEDURE
ANESTH DX KNEE ARTHROSCOPY
ANESTH KNEE JOINT SURGERY
ANESTH KNEE ARTHROPLASTY
ANESTH AMPUTATION AT KNEE
ANESTH KNEE JOINT CASTING
ANESTH KNEE VEINS SURGERY
ANESTH KNEE VESSEL SURG
ANESTH KNEE ARTERIES SURG
ANESTH KNEE ARTERY SURG
ANESTH KNEE ARTERY REPAIR
ANESTH LOWER LEG PROCEDURE
ANESTH ANKLE/FT ARTHROSCOPY
RVU
6
4
5
4
5
6
3
15
10
4
8
12
3
4
4
4
6
10
8
10
4
6
5
8
4
3
8
4
6
4
4
5
3
3
3
4
4
7
5
3
3
6
8
8
8
3
3
RVU Factor Amount
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Service Type
Procedure
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
01470
01472
01474
01480
01482
01484
01486
01490
01500
01502
01520
01522
01610
01620
01622
01630
01634
01636
01638
01650
01652
01654
01656
01670
01680
01682
01710
01712
01714
01716
01730
01732
01740
01742
01744
01756
01758
01760
01770
01772
01780
01782
01810
01820
01829
01830
01832
Description
ANESTH ACHILLES TENDON SURG
ANESTH LOWER LEG BONE SURG
ANESTH RADICAL LEG SURGERY
ANESTH LOWER LEG REVISION
ANESTH ANKLE REPLACEMENT
ANESTH LOWER LEG CASTING
ANESTH LEG ARTERIES SURG
ANESTH LWR LEG EMBOLECTOMY
ANESTH SHOULDER PROCEDURE
ANES DX SHOULDER ARTHROSCOPY
ANESTH SHOULDER JOINT AMPUT
ANESTH FOREQUARTER AMPUT
ANESTH SHOULDER REPLACEMENT
ANESTH SHOULDER ARTERY SURG
ANESTH ARM-LEG VESSEL SURG
ANESTH SHOULDER VEIN SURG
ANESTH SHOULDER CASTING
ANESTH AIRPLANE CAST
ANESTH ELBOW AREA SURGERY
ANESTH BICEPS TENDON REPAIR
ANESTH UPPR ARM PROCEDURE
ANESTH DX ELBOW ARTHROSCOPY
ANESTH UPPER ARM SURGERY
ANESTH HUMERUS SURGERY
ANESTH HUMERUS REPAIR
ANESTH RADICAL HUMERUS SURG
ANESTH HUMERAL LESION SURG
ANESTH ELBOW REPLACEMENT
ANESTH UPPR ARM ARTERY SURG
ANESTH UPPR ARM EMBOLECTOMY
ANESTH UPPER ARM VEIN SURG
ANESTH UPPR ARM VEIN REPAIR
ANESTH LOWER ARM PROCEDURE
ANESTH DX WRIST ARTHROSCOPY
ANESTH WRIST REPLACEMENT
RVU
3
5
5
3
4
4
7
3
8
6
3
5
5
4
4
5
9
15
10
6
10
8
10
4
3
4
3
5
5
5
3
3
4
5
5
6
5
7
6
6
3
4
3
3
3
3
6
RVU Factor Amount
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
20
20
20
20
20
20
20
20
20
20
20
30
50
Service Type
Procedure
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Anesthesia
Surgery
Surgery
Surgery
Surgery
Surgery
Surgery
Surgery
Surgery
Surgery
Surgery
Surgery
Radiology/
Medicine
01840
01842
01844
01850
01852
01860
01916
01920
01922
01924
01925
01926
01930
01931
01932
01933
01935
01936
01951
01952
01958
01960
01961
01962
01963
01965
01966
01967
01968
01969
01990
01991
01992
01996
15850
22841
37195
41820
43496
44133
44136
49906
54440
65767
69710
77371
97039
Description
ANESTH LWR ARM ARTERY SURG
ANESTH LWR ARM EMBOLECTOMY
ANESTH VASCULAR SHUNT SURG
ANESTH LOWER ARM VEIN SURG
ANESTH LWR ARM VEIN REPAIR
ANESTH LOWER ARM CASTING
ANESTH DX ARTERIOGRAPHY
ANESTH CATHETERIZE HEART
ANESTH CAT OR MRI SCAN
ANES THER INTERVEN RAD ARTRL
ANES THER INTERVEN RAD CARD
ANES TX INTERV RAD HRT/CRAN
ANES THER INTERVEN RAD VEIN
ANES THER INTERVEN RAD TIPS
ANES TX INTERV RAD TH VEIN
ANES TX INTERV RAD CRAN VEIN
ANESTH PERC IMG DX SP PROC
ANESTH PERC IMG TX SP PROC
ANESTH BURN LESS 4 PERCENT
ANESTH BURN 4-9 PERCENT
ANESTH ANTEPARTUM MANIPUL
ANESTH VAGINAL DELIVERY
ANESTH CS DELIVERY
ANESTH EMER HYSTERECTOMY
ANESTH CS HYSTERECTOMY
ANESTH INC/MISSED AB PROC
ANESTH INDUCED AB PROCEDURE
ANESTH/ANALG VAG DELIVERY
ANES/ANALG CS DELIVER ADD-ON
ANESTH/ANALG CS HYST ADD-ON
SUPPORT FOR ORGAN DONOR
ANESTH NERVE BLOCK/INJ
ANESTH N BLOCK/INJ PRONE
HOSP MANAGE CONT DRUG ADMIN
REMOVE SUTURES SAME SURGEON
THROMBOLYTIC THERAPY STROKE
EXCISION GUM EACH QUADRANT
FREE JEJUNUM FLAP MICROVASC
ENTERECTOMY LIVE DONOR
INTESTINE TRANSPLANT LIVE
FREE OMENTAL FLAP MICROVASC
REPAIR OF PENIS
CORNEAL TISSUE TRANSPLANT
IMPLANT/REPLACE HEARING AID
SRS MULTISOURCE
PHYSICAL THERAPY TREATMENT
RVU
6
6
6
3
4
3
6
7
7
6
8
10
5
6
8
10
5
5
3
5
5
5
7
5
8
4
4
5
3
5
7
3
5
1
5
13
8.54
4
5
6
6
4
3
5
5
30.24
0.31
RVU Factor Amount
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
22.88
1
1
1
1
1
1
1
1
1
1
1
1
1
Service Type
50 Medicine
Procedure
97139
Description
RVU
0.42
RVU Factor Amount
1
Procedure Code
11980
11981
11983
51725
51725
51726
51726
51727
51727
51728
51728
51729
51729
51736
51736
51741
51741
51784
51784
51785
51785
51792
51792
51797
51797
58300
59020
59020
59025
59025
62252
62252
70015
70015
70030
70030
70100
70100
70110
70110
70120
70120
70130
70130
70134
70134
70140
Pricing Code Modifier
26
26
26
26
TC
26
TC
26
TC
26
TC
26
TC
TC
26
TC
26
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
Pricing Action Code
5
5
5
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
5
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Modifier Price
$95.78
$144.29
$227.03
$78.51
$112.24
$87.81
$180.31
$110.05
$208.18
$107.51
$212.90
$130.11
$216.51
$7.26
$8.59
$7.62
$8.59
$78.86
$116.96
$90.12
$171.99
$57.01
$158.59
$41.23
$72.77
$74.16
$34.77
$38.56
$18.85
$31.00
$39.84
$49.61
$63.51
$91.96
$8.59
$19.57
$9.31
$23.91
$12.89
$25.36
$9.31
$25.00
$17.55
$37.66
$17.89
$34.05
$10.75
Procedure Code
70140
70150
70150
70160
70160
70170
70190
70190
70200
70200
70210
70210
70220
70220
70240
70240
70250
70250
70260
70260
70300
70300
70310
70310
70320
70320
70328
70328
70330
70330
70332
70332
70336
70336
70350
70350
70355
70355
70360
70360
70370
70370
70371
70371
70380
70380
70390
TC
26
TC
26
TC
26
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
TC
26
TC
26
26
TC
26
TC
26
TC
26
TC
26
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Modifier Price
$19.21
$13.60
$28.25
$8.96
$23.91
$15.41
$11.47
$24.64
$14.31
$28.25
$8.96
$21.01
$12.89
$25.00
$10.03
$20.29
$12.89
$23.55
$17.91
$28.25
$6.11
$9.07
$8.24
$28.98
$12.18
$40.92
$9.31
$21.74
$12.89
$34.77
$31.93
$50.70
$74.81
$249.81
$9.79
$10.42
$9.43
$11.49
$8.59
$19.92
$16.47
$61.19
$43.70
$48.89
$9.32
$27.17
$19.34
Procedure Code
70390
70450
70450
70460
70460
70470
70470
70480
70480
70481
70481
70482
70482
70486
70486
70487
70487
70488
70488
70490
70490
70491
70491
70492
70492
70496
70496
70498
70498
70540
70540
70542
70542
70543
70543
70544
70544
70545
70545
70546
70546
70547
70547
70548
70548
70549
70549
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Modifier Price
$76.04
$43.33
$73.86
$57.63
$106.09
$64.80
$128.89
$65.52
$113.69
$70.54
$209.25
$73.75
$231.71
$43.69
$98.12
$57.63
$112.60
$64.80
$143.01
$65.52
$113.33
$70.90
$167.98
$73.75
$207.45
$89.15
$209.27
$89.15
$207.82
$68.75
$275.88
$82.70
$324.75
$109.19
$389.19
$61.23
$275.88
$61.23
$331.27
$91.65
$457.96
$61.59
$275.88
$61.23
$357.33
$91.65
$457.96
Procedure Code
70551
70551
70552
70552
70553
70553
70554
70554
70555
70557
70558
70559
71010
71010
71015
71015
71020
71020
71021
71021
71022
71022
71023
71023
71030
71030
71034
71034
71035
71035
71100
71100
71101
71101
71110
71110
71111
71111
71120
71120
71130
71130
71250
71250
71260
71260
71270
26
TC
26
TC
26
TC
26
TC
26
26
26
26
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Modifier Price
$75.54
$157.85
$90.94
$232.80
$117.08
$265.38
$108.52
$348.65
$128.88
$148.97
$163.99
$165.13
$9.31
$13.42
$11.10
$17.03
$11.09
$17.03
$13.96
$20.29
$16.83
$25.36
$19.34
$44.90
$16.12
$26.08
$23.66
$60.48
$9.31
$23.91
$11.46
$21.74
$13.97
$22.82
$13.96
$23.91
$16.84
$31.52
$10.38
$19.57
$11.46
$25.00
$52.28
$113.33
$63.74
$168.71
$70.54
Procedure Code
71270
71275
71275
71550
71550
71551
71551
71552
71552
71555
71555
72020
72020
72040
72040
72050
72050
72052
72052
72070
72070
72072
72072
72074
72074
72080
72080
72081
72081
72082
72082
72083
72083
72084
72084
72100
72100
72110
72110
72114
72114
72120
72120
72125
72125
72126
72126
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Modifier Price
$208.17
$92.73
$210.72
$74.47
$275.88
$88.08
$376.52
$115.30
$457.98
$91.27
$311.36
$7.88
$14.49
$11.46
$22.10
$16.12
$29.34
$18.62
$38.39
$11.46
$22.82
$11.09
$23.91
$11.09
$28.62
$11.09
$19.92
$13.62
$25.73
$16.48
$46.72
$17.90
$50.70
$20.76
$60.84
$11.46
$23.91
$16.12
$33.32
$16.84
$46.35
$11.46
$29.34
$54.78
$113.33
$62.30
$169.79
Procedure Code
72127
72127
72128
72128
72129
72129
72130
72130
72131
72131
72132
72132
72133
72133
72141
72141
72142
72142
72146
72146
72147
72147
72148
72148
72149
72149
72156
72156
72157
72157
72158
72158
72159
72159
72170
72170
72190
72190
72191
72191
72192
72192
72193
72193
72194
72194
72195
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Modifier Price
$64.80
$209.61
$51.21
$113.33
$62.30
$170.16
$64.80
$211.43
$51.21
$113.33
$62.30
$169.07
$64.82
$209.25
$75.92
$150.61
$91.69
$237.50
$75.92
$150.97
$90.94
$234.61
$75.92
$149.52
$91.33
$233.52
$117.08
$267.19
$117.08
$267.55
$117.08
$266.11
$92.01
$330.18
$8.96
$23.19
$11.10
$27.53
$92.02
$217.24
$55.49
$91.96
$59.45
$169.43
$61.94
$201.65
$74.47
Procedure Code
72195
72196
72196
72197
72197
72198
72198
72200
72200
72202
72202
72220
72220
72240
72240
72255
72255
72265
72265
72270
72270
72275
72275
72285
72285
72295
72295
73000
73000
73010
73010
73020
73020
73030
73030
73040
73040
73050
73050
73060
73060
73070
73070
73080
73080
73085
73085
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
TC
26
26
TC
TC
26
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Modifier Price
$275.88
$88.45
$328.37
$115.30
$396.78
$90.92
$314.61
$8.96
$19.92
$9.66
$23.55
$8.96
$19.57
$46.54
$52.51
$47.29
$51.42
$42.62
$50.70
$60.48
$68.40
$40.11
$77.49
$53.96
$62.34
$44.44
$56.12
$8.59
$19.21
$9.32
$21.01
$7.88
$15.22
$9.67
$19.57
$27.93
$73.50
$10.74
$25.36
$8.59
$20.65
$8.24
$19.57
$8.96
$22.46
$29.40
$69.52
Procedure Code
73090
73090
73092
73092
73100
73100
73110
73110
73115
73115
73120
73120
73130
73130
73140
73140
73200
73200
73201
73201
73202
73202
73206
73206
73218
73218
73219
73219
73220
73220
73221
73221
73222
73222
73223
73223
73225
73225
73501
73501
73502
73502
73503
73503
73521
73521
73522
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Modifier Price
$8.59
$17.40
$8.24
$19.21
$8.59
$21.01
$8.96
$26.80
$29.04
$79.29
$8.59
$17.76
$8.96
$22.10
$7.17
$24.64
$51.21
$113.33
$59.45
$166.18
$62.30
$219.03
$91.65
$238.59
$69.11
$275.88
$82.70
$326.92
$109.92
$396.78
$69.47
$169.81
$83.06
$300.13
$109.92
$365.66
$87.36
$323.30
$9.67
$20.65
$11.46
$30.43
$14.70
$37.66
$11.82
$28.62
$15.41
Procedure Code
73522
73523
73523
73525
73525
73551
73551
73552
73552
73560
73560
73562
73562
73564
73564
73565
73565
73580
73580
73590
73590
73592
73592
73600
73600
73610
73610
73615
73615
73620
73620
73630
73630
73650
73650
73660
73660
73700
73700
73701
73701
73702
73702
73706
73706
73718
73718
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Modifier Price
$34.05
$16.48
$40.92
$29.40
$73.86
$8.59
$19.57
$9.67
$23.19
$8.59
$22.82
$9.67
$26.44
$11.46
$28.62
$8.96
$27.53
$29.04
$87.98
$8.59
$20.29
$8.24
$19.92
$8.59
$21.74
$8.96
$22.82
$29.38
$77.49
$7.88
$18.48
$8.59
$21.01
$8.24
$19.21
$6.81
$21.74
$51.21
$113.33
$59.45
$169.79
$61.94
$216.49
$96.31
$238.97
$69.11
$275.88
Procedure Code
73719
73719
73720
73720
73721
73721
73722
73722
73723
73723
73725
73725
74000
74000
74010
74010
74020
74020
74022
74022
74150
74150
74160
74160
74170
74170
74174
74174
74175
74175
74176
74176
74177
74177
74178
74178
74181
74181
74182
74182
74183
74183
74185
74185
74190
74210
74210
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
26
TC
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Modifier Price
$82.70
$326.92
$109.55
$399.68
$69.47
$170.18
$83.06
$304.11
$109.55
$367.10
$91.64
$314.97
$9.31
$14.49
$11.81
$23.91
$13.97
$23.91
$16.47
$28.62
$60.88
$90.52
$64.80
$168.71
$71.61
$194.05
$111.71
$281.67
$92.37
$218.32
$88.80
$113.33
$93.09
$222.28
$102.39
$254.88
$74.47
$262.85
$88.45
$371.81
$115.30
$397.87
$91.29
$317.15
$23.99
$18.26
$60.48
Procedure Code
74220
74220
74230
74230
74235
74240
74240
74241
74241
74245
74245
74246
74246
74247
74247
74249
74249
74250
74250
74251
74251
74260
74260
74261
74261
74262
74262
74263
74263
74270
74270
74280
74280
74283
74283
74290
74290
74301
74328
74329
74330
74340
74355
74360
74363
74400
74400
26
TC
26
TC
26
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
TC
26
26
TC
26
TC
26
TC
26
TC
TC
26
26
TC
26
26
26
26
26
26
26
26
26
TC
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Modifier Price
$23.64
$66.27
$27.21
$101.38
$64.08
$35.45
$79.29
$35.45
$84.01
$46.54
$127.08
$35.08
$93.41
$35.45
$101.38
$46.54
$139.75
$23.99
$81.10
$35.45
$193.69
$25.42
$193.69
$113.69
$122.82
$127.82
$238.57
$115.17
$651.63
$35.45
$101.38
$50.85
$164.73
$103.55
$104.21
$16.47
$54.68
$10.76
$36.17
$36.53
$46.19
$27.57
$39.45
$29.06
$43.67
$25.07
$85.81
Procedure Code
74410
74410
74415
74415
74420
74425
74430
74430
74440
74440
74445
74450
74455
74455
74470
74485
74485
74710
74710
74712
74712
74713
74713
74740
74740
74775
75557
75557
75559
75559
75561
75561
75563
75563
75565
75565
75572
75572
75573
75573
75574
75574
75600
75600
75605
75605
75625
26
TC
26
TC
26
26
26
TC
26
TC
26
26
26
TC
26
26
TC
26
TC
26
TC
26
TC
26
TC
26
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Modifier Price
$24.71
$84.72
$25.07
$113.33
$17.88
$17.89
$16.11
$21.74
$18.59
$63.73
$55.05
$16.83
$16.83
$65.91
$26.84
$26.46
$66.98
$17.55
$19.57
$153.61
$275.88
$90.94
$143.37
$19.34
$56.49
$31.88
$117.73
$204.18
$145.21
$295.41
$129.89
$297.96
$148.81
$359.14
$12.52
$43.08
$88.05
$199.14
$128.14
$238.59
$120.25
$238.59
$24.75
$176.31
$56.98
$84.37
$57.04
Procedure Code
75625
75630
75630
75635
75635
75658
75658
75705
75705
75710
75710
75716
75716
75726
75726
75731
75731
75733
75733
75736
75736
75741
75741
75743
75743
75746
75746
75756
75756
75774
75774
75791
75791
75801
75803
75805
75807
75809
75809
75810
75820
75820
75822
75822
75825
75825
75827
TC
TC
26
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
26
26
26
26
TC
26
26
TC
26
TC
26
TC
26
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Modifier Price
$83.64
$83.64
$89.99
$121.37
$238.97
$64.93
$103.93
$116.73
$131.44
$57.40
$109.00
$65.63
$124.94
$56.59
$95.23
$58.36
$116.96
$64.38
$122.41
$56.25
$106.47
$64.80
$88.71
$81.99
$89.80
$57.29
$97.41
$57.42
$111.90
$17.91
$71.33
$87.98
$242.20
$45.75
$59.78
$41.54
$60.16
$24.35
$76.76
$58.37
$35.48
$82.19
$53.39
$86.53
$57.76
$81.47
$57.42
Procedure Code
75827
75831
75831
75833
75833
75840
75840
75842
75842
75860
75860
75870
75870
75872
75872
75880
75880
75885
75885
75887
75887
75889
75889
75891
75891
75893
75893
75894
75898
75901
75901
75902
75902
75952
75953
75954
75956
75957
75958
75959
75962
75962
75964
75964
75966
75966
75968
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
26
26
TC
26
TC
26
26
26
26
26
26
26
26
TC
26
TC
26
TC
26
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Modifier Price
$83.64
$56.25
$86.53
$73.90
$93.43
$58.36
$92.69
$75.89
$107.55
$56.96
$88.71
$58.36
$91.96
$54.41
$88.35
$36.89
$108.61
$70.52
$90.16
$70.86
$90.52
$56.20
$90.16
$56.93
$90.88
$27.57
$92.69
$67.80
$85.75
$24.34
$155.67
$19.35
$53.60
$230.47
$69.76
$116.55
$360.01
$308.98
$205.01
$178.74
$27.26
$115.51
$18.32
$71.70
$65.61
$108.63
$18.28
Procedure Code
75968
75970
75978
75978
75984
75984
75989
75989
76000
76000
76001
76010
76010
76080
76080
76098
76098
76100
76100
76101
76101
76102
76102
76120
76120
76125
76376
76376
76377
76377
76380
76380
76390
76390
76506
76506
76510
76510
76511
76511
76512
76512
76513
76513
76514
76514
76516
TC
26
26
TC
26
TC
26
TC
26
TC
26
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
26
TC
TC
26
26
TC
26
TC
26
TC
TC
26
TC
26
TC
26
26
TC
TC
26
26
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Modifier Price
$70.97
$40.81
$27.26
$113.70
$35.79
$72.42
$59.43
$63.00
$8.98
$39.11
$36.99
$9.31
$17.03
$26.84
$28.98
$8.24
$8.70
$32.64
$61.55
$34.42
$99.57
$35.16
$143.02
$19.69
$65.18
$14.72
$10.03
$13.42
$25.00
$40.47
$50.14
$61.55
$70.81
$381.20
$32.98
$87.62
$83.28
$90.23
$49.25
$53.69
$40.56
$53.69
$36.14
$60.48
$5.45
$10.05
$31.52
Procedure Code
76516
76519
76519
76529
76529
76536
76536
76604
76604
76641
76641
76642
76642
76700
76700
76705
76705
76770
76770
76775
76775
76776
76776
76800
76800
76801
76801
76802
76802
76805
76805
76810
76810
76811
76811
76812
76812
76813
76813
76814
76814
76815
76815
76816
76816
76817
76817
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
TC
26
26
TC
TC
26
TC
26
26
TC
TC
26
TC
26
26
TC
26
TC
26
TC
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Modifier Price
$48.89
$31.88
$54.32
$32.94
$47.80
$28.65
$89.80
$27.56
$62.28
$37.23
$72.42
$34.73
$55.40
$41.16
$84.01
$30.07
$63.00
$37.59
$77.85
$29.35
$29.70
$38.66
$121.28
$61.80
$82.92
$51.21
$74.95
$22.80
$43.36
$51.60
$93.41
$44.52
$51.24
$86.19
$100.38
$94.30
$117.31
$61.92
$62.39
$30.79
$52.71
$33.30
$52.87
$44.81
$73.14
$39.05
$60.48
Procedure Code
76818
76818
76819
76819
76820
76820
76821
76821
76825
76825
76826
76826
76827
76827
76828
76828
76830
76830
76831
76831
76856
76856
76857
76857
76870
76870
76872
76872
76873
76873
76881
76881
76882
76882
76885
76885
76886
76886
76930
76932
76936
76936
76937
76937
76940
76941
76942
26
TC
26
TC
TC
26
26
TC
26
TC
26
TC
26
TC
TC
26
26
TC
26
TC
26
TC
TC
26
26
TC
26
TC
26
TC
26
TC
TC
26
26
TC
26
TC
26
26
26
TC
26
TC
26
26
TC
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Modifier Price
$55.58
$69.18
$40.50
$50.70
$22.46
$26.53
$36.93
$58.30
$85.58
$197.32
$42.24
$124.91
$29.35
$48.17
$25.73
$29.02
$35.45
$89.07
$37.62
$84.01
$35.08
$77.13
$23.19
$25.06
$32.59
$36.22
$33.97
$61.92
$79.08
$91.60
$32.21
$85.45
$11.60
$25.07
$37.96
$92.69
$31.13
$77.13
$33.27
$32.91
$100.51
$176.69
$14.68
$17.38
$105.55
$69.93
$28.25
Procedure Code
76942
76945
76946
76946
76965
76965
76970
76970
76975
76977
76977
76998
77001
77001
77002
77002
77003
77003
77011
77011
77012
77012
77013
77014
77014
77021
77021
77022
77051
77051
77052
77052
77053
77053
77054
77054
77055
77055
77056
77056
77057
77057
77058
77058
77059
77059
77072
26
26
TC
26
TC
26
26
TC
26
26
TC
26
26
TC
26
TC
26
TC
26
TC
26
TC
26
26
TC
26
TC
26
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Modifier Price
$34.02
$35.50
$13.42
$20.07
$24.27
$67.24
$19.68
$75.68
$43.38
$2.88
$4.36
$65.12
$19.35
$52.13
$28.67
$65.91
$30.78
$56.85
$63.76
$162.55
$58.36
$67.71
$199.03
$44.39
$75.31
$76.27
$332.69
$216.30
$2.85
$5.43
$2.85
$5.43
$18.26
$40.92
$23.28
$54.68
$35.81
$55.40
$44.39
$72.78
$35.81
$47.80
$83.06
$457.98
$83.06
$457.98
$9.66
Procedure Code
77072
77073
77073
77074
77074
77075
77075
77076
77076
77077
77077
77078
77078
77080
77080
77081
77081
77084
77084
77280
77280
77285
77285
77290
77290
77293
77293
77295
77295
77300
77300
77301
77301
77306
77306
77307
77307
77316
77316
77317
77317
77318
77318
77321
77321
77331
77331
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
TC
26
26
TC
26
TC
26
TC
TC
26
TC
26
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Modifier Price
$13.78
$14.70
$22.10
$23.28
$42.01
$27.57
$61.19
$35.81
$61.55
$16.48
$21.37
$12.52
$61.55
$10.38
$31.52
$11.09
$17.40
$82.00
$275.88
$36.51
$242.20
$55.13
$384.46
$81.62
$443.11
$104.54
$370.00
$224.08
$274.13
$32.59
$35.13
$417.02
$1,572.98
$73.02
$78.59
$141.60
$151.41
$73.38
$118.42
$95.58
$153.92
$151.41
$208.99
$44.54
$49.75
$19.21
$45.46
Procedure Code
77332
77332
77333
77333
77334
77334
77338
77338
77470
77470
77620
77620
77750
77750
77761
77761
77762
77762
77763
77763
77778
77778
77789
77789
78012
78012
78013
78013
78014
78014
78015
78015
78016
78016
78018
78018
78020
78020
78070
78070
78071
78071
78072
78072
78075
78075
78102
26
TC
TC
26
26
TC
26
TC
TC
26
26
TC
TC
26
TC
26
TC
26
TC
26
TC
26
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Modifier Price
$28.64
$56.12
$9.79
$44.04
$64.79
$90.16
$224.08
$291.88
$49.26
$109.18
$81.62
$309.22
$115.55
$260.58
$196.66
$198.69
$225.64
$299.97
$291.93
$452.10
$375.98
$416.28
$60.14
$61.92
$9.66
$73.52
$18.61
$181.78
$25.06
$228.84
$33.27
$198.07
$34.58
$258.18
$41.86
$286.05
$28.23
$59.05
$39.72
$274.81
$59.40
$316.46
$77.98
$355.92
$35.76
$413.85
$26.84
Procedure Code
78102
78103
78103
78104
78104
78110
78110
78111
78111
78120
78120
78121
78121
78122
78130
78130
78135
78135
78140
78140
78185
78185
78190
78190
78191
78191
78195
78195
78201
78201
78202
78202
78205
78205
78206
78206
78215
78215
78216
78216
78226
78226
78227
78227
78230
78230
78231
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
9
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Modifier Price
$151.01
$36.86
$196.62
$38.99
$218.34
$9.66
$88.75
$11.09
$89.83
$11.81
$86.57
$16.47
$90.55
$23.48
$30.76
$145.96
$32.57
$335.29
$31.14
$111.55
$20.40
$202.05
$55.08
$358.82
$30.76
$145.96
$59.78
$313.92
$21.46
$175.63
$24.31
$187.57
$34.33
$187.93
$47.60
$312.47
$24.71
$179.97
$27.91
$103.59
$37.23
$311.40
$45.46
$335.29
$19.27
$128.57
$26.50
Procedure Code
78231
78232
78232
78258
78258
78261
78261
78262
78262
78264
78264
78265
78265
78266
78266
78270
78270
78271
78271
78272
78272
78278
78278
78282
78290
78290
78291
78291
78300
78300
78305
78305
78306
78306
78315
78315
78320
78320
78350
78350
78414
78428
78428
78445
78445
78451
78451
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
26
TC
26
TC
26
TC
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Modifier Price
$109.74
$19.97
$83.31
$37.23
$195.53
$34.73
$226.30
$33.63
$223.05
$37.23
$314.65
$49.03
$335.30
$54.41
$443.18
$10.74
$95.26
$10.38
$84.76
$13.59
$88.02
$49.74
$316.82
$19.34
$34.37
$316.46
$42.92
$221.60
$31.88
$158.25
$41.90
$200.96
$43.32
$221.96
$50.81
$313.56
$51.17
$187.57
$11.09
$22.46
$22.54
$38.27
$150.65
$23.60
$160.05
$67.97
$289.67
Procedure Code
78452
78452
78453
78453
78454
78454
78456
78456
78457
78457
78458
78458
78459
78466
78466
78468
78468
78469
78469
78472
78472
78473
78473
78481
78481
78483
78483
78491
78492
78494
78494
78496
78496
78579
78579
78580
78580
78582
78582
78597
78597
78598
78598
78600
78600
78601
78601
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
26
26
TC
TC
26
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Modifier Price
$80.13
$416.41
$50.11
$269.04
$67.65
$391.41
$49.36
$282.44
$39.07
$158.25
$38.17
$136.89
$71.51
$35.44
$167.30
$39.70
$167.66
$46.16
$192.28
$48.67
$192.28
$72.26
$230.66
$48.28
$133.98
$72.26
$180.33
$72.24
$90.83
$58.66
$176.35
$21.01
$24.68
$23.96
$172.00
$37.23
$214.36
$53.69
$298.36
$36.11
$175.99
$42.22
$280.26
$22.57
$171.64
$25.42
$199.52
Procedure Code
78605
78605
78606
78606
78607
78607
78608
78609
78610
78610
78630
78630
78635
78635
78645
78645
78647
78647
78650
78650
78660
78660
78700
78700
78701
78701
78707
78707
78708
78708
78709
78709
78710
78710
78725
78725
78730
78730
78740
78740
78761
78761
78800
78800
78801
78801
78802
26
TC
26
TC
26
TC
26
26
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Modifier Price
$27.21
$182.14
$31.85
$316.10
$60.10
$308.49
$72.97
$75.45
$15.41
$168.38
$34.37
$321.89
$31.14
$325.51
$28.27
$311.40
$45.82
$322.25
$30.42
$316.10
$27.21
$162.23
$22.54
$158.25
$23.96
$197.71
$47.60
$196.25
$60.11
$121.71
$69.41
$312.11
$31.11
$178.88
$18.61
$94.54
$7.88
$72.42
$27.89
$200.96
$36.16
$182.87
$34.42
$166.57
$40.87
$233.54
$42.58
Procedure Code
78802
78803
78803
78804
78804
78805
78805
78806
78806
78807
78807
78811
78812
78813
78814
78815
78816
79005
79005
79101
79101
79200
79200
79300
79403
79403
79440
79440
79445
83020
84165
84166
84181
84182
85390
85576
86255
86256
86320
86325
86327
86334
86335
87164
87207
88104
88104
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
26
26
26
26
26
TC
26
TC
26
TC
26
26
TC
26
TC
26
26
26
26
26
26
26
26
26
26
26
26
26
26
26
26
26
26
TC
26
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Modifier Price
$299.09
$52.58
$304.88
$52.59
$543.49
$36.51
$154.62
$42.58
$307.04
$52.58
$304.52
$78.41
$95.53
$99.48
$110.23
$121.30
$122.35
$50.35
$89.08
$48.89
$96.58
$59.77
$103.44
$80.84
$84.04
$112.71
$51.42
$96.18
$116.99
$18.07
$15.07
$25.03
$23.91
$25.26
$7.25
$30.15
$16.91
$12.28
$31.46
$29.92
$31.85
$31.36
$41.20
$15.07
$8.09
$19.92
$31.57
Procedure Code
88106
88106
88108
88108
88112
88112
88121
88121
88125
88125
88160
88160
88161
88161
88162
88162
88172
88172
88173
88173
88177
88177
88182
88182
88300
88300
88302
88302
88304
88304
88305
88305
88307
88307
88309
88309
88311
88311
88312
88312
88313
88313
88314
88314
88319
88319
88331
TC
26
TC
26
TC
26
26
TC
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
26
TC
26
TC
26
TC
26
TC
26
TC
TC
26
TC
26
TC
26
26
TC
26
TC
26
TC
26
TC
TC
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Modifier Price
$14.90
$31.57
$22.24
$31.57
$57.41
$66.40
$50.66
$492.62
$5.71
$14.83
$27.65
$28.12
$26.10
$28.12
$13.74
$43.25
$15.67
$33.86
$45.04
$77.87
$6.46
$21.31
$43.63
$49.50
$4.89
$9.57
$7.56
$24.94
$12.53
$30.35
$42.27
$55.30
$77.54
$89.26
$88.75
$128.39
$3.78
$13.68
$30.42
$43.19
$13.68
$38.17
$25.45
$27.26
$29.65
$64.75
$18.97
Procedure Code
88331
88332
88332
88333
88333
88334
88334
88341
88341
88342
88342
88344
88344
88346
88346
88348
88348
88355
88355
88356
88356
88358
88358
88360
88360
88361
88361
88362
88362
88364
88364
88365
88365
88366
88366
88367
88367
88368
88368
88369
88369
88371
88372
88373
88373
88374
88374
26
TC
26
TC
26
TC
26
26
TC
TC
26
26
TC
TC
26
26
TC
TC
26
TC
26
TC
26
TC
26
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
TC
26
26
TC
26
26
26
TC
26
TC
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Modifier Price
$66.87
$9.87
$33.09
$30.69
$59.71
$18.30
$34.67
$21.78
$46.26
$38.47
$47.84
$39.96
$77.68
$41.95
$48.22
$84.37
$304.29
$71.36
$103.70
$63.93
$167.57
$7.51
$55.97
$47.05
$59.52
$55.20
$86.34
$120.90
$135.89
$27.12
$70.82
$52.43
$70.16
$62.78
$87.45
$69.42
$130.83
$68.23
$75.29
$24.95
$49.15
$31.19
$31.93
$21.05
$39.76
$44.91
$161.14
Procedure Code
88377
88377
88381
88381
88387
88387
89060
91010
91010
91013
91013
91020
91020
91022
91022
91030
91030
91034
91034
91035
91035
91037
91037
91038
91038
91040
91040
91065
91065
91110
91110
91111
91111
91112
91112
91120
91120
91122
91122
91132
91132
91133
91133
91200
91200
92025
92025
26
TC
26
TC
TC
26
26
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
TC
26
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Modifier Price
$65.20
$149.94
$54.87
$107.45
$8.18
$31.97
$10.04
$68.43
$110.79
$9.67
$14.12
$76.64
$161.85
$76.62
$93.78
$47.97
$90.52
$52.33
$140.84
$85.67
$404.73
$51.57
$111.51
$58.74
$400.39
$50.81
$392.06
$10.38
$69.52
$193.71
$706.28
$53.36
$686.36
$111.74
$991.53
$51.24
$383.01
$92.09
$139.04
$28.74
$128.89
$35.09
$140.11
$13.23
$15.58
$18.12
$20.42
Procedure Code
92060
92060
92065
92065
92081
92081
92082
92082
92083
92083
92132
92132
92133
92133
92134
92134
92136
92136
92145
92145
92228
92228
92235
92235
92240
92240
92250
92250
92265
92265
92270
92270
92275
92275
92283
92283
92284
92284
92285
92285
92286
92286
92287
92287
92537
92537
92538
TC
26
26
TC
26
TC
26
TC
26
TC
TC
26
TC
26
TC
26
26
TC
TC
26
TC
26
26
TC
26
TC
26
TC
TC
26
26
TC
26
TC
26
TC
26
TC
26
TC
TC
26
26
TC
TC
26
TC
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Modifier Price
$27.17
$38.65
$17.88
$34.77
$16.47
$17.76
$21.83
$26.44
$28.28
$36.95
$15.94
$19.34
$16.31
$28.28
$16.67
$29.01
$31.88
$60.11
$6.90
$8.96
$13.78
$21.13
$47.63
$64.09
$64.83
$195.50
$23.98
$55.40
$36.22
$43.32
$41.87
$51.06
$54.37
$94.88
$9.32
$46.72
$12.52
$48.89
$3.24
$17.76
$16.31
$22.20
$47.63
$91.98
$8.70
$32.21
$4.72
Procedure Code
92538
92540
92540
92541
92541
92542
92542
92544
92544
92545
92545
92546
92546
92548
92548
92585
92585
92587
92587
92588
92588
92978
92979
93024
93024
93025
93025
93050
93050
93260
93260
93261
93261
93278
93278
93279
93279
93280
93280
93281
93281
93282
93282
93283
93283
93284
93284
26
TC
26
TC
26
TC
26
TC
26
TC
26
26
TC
26
TC
26
TC
TC
26
TC
26
26
26
TC
26
26
TC
26
TC
TC
26
TC
26
26
TC
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Modifier Price
$16.11
$22.46
$80.54
$3.27
$21.11
$2.91
$25.42
$2.55
$14.32
$2.19
$13.25
$15.03
$89.81
$26.49
$77.49
$27.21
$110.81
$3.27
$18.61
$4.00
$29.33
$99.73
$79.93
$55.78
$57.58
$37.20
$124.91
$8.96
$9.07
$22.46
$45.46
$22.46
$39.00
$12.52
$18.12
$17.76
$32.55
$19.92
$38.64
$23.55
$45.43
$20.65
$42.92
$24.27
$58.31
$27.53
$63.69
Procedure Code
93285
93285
93286
93286
93287
93287
93288
93288
93289
93289
93290
93290
93291
93291
93292
93292
93293
93293
93303
93303
93304
93304
93306
93306
93307
93307
93308
93308
93312
93312
93314
93314
93315
93317
93318
93320
93320
93321
93321
93325
93325
93350
93350
93351
93351
93451
93451
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
26
26
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Modifier Price
$16.31
$26.48
$12.33
$15.39
$13.42
$23.27
$15.94
$21.47
$19.92
$46.14
$9.79
$21.83
$14.86
$21.83
$11.24
$21.47
$15.73
$38.39
$64.75
$177.78
$37.20
$121.28
$64.39
$167.28
$45.78
$86.53
$26.11
$100.66
$123.37
$189.02
$105.71
$199.88
$144.16
$107.93
$118.89
$18.59
$36.56
$7.52
$20.28
$3.21
$22.80
$71.88
$172.71
$86.18
$189.02
$149.72
$651.29
Procedure Code
93452
93452
93453
93453
93454
93454
93455
93455
93456
93456
93457
93457
93458
93458
93459
93459
93460
93460
93461
93461
93464
93464
93505
93505
93530
93531
93532
93533
93561
93562
93571
93572
93600
93602
93603
93609
93610
93612
93615
93616
93618
93619
93620
93621
93622
93623
93624
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
26
26
26
26
26
26
26
26
26
26
26
26
26
26
26
26
26
26
26
26
26
26
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Modifier Price
$262.75
$641.54
$347.13
$817.49
$266.47
$650.22
$307.88
$759.92
$341.72
$806.98
$383.14
$915.95
$325.54
$774.77
$366.94
$848.61
$408.34
$895.31
$450.12
$1,040.86
$88.70
$190.44
$242.68
$538.71
$229.08
$447.12
$556.09
$371.27
$26.19
$8.24
$99.73
$79.93
$123.18
$120.62
$120.62
$288.87
$171.03
$169.92
$53.35
$66.46
$246.36
$420.67
$667.75
$121.74
$177.91
$165.32
$273.74
Procedure Code
93631
93640
93641
93642
93642
93644
93644
93660
93660
93662
93724
93724
93880
93880
93882
93882
93886
93886
93888
93888
93890
93890
93892
93892
93893
93893
93922
93922
93923
93923
93924
93924
93925
93925
93926
93926
93930
93930
93931
93931
93965
93965
93970
93970
93971
93971
93975
26
26
26
TC
26
TC
26
TC
26
26
TC
26
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Modifier Price
$416.69
$200.26
$340.36
$155.37
$282.78
$107.55
$175.73
$64.84
$95.52
$144.92
$28.62
$245.40
$40.87
$154.97
$25.86
$106.81
$48.39
$154.60
$26.17
$124.55
$52.66
$154.60
$62.43
$93.05
$60.92
$93.05
$12.92
$78.21
$22.96
$118.78
$25.46
$152.44
$40.12
$154.60
$24.74
$132.16
$40.88
$154.97
$25.10
$106.45
$17.56
$104.63
$35.48
$154.97
$22.94
$100.29
$59.14
Procedure Code
93975
93976
93976
93978
93978
93979
93979
93980
93980
93981
93981
93990
93990
94010
94010
94060
94060
94070
94070
94150
94150
94200
94200
94250
94250
94375
94375
94400
94400
94450
94450
94452
94452
94453
94453
94620
94620
94621
94621
94680
94680
94681
94681
94690
94690
94726
94726
TC
26
TC
26
TC
26
TC
TC
26
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
TC
26
26
TC
26
TC
26
TC
26
TC
26
TC
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Modifier Price
$154.60
$40.46
$126.35
$40.53
$154.97
$25.48
$97.39
$60.84
$62.25
$22.60
$52.51
$25.52
$92.69
$8.59
$27.89
$13.23
$48.89
$29.34
$31.52
$3.95
$22.10
$5.73
$19.92
$5.37
$21.37
$15.01
$25.00
$20.04
$36.95
$20.40
$49.25
$14.65
$44.18
$19.32
$62.28
$25.73
$31.12
$69.76
$95.96
$12.88
$45.63
$10.03
$43.82
$3.95
$47.08
$12.51
$41.29
Procedure Code
94727
94727
94728
94728
94729
94729
94750
94750
95782
95782
95783
95783
95805
95805
95806
95806
95807
95807
95808
95808
95810
95810
95811
95811
95812
95812
95813
95813
95816
95816
95819
95819
95822
95822
95824
95827
95827
95829
95829
95860
95860
95861
95861
95863
95863
95864
95864
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Modifier Price
$12.51
$30.43
$12.88
$28.25
$9.30
$46.35
$11.45
$70.61
$128.44
$919.43
$142.35
$958.90
$60.10
$375.88
$61.89
$109.34
$63.33
$425.11
$89.12
$554.00
$123.78
$512.03
$128.80
$539.20
$58.76
$297.25
$93.49
$336.36
$58.76
$309.93
$58.76
$363.16
$58.76
$321.15
$40.12
$58.04
$652.89
$343.25
$1,575.53
$52.65
$71.70
$84.56
$89.80
$101.72
$114.77
$110.06
$134.32
Procedure Code
95865
95865
95866
95866
95867
95867
95868
95868
95869
95869
95870
95870
95873
95873
95874
95874
95875
95875
95885
95885
95886
95886
95887
95887
95905
95905
95907
95907
95908
95908
95909
95909
95910
95910
95911
95911
95912
95912
95913
95913
95921
95921
95922
95922
95923
95923
95924
TC
26
TC
26
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
TC
26
26
TC
26
TC
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
26
TC
26
TC
TC
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Modifier Price
$60.48
$86.40
$67.35
$68.39
$42.62
$53.60
$64.50
$70.61
$20.42
$74.59
$20.06
$74.59
$20.40
$54.66
$20.42
$53.94
$60.21
$66.98
$19.36
$40.18
$45.61
$46.92
$38.69
$43.81
$2.88
$69.16
$42.74
$54.45
$52.51
$67.69
$65.18
$81.66
$85.81
$109.26
$99.21
$136.47
$102.11
$161.90
$110.06
$191.62
$41.29
$46.17
$49.39
$53.23
$47.29
$119.84
$60.48
Procedure Code
95924
95925
95925
95926
95926
95927
95927
95928
95928
95929
95929
95930
95930
95933
95933
95937
95937
95938
95938
95939
95939
95950
95950
95951
95953
95953
95956
95956
95957
95957
95961
95961
95962
95962
95965
95966
95967
96020
A4618
A4618
A7017
A7017
A7045
A7045
B9000
B9000
B9002
26
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
TC
26
26
TC
26
TC
26
TC
TC
26
TC
26
26
26
26
26
RR
UE
RR
UE
RR
UE
RR
UE
RR
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Modifier Price
$90.99
$28.66
$130.00
$27.93
$112.26
$27.93
$116.98
$81.68
$147.35
$82.08
$148.44
$18.61
$111.90
$31.88
$44.54
$35.11
$47.80
$46.94
$301.23
$121.79
$388.14
$81.31
$255.26
$325.30
$166.96
$261.78
$194.88
$1,477.30
$107.11
$213.26
$133.96
$165.79
$89.43
$176.74
$427.30
$216.75
$188.79
$165.97
$1.14
$7.37
$12.82
$96.17
$1.95
$14.60
$125.00
$741.00
$91.99
Procedure Code
B9002
B9004
B9004
B9006
B9006
E0100
E0100
E0105
E0105
E0110
E0110
E0111
E0111
E0112
E0112
E0113
E0113
E0114
E0114
E0116
E0116
E0130
E0130
E0135
E0135
E0141
E0141
E0143
E0143
E0144
E0144
E0147
E0147
E0148
E0148
E0149
E0149
E0153
E0153
E0154
E0154
E0155
E0155
E0156
E0156
E0157
E0157
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Modifier Price
$704.69
$458.53
$2,172.41
$400.00
$1,478.10
$5.30
$17.62
$7.46
$32.84
$15.31
$52.16
$8.06
$39.32
$9.50
$27.00
$4.92
$15.18
$8.99
$37.41
$5.17
$17.07
$16.10
$51.20
$16.51
$56.91
$21.39
$82.73
$12.96
$62.93
$25.91
$194.21
$54.98
$412.45
$12.17
$91.15
$21.35
$160.14
$7.49
$49.77
$7.74
$47.04
$3.68
$23.01
$2.34
$14.93
$8.60
$49.97
Procedure Code
E0158
E0158
E0160
E0160
E0161
E0161
E0162
E0162
E0163
E0163
E0165
E0165
E0167
E0167
E0168
E0168
E0175
E0175
E0181
E0181
E0182
E0182
E0183
E0184
E0184
E0185
E0185
E0186
E0187
E0188
E0189
E0189
E0191
E0191
E0193
E0193
E0194
E0196
E0197
E0197
E0198
E0198
E0199
E0199
E0200
E0200
E0202
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
UE
RR
UE
RR
UE
RR
RR
UE
RR
UE
RR
UE
RR
UE
RR
RR
RR
UE
RR
UE
RR
UE
RR
UE
RR
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
9
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Modifier Price
$3.39
$23.24
$4.14
$23.70
$3.41
$18.80
$14.62
$108.10
$17.01
$73.35
$15.80
$118.50
$1.21
$7.58
$15.24
$114.04
$5.39
$39.64
$24.48
$183.60
$25.05
$216.38
$233.34
$23.50
$142.86
$35.26
$213.83
$19.42
$22.21
$14.04
$3.63
$23.31
$0.97
$7.14
$806.39
$5,217.23
$3,413.64
$30.54
$29.25
$186.21
$21.96
$160.86
$3.06
$23.00
$10.29
$56.90
$59.90
Procedure Code
E0202
E0205
E0205
E0210
E0210
E0215
E0215
E0217
E0217
E0225
E0225
E0235
E0235
E0236
E0239
E0239
E0249
E0249
E0250
E0250
E0251
E0251
E0255
E0255
E0256
E0260
E0260
E0261
E0265
E0265
E0266
E0266
E0271
E0271
E0272
E0272
E0275
E0275
E0276
E0276
E0277
E0280
E0280
E0290
E0291
E0292
E0293
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
RR
UE
RR
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
RR
UE
RR
RR
RR
RR
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Modifier Price
$673.58
$20.42
$118.35
$2.94
$23.42
$7.09
$50.83
$44.96
$302.77
$31.15
$237.02
$16.51
$148.28
$38.12
$43.04
$322.78
$10.47
$71.46
$93.53
$712.05
$70.87
$601.88
$112.39
$688.88
$66.66
$101.31
$759.83
$123.81
$163.27
$1,224.53
$144.42
$938.40
$17.14
$128.74
$20.21
$139.85
$1.52
$10.98
$1.49
$10.07
$583.56
$3.93
$26.55
$71.50
$51.95
$74.50
$68.41
Procedure Code
E0294
E0295
E0296
E0297
E0305
E0305
E0310
E0310
E0325
E0326
E0326
E0371
E0372
E0373
E0424
E0431
E0434
E0439
E0453
E0457
E0459
E0462
E0462
E0470
E0471
E0480
E0480
E0484
E0484
E0500
E0550
E0550
E0560
E0560
E0561
E0561
E0562
E0562
E0565
E0565
E0570
E0570
E0572
E0574
E0575
E0585
E0600
RR
RR
RR
RR
RR
UE
RR
UE
UE
RR
UE
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
RR
UE
RR
RR
RR
UE
RR
UE
RR
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
RR
RR
RR
UE
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
5
3
5
3
3
3
3
9
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
5
5
3
3
3
Modifier Price
$124.99
$121.83
$157.09
$114.39
$17.02
$104.02
$21.78
$140.55
$6.40
$1.14
$7.07
$415.05
$503.67
$576.95
$230.17
$24.75
$24.75
$135.14
$520.64
$58.79
$48.69
$278.78
$1,831.27
$197.19
$406.86
$42.04
$289.20
$3.69
$27.70
$98.86
$47.95
$373.50
$19.23
$123.07
$10.69
$80.24
$21.62
$162.20
$54.75
$410.63
$14.49
$108.68
$35.76
$37.81
$94.83
$33.55
$5.00
Procedure Code
E0600
E0601
E0603
E0605
E0605
E0606
E0610
E0610
E0615
E0615
E0618
E0621
E0621
E0627
E0627
E0628
E0628
E0629
E0629
E0630
E0630
E0635
E0635
E0650
E0650
E0651
E0651
E0652
E0652
E0655
E0655
E0660
E0660
E0665
E0665
E0666
E0666
E0667
E0667
E0668
E0668
E0669
E0669
E0720
E0730
E0730
E0744
RR
RR
RR
RR
UE
RR
RR
UE
RR
UE
RR
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
RR
UE
RR
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Modifier Price
$50.62
$72.72
$13.50
$2.94
$20.82
$18.66
$24.00
$170.69
$55.97
$302.46
$300.00
$9.24
$71.01
$31.64
$237.27
$31.64
$237.27
$31.64
$237.27
$91.12
$683.40
$109.10
$818.25
$85.01
$516.77
$96.34
$722.54
$501.26
$3,759.53
$12.13
$65.91
$15.91
$104.30
$13.46
$83.66
$13.62
$84.24
$30.98
$232.30
$38.88
$295.49
$16.66
$124.90
$29.59
$38.87
$291.53
$87.60
Procedure Code
E0744
E0745
E0745
E0747
E0747
E0748
E0748
E0776
E0776
E0781
E0781
E0791
E0791
E0840
E0840
E0850
E0850
E0855
E0855
E0860
E0860
E0870
E0870
E0880
E0880
E0890
E0890
E0900
E0900
E0910
E0910
E0920
E0920
E0930
E0930
E0935
E0940
E0940
E0941
E0941
E0942
E0942
E0944
E0944
E0945
E0945
E0946
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
5
3
3
3
3
3
3
3
3
3
3
3
Modifier Price
$632.40
$85.64
$603.75
$417.26
$3,129.75
$430.10
$3,225.91
$17.20
$109.89
$236.16
$1,771.20
$257.13
$1,391.93
$15.61
$44.67
$12.65
$64.08
$48.08
$360.64
$6.23
$28.23
$12.65
$75.39
$18.86
$77.27
$30.34
$78.87
$26.43
$78.17
$18.08
$135.60
$44.14
$292.05
$39.52
$254.40
$23.85
$33.26
$217.20
$38.56
$278.40
$2.24
$14.22
$4.40
$32.92
$4.24
$32.83
$56.60
Procedure Code
E0946
E0947
E0947
E0948
E0948
E0950
E0950
E0951
E0951
E0952
E0952
E0959
E0959
E0961
E0961
E0966
E0966
E0967
E0967
E0968
E0968
E0969
E0969
E0970
E0970
E0971
E0971
E0973
E0973
E0974
E0974
E0978
E0978
E0980
E0980
E0990
E0990
E0992
E0992
E0994
E0994
E0995
E0995
E1007
E1007
E1008
E1008
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Modifier Price
$408.08
$60.17
$435.14
$56.10
$395.78
$8.51
$63.72
$1.50
$11.21
$1.67
$12.49
$8.50
$64.02
$2.48
$13.53
$6.91
$51.83
$6.88
$51.66
$17.15
$111.15
$13.99
$104.89
$4.11
$34.56
$3.83
$28.68
$7.80
$60.47
$7.95
$56.69
$3.23
$24.07
$3.15
$23.59
$9.61
$68.53
$8.53
$64.01
$1.52
$11.37
$2.50
$18.72
$785.57
$5,891.78
$790.36
$5,927.75
Procedure Code
E1028
E1028
E1031
E1031
E1050
E1050
E1060
E1060
E1070
E1070
E1083
E1083
E1084
E1084
E1085
E1085
E1086
E1086
E1087
E1087
E1088
E1088
E1089
E1089
E1090
E1090
E1092
E1092
E1093
E1093
E1100
E1100
E1110
E1110
E1130
E1130
E1140
E1140
E1150
E1150
E1160
E1160
E1170
E1170
E1171
E1171
E1172
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Modifier Price
$16.23
$121.77
$52.99
$397.43
$97.43
$651.53
$120.61
$769.57
$89.06
$544.05
$75.33
$462.83
$93.85
$590.70
$66.21
$443.55
$80.40
$540.83
$121.03
$855.90
$144.24
$890.63
$114.99
$798.38
$110.73
$633.38
$122.94
$896.93
$105.74
$763.13
$99.32
$627.53
$82.66
$541.05
$44.67
$316.05
$68.73
$498.08
$90.18
$676.35
$59.79
$420.00
$85.45
$522.98
$68.33
$480.08
$87.87
Procedure Code
E1172
E1180
E1180
E1190
E1190
E1195
E1195
E1200
E1200
E1221
E1222
E1223
E1223
E1224
E1225
E1226
E1226
E1228
E1230
E1230
E1240
E1240
E1250
E1250
E1270
E1270
E1280
E1280
E1285
E1285
E1290
E1290
E1295
E1295
E1296
E1296
E1297
E1297
E1298
E1298
E1310
E1310
E1353
E1355
E1355
E1372
E1372
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
RR
RR
UE
RR
RR
RR
UE
RR
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
RR
UE
RR
UE
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
5
3
3
3
3
Modifier Price
$537.75
$82.41
$497.33
$112.01
$693.08
$102.16
$562.95
$73.20
$447.97
$45.45
$64.85
$70.81
$477.15
$77.64
$42.63
$48.69
$358.53
$22.79
$194.69
$1,454.64
$113.89
$854.18
$72.71
$441.68
$64.19
$407.63
$106.74
$681.23
$98.07
$592.05
$101.77
$566.33
$111.11
$679.95
$40.61
$299.87
$9.44
$63.79
$36.55
$274.02
$175.72
$1,540.80
$308.71
$4.67
$35.00
$22.66
$115.46
Procedure Code
E1390
E1405
E1406
E2000
E2206
E2206
E2311
E2311
E2360
E2360
E2361
E2361
E2362
E2362
E2363
E2363
E2364
E2364
E2365
E2365
E2366
E2366
E2367
E2367
G0202
G0202
G0204
G0204
G0206
G0206
G0252
G0252
G0279
G0279
G6001
G6001
G6002
G6002
K0001
K0001
K0002
K0003
K0004
K0005
K0005
K0006
K0015
RR
RR
RR
RR
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
26
TC
26
TC
26
TC
26
TC
TC
26
TC
26
26
TC
RR
UE
RR
RR
RR
RR
UE
RR
RR
Pricing Action Code
3
5
5
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
5
3
3
3
3
3
3
Modifier Price
$135.14
$263.04
$248.37
$50.57
$3.95
$29.69
$214.14
$1,606.05
$11.24
$84.26
$11.85
$88.88
$9.20
$68.98
$15.34
$115.05
$11.24
$84.26
$8.84
$66.33
$20.00
$149.77
$41.91
$314.31
$34.26
$106.39
$42.66
$128.67
$34.26
$100.82
$74.46
$447.50
$26.03
$30.74
$22.05
$29.64
$20.37
$55.29
$41.88
$314.10
$81.43
$61.04
$87.07
$204.36
$1,532.83
$95.07
$14.62
Procedure Code
K0015
K0017
K0017
K0018
K0018
K0019
K0019
K0020
K0020
K0037
K0037
K0038
K0038
K0039
K0039
K0040
K0040
K0041
K0041
K0042
K0042
K0043
K0043
K0044
K0044
K0045
K0045
K0046
K0046
K0047
K0047
K0050
K0050
K0051
K0051
K0052
K0052
K0053
K0053
K0056
K0056
K0065
K0065
K0069
K0069
K0070
K0070
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Modifier Price
$109.65
$4.62
$34.66
$2.59
$19.45
$1.33
$9.92
$4.63
$34.66
$4.09
$32.61
$2.25
$16.84
$4.92
$36.81
$6.04
$45.32
$4.78
$35.69
$3.17
$23.79
$1.81
$13.65
$1.57
$11.73
$5.12
$38.40
$1.94
$14.59
$6.81
$50.98
$3.22
$24.26
$4.84
$36.16
$7.57
$56.74
$9.21
$69.17
$9.51
$71.33
$4.43
$33.18
$9.77
$73.31
$17.77
$133.20
Procedure Code
K0071
K0071
K0072
K0072
K0073
K0073
K0077
K0077
K0098
K0098
K0105
K0105
K0193
K0195
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
UE
RR
RR
Pricing Action Code
3
3
3
3
3
3
3
3
3
3
3
3
9
3
Modifier Price
$11.23
$84.18
$6.83
$51.21
$3.46
$25.97
$5.65
$42.41
$2.71
$20.29
$10.30
$77.25
$107.84
$15.22

Procedure Code Description Pricing Action Code Maximum

Transcription

Similar documents

Die BUCHSTAVIER - Das Dosierte Leben

GI/GU Endorsement Maintenance Pilot Project, 2012

carta circular - Cartas Circulares – Triple

Regence BlueCross BlueShield of Oregon

HCPCS Codes

Regence BlueShield of Idaho